Every finding on record at Rose Haven Nursing Home

Based on staff interviews, clinical record review, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement transmission based precaution procedures, monitor, and test residents with symptoms or exposure to COVID-19 virus for 2 of 4 residents reviewed for infection control. The facility failed to ensure that criteria was followed to reduce the risk of COVID-19 transmission when Resident #2 tested positive for COVID-19 on 2/19/26 at the hospital, then returned to the facility on 2/25/26 (7 days), the facility did not provide additional precautions for Resident #2 who continued to have respiratory symptoms. The facility further failed to prevent transmission of COVID-19 when 2 direct care staff reported symptoms while working of fever, body aches, cough, decreased smell/taste, and tested positive for COVID-19 at the facility on 2/24/26, both staff continued to provide direct cares and work 12 hour shifts on 3 of 3 hallways. The facility additionally failed to conduct any further testing or monitoring for additional cases of COVID-19, Resident #1 complained of excessive fatigue, anxiety and had diminished lung sounds on 2/18/26, continued with these symptoms, then was admitted to the hospital on [DATE] for diagnoses including COVID-19 and nursing-home acquired pneumonia. Resident #1 continued to decline and died at the hospital on 3/02/26 from chronic respiratory failure as a consequence of viral pneumonia. The facility reported a census of 50 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment, dated 2/18/26, revealed that Resident #2 had modified independence for cognitive skills in daily decision making. The list of diagnoses included acute and chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD), malnutrition, anxiety disorder, and history of pneumonia.Review of Resident #2's Care Plan, initiated on 2/20/24 and revised on 4/01/26, revealed a Focus area for Resident #2's risk for altered respiratory status/difficulty breathing related to COPD, history of respiratory failure, history of pneumonia, COPD exacerbation on 4/29/24, readmission following hospitalization for sepsis, acute respiratory failure, pneumonia, and recurrent hospitalization for pneumonia.Review of a Nurses Note, dated 2/18/26 at 8:32 PM, revealed the following entry: Called to resident's room by staff, resident having increased confusion, color is dusky/ashy, using accessory muscles to breath, eyes rolled back in head. Vital Signs: 144/80, Temperature 100.7 (degrees Fahrenheit) (normal is 98.6 to 99.6 degrees Fahrenheit), 84% oxygen saturation (normal is greater than 90%) while on 4 liters (L) of oxygen per nasal cannula, pulse 136 beats per minute (bpm), (normal is 60-100 bpm). Spoke with the physician and obtained an order to have the Resident transferred to the hospital to be evaluated. Called the family to inform them of the resident's condition and transfer. Review of a Nurses Note, dated 2/19/26 at 1:53 AM, revealed an entry that an update was received from the hospital, reporting that Resident #2 had septic shock due to respiratory illness. The Note documented that Resident #2 was COVID-19 positive and admitted to the hospital for intravenous (IV) antibiotics. Review of a Nurses Notes revealed the following entries, in part: On 2/25/26 at 11:50 AM, Resident #2 returned to the facility on 2 L of oxygen, and was noted to have a productive cough. On 2/26/26 at 12:21 AM, Resident #2 was receiving skilled care with Physical Therapy (PT) and Occupational Therapy (OT) post hospital stay for COVID-19 infection and pneumonia. Resident #2 continued taking antibiotics x3, had occasional loose cough, productive at times, and lung sounds noted with expiratory wheeze to lower right lobe. On 2/27/26 at 1:49 PM, Resident #2 up per usual self and ambulating in hallway.On 2/27/26 3:46 PM, Resident Lung sounds with expiratory wheezes.On 3/01/26 at 10:41 AM, Resident #2 continues on antibiotics for pneumonia, noted to have a loose cough that the resident reported being productive at times with green/yellow sputum. Lung sounds noted to have diminished bases, respirations were even and unlabored, nasal cannula in place, no signs of respiratory distress, and resident denying any chest pain. Review of the Hospital Discharge Summary Notes, revealed that Resident #2 was admitted on [DATE] and discharged on 2/25/26 from the hospital. The hospital course revealed that Resident #2 was admitted for shock in the setting of COVID-19 infection, was weaned off pressors (powerful intravenous medications used to treat life-threatening hypotension by constricting blood vessels and increasing blood pressure to ensure adequate organ perfusion) when he arrived to the Medical Intensive Care Unit (MICU). Required ongoing respiratory support with supplemental oxygen due to Acute Hypoxemic (low level of oxygen in the blood) Respiratory Failure (AHRF). Infectious Disease (ID) was consulted for assistance with antibiotic regimen and Resident #2 was medically ready to discharge back to the facility on 2/25/26 with oral antibiotics and follow up with the physician one week post-hospitalization. Physical Exam documented productive cough with moderate amounts of thick, cream colored sputum. Laboratory results documented: high white blood cell count at 18.9, Methicillin-resistant Staphylococcus aureus (MRSA) positive result,Review of the Hospital Discharge summary, dated [DATE], included a problem list of the following active problems/diagnoses: Shock, suspect septic shock in the setting of COVID-19 infection (Resolved)COVID-19 InfectionHistory of recent Methacillin Resistant Staphylococcus Aureus (MRSA) empyema (accumulation of pus containing MRSA in the pleural space- between lung and chest wall)History of recurrent pneumoniaConcern for recurrent aspirationCOPD exacerbationRespiratory acidosis with metabolic compensation Leukocytosis (higher than normal white blood cell count), likely secondary to COVID-19 infection and possible pneumoniaReview of Resident #2's Care Plan, identified a resolved Focus area for COVID-19 infection, date resolved on 9/24/24, which instructed to follow isolation precautions per protocol. Review of the Care Plan lacked additional documentation for COVID-19 infection following resolution of Focus area on 9/24/24. During an interview on 5/06/26 at 11:50 AM, Staff E, Licensed Practical Nurse (LPN) reported that if a resident were to have COVID-19 they would be in isolation and staff would don additional Personal Protective Equipment (PPE) during resident care. Staff E stated that Resident #2 had not been on isolation precautions upon return from the hospital on 2/25/26 due to having aspiration pneumonia. During an interview on 5/06/26 at 11:55 AM, Staff F, Registered Nurse (RN) reported that no residents have been on COVID-19 transmission based precautions (TBP) within the past year. During an interview on 5/06/26 at 2:30 PM, the Director of Nursing (DON) reported also holding the role of the facility's Infection Preventionist (IP). The DON stated that for residents positive with COVID-19 infection, TBP procedures would be implemented to prevent cross-contamination of the virus. When queried how long residents would remain in TBP procedures, the DON stated she believed it was at least 10 days and if a resident was still having symptoms, might need to continue past 10 days or may depend on a negative test. The DON confirmed that Resident #2 tested positive for COVID-19 in the hospital on 2/19/26 and returned to the facility on 2/25/26 (7 days). The DON said Resident #2 was not placed on TBP procedures upon return to the facility, due to the hospital discharge indicating COVID-19 was resolved. When asked to clarify if septic shock in the setting of COVID-19 was resolved and COVID-19 infection remained, the DON stated nursing received report from the hospital that Resident #2's COVID-19 was resolved. The DON was unable to recall if Resident #2 had negative COVID-19 testing at the hospital and denied testing Resident #2 to determine a negative COVID-19 test upon readmission. When queried about Resident #2's continued occasional loose cough producing yellow/green colored sputum and adventitious lung sounds, documented in Nurses Notes following readmission on [DATE], the DON stated Resident #2 had this at baseline. During an interview on 5/07/26 at 12:15 PM, the Medical Director stated Resident #2 had a long history of respiratory and pulmonary issues and was at higher risk for complications related to COVID-19 infection. 2. Review of the facility provided nursing staff schedule, dated 2/24/26, revealed the following working schedule of staff, in part: Staff A worked 6:00 AM to 2:30 PMStaff D worked 6:00 AM to 2:30 PMStaff B worked 6:00 AM to 6:00 PMStaff G worked 6:30 AM to 6:30 PMStaff C worked 10:00 AM to 10:30 PMStaff H worked 6:30 PM to 10:30 PMDuring an interview on 5/05/26 at 4:25 PM, Staff A, Certified Nursing Assistant (CNA), confirmed working on 2/24/26, and reported working alongside Staff B and Staff C who had respiratory symptoms and tested positive for COVID-19 during their shifts on 2/24/26. Staff A denied being asked to test for COVID-19 infection following potential exposure to COVID-19. During an interview on 5/06/26 at 10:55 AM, Staff D, CNA, recalled a couple of residents and a couple of CNA staff tested positive for COVID-19 around the same time. Staff D stated she was unsure about the facility's current guidance on what to do if staff tested positive for COVID-19 as it related to wearing a mask, testing, and staying home when sick. During an interview on 5/06/26 at 9:45 AM, Staff B, CNA, confirmed working on 2/24/26 and reported working throughout the facility on 3 of 3 hallways providing direct care to residents. Staff B recalled having symptoms of sore throat, body aches, and dizziness beginning while working her shift on 2/24/26 and reported these symptoms to Staff G, RN. Staff B revealed that Staff G gave her a COVID-19 test, which showed positive results. Staff B said Staff G told her to let management know and Staff B said she then went and reported the positive test and symptoms to the Business Office Manager(BOM)/Human Resources(HR) who indicated she would call the facility Administrator for guidance. Staff B reported that approximately 10 minutes later the BOM/HR directed Staff B to continue working her scheduled 12 hour shift on 2/24/26. Staff B stated she then called in for the following shifts scheduled to work on 2/26/26 and 2/27/26 due to symptoms and positive COVID-19 test.During an interview on 5/06/26 at 10:15 AM, Staff C, CNA, confirmed working on 2/24/26 and reported working throughout the facility on 3 of 3 hallways providing direct care to residents. Staff C recalled having symptoms of cough, congestion, and change in taste/smell worsening while working her shift on 2/24/26 and reported these symptoms to Staff G, RN, at approximately 4:00 PM. Staff C revealed that Staff G gave her a COVID-19 test, which showed positive results and was instructed by Staff G to notify management staff. Staff C revealed that she then notified BOM/HR who indicated that she would call the facility Administrator for guidance. Staff C reported that approximately 10 minutes later, the BOM/HR directed Staff C to continue working a 12 hour shift on 2/24/26, as scheduled until 10:30 PM. Staff C stated she then called in for her next scheduled shift on 2/27/26 due to fever.During an interview on 5/07/26 at 10:30 AM, Staff G, RN, confirmed working on 2/24/26 and was notified by both Staff B and Staff C of respiratory symptoms that they developed while working their shifts on 2/24/26. Staff G said she assisted Staff B and Staff C with testing for COVID-19 and stated that both Staff B and Staff C tested positive for COVID-19. Staff G said she then instructed Staff B and Staff C to go tell the office and see if they want Staff B and Staff C to continue to work. Staff G said she was told by Staff B and Staff C that they were instructed to continue working by BOM/HR. Staff G recalled that shortly after, the BOM/HR approached Staff G and told her not to mention the staff's positive COVID-19 tests. Staff G reported that on 3/02/26 she then received a write up by the DON and facility Administrator for utilizing COVID-19 tests on Staff B and Staff C. Staff G denied receiving instruction for any additional testing or monitoring of residents or staff following potential exposure. During an interview on 5/07/26 at 5:00 PM, Staff H, RN, confirmed working on 2/24/26 and stated that when she came into work at 6:30 PM, Staff B and Staff C both appeared to be ill and was informed that they both tested positive for COVID-19 and were instructed to continue working 12 hour shifts on 2/24/26. Staff H stated that the guidance for nurses was to go through Human Resources/scheduling for staff to leave early and stated she had been talked to in the past for sending staff home early. Staff H reported that she also came into the facility the following day, 2/25/26 on her day off, to ask the facility Administrator about COVID-19 positive staff and usage/availability of masks and then again brought up the positive staff who worked to the facility Administrator on 2/27/26 and Staff H said she received no answers. Staff H revealed that the facility had no current COVID-19 policies or procedures and stated there was no guidance on monitoring or testing exposed residents and/or staff. During an interview on 5/06/26 at 1:18 PM, the BOM/HR reported that when staff become ill at work, the current direction is that staff need to ask the charge nurse if they could go home and not BOM/HR to direct them. The BOM/HR confirmed that Staff B and Staff C let her know about being sick and testing positive for COVID-19. The BOM/HR denied talking to the nurse about positive tests but stated she let the facility Administrator know and was instructed to tell the DON. The BOM/HR stated she could not remember if she talked to the DON and said she did not remember any guidance received. The BOM/HR reported that when she was asked by Staff C if she should wear a mask, the BOM/HR told Staff C if she hadn't worn a mask all day, it would be up to Staff C if she wanted to wear a mask for the rest of the day. The BOM/HR stated she did not remember if Staff B and Staff C continued to work their shifts on 2/24/26 after reporting respiratory symptoms and COVID-19 positive tests.During an interview on 5/06/26 at 2:30 PM, the DON reported that employees who tested positive for COVID-19 would stay home for 7 days and the facility would do contact tracing. When queried about Staff B and Staff C testing positive at the facility on 2/24/26, the DON stated no one talked to her or left any notes about this. The DON stated that on 2/25/26, she identified a used COVID-19 test in the public bathroom trash that appeared to be negative, and no one knew anything about the test. The DON reported that staff would not be tested at the facility but would refer staff to leave or not come into work if sick and visit their provider for COVID-19 testing instead. During an interview on 5/07/26 at 1:27 PM, the facility Administrator stated that she was off work on 2/24/26 and upon return to work, word of mouth got to her that Staff B and Staff C were tested for COVID-19. The facility Administrator stated that she received many calls while off, but no calls were related to COVID-19. During an interview on 5/07/26 at 1:35 PM, the DON and the facility Administrator both deny knowledge of Staff B and Staff C testing positive for COVID-19 until Saturday or Sunday (2/28/26 or 3/01/26). The DON and facility Administrator state that there was no proof/doctor note of Staff B and Staff C testing positive for COVID-19. The DON and facility Administrator revealed the expectation that the charge nurse uses discretion to send staff home who are sick. Review of an image captured on Staff B's cellular phone, dated 2/24/26 at 3:07 PM, revealed a picture of a testing device labeled for COVID-19. The results box appeared to have a line for the control test present and a line for the COVID-19 test present, indicating that the COVID-19 test showed positive results. Review of Staff G's employee file, revealed a document titled, Coaching Form, dated 3/02/26, revealed the following description of concern: On 2/25/26, the DON found COVID-19 test kits in the bathroom trash and when Staff G was asked if she knew who had tested, Staff G stated that she had no idea. Reported by staff to DON that Staff G suggested that 2 certain employees test for COVID-19 and got them the tests from the facility stock and was present for the testing. The Coaching Form instructed the following plan of correction for COVID-19 testing: COVID-19 tests are the property of the facility. Employees are expected to purchase their own at home tests or go through their physician. The Coaching Form was signed on 3/02/26 by the DON and the facility Administrator. 3. Review of the MDS assessment, dated 2/28/26, revealed that Resident #1 had modified independence for cognitive skills in daily decision making. The list of diagnoses included respiratory failure, anemia, malnutrition, and anxiety disorder. Review of the Care Plan, initiated on 5/20/25 and revised on 11/10/25, revealed a Focus area for Resident #1's altered respiratory status/difficulty breathing related to history of pneumonia and interstitial lung disease. The Care Plan identified the following intervention: Monitor for signs and symptoms of respiratory distress and report to provider as needed: Increased respirations, decreased pulse oximetry, increased heart rate (Tachycardia), restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis (bloody sputum), cough, pleuritic pain, accessory muscle usage, skin color changes to blue/grey. Review of Resident #1's Nursing Notes revealed the following entries documented, in part: On 2/18/26 at 2:46 PM, Resident #1's vital signs were within normal limits. Resident complained of excessive tiredness and weakness, does not want this nurse to contact anyone (family or provider) at this time. On 2/19/26 at 7:21 AM, Resident #1's provider and family aware of reports of increased fatigue. Reviewed medication use with resident and new order for as needed Lorazepam (a benzodiazepine medication used for short-term relief of severe anxiety) which may be increasing fatigue. Resident #1 reported that she would rather have less anxiety and be a little more tired. On 2/21/26 at 2:59 PM, Resident #1's vital signs noted to be within normal limits and lung sounds had diminished sounds in the bases of lungs. On 2/24/26 at 3:11 PM, the provider at the facility for a routine 60 day visit and increased Resident #1s lorazepam from 1 milligram (mg) every 12 hours as needed to lorazepam 1mg three times a day as needed.On 2/27/26 at 3:18 PM, Resident #1 endorsed head congestion and noted with lung sounds diminished in the bases. Vital signs within normal limits. On 2/28/26 at 5:00 PM, Resident #1 noted to be more tired and weaker than usual. Resident #1 requested to eat supper in her room. On 2/28/26 at 6:20 PM, Resident #1 continued with increased weakness and anxiety, family requesting for Resident #1 to be seen at the hospital Emergency Department (ED). An ambulance arrived at 6:15 PM to transport the resident. On 3/02/26 at 12:59 PM, Resident #1 not expected to be leaving the hospital, resident receiving comfort cares. On 3/02/26 at 9:40 PM, the hospital called the facility and reported that Resident #1 had expired. Review of the Hospital Emergency Department (ED) Note, dated 2/28/26, revealed that Resident #1 had complaints of not feeling well for several weeks and noted decreased appetite, fatigue, dyspnea (difficulty breathing), orthopnea (difficulty breathing while lying flat), diarrhea, chest tightness, and nausea. Resident #1 noted a productive cough for 3 days and coryza (a medical term for an acute inflammatory, contagious disease of the upper respiratory tract). Resident #1 normally on 2 liters (L) of oxygen, her residential facility increased oxygen to 4L and Emergency Medical Services (EMS) increased it to 6L. The Hospital ED Note identified the following symptoms in a physical exam: Respiratory rate: 40 breaths per minute (normal is 12-20 breaths per minute) General: She is in acute distress (mild to moderate)Breath sounds: Rhonchi (low-pitched, rattling, or snoring-like lung sounds caused by air flowing through large airways obstructed by mucus, fluid, or inflammation) present. Tachypenic (rapid shallow breathing). Lung sounds diminished in the bases. Anxious at times with panic. The Hospital ED Note documented Resident #1 positive for SARS-COV-2 (COVID-19) virus on 2/28/26. Review of the Hospital Discharge summary, dated [DATE], listed the following admission diagnoses: Principle Problem: Acute on chronic respiratory failure with hypoxia (low oxygen saturation)Nursing home-acquired pneumoniaMetabolic alkalosisSevere protein-calorie malnutritionChronic bilateral pleural effusionsCOVID-19Review of the Hospital Discharge Summary, revealed an admission date of 2/28/26 and a discharge date of 3/02/26. The hospital course documented that Resident #1 was admitted through the ED on 2/28/26 due to progressive chronic symptoms of fatigue, dyspnea, chest tightness, and shortness of breath and also had progressive productive cough. Resident #1 had chronically received supplemental oxygen via nasal cannula due to Congestive Heart Failure (CHF) and recurrent pneumonia and had been hospitalized multiple times in the past several months. The hospital course documented that imaging had revealed low lung volumes with moderate bilateral pleural effusions (excess fluid in the lining of lungs) and antibiotics were started empirically for pneumonia. Resident #1 was given IV albumin (plasma protein), normal saline, and lasix (diuretic medication). Resident #1 did not want a chest tube, thoracentesis, or Computed Tomography (CT) scan, only interested in comfort measures and passed away peacefully with family present. Review of the Certificate of Death, revealed Resident #1 date of death on 3/02/26 at 9:19 PM. The immediate cause of death listed as: Chronic Hypoxic Respiratory Failure, due to or as a consequence of viral pneumonia.During an interview on 5/07/26 at 2:30 PM, Staff F, RN, reported Resident #1 always had a long history of anxiety and chronic respiratory symptoms. Staff F stated there were no new or worsening signs or symptoms of a respiratory illness she recalled leading up to Resident #1's hospitalization on 2/28/26. During an interview on 5/07/26 at 3:00 PM, Staff E, LPN reported Resident #1 had a history of being anxious throughout the overnight shift and had chronic respiratory symptoms she believed were either related to CHF or COPD and denied new or worsening symptoms of respiratory illness identified leading up to Resident #1's hospitalization on 2/28/26. During an interview on 5/06/26 at 2:30 PM, the DON/Infection Preventionist, revealed that a resident's physician would be contacted with respiratory symptoms to ask if they wanted to test the resident for COVID-19. The DON reported that residents with new, worsening or positive COVID-19 tests would be charted on every shift until symptoms resolved and documentation would include vital signs, lung sounds and a respiratory assessment. The DON reported that Resident #1 was being monitored prior to hospitalization on 2/28/26 for side effects of fatigue related to new lorazepam medication and had weakness/fatigue, anxiety at Resident #1's baseline. During an interview on 5/07/26 at 1:27 PM, the DON/Infection Preventionist and facility Administrator denied having documentation related to contact tracing for potential exposure or additional COVID-19 testing when made aware of 2 residents and 2 staff testing positive for COVID-19 within a 10 day time period. The DON/Infection Preventionist and facility Administrator revealed that the facility followed guidance from the CDC. During an interview on 5/07/26 at 12:15 PM, the facility's Medical Director revealed the expectation that the facility would implement isolation with TBP procedures for a resident who tested positive for COVID-19 and would follow the CDC guidelines for how long to isolate. The Medical Director revealed the expectation of the facility to test residents for COVID-19 who were potentially exposed to the virus, if staff working tested positive, as soon as they find out, and expected staff to be home for the recommended period of time. The Medical Director stated the facility may follow standing orders to test residents for COVID-19 and notify providers of the results. Review of the facility provided document titled, Infection Surveillance Report, dated 1/01/26 through 5/06/26, lacked identification of residents who had COVID-19 infection during this time period. On 5/07/26 at 2:00 PM, the facility Administrator and DON denied having any facility policies or procedures related to COVID-19. Review of the facility policy, titled Infection Surveillance Policy, dated 2/12/26, revealed the following:A. Purpose Statement: The purpose of this policy is to establish a comprehensive Infection Surveillance Program that detects infections early, prevents transmission within the facility, monitors infection trends and outbreaks, identifies opportunities for performance improvement, supports antibiotic stewardship initiatives, and promotes resident safety and quality of care based upon the facility's unique resident population and services and care provided.B. Policy Statement: It is the policy of the facility to maintain an organized, ongoing, facility-wide Infection Surveillance Program as part of the Infection Prevention and Control Program (IPCP) to identify, investigate, monitor, track, trend, prevent, and control infections and communicable diseases among residents, staff, volunteers, visitors, and contracted service providers.C. Procedures: Surveillance Program OversightThe Infection Preventionist (IP) shall coordinate and oversee the Infection Surveillance Program, maintain specialized infection prevention training, conduct routine surveillance activities, analyze infection data and trends, initiate investigations of suspected outbreaks, collaborate with leadership, and report findings to Quality Assurance and Performance Improvement (QAPI).Surveillance ActivitiesThe facility shall maintain active surveillance for:Respiratory infectionsInfluenza-like illnessCOVID-19PneumoniaEmployee Illness SurveillanceMonitoring shall include employee-reported illnesses/communicable diseases, infected skin lesions, work restrictions, exposure tracking, vaccination compliance, return-to-work clearance, and outbreak-related staffing concerns.Environmental SurveillanceMonitoring may include cleaning/disinfection practices, high-touch surfaces, shared equipment sanitation, water management, ice machine sanitation, linen handling, waste management, ventilation concerns, and environmental contamination risks.Infection Identification and InvestigationInfection IdentificationNursing reportsNew infectionsChange in conditionLaboratory results/positive culturesReportable disease concernsWhen a suspected infection is identified:Appropriate precautions shall be initiated;The physician/practitioner shall be notified;Diagnostic testing shall be obtained as ordered;Exposed individuals shall be assessed; andFindings shall be documented.Review of the facility policy, titled Infection Control Interventions-Precautions, revised on 3/24/26 revealed the Purpose Statement that it is the policy of this facility to implement and take appropriate precautions to prevent transmission of pathogens and multidrug-resistant organismsThe Section titled, Procedure directed the following, in part: Isolation Protocol (Transmission-Based Precautions): A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Residents on transmission-based precautions should be placed into a private/single room if available/appropriate, or are cohorted with residents with the same pathogen, or share a room with a roommate with limited risk factors, in accordance with national standards. Residents will be placed on the least restrictive transmission-based precaution for the shortest duration possible under the circumstances.When a resident on transmission-based precautions must leave the resident care unit/area, the charge nurse on that unit/area shall communicate to all involved departments the nature of the isolation and shall prepare the resident for transport in accordance with current transmission-based precaution guidelines.Residents with tuberculosis are placed on airborne precautions and placed in a special room that is equipped with special air handling and ventilation capacity. If no such room is available, the resident(s) will be discharged to a facility with such capabilities.Visitors coming to visit a resident who is on transmission-based precautions or quarantine, will be informed by the facility of the potential risk of visiting and precautions necessary when visiting the resident.Review of the facility policy titled, Infection Prevention and Control Policy, revised on 8/24/25, revealed the Purpose Statement was to establish and maintain a facility-wide infection prevention and control program that is evidence-based and designed to prevent, identify, investigate, and control infections and communicable diseases among residents, staff and visitors.The Section titled Procedure directed the following, in part: The infection prevention and control program applies to all departments and staff, contracted services, volunteers, and visitors. Educate team member in regard to- When a resident requires isolation to prevent spread of infection Prohibit Team members with a communicable disease or infected skin lesions from direct contact with residents or their food if direct contact will spread the disease/infection. Require team members to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practices. 2. Provide surveillance and monitoring to: Minimize exposure to potential source of infection Uses appropriate hand hygiene prior to and after all procedures Uses CDC, NHSN, McGeer CriteriaEnsures appropriate sterile / aseptic techniques are followed as warranted Use of Personal Protective Equipment (PPE) when indicated Ensures reusable equipment is appropriately disinfected / cleaned Use single-use medication vials and other single use items appropriately and proper disposal of items. Collect data, track infections, MDROs, and outbreaks to evaluate for trends 3. Reducing the risk of spread of infection by: Following infection control practices to include (but not limited to):i. Standard Precautionsii. Enhanced Barrier Precautionsiii. Isolation Proceduresiv. Infection screening of new residents and team membersv. Blood-borne pathogensvi. Air-borne, contact and droplet precautionsb. Monitoring and documenting infections, including tracking, and analyzing outbreaks of infection as well as implementing and documenting actions to resolve any noted issue. c. Work with community, state, and federal health agencies as warranted d. Manage food safety, including team member health and hygiene, pest control, investigation of potential food-borne illnesses and wash disposal. e. Define and manage appropriate health initiatives, such as, immunization program & TB screening on admission and following discovery of a new active case consistent with State requirements. Review of the CDC Infection Control Guidance: SARS COV-2, updated 12/11/2025, revealed the following practices for COVID-19 in Long Term Care Facilities: 1. Health Care Professionals (HCP) who enter the room of a patient with suspected or confirmed COVID-19 infection should adhere to Standard Precautions and use an approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection. (i.e. goggles or face shield that covers the front and sides of the face). Duration of Transmission Based Precautions for Patients with COVID-19 infection should continue to wear source control until symptoms resolve or, for those who never developed symptoms, until they meet the criteria to end isolation as list

