Every finding on record at Seven Acres Jewish Senior Care Services

Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment with services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 22 residents (Resident #14, #21, and #80) reviewed for care plans. The facility failed to implement Resident #14's care plan intervention requiring a fall mat on the right side of the bed. Resident #14 experienced an unwitnessed fall and was found sitting on the floor on the right side of her bed without the fall mat in place. The facility failed to include Resident #21's significant unplanned weight loss in comprehensive care plan. The facility failed to develop individualized goals and interventions to address Resident #21 nutritional risk. The facility failed to include PASRR recommendations and NFSS in Resident #80's comprehensive care plan. These failures placed the residents at risk for fall-related injuries, hospitalization, and a decline in physical functioning Findings included: Resident #14 Record review of Resident #14's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Bipolar disorder (mental health condition characterized by extreme, unpredictable shifts in mood, energy, activity levels, and concentration), Age-related osteoporosis (occurs when bone breakdown outpaces bone renewal, resulting in brittle, fragile bones), Muscle wasting and atrophy (partial or complete wasting away, thinning, or loss of cells, tissues, or organ), Muscle weakness, abnormalities of gait and mobility, lack of coordination, and dementia (a decline in mental ability severe enough to interfere with daily life). Record review of Resident #14's Quarterly MDS dated [DATE] revealed a BIMS score of 4 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed she had no history of falls. Record review of Resident #14's Care Plan started on 2/18/2026 revealed a problem area of falls which noted risk for falling related to muscle weakness, unsteady gait. Problem further noted, Uses wheelchair for mobility, able to transfer self. Found on floor 3/1/26, Found on floor 3/27/26, 4/15/26, 4/29/26, 6/1/26, 6/24/26, 6/25/26. Review of care plan interventions in part, .Keep bed in lowest position with brakes locked. High Density Mat placed on side of bed. Right side. Observation on 6/23/2026 at 10:00am, revealed Resident #14 was lying in her bed sleeping with her wheelchair at her bedside. No fall mat observed on floor. Observation and interview on 6/24/2026 at 2:20pm, Resident #14 observed sitting on the floor on the right side of her bed with no fall mat on the floor. Resident's right hand had blood on it. NP S was in the room with her and asked if someone was coming to help and stated when she came into the room Resident #14 was already on the floor but she was okay. Unit Manager was found at the nurse's station speaking with other nurses and said they were aware Resident #14 was on the floor and a nurse was getting her cart and about to head to the room now. Record review of Resident #14's progress noted dated 6/24/2026 at 2:20pm revealed, .Writer was called to resident by staff, noted resident was in a sitting position, NP was assessing resident at this time. Writer noted resident with opening to right hand, between thumb and second finger. Per NP cleaned with [NAME] saline, pat dry and applied bandage to finger. Range of motion performed to upper and lower extremities without difficulty. Assist x2 up onto the wheelchair. No signs or symptoms of distress noted. No complaints of pain voiced at this time. Received new order from NP X-Ray right knee, pelvis, hip, right hand. X-Ray order placed awaiting x-ray to be completed. Observation on 6/24/2026 at 3:30pm, Resident #14 was not in her room but a fall mat was on the floor on the right side of her bed. Observation and interview on 6/24/2026 at 3:32pm, Resident #14 was sitting in her wheelchair in the TV area with a bandage on her right thumb and skin tear on right forearm. Resident #14 could not remember the fall or how she got on the floor earlier. Resident denied pain where her skin tear was. Record review of Resident #14's x-rays dated 6/24/2026 at 11:42pm revealed x-ray to right hand, bilateral hips, and right knee revealed no fractures or significant findings. Observation and interview on 6/25/2026 at 11:05am, Resident #14 was lying in bed with a book. Resident #14 said she had pain in her right knee and right shoulder and arm from the fall she had. Resident #14 had jeans on but said there was a knot on the side of her knee, and she did not know what was going on. Resident #14 said she thought an x-ray was done yesterday to check her right side, but she did not know what the results were. There was not a fall mat at the bedside or observed in the room. Interview on 6/25/2026 at 11:12am, CNA H said she was working with Resident #14 today and stated the fall interventions they used with her was to keep a close eye on her and check on her frequently when she is in her room, stay with her while she is going to the toilet and attempting to transfer because she could be unsteady. CNA H said they also keep a fall mat at her bedside. Advised there was not a fall mat seen in the room and she said she would go and check it. Interview on 6/25/2026 at 11:54am, Unit Manager said staff encourage Resident #14 to use her call light, she could transfer herself, but they try to encourage her to ask for assistance with transfer because she is unsteady. The Unit Manager stated she did go and put her fall mat down on the floor after her fall on 6/24/2026 and stated she should have had the fall mat down. The Unit Manager was informed the fall mat was not observed in the room earlier and she said she would go to the room and check why it was moved. Interview on 6/25/2026 at 1:57pm, the DON said part of Resident #14's fall interventions was to have a fall mat down on the side of her bed for protection if she falls. The DON said the fall mat may have been put up in the bathroom and had not been laid back down and stated she would go to investigate why it was not at the resident's bedside. Interview on 6/25/2026 at 5:23pm, MDS Coordinator said she does the care plans for the residents on the second floor including Resident #14. The MDS Coordinator said care plans are updated and interventions are added when a new situation occurs such as a fall. The MDS Coordinator said an intervention listed in Resident #14's care plan regarding her falls was to have a fall mat at her bedside. The MDS Coordinator said there should have been a fall mat at Resident #14's bedside and the purpose was to help with the impact if she falls and to hopefully prevent injuries in the event she falls. The MDS Coordinator said the purpose of the care plan was to have a plan of care to address different issues residents may have. Resident #21 Record review of Resident #21's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Alzheimer's (a progressive memory disease that affects thinking, behavior, and the ability to care for oneself), dysphagia (difficulty swallowing), cerebral infarction (a blockage in the brain that damaged part of the brain), hemiplegia (unable to move one side of the body), dysarthria (slurred or difficult to understand speech caused by weakness of the speech muscle), vascular dementia (caused by reduced blood flow in the brain leading to memory and thinking problems), and hypertension (high blood pressure). Record Review of Residents #21 Quarterly MDS dated [DATE] revealed the K0300 was coded '2' indicating the resident experienced weight loss not associated with a physician-prescribed weight loss regimen. Record review of Resident #21 Care Plan revised on 6/4/2026 revealed- Problem: Nutritional Status Overweight related to over intake estimated needs, as evidenced by Body Mass Index (a measure of body weight compared to height) > 27 for elderly; Body Mass Index 29.75. Goal: Resident to maintain weight without any significant weight gain of 5% in 30 days. Approach: Continue diet to meet estimated needs. Last reviewed/revised 9/24/2025. Also revealed weight loss was not identified as a problem. Interview on 6/25/2026 at 12:50 pm NP, she said Resident #21s treatment for unplanned weight loss was started at the end of May and included protein supplements, appetite stimulant, and weekly weight monitoring. She stated there were no clinical issues causing her weight loss. The next step will be to have a discussion with family about placing a feeding tube. She said she was notified of weight loss 3-4 weeks ago. The Dietician was also monitoring. Interview with MDS Nurse 6/25/2026 at 1:57 pm, she said she does the MDS and care plans for all long-term residents at the facility. Care plans are updated for significant changes like weight loss. She said Resident #21's care plan only states self-feeding difficulties requiring assistance with meals for nutrition. Record Review of Registered Dietician (RD) Consult Summary dated 6/21/2026 revealed, Weight Variance Report, Resident #21 weight loss 30 days -7.1%, 90 Days -14.0%, 180 Days – 13.7%, comments – [AGE] year old female, low intake, multiple supplement and appetite stimulant started. Resident #80 Record review of Resident #80's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Down syndrome (a genetic condition where a person is born with an extra chromosome), osteoarthritis (condition where the cushioning (cartilage) between the bones in a joint wears down over time, causing pain, stiffness, swelling, and difficulty moving), Alzheimer's (a progressive memory disease that affects thinking, behavior, and the ability to care for oneself), cognitive communication deficit (problems with thinking skills that affect a person's ability to communicate effectively), dementia (decline in memory and thinking that makes it difficult to manage daily life), muscle wasting and atrophy (loss of muscle size and strength). Record review of Resident #80's admission MDS dated [DATE] revealed a BIMS score of 2 indicating severe cognition impairment and used a walker for mobility. Record review of Resident #80's Care Plan revised on 6/9/2026 revealed no documentation of resident being PASRR positive, PASRR needs, goals, interventions, and nursing facility specialized services. Record review and interview with MDS Nurse 6/25/2026 at 4:30 pm., she reviewed Resident #80s care plan, she said she didn't include any PASRR needs, goals, interventions and nursing facility specialized services in his care plan. She said Resident #80 received Physical Therapy and Occupational Therapy but it was not indicated on his care plan. Record review of facility's Quality of Care policy dated 2/2020 read, The facility will ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; is offered sufficient fluid intake to maintain proper hydration and health; and is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. Record review of facility's Comprehensive Resident Centered Care Plans dated 2/2020 read, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: .2. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: . f. PASARR recommendation, if applicable. Record review of facility's Comprehensive Resident Centered Care Plans dated 2/2020 read, Updating Care Plans: 1. Care plans are modified between care plan conferences when appropriate to meet the resident's current needs, problems and goals. 3. The Care Plan will be updated and/or revised for the following reasons: a. Significant change in the resident's condition. b. A change in planned interventions. C. Goals are obtained and new goals established to meet current resident needs and/or goals. d. New diagnosis, new medications, or abnormal labs. Record review of the facility Care Plan policy with effective date of February 2020 revealed in part, .It is the policy of the facility to promote seamless interdisciplinary care for our residents by utilizing the interdisciplinary plan of care based on assessment, planning, treatment, service and intervention. It is utilized to plan for and manage resident care as evidenced by documentation from admission through discharge for each resident.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 out of 22 residents (Resident #45, Resident #99, Resident #1) reviewed for infection control. -The facility failed to follow their policy and procedure regarding infection control measures for prevention of candida auris (a type of yeast that can cause severe illness and spread easily among very sick patients in healthcare facilities). Resident #45 and Resident #99 were infected with candida auris and did not have a physician's order for contact precautions to prevent the spread of the infection to other residents or staff and staff were not aware of infection. -The facility failed to ensure LVN A had a complete PPE during g-tube medication administering to Resident #1 who was on EBP, on 6/23/2026These failures could place residents and staff at risk of cross contamination and infection.The findings included:Resident #45Record review of Resident #45's Face Sheet generated on 6/25/26 revealed she was admitted to the facility on [DATE] with diagnoses of dementia, candidiasis (a fungal infection caused by an overgrowth of Candida yeast) and chronic obstructive pulmonary disease (a progressive, long-term lung condition that causes restricted airflow and severe breathing difficulties). She was [AGE] years old. Record review of Resident #45's quarterly MDS assessment dated [DATE] revealed she had not received isolation or quarantine precautions for active infectious disease. She had a BIMS of 3, indicating she had severe cognitive impairment. Record review of Resident #45's SNF Follow-up document signed by NP S on 6/5/26 revealed she was positive for Candida and contact precautions (infection control measures used in healthcare settings to prevent the spread of diseases transmitted through direct or indirect contact) were in place. Contact precautions in place; patient stays in room except for visits from friends. Record review of Resident #45's SNF Follow-up document signed by MD T on 6/18/26 revealed she was positive for Candida and contact precautions were in place. Contact precautions in place; patient stays in room except for visits from friends. Record review of Resident #45's physician orders in the electronic medical record on 6/25/26 revealed she did not have an order for isolation, quarantine or enhanced barrier precautions (an infection control measure used in nursing homes to prevent the spread of multidrug-resistant organisms). In an observation and interview on 6/23/26 at 11:36am, Resident #45 had a sign on her door that stated she had enhanced barrier precautions. The instructions on the sign indicated that everyone must clean hands before entering and when leaving, andproviders must wear gloves and gowns for the following high contact resident care activities- dressing, bathing, transferring, changing linens, changing briefs, personal hygiene, wound care. She had a g-tube pump giving her nutrition through a tube in her stomach. Resident #45 said she had been itching on her arms. She said she had these symptoms for about 2 weeks. She had red scratch marks on her left arm. In an interview on 6/24/26 at 3:35pm, LVN M said Resident #45 had some skin issues that caused itching. He said to help her with symptoms, they tried to keep her room cool, use lotion and the use of geri-sleeves (protective arm and leg sleeves designed to safeguard fragile skin, prevent abrasions, bruises, and tears, and provide slight compression to relieve swelling) to protect her arms. He could not say what was causing the symptoms. In an observation on 6/25/26 at 9:44am, Resident #45 had a sign on her door that stated she had enhanced barrier precautions. In an interview on 6/25/26 at 11:12am, LVN R said she was caring for Resident #45. She said Resident #45 was on enhanced barrier precautions due to having a g-tube. She said she was not sure if Resident #45 had an infection. She said if Resident #45 had an infection, there would be an order for isolation precautions and there would be different signage on her door. She said staff would follow the same precautions and wear gowns and gloves when providing care and performing hand hygiene. She said she was not aware Resident #45 had C. Auris. Resident #99Record review of Resident # 99's face sheet dated 6/24/2026 revealed a [AGE] year-old-female admitted on [DATE]. Diagnoses included Nausea, Abnormalities of gait and mobility (any irregular walking pattern or difficulty moving), Gastro-esophageal reflux disease without esophagitis (chronic acid reflux symptoms like heartburn and regurgitation but leaves the esophagus looking normal during an endoscopy without any visible inflammation, erosions, or ulcer), Depression (common, serious, and highly treatable mood disorder characterized by persistent sadness and a loss of interest in activities), Vitamin Deficiency (occurs when your body doesn't get or absorb the required amounts of essential nutrients), Anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure), Hypertension (a chronic medical condition where the force of blood against your artery walls is consistently too high), Atrial Fibrillation (a chaotic, irregular heartbeat in the heart's upper chambers). Record review of Resident # 99's hospital record printed date of 6/10/2026 revealed admission date of 5/16/2026 and read in part Infection: ESBL Extended-Spectrum Beta-Lactamase. (group of enzymes produced by certain bacteria (such as E. coli and Klebsiella pneumoniae) that break down and destroy many common antibiotics) (1/1/2026), Candida Auris confirmed (6/4/2026).chief complaint: Ureteral calculus (a kidney stone that has traveled into the ureter-the muscular tube connecting the kidney to the bladder), Gross hematuria (visible blood in your urine, making it appear pink, red, or cola-colored). Procedure: Hand-assisted laparoscopic right radical nephrectomy on 6/4/2026 (is a minimally invasive surgery to remove the entire right kidney, usually due to a renal tumor) 9 centimeter right renal (kidney) mass.wound 6/4/2026 right, multiple scattered abdomen: staples, covered with abdominal binder, clean, dry.Carrier of Candida auris positive on 6/4/2026. Maintain isolation precautions. No treatment indicated at this time. Record review of Resident # 99's follow-up at SNF with NP on 6/12/2026 read in part [Resident # 99] history of gross hematuria and 1 day history of severe left flank pain.Record review of Resident # 99's follow-up at SNF with NP on 6/18/2026 read in part [Resident # 99] has returned to SNF following completion of right nephrectomy for skilled care and ongoing surgical recovery.Surgical site is clean and dry with staples in place. Resident reports dysuria (is pain or discomfort when you urinate) with urination as well as nausea. Stat labs and UA C&S (standard laboratory tests often performed together to diagnose urinary tract infection) have been requested for evaluation of dysuriaRecord review of Resident # 99's MDS dated [DATE] revealed a BIMs score of 13 indicated Resident # 99 was able to recall phrases or repeat information. Record review of Resident # 99's Care Plan dated 6/18/2026 revealed care area start date 6/17/2026 read in part I have a need for isolation related to active infectious disease (Candida) Short Term Goal Target Date of 6/25/2026 read in part Isolation will reduce the spread of the infectious agent and minimize the transmission of the infection.Approach Start Date:6/17/2026 read in part Follow facility's Infection Control policies/ procedures.use principles of infection control and universal/standard precautions. care area related to surgery wound not specified.Record review of Resident # 99's Orders as of 6/24/2026 did not indicate order for isolation precaution for Candida Auris. Record review of Resident # 99's Progress Note dated 6/11/2026 at 5:21pm read in part Follow up new admit from hospital. skin noted with surgical incision to abdomen with 26 staplesRecord review of Resident # 99's Progress Note dated 6/12/2026 at 4:07 am read in part [Resident #99] new admit day 1/3. Surgical incision to abdomen with 26 staples dry and intact.Record review of Resident # 99's Progress Note dated 6/12/2026 at 2:30 pm read in part [Resident #99] is on contact isolation of Candida Aureus, contact precaution maintained Candida Aureus contact isolation was noted in progress notes until 6/18/2026 and again on 6/24/2026.During an observation and interview on 6/23/2026 at 1:58pm with Resident #99, an EBP sign was on door and door was open in a solo room. Family Member was seen in room without PPE. Resident #99 was seen in wheelchair. Resident #99 said she completed test results to see if she has an infection, however she was not sure yet. Facility recently informed Resident #99 of Candida Aureus after previously allowing resident to participate in activities outside of room. She was confined to room although all staff were not aware she was isolated to room and asked Resident #99 to participate in therapies and activities. Resident #99 said was not told by hospital of Candida Aureus infection. Resident #99 was to be tested again for Candida Aureus to be sure of results. Family Member stated it was not clear if Resident #99 had an infection from the hospital or when isolation would be over at the facility and if treatment was to begin for the infection. During an interview on 6/24/2026 at 4:20pm LVN P said EBP was for residents that have a g-tube or wounds. Resident #99 had candida of the skin and precautions were to wear a gown when providing care. During an interview on 6/25/2026 at 9:45am LVN K stated Resident #99 was on precautions for Candida and tests were completed by the lab. LVN K was notified by in-service, and the treatment was done at the hospital. Resident #99 was to be monitored until infection was completely out of system which may take longer. The doctor may order another round of antibiotic after the lab results return. Precautions for Resident #99 was in the eMAR.In an interview on 6/25/26 at 11:45am, the Unit Manager said enhanced barrier precautions were used to prevent infections for individuals who had an opening of the skin, like a foley catheter, g-tube or colostomy. She said the facility had 3 residents with C. auris infections. She said they used enhanced barrier precautions for these residents because the local health department recommended to use those precautions. She said someone with C. auris could have it for a lifetime. She said the infection was spread by saliva or an open wound. She said it was a fungal infection. She said it could be on the resident's skin and nails. She said residents with C. auris could leave their room but had to be slightly separated from others. She said the staff should be aware that a resident had C. auris. She said the residents with C. auris obtained the infection from the hospital rather than the nursing facility. She said Resident #45's skin issue could be a symptom of C. auris. During an interview on 6/25/2026 at 12:50 pm NP stated Resident #99 had Candida from the hospital and tested positive. NP stated the facility would only test again if there were new symptoms. Resident #99 was on contact isolation, but visitors would need to exercise precaution. Facility policy was to follow the County's policy. Resident #99 was admitted to the facility from the hospital with an isolation precaution order. Resident #99 would not be given antibiotics or any other treatment for Candida because it was a life-long infection. NP said the facility would call the County to report the infection and get one on one recommendations which was contact isolation. NP would also assess any new symptoms. NP said Resident #99 had a urinalysis that came back negative sometime last week. NP said residents can come out of room but cannot be in group contact. During an interview on 6/25/2026 at 1:15 pm DON stated Resident #99 and Resident #45 did not have an open area on the skin, and the precautions are EBP but if there were an open area like wounds, bed sores or surgical incisions then they would be on contact precautions. She said Resident #99 has a sign on the door for EBP and PPE available. DON said the County sent the facility an email with recommendations for Candida. Resident #99 would be in a solo room and would continue precaution until she leaves facility. DON said the facility explained to Resident #99 that the sign was to be on her door and what the precautions were. DON said a family member told the facility Resident #99 was on contact isolation at the hospital. Facility was to inform any appointment and transportation the resident was on contact isolation for Candida. During an interview on 6/25/2026 at 4:04pm with the Unit Manager, she confirmed she was the Infection Preventionist. She stated more than 2 residents would be considered an outbreak and if it spreads, they monitor and complete in-services to staff for hand washing and a letter would be sent to inform of the outbreak. EBP was an infection control prevention for residents with no symptoms. TBP was used no matter if someone was touching the resident or not and staff would need to wear gown and use sanitizer and gloves for contact precaution. If the infection were airborne then a mask was worn. Unit Manager stated a resident on EBP would not be on isolation, and can go to activities. A resident's door would have a sign for either EBP or TBP for contact isolation. If a resident was on a contact isolation but the door has a sign for EBP, there would be a risk of infection to the resident and staff. The facility would need an order for contact isolation. The Unit Manager was not familiar with Resident #99 and DON handled that resident. The facility orders a test for Candida in the first week of symptoms then again, the second week for a result. There would not be a third test by the facility, and the results of the second test are considered final and would not change. Unit Manager stated if the resident's skin was closed the precaution was to go from contact isolation to EBP. Although resident would test positive after the second test, the resident was able to come out of the room but within a distance from other residents. A resident would not initially be on contact isolation upon admission unless skin was open, and would only be on contact isolation if the skin stayed open. Record review of the facility's policy regarding C. Auris dated 2/5/26 read, The primary infection control measures for prevention of C. auris transmission in healthcare settings are: Adherence to hand hygiene. Appropriate use of transmission-based precautions based on setting. Cleaning and disinfecting the patient care environment (daily and terminal cleaning) and reusable equipment with recommended products. Inter-facility communication about patient's C. auris status when patient is transferred to another healthcare facility. Screening contacts of newly identified case patients to identify C. auris colonization. Laboratory surveillance of clinical specimens to detect additional cases.Residents with C. auris in nursing homes should be managed using contact precautions. Resident should not be in general population during meals or therapy, isolation is required.Patients and residents in healthcare facilities often remain colonized with C. auris for many months, perhaps indefinitely, even after acute infection (if present) has been treated and resolves.CDC recommends continuing setting appropriate transmission-based precautions for the entire duration of the patient's stay in the facility. Record review of Facility policy titled Contact Isolation Precautions dated 2/2/2026 read in part will implement Isolation Precautions in addition to Standard Precautions to protect each resident from the spread of the infection when it is deemed that the infection can be transmitted by direct contact or indirect contact with other residents or staff.Institute Isolation Precautions-must have physician's order.Fill out infection control form in Matrix.Record review of facility Matrix dated 6/23/2026 did not indicate Resident #99 and Resident #45 had an infection. Resident #1 Record review of Resident #1's face sheet dated 04/02/2026 revealed he was an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: infection of the bladder or kidney, pneumonia (disease of the respiratory system), acute respiratory failure (when the lungs cannot provide enough oxygen), benign neoplasm of prostate (abnormal growth of prostate cells).Record review of Resident #1's MDS dated [DATE] revealed cognitive patterns-C0500 was coded 10-moderate impairment in thinking and memory. He was dependent on staff for all activities of daily living.Record review of Resident #1's comprehensive care plan dated 04/02/2026 revealed: Pressure ulcer stage 3. Goal: ulcer will heal without complications. Intervention: assess pressure ulcer and condition of surrounding site. Feeding tube. Goal: Resident will not exhibit signs of complications. Intervention: check and replace stomach content if less than 150 cubic centimeters.Observation of peg tube medication administration on 06/23/2026 at 4:30 p.m., revealed LVN A administered medications without using the complete PPE-She had gloves on but did not wear a contamination prevention gown.Observation of Resident #1's door on 06/23/2026 at 4:30 p.m., revealed there was a colored poster with the following instructions: STOP. EBP. Everyone must: clean their hands, including before entering and when leaving. Providers and staff must also: wear gloves and gowns for the following: Dressing, bathing/showering, transferring, changing linen, providing hygiene, device care or use: central line, urinary catheter, feeding tube and tracheostomy.In an interview with LVN A on 06/23/2026 at 5:00 p.m., she said residents on EBP are those with wounds and g-tubes. She said the yellow gown was worn by staff prior to residents' care and procedures such as g-tube medication administration to prevent cross-contamination. LVN A said the fact that she failed to wear the yellow gown meant she violated infection prevention protocol.In an interview with RN A on 06/24/2026 at 11:10 a.m., she said the yellow infection prevention gowns are used each time a nurse went into administer medication and flushing and medication administration via peg-tubes. She said the gown was used not only for medication administration but also for feeding and other activities of daily living care. RN A said if LVN A had not worn the yellow gown, it meant she violated the infection control process. She said if a nurse did not wear the complete and right PPE's they could transmit infection. She said all staff were trained in infection prevention and the right PPE to use. In an interview with the wound care nurse on 06/24/2026 at 11:23 a.m., she said the yellow gown was used to protect the residents so that there would not be contamination from the staff since staff moved from one resident room to another. She said staff were trained to use the infection protection gown during g-tube care and medication administration, foley catheter and pressure ulcer care. The WCN said if LVN A did not wear the yellow gown there was a risk of infection from LVN A's scrub that could have been transmitted to Resident #1. She said the facility had geriatric residents whose immune system was low.In an interview with RN B on 06/25/2026 at 08:57 p.m., she said infection prevention training was her responsibility. She said the last infection prevention training on EBP was in May of 2026. She said she expected her staff to use the proper PPE. She said the gown was used for safety for both the staff and the residents. RN B said, if staff did not wear the protective gown, they were violating the facility policy which required staff to wear the proper PPE during peg-tube medication administration.In an interview with the DON on 06/25/22026 at 09:36 a.m., she said the yellow gowns were used to prevent the spread of infection. She said during peg-tube medication administration, she expected the nurses to wear a gown, gloves and a mask if the resident had a respiratory infection. The DON said if the staff administered peg-tube medications without the right PPE, they violated the infection control policy.In an interview with the ADM on 06/25/2026 at 10:08 a.m., she said the yellow gowns were used for prevention of infection. She said she expected staff to have a gown and gloves on when they provide care or administer medication via peg-tube in an EBP room. She said that would protect the staff and the residents. The ADM said if the staff did not have a gown and gloves, they violated the requirements to perform their job.

