Every finding on record at Spjst Rest Home 1

Based on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of five residents reviewed for care plan in that: The facility failed to update Resident #1's care plan after an X-ray (a form of electromagnetic radiation used in medicine to create images of the inside of the body for diagnostic purposes) result dated 07/01/2026 reflected a nondisplaced (a fracture where the bone pieces stay properly aligned) acute appearing fracture noted of the right distal tibia (the lower end of the shinbone (tibia) that connects to the ankle joint) This deficient practice placed residents at risk for not getting right interventions, risk for harm and hospitalization.Findings included: Review of Resident #1's face sheet printed 07/14/2026 reflected a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with the following dx: Alzheimer's disease with late onset (the most common form of dementia, developing in individuals aged 65 and older. It typically presents with progressive short-term memory loss, language difficulties, and impaired judgment.), Age-related physical debility, Pain in right lower leg. Review of Resident#1's quarterly MDS assessment dated [DATE] reflected a BIMS score of 00, indicating the Resident #1 was unable to participate. It also indicated both short and long-term memory problems. Review of Resident 1's care plan edited 06/09/2026 reflected Resident #1 was at risk for falls due to weakness and impaired cognition, had complaints of pain/discomfort and is at risk for injury from decrease in ADLs fragile skin and a potential for skin tears and bruising and Resident #1 had impaired decision-making related to Alzheimer. Resident #1's care plan did not address Resident #1 having a fracture of her right tibia. Review of Resident #1's progress notes dated 07/01/2026 at 10:39 am written by LVN A reflected: 8/9 RLE discoloration, resident is up in wc this shift, continues to express pain to RLE when moved. Resident will not keep leg elevated on footrest while in wc. Residents have PRN acetaminophen 325 mg x 2 order for pain medication, will administer to resident. Resident has received an order from hospice nurse [name] for x ray to RLE, at RP request. [Company name] Radiology has been faxed with orders, phone call to verify received, no ETA given. Review of Resident #1's X-ray completed on 07/01/2026 reflected: RIGHT ANKLE. AND TIBIA/FIBULA (the calf bone), 3 VIEWS-- There is a nondisplaced fracture noted of the distal tibia. Talar dome (upper surface of the ankle and ankle mortise(a joint that connect 2 pieces) appear normal. The bony mineralization is unremarkable (within normal limit). There is mild soft tissue swelling noted. Impression:Nondisplaced acute appearing fracture noted of the distal tibia. Review of Resident #1's Progress notes dated 07/01/2026 at 09:55 pm written by LVN B reflected: At 3:00 pm in bed resting [Company name] radiology here to do X-ray R leg, when results received DON aware of findings, 7:20 pm new order from [Hospice nurse] RN place boot on R foot with fracture, elevate foot, leave in bed next 2-3 days turn and reposition as needed, 9:00 pm resting quietly will monitor, RLE with dark purple bruising and swelling note is on eliquis 2.5 mg (blood thinner medication) oral will continue to monitor. During an interview on 07/14/2026 at 2:27 pm the DON stated the facility was aware of Resident #1's right tibia fracture. The DON stated the X-ray was completed on 07/01/2026 on Resident #1's right tibia and was positive for fracture. The DON stated Resident #1 went out on pass with her family on 06/27/2026 and by 06/29/2026 the facility noticed discoloration at right leg and was monitoring due to Resident #1 being on a blood thinner medication. The DON stated Resident #1's right tibia fracture should have been care planned to enable staff to know what interventions to provide for Resident #1. The DON stated she, the ADON and the MDS Nurse were responsible to update Resident #1's care plan to reflect right tibia fracture with interventions. The DON stated she was supposed to ensure all care plans were updated. During an interview on 07/14/2026 at 3:06 pm the ADON stated she was aware of her Resident #1's fracture. The ADON stated she and the DON were responsible for updating care plans as needed when there was a change or some incident or the resident was on an ABT. The ADON stated she and the DON would update the care plan for the fracture to indicate increased care, and that Resident #1 was wearing a boot to her right leg. The ADON stated she did not update Resident #1's care plan to reflect the fracture, she just did not get to it. During an interview on 07/14/2026 at 3:51 pm the MDS Nurse stated she was responsible for completing and updating comprehensive care plan. The MDS Nurse stated care plans were updated quarterly and for significant changes like falls, antibiotics, fracture, etc. (the rest). The MDS Nurse stated she only worked part-time and the DON and ADON were responsible for updating care plans when there were changes. The MDS Nurse stated Resident #1 care plan should have been updated after the fracture to reflect the boot, pain management, level of assist and transfer needed. The MDS Nurse stated it was supposed to be updated so the staff can know the interventions that were in place. The MDS Nurse stated she did not update Resident #1's care plan. Review of facility's policy revised December 2016 titled Care Plans, Comprehensive Person-Center reflected: Policy Statement: A comprehensive, person-center care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation:The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representatives, develops and implements comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessment of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.The Interdisciplinary Team must review and update the care plan:--when there has been a significant change in the residents' condition.--when the desire outcome is not met.--when the resident has been readmitted to the facility from a hospital stay; and--at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to properly thaw raw chicken in the sink, not under running water, in its kitchen on 01/13/2026.2. The facility failed to properly store, label, and date all food items located in the facility refrigerators, freezers and in the dry food pantry area on 01/13/2026 and 01/14/2026. 3. The facility failed to discard outdated food items located in the refrigerators on 01/13/2026 and 01/14/2026. 4. The facility failed to properly seal food product bags in the dry storage area to prevent exposure to air on 01/13/2026 and 01/14/2026. 5. The facility failed to properly store, label, and date all food items located in the satellite refrigerators on halls 100/200,400, and 500/600 on 01/13/2026.These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.Observation during the initial tour of the kitchen on 01/13/2026 beginning at 9:02 AM revealed the following:Refrigerator 1:6 bowls of potato salad, no name, no date, no discard/use by date5 chef salads, no name, no date, no discard/use by date 2 plates of cheese sandwiches, no name, no date, no discard/use by date1 small bowl of pickles and tomatoes, no name, no date, no discard/use by date1 small bowl of mixed berries, no name, no date, no discard/use by date 1 large opened bag of chocolate chips, not sealed with receive date of 10/23/2025, no open or discard date.12 cartons of expired Heavy Whipping Cream, expired 11/14/2025.1 storage bag with unknown prepared product that resembles icing, no name, no date, no discard/use by date Kitchen area: 1large bin of sugar, no name, no date, no discard/use by date 1 large bin of flour, no name, no date, no discard/use by date 1 large bin of unknown product that resemble white corn meal, no name, no date, no discard/use by date 1 storage bag of raw chicken sitting in container in sink, not under running water. Dry Food Pantry area:10 packs of hot dog buns, no received dates, no discard/use by dates1 hamburger buns, no open or discard date.1 opened package of pasta dated 11/10/2025, no discard/use by dates2 opened package of macaroni, no open, discard/use by date1 opened package of bowtie pasta, not sealed open to air, no open, discard/use by date1opened bag of cake mixes, not sealed open to air, no open, discard/use by date1 opened bag of baking soda labeled 6/523 and another open bag of baking soda labeled 11/5/231 large container of Asian sauce, open date 11/24/25, no discard/use by date1 large container of corn meal, marked 9/23/25 no discard/use by dateWalk in Freezer:3 packages of unlabeled meat that resembles turkey, no name label, or receive date1 box of open pizza crust, open to air with receive date of 10/13/251 storage bag of open popcorn chicken, open date, no discard/use by date 1 open bag of open fish, no open date, no discard/use by dateWalk in Refrigerator :Container of opened peaches, not labeled, no open date, no discard/use by date5 large gallon containers of opened salad dressings (open dates ranging from 10/6/25 -12/15/25), no discard/use by dates1 prepared pan of sliced tomatoes with only date of 1/8/26 , no discard/use by date1 open bags of lettuce, with only date of 1/5/26 on it, no discard/use by dateObservation and interview conducted 01/13/2026 at 9:36 AM. Observed raw chicken still sitting in the container in the sink. The [NAME] was asked, is that the way they thaw their meat? He responded, Normally, sometimes water runs over it, but we leave it in the sink.Satellite Refrigerator for Hall 500/600: 1 container of apple juice, prep date of 1/9/26, no discard date1 container of orange juice, prep date of 1//26, no discard date 1 container of apple juice, prep date of 1/13/26, no discard dateSatellite Refrigerator for Hall 100/200: 1 container of tea , prep date of 1/9/26, no discard date1 container of orange juice, prep date of 1/9/26, no discard date 1 container of apple juice , prep date of 1/13/26, no discard date 1 open gallon of milk, with best buy date of 1/12/26, no discard date Satellite Refrigerator for Hall 400 1 container of fruit punch , prep date of 1/12/26, no discard date 2 bowls of potato salad no name, no prepared date, no discard date 1 plate of cheese sandwich, no name, no prepared date, no discard date 1 bowl of peaches with cottage cheese, no name, no prep date, no discard date Observation during the follow up tour of the kitchen on 01/14/2026 beginning at 11:00 AM, revealed the following:Refrigerator 1:1 large, opened bag of chocolate chips, not sealed with receive date of 10/23/2025, no open or discard date.12 cartons of expired Heavy Whipping Cream, expired 11/14/2025.1 storage bag with unknown prepared product that resembles icing, no name, no date, no discard/use by date Kitchen area: 1large bin of sugar, no name, no date, no discard/use by date 1 large bin of flour, no name, no date, no discard/use by date 1 large bin of unknown product that resemble white corn meal, no name, no date, no discard/use by date 10 packs of hot dog buns , no receive dates, no discard/use by dates1 hamburger buns, no open or discard date.1 opened package of pasta dated 11/10/2025, no discard/use by dates2 opened package of macaroni, no open, discard/use by date1 opened package of bowtie pasta, not sealed open to air, no open, discard/use by date1opened bag of cake mixes, not sealed open to air, no open, discard/use by date1 opened bag of baking soda labeled 6/523 and another open bag of baking soda labeled 11/5/231 large container of Asian sauce, open date 11/24/25, no discard/use by date1 large container of corn meal, marked 9/23/25 no discard/use by dateInterview conducted with the [NAME] on 01/15/2026, at 4:16 PM. The [NAME] stated he has worked as a cook with the facility since April 1st, 2025. The [NAME] stated he has been trained on the food handling policy. Surveyor asked the [NAME] did he think the chicken observed in the kitchen sink on 1/13/2026 was thawing properly. The Cooks stated he found out one of the staff placed the chicken