Every finding on record at New Iberia Manor South

Based on interviews and record review, the facility failed to document behaviors of a resident diagnosed with mental disorders, to ensure the resident attained the highest practicable mental and psychosocial well-being for 1 (Resident #1) out of 8 (#1- #8) sampled residents. Findings: Review of Resident #1's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE], with diagnoses that included, but were not limited to, bipolar disorder, anxiety disorder, and dementia. Review of Resident #1's January 2026 Physician's Orders revealed the following in part: - busPIRone HCl (Hydrochloride) Oral Tablet 10 MG (milligrams) (Buspirone HCl)- Give 10 mg by mouth three times a day for anxiety. Ordered 12/09/2025 -OLANZapine Oral Tablet 5 MG (Olanzapine) Give 5 mg by mouth two times a day for dementia. Ordered 06/28/2025. -Venlafaxine HCl ER Tablet Extended Release 24 Hour 75 mg- Give 1 tablet by mouth one time a day for depression. Ordered 06/1/2024. - Behavior monitoring Anti-Psychotic Q Shift: 0.None 1.Afraid 2.Agitated 3.Angry 4.Anxious 5.Mood change 6.Noisy 7.Restless 8.Withdrawn/crying 9.Crying 10.Combative 11. See nurses notes -Behavior monitoring Anti-Anxiety Q Shift: 0.None 1.Afraid 2.Agitated 3.Angry 4.Anxious 5.Mood Change 6.Noisy 7.Restless 8.Withdrawn/depressed 9.Crying 10.Combative 11. See nurses notes-Behavior Monitoring Anti-Depression Q Shift: 0.None 1.Afraid 2.Agitated 3.Angry 4.Anxious 5.Mood change 6.Noisey 7.Restless 8.Withdrawn/depressed 9.Crying 10.Combative 11. See nurses notesReview of Resident #1's plan of care revealed the following in part: - The resident uses anti-anxiety medications r/t (related to) anxiety disorder. Interventions in part . monitor for side effects and effectiveness Q shift (every shift). - The resident uses antidepressant medication r/t depression. Interventions in part: Behavior Monitoring Anti-Depression Q Shift: 0.None 1.Afraid 2.Agitated 3.Angry 4.Anxious 5.Mood change 6.Noisey 7.Restless 8.Withdrawn/depressed 9.Crying 10.Combative 11.- The resident has a mood problem r/t dementia, depression, anxiety. Interventions in part: Administer medications as ordered. Monitor/document for side effects and effectiveness. Monitor/record/ report to MD (Medical Director) prn (as needed) patterns s/sx (signs and symptoms) of depression, anxiety, sad mood as per facility behavior monitoring protocols. Review of Resident #1's MAR (Medication Administration Record) from October 2025 to January 2026 revealed the following in part: -Behavior monitoring antianxiety q (every) shift- 6. Noisy was documented on night shift on 10/16/2025 and 12/09/2025, and on day and evening shift on 10/17/2025 and 12/10/2025. -Behavior monitoring anti-depression q shift & - Behavior monitoring Anti-psychotic q shift 6. Noisy was documented on the night shift on 12/09/2025, and on the day and evening shift on 12/10/2025. On 01/05/2026 at 11:10 a.m., an interview was conducted with S4LPN (Licensed Practical Nurse) who stated she had been the resident's day shift nurse for several months. S4LPN stated that the night shift nurses had reported that Resident #1 yells out at night and that was his normal behavior. She stated that it was reported to her by the night shift nurses that he yells to get the attention of staff because he had bad dreams and did not want to be by himself. On 01/05/2026 at 11:28 a.m., an interview was conducted with S7CNA (Certified Nursing Assistant) who stated that Resident #1 yells out or hollers during the day and at night to get the attention of staff because he did not want to be alone. On 01/05/2026 at 11:57 a.m., a phone interview was conducted with S5LPN who stated that on 12/17/2025 at approximately 2:45 a.m., Resident #1 began yelling. She stated he did not like to be alone, which had been an ongoing problem for him. S5LPN stated she would go into Resident #1's room and asked him to stop yelling because other residents were trying to sleep, and he would stop for a little while and start again.On 01/05/2026 at 3:30 p.m., an interview was conducted with S1ADMIN (Administrator). She stated that neither the nurses nor CNAs told her that Resident #1 yelled out or hollered at night prior to 12/17/2025. She stated that if she or S2DON (Director of Nursing) had known, they would have tried to get to the root cause of the outbursts or contacted his psychiatric provider for a possible medication change. On 01/06/2026 at 1:50 p.m., a phone interview was conducted with S6LPN. She stated that she had worked night shift and had been Resident #1's nurse since he was admitted to the facility. She stated the resident always had outbursts and yelled at night since his admission. She stated the resident hollered and said different things. Sometimes he wanted to get up and get out of bed, then he would want to get right back in bed. S6LPN stated sometimes the resident didn't need anything and when he was told that other residents were sleeping, he would sometimes say he didn't care and continued to holler. She stated that she and the CNAs would try to get the resident what he asked for, but he continued to holler which was a known behavior he had often. S6LPN stated that she wrote a note in July 2025 about the resident's behavior because she was simply charting the behavior, however the nurses usually documented this behavior on their nurse report sheets which was a tool the nurses shared among themselves when reporting off for shift, and not a part of the resident's clinical record. On 01/06/2026 at 3:28 p.m., a joint interview was conducted with S1ADMIN, S2DON, and S3CORP (Corporate Nurse). S2DON stated she was unaware of Resident #1's outbursts at night prior to the documented behavior on July, 13 2025. S2DON stated that when a resident had a new behavior, their process was to contact psychiatric services. She stated she assumed Resident #1 was already on psychiatric rotations. Review of the resident's October 2025 to January 2026 MARs was conducted with S2DON and S3CORP, who both confirmed that the nurses were not documenting the resident's behaviors on the MARs. S2DON was asked if the nurses' report sheets were official documentation for the residents' record and she stated they were not. S3CORP stated the nurses should have been documenting the resident's behaviors on the MARs.On 01/07/2026 at 9:55 a.m., a review of monthly psychiatric services notes provided by S1ADMIN was conducted with S1ADMIN, S2DON, and S3CORP. The psychiatric provider reported that Resident #1's sleep was fair. S1DON was asked if the psychiatric provider spoke with or consulted the nurses to ask about the residents' behaviors. S3CORP stated the providers used the 24 hour nursing reports which were generated from the MARs and progress notes. They stated had the nurses documented Resident #1's behaviors at night, it would have been on the report, and the psychiatric provider would have known about the resident's behaviors and provided services to treat those behaviors.

Based on record review and interviews, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, by failing to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 (#37) of 1 (#37) resident investigated for dialysis.On 07/23/2025, a review of the facility's dialysis protocols with a reviewed date of 07/11/2025 read in part.2. Implement dialysis communication regarding plan of care. Resident #37 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to end stage renal disease and dependence on renal dialysis. Review of Resident #37's July 2025 Physician's orders revealed an order written on 06/30/2025 for Resident #37 to receive dialysis 3 days a week on Monday, Wednesday, and Friday at a dialysis provider center. Review of Resident #37's dialysis communication sheets between the facility and the dialysis provider revealed the following:06/27/2025 the form was missing pre-dialysis information for meal provision and condition alert.06/30/2025 the resident specific pre-dialysis information for medication administered, meal provision, and condition alert were left blank. 07/07/2025 there was no resident specific pre-dialysis information and the form was not signed.07/09/2025 there was no resident specific pre-dialysis information and the form was not signed by facility staff.07/11/2025 there was no resident specific pre-dialysis information.07/14/2025 there was no resident specific pre- dialysis information07/16/2025 there was no resident specific pre-dialysis information and the form was not signed.07/18/2025 there was no form for that date07/21/2025 there was no form for that date.On 07/23/2025 at 8:30 a.m., an interview was conducted with S2DON (Director of Nursing). She confirmed the missing information and stated that she would check the facility's policy.On 07/23/2025 at 8:59 a.m., an interview was conducted with S5LPN (Licensed Practical Nurse). She confirmed the missing information and forms. She stated that the form was to be completed with vital signs, whether they ate, refused meal or was sent with a snack, and whether they are awake, alert, oriented. S5LPN also stated when the resident returned from dialysis, the assigned nurse should have checked the section filled out by the dialysis agency, then signed the form. S5LPN further stated the form must be completed because that's how they communicate with the dialysis provider. On 07/23/2025 at 9:47 a.m., S5LPN provided the form for 07/21/2025 and stated she took it off the fax machine.On 07/23/2025 at 10:35 a.m., a follow up interview was conducted with S2DON. She stated that she reviewed the dialysis protocols and the communication sheets were supposed to have been completed and signed by the nurse per the facility's protocol.

Based on observations, interviews, and record reviews, the facility failed to ensure nursing staff provided services reflecting accepted standards of quality care as evidenced by medications being left at the bedside for 3 residents (#17, #84 and #90) out of a finalized sample of 36 residents. Resident #17:Resident #17 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to history of falling and allergic rhinitis.Review of Resident #17's admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident's cognitive function was intact.Review of physician's orders revealed an order written on 07/14/2025 for Zyrtec allergy oral tablet 10 mg (Cetirizine HCL [hydrochloride]) give 10 mg (milligrams) by mouth one time a day for allergic rhinitis.On 07/21/2025 at 10:38 a.m., an observation and interview was conducted with Resident #17. An oval shaped white pill was observed on the resident's bed. The resident picked up the pill and stated that it was her pill that the nurse had given her. The resident stated that she did not sign a form to be able to self-administer her medications. The resident put her call light on to call the nurse.On 07/21/2025 at 10:38 a.m., an interview and observation of the pill was conducted with S4LPN (Licensed Practical Nurse). She stated it was Resident #17's Zyrtec, and confirmed it should not have been left in the resident's room.Resident #84:Resident #84 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to history of falling, other fracture of head and neck of left femur, and aftercare following joint replacement surgery.Review of Resident #84's admission Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment.Review of Resident's EHR revealed no signed document that she was able to self-administer her medications.Review of Resident #84's physician's orders revealed an order written on 06/27/2025 for Cholecalciferol (Vitamin D3) oral tablet 25mcg (microgram) (1000 UT [units]) (Cholecalciferol) Give 1000 unit orally one time a day for vitamin deficiency related to vitamin deficiency, unspecified.On 07/21/2025 at 10:17 a.m., an observation was made of Resident #84 in her room. A whitish round pill was noted on the over bed table in the corner of the resident's room. On 07/21/2025 at 10:19 a.m., an observation and interview was conducted with S4LPN. She stated the pill looked like Resident #84's Vitamin D because it had no writing on it. S4LPN took the pill and walked to her medication cart then returned and stated the pill matched Resident #84's Vitamin D in her cart. She stated she didn't know how the pill got to the resident's over bed table and was not supposed to be left in her room.Resident #90Resident #90 was admitted to the facility on [DATE] with pertinent diagnoses, including but not limited to bipolar disorder, depression, dysphagia following cerebral infarction and shortness of breath. Review of Resident #90's quarterly MDS assessment dated [DATE] revealed a BIMS score of 13 indicating the resident's cognition was intact. Review of Resident #90's July 2025 physician's orders revealed an order dated 06/03/2025 for Albuterol Sulfate Inhalation Aerosol Solution 108 (90 Base) MCG/ACT(microgram/actuation) (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed for SOB. Review of nursing progress notes revealed an entry on 07/17/2025 per S10LPN read: RP called the facility and stated that her brother (Resident #90) needs assistance with getting inhaler from jacket pocket. Nurse went into the room and grabbed inhaler from jacket pocket and handed it to the resident.On 07/21/2025 at 2:19 p.m., an observation was made of Resident #90 propelling himself in his wheelchair towards his room to get his Albuterol inhaler. An observation was made of Resident #90 grabbing his inhaler from his window seal in his room.On 07/22/2025 at 10:01 a.m., an observation was made of Resident #90's resident's Albuterol inhaler located on the resident's window seal in his room.On 07/23/2025 at 4:15 p.m., an interview was conducted with S18LPN who confirmed Resident #90 kept his Albuterol inhaler on him and stated the S11MDS (Minimum Data Set Nurse) would provide the documentation supporting the resident had been assessed to safely administer his Albuterol inhaler.On 07/23/2025 at 5:30 p.m., during exit conference, S11MDS (Minimum Data Set Nurse) confirmed the facility did not have documented evidence that Resident #90 was assessed to safely self-administer his Albuterol inhaler.

