Every finding on record at Rosewood Nursing Center

Based on observation, interviews, and record reviews, the facility failed to ensure residents were free from hazards for 1 (Resident #1) out of 8 sampled residents.This deficient practice resulted in actual harm on 03/12/2026 during the 10:00 a.m. group activity when Resident #1 spilled hot coffee on her lap. The dietary staff failed to follow the facility's hot beverage policy when S8DA distributed coffee for residents at an unsafe temperature. As a result, Resident #1 sustained a 2nd degree and a 3rd degree burn to her left thigh and received treatment at the facility.The facility implemented a corrective action plan on 03/15/2026 and was in substantial compliance at the time of the state agency's investigation on 03/31/2026; thus it was determined to be a Past Noncompliance citation.Findings:On 03/30/2026, a review of the facility's policy and procedure titled, Serving Hot Beverages and Soup with a revised date of 07/2007 read in part in part: Policy: The Food Service Department will monitor the temperature of all hot liquids being prepared to ensure that hot liquids are served at a temperature that will prevent burns if they should come into contact with skin. Procedure: 1. The Food Service Manager will monitor the temperature that coffee is brewed at. 3. The coffee should be chilled to 120 - 130 degrees F (Fahrenheit) before being served to residents.4. The Food Service Department is responsible for ensuring that all hot beverages leave the kitchen at the proper temperature. This includes hot beverages for activities.A review of the facility's forms labeled Coffee Temp Log March 2026 revealed from 03/01/2026 through 03/15/2026 temperatures were logged for 6:00 a.m. and 2:00 p.m. The form did not include a log for 10:00 a.m. temperatures.A review of Resident #1's medical records revealed the resident was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease, unspecified dementia, essential tremor, and legal blindness.A review of Resident #1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/31/2025 revealed the resident had a BIMS (Brief Interview for Mental Status) of 13 which indicated the resident was cognitively intact. Section GG revealed the resident had no functional limited range of motion to the upper extremities.A review of Resident #1's current care plan revealed the following in part:Focus: Date initiated 03/22/2024, Resident is at risk for burns from hot liquids. Interventions included: Encourage resident to consume hot liquids while sitting at a table, date initiated 03/16/2026. Resident to use a cup with a lid for all hot beverages, date initiated 03/22/2024. Temperature of hot liquids, not to exceed 130 degrees, date initiated 03/22/2024.Focus: Date initiated 08/04/2021, Resident has impaired visual function related to legally blind. Interventions included in part: Provide activity that adjust to resident vision disability.A review of Resident #1's nursing notes revealed the following in part:At 03/15/2026 at 11:35 p.m. S3LPN wrote, this nurse notified by CNA that resident has 2 wounds on her upper thigh, 1 a blister and 1 looked like a blister that had broken open and scabbed over. When interviewing the resident, she states I spilled coffee on myself a few days ago. On call NP (Nurse Practitioner) notified. New orders to apply Bactroban 2% and dry dressing until in house NP can assess tomorrow during regular rounds.A review of Resident #1's physician's orders revealed the following orders in part:An order with the start date of 03/15/2026 for Mupirocin External Ointment 2% (topical antibiotic), apply to left front thigh topically every day shift for wound care. The order was discontinued on 03/17/2026.An order with the start date of 03/16/2026 to consult (outside wound care company).Review of Resident #1's initial wound evaluation by S4NP on 3/16/2026 at 2:21 p.m. revealed:#001: Skin issue has been evaluated. Location: Front left thigh. Issue type: Blister. Progress: New: new wound. Wound acquired in-house. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 2.3 Width (cm): 3.52 Depth (cm): 0 Area (cm2): 6.24 Undermining: No. Tunneling: No. Epithelial: 100%. Exudate amount: None. Exudate type: None. Odor after cleansing: None. Other wound bed: none. Peri-wound: Attached. Surrounding tissue: Intact. Induration: None present. Edema: No swelling or edema. Peri-wound temperature: Normal. Dressing appearance: Intact. Dressing saturation: None 0%. Cleansing solution: Normal saline. Other primary dressing: XEROFORM Secondary dressing: Dry. Modalities: None. frequency of treatment: DAILY#002: Skin issue has been evaluated. Location: Front left thigh. Issue type: Burn. Progress: New: new wound. Wound acquired in-house. It is unknown how long the wound has been present. Signs and symptoms of infection: None. Painful: No. Staged by: In-house nursing. Length (cm): 2.31 Width (cm): 4.07 Depth (cm): 0.1 Area (cm2): 6.56 Undermining: No. Tunneling: No. Epithelial: 10%. Slough: 90. Exudate amount: Light. Exudate type: Serous: clear watery fluid, which is separated from solid elements. Odor after cleansing: None. Other wound bed: none. Peri-wound: Attached. Surrounding tissue: Intact. Induration: None present. Edema: No swelling or edema. Peri-wound temperature: Normal. Dressing appearance: Intact. Dressing saturation: Minimal < 25%. Cleansing solution: Normal saline. Other primary dressing: XEROFORM Secondary dressing: Dry. Modalities: None. frequency of treatment: DAILYA review of S4NP's progress note dated 03/24/2026 read in part: admitted to the wound care provider on 3/17/2026, for initial evaluation and treatment of a wound. The staff reports this area started secondary to patient spilling coffee on herself about a week ago. Assessment: 1. Full thickness burn of left thigh, initial encounter 2. Essential tremor. Clinical Notes: Wound #1 LLE (Left Lower Extremity) anterior upper thigh 3/24/26 = 2.9x4.5x0.1 (90 slough 10 epi (epithelial); Wound #2 LLE anterior lower thigh 3/24/26 = 1.9x2.7x0.1 (100 epi).On 03/31/2026 at 11:53 a.m., an interview was conducted with S4NP who stated Resident #1 had two burns to her upper left leg. Wound #1 was a full thickness, 3rd degree burn. Wound #2 was a partial thickness, 2nd degree burn. S4NP further stated both wounds were healing and have had no signs of infection.A review of the facility's investigative report revealed the following in part:On 3/15/2026, at approximately 8:10 p.m., S2DON was notified that the Resident #1 appeared to have a burn on her left upper thigh area. S2DON immediately went to the facility to assess and noted Resident #1 with a blistered area that was the result of a hot beverage spill. Resident states that she spilled her coffee onto her person.On 03/30/2026 at 1:55 p.m., an interview was conducted with S5DM. She confirmed that coffee was served at 6:30 a.m., 10:00 a.m., and 2:00 p.m. She confirmed that all dietary staff were trained on the facility's policy Serving Hot Beverages and Soup and ensuring the temperature is 120 - 130 degrees F prior to serving before to the incident occurred. She stated the temperature of the coffee is obtained after the coffee is made, then iced down until the proper temperature is obtained. S5DM stated the S8DA made the coffee on 03/12/2026. S5DM stated that during the investigation, S8DA reported that the coffee temperature was 140 degrees F. S8DA was terminated for serving the coffee too hot. S5DM stated prior to Resident #1's incident, the temperature was only logged for 6:00 a.m. and 2:00 p.m. She stated the temperature was always checked at 10:00 a.m., however, there was no 10:00 a.m. slot to log the temperature. Since the incident, the 10:00 a.m. slot has been added to the temperature log. S8DA was no longer employed by the facility and unable to be interviewed.On 03/30/2026 at 4:26 p.m., a review of the facility's coffee temperature logs for March 2026 was conducted with S1ADM. She stated prior to the incident the coffee temperature log was only completed for 6:00 a.m. and 2:00 p.m. She confirmed there was no coffee temperature logged for 03/12/2026 at 10:00 a.m. She added that since the incident, the temperature log was revised on 3/16/2026 to include 10:00 a.m.On 03/31/2026 11:45 a.m., an interview was conducted with Resident #1. She stated about 2 weeks ago she spilled hot coffee on her left leg while sitting at a table in the activity room. She stated it was an accident and not sure how it spilled. She stated the coffee was hot and it burned when she spilled it. She also did not know if her cup had a lid. She stated that she had a little pain for a few seconds, then it went away. She was not able to give a number on the pain scale. She denied any pain after the incident occurred. She did not report any pain to staff after it the spill happened. She further stated prior to this incident, the coffee was not too hot and has not been too hot since she spilled. The resident stated she holds her coffee in her right hand and is able to use left hand, but it is weak. She denied any tremors or shakiness when the incident occurred.During the survey, dietary staff and clinical staff were interviewed regarding the facility's hot beverage policy. All staff interviewed confirmed receiving re-education on the hot beverage policy. Review of the coffee temperature log at 6:30 a.m., 10:00 a.m., and 2:00 p.m. from 03/16/2026 through 03/30/2026 revealed temperatures were between 122 - 130 degrees F as per the facility's policy. Observations on 03/30/2026 and 03/31/2026 revealed coffee was distributed in cups with lids. Observation on 3/30/2026 of prepared carafes temperature prior to being served to residents was 120.3 degrees F. On 03/30/2026 at 2:22 p.m. S9ACT was observed pouring coffee into blue cups and placing lids on the cups prior to giving it to the residents. On 3/30/2026 at 1:55 p.m., an interview and observation of coffee temperatures was conducted with S5DM. She stated the coffee had already been prepared, temped. Upon request S5DM obtained the temperatures again, readings were both 120.3.On 03/31/2026 at 8:30 a.m., several residents were observed in activity room drinking coffee from blue cups with lids.On 03/31/2026 at 11:38 a.m., observed resident #R8 in activity room with cup with lid. He stated he was drinking coffee.The facility implemented the following actions to correct the deficient practice: I. On 03/15/2026, the facility began an immediate investigation.On 03/16/2026, a suspension was immediately implemented for S8DA who temped the coffee on 3/12/26 at the incorrect temperature.On 03/20/2026, upon completion of the investigation, a termination was implemented for S8DA. II. On 03/16/2026, education and in-service for all clinical and dietary staff were re-educated on the Hot Beverage Policy.On 03/16/2026, an audit of all resident's plan of care was completed.On 03/16/2026, a skin audit of residents that had impaired cognition or nonverbal was conducted to ensure no other residents were affected.On 03/16/2026, a questionnaire was completed for all other residents who are verbal and hold a BIMS score of 13 or higher.Previously, on 03/02/2026, residents began complaining about the chilled temperature of the coffee because they wanted it hotter. The administrator then called a Resident Council meeting on 3/2/2026 to educate residents on the Hot Beverage policy. III. On 03/16/2026, QAPI meeting was held by ID team to discuss progression of the investigation and why this past noncompliance was developed and implemented.On 03/16/2026, Community Medical Director notified of event.On 03/16/2026 through 03/17/2026, a mandatory meeting called at the facility for all clinical staff and dietary staff to in-service on the Hot Beverage Policy and Abuse, Neglect, and Timely reporting policy, and lids placed on all coffee drinks prior to serving.On 03/16/2026, reeducation completed with dietary manager and dietary staff on following Hot Beverage policy, temp requirement and who is responsible for temping hot beverage.Education will require staff return demonstration from dietary staff of temping hot beverage with the thermometer to validate competency. Dietary staff will not be allowed to return to duty until completion of education and return demonstration. IV. Quality Assurance plans to monitor facility compliance to make sure that corrections are achieved and permanent.Routine reviews will be completed 3 times a week for 90 days on sample selection of facility staff using abuse, neglect timely reporting quiz to assess knowledge base. To be completed by June 14, 2026.Routine reviews will be completed by S1ADM, S2DON, S5DM of dietary staff 3 times per week for 90 days. Results of routine review will be reported during morning stand up meeting. To be completed by June 14, 2026 V. Date of Compliance was 03/17/2026.Anticipatory monitoring completion date by 06/14/2026.

