Every finding on record at Shenandoah Center

Based on observation and staff interviews, the facility failed to ensure resident's environment remained as free of accident hazards as is possible in regard to resident's rooms and vanity drawers, to be free of razors, scissors, and inedible care items in the 300 hall, mounted wall heater and broken inwall receded night light in resident bathroom, also resident's bedside table with a straw in her lotion bottle. This failed practice was a random opportunity for discovery. Resident identifier: #'s 3, 44, 50, 56 , and 88. Facility Census: 76.Findings Included: a) room [ROOM NUMBER] -During facility walk through and resident interviews on 03/05/26 at 10:56AM, 4 cans of shaving cream and 2 opened packages of razors, among other bathing products such as body lotions, shampoo, and mouthwash were found in the top 2 (two) drawers of the resident's shared sink/vanity area in room [ROOM NUMBER]. These drawers were easily accessible to any resident that may wander into the room. During an interview with Resident #3 he stated the top two drawers were not his. They belonged to his room mate. Resident #3 stated he had made complaints that resident #50 gets into his bedside drawers and all other drawers in the room. b) Rooms #301 and #303 Shared bathroom On 03/05/26 at 10:16AM during entrance interviews and facility walkthrough, it was observed in the shared bathroom between room [ROOM NUMBER] and #303, the top of the metal baseboard heater was broken protruding and jagged edges. Further observation found a broken encased wall night light with the glass cover out of place exposing the glass bulb and electrical wiring. In an interview with the Environmental Account Manager #89 on 03/05/26 at 10:35AM, she acknowledged the hazards in the shared bathroom for room [ROOM NUMBER] and #303, and stated she would report it to the maintenance department for immediate repair. In an interview with the Facility Administrator on 03/06/26 at 9:54AM, she stated she was made aware of the hazards in the shared bathroom of room [ROOM NUMBER] and #303 and stated maintenance were actively repairing it.

Based on observation, interview and policy review the facility failed to properly store food in accordance with professional standards. issues with food storage were found in the facility kitchen freezer This had the potential to affect all residents in the facility. Facility census: 76On 03/09/26 at 11:10 AM, during the 2nd kitchen visit, with the Corporate Dietary Manager (CDM) revealed the CDM acknowledged the following in the freezer : -1(one) opened box of frozen ground beef with inner plastic unsealed and left open to air -1(one) opened box of fish filet's with inner plastic unsealed and left open to air Interview with Kitchen Manager on 3/9/26 at 11:10 AM, He acknowledged the frozen ground beef and frozen fish filets were left open to air and stated the staff were supposed to tie the plastic to reseal once they have been opened. -On 03/10/25 at 2:35 PM a review facility policy labeled HCSG (Health Care Services Group) Policy 019, Food Storage: Cold Foods. Procedures, number 5 stated All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.

Based on observation, staff interview and resident interviews it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Several issues were identified related to staff response times to call lights. Facility census: 76.Findings Included:a) Resident #11On 03/05/26 at 2:50 PM after completing a representative Interview with Resident #11's family member outside his room, it was observed his call light was on. Upon walking into his room, he stated he was trying to call for staff. At 3:17PM two Nurse Aide (NA) #68 and #72 came in and asked if they could help him. Resident #11 asked for a glass of water and the bed pan. One NA stated she would get the water for him and the other stated she would get him someone to help him with his bed pan and the NA left the room. At 3:25 PM Nurse Aide #45 came in to assist him with the bed pan. On 03/05/26 at 3:35 PM during an interview with NA #45 the NA acknowledged Resident #11's wait time of 30 minutes for the help and care he needed and stated, Thank you for letting me know.On 03/05/26 at 4:25 PM during an interview with the Director of Nursing (DON), she stated she was aware of the amount of time Resident #11 had to wait for his call light to be answered and stated it was too long and not acceptable.03/05/26 at 2:50 PM during a family interview Resident #11's sister stated her brother hates to ask staff for help because he had to wait too long for help and they are always saying they are so busy that it takes long periods of time for them to get to him. She reported on 03/05/26 he needed to be changed when she got there. She said his skin was getting red from being in feces too long. She stated she was going to speak the DON.b) Resident #4On 03/04/26 at 2:00 PM, Resident #4 who had capacity stated, At times I have waited 45 minutes for someone to answer my call light. When asked if this happens on any specific shifts or days, he stated mostly dayshift but has been other times as well.c) Resident #61On 03/04/26 at approximately 2:20PM, Resident #61 reported that sometimes call lights take longer than a half hour to get answered as the staff tells her they are very busy. d) Resident #3On 03/05/26 at 11:15AM Resident #3 stated he had waited 30 minutes for his call light to be answered.Resident Council meeting held on 04/05/26 at 10:30 AM residents with capacity in attendance expressed concerns regarding long wait times for call lights to be answered.e) Resident #9Resident Council [NAME] President, Resident identifier #9, stated he felt the nursed aides are nice and are trying very hard but he has had to wait up to 45 minutes for his call light to be answered.f) Resident #71Resident #71 stated she has had to wait 30 minutes for her call light to be answered and sometimes they forget to come back if they turn it off and say they will return. g) Resident #29Resident #29 stated he has had trouble with staff not coming to answer his call light for up to 45 minutes and sometimes it takes longer depending on who is working.On 03/05/26 at 3:35PM during an interview with Nurse Aide employee identifier # 45 acknowledged resident # 11's long wait time of 30 minutes for the help and care he needed and stated thank you for letting me know.On 03/05/26 at 4:25 PM in an interview with the Director of Nursing, she stated she was aware of the amount of time Resident #11 had to wait for his call light to be answered and stated it was too long and unacceptable.

The facility failed to ensure a dignified existence for residents. Resident #16 Based on observation and staff interviews the facility failed to ensure resident #16 had a right to a dignified existence Inside the facility.This failed practice was a random opportunity for discovery. Resident #16. Facility Census 76.Findings Included:On 03/04/2026 at 11:46 AM during a facility walk through on the 100 hall it was observed that Resident#16's private areas and brief was exposed with the room door wide open. Three staff members were observed present in the hall with visuals into the room and did not offer privacy for the resident prior to surveyor staff bringing it to Employee #36's attention. Employee #36 then stepped into the room and pulled the curtain for privacy. In an interview with the Director of Nursing on 03/04/26 at 12:15 PM, she acknowledged the door was open while Resident #16's son was changing her but staff members in the hall did not provide privacy for resident until surveyor staff brought it to their attention.

Based on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed the resident at risk of not being informed of his rights prior to the end of Medicare Part A covered services. Resident identifier: #31. Facility census: 76.Findings included: a) Resident #31On 03/10/26 at 11:02 AM, a beneficiary notification record review was completed.Resident #31 remained in the facility after his last covered Medicare Part A day on 11/11/25. There was no evidence that the SNF-ABN was ever reviewed with the resident. During an interview on 03/10/26 at 12:24 PM, the Business Office Manager reported that a SNF-ABN had not been issued.

Based on record review and staff interview, the facility failed to provide a written Bed Hold Notice for one (1) of three residents. Resident #45 was discharged to an acute care setting. Resident Identifier: #45. Facility Census: 76.Findings included: a) Resident #45An electronic medical record review was completed on 03/10/2026 at 9:56 PM. Resident #45 was transferred to the hospital on [DATE]. There was no evidence in resident's medical record to reflect that a bed hold notice had been provided to the resident or the resident's representative. During an interview, on 03/11/26 at 8:30 AM, the Administrator acknowledged the facility could not provide evidence that a written bed hold notice had been given.

Based on resident interview, record review, and staff interview, the facility failed to ensure a resident received trauma-informed care which accounted for the resident's experiences and preferences in order to mitigate triggers that may cause re-traumatization. Resident identifier: #62. Facility census: 76. Findings included:a) Resident #62 During an interview, on 03/05/26 at 9:18 AM, Resident #62 revealed she had a Post-Traumatic Stress Disorder diagnosis stemming from a marriage involving severe domestic violence. The resident reported that loud voices directed towards her, closed doors, and any rough handling would be potential triggers for her experiencing re-traumatization. A medical record review, completed on 03/10/2026 at 10:08 PM, revealed a Social Services Assessment which reflected the PTSD diagnosis and the potential trigger of yelling. However, review of Resident #62's care plan did not find the PTSD diagnosis and potential triggers for experiencing re-traumatization addressed in any fashion. On 03/11/2026 at 9:50 AM, the Social Worker confirmed resident's care plan did not address the resident's PTSD diagnosis. The Social Worker acknowledged lack of proper care planning could potentially lead to re-traumatization of the resident, resulting in unnecessary mental anguish.

Based on observation and staff interview, 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 . This failed practice was a random opportunity of discovery. Resident identifiers: #94, #9, #55, #12. Facility census: 76.- 03/04/26 at 12:04 PM: It was observed that Employee #7 handled Resident #94's hamburger buns without gloves.- 03/04/26 at 12:06 PM: During an interview, Employee #7 acknowledged the incident and stated she returned the plate to the kitchen for a replacement. - 03/04/26 at 9:55 AM: In room [ROOM NUMBER], the wheelchairs for Resident #9 and #55 had rips and tears on both armrests, exposing the inner padding.- 03/04/26 at 10:00 AM: Resident #12's wheelchair was observed to have holes and tears in the right armrest with exposed inner padding.- 03/04/26 at 2:50 PM: During an interview, the Facility DON and Administrator acknowledged the condition of the wheelchairs and agreed that the damaged arm pads cannot be properly sanitized to prevent infection. They stated that a facility-wide audit will be completed to address wheelchair repairs and replacements.

Tag F657 care plan timing and revision.Based upon record review and staff interview, the facility FAILED to ensure accurate and up to date information was reflected in the residents care plan for Resident #48. This was found to be true for one of three resident record reviewed. This has the ability to effect more then one resident.resident effected #48Residents reviewed #48, #72 and #60Census: 75 Findings include:A) Resident #48Resident #48 was seen wandering into other residents' rooms drinking from their cups, eating other residents' food and getting ice out of the ice chest with bare hands. Resident #48 is not care planned for behaviors mentioned in a complaint (entering other rooms, public urination or displaying privates, using other residents' items eating from common food sources)Interview with Admin #10 stated that resident #48 that we have tried to find a more suitable place for resident #48 long term due to all his needs. Interview with RN #56 stated resident #48 had a hard time when he first got here. The resident needed and still needs a lot of re-queuing and re-direction. He took a few weeks to adjust to the new setting of being here and still comments about wanting to go home. When the ADMIN #10 was presented with the fact that the care plan didn't reflect the behaviors that both other residents and staff have seen and documented the administrator stated that she would make sure they are correct going forward.