Based on observations, interviews, and record review, the facility failed to ensure residents' environment remained free of accident hazards, by failing to lower and lock beds for 2 (#17 and #84) of 3 (#10, #17, and #84) residents investigated for accidents.On 07/23/2025, a review of the facility's policy titled, Fall Prevention Program with a last review date of 06/18/2025, read in part.All residents will be assessed for the risk for falls at the time of admission, on a quarterly basis.Based on the results of this assessment, interventions will be implemented to minimize falls, avoid repeat falls and minimize falls resulting in significant injury. 3. The following is a list of commonly used interventions that may be considered to minimize falls and injury.c. Bed maintained in low position.Resident #17:Resident #17 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to history of falling, fracture of left pubis, and aftercare following joint replacement surgery.Review of a therapy screen dated 07/02/2025, revealed safety awareness/safety concerns: Resident has had a change in level of safety awareness and has a potential for safety concerns to develop. Fall risk status: Resident is a fall risk.On 07/21/2025 at 10:38 a.m., an observation was made of Resident #17. A yellow falling star was observed outside the resident's room indicating she was at risk for falls. Resident #17 was in her bed and sat up as surveyor entered room. Further observation revealed the red lever on the resident's bed was up and the green down.On 07/21/2025 at 10:39 a.m., an interview and observation of Resident #17's bed was conducted with S4LPN. She confirmed the bed was not locked and should have been. S4LPN further stated that the bed is locked when the red lever is down and the green up.Resident #84:Resident #84 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to history of falling, other fracture of head and neck of left femur, and aftercare following joint replacement surgery.Review of Resident #84's care plan revealed a focus area dated 06/30/2025 the resident is at risk for falls r/t (related to) history of falls.Interventions included place bed in lowest position. On 07/21/2025 at 10:17 a.m., an observation and interview conducted with Resident #84. There was a yellow falling star posted outside the resident's room indicating she was a fall risk. The resident was lying on her lifter pad in bed, and the bed was in the highest position. There was a hoyer lift at the resident's bedside, but no staff was present. Resident #84 stated staff had been in her room to get her up for therapy, but left.On 07/21/2025 at 10:19 a.m., an observation and interview was conducted with S4LPN (Licensed Practical Nurse). She confirmed the resident's bed was left on the highest position. S4LPN stated that the resident's bed should not have been left on the highest position.

Based on observation, record review and interview, the facility failed to ensure food was served to residents that was palatable, attractive, and at a safe and appetizing temperature for 3 (#4, #7, #37) out 3 (#4, #7, #37) residents investigated for food out of a total sample of 36 residents1. Resident #4. On 07/21/2025 at 11:43 a.m., the resident stated that he did not like the way the food was prepared. On 07/22/2025 at 10:10 a.m. during the resident council meeting, the resident stated the food was served cold and the portion sizes were too small. 2. Resident #7. On 07/21/2025 at 12:47 p.m., the resident stated the food was not good, not seasoned, the meat was tough, and the portion sizes were for a child. On 07/22/2025 at 8:55 a.m., S14CNA (Certified Nursing Assistant) was observed picking up the resident's breakfast tray out of his room. On 07/22/2025 at 9:08 a.m., an interview was conducted with S14CNA. She stated the resident did not eat his meals because he did not like the food that was served. 3. Resident #37: Resident #37 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified severe protein-calorie malnutrition, and end stage renal disease. Review of Resident #37’s admission Minimum Data Set (MDS) dated [DATE] revealed in “Section C” that she had a Brief Interview for Mental Status of 14, indicating her cognition was intact. Further review revealed in “Section K” that the resident had complaints of difficulty or pain when swallowing. Review of Resident #37’s Physician’s Orders revealed she was on a renal diet, regular texture, thin consistency. On 07/21/2025 at 12:11 p.m., an observation was made of Resident #37 during lunch. The resident received a dinner roll, a hamburger patty and steamed vegetables on her plate. The hamburger patty looked burnt and hard and Resident #37 was observed struggling to cut it. On 07/21/2025 at 12:11 p.m., S4LPN (Licensed Practical Nurse) tried cutting the hamburger on Resident #37’s plate and stated that she would not serve that hamburger to anyone. S7CNA (Certified Nursing Assistant) also tried cutting the resident’s hamburger and stated that it was hard and she would not serve it to anyone. On 07/21/2025 at 12:19 p.m. S6RD (Registered Dietician) cut Resident #37’s hamburger patty with a metal knife and fork and told S1ADM (Administrator) who was called to the dining room that the meat was hard and dry.

Based on observations, and interview, the facility failed to store food in accordance with professional standards for food service, and ensure sanitary conditions were maintained in the kitchen as evidenced by: opened food items in the walk in cooler not labeled with the date and time; thick layer of debris and food residue on the deep fryer cooking oil collection area; andexposed facial hairThe facility had a census of 84 residents.Findings:On 07/21/2025, a review of the facility's policy titled, Food Receiving and Storage, with a last revision date of 06/23/2025, revealed in part. Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation:.8. All food stored in the refrigerator or freezer will be covered, labeled and dated ( use by date).On 07/21/2025, a review of the facility's policy titled, Refrigerator and Freezer, with a last reviewed date of 06/25/2025, revealed in part.Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation.7. Use by dates will be completed with expiration dates on all prepared food in refrigerators.On 07/21/2025, a review of the facility's policy titled, Dietary Employee Dress Code, with a last revision date of 07/03/2025, revealed in part.Protocol: All employees will wear approved attire to perform their assigned duties. Procedure: 1. All staff will have their hair off their shoulders, confined in a hairnet or cap-facial hair covered properly.a. According to the Food Code, food service staff must wear hairnets when cooking, preparing, or assembling food, such as stirring pots or assembling the ingredients of a salad.On 07/21/2025 at 9:09 a.m., a tour of the facility's kitchen was conducted with S8DA (Dietary Aide), who stated that she was the in charge for the day shift.On 07/21/2025 at 9:25 a.m., an observation of the walk in cooler was conducted with S8DA and revealed the following items were opened and not labeled with the date and time they were opened nor the use by date: large container of minced garliclarge container of mayonnaiselarge container of cherrieslarge container of mustardlarge block of margarineplastic gallon bag of shredded carrotsplastic gallon bag of green bell pepperplastic gallon bag of celeryplastic gallon bag of onionsplastic gallon bag of baconplastic gallon bag of apple slicesplastic gallon bag of cinnamon rollsplastic gallon bag of sliced cheddar cheese(2) large containers of green grapes S8DA confirmed the food items listed above were opened, and not labeled with the date and time they were opened nor the use by date, and should have been. On 07/21/2025 at 9:36 a.m., an observation of the deep fryer was conducted with S8DA that revealed the cooking oil collection area had a thick layer of debris, and large pieces of fried food material. S8DA stated the deep fryer was last used sometime last week, and confirmed that is was not cleaned after it was used and should have been. On 07/21/2025 at 10:39 a.m., S9COOK was observed in the kitchen with facial hair exposed while he was preparing to puree the lunch meal. S9COOK confirmed that his facial hair should be covered and was not.

Based on record review and interview, the facility failed to ensure the grievances the resident group voiced in regards to the food that was being served were acted upon and resolved. Review of the monthly resident council meeting minutes dated from 01/13/2025 to 07/03/2025 revealed there were complaints that the food was cold, improperly cooked, and portion sizes were small. On 07/22/2025 at 10:10 a.m. during the resident council meeting, the residents in attendance stated the food issues were not addressed and was worse. The residents complained the food was served uncooked, cold, and the meat was tough. The residents in attendance were Resident #4, #11, #16, #39, #50, #66, #69, #85, #87, and #90. During the resident council meeting on 07/22/2025 at 10:10 a.m., S15AD (Activity Director) was present during the meeting per the residents' request. S15AD confirmed the complaints about the food had been ongoing since 01/13/2025 to present date.

Based on record review and interview, the facility failed to provide evidence that Resident #7's grievance was reported and investigated for 1 (#7) out of 36 sampled residents. Resident #7. On 07/21/2025 at 12:41 p.m., the resident stated that about 6 months ago when he was admitted to the facility his wallet was stolen. The resident stated that his wallet contained 350 dollars, driver's license and social security card. The resident stated he reported it to the administrative staff. The resident stated that no one has followed up with him concerning his stolen wallet. The resident stated that he does not know if there was an investigation.Review of the resident's general nurses notes dated 10/27/2024 at 11:30 a.m. revealed, Resident reported theft of a wallet (containing: bank card, social security card, driver's license, insurance card and $350.00 cash) and a pair of sunglasses. He says that this occurred the first week he got here . On 07/23/2025 at 3:00 p.m., an interview was conducted with S16RN (Registered Nurse). S16RN stated she remembers the resident reporting to her that his wallet with money and cards were stolen when he was on the rehabilitation side of the facility. S16RN stated she does not remember if she reported the grievance to anyone.On 07/23/2025 at 3:15 p.m., an interview was conducted with S1ADM (Administrator). S1ADM stated she was aware of the grievance and that she would look for documentation addressing the grievance. S1ADM did not provide evidence the resident's grievance was addressed and investigated by the time of the exit conference on 07/23/2025 at 5:45 p.m.

Based on observation, interview and record review, the facility failed to implement physician's orders by failing to change the dressing on a peripherally inserted central catheter site for 1(#56) of 5 (#9, #11, #43, #56, and #58) residents investigated for infections.Resident #56 was admitted to the facility on [DATE], with diagnoses which included, but were not limited to, urinary tract infection, extended beta lactamase (ESBL) resistance, and enterococcus as the cause of diseases.Review of physician's orders revealed an order written on 07/11/2025 to change midline dressing following technique and apply BIO (round antimicrobial dressing used to prevent infections at catheter insertion sites) patch every day shift every Fri (Friday).On 07/21/2025 at 10:54 a.m., an observation was made of Resident #56. The resident had a midline catheter with an exit site on her left arm which was dated 07/11/2025. Further observation revealed a sign taped over the residents bed which read, midline was inserted 07/11/2025.On 07/21/2025 at 3:27 p.m., an interview was conducted with S3ADONIP (Assistant Director of Nursing/Infection Preventionist). She confirmed that Resident #56's midline dressing was dated 07/11/2025. She further stated the dressing should have been changed on 07/18/2025 and was not.

Based on record review and interview, the facility failed to ensure the residents received all care and treatment in accordance with professional standards of practice by failing to inform the resident's physician/nurse practitioner that resident (#4), who has a diagnosis of Heart Failure, was having difficulty breathing and had a low O2 sat (oxygen saturation- the amount of oxygen circulating in blood) reading of 88% for 1 (#4) out of 4 (#4, #7, #13, #92) residents investigated for hospitalizations out of a total sample of 36 residents.Resident #4. Review of the resident's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction, Heart Disease, Heart Failure, Hepatitis C, and Diabetes. Review of the resident's significant change MDS (Minimum Data Set) dated 06/12/2025 revealed the resident's BIMS score was 14 for being cognitively intact. Further review of the MDS revealed the resident had respiratory issues that included COPD (Chronic Obstructive Pulmonary Disease). Review of the resident's weekly vital sign log revealed the resident's vital signs on 03/19/2025 was, temperature 98.1; blood pressure 150/72; pulse 56; respirations 18; and oxygen saturation was 96%. Review of the resident's general nurses notes dated 03/24/2025 at 1:06 p.m. revealed, Resident left with . driver for appt (doctor's appointment) with 2L (liters) of oxygen applied r/t (related to) hypoxia. Review of the resident's general nurses notes dated 03/24/2025 at 2:56 p.m. revealed, Spoke with RP (Responsible Party) . RP is at . appt with resident and RP explained that the nurse from (doctor's appointment) recommended resident to go to hospital. RP wants resident to be transferred to (hospital) . Review of the resident's general nurses notes dated 03/24/2025 at 9:17 p.m. revealed, Received report from (nurse at the hospital) in ER (Emergency Room). Nurse reported to writer that resident presented with SOB (Shortness of Breath) to ER . is in fluid overload. Resident is breathing slower than when first entering the ER . Review of the resident's ED (Emergency Department) provider notes dated 3/24/2025 at 5:09 p.m. revealed, .chief complaint: patient presents with Shortness of Breath onset this AM and BLE (bilateral lower extremity) edema for 1 week. [AGE] year-old male with a history of chronic kidney disease as well as cirrhosis presents to the emergency department because of increased shortness of breath and swelling of the lower extremities and abdomen. Patient has chronic kidney disease reports that over the past 2 to 3 days has had increased swelling and increased shortness of breath . On 07/23/2025 at 10:55 a.m., an interview was conducted with S13TD (Transportation Driver). S13TD stated she remembers transporting Resident #4 to his scheduled doctor's appointment. S13TD remembers the resident was having shortness of breath and noticed that he had his oxygen with him. S13TD stated she encouraged the resident to use his oxygen. S13TD stated that no one reported to her the resident was having trouble breathing that day. On 07/23/2025 at 12:55 p.m., an interview was conducted with S12LPN (Licensed Practical Nurse). S12LPN stated the day the resident was transported to his doctor's appointment that she remembers the resident's O2 saturation being low. S12LPN stated the resident normally has an O2 saturation of 96% and on that day it was 88%. S12LPN stated she applied oxygen at 2 liters for his low O2 saturation. S12LPN stated she did not document the resident's O2 saturation or an assessment of the resident's condition prior to him going out to his scheduled doctor's appointment and stated that she should have. S12LPN stated she did not report the resident's low O2 saturation to the nurse practitioner. On 07/23/2025 at 2:11 p.m., an interview was conducted with S11MDS (Minimum Data Set). S11MDS reviewed the resident's electronic clinical record and confirmed that there was no evidence of the resident's clinical condition prior to being transported to his scheduled doctor's appointment. S11MDS stated the nurse should have documented the resident's condition. On 07/23/2025 at 3:30 p.m., an interview was conducted with S2DON (Director of Nursing). S2DON reviewed the resident's electronic clinical records and confirmed there was no evidence of the resident's condition prior to being transported to his scheduled doctor's appointment and there should have been. S2DON confirmed there was no evidence the physician or nurse practitioner was informed of the resident's condition prior to being transported to the doctor's appointment.

