Every finding on record at Picayune Rehabilitation and Healthcare Center

Based on observation, staff interviews, and record review the facility failed to maintain sanitary conditions in the dietary department by failing to ensure dishes washed in a low-temperature dishwasher were sanitized with the required chlorine concentration prior to reuse and by failing to wash and sanitize used beverage pitchers before returning them to refrigerated storage for two (2) of three (3) days of kitchen observations.Findings include:On 07/07/2026 at 10:40 AM, during an observation and interview with Dietary Aide (DA) #1, observed DA #1 was operating the low-temperature dishwasher. DA #1 used a chlorine test strip to verify the sanitizer concentration. The test strip remained white, indicating no detectable chlorine sanitizer. DA #1 asked whether she should notify the District Manager (DM) and then informed the DM that the test strip did not register any chlorine. The DM observed the test strip and confirmed no chlorine was present. During the interview, DA #1 stated she routinely tested the chlorine level during each wash cycle but was unsure why the sanitizer was not registering. She confirmed the chlorine test strip measured 10, 50, 100, and 200 parts per million (ppm) and acknowledged documenting chlorine values such as 61 and 62 ppm represented her estimate of the closest reading. On 07/07/2026 at 3:30 PM, during observation and interview, DA #2 was observed washing dishes in the low-temperature dishwasher. During interview in the presence of the DM, DA #2 confirmed she had not checked the chlorine sanitizer concentration before washing the dishes. She stated she had been trained by the previous Dietary Manager to wash all dishes before checking the sanitizer concentration. She further stated she usually did not document the chlorine level because the dietary aide working earlier had already completed the dishwasher log for the dinner meal. During an interview at the same time, with the DM, she reported that the Eco Lab representative had been notified. The DM confirmed that the kitchen staff have continued to use the dishwasher after observing the chlorine test strip showed no detectable sanitizer. She stated staff were expected to notify her of any dishwasher malfunction and acknowledged the dishwasher should have been producing adequate chlorine sanitizer during operation. She further stated the varying chlorine values documented on the dishwasher log reflected staff estimating the sanitizer concentration rather than recording actual readings.On 07/07/2026 at 4:07 PM, during an interview, the Dishwasher Manufacturer Representative (DMR) stated the minimum acceptable chlorine concentration was 50 ppm and the minimum rinse temperature was 120 F. He explained that staff should record only the actual chlorine concentration indicated on the test strip. He confirmed entries such as 57 ppm and 66 ppm were not valid readings and indicated staff were estimating the sanitizer concentration rather than documenting the actual test strip result.On 07/08/2026 at 10:36 AM, during an observation and interview with DA #3, DA #3 was observed to bring in three (3) beverage pitchers that had been used on the resident care unit. DA #3 placed the used pitchers containing remaining beverage back into the kitchen refrigerator without emptying, washing, or sanitizing them. An interview with DA #3 revealed it is her standard practice to place pitchers that are at least half filled back into the refrigerator after bringing them back into the kitchen after meal service. An interview with the District Supervisor (DS) revealed she observed the used beverage pitchers in the refrigerator. The DS confirmed used beverage pitchers returned from the resident care units should be emptied, washed, and sanitized before being placed back into refrigeration. On 07/09/2026 at 3:31 PM, during an interview, the Administrator stated she expected dietary staff to maintain sanitary food service practices, including ensuring dishes were properly sanitized and used beverage pitchers were washed before reuse. She stated additional education would be provided regarding sanitation, food safety, and proper operation of the low-temperature dishwasher.A review of the Dish Machine Log - Low Temperature (Chemical Sanitizer) for July 2026 revealed chlorine concentrations ppm's were documented as 57 through 63 ppm. These documented values were inconsistent with the manufacturer's test strip, which only measured chlorine concentrations of 10, 50, 100, or 200 ppm.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to implement appropriate Contact Precautions in accordance with Centers for Disease Control and Prevention (CDC) guidelines by failing to provide designated disposal containers for contaminated personal protective equipment (PPE), contaminated linens, and other contaminated materials in resident rooms, resulting in contaminated PPE, linens, and other contaminated materials being discarded with routine waste and laundry for two (2) of five (5) residents reviewed for infection prevention and control (Residents #4 and #110).Findings include:A record review of the facility's policy titled, Infection Prevention and Control Program with review date 3/03/2026 revealed . An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Interpretation and Implementation. 11. Prevention of Infection a. Important facets of infection prevention include: . 7. Implementing appropriate isolation precautions when necessary; and 8. Following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).A record review of the Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting (2007)) last updated September 2024 revealed . III.B.1. Contact Precautions. Contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contract with the patient or the patient's environment. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. Healthcare personnels caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE (Personal Protective Equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination.On 07/06/2026 at 10:45 AM, during an observation and interview with Certified Nursing Assistant (CNA) #1, the State Agency (SA) observed Contact Isolation signage and PPE available outside Resident #110's room. CNA #1 stated Resident #110 had been admitted on Contact Precautions related to a urinary tract infection (UTI) and staff were required to wear PPE when providing care.On 07/06/2026 at 11:24 AM, during an observation and interview with Resident #110, the SA observed a bedside commode lined with clear plastic bags. No designated biohazard waste container or designated contaminated linen receptacle was observed in the resident's room or bathroom.On 07/06/2026 at 12:15 PM, during an observation, the SA observed Contact Isolation and Enhanced Barrier Precautions signage and PPE available outside Resident #4's room. Resident #4's wife stated the resident remained on Contact Precautions due to an infected wound on his right foot/toe.On 07/06/2026 at 2:45 PM, during an observation and interview with Resident #4, the SA observed no designated disposal containers for contaminated PPE, linens, or other contaminated materials in the resident's room. Resident #4 reported drainage had periodically leaked from his wound onto his sock prior to the dressing being changed.On 07/07/2026 at 11:05 AM, during an observation and interview with Resident #4, Contact Isolation signage and PPE remained in place; however, no designated disposal containers were observed in the resident's room or bathroom. Resident #4 stated staff wore gowns and gloves while providing care and discarded the PPE in the regular trash container located in the room.On 07/07/2026 at 2:25 PM, during an interview, Licensed Practical Nurse (LPN) #1 confirmed Resident #4 remained on Contact Precautions following a positive wound culture for Methicillin-resistant Staphylococcus aureus (MRSA). LPN #1 stated staff were required to wear PPE whenever providing direct care.On 07/07/2026 at 2:40 PM, during an observation and interview with Resident #4, resident observed sitting up in his high back wheelchair with right foot observed with dressing dry and intact. No designated disposal containers were observed in his room.On 07/07/2026 at 3:42 PM, during an interview, LPN #2 stated Resident #110 was admitted on Contact Precautions for Extended-Spectrum Beta-Lactamase (ESBL) in the urine. She stated staff were required to don (put on) PPE before entering the room and remove and discard PPE before exiting the room. LPN #2 reported PPE had been discarded in the regular trash container located in the resident's room.On 07/08/2026 at 8:00 AM, during an observation and interview, the SA observed LPN #3 place two designated disposal containers into Resident #110's room. LPN #3 stated she had just been instructed by the Director of Nursing (DON) to place the containers in the room and confirmed no designated disposal containers had been present since the resident's admission on [DATE].On 07/08/2026 at 8:10 AM, during an observation and interview, Registered Nurse (RN) #1 observed donning proper PPE while administering intravenous antibiotics and discarded the PPE in the regular trash container. RN #1 stated Resident #110 had remained on Contact Precautions since his admission on [DATE].On 07/08/2026 at 1:00 PM, during an interview, CNA #6 stated no designated disposal containers had been present in Resident #110's room. CNA #6 reported contaminated gowns were placed in routine linen bags with other facility linens, bed linens were placed in the routine laundry, PPE was discarded in the regular trash container, and bedside commode liner bags were discarded in the regular trash after use.On 07/08/2026 at 2:30 PM, during an interview, CNA #2 stated Resident #4 had no designated disposal containers in the room throughout the weekend. She reported contaminated linens were placed in routine laundry bags with other facility linens because no designated contaminated linen receptacle was available. PPE was discarded in the regular trash container.On 07/08/2026 at 3:05 PM, during an interview, CNA #3 confirmed no designated disposal containers were present in Resident #4's room during her shift. She reported PPE worn while providing care was discarded in the regular trash container.On 07/08/2026 at 4:30 PM, during an interview, RN #2 stated residents placed on Contact Precautions were expected to have Contact Isolation signage, PPE, and two designated disposal containers in the room, including one container for contaminated linens and one container for biohazardous waste. RN #2 confirmed neither Resident #4 nor Resident #110 had designated disposal containers until 07/08/2026. RN #2 stated that without designated disposal containers, contaminated PPE, linens, and other contaminated materials could be discarded with routine waste or laundry, increasing the risk for transmission of organisms such as MRSA and Extended-Spectrum Beta-Lactamase (ESBL).On 07/09/2026 at 2:00 PM, during an interview, the DON confirmed residents on Contact Precautions were expected to have designated disposal containers for contaminated linens and biohazardous waste placed in their rooms. The DON stated staff were expected to follow Contact Precaution procedures to prevent the transmission of infectious organisms and confirmed any nursing staff member could obtain and place the required disposal containers in the resident room.On 07/09/2026 at 3:00 PM, during an interview, the Administrator stated she expected staff to follow CDC Contact Precaution guidelines, including ensuring resident rooms were properly equipped with required infection control supplies and promptly reporting missing equipment needed to safely implement Contact Precautions.Resident #4A record review of Resident #4's admission Record revealed the facility admitted the resident on 11/25/2025 with the diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy Without Gangrene, and Peripheral Vascular Disease, Unspecified.A record review of Resident #4's Order Details with order date 06/25/2026 revealed order for obtain wound culture and sensitivity r/t (related to) rt (right) foot 2nd toe wound drainage. one time only .A record review of Resident #4's Order Details with order date 06/30/2026 revealed order for contact isolation r/t MRSA wound every shift for 8 (eight) days .A record review of Resident #4's Order Summary Report revealed orders for . contact isolation r/t MRSA wound every shift for 1 Month with start date 07/09/2026 and stop date 08/09/2026 . Wound #3 arterial ulcer R (right) 2nd toe; clean with wound cleanser, paint with betadine, apply dry dressing, change 3 times a week and PRN (as needed), start date 7/8/26 . Bactrim DS Oral Tablet 800-160 milligrams (mg) . Give 1 tablet by mouth two times a day for wound infection/MRSA/RT (right) foot 2nd toe for 7 days with start date 07/08/2026 .A record review of Resident #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/26/2026 revealed Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicated cognitively intact. A record review of Resident #4's View Progress Notes with effective date 6/25/2026 12:41 PM revealed . During wound care rounds resident's Right 2nd toe wound noted to have purulent drainage on bed and sock. Notified (Proper Name) Wound Care Service's Nurse Practitioner new order to obtain wound culture. Wound culture obtained and sent to lab .A record review of Resident #4's Wound Culture with resulted date 06/29/2026 revealed 3+ Staphlococcus Aureus MRSA (Methicillin-resistant Staphylococcus aureus) a group of bacteria that causes infection. Resident #110A record review of Resident #110's admission Record revealed the facility admitted the resident on 07/03/2026 with the diagnosis of Acute Cystitis with Hematuria.A record review of Resident #110's Order Summary Report revealed orders for . Isolation Precautions: Contact precautions R/T (related to) ESBL (Extended-Spectrum Beta-Lactamases) UTI (Urinary Tract Infection) every shift until 07/10/2026 start date 07/03/2026 . Ertapenem Sodium Injection Solution Reconstituted (Ertapenem Sodium) . Use 1 (one) gram intravenously one time a day related to Acute Cystitis with Hematuria for 5 (five) Days start date 07/04/2026 .A record review of Resident #110's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/09/2026 revealed a Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicated cognitively intact.A record review of Resident #110's Urine Culture with resulted date 06/27/2026 revealed greater than 100,000 CFU/ml (Cetrimide, Fucidin, and Cephalosporin per milliliters) Klebsiella Pneumoniae ESBL (Extended-Spectrum Beta-Lactamases) a group of bacteria that causes infections.

