Every finding on record at Riviere de Soleil Community Care Center

Based on observation, interview, and record review, the facility failed to ensure nursing staff immediately notified the medical provider of a significant change in condition for 1 (Resident #107) of 3 closed record reviewed. The facility failed to report Resident #107's dark, tarry stools to the medical provider.This deficient practice resulted in an Immediate Jeopardy situation beginning on 07/24/2026 at 4:35 p.m., when S5LPN observed Resident #107, who was ordered anticoagulant and antiplatelet medication daily, was having dark, tarry, foul smelling stools and failed to notify the resident's provider. On 07/25/2026 at 4:00 a.m., S4LPN documented that Resident #107 had black, tarry stool and failed to notify the medical provider. On 07/27/2026, #107 was transferred to the emergency department due to the critically low hemoglobin of 4.0 g/dL and hematocrit of 13.8%. Review of hospital records revealed findings consistent with a GI bleed and acute blood loss anemia. Resident #107 required medication to reverse the effects of anticoagulant and antiplatelet therapy, blood transfusions, and transfer to a second hospital for intensive care unit (ICU) placement and specialized GI services.The deficient practice had the potential to cause more than minimal harm to any residents who may experience a significant change in condition and require consultation with the medical provider. The census was 106. S1Admin was notified of the Immediate Jeopardy situation on 08/19/2026 at 6:35 p.m. On 08/20/2026, a review of the facility's undated policy titled, Change in a Resident's Condition or Status, revealed, in part: Our facility notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status in a timely manner. The policy further revealed The nurse will notify the resident's attending physician or physician on call when there has been a(n): . D. significant change in the resident's physical/emotional/mental condition.Review of Resident #107's medical record revealed an admission date of 07/14/2026 and a discharge date of 07/27/2026. Diagnoses included, in part, Primary Hypertension, Pulmonary Embolism, Hyperlipidemia, Peripheral Vascular Disease, and Alcohol Abuse. Review of Resident #107's admission MDS with an Assessment Reference Date (ARD) of 07/20/2026 revealed a BIMS score of 15, indicating intact cognition. The resident was frequently incontinent of bowel and was receiving anticoagulant and antiplatelet medications.Review of Resident #107's July 2026 physician orders revealed, in part:07/14/2026: Monitor for side effects of anticoagulant therapy/signs of bleeding, including black, tarry stool.07/14/2026: Apixaban (an anticoagulant) 5 mg by mouth twice daily for pulmonary embolism.07/15/2026: Aspirin 81 mg by mouth daily for pulmonary embolism.07/15/2026: Clopidogrel (an antiplatelet medication) 37.2 mg by mouth daily, to be given with 75 mg for a total dose of 112.2 mg for blood clot prevention.07/15/2026: Clopidogrel 75 mg by mouth daily, to be given with 37.2 mg for a total dose of 112.2 mg for blood clot prevention.Review of Resident #107's electronic health record (EHR) revealed a progress note created by S5LPN on 07/24/2026 at 4:35 p.m., which revealed in part, that Resident #107 was having repeated bowel movements, requiring CNAs to change him frequently, with 3 to 4 episodes since the beginning of the shift at 2:00 p.m. The note further revealed that the resident was smearing his stool on the bed and himself and was unable to explain the change in his behavior. The note documented that Resident #107 was unable to answer questions at all. S6NP was notified via telephone call and new orders were received for CBC and BMP for Monday 07/20/2026. Loperamide 4mg tab po 1x dose administered stat. The note further revealed that the resident slept after receiving a shower and, upon waking, had another bowel movement. The stool was described as very dark and tarry. The resident stated he was unable to feel the urge to have a bowel movement and could not control his bowels. Review of Resident #107's July 2026 electronic medication administration record (EMAR) revealed that on 07/24/2026 at 8:00 p.m., S5LPN documented #3 indicating black, tarry stool, and #9 indicating see progress note/other, on the EMAR for the physician order to monitor for signs of bleeding related to anticoagulant therapy.On 07/25/2026 at 4:00 a.m., S4LPN documented on Resident #107's July 2026 EMAR #3 indicating black, tarry stool, for the physician order to monitor for signs of bleeding related to anticoagulant therapy. Review of Resident #107's laboratory results dated [DATE] revealed a critical hemoglobin of 4.0 g/dL and hematocrit of 13.8%. Review of Resident #107's EHR revealed a progress note created by S2DON on 07/27/2026 at 10:23 a.m. which read in part. Resident had blood drawn this a.m. Notified by lab that resident has critical H and H of 4.0 and 13.8. Resident is awake/alert with confusion noted. Progress note further revealed S6NP was notified on 07/27/2026 at 10:22 a.m. of critical laboratory values and gave order to send Resident #107 out to the emergency room. Review of Resident #107's emergency department paperwork from Hospital #1 dated 07/27/2026 at 11:25 a.m. revealed the resident was transferred for black/tarry stool and critically low hemoglobin and hematocrit. Hospital documentation indicated a hemoglobin of 4.4 g/dL and findings consistent with a GI bleed. The resident was transfused with packed red blood cells (PRBCs).Further review of Hospital #1 documentation revealed Resident #107 was transferred on 07/27/2026 to Hospital #2 due to the need for specialized GI services and ICU placement.Review of Resident #107's records from Hospital #2 revealed the resident was diagnosed with a GI bleed and acute blood loss anemia. The resident was administered Balfaxar (a blood clotting medication) and received 2 units of PRBCs. Critical care was contacted for ICU admission due to the resident's critically low hemoglobin. On 08/19/2026 at 2:47 p.m., an interview with S5LPN revealed she was familiar with Resident #107 and the care he required. S5LPN stated that on 07/24/2026, she was assigned to care for Resident #107 when he experienced a change in status. S5LPN stated the resident had multiple bowel movements and a change in mental status. She described the resident's stool as dark, tarry, and having a very foul smell. S5LPN stated she could not recall whether she reported the dark, tarry stools to S6NP.On 08/20/2026 at 9:38 a.m., a telephone interview with S4LPN revealed she worked from 10:00 p.m. on 07/24/2026 through 6:00 a.m. on 07/25/2026 and was assigned to care for Resident #107. S4LPN stated a CNA notified her that Resident #107 had a bowel movement and the stool was black and tarry. When asked whether she knew why a resident would have black, tarry stool, S4LPN stated, A possible bleed. S4LPN confirmed she did not notify the medical provider of Resident #107's black, tarry stool and stated she should have.On 08/19/2026 at 3:14 p.m., an interview with S6NP revealed she was notified on Friday, 07/24/2026, that Resident #107 was exhibiting unusual behaviors, including wiping feces on the bed and wall, refusing medications, and having stable vital signs. S6NP stated she remained in contact with the nurses throughout the weekend of 07/25/2026 and 07/26/2026 and was only notified that Resident #107 was refusing medications. S6NP stated she was never notified by S5LPN or any other nurse that Resident #107 was having dark, tarry stools. S6NP stated that if she had been notified on 07/24/2026 through 07/26/2026 that Resident #107 was having dark, tarry stools, she would have ordered laboratory work STAT and/or sent Resident #107 to the hospital. On 08/19/2026 at 5:19 p.m., an interview with S2DON revealed she was not aware, until the time of the interview, that the medical provider had not been notified that Resident #107 was experiencing dark, tarry stool on 07/24/2026 and 07/25/2026. S2DON confirmed when a resident is receiving anticoagulant medication and develops dark, tarry stool, the finding should be communicated to the medical provider immediately. The facility has implemented the following actions to correct the deficient practice:Resident #107 transferred to a local hospital on [DATE].Facility has completed a root cause analysis on 08/19/2026 at 08:30 p.m. to identify the cause of the failure was the nurse failed to follow the policy related to reporting a change in condition accurately.The Director of Nurses and/or Designee will audit all residents (100%) to ensure there are no significant changes that require provider notification. This will be completed on 08/20/2026.The Director of Nurses completed in-services with the nurse using the facility's policy (Change in a Residents Condition or Status) on the current evening shift on 08/19/2026. The Director of Nurses and/or Designee will call and in-service nurses on the oncoming night shift (Completed by 08/19/2026) and the oncoming dayshift (08/20/2026) prior to their shift starting. Completed by 08/20/2026. The Director of Nurses and/or Designee will provide retraining regarding notifying the provider of abnormalities identified on medication monitoring orders.Director of Nursing and/or Designee will continue in-servicing nurses prior to beginning of their shift regarding notification of the provider for residents experiencing a significant change in health status. Completion date on going. Implemented 08/19/2026The Director of Nurses and/or Designee will audit at least 10 residents per day for 2 weeks to ensure there are no significant changes that require provider notification. This information will be presented to the QAPI Committee to determine future frequencies. Completion date on-going. No other residents were affected by the deficient practice.Areas of concern will be reported to the Quality Assurance Committee for additional education and monitoring. The Quality Assurance Committee will meet weekly beginning 8/19/2026 to evaluate the process for recommendations, revisions, or resolutions.Completion Date: 08/20/2026 with monitoring and training ongoing. The likelihood of the remaining 106 residents being affected is significantly decreased on 08/20/2026 at 10:00 a.m., by a 100% record review without any negative findingsThe Immediate Jeopardy was removed on 08/20/2026 at 1:05 p.m., when the facility submitted an acceptable Plan of Removal (POR). Through observation, record review, and interview, the survey team determined the facility had initiated and/or implemented the corrective actions identified in the POR.

Based on observations and interviews, the facility failed to ensure medications and wound care products were stored in accordance with currently accepted professional principles. The facility failed to ensure:1. Treatment carts were free from expired wound care products and medications; and2. Prescription medication had a pharmacy label and was stored in original packaging.A review of the facility policy titled Storage of Medication, revised [DATE], revealed in part. The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.A review of facility policy titled Labeling of Medication Containers, revised [DATE], revealed in part. All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. 2. Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. Labels for individual resident medications include all necessary information, such as: a. the resident's name. b. The prescribing physician's name; c. The name, address, and telephone number of the issuing pharmacy; e. The prescription number (if applicable); f. The date the medication was dispensed; i. directions for use.1.On [DATE] at 12:06 p.m., observation of Cart A with S6 Treatment RN revealed the following:- Ten Petroleum Gauze dressings with expiration date of 08/2024.- Five 6-inch x 6-inch Extra absorbent adhesive pads with an expiration date of [DATE].- One 8-inch x 10-inch Silicone Super Absorbent Dressing with an expiration date of [DATE].- Ten Excel Silicone Superabsorbent dressings with an expiration date of [DATE]. - Eight Excel Silicone Superabsorbent dressings with an expiration date of [DATE].On [DATE] at 12:10 p.m., S6 Treatment RN confirmed the above listed wound care products stocked on Cart A were expired, and should not have been. On [DATE] at 12:15 p.m., observation of Cart B with S6 Treatment RN revealed one 473 ml bottle of Dakin's Solution Half Strength with an expiration date of [DATE]. S6 Treatment RN confirmed that the Dakin's Solution Half Strength stocked on Cart B was expired, and should not have been.2.On [DATE] at 12:50 p.m., observation of Cart C with S7 RN revealed one tube of Diclofenac Sodium Topical Gel 1% without the original product box and pharmacy label. The tube of medication read in part . RX Only, indicating the medication was a prescription, and USE DOSING CARD INSIDE CARTON. S7 RN confirmed that the prescription medication should have been stored in the original packaging for proper storage and dosing, but was not. S7 RN confirmed the prescription medication should have had a pharmacy label, and did not. In an interview on [DATE] at 2:03 p.m., S1 DON confirmed expired items were present on facility treatment and medication carts and should not have been. S1 DON confirmed that the prescription medication Diclofenac Sodium Topical Gel 1% should have been stored in the original product packaging for proper storage and dosing, and was not. S1 DON confirmed that the prescription medication Diclofenac Sodium Topical Gel 1% should have had a pharmacy label, and did not

Based on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (Resident #44) of 4 (Resident #44, Resident #48, Resident #87, and Resident #90) resident's reviewed for accidents. The facility failed to ensure Resident #44 had a call light in reach in order to call for assistance. The total sample size was 41. Findings:Review of the facility's current policy titled Call light/Call Pager Systems with effective date of 09/09/2022 read in part. To provide a means of communication to staff for notification of resident needs and a system of communication of staff in the facility; including emergency notifications. The call system must be accessible to residents while in their bed or other sleeping accommodations within the resident's room.Review of Resident #44's medical record revealed an admission date of 04/15/2024. Resident #44 had diagnoses that included in part . Hemiplegia affecting Left Non-dominant Side, Cerebral Infarction due to Thrombosis of Right Middle Cerebral Artery, Generalized Muscle Weakness, Unsteadiness on Feet, and Repeated Falls.Review of Resident #44's Quarterly MDS with ARD of 08/13/2025 revealed Resident had a BIMS of 09, indicating moderate cognitive impairment. Resident #44 had upper and lower extremity range of motion impairment on one side. Resident #44 required substantial/maximal assistance from staff for chair/bed to chair transfers.Review of Resident #44's Comprehensive Person Centered Care Plan revealed in part.I am at risk for falls related to hemiplegia affecting left non dominant side and generalized weakness. Interventions: Follow facility fall protocol. I need a safe environment with a working and reachable call light. I will have my call light within reach.Review of Resident #44's Fall Risk Evaluation Report dated 08/12/2025 revealed Resident #44 was determined at risk for falls. Review of Resident #44's Departmental Progress Notes revealed in part.09/07/2025 9:38 a.m. S9 LPN documented in part; Front desk notified this nurse that resident's daughter called and said her mom was on the floor and needed help. Resident was trying to elevate legs in recliner, due to chair being too close to the wall, resident slid out of chair on the floor.09/07/2025 9:40 a.m. S9 LPN documented in part; Post Fall Evaluation- Bedside call light on when Resident was found: No.Interview on 09/08/2025 at 10:35 a.m. with Resident #44 revealed on 09/07/2025 she had a fall when she slipped out of her recliner. Resident #44 stated she did not have her call light by her, so she had to call her daughter from her cellphone to get help off of the floor.Observation on 09/09/2025 at 9:05 a.m. of Resident #44 revealed she was sitting up in her wheelchair that was located in the middle of her room. Resident #44's call light was not within reach of resident and was observed hanging on the wall, on the call light box, on the left side of her bed. Resident #44 stated she could not reach her call light, and that staff forgot to give it to her when they got her out of bed and into her wheelchair this morning.Interview on 09/09/2025 at 9:19 a.m. with S4 LPN confirmed Resident #44 had a fall on 09/07/2025 when she slipped out of her recliner, and no injury had occurred. Observation of Resident #44's room with S4 LPN confirmed resident's call light was not in reach of resident, but should be.

