Every finding on record at Matlock Place Health & Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents and assistance devices to prevent accidents for 1 (Residents #109) of 10 residents reviewed for accidents and hazards.The facility failed on 6/28/26 to ensure Resident #109 was provided with appropriate assistance during incontinent care resulting in Resident #109 falling off the bed, receiving a laceration to his head, which required staples.On 7/07/26 at 7:10 p.m. an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. This failure could place residents at risk for falls, injuries, hospitalization, or death.Finding included:Record Review of Resident#109's face sheet, dated 7/07/26, reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Acute Cystitis with Hematuria (inflammation of the bladder), Chronic Obstructive Pulmonary Disease (incurable lung condition), Epilepsy (a chronic brain condition that causes repeated seizures), Muscle Wasting and Atrophy (the thinning or loss of muscle tissue), Cognitive Communication Deficit (deficits in communication skills as a result of underlying deficits in cognition), Quadriplegia (paralysis that affects all limbs and body from the neck down), and Acute and Chronic Respiratory Failure with Hypoxia (sudden, life-threatening worsening of a long-term lung condition). Record review of Resident #109's quarterly Minimum Data Set assessment dated [DATE] reflected a Brief Interview for Mental Status score of 09 which indicated moderate cognitive impairment. Section GG0130 (Functional Abilities) reflected Resident #109 was dependent on staff for toileting hygiene.Record review of Resident #109's care plan, dated 5/21/26, revealed an ADL self-care deficit with resulting quadriplegia (paralysis that affects all limbs of the bod from the neck down). Interventions/Tasks: Resident #109 was totally dependent on 2 staff for incontinent care.Record review of a witness fall report dated 6/28/26 documented by RN M revealed CNA K reported that while changing the resident (#109), resident fell on the floor and upon arrival to resident room resident observed lying on the bed. CNA K stated that he assisted resident from the floor to the bed. Resident was observed with a bump with active bleeding to the left side of the forehead. Resident was unable to give a description of what happened.Record review of Resident #109's hospital record dated 6/28/26 revealed a posterior scalp laceration, stapled in ED.During an interview on 7/7/26 at 11:54 a.m., CNA K stated he prepared to change Resident #109 and turned him on his side when Resident #109 tipped over and fell onto the floor. CNA K stated he picked Resident #109 up from the floor and placed him back on the bed and left to get the charge nurse. CNA K stated he was new and PRN and it was his first day working with Resident #109. He stated he did not have a log-in for the computer system to access Resident #109's care needs. He stated he normally asked residents about their care needs or the charge nurse.During an interview on 7/07/26 at 1:30 p.m., Resident #109 responded that he was blessed and uttered language difficult to understand to every question asked regarding the incident. Resident #109 was unable to be interviewed.During an interview on 7/07/26 at 2:14 p.m., RN M stated CNA K informed her Resident #109 fell. She stated Resident #109 was in his bed when she entered the room. She stated she observed blood and a big bump on Resident #109's forehead. She stated fall protocol included contacting the nurse immediately for an assessment prior to moving the resident. She stated she was aware Resident #109 required 2 staff assistance with incontinent care. She stated she only worked weekends and was unaware if CNA K was PRN or worked during the week. She stated it was important for CNAs to have access to the electronic care plan system for charting and to know the residents' needs and proper care to provide.During an interview on 7/07/26 at 4:52 p.m., CNA L revealed CNA K trained with her one day during the week prior to his first day of working alone. She stated CNA K participated in patient care including assistance with repositioning and incontinent care. CNA L stated CNA K informed her he didn't have access to the POC system. She stated she planned to request access from Human Resources the next day of their training, but CNA K only trained with her for the one day.During an interview on 7/07/26 at 3:18 p.m., the DON stated that she was responsible for providing POC/Kardex access which was provided via text prior to the 3rd day of training for new hires including PRN CNAs. She stated there wasn't documentation that CNA K received access prior to starting his first day with Resident #109.During an interview on 07/09/26 at 7:05 p.m., the Administrator stated the expectation was for new hires including PRN staff to have access to the electronic system, which contained resident care plans, prior to working by themselves. The Administrator stated that without access, staff were unable to properly care for residents. The Administrator stated the expectation was for CNAs to find another direct care staff for assistance when the resident's care plan reflected 2-person assistance. The Administrator stated the expectation regarding falls was for staff to notify the nurse immediately for nurse assessment prior to helping the resident up.Record review of the facility's policy titled, Falls and Fall Risk Managing revised March 2018 reflected, .staff will identify and implement relevant interventions to try to minimize serious consequences of falling.The Administrator was notified on 7/07/2026 at 7:10pm that an Immediate Jeopardy had been identified due to the above. A plan of removal was requested.The facility's plan of removal was accepted on 7/08/26 at 10:45am. The accepted plan of removal for the Immediate Jeopardy included the following: Plan:Start date: 6/28/26Completion date: 7/08/26Before returning to resident care, all licensed nurses, Certified Nursing Assistants, PRN staff, and newly hired employees received mandatory education that included:Resident abuse, neglect, and exploitation prevention.Resident safety and accident prevention.Proper use of the KARDEX and electronic care plans.Safe bed mobility and repositioning techniques.Proper transfer procedures and use of gait belts and mechanical lifts when indicated.Identification of residents requiring one-person versus two-person assistance.Each employee completed a post-test and return demonstration. Staff who were unable to demonstrate competency received additional education and were not permitted to provide resident care until competency was successfully validated.The plan of removal was monitored as follows:Interviews with staff were conducted on 7/09/26 between 8:56 a.m. and 5:15 p.m. to determine if they had received appropriate training and instructional guidance about falls, the electronic care plan system, as well as to determine if all elements of the plan of removal had been accomplished. Seventeen CNAs (CNA A, CNA B, CNA C, CNA I, CNA J, CNA K, CNA L, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W) including PRN CNAs, Eight nurses (RN F, RN M, RN X, RN Y, RN, Z, LVN H, LVN AA, LVN AB), and one MA (MA G), the Administrator, Director of Nursing, and Assistant Director of Nursing were interviewed on in-services or training and Kardex/POC access. Staff described what they would do in the event of a resident fall and confirmed in-services/training regarding abuse, neglect, proper use of the Kardex system and electronic care planning, safe bed mobility, repositioning techniques, transfer procedures, and how to identify residents that require one versus two-person assistance. An observation of incontinent care on 7/09/26 at 11:45 a.m. for Resident #109 revealed 2-staff assistance. Record review revealed direct care observations conducted by the DON on 7/07/26-7/08/26 for residents requiring extensive assistance to ensure compliance. Record review revealed in-services on 7/07/26-7/08/26 with staff on abuse and neglect, POC: Kardex and Care Plans, fall prevention, fall policy, resident safety and accident prevention, bed mobility and repositioning. Record review revealed ADON AE would be responsible for ensuring the New Employee Orientation and Competency Checklist. The New Employee Orientation and Competency Checklist included checklists for electronic access, care plan review, Kardex review, and fall prevention. Record review revealed pre/posttests on 7/08/26-7/09/26 with staff on falls prevention, resident safety, and POC.The IJ was lifted on 7/09/2026 at 6:58 p.m. after interviewing and confirming the fall protocol, Kardex access, and all elements in the plan of removal were accomplished.

Based on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 direct-care staff (CNA K) and 1of 1 resident (Resident #109) reviewed for proficiency of nurse aides.The facility failed to ensure CNA K was trained on fall protocol. On 6/28/26, CNA K performed incontinent care independently on Resident #109, which required a 2-person assist, that resulted in Resident #109 falling off the bed and sustaining a laceration to his head. The facility failed to ensure CNA K was granted access to the electronic system which contained resident care instructions.On 7/07/26 at 7:10 p.m. and Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time.These failures placed residents with ADL self-care performance deficit at risk of injury by not receiving care and services in accordance with resident care plans, facility policy, and stated professional standards.Record Review of Resident#109's face sheet reflected a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included Acute Cystitis with Hematuria (inflammation of the bladder), Chronic Obstructive Pulmonary Disease (incurable lung condition), Epilepsy (a chronic brain condition that causes repeated seizures), Muscle Wasting and Atrophy (the thinning or loss of muscle tissue), Cognitive Communication Deficit (deficits in communication skills as a result of underlying deficits in cognition), Quadriplegia (paralysis that affects all limbs and body from the neck down), and Acute and Chronic Respiratory Failure with Hypoxia (sudden, life-threatening worsening of a long-term lung condition. Record review of Resident #109's quarterly Minimum Data Set assessment dated [DATE] reflected a Brief Interview for Mental Status score of 09 which indicated moderate cognitive impairment. Section GG0130 (Functional Abilities) reflected Resident #109 was dependent on staff for toileting hygiene.Record review of Resident #109's care plan, dated 5/21/26, revealed an ADL self-care deficit related to quadriplegia (paralysis that affects all limbs of the body from the neck down). Interventions/Tasks: Resident #109 was totally dependent on 2 staff for incontinent care.Record review of a witness fall report dated 6/28/26 documented by RN M revealed a statement, CNA reported to this writer that while changing the resident, resident fell on the floor and upon arrival to resident room resident observed lying on the bed and this staff CNS stated that he assisted resident from the floor to bed, resident and noted a bump with active bleeding to the left side of the forehead. Resident unable to give description of what happened. Record review of Resident #109's hospital record dated 6/28/26 revealed a posterior scalp laceration, stapled in ED. Record review of the training records of the undated Orientation Packet for CNA K revealed general information on falls, fall prevention, and reducing fall risk. Record review revealed the Orientation Packet was unsigned by CNA K. Record review of the New Employee Orientation and Competency Checklist for CNA K did not reveal competency for fall procedures. During an interview on 7/7/26 at 11:54 a.m., CNA K stated he prepared to change Resident #109 and turned him on his side when Resident #109 tipped over and fell onto the floor. CNA K stated he picked Resident #109 up from the floor and placed him back on the bed and left to get the charge nurse. CNA K stated he was new and PRN and it was his first day working with Resident #109. He stated he trained for 3 days during the week prior to the first shift of working alone. He stated he did not have a log-in for the computer system to access Resident #109's care needs. He stated he normally asked residents about their care needs or the charge nurse. He stated he was provided a procedure packet prior to working alone, but he was with a trainer and was too busy during his first day of working alone. CNA K revealed he did not review the procedure packet until after the incident. He stated he was not trained on facility fall protocol prior to the incident. During an interview on 7/07/26 at 1:30 p.m., Resident #109 responded he was blessed and uttered language difficult to understand to every question asked regarding the incident. Resident #109 was not interviewable. During an interview on 7/07/26 at 2:14 p.m., RN M stated CNA K informed her Resident #109 fell. She stated Resident #109 was in his bed when she entered the room. She stated she observed blood and a big bump on Resident #109's forehead. She stated fall protocol included contacting the nurse immediately for an assessment prior to removing the resident. She stated she was aware Resident #109 required 2 staff assistance with incontinent care. She stated she only worked weekends and was unaware if CNA was PRN or worked during the week. She stated it was important for CNAs to have access to the Kardex/POC system for charting and to know resident needs and proper care. During an interview on 7/07/26 at 4:52 p.m., CNA L revealed CNA K trained with her one day during the week prior to his first day. She stated CNA K participated in patient care including assistance with repositioning and incontinent care. CNA L stated CNA K informed her he didn't have access to the POC system. She stated she planned to request access from Human Resources the next day of their training but CNA K trained with her for the one day. During an interview on 7/07/26 at 3:18 p.m., the DON stated that POC/Kardex access was provided via text prior to the 3rd day of training for new hires including PRN CNAs. She stated there wasn't confirmation that CNA K received access prior to starting his first day with Resident #109. During an interview on 07/09/26 at 7:05 p.m., the Administrator stated the expectation was for new hires including PRN staff to have access to the PCC system, which contained resident care plans, prior to working by themselves. The Administrator stated that without access, staff was unable to properly care for residents. The Administrator stated the expectation was for CNAs to find another direct care staff for assistance when the resident's care plan reflected 2-person assistance. The Administrator stated the expectation regarding falls was for staff to notify the nurse immediately for nurse assessment prior to helping the resident up. Record review of the facility's policy titled, Falls and Fall Risk Managing revised March 2018 reflected, staff will identify and implement relevant interventions to try to minimize serious consequences of falling. The Administrator was notified on 7/07/2026 at 7:10pm that an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided. The facility's plan of removal was accepted on 7/08/26 at 10:45am. The accepted plan of removal for the Immediate Jeopardy included the following: Plan:Start date: 6/28/26Completion date: 7/08/26Before returning to resident care, all licensed nurses, Certified Nursing Assistants, PRN staff, and newly hired employees received mandatory education that included:Resident abuse, neglect, and exploitation prevention.Resident safety and accident prevention.Proper use of the KARDEX and electronic care plans.Safe bed mobility and repositioning techniques.Proper transfer procedures and use of gait belts and mechanical lifts when indicated.Identification of residents requiring one-person versus two-person assistance.Each employee completed a post-test and return demonstration. Staff who were unable to demonstrate competency received additional education and were not permitted to provide resident care until competency was successfully validated.The plan of removal was monitored as follows:Interviews with staff were conducted on 7/09/26 between 8:56 a.m. and 5:15 p.m. to determine if they had received appropriate training and instructional guidance about falls, the electronic care plan system, as well as to determine if all elements of the plan of removal had been accomplished. Seventeen CNAs (CNA A, CNA B, CNA C, CNA I, CNA J, CNA K, CNA L, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W) including PRN CNAs, Eight nurses (RN F, RN M, RN X, RN Y, RN, Z, LVN H, LVN AA, LVN AB), and one MA (MA G), the Administrator, Director of Nursing, and Assistant Director of Nursing were interviewed on in-services or training and Kardex/POC access. Staff described what they would do in the event of a resident fall and confirmed in-services/training regarding abuse, neglect, proper use of the Kardex system and electronic care planning, safe bed mobility, repositioning techniques, transfer procedures, and how to identify residents that require one versus two-person assistance. An observation of incontinent care on 7/09/26 at 11:45 a.m. for Resident #109 revealed 2-staff assistance. Record review revealed direct care observations conducted by the DON on 7/07/26-7/08/26 for residents requiring extensive assistance to ensure compliance. Record review revealed in-services on 7/07/26-7/08/26 with staff on abuse and neglect, POC: Kardex and Care Plans, fall prevention, fall policy, resident safety and accident prevention, bed mobility and repositioning. Record review revealed ADON AE would be responsible for ensuring the New Employee Orientation and Competency Checklist. The New Employee Orientation and Competency Checklist included checklists for electronic access, care plan review, Kardex review, and fall prevention. Record review revealed pre/posttests on 7/08/26-7/09/26 with staff on falls prevention, resident safety, and POC.The IJ was lifted on 7/09/2026 at 6:58 p.m. after interviewing and confirming the fall protocol, Kardex access, and all elements in the plan of removal were accomplished.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 3 (Nurses' Medication cart 100/300/400 Halls, Nurses' Medication cart 500 Hall, MAs' medication cart 100/300 Halls ) of 5 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of potential diversion of controlled medications when RN F, RN E, and MA G did not report a damaged blister packs of Lorazepam 0.5 mg (controlled medication), Acetaminophen-Codeine 300-30 mg (controlled medication), and Alprazolam 0.5 mg (controlled medication). This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.Findings included:1-Record review of Resident#57's face sheet dated 07/09/26 reflected she was an [AGE] year-old female with admission date of 05/05/25. Resident#57's diagnoses included metabolic encephalopathy (Metabolic encephalopathy is a brain dysfunction caused by systemic metabolic disturbances that impair normal brain function, leading to confusion, memory loss, or even coma), reduced mobility, muscle weakness, cognitive communication deficit, vascular dementia (results from conditions that damage blood vessels and block blood flow to your brain), severe, with other behavioral disturbance. Record review of Resident#57's Physician order summary reflected Acetaminophen-codeine oral tablet 300-30 mg give one tablet by mouth three times a day for pain with a start date 04/18/26. An observation on 07/07/26 at 10:40 a.m. of medication cart with RN F revealed the blister pack in Nurses' medication Cart for 100-300-400 Hall, for Resident#57's Acetaminophen-codeine oral tablet 300-30 mg (controlled medication) had one blister pill area seal broken, taped on the back, and there was pill still in the blister. Review of the controlled medication count sheet dated 07/07/26 for Resident#57's Acetaminophen-codeine oral tablet 300-30 mg reflected that the count was accurate when compared to the medications in the drawer. In an interview on 07/07/26 at 10:42 a.m. RN F stated she was unaware when the blister pack seal became broken. She stated that the seals were easily torn when they are handled every shift to be counted. She stated the medication was supposed to be discarded if opened to prevent potential diversion of controlled medications. 2- Record review of Resident #15's face sheet dated 07/09/26 reflected he was an [AGE] year-old male with admission date of 02/20/24. Resident#15's diagnoses included Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain. It is the commonest cause of premature senility), pain, muscle wasting and atrophy (is the partial or complete wasting away of a part of the body), mood [affective] disorder, major depressive disorder, anxiety disorder, and cognitive communication deficit. Record review of Resident#15's Physician order summary on 07/07/26 reflected Alprazolam oral tablet 0.5 mg (Controlled drug). Give 0.5 mg tablet by mouth every 12 hours related to anxiety disorder. with a start date 05/08/26. An observation on 07/07/26 at 10:50 a.m. of medication carts with MA G revealed the blister pack in MAs' medication Cart for 100-300 Hall, for Resident#15's Lorazepam 0.5 mg (controlled medication) had 2 blisters pills area seal broken, taped on the back, and there was pills still in the blisters. Review of the controlled medication count sheet dated 07/07/26 for Resident #15's Lorazepam 0.5 mg reflected that the count was accurate when compared to the medications in the drawer. In an interview on 07/07/26 at 10:52 a.m. MA G stated she was unaware when the blister pack seal became broken. She stated that the seals were easily torn when they are handled every shift to be counted. She stated the medication was supposed to be discarded if opened to prevent potential diversion of controlled medications. 3- Record review of Resident #31's Quarterly MDS assessment, dated 01/26/25, reflected she was an [AGE] year-old female with admission date of 11/30/23. Resident#5's BIMs score was 6/15 which indicated severe cognition impairment. Her diagnoses included diabetes mellitus (elevated blood sugar), dementia (diseases that affect memory, thinking, and the ability to perform daily activities), hypertension (elevated blood pressure). Record review of Resident#31's Physician order summary report dated March 3, 2025, reflected Lorazepam-Schedule IV tablet; 0.5 mg; amt: 0.5 tablet 0.25 mg; oral once a day-PRN with a start date 05/01/26. An observation on 07/07/26 at 11:15 a.m. of medication cart with RN E revealed the blister pack in medication Cart for 500 Hall, for Resident #31's Lorazepam 0.5 mg (controlled medication) had 1 blister pill area seal broken, taped on the back, and there was pill still in the blisters. Review of the controlled medication count sheet dated 07/07/26 for Resident #31's lorazepam 0.5 mg reflected that the count was accurate when compared to the medications in the drawer. In an interview on 07/07/26 at 11:20 a.m. RN E stated she was unaware when the blister pack seal became broken. She stated that the seals were easily torn when they are handled every shift to be counted. She stated the medication was supposed to be discarded if opened to prevent potential diversion of controlled medications. 4- Record review of Resident #91's Quarterly MDS assessment, dated 01/26/25, reflected she was an [AGE] year-old female with admission date of 11/30/23. Resident#5's BIMs score was 6/15 which indicated severe cognition impairment. Her diagnoses included diabetes mellitus (elevated blood sugar), dementia (diseases that affect memory, thinking, and the ability to perform daily activities), hypertension (elevated blood pressure). Record review of Resident#91's Physician order summary report dated 03/03/25, reflected Lorazepam-Schedule IV tablet; 0.5 mg; amt: 0.5 tablet 0.25 mg; oral once a day-PRN with a start date 06/16/26. An observation on 07/07/26 at 11:15 a.m. of medication carts with RN E revealed the blister pack in medication Cart for 500 Hall, for Resident #91's Lorazepam 0.5 mg (controlled medication) had 2 blisters pills area seal broken, taped on the back, and there was pills still in the blisters. Review of the controlled medication count sheet dated 07/07/26 for Resident #91's lorazepam 0.5 mg reflected that the count was accurate when compared to the medications in the drawer. In an interview on 07/07/26 at 11:20 a.m. RN E stated she was unaware when the blister pack seal became broken. She stated that the seals were easily torn when they are handled every shift to be counted. She stated the medication was supposed to be discarded if opened to prevent potential diversion of controlled medications. In an interview on 07/09/26 at 11:14 AM, the DON revealed she expected if a blister pack medication seal was broken; the pill should be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk to residents would be development of infection, and drug diversion. The DON stated charge nurses were responsible to check, every day, the carts for medications with broken seals during the count with the relieving nurses. Record review of the facility's Controlled Substances Administration and Accountability policy, dated 01/01/23, reflected the following: .All controlled substance (Scheduled ii iii iv, v) are accounted for in one of the following ways: .ii. All controlled substance obtained from non- automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for six residents (Resident #8, Resident #38, Resident #40, Resident #46, Resident #65, Resident #100) of 10 residents reviewed for ADL care. The facility failed to ensure Resident #46, had his fingernails trimmed on his left hand on 07/07/2026.The facility failed to ensure Resident #8 had her fingernails trimmed on 07/07/26.The facility failed to ensure Resident #38, Resident #40, Resident #65, and Resident #100 had their fingernails cleaned and trimmed on 07/07/2026. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life. Findings included: 1.Record review of Resident #46's MDS assessment dated [DATE] reflected he was a [AGE] year old male with as admission date of 06/26/2026. His diagnoses included Hypo-Osmolality and Hyponatremia (A condition where blood is too dilute, causing water to shift into cells and swell them), Hemiplegia (Paralysis of one side of the body). He had a BIMS score of 13 indicating his cognition was intact. Resident #46 needed moderate assistance with toileting and personal hygiene. Record review of Resident #46's care plan dated 07/01/2026 reflected he had an ADL self-care performance deficit, Interventions: Resident #46 requires supervision assistance by one staff to turn and reposition in bed as necessary, partial assistance by one staff for toileting. Resident #46's care plan did not include interventions for personal hygiene/bathing or nail care. Observation and interview on 07/07/2026 at 12:03 PM with Resident #46 revealed he was sitting in his wheelchair in his room. Resident #46 was observed biting his long fingernails on his left hand, which measured around .25 to .5 long from the tip of his fingers. Resident #46 stated he would like his fingernails trimmed but none of the staff offered to trim it. An interview on 07/09/2026 at 10:50 AM with LVN H revealed she was familiar with Resident #46, she stated it was the responsibility of the nurses to ensure the resident fingernails were cleaned and trimmed. She stated Resident #46 refused fingernail care when she had offered but she had not documented it anywhere, she was responsible for documenting it in the progress note. LVN H stated not trimming fingernails put residents at risk for skin tears and infections. She stated she could not remember when the last time she received in-service on fingernail care. An interview on 07/09/2026 at 11:00 AM with CNA I revealed the nurses were responsible to trim the fingernails for residents, she stated she was not aware that Resident #46 had long fingernails. She stated she would notify the nurse if the resident had a long fingernail. CNA I stated that long fingernails put residents at risk for infections and injuries. An interview on 07/09/2026 at 11:33 AM with the ADON revealed she was responsible for the nursing staff to ensure they render the services and assistance to the residents in 600, 700 and 800 halls, and she ensured the nursing staff complied with the rules and regulations. She stated CNAs were responsible to clean and trim resident fingernails, nurses were responsible to trim fingernails if the resident had a diagnosis of diabetes. She stated not trimming fingernails put residents at risk for skin tears and infections, especially if the resident was biting on his fingernails. She stated all staff received in service on fingernail care within this year. An interview on 07/09/2026 at 01:38 PM with CNA J revealed the nurses were responsible for trimming resident fingernails and she had cleaned resident fingernails but not trimmed it. She stated she would notify the nurse if a resident had long fingernails, it would put residents at risk for self-harm and infections if the fingernails were not cleaned and trimmed. She stated she received in-service on fingernail care within this year. She stated she was not aware Resident #46 had long fingernails. 2.Record review of Resident #100's quarterly MDS assessment, dated 05/28/26, reflected a [AGE] year-old female with an admission date of 09/28/20, and readmission on [DATE]. Resident #100's diagnoses included hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar). Resident#100 BIMS score was 07/15 indicating moderate cognition impairment. Further review revealed Resident#100 was Substantial/maximal assistance for personal hygiene. Record review of Resident #100's care plan revised on 01/11/26 reflected, Focus: [Resident #100] has an ADL self-care performance deficit r/t Pain d/t radiculopathy. Goal: [Resident #100 will improve current level of function in transfers, mobility through the review date. Intervention: personal hygiene: The resident requires moderate assistance by 1 staff with personal hygiene . Observed Resident #100 lying in bed on 07/07/26 at 10:22 a.m. Residents' nails were observed to be approximately 1/4 inches in length with black matter underneath. Resident#100 stated she had been asking the staff for her fingernails to be cleaned, trimmed and polished. In an interview and observation with CNA A on 07/07/26 at 2:02 p.m., CNA A physically assessed Resident#100's fingernails and stated it needed cleaning due to black matter underneath, and trimming. CNA A stated that nail care for the residents were performed by CNAs on shower days and it was the responsibility of the nurses and CNAs to ensure resident's nails kept clean and trimmed to prevent infection, and skin injury through scratching. CNA A stated the risk to Resident#100 could be infection development, skin integrity, and dignity issue. 3.Record review of Resident #40's quarterly MDS assessment, dated 06/05/26, reflected a [AGE] year-old female with an admission date of 06/22/22, and readmission on [DATE]. Resident#40's diagnoses included hypertension (elevated blood pressure), and diabetes mellitus (elevated blood sugar), and Non-Alzheimer's Dementia (cognitive decline caused by various brain diseases other than Alzheimer's). Resident #40's BIMS score was 00/15 indicating severe cognition impairment. Further review revealed Resident #40 was dependent for personal hygiene function. Record review of Resident #40's care plan revised on 03/24/26 reflected, Focus: The resident has an ADL self-care performance deficit r/t limited functional ability. Goal: The resident will maintain current level of function through the review date. Interventions: personal hygiene: The resident is totally dependent on 1 staff for personal hygiene. Observed Resident #40 lying in bed on 07/07/26 at 10:19 a.m. Residents' nails were observed to be approximately 0.6 cm in length. Resident #40's right hand fingernails had brown matter underneath. Resident #40 appeared to understand questions but was unable to respond. In an interview with CNA C on 07/09/26 at 10:21 a.m., CNA C stated resident's nails should be checked every day and nail care to be done weekly or as needed. CNA C stated she thought the Activities Director did the residents nails care, or trim if the resident needed it. CNA stated it was the responsibility of the CNAs and nurses to check and do residents nails care, unless if the resident was diabetic only nurses could trim their nails. CNA C stated the Resident#40 was on hospice and the hospice CNA was coming daily to do resident care. CNA C stated the risk to residents having long dirty nails, development of infection and skin issues. 4. Record review of Resident #8's quarterly MDS assessment, dated 03/02/26, reflected a [AGE] year-old female with an admission date of 09/16/22. Resident #8's diagnoses included hypertension (elevated blood pressure), Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), Schizophrenia (a chronic and severe brain disorder that causes individuals to interpret reality abnormally), and limitation of activities due to disability. Resident #8's BIMS score was 14/15 indicating intact cognition. Resident #8 was dependent on staff for personal hygiene. Record review of Resident #8's care plan revised on 07/03/26 reflected, Focus:[Resident #8] has an ADL self-care performance deficit r/t Limited Mobility. Goal: The resident will maintain current level of function with adl's through the review date. Interventions: personal hygiene: The resident requires (moderate assistance) by (1) staff with personal hygiene. Observation and interview with Resident #8 revealed she was up in wheelchair in the Hallway on 07/07/26 at 1:20 p.m. Resident's nails were observed to be approximately 1/4 inches in length, chipped. Resident #8 stated she wanted her fingernails to be trimmed and polished. In an interview and observation with CNA A on 07/07/26 at 2:02 p.m., CNA A physically assessed Resident#8's fingernails and stated it needed trimming. CNA A stated that nail care for the residents was performed by CNAs on shower days and it was the responsibility of the nurses and CNAs to ensure resident's nails kept clean and trimmed to prevent infection, and skin injury through scratching. CNA A stated the risk to Resident #8 could be infection development, skin integrity, and dignity issue. Interview with the DON on 07/09/26 at 10:31 a.m. she stated residents' fingernails should be cleaned and filed short, at the resident likeness. She stated it was the responsibility of the CNAs to clean and trim residents' fingernails. She stated the nurses could do it sometimes and the activities personnel could do residents' nails care, but it should be nurses and CNAs responsibility. She stated failing to keep resident's nails trimmed and clean could cause skin scratches, and risk of development of infections. Record review of the facility's policy titled, Nails Care dated 2022, reflected, Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health.Assessments of resident nails will be conducted on admission and readmission to determine the resident's nail condition, needs, and preferences for nail care, if possible.Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as weekly on Wednesday 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. 5.Record review of Resident #38's Quarterly MDS assessment, dated 06/22/26, revealed Resident #38 [SP40.1]was a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #38 had cognition intact with a BIMS score of 15 (indicating cognitive impairment intact). Resident #38 required set up assistance from staff with eating and was dependent on staff for oral hygiene, shower/bath, and personal hygiene. Active diagnoses included high blood pressure, Cirrhosis (advanced scarring of the liver), Stroke (blood supply to the brain is interrupted or reduced, preventing brain tissue from getting enough oxygen and nutrients, and Anxiety Disorder (mental health condition characterized by excessive, uncontrollable worry about everyday issues, affecting daily functioning and quality of life. Record review of Resident #38's care plan, initiated 06/24/26, reflected Resident #38 has an activity of daily living self-care performance deficit Goal: Resident #38 will maintain current level of function. Interventions included to encourage resident to use call light to call for assistance. Monitor/document/report as needed any changes, any potential improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self-care. Resident #38 has potential impairment to skin integrity. Goal: Resident will maintain or develop clean and intact skin by the review date. Interventions included to avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Follow facility protocols for treatment of injury. Interview and observation on 07/07/26 at 10:23 AM revealed Resident #38 was lying in bed. His finger nails were observed to be at least one inch long. Resident #38 said his nails and toe nails were way too long, and he would like to have them cut down. Resident #38 stated he was unsure of his shower days and could not recall when the hospice staff assisted him with showers and bathing. Resident #38 said staff had not addressed his request to have his finger and toe nails cut down. 2.Record review of Resident #65's Quarterly MDS assessment, dated 05/28/26, revealed Resident #65 was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted on [DATE] and again on 05/07/26. Resident #65 had cognition intact with a BIMS score of 14 (indicating cognitive impairment intact). Resident #65 required partial/moderate assistance from staff with shower/baths and substantial/maximal assistance with personal hygiene. Active diagnoses included high blood pressure, high blood sugar, end – stage renal disease (when kidneys can no longer function adequately to sustain life without treatment), and need for assistance with personal care. Record review of Resident #65's care plan, revised 07/03/26, reflected Resident #65 has an activity of daily living self-care performance deficit related to Neuropathy (nerve disease or malfunctions that can affect any part of the body). Goal: Resident #65 will maintain current level of function. Interventions included to encourage resident to use call light to call for assistance. Monitor/document/report as needed any changes, any potential improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self-care. [SP41.1]Resident #65's care plan did not have any specific plan of care for nail care, personal hygiene or bathing. Interview and observation on 07/07/26 at 10:28 AM revealed Resident #65 was lying in bed on his left side. observation of his finger nails revealed they were at least half inch long with black debris underneath. Resident #65 stated his shower days were Tuesday, Thursday, and Saturdays. Resident #65 said his nails were longer than he would like, and he asked LVN AC for assistance with cutting his fingernails today on 07/07/26. Resident #65 stated he would take a shower today, but was unsure if LVN AC would have any time to trim and clean his nails. Interview and observation 07/08/2026 at 3:26 PM with LVN AC revealed Resident #38's fingernails and toenails were thick and at least 1 inch long, LVN AC stated she was not aware of Resident #38's long nails. LVN AC further revealed Resident #65 asked her on 07/07/26 to perform nail care, to trim and clean his nails, due to them observed to be with black debris and at least a half inch long. LVN AC stated she was not able to complete the task of assisting Resident #65 with nail care due to the busy schedule. LVN AC stated either the nurse aides or herself (a nurse) were able to clean, cut or trim resident nails and toe nails. LVN AC stated when aides were providing showers or bed baths she expected the nurse aides to address resident's nails and toenails by cleaning, trimming or cutting them. LVN AC stated if this was something that the nurse aides could not do either by difficulty, refusals or if the resident had diagnosis of being a diabetic the nurse aide would notify her so she could access the situation. LVN AC stated that not addressing resident nail care placed residents at risk of infections. Interview on 07/08/2026 at 3:51 PM CNA AD revealed she worked at the back of 400 hall with Resident #38 and Resident #65. CNA AD stated she addressed resident needs from head to toe which included resident finger and toe nails. CNA AD stated Resident #38 had hospice staff that addressed his bathing needs daily, and that she looked at Resident #38's toe nails on 07/07/26 and expressed they are a bit long and were due for a cut. CNA AD stated Resident #38's toe nails were pretty thick; she would not have been able to cut his toe nails because she did not have the right tools. CNA AD stated she needed to notify the nurse so his feet could be assessed or trimmed by the nurse. CNA AD stated Resident #65's nail care should be addressed during the morning hours when he showered, however if asked nail care was something she could do for Resident #65, and not addressing nail care placed residents at risk of infection. Interview 07/09/26 at 1:32 PM with the ADON revealed aides were expected to complete care for finger and toe nails during resident shower or bed bath days. The ADON stated if there were issues such as residents refusing or if a resident had diagnosis of being a diabetic and required their nails to be trimmed, she expected nurse aides to report this information to the nurse so they could complete the task. The ADON stated there were sometimes when residents required the assistance of a podiatrist, therefore they will be added to the list by the social worker to have their nails cut or trimmed by a podiatrist. The ADON stated that not completing nail care placed residents at risk of infection, bacteria, and possible skin tears.

