Every finding on record at Pilgrim Manor Skilled Nursing and Rehabilitation

Based on record review and interviews, the facility failed to follow physician's orders for 1 (Resident #47) of 1 (Resident #47) resident reviewed for UTI. Findings: Review of Resident #47's medical record revealed an admit date of 09/26/2017 with a re-entry date of 11/22/2021. Resident #47 had diagnoses which included in part type 2 diabetes, postmenopausal atrophic vaginitis, unilateral primary osteoarthritis of the right hip and polyneuropathy. Review of Resident #47's Quarterly MDS dated [DATE] revealed in part a BIMS score of 15, indicating intact cognition. Review of Resident #47's comprehensive care plan revealed in part, Resident #47 was frequently to always incontinent of bowel and bladder with interventions initiated on 05/07/2024 to monitor for s/sx of UTI: pain, burning, and urinary frequency. Review of Resident #47's physician orders revealed an order dated 07/23/2025 for estradiol vaginal cream 0.1 mg/gm 1 application vaginally q day for vaginal irritation related to postmenopausal atrophic vaginitis. Review of Resident #47's February 2026 MAR reveal in part, estradiol vaginal cream was not documented as administered on the following dates: 02/01/2026, 02/04/2026, 02/05/2026, 02/09/2026, 02/10/2026, 02/11/2026, 02/12/2026, 02/13/2026, 02/15/2026, 02/16/2026, 02/18/2026, 02/19/2026, 02/21/2026, 02/22/2026, and 02/23/2026. During an interview on 02/23/2026 at 11:20 a.m., Resident #47 reported S7MD had put her on the vaginal cream to help with the burning and itching. Resident #47 further reported she had not gotten the vaginal cream in months and was in 8.5-9 out of a 10 pain level when she voided. During an interview on 02/24/2026 at 9:20 a.m., S8ADON reviewed Resident #47's February 2026 MAR and acknowledged Resident #47 had not received the daily dose of vaginal cream and should have. During an interview on 02/24/2026 at 12:55 p.m., S7MD reported estradiol cream was to be administered to Resident #47 daily and stated Resident #47 has severe atrophic vaginitis. S7MD acknowledged nursing staff had not administered the vaginal cream daily as ordered. During an interview on 02/24/2026 at 12:00 p.m., S1DON acknowledged Resident #47 had not received daily doses of estradiol cream as ordered and should have.

Based on medication administration observations, record reviews, and interviews, the facility failed to ensure the facility was free from a medication error rate of 5% or greater. The facility had a 14.29% medication error rate with 4 medication errors out of 28 opportunities.Findings: Resident #19 Observation of the medication pass for Resident #19 on 02/23/2026 at 8:15 a.m. revealed S2LPN administered 13 oral medications to Resident #19. Review of Resident #19's current physician orders and MAR revealed Resident #19 had not received the following medications during medication pass, which were due on 02/23/2026 at 9:00 a.m.: Fluticasone propionate 50 mcg/at 1 spray in each nostril bidOlopatadine hcl solution 0.1% 1 drop in right eye q dayCyclosporine emulsion 0.05% 1 drop in both eyes bid During an interview on 02/23/2026 at 11:10 a.m. S2LPN acknowledged she administered fluticasone propionate, olopatadine hcl and cyclosporine emulsion to Resident #19 after medication pass observations had been completed. S2LPN acknowledged she should have notified surveyor to observe the administrations and did not. Resident #47 Observation of the medication pass for Resident #47 on 02/23/2026 at 8:08 a.m. revealedS2LPN administered 11 oral medications to Resident #47. Review of Resident #47's current physician orders and MAR revealed Resident #47 had not received the following medication during medication pass, which were due on 02/23/2026 at 9:00 a.m.: Estradiol vaginal cream 0.1 mg/gm 1 application vaginally q day During an interview on 02/23/2026 at 11:10 a.m., S2LPN acknowledged she administered estradiol vaginal cream to Resident #47 after medication pass observations had been completed.

Based on record reviews and interview the facility failed to inform and provide written information to residents or resident's representative concerning the right to formulate an advance directive for 2 (#38, #96) of the 48 sampled residents. Findings:Review of facility's policy titled Advance Directives with revision date of 05/31/2023 revealed in part:Policy StatementAdvance directives will be respected in accordance with state law and facility policy.Policy Interpretation and Implementation1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Resident #38 Review of Resident #38's medical record revealed an date of 02/17/2025. Further review of Resident #38's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. During an interview on 02/24/2026 at 2:53 p.m., S3admission Coordinator reported it was the facility's policy to provide printed material regarding advance directives upon admission. S3admission Coordinator confirmed she could not locate documentation Resident #38 was provided with written information concerning advance directives upon admission. Resident #96 Review of Resident #96's medical record revealed an date of 07/15/2024. Further review of Resident #96's medical record failed to reveal resident or resident's representative was provided with written information concerning advance directives. During an interview on 02/24/2026 at 2:53 p.m., S3admission Coordinator reported it was the facility's policy to provide printed material regarding advance directives upon admission. S3admission Coordinator confirmed she could not locate documentation Resident #96 was provided with written information concerning advance directives upon admission.

Based on record review and interview the facility failed to revise the care plan to reflect changes of a resident refusing medication/treatment for 1 (#31) of 1 sampled resident reviewed for care planning.Findings:Review of Resident #31's record revealed an admission date of 09/02/2020 with the following diagnoses which included but not limited to: Muscle wasting atrophy, Chronic Obstructive Pulmonary Disease, Mild protein-calorie malnutrition; and unspecified dementia.Review of Resident #31's Quarterly MDS dated [DATE] revealed a BIMS of 13 indicating intact cognition. Further review revealed under Section E: Rejection of Care was coded 0 indicating the behavior was not exhibited.Review of Resident #31's Discharge MDS dated [DATE] revealed under Section E: Rejection of Care was coded a 0 indicating the behavior was not exhibited. Review of Resident #31's Physician Order dated 06/18/2024 revealed an order for Estrace Vaginal Cream 0.1 milligram/gram, insert 1 application vaginally at bedtime.Review of Resident #31's January and February 2026 MAR revealed Resident #31 refused Estrace vaginal cream on the following dates in January: 2 - 4, 6-14, 16-20, 26, 28, 30 and 31. Further review revealed Resident #31 refused Estrace vaginal cream on the following dates in February: 1, 2, 10-14, 16, 17, 20, 22, 23 and 24. During an interview on 02/25/2026 at 10:28 a.m. S1DON reported if a resident consistently refuses medication/treatment, their care plan should be reviewed and revised to include refusal of medication/treatment.

Based on observations, interview and record review the facility failed to provide nutritional and hydration care and services for 1(#57) of 5 (#4, #7, #13, #14 and 57) resident reviewed for nutrition. The facility failed to provide care and services for resident #7 consistent with the resident's comprehensive assessment resulting in weight loss.Findings: Review of Resident #57's Comprehensive Plan of Care dated 05/17//2025 revealed Resident #57 had an ADL self-care performance deficit related to cerebral vascular accident times two, other symptoms and signs involving cognitive functions following cerebral infarction, vision loss. Eating, resident requires supervision to touch assistance with eating due to blindness, CVA.Review of Resident #57's record revealed diagnoses which included visuospatial deficit and spatial neglect following cerebral infarction, need for assistance with personal care, other lack of coordination and transient cerebral ischemic attack.Review of Resident #57's most recent Quarterly MDS dated [DATE] revealed Section C- cognitive pattern a BIMS score of 11 which indicated moderately impaired. Section GG - Functional Abilities Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident. Requires supervision or touch assistance.Review of the facility's weights for Resident #57's revealed a 6.12-pound weight loss in one month. January 07, 2026 = 176.4 and February 09, 2026 = 165.6.Review of Resident #57; current Physician orders revealed an` order dated 11/14/2025 Regular/Enhanced diet. Regular texture, Regular consistencyReview of the S5 RD documentation dated 02/23/2026 regarding Resident #57 weight loss revealed in part: Resident #57 with no chewing/swallowing difficulty at this time. Resident reported having a good appetite and reports he needs help during mealtimes. Noted resident with signs symptoms of subcutaneous fat loss to orbital region and muscle wasting to temples and hands. Recommendation: Recommend providing resident with total assistance during mealtimes.During an interview 02/23/2026 at 1:00 p.m. Resident #57 reported he did not know what he had to eat, because he was blind and unable to see his food. Resident #57 reported no one had told him what was on his plate.Observation on 02/23/2026 at 1:00 p.m. Resident #57 attempting to feed himself. Resident #57's plate had a small bowl of corn, green peas, ice cream, rice, iced tea and water. Observed Resident #57 trying to place the corn on his spoon. Resident #57 was unable to gather any of the food on his spoon.During an interview on 02/23/2026 at 1:20 p.m.S5 RD agreed Resident #57 should have had assistance with his meals. During an interview on 02/23/2026 at 1:20 p.m. S6 CNA entered Resident #57's room to pick up his meal tray. S6 CNA reported Resident #57 can feed himself. Observation on 02/23/2026 at 1:20 p.m. Resident #57 had covered his plate of food. When asked if he had eaten enough, Resident #57 reported he could not see the food to eat it.

Based on observation, interview and record review the facility failed to use infection control standards of practice for 1(#7) of 5 (#4, #7, #13, #14 and 57) residents reviewed for nutrition by not providing proper placement of a resident's gastrostomy tubing to prevent an increased risk of contamination and infection. Resident #7's gastrostomy tubing with the cap or cover was attached to the feeding pump tubing laying on the floor.Observation on 02/23/2026 at 12:50 p.m. with S4 LPN revealed Resident #7's PEG tube was disconnected. The gastrostomy tubing extended from Resident #7's abdomen did not have a cap or cover; it was opened. The cap or cover attached to the feeding pump tubing laying on the floor. S4 LPN removed the cap or cover from the floor and attached it to Resident #7's gastrostomy tube.During an interview on 02/23/2026 at 12:50 p.m. S4 LPN reported she would have to change the tubing later.Review of Resident #7's record revealed diagnoses which included gastrostomy status, dysphagia, right hemiplegia, cerebral ischemia, type 2 diabetes, aphasia, gastroenteritis, and cerebrovascular disease.Review of Resident #7's Physician orders revealed an order dated 02/09/2025 nursing intervention: implement and maintain enhanced barrier precautions when performing high contact care activities, every shift for wounds and PEG tube.Review of Resident #7's annual MDS dated [DATE] revealed cognitive pattern as severely impaired. Functional abilities impaired on one side of upper extremities and impaired on both sides of lower extremities.Review of Resident #7 Comprehensive Plan of Care revealed resident requires PEG feeding related to dysphagia following a cerebral infarction. Resident #7 received nothing by mouth. Resident will remain free of side effects or complications related to tube feeding through next review. Resident's insertion site will be free of signs/symptoms of infection through the next review.