Based on observation, interview and record review the facility failed to ensure personal privacy for 1 of 5 residents (Resident #2) observed for medication administration in that: The facility failed to ensure MA A on 06/24/2026 provided Resident #2 privacy during medication administration. MA A administered medication to Resident #2 in the day area.This deficient practice could lead to psychosocial harm due to feelings of low self-esteem and/or embarrassment regardless of resident cognition.Findings included:Record review of Resident #2's face sheet dated 06/16/2026 revealed he was an [AGE] year-old admitted on [DATE] with the following diagnoses: conversion disorder with seizure (abnormal activity of the brain) depression and high blood pressure.Record review of Resident #2's MDS comprehensive record dated 06/23/2026 revealed his BIMS score was 13- indicating normal thinking and memory. His mood was coded-feeling down, depressed or hopeless.Record review of Resident #2's baseline care plan dated 06/16/2026 revealed: Experienced recent death of a family member. Goal: Resident will express feelings about recent loss appropriately and freely. Intervention: Provide opportunity for resident to express feelings. In an observation and interview during medication administration to Resident #2 on 6/24/2026 at 07:47 a.m., MA A administered his medication in the day area in the presence of another resident. CMA A said, I have your high blood pressure and seizure medication. She said Resident #2 did not refuse his medications in the past. She said she was told to administer medications in the residents' rooms.In an interview on 06/24/2026 at 11:10 a.m., with RN A she said nurses were trained to administer medication to residents in their rooms. She said medications were administered in the residents' rooms to show dignity and respect for the residents. She said MA A violated Resident 2's right of privacy when she mentioned high blood pressure and seizures medications in the presence of another resident.In an interview with RN B on 06/24/2026 at 11:23 a.m., she said medications were administered in residents' rooms. She said if a resident requested their medication in the day area, the nurses should encourage them to return to their respective rooms. RN B said if medication was administered in the hallway, that was violation of HIPAA rule of privacy.In an interview with MA A on 06/24/2026 at 11:34 a.m., she said she was supposed to have provided privacy. She said she administered medications to Resident # 2 in the day area because she was surprised to have seen him there at that time of the day. She said she knew it was a violation of medication administration policy.In an interview with the UM on 06/25/2026 at 08:57 a.m., she said residents' received medications in their rooms. She said MA A was supposed to have administered Resident #2's medication in his room and should not have mentioned the names and what the medications were used for. The UM said that was HIPAA violation.In an interview with the DON on 06/25/2026 at 09:36 a.m., she said residents' received medication in the hallway if they were alone in a private area where no one would listen to what the nurses were saying. The DON said if Resident #2 was sitting next to another resident during his medication administration in the day area, the MA had violated HIPAA rule of privacy. She said if she knew CMA A had administered medication in the day area and said the names of the medication and Resident #2's diagnoses she would have reeducated her on medication administration.In an interview with the ADM on 06/25/2026 at 10:08 a.m., she said she had seen nurses administer medications in the common areas and she did not consider that a privacy issue. She said she saw residents who came to the nursing station to take their medications.In an interview with Resident #2 on 06/25/2026 at 11:25 am, he said he could not say anything even when he did not like what happened around him because staff was there to care for him.Facility's Medication Administration Policy and Procedures dated 02/18/2005 stated: For resident not in their rooms or otherwise unavailable to receive medication, the medication administration record is flagged according to the facility policy. Before completing the medication pass, the nurse returns to the missed resident to administer the medication.Facility's Residents Rights and Guidelines-Policies and procedures, stated: Each resident has the right to be treated with dignity and respect.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 22 residents (Resident #12) reviewed for resident rights. -The facility failed to ensure Resident #12's call light and water pitcher were accessible to him while he was in bed on 6/23/26 and 6/24/26. This failure could place residents at risk of unmet needs, dehydration and feelings of helplessness. Findings include: Record review of Resident #12's Care Plan (undated) revealed he was admitted to the facility on [DATE] and had diagnoses of osteoporosis (a chronic bone disease that causes bones to become porous, brittle, and highly susceptible to fractures from minor falls or daily activities), dementia (an umbrella term for a loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), displaced intertrochanteric fracture of left femur (a specific type of broken hip), and abnormalities of gait and mobility (irregularities in your natural walking pattern or the ability to move freely). He was [AGE] years old. Further review of Resident #12's Care Plan revealed he had limited ability to transfer self and required maximum assistance of one person to assist with transfers. Record review of Resident #12's quarterly MDS assessment dated [DATE] revealed he had a BIMS (a brief, standardized test used by healthcare providers to check basic brain function, focusing on a patient's attention, orientation, and memory) score of 4, indicating he had severe cognitive impairment. The assessment indicated that he required setup assistance with eating and could independently roll from his left to right in bed. He could not walk 10 feet due to medical condition or safety concerns. In an observation and interview on 6/23/26 at 11:26am, Resident #12 was lying in his bed. His call light was unplugged from the wall, and the call light button could not be found. Resident #12 said he was thirsty and wanted something to drink from the refrigerator in his room. His tray table was against a wall across the room and a water pitcher on top of the tray table was inaccessible to the resident. In an interview on 6/23/26 at 11:33am, CNA G said she was caring for Resident #12 this morning. She said she pulled him up in bed and she may have accidentally unplugged his call light. She said she last saw Resident #12 when she fed him breakfast. She said she usually made sure the call light was in reach for the residents. In an observation and interview on 6/24/26 at 3:15pm, Resident #12 was lying in bed. His tray table was against a wall across the room and a water pitcher on top of the tray table was inaccessible to the resident. Resident #12 said he wanted a drink from his refrigerator. In an observation and interview on 6/24/26 at 3:17pm, LVN M entered Resident #12's room and gave Resident #12 a nutritional drink from his refrigerator. He said he liked to drink nutritional drinks. When asked about his bedside table, he said that the aide may have moved it during incontinent care. LVN M said Resident #12 could reach for his water and drinking when he needed it. In an interview on 6/24/26 at 3:35pm, LVN M said Resident #12's water should be at his bedside. He said Resident #12 did not have signs of dehydration. In an interview on 6/25/26 at 11:12am, LVN R said Resident #12's call light should be in reach because he could use it. He said he frequently asked for something to drink from his fridge when the staff walked in to assist him. She said they encouraged him to drink water, but he did not enjoy it much. In an interview on 6/25/26 at 11:45am, the Unit Manager said all residents should have their call light in reach. She said before leaving the resident's room, staff need to make sure call lights were within reach and ensure the resident was comfortable. She said some residents could not get up and walk. She said they were completely dependent on the staff. Record review of the policy and procedure regarding Nurse Call System dated 4/26/16 read, Purpose: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response. Staff will ensure the call light is within reach of resident and secured, as needed. The call system will be accessible to residents while in their bed or other sleeping accommodations within the resident's room.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 resident (Resident #80) reviewed for PASRR services. The facility failed to submit a complete and accurate request for nursing facility specialized services (NFSS) in the Long-Term Care (LTC) Online Portal within 20 business days following Resident #80's PASRR Interdisciplinary Team meeting. This failure placed residents at risk for inadequate care, and losing access to specialized mental health or intellectual disability services.Findings included:Record review of Resident #80's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: Down Syndrome (a genetic condition where a person is born with an extra chromosome), osteoarthritis (condition where the cushioning (cartilage) between the bones in a joint wears down over time, causing pain, stiffness, swelling, and difficulty moving), Alzheimer's (a progressive memory disease that affects thinking, behavior, and the ability to care for oneself), cognitive communication deficit (problems with thinking skills that affect a person's ability to communicate effectively), dementia (decline in memory and thinking that makes it difficult to manage daily life), muscle wasting and atrophy (loss of muscle size and strength).Record review of Resident #80's admission MDS dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment and used a walker for mobility. Record review of Resident #80's Care Plan initiated 1/13/2026 and last revised 6/18/2026 revealed no focus area for PASRR positive. Record review of Resident #80's PASRR Comprehensive Service Plan Form dated 5/7/2026 revealed the updated PASRR Interdisciplinary Team meeting was held 5/7/2026. The Nursing Facility Specialized Services indicated are: A2800B Customized Manual Wheelchair A2800D Specialized Assessment Occupational Therapy A2800E Specialized Assessment Physical Therapy A2800F Specialized Assessment Speech Therapy A2800G Specialized Occupational Therapy A2800H Specialized Physical Therapy A2800I Specialized Speech TherapyRecord review of Resident #80's LTC Online Portal history revealed NFSS request submitted 5/21/2026.Interview and observation 6/25/2026 at 10:40 am with Resident #80 revealed he was with a private caregiver in the hall in his wheelchair. He smiled but didn't answer any questions.Interview 6/25/2026 at 1:35pm, State PASSR Specialist stated that after the facility has an initial PASRR Interdisciplinary Team meeting and services are agreed upon to request, the facility has 20 days from the date of the meeting to submit the request in the LTC portal for PASRR services. The facility held the PASRR Interdisciplinary Team meeting on 3/26/2026. The state PASSR Program Specialist stated the facility had not submitted the NFSS request within the 20 days of Resident #80's PASRR Interdisciplinary Team meeting. She said an email was sent to the DON and Administrator (ADM) requesting the information be uploaded. The NFSS request still hasn't been uploaded which placed the facility in non-compliance.Record review of email dated 5/18/2026 at 2:52pm from State Agency PASSR services to ADM and DON revealed the facility was not in compliance with submitting nursing facility specialized service request to the LTC portal within 20 days of the PASSR Interdisciplinary Team meeting. The email requested the information be uploaded within 3 -5 days upon receiving the email. Further review of the email chain showed on 5/29/2026 at 1:55 PM the DON replied, Facility did an update Interdisciplinary Team meeting on May 7th, because the wheelchair evaluation deadline has passed. The chair evaluation has been done, waiting for the order form and wheelchair vendor letters to be approved and to input documents into the portal. The email chain showed a response from PASRR Quality Monitoring on 5/26/2026 at 1:46 pm requesting that the NFSS requests be submitted as soon as possible. Interview 6/25/2026 at 3:45 pm, DON stated she does the PASRR. The only PASRR resident at the facility is Resident #80. The first PASRR Interdisciplinary Team (IDT) meeting was held 3/26/2026. She said another PASRR Interdisciplinary Team meeting was held because it was past the 20 business days due date to submit NFSS. She said she didn't know about the 20 days before, but now she knew they only have 20 days after the PASRR Interdisciplinary Team meeting to submit. Record Review of facility's PASSR policy reviewed 6/2026 revealed in part, .Submit NFSS requests for authorization into the LTC Online Portal within 20 business days after the Interdisciplinary Team meeting or a specialized service review meeting.

Number of residents sampled: Number of residents cited: Based on observations, interviews and record review the facility failed to ensure a resident receiving enteral feeding received appropriate treatment and services to prevent complications of enteral feeding for 1 out of 4 resident (Resident # 71) sampled for gastrostomy tube feeding quality of care. The facility failed to ensure Resident # 71 received ordered amount of tube feeding formula Jevity 1.5 CAL on 6/23/2026, 6/24/2026, and 6/25/2026 This failure could place residents with the use of the gastrostomy tubes at risk of inadequate intake of daily protein and calories. Findings include: Record review of Resident #71's face sheet dated 6/25/2026 revealed an [AGE] year-old female. admit date of 1/16/2025. Diagnoses included Osteomyelitis (a serious, often bacterial, infection of the bone that causes inflammation and swelling within the bone marrow), Dementia (decline in mental ability severe enough to interfere with daily life), Depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), Gastrostomy (a surgical procedure that creates a small opening, known as a stoma, through the abdomen directly into the stomach. This opening allows for the insertion of a feeding tube (often called a G-tube) to deliver nutrition, fluids, or medications, as well as to vent gas or drain fluids from the stomach), Dysphagia (difficulty swallowing), Lack of coordination (struggling to control body movements, leading to clumsiness, frequent stumbling), Polyneuropathy (a condition where multiple peripheral nerves outside the brain and spinal cord malfunction simultaneously), Protein Deficiency (occurs when your intake falls below the recommended minimum of 0.8 g per kg of body weight), Anemia (body lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to your tissues), Vitamin D Deficiency (occurs when your body lacks adequate levels of this essential nutrient, usually caused by insufficient sun exposure, poor dietary intake, or malabsorption issues), underdosing of appetite suppressant (loss of appetite or an inability to eat). Record review of Resident # 71's MDS dated [DATE] revealed a BIMs score of 99 indicated Resident # 71 was unable to repeat phrases or recall words, also indicated complaints of difficulty or pain with swallowing. Record review of Resident # 71's Care Plan dated 3/4/2026 revealed a care area dated 3/2/2026 for tube feeding with a goal of not exhibiting signs of complications from feeding tube or enteral feeding solution. Care area approaches included record and monitor intake and output every shift. Approach did not indicate formula or frequency. Further review of same care plan revealed care area of feeding tube dated 5/1/2025 and approaches included a discontinued order read in part Administer Jevity enteral feeding at 75cc every 12 hours (900cc/mL). Record review of Resident # 71's orders as of 1/7/2026 read in part enteral feeding: formula Jevity 1.5 (provides 1.5 calories for volume-restricted patients requiring high protein and concentrated energy) Cal flow Rate 50cc/mL every hour for 21 hours (1050 cc/mL). Record review of Resident#71's progress note dated 6/21/2026 completed by LD read in part Enteral feeding of Jevity 1.5 at 50ml per hour for 21 hours to provide 1050ml of formula. Record review of Resident # 71's MAR dated 6/1/2026 – 6/25/2026 read in part enteral feeding: formula Jevity 1.5 Cal flow Rate 50 cc every 21 hours, frequency: every shift, start date: 1/7/2026 Initials located on the MAR indicated LVN J hung and started formula Jevity 1.5 on 6/22/2026 – 6/24/2026. Record review of Resident # 71's MAR dated 6/1/2026 – 6/25/2026 read in part start water flush 100mL every 4 hours via peg-tube at 5am, 9am, 1pm, 5pm, 9pm, 1am start date of 1/21/2026 - open. Indicates 600mL of water in 24hours Record review of Resident # 71's MAR dated 6/1/2026 – 6/25/2026 read in part Enteral Feeding: Total 24hour intake. Special Instructions: Record total daily on 3-11 shift. Start date: 2/22/2025 – open. Indicates daily intake of ordered 1050mL of formula and 600mL of water equal to 1650mL. Further review of MAR on 6/23/2026 read in part Total intake: 2150cc. On 6/24/2026 read in part Total intake: 1933cc. Observation and attempted interview on 6/23/2026 at 2:28pm revealed Resident #71 sleeping on their left side with eyes closed and did not respond to a verbal prompt. A 1,000 mL bottle of Jevity 1.5 Cal formula was observed hanging in the room. A physical inspection of the bottle's label revealed handwritten entries using two distinct ink types: the resident's last name, room number, and a start time of 5:30 AM were written in thick black ink, while the date (6/23/26) and feed rate (50) were written in thin purple ink. At 2:28 pm the physical fluid level inside the Jevity bottle was measured at the 700 mL mark, establishing that 300 mL of formula had left the bottle over an approximate 9-hour period. (From the documented 5:30 AM start time to observation 2:28 PM.) Observation and attempted interview on 6/24/2026 at 12:20pm revealed Resident #71 sleeping and did not respond to a verbal prompt. A 1,000 mL bottle of Jevity 1.5 Cal formula was observed hanging in the room. A close inspection of the bottle's handwritten label revealed conflicting ink colors, indicating alteration from the previous day (6/23/2026). The resident's last name, room number, and the start time of 5:30 AM remained in the thick black ink observed on 6/23/2026. The month (6) also remained in the original thin purple ink from the prior day. However, the day (24), the year (2026), and the rate (50) had been written over in thick black ink. At 12:20 pm the physical fluid level inside the Jevity bottle was at the 700 mL mark, establishing that 300 mL of formula had left the bottle over an approximate 7-hour period. (From the documented 5:30 AM start time to observation at 12:20 PM). Both observations indicate 1,000 mL bottle of Jevity 1.5 Cal formula was reused across both days. Also, the inconsistency on 6/23/2026, the Jevity 1.5 Cal bottle dropped by 300 mL over a 9-hour period (5:30 AM to 2:28 PM). However, on 6/24/2026, the bottle dropped by the exact same volume of 300 mL over a shorter 7-hour period (5:30 AM to 12:20 PM). Despite a 2-hour variance in total infusion time between the two days, there was no difference in the physical amount of formula level delivered to Resident #71. Observation and attempted interview on 6/25/2026 at 9:41am revealed Resident #71 sleeping on their right side with eyes closed and did not respond to a verbal prompt. A 1-Liter (1,000 mL) bottle of Jevity 1.5 Cal nutritional formula was observed hanging in the room. The handwritten label on the front of the bottle listed the resident's last name, room number, the date 6/25/26, a start time of 5:34 AM, and a feed rate of 50 mL/hr. At 9:41 AM (approximately 4 hours after the documented start time), the enteral feeding pump screen displayed: Running . 50ml/hr . 193mL fed. However, a physical inspection of the hanging Jevity bottle showed the fluid level was at the 950 mL mark, meaning only 50 mL had actually left the container. This revealed a 143 mL discrepancy between the pump's electronic reading and the physical volume remaining in the bottle. Interview on 6/25/2026 at 9:45am with LVN K stated formula bags are changed every 24 hours finished or not and once that bag was finished in those 24 hours, another would be hung per MAR. Once a new bag was hung the date and start time was written on the bag. Nurses are to follow the MAR for the amount to administer using the pump. LVN K said Resident # 71's formula bag was changed when she arrived this morning 6/25/2026 for her shift (7am – 3pm) and there were no concerns with g tube placement or the amount of formula consumed. LVN K reviewed Resident #71 MAR and stated Resident # 71 was to receive 50mL of formula every hour which would be 100mL of formula every 2 hours for 21 hours. LVN K stated at least 400ml of formula would be finished within 8 hours although flushing 100mL of water every 4 hours and administration of medication may change the amount because the pump manually stops then starts again briefly. Interview on 6/25/2026 at 2:50pm with LVN K stated Resident # 71's feeding pump screen reads how much water was flushed or how much fluid was consumed at that point. LVN K observed photo taken at 9:41am on 6/25/2026 of Resident #71's feeding pump that read 193mL fed and the liquid nutritional formula Jevity 1.5 CAL 1Liter/1000mL contents were at 950mL from start amount of 1000 mL. LVN K stated the formula contents and the feeding pump are not generally the same number or amount however was unable to explain the discrepancy between the formula bag contents consumed at least 50mL and the feeding pump read 193mL fed. Interview on 6/25/2026 at 3:01pm with DON stated formula bags were to be labeled with date, time and initials of nurse who hung the bag each time a new formula bag was used. DON stated Resident #71's g-tube had no concerns of clogs and Resident #71's feeding should be as scheduled according to MAR. DON observed photos of Resident # 71's formula bag on 6/23/2026, 6/24/2026, and 6/25/2026. DON was unable to determine why the black ink was written over the purple ink on 6/24/2026. DON stated if there was a mistake written on the formula bag they are to cross out the mistake and initial. DON said the amount of formula or water fed to Resident # 71 would be indicated on the pump screen. DON stated Resident #71's formula bag dated 6/24 and 6/25 was hung by the overnight nurse LVN J. DON stated Resident #71's formula bag label looked written over in black ink from purple ink pictured the day before. DON stated it would be a risk if the same formula bag was used more than 24hr as it was no longer good to use and Resident #71 would be at risk of malnutrition if not receiving the correct amount of cc per day due to same bag used on both days. DON stated Resident #71 had no concerns for weight loss at that time. DON stated she was unable to reach LVN J by phone. An attempted interview on 6/25/2026 at 3:57pm with LVN J. Left voicemail with call back information. An attempted interview on 7/3/2026 at 2:32 pm with Family Member. Left voicemail with call back information. An attempted interview on 7/3/2026 at 2:37pm with LVN J. Left voicemail with call back information. Record review of facility policy titled Medication Administration Enteral Tubes dated 12/12 read in part Inservice training on safety, administration, and monitoring of enteral solutions and medication via the enteral tube is provided by the nursing care center to nursing personnel. the manufacturer's written recommendations regarding suggested time period for hanging of the product are consulted when determining the schedule for enteral feeding administration. Record review of facility policy titled Quality of Care dated 2/20/2025 read in part It is the policy of the facility to ensure that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, in accordance with State and Federal Regulations.a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding. Based on observations, interviews and record review the facility failed to ensure a resident receiving enteral feeding received appropriate treatment and services to prevent complications of enteral feeding for 1 out of 4 resident (Resident # 71) sampled for gastrostomy tube feeding quality of care. The facility failed to ensure Resident # 71 received ordered amount of tube feeding formula Jevity 1.5 CAL on 6/23/2026, 6/24/2026, and 6/25/2026 This failure could place residents with the use of the gastrostomy tubes at risk of inadequate intake of daily protein and calories. Findings include: Record review of Resident #71's face sheet dated 6/25/2026 revealed an [AGE] year-old female. admit date of 1/16/2025. Diagnoses included Osteomyelitis (a serious, often bacterial, infection of the bone that causes inflammation and swelling within the bone marrow), Dementia (decline in mental ability severe enough to interfere with daily life), Depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), Gastrostomy (a surgical procedure that creates a small opening, known as a stoma, through the abdomen directly into the stomach. This opening allows for the insertion of a feeding tube (often called a G-tube) to deliver nutrition, fluids, or medications, as well as to vent gas or drain fluids from the stomach), Dysphagia (difficulty swallowing), Lack of coordination (struggling to control body movements, leading to clumsiness, frequent stumbling), Polyneuropathy (a condition where multiple peripheral nerves outside the brain and spinal cord malfunction simultaneously), Protein Deficiency (occurs when your intake falls below the recommended minimum of 0.8 g per kg of body weight), Anemia (body lacks enough healthy red blood cells or hemoglobin to carry adequate oxygen to your tissues), Vitamin D Deficiency (occurs when your body lacks adequate levels of this essential nutrient, usually caused by insufficient sun exposure, poor dietary intake, or malabsorption issues), underdosing of appetite suppressant (loss of appetite or an inability to eat). Record review of Resident # 71's MDS dated [DATE] revealed a BIMs score of 99 indicated Resident # 71 was unable to repeat phrases or recall words, also indicated complaints of difficulty or pain with swallowing Record review of Resident # 71's Care Plan dated 3/4/2026 revealed a care area dated 3/2/2026 for tube feeding with a goal of not exhibiting signs of complications from feeding tube or enteral feeding solution. Care area approaches included record and monitor intake and output every shift. Approach did not indicate formula or frequency. Further review of same care plan revealed care area of feeding tube dated 5/1/2025 and approaches included discontinued order read in part Administer Jevity enteral feeding at 75cc every 12 hours. Record review of Resident # 71's orders as of 1/7/2026 read in part enteral feeding: formula Jevity 1.5 (provides 1.5 calories for volume-restricted patients requiring high protein and concentrated energy) Cal flow Rate 50 cc every 21 hours. Every shift. Day:0700 – 1500 (7 am – 3pm), Evening:1500-2300 (3:pm – 11pm), 2300 – 0700 (11pm – 7am). 50cc = 50mL Record review of Resident#71's progress note dated 6/21/2026 completed by LD read in part Enteral feeding of Jevity 1.5 at 50ml per hour for 21 hours to provide 1050ml of formula. Record review of Resident # 71's MAR dated 6/1/2026 – 6/25/2026 read in part enteral feeding: formula Jevity 1.5 Cal flow Rate 50 cc every 21 hours, frequency: every shift, start date: 1/7/2026 Initials located on the MAR indicated LVN K administered formula Jevity 1.5 on 6/22/2026 – 6/24/2026. Record review of Resident # 71's MAR dated 6/1/2026 – 6/25/2026 read in part start water flush 100ml every 4 hours via peg-tube. 5am, 9am, 1pm, 5pm, 9pm, 1am start date of 1/21/2026 - open. Record review of Resident # 71's MAR dated 6/1/2026 – 6/25/2026 read in part Enteral Feeding: Total 24hour intake. Frequency: Once a day. Special Instructions: Record total daily on 3-11 shift. Start date: 2/22/2025 – open. Further review of MAR on 6/23/2026 read in part Total intake: 2150cc. Further review of MAR on 6/24/2026 read in part Total intake: 1933cc Observation and attempted interview on 6/23/2026 at 2:28pm. Resident #71 sleeping and did not wake when prompted with hello lying on the left side of body with eyes closed. Observation of liquid nutritional formula Jevity 1.5 CAL 1Liter/1000mL hung in Resident #71's room had information handwritten in different color ink on blank lines on the front of the bottle label. Resident # 71 last name and room number was handwritten in thick black ink, the time 5:30am was handwritten also in thick black ink. Further observation of the same label had the date 6/23/26 and the number 50 (to indicate mL per hour) was handwritten in thin purple ink. The feeding pump read Running. 50ml/hour.100ml flush. flush 100ml every 4 hours indicating 100ml was flushed by the time of 2:28pm. The Jevity 1.5 CAL bag contents were at 700mL from start amount of 1000mL indicating 300mL was consumed or had left the bottle in approx. 9 hours from 5:32 am to 2:28pm. Observation and attempted interview on 6/24/2026 at 12:20pm revealed Resident #71 sleeping and did not wake when prompted with hello. Observation of liquid nutritional formula Jevity 1.5 CAL 1Liter/1000mL hung in Resident #71's room had information handwritten in different color ink on blank lines on the front of the bottle label. Resident # 71 last name, room number and the time 5:30am was in the same thick black ink as seen the day before on 6/23/2026. Further observation of the same label handwritten over thin purple ink now in thick black ink was the day 24, the year 2026 and the number 50 (to indicate mL per hour) however month 6 was in same thin purple ink as the day before on 6/23/2026. The feeding pump read Running. 50ml/hr.100ml flush. flush 100ml every 4 hours indicating 100ml of water was flushed by the time of 12:20pm. The Jevity 1.5 CAL bag contents were at 700mL from start amount of 1000mL indicating 300mL was consumed or had left the bottle in approx. 7 hours from 5:32 am to 12:20 pm. Observation and attempted interview on 6/25/2026 at 9:41am revealed Resident #71 sleeping and did not wake when prompted with hello lying on right side of body with eyes closed. Observation of liquid nutritional formula Jevity 1.5 CAL 1Liter/1000mL hung in Resident #71's room handwritten on blank lines on the front of the bottle label was Resident # 71 last name, room number ,time 5:34am ,date 6/25/26 and the number 50 (to indicate mL per hour) all handwritten in black thick ink with no indication of ink from day before. The feeding pump read Running. 50ml/hr.193mL fed. flush 100ml of water every 4 hours indicating 193mL was fed by the time of 9:41am. The Jevity 1.5 CAL bag contents were at 950mL from start amount of 1000mL indicating 50mL was consumed or had left the bottle in approx. 4hours from 5:34am – 9:41am. Further observation on 6/25/2026 at 3:01pm of liquid nutritional formula Jevity 1.5 CAL 1Liter/1000mL hung in Resident #71's room contents were at 650mL from start amount of 1000mL indicating 350mL was consumed or had left in the bottle in approx. 9.5 hours from 5:34 am to3:01pm Interview on 6/25/2026 at 9:45am with LVN K stated formula bags are changed every 24 hours finished or not and once that bag was finished in those 24 hours, another would be hung per MAR. Once a new bag was hung the date and start time was written on the bag. Nurses are to follow the MAR for the amount to administer using the pump. LVN K said Resident # 71's formula bag was changed when she arrived this morning 6/25/2026 for her shift (7am – 3pm) and there were no concerns with g tube placement or the amount of formula consumed. LVN K reviewed Resident #71 MAR and stated Resident # 71 was to receive 50mL of formula every hour which would be 100mL of formula every 2 hours for 21 hours. LVN K stated at least 400ml of formula would be finished within 8 hours although flushing 100mL of water every 4 hours and administration of medication may change the amount because the pump manually stops then starts again briefly. Interview on 6/25/2026 at 2:50pm with LVN K stated Resident # 71's feeding pump screen reads how much water was flushed or how much fluid was consumed at that point. LVN K observed photo taken at 9:41am on 6/25/2026 of Resident #71's feeding pump that read 193mL fed and the liquid nutritional formula Jevity 1.5 CAL 1Liter/1000mL contents were at 950mL from start amount of 1000 mL. LVN K stated the formula contents and the feeding pump are not generally the same number or amount however was unable to explain the discrepancy between the formula bag contents consumed at least 50mL and the feeding pump read 193mL fed. Interview on 6/25/2026 at 3:01pm with DON stated formula bags were to be labeled with date, time and initials of nurse who hung the bag each time a new formula bag was used. DON stated Resident #71's g-tube had no concerns of clogs and Resident #71's feeding should be as scheduled according to MAR. DON observed photos of Resident # 71's formula bag on 6/23/2026, 6/24/2026, and 6/25/2026. DON was unable to determine why the black ink was written over the purple ink on 6/24/2026. DON stated if there was a mistake written on the formula bag they are to cross out the mistake and initial. DON said the amount of formula or water fed to Resident # 71 would be indicated on the pump screen. DON stated Resident #71's formula bag dated 6/24 and 6/25 was hung by the overnight nurse LVN J. DON stated Resident #71's formula bag label looked written over in black ink from purple ink pictured the day before. DON stated it would be a risk if the same formula bag was used more than 24hr as it was no longer good to use and Resident #71 would be at risk of malnutrition if not receiving the correct amount of cc per day due to same bag used on both days. DON stated Resident #71 had no concerns for weight loss at that time. DON stated she was unable to reach LVN J by phone. An attempted interview on 6/25/2026 at 3:57pm with LVN J. Left voicemail with call back information. An attempted interview on 7/3/2026 at 2:32 pm with Family Member. Left voicemail with call back information. An attempted interview on 7/3/2026 at 2:37pm with LVN J. Left voicemail with call back information. Record review of facility policy titled Medication Administration Enteral Tubes dated 12/12 read in part Inservice training on safety, administration, and monitoring of enteral solutions and medication via the enteral tube is provided by the nursing care center to nursing personnel. the manufacturer's written recommendations regarding suggested time period for hanging of the product are consulted when determining the schedule for enteral feeding administration. Record review of facility policy titled Quality of Care dated 2/20/2025 read in part It is the policy of the facility to ensure that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care, in accordance with State and Federal Regulations.a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 25 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure MA A documented Resident #2's medication administration accurately in the facility's electronic medical record. MA A documented medications prior to administration to Resident #2 on 06/24/2026. This failure could place residents at risk of errors in care and treatment. Findings included:Record review of Resident #2's face sheet dated 06/16/2026 revealed he was an [AGE] year-old admitted on [DATE] with the following diagnoses: conversion disorder with seizure (abnormal activity of the brain) depression and high blood pressure.Record review of Resident #2's MDS dated [DATE] revealed his BIMS was coded 13- indicating intact thinking and memory. His mood was coded-feeling down, depressed or hopeless.Record review of Resident #2's baseline care plan dated 06/16/2026 revealed: Experienced recent death of a family member. Goal: Resident will express feelings about recent loss appropriately and freely. Intervention: Provide opportunity for resident to express feelings.In an observation and interview during medication administration on 06/24/2026 at 07:47 a.m., CMA A documented the following medications prior to administration to Resident #2: Hydralazine 10 mg, Levetiracetam 500 mg, Ranolazine 500 mg, Aspirin 81 mg, Clopidogrel 75 mg, Isosorbide mono nitrate extended release 30 mg. Nifedipine 30 mg, Omeprazole 40 mg and Sertraline 75 mg. She said she documented prior to administration because Resident #2 had never refused his medications.In an interview with RN A on 06/24/2026 at 11:10 a.m., she said nurses did not have to document medication prior to administration. She said the documentation should be done after the resident swallowed the medication. She said if CMA A documented Resident #2's medications prior to administration, that was falsification of records. RN A said a staff should not document any action that had not occurred.In an interview with the UM on 06/25/2026 at 08:57 a.m., she said she expected the staff to document medication only after it has been administered. She said if staff documented prior to administration, they would violate the policy of medication administration and documentation policy. She said, that it was considered medication error. The UM said documentation of what did not occur was falsification of medical records.In an interview with the DON on 06/25/2026 at 09:36 a.m., she said staff were trained to document on medication only after it was administered. She said the staff could not document before administration because it was not known if the resident would refuse. The DON said the facility policy stated you administer the medication before documentation. She said if she knew a staff had documented medication prior to administration, she would have reviewed the policy of medication administration with the staff.In an interview with the ADM on 06/25/2026 at 10:08 a.m., she said, if she had to guess, she would say documentation should be done after administration because the resident might refuse the medication.Facility's Medication Administration and Policies and Procedures dated 02/18/2005 stated: Medications are administered as prescribed, in accordance with good nursing principles and practices.