Based on observation, interviews and record review, the facility failed to store food in accordance with professional standards for the facility's only kitchen observed for food service safety. The facility failed to:Ensure food items in the facility refrigerators and dry storage were dated and labeled on 07/07/2026.Ensure food items were labeled, dated, and stored in separate boxes in the freezer on 07/07/2026.Ensure expired food items stored in the dry storage area were discarded on 07/07/2026. These failures could place residents at risk for food borne illnesses and food contamination.Findings included:An observation of the facility's only kitchen on 07/07/2026 at 10:20 AM revealed:Walk-In Freezer:Chicken tenders in an unlabeled and undated transparent plastic bag were stored inside a box alongside frozen potato fries.Dry Storage Room:One box of Sysco Imperial thickened tea (nectar consistency) was observed with an expired use-by date of 11/06/2020.Three boxes of ReadyCare thickened hot cocoa (nectar consistency) were observed with an expired use-by date of 12/27/2021.One box of Swiss Miss hot cocoa mix was observed with an expired use-by date of 03/10/2026.Seven 32-ounce plastic containers of previously opened spices were observed lacking both open dates and use-by dates. During an interview on 07/07/2026 at 11:44 AM with the Dietary Manager, she stated all the dietary staff were responsible for ensuring: the containers of spices had the open and use by date, each food item was stored in separate boxes in the freezer, and the expired food items were discarded. She stated mixing food items in a box had the potential risk for cross contamination, not dating and labelling food items made it difficult for the staff to understand if that item was safe to use. She stated not dating, labeling, mixing food items, not discarding expired food items put residents at risk for foodborne illnesses. She stated she discarded all the expired food items. During an interview on 07/09/2026 at 01:24 PM with Cook/ Dietary aide, she stated she worked as a PRN cook and a dietary aide. She stated it was very important to label food items with both the opening date and the use-by date to ensure that all food stored in the kitchen was safe to use. She stated that mixing chicken tenders with potato fries could cause cross-contamination. She stated that failing to date, label, or discard expired food items put residents at risk for foodborne illnesses. Record review of facility policy with review date of 1/1/25, titled Food Storage. Purpose:To establish safe and sanitary food storage practices within the facility's dietary department, ensuring compliance with state and federal regulations, preventing foodborne illness, and maintaining quality and nutritional integrity of food items. Policy StatementIt is the policy of this facility to store all food and dietary supplies in a safe, sanitary, and organized manner that prevents contamination, spoilage, and foodborne illness. Food storage practices will follow Centers for Medicare & Medicaid Services (CMS), Food and Drug Administration (FDA) Food Code, and state/local health department requirements. Procedure:. All foods must be covered, labeled, and dated upon receipt and after opening.Inspect for damaged, bulging, or expired canned goods; discard immediately.Dairy, eggs, and perishable items must be used by manufacturer's 'use by' or facility-established guidelines.

Based on observation, interview, and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 5 residents (Resident #7) reviewed for nutrition status maintenance. 1. The facility failed to ensure Resident #7 had 2 CAL (Med Pass) three times a day leaving her with 105 missed doses. 2. The facility failed to measure and record Resident #7's body weight, as ordered by the resident's physician, for four weeks from 06/17/26 until 07/01/26.These failures could place residents at risk of weight loss, nutritional deficit, and adverse health consequences.Findings included:Record review of Resident #7's Quarterly Minimum Data Set reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #7's Quarterly Minimum Data Set, dated [DATE], reflected a BIMS score was blank, which indicated she was not able to successfully complete the interview. Her Functional Status indicated she required a walker to ambulate, set up, or clean up assistance with eating, supervision, or touching assistance with oral hygiene. Resident #7 had diagnoses which included high blood pressure, Non-Alzheimer's Dementia (a decline in memory and cognitive function), anxiety disorder (persistent and excessive worry about various aspects of life) and Depression (mood disorder that causes a persistent feeling of sadness and loss of interests). Section K - weight 162 pounds, with loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Section L - Oral/Dental status revealed none of the above were present which included: Broken or loosely fitting full or partial denture. Record review of Resident #7's undated care plan revealed Resident #7 was on a regular diet, thin liquids. Goal: Will ensure she eats all meals related per diet, to prevent weight loss. Interventions included: Will encourage hydration with meal times and in - between meals. Resident #7 had unexpected weight loss related to poor food intake. Goal: Resident will consume 75 percent of two of three meals pre day. Resident will regain lost weight at (5) pounds per month. Interventions included: Med Pass 90cc TID, double portions, and fortified foods. Monitor and evaluate any weight loss. Determine percentage lost and follow facility protocol for weight loss. Weigh at same time of day and record: (weekly). The resident is weighed at (mornings) using (standing scale). Record review of Resident #7's Progress notes revealed: 6/17/2026 2:30 PM Orders - Administration NoteNote Text: Weekly weights one time a day every 7 day(s) for Weight indifference for 30. 6/4/2026 12:39 PM written by Registered Dietician: ADON notified physician regarding weight loss. Physician ordered appetite stimulant.6/4/2026 12:33 PM written by Registered Dietitian: Significant weight loss noted. -21.8#/3 months, BMI 22.7, Within limits. Resident has been eating well at meals, nursing reports res eating well at meals. Did not eat lunch today, refused assistance. Recommend house shakes with meals, continue weekly weights x 4 weeks. Refer to physician for assessment as well.5/20/2026 1:25 PM written by Registered Dietician: Significant weight loss noted. BMI 23.6, Within limits. Resident has overall good oral intake. Ate most of lunch except coleslaw. Nurse reports resident is eating most of meals. Receives appropriate therapeutic diet. Recommend weekly weights x 4 weeks to monitor trend. Goal is for weight to remain stable.5/11/2026 1:02 PM written by Registered Dietician: Recommend reweigh to clarify accuracy of weight loss.Record review of Resident #7's physician orders revealed: 1. Regular diet, Regular texture, thin consistency; FORTIFIED FOODS/DOUBLE PORTIONS for diet Active Date 10/20/2025 6:54 PM2. 2 Cal (Med Pass) three times a day for weight loss Supplement Active Date 6/5/2026 15:006/5/20263. Weekly weights one time a day every 7 day(s) for Weight indifference for 30 Days Active Date 6/10/2026 08:00 AM - 7/10/2026 4. House Shake with meals for weight loss SupplementActive Date 6/4/2026 5:00 PMRecord review of Resident #7's Medication Administration Record and Treatment Administration Record revealed she did not have orders for:2 Cal (Med Pass) three times a day for weight loss Supplement Active Date 6/5/2026 15:006/5/2026House Shake with meals for weight loss Supplement. Active6/4/2026 17:006/4/2026Record review of Resident #7's weekly weights:7/8/202609:30148.6 Lbs.Standing7/6/2026 16:25154.4 Lbs.Wheelchair6/24/2026 09:57147.0 Lbs.Standing6/10/2026 08:30147.0 Lbs.Standing6/2/2026 11:09149.6 Lbs.Wheelchair6/1/2026 09:26149.6 Lbs.Standing5/25/2026 08:40150.2 Lbs.Standing5/8/2026 12:11155.2 Lbs.Wheelchair4/10/2026 10:19162.4 Lbs.Standing4/9/2026 12:15161.2 Lbs.Standing3/11/2026 11:50171.4 Lbs.Wheelchair2/11/202614:17180.6 Lbs.Wheelchair1/8/2026 07:03174.6 Lbs.WheelchairObservation on 07/09/26 at 11:50 PM, revealed Resident #7 in dining room at the table for lunch. Resident #7's meal tray corroborated with her meal ticket of large portions. Resident #7 observed being able to feed herself without any complications or distress. Resident #7 at 90 percent of her meal tray and had a house shake. Interview on 07/09/26 at 12:10 PM with Resident #7, revealed she enjoys the food and has no issues with eating. Resident #7 stated when she was hungry or wanted a snack, she asked the staff and was able to have as much as she would like. Interview on 07/09/26 at 12:15 PM with RN Y revealed she was aware Resident #7 was pinned for weight loss however she did not understand why. RN Y stated Resident #7 enjoy eating and snacking all day long and at times would attempt to gain food from other resident's plate. RN Y stated Resident #7 received double portions on all meals throughout the day from the kitchen, Resident #7 also was up throughout the night, so staff provided her with snacks. RN Y further stated Resident #7 liked to wander throughout the memory care unit all day long. RN Y stated Resident #7 did receive house shakes with her meals, however Resident #7 did not have an order for 2 Cal (Med Pass). Observation on 07/09/26 at 12:21 PM with RN Y revealed Resident #7 walking to the scale with her walker; stepped on the scale to weigh 152.6. RN Y stated Resident #7 usually ambulated with a walker, perhaps when Resident #7 was weighed with wheelchair the chair weight was not properly subtracted to get an accurate weight. Interview on 07/09/2026 at 12:52 PM with RN Y revealed she reviewed Resident #7's orders and advised that she identified the order for the Med Pass, however Resident #7 was not one of three residents that she administered the Med Pass to. RN Y then reviewed Resident #7's Medication and Treatment Administration Record and stated, the orders for Med Pass or house shakes were not indicated on the record, this could be the reason she had not received the treatment. RN Y stated Resident #7 was not placed at risk because she ate well and the supplement would only be used to boost the food intake. RN Y stated the nurses or the dietician were responsible for entering orders, and the ADON and DON were responsible for ensuring orders were updated and entered correctly. Interview on 07/09/26 at 1:37 PM with the ADON revealed the Registered Dietician alerted the facility of Resident #7's weight loss. The ADON stated, Resident #7 had a healthy appetite, however, intervention measures were added to include large portions and 2 Cal (Med Pass). The ADON stated, once the orders were entered by the Registered Dietician, nurse, ADONs or the DON they should fall over the Mediation and Treatment Administration Record, triggering for the nurses to administer. The ADON stated Resident #7's order for Med Pass was to be administered 3 times a day leaving her with several missed doses from 06/05/26 - 07/09/26. The ADON further stated upon record review she noted Resident #7 was to be weighed weekly revealing there were missed opportunities on 06/17/26 and 07/01/26. The ADON stated after close monitoring, if the interventions aren't increasing Resident #7's weight within the time limit set by the Registered Dietician Resident #7's physician will be notified for labs. The ADON stated not following physician orders and interventions set by the dietician placed Resident #7 at risk of not getting as many calories as planned, furthering her weight loss.Interview on 07/09/26 at 1:50 PM with the Registered Dietician revealed she was aware of Resident #7's weight loss and she notified the facility nurse and DON. The Registered Dietician stated she expected the facility to follow her recommendations of administering Resident #7 2 Cal (Med Pass) and completing weekly weights. The Registered Dietician stated she will visit on 07/10/26 and upon her review she should see an increase in Resident #7's weight if all interventions were completed. The Registered Dietician stated she could see the orders have been entered therefore, not following physician orders and interventions placed Resident #7 at risk because she (Registered Dietician) would assume interventions were in place, and we would not know why Resident #7 was continuing to lose weight or may be over supplementing her based off expectations. Interview on 07/09/26 at 5:03 PM with the DON revealed she was aware Resident #7 had weight loss, and she entered orders from the Registered Dietician which should have been implemented through the Medication and Treatment Administration Record as of 06/05/26. The DON stated after record review, it was identified that orders were entered however they did not move over causing Resident #7 to have several missed doses of Med Pass from 06/05/26 - 07/09/26. The DON stated there was a designated person to complete weekly weights, however on the days he was out it appeared they did not have a backup designated person to fill in for the tasks causing Resident #7 to have missed weights on 06/17/26 and 07/01/26. The DON stated she was responsible for ensuring weekly weights were completed even if she had to do them herself and to review and audit resident orders. The DON stated not ensuring the orders converted to the Medication and Treatment Administration Record placed Resident #7 at risk of continued weight loss and overall decline to happen faster. The DON stated the physician was notified of interventions for the weekly weight and Med Pass were not being followed, and he advised to continue with double portions, Med Pass, and weekly weights and to follow the dietician's new orders or recommendations. Review of the facility's policy, revised October 2017, and titled Nutritional Assessment reflected the following: As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident.The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition.As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.1.An estimate of calorie, protein, nutrient, and fluid needs.2.Whether the resident's current intake is adequate to meet his or her nutritional needs; and3.Special food formulations.The multidisciplinary team shall identify, upon the resident's admission and upon his or her change of condition, the following situations that place the resident at increased risk for impaired nutrition.Whenever possible, oral diet with supplementation will be used to administer nutrition therapy.