Based on record reviews and interviews, the facility failed to report an injury of unknown origin to the State Agency no later than 2 hours later in accordance with State law for 1 (#1) of 8 (#1 ,#2, #3, #4, #R1, #R2, #R3, #R4) sampled residents. The deficient practice had a potential to affect a total census of 66 residents. Findings: A review of the facility's policy titled Abuse, Prevention and Prohibition Policy, with an approval date of 03/2025, revealed in part: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately to the administrator. The allegation will be reported no later than 2 hours, or per state regulations after the allegation is made. A review of the resident's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus without complications, Schizoaffective Disorder, and History of Falling. A review of Resident #1's admission MDS (Minimal Data Set) dated 03/05/2025 revealed the resident had a BIMS (Brief Interview Mental Status) score of 13 indicating the resident was cognitively intact. A review of Resident #1's progress note dated 05/22/2025 at 4:08 p.m., documented by S1ADM (Administrator) that read as follows: Resident also has a red abrasion area to his right hip area. Approximately 6cm (centimeters) x 4cm in diameter. Sending resident to the ER (Emergency Room) for evaluation and x-rays. Again resident denies stubbing toe and falling. A review of the State Agency report revealed the date of discovery was 05/22/2025 and the date entered was 05/27/2025. On 06/23/2025 at 3:30 p.m., an interview was conducted with S1ADM. S1ADM stated she is responsible for reporting incidents to the State Agency. S1ADM confirmed that on 05/22/2025 it was reported to her, upon discovery, new skin findings on Resident #1 that included a wound to his right foot and an abrasion to his right hip area. S1ADM stated that through investigation, they (referring to herself and her corporate team) determined that the wound was not as a result of neglect; therefore, the report to the State Agency within 2 hours was not warranted per policy and state law. S1ADM was further interviewed regarding the abrasion to Resident #1's right hip. S1ADM confirmed that the resident was unable to recall or verbalize how he sustained this injury. S1ADM agreed that since the facility was unaware of this injury and how it occurred and because the resident could not recall how he sustained it, that this would be considered an injury of unknown origin and should have been reported to the State Agency within the required 2 hour timeframe.

Based on observation and interview, the facility failed to post nurse staffing information in a prominent place, readily accessible to residents and visitors. The information should be posted on a daily basis and include the resident census and total number of actual hours worked by RNs (Registered Nurses), LPNs (Licensed Practical Nurses), and CNA (Certified Nurse Assistant) staff directly responsible for resident care per shift. The facility census was 63. Findings: On 12/10/2024 at 6:54 p.m., an interview with S1ADM (Administrator) and S9PM (Payroll Manager) verified that the facility did not post daily nurse staffing information that included the resident census and total number of actual hours worked by RNs, LPNs, and CNA staff directly responsible for resident care per shift anywhere in the facility. On 12/10/2024 at 7:30 p.m., an interview with S3RDO (Regional Director of Operations) was conducted. S3RDO was questioned regarding the posting of nurse staffing information that included resident census and total number of actual hours worked by RNs, LPNs, and CNA staff directly responsible for resident care per shift on a daily basis. S3RDO responded, We don't post the daily staffing information, but probably should.

Based on observations, interview, and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 3 (#11, #33, #37) out of 3 (#11, #33, #37) residents reviewed for respiratory care, with the potential to effect 7 residents receiving oxygen therapy. Findings: Review of the facility's policy titled Oxygen Administration with an approval date of 12/2024, revealed in part: Steps in the procedure . 10. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is enough that the water bubbles as oxygen flows through. 12. Replenish water to humidifier jar as needed. Resident #11 Review of the physician's orders for Resident #11 revealed an order dated 12/09/2024 - Oxygen (O2) 3L/NC (liters per nasal cannula). On 12/08/2024 at 9:37 a.m., an observation of Resident #11's O2 concentrator was done. The humidifier jar, attached to concentrator tubing, was on floor without H2O (water) in the humidifier jar. On 12/08/2024 at 9:44 a.m., during an observation and interview with S4LPN, she observed and confirmed the oxygen humidifier jar for the concentrator was on the floor and the humidifier jar was empty. She reported the tubing and canister are changed at night on Sundays and PRN. She also confirmed the oxygen was infusing at 3 L/NC as ordered. Resident #33 Review of the physician's orders for Resident #33 revealed an order dated 10/21/2424 - O2 at 3L/NC as needed for SOB (Shortness of Breath) On 12/08/2024 at 10:21 a.m., an observation of Resident #33's O2 concentrator was done. The humidifier jar was without H2O in the humidifier jar. On 12/08/2024 at 10:25 a.m., an interview was conducted with Resident #33. She stated she uses supplemental oxygen through her nose all the time. On 12/08/2024 at 10:43 a.m., an observation and interview with S5RN (Registered Nurse) of Resident #33's O2 concentrator was conducted. She confirmed the humidifier jar for the oxygen was empty and should have been checked regularly and had water added to it as needed. Resident #37 Review of the physician's orders for Resident #37 revealed an order dated 02/29/2024 O2 3L/NC as needed for Shortness of Breath. On 12/08/2024 at 10:04 a.m., an observation of Resident #33's O2 concentrator was done. The humidifier jar was empty, without H2O. On 12/08/2024 at 10:10 a.m., an observation and interview with S8LPN of Resident #37's O2 concentrator was conducted. She also confirmed the humidifier jar was empty, and should have water and bubbling when in use administering oxygen. Or while administering oxygen.

Based on record reviews, observations, and interviews, the facility failed to ensure that residents' enteral feeding was properly labeled for 2 (#34 and #35) out of 2 (#34 and #35) sampled residents reviewed for tube feeding. The deficient practice had the potential to affect a total of 9 residents that received tube feedings. Findings: Resident #34 Review of Resident #34's electronic health record revealed he was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Gastrostomy Status, Dysphagia Pharyngeal Phase, Moderate Protein Calorie Malnutrition, and Vascular Dementia. Review of Resident #34's physician's orders revealed an order dated 11/26/2024 that read: Enteral feed every night shift for supplement r/t (related to) Mod (moderate) PCM (Protein Calorie Malnutrition), and Dysphagia. Administer Isosource 1.5 via peg tube at 45 ml (milliliters)/hr. (per hour) continuous and flush of 60 ml/hr. Total volume to be infused 1080 ml in 24 hours. On 12/08/2024 at 10:46 a.m., an observation of Resident #34's tube feeding administration set revealed the formula label read, Isosource 1.5, the resident's name, a date of 12/08/2024, 1:00 a.m., and nurse's initials. There was no rate listed on the administration set. Further observation of the tube feeding administration set revealed the flush bag was not labeled. On 12/09/2024 at 10:24 a.m., a second observation was conducted of Resident #34's tube feeding administration set revealed the flush bag was not labeled. On 12/09/2024 at 10:48 a.m., an observation of Resident #34's tube feeding administration set was conducted with S7LPN (Licensed Practical Nurse). S7LPN confirmed the flush bag of the tube feeding administration set was not labeled and it should have been labeled with the resident's name, contents, rate, date, time, room number, and initials. Resident #35 Review of Resident #35's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses including Hemiplegia following Cerebrovascular Disease, Type II Diabetes Mellitus, Dementia, Gastrostomy Status, Dysphagia, and Aphasia. Review of Resident #34's physician's orders revealed an order dated 11/27/2024 that read: Enteral feed Diabetisource via peg tube at 45ml/hr. with flush of 80 mls per 4 hours. On 12/08/2024 at 9:25 a.m., an observation of Resident #35's tube feeding administration set was conducted revealed the formula label read, Diabetisource AC, the resident's name, a date of 12/08/2024, 1:00 a.m., and the nurse's initials. There was no rate listed on the administration set. Further observation of the tube feeding administration set revealed the flush bag was not labeled. On 12/09/2024 at 10:26 a.m., an observation of Resident #35's tube feeding administration set was conducted that revealed the flush bag was not labeled. On 12/09/2024 at 10:50 a.m., an observation of Resident #35's tube feeding administration set was conducted with S7LPN. S7LPN confirmed the flush bag of the tube feeding administration set was not labeled. S7LPN confirmed the flush bag should have been labeled with the resident's name, contents, rate, date, time, room number, and initials. On 12/10/24 at 8:44 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON confirmed the tube feeding administration set to include the formula bag and the flush bag should have each been labeled with the date, time, nurse's initials, rate and contents to ensure the resident received the proper nutrition and hydration. Further interview with S2DON revealed the facility had no policy and procedure related to labeling the tube feeding administration set.