in the sink, he stated it was not for the residents, it was for staff. The [NAME] stated he does not believe staff can prepare food from home in the kitchen. The [NAME] stated he normally does not thaw food on his shift as it is thawed prior to his shift. In regard to labeling, dating, and discarding of food items, the [NAME] stated the food is labeled with the date received and opened. He was asked about the discard date, the [NAME] stated it depends on the item. He stated juices and ice teas have 3 days of shelf life, sandwiches 2 days of shelf life. He stated he has not seen cooked food sit for longer than a week. The [NAME] stated he does not know the facility discard policy or if he has seen it or not. The [NAME] stated they dispose of expired foods in the mornings. He stated the dietary aide does most of the discarding of expired foods, but it is everyone's responsibility. He stated that if residents eat outdated food, they can possibly get food poisoning, salmonella, and become sick.Interview conducted with DM A on 01/15/2026, at 4:40 PM. DM A stated she has worked at the facility for 2 years and she became the dietary manager in July 2025. DM A stated that she pairs new dietary staff with an experienced staff member to review kitchen tasks. DM A explained that when thawing food, staff remove items from the freezer and place them under running cold water. She stated that she saw the chicken thawing on Tuesday while surveyors were present and turned the water back on. DM A reported that food items are labeled with the date received, and once they are opened, they are labeled with the open date but not always a discard date. When asked how staff know when to discard items, DM A stated that items are discarded after seven days. She stated that juices have a five-day shelf life, and teas are discarded after 24 hours. She stated that cooked food items are good for five days. DM A stated that dietary staff conduct weekly inventory checks and monitor for expired items. She stated that dietary staff are responsible for checking satellite kitchens daily. Surveyor showed her pictures of expired and leftover food items that remained in the refrigerators that were not discarded, Dietary Manager stated the items should have been discarded, and she would throw them out. DM A stated that potential harm to residents from consuming expired food includes upset stomach, vomiting, and possible hospitalization. Interview conducted 01/15/2025 at 6:32 PM, the ADM stated he has been with the facility since July 1, 2025. ADM stated raw chicken should not be sitting out, whether it is for the residents or the staff. He stated he could not fully explain the labeling and dating policy, he stated he knows the items should be labeled with the date in and date opened. He stated all items should have some type of a label and date. ADM stated he expects his dietary staff to follow the policy. He stated a resident could become ill if they ate expired food items. Interview conducted with DM B on 01/16/2026, at 10:11 AM. DM B stated that food labeling should include the date received, date opened, and expiration date. DM B stated that she tells the staff tons of times, this procedure. She stated that staff turnover is high, and employees often leave. DM B stated that food is discarded after three days, five days, or seven days depending on the item, and that the facility does not keep a large amount of cooked food. She stated that potential harm to residents from consuming expired food includes food poisoning, which is especially dangerous for elderly residents.Interview conducted with the Dietary Aide on 01/15/2026 at 10:24 AM. The Dietary Aide stated he has been employed at the facility for seven years. He stated he was initially trained by a previous Dietary Manager, many years ago. The Dietary Aide stated all staff are responsible for labeling and dating food items. He reported staff are expected to write the date received, the date opened, and the discard date, which is three days for food that is open and 7 days for juices. The Dietary Aide stated that the potential harm that could occur if food is not discarded properly is that a resident could become very sick with diarrhea or vomiting.Record review of the facility's policy dated July 2014, named Preventing Foodborne Illness-Food Handling revealed:Policy Statement Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.1. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; b. Inadequate cooking and improper holding temperatures; c. Contaminated equipment; and d. Unsafe food sources.2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents.3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.Record review facility's policy dated July 2014, named Food receiving and Storage revealed:Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices.7. Dry foods that are stored in bins will either be removed from their original packaging, placed in a clean and dry bin, labeled and dated, or left in its original packaging with the proper date on the packaging. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).9. Refrigerated foods must be stored below 41 F unless otherwise specified by law.10. Refrigerated foods will be stored in such a way that promotes adequate air circulation around food storage containers. Refrigerators/walk-ins will not be overcrowded.11. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing.12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.13. Uncooked and raw animal products, including raw eggs) and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods.14. Food items and snacks kept on the nursing units must be maintained as indicated below:All food items to be kept below 41 F All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Beverages must be dated when opened and discarded after twenty-four (24) hours.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 5 medication carts (200-Hall Treatment Cart and 500-Hall Medication Cart). 1. The facility failed to ensure the 200-hall treatment cart was locked, medications and/or treatments secured, and not accessible to other staff, residents, and/or visitors.2. The facility failed to ensure Latanoprost (a medicated eye drop used to lower the pressure inside the eye) was stored at the proper temperature per manufacturer's recommendations. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications, missing medications, and access of others to residents' medications.Findings included:During an observation on 01/14/2026 at 11:30 AM, LVN C was observed pulling supplies to perform wound care from the 200-hall treatment cart. She shut the drawer to the cart and entered a resident's room, leaving the medication cart unlocked, and shut the door to the room.During an interview on 01/14/2026 at 11:36 AM, LVN C stated she had worked at the facility for about 13 years and had been trained in securing medications. She stated it was policy to lock the treatment cart before walking away from it. She stated she forgot to lock it before going into a resident's room. LVN C stated it was important to lock the treatment cart because a resident could open the cart and take something that was not meant for them. She stated all staff monitored for unlocked medication and treatment carts when walking the hallways and performing rounds.During an interview on 01/15/2026 at 12:51 PM, the ADON stated she was assisted with training new staff. She stated it was expected for nursing staff to ensure all medication and treatment carts were locked when left unattended. She stated management monitored for ensuring medication and treatment carts were locked when they performed their walking rounds. The ADON stated any residents could possibly get into the carts and take something that was not intended for them, and it could cause harm if the medication or treatment cart is left unlocked.During an observation on 01/15/2026 at 3:12 PM of the 500-hall medication cart, an unopened bottle of Latanoprost, dated 12/12/2025, was found inside a paper bag in the bottom drawer. An unopened bottle of Latanoprost, dated 11/04/2025, was also found in a paper bag that had been stapled shut in the top drawer. Both bottles were inside boxes that stated, Store unopened bottle under refrigeration at 2 to 8 (36 to 46 ). and During shipment to the patient, the bottle may be maintained at temperature up to 40 (104 ) for a period not exceeding 8 days.During an interview on 01/15/2026 at 03:20 PM, MA G stated she was trained on medication storage. She stated she was trained to secure all medications behind a lock and key when walking away from the medication cart. MA G stated if a medication cart were to be left unlocked and unattended then a resident could get into the cart and take something that may injure or even kill them. She stated management monitored for locked medication carts during their walking rounds. MA G stated Latanoprost should be stored in the refrigerator until it is opened but it could be out of the refrigerator for up to 8 days prior to opening. She stated the bottles of medication found in the 500-hall medication appeared to have been delivered in November 2025 and December 2025. MA G stated both bottles of medication were unopened. She stated the medication was not stored appropriately and she would discard the medication. MA G stated the medication could lose effectiveness if not stored at the temperature stated by the manufacturer.During an interview on 01/15/2026 at 05:07 PM, the RPh stated Latanoprost was to be stored in the refrigerator until it is opened, then it could be stored at room temperature. He stated it could be stored at room temperature for up to 8 days prior to opening without affecting the integrity of the medication. He stated if the medication was not stored at the appropriate temperature prior to opening then it could decrease the effectiveness of the medication, but it would not harm the resident.During an interview on 01/15/2026 at 7:11 PM, the DON stated she had worked at the facility for the past 4 years. She stated the policy for securing medications required all medications to be in the medications cart and the medication locked when walking away from the cart. She stated the medication carts and treatment carts were treated the same. The DON stated if the cart was left unlocked when staff walked away, then a resident could have easy access to the contents and take something they could possibly be allergic to. She stated it was her expectation that all medications be stored at the appropriate temperature per the manufacturer's instructions. The DON stated, after reviewing the box for Latanoprost, that the medication should be stored in the refrigerator prior to opening. She stated the medication could be stored for up to eight days at room temperature prior to opening. The DON stated if the medication was not stored at the proper temperature per the manufacturer's instructions, then the medication could lose effectiveness.During an interview on 01/16/2026 at 10:13 AM, the ADM stated he had worked at the facility since July 1, 2025. He stated he expected medication and treatment carts to be locked when left unattended. He stated management monitored to ensure the carts were locked during walking rounds. The ADM stated if the carts were left unlocked then a resident who may not be of sound mind could take something from the cart that they are not supposed to. He stated, after reviewing the Latanoprost box, that the medication should be stored in the refrigerator prior to opening but could be at room temperature for up to 8 days prior to opening. He stated he was unsure how the resident might be affected if the medication was not stored according to the manufacturer's instructions.Review of facility policy titled Storage of Medications, dated 2001 and last revised April 2007, reflected Policy Statement.The facility shall store all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation.7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.9. Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location.

Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 9 of 20 residents (Resident #3, Resident #19, Resident #27, Resident #34, Resident #38, Resident #43, Resident #63, Resident #64, and Resident #88) reviewed for misappropriation.The facility failed to prevent the misappropriation of Residents #3, 34, 38, 64, and 88's tramadol (a schedule IV controlled opioid medication used to treat moderate to severe pain), Residents #19, 27, and 63's lorazepam (a schedule IV controlled benzodiazepine medication used to treat anxiety), Residents #27 and #63's hydrocodone-acetaminophen (a schedule II controlled opioid medication used to treat severe pain), Resident # 43's acetaminophen-codeine (a schedule III opioid medication used to treat moderate to severe pain), and Resident #88's oxycodone (a schedule II opioid medication used to treat moderate to severe pain) taken from 01/03/2026 through 01/15/2026.This failure placed residents at risk for not receiving prescribed medications for pain and anxiety relief.Findings included:1. Review of Resident #3's face sheet, dated 01/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region (opening in skin due to pressure to lower back/buttock area), unspecified pain, and retention of urine.Review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 01 which indicated severe cognitive impairment.Review of Resident #3's undated order summary reflected tramadol - Schedule IV tablet; 50 mg; amt: 1 tab; oral Every 6 Hours - PRN with a start date of 08/20/2024.Review of Resident #3's care plan, dated 01/02/2026, reflected I have chronic pain with turning positioning and treatment to my wound. With approaches that included Administer Tramadol as ordered Apply Lidocaine patch as ordered. Turn reposition to keep comfortable.2. Review of Resident #64's face sheet, dated 01/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] and most recent readmission on [DATE] with diagnoses that included pressure ulcer of the left ankle, chronic pain syndrome (a complex condition characterized by persistent pain lasting longer than three months), and primary osteoarthritis (the cartilage between the bones wears away causing pain) unspecified site.Review of Resident #64's Quarterly MDS, dated [DATE], reflected a BIMS score of 08 which indicated moderate cognitive impairment.Review of Resident #64's undated order summary reflected tramadol - Schedule IV tablet; 50 mg; amt: 1 tablet; oral Three Times A Day 08:30 AM, 12:30 PM, 08:30 PM with a start date of 06/06/2024.Review of Resident #64's care plan, dated 12/12/2024 and last revised 12/09/2025, reflected I have complains of increased pain/discomfort and is a risk for injury from decrease in ADLs. [sic] With approaches that included Administer medication as ordered per the physician.3. Review of Resident #63's face sheet, dated 01/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified pain, generalized anxiety disorder (a mental health condition characterized by excessive, uncontrollable worry about everyday issues), and osteoarthritis (the cartilage between the bones wears away causing pain) of the left shoulder and left knee.Review of Resident #63's Comprehensive MDS, dated [DATE], reflected a BIMS score of 13 which indicated no cognitive impairment.Review of Resident #63's undated order summary reflected hydrocodone-acetaminophen - Schedule II tablet; 5-325 mg; amt: 1 tab; oral Three Times A Day 09:30 AM, 01:30 PM, 05:30 PM with a start date of 07/18/2025 and lorazepam - Schedule IV tablet; 1 mg; amt: 1 tablet; oral Every 6 Hours 06:00 AM, 12:00 PM, 06:00 PM, 12:00 AM with a start date of 03/21/2025.Review of Resident #63's care plan, dated 08/01/2024 and last revised 12/23/2025, reflected I am taking anti-anxiety medication. And I have complains of increased pain/discomfort and is a risk for injury from decrease in ADLs. I have pain from osteoarthritis to the left shoulder and of the left knee. This causes me debility. [sic] With approaches that include Administer medication as ordered per the physician.4. Review of Resident #19's face sheet, dated 01/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified pain, restlessness and agitation.Review of Resident #19's Quarterly MDS, dated [DATE], reflected a BIMS score of 11, which indicated moderate cognitive impairment.Review of Resident #19's undated order summary reflected lorazepam - Schedule IV tablet; 1 mg; amt: 1 tab; oral At Bedtime 08:30 PM with a start date of 09/15/2025 and lorazepam - Schedule IV tablet; 1 mg; amt: 1 tab; oral Special Instructions: x 180 days Every 4 Hours - PRN with a start date of 09/15/2025.Review of Resident #19's care plan, dated 09/15/2025 and last revised 01/05/2026, reflected I am taking anti-anxiety medication r/t y[sic?] restlessness and forgetfulness.5. Review of Resident #27's face sheet, dated 01/16/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unspecified pain, anxiety disorder (a mental health condition that causes intense and excessive worry and fear), and cognitive communication deficit (problem with communication caused by cognition rather than a language or speech deficit).Review of Resident #27's Comprehensive MDS, dated [DATE], reflected she had a memory problem with Short-term and Long-term Memory.Review of Resident #27's undated order summary reflected Ativan (lorazepam) - Schedule IV tablet; 0.5 mg; amt: 1 tab; oral Special Instructions: Dose 0.5mg, give 1 tab for anxiety and increased tremors Twice A Day 09:30 AM, 08:30 PM with a start date 09/09/2025 and hydrocodone-acetaminophen - Schedule II tablet; 5-325 mg; amt: 1; oral Four Times A Day 09:30 AM, 12:30 PM, 04:30 PM, 08:30 PM with a start date 10/09/2025.Review of Resident #27's care plan, dated 10/29/2024 and last revised 01/06/2026, reflected I am taking anti-anxiety medication. I take Ativan twice a day and I have complains of increased pain/discomfort and is a risk for injury from decrease in ADLs. With approaches that included Administer medication as ordered per the physician.6. Review of Resident #34's face sheet, dated 01/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Pain in left knee, unspecified pain and spinal stenosis (a condition characterized by the narrowing of the spinal canal which can put pressure on the spinal cord and nerves causing pain).Review of Resident #34's Quarterly MDS, dated [DATE], reflected a BIMS score of 09 which indicated moderate cognitive impairment.Review of Resident #34's undated order summary reflected tramadol - Schedule IV tablet; 25 mg; amt: 1 tab; oral Special Instructions: Hold for sedation Twice A Day - PRN with a start date 11/15/2024 and tramadol - Schedule IV tablet; 25 mg; amt: 1 tab; oral Special Instructions: Hold for Sedation Twice A Day 08:30 AM, 08:30 PM with a start date 05/08/2025.Review of Resident #34's care plan, dated 04/16/2024 and last revised 12/16/2025, reflected Resident has complaints of chronic pain R/T spinal stenosis with approaches that included Administer medications. Return to assess effectiveness.7. Review of Resident #38's face sheet, dated 01/16/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome (a complex condition characterized by persistent pain lasting longer than three months), Pain in unspecified shoulder, stiffness of unspecified joint, and wedge compression fracture of second lumbar vertebra (one side of the bones in the spine collapse creating a wedge shape of the lower back).Review of Resident #38's Comprehensive MDS, dated [DATE], reflected a BIMS score of 09 which indicated moderate cognitive impairment.Review of Resident #38's order summary reflected tramadol - Schedule IV tablet; 50 mg; amt: 1 tab; oral Three Times A Day 08:30 AM, 01:30 PM, 08:30 PM with a start date 12/15/2025.Review of Resident #38's care plan, dated 12/31/2025, reflected I have complains of Chronic pain syndrome/discomfort and is a risk for injury from decrease in ADLs. [sic] With approaches that included Administer medication Tramadol as ordered per the physician.8. Review of Resident #43's face sheet, dated 01/16/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pneumonia (an infection that inflames the air sacs in one or both lungs), gastroparesis (a condition in which the muscles in the stomach do not move food as they should sometimes causing pain), primary biliary cirrhosis (a progressive liver disease that causes the bile ducts in the liver to become inflamed and eventually destroyed), progressive systemic sclerosis (a rare autoimmune disease characterized by the hardening and tightening of the skin and connective tissues), and unspecified pain.Review of Resident #43's Comprehensive MDS, dated [DATE], reflected a BIMS score of 14 which indicated no cognitive impairment.Review of Resident #43's undated order summary reflected acetaminophen-codeine - Schedule III tablet; 300-15 mg; amt: 1 tab; oral Every 8 Hours - PRN with a start date 12/26/2025.Review of Resident #43's care plan, dated 01/10/2026 and revised last on 01/12/2026, reflected I have complaints of chronic pain R/T Rheumatoid Arthritis. (a chronic autoimmune disease that primarily affects the joints causing pain, swelling and stiffness).9. Review of Resident #88's face sheet, dated 01/15/2026, reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included unstable burst fracture of T11-T12 vertebra (a severe spinal injury characterized by the shattering of a bone in the mid to lower back).Review of Resident #88's Comprehensive MDS, dated [DATE], reflected a BIMS score of 06 which indicated severe cognitive impairment.Review of Resident #88's undated order summary reflected oxycodone - Schedule II tablet; 5 mg; amt: 1 tablet; oral Once An Evening 08:30 PM with start date 01/06/2026 and tramadol - Schedule IV tablet; 50 mg; amt: 1 tablet; oral Special Instructions: Hold for sedation Twice A Day 08:30 AM, 01:00 PM with a start date 01/10/2026Review of Resident #88's care plan, dated 01/08/2026 and revised on 01/12/2026 reflected I have complains of increased pain/discomfort and is a risk for injury from decrease in ADLs. I take oral pain meds. [sic]Review of Provider investigation Report, dated 01/20/2026, reflected On 01/13/2026 it was reported that there were 24 Tramadol pills missing. Then, on 01/14/2026, it was reported that an additional 2 Tramadol cards (60 pills) missing. The investigation summary reflected 01/13/2026, a hospice nurse informed facility DON that a card of 24 Tramadol was missing for one of their patients. On 01/14/2026, facility nurse informed corporate admin that 2 of 3 cards of Tramadol, total count of 60, were missing. Total count of missing pills at that time was 84. During the investigation, nursing admin uncovered more discrepancies. This also included Hydrocodone/Acetaminophen, Lorazapam[sic], Xanax, and Oxycodone. Once we discovered which nurse was the alleged perpetrator, we blocked her access to the building since she was an agency nurse. Administrator and DON interviewed the nurses and med aides on the 100/200 and 300/400 hall which worked during the time frame of the missing medication and no one, except the agency nurse [LVN K] was suspected of taking the medication. On 01/14/2026 the Police Department was contacted and we received a case #. On 01/16/2026, PD