Based on resident interviews, staff interviews, record review, and facility policy review, the facility failed to promote resident self-determination and honor resident rights by failing to allow residents to choose their dining location on weekends, requiring residents to receive meals in their rooms for three (3) of (20) residents reviewed for Resident Rights. (Residents #63, #75, and #77).Findings include:A record review of the facility's policy titled, Resident Rights with a revised date of 4/2017, revealed .a. Be encouraged in the exercise of their.rights, benefits or privileges guaranteed by the constitution of the United States and the constitution of the state of Louisiana including the right to be free of discrimination or segregation based upon race, sex, handicap, religion, creed, national background or ancestry with respect to residency, b. Be treated as individuals in a manner that supports their dignity, c. Be assured choice and privacy and the opportunity to act autonomously, take risks to enhance independence, and share responsibility for decisions.e. Receive care and services that are adequate, appropriate, and in compliance with contractual terms of residency, relevant federal and state laws, rules and regulations and shall include the right to refuse such care and services. On 07/06/2026 at 11:29 AM, during an interview, Resident #63 stated residents eat breakfast, lunch, and dinner in their rooms on weekends because they don't have enough staff.On 07/07/2026 at 11:45 AM, during an interview, Resident #75 stated residents are not allowed to eat breakfast, lunch, or dinner in the dining room on weekends. Resident #75 stated the dining room doors are usually closed on the weekend except for a 30-minute activity on Saturdays periodically. On 07/07/2026 at 12:00 PM, during an interview, Resident #77 stated he enjoys eating meals in the dining room because it allows him to socialize with other residents. He stated that on weekends he doesn't get out of bed because he is required to eat breakfast, lunch, and dinner in his room and is not permitted to eat in the dining room.On 07/09/2026 at 9:00 AM, during an interview, Certified Nursing Aide (CNA) #6 stated residents routinely eat all meals in their rooms on weekends because there are not enough staff to supervise and assist residents in the dining room. CNA #6 stated that residents are occasionally permitted to eat in the dining room on Saturdays if staffing permits; however, residents do not eat in the dining room on Sundays because the dining room remains closed. On 7/9/26 at 9:10 AM during an interview, Licensed Practical Nurse (LPN) # 6 stated that the residents eat in their rooms on the weekends because there are not enough staff to cover the residents or to assist the residents with their meals in the dining room. LPN #6 also stated that at times the facility is down two (2) nurses or (2) CNA's which prevent them from assisting the residents in the dining room, she states that they try to meet the residents' basic needs.On 7/9/26 at 9:25 AM during an interview CNA # 7 confirmed residents routinely receive meals in their rooms on Saturdays and Sundays due to staffing shortages. She stated residents may occasionally eat in the dining room on Saturdays if staffing allows; however, residents are never permitted to eat in the dining room on Sundays. On 07/09/2026 at 9:45 AM, during an interview, the Director of Nursing (DON) stated he attempted to provide residents with dining services on weekends to the best of the facility's ability. He stated there may be circumstances in which residents were unable to dine in the dining room; however, staff were encouraged to provide residents with a positive dining experience. The DON stated he was not aware residents were routinely receiving breakfast, lunch, and dinner in their rooms on weekends rather than being afforded the opportunity to dine in the dining room.On 07/09/2026 at 10:00 AM, during an interview, the Administrator stated she was unaware residents routinely received meals in their rooms on weekends. She confirmed residents have the right to choose where they eat their meals and stated staff are expected to honor resident choice regarding dining location.Resident # 63A record review of Resident #63's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Unspecified Fracture of unspecified Lumber Vertebra and Type 2 Diabetes Mellitus without complication.A record review of residents' admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/26 revealed Brief Interview Mental Status (BIMS) score of 14 which indicated cognitively intact.Resident #75A record review of Resident #75's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Paranoid Schizophrenia and Borderline Intellectual Functioning. A record review of the Annual MDS with an ARD of 5/19/26 revealed a BIMS score of 15, which indicates cognitively intact.Resident #77A record review of Resident #77's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side and Reduced Mobility. A record review of residents' Annual MDS with an ARD of 5/28/26 revealed BIMS score of 11 which indicated moderate cognitive impairment.

Based on interview, record review, and facility policy review, the facility failed to ensure residents who had not executed an Advance Directive were informed of their right to formulate an Advance Directive and were offered assistance in establishing an Advance Directive for two (2) of (20) residents reviewed for Advance Directives. (Residents #11 and #75).Findings include:A review of the facility's policy titled, Advance Directives Policy, with no date, revealed, .The resident has the right to make his or her own decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives. Our facility acknowledges the resident's right to provide written Advance Directives, as required under the Patient Self-Determination Act of 1990, which communicates preference for treatment and care (allowed by the state) in the event he or she becomes incapacitated and unable to express his or her wishes.A review of the facility's policy titled, Advance Directives, revised in [DATE], revealed, Advance directives will be respected in accordance with state law and facility policy. Policy Interpretation and Implementation, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical treatment and to formulate an advanced directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advance directives and applicable state law. 6. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, .family members, .and/or.legal representative about the existence of any written advance directives. 7. Information about whether or not the resident has executed advance directives shall be displayed in the medical record. 8. If the resident indicates he or she has not established advance directives, facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Facility staff will document the offer in the patient's record to include acceptance/ denial.A record review of the clinical records for Residents #11 and #75 revealed no documentation the residents or their Resident Representatives (RR) received written information regarding the right to formulate an Advance Directive (AD) or were offered assistance in establishing an AD.On 07/06/2026 at 11:08 AM, during an interview, Licensed Vocational Nurse (LVN) #1 stated the Social Services Director (SSD) was responsible for providing residents and RR information regarding Advance Directives and maintaining the documentation in the electronic medical record. LVN #1 confirmed no Advance Directive documentation was available for Residents #11 or #75.On 07/09/2026 at 2:32 PM, during an interview, the Administrator stated the SSD was responsible for educating residents and RRs regarding Advanced Directive and maintaining the required documentation in the resident's medical record. The Administrator acknowledged residents and RRs were expected to receive information regarding the residents' right to formulate an Advanced Directive and, if an Advanced Directive had not been established, to be offered assistance in establishing an Advanced Directive. The Administrator further acknowledged documentation of the Advanced Directive provided, and any offer of assistance was expected to be maintained in the resident's medical record. The Administrator confirmed the facility was unable to provide documentation demonstrating Resident #11 or Resident #75 received information regarding the right to formulate an Advanced Directive or were offered assistance in establishing an Advanced Directive.Resident #11A record review of the admission Record for Resident #11 revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Unspecified, Major Depressive Disorder, Recurrent Severe Without Psychotic Features, and Schizoaffective Disorder, Unspecified.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/26 revealed Resident #11 had a Brief Interview Mental Status (BIMS) score of 10, which indicated moderately impaired cognition.Resident #75A record review of the admission Record for Resident #75 revealed the resident was admitted to the facility on [DATE] with diagnoses including Paranoid Schizophrenia and Borderline Intellectual Functioning.A record review of the Annual MDS with an ARD of 5/19/26 revealed Resident #75 had a BIMS score of 15, which indicated intact cognition.

Based on interview, record review, and facility policy review, the facility failed to develop and implement an individualized comprehensive person-centered care plan for a resident requiring mechanical lift transfer assistance for one (1) of (20) sampled residents. (Resident #107).Findings Include:A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered reviewed 6/2/2025, revealed .a comprehensive person-centered care plan.is developed and implemented for each resident. Policy Interpretation and Implementation.8. a. include measurable objectives and timeframes; b. describe the services that are to be furnished to attain.the resident's highest practicable physical, mental, and psychosocial well-being .A review of the facility's policy titled, Resident Rights with a revised date of 4/2017, revealed, .b. be treated as individuals in a manner that supports their dignity.e. receive care and services that are adequate, appropriate, and in compliance with.relevant federal and state laws. A record review of Resident #107's Care Plan Report revealed no individualized interventions directing staff to utilize a Hoyer (mechanical) lift, identifying the required sling type or size, or describing resident-specific transfer techniques or precautions related to the resident's metastatic bone disease. The care plan lacked individualized guidance for staff to safely transfer the resident while mechanical lift assistance was required.On 07/07/2026 at 2:34 PM, during an interview, the Minimum Data Set (MDS)/Care Plan Nurse/Registered Nurse (RN) #5 stated the comprehensive care plan is intended to communicate each resident's individualized care needs to staff and should include resident-specific transfer interventions for residents requiring mechanical lift assistance. RN #5 stated care plans should provide specific instructions describing how staff are to safely transfer residents.On 07/07/2026 at 3:06 PM, during an interview, the Rehabilitation Director confirmed Resident #107's comprehensive care plan contained no interventions identifying Hoyer (mechanical) lift use, sling type, sling size, or resident-specific transfer precautions. The Rehabilitation Director stated Resident #107 had complained of neck pain before hospitalization, which was later determined to be associated with a cervical fracture.On 07/08/2026 at 10:05 AM, during an interview and record review, Charge Nurse (RN #4) reviewed the electronic medical record and confirmed there was no physician order identifying Hoyer lift transfers, no therapy documentation identifying sling type or size, and no care plan interventions directing staff regarding Hoyer lift use or sling requirements. RN #4 stated therapy may have provided recommendations; however, no such documentation was present in the medical record.On 07/09/2026 at 3:40 PM, during an interview, the Administrator stated she expected each resident's comprehensive care plan to accurately reflect individualized care needs and include resident-specific interventions to guide staff in providing safe care, including safe transfer techniques when mechanical lift assistance is required.A record review of Resident #107's Discharge MDS with an Assessment Reference Date (ARD) of 06/03/2026 revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Section GG revealed the resident utilized a manual wheelchair at the time of discharge.A record review of the admission Record for Resident #107 revealed the resident was re-admitted to the facility on [DATE] with a diagnosis of Pathological Fracture in Neoplastic Disease Other Specified Site, Sequela.A record review of the Order Summary Report for Resident #107 revealed an active order for therapy evaluation and treatment, dated 3/18/26.