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #21) of one resident reviewed for pain management. The facility failed to ensure Resident #21 received pain assessments on every shift. This failure could place residents at risk of experiencing significant pain and, discomfort.Findings included:Record review of Resident #21's MDS assessment dated [DATE] reflected she was a [AGE] year-old female with an initial admission date of 09/18/2024 and current admission date of 01/10/2026. Diagnoses included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple daily tasks), Dementia, Muscle wasting and atrophy (thinning or loss of muscle tissue). Resident #21 had no BIMS score since resident was rarely/never understood. Section J0100 B of MDS assessment was coded as 0 indicting Resident #21 did not receive PRN pain medication or was offered and declined, in the last 5 days. Resident #21 was dependent on staff for toileting, personal hygiene and tub/shower transfers. Record review of Resident #21's care plan dated 01/25/2026 reflected Resident #21 received services from Hospice for end stage Alzheimer's Disease. Goal:. The resident's comfort will be maintained through next review date 03/09/2026. Interventions/tasks: . Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Work with nursing staff to provide maximum comfort for the resident. Record review of Resident #21's Physician order summary report dated 07/09/2026 reflected resident had standing orders for pain assessment every shift with an order date of 09/18/2024, Tylenol Oral Tablet 325 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for pain/headache with an order and start date of 09/23/2024, Morphine Sulfate (Concentrate) Oral Solution 100 MG/5 ML (Morphine Sulfate) Give 0.25 ml by mouth every 3 hours as needed for pain, with an order and start date of 01/23/2026. Record review of Resident #21's Medication Administration Review for the month of May 2026 reflected on 05/14/2026 and 05/27/2026 she had a pain level of 03 and she received her Tylenol. Record review of Resident #21's Medication Administration Review for the month of June 2026 reflected on 06/06/2026 resident had a pain level of 02, on 06/13/2026 she had a pain level of 03 and she received Tylenol on both days. Record review of Resident #21's Medication Administration Review for the month of July 2026 reflected on 07/09/2026 resident had a pain level of 03 and she received her Tylenol. Record review of Resident #21's Medication Administration Review for the months of May, June and July 2026 reflected she did not receive Morphine Sulphate oral solution for pain. Record review of Resident #21's pain level summary for the last 90 days reflected that she received a total of 13 pain assessments during this time. Date and time, Value.04/25/2026 02.09 PM, 204/25/2026 06:03 PM, 005/14/2026 07:47 AM, 305/14/2026 09:57 AM, 005/27/2026 12:41 PM, 006/06/2026 06:58 PM, 206/06/2026 08:32 PM, 006/13/2026 08:07 AM, 006/13/2026 10:10 AM, 306/13/2026 10:59 AM, 007/09/2026 08:33 AM, 307/09/2026 01:37 PM, 0. During an observation and interview on 07/07/2026 at 01:48 with Resident #21 revealed she was lying in her bed. Resident #21 did not respond to any questions. Resident #21's family member stated the facility staff did not complete a pain assessment for Resident #21 every day. Unless asked, she may not tell the staff that she was in pain. Interview on 07/09/2026 at 10:52 AM with LVN H, she stated Resident #21 could not verbalize she was in pain, she would say I'm hurting or I need help. LVN H stated she was trained to assess pain using PAINAD- a scale used to assess pain among residents who were cognitively impaired. She stated she did not assess Resident #21 for pain during every shift or every day since there was no need for it. She stated she had given Tylenol to Resident#21 a few times when she had expressed pain and her family was very involved. A follow up interview on 07/09/2026 at 01:15 PM with LVN H, she stated she did not assess Resident #21 for pain during every shift or every day since there was no order for it. She stated Resident #21 received PRN pain medicine Tylenol whenever she expressed she was hurting, she also had a PRN order for Morphine Sulfate which LVN H had not administered yet to Resident #21 since she was not in severe pain. When asked about the standing physician order for pain assessment during every shift from 09/18/2024, she stated that she was responsible to complete pain assessment every shift and somehow, she missed that order. LVN H stated it was important to assess residents for pain to understand what they were going through and it was her responsibility to assess Resident #21 for pain. She stated not completing pain assessments put residents at risk for continued pain, restlessness, disturbed mood and sleep. LVN H stated she could not remember when she last received in-service training on pain management. An interview on 07/09/2026 at 01:49 PM with ADON, stated she was responsible for ensuring the staff were rendering care to residents as per the regulations and facility policies. She stated Resident #21 did not require pain assessment every shift since she did not have a physician order for it. When asked about the standing physician order for pain assessment during every shift from 09/18/2024, she stated that was not current and that ended on 07/09/2026. DON stated as per that order the nurses were responsible for completing pain assessments during every shift until 07/09/2026. She stated the Licensed Nurse was responsible to assess resident for pain and not completing pain assessment put Resident #21 at risk for continued pain, disturbed mood and sleep. ADON stated she could not remember when the employees last received in-service training on pain management. An interview on 07/09/2026 at 03:59 PM with RN X, revealed he was responsible to assess Resident #21 for pain, and he did not know that Resident #21 had a physician order to complete pain assessment during every shift. He stated it was important to complete a pain assessment to understand what the resident was going through, and not completing pain assessments put Resident #21 at risk for continued pain, behavior and sleep disturbances. RN X stated he could not remember when he last received in-service training on pain management. An interview on 07/09/2026 at 04:56 PM with the DON revealed the nurses were responsible for completing pain assessments for residents, it was important to assess residents for pain to understand to keep them comfortable. DON stated Resident #21 required to have her pain assessed during every shift, using PAINAD scale since she could not verbalize pain, staff were to observe and monitor resident's behavior and recognize signs of pain and document it. DON stated not completing pain assessments put residents at risk for unmanaged pain, behavior issues, and sleep deprivation. She stated she could not remember when the last time employees were offered in-service training on pain management. Record review of undated facility policy titled Pain Assessment and Management: Level III 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. General GuidelinesThe pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. Pain management is a multidisciplinary care process that includes the following:Assessing the potential for pain;Recognizing the presence of pain;Identifying the characteristics of pain;Addressing the underlying causes of the pain;. Comprehensive pain assessments are conducted upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. For stable chronic pain the resident's pain and consequences of pain are assessed at least weekly. Assessing PainAssess the resident at admission and during ongoing assessments to help identify the resident who is experiencing pain or for whom pain may be anticipated during specific procedures, care, or treatment.Monitor the resident for the presence of pain and the need for further assessment when there is a change of condition.Assess the resident whenever there is a suspicion of new pain or worsening of existing pain.Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #65) reviewed for dialysis.The facility failed to ensure Resident #65 had physician orders for his dialysis treatments. This failure could place residents at risk of missed dialysis appointments and decline in quality of life.Findings included:Record review of Resident #65's Quarterly MDS assessment, dated 05/28/26, revealed Resident #65 was a [AGE] year-old male originally admitted to the facility on [DATE], readmitted on [DATE] and again on 05/07/26. Resident #65 had cognition intact with a BIMS score of 14 (indicating cognitive impairment intact). Resident #65 required partial/moderate assistance from staff with shower/baths and substantial/maximal assistance with personal hygiene. Active diagnoses included high blood pressure, high blood sugar, end - stage renal disease (when kidneys can no longer function adequately to sustain life without treatment). Resident #65 required dialysis while a resident. Record review of Resident #65's care plan, revised 07/03/26, reflected Resident #65 required hemodialysis for renal failure. Goal: Resident #65 will have immediate intervention should any signs or symptoms of complications from dialysis. Resident will have no signs or symptoms of complications from dialysis. Interventions included Check and change dressing daily at access site. Document. Do not draw blood or take blood pressure in left arm. Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis three times per week. Monitor for dry skin and apply lotion as needed. Monitor labs and report to doctor as needed. Monitor vital signs as ordered and indicated. Notify physician of significant abnormalities. Dialysis shunt site monitoring and vital signs before and after dialysis as ordered. Monitor/document report to physician signs and symptoms of depression. Obtain order for mental health consult if needed. Monitor/document report as needed any signs of infection to access site: Redness, swelling, warmth, or drainage. Monitor/document report as needed for signs and symptoms of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor document report as needed signs and symptoms of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Monitor document report as needed new/worsening peripheral edema. Work with resident to relieve discomfort for side effects of the disease and treatment. Record review of Resident #65's physician's order revealed Resident #65 did not have a physician order for dialysis treatment. Record review of Resident #65's dialysis communication forms reflected dialysis treatments were provided on Monday, Wednesday, and Fridays with a chair time of 5:30 AM dated back to at least 05/01/26.Interview and observation on 07/07/26 at 10:28 AM revealed Resident #65 was lying in bed on the left side. Resident #65 stated he attends dialysis three times a week. Resident #65 stated he had been doing better with attending his dialysis chair times on Monday, Wednesday and Fridays at 5:30 AM. Resident #65 stated he had no concerns or issues with his port site. Observation of the area revealed it was covered by white bandage, with no swelling or redness. Resident #65 explained that upon return from dialysis the port was always covered, and the facility assessed the cite when he returned. Resident #65 stated that on his shower days, Tuesday, Thursday and Saturdays the facility assessed the area and removed the bandage, which there had not been any concerns for infection. Interview on 07/08/26 at 10:57 AM with LVN AB revealed she was aware Resident #65 attended Dialysis on Monday, Wednesday, and Fridays with an early morning chair time. LVN AB stated when she arrived to her shift Resident #65 was usually gone. LVN AB stated upon Resident #65's return to the facility after dialysis she was responsible for accessing his left arm which housed his dialysis port (specialized access site used for dialysis treatment) and reviewed his dialysis communication form. After record review, LVN AB stated she could not find a current physician order revealing his dialysis treatment. LVN AB stated the order may have been deleted during his hospital stay some time ago. LVN AB stated the admitting nurse was responsible for ensuring orders were entered, and the ADON was responsible for review resident orders. LVN AB stated when physician's dialysis orders were missed or not entered it placed residents at risk of missed treatments. Interview 07/09/26 at 1:32 PM with ADON AE revealed he was aware Resident #65 attended dialysis 3 times a week, Monday, Wednesday, and Friday at 5:30 AM. ADON AE stated he was notified by staff Resident #65 did not have a physician's order for his dialysis treatment. ADON AE stated after his review he could not locate the order. ADON AE stated admitting nurses were responsible for entering physician orders, and ADON's were responsible for reviewing the orders to ensure all orders were entered and entered correctly. ADON AE stated not ensuring Resident #65 had an order for his dialysis treatment placed him at risk for missed appointments. Interview on 07/09/26 at 3:34 PM [SP44.1]with the DON revealed it was the admitting nurses' responsibility to enter all new and updated physician orders. She stated ADON's were responsible for ensuring nurses had entered resident orders upon admission, and she completed audits on resident charts, checking physician orders. The DON stated while she recently did an audit, this was a chart that was missed. According to the DON, when resident orders are not entered, or entered correctly it placed residents at risk of missed treatments. Record review of the facility's policy, Hemodialysis revised 01/01/25 reflected the following, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis.10.The facility will ensure that the physician's orders for dialysis include:a.The type of access for dialysis (e.g. graft, arteriovenous shunt, external dialysis catheter) and location.b.The dialysis schedule.c.The nephrologist name and phone number.d.The dialysis facility name and phone number.e.Transportation arrangements to and from the dialysis facility.f.Any medication administration or withholding of specific medications prior to dialysis treatments.g.Any fluid restriction if ordered by the physician.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 5 residents (Residents #22 and #53) observed for infection control. 1. CAN B failed to wear appropriate PPE and perform hand hygiene while providing incontinence care to Resident #53 who was on EBP for open wound on 07/08/26. 2. The facility failed to ensure LVN D (Wound Care Nurse) wear appropriate PPE and performed hand hygiene during the wound care for Resident#22 who was on EBP for open wound on 07/08/26. This failure could affect the residents, by placing them at risk for worsening conditions and cross-contamination. Findings included:1-Record review of Resident #53's quarterly MDS assessment, dated 06/19/26, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #53 had a diagnosis of hypertension (elevated blood pressure), Alzheimer's Disease (a progressive, irreversible brain disorder that accounts for 60% to 80% of dementia cases), and Respiratory Failure (a serious condition that makes it difficult to breathe on your own). She had a BIMS score of 10/15, which indicated moderate cognition impairment. Further review revealed Resident#53 was Partial/moderate assistance with Toileting hygiene. Record review of Resident #53 's care plan revised on 02/26/26 reflected Focus: [Resident#53] has an ADL self-care performance deficit r/t Alzheimer's. Goal: [Resident#53] will maintain current level of function through the review date. Intervention: Encourage the resident to participate to the fullest extent possible with each interaction.Focus: has been placed on Enhanced Barrier Precautions R/T Wound(s). Goal: Resident will not have a decline in psychosocial wellbeing related to being place on enhanced barrier precaution, resident will not have out-of-room activities restricted. Intervention Gowns and gloves will be made available immediately near or outside of the Resident's room. Would care: any skin opening requiring a dressing. Observation on 07/08/26 at 1:30 PM revealed Resident #53 was on Enhanced barriers precautions. There was signage on the left side of the door that informed visitors/staff she was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. CNA B entered Resident #53's room without any form of PPE, there was PPE cart in front of the Resident#53's room on the right side of the room door. CNA B washed hands, donned gloves and procced to do incontinent care for Residnt#53 without wearing gowns. CNA B unfastened Resident#53 brief. She cleaned Resident#53 front area using one wipe at a time and disposed of it in the trash can. CNA B removed gloves and put on clean gloves without performing any kind of hands hygiene (sanitized with hands sanitized or washing hands). CNA B helped Resident#53 turned to her right side, cleaned Resident#53 buttocks area using one wipe at a time. CNA B changed gloves without any form of hands hygiene, get the clean brief put on the resident. CNA B covered Resident#53. CNA B removed gloves, gathered the trash, washed hands and exited the room. Interview with CNA B on 07/08/26 at 1:51 PM revealed she knew that she was supposed to wear gown for the resident peri care, but she forgot. She stated she forgot to perform hand hygiene during perineal care. CNA B stated she was expected to clean hands before in between the care if her hands were soiled and after care, but she forgot she was only changing the gloves. She stated she was in-serviced regarding different types of infection control during orientation. She stated the risk of not wearing proper PPE in enhanced barriers precautions residents' rooms, and not following proper hands hygiene was exposing herself and others to the development of infection and spreading germs from one resident to another resident. Record review of Resident #22's quarterly MDS assessment, dated 06/01/26, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #22 had a diagnosis of hypertension (elevated blood pressure), Non-Alzheimer's Dementia (brain disorders that cause cognitive and behavioral decline but are driven by different physical changes in the brain), Cerebrovascular Accident (a medical emergency that occurs when blood flow to a part of the brain is interrupted or reduced), and muscle weakness. She had a BIMS score of 06/15, which indicated her cognition was severely impaired. Record review of Resident#22 's care plan revised on 05/14/26 reflected Focus: - Resident has been placed on Enhanced Barrier Precautions R/T Wound(s). Goal: Resident will not have a decline in psychosocial wellbeing related to being place on enhanced barrier precaution, resident will not have out-of-room activities restricted. Intervention: Gowns and gloves will be made available immediately near or outside of the resident's room. Wound care: any skin opening requiring a dressing. Observation on 07/08/26 at 1:20 AM revealed the LVN D got all supplies ready outside Resident #22's room. There was signage on the right side of the door that informed visitors/staff she was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. He washed hands put on gloves, and no gown. He entered Resident#22's room and explained the procedure. Removed the old dressing on the Resident middle upper back. He changed the gloves without performing any form of hand hygiene (hands sanitizing or washing). He cleansed Resident#22's, wound with wound cleanser. He changed gloves without any form of hands hygiene he pat dried the wound. He removed gloves and put on clean gloves without performing any form of hands hygiene. He applied the skin prep on the edges let it dry and then applied the calcium alginate and dry dressing dated 07/08/26. He then removed the gloves, put on clean gloves, disinfected the table, removed gloves, washed hands, and exited the room. Interview with LVN D on 07/08/26 at 1:33 PM revealed he was supposed to wash hands each time he changed gloves. He stated he was supposed to wear gown while performing wound care for the Resident. He stated failure to follow proper infection control like performing hands hygiene between change of gloves, and putting on proper PPE would cause cross contamination and spread of infection. He stated he had done training on infection control, handwashing, and wound care. Interview on 07/09/26 at 10:40 AM with the DON revealed her expectation was the staff were supposed perform hands hygiene each time they remove gloves, and before putting clean gloves. She stated she expected staff to wear appropriate PPE (gown, gloves) for any high contact care for the residents including incontinent care, wound care . The DON stated the risk to residents if the staff were not following proper infection control, spread of germ, and development of infection. Record review of the facility's policy titled Enhanced [NAME] precaution dated 01/01/25, reflected: Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). Record review of the facility's policy titled Handwashing/Hand Hygiene dated October, 2023 reflected: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.1.All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2.All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Hand hygiene is indicated:.immediately after glove removal.

Based on observation and interview, the facility failed to right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 6 residents (Resident#1, and Resident#2) reviewed for accommodation of needs.The facility failed to ensure the call light system was within reach of the Resident #1 and Resident #2 on 06/30/2026. This failure could place residents in the facility at risk of being unable to obtain timely assistance form staff. Findings included:1. A record review of Resident #1's quarterly MDS assessment dated [DATE] reflected Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of: hypertension (elevated blood pressure), neurogenic bladder (a loss of bladder control caused by nerve damage), Non-Alzheimer's Dementia (a broad group of brain disorders causing cognitive decline), and muscle weakness (Generalized). Resident#1 had a BIMS score of 15 of 15 indicating intact cognition. A record review of Resident #1's Comprehensive Care Plan dated 01/13/26 reflected Focus: [Resident#1] has Impaired Physical Mobility related to general weakness. Goal: Resident will be able to perform activity within Physical Limits. Interventions: . Ensure call light is available to Resident. Observation on 06/30/26 at 09:30 AM revealed Resident#1 was sitting by the foot edge of the bed and asking for help to use the bathroom. Resident#1 could not reach the call light button laying in the floor at bed side. Resident#1 could not reach the call light. The call light on Resident#1's roommate side was pressed, and LVN A entered the room to answer the call light. LVN A located the call light on the floor. LVN A took the call light from the floor and placed it next to Resident#1in the bed, then called an aide to take Resident#1 to the bathroom. Interview on 06/30/26 at 09:33 AM, LVN A stated the call light was not within Resident#1's reach. LVN A stated call light should always be within residents reach. LVN A stated the risk to residents not getting help on time, were falls, and possible injury. LVN A stated it was the responsibility of all the staff to make sure the call light was within resident's reach before exiting the room. 2. A record review of Resident #2's quarterly MDS assessment dated [DATE] reflected Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis of: Non-Alzheimer's Dementia (a broad group of brain disorders causing cognitive decline), and muscle weakness (Generalized). Resident#1 had a BIMS score of 06 of 15 indicating severe cognitive impairment. A record review of Resident #2's Comprehensive Care Plan dated 04/03/26 reflected Focus: [Resident#2] has IMPAIRED COGNITION, MEMORY LOSS ANDIMPAIRED DECISION MAKING related to Dementia. Goal: [Resident#2] will be able to communicate basic needs on a daily basis through the review date. Interventions. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation Encourage to discuss feelings about self-care deficit. Observation on 06/30/26 at 10:44 AM revealed Resident#2 was lying in bed, awake, and watching TV. Resident#2's special call light device was on the floor, under the head of the bed. Resident#2's roommate turned her call light on, and the DON entered the room to answer the call light. Resident#2's call light on the floor, and the DON took the call light from the floor and clipped it to Resident#2's linen next to her. Interview on 06/30/26 at 10:48 AM, the DON stated all call lights needed to always be within reach of the resident. The DON stated the risk to the residents, if they could not reach the call light, was they could not call for help, and they will not get the help they need. In an interview on 06/30/26 at 1:25 PM, the Administrator stated it was the responsibility of every staff to make sure the call light device was within resident reach before leaving the room. The administrator stated the risk to residents, if the call light was not within resident reach, or did not work properly was the residents could not call for help. Review of the facility's policy titled Answering the Call Light, revised 09/2022 revealed PurposeThe purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines1. Upon admission and periodically as needed, .5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse of residents are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to HHSC for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to report, within 2 hours, to the SA after Resident #1 alleged sexual abuse to her Mental Health Habilitator on [DATE], who then notified the facility the same day on [DATE]. The facility did not report Resident #1's allegation to law enforcement, nor the SA. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. Findings included:Record review of Resident #1's admission record, dated [DATE], reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and had diagnoses including Bipolar Disorder (brain disorder causing extreme mood swings), Cognitive Communication Deficit (impaired thinking skills), Impulse Disorder (difficult to control your actions or reactions), Dementia (group of symptoms affecting memory, thinking and social abilities), Down Syndrome (genetic condition causing developmental delays and learning challenges), Glaucoma (irreversible vision loss), Major Depressive Disorder (mood disorder), Unspecified Speech Disturbances (slurred, broken, or disorganized speech). Record review of Resident #1's quarterly MDS assessment, dated [DATE], reflected she had a BIMS score of 5, which indicated she had severe cognitive impairment. Resident #1's functional abilities section indicated she was dependent on staff for her personal hygiene and required partial/moderate assistance with dressing and eating. Resident #1 always had urinary and bowel incontinence. Record review of Resident #1's care plan, revised [DATE], reflected Resident #1 verbalized an event related to sexual abuse the resident experienced in her younger years - resident on occasion relives trauma. Some of the interventions included: -Provide the resident with consistency, predictability and choice making opportunities, remind resident she is safe. -Resident is triggered by safe surveys and trauma assessments, do not interview resident about trauma, she will relive it in that moment. Record review of Resident #1's care plan, revised [DATE], reflected Resident #1 had a behavior problem r/t Down Syndrome and would report allegations of abuse from other residents and staff on occasion, have been determined to be false on investigation. Some of the interventions included: -Minimize potential for the resident's disruptive behaviors by offering tasks which divert attention.-Explain all procedures to the resident before starting and allow the resident to adjust to changes.-If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Record review of TULIP intake for Resident #1 indicated information date received on [DATE] at 11:23 AM, read that the allegation of abuse was made on [DATE] at 09:00 AM (2 hours prior). Caller information indicated that the reporter of the allegation was the HAB. The intake stated, The HAB came to work with [Resident #1]. Before any services could be provided, [Resident #1] was crying and told HAB that They raped me. The HAB inquired immediately about names, timeframes, and other details. The HAB asked [Resident #1] multiple times for additional information; however, [Resident #1] was only able to provide the limited information below. On [DATE] at 9:00 AM, Resident #1 reported a white man, after dinner, hit my head. In addition, Resident #1 showed gestures of penetration by moving her arms and pelvis to reenact the rape. Additional details were unknown to Resident #1 when probed further by the HAB. The HAB reports that Resident #1 was unable to provide other demographics about the white male, unable to articulate an exact date or timeframe of the rape, and not able to provide details about a head injury. On [DATE], after 9:00 AM, after the above interaction, the HAB informed facility [ADON] about what just occurred. The [ADON] was not concerned and told the HAB that it was a recurring behavior history that [Resident #1] exhibits. On [DATE], after 9:00 AM, the [ADON] left and came back informing the HAB that he looked in [Resident #1's] facility file to see if there was any documentation indicating that [Resident #1] had been raped recently. The [ADON] reported to the HAB that [Resident #1] has a tendency to have flashbacks of when she was previously raped and is possibly reliving it. The HAB remains concerned that a rape potentially occurred recently due to allegations of rape not being a pattern of behavior that [Resident #1] has exhibited in front of the HAB in the past. Since 2024, the HAB has never observed any type of flashback behaviors or allegations of rape from [Resident #1] while working with her as indicated by the [ADON]. The HAB wishes for [State Surveyor] to confirm if a rape occurred or if it was a previous memory as indicated by the [ADON]. Observation on [DATE] at 9:30 AM revealed Resident #1 sitting in the lobby in her wheelchair. Resident #1 appeared happy as she smiled and waved at State Surveyor. Resident #1 stated, You my friend, give me a hug. Resident #1 was clean and appropriately dressed for the weather. Resident #1 did not have any visible marks or bruises. During an interview on [DATE] at 9:00 AM, the HAB stated she was assigned to Resident #1 in 2024 through [her mental health facility] and she met with Resident #1 once a week on Tuesdays. The HAB stated Resident #1 had never mentioned being raped or displayed any behaviors to her before. The HAB stated she escorted Resident #1 to the front of the facility. The HAB stated she informed the ADON that Resident #1 wanted to speak with someone. The HAB stated Resident #1 told the ADON that someone raped her. The HAB stated Resident #1 would only say after dinner, but she could not provide a date or time. The HAB stated she asked Resident #1 if it was yesterday or last week and Resident #1 just kept repeating after dinner. During an interview on [DATE] at 10:40 AM, Resident #1 stated she was fine, and staff treated her good. Resident #1 showed me her nails and stated they were pretty. Resident #1 stated no one had hurt her. Resident #1 stated she was not afraid of anyone and that she felt safe at the facility. Resident #1 provided short answers without great detail. During an interview on [DATE] at 11:10 AM, the Psych NP stated he had treated Resident #1 since [DATE]. The NP stated Resident #1 never mentioned being raped to him. The NP stated he saw Resident #1 last week, and the facility asked him to see her again ([DATE]) due to the allegations Resident #1 made to her HAB. The NP stated he spoke with Resident #1 in her room, and he asked her about being raped and she responded, Not me. The NP stated he asked Resident #1 if she was sure and she responded, a black man and started laughing. The NP stated Resident #1 did not appear distressed, upset or angry. The NP stated Resident #1 was pleasant, smiling and laughing. The NP stated Resident #1 had a history of making up stories. The NP stated Resident #1 pointed at the ADON's door and said the ADON was her husband. The NP stated he corrected Resident #1 and told her that the ADON was not her husband. The NP stated then Resident #1 changed her story and said he was her husband. The NP stated he believed Resident #1 made up [NAME] stories. The NP stated Resident #1 appeared at her baseline and she could not elaborate on any details. The NP stated he then asked Resident #1 about the allegations again and she repeated, Not me. The NP stated he did not know where the story stemmed. The NP stated Resident #1 appeared very comfortable and not agitated. The NP stated, in his opinion, he felt the accusation was not deemed probable and he did not make any medication adjustments. The NP stated it was difficult to extract information from Resident #1 and when he tried to get her to elaborate, she repeated Not me. The NP stated with Resident #1's baseline, you never knew what you would get from her. The NP stated Resident #1 had very childlike behavior. The NP stated honestly, he had no concerns, and he came to visit Resident #1 due to the facility requesting him to speak with her regarding the statement she made. During an interview on [DATE] at 11:35 AM, FAM A stated she was unaware of Resident #1 experiencing any type of sexual abuse when they were children. FAM A stated when Resident #1 lived in the group home, she was not made aware of incidents of sexual abuse. FAM A stated she could not confirm any of the information as their [family members] were both deceased . During an interview on [DATE] at 1:50 PM, CNA A stated Resident #1 liked to go into other residents' rooms, and staff would have to remove her. CNA A stated Resident #1 liked to touch and hug people. CNA A stated that sometimes at night, Resident #1 would wake up, stand up, and scream. CNA A stated it was documented in Resident #1's Care Plan that she screamed. CNA A stated Resident #1 had never made any allegations to her about being inappropriately touched or sexually assaulted. CNA A stated if Resident #1 had told her the allegations, she would have reported it to the Charge Nurse and the ADM. CNA A stated they took mistreatment of residents very seriously. CNA A stated since she had worked at the facility for the last five months, there had not been any incidents of inappropriate behavior by any residents. CNA A stated she did not know why Resident #1 would say she was raped, but based on her screaming at night, maybe she had had some past trauma. CNA A stated she had received training on all types of abuse and neglect, including Dementia. CNA A stated she did not have any concerns for Resident #1 as far as anyone abusing her. CNA A stated Resident #1's roommate was very vocal, and if she heard or saw something, she would call out for help. During an interview on [DATE] at 2:40 PM, the ADON stated Resident #1's HAB told him that Resident #1 said she had been raped after dinner. The ADON stated he went and told the ADM immediately. The ADON stated him and the ADM spoke with Resident #1 in the office and asked her who did it and Resident #1 said that white lady [name]. The ADON stated they did not have anyone that worked at the facility by the name Resident #1gave. The ADON stated they then asked Resident #1 when it happened, and she said, A long time ago. The ADON stated he informed the HAB that Resident #1 was care planned related to relived trauma in 2023. The ADON stated since the information of the past trauma was shared with the facility in 2023, Resident #1 was Care Planned, but she had not had any episodes. The ADON stated there could be people sitting around and if Resident #1 became angry, she would stand up and say, That girl yelled at me. The ADON stated, but in actuality, no one had yelled at her. The ADON stated he knew Resident #1 well and he did not believe it was something that happened there at the facility. The ADON stated it was included in her Care Plan, and it was up to the ADM to report it. The ADON stated by the time he went and looked at the Care Plan and returned to the lobby, Resident #1 and her HAB had already moved to the day room and were listening to music. The ADON stated that when he joined them, Resident #1 smiled and told him to come sit down and listen to the music. The ADON stated he believed Resident #1 was in a safe environment and was looked after well by staff. The ADON stated normally a Nurse would assess the Resident, they would contact law enforcement, send the Resident to the hospital to be examined, and file a report with the SA. The ADON said his expectations were for staff to report any suspicions or allegations of abuse or neglect immediately to the ADM. During an interview on [DATE] at 3:05 PM, the DON stated she was made aware yesterday afternoon ([DATE]) by the ADON that Resident #1 made an outcry to her HAB that she had been raped on an unknown date and time. The DON stated that the ADON said he informed the ADM. The DON stated because they truly knew Resident #1, they did not believe they swept the allegation under the rug. The DON stated her gut, and her heart told her it did not happen there in that facility. The DON stated things could have been did differently. The DON stated that moving forward even if a Resident was Care Planned for any type of trauma from prior abuse the facility should report it to the State within timeframe. The DON stated the worse thing was that it could be absolutely true. The DON said that due to Resident #1 being care planned for prior trauma since 2023, they did not feel the allegation of sexual assault/abuse was true. However, she realized, at that time, that the allegation should have been reported to HHSC within 2 hours of the alleged incident. The DON said her expectations were for the facility staff to report all suspicions or allegations of abuse immediately to the ADM, as the abuse coordinator. The DON said the incident should have been reported to the SA within 2 hours of the allegation. During an interview on [DATE] at 3:45 PM, LVN B stated Resident #1 had never mentioned anything to her about being assaulted. LVN B stated Resident #1 sat and talked with her at the nursing station every day. LVN B stated Resident #1 moved around freely using her wheelchair. LVN B stated Resident #1 was a very peaceful person, and did not like people to speak loudly. LVN B stated she did not have any concerns for Resident #1. LVN B stated she was trained on abuse and neglect and was aware of reporting any allegations of abuse to the ADM immediately. LVN B stated the facility should have reported the allegation to law enforcement and to the State. During an interview on [DATE] at 4:20 PM, the ADM stated on Tuesday ([DATE]), the ADON came to her office and told her that Resident #1's HAB informed him that Resident #1 said she had been raped. The ADM stated her and the ADON went and spoke with Resident #1, and Resident #1 said, I've been raped. The ADM stated she asked Resident #1 what was going on and by whom, and Resident #1 said [name]. The ADM stated she asked Resident #1 if that person worked at the facility, and Resident #1 said, No. The ADM stated she asked Resident #1 when it happened and Resident #1 responded, I don't know. The ADM stated she looked at the ADON and as far as she knew, they did not have anyone that worked at the facility by that name. The ADM stated the ADON questioned Resident #1, and she repeated the same responses. The ADM stated she spoke with the HAB and shared with her that Resident #1 had been Care Planned for an event related to sexual abuse that she experienced in her younger years, and that on occasion, she relived the trauma. The ADM stated Resident #1 then started joking and told the ADON, I feel safe with you, can I go home with you? The ADM stated the ADON told Resident #1 that she was safe at the facility and Resident #1 started laughing. The ADM said her and the ADON returned to their morning meeting, and she told the ADON to follow up with the HAB to let her know that Resident #1 was being followed by Psyche, and they would have Psyche come to the facility to assess Resident #1. The ADM said when the ADON went to tell them, he found them in the Day Room listening to music. The ADM said Resident #1 had already forgotten about the allegation and the HAB said she had already reported the concerns to her supervisor, and they were going to make a report to APS. The ADM said she told the HAB it was fine, and she understood they had protocols. The ADM stated, therefore, she did not believe that it needed to be reported. The ADM stated she was the Abuse and Neglect Coordinator and after working at the facility for 6 months, she knew Resident #1 well and everyone protected her. The ADM stated she did not report the allegations to law enforcement or the State because it was a past trauma reported by family and Resident #1 and the facility had Care Planned it in 2023. The ADM stated her expectations were for staff to report all allegations of abuse and neglect to her. Record review of the facility's Abuse, Neglect, Exploitation policy, revised [DATE], reflected the following, Policy Explanation and Compliance Guidelines: .2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or . B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observation, interviews, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for 5 of 5 residents (Residents #10, #22, #3, #4, #5 and #10) reviewed for care plans, in that: Resident #10, #22, Resident #3, Resident #4 and Resident #5's care plan did not address the respiratory treatments. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. Findings included:Resident #10Record Review of Resident #10's face sheet dated 11/23/2025, reflected the resident was a 78 years-old female that was admitted on [DATE]. The resident was diagnosed with: Alzheimer's Disease (progressive disease that impairs memory) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen). Record Review of Resident #10's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 15, indicating she was cognitively intact. Resident #10 was dependent on staff for all personal hygiene task, toileting, showers, and dressing, She required set up for Meals. Sections O special treatments and procedures addressed the resident's oxygen therapy. Record review of Resident #10's Care Plan (CP) dated 05/13/2025 reflected that she has an ADL self-care deficit related to Alzheimer's and required substantial maximum assistance from staff. Resident #10's respiratory treatment was not addressed in her care plan. Record Review of Resident #10's MD active orders dated 02/11/2022 reflected O2: Check O2 sat every shift. Vital sign q shifts every shift Alert provider for temperature >101 or pulse greater than 110. During an observation and interview on 11/23/2025 at 10:00 AM Resident #10 was observed lying in her bed on her back. She stated that the staff administer her nebulizer treatment when needed. She stated the Nebulizer mask had not been cleaned by the staff or bagged.Resident #22Record Review of Resident #22 face sheet dated 11/23/2025, reflected the resident was an 80- years-old male that was admitted on [DATE]. The resident was diagnosed with: Vascular Dementia (impaired blood supply to the brain), Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen) and atherosclerotic heart disease of native coronary artery. (artery build-up of fat and plaque).Record Review of Resident #22's Annual MDS dated [DATE] reflected the resident had a BIMS score of 00, indicating he was severely impaired cognitively. Resident #22 was dependent on staff maximal assistance with personal hygiene task, toileting, showers, and dressing. Resident #22 required staff set up for Meals. Record Review of Resident #22 care plan dated 11/07/2025 reflected impaired cognition, decision making, and memory loss. Resident #22's care plan did not address the use of respiratory treatment. During an observation and interview with Resident #22 on 11/23/2025 at 11:30 AM his nebulizer tubing was located on his nightstand and NC was not found. Resident #22 stated that the staff had removed his NC this morning. Resident #3 Record Review of Resident #3 face sheet dated 11/23/2025, reflected the resident was a 67- years-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic Encephalopathy (problem in the brain) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen). Record Review of Resident #3's Annual MDS dated [DATE] reflected the resident had a BIMS score of 04, indicating he was severely impaired cognitively. Resident #1 was dependent on staff and required maximum assistance with all personal hygiene task, toileting, showers, and dressing, he required partial assistance with meals. Record Review of Resident #3's care plan dated 08/22/2025 reflected he had a terminal illness and received hospice palliative care r/t Senile Degenerative of the brain (progressive decline in the brain cognition). Resident #3's respiratory treatments were not addressed in the care plan.Record Review of Resident #3's MD orders reflected active orders dated 09/11/2025.02: Change H20 bottles on concentrators once a week. every night shifts every Sunday. 02: Change 02 tubing and date once a week every night shifts every Sundays. 02: Check 02 sat every night shift every Sunday.02: Clean 02 concentrator filters once a week.every night shifts every Sunday. 02: Oxygen (2-51pm) via (NC) as needed 02 sats above 92%.During an observation and interview with Resident #3 on 11/23/2025 at 11:45 AM oxygen tubing and nebulizer equipment was observed. Resident stated that the staff administer the treatments daily. Resident #4Record Review of Resident #4 face sheet dated 11/23/2025, reflected the resident was an 81- years-old male that was admitted on [DATE]. The resident was diagnosed with: Senile Degenerative of the brain (progressive decline in the brain cognition) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen).Record Review of Resident #4's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 00, indicating he was severely impaired cognitively. Resident #4 was dependent on staff for all personal hygiene task, toileting, showers, dressing, and meal support for eating. Record Review of Resident #4's care plan dated 08/08/2025 reflected he had a terminal illness and received hospice palliative care r/t Senile Degenerative of the brain (progressive decline in the brain cognition). Resident #4's respiratory treatments were not addressed in the care plan. Record review of Resident #4's TAR reflected Ipratropium-Albuterol Inhalation Solution .5-2.5 (3) MG/3ML (ipratropium albuterol) 3 ml inhale orally three times a day for 7 days.During an observation on 11/23/2025 at 12:00 PM, Resident #4's was observed in the dining room. Resident #4 was not interviewable due to confusion and communication deficit. Resident #5Record Review of Resident #5 face sheet dated 11/23/2025, reflected the resident was an 84- years-old female that was admitted on [DATE]. The resident was diagnosed with: Dysphagia Oropharyngeal Phase (swallowing problems).Record Review of Resident #5's quarterly MDS completed by LVN R and dated 10/17/2025 reflected that the resident had a BIMS score of 03, indicating she was severely impaired cognitively. Resident #5 was dependent on staff for all personal hygiene task, toileting, showers, and dressing. Resident#5's MDS addressed the resident special treatments for care. Record Review of Resident #5's Care plan dated 10/18/2025 reflected the resident has an ADL self-care performance deficit r/t mobility issue. Resident #5's care plan did not address her respiratory treatments.Record Review of Resident #5's MD order dated 10/13/2025 reflected ipratropium-Bromide Inhalation Solution 0.02% (ipratropium-Bromide) .2.5 ML inhale orally 4 hours Albuterol Sulfate (2.5 MG/3ML) 0.083% Nebulization solution Give 3 ml by mouth every 8 hours as needed for Wheezing or SOB. Budesonide Inhalation Suspension 0.5 MG/2ML. (Budesonide (Inhalation)) 2 ml inhale orally two times a day for COPD Rinse mouth with water after use. Sodium Chloride Inhalation Nebulization Solution 3 % inhalant)) 4 ml inhale orally three times a day for Mucus plugging.Sodium Chloride (Inhalant Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT (Fluticasone Umeclidinium-Vilanterol) 1 puff inhale orally in the morning for COPD.MD order dated 10/14/2025 reflected Albuterol Sulfate HFA 108 (90 Base) MCG/ACT Aerosol, solution Give 2 puff by mouth every 06 hours s needed for wheezing.) During an observation of Resident #5 on 11/21/2025 at 1:30 PM a revealed the resident lying in bed with her eyes closed, with midline IV, enteral feeding equipment dated and operating appropriately. During an interview on 11/23/2025 1:10 PM the DON stated Resident care plans should reflect MD orders and all medical treatments. The DON stated that the nursing staff and interdisciplinary team were responsible for developing the care plan. The DON said it was the ADON and DON responsibility to monitor and update care plans to reflect the resident's care and treatment and failing to monitor could result in the resident treatment not being monitoring and provided. During an interview with the ADM on 11/23/2025 at 1:20 PM, she stated it was her expectation that the DON monitored and updated the care plans timely to reflect the resident's current care and treatments. The ADM stated that failing to document individualized treatment could result in the resident missing care. Record review of the policy and procedure entitled Comprehensive Person-Centered Care Planning dated 3-2022; 12.2023 read in part .It is the policy of this facility that the interdisciplinary team (IDT) along with the resident, legal representative, and clinical staff develop a comprehensive person-centered care plan includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment . to provide effective and person-centered care that meet professional

Based on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the status for 3 of 5 residents (Residents #3, #4, and #22) reviewed for accuracy of assessments in that: The facility staff failed to address Resident #22, Resident #3, Resident #4, and Resident#5's respiratory treatments on the MDS.These failures could place residents at risk of not receiving care and treatments. Findings included:1.Record review of Resident #22 face sheet dated 11/23/2025, reflected the resident was an 80- year-old male that was admitted on [DATE]. The resident was diagnosed with: Vascular Dementia (impaired blood supply to the brain), Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen) and atherosclerotic heart disease of native coronary artery. (artery build-up of fat and plaque).Record review of Resident #22's Annual MDS dated [DATE] reflected the resident had a BIMS score of 00, indicating he was severely impaired cognitively. Resident #22 was dependent on facility staff for total care of ADL task. MDS Sections O for respiratory treatments were not addressed. MDS-P and MDS-G signed that the MDS was completed on 11/08/2025.Record review of Resident #22's care plan dated 11/07/2025 reflected he had impaired cognition, poor safety decision making, and memory loss. Record review of Resident #22's MAR and progress note reflected Albuterol Sulfate Inhalation Nebulization Solution 1application inhale orally via nebulizer every shift for wheezing.During an observation and interview with Resident #22 on 11/21/2025 at 11:30 AM, the resident was sitting in his wheelchair outside his room. Resident #22 stated that the staff were assisting with administration of his oxygen and nebulizer mask. 2. Record review of Resident #3 face sheet dated 11/23/2025, reflected the resident was a 67- years-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic Encephalopathy (problem in the brain) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen). Record review of Resident #3's Annual MDS dated [DATE] reflected the resident had a BIMS score of 04, indicating he was severely impaired cognitively. Resident #4 was dependent on staff for all ADL task with maximum assistance. Sections O. Respiratory treatments were not addressed. MDS-R and MDS-G signed that the MDS was completed on 09/05/2025. Record review of Resident 3's care plan dated 08/22/2025 reflected Resident #3's had cognitive loss and impaired thought process r/t History of CVA. Resident has a terminal prognosis r/t Senile Degeneration of the Brain (decline in cognitive function) and receive hospice services for palliative care. Record review of Resident #3's MD orders reflected active orders dated 09/11/2025.02: Change H20 bottles on concentrators once a week. every night shifts every Sunday.02: Change 02 tubing and date once a week every night shifts every Sundays.02: Check 02 sat every night shift every Sunday.02: Clean 02 concentrator filters once a week.every night shifts every Sunday. 02: Oxygen (2-51pm) via (NC) as needed 02 sats above 92%. During an observation and interview on 11/23/2025 at 1:45 PM with Resident #3's nebulizer machine and oxygen concentrator was observed, and treatment were not performed. Resident stated that he does use the machines when needed. 3. Record review of Resident #4 face sheet dated 11/23/2025, reflected the resident was an 81- years-old male that was admitted on [DATE]. The resident was diagnosed with: Senile Degenerative of the brain (progressive decline in the brain cognition) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen)Record review of Resident #4's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 00, indicating he was severely impaired cognitively. Resident #4 was dependent on staff for all personal hygiene task, toileting, showers, dressing, and meal support for eating. Sections O special treatments and procedures Resident #4's respiratory treatments were not addressed. MDS-R and MDS-G signed that the MDS was completed on 10/31/2025.Record review of Resident #4's care plan dated 08/08/2025 reflected he had a terminal illness and received hospice palliative care r/t Senile Degenerative of the brain (progressive decline in the brain cognition). Record review of Resident #4's MAR reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (ipratropium-Albuterol) 3 ml inhale orally three times a day for 7 Days. The order was not dated. Albuterol Sulfate HFA Inhalation Aerosol Respiratory Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally as needed for Shortness of breath.Order for Morphine Sulfate (concentrate) solution 20 MG/ML.give 0.25 ML orally every 1 hours as needed for pain.During an observation on 11/23/2025 at 12:00 PM with Resident #4's was located in the facility dining room sitting in his wheelchair. Resident #4 was not interviewable due to confusion and communication deficit.During an interview on 11/23/2025 at 1:10 PM the DON stated the MDS should be coded for the care that the resident was receiving to reflect on the care plan for care. She stated that the ADON and DON were responsible for reviewing finalized MDS assessment to ensure accuracy. She stated that failing to code the MDS correctly could result in the resident missing care and treatment ordered by the MD. During an interview on 11/23/2025 at 1:20 PM, the Administrator stated that it was her expectation that the MDS reflect the services, care, and treatment that the resident was receiving at the facility. She stated that failing to code correctly could result in the resident missing individualized care. The MDS coordinator was not interviewed nor attempted as the failure was observed on the weekend. Record review of the facility's Maintain Minimum Data Set Assessments policy, dated 10/01/2023, reflected it did not address the accuracy of assessments.

Based on observations, interviews, and record review the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 (Residents #10, Resident #22, Resident #3, Resident #4, and Resident #5) of 10 residents reviewed for respiratory care, in that:. Resident #10, Resident #22, Resident #3, and Resident #4's nebulizer mask was not bagged.Resident #4's and Resident #5's NC tubing was not dated.These failures could place residents at risk of receiving inadequate respiratory careFindings: Resident #10 Record Review of Resident #10's face sheet dated 11/23/2025, reflected the resident was a 78 years-old female that was admitted on [DATE]. The resident was diagnosed with: Alzheimer's Disease (progressive disease that impairs memory) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen). Record Review of Resident #10's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 15, indicating she was cognitively intact. Resident #10 was dependent on staff for all personal hygiene task, toileting, showers, and dressing, She required set up for Meals. Sections O special treatments and procedures addressed the resident's oxygen therapy. Record review of Resident #10's Care Plan (CP) dated 05/13/2025 reflected that she has an ADL self-care deficit related to Alzheimer's and required substantial maximum assistance from staff. Resident #10's respiratory treatment was not addressed in her care plan. Record Review of Resident #10's MD active orders dated 02/11/2022 reflected O2: Check O2 sat every shift. Vital sign q shifts every shift Alert provider for temperature >101 or pulse greater than 110. During an observation and interview on 11/23/2025 at 10:00 AM Resident #10 was observed lying in her bed on her back. She stated that the staff administer her nebulizer treatment when needed. She stated the Nebulizer mask had not been cleaned by the staff or bagged. 02/11/202 Resident #22, Record Review of Resident #22 face sheet dated 11/23/2025, reflected the resident was an 80- years-old male that was admitted on [DATE]. The resident was diagnosed with: Vascular Dementia (impaired blood flow to the brain), Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen) and atherosclerotic heart disease of native coronary artery. (artery build-up of fat and plaque). Record Review of Resident #22's Annual MDS dated [DATE] reflected the resident had a BIMS score of 00, indicating he was severely impaired cognitively. Resident #22 was dependent on staff maximal assistance with personal hygiene task, toileting, showers, and dressing. Resident #2 required set up for Meals. MDS Sections O for respiratory treatments were not addressed. MDS-P and MDS-G signed that the MDS was completed on 11/08/2025. Record Review of Resident #22's care plan dated 10/12/2025 reflected he had an unwitnessed fall on 10/12/2025 and the care plan was updated. Resident #22's care plan did not address the use of respiratory treatment. During an observation and interview on 11/23/2025 at 11:30 AM. with Resident #22's Nebulizer mask was stored on the nightstand not bagged. Resident stated that the staff had removed his NC this morning. He stated the nebulizer mask was not cleaned, changed, or bagged. Resident #22 does not recall if the staff cleaned the mask. Resident #3 Record Review of Resident #3 face sheet dated 11/23/2025, reflected the resident was a 67- years-old male that was admitted on [DATE]. The resident was diagnosed with: Metabolic Encephalopathy (problem in the brain) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen). Record Review of Resident #3's Annual MDS dated [DATE] reflected the resident had a BIMS score of 04, indicating he was severely impaired cognitively. Resident #1 was dependent on staff and required maximum assistance with all personal hygiene task, toileting, showers, and dressing, he required partial assistance with meals. Record Review of Resident #3's care plan dated 08/22/2025 reflected he had a terminal illness and received hospice palliative care r/t Senile Degenerative of the brain (progressive decline in the brain cognition). Resident #3's respiratory treatments were not addressed in the care plan. Record Review of Resident #3's MD orders reflected active orders dated 09/11/2025. reflected 02: Change 02 tubing and date once a week every night shifts every Sundays. 02: Check 02 sat every night shift every Sunday.02: Clean 02 concentrator filters once a week.every night shift every Sunday.02: Oxygen (2-51pm) via (NC) as needed 02 sats above 92%. During an observation and interview on 11/23/2025 at 1:45 AM with Resident #3, his NC tubing was not dated and bagged. His oxygen concentrator machine was observed with white, tan and gray small particles. His nebulizer mask was observed on the nightstand not bagged. Resident #3 stated that the used both the nebulizer machine and mask and oxygen concentrator machine and the staff had not bagged the nebulizer mask. Resident #3 did not remember if the staff cleaned the mask routinely. Resident #4 Record Review of Resident #4 face sheet dated 11/23/2025, reflected the resident was an 81- years-old male that was admitted on [DATE]. The resident was diagnosed with: Senile Degenerative of the brain (progressive decline in the brain cognition) and Acute Respiratory with Hypoxia (inability to maintain blood in the oxygen). Record Review of Resident #4's care plan dated 08/08/2025 reflected he had a terminal illness and received hospice palliative care r/t Senile Degenerative of the brain (progressive decline in the brain cognition). Record Review of Resident #4's Quarterly MDS dated [DATE] reflected the resident had a BIMS score of 00, indicating he was severely impaired cognitively. Resident #4 was dependent on staff for all personal hygiene task, toileting, showers, dressing, and meal support for eating. Sections O special treatments and procedures Resident #4's respiratory treatments were not addressed. MDS-R and MDS-G signed that the MDS was completed on 10/31/2025. Record Review of Resident #4's active MD orders dated ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (ipratropium-Albuterol) 3 ml inhale orally three times a day for 7 Days. The order was not dated.Albuterol Sulfate HFA Inhalation Aerosol Respiratory Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally as needed for Shortness of breath. The was no order for NC or respiratory treatments. Record review of Resident #4's progress note dated 11/08/2025 at 10:26 AM by LPN-T reflected ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 ml inhale orally three times a day for 7 Days. Upon assessment prior to administering breathing treatment, pt's SpO2 improved to 99% and HR decreased to 89 bpm. Prior SpO2 was 80% and HR 136 bpm. Breathing treatment then given as ordered. Pt. tolerated treatment well. The plan of care is ongoing. Record review of Resident #4's progress note dated 11/08/2025 at 4:55 PM by LPN-T reflected Pt. agitated and restlessness, respirations labored.his 02 reading low 80% and his HR 145 BPS. Morphine given per PRN hospice order for comfort and SOB. The plan of care is ongoing. This progress note was added in relation to his Morphine order and treatment for SOB. During an observation on 11/23/2025 at 12:00 PM, Resident #4's was observed in the dining room with his NC tubing wrapped around the oxygen tank. The tubing was not dated and not bagged. Resident #4 was not interviewable due to confusion and communication deficit. During an interview with LVN-C on 11/23/2025 12:55 PM for Resident's #10 and Resident #22, she stated that she had conducted rounds and failed to observe the tubing undated and masked unbagged. She stated that NC tubing was changed on Sundays during the overnight shift, and as needed. She stated that the nursing staff were responsible for washing the nebulizer mask as needed, then bag and date for sanitation. She stated that expectation was to monitor the respiratory equipment for sanitation and operations during rounds. She stated this was an error that could result in infections for the residents. During an interview with LVN-T on 11/23/2025 at 12:58 PM for Resident's #3 and Resident #4 she stated all respiratory equipment was cleaned and tubing was changed and dated weekly on the night shift every Sunday. She said residents could get infections from cross contamination and when the procedures were not followed. She stated she had not noticed the equipment unbagged during her rounds. During an interview on 11/23/2025 at 1:10 PM the DON stated it was her expectations for the nursing staff to monitor respiratory equipment for sanitation, storage, dates, and labeling during resident rounds. She said failing to bag and dated the nebulizer mask and tubing when not in sue could result in infections to the resident. She stated it was the charge nurse, ADON, and DON's responsibility to monitoring the nursing clinical care task. During an interview on 11/23/2025 at 1:20 PM, the Administrator stated that everything used for the resident should be kept clean to prevent cross contamination and respiratory infection. She stated that all assigned equipment with tubing was to be bagged when not in use for sanitation. She stated that it was the responsibility of the DON to monitor and educate the staff on respiratory protocol. There were no weekend night shift nurses interviewed about respiratory equipment protocol. The quality-of-care respiratory treatments policy was requested on 11/23/2025 at 12:00 PM and was not provided prior to exiting the building.

Based on observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 Residents (Resident #1 Resident #2 and Resident #3) observed for infection control. 1.The facility failed to ensure CNA F utilized Enhanced Barrier Precautions, performed hand hygiene during incontinence for Resident #1 and performed hand hygiene prior to leaving Resident #1 room on 11/23/25. 2.The facility failed to ensure CNA E utilized Enhanced Barrier Precautions, performed hand hygiene during incontinence care and mechanical lift transfer to Resident #2 and performed hand hygiene prior to leaving Resident #2's room on 11/23/25. 3. The facility failed to ensure CNA G properly removed her Enhanced barrier equipment and performed hand hygiene prior to leaving Resident #2's room on 11/23/25. 4. The facility failed to ensure LVN A performed hand hygiene during wound care and changed her gloves and performed hand hygiene after cleaning each wound on Resident #3's feet on 11/23/25. Findings included: 1. Record Review of Resident #1's quarterly MDS assessment, dated 09/02/25 reflected a [AGE] year-old female with a BIMS score of 2 which indicated she was severely cognitively impaired. She was dependent for all activities of daily living with exception of eating and required the assistance of 2 persons for transfers. She was always incontinent of bladder and bowel. Diagnoses included dementia and multiple sclerosis (chronic disease of the central nervous system) In an observation on 11/23/25 at 07:40 a.m. CNA F entered Resident #1's room to provide incontinence care and get her up for breakfast. A sign was posted over the resident's bed which indicated the resident was on Enhanced Barrier Precautions ( a set of infection control measures used to reduce the spread of mulit-drug resistance organisms). CNA F put on gloves without performing hand hygiene and did not put on a gown. CNA F opened the residents brief and wiped down the middle and out to both sides, changing the surface of the wipe with each swipe. He then assisted resident onto her side and wiped her anal area from front to back, changing the surface of the wipe. CNA F then placed the clean brief under the resident while wearing the same soiled gloves and rolled her back onto her back. CNA F removed his gloves and did not perform hand hygiene. He then went to the resident's closet and pulled out a couple of items of clothing and asked the resident what she wanted to wear today. After resident selected her clothing, he placed the remaining items back in the closet. CNA F then put on gloves with no hand hygiene and dressed the resident. CNA F transferred the resident into the wheelchair. CNA F then removed his gloves and left the room without performing hand hygiene and pushed the resident down to the dining room. In an interview with CNA F on 11/23/25 at 08:00 a.m. he stated he was supposed to perform hand hygiene before entering the resident's room and before leaving the resident's room. He stated he had used the hand sanitizer in the hall before coming into the resident's room but acknowledged he had not performed hand hygiene before he left the room. He stated he had worn gloves during incontinence care and did not know he had to change his gloves before placing the clean brief and residents' clothing on her. He stated he had not noticed the sign indicating the resident was on Enhanced Barrier Precautions. He stated the risk of not providing hand hygiene and wearing the proper personal protective equipment was the spread of germs. In an interview with the DON on 11/23/25 at 8:10 a.m. she stated any resident who was on enhanced barrier precautions would have a sign posted over their bed to let the staff know what type of precautions were to be used. She stated Resident #1 was on enhanced barrier precautions due to a chronic eye infection which they were currently treating. She stated the CNAs were required to wear gown and gloves during direct care for her. 2. Record review of Resident #2's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old female with an admission date of 09/28/20. Resident had a BIMS of 13 which indicated she was cognitively intact. She required substantial to max assistance with ADLs. She was always incontinent of urine and had colostomy. (an opening in the abdomen to connect the colon to the outside of the body). She had non-pressure wounds to her feet. Diagnoses included diabetes. In an interview and observation on 11/23/25 at 08:05 a.m. Resident #2 resident was observed in her bed. The resident had O2 via nasal cannula in use and an Enhanced Barrier Precaution sign posted over her bed. She stated she had some wounds on her feet, and the staff were dressing them. She stated she also had a colostomy which the nurses change for her. In an observation on 11/23/25 at 08:50 a.m. CNA E entered Resident #2's room and put on gloves without performing hand hygiene and did not put on a gown to provide incontinence care and get the resident up for the day. CNA E unfasted the resident's brief and sprayed peri-wash under the resident's belly fold to wipe of a thick layer of powder and cream. CNA E then wiped downward and then outward toward the resident's groin, changing the surface of the wipes with each stroke. CNA E then rolled the resident onto her side and wiped from front to back. CNA E then placed a clean brief under the resident and applied barrier cream to the resident's buttocks and then rolled her over applied to her inner thigh and under her belly fold with the same gloves used for cleaning the resident's peri (the diamond-shaped area between the anus and the vulva) and anal areas. CNA E fastened the brief. Still wearing the same gloves, CNA E opened the resident's closet and retrieved a clean shirt and pants. He then dressed the resident and handed her O2 nasal cannula which had been taken off, to change her shirt, still wearing soiled gloves. After dressing the resident, the CNA left the room without performing hand hygiene to obtain the mechanical lift and assistance to get the resident up and the nurse to empty the resident's colostomy bag. In an observation on 11/23/25 at 09:20 a.m. LVN B and CNA G performed hand hygiene, put on gown and gloves and entered Resident #2's room. CNA E entered behind them with the mechanical lift. CNA E put on gloves without performing hand hygiene and did not put on a gown. LVN B changed out the colotomy bag, removed her PPE and washed her hands and left the room. CNA E and CNA G then placed the mechanical sling under the resident and attached it to the lift and transferred her to her wheelchair. CNA G then took the lift out of the room still wearing her gown and gloves and took it down the hall and placed it in a storage room by the nurse's station. She then removed her gown and gloves and used the hand sanitizer in the hallway. CNA E finished adjusting the resident in her wheelchair, handed her cell phone to her and removed his gloves and left the room without performing hand hygiene. In an interview with CNAs E and CNA G on 11/23/25 at 9:35 a.m. both stated they were supposed to perform hand hygiene before and after care. CNA E stated he did not know he had to change his gloves and perform hand hygiene during incontinence care. He stated he forgot about putting on a gown. Both staff stated they had had just had training on Enhanced Barrier Precautions which also covered hand hygiene about a week ago. CNA G stated she was supposed to remove her gown and gloves before leaving the room and just simply forgot to do that. Both staff stated the risk of not following proper infection control protocols was the spread of germ and increased risk of infections. 3. Record review of Resident #3's Quarterly MDS assessment, dated 10/31/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The staff had assessed the resident to severely cognitively impaired. She was dependent on staff with all ADL care and was always incontinent of urine and bowel. She had a feeding tube and received 51 % of her nutrition through a feeding tube. She was coded to be at risk of pressure ulcers. Her active diagnoses included Alzheimer's disease, malnutrition, abnormal posture and muscle wasting. In an observation on 11/23/25 at 10:00 a.m. revealed LVN A performed hand hygiene and put on gloves and gowns. LVN A entered Resident #3's room. She had all her wound care supplies placed on the bedside table on top of a towel. LVN A removed all of the old dressing from all four wounds on the resident's feet, removed her gloves, and put on clean gloves without performing hand hygiene. LVN A then sprayed wound cleanser on the wound on the left dorsal (the top upper surface of the foot) and cleansed the area with gauze. She then proceeded to the large wound on the resident's right outer ankle and top of her right foot and sprayed it with wound cleanser and cleaned with gauze, still wearing the same gloves she wore to clean the wound on the left foot. Still wearing the same gloves, she had CNA F hold up the resident's left leg and she sprayed wound cleanser on a gauze and cleansed the smaller wound on her left outer ankle. LVN A then changed her gloves but did not perform hand hygiene and sprayed wound cleanser on a gauze and cleansed the small wound on the bottom of the resident's right foot. LVN A then removed her gloves, performed hand hygiene, and put on clean gloves. She applied the calcium alginate (absorbent dressing made of seaweed) to the left dorsal wound and covered it with a border dressing. She removed her gloves, sanitized her hands, put on clean gloves, and applied the calcium alginate to the right medial ankle and upper foot wound and covered it with a bordered dressing. Removed her gloves, sanitized her hands, and applied calcium alginate to the left ankle wound, and removed her gloves, sanitized her hands, put on clean gloves, and applied calcium alginate to the wound on the bottom of her right foot. LVN then removed her gloves and gown and performed hand hygiene. In an interview with LVN A on 11/23/25 at 10:20 a.m. she stated she was supposed to perform glove changes and hand hygiene when applying the treatments to a resident's wound, but stated she was not aware she had to do so when cleaning the wounds. She stated she used clean gauze for each wound but did not change her gloves. She stated she could see where this could create potential for cross contamination of the wounds. In an interview with the DON on 11/23/25 at 01:15 p.m. she stated staff were to change their gloves and perform hand hygiene before going form dirty to clean, before entering a resident's room, before leaving a room and were never to wear PPE in the hallway. She stated all residents who were in Enhanced Barrier Precautions had signs posted over their beds and the staff was expected to follow those protocols. She stated they train and do in-services constantly on infection control. She stated that failing to follow those protocol places residents at a higher risk of infections. She stated wound care was to be done one wound at a time and they should do the least wound going toward the worst wound last. She stated this was to prevent cross contamination from wound to wound. She stated the infection preventionist trains and in-services and monitors to track and trend and focused their training needs accordingly. Record review of the facility's policy titled, Enhanced Barrier Precautions, dated April 2024, reflected, It is the policy of this facility to implement enhance barrier precautions for the prevention of transmission of multidrug-resident organisms.An order for enhanced barrier precautions will be obtained for residents with any of the following.Wounds.Infection or colonization with a CDC-targeted MDRO when Contact Precautions do not otherwise apply.PPE for enhanced barrier precautions is only necessary when performing high-contact care.High-contact resident care activities include.Dressing, bathing, transferring, providing hygiene, changing linens, changing briefs.Wound care. Record review of the facility's' policy titled, Handwashing/Hand hygiene dated October 2023 reflected, .The facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.All staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.Hand Hygiene is indicated.Immediately before touching a resident.After contact with blood, body fluids, or contaminated surfaces.After touching a resident.after touching the resident's environment.Before moving from work on a soiled body site to clean body site on the same resident and immediately after glove removal.The use of gloves does not replace hand washing/hand hygiene.