officer [name provided] arrived at facility to collect what information we had on the case. DON is continuing to gather information of alleged misappropriation of meds. Attached to the provider investigation report was a referral made to the Texas Board of Nursing. Also attached to the provider investigation report was Documentation of missing Narcotics January 2026 that reflected, On Tuesday, January 13, 2026 , as [the DON] was making her morning rounds, she had 2 residents on this day who voiced complaints about the nurse that worked last night [LVN K], after speaking to both residents, [the DON] immediately marked this nurse as Do Not Return to the facility on the [agency] website. Both residents were notified this nurse would never be back in the facility and they both appeared happy with that decision. Later that evening, hospice nurse, [RN F], was at the facility rounding on her resident [Resident #3]. [RN F] brought to the DON and ADON's attention, that her resident was missing 24 doses of Tramadol. [RN F] stated she was last at the facility on Friday January 9, 2026, and there was 24 Tramadol on the narcotic count sheet for her resident. Now, Tuesday, there is not a narcotic count sheet, nor a narcotic card for her resident. Last documented dose administered to [Resident #3] was January 4, 2026. It was decided that hospice would order 10 more doses of Tramadol to have on hand for resident and a thorough investigation would begin tomorrow to verify the doses were not around the facility in the destroyed meds or extra storage of medications. All information was discussed with administrator and agreement to begin investigation Wednesday AM. Today was day 1 of the facilities Full Book inspection with the State of Texas.On Wednesday (day 2 of full book), upon arriving to the facility and between obtaining information for the state for the full book inspection and doing her daily duties, [the DON] began to look thru all discontinued medications in the medication rooms. [The DON] and [the ADON] began to look through every medication cart to verify the Tramadol was not misplaced in the cart. Narcotic book was searched through for the missing page. Residents chart was searched through to verify that the order was not discontinued. Verifying this would help to rule out the medication being pulled from the cart because it was discontinued. This evidence was not found as Tramadol was still an active order in the residents chart. [The DON] and [the ADON] searched thru the narcotic closet in [the ADON]'s office and it was verified that the medication card and count sheet were not in the to be destroyed medications. [The DON] began pulling the daily assignment sheets to verify who was on the medication carts for these days. The only agency nursing staff was [LVN K]. [The DON] began watching videos of the shifts that [LVN K] worked at the facility from 01/09/2026 to 01/13/2026. There were 5 shifts all together that [LVN K] worked in this time frame. Wednesday evening, it was brought to management's attention that possibly 60 tramadol doses from another hall have disappeared off the cart. The Nurse [LVN E], who brought the findings to management, remembers checking in 90 days of Tramadol for 1 resident on Monday evening shift and labeling the cards and count sheets (1 of 3, 2 of 3, and 3 of 3), However the only narcotic card and count sheet that remain on the cart and in the narcotic count book are 1 of 3. Executive Director of Operations, Administrator and DON decided to report the possible drug diversion as a self report. Police were also notified of the incident and a case number was obtained.Thursday, January 14, 2026, hours of video were watched on this day by multiple team members. Strange behavior was determined of the nurse [LVN K] while at the medication cart . [LVN K] was looking around suspiciously before unlocking the narcotic box on hall 200 cart and appeared to pop out 3 tablets from the same narcotic card but not able to visualize pill placement into a cup for administration. [LVN K] stood at the medication cart for long periods of time flipping through the narcotic sheet binder, appearing to be studying it. After rewatching the video, another management member noted [LVN K] to be writing on a paper after looking at the narcotic binder for some time, take the paper to the nurses station, use the three hole punch on the page, walk back to the medication cart and place paper in the binder. Then [LVN K] picked up what appeared to be a narcotic card and put the sheet around it. [LVN K] then gathered what appeared to be the paper, narc card, cup of water, and a medication cup and walk down hall 100 with all above in her hands. DON and ADON went to the 100 hall Narcotic book and made the discovery that [Resident #63]'s Norco sheet appeared to be have rewrote. Penmenship appeared to be the same on the top of the paper as well as the received line and the first administrations of norco were all signed out by [LVN K], however, [LVN K] did not work on some of the administration days and times at the facility. Upon pulling the narcotic card of Norco from the narcotic box, it was determined that the QTY on the label of the medication card was 90. The re-written narcotic sheet was marked with a QTY of 60. The started card had 60 doses so it appeared there was a missing card of 30 Hydrocodone (Norco) tablets. Management decided at this time to conduct a facility wide narcotic investigation. Executive Director of Operations, Administrator, and DON made copies of all narcotic count sheet and copies of all the current cards on every medications cart in the facility (6 medication carts total). DON gathered all copies and began a detailed verification of every narcotic that was signed out of the narcotic book on the current cards, were documented in the medication administration record (MAR).Narcotic Count Sheet Findings: All medications were appropriately documented in the MAR and count sheet except the following:Hall 100:[Resident #27]- Lorazepam- 1 dose signed out on 1/12/26 at 1300[01:00 PM] by [LVN K] (not medication administration time. Medication is ordered twice a day 8:30 AM and PM)[Resident #27]- Norco- 1 dose signed out on 1/11/26 at 1500 [3:00 PM] by [LVN K]. (medication is ordered every 6 hours. Previous dose was documented 4 hours prior)[Resident #27]- Norco- 1 dose signed out on 1/13/26 at 0000 [12:00 AM] by [LVN K]. (medication is ordered every 6 hours. Previous dose was documented 3.5 hours prior)[Resident #63]- Norco- This narc sheet is the one suspected to have been rewritten. Incorrect date at the top of page, documented as 11/07/2026, 6 first administrations were signed by [LVN K] on the narc sheet, however according to the MAR, the administrations were between [LVN K] and 2 other nurses . Documented QTY on Narc count sheet is 60, however according to the medication card, QTY is 90 .[Resident #63]- Lorazepam- Documentation of this count sheet is off, however DON was unable to determine what occurred and what exactly the nurse did. QTY is accurate and matches what the pharmacy dispensed to the facility along with the date. However, [LVN K] signed 3 consecutive administrations. According to the MAR, [LVN K] did not administer 3 consecutive doses .Hall 200:[Resident #38]- Tramadol- 1 dose signed out on 1/11/26 by [LVN K] at 1200[PM].[Resident #88]- Oxycodone- 1 dose signed out on 1/10/26 by [LVN K] at 1200[PM]. (signed out 2 hours after last documented dose. Medication is ordered every 6 hours as needed.)[Resident #88]- Oxycodone- 1 dose signed out on 1/11/26 by [LVN K] at 0800[AM].[Resident #88]- Oxycodone- 1 dose signed out on 1/11/26 by [LVN K] at 1100[AM]. (this dose signed out 3 hours after the previous documented dose. Medication is ordered every 6 hours as needed.)[Resident #88]- Oxycodone- 1 dose signed out on 1/12/26 by [LVN K] at 1500[3:00 PM]. (signed out 5 hours after the previous signed out dose)[Resident #88]- Oxycodone- 1 dose signed out on 1/12/26 by [LVN K] at 2200[10:00 PM]. (signed out 5 hours after the previous signed out dose)[Resident #88]- Tramadol- 1 dose signed out on 1/11/26 by [LVN K] at 0900[AM]Hall 400:[Resident #43]- Tylenol #3- 1 dose signed out on 1/13/26 by [LVN K] at 0730[AM].[Resident #64]- Missing 2 cards of 30 tabs each of tramadol 50 mg. Received 3 cards of 30 doses each on 1/12/26 by [LVN E].[Resident #34]- Tramadol- 1 dose signed out on 1/13/2026 by [LVN K] at 0730[AM].Hall 500:[Resident #19]- Lorazepam- 1 dose signed out on 1/3/26 by [LVN K] at 2100[9:00 PM].Video Findings:Video evidence shows nurse [LVN K] to be standing at the medication carts on numerous occasions flipping through the narcotic sheet binder.Saturday 1/12/26: (She=[LVN K])[LVN K] is not assigned to a medication cart on this day. She has an assigned medication aid. 0755[AM], she is standing at the 100 medication cart flipping thru the narc binder. 0757[AM] she is writing something in the narc binder. 0758[AM] She unlocks the cart and opens the narc drawer. She appears to pull 2 cards from the narc box and pops 2 medications. At 0759[AM], she walked away from the medication cart without a cup of water or a cup of medications. At 0759.50[AM] she is back in view of the camera.0801[AM] she walks into the medication room0802[AM] she walks out of the medication room0814[AM] she is standing at the medication cart again flipping thru the narcotic binder. 0823[AM] still looking through the narcotic binder0859[AM] Medication aid brings medication cart for 200 hall back to the nurses station and plugs in the computer.1019[AM] She is flipping through the narcotic book on 200 cart. At 1020[AM], CNA approaches [LVN K] and she closes the narc book and went to the nurses station.1044[AM] she is at the hall 200 medication cart with the keys to the cart with the narc book open after she spoke with family member and [Resident #88].1045[AM] she opens the narc drawer1046[AM] she is writing in the narc book1047[AM] she appears to pop medications from a narc card and places them in a cup, gathers a cup of water, and takes them to the resident who is at the nurses station with her spouse and therapy.1048[AM] She is back at the medication cart for 200 hall and appears to be writing and looking at the narcotic book. She then closes the book, unlocks the narc drawer, removes a narc card from the drawer, closes and locks the narc drawer. She then opens the narc binder, places the narc card inside of the binder, carries the narc binder to the nurses desk and appears to dump the narc card into her black bag that is under the desk. Immediately turns in her chair and takes the narc book back to the medication cart.Monday 1/12/2026: (She = [LVN K])Numerous times she is videoed standing at the medication cart on 100 hall flipping thru the narcotic book as if studying it.Multiple times, it appears she opens the narcotic drawer but does not remove any medication for administration.2055[8:55 PM] she opens the narcotic drawer of cart 100. Pulls out a narc card and places it on top of the cart.2058[8:58 PM] she opens the OTC (over the counter) drawer and 2 medications and puts in medication cup.2059[8:59 PM] She is flipping through the narcotic book again.2107[9:07 PM] she is writing on a