Based on record review and interview, the facility failed to ensure that residents with an order for psychotropic medication were not subjected to chemical restraints for 1 (#75) of the 5 residents (#4, #5, #12, #38, #75) reviewed for unnecessary medications. The facility failed to:1. Ensure as needed or PRN (pro re nata) orders for a psychotropic medication were limited to 14 days for Resident #75.Findings:Resident #75Review of the facility's policy titled, Psychotropic and Antipsychotic Medications and Non-pharmaceutical Intervention, Revision #5, with an effective date of 01/25, reveals in part under the section heading, PRN Psychotropic Medications.if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.Review of Resident #75's medical record revealed a readmission date of 05/09/2022 with diagnoses that included, in part, Parkinson's Disease with dyskinesia, without mention of fluctuations; Psychotic Disorder with delusions due to known physiological condition; Bipolar Disorder, current episode mixed, severe, with psychotic features; General Anxiety Disorder; Major Depressive Disorder; and Muscle Weakness.Review of Resident #75's current medication orders revealed in part, an order for as needed or PRN Trazodone HCl Oral Tablet 50 MG (milligram) (a medication given to treat major depressive disorder) with directions to Give 1 tablet by mouth every 24 hours as needed for Anxiety/Depression/Insomnia/Paranoia related to psychotic disorder with delusions due to known physiological condition; Bipolar Disorder, Current Episode Mixed, Severe, with Psychotic Features; Major Depressive Disorder, Recurrent, Unspecified Take at bedtime. The order had a start date of 03/25/2025 with no end date indicated.Review of the 05/27/2025 Gradual Dose Reduction initiated by the pharmacist and signed on 06/23/2025 by the physician, revealed the following, in part.7. Trazodone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth every 24 hours as needed for Anxiety/Depression/Insomnia/Paranoia. Take at bedtime. (Please provide a specific duration/stop date)8. (PRN Psychotropic: is limited to 14 days and requires the prescriber to evaluate the resident prior to extending the order; if extending, document the rationale for the extended time period in the medical record and indicate a specific duration).Review of Resident #75's medical record revealed there was no rationale provided for the continuation of the as needed Trazodone by the attending physician or prescribing practitioner to extend the orders past 14 days.On 09/10/2025 at 12:45 p.m., S1 DON was notified about the PRN psychotropic medication for Resident #75, and she confirmed that the PRN psychotropic medication was not limited to 14 days.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #42 and Resident #70) of 3 (Resident #24, Resident #42, and Resident #70) sampled residents reviewed for respiratory care. The facility failed to ensure physician orders were followed for oxygen administration for Residents #42 and #70, and that oxygen equipment was stored appropriately for Resident #70.Findings: Review of the facility's undated policy titled, “Oxygen Administration,” read in part…Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Resident #42 Review of Resident #42's medical record revealed an admit date of 08/23/2024 with a re-entry date of 08/06/2025 with diagnoses that included in part .Heart Failure, Chronic Respiratory Failure with Hypoxia, and Pleural Effusion in Other Conditions. Review of Resident #42's 09/2025 Physician orders revealed the following orders in part .07/14/2025 Oxygen: Oxygen at 2 liters/nasal cannula. Review of Resident #42's Significant Change MDS with an ARD of 08/12/2025 revealed a BIMS summary score of 15 indicating intact cognition. Resident #42 required oxygen therapy. Observation on 09/08/2025 at 10:48 a.m. revealed Resident #42 lying in bed awake and alert with oxygen infusing via nasal cannula. Resident #42 stated he required continuous oxygen at 2liters/minute. Oxygen concentrator observed with oxygen set at 3 liters/minute. Observation on 09/08/2025 at 3:46 p.m., revealed Resident #42 lying in bed asleep wearing a nasal cannula with oxygen infusing at 3 liters/minute via oxygen concentrator. Observation on 09/09/2025 at 8:27 a.m., revealed Resident #42 lying in bed asleep on room air. Nasal cannula observed next to Resident #42. Oxygen concentrator observed on and oxygen infusing at 3 liters/minute. Interview on 09/09/2025 at 8:31 a.m., with S3 LPN revealed Resident #42 wore oxygen continuously and staff made frequent rounds on Resident #42. S3 LPN stated Resident #42 was originally on 3 liters/minute and requested to have his oxygen down to 2 liters/minute. S3 LPN revealed Resident #42 was ordered oxygen at 2liters/minute. S3 LPN stated all staff are required to follow the physician orders for oxygen administration and that Resident #42 should currently be on 2 liters/minute. S3 LPN observed Resident #42's oxygen concentrator and confirmed that the oxygen concentrator was set at 3 liters/minute and should have been on 2 liters/minute. Resident #70 Review of Resident #70's medical record revealed an admission date of 07/24/2020. Resident #70 had diagnoses that included in part… Chronic Respiratory Failure with Hypoxia, and COPD (Chronic Obstructive Pulmonary Disease). Review of Resident #70's Quarterly MDS with ARD of 07/09/2025 revealed the resident had a BIMS of 08, indicating moderate cognitive impairment. Resident #70 was not coded for refusals of care. Resident#70 received oxygen therapy. Review of Resident #70's current 09/2025 physician orders revealed in part… Order date: 07/14/2024: Oxygen every shift at 2L/NC, may remove for bathing and ADL care. Order date: 04/24/2023: Ensure resident has continuous oxygen in place at all times. Every 4 hours for low oxygen saturation. Order Date: 04/09/2025: Respiratory Therapy 7 days a week, 2 times a day for 15 minutes. Review of Resident #70's Comprehensive Person Centered Care Plan revealed in part… I am currently receiving respiratory therapy services related to diagnoses of: COPD, Chronic Respiratory Failure with Hypoxia, and Pneumonia. Interventions: Oxygen Settings: Administer Oxygen as ordered by the MD. I am high risk for falls related to history of falls, poor balance, increased weakness, and diagnosis of dementia. Interventions: Nurse to ensure oxygen is in place while resident is in bed. Nurses are educated to ensure resident has continuous oxygen in place at all times due to increased confusion from oxygen deprivation. Observation on 09/08/2025 at 10:42 a.m. of Resident #70 revealed her nasal cannula oxygen tubing was lying uncovered and draped over the first drawer of her nightstand beside her bed. Resident #70 was observed sitting up in her recliner without oxygen therapy being administered. Resident #70 stated she always wore oxygen, and did not know why staff did not give her oxygen back to her when they assisted her out of her bed to her chair this morning. Observation on 09/08/2025 at 3:50 p.m. revealed Resident #70 remained out of bed, sitting in her recliner without oxygen therapy being administered as ordered. Resident #70's nasal cannula oxygen tubing remained uncovered, draped over the first drawer of her nightstand. Interview on 09/08/2025 at 3:57 p.m. with S9 LPN confirmed Resident #70 should be wearing oxygen at 2L per nasal cannula continuously, and if not in use the oxygen tubing should have been stored covered within a bag, but was not. Observation on 09/09/2025 at 9:11 a.m. of Resident #70 revealed she was without oxygen therapy as ordered, and the oxygen tubing was laid uncovered draped over the top of her oxygen concentrator machine. Observation on 09/09/2025 at 4:15 p.m. of Resident #70 revealed she was without oxygen therapy as ordered, and the oxygen tubing was laid uncovered draped over the top of her oxygen concentrator machine. Observation on 09/10/2025 at 8:35 a.m. of Resident #70 revealed she was without oxygen therapy as ordered. Interview on 09/10/2025 at 8:40 a.m. with S3 LPN confirmed Resident #70 was without oxygen therapy as ordered, and confirmed according to physician orders, Resident #70 was to wear oxygen continuously.

.Based on record review, observation, and interview, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. During a COVID outbreak, the facility failed to ensure:1. Staff performed hand hygiene between residents while preparing and serving lunch trays to residents; and2. Staff donned PPE appropriately while preparing and serving lunch trays to residents.This deficient practice had the potential to affect all 12 residents who resided in Neighborhood X.Findings:On 09/10/2025, a review of the facility's policy titled Infection Control Interim Policy for Coronavirus dated 02/21/2025 revealed in part.Source control options for HCP (health care professional) include.a well-fitting facemask.On 09/10/2025, a review of the facility's policy titled Handwashing/Hand Hygiene revised 08/2015 revealed in part.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.7. Use alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: o. before and after eating or handling food; p. before and after assisting a resident with meals. In an interview on 09/10/2025 at 10:35 a.m., S3 LPN confirmed there were 7 positive cases of COVID at this time in Neighborhood X. Observation in Neighborhood X on 09/10/2025 at 11:30 a.m., revealed S8 CNA wearing a surgical mask covering her mouth and chin, but not covering her nose. S8 CNA filled a glass with water, covered it with plastic wrap, placed the glass on a lunch tray, and then carried the tray to the door of a resident's room. S8 CNA passed the tray to another CNA in the resident's room. S8 CNA then returned to the kitchen counter and repeated these steps twice more without washing or sanitizing her hands. At 11:35 a.m., S8 CNA entered a resident's room. Upon exiting the room, S8 CNA returned to the kitchen counter, without washing or sanitizing her hands. S8 CNA removed plastic wrap from the box and covered the drink for the next resident's lunch tray. S8 CNA then touched the kitchen counter, put her hands in her pockets, then prepared and served lunch trays without sanitizing her hands. In an interview on 09/10/2025 at 11:36 a.m., S8 CNA confirmed her mask was not covering her nose and stated I chew gum so my mask falls down a lot. S8 CNA confirmed she prepped the glasses of water and delivered multiple lunch trays without gelling or washing her hands between trays. S8 CNA stated it gets crazy and I forgot. S8 CNA confirmed she should have sanitized her hands. In an interview on 09/10/2025 at 11:43 a.m., S2 LPN confirmed she was the facility's Infection Preventionist. S2 LPN was notified of the lunch observations on Neighborhood X. S2 LPN acknowledged S8 CNA was not wearing her mask properly and not performing hand hygiene between resident trays, but should have.

Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) out of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents, by failing to ensure she was free of facial hair and by failing to honor her food choices. Findings: Review of the facility's policy titled Dignity with a revision date of 02/2021 revealed in part .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 1. Residents are treated with dignity and respect at all times. 2. The facility culture supports dignity and respect by honoring resident goals, choices, preferences, values and beliefs. 5. When assisting with care, residents are supported in exercising their right, for example, residents are: groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). 1. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included: Type 2 Diabetes Mellitus, Pressure Ulcer of Sacral Region Stage 3, Chronic Kidney Disease Unspecified, Dysphagia following Cerebral Infarction, and Malignant Neoplasm of Unspecified Ovary. Review of Resident #1's Quarterly MDS with an ARD of 08/23/2024, revealed she had a BIMS score of 5 (indicating severe cognitive impairment). The MDS revealed Resident #1 required substantial/maximal assistance with oral hygiene, bathing, dressing and personal hygiene; and dependent for toileting hygiene. Partial/moderate assistance with eating. Resident #1's MDS coded for with no behaviors. Review of Resident #1's care plan revealed she required assistance with personal hygiene, eating, grooming/dressing, and bathing as needed. Observation and interview on 10/17/2024 at 10:20 a.m. revealed Resident #1noted to have long chin hair approximately half an inch long. S2 CNA revealed she had just bathed Resident #1, and had not offered to remove Resident #1's facial hair. S3 LPN entered the room and confirmed Resident #1 had long chin hair approximately half an inch long. 2. Review of Resident #1's current physician's orders read in part .Ice Cream one time a day for weight loss, administer with lunch tray. Telephone interview on 10/21/2024 at 8:21 a.m. with Resident #1's Responsible Party, revealed Resident #1 did not like ice cream. Observation on 10/21/2024 at 11:33 a.m. revealed, Resident #1 had two bowls of ice cream with her lunch tray. Interview on 10/21/2024 at 1:05 p.m. with S2 CNA revealed Resident #1 did not eat the ice cream at lunch time, and that Resident #1 didn't like ice cream. Interview on 10/21/2024 at 2:25 p.m. with S4 RN Clinical Coordinator revealed, she was aware of Resident #1's dislike of dairy products. Interview on 10/21/2024 at 2:53 p.m. with S1 DON revealed, she was aware of Resident #1's dislike of dairy products, but continued to serve different flavors to Resident #1 due to the Registered Dietician's recommendation to give ice cream with lunch tray. Telephone Interview on 10/21/2024 at 3:23 p.m. with S5 Registered Dietician revealed she was not aware of Resident #1's dislike of ice cream. S5 Registered Dietician revealed ice cream was not listed on Resident #1's diet order details.