Based on interviews, record review, and facility policy review, the facility failed to provide an ongoing program of activities designed to meet the interests, preferences, and psychosocial well-being of residents by failing to implement scheduled weekend activities and provide activity opportunities for bedbound residents for two (2) of (2) residents reviewed for activities. (Residents #13 and #63).Findings include:A review of the facility's policy titled, Resident Rights, revised 04/2017, revealed, .Residents shall.n. Have choices about participation in community activities and in preferred activities .A review of the facility's policy titled, Activity Programs, Revision Date June 2018, revealed, .Activity programs are designed to meet the interests of and support the.psychological well-being of each resident.5.activity programs are designed to encourage maximum individual participation and are geared to the individual resident's need. 6. Activities are scheduled 7 (seven) days a week. A review of the facility's July 2026 activity calendar revealed scheduled activities on Saturdays and Sundays.On 07/06/2026 at 11:40 AM, during an interview, Resident #63 stated the facility did not provide activities on weekends, leaving residents with nothing to do for two days. The resident reported that on Saturday's staff occasionally played a movie in the dining room for residents who wished to watch and were able to attend. The resident stated no other structured activities were offered during the remainder of the weekend. Resident #63 further stated residents can't wait for the weekends to end because they become bored with nothing to do. On 07/09/2026 at 4:00 PM, during an interview, the Activities Director (AD) stated the monthly activity calendar listed multiple activities for Saturdays and Sundays; however, the Activities Department was only present on Saturdays for approximately 30 minutes to conduct one activity for residents able to attend the activity room. The AD confirmed staff did not conduct room-to-room activities for bedbound residents on Saturdays and could not confirm bedbound residents received activities during Sunday church visits.On 07/09/2026 at 4:15 PM, during an interview, Resident #13 stated she remained in bed most of the time and was not offered activities on weekends. The resident stated having nothing to do on weekends bothered her because she became bored and would like to be offered activities to keep her busy.On 07/09/2026 at 4:38 PM, during an interview, the Administrator was informed the Activities Department was not implementing all scheduled weekend activities and that bedbound residents were not being offered weekend activities. The Administrator stated she felt it was important for bedbound residents to have weekend activities and expected bedbound residents to start having consistent weekend activities. Resident #13A record review of the facility's admission Record revealed the facility admitted Resident #13 on 01/15/2026 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 through Stage 4 chronic kidney disease, or Unspecified Chronic Kidney Disease. A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/7/2026 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. Resident #63A record review of the facility's admission Record revealed the facility admitted Resident #63 on 05/05/2026 with diagnoses including Unspecified Fracture of Unspecified Lumbar Vertebrae, Sequela. A record review of the admission MDS with an ARD of 05/11/2026 revealed Resident #63 had a BIMS score of 14 indicating cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to provide necessary care and services to protect residents from neglect when staff failed to ensure safe transfers for a resident who required a mechanical lift, failed to ensure a licensed nurse timely assessed the resident following a fall, failed to initiate timely neurological monitoring, and failed to timely notify the physician of the fall and subsequent head injury for one (1) of six (6) residents reviewed for falls. Resident #1. The facility's failure to ensure appropriate post-fall assessment, monitoring, communication, and timely medical evaluation resulted in serious harm to Resident #1 and placed other residents with falls at risk for serious harm, serious impairment, or death.The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 1/20/26, when Resident #1 fell and was manually lifted back into bed without a licensed nurse assessment and without timely initiation of neurological monitoring or physician notification following a suspected head injury. The facility Administrator was notified of the IJ on 2/4/26 at 4:00 PM and was presented with the IJ template. The facility provided an acceptable Removal Plan on 2/4/26, in which they alleged all corrective actions to remove the IJ were completed on 2/4/26, and the IJ was removed on 2/5/26.The State Agency (SA) validated the Removal Plan on 2/5/26 and determined the IJ was removed on 2/5/26, prior to exit. Therefore, the scope and severity for CFR S483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include:A review of the facility's Abuse Prohibition Policy, reviewed 6/2/25, revealed .Intent: This protocol was intended to assist in the prevention of abuse, neglect.Definitions.Neglect is defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, good or services that a resident (s) requires but the facility fails to provide them to the resident (s), that has resulted in or may result in physical harm, pain. A review of the facility's policy, Fall Prevention Program, dated 6/18/25, revealed .5. If a fall occurs, the following will be done: a. The licensed nurse will complete a thorough assessment of the resident to evaluate for injury.k. If the resident with dementia sustains a fall, in addition to the nursing assessment, the facility will also prioritize diagnostics such as STAT (immediate)Xray/transfer to ER (emergency room) for appropriate investigation and intervention.A record review of the admission Record revealed the facility admitted Resident #1 on 01/25/18 and she had current diagnoses including Alzheimer's Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated her cognition was severely impaired.A record review of the Orders/Notes, dated 1/20/26, revealed Resident #1 1/20/26 - Fall (with) injury, large bruise atop R (Right) shoulder. The Orders/Notes, dated 1/23/26, revealed Resident #1 1/21 fall (with) bruising to R shoulder/R arm neuro (neurological checks (1/24) . A record review of the facility's incident report, dated 1/21/2026 at 6:15 AM, revealed the Incident Description included a Nursing Description of CNA (Certified Nurse Assistant) reported to this nurse while given patient care staff stated the resident was turned to the edge of the bed, resident then grabbed the sheet and pulled herself off the bed staff was unable to prevent resident from falling to the floor, and put her back into bed. Statements, dated 1/22/26, revealed, .CNA stated while providing incontinent care for (Proper Name of Resident #1), had one hand placed on her hip for support and using other hand to provide perineal care. Resident grabbed the sheet and pulled herself over toward edge of bed, causing her to fall. I was unable to catch resident and prevent from falling. A review of the Agencies/People Notified revealed the Physician was notified on 1/21/26 at 8:15 AM of the resident's fall. Notes, dated 1/22/26, revealed, Witnessed fall investigated by DON (Director of Nurses). While CNA was performing incontinent care, resident grabbed bed and pulled herself causing her to fall. CNA was unable to stop from hitting floor. The incident report did not include the date and time the fall actually occurred, which was on 1/20/26. The report described Immediate Action Taken as Resident was assessed upon being notified of bruising atop resident's right shoulder. Assessed for ROM (Range of Motion).A record review of the Progress Note, dated 1/21/26 at 10:04 PM, for Resident #1 revealed, Nurse called to resident's room by the aide to report new found ecchymosis (bruising) to pt's (patient's) right shoulder blade and her neck.Pt reports tenderness to light palpitation. Range of motion is guarded by resident, but functional. Resident also has bruising to her right side of her head with a hematoma, mild swelling and tenderness. Resident states she doesn't remember what happened. A record review of the Progress Note which indicated Late Entry that was Created on 1/22/26 at 1:21 PM with an Effective Date of 1/21/26 at 6:15 AM, for Resident #1 revealed, CNA reported to this nurse while giving patient care staff stated the resident was turned to the edge of the bed, resident then grabbed the sheet and pulled herself off the bed staff was unable to prevent resident from falling to the floor. CNA stated they put her back into the bed. Resident was assessed upon being notified of bruising atop resident's right shoulder. Assessed for ROM resident denied pain at that time. The progress note did not indicate the date or time the fall actually occurred.A record review of the Order Summary Report with active orders as of 1/25/26, revealed Resident #1 had a Physician's Order, dated 04/09/20, for Aspirin Tablet 81 milligrams (mg) and Plavix Tablet 75 mg, which are both antiplatelet agents (affects how the blood clots). Further review revealed a Physician's Order, dated 3/21/23 for Hoyer lift (type of mechanical lift) x (times) 2 people for transfers.A record review of the Medication Administration Record (MAR) for January 2026 revealed Resident #1 continued to be administered aspirin and Plavix from 1/21/26, which was the date her head injury was observed and documented, until 1/26/26 when Resident #1 was transferred to an acute care hospital for altered mental status.A record review of the Emergency Department Encounter, dated 1/26/26 revealed the Chief Complaint as .Altered Mental Status Patient had fall on 1/21, patient had left sided facial droop.History.staff went to feed her at 1145 and found her confused with a left-sided facial droop.CT (Computed Tomography) Noncontrast head.Findings: There is hemispheric subdural on the right extending from the vertex through to inferior skull base on the right involving the frontal, parietal, temporal and occipital lobes with extension posteriorly medially into the interhemispheric fissure. This measures at least 1.8 cm (centimeter). There is approximately 8 mm(millimeter) of right-to-left midline shaft with compression of the right lateral ventricle and slight dilatation of the left lateral ventricle.Medical Decision Making.transferred for.higher level of care.A record review of the ED Provider Notes, from acute hospital with higher level of care, dated 1/26/26 revealed History of .She has a history of a fall 5 days ago where she struck her head but did not seek medical attention.CT of the head in outlying facility shows large intracranial bleed Further review revealed, .I have discussed with patient's husband via telephone.I was able to detail for him the findings on the head CT identifying both acute and chronic blood .which could enlarge, particularly in a patient who has been on blood thinning medications including aspirin and Plavix.On 2/3/26 at 2:00 PM, during an interview with CNA #1, she explained that on 1/20/26 at approximately 10:00 PM, Resident #1 fell to the floor after slipping between the bed and the wall and landed on her right side. CNA #1 stated she notified Licensed Practical Nurse (LPN) #3 and LPN #1 of the fall and obtained assistance from CNA #2 to return the resident to bed. CNA #1 also confirmed the resident required the use of a mechanical lift for transfers. CNA #1 was unable to explain why a mechanical lift was not used or why the resident was returned to bed prior to a licensed nurse assessing the resident. CNA #1 was unable to confirm when a licensed nurse assessed Resident #1 following the fall.On 2/3/26 at 2:15 PM, during an interview with CNA #2, she confirmed that she assisted CNA #1, in placing Resident #1 back into the bed. She reported that a mechanical lift was not used and that they manually lifted the resident by her arms and legs to return her to bed. She reported that facility policy requires staff to immediately notify a nurse following a fall so the residents can be assessed and, if needed, a mechanical lift used to assist with transferring. She reported being confused as to why a nurse was not present in the room at that time.On 2/3/26 at 3:30 PM, during an interview with LPN #3, she explained that she was working on 1/20/26. She denied that CNA #1 had informed her that Resident #1 had fallen on 1/20/26.On 2/3/26 at 4:00 PM, during an interview with LPN #1, she reported she was working the night of 1/20/26 and was not informed of Resident #1's fall at the time it occurred. LPN #1 stated she first became aware of the fall at approximately 6:00 AM on 1/21/26 and at that time notified the physician and family and initiated neurological checks. LPN #1 confirmed that she had documented the fall on the 24-Hour report, which is the Orders/Notes notes. LPN #1 confirmed that CNA #1 was present and witnessed the fall. LPN #1 reported she did not complete an incident report or document the event until 1/22/26, which was two (2) days after the fall occurred and explained the documentation was entered as late documentation in a nurse's note per direction of the DON.On 2/3/26 at 4:30 PM, during an interview with LPN #2, she reported that on 1/21/26 at approximately 10:00 PM she observed a hematoma on the right side of Resident #1's head. LPN #2 stated she notified the DON in the early morning hours of 1/22/26. LPN #2 reported she did not notify the medical provider because she believed the injury appeared old based on the yellow discoloration of the surrounding bruising. LPN #2 confirmed she was not aware Resident #1 had fallen on 1/20/26, did not complete neurological monitoring during her shift on 1/21/26, and did not notify the medical provider on 1/21/26 that Resident #1 had a head injury.On 2/4/26 at 9:00 AM, during an interview with the DON, he confirmed he did not become aware of Resident #1's fall until 1/22/26 at approximately 7:41 AM, when LPN #2, contacted him by phone. He reported he was informed that the resident had sustained bruising to her shoulder and was at her neurological baseline at that time. He explained he was not informed of the presence of a hematoma and reported he did not review the nursing notes, dated 1/21/26, that had documented the hematoma. The DON confirmed he assessed the resident on 1/22/26, which was two (2) days after the fall occurred on 1/20/26. He admitted that he did not physically assess the resident's head at that time. The DON confirmed the medical provider was notified of the resident's fall at that time and received a physician order to obtain a right shoulder x-ray for Resident #1. The DON further confirmed that following the notification on 1/22/26, he initiated an investigation into the incident. He identified that CNA #1 did not follow facility expectations by failing to obtain licensed nursing to assess the resident after the fall. He also identified that LPN #2, did not follow facility expectations by failing to notify the medical provider of the resident's hematoma that she discovered on 1/21/26. On 2/4/26 at 12:44 PM, during an interview with the Medical Provider, he confirmed that he was not aware of Resident #1's fall that occurred on 1/20/26 until 1/22/26. At that time, he ordered an x-ray of the right shoulder due to complaints of shoulder pain. He reported he was not informed that Resident #1 had a hematoma to her head and that no one had called him at the time it was documented on 1/21/26 by the nurse. He stated that had he been notified of the hematoma, he would have ordered the resident to be transferred to the local emergency room for further evaluation. On 2/4/26 at 2:06 PM, during an interview with the Administrator, she confirmed she was not aware of Resident #1's fall that occurred on 1/20/26 until 1/22/26, two (2) days after the fall occurred. The Administrator confirmed facility policy required CNAs to immediately report any resident fall to the nurse in charge. She confirmed CNA #1 did not notify nursing staff of the fall on 1/20/26 and that the resident was transferred back to bed without a licensed nurse assessment. The Administrator further confirmed LPN #1 did not report the fall to nursing leadership, including the DON on 1/20/26 or 1/21/26. The facility submitted the following acceptable Removal Plan on 2/4/26. On 01/20/2026 at approximately 10:00 PM, Resident #1 experienced a fall during activities of daily living (ADL) care. Certified Nursing Assistant (CNA) #1 was assisting with ADL care when Resident #1, while being repositioned onto her side, grasped the bed and inadvertently pulled herself off, resulting in a fall to the floor. Licensed Practical Nurse (LPN) #1 was notified at 6:15 am on 01/21/2026 and began neuro checks that day. On 01/26/2026, Resident #1 showed left facial droop and slurred speech and was sent to the hospital. The investigation found staff did not use proper lifting techniques, assess Resident #1 quickly, or notify the physician promptly after the fall and head injury.Corrective ActionsOn 01/22/2026, at approximately 7:41 a.m., the Director of Nursing (DON) was notified by Licensed Practical Nurse (LPN) #2 regarding discoloration observed on Resident #1's right shoulder.On 01/22/26 at approximately 8:15 a.m., the Registered Nurse (RN)#1 assessed Resident #1 and obtained an order for right shoulder X-ray.On 01/22/26 at approximately 09:20 a.m., the Director of Nursing (DON) contacted Licensed Practical Nurse (LPN) #3 to inquire about any knowledge regarding Resident #1's fall. Licensed Practical Nurse (LPN) #3 reported having no knowledge of the incident.On 1/22/2026 at approximately 9:30 a.m, the Director of Nursing (DON) interviewed Certified Nurse Assistant (CNA) #1 regarding Resident #1's fall. Certified Nurse Assistant (CNA) #1 gave a verbal account of the incident.On 1/22/2026 at approximately 9:40 am, the Director of Nurses interviewed Licensed Practical Nurse (LPN)#1 regarding Resident #1's fall. Licensed Practical Nurse (LPN) #1 gave a verbal account of the incident.On 01/22/2026 at approximately 11:15 a.m., X-ray findings for Resident #1's right shoulder indicated no evidence of acute fracture or dislocation.On 01/22/2026 at approximately 1:00 pm, Licensed Practical Nurse (LPN) #1 initiated a facility-based incident report regarding Resident #1's fall and subsequently completed the associated documentation of the event.On 01/22/2026 at approximately 1:15pm, Director of Nurses reviewed Resident #1 Neuro check log to ensure no abnormalities. Resident #1 remained at baseline with current neuro checks in place every four hours to monitor neuro deficits.On 01/22/2026 at approximately 10:00pm Neuro checks continued Resident #1 at every eight (8) hours intervals. No neurological deficits were found. The resident remained at the baseline.On 01/24/2026 at approximately 6:15am, Neuro checks were completed for Resident #1.On 01/26/26 at approximately 12:30pm Resident #1 was noted to have drooped to left side and slurred speech. Nurse Practitioner (NP) #1 was notified, and orders were obtained to transfer to local hospital.On 01/26/2026 at approximately 12:34 Resident #1 was transferred to local hospital via stretcher.On 01/29/2026 at approximately 6:45pm, the Director of Nursing (DON) received notification from Licensed Practical Nurse (LPN) #1 that she resigned from employment effective immediately.On 01/30/2026 at approximately 10:00am an audit was conducted by the Director of Nursing (DON) on all current residents that had an accident or incident occur in the past thirty (30) days to determine the potential of any further residents affected. The results indicated no negative outcomes.On 02/03/2026 at approximately 5:30 p.m., the Director of Nurses provided education to all licensed nurses and Certified Nursing Assistants on fall prevention, safe handling, and proper resident transfers. Training also included fall prevention along with neuro checks. change in condition notifications, Abuse and Neglect protocols, Resident Rights, and the Vulnerable Adult Act. All staff must complete this training before returning to work.On 2/4/2026 at 4:00 P.M. Agency (SA) notified Administrator of Immediate Jeopardy. State Agency (SA) provided the facility with the Immediate Jeopardy templates.On 02/04/2026 at approximately 5:00pm Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing, and Corporate Clinical Specialist held Ad hoc Quality Assurance Performance Improvement Meeting to include Resident #1 fall occurring on 01/20/2026 along with investigation, immediate jeopardy, along with the corrective action plan. The fall prevention policy was evaluated and reviewed to incorporate updated procedures and training for new staff on adhering to the Interact Care Path for acute mental status changes.On 02/04/2026 at approximately 6:00 P.M., a Resident Council Meeting was held with the Assistant Director of Nursing, the Resident Council President, and eleven (11) resident members. They were informed that the facility received one Immediate Jeopardy citation due to inadequate lifting techniques and failure to assess a resident after a fall.On 02/04/2026 at approximately 6:15 p.m., the Administrator, Director of Nursing, and Corporate Clinical Specialist conducted a comprehensive review of the investigation, including all relevant components such as interviews, statements, and electronic records, to perform a root cause analysis. The outcome of this analysis identified a failure in communication as the primary issue.On 02/04/2026 at approximately 6:30 p.m., Certified Nurse Assistant (CNA) #2 received individual training from the Administrator on how to identify each resident's lifting status according to their specific care plan, as well as safe handling and lifting procedures along with receiving a disciplinary action.On 02/04/2026 at approximately 6:45pm Licensed Practical Nurse (LPN) #2 received one to one Inservice from the Administrator and Director of Nurses on Abuse and Neglect, Resident Rights, Vulnerable Adults act, notification of change in condition, fall prevention, and safe patient handling and moving protocols along with receiving a disciplinary action.On 02/04/2026 at approximately 6:50 p.m., Certified Nursing Assistant (CNA) #1 received individual training from the Administrator regarding how to identify each resident's lifting status according to their specific care plan, as well as safe handling and lifting procedures along with receiving a disciplinary action.On 02/04/2026 at approximately 7:30 p.m., the Director of Nursing (DON) conducted a training session for all licensed nursing staff regarding adherence to the Interact Care path for acute mental status changes following post-fall assessments. Completion of this training is mandatory for all staff prior to their return to work.Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/04/2026 and the Immediate Jeopardy was removed on 02/05/2026.Validation: The SA validated the removal plan through observations, interviews, and record reviews on 2/5/26 and the immediacy was removed on 2/5/26 prior to exit.