Based on record review and interview the facility failed to ensure that each residents' medication regimen was free from unnecessary medications by failing to monitor for side effects for antipsychotropic medications for 1 (#42) of 5 (#11, #24, #27, #42, #47) residents reviewed for unnecessary medications. The deficient practice had the potential to affect a total census of 63. Findings: On 12/10/2024 at 1:07 p.m., a request was made for a policy regarding monitoring for antipsychotropic medications. No such policy was provided by the time of the survey conclusion. A review of Resident #42's record revealed an admitted [DATE] with diagnoses that included Vascular Dementia, Anxiety Disorder and Depression. A review of Resident #42's November 2024 and December 2024 EMAR's (Electronic Medication Administration Record) revealed Resident #42 was receiving the following medications: An antipsychotic, Quetiapine 200mg (milligram) twice daily with a start date of 11/14/2024, An antidepressant, Duloxetine 60mg 2 capsules daily with a start date of 11/15/2024, An antidepressant, Mirtazapine 15mg at bedtime with a start date of 11/14/2024, and An antianxiety, Buspirone 5mg three times daily with a start date of 11/21/2024. Further review of Resident #42's November 2024 and December 2024 EMAR failed to reveal side effect monitoring. On 12/20/2024 at 9:50 a.m., a concurrent record review and interview was conducted with S7LPN (Licensed Practical Nurse). S7LPN reviewed Resident #42's November 2024 and December 2024 EMAR and confirmed the resident was taking the Quetiapine, Duloxetine, Mirtazapine, and Buspirone and that all of the medications required monitoring for side effects and targeted behaviors. S7LPN confirmed this monitoring should be documented on the EMAR, and was not being done and should be. On 12/20/2024 at 1:07 p.m., a concurrent record review and interview was conducted with S2DON (Director of Nursing). S2DON reviewed Resident #42's November 2024 and December 2024 EMAR and confirmed the resident was taking the Quetiapine, Duloxetine, Mirtazapine, and Buspirone and that all of the medications required monitoring for side effects and targeted behaviors. S2DON confirmed this monitoring should be documented on the EMAR, and was not being done and should be.

Based on observation and interview, the facility failed to ensure food products were properly refrigerated after being opened. This deficient practice has the potential to effect the 56 residents that eat meals from the from the facility's kitchen. Findings: On 12/08/2024 at 8:45 a.m., an initial observation of the kitchen's dry storage room was conducted. One 48 ounce container of Concord Grape Jelly, was opened with approximately one-third of the jelly missing. Upon further inspection of the container, it read Refrigerate after opening. On 12/08/2024 at 11:15 a.m., a second observation of the kitchen's dry storage room was conducted with S6DM (Dietary Manager). She confirmed the container of Concord Grape Jelly had been opened, and on further review of the label, that is should be been refrigerated after opening.

Based on observations and interviews, the facility failed to provide a clean, comfortable, and homelike environment for 1 (#33) out of 35 sampled residents. The deficient practice had the potential to affect a census of 63. Findings: On 12/08/2024 at 10:19 a.m., an observation was conducted of Resident #33's room. The room had a silver pole on wheels that held the TF (Tube Feeding) machine, it had dry white substance(s) running down the pole and a tan , crusty substance covering almost the entire wheel base. Further observation revealed the oxygen concentrator had dried white and tan crusty splattered substance and drip spots on the front and top of the concentrator. On 12/08/2024 at 10:20 a.m., resident stated they should clean that machine and pole, it is dirty and they don't even attempt to clean it. On 12/08/2024 at 10:43 a.m., an observation of Resident #33's room and interview was conducted with S5RN (Registered Nurse). She confirmed the findings from above, and stated they should have been cleaned.

Based on interview and record review, the facility failed to ensure RD (Registered Dietitian) recommendations in response to identified weight loss were relayed to the physician for review and implementation for 1 (#44) of 9 (#3, #5, #23, #33, #34, #35, #44, #46, #212) residents that receive nutrition from enteral feedings. Findings: A review of Resident #44's record revealed an admitted [DATE] with diagnoses that included Dysphagia, Aphasia, Protein-Calorie Malnutrition, and Encounter for Attention to Gastrostomy (feeding/PEG tube). A review of Resident #44's care plan revealed a focus area for potential nutritional problem related to disease process, dysphagia, malnutrition, and has unplanned weight loss. Interventions included, provide and serve diet/provide peg (feeding) tube as per order and RD to evaluate and make diet change recommendations. A review of Resident #44's current physician's orders for November 2024 and December 2024 failed to reveal an order for tube feeding formula and rate. A review of Resident #44's November 2024 EMAR (Electronic Medication Administration Record) revealed an order that stated May substitute Isosource 1.5 for Jevity but failed to include administration instructions for rate. Review of Resident #44's December 2024 EMAR revealed an order that stated May substitute Isosource 1.5 for Jevity but also failed to include administration instructions for rate. Review of the RD Consultant Dietitian report Summary of Nutritional Care dated 11/15/2024 for Resident #44 revealed the following: Consult on [AGE] year old male who was eating initially by PO (by mouth) and after MBS (Modified Barium Swallow) test, he is NPO (nothing by mouth) and receiving Isosource 1.5 (liquid nutrition for tube feeding) at 50ml/hr (milliliters per hour) with 30ml/hr flush (water) He has had a 13.4 pound weight loss in past month and is currently at 134.8 pounds. BMI: 21.8 and is 90% of IBW (Ideal body weight) range: 149-180 pounds. Recommended increase to Isosource 1.5 TF (tube feeding) to 65ml/hr continuously . On 12/10/2024 at 10:45 a.m., an interview was conducted with S10RD. S10RD stated she assesses all residents' nutritional needs. The results, including changes and recommendations, are then emailed to the facility's administrative staff. The administrative staff is responsible for implementing the changes. She viewed her Consultant Dietitian Report dated 11/15/2024 and confirmed she had identified Resident #44's weight loss and made recommendations to increase the tube feeding rate according to the resident's estimated nutritional needs. She confirmed this report was sent to administrative staff, which included the DON (Director of Nursing), ADON (Assistant Director of Nursing), and the Administrator via e-mail. On 12/10/2024 at 3:03 p.m., a concurrent record review and interview was conducted with S2DON. S2DON confirmed she received the RD consultant report dated 11/15/2024 that included Resident #44's recommendations for the increased tube feeding rate. S2DON then viewed Resident #44's record and failed to identify that the recommendation had been implemented and confirmed there was no order to increase the tube feeding rate and should have been. On 12/10/2024 at 4:15 p.m., an additional interview was conducted with S2DON who stated that the resident's current weight is 135 lbs and has not had a weight loss from November 2024 to December 2024. During the interview, a request was made for a policy in regards to the process for reviewing and implementing Registered Dietitian recommendations. No such policy was provided by the time of survey completion.