Based on record reviews and interviews, the facility failed to use a Hoyer lift, as determined necessary by the resident's comprehensive care plan, during a transfer from the resident's bed to wheelchair for 1 (#1) of 3 (#1, #2, #3) sampled residents which resulted in a right humeral neck fracture.The deficient practice resulted in harm for Resident #1 on 07/14/2025 at approximately 10:30 a.m. when S6 agency CNA (Certified Nursing Assistant) transferred Resident #1 from the bed to a wheelchair with a stand and pivot method without utilization of a Hoyer lift. Resident #1 had an onset of acute pain to her right arm/shoulder and reported her right arm hit the wheelchair armrest during transfer. Resident #1 was care planned for activities of daily living self-care deficit with intervention of dependent in transferring with the use of Hoyer lift. S7 agency LPN (Licensed Practical Nurse), Hospice and Resident #1's Responsible Party were notified. Resident #1's right shoulder x-ray results dated 07/14/2025 revealed an acute complex impacted fracture involving the right humeral neck. Resident #1 was sent to the emergency room for further evaluation and treatment and returned to the facility with a right upper arm sling in place. Findings:Review of Resident #1's record revealed an admit date of 09/14/2023 with a re-admit on 12/13/2023 with diagnoses that included in part other sequelae of cerebral infarction, rheumatoid arthritis, generalized muscle weakness, muscle wasting and atrophy bilateral shoulders, and generalized osteoarthritis. Resident #1 was admitted to hospice for cerebral infarction on 12/16/2023 and passed away on 07/28/2025 in the facility.Review of Resident #1's Minimum Data Set assessment dated [DATE] revealed a Brief Mental Status of 8 which indicated moderately impaired cognition. Resident #1 had impaired functional range of motion in bilateral upper extremities and was dependent on staff for bed mobility and transfer.Review of Resident #1's Comprehensive Care Plan revealed the following problems with interventions: At risk for falls with intervention of transfer with Hoyer lift initiated on 11/23/2023.Activities of daily living self-care deficit with intervention of totally dependent in transferring with the use of Hoyer lift initiated on 01/01/2024. At risk for pain initiated 01/24/2024 with an update on 07/14/2025 for intervention right arm sling due to fracture of proximal end of right humerus.Review of the facility's Incident Report dated 07/14/2025 created by S7 agency LPN included in part S6 agency CNA was assisting Resident #1 into the wheelchair. Resident #1 reported during transfer she hit her right arm on the right wheelchair armrest and had an acute onset of pain rated 10 out of 10 to her right arm and more defined in right shoulder. Resident #1 was assessed and Resident #1 was able to move her hand but refused to perform range of motion to her right upper arm and shoulder due to pain. Resident #1's Hospice and Responsible Party were notified.Review of Resident #1's three view right shoulder x-ray results dated 07/14/2025 revealed an acute complex impacted fracture involving the right humeral neck.Review of Resident #1's Nurses Notes revealed in part Resident #1 was sent to the a local emergency room and returned to the facility the same day with a sling in place to her right arm.Review of the facilities training records revealed an Agency Facility Orientation sheet signed by S6 agency CNA on 04/14/2025. S6 agency CNA was oriented on locating CNA care guides including each resident's individual plan of care at CNA stations.Review of _______Staffing Agency records for staff in the facility July 2025 indicated S6 agency CNA worked at the facility on the following dates:07/01/2025; 07/05/2025; 07/06/2025; 07/08/2025; 07/13/2025; and 07/14/2025.During an interview on 08/26/2025 at 1:40 p.m. S8 agency CNA reported Resident #1 was able to make her needs known and was a two person assist with the Hoyer lift for transfers.During an interview on 08/26/2025 at 1:52 p.m. S9 LPN reported Resident #1 was able to make her needs known and was a two person assist with the Hoyer lift for transfers. S9 LPN reported a list of resident's activities of daily living needs was kept at the nurses' station and if the resident required a Hoyer lift for transfer there would be a sign over the resident's bed. During a telephone interview on 08/27/2025 at 1:40 p.m. S7 agency LPN reported on 07/14/2025 S6 agency CNA transferred Resident #1 using a turn pivot method. S7 agency LPN reported residents who required the Hoyer lift for transfer had signs over their bed and Resident #1 did not on 07/14/2025. S7 agency LPN reported S6 agency CNA did not ask her about Resident #1's transfer abilities prior to using a turn pivot method. S7 agency LPN reported Resident #1 complained of shoulder pain and reported Resident #1 had bumped her arm on the wheelchair when transferring from the bed to the wheelchair. S7 agency LPN reported she notified Hospice and an x-ray was ordered. S7 agency LPN reported the x-ray indicated a fracture and Resident #1 was sent to the emergency room for further evaluation and treatment.During an attempted telephone interview on 08/27/2025 at 2:25 p.m. with S6 agency CNA there was no answer. Surveyor immediately received a call back from S6 agency CNA's telephone number. During this interview, S6 agency CNA reported she had worked agency throughout the facility wherever she was assigned. S6 agency CNA reported she had training at the facility, reported a resident's level of care could be checked in the computer, and if a resident required a Hoyer lift for transfer there would be a sign over the resident's bed. During interview on 08/27/2025 at 3:34 p.m. S3 DON reported Resident #1 had been on hospice for about 2 years, was able to make her needs known, and was a two person assist with the Hoyer lift for transfers. When asked about Resident #1's incident on 07/14/2025 S3 DON reported Resident #1 told her she hit her elbow on the arm of the wheelchair when the CNA transferred her to the wheelchair. S3 DON reported Resident #1 was assessed and indicated it appeared as though Resident #1's shoulder had possibly come out of socket. S3 DON reported Resident #1 reported pain and guarded her arm and shoulder. S3 DON reported Resident #1's Hospice and Responsible Party were notified and an x-ray was ordered. S3 DON reported the x-ray indicated a fracture and Resident #1 was sent to the emergency room and returned that evening with a sling in place to her arm. During a telephone interview with S11 agency CNA on 09/02/2025 at 8:18 a.m. S11 agency CNA reported she did not recall having cared for Resident #1. S11 agency CNA reported she learned of resident's transfer abilities from report or in the resident's chart. S11 agency CNA reported she recalled a resident being hurt during transfer. S11 agency CNA reported she recalled S6 agency CNA crying and telling her she had transferred a resident and did not know she was supposed to use the Hoyer lift. S11 agency CNA reported there was not a sign over the resident's bed.During an attempted phone interview with Resident #1's Responsible Party on 09/02/2025 at 9:13 a.m. there was no answer.During an interview on 09/02/2025 at 10:05 a.m. S12 agency LPN reported Resident #1 was not able to move on her own, and was not able to make her needs known all the time. S12 agency LPN reported when she provided care to Resident #1 there was a sign over her bed that indicated Resident #1 was transferred with a Hoyer lift.During an interview on 09/02/2025 at 10:45 a.m. S13 CNA reported Resident #1 was transferred with a Hoyer lift and had a sign over her bed that indicated Resident #1 was transferred with a Hoyer lift.During an attempted telephone interview with Resident #1's Responsible Party on 09/02/2025 at 12:59 p.m. there was no answer.During an interview on 09/02/2025 at 1:10 p.m. S3 DON and S4 ADON reported new staff and agency CNA staff were oriented to the facility, given access to the CNA charting record, and trained on how to locate things in a resident's CNA charting including transfer abilities prior to working. S3 DON and S4 ADON reported the agency CNAs sign on the Agency Facility Orientation sheet indicating they were oriented to the facility CNA charting system.During an interview on 09/02/2025 at 1:24 p.m. S1 Quality Improvement Nurse and S2 Quality Improvement Nurse confirmed new staff and agency CNA staff were oriented to the facility, given access to the CNA charting record, and trained on how to locate things in a resident's CNA charting including transfer abilities. S1 Quality Improvement Nurse and S2 Quality Improvement Nurse confirmed the agency CNAs sign on the Agency Facility Orientation sheet indicating they were oriented to the facility CNA charting system.During an interview on 09/02/2025 at 2:20 p.m. S5 ADON confirmed new staff and agency CNA staff were oriented to the facility, given access to the CNA charting record, and trained on how to locate things in a resident's CNA charting including transfer abilities prior to working. S5 ADON confirmed the agency CNAs sign on the Agency Facility Orientation sheet indicating they were oriented to the facility CNA charting system. S5 ADON reported she had scheduled staff for Resident #1's hall. S5 ADON reported on 07/14/2025 S6 agency CNA arrived late to the facility because she had to call the agency to cover staff due to a late call in. S5 ADON reported she was called to go with S3 DON when the incident with Resident #1 occurred on 07/14/2025. S5 ADON reported she was told Resident #1 was transferred using a lift and pivot method. S5 ADON reported she did not recall Resident #1's transfer abilities without reviewing Resident #1's record.During an interview on 09/03/2025 at 10:15 a.m. S14 RN (Registered Nurse)/Wound Care Nurse reported Resident #1 could not do anything on her own and required the Hoyer lift for transfers. S14 RN/Wound Care Nurse reported there should have been a sign over Resident #1's door indicating she required a Hoyer lift for transfers.During an interview on 09/03/2025 at 11:00 a.m. S6 agency CNA reported on 07/14/2025 she came late and was given access to the CNA charting record and her assigned residents. S6 agency CNA reported she transferred Resident #1 with a stand and pivot method and Resident #1 told her she hit her arm on the wheelchair and complained of pain. S6 agency CNA reported she notified the nurse and DON and they assessed Resident #1, an x-ray was done, and Resident #1 had a fracture. S6 agency CNA reported she did not know Resident #1 was to be transferred with a Hoyer lift until after the incident. S6 agency CNA reported she did not know how to look up a resident's transfer abilities until after the incident. When asked if she had worked at the facility before S6 agency CNA reported she had worked at the facility once before that date and had not come back until recently. S6 agency CNA reported she was in-serviced regarding obtaining information regarding proper transfer after the incident with Resident #1.During an interview on 09/03/2025 at 12:30 p.m. S2 Quality Improvement Nurse reviewed S6 agency CNA's work history in the facility and reported S6 agency CNA first worked at the facility on 04/14/2025 and did not work again at the facility until 07/01/2025. S2 Quality Improvement Nurse confirmed S6 agency CNA had worked at the facility on 07/01/2025; 07/05/2025; 07/06/2025; 07/08/2025; 07/13/2025; and 07/14/2025 and confirmed documentation of S6 agency CNA's charting record entries for the dates worked in July 2025 which indicated proficient use by the CNA of resident's care guides.