Based on observation, interview, and record review, the facility failed to ensure resident environment remains as free of accident hazards as is possible for 1 of 22 residents (Resident #14) reviewed for accidents and supervision. The facility failed to ensure Resident #14's fall mat was placed on the right side of her bed to help prevent injuries from falls. Resident #14 experienced an unwitnessed fall and was found sitting on the floor on the right side of her bed without the fall mat in place. These failures placed the residents at risk for fall-related injuries, hospitalization, and a decline in physical functioning.Findings included: Record review of Resident #14's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: Bipolar disorder (mental health condition characterized by extreme, unpredictable shifts in mood, energy, activity levels, and concentration), Age-related osteoporosis (occurs when bone breakdown outpaces bone renewal, resulting in brittle, fragile bones), Muscle wasting and atrophy (partial or complete wasting away, thinning, or loss of cells, tissues, or organ), Muscle weakness, abnormalities of gait and mobility, lack of coordination, and dementia (a decline in mental ability severe enough to interfere with daily life). Record review of Resident #14's Quarterly MDS dated [DATE] revealed a BIMS score of 4 out of 15 indicating severe cognitive impairment. Further review of the MDS revealed she had no history of falls. Record review of Resident #14's Care Plan started on 2/18/2026 revealed a problem area of falls which noted risk for falling related to muscle weakness, unsteady gait. Problem further noted, Uses wheelchair for mobility, able to transfer self. Found on floor 3/1/26, Found on floor 3/27/26, 4/15/26, 4/29/26, 6/1/26, 6/24/26, 6/25/26. Review of care plan interventions in part, .Keep bed in lowest position with brakes locked. High Density Mat placed on side of bed. Right side. Observation on 6/23/2026 at 10:00am, revealed Resident #14 was lying in her bed sleeping with her wheelchair at her bedside. No fall mat observed on floor. Observation and interview on 6/24/2026 at 2:20pm, Resident #14 observed sitting on the floor on the right side of her bed with no fall mat on the floor. Resident's right hand had blood on it. NP S was in the room with her and asked if someone was coming to help and stated when she came into the room Resident #14 was already on the floor but she was okay. Unit Manager was found at the nurse's station speaking with other nurses and said they were aware Resident #14 was on the floor and a nurse was getting her cart and about to head to the room now. Record review of Resident #14's progress noted dated 6/24/2026 at 2:20pm revealed, .Writer was called to resident by staff, noted resident was in a sitting position, NP was assessing resident at this time. Writer noted resident with opening to right hand, between thumb and second finger. Per NP cleaned with normal saline, pat dry and applied bandage to finger. Range of motion performed to upper and lower extremities without difficulty. Assist x2 up onto the wheelchair. No signs or symptoms of distress noted. No complaints of pain voiced at this time. Received new order from NP X-Ray right knee, pelvis, hip, right hand. X-Ray order placed awaiting x-ray to be completed. Observation on 6/24/2026 at 3:30pm, Resident #14 was not in her room but a fall mat was on the floor on the right side of her bed. Observation and interview on 6/24/2026 at 3:32pm, Resident #14 was sitting in her wheelchair in the TV area with a bandage on her right thumb and skin tear on right forearm. Resident #14 could not remember the fall or how she got on the floor earlier. Resident denied pain where her skin tear was. Record review of Resident #14's x-rays dated 6/24/2026 at 11:42pm revealed x-ray to right hand, bilateral hips, and right knee revealed no fractures or significant findings. Observation and interview on 6/25/2026 at 11:05am, Resident #14 was lying in bed with a book. Resident #14 said she had pain in her right knee and right shoulder and arm from the fall she had. Resident #14 had jeans on but said there was a knot on the side of her knee, and she did not know what was going on. Resident #14 said she thought an x-ray was done yesterday to check her right side, but she did not know what the results were. There was not a fall mat at the bedside or observed in the room. Interview on 6/25/2026 at 11:12am, CNA H said she was working with Resident #14 today and stated the fall interventions they used with her was to keep a close eye on her and check on her frequently when she is in her room, stay with her while she is going to the toilet and attempting to transfer because she could be unsteady. CNA H said they also keep a fall mat at her bedside. Advised there was not a fall mat seen in the room and she said she would go and check it. Interview on 6/25/2026 at 11:54am, Unit Manager said staff encourage Resident #14 to use her call light, she could transfer herself, but they try to encourage her to ask for assistance with transfer because she is unsteady. The Unit Manager stated she did go and put her fall mat down on the floor after her fall on 6/24/2026 and stated she should have had the fall mat down. The Unit Manager was informed the fall mat was not observed in the room earlier and she said she would go to the room and check why it was moved. Interview on 6/25/2026 at 1:57pm, the DON said part of Resident #14's fall interventions was to have a fall mat down on the side of her bed for protection if she falls. The DON said the fall mat may have been put up in the bathroom and had not been laid back down and stated she would go to investigate why it was not at the resident's bedside. Interview on 6/25/2026 at 5:23pm, MDS Coordinator said she does the care plans for the residents on the second floor including Resident #14. The MDS Coordinator said care plans are updated and interventions are added when a new situation occurs such as a fall. The MDS Coordinator said an intervention listed in Resident #14's care plan regarding her falls was to have a fall mat at her bedside. The MDS Coordinator said there should have been a fall mat at Resident #14's bedside and the purpose was to help with the impact if she falls and to hopefully prevent injuries in the event she falls. The MDS Coordinator said the purpose of the care plan was to have a plan of care to address different issues residents may have. Record review of the facility undated Fall Reduction Program policy revealed in part, .All residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls. Each resident will be evaluated for safety risks including falls and accidents. Care plans will be created and implemented based on the individuals risk factors to aid in the prevention of falls.

Based on interview and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 4 (Resident #2, Resident #3, Resident #4 and Resident #5) of 10 residents reviewed for Activities of Daily Living.The facility failed to provide Residents #2, Resident #3, Resident #4 and Resident #5 with adequate services to maintain personal hygiene that included incontinence care and periodic turning and repositioning. This failure could place residents at risk of diminished quality of life, decreased self-esteem or skin breakdown. Findings included: Record review of Resident #2's face sheet dated 2/26/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (stroke). Record review of Resident #2's quarterly MDS dated [DATE], section C revealed a BIMS interview could not be conducted as the resident was rarely or never understood. Section GG revealed Resident #2 was dependent regarding toileting hygiene. Section H revealed Resident #2 always had urinary incontinence. Record review of Resident #2's care plan as of 2/26/26 revealed category of urinary incontinence with approach start date of 8/30/24 to check for incontinent episodes at least every 2 hours. Record review of Resident #2's Weekly Skin assessment dated [DATE] revealed an arterial ulcer on her left second toe but no other skin breakdown. During interview on 2/24/26 at 11:34 a.m., Resident #2's family member said on 2/4/26 there were 14 hours that Resident #2 was not changed. Resident #2's family member said Resident #2 was last changed around 9 p.m. on 2/3/26, and was not changed until the day and was not changed by the overnight staff. Resident #2's family member said there was a camera in Resident #2's room and that was how they knew Resident #2 was not changed. Resident #2's family member said that this had been the first time that Resident #2 had not been changed in a while but was had been an ongoing issue with the overnight staff with them not checking residents and changing them. Resident #2's family member said it had been about a year and a half with no issues but since December 2025 it had been one issue after another. Observation on 2/25/26 at 9:36 a.m. revealed Resident #2 was clean and dressed lying in bed with her eyes closed and no foul odors noted. Observation and an attempted interview on 2/25/26 at 10:01 a.m. revealed Resident #2 was clean and dressed sitting in a wheelchair in her room. Resident #2 vocalized noises but did not speak words or shake her head yes or no to questions. Observation on 2/26/26 at 8:58 a.m. revealed Resident #2 was clean and dressed lying in bed with her eyes closed and no foul odors noted. Resident #3Record review of Resident #3's face sheet dated 2/26/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia (group of symptoms affecting memory, thinking and social abilities.)Record review of Resident #3's annual MDS dated [DATE], section C revealed a revealed a BIMS score of 14 that indicated cognition was intact. Section GG revealed Resident #3 was dependent regarding toileting hygiene. Section H revealed Resident #3 always had urinary incontinence. Record review of Resident #3's care plan as of 2/26/26 revealed category of urinary incontinence with approach start date of 12/10/25 to check for incontinent episodes at least every 2 hours. Record review of Resident #3's Weekly Skin assessment dated [DATE] revealed Resident #3 had no skin breakdown noted. During interview and observation on 2/24/26 at 12:31 p.m., Resident #3 was clean and dressed sitting in a wheelchair in her room with no foul odors noted. Resident #3 said her care was terrible. Resident #3 said they do not have enough help and the help they do have had lax ability. Resident #3 said she wears a diaper. Resident #3 said the second shift would say it was the third shift's job, and the third shift would say it was the second shift's job. Resident #3 answered yes when asked if she had problems with the overnight shift not checking on her or changing her. Resident #3 said it was recent when the overnight shift last did not check on her, but she thought it was the week before last. Resident #3 said it depended on who was on the overnight shift and some were good and some were not and it was the same as the day shift. Resident #3 said it happened about three to four times a month that the overnight shift did not check on her.Resident #4Record review of Resident #4's face sheet dated 2/26/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (progressive brain disorder that destroys memory and thinking skills).Record review of Resident #4's annual MDS dated [DATE], section C revealed a BIMS score of 7 that indicated moderate cognitive impairment. Section GG revealed Resident #4 was dependent regarding toileting hygiene. Section H revealed Resident #4 always had urinary incontinence. Record review of Resident #4's care plan as of 2/26/26 revealed category of urinary incontinence with approach start date of 12/22/25 to check for incontinent episodes at least every 2 hours. Record review of Resident #4's Weekly Skin assessment dated [DATE] revealed Resident #4 had no skin breakdown noted. Record review of Grievance/Complaint Report dated 2/5/26 revealed grievance regarding Resident #4 by a family member that Resident #4 was not provided with incontinent care from 11-7 shift. Resolution included that Resident #4 was assessed with no skin breakdown noted, in-service provided to staff and the two CNAs who were assigned and unnamed in the grievance to the resident received verbal warnings. During interview on 2/24/26 at 9:25 a.m., Resident #4's family member said Resident #4 was not changed for 14 hours and 37 minutes overnight 2/3-2/4/26 which was obtained this information from camera footage in Resident #4's room. Resident #4's family member said Resident #4 was not changed on 2/4/26 until she notified the CNA. Record review of email 2/24/26 at 11:46 a.m. from dated Resident #4's family member per their documentation revealed Resident #4's diaper was changed on 2/3/26 at 10:04 p.m. Resident #4's family member arrived at the facility and found Resident #4 soaked and documented Resident #4 had not been changed in 14 hours and 37 minutes. Record review of email from Resident #4's family member dated 2/24/26 at 11:50 a.m. revealed screen shot of all the clips from camera in Resident #4's room from 12 a.m. to 6 a.m. on 2/4/26. Events from camera footage for Resident #4 on 2/4/26 revealed events with screenshots at 12:54 a.m. of 12 seconds, 4:18 a.m. of 12 seconds and 6:01 a.m. of 31 seconds but no staff members were present in the footage. Screenshot at 12:54 a.m. revealed the lights were dimmed in the room and Resident #4 and Resident #5 can be seen lying in bed covered by linens. Screenshot at 4:18 a.m. revealed the lights were dimmed in the room and Resident #4 and Resident #5 can be seen lying in bed covered by linens. Screenshot at 6:01 a.m. revealed Resident #4 and Resident #5 lying in bed covered by blankets and an unknown staff member is standing at the door of the room. Observation on 2/25/26 at 9:37 a.m. revealed Resident #4 was clean and dressed lying in bed with her eyes closed and no foul odors noted. During interview on 2/25/26 at 9:49 a.m., Resident #4 said her care was so far so good. Resident #4 denied any problems with staff not checking on her or not changing her. Resident #4 kept closing her eyes during the interview. During interview on 2/26/26 at 8:59 am., Resident #4 was clean and dressed lying in bed with no foul odors noted. When Resident #4 was asked if someone checked on her last night, she replied what for?Resident #5Record review of Resident #5's face sheet dated 2/26/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (group of symptoms affecting memory, thinking and social abilities).Record review of Resident #5's quarterly MDS dated [DATE], section C a BIMS interview could not be conducted as the resident was rarely or never understood. Section GG revealed Resident #5 was dependent regarding toileting hygiene. Section H revealed Resident #5 always had urinary incontinence. Record review of Grievance/Complaint Report dated 2/5/26 revealed grievance regarding Resident #5 by a family member that Resident #5 was not provided with incontinent care on 2/4/26 during the 11-7 shift. Resolution included that in-service was provided and Resident #5 was assessed with no redness or breakdown observed. Record review of Resident #5's care plan as of 2/26/26 revealed category of urinary incontinence with approach start date of 6/19/25 to check for incontinent episodes at least every 2 hours. Record review of Resident #5's Weekly Skin assessment dated [DATE] revealed Resident #5 had no skin breakdown noted. Record review of video footage received from Resident #4's family member 2/3-2/4/26 revealed the times staff members were present in Resident #4's room on 2/3/26 at 10:04 p.m. and next time occurring on 2/4/26 at 12:40 p.m. On 2/3/26 at 10:04 p.m., staff member was observed appearing to have recently changed Resident #4's diaper as there is a diaper in a bag. On 2/4/26 at 12:40 p.m., two staff members are observed changing Resident #4's diaper. Record review of email dated 2/25/26 from Resident #5's family member revealed the following timeline of events from 2/3-2/4/26 from reviewing camera footage in Resident #5's room: 2/3/26 at 8:35 p.m. - Resident #5 was placed in bed 2/3/26 at 8:40 p.m. - Resident #5's diaper was changed 2/4/26 at 7:24 a.m. - Staff adjusted Resident #5's blanket but did not check her diaper 2/4/26 at 9:13 a.m. - Resident #5 was fed but diaper was not checked 2/4/26 at 12:58 p.m. - Resident #5's diaper was changed During interview on 2/25/26 at 2:31 p.m., Resident #5's family member said Resident #5 was put to bed and was not checked or changed that whole night from 2/3-2/4/26. Resident #5's family member said the person who came in that next morning did not change Resident #5 until the next morning and had gone almost 14 hours without being changed. Resident #5's family member saidshe had written in her notes that Resident #5 was put to bed at 8:30 p.m. on 2/3/26 and was not changed until 12:45 p.m. on 2/4/26. Resident #5's family member said Resident #5 should have been out of bed and done with lunch by 12:45 p.m. Resident #5's family member said she knew Resident #5 had gone 14 hours without being changed because there was camera in Resident #5's room and they had reviewed the footage. Resident #5's family member said her main concern was that there was no system in place and that it could happen again. During interview on 2/25/26 at 9:54 a.m., Resident #5 was clean and dressed lying in bed with eyes closed and no foul odors noted. Observation on 2/26/26 at 8:59 a.m. revealed Resident #5 was clean and dressed lying in bed with her eyes closed and no foul odors noted. A staff member was feeding Resident #5 breakfast. Record review of Daily Staffing Sheet from 11P-7A on 2/3/2026 revealed CNA B was scheduled on the unit with Resident #2, Resident #3, Resident #4 and Resident #5 but did not list specific room assignments. Record review of Personnel Action Form that was undated for CNA B revealed termination as of 2/5/26. During interview on 2/26/26 at 1:44 p.m., CNA B said she was given her schedule of residents in writing of which she was supposed to attend to which she did. CNA B said she gave the vital signs of the residents she was assigned to the nurse, and no one ever told her that there were other patients assigned to me. CNA B said when she was being questioned by the DON regarding care not being given, she was told by the DON that there was a list of assignments at the nurses' station and CNA B said she was a new staff and did not know that. CNA B said she had cleaned Resident #4 and Resident #5 many times and did not have a problem cleaning the residents. CNA B said on the night of 2/3/25 she did the residents' vital signs and cared for the residents she was assigned to. CNA B said she did not neglect any residents. During interview on 2/25/26 at 1:00 p.m., CNA C said she worked on the unit with Resident #2, Resident #3, Resident #4 and Resident #5 from 7 a.m. to 3 p.m. CNA C said they were not working on 2/4/26. CNA C said when they came in the morning sometimes the residents were clean and dry depending on what time the night shift started changing them because they would start changing them at 5-6 a.m. if they were heavy wetters. CNA C denied any of the residents being wet or concerns regarding night shift not changing residents as sometimes when they were coming in they were still changing residents. CNA C said they rounded on the residents twice per shift. CNA C denied any concerns regarding neglect at this time. During interview on 2/25/26 at 1:13 p.m., CNA D said she worked from 7 a.m. to 3 p.m. and worked on 2/4/26 but could not remember which unit they worked. CNA D denied any concerns with the residents not being changed on the night shift. CNA D denied any concerns regarding neglect currently. During interview on 2/25/26 at 1:22 p.m., CNA E said they worked from 7 a.m. to 3 p.m. and worked on 2/4/26 but could not remember which unit they worked. CNA E denied any concerns about residents not being changed overnight. CNA E said if she was not busy, she checked on residents every hour. CNA E denied any concerns regarding neglect of residents. During interview on 2/25/26 at 1:30 p.m., CNA F said when she came in the mornings if residents were wet she helped the night shift change the residents. CNA F said for the most part everybody was clean when she came in and it was a rarity that she found residents dirty and did not remember anything abnormal about 2/4/26 when she came in that day. CNA F said the requirement was every two hours to round on residents who were incontinent but could be more if needed. CNA F denied any concerns regarding neglect currently because she said if she saw something she would tell especially if it was bringing harm to a patient. During interview on 2/25/26 at 1:47 p.m., the Unit Manager said she was probably working on 2/4/26. The Unit Manager said she just had a complaint from Resident #4's family member that Resident #4 had not been changed and she believed Resident #5's family member had also made a complaint as well. The Unit Manger said she spoke to DON, and they performed an in-service and the DON let that person go. The Unit Manager said the complaints were related to the 11-7 shift going into 2/4/26 probably, but she would have to check. The Unit Manager denied any concerns regarding abuse or neglect of the residents currently. During interview on 2/26/26 at 10:02 a.m., the DON said she was aware that Resident #4 and Resident #5 were not changed on the night of 2/3/26. The DON said she talked to CNA B and CNA B said she did not look at the assignment at the nurses' station and another CNA had given CNA B a piece of paper with her assignment and it did not have the room numbers for Resident #4 and Resident #5. The DON said she terminated CNA B. The DON said we went ahead and did an in-service with all shifts to make sure they did rounds and the nurses check on the staff and make sure they were doing what they were supposed to do. The DON said when the CNAs were hired, they go to the classroom training and then go on the unit for three days with certain CNA mentors who have been here a long time. During interview on 2/26/26 at 12:16 p.m., the DON said if residents' diapers were not changed, they could have skin breakdown. Record review of facility's policy Incontinent Care last reviewed 6/6/25 revealed Incontinent monitoring will be conducted by round every two to three hours per shift.