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to determine that it was clinically appropriate and safe for a resident to self-administer medications for 1 of 1 residents reviewed for the self-administration of medications(Resident #13). The facility reported a census of 45 residents. Findings included: The Quarterly Minimum Data Set(MDS) assessment tool, dated 9/30/25, listed diagnoses for Resident #13 which included chronic obstructive pulmonary disease(COPD), a disease which caused symptoms such as shortness of breath), heart failure, and diabetes. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The 2022 facility policy Self-Administration of Medications stated residents had the right to self-administer medications if the interdisciplinary team determined that it was clinically appropriate and safe for the resident to do so. The December 2025 Medication Administration Record(MAR) listed a 7/21/25 order for Ipratropium-Albuterol Solution(a medication used to treat COPD) 0.5-2.5 milligrams(mg)/milliliters(ml) 3 ml inhale orally four times a day related to COPD.2/20/24 Care Plan entries stated the resident was at risk for altered respiratory status and difficulty breathing related to COPD, a history of respiratory failure, and a history of pneumonia. The entries directed staff to administer medications as ordered and monitor for effectiveness.On 12/11/25 at 1:00 p.m. Staff A Licensed Practical Nurse(LPN) stated that she would administer the resident's nebulizer(a medical device that turns liquid medicine into a fine, inhalable mist) treatment. She retrieved a 3 ml vial of Ipratropium-Albuterol Solution 0.5-2.5 mg/ml from the medication cart and went to the resident's room. When she arrived, the resident was putting the cap on his nebulizer's medicine cup and stated he already added the medication from a vial he had in his pocket. The facility lacked documentation of an assessment carried out to show the resident was safe to self-administer his medication.On 12/10/25 at 1:05 p.m. Staff A stated Resident #13 was not supposed to carry out his nebulizer treatments on his own. On 12/11/25 at 11:19 a.m., the Assistant Director of Nursing(ADON) stated residents who did not have an assessment completed for the self-administration of medications should not keep medications in their rooms. She stated the nurses should administer the resident's nebulizer treatment.On 12/11/25 at 11:51 a.m., the Director of Nursing(DON) stated residents should not keep albuterol vials in their rooms for self-administration.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to ensure residents were free from physical abuse for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents. Findings:The Minimum Data Set(MDS) assessment tool, dated 9/2/25, listed diagnoses for Resident #35 which included unspecified intellectual disabilities, hearing loss, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severely impaired cognition. The facility Abuse Policy, dated 7/1/25, stated all residents had the right to be free from abuse and neglect. The policy stated assault of a dependent adult was the commission of any act which was generally intended to cause pain or injury or which was generally intended to result in physical contact considered by a reasonable person to be insulting or offensive or any act intended to place another in fear of immediate physical contact which would be painful, injurious, insulting, or offensive, coupled with the apparent ability to execute the act.Care Plan entries, dated 4/4/25, stated the resident had impaired cognitive function, intellectual disability, and hearing loss impeding communications. The entries directed staff to orient the resident as needed, keep his routine consistent, and engage him in simple structured activities that avoided overly demanding tasks. An Unwitnessed Fall report, dated 10/28/25 at 1:46 p.m., stated the resident sat on the floor after he slid out of bed. The resident did not have any observable injuries. A 10/28/25 2:59 p.m. Nurses Note stated the resident sat on the floor in front of the bed. He denied injuries and stated he slipped out of bed. The facility applied slide strips in front of his bed for safety. An untitled facility investigation, dated 12/8/25, stated that the staff notified the Administrator on 10/28/25 that Staff A Licensed Practical Nurse(LPN) yelled and poked the resident in the chest. The resident reported that no one poked him in the chest or yelled at him. The resident denied being fearful or afraid of the nursing staff. A 10/28/25 statement, written by Staff B Certified Nursing Assistant(CNA), stated she went into the resident's room to help him up and Staff A came in and asked what happened. Staff A started poking him in the chest and stated that she was sicker than him and this was not funny, she didn't feel good, and was stuck here until 4:00 p.m. because you(the resident) couldn't stay off the floor.A 10/28/25 statement, written by Staff F CNA, stated she was in the room after Resident #35 fell. Staff A came in and started to get stern with him and told him this wasn't funny and he should stay off the floor. She then cried and got in his face and told him that she was sicker than you(the resident) and she could not deal with this. A 10/28/25 statement, written by Staff C CNA, stated the resident fell out of bed around 1:30 p.m. and Staff A came in and was upset because this was the second fall of the day. Staff A yelled and said that she felt worse than the resident did and now she had to stay until 4:00 pm. to keep an eye on him. While she said this, she poked the resident's chest kind of roughly. A 10/28/25 statement, written by Staff D CNA stated Resident #35 was on the floor and Staff A came in and almost cried and said he was the second person on the floor and she wouldn't be able to finish work until 4:00 p.m. and she didn't feel good. Staff D stated she did not see Staff A poke the resident and stated this was blown up for nothing.A 10/28/25 statement, written by Staff A, stated staff called her to the room and the resident sat on the floor and leaned against his bed. Staff A stated she felt overwhelmed by the number of aides in the room and tried to finish her assessment. She spoke very loudly to the resident due to his hearing loss. She stated she did not feel well today and was upset about not being able to leave on time due to another fall. She wrote that she did become visually frustrated in the room and teared up during her assessment. She stated she did not yell at the resident or poke at him in any way. She stated she did feel frustrated with the CNAs at the time. On 12/8/25 at 2:13 p.m., Resident #35 sat in his recliner in his room. The resident did not answer when spoken to by the State Agency. On 12/8/25 at 12:21 p.m., via phone, Staff B stated she received a page that the resident was on the floor. The resident sat on the floor and Staff A asked why he was still on the floor. Staff A stated she wasn't worried about the resident's vitals. She walked up to him and poked him in the chest because she had to work late. The resident was standing at the time she jabbed him. Staff B stated after this occurred, she and Staff F told the Administrator and wrote out statements. She stated she did not see Staff A be physical before this but it was normal for her to be rude. On 12/10/25 at 10:57 a.m., Staff F stated on the day Resident #35 fell, Staff A had a rough day. She had had surgery and was feeling under the weather. She stated when the resident fell, she, Staff B CNA, Staff C CNA and another CNA entered the room and then Staff A came in. She stated another resident had just fallen prior to this and Staff A was overwhelmed and crying and this was toward the end of the shift. Staff F stated Staff A entered the room and said why did you fall on the floor, what are you doing?. Staff F stated the resident was on the floor but leaned against the bed. Staff F stated Staff A completed an assessment including obtaining vitals and looking over his legs. Staff F stated they stood him up and he was walking and Staff A tapped his left shoulder one time and stated why did you do that?. Staff F demonstrated on the table how hard she thought Staff A tapped the resident. Staff F tapped the table in a manner that did not appear to be with any force. She stated after the incident, she went to the Administrator to report this and filled out a statement.On 12/10/25 at 1:50 p.m., Staff F stated after the resident fell, he was startled and overwhelmed but was not crying and did not appear scared. On 12/11/25 at 8:08 a.m., Staff F stated Staff A already had her vital equipment with her when she walked in the resident's room. On 12/10/25 at 11:08 a.m., via phone Staff C stated the day Resident #35 fell was chaotic and another resident had also fallen. She stated she and other staff entered the room after he fell and Staff A followed. Staff C stated Staff A was pretty angry and wanted them to get him up but she hadn't taken his vitals. They got him off the floor and Staff A didn't check him at all. Staff A told them to get him off the floor. After they assisted him to stand, Staff A obtained his vitals and started yelling that she felt worse than you referring to the resident and now she had to stay later because you had to fall. Staff C stated she poked him in his chest and sternum. She stated she poked him 3-4 times in a rough manner. Staff C stated that Staff A was mean to the residents but could not give an example of which residents or further details. She stated she wrote out a statement for the Administrator related to this incident. On 12/10/25 at 1:54 p.m., via phone, Staff C stated after the fall, the resident seemed confused like he didn't understand what was happening or why Staff A was upset with him but he was not crying. On 12/10/25 at 1:05 p.m. Staff A stated on the day the resident fell, she was sick and had just returned from the facility after surgery. She stated 20 minutes before the end of her shift, she had another resident fall. She had just gotten the other resident to the nursing station to continue neurological checks when staff notified her that Resident #35 was on the floor. Staff A stated she was tearful and disappointed with her staff. She stated when she walked into the resident's room, she was tearful and disappointed that the staff were not watching the residents but instead stood at the nursing station waiting for their shift to end. Staff A stated she said to Staff B that she was sick and didn't feel good and now had to stay longer. Staff A stated she told staff to back away from the resident and admitted she was terse at this time. She assessed the resident on the floor. She stated she is sure she raised her voice but did not change her tone. She stated she had to talk to the resident into his left ear. She stated she did not ask the resident why he fell and did not poke him. She stated none of her comments were directed to the resident but were directed to Staff B. She stated the resident did not cry during this event. Staff A stated she immediately implemented the intervention of placing strips in his room and sat with the resident after the fall. She stated she would not ask the resident why he fell because this would hurt his pride. She stated after the incident, the office called her in and she told them the same thing. Staff A stated she should have never said anything to Staff B(regarding being sick or having to work later). On 12/10/25 at 2:16 p.m. via phone, Staff D stated when the resident fell, Staff A assessed him before they got him up. On 12/10/25 at 2:53 p.m., the Administrator stated that 2 CNAs approached her and said that Resident #35 fell and Staff A was in his face and yelled at him. They stated Staff A and the resident were both crying so she said she would look at that. She interviewed the resident and Staff A. On 12/11/25 at 9:53 a.m., Staff A stated staff called her down to Resident #35's room and she was tearful. She stated to Staff B that she didn't feel good and just wanted to go home. She stated she already had her vitals equipment with her as well as a neurological sheet. She completed an assessment on the resident including obtaining vital signs and checking range of motion. She asked the aides if this was the third time the resident had a fall to verify this. She stated after the fall they placed strips on his floor. After she assessed him, she asked them to assist him into a wheelchair and bring him to the nursing station so she could carry out 15 minute neurological checks. She stated she did not poke the resident's shoulder or his chest. She stated she had asked staff to back away while she assessed the resident and they were behind her so she didn't know how they would have seen her poke his chest. She stated the resident's assessment was normal and he did not have any injuries or bruises. She stated she did not ask the resident why he fell and did not say that she was sicker than the resident. She stated she did say that now she had to stay late but did not say it to the resident but to the staff in the room. She stated she did not say that she didn't care about the vital signs and to just get him up. She stated she regretted that she said she was sick and wanted to go home. She stated after the fall, she stayed at the facility to complete assessments. She stated the resident was fine and had a soft drink and she sat with him. She stated the resident did not cry during or after this incident. On 12/11/25 at 11:19 a.m., the Assistant Director of Nursing(ADON) stated staff should treat residents with respect and dignity. On 12/11/25 at 11:51 a.m., the Director of Nursing(DON) stated staff should report allegations of abuse to the administrator and they would remove the staff member(from resident care) and notify the State Agency. On 12/11/25 at 12:45 p.m., the Administrator stated the facility should report all allegations of abuse to the State Agency. She stated she trusted the previous DON's judgement regarding this and she shouldn't have. She stated the facility would suspend the staff member pending an investigation.