Based on record review, observation and staff interview the facility failed to ensure Resident #9 who requires dialysis received such services, in accordance with professional standards of practice. Resident #9 had an arteriovenous (AV) fistula in their left arm. The facility on multiple occurrences documented they were obtaining the residents blood pressure in their left arm. Obtaining blood pressure in the arm where the AV fistula is located may result in clots, clots that can dislodge, loss of use of the fistula and could cause a stroke. All of these things put the resident in an immediate risk of serious injury and/or death. The state agency (SA) determined this failure to be an immediate jeopardy (IJ) situation. The facility was notified of the IJ on 07/25/24 at 11:09 am. The SA accepted the facility's plan of correction (POC) on 07/25/24 at 1:15 PM. After observation of implementation of the POC the IJ was abated at 3:30 PM on 07/26/24. After the immediacy was removed a deficient practice remained for Resident #9 in regard to the completion of Post dialysis assessments at which time the Scope and severity was decreased form a K to an E. These failed practices were true for one (1) of one (1) residents reviewed for the care area of dialysis during the long term care survey process. Resident Identifier: #9. Facility Census: #71. Findings include: a) Resident #9 A review of Resident #9's medical record on 07/25/24 at approximately 10:00 am found the following physician order: A review of Resident #9's electronic medical record on 07/25/24 found under the blood pressure vital signs tab the following dates and times when facility staff documented they had taken Resident #9's blood pressure in his left arm: -- 12/16/23 at 2:25 PM -- 12/18/23 at 11:53 AM -- 01/10/24 at 9:30 AM -- 05/14/24 at :48 PM -- 05/26/24 at 2:41 AM -- 05/28/24 at 6:36 PM -- 05/29/24 at 6:25 PM -- 06/08/24 at 11:53 AM -- 06/09/24 at 5:40 PM -- 06/20/24 at 11:26 AM -- 06/21/24 at 1:27 PM -- 06/22/24 at 11:57 PM -- 06/23/24 at 10:42 PM and -- 06/25/24 11:50 PM. Continued record review on 07/25/24 found an order stating, Monitor AV fistula.graft site to left arm for S/S infection, edema, bleeding and upon return from dialysis, notify primary care physician and dialysis if AV fistula/graft site is bleeding apply pressure for 15 minutes and notify MD/Physician if bleeding does not stop. Record review of the Dialysis communication book revealed the facility was not completing POST dialysis assessments on Resident #9 after returning from dialysis. Record review of Residents # 9's care plan revealed the following: - Do not take B/P in my left arm due to my AV - Monitor for s/s of infection, edema, bleeding upon return from dialysis An observation on 07/25/24 at approximately 10:30 AM, revealed Resident #9 had no signage in room stating not to take BP in left arm Further observation of Resident #9 found his room and person was void of any signage and/or bracelet which would have brought awareness to the staff that Resident #9 had a restricted limb. During an interview on 07/25/24 with LPN #68, stated they take blood pressure in the opposite arm of the AV fistula, Record review had previously revealed LPN #68 had documented having taken blood pressure in Resident #9's left arm. On 07/25/24 at 11:30 AM, The Director of nursing (DON) stated, The orders and care plan should have been followed to not take a B/P in the left arm and complete the POST dialysis assessment in the resident's dialysis book. b) Facility plan of correction (typed as written): Resident #9 will be evaluated by the licensed nurse upon return to the facility. All dialysis residents have the potential to be affected. The Unit Managers/designee conducted an audit on 07/25/2024 for all residents on dialysis with specific B/P orders to be taken and POST dialysis assessment is completed upon return to the facility with any corrective action immediately upon discovery. The Order for B/P not to be taken in the Left arm on Resident #9 will be added to the Medication Administration Record in all Capital letters and will be added to the care plan and kardex in capital letters. The Director of Nursing(DON)/designee will reeducate all nursing staff with a posttest to validate understanding regarding hemodialysis graft, fistula care, communication, and documentation (as follows): Procedure: 1. Verify orders and instructions from hemodialysis facility or hospital, if patient is a new Admission. 2. Evaluate access site daily and on completion of hemodialysis (HD) or home hemodialysis (HHD) treatment. Observe for signs of complications. 2.1 Inspect fistula site for decrease or absence of vein dilation. 2.2 Palpate for distal thrill. 2.3 Auscultate for bruit. 2.4 Palpate skin around graft/fistula for warmth. 2.5 Evaluate skin around vascular access noting redness, swelling, local warmth, exudate, tenderness. 3. Observe for presence of fever, chills, hypotension and notify physician/advanced practice provider (APP) and hemodialysis facility staff for. 3.1 Pain, numbness, swelling, redness, odor, bleeding or drainage at site; 3.2 Extreme warmth or coolness of extremity; 3.3 Blebs (ballooning or bulging) of the vascular access site; 3.4 Absence of pulses distal to access site; 3.5 Absence of bruit or thrill. 4. Protect access site from getting wet for several hours after HD or HHD treatment. 5. Avoid trauma or treatment procedures in the accessed extremity, such as: 5.1 Limit activity of extremity, 5.2 Blood pressure measurement, 5.3 Venipuncture, injection of any type, 5.4 Use of creams or lotions on the access site. 6. Instruct patient: 6.1 To avoid excessive pressure on the extremity or strain (e.g., laying on it or lifting heavy object with it). 6.2 In strengthening exercises to enhance blood flow such as squeezing small rubber ball, if permitted by physician/APP and dialysis facility. 6.3 In proper care of fistula/graft. 7. Document: 7.1 Location of access site on admission assessment; 7.2 Status of access site in Nurses' 7.3 Status of pulses distal to access area; 7.4 Color and temperature of extremity; 7.5 Presence or absence of pain or numbness; 7.6 Status of bruit and thrill; 7.7 Notification and response of physician/APP and dialysis facility, if indicated; 7.8 Patient education and family involvement; 7.9 Nursing intervention. Policy: Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility. PURPOSE: To ensure ongoing communication and collaboration with the certified dialysis facility regarding hemodialysis (HD) patient care and services. 1. Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record, or the state required form and send with the patient to his/her HD facility visit. 2. Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient. 3. Upon return of the patient to the Center, a licensed nurse will: 3.1 Review the certified dialysis facility communication; 3.2 Evaluate/observe the patient; and 3.3 Complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form. 4. Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center. 4.1 Document notification of certified dialysis facility regarding return of form or other Communication. 5. Maintain the Hemodialysis Communication Record or state required form in the patient's medical record. Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work. New Licensed nurses will be provided education, including post-test during orientation by the DON/designee. Annual in-servicing will be provided to licensed nurses regarding medication administration. The DON/designee will complete medication pass competencies quarterly x 2 quarters to ensure physician orders are followed including ensuring B/P ' s are not taken in restricted arm. The Unit Managers (UM)/Designee will conduct observations starting on 7/25/2024 to ensure all licensed nurses are taking B/P and the licensed nurse is completing the dialysis communication sheets POST dialysis daily across all shifts for 2 weeks including weekends and holidays, then 5 times a week for 4 weeks, then 3 times a week for 4 weeks, then randomly thereafter. Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.

Based on record review and staff interview, the facility failed to provide an environment free from abuse and/or neglect from staff or other residents. Resident #123 was physically abused by Licensed Practical Nurse (LPN) #91. This created an immediate jeopardy situation. The LPN admitted to losing her temper and backhanding a combative resident. The facility took all appropriate steps after the situation including terminating the LPN. This issue is being cited as past noncompliance. Resident #23 was neglected by Nurse Aide (NA) #94. These were random opportunities for discovery. Resident identifiers: #123, and #23. Facility Census: 71. Findings included: a) Resident #123 A record review on 07/25/24 at 12:30 PM of a Complaint #29751 revealed an incident where a Licensed Practical Nurse (LPN) #91 had struck Resident #123 in the face on 11/09/23 at approximately 11:30 PM. Further record review revealed at the time of this incident Nurse Aides (NA) #45 and #55 were attempting to provide incontinence care to Resident #123. During care Resident #123 became combative with the NA. At this time, LPN #91 attempted to administer medication and water to the resident. Resident #123 spit at the LPN #91 and knocked the water out of her hands, and LPN #91 backhanded Resident #123(Typed as written.). On 07/25/24 at 1:00 PM, an interview with the Administrator was held. The Administrator stated, I was not here but I do know about the incident. On 07/25/24 at 1:05 PM, the Administrator provided all paperwork in regards to this event. The immediate fax reporting of the incident was dated 11/10/23 stating, I, (Name of previous Director of Nursing) received a call on 11/09/23 at 11:21 PM from CNA (certified nursing assistant) #94 reporting that another CNA #92 witnessed a nurse hit a resident in his room around 10:40 PM. I began to get dressed to head into the facility and I placed a call to the administrator, (Name of previous Administrator), as well as the facility social services director, (Name of social services director). (Name of social services director) and I agreed to meet at the facility to interview the staff and determine the situation. I arrived to the facility around 11:45 PM with (Name of social services director) and we began interviewing staff. We began by interviewing NA #92, followed by NA #45, NA #94, and then interviewed LPN #91. (Typed as written.) NA #92 stated that she went to assist NA #45, LPN #91 and NA #55 with incontinence care for the Resident #123. NA #92 states the resident kicked NA #55 and when she entered the room, NA #55 was laying on the floor, crying in pain. NA #92 states she was assisting with changing the resident, NA #45 held his hands to prevent him from hitting, and NA #92 changed his brief. LPN #91 attempted to administer medications to the resident and the resident spit them out at her. The resident then allegedly attempted to hit LPN #91, and LPN #91 then reportedly pulled her arm back and struck the resident in the right side of his face while he was in bed. At this time, there were 3 (three) CNAs present in the room. NA #92, NA #55 and NA #45. NA #92 was the CNA that reported this incident by phone call at 11:21 PM to me. (Typed as written.) 'During the interview with LPN #91, LPN #91 admitted to myself and (Name of social services director) that she did lose her temper and backhanded him with an open fist. Upon completion of interviews, I counted both the narcotic drawers with LPN #91, walked her to the time clock and out of the building. (Typed as written.) All state agencies, OHFLAC, Ombudsman, APS, Law Enforcement were notified of the incident. The immediate action to protect the resident(s) listed were investigation initiated, perpetrator suspended and Law Enforcement notified. The five (5) day follow-up was dated 11/13/23. The statement was completed by the previous Administrator, which stated, (Name of Resident #123) is a (age) (sex) admitted into the (Name of facility) with the following diagnosis: non-st elevation myocardial infarction, type 2 (two) diabetes, transient cerebral ischemic attack, hypertensive heart and chronic kidney disease with heart failure and with stage 5 (five) chronic kidney disease or end stage renal disease, personal history of transient ischemic attack and cerebral infarction without residual deficits, cerebral infarction, muscle weakness, lack of coordination, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, dementia, repeated falls, cardiomyopathy, weakness, osteoarthritis, proteinuria, chronic systolic heart failure, anemia in chronic kidney disease, benign prostatic hyperplasia without lower urinary tract symptoms, pain, hyperlipidemia, chronic kidney disease stage 3B, difficulty in walking and unspecified fall. (Typed as written.) Resident is receiving the following medications: Milk of Magnesia, Atorvastatin, Aspirin, Docusate, Clopidogrel, Carvedilol, Famotidine, Mirtazapine, Flomax, Quetiapine and Acetaminophen. (Typed as written.) An assessment completed on November 1, 2023 showed a BIMS (Brief Interview for Mental Status) score of 8 (eight) and a PHQ9 (Patient Health Questionnaire 9) of 0 (zero). The resident does not have capacity and (Name of Medical Power of Attorney) and was notified of the incident. (Typed as written.) On November 9, 2023, at approximately 11:00 pm, the Director of Nursing, (Name of the Director of Nursing), was contacted and it was reported to her that a CNA witnessed LPN, #91, strike a resident in the face. Witness statement obtained from CNA #92, reported that while staff were attempting to provide care to the resident, the resident became combative and kicked another CNA who fell to the floor and had to be sent to the ER (emergency room ) via ambulance. During the incident, the LPN attempted to give the resident water. The resident spit at the LPN and the LPN subsequently struck the resident in the face. The LPN admitted to striking the resident during her interview. (Typed as written.) The Director of Nursing Services and the Director of Social Services entered the building to obtain statements and a report was made to OHFLAC (Office of Health Facility Licensure and Certification), APS (Adult Protective Services) ,Ombudsman and WV State Police (Incident #23-230449). The LPN was suspended pending investigation. (Typed as written.) A report was made to the [NAME] Virginia LPN board by the Director of Nursing on November 10, 2023. (Typed as written.) Skin check was performed on the resident following incident by the Director of Nursing, with no injuries observed. Skin checks were performed on November 11, 2023, by RN, on all non interviewable residents with no indicators of abuse found. (Typed as written.) Interviewable residents were interviewed by the Recreation Director on November 11, 2023, asking if they were ever subjected to any form of abuse or witnessed any form of abuse, with none reported. (Typed as written.) Re-education, with a post test, has been initiated with all employees regarding the process of reporting abuse as well as how to deal with a combative resident who is refusing care. (Typed as written.) Medical Director ordered labs and a UA (urinalysis) on resident on November 10, 2023. (Typed as written.) Based on the above, the allegation of abuse is substantiated. The LPN's employment is being terminated with the (Name of the facility) effective immediately. (Typed as written.) A review of the facility policy, entitled Abuse Prohibition, was completed on 07/26/24. The Federal Definition of physical abuse includes hitting, slapping, pinching, kicking, etc., as well as controlling behavior through corporal punishment. (Typed as written.) The surveyor interviewed various staff members on 07/26/24 at 10:00 AM from nursing and housekeeping regarding education on abuse. They knew the definitions of abuse and when to report. They also indicated they knew what to do if they became frustrated with a resident. This education was done to prevent other instances of physical abuse from staff to residents. The State agency determined these failures placed the residents in an immediate jeopardy (IJ) situation for past non-compliance due to the potential of serious injury and/or death as a result of documented physical abuse by staff to a resident. The State agency notified the Nursing Home Administrator of the immediate jeopardy at 2:17 PM on 07/25/24. The State agency verified the facility had completed their in-house plan on 12/09/23, which was verified by conducting staff interviews and providing education regarding abuse, on 07/26/24 at 10:00 AM. b) Resident #23 According to a facility reported incident, on 04/07/24, it was alleged by Nurse Aide (NA) #62 that NA #94 left Resident #23 and his bed soiled with vomit, feces, and urine. NA #62 stated she noticed Resident #23 had vomit on his pants, dried feces on his legs, and his bed was soiled with urine and feces. According to NA #62, NA #94 stated Resident #23 had thrown up and had vomit on his shirt and he had not changed the resident. An interview was conducted with Licensed Practical Nurse (LPN) #68, the nurse assigned to Resident #23 that night. LPN #68 confirmed Resident #23 was heavily soiled and had not been changed. According to a statement from NA #94, he did not change Resident #23 because he was attempting to use common sense by not waking up the resident due to the possibility of him becoming combative while receiving care. The facility substantiated the allegation of abuse and terminated NA #94 on 04/12/2024. NA #94 did not return to work after being suspended pending investigation. They did not have evidence of any education to the other staff or any other actions/plans to prevent recurrence of a situation like this. 49467 50795