Based on record review, observations and interview, the facility failed to ensure a resident remained free from neglect when nursing staff failed to use a Hoyer lift to transfer 1 (Resident #F3) of 4 (Residents #F1, #F2, #F3, and #F4) sampled residents who required a mechanical lift for transfers.Findings:Review of the facility's Abuse and Neglect - Clinical Protocol policy with a revision date of 10/15/2025 revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Definitions. Neglect, as defined by S483.5 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, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident(s) requires but fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress. Review of the facility's Lifting Machine, Using a Mechanical policy with a revision date of March 2025 revealed in part: The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. General guidelines: 2. Mechanical lifts may be used for tasks that require: b. transferring a resident from bed to chair.Steps in the procedure: 1. Before using a lifting device, assess the resident's current transfer ability utilizing the [plan of care] located in the electronic health system. Review of the facility's Safe Lifting and Movement of Residents policy with a revision date of September 8, 2024 revealed in part: In order to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Policy Interpretation and Implementation1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents.2. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on admission, readmission, with MDS changes including IPA's, quarterly or significant change MDS and prn using the Therapy Screen Request 2.0 form. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include:b. Resident's mobility (degree of dependency);4. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Review of Resident #F3's medical record revealed an admit date of 03/03/2025 with diagnoses including in part peripheral vascular disease, spondylopathy of the lumbar area, vascular dementia and anxiety. Review of Resident #F3's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part, a BIMS (Brief Interview of Mental Status) score of 10 indicating moderately impaired cognition. Further review revealed Resident #F3 was dependent upon staff for bed to wheelchair transfers. Review of Resident #F3's comprehensive care plan revealed in part, Resident #F3 was at risk for falls and was totally dependent on staff for transfers, with an intervention in place for the use of a Hoyer lift. Review of Resident #F3's Therapy Screen Request dated 09/11/2025 revealed Resident #F3 required total lift for transfers with a transfer plan to use a Hoyer lift. Review of Resident #F3's quarterly Lift Transfer Assessment dated 10/14/2025 revealed in part, Resident #F3's current level of assistance was total lift. Review of the facility's Lift Residents list with a revision date of 10/14/2025 revealed Resident #F3 was identified as requiring a Hoyer lift. An observation on 10/28/2025 at 8:00 a.m. revealed Resident #F3 sitting in a wheelchair in the dining room dressed in clean appropriate daytime clothing. Further observation failed to reveal a Hoyer lift pad was in place under Resident #F3. An Observation on 10/28/2025 at 8:30 a.m. revealed Resident #F3 sitting in wheelchair in therapy without a Hoyer lift pad in place. During an interview on 10/28/2025 at 8:30 a.m. Resident #F3 reported she did not remember who got her out of bed or how she got out of bed this morning and into the wheelchair. During an interview on 10/28/2025 at 8:35 a.m., SF2PTA (Physical Therapy Assistant) acknowledged Resident #F3 did not have a Hoyer lift pad beneath her in the wheelchair. SF2PTA indicated staff had not used the Hoyer lift to get Resident #F3 out of bed this morning and reported Hoyer lift pads were routinely kept under the resident while in a wheelchair in order to transfer resident back into bed. SF2PTA reported Resident #F3 required maximum assistance by staff for transfers. During an interview on 10/28/2025 at 8:50 a.m., SF3CNA (Certified Nursing Assistant) Supervisor, reported Resident #F3 had not been transferred out of bed this morning with the use of a Hoyer lift. SF3CNA Supervisor reported she observed the absence of a Hoyer lift pad in Resident #F3's wheelchair when she arrived to work this morning and stated she (Resident #F3) was not transferred right. SF3CNA Supervisor reported the night shift staff assigned to Resident #F3 was SF4Agency CNA. SF3CNA Supervisor acknowledged Resident #F3 was care planned for Hoyer lift transfers. SF3CNA Supervisor reported all nursing staff including agency staff should have been in-serviced on the correct use of a Hoyer lift and how to locate a resident's plan of care in the kiosk system. During an interview on 10/28/2025 at 9:00 a.m., SF5RN (Registered Nurse) Supervisor, reported staff did not follow the proper procedure when getting Resident #F3 out of bed this morning. SF5RN Supervisor reported she observed Resident #F3 seated in the dining room this morning without a lift pad in her wheelchair. SF5RN Supervisor reported the correct process for a Hoyer lift transfer included leaving the transfer pad under the resident once transferred into a wheelchair until the resident has been transferred back into bed. SF5RN Supervisor further reported once the resident has been transferred back into the bed by the Hoyer lift, the transfer pad would be removed. SF5RN Supervisor reported nursing staff and agency staff had been trained and in-serviced on the correct use of a Hoyer lift and how to locate a resident's plan of care in the kiosk system. SF5RN Supervisor acknowledged Resident #F3's current care plan indicated the use of a Hoyer lift for transfers. During a telephone interview on 10/28/2025 at 12:20 p.m., SF4Agency CNA confirmed she had worked the 10/27/2025 night shift which began at 7:00 p.m. and was assigned to Resident #F3. SF4Agency CNA confirmed she transferred Resident #F3 out of bed this morning, 10/28/2025, without the use of a Hoyer lift. SF4Agency CNA reported she did not use the Hoyer lift because Resident #F3 was able to help her with the transfer. SF4Agency CNA reported she knew how to use a Hoyer lift but used the stand and pivot transfer method she had learned in school to transfer Resident #F3 into her wheelchair. SF4Agency CNA reported she was trained by the facility on how to use the kiosk system to review a resident's plan of care and acknowledged Resident #F3 was care planned for the use of a Hoyer lift. SF4Agency CNA reported Resident #F3 did not have a Hoyer lift pad in her room and stated so I just transferred her (Resident #F3) the old school way. Review of S4Agency CNA's personnel record revealed an Agency CNA Facility Orientation acknowledgement dated and signed by SF4Agency CNA on 09/08/2025. Further review of SF4Agency CNA's Agency CNA Facility Orientation acknowledgement revealed the following responsibilities in part: - Locate Care Guide Care Guide and ____ in [kiosk]- Resident's plan of care is made by the team. The plan of care cannot be changed without or until the nurse or management has reassessed the resident. *As an agency staff member, I understand and acknowledge, it is my responsibility to provide quality of care consistent to the resident's needs. Any questions or concerns should be reported to the DON (Director of Nursing) or Administration. During an interview on 10/28/2025 at 3:00 p.m., SF6DOR (Director of Rehabilitation) reported she had assisted nursing staff with resident transfer assessments and recommendations for the need of Hoyer lifts. SF6DOR further reported the transfer recommendation for Resident #F3 remained as a Hoyer lift resident as indicated on the most recent 10/14/2025 facility list. SF6DOR acknowledged Resident #F3 had a status of total lift and CNAs should use a Hoyer lift with 2 staff assistance for total lift residents. During an interview on 10/28/2025 at 3:30 p.m., SF1Corporate Nurse acknowledged Resident #F3 required a Hoyer lift with 2 person assist for transfers and should have been transferred from the bed to the wheelchair with a Hoyer lift by SF4Agency CNA. [KH1]

45317 Based on record reviews, observations and interviews, the facility failed to provide services that met professional standards for 2 (#102, #105) of 26 sampled residents. The facility failed to ensure safe oral medication administration practices by leaving medication at the bedside. Findings: Review of the facility's policy Administering Oral Medications with a revision date of October 2010 revealed in part: Purpose: The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Preparation: 21. Remain with the resident until all medications have been taken. Resident #102 Review of Resident #102's medical record revealed an admitted 07 /11/2023 with a diagnosis including, but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #102's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 15 indicating intact cognition. An observation on 12/15/2024 at 8:35 a.m. revealed a medicine cup with one pinkish colored pill and four white colored pills on Resident #102's bedside table. During an interview on 12/15/2024 at 8:35 a.m., Resident #102 reported the nurse left her medications on her table for her to take after she finished eating. During an interview on 12/15/2024 at 8:40 a.m. S4LPN (Licensed Practical Nurse) confirmed she left Resident #102's medications in a medication cup at the bedside. S4LPN further confirmeded Resident #102 did not have an order for self-administration of medications. S4LPN reported medications should not have been left at Resident #102's bedside. During an interview on 12/15/2024 at 9:20 a.m. S11RN (Registered Nurse) confirmed a resident must have an order to leave medications at bedside for a resident to take on their own. During an interview on 12/17/2024 at 11:00 a.m. S3DON (Director of Nursing) confirmed Resident #102 did not have an order for self-administration, and medications should not have been left at the bedside. Resident #105 Review of Resident #105's medical record revealed an admitted [DATE] with a diagnosis including, but not limited to malignant neoplasm of the right kidney. Review of Resident #105's annual MDS assessment dated [DATE] revealed a BIMS of 15 indicating intact cognition. An observation on 12/15/2024 at 11: 20 a.m. revealed a medicine cup on Resident #105's bedside table containing one small white pill and one small pink pill. During an interview on 12/15/2024 at 11:20 a.m., Resident #105 reported the pills were left there this morning and he fell asleep before he could take them. Resident #105 stated that is my Oxycodone and my Lexapro. During an interview on 11/15/2024 at 11:25 a.m., S10 LPN confirmed the pills in the medicine cup on Resident #105's bedside were Lexpro and Oxycodone from the morning medication pass. S10LPN acknowledged she left Resident #105's room before Resident #105 had taken his medications. During an interview on 12/15/2024 at 11:45 a.m., S2Corporate Nurse, reported Resident #105 did not have an order for self-administration. S2Corporate Nurse acknowledged medications should not have been left at the bedside and a nurse should stay at the bedside until medication administration has been completed.

Based on observations, interviews, and record reviews, the facility failed to provide respiratory care consistent with professional standards of practice for 2 (#27, #224) out of 2 (#27, #224) residents reviewed for respiratory services. The facility failed to: 1. Change the humidification bottle and nasal cannula weekly as ordered for Resident #27, and 2. Ensure oxygen tubing was dated, and humidification was administered with oxygen for Resident #224. Findings: Review of facility policies related to oxygen therapy revealed in part: Department (Respiratory Therapy)-Prevention of Infection (revised November 2011): Use distilled water for humidification per facility protocol. [NAME] bottle with date and initials upon opening . Oxygen Administration (Revised October 2010)-The purpose of this procedure is to provide guidelines for safe oxygen administration .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .The following equipment and supplies will be necessary when performing this procedure. 1) portable oxygen cylinder or concentrator 2) nasal cannula, nasal catheter, mask (as ordered), 3) humidifier bottle . Resident #27 Review of Resident #27's medical record revealed an admitted [DATE], and diagnoses including but not limited to: other sequelae of cerebral infarction, generalized anxiety disorder, unspecified dementia, shortness of breath, and atrial fibrillation. Review of Resident #27's current physician's orders as of 12/16/2024 included: -an order dated 02/16/2023-oxygen-may have oxygen at 2 liters per nasal cannula or mask related to shortness of breath -an order dated 06/14/2024-oxygen: change mask, O2 (oxygen) tubing, water bottle, and clean concentrator filter every Friday night shift Observation on 12/15/2024 at 10:20 a.m. revealed Resident #27's humidification bottle with attached cannula were dated 12/01/2024. Observation on 12/16/2024 at 8:20 a.m. revealed Resident #27's oxygen humidification bottle with attached nasal cannula was dated 12/01/2024. During an interview on 12/16/2024 at 8:25 a.m. S9 LPN (Licensed Practical Nurse) viewed Resident #27's oxygen set up and confirmed the humidification bottle with attached nasal cannula was dated 12/01/2024. S9 LPN further confirmed the set up should be changed weekly and had not been. Resident #224 Review of Resident #224's medical record revealed an admitted [DATE], and diagnoses including but not limited to sepsis and dependence on supplemental oxygen. Review of Resident #224's current physician's orders as of 12/16/2024 revealed orders including: -an order dated 12/13/2024-oxygen: administer continuous oxygen at 3L/NC (liters per nasal cannula) -an order dated 12/13/2024-oxygen: change mask, O2 tubing, water bottle and clean concentrator filter every day shift every Saturday. Observation on 12/15/2024 at 10:10 a.m. revealed Resident #224 had oxygen in use at 3L/NC connected to concentrator with no humidification bottle and no date on cannula tubing. Observation on 12/16/2024 at 8:20 a.m. revealed Resident #224 had oxygen in use at 3L/NC connected to concentrator with no humidification bottle and no date on cannula tubing. During an interview on 12/16/2024 at 8:25 a.m. S9 LPN viewed Resident #224's oxygen setup and confirmed there was no humidification and no date on the cannula tubing and there should be.

Based on observations and interviews, the facility failed to ensure dietary services were provided in a safe, sanitary environment to prevent contamination and food borne illness for the 121 residents served a meal tray from the kitchen per the Dietary Manager. The facility failed to ensure frozen meat was thawed following accepted practices. Findings: Observation in the facility kitchen on 12/15/2024 at 7:50 a.m. revealed 2 large tube shaped chubs of ground beef in plastic packing and 3 large tube shaped pork tenderloins in plastic packing submerged in standing water in the sink. During an interview on 12/15/2024 at 7:58 a.m. S7 [NAME] confirmed the meat should be thawing under running water, and should not be submerged in standing water. S7 [NAME] further reported the pork tenderloin was for the day's lunch, and the ground beef was for spaghetti for supper. During an interview on 12/15/2024 at 8:32 a.m. S6 Dietary Manager confirmed meat should be thawed under running, not standing, water. Observation in the facility kitchen on 12/16/2024 at 8:13 a.m. revealed multiple loose pork chops, out of packaging, along with ground beef in a zip lock bag thawing in a sink full of standing water. During an interview on 12/16/2024 at 8:15 a.m. S8 [NAME] confirmed the meat should be thawed under running, not standing, water. S8 [NAME] further reported she did not know how the sink was cleaned before the meat was placed in direct contact with the sink. During an interview on 12/16/2024 at 3:27 p.m. S6 Dietary Manager reported there were 121 residents served meal trays from the kitchen on 12/15/2024 and 12/16/2024.