Based on observation and interview, the facility failed to provide a sanitary and homelike environment for 1 (#9) out of 36 sampled residents.Resident #9. On 07/21/2025 at 10:23 a.m., the resident was observed siting up in bed in his room. During this observation, a suction canister was observed on the resident's dresser. There was drainage noted in the canister. The resident stated that the suction canister had been on the dresser for days. On 07/21/2025 at 10:24 am, S17LPN (Licensed Practical Nurse) entered the room and observed the canister on the dresser. S17LPN stated she did not know how long the canister had been on the dresser and that it should have been discarded. On 07/23/2025 at 10:33 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON stated the facility did not have a policy and procedure on suction equipment but stated the canister should have been changed out.

Based on record reviews and interviews, the facility failed to ensure an assessment and ongoing communication with the dialysis facility by using dialysis communication forms for 1 (#3) out of 3 (#1, #2, and #3) residents sampled. Findings: A review of the facility's agreement with the Contracted Dialysis Agency with an effective date of 02/15/2019 read in part, Responsibilities of Long Term Care Facility (LTCF): LTCF healthcare staff will make an assessment of each patient's physical condition and determine whether the patient is stable enough to be dialyzed on an outpatient basis . This assessment and communication will occur prior to each and every transfer of a patient to the contracted dialysis agency for hemodialysis on an outpatient basis regardless of the number of time any particular patient may be transferred and dialyzed . A review of Resident #3's admission record revealed a re-admission date of 04/15/2025 with diagnoses that included but were not limited to, End Stage Renal Disease and Dependence on Renal Dialysis. A review of Resident #3's most recent Medicare 5-Day Minimum Data Set (MDS) assessment dated [DATE] read in part, Section O: Special Treatments, Procedures, and Programs revealed the resident was receiving dialysis. A review of Resident #3's care plan initiated on 03/25/2025 revealed the resident needs dialysis. Interventions read in part, dialysis 3 days a week on Monday, Wednesday, & Friday at a contracted dialysis agency. A review of Resident #3's dialysis communication record form located in the resident's electronic health record (EHR) from the re-admission date of 04/15/2025 to the present was reviewed. The EHR revealed no documented evidence of a dialysis communication record form on Friday 04/18/2025 and Friday 04/25/2025. On 04/30/2025 at 11:47 a.m., an interview was conducted with S4LPN (Licensed Practical Nurse). She stated dialysis communication forms which consist of assessing the resident are to be completed before each time the resident goes to dialysis. She stated when the resident arrived back to the facility from dialysis this form was to be returned to the nurse who was working so they could look at what happened at dialysis such as how many liters were taken off, compare the resident's weight and see if the dialysis nurse or doctor added any new medications, and this was all documented on the form. She stated after the nurse reviewed the form it was then given to medical records to scan into the EHR. She confirmed that it was their communication method between the facility and the dialysis agency. On 04/30/2025 at 1:25 p.m., an interview was conducted with S3ADON (Assistant Director of Nursing), and she confirmed that Resident #3's dialysis communication forms were not in the facility and they had to reach out to the contracted dialysis agency to get the dialysis communication forms. On 04/30/2025 at 1:35 p.m., an interview was conducted with S2DON (Director of Nursing), and she confirmed there were no dialysis communication forms on Friday 04/18/2025 and Friday 04/25/2025 and should have been.

Based on observations, interviews, and record review, the facility failed to ensure the residents right to be free from physical restraints imposed for purposes of discipline or convenience, for 1 (#2) of three (#1, #2, and #3) sampled residents. This deficient practice was evidenced by Resident #2's use of a wheelchair seat belt the resident was unable to remove. Findings: On 04/30/2025, a review of the facility's policy titled Facility Policy on PSDs (Personal Safety Devices) -Enablers-Side Rails & Restraints with a last revised date of 02/2025, read in part .Restraint Policy Intent: Patients/Residents have the right to be free from any physical restraint imposed for purposes of discipline or convenience and when not required to treat the patient's/resident's medical condition. Patients/Residents have the right to function at their highest practicable level in the least restrictive environment possible. Policy: 1. Restraints will not be used unless the facility's Interdisciplinary Team has completed an assessment and evaluation to identify causative medical or environmental factors and considered less restrictive alternatives . Review of Resident #2's electronic face sheet revealed she was admitted to the facility on [DATE], with diagnoses which included, but were not limited to cerebral palsy, severe intellectual disabilities and aphasia. On 04/29/2025 at 5:25 a.m., an observation was made of Resident #2 sitting in her wheelchair at the nurses' station on Hall W. The resident was awake and had a seat belt secured across her lap. The resident was asked if she could remove the seat belt and she looked at surveyor and did not respond. During an interview with S6CNA (Certified Nursing Assistant) on 04/29/2025 at 5:25 a.m., she confirmed Resident #2 was using a seat belt and stated that staff used the seat belt to prevent her from falling. She confirmed the resident was not able to remove the seat belt. During an interview and observation of Resident #2 with S7LPN (Licensed Practical Nurse) on 04/29/2025 at 6:08 a.m., she confirmed the resident had a seat belt secured across her lap. S7 LPN confirmed Resident #2 had been using the seat belt since she came to the facility. She confirmed Resident #2 was unable to remove the seat belt after it had been secured. Review of Resident #2's admission MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99 in section C0500, indicating the resident was unable to complete the assessment. The resident received a score of 3 in section C1000 indicating her cognitive skills for daily decision making were severely impaired. Further review of the MDS assessment revealed the resident was not coded for using restraints in section P0100. Review of Resident #2's current physician orders revealed no order for a seat belt or any other type of restraint. Review of Resident #2's current care plan report revealed no focus area or intervention for the use of a seat belt. During a follow-up interview with S7LPN on 04/29/2025 at 10:40 a.m., she stated Resident #2 should not have been wearing a seat belt because she had not been assessed, care planned, or had a physician order for it. During an interview with S2DON (Director of Nursing) on 04/29/2025 at 1:07 p.m., she confirmed that she became aware Resident #2 was using the seat belt last week. She stated that her MDS nurse told her the resident was unable to remove the seat belt after the surveyor asked about it. S2DON stated that the resident should not have been using a seat belt because the Interdisciplinary team (IDT) did not complete an assessment and evaluation, and there were no physician orders or care plans for its use.

Based on record review and interview, the facility failed to notify the State Long Term care Ombudsman of a facility-initiated transfer for 1 (#3) out of 3 (#1, #2, and #3) residents sampled. Findings: A review of Resident #3's admission record revealed an initial admission date of 08/29/2024 and a re-admission date of 04/15/2025 with diagnoses that included but were not limited to, End Stage Renal Disease and Dependence on Renal Dialysis. A review of Resident #3's nurse's notes revealed on 03/30/2025 at 11:45 a.m., the resident was transferred to the hospital. Further review of the nurse's notes revealed that on 04/15/2025 the resident returned from the hospital back to the facility. A review of the Emergency Transfer Log for March 2025 and April 2025 revealed Resident #3's transfer to the hospital on [DATE] was not identified on the list. On 04/30/2025 at 1:49 p.m., an interview and record review were conducted with S5SSD (Social Service Director). S5SSD stated she is responsible for completing and sending the Emergency Transfer Log to the State Long Term Care Ombudsman. A review of Resident #3's nurse's notes with S5SSD was conducted at this time, she confirmed Resident #3 was transferred to the hospital on [DATE] and returned 04/15/2025. A review of the Emergency Transfer Log for March 2025 and April 2025 was conducted, and S5SSD confirmed that Resident #3's facility-initiated transfer was not on the notification list sent to the State Long-Term Care Ombudsman, and should have been. On 04/30/2025 at 2:11 p.m., an interview and record review were conducted with S1ADM (Administrator). S1ADM stated Resident #3 was transferred to the hospital on [DATE] and returned on 04/15/2025. A review of the Emergency Transfer Log for March 2025 and April 2025 was conducted, and S1ADM confirmed the State Long Term Care Ombudsman was not notified of Resident #3's facility-initiated transfer was not notified to the State Long-Term Care Ombudsman, and should have been.

Based on interview and record review, the facility failed to ensure a yearly performance review was completed on every Certified Nurse Assistant (CNA) for 1 (S8CNA) of 4 (S8CNA - S11CNA) CNAs personnel records reviewed. Findings: During an interview with S8CNA on 04/29/2025 at 5:25 a.m., the CNA stated she had not received a performance evaluation since she started working at the facility. Review of S8CNA's personnel records revealed a Personnel Action Form with a hire date of 06/06/2023. Further review of the CNA's personnel records revealed no performance evaluation. During an interview with S2DON (Director of Nursing) on 04/30/2025 at 12:04 p.m., she stated that S8CNA is a PRN (as needed) staff and had not received a performance evaluation because she did not receive raises. During an interview with S1ADM (Administrator) on 04/30/2025 at 3:55 p.m., she stated that she was not aware that performance evaluations were required for PRN staff.

Based on record review and interviews, the facility failed to ensure pain management was provided to residents complaining of pain for 1 (Resident #3) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This had the potential to affect the 82 residents that resided in the facility. Findings: On 03/25/2025 a review of the facility's policy titled, Pain Management Program Policy, with a revised and reviewed dated of 01/2025 read in part . The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan and the resident's choices, related to pain management. If pain is identified, the following steps are initiated:-Created a Pain Care Plan using standardized pain assessment tools, obtain orders for pharmaceutical and/or non pharmaceutical interventions. Nurses will assess residents' pain every shift using the appropriate pain evaluation tool and document the effectiveness of interventions. Review of Resident #3's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to, atrial septal defect as current complication following acute myocardial infarction, encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft (CABG), spastic cerebral palsy, paraplegia, spastic hemiplegia, chronic systolic congestive heart failure and dysarthria following cerebrovascular disease. Review of Resident #3's March 2025 physician's orders revealed an order dated 03/11/2025 for Hydrocodone-Acetaminophen oral tablet 5-325 mg (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #3's current care plan revealed Resident #3 was at risk for Potential/actual pain r/t (related to) spasticity, Cerebral palsy, recent CABG, history of angina (chest pain) with interventions including, but not limited to: Hydrocodone-Actaminophen, Monitor/record/report to nurse if resident complaints of pain or requests for pain treatment, Monitor /record pain characteristics Q (every) shift and PRN as needed, Monitor/record/report to nurse any signs and symtoms of non-verbal pain and Notify physician if interventions are unsuccessful. Review of Resident #3's electronic clinical record revealed the following nursing progress notes: Dated 03/12/2025 at 11:30 AM per S3LPN (Licensed Practical Nurse) read: The resident's mother came to the nurse's station asking when the resident's pain meds will be in. S3LPN went through all the bins that the pharmacy sent and no pain meds were in the bin for the resident. S3LPN explained to the mother that a hard script from the NP (Nurse Practitioner) will be needed for the pharmacy to fill his med (medication). Dated 03/13/2025 at 1:00 AM per S3LPN read: Resident c/o (complains of) chest pain. Tylenol was offered d/t (due to) pain medication not in, the patient refused and stated he needed something stronger. S3LPN explained to the resident and his mother that need a physician's order to give pain meds. A note was left for S5NP (Nurse Practitioner) to review the resident's medications. Dated 03/13/2025 at 1:30 AM per S3LPN read: The resident's mother asked if S3LPN could give the resident someone else's pain med. S3LPN explained that nurses are not allowed to share medications. Dated 03/13/2025 at 14:30 (2:30 PM) per S4LPN read: therapist stated to S4LPN that resident would like to see a nurse, for pain relief. S4LPN went in to assess Resident #3 for pain, he stated that he is in pain. S4LPN stated that she could possibly give a standing order pain relief medication, expressing that, the hydrocodone pain medication is on order and has not been delivered at this time. Resident called mother and gave the phone to S4LPN. S4LPN spoke with Resident #3's mother and the mother stated that the doctor okayed pain medication administration to the resident there is no narcotic available to administer presently. S4LPN informed resident's mother of this and stated that she would have to clarify giving anything other than standing order medications with the NP or DON (Director of Nursing). Review of Resident #3's eMAR (electronic Medication Administration Record) for March 2025 revealed Hydrocodone-Acetaminophen 5-325 mg was not administered on 03/12/2025 or 03/13/2025. Further review of the resident's eMAR revealed that on 03/12/2025 the resident complained of pain of 5 on a pain scale of 0-10 with 5 being moderate pain on the night shift. There was no documentation the resident received anything for pain on 03/12/2025. On 03/24/2025 at 4:30 PM, a phone interview was attempted with Resident #3's representative but no answer was received. On 03/25/2025 at 8:00 AM, a second attempt was made to notify Resident #3's representative via phone but no answer was received. On 03/25/2025 at 12:35 PM, an interview was conducted with S7LPN. S7LPN verified medications were ordered through an out of town pharmacy. S7LPN stated there was confusion with Resident #3's Hydrocodone-Acetaminophen 5-325 mg prescription and S5NP ended up having to write a second prescription on 03/13/2025. On 03/25/2025 at 12:45 PM, a third attempt was made to notify Resident #3's representative via phone but no answer was received. On 03/25/2025 at 2:38 PM, a phone interview was conducted with S3LPN. S3LPN stated Resident #3 had complained of pain and she went to look for his medication but it had not yet been delivered. S3LPN stated she had notified S5NP via text message about Resident #3's pain medication not being delivered, but did not get a response. S3LPN denied notifying administrative staff about not having the resident's ordered pain medication in the facility upon the resident's admit to the facility on [DATE]. On 03/25/2025 at 3:50 PM, an interview was conducted with S4LPN. S4LPN stated Resident #3 was newly admitted to the facility on [DATE] and when the resident's mother inquired about the resident's Hydrocodone-Acetaminophen 5-325 mg prescription, S4LPN attempted to give Tylenol but the resident had refused. S4LPN was unable to recall if S5NP was aware of the delivery delay of the Hydrocodone-Acetaminophen 5-325 mg. S4LPN explained the facility had a white binder where the receipt of prescriptions faxed and delivered from the out of town pharmacy were kept. On 03/25/2025 at 4:02 PM, an interview was conducted with S2ADON (Assistant Director of Nursing) who confirmed she reviewed Resident #3's admit orders on 03/11/2025. She explained at times the discharging hospital will electronically file the prescriptions. S2ADON review the electronic health record system and the white binder. She was unable to find confirmation that the resident's prescription for Hydrocodone-Acetaminophen 5-325 mg-Give 1 tablet by mouth every 6 hours as needed for pain was sent to the pharmacy. On 03/25/2025 at 4:33 PM, a phone interview was conducted with S5NP. S5NP confirmed he was made aware that Resident #3's prescription for Hydrocodone-Acetaminophen 5-325 mg 1 tablet by mouth every 6 hours as needed for pain was delayed since admit. S5NP was unable to recall exactly when he was notified of the delay. S5NP denied implementing an alternative order until the medication was delivered.