Based on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of six residents (Resident #1) reviewed for accidents hazards The Facility failed to ensure CNA F provided a safe two-person transfer and instead lifted Resident #1 under her arms when transferring her from her bed to her wheelchair on 11/23/25. These failures could affect the residents by placing the residents at risk for falls, injuries, and skin tears.Findings included: Record Review of Resident #1's quarterly MDS assessment, dated 09/02/25 reflected a [AGE] year-old female with a BIMS score of 2 which indicated she was severely cognitively impaired. She was dependent on all activities of daily living with exception of eating and required the assistance of 2 persons for transfers. She was always incontinent with bladder and bowel. Diagnoses included dementia and multiple sclerosis (chronic disease of the central nervous system) Review of Resident #1s care plan initiated on 03/24/25 reflected, [Resident #1] has an ADL self- care Performance Deficit related to impaired balance.Intervention.Transfer: The resident requires mechanical lift.with 2 staff assistance for transfers. In an observation on 11/23/25 at 07:40 a.m. CNA F entered Resident #1's room to provide incontinent care and get her up for breakfast. Resident #1 was very petite and could follow direction from the staff when asked to turn or reposition during care. After completion of incontinence care CNA F positioned the resident's wheelchair beside the bed, assisted the resident onto the side of the bed and placed both his arms under the resident's arm pits and lifted her up and over into the wheelchair. The resident did not bear weight during the transfer and did not appear to be in pain. CNA F then stated he was going to take her to the dining room. In an interview with CNA F on 11/23/25 at 08:00 a.m. he stated he had been taught that any transfer required a gait belt but stated he did not see a gait belt in her room. He stated he was not that familiar with the resident and should have asked before providing her care or should have looked at the resident's care plan. He stated the risk of lifting someone under the arms was injury to the resident's shoulders. In an interview with PTA D on 11/23/25 at 12:00 p.m. he stated any resident who required assistance with one person for transfers required the use of a gait belt to help prevent injury to the resident and to the staff. He stated staff were never to lift a resident under the arms due to the risk of dislocating their shoulder. He stated when a resident requires two-person maximum assistance they usually recommended a mechanical lift transfer. He stated if therapy had seen a resident they will indicate to nursing what level of assistance a resident needs, or nursing will make the determination for resident who had not been on therapy. In an interview with the DON on 11/23/25 at 01:15 p.m. she stated the staff were to always use a gait belt when transferring a resident if they were a one-person transfer. She stated if resident required two-person transfers they were to use a mechanical lift unless it was contraindicated. She stated they do training on transfers during orientation and annually or when they determine there is an issue. She stated they would be in-servicing staff on proper transfer techniques. She stated Resident #1 was care planned for a mechanical lift transfer. She stated the CNA should have never done a one person transfer on her. She stated he was a PRN staff member but stated he should have asked if he was unsure of her care needs. She stated the risk was injury to the resident and staff member. Record review of the facility's policy titled, Safe Lifting and Movement of Residents, dated July 2017, reflected, In order to protect the safety of and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.Manual lifting of residents shall be eliminated when feasible.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts,.) and mechanical lifting devices.

Based on interview, observation, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one of six residents (Resident #3) reviewed for pressure ulcers The facility failed to ensure LVN A provided Resident #3 her physician ordered wound care on 11/22/25. This failure could place residents at risk of developing infections or worsening of their wounds.Findings included: Record review of Resident #3's Quarterly MDS assessment, dated 10/31/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The staff had assessed the resident to severely cognitively impaired. She was dependent on staff with all ADL care and was always incontinent of urine and bowel. She had a feeding tube and received 51 % of her nutrition through a feeding tube. She was coded to be at risk of pressure ulcers. Her active diagnoses included Alzheimer's disease, malnutrition, abnormal posture and muscle wasting. Record review of Resident #3's care plan with a revision date of 06/25/25 reflected, The resident has a Stage 4 pressure injury on her right lateral (outside) ankle related to history of ulcers.Interventions.Administer treatments as ordered and monitor for effectiveness. Record review of Resident #3's Physician order summary report dated 11/23/25, reflected, Cleanse non-pressure wound to right medial foot with wound. and pressure wound to right lateral ankle with wound cleanser, pat dry. Apply calcium alginate (absorbent dressing made of seaweed) to wound bed. Cover with dry dressing daily and PRN if saturated, soiled or dislodged, with a start date of 11/07/25. Cleanse open areas to left medial and dorsal foot with wound cleanser, pat dry. Apply calcium alginate (absorbent dressing made of seaweed) to wound bed. Cover with dry dressing daily and PRN if saturated, soiled or dislodged, with a start date of 11/04/25. Record review of Resident #3's Wound care administration record for November 2025 reflected no treatment was provided on 11/22/25 for any of the wounds on the resident's left or right foot. In an observation and interview on 11/23/25 at 9:45 a.m. revealed LVN A and CNA F in Resident #3's room repositioning her in preparation to provide wound care to the resident's feet. Resident #1 had a feeding tube, and her legs were drawn up into a fetal position. Resident #1 was positioned on her left side with pillows between her legs to offload them and a pillow under her left ankle. The resident had an alternating pressure mattress in use. The resident was nonverbal. The dressings on residents' right foot and left foot were dated 11/21/25. The resident's right foot was edematous (swollen with excess fluid) and the dressing on her foot was soaked with drainage and had a foul odor. LVN A stated she was working yesterday (11/22/25) and stated she did not do the wound care on Resident #1. She stated it was a crazy shift, and she just did not get around to doing it. She stated she should have asked the oncoming shift to do it but stated she did not ask them. She stated she was getting her supplies together now to change the dressings. In an observation of 11/23/25 at 10:00 a.m. revealed LVN A performed hand hygiene and put on gloves and gowns. LVN A stated the resident had 4 different wounds, two of both feet and all were to be cleansed with wound cleanser, pat dry, and apply calcium alginate and covered with a bordered dressing. LVN A entered the room. She had all the wound care supplies placed on the bedside table on top of a towel. LVN A opened the packages of the boarded dressing and placed today's date (11/23/25) on the dressing. The resident was positioned on her left side. LVN removed all of the dressing from all four wounds, cleansed them with wound cleanser and applied calcium alginate and covered with bordered dressing. In an interview with LVN A on 11/23/25 at 10:20 a.m. she stated she knew the resident had daily wound care orders and felt bad she did not get the wound care done yesterday. She stated the wound on the resident's right foot does not have an odor once it was cleaned. She stated once the dressing becomes saturated with the drainage it will start to have an odor. In an interview with the DON on 11/23/25 at 11:15 a.m. she stated they had a Treatment Nurse who worked Monday through Friday, and the weekend nurses were responsible for their wound care. She stated Resident #3 had chronic wounds with poor prognosis due to her debilitated state. She stated the wound on her right foot had a lot of drainage due to the edema. She stated the wound care physician had told them once the dressing became soaked it would start to have an odor, but the wound itself did not have an odor. She stated they had an order to change the dressing daily or more often if it became soiled or dislodged. She stated since it did not get changed yesterday she understood why it had an odor. She stated she was not aware of the wound care being missed on 11/22/25 until today (11/23/25). She stated the Treatment Nurse had not told her of any wound care not being completed on the weekends but stated if it was not completed on Saturday and done on Sunday, she would not know it was not being completed. She stated going forward the ADON's were going to have monitor the Treatment administration records. In an interview on 11/23/25 at 11:40 a.m. with the Wound Care physician he stated he had been providing wound consultation for Resident #3. He stated her wounds were chronic and had poor chances of healing due to her debilitated state, her advanced contractures, and her bedbound status. He stated the wound on her right foot did not have any signs of infection. He stated the drainage would start to have an odor if it was left for an extended period of time, which is why he provided an order for the nurses to change it daily and anytime it became soiled and saturated. He stated it was his expectation for the wound care to be provided as ordered. He stated not keeping the wound clean could lead to more deterioration of the wound bed and the surrounding skin. Record review of the facility's policy titled, Wound Treatment Management, dated January 2023, reflected, Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.Treatments will be documented on the Treatment Administration Record or in the electronic health record.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #2) reviewed for care plan accuracy. The facility failed to develop and implement a care plan revised on 08/14/25 for Resident #2, which addressed her physically aggressive behaviors towards others between 08/02/25 to 08/26/25. LVN A and CNA E were able to pull Resident #2's hand away from Resident #1's neck on 08/26/2025. An IJ was identified on 08/27/25. The IJ template was provided to the facility on [DATE] at 5:18 PM. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems. This failure placed residents at risk of not receiving needed services due to inaccurate comprehensive care plans. Findings included: Review of Resident #2's admission MDS Assessment, dated 07/29/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score could not be conducted, but it was noted she had both short-term and long-term memory problems and could not make her own daily decisions. She was noted to not have any physical or verbal behaviors towards others, but did wander daily that intruded on the privacy or activity of others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). Review of Resident #2's care plan, revised on 08/14/25, revealed it did not reflect anything regarding her aggressive behaviors. Review of Resident #2's Physician's Orders reflected the following:- Ativan Gel 0.5mg q 12 hours prn apply topically every 12 hours as needed for agitation for 14 days- Seroquel Oral Tablet 25 MG Give 1 Tablet by mouth two times a day for agitation Review of Resident #2's Treatment Administration Record reflected the following:- She was administered the Ativan Gel on the following dates: 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/24/25, 08/25/25, and 08/26/25. - She was noted to have behaviors on the following dates as monitored for psychoactive behaviors: 08/02/25, 08/03/25, 08/08/25, 08/09/25, 08/14/25, 08/16/25, 08/17/25, 08/20/25, 08/21/25, 08/23/25, 08/24/25, 08/25/25, and 08/26/25.- She was administered the Seroquel on the following dates: 08/25/25, 08/26/25, and 08/27/25. Review of Resident #2's Progress Notes reflected the following:- LVN B wrote on 07/25/25 at 2:57 PM: Resident follow up on new admit, resident continue pacing down the hallway, attempt to push fire alarm during this shift, resident continue to monitor [sic]- LVN C wrote on 07/27/25 at 1:39 AM: The resident woke up, and was very agitated, throwing around everything she could come across in her room. She was yelling out at the staff when they were offering incontinent care to her. She was calmed down and laid back to bed but still kept on waking up and coming out of her room, and re-direction was done appropriately.- LVN D wrote on 07/27/25 at 8:49 PM: Resident combative with incontinent care. She came out from the room and started pushing dining table and chairs. Resident able to redirect, sleeping in bed at this time. No s/s of acute distress noted. Bed in low position, call light within reach.- LVN C wrote on 07/28/25 at 2:14 AM: The resident woke up and was banging stuff in her room and bathroom. Staff redirected her back to bed, but she was combative, and yelling. She was brought to the dining room via wheelchair but kept standing up and pushing the tables and chairs around. She wandered through the hallway back and forth. She was redirected back to her room and agreed to lay back in bed. Right now, she is resting in bed eyes closed.- LVN B wrote on 08/07/25 at 8:47 AM: Resident going all other [sic] resident room [sic] attempting to pull them from the bed staffs [sic] continue redirecting the resident.- LVN A wrote on 08/08/25 at 1:01 AM: Resident is combative, non-compliant to care, yelling and destroying anything within her reach. Resident refused to sleep, attempting to pull roommate from the bed. All efforts to redirect resident is ineffective. NP and DON notified.- LVN C wrote on 08/10/25 at 6:29 AM: The resident pacing [sic] in the hallway entering into other patients' rooms and banging doors and throwing everything she comes across. At the dining room at the moment, throwing chairs all over and moving tables around.- LVN A wrote on 08/26/25 at 9:40 PM: Resident noted with aggressive behavior. She was seen by the CNA putting her hand around another resident's neck (Resident #1) in the dining room. Nurse and CNA immediately ran towards them and intervened. Resident was fighting and kicking staff while being redirected. PRN Ativan gel was applied with little effect. Resident also tried to pull her roommate from the bed earlier today per therapist. NP and DON notified. Resident's RP informed. Resident is currently on Q 15 mins checks for behavior. she [sic] is lying in bed in the room no behavior [sic] noted at this time.- LVN C wrote on 08/27/25 at 1:10 AM: The resident is on aggressive behavior monitoring q 15 minutes. Resident is in bed at the moment sleeping.- LVN C wrote on 08/27/25 at 5:15 AM: The resident woke up and started throwing stuff in her room. The nursing staff tried to redirect and offer incontinent care, but the resident was extremely aggressive/combative. The staff left the room. The resident kept yelling from her room. Review of Resident #2's Psychiatric Initial Assessment, dated 07/30/25, reflected the following: .Patient referred for medical management services for sx including Agitation, Adjustment Disorder, Noncompliance, Verbal Aggression, Physical Aggression. Patient made eye contact with provider when approached, but was unable to appropriately participate/interact. Staff report frequent periods of anxiousness/restlessness and difficulty with redirection being exhibited by patient.At this time, recommend increasing frequency of Ativan to 0.5 mg/TID per frequent symptoms of anxiety and difficulty with redirection. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/06/25, reflected the following: .During previous visit, Ativan frequency increased to TID due to reported periods of agitation and behavioral concerns. Staff states agitation decreased but continues during periods of care. Staff also report patient frequently pacing throughout secured unit and wandering into other residents rooms. Staff reports patient being aggressive and difficult to calm/redirect.At this time, due to reported continued periods of agitation and aggression during periods of care, recommend initiation of Ativan gel 0.5 mg/Q12 HR PRN X 14 days for acute agitation/aggressive behavior. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/20/25, reflected the following: .Staff reports continued behavioral concerns being exhibited by patient. Per ADON, patient reported to have ‘taken the tank off of her toilet and breaking it, as well as tearing soap dispensers off the wall.' Nursing staff within secured unit report patient often ‘easily agitated and physically aggressive. Staff states patient will attempt to hit staff during attempted periods of care. When attempting to initiate assessment, patient was found leaning over another resident within secured unit, whom was sitting on her wheelchair, and pushing her down the hall.'.At this time, due to reported symptoms of disorganized/delusional thoughts reported, Recommend [sic] initiation of Seroquel 25 mg/BID. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/27/25, reflected the following: .During previous visit, Seroquel 25 mg/BID order recommended.Staff states the day prior to exam, patient exhibited ongoing physically aggressive behaviors and ‘Choked [sic] another resident.' Per note in [EHR], on 8/26, patient was observed by the CNA ‘putting her hand around another resident's neck' in the dining room of the secured unit. During attempted intervention by nurse and CNA, patient was ‘fighting and kicking staff' during attempted redirection. Resident was placed on Q15 min safety checks, and staff denied observing physically aggressive behaviors being exhibited prior to today's assessment.Due to minimal symptom relief with currently ordered Ativan, recommend discontinuation of Ativan and initiation of clonazepam 0.5 mg/TID with consent from POA. Observation and attempted interview on 08/27/25 at 10:35 AM with Resident #2 revealed she was sitting in a chair in the dining room mumbling to herself. Resident #2 did not look the surveyor's way or at the surveyor until the surveyor continued trying to talk to her. Resident #2 appeared calm but was not able to answer any questions. Review of Resident #1's Quarterly MDS Assessment, dated 05/02/25, revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score was 05, indicating severe cognitive impairment. Her MDS indicated she did not have any physical or verbal behaviors towards others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Depression (a mood disorder that causes persistent sadness and changes in how you think, sleep, eat, and act). Review of Resident #1's care plan, revised 11/17/24, reflected: Focus: The resident is/has potential to be physically/verbally aggressive and resistive to care r/t Dementia.Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of Resident #1's Progress Notes reflected the following:- LVN A wrote on 08/26/25 at 7:48 PM: The resident was attacked by an aggressive resident in the dining room. The aggressive resident was seen by the CNA putting her hand around the resident's neck (Resident #1) in the dining room. Nurse and CNA immediately ran towards them and intervened. Upon assessment, no injury noted. resident [sic] denies pain. Resident was redirected and taken to another seat away from the aggressive resident. NP and DON notified. Review of Resident #1's skin assessment, dated 08/27/25, reflected she had redness and an open spot on the right side of her neck and redness/spot to her right cheek. Observation and interview on 08/27/25 at 10:40 AM with Resident #1 revealed she was sitting in a chair in the dining room. Resident #1 said she was doing great today. Resident #1 was observed to have redness to the right side of her neck that appeared to be a bruise that was about two inches long and an inch wide with a small open area. Resident #1 also appeared to have a small scratch to the right side of her cheek on her jawline that was also reddened. Resident #1 said she did not know what happened to her cheek or neck but it did not bother her. Interview on 08/27/25 at 10:23 AM with LVN B revealed she got report from the night nurse this morning that Resident #2 attacked or scratched Resident #1 yesterday. LVN B said Resident #1 had some redness to her neck that looked like it was a scratch but she was not sure if it was from the incident with Resident #2 or not. LVN B said Resident #2 had wandered a lot around the unit and was a difficult resident to handle. LVN B said Resident #2 would get mad and yell and be agitated for no reason. LVN B said staff were monitoring Resident #2 every 15 minutes right now by just keeping an eye on her. LVN B said Resident #2 tried to touch other residents but staff usually intervened before anything could happen because if anyone was near her anything could set her off. LVN B said when Resident #2 started to show agitation, staff would try to calm her down by singing with her, taking her for a walk outside, or getting her something to eat or drink. LVN B said Resident #2's behaviors were unpredictable and there was no trigger for it. LVN B said she was not sure if she had been trained on what to do specifically with Resident #2 in order to decrease her behaviors or reduce her agitation. LVN B said she had never seen Resident #2 be physically aggressive with another resident during her shift. Follow-up interview on 08/27/25 at 10:40 AM with LVN B revealed she saw Resident #1's reddened areas to her neck and cheek but could not recall if they were there yesterday or not. LVN B said she did not pay much attention to Resident #1 yesterday so she was not sure if the reddened areas were a result of the incident with Resident #2 or not. Phone interview on 08/27/25 at 11:04 AM with CNA D, who worked with Residents #1 and #2 on 08/26/25, was unsuccessful as she did not answer or call back prior to exit. Phone interview on 08/27/25 at 11:05 AM with LVN C, who worked with Residents #1 and #2 on 08/26/25, was unsuccessful as she did not answer or call back prior to exit. Phone interview on 08/27/25 at 11:08 AM with LVN A revealed she was at the nurses' station when she heard CNA E yelling, She's about to choke the resident. LVN A said she and CNA E ran towards Residents #1 and #2 and when they got to them, Resident #2's hand was round Resident #1's neck. LVN A said her and CNA E were able to pull Resident #2's hand away from Resident #1's neck, but Resident #2 continued to fight staff while trying to redirect her. LVN A said that when she assessed Resident #1 she saw there was a reddened and opened areas to her neck and cheek but she did not think that was related to the incident, but that it was a rash. LVN A said that Resident #2 had physically aggressive behaviors such as she pushed another resident in the dining room on Monday, which was reported to the Abuse Coordinator but the resident did not sustain any injuries. LVN A said she communicated with the Psych NP about Resident #2's behaviors and PRN Ativan gel was added to her orders. LVN A said Resident #2 became agitated and unable to be redirected, she would apply the gel. Follow-up interview on 08/27/25 at 3:03 PM with LVN A revealed she did not check Resident #1's skin prior to the incident and did not know if it was due to the incident or a rash. LVN A said she only noticed the rash after the incident because she had to do a skin assessment. LVN A was unable to say how long Resident #1 had the rash to her skin and could not describe what it looked like. LVN A said that Resident #2 had been having an increase in her agitation and physical behaviors. LVN A said when Resident #2 first came to the facility, she was flinging chairs and tables around the dining room. LVN A said she reported this to the NP who ordered new medications but Resident #2's behaviors did not change. LVN A said that was when the NP ordered the PRN Ativan gel but it did not work either. LVN A said she did communicate with the DON when she saw Resident #2 become physically aggressive with other residents. LVN A showed a text message exchange between her and the DON from 08/08/25 discussing Resident #2's agitation and physically aggressive behaviors regarding resisting care and destroying anything within her reach. LVN A said she knew to report any incident to the DON immediately that concerned residents. Phone interview on 08/27/25 at 11:21 AM with CNA E revealed Resident #2 was very aggressive last night and very agitated. CNA E said Resident #2 was trying to pull the table and chairs in the dining room. CNA E said she tried to move closer to Resident #2 and get her to calm down by talking to her but the resident refused. CNA E said she also tried redirecting her but again, Resident #2 refused. CNA E said when she moved closer to Resident #2, Resident #2 moved close to Resident #1 and grabbed her neck choking her. CNA E said she rushed towards the residents and tried to separate them and pull Resident #2's hands off Resident #1's neck. CNA E said this behavior was normal for Resident #2 because she was always agitated and aggressive. CNA E said when Resident #2 became agitated she would try to calm her down, move close to her, and talk to her. CNA E said Resident #2 was very strong and would fight staff during care and drag staff to the ground because she was so strong. CNA E said staff would have to act fast to be near her to make sure she did not harm other residents. CNA E said she did everything she could to try and keep Resident #2 from hurting others but nothing seemed to work. Follow-up interview on 08/27/25 at 2:42 PM with CNA E revealed Resident #2 had physically aggressive behaviors towards others ever since she arrived to the facility. CNA E said especially the last few days, Resident #2 had been showing signs of agitation and aggression. CNA E said Resident #2 pushed another resident in the dining room the other day and then had choked Resident #1 last night while she was upset. CNA E said Resident #2 would get upset and staff had to calm her down. CNA E said staff had to be alert and watch Resident #2 closely when she became agitated because when she got angry she was very strong in trying to push tables, chairs, and throw things. CNA E said staff would redirect her during these behaviors but the redirection did not work and Resident #2 would continue her behaviors. CNA E said when these behaviors occurred, she would tell the nurse and assumed the nurse would let the ADON/DON know. CNA E said she had not been trained on anything specific to do with Resident #2 regarding her behaviors. Interview on 08/27/25 at 11:43 AM with CNA F revealed she cared for Resident #1 yesterday and did not see any redness or scratches to her cheek or neck. CNA F said when she came to work this morning, she heard that a fight happened between Residents #1 and #2. CNA F said she figured the scratches and redness to Resident #1's cheek and neck happened from the incident with Resident #2. CNA F said that since the incident happened, the nurse was monitoring Resident #2 every 15 minutes, but she was not informed to do anything different regarding Resident #2. CNA F said Resident #2 had been calm this morning but did start to yell and after going to her side and talking to her, the resident calmed down. CNA F said Resident #2 was always agitated, wild, and out of control. CNA F said when Resident #2 got that way staff tried to calm her down by giving her something to drink or taking her somewhere else to calm down. CNA F said sometimes those interventions helped Resident #2 to calm down, and sometimes they did not. CNA F said when redirection did not work, they would leave Resident #2 alone and just monitor her closely because she would try to go to other resident's rooms. CNA F said one day she saw Resident #2 trying to get into her roommate's bed and was trying to get the roommate out of the bed. CNA F said she rushed into the room to stop Resident #2 from hurting the roommate and nothing happened. Interview on 08/27/25 at 1:24 PM with CNA H revealed she had only been working at the facility for a month but knew Resident #2 was easily agitated. CNA H said she had never seen Resident #2 be physically aggressive with another resident. CNA H said she knew to follow closely behind Resident #2 and make sure she was safe and not going to hurt anyone because she wandered around a lot. CNA H said Resident #2 was on every 15-minute checks right now because of what happened. CNA H said if she saw any resident trying to hurt another resident she would separate them and call for the nurse. CNA H said she knew when Resident #2 got upset, staff needed to help calm her down by offering her something to drink or eat. Interview on 08/27/25 at 2:49 PM with CNA I revealed Resident #2 was very erratic at times and when she got that way she would try to hurt other residents and staff. CNA I said staff would try to redirect Resident #2 to calm her down but it did not work because she did not want to be redirected. CNA I said last night specifically, Resident #2 was very upset and was behaving so badly that she was sitting at a table trying to push it away and knock residents out of their wheelchairs while hitting and swinging at them. CNA I said Resident #2 put her hands around Resident #1's neck to choke her. CNA I said when she saw Resident #1 before the incident, she did not have any marks on her cheek or neck but after the incident, Resident #1 had red spots on her cheek and neck. CNA I said Resident #2 also had a habit of wanting to get in her roommate's bed even while the resident was in the bed and if staff tried to stop her she would get more upset. CNA I said Resident #2's roommate was moved out of her room last night so that she would be safe. CNA I said Resident #2's behaviors were unpredictable in that she would be walking around and then walk up to a resident and start trying to be physical towards them. CNA I said there was not a trigger causing Resident #2's behaviors that she could identify. CNA I said Resident #2 had acted this way ever since she got to the facility, but her behavior was getting worse. CNA I said she had not talked to anyone in management about Resident #2's behaviors because she was told to just redirect her even though she refused the redirection. CNA I said the nurse on shift knew about Resident #2's behaviors and she thought the nurse would report everything to management. CNA I said before Resident #2 choked Resident #1, she had not harmed or hurt any other resident. Follow-up interview on 08/27/25 at 4:08 PM with CNA I revealed after Resident #2 had choked Resident #1, Resident #1 was very upset and scared. CNA I said she herself was also scared after the incident, and Resident #1 seemed very emotional afterwards asking why someone would do that to her. CNA I said she tried to calm her down and assure her she was safe. Interview on 08/27/25 at 2:37 PM with the MDS Coordinator revealed she was ultimately