Based on record review and interview, the facility failed to electronically submit accurate payroll information for direct care staffing as required. Findings: Review of the PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 4 2024 (July 1- September 30) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. During an interview on 12/16/2024 at 11:30 a.m. S5 Regional [NAME] President acknowledged, for the FY Quarter 4 2024 (July 1 - September 30), there was a PBJ system reporting error to CMS (Center for Medicaid and Medicare Services) for staffing.

Based on record review, video footage review, and interviews, the facility failed to protect the resident's right to be free from deprivation of goods and services by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents when staff failed to utilize a Hoyer lift during a transfer. The deficient practice resulted in an immediate jeopardy for Resident #1 on 11/17/2024 when Resident #1 was transferred from a Geri chair to the bed without utilization of a Hoyer lift. Resident #1 was transferred to a local hospital related to a left lower leg wound which had adipose tissue and bone exposed. Review of Resident #1's hospital record revealed, Resident #1 was admitted with the primary diagnosis type I or II open non-displaced spiral fracture of shaft of left fibula with a laceration to distal LLE (left lower extremity) above the ankle mortis with exposed fibula. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation. Findings: Review of Resident #1's hospital record with an admitted [DATE] revealed in part, Resident #1 was admitted with the primary diagnosis type I or II open non-displaced spiral fracture of shaft of left fibula with a laceration to distal LLE above the ankle mortis with exposed fibula. Further review of Resident #1's hospital record revealed Resident #1 underwent incision and debridement surgical intervention to left ankle/leg wound on 11/18/2024 and 11/21/2024 with wound vacuum placement and was discharged on [DATE] to a different local nursing home. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses including, but not limited to, cerebral ischemia, polyosteoarthritis, periprosthetic fracture around internal prosthetic left hip joint, Parkinson's disease, and Alzheimer's disease. Review of Resident #1's medical record revealed Resident #1 resided on Hall A in Room A while a resident in the facility. Further review of Resident #1's medical record revealed Resident #1 discharged from the facility on 11/17/2024 and did not return to the facility. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed in part Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8, indicating moderately impaired cognition. Further review of Resident #1's MDS dated [DATE] revealed Resident #1 was totally dependent upon two staff members for transfer. Review of Resident #1's physician orders revealed in part: 11/24/2023 Resident may be up in Geri chair for trunk control and positioning. 10/09/2024 Non-weight bearing to left leg. Review of Resident #1's comprehensive care plan, updated 10/08/2024, revealed Resident #1 required assistance with ADLs (Activities of Daily Living) and was totally dependent in transferring with the use a Hoyer lift. Review of the facility's in-service dated 10/07/2024 included in part, how to use a lift for transfers. Further review of the facility's in-service and attendance record dated 10/07/2024 revealed S5CNA (Certified Nursing Assistant) signed the attendance record dated 10/07/2024. Review of the facility's Incident Report dated 11/17/2024 for Resident #1 revealed Resident #1 was propelled to her room in a Geri chair by S5CNA. S5CNA was in Resident #1's room for about a minute and a half before going to the nurse's station and informing S3RN (Registered Nurse) Supervisor that Resident #1's leg was bleeding. S3RN Supervisor and S4LPN (Licensed Practical Nurse) went to Resident #1's room where Resident #1 was found lying in bed with a laceration to her left leg. Resident #1's Geri chair, with lift pad still present, was observed to be perpendicular to Resident #1's bed. Resident #1 was assessed by S3RN Supervisor and S4LPN, 911 was called, and Resident #1 was transported to hospital. Further review of facility's Incident Report dated 11/17/2024 for Resident #1 revealed local law enforcement was called and transported S5CNA to police station for further questioning related to S5CNA's statement which did not match the facility's video surveillance. Review of S3RN Supervisor's written statement for Resident #1's 11/17/2024 incident revealed: Summoned to room per S5CNA yelling that Resident #1's left leg was cut and bleeding. Found resident in bed lying flat and face up. Resident #1's left lower leg had a laceration measuring 6 inches with adipose tissue and bone exposed. Towels were immediately placed on wound placing adipose tissue back in wound. Blood was noted on floor on right side of Geri chair. Blood was also noted on Geri chair seat, on Geri chair leg rest, lift sling, and 2 screws on the left side of Geri chair foot rest. Geri chair was in a reclined position with brakes applied. Resident #1 was asked what happened and she replied The man in the hall with a bed did it. Review of S5CNA's written statement for Resident #1's 11/17/2024 incident revealed: Resident #1 was in the dining room. I took Resident #1 to her bedroom so I could go get the Hoyer lift machine. When I came back I saw blood everywhere and that is when I went and got the nurse supervisor. Review of facility's video surveillance of hall A dated 11/17/2024 with S1Administrator on 12/03/2024 at 12:00 p.m. revealed: At 2:48 p.m. on 11/17/2024, Resident #1 was observed in Geri chair with legs elevated and resting on Geri chair foot rest. Resident #1 was wheeled down hall A and into Resident #1's room by staff member, who was identified as S5CNA. Further observation failed to reveal any blood on Resident #1's lower extremity clothing or Resident #1's skin which was visible between socks and clothing. At 2:49 p.m. on 11/17/2024, S5CNA exited Resident #1's room and walked directly to nurse's station and approached nurse, identified as S3RN Supervisor. S3RN Supervisor walked out of nurse's station and followed S5CNA to Resident #1's room. At 2:50 p.m. on 11/17/2024, S5CNA and S3RN Supervisor, entered Resident #1's room followed by a third staff member, identified as S4LPN. Review of facility's video surveillance from 11/17/2024 of hall A failed to reveal S5CNA left Resident #1's room to obtain a lift. After viewing the facility's video surveillance, S1Administrator reported it was clear in the video that S5CNA never went to get a Hoyer lift as she only left the room once and went directly to the nurse's station. During an interview on 12/02/2024 at 12:45 p.m., S1Administrator reported S5CNA was an agency CNA and had not worked at the facility since the incident on 11/17/2024. During an interview on 12/03/2024 at 9:50 a.m., S6CNA reported she was working hall A with S5CNA on 11/17/2024 at time of Resident #1's incident. S6CNA reported she remembered Resident #1 was a resident who required a Hoyer lift and two persons for transfers. During an interview on 12/03/2024 at 12:05 p.m., S3RN Supervisor reported she remembered the incident on 11/17/2024 involving Resident #1. S3RN Supervisor reported S5CNA came up to her and reported Resident #1's leg was bleeding and S3RN Supervisor followed S5CNA into Resident #1's room. S3RN Supervisor observed Resident #1 lying in bed, face up, with a wound to her lower left leg which had adipose tissue and bone exposed. S3RN Supervisor reported she covered the wound and called 911. S3RN Supervisor reported when she entered Resident #1's room she also observed the Geri chair perpendicular to Resident #1's bed in a reclined position. S3RN Supervisor reported Resident #1's Hoyer lift sling was still in the Geri chair and there was not a Hoyer lift in Resident #1's room. S3RN reported S5CNA stated Resident #1 must have injured her leg herself. S3RN Supervisor further reported prior to being summoned to Resident #1's room, Resident #1 was in her Geri chair in the dining room, which was visible from nurse's station, and S3RN Supervisor had not observed any blood or injury to Resident #1. During a telephone interview on 12/03/2024 at 12:18 p.m., S4LPN reported she remembered the incident on 11/17/2024 involving Resident #1. S4LPN confirmed she was the nurse working hall A on 11/17/2024. S4LPN reported prior to the incident on 11/17/2024, Resident #1 had been in the dining room in her Geri chair and Resident #1 did not have any blood on her or injury. During a telephone interview on 12/04/2024 at 8:25 a.m. S5CNA reported she remembered the incident on 11/17/2024 involving Resident #1 and confirmed she was Resident #1's assigned CNA at the time of the incident. S5CNA reported Resident #1 was in her Geri chair in the dining area and a staff member told her Resident #1 was ready to return to her bed. S5CNA reported she took Resident #1 back to her room in the Geri chair and left Resident #1's room to get the Hoyer lift. S5CNA reported Resident #1 was in the Geri chair and the Geri chair foot rest was pushed up to the side of the bed when she exited the room. S5CNA reported when she went back into Resident #1's room, Resident #1 was in bed with a wound to her leg. S5CNA reported she exited the room again and went to get the nurse. During an interview on 12/04/2024 at 10:30 a.m., S1Administrator reported S5CNA had been in-serviced, knew how to use a lift, and the lift sling was still in Resident #1's Geri chair. S1 Administrator acknowledged S5CNA failed to follow Resident #1's plan of care and utilize a Hoyer lift during transfers. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice beginning on 11/17/2024 with a completion date of 11/26/2024: 1. Nursing staff will be educated in the proper usage of a mechanical lift using 2 staff members by 11/25/2024. 2. Nursing staff will be in-serviced on how to access the Kardex in the resident's electronic health record by 11/25/2024. 3. All residents who require a mechanical lift will be reassessed by the DON (Director of Nursing) or designee. The QI (Quality Improvement) Nurse will open a retired assessment for quality assurance purpose only. The assessment will then be turned off and the facility will resume the therapy screen by 11/25/2024. 4. The DOR (Director of Rehabilitation) was in-serviced on completing therapy screens upon admission, readmission, quarterly, and as needed. As needed screens will be requested after the interdisciplinary team determines the need. QI Nurse completed this on 11/22/2024. 5. The DON or designee will evaluate staff members using the mechanical lift or assessing 2 person assist transfers at least 3 days a week for 4 weeks. Any issues found will be addressed immediately, staff educated, and the QAPI (Quality Assurance and Performance Improvement) committee will be notified beginning 11/22/2024. 6. A sign was placed at the head of the bed of any resident assisted in transfers with the mechanical lift to remind staff to use the mechanical lift and that it requires two people beginning 11/22/2024 and is ongoing with any changes in Residents' condition or new admissions. 7. The DON or designee will monitor that nursing staff, including agency nursing staff, can access the Kardex from the computer by observation of staff retrieval of the data from the electronic health record. 8. The Administrator, DON, DOR, MDS staff were in-serviced by QI Nurse on proper completion of therapy screen assessments on 11/26/2024. (Completed prior to surveyor's arrival on 11/26/2024 at 12:55 p.m.) 9. The CNA involved in the incident was reported to the CNA board on 11/18/2024 by the Administrator. The QAPI committee will review this plan weekly for four weeks, then monthly, and as needed after that to make certain the plan is being implemented, functioning, and appropriate to meet the needs of the residents in the facility.