Based on clinical record review, policy review, and staff interviews, the facility failed to carry out a gradual dose reduction(GDR) or ensure the provider documented why the reduction would be clinically contraindicated for 1 of 5 residents reviewed for psychotropic medications(Resident #35). The facility reported a census of 45 residents. Findings included:The Minimum Data Set(MDS) assessment tool, dated 9/2/25, listed diagnoses for Resident #35 which included unspecified intellectual disabilities, hearing loss, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severely impaired cognition. The December 2025 Medication Administration Record(MAR) listed the following:A 3/27/25 order for Trazodone(an antidepressant) 100 milligrams(mg) daily.A 3/28/25 order for Duloxetine(an antidepressant) 120 mg daily. As of 12/8/25, the facility lacked documentation of an attempted GDR for the above medications or provider documentation as to why the reduction would be clinically contraindicated.On 12/11/25, the Administrator provided a 9/26/25 Pharmacist's Recommendation to Prescriber form. On 12/10/25, the provider checked the form's boxes which stated a reduction of the medications was contraindicated but did not provide documentation as to why the reductions were contraindicated. The facility lacked provider documentation related to the GDRs prior to 12/10/25, after the State Agency requested information. On 12/11/25 at 11:19 a.m., the Assistant Director of Nursing(ADON) stated within the first year of a resident starting a psychotropic medication, they needed to make two attempts at a GDR in 2 separate quarters or have supporting documentation from the provider as to why the GDR would be contraindicated. She stated they faxed the provider multiple times and they did not get a response.The undated facility policy Psychotropic Drug Monitoring stated all psychotropic medication use would be appropriate and given in the lowest effective dose to help minimize the risk of side effects. The policy stated that the facility should carry out a GDR twice in 2 separate quarters during the first year of the medication's usage.

Based on clinical record review, policy review, and staff interviews, the facility failed to report an allegation of abuse to the State Agency for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents. Findings:The Minimum Data Set(MDS) assessment tool, dated 9/2/25, listed diagnoses for Resident #35 which included unspecified intellectual disabilities, hearing loss, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severely impaired cognition. The facility Abuse Policy, dated 7/1/25, stated the facility would report all allegations of abuse to the State Agency within 2 hours.Care Plan entries, dated 4/4/25, stated the resident had impaired cognitive function, intellectual disability, and hearing loss impeding communications. The entries directed staff to orient the resident as needed, keep his routine consistent, and engage him in simple structured activities that avoided overly demanding tasks. An Unwitnessed Fall report, dated 10/28/25 at 1:46 p.m., stated the resident sat on the floor after he slid out of bed. The resident did not have any observable injuries. A 10/28/25 2:59 p.m. Nurses Note stated the resident sat on the floor in front of the bed. He denied injuries and stated he slipped out of bed. The facility applied slide strips in front of his bed for safety. An untitled facility investigation, dated 12/8/25, stated that the staff notified the Administrator on 10/28/25 that Staff A Licensed Practical Nurse(LPN) yelled and poked the resident in the chest. The resident reported that no one poked him in the chest or yelled at him. The resident denied being fearful or afraid of the nursing staff. A 10/28/25 statement, written by Staff B Certified Nursing Assistant(CNA), stated she went into the resident's room to help him up and Staff A came in and asked what happened. Staff A started poking him in the chest and stated that she was sicker than him and this was not funny, she didn't feel good, and was stuck here until 4:00 p.m. because you(the resident) couldn't stay off the floor.A 10/28/25 statement, written by Staff F CNA, stated she was in the room after Resident #35 fell. Staff A came in and started to get stern with him and told him this wasn't funny and he should stay off the floor. She then cried and got in his face and told him that she was sicker than you(the resident) and she could not deal with this. A 10/28/25 statement, written by Staff C CNA, stated the resident fell out of bed around 1:30 p.m. and Staff A came in and was upset because this was the second fall of the day. Staff A yelled and said that she felt worse than the resident did and now she had to stay until 4:00 pm. to keep an eye on him. While she said this, she poked the resident's chest kind of roughly. A 10/28/25 statement, written by Staff D CNA stated Resident #35 was on the floor and Staff A came in and almost cried and said he was the second person on the floor and she wouldn't be able to finish work until 4:00 p.m. and she didn't feel good. Staff D stated she did not see Staff A poke the resident and stated this was blown up for nothing.A 10/28/25 statement, written by Staff A, stated staff called her to the room and the resident sat on the floor and leaned against his bed. Staff A stated she felt overwhelmed by the number of aides in the room and tried to finish her assessment. She spoke very loudly to the resident due to his hearing loss. She stated she did not feel well today and was upset about not being able to leave on time due to another fall. She wrote that she did become visually frustrated in the room and teared up during her assessment. She stated she did not yell at the resident or poke at him in any way. She stated she did feel frustrated with the CNAs at the time. The facility lacked documentation they reported the allegation of abuse to the State Agency.On 12/8/25 at 2:13 p.m., Resident #35 sat in his recliner in his room. The resident did not answer when spoken to by the State Agency. On 12/8/25 at 12:21 p.m., via phone, Staff B stated she received a page that the resident was on the floor. The resident sat on the floor and Staff A asked why he was still on the floor. Staff A stated she wasn't worried about the resident's vitals. She walked up to him and poked him in the chest because she had to work late. The resident was standing at the time she jabbed him. Staff B stated after this occurred, she and Staff F told the Administrator and wrote out statements. She stated she did not see Staff A be physical before this but it was normal for her to be rude. On 12/10/25 at 10:57 a.m., Staff F stated on the day Resident #35 fell, Staff A had a rough day. She had had surgery and was feeling under the weather. She stated when the resident fell, she, Staff B CNA, Staff C CNA and another CNA entered the room and then Staff A came in. She stated another resident had just fallen prior to this and Staff A was overwhelmed and crying and this was toward the end of the shift. Staff F stated Staff A entered the room and said why did you fall on the floor, what are you doing?. Staff F stated the resident was on the floor but leaned against the bed. Staff F stated Staff A completed an assessment including obtaining vitals and looking over his legs. Staff F stated they stood him up and he was walking and Staff A tapped his left shoulder one time and stated why did you do that?. Staff F demonstrated on the table how hard she thought Staff A tapped the resident. Staff F tapped the table in a manner that did not appear to be with any force. She stated after the incident, she went to the Administrator to report this and filled out a statement.On 12/10/25 at 1:50 p.m., Staff F stated after the resident fell, he was startled and overwhelmed but was not crying and did not appear scared. On 12/11/25 at 8:08 a.m., Staff F stated Staff A already had her vital equipment with her when she walked in the resident's room. On 12/10/25 at 11:08 a.m., via phone Staff C stated the day Resident #35 fell was chaotic and another resident had also fallen. She stated she and other staff entered the room after he fell and Staff A followed. Staff C stated Staff A was pretty angry and wanted them to get him up but she hadn't taken his vitals. They got him off the floor and Staff A didn't check him at all. Staff A told them to get him off the floor. After they assisted him to stand, Staff A obtained his vitals and started yelling that she felt worse than you referring to the resident and now she had to stay later because you had to fall. Staff C stated she poked him in his chest and sternum. She stated she poked him 3-4 times in a rough manner. Staff C stated that Staff A was mean to the residents but could not give an example of which residents or further details. She stated she wrote out a statement for the Administrator related to this incident. On 12/10/25 at 1:54 p.m., via phone, Staff C stated after the fall, the resident seemed confused like he didn't understand what was happening or why Staff A was upset with him but he was not crying. On 12/10/25 at 1:05 p.m. Staff A stated on the day the resident fell, she was sick and had just returned from the facility after surgery. She stated 20 minutes before the end of her shift, she had another resident fall. She had just gotten the other resident to the nursing station to continue neurological checks when staff notified her that Resident #35 was on the floor. Staff A stated she was tearful and disappointed with her staff. She stated when she walked into the resident's room, she was tearful and disappointed that the staff were not watching the residents but instead stood at the nursing station waiting for their shift to end. Staff A stated she said to Staff B that she was sick and didn't feel good and now had to stay longer. Staff A stated she told staff to back away from the resident and admitted she was terse at this time. She assessed the resident on the floor. She stated she is sure she raised her voice but did not change her tone. She stated she had to talk to the resident into his left ear. She stated she did not ask the resident why he fell and did not poke him. She stated none of her comments were directed to the resident but were directed to Staff B. She stated the resident did not cry during this event. Staff A stated she immediately implemented the intervention of placing strips in his room and sat with the resident after the fall. She stated she would not ask the resident why he fell because this would hurt his pride. She stated after the incident, the office called her in and she told them the same thing. Staff A stated she should have never said anything to Staff B(regarding being sick or having to work later). On 12/10/25 at 2:16 p.m. via phone, Staff D stated when the resident fell, Staff A assessed him before they got him up. On 12/10/25 at 2:53 p.m., the Administrator stated that 2 CNAs approached her and said that Resident #35 fell and Staff A was in his face and yelled at him. They stated Staff A and the resident were both crying so she said she would look at that. She interviewed the resident and Staff A. On 12/11/25 at 9:53 a.m., Staff A stated staff called her down to Resident #35's room and she was tearful. She stated to Staff B that she didn't feel good and just wanted to go home. She stated she already had her vitals equipment with her as well as a neurological sheet. She completed an assessment on the resident including obtaining vital signs and checking range of motion. She asked the aides if this was the third time the resident had a fall to verify this. She stated after the fall they placed strips on his floor. After she assessed him, she asked them to assist him into a wheelchair and bring him to the nursing station so she could carry out 15 minute neurological checks. She stated she did not poke the resident's shoulder or his chest. She stated she had asked staff to back away while she assessed the resident and they were behind her so she didn't know how they would have seen her poke his chest. She stated the resident's assessment was normal and he did not have any injuries or bruises. She stated she did not ask the resident why he fell and did not say that she was sicker than the resident. She stated she did say that now she had to stay late but did not say it to the resident but to the staff in the room. She stated she did not say that she didn't care about the vital signs and to just get him up. She stated she regretted that she said she was sick and wanted to go home. She stated after the fall, she stayed at the facility to complete assessments. She stated the resident was fine and had a soft drink and she sat with him. She stated the resident did not cry during or after this incident. On 12/11/25 at 11:19 a.m., the Assistant Director of Nursing(ADON) stated staff should treat residents with respect and dignity. On 12/11/25 at 11:51 a.m., the Director of Nursing(DON) stated staff should report allegations of abuse to the administrator and they would remove the staff member(from resident care) and notify the State Agency. On 12/11/25 at 12:45 p.m., the Administrator stated the facility should report all allegations of abuse to the State Agency. She stated she trusted the previous DON's judgement regarding this and she shouldn't have. She stated the facility would suspend the staff member pending an investigation.