Based on interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for 1 (Resident #1) of 10 residents reviewed for accidents and hazards.The facility failed to ensure that CNA A used a full body lift instead of a standing lift as instructed on Resident #1's care plan and had two staff members present when using a mechanical lift when transferring Resident #1 on 2/19/26. The failure could place residents at risk of possible injury. Findings included: Record review of Resident #1's face sheet dated 2/26/26, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (weakness of the right side following a stroke). Record review of Resident #1's annual MDS dated [DATE], section C revealed a BIMS score of 8 that indicated moderate cognitive impairment. Section GG revealed Resident #1 was dependent for chair/bed to chair transfers.Record review of Resident #1's orders did not reveal any information related to transferring or mechanical lifts. Record review of Resident #1's care plan as of 2/26/26 revealed categories as follows: *ADLs Functional for Resident #1 limited in their ability to transfer due to impaired mobility and required to be assisted with transferring using the full body life and was 2 person assistance with approach start date of 2/19/26. *ADLs Functional with approach start date of 3/27/24 that says I will be assisted with transferring using the Full body lift, 2 person assist with approach start date of 3/27/24. Record review of written statement by CNA A on 2/19/26 revealed when CNA A did not find a full body sling in Resident #1's room they used the standing lift to transfer Resident #1. CNA A wrote Resident #1 chose to sit on the floor and CNA A slowly lowered Resident #1 to the floor. CNA A wrote that Resident #1 did not complain about anything at that time. Record review of written statement by RN A on 2/19/26 revealed they assessed Resident #1 from head to toe, and no injury was found and Resident #1 denied pain at the time the resident was found to be on the floor.Record review of Resident #1's progress notes written by RN A dated 2/19/26 at 4:52 p.m. revealed Resident #1 denied pain when assessed at the time she was on the floor after transferring. Record review of Resident #1's hospital records dated 2/19/26 revealed results of a head CT of no acute intracranial (within the skull) abnormality and right shoulder x-ray that showed no acute findings. Record review of Resident #1's progress notes written by LVN A dated 2/20/26 at 6:47 a.m. revealed Resident #1 was assessed at a hospital and Resident #1's skin remained intact with no injuries noted. Resident #1 was not found to have fractures per hospital discharge papers and no new orders. Record review of Resident #1's NP Progress Note SNF Follow Up dated 2/20/26 revealed Resident #1 was evaluated at the hospital with negative findings after a transfer incident in which Resident #1 was reportedly lowered to the ground. Progress note revealed no pain and review of systems was otherwise unremarkable aside from chronic generalized weakness. During interview on 2/25/26 at 1:47 p.m., the Unit Manager said there were always two people when transferring residents with the standing or full body lift. During interview on 2/26/26 at 9:03 a.m., Resident #1 said regarding when she fell on the floor, it was Thursday a week ago. Resident #1 said they used a lift that was not a good lift and was an older lift and they tried to move me to the wheelchair, and I fell before I got to the wheelchair. Resident #1 said she felt like her legs were hurt but they send her to the hospital and did not find anything. Resident #1 said there were two staff members when they were moving her with the lift when she fell. During interview on 2/26/26 at 10:02 a.m., the DON said she was at the facility during the incident with Resident #1 on 2/19/26. The DON said the aide said it was time for Resident #1 to get up for lunch, and the aide was looking for the sling for the full body lift and could not find the sling, so the aide took the standing lift to the room. The DON said that in the process of transferring Resident #1 from the bed to the chair the aide had to lower Resident #1 to the floor and the aide notified the charge nurse. The DON said the charge nurse came and assessed Resident #1 and Resident #1 did not complain of any pain at that time. The DON said at about 3 p.m. Resident #1 complained of right shoulder and bilateral knee pain and we notified the doctor of what happened with the transfer and the doctor said to send Resident #1 to the ER for an evaluation. The DON said the CNA's name was CNA A. The DON said CNA A admitted on her statement that she did not follow Resident #1's plan of care and her excuse was that she could not find the sling. The DON said she terminated CNA A. The DON said we had a sheet for the lifts that said to follow the care plan. The DON said we trained everyone again regarding lifts except nine employees that were either on medical leave or on vacation. On 2/26/26 at 11:51 a.m., surveyor attempted to contact RN A via phone but was unsuccessful and left a message to call surveyor but did not receive a call back. During interview on 2/26/26 at 11:54 a.m., CNA A said on 2/19/26 she lowered Resident #1 to the floor and Resident #1 did not fall. CNA A said Resident #1 did not complain of anything at the time of the incident. CNA A said no one was helping her with the standing lift when she was transferring Resident #1 because they were all busy and there were only a few staff. CNA A said there was usually someone who could come to help her transfer residents. CNA A said when we were not busy, they use two people. CNA A said she had received training regarding how to use the lifts when she was hired. CNA A said it was her first time taking care of Resident #1 and she did not know she was not supposed to use the standing lift for Resident #1. CNA A said that if the full body lifts were busy, she would use the standing lift to transfer residents. During interview on 2/26/26 at 12:16 p.m., the DON said if only one person was using a lift you may not be able to complete the transfer and there was a potential for injury.Record review of CNA A's employee profile revealed termination with effective date of 2/19/2026. Record review of CNA A's Mechanical Lift in-service dated 1/2/26 revealed CNA A signed their initials indicating topics of the use of the correct lift despite family request and two person assist for all lift transfers was discussed in detail. Total Mechanical Lift and Sit/Stand Mechanical Lift Competency checklists were also completed.Record review of the facility's Mechanical Lift In-services revealed training regarding use of the correct lift despite family request and two person assist for all lift transfer for staff members from 2/19-2/25/26.Record review of Attendance Record for subject Abuse and Neglect revealed training was completed with staff members from 2/19-2/21/26. Record review of the facility's policy Transfer Techniques reviewed last on 2/12/25 revealed the nursing staff were to ensure the correct lift is being used and all residents require 2 person transfer with lift equipment at Seven Acres.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for two (Resident #35 and Resident #1) of six residents reviewed for accidents and hazards. 1. The facility failed to ensure Resident #35 was free of accident hazards when CNA A used a mechanical standing lift (a medical device that assists individuals with limited mobility in transitioning from a seated to a standing position) while showering the resident, which resulted in the resident's foot slipping from the lift, falling to her knees, and sustaining compression fractures (a break in a vertebrae and then collapses to) the L1, L3, L4, and L5 vertebrae on 2/11/25. 2. The facility failed to ensure Resident #1 was adequately supervised to prevent her from leaving the facility unsupervised on 03/25/2025. An Immediate Jeopardy was identified on 04/30/25. The Immediate Jeopardy template was provided to the facility on [DATE] at 5:50 pm. While the Immediate Jeopardy was removed on 5/4/25, the facility remained at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for harm, pain, and injury. Findings included: Record review of Resident #35's face sheet, dated 4/29/25, revealed an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included: wedge compression fracture of unspecified lumbar vertebra, polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), unspecified dementia (a group of thinking and social symptoms that interfere with daily functioning), pain in unspecified lower leg, low back pain, other osteoporosis without current pathological fracture. Record review of Resident #35's comprehensive MDS dated [DATE] indicated she had a BIMS score of 6 which indicated a severe cognitive impairment. Further review of the comprehensive MDS indicated she was dependent on staff for toileting, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. Record review of Resident #35's care plan dated 1/9/25 indicated she was limited in her ability to transfer due to impaired mobility; she was unable to ambulate or stand. Interventions included: assist with transferring using the full body lift (a type of lift used to assist caregivers in lifting and transferring individuals who are unable to move themselves independently) , 2-person assist, keep call light within reach, monitor extremities to avoid injury, notify nurse if any injury occurs, provide 2-person assistance for transferring, and when transferring, resident should be face-to-face with caregiver. Record review of the Physical Therapy Plan of Care dated 2/22/24 indicated Resident #35 was at a level of maximum assist (76-99% assist) with transfers. Further review of Resident #35's care plan dated 1/9/25 indicated she was at risk for falling r/t impaired mobility, decreased muscle strength. Resident #35 uses w/c for mobility with full staff assistance. Fall r/t standing lift 2/11/25. Interventions included: transfer to hospital for evaluation, keep bed in lowest position with brakes locked, keep call light in reach at all times, keep personal items and frequently used items within reach when appropriate. Record review of the incident/accident report for February 2025 indicated on 2/11/25 Resident #35 was lowered to her knees in front of shower chair to ER for eval fx L1. Record review of Resident #35's progress note dated 2/11/25 at 5:21 pm by LVN A reflected the following: Reported by CNA A resident was being showered and CNA A was using stand up lift to transfer back to wheelchair after shower. Resident's foot slipped off the pedal causing the sling to move upward. CNA A loosened sling and she was lowered to her knees in front of shower chair. This is the position this writer observed when called to the shower room at 4:30 pm. No LOC. 3-11 supervisor called to floor at 4:35 pm and 911 was called at 4:39 pm by supervisor. RP called at 4:39 pm. T 97.4, P 56, R 20, B/P 143/67, O2 sat on RA 96%. ROM x4 extremities. No internal or external rotation of the feet or negs noted. NVS WNL. Resident stated, I hurt all over. EMS here at 4:55 pm. Resident in transit via stretcher to hospital at 5:10 pm. Interview with Resident #35 on 4/30/25 at 8:58 am, she said she could not remember the incident that happened in the shower, she could not remember if she was injured. Resident #35 said she remembered going to the hospital but could not remember why she was there. Interview with CNA A on 4/30/25 at 12:32 pm, she said before she gave Resident #35 a shower, she tested the standing lift in the shower room. After testing the standing lift, CNA A said she brought Resident #35 in her wheelchair to the shower room and hooked her up to the standing lift. CNA A said as she was lifting Resident #35 up with the lift, she noticed Resident #35's leg slip off the platform of the lift. CNA A said she called for help and CNA B came over to assist. CNA A and CNA B unhooked Resident #35 from the lift and lowered her to the floor. RN A was notified and came to the shower room to assess Resident #35. CNA A said she could not remember if Resident #35 said anything at that time. CNA A said after RN A assessed Resident #35, she, CNA B and RN A got her off the floor and put her in the wheelchair. CNA A said she was wheeled back to her room and put her in the bed. CNA A said she and CNA B stayed in the room with the resident while RN A stood in the hallway and waited for EMS to arrive. CNA A said EMS showed up within 20 minutes. CNA A said she was suspended for 3 days and was fired. Interview with CNA A on 5/2/25 at 12:30 pm, she said LVN A told her to take Resident #35 to her room and transfer her to the bed. She said at the time of the incident Resident #35 was supposed to be transferred using a standing lift. CNA A said she had seen the Family Member use a standing lift on Resident #35 as well. CNA A said the charge nurse would tell her if a resident was standing lift or Hoyer. CNA A said the risk to the resident when the wrong type of lift was used was an accident can happen. Interview with CNA B on 4/29/25 at 6:08 pm, she said she was in the shower room with her resident when CNA A called for help. CNA B said when she came over to help, she saw Resident #35 on her knees on the platform of the lift and the sling was around her chest area. CNA B said Resident #35 was not alert, but her eyes were open. CNA B said she held Resident #35 from underneath her arms until RN A came. CNA B said she and RN A tried to lift Resident #35 to put her in the wheelchair but were unable to. CNA B said she went back to her resident in the shower room once LVN A showed up. CNA B said she was not aware of any injury to Resident #35. Interview with RN A on 4/30/25 at 7:26 pm, she said she was giving out medication in room [ROOM NUMBER] when she was alerted by CNA C to go to the shower room. RN A said by the time she got to the shower room; she saw Resident #35 kneeling on the floor. RN A said Resident #35 was leaning sideways towards the tub. RN A said she stood in between the shower tub and the resident so Resident #35 was leaning on her lap. RN A said LVN A checked Resident #35's vitals. After Resident #35's vitals were taken, RN A said the resident was transferred to her wheelchair by Hoyer lift. RN A said Resident #35 was taken back to her room and EMS showed up shortly after. RN A said Resident #35 has always used the standing lift. RN A said Resident #35 was now on Hoyer lift since she came back from the hospital. Interview with CNA C on 5/2/25 at 10:53 am, she said she was in the shower room next door when she was called for help. CNA C said she saw Resident #35 on the floor. CNA C got RN A to help Resident #35. CNA C said she, CNA A and LVN A put Resident #35 in her wheelchair. CNA C said once Resident #35 was in her wheelchair, she went back to the shower room next door. CNA C said at the time of the incident, staff were using a standing lift for Resident #35. CNA C said there was an assignment binder located at the nurse's station that shows what type of lift each resident uses. CNA C said she was not sure how often the binder was updated. CNA C said the risk to the resident when the wrong type of lift was used could cause injury to the resident. Interview with LVN A on 5/1/25 at 3:20 pm, she said she was at the nurse's station when she was alerted Resident #35 was on the floor. LVN A said when she went to the shower room, she saw Resident #35 on the floor. She said Resident #35 was on her knees in front of the shower tub. LVN A said she assessed Resident #35 while she was on the floor. LVN A said Resident #35 stated I hurt all over. LVN A said CNA A and CNA C assisted Resident #35 off the floor and into her wheelchair using the Hoyer lift. LVN A said CNA A told her that she was alone when she was operating the standing lift. LVN A said the RN Supervisor told the CNA A and CNA C to keep Resident #35 in the shower room. LVN A said she was not sure who took Resident #35 back to her room, she thought it was CNA A and CNA C. She said the RN Supervisor made the phone calls to EMS, family, MD, DON, and Administrator. LVN A said the risk to the resident when the wrong type of lift was used was, they could fall because the resident would not be able to bear weight on their legs. Interview with the Nurse Practitioner on 4/30/25 at 2:23 pm, she said she remembered getting a phone call about the shower incident with Resident #35. The NP said because of the fall, Resident #35 sustained a fracture to the superior end plate of L1 and chronic compression fracture of the L3 to L5 vertebrae. The NP said this type of fracture can happen when a person sits or lands hard on a surface. She said this type of injury could not happen if a person slid down slowly onto the floor. The NP said the risk to the resident when the wrong type of lift is used could be major injury. Interview with the Physical Therapist on 5/1/25 at 11:51 am, he said Resident #35 has been on a Hoyer lift for at least a year. The Physical Therapist said Resident #35 was not a good candidate for the stand-up lift, because she was not able to roll on her own and did not follow directions. He said Resident #35's family requested to have her out of bed daily. He said the risk to a resident when the inappropriate lift is not used was they could fall. Interview with Resident #35's Family Member on 4/29/25 at 4:44 pm, she said LVN A initially told her about the shower incident. The Family Member said CNA A was by herself when she loosened the sling and Resident #35 fell to her knees. The Family Member said none of the staff told her Resident #35 hit her head. The Family Member said CNA B told her the sling was around Resident #35's neck and was choking her. The Family Member said when Resident #35 was hospitalized , Resident #35 had an egg sized hematoma on her forehead, scratches on the side of her face, and her shins were bruised . The Family Member said Resident #35 had an L1 fracture that required a kyphoplasty procedure (a surgical procedure used to treat painful compression fractures of the spine) and her L3, L4, and L5 vertebrae were fused. The Family Member said Resident #35's flexibility and functional ability will never be the same after the accident. The Family Member said before the shower incident she used the standing lift to transfer Resident #35 and requested staff to use the standing lift as well. Interview with the DON on 4/30/25 at 3:11 pm, she said the CNAs were expected to follow the policies and procedures for transfers when using the lifts and listen to the nurses. The DON said Resident #35 was supposed to be on a full body lift and not the standing lift. The DON said Resident #35's Family Member requested to use the standing lift. The DON said they had a meeting with the Family Member around 10/15/24 and gave her the PT evaluation. PT had recommended full body lift for Resident #35. The DON said the risk to the resident when the wrong type of lift was used was injury to the resident. Record review of the Transfer Techniques policy dated 6/13/16 and last reviewed on 2/12/25 under section Mechanical lift using lift equipment read in part . If resident requires lift equipment, nursing staff are to ensure .the correct lift is being used .all residents require 2 person transfer with lift equipment . On 4/30/25 at 5:50 p.m., the Administrator was informed that an Immediate Jeopardy situation was identified due to the above failures. The following Plan of Removal was submitted by the facility and accepted on 5/2/25 at 3:15 p.m.: PLAN OF REMOVAL - Version 6 Name of Facility: Submitted Date: May 2, 2025 F689 Free from Accidents and Incidents The facility failed to use the proper lift on Resident #35 because CNA A used a standing lift, at the request of the family member, instead of following the plan of care which required a Hoyer lift for transfer resulting in an injury to the resident. 1. On February 18, 2025, CNA A was terminated. 2. On May 1, 2025, documentation of the identified accident was included in the Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting. The documentation confirmed that the CNA used the incorrect lift due to the family request and the incorrect number of staff to perform the transfer, despite having been trained regarding the appropriate procedure. 3. On May 1, 2025, the CEO/LNHA, Director of Nursing, and Medical Director re-reviewed the [facility name] policies on Reporting Accidents and Incidents and Transfer Techniques. No policy changes or recommendations were made because of this review. 4. On May 2, 2025, Resident #35 had a therapy evaluation completed that revealed the resident continues to require a full body mechanical lift for transfer. A meeting was held with the resident's family member, and she was informed of the findings that the resident continues to require a full body Hoyer mechanical lift for transfers. 5. On May 2, 2025, the progress notes (nurses notes) were reviewed for Resident #35 from January 11, 2025, to February 11, 2025. The progress notes did not reveal that any other staff members utilized the stand-up lift to care for the resident. 6. On May 2, 2025, Staff that cared for R#35 from January 11, 2025 to February 11, 2025, were interviewed by the Director of Nursing to determine if they cared for the resident utilizing the stand-up lift. Some staff members interviewed admitted to using the standing lift to transfer Resident #35 per the family request. 7. From May 1, 2025 through May 2, 2025 all nursing (CNA, CMA, LVN, RN) employees, were reeducated by the Director of Nursing, Unit Manager, or Nursing Supervisors and a competency assessment was conducted for following the plan of care despite requests from family members and the location and use of the resident transfer list assignment sheet. Nursing staff (CNA, CMA, LVN, RN) working after May 2, 2025, will not be allowed to work without completion of the competency assessment. 8. On May 2, 2025, the DON, Unit Managers, and Supervisors conducted an audit to review all residents requiring the use of a mechanical lift. Point of Care documentation and progress notes were reviewed for a two-person transfer using the appropriate lift from April 1, 2025 through April 30, 2025. New residents will be assessed by therapy on admission for transfer needs and the DON, Unit Managers, MDS Coordinators, or Nursing Supervisors will update the care plan and the transfer assignment sheet at that time of the evaluation. Existing residents with changes in transfer status will be referred to therapy for an evaluation and determination of the appropriate transfer method. At that time the DON, Unit Manager, MDS Coordinator, or Nursing Supervisor will update the care plan and the transfer assignment sheet. Sincerely, Chief Executive Officer Monitoring of the plan of removal included the following (5/2/25 - 5/4/25 ): Monitoring observation on 05/02/2025 4:35 PM. Observation of sit to stand mechanical lift transfer for Resident #4 by CNA B and CNA L. Resident #4 sitting in wheelchair in room. CNA B moved the lift in front of the Resident #4. Resident #4 placed her feet on the platform. CNAs placed the safety belt around the Resident #4's waist connected the loops to both hooks on both sides of the lift. Resident #4 was holding on with both hands and began to lift. CNA's checked if they were high enough Resident #4 requested to go a little higher. Resident #4 was raised a small amount higher. CNA L announced she was removing the chair and removed the chair from under the resident. The lift was turned and positioned Resident #4 over the bed at the side of the bed. Resident #4 was lowered and positioned on the side of the bed. Tolerated well by Resident #4. Record review of the Special Interview Report dated 2/12/25 indicated CNA A was suspended on 2/12/25 during investigation and terminated on 2/18/25. Record review of the QAPI meeting sign in sheet indicated the QAPI meeting was held on 5/1/25 at 9:00 pm for removal of the IJ. The DON, ADON, MDS Coordinators, CEO, and Medical Director attended. Record review of the PT Evaluation and Plan of Treatment dated 5/2/25 indicated Resident #35 required total assist for bed mobility and transfer activities. Hoyer lift was recommended as Resident #35 was not able to tolerate static sitting balance on the edge of the bed for more than 30 seconds. Stand up lift was not recommended. Record review of the Curriculum Specific to the Plan of Removal dated 5/2/25, indicated all nursing staff were re-educated on Following the Plan of Care Despite Family Request, Location of the Lift Assignment Sheet. Record review of the Competency Checklist for Total Mechanical Lift and Sit/Stand Mechanical Lift listed check points for pre-operations check and lift operation. Interviews were conducted on 5/2/25 - 5/4/25 with staff on all shifts (7:00 a.m. - 3:00 p.m., 3:00 p.m. - 11:00 p.m., and 11:00 p.m. - 7:00 a.m.) and included RN B, RN C, LVN A, LVN B, LVN C, LVN D, CMA A, CMA B, CMA C, CNA B, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, and CNA J to verify the in-services were conducted and to validate the staff understanding of the information presented to them. Nursing staff knew where to locate the transfer lift assignment sheet for the [NAME] and [NAME] Units. Nursing staff knew what to do in the event a new resident came into the facility and the resident was not listed on the assignment sheet. Nursing staff knew to follow the care plan despite any requests from family members regarding using the type of lifts. Nursing staff knew mechanical lifts required 2-person assist. The Chief Financial & Administrative Officer was notified on 5/4/25 at 12:22 p.m., the Immediate Jeopardy was removed. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 2. Record review of Resident #1's undated face sheet reflected Resident #1 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included: dementia (confusion and forgetfulness), acute kidney failure (kidneys suddenly cannot filter waste from the blood), weakness, and syncope and collapse (loss of consciousness). Record review of Resident #1's Quarterly MDS Assessment, dated 03/13/2025, reflected Resident #1 had a BIMs score of 4, which indicated severe cognitive impairment. Record review of Resident #1's revised care plan, dated 10/09/24, reflected that Resident #1 had cognition loss, confusion, and poor judgment. The interventions included no harm/injury. Record review of Resident #1's Elopement Risk Assessment completed on 03/25/2025 indicated that she was not a high risk for elopement and did not display any abnormal behaviors or exhibit a change of mental status prior to elopement. Record review of Resident #1's physician orders reflected a new order on 03/26/25 for placement of the Wander guard. Record review of Resident #1's progress note dated 03/25/2025 at 9:30 PM, written by LVN A, revealed that Resident #1 was observed sitting in a wheelchair in the facility's parking lot at 8:45 PM by another resident's family member. The family member returned Resident #1 to the facility, and the supervisor and RP were notified of the incident. During an observation and interview on 05/01/2025 at 12:05 PM Resident #1 was alert and oriented lying down in bed and said she did not remember the incident. During an interview on 04/30/25 at 3:39 PM, CNA V said she was informed that Resident #1 was looking for her family member and was found outside the facility. She said she was a very confused resident who normally stays in her room. She said the doors were monitored by security when she leaves at 11 PM, so she was unsure how the resident could get out. She said the risk to the resident was that the resident could fall out of her wheelchair, or someone could harm her. She said she was in-serviced on 03/28/25 on elopement because Resident #1 was found outside of the facility. During an Interview on 04/30/25 at 4:12 PM, CNA C said she works the 3-11pm shift but was not at work when Resident #1 was found outside. She said she was in-serviced on elopement in March after the incident and was in-serviced on abuse and neglect approximately 1-2 weeks ago. She said the risk to the resident being found outside in the parking lot was that she could get injured. Attempted telephone interview on 05/01/25 at 9:03 AM with RP, surveyor left a voicemail. During an interview on 05/01/25 at 2:44 PM, the ADON said she left around 7-8 PM on the day of the incident and denied any change of condition with Resident #1. She said she was not exit-seeking before incident and was not at high risk for elopement. She said Resident # 1 was confused and forgetful and preferred staying in her room. She said the NP, RP, and DON were notified on the day of the incident. She said the NP ordered a Wander Guard that was placed on the resident's wheelchair. She said the Wander Guard was recently removed after frequent monitoring, and it was found that the resident was no longer exit-seeking. She said that it was not safe for a resident with cognition concerns to leave because they could get injured, or someone could harm them. During an interview on 05/01/25 at 3:19 PM, LVN A said she was familiar with Resident #1 and remembered the incident in March when she was found outside in the facility's parking lot. She said the resident went downstairs that day, and a family member saw her in the parking lot and brought her back into the facility. She said she did not know how long she was outside but remembered seeing her in the hall 1 hour prior to returning to the floor. She said when she returned to the floor, she did a head-to-toe assessment, and no injuries were noted. She said she also did every 30-minute observation for her shift, and labs were drawn. She said the NP, RP, and DON were notified of the incident immediately. LVN A denied that the resident was exit-seeking before or after the incident. She said the risk of her leaving the facility was falling out of the wheelchair or someone harming her. During an interview on 05/01/25 at 3:43 PM, the administrator said the resident was talking with the security guard in the lobby at 8:30 PM. She stayed in the lobby for 5 mins (8:35 PM). She said she watched the video and could see the security guard on the phone and watching the resident on the camera. She said another resident's family member brought the resident back into the facility at 8:50 PM. She said the facility did an in-serviced after the incident on elopement, and the security guard on duty was not allowed to return to the facility. She said they also had other security staff in-serviced and educated on elopement procedures and protocols before they could work at the facility. During an Interview on 05/01/25 at 4:09 PM, CNA K said she was not assigned to Resident #1 on the day of the incident. She said that she was aware that the resident went downstairs and was found outside of the facility. She denied having any elopement concerns with Resident #1 before or after the incident. She said after the incident the staff was trained to notify the charge nurse/supervisor if there was a missing resident. CNA K said the risk of having an elopement was that Resident #1 could fall out of the wheelchair and injury herself. During a telephone interview on 05/04/25 at 9:40 AM, the RP said the facility called him between 8 and 9 PM to inform him that Resident #1 was found outside the building. He said he was surprised because she had never tried to leave the facility before and preferred to stay in her room. He said he was also surprised because security was always at the front desk at 8:00 PM, and he was not sure how she could leave the facility. The RP denied injury to Resident #1 and said a wander guard was placed on her w/c that was recently removed. Observation on the facility's security camera on 05/04/25 reflected: 03/25/25 at 8:35PM: Resident #1 left out of the facility's doors leading outside in her wheelchair following behind another resident's family member. 8:38PM: The family member who initially left returned to the front desk by the security guard and points towards outside. 8:39PM: The security officer can be seen checking the security cameras and calling on the phone. 8:43 PM: The resident can be seen via the outside security cameras in the parking lot sitting in her wheelchair. 8:44PM: The security officer goes outside to check on resident at the edge of the driveway, bending over next to the resident. 8:48 PM: The security officer returns and can be seen looking through a binder and using the phone. 8:49 PM: another resident's family member wheels Resident #1 back into the facility lobby. Record review of the facility's policy titled Wandering and Elopement of Residents revised 10/13/2023, read in part . Policy: To attempt to maintain the safety of our Residents, while allowing them maximum independence. Potential Risks for Wandering and Elopement: 2. Residents who have dementia/Alzheimer .