Based on resident interview and record review the facility failed to ensure Resident #65 was free from significant medication errors. Resident #65 was administered an injection of 25 units of insulin on 04/19/24 when the resident was not ordered any insulin nor was he a diabetic. Giving a resident an insulin injection when they are not ordered the medication, nor a diabetic can cause serious consequences including serious harm and or death. The state agency (SA) determined this to be an Immediate Jeopardy (IJ) situation. The facility was notified of the IJ on 07/22/24 at 6:49 PM. The SA accepted the facility's Plan of Correction (POC) on 07/22/24 at 7:40 PM. After completing observations, record reviews, and staff interviews regarding the implementation of the POC the IJ was abated at 07/23/24 at 2:30 pm. This failed practice was a random discovery and was true for Resident #65, but due to the systemic failures the failed practice had the potential to affect more than a limited number of residents. Resident identifier: 65. Facility Census: 71. Findings include: a) Resident #65 During an interview on 07/22/24 at approximately 3:45 PM, Resident #65 stated back in April 2024 a male nurse who he was unable to recall their name gave him an insulin shot and he was not a diabetic. The resident continued to state, the nurse did not verify who they were giving the insulin shot to. Record review revealed a progress note dated 04/19/24 which read as follows: Resident was administered with 25 units of Lantus at 9pm by error. Residents had a room change from this shift from 401A to 107. Resident BS before the insulin was administered was 135. Resident was notified and he was upset because he was given the wrong medication. He said he never took any medications till he was admitted to the facility. On- call Dr called and initial orders were given to monitor resident BS Q for 15 minutes. Resident refused to have his blood sugar checked. At 10:30 after speaking to his wife he allowed a BS check and it was 118. On- Call (Dr Name) was notified and gave orders to check Blood Sugar (BS) at 5AM and Q shift for tomorrow. The facility was unable to provide any documentation to prove they investigated and or implemented any process to ensure this failure never occurred again. Further record review revealed the following change in condition Situation: At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 112/75 - 4/19/2024 21:08 Position: Lying l/arm - Pulse: P 78 - 4/19/2024 21:08 Pulse Type: Regular - RR (respirations): R 18 - 4/19/2024 21:10 - Temp (Temperature): T 97.7 - 4/19/2024 21:10 Route: Forehead (non-contact) - Weight: W 198.6 lb. - 4/10/2024 08:23 Scale: Wheelchair - Pulse Oximetry: O2 97.0 % - 4/18/2024 22:59 Method: Room Air - Blood Glucose: BS 118 - 4/19/2024 22:30 Nursing observations, evaluation, and recommendations were :No changes noted to resident at this time, will continue to monitor for changes. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recheck Blood Sugar at 5:00 AM and every shift tomorrow. Continue to monitor all shifts. During an interview with LPN#66 the LPN at approximately 4:30 PM stated, they had gotten report on a different resident and when he went to give the meds he didn't verify because he didn't know the residents had switched rooms. An interview on 07/22/24 at approximately 6:00 PM with the facility Administrator revealed at the time of the error a one-to-one education/competency was completed with LPN#66 on 06/19/24, the error occurred on 04/19/24, at this time the DON stated LPN#66 is not full time and works part time or as needed. b) Facility Plan of Correction The facilities Plan of Correction (POC) read as follows. The licensed nurse conducted a change in condition on 04/19/24 with notification to the medical provider for Resident#65. All residents of the facility have the potential to be affected. The Nurse Educator conducted an audit on 07/22/2024 of all licensed nurse's medication administration competencies to ensure all licensed nurses are competent with medication administration within the last 12 months with any corrective action immediately upon discovery. The Administrator/Designee conducted an audit on 07/22/2024 for all residents to ensure they had a photo identification on the eMar with any corrective action immediately upon discovery. No residents were identified. Re-education as provided by the DON/Designee to all licensed nurses starting on 7/22/24 on safe medication administration practices including verification of correct: Patient, drug, route, dose, time, special considerations, and expiration date with a POST test to validate understanding. Any licensed nurse not available during this time frame will be provided re-education, including post-test and return demonstration by DON/Designee prior to the beginning of the next shift to work. New licensed nurses will be provided education, including post-test during orientation by DON/Designee. Annual in-servicing will be provided to licensed nurses regarding medication administration. The unit managers(UM)/Designee will conduct observations starting on 7/22/24 to ensure all licensed nurses are passing medications with verification of right person, drug, route, dose, time, special considerations, and expiration dates across all shifts for two weeks, including holidays, then five times a week for four weeks, then three times a week for four weeks, then randomly thereafter. Results of observations will be reported by the UM/designee monthly to the Quality Improvement Committee(QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter determined by the QIC committee. A review of the facility POST test was reviewed on 07/23/24 at 11:00 AM: The following Licenses nurses were interviewed and confirmed they had got the training and took the posttest and understood what was being educated to them. ~Registered Nurse(RN)#31 ~RN#20 ~RN#13 ~RN#21 ~LPN#35 ~LPN#48 ~LPN#50 ~LPN#52 IJ was abated 07/23/24 at 2:30 PM