Based on record review and interviews, the facility failed to ensure pain medication was available for 1 (Resident #3) out of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. This had the potential to affect the 82 residents that resided in the facility. Findings: Review of Resident #3's electronic clinical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included, but were not limited to: atrial septal defect as current complication following acute myocardial infarction, encounter for surgical aftercare following surgery on the circulatory system, presence of aortocoronary bypass graft (CABG), spastic cerebral palsy, paraplegia, spastic hemiplegia, chronic systolic congestive heart failure and dysarthria following cerebrovascular disease. Review of Resident #3's March 2025 physician's orders revealed an order dated 03/11/2025 for Hydrocodone-Acetaminophen oral tablet 5-325 mg (milligrams) Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #3's electronic clinical record revealed the following nursing progress notes: Dated 03/12/2025 at 11:30 AM per S3LPN (Licensed Practical Nurse) read: The resident's mother came to the nurses station asking when the resident's pain meds will be in. S3LPN went through all the bins that the pharmacy sent and no pain meds were in the bin for the resident. S3LPN explained to the mother that a hard script from the NP (Nurse Practitioner) will be needed for the pharmacy to fill his med. Dated 03/13/2025 at 1:00 AM per S3LPN revealed: Resident c/o (complains of) chest pain. Tylenol was offered d/t (due to) pain medication not in. S3LPN explained to the resident and his mother that need a Physician's order to give pain meds. A note was left for S5NP (Nurse Practitioner) to review the resident's medications. Dated 03/13/2025 at 14:30 (2:30 PM) per S4LPN revealed: The hydrocodone pain medication is on order and had not been delivered at this time. Resident called mother and gave the phone to S4LPN. S4LPN spoke with Resident #3's mother and the mother states that the doctor okayed pain medication administration to the resident there is no narcotic available to administer presently. Review of Resident #3's eMAR (electronic Medication Administration Record) for March 2025 revealed Hydrocodone-Acetaminophen 5-325 mg was not administered on 03/12/2025 after the resident complained of pain due to medication not being available. On 03/25/2025 at 2:33 PM, a phone interview was conducted with S6Pharm (Certified Pharmacy Technician) who verified the only pain medication prescription the pharmacy received for Resident #3 was on 03/13/2025 for Hydrocodone-acetaminophen 7.5-325 mg per S5NP. On 03/25/2025 at 4:02 PM, an interview was conducted with S2ADON (Assistant Director of Nursing) who confirmed she reviewed Resident #3's admit orders on 03/11/2025. S2ADON was unable to find confirmation that the resident's prescription for Hydrocodone-acetaminophen 5-325 mg-Give 1 tablet by mouth every 6 hours as needed for pain was sent to the pharmacy on 03/11/2025.

Based on record review and interviews, the facility failed to ensure the resident's comprehensive plan of care was implemented for 2 (#1, #3) residents out of 6 (#1-#6) sampled residents. The facility failed to: 1. Monitor a hematoma and perform wound care for a laceration as ordered for Resident #1; and 2. Perform wound care as ordered for Resident #3's surgical incisions. Findings: Resident #1 Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, End Stage Renal Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Diabetes Mellitus, Severe Protein Malnutrition, and Muscle Wasting and Atrophy. Review of Resident #1's October 2024 physician's orders revealed the following orders dated 10/18/2024: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily every day shift for laceration from fall. Review of Resident #1's October 2024 TAR (Treatment Administration Record) revealed the following: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from Fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily every day shift for laceration from fall. There was no documentation that monitoring for the hematoma or treatment for the laceration was done for the resident on the date of 10/31/2024. Review of Resident #1's November 2024 physician's orders revealed the following orders dated 10/18/2024: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily every day shift for laceration from fall. Review of Resident #1's November 2024 TAR revealed the following: Monitor Hematoma to Left Eye daily for changes every day shift for Hematoma from Fall; Wound #4-Laceration to Left Eye: Cleanse with wound cleanser, pat dry and leave open to air daily every day shift for Laceration from fall. There was no documentation that monitoring for hematoma or treatment for the laceration was done for the resident on the dates of 11/01/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/16/2024, and 11/17/2024. Resident #3 Review of Resident #3's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Displaced Intertrochanteric Fracture of Left Femur, Dementia, Diabetes Mellitus, Major Depressive Disorder, Schizophrenia, Severe Protein Malnutrition, and Muscle Wasting and Atrophy. Review of Resident #3's December 2024 physician's orders revealed the following orders dated 11/29/2024: Wound #2-Surgical Incision to Left Knee: Cleanse with wound cleanser, pat dry, apply island dressing. Change QOD (every other day) and PRN (as needed) soilage every day shift related to Displaced Intertrochanteric Fracture of Left Femur; Wound #3-Surgical Incision to Left Thigh: Cleanse with wound cleanser, pat dry, apply island dressing. Change QOD (every other day) and PRN (as needed) soilage every day shift related to Displaced Intertrochanteric Fracture of Left Femur. Review of Resident #3's December 2024 TAR revealed the following: Wound #2-Surgical Incision to Left Knee: Cleanse with wound cleanser, pat dry, apply island dressing. Change QOD (every other day) and PRN (as needed) soilage every day shift related to Displaced Intertrochanteric Fracture of Left Femur; Wound #3-Surgical Incision to Left Thigh: Cleanse with wound cleanser, pat dry, apply island dressing. Change QOD and PRN soilage every day shift related to Displaced Intertrochanteric Fracture of Left Femur. There was no documentation that treatment was done for the resident's surgical incisions on the dates of 12/02/2024, 12/07/2024, and 12/08/2024. On 12/11/2024 at 3:30 p.m., an interview and record review was conducted with S2TN (Treatment Nurse). She reviewed Resident #1's TAR and confirmed the resident's monitoring and treatments were not completed as ordered in October and November 2024. She also reviewed Resident 3's TAR and confirmed the resident's treatments were not completed as ordered in December 2024.