Based on interviews, observations, and record reviews, the facility failed to ensure a resident was free from accidents hazards during a mechanical lift transfer for 1 (#1) of 7 (#1, #2, #3, R1, R2, R3, and R4) sampled residents who required two-person transfer with a mechanical lift. This deficient practice resulted in an actual harm for Resident #1 on 08/08/2024 at 2:15 p.m., when S3CNA (Certified Nursing Assistant) attempted to transfer the resident from a shower bed to bed while utilizing the mechanical lift without assistance of another qualified staff person. Resident #1 fell from the lift sling during the transfer and landed on the floor resulting in a fractured right leg. Resident #1 was transferred to the hospital on 08/08/2024. X-ray report dated 08/08/2024 at 4:53 p.m. showed a suspected nondisplaced fracture of the distal fibula. A CT (comp tomography) scan done on 08/09/2024 at 7:43 a.m. revealed a comminuted, displaced distal femoral fracture with multiple ossific fragments and surrounding hemorrhage. Resident #1 underwent surgery; intramedullary nailing of the right femur on 08/10/2024. The resident remains in the hospital at the time of survey as a result of the fall with fracture and surgical repair. The facility implemented corrective action plan on 08/08/2024 which was completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: A review of the facility's Mechanical Lift Policy, last reviewed by the facility in July 2024 revealed the following, in part: Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. Review of the facility's CNA Professional Orientation Guidebook revealed in part: Mechanical Lift Transfers: All mechanical lifts require two people. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Heart Failure, Vascular Dementia, Major Depressive Disorder, and Cognitive Communication Deficit. Review of Resident #1's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/26/2024, revealed the following, in part: BIMS (Brief Interview for Mental Status) of 99 which indicated the assessment for cognition could not be complete because resident did not participate; Bed mobility- extensive assistance/2-person assist. Review of Resident #1's current care plan initiated 10/14/2022 revealed the following, in part: 05/23/2022 .Problem: The resident has an ADL self-care performance deficit related to cognitive and physical impairment .Approaches: The resident requires two person and mechanical aid (Hoyer lift) for transfers. Review of Resident #1's Fall Incident Report dated 08/08/2024 revealed the following, in part: Was called to the room by the CNA because the resident fell on the floor. CNA stated the sling pad popped Resident was left in the position that she was found in. The ambulance was called to get resident up and bring her to the ER (emergency room ). Review of Resident #1's hospital records revealed an x-ray report dated 08/08/2024 at 4:53 p.m. that showed a suspected non displaced fracture of the distal fibula. A CT (comp tomography) scan done on 08/09/2024 at 7:43 a.m. revealed a comminuted, displaced distal femoral fracture with multiple ossific fragments and surrounding hemorrhage. Resident #1 underwent surgery, intramedullary nailing of the right femur, on 08/10/2024. Review of the facility's Investigative Report revealed the following, in part: on 08/08/2024, S3CNA failed to properly follow community policy as it related to assessment and functionality of the sling and requirements of two-person assistance while utilizing Hoyer lifts resulting in resident falling from Hoyer lift and sustaining fracture. Identified staff member immediately suspended pending investigation. On 08/14/2024 at 3:15 pm., an interview was conducted with S4LPN (Licensed Practical Nurse). S4LPN confirmed she cared for Resident #1 on 08/08/2024. She confirmed she was aware that Resident #1 required transfers with a Hoyer lift and two person assistance. She denied ever being asked for assistance with any transfers on 08/08/2024. She stated she was made aware Resident #1 had fallen when S3CNA came into the hallway calling for help. S4LPN stated when she entered the resident's room, she noted both the shower bed and Hoyer lift were in the room and the Resident #1 was lying next to the bed on her right side with her right leg under the bed. S4LPN stated she observed Resident #1's right leg was bent in the opposite direction behind her in an unnatural alignment with a protrusion from the right thigh. She stated she suspected a fracture of the femur and chose not to move the resident until EMS arrived. On 08/15/2024 at 9:00 a.m., a phone interview was conducted with S3CNA. She confirmed she provided care to Resident #1 on 08/08/2024. S3CNA stated she had taken care of Resident #1 previously and was familiar with the type of care the resident required including that the resident required two persons for transfers with the lifter. She stated that she and another CNA (later identified as S5CNA) transferred Resident #1 from her bed to her shower bed using the Hoyer lift, brought the resident into the shower room, and gave her a shower. When done, she (S3CNA) transported Resident #1 on the shower bed back inside her room. S3CNA stated she rang the call bell to request assistance from another staff member. After waiting approximately 1 minute, Resident #1 began to cry. S3CNA stated she didn't want to make the resident wait any longer, so she proceeded to transfer the resident on her own without assistance. Resident #1 was on a lifter pad, then hooked up to the mechanical lift. S3CNA stated once Resident #1 was lifted into the air, she heard a noise which she believed was the lifter pad ripping, then the resident just fell to the floor. She further explained the resident fell on to her right side with her right leg under the bed. S3CNA stated she immediately went into the hallway and called for nursing assistance; S4LPN responded immediately. S3CNA confirmed she was aware Resident #1 required two staff members for transfers, but failed to follow the resident's care plan. On 08/15/2024 at 1:30 p.m., an interview was conducted with S5CNA. She stated on 08/08/2024, while walking on the hallway, she observed S3CNA attempting to transfer Resident #1 from her bed to the shower bed using the Hoyer lift without assistance. When she observed this, she entered the room and assisted S3CNA with the transfer because she was aware that Resident #1 required two persons with all transfers. S3CNA went into the shower room with the resident after the transfer while she continued on with her own tasks. S5CNA denied being asked to assist with any transfers, and also denied hearing a call bell singling for assistance. On 08/15/2024 at 1:45 p.m., an interview was conducted with S1ADM (Administrator). S1ADM confirmed Resident #1 had been hospitalized since 08/08/2024 as a result of the fall resulting in a leg fracture that required surgical repair on 08/10/2024. She stated that, during the investigation of the incident and interview with S3CNA, it was determined that S3CNA failed to follow Resident #1's care plan for two person assist and to assess the functionality of the sling prior to using the lift. S1ADM stated the lift sling was inspected after Resident #1's fall which was noted to have come unsewn at the seam where the hooks were attached. S1ADM denied the sling had any frayed areas. S1ADM stated they immediately inspected all slings in the facility as well as all Hoyer lifts. She stated all Hoyer lifts were in good working order with no deficits were found in any of the other slings. Then they began in-servicing all clinical staff which included: a physical demonstration, on proper use of Hoyer lifts, assessing slings for functionality, abuse/neglect, and change in condition. The facility also did an audit on all care plans to ensure each resident's transfer requirements were correct. She asserted there were no negative findings as a result of this audit. S1ADM further stated the facility had an AD HOC (impromptu) QAPI (Quality Assurance Performance Improvement) meeting on 08/08/2024 to begin investigations and initiate corrective actions and on the repeat AD HOC QAPI meeting on 08/09/2024 where they determined the deficient practice had been corrected. S1ADM reported the facility's monitoring began the following day (08/09/2024) and was ongoing. She denied any negative findings with the monitoring and stated there had been no further incidents regarding transfers, Hoyer lifts, or lifter slings. S1ADM reported she and the Director of Nursing would conducted monitoring for 90 days. Projected completion of monitoring was 09/01/2024 if no negative findings. The monitoring would be extended for an additional 60 days if any negative findings were identified. Multiple Nurses and CNA's were interviewed about the use of the mechanical lift. All staff interviewed were knowledgeable about the facility's policy that two trained staff members should be present when lifting a resident using the mechanical lift. All staff members stated they had received multiple trainings on the proper use of mechanical lifts. Five random residents, who required use of a mechanical lift for transfers, were observed on 08/14/2024 and 08/15/2024 having two or more staff members present when the mechanical lift was used on them. No concerns were identified. The facility implemented the following actions to correct the deficient practice: 08/08/2024- Continuous Quality Assessment and Improvement Corrective Action Plan: I. Immediate evaluation of all Hoyer lift and slings. II. Immediate reeducation of clinical staff for safe mechanical transfer procedure, lift sling evaluation and reporting, and abuse, neglect and change in condition reporting. III. Employee monitoring of resident transfers utilizing Hoyer lift and lift slings by administrator or designee. IV. Monitoring or Hoyer lift and lift slings by administrator or designee. V. Continued education on the use of Hoyer lifts, slings, and their usage at the time of hire, annually and as needed. 08/09/2024- All clinical staff have received re-education; monitoring conducted and documented with ongoing trainings continued.

Based on interview and record review, the facility failed to ensure that residents who required dialysis received such services consistent with professional standards of practice for 1 (#1) out of 2 (#1, #2) residents sampled for dialysis services as evidenced by: 1. Failing to conduct comprehensive post dialysis assessments; and 2. failing to ensure that communication received from the dialysis provider was addressed and communicated with staff. Findings: Review of the facility's policy titled, Dialysis Communication, read in part .6. The nurse will complete post dialysis information on the dialysis communication form. 7. Nurse will communicate any significant information (complications or concerns) to the medical practitioner and/or representative. Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included, in part but not limited to; End Stage Renal Disease and Dependence on Renal Dialysis. Review of Resident #1's care plan revealed an intervention to review communication form or flow sheet after treatment, implement new orders or recommendations, and encourage resident to complete treatment. Review of Resident #1 dialysis communication binder revealed a Dialysis Communication Form dated 12/27/2023 with the Post Dialysis Facility Information portion not completed or signed by the facility nurse. Review of Dialysis Communication Form dated 12/29/2023 revealed concerns during dialysis that read in part .Patient will need someone to sit with her during treatment for safety. The Post Dialysis Facility Information was not complete or signed by the facility nurse. Further review of the communication form sent by the dialysis provider revealed a comment on 01/03/2024 that read in part .needs sitter during treatment for safety concerns. There was no Post Dialysis Facility Information documented. Review of Resident #1's dialysis clinical notes revealed an entry on 01/03/2024 that read in part .On 12/29/2023, this RN (Registered Nurse) requested NH (Nursing Home) to send sitter with patient during treatment for safety but no sitter sent 12/31/2023 nor 01/03/2024 .spoke with S2DON (Director of Nursing) who stated she did receive request via communication sheet but did not believe patient needs sitter during treatment. On 01/18/2024 at 10:05 a.m., an interview was conducted with S2DON. S2DON stated she was never notified by her staff of any requests made by the dialysis provider for a sitter during Resident #1's dialysis treatments. On 01/18/2024 at 3:30 p.m., a follow up interview and review of Resident #1's Dialysis communication Forms dated 12/27/2023, 12/29/2023, and 01/03/2024 was conducted with S2DON. S2DON confirmed that, had S3LPN reviewed, completed the post dialysis form, and followed policy, there would not have been a failure in dialysis communication and collaboration and the request made by the dialysis provider could have been addressed. S2DON acknowledged and confirmed the Post Dialysis Facility Information was incomplete and should be done by the facility nurse upon the resident's return from dialysis treatment. On 01/18/2024 at 3:45 p.m., an interview and review of Resident #1's dialysis communication forms dated 12/27/2023, 12/29/2023 and 01/03/2024 was conducted with S3LPN (Licensed Practical Nurse). She confirmed that she did not complete the Post Dialysis Facility Information portion. S3LPN also confirmed she saw the concerns documented by the dialysis provider on 12/29/2023 requesting a sitter for the resident, did not communicate this information to any staff member and should have.