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for kitchen sanitation. Several food items in the refrigerator had use by dates that were expired but were still observed in refrigerator during initial kitchen observation. This failure could have the potential to affect residents who ate food from the facility's kitchen placing them at risk of foodborne illness. Findings included: Observation of the kitchen with the COO on [DATE] at 8:29 a.m revealed in the refrigerator there were: a. Two blocks of [NAME] American Cheese in an unopened plastic wrap with used by date of [DATE]. b. Cottage Cheese in a plastic container had a used by date of [DATE]. The stated, these items should not be in the refrigerator. She pulled the identified expired food items from refrigerator and discarded them. In an interview on [DATE] at 8:39 a.m. with the COO, who stated that foods in the refrigerator that have exceeded the dates noted on the packaging should be discarded and not still in the refrigerator. In an Interview on [DATE] at 8:50 a.m., the Dietary Manager stated the food items stored in the refrigerator should have been discarded after the used by dates were exceeded. The dietary manager stated that Kitchen Staff E checked expired food items weekly. He stated that if the facility served expired food, the resident could get sick and have an upset stomach, which could lead to death. The dietary manager stated a Labeling and Dating Inservice was performed by the Registered Dietitian on [DATE] at 7:00am. The Dietary Manager stated he will also Inservice the evening kitchen staff later today. Interview with Kitchen Staff E on [DATE] at 11:34 a.m. She stated she was responsible for incoming food supply and checking expiration dates daily in the dairy cooler when she worked. She usually discarded expired foods and rotate foods based on upcoming expiration dates. She stated, I put food items that are expiring sooner to the front of the cooler shelf, and the items that are expiring later are placed toward the back of the cooler if there was room or to the side if there is no room left. She stated that if residents ate expired food items, the resident could become sick. Record review of the facility's Food and Nutrition Policy & Procedure undated revealed that Food products are routinely checked for expiration dates and use by dates and discarded when identified.

Based on observation, interview, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 6 community bathrooms (shower #2) reviewed for physical environment in that: -Shower #2 on the second floor had mold on shower mattress and pillow. This failure could place residents at risk of infection leading to a diminished quality of life. Findings Included: Observation and interview on 02/13/2024 at 2:10 PM, LVN A accompanied surveyor to shower room [ROOM NUMBER] revealed shower #2 had a wedge pillow and the shower mattress covered with black and gray spots. LVN A said, That's mold. She said it was everyone's responsibility to keep the equipment clean. She said, housekeeping was in here earlier. Observation and interview on 02/13/2024 at 2:32 PM, revealed CNA A was in shower room [ROOM NUMBER], attempting to clean the spots off the shower pillow. She said the black and gray spots noted were mildew. She said she had to wait for more cleaning products to get them cleaned. Observation on 02/13/2024 at 3:16 PM, LVN B accompanied surveyor to shower room [ROOM NUMBER] revealed shower #2 still had a wedge pillow and the shower mattress covered with black and gray spots. LVN B said, they're just stains. LVN B attempted to scrape off the spots, but the spots would not disappear. LVN B said housekeeping was responsible for cleaning community bathrooms including the bed and pillows in the shower room after each resident use. LVN B said the staff called housekeeping to clean because they were always present on the floor. Observation on 02/15/2024 at 9:14 am revealed shower room [ROOM NUMBER] with no wedge pillow observed in the room or on the shower mattress. Shower #2 still had shower mattress covered with black and gray spots. Interview on 02/15/24 at 02:51 PM with the housekeeping director, he said housekeeping was only responsible for the upkeep of the shower room walls, toilet and floors. He said the pillows and shower mattress beds in the shower rooms used by resident were the nursing staff's responsibility for sanitizing them between each resident's use. He said housekeeping staff did not clean nor mop showers in between resident use of showers. The Housekeeping Director said community showers were cleaned and disinfected after all residents showered and/or at the end of each shift. Interview on 02/15/2024 at 3:14 PM with the Director of Nursing, she said housekeeping was responsible for the cleanliness of the resident showers which included cleaning the floors, toilet, sink, and bathroom surfaces. The Director of Nursing said CNAs were responsible for the equipment which included the shower beds, pillows, and chairs; She said each piece of equipment needed to be cleaned and disinfected with spray by the CNAs between resident's use. Record review of the facility's Policy titled; Environmental Services Policy revised on 03/30/2020 read in part . Shower Cleaning: disinfect all surfaces Record review of the facility's Policy, titled; Nursing Department Policy effective date 2/22/2001 read in part . Procedure II. E. Clean shower and bathroom

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing of all drugs and biologicals to meet the needs of one resident (Resident #22) of four residents observed for medication pass. -Residents #22 was administered one tablet medications (Metoprolol ER [Extended Release]) that was crushed, even though crushing the medication was contraindicated. -The tablet of Metoprolol ER was crushed, which likely prevented the medication to be metabolized for its intended extended time release. -The MA combined 9 medications together by crushing 8 together and adding the contents of the capsule. The medications were than administered together to Resident #22. The failure could place residents at risk for adverse reactions to medications that were intended to be time-released and for complications of combining crushed medications together. Findings include: Record review of the Face Sheet for Resident #22 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cerebral infarction (stroke), Type 2 diabetes mellitus, bipolar disorder, history of high blood pressure, heart failure, and allergies. Record review of the MDS assessment for Resident #22 dated 12/27/2023 revealed a BIMS score of 6, indicative of severe cognitive impairment. Record review of Resident #22's Care Plan dated 01/04/2023 revealed it did not address crushing medications or opening capsules. Observation on 02/14/2024 at 7:45 a.m. revealed MA A at her medication cart preparing medications for Resident #22. MA A dispensed one of each of the following medications into a small paper medication cup: *Cymbalta 60 mg tablet *Divalproex Sodium 125 mg capsule *Gabapentin 300 mg tablet *Hydrochlorothiazide 50 mg tablet *Metformin 500 mg tablet *Metoprolol ER (extended release) 25 mg tablet *Montelukast 10 mg tablet *Amlodipine 10 mg tablet *Cetirizine 10 mg tablet Continued observation revealed MA A place all 8 of the tablets into a plastic sleeve and crush them with a pill crusher. MA A then poured the crushed medications into a 30 cc plastic cup. MA A opened the capsule of Divalproex Sodium and poured the contents into the cup. MA A then opened a small container of grape jelly. MA A added the jelly to the cup of crushed medications. MA A entered Resident #22's room. MA A administered the medications orally to Resident #22, using a wooden spoon. MA A then gave Resident #22 approximately 200 cc of water. Record review of the facility document entitled 'Medications Not To Be Crushed' (revised December 2014) revealed Metoprolol ER was not to be crushed. The rationale was reflected as the medication formulation was time release. Review of the Metoprolol ER manufacturer package insert (revised January 2018) revealed in part .2.4 Administration Metoprolol succinate extended-release capsules should be swallowed whole. For patients unable to swallow an intact capsule, alternative administration options are available. In an interview on 02/14/2024 at 08:35 a.m., MA A said she crushed one medication by mistake, the Metoprolol ER. In an interview on 02/15/2024 at 07:45 a.m. the DON said the medications that should not have been crushed may have not had the effect they were intended to have. She said medications should not be crushed together because they could affect each other. In a telephone interview on 02/15/2024 at 3:23 p.m. NP C said she was unaware that medications for Resident #22 were being crushed and mixed. When the surveyor informed her which medications were crushed, she acknowledged some of them should not have been crushed. She said that each crushed medication should be administered individually, not mixed. The facility policy Medication Administration (revised 07/06/2023) read in part .3. Medications are administered in accordance with written orders of attending physicians, manufacturer's specifications, and professional standards of practice.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident#53) reviewed for infection control, in that: - The Wound Care Nurse failed to perform hand hygiene when moving from a dirty to clean site, while performing Resident #53's wound care. This failure could place residents at risk for or infections. Findings included: Record review of the admission sheet for Resident #53 revealed he was [AGE] year-old male admitted on [DATE] and readmitted on [DATE]. His diagnoses included pressure ulcer of right buttock (an injury that breaks down the skin and underlying tissue), stage 3, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and pressure ulcer of other site, unstageable (an injury that breaks down the skin and underlying tissue). Record review of Resident #53's Comprehensive MDS assessment, dated 11/07/2022, revealed a BIMS score of 99 out of 15. Staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. He was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. Further review of Section M0150 revealed Resident #53 was at risk of developing pressure ulcer or injuries. Section M0210. Does this resident have one or more unhealed pressure ulcers/injures? Coded yes. Record review of Resident #53's care plan, initiated 11/18/22 and revised on 01/13/2023, revealed the following: Problem: I have a diagnosis of a pressure ulcer. Location/stage: Right ischial/stage 3; 12/7/22 RE-classified as stage 4. Goal: Ulcer will heal without complications. Approach: Treatment per MD orders. If wound care treatment is not responding or declining to current treatment notify MD/NP every week and prn. Record review of Resident #53's physician order, dated 01/11/2023, revealed an order to cleanse wound with normal saline, apply Alginate w/ silver , cover wound with dry absorptive dressing daily. Record review of Resident #53's Wound Care evaluation dated 01/11/2023 read in part: .S/S of Infection: confirmation description & Treatment plan: signs & symptoms present, Topical Antibiotics prescribed. Assessment Notes: fractured bone within wound bed indicates clinical osteomyelitis but [family member] does not want aggressive IV antibiotics . Observation on 01/19/2023 at 10:02 a.m., revealed the WCN provided wound care for Resident #53. The WCN was assisted by the Unit Manager. Without performing hand hygiene and donning clean gloves the WCN gathered the supplies from the treatment cart (contaminated them by opening several packages of 4 x 4 gauze, dry dressing, package of silver alginate, 2 prefilled normal saline syringes, 2 swab sticks and placed two dry 4 x 4 gauze in 2 separate medication cups) placed on the bedside table in the hallway, then brought them in to Resident #53's room. The WCN assisted Resident#53 turn onto his left side. Unfastened the brief and tucked a clear trash bag under the resident. Observation revealed there was a dressing on the resident's right ischial area. The dressing contained a moderate amount of bloody drainage. There was no date visible on the dressing. Continued observation revealed WCN removed the dressing and discarded it into the clear trash bag tucked under the resident. The resident exhibited an open area on the right ischial area, of approximately 4cm, with superficial depth. The WCN did not clean the right ischial wound from the inside to out. WCN nurse used the contaminated swab to insert the silver alginate to pack the wound. The WCN changed gloves 2 times during the wound care and placed her dirty gloves, dirty 4 x 4 gauzes on the resident bed pad. Contaminating the resident's bed pad. The WCN picked up soiled gauze, dirty gloves and placed it back in the clear trash bag tucked under the resident. The WCN then placed the trash bag on the bedside table. The WCN then fasten the same dirty brief, touched the bed linens, fixed resident's shirt, repositioned and covered the resident. The WCN did not clean the resident's bedside table. Placed Resident's water cup from the side table on to the bedside table. The WCN exited the room without sanitizing her hands with the clear trash bag. In an interview on 01/19/2023 at 10:15a.m., with the WCN , she said she was not a certified wound care nurse. She said she started working at this facility a month ago. She said she had received 3 days of training on the floor with another wound care nurse. She said she did not recall having to do wound care competency checks with the DON. She said the facility provided in-servicing on infection control upon orientation. She said she could not recall the exact date. She said she performed hand hygiene when Surveyors asked to observed wound care. She said, I had to go look for help. Grabbed the Unit Manager to assist and prior to that had to help another resident that was high fall risk. She said she did not recall performing hand hygiene prior to setting up supplies on the hallway as she was nervous. She said, I did not wash my hands prior to leaving the room because the trash bag was dirty. I had to carry the trash bag out of the room. I washed my hands after I threw the trash bag away. When Surveyors shared the wound care observation from earlier, the WCN . The Wound Care Nurse said, I disagree. Have a good day and turned her back. In an interview on 1/19/23 at 10:26 a.m., with the DON, she said she expected staff to follow standard infection control techniques; to perform handwashing before the treatment, between gloves change and after, before leaving the room as it placed risk for infections. She said staff were provided training on infection control and hand hygiene often. She said the WCN was observed by the downstairs WCN and person that provided wound care supplies. She said she had not spot-checked the WCN. She said the potential risk to the resident, due to this failure, was cross contamination. At this time, WCN competency check off was requested. In a telephone interview with the Wound Care Doctor on 1/19/23 at 11:36 a.m., he said, Resident #53's wound is bad, super bad, has foul odor and bone infection. He said he was using Silver Alginate as topical antibiotic. He said silver fought infection and Alginate absorbed heavy drainage due to infection. He said Resident #53 needed IV antibiotics to treat osteomyelitis but the family member refused aggressive treatment. He said, all we can do now is to provide proper wound care as the bone infection will not treat itself without 6 weeks of IV antibiotics). WCN competency check off was not provided upon exit. Record review of facility's Infection Control policy (dated 1/2/21) read in part: .Purpose: to establish need for infection control policies in the facility. [facility name] has multiple policies for infection control. Each organism causing an infection may be difficult to resolve if treated in the same fashion . Record review of facility's Handwashing Technique policy dated 11/30/16 read in part: .Policy: All staff will use correct handwashing techniques as follows: A. All staff should wash their hands with soap and water whenever the potential exists for contact with blood, bodily fluids, mucus membranes and/or non-intact skin. Hand sanitizers not to be used if hands are visibly soiled. B. Hand washing should be done at the following times: Prior to wearing gloves and after removing gloves. Before & after changing a dressing. Purpose: To provide correct and effective handwashing technique by staff which will reduce the spread of infections among staff, residents, families and visitors . 47572

40249 Based on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access for 1 of 5 residents (Resident #199) and 1 of 2 Nurse Medication Carts reviewed for medications in that: -The facility failed to ensure the Nurse Medication Cart Second Floor B Side was locked when unattended. -The facility failed to ensure Resident #199 did not have medication in her room. These failures could affect all residents and place them at risk for medication diversion, being administered the wrong medication, injury, and hospitalization . Findings include: Observation on 01/17/2023 at 12:37 PM, revealed the Nurse Medication Cart Second Floor B Side was parked in the hall across from the nurse's station unlocked no staff, visitors, or residents were in the area. Observation on 01/17/2023 at 12:40 PM, revealed LVN A returned to the Nurse Medication Cart Second Floor B Side. LVN A stated the reason she left the medication cart was because she rushed to the dining room to make sure the resident she gave insulin too received his lunch immediately. LVN A stated when leaving the medication cart it was the nurse working on the cart's responsibility to push the lock in and make sure it was locked before leaving it. LVN A stated she did not lock the medication cart prior to leaving due to being rushed. LVN A stated the risk of leaving the medication cart unlocked was that a resident would be able to get into the medication cart and get medicines from it. The medication cart was to be locked when it was unattended. Inventory of the Nurse Medication Cart Second Floor B Side at 1/17/2023 at 12:40PM time accompanied by LVN A revealed: Drawer 1: insulins, eye lid scrub pads, eye drops, Drawer 2: locked empty narcotic box, resident individual medications, MiraLAX (laxative for constipation), nasal allergy sprays, Drawer #3: Betadine (skin antiseptic), nystatin cream (antifungal), lidocaine patches (pain patches), Drawer #4: Gloves, medication administration supplies. In an interview on 01/18/2023 at 2:45 PM, the DON stated her expectations were the medication carts were not to be left unlocked when unattended. The DON stated medication carts were to be locked by the staff member working on the cart. The DON stated the staff working on the cart was responsible for locking the cart. The risk of an unlocked medication cart was that anyone could take medications out of the medication cart. The plan was to inservice the staff that the medications carts were to be locked when leaving it. The staff have been inserviced in the past regarding locking medication carts. In an interview with the Administrator, he stated the staff member working on the medication cart was the one responsible for making sure the cart was locked when out of their sight. The Administrator stated it was important to lock medication carts to prevent the resident from access to the medications in the medication cart. The administrator stated the unlocked medication cart could affect the resident in two ways one was a medication may be taken out of the cart and not available to administer when needed or a resident may take a medication they should not have. The Administrator stated the plan to prevent this again the DON has begun inservices for all staff working on the medication cart. Resident #199 Record review of the admission sheet (undated) for Resident #199 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), pressure ulcer of left buttock, stage 3 (an injury that affects areas of the skin and underlying tissue) and hypertension (A condition in which the force of the blood against the artery walls is too high). Record review of Resident #199's Comprehensive MDS assessment, dated 01/14/2023, revealed a BIMS score was blank her staff assessment for mental status was conducted due to the resident was unable to complete the brief interview for mental status questions. She was assessed as having short term memory problems, long term memory problems, and cognitive skills for daily decision making was severely impaired never/rarely made decision. Record review of Resident #199's care plan, dated 01/18/2023 revealed the following care plan: Problem: cognitive loss/ dementia. Have mild cognitive impairment as evidenced by need for assistance with daily decisions, forgetfulness at times. Goal: I will utilize my existing cognitive abilities. I will have choice and control in decision making. Approach: Staff will provide reminders as needed. Staff will encourage reminiscence to stimulate memory. Staff will help me explore and focus on my strengths and talents. Staff will honor my right to have choice and control. Resident #199 was not care planned for having meds at bedside. During an observation and interview on 1/7/23 at 10:03 a.m., of Resident #199, in her room, revealed a bottle of Women's multivitamin with iron, bacitracin [NAME] ointment and pill reminder box with pills in it sitting on top of the bedside table. Resident #199 said her friend brought OTC/meds sitting at bedside 3 days ago. Resident #199 was unable to name the pills in the pill reminder box. Record review of Resident #199's physician's order revealed Resident #199 was not prescribed the above-mentioned medication. There were no orders for self-administration. During an observation and interview on 1/17/23 at 11:39 a.m. with LVN B, she said residents were not supposed to have any medications at bedside because they could react with any other medications given to them per their orders. She said she did not know how the medications got in her room. LVN B said the resident did not have orders for it. LVN B asked Resident #199 you know who brought these meds. Resident #199 said, 3 days ago my friend brought it. LVN B took the medication and told Resident #199, If you need these medications, we have it at the facility, but I need to get an order for it. I am going to have to take it with me and give it to my supervisor. She said we needed to verify any allergy or adverse effect of the medication before giving it to the resident. She said the doctor had to approve it first. In an interview on 1/18/23 at 2:40 p.m., the DON said residents were not allowed to have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they would also need a doctor's order. She said Resident #199 was not deemed safe to have medications in her room. She said nurses made rounds and were responsible for checking the rooms for medications. She said Resident #199 told her that her friend brought those meds night before yesterday. She said 11-7am shift nurse should have noticed that. She said risk for leaving OTC at bedside was not safe med administration, might not be right dose, have adverse effect, OTC meds could interact with prescribed meds, overdose and wanders can get hold of meds. Record review of facility's Medication Storage Bedside Medication storage policy (dated 05/16) read in part: .5. All nurses and nursing aides are required to report to the charge nurse on duty any medications found at bedside not authorized for bedside storage and to give unauthorized medications to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary . Record review of the facility's policy, Medication Administration dated November 2017 read in part Policy: To administer oral medication in an organized, accurate and safe manner . Procedures 4. Unlock medication cart. Cart may remain unlocked only when in direct line of sight and control by the nurse or medication aide who is administering medication .

Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 residents (Resident #50) reviewed for PASARR. -Resident #50 with diagnoses of mental illness did not receive a PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Review of Resident #50's face sheet, undated revealed Resident #50 was a [AGE] year-old female, admitted to the facility on [DATE], with the following diagnoses: bipolar disease (a brain disorder that causes changes in a person's mood, energy, and ability to function), paranoid personality disorder 9 a mental condition in which a person has a long-term pattern of distrust and suspicion of others) and unspecified mood [affective] disorder (mental disorders that primarily affect a person's emotional state). Review of Resident #50's admission MDS dated [DATE], revealed, in the section pertaining to PASARR, the assessment indicated Resident #50 did not have a serious mental illness. Review of the admission PASARR Level I for Resident #50 dated 03/01/2021 revealed it indicated yes to the question: Is there evidence or an indicator this is an individual that has a Mental Illness? Review of Resident #50's clinical record revealed there was no evidence that Resident #50 had a PASARR Level II Screening. Record review and interview on 01/19/23 at 1:04 p.m., the DON provided a copy of documentation dated 03/08/2021 indicating Resident # 50 was eligible for PASARR Specialized Services. In an interview on 01/19/23 at 12:39 p.m., the MDS Coordinator said the Director of Nursing (DON) was responsible for completing the PASARR. The PASARR I was completed for all residents of the facility. The MDS Coordinator said after the results were sent to the state agency immediately upon completion of the PASARR I. Following a positive PASARR I determination the state agency would make contact with the facility to organize an interview of the resident to determine the resident was eligible for additional therapeutic services. The MDS coordinator said she did not complete any follow-up related to the PASARR system. The MDS Coordinator said the DON would be responsible for any follow-up concerning the PASARR system. In an interview on 01/19/23 at 12:46 p.m., with the DON, she said the facility had reached out to the state agency yesterday 1/18/2023 after Surveyor's questioning of Resident#50's PASARR 11 screening. The DON said she requested information regarding the PASARR II interview and services for Resident #50. The DON said the facility had not yet heard back from the state agency as of today (1/19/23). The DON said PASARR I indicated a resident was eligible for PASARR II services but there was no communication from the state agency after PASARR I. She said she should have made a phone call to follow-up on the status of the interview. The DON said there was no policy in place to address when a PASARR I with a positive determination was not followed up by the state agency to schedule PASARR II interview. The DON said a resident may not receive the services he/she needed if the PASARR II interview was not completed. Review of Facility's Coordination-Pre-Admission Screening and Resident Review (PASARR program) policy (not dated) read in part: .2. Coordination includes: a. incorporating the recommendations from the PASARR level ll determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. b. Referring all level ll residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level ll resident review upon a significant change in status assessment . 47572

Based on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 (Resident #50) reviewed for PASARR. -Resident #50 with diagnoses of mental illness did not receive a PASARR Level II screening. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Review of Resident #50's face sheet, undated revealed Resident #50 was a [AGE] year-old female, admitted to the facility on [DATE], with the following diagnoses: bipolar disease (a brain disorder that causes changes in a person's mood, energy, and ability to function), paranoid personality disorder 9 a mental condition in which a person has a long-term pattern of distrust and suspicion of others) and unspecified mood [affective] disorder (mental disorders that primarily affect a person's emotional state). Review of Resident #50's admission MDS dated [DATE], revealed, in the section pertaining to PASARR, the assessment indicated Resident #50 did not have a serious mental illness. Review of the admission PASARR Level I for Resident #50 dated 03/01/2021 revealed it indicated yes to the question: Is there evidence or an indicator this is an individual that has a Mental Illness? Review of Resident #50's clinical record revealed there was no evidence that Resident #50 had a PASARR Level II Screening. Record review and interview on 01/19/23 at 1:04 p.m., the DON provided a copy of documentation dated 03/08/2021 indicating Resident # 50 was eligible for PASARR Specialized Services. In an interview on 01/19/23 at 12:39 p.m., with the MDS Coordinator. MDS Coordinator said the Director of Nursing (DON) was responsible for completing the PASARR. PASARR I was completed for all residents of the facility. MDS Coordinator said after the results were sent to the state agency immediately upon completion of the PASARR I. Following a positive PASARR I determination the state agency would make contact with the facility to organize an interview of the resident to determine the resident was eligible for additional therapeutic services. MDS coordinator said she did not complete any follow-up related to the PASARR system. MDS Coordinator said the DON would be responsible for any follow-up concerning the PASARR system. In an interview on 01/19/23 at 12:46 p.m., with the DON, she said the facility had reached out to the state agency yesterday 1/18/2023 after Surveyor's questioning of Resident#50's PASARR 11 screening. The DON said she requested information regarding the PASARR II interview and services for Resident #50. DON said the facility had not yet heard back from the state agency as of today (1/19/23). DON said PASARR I indicated a resident was eligible for PASARR II services but there was no communication from the state agency after PASARR I. She said she should have made a phone call to follow-up on the status of the interview. DON said there was no policy in place to address when a PASARR I with a positive determination was not followed up by the state agency to schedule PASARR II interview. DON said a resident may not receive the services he/she needed if the PASARR II interview was not completed. Review of Facility's Coordination-Pre-Admission Screening and Resident Review (PASARR program) policy (not dated) read in part: .2. Coordination includes: a. incorporating the recommendations from the PASARR level ll determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. b. Referring all level ll residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level ll resident review upon a significant change in status assessment .

Based on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster lids and doors were secured. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation on 01-17-23 at 8:30 am revealed the facility's dumpster area, which was in the lot behind the dietary department had a commercial -size dumpster 3/4 full of garbage and the door was open. Interview on 01-17-23 at 8:45 a.m., with the Executive Chef he stated that the dumpster lids always must be closed to prevent infestation with rodents and bugs out of the dumpster and from entering the facility. He stated that he will do an in-service training with the facility staff. Record review of facility policy and procedure on waste disposal dated 01/01/23, indicated: Procedure : 3. The dumpster doors are to be closed after each deposit and are to remain closed when not in use. 5. If any [facility name] employee observes the dumpster doors being left open when not in use, please close them or call Housekeeping at ext. 737/239/289 or cell phone number [PHONE NUMBER].6. Housekeeping Porters and Dining Services utility employees are the normal people that take garbage to the dumpsters.

FACILITY Kitchen Based on observation, interview and record review the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. 1. The facility failed to ensure trays of beverages and food were labeled. 2. The facility failed to ensure boxes of food were not on the floor in the walk-in freezer. 3. The facility failed to ensure a package of sliced tomatoes, in the fridge, were was properly sealed. 4. The facility failed to ensure Dietary Aide K properly washed and sanitized a cooking utensil. These failures could place residents at risk for food borne illness. Findings include: Observations of the kitchen 1 on 10/26/2021 at 9:20 AM, revealed a case of opened sliced tomatoes resting on the shelf of the walk-in cooler, the tomatoes were not properly sealed, 9 boxes of frozen food were rest on the floor in the walk-in freezer and 2 trays of unlabeled and individually poured beverages were in the dry storage. Observation of the food preparation station on 10/27/2021 at 10:50 AM, revealed Dietary Aide K took a dirty pitcher with gravy residue and rinsed the pitcher with water and placed it on the shelf to dry without, washing or sanitizing it. Observations of kitchen 2 on the second floor on 10/27/2021 at 11:10 AM, revealed a tray of unlabeled, individually pour beverages in the fridge. In an interview with the Dietary Manager on 10/26/2021 at 9:25 AM, he stated the tomatoes were not resealed so they had to be disposed of and they usually didn't label their individually poured beverages . He stated the boxes of frozen foods were found on the floor because the vendors delivered the boxes on a [NAME] and left them on the floor in the freezer. The Dietary Manager stated it was not appropriate for boxes to be left on the floor but he tried to have his staff stack them on the pallets in the order of first in, first out within two hours after delivery so they were not there for long. In an interview with Dietary Aide K on 10/27/2021 at 10:52 AM, he stated the pitcher was clean. Dietary Aide A stated most of the time he cleaned the dishes in the 3-compartment sink to wash, rinse, then sanitize the dishes but he was not aware he forgot to wash, rinse and sanitize the pitcher. In an interview with the Dietary Manager on 10/27/2021 at 11:02 AM, he stated all utensils were supposed to be washed, rinsed and sanitized in order to be considered clean. He stated Dietary Aide A has been trained and should have known to do that. Record review of the facility's policy on Pot Washing, dated 01/30/2019, revealed, . Pots, pans & utensils washed by hand will be clean & sanitized . scrub & wash pots thoroughly inside & out . Immerse washed pots completely in rinse water . immerse washed & rinsed pots completely in the sanitizing solution Record review of the facility's policy on Procurement, Receiving and Storage, dated 10/26/2021, revealed .upon receiving food, supplies & etc., all items must put on holding shelf or a flat bed and properly put away . all foods, supplies etc. are stored at least six inches above the floor in clean, dry, & ventilated room that is not subject to wastewater backflow Record review of the facility's policy on FIFO labeling, dated 02/01/2020, stated, . any food item that has been opened in the dry storage, refrigerator or freezer, will be kept in the original packaging, as able, and labeled clearly with the contents & date that the food was opened . All opened food will be sealed properly by using ziplock backs or the vacuum sealer.