Based on record review, and interview, the facility failed to provide care and services to prevent and treat pressure ulcers for 5 (#1, #2, #3, #4 and #5) residents of 5 (#1, #2, #3, #4 and #5) sampled residents investigated for pressure ulcers. The facility failed to provide wound care as ordered by the physician for Residents #1, #2, #3, #4 and Resident #5; and monitor proper functioning of a low air loss mattress for Resident #1 per the resident's plan of care. Findings: Resident #1 Review of Resident #1's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Cerebral Infarction, End Stage Renal Disease, Atherosclerotic Heart Disease of Native Coronary Artery, Diabetes Mellitus, Severe Protein Malnutrition and Muscle Wasting and Atrophy. October 2024 Review of Resident #1's October 2024 physician's orders revealed the following orders dated 10/07/2024: -Wound #1 Pressure Injury to the Left Ankle: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Ankle; -Wound #2 Pressure Injury to the Left Foot: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Heel; -Wound #3- Pressure Injury to the Right Heel: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Right Heel. Review of Resident #1's October 2024 TAR (Treatment Administration Record) revealed the treatment orders as noted above for wounds #1-#3. There was no documentation that treatment was administered for the resident's wounds on the dates of 10/07/2024, 10/10/2024, and 10/31/2024. November 2024 Review of Resident #1's November 2024 physician's orders revealed the following orders dated 10/07/2024: -Wound #1 Pressure Injury to the Left Ankle: Apply Gentia [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Ankle; -Wound #2 Pressure Injury to the Left Foot: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Heel; -Wound #3- Pressure Injury to the Right Heel: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Right Heel. Further review revealed orders dated 11/14/2024: -Wound #6-Pressure Injury to Left Ischium: Cleanse with wound cleanser, pat dry, apply Therahoney, and cover with Optifoam SA (Silicone Adhesive) dressing. Change Q3D (every three days) and PRN (as needed) soilage every day shift related to Pressure Ulcer to Left Hip; -Low air loss mattress to bed, check for proper function q (every) shift every day shift related to Pressure Ulcer of left hip. Another order dated 11/19/2024 revealed: -Wound #6-Pressure Injury to Left Ischium: Cleanse with wound cleanser, pat dry, apply Therahoney, Calcium Alginate, cover with Optifoam SA dressing. Change Q3D and PRN soilage every day shift related to Pressure Ulcer to Left Hip. Review of Resident #1's November 2024 TAR revealed the revealed the following: Wound #1 Pressure Injury to the Left Ankle: no documentation the treatment was administered on 11/01/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/16/2024 and 11/17/2024. Wound #2 Pressure Injury to the Left Foot: no documentation the treatment was administered on 11/01/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/16/2024, 11/17/2024, 11/23/2024 and 11/30/2024. Wound #3- Pressure Injury to the Right Heel: no documentation the treatment was administered on 11/01/2024, 11/07/2024, 11/08/2024, 11/09/2024, 11/16/2024 and 11/17/2024. Wound #6-Pressure Injury to Left Ischium: no documentation the treatment was administered on 11/16/2024 and 11/17/2024. Low air loss mattress to bed, check for proper function q shift every day shift related to Pressure Ulcer of left hip. There was no documentation that checking for proper function of low air loss mattress was completed for the resident on the dates of 11/16/2024, 11/17/2024, and 11/30/2024. Wound #6 Pressure Injury to Left Ischium: no documentation that treatment was administered on 11/30/2024. December 2024 Review of Resident #1's December 2024 physician's orders revealed the following orders dated: -10/07/2024 Wound #2 Pressure Injury to the Left Foot: Apply Gentian [NAME] daily every day shift related to Pressure Induced Deep Tissue Damage of Left Heel. -11/14/2024 Low air loss mattress to bed, check for proper function q shift every day shift related to Pressure Ulcer of left hip; and -11/19/2024 Wound #6-Pressure Injury to Left Ischium: Cleanse with wound cleanser, pat dry, apply Therahoney, Calcium Alginate, cover with Optifoam SA dressing. Change Q3D and PRN soilage every day shift related to Pressure Ulcer to Left Hip. Review of Resident #1's December 2024 TAR revealed the following: Low air loss mattress to bed, check for proper function q shift every day shift related to Pressure Ulcer of left hip. There was no documentation that checking for proper function of low air loss mattress was done for the resident on the date of 12/01/2024. Wound #6-Pressure Injury to Left Ischium: no documentation that treatment was administered on 12/01/2024. Resident #2 Review of Resident #2's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Post Hemorrhagic Anemia, Acute Gastric Ulcer with Hemorrhage, Pneumonia, Atherosclerotic Heart Disease of Native Coronary Artery, Peripheral Vascular Disease, Severe Protein Malnutrition and Muscle Wasting and Atrophy. Review of Resident #2's December 2024 physician's orders revealed the following orders dated 11/29/2024: -Wound #2 Pressure Injury to the Left Buttocks: Cleanse with normal saline, pat dry, apply Therahoney, and cover with Optifoam SA dressing. Change Q3D and PRN soilage; -Wound #3 Pressure Injury to the Right Lower Lateral Leg: Cleanse with normal saline, pat dry, apply Therahoney and cover with Optifoam SA dressing. Change Q3D and PRN soilage; daily every day shift related to Pressure Induced Deep Tissue Damage of Right Heel; -Wound #4 Pressure Injury to the Right Heel: Apply Optifoam SA dressing. Change Q3D and PRN soilage daily every day shift related to Pressure Induced Deep Tissue Damage of Right Heel. Further review revealed orders dated 12/05/2024: -Gentamicin Sulfate External Cream 0.1% Topical. Apply to right buttocks topically every day shift related to Pressure Ulcer of Right Buttock; Santyl Ointment 2500 unit/gm (gram). Apply to right buttocks wound topically every day shift related to Pressure Ulcer of Right Buttock; -Wound #1-Pressure Injury to the Right Buttocks: Cleanse with Vashe, pat dry, apply Santyl [NAME] thick and Gentamicin 0.1% ointment, Vashe soaked gauze, skin prep wound edges, ABD (abdominal pad) and secure with tape. Change daily and PRN soilage. Review of Resident #2's December 2024 TAR revealed the wound treatment orders as noted above and the following: Wound #2 Pressure Injury to the Left Buttocks & Wound #1-Pressure Injury to the Right Buttocks: no documentation that treatment was administered on 12/7/2024. Wound #3 Pressure Injury to the Right Lower Lateral Leg & Wound #4 Pressure Injury to the Right Heel: no documentation that treatment was administered on 12/07/2024 and 12/08/2024. Resident #3 Review of Resident #3's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Displaced Intertrochanteric Fracture of Left Femur, Dementia, Diabetes Mellitus, Major Depressive Disorder, Schizophrenia, Severe Protein Malnutrition and Muscle Wasting and Atrophy. Review of Resident #3's December 2024 physician's orders revealed the following orders dated 11/29/2024: -Wound #5 Pressure Injury to the Right Buttocks: Apply Calazime skin paste daily and PRN every day shift related to Pressure Ulcer of Right Buttock; -Wound #6-Pressure Injury to the Sacrum: Apply Optifoam SA dressing. Change Q3D and PRN soilage every day shift related to Pressure Induced Deep Tissue Damage of Sacral Region. Further review revealed the following orders dated 12/05/2024: -Wound #4-Pressure Injury to Left Ankle: Cleanse with wound cleanser, pat dry, apply Medihoney, cover with Optifoam SA dressing. Change 3x a week and PRN soilage every day shift related to Pressure-Induced Deep Tissue Damage of Left Ankle; -Wound #6-Pressure Injury to the Sacrum: Apply Calazime skin paste daily and PRN every day shift related to Pressure Induced Deep Tissue Damage of Sacral Region. Review of Resident #3's December 2024 TAR revealed a listing of the orders noted above and the following: Wound #6 Pressure Injury to the Sacrum: no documentation that the treatment was administered on 12/02/2024. Wound #4 Pressure Injury to Left Ankle & Wound #6 Pressure Injury to the Sacrum: no documentation that the treatment administered on 12/7/2024 and 12/08/2024. Wound #5 Pressure Injury to the Right Buttocks: no documentation that the treatment was administered on 12/02/2024, 12/07/2024, and 12/08/2024. On 12/11/2024 at 3:30 p.m., an interview and record review was conducted with S2TN (Treatment Nurse). She reviewed Resident #1's TAR and confirmed the resident's treatments were not completed as ordered in October, November and December 2024. She further stated checking the proper function of Resident #1's mattress was not completed in November and December of 2024. S2TN reviewed Resident #2's and 3's TAR and confirmed the residents' treatments were not completed as ordered in December 2024. 49784 Resident #4 Review of Resident #4's electronic health record revealed and admitted [DATE] with diagnoses which included, but were not limited to, Muscle Wasting and Atrophy, Chronic Kidney Disease, Stage 4 (Severe), Type 2 Diabetes Mellitus and Anorexia. The resident was discharged from the facility on 04/15/2024. Review of Resident #4's monthly physician orders and TARs from her admission through discharge revealed orders for wound care with missing documentation that wound care had been administered: -Wound #1- Pressure Injury to sacrum: Cleanse with wound cleanser, pat dry, apply Dakins moistened gauze and cover with optifoam SA (Silicone Adhesive) Dressing. Change Daily and prn (as needed) soilage every day shift related to Pressure Ulcer of Sacral Region, Unstageable. Order Date: 08/25/2023 Review of TARs revealed wound care was not administered for dates: 08/27/2023, 09/02/2023, and 09/11/2023. -Wound #5- Pressure Injury to right hip: cleanse with wound cleanser, pat dry, apply Mesalt and cover with optifoam SA dressing. Change daily and prn soilage every day shift related to Pressure Ulcer of Right Hip, Unstageable. Order Date: 08/25/2023 Review of TARs revealed no documentation wound treatment was administered on 09/02/2023 and 09/11/2023. -Wound #5- Pressure Injury to Right Hip: Cleanse with wound cleanser, pat dry, apply Mesalt and cover with Optifoam SA Dressing. Change daily and prn soilage every day shift related to Pressure Ulcer of Right Hip, Unstagable. Order date: 03/22/2024 Review of TARs revealed no evidence wound treatment was administered on 03/24/2024. On 12/11/2024 at 12:04 p.m., a review of Resident #4's TAR was conducted with S2TN (Treatment Nurse) and S1DON/IP (Director of Nursing/Infection Preventionist) who confirmed missing documentation in the months of August 2023, September 2023, and March 2024 for wound care treatments. S2TN and S1DON were unable to provide evidence that the treatments had been administered as ordered. Resident #5 Review of Resident #5's electronic health record revealed an admitted [DATE] with diagnosis which included, but were not limited to, Unspecified Protein- Calorie Malnutrition, Anorexia, and, Paraplegia. Review of Resident #5's monthly physician orders and TARs August 2024-December 2024 revealed orders for wound care with missing documentation that wound care had been administered: -Gentamycin Sulfate External Ointment 0.1% (Topical). Apply to wounds topically every day shift related to Pressure Ulcer of Sacral Region, Stage 4; Pressure Ulcer of Left Buttock, Stage 4; Pressure Ulcer of Left Hip, Stage 4. Order Date: 08/30/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024, 09/03/2024, and 09/13/2024. -Santyl Ointment 250 Unit/GM (gram) (Collagenase). Apply to per additional directions topically every day shift for wound care. Order Date: 08/30/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024, 09/03/2024, and 09/13/2024. -Wound #1- Pressure Injury to Sacrum; Cleanse with Vashe, pat dry, Santyl nickel thick, Gentamycin 0.1%, Hydrofera Blue, Gent (Gentian) [NAME] to periwound, then cover with ABD pad, secure with tape. Change daily and prn soilage every day shift related to Pressure Ulcer of Sacral Region, Stage 4. Order date: 08/28/2024. Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024 and 09/13/2024. -Wound #2- Pressure Injury to Left Ischium: Cleanse with Vashe, pat dry, apply Santyl nickel thick, Gentamycin 0.1%, apply saline moistened gauze to undermining with Santyl and Gentamycin to gauze, Hydrofera Blue, Gent [NAME] to periwound, optilock and secure with tape. Change daily and prn soilage every day related to Pressure Ulcer of Left Buttock, Stage 4. Order date: 08/28/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024 and 09/13/2024. -Wound #3- Pressure Injury to Left Hip: Cleanse with Vashe, pat dry, apply Santyl nickel thick, Gentamycin 0.1%, apply saline moistened gauze to undermining with Santyl and Gent to gauze, Hydrofera Blue, Gen violet to periwound, ABD Pad and secure with tape. Change daily and prn soilage every day shift related to Pressure Ulcer of Left Hip, Stage 4. Order date: 08/28/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 09/02/2024 and 09/13/2024. -Wound #1- Pressure Injury to Sacrum: Cleanse with Vashe, pat dry, apply Meropenem 1 GM and Colistimethate 150 mg, sprinkle powder onto saline moistened gauze, apply saline soaked gauze, Gent [NAME] to periwound, ABD pad and secure with tape, change daily and prn soilage every day shift related to Pressure Ulcer of Sacral Region, Stage 4. Order date: 10/02/2024. Review of TARs revealed no documentation that wound treatments were administered for dates: 10/19/2024, 10/26/2024, 10/28/2024, 11/01/2024, 11/07/2024, 11/09/2024, 11/16/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/29/2024, 12/02/2024, 12/07/2024, 12/08/2024. -Wound #2- Pressure Injury to Left Ischium: cleanse with Vashe, pat dry, apply Meropenem 1gm and Colistimethate 150mg power sprinkle onto wound bed, Gent [NAME] to periwound, apply saline soaked gauze, ABD pad and secure with tape. Change daily and prn soilage every day shift relate to Pressure Ulcer of Left Buttock, Stage 4. Order date: 10/02/2024 Review of TARs revealed no documentation that wound treatments were administered for dates: 10/19/2024, 10/26/2024, 10/28/2024, 11/01/2024, 11/07/2024, 11/09/2024, 11/16/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/29/2024, 12/02/2024, 12/07/2024, and 12/08/2024. -Wound #3- Pressure Injury to Left Hip: Cleanse with Vashe, pat dry, apply Meropenem 1gm and Colistimethate 150mg , sprinkle powder onto saline moistened gauze, apply saline soaked gauze, Gent violet to periwound, ABD pad and secure with tape. Change daily and prn soilage every day shift related to Pressure Ulcer of Left Hip, Stage 4. Order date: 10/02/2024. Review of TARs revealed no documentation that wound treatments were administered for dates: 10/19/2024, 10/26/2024, 10/28/2024, 11/01/2024, 11/07/2024, 11/09/2024, 11/16/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/29/2024, 12/02/2024, 12/07/2024, and 12/08/2024. On 12/11/2024 at 03:00 p.m., a review of Resident #5's TARs was conducted with S2TN (Treatment Nurse) who confirmed there was no documentation that treatments were administered as ordered above in the months of September 2024, October 2024, November 2024, and December 2024. S2LPN was unable to provide evidence that the treatments had been administered as ordered.

Based on observation and interview, the facility failed to post daily nursing staffing that included the facility name, date, census, and the total number and actual hours worked by staff responsible for resident care in a prominent place readily accessible to residents and visitors. Findings: On 07/22/2024 at 3:30 p.m., an observation was made throughout the entire facility, and there was no evidence that the daily nursing staffing was posted. On 07/22/2024 at 4:00 p.m., an interview was conducted with S6Corp (Corporate Nurse) who confirmed that the census should be posted daily. She stated that staff had been posting it on Hall B. At that time, an observation was conducted with S6Corp on Hall B. A white dry-eraser board was observed located under the TV against the back wall. A closer observation revealed that the board did not contain any information. S6Corp stated that the board should have the census, the number of staff, and the total number and actual hours worked. She also confirmed that the board was not and should have been in an area where it was visible for all residents and visitors.

Based on interviews and record reviews, the facility failed to protect the resident's right to be free from physical abuse from other residents for 1 (#1) out of 4 (#1, #2, #3, and #4) sampled residents. The facility failed to protect Resident #1 from being bit by Resident #4. This deficient practice resulted in actual physical harm for Resident #1 on 12/23/2023 at 1:00 p.m. when S4CNA and S3LPN failed to protect Resident #1 from Resident #4 who was known to be verbally and physically aggressive. Both S4CNA and S3LPN observed Resident #4 in an agitated state when she kept repeating that Resident #1 had her baby. S4CNA and S3LPN allowed Resident #4 propel her wheelchair down the hallway towards Resident #1. Ten minutes later, S4CNA heard screaming down the hallway and observed Resident #4 hitting Resident #1 in the face while screaming she has my baby! Resident #4 hit Resident #1 multiple times in the face causing redness to her forehead, right eye, and cheek. Findings: A review of the Facility's Abuse Prohibition Policy, read in part: Each resident has the right to be free from abuse .Physical Abuse includes, hitting .Prevention: 3. Staff will be instructed to report any signs of stress from individuals involved with the residents that may lead to abuse and intervene appropriately. A review of the facility's incident log for December 2023 revealed physical contact between Resident #1 and Resident #4 on 12/23/2023 at 1:00 p.m. Resident #1 Review of Resident #1's clinical record revealed an admitted [DATE] with diagnoses of Cerebral Palsy, Bipolar Disorder, Anxiety Disorder, and unspecified Dementia with other Behavior Disturbances. Review of Resident #1's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 7, indicating she had severe cognitive impairment. Review of Resident #1's current plan of care revealed on 12/23/2023 she received physical aggression from another resident by being struck on the right side of her head. Review of the facility's incident report for 12/23/2023 at 1:15 p.m. revealed Resident #4 propelled herself to another unit and hit Resident #1 in the face multiple times. Resident #1 was assessed and had redness to her forehead, right eye, and cheek. On 02/07/2024 at 2:25 p.m., an interview was conducted with Resident #1. She denied any knowledge of the incident that occurred on 12/23/2023 and being struck in the face by Resident #4. Resident #4 Review of Resident #4's clinical record revealed an admitted [DATE] with diagnoses of Alzheimer's disease, Schizoaffective Disorder, Major Depressive Disorder, and unspecified Dementia. Review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 4, indicating she had severe cognitive impairment. Review of Resident #4's plan of care revealed she is verbally and physically aggressive at times. Interventions included when she became agitated that staff should intervene before the agitation escalated and guide the resident away from the source of distress. On 02/08/2024 at 7:55 a.m., an interview was conducted with S4CNA (Certified Nursing Assistant). She verbalized that on 12/23/2023, Resident #4 was agitated and kept repeating that Resident #1 had her baby. S4CNA stated she informed Resident #4 that Resident #1 did not have her baby. S4CNA stated about 10 minutes later, she heard screaming down the hallway and saw Resident #4 hitting Resident #1 in the face. Resident #4 was screaming she has my baby. S4CNA verbalized she should have taken Resident #4 back to her room when she first noticed she was agitated before it escalated. On 02/08/2024 at 11:32 a.m., an interview was conducted with S3LPN (Licensed Practical Nurse). She stated on 12/23/2024, Resident #4 was propelling down the hallway looking for her baby. She reported that S4CNA told the resident that no one had her baby and attempted to redirect her. Resident #4 became more agitated and was allowed to propel her wheelchair down the hallway. Resident #4 then attempted to enter Resident #1's room but Resident #1 stuck her leg out to stop her. Resident #4 began to hit Resident #1 in the face and they both began to scream at each other. S3LPN stated she intervened and separated the residents. Resident #1 was observed to have redness where she was slapped on her forehead, right eye and cheek by Resident #4. During an interview on 02/08/2024 at 12:00 p.m., with S1ADM (Administrator) and S2DON (Director of Nursing) they both confirmed they were aware that Resident #4 had propelled her wheelchair down the hallway and hit Resident #1 in the face multiple times leaving reddened areas where she was hit. S2DON verbalized that staff had attempted to redirect her but she was agitated. She confirmed that Resident #4 has a history of agitation but felt that the incident was not considered abuse due to her diagnosis of dementia.