Based on resident and staff interview and record review, the facility failed to provide showers and/or bed baths in accordance with the residents' preference and/or plan of care. Residents stated the staff preferred to give them bed/sponge baths, rather than a shower, because it is less work. This was true for three (3) of six (6) residents reviewed for the care area of choices and for five (5) of seven (7) residents reviewed for the care area of Activities of Daily Living (ADL) during the long-term care survey process. For Resident #42 the facility failed to provide a timely transfer from her chair to her bed causing the resident to become agitated and cry out for a period of 30 minutes. This resulted in actual psychosocial harm for Resident #42. Resident # 42 was a random opportunity for discovery. Resident Identifiers: #48, #40, #3, #51, #65, #22, #60, #63 and #42. Facility census: 71. Findings Include: a) Resident #42 During a night observation on 07/23/24 at 11:22 PM, Resident #42 was crying and saying over and over, Oh, God help me. Resident #42 would not talk to or acknowledge the surveyor. During an interview on 07/23/24 at 11:29 PM, Licensed Practical Nurse (LPN) #48 stated, She gets upset because she doesn't like to wait. She is a lift. I have to wait on someone to help me. Further observation at 11:32 PM, Resident #42 continued to cry out, Oh, God help me. (2) two nurses were sitting at the nurses' station. The surveyor again went into Resident #42's room. Resident #42 would not talk to the surveyor. Continued observation at 11:35 PM showed (2) nurses continuing to sit at the nurses' station. During an interview on 07/23/24 at 11:41 PM, LPN #48 stated, She is like that a lot. She wants to be up all the time. If she doesn't get attended to in a timely manner she gets upset. Unfortunately, the other Certified Nursing Assistant (CNA) is talking to the surveyor and those (2) nurses are doing an admission. An observation on 07/23/24 at 11:46 PM, found Resident #42 was continuing to cry out. A final observation at 11:52 PM showed LPN #48 and CNA #39 going into the resident room with the mechanical lift. b) Resident #48 During an interview with Resident #48 on 07/23/24 at 2:38 PM, he stated, the facility did not honor his request for showers. He stated he was scheduled for a shower two times a week, on Tuesday and Friday. He further stated he had not had a shower for over thirty (30) days. A review of the resident's minimum data set (MDS) dated [DATE] at 3:20 PM, revealed under MDS Section F0400 for daily preferences, resident had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? His response was - Somewhat important Further review of resident's MDS dated [DATE] at 10:37 AM revealed, he had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? His response was - Very Important Record review of Resident #48's shower logs revealed the following: For the month of January 2024, the resident received 13 bed/sponge baths, and no showers. For the month of February 2024, the resident received 14 bed/sponge baths, and no showers For the month of April 2024, the resident received two (2) bed/sponge baths, and one (1) shower. It was also noted, one bed/sponge bath was given on 04/03/24 and the next bed/sponge bath was given two (2) weeks later, on 04/17/24. For the month of May 2024, the resident received 13 bed/sponge baths, and no showers. One bed/sponge bath was given on 05/16/24, and the next was given seven (7) days later, on 05/23/24. For the month of June 2024, the resident received five (5) bed/sponge baths, and two (2) showers. One shower was given on 06/07/24, and the next bed/sponge bath was given six (6) days later, on 06/13/24. Another bed/sponge bath was given on 06/17/24, and the next bed/sponge bath was given six (6) days later, on 06/23/24. The bed/sponge bath on 06/23/24 was the last bed/sponge bath given for the month of June 2024. The next bed/sponge bath was given 12 days later, on 07/05/24. A total of seven (7) bed/sponge were given as of 07/24/24. c) Resident #40 An interview with Resident #40 on 07/23/24 at 2:55 PM, revealed the facility did not honor his request for showers. He stated he was scheduled for a shower two times a week, on Monday and Thursday. He further stated he had not had a shower for over thirty (30) days. A review of the resident's MDS dated [DATE] at 10:58 AM, revealed under MDS Section F0400 for daily preferences the resident had had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident's response was - Not very important Further review of resident's MDS dated [DATE] at 4:10 PM revealed, he had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident's response was - Somewhat Important Record review of Resident #40's shower logs revealed the following: For the month of January 2024, the resident received eight (8) bed/sponge baths, and no showers. The resident received one bed/sponge bath on 01/04/24 and the next bed/sponge bath 11 days later, on 01/15/24. It was further noted his next bed/sponge bath was seven (7) days later on 1/22/24. For the month of February 2024, the resident received eight (8) bed/sponge baths, and no showers. One bed /sponge bath was given on 02/10/24, and the next bed/sponge bath was given 11 days later on 02/21/24. For the month of March 2024, the resident received seven (7) bed/sponge baths, and no showers. It was also noted the resident had received no bed/sponge baths, or showers, for eight (8) days, from 03/10/24 to 03/18/24. For the month of April 2024, the resident received four (4) bed/sponge baths, and no showers. A record review revealed the resident had received no bed/sponge baths or showers for fifteen (15) days, from 04/12/24 to 04/27/24. For the month of May 2024, the resident received two (2) bed/sponge baths, and no showers. The resident received no bed/sponge baths, or showers for 18 days, from 04/27/24 to 05/15/24. Further, the resident also did not receive bed/sponge baths, or showers for 12 days, from 05/19/24 to 05/31/24. For the month of June 2024, the resident received seven (7) bed/sponge baths, and one (1) shower. Further record review revealed the resident did not receive a bed/sponge bath, or shower for twelve (12) days, from 05/19/24 to 06/04/24, and for seven (7) days, from 06/13/24 to 06/20/24 For the month of July 2024, the resident received three (3) bed/sponge baths and no showers, as of 07/24/24. The resident received a bed/sponge bath on 07/08/24 and then received a bed/sponge bath ten days later, on 07/18/24. The resident also did not receive a bed/sponge bath, or shower for six (6) days, from 07/18/24 to 07/24/24. d) Resident #3 An interview with Resident #3 on 07/23/24 at 2:49 PM, revealed the facility did not honor his request for showers. He stated he is scheduled for a shower two times a week, on Wednesday and Saturday. He further stated, he had not had a shower for over thirty (30) days. A review of the resident's MDS dated [DATE], at 1:19 PM, revealed, under MDS Section F0400 daily preferences were not assessed. Further review of the resident's MDS dated [DATE] at 4:10 PM revealed, he had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? His response was - Very Important Record review of Resident #3's shower logs reveal: For the month of January 2024, the resident received three (3) bed/sponge baths, and no showers. For the month of February 2024, the resident received three (3) bed/sponge baths, and no showers. For the month of March 2024, the resident received three (3) bed/sponge baths, and one (1) shower. It was also noted the resident had received no bed/sponge baths, or showers for 17 days, from 2/29/24 to 3/18/24. For the month of April 2024, the resident received one (1) bed/sponge baths, and no showers. A record review revealed the resident had received no bed/sponge baths or showers for 19 days, from 03/27/24 to 04/16/24. For the month of May 2024, the resident received one (1) shower. For the month of June 2024, the resident received four (4) bed/sponge baths, and one (1) shower. The resident's last shower in May was on 05/22/24, and his next shower was twenty (20) days later, on 06/11/24. For the month of July 2024, the resident received eight (8) bed/sponge baths and no showers, as of 07/24/24. e) Resident #51 On 07/24/24 at 1:28 PM a record review revealed, Resident #51 was admitted on [DATE] and has only received 1 shower. On 07/24/24 at 1:36 PMm during an interview Resident #51 stated they don't give much showers here even if I ask. Further review of the record on 07/24/24 revealed Resident #51 is care planned to have showers per preference. During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working on getting those issues resolved. f) Resident #65 On 07/22/24 at 3:36 PM, during an interview Resident #65 stated I don't get showers when I want one, it's been weeks since I have had a shower. On 07/24/24 at 1:41 PM, a record review revealed Resident #65 has had two (2) showers and 13 bed baths from 04/01/24 through 06/31/24. On 07/22/24 at 3:36 PM resident stated, I don't get showers when i want one, its been weeks since i have had a shower. During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working on getting those issues resolved. g) Resident #22 On 07/22/24 at 2:07 PM, during an interview Resident #22 stated I have not had a shower in two (2) weeks. On 07/24/24 at 12:03 PM, a record review revealed Resident #22 has had one (1) shower on 07/03/24 in the past month from 06/24/24 to 07/24/24. Further record review on 07/24/24 revealed Resident #22 had received four (4) showers from 04/01/24 through 06/31/24 and only seven (7) bed baths in this time frame. On 07/24/24 at 1:20 PM, a review of Resident #22's care plan revealed the following care plan intervention, showers per preference and requires extensive assistance with showers/bathing. During an interview with the Administrator on 7/25/24 at 11:00 AM she states they have identified some issues with showers and are currently working getting those issues resolved g) Resident #60 During the initial interview on 07/22/24 at 1:22 PM, Resident #60 stated, I don't get showers often. Heck, I would be happy with at least a bed bath once a week. I was in an actual shower probably over a month ago. I have asked for showers and they say they will get to me as soon as they can and then end up doing a bed bath or not a bath at all. A record review on 07/24/24 at 12:10 PM, revealed the following care plan: Focus: I need assistance with my ADL's due to my physical limitations and history of electrolyte imbalance and weakness Intervention: - Shower/bed bath scheduled per my preference. Monitor and document refusals. Further record review showed, Resident #60 is scheduled to have a shower on Wednesday's and Saturday's. Resident #60 received the following showers and/or bed baths from 05/02/24 to present: None noted for the month of May. No refusals noted from 05/02/24 to present. 06/11/24-Shower 06/19/24-Shower 06/22/24-Bed bath 06/23/24-Bed bath 06/25/24-Bed bath 06/26/24-Bed bath 06/27/24-Bed bath 06/29/24-Bed bath 06/30/24-Bed bath 07/04/24-Bed bath 07/11/24-Bed bath 07/18/24-Bed bath 07/21/21-Bed bath During an interview on 07/24/24 at 11:53 AM, The Director of Nursing (DON) stated, We have identified this problem and are working on it. She later confirmed, Resident #60 had not had a shower since 06/19/24, and had not been bathed according to schedule. h) Resident #63 During the initial interview on 07/22/24 at 1:46 PM, Resident #63 stated, The most recent shower I have had I believe was the fourth of July. They haven't offered. Well now that I think about it, I think the fourth of July was a bed bath. I have not had a shower since I have been in this room for about a month and a half. A record review on 07/24/24 at 12:10 PM, revealed the following care plan: Focus: Resident/Patient is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to: left AKA with complications of, history of cerebral infarction, spina bifida Intervention: -Provide resident/patient with substantial/maximal assist of staff for bathing. He refuses at times. Further record review showed that Resident #63 is scheduled to have a shower on Wednesday's and Saturday's. Resident #63 received the following showers and/ or bed bath from 05/02/24 to present: No refusals are noted. 05/07/24-Shower 05/19/24-Bed bath 05/20/24-Bed bath 06/12/24-Bed bath 06/23/24-Bed bath 06/25/24-Bed bath 06/26/24-Bed bath 06/27/24-Bed bath 07/04/24-Bed bath 07/06/24-Bed bath 07/11/24-Bed bath 07/16/24-Bed bath 07/21/24-Bed bath During an interview on 07/24/24 at 11:53 AM, The Director of Nursing (DON) stated, We have identified this problem and are working on it. She later confirmed that Resident #60 had not had a shower since 06/19/24 and had not been bathed according to schedule. 49751 50795

Based on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program for disposal of soiled linen, not wearing proper personal protective equipment (PPE) in enhanced barrier precaution (EBP) rooms, storage of used bedpans, placing a dirty dinner tray on the cart of clean trays and disposal of soiled gloves. These were random opportunities for discovery and had the potential to affect more than an isolated number of residents. Facility Census: 71. Findings included: a) Soiled Linen On 07/23/24 at 11:09 PM, an observation was made of linen laying on the PPE cart and soiled linen on the floor in room [ROOM NUMBER]. Registered Nurse (RN) #48 was notified and removed the soiled linen immediately. On 07/24/24 at 9:55 AM, the Administrator was notified and confirmed soiled linen should be disposed of in the appropriate container. b) Enhanced Barrier Precautions On 07/23/24 at 11:55 PM, an observation was made of RN #48 and Nurse Aide (NA) #39 transferring Resident #42, who was in an EBP room, without wearing the proper PPE. On 07/24/24 at 12:05 AM, a continued observation of NA #39 and NA #65 revealed they were providing incontinence care for Resident #42 without wearing the proper PPE. On 07/24/24 at 12:08 AM, NA #39 was interviewed regarding PPE. NA #39 stated, they have those signs hanging everywhere. NA #65 stated, it could have been from the resident who was in the room before. On 07/24/24 at 12:10 AM, RN #48 was interviewed regarding wearing PPE in EBP rooms. RN #48 nodded his head in regards PPE should be worn in EBP rooms. On 07/24/24 at 9:58 AM, the Administrator was notified. The Administrator confirmed PPE should be worn in EBP rooms. c) Door Signage On 07/25/24 at 10:05 AM, a copy of the door signage entitled Enhanced Barrier Precautions was received. The door signage gives guidance of what PPE should be worn when caring for the residents. The following activities were listed: --dressing --bathing/showering --transferring --providing hygiene --changing linens --changing briefs or assisting with toileting --device care or use of device --wound care On 07/25/24 at 10:06 AM, the Regional Nurse confirmed PPE should be worn in EBP rooms when providing the activities described on the door signage. d) Meal service On 07/22/24 at approximately 5:18 PM, Nurse Aide (NA) #60 removed a tray from the tray delivery cart on the 100 hall of the facility. NA #60 took the tray to a room and the resident refused the tray. NA #60 then proceeded to place the tray back onto the delivery cart. NA #60 acknowledged she placed the tray back onto the cart stating, I don't know what else to do with it. e) Bedpan in floor On 07/22/24 at 1:15 PM, three (3) bedpans were observed laying uncovered in the restroom of room [ROOM NUMBER]. On 07/22/24 at 2:25 PM, three (3) bedpans were laying uncovered in the restroom of room [ROOM NUMBER] On 07/22/24 at 4:43 PM, Nurse Aide(NA) #64 confirmed the three (3) bedpans should not be on the floor uncovered and picked them up to throw away. 50795 An observation, on 07/23/24 at 11:16 PM, revealed a pair of soiled, discarded, gloves on the floor of the 300 hallway. LPN #48 confirmed this was an infection control issue, and the gloves should have been discarded in the appropriate receptacle. During an interview on 07/25/24 at 10:31 AM , LPN #68 stated soiled gloves were to be discarded the in trash can in the resident's room. On 07/23/34 at 12:18 PM, NA #58 stated soiled dressings and gloves were to be discarded in the appropriate receptacle, in resident's room.