Based on record review, video footage review, and interviews, the facility failed to ensure a resident received adequate assistance to prevent accidents for 1 (#1) of 3 (#1, #2, #3) residents reviewed for transfers by failing to follow Resident #1's plan of care. The deficient practice resulted in an immediate jeopardy for Resident #1 on 11/17/2024 when Resident #1 was transferred from a Geri chair to the bed without utilization of a Hoyer lift. Resident #1 was transferred to a local hospital related to a left lower leg wound which had adipose tissue and bone exposed. Review of Resident #1's hospital record revealed, Resident #1 was admitted with the primary diagnosis type I or II open non-displaced spiral fracture of shaft of left fibula with a laceration to distal LLE (left lower extremity) above the ankle mortis with exposed fibula. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a past noncompliance citation. Findings: Review of Resident #1's hospital record with an admitted [DATE] revealed in part, Resident #1 was admitted with the primary diagnosis type I or II open non-displaced spiral fracture of shaft of left fibula with a laceration to distal LLE above the ankle mortis with exposed fibula. Further review of Resident #1's hospital record revealed Resident #1 underwent incision and debridement surgical intervention to left ankle/leg wound on 11/18/2024 and 11/21/2024 with wound vacuum placement and was discharged on [DATE] to a different local nursing home. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses including, but not limited to, cerebral ischemia, polyosteoarthritis, periprosthetic fracture around internal prosthetic left hip joint, Parkinson's disease, and Alzheimer's disease. Review of Resident #1's medical record revealed Resident #1 resided on Hall A in Room A while a resident in the facility. Further review of Resident #1's medical record revealed Resident #1 discharged from the facility on 11/17/2024 and did not return to the facility. Review of Resident #1's MDS (Minimum Data Set) assessment dated [DATE] revealed in part Resident #1 had a BIMS (Brief Interview for Mental Status) score of 8, indicating moderately impaired cognition. Further review of Resident #1's MDS dated [DATE] revealed Resident #1 was totally dependent upon two staff members for transfer. Review of Resident #1's physician orders revealed in part: 11/24/2023 Resident may be up in Geri chair for trunk control and positioning. 10/09/2024 Non-weight bearing to left leg. Review of Resident #1's comprehensive care plan, updated 10/08/2024, revealed Resident #1 required assistance with ADLs (Activities of Daily Living) and was totally dependent in transferring with the use a Hoyer lift. Review of the facility's in-service dated 10/07/2024 included in part, how to use a lift for transfers. Further review of the facility's in-service and attendance record dated 10/07/2024 revealed S5CNA (Certified Nursing Assistant) signed the attendance record dated 10/07/2024. Review of the facility's Incident Report dated 11/17/2024 for Resident #1 revealed Resident #1 was propelled to her room in a Geri chair by S5CNA. S5CNA was in Resident #1's room for about a minute and a half before going to the nurse's station and informing S3RN (Registered Nurse) Supervisor that Resident #1's leg was bleeding. S3RN Supervisor and S4LPN (Licensed Practical Nurse) went to Resident #1's room where Resident #1 was found lying in bed with a laceration to her left leg. Resident #1's Geri chair, with lift pad still present, was observed to be perpendicular to Resident #1's bed. Resident #1 was assessed by S3RN Supervisor and S4LPN, 911 was called, and Resident #1 was transported to hospital. Further review of facility's Incident Report dated 11/17/2024 for Resident #1 revealed local law enforcement was called and transported S5CNA to police station for further questioning related to S5CNA's statement which did not match the facility's video surveillance. Review of S3RN Supervisor's written statement for Resident #1's 11/17/2024 incident revealed: Summoned to room per S5CNA yelling that Resident #1's left leg was cut and bleeding. Found resident in bed lying flat and face up. Resident #1's left lower leg had a laceration measuring 6 inches with adipose tissue and bone exposed. Towels were immediately placed on wound placing adipose tissue back in wound. Blood was noted on floor on right side of Geri chair. Blood was also noted on Geri chair seat, on Geri chair leg rest, lift sling, and 2 screws on the left side of Geri chair foot rest. Geri chair was in a reclined position with brakes applied. Resident #1 was asked what happened and she replied The man in the hall with a bed did it. Review of S5CNA's written statement for Resident #1's 11/17/2024 incident revealed: Resident #1 was in the dining room. I took Resident #1 to her bedroom so I could go get the Hoyer lift machine. When I came back I saw blood everywhere and that is when I went and got the nurse supervisor. Review of facility's video surveillance of hall A dated 11/17/2024 with S1Administrator on 12/03/2024 at 12:00 p.m. revealed: At 2:48 p.m. on 11/17/2024, Resident #1 was observed in Geri chair with legs elevated and resting on Geri chair foot rest. Resident #1 was wheeled down hall A and into Resident #1's room by staff member, who was identified as S5CNA. Further observation failed to reveal any blood on Resident #1's lower extremity clothing or Resident #1's skin which was visible between socks and clothing. At 2:49 p.m. on 11/17/2024, S5CNA exited Resident #1's room and walked directly to nurse's station and approached nurse, identified as S3RN Supervisor. S3RN Supervisor walked out of nurse's station and followed S5CNA to Resident #1's room. At 2:50 p.m. on 11/17/2024, S5CNA and S3RN Supervisor, entered Resident #1's room followed by a third staff member, identified as S4LPN. Review of facility's video surveillance from 11/17/2024 of hall A failed to reveal S5CNA left Resident #1's room to obtain a lift. After viewing the facility's video surveillance, S1Administrator reported it was clear in the video that S5CNA never went to get a Hoyer lift as she only left the room once and went directly to the nurse's station. During an interview on 12/03/2024 at 9:50 a.m., S6CNA reported she was working hall A with S5CNA on 11/17/2024 at time of Resident #1's incident. S6CNA reported she remembered Resident #1 was a resident who required a Hoyer lift and two persons for transfers. During an interview on 12/03/2024 at 12:05 p.m., S3RN Supervisor reported she remembered the incident on 11/17/2024 involving Resident #1. S3RN Supervisor reported S5CNA came up to her and reported Resident #1's leg was bleeding and S3RN Supervisor followed S5CNA into Resident #1's room. S3RN Supervisor observed Resident #1 lying in bed, face up, with a wound to her lower left leg which had adipose tissue and bone exposed. S3RN Supervisor reported she covered the wound and called 911. S3RN Supervisor reported when she entered Resident #1's room she also observed the Geri chair perpendicular to Resident #1's bed in a reclined position. S3RN Supervisor reported Resident #1's Hoyer lift sling was still in the Geri chair and there was not a Hoyer lift in Resident #1's room. S3RN reported S5CNA stated Resident #1 must have injured her leg herself. S3RN Supervisor further reported prior to being summoned to Resident #1's room, Resident #1 was in her Geri chair in the dining room, which was visible from nurse's station, and S3RN Supervisor had not observed any blood or injury to Resident #1. During a telephone interview on 12/03/2024 at 12:18 p.m., S4LPN reported she remembered the incident on 11/17/2024 involving Resident #1. S4LPN confirmed she was the nurse working hall A on 11/17/2024. S4LPN reported prior to the incident on 11/17/2024, Resident #1 had been in the dining room in her Geri chair and Resident #1 did not have any blood on her or injury. During a telephone interview on 12/04/2024 at 8:25 a.m. S5CNA reported she remembered the incident on 11/17/2024 involving Resident #1 and confirmed she was Resident #1's assigned CNA at the time of the incident. S5CNA reported Resident #1 was in her Geri chair in the dining area and a staff member told her Resident #1 was ready to return to her bed. S5CNA reported she took Resident #1 back to her room in the Geri chair and left Resident #1's room to get the Hoyer lift. S5CNA reported Resident #1 was in the Geri chair and the Geri chair foot rest was pushed up to the side of the bed when she exited the room. S5CNA reported when she went back into Resident #1's room, Resident #1 was in bed with a wound to her leg. S5CNA reported she exited the room again and went to get the nurse. During an interview on 12/04/2024 at 10:30 a.m., S1Administrator reported S5CNA had been in-serviced, knew how to use a lift, and the lift sling was still in Resident #1's Geri chair. S1 Administrator acknowledged S5CNA failed to follow Resident #1's plan of care and utilize a Hoyer lift during transfers. During the survey, in-service records and Quality Assurance (QA) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice beginning on 11/17/2024 with a completion date of 11/26/2024: 1. Nursing staff will be educated in the proper usage of a mechanical lift using 2 staff members by 11/25/2024. 2. Nursing staff will be in-serviced on how to access the Kardex in the resident's electronic health record by 11/25/2024. 3. All residents who require a mechanical lift will be reassessed by the DON (Director of Nursing) or designee. The QI (Quality Improvement) Nurse will open a retired assessment for quality assurance purpose only. The assessment will then be turned off and the facility will resume the therapy screen by 11/25/2024. 4. The DOR (Director of Rehabilitation) was in-serviced on completing therapy screens upon admission, readmission, quarterly, and as needed. As needed screens will be requested after the interdisciplinary team determines the need. QI Nurse completed this on 11/22/2024. 5. The DON or designee will evaluate staff members using the mechanical lift or assessing 2 person assist transfers at least 3 days a week for 4 weeks. Any issues found will be addressed immediately, staff educated, and the QAPI (Quality Assurance and Performance Improvement) committee will be notified beginning 11/22/2024. 6. A sign was placed at the head of the bed of any resident assisted in transfers with the mechanical lift to remind staff to use the mechanical lift and that it requires two people beginning 11/22/2024 and is ongoing with any changes in Residents' condition or new admissions. 7. The DON or designee will monitor that nursing staff, including agency nursing staff, can access the Kardex from the computer by observation of staff retrieval of the data from the electronic health record. 8. The Administrator, DON, DOR, MDS staff were in-serviced by QI Nurse on proper completion of therapy screen assessments on 11/26/2024. (Completed prior to surveyor's arrival on 11/26/2024 at 12:55 p.m.) 9. The CNA involved in the incident was reported to the CNA board on 11/18/2024 by the Administrator. The QAPI committee will review this plan weekly for four weeks, then monthly, and as needed after that to make certain the plan is being implemented, functioning, and appropriate to meet the needs of the residents in the facility.