Based on record review and interview, the facility failed to ensure a RN (Registered Nurse) was on duty for 8 consecutive hours per day for 7 days per week. Findings: Review of the facility's PBJ (Payroll Based Journal) Staffing Data Report for FY (Fiscal Year) Quarter 4 2023 (July 1 - September 30), revealed a trigger for no RN hours and a One Star Staffing Rating. Review of Time Card Reports and RN clock in hours for the months of July 2023 to September 2023 revealed no RN hours for 4 days in the month of July. On 12/19/2023 at 2:50 p.m. a review of the Time Card Reports for July 2023 was conducted with S1ADM (Administrator). S1ADM confirmed that there was no RN coverage for 07/03/2023, 07/07/2023, 07/12/2023, and 07/13/2023.

Based on record review and interview, the facility failed to accurately maintain resident records by failing to have a written order to release body to funeral home for 1 (#51) out of 1 (#51) sampled death resident records. Findings: Resident #51 was admitted to the facility on [DATE] with diagnoses including Senile Degeneration of Brain, Dementia and Emphysema. A review of the physician's orders for Resident #46 revealed 10/30/2023 - Admit to facility under the care of - Hospice. Further review of physician's orders for Resident #46, had no order to release resident to funeral home. Review of Resident #46's electronic records nursing progress notes revealed on 11/07/2023 at 3:05 a.m., time of death 3:05 a.m., by hospice. Further review of nurses' progress on 11/07/2023 at 4:42 a.m., resident leaving facility with staff from --- Funeral Home. On 12/19/2023 at 11:45 a.m., an interview was conducted with S3DON. She reviewed the resident's records and hospice records and confirmed there was not an order to release the body to the funeral home. She also confirmed they should have had an order to release the body to the funeral home.

Based on observations, record review and interview, the facility failed to maintain an effective infection prevention and control program by failing to ensure staff performed hand hygiene according to accepted standards of practice during wound care for 1 (#46) out of 1 (#46) residents sampled for pressure wounds. Findings: Review of Resident #46's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating the resident had moderate cognitive impairment. Review of Resident #46's electronic medical record revealed an admitted [DATE] with diagnoses including, but not limited to Cerebral Vascular Accident, Gastrostomy Tube, Anxiety, Diabetes Mellitus II, Dysphagia, Stage IV Sacral Pressure Ulcer and Protein-calorie Malnutrition. Review of the resident's current physician's orders revealed an order written on 12/14/2023 - daily wound care to sacral wound: cleanse with NS (normal saline) or wound cleanser. Apply collagen powder, cover with Vashe or Dakins moistened gauze and ABD (abdominal) pad. Secure with dry dressing. On 12/20/2023 at 10:00 a.m., an observation was made of S9RN (Registered Nurse) providing wound care to Resident #46. There was no dressing covering the wound. S9RN applied clean gloves, wound cleanser to clean the wound bed with her gloved hand, then patted the wound dry with gauze. S9RN proceeded to apply collagen powder to gauze then applied to the wound bed without changing her dirty gloves. The wound was then covered with a clean ABD pad and secured with tape. On 12/20/23 at 10:15 a.m., an interview was conducted with S9RN. S9RNconfirmed she did not change her dirty gloves after cleaning the wound and before applying the new dressing. She stated she should have changed her dirty gloves after cleaning Resident #46's wound and before she applied the new clean dressing.

Based on observation and interviews, the facility failed to ensure that expired medication/biologicals were properly discarded and not available for use. This was evidenced by having expired Influenza vaccinations stored in a medication refrigerator. Findings: On [DATE] at 9:40 a.m., an observation of Medication Room A was conducted with S5LPN. During the inspection of the mediation refrigerator, 3 unopened boxes and 1 opened box with 2 remaining doses of Influenza Vaccine-Fluzone High Dose-Quadrivalent (10 dose box) were noted expired. The manufacturer expiration date on each box read [DATE]. S5LPN confirmed expiration date and confirmed they should have been discarded. On [DATE] at 11:30 a.m., an interview was conducted with S1ADM, who confirmed that expired medication should not have been in the medication refrigerator.

Based on observations, interviews and record reviews, the facility failed to provide pharmaceutical services that were in order and accounted for the drug record reconciliation of all controlled drugs during shift changes for medication carts A and B. This deficient practice had the potential to affect the 52 residents residing in the facility. Findings: A review of the facility's policy titled, Controlled Substance Policy revealed, in part .4. The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift. The count is to be performed by the on-coming licensed nurse and the off-going licensed nurse .Both nurses will sign on the narcotic sign in and out sheet that the count was completed. On 12/20/2023 at 12:55 p.m., an observation of A Hall narcotic drug log was performed with S6LPN (Licensed Practical Nurse). Review of the log revealed that there were missing signatures for 4 days in the month of December 2023; 12/05/2023, 12/07/2023, 12/08/2023, and 12/19/2023. S6LPN confirmed the dates without signatures indicated a narcotic reconciliation had not been performed. S6LPN further confirmed the reconciliation should be done by the off-going and on-coming nurses at the beginning and end of every shift and was not. On 12/20/2023 at 2:55 p.m., an observation of B Hall narcotic drug log was performed with S7LPN. Review of the log revealed there were 6 days with missing signatures in the month of November 2023; 11/23/2023, 11/24/2023, 11/27/2023, 11/29/2023, and 11/30/2023. For the month of December 2023, there were 12 days with missing signatures; 12/01/2023, 12/02/2023, 12/03/2023, 12/04/2023, 12/05/2023, 12/07/2023, 12/08/2023, 12/09/2023, 12/10/2023, 12/11/2023, 12/15/2023 and 12/16/2023 indicating a narcotic reconciliation had not been performed. S7LPN confirmed the reconciliation should be done by the off-going and on-coming nurses at the beginning and end of every shift and was not. On 12/20/2023 at 3:29 p.m., an interview was conducted with S1ADM (Administrator). She confirmed that both on-coming and off-going nurses should be reconciling narcotics at the beginning and end of every shift and should be signing the logs to verify it was done. S1ADM reviewed A and B hall narcotic drug logs and she confirmed the presence of missing signatures. She further confirmed the narcotic logs should not have missing signatures.

Based on interview and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice by failing to ensure oxygen was delivered at the ordered for 1 (#153) out of 1 (#153) resident reviewed for respiratory care out of a total sample of 30 residents. Findings: Resident #153 was admitted on [DATE], with diagnoses not limited to Chronic Obstructive Pulmonary Disease and Parkinson 's Disease. Review of the Resident's physician's orders for December 2023 revealed on 12/15/2023, resident to be placed on oxygen (O2) therapy at 2 liters per nasal cannula (L/NC) as needed (PRN) for oxygen saturation (O2 Sat) 92% or lower. Review of Resident #153's electronic medical record revealed her vital signs and O2 Sat monitoring was recorded 3 times a day between 12/15/2023 to 12/19/2023 with his or her O2 sat ranging from 92% to 98%. The O2 Sat documented for 12/15/2023 at 10:00 p.m. and 12/15/2023 at 11:34 p.m., was 92%. Further review of the electronic medical record revealed the nurses' progress notes and admission assessment had no documented evidence that oxygen had been administered for O2 sats of 92% on 12/15/2023. On 12/20/2023 at 1:15 p.m., an interview was conducted with S7LPN, she reported the resident is on oxygen PRN. She reviewed the resident's order and confirmed there was an order was oxygen 2L/NC PRN for O2 sat 92% or less. She then reviewed the O2 Sat levels documented from 12/15/2023 to 12/20/2023 and confirmed the resident had O2 sat levels of 92% documented on 12/15/2023 at 10:00 p.m. and 11:34 p.m She then reviewed the progress noted and nursing admission assessment and confirmed there was no documentation the resident was administered oxygen as ordered when their O2 sat was 92%. She confirmed the resident should have been provided supplemental oxygen when their O2 sat was 92%.

Based on observations, interviews and record review, the facility failed to ensure hospice agencies communicated with facility staff, and maintained and updated the residents' medical record that reflected the services provided for 1 (#31) of 2 (#31, #51) sampled resident that were provided Hospice Services. Findings: Record review of Resident #31's hospice binder and facility electronic record revealed she was admitted to the facility on [DATE] with an order dated [DATE] to admit to --- hospice for terminal Senile Degeneration of the Brain. Her cumulative diagnoses were in part: Senile Degeneration of Brain, Diabetes Mellitus II, Hypertension, Psychosis, Depression, Dementia, Dysphagia, Cerebral Vascular Accident, Anxiety and Major Depressive Disorder. Review of Resident #31's Quarterly MDS (Minimum Data Set) dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 03, which indicated the resident had severely impaired cognition. Record review of Resident #31's hospice medical record binder revealed a Hospice Recertification Plan of Care (POC) Update for a 60-day period had a benefit period from [DATE] to [DATE], signed by the hospice physician on [DATE]. The Hospice Certification of Terminal Illness (CTI) was signed by the hospice physician on [DATE], which indicated the resident was still considered terminally ill with a life expectancy of 6 months or less if the terminal illness runs it normal course. There was no recertification statement in medical records after [DATE]. Review of the hospice binder physician's order/plan of care revealed the following: [DATE] SN (Skilled Nurse) visits 1 time a week for 9 weeks and 3 PRN (as needed)/ status change. Social Worker (SW) effective [DATE], 1 visit per month for 2 months, with 2 PRN psychosocial needs and Home Health Aide (HHA) effective [DATE], 5 times a week for 8 weeks and 4 times a week for 1 week. A review of the facility's hospice binder revealed there were no documentation of an SN visit since [DATE]. There were no documented visits for SW. Further review revealed the HHA had no visits documented since ,d+[DATE] in the facility's hospice medical binder. On [DATE] at 11:50 a.m., an Interview and review of Resident #31's hospice binder was conducted with S3DON. She confirmed the residents' hospice POC had expired on [DATE] and no new POC was in the hospice records. She also confirmed the last documentation of a hospice nurse visit was dated [DATE]. S3DON stated all hospice documentation was to be kept in the hospice binder and documentation should be added to the binder after each visit made to the resident and was not. On [DATE] at 12:40 p.m., an interview was conducted with S8LPN. She stated the hospice nurse was responsible for putting the visit notes in the hospice binder, along with a current POC. She further stated the facility staff is was responsible for ensuring the hospice binder are was up to date with documentation of hospice records and she could not recall the last time she had checked the to ensure the hospice binder was up to date.