Based on interviews, record review, job description review and facility policy review, the facility failed to protect the residents' right to be free from verbal abuse from a staff member for one (1) of 21 sampled residents. (Resident #17) Resident #17 was verbally abused and threatened on 2/8/25 when Certified Nursing Aide (CNA) #1 used profanity in an argument and aimed a spray bottle of chemical cleaner toward him. The facility's failure to protect Resident #17 resulted in his reporting he felt nervous and afraid. Additionally, the facility's failure to immediately remove CNA #1 from the facility placed this resident and other residents at risk for similar abuse. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 3/12/25 at 2:15 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 02/12/25, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 02/13/25 prior to the SA's entrance on 03/11/25. Findings include: A review of the facility's, Abuse Prohibition Policy, dated 5/17/24, revealed, Intent .Each resident has the right to be free from abuse, mistreatment .Policy: 1. The facility will prohibit neglect, mental or physical abuse .of residents .Definitions .Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents .within their hearing distance .Examples of verbal/mental abuse include .cursing, yelling, saying things to frighten a resident . A record review of the facility's Certified Nursing Assistant (CNA) Job Description dated March 2017, revealed, .Function: Cares for Residents under the direction and supervision of a registered nurse or a licensed practical/vocational nurse .Knows how to respond to Residents' behaviors .Demonstrates a basic understanding of behavior treats Residents with dignity and respect . A record review of the facility's investigation, dated 02/15/25, revealed On Saturday, February 8, 2025, Certified Nursing Assistant (proper name) was entering the dining room and encountered (Resident proper name) .(Resident proper name) began yelling expletives at (CNA proper name) .(CNA proper name) began arguing back with the resident using profanity .(Resident proper name) was interviewed and stated he was speaking with Licensed Practical Nurse (LPN) proper name) in the dining area when (CNA proper name) entered. He began cursing and calling CNA names and (CNA proper name) became argumentative and also used profanity. He stated that Nurse (proper name) took him back to his room and calmed him down .(CNA proper name) was interviewed. CNA stated (Resident proper name) began screaming swear words at her and then proceeded to roll his wheelchair towards her threatening to slap her in the face. Employee said this made her feel scared so she picked up a spray bottle and told him not to come any closer LPN (proper name) was interviewed. Nurse stated that her and (Resident proper name) were indeed having a conversation in the dining area when (CNA proper name) entered. Nurse stated that (Resident proper name)began cursing at (CNA proper name) and the employee began arguing back. Both (CNA proper name) and (Resident proper name) were using profanity. (CNA proper name) then picked up a spray bottle and pointed towards (Resident proper name) but did not spray the bottle. The resident was then taken back to his room .Life rounds were completed and residents with a BIMS (Brief Interview of Mental Status) of 12 or higher. One resident stated that CNA (proper name) had a smart mouth and another resident stated that he hears her being loud and using profanity in the hallway. Life rounds completed with staff with no issues noted. In services initiated with staff on Resident Rights, Vulnerable Adult, Abuse, Neglect and Customer Service. Currently, the facility decided to terminate employee (proper name) due to multiple policy violations . A record review of the time sheet for CNA #1 revealed on 2/8/25 she worked from 7:31 AM to 6:45 PM. On 2/9/25 she worked from 8:20 AM to 7:26 PM, and on 2/12/25 she worked from 7:56 AM to 11:30 AM, which was after the abuse occurred on 2/8/25. On 03/11/25 at 9:00 AM, during an interview Resident #17 confirmed that he and CNA #1 had a disagreement that occurred during the smoke break on 2/7/25. He stated that the CNA had refused to go back into the facility to get his cigarettes. The resident reported that on 2/8/25, he and LPN #1 were in the dining area talking, when CNA #1 entered the dining area. The resident stated he was still upset about the incident from the smoke break and stated to LPN #1 that CNA #1 was a lazy (expletive). CNA #1 then approached him and started using profanity toward him, and she then grabbed a bottle containing cleaning solution, that was sitting on a housekeeping cart and pointed it toward him. Resident #17 stated she did not spray it on him, but he was nervous and afraid because he thought she might spray him. On 03/11/25 at 10:03 AM, during an interview with the Risk Manager (RM) she acknowledged that she was made aware of the incident on 2/12/25 by the Administrator, which was four (4) days after the abuse occurred. The RM stated she and the Administrator called CNA #1 in for an interview, and she was then suspended. The RM stated CNA #1 fully admitted the details of the incident as reported by Resident #17 and LPN #1. On 03/11/25 at 3:40 PM, during an interview, LPN #1 stated that on 2/8/25, while walking down the hall, she encountered Resident #17, who looked toward CNA #1 and said, Go hit that (expletive) in the back of the head. LPN #1 stated she initially thought the resident was joking, as he is typically pleasant. As they continued speaking, CNA #1 approached and confronted the resident, saying, Are you talking about me? You better keep my name out of your mouth. LPN #1 stated the resident then called CNA #1 a lazy (expletive), and CNA #1 walked away, but the resident followed her and the two continued yelling at each other. CNA #1 then asked LPN #1 if she was going to intervene to de-escalate the situation. LPN #1 reported that CNA #1 grabbed a spray bottle from a housekeeping cart, pointed it at the resident, and yelled, Back the (expletive) up, back the (expletive) up! I'm going to get [another resident] to come down here to beat you in the head. LPN #1 stated the resident backed away and CNA #1 walked off. LPN #1 reported the incident to LPN #2, the Charge Nurse. Shortly afterward, LPN #3 informed LPN #1 and LPN #2 that CNA #1 had also reported the incident to her. LPN #1 stated that as LPN #3 was preparing to call the Director of Nursing (DON), CNA #1 approached them and began yelling about what should be done to Resident #17. LPN #3 escorted CNA #1 back to her unit and called the Director of Nursing (DON), who later spoke with LPN #2 and advised that he would handle the incident on Monday. LPN #1 stated she was not instructed to send CNA #1 home and did not tell CNA #1 to leave out of fear the hostility might escalate. LPN #1 acknowledged she was aware that Resident #17 was being verbally abused and threatened by CNA #1. She stated she believed reporting the incident to the Charge Nurse fulfilled her obligation but admitted she should have removed the resident once the situation escalated. LPN #1 confirmed that CNA #1 completed her shift on 2/8/25 and was still working at the facility when LPN #1 returned on 2/12/25. She also confirmed she had not been contacted by the DON for a statement prior to meeting with the Administrator on 2/12/25. LPN #1 stated that staff receive frequent in-service training on abuse prevention through computer-based modules, which include topics on de-escalation and resident safety. On 03/11/25 at 4:15 PM, during an interview, the DON stated that on 2/8/25 at approximately 10:00 AM, he received a phone call from LPN #3 reporting that Resident #17 had directed profanity toward CNA #1. The DON stated that he instructed LPN #3 to ensure that CNA #1 did not assist Resident #17 with smoke breaks moving forward. The DON further explained that around 12:00 PM that same day, he contacted LPN #2 and was informed that CNA #1 had raised her voice at Resident #17 and had been separated from the resident. The DON reported that based on the information provided at the time, he did not view the incident as abuse and, therefore, did not instruct staff to send CNA #1 home. On 03/11/25 at 4:33 PM, during an interview, LPN #2 confirmed that on 2/8/25, LPN #1 approached her at the nurse's station and informed her about the incident between Resident #17 and CNA #1. Shortly after, LPN #3 arrived from the other unit to inquire about what had occurred. LPN #2 stated that CNA #1 then came to the nurse's station, visibly agitated and upset, and said, Who the (expletive) are you sending home? LPN #2 reported that LPN #3 subsequently escorted CNA #1 back to the other unit and placed a call to the DON to report the situation. LPN #2 stated that when the DON called her later that day, she relayed what LPN #1 had reported, and suggested that the DON follow up directly with LPN #1. LPN #2 confirmed that she specifically informed the DON that CNA #1 had verbally retaliated against Resident #17, stating, Who the (expletive) are you talking to? Who the (expletive) are you calling a (expletive)? LPN #2 also reported that she told the DON about the allegation that CNA #1 had aimed a chemical-filled spray bottle at the resident and threatened to recruit another resident to physically harm him. LPN #2 stated that the DON responded that he would handle the situation on Monday. LPN #2 explained that she did not send CNA #1 home that day, as she was waiting for direct instructions from the DON. On 3/12/25 at 10:02 AM, during a phone interview, CNA #1 stated that on 2/8/25, she was in the dining area when she noticed Resident #17 speaking with his nurse (LPN#1). CNA #1 reported that she approached them and asked, Is there something you need to tell me? According to CNA #1, Resident #17 began using profanity toward her. CNA #1 stated she turned to the nurse and asked, Are you going to intervene with your resident? CNA #1 reported that Resident #17 then threatened to slap her. In response, she stated that she grabbed a spray bottle of cleaning solution from a nearby cart, aimed it at the resident, and told him not to put his hands on her. CNA #1 said she did not view pointing the spray bottle at the resident as a threatening act but rather as a defensive measure. CNA #1 acknowledged that the facility regularly provides abuse prevention training, which includes guidance on appropriate responses to escalating situations. On 03/12/25 at 12:15 PM, during an interview, LPN #3 stated that she did not personally witness the incident involving CNA #1 and Resident #17 on 2/8/25. She reported that CNA #1 informed her that Resident #17 had cursed at her, and in response, she cursed back and aimed a spray bottle of cleaning fluid at him. LPN #3 stated that CNA #1 was frustrated because LPN #1 had been standing next to the resident during the incident and did not intervene. LPN #3 explained that she went to the Unit 2 nurse's station to discuss the matter with LPN #1 and LPN #2. According to LPN #3, LPN #2 instructed her to notify the DON. LPN #3 stated that she contacted the DON and informed him that CNA #1 admitted to cursing at Resident #17 and pointing a spray bottle of cleaner at him. LPN #3 reported that the DON instructed her to document a statement and assured her that he would address the issue on Monday. LPN #3 added that she also reminded the DON about CNA #1's responsibility for taking residents to their scheduled smoke breaks. On 03/12/25 at 12:51 PM, during an interview, the Administrator stated she became aware of the incident from 2/8/25 when CNA #4 approached her on 2/12/25 and asked if she had been made aware of what had occurred. The Administrator explained that, following this, she immediately spoke with Resident #17, the DON, the involved nurses, and CNA #1. The Administrator reported that CNA #1 admitted to the incident as described and was subsequently sent home on 2/12/25. She further stated that in-services were held with all staff to reinforce how to identify and report abuse, which included drills and refresher training. The Administrator confirmed that all staff are regularly trained on appropriate actions in response to allegations or incidents of abuse. She acknowledged that the nursing staff did not follow the facility's abuse policy and protocol, specifically stating that CNA #1 should have been removed from duty immediately. A record review of the Admission Record revealed the facility admitted Resident #17 on 7/15/24 with diagnoses including Anxiety Disorder. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/25 revealed Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. A review of Section E revealed the resident had not exhibited any verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others). Facility Corrective Action Plan: On 03/12/2025 at 3:15 PM State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ) templates. Facility respectfully submits this corrective action plan. Brief Summary of Events On 02/12/2025 at 10:45AM the Administrator was notified of allegation of verbal abuse involving Resident #17 and CNA (Certified Nursing Assistant) #1. On 02/08/2025 CNA #1 was delivering a resident tray when she overheard Resident #17 and staff member laughing. The CNA #1 questioned the contents of their conversation. Resident #17 started using profanity directed at her. CNA #1 picked up a spray bottle pointing it in the direction of Resident # 17. CNA # I was using profanity as she was walking away from Resident # 17. CNA #1continued to work in facility in separate care area until allegation was reported to administration on 2/12/2025. Corrective Actions 1. On 02/12/2025 at 9:30am. The Treatment Nurse conducted a routine head-to-toe body assessment on Resident #17 to review for any skin abnormalities or concerns. Resident #17 had no negative skin issues or concerns. 2. On 02/12/2025 at 10:55am The Director of Nursing and Administrator interviewed Resident #17 regarding the allegation of abuse. Resident #17 provided statement of events. 3. On 2/12/2025 at 1130am, CNA (Certified Nursing Assistant) #1 was interviewed, statement obtained and suspended pending investigation by the Administrator. CNA #1 was subsequently terminated. 4. On 02/12/2025 at approximately 11:30am an allegation of abuse involving Resident #17 was reported to the State Agency (SA) by the Facility Risk Manager. 5. On 02/12/2025 at approximately 1140am an allegation of abuse involving Resident #17 was submitted to the Attorney General (AG) complaint website by the Risk Manager regarding allegation of abuse. 6. On 2/12/2025 at 11:40am, Referral was sent to Psychologist Nurse Practitioner by the Director of Nursing for evaluation and follow up. 7. On 2/12/2025 at 11:40am, The Medical Director was notified of the allegation by the Administrator. 8. 02/12/2025 at 12:00pm The Administrator notified ombudsman with no answer and left message. 9. On 2/12/2025 at 12:14pm, The DON conducted Trauma Assessment on Resident #17 with no negative findings. 10. On 2/12/2025 at 12:30pm, The Risk Manager initiated Life satisfaction rounds on with residents with BIMS (Brief Interview of Mental Status} of 12 or higher regarding Abuse and Safety in the facility. two negative findings on unprofessional behavior resulted with a report of being rude and loud. No allegations of abuse resulted. 11. On 2/12/2025 at 1:30pm, Peer reviews initiated by Risk Manager regarding Abuse and Safety in the facility involving CNA #1. One finding resulted in witnessing the allegation involving Resident #17. On 2/12/2025 at 1:30-1:45pm, An Abuse Drill Evaluation completed with Station I and II by the DON and Administrator as part of an ongoing monitoring plan. Life satisfaction rounds with two residents having a BIMS of twelve or higher will be completed by the Administrator/DON or Risk Manager weekly times four weeks, every other week times eight and monthly thereafter for three months. The QAPI committee will evaluate additional action based on results. The DON will conduct two random interviews on residents with BIMS of twelve or higher for any allegations of abuse or neglect weekly times four weeks, every other week times eight weeks and monthly times three months thereafter. The DON, Assistant Director of Nursing, or Risk Manager will conduct two random body audits on residents with BIMS below twelve for any indicators of abuse or neglect weekly times four weeks, every other week for eight weeks and monthly times three months thereafter. The QAPI committee will evaluate additional action based on results. The QAPI Committee will review potential trends and patterns and provide recommendations as needed. 12. On 2/12/2025 at 2:30pm, an in-service initiated by Risk Manager/ DON/ADM on Abuse and Neglect, Resident Rights, Vulnerable Adult, along with the reporting guidelines including how to address if abuse is noted. No staff was allowed to return to work prior to completion. 13. On 2/12/2025 at 3:00pm, QAPI Committee held a Quality Assurance Meeting to include Medical Director, Director of Nursing, Assistant Director of Nursing, Risk Manager/Infection Preventionist, Medical Records, Director of Rehabilitation, [NAME] Office Manager, Activity Director and Minimum Data Set Nurse to discuss allegations of abuse along with corrective action and monitoring in place. Policies were reviewed with no revisions needed. 14. On 3/12/2025 at 3:15pm. State Agency (SA) notified the Administrator of Immediate Jeopardy with past noncompliance of 02/12/2025. The State Agency (SA) provided the facility with the Immediate Jeopardy templates. 15. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/12/2025 and the Immediate Jeopardy was removed 02/13/2025. Validation: The SA validated on 3/13/2025, through interview and record review that all corrective actions had been implemented as of 2/12/25, and the facility was in compliance as of 2/13/25, prior to the SA's entrance on 3/11/2025.