Based on record review, video review, and interviews the facility failed to supervise a cognitively impaired resident from exiting the facility for 1 (Resident #1) of 9 ( #1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 walked out of the front entrance of the facility after S5Evening Receptionist remotely released the front sliding doors to an open position for Resident #1 to exit. Staff had not realized Resident #1 eloped from the facility until 07/23/2024 at approximately 7:30 p.m., when the search began and local police and Resident #1's RP (Responsible Party) were notified. Resident #1 was found with no injuries on 07/23/2024 at approximately 8:25 p.m. by Resident #1's RP. Resident #1 was located at a local restaurant approximately one mile from the facility, in which Resident #1 had crossed two four-lane roads. Resident #1's RP returned Resident #1 to the facility on [DATE] at 8:34 p.m. Resident #1 had been inaccurately assessed upon admission to the facility on [DATE] as not at risk for elopement and protective measures had not been put into place related to Resident #1's history of elopement from home. Multiple observations throughout the survey revealed the front entrance door, which opened to a large sitting area accessible to the residents, was not locked during the day and allowed staff and visitors open access to enter the facility. S1Adminsitrator was notified of the Immediate Jeopardy on 07/30/2024 at 3:45 p.m. This deficient practice had the likelihood to cause more than minimal harm to any resident residing in the facility at risk for elopement. The Immediate Jeopardy was removed on 07/31/2024 at 4:05 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings: Review of the facility's Wandering and Elopements policy with a revision date of 11/15/2023 revealed in part: Policy Statement: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measure to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. Identifying Residents at Risk 1. On admission/readmission, quarterly during observation period of MDS (Minimum Data Set), annual, significant changes and PRN (as needed), the nursing staff will screen each resident for elopement risk using the Elopement risk Evaluation V (version) 2.0, or equivalent form. After reviewing this information, the nursing staff will determine if the resident is at risk for wandering/elopement. 2. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 4. The following items will be used to increase staff awareness of residents at risk to wander/elope: A list of residents that are high risk for elopement or with security bracelets will be posted at the nurse's stations. Identification of each resident with a picture and face sheet will be with the resident list at the nurse's stations. Orientation of all staff to potential wanderers will be performed on an on-going basis. Review of the Resident #1's medical record revealed an admitted [DATE] at 12:58 p.m. with diagnoses including Dementia (unspecified severity) with Mood Disturbance, Chronic Obstructive Pulmonary Disease and Nicotine Dependence. Review of Resident #1's Elopement Risk Evaluation Audit Report revealed Resident #1, who had a history of elopement from home, was assessed as not at risk for elopement on 07/23/2024 at 3:59 p.m. by S4ADON (Assistant Director of Nursing). Review Resident #1's Nursing Admission assessment dated [DATE] revealed Resident #1 walked independently and needed no assistance from staff. Review of Resident #1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #1 had a BIMS score of 03, indicating severe cognitive impairment. Review Resident #1's Baseline Care Plan failed to reveal Resident #1 was at risk for elopement and had a history of elopement from home. Review of an internet mapping site revealed Resident #1 was located approximately 1 mile from the facility and had to cross two four-lane roads. Review of Resident #1's Interdisciplinary Notes revealed a late entry by S7LPN (Licensed Practical Nurse) dated 07/24/2024 at 5:05 a.m. which read in part, (07/23/2024) 7:30 p.m., upon rounding, Resident #1 was not in room nor bathroom. S7LPN alerted staff. Search began. Notified S2DON (Director of Nursing). Notified RP. (07/23/2024) 8:45 p.m. Resident #1 returned to facility via private vehicle, accompanied by RP. Resident redirected to assigned room. Vital Signs: 133/70 (blood pressure), 68 (heart rate), 20 (respiratory rate), 97.7 (temperature) and 98% RA (oxygenation on room air). Body Audit performed. No bruising. No opened areas. Close monitoring in progress. Will continue to monitor. Observation on 07/29/2024 at 10:30 a.m. revealed Resident #1 smoking a cigarette on the designated smoking patio with an assigned CNA (Certified Nursing Assistant) present. During an interview on 07/29/2024 at 10:30 a.m., Resident #1 stated multiple times I want to go home; can you take me home? Resident #1 also asked do you have a car; can you take me home? During an interview on 07/29/2024 at 10:40 a.m., S10Agency LPN reported the off-going night nurse on 07/23/2024 informed her during shift change report, Resident #1 was to have 1 on 1 supervision at all times and could not go up front because the entrance doors do not lock. During an interview on 07/29/2024 at 11:00 a.m., S2DON confirmed Resident #1 told staff on admission day, he was ready to leave and go home. S2DON confirmed Resident #1 was seen on the facility video exiting through the front door on 07/23/2024 at 6:00 p.m. and S5Evening Receptionist opened the door remotely to let Resident #1 out. S2DON acknowledged staff did not realize Resident #1 was missing until around 8:00 p.m. During an interview on 07/29/2024 at 1:30 p.m., S2DON confirmed Resident #1 was not deemed at risk for elopement on the Admission Elopement Risk Evaluation dated 07/23/2024 at 15:59 p.m. by S4ADON and should have been. During an interview on 07/29/2024 at 1:40 p.m., S4ADON acknowledged she had interviewed Resident #1, who had a diagnosis of Dementia, upon admission and evaluated Resident #1 as not at risk for elopement. S4ADON acknowledged she performed an inaccurate assessment by not interviewing the family or RP who were present at the time. S4ADON acknowledged had she interviewed the family during the initial evaluation, Resident #1 may not have eloped from the facility. During an interview on 07/29/2024 at 2:40 p.m., S9Day Receptionist, reported she was not informed Resident #1 was a new admit or an elopement risk on 07/23/2024. S9Day Receptionist reported the front door was unlocked during the day for anyone to enter the facility and the sliding glass door automatically opens when a person approaches the front entrance. During an interview on 07/29/2024 at 4:15 p.m., Resident #1's RP reported he found Resident #1 at a local restaurant at approximately 8:25 p.m. Resident #1's RP further reported Resident #1 had eloped from home about 2 months ago and was found by a construction crew. During an interview on 07/29/2024 at 4:40 p.m., S5Evening Receptionist reported she was assigned to the front desk on the 07/23/2024 evening shift and acknowledged she had let Resident #1 out, not realizing he was a resident. S5Evening Receptionist further reported she was not notified on 07/23/2024 of any new admits who were at risk for elopement. Review of the facility's surveillance video footage of the front entrance area on 07/30/2024 at 8:50 a.m. with S1Administrator and S3Corporate Nurse revealed in part, the following sequence of events on 07/23/2024: 5:55:30 p.m. Resident #1 walked past the front desk with his personal coffee cup towards the front door and was seen by S5Evening Receptionist who was sitting at the front desk. 5:55:41 p.m. S5Evening Receptionist unlocked and opened the front sliding doors with the remote control button for Resident #1 to exit. 5:55:46 p.m. Resident #1 walked out of the facility and remained on the front porch for a brief time. 5:56:58 p.m. Resident #1 exited the facility's front porch and began walking away in a left direction. 8:31:55 p.m. A white truck was observed to pull up to front entrance of facility. 8:34:00 p.m. Resident #1 was observed getting out of the white truck and walked back into facility. Further review of facility's surveillance video footage of the front entrance area on 07/30/2024 at 8:50 a.m. with S1Administrator and S3Corporate Nurse revealed in part, the following sequence of events on 07/23/2024: 6:59:40 p.m. S5Evening Receptionist left the front desk to assist a wheelchair bound resident towards the back of the facility. 6:59:50 A visitor was observed entering the facility through the sliding doors, which opened upon approach to the entrance; front desk was observed to be unattended. 7:03:15 p.m. S5Evening Receptionist, returned to front desk, having left the front desk unattended for approximately 3 to 4 minutes. During an interview on 07/30/2024 at 9:20 a.m., S11CNA reported she was working on 07/23/2024 and Resident #1 asked if she would open the front door because he wanted to go home. During a telephone interview on 07/30/2024 at 10:20 a.m., S7LPN reported she came to work on 07/23/2024 at 7:00 p.m. and did not see Resident #1 on initial rounds. S7LPN reported she began medication pass and by around 8:00 p.m. had still not located Resident #1 and that is when she and staff started searching and got S2DON involved. S7LPN acknowledged the day shift nurse reported to her on 07/23/2024 during change of shift report, Resident #1 was a wanderer. During an interview on 07/31/2024 at 1:05 p.m., S2DON reported once a resident has had an elopement assessment indicating at risk for elopement or a resident is known to wander, the resident's name will remain on the facility's Elopement List as an indicator of high risk for elopement, even if the resident has a follow-up assessment revealing no risk for elopement. During an interview on 07/30/2024 at 9:00 a.m., S1Administrator, reported the S5Evening Receptionist not knowing Resident #1 was a resident and was at risk for elopement contributed to the safety process failure. S1Administrator acknowledged the front door was left unattended upon review of 07/23/2024's surveillance video and confirmed a resident could elope when someone enters the unlocked front door. S1Administrator acknowledged the front door entrance was not secure and there were times the desk may not be manned. S1Administrator further acknowledged the facility did not have a lock down unit or wander guard system in place to aide in measures to prevent elopement.

Based on record review, video review, an interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently by failing to implement a system to provide quality care to meet the needs of each resident by failing to: 1. Ensure a process was in place to prevent a cognitively impaired resident from exiting the facility for 1 (Resident #1) of 9 (#1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. and 2. Ensure the nursing staff possessed the competency to accurately assess a resident for an elopement risk. The lack of administrative oversight resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 walked out of the front entrance of the facility after S5Evening Receptionist remotely released the front sliding doors to an open position for Resident #1 to exit. Staff had not realized Resident #1 eloped from the facility until 07/23/2024 at approximately 7:30 p.m., when the search began and local police and Resident #1's RP (Responsible Party) were notified. Resident #1 was found with no injuries on 07/23/2024 at approximately 8:25 p.m. by Resident #1's RP. Resident #1 was located at a local restaurant approximately one mile from the facility, in which Resident #1 had crossed two four-lane roads. Resident #1's RP returned Resident #1 to the facility on [DATE] at 8:34 p.m. Resident #1 had been inaccurately assessed upon admission to the facility on [DATE] by S4ADON (Assistant Director of Nursing) as not at risk for elopement. S4ADON failed to interview Resident #1's family or RP (Responsible Party) at the time of the initial elopement risk assessment and did not capture Resident #1's history of elopement from home prior to admission to the facility, failed to capture Resident #1 told staff on the day of admission he was ready to leave and go home and family reported wandering behaviors. Therefore, protective measures had not been put into place related to Resident #1's elopement risk. Multiple observations throughout the survey revealed the front entrance door, which opened to a large sitting area accessible to the residents, was not locked during the day and allowed staff and visitors open access to enter the facility. S1Administrator was notified of the Immediate Jeopardy on 07/30/2024 at 3:45 p.m. This deficient practice had the likelihood to cause more than minimal harm to any resident residing in the facility at risk for elopement. The Immediate Jeopardy was removed on 07/31/2024 at 4:05 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings: Cross Reference F689 and F726 Review of facility's surveillance video footage of the front entrance area on 07/30/2024 at 8:50 a.m. with S1Administrator and S3Corporate Nurse revealed in part, the following sequence of events on 07/23/2024: 6:59:40 p.m. S5Evening Receptionist left the front desk to assist a wheelchair bound resident towards the back of the facility. 6:59:50 A visitor was observed entering the facility through the sliding doors, which opened upon approach to the entrance; front desk was observed to be unattended. 7:03:15 p.m. S5Evening Receptionist, returned to front desk, having left the front desk unattended for approximately 3 to 4 minutes. During an interview on 07/29/2024 at 2:40 p.m., S9Day Receptionist reported the front door was unlocked during the day for anyone to enter the facility and the sliding glass door automatically opened when a person approaches the front entrance. During an interview on 07/30/2024 at 9:00 a.m., S1Administrator, reported the S5Evening Receptionist not knowing Resident #1 was a resident and was at risk for elopement contributed to the safety process failure. S1Administrator acknowledged the front door was left unattended upon review of 07/23/2024's surveillance video and confirmed a resident could elope when someone enters the unlocked front door. S1Administrator acknowledged the front door entrance was not secure and there were times the desk may not be manned. S1Administrator further acknowledged the facility did not have a lock down unit or wander guard system in place to aide in measures to prevent elopement. During an interview on 07/30/2024 at 9:10 a.m., S3Corporate Nurse, reported she reviewed Resident #1's initial elopement assessment the night Resident #1eloped and confirmed Resident #1 had been evaluated as not at risk for elopement by S4ADON. S3Corporate Nurse further acknowledged the 07/23/2024 elopement evaluation failed to include the family in the elopement assessment process, and S4ADON should have, to capture a history of elopement from the home. Review of S4ADON's personnel record failed to reveal nursing assessment competencies were completed.