Based on observation, interview, and record review the facility failed to ensure that all Residents who were unable to carry out ADLs (Activities of Daily Living) received necessary services to maintain good grooming and personal hygiene. The facility failed to provide trimmed nails and oral care to dependent Residents for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents. Findings: Review of the facility's policy titled Activities of Daily Living (ADLs), Supporting with a revision date of 03/2018 revealed in part . Policy Statement Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out Activities of Daily Living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of Resident #1's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Type 2 Diabetes Mellitus, Pressure Ulcer of Sacral Region Stage 3, Chronic Kidney Disease Unspecified, Dysphagia following Cerebral Infarction, Malignant Neoplasm of Unspecified Ovary and Aphasia following Cerebral Infarction. Review of Resident #1's Quarterly MDS with an ARD of 08/23/2024 revealed she had a BIMS score of 5 (indicating severe cognitive impairment). The MDS revealed Resident #1 required substantial/maximal assistance with oral hygiene, bathing, dressing and personal hygiene; and dependent for toileting hygiene. Resident #1's MDS coded with no behaviors. Review of Resident #1's care plan revealed she required assistance with personal hygiene, grooming/dressing, and bathing as needed with approaches that included assist me with bed mobility, toileting, eating, personal hygiene, grooming/dressing, and bathing as needed. Observation and interview on 10/17/2024 at 10:20 a.m. revealed Resident #1 lying in bed fully dressed. Resident #1 noted to have a dried brown substance around her mouth and fingernails approximately one inch long. S2 CNA revealed she had just bathed Resident #1. S2 CNA revealed the dried brown substance around Resident #1's might have been food. S3 LPN entered room and confirmed Resident #1 had a dried brown substance around her mouth and fingernails were long. S3 LPN asked Resident #1 if she would like her nails cleaned and trimmed and Resident #1 shook her head yes. Telephone interview on 10/21/2024 at 8:21 a.m. with Resident #1's Responsible Party revealed the facility had not notified her of Resident #1 ever refusing nail care.

Based on interview and record review the Facility failed to ensure that a Resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable weight range for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents. Findings: Review of the Facility policy titled: Weight Assessment and Intervention, with a revision date of 03/2022 revealed in part . Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain. Policy Interpretation and Implementation: Weight Assessment 1. Residents are weighed upon admission and readmission to the facility, as well as weekly x 4 after admission and readmission. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: A. 1 month - 5% weight loss is significant; greater than 5% is severe. B. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe. Review of the Weight Assessment and Intervention policy revealed there were no additional instructions for obtaining weights after instructions listed in #1 above. Resident #1 Review of Resident #1's medical record revealed she was admitted to the facility on [DATE], with diagnoses that included: Anorexia, Type 2 Diabetes Mellitus, Pressure Ulcer of Sacral Region Stage 3, Chronic Kidney Disease Unspecified, Dysphagia following Cerebral Infarction, Malignant Neoplasm of Unspecified Ovary, and Aphasia following Cerebral Infarction. Review of Resident #1's Quarterly MDS, with an ARD of 08/23/2024, revealed she had a BIMS score of 5 (indicating severe cognitive impairment). The MDS revealed Resident #1 required partial/moderate assistance with eating. Review of Resident #1's care plan (with no review date listed), revealed in part . I am at risk for a nutritional problem related to diagnoses: Anorexia, Dysphagia, and Diabetes, and poor appetite at times. Approaches included: Monitor/record/report to MD PRN if exhibit signs and symptoms of significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Review of Resident #1's weights revealed the following: 08/19/2024 = 131.5 pounds (return from the hospital on 08/17/2024). 09/05/2024 = 125 pounds (6.5 pound/4.9% weight loss in 2 weeks). Review of Resident #1's medical record revealed Resident #1 was not weighed upon readmission to the facility from a hospital stay, and was not weighed weekly times four upon readmission to the facility on [DATE], as directed in the Facility's Weight Assessment and Intervention Policy. Review of the Registered Dietician's Progress Note dated 09/05/2024, revealed in part . Ensure clear 4 ounces BID added on this date. Interview on 10/21/2024 at 2:41 p.m. with S1 DON, revealed the facility's procedure was to weigh all new admissions and readmissions within 24 hours of returning to the facility; record the weight, and then weigh weekly for four weeks. S1 DON confirmed Resident #1 should have been weighed on 08/17/2024 or 08/18/2024 (within 24 hours of returning from the hospital), and was not weighed until 08/19/024. S1 DON confirmed Resident #1's weight on 08/19/2024 was 131.5 pounds, and that she was not weighed again until 09/05/2024. S1 DON stated Resident #1's weight was 125 pounds, a 6.5 pound and 4.9% weight loss in 16 days. S1 DON confirmed Resident #1 was not weighed weekly when she returned from the hospital. Resident #3 Review of Resident #3's medical record revealed he was admitted to the facility on [DATE], with diagnoses which included: Heart Failure, Hypertension, Anemia, Major Depressive Disorder, Unspecified Atrial Fibrillation, Chronic Kidney Disease Stage 3, Hyperlipidemia, and Transient Cerebral Ischemic Attack Unspecified. Review of Resident #3's Admission MDS with an ARD of 09/04/2024, revealed a BIMS score of 11 (indicating moderate cognitive impairment). The MDS revealed Resident #3 required setup or clean-up assistance with eating. Review of Resident #3's care plan (with no review date listed), revealed in part .I have a potential for a nutritional problem related to poor appetite at times with approaches that included: Monitor/record/report to MD PRN if exhibit signs and symptoms of significant weight loss: 3 pounds in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Review of Resident #3's weights revealed the following: 08/23/2024 = 148.8 pounds (admission weight) 09/05/2024 = 145 pounds 10/11/2024 = 136.2 pounds Review of the Registered Dietician's Progress Note dated 10/11/2024 read in part .Trigger for significant weight loss noted. Current weight 136.2 pounds (10/11/2024) 8.8 pounds weight loss in the past month. House supplement 4 ounces once daily added on this date. Recommend add double desserts to meals. Interview on 10/21/2024 at 2:41 p.m. with S1 DON, confirmed Resident #3's weight on 09/04/2024 was 145 pounds, and he was not weighed again until 10/11/2024. Resident #3's weight on 10/11/2024 was 136.2 pounds, a 8.8 pound and 5.9% weight loss in 36 days. S1 DON revealed the facility's procedure was to weigh all new admissions and readmissions within 24 hours of returning to the facility; record the weight, and then weigh weekly times four weeks. S1 DON confirmed Resident #3 had not been weighed weekly for four weeks, but should have been.

Based on observation, record review, and interview, the facility failed to ensure residents obtained routine dental services for 1 (Resident #89) of 2 (Resident #89 and Resident #98) sampled residents for dental. Total sample size was 26. Findings: The Facility's Policy Titled Dental Examination/Assessment with a Revision date of December 2013, read in part . Policy statement: Each resident shall undergo a dental assessment prior to or within 90 days of admission. Policy Interpretation and Implementation: 1. Resident shall be offered dental services as needed. Review of Resident #89's clinical record revealed an admitted [DATE] with diagnoses which included in part: Type 1 Diabetes Mellitus, Hypertension, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominant side. Review of Resident #89's Quarterly MDS with an ARD of 05/29/2024 revealed a BIMS score of 14 indicating intact cognition. Resident #89 required setup or clean-up assistance with meals and oral hygiene. Review of Resident #89's care plan with a target date of 08/08/2024 read in part .I am at risk for oral/dental health problems related to poor oral hygiene with approaches that included arrangements coordinated for dental care, transportation as needed. Observation and interview on 07/08/2024 at 10:47 a.m. revealed Resident #89 was edentulous. Resident #89 stated he was [AGE] years old and had not seen the dentist since he was admitted to the facility. Resident #89 stated he would like to be seen by the dentist for dentures. Review of Resident #89's Dental progress notes revealed Resident #89 had scheduled dental appointments on 03/09/2024 and the appointment was rescheduled, for 09/07/2023 with no documented reason of why. On 09/07/2023, Resident #89 was not seen by the Dentist as the dental progress notes read in part . 09/07/2023 patiently currently in patient care. Will reschedule. Review of Resident #89's Dental Visit Notification Forms revealed the following: 09/07/2024- Therapy Conflict (Resident #89 was in therapy). 10/25/2024-Time conflict (Dentist ran out of time before Resident #89 could be seen). 01/26/2024-Resident #89 not seen due to scheduling (Dentist ran out of time). Interview on 07/09/2024 at 1:47 p.m. with Resident #89 revealed he had spoken to the staff (unable to recall the date and/or staff) requesting to see the dentist and as of today, he was still waiting on a reply and/or on an appointment. Interview on 07/09/2024 at 1:50 p.m. with S9 RN confirmed after reviewing Resident #89's dental progress notes that Resident #89 had not been seen by a dentist since admission and should have been. Interview on 07/09/2024 at 1:55 p.m. with S8 Social Worker revealed she was uncertain as to why Resident #89's appointments had been rescheduled and he had not been seen by a Dentist before now. After reviewing Resident #89's Dental Visit Notification Forms, S8 Social Worker confirmed Resident #89 should have been seen by the Dentist. Interview on 07/09/2024 at 3:00 p.m. with S5 DON confirmed that Resident #89 had been scheduled but was not seen and/or had a Dental assessment within 90 days of his admission to the facility and should have.

Based on observation and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings: Review of the facility's policy dated ,d+[DATE] titled Food Service Operational Standards for Purchasing, Cooking and Storage read in part: Policy: The facility stores, prepares, distributes and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. Procedure: 8. Cooling and storing - g. Label and store foods with the date and time they were prepared to indicate when to discard. Review of the facility's policy dated ,d+[DATE] titled Storage of Cooked Foods read in part: Procedure: 5. Discard food that has exceeded maximum storage time. j. Gravy - Discard. Review of the facility's policy dated ,d+[DATE] titled Food Receiving and Storage read in part: Policy Statement - Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation - 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (received and/or open date). Observation on [DATE] at 8:55 a.m. of the facility kitchen with S3 Dietary Manager revealed the following expired items noted in the pantry and in the reach in refrigerator: Plate Scraper - 2 cans - expired [DATE] Tomato Paste 12 ounce cans - 20 cans - expired [DATE] and [DATE] Potato Salad - 1 gallon - expired [DATE] Garlic in Water - 2 jars - expired [DATE] 1 unlabeled, undated pitcher of prepared brown gravy Interview on [DATE] at 9:45 a.m. with S3 Dietary Manager confirmed the above findings. S3 Dietary Manager stated the items should have been disposed and were not.

Based on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to wait until all residents eating at a table were finished with their meal before picking up trays. Total sample size was 26. Findings: Observation of X Hall dining room on 07/09/2024 at 11:43 a.m. revealed S7 CNA removing plates from the dining table, while other residents at the same dining table were still eating. Interview on 07/09/2024 at 11:45 a.m. with S7 CNA revealed she did not know she should wait until all residents at the dining table were finished eating before removing their plates. Interview on 07/09/2024 at 11:50 a.m. with S10 LPN confirmed S7 CNA should have waited until all residents at the dining table were finished eating, before removing any plates from the table. Interview on 07/10/2024 at 1:40 p.m. with Resident #57 who had a BIMS score of 14 (indicating intact cognition), revealed on yesterday (07/09/2024) when S7 CNA started removing plates from the dining table while she was still eating, it made her feel rushed to finish eating.

Based on interview and record review, the facility failed to ensure a personal funds statement was provided quarterly for 1(#24) of 1 resident reviewed for personal funds. Findings: Review of an undated facility policy titled Resident Trust Fund Policy/Procedure [NAME] read in part: .Quarterly Statements. The facility provides a written statement quarterly to each resident or authorized representative within 30 days after the end of the quarter. A copy is also filed in the resident's trust fund folder. The quarterly statement includes the following: balance at the beginning of the statement period, total deposits and withdrawals, interest earned, if any, and ending balance. A Resident Trust Fund Quarterly Statement Distribution Form should be signed and dated by the Administrator and two witnesses indicating that the quarterly accounting statements have been distributed and the completed form is to be kept in the Administrative office with the trust fund records . Review of Resident #24's Medical Record revealed she was admitted to the facility on [DATE], with a primary diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation. Review of Resident #24's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/17/2024 revealed Resident #24 had a BIMS (Brief Interview for Mental Status) of 10 (moderately impaired cognition). Interview with Resident #24 on 07/09/2024 at 9:21 a.m. revealed the facility managed her money. Resident #24 stated she was admitted to the facility approximately 6 months ago and had not received a quarterly account statement. Interview with S2 Administrative Assistant, on 07/09/2024 at 10:30 a.m. revealed she was responsible for sending out quarterly account statements. S2 Administrative Assistant indicated that she mailed the statements out to the resident's responsible party quarterly. S2 Administrative Assistant stated for residents that were their own RP, she provided account balances when resident's came to request money. S2 Administrative Assistant indicated she did not have a system for residents that were their own responsible party, to receive quarterly statements. S2 Administrative Assistant indicated that Resident #24 had withdrawn money on 04/21/2024, 04/23/2024 and 04/24/2024, and thinks she would have given Resident #24 an account balance then, but could not confirm Resident #24 received a quarterly statement. Interview with S1 Administrator, on 07/09/2024 at 4:20 p.m. revealed he signed the Trust Fund Quarterly Statement Distribution Form. S1 Administrator indicated that his signature was acknowledgment he received the statements from cooperate office, but not a verification that the quarterly statements were distributed to residents. S1 Administrator indicated that he had spoken to Resident #24 and verified she did want to receive her statements quarterly. S1 Administrator stated he did not have documentation that Resident #24 received her quarterly statement, but should have.

Based on observation, interview and record review the facility failed to ensure resident equipment, a Pommel cushion, was in good repair for 1 (#49) of 4 (#23, #43, #49 and #85) residents reviewed for environment. Findings: Review of the facility's policy Assistive Devices and Equipment with Revision date January 2020 revealed . c. Device condition- devices and equipment are maintained on schedule and according to manufacturer's instructions. Defective or worn devices are discarded or repaired . Review of the Resident #49's MDS with ARD of 05/21/2024, revealed Resident #49 had a BIMS of 12 which indicated moderate cognitive impairment. Review of Resident #49's current Care Plan revealed .Pommel cushion applied to my wheelchair to aid in the prevention of me slipping out of chair . with start date 09/10/2019. Observation on 07/08/2024 at 10:21 a.m. revealed Resident #49 was seated in his wheelchair with Pommel cushion in place. Resident #49's Pommel cushion had a 3 inch tear along the seam with the inner foam exposed. Observation on 07/09/2024 at 8:43 a.m. revealed Resident #49 was seated in his wheelchair with Pommel cushion in place. Resident #49's Pommel cushion had a 3 inch tear along the seam with the inner foam exposed. Resident #49 stated It's been like that for 2 1/2 to 3 weeks. Interview on 07/09/2024 at 1:00 p.m. with S4 LPN revealed she was responsible for overseeing the care of Resident #49. S4 LPN stated Resident #49's pommel cushion should be inspected and cleaned every day, and replaced if in disrepair. S4 LPN indicated Resident #49's Pommel cushion should have been replaced.