piece of paper on the medication cart.2108[9:08 PM] she walks to the nurses station with the paper and locates the 3 hole punch in the drawer and appears to hole punch the new paper. She then turns and returns to the medication cart.2109[9:09 PM] she places the new paper in the narcotic binder, removes a page from the narcotic book and places it on the medication cart. Then uses the keys to pen the narc drawer and remove a card which she then wraps the paper around.2110[9:10 PM] She gathers a cup of water, the medication cup, the narc card and piece of paper and walks down hall 100.Changing cameras, She can be visualized going to assist 2 CNA's with readjusting a resident in his wheelchair. She stops to talk with them, then places the cup of water, cup of medications, narc card and piece of paper at the CNA station. Once assisting the CNA's, the CNA's take the resident toward his room. She returns to the CNA station. She appears to gather her items and enter the residents room right by the CNA station (room [ROOM NUMBER]). She exits the residents room at 2020[8:20 PM] empty handed, sanitizes her hands and walks back toward the nurses station. Along the way, she stops, feels on her pant legs, turns arounds, walks a few steps back toward 109, as she continues to feel on her pant legs, she then turns back toward the nurses station, walks 2 doors down and enters another residents room for a split second before exiting. She is back in view of the camera and at the nurse station at 2122[9:22 PM]. She is joined by a CMA shortly after arriving to the nurses station.It is unclear what happened to the Narc card and sheet, but she does appear to enter room [ROOM NUMBER] possibly with them in her left hand, but does not exit with them in either hand.As for the 2 missing narcotic cards from 400 hall, there is not a camera that faces directed to the exit of the medication room on the 400 hall. However, there is a camera that faces the 300 hall side of the medication room. It is difficult to see but you can see when the medication room light turns on, which is motion sensitive.1/12/26: light turns on at 2247[10:47 PM] and turns off at 2252[10:52 PM]. Possible narc count with off going and on coming nurse.2255-2258 [10:55 PM-10:58 PM] medication room light is on.2346-0010 (11:46 PM-12:10 AM] Medication room light is on. At 2346 [11:46 PM] it appears an individual in the same colored scrubs as [LVN K] is looking thru the cabinets in the medication room.0224-0236 [02:24 AM-02:36 AM] medication room light is on0656 [AM]- medication room light is on- possibly narcotic count with off going and on coming nurse.Everything listed above is to the best of my knowledge and from visualization of documentation and watching video for hours on end.[Signed by the DON] [sic]During an interview on 01/15/2026 at 08:00 AM, the ADM stated there was a discovery of a drug diversion the previous night and the facility had identified 87 missing Tramadol pills. He stated they felt they had identified the alleged perpetrator as an agency nurse because of her acting shady on camera.During an interview on 01/15/2026 at 08:15 AM with the ADM and the DON, they stated RN F was in the facility on 01/13/2026 and discovered 24 missing tramadol pills and reported it. They stated on 01/14/2026 LVN E reported there were 2 cards equaling 60 pills of tramadol missing for a different resident. They stated the narcotic count sheets were missing as well. They stated they were still investigating the missing medications and were in the process of reaching out to all nurses and medication aides with a questionnaire. They stated [LVN K] would be included in the questionnaire process. The ADM stated a police report and self-report had been made. The ADM stated there was not any evidence to indicate any residents went without medication. He stated if the resident was out of medication, then the facility would utilize the emergency kit to obtain the needed medication.During an interview on 01/15/2026 at 11:47 AM, LVN E stated she had worked at the facility for 7 years. She stated she had been trained on abuse, neglect, exploitation and misappropriation. She stated on 01/12/2026 she received 3 cards of tramadol and on the narcotic count sheet she had labeled them 1 of 3, 2 of 3 and 3 of 3. She stated she dated and numbered the narcotic count sheets. She stated when she was counting the narcotics with another nurse on 1/13/2026 she discovered there were 2 missing narcotic medication cards and 2 count sheets for the tramadol she had received on 1/12/2026. She stated she reported it to management.During an interview on 01/15/2026 at 11:55 AM, RN F stated she worked for the facility and also for a hospice agency. She stated she performed a medication check for one of her hospice residents [Resident #3] and discovered that the narcotic log and medications were missing. She stated she had performed a medication check on 01/09/2026. She stated she immediately checked on Resident #3, then notified the DON and the ADON. She stated a refill for the medication was sent to the pharmacy to ensure Resident #3 did not go without her pain medication. She stated Resident #3 had not had any changes in her demeanor. RN F stated Resident #3 did not utilize her as needed pain medication frequently, so there was no hinderance in Resident #3's care.During a phone interview on 01/15/2026 at 06:50 PM, LVN K stated she had picked up a few shifts at the facility, but she worked for an agency. LVN K stated she had been trained on abuse, neglect, exploitation and misappropriation. She stated she had worked the previous weekend, including her last shift from Monday 1/12/2026 at 3:00 PM until Tuesday 1/13/2026 at 07:00 AM. She stated she was not responsible for passing medications on that shift therefore she was not in the medication carts. LVN K stated she started working on the 100 and 200 hall at 03:00 PM and moved to 300 and 400 halls at 11:00 PM. She stated she remembered that she didn't have a medication aide for 100 hall, and she did pass medications down 100 hall until 07:00 PM or 08:00 PM that evening. LVN K stated she counted all narcotic medications with their count sheets before and after each 8-hour shift. She stated on the evening of 1/12/2026 into the morning on 1/13/2026 she did not administer any tramadol but did remember administering 2 Norco tablets and something for anxiety to Resident #63. She stated she worked on 1/10/2026 and administered Norco to Resident #63 that day as well. She stated she did not notice any medications missing from the cart. She denied seeing anyone take anything from the medication cart for personal use. She denied taking medications out of the cart for personal use. She denied administering the last dose of medication from any of the narcotic cards.During an interview on 01/15/2026 at 07:11 PM, the DON stated she had worked at the facility for 4 years. She stated she had been trained on abuse, neglect, exploitation, and misappropriation. The DON stated taking a resident's narcotic medication was a form of misappropriation. She stated if the medication was not located in the emergency medication kit, then the resident could possibly remain in pain. She stated she had reviewed video footage of what appeared to be LVN K filling out a new narcotic count sheet for an unknown medication on 100-hall. She stated she also found medications that were signed out for residents but there was no associated administration in the medication administration record. The DON stated they were initiating a new process to count the narcotic count sheets and number of narcotic cards and verify the numbers on a log for each medication cart. She stated they were still investigating the missing narcotics.During an interview on 01/16/2026 at 09:10 AM, an officer with the local Police Department stated he was at the facility to collect additional evidence related to the missing medications, but he was not the officer in charge of the investigation. He stated he would have the officer in charge of the investigation contact this investigator that evening when he arrived on shift. No call was received from the officer in charge of the investigation.During an interview on 01/16/2026 at 10:03 AM, the DON stated she would be making a referral to the Texas Board of Nursing for LVN K related to the missing narcotics.During an interview on 01/16/2026 at 10:13 AM, the ADM stated he had worked at the facility since July 1, 2025, and he was the abuse coordinator. He stated he was notified on the evening on 01/14/2026 that RN F had identified 24 missing tramadol pills for Resident #3. He stated there was an investigation started to identify where the medication went. On the evening on 1/15/2026 he stated 60 tablets of Tramadol for Resident #64 were identified as missing as well. He stated the facility then made a self-report to state agency and notified the local police department. The ADM stated through their investigation that night they were able to identify a possible alleged perpetrator. He stated the alleged perpetrator was LVN K and she worked for an agency that the facility contracted with. He stated LVN K was placed on a do not return list. The ADM stated management had started a q

Based on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program, including hand hygiene and enhanced barrier precautions, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 8 (Resident #3, Resident #15, Resident #26, Resident #29, Resident #41, Resident #58, Resident #69 and Resident #87) of 23 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure LVN C practiced proper hand hygiene while serving and assisting Residents #15, # 29, #58, # 69, and #87 during the lunch meal on 01/13/2026.2. Ensure LVN C and CNA I practiced proper enhanced barrier precautions by wearing the appropriate personal protective equipment when performing wound care for Resident #3 on 1/14/2026.3. Ensure LVN C practiced proper hand hygiene while assisting Resident #58 during the lunch meal on 01/14/2026.4. Ensure LVN D and CNA E practiced proper hand hygiene while assisting residents #26 and #41 during the lunch meal on 01/15/2026.These failures could place residents at risk for healthcare associated cross-contamination and infections. 