Based on record review and interview, the facility failed to ensure that the resident receives adequate assistance to prevent accidents as evidence by failing to provide 2 person assist during transfers for 1 (Resident #81) of 4 residents reviewed for accident/hazards. (Resident #45, #53, #74, #81) The facility's failure to assure 2 person assist was provided during transfers for Resident #81 resulted in an actual harm for Resident #81 on 9-5-15 at 6:00pm when S8CNA transferred Resident #81 from wheelchair to bed, using 1 person transfer technique, she reported hearing a popping joint sound as she was attempting to reposition the resident in the bed. An x-ray was obtained on 9-6-15 at 15:22 with the following finding: Distal femoral fracture with mild displacement and angulation. Resident #81 was admitted to the hospital at which time she underwent an ORIF of the right femur. FINDINGS: A review of the clinical record revealed that Resident #81 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the facilities accident/incident log revealed that Resident #81 sustained an injury of unknown origin on 9-5-15. A review of the nurses notes for Resident #81 revealed the following entries: 9-6-15 at 3:17pm late entry for 9-5-15 at 20:00. Informed by CNA___ that resident was having increased pain to R knee after being transferred into bed, upon assessment of knees no redness or edema was noted to bilateral knees, ROM noted to be limited prior to increased pain, Ultram 100mg po given .will monitor. 9-6-15 3:30pm late entry for 0630: informed by CNA___that resident noted to be in pain, upon assessment noted resident to be guarding right knee and facial grimacing noted, no swelling noted at sight, asked if she was in pain and resident stated yeah Ultram 100mg po given for pain .NP notified .x-ray to right knee today. 9-6-15 3:43pm late entry for 12:45pm: x-ray report received stating oblique well aligned supra condylar fracture of right femur, mild arthritic changes in the right knee, NP notified, send to ER for further evaluation Review of ER record dated 9-6-15 at 14:06 read: arrived per ambulance; ? twisting leg in bed; Severe pain; location of injury right thigh; alert; tenderness to right thigh/hip; labs and x-ray ordered; admit to hospital for closed displaced femoral fracture/ volume depletion/dehydration. Resident discharged back to facility on 9-9-15 s/p ORIF right femur. A review of the annual MDS dated [DATE] revealed the following information: Cognition with a BIMS score of 9- moderately severe; functional status for transfer: self-performance-total dependence; transfer: support provided-two + person physical assist. A review of Resident #81 ' s plan of care revealed resident requires assistance with ADL ' s related to CVA with Right sided hemiparesis: Two person with transfers. A phone interview was conducted with S8CNA on 9-17-15 at 8:47am. S8CNA stated that she was assigned to work with Resident #81 on 9-5-15 for the 2-10 shift. S8CNA stated that the family requested that she get the resident up so they could visit with her at about 3:00pm. Resident #81 was complaining of pain and I noticed when I got her up to the wheelchair that she felt like she was running a temperature. I reported this to the nurse who gave her medicine for pain and fever. Resident #81 stayed up in the wheelchair and appeared to tolerate it well. After supper I put her back to bed like I usually do. S8CNA stated that the resident was complaining that her knee hurt. I looked at her knee and didn ' t notice anything unusual. I even touch a few spots but all she would say is that my knee hurts. S8CNA stated that she put the resident to bed and then went and told the nurse. S8CNA ' s written statement for 9-5-15 read, I got her up at which time everything was good. When I put her down, I heard like a bone joint pop. When I covered her up she said that she was in pain and I told the nurse. S8CNA confirmed that she did write this statement and that she did hear this popping sound which she had never heard before. When questioned as to how she transferred the resident to bed, S8CNA verified that she did so by herself. S8CNA stated that on the door it said resident was a one person assist but the facility called and told her she was a 2 person assist. An interview was conducted with S12LPN on 9-17-15 at 4:00pm. After a review of the clinical record, S12LPN confirmed that she had cared for Resident #81 on 9-5-15. S12LPN stated that during her shift, a family member mentioned to her that the resident was kind of uncomfortable and hurting today. The family did not request any medication for the resident at this time. S12LPN stated that later on, around 3:00/3:30 pm, the CNA reported to her that the resident was running a fever of 101.4 at which time she medicated her with Tylenol as per the standing orders. S12LPN stated she continued to monitor the temperature of the resident throughout the shift. Surveyor than questioned S12LPN as to if she was aware of the resident complaining of knee pain. S12LPN stated that the CNA reported to her around 6:00pm on 9-5-15 that the resident was complaining of right knee pain. S12LPN stated that when she went to assess the resident, she had to wake the resident up to do so. S12LPN confirmed she did not notice any swelling, redness or deformity upon her assessment therefore she medicated the resident and continued to monitor her throughout her shift. S12LPN then stated that at around 6:30am, the resident again complained of knee pain as reported to her by the CNA. S12LPN stated she re- assessed the resident ' s knee but did not notice anything unusual. Resident #81 was administered Ultram 100mg for pain as well as Tylenol for a temperature. S12LPN stated that at this time she call the NP on duty and reported the status of the resident in regards to temperature/pain and new orders were obtained for lab work and a knee x-ray. During the interview, S12LPN confirmed that Resident #81 was a two person assist with transfers. During this interview, the surveyor then went over the statement of S8CNA and mentioned to S12LPN the verbiage of hearing a joint popping sound . Surveyor then inquired if S12LPN recalled this information being reported to her by the CNA on duty. After thinking a few moments, S12LPN stated , Yes, now that you mention it I think I do remember her saying something to that affect. S12LPN was then questioned as to the increased level of pain throughout the shift for Resident #81 on 9-5-15. S12LPN stated that the resident frequently complained of knee pain and general pain due to arthritis and she didn ' t feel it was something to report at the time as her assessment failed to indicate any obvious issue. An interview was held with S3ADON on 9-18-15 at 8:30am. S3ADON stated that the resident had a history of [REDACTED]. At this time, a review of the resident ' s MAR for July, August and September, 2015 was conducted with the surveyor. A review of these documents revealed the following information: September, 2015 Monitor pain level every shift with no indication of pain until 9-6-15 at a level of 5 on a scale of 1-10; Ultram 100mg by mouth every 6 hours as needed for pain with indication of administering of medication on 9-5-15 at 8:30pm, 9-6-15 at 0630 and 9-6-15 at 12:30pm all indicated for knee pain; August, 2015 Monitor pain level every shift with indicated on pain on 8-17-15 at a level of 5 on a scale of 1-10; Ultram 100mg was administered at 3:00pm on 8-17-15 for complaint of a headache; Tylenol 650mg by mouth every 6 hours as needed for mild pain administered at 11:00am on 8-14-15 for general pain; July, 2015 monitor pain level every shift with no indication of pain for this time period; Ultram 100mg was administered on 7-10-15 for complaint of back pain at 12:30 and 7-25-15 at 3:30 for general pain.

Based on observations, record review and interviews the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs as evident by: 1. S8CNA failing to transfer a resident using two people as required for Resident #81 2. S20CNA failing to transfer a resident using two person transfer for Resident #29 and 3. failing to accurately weigh a resident for 2 months for Resident #5 for 3 (Resident # 5,# 29, #81) out of 5 (Resident #5, # 7, #24, #29, #81) residents observed for ADL/Transfer from a sum total of 36 stage 2 sampled residents. The failure of S8CNA to transfer Resident #81 with two person assist as required by the plan of care resulted in an actual harm due to the resident experiencing increased pain of the right knee which began on 9-5-15 at 6:00pm. Resident #81 continued with severe knee pain on 9-6-15 at which time a right leg x-ray was performed. The findings of the x-ray performed on 9-6-15 revealed a fractured right femur resulting in the resident undergoing an ORIF of the right femur. Findings: 1. Resident #81. A review of the clinical record revealed that Resident #81 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. A review of the facilities accident/incident log revealed that Resident #81 sustained an injury of unknown origin on 9-5-15. A review of the nurses notes for Resident #81 revealed the following entries: 9-6-15 at 3:17pm late entry for 9-5-15 at 20:00. Informed by CNA___ that resident was having increased pain to R knee after being transferred into bed, upon assessment of knees no redness or [MEDICAL CONDITION] was noted to bilateral knees, ROM noted to be limited prior to increased pain, [MEDICATION NAME] 100mg po given .will monitor. 9-6-15 3:30pm late entry for 0630: informed by CNA___that resident noted to be in pain, upon assessment noted resident to be guarding right knee and facial grimacing noted, no swelling noted at sight, asked if she was in pain and resident stated yeah [MEDICATION NAME] 100mg po given for pain .NP notified .x-ray to right knee today. 9-6-15 3:43pm late entry for 12:45pm: x-ray report received stating oblique well aligned supra condylar fracture of right femur, mild arthritic changes in the right knee, NP notified, send to ER for further evaluation Review of ER record dated 9-6-15 at 14:06 read: arrived per ambulance; ? twisting leg in bed; Severe pain; location of injury right thigh; alert; tenderness to right thigh/hip; labs and x-ray ordered; admit to hospital for closed displaced femoral fracture/ volume depletion/dehydration. Admit to hospital for Ortho services. A review of the annual MDS dated [DATE] revealed the following information: Cognition with a BIMS score of 9- moderately severe; functional status for transfer: self-performance-total dependence; transfer: support provided-two + person physical assist. A review of Resident #81 ' s plan of care revealed resident requires assistance with ADL ' s related [MEDICAL CONDITION] Right sided [MEDICAL CONDITION]: Two person with transfers. A review of S8CNA's personnel record was reviewed on 9-17-15 which revealed a written reprimand for improper transfer dated 7-27-15. This incident was in relation to S8CNA failing to use a gait belt with transfers as per the facility policy with a resident. A phone interview was conducted with S8CNA on 9-17-15 at 8:47am. S8CNA stated that she was assigned to work with Resident #81 on 9-5-15 for the 2-10 shift. S8CNA stated that the family requested that she get the resident up so they could visit with her at about 3:00pm. Resident #81 was complaining of pain and I noticed when I got her up to the wheelchair that she felt like she was running a temperature. I reported this to the nurse who gave her medicine for pain and fever. Resident #81 stayed up in the wheelchair and appeared to tolerate it well. After supper I put her back to bed like I usually do. S8CNA stated that the resident was complaining that her knee hurt. I looked at her knee and didn't notice anything unusual. I even touch a few spots but all she would say is that my knee hurts. S8CNA stated that she put the resident to bed and then went and told the nurse. At this time, surveyor reviewed S8CNA ' s written statement for 9-5-15 at which time she wrote , I got her up at which time everything was good. When I put her down, I heard like a bone joint pop. When I covered her up she said that she was in pain and I told the nurse. S8CNA confirmed that she did write this statement and that she did hear this popping joint sound which she had never heard before. When questioned as to how she transferred the resident to bed, S8CNA verified that she did so by herself. S8CNA stated that on the door it said resident was a one person assist but the facility called and told her she was a 2 person assist. S8CNA stated that she was not the only CNA that transferred this resident by herself. During this same interview, S8CNA also stated that before she transferred the resident to bed, she did attempt to get someone to help her since the resident was complaining of pain but no one was available at the time. A face to face interview was conducted with S12LPN on 9-17-15 at 4:00pm. During this interview, S12LPN confirmed that S8CNA had reported to her that Resident #81 was complaining of right knee pain. S12LPN stated she medicated the resident after she assessed her and continued to monitor her throughout her shift. S12LPN confirmed that Resident #81 was a two person assist with transfer and never questioned the CNA as to how resident was transferred. An interview was held with S3ADON on 9-18-15 at 8:30am. A review of the resident's clinical record was conducted at this time. A review of the care plan was conducted by S3ADON who confirmed that according to the care plan, Resident #81 required a two person assist for transfers 2. Resident #29: A review of Resident #29 ' s record revealed that she was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of pages 8 and 9 of Resident #29 ' s care plan revealed that she required assistance with ADLs (Activities of Daily Living) related to General Weakness and that she needed extensive assistance with Transfers. Further review of the care plan revealed that X ONE had been typed on the care plan as what was needed with transfer assistance but a line had been drawn through it. X TWO had been written over it. A hand written entry on page 9 revealed Resident requires more assist she is being seen by Therapy to assist with muscle weakness . A review of Resident #29 ' s quarterly MDS dated [DATE] revealed that she needed extensive assistance with transfers by two persons and that she used a wheelchair for mobility. On 9/14/15 at 2:30 PM, an interview was conducted with Resident #29. She stated that an aide transferred her into her bed by herself by grasping the legs of her pants as she sat in her wheelchair and throwing her legs onto her bed. Resident #29 stated that she had to pull her own body into her bed by usign her enabler bar. She further stated that she required 2 aids to transfer into bed and that she had twisted her back when she had to pull herself into her bed when the aid transferred her without assistance from a second aide. On 9/17/15 at 3:00 PM, an interview was conducted S20CNA. She stated that she provided transfer assistance to Resident #29 routinely, which included transferring her in and out of her bed. S20CNA stated that she would ask Resident #29 if she was able to stand by herself and if the resident told her yes, then she transferred her into her bed by herself, without assistance from a second CNA. S20CNA further stated that she would instruct the resident to hold onto the enabler bar of her bed and transfer her into her bed without assistance from a second CNA. 3. Resident #5. Record review of Resident #5's computerized Vital Signs read as follows; On 2-17-15 Resident #5 ' s weight was156 On 3-7-15 Resident #5 ' s weight was 158 On 4-7-15 Resident #5 ' s weight was 159 On 5-7-15 Resident #5 ' s weight was 160 On 6-7-15 Resident #5 ' s weight was 162 On 7-7-15 Resident #5 ' s weight was 163 On 8-7-15 Resident #5 ' s weight was 149 On 9-7-15 Resident #5 ' s weight was 140 On 9-13-15 Resident #5 ' s weight was 140 Record review of the Dietician Notes dated 8-25-15 read, Mother stated she does not see No difference in Resident #5's eating habits and that he eats well in her opinion. Residents Height was 72 inches and his weight was 147 pounds. The resident had a significant weight loss in one month of 9.98%. The Resident staff reflect 98% meal intake. At this time will monitor weight but not recommend supplements. At this time discussed weight and possible re-weight. DON reports this was his typical summer pattern. This document was signed by S30 RD. Record review of Nursing Notes dated 9-11-15 read, Weight Loss of 5.15% in one month and -13.90 % in 3 months. Resident current weight was 140 pounds. The Residents appetite was good. Family Nurse Practitioner was notified of weight loss trend will continue to monitor. This document was signed by S2 DON. Record review of Resident #5's computerized Vital Signs record for 2014 read as follows; On 3-7-14 Resident #5 ' s weight was 166 On 4-7-14 Resident #5 ' s weight was 163 On 5-7-14 Resident #5 ' s weight was 162 On 6-7-14 Resident #5 ' s weight was 163 On 7-7-14 Resident #5 ' s weight was 166 On 8-7-14 Resident #5 ' s weight was 161 On 9-7-14 Resident #5 ' s weight was 159 There was no significant weight lose noted from 3/2014 to 9/2014 On 09/17/2015 2:48 PM an interview with Resident #5's Mother revealed the staff did not weigh her son correctly. She revealed he did not lose 20 pounds in a month. She revealed he does not miss Breakfast, lunch or supper and consumes 100% of his meals. On 09/17/2015 at 3:26 PM an interview with S1ADM revealed Resident #5 could not weigh 140 pounds with a 20 pound weight loss in a month. He revealed the staff should have reweighed the resident. On 09/17/2015 3:22:12 PM an observation of S18 C.N.A. and S26 C.N.A. weighing Resident #5 revealed S18 C.N.A hooked the slings to the Lift spreader bars and zeroed the scale while residents leg was pushing on the sling causing the scale to be off. At this time she stated this was the proper method of weighing the resident. She attempted to zero the scale three times while Resident #5 would move spastically causing the scale to be off. During the fourth attempt she managed to keep Resident #5's legs still while she zeroed the scale. At this time the resident ' s weight was noted to be 162.4 LB. On 09/18/2015 at 10:02 AM an interview with S24 LPN MDS Coordinator revealed Resident #5 was care planned with a significant weight loss in 21 days at 5.13 % from 8-23-15 to 9-13-15. She revealed at this time Resident #5 weighed 140.6 pounds. She revealed she could look at Resident #5 and tell he doesn ' t weigh 140 pounds. She revealed the staff should have reweighed the resident because this weight was inaccurate. Record review of the policy titled Weight Management read as follows, 3. Residents will be weighed by designated staff by the first week of each month. 5. Facility will ensure that daily weights are done by a designated person and documented appropriately. 6. If the weight was greater or less than 5 LB, the resident will be re-weighed and verified by designated staff. 12. The DON monitoring prevalence of unintended weight loss on a monthly basis through analysis of the weight variance tracking log, and the QI (Quality Insurance) report. 13. The DON reports results and required process improvement to the QA and assurance committee for ongoing recommendations. Record review of the Operations Manuel for Weighing the Patient read, 1. Attach sling straps to the swivel bar. 2. Press the on/off key. 3. Press the Zero Key. 4. Place the patient in the sling. 5 Activate the lift mechanism to raise the patient until they are completely supported by the lift. 6. Note the weight display. 7. When the weight display becomes stable press the Lock button to lock the weight display. On 09/18/2015 at 2:49 PM an observation with S24 LPN MDS Coordinator revealed Resident #5 has involuntary [DIAGNOSES REDACTED]. At this time she reviewed the document labeled Abnormal Involuntary Movement Scale (AIMS) dated 8-25-15. This record revealed Resident #5 ' s score was 17. She revealed this score meant the residents had uncontrollable involuntary movements.