Based on clinical record review, policy review, and staff interviews, the facility failed to separate an alleged perpetrator of abuse from residents for 1 of 1 residents reviewed for abuse(Resident #35). The facility reported a census of 45 residents. Findings:The Minimum Data Set(MDS) assessment tool, dated 9/2/25, listed diagnoses for Resident #35 which included unspecified intellectual disabilities, hearing loss, and coronary artery disease. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 6 out of 15, indicating severely impaired cognition. The facility Abuse Policy, dated 7/1/25, stated the facility would separate the employee accused of abuse from all residents.Care Plan entries, dated 4/4/25, stated the resident had impaired cognitive function, intellectual disability, and hearing loss impeding communications. The entries directed staff to orient the resident as needed, keep his routine consistent, and engage him in simple structured activities that avoided overly demanding tasks. An Unwitnessed Fall report, dated 10/28/25 at 1:46 p.m., stated the resident sat on the floor after he slid out of bed. The resident did not have any observable injuries. A 10/28/25 2:59 p.m. Nurses Note stated the resident sat on the floor in front of the bed. He denied injuries and stated he slipped out of bed. The facility applied slide strips in front of his bed for safety. An untitled facility investigation, dated 12/8/25, stated that the staff notified the Administrator on 10/28/25 that Staff A Licensed Practical Nurse(LPN) yelled and poked the resident in the chest. The resident reported that no one poked him in the chest or yelled at him. The resident denied being fearful or afraid of the nursing staff. A 10/28/25 statement, written by Staff B Certified Nursing Assistant(CNA), stated she went into the resident's room to help him up and Staff A came in and asked what happened. Staff A started poking him in the chest and stated that she was sicker than him and this was not funny, she didn't feel good, and was stuck here until 4:00 p.m. because you(the resident) couldn't stay off the floor.A 10/28/25 statement, written by Staff F CNA, stated she was in the room after Resident #35 fell. Staff A came in and started to get stern with him and told him this wasn't funny and he should stay off the floor. She then cried and got in his face and told him that she was sicker than you(the resident) and she could not deal with this. A 10/28/25 statement, written by Staff C CNA, stated the resident fell out of bed around 1:30 p.m. and Staff A came in and was upset because this was the second fall of the day. Staff A yelled and said that she felt worse than the resident did and now she had to stay until 4:00 pm. to keep an eye on him. While she said this, she poked the resident's chest kind of roughly. A 10/28/25 statement, written by Staff D CNA stated Resident #35 was on the floor and Staff A came in and almost cried and said he was the second person on the floor and she wouldn't be able to finish work until 4:00 p.m. and she didn't feel good. Staff D stated she did not see Staff A poke the resident and stated this was blown up for nothing.A 10/28/25 statement, written by Staff A, stated staff called her to the room and the resident sat on the floor and leaned against his bed. Staff A stated she felt overwhelmed by the number of aides in the room and tried to finish her assessment. She spoke very loudly to the resident due to his hearing loss. She stated she did not feel well today and was upset about not being able to leave on time due to another fall. She wrote that she did become visually frustrated in the room and teared up during her assessment. She stated she did not yell at the resident or poke at him in any way. She stated she did feel frustrated with the CNAs at the time. Staff A's Archived Time Card Report documented she continued to work at the facility from the date of the allegation of abuse on 10/28/25 until 12/10/25.On 12/8/25 at 2:13 p.m., Resident #35 sat in his recliner in his room. The resident did not answer when spoken to by the State Agency. On 12/8/25 at 12:21 p.m., via phone, Staff B stated she received a page that the resident was on the floor. The resident sat on the floor and Staff A asked why he was still on the floor. Staff A stated she wasn't worried about the resident's vitals. She walked up to him and poked him in the chest because she had to work late. The resident was standing at the time she jabbed him. Staff B stated after this occurred, she and Staff F told the Administrator and wrote out statements. She stated she did not see Staff A be physical before this but it was normal for her to be rude. On 12/10/25 at 10:57 a.m., Staff F stated on the day Resident #35 fell, Staff A had a rough day. She had had surgery and was feeling under the weather. She stated when the resident fell, she, Staff B CNA, Staff C CNA and another CNA entered the room and then Staff A came in. She stated another resident had just fallen prior to this and Staff A was overwhelmed and crying and this was toward the end of the shift. Staff F stated Staff A entered the room and said why did you fall on the floor, what are you doing?. Staff F stated the resident was on the floor but leaned against the bed. Staff F stated Staff A completed an assessment including obtaining vitals and looking over his legs. Staff F stated they stood him up and he was walking and Staff A tapped his left shoulder one time and stated why did you do that?. Staff F demonstrated on the table how hard she thought Staff A tapped the resident. Staff F tapped the table in a manner that did not appear to be with any force. She stated after the incident, she went to the Administrator to report this and filled out a statement.On 12/10/25 at 1:50 p.m., Staff F stated after the resident fell, he was startled and overwhelmed but was not crying and did not appear scared. On 12/11/25 at 8:08 a.m., Staff F stated Staff A already had her vital equipment with her when she walked in the resident's room. On 12/10/25 at 11:08 a.m., via phone Staff C stated the day Resident #35 fell was chaotic and another resident had also fallen. She stated she and other staff entered the room after he fell and Staff A followed. Staff C stated Staff A was pretty angry and wanted them to get him up but she hadn't taken his vitals. They got him off the floor and Staff A didn't check him at all. Staff A told them to get him off the floor. After they assisted him to stand, Staff A obtained his vitals and started yelling that she felt worse than you referring to the resident and now she had to stay later because you had to fall. Staff C stated she poked him in his chest and sternum. She stated she poked him 3-4 times in a rough manner. Staff C stated that Staff A was mean to the residents but could not give an example of which residents or further details. She stated she wrote out a statement for the Administrator related to this incident. On 12/10/25 at 1:54 p.m., via phone, Staff C stated after the fall, the resident seemed confused like he didn't understand what was happening or why Staff A was upset with him but he was not crying. On 12/10/25 at 1:05 p.m. Staff A stated on the day the resident fell, she was sick and had just returned from the facility after surgery. She stated 20 minutes before the end of her shift, she had another resident fall. She had just gotten the other resident to the nursing station to continue neurological checks when staff notified her that Resident #35 was on the floor. Staff A stated she was tearful and disappointed with her staff. She stated when she walked into the resident's room, she was tearful and disappointed that the staff were not watching the residents but instead stood at the nursing station waiting for their shift to end. Staff A stated she said to Staff B that she was sick and didn't feel good and now had to stay longer. Staff A stated she told staff to back away from the resident and admitted she was terse at this time. She assessed the resident on the floor. She stated she is sure she raised her voice but did not change her tone. She stated she had to talk to the resident into his left ear. She stated she did not ask the resident why he fell and did not poke him. She stated none of her comments were directed to the resident but were directed to Staff B. She stated the resident did not cry during this event. Staff A stated she immediately implemented the intervention of placing strips in his room and sat with the resident after the fall. She stated she would not ask the resident why he fell because this would hurt his pride. She stated after the incident, the office called her in and she told them the same thing. Staff A stated she should have never said anything to Staff B(regarding being sick or having to work later). On 12/10/25 at 2:16 p.m. via phone, Staff D stated when the resident fell, Staff A assessed him before they got him up. On 12/10/25 at 2:53 p.m., the Administrator stated that 2 CNAs approached her and said that Resident #35 fell and Staff A was in his face and yelled at him. They stated Staff A and the resident were both crying so she said she would look at that. She interviewed the resident and Staff A. On 12/11/25 at 9:53 a.m., Staff A stated staff called her down to Resident #35's room and she was tearful. She stated to Staff B that she didn't feel good and just wanted to go home. She stated she already had her vitals equipment with her as well as a neurological sheet. She completed an assessment on the resident including obtaining vital signs and checking range of motion. She asked the aides if this was the third time the resident had a fall to verify this. She stated after the fall they placed strips on his floor. After she assessed him, she asked them to assist him into a wheelchair and bring him to the nursing station so she could carry out 15 minute neurological checks. She stated she did not poke the resident's shoulder or his chest. She stated she had asked staff to back away while she assessed the resident and they were behind her so she didn't know how they would have seen her poke his chest. She stated the resident's assessment was normal and he did not have any injuries or bruises. She stated she did not ask the resident why he fell and did not say that she was sicker than the resident. She stated she did say that now she had to stay late but did not say it to the resident but to the staff in the room. She stated she did not say that she didn't care about the vital signs and to just get him up. She stated she regretted that she said she was sick and wanted to go home. She stated after the fall, she stayed at the facility to complete assessments. She stated the resident was fine and had a soft drink and she sat with him. She stated the resident did not cry during or after this incident. On 12/11/25 at 11:19 a.m., the Assistant Director of Nursing(ADON) stated staff should treat residents with respect and dignity. On 12/11/25 at 11:51 a.m., the Director of Nursing(DON) stated staff should report allegations of abuse to the administrator and they would remove the staff member(from resident care) and notify the State Agency. On 12/11/25 at 12:45 p.m., the Administrator stated the facility should report all allegations of abuse to the State Agency. She stated she trusted the previous DON's judgement regarding this and she shouldn't have. She stated the facility would suspend the staff member pending an investigation.

Based on clinical record review, policy review, and staff interview, the facility failed to administer insulin in a timely manner with respect to the obtainment of the resident's blood sugar(BS) for 1 of 2 residents(Resident #2) reviewed for insulin(an injectable medication used to lower blood sugars). The facility reported a census of 45 residents.Findings included:The Minimum Data Set(MDS) assessment tool, dated 11/2/25, listed diagnoses for Resident #2 which included diabetes(a disease which causes irregularities in blood sugars), arthritis, and anxiety, and listed his Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. The resident's Blood Sugar Summary included the following blood sugar readings:11/23/25 5:20 a.m. 110 mg/dl(milligrams(mg)/deciliter(dl) and 8:11 a.m. 110 mg/dl11/24/25 5:25 a.m. 150 mg/dl and 9:18 a.m. 150 mg/dl11/25/25 5:30 a.m. 225 mg/dl and 6:50 a.m. 225 mg/dl11/26/25 6:23 a.m. 222 mg/dl and 8:58 a.m. 222 mg/dl11/29/25 5:37 a.m. 188 mg/dl and 8:28 a.m. 188 mg/dl11/30/25 5:19 a.m. 253 mg/dl and 826 a.m. 253 mg/dlThe November 2025 Medication Administration Record(MAR) listed an 11/21/25 order for humalog(a type of insulin) per sliding scale as follows: 20 units for BS between 60 and 150 mg/dl and 40 units for BS between 151 and 400 mg/dl. The order directed staff to call the provider for BS under 60 or over 400 mg/dl. The MAR documented nurses utilized the above blood sugars obtained on the night shift to determine the resident's breakfast sliding scale insulin amount. On 12/10/25 at 10:50 a.m., Staff E Registered Nurse(RN) stated the third shift nurses obtained blood sugars and the day shift nurses utilized that reading to determine the amount of sliding scale insulin to administer.On 12/10/25 at 1:05 p.m. Staff A Licensed Practical Nurse(LPN) stated that third shift staff obtained most blood sugars and the day shift nurses utilized those to determine the amount of sliding scale insulin to give. She stated the day shift nurses entered the third shift blood sugars into the electronic record when they administered the sliding scale insulin. Staff A stated breakfast used to be at 7:00 a.m. but was now later so this needed discussed. On 12/11/25 at 11:19 a.m., the Assistant Director of Nursing(ADON) stated the night nurse carried out blood sugars but stated best practice would be to check it within 30 minutes of the administration of sliding scale insulin. On 12/11/25 at 11:51 a.m., the Director of Nursing(DON) stated staff should carry out blood sugars around 30 minutes prior to the administration of sliding scale insulin, or as close as they could get. The undated facility policy Insulin Pen Administration did not provide guidelines for staff with regard to the obtainment of blood sugars in relation to the administration time of sliding scale insulin.

Based on clinical record review, policy review, and staff interview, the facility failed to assess and intervene in a timely manner after a resident complained of signs and symptoms of an infection for 1 of 2 residents reviewed for a change in condition(Resident #26). The facility reported a census of 45 residents. Findings included:The Minimum Data Set(MDS) assessment tool, dated 9/23/25, listed diagnoses for Resident #26 which included diabetes(a disease which caused irregularities in blood sugars), non-Alzheimer's dementia, and depression. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. On 12/8/25 at 1:42 p.m., Resident #26 stated it took the facility a week before they obtained medication for her yeast infection. She stated she had burning and itching and it was very, very uncomfortable.A 11/25/25 5:11 AM Nurses Note documented that the facility sent a fax to the resident's provider related to a possible yeast infection. The resident's vaginal area was red and she had discomfort when using the bathroom and sitting. The resident requested an order for Diflucan(an antifungal medication). A 12/2/25 Nurses Note stated the facility received an order for Diflucan 150 milligrams(mg) x 1 dose. The facility lacked documentation of a follow-up to the fax sent between 11/25/25 and 12/2/25 and lacked documentation of assessments carried out related to the resident's concern between 11/25/25 and 12/7/25.On 12/10/25 at 1:05 p.m. Staff A Licensed Practical Nurse(LPN) stated if a resident had signs and symptoms of an infection, she would assess them and notify the doctor. She stated if they didn't get a response to a provider's fax in 24 hours, they would call them. She stated the nurses had a clipboard and should check it every shift. She stated this may be where the communication breakdown occurred. She stated if nurses didn't go through the clipboard, they wouldn't know what needed followed up on. She stated if a resident started a medication, the nurses would complete follow-up assessments. On 12/11/25 at 11:19 a.m., the Assistant Director of Nursing(ADON) stated if a resident complained of signs and symptoms of infection, they would obtain vitals and complete an assessment. She stated they would call or fax the provider. She stated nurses had a clipboard to follow up on the faxes. She stated she was gone on vacation and had inquired as to what happened with regard to Resident #26's complaints. On 12/11/25 at 11:51 a.m., the Director of Nursing(DON) stated staff should follow up on a fax to a provider within 24 hours. The undated facility policy Documentation Assessment Guidelines stated the facility should facilitate accurate assessments of residents when the resident had physical changes.

Based on observation, clinical record review, staff and resident interviews and facility policy review the facility failed to treat one out of four residents reviewed in a dignified manor (Resident#5). The facility reported a census of 49 residents. Finding include: The Significant Minimum Data Set (MDS) assessment for Resident #5 dated 2/18/25, included diagnoses of neurogenic bladder, pressure ulcer, diabetes mellitus (DM), anxiety, and depression. The MDS reflected Resident#5's Brief Interview for Mental Status score of 15 (intact cognition). The MDS listed Resident#5 dependent on staff for toilet transfers and toilet hygiene. The Care Plan for Resident#5 dated 2/18/25, directed Staff to assist her with toileting upon her request, Resident#5 often preferred to utilize the commode. Staff assist with peri cares (procedure to clean and maintain the genital and anal areas) every AM, PM and as needed with incontinence episodes. On 3/6/35 at 8:30 AM, Resident#5 sat in her room in her wheelchair and she confirmed Staff B, Certified Nurses Aid (CNA) told her to go to the bathroom in her bed if she needed to have a bowel movement (BM) right now. On 3/6/25 at 5:47 AM, Staff G, Registered Nurse (RN) reported Resident#5 told her Staff B, directed Resident#5 to go the the bathroom in her bed. Staff G revealed her shock over that direction from staff. She reported she wrote up Staff B and slid it under the office door for the Director of Nursing to follow up on. On 3/10/25 at 3:16 PM, the Director of Nursing (DON) confirmed she knew that Staff B told Resident#5 to go to the bathroom in her bed. The DON reported she provided verbal education on dignity and explained that is an unacceptable practice. She stated the staff are expected to take the resident to the bathroom. The facility provided documentation of a Five Minute Meeting for Employees dated 1/4/25, that covered the Resident's [NAME] of Rights. Staff G, signed she received the education. The facility provided the Residents' [NAME] of Rights dated 11/2016, it directed facility staff as follows: A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source.

Based on clinical record review, resident interviews, and facility policy review the facility failed to report an allegation of abuse in a timely manner for 1 out of 4 residents reviewed for abuse ( Resident#2). The facility reported a census of 49 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident#2 dated 1/24/25, listed diagnoses of respiratory failure, heart failure, and diabetes mellitus. The BIMS reflected a score of 12 (moderate cognitive impairment). The MDS reflected Resident#2 required substantial/maximal assistance with toileting hygiene and partial/ moderate assistance to transfer off the toilet. The Care Plan for Resident#2 dated 8/8/24 directed assist of one staff for transfers, ambulation with walker and toileting. A facility document titled #408 Alleged Abuse dated 3/4/25, Resident#2 reported one of the CNA slammed her down on the toilet over the weekend. The document showed the facility asked eight residents about the care staff provided at the facility. During an interview on 3/4/25 at 12:52 PM, Resident#2 reported one CNA slammed her down on the toilet a few days ago. Resident#2 stated her bottom hurt when it happened. Resident#2 explained she goes in the bathroom with the walker and the wheelchair (w/c). During an interview on 3/6/25 at 09:16 AM, Staff M, CNA/Rehabilitation aid pushed Resident#2 into her room, applied the Gait Belt (GB) above the breasts, assisted her to Stand Pivot Transfer (SPT) with her walker to the recliner in her room. During an interview on 3/10/25 at 11:06 AM Staff O, CNA said she went to get Resident#2's light after lunch last Sunday 3/2/25. She reported Resident#2 told her that someone there threw her on the toilet. Staff O reported she worked with Staff P, CNA on that day. Staff O reported Staff P's tone can seem harsh and short at times. She thought she reported Resident#2's complaint to the nurse right after it happened, but she may not have listened to her. During an interview on 3/10/25 at 11:20 AM, Staff N, CNA, stated She said Staff O, CNA told her that Resident#2 told her that someone slammed her on the toilet on 3/2/25. During an interview on 3/10/25 at 3:24 PM, the Director of Nursing (DON) reported any concerns the staff needed to report and make sure the nurses listened to them. During an interview on 3/10/25 at 3:44 PM, the Administrator stated she expected each staff to report any concerns to the nurse and make sure the nurse listened or report the concern to the DON independently. The facility provided a policy undated titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, the policy directed Investigation Protocols: Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. Review documentation in resident record (including review of assessment if resident injury). Assess the resident for injury if the allegation involves physical or sexual abuse; Provide proper notifications to primary care provider, responsible party, etc. Attempt to obtain witness statements (oral and/or written) from all known witnesses. If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination or intimidation. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the State Agency. This written report shall be forwarded to the Department within five days of the initial report.