Based on record reviews, and interviews the facility failed to ensure the nursing staff possessed the competency to accurately assess a resident for elopement risk for 1 (Resident #1) of 9 ( #1, #2, #3, #4, #5, #6, #7, #8 and #9) sampled residents reviewed for elopement. This deficient practice resulted in an Immediate Jeopardy on 07/23/2024 at 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 walked out of the front entrance of the facility after S5Evening Receptionist remotely released the front sliding doors to an open position for Resident #1 to exit. Staff had not realized Resident #1 eloped from the facility until 07/23/2024 at approximately 7:30 p.m. Resident #1 had been inaccurately assessed upon admission to the facility on [DATE] by S4ADON (Assistant Director of Nursing) as not at risk for elopement. S4ADON failed to interview Resident #1's family or RP (Responsible Party) at the time of the initial elopement risk assessment and did not capture Resident #1's history of elopement from home prior to admission to the facility, failed to capture Resident #1 told staff on the day of admission he was ready to leave and go home and family reported wandering behaviors. Therefore, protective measures had not been put into place related to Resident #1's elopement risk. S1Adminsitrator was notified of the Immediate Jeopardy on 07/30/2024 at 3:45 p.m. This deficient practice had the likelihood to cause more than minimal harm to any resident residing in the facility at risk for elopement. The Immediate Jeopardy was removed on 07/31/2024 at 4:05 p.m. when it was determined the facility had implemented an acceptable Plan of Removal as confirmed through onsite interviews, observations, and record reviews prior to exit. Findings: Review of the facility's Admission Assessment and Follow Up: Role of the Nurse with a revision date of September 2012 revealed in part: Purpose: the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments, including the MDS (Minimum Data Set). Steps in the Procedure: 5. Conduct an admission assessment (history and physical), including: a. A summary of the individual's recent medical history, including hospitalization s, acute illnesses, and overall status prior to admission . b. Relevant medical, social and family history if available. Review of the facility's Wandering and Elopements policy with a revision date of 11/15/2023 revealed in part: Policy Statement: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measure to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. Identifying Residents at Risk 1. On admission/readmission, quarterly during observation period of MDS, annual, significant changes and PRN (as needed), the nursing staff will screen each resident for elopement risk using the Elopement risk Evaluation V (version) 2.0, or equivalent form. After reviewing this information, the nursing staff will determine if the resident is at risk for wandering/elopement. 2. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. 4. The following items will be used to increase staff awareness of residents at risk to wander/elope: A list of residents that are high risk for elopement or with security bracelets will be posted at the nurse's stations. Identification of each resident with a picture and face sheet will be with the resident list at the nurse's stations. Orientation of all staff to potential wanderers will be performed on an on-going basis. Review of the Resident #1's medical record revealed an admitted [DATE] at 12:58 p.m. with diagnoses including Dementia (unspecified severity) with Mood Disturbance, Chronic Obstructive Pulmonary Disease and Nicotine Dependence. Review of Resident #1's Elopement Risk Evaluation Audit Report revealed Resident #1, who had a history of elopement from home, was assessed as not at risk for elopement on 07/23/2024 at 3:59 p.m. by S4ADON (Assistant Director of Nursing). Review Resident #1's Nursing Admission assessment dated [DATE] revealed Resident #1 walked independently and needed no assistance from staff. Review of Resident #1's Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed Resident #1 had a BIMS score of 03, indicating severe cognitive impairment. Review Resident #1's Baseline Care Plan failed to reveal Resident #1 was at risk for elopement and had a history of elopement from home. During an interview on 07/29/2024 at 10:30 a.m., Resident #1 stated multiple times I want to go home; can you take me home? Resident #1 also asked do you have a car; can you take me home? During an interview on 07/29/2024 at 11:00 a.m., S2DON (Director of Nursing) confirmed Resident #1 told staff on admission day, he was ready to leave and go home and Resident #1's family reported he had wandering behaviors. S2DON reported Resident #1 should have been placed on the list of Residents at risk for elopement. During an interview on 07/29/2024 at 1:30 p.m., S2DON reported she reviewed Resident #1's initial Admission Elopement Evaluation on the night Resident #1 eloped and Resident #1 had been evaluated as not at risk for elopement by S4ADON (Assistant Director of Nursing) on 07/23/2024 at 3:59 p.m. S2DON confirmed S4ADON did not complete an accurate Admission Elopement Risk Evaluation for Resident #1 and should have. S2DON reported she had not looked at Resident #1's initial evaluation again until 07/29/2024, when she realized some of the answers had been changed. Review of Resident #1's Elopement Risk Evaluation Audit Report dated 07/29/2024 with S2DON revealed questions #3 and 5 had been changed from no as entered on 07/23/2024 at 3:59 p.m. to yes on 07/24/2024 at 7:55 a.m. by S4ADON. Further review of Resident #1's Admission Elopement Risk Evaluation dated 07/23/2024 revealed in part, a 'yes' answer to any question identified with an asterisk (*) identifies a risk for elopement: Question #3. *Does the resident have a history of elopement or an attempted elopement while at home and Question #5. *Has the resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door? S2DON confirmed these answer changes made Resident #1 at a high risk for elopement. S2DON reported S4ADON should not have changed answers on the initial elopement risk evaluation and a new elopement evaluation should have been completed after Resident #1 eloped. During an interview on 07/29/2024 at 1:40 p.m., S4ADON acknowledged she had interviewed Resident #1, who had a diagnosis of Dementia, upon admission and evaluated Resident #1 as not at risk for elopement. S4ADON acknowledged she performed an inaccurate assessment by not interviewing the family or RP who were present at the time. S4ADON further acknowledged she changed some of the answers on Resident #1's initial elopement risk evaluation on the morning of 07/24/2024 to reflect Resident #1 was at risk for elopement, after she learned Resident #1 had eloped on 07/23/2024. S4ADON acknowledged she should not have changed the answers and instead should have opened a new elopement assessment. S4ADON reported risk assessments were a new task and was not sure if she was doing it right because she was not accustomed to performing assessments. S4ADON acknowledged she did not alert staff or put elopement interventions into place for Resident #1 until after he had eloped on 07/24/2024. S4ADON acknowledged had she interviewed the family during the initial evaluation and put protective measures into place, Resident #1 may not have eloped from the facility. During an interview on 07/29/2024 at 4:15 p.m., Resident #1's RP reported Resident #1 had eloped from home about 2 months ago and was found by a construction crew. During an interview on 07/29/2024 at 4:40 p.m., S5Evening Receptionist reported she was assigned to the front desk on the 07/23/2024 evening shift and acknowledged she had let Resident #1 out, not realizing he was a resident. S5Evening Receptionist further reported she was not notified on 07/23/2024 of any new admits who were at risk for elopement. During an interview on 07/30/2024 at 9:00 a.m., S1Administrator, reported the S5Evening Receptionist not knowing Resident #1 was a resident and was at risk for elopement contributed to the safety process failure. During an interview on 07/30/2024 at 9:10 a.m., S3Corporate Nurse, reported she reviewed Resident #1's initial elopement assessment the night Resident #1eloped and confirmed Resident #1 had been evaluated as not at risk for elopement by S4ADON. S3Corporate Nurse further acknowledged the 07/23/2024 elopement evaluation was inaccurate and S4ADON should have interviewed the family during the initial elopement assessment. S3Corporate Nurse acknowledged the initial assessment was changed the following day 07/24/2024 by S4ADON and should not have been. Review of S4ADON's personnel record failed to reveal nursing assessment competencies were completed.

Based on record review and interviews the facility failed to ensure grievances/complaints had been documented and investigated. The facility failed to follow their policy for reporting and investigating grievances for 1 (#1) of 4 (#1, #2, #3, #4) sampled residents. Findings: Review of policy titled Resident Grievances/Complaints, Filing with revision date of 11/01/2023 revealed: Policy Statement The facility shall establish a grievance policy in order to ensure prompt resolution of all grievances regarding the residents' rights. All residents, family and resident representatives are to be encouraged and assisted (if necessary) in filing grievances, in the event they have a need to make a concern known. Policy Interpretation and Implementation 1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. 4. Grievances and/or complaints may be submitted orally or in writing, and may be filed anonymously. 7. Upon receipt of a grievance/complaint the staff receiving the complaint will initiate the RESIDENT GRIEVANCE/COMPLAINT FORM. An investigation lead by the Grievance Officer or designee based on the allegations will be set forth. Upon receipt of a grievance and/or complaint, the Grievance Officer and/or designee will review and investigate the allegations and discuss findings and recommendations with the Administrator. Findings will be discussed with the complainant within five (5) working days of receiving the grievance and/or complaint. 9. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. Review of Resident #1's medical record revealed an initial admitted [DATE] with diagnoses that included, in part, hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, aphasia following cerebral infarction, muscle wasting and atrophy not elsewhere classified multiple sites, chronic combined systolic (congestive) and diastolic (congestive) heart failure, contracture right elbow, primary osteoarthritis right shoulder, primary osteoarthritis right shoulder, gastrostomy status, essential (primary) hypertension, vascular dementia, and type 2 diabetes mellitus. Review of Resident #1's quarterly MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 04/02/2024 revealed Resident #1 had a BIMS (Brief Interview Mental Status) score of 99, indicating Resident #1 was unable to complete the interview. The MDS further revealed Resident #1 had no memory/recall ability and cognitive skills for daily decision making were severely impaired. Review of 2024 Complaint/Grievance Log failed to reveal any grievance in regard to Resident #1. During an interview on 04/22/2024 at 11:20 a.m. S1 Administrator reported any resident/family issues that could be resolved quickly for residents were not included in the grievance log. During an interview on 04/23/2024 at 10:15 a.m. Resident #1's family member reported informing S1 Administrator that Resident #1 was repeatedly found in a soiled brief when visiting. During an interview on 04/24/2024 at 8:20 a.m. S1 Administrator reported about 4 weeks ago Resident #1's family member had complained that upon arriving for visits, Resident #1's brief was always soiled. S1 Administrator further confirmed he had not initiated a resident grievance/complaint form and did not have a documented investigation for the family member's voiced concern.

Based on record review and interview, the facility failed to ensure residents and/or the resident's representative were provided with written information concerning advance directives and/or the option to formulate an advanced directive for 14 (#1, #3, #20, #21, #22, #24, #28, #40, #45, #50, #58, #65, #67, #74) of 15 (#1, #3, #20, #21, #22, #24, #28, #33, #40, #45, #50, #58, #65, #67, #74) residents reviewed for Advanced Directives. Findings: Resident #1 Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE]. Further review of Resident #1's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #13 Review of Resident #13's medical record revealed Resident #13 was admitted to the facility on [DATE]. Further review of Resident #13's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #20 Review of Resident #20's medical record revealed Resident #20 was admitted to the facility on [DATE]. Further review of Resident #20's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #21 Review of Resident #21's medical record revealed Resident #21 was admitted to the facility on [DATE]. Further review of Resident #21's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #22 Review of Resident #22's medical record revealed Resident #22 was admitted to the facility on [DATE]. Further review of Resident #22's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #24 Review of Resident #24's medical record revealed Resident #24 was admitted to the facility on [DATE]. Further review of Resident #24's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #28 Review of Resident #28's medical record revealed Resident #28 was admitted to the facility on [DATE]. Further review of Resident #28's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #40 Review of Resident #40's medical record revealed Resident #40 was admitted to the facility on [DATE]. Further review of Resident #40's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #45 Review of Resident #45's medical record revealed Resident #45 was admitted to the facility on [DATE]. Further review of Resident #45's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #50 Review of Resident #50's medical record revealed Resident #50 was admitted to the facility on [DATE]. Further review of Resident #50's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #58 Review of Resident #58's medical record revealed Resident #58 was admitted to the facility on [DATE]. Further review of Resident #58's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #65 Review of Resident #65's medical record revealed Resident #65 was admitted to the facility on [DATE]. Further review of Resident #65's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #67 Review of Resident #67's medical record revealed Resident #67 was admitted to the facility on [DATE]. Further review of Resident #67's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. Resident #74 Review of Resident #74's medical record revealed Resident #74 was admitted to the facility on [DATE]. Further review of Resident #74's medical record failed to reveal resident or resident's representative was provided with written information concerning advanced directives and/or the option to formulate an advanced directive. During an interview on 01/30/2024 at 8:48 a.m. S1 ADM (Admissions Coordinator) confirmed Residents #1, #13, #20, #21, #22, #24, #28, #40, #45, #50, #58, #65, #67, and #74's medical records did not contain documentation that resident or resident's representative were provided with written information concerning advanced directives and/or the option to formulate an advanced directive. During an interview on 01/30/2024 at 8:48 a.m. S2 SS (Social Services) also confirmed Residents #1, #13, #20, #21, #22, #24, #28, #40, #45, #50, #58, #65, #67, and #74's medical record did not contain documentation that resident or resident's representative were provided with written information concerning advanced directives and/or the option to formulate an advanced directive. 36664 40957

Based on record reviews and interviews the facility failed to ensure resident assessments were transmitted within the required timeframe for 3 (#88, #60, #49) of 19 residents reviewed for assessments out of a total of 28 sampled residents. Findings: Review of Resident #88's MDS (Minimum Data Set) assessments revealed a Quarterly/State Optional MDS dated [DATE] with a status of in progress. Further review revealed Resident #88's last transmitted Quarterly MDS was dated 09/14/2023. Review of Resident #60's MDS assessments revealed a Quarterly/State Optional MDS dated [DATE] with a status of in progress. Further review revealed Resident #60's last transmitted Quarterly/State Optional MDS was dated 12/14/2023. Review of Resident #49's MDS assessments revealed an Annual/State Optional MDS dated [DATE] with a status of in progress. Further review revealed Resident #49's last transmitted Quarterly MDS was dated 09/19/2023. During an interview on 01/30/2024 at 1:15 p.m. S7 Licensed Practical Nurse/MDS Nurse reviewed Resident #88, Resident #60, and Resident #49's MDS assessments and acknowledged their MDS assessments had not been completed and transmitted to CMS (Centers for Medicare and Medicaid Services) within the required time frame.