Based on interviews, record review, and facility policy review, the facility failed to report an allegation of abuse within the required two (2) hour timeframe for one (1) of 21 sampled residents. Resident #17. Resident #17 was verbally abused and threatened on 2/8/25 when Certified Nurse Aide (CNA) #1 used profanity in an argument and aimed a spray bottle of chemical cleaner toward him. This was witnessed by Licensed Practical Nurse (LPN) #1. This occurred on 02/08/25, however, the facility did not report it to the State Agency (SA) until 02/12/25, delaying the facility's ability to protect the resident from further mistreatment. The facility's failure to ensure immediate reporting increased the risk of harm which left Resident #17 and other residents in a situation that was likely to cause serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The State Agency (SA) notified the Administrator of the IJ and SQC on 03/12/25 at 2:15 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 02/12/25, the SA determined the IJ and SQC to be Past-Non-Compliance (PNC) and the IJ was removed on 02/13/25 prior to the SA's entrance on 03/11/25. Findings include: A review of the facility's, Abuse Prohibition Policy, dated 5/17/24, revealed, Intent .Each resident has the right to be free from abuse, mistreatment .Policy: 1. The facility will prohibit neglect, mental or physical abuse .of residents .Definitions .Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents .within their hearing distance .Examples of verbal/mental abuse include .cursing, yelling, saying things to frighten a resident . The facility will report all allegations and substantiated occurrences of abuse .to the state agency and to all other agencies as required by law .The Abuse Coordinator will report all allegations of abuse .immediately or within 2 hours of the allegation . A record review of the facility's investigation, dated 02/15/25, revealed On Saturday, February 8, 2025, Certified Nursing Assistant (proper name) was entering the dining room and encountered Resident (proper name) .(Resident proper name) began yelling expletives at (CNA proper name) .(CNA proper name) began arguing back with the resident using profanity .(Resident proper name was interviewed and stated he was speaking with (Licensed Practical Nurse (LPN) (proper name) in the dining area when (CNA proper name) entered. He began cussing and calling CNA names and (CNA proper name) became argumentative and also used profanity. He stated that Nurse (proper name) took him back to his room and calmed him down .CNA (proper name was interviewed. CNA stated (Resident proper name) began screaming swear words at her and then proceeded to roll his wheelchair towards her threatening to slap her in the face. Employee said this made her feel scared so she picked up a spray bottle and told him not to come any closer LPN, (proper name) was interviewed. Nurse stated that her and (Resident proper name) were indeed having a conversation in the dining area when (CNA proper name) entered. Nurse stated that (Resident proper name began cursing at (CNA proper name) and the employee began arguing back. Both (CNA proper name) and (Resident proper name) were using profanity. (CNA proper name) then picked up a spray bottle and pointed towards (Resident proper name) but did not spray the bottle. The resident was then taken back to his room .Life rounds were completed and residents with a BIMS of 12 or higher. One resident stated that CNA (proper name) had a smart mouth and another resident stated that he hears her being loud and using profanity in the hallway. Life rounds completed with staff with no issues noted. In services initiated with staff on Resident Rights, Vulnerable Adult, Abuse, Neglect and Customer Service. Currently, the facility decided to terminate employee (proper name) due to multiple policy violations . During an interview on 03/11/25 at 9:00 AM, an interview with Resident #17 revealed that he and CNA #1 got into an argument on 2/8/25 when he was in the dining area talking to LPN #1. Resident #17 admitted that he called CNA #1 a lazy (expletive) and then CNA #1 approached him, using profanity, and grabbed a bottle of cleaning spray and pointed it toward him. He stated he was nervous and afraid that the CNA was going to spray him. He confirmed that LPN #1 witnessed the altercation. During an interview on 03/11/25 at 10:03 AM, the Risk Manager (RM) revealed she was made aware of the incident on 2/12/25 by the Administrator. The RM stated she and the Administrator called CNA #1 in for an interview on 2/12/25 and she was then suspended. The RM stated CNA #1 fully admitted the details of the incident as reported by the resident and LPN #1. During an interview on 03/11/25 at 3:40 PM, Licensed Practical Nurse (LPN) #1 explained that on 2/8/25 she witnessed a verbal altercation between Resident #17 and CNA #1. LPN #1 reported the incident to LPN #2, who was the Charge Nurse at the time. Shortly after, LPN #3 approached both LPN #1 and LPN #2 to inform them that CNA #1 had also reported the incident to her. LPN #1 stated that LPN #3 was the one who contacted the Director of Nursing (DON) regarding the situation. LPN #1 confirmed she was not given instructions to send CNA #1 home and admitted that she did not direct CNA #1 to leave because she was concerned the situation could escalate further. LPN #1 acknowledged that she was aware CNA #1 verbally abused and threatened Resident #17 and believed she followed protocol by reporting the incident to the Charge Nurse. LPN #1 also stated she should have immediately removed the resident from the escalating situation. She further noted that she was not contacted by the DON to provide a statement about the incident until 2/12/25. During an interview on 03/11/25 at 4:15 PM, the DON revealed he received a phone call from LPN #3 at 10:00 AM on 2/8/25 to inform him that Resident #17 has cursed the CNA. The DON stated he instructed LPN #3 to not have CNA #1 assist the resident with smoke breaks. The DON stated that at 12:00 PM on 2/8/25 he called LPN #2 and was told that CNA #1 got loud with Resident #17 and was separated from Resident #17. The DON stated he did not report the incident to the State Agency on 2/8/25 because he did not feel the incident was an abuse situation from the information he had been told by the nurses. During an interview on 03/11/25 at 4:33 PM, LPN #2 explained that on 2/8/25, LPN #1 approached her at the nursing station and reported the incident involving Resident #17 and CNA #1. LPN #2 stated that CNA #1 then came to the nursing station, visibly aggravated and upset, and stated, Who the (expletive) are you sending home? LPN #2 reported that LPN #3 then escorted CNA #1 back to the other unit and called the DON to report the incident. LPN #2 explained that when the DON called her directly, she relayed what LPN #1 had reported and recommended that the DON speak directly with LPN #1 for further details. LPN #2 stated she specifically informed the DON that CNA #1 had retaliated against the resident by yelling, Who the (expletive) are you talking to? Who the (expletive) are you calling a (expletive)? LPN #2 further reported that she told the DON about CNA #1 aiming a spray bottle containing cleaning chemicals at Resident #17 and threatening to enlist another resident to physically harm him. LPN #2 stated the DON informed her that he would address the situation on Monday. LPN #2 acknowledged that she did not send CNA #1 home because she was waiting for direction from the DON. She stated that during a meeting with the Administrator on the following Wednesday, she was asked why she had not contacted the Administrator directly. LPN #2 explained that she believed notifying the DON was the appropriate course of action. During an interview on 03/12/25 at 12:15 PM, LPN #3 stated that she did not personally witness the incident involving CNA #1 and Resident #17 on 2/8/25. LPN #3 stated that she contacted the DON and informed him that CNA #1 admitted to cursing at Resident #17 and pointing a spray bottle of cleaner at him. LPN #3 reported that the DON instructed her to document a statement and assured her that he would address the issue on Monday. During an interview on 03/12/25 at 12:30 PM, in a follow up interview with the RM she explained the DON was questioned as to why he did not report the incident on 2/8/25, the day he was informed about the verbal abuse and threats made to Resident #17 by CNA #1. The RM reported the DON stated he felt the incident was downplayed when it was reported to him and the resident was safe. During an interview on 03/12/25 at 12:51 PM, the Administrator stated she became aware of the incident that occurred on 2/8/25 when CNA #4 approached her on 2/12/25 and asked if she had been made aware of the incident. The Administrator explained that, following this, she immediately spoke with Resident #17, the DON, the involved nurses, and CNA #1. The Administrator reported that CNA #1 admitted to the incident as described and was subsequently sent home on 2/12/25. She acknowledged that the nursing staff did not follow the facility's abuse policy and protocol, specifically stating that CNA #1 should have been removed from duty immediately. A record review of the Admission Record revealed the facility admitted Resident #17 on 7/15/24 with diagnoses including Anxiety Disorder. Facility Corrective Action Plan: On 03/12/2025 at 3:15PM State Agency (SA) notified facility Administrator of Immediate Jeopardy (IJ). State Agency Surveyor provided the facility with the Immediate Jeopardy (IJ} templates. Facility respectfully submits this corrective action plan. Brief Summary of Events On 02/12/2025 at 10:45AM the Administrator was notified of allegation of verbal abuse involving Resident #17 and CNA(Certified Nursing Assistant) #1. On 02/08/2025 CNA #1 was delivering a resident tray when she overheard Resident #17 and staff member laughing. The CNA #1 questioned the contents of their conversation. Resident #17 started using profanity directed at her. CNA #1 picked up a spray bottle pointing it in the direction of Resident # 17. CNA # 1 was using profanity as she was walking away from Resident # 17. CNA #1 continued to work in facility in separate care area until allegation was reported to administration on 2/12/2025. Corrective Actions 1. On 02/12/2025 at 9:30am. The Treatment Nurse conducted a routine head-to-toe body assessment on Resident #17 to review for any skin abnormalities or concerns. Resident #17 had no negative skin issues or concerns. 2. On 02/12/2025 at 10:55am The Director of Nursing and Administrator interviewed Resident #17 regarding the allegation of abuse. Resident #17 provided statement of events. 3. On 2/12/2025 at 1130am, CNA (Certified Nursing Assistant) #1 was interviewed, statement obtained and suspended pending investigation by the Administrator. CNA #1 was subsequently terminated. 4. On 02/12/2025 at approximately 11:30am an allegation of abuse involving Resident #17 was reported to the State Agency (SA) by the Facility Risk Manager. 5. On 02/12/2025 at approximately 1140am an allegation of abuse involving Resident #17 was submitted to the Attorney General (AG) complaint website by the Risk Manager regarding allegation of abuse. 6. On 2/12/2025 at 11:40am, Referral was sent to Psychologist Nurse Practitioner by the Director of Nursing for evaluation and follow up. 7. On 2/12/2025 at 11:40am, The Medical Director was notified of the allegation by the Administrator. 8. 02/12/2025 at 12:00pm The Administrator notified ombudsman with no answer and left message. 9. On 2/12/2025 at 12:14pm, The DON conducted Trauma Assessment on Resident #17 with no negative findings. 10. On 2/12/2025 at 12:30pm, The Risk Manager initiated Life satisfaction rounds on with residents with BIMS (Brief Interview of Mental Status) of 12 or higher regarding Abuse and Safety in the facility. two negative findings on unprofessional behavior resulted with a report of being rude and loud. No allegations of abuse resulted. 11. On 2/12/2025 at 1:30pm, Peer reviews initiated by Risk Manager regarding Abuse and Safety in the facility involving CNA #1. One finding resulted in witnessing the allegation involving Resident #17. On 2/12/2025 at 1:30-1:45pm, An Abuse Drill Evaluation completed with Station I and II by the DON and Administrator as part of an ongoing monitoring plan. Life satisfaction rounds with two residents having a BIMS of twelve or higher will be completed by the Administrator/DON or Risk Manager weekly times four weeks, every other week times eight and monthly thereafter for three months. The QAPI committee will evaluate additional action based on results. The DON will conduct two random interviews on residents with BIMS of twelve or higher for any allegations of abuse or neglect weekly times four weeks, every other week times eight weeks and monthly times three months thereafter. The DON, Assistant Director of Nursing, or Risk Manager will conduct two random body audits on residents with BIMS below twelve for any indicators of abuse or neglect weekly times four weeks, every other week for eight weeks and monthly times three months thereafter. The QAPI committee will evaluate additional action based on results. The QAPI Committee will review potential trends and patterns and provide recommendations as needed. 12. On 2/12/2025 at 2:30pm, an in-service initiated by Risk Manager/ DON/ADM on Abuse and Neglect, Resident Rights, Vulnerable Adult, along with the reporting guidelines including how to address if abuse is noted. No staff was allowed to return to work prior to completion. 13. On 2/12/2025 at 3:00pm, QAPI Committee held a Quality Assurance Meeting to include Medical Director, Director of Nursing, Assistant Director of Nursing, Risk Manager/Infection Preventionist, Medical Records, Director of Rehabilitation, [NAME] Office Manager, Activity Director and Minimum Data Set Nurse to discuss allegations of abuse along with corrective action and monitoring in place. Policies were reviewed with no revisions needed. 14. On 3/12/2025 at 3:15pm. State Agency (SA) notified the Administrator of Immediate Jeopardy with past noncompliance of 02/12/2025. The State Agency (SA) provided the facility with the Immediate Jeopardy templates. 15. Facility is alleging that all activities to remove the Immediate Jeopardy were completed as of 02/12/2025 and the Immediate Jeopardy was removed 02/13/2025. Validation: The SA validated on 3/13/2025, through interview and record review that all corrective actions had been implemented as of 2/12/25, and the facility was in compliance as of 2/13/25, prior to the SA's entrance on 3/11/2025.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to reasonable accommodation as evidenced by a call light that was not within reach for one (1) of twenty-one (21) sampled residents, Resident #39. Findings included: A review of the facility's policy titled Resident Call System, dated 3/28/23, revealed, . Residents are provided with a means to call staff for assistance . Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistance . On 03/11/2025 at 11:38 AM, during an observation, Resident #39's call light was observed draped over a shelf and out of reach. Certified Nurse Aide (CNA) #1 confirmed the call light was not within reach of Resident #39. On 03/12/2025 at 10:08 AM, during an interview, Licensed Practical Nurse (LPN) #1 stated that call lights are supposed to be left within reach of the resident after each visit, and that CNAs are expected to make rounds every two (2) hours. On 03/13/2025 at 8:51 AM, during an interview, CNA #2 stated that on every visit to a resident's room, CNAs are trained to ensure the resident is comfortable, the call light is within reach, and that the resident does not need anything else. CNA #2 further explained the importance of answering call lights quickly to ensure residents receive the help they need. On 03/13/2025 at 2:40 PM, during an interview, the Administrator stated that staff are expected to have the call light within reach and to answer call lights in a timely manner. On 03/13/2025 at 2:45 PM, during an interview, the CNA Supervisor stated that staff completed in-services in February 2025 and that call light procedures are reviewed at orientation, quarterly, and as needed. The CNA Supervisor confirmed that CNAs are expected to leave call lights within reach of residents before exiting the room. On 03/13/2025 at 3:21 PM, during an interview, the Director of Nursing (DON) stated that CNAs are expected to leave call lights within reach of residents upon exiting the room and to answer call lights in a timely manner. A record review of the Admission Record revealed the facility admitted Resident #39 on 12/12/2021 and he had current diagnoses including Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side. A record review of Resident #39's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/2024 revealed the resident required a staff interview to assess cognition and his cognition was severely impaired. A review of the facility's In-service Training with a subject of answering call lights in a timely manner, dated 02/27/2025 revealed the facility staff received education to . Make sure call lights are always within reach of your Residents every time you enter and exit the room .