Based on record review, staff interview and resident interview the facility failed to honor residents' preference for bed bath/showers. This failed practice was found true for five (5) of (7) seven residents reviewed for the care area of choices during the Long-Term Care Survey Process. Resident identifiers: #60, #63, #40, #3 and #48. Facility Census: 71. Findings included: a) Resident #60 During the initial interview, on 07/22/24 at 1:22PM, Resident #60 stated, I don't get showers often. Heck, I would be happy with at least a bed bath once a week. I was in an actual shower probably over a month ago. I have asked for showers, and they say they will get to me as soon as they can and then end up doing a bed bath or not a bath at all. A record review on 07/24/24 at 12:10 PM, revealed the following care plan: Focus: I need assistance with my ADL's due to my physical limitations and history of electrolyte imbalance and weakness. Intervention: - Shower/bed bath scheduled per my preference. Monitor and document refusals. Further record review showed Resident #60 was scheduled to have a shower on Wednesday and Saturday. Resident #60 received the following showers from 05/02/24 to present: - 06/11/24 - 06/19/24 During an interview, on 07/24/24 at 11:53 AM, the Director of Nursing (DON) confirmed Resident #60 had not had a shower since 06/19/24. She said, We are working on this problem. b) Resident #63 During the initial interview on 07/22/24 at 1:46 PM, Resident #63 stated, The most recent shower I have had I believe was the fourth of July. They haven't offered. Well now I think about it, I think the fourth of July was a bed bath. I have not had a shower since I have been in this room for about a month and a half. A record review on 07/24/24 at 12:10 PM, revealed the following care plan: Focus: 'Resident/Patient is at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to: left AKA with complications of, history of cerebral infarction, spina bifida.' Intervention: -Provide resident/patient with substantial/maximal assist of staff for bathing. He refuses at times. Further record review showed Resident #63 is scheduled to have a shower on Wednesday's and Saturday's. Resident #63 received only one (1) shower on 05/07/24 for the time frame of 05/02/24 to current. During an interview on 07/24/24 at 11:53 AM, The Director of Nursing (DON) stated, We have identified this problem and are working on it. She later confirmed Resident #63 had not had a shower since 05/07/24. c) Resident #48 During an interview with Resident #48 on 07/23/24 at 2:38 PM, he stated the facility did not honor his request for showers. He stated he was scheduled for a shower two times a week, on Tuesday and Friday. He further stated he had not had a shower for over thirty (30) days. A review of Resident #48's MDS dated [DATE] at 3:20 PM, revealed under MDS Section F0400 for daily preferences, resident had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? His response was - Somewhat important Further review of resident's MDS dated [DATE] at 10:37 AM revealed he had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? His response was - Very Important Record review of Resident #48's shower logs revealed : January 2024 For the month of January 2024, the resident received only 13 bed/sponge baths, and no showers. February 2024 For the month of February 2024, the resident received only 14 bed/sponge baths, and no showers April 2024 For the month of April 2024, the resident received only two (2) bed/sponge baths, and one (1) shower. It was also noted one bed/sponge bath was given on 04/03/24 and the next bed/sponge bath was given two (2) weeks later, on 04/17/24. May 2024 For the month of May 2024, the resident received only 13 bed/sponge baths, and no showers. One bed/sponge bath was given on 05/16/24, and the next was given seven (7) days later, on 05/23/24. June 2024 For the month of June 2024, the resident received five (5) bed/sponge baths, and two (2) showers. One shower was given on 06/07/24, and the next bed/sponge bath was given six (6) days later, on 06/13/24. Another bed/sponge bath was given on 06/17/24, and the next bed/sponge bath was given six (6) days later, on 06/23/24. The bed/sponge bath on 06/23/24 was the last bed/sponge bath given for the month of June 2024. The next bed/sponge bath was given twelve (12) days later, on 07/05/24. A total of seven (7) bed/sponge were given as of 07/24/24. d) Resident #40 An interview with Resident #40 on 07/23/24 at 2:55 PM, revealed the facility did not honor his request for showers. He stated, he is scheduled for a shower two times a week, on Monday and Thursday. He further stated he had not had a shower for over thirty (30) days. A review of Resident #40's MDS dated [DATE] at 10:58 AM, revealed under MDS Section F0400 for daily preferences resident had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident's response - Not very important Further review of resident's MDS dated [DATE] at 4:10 PM, revealed he had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Resident's response was - Somewhat Important Record review of Resident #40's shower logs revealed : January 2024 For the month of January 2024, Resident #40 received eight (8) bed/sponge baths, and no showers. Resident received one bed/sponge bath on 01/04/24 and the next bed/sponge bath 11 days later, on 01/15/24. It was further noted his next bed/sponge bath was seven (7) days later on 1/22/24. February 2024 For the month of February 2024, Resident #40 received eight (8) bed/sponge baths, and no showers. One bed /sponge bath was given on 02/10/24, and the next bed/sponge bath was given eleven (11) days later on 02/21/24. March 2024 For the month of March 2024, Resident #40 received seven (7) bed/sponge baths, and no showers. It was also noted Resident #40 had received no bed/sponge baths, or showers, for eight (8) days, from 03/10/24 to 03/18/24. April 2024 For the month of April 2024, Resident #40 received four (4) bed/sponge baths, and no showers. Record review revealed resident had received no bed/sponge baths or showers for 15 days, from 04/12/24 to 04/27/24. May 2024 For the month of May 2024, Resident #40 received two (2) bed/sponge baths, and no showers. The resident received no bed/sponge baths, or showers for eighteen (18) days, from 04/27/24 to 05/15/24. Further, the resident also did not receive bed/sponge baths, or showers for twelve (12) days, from 05/19/24 to 05/31/24. June 2024 For the month of June 2024, Resident #40 received seven (7) bed/sponge baths, and one (1) shower. Record review revealed resident did not receive a bed/sponge bath, or shower for 12 days, from 05/19/24 to 06/04/24, and for seven (7) days, from 06/13/24 to 06/20/24 July 2024 For the month of July 2024, Resident #40 received three (3) bed/sponge baths and no showers, as of 07/24/24. Resident #40 received a bed/sponge bath on 07/08/24 and then received a bed/sponge bath 10 days later, on 07/18/24.Resident also did not receive a bed/sponge bath, or shower for six (6) days, from 07/18/24 to 07/24/24. e) Resident #3 An interview with Resident #3 on 07/23/24 at 2:49 PM, revealed the facility did not honor his request for showers. He stated he was scheduled for a shower two (2) times a week, on Wednesday and Saturday. He further stated he had not had a shower for over thirty (30) days. A review of Resident #3's MDS dated [DATE], at 1:19 PM, revealed under MDS Section F0400 daily preferences were not assessed. Further review of resident's MDS dated [DATE] at 4:10 PM, revealed he had responded to the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? His response was - Very Important Record review of Resident #3's shower logs revealed : January 2024 For the month of January 2024, the resident received three (3) bed/sponge baths, and no showers. February 2024 For the month of February 2024, the resident received three (3) bed/sponge baths, and no showers. March 2024 For the month of March 2024, the resident received three (3) bed/sponge baths, and one (1) shower. It was also noted resident had received no bed/sponge baths, or showers for seventeen (17) days, from 2/29/24 to 3/18/24. April 2024 For the month of April 2024, the resident received one (1) bed/sponge baths, and no showers. Record review revealed resident had received no bed/sponge baths or showers for nineteen (19) days, from 03/27/24 to 04/16/24. May 2024 For the month of May 2024, the resident received one (1) shower. June 2024 For the month of June 2024, the resident received four (4) bed/sponge baths, and one (1) shower. The resident's last shower was on 05/22/24, and his next shower was 20 days later, on 06/11/24. July 2024 For the month of July 2024, resident received eight (8) bed/sponge baths and no showers, as of 07/24/24. During an interview, on 07/24/24 at 11:53 AM, the Director of Nursing (DON) stated, We have identified this problem and are working on it. 50795

Based on observations and staff interviews the facility failed to keep residents' medical information confidential. Facility staff left a laptop open with resident information which was visible to the public. This was a random opportunity for discovery and had the potential to affect more than a minimal number of residents residing in the Long-Term Care facility. Facility census :71 Findings include: On 07/23/24 at 11:04 PM Licensed Practical Nurse (LPN) #48 was observed setting at the nurses' station on the computer. On 07/23/24 at 11:08 PM a computer was observed sitting on top of the medication cart unattended by staff. On the screen was resident identifiable information. During an interview on 07/23/24 at 11:12 PM, LPN #48 returned to the medication cart and locked the computer screen. He stated he was aware it was unlocked. During an interview with the Director of Nursing(DON) on 07/24/24 at 10:00 AM, The DON stated the computer and med (Medication) cart should have been locked.

Based on observation, resident interview and staff interview, the facility failed to provide a comfortable, homelike environment for residents residing in room [ROOM NUMBER], #202, #203, #303, #306, #309, #310, #312, #402, #404, #407, #408, #409, #410 and the slats of the packaged terminal air conditioner (PTAC) in Resident #60's room. These were random opportunities for discovery and had the potential to affect more than a limited number of residents. Facility Census: 71. Findings included: a) Resident Doors On 07/23/24 at 11:25 PM, a tour of the facility was complete. The tour found the following resident doors had putty applied to the visible cracks and door frames with rough edges of wood: --201 --202 --203 --303 --306 --309 --310 --312 --402 --404 --407 --408 --409 --410 On 07/24/24 at 9:55 AM, the Administrator was notified of issues found with the resident doors. The Administrator stated, I'll have maintenance check those. b) Resident #60 During the initial observation on 07/22/24 at 1:40 PM, it was found the slats in the Packaged Terminal Air Conditioner (PTAC) unit in Resident #60's room were covered in a moldlike substance. During an interview on 07/22/24 at 1:40 PM, Resident #60 stated, That could be why I have allergies. I can't remember if I am on allergy medicine. During an interview on 07/24/24 at 1:30 PM, The Maintenance Supervisor (MS) stated, Yes it is mold. I will get cleaned. 49465

Based on record review and staff interview the facility failed to develop and/or implement care plans related to Dementia, Anxiety, Dialysis and showers. This failed practice was found true for seven (7) of 34 residents reviewed for care plan accuracy and implementation during the Long-Term Care Survey Process. Resident identifiers: #54, #22, #65, #51, #61, #9 and #71. Facility Census 71. Findings included: a) Resident #54 A record review on 07/23/24 at 12:30PM, of Resident #54's medial record revealed a diagnosis of Dementia with an onset date of 10/04/23. Further record review showed no diagnosis of Dementia within the care plan. During an interview on 07/24/23 at 1:30PM, The Director of Nursing (DON), confirmed the diagnosis of Dementia was not in Resident #54's care plan. b) Resident #61 On 07/24/24 at 9:00 AM, a record review was completed of Resident #61's medical record. The review found the care plan had not been developed regarding the diagnosis of anxiety disorder. The resident was seen on two (2) occasions, listed as psychological telemedicine visits, dated 07/12/24 and 07/25/24 for Major Depressive Disorder and Generalized Anxiety Disorder as diagnoses. On 07/24/24 9:46 AM, an interview was held with Resident #61. The resident stated, I am feeling good .I do have problems with anxiety at times but if I have a problem I will talk to the nurse. On 07/24/24 at 1:23 PM, the Administrator was notified and confirmed the care plan was not developed for the diagnosis of anxiety. c) Resident #71 On 07/23/24 at 11:44 AM, a record review was completed for Resident #71. The review found the care plan had not been developed regarding the focus areas of activities of daily living (ADLs), suspected/actual infection, and risk for skin breakdown. Multiple blanks were noted under each focus area. On 07/23/24 at 1:00 PM, the Administrator was notified and confirmed the care plan had not been developed for the focus areas of ADLs, suspected/actual infection, and risk for skin breakdown. d) Resident #51 On 07/24/24 at 1:28 PM, a record review of Resident #51's medical record revealed Resident #51 was admitted on [DATE] and has only received 1 shower. On 07/24/24 at 1:36 PM, Resident #51 stated they don't give much showers here even if I ask. A further review of Resident #51's medical record found the following care plan intervention related to the residents Activities of Daily Living focus, Shower/bed bath scheduled per my preference. Monitor and document refusals. During an interview with the Administrator on 7/25/24 at 11:00 AM she stated they have identified some issues with showers and are currently working getting those issues resolved. e) Resident #65 On 07/22/24 at 3:36 PM Resident #65 stated I don't get showers when I want one, it's been weeks since I have had a shower. On 07/24/24 at 1:41 PM, A record review revealed Resident #65 has had two (2) showers and 13 bed baths from 04/01/24 through 06/31/24. Further review of Resident #65's care plan found it was void of any interventions related to how many times Resident #65 perferred to be showered. During an interview with the Administrator on 7/25/24 at 11:00 AM she stated they have identified some issues with showers and are currently working getting those issues resolved. f) Resident #22 On 07/22/24 at 02:07 PM Resident #22 stated I have not had a shower in two weeks. On 07/24/24 at 12:03 PM a Record review revealed Residen t#22 has had one (1) shower in the past month from 06/24/24 till 07/24/24. The one (1) shower was on 07/03/24. Further record review on 07/24/24 revealed Resident#22 had received four (4) showers from 04/01/24 through 06/31/24 and only seven (7) bed baths in that time frame. On 07/24/24 at 1:20 PM further review of care plan revealed Resident # 22 is care planned for getting showers per preference and requires extensive assistance with showers/bathing. During an interview with the Administrator on 7/25/24 at 11:00 AM she stated they had identified some issues with showers and were currently working on getting those issues resolved. g) Resident #9 A review of Resident #9's care plan found the following care plan intervention: Do Not take B/P (blood pressure) in my left arm due to anterior [NAME] (AV). Record review of weights/Vital summary revealed between 08/02/23 through 06/25/24, it is documented that resident #9 had a BP taken in the left arm on 17 different occasions. On 07/25/24 at 11:30 AM, The Director of nursing (DON) stated, The orders and care plan should have been followed to not take a B/P in the left arm. 49465 49751

Based on observation, policy review, and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents currently residing at the facility. Facility Census: 71. Findings Include: a) Treatment Cart On 07/22/24 at 12:50 PM, an observation found an unlocked, unattended treatment cart in the resident tv room. The cart was in a place which was easily accessible allowing access to these medication/treatment supplies by residents, unauthorized persons, or visitors. On 07/22/24 at 1:42 PM, during an interview with Registered Nurse (RN) #21, it was confirmand the Treatment cart was unlocked. RN #21 verified the treatment cart should not be unlocked when unattended. She closed and locked the cart at this time. b) Resident #57 An observation on 07/22/24 at 1:23 PM found nystatin powder generic myconustatin 60 gm, at Resident #57's bed side, unsecured and unattended and allowing access to this medication by residents, unauthorized staff, or visitors. During an interview on 07/22/24 at 1:28 PM, RN #21 confirmed, the nystatin powder generic myconustatin 60 gm, at Resident #57's bed side should not be left out in the room. RN #21 removed the nystatin powder at this time.