Based on observation, record review and interview the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1(#1) of 5 (#1, #2, #3, #4, #5) sampled residents that wandered, were at risk for elopement and wore a Wander Guard bracelet. The facility failed to: 1. Ensure that Resident#1, assessed with [REDACTED]. 2. Ensure that staff responded to the door alarm system when Resident #1, wearing a wander guard device, exited the building causing the activation of the door alarm system. An Immediate Jeopardy situation began on [DATE] at 6:30 PM, when Resident #1, with a severe cognitive impairment, wandered outside the facility undetected by the facility ' s staff. As a visitor entered the facility through Exit Door a , Resident #1 exited the facility through the same door. When Resident #1 exited the building with his Wander Guard bracelet in place the audible door alarm was activated. Resident #1 was found propelling himself in his wheelchair down the high traffic residential street in front of the facility. The resident had traveled 54 feet from the exit door onto the street, turned right, and then traveled the distance of at least 1 full hallway of 8 resident rooms before the nursing staff reached him. Interviews revealed that at least 5 staff members were present at the nurse's station and/or the dining room area that was located near the nurse ' s station which was within hearing distance of the audible alarm. Resident #1 was assessed as a wanderer and at risk for elopement when admitted to the facility on [DATE]. The record review for Resident #1 revealed a nurses ' note dated [DATE] at 2:16 PM that read, informed by CNA while going to check on alarm to front door, that she noted resident outside near sidewalk. The facility Administrator and Director of Nursing were notified of the Immediate Jeopardy situation on [DATE] at 4:10 PM. This deficient practice was identified for 1 (Resident #1) of 5 sampled residents who were identified by the facility to be at risk for elopement. The Immediate Jeopardy situation was removed on [DATE] at 10:40 AM, when an acceptable plan of removal was presented. The facility ' s plan to remove the Immediate Jeopardy situation included: *Resident wander guard device checked and is in working order to ensure safety. *Doors were checked to assure in functioning order to ensure elopement residents safety. *All elopement residents devices were validated in working order to ensure all elopement risk residents are safe. *Signs immediately placed on all exit doors to assure that visitors are aware to check with staff prior to letting residents out of facility. *Individual letters sent to responsible parties notifying them of the risks of letting residents out. Letter also instructed to RP (responsible party) to relay message to any potential visitors. *Notification placed in facility newsletter to assure that residents are not let out of facility without checking with staff. *Changed the codes on the two emergency exit doors at end of ,[DATE] hall. Line staffs do not have access to these codes. *Started in service on elopement protocol including device checking and response time to door alarms to staff. *DON (Director of Nursing)/ADM (Administrator) will validate signs on exit doors weekly *ADM/ADM Nursing validates staff response times ongoing when alarms sound in the facility. The deficient practice remains at a potential for more than minimal harm. Findings: Record review revealed Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Record review of Resident #1 ' s admission MDS (Minimum Data Set) assessment dated [DATE] revealed the following: BIMS (Brief Interview of Mental Status) score of 5, cognition was severely impaired. Behavior- Resident wandered 1 to 3 days of the 7 day look back period, which placed the resident at significant risk of getting to a potentially dangerous place (e.g., outside of facility. Mobility Devices-Wheelchair. Record review of the Wander Data Collection Tool dated [DATE], the resident ' s admitted , revealed the resident wandered at home, in previous living settings; the resident ' s family/significant others voiced concerns; the resident ' s wandering placed the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility); the resident was cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking); the resident was a new admission and did not accept the new situation; the resident ambulated independently, with or without the use of assistive devices (includes wheelchair); the resident verbally expressed the desire to go home or packed belongings to leave; this was a new behavior or changes in his functional status/routing (i.e. new medication, pain, acute illness/infection, personal tragedy, new active diagnosis, upsetting information); the resident was seeking to find spouse/family. Based on the summary of findings the resident was a wander/elopement risk. Record review of the Wander Data Collection Tool dated [DATE] revealed all noted on the [DATE] form and an additional entry which read, resident ' s former lifestyle/profession affected the current behavior/wandering. Based on the summary of findings the resident was a wander/elopement risk. Record review of Resident #1's Nurses ' Notes revealed: [DATE] at 2:43 PM: Late entry 1430 (2:30 PM) Resident is in his wheelchair located at the front door of the building stating that he wants to go home . [DATE] at 1:40 PM: Resident noted outside on sidewalk in wheelchair upon getting to resident. Resident questioned as to what was wrong and res stated I need to go home . [DATE] at 12:40 AM: Noted res walking to front door, got up and asked what he was doing .Resident stated I was just going to peek outside . [DATE] at 4:27 PM: Ambulating via w/c independently around facility .Stated I am trying to get to my house . [DATE] at 1:46 PM: Resident noted wandering .Redirecting unsuccessful. Stated I have to take care of business . [DATE] at 4:10 PM: .noted by nurse that resident had cut off his wander guard, another was reapplied .Unsure how he cut it off and he didn ' t admit to anything [DATE] at 6:49 PM: Notified by CNA that resident was found outside of building in wheelchair. Resident was able to get out of building when a family member was opening the main lobby doors. CNA was able to assist resident back into facility with minimal difficulty. Resident was cooperative. Stated I was just going to the store . Record review of the Resident Incident Report, dated [DATE] for Resident #1 revealed the following: Incident: Wander from Grounds. Date/Time: [DATE] at 6:31 PM. Narrative of incident: Resident was able to get out main lobby doors when a resident family member was exiting the building. Near Station 1; Resident seen wheeling self down road way in front of building by staff member, and was escorted back into the building with minimal difficulty. Immediate Actions Taken: Reminded resident that he needs to ask for assistance to go outside. Medical risk factors possibly related to incident: Elopement Risk A Witness Form dated [DATE] revealed the following: Date of Incident/Accident: [DATE] at 6:45 PM. Witness Name: (S5LPN). Description of Incident: Sitting at nurse ' s station charting, Alarm sounded saw family member enter door. Went to turn off alarm, saw S6CNA (Certified Nursing Assistant) running down hall screaming a resident is outside. Went to door turned alarm off and ran to get resident who was on (street in front of facility). Resident stated 'I was just going to the store' Brought resident back into facility, verified safety device still worked. No distress/harm to resident. Reoriented resident that this is his home he needs permission to go outside. RP (Responsible Party) and PCP (Primary Care Physician) notified. Explained to family member to see a nurse before letting any resident out of facility. Pointed out 2 signs by door. The form was signed and dated by S5LPN on [DATE]. During an interview on [DATE] at 4:40 PM with S5LPN regarding Resident #1's incident on [DATE], she stated that she retrieved the resident from the street after his elopement. S5LPN stated that at the time of the incident she was charting at Station 2's nurse ' s desk and heard the front door alarm going off. She revealed that she heard S6CNA yelling from the end of Hall f to alert her that Resident #1 was outside on the street in front of the facility. The resident was traveling down the road in his wheelchair headed toward a street that intersected the street in front of the facility. She stated that she heard alarms going off all the time and therefore, she did not know how long the alarm was sounding before she attended to the door alarm. She stated that the incident occurred after the dinner meal and several staff members, including 4 CNA's and 1 LPN (Licensed Practical Nurse) were present at the nurse ' s station and at the nearby dining room, within hearing distance of the audible alarm. She stated that she assumed someone else had responded to the sounding door alarm. She reported that she waited at least 30 seconds before she responded to the audible door alarm and confirmed that she should have acted upon the sounding alarm in a timelier manner. After review of the facility ' s Overall Floor Plan, it was noted that Resident #1 traveled 54 feet down the sidewalk from Exit Door a and into the street, turned right, and traveled another distance of at least 1 full hallway of 8 resident rooms by the time the nursing staff reached him. The facility was located in a high traffic residential area. A second Witness Form dated [DATE] revealed the following: Date of Incident/Accident: [DATE]. Witness Name: (S6CNA). How did you learn of the incident/accident: I saw him out the window. Description of Incident: I was walking past a residents room (resident ' s name) and noticed out the window Resident #1 propelling himself down the street. I ran down the Hall called for S5LPN and told her and she ran outside and brought him back to the facility. The form was signed and dated by S6CNA on [DATE]. During an interview on [DATE] at 9:30 AM with S6CNA, she stated that on the evening of [DATE], she observed Resident #1 out of a resident ' s room window at the end of Hall f She reported that the resident was wheeling himself down the road as fast as he could go. She stated that when she saw him, she called for S5LPN, but then started yelling down the hall because she realized S5LPN was all the way at the nurse ' s station near the beginning of the hall. She stated S5LPN then ran out the front door and brought the resident back into the facility. She revealed that when an alarm goes off, she was instructed to stop everything, see which alarm was going off and why it was going off, to go as soon as possible and to not wait. When S6CNA was asked to describe Resident #1, she stated the following: He always definitely likes to go outside. He always wants to go outside, and he will ask anybody to let him go outside. He always asks to go to the store, and he thinks the store is across the street. He often sits on the couch near the Exit Door c and Exit Door a. About two weeks ago, I was coming on shift and he was near Exit Door a and he asked me if I would bring him to the store. He asks anybody to get out of the door and he sits by the exit doors often and this is probably why because he wants to get out. I keep my eyes especially on Resident #1 because he will sneak away. He is very fast in his wheelchair. Record review of the OTIS (Online Tracking Incident System) report submitted by the facility regarding Resident #1 ' s elopement on [DATE] at 6:30 PM included a summary of the incident, which indicated the resident was an elopement risk and had a Wander Guard bracelet. The Summary on the report revealed staff noted the Wander Guard alarm was sounding at the exit door just prior to the resident being found on the street; a family member let the resident out of the facility; staff noted there were multiple individuals around the exit door at the time of the elopement; and staff was to be in-serviced to remind them of importance of response time to Wander Guard alarm. During an interview on [DATE] at 11:30 AM with S2DON regarding Resident #1's incident on [DATE], she stated the following, Another resident family member let him out. He spends most of his time near the exits. He just sits there at door exits, and he is an opportunist and waits for an opportunity to get out. He moves fast. S2DON revealed that when an alarm sounds, she expected staff to respond promptly. She reported that she in-serviced staff on responding promptly because she found that to be part of the problem of the [DATE] incident. During an interview on [DATE] at 5:23 PM with S11CNA, she stated she had been working with Resident #1 for about 3 months. When asked to describe Resident #1, she stated the following, He doesn ' t want to be here. He always wants to go home. He wants me to go buy him liquor from the store, and he asks me that a lot. He talks to his daughter on the phone and tells her he doesn ' t want to stay. He asks me what time I get off, and I tell him and then he asks me to bring him home. He sits in the lobby a lot. He wants to go home and wants to go to the store. He asks me to buy him a bottle of gin. He tells me he lives down the street. He asked me today to buy him some liquor, and he asked me yesterday to let him go to the store. S11CNA further stated that she would think Resident #1 was at risk for elopement prior to the incident because of what he said like he wants to go home and wants to go to the store. She reported that when the door alarms sound, she was instructed to go look at the door immediately to see why the alarm was sounding and that if she didn ' t see a resident near the door or area near the door, then she should go look outside to make sure the resident didn ' t get out and was wandering outside. During an interview on [DATE] at 10:30 AM with S1ADM and S10CN, S10CN stated that before the resident was admitted to the facility, he ' d go to the store to get liquor. S10CN and S1ADM confirmed that Resident #1 asked all the time to go to the store. Record review of the resident ' s Admission Care Plan dated [DATE] revealed the resident was care planned for the following: -Elopement Risk: Approaches-Keep call bell in reach; Encourage use of call light; If unable to use call light, Nursing Assistant will assess resident every ,[DATE] minutes; Instruct resident on safety measures; Physical Therapy referral; Wander alarm; Assess resident ' s footwear for proper fit and non-skid soles Record review of the resident ' s current Care Plan revealed the resident was care planned for the following: -Problem Onset: [DATE]-Wandering r/t (related to) * Wandering daily or more frequently-Signal Device in Place. Goal-Resident will be safe and secure in facility [DATE]. Approaches: Observe and document frequency/severity of target behavior; Check frequently for wandering; Redirect resident when found wandering in unauthorized areas; Remove resident from others rooms and unsafe situations; Remove resident from area when disruptive; Monitor signaling device q (every) shift for placement due to risk of elopement; Check skin at signal site QD (every day) Further record review of Resident #1 ' s Nurses Notes revealed: [DATE] at 10:54 AM: .does sit calmly at doorway and observe . [DATE] at 2:16 PM: Informed by CNA _____ while going to check on alarm to front door noted resident outside near sidewalk, was able to assist resident back into facility without diff. Resident was let out of facility by visitor, when asked where he was going he said I don ' t know . [DATE] at 1:12 PM: SSD (Social Services Director) called RP to discuss about previous elopement .daughter stated he maybe seeking to go outside because he likes the outdoors .prenursing home living ' did go to the store a lot ' . Record review of the facility ' s Incident and Accidents Prevention System- Wanderer Management, Monitoring System & (and) Resident Elopement Protocol, revised ,[DATE], revealed in part: Purpose-To monitor safety of residents at risk for elopement. To provide a system to alert staff that a resident may be attempting to leave the facility. Policy-It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. Responsibility-All staff is responsible to ensure resident safety. Procedures: A. Identification and Prevention of Elopement- 10. An Elopement Risk binder will be maintained in a centrally located nurse ' s station; Elopement Risk binders will contain a current picture of the resident and a current face sheet. 12. Devices, the following and place in the Elopement Risk Binder: *Name of Resident *The date device applied and location *The date due to expire *The date of replacement and location B. Interdisciplinary interventions-When a door alarm sounds, staff shall respond immediately and determine cause of the alarm. During an interview on [DATE] at 2:10 PM with S9SSD, she stated that when the door alarm goes off the protocol is to immediately go check on the doors. She also stated that she was in charge of maintaining the facility ' s Elopement Binders located at each nurses ' station. S9SSD stated that the only thing she puts in the elopement binder was the face sheet of each resident that was an elopement risk. She stated that she assessed the binder every time she got a new list of residents at risk for elopement. The Elopement Binder at the front desk was assessed and contained only the Face Sheets for 6 of the 8 residents that were elopement risks; Resident #3 and Resident #8 ' s Face Sheets were missing. The Elopement Binder at the back nursing desk was assessed and was found to have a Face Sheet for 6 of the 8 residents at risk for elopement; Resident #3 and Resident #8 ' s Face Sheets were missing. The Elopement Binders failed to contain the dates the devices were applied and location on the residents, the dates the devices expired and the dates of replacements and locations. Record review of the Secure Care Products Inc. User Guide for Model SC-40 STAT Tester used by the facility stated, Secure Care' s software, parts and products have been designed to augment a facility ' s reasonable procedures for protecting residents, patients, and infants. However, no system or combination of procedures and equipment can eliminate all risk or assure complete security. Secure Care's system is not intended as a substitute for the careful identification and monitoring of residents, patients, and infants by a facility's professional staff. During an interview with S1ADM and S10CN on [DATE] at 5:00 PM, the facility ' s outside surveillance video footage of Resident #1 ' s elopement on [DATE] was reviewed. During the observation of the video, no sounds were audible. Resident #1 exited the building at 6:28:26 PM and was brought back into the facility by staff at 6:31:28 PM. After review of the video, S1ADM confirmed the facility's outside surveillance system did not have an audio function and no sounds were audible on the videos. S1ADM stated that the facility did not have video surveillance cameras inside the facility, and he confirmed that he could not determine the length of time the door alarm had been sounding at the time of Resident #1 ' s elopement.