Based on clinical record review, resident interviews, and facility policy review the facility failed to do a thorough investigation into an allegation of abuse for 1 out of 4 residents reviewed Resident#2). The facility reported a census of 49 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident#2 dated 1/24/25, listed diagnoses of respiratory failure, heart failure, and diabetes mellitus. The BIMS reflected a score of 12 (moderate cognitive impairment). The MDS reflected Resident#2 required substantial/maximal assistance with toileting hygiene and partial/ moderate assistance to transfer off the toilet. The Care Plan for Resident#2 dated 8/8/24 directed assist of one staff for transfers, ambulation with walker and toileting. A facility document titled #408 Alleged Abuse dated 3/4/25, Resident#2 reported one of the CNA slammed her down on the toilet over the weekend. The document showed the facility asked eight residents about the care staff provided at the facility. During an interview on 3/4/25 at 12:52 PM, Resident#2 reported one CNA slammed her down on the toilet a few days ago. Resident#2 stated her bottom hurt when it happened. Resident#2 explained she goes in the bathroom with the walker and the wheelchair (w/c). During an interview on 3/10/25 at 3:42 PM, the Administrator reported the residents she interviewed after the first incident failed to report further concerns about staff treatment and after the second incident she the resident failed to identify staff mistreatment. The facility provided a list of the current resident's BIMS dated 3/4/25, that included 20 cognitively intact residents. The facility interviewed 13 in reference to staff treatment. The facility failed to provide evidence that an alleged allegation of abuse related to Resident#2 was thoroughly investigated. For example the investigation notes lacked documentation that the discription of the staff member Resident#2 discribed was followed up on. The facility provided a policy undated titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, the policy directed Investigation Protocols: Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. Review documentation in resident record (including review of assessment if resident injury). Assess the resident for injury if the allegation involves physical or sexual abuse; Provide proper notifications to primary care provider, responsible party, etc. Attempt to obtain witness statements (oral and/or written) from all known witnesses. If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with. The facility will establish and enforce an environment that encourages individuals to report allegations of abuse without fear of recrimination or intimidation. Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the State Agency. This written report shall be forwarded to the Department within five days of the initial report.

Based on observation, resident and staff interviews and facility policy review the facility failed to transfer 3 out of 4 residents safely Resident#1, #2, and #5). The facility reported a census of 49 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident#1 dated 12/10/24, listed diagnoses of pulmonary hypertension (blood pressure in the arteries of the lungs is abnormally high), hyperthyroidism and insomnia. The MDS reflected a Brief Interview for Mental Statues score of 15 (intact cognition). The MDS identified Resident#1 independent with sit to stand and ambulation up to 150 feet. The MDS reflected she needed partial/moderate assistance with toileting hygiene. The Care Plan for Resident#1 dated 9/30/24, identified Resident #1 independent in the facility with her walker, and independent with toileting. Staff assist her as needed upon her request. The Progress Notes for Resident#1 dated 1/4/25 at 9:43 AM, reflected Resident#1 went to the nurse's station and showed Staff I, Licensed Practical Nurse (LPN) a bruise on her left forearm, 3 centimeters (cm) by 2.5 cm, maroon in color. Resident#1 reported that Staff C, Certified Nurses Aid (CNA), caused the bruise by applying to much pressure to her arm. A facility document titled #363 Alleged Abuse dated 1/4/25, revealed Resident#1 reported Staff C, gripped her left forearm hard enough to bruise her, and it hurt her. The document reflected staff member educated on gait belt use for transfers. On 3/6/25 at 11:48 AM, Staff P, CNA placed a gait belt on Resident#1 and walked her out of the dining room, down her hall. On 3/4/25 at 12:23 PM, Resident#1 reported Staff C, CNA walked her out of the bathroom back to her bed. Resident#1 stated Staff C grabbed her arm and squeezed. On 3/5/25 at 10:44 AM, Staff K, Licensed Practical Nurse (LPN) revealed when the CNAs need to boost Resident#1 to stand they go under her arm, when she's up they walk with her Stand By Assist (SBA) they don't need a Gait Belt (GB). On 3/6/25 at 2:35 PM, Staff C, reported the day of the incident she went right to Resident#1's room to get her call light. Staff C said she normally helped Resident#1 sit up on the side of the bed. She wound uncovered her, puts her left arm under legs, her right over legs and pull her legs off the edge of the bed. Resident#1 took her hands to sit up. Staff C revealed she reached her left arm out, Resident#1 reached up with her left arm and took a hold of Staff C's left arm by her elbow. Staff C stated she grabbed Resident#1 arm near her elbow. She revealed she reached her other arm behind her back and pulled Resident#1 up. She confirmed Resident #1 called out in pain. 2. The Quarterly Minimum Data Set (MDS) assessment for Resident#2 dated 1/24/25, listed diagnoses of respiratory failure, heart failure, and diabetes mellitus. The BIMS reflected a score of 12 (moderate cognitive impairment). The MDS reflected Resident#2 required substantial/maximal assistance with toileting hygiene and partial/ moderate assistance to transfer off the toilet. The Care Plan for Resident#2 dated 8/8/24 directed assist of one staff for transfers, ambulation with walker and toileting. On 3/6/25 at 09:16 AM, Staff M, CNA/Rehabilitation aid pushed Resident#2 into her room, applied the GB above the breasts, assisted her to Stand Pivot Transfer (SPT) with her walker to the recliner in her room. On 3/4/25 at 12:52 PM, Resident#2 reported one CNA slammed her down on the toilet a few days ago. Resident#2 stated her bottom hurt when it happened. Resident#2 explained she goes in the bathroom with the walker and the wheelchair (w/c). She said she gets up out of the w/c and wiggled herself to the stool. She reported she's not sure why the CNA came in there to bother her. On 3/5/25 at 11:14 PM, Staff A, CNA, said if the transfer is a stand pivot transfer (SPT) he doesn't always use the GB. Staff A reported Resident#2 needed SPT to the toilet, he said he will clean her up, she stood and sat on her own. On 3/10/25 at 11:06 AM, Staff O reported she doesn't normally a use GB during transfers with Resident#2. 3. The Quarterly MDS assessment for Resident#6 dated 2/18/25, listed diagnoses of heart failure, diabetes mellitus, and respiratory failure. The MDS included a BIMS score of The MDS reflected Resident#6 dependent on staff for chair/bed/toilet transfers. The Care Plan dated 2/20/25, directed transfers with staff assistance of two using a stand lift for all transfers. The facility document titled #397Fall During Staff Assist dated 2/13/25 at 8:45 PM, described two CNAs were in Resident#6's room lifting her up in EZ-stand, and she passed out and fell to the floor. The report reflected Resident#6 failed to remember the fall. The Progress Note dated 2/02/25 at 8:30 PM, revealed staff reported that when they lifted resident up with stand lift, resident slumped forward with her eyes closed and became unresponsive. After lowering resident back down into her recliner, resident began to open her eyes and spook to staff. On 3/10/25 at 12:34 PM, Staff O reported Resident#6 fell to the floor through the stand lift during a transfer. She clarified they grabbed her arms as she fell through the strap and lowered her to the floor. She reported the strap sat at Resident#6's waist or near her breasts she failed to know, she revealed it happened so fast. It was just like how she fell before she went to the hospital. On 3/10/25 at 1:00 PM, the Physical Therapy Assistant reported a resident shouldn't fall from a stand lift if it's all hooked up correctly. On 3/10/25 at 3:21 PM, the Director of Nursing (DON) reported she felt the bruise to Resident#1's left arm resulted from Staff C's lack of gait belt use. The DON stated a resident may fall from the stand lift if they fainted and went limp. On 3/10/25 at 3:44 PM, the Administrator stated she expected Staff to use the gait belt with transfers. Reported Resident#6 failed to fall to the floor she said the staff lowered her to the floor. The facility provided a policy titled Gait Belts dated 12/5/24, identified the purpose: All employees providing direct resident care are required to utilize a gait belt whenever hands on assistance is needed for resident transfer and/or ambulation unless otherwise contraindicated. The facility provided the Stand Lift Operating Instruction dated 1/01, directed the resident needed to bear weight.

Based on staff interview, facility record review and facility policy review the facility failed to address previously cited deficiencies in the Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 49 residents. Findings include: The Centers for Medicare and Medicaid Services (CMS) Statements of Deficiencies 2567 dated 10/24/24, included violation at F609 and F610. The current survey dated 3/4/25 through 3/10/25 identified the same violation at F609 and F610. Form CMS-2567 dated of 11/13/24, reflected acceptance of your credible allegation of substantial compliance and Plan of Correction. On 3/10/25 at 3:44 PM, the Administrator reported the facility followed up on other previous deficiencies cited. The facility Quality Assessment and Performance Improvement (QAPI) policy undated, that identified: The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process included developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed.

Based on observation, clinical record review, staff interviews and facility policy review the facility failed to store medication in the packaging the medications came in, in the medication cart and stored held in a medication cup for one out of one resident s reviewed, the facility failed to keep one out of one refrigerators locked for 1 out of 3 days and failed to date one out of one insulin pens after staff opened it. The facility reported a census of 47 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident#24 dated [DATE] listed diagnoses of cancer, diabetes mellitus, and dementia. The Care Plan for Resident #24 dated [DATE], identified a risk for pain related to high blood pressure (HTN), irregular heart beat (A-fib), Coronary Artery Disease, depression, anxiety, cancer of prostate and bone, mood disorder, chronic pain, diabetes, attention deficit hyper activity disorder bipolar disorder, and osteoarthritis (degenerative joint disease). The Care Plan directed, please provide Resident#24 any pain management that my physician ordered and any as needed pain medications as he may need them. The Medication Administration Record (MAR) for Resident#24 dated ,d+[DATE], directed the staff to administer PM medication that included: a. Warfarin Sodium Oral Tablet 7.5 milligrams (mg) give 1 tablet in the evening. b. Metoprolol 50 mg give 1 tablet two times a day. c. Midodrine 5 mg 1 tablet two times a day. d. Senna plus 8XXX,d+[DATE] mg two times a day e. Gabapentin 600 mg 1 tablet three times a day. f. Hydrocodone/acetaminophen ,d+[DATE] mg 1 tablet four times a day. The MAR directed acetaminophen 325 MG TABS give 2 tablet every 6 hours as needed. The facility provided a statement signed by Staff F, Licensed Practical Nurse (LPN) dated [DATE], she wrote on the evening of [DATE] after she completed the bedtime (HS) medication pass in the facility Staff C, Registered Nurse told her one of the residents requested an as needed medication. Staff F revealed while she looked for the resident's medication in the medication cart she found a medication cup that held medication with the first name of Resident#24 on the cup. Staff F reported the medication she found in the cup to the charge nurse and showed her. The nurses determined the medication were from the PM medication pass. The facility provided a statement signed by Staff C, Registered Nurse (RN) dated [DATE], she reported on Sunday [DATE] Staff F reported to her she found medication in the mediation cart that held the name of Resident #24. Staff C reported she and Staff F reviewed the medication with the medication in the medication cart for Resident #24. The facility provided an untitled, undated investigation summary that reflected Staff C, called and notified the Director of Nursing on [DATE] that the other nurse on duty at the facility found a medication cup in the medication cart full of pills. Staff C reported the cup reflected the name of Resident#24. Staff C explained to the Director of Nursing (DON) she and the other nurse checked the medications with the MAR for Resident #24 and the medication appeared from the PM medication pass. On [DATE] at 2:45 PM, Staff H, previous Administrator reported she expected the medication administrated as ordered by the Physician and stored in their original packaging until administered. 2. On [DATE] at 10:00 AM, the three-foot-tall black unlocked refrigerator in the unlocked nurse's area held the locked refrigerator medication box that contained the following: a. Clear 12-inch-long by 4-inch-wide and 4-inch-high box plastic box covered with a white lid labeled Extra Insulin that held several bags that held multiple insulin pens b. The refrigerator held an approximately 10-inch-long by 5-inch-wide and 2 inches deep plastic box labeled Refrig Pen E-Kit, that held: a. Lorazepam (Benzodiazepines) 2 mg/milliliter (ml) oral solution 30 ml. b. Basaglar Kwickpen insulin 3 ml. c. Humalog Kwickpen insulin 3 ml. d. Humulin ,d+[DATE] Kwickpen insulin 3 ml. e. Humulin R insulin 3 ml. f. Lantus SoloStaf insulin 3 ml. g. Levemir FlexTouch insulin 3 ml. h. Novolog ,d+[DATE] Flexpen insulin 3 ml. i. Novolog Flexpen insulin 3 ml. j. Tresiba 100u/ml insulin 3 ml. On [DATE] at 10:03 AM, the DON observed the unlocked medication refrigerator, she reported she expected the medication refrigerator locked. The DON retrieved Staff B, LPN to show her how to lock the door. The Staff B, reported she must have forgotten to lock the medication refrigerator. Staff B reported being in the fridge about 30 minutes ago. A resident came to the nurse station asked how far the radar is. Staff B asked the resident if she meant microwave. The Resident said yes, she needed coffee reheated. Staff B, said she'd help her. On [DATE] at 11:57 AM, the Administrator confirmed the potential of drug diversion of Insulin and the Lorazepam. The Administrator reported she expected a thorough investigation for missing medications. The facility policy titled Medication Storage in the facility dated [DATE], the director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. The policy failed to address the storage of storage of other prescription medications. 48374 3. The Quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #39 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 11 out of 15 and had the following diagnoses: Type 2 Diabetes Mellitus without complications, Personal History of other Diseases of the Digestive System, and Acute Posthemorrhagic Anemia. A review of the physician orders active [DATE] revealed the following: a. Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro) Inject 13 unit subcutaneously two times a day related to Type Two Diabetes Mellitus without complications. During an observation on [DATE] at 11:25 AM. Staff I, Registered Nurse (RN) informed she was ready to give Resident #39 their insulin. Staff I had already prepared the KwikPen and insulin. Staff I advised she had washed her hands, primed the pen and drew 13 units of insulin and replaced the end cap. Staff I knocked as she entered the resident's room and asked the resident if she was ready for her insulin. It was verified Staff I had 13 units of Humalog prepared and after she washed her hands and cleaned an area on the resident's left lower abdomen, she then gave the injection holding the pen to the skin for approximately 5 seconds after the injection. When Staff I returned to the nursing station the insulin storage area and the the insulin pen outer lid outer lid was observed. The KwikPen was not marked or dated with the date opened. Staff I advised she had not noticed this and would have discarded the undated KwikPen and opened a new one. When asked, Staff I advised although it varies once opened insulin is typically good for 28 days. Staff I advised she should have checked for the expiration date before the insulin was given to the resident. On [DATE] at 12:15 PM Resident #39 Medication Administration Record (MAR) was reviewed. The resident was Humalog KwikPen Subcutaneous Solution Peninjector 100 unit/milliliter (Insulin Lispro) Inject 13 unit subcutaneously two times a day related to type 2 diabetes mellitus without complications (E11.9) was administered by Staff I. On [DATE] at 08:44 AM the Assistant Director of Nursing (ADON) was queried regarding insulin labeling. The ADON advised, the insulin comes from the pharmacy and it is immediately placed in the locked refrigerator. When the insulin is opened it has to be marked and dated as to the date opened. Each individual resident has a container with their name on it and it is locked. Once opened the KwikPens do not have to be refrigerated. Most insulin's are good for 28 days. Humalog is good for 28 days after opened. When it is opened it is a priority that it marked and dated. It is my expectation all nurses must date insulin when opened. Additional education will be provided to all nursing staff. If insulin is not dated it should be discarded immediately. For the safety of the resident we would not want to give an unlabeled, undated or expired medication. On [DATE] at 09:02 AM during an observation with the Assistant Director of Nursing (ADON), all insulin pens for other resident's receiving insulin in the facility were verified they were marked for the dates they were opened without further errors. On [DATE] at 9:30 AM the Director of Nursing (DON) was queried. The DON advised she had been informed of the incident. The DON advised it is her expectation that a pen be dated as soon as it is opened. If it is not dated is should be discarded properly. Additional education to staff will be provided. On [DATE] at 01:21 PM staff I was queried and advised she had not been feeling well and it was an oversight on her part. Staff I shared she did not notice the KwikPen was not dated and should have and that is her fault. The medication should have been thrown out to ensure it had not expired. Staff I advised she went home sick later that day. Staff I shared she had been trained on insulin and the appropriate procedures many times and it was an oversight. The Facility Pharmacy documentation dated [DATE] and titled, Suggested Drug Storage Policies (per manufacturer specification) documents the following: Humalog Vial/Pen: Expiration 28 days. The Facility Policy titled Policy/Procedure: INSULIN PEN ADMINISTRATION documents the following: Procedure: 4. Compare the insulin pen label to the order on the Medication Administration Record a. Check the expiration and opened on date on the pen i. Never use an expired pen ii. If the pen has been open more than 28 days, do not use unless indicated per manufacturers specifications