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #26, and Resident #46) of 26 sampled Residents. Findings: Resident #26 Review of Resident #26's medical record revealed an admitted [DATE]. Resident #26 had the following diagnoses in part . Primary Osteoarthritis of Right Shoulder, Retention of Urine, Urinary Tract Infection, Constipation, Paroxysmal Atrial Fibrillation, and Generalized Anxiety Disorder. Review of Resident #26's Quarterly MDS with an ARD of 05/22/2024 revealed Resident #26 had a BIMS of 15 (Cognition Intact). Resident #26 was dependent on staff for toileting. Review of Resident #26's Comprehensive Person Centered Care Plan with a target completion date of 07/16/2024 revealed the following in part . I have constipation. I have occasional diarrhea. Interventions included the following in part . Record my bowel movement pattern each day. Describe amount, color and consistency. Review of Resident #26's medical record revealed she was hospitalized [DATE]- 05/16/2024 with a diagnosis of Fecal Impaction. Review of Resident #26's 05/2024 Bowel and Bladder Elimination Record revealed 14 out of 40 documented bowel movements did not have size and consistency documented. Interview on 07/08/2024 at 9:26 a.m. with Resident #26 revealed she had been recently hospitalized . Resident #26 stated she had stomach issues, and I had to get my belly cleaned out at the hospital. Interview on 07/09/2024 at 2:50 p.m. with S5 DON confirmed CNA's are required to document Bowel Continence, Size, and Consistency of bowel movements on resident's Bowel and Bladder Elimination Record. Review of Resident #26's 05/2024 Bowel and Bladder Elimination record with S5 DON revealed Resident #26's 05/2024 Bowel and Bladder Elimination record did not have documentation to include bowel size and consistency, and it should have been. Interview on 07/10/2024 at 9:59 a.m. with S11 LPN revealed Resident #26 had a history of constipation and diarrhea. S11 LPN stated she sent Resident#26 to the hospital on 05/13/2024 due to the resident vomiting, and not feeling well. S11 LPN stated Resident#26 denied constipation on 05/13/2024, and stated Resident #26 was good about letting staff know if she did not have a bowel movement. Review of Resident #26's 05/2024 Bowel and Bladder Elimination report with S11 LPN. S11 LPN stated Resident #26 had bowel movements on 05/09/2024, and 05/11/2024, but the size and consistency were not documented. S11 LPN confirmed CNA's should document bowel movement size and consistency on the record when documenting bowel movements, but had not. Interview on 07/10/2024 at 2:16 p.m. with S12 CNA revealed she was required to document bowel movement continence, size, and consistency on the Bowel and Bladder Elimination Report, and had failed to do so. 38894 Resident #46 Review of the facility's policy dated 2017 titled Medication and Treatment Orders read in part: Policy Statement - Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation - Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order. Review of Resident #46's EHR revealed an admitted [DATE] with the following diagnoses including: Acute Respiratory Failure and CHF. Review of Resident #46's 07/2024 MD Orders revealed the following including: 08//23/2023 - DNR 04/30/2024 - Admit to All Saints Hospice: Dx: CHF 05/10/2024 - Feeder and assist per staff with all meals 06/17/2024 - MS 100 mg/5 ml Concentrate - give 0.5 ml SL every 2 hours prn pain/air hunger 06/20/2024 - crush medications every shift 06/26/2024 - Lorazepam Oral Concentrate 2 mg/ml Give 0.5 ml sublingually every 4 hours as needed for Anxiety for 14 Days 07/02/2024 - Tramadol HCL 50 mg q 8 hours prn Review of Resident #46's 04/30/2024 - 07/09/2024 Nurse Notes revealed Resident #46 was admitted to hospice on 04/30/2024. On 07/08/2024 there was documentation that stated the MD visited today with new orders to hold medication due to Resident #46 not swallowing; RP notified. Review of Resident #46's 07/2024 e-MAR revealed the Resident #46 had not been given any po medications since 07/08/2024. Review of Resident #46's facility chart revealed no MD order concerning holding medications. Interview on 07/09/2024 at 1:22 p.m. with S6 LPN revealed Resident #46's physician made rounds yesterday (07/08/2024) and gave a verbal order to hold po medications due to Resident #46 having problems swallowing. S6 LPN stated she did not write an order for the verbal order given by Resident #46's physician and she should have.

Based on observation and interview the facility failed to keep all information in the Medical Record confidential for 4 (Resident #92, Resident #74, Resident #57 and Resident #58) 6 residents receiving Dialysis outside of the facility. Total sample size was 26. Findings: Observation on 07/09/2024 at 4:05 p.m. of the facility's front desk revealed a sheet attached to a clip board, which contained 4 Residents full name and the times they needed to be at Dialysis. The list was visible to the public. Visitors were observed at the front desk several times throughout the survey process. The sheet read in part . Dialysis Schedule: Monday, Wednesdays and Friday Resident #92-chair time 6:15 a.m. Resident #74-chair time 11:20 p.m. Tuesdays, Thursdays and Saturdays Resident #57-chair time 5:50 a.m. Resident #58-chair time 11:30 a.m. Interview on 07/09/2024 at 4:05 p.m. with S5 DON confirmed the list with resident's full names and Dialysis times were visible to visitors, and it should not have been.

Based on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. The facility failed to ensure a comprehensive care plan was developed for a resident diagnosed with Chronic Diastolic (CHF) Congestive Heart Failure who required fluid restriction and to be weighed every 3 days. Findings: Review of Resident #1's electronic Medical Record revealed an admitted [DATE] with diagnoses that included: Acute Renal Failure with Hypoxia, Essential Primary Hypertension, Hypo-osmality and Hyponatremia, Type 2 DM, Morbid Obesity due to Excess Calories, Hypotension, Chronic Diastolic Congestive Heart Failure and Chronic COPD with Acute Exacerbation. Review of Resident #1's Physician's Orders for 11/2023 and 12/2023 revealed in part . 10/26/2023 - Fluid restriction 1500ml TID 10/26/2023 - Weigh every 3 days in the morning for monitoring related to Chronic Diastolic CHF. Review of Resident #1's Admission MDS with an ARD of 10/30/2023 revealed a BIMS score of 12 (moderately impaired cognition). Review of Resident #1's Care Plan revealed no care plan developed for Fluid restrictions related to diagnosis of Chronic Diastolic Congestive Heart Failure. Interview on 02/07/2024 at 4:45 p.m. with S3 MDS RN revealed she was responsible for resident care plans. She stated she had not developed a care plan for Resident #1's fluid restrictions and weights every 3 days related to her diagnosis of Chronic CHF and should have. Interview on 02/08/2024 at 11:15 a.m. with S2 ADON revealed S3 MDS RN was responsible for Resident #1's care plan. S2 ADON confirmed Resident #1 was not care planned for 1500ml fluid restrictions and weight every 3 days related to her diagnosis of Chronic CHF and should have been. Interview on 02/08/2024 at 12:20 p.m. with S1 DON confirmed that Resident #1 did not have a comprehensive care plan in place to ensure 1500ml restricted fluids daily that required her to be weighed every 3 days related to her diagnosis of Chronic CHF and should have.

Based on interview and record revealed the facility failed to provide care and services that meet professional standards of practice and quality care for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents reviewed for hydration. The facility failed to ensure a resident diagnosed with Chronic Diastolic Congestive Heart Failure (CHF) with restricted fluids was weighed every 3 days as ordered. Findings: Review of the facility's policy titled, Heart Failure - Clinical Protocol read in part . Assessment and Recognition: 1. As part of the initial assessment, the physician will help identify individuals with a history of heart failure (HF) and will clarify, as much as possible, its severity and underlying causes. Treatment/ Management: 1.The physician will review and make recommendations for relevant aspects of the nursing care plan, for example, what symptoms to expect, how often and what (weights, renal function, etc.) to monitor, when to report findings to the physician, etc. Review of Resident #1's electronic Medical Record revealed an admitted [DATE] with diagnoses that included: Acute Renal Failure with Hypoxia, Essential Primary Hypertension, Hypo-osmality and Hyponatremia, Type 2 DM, Morbid Obesity due to Excess Calories, Hypotension, Chronic Diastolic Congestive Heart Failure and Chronic COPD with Acute Exacerbation. Review of Resident #1's Physician's Orders for 11/2023 and 12/2023 revealed in part . 10/26/2023 - Fluid restriction 1500ml TID 10/26/2023 - Weigh every 3 days in the morning for monitoring related to Chronic Diastolic CHF. Review of Resident #1's Admission MDS with an ARD of 10/30/2023 revealed a BIMS score of 12 (moderately impaired cognition). Review of Resident #1's Care Plan revealed no care plan developed for Fluid restrictions related to diagnosis of Chronic Diastolic Congestive Heart Failure. Review of Resident #1's MARs for 11/2023 and 12/2023 revealed no documentation of weights on: 11/30/2023, 12/15/2023, 12/18/2023, 12/21/2023 and 12/24/2023. Interview on 02/08/2024 at 4:30 p.m. with S2 ADON confirmed the above findings. S2 ADON confirmed Resident #1 was on 1500ml fluid restrictions and required to be weighed every 3 days related to her diagnosis of Chronic Diastolic CHF and was not. Interview on 02/08/2024 at 4:50 p.m. with S1 DON confirmed that Resident #1 had Physician's orders for 1500ml fluid restriction that required her to be weighed every 3 days and was not done as ordered.

Based on interview and record review the facility failed to ensure Resident #3's RP was informed of changes in the resident's condition for 1 (Resident #3) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings: Review of the facility policy titled: Change in Resident's Condition or Status, revealed in part .Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the residents medical/mental condition and/or status. Review of Resident #3's clinical record revealed an admitted [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for orthopedic aftercare following surgical amputation, encounter for attention to gastrostomy and pressure ulcer. Review of Resident #3's quarterly MDS assessment with ARD 08/01/2023 revealed a BIMS score of 12, indicating mild cognitive impairment. Review also revealed Resident #3 was incontinent of bowels of bladder and required assistance with toileting, personal hygiene, bed mobility and transfers. Telephone interview on 10/26/2023 with Resident #3's RP revealed that while performing incontinent care on Resident #3, while out on pass, she noticed a severe rash to Resident #3's buttocks, groin, thighs and under her breast. Resident #3's RP stated she had been given a tube of cream and a small container of powder when she picked up her mother but had no idea Resident #3's skin was in such a terrible state. Review of Resident #3's September Physician's Orders revealed in part .Nystatin Powder (Nystatin bulk) Apply to lower abdominal fold and groin topically two times a day for fungal infection until 09/18/2023. Start date 09/04/2023. Review of a nurses' noted dated 09/03/2023 and documented by S2 LPN revealed in part .Resident c/o itching to left groin area and lower abdominal folds. Fungi, redness and swelling noted to areas. FNP notified of findings. New order for Nystatin BID x 14 days. No c/o pain. Remains afebrile. Call light in reach. Bed in low position. Telephone interview on 10/30/2023 at 10:24 a.m. with S2 LPN revealed she did not remember if she notified Resident #3's family about the fungal rash and new treatment orders on 09/03/2023. S2 LPN stated she normally documents who she calls and their relationship to the resident when she calls a family member about a resident and she had not done so on 09/03/2023 for Resident #3 and should have. Interview on 10/30/2023 at 12:15 p.m. with S1 DON revealed there was no evidence that Resident #3's RP had been notified of her skin impairment and new orders for fungal treatment on 09/03/2023. S1 DON confirmed Resident #3's RP should have been notified and had not been.