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the residents' right to a comfortable, homelike environment related to the facility being an uncomfortably cold temperature for five (5) of 21 sampled residents, with the potential to affect all 99 residents in the facility. Residents #82, Resident #43, Resident #45, Resident #5, and Resident # 34. Findings included: A review of the facility's policy titled Resident Rights, revised April 2017, revealed, .Residents shall .r. Live in a physical environment which ensures their physical and emotional security and well-being . Resident #82 On 03/11/2025 at 9:30 AM, during an interview and observation, the room was cold and Resident #82 stated that it is always cold in her room. She was observed wearing long sleeves, a blouse, a jacket, and was covered with a blanket. A record review of the Admission Record revealed the facility admitted Resident #82 on 06/07/2024 with current diagnoses including Alzheimer's Disease with Late Onset. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/2025 revealed Resident #82 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #43 On 03/11/2025 at 10:48 AM, during an observation and interview, Resident #43 complained about the cold temperature in his room. The resident had two blankets on his bed, while two additional blankets were folded on his roommate's bed. Resident #43 stated it was always too cold in his room. On 03/11/2025 at 2:35 PM, Resident #43's family member confirmed that his father consistently complains about being cold, and that both his father and the roommate have jackets and extra blankets. A record review of the Admission Record revealed the facility admitted Resident #43 on 06/10/2024 with current diagnoses including Chronic Diastolic (Congestive) Heart Failure. A record review of the Quarterly MDS with an ARD of 12/18/2024 revealed Resident #43 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #45 On 03/11/2025 at 9:41 AM, Resident #45 was observed sitting in the hallway wearing a jacket. Resident #45 reported that his room is always too cold, which is why he wears his jacket and stays in the hallway. A record review of the Admission Record revealed the facility admitted Resident #45 on 11/18/2021 with current diagnoses including Peripheral Vascular Disease. A record review of the Quarterly MDS with an ARD of 11/29/24 revealed Resident #45 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #5 On 03/11/2025 at 2:25 PM, in an observation and interview, Resident #5 reported that her room is cold. She was observed wearing a gown and a thick robe near the window and the room was cold. A record review of the Admission Record revealed the facility admitted Resident #5 on 05/11/2022 with current diagnoses including Unspecified Dementia. A record review of the Quarterly MDS, with an ARD of 12/16/2024 revealed Resident #5 had a BIMS score of 9, which indicated moderate cognitive impairment. Resident #34 On 03/11/2025 at 11:18 AM, during an observation and interview, Resident #34's room was cold. The resident had placed a sheet in the window to block the draft and reported that his room is normally cold, especially after showers. The resident stated that staff informed him the facility has to remain cold. A record review of the Admission Record revealed the facility admitted Resident #34 on 10/18/2024 with current diagnoses including Acute and Chronic Respiratory Failure with Hypoxia. A record review of the Quarterly MDS with an ARD of 1/17/2025 revealed Resident #34 had a BIMS score of 15, which indicated the resident was cognitively intact. On 03/11/2025 at 3:12 PM, temperatures were checked in multiple rooms after residents complained about feeling cold. The following temperatures were observed: Resident #5's room at 3:15 PM measured 67.5 degrees ( ) Fahrenheit (F); Resident #82's room at 3:20 PM measured 69 F; Resident #34's room at 3:23 PM measured 65 F; Resident #43 and Resident #45's room at 3:26 PM measured 65.5 F. The Maintenance Director confirmed that thermostats were set at 72 F on the cool setting. On 03/11/2025 3:30 PM, during an interview, the Maintenance Director stated that he typically keeps the thermostats set at 72 F, but adjustments are made based on resident complaints. He explained that maintaining consistent temperatures is difficult due to varying preferences, building layout, and vent placement. He also mentioned that an igniter malfunctioned in January 2025 on one of the halls and took three days to repair. On 03/12/2025 10:50 AM, during an interview the Administrator stated that she believed the facility usually meets the federal requirement of 71 F but acknowledged that the building's age, traffic patterns, and vent placements can affect room temperatures. On 03/12/2025 at 3:00 PM, during an interview, Certified Nurse Aide (CNA) #10 stated that rooms 34, 35, 36, and 37 are always cold and that blankets are placed in the windows to block the cold air. CNA #10 confirmed that residents frequently complain about the cold and that staff provide extra blankets. On 03/12/2025 at 3:45 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated that rooms near doors throughout the facility have always been colder than other rooms. LPN #1 confirmed that residents frequently complain, and that staff provide extra blankets and block window drafts with blankets. She confirmed that maintenance and management have been informed of the issue. On 03/12/2025 at 3:50 PM, during an interview with LPN #2 revealed that about one (1) or two (2) residents on each hall occasionally complain about the cold, but staff typically notify maintenance and provide residents with extra blankets or jackets. On 03/12/2025, at 3:55 PM, during an interview with CNA #9 revealed that some residents occasionally complain about cold rooms, but maintenance usually addresses complaints within approximately 30 minutes, and staff provide extra blankets as needed. On 03/13/2025 at 10:47 AM, the Maintenance Director verified room temperatures again. The temperatures were as follows: Resident #5's room was measured at 70.5 F; Resident #82's room at 71 F; Resident #43 and Resident #45's room at 70 F; Resident #34's room measured 70.5 F by the door and 67.5 F by the window; room [ROOM NUMBER] measured 69.5 F. Thermostats were set at 74 F on the cool setting.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to revise the comprehensive care plan to include the use of zinc oxide, as per a physician's order for one (1) of 21 care plans reviewed. (Resident #22) Findings included: A review of the facility's Care Plans, Comprehensive Person-Centered dated 2/24/25, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . On 03/11/2025 at 12:56 PM, during an observation of incontinence care, Certified Nursing Assistant (CNA) #8 applied zinc oxide to the resident's buttocks after providing perineal care. A record review of Resident #22's Comprehensive Care Plan revealed, I have potential for impairment of my skin integrity related to weakness, decreased mobility, bowel and bladder incontinence, severe protein-calorie malnutrition . There were no interventions in place to address applying zinc oxide. A record review of the Order Summary Report with active orders as of 3/13/25 revealed Resident #22 had a physician's order, dated 02/15/2025 for Redness: Apply zinc barrier cream to sacrum every day shift. On 03/13/2025 at 12:56 PM, during an interview, the Director of Nursing (DON) explained that the Care Plan Nurse is responsible for updating the care plan daily by reviewing the physician's orders. The DON confirmed the care plan was not updated to include the application of zinc oxide to Resident #22's buttocks. On 03/13/2025 at 1:07 PM, during an interview, the Administrator stated that she expects staff to follow the facility's policies and standards of practice. The Administrator further stated she expects staff to update residents' care plans according to facility policy. On 03/13/2025 at 1:11 PM, during an interview, Registered Nurse (RN) #1 confirmed that the care plan was not updated to reflect the use of zinc oxide. RN #1 stated that she had not yet had a chance to update the care plan and that care plans are updated according to physicians' orders. RN #1 explained that the care plan is used to direct the care of the resident and to assign responsibilities according to staff job descriptions and training. A record review of the Admission Record revealed the facility admitted Resident #22 on 09/10/2024 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section GG revealed Resident #22 was incontinent of bowel and bladder and required partial to moderate assistance for bathing, toileting, and personal hygiene.