Based on record reviews and interviews the facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's wheelchair to bed for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents who required two-person assist with transfers. The deficient practice resulted in actual harm for resident #5 on 8/3/2022 when the resident was being transferred from a wheelchair to her bed. Resident #5 required two plus person physical assistance for bed mobility and transfers. Resident # 5 was being transferred by only one person when her left leg was hit on the bed rails and injured. On the morning of 8/4/2022 after resident #5 left leg was hit on the bedrail she complained of pain and discomfort. Resident #5 was assessed by a facility nurse, an x-ray was ordered and it was confirmed resident #5 had a left tibia/fibula fracture. Resident #5 was sent to a local hospital with at diagnosis of proximal fibula fracture with mid shaft comminuted spiral tibia fracture with non-displaced fracture of medical malleolus. Findings: Review of the facility's Safety and Supervision of Residents Policy revealed in part: Revised July 2017 Policy Statement: Our facility strives to make environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Policy Interpretation and Implementation Individualized, Resident - Centered Approach to Safety 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently. Resident Risks and Environmental Hazards 1. B. Safe Lifting and Movement of Residents Review of resident #5's clinical records revealed an admitted [DATE] to this facility and a discharge date of [DATE]. Diagnoses include [CONDITION(S)] following a cerebral infraction affecting right dominant side, diabetes, arthritis, [CONDITION(S)], Non-Alzheimer's dementia and muscle wasting and weakness. Review of resident #5's MDS (Minimum Data Set) with ARD (Assessment Reference Date) 7/15/2022 revealed the resident required two plus persons physical assistance for bed mobility and transfers. Review of resident #5's Comprehensive Plan of Care revealed she required staff assistance for all activities of daily living. Resident #5 needs included extensive assist with bed mobility, transfers, and toileting. Some of the approaches are staff will provide assistance with transfers using two people. 7/13/2022 May use sliding board for transfers. 8/5/2022 Transfer with mechanical lift. Review of a hand written statement dated 8/3/2022 by S4 Agency CNA (Certified Nursing Assistance) revealed: upon putting resident #5 in the bed during the transfer I heard her leg pop as we were putting her in the bed on yesterday and after I heard it pop I asked her was she okay. She said she was, but her legs always hurt like that and she was rubbing the left one saying that if you have it just right it'll go back right. When I was transferring her we started out using the sliding board but as we were using it she was having difficulty getting on it right so I turned her around towards the bed to put her in it so it would be more helpful for her to get in the bed. We did not use the sliding board because it was easier for her without it. Review of S14 LPN Charge Nurse Hand written statement, documented on 8/3/2022 she was scheduled to work on the same hall with S4 Agency CNA. I noticed S4 Agency CNA transferring resident #5 from her wheelchair to her bed by himself. Review of S10 CNA hand written statement dated 8/9/2022 documented, the day resident #5's had her incident I witnessed almost the ending I was in the process of putting resident ____ in the bed and I heard something like a loud yell. S4 Agency CNA was putting resident #5 in the bed by himself. Resident #5 said her leg hurt he continued to adjust her in the bed. As far as anyone helping S4 Agency CNA put resident #5 in bed there was no one helping him. Review of S2 DON (Director of Nursing) notes dated 8/4/2022 revealed the following documentation: 10:00 a.m. resident #5 was found to have pain by daytime nurse S13 LPN. S13 LPN assessed resident #5 left lower leg. Left lower leg noted swollen, warm to touch, and with bruising to medial aspect of leg. Left leg was noted to be turned in an outward position towards the patient's left side. Resident voiced the person who put her to bed from the wheelchair, the night before, bumped her leg on the bed frame, but he did not use the sliding board. Dr._____ was notified of the above findings and new orders were notified for x-ray and Doppler ultrasound of left leg. 3:40 p.m. x-ray tech arrived and completed x-ray indicating possible fracture. NP (Nurse Practitioner) aware of x-ray results and referred resident to ER (emergency room ) for evaluation. 4:13 p.m. resident transport to ER for evaluation per____ stretcher prior to being able to do a Doppler ultrasound. 8/5/2022 at 11:00 a.m. Administrator and I spoke with resident #5's RP (responsible party) related to resident's incident on 8/3/2022. Informed resident #5's RP the CNA who performed the transfer from the wheelchair to the bed 8/3/2022 did not use proper procedure in placing resident in the bed with a slide board, even after resident stated to him to use it. CNA stated to me that he felt he could do the transfer without it. CNA will no longer be working at this facility because of the lack of proper transferring technique resulting in a resident's injury. Review of resident #5's Nurse Notes revealed: Nurse's notes dated 8/4/2022 at 10:00 a.m. S13 LPN (Licensed Practical Nurse) documented writer called to resident #5's room by PT (physical therapist) for resident complaint of pain to left lower leg. Examined and noted purple bruise to left lower leg, swollen, warm to touch and painful. Resident able to flex foot but notable to rotate inward. Resident reported she bumped her leg on bed frame when they were putting her to bed last night. Call to Dr. _____ notified new order for x-ray and Doppler study. Resident given APAP (Tylenol) 650mg (milligram) by mouth for pain. Review of nurse's notes dated 8/4/2022 at 11:30 a.m. S16 LPN documented late entry writer received report from floor nurse that resident has swelling and bruising to her left lower leg. Writer went to resident's room to evaluate resident left lower extremity, swollen, warm to touch with bruising noted to medial aspect of leg. Resident left foot is also turned outward. Resident stated that she is experiencing intense pain when writer touched her leg. When trying to lift resident's leg she screamed in pain. Floor nurse administered resident prn pain meds and contacted doctor for new orders Review of nurse's notes dated 8/4/2022 at 4:34 p.m. S16 LPN documented __ Imaging arrived to perform x-ray of resident's left leg at 3:40 p.m. Upon completion of x-ray tech showed NP (Nurse Practitioner) resident's imaging and NP stated that resident needs to be sent to the ER(emergency room ) due to possible bone fracture. EMS (emergency medical services) was called and they arrived to facility at 4:13 pm to transport resident. Resident #5 left facility in stable condition. Vital signs 96% - 97.3-130/80-78-18. Resident #5 stated that she was still having intense leg pain. Review of the hospital emergency room notes dated 8/4/2022 at 4:55 p.m. revealed the chief complaint, leg injury. [AGE] year old female presents to the emergency department with complaint of left lower leg injury. Patient states she was being moved into bed when her lower leg hit the bed. Content: other (hit on side of bed). Extremity/Vascular: Left lower extremity: Knee joint (swelling noted), lower leg left; Lower leg: Inspection (bruising from mid to distal left anterior shin) and palpation (tenderness of mid left anterior shin distally to left ankle) and ankle joint (ankle deformity with left foot rotated laterally. Imaging Data Attestation imaging: X-ray left tib-fib (tibia-fibula) and left ankle: Proximal fibula fracture with mid shaft comminuted spiral tibia fracture with non-displaced fracture of medical malleolus, mortise appears intact. Impression: Fractured tibia and fibula as described. 2. Fracture medial malleolus. Attempted to interview S4 Agency CNA (Certified Nursing Assistant) by phone on 11/21/2022 at 1:34 p.m. and 6:04 p.m., with no answer. During an interview on 11/21/2022 at 9:36 a.m. S2 DON reported she had notified the Staffing Agency, S4 Agency CNA is not to return to work at this facility again. S2 DON reported S4 Agency CNA did not follow the resident plan of care. S2 DON reported S4 Agency CNA admitted he did not use the resident sliding board, he thought he could get her into bed by himself. S2 DON reported resident #5 did not complain of pain or anything until the next day. S15 Physical therapist reported to S13 LPN resident #5 complained of pain and discomfort to her left leg. At this time S13 LPN assessed resident #5 and found her left leg red, warm, painful and swollen. During an interview on 11/21/2022 at 10:15 a.m. S13 LPN reported she was notified by S15 PT (Physical Therapist) on 8/4/2022 at 10:00 a.m. that resident #5 was complaining of pain to her left lower extremity. S13 LPN reported she assessed resident #5 and found her left lower extremity to be swollen, red, warm, rotated outward and hurting. S13 LPN reported she notified S2 DON and she assessed resident #5 herself. S13 LPN reported she administered Tylenol for pain, she reported it was effective. S13 LPN reported the Unit Manager notified the family. S13 LPN reported resident #5's physician was notified. X-rays was ordered and it showed resident #5 had a fracture. S13 LPN reported resident #5 requires maximum assistance with 2 persons for transfer and bed mobility. S13 LPN reported resident #5 can use the sliding board with assistance. S13 LPN reported resident #5 is alert and able to make her needs know. During an interview on 11/21/2022 at 12:55 pm S21 Corporate Nurse reported they have a contract with _______ Staffing Agency that they are provided trained and competent staff. She further reported an agency CNA has a sign in code where they have access to all resident's plans of care. During an interview on 11/21/2022 at 1:51 p.m. S10 CNA reported she and another CNA were working on the hall with S4 Agency CNA on 8/3/2022. S10 CNA reported they passed resident #5's room in route to help put another resident to bed. S10 CNA reported she asked S4 Agency CNA if he need some help to put resident #5 in bed and he declined help. S10 CNA reported she knew he needed assistance because resident #5 requires 2 person assistance with transfers. She reported S4 Agency CNA refused any help. During an interview 11/21/2022 at 2:16 p.m. S14 LPN reported she works 2 days a week at this facility for ____ Staffing Agency. S14 LPN reported on 8/3/2022 she was in the room across from resident #5 room when she noticed S4 Agency CNA helping resident #5 from her wheelchair to the bed. S4 Agency CNA was in the process of transferring resident #5. S14 LPN reported before she could remove her PPE's (personal protective equipment) S4 Agency CNA had transferred resident #5 to her bed without any assistance. She reported S4 Agency CNA did not wait for any assistance, did not use a sliding board or the mechanical lift. S14 LPN reported the reason she was concerned about S4 Agency CNA moving resident #5 by himself is because he is a small man and she is a large woman. S14 LPN reported that entire night resident #5 never complained of foot or leg pain. S14 LPN reported she was aware resident #5 required extensive assistance, 2 plus assistance for transfers and bed mobility. During an interview on 11/21/2022 at 6:58 p.m. resident #5's RP (Responsible Party) reported her mother was not available for an interview. She reported her mother confirmed she tried to tell S4 Agency CNA he could not get her up by himself but he would not listen. She acknowledged her mother is over 6 feet tall and weighs over 200 pounds and S4 Agency CNA was a small guy. During an interview on 11/22/ at 9:10 a.m. S15 PT (Physical Therapist) reported he was performing side board training with resident #5. S15 PT reported the morning of 8/4/2022 he arrived in the resident's room and she complained of not feeling very good. She complained of pain to her left leg, so I said let's just do the training in the bed this morning. S15 PT reported resident #5's left leg was swollen, red and tender. S15 PT reported he notified the floor nurse, S13 LPN about resident #5 complaint about her left leg. S15 PT reported resident #5 required 2 plus person assistance with transfers and bed mobility.