Based on record review and interview, the facility failed to supervise Resident # 1, identified as a high elopement risk, to prevent elopement on [DATE] and [DATE], and the facility failed to adequately supervise Resident #3, identified as a high fall risk to prevent an accident that resulted in a major injury, for 2 of 11 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident#5, #R1, #R2, #R3, #R4, #R5, and #R6). I. Elopement This deficient practice resulted in an immediate jeopardy situation on [DATE] at 6:06 p.m. when Resident #1, a cognitively impaired resident who was at risk for elopement and wore a wander guard bracelet, exited the facility unsupervised, and was found approximately 700 feet from the front door of the facility near a free-standing physical therapy center. The immediate jeopardy continued for Resident #1 when she exited the facility again on [DATE] and was discovered outside the facility unsupervised approximately 300 feet away from a side exit door. Resident #1 was discharged on [DATE]. This deficient practice continued at a potential for more than minimal harm for the remaining 10 residents (Resident #2, Resident #3, Resident #4, Resident #5, #R1, #R2, #R3, #R4, #R5, and #R6) identified as elopement risks, and wore wander guard devices. S1 Administrator was notified of the Immediate Jeopardy on [DATE] at 5:50 p.m. The Immediate Jeopardy was removed on [DATE] at 4:30 p.m. after it was verified through observation, interview and record review that the facility submitted and implemented a Plan of Removal that included the following: On [DATE] and [DATE] Resident #1 was able to exit the facility unsupervised while wearing a wander guard bracelet. These incidents have the potential to affect all 10 residents who are at risk for elopement and have been identified with wandering and/or exit seeking behaviors. On [DATE] surveyors identified two malfunctioning exit doors. Supervision for at risk residents had not been increased, therefore the potential for elopement remained for the 10 residents with elopement risk. MD/NP and Responsible Party were both notified in a timely manner after each elopement incident. Residents #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5, and #R6 who were specifically identified to be affected, related to risk for elopement had adequate supervision provided every hour by assigned floor nurses and CNAs to assess for exiting seeking behaviors starting [DATE], so that the staff can account for residents at risk. Residents at risk will be monitored every hour for 2 weeks, then reassessed for the need for continued hourly monitored by Administrator or designee. If no exit seeking behavior is exhibited, resume every 2 hour monitoring. Care plans for residents at risk for elopement updated [DATE] to reflect frequency of monitoring for adequate supervision. Facility conducted a Root Cause Analysis on [DATE] to identify failure for F689. Review of the elopement policy and procedure conducted on [DATE] with no changes needed. Review of the Secure Care Guardian U-DE owner's manual, of exit door locking mechanisms, conducted on [DATE] with no change needed, developed and implemented a monitoring tool to check all exit doors every shift for 7 days, then every day for 7 days, then weekly thereafter by administrator or designee with Regional Director of Operations supervision daily, Monday-Friday, for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month. Education of all staff began immediately on [DATE] to include wandering and elopement policy and procedures, location of elopement binders, including Face Sheet of identified residents at risk for elopement and photo, and Code W procedures completed by DON. Binders are located at incident command center (front desk) and 1 in each neighborhood, totaling 4 in the facility. Administrator or designee will continue in-servicing employees prior to the beginning of shift for conformance with wandering and elopement. Completion date of [DATE]. In reference to above, the Administrator or designee will administer post training evaluation of staff on wandering and elopement policy and procedures and location of elopement binder to be completed before employee begins shift for conformance with wandering and elopement. Quality Assurance Committee met [DATE] and will monitor for elopement risk to prevent the likelihood of serious harm or death weekly for 8 weeks. Administrator in-serviced on elopement policy and procedure by Regional Director of Operations and DON in-serviced by Corporate Nurse on [DATE]. Administrator will be supervised on facility compliance by Regional Director of Operations daily, Monday-Friday, for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month. Requested and received approval on [DATE] to install a [NAME] mag lock system to the C Hall access door to the exit, plans will be submitted to the fire marshal's office for approval of installation. Completion date: [DATE]. Findings: Review of the facility's Wandering and Elopement Assessment/Management/ Security policy dated [DATE] read as follows in part . Elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration, and/or other medical complications, drowning, or being struck by a car. Interventions which address/prevent unsafe wandering/elopement will be developed within the resident care plan for at risk residents. (i.e., supervision/periodic checks, activity programs, exit door alarms, highlight name on census report at nurses' station, Personal signal device, etc.). In facilities with electronic wander alarm systems, residents assessed to be at risk for unsafe wandering may be placed on the Resident Security System as a measure to reduce the risk of harm from unsafe wandering activities. There was no facility policy that addressed the supervision of residents who wandered and/or who wore wander guard devices and were identified at risk for elopement. Resident #1 Review of Resident #1's Face Sheet revealed an admitted [DATE]. Diagnosis included: Alzheimer's disease, Major Depressive D/O, Anxiety D/O, and HTN. Review of Client #1's Risk of Elopement Wandering assessments dated [DATE], [DATE], and [DATE], indicated the resident was a high risk with scores that ranged from ,d+[DATE]. Review of Resident #1's Quarterly MDS with an ARD of [DATE], revealed Resident #1 had a BIMS of 10 (moderate cognitive impairment). Resident #1 required supervision with bed mobility, transfers, walk in room/corridor, dressing, toilet use, personal hygiene, and bathing. The MDS revealed Resident #1 ambulated with use of a walker, and used Wander/elopement alarm daily. Review of Resident #1's Care Plan with target date of [DATE] revealed in part: An elopement risk/wanderer r/t disoriented to place and verbally saying I'm going home, how I get there? The Care Plan indicated the resident had a Dx. Of Dementia, attempted to open doors at times and that the resident wore a wander guard to left ankle at all times. The Care Plan did not include supervision measures staff were to follow. After the [DATE] elopement, the care plan was updated on [DATE] to reflect the addition of a wind chime to the resident's walker to alert staff when resident is ambulating and on [DATE] to reflect the addition of a wander guard to the resident's walker as an extra security measure due to continued exit seeking behaviors. There was no Care Plan intervention for the level of supervision required for Resident # 1, or staff training/inservice of the need for increased supervision except for 1:1 supervision for a brief period of time after each elopement. Review of Resident #1's 2023 Physician's Orders revealed in part: [DATE], [DATE] and [DATE] - Wander Guard to right ankle-verify placement, inspect skin at band location, and confirm signal operation every shift; Review of Resident #1's Progress Notes revealed in part: [DATE] at 10:42 a.m. - Resident continues to stop staff and random visitors at this time asking which way she could exit facility because she needs to go home. Unable to redirect at this time. [DATE] at 6:02 a.m. - Resident awake and wandering around attempting to exit facility and entering other residents' rooms. Redirected with limited success. [DATE] at 6:25 p.m. - CNA indicated she did not see resident on the hall. It was confirmed her wander guard was observed intact and working earlier in the shift. CNA stated the resident ambulated in the building to front entrance and other halls. CNA stated she heard a car horn and she went toward the front entrance. Approximately ,d+[DATE] minutes later a pager alert went off for the main entrance/front door. Resident #1 was observed ambulating with her walker through front entrance accompanied by 2 CNAs. One of the CNAs saw the resident walking on the driveway, recognized her as a frequent wanderer, and asked the resident to accompany her back inside the facility. No injuries, guard intact. [DATE] at 9:01 p.m. - LATE ENTRY - one on one observation of resident implemented. Security cameras were viewed to determine how resident left the building. Maintenance department came to facility to determine how resident was able to leave the facility with wander guard in place, and found that the front door was not reset correctly following fire alarm earlier that day. All staff were notified of protocol per DON. RP/MD were notified. [DATE] at 3:07 p.m. - Resident #1 standing at the door crying saying she needs to get out to go take care of her mom. CNA redirected resident to chair in dining room. Resident #1 states, You people are crazy! First chance I get I'm going to save my mom. [DATE] at 4:01 p.m. - Resident #1 constantly ambulating asking for someone to open the door. States, I gotta go home, my momma and daddy are waiting on me. Resident redirected. [DATE] at 3:40 p.m. - LPN spoke with Resident #1's RP, concerning statements of wanting to go home and her saying how she has to get out of here. NP made aware of orders to refer to inpatient behavior unit due to high risk of elopement/safety. admitted to behavior hospital. [DATE] at 1:50 p.m.-returned to facility from inpatient behavioral hospital [DATE] at 5:59 p.m. - Resident #1 was hollering, cursing, and threatening to hit staff because she thought they had her car keys. Resident #1 also wanted to be let out. Resident #1 stated, If you don't give me my keys I am going to do something to you, I am not crazy, give me my f .king keys, and then she would bang her walker on the floor. [DATE] at 12:40 p.m. - Resident up ambulating with walker back and forth between left and middle houses. States, I'm looking for the bus. Resident #1 continues to say she is, tired and needs to go home. [DATE] at 2:56 p.m. - Resident #1 having bad anxiety. Walking up and down hall looking for someone and saying that we are not taking care of the other residents. Order received to administer Xanax 0.25 mg one time dose. [DATE] at 7:30 p.m. - Resident #1 began wandering after visit from daughter. Stated she had to go home. Easily redirected. [DATE] at 10:09 a.m. - Resident #1 wandering from middle house to left house. States, I'm looking for my daddy. Confusion noted. Unable to redirect. Wander guard in place and working properly. [DATE] at 6:09 p.m. - Resident #1 ambulating all over the building, when nurse attempted to redirect resident back to her room she screamed, You just want to lock me up and kill me. Unable to redirect. [DATE] at 10:45 a.m. - Resident #1 with increased agitation. Pacing back and forth to doors. States, I have to get to my daddy, he died . Consoled resident and redirected by distracting and offering a snack. [DATE] at 12:45 p.m. - Fire alarm went off at this time. Staff voiced that Resident #1 pulled alarm in middle Hall f. Asked Resident #1 why she did that? Resident #1 stated, I wanted ya'll to come get me. Monitored on 1:1 until doors reset to maintain safety. Resident #1 voiced concerns of momma is going to be looking for me. Redirected by listening to music. [DATE] at 4:30 a.m. - Resident #1 ambulating looking for bus. Redirected to room and got back up. [DATE] at 10:43 a.m. - Resident #1 pacing back and forth from house to house looking for her little children. [DATE] at 6:40 p.m. - Resident #1 ambulating toward front entrance. LPN attempted to redirect resident. Resident #1 became agitated and stated, I don't know what your problem is telling me what to do, but if it wasn't for me and your grandma your house would be a big pile of sh .t. [DATE] at 10:45 a.m. - Resident #1 noted in and out of residents' rooms. Easily redirected back to hall. [DATE] at 11:05 a.m. - Resident #1 ambulating towards the front entrance with bible in her hand and dragging walker. Attempted to redirect, Resident #1 screamed, you don't tell me what to do. [DATE] at 3:20 p.m. - Resident #1 ambulating up and down hallway with walker. Stated, I have to go check on my momma, she's sick and the baby is running a fever with no meds. [DATE] at 9:40 a.m. - Resident #1 ambulating up and down hallway with walker. Stated, I'm trying to get out of here to go check on my momma, she's sick. Redirected to her room. [DATE] at 10:40 a.m. - Resident #1 ambulating back and forth to front door. Stated, I got to get out of here and go catch the bus, daddy is going to be mad if I miss it. Unable to redirect. Continues to pace. [DATE] at 9:34 p.m. - Resident wandering in other resident rooms turning on their lights looking for her children. Unable to redirect. [DATE] at 10:35 p.m. - Resident wandering around the house. Refused to put on pajamas. Trying to go home. [DATE] at 9:55 p.m. - Resident #1 ambulating and going into other residents' rooms. Using racial slurs and combative towards staff. [DATE] at 10:00 p.m. - Resident ambulated to Hall d looking for her children. Resident assisted back to hall f. [DATE] at 11:18 p.m. - Resident continues to wander. Went into another resident's room several times. Stated she was going to call the police because another resident was trying to kill her. Resident continues to wander from hall to hall. [DATE] at 6:42 p.m. - Resident in common area wandering, redirected often, wander guard in place. [DATE] at 7:30 p.m. - A resident was sitting outside on the porch and noticed Resident #1 walking around the corner of the building, she knocked on the door to alert staff. CNA went outside immediately and went to resident and brought her safely inside. Assessed-no injuries. All residents were checked for safety and accountability. Maintenance called in to check all doors for proper functioning. All wander guards checked including Resident #1's, and were functioning correctly and located on residents as they should be. MD/RP notified. Resident #1 placed on 1:1 observation at all times. [DATE] at 1:31 p.m., Resident #1 was discharged to another long term care facility. Interview with S2 DON on [DATE] at 10:15 a.m. revealed she trained staff after each elopement. S2 DON handed the facility's Post elopement binder dated [DATE] to the surveyor. Documentation contained in the binder reflected staff were trained on the wander/elopement policy, abuse/neglect wanderguard system/alarms, the locking system, and barrel key placement. There was no documentation that addressed resident supervision. Interview on [DATE] at 10:15 a.m. with S1 Administrator revealed after Resident eloped on [DATE], she reviewed the video footage and discovered the resident exited through the front door at 6:06 p.m. and was returned to the facility by staff at 6:16 p.m. S1 Administrator stated, S10 Former [NAME] Clerk reset the front door alarms after they kept going off on [DATE], and apparently did not turn the key to the proper position to keep it locked. She confirmed the wander guard/alarm system was the facility's elopement prevention system used for residents on elopement risk. Interview on [DATE] at 2:15 p.m. with S12 CNA revealed she worked the 2:00 p.m. to 10:00 p.m. shift on [DATE] and saw Resident #1 wandering up and down the halls. S12 CNA stated around approximately 6:00 p.m. she sat down to do her charting, and after approximately 5 minutes she noticed Resident #1 had not returned to her assigned hall. S12 CNA stated she got up to look for Resident #1, and noticed the lights on the front door alarm panel were blinking. S12 CNA stated she ran back to her hall and alerted the nurse that Resident #1 was missing and then went outside to search for Resident #1. S12 CNA stated she noted an agency CNA was coming up the driveway with Resident #1 in her vehicle. S12 CNA stated she was told the Agency CNA picked up Resident #1 down the facility's driveway at a Physical Therapy office located near the facility. Interview on [DATE] at 2:30 p.m. with S2 DON stated Resident #1 had a history of wandering in and out of rooms and being anxious. S2 DON confirmed there was no increased supervision for residents with exit seeking or elopement behaviors. S2 DON stated residents who wandered, had wander guard devices in place as a measure to prevent elopement and that all residents were monitored every 2 hours. Interview on [DATE] at 3:36 p.m. with S16 CNA Coordinator revealed they viewed the video cameras on [DATE], and noted Resident #1 left the facility through one of the therapy department doors. After Resident # 2's second elopement on [DATE], the Post elopement binder was updated. Review of the [DATE] revealed all staff were inserviced on maintaining pagers on them at all times, responding to alarms immediately, making rounds, and turning barrel key on doors. There was no inservice documentation and/or staff guidance regarding the supervision/monitoring of residents who wander and who were identified at high risk for elopement. II. Accident - Fall Risk This deficient practice resulted in an actual harm for Resident #3, a cognitively impaired resident, at high risk for falls, was left unsupervised in the dayroom/dining area of Hall f on [DATE] when the resident stood up and attempted to walk unassisted in full view of S5 CNA. S5 CNA failed to intervene and/or redirect Resident #3 who subsequently fell and sustained an acute burst compression fracture of L1. Findings: Review of Resident #3's clinical record revealed an admitted [DATE], with diagnosis that included: Neuropathy, Insomnia, Major Depressive Disorder, Type II DM, Mood Disorder, and Primary Generalized Osteoarthritis. Review of Resident #3's Quarterly MDS with an ARD date of [DATE] revealed in part: BIMS 00 (severe cognitive impairment); Bed mobility, Transfer: extensive assistance/2 persons physical assist; Dressing: Limited assistance/1 person physical assist; Eating: extensive assistance/1 person physical assist; Toilet use: total dependence/2+ person physical assist; Personal hygiene: Limited assistance/1 person physical assist; Bathing: Physical help in part of bathing activity/1 person physical assist; ROM: Upper extremity 0. No impairment, Lower extremity 1. Impairment on one side; and Mobility devices: Wheelchair. Review of Resident #3's Comprehensive Plan of Care revealed in part: the resident was a high risk for falls r/t neuropathy. Fall dates, interventions, and staff education noted on the Plan of Care were: [DATE] no injury: wander guard placed on left ankle and staff to accompany resident to go outside to prevent serious injury. [DATE] no injury: staff informed and educated on resident decline in status and need for assistance by staff. [DATE] fall hip fracture: staff to take resident on porch (well lit area) to smoke after hours [DATE] fall no injury. [DATE] burst compression fracture at L1: educate staff to offer assistance if they see resident standing. Resident #3 was not care planned specifically for attempting to stand unassisted; however, on [DATE] staff were informed and educated on the resident's need for assistance by staff related to her high fall potential. There were no planned interventions to increase staff supervision of Resident # 3, who was noted to have severe cognitive impairment. Review of nurses' notes revealed the following in part . [DATE] at 3:50 p.m. - documented by S6 Agency LPN - Resident #3 attempted to get out of her wheelchair without assistance and walk to the counter in the main dining room when she lost her balance falling to the floor landing on her buttocks. This nurse was summoned to the main dining room by CNA. Resident #3 was laying on her back in front of the dining counter. When asked what she was trying to do she stated reaching for a snack. Head to toe assessment was done. Active ROM to upper extremities and lower extremities without difficulty. No complaints of pain at this time. Neuros were initiated at this time. CNA supervisor along with another CNA assisted the resident back to her wheelchair. No injuries present at this time. Notified PCP and RP. VS ,d+[DATE], 94, 17, 97.8 and 95% on room air. Will continue neuro checks. [DATE] LPN S7 documented: 3:40 p.m. Resident #3 complains of increased pain r/t fall yesterday. FNP notified. New orders noted to obtain spinal x-ray per imaging. RP notified. 4:00 p.m. X-ray obtained at this time per imaging. 6:34 p.m. Received x-ray results. Impression: Spondylitic changes of the lumbar spine with degenerative changes worse at L5-S1. FNP notified. Phoned RP x 2, no answer. 7:20 p.m. RP returned call. Notified of x-ray results. Verbalized understanding. 8:30 p.m. Received a call from S2 DON, stating that Resident #3's RP is requesting Resident #3 be sent to the ER for evaluation. RP voices that she does not trust portable x-rays. Resident #3 asleep in bed at this time. No further complaints of pain since Ultram was administered. Phoned FNP and notified of the above. New order to send to ER for evaluation and treatment related to fall. Phoned for transfer. Phoned RP and notified of above, Called report to ER. [DATE] 1:40 a.m. by S9 LPN - Received report per ER. ER staff stated Resident #3 had a lumbar CT done and was noted to have a burst compression fracture at L1. Follow-up with orthopedic. CT scan of head noted with no acute changes. [DATE] 3:56 a.m. by S9 LPN - Notified RP of Resident #3's return. Explained in detail x-ray and CT results. Voiced understanding and wants Resident #3 to follow-up with Ortho. Explained that resident had an appointment with Orthopedist on ,d+[DATE] and RP asked if appointment could be moved up. RP also asked for chair alarm for resident. Will notify DON. Review of a radiology report dated [DATE] revealed a CT of the Lumbar Spine had been performed on Resident #3. CT findings included: Acute burst compression fracture of L1. 30% loss of height. No retropulsion. Interview on [DATE] at 1:59 p.m. with S7 LPN revealed Resident #3 was ambulatory and very independent on admission, but declined rapidly. S7 LPN stated Resident #3 was in a wheelchair after her right hip fracture in June and would propel herself around the neighborhood with her left leg. S7 LPN stated Resident #3 was a 2-person transfer, would attempt to stand unassisted, and was not easily redirected. A telephone interview with S6 Agency LPN on [DATE] at 3:10 p.m. was unsuccessful. A telephone interview with S9 LPN on [DATE] at 3:16 p.m. was unsuccessful. Telephone interview on [DATE] at 3:23 p.m. with S5 CNA revealed she worked the 6:00 a.m. to 6:00 p.m. shift on [DATE] with Resident #3. S5 CNA stated Resident #3 was seated in her wheelchair near the water dispenser in the dining area. S5 CNA stated she turned away from Resident #3 and sat down to chart, and she heard another resident yell out Sit down Resident #3 before you fall. S5 CNA stated when she turned around Resident #3 was in the process of falling. Observation on [DATE] at 4:28 p.m. with S2 DON and S1 Administrator of the facility's video footage from [DATE] at 3:33:31 p.m. to 3:37 p.m. revealed the following: 3:34:31 p.m. - Resident #3 stands up from her wheelchair, in the day/dining area of her assigned hall, takes steps holding onto the counter, and grabs cloth napkins. 3:36:26 p.m. - S5 CNA walks into the dayroom/dining from a side patio door, with an unobstructed view, facing Resident #3 who is standing at the counter directly across from the side patio door. Resident #3, who remains standing, turns and looks at S5 CNA as S5 CNA enters. S5 CNA proceeds to walk over to a desk in the day/dining area and sit down at computer. There were no other staff present. 3:36:44 p.m. - 3:37 p.m. - Resident #3 begins to lose balance and falls to the floor, onto her back. S5 CNA then gets up from the computer desk and walks over to Resident #3 and begins to render aide. Interview on [DATE] at 4:33 p.m. with S2 DON revealed S5 CNA should have gone over and redirected Resident #3 when she entered the dayroom and saw Resident #3 standing at the counter, and S5 CNA did not. Telephone interview on [DATE] at 11:59 a.m. with S5 CNA revealed inpart .she was really not familiar with Resident #3, but stated Resident #3 was not supposed to stand unassisted. S5 CNA stated residents at risk for falls are supposed to be assisted and redirected if they try to get up unassisted. 41124