Based on record review and staff interview, the facility failed to conduct yearly performance evaluations for each Nurse Aide. This was true for three (3) out of five (5) Nurse Aides reviewed during the survey process. Staff identifiers: NA #34, NA #63, NA# 61. Facility census: 71. Findings included: A) Record review At approximately 2:45 PM on 07/23/24 a review of yearly performance evaluations and educations were conducted for randomly selected Nurse Aides (NA). During review, it was discovered the facility was missing yearly performance evaluations for NA #34, NA #63, and NA #61. B) Staff interviews At approximately 3:30 PM on 07/23/24 an interview was conducted with the Administrator. During the interview, the administrator confirmed the absence of performance evaluations for the three (3) NAs. The administrator stated We knew there were some missing and we are aware of it. We are trying to get caught up on them.

Based on observation, record review and interviews, the facility failed to provide a cognitively impaired resident with adequate supervision to prevent a fall with injury. This affected one (Resident #67) of one sampled resident reviewed for falls. Resident #67 experienced actual harm due to an avoidable fall resulting in a fracture to the right femur requiring surgical repair. The facility census was 74. Findings included: a) Resident #67 The clinical record was reviewed on 10/09/18 at 4:44 PM. An admission history form dated 08/01/18, documented Resident #67 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) of six of 15 indicating significant memory impairment. Under section G of the MDS was documented that Resident #67 needed the assistance of one person to steady his balance and transfer. The Plan of Care (P[NAME]) dated 08/01/18 and revised on 08/17/18 that focused on falls documented that Resident #67 was at high risk for falls due to impaired mobility, cognitive impairment causing lack of safety awareness, history of falls and need for assistance with balance during transfers. Review of the change of condition notes in the clinical record on 10/09/18 at 4:44 PM revealed that Resident #67 sustained a fall on 08/25/18 at 3:30 AM. Resident #67 was found sitting on the floor to the right side of his bed. He stated that he thought he was strong enough to get up on his own. The fall resulted in a skin tear to his left elbow. Resident #67 was reminded to use his call light for assistance. Review of the facility fall investigation for the 08/25/18 incident documented the corrective action to prevent reoccurrence was to educate Resident #67 about not getting up by himself and to use the call light. The P[NAME] was reviewed by the facility after the fall and the goal was to have no falls with injury. The intervention was to remind Resident #67 to use his call light when attempting to ambulate or transfer even though Resident #67 had a BIMS of six; thereby, indicating significant memory impairment. Continued review of the clinical record revealed Resident #67 received Occupational Therapy (OT) from 08/02/18 through 08/27/18. On the OT discharge summary, dated 08/28/18, documented that Resident #67 met the goal of transfer with contact guard with verbal cues to optimize opportunity for functional independence. Under the section of precautions, it was documented that Resident #67 had poor cognition and was a fall risk. Resident #67 received Physical Therapy (PT) from 08/02/18 through 08/31/18. On the PT discharge summary, dated 08/27/18, documented that Resident #67 met the goal of transfer with contact guard with verbal cues to optimize opportunity for functional independence. Under the section of precautions, it was documented that Resident #67 had poor cognition and was a fall risk. Under the summary of care, was documented that Resident #67 was now at supervision level for mobility tasks including ambulation with improved overall strength; however, Resident #67 remained limited due to poor balance. The change of condition note in the clinical records documented, on 09/04/18 at 3:30 PM, Resident #67 was found on the floor by the nurse's station. He stated that he was trying to go from his wheelchair to the rocking chair and bumped his head and had pain in his hip. He was sent to the hospital and had fractured his right femur. An Open Reduction Internal Fixation (ORIF) surgical procedure was performed to his right femur. On 10/10/18 at 9:14 AM and on 10/11/18 at 8:55 AM, Resident #67 was observed lying in bed. Resident #67 was now receiving hospice services and chose to remain in bed due to increased pain. On 10/11/18 at 9:09 AM, Licensed Practical Nurse (LPN) #49 was interviewed at the nurses station. LPN #49 stated that Resident #67 liked to stay in bed and read. She would always offer for him to get up. LPN #49 stated that Resident #67 would get up for therapy and on occasion he would stay up in the wheelchair and wheel himself around the hallways. She never observed him trying to transfer himself and confirmed that he had poor safety awareness. LPN #49 stated that the morning of his fall, he was looking to go to work. She was excited because that morning he was more talkative then usual and appeared happy to be up in the wheelchair. On 10/11/18 at 1:35 PM, Certified Occupational Therapy Assistant (COTA) #101 and Physical Therapy Assistant (PTA) #106 were interviewed. COTA #101 stated that after Resident #67's first fall on 08/25/18, OT was working on safety, making sure he knew not to get up by himself. COTA #101 stated that after a therapy session, therapy staff would inform the nursing staff that he was back in his room due to his impulsivity and poor safety awareness. PTA #106 stated that Resident #67 had issues with follow through due to his poor memory. It was hit or miss and a lot of time, it was more miss than hit (with Resident #67). It's difficult to manage dementia and this facility is not a dedicated dementia unit and it's difficult with the number of staff that we have. PTA #106 stated that therapy was able to improve his bed mobility and transfers, but not transfer safely. Resident #67 was someone with enough mobility and altered mental status to be dangerous. Upon discharge from PT, he was at a supervised level for his transfers. PTA #106 stated that Resident #67 was not safe, but he was mobile. On 10/11/18 at 2:00 PM, the Medical Director was interviewed. The Medical Director stated that he arrived at the facility just after Resident #67 fell . He was told that the resident was trying to transfer from his wheelchair to the rocking chair. The Medical Director assessed Resident #67 and sent him to the hospital for a probable femur fracture. On 10/11/18 at 2:15 PM, Registered Nurse (RN) #44 was interviewed. RN #44 stated the day of Resident #67's fall, she had just come on shift and was happy to see Resident #67 up in his wheelchair scooting around, because he usually liked to stay in bed. RN #44 stated that she had never observed Resident #67 try to transfer himself out of his wheelchair. RN #44 was passing medications when a Certified Nursing Assistant (CNA) informed her of the fall. She stated the area around the nurse's station was empty and there was no staff present to provide supervision to prevent the fall. On 10/11/18 at 3:20 PM, CNA #10 was interviewed. CNA #10 did not witness the fall but was aware that Resident #67 was up in his wheelchair because earlier in the day he was trying to get out of bed. CNA #10 stated that Resident #67 didn't say much, he just wheeled around. Resident #67 experienced actual harm due to an avoidable fall with fracture requiring surgical repair. The actual harm to Resident #67 resulted from the facility implementing inappropriate interventions for a resident with severe cognitive impairment with a high risk of falls from impaired mobility.

Based on medical record review, review of incident reports, staff interview, resident interview, and family interview, the facility failed to ensure each resident was free from neglect. Two (2) of seven (7) residents reviewed for falls were not provided care and services necessary to prevent physical harm. A paraplegic [MEDICAL CONDITION] fell out of bed while care was being provided, and sustained a significant injury. Appropriate interventions were not initiated until after the resident had a fall resulting in a serious injury which required surgery. Another resident fell when left unattended in the bathroom. The resident's minimum data set (MDS) assessment prior to the fall noted the resident required extensive assist of one for transfers and required staff assistance when moving (including on and off the toilet) due to unsteadiness. The MDS indicated the resident required extensive assist (weight bearing) of one with toileting. Resident identifiers: #71 and #20. Facility census: 73. Findings include: a) Resident #71 [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/14/12, revealed she was coded for bed mobility as totally dependent. She required a two+ person physical assist to complete this task. She scored a 15 (fifteen) on the Brief Mental Assessment (BIM), the highest score possible to attain, which signified that she was cognitively intact. An incident report, dated 01/19/13 at 2:25 p.m., was reviewed. It revealed Resident #71 slid out of bed onto the floor while one (1) aide, Employee #97, was providing incontinence care for her. She was transferred to an acute care facility at 2:40 p.m. From there, she was transferred and admitted to another acute care hospital, where she underwent surgery to repair a fractured right femur that was sustained from the fall. Review of a nurse progress note, dated 01/20/13 at 8:38 a.m., as a late entry for 01/19/13 at 2:25 p.m., revealed the resident was found on the floor next to her bed, with her head at the foot end of the bed, and lying on her back. The nurse assessed the resident was alert at the time of the incident. The resident's November 2012 care plan revealed no specific guidelines related to the number of persons required to assist with transfers and turning, but did say nursing assistants (NAs) were to provide care for her in pairs. During an interview with the administrator, on 02/11/13 at 11:45 a.m., she said this resident had been a one-person assist for activities of daily living (ADL) and hygiene prior to her fall on 01/19/13. She said aides were to care for this resident in pairs due to safety needs of the aides, as this resident had been known to make untrue allegations in the past, and had exhibited attention seeking behaviors toward staff. An interview was conducted with the resident on 02/11/13 at 12:30 p.m. At that time, she alleged Employee #97 assisted her to bed on 01/19/13 with the Hoyer lift, with no other staff assistance. She said the aide did not place her up high enough in the bed during the Hoyer lift transfer, and she had little of the left upper side rail to hold on to. She alleged the aide refused assistance from other staff twice, and proceeded to clean and help the resident turn, with no other staff assistance. The resident alleged the aide had accidentally flipped her out onto the floor after she told the resident to turn onto her left side, and then pulled quickly on the pad beneath her. The resident said since her return to the facility, after having surgery to repair the fractured right femur sustained from the fall, there were always two (2) staff present when turning her because she had to be log rolled. Also, she said since the accident, staff now always raised the lower left rail when they were turning her until she was repositioned. Confidential staff interviews, with twelve (12) nursing assistants on two (2) shifts, on 02/11/13, found that seven (7) of those interviewed acknowledged this resident was able to assist with turning during care, and only one (1) staff member was required for this task prior to her fall on 01/19/13. Five (5) of those interviewed reported that prior to the fall, they always used two (2) people to help with the turning and repositioning of this resident. They unanimously agreed that since the fall on 01/19/13, they now always used two (2) staff members for turning, repositioning and cleaning this resident. In addition, they now raised the left lower rail when turning her onto her left side. The upper rails were always left raised. Review of the current care plan revealed a revision, dated 01/23/13, to raise the left lower side rail when giving care or turning the resident, otherwise it was to be down. On 02/11/13 at 3:00 p.m., the administrator produced an in-service education agenda, dated 01/24/13 and signed by the Director of Nursing, noting that a third side rail had been added to the left side of Resident #71's bed at the bottom. When rendering care to her, both rails at the top of the bed, in addition to the bottom left side of the bed, were to be raised. After care had been completed and the resident positioned in bed, the bottom rail might be lowered. "This will assist in keeping her leg from coming off the bed when turning her to the left side during care." The sign-in sheet contained signatures of 35 NAs. A second in-service education agenda was signed and dated by the Director of Nursing on 01/29/13. In it, she directed that two (2) people were to turn and reposition Resident #71. The use of the third side rail on the left side of her bed was to be up when turning and repositioning, then lowered after the repositioning was complete. Also, pillows were to be placed between the legs when turning her (log rolling), and utilizing the draw sheet to turn her as a unit. The sign-in sheet was signed by thirteen (13) registered nurses, eight (8) licensed practical nurses, and thirty-one (31) nursing assistants. Review of the current care plan revealed a revision, dated 01/30/13, for a pillow to be placed beneath the resident's right leg when turning to stabilize the leg, and to turn her utilizing the log roll method to keep the leg in position. . . b) Resident #20 The roster/sample matrix, printed 02/11/13, was reviewed on 02/11/13 at 11:00 a.m. Resident #20 was noted to have fallen. Review of the incident reports revealed a fall occurred on 11/26/12. Further review of the incident report, dated 11/26/12, revealed the resident had been left unattended in the bathroom. The nursing assistant related she had left the resident unattended while obtaining supplies. The medical record, change in condition progress note, dated 11/26/12, noted the resident had fallen in the bathroom. It also noted a loss of balance, with lower extremity weakness. Further review of the change in condition progress notes revealed a history of falls. The physical therapy evaluation, completed on 11/28/12, was reviewed with Employee #98 (Physical Therapist.) She said the evaluation indicated Resident #20 required assistance with transfers. During a resident observation, on 02/11/13 at 10:15 a.m., Resident #20 was propelling herself in her wheelchair. She was going from room to room, searching for her daughters. Resident #23 said, "she's confused." The resident was again observed on 02/11/13 at 11:20 a.m. She was visiting with a family member. She was not oriented to place or time. Another observation, on 02/12/13 at 8:00 a.m., revealed the resident lying in bed. She was alert and talkative. She was unable to relate place and time concepts. She could not state the season, month, or year. She did not know who was president of the United States. Review of the care plan, on 02/12/12 at 11:30 a.m., revealed the resident was easily distracted and had trouble staying focused. It also noted she had poor safety awareness and needed frequent reminding. The social services evaluation, completed on 11/05/12, noted the resident's BIMS score was 3 (severely cognitively impaired). A family member was interviewed on 02/11/12 at 11:19 a.m. She stated she was aware the resident had fallen. She said, "it usually happens right around the 4:00 hour, when (Resident #20) gets agitated and nervous." She said the resident required assistance when toileting. She related the resident had "fallen twice, recently." She said one incident occurred when "she was on the potty." She said the resident told her, "I fell in my sh__." She further added the resident "probably didn't want to sit there any longer." Nursing assistant, Employee #17, was interviewed on 02/11/12 at 2:30 p.m. She said Resident #20 required assist of one (1) for transfers with limited assistance. She also stated the resident was at risk for falls, but had no fall precautions. Review of the medical record, on 02/11/13 at 5:00 p.m., revealed on 09/27/12, prior to the fall on 11/26/12, a lift-transfer-repositioning evaluation was completed. It noted the resident required the use of a gait belt for transfers. The evaluation noted the resident could not ambulate or transfer safely, independently, or without supervision. The MDS nursing assessment, completed on 11/05/12, indicated Resident #20 had fallen since the prior assessment. It also noted she had severe alteration in judgement. The MDS, with an ARD of 11/06/12, noted the resident required extensive assist of one for transfers. It also noted she was not steady, and only able to stabilize with staff assistance when moving from a seated to standing position; walking; turning around; moving on and off the toilet and surface to surface transfers. The MDS indicated the resident required extensive assist (weight bearing) of one with toileting. The physician's orders [REDACTED]. These included [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (narcotic [MEDICATION NAME]), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (diuretic), and [MEDICATION NAME] (narcotic [MEDICATION NAME]). Employee #46, a licensed practical nurse, (LPN) was interviewed on 02/12/13 at 7:54 a.m. She stated falls interventions depended on the care plan and the resident's cognition. She was unaware of a protocol for fall prevention when toileting a resident at risk for falls. On 02/12/13 at 7:58 a.m., Employee #16, a nursing assistant, was interviewed. When questioned about Resident #20's toileting protocol, she stated, "We stay with her, because she is a fall risk. She gets up and down." "We have to stay with them, because they get down and up, Resident #20, I'll have to look. She may need help," stated Employee #64, an LPN, on 02/12/13 at 8:05 a.m. She then reviewed the resident's activities of daily living (ADL) flow sheet, and stated, "Yes, she is dependent on staff, they should have stayed with her." .