Based on clinical record review, staff interviews and facility policy review the facility failed to follow the facilities abuse policy and procedures after identifying a missing narcotic medication for 1 of 1 resident reviewed (Resident#24). The facility reported a census of 47 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident#24 dated 12/7/23 listed diagnoses of cancer, diabetes mellitus, and dementia. The Care Plan for Resident #24 dated 7/13/22, identified a risk for pain related to high blood pressure (HTN), irregular heart beat (A-fib), Coronary Artery Disease, depression, anxiety, cancer of prostate and bone, mood disorder, chronic pain,diabetes, attention deficit hyper activity disorder bipolar disorder, and osteoarthritis (degenerative joint disease). The Care Plan directed, please provide Resident#24 any pain management that my physician ordered and any as needed pain meds as he may need them. The Medication Administration Record (MAR) for Resident#24 dated 1/2024, directed the staff to administer PM medication that included: a. Warfarin Sodium Oral Tablet 7.5 milligrams (mg) give 1 tablet in the evening. b. Metoprolol 50 mg give 1 tablet two times a day. c. Midodrine 5 mg 1 tablet two times a day. d. Senna plus 8.6-50 mg two times a day e. Gabapentin 600 mg 1 tablet three times a day. f. Hydrocodone/acetaminophen 10-325 mg 1 tablet four times a day. The MAR directed acetaminophen 325 MG TABS give 2 tablet every 6 hours as needed. Review of the Nursing schedule dated 1/14/ 24 listed the NURSES: Staff J, Licensed Practical (LPN) worked 6:30 AM-6:30 PM Staff F, LPN worked 6:30 AM- 10:30 PM Staff C, Registered Nurse (RN) worked 6:30 PM- 6:30 AM On 10/23/24 at 8:30 PM, Staff F reported after she learned about the medications in the pill cup in the medication cart she and Staff C, RN figured out the medications were from Resident#24's PM medications. She reported the medication cup failed to include Resident#24's scheduled Hydrocodone/Acetaminophen 10-325 mg, but included an Acetaminophen 500 mg tabled that he lacked an order for. She stated how similar the Acetaminophen and the Hydrocodone tablet looked. The Nursing scheduled dated 1/14/24, listed eight (CNA)'s worked. On 10/24/24 at 9:03AM Staff E, Certified Nurses Aid (CNA) reported he never saw anything with Staff J that he was worried about. Staff J reported the Administrator and the Director of Nursing (DON) failed to talked to him about any incidents on 1/14/24. On 10/24/24 at 9:05 AM, Staff D, CNA reported the Administrator, and DON, and other nurses failed to ask him if he saw anything on 1/14/14 related to medication and or about Staff J. On 10/23/24 at 2:43 PM, Staff H, Previous Administrator stated she worked at the facility from 11/2017 through 5/2024. Staff H reported her investigation of the medication in the medication cart cup that failed to include the Hydrocodone 10/315 milligram (mg) tablet scheduled for Resident #24 included her talking to the nurses and none of the CNA's. On 10/24/24 at 3:00 PM, the Administrator confirmed the medication carts are located at the nurse station all the time and it's possible that one of the other staff may have observed something with the nurse and the narcotic medication. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy undated, reflected All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking part in acts that result in person degradation, including the taking or using photographs or recordings in any manner that would demean or humiliate a resident, and prohibits using any type of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep, or distribute photographs and/or recordings on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. These procedures shall include the screening and training of employees, protection of residents and the prevention, identification, investigation, and timely reporting of abuse, neglect, mistreatment, and misappropriation of property, without fear of recrimination or intimidation. Misappropriation of Resident property means the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a Resident's belongings or money without the Resident's consent. This includes misappropriation or diversion of resident medications. The policy directed the Investigation Protocols Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident. Review documentation in resident record (including review of assessment if resident injury). Assess the resident for injury if the allegation involves physical or sexual abuse; Provide proper notifications to primary care provider, responsible party, etc. Attempt to obtain witness statements (oral and/or written) from all known witnesses. If there is physical evidence that can be preserved, attempt to do so, and maintain in a safe location to minimize risk of evidence being tampered with.

Based on clinical record review, staff and resident interviews and facility policy review the facility failed to do a thorough investigation into medications found in a medication cup that failed to include a prescribed narcotic for 1 out of 1 resident reviewed Resident#24. The facility reported a census of 47 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment for Resident#24 dated 12/7/23 listed diagnoses of cancer, diabetes mellitus, and dementia. The Care Plan for Resident #24 dated 7/13/22, identified a risk for pain related to high blood pressure (HTN), irregular heart beat (A-fib), Coronary Artery Disease, depression, anxiety, cancer of prostate and bone, mood disorder, chronic pain, diabetes, attention deficit hyper activity disorder bipolar disorder, and osteoarthritis (degenerative joint disease). The Care Plan directed, please provide Resident#24 any pain management that my physician ordered and any as needed pain medication as he may need them. The Medication Administration Record (MAR) for Resident#24 dated 1/2024, directed the staff to administer PM medication that included: a. Warfarin Sodium Oral Tablet 7.5 milligrams (mg) give 1 tablet in the evening. b. Metoprolol 50 mg give 1 tablet two times a day. c. Midodrine 5 mg 1 tablet two times a day. d. Senna plus 8.6-50 mg two times a day e. Gabapentin 600 mg 1 tablet three times a day. f. Hydrocodone/acetaminophen 10-325 mg 1 tablet four times a day. The MAR directed acetaminophen 325 MG TABS give 2 tablet every 6 hours as needed. Review of the Nursing schedule dated 1/14/ 24 listed the NURSES: Staff J, Licensed Practical (LPN) worked 6:30 AM-6:30 PM Staff F, LPN worked 6:30 AM- 10:30 PM Staff C, Registered Nurse (RN) worked 6:30 PM- 6:30 AM On 10/23/24 at 8:30 PM, Staff F reported after she learned about the medications in the pill cup in the medication cart she and Staff C, RN figured out the medications were from Resident#24's PM medications. She reported the medication cup failed to include Resident#24's scheduled Hydrocodone/Acetaminophen 10-325 mg, but included an Acetaminophen 500 mg tabled that he lacked an order for. She stated how similar the Acetaminophen and the Hydrocodone tablet looked. The Nursing scheduled dated 1/14/24, listed eight (CNA)'s worked. On 10/24/24 at 9:03 Staff E, Certified Nurses Aid (CNA) reported he never saw anything with Staff J that he was worried about. Staff J reported the Administrator and the Director of Nursing (DON) failed to talked to him about any incidents on 1/14/24. On 10/24/24 at 9:05 AM, Staff D, CNA reported the Administrator, and DON, and other nurses failed to ask him if he saw anything on 1/14/14 related to medication and or about Staff J. On 10/23/24 at 2:43 PM, Staff H, Previous Administrator stated she worked at the facility from 11/2017 through 5/2024. Staff H reported her investigation of the medication in the medication cart cup that failed to include the Hydrocodone 10/315 milligram (mg) tablet scheduled for Resident #24 included her talking to the nurses and none of the CNA's. On 10/23/24 at 10:44 AM, Resident # 24 reported he failed to remember not getting his med on 1/14/24. He said it sounded familiar but it was a long time ago. The facility policy titled Medication Storage in the facility dated 5/1/22, the director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulations in the handling of controlled substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. The policy failed to address the storage of storage of other prescription medications.

Based on clinical record review, observations, State Climatologist Report, staff and resident interviews, and facility policy review, the facility failed to provide adequate supervision to prevent hazards during a temporary modification of a safety intervention. The Maintenance Supervisor turned off the alarm to the southeast outside door to allow workers access to resident areas for repairs and failed to notify nursing staff for 2 1/2 hours. A confused, independently mobile resident exited the door in his wheelchair and was found outside in 36-degree weather at the time of his exit from the building with wind gusts of 24 mph causing a Wind Chill of 27 degrees and no coat to protect him. Estimated time outside of the building was 10-15 minutes. The failure resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident. The facility reported a census of 44 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 30, 2023 on November 2, 2023 at 10:45 a.m. The facility staff removed the Immediate Jeopardy on October 31, 2023 by implementing the following actions: a. Resident #1 was returned into the facility and an assessment was completed. b. The Door Alarm was immediately armed and checked/verified to ensure that it was in proper working order. c. The Door Alarm policy was updated. d. All staff were educated beginning on 10/31/2023. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures updated. Findings Include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 revealed a diagnosis of depression and anxiety, with a Brief Interview for Mental Status (BIMS) score of 7 out of 15, indicating a severe cognitive impairment. The MDS identified Resident #1 utilized a manual wheelchair and was able to independently wheel at least 150 feet in a corridor or similar space. The Care Plan dated 10/4/23 revealed that Resident #1 demonstrated signs of delirium to include inattention and disorganized thinking that may fluctuate at times, depending on alertness. Resident #1 was at risk for elopement due to being able to propel self, depression and anxiety, and disorientation. Resident #1 was to only leave the facility with proper supervision and all exit doors were to be coded, alarmed, tested and monitored daily. During an observation on 11/1/23 at 12:16 PM, Resident #1 was in the south hall, outside of his room in a wheelchair, fully dressed, and wearing a baseball cap. Resident was confused, calm and pleasant. Observation on 11/1/23 at 12:30 PM, Surveyor activated all exit doors, all alarmed and staff responded to the alarms immediately. Progress Notes for Resident #1 dated 10/30/23 at 12:51 PM, documentation by the Director of Nursing (DON) revealed: a. Resident #3 returned to the facility via transport van from an appointment and asked why Resident #1 was outside. b. The DON went outside with a Certified Nursing Assistant (CNA) and brought Resident #1 in the facility. c. The DON performed an assessment and found no redness to face, arms or legs. d. Resident #1 was described as fully dressed with a sweat shirt, pants, socks, shoes and baseball cap. e. Vital Signs: Temperature 97.6, Pulse 81, Respirations 17, Oxygen Saturation 96%, Blood Pressure 129/73. f. Last seen by the Cook at 12:10. g. Family and provider notified. h. Temperature outside 40 degrees and sunny. During an interview on 11/1/23 at 11:16 AM, Staff G, CNA, stated she worked on 10/30/23 and was assisting a resident to eat in the assisted dining room when she heard across the radio that Resident #1 was outside. Staff G explained she responded and seen Resident #1 outside on the sidewalk in his wheelchair near the stop sign fully dressed but no coat and was unattended. Staff G reported the DON had responded and assisted Resident #1 back into the building. Staff G stated she was unaware the alarm was disarmed; not sounding and unaware Resident #1 was outside unattended. During an interview on 11/1/23 at 1:32 PM, Staff F, Business Office Manager stated she was working in her office on 10/30/23. Staff F reported about 12:15 PM, Resident #3 was returning from an appointment via the transportation bus, the driver left Resident #3 at the door and left. Staff F stated Resident #3 reported that Resident #1 was outside, Staff F used the radio to report this to staff and the DON responded and ran outside. Staff F stated she called the Administrator and asked what were the next steps to follow. Staff F summoned the Maintenance Supervisor to her office to talk about the door alarm since no door alarms sounded. Staff F explained the Maintenance Supervisor reported that the contract workers were using that door for entrance and he had disabled the alarm. Staff F stated, I made him go immediately to turn it on, I did not know it was off. Staff F stated that if the alarm is disarmed, staff should be monitoring the door, not leave it unattended. Staff F acknowledged, That did not happen in this case. During an interview on 11/1/23 at 1:41 PM, the DON stated she worked on 10/30/23, I was in my office and last time I looked at clock, it was 12:15 PM. The DON reported she overheard Staff F calling on the radio that Resident #1 was outside unattended. The DON explained she responded and found Resident #1 near the gazebo, on the sidewalk, outside the gate that was to be closed and secured. The DON stated Staff G assisted to bring Resident #1 inside to assess the resident, and noted the door alarm did not sound. The DON stated her expectations are that the door alarms are to be active. During an interview on 11/1/23 at 2:08 PM, Staff C, Maintenance Supervisor, stated on 10/30/23 contractors were at the center to replace 2 heating units in the East Hall. Staff C stated 2 men arrived about 9:30 AM, I let them in the southeast wing door, with the gazebo and turned off the alarm. Staff C reported they were in and out the unalarmed door, brought in the tools and units and took out the old units through the same door. Staff C explained, they (contractors) have been here enough and I don't have to stay with them, I don't have to babysit them. Staff C stated he checked on them to see if they needed the power on and the last time he seen them was about 11:15 AM, but did not see them physically leave. Staff C stated, I told them I would take care of the trash so they didn't try to take it in that wind. Staff C reported he took the boxes up the hall, out the front door and went to lunch. Staff C explained Staff F used the radio to call him to the front office and asked why the alarm was not turned on for the southeast hall door. Staff C expressed, I got side tracked. Staff C stated he did not tell anyone the alarm was disabled, and he went right down and turned on the alarm after he talked to Staff F. Staff C reported he performs a test on every door, every morning, Monday through Friday, and Housekeeping Staff checks the alarm doors every weekend. Staff C reported no one was assigned to watch the doors while the alarm was disabled from 9:30 AM to 12:30 PM. During an interview on 11/1/23 at 2:33 PM Staff D, Licensed Practical Nurse (LPN) stated on 10/30/23, worked day shift, I did not hear over the radio that someone was outside and none of the alarms went off. Staff D stated Resident #1 can be confused at times, was confused on 10/30/23. Staff D reported the DON brought Resident #1 in and assessed him. Staff D explained, did not know the Maintenance staff turned off the alarm, and the Nursing Staff unaware the alarms were disabled. Staff D stated the follow up on 11/1/23 was a 5-minute training form that read if an alarm is off that someone will be on the door so no one goes out and she had to sign it. During an interview on 11/2/23 at 12:53 PM, Staff A, Night Cook, stated he was in the dining room on 10/30/23 at 12:05 PM, Resident #1 was in the dining room doorway to East Hall and a staff member moved him as he was blocking the doorway and other residents needed to go through there. Staff A reported he did not see Resident #1 after that, returned to the kitchen about 12:40 PM and was told Resident #1 got outside. Staff A stated he was unaware the alarm was turned off. During an interview on 11/2/23 at 1:41 PM Staff B, Activity Assistant, stated she seen Resident #1 at 12:00 PM, then went to lunch, at 12:15 PM returned to the dining room to assist Staff A to clean up and Resident #1 was not in the dining room. Staff B stated she heard from another staff member that Resident #1 was outside. Staff B stated she was unaware the alarm was disarmed on East Hall and did not hear an alarm sound. On 11/2/23 a phone call to the State Climatologist revealed the local Hourly Weather Observations report for October 2023 provided for 10/30/23 at 12:00 PM, the temp was 36 degrees, wind 15 miles per hour (mph) sustained and 24 peak gusts, with a wind chill of 27 degrees. During an interview on 11/6/23 at 1:45 PM, Resident #3 stated she was returning on the van from an appointment and seen Resident #1 at the street corner getting ready to cross the street. Resident #3 stated she called to him, asked him what he was doing outside, as it was cold out. Resident #3 stated she went in the facility and told the staff Resident #1 was outside. Interview on 11/8/23 at 8:52 AM Staff E, Contracted Worker stated he was at the facility on 10/30/23 about 9:30 AM and installed 2 heating units utilizing the southeast door that was unlocked by the Maintenance Supervisor. Staff E explained The alarm never sounded. Staff E reported he left the building before 11:30 AM and did not see a resident near the exit door. The facility provided a Matrix and identified 26 confused residents, in which 18 are mobile (wheelchair or ambulatory per self) and 10 of those 18 live in East hall (the new wing) where the alarm was turned off at the end of that hall leading to the gazebo. Daily Door Alarm Log dated October 2023 reviewed and a check mark was made every day for every door with an alarm. Date 10/30/23 was initialed by Staff C, Maintenance Supervisor. Policy titled Door Alarms, updated 11/2/23, revealed: a. Facility installed Door Guardian by Secure Care for resident safety. b. Each alarm had a key pad requiring those staff or visitors exiting the door to type in a designated code or alarm will sound. c. Guests leaving are to ask staff for assistance. During an interview on 11/6/23 at 8:53 AM, the Administrator stated her expectation was that the door not be unattended if the alarm was temporarily disabled and to do a count of residents if someone eloped.