Based on observation, interview and record review the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and received the necessary treatment and services, to promote healing, prevent infection for 1 of 5 residents (Resident #1) reviewed for pressure ulcer in that: -The facility failed to assess Resident #1's Stage II pressure ulcer to her sacrum routinely and accurately to ensure the pressure ulcer did not decline and ensure the physician was consulted of any changes. -The facility did not follow up on wound cultures ordered by the physician in a timely manner. Wound culture had to be ordered twice, delaying the administration of antibiotics. -The facility did not implement effective measures to prevent the development of Resident #1's sacral pressure ulcer/injuries that deteriorated to a Stage IV ulcer that needed multiple debridement and the resident developed osteo[DIAGNOSES REDACTED] (infection to the bone). An IJ was identified on [DATE]. While the IJ was lowered on [DATE], the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one resident and placed her at risk of pain,[MEDICAL CONDITION] and worsening of her pressure sores. Findings included: Record review of the admission sheet for Resident # 1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #1's Care Plan initiated [DATE] revealed Resident #1 was incontinent of bladder and bowel and at risk for skin breakdown and pressure ulcers r/t sitting for long period of time and Dementia. Goal: resident will not develop skin breakdown related to incontinence. Approach: Apply moisture barrier to skin, check for incontinent episodes at least every 2 hours and PRN, encourage adequate hydration, provide incontinence care after each incontinent episode. Report any signs or skin breakdown. Weekly skin assessment. Further review of the care plan problem start date [DATE] revealed the resident had developed a pressure ulcer r/t sitting for long periods of time and incontinence. Stage unstageable location: left buttock. Stage unstageable location: right buttock. Goal: Resident's ulcer will heal without complications. Approach: assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization. Conduct a systematic skin inspection. Report any signs of further skin breakdown. Keep clean and dry as possible. Minimize skin exposure to moisture. Keep linens clean, dry and wrinkle free. Conduct a weekly skin assessment. Record review of care plan Problem start date [DATE] revealed Resident #1 was started on ABT for wound infection (Doxycline). Goal: condition will resolve without any complications. Approach: Notify MD/NP of any complications. Record Review of Resident #1's significant change comprehensive MDS assessment dated [DATE] revealed a BIMS of 03 indicating severely impaired cognition. Resident # 1 had short term memory problem, long term memory problem, and cognitive skills for daily decision making was severely impaired and she never/rarely made decision. Further review of the MDS revealed that she required extensive assistance from staff for one staff for dressing, toilet use and personal hygiene and extensive assistance of two people for transfers and bed mobility. Resident #1 was incontinent of bowel and bladder. Section M revealed that the resident had 2 stage II pressure ulcers. Record review of Resident # 1's Weekly Skin assessment dated [DATE] and [DATE] revealed no skin problem noted. Record review of Resident #1's nurses' notes dated [DATE] revealed open area to buttock 5x4 cm redness, [MEDICATION NAME] applied. Resident on Doctor log for evaluation. In an interview on [DATE] at 3:20pm RN A, she said the protocol for the stage 2 pressure ulcer was to measure the open area, cleanse with normal saline and to apply [MEDICATION NAME]. She said the nurses would continue to apply [MEDICATION NAME] until doctor changes the order. She said the nurses make a note in the doctor's log for them to review. She said doctors and the NP visit the facility almost every day. Surveyors reviewed the nurses note dated [DATE] written by the RN [NAME] She said [MEDICATION NAME] was a skin protectant/skin barrier used for redness on residents that were incontinent of bowel and bladder to prevent further breakdown. She said she would call the doctor instead of documenting in the doctor's log. She said she would call the doctor to notify them of any changes in the resident's skin for example rash, bruise or any open area. She said she should have called the doctor because the Resident had Stage 2 open area. She said she try to write on doctor's log instead of calling them because they are busy. Record review of Resident #1's Medical Record did not reflect notification to the physician regarding the [DATE] wound assessment. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. In an interview on [DATE] on 10:08 am with the DON, she said usually Calcium Alginate was not used on a Stage 2 pressure sore if there was no drainage as it will damage the good tissue. In an interview on [DATE] at 10:30 am the Medical Director, said stage 2 pressure ulcer treatment depends on the resident's wound. He said Calcium Alginate was used on a case by case situation. He said the most important thing was to keep the wound clean. Record review of Resident #1's Weekly Skin assessment dated [DATE] revealed Right buttock stage 2 measuring 5.0 cm x 4.0 cm. Left buttock stage 2 with no measurements recorded. Record review of Resident #1's nurses notes dated [DATE] revealed RP made aware regarding wound on both buttocks by the wound care nurse. Record review of Resident #1's dietary notes dated [DATE] revealed Quarterly/ Pressure Injury: Stage 2 right buttock measuring 5.0 cm x4.0 cm; Stage 2 Left buttock 2.0 cm x2.0 cm. On NAS, NCS diet with MVI. Recommend adding protein supplement 30 ml bid po x 60 days for increased needs with healing. Monitor for healing or change in needs. Record review of the physician's orders [REDACTED]. Record review of Resident #1's Weekly Skin assessment dated ,[DATE] /19 revealed Right buttock stage 3. The form had no documented measurements or depth of the wound . Left buttock stage 2 (no measurements documented). Record review of Resident #1's Weekly Skin assessment dated ,[DATE] /19 revealed Right buttock stage 3 with slight odor measuring 4.0 cm x 3.0 cm (depth of the wound not documented). Left buttock stage 3 measuring 0.2 cm x 0.2cm (depth of the wound not documented). Record review of Resident #1's Medical Record did not reflect notification to the physician regarding the [DATE] wound assessment indicating wounds have deteriorated and had slight odor. Record review of Resident #1's Braden scale for predicting pressure sore risk dated [DATE] revealed risk factor sensory perception: slight limited, moisture: often moist, activity: chairfast, mobility: very limited, nutrition: adequate, friction and shear: problem. Total score: 13 indicating moderate risk ,[DATE]. Record review of Resident #1's nurses' notes dated [DATE] revealed the resident had pain/fever, Tylenol 650 mg PRN was given at 9:40 pm. Record review of Resident #1's nurses' notes dated [DATE] revealed Called NP reported status of buttocks wound and episode of Temperature of 99.5 yesterday on ,[DATE] shift. Wound with necrotic elements, bloody discharge, and foul odor. Received order for CBC w/diff, BMP, UA c/s and wound culture. Record review of Resident #1's nurses notes dated [DATE] read in part at 2:40 pm noted resident is warm to touch VS 100.2, 99, 23, ,[DATE], 95%. C/o of generalized pain. Accepted PO Tylenol 650 mg, water 120 cc, removed warm covers, applied cold to armpits and groin. Received order for blood culture. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Special instructions: infected wound discontinued on [DATE]. Record review of Resident #1's Wound Care assessment dated [DATE] revealed read in part wound location: Sacral, wound type: Pressure ulcer, Length: 6.5cm, Width: 8.5, Depth: 0. Wound encounter: initial. S/S present: s/s of infection. Post debridement measurements Length: 6.5cm, Width: 8.5cm, Depth: 3.5cm Record review of the physician's orders [REDACTED]. Observation and Interview on [DATE] at 4:31pm with Resident #1 revealed resident lying in bed on her right side. She did not answer to questions asked about her pressure sore/injuries. In an interview on [DATE] at 4:32pm with the Sitter A, she said she worked with Resident #1 Monday to Friday. She said she was Resident #1's private sitter. She said she was responsible to feed the resident breakfast and lunch. She said CNAs provided incontinent care to the resident. She said the resident had a wound on her bottom. She said the resident was able to tell if she was in pain. In an interview on [DATE] at 4:36 pm Wound Care Nurse A, said she worked Monday to Friday at this facility. She said she was made aware on [DATE] that the resident had an open area. She said when she assessed the resident she observed a stage 2 pressure ulcer on both of her buttocks. She said she received an order to apply Calcium Alginate and cover with dry dressing. She said she performed Resident #1's wound care daily before the resident ate breakfast. She said on [DATE] during dressing change she noticed slough on the island of the wound bed and the wound was then Stage 3. She said she received an order to apply Santyl, Calcium Alginate and to cover with dry dressing. She said there was a slight odor on [DATE] while preforming wound care and on [DATE] she noted slight drainage and a foul odor. She said she did not notify the doctor of the odor and drainage as she was monitoring the site. She said she was off from Saturday [DATE] to Monday [DATE]. She said when she returned to work on [DATE] the wounds looked big with necrotic tissue and they had merged together. She said the wound had become unstageable. She said the Wound Care doctor happened to be in the building on [DATE] and she asked him to assess Resident #1's wound. She said at that time the R and L buttock wounds had merged together and anatomically the wound was on the sacral area. She said the Wound Care doctor debrided the wound on [DATE] and staged it as stage 4. She said a new order was received to apply Santyl and Calcium alginate to the sacrum. She said the RN supervisor was in charge of wound care on the weekends. She said if a nurse/CNA found any skin related pressure ulcer concerns they should call the doctor and describe the wound in order to get a proper treatment order for 7 days. She said they should not wait on the wound care nurse to address concerns. The surveyor reviewed Resident #1's (MONTH) nurses' notes with the Wound Care Nurse. She said a Stage 2 pressure ulcer required a treatment order. She said stage 2 meant the resident had an open area. She said applying [MEDICATION NAME] cream was not sufficient. She said [MEDICATION NAME] cream was a skin protectant/skin barrier used for redness on residents that were incontinent of bowel and bladder to prevent further breakdown. She said on each nurse's station there was a folder with the facility's protocol and procedures for the nurses to follow. She said the nurse on duty should have followed proper protocol for stage 2 treatment. She said nurses were responsible to complete the weekly skin assessment. Surveyors requested the list of residents with pressure ulcers and their wound measurements for which she provides wound care daily. She said she was aware that wound cultures and labs were ordered for Resident #1, but since the resident was placed on antibiotics for wound infection, she did not follow up on the culture results. In an interview on [DATE] at 5:00 pm with the Sitter B, she said she worked 5 days a week with Resident #1. She said about 3 weeks to a month ago she was assisting the CNA with providing incontinent care to the resident. While providing care, she said she noticed a quarter sized piece of skin that had come off and was on the brief. She said she notified the nurse on duty. She said the nurse assessed the area and applied cream and covered it with a dry dressing and dated it. She said yesterday ([DATE]) she assisted the CNA in providing incontinent care to the resident. She said there was no dressing on the resident's bottom. Sitter B said the CNA applied Zinc oxide over the wound and did not notify the nurse. She said she assumed they were leaving the wound open to air. She said usually they could see the dressing through the brief, but none was noticed yesterday. Observation and interview on [DATE] at 5:12 pm revealed the Wound Care Nurse performed wound care on Resident # 1 assisted by CNA A and CNA B. Prior to initiation of the treatment, Resident #1 denied having pain. Resident #1 was assisted onto her right side. Observation revealed the dressing that was adhered to the resident's back was dated [DATE]. When the pressure sore wound dressing was removed from the sacrum area, observation revealed a stage 4 pressure ulcer to the sacral/ coccyx area approximately 6 cm in diameter, a stage 3 to the R buttock approximately 4 cm in diameter and an unstageable pressure ulcer to the L buttock approximately 3 cm in diameter and there was 0.5 cm area of slough in the middle of the pressure ulcer. The Wound Care Nurse confirmed the resident had a stage 3 to R buttock and an unstageable to L buttock. She said the L buttock open area had slough so she could not determine the depth. She said she would follow the same orders for the sacral wound as she did not have an order to treat the two new open areas or the measurements. In an interview on [DATE] at 5:45 pm LVN A, said she worked with Resident #1 yesterday ([DATE]). She said no one notified her that the resident's dressing was dislodged. When asked if she was aware that the resident had wounds, the nurse replied no, and said it was the Wound Care Nurse that did the dressing changes. She said if the dressing on the resident's wound needed to be changed or was soiled then she would look to see if any PRN dressing changes were ordered. She said if none were ordered then she would call the doctor to get a new order to cover the wound. LVN A reviewed Resident #1's orders and confirmed there were no PRN dressings orders. She said nurses were responsible to complete a weekly skin assessment. Record review of Resident #1's Weekly Skin Assessment performed by the Wound Care Nurse dated [DATE] revealed sacrum pressure ulcer stage 4 measuring 6.5 cm x 8.5 cm x 3.5 cm. Serous drainage and foul odor. Response to treatment: Deteriorated. Record review of Resident #1's nurses notes dated [DATE] revealed in part : .Wound care done as ordered this morning, scant amount of brownish drainage noted with slight foul odor. Procedure tolerated well. Resident keep on her side to off load the wound, staff reminded. RP visited the resident at lunch time and informed him the condition of the wound that it's bad and big and deep, he asked for the depth and informed him that it's about 3.5 cm . Record review of Resident #1's Medical Record did not reflect notification to the physician regarding the [DATE] wound assessment. Record review of the physician's orders [REDACTED]. Change dressing as needed when get soiled seven days a week discontinued on [DATE]. Record review of Resident #1's nurses' notes dated [DATE] revealed read in part: . writer noted a lab report from the lab from the Physician`s Notification Manual that stated that wound culture ordered on [DATE] was not done because specimen was mislabeled and also that blood culture was not done because the lab staff used an expired tube for specimen. CMP was also not done by lab. CBC ordered on [DATE] and transcribed in lab was not done . lab called and spoke with customer care Representative who confirmed the report and stated she would send out a lab staff to draw labs for blood culture . Writer notified NP who reordered wound culture, blood culture x2 (aerobic and anaerobic, BMP, CBD with diff, CMP STAT for leukocytosis and [MEDICAL CONDITION] and wound culture buttocks/sacral area. Orders transcribed . Record review of Resident #1's nurses' notes dated [DATE] read in part per lab, wound culture was not performed due to mislabeled/missing information. CMP not done due to specimen integrity and blood culture not done due to specimen integrity/expired collection tube. Record review of Resident #1's nurses notes dated [DATE]- Late entry for [DATE] by wound care nurse Spoke with RP and resident's family member and they wanted to know what's the plan after the Antibiotic treatment was and explained to them that she could not tell them what is the next treatment that would be doctor's decision. She made them aware that the wound is big and deep with foul odor. Record review of the physician's orders [REDACTED]. Special instructions: infected wound discontinued on [DATE]. Record review of the physician's orders [REDACTED].#16 or #14 x 2 weeks special instruction: DX: stage IV sacral wound. Record review of the physician's orders [REDACTED]. Record review of the physician's orders [REDACTED]. Change dressing as needed when gets soiled seven days a week. Record review of the physician's orders [REDACTED]. Record review of Resident #1's Wound Care assessment dated [DATE] revealed read in part wound encounter: subsequent. Length: 6, Width: 9, Depth: 4. S/S present: s/s of infection confirmation description and treatment plan: [REDACTED]. Post debridement measurements Length: 6cm, Width: 9cm, Depth: 4.1cm. Assessment notes: fractured bone within wound bed indicates clinical osteo[DIAGNOSES REDACTED]. Record review of Resident #1's laboratory report dated [DATE] revealed wound site unspecified collected on [DATE] at 2:15pm. The laboratory result indicated heavy growth of proteus mirabilis isolated and heavy growth of [MEDICATION NAME] faecalis isolated. Record review of Resident #1's laboratory report dated [DATE] revealed read in part order choice comments test not performed collected [DATE] at 7:35pm wound culture was not performed due to mislabeled/missing info. Nurses not available notified; will be collected next routines. Left message for call back on [DATE] at 12:43pm. CMP was not performed due to specimen integrity/unspun. Nurse not available try later notified; will be collected next routines [DATE] at 10:47am .blood cultures were not performed due to specimen integrity/expired collection tube. Nurse not available try later notified; will be collected next routines [DATE] at 10:45am. In a phone interview on [DATE] at 11:14 am the Wound Care Doctor said that Resident #1 had a wound on her tail bone. He said the facility found out early (MONTH) or late August. He said they did not consult him until [DATE]. He said when he assessed the wound, it looked like a pretty deep bed sore from lying in bed for a prolonged period time. He said since there was a foul odor and drainage there might have been an infection, but he could not guarantee if it could be a bone infection. He said he spoke with the RP and received consent to debride the wound. He said the debridement required a staple blade to remove dead tissue which created an odor. He said the facility ordered labs. He said he was informed that the resident started having fevers and her white blood count increased. He said on [DATE] when he assessed the wound again, sure enough there was infection to the bone. He said that when he debrided the wound, the tail bone had cracks on it. He said when there was an infection, the bones become thin and brittle and could crack easily. He said he could feel the sharp edges of the bones. He said he took edges of two pieces of cracked bone for cultures. He said it would take 3 days for cultures to arrive, so he also gave a sample to the pathologist who confirmed there was a bone infection. He said to treat osteo[DIAGNOSES REDACTED] 6 weeks of IV antibiotics are recommended. He said he consulted with the NP from the primary team late afternoon yesterday and sent over the results in the evening. He said the NP was waiting on the wound cultures results to start IV antibiotics. He said the resident was on Bactrim PO antibiotics which does not do any good for a bone infection. He said the NP was waiting on the bone cultures to see what bacteria it was and what it was sensitive to. He said he saw other open areas but measured the wound as one big wound because as the wound deteriorates it becomes one big wound like the size of the palm. He said the wound was on the center of the bony area therefore it was considered a sacral wound. When ask, he said for stage 2 applying [MEDICATION NAME] was not ideal and he would have recommended hydrogel dressing. In an interview on [DATE] at 12:02 pm with the NP, she said she found out mid-August that the wound for Resident #1 was getting worse. Prior to that she was not informed of a Stage 2 pressure ulcer as the facility had protocols that they follow. She said the resident started to have fevers, so they initiated blood work and collected U[NAME] The resident was started on antibiotics as they could not pin point if it was the ulcer, a UTI, or a cold/flu. She said the results came back positive for UTI which was causing the fevers. She said the wound also started to deteriorate and a Foley was started for two weeks for proper healing. She said at stage 3 and 4 the doctor saw her initially and bedside debridement was done along with daily dressing changes. She said last night she found out from the bone biopsy that it was positive for osteo[DIAGNOSES REDACTED] as they expected. She said they were waiting for bone cultures to see what bacteria it was, and which antibiotics would be good for her. She said to treat osteo[DIAGNOSES REDACTED] the resident would require IV antibiotics. She said [MEDICATION NAME] was a strong medication however after the 3rd dose it was hard on the kidneys and liver. She said there were associated complications. She said she was going to call the RP today to explain to them the treatment and get their consent. In an interview on [DATE] at 12:34 pm with the DON and the ADON, the Surveyor asked what preventative measures were used for residents with pressure ulcers. The DON said to reposition every 2 hours and to keep residents clean and dry. Aides were to make rounds and as needed. She said a certified Wound Care Nurse does all the wound care in the facility from Monday to Friday. She said they just hired a weekend RN Wound Care Nurse a month ago who will get certified soon. When asked what the protocol was if a new open area was observed on the resident, She said to clean the area, apply dry dressing and to notify the doctor. The Surveyor went over Resident #1's nurses notes with the ADON and DON and they both agreed that the doctor/NP was not notified. The DON said there was also a delay in getting the wound culture as ordered due to mislabeling. She said there was no follow up prior to [DATE] as it took 3 days to get culture results back. She said a new wound culture was collected on [DATE]. The DON said the Resident was on Bactrim and awaiting bone culture. In an interview on [DATE] at 1:37 pm with Resident #1's RP, he said a month ago it started off as a tiny wound and now it has gotten worse to the point that it had an infection to the tail bone. He said the facility should have treated it more aggressively and started the IV antibiotics sooner. He said last week they took wound cultures and were talking about starting her on IV antibiotics. He said he thought by now IV antibiotics should have been started, but they have not. He said he was not informed that there was a delay in getting the cultures back due to mislabeling. He said as per the NP they had to wait on getting the cultures back before they could start IV antibiotics. He said he signed the consent form today and was hoping to start IV antibiotics on Sunday for the resident. He said by looking at the size of the wound it would take months to heal. Record review of the following documents revealed that after surveyor's intervention the following was implemented by the facility: Record review of Resident #1's nurses' notes dated [DATE] at 9:39 pm revealed PICC line with 2 lumens to right upper arm established patent. Resident will Start IV ABT [DATE] at 8 am. Record review of Resident #1's nurses' notes dated [DATE] at 10:30pm revealed PICC line inserted and chest x-ray confirmed. [MEDICATION NAME] infusing no distress noted. Record review of the physician's orders [REDACTED]. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's care plan updated Problem start date: [DATE] Resident have a pressure ulcer sacrum post debridement stage 4. Goal: Ulcer will heal without complications. Approach: Assess resident for pain related to pressure ulcer or its treatment. Prevent or treat pain by 1. Medicating and allowing time for effectiveness of medication. Checking back and if pain has resolved do wound care. If pain persists other pain meds will be considered by physician. Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization, and condition of surrounding skin. Conduct a systematic skin inspection weekly. Report any signs of any further skin breakdown (sore, tender, red, or broken areas). Keep clean and dry as possible. Minimize skin exposure to moisture. Keep resident off buttocks as much as possible. Problem start date [DATE] Resident on ABT for osteo[DIAGNOSES REDACTED] ([MEDICATION NAME]) Goal: Condition will resolve without any complications. Approach: Antibiotic therapy as ordered. Encourage fluids and adequate nutritional intake, monitor vitals every shift and notify MD/NP of any complications. In an interview on [DATE] at 9:10 am Resident #1's RP said he received a call last night around 9;00 pm from the facility explaining him options to move the resident to the LTACH (long-term acute care hospital). He said they told him they had a bed available in other facility to better treat the resident. He said I thought to myself was the her prognosis that bad that they wanted to dump her overnight. He said he refused to move her to another facility as he did not want to delay treatment any further. He said if he was to move the resident the facility would do their own set of cultures which would delay treating the wound. In an interview on [DATE] at 9:20am the Medical Director said he was not involved in the resident's wound care, the primary care doctor was over Resident #1's care. He said he was informed last night about osteo[DIAGNOSES REDACTED] and [MEDICATION NAME] was started as it is a broad-spectrum antibiotic. In an interview on [DATE] at 9:10 am LVN M said [MEDICATION NAME] was started last night around 10:00 pm for osteo[DIAGNOSES REDACTED]. She said nurses were responsible for completing the weekly skin assessments. She said she knew Resident #1 had a wound on her sacrum but was unable to describe type of wound/injury, its treatment orders or the condition. She said the Wound Care Nurse performed all the treatments. She said the Medical Director ordered STAT CBC, CMP and [MEDICATION NAME] trough level before starting the 3rd dose. In an interview on [DATE] at 9:20 am with the Weekend Supervisor, she said the Wound Care Nurse B informed her on [DATE] that the Resident was running a fever and the wound on her sacrum had drainage and a foul odor. She said she assessed the wound it had drainage and a foul odor. She said there were no notes from the Wound Care nurse with a change of condition, so she contacted the doctor and received an order to collect labs and wound cultures. She said when she came to work the following weekend on [DATE] and tried to check for the results of the wound culture, she was unable to retrieve them due to mislabeling. She said there was no follow up from Monday-Friday on cultures. She said she called the lab and was told she did not label the culture correctly therefore they were unable to run labs. She said she labeled the culture but was unaware that the lab had to place their own label on the culture as well. She said she called the doctor and received a new order to collect the wound culture again. She said UA results were clear, so the doctor ordered Doxycline [MEDICATION NAME] for fever and Bactrim started after the 2nd cultures. She said the nurses were in charge of follow up on labs/cultures