Based on resident interview, record review, and staff interview, the facility failed to ensure adequate supervision and assistance devices to prevent avoidable accidents for two (2) of seven (7) sample residents, one (1) of whom sustained a significant injury. The resident who sustained the injury had paralysis and a left above the knee amputation. The facility had no individualized interventions in place to prevent accidents regarding bed mobility and transfers, even though the resident was assessed as totally dependent in these areas. Additionally, the resident was assessed as requiring a two (2) person physical assist with bed mobility and transfers. Accident prevention interventions were not put into place until after the resident sustained [REDACTED]. The other resident was left unattended on the toilet. Her assessments noted she was cognitively impaired, had balance problems, lower extremity weakness, and a history of falls. The comprehensive assessment noted she was not steady, and was only able to stabilize with staff assistance when moving from a seated to standing position; walking; turning around; moving on and off the toilet and surface to surface transfers. There were no individualized interventions in place, for assistance devices or supervision to prevent accidents, related to this resident's identified mental and physical limitations. Resident identifiers: #71 and #20. Facility census: 73. Findings include: a) Resident #71 [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/14/12, revealed she was coded for bed mobility as being totally dependent on staff, and required a two+ person physical assist to complete this task. The incident report, dated 01/19/13 at 2:25 p.m., was reviewed. It revealed Resident #71 slid out of bed onto the floor while one (1) nursing assistant, Employee #97, was providing incontinence care for her. She was transferred to an acute care facility at 2:40 p.m. From there, she was transferred and admitted to another acute care hospital, where she underwent surgery to repair a fractured right femur that was sustained from the fall. Review of a nurse's progress note, dated 01/20/13 at 8:38 a.m., as a late entry for 01/19/13 at 2:25 p.m., revealed the resident was found on the floor next to her bed, with her head at the foot end of the bed and lying on her back. The resident's November 2012 care plan revealed no specific guidelines related to the number of persons required to assist with transfers and turning, but did say that nursing assistants (NAs) were to provide care for her in pairs. During an interview with the administrator, on 02/11/13 at 11:45 a.m., she said this resident had been a one-person assist for Activities of Daily Living (ADLs) and hygiene prior to her fall on 01/19/13. She said aides were to care for this resident in pairs. The administrator stated this for the safety needs of the aides, as this resident was known to make untrue allegations in the past, and exhibited attention seeking behaviors toward staff. Confidential staff interviews, with twelve (12) nursing assistants on two shifts, on 02/11/13, found that seven (7) of those interviewed acknowledged this resident was able to assist with turning during care, and only one (1) staff member was required for this task prior to her fall on 01/19/13. Five (5) of those interviewed reported that prior to the fall, they always used two (2) people to help with the turning and repositioning of this resident. They unanimously agreed that since the fall on 01/19/13, they now always used two (2) staff members for turning, repositioning and cleaning this resident. In addition, they stated they now raise the left lower rail when turning her onto her left side, and the upper rails were always left raised. Review of the current care plan revealed a revision, dated 01/23/13, to raise the left lower side rail when giving care or turning the resident, otherwise it was to be down. On 02/11/13 at 3:00 p.m., the administrator produced an in-service education agenda, dated 01/24/13 by the Director of Nursing, noting that a third side rail had been added to the left side of Resident #71's bed at the bottom. When rendering care to her, both rails at the top of the bed, in addition to the bottom left side of the bed, were to be raised. After completion of care, and the resident was positioned in bed, the bottom rail may be lowered. "This will assist in keeping her leg from coming off the bed when turning her to the left side during care." The sign-in sheet contained signatures of 35 nursing assistants.. A second in-service education agenda was signed and dated by the Director of Nursing on 01/29/13. In it, she directed that two (2) people were to turn and reposition Resident #71. The use of the third side rail on the left side of her bed was to be up when turning and repositioning, then lowered after the repositioning was complete. Also, pillows were to be placed between the legs when turning her (log rolling), and a draw sheet was to be used to turn her as a unit. The sign-in sheet was signed by 13 registered nurses, eight licensed practical nurses, and 31 nursing assistants.. Review of the current care plan revealed a revision, dated 01/30/13, that she was to have a pillow placed beneath her right leg when turning to stabilize the leg, and turn utilizing the log roll method to keep the leg in position. All the safety and accident prevention interventions were initiated after the fact. There were no such interventions to ensure adequate supervision and/or assistance devices were provided to prevent accidents to the extent possible. . b) Resident # 20 Review of incident reports revealed this resident fell on [DATE]. According to the report, the resident was left unattended in the bathroom and fell during that time. The report indicated the nursing assistant left the resident unattended while obtaining supplies. The medical record change in condition progress note, dated 11/26/12, which described the fall, noted the resident had balance problems, lower extremity weakness, and a history of falls. The physical therapy evaluation, completed on 11/28/12, was reviewed with Employee #98 (Physical Therapist.) She said the evaluation indicated Resident #20 required assistance with transfers. A family member was interviewed on 02/11/13 at 11:19 a.m. She stated she was aware the resident had fallen. She said, "it usually happens right around 4:00 hour, when she gets agitated and nervous." She said the resident required assistance when toileting. She related the resident had "fallen twice, recently." She said one incident occurred when "she was on the potty." She further added the resident "probably didn't want to sit there any longer." A nursing assistant, Employee #17 was interviewed on 02/11/13 at 2:30 p.m. She said Resident #20 required assistance of one for transfers with limited assistance. She also stated the resident was at risk for falls, but had no fall precautions. Review of the medical record, on 02/11/13 at 5:00 p.m., revealed on 09/27/12, prior to the fall on 11/26/12, a lift-transfer-repositioning evaluation was completed. It noted the resident required the use of a gait belt for transfers. The evaluation noted the resident could not ambulate or transfer safely, independently, or without supervision. The MDS, with an ARD of 11/06/12, noted the resident required extensive assist of one for transfers. It also noted she was not steady, and only able to stabilize with staff assistance when moving from a seated to standing position; walking; turning around; moving on and off the toilet and surface to surface transfers. The MDS indicated the resident required extensive assist (weight bearing) of one with toileting. An observation, on 02/12/13 at 8:00 a.m., found the resident was alert and talkative, but unable to relate place and time concepts. She could not state the season, month, or year, and did not know who was president of the United States. Review of the care plan, on 02/12/13 at 11:30 a.m., revealed the resident was easily distracted and had trouble staying focused. It also noted she had poor safety awareness and needed frequent reminding. The social services evaluation, completed on 11/05/12, noted the resident's BIMS score was 3 (severely cognitively impaired). However, the care plan did contain interventions regarding the needs identified in the lift-transfer-repositioning evaluation, which noted the resident required the use of a gait belt for transfers, and also noted the resident could not ambulate or transfer safely, independently, or without supervision. Additionally, the facility did not develop a care plan using the results of the MDS which noted the resident was not steady, was only able to stabilize with staff assistance when moving from a seated to standing position; walking; turning around; moving on and off the toilet and surface to surface transfers, and that the resident required extensive assist (weight bearing) of one with toileting. Additionally, another incident report revealed the resident had fallen on 01/23/13 at 3:30 p.m., while helping another resident. She was found on the floor in room 311a. Resident #20 resided in room 202b. It should be noted, the current care plan described the resident was to be kept in a supervised area when she was out of bed in her wheelchair. On 02/12/13 at 7:58 a.m., Employee #16, a nursing assistant, was interviewed. When questioned about Resident #20's toileting protocol, she stated, "We stay with her, because she is a fall risk. She gets up and down." "We have to stay with them, because they get down and up, Resident #20, I'll have to look. She may need help," stated Employee #64, an LPN, on 02/12/13 at 8:05 a.m. She then reviewed the resident's activities of daily living (ADL) flow sheet, and stated, "Yes, she is dependent on staff, they should have stayed with her." The facility did not develop a care plan which reflected the needs identified in the lift-transfer-repositioning evaluation This evaluation noted the resident required the use of a gait belt for transfers and noted the resident could not ambulate or transfer safely, independently, or without supervision. Additionally, the facility did not develop a care plan using the results of the MDS which noted the resident was not steady, was only able to stabilize with staff assistance when moving from a seated to standing position; walking; turning around; moving on and off the toilet and surface to surface transfers, and that the resident required extensive assist (weight bearing) of one with toileting. Employee #46, licensed practical nurse, (LPN) was interviewed on 02/12/13 at 7:54 a.m. She stated falls intervention depends on the care plan and the resident's cognition. She was unaware of a protocol for fall prevention when toileting a resident at risk for falls. On 02/12/13 at 7:58 a.m., Employee #16 was interviewed. When questioned about Resident #20's toileting protocol, she stated, "We stay with her, because she is a fall risk. She gets up and down." "We have to stay with them, because they get down and up, Resident #20, I'll have to look. She may need help," stated Employee #64, on 02/12/13 at 8:05 a.m. She then reviewed her activities of daily living (ADL) flow sheet, and stated, "Yes, she is dependent on staff, they should have stayed with her." Employee #85 (nurse practice educator) was interviewed on 02/12/13 at approximately 9:00 a.m. She said if the resident understood how to use the call bell she would be left alone in the bathroom. She did not provide information related to residents with memory impairment. During an interview with the administrator (Employee #20), she relayed the resident knew how to pull the call bell. It was questionable whether the resident would know she needed to call for assistance, since the social services evaluation, completed on 11/05/12, noted the resident's BIMS score was three (3), representing "severely cognitively impaired." The administrator agreed, during an interview on 02/12/13 at 12:00 p.m., residents with cognitive impairment may not remember to utilize the call bell. She said, "We will educate the staff regarding leaving residents unattended in the bathroom." .