Based on observation, interview and record review the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#1) of 11 residents (#1, #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5 and #R6) identified as at risk for elopement. The facility's administration failed to: 1. Ensure increase supervision of Resident #1 who eloped from the facility on 07/01/2023 and 08/18/2023; 2. Ensure an effective system of adequate supervision of the remaining 10 residents who were identified by the facility to be at risk for elopement (Residents #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5, and #R6). This deficient practice resulted in an immediate jeopardy situation on 07/01/2023 at 6:06 p.m. when Resident #1, a cognitively impaired resident who was at risk for elopement and wore a wander guard bracelet, exited the facility unsupervised, and was found approximately 700 feet from the front door of the facility near a free-standing physical therapy center. The immediate jeopardy continued for Resident #1 when she exited the facility again on 08/18/2023 and was discovered outside the facility unsupervised approximately 300 feet away from a side exit door. Resident #1 was discharged on [DATE]. This deficient practice continued at a potential for more than minimal harm for the remaining 10 residents (Resident #2, Resident #3, Resident #4, Resident #5, #R1, #R2, #R3, #R4, #R5, and #R6) identified as elopement risks, and wore wander guard devices in the facility. S1 Administrator was notified of the Immediate Jeopardy on 09/20/2023 at 5:50 p.m. The Immediate Jeopardy was removed on 09/21/2023 at 4:30 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented: The Facility's plan to remove the immediate jeopardy situation included: On 07/01/2023 and 08/18/2023 Resident #1 was able to exit the facility unsupervised while wearing a wander guard bracelet. These incidents have the potential to affect all 10 residents who are at risk for elopement and have been identified with wandering and/or exit seeking behaviors. On 09/20/2023 surveyors identified two malfunctioning exit doors. Supervision for at risk residents had not been increased, therefore the potential for elopement remained for the 10 residents with elopement risk. MD/NP and Responsible Party were both notified in a timely manner after each elopement incident. Residents #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5, and #R6 who were specifically identified to be affected, related to risk for elopement had adequate supervision provided every hour by assigned floor nurses and CNAs to assess for exiting seeking behaviors starting 09/21/2023, so that the staff can account for residents at risk. Residents at risk will be monitored every hour for 2 weeks, then reassessed for the need for continued hourly monitored by Administrator or designee. If no exit seeking behavior is exhibited, resume every 2 hour monitoring. Care plans for residents at risk for elopement updated 09/21/2023 to reflect frequency of monitoring for adequate supervision. Facility conducted a Root Cause Analysis on 09/20/2023 to identify failure for F835. Review of the elopement policy and procedure conducted on 09/20/2023 with no changes needed. Review of the Secure Care Guardian U-DE owner's manual, of exit door locking mechanisms, conducted on 09/20/2023 with no changed needed, developed and implemented a monitoring tool to check all exit doors every shift for 7 days, then every day for 7 days, then weekly thereafter by administrator or designee with Regional Director of Operations supervision daily, Monday-Friday, for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month. Education of all staff began on immediately on 09/20/2023 to include wandering and elopement policy and procedures, location of elopement binders, including Face Sheets of identified residents at risk for elopement and Photo, and Code W procedures completed by DON. Binders are located at incident command center (front desk) and 1 in each neighborhood, totaling 4 in the facility. Administrator or designee will continue in-servicing employees prior to the beginning of shift for conformance with wandering and elopement. Completion date of 09/22/2023. In reference to above, the Administrator or designee will administer post training evaluation of staff on wandering and elopement policy and procedures and location of elopement binder to be completed before employee begins shift for conformance with wandering and elopement. Quality Assurance Committee met 09/21/2023 and will monitor for elopement risk to prevent the likelihood of serious harm or death weekly for 8 weeks. Administrator in-serviced on elopement policy and procedure by Regional Director of Operations and DON in-serviced by Corporate Nurse on 09/20/2023. Administrator will be supervised on facility compliance by Regional Director of Operations daily, Monday-Friday, for 2 weeks, then 3 times a week for 2 weeks, then weekly for 1 month. Requested and received approval on 09/21/2023 to install a [NAME] mag lock system to the C Hall access door to the exit, plans will be submitted to the fire marshal's office for approval of installation. Completion date: 09/22/2023. Findings: Cross refer to F689. Review of the facility's Wandering and Elopement Assessment/Management/ Security policy dated 10/28/2022 read as follows in part . Elopement is a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision. This situation represents a risk to the resident's health and safety and places the resident at risk of heat or cold exposure, dehydration, and/or other medical complications, drowning, or being struck by a car. Interventions which address/prevent unsafe wandering/elopement will be developed within the resident care plan for at risk residents. (i.e., supervision/periodic checks, activity programs, exit door alarms, highlight name on census report at nurses' station, Personal signal device, etc.). In facilities with electronic wander alarm systems, residents assessed to be at risk for unsafe wandering may be placed on the Resident Security System as a measure to reduce the risk of harm from unsafe wandering activities. There was no facility policy that addressed supervision of residents who wandered and/or were at risk for elopement. Interview with S2 DON on 09/15/2023 at 10:15 a.m. revealed she trained staff after each elopement. S2 DON handed the facility's Post elopement binder dated 07/01/2023 to the surveyor. Documentation contained in the binder reflected staff were trained on the wander/elopement policy, abuse/neglect wanderguard system/alarms, the locking system, and barrel key placement. There was no documentation that addressed resident supervision. After Resident # 2's second elopement on 08/18/2023, the Post elopement binder was updated. Review of the 08/18/2023 revealed all staff were inserviced on maintaining pagers on them at all times, responding to alarms immediately, making rounds, and turning barrel key on doors. There was no inservice documentation and/or staff guidance regarding the supervision/monitoring of residents who wander and who were identified at high risk for elopement. Interview on 09/19/2023 at 10:15 a.m. with S1 Administrator revealed S10 Former [NAME] Clerk reset the front door alarms after they kept going off on 07/01/2023, and apparently did not turn the key to the proper position to keep it locked. She confirmed the wander guard/alarm system was the facility's elopement prevention system used for residents on elopement risk. Interview on 09/19/2023 at 2:30 p.m. with S2 DON stated Resident #1 had a history of wandering in and out of rooms and being anxious. S2 DON confirmed there was no increased supervision for residents with exit seeking or elopement behaviors. S2 DON stated residents who wandered, had wander guard devices in place as a measure to prevent elopement and that all residents were monitored every 2 hours. Interview on 09/20/2023 at 6:15 p.m. with S1 Administrator confirmed she was the person in charge of the day to day operations of the facility.