1. An observation of the lunch meal on 01/13/2026 of satellite kitchen area 100/200 between 12:35PM and 1:20PM revealed LVN C serving and assisting with the lunch meal.At 12:41 PM, LVN C was observed to prepare a plate for Resident #87. During food preparation, LVN C scratched her head with her right hand and continued handling the plate without performing hand hygiene.At 12:43 PM, LVN C scratched her nose while continuing to prepare the same plate, then covered the plate and provided it to a staff member for transport to room [ROOM NUMBER] for Resident #87.At 12:51 PM, LVN C donned a blue glove on her right hand without performing hand hygiene and handed Resident #58 a sandwich.LVN C then sat with a resident for approximately five minutes and scratched underneath her scrub top with her left hand. Upon leaving the table, LVN C disposed of the glove in a trash receptacle and did not perform hand hygiene.At 12:59 PM, LVN C gathered a plate for Resident #29 without performing hand hygiene.At 1:16 PM, LVN C sat at the table with Resident #29 and #69 then at 1:17 PM, LVN C wiped the mouth of Resident #69 using the resident's clothing protector.At 1:18 PM, LVN C picked up a drink and handed it to Resident #15 without performing hand hygiene between resident contacts.2. Review of Resident #3's face sheet, dated 01/15/2026, reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region (opening in skin due to pressure to lower back/buttock area), unspecified pain, and retention of urine. Review of Resident #3's Quarterly MDS, dated [DATE], reflected a BIMS score of 01 which indicated severe cognitive impairment. Review of Resident #3's undated order summary reflected Enhanced Barrier Precautions: wear PPE with all care. Every Shift with a start date 07/30/2025.An observation on 01/14/2026 at 11:26 AM revealed LVN C and CNA I washed hands, applied gloves and approached Resident #3 to start wound care. Neither LVN C nor CNA I put on a gown prior to providing wound care. CNA I assisted with positioning and verbally comforting Resident #3 while LVN C performed wound care to Resident #3's lower back/buttock area. A sign was observed outside the resident's door that indicated Resident #3 required Enhanced Barrier Precautions with a 3-drawer tote inside Resident #3's room that contained gowns and gloves. During an interview conducted on 01/14/2026 at 11:36 AM, LVN C stated she had worked at the facility for 13 years. She stated she had been trained on infection prevention and control. She stated she forgot to wear the proper enhanced barrier precautions that included a gown when performing wound care for Resident #3. She stated enhanced barrier precautions were used to prevent transmitting bacteria and infection to or from the resident. She stated she was not sure if anyone monitored to ensure the proper precautions were being utilized. During an interview conducted on 01/14/2026 at 11:43 AM, CNA I stated she had been trained on infection prevention and control including the use of enhanced barrier precautions. She stated enhanced barrier precautions were used for the safety of the resident to prevent transmission of infections. She stated she did not wear a gown while performing care to Resident #3. She stated she forgot to wear a gown while assisting LVN C with wound care for Resident #3. 3. An observation of the lunch meal on 01/14/2026 of satellite kitchen area 100/200 between 12:50 PM and 1:15PM revealed LVN C to walk from hallway 100 over to the satellite dining area. LVN C removed a blue glove from the kitchen area and donned the glove on her right hand without performing hand hygiene. She then approached the table of Resident #58, handed the resident half of a sandwich, and sat at the table with the resident.At 1:05 PM, LVN C removed the blue glove and held it balled up in her hand. She was then observed to wipe Resident #58's mouth with the same hand where the glove was balled. No hand sanitizing observed. She then proceeded to escort the resident to the TV area.4. An observation of the lunch meal on 01/15/2026 of satellite dining area 400 between 12:45 PM and 1:20 PM revealed:At 12:45 PM, CNA E was observed seated and providing feeding assistance to two residents simultaneously, Resident #26 and Resident #41 without performing hand hygiene between contacts.At 1:03 PM, LVN D was observed walking from the middle of the dining area 400 to the table where Residents #26 and #41 were seated. LVN D asked CNA E to take over feeding one of the residents and assumed feeding assistance for Resident #41 without performing hand hygiene prior to contact.At 1:18 PM, LVN D was observed removing keys from her pocket with her right hand and handing them to another staff member. LVN D then resumed feeding Resident #41 without performing hand hygiene.During an interview on 01/15/2026 at 12:28 PM, the ADON stated she was responsible for the infection prevention and control program. She stated it was her responsibility to train staff on proper infection prevention policies. She stated she had done an in-service related to enhanced barrier precautions when it was initiated, but it had been a while. She stated enhanced barrier precautions were used if a resident had an open wound, foley catheter, central line, and/or a multi-drug-resistant organism. She stated it was expected for staff to use a gown and gloves when providing any hands-on care to a resident that had the previously listed conditions. The ADON stated enhanced barrier precautions were used to keep from transmitting infections from resident to resident. She stated she monitored this when she was walking around the facility, but it could be monitored more closely. She stated any staff providing hands-on care to a resident with a wound was expected to wear a gown and gloves. The ADON stated by not wearing gowns and gloves to provide care to a resident with an open wound, the resident is already at risk and the staff could give the resident an infection transmitted on their clothing. An interview conducted with LVN D on 01/15/2026 at 5:33 PM revealed she was trained on proper hand hygiene. She stated that she has been working at the facility for 6 years. The surveyor informed LVN of observations where she failed to wash or sanitize her hands-once when she sat to feed Resident #41 and another time when removing keys from her pocket and continued to feed Resident #41. LVN D stated she sanitized her hands before she sat to feed resident, she stated she stopped to speak with a staff member on the way and did not recall touching anything prior to sitting at the table. LVN D stated she clearly remembered that she removed the keys from her pocket without using sanitizer. LVN D stated a resident can obtain an infection from not performing proper handwashing.An interview conducted on 1/15/2026 at 5:41 p.m., CNA E stated that she has been working at the facility for almost two years. When asked if she had received training on hand hygiene and assisting residents during dining, she confirmed that she had been trained in proper handwashing procedures. She stated that she typically used hand sanitizer, but she knew today she did not. CNA E stated she tried very hard to make sure that the utensils for Residents #26 and #41 did not touch anything but their food and their mouths. She stated she wished they had more staff to feed the residents. CNA E stated bacteria can be transferred to a resident from not using proper hand hygiene, which could cause a resident to become sick.An interview conducted on 1/15/2026 at 6:00 PM, LVN C revealed she was trained in proper hand hygiene. LVN C was informed of the observations in which she failed to perform hand hygiene on 1/13/2026 while serving and assisting Residents # 15, # 29, 58, 69, and #87. LVN C stated she believed she sanitized her hands between the residents, she stated it was a busy day, and she did not remember. LVN C stated on 1/14/2026 she only recalled assisting one resident which was Resident #58, she stated she did not recall holding the glove in her hand because she knew it went in the trash. LVN C acknowledged that failure to perform proper hand hygiene could lead to cross contamination and potential illness.During an interview on 01/15/2026 at 07:11 PM, the DON stated she had worked at the facility for 4 years. She stated she was trained on infection prevention and control policies, including enhanced barrier precautions. The DON stated any resident who had any open areas required the use of enhanced barrier precautions, including a gown and gloves, when staff provided hands-on care. She stated she expected staff to use enhanced barrier precautions including the use of gown and gloves to prevent transmission of bacteria to residents who had any open areas. The DON stated there had not been any recent monitoring of staff to ensure they were utilizing enhanced barrier precautions appropriately, but she had performed checkoffs and in-services related to enhanced barrier precautions within the past year. During an interview on 01/16/2026 at 10:13 AM, the ADM stated he had worked at the facility since July 1, 2025. He stated he had been trained in infection prevention and control policies, including enhanced barrier precautions. He stated he was unsure of the reasoning for implementing enhanced barrier precautions, but the residents that required it had signs posted on their door and supplies just inside of their rooms. The ADM stated residents with signs posted required anyone providing hands on care to utilize gowns and gloves to prevent any possible infection to or from the residents. He stated he was unsure if there was any monitoring in place to ensure enhanced barrier precautions were being utilized appropriately. Record review of facility policy Handwashing/Hand Hygiene revised August 2015 read: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of infections.Policy Interpretation and Implementation1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies.6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations:a. When hands are visibly soiled; andb. After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:a. Before and after coming on duty;b. Before and after direct contact with residents;c. Before preparing or handling medications;d. Before performing any non-surgical invasive procedures;e. Before and after handling an invasive device (e.g., urinary catheters, IV access sites);f. Before donning sterile gloves;g. Before handling clean or soiled dressings, gauze pads, etc.;h. Before moving from a contaminated body site to a clean body site during resident care;i. After contact with a resident's intact skin;j. After contact with blood or bodily fluids;k. After handling used dressings, contaminated equipment, etc.1. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;m. After removing gloves;n. Before and after entering isolation precaution settings;o. Before and after eating or handling food;p. Before and after assisting a resident with meals; andq. After personal use of the toilet or conducting your personal hygiene.8. Hand hygiene is the final step after removing and disposing of personal protective equipment.2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff.3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out.4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove.5. Perform hand hygiene.Review of facility policy titled Enhanced Barrier Precautions, dated 2021 and last revised December 2025, reflected Policy StatementEnhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.Policy Interpretation and Implementation1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities2. Enhanced barrier precautions apply when:.b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; andc. Contact precautions do not otherwise apply.5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs.7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:.j. wound care (any skin opening requiring a dressing).12. Enhanced barrier precautions are in place for the duration of the resident's stay or until resolution of the wound.16. Staff are trained prior to caring for residents on EBPs.17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required.