Based on record review and interview, the facility failed to ensure the assessment accurately reflected the resident's status by failing to accurately code the Minimum Data Set (MDS) for smoking for 1 (#28) of 30 residents reviewed in the initial pool. Findings: Review of Resident #28's electronic health record revealed she was admitted on [DATE] with diagnoses that included: Quadriplegia, Muscle Wasting and Atrophy, Major Depressive Disorder, and Abnormal Posture. A review of the Quarterly MDS with an Assessment Reference Date (ARD) of 03/31/2023 for Resident #28 revealed, Section J: Current Tobacco Use, was coded 0 which indicated no. On 12/20/2023 at 1:02 p.m., an interview was conducted with S4MDSLPN. S4MDSLPN confirmed that the resident is a smoker. [NAME] viewed Resident #28's comprehensive assessment from 03/31/2023 and confirmed the MDS was coded incorrectly.

Based on record reviews and interviews, the facility failed to ensure direct care staff provided basic life support, including CPR, to a resident requiring emergency care according to the resident's advanced directive and physician's order for 1 (Resident #1) out of 4 (Resident #1, Resident #2, Resident #3, Resident #6) residents reviewed for advanced directives. On [DATE] at 9:20 p.m., an Immediate Jeopardy occurred for Resident #1 when the resident, who was a full code status, did not receive CPR (Cardio-pulmonary Resuscitation) upon being found unresponsive by S2LPN. At approximately 9:31 p.m. on [DATE], S2LPN notified S4MD and the hospice nurse that the resident was found with her eyes open, mouth open, and lips purple. S2LPN did not administer CPR per the resident's advanced directives and physician's order and notified the hospice nurse instead. On [DATE] at approximately 10:11 p.m., the hospice RN arrived at the facility and pronounced the time of death for Resident #1 at 10:15 p.m. The facility implemented corrective actions prior to the State Agency's investigation on [DATE]; thus, it was determined to be a Past Non-compliance citation. Findings: Review of the facility's policy for Emergency Procedure - Cardiopulmonary Resuscitation revealed the following: 8. If a resident is found unresponsive and not breathing normally, a licensed staff member will verify code status using the medical record. 9. If the resident is a full code, per the medical record, a staff member that is certified in CPR will initiate CPR. Review of Resident #1's clinical record revealed the resident was admitted on [DATE] with diagnoses that included: Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance, Disorganized Schizophrenia, Moderate Protein-Calorie Malnutrition, Chronic Kidney Disease Stage 3A, Anemia in Chronic Kidney Disease, Dysphagia Oropharyngeal Phase. Resident #1 was admitted to Hospice services on [DATE]. Review of Resident #1's LaPost (Louisiana Physician Orders for Scope of Treatment revealed that CPR (Cardiopulmonary Resuscitation)/Attempt Resuscitation was to be administered if the resident is unresponsive, pulseless and is not breathing. This form was dated [DATE] and signed by Resident #1's daughter. Review of MDS (Minimal Data Set, a standardized health status assessment) with an ARD (Assessment Reference Date) of [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 7, which indicated the Resident #1 was severely cognitively impaired. The resident's MDS also revealed that she was receiving Hospice care. Review of Resident #1's Care Plan revealed the following, in part: Date initiated: [DATE]. Advanced Directive/End of Life Care Plan, Resident is not at or approaching end of life at this time. Goal: Resident's wishes for Advanced Directives and end of life care will be honored .target date [DATE]. Interventions: Code Status: FULL CODE, Ensure resident's wishes are honored in regard to any Advanced Directive, Maintain Advanced Directives in file. Date initiated: [DATE]. The resident has a terminal prognosis. Goal: The resident's comfort will be maintained through the review date .target date [DATE]. Interventions: Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Review of Resident #1's Physician's Orders for the date range of [DATE] - [DATE] revealed the following orders: [DATE]: Admit to .Hospice. Dx (diagnosis): Senile Dementia. [DATE]: Full Code. An interview on [DATE] at 11:40 a.m. was conducted with S1ADM. S1ADM stated that S2LPN phoned her the night of [DATE] to notify her of Resident #1's death. She instructed S2LPN to look in the chart and do everything she's supposed to do. It wasn't until the following morning when she learned that the resident had not been administered CPR as made known on her Advanced Directive. She then immediately opened an investigation and started a corrective action plan. S1ADM stated that by that time (the following day [DATE]) S2LPN had e-mailed her resignation. She made multiple attempts to reach S2LPN for questioning but she was never able to speak to her regarding the incident. During the interview, S1ADM also provided the corrective actions put into place that included proof of in-service education. The summary of information presented included the following: Code Status: CPR must be initiated on all full code residents or residents with no declared status. Non clinical staff must immediately get the nurse if there is a significant change in resident's condition and clinical staff must immediately check the code status/CPR policy education. An interview on [DATE] at 1:45 p.m. was conducted with S3CNA. S3CNA confirmed she was the CNA (Certified Nursing Assistant) assigned to Resident #1 on the night she expired ([DATE]). S3CNA stated she had been in the room twice previously and the resident was awake and alert. When she was making her last rounds of the night, at approximately 9:20 p.m., she entered Resident #1's room and found her with her mouth open; purple lips; skin cold to touch; and she would not respond. S3CNA stated she attempted to feel for a pulse but was unable to find one and stated she observed Resident #1 making no attempts at breathing. S3CNA stated she immediately told S2LPN. S3CNA stated S2LPN that Resident #1 was unresponsive and had no pulse. S3CNA stated that S2LPN made a phone call on her cell phone and went into Resident #1's room. S3CNA could not confirm who S2LPN called. S3CNA confirmed that CPR was never initiated on Resident #1 and that the emergency cart was never brought to Resident #1's room. S3CNA stated she had been in serviced on how and when to verify a resident's code status the following day on [DATE]. A phone interview was conducted on [DATE] at 8:56 a.m. with S2LPN. S2LPN confirmed that she was notified by S3CNA that it appeared Resident #1 had expired. S2LPN stated she immediately entered Resident #1's room and observed Resident #1's eyes open; fixed and dilated; mouth open; skin was cold; and chest was rigid. At that time she attempted to listen for a heartbeat with a stethoscope and obtain a blood oxygen saturation level with a pulse oximeter. S2LPN stated she could not obtain any vital signs. S2LPN stated as soon as she could not obtain vital signs, she called the doctor and checked the residents chart for the code status simultaneously. S2LPN stated once she was on the phone with S4MD, S4MD asked her if the resident was on hospice and what her code status was. S2LPN stated she replied to S4MD that yes, Resident #1 was under hospice care and was a full code but went on to inform S4MD that she did not feel like she could compress Resident #1's chest due to rigidity. S2LPN stated that S4MD instructed her to call hospice to inform them of Resident #1's condition and have them (hospice) come out. S2LPN confirmed she did not initiate CPR and followed S4MD's instructions and called hospice to come and assess Resident #1. S2LPN stated she phoned S1ADM to notify her of Resident #1's death. An attempt to interview the hospice nurse was made on [DATE] at 2:16 p.m. but she did not return the call. An interview was conducted on [DATE] at 9:29 a.m. with S4MD. S4MD stated he could not recall the events of the night in question ([DATE]), the circumstances of Resident #1's death, nor could he recall speaking to S2LPN. Throughout the survey dates of [DATE] - [DATE], 12 staff were (nurse's, CNA's, Physical Therapist, Transportation driver) interviewed on how to locate resident code status and the proper procedure if a resident was found unresponsive. All staff interviewed were knowledgeable of where to locate code status and CPR procedure. The facility implemented the following actions beginning on [DATE] to correct the deficient practice that occurred on [DATE]: 1. On [DATE], S2LPN, failed to provide CPR to a full code hospice resident. The S2LPN resigned prior to being suspended. It was ultimately determined that S2LPN failed to follow policy when she did not verify the code status of the hospice patient. Prior to the S2LPN being suspended, the nurse resigned. 2. On [DATE], 100% of code status audit was performed and completed that included and identified issues were corrected: 100% audit of all resident code status, 100% audit that each resident had a LaPost in place that matches their code status order and ensuring that all signatures were in place, and both pages were scanned into the residents electronic medical record, 100% code status check on patient care plans to ensure these matched the orders and the LaPosts. This compliance was achieved on [DATE]. 3. On [DATE], re-education with all staff, including certified and licensed staff on the following policies: CPR Policy and Advanced Directives Policy. To include that when a resident is found unresponsive without pulse or blood pressure, and not breathing normally, a nurse will assess them and then a verification of the resident's code status will be done. If the resident is a full code, CPR will be initiated and [DATE] will be activated. The nursing staff will continue CPR until paramedics arrive. This compliance was achieved on [DATE]. 4. Nursing staff will continue to be educated at the time of hire on the aforementioned information as part of the orientation process, including location of information of Advanced Directives. 5. Mock codes initiated and completed on each shift. 6. Beginning [DATE], the facility nursing management team will audit certified and licensed nursing staff on the appropriate action if a resident is found with no pulse, blood pressure, or respiration. This audit will take place three times per week for the next 90 days. Any noted issues to be discussed during the QAPI process. 7. This is discussed in the monthly QAPI meeting for the next three months. 8. The facility will continue to utilize the current system in place for identification of code status by the staff checking the EMR (Electronic Medical Record) in the event of an arrest (resident's death). As a backup, the facility will also continue to print a current list of all resident code statuses out of the EMR record and place on the crash carts every night at midnight. Compliance achieved on [DATE]. An AD HOC (needed) QAPI (Quality Assurance and Performance Improvement) was conducted on [DATE]. Discussed the reportable, our policy and the POC (Plan of Correction) for advanced directives. Team verbalized understanding and voiced no concerns. An AD HOC (needed) QAPI was conducted on [DATE]. Discussed the conclusion of the investigation and the past non-compliance was also on the agenda; as well as, mechanisms put into place for auditing and ensuring compliance. A review of QAPI minutes dated [DATE] revealed the past non-compliance was reviewed in meeting. Stated as follows: Issues: CPR past non-compliance monitoring until [DATE]-90 days from occurrence (Resident #1 name). Staff in attendance with signatures included, in part, as follows: Medical Director, Administrator, DON, MDS nurse, Social Service Director, Payroll Clerk, ADON.