Based on observation, interview and record review, the facility failed to ensure facility staff and a contract hospice staff properly placed a lift pad/sling underneath a resident prior to transferring the resident from the bed to the Geri-Chair with a mechanical lift, for 1 (Resident #5) of 1 residents sampled for accidents. An Actual Harm occurred for Resident #5 on 06/02/2023 at approximately 10:55 a.m., when S5 CNA, S6 CNA and S7 Hospice RN failed to ensure the lift pad had been properly placed underneath Resident #5 prior to transfer with a mechanical lift. Resident #5 fell from the mechanical lift to the floor during transfer from the bed to the Geri-Chair. Resident #5 was transferred to the emergency department of a local hospital and diagnosed with Traumatic Hemorrhage of Cerebrum, Unspecified, with Loss of Consciousness of Unspecified Duration, and Laceration without Foreign Body of Other Part of Head, that required suturing. Resident #5 was transferred to another hospital on 06/02/2023 at 2:39 p.m. for a higher level of care where she remained hospitalized during time of survey. The facility implemented corrective actions prior to the State Agency's investigation therefore, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's policy titled Transfer and Lift Policy read in part .Each resident will have a Lift Assessment completed by licensed nurse upon admission, quarterly, annually, and with significant change. All staff are responsible for using the required number of assistants for resident transfer and lifts, as well as the appropriated colored sling as designated per the resident's personal lift assessment. Two persons are always required for standup lifts (Vera) and bed lifts (Vander), and the ceiling lift (Go Lift Portable 450). A color coded legend is used to designate the type of lift and sling required per the residents lift assessment. Color coded stickers are placed at the head of the resident's bed and/or noted on the computer kiosk: Lifts: Red- Total bed lift (e.g., Vander Lift), 2 person. Slings: Red (Medium) Average user weight 110-190lbs. The Vander Lift was used during Resident #5's transfer from the bed to the Geri-Chair on 06/02/2023. Review of Resident #5's medical record revealed an admitted [DATE], with diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebral Vascular Attack affecting Right Dominant Side, Unspecified Dementia, and Generalized Anxiety Disorder. Review of Resident #5's Side Rail/Bed Mobility/Lift Assessment completed on 02/19/2023 revealed Resident weighed 136lbs, was non-weight bearing, cooperative and could follow simple commands. Resident had right sided weakness of upper and lower extremities. Resident required: 2 person assist- total bed lift with Vander Lift-Red dot. Sling type/size for Vander Lift: Medium-110 to 190lbs (Red). Review of a Quarterly MDS Assessment with an ARD of 02/22/2023 revealed Resident #5 had a BIMS of 2 (Severe Cognitive Impairment). Resident #5 was totally dependent upon staff and required 2 + person physical assist for bed mobility and transfers. Review of Resident# 5's Electronic Fall Risk Assessment completed on 05/24/2023 revealed Resident#1 determined by the facility to be at high risk for falls. The assessment revealed a score of 45 or higher indicated a high risk for falls. Resident #5's score was 55. Review of Resident #5's Care Plan with a target date of 06/20/2023 revealed a problem of: ADL self-care deficit related to right sided hemiplegia following CVA. Approaches included: I am totally dependent on 2 staff for repositioning and turning in bed, turn every 2 hours. Transfer: I require mechanical lift with 2 staff assistance for transfers. Review of Resident #5's Departmental Notes dated 06/02/2023 at 11:45 a.m. written by S4 RN read as follows: Resident fell during transfer from bed to Geri chair and resident sustained hematoma to right forehead approximately 3cm x 3cm. Left forehead with hematoma and lacerated wound with bleeding noted. Pressure dressings were applied. Below left knee hematoma measuring 6cm x 7cm x 1 cm. Skin tear below left ankle with superficial skin loose measuring 1cm x 1 cm. Resident has eye opening to outside stimuli. Pupil size 3 equally non-reactive to light. B/P 200/73. Doctor and Resident representative notified, Resident sent to local hospital. Review of a statement dated 06/02/2023 and written by S6 CNA, revealed in part . S6 CNA assisted S7 Hospice RN with placing lift sling underneath Resident. S7 Hospice RN asked S6 CNA if she knew how to use the mechanical lift. S6 CNA then went to get help, and S5 CNA entered room to assist with transfer and operate mechanical lift. S5 CNA, S6 CNA, and S7 Hospice RN connected lift sling to the mechanical lift. S5 CNA began to operate the mechanical lift. Once Resident was off of the bed, S6 CNA heard S7 Hospice RN ask if the Resident was in the correct position, and the Resident then fell from the mechanical lift to the floor. Review of a statement dated 06/02/2023 and written by S5 CNA revealed in part . S5 CNA entered Resident #5's room and observed a lift sling was already underneath Resident. S5 CNA and S7 Hospice RN connected lift sling to the mechanical lift. S5 CNA began operating the mechanical lift. During transfer when Resident was off of bed, S7 Hospice RN asked if Resident was in the correct position. S5 CNA assessed and stated yes. Immediately after the question was asked the Resident fell forward from mechanical lift to the floor. S4 RN was standing in doorway of room, and S6 CNA was standing on opposite side of bed. Review of a statement dated 06/02/2023 and written by S7 Hospice RN revealed in part . S7 Hospice RN and S6 CNA placed lift sling underneath Resident. S6 CNA then sought the attention of S5 CNA to operate mechanical lift. S5 CNA and S6 CNA then proceeded with lifting Resident using mechanical lift. Resident fell from mechanical lift to floor. Resident was then assessed by S7 Hospice RN. Telephone interview on 06/06/2023 at 10:22 a.m. with S5 CNA revealed on Friday 06/02/2023, Resident #5 had a fall. S5 CNA stated, S7 Hospice RN and S6 CNA were present in Resident #5's room around 11:00 a.m. performing ADL care. S5 CNA stated S6 CNA came to her and asked her to help transfer Resident #5 with the mechanical lift. S5 CNA then went to Resident's room. S5 CNA stated S6 CNA and S7 Hospice RN already had the lift sling underneath Resident #5. S5 CNA stated once transfer began She didn't put the sling under her correctly, and she leaned forward and fell from the lift. S5 CNA stated she was unsure who placed the sling underneath Resident #5. S5 CNA stated I wish I had checked, but I automatically thought the sling was correct, and I didn't want to question the nurse. S5 CNA stated the nurses came in to assess Resident #5 after the fall. S5 CNA stated she had received training from the facility on using the lift when she was hired, and stated I know how to work the lift, but I didn't think to check the sling. S5 CNA stated she had training on using the mechanical lift following the incident on 06/02/2023. Telephone interview on 06/06/2023 at 11:03 a.m. with S7 Hospice RN revealed she and S6 CNA gave Resident #5 a bath on 06/02/2023. S7 Hospice RN stated after the bath, she wanted to place Resident #5 in a Geri Chair so that she could change her bed to an air mattress. S7 Hospice RN stated she and S6 CNA both placed the lift pad under Resident #5. S7 Hospice RN stated she wasn't sure on how to use the mechanical lift, so S6 CNA went to get help from S5 CNA. S7 Hospice RN stated both S5 CNA and S6 CNA connected the lift pad to the mechanical lift. S7 Hospice RN stated Resident was then in the air and fell forward. S7 Hospice RN stated she assessed Resident #5 immediately after the fall, and S4 RN who was also present, helped to assess Resident#5. S7 Hospice RN stated Resident #5 sustained a hematoma to both eyes, skin tear to left knee, abrasion to right great toe, and a laceration above her right eye. S7 Hospice RN stated she had not been trained on how to use the mechanical lift by the facility, nor by the hospice company she worked for. S7 Hospice RN stated she asked S5 CNA and S6 CNA if Resident #5 was positioned on the pad correctly, and S5 CNA stated yes. S7 Hospice RN stated Resident was sent to emergency room , and is currently hospitalized . Telephone interview on 06/06/2023 at 11:13 a.m. with S6 CNA revealed after she and S7 Hospice RN bathed Resident #5, they were to transfer Resident #5 from the bed to the Geri Chair using a mechanical lift. S6 CNA stated she and S7 Hospice RN placed the lift pad under Resident #5, and S7 Hospice RN then asked, Do you know how to do this? S6 CNA stated she informed S7 Hospice RN No and stated she (S6 CNA) then went to get S5 CNA to help. S6 CNA stated apparently her legs weren't crossed, and she fell forward on the floor. S6 CNA stated S5 CNA thought the pad was under the Resident correctly, but that's why I brought her in there, because we weren't sure S5 CNA stated she received training on using the lift when she first started working at the facility, and again following the incident on 06/02/2023. S6 CNA stated we all should have known better, but it was an accident. Interview on 06/06/2023 at 11:25 a.m. with S4 RN revealed she was in Resident #5's room near the doorway at time of the incident on 06/02/2023. S4 RN stated she did not check placement of the lift pad, as she only was there to bring a battery to the room. S4 RN stated S5 CNA and S6 CNA did not report to her that they were uncomfortable using the mechanical lift. S4 RN stated immediately after Resident #5 fell , she could see that the lift pad was placed incorrectly. S4 RN stated the lift pad was not crisscrossed as it was still attached to the mechanical lift. S4 RN stated she immediately assessed Resident #5, and could tell Resident #5 was hurt. S4 RN stated she notified the doctor and Resident #5's family. Resident #5 was sent to the emergency room , and remains hospitalized due to her injuries sustained from the fall. Interview on 06/06/2023 at 12:41 p.m. with S2 DON revealed the facility's process for staff using mechanical lifts on residents was to refer to the resident's lift assessment, and the signage posted in each resident's room. S2 DON stated if a resident is to use a mechanical lift, there would be a red dot located above the resident's head of bed. S2 DON stated each resident who used a mechanical lift for transfers would also have a colored triangle above the resident's head of bed, and that would indicate what size sling to use. Throughout the survey from 06/05/2023 thru 06/07/2023, random interviews of staff were conducted. Staff stated that they had previously received training on transferring residents with mechanical lifts, and had been recently in-serviced on the use of mechanical lifts. Review of a list of residents who required a mechanical lift for transfers revealed 21 residents required the use of a lift for transfers, and 12 of the 21 residents received hospice services. Observations on 06/07/2023 revealed Resident #33, Resident #47, Resident #48, Resident #71, and Resident #92 were transferred with the use of a mechanical lift and the assistance of 2 CNA's. There were no concerns observed with the transfers. Interview on 06/07/2023 at 9:48 a.m. with S8 Hospice CNA revealed following the incident on 06/02/2023, the facility informed her that Hospice staff would not be allowed to transfer residents with a mechanical lift, and she had not transferred any residents with a mechanical lift since being informed. Interview on 06/07/2023 at 10:55 a.m. with S1 Administrator revealed following the incident on 06/02/2023, she had spoken to all Hospice providers that service the facility to inform them Hospice Staff would not be allowed to transfer residents with a mechanical lift until further training could be completed with the Hospice staff. S1 Administrator stated the investigation of the incident was complete, but monitoring would continue. Telephone interview on 06/07/2023 at 11:25 a.m. with the DON of a contract hospice agency revealed S1 Administrator had contacted the hospice agency to inform them that Hospice staff would not be allowed to use mechanical lifts for transfers of residents. The facility has implemented the following actions to correct the deficient practice: 1. A Root Cause Analysis was completed, and it was determined that the lift pad was not positioned correctly for Resident #5 prior to transfer on 06/02/2023, causing Resident #5 to fall from the lift. Equipment (sling and lift) was in proper working condition. However, the Hospice nurse, and the CNAs involved in the transfer did not follow the education given and criteria for use. 2. All lifts and slings in operation, and over bed signage for all residents evaluated. Results: lifts and slings in good and appropriate condition, and over bed signage correctly displayed - all 21 residents who require a lift for transfer were care planned for lift transfer. Completed 06/02/2023. 3. Staff in-services immediately initiated regarding procedure/steps for proper use of sling and lifts. Initiated 06/02/2023 and is ongoing at the beginning of each shift until all 77 facility staff are re-educated before scheduled shift. Completion date 07/22/2023. 4. Policy/Procedure changes: DON, Staff Development Coordinator, or Designee will observe and supervise as necessary 6 lift transfers per week, per neighborhood (total of 18 lift transfers per week) for 6 weeks. There are a total of 3 neighborhoods in the facility. Any concerns identified will be reported to the IDT and appropriate action taken to include retraining, further observations etc. The results of the observations will be reviewed with the QA Committee Monthly for review of continued compliance. 5. Monitoring: Weekly observations throughout facility, of 21 residents requiring lift transfer (minimum of 18 per week for 6 weeks then re-evaluate). DON, Staff Development and/or other Nursing Administrative staff or IDT members to perform monitoring. QA Committee will monitor monthly or more frequently if needed for continued compliance. 6. Corrective Action Plan effective as of 06/02/2023.