Based on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident #1) reviewed for pain management in that -Resident #1 cried and yelled from pain while being treated for [REDACTED]. -Resident #1's pain level assessment was inaccurately documented during wound care treatment. -Facility Staff failed to use appropriate pain scale and follow up method to adequately assess and monitor Resident #1's pain. -Other pain medication alternatives were not ordered for the resident until family intervention. An Immediate jeopardy (IJ) was identified on 9/13/19. While the IJ was lowered on 9/17/19, the facility remained out of compliance at a scope of isolated and severity of actual harm that is not immediate jeopardy due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one resident placing her at risk for continued unnecessary pain and at risk of not receiving necessary wound care treatment. Findings included: Record review of the admission sheet for Resident # 1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1 [DIAGNOSES REDACTED]. Record Review of Resident #1's comprehensive MDS assessment dated [DATE] revealed a BIMS of 03 indicating severely impaired cognitively. Staff assessment for mental status was conducted resident was unable to complete interview. Resident # 1 had short term memory problem, long term memory problem, and cognitive skills for daily decision making was severely impaired and she never/rarely made decision. Further review of the MDS revealed that she required extensive assistance from staff for one staff for dressing, toilet use and personal hygiene. Resident was incontinent of bowel and bladder. Section M revealed that the resident had 2 stage II pressure ulcers. Further review of Section J revealed Resident #1 did not receive scheduled pain medication regimen, should assessed for pain and was unbale to answer staff assessment questions for pain. MDS indicated staff assessment for was not conducted and pain indicators were not present. Record review of Resident #1's physician's orders [REDACTED]. dx: other chronic pain. Record review of Resident #1's physician's orders [REDACTED]. Notify physician / nurse practitioner for pain greater than 5. In an interview on 9/5/19 at 3:16pm with the Sitter A, she said she worked with Resident #1 Monday to Friday. She said she was Resident #1's private sitter. She said the resident was able to tell if she was in pain. Observation on 9/5/19 at 5:12pm revealed the Wound Care Nurse performed wound care on Resident # 1 assisted by CNA A and CNA B. Prior to initiation of the treatment, Resident #1 denied having pain. Resident #1 was assisted onto her right side. Observation revealed the dressing that was adhered to the Resident's back was dated 9/5/19. When the pressure sore wound dressing was removed from the Sacrum area, observation revealed a stage 4 to the sacral/ Coccyx area approximately 6cm in diameter. Stage 3 to the R buttock approximately 4 cm in diameter and unstageable to the L buttock approximately 3 cm in diameter there was 0.5 cm area of slough in the middle of the pressure ulcer. The Wound Care Nurse cleaned the center of the wound, and the Resident cried out in pain. The Wound Care Nurse cleaned the perimeter of the wound, and the resident yelled. The Wound Care Nurse asked the resident if she was in pain. The Resident said no. The nurse continued with the treatment. When the Wound Care Nurse dried the area with a dry 4 x 4-inch gauze, the resident cried out in pain again. The Wound Care Nurse asked the resident if she was in pain. The resident said yes. The Wound Care Nurse said she was going to stop the treatment and have the Med Aide medicate the resident for pain. Observation at this time revealed that the Med Aide administered two tablets of Tylenol to the resident. In an interview on 9/5/19 at 5:17pm with Medication Aide A, she said she did not ask Resident #1 what her pain level was. She said she assumed the resident's pain level was 5 as the resident was grimacing. She said she gave the resident two tabs of Tylenol 325mg as needed for pain at the request of the Wound Care Nurse. She confirmed the resident only had an order for [REDACTED].#1 Tylenol 325mg 2 tabs every day during her shift. She said usually CNAs would tell her that the resident was in pain after incontinent care was provided or she used her own assessment. Observation on 9/5/19 at 5:56 pm the Wound Care Nurse started the treatment again. The resident cried out in pain. The wound care nurse said the resident had received Tylenol, but it was not helping with the pain. The Wound Care Nurse said she was unable to complete the wound care for the resident as she was still in pain. She said she will ask the resident's nurse if the resident had other PRN pain medications ordered and will cover the wound with dressing. She said she covered the wound with dry dressing and informed the nurse to reassess her pain later. She said she would do the dressing change tomorrow as scheduled. In an interview on 9/5/19 at 6:15 pm CNA C said she worked full time at this facility during the 2-10pm shift. She said Resident #1 had a wound on her bottom. She said the resident complained of pain while CNAs provide incontinent care or reposition her. She said Resident #1 was alert and verbal when you asked her where the pain was located, and she would point to her back and said it hurt a lot. Record review Resident #1's MAR for (MONTH) 2019 revealed that on 9/5/19 noted '0' pain for the shift, even though Resident #1 cried in pain when Wound Care nurse performed wound care that shift. Record review of Resident #1's (MONTH) and (MONTH) 2019 MAR indicated [REDACTED]. Record review of Resident#1's nurses notes for (MONTH) 2019 revealed there was no documentation that the resident was receiving medication or non-pharmacological intervention for pain prior to wound care daily or that the physician was contacted to address pain management for the resident. After surveyor's intervention, the following physician's orders [REDACTED].#1's chart: Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's care plan revealed a new care plan for problem start date 9/9/19 Resident has complaints of chronic pain r/t wound care. Pain site(s): left and right buttocks and sacrum. Goal: Resident will verbalize reduction of pain. Approach: Administer medication: Monitor and record effectiveness. Report adverse side effect. Evaluate effectiveness of pain management interventions. Adjust if ineffective or adverse side effects emerge. Monitor and record any non-verbal signs of pain: (e.g. crying, guarding, moaning, restlessness, grimacing, diaphoresis, withdrawal, etc.) Observation on 9/13/19 at 10:34 am revealed the Wound Care Nurse performed wound care on Resident # 1 assisted by CNA D. Prior to initiation of the treatment, Resident #1 denied having pain. Resident #1 was assisted onto her right side. Observation revealed the dressing that was adhered to the resident's back was dated 9/12/19. When the pressure sore wound dressing was removed from the Sacrum area, the resident cried out in pain. The Wound Care Nurse said resident had received her pain medication an hour ago. She said the resident wanted to eat her breakfast, so she had to wait. She said she was going to see if the resident had anything for breakthrough pain. She said she was unable to perform the wound care treatment at this time. Record review Resident #1's Medication Administration Record [REDACTED]. In an interview on 9/13/19 at 10:55am CNA D, said she worked full time at this facility. She said Resident #1 would complain of pain when the aides provided incontinent care or reposition her. She said she reported to the Medication Aide whenever the resident complained of pain. In an interview on 9/13/19 at 12:02 pm the NP said Tylenol 325mg 2 tabs were standard for all the residents for pain. She said a sacral pressure ulcer's pain was controlled with the Tylenol. She said if a resident had an infection to the wound and the resident started complaining of pain the nurses need to communicate so the medication could be changed. She said [MEDICATION NAME] was ordered on [DATE] for Resident #1. Surveyor discussed findings of the wound care observation on 9/5/19 and 9/13/19 and how the resident cried out in pain and the Wound Care Nurse was unable to perform the treatment. The NP said Resident #1 required [MEDICATION NAME], but she would not be able to order that and only doctors could order that. She also said Resident #1 has dementia. She said residents with dementia perceive everything associated to fear as pain. She said even when you provide care to them they will perceive as pain. She said, It is in their head. In an interview on 9/13/19 at 5:20 pm with the Administrator, COO, DON and ADON, the COO said Resident #1 had these behaviors and even when staff provide incontinent care to the resident, she complains of pain. The Surveyor explained if that was an associated behavior it was not documented in the resident's chart, nurses' notes or care plan. In an interview on 9/14/19 at 9:01am Medication Aide B, she said she worked full time at this facility. She said Resident #1 had scheduled [MEDICATION NAME] and Tylenol as needed for pain. She said Resident #1 had a private sitter who would come and tell her if the resident was in pain. She said the resident was able to tell when asked if she needed pain medicine. The resident would say it hurt really bad and would point to her legs or back. In an interview on 9/14/19 at 9:10 am Resident #1's RP said he was contacted and told that the doctor was able to observe the wound care and Resident #1 cried in pain. He said the resident was on [MEDICATION NAME] which does not manage the resident's pain. He said [MEDICATION NAME] usually works for her, so the doctor ordered [MEDICATION NAME] before treatment. In an interview on 09/14/19 at 9:20 am the Medical Director said as per Resident #1's RP, [MEDICATION NAME] worked in managing her pain. He said since [MEDICATION NAME] was no longer available, he ordered [MEDICATION NAME] BID and PRN for the resident. He said residents with dementia cannot tell you if they were in pain, so they express pain differently. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's physician's orders [REDACTED]. Record review of facility's Pain Assessment and Management (reviewed 8/1/16) read in part: .Policy: Residents with acute or chronic pain will be assessed, treated with pharmacologic and/or nonpharmacologic interventions. Nursing staff will be familiar with assessing dementia residents who are experiencing pain. Pain intervention must be individualized. The medical plan of care is directed by the physician (s) managing the resident in collaborative with the resident and the healthcare team. Procedure: III. The pain assessment should be based on the resident's self-report, both objective and subjective. Note facial grimacing, resistance to touch. IV. Nursing is to be cognizant of dementia residents' expressions of pain-fidgeting, groaning, resistant to care, facial grimacing, resistant to touch, striking out, non-verbal cues, body language. IX. If there is no pain relief the provider is contacted and updated . Record review of the Alzheimer's Association Best Practices in Nursing Care to Older Adults issue titled Assessing Pain in Older Adults with Dementia accessed on 9-24-19 read in part: .STRENGTHS AND LIMITATIONS: Pain is a subjective experience and there are no definitive, universal tests for pain. For patients with dementia, it is particularly important to know the patient and to consult with family and usual caregivers. BARRIERS to PAIN MANAGEMENT in OLDER ADULTS with DEMENTIA: There are many barriers to effective pain management in this population. Some common myths are: pain is a normal part of aging; if a person doesn't verbalize that they have pain, they must not be experiencing it; and that strong [MEDICATION NAME] (e.g., opioids) must be avoided.SUMMARY: An effective approach to pain management in older adults with dementia is to assume that they do have pain if they have conditions and/or medical procedures that are typically associated with pain. Take a proactive approach in pain assessment and management. The use of a standardized pain assessment tool is important in measuring pain. It enables health care providers to document their assessment, measure change in pain, evaluate treatment effectiveness, and communicate to other health care providers, the patient, and the family . The Administrator, COO, DON and the ADON were notified of the IJ on 9/13/19 at 5:25pm due to the above referenced failures. A Plan of Removal was requested at that time. After several revisions the plan was accepted on 09/16/19 at 10:26 am. The plan read in part: . Resident developed stage IV sacral pressure ulcer that needed debridement and now has [DIAGNOSES REDACTED]. Surveyor believes one resident was put at risk for .and severe pain . 1. Nursing staff will be in-serviced on the following: . B. In-service Licensed Staff on pain assessment, appropriate intervention and documentation. 1. .Medical Director, will review the resident's current clinical condition to determine the best course of treatment at this time. 2. Measures to correct the surveyor's observation are the following: 2.1 The Medical Director will assess all residents wounds and update treatment plan if necessary. 2.2 The Medical Director will observe selected residents wound treatments to immediately address any pain issues if necessary .a complete skin assessment within the past 7 days. Any abnormal results will be resulted in a new skin assessment. 4. The Director of Quality and Designee will in-service CNA's on: a) Identifying skin changes during ADL care and reporting to nurse. b) Assessing and identifying pain during ADL care and reporting to nurse. 5. The Director of Quality and Designee will train all nursing staff on assessing and reporting unresolved pain management to medical staff . 1. The DON will observe the treatments of any resident expressing pain when observed on Saturday (MONTH) 14, 2019. These observations will be discusses with the Medical Director. 2. The Medical Director will determine if the pain treatment plan requires modification. 3. The DON will observe the wound care treatments for residents with wounds to insure that individualized plan of care and pain is affective. The Care Plan will be updated as required 3. Starting the evening shift nursing staff will be prohibited to work until the Trainings and In-services mentioned in this plan of removal has been completed . Following acceptance of the facility's Plan of Removal, the facility was monitored from 9/13/19 to 9/17/19. In an interview on 9/15/19 at 9:10 am LVN M, she said Resident #1 was able to express pain to some extent. If the resident was in pain she would cried out Ouch. In an interview on 9/17/19 at 3:50 pm with the Quality Assurance Director, he said CNAs were in serviced on how to prevent and report any new issues to the nurse immediately and if the resident complained of pain stop what they were doing and to get the nurse. Record review was conducted of the facility's in-services that had been initiated for Licensed Nurses, CNAs and Medication Aides. Documentation of the following was reviewed: Documentation of in-services for Licensed Nurses from 9/13/19 to 9/17/19 on the topics of pain assessment. Nurse aide proficiency on pressure ulcer prevention and care in services documentation form 9/14/19 to 9/17/19. Interviews were conducted with 2 ADONs, 1 MDS Nurse, 2 RN, 4 LVN, 2 medication aide, and 19 CNAs from different shifts to verify the in-services had in fact been conducted and to validate the staff understanding of the information presented to them regarding pain management. No concerns found. The Administrator was notified that the IJ was lowered on 09/17/19 at 5:23 pm however, the facility remained out of compliance at a severity of level of actual harm that was not IJ and a scope of isolated due to the facility needing more time to monitor the plan of correction effectiveness.

Based on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for one (Resident #1) of 6 residents reviewed for therapeutic diets. - LVN A did not follow Resident #1's physician ordered for a pureed diet and gave the resident cookies. Resident #1 started chocking and was transferred to the hospital where she was diagnosed with [REDACTED]. This failure affected 1 resident placing her at risk of choking and aspiration pneumonia. Findings include: Resident #1 Record review of Resident #1's face sheet revealed that the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted to the facility 04/18/2019. Resident #1's [DIAGNOSES REDACTED]. Record review of Resident #1's Significant Change MDS assessment dated [DATE] Section C1000: she was coded as a 3 indicating she was severely impaired for Cognitive Skills for Decision Making. In Section G: Functional Status Resident #1 required Supervision (oversight, encouragement or cueing) with one person assisted for eating and extensive assistance from two plus staff with bed mobility, transfer, dressing and personal hygiene. Resident #1 uses a wheelchair for mobility. Section 0K510. Nutritional Approaches coded Resident #1 as having a mechanically altered diet- required change in texture of food or liquids (e.g. pureed food and thickened liquids) and a therapeutic diet (e.g. low salt diabetic, low cholesterol). Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's Dietitian's Medical Nutritional Annual Assessment Therapy dated 11/13/18 read in part: . Nutrition and Diet Orders: Feeding: Resident needs cueing and assistance. Oral Issues Problems: Chewing and swallowing problems. Diet: NAS, NCS, Puree and Nectar Liquids. Nutrition Diagnoses: [REDACTED]. Record review of the care plan for Resident #1 that was reviewed and revised on 11/13/2018 documented that Resident #1 has diagnosed of chewing and swallowing and requires a mechanical altered diet. The Goal was for Resident #1 to have no signs and symptoms of dysphagia, choking or aspiration. Plan: Continue mechanical altered diet and monitor for tolerance. Record review of the Provider's Incident Report dated 04/14/19 read in part: . Nurse gave Resident some small pieces of cookies, she was eating them and started choking, unable to breath, staff performed the [MEDICATION NAME] Maneuver, she was put on O2, Then Resident #1 started vomiting pieces of the cookies and after that she started breathing on her own. Other staff had notified the doctor and the resident's family. 911 was called and she was taken to the hospital for further evaluation . Record review of Resident #1's hospital emergency room admission notes dated 4/14/2019 read in part: . patient was admitted from the nursing home with cough and shortness of breath found to have aspiration pneumonia. Patient [MEDICAL CONDITION] due to aspiration pneumonia versus pneumonitis. Patient was treated empirically with [MEDICATION NAME] and [MEDICATION NAME]. At this time leukocytosis and fever has resolved. Patient has dysphagia. Patient passed swallow evaluation by speech therapy and can have dysphagia pureed diet with thin liquids . In an interview with MA B on 5/17/19 at 10:30 AM she said she had just gotten to work on 04/14/19 and saw Resident #1 sitting at the table. She said she went over to her to say good morning, and she noticed brown crumbs on the resident's clothes and a piece of what she thought was a cookie on the floor. She said she immediately asked the nurse who gave Resident #1 cookies to eat as she was on a pureed diet. She said the nurse said she did and that the resident was alright. MA B said she went to put her stuff down when CNA D called her stating that Resident #1 was not looking good. She said she went over to the resident and noticed she was changing color she said she tried to talk to her, but she looked like she was choking. She said she told CNA D to stay with the resident while she was screaming for the nurse to come for Resident #1 was choking. She said CNA D started doing the [MEDICATION NAME] Maneuver and pieces of cookie came out of Resident #1's mouth. She said the resident stopped breathing, but at that time the nurses came and took over and 911 had been called and the resident was sent to the hospital. In an interview with the Charge Nurse on 05/17/19 at 10:45 AM regarding residents on therapeutic diets, she said that the nurses who work on that hall knew all the residents and their diets. She said the residents on therapeutic diets were listed in a book at the nurse's station and they were color coded on their doors. She said because of the renovations the doors may have not been up to date. She said during meal times the nurses would check the cart to ensure that residents were receiving the correct diets. She said the MA's usually gives out the snack. She said she did not know what happen and why the nurse gave the resident that snack. Record review of the CNA Assignment Book book at the nurse's station revealed different colors indication different types of therapeutic diet. Purple = thickened Liquids and Blue = pureed diet. Resident #1's name was included on the list with residents receiving pureed diet. In an interview on 5/17/19 at 11:30 AM with the ADON regarding Resident #1 having a [MEDICATION NAME] Swallow test done recently she said no test had been done recently. She said she had been working at the facility for over six years and the resident always received a pureed diet. She said if a [MEDICATION NAME] swallow was done it was probably a long time ago and it would be in her thinned record. In an interview with CNA D on 5/17/19 at 3:50 p.m. she said she went to work the morning of 4/14/19 and Resident #1 was choking and saw her sitting at the table. She said she noticed she had changed color and call MA B to come look at her. She said she started the [MEDICATION NAME] maneuver because the resident was choking, and pieces of cookie came up. She said it seemed as if the resident had stopped breathing, the nurses came and they put her on the floor, took over and 911 was called and she was transported to the hospital. Observation on 5/17/19 at 10:30 AM revealed Resident #1 was observed in the dining room eating snack. She was alert with confusion. Her meals consisted of pureed snack with nectar thickened liquids. Observation and record review on 5/17/19 12:47 PM revealed Resident #1 was observed in the dining room eating lunch. Her meals consisted of pureed diet with nectar thickened liquids. Resident #1's meal ticket revealed pureed diet with thickened liquids. Observation and record review on 5/17/19 5:30 PM revealed Resident #1 was observed in the dining room eating dinner. Her meals consisted of pureed diet with nectar thickened liquids. Resident #1's meal ticket revealed pureed diet with thickened liquids. In an interview with LVN A on 5/17/19 at 6:00 PM she said the morning of the incident Resident #1 was complaining that she was hungry. She said she put the fig cookies on the table and Resident #1 picked them up and ate them. She said she knew that Resident #1 would eat them. When asked, she said she knew Resident #1 was on a pureed diet with nectar thickened liquids. She said she was going to get some thickened milk to pour on the fig to soften it to give to the resident, but she I don't know what I was thinking because I normally would give Resident #1 thickened liquids and pureed food Record review of the Quality Assurance ad hoc meeting attended by the DON, ADON, Administrator and Heads of Departments dated (MONTH) 2019, after the incident occur with Resident #1 revealed in part: Dietary Plan: Staff were in-serviced : Continue to monitor diets, weight per policy and procedures and make changes as recommended with physician's orders [REDACTED].>Action Plan: - Review new diet plan/menu In an interview with the DON on 5/17/19 at 6:15 PM she said LVN A was reprimended and re-inserviced. She said the staff was in-service on ensuring that residents received the proper diets as order and the safety of proper diet including pureed or mechanical soft. She said she did not know why LVN A gave the resident the cookies. Record review revealed the facility in-service record dated 04/14/19 and 04/15/19 revealed staff were in serviced on the Importance of following the proper diet and Diet Safety. Further record review revealed that LVN A participated in the training. Record review of Nutrition and Dining Services, Policy and Procedures revised 01/01/2019 read in part: .Purpose: To provide therapeutic diets and specific recommendations to meet the nutritional needs, medical and religious restrictions, personal likes, dislikes and taste of each resident. The Academy of Nutrition and Dietetics recommends that long term care facilities liberalize therapeutic diets to maximize meal intake of residents who are at nutritional risk . Procedures: Diets will be ordered by the doctor at admission. d. All diet orders should reflect the nutrient & consistency modification as needed by the resident, i.e., Regular Diet, Pureed NCS, Honey Thickened Clear Liquid. Mechanically Altered Diets: c. Puree i. All food pureed to a consistency that requires little or no chewing. d. Thickened liquids i. Will be distributed to residents according to the recommendation of the Speech Pathologist or per physician's orders [REDACTED].> ii. Nutrition and Dining Services will use commercially thickened drinks iii. Soups & other liquids will be thickened with a thickening agent iv. Nectar or honey thickened liquids will be specific with all diet orders .

Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed for accidents. (CR #1) CNA-A transfer CR #1 without a Hoyer lift and according to the plan of care. As a result CR #1 sustained a femur fracture. This failure affected 1 resident and place 9 residents in Miller Unit that require assistance with transfers at risk of accidents resulting in injuries. Findings include: CR #1 Record review of CR #1 face sheet revealed a [AGE] year old female who was originally admitted to the facility on [DATE] with the following diagnoses; muscle weakness, unspecified, [DIAGNOSES REDACTED] unspecified [MEDICAL CONDITION], essential (primary) hypertension, long term (current) use of anticoagulant [MEDICAL CONDITION] with behavioral disturbance, constipation unspecified, [MEDICAL CONDITION] unspecified, age related [MEDICAL CONDITION] with current Pathological Fracture of Right Femur. The resident was discharged to the hospital on [DATE]. Record review of CR #1 quarterly Minimum Data Set ( (MDS) dated [DATE] revealed a BIMS score of 9 indicating moderately Impaired cognitive skills and required extensive assistance with two person physical assisted for transfers, bed mobility, locomotion on unit, dressing, toilet use, and personal hygiene. Further record review of CR # 1 MDS revealed the functional limitation in range of motion is impaired on both sides on the lower extremity. Record review of CR #1 Care Plan dated 07/20/17 and revised 02/14/18 revealed CR #1 had a transfer deficit secondary to lower muscle weakness/rigidness, non-weight bearing with transfers' weakness. Interventions included to use a standing lift, monitor extremities to avoid injury. The approach was to use full staff performance using full body lift with transfers 2 persons. Record review of an Incident Report on CR #1 dated 3/26/18 revealed that on 03/26/18 at 10:35 a.m. , Certified Nurse Aide (CNA B) reported to Assistant Director of Nurses (ADON) B that she noted CR #1's right leg swollen and had some discoloration. CR #1 complained of pain to right knee when touched. ADON B assessed CR #1 head to toe. CR #1 was medicated for the pain and the Nurse Practitioner (NP) was notified. The NP gave orders for X-ray rule out fracture. Record review of a statement completed by CNA A dated 03/27/18 revealed in part: at 5:00 am (on 03/26/18) .attempted to put her in the chair her leg gave away and I slide her to the floor .on the mat .I called the nurse to help me .never complaint of pain so I though she was fine . The following was the X-ray result: Record review of X-ray result dated 3/26/18 revealed: Right Femur min 2 views and Tibia/Fibula anterior and lateral The images and report compared with prior studies most recently dated 5/17/2017. The conclusion was proximal tibia and fibula, new from before. CR #1 was transferred to a local hospital. In an interview on 3/28/18 at 2:20 p.m. ADON A said CNA A should have used the Hoyer lift to transfer CR #1. Record review of the facility list of resident requiring Hoyer lifts on the Miller Unit (no date) revealed that CR #1 was on the list as requiring a Hoyer lift with two person assist. In an interview on 3/28/18 at 2:30 p.m. ADON B said that CR #1 required a Hoyer lift to be assisted out of the bed to the wheelchair. She said that CNA A did not use the Hoyer lift on the day (3/26/18) of the incident as she was supposed to. She said that she was the one that assessed the resident on 03/26/18, called the MD that requested the x-ray. In an interview on 3/28/18 at 2:34 p.m. LVN A said about CR #1's incident on 03/26/18 that at around 5:00 am he was in another resident's room, when CNA A called him to CR #1's room and he saw the resident on the floor. CNA A said to him that she was getting CR #1 up and out of bed and transferring to the wheelchair that morning and CR #1 leg was giving out and she lowered the resident to the floor. LVN A said CR #1 was among the residents they always took to the Dining Room to eat breakfast. LVN A said he assessed CR #1 and she denied any pain at that time. He said that CNA A always transferred CR #1 by herself. He said he used to work in another unit and that he did know CR #1 was two person transfer with Hoyer lift. An attempt was made to interview CNA A by phone on 03/28/18 but there was no response. Record review of the facility in-services revealed the following: - 03/26/18 for transfers. Further review of the form sign-in sheet revealed that CNA A had not sign as attending the in-service. According to the list provided by the facility, 10 residents require use of a Hoyer lift in Miller Unit.