Based on observation, interview, and record review, the facility failed to ensure residents received the necessary treatment and services, consistent with professional standards of practice, to prevent new pressure ulcers from developing by failing to conduct weekly skin assessments for 2 (#R2, and #R12) of 4 (#1, #R2, #R11 and #R12) residents reviewed for facility acquired pressure ulcers. This deficient practice resulted in an actual harm for: 1. Resident #R2, who was a risk for developing pressure ulcers, was discovered to have a Stage 3 pressure ulcer on her left elbow on 2/15/23 at 3:24 p.m. Staff failed to conduct a weekly skin assessment from 02/01/23 to 02/14/23, which delayed the identification and treatment of the wound. 2. Resident #R12, who was at risk for developing pressures ulcers, was discovered with a Stage 2 pressure ulcer on her left and right buttock on 02/06/2023. Staff failed to conduct skin assessments from 12/19/22 to 2/6/2023, which delayed the identification and treatment of the wound. Finding: Review of the facility's policy titled, Wound Care System Requirements, read in part, The facility has a designated Wound Care Nurse, who completes weekly assessment and documentation .Skin checks by licensed staff weekly for all residents .Monthly 100% Skin Audits of all residents by DON (Director Of Nursing) and administrative nurse team completed by the 10th of each month .Weekly wound assessment is being completed, with individual documentation . Resident #R2: Resident #R2 was admitted to the facility on [DATE]. Her admitting diagnosis was End Stage Renal Disease. Other diagnoses in part included, Type 2 Diabetes Mellitus, Contracture of Muscle, Left Hand, Lack of Coordination, Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-dominant Side, Pressure Ulcer Of Right Buttock, Stage 2, and Muscle Weakness. Review of Resident #R2's quarterly MDS (Minimum Data Set) dated 12/09/22 revealed that resident's BIMS (Brief Interview of Mental Status) score of 4 which indicated severe impaired cognition. Further review of the MDS revealed that the resident required extensive assistance with one person physical assist for bed mobility and toileting; and total assistance with two person physical assist with transfers. Review of Resident #R2's care plan revealed she was care planned for impairment to skin integrity related to impaired mobility and incontinence. Pressure wound identified. Interventions included: pressure reducing mattress on bed, pressure reducing cushion to protect the skin while Review of Resident #R2's Braden Scale dated 12/30/22 revealed a score of 13, which indicated that the resident was a moderate risk for the development of a pressure ulcer. Review of the resident's electronic record failed to reveal evidence that weekly skin assessments had been conducted for the month of January 2023. A continued review of the record revealed a monthly skin check was conducted S2DON on 02/01/2023 at 1:00 p.m., indicated that the resident had no new areas of skin impairment. Further review revealed there were no weekly skin assessment conducted until 02/15/2022, which was 14 days after her last skin assessment. A Pressure Ulcer Weekly Wound Evaluation dated 02/15/2023 at 3:24 p.m. revealed that the clinician was notified of the wound on the resident's left elbow by S5LPN on 02/15/2023 at 12:50 p.m. The date the wound was acquired was 02/15/2023. The wound was assessed as a Stage 3 pressure ulcer. The wound was described as the following: wound bed moist, beefy red granulation tissue present. There was 25% granulation tissue and 75% slough tissue in the wound bed with a moderate amount of serosanguineous (yellowish fluid with small amounts of blood) drainage. It measured 2 cm (centimeters) by 2cm by 0.1cm (approximately 3.1-4.0cm in size). There was no peri-wound (tissue surrounding the wound) and the wound edges and shape were attached and flat. The wound was described as a new wound. On 02/28/23 at 1:10 p.m., Resident #R2's wound observation was conducted with S5LPN. The dressing on the resident's left elbow was removed by the nurse. The wound was elongated with an indented dark color wound bed, with edges well approximated. There was no drainage or signs of infection noted. On 03/01/2023 at 5:00 p.m., an interview was conducted with S5LPN. S5LPN stated that on 02/15/2023, the shower aide informed her that Resident #R2 had a dressing on her left elbow. She stated that there was no date, time or initials on the dressing; so therefore, she did not know when or who had placed the dressing on the resident's elbow. She stated that she reported the finding to the S2DON. Resident #R12: Resident #R12 was admitted to the facility on [DATE]. Her diagnoses included in part, Dementia, Congestive Heart Failure, Anxiety, Diabetes Type 2, Morbid Obesity and Depression. Review of Resident #R12's quarterly MDS dated [DATE] revealed she had BIMS of 00, severe impaired cognition. She required extensive assistance with two plus person physical assist for bed mobility and toileting. She also total assistance with two plus person physical assist with transfer. Review of Resident #R12's care plan addressed the resident's potential for impairment/actual impairment to skin integrity related to the resident's impaired mobility status and the need for ADL (Activities of Daily Living) assistance. The interventions did not include weekly skin assessments. Review of Resident #R12's Braden Scale dated 01/18/2023 revealed a score of 14, which indicated that the resident was a moderate risk for the development of a pressure ulcer. Review of Resident #R12's electronic record revealed a skin assessment dated [DATE] was conducted with no new skin impairments noted. A continued review of the record revealed there were no weekly skin assessments had been conducted for the month of January 2023. Further review revealed a skin assessment was conducted on 02/06/2023, seven weeks after her last skin assessment, which revealed that the resident had a pressure ulcer on her right and left buttocks. A Pressure Ulcer Weekly Wound Evaluation dated 02/08/2023 at 02:08 p.m. revealed that the S18MD was notified of the wound on Resident #R12's left buttock on 02/15/2023 at 12:00 a.m. The date the wound was acquired was 02/06/2023. The wound was assessed as a Stage 2 pressure ulcer. The wound was described as the following: wound bed moist, beefy red granulation tissue present. There was 100% granulation tissue, no slough tissue in the wound bed and a light amount of serosanguineous (yellowish fluid with small amounts of blood) drainage. It measured 1.5 cm (centimeters) by 1 cm by 0.1cm (approximately 1.1-2.0 cm in size). There was no peri-wound (tissue surrounding the wound) and the wound edges and shape were attached and flat. The wound was described as a new wound. A Pressure Ulcer Weekly Wound Evaluation dated 2/8/2023 at 02:13 p.m. revealed that the clinician was notified of the wound on Resident #R12's right buttock on 02/08/2023. The date the wound was acquired was 02/06/2023. The wound was assessed as a Stage 2 pressure ulcer. The wound was described as the following: wound bed moist, beefy red granulation tissue present. There was 100% granulation tissue, no slough tissue in the wound bed and a light amount of serosanguineous (yellowish fluid with small amounts of blood) drainage. It measured 1 cm (centimeters) by 1 cm by 0.1cm (approximately 0.7-1.0 cm in size). There was no peri-wound (tissue surrounding the wound) and the wound edges and shape were attached and flat. The wound was described as a new wound. No wound observation was conducted for Resident #R12 because she was not in the facility during the survey. On 03/01/23 at 6:15 p.m., an interview was conducted with S1DON. S3ADON and S1ADM were present during the interview. S2DON was asked to pull up Resident #R2's skin assessments in the electronic health record. She reviewed the skin assessments and confirmed that the resident did not have any skin assessments conducted for the month of January 2023. She also confirmed that the resident did not have a skin assessment conducted at any time from 02/05/23 to 02/11/23. She stated that the resident had a skin assessment conducted on 02/01/23 and did not have another skin assessment until 02/15/23, 14 days later, when a Stage 3 pressure ulcer was discovered on the resident's elbow. S1DON stated that all residents in the facility were to receive a weekly skin assessment. She stated that there was a built-in report in the EHR (Electronic Health Record) for skin assessments that alerted the nurses when a skin assessment was due. The nurse assigned to the resident was responsible for conducting the skin assessment. She also stated that the S3ADON will run a UDA (User Defined Assessment) report weekly in order to determine if all required assessment had been done. S3ADON confirmed that she was responsible for running UDA report weekly and stated that when assessments were missed she counseled/in-serviced the nurse who did not complete the assessment. When asked if a missed assessment could be completed a day or more after it was late, she said yes. S2DON confirmed that she did not ensure that the missed skin assessments were completed. She confirmed that staff should have noticed the change in the resident's skin before it was noted to be a Stage 3 pressure ulcer. S3ADON did not provide documented evidence of the counseling/in-services conducted with the staff related to the missed skin assessments before the survey was completed.