responsible for updating resident's care plans, but all nurses could update them as well. The MDS Coordinator said she had not heard that Resident #2 had behaviors towards others so she did not know to update her care plan to address them. The MDS Coordinator said she attended all the clinical morning meetings where staff would discuss such behaviors and then she would update the resident's care plan then. Interview on 08/27/25 at 1:10 PM with ADON G revealed she understood that Resident #2 had sporadic behaviors at times, like when she went towards Resident #1 and grabbed her neck. ADON G said staff were able to separate the two residents during the incident. ADON G said they have been dealing with Resident #2 because she gets agitated but they thought it was because she was in a new environment since she was a newer admit and needed time to adjust. ADON G said Resident #2 has these sporadic moments where staff did not know what was going to happen so they closely monitored her. ADON G said she was not sure if the redness and scratches to Resident #1's cheek and neck were from the incident with Resident #2 or not because she had not seen them for herself yet. Follow-up interview on 08/27/25 at 1:41 PM with ADON G revealed she saw Resident #1 and noticed she had 4 dots, 2 of which were prominent but dried up and closed now. ADON G said she thought the redness to Resident #1's skin was from a scratch but she could not be sure. ADON G said Resident #2 had been physically aggressive with staff before the incident with Resident #1 but she had swung towards other residents before, just never made contact with them. ADON G said Resident #2 had also pushed another resident on Monday (08/25/25) in the dining room but that resident did not sustain any injuries. ADON G said she was not sure what interventions were put in place to keep other residents safe from Resident #2's physically aggressive behaviors but she would have the Psych NP review her medications again. ADON G said she knew the Psych NP already ordered PRN Ativan gel and Seroquel to help with Resident #2's behaviors but staff were reporting that the medications were not working. ADON G said she was going to have to meet with the IDT to see what the next steps were for Resident #2. ADON G said she also received a report that Resident #2 tried to get in her roommate's bed and move the roommate out of the bed but the CNA intervened and stopped it from happening. ADON G said right now, Resident #2 was being monitored every 15 minutes by the nurse until the facility could decide what next steps to take with her regarding her behaviors. ADON G said what happened between Residents #1 and #2 was considered physical abuse. ADON G said that all residents had the right to be free from abuse. ADON G said that staff had been in-serviced regarding abuse as they went over who the AC was for the facility, the types of abuse, and what to do when someone abuses someone and how quickly to report abuse. ADON G said she did Interview on 08/27/25 at 2:06 PM with the DON revealed she was told last night that Resident #2 had tried to choke Resident #1 but staff were able to separate the two residents. The DON said Resident #2 was placed on every 15-minute checks by the nurse and then she herself came to the building. The DON said Resident #2 had a roommate at the time who was moved out of the room for her safety. The DON said staff also gave Resident #2 a shower and she fought during that which was normal behavior for her. The DON said after that Resident #2 went to bed. The DON said the NP was contacted and responded that a psychiatric evaluation needed to be completed. The DON said the Psych NP came today (08/27/25) to meet and evaluate Resident #2. The DON said Resident #2 was just ordered Seroquel a few days ago and had not had the chance to become effective. The DON said she looked at Resident #1 while she was here and she was upset but calmed down and sat at the nurse's station. The DON said she noticed two spots on Resident #1's neck and cheek but she was not sure if they were caused by the incident with Resident #2 or not. The DON said the two spots looked dry and scabbed over. The DON said she knew about Resident #2's behaviors because she was told on Monday that the resident had pushed another resident. The DON said she was told by staff that Resident #2 was resistive to care and would fight with staff but never tried to attack residents. The DON said if the staff did not tell her what was happening with Resident #2, she could not fix anything or address her behaviors. The DON said sometimes she reviewed staff's charting and the 24-hour report but it was not a regular occurrence for her. The DON said the plan to address Resident #2's behaviors now were that the Psych NP was going to adjust her medications after his evaluation. The DON said she knew to help clam Resident #2 down, she liked to go outside when she was agitated so that was an intervention staff could use. The DON said Resident #2's care plan did not address her behaviors because before this incident she was not aware of them. The DON said the ADON and the MDS Coordinator were responsible for updating a resident's care plan if they knew what to update it with. The DON said the purpose of the care plan was to know what interventions should be used to address the situation or behavior. The DON said if the care plan was not updated for a resident, then staff would not know how to manage the resident's behavior and things could escalate. The DON said what happened between Residents #1 and #2 was considered physical abuse. The DON said all residents should be free from abuse. The DON said all staff were responsible for ensuring all residents were free from abuse. The DON said if residents were not free from abuse, they were at risk of potential injury, death, and being harmed. The DON said all staff had been trained on the facility's policy regarding abuse, specifically going over who to report abuse to, the types of abuse, and the timeliness to report abuse. Interview on 08/27/25 at 3:15 PM with the Administrator revealed she was told by the DON that Resident #2 had put her hands around Resident #1's neck. The Administrator said she and the DON got to the facility to get the statements from the nurse and CNA about what happened. The Administrator said the CNA told her that she was nearby Resident #2 who walked towards Resident #1 and started grabbing her neck. The Administrator said the CNA had quickly removed Resident #2's hands from Resident #1 and then separated the residents. The Administrator said Resident #2 was placed on every 15-minute checks by the nurse after everything was settled. The Administrator said the DON started an abuse in-service with staff that went over who to report abuse to, the types of abuse, and how quickly staff were supposed to report abuse. The Administrator said she did not look to see if Resident #1 had any injuries from Resident #2 or not. The Administrator said the 6 AM to 2 PM nurse, LVN B, came to the morning clinical meetings and would explain that she got agitated with staff and she would be redirected and kept away from other residents. The Administrator said no other shift nurses reported to the clinical meetings, it was only the 6 AM to 2 PM shift nurses. The Administrator said other shift nurses reported things on the 24-hour report or would call the DON to let her know what was going on, such as if a resident began to have behaviors. The Administrator said she knew CNA's were told to redirect Resident #2 and get her involved in some type of activity, take her outside, or play some music. The Administrator said she heard that Resident #2 had pushed another resident a few days ago but that resident did not have any injuries from the situation. The Administrator said she had not been told that Resident #2 had been swinging at or trying to hit other residents. The Administrator said she could only intervene if she knew what was happening and since she did not know about Resident #2's behaviors, she could not put things in place. The Administrator said she expected staff to communicate with her when a resident showed signs of increased agitation and behaviors. The Administrator said if she knew about the extent of Resident #2's behaviors she could have taken other steps to ensure the residents' safety, such as transferring her to be evaluated. The Administrator said Resident #2's care plan was not updated either to reflect her behaviors because the management staff did not know about it. The Administrator said she was the abuse coordinator for the facility, and this situation was considered physical abuse. The Administrator said all residents had the right to be free from abuse and all staff were responsible for making sure they were. The Administrator said if residents were not free from abuse they would be harmed or have some type of trauma happen to them up to and including death. Phone interview on 08/28/25 at 9:32 AM with the Psych NP revealed Resident #2 was physically aggressive during moments of agitation and was difficult to redirect. The Psych NP said staff had been communicating with him about the increase in her behaviors and he had added orders for a PRN Ativan gel and Seroquel more recently. The Psych NP said he noticed during his meetings with her that she was uncooperative, non-compliant, and had disorganized speech and he was not sure what was causing all of these behaviors. The Psych NP said staff also explained to him how difficult Resident #2 was to manage and control, that she had taken off the tank to the toilet and the soap dispensers from the walls, she was wheeling another resident down the hall in her wheelchair in an aggressive manner, and now she had choked another resident. The Psych NP said Resident #2's behaviors were quite frequent and often from what he had witnessed and was told. The Psych NP said from what he was told and understood, staff were trying to minimize her behaviors the be

Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of six residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #2, who had prior behaviors towards others, did not physically abuse Resident #1. On 08/26/25, Resident #2 had her hands around Resident #1's neck and had to be separated by facility staff. An Immediate Jeopardy (IJ) situation was identified on 08/27/25. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse. Findings included: Review of Resident #1's Quarterly MDS Assessment, dated 05/02/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score was 05, which indicated severe cognitive impairment. Resident #1 did not have any physical or verbal behaviors towards others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Depression (a mood disorder that causes persistent sadness and changes in how you think, sleep, eat, and act). Review of Resident #1's care plan, revised 11/17/24, reflected: Focus: The resident is/has potential to be physically/verbally aggressive and resistive to care r/t Dementia.Interventions/Tasks: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. Review of Resident #1's skin assessment, dated 08/27/25 at 4:43 AM, reflected the resident had redness and an open spot on the right side of her neck and redness/spot on her right cheek. Review of Resident #1's Progress Notes reflected the following: LVN A wrote on 08/26/25 at 7:48 PM: The resident was attacked by an aggressive resident in the dining room. The aggressive resident was seen by the CNA putting her hand around the resident's neck [Resident #1] in the dining room. Nurse and CNA immediately ran towards them and intervened. Upon assessment, no injury noted. resident [sic] denies pain. Resident was redirected and taken to another seat away from the aggressive resident. NP and DON notified. Observation and interview on 08/27/25 at 10:40 AM with Resident #1 revealed she was sitting in a chair in the dining room. Resident #1 said she was doing great today. Resident #1 was observed to have redness to the right side of her neck that appeared to be a bruise that was about two inches long and an inch wide with a small open area. Resident #1 also appeared to have a small scratch to the right side of her cheek on her jawline that was also reddened. Resident #1 said she did not know what happened to her cheek or neck but it did not bother her. Review of Resident #2's admission MDS Assessment, dated 07/29/25, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score could not be conducted, but it was noted she had both short-term and long-term memory problems and could not make her own daily decisions. She was noted to not have any physical or verbal behaviors towards others but wandered daily that intruded on the privacy or activity of others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). Review of Resident #2's Physician's Orders, dated 08/27/25, reflected the following:- Ativan Gel 0.5mg q 12 hours prn apply topically every 12 hours as needed for agitation for 14 days- Seroquel Oral Tablet 25 MG Give 1 Tablet by mouth two times a day for agitation Review of Resident #2's Treatment Administration Record reflected the following: - Resident #2 was administered the Ativan Gel (which had an order start date of 08/13/25) on the following dates: 08/14/25, 08/16/25, 08/17/25, 08/18/25, 08/19/25, 08/20/25, 08/24/25, 08/25/25, and 08/26/25. - Resident #2 was noted to have behaviors on the following dates as monitored for psychoactive behaviors: 08/02/25, 08/03/25, 08/08/25, 08/09/25, 08/14/25, 08/16/25, 08/17/25, 08/20/25, 08/21/25, 08/23/25, 08/24/25, 08/25/25, and 08/26/25. - Resident #2 was administered the Seroquel (which had a start date of 08/25/25) on the following dates: 08/25/25, 08/26/25, and 08/27/25. Review of Resident #2's Progress Notes reflected the following entries: - LVN B wrote on 07/25/25 at 2:57 PM: Resident follow up on new admit, resident continue pacing down the hallway, attempt to push fire alarm during this shift, resident continue to monitor [sic] - LVN C wrote on 07/27/25 at 1:39 AM: The resident woke up, and was very agitated, throwing around everything she could come across in her room. She was yelling out at the staff when they were offering incontinent care to her. She was calmed down and laid back to bed but still kept on waking up and coming out of her room, and re-direction was done appropriately. - LVN D wrote on 07/27/25 at 8:49 PM: Resident combative with incontinent care. She came out from the room and started pushing dining table and chairs. Resident able to redirect, sleeping in bed at this time. No s/s of acute distress noted. Bed in low position, call light within reach. - LVN C wrote on 07/28/25 at 2:14 AM: The resident woke up and was banging stuff in her room and bathroom. Staff redirected her back to bed, but she was combative, and yelling. She was brought to the dining room via wheelchair but kept standing up and pushing the tables and chairs around. She wandered through the hallway back and forth. She was redirected back to her room and agreed to lay back in bed. Right now, she is resting in bed eyes closed. - LVN B wrote on 08/07/25 at 8:47 AM: Resident going all other [sic] resident room [sic] attempting to pull them from the bed staffs [sic] continue redirecting the resident. - LVN A wrote on 08/08/25 at 1:01 AM: Resident is combative, non-compliant to care, yelling and destroying anything within her reach. Resident refused to sleep, attempting to pull roommate from the bed. All efforts to redirect resident is ineffective. NP and DON notified. - LVN C wrote on 08/10/25 at 6:29 AM: The resident pacing [sic] in the hallway entering into other patients' rooms and banging doors and throwing everything she comes across. At the dining room at the moment, throwing chairs all over and moving tables around. - LVN A wrote on 08/26/25 at 9:40 PM: Resident noted with aggressive behavior. She was seen by the CNA putting her hand around another resident's neck [Resident #1] in the dining room. Nurse and CNA immediately ran towards them and intervened. Resident was fighting and kicking staff while being redirected. PRN Ativan gel was applied with little effect. Resident also tried to pull her roommate from the bed earlier today per therapist. NP and DON notified. Resident's RP informed. Resident is currently on Q 15 mins checks for behavior. she [sic] is lying in bed in the room no behavior [sic] noted at this time. - LVN C wrote on 08/27/25 at 1:10 AM: The resident is on aggressive behavior monitoring q 15 minutes. Resident is in bed at the moment sleeping. - LVN C wrote on 08/27/25 at 5:15 AM: The resident woke up and started throwing stuff in her room. The nursing staff tried to redirect and offer incontinent care, but the resident was extremely aggressive/combative. The staff left the room. The resident kept yelling from her room. Review of Resident #2's care plan, revised on 08/14/25, did not reflect anything regarding her aggressive behaviors. Review of Resident #2's Psychiatric Initial Assessment, dated 07/30/25, reflected the following: .Patient referred for medical management services for sx including Agitation, Adjustment Disorder, Noncompliance, Verbal Aggression, Physical Aggression. Patient made eye contact with provider when approached, but was unable to appropriately participate/interact. Staff report frequent periods of anxiousness/restlessness and difficulty with redirection being exhibited by patient.At this time, recommend increasing frequency of Ativan to 0.5 mg/TID per frequent symptoms of anxiety and difficulty with redirection. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/06/25, reflected the following: .During previous visit, Ativan frequency increased to TID due to reported periods of agitation and behavioral concerns. Staff states agitation decreased but continues during periods of care. Staff also report patient frequently pacing throughout secured unit and wandering into other residents rooms. Staff reports patient being aggressive and difficult to calm/redirect.At this time, due to reported continued periods of agitation and aggression during periods of care, recommend initiation of Ativan gel 0.5 mg/Q12 HR PRN X 14 days for acute agitation/aggressive behavior. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/20/25, reflected the following: .Staff reports continued behavioral concerns being exhibited by patient. Per ADON, patient reported to have ‘taken the tank off of her toilet and breaking it, as well as tearing soap dispensers off the wall.' Nursing staff within secured unit report patient often ‘easily agitated and physically aggressive. Staff states patient will attempt to hit staff during attempted periods of care. When attempting to initiate assessment, patient was found leaning over another resident within secured unit, whom was sitting on her wheelchair, and pushing her down the hall.'.At this time, due to reported symptoms of disorganized/delusional thoughts reported, Recommend [sic] initiation of Seroquel 25 mg/BID. Review of Resident #2's Psychiatric Subsequent Assessment, dated 08/27/25, reflected the following: .During previous visit, Seroquel 25 mg/BID order recommended.Staff states the day prior to exam, patient exhibited ongoing physically aggressive behaviors and ‘Choked [sic] another resident.' Per note in [EHR], on 8/26, patient was observed by the CNA ‘putting her hand around another resident's neck' in the dining room of the secured unit. During attempted intervention by nurse and CNA, patient was ‘fighting and kicking staff' during attempted redirection. Resident was placed on Q15 min safety checks, and staff denied observing physically aggressive behaviors being exhibited prior to today's assessment.Due to minimal symptom relief with currently ordered Ativan, recommend discontinuation of Ativan and initiation of clonazepam 0.5 mg/TID with consent from POA. Observation and attempted interview on 08/27/25 at 10:35 AM with Resident #2 revealed she was sitting in a chair in the dining room mumbling to herself. Resident #2 did not look the state surveyor's way or at the state surveyor until the state surveyor continued trying to talk to her. Resident #2 appeared calm but was not able to answer any questions. Phone interview on 08/28/25 at 9:32 AM with the Psych NP revealed Resident #2 was physically aggressive during moments of agitation and was difficult to redirect. The Psych NP said staff had been communicating with him about the increase in her behaviors and he added orders for a PRN Ativan gel and Seroquel more recently. The Psych NP said he noticed during his meetings with her that she was uncooperative, non-compliant, and had disorganized speech and he was not sure what was causing all of these behaviors. The Psych NP said staff also explained to him how difficult Resident #2 was to manage and control, that she had taken off the tank to the toilet and the soap dispensers from the walls, she was wheeling another unknown resident down the hall in her wheelchair in an aggressive manner, and now she had choked another resident (Resident #1). The Psych NP said Resident #2's behaviors were quite frequent and often from what he had witnessed and was told. The Psych NP said from what he was told and understood, staff were trying to minimize her behaviors the best they could and limited her interactions with others. The Psych NP said it was almost to the point that she needed 1:1 care because her behaviors were so severe. The Psych NP said he was working to get her on the right medication regiment hoping that would help to reduce her behaviors. Interview on 08/27/25 at 10:23 AM with LVN B revealed she got report from the night nurse this morning that Resident #2 attacked or scratched Resident #1 yesterday. LVN B said Resident #1 had some redness to her neck that looked like it was a scratch but she was not sure if it was from the incident with Resident #2 or not. LVN B said Resident #2 wandered a lot around the unit and was a difficult resident to handle. LVN B said Resident #2 would get mad and yell and be agitated for no reason. LVN B said staff were monitoring Resident #2 every 15 minutes right now by just keeping an eye on her in general and noting where she was or what she was doing. LVN B said Resident #2 tried to touch other residents but staff usually intervened before anything could happen because if anyone was near her anything could set her off. LVN B said when Resident #2 started to show agitation, staff would try to calm her down by singing with her, taking her for a walk outside, or getting her something to eat or drink. LVN B said Resident #2's behaviors were unpredictable and there was no trigger for it. LVN B said she was not sure if she had been trained on what to do specifically with Resident #2 in order to decrease her behaviors or reduce her agitation. LVN B said she had never seen Resident #2 be physically aggressive with another resident during her shift. Follow-up interview on 08/27/25 at 10:40 AM with LVN B revealed she saw Resident #1's reddened areas to her neck and cheek but could not recall if the reddened areas were there yesterday or not. LVN B said she did not pay much attention to Resident #1 yesterday, so she was not sure if the reddened areas were a result of the incident with Resident #2 or not. Attempted phone interview on 08/27/25 at 11:04 AM with CNA D, who worked with Residents #1 and #2 on 08/26/25, was unsuccessful as she did not answer or call back prior to exit. Attempted phone interview on 08/27/25 at 11:05 AM with LVN C, who worked with Residents #1 and #2 on 08/26/25, was unsuccessful as she did not answer or call back prior to exit. Phone interview on 08/27/25 at 11:08 AM with LVN A revealed she was at the nurses' station when she heard CNA E yelling, She's about to choke the resident. LVN A said she and CNA E ran towards Residents #1 and #2 and when they got to them, Resident #2's hand was round Resident #1's neck. LVN A said her and CNA E were able to pull Resident #2's hand away from Resident #1's neck, but Resident #2 continued to fight staff while trying to redirect her. LVN A said when she assessed Resident #1 she saw there were reddened and open areas on Resident #1's neck and cheek, but she did not think that was related to the incident, but that it was a rash. LVN A said Resident #2 had physically aggressive behaviors such as she pushed another unknown resident in the dining room on Monday, which was reported to the Abuse Coordinator, but the resident did not sustain any injuries. LVN A said she communicated with the Psych NP about Resident #2's behaviors and PRN Ativan gel was added to her orders. LVN A said when Resident #2 became agitated and unable to be redirected, she would apply the gel. Follow-up interview on 08/27/25 at 3:03 PM with LVN A revealed she did not check Resident #1's skin prior to the incident and did not know if it was due to the incident or a rash. LVN A said she only noticed the rash after the incident because she had to do a skin assessment. LVN A was unable to say how long Resident #1 had the rash to her skin and could not describe what it looked like. LVN A said Resident #2 was having an increase in her agitation and physical behaviors. LVN A said when Resident #2 first came to the facility, she was flinging chairs and tables around the dining room. LVN A said she reported this to the NP who ordered new medications, but Resident #2's behaviors did not change. LVN A said that was when the NP ordered the PRN Ativan gel but it did not work either. LVN A said she did communicate with the DON when she saw Resident #2 become physically aggressive with other residents. LVN A showed a text message exchange between her and the DON from 08/08/25 discussing Resident #2's agitation and physically aggressive behaviors regarding resisting care and destroying anything within her reach. LVN A said she knew to report any incident to the DON immediately that concerned residents. Phone interview on 08/27/25 at 11:21 AM with CNA E revealed Resident #2 was very aggressive last night and very agitated. CNA E said Resident #2 was trying to pull the table and chairs in the dining room. CNA E said she tried to move closer to Resident #2 and get her to calm down by talking to her but the resident refused. CNA E said she also tried redirecting her but again, Resident #2 refused. CNA E said when she moved closer to Resident #2, Resident #2 moved closer to Resident #1 and grabbed her neck, choking her. CNA E said she rushed towards the residents and tried to separate them and pulled Resident #2's hands off Resident #1's neck. CNA E said this behavior was normal for Resident #2 because she was always agitated and aggressive. CNA E said when Resident #2 became agitated she would try to calm her down, move close to her, and talk to her. CNA E said Resident #2 was very strong and would fight staff during care and drag staff to the ground because she was so strong. CNA E said staff would have to act fast to be near her to make sure she did not harm other residents. CNA E said she did everything she could to try and keep Resident #2 from hurting others, but nothing seemed to work. Follow-up interview on 08/27/25 at 2:42 PM with CNA E revealed Resident #2 had physically aggressive behaviors towards others ever since she arrived at the facility. CNA E said especially the last few days, Resident #2 had been showing signs of agitation and aggression. CNA E said Resident #2 pushed another resident in the dining room the other day and then had choked Resident #1 last night while she was upset. CNA E said Resident #2 would get upset and staff had to calm her down. CNA E said staff had to be alert and watch Resident #2 closely when she became agitated because when she got angry she was very strong and tried to push tables, chairs, and throw things. CNA E said staff would redirect her during these behaviors, but the redirection did not work and Resident #2 would continue her behaviors. CNA E said when these behaviors occurred, she would tell the nurse and assumed the nurse would let the ADON/DON know. Interview on 08/27/25 at 11:43 AM with CNA F revealed she cared for Resident #1 yesterday (08/26/25) and did not see any redness or scratches to her cheek or neck. CNA F said when she came to work this morning, she heard a fight happened between Residents #1 and #2. CNA F said she figured the scratches and redness to Resident #1's cheek and neck happened from the incident with Resident #2. CNA F said since the incident happened, the nurse was monitoring Resident #2 every 15 minutes, but she was not informed to do anything different regarding Resident #2. CNA F said Resident #2 was calm this morning, but she did start to yell. After going to the resident's side and talking to her, the resident calmed down. CNA F said Resident #2 was always agitated, wild, and out of control. CNA F said when Resident #2 got that way staff tried to calm her down by giving her something to drink or taking her somewhere else to calm down. CNA F said sometimes those interventions helped Resident #2 calm down, and sometimes they did not. CNA F said when redirection did not work, they would leave Resident #2 alone and just monitor her closely because she would try to go to other resident's rooms. CNA F said one day she saw Resident #2 trying to get into her roommate's bed and was trying to get the roommate out of the bed. CNA F said she rushed into the room to stop Resident #2 from hurting the roommate and nothing happened. Interview on 08/27/25 at 1:24 PM with CNA H revealed she had only been working at the facility for a month but knew Resident #2 was easily agitated. CNA H said she never seen Resident #2 be physically aggressive with another resident. CNA H said she knew to follow closely behind Resident #2 and make sure she was safe and not going to hurt anyone because she wandered around a lot. CNA H said Resident #2 was on every 15-minute checks right now because of what happened. CNA H said if she saw any resident trying to hurt another resident she would separate them and call for the nurse. CNA H said she knew when Resident #2 got upset, staff needed to help calm her down by offering her something to drink or eat. Interview on 08/27/25 at 2:49 PM with CNA I revealed Resident #2 was very erratic at times and when she got that way she would try to hurt other residents and staff. CNA I said staff would try to redirect Resident #2 to calm her down but it did not work because she did not want to be redirected. CNA I said last night specifically, Resident #2 was very upset and was behaving so badly, she was sitting at a table trying to push it away and knock residents out of their wheelchairs while hitting and swinging at them. CNA I said Resident #2 put her hands around Resident #1's neck to choke her. CNA I said when she saw Resident #1 before the incident, she did not have any marks on her cheek or neck but after the incident, Resident #1 had red spots on her cheek and neck. CNA I said Resident #2 also had a habit of wanting to get in her roommate's bed even while the resident was in the bed and if staff tried to stop her she would get more upset. CNA I said Resident #2's roommate was moved out of her room last night so she would be safe. CNA I said Resident #2's behaviors were unpredictable in that she would be walking around and then walk up to a resident and