Based on observations, record review, and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 1 kitchen reviewed for food and nutrition services.The facility failed to ensure DM B refrained from adding an unmeasured amount of liquid to Salisbury steak with gravy, seas white beans, and sauteed cabbage pureed meals during lunch service on 01/14/2026.This failure could place residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss.Observation and interview of the pureed diet process, on 01/14/2025, at 11:09 AM, revealed DM B poured an unmeasured amount of chicken broth into the sea beans without measuring after mixing one time, she poured the beans into a serving pan, the beans were runny in appearance. DM B proceeded to puree the sauteed cabbage which appeared to be over boiled instead of sauteed. DM B poured another unmeasured amount of chicken broth from a plastic container into the blender with the cabbage. After mixing the first time, she added another unmeasured amount of chicken broth into the mixture. When DM B poured the cabbage into the serving dish, it had a watery consistency. DM B pureed the ground meat for the Salisbury Steak next in which she poured unmeasured amounts of beef broth from a container into the meat. The first blend was a thin texture; she added more beef and then more unmeasured beef broth. DM B poured the steak in a serving container; it was not of a pudding consistency texture. When she was done, Surveyor mentioned to DM B that the meal items had a thin consistency, she responded, they will thicken while sitting on the steam table. DM B was asked how much liquid was used per serving, she responded she did not know how much was used. DM B stated, This is the way I do it all the time, I don't measure. I put everything in the blender for about 5-8 cups and then add broth. Surveyor asked DM B if she had followed the recipe book, she stated they do not have recipe books, they printed the recipes off the computer. DM A provided surveyor with a copy of the recipes for the day. The recipe showed the meat, beans, and cabbage should be processed in 5 portions at a time as needed. The recipe showed the meat should be pureed to a pudding consistency. The cabbage recipe showed the sauteed cabbage should have included green pepper, onions, garlic cloves, and sliced bacon, but omit the bacon on the puree serving. A Test tray was requested and received on 01/14/2026 at 12:40 PM. The meal was Salisbury steak with gravy, seas white beans, sauteed cabbage, and cornbread. A test tray was received for a regular texture diet and puree diet. The Salisbury steak, the cabbage, and beans on the puree diet plate all had excess liquid, neither item was of a pudding like texture, the cornbread was the only item with pudding like texture. The meat had flavor, but the other items tasted bland. The regular diet plate was tested, and the meat was tasty but a little rubbery, the sauteed cabbage was bland and had no flavor, there was no indication that green pepper, onions, garlic cloves, and sliced bacon had been used in the recipe. During a confidential group interview meeting at an undisclosed date and time, 3 anonymous residents stated lunch today had no taste. One anonymous resident stated, Everything was white, meals are supposed to have colors.An attempted interview on 01/15/2026 at 4:15 PM, with DM B, was unsuccessful, she had left for the day.Interview conducted with the [NAME] on 01/15/2026, at 4:16 PM. The [NAME] stated he has worked as a cook with the facility since April 1st, 2025. The [NAME] stated he was trained on puree diets by a previous dietary manager who no longer works at the facility. The [NAME] stated he uses one third cup of thickener depending on the recipe. He stated he uses a little scoop of it at a time when blending. He stated the residents do not like it too thick, so he listens to what the residents say also. The [NAME] stated the puree food items should be like pudding, not too runny and not too thick. The [NAME] stated he followed the recipe book and stated if the residents did not eat their food, they could lose weight and possibly get sick.Interview conducted with DM A on 01/15/2026, at 4:40 PM. DM A stated she has worked at the facility for 2 years and she became the dietary manager in July 2025. DM A stated the cooks are trained by the dietician in preparing diet textures. DM A stated she does not personally prepare pureed diets. She stated DM B has been provided training on pureed diets with the dietitian. She stated the DM B reviews the recipe if she has not prepared it before or recently. She stated the pureed texture should be smooth and hold its shape, like pudding. She stated her expectation is that measuring cups be used when preparing food products. She stated that if a recipe is not followed, a resident could be at risk for choking or weight loss.Interview conducted with the ADM on 01/15/2026, at 6:23 PM, ADM stated his expectation was for dietary staff to follow the recipes as written. He stated he does not train the kitchen staff, but they have a dietician that comes to the facility monthly. ADM explained that if the pureed diet was not prepared according to the recipe, the food could lose its flavor and not taste good. He stated the potential harm to residents was that they may possibly stop eating and the residents could lose weight. Interview conducted with the DON on 01/15/2026, at 6:39 PM. DON was asked, how are physician-ordered diets (such as pureed diets) communicated to nursing and dietary staff. DON stated the SLP initiated the recommendation which is sent to the physician. DON stated the recommendations are returned to her and the ADON and they send a communication slip to the kitchen. DON was asked what systems are in place to ensure residents consistently receive the prescribed diet texture, she responded that the servers prepare the plates, tray ticket and food consistency is verified by the nurse before being given to the residents. DON stated she expects the dietary department to follow the recipes. DON stated if a puree diet recipe was not followed, residents could potentially choke, not receive the right amount of nutrients or lose calories if too much liquid was used. DON also stated too much liquid could cause aspiration.A follow up interview was conducted with DM B on 01/16/2026, at 10:11 AM. DM B stated she was employed at the facility for 6 years but just returned March 2025. DM B stated no one trained her in the pureed process, she mostly taught herself. She stated a dietician comes and checks the food. When asked why a physician orders a pureed diet, DM B stated that some residents have swallowing issues with regular food and require specific textures to eat safely. When asked how she ensures the correct texture and consistency, she stated that when the food is poured into the pan it should not be lumpy, too thick, or too runny. Surveyor showed DM B pictures of the pureed meal served on 1/14/2026, she stated she was nervous on that day. DM B stated she will be looking more closely at the recipes. When asked what risks could occur if the pureed diet is not prepared according to the recipe, the DM B stated that the resident could choke if the texture is incorrect and that this could cause harm to the resident.Record Review of the facility's puree diets received 1/14/2026 from ADM revealed there were 11 residents on pureed diets. Record Review of the facility policy Therapeutic Diets dated October 2017 states: Policy StatementTherapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.Policy Interpretation and Implementation1. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. Diagnosis alone will not determine whether the resident is prescribed a therapeutic diet.2.A therapeutic diet must be prescribed by the resident's attending physician (or non-physician provider). The attending physician may delegate this task to a registered or licensed dietitian as permitted by state law.3.Diet order should match the terminology used by the food and nutrition services department.4.A 'therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example:a. diabetic/calorie controlled diet;b. low sodium diet;c. cardiac diet; andd. altered consistency diet.5. If a mechanically altered diet is ordered, the provider will specify the texture modification.7. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets.8. The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record.9. Snacks will be compatible with the therapeutic diet.