Based on observation, medical record review, review of the Centers for Medicaid and Medicare (CMS) "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual" for the Minimum Data Set (MDS) 3.0, review of the National Pressure Ulcer Advisory Panel (NPUAP), and staff interview, the facility failed to provide care and services to promote healing of a pressure ulcer for one (1) of four (4) sampled residents with pressure ulcers. A resident who was admitted with a Stage II pressure ulcer to the right outer ankle did not receive care and services to promote healing of the wound. As a result of the staff not providing care and services, the resident suffered harm as the wound progressed to a Stage III area, indicating further tissue damage, and exhibited signs and symptoms of infection. It was further determined nursing staff failed to stage the resident's pressure ulcer in accordance with the RAI and NPUAP guidelines. Resident identifier: #195. Facility census: 74. Findings include: a) Resident #195 During a family interview, conducted in Resident #195's room at 3:15 p.m. on 03/26/12, it was noted Resident #195 was positioned on his right side with a pillow between his lower extremities and his left leg resting on his right leg. Review of the medical record found Resident #195 was admitted to the facility on [DATE] with a Stage II pressure ulcer on his outer right ankle. His assessment also identified he was at risk of developing pressure ulcers. His [DIAGNOSES REDACTED]. The MDS assessment, with an assessment reference date (ARD) of 03/22/12, was coded the resident had one (1) Stage II pressure ulcer which was present upon admission. The assessment also indicated the tissue type for the ulcer at the most advanced stage was granulation tissue. The presence of granulation tissue would indicate the wound was at least a Stage III as this tissue type would not be present in a Stage I or II ulcer. Additionally, the resident was assessed as requiring the extensive assistance of two (2) staff members for bed mobility. However, according to the assessment, the resident was not on a turning/repositioning program. The care plan, initiated on 03/15/12, found nursing staff were to float the resident's heels while in bed. Subsequent observations, conducted on the evening of 03/26/12, the morning and afternoon of 03/27/12, and every 30 minute observations from 8:30 a.m. through 11:30 a.m. on 03/28/12, found the resident positioned on his right side with a pillow placed between his lower extremities. His left leg rested on his right leg with his right outer ankle resting directly on the mattress. This position allowed the wound on his right outer ankle to be subjected to pressure from the weight of his right leg and his left leg. He was not observed to have his heels floated during these observations. At 1:00 p.m. on 03/28/12, nursing assistant (NA) staff were observed transferring the resident from a geriatric chair to his bed with a mechanical lift. The resident's outer right ankle was noted to be covered with a clear dressing. The wound was noted to have a yellowish colored exudate in the center. The resident's nurse, Employee #50, was interviewed at 1:15 p.m. on 03/28/12, concerning the resident's pressure ulcer. She was apprised of the observation of the yellow exudate visible through the dressing. Employee #50 stated she had dressed the resident's ankle that morning and the wound was clean and dry with no drainage. She said it had looked "much better." Employee #50 assessed the resident's wound following the conversation. She removed the clear dressing and yellowish colored exudate was noted to drain from the resident's wound onto the dressing. The wound bed was beefy red in color with yellow tissue remaining within the borders of the wound. Employee #50 stated, "It did not look like that this morning, I swear." The skin integrity reports included nursing assessments of the pressure ulcer present on the resident's right ankle. The wound was described as follows: -- On 03/15/12, the wound as assessed as a Stage 2 measuring 2.6 cm x 1.4 cm with no depth. -- On 03/21/12, the wound was assessed as remaining a Stage 2, measuring 2.4 cm x 1.2 cm with no depth. -- On 03/28/12 at 1:00 p.m., Employee #50 assessed the wound as remaining a Stage 2 which had increased in size. The nurse documented the wound measured 2.5 cm x 2.0 cm x 1 cm depth with granulation tissue and slough. The surrounding tissue was noted to be inflamed/indurated, the wound edges calloused and macerated. These conditions were not present on previous weekly assessments. On 03/29/12 at 7:21 a.m., the director of nursing (DON), Employee #30, wrote "Right ankle assessed this a.m. Small amt. of yellow drainage noted on old dresing (sic) without odor. Surrounding tissue with s/s (signs and symptoms) of infection, redness or swelling. Wound bed with granulation and area with less moisture. Area cleansed with WSC (wound skin cleanser) surrounding tissue skinprepped, antibiotic ointment applied and covered with [MEDICATION NAME] ...". Review of the CMS RAI 3.0 Manual, page M-9, found the following language, "A Stage 2 pressure ulcer presents as a shiny or dry shallow ulcer without slough or bruising." On page M-22 the manual includes, "Stage 2 pressure ulcers should not be coded as having granulation, slough, or necrotic tissue as by definition they do not have this extent of damage ... ". Review of NPUAP pressure ulcer staging guidelines found the following: "Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. . . .Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling." The nursing staff failed to accurately stage this pressure ulcer as a Stage 3 wound in accordance with established guidelines. The staff also failed to provide appropriate and effective pressure relieving measures in an attempt to avoid further breakdown on the resident's right outer ankle. .

Based on observations, a review of the medical record, and staff interviews, the facility did not ensure one (1) resident of random opportunity received appropriate and timely care and services after indicating to a nurse that her mouth and throat were sore and that she could not eat because of the irritation. Resident identifier: #33. Facility census: 73. Findings include: a) Resident #33 Random observation, on 08/26/09 at 12:30 p.m., found Resident #33 sitting up in bed with a food tray on the overbed table in front of the resident. The resident was not eating. When interviewed, the resident stated she could not eat, because her mouth and throat were burning and very sore. When asked if she had reported this to a nurse, the resident stated she had told the nurse a little while ago. A registered nurse (RN - Employee #5) caring for Resident #33 was asked by this nurse surveyor to assess the resident's mouth and throat, because the resident could not eat and was complaining of a sore mouth and throat. The RN came into the room and asked the resident if her mouth and throat were sore, but she did not look inside the resident's mouth. The nurse surveyor asked the director of nursing (DON - Employee #30) to accompany the RN (Employee #5) to the room for an assessment of the resident's mouth and throat. The RN stated she had ordered "swish and swallow" for the resident. A review of the physician's orders did not indicate any new orders were received for the resident's mouth and throat. At 12:35 p.m., the DON and the RN entered the resident's room. The RN stated to the resident that she was sorry for bothering the resident during lunch. The resident stated, "I can't eat my lunch, because my mouth and throat are so sore." The DON brought a flash light and a tongue blade for the assessment of the resident's mouth. The DON stated that the resident's mouth was red and the resident's throat was also very red. An observation of the resident's mouth revealed the resident's upper gum was red and irritated, and the resident's throat was also red and irritated. An order, dated 08/26/09 at 12:45 p.m., was received from the physician for: "Magic mouthwash swish around in mouth 3 x's daily until soreness resolves." A review of the resident's medical record revealed [REDACTED]. Nursing notes or physician progress notes [REDACTED]. A lab report, dated 08/12/09, indicated, "Culture throat - no Beta-[DIAGNOSES REDACTED] source - Streptococcus isolated." An interview with the DON, on 08/26/09 at 1:30 p.m., revealed the physician was in the building the evening of 08/09/09 and ordered the culture of the resident's throat. She was unaware as to why the culture was ordered. .

Based on observations, a review of the medical record, and staff interviews, the facility failed to ensure two (2) of a sample of nine (9) residents (#64 and #24) received care and services, to include prompt identification and treatment of [REDACTED]. Resident #64 developed a coccygeal pressure ulcer during a hospital stay which was being treated by the facility. Upon removal of the dressing to this wound on the morning of 08/25/09, observation revealed two (2) additional breaks in skin integrity of which the nurse was not previously aware and for which no treatment had been initiated. One (1) of these wounds was a Stage II and the other was a Stage IV. Resident #24 had a pre-existing pressure ulcer to her coccyx and received dressings to her right foot and ankle. Upon removal of the dressing to the coccygeal wound on the morning of 08/25/09, observation two (2) additional breaks in skin integrity of which the nurse was not previously aware and for which no treatment had been initiated, both of which were dime-size and open. Additionally, observation of the resident's right foot at that time found the area on her right ankle was not covered with a dressing. Facility census: 73. Findings include: a) Resident #64 On 08/25/09 at 9:40 a.m., observation revealed the resident was receiving a dressing change to a pressure area on her coccyx. A registered nurse (RN - Employee #5) removed the dressing on the pressure sore and, below the coccygeal pressure sore, two (2) new pressure sores had developed. Employee #5 was unaware these two (2) new pressure sores had developed. She identified one (1) pressure sore as a Stage II and the other as a Stage IV. An observation revealed one (1) area was dime-size and open. The other area was nickel-size and open with white tissue in the center. An interview with the director of nursing (DON - Employee #30), on 08/25/09 at 11:30 a.m., revealed dressings were changed every day for this resident. She further stated she was responsible for the weekly measurements of the pressure sores in the facility and that she monitored the treatments for these pressure sores. A review of the resident's medical record revealed [REDACTED]. Orders were then written to treat the two (2) new pressure areas of which staff at the facility was not aware existed. A subsequent interview with the DON, on 08/26/09 at 10:00 a.m., revealed the physician had arrived at the facility on the evening of 08/25/09, assessed the two (2) new pressure sores for Resident #64, and had written orders to treat the new pressure sores. b) Resident #24 On 08/25/09 at 11:10 a.m., observation revealed the resident was receiving a dressing change to the coccyx area. The licensed practical nurse (LPN - Employee #87) removed the dressing to the coccygeal area, and two (2) new pressure areas were observed below the coccyx area. Both areas were dime-size and were open. The LPN was unaware of the two (2) new pressure sores. She stated that daily dressing were ordered to the pressure ulcer on the resident's coccyx and to the resident's right foot and ankle. Observation of the resident's right foot revealed a nickel-size open area that was not covered with a dressing. The LPN indicated the open area needed to be dressed and when she did the dressing change to the resident's right foot, a dressing was applied to the ankle. An interview with the DON, on 08/25/09 at 11:30 a.m., revealed dressings were changed every day for this resident. She further stated she was responsible for the weekly measurements of the pressure sores in the facility and that she monitored the treatments for these pressure sores. A subsequent interview with the DON, on 08/26/09 at 10:00 a.m., revealed the physician arrived at the facility on the evening of 08/25/09, assessed the two (2) new pressure sores for Resident #24, and wrote orders to treat the new pressure sores. .