Based on observation, staff interview, record review, and the facility's Certified Nurse Assistant (CNA) job description review, the facility failed to ensure professional standards practices were maintained when a CNA applied a medicated cream to a resident during one (1) of two (2) incontinent resident care observations. (Resident #22) Findings Include: A record review of the facility's Certified Nursing Assistant (CNA) Job Description dated March 2017, revealed, .Function: Cares for Residents under the direction and supervision of a registered nurse or a licensed practical/vocational nurse . A record review of a letter from the State Board of Nursing, dated 7/15/2005, revealed, .medication administration may only be delegated to another registered nurse or licensed practical nurse and not an unlicensed person. This would include medicated ointments, lotions and protective barriers, regardless of skin integrity . In an observation of incontinence care on 3/11/25 at 12:56 PM, Licensed Practical Nurse (LPN) #7/MDS Nurse gave CNA #8 zinc oxide cream to put on the resident's buttocks. CNA #8 applied the zinc oxide to the resident's sacrum after completing incontinence care. A record review of the Order Summary Report with active orders as of 3/13/25, revealed Resident #22 had Physician's Order, dated 02/15/2025, for Redness: Apply zinc barrier cream to sacrum every day shift. On 03/13/25 at 12:32 PM, in an interview, LPN #7 confirmed she gave CNA #8 the cream to apply to Resident #22's buttocks. She acknowledged that the facility does not allow CNA's to apply medicated creams such as zinc oxide to the residents because CNA's cannot administer medications. During an interview on 03/13/25 at 12:56 PM, with the Director of Nursing (DON), he stated the facility does not allow the CNAs to apply zinc oxide to the residents and that CNA's do not administer medications. The DON also said both the nurse and CNA have been trained that CNA's cannot administer medications. During an interview on 03/13/25 01:07 PM, the Administrator stated she expects the staff to follow the facility policies and standards of practice and confirmed the facility does not allow CNAs to administer medications. A record review of the Admission Record revealed the facility admitted Resident #22 on 09/10/2024 with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/18/2024 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section GG revealed Resident #22 was incontinent of bowel and bladder and required partial to moderate assistance for bathing, toileting, and personal hygiene.

Based on observation, staff interview, and facility policy review, the facility failed to ensure food items in the cooler and freezer were wrapped, covered, and dated and ensure serving bowls were cleaned appropriately for one (1) of three (3) days of survey. Findings included: A review of the facility's policy titled Food Storage: Cold Foods dated 02/2023 revealed, .All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored . Procedures . 5. All foods will be stored wrapped or covered in containers, labeled and dated . A review of the facility's policy titled Ware Washing, dated 02/2023 revealed, .All dishware, serviceware, and utensils will be cleaned and sanitized after each use . On 03/11/2025 at 8:43 AM, during an observation of the kitchen and interview with Dietary Manager (DM) #1 revealed: Walk-In Cooler #1, there was an opened cheesecake box, which did not indicate the date opened, and the cheesecake was not fully wrapped or covered in the container. In Freezer #1, an opened frozen mixed vegetables container and an opened box of beef patties were not fully wrapped or covered in the containers and were exposed. Dried and stuck-on food residue was observed on serving bowls that were considered washed. The DM stated that these dishes were washed and stacked by the night shift. On 03/12/2025 at 12:35 PM, during an interview, Dietary Aide (DA) #4 confirmed the importance of ensuring plates and dishes are cleaned and sanitized to prevent residents from becoming sick. On 03/13/2025 at 2:40 PM, during an interview, the Administrator stated that her expectation is that kitchen staff prepare, store, label, and date foods according to facility policy.

Based on observation, interviews, record review, and facility policy review, the facility failed to maintain proper infection control practices by failing to prevent cross-contamination of perineal wipes during perineal care for one (1) of four (4) residents observed. Resident #58. Findings included: A review of the facility's policy titled Perineal Care, revised 04/16/2024, revealed, .The purposes of this procedure are to provide cleanliness and comfort to the resident . to prevent infections and skin irritation . On 03/13/2025 at 9:18 AM, during an observation of perineal care of Resident #58, Certified Nursing Assistant (CNA)#3, assisted by CNA #5, gathered supplies, sanitized her hands, and donned gloves. CNA #3 removed six (6) premoistened wipes from the pack and used the wipes to clean the front area of the resident. The resident was assisted to her left side and then CNA #3 pulled six (6) additional wipes from the pack, touching the package with contaminated gloves, and then continued perineal care in the buttocks area. Resident #58 had a bowel movement during care and CNA #3's gloves were visibly soiled with feces. CNA #3 pulled six (6) more wipes from the pack, touching the package with visibly soiled gloves. CNA #3 then removed her soiled gloves, sanitized hands, applied clean gloves, and then pulled more wipes from the pack to continue cleaning the resident. On 03/13/2025 at 9:33 AM, during an interview, CNA #3 stated she improperly removed wipes during care. She confirmed she contaminated the wipes container by pulling more wipes from the pack with soiled gloves. On 03/13/2025 at 11:36 AM, during an interview, the Risk Manager (RM)/Infection Preventionist (IP) stated that CNA #3 contaminated the wipes each time she pulled them from the pack with dirty gloves on. On 03/13/2025 at 1:57 PM, during an interview, the Director of Nursing (DON) stated CNA #3 should have pulled enough wipes from the container before beginning care. The DON confirmed there was potential for contamination and possible infection. A record review of the Admission Record revealed the facility admitted Resident #58 on 11/02/2021 with diagnoses including Unspecified Dementia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/28/2025 revealed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section GG revealed the resident requires partial to moderate assistance with toileting. A record review of the facility's Perineal Care Check List, dated 8/22/24, revealed CNA #3 received training and performed a return demonstration regarding perineal care.

Based on record review, staff interview, and facility policy review, the facility failed to document in the medical record discussions regarding a resident's decision to accept or decline assistance with formulating an Advanced Directive (AD) for five (5) of 25 resident records reviewed. Resident #6, Resident #34, Resident #90, Resident #93, and Resident #96. Findings include: Review of the facility's policy, Advance Directives, revised 09/2022, revealed, The resident has the right to formulate an advance directive .If the Resident does not have an Advance Directive 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident or representative is given the option to accept or decline assistance .b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance . A review of the medical record for Resident #6, Resident #34, Resident #90, Resident #93, and Resident #96 revealed there was no documentation indicating the resident's decision to accept or decline assistance with formulating an AD. On 08/29/23 at 09:15 AM, during an interview with the Director of Nursing (DON), he stated that the facility discussed ADs with the resident and family upon admission and completed the Baseline Care plan based upon those discussions. He explained that the facility offers to assist with formulating an AD if the resident does not have one, however, he confirmed that the facility does not document those discussions in the medical record as per the facility policy. He stated that nursing staff should document in the medical record the offer to assist and the decision the resident makes to accept or decline assistance. On 08/31/2023 at 11:50 AM, in an interview with the Administrator, she confirmed the required documentation regarding assistance with formulating ADs were absent in the medical records of the residents. Record review of the Admission Record revealed the facility admitted Resident #6 on 6/24/2017 with diagnoses that included Osteomyelitis. Record review of the Admission Record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia. Record review of the Admission Record revealed Resident #90 was admitted to the facility on [DATE] with diagnoses that included Cognitive communication deficit and muscle weakness. Record review of the Admission Record revealed Resident #93 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease. Record review of the Admission Record revealed Resident #96 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction and Adult failure to thrive.

Based on observation, interviews, record review, and facility policy review the facility failed to ensure a call light was accessible to a resident in her room for one (1) of 25 sampled residents. Resident #47 Findings include: A record review of the facility's policy Answering the Call Light, revised September 2022, revealed The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines . 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor . On 08/28/2023 at 10:58 AM, during an observation, Certified Nurse Aide #3 (CNA) pushed Resident #47, who was sitting in a shower chair, into her room and explained to the resident that she would go get her CNA and they would be right back. CNA #3 instructed Resident #47 to not try to get up and she left the room. Resident #47 was covered with a shower blanket while sitting in the shower chair near the bed. The call light was on the resident's bed but was out of reach for the resident and the resident was unable to move the shower chair to be able to access the call light. After three (3) minutes, CNA #1 entered the resident's room and explained to Resident #47 that she was going to assist her because her assigned CNA was occupied. On 08/29/23 at 03:23 PM, during an interview with Resident # 47, she explained that every time she received a shower, the CNA pushed her back to her room and left her on the shower chair for several minutes until her aide was able to transfer her off the shower chair. She confirmed that because she was covered up with the shower blanket, she could not reach the call light and that sometimes she was in the room by herself. On 08/30/23 at 02:00 PM, during an interview with CNA #2, she explained she was the CNA assigned to Resident #47 on 08/28/2023. She confirmed Resident #47 received a shower from the shower aid. She stated the process is that the shower aide completed the showers for the residents and once the shower was completed, the shower aid assisted the residents back to their room and notified the CNA assigned to the resident that the resident was back in their room. She confirmed the shower aid left residents in their room on the shower chair, covered with a blanket after each shower most of the time, and that sometimes it would take a few minutes for the assigned CNA to assist the resident if she was busy with another resident. On 08/30/23 at 02:20 PM, during an interview with CNA #3, she explained she was the shower aid and worked Monday through Friday and every other Saturday. She confirmed that on 08/28/2023, when Resident #47's shower was completed, the resident was left in her room on the shower chair, covered with two shower blankets with no staff present, and the call light was not within the resident's reach. She confirmed that because the resident was wrapped with the shower blankets, Resident #47 could not access the call light that was located on her bed. On 08/31/23 at 10:53 AM, during an interview the Director of Nursing (DON), he explained that he expected the staff to always have a resident's call light within reach and not to leave a resident unattended on a shower chair. On 08/31/23 at 11:00 AM, during an interview with the Administrator, she explained she expected the staff to not leave a resident unattended on a shower chair and to always have call lights within reach. A record review of the Admission Record revealed the facility admitted Resident #47 on 12/14/2021 with diagnoses that included Chronic Diastolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrillation, and Muscle Weakness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/23, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. Further review of the MDS revealed she required assistance from staff with transferring and bathing.

Based on observations, resident and staff interviews, record reviews, and the facility policy review the facility failed to implement a care plan to ensure the call light was within reach for (1) of 25 sampled residents. Resident #47 Findings include: A review of the facility's policy, Care Plans, Comprehensive Person-Centered with a reviewed date of January 2023, revealed A comprehensive, person-centered care plan . to meet the resident's physical, psychosocial and functional needs is .implemented for each resident . A record review of the Comprehensive Care Plan, undated, revealed Focus: I am at risk for falls .Interventions/Tasks .Be sure my call light is within reach . During an observation on 08/28/2023 at 10:58 AM, Certified Nurse Aide #3 (CNA) pushed Resident #47, who was sitting in a shower chair, into her room. The call light was on the resident's bed but was out of reach for the resident and the resident was unable to move the shower chair to be able to access the call light. After three (3) minutes, CNA #1 entered the resident's room and explained to Resident #47 that she was going to assist her because her assigned CNA was occupied. In an interview with CNA #3 on 08/30/2023 at 02:20 PM, she confirmed that on 08/28/2023, when Resident #47's shower was completed, the resident was left in her room on the shower chair, covered with two shower blankets with no staff present, and the call light was not within the resident's reach. She confirmed that because the resident was wrapped with the shower blankets, Resident #47 could not access the call light that was located on her bed. On 08/31/2023 at 10:53 AM, during an interview the Director of Nursing (DON), he explained that he expected staff to always follow a resident's care plan and that all care plans can be viewed on the CNA's Kardex. On 08/31/2023 at 11:10 AM, during an interview with Registered Nurse (RN) #1/Care Plan Nurse, she explained the purpose of the care plan was for staff to know how to care for the residents. She stated that all residents' care plans are available on the computer and on the Kardex for the CNA to assess. She expressed that as the care plan nurse, she expected facility staff to follow the care plan for resident care. A record review of the Admission Record revealed the facility admitted Resident #47 on 12/14/2021 with diagnoses including Chronic Diastolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrillation, and Muscle Weakness.

Based on observation, staff interviews and the facility policy review, the facility failed to accommodate Resident #87's needs in creating an individualized, home-like environment, as evidenced by not providing him access to his room and bathroom for one (1) of four (4) days of observations. Findings include Review of the facility's policy titled, Resident Rights, no date, revealed residents will be treated with consideration, respect, and full recognition of his dignity, and individuality, including privacy in treatment and in care for his personal needs. During the initial tour of the facility, on 1/6/2020 at 10:26 AM, an observation revealed Resident #87 was in a wheel chair, trying to propel himself into his room. The door to the resident's room would only open approximately eight (8) inches due to the door was being blocked by the end of the D bed that was positioned closest to the room door. During an interview, on 1/6/2020 at 10:28 AM, Resident #87 confirmed he was having a problem not being able to get back into his room. Resident #87 stated, It happens all the time. Resident #87 also revealed he can't always get to his bed or go to the bathroom when he needs to, because when the Certified Nursing Assistants (CNAs) go in to check on or help his roommate, they forget to move the bed back, so that it doesn't block the door. During an interview, on 1/6/2020 at 11:31 AM, CNA #2 stated the resident in the D bed or the bed next to the door has a low bed, and for it to be moved back in place, it must be in the lowest position. CNA #2 stated that forgetting to re-position the D bed after providing care, has happened, but she was not sure how many times. CNA #2 stated she thinks Resident #87 pushes on the bed when he goes in and out of the room and this causes the door to be blocked. During a follow-up interview, on 1/8/2020 at 9:36 AM, Resident #87 stated he was continuing to have a problem with the door being blocked. Resident #87 stated the previous night, he was again unable to go back into his room, because they had not put his roommate's bed back. Resident #87 stated he had to wait until he could get someone's attention to move his roommate's bed before he could go into his room. Review of the Face Sheet revealed Resident #87 was admitted by the facility, on 4/14/2018, with [DIAGNOSES REDACTED]. Review of the Resident's most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/2019, revealed Resident #87 has a Brief Interview Mental Status (BIMS) score of fifteen (15), indicating intact cognition.