Based on record review, and interview, the facility failed to ensure residents were free of accident hazards by failing to: 1. properly restrain a resident in her wheelchair during transport in the facility's van for 1 (Resident #1) out of 4 (#1, #R3, #R4, #R5) residents who were transported in the facility's van. 2. provide adequate supervision for 1 (#3) out of 7 (#3, #R6, #R7, #R8, #R9, #R10, #R11) residents who were assessed to be at risk for wandering. The deficient practice resulted in an actual harm for: 1. Resident #1 when S12CNADriver (Certified Nursing Assistant) failed to use the seat/lap belt to properly secure the resident in her wheelchair during transport. On 10/01/22 at 5:29 a.m., S12CNA Driver and Resident #1 were involved in a motor vehicle accident. Resident #1 was transported from the scene of the accident by ambulance to the emergency room where she was diagnosed with a Tibia/Fibula fracture. 2. Resident #3, who was assessed as an elopement/wander risk, was found in an empty on the floor and sustained bruising and a puncture wound to the left temporal (near the ear) region of her head. Findings: Resident #1: Facility failed to provide a the following documents upon completion of the survey: policy for the use of the facility's van; manufacturer's instruction for the van's restraint system; transportation log; competencies for all transport personnel prior to exit in-service for all staff related to transportation guidelines and occupant safety. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus Type II, End Stage Renal Disease, Muscle Weakness, Abnormalities of Gait and Mobility, Dysphagia, Anxiety, Dyspnea, Depression, Congestive Heart Failure, Obesity, Dementia and Peripheral Vascular Disease. Review of Resident #1's quarterly MDS (Minimum Data Set) dated 07/12/22 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 14 indicating the resident was cognitively intact. Further review revealed the resident was ambulatory with 1 person assistance and utilized a wheelchair. Review of Resident #1's significant change MDS dated [DATE] revealed the resident had a BIMS score of 08 indicating resident had recall memory deficits. Further review revealed the resident was used a wheelchair and did not ambulate with impairment to one side lower extremity. Review of S12CNADriver's handwritten statement dated 10/01/22 revealed in part: transporting Resident #1 to dialysis. I wheeled Resident #1 outside to the van around 5:25 a.m. I put the lift gate down and got inside the van and lifted the swift for the seat belt. I grabbed the three of them, I hooked on the bar on her wheelchair and the other two on each side above the leg rest. Then the last one I hooked right behind under the seat on the middle bar .I was coming up to the turning lane and put my right signal on and a truck turned in front of me. Then his passenger was on the phone with 911 and asked me did I need an ambulance, I said yes for my resident. Review of the hospital emergency room (ER) visit notes dated 10/01/23 read in part . resident presented to the ER at 6:32 am on 10/01/22 with complaints of pain to the right leg via emergency medical services. X-rays of the right leg were obtained with impression: Mildly displaced fracture of the distal fibular metaphysis and tibial diaphysis. ER disposition was admit. Review of Resident #1's facility incident report completed by S2DON dated 10/01/22 read in part .Incident location - Out of facility/during transport. Incident description-S12CNADriver reported to S16PADIM while transporting Resident #1 to dialysis, a car turned in front of her van causing a car accident. Resident #1 was transported to hospital from the scene of the accident. Review of investigation records provided facility completed by S17ADM revealed in part Summary of events: resident diagnosis - left tibia/fibia fracture. Resident was involved in a vehicle accident with the facility transportation vehicle she was being transported to dialysis on October 1, 2022 at 5:45 a.m. Staff member S12CNADriver was the driver the facility van at the time of the accident and was the only staff member with the resident. Resident #1 was transported to the hospital via ambulance with a medical stretcher. On 10/01/22, the resident was seated in a wheelchair and locked-in/wheelchair braced as per transportation guidelines in the facility transportation vehicle and the vehicle sustained a head on collision due to fault of another driver. The resident sustained a tibia/fibula fracture of the left leg, resident was transported to hospital where the resident had surgery to repair the fracture. Facility completed an in-service for all nursing staff in regards to resident transportation guidelines and occupant safety. Review of the facility's Supervisor's Incident and Investigation Report revealed in part .S16PADM was notified at 5:50 a.m., on 10/03/22 about a traffic accident. Another vehicle hit the facility van head on with S12CNADriver, employee, and Resident #1 in the vehicle while being transported to dialysis. Louisiana Uniform Crash Report completed by (local police department): the driver of vehicle #2, facility van, was driven by S12CNADriver, license information, valid, license class Regular driver license, type non-CDL (Commercial Driver's License). Passenger in vehicle #2 was Resident #1, seat position-other enclosed cargo area, air bag did not deploy, type of medical transport-EMS (Emergency Medical Service) ground, Injury status-possible injury. Review of facility's Employee Corrective Action Form revealed in part: Employee was transporting Resident #1 in the facility van. Employee did not put the seat belt/safety belt on Resident #1 while transporting causing serious bodily injury. Action: Termination of employment. Signed by S16PADM on 10/05/22. Review of Resident #1's nursing notes revealed in part: 10/06/22 6:15 pm - Resident return from hospital via AASI, alert, awake, no c/o pain. Further review revealed that note did not address the status of the resident's leg. Review of the hospital written discharge instructions dated 10/06/22 revealed in part WBAT (Weight Bearing as tolerated) to RLE (Right lower extremity) for transfers, activity/mobility with assistance and diagnosis at time of discharge MVC (motor vehicle crash), multiple fx (fractures). Surgical / Procedure 10/03/22 - Rt (right) tibia I & D (incision and drainage), IM (Intramedullary) nail with casting (added for above question nothing found in documentation I have of a cast applied) On 02/27/23 at 11:10 a.m., an interview was conducted with Resident #1. When asked about the accident that happened on 10/01/22, she stated that she was going to dialysis, something happened, can't really remember it all, she went to the hospital and was there for 2 days, might have been longer than that, I don't remember. She can't recall how long it had been since she was walking, but stated when she came in the facility she was walking, but it had been a good while since had walked. Put in proper POD, complete sentences. On 02/27/23 at 12:10 p.m., an interview was conducted with S1ADM (Administrator) and S2DON. Both S1ADM and S2DON confirmed the facility van used during the MVA (motor vehicle accident) was totaled and no longer in their possession. S1ADM confirmed the facility had obtained a new transportation van that has yet to be used as they are still waiting on registration documents. S1ADM stated that the facility had been using an ambulance or a 3rd party contractor for resident transport since the accident. S1ADM confirmed he did not have the transportation log or manufacturer's instruction manual for the van's restraint system, as it was left in the van that had been involved in the MVA. On 02/28/23 at 4:35 p.m., an interview was conducted with S2DON (Director of Nursing), reviewed the form titled Employee Corrective Action form and confirmed it was a form for S12CNADriver. She confirmed the resident identified on the report was Resident #1. She stated she could not give a reason for the termination of S12CNADriver, because she was not involved with the termination of S12CNADriver. She was only told by S16PADMN that the employee was terminated on 03/01/23 at 10:48 a.m., a phone interview was conducted with S12CNADriver. She stated she would call her attorney to see if she could provide an interview about the accident that occurred on 10/01/2022. On 03/01/23 at 11:03 a.m., a second phone interview was conducted with S12CNADriver. She stated she had spoken with her attorney who advised her not to provide an interview. 39319 Resident #3 Review of the hospital ER (emergency room ) visit notes dated 1/16/23 read in part, The resident presented to the ER for evaluation of fall .patient is a fall risk, she wandered off and was found on the floor, it appears she had hit her head on the left temporal region where there is a bruise and a puncture wound . Further review revealed that Resident 3 was recently admitted to the hospital for a subarachnoid, intraparenchymal and subdural hemorrhage (bleeding on the brain) and was discharged to the facility on [DATE]. An interview was conducted on 2/27/23 at 3:00 p.m. with S3ADON. She stated that S11CNA had just put the resident in her bed and when she went back to check on the resident and discovered the resident was not in bed. She stated the Business Office Manager informed her and the CNA that she had seen the resident walking by her office earlier going towards the therapy room. They went down the hall to the therapy department but the resident was not in the therapy department. They started looking for the resident in the rooms on the hall. The resident was found in an empty room on the floor. She stated the resident was assessed and had a bruise to her left eye. S3ADON confirmed that the resident was at risk for wandering and confused at times. She also confirmed that the resident was not able to ambulate without assistance. When asked what interventions were put in place addressing the resident's wandering, she stated, I'm not sure. I don't remember. An interview was conducted on 2/28/23 at 10:45 a.m. with S11CNA. She stated that she put the resident in her bed after lunch between 12:30-12:45 p.m. She then went to the dining room to get another resident to put to bed. When she passed by the resident's room, she noticed the resident was not in her bed. She checked in the resident's bathroom and the resident was not in her bathroom. She stated that the DON's (Director of Nurses) office was across from the resident's room and the door was open. She asked the DON and the ADON (Assistant Director of Nurses) if they had seen the resident leave her room. She stated that they told her they did not see the resident. She asked the nurse and the nurse stated that she did not see the resident. She asked the Business Office manager if she had seen the resident and the Business Office Manager told her that she had seen the resident walking towards the therapy department. S11CNA stated that she, the ADON and the Business Office Manager began looking for the resident. They did not find the resident in the therapy department, so they looked in the empty rooms down the hall. The resident was found in one of the empty rooms next to the bed and chair on the floor. She confirmed that the resident was confused most of the time, not able to use the call bell to call for assistance or not able to walk without assistance. She stated that the night CNAs (Certified Nursing Assistant) had reported to her that the resident would frequently wander and needed to be monitored. S11CNA confirmed on the day that the resident fell (1/16/23), she was the only CNA working on that hall. On 2/28/23 at 11:00 a.m., an observation was made on Hall A of Resident 3's room which was across from the DON's office and was also visible from the nurse's station. On 2/28/23 at 1:50 p.m., an interview was conducted with S1DON. She confirmed that S11CNA was the only CNA assigned on Hall A where the resident resided.