Based on staff interview and Facility Assessment review, the facility failed to employ a Registered Nurse (RN) to serve as the Director of Nursing (DON) since March 9, 2023. The facility reported a census of 45 residents. Findings include: In an interview on 8/29/23 at 12:40 PM, the Administrator reported the facility did not currently employ a Director of Nursing (DON). She reported the previous DON and Infection Preventionist was staff I, Registered Nurse (RN). Staff I, RN went on leave and was to return on 6/12/23 into the Infection Preventionist role but did not plan to return to the DON role. She stated the facility had been without a DON since 3/9/23. The Administrator stated the facility had been actively trying to hire a new DON but had not been successful to this point and none of the current facility RN's were interested in taking the position. She stated the facility considered hiring an interim DON but the hourly cost was significant and she felt it was cost prohibitive and the facility could not afford it. The facility had a DON hired as of 6/16/23 but the RN called and rescinded the offer 1 week before the start date. The Administrator reported she had one interview for the position scheduled. The Administrator stated the facility hired an Assistant Director of Nursing (ADON) on 8/21/23. In an interview on 8/29/23 at 12:43 PM, the Administrator stated the DON is a very important role and the expectation was that the role be filled. The Facility assessment dated [DATE] stated the number of personnel for the facility was a total of 58. There was to be one (1) DON.

Based on observations, clinical record review, family, resident and staff interviews, and also facility document and policy review, the facility failed to provide privacy during personal cares, speak to residents in a respectful and dignified manner, and provide a dignity bag covering for a resident with an indwelling catheter for 4 of 5 residents reviewed (Residents #11, #18, #23 and #27). The facility reported a census of 45 residents. 1. During an observation on 8/27/23 at 2:06 PM, Resident #27 was lying in bed without clothes, no depend on, moaning loudly and the door to the hall was open. During the continuous observation on 8/27/23 at 2:32 PM, Staff A, Maintenance Manager and Staff G, Activity Assistant, walked past the open door and looked in to Resident #27's open door, and did not intervene. Resident #27 continued to moan loudly. During an observation on 8/27/23 at 2:38 PM Staff B, Certified Nursing Assistant (CNA), entered Resident #27's room and shut the door. The Minimum Data Set (MDS) dated [DATE] revealed Resident #27 had a diagnosis of brain injury and cerebral vascular accident (CVA, a stroke) and required assistance of 2 persons for bed mobility, transfers, dressing and personal hygiene. The Care Plan dated 8/10/23 revealed Resident #27 had an activity of daily living self-care performance deficit and directed staff to dress, groom, provide peri care after incontinence episodes every morning, evening and as needed. During an interview on 8/29/23 at 10:45 AM, Staff C, CNA stated they leave Resident #27's shirt and depends on when he's in bed during the day, but the shirt is removed at night as Resident #27 get's hot. During an interview on 8/29/23 at 11:57 AM, Staff E, CNA stated she worked on 8/27/23 day shift and transferred Resident #27 to bed with Staff D, CNA. Staff E stated, We removed his pants, changed him since his shirt was soaking wet from lunch, and provided peri care, then covered him with his blanket. Staff E stated, I absolutely would not leave him in bed naked, ever. During an interview on 8/29/23 at 11:20 AM, Staff D, CNA stated she had assisted to transfer Resident #27 to bed on 8/27/23 and he was dressed in a shirt and depend when she left at 2:00 PM. During an interview on 8/29/23 at 11:18 AM, Staff H, Licensed Practical Nurse (LPN) stated she worked on 8/27/23 and did not know Resident #27 was laying in bed naked with the door open to the hall. During an interview on 8/29/23 at 3:02 PM, Staff G, Activity Assistant stated, I have never seen him (Resident #27) in bed naked until Sunday (8/27/23) and I don't know why. During an interview on 8/29/23 at 11:09 AM Staff F, Registered Nurse (RN) stated her expectation would be that no residents would be left in bed naked, alone with the door open to the hall. During an interview on 8/29/23 at 2:51 PM, the Administrator reported, would expect that the staff would not leave a resident naked in bed. 45775 2. The MDS Assessment Tool, dated 8/3/23, listed diagnosis for Resident #11 included: Intestinal adhesions (scar tissue in the bowel) and colostomy, depression and chronic pain. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, and personal hygiene. The MDS documented the resident's BIMS score as 15 out of 15, indicating intact cognition. A clinical record review revealed a Physician Order for colostomy care, with colostomy bag changes twice weekly on shower days. The Care Plan directed staff to assist with emptying the colostomy bag every shift and as needed. During an interview on 8/28/23 at 9:34 AM, the resident stated there are times the colostomy bag will pop off due to a gas build up. The resident stated that when this happens Staff D, CNA has yelled at him to stop playing with the bag. He stated the staff asks why he does this and he has to stop. Resident #11 stated he feels bad when this happens and finds it upsetting. During an interview on 8/29/23 at 8:45 AM, Resident #18 stated she has heard Staff D, CNA yelling at Resident #11 in his room, directly across the hall. During an interview on 8/29/23 at 11:10 AM, Staff F, RN stated staff have expressed irritation when the residents colostomy bag pops off. Staff F stated the resident will pick at the side of the bag, and needs reminders to stop. 3. The MDS Assessment Tool, dated 8/3/23, listed diagnosis for Resident #18 included: essential tremor, anxiety disorder, and polymyalgia rheumatica (muscle pain and stiffness around shoulders and hips). The MDS assessed the resident required extensive assistance of one staff for: bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an interview on 8/27/23 at 12:27 PM, Resident #18 stated Staff D, Certified Nursing Assistant (CNA) hates and yells at her about everything. The resident reported the staff caused her to cry several times. She stated the staff tells her she is left for last to get ready in the morning because she is so slow. The resident stated this makes her feel bad. The resident stated in the last several weeks, Staff D yelled at another staff through the door while assisting her in the restroom. The resident stated she found this very upsetting. During an interview on 8/28/23 at 4:24 PM, Staff G, CNA stated on 8/13/23 she knocked on Resident #18's door and opened it slightly to ask the resident for her breakfast order. Staff G stated Staff D, CNA started yelling. Stating the resident is using the bathroom and slammed the door. Staff G stated she talked to the resident after the incident and found her crying and very upset. During an interview on 8/30/23 at 9:43 AM, the Activity Director (AD) stated the resident talked to her about the incident that happened between staff on 8/13/23. The AD stated the resident cried and discussed how upsetting she found the situation. During an interview on 8/29/23 at 11:15 AM, Staff F, Registered Nurse (RN) stated Resident #18 has become upset when talking about how several staff talk to her and started crying. Staff F stated the resident sometimes is a pivot transfer and sometimes she uses the EZ Stand (mechanical transfer device). She will refuse to pivot transfer due to discomfort, but she has heard staff continue to try to get her to transfer. This upsets the resident. The Therapy Department developed a statement outlining if the resident refuses a pivot transfer to use the EZ stand. During an interview on 8/29/23 at 2:48 PM, the Administrator stated that there have not been any recent concerns with staff attitude. The Administrator stated staff attitude started to be discussed in Resident Council Meetings in May 2023, and completed education with Staff D, CNA. The Administrator stated she has talked to residents and they stated there has been improvement. Review of Resident Council Notes from the 8/28/23 revealed one resident felt Staff D, CNA improved some. Another resident stated Staff D snapped at everybody. The facility document, dated November 2016, titled Residents' [NAME] of Rights informed residents on admission 1. Residents Rights (1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each residents;s individuality. The facility must protect and promote the rights of the resident. 4. The MDS Assessment Tool, dated 8/3/23, listed diagnosis for Resident #23 included: Type 2 diabetes mellitus, and amputation of left lesser toe (not the big toe). The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The Care Plan revealed a the resident admitted to the facility with an indwelling Foley catheter During an observation on 8/27/23 at 12:41 PM, the resident's catheter bag lacked a dignity cover. During an observation on 8/29/23 at 12:43 PM, the resident's catheter bag lacked a dignity cover. During an interview on 8/29/23 at 11:21 AM Staff F, RN stated all catheter bags should be placed and kept in a dignity bag. During an interview on 8/29/23 at 12:03 PM, Staff E, Certified Nursing Assistant (CNA) stated all catheter bags should be placed and kept in a dignity bag. The undated facility policy, titled Catheter Care lacked direction on the use of a dignity cover for an indwelling catheter urine collection bag.

Based on observation, staff and resident interviews, and facility document review the facility failed to promote resident choice in their morning schedule for 1 of 1 residents in the sample (Resident #11). The facility reported a census of 46 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 8/3/23, listed diagnosis for Resident #11 included: Intestinal adhesions (scar tissue in the bowel) and colostomy, depression and chronic pain. The MDS assessed the resident required extensive assistance of one staff for: bed mobility, and personal hygiene. Total dependence is required for transfers. The MDS documented the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. During an observation on 8/27/23 at 11:00 AM, Resident #11 found to be in his bed resting. During an interview on 8/28/23 at 9:29 AM, Resident #11 stated that several staff will not get him up in the morning for breakfast. He stated this often happens on his scheduled shower days. The resident stated he could be left in bed as long as 11:15 AM. The resident stated he has told staff he would rather get up and have breakfast in the dining room with other residents. During an interview on 8/29/23 at 10:58 AM, Staff C, Certified Nursing Assistant (CNA) stated she will assist Resident #11 with getting up by 9:30 AM. She stated there are other staff who do not do this and wait until lunch time to get him up and ready for the day. During an interview on 8/29/23 at 12:07 AM, Staff E, CNA stated there are staff who will not get Resident #11 up out of bed for the day until late as 11:15 AM. During an interview on 8/30/23 at 1:10 PM, the Activity Director (AD) stated Resident #11 likes to get up early and have breakfast with other residents. The AD stated she has observed the resident getting a room tray for breakfast and get out of bed as late as 11: 15 AM. During an interview on 8/30/23 at 2:48 PM, the Administrator stated she expected staff to get residents up in the morning based on the resident's preferred time. When queried if a resident should be kept in bed until their shower time the resident stated it is okay to do this if the resident agrees. The facility document, dated November 2016, titled Residents' [NAME] of Rights informed residents on admission #6. Self-Determination (1) The resident has a right to choose activities, schedules (including sleeping and waking hours), healthcare and providers of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions on this part.

Based on record review and staff interviews, the facility failed to provide a call system or provide proper supervision when leaving a resident alone in a recliner in an upright reclined position, allowing the resident to get up and fall sustaining a major injury for one of two residents reviewed with falls with major injuries. (Resident #90). The facility identified a census of 44 residents. Findings Include: Resident #90's Quarterly Minimum Data Set (MDS) Assessment Tool completed 1/31/21 documented the following diagnoses: fracture of the left femur, [CONDITION(S)] (an abnormal heart rhythm) and hip fracture. It also identified the resident as cognitively impaired, requiring limited to extensive assistance of staff for most activities of daily living due to not steady with moving from a seated to standing position, walking, moving on and off the toilet or transferring between bed and chair or wheelchair without staff assistance . It also identified the resident to have 3 falls after admission to the facility, one with no injury and 2 with injury, but not major. A review of the Care Plan identified the resident with the problem of being at risk for falls related to cognitive decline, congestive heart failure (CHF) and a history of falls (initiated 12/9/20 after admitted to the facility 12/2/20) ) and directed staff to: a. On 12/9/20 in the event of a fall please notify my family and MD regardless of any injuries, provide me with first aid as I may need it. b. On 12/16/20 please assist me with all my toileting needs with extensive assist of 2. c. On 1/4/21 please encourage me to sit in a recliner after lunch for better observation and added safety. A review of the Fall Assessment Sheet had documentation of the following: On 2/12/21 at 12:20 PM in the main dining room, the resident climbed out of a recliner in the dining room and attempted to push another resident's wheelchair out of the way and witnessed by housekeeping. The resident moved all extremities without difficulty, denied hitting head, and once a shift neuros initiated. The resident fully clothed, footwear in place, and no injuries noted. A review of the Nurse's Notes revealed the following: a. On 2/12/21 at 12:20 PM - 24 hour neuro checks initiated. Resident noted to have climbed out of recliner in main dining room, attempting to push another resident in their wheelchair and fell . Fall witnessed by housekeeping, denies hitting head, and moves all extremities without difficulty. Complaining of left leg but unable to rate. No injuries noted. Fully clothed with appropriate footwear. b. On 2/12/21 at 5:30 PM - Follow up for the incident - the resident up in a wheelchair, alert and oriented x 2, grips strong, and pupils equal and reactive to light, in the main dining room for the evening meal, denies pain or discomfort. c. On 2/12/21 at 7:30 PM - The nurse called to resident's room. The resident noted with a very painful left side, painful with any movement to left side and left lower extremity appears rotating outward. d. On 2/12//21 at 9:45 PM - Staff states that when he stood the resident up from the wheelchair to transport her to the bed, the resident said ow and the resident had a very difficult time moving her left leg, loosing balance to the left and staff able to set her back down in the wheelchair. e. On 2/12/21 10:20 PM - Resident rolled to right side in bed and a pop sound heard by the nurse. Resident yelled out in pain. Dr. notified, orders received to send the resident to emergency room (ER) by ambulance for evaluation and treatment. Resident transported at 10:20 PM f. On 2/13/21 1:35 AM received call from hospital resident admitted for left hip fracture. A review of the Letter of Medical Predictability dated 2/15/21 identified the resident with the diagnosis of left distal femur fracture and did not have surgery. A review of the visit note dictated by the resident's primary care physician dated 2/18/21 documented the following: a. Non-ambulatory and bed-bound now since recent hospitalization and return to care center. Not progressing with therapy, so changed to an Intermediary Care Facility (ICF) level of care. Appetite poor and not taking anything in for the last two days. She has been losing weight for some time, including gradual weight loss since initial admission here in December. b. Had a fall sliding out of a chair on 2/12/21. Was getting up on her own and fell back on to her bottom. Had only minimal pain at that time and no reduced range of motion in the early afternoon. Later in the late afternoon, she complained of some left side pain and was put to bed. At some point was repositioned and then had increased left leg pain with leg appearing shortened and rotated. Sent to the emergency room (ER) for evaluation and found to have a minimally displaced oblique fracture of the distal left femur. Ortho was consulted and after discussion with her family, they decided to forego any surgery and treat conservatively with a knee immobilizer and non-weight bearing status. That decision was made owing to her significant cardiac history as well as worsening dementia and a generally limited weight bearing status even before this injury. The resident sent back to the care center on 2/15/21 for rehab. Since her return, she started yelling out and crying out in distress, wanting to die. In an interview on 5/5/21 at 6:14 PM, Staff I, Housekeeper reported she witnessed the resident stand at the end of the main dining room and pushed another resident in a wheelchair and fell landing on her bottom. She did not see any staff in the main dining room, she saw staff in the assisted dining room and in the hallway passing medications. Staff I called for help to let the staff know the resident fell . The nurse aides and nurse came out and lifted the resident up into her wheelchair. The resident had cried hysterically and looked like she was in pain. Once the Nurse Aides had her, Staff I returned to cleaning. In an interview on 5/5/21 at 12:28 PM, Staff A, Licensed Practical Nurse (LPN) reported the resident admitted to the facility with a leg fracture and received skilled services for a short time. The resident noted with dementia and had fallen after being admitted and fractured the same hip. In an interview on 5/5/21 at 12:38 PM, Staff F, Certified Nursing Assistant (CNA) reported prior to her fall, the resident transferred with 1-2 person assist. Staff F reported being in the assisted dining room, when one of the Housekeepers said that the resident fell . Staff F and Staff J, Registered Nurse (RN) went to the main dining room and found the resident sitting up on the floor by the chair in the main dining room. Staff F placed her gait belt around her, and both staff helped the resident up and to the wheelchair and took her to her room and examined her for any bumps or bruises. Staff J came with her to the room. They helped the resident stand up and checked her out, she didn't complain of any pain and said, I'm fine, I'm OK. In an interview on 5/5/21 at 1:09 PM, Staff G, CNA reported the resident had required two staff to assist to transfer her using a mechanical lift since the fall. She had worked the shift after the resident fell , the resident attended an activity and did not complain of pain. When another aide and Staff G repositioned the resident later that night at 10:00 PM, they heard a pop and went to get the nurse, Staff H as the resident had been in a lot of pain. After Staff H assessed the resident, she called the doctor and the ambulance transferred the resident to the hospital. In an interview on 5/5/21 at 2:31 PM, Staff H, LPN reported the resident required two staff to assist to transfer her using a mechanical lift since the fall. She took care of the resident on second shift after the resident fell and at 3:00 PM, the resident asked for Tylenol for pain to her right knee. She did not get had any relief from the Tylenol and she had been given Oxycodone without relief and called the doctor to let him know. Later at 6:45 PM, the CNA had tried to reposition her, when she heard the resident screaming, she went to the room and helped to turn the resident when they heard a pop. Any movement after that caused the resident extreme pain. Staff H notified the doctor and received an order to transfer her to the emergency room (ER) for evaluation and treatment at 7:00 PM. She could not recall the exact time the resident had been transferred. In an interview on 5/6/21 at 8:15 AM, Staff B, CNA reported the resident should not have been left alone before she fell . In an interview on 5/6/21 8:43 AM, Staff C, LPN reported the resident should not have been left alone before she fell , after the fall, she had participated in an activity and did not appear to be in pain. In an interview on 5/6/21 at 9:10 AM, Staff D, CNA reported the resident had been allowed to be left alone as she did not have the tendency to get up on her own and that there always should be a staff member in the main dining room to watch residents. In an interview on 5/6/21 at 9:27 AM, Staff E, CNA reported she worked as the whirlpool aide the day the resident fell . She had toileted the resident, assisted her to sit in a recliner and elevated her feet. Later she heard Staff I, Housekeeper yell out that the resident fell . When Staff E checked on the resident. The nurse asked the resident if she was in pain and she said no. The staff helped her up to the wheelchair and she participated in an activity afterward. Once she had been assisted to bed, she kept rubbing her leg and moaning like she had pain. After she got Tylenol she seemed better. In an interview on 5/6/21 at 9:53 AM, Staff F, CNA reported the resident had been allowed to sit alone in the area by the main dining room as there are supposed to be staff nearby at all times. When she fell , Staff F thought the resident had been left by herself before the Housekeeper saw her fall. In an interview on 5/6/21 at 10:22 AM, the Director of Nursing reported that the resident had required assistance for transfers and when asked how residents while sitting in the area by the main dining room call for help when there is no staff nearby, she reported I don't have a good answer for you. If the nurse had given Tylenol and Oxycodone without relief, she would expect the nurse to call the doctor to see if he wanted orders for an x-ray. She also reported the resident fractured the same hip that had fractured prior to her admission to the facility.