Based on observation, interview and record review the facility failed to provide services in accordance with the written plan of care for 2 of 5 residents reviewed for plan of care. (Resident #1 and #3) --Resident # 3's dressing to lower left extremity was not changed daily according to physician order. - CNA-A did not follow the facility plan of care to use a standing lift during transfer for Resident # 1. As a result Resident #1 had a fall and sustained a femur fracture. This failure affected 2 residents and place 101 residents in two units at risk of a decline in their health and well being. Findings include: Resident #1 Record review of Resident #1 face sheet revealed a [AGE] year old female who was originally admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses; Age Related [MEDICAL CONDITION] with current Pathological Fracture of Right Femur, Chronic Pain, Dental Procedure Status, Candidiasis, Hypertension, [MEDICAL CONDITION], Urinary Tract Infection, Alzheirmer ' s Disease, Gastro-[MEDICAL CONDITION] Reflux Disease without Esophagitis, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Observation on 12/07/16 at 9:05 a.m. revealed resident #1 in the hallway in her wheelchair. She was clean and groomed and without odor. Resident #1 was alert and oriented to name. An interview was attempted at that time but Resident #1 was unable to response appropriately. Record review of Resident #1 MDS dated [DATE] revealed a BIMS score of 2 (Severely Impaired cognitive skills) and required extensive assistance with one person physical assisted for transfers, bed mobility, locomotion on unit, dressing, toilet use, and personal hygiene. Further record review of Resident # 1 MDS revealed the functional limitation in range of motion is impaired on both sides of lower extremity. Record review of Resident #1 Care Plan dated 06/23/16 and revised 12/01/16 revealed Resident #1 had a transfer deficit secondary to bilateral weakness. Interventions included to use a standing lift, monitor extremities to avoid injury. The approach was to use 1-2 CNA's to transfer using the lift. Record review of an Incident Report on Resident #1 dated 11/19/16 revealed that CNA-A was attempting to transfer resident from bed to the wheelchair, unable to complete transfer and that Resident #1 was lowered to the floor. Resident # 1 later complained of pain and an X-ray of the right knee was ordered. The X-ray results of right knee showed no fracture. On 11/22/16 Resident #1 complained of pain again, was medicated for the pain and the NP was notified. The NP gave orders for another X-Ray that revealed a distal femur fracture. According to the X Ray the bones appared diffusely demineralized. Record review of x-ray result dated 11/22/16 revealed: Right HiP Uniliteral W Pelvis 2- V, RT Femur min 2 views The images and report of right knee examination dated November 22, 2016 have been reviewed and compared with prior studies most recently dated November 19, 2016. The fracture the distal femur demonstrated on the current examination is correctly reported. The report includes a statement that the fracture is new compared to the most recent prior study dated November 19, 2016. Record review of Resident # 1 Nursing Notes dated 11/19/16 revealed that at 8:45 a.m. LVN-B was called to Resident #1 room and found Resident # 1 on the floor. CNA-A told LVN-B that Resident # 1 was going to fall and she lowered the resident to the floor. Resident was helped up in wheelchair by 3 of the staff. Resident #1 later in the dining room complained of knee pain. Interview on 12/07/16 at 11:10 a.m. with CNA-A she said she that on 11/19/16 she tried to get Resident #1 up and out of bed to be transferred to the wheelchair that morning to take to the Dining Room to eat breakfast. CNA-A said she assisted Resident #1 in bed to the sitting position on the side of the bed and put her hands underneath Resident #1 armpits and had Resident #1 to place her hand and arms on top of her shoulders. CNA-A said she then proceeded to assist Resident #1 to the standing position to transfer resident to the wheelchair. CNA-A said that during the transfer, Resident # 1 began not to continue standing and she realized that Resident # 1 was beginning to fall. CNA-A said she eased Resident #1 down to the floor at the bedside and put a pillow behind her head and left to go and get help. She said it was her first time working on that Unit and that she did not know that the resident needed a standing lift for transfers. Interview on 12/07/16 at 12:35 p.m. with LVN-B and ADON-C both said that Resident #1 required a standing lift to be assisted out of the bed to wheelchair and that CNA-A did not use the standing lift on the day (11/19/16) of the incident as she was supposed to. Interview on 12/07/16 at 4:20 p.m. with DON-E saying CNA-A should have used the standing lift to transfer Resident #1. Resident #3: Record review of Resident # 3 face sheet revealed a [AGE] year old female who was admitted to the facility on [DATE] with the following diagnoses; Diabetes Mellitus, Hypertension, Dyspepsia, Agitation, Cough, Vitamin D Deficiency, Urinary Tract Infection, Chronic Pain, [MEDICAL CONDITION], Depression, and Gastro-[MEDICAL CONDITION] Reflux Disease. Record review of Resident # 3 MDS dated [DATE] revealed a BIMS score of 14 indicating she was cognitively intact and required supervision with activities of daily living. Record review of Resident # 3 Physician orders [REDACTED]. Observation on 12/07/16 at 2:45 p.m. of Resident # 3 revealed she was sitting in the door way of room in a wheelchair. Her left pant leg was raised up to the knee exposing a dressing to the lower left extremity. She had a dressing that was dated 12/04/16. Interview on 12/07/16 at 2:45 p.m. LVN-D who was standing in the hallway said she was getting ready to change the dressing to Resident #3 lower left leg. LVN-D said the dressing to Resident #3 lower left leg was to be changed daily at 10:00 a.m. Observation on 12/07/16 at 2:55 p.m. of LVN-D removing the old dressing to Resident #3 lower left leg. The old dressing with a small amount of dry pale yellow drainage. The wound site to Resident # 3 lower left leg had 2 small open areas. Interview on 12/07/16 at 2:55 p.m. LVN-D said she took care of Resident # 3 on 12/05/16 and 12/06/16. When asked why was Resident #3's dressing not changed, LVN-D shook her head and said, I don ' t know, I guess I got busy. Interview on 12/07/16 at 4:45p.m. DON-E said when a Physician gives an order for [REDACTED]. Record review of Resident #3 MAR for the month of December 2016 dated 12/05 and 12/06 revealed that LVN-D had documented that Resident # 3 dressing change to the left lower leg was being done. According to Facility room roster for Cohen Unit and Wolf Unit revealed a census of 103.

Based on observation, interview and record review the facility failed to ensure 1 of 21 residents (Resident #1) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: --Resident #1 was groaning in pain during wound care and treatment was not stopped. ulcer. This failure affected 1 resident and placed 14 other residents with pressure ulcers at risk of a diminish quality of life, increased risk for pain and decline in overall well-being. Findings include: Resident #1 Record review of Resident #1's face sheet revealed an [AGE] year old female with an admission date of [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Significant Change MDS assessment dated [DATE] revealed a BIMS score of 3 indicating she had severely impaired desicions skills. Resident #1 need extensive assistance of one person for ADL's in areas for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Resident #1 was also incontinent of bowel and bladder. Further record review of the MDS assessment dated [DATE] revealed that under Section M, Resident #1 was coded as having four Stage II Pressure Ulcers. Further review of Section J revealed Resident #1 received schedule pain medication regimen. Record review of the Interdisciplinary Care Plan, dated 06/30/16, revealed Resident #1 had been identified with wound to her left lateral foot. An update to the care plan, dated 06/23/16 revealed Resident #1 had also been identified with a right heel wound which was a deep tissue injury (and, therefore, unstageable). Interventions included: perform treatment as ordered by the physician, monitor for healing and notify the doctor of changes. Observation on 07/14/16 at 8:30 a.m. revealed Wound Care Doctor A and Treatment Nurse LVN C providing pressure sore treatment for [REDACTED]. The Wound care Doctor removed the soiled dressing from Resident #1 Left foot and started cleaning Resident #1 ' s wound. Resident #1 started groaning and pulling her left foot. Neither the Wound Care Doctor A nor the Treatment Nurse LVN C asked Resident #1 if she was in pain they just said they would soon be finished. The Wound Care Doctor proceeded to clean Resident #1 ' s right heel and Resident #1 started groaning and pulling her right foot again and still no one asked if she was in pain. Record review of the physician's recapitulation order for July 2016 revealed an order dated 4/25/16 stating that Resident #1 should receive [MEDICATION NAME] 50 mg two times at day 8:00 a.m. and 5:00 p.m. and another order dated 7/13/16 for [MEDICATION NAME] 50 mg 30 minutes before treatment. During an interview with MA D on 7/14/16 at 9:00 a.m., she said scheduled [MEDICATION NAME] 50 mg was given at 8:00 a.m. to Resident #1. The treatment was done at 8:30 a.m. for Resident #1. In an interview with Treatment Nurse LVN C on 7/14/16 at 9:05 a.m. she said that Resident #1 received [MEDICATION NAME] 50 mg two times a day. She said [MEDICATION NAME] 50 mg was given at 8:00 a.m. and then again at 9:30 a.m. after the wound treatment. She further said that she should have asked Resident #1 if she was in pain, when she started groaning and pulling her foot. She did not mention that Resident #1 should be given [MEDICATION NAME] 50 mg 30 minutes before treatment. In an interview on 07/14/16 at 9:20 am, the ADON B she said that the staff should have given Resident #1 pain medication since it stated she should get it 30 minutes before treatment. She said that she was going to ask the doctor to change the order to 100 mg in morning before treatment so there would be no misunderstanding. Record review of the facility policy for Dressing Change protocol dated 06/02/15 revealed in part: . Procedure 1. Explain procedure to resident and assess for pain. If resident complain of pain administer pain medication. Before treatment begins allow time for medication to become effective. Ask resident if there is pain relief . Record review of the Facility Policy for Pain assessment and Management dated 7/22/14 revealed in part. Policy: Resident with acute or chronic pain will be assessed and treated with pharmacological and or non-pharmacological interventions. Procedures: 2. The assessment shall be based on the resident's self-report, facial grimaces from observations and or resident's behavior . The facility's CMs 672 revealed there where 15 residents with pressure sores.

Based on observation, interview and record review the facility failed to implement their written policy and procedure that prohibits neglect for 1 of six residents reviewed for abuse and neglect. (Resident #1) - On 04/21/15 Certified Nurse Aide (CNA) A transfered Resident #1 from the shower chair to the motorized wheelchair without the assistance of another staff member as required by the care plan. Resident #1 sustained an acute displaced [MEDICAL CONDITION] hip and acute fracture involving the right proximal femur. This failure affected 1 resident and placed 9 additional residents in the Miller unit requiring assistance with full body transfers at risk for injury and unnecessary pain. Findings include: Resident #1: Review of the face sheet for Resident #1 revealed that he was [AGE] years old. He was admitted on [DATE], readmitted on [DATE] and 04/29/15. His [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Annual Minimum Data Set assessment completed on 11/15/14 and his Quarterly MDS assessment dated [DATE] revealed he required total assistance of two staff for transfers and had limitation of movement on both upper and lower extremities. Record review of Resident #1's care plan dated originally dated 11/28/14 and updated on 02/19/15 for activities of daily living (ADLs) revealed he required total assistance with transfers using a Full-Body lift with an extra-large sling and assistance of 2 CNA ' s for transfers. His care plan for transfers deficit due to [MEDICAL CONDITION] and [MEDICAL CONDITION] dated 11/28/14 and updated on 02/19/15 revealed he required 2 CNA ' s to transfer using a Full-Body lift with an extra-large sling. Review of the facility incident report dated 4-21-15 revealed Resident #1 required total assistance with transfers and was interviewable. The description of the allegation was " While CNA was transferring resident from the shower chair to power wheel chair using lift, the sling hooks broke and the resident fell to the floor " . The resident was assessed and transferred to his wheelchair. The physician did a full assessment and an x-ray was ordered. Staff was interviewed, statements were taken and in-services on all units re: the proper use of lifts and slings was completed. The x-ray results came back positive for fracture, the resident was medicated for pain and transferred to the hospital. Additional in-services were completed with all staff on proper use of lifts and slings, checking equipment prior to use and checking resident ' s plan of care. A Sling Log was developed for checking sling condition. Any slings not in good working condition were removed. Observation and interview on 05/06/15 at 9:50 am Resident #1 was sitting in his motorized wheelchair in his room. He said on 04/21/15 he was transfer from the bed to the shower chair by 2 CNAs and then taken to the shower in a shower chair by (1) CNA. When CNA A finished showering him she picked him up in the lift. She was by herself. He said the strap to the sling was frayed at the plastic part of the sling that connected it to the lift. He said the CNA was transferring him to his motorized wheelchair, he was 3 feet up in the air and the sling broke at the connection. He said he fell to the floor of the shower room. He said he had never felt that much pain in his life. He said he was taken to the hospital, his right hip was cracked and his femur was broke in 2 places. He said he had surgery, they put a pin in his hip, replaced his femur with a steel rod and he currently still had staples in his leg. Interview on 05/06/15 at 3:30 p.m. CNA A said Resident #1 received showers 3 times each week. She said she assisted with Resident #1 ' s shower on 04/21/15. She said the sling for his transfer was lying in his chair next to his bed, that the staff earlier in the day had used it to transfer him to his bed. She said she inspected it and did not see any frayed areas. She said CNA B assisted in Resident #1's transfer from the bed to the shower chair. She said CNA B accompanied them to the shower room, but she left the shower room to attend to another resident. CNA A said she did not wait for CNA B to return and she transferred Resident #1 by herself. She said she knew he was a 2 person transfer, but she had done it by herself before and thought she could manage it. She said that while transferring Resident #1 the tab tored/ripped, the plastic part was still attached to the lift and Resident #1 fell to the floor on his bottom with his back against the wheelchair. She said she called for help and the nurse came to assist them. She said Resident #1 was assessed, he complained of pain, he was transferred to his motorized wheelchair and he propelled himself back to his room. She said she was suspended for 3 days due to the incident. During an interview on 05/07/15 at 9:30 a.m. the Administrator of Health Services said the facility had in-serviced staff after Resident #1's fall in 04/2015. She said they had met with the management staff again that morning and re-trained the night staff regarding lift transfers and using 1-2 staff for each transfer as stated in their care plans. She said the facility developed a new system and now required the nurse's to monitor lift transfers of residents requiring 2-staff. She said when the resident care plans required 1-2 staff as needed, the number of staff that would be used for a transfer was determined by the CNA's and nursing according to each resident ' s condition or change in condition. She said the nursing staff would notify their supervisor if a resident became anxious or combative or if any other changes in condition occurred. During an interview on 05/07/15 at 10:40 a.m. with the Therapy Services Director she said the therapy department would in-service nursing staff regarding resident transfers if the resident had a change in condition or change in handling during transfers. She said PT A in-serviced nursing staff after Resident #1 ' s fall due to the change in transferring technique due to his fracture. PT A said he in-serviced the nursing staff by demonstration of transferring Resident #1 to/from his bed and motorized wheelchair. He said he concentrated on the safety of the transfer. He said the nursing department determined whether the resident's transfer required 1 or 2 staff to assist in the care plan. Record review of the Resident ' s Requiring Lifts sheet posted at the Miller Unit nurse ' s station dated 03/10/15 revealed: Resident #1, Type of Lift: Full-Body/2-Person, size 2X. Record review of the facility in-services revealed the following: - 05/06/15 Complying with (2)-person assists for transfers. Record review of the facility policies revealed Abuse Protocol for Assessment and Prevention dated 03/01/14: Policy - Each resident has the right to be free from abuse, corporal punishment, involuntary seclusion, mistreatment, neglect... Neglect means the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. It is a deprivation of life's necessities of food, water, or shelter, or a failure of an individual to provide services, treatment, or care to a resident which causes or could cause mental or physical injury, or harm or death to the resident. Neglect may include self-neglect or caregiver neglect. The Daily Census Report revealed 56 residents in the Miller Unit, with a total facility census of 279.

Based on interview, observation and record review the facility failed to ensure that the resident environment remained as free of accident/hazards and received adequate supervision and assistance devices during transfers for 1 of 10 residents reviewed for prevention of avoidable accidents and injuries. (Resident #1). - On 04/21/15 Certified Nurse Aide (CNA) A transfered Resident #1 from the shower chair to the motorized wheelchair using a Full-Body Lift without the assistance of another staff member as required by the care plan. - Resident #1 was transferred via Full-Body Lift, the sling hooks broke and the resident fell to the floor. - Resident #1 sustained an acute displaced fracture of the right hip and acute fracture involving the right proximal femur. These failures caused pain and injury to Resident #1 and placed 9 other residents in the Miller Unit requiring assistance with full body transfers at risk for injury and unnecessary pain. Findings include: Resident #1: Review of the face sheet for Resident #1 revealed that he was [AGE] years old. He was 12/26/13, readmitted on [DATE] and 04/29/15. His [DIAGNOSES REDACTED]. Record review of Resident #1 ' s Annual Minimum Data Set assessment completed on 11/15/14 and his Quarterly MDS assessment dated [DATE] revealed he required total assistance of two staff for transfers and had limitation of movement on both upper and lower extremities. Record review of Resident #1's care plan dated originally dated 11/28/14 and updated on 02/19/15 for activities of daily living (ADLs) revealed he required total assistance with transfers using a Full-Body lift with an extra-large sling and assistance of 2 CNA ' s for transfers. His care plan for transfers deficit due to [DIAGNOSES REDACTED] and multiple sclerosis dated 11/28/14 and updated on 02/19/15 revealed he required 2 CNA ' s to transfer using Full-Body lift with an extra-large sling. Review of the facility incident report dated 04/21/15 revealed Resident #1 required total assistance with transfers and was interviewable. The description of the allegation was " While CNA was transferring resident from the shower chair to power wheel chair using lift, the sling hooks broke and the resident fell to the floor " . The resident was assessed and transferred to his wheelchair. The physician did a full assessment and an x-ray was ordered. Staff was interviewed, statements were taken and in-services on all units re: the proper use of lifts and slings was completed. The x-ray results came back positive for fracture, the resident was medicated for pain and transferred to the hospital. CNA A was suspended during the investigation. Additional in-services were completed with all staff on proper use of lifts and slings, checking equipment prior to use and checking resident ' s plan of care. A Sling Log was developed for checking sling condition. Any slings not in good working condition were removed. Observation and interview on 05/06/15 at 9:50 am Resident #1 was sitting in his motorized wheelchair in his room. He said on 04/21/15 he was transfer from the bed to the shower chairby 2 CNAs and then taken to the shower in a shower chair by (1) CNA. When CNA A finished showering him she picked him up in the lift. She was by herself. He said the strap to the sling was frayed at the plastic part of the sling that connected it to the lift. He said the CNA was transferring him to his motorized wheelchair, he was 3 feet up in the air and the sling broke at the connection. He said he fell to the floor of the shower room. He said he had never felt that much pain in his life. He said he was taken to the hospital, his right hip was cracked and his femur was broke in 2 places. He said he had surgery, they put a pin in his hip, replaced his femur with a steel rod and he currently still had staples in his leg. During an interview on 05/06/15 at 2:50 p.m. the Executive DON said in the past the CNA ' s on the night shifts went directly to the laundry and obtained clean slings possibly with tears in them, without notifying the nurses. After the incident with Resident #1 they now implemented a new system. The clean slings went to the nurse ' s office, were they are inspected, checked off and logged in as the CNA ' s needed them, before they were used with the lifts. The facility was also implementing a program to attach plastic cards to each lift sling so it could be inspected, dated and initialed by staff monthly for each individual sling. Interview on 05/06/15 at 3:30 p.m. CNA A said Resident #1 received showers 3 times each week. She said she assisted with Resident #1 ' s shower on 04/21/15. She said the sling for his transfer was lying in his chair next to his bed, that the staff earlier in the day had used it to transfer him to his bed. She said she inspected it and did not see any frayed areas. She said CNA B assisted in Resident #1's transfer from the bed to the shower chair. She said CNA B accompanied them to the shower room, but she left the shower room to attend to another resident. CNA A said she did not wait for CNA B to return and she transferred Resident #1 by herself. She said she knew he was a 2 person transfer, but she had done it by herself before and thought she could manage it. She said that while transferring Resident #1 the tab tored/ripped, the plastic part was still attached to the lift and Resident #1 fell to the floor on his bottom with his back against the wheelchair. She said she called for help and the nurse came to assist them. She said Resident #1 was assessed, he complained of pain, he was transferred to his motorized wheelchair and he propelled himself back to his room. She said she was suspended for 3 days due to the incident. During an interview on 05/07/15 at 9:30 a.m. the Administrator of Health Services said the facility had in-serviced staff after Resident #1's fall in 04/2015. She said they had met with the management staff again that morning and re-trained the night staff regarding lift transfers and using 1-2 staff for each transfer via the care plans. She said the facility developed a new system and now required the nurse ' s to monitor lift transfers of residents requiring 2-staff. She said when the resident care plans required 1-2 staff as needed; the number of staff that would be used for a transfer was determined by the CNA ' s and nursing according to each resident ' s condition or change in condition. She said the nursing staff would notify their supervisor ' s if a resident became anxious or combative or if any other changes in condition occurred. During an interview on 05/07/15 at 10:40 a.m. with the Therapy Services Director said the therapy department would in-service nursing staff regarding resident transfers if the resident had a change in condition or change in handling during transfers. She said Physical Therapist A in-serviced nursing staff after Resident #1 ' s fall due to the change in transferring technique due to his fracture. PT A said he in-serviced the nursing staff by demonstration of transferring Resident #1 to/from his bed and motorized wheelchair. He said he concentrated on the safety of the transfer. He said the nursing department determined whether the resident ' s transfer required 1 or 2 staff to assist. Record review of the Resident ' s Requiring Lifts sheet posted at the Miller Unit nurse ' s station dated 03/10/15 revealed: Resident #1, Type of Lift: Full-Body/2-Person, size 2X. Record review of the facility in-services revealed the following: - 11/08/14, 04/04, 05/04/15 Abuse/neglect (CNA A attended). - 11/11/14 Proper transfers - 01/27/15 Proper transferring using proper lifts - 01/28/15 Check equipment prior to use - 04/29/15 Maintenance of lifts and slings.( CNA A attended) - 04/30/15 & 05/01/15 Proper use of lifts and slings re: New policy (CNA A attended). - 05/06/15 Complying with (2)-person assists for transfers. (CNA A attended) Record review of the facility Sling Check Log dated May 2015 revealed 55 slings were checked from 04/22/15-05/16/15 as being in good condition by the Health Services Manager. Record review of the facility policies revealed policies in place for: - Safety, Care and maintenance of lifts and slings dated 02/28/10 and reviewed/revised on 04/28/15: " During lift and sling use the safety of the resident is the primary focus ... Procedure: ... 2. The nurse assigns the appropriate lift for the resident and determines if the resident requires more than one staff for the lift transfer ... 5. Assess sling to make sure it is not torn, tattered, damaged. Check the hooks on the sling to make sure they are secure and in working order. Make sure the sling is safe for usage ... 8. If sling is tattered or torn it is taken out of circulation immediately and brought to the nursing office or Health Services Manager ' s office for replacement ... 11. When in doubt do not use the sling ... 14. Slings will be checked monthly for any damage by a supervisor or the Health Services Manager. " - Fall Intervention dated 06/01/99 and reviewed on 04/01/14. Any fall (observed or non-observed will be reported ... The Daily Census Report revealed 56 residents in the Miller Unit, with a total facility census of 279.

Based on observation, interview and record review the facility failed to ensure 1 of 30 resident (#20) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: --Resident #20 was moaning, had facial grimacing and was jerking during wound care. She was not medicated for pain prior to her wound dressing change and after the dressing was changed. LVN AAA failed to assess Resident #20 for pain and she continued with the wound care. Resident #20 had a Stage III Pressure Ulcer. This failure affected 1 resident and placed 181 residents on pain management at risk of not receiving adequate assessments, medical care and services which could have a negative impact on their health and well-being. Findings: Record review of Resident #20's face sheet revealed that she was a [AGE] year old female who was admitted on [DATE] with [DIAGNOSES REDACTED]. She was a Hospice resident. Record review of Resident #20's Quarterly MDS assessment dated [DATE] revealed that under Hearing, Speech and Vision: Resident #20 had no speech, she had impaired vision and she had minimal difficulty hearing. She was coded as "rarely/never understood" in her ability to express ideas and wants. She was also coded as "rarely/never understands" in her understanding verbal content. Cognitive Patterns: Resident #20's cognitive skills were severely impaired. Functional Status: Resident #20 was dependent on staff for bed mobility, dressing, eating, toilet use, personal hygiene and bathing. She had an impairment on one side of the upper extremities and both sides of the lower extremities. Bowel and Bladder: Resident #20 was incontinent of bowel and bladder. Health Conditions: she was coded as not on any scheduled pain medication regimen, she had not received any PRN pain medications and she had not received non-medication intervention for pain. Indicators of Pain or Possible Pain in the last 5 days: Resident #20 was coded as no signs of non-verbal sounds, vocal complaints of pain, facial expressions and protective body movements of postures observed. Skin Conditions: Resident #20 had a Stage III pressure ulcer that was not present on admission. The Stage III pressure ulcer measured 1.5 cm x 1.0 cm x 1.0 cm and had a presence of Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clmps, or is mucinous). Resident #20 was under Hospice care. Record review of Resident #20's summary of physician's orders [REDACTED]. -Sacral Stage III Ulcer - cleanse area with Normal Saline, Pat dry. Apply [MEDICATION NAME] over ulcer with gauze; secure with adhesive foam dressing. Change dressing daily and as needed if soiled until healed. -Pain Management: for Resident with Dementia use Pain AD Scale Add Pain AD Score and Record. -Pain Management: Assess for pain weekly on Tuesday if pain greater than 5 notify MD. -Pain Management: 1. Date: _________ Location: __________ Record review of Resident #20's Treatment Flowsheet for April 2014 revealed that charge nurses were supposed to assess for pain and use the Pain Scale located at the back page and record the pain AD score on Tuesdays. It was only done on 2 of 5 Tuesdays for the month of April: 4/15/14 and 4/22/14. Record review of Resident #20's Treatment Flowsheet for May 2014 revealed blank pain scores on all the Tuesdays that Resident #20 was supposed to be assessed for pain. Record review of Resident #20's MAR for May 2014 revealed that no pain medications were given to Resident #20. Record review of Resident #20's MAR for June 2014 revealed that she had not received any pain medications prior to wound care on 6/11/14 and even after Resident #20 had pain during wound care on 6/11/14. Record review of Resident #20's care plan dated 5/21/14 revealed Pain Management due to Arthritis, Skin or tissue impairment, Dementia, Fracture Left Tibial Tuberosity, Stage III to coccyx. The approaches included were to monitor for signs and symptoms of pain, administer meds per MD orders and monitor for adequate control of pain if med ineffective notify MD, monitor for causes of pain and ways to alleviate factors. Observation of Resident #20 on 6/11/14 on 9:54 am revealed that LVN AAA was doing wound care on Resident #20. During the wound care [MEDICATION NAME] 30 minutes, Resident #20 was moaning and groaning with facial grimacing and jerking each time LVN AAA wiped the wound with gauze. When asked what the facial grimace meant and the jerking, LVN AAA said that it was an "indication of pain but it will take half an hour for the pain medication to take effect". LVN AAA continued to say that it could also mean " various things such as uncomfortable position". LVN AAA continued with the wound care while Resident #20 continued to grimaced and jerked whenever LVN AAA touched the Stage III pressure ulcer. CNA V and CNA Z were assisting LVN AAA during the wound care. In an interview with Unit Manager A on 6/12/14 at 11:00 am said when doing wound care, the nurse should medicate the residents with pressure ulcer with pain medication half an hour prior. During wound care, the nurse should assess the resident and look for facial grimace if the resident was in pain. If the resident was found to be in pain, the nurse should stop the wound care and medicate the resident for pain or call the physician if the pain medication was not adequate. In an interview with the Hospice Nurse on 6/12/14 at 1:15 pm she said she did not know that Resident #20 was not medicated for pain prior to wound care. She said that she had called the Hospice physician and obtained an order for [REDACTED]. In an interview with LVN H on 6/13/14 at 9:30 am she said that Resident #20's Stage III Pressure Ulcer "used to be sensitive, but not recently". She said that Resident #20 "always jerks". In an interview with CNA V on 6/13/14 at 9:40 in the presence of LVN H she said Resident #20 was in pain during wound care. She said that Resident #20 jerked each time LVN AAA wiped the Stage III Pressure Ulcer. CNA V said that Resident #20 did not jerk when she did an incontinent care right after the wound care. In an interview with the DON on 6/13/14 at 10:10 am revealed that LVN AAA should have given pain medications to Resident #20 when she learned that she was in pain. Record review of the facility ' s Policy and procedure on Pain Assessment and Management dated 5/1/11 revealed, read in parts, " ...2. The assessment shall be based on the resident ' s self report, facial grimaces from observations, and or resident ' s behavior ...3.Timely intervention will be implemented to relieve resident ' s complaints of pain ...8. Residents who not able to make their needs known due to dementia will be assessa and use of the PAINAB scale. 9. Documentation will occur on the back of the MAR indicated [REDACTED]. Record review of the facility ' s Pressure Ulcer Protocol dated 2/25/13 revealed, read in parts, " ...Stage III ...Medicate Resident as ordered prior to treatment if required. " Review of the facility ' s CMS 672 revealed that there were 182 residents on pain management.