start trying to be physical towards them. CNA I said there was not a trigger causing Resident #2's behaviors that she could identify. CNA I said Resident #2 acted this way ever since she got to the facility, but her behavior was getting worse. CNA I said she had not talked to anyone in management about Resident #2's behaviors because she was told to just redirect her even though she refused the redirection. CNA I said the nurse on shift knew about Resident #2's behaviors and she thought the nurse would report everything to management. CNA I said before Resident #2 choked Resident #1, she had not harmed or hurt any other resident. Follow-up interview on 08/27/25 at 4:08 PM with CNA I revealed after Resident #2 had choked Resident #1, Resident #1 was very upset and scared. CNA I said she herself was also scared after the incident, and Resident #1 seemed very emotional afterwards asking why someone would do that to her. CNA I said she tried to calm her down and assured her she was safe. Interview on 08/27/25 at 2:37 PM with the MDS Coordinator revealed she was ultimately responsible for updating the resident's care plans, but all nurses could update them as well. The MDS Coordinator said she had not heard Resident #2 had behaviors towards others so she did not know to update her care plan to address them. The MDS Coordinator said she attended all the clinical morning meetings where staff would discuss such behaviors and then she would update the resident's care plan then. Interview on 08/27/25 at 1:10 PM with ADON G revealed she understood Resident #2 had sporadic behaviors at times, like when she went towards Resident #1 and grabbed her neck. ADON G said staff were able to separate the two residents during the incident. ADON G said they were dealing with Resident #2 because she got agitated but they thought it was because she was in a new environment since she was a newer admit and needed time to adjust. ADON G said Resident #2 had these sporadic moments where staff did not know what was going to happen, so they closely monitored her. ADON G said she was not sure if the redness and scratches to Resident #1's cheek and neck were from the incident with Resident #2 or not, because she had not seen them for herself yet. Follow-up interview on 08/27/25 at 1:41 PM with ADON G revealed she saw Resident #1 and noticed she had 4 dots, two of which were prominent but dried up and closed now. ADON G said she thought the redness to Resident #1's skin was from a scratch but she could not be sure. ADON G said Resident #2 was physically aggressive with staff before the incident with Resident #1 but she had swung towards other residents before, just never made contact with them. ADON G said Resident #2 had also pushed another resident on Monday (08/25/25) in the dining room but the resident did not sustain any injuries. ADON G said she was not sure what interventions were put in place to keep other residents safe from Resident #2's physically aggressive behaviors but she would have the Psych NP review her medications again. ADON G said she knew the Psych NP already ordered PRN Ativan gel and Seroquel to help with Resident #2's behaviors but staff reported the medications were not working. ADON G said she was going to have to meet with the IDT to see what the next steps were for Resident #2. ADON G said she also received a report that Resident #2 tried to get in her roommate's bed and move the roommate out of the bed but the CNA intervened and stopped it from happening. ADON G said right now, Resident #2 was being monitored every 15 minutes by the nurse until the facility could decide what next steps to take with her regarding her behaviors. ADON G said what happened between Residents #1 and #2 was considered physical abuse. ADON G said all residents had the right to be free from abuse. ADON G said staff were in-serviced regarding abuse as they went over who the abuse coordinator was for the facility, the types of abuse, and what to do when someone abused someone and how quickly to report abuse. Interview on 08/27/25 at 2:06 PM with the DON revealed she was told last night Resident #2 tried to choke Resident #1 but staff were able to separate the two residents. The DON said Resident #2 was placed on every 15-minute checks by the nurse and then she, herself, came to the building. The DON said Resident #2 had a roommate at the time who was moved out of the room for her safety. The DON said staff also gave Resident #2 a shower and she fought during that, which was normal behavior for her. The DON said after Resident #2 went to bed. The DON said the NP was contacted and responded a psychiatric evaluation needed to be completed. The DON said the Psych NP came today (08/27/25) to meet and evaluate Resident #2. The DON said Resident #2 was just ordered Seroquel a few days ago and had not had the chance to become effective. The DON said she looked at Resident #1 and she was upset but calmed down and sat at the nurse's station. The DON said she noticed two spots on Resident #1's neck and cheek but she was not sure if they were caused by the incident with Resident #2 or not. The DON said the two spots looked dry and scabbed over. The DON said she knew about Resident #2's behaviors because she was told on Monday the resident pushed another resident. The DON said she was told by staff Resident #2 was resistive to care and would fight with staff but never tried to attack residents. The DON said if the staff did not tell her what was happening with Resident #2, she could not fix anything or address her behaviors. The DON said sometimes she reviewed staff's charting and the 24-hour report but it was not a regular occurrence for her. The DON said the plan to address Resident #2's behaviors now were that the Psych NP was going to adjust her medications after his evaluation. The DON said she knew to help clam Resident #2 down, she liked to go outside when she was agitated so that was an intervention staff could use. The DON said Resident #2's care plan did not address her behaviors because before this incident she was not aware of them. The DON said the ADON and the MDS Coordinator were responsible for updating a resident's care plan if they knew what to update it with. The DON said the purpose of the care plan was to know what interventions should be used to address the situation or behavior. The DON said if the care plan was not updated for a resident, then staff would not know how to manage the resident's behavior and things could escalate. The DON said what happened between Residents #1 and #2 was considered physical abuse. The DON said all residents should be free from abuse. The DON said all staff were responsible for ensuring all residents were free from abuse. The DON said if residents were not free from abuse, they were at risk of potential injury, death, and being harmed. The DON said all staff were trained on the facility's policy regarding abuse, specifically going over who to report abuse to, the types of abuse, and the timeliness to report abuse. Interview on 08/27/25 at 3:15 PM with the Administrator revealed she was told by the DON Resident #2 had put her hands around Resident #1's neck. The Administrator said she and the DON got to the facility to get the statements from the nurse and CNA about what happened. The Administrator said the CNA told her she was nearby Resident #2 who walked towards Resident #1 and started grabbing her neck. The Administrator said the CNA quickly removed Resident #2's hands from Resident #1 and then separated the residents. The Administrator said Resident #2 was placed on every 15-minute checks by the nurse after everything was settled. The Administrator said the DON started an abuse in-service with staff that went over who to report abuse to, the types of abuse, and how quickly staff were supposed to report abuse. The Administrator said she did not look to see if Resident #1 had any injuries from Resident #2 or not. The Administrator said the 6 AM to 2 PM nurse, LVN B, came to the morning clinical meetings and would explain the resident got agitated with staff and she would be redirected and kept away from other residents. The Administrator said no other shift nurses reported to the clinical meetings, it was only the 6 AM to 2 PM shift nurses. The Administrator said other shift nurses reported things on the 24-hour report or would call the DON to let her know what was going on, such as if a resident began to have behaviors. The Administrator said she knew CNA's were told to redirect Resident #2 and get her involved in some type of activity, take her outside, or play some music. The Administrator said she heard Resident #2 pushed another resident a few days ago but the resident did not have any injuries from the situation. The Administrator said she was not told Resident #2 had been swinging at or trying to hit other residents. The Administrator said she could only intervene if she knew what was happening and since she did not know about Resident #2's behaviors, she could not put things in place. The Administrator said she expected staff to communicate with her when a resident showed signs of increased agitation and behaviors. The Administrator said if she knew about the extent of Resident #2's behaviors she could have taken other steps to ensure the residents' safety, such as transferring her to be evaluated. The Administrator said Resident #2's care plan was not updated either to reflect her behaviors because the management staff did not know about it. The Administrator said she was the abuse coordinator for the facility, and this situation was considered physical abuse. The Administrator said all residents had the right to be free from abuse and all staff were responsible for making sure they were. The Administrator said if residents were not free from abuse they would be harmed or have some type of trauma happen to them up to and including death. Review of the facility's policy, revised 06/24/24, and titled Abuse, Neglect and Exploitation reflected: Definitions: ‘Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for one of five residents (Resident #2) reviewed for unnecessary medications.The facility failed when ADON J did not ensure Resident #2, who had a diagnosis of Alzheimer's disease (dementia), was not prescribed an antipsychotic medication, Seroquel, without a diagnosis for the use of the antipsychotic and that was not approved for treatment of patients with dementia-related psychosis. The Psych NP said he had ordered the Seroquel for Resident #2's unspecified psychosis which he diagnosed her with after meeting Resident #2 a few times. Resident was administered Seroquel on 08/25/25, 08/26/25, and 08/27/25. This failure could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate indication. Findings included: Review of Resident #2's admission MDS Assessment, dated 07/29/25, reflected she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her BIMS score could not be conducted, but it was noted she had both short-term and long-term memory problems and could not make her own daily decisions. She was noted to not have any physical or verbal behaviors towards others but did wander daily that intruded on the privacy or activity of others. Her active diagnoses included Alzheimer's Disease (a brain condition that gradually destroys memory and cognitive skills, interfering with daily life) and Insomnia (a common sleep disorder that can make it hard to fall asleep or stay asleep). Review of Resident #2's Physician's Orders reflected the following:- Seroquel Oral Tablet 25 MG Give 1 Tablet by mouth two times a day for agitation with an active order date of 08/25/25 Review of Resident #2's Treatment Administration Record reflected the following:- Resident #2 was administered the Seroquel on the following dates: 08/25/25, 08/26/25, and 08/27/25. Observation and attempted interview on 08/27/25 at 10:35 AM with Resident #2 revealed she was sitting in a chair in the dining room mumbling to herself. Resident #2 did not look the surveyor's way or at the surveyor until the surveyor continued trying to talk to her. Resident #2 appeared calm but was not able to answer any questions. Phone interview on 08/28/25 at 9:32 AM with the Psych NP revealed Resident #2 was physically aggressive during moments of agitation and was difficult to redirect. The Psych NP said staff had been communicating with him about the increase in her behaviors and he had added orders for a PRN Ativan gel and Seroquel more recently. The Psych NP said he had ordered the Seroquel for Resident #2's unspecified psychosis which he diagnosed her with after meeting with her a few times. The Psych NP said he provides the facility with his notes and any additional new diagnoses as well as any new medication orders. The Psych NP said the order should have specified Resident #2's diagnosis for the medication. Interview on 08/28/25 at 3:51 PM with ADON J revealed he added Resident #2's order to her chart for Seroquel. ADON J said the indication for use of the medication was agitation but that was not the associating diagnosis. ADON J said he should have added the associating diagnosis to the order. ADON J said the purpose of this was to ensure the resident has appropriate medications for appropriate things. ADON J said if the diagnosis was not with the order, the wrong medication could be used for the resident. ADON J said he had been trained to make sure the diagnosis was included with the medication order. Interview on 08/28/25 at 4:21 PM with the DON revealed Resident #2's Seroquel order should have had an associating diagnosis instead of just the indication for use on it. The DON said normally the MDS Coordinator, the ADON's, and herself check resident's orders to ensure they are correct. The DON said ADON J would have been responsible for making sure the diagnosis was listed with the medication order since he was the one to add the order to her chart. The DON said the purpose of this was so that the medication was given for the right reason. The DON said if this was not done, the medication may be given for an inappropriate reason. The DON said all staff had been trained to ensure the diagnosis was always included with a medication order. Review of the facility's Psychotropic Medication Use policy, dated 2001, reflected it did not address having a diagnosis for a medication order. Review of the manufacturer's information, dated January 2025, for Seroquel (quetiapine fumarate) reflected the following black box warning: Increased Mortality in Elderly Patients with Dementia-Related Psychosis; and Suicidal Thoughts and Behaviors Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death.Seroquel (quetiapine) is not approved for the treatment of patients with Dementia-Related Psychosis.

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA B transferred her roughly from bed to a geri-chair and then slapped her hand when she attempted to hold onto the bed on 08/31/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/31/24 and ended on 09/03/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of abuse, trauma, and psychosocial harm. Findings included: Review of Resident #1's Admission Record, dated 10/31/24, reflected the resident was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Quarterly MDS Assessment, dated 07/04/24, reflected there was not a BIMS score calculated. Further review reflected a Staff Assessment for Mental Status was completed which revealed Resident #1 had a memory problem resulting in inattention and an altered level of consciousness. For the section regarding Functional Abilities and Goals reflected Resident #1 required substantial/maximal assistance with rolling left and right, lying to sitting on side of bed, and chair/bed-to-chair transfer which meant that the helper did more than half of the effort. The same section reflected Resident #1 used a manual wheelchair. Review of Resident #1's Annual MDS Assessment, dated 10/04/24, reflected for her Functional Abilities section, Resident #1 was dependent with rolling left and right and chair/bed-to-chair transfer meaning the helper did all the effort or the assistance of 2 or more helpers was required to complete the activity. Resident #1 had active diagnoses of Non-Alzheimer's Dementia (a neurodegenerative disease that starts slowly and progressively worsens), Seizure Disorder or Epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), and Senile Degeneration of Brain (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities). Review of Resident #1's progress notes reflected the following: - On 09/03/24 at 5:27 AM the DON wrote: Notified by POA that patient was the recipient of physical aggression from staff. Noted that resident was handled roughly during transfer from bed to Geri-chair and subsequently was slapped on the hand when being moved in Geri chair. No injury noted to resident at time of notification. - On 09/03/24 at 2:33 PM the DON wrote: Patient needs stat x-ray of c-spine, back, left shoulder, arm, right wrist/forearm to rule out fracture. Patient is unable to sit upright for extended periods of time independently, is unable to use right arm. - On 09/04/24 at 6:13 AM RN A wrote: The X-ray in the previous shift was done during the shift, no evidence of fractures, results sent to Dr [Physician C], she denied pain at this time, no new complaint from her, will continue with the plan of care. - On 09/05/24 at 2:00 PM the DON wrote: Resident noted to be up in Geri chair. No adverse effects noted at this time related to occurrence that happened on 8/31/24. No skin issues noted/reported at this time. Resident remains at baseline. Review of Resident #1's care plan reflected the following: - Focus: Resident has an allegation of (Abuse), Date Initiated: 09/03/2024; Goal: Resident will not experience a negative outcome from alleged event through this review period; Interventions/Tasks: Any negative event will be reported to the abuse coordinator immediately. The facility will adhere to the abuse and neglect policies and protocols. - Focus: Resident requires a mechanical lift transfer(Hoyer) r/t (inability to bear weight) 2 person assist. Date Initiated: 09/03/2024; Goal: Resident will be provided a safe transfer utilizing a mechanical lift(Hoyer)throughout the review period.; Interventions/Tasks: 1. Resident has been identified as totally dependent for transfers. 2. Lifting equipment will be operated in accordance with instruction and training. 5. Report change in conditions which may necessitate a re-evaluation of the resident and the lift. [sic] - Focus: [Resident #1] has a communication problem r/t Dementia, non-verbal .Interventions/Tasks: Ensure/provide a safe environment. Observation of the first video provided by Resident #1's POA on 10/30/24 at 8:22 AM revealed the following: The video was time stamped and dated for 08/31/24 at 6:58 AM; the video did not include any sound. The video began and Resident #1 was in bed. There was a geri-chair at the foot of the bed and CNA B began pushing the geri-chair to the side of the bed. CNA B locked the left side of the geri-chair from the back and then walked in front of the geri-chair and pulled it closer to the bed. CNA B turned to Resident #1 and pulled her legs over the side of the bed and used his left arm to raise her up. CNA B used his right hand to reposition Resident #1's knees. Resident #1 had her arms crossed on her chest and CNA B uncrossed the resident's arms to put his underneath hers to lift her up and transfer her to the geri-chair. The geri-chair began to move backwards and CNA B used his left arm to hold the geri-chair while he used his right arm to hold Resident #1 up. CNA B placed Resident #1 on her back on the geri-chair seat portion, grabbed her left leg to raise it with his right hand while his left hand went under her left arm to pull her up towards him and into the chair, but the chair began to again move backwards. CNA B put Resident #1 back in the bed and rolled her over onto the bed, pulled the geri-chair closer to the side of the bed and locked the right side of the geri-chair from the back. CNA B walked to the front of the geri-chair and to the side of Resident #1's bed where she was still lying there. CNA B turned Resident #1 over and put his right arm underneath her bent legs and used his left arm to hold her by her neck to transfer her to the geri-chair. CNA B put Resident #1 in the geri-chair perpendicular where her head and legs were on the armrests of the chair. The video ended. Observation of the second video provided by Resident #1's POA on 10/30/24 at 8:22 AM revealed the following: The video was time stamped and dated for 08/31/24 at 7:09 AM; the video did not include any sound. The video began and Resident #1 was in the geri-chair, her bed was made, and she had a blanket covering her. CNA B had a trash bag in his hand, and he grabbed something (unable to determine what it was) from Resident #1's recliner in the corner and walked behind the geri-chair and set the item down out of the camera's view. CNA B then started to pull Resident #1's geri-chair backwards with his right hand while he still had the trash bag in his left hand. Resident #1's arms and hands were underneath the blanket but could be seen on the armrests. While being wheeled backwards, Resident #1 grabs the edge of the bed when CNA B forcefully takes her arm and placed it on her lap. CNA B then smacked Resident #1's arm from on top of the blanket. Resident #1 moved her arm back to the armrest and was wheeled out of the room away from the camera's view. The video ended. Observation on 10/31/24 at 9:45 AM of Resident #1 revealed she was in a common area lying in a geri-chair. The resident was dressed and groomed. Resident #1 had her eyes closed, and she did not awaken or respond when spoken to. Resident #1 was wearing a long-sleeved shirt but did not appear to have any bruises, injuries, or pain. Observation on 10/31/24 at 12:30 PM of Resident #1 revealed she was in the dining room with her POA being assisted to eat lunch. Resident #1 was still in her geri-chair and was falling asleep during the meal. Resident #1 was not able to answer any questions or acknowledge the surveyor's presence due to her cognitive condition. Telephone interview on 10/28/24 at 12:13 PM with Resident #1's POA revealed she showed the Administrator, who was the Abuse Coordinator, a video of Resident #1 being abused by CNA B from 08/31/24. Resident #1's POA said she showed the Administrator the video on 09/03/24. Resident #1's POA said after seeing the video, the Administrator called the police and the facility terminated CNA B. Resident #1's POA said the facility took x-rays and followed up to check on Resident #1. Resident #1's POA said Resident #1 does not have the ability to show any emotion or pain and did not have any bruises or injuries from the situation. Telephone interview on on 10/31/24 at 12:48 PM with CNA B revealed he remembered caring for Resident #1, but that it was some time ago. CNA B said he was trying to transfer Resident #1 to her geri-chair one day when she was holding onto him. CNA B said he had to take Resident #1's hand off of him while still holding onto her during the transfer. CNA B said he had locked the chair but what happened during the transfer was that Resident #1 was very heavy and he could not hold her up for the transfer. CNA B said he did not use a gait belt to transfer Resident #1. CNA B said he did not slap Resident #1's hand or arm at any point and had transferred her appropriately. CNA B said he was terminated from the facility. Observation on 10/31/24 at 1:13 PM of revealed CNA F and RA Z transferred Resident #1 using a Hoyer lift from her geri-chair to her bed, and the transfer was completed safely and using proper technique. Interview on 10/31/24 at 2:37 PM with the ADON revealed he saw the video provided by Resident #1's POA which showed CNA B had transferred Resident #1 to the geri-chair. The ADON said the video then showed CNA B pulling the geri-chair backwards when Resident #1 grabbed the end of the bed and CNA B smacked her hand. The ADON said at the time of the video, Resident #1 was a one-person transfer using a gait belt and now was a hoyer lift transfer requiring at least two people. The ADON said CNA B was not appropriate in the type of care he provided Resident #1, and it was considered abuse which should never occur. The ADON said Resident #1 was assessed and she did not have any injuries or bruises from the incident. The ADON said safe surveys were completed for other residents to make sure they had not suffered any injuries either. The ADON said the facility decided to terminate CNA B immediately based on what they saw in the video. The ADON said the facility also began in-servicing staff immediately on abuse and neglect. The ADON said the facility also began checking on Resident #1 and ensuring staff were doing what they were supposed to regarding her care to monitor the situation. Interview on 10/31/24 at 2:53 PM with the Administrator revealed he got a call from Resident #1's POA, who said she had a video she wanted to show him on 09/03/24. The Administrator said he was concerned with what he saw on the videos. The Administrator said he saw CNA B trying to transfer Resident #1 by picking her up and putting her into the chair instead of using a gait belt to transfer her. The Administrator said the video showed CNA B trying to get Resident #1 to the chair without the amount of help that was needed to complete the transfer safely. The Administrator said the video also showed that when CNA B was pulling Resident #1 out of the room, she grabbed onto things to prevent herself from moving and he grabbed her hand off the bed and swatted at her wrist. The Administrator said after reviewing the videos he immediately reported the incident and terminated CNA B. The Administrator said the facility did extensive training on abuse with staff to try and prevent this incident from happening again. The Administrator said a head-to-toe assessment was also completed on Resident #1 which revealed no bruising or marks of any kind to her body. The Administrator said multiple x-rays were completed on Resident #1 as well which all came back negative for any injuries. The Administrator said safety rounds with other residents were also completed to see if anyone else in the building had been abused by CNA B, which none were. The Administrator said abuse of residents was not tolerated in the facility and would never be. The Administrator said the techniques of CNA B's transfer were so poor which ended up meaning he provided rough care and a rough transfer. The Administrator said all staff were responsible for ensuring all residents were free from any abuse. The Administrator said each resident had the right to be free from abuse in the facility. The Administrator said if residents were abused that could cause psychological or physical harm to them. The Administrator said CNA B was not following the facility's abuse policy based on what he saw in the videos. Record review of the facility's Provider Investigation Report, dated 09/10/24, reflected the following: - Investigation Summary: Administrator approached by [Resident #1's POA] regarding a video she recorded in resident room. On video it showed [CNA B] trying to transfer resident to geri-chair. It shows CNA struggling to get her into the chair, holding resident under her arms and then back to the bed in the same way. It then shows him trying to pick her up under her knees and behind her back to get her to chair, hitting her back on the arm rests, then pulling on her arms to pull her up. Upon leaving the room, the resident holds onto the bed. The CNA removes her hand from the bed, then swats at her hand. Provider completed provider response as outlined above. All xrays and head to toe assessments came back negative. All safe surveys came back with no other abuse present. Facility completed all in-service and competencies. CNA was terminated immediately, board notified, police called. - Investigation Findings: Confirmed Record review of undated safe surveys completed with residents revealed 33 residents were interviewed and no concerns were noted regarding care provided by CNA B. Record review of CNA B's personnel file included a disciplinary action form, dated 09/03/24, which reflected he was terminated due to an allegation of abuse that was founded on a video. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Customer Service and that all residents [were] to be treated with dignity and respect. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Safe Handling and Transfers and that Hoyer lift requires 2 people, All transfers require use of gait belt, 2 person assist equals 2 person assist .if in doubt how to transfer ask for clarification .gait belts [sic]. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Abuse and Neglect that covered the Abuse Coordinator, Time to Report, What to Report, and Abuse versus Neglect. Interview on 10/31/24 at 11:37 AM with CNA C revealed he knew the facility's abuse policy and that hitting a resident or providing rough care to a resident would be considered abuse. CNA C said he had been trained on how to properly transfer a resident. Interview on 10/31/24 at 1:32 PM with RN D revealed she knew the facility's abuse policy and that hitting a resident or providing rough care to a resident would be considered abuse. RN D said she had been trained on how to properly transfer a resident. Record review of the facility's Abuse, Neglect and Exploitation policy, dated 01/01/23, reflected: Definitions: 'Abuse' means the willful infliction of injury .with resulting physical harm, pain or mental anguish, which can include staff to resident abuse .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse .'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .'Physical Abuse' includes, but is not limited to hitting, slapping, punching, biting, and kicking .VI. Protection of Resident, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The Administrator was notified on 10/31/24 at 4:52 PM, that a past non-compliance IJ situation had been identified due to the above failures. It was determined this failure placed Resident #1 in an IJ situation on 08/31/24.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. CNA B failed to use a gait-belt to transfer Resident #1 from the bed to a geri-chair on 08/31/24 resulting in rough care during the transfer. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/31/24 and ended on 09/03/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for neglect, harm, pain, and injuries. Findings included: Record review of Resident #1's Admission Record, dated 10/31/24, reflected the resident was a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Quarterly MDS Assessment, dated 07/04/24, reflected there was not a BIMS score calculated. Further review reflected a Staff Assessment for Mental Status was completed which revealed Resident #1 had a memory problem resulting in inattention and an altered level of consciousness. For the section regarding Functional Abilities and Goals reflected Resident #1 required substantial/maximal assistance with rolling left and right, lying to sitting on side of bed, and chair/bed-to-chair transfer which meant that the helper did more than half of the effort. The same section reflected Resident #1 used a manual wheelchair. Record review of Resident #1's Annual MDS Assessment, dated 10/04/24, reflected for her Functional Abilities section, Resident #1 was dependent with rolling left and right and chair/bed-to-chair transfer meaning the helper did all the effort or the assistance of 2 or more helpers was required to complete the activity. Resident #1 had active diagnoses of Non-Alzheimer's Dementia (a neurodegenerative disease that starts slowly and progressively worsens), Seizure Disorder or Epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), and Senile Degeneration of Brain (a syndrome associated with many neurodegenerative diseases, characterized by a general decline in cognitive abilities that affects a person's ability to perform everyday activities). Record review of Resident #1's progress notes reflected the following: -On 09/03/24 at 05:27 (5:27 AM) the DON wrote: Notified by POA that patient was the recipient of physical aggression from staff. Noted that resident was handled roughly during transfer from bed to Geri-chair and subsequently was slapped on the hand when being moved in Geri chair. No injury noted to resident at time of notification. Record review of Resident #1's care plan reflected the following: -Focus: Resident has an allegation of (Abuse), Date Initiated: 09/03/2024; Goal: Resident will not experience a negative outcome from alleged event through this review period; Interventions/Tasks: Any negative event will be reported to the abuse coordinator immediately. The facility will adhere to the abuse and neglect policies and protocols. -Focus: Resident requires a mechanical lift transfer(Hoyer) r/t (inability to bear weight) 2 person assist. Date Initiated: 09/03/2024; Goal: Resident will be provided a safe transfer utilizing a mechanical lift(Hoyer)throughout the review period.; Interventions/Tasks: 1. Resident has been identified as totally dependent for transfers. 2. Lifting equipment will be operated in accordance with instruction and training. 5. Report change in conditions which may necessitate a re-evaluation of the resident and the lift. [sic] -Focus: [Resident #1] has a communication problem r/t Dementia, non-verbal .Interventions/Tasks: Ensure/provide a safe environment. Telephone interview on 10/28/24 at 12:13 PM with Resident #1's POA revealed she showed the Administrator, who was the Abuse Coordinator, a video of Resident #1 being abused by CNA B from 08/31/24. Resident #1's POA said after seeing the video, the Administrator called the police and the facility terminated CNA B. Resident #1's POA said the facility took x-rays and followed up to check on Resident #1. Resident #1's POA said Resident #1 does not have the ability to show any emotion or pain and did not have any bruises or injuries from the situation. Observation of the first video provided by Resident #1's POA on 10/30/24 at 8:22 AM revealed the following: The video was time stamped and dated for 08/31/24 at 6:58 AM; the video did not include any sound. The video began and Resident #1 was in bed. There was a geri-chair at the foot of the bed and CNA B began pushing the geri-chair to the side of the bed. CNA B locked the left side of the geri-chair from the back and then walked in front of the geri-chair and pulled it closer to the bed. CNA B turned to Resident #1 and pulled her legs over the side of the bed and used his left arm to raise her up. CNA B used his right hand to reposition Resident #1's knees. Resident #1 had her arms crossed on her chest and CNA B uncrossed the resident's arms to put his underneath hers to lift her up and transfer her to the geri-chair. The geri-chair began to move backwards and CNA B used his left arm to hold the geri-chair while he used his right arm to hold Resident #1 up. CNA B placed Resident #1 on her back on the geri-chair seat portion, grabbed her left leg to raise it with his right hand while his left hand went under her left arm to pull her up towards him and into the chair but the chair began to again move backwards. CNA B put Resident #1 back in the bed and rolled her over onto the bed, pulled the geri-chair closer to the side of the bed and locked the right side of the geri-chair from the back. CNA B walked to the front of the geri-chair and to the side of Resident #1's bed where she was still lying there. CNA B turned Resident #1 over and put his right arm underneath her bent legs and used his left arm to hold her by her neck to transfer her to the geri-chair. CNA B put Resident #1 in the geri-chair perpendicular where her head and legs were on the armrests of the chair. The video ended. Observation on 10/31/24 at 9:45 AM of Resident #1 revealed she was in a common area lying in a geri-chair; she appeared dressed and groomed. Resident #1 had her eyes closed and she did not wake while being talked to by the surveyor. Resident #1 was wearing a long-sleeved shirt but did not appear to have any bruises, injuries, or pain. Observation on 10/31/24 at 12:30 PM of Resident #1 revealed she was in the dining room with her POA being assisted to eat lunch. Resident #1 was still in her geri-chair and was falling asleep during the meal. Resident #1 was not able to answer any questions or acknowledge the surveyor's presence due to her cognitive condition. Telephone interview on 10/31/24 at 12:48 PM with CNA B revealed he remembered caring for Resident #1, but that it was some time ago. CNA B said he was trying to transfer Resident #1 to her geri-chair one day when she was holding onto him. CNA B said he had to take Resident #1's hand off of him while still holding onto her during the transfer. CNA B said he had locked the chair but what happened during the transfer was that Resident #1 was very heavy and he could not hold her up for the transfer. CNA B said he did not use a gait belt to transfer Resident #1. CNA B said he was terminated from the facility. Observation on 10/31/24 at 1:13 PM revealed CNA F and RA Z transferring Resident #1 by Hoyer lift from her geri-chair to her bed, and the transfer was completed was completed safely and using proper technique. Interview on 10/31/24 at 2:37 PM with the ADON revealed he saw the video provided by Resident #1's POA which showed CNA B had transferred Resident #1 to the geri-chair. The ADON said at the time of the video, Resident #1 was a one person transfer using a gait belt and now was a hoyer lift transfer requiring at least two people. The ADON said CNA B was not appropriate in the type of care he provided Resident #1, and it was considered abuse which should never occur. The ADON said Resident #1 was assessed and she did not have any injuries or bruises from the incident. The ADON said safe surveys were completed for other residents to make sure they had not suffered any injuries either. The ADON said the facility decided to terminate CNA B immediately based on what they saw in the video. The ADON said the facility also began in-servicing staff immediately on abuse and neglect. The ADON said the facility also began checking on Resident #1 and ensuring staff were doing what they were supposed to regarding her care to monitor the situation. Interview on 10/31/24 at 2:53 PM with the Administrator revealed he got a call from Resident #1's POA who said she had a video she wanted to show him. The Administrator said he was concerned with what he saw on the videos. The Administrator said he saw CNA B trying to transfer Resident #1 by picking her up and putting her into the chair instead of using a gait belt to transfer her. The Administrator said the video showed CNA B trying to get Resident #1 to the chair without the amount of help that was needed to complete the transfer safely. The Administrator said after reviewing the videos he immediately reported the incident and terminated CNA B. The Administrator said a head-to-toe assessment was also completed on Resident #1 which revealed no bruising or marks of any kind to her body. The Administrator said multiple x-rays were completed on Resident #1 as well which all came back negative for any injuries. The Administrator said the techniques of CNA B's transfer were so poor which ended up meaning he provided rough care and a rough transfer. Follow-up interview on 10/31/24 at 4:52 PM with the Administrator revealed staff should seek help if they could not complete a transfer safely. The Administrator said the purpose of a safe transfer was to prevent injury or any negative outcome to the resident. The Administrator said staff were in-serviced regarding safe transfers and all staff were responsible for providing safe transfers to residents. Record review of the facility's Provider Investigation Report, dated 09/10/24, reflected the following: - Investigation Summary: Administrator approached by [Resident #1's POA] regarding a video she recorded in resident room. On video it showed [CNA B] trying to transfer resident to geri-chair. It shows CNA struggling to get her into the chair, holding resident under her arms and then back to the bed in the same way. It then shows him trying to pick her up under her knees and behind her back to get her to chair, hitting her back on the arm rests, then pulling on her arms to pull her up. Upon leaving the room, the resident holds onto the bed. The CNA removes her hand from the bed, then swats at her hand. Provider completed provider response as outlined above. All xrays and head to toe assessments came back negative. All safe surveys came back with no other abuse present. Facility completed all in-service and competencies. CNA was terminated immediately, board notified, police called. - Investigation Findings: Confirmed Record review of undated safe surveys completed with residents revealed 33 residents were interviewed and no concerns were noted. Record review of CNA B's personnel file included a disciplinary action form, dated 09/03/24, which reflected he was terminated due to an allegation of abuse that was founded on a video. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Customer Service and that all residents [were] to be treated with dignity and respect. Record review of an in-service, dated 09/03/24, reflected staff had been trained regarding Safe Handling and Transfers and that Hoyer lift requires 2 people, All transfers require use of gait belt, 2 person assist equals 2 person assist .if in doubt how to transfer ask for clarification .gait belts [sic]. Interview on 10/31/24 at 11:37 AM with CNA C revealed he had been trained on how to properly transfer a resident. Interview on 10/31/24 at 1:15 PM with CNA F revealed she had been trained on how properly transfer a resident. CNA F said Resident #1 was now transferred using a hoyer lift whereas she was previously transferred using a gait belt. Interview on 10/31/24 at 1:32 PM with RN D revealed she had been trained on how to properly transfer a resident. RN D said Resident #1 was now transferred using a hoyer lift whereas she was previously transferred using a gait belt. Record review of the facility's Safe Resident Handling/Transfers policy, dated 09/03/24, reflected: Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them .13. Staff members are expected to maintain compliance with safe handling/transfer practices. The Administrator was notified on 11/13/24 that a past non-compliance IJ situation had been identified following administrative review due to the above failure.

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents. On 04/04/24, Resident #1 sustained a right shoulder fracture when CNA B left him unattended in his room while he was sitting in a shower chair. The noncompliance was identified as PNC. The noncompliance began on 04/04/24 and ended on 04/04/24. The facility has corrected the noncompliance before the survey began. This failure could place residents at risk for serious injuries. Findings included: Review of Resident #1's Admission Record, dated 06/04/24, reflected the resident was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's quarterly MDS Assessment, dated 04/17/24, reflected he had a BIMS score of 15 indicating no cognitive impairment. Resident #1 was dependent on staff for transfers from chair/bed-to-chair transfer. Resident #1 had diagnoses of a stroke and hemiplegia or hemiparesis (weakness of one entire side of the body). Review of Resident #1's care plan, dated 05/17/24, reflected the following: Focus: [Resident #1] had a fall with/without injury. His fall risk assessment score is 17, indicating resident is at high risk for falls d/t Poor Balance .4/4/24 fall with injury .Goal: [Resident #1] will resume usual activities without further incident through the review date .Interventions/Tasks: 4/4/24 Staff to use shower bed for showering .[sic]. Review of Resident #1's progress notes for April 2024 reflected the following: - 04/04/24 at 11:30 AM, [at]1130 CNA reported that he found the resident on the floor, Upon assessment, the nurse helped the patient to lay on bed, completed HTT assessment, vitals B/P 148/81, P 92, RR 25, T 97.8 and SPO2 93, resident complained feeling pain of 7 on the right shoulder, gave tramadol. Continue with the Neuro checks. Notified the MDS. New order for X-ray STAT. Family notified. Continue to monitor. Written by LVN A - 04/04/24 at 12:57 PM, Resident had fall new order for stat right shoulder X-ray due to complaint of pain. Must be portable due to immobility high fall risk. Written by the ADON - 04/04/24 at 17:11 (5:11 PM), Resident had x-ray of the Right shoulder done, result pending. Written by LVN C - 04/04/24 18:16 (6:16 PM), X-ray to the right shoulder received,MD notified, n/o received for outpatient Ortho referral, sling to the Right shoulder .Resident is bed,awake and alert, Tramadol 50mg administered for pain.safety maintained. [sic] written by LVN C - 04/05/24 1:17 AM, .Thirdly, Incidental note is made of mildly displaced fracture at the surgical neck of the humerus. Suggest right shoulder joint radiography. Correlation, if clinically indicated. Result send to [Physician E]. Resident resting quietly at this time, no distress or discomfort noted. Nursing will continue to monitor. Written by RN D - 04/08/24 3:24 PM, New orthopedic appointment set for resident with [Physician G] for right shoulder on 4-16-2024 at 1045. Address is [Physician G's office address and phone number]. Family updated. Written by the ADON Review of Resident #1's Radiology Results Report, dated 04/04/24, reflected the following: Procedure: XR Right Shoulder 1 View .Interpretation .Examination: Right Shoulder .Clinical Indication: Pain in right shoulder .See Note: Findings: There is a nondisplaced fracture of the surgical neck of the right humerus of indeterminate age. There is no dislocation . Observation and interview on 06/04/24 at 8:45 AM with Resident #1 revealed he was in his bed resting. Resident #1 said he was not in any pain and remembered he had a fall a few months ago. Resident #1 said the aide left him in the shower chair because he was not thinking when he left the room. Resident #1 said he felt safe in the facility and now used a shower bed instead of the shower chair. Observation on 06/04/24 at 9:41 AM revealed Resident #1 was being prepped for his shower by two CNAs. The two CNAs transferred Resident #1 using the Hoyer lift from the resident's bed to the shower bed using proper technique. Observation on 06/04/24 at 10:15 AM revealed Resident #1 had finished his shower and was being transferred by two CNAs from the shower bed to his bed using the Hoyer lift using proper technique. Review of the facility's Provider Investigation Report, dated 04/11/24, reflected under Investigation Summary: After shower, resident was sitting up in shower chair in his room. During shower his hoyer sling was soiled, so it was taken out from under him. An aide went to go get a hoyer sling and [CNA B] was supposed to watch [Resident #1] while she did so. During this time, [CNA B] decides to look for a hoyer sling as well. During the time while [CNA B] was gone, [Resident #1] fell from the shower chair, fracturing his humerus. Review of an undated written statement by CNA B reflected the following: This morning after breakfast I was getting [Resident #1] a shower .I took him back to his room (covered). When I got to his room, I saw that the hoyer lift wasn't there in the room, cause [CNA F] took it, or somebody did .So I was trying to look for one, because no one really told me they just said go look for [CNA F] or something like that. When I brought [Resident #1] back to his room I was looking for someone to help me because I can't transfer him to the chair to the bed, not even with 2 people, so I called and texted [CNA F] if there was another one I could use but she didn't respond. So I didn't really know what to do, so I walked out the room to ask for help, and when I was in the office area, I heard him call for help, and I ran back as fast as I could and I saw him laying on the floor and I called for help. So we helped he's on his bed resting so we've taking care off that .I [CNA B] apologize for my actions to [Resident #1] [sic] . Attempted interview via telephone on 06/04/24 at 10:59 AM to CNA B was unsuccessful as they did not answer. Interview on 06/04/24 at 11:09 AM with CNA F revealed she originally helped to transfer Resident #1 to the shower chair before his shower on 04/04/24. CNA F said she was busy helping another after Resident #1 got his shower, so she was not involved in transferring Resident #1 back to bed. CNA F said after Resident #1 fell out of the shower chair, she was told to only use the shower bed from then on and no longer use the shower chair for Resident #1. CNA F said she was in-serviced on never leaving a resident alone in the shower chair or shower bed. Interview on 06/04/24 at 11:32 AM with LVN A revealed she was passing medications the morning of 04/04/24 in the hallway near Resident #1's room. LVN A said Resident #1 had a shower that morning and when the staff brought him back to the room, there was a nurse and an aide. LVN A said the aide came to her and told her Resident #1 had fallen out of the shower chair. LVN A said she went to the room and assessed Resident #1. LVN A said it appeared that Resident #1 was left alone in the room in the shower chair and slid out of it. LVN A said Resident #1 landed on his right side and had complained of pain to his right shoulder. LVN A said she called the doctor to get an x-ray order and provided him pain medication. LVN A said after the fall, staff only used the shower bed instead of the shower chair for Resident #1. LVN A said she knew to never leave a resident alone in the shower bed or the shower chair. Interview on 06/04/24 at 1:30 PM with the ADON revealed Resident #1 was given a shower and was put in a shower chair and taken back to his room where he fell out of the shower chair on 04/04/24. The ADON said CNA B and a nurse were in the room with Resident #1 when the nurse left to get the Hoyer lift. The ADON said CNA B also left the room to see where it was and what was happening. The ADON said an x-ray was ordered and showed Resident #1 had a fracture in his right shoulder. The ADON said CNA B was not supposed to leave Resident #1 in the shower chair unattended, and he was terminated the same day the incident occurred. The ADON said he completed in-services with staff regarding transfers and Hoyer lifts and stressed the importance of not leaving residents unattended in shower chairs. Interview on 06/04/24 at 1:45 PM with the DON revealed she was new to the facility and was not at the facility when Resident #1 fell on [DATE]. The DON said she expected staff to never leave a resident unattended in a shower chair to ensure the resident did not fall out of the chair. The DON said any staff assisting a resident who was in a shower chair was responsible for making sure they were safe and not left alone. The DON said when a resident was in a shower chair and the staff needed help, they could use the resident's call light or holler out for help but they should never leave the resident alone. Interview on 06/04/24 at 1:53 PM with the Administrator revealed staff got Resident #1 ready for a shower and put him in the shower chair. The Administrator said Resident #1 had finished with his shower and was taken back to his room to be put back in bed. The Administrator said for some reason the staff needed a new Hoyer sling and there were two staff with the resident as there should have been. The Administrator said one staff went to look for a sling while the other one was supposed to stay with Resident #1, which was CNA B. The Administrator said he was not sure why, but CNA B also left the room to find a sling and Resident #1 fell out of the shower chair and fractured his arm. The Administrator said because CNA B left Resident #1 in the room alone in a shower chair, he was terminated. The Administrator said in-services were completed with all staff to ensure they did not leave a resident unattended in a shower chair and what the process was for getting a resident to and from a shower. The Administrator said he expected CNA B to stay in the room with Resident #1 while he was in the shower chair. The Administrator said after the fall, Resident #1's care plan was updated so that he only used the shower bed and not the shower chair anymore. Review of a Disciplinary Action Form for CNA B, dated and signed by CNA B on 04/04/24, reflected he was terminated due to a failure to follow procedures regarding resident safety in the shower chair. Review of in-service records completed on 04/04/24 regarding Showers and Shower Chair included: When giving a resident a shower and up in a shower chair they must be monitored at all times. When resident up in shower chair and stationery ensure brakes on shower chair are locked. Never leave a resident by themselves when up in shower chair completed with CNA B and 32 staff. Review of the facility's policy, dated 04/02/24, and titled Resident Showers revealed it did not address supervising a resident while seated in a shower chair.

Based on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of four residents reviewed for accidents and supervision. CNA B and CNA C failed to transfer Resident #1 appropriately, resulting in her leg being fractured. On 05/16/20 Resident #1 was transferred by CNA B in the morning and CNA C in the evening, both times being lowered to the floor by the aide. After the evening transfer, the resident had an X-ray ordered which showed a fractured left tibia (the larger of two bones in the lower leg). This failure placed residents at risk for pain, significant injury, and decreased level of functioning and quality of life. Findings included: Review of a census dated 07/27/21 revealed Resident #1 was no longer in the facility. Review of Resident #1's face sheet, dated 07/29/21 , revealed she was a [AGE] year old female originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE]. Her diagnoses included abnormalities of gait and mobility, difficult in walking, repeated falls, dementia, and cognitive communication deficit. Review of Resident #1's quarterly MDS assessment, dated 04/10/20, revealed she required extensive assistance and needed two or more persons for transfers, bed mobility, dressing, and toilet use. Review of Resident #1's care plan, revised 04/17/20, revealed she was a two person Hoyer lift with all transfers and required extensive assistance of two staff to move between surfaces using a hoyer lift. Review of the provider investigation report of the incident dated 05/22/20, revealed CNA C attempted to transfer Resident #1 to her bed. Resident #1 required two people to assist with transfer[s]. CNA C did not ask for assistance and attempted to transfer her alone. CNA C and Resident #1 both fell . Resident #1 now has a fractured tibia. She has a diagnosis of Osteopenia. After the fall, Resident #1 was treated for pain and then sent to [the hospital] for treatment of injury. An appoint[ment] was sent for 05/18/20 to see an orthopedic surgeon. Surgery scheduled for 05/22/20 to repair injury. An interview with Resident #1 was completed by ADON A and revealed, .'my legs went out on me and we both went down .it scared me to death when her head bounced on the floor .[the CNA] fell on me but I don't know what part of my body she fell on , my legs just gave way .'. An interview with CNA B during the provider investigation revealed she said, .the girl that quit used to take care of [Resident #1] by herself. [CNA B] stated she wasn't aware [Resident #1] was a two person assist. [CNA B] stated she had received training on gait belts and used a gait belt when transferring [Resident #1] from her bed to her wheelchair. [CNA B] stated [Resident #1's] shoe fell off during the transfers and she 'couldn't hold her anymore' so she lowered her to the floor. [CNA B] stated she notified the nurse who assessed [Resident #1] for injury and found no injury or complaint of pain at the time. An interview with CNA C during the provider investigation revealed she said, [CNA C] stated she has been trained on gait belt use. She stated she normally uses the hoyer lift with [Resident #1], but she couldn't find a sling last Friday [05/15/20]. [CNA C] confirmed she uses two people with hoyer lift transfers. [CNA C] stated she did not use a gait belt with the transfer. When asked why she didn't obtain assistance with the transfer, she stated the other aides were busy and couldn't help. When asked if she requested the med aide or charge nurse help her with the transfer, she stated she did not. [CNA C] stated [Resident #1] normally is able to assist somewhat with her transfers, but on Friday she was unable to. [CNA C] stated she lowered [Resident #1] to the floor and then she started to get up, lost her own balance and fell backward. [CNA C] stated she did not hit her head and denied falling or leaning on the resident at any time. Review of Resident #1's progress notes revealed the following: on 05/15/20 at 3:54 PM CNA called this nurse to resident room, upon entering resident's room, observed resident sitting on the floor. When resident asked what happen? She stated 'my legs gave up during transfer my aide lower me slowly to the floor. I did not fall'. Assessment done, resident able to move both extremities without any discomfort, denies pain. Resident assisted off the floor to the chair x3 using a gait belt. VS (vital signs) stable. NP (Nurse Practitioner), DON and RP (Responsible Party) notified. Will continue to monitor resident closely. Further review of Resident #1's progress notes also revealed the following: on 05/15/20 at 7:53 PM Patient assisted to the floor this pm by the patient tech during transfer, She stated, My legs gave up and then tech had to help me to the floor for safety. Patient complain of pain on the left knee and unable to stretch the leg. Patient transferred to bed via Draw sheet and x4 staff assist and re-positioned to comfort. NP- notified and received a new order to do left knee X-ray to rule out any fractures and administer PRN (as needed) Pain pill. Daughter and family POA (power of attorney) notified of incident and orders received with effect. On 05/15/20 at 10:44: X-ray results received and noted with an acute fracture on left tibia. PCP (Primary Care Physician) notified and ordered pt. (patient) to be transferred to [the hospital] ER (emergency room ) for further evaluation. Daughter notified of changes and transfer with understanding. Orders noted, transcribed, and effected. An attempted interview with CNA B on 07/28/21 at 3:46 PM was made and was unsuccessful. CNA B was no longer working at the facility. An attempted interview with CNA C on 07/28/21 at 3:47 PM was made and was unsuccessful. CNA C was no longer working at the facility. In an interview on 07/29/21 at 8:30 AM with LVN D revealed she was the nurse back in May 2020 who assessed Resident #1 on the morning shift. LVN D said CNA B came to her and they went to the Resident #1's room where she was sitting on the floor. LVN D said Resident #1 was able to move her extremities and denied any pain. LVN D said she asked Resident #1 what happened and was told while CNA B was transferring her, her legs gave out and the aide lowered her to the floor. LVN D said she notified the NP, DON, and family member. LVN D said Resident #1 was a two-person transfer and she was not sure why CNA B transferred her by herself. LVN D said CNA B did not have a reason for the improper transfer. In an interview on 07/29/21 at 8:58 AM with RN E revealed he was the nurse back in May 2020 who assessed Resident #1 on the afternoon shift. RN E said he remembered that CNA C was transferring Resident #1 by herself and the resident fell . RN E said he went into the room and completed an assessment on Resident #1. RN E said he noticed Resident #1 had a swollen leg and was in pain. RN E said he called the doctor and received an order for an X-ray that showed she had a fracture. RN E said CNA C told him they were short staffed and could not find another person to complete a two-person transfer as the resident required. In an interview on 07/28/21 at 2:15 PM with ADON A revealed Resident #1 was a two-person hoyer lift transfer, but back in May 2020 Resident #1 was transferred using only one aide two times within the same day. ADON A said the aides involved were terminated and Resident #1 had her leg repaired. ADON A said the aides had probably been transferring Resident #1 with one person prior to the incident and thought it was okay. ADON A said the concern with staff not transferring residents properly was that they could be harmed. ADON A said Resident #1 suffered a fracture to her leg which required surgery. ADON A said after the incident, staff were in-serviced on proper transfers and she followed up daily to ensure staff were completing the appropriate transfers for all residents. In an interview on 07/28/21 at 2:50 PM with the DON revealed Resident #1 was transferred improperly twice in the same day back in May 2020. The DON said Resident #1 was transferred with one person on the morning shift and again on the afternoon shift with different aides. The DON said after the first improper transfer occurred, staff were in-serviced about Resident #1 being a two-person transfer; however, the afternoon shift was not included on the in-service. The DON said the first transfer happened because there was a new aide who was unfamiliar with the resident. The DON said she was not sure what happened with the second transfer because the aide was familiar with the resident and knew she was a two-person transfer. The DON said Resident #1 was inconsistent with her weight bearing abilities which was why she was a two-person transfer. The DON said staff were responsible for looking on the Kardex, transfer list, or asking the charge nurse to know the transfer capabilities of residents on their halls. The DON said the concern with staff not completing proper transfers with residents was that they could be harmed. The Administrator was unavailable for an interview. Review of the facility's policy, dated July 2017, and titled Safe Lifting and Movement of Residents reflected the following: 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. Review of the facility's policy, dated July 2017, and titled Lifting Machine, Using a Mechanical reflected the following: 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.