Based on clinical record review and staff interviews the facility failed to appropriately supervise one of three residents reviewed to prevent a fall with injury (Resident #1). The facility reported a census of 54 residents. Findings include: According to the Minimum Data Set ((MDS) dated [DATE] and 9/19/2019, Resident #1 identified with no memory impairment, transferred and ambulated with limited assistance of one staff, and unsteady balance moving from a seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer. The resident with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. According to the MDS dated [DATE], Resident #1 required extensive assistance to transfer and ambulate, after a fall with major injury, and experienced frequent pain. The Care Plan initiated 8/26/2019 revealed Resident #1 with a fall risk related to [DIAGNOSES REDACTED]. The Care Plan directed staff to assist resident with all transfers and ambulation with the use of a gait belt and walker with limited assistance of one initiated 8/26/2019. On 10/23/2019 the Care Plan added, please assist with transfer assist times two due to recent arm fracture and arm is in a sling. The (MONTH) 2019 Plan of Care Kardex revealed Resident #1 transferred and ambulated with assist of one and a walker. The Resident Fall Assessment Sheet dated 10/23/2019 revealed Resident #1 sustained a fall at 7:30 a.m The report documented the resident with risk factors including decline in functional status, acute condition making resident unstable, unsteady gait, decline in cognitive skills, depression, impaired hearing, impaired vision and dizziness. The resident's decline in functional status puts her at increased risk for falls and the resident used assistive devices including walker and wheel chair. The report states Staff A, Licensed Practical Nurse (LPN) called to the resident's bathroom and noted the resident sitting on buttocks on the bathroom floor and leaning against door frame with legs and arms extended. Resident denies bumping head. Neurological (Neuro's) checks initiated, walker upright in front of toilet, resident wearing pajamas and slipper socks. Resident ambulating to bathroom with walker and SBA (stand by assist) when she reported she got dizzy and lost balance and fell . Noted two small skin tears on right wrist and elbow without bruising. Skin sheet completed and order of antibiotic ointment and Band-Aid every day. Resident moved all extremities without difficulty or pain, assisted up to toilet, and without needs voiced. The self report included: Staff assisted resident to the bathroom with walker. Resident wore slipper socks, pajama top and bottoms, and pull-up liner on. Resident became dizzy and lost balance and staff walked beside him/her. Staff thought resident only needed stand by assist. Resident started to turn towards the toilet and lost his/her balance, fell into the doorjamb and sat on the floor. Staff witnessed the fall and stated resident did not bump head. Legs were extended out in front and resident noted to have two small skin tears to right wrist and right elbow, able to move extremities without difficulty, and no bruising or pain with exam, Neuro's were intact at that time. After lunch the resident complained of pain to right arm and shoulder. The physician ordered an x-ray. The resident had a fracture to the head of the right humerus (upper arm bone). Resident walked out to breakfast and lunch without complaint. At 12:08 P.M. staff administered Tylenol for pain. The 10 Questions at the time of a fall included the following questions and responses: 1. Are you okay? Yes 2. What were you trying to do? Going to bathroom 3. What was different this time? Aide without assistance 4. Position of Resident: near toilet, on buttocks with legs and arms extended. 5. and 6. Poor lighting, and shiny, tile floor. 7. Resident wore non-skid slippers. 8. Assistive device: walker. 9. No glasses's or hearing aides. 10. Staff in the area when resident fell ? Staff B, Certified Nurse's Aide (CNA). The emergency room summary dated 10/23/2019 revealed Resident #1 with an arm injury and [DIAGNOSES REDACTED]. The resident received an arm sling, and prescriptions for an antibiotic and pain medication and returned to the facility. During an interview on 2/5/2020 at 2:30 p.m., Staff C, Administrator indicated staff had access to Care Plans in the front of resident charts. The Plan of Care Kardex is completed by the assigned CNA at the end of the shift. Assignment sheets are kept at the time clock. Staff B, CNA would have learned of the float assignment that day and should have picked up all the sheets. Staff use Walkie-talkies to communicate with one another, seek help and ask questions. The first time an Agency Staff works at the facility, they arrive an hour early for the shift and receive a tour, information and assignment sheets. Staff B indicated he/she thought Resident #1 ambulated with stand by assistance. Staff B received a discipline. Staff D, Director of Nursing (DON) handled the investigation. The facility had no prior concerns with Staff B. Per physical therapy, the resident always transferred with a minimum of one assist. During an interview on 2/5/2020 at 2:45 p.m., Staff D, DON reported he/she did the investigation when Resident #1 had a fall with injury. Staff D arrived to work at approximately 8:30 a.m. that day and the resident walked to breakfast and lunch without complaint. After lunch the resident complained of pain and they sent the resident to the emergency room where the resident's x-ray revealed a fractured humerus. Staff D reported the incident to DIA (Department of Inspections and Appeals) and the Agency Staffing Company. Staff B seemed upset about the incident and thought Resident #1 ambulated with stand by assist. The resident wanted to do more for him/her self and worked with therapy. Staff B worked as a float that day, had no assignment sheets but did have a Walkie-talkie. Stand by assist means staff needs to be present but not assisting with a gait belt. The facility had no gait belt policy but expectation is it is to be used with assistance of one or greater. Staff B worked at the facility prior and they had no prior concerns. The Agency Staffing Company reported they direct staff to use a gait belt always when in doubt. After the incident they did a fall huddle and discussed the event. Staff D communicated to staff via the Walkie talkie and reminded them to use a gait belt. Staff B chose not to return to the facility. During an interview on 2/5/2020 at 10:30 a.m., Staff A, LPN reported working the day Resident #1 fell . Staff B summoned Staff A to Resident #1's bathroom and found the resident sitting on the floor leaning up against the door frame with a gait belt on. The resident denied hitting his/her head, had two small lacerations on the right arm and complained of right shoulder pain. The resident said the Aide did not have a hold of him/her and the Aide had just put the gait belt on. Staff A wrote the Staff B,CNA a warning and he/she has not worked at the facility since. The resident ate breakfast and lunch and then complained of right arm pain. They sent the resident to the emergency room and he/she returned with an arm sling. The resident had a right humerus fracture. The resident transferred to another facility to be closer to family. CNA's have wing sheets that reveal resident's needs. Staff B did not have an excuse as to why he/she did not have sheets. Staff A had no prior concerns with Staff B. The resident had a history of [REDACTED]. During an interview on 2/5/2020 at 12:15 p.m., Staff B, CNA revealed he/she worked for the Agency Staffing Company for one year and worked at the facility quite a bit. When Resident #1 fell , Staff B assisted the resident in the morning to get ready for the day. Staff B walked with the resident to the bathroom without a gait belt, though Staff B had a gait belt available. The resident tried to turn towards the toilet and fell . Staff B thought the resident had the walker. Staff B stated did not put the gait belt on the resident because he/she had been told prior the resident a stand by assist. That day, Staff B worked as a float and covered the entire building. Staff B reported worked with the resident 6-12 times prior, usually as a float, and unaware the resident transferred and ambulated with assist of one. As the resident turned, Staff B stood by him/her. Staff B unaware of the resident's [DIAGNOSES REDACTED] or history of dizziness. Staff B asked other staff as needed, but did not ask anyone the day the resident fell because he/she thought she was told the resident ambulated with stand by assist. Stand by assist means you are with the resident and guide them without a gait belt. Staff receive morning report from the nurse letting them know any changes and appointments. Staff B did not recall of any mention of anything reported regarding Resident #1. Staff B indicated he/she put a gait belt on the resident after the fall because he/she knew they would need it to get the resident up off of the floor, and the resident complained of right arm pain. Staff B reported he/she ambulated the resident to meals, never put a gait belt on him/her, and never saw any staff use a gait belt, so he/she believed the resident was a stand by assist. The Agency Staffing Company wrote Staff B up for not using a gait belt after the incident. Staff B had no other disciplines. Record review revealed Staff A, LPN issued a Warning Notice to Staff B, CNA dated 10/23/2020 for violation of Policies/Procedures. Description of violation: resident assisted to bathroom without a gait belt and fell . During an interview on 2/5/2020 at 1:50 p.m , Staff E, CNA reported working full time at the facility. Staff [NAME] recalled Resident #1 returned from the emergency room with an arm sling and said the Agency Aide did not put a gait belt on the resident and he/she lost his/her balance. Staff [NAME] reported the resident had dizzy spells, but could use the call light and make his/her needs known. Staff is to use a gait belt with every resident who requires one assist. Resident #1 always required assist of one. Staff has Daily Assignment Sheets with list of residents and assistance needed to review. The float staff could take Daily Assignment Sheets from all halls. The facility corrected the deficient practice on (MONTH) 23,2019 prior the Incident investigation by contacting the Agency Staffing Company who educated the staff employed and the facility did education with facility CNA's to utilize gait belts on all transfers with residents who needed one person assist. Because the facility corrected the deficient practice, the situation identified as past non-compliance.

Based on observation, record review and staff interviews, the facility failed to ensure the residents ' environment remained free from physical hazards as possible for 1 of 4 residents reviewed. (Resident #1). Resident #1 received burns from a base board heater. Two of three hallways had resident beds parallel to base board heaters. The west and south hallways had 30 residents with base board heaters in their rooms. On [DATE], the facility moved the remaining 3 beds from the base board heaters and disabled the west hallway unit under the handrail. The facility reported a census of 53 residents. Findings include: Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS identified Resident #1 had short and long term memory deficits and severely impaired cognitive abilities for daily decision making. Resident #1 required total dependence with bed mobility, transfers, dressing, eating, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. The care plan dated [DATE], identified a problem with risk of falling related to Alzheimer's disease, increased confusion, weakness and occasional combative behavior. The care plan interventions directed the staff and included keeping the bed in the lowest position, bilateral side rails, a ditch mattress, and landing strips at bedside. On [DATE] at 2:42 p.m. Staff A, Certified Nurse Aide, was interviewed and stated she did final rounds at 11:00 p.m. on the evening of [DATE]. Staff A stated she entered the room of Resident #1 who was incontinent and needed changed. Resident #1's bed was positioned parallel with the wall and the base board heating unit about a foot from the wall. Staff A stated she gathered her supplies and then grabbed the bed pad and pulled causing Resident #1 to roll onto his/her right side. Staff A removed the soiled brief and as she started to wipe the resident's bottom, without notice, Resident #1's legs flopped off the opposite side of the bed and Resident #1 went onto his/her knees between the bed and wall, with his/her hands grasping the side rail. Staff A came around to the other side of the bed and was able to get Resident #1 to release the side rail and lowered him/her onto the floor onto his/her left side. Staff A then ran out of the room to get help. Within seconds she and Staff B returned to the room. The nurse, Staff C arrived shortly after. Staff A stated when Resident #1 went to the floor she panicked and didn't recall whether Resident #1 was up against the base board heating unit or not. Staff A stated in hindsight she wished she would have had help with providing cares, but noted Resident #1 only required assistance of one staff person with perineal cares. On [DATE] at 3:10 p.m. Staff B, Certified Nurse Aide, was interviewed and stated she and Staff C were in a resident's room on the new wing at around 10:50 p.m. when she heard Staff A hollering her name in the dining room. Staff B immediately responded and followed Staff A into Resident #1's room. Resident #1 was lying up against the wall on his/her left side, between the bed and wall. Staff B instructed Staff A to move the bed as she lifted and slid Resident #1 away from the base board heating unit. Staff B then left the room to get the Hoyer (mechanical) lift and upon returning, Staff C and several other staff were attending to Resident #1. Staff B stated at that point, she left the room and allowed the other staff to deal with the situation. Staff B stated Resident #1 was typically just a one person assist with perineal cares and she has never known him/her to roll out of bed. Staff B stated Resident #1's bed had been positioned parallel with the wall and base board heating unit at the time of the incident, but has since been changed. On [DATE] at 2:19 p.m. Staff C, Registered Nurse, was interviewed and stated at around 10:55 p.m. Staff A came to the nurse's station hollering for Staff B to come to Resident #1's room. Staff C stated she finished with the resident she was with and also went to Resident #1's room. Upon arriving, there were several staff in the room. Resident #1 was lying on the floor, on his/her left side in a fetal position. Resident #1's back was towards the heat register, but not in contact with it. Staff C assessed Resident #1 and then had him/her lifted into bed using the Hoyer lift. Once in bed, Resident #1 was rolled onto his/her side and at that time she noticed burns along his/her coccyx area. Staff C stated she began measuring the burns and then contacted the physician and administrative staff. Staff C then made arrangements to have Resident #1 sent to the emergency room . Staff C stated Resident #1's bed was usually positioned parallel with the base board heating unit. The Nurse's Notes dated [DATE] at 10:25 p.m. and written by Staff C identified Resident #1 as being changed by one certified nurse aide (CNA). Resident #1 rolled off the opposite side of the bed, landed on the floor with his/her buttocks against the electrical wall heater. The Resident Fall Assessment Sheet dated [DATE] at 10:55 p.m. indicated Resident #1 slid off the bed while being changed by Staff A. Lying on the left side in a fetal position. Staff B stated Resident #1 was up against the electric wall heater. Resident #1 was lifted by a Hoyer lift into bed. Wound #1 measured 18 centimeters by 3 centimeters, white burn and #2 area measured 16 centimeters by 1.5 centimeters white burn noted in sacral area. Some skin was peeling and the resident sent to the hospital. On [DATE] at 3:30 p.m. the Administrator stated she was first notified of the incident involving Resident #1 on [DATE]. The Administrator immediately initiated an investigation and began interviews. The following morning the Administrator and maintenance began evaluating the room and heating source noting concerns with the access to thermostats, the potential exposure to the heating units and positioning of the resident's bed. The Administrator had locked covers placed over room thermostats, ordered coverings for all base board units and began repositioning beds so they would not be parallel with the base board heating units. Observations on [DATE] at 12:15 p.m. identified rooms S-01 through S-09 and rooms W-01 through W-10 all heated with electrical baseboard heating units. All protective coverings and shields were in place and could be touched without discomfort. However there were portions of the internal heating elements that were exposed and when touched were extremely hot and within seconds of contact would cause burning. The temperature taken of the exposed heating element in Resident #1' room at 3:30 p.m. were in excess of 220 degrees Fahrenheit and the shields were too hot to maintain contact more than ,[DATE] seconds. There were three beds observed positioned parallel with the base board heating units. Two beds in room S-03 and one bed in room W-01. All three beds were in excess of three feet from the wall/base board heating units. All other beds were positioned with the head of the bed against the base board heating units. In the west hall, an electric heater was observed in the hallway below the hand rail. The facility turned the heater off. The hospital records indicated the document titled Pertinent History identified the resident was transported to the burn unit and had burns involving less than 10 percent of body surface. On [DATE], a chest x-ray identified the resident had pleural effusions of both lungs, indicative of pneumonia or aspiration. The resident died on [DATE]. The primary cause of death was respiratory failure. The conditions directly contributing to death, was an aspiration (inhalation of food, liquids, vomit, etc) event. Note: At the time of the complaint investigation, the complaint was coded at a K, immediate and serious jeopardy. By [DATE] the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the E level. The facility moved all the beds in the rooms located in the south and west hall away from the electric base board heaters and not parallel to the bed. The facility ordered protective shields to completely cover the heaters and the heater located in the west hall way was disabled. As of the [DATE] exit conference the facility continued to need to: · monitor the electric base board heaters to ensure the shields are covering the entire unit and the beds remain away from the heaters (not parallel).