Based on observation, staff interview, record review and facility policy review, the facility failed to provide privacy for Resident #34, during an invasive procedure, for one (1) of three (3) resident blood draw observations. Findings include: Review of the facility's policy titled, Resident Rights, no date, revealed residents will be treated with consideration, respect, and full recognition of his dignity, and individuality, including privacy in treatment and in care for his personal needs. During an observation, on 1/6/2020 at 10:06 AM, it was revealed Resident #34 was sitting in his wheel chair next to his bed having his blood drawn, by the Phlebotomist, with the privacy curtain open. Resident #34's roommate was on his side of the room, but able to view the Phlebotomist perform the blood draw on Resident #34. During an interview, on 1/6/2020 at 10:16 AM, Resident #34 stated that he wanted the curtain pulled between him and his roommate while he was getting his blood drawn. Resident #34 stated he would have appreciated having privacy. During an interview, on 1/8/2020 at 1:55 PM, the Assistant Director of Nursing (ADON), revealed the facility had called the Phlebotomist back to the facility and provided an in-service on Resident Rights, specifically about performing blood draws in a resident's room. The ADON stated the Phlebotomist signed and dated the form titled, Inservice Training. Review of the facility's Inservice Training documentation, dated 1/6/2020, revealed that an in-service on the topics of Infection Control, Privacy, Blood Draws, and Resident Rights was provided by Registered Nurse (RN) #1, and received by the Phlebotomist serving the facility on 1/6/2020. Review of the Face Sheet revealed Resident #34 was admitted by the facility, on 5/13/2019, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/03/2019, revealed Resident #34 had a Brief Interview Mental Status (BIMS) score of fifteen (15), indicating intact cognition.

Based on observation, staff interview, nurses notes review, and care plan review, the facility failed to revise a resident's care plan following a resident fall to prevent repeated falls with injury to the resident for one (1) of seven (7) residents reviewed for falls, Resident #7. Findings Include: Review of the facility's policy entitled Care Plans dated 05/8/13 revealed each resident's care plan would be updated and/or revised as the resident's condition changes. Review of the facility's current care plan for Resident#7 listed Problem/Need of Fall: High fall risk related to weakness and decreased safety awareness. Resident with history of falls. There was no fall listed for 05/15/15 and there was no documentation stating Resident #7 was a two person assist with transfers. Interview on 07/30/15 at 10:50 AM with MDS Director revealed, What we don't have on the care plan, are the ADL requirements like the two person assist with transfer. Interview on 08/06/15 at 4:00 PM with the DON, when asked who updates the care plans and MDS assessments, she replied, The MDS nurses would make those changes. Review of the facility's Minimum Data Set ((MDS) dated [DATE] revealed Resident#7 was coded, Transfer: self performance -3. Extensive assistance-resident involved in activity, staff provide weight-bearing support. The MDS also included, Transfer: support provided- 3. Two (plus) persons physical assist. The most recent MDS assessment prior to May was dated 11/28/14 which also had Resident#7 coded as a two person assist with transfer. Review of the facility's fall risk assessments for Resident #7 revealed she scored as a HIGH RISK on the 12/26/14, 02/22/15, and the 05/09/15 assessments. Review of the facility's May Activities of Daily Living (ADL) sheets for Resident#7 revealed the facility coded transfers as two person assist on 05/15/15. Review of the facility's Nurses' Notes for Resident #7 revealed the following entry, dated 05/15/15 at 8:02 AM. Noted this nurse called to resident room by housekeeping with report of possible fall. Found resident sitting in wheelchair in room. c/o (Complains of) knee pain to right knee with movement. CNA (Certified Nursing Assistant) in room-stated that transferring resident from bed to wheelchair and resident became weak. Note resident stated the same thing, transferring and became weak in the knees. Report that resident did not hit the floor by both CNAs (CNA #8 and CNA #9) and resident. Noted (Name of CNA #8) was transferring resident solo with no help and c/o (complains of) pain in back. Interview on 08/06/15 at 3:50 PM with CNA #9 revealed, CNA #8 screamed for me to come in the room. She was putting Resident #7 in her chair so she could have breakfast. Resident #7 was in the bed and CNA #8 had tried to transfer her by herself. Interview on 07/30/15 at 8:30 AM with Registered Nurse (RN) #4 revealed, I remember that incident. CNA #8 was transferring the resident by herself. The state surveyor attempted to contact CNA #8 for interview without success. Further review of Resident #7's Nurses' Notes, dated 07/04/15 at 3:50 PM, by RN #3 revealed, Called into room per CNA, resident on knees between bed and wheelchair, upper body lying across bed. Right knee has two open areas. Contacted NP (Nurse Practitioner) new verbal order xray right knee stat. Resident's CNA states CNA was in the process of transferring resident from bed to wheelchair, leg gave out, resident went to knees. Given [MEDICATION NAME] as ordered for complaint of right knee pain. Review of the facility's Investigation of Incident/Accident form dated 07/07/15 revealed Employees involved with this transfer/lift-CNA #3 transferred resident. The form also included an intervention/corrective action/supervisor follow up which revealed, While CNA was assisting resident to transfer from bed to wheelchair, resident became weak and went to knees. The form was dated 07/07/15 and signed by the Assistant Director of Nursing (ADON). Interview on 07/29/15 at 3:00 PM with CNA #3 revealed, when asked if she transferred Resident#7 by herself, CNA #3 stated, No. The nurse (RN #3) was in there with me. Interview on 07/29/15 at 5:40 PM with RN #3 revealed CNA #3 transferred the resident by herself. Review of the facility's face sheet revealed, the facility admitted the resident on 07/09/11. Resident#7's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 05/15/15 revealed Resident#7 had a Brief Interview of Mental Status (BIMS) score of nine (9) indicating the resident had moderate cognitive impairment.

Based on record review, staff interview, and facility policy review, the facility failed to ensure a resident was free from falls with injuries for one (1) of seven (7) residents reviewed for falls, Resident #7. This was evidenced by in September 2014 Resident #7 had a fall with fracture related to one person assisting the resident with transfer. The facility continued to allow one person assist with transfers after the resident was assessed for two person assist with transfer per Minimum Data Set requirements. This resulted in repeated falls in May 2015 and July 2015. Findings include: Review of the facility policy entitled Accidents and Incidents, with revision date of 07/10, revealed All accidents, incidents or unusual occurrences involving a resident, visitor or employee will be documented and reported to meet all the regulatory requirements. This policy included the definition of an accident as, Any unexpected or unintentional incident or chain of events, which may or may not result in injury or illness to a resident. The policy also included, Reporting- Regardless of how minor an accident or incident may be, it must be reported to the department supervisor, and an Incident Report form must be completed on the shift that the accident or incident occurred. The facility had no policy related to transfer of residents. Interview on 07/29/15 at 5:00 PM with the DON revealed We don't have a fall policy. We use the Center for Medicare and Medicaid Services (CMS) guidelines. The DON provided the surveyor with a copy of the guidelines. Review of the CMS manual copy, dated 05/11, revealed, Definitions: Fall- Unintentional change in position coming to rest on the ground, floor or onto the next lower surface. An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person-this is still considered a fall. Review of the facility's Nurses' Notes for Resident #7 revealed the following entry, dated 05/15/15 at 8:02 AM. Noted this nurse called to resident room by housekeeping with report of possible fall. Found resident sitting in wheelchair in room. c/o (Complains of) knee pain to right knee with movement. CNA (Certified Nursing Assistant) in room-stated that transferring resident from bed to wheelchair and resident became weak. Note resident stated the same thing, transferring and became weak in the knees. Report that resident did not hit the floor by both CNAs (CNA #8 and CNA #9) and resident. Noted (Name of CNA #8) was transferring resident solo with no help and c/o (complains of) pain in back. Review of the facility's fall risk assessments for Resident #7 revealed she scored as a HIGH RISK on the 12/26/14, 02/22/15, and the 05/09/15 assessments. Review of the facility's Minimum Data Set ((MDS) dated [DATE] revealed Resident#7 was coded Transfer: self performance -3. Extensive assistance-resident involved in activity, staff provide weight-bearing support. The MDS also included Transfer: support provided-3. Two (plus) persons physical assist. The most recent MDS assessment prior to May was dated 11/28/14 which also had Resident#7 coded as a two person assist with transfer. Review of the facility's May Activities of Daily Living (ADL) sheets for Resident#7 revealed the facility coded transfers as two person assist on 05/15/15. Review of the Physical Therapy progress notes, dated 04/21/15, for Resident #7 revealed, Current Level of Function-The patient is able to safely transfer from bed to wheelchair requiring moderate assistance (26-75 percent assist). The state surveyor attempted to contact CNA #8 for interview without success. Interview on 08/06/15 at 2:45 PM with the Human Resources Director revealed, I have tried calling corporate and her (CNA #8's) attorney and everyone has that same number. Interview on 08/06/15 at 3:50 PM with CNA #9 revealed, CNA #8 screamed for me to come in the room. She was putting Resident #7 in her chair so she could have breakfast. Resident #7 was in the bed and CNA #8 had tried to transfer her by herself and they both were lying across the bed. The next day CNA #8 said her back was hurting because of Resident #7. Interview on 07/30/15 at 8:30 AM with Registered Nurse (RN) #4 revealed, I remember that incident. CNA #8 was transferring the resident by herself. In fact, she's not working now because of a back injury from that. I asked my supervisor if I needed to write an incident report and she said no. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) have always told us that if they (residents) don't hit the floor, it isn't a fall. Interview on 07/30/15 at 10:05 AM also revealed CNA #7 stated, If they (residents) don't hit the floor, it is not a fall. Interview on 07/29/15 at 4:40 PM with the DON revealed, There wasn't an accident report for the incident in May because both CNAs said she didn't hit the floor. It was not considered a fall. Further review of Resident #7's Nurses' Notes, dated 07/04/15 at 3:50 PM, by RN #3 revealed, Called into room per CNA, resident on knees between bed and wheelchair, upper body lying across bed. Right knee has two open areas. Contacted NP (Nurse Practitioner) new verbal order xray right knee stat. Resident's CNA states CNA was in the process of transferring resident from bed to wheelchair, leg gave out, resident went to knees. Given Norco as ordered for complaint of right knee pain. Interview on 07/29/15 at 3:00 PM with CNA #3 revealed, The nurse (RN #3) was in there with me, when asked if she transferred Resident#7 by herself. Interview on 07/29/15 at 5:40 PM with RN #3 revealed, I remember what happened. I was out in the hallway at my medication cart and CNA #3 called me into the room. The resident was on her knees beside the bed and I helped the CNA get the resident into the wheelchair. She did transfer the resident by herself. Interview on 07/29/15 at 2:05 PM with CNA #5 revealed I've been here about a year and as far as I can remember, Resident #7 has always been a two person assist with transfers. Interview on 07/29/15 at 2:00 PM with CNA #4 revealed, Resident #7 has been a two person assist with transfers since I started. Review of the facility's Investigation of Incident/Accident form dated 07/07/15 revealed Employees involved with this transfer/lift-CNA #3 transferred resident. The form also included an intervention/corrective action/supervisor follow up which revealed, While CNA was assisting resident to transfer from bed to wheelchair, resident became weak and went to knees. The form was dated 07/07/15 and signed by the Assistant Director of Nursing (ADON). Review of the July ADL sheets for Resident #7 revealed Transfers were coded as two person assist, including the fall date of 07/04/15. Interview on 08/06/15 at 11:30 AM with Physical Therapy Assistant #1 revealed, In the beginning we were doing about seventy five percent of transfer assistance, then she began doing better and required less assistance. But along the way, she would have days where she required maximum assistance. There really wasn't any warning. She would just require maximum assistance. You would just have to go in there and work with her/him to see where she was. After we would assess her/him, we would find the CNA and let them know if she needed two people or one person. Interview on 08/06/15 at 4:00 PM with the DON revealed, The actual ADL binders come to the morning meeting and we can change them then or if things change throughout the day. That change would be based on a team decision done in the morning meeting. When the DON was asked how the CNAs were informed of transfer requirements, she replied, They do off duty walk arounds, and, of course, their guides they go by and communicating with the nurse. Review of the facility's face sheet revealed, the facility admitted the resident on 07/09/11. Resident#7's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 05/15/15 revealed Resident#7 had a Brief Interview of Mental Status (BIMS) score of nine (9) indicating the resident had moderate cognitive impairment.