Based on observation, record review and interview, the facility was not administered in a manner that enabled it to use its resources effectively to maintain the highest physical well-being of residents for 1 of 5 sample residents (Resident #2) reviewed for accidents when Administration failed to ensure staff utilized the Pre-trip vehicle and wheelchair inspection procedure by failing to periodically validate that the procedure was being followed. On 9/27/11, Van Driver S3 failed to properly secure Resident #2 in her wheelchair by only using two of the four required straps during transport, and during acceleration, Resident #2 flipped backwards in her wheelchair and sustained a fractured rib. The Immediate Jeopardy Situation began on 9/27/11, when Van Driver S3 failed to properly secure Resident #2 (time undocumented) and continued until 9/27/11 at 4:30 PM, when the ambulance service took responsibility of Resident #2. The Administrator S4 was informed of the Immediate Jeopardy situation on 10/11/11 at 2:18 PM. This deficient practice remains at the actual harm level for Resident #2. Findings: Resident #2 was a [AGE] year old female with [DIAGNOSES REDACTED]. Resident #2's incident/accident report form dated 9/27/11 revealed she was in her personal wheelchair and the front wheels had not been strapped. The back wheels had been secured with two straps. At acceleration from a stop light, Resident #2's wheelchair flipped backwards. The resident complained of "rib cage" discomfort. Resident #2's post fall review form dated 9/27/11 read: description of fall: front straps not used on wheelchair. Wheelchair flipped backwards. According to Resident #2's radiology report dated 9/27/11 at 5:01 PM, it was very suggestive of a nondisplaced acute fracture of her left eighth rib. A copy of an inservice dated 9/28/11 was provided by the facility which included a Pre-Trip wheelchair Inspection form. This form read: The driver completes this checklist prior to each trip involving transportation of residents in wheelchairs. Maintain a blank form in the facility vehicle log and make copies as needed to complete for each trip. ....The driver checks that the following guidelines have been followed: - Strap passenger's wheelchair front first from the lower bottom bar on top of wheel. Straps should attach to a solid, structural frame member of wheelchair. - Apply the brake on the wheelchair. Strap the rear of the wheelchair to the floor of the vehicle. - ....... - Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or from side to side. File the completed form in the facility vehicle log. Retain for seven years. On 10/10/11 at 1:55 PM, AIT (Administrator in training) S1 stated that they had not been using the Pre-Trip wheelchair inspection form. It was a corporate form and they should have been using them, but had not been. A review of the facility's driver and vehicle safety policy and procedure read: ....The Administrator will periodically validate that the procedures listed below are being followed....Pre-trip vehicle and wheelchair inspections are conducted and documented as per the facility vehicle log. On 10/11/11 at 10:45 AM, Administrator S4 confirmed they had not been utilizing the Pre-Trip wheelchair inspection forms, and she had not performed a periodic review to ensure the inspections were being conducted.

Based on observation, record review, and staff interview, the facility failed to ensure assistive devices were provided to each resident to prevent avoidable accidents by failing to secure Resident #2 properly during transportation in the facility van on 9/27/11. Two out of the four required straps were not used, and when the Van driver accelerated, Resident #2 flipped backwards in her wheelchair and sustained a fractured rib. The Immediate Jeopardy Situation began on 9/27/11, when Van Driver S3 failed to properly secure Resident #2 (time undocumented) and continued until 9/27/11 at 4:30 PM, when the ambulance service took responsibility of Resident #2. The Administrator S4 was informed of the Immediate Jeopardy situation on 10/11/11 at 2:18 PM. This deficient practice remains at the actual harm level for Resident #2. Findings: Resident #2 was a [AGE] year old female with [DIAGNOSES REDACTED]. A review of Resident #2's MDS (minimum data set) dated 6/14/11 revealed she had a BIMS (brief interview for mental status) score of 15 which indicated she was cognitively intact. Resident #2's incident/accident report form dated 9/27/11 revealed she was in her personal wheelchair and the front wheels had not been strapped. The back wheels had been secured with two straps. At acceleration from a stop light, Resident #2's wheelchair flipped backwards. The resident complained of "rib cage" discomfort. Resident #2's post fall review form dated 9/27/11 read: description of fall: front straps not used on wheelchair. Wheelchair flipped backwards. According to Resident #2's radiology report dated 9/27/11 at 5:01 PM, it was very suggestive of a nondisplaced acute fracture of her left eighth rib. A copy of an inservice dated 9/28/11 was provided by the facility which included a Pre-Trip wheelchair Inspection form. This form read: The driver completes this checklist prior to each trip involving transportation of residents in wheelchairs. Maintain a blank form in the facility vehicle log and make copies as needed to complete for each trip. ....The driver checks that the following guidelines have been followed: - Strap passenger's wheelchair front first from the lower bottom bar on top of wheel. Straps should attach to a solid, structural frame member of wheelchair. - Apply the brake on the wheelchair. Strap the rear of the wheelchair to the floor of the vehicle. - ....... - Prior to transport, make a final check of all secured passengers to ensure that all straps are properly attached. If there are any wheelchairs, be sure that they are secured and there is no possible movement from the front to rear or from side to side. File the completed form in the facility vehicle log. Retain for seven years. On 10/10/11 at 1:55 PM, AIT (Administrator in training) S1 stated that they had not been using the Pre-Trip wheelchair inspection form. It was a corporate form and they should have been using them, but had not been. On 10/10/11 at 2:10 PM, an observation was made of Activity Director S9 securing a wheelchair in the facility's van. She attached straps with hooks to all four sides of the wheelchair frame, and a shoulder style seatbelt strap through the arms of the wheelchair. She then demonstrated there was no movement of the wheelchair when tugged on. Maintenance S2 was present during this demonstration and confirmed it was the proper way to secure a wheelchair in the van. An instruction schematic on proper use of straps and seatbelts to secure wheelchairs was posted in the van on the window, which indicated the need for four straps, one on each side of the wheelchair, to properly secure a wheelchair. A review of the facility's driver and vehicle safety policy and procedure read: ....The Administrator will periodically validate that the procedures listed below are being followed....Pre-trip vehicle and wheelchair inspections are conducted and documented as per the facility vehicle log. On 10/11/11 at 10:45 AM, Administrator S4 confirmed they had not been utilizing the Pre-Trip wheelchair inspection forms, and she had not performed a periodic review to ensure the inspections were being conducted. On 10/11/11 at 2:45 PM, Resident #2 revealed she was still in substantial pain from the broken rib sustained on 9/27/11. She indicated it was harder for her to get dress, and now cannot do things for herself. For example, she used to take her own jacket off of her shoulders, and now she cannot do that because it hurts too much. At the time of this interview, Resident #2 was sitting outside in her wheelchair with her jacket draped over her shoulders, she demonstrated that she could not get the jacket off of her shoulders if she got too warm. She also indicated she is afraid when she rides in the van now.