Based on observation, interview, and record review, the facility failed to ensure residents were free from physical, verbal, and mental abuse for 2 (#1 and #5) residents out of a total sample of 5 residents reviewed for abuse (#1, #2, #3, #4 and #5). This deficient practice resulted in actual harm beginning on 6/26/2021, when a facility staff observed S1 TNA taunting, badgering, teasing, and mimicking involuntary mouth movements of Resident #1, a severely cognitively impaired resident. S1 TNA made whimpering noises that sounded like the resident, causing the resident to cry. S1 TNA was also observed by another facility staff on several occasions, jumping in front of Resident #1 hollering boo to scare her, causing the resident to be nervous. On 7/20/2021, S1 TNA was witnessed again by a facility staff, abusing Resident #1. S1 TNA was observed slapping Resident #1 twice in the back of her head. Also on 6/26/2021, S1 TNA was observed twice, pouring cold water down the back of Resident #5, another severely cognitively impaired resident, while he was seated in a wheelchair in the dining room. In July 2021 (date unknown), a facility staff observed S1 TNA pushing Resident #5 real, real fast in his wheelchair circling the dining area four to five times causing Resident #5 to tell S1 TNA to stop. Findings: Review of the facility's Abuse Components Plan/Elder Justice Act Policy revealed, in part . 3.0 Procedure Identification: Immediately upon discovery of any alleged and or suspected incident of abuse, neglect, mistreatment, major injury, injury of unknown origin .or other reportable incident requires immediate notification of the facility Administrator or their designee. Resident #1 Review of resident #1's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Quarterly MDS with ARD of 06/09/2021 revealed a BIMS of 3, which indicated severe cognitive impairment. Further review of the MDS assessment revealed she required extensive assistance for bed mobility, transfers, toileting and bathing. Observation of resident #1 on 07/22/2021 at 11:24 a.m. during lunch revealed she was seated in her wheelchair at a dining table. She was observed to eat independently. An attempt to interview the resident at this time revealed she was unwilling to respond to questions. Telephone Interview with S9 CNA on 07/22/2021 at 1:42 p.m. revealed she worked on the 6:00 a.m. - 6:00 p.m. shift. She stated she was paired to work with S1 TNA when she was hired by the facility in mid-June, and they were assigned care of resident #1. She stated the resident had anxiety and had a problem of moving her mouth randomly and whimpering, because of her nerves. S9 CNA stated she and S1 TNA worked together on the week-end of 06/26/2021, not long after S1 TNA started working here, and S1 TNA started mocking the resident by standing in front of her, moving her mouth, making faces and whimpering. She stated it upset the resident and made her sad and aggravated. S9 CNA stated she took the resident outside to sit on the back porch, and she began crying. She stated she tried to talk to the resident about it, but she didn't want to talk. Further interview with S9 CNA revealed that on the Monday following that week-end, (06/28/2021) she told S11 LPN, Household Coordinator that she did not want to work with S1 TNA anymore because she did not like the way S1 TNA treated resident #1. She stated she explained the way S1 TNA mocked and made fun of the resident, and S11 LPN replied, that's abuse! She stated she wasn't sure what S11 LPN did about it, because she continued to see S1 TNA work on C-Middle, and she continued to mock and mimic resident #1. Further interview with S9 CNA on 07/23/2021 at 8:40 a.m. revealed that she worked on 07/20/2021 and was called from C-Right to work C- Middle because S1 TNA had been sent home after slapping resident #1, and the resident complained of a headache. S9 CNA stated that S10 LPN was working the home that day, and she told S10 LPN that she was not surprised at all about what happened, and that she had warned S11 LPN weeks before the incident of S1 TNA's behavior toward resident #1. She said S1 TNA just liked to pick on resident #1. Interview with S10 LPN on 07/23/2021 at 8:52 a.m. revealed that S9 CNA told her that she told S11 LPN weeks ago that S1 TNA was always picking on resident #1, but nothing changed. Interview with S11 LPN, Household Coordinator on 07/22/2021 at 2:20 p.m. revealed she had never received any reports of resident abuse by S1 TNA from any of the staff. She stated S9 CNA told her a few weeks ago that she didn't like to work with S1 TNA because she didn't do her share of work. S11 LPN stated she started rotating the care partners to work different sections of C home so that the same staff didn't work together all the time and the same staff did not work C middle all the time. She stated she did not recall S9 CNA telling her that S1 TNA had been mocking resident #1 and had caused her to cry. She stated S1 TNA began working with residents on 06/16/2021 and confirmed that S1 TNA and S9 CNA had worked together the week-end of 06/26/2021. Interview with S6 Homemaker on 07/23/2021 at 8:14 a.m. revealed that, on 07/20/2021 at around 2:00 p.m., she was sitting in the dining area with resident #1. She stated S1 TNA was working that day and approached the resident to give her a cell phone that displayed a photograph of S1 TNA on the home screen. S6 Homemaker stated the resident looked at the photo and said, that's an ugly girl. She further stated that, upon hearing the comment, S1 TNA tapped resident #1 on the back of her head, walked away briefly, then returned and pushed on the back of the resident's chair. S6 Homemaker stated she walked to the laundry room, then returned and slapped the resident on the back of her head, causing her head and shoulders to propel forward in the chair. Interview with S14 Homemaker on 07/23/2021 at 9:12 a.m. revealed she had worked at the facility since February 2020. She stated she had witnessed on several occasions as S1 TNA jumped in front of resident #1 when she was sitting in her chair and hollered boo or something of the like, to scare her. She stated the resident was very nervous and didn't like this. She stated she told S1 TNA to stop doing that, but she would just laugh and do it again another day. Observation on 07/23/2021 at 10:02 a.m., with S4 DON, of video footage dated 07/20/21 at 1:53 p.m. revealed: Resident #1 was observed seated in a wing back chair in the living/dining area, with her back to the laundry area and nurses station. S6 Homemaker was observed seated to her left. S1 TNA was observed to approach resident #1 to give her a cell phone. The resident looked at the phone as S1 TNA walked away for a brief period, then returned and walked up behind resident #1 and slapped her lightly on the back of her head with her hand, then pushed the back of the resident's chair. She then walked behind the resident, into the laundry room. She exited the laundry room holding a piece of laundry, walked up behind the resident, and slapped her forcefully in the back of her head with her hand. Resident #1's head, neck and shoulders were pushed slightly forward by the impact of the slap. S1 TNA was observed to walk away. Interview with S4 DON and S12 Admin on 07/23/2021 at 10:02 a.m. confirmed that S1 TNA had physically abused resident #1. Resident #5 Review of the resident #5's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's Quarterly MDS with ARD of 05/14/2021 revealed a BIMS score of 1, indicating severe cognitive impairment. Further review of MDS assessment revealed he required extensive assistance of 1 person for bed mobility, locomotion on unit, dressing, eating, toileting, and personal hygiene. Observation on 07/22/2021 at 11:15 a.m. of resident #5 revealed him lying in a low bed, positioned against the wall with a fall mat in place. He was alert and pleasantly confused. He stated my memory has been gone for a long time. He stated he did remember enough of anything to answer any questions. Interview with S7 Homemaker on 07/22/2021 at 12:15 p.m. revealed she had been working on C home for about 3 weeks. She stated she observed S1 TNA pour cold water down resident #5's back a few weeks ago (she could not state an exact date). S7 Homemaker stated she was washing dishes, and resident #5 was sitting in his wheelchair at one of the dining tables. She stated as she turned around, she witnessed S1 TNA pour cold water from the dispenser onto the resident's back. She stated he asked her, why did you do that?, and S1 TNA started laughing and walked away. Interview with S14 Homemaker on 07/23/2021 at 9:12 a.m. revealed she had witnessed on a week-day in the middle of July (she could not recall the exact date) S1 TNA as she pushed resident #5 around the C Middle dining area real real fast in his wheelchair. S14 Homemaker stated the resident kept telling her to stop, and she just laughed and kept pushing him. S14 Homemaker stated she told S1 TNA to stop, that she was going to make him sick, and he didn't like that. She stated she finally stopped after circling the area 4 or 5 times. Observation on 07/23/2021 at 9:55 a.m., with S4 DON, of video footage dated 06/26/2021 at 11:24 a.m. revealed resident #5 seated in his wheelchair at a dining table near the home's kitchen serving area. Behind him, S1 TNA was observed filling a cup with a clear liquid from a tabletop dispenser, of which S4 DON confirmed to contain ice cold water. She walked up behind the resident and poured the glass of cold water down his back. The resident sat up straighter and looked back at S1 TNA. No sound was available on the video. S1 TNA immediately returned to the water dispenser and filled the glass with cold water once more. She walked up behind resident #5 and poured the glass of water down his back a second time. He straightened his back and looked back at her as she walked away. Another staff member, identified by S4 DON as S7 Homemaker, was observed in the kitchen standing at the sink. Interview with S4 DON on 07/23/2021 at 10:00 a.m. confirmed that S1 TNA had physically abused resident #5. In an interview with S4 DON and S12 Admin on 07/23/2021 at 10:02 a.m., S4 DON stated that they were informed by S7 Homemaker on 07/20/2021 that she had witnessed S1 TNA pour cold water down resident #5's back several weeks ago.

Based on interview and record review, the facility failed to report incidents of verbal, mental, and physical abuse for 2 (#1 and #5) of 5 (#1 - #5) residents reviewed for abuse, immediately to the Administrator so that the incidents could be reported no later than 2 hours after the abuse occurred to the State Survey Agency and law enforcement in accordance with state law. This deficient practice resulted in actual harm beginning on 6/26/2021, when a facility staff observed S1 TNA taunting, badgering, teasing, and mimicking involuntary mouth movements of Resident #1, a severely cognitively impaired resident. S1 TNA made whimpering noises that sounded like the resident, causing the resident to cry. S1 TNA was also observed by another facility staff on several occasions, jumping in front of Resident #1 hollering boo to scare her, causing the resident to be nervous. On 7/20/2021, S1 TNA was witnessed again by a facility staff, abusing Resident #1. S1 TNA was observed slapping Resident #1 twice in the back of her head. Also on 6/26/2021, S1 TNA was observed twice, pouring cold water down the back of Resident #5, another severely cognitively impaired resident, while he was seated in a wheelchair in the dining room. In July 2021 (date unknown), a facility staff observed S1 TNA pushing Resident #5 real, real fast in his wheelchair circling the dining area four to five times causing Resident #5 to tell S1 TNA to stop. Findings: Review of the facility's Abuse Components Plan/Elder Justice Act Policy revealed, in part . 3.0 Procedure Reporting: 1. All alleged violations involving abuse, neglect, and/or other reportable incidents will be reported by the Administrator or designee to the following persons or agencies as required to provide notifications: LDH required database reporting system, Law Enforcement officials, if warranted, and Adult Protective Services, if warranted. 2. An alleged violation involving abuse, neglect, and/or any other reportable incident will be reported immediately, but no later than 2 hours if the incident involves abuse or has resulted in serious bodily injury. Resident #1 Review of resident #1's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Quarterly MDS with ARD of 06/09/2021 revealed a BIMS of 3, which indicated severe cognitive impairment. Telephone Interview with S9 CNA on 07/22/2021 at 1:42 p.m. revealed she worked on the 6:00 a.m. - 6:00 p.m. shift. She stated resident #1 had anxiety and had a problem of moving her mouth randomly and whimpering, because of her nerves. S9 CNA stated she and S1 TNA worked together on the week-end of 06/26/2021. She revealed S1 TNA started mocking the resident by standing in front of her, moving her mouth, making faces and whimpering. She stated it upset the resident and made her sad and aggravated. S9 CNA stated she took the resident outside to sit on the back porch, and she began crying. S9 CNA revealed that on the Monday following that week-end, (06/28/2021) she told S11 LPN Household Coordinator that S1 TNA mocked and made fun of the resident, and S11 LPN replied, that's abuse! She stated she wasn't sure what S11 LPN did about it, because she continued to see S1 TNA work on C-Middle, and she continued to mock and mimic resident #1. Interview with S9 CNA on 07/23/2021 at 8:40 a.m. revealed that she worked on 07/20/2021on C- Middle because S1 TNA had been sent home after slapping resident #1, and the resident complained of a headache. S9 CNA stated that she had warned S11 LPN weeks before the incident of S1 TNA's behavior toward resident #1. She said S1 TNA just liked to pick on resident #1. S9 CNA stated she did not report the behavior again because she didn't want to be labeled a troublemaker or tattletale by her co-workers. Interview with S14 Homemaker on 07/23/2021 at 9:12 a.m. revealed she had witnessed on several occasions as S1 TNA jumped in front of resident #1 when she was sitting in her chair and hollered boo or something of the like, to scare her. She stated the resident was very nervous and didn't like this. She stated she told S1 TNA to stop doing that, but she would just laugh and do it again another day. She stated she didn't report this to anyone, because she just didn't want to get in the middle of anything or get anybody in trouble. Observation on 07/23/2021 at 10:02 a.m., with S4 DON, of video footage dated 07/20/21 at 1:53 p.m. revealed: Resident #1 was observed seated in a wing back chair in the living/dining area, with her back to the laundry area and nurses station. S6 Homemaker was observed seated to her left. S1 TNA was observed to approach resident #1 to give her a cell phone. The resident looked at the phone as S1 TNA walked away for a brief period, then returned and walked up behind resident #1 and slapped her lightly on the back of her head with her hand, then pushed the back of the resident's chair. She then walked behind the resident, into the laundry room. She exited the laundry room holding a piece of laundry, walked up behind the resident, and slapped her forcefully in the back of her head with her hand. Resident #1's head, neck and shoulders were pushed slightly forward by the impact of the slap. S1 TNA was observed to walk away. Interview with S4 DON and S12 Admin on 07/23/2021 at 10:02 a.m. confirmed that S9 CNA should have reported the continued incidents she witnessed between S1 TNA and resident #1 from 06/26/2021 until 07/20/2021, and S14 Homemaker should have immediately reported the incidents she witnessed, and both had failed to do so. During an interview with S12 Admin on 07/23/2021 at 1:30 p.m., she stated that employees did not report witnessed incidents of emotional and physical abuse involving S1 TNA between 06/26/2021 and 07/20/2021. S12 Admin further stated that the facility had not contacted law enforcement about this incident, because there was no physical injury. Resident #5 Review of the resident #5's medical record revealed an admitted [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of #5's Quarterly MDS with ARD of 05/14/2021 revealed a BIMS score of 1, which indicated severe cognitive impairment. Observation on 07/22/2021 at 11:15 a.m. of resident #5 revealed him lying in a low bed, positioned against the wall with a fall mat in place. He was alert and pleasantly confused. He stated my memory has been gone for a long time. He stated he did remember enough of anything to answer any questions. Interview with S7 Homemaker on 07/22/2021 at 12:15 p.m. revealed she had been working on C home for about 3 weeks. She stated she observed S1 TNA pour cold water down resident #5's back a few weeks ago (she could not state an exact date). S7 Homemaker stated she was washing dishes, and resident #5 was sitting in his wheelchair at one of the dining tables. She stated as she turned around, she witnessed S1 TNA pour cold water from the dispenser onto the resident's back. She stated he asked her, why did you do that? and S1 TNA started laughing and walked away. S7 Homemaker stated she did not report it to anyone until she found out that S1 TNA had slapped resident #1 on 07/20/2021. Interview with S14 Homemaker on 07/23/2021 at 9:12 a.m. revealed she had witnessed on a week-day in the middle of July (she could not recall the exact date) S1 TNA as she pushed resident #5 around the C Middle dining area real, real fast in his wheelchair. S14 Homemaker stated the resident kept telling her to stop, and she just laughed and kept pushing him. S14 Homemaker stated she told S1 TNA to stop, that she was going to make him sick, and he didn't like that. She stated she finally stopped after circling the area 4 or 5 times. She stated she didn't report what she witnessed to anyone, because she just didn't want to get in the middle of anything or get anybody in trouble. Observation on 07/23/2021 at 9:55 a.m., with S4 DON, of video footage dated 06/26/2021 at 11:24 a.m. revealed resident #5 seated in his wheelchair at a dining table near the home's kitchen serving area. Behind him, S1 TNA was observed filling a cup with a clear liquid from a tabletop dispenser, of which S4 DON confirmed to contain ice water. She walked up behind the resident and poured the glass of cold water down his back. The resident sat up straighter and looked back at S1 TNA. No sound was available on the video. S1 TNA immediately returned to the water dispenser and filled the glass with cold water once more. She walked up behind resident #5 and poured the glass of water down his back a second time. He straightened his back and looked back at her as she walked away. Another staff member, identified by S4 DON as S7 Homemaker, was observed in the kitchen standing at the sink. Interview with S4 DON on 07/23/2021 at 10:00 a.m. confirmed the incident should have been reported to administration immediately by S7 Homemaker. She further stated that S14 Homemaker should have immediately reported the incidents she observed in July 2021 between S1 TNA and resident #5, and had failed to do so. In an interview with S4 DON and S12 Admin on 07/23/2021 at 10:02 a.m., S4 DON stated that they were informed by S7 Homemaker on 07/20/2021 that she had witnessed S1 TNA pour cold water down resident #5's back several weeks ago, but had not told anyone.