Based on observations, record reviews, and interviews, the facility failed to treat each resident with respect and dignity and failed to provide care for each resident in a manner and environment that promoted the maintenance or enhancement of their quality of life for 2 (Resident #26, Resident #41) of 12 residents reviewed for dignity.The facility failed to ensure that Resident #26 and Resident # 41 were provided dignified and individualized feeding assistance during the lunch meal on 01/15/2026.This failure could place residents at risk of diminished dignity and negatively affect their quality of life.Record review of Resident #26's Face sheet dated 01/15/2026, reflected she was a [AGE] year-old female, who was admitted to facility on 03/09/2021 with diagnoses of Hypertensive heart disease with heart failure (high blood pressure damaged the heart), Neurocognitive disorder with Lewy bodies (brain condition that cause problems with memory), Unspecified dementia (memory loss), Major depressive disorder (feel sad, hopeless), and Vitamin deficiency. Record review of Resident # 26's MDS assessment, dated 11/20/2025, indicated a Brief Interview for Mental Status (BIMS) was not conducted. The Staff Assessment for Mental Status revealed a score of 3 indicating severely impaired cognition (never/rarely made decisions). Record review of Resident # 26's care plan, dated 11/28/2025 reflected Nutritional Status: I am in need of a special utensil to assist with meal time. I need a high sided plate to help with getting the food on my utensil I will be able to assist myself at mealtimes thru this review period. Monitor effectiveness of the utensil, notify physician of any significant changes.Record review of Resident #41's Face dated 01/15/2026, reflected she was an [AGE] year-old female, who was admitted to facility on 05/18/2021 with diagnoses of Alzheimer's disease with late onset (brain disorder slowly destroys memory), Gastro-esophageal reflux disease without esophagitis (stomach acid flows back into the esophagus), Anorexia (no desire to eat, leading to weight loss), and Unspecified dementia (memory loss).Record review of Resident # 41's MDS, dated [DATE], indicated a Brief Interview for Mental Status (BIMS) was not conducted. The Staff Assessment for Mental Status revealed a score of 3 indicating severely impaired cognition (never/rarely made decisions). MDS also indicated Resident #41 required total assistance with eating.Record review of Resident # 41's care plan dated 12/16/2025 reflected resident has a nutritional problem with the potential for unintended weight loss related to requiring assistance with meals and poor intake. Resident #41 should have assistance with her meals and fluid intake during mealtimes.Observation of the facility's dining room [ROOM NUMBER] on 01/15/2026 between 12:45 PM and 1:20 PM, revealed that at 12:45 PM, Resident #26 and Resident #41 were being fed their lunch meal at the same time by CNA E. Resident #26 and Resident #41 was observed waiting on their food while CNA E assisted the other resident, resulting in delayed assistance and individualized care. CNA E did not wash her hands, nor did she use any hand sanitizer at the table between the two residents. Continued observation on 12/2/2025 at 1:03 PM revealed LVN D walked over and asked CNA E to take over feeding of Resident #41. Interview conducted 1/15/2026, at 1:47 PM, revealed SLP had worked for four months at the facility. SLP stated she was aware residents had the right to be treated with dignity and respect during meals. SLP stated she could not say that feeding two residents at the same time was a rights violation unless the residents were documented as needing required feeding assistance. She stated it would be a cross-contamination concern. SLP stated a resident would be assessed on a resident-specific basis. Regarding if it was a safety concern, SLP stated, it depends on whether a resident was considered a high risk at mealtimes. She added that feeding two residents at the same time could cause the residents to feel confused or left out.Interview conducted 1/15/2026, at 5:33 PM, revealed LVN D had been working for almost 6 years at the facility. LVN D stated she has been trained on the facility's abuse and neglect, resident rights, and promoting/maintaining resident dignity procedures. LVN D revealed she was aware residents had the right to be treated with dignity and respect during meals. LVN D stated she witnessed the incident involving Resident #26 and Resident #41 being fed at the same time. LVN D stated she did not believe feeding two residents at the same time to be a rights or dignity violation; however, she stated she could see how it could be a problem. LVN D stated that residents should have the right to eat in a safe environment. She further stated feeding two residents at the same time could make a resident feel abandoned.Interview conducted 01/15/2026 at 5:41 PM, with CNA E revealed she worked as a CNA for almost 2 years with the facility. CNA E stated she has been trained on the facility's abuse and neglect, resident rights and dignity by the DON and other facility staff. CNA E stated it was not appropriate to feed two residents at the same time. CNA E acknowledged she fed two residents today at the same time while waiting on another staff to assist. CNA E stated she prefers to feed only one resident at a time; however, she stated she wished the facility had more staff available to assist with feeding. CNA E stated a facility staff could accidentally use the same feeding utensils for both residents, which would create a cross-contamination issue as well as a dignity concern. CNA E stated the possible effect on the residents is that the residents could feel upset because the focus is not on them individually. Interview conducted 01/15/2025 at 6:18 PM, the ADM stated he has been with the facility since July 1, 2025. ADM stated that all administrative staff were responsible for training staff in resident rights and dignity policies. The ADM stated staff should only feed one resident at a time to ensure a safe dining environment. The ADM stated the situation is a Catch-22 and mentioned that he was unsure of it being a rights violation, but dignity concerns could go either way. When asked about residents' right to a safe environment during mealtimes, ADM stated residents had the right to eat in a safe environment. He stated if a resident aspirated or choked while staff helped another resident it would not be a safe environment. The ADM stated this practice, could cause a resident to think, why they have to wait. Record review of the facility's policy on Resident Rights, dated October 2025, stated: Policy StatementEmployees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms;e. self-determination;Record review of the facility's policy on Dignity, dated October 2025, stated:Policy StatementResidents are treated with dignity and respect at all times.Policy Interpretation and Implementation1. Each resident is cared for in a manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem.2. Resident goals, choices, preferences, values, and beliefs are respected and honored to the extent possible. This begins with the initial admission and continues throughout the resident's facility stay.3. Individual needs and preferences of the resident are identified through the comprehensive assessment process, which includes resident and family interviews.4. Residents may exercise their rights without interference, coercion, discrimination, or reprisal from any person or entity associated with this facility.5. When assisting with care, residents are supported in exercising their rights. For example, residents are encouraged to:a. maintain personal grooming styles (e.g., hair styles, nails, etc.);b. attend the activities of their choice, including religious, political, civic, recreational, or social activities;c. dress in clothing they prefer; andd. sleep, eat, and conduct activities of daily living as they choose. 9. Staff inform and orient residents to their environment. Procedures are explained before they are performed and residents will be told in advance if they are going to be taken out of their usual or familiar surroundings. 13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example:a. addressing the underlying motives or root causes for behavior; and not challenging or contradicting the resident's beliefs or statements.

Based on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #7) of seven residents reviewed for quality of care. The facility failed to assess Resident #7 for emotional and physical distress after he was exposed to smoke inhalation after the air conditioning/heating unit began to smoke in his room and subsequently began not feeling well and had pain in his chest form smoke exposure. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization . Findings included: Review of Resident #7's face sheet revealed an [AGE] year-old man admitted on [DATE] and diagnoses included: malignant neoplasm of prostate (cancerous tumor that forms in the prostate gland), chronic obstructive pulmonary disease (chronic lung disease that limits airflow and causes ongoing respiratory symptoms), unspecified asthma (chronic disease in which the bronchial airways in the lungs become narrowed and swollen and make it difficult to breathe), and atherosclerotic heart disease (condition that occurs when plaque builds up in the arteries, hardening them and limiting blood flow to the heart), and unspecified combined systolic heart failure (caused by other conditions that weaken the heart muscle). Review of Resident #7's quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated no cognitive impairment. Review of Resident #7 active diagnoses revealed resident had a diagnosies of asthma and/or COPD. Review of Resident #7's care plan dated 09/24/2024 revealed the resident has ineffective tissue perfusion related to potential syncope. Cardiac dysfunction and had an AEB pacemaker in place. Interventions included that resident's safety and comfort will be maintained this review period. Further review of the care plan revealed the resident was at risk for activity intolerance related to imbalance between supply oxygenation needs. Review of Resident #7's physician orders dated 07/02/2024 revealed the resident had an order for O2 per nasal cannula/mask as needed for shortness of breath, cough, or congestion. Further review of Resident #7's progress notes dated 10/14/2024 to 10/15/2024 revealed no progress note related to incident in which the resident was exposed to smoke inhalation on 10/14/2024. Review of Resident #7's progress note dated 10/16/2024 revealed the resident complained of increased pain and discomfort to the center of his chest around the sternum. Resident #7 stated that he had a slight dry cough and that the pain made it difficult to swallow. Review of Resident #7's vital signs from 10/14/2024 through 10/17/2024 revealed only Resident #7's blood pressure had been taken and recorded. There were no vitals documented for respirations, oxygen saturation, temperature, or pulse. Further review revealed that blood pressure taken during this time frame were taken by medication aides. Review of Resident #7's skin assessments from 10/14/2024 to 10/17/2024 revealed no assessment was completed following the incident with resident's air conditioning/heating unit in the room. Further review of Resident #7's chart indicated there was no trauma/psychosocial assessment completed. Review of the nurse practitioner progress note dated 10/14/2024 revealed the NP visited the resident with chief complaint as nausea and history of present illness for the visit was the resident was exposed to smoke that was coming out of the air conditioning unit in his room, per DON report, he is participating in morning activities, c/o nausea denies any sob, cp, headache. Assessment and plan included order for Zofran every 6 hours as needed for nausea. Assessment and plan for Asthma/COPD included stable, on room air without exacerbation, and to monitor respiratory status with no issues reported at the time of the assessment. During an interview on 10/17/24 at 10:08 AM LVN F stated that the incident with the smoking unit happened Monday (10/14/2024) and that she was Resident #7's nurse on Tuesday. LVN stated that his vitals were normal, lung sounds were clear, and he was at baseline. LVN F stated that if she was Resident #7's nurse when the incident happened, she would have done a head- to- toe assessment on him and full vitals. LVN F stated that normally the NP iwas there, and she would have notified her as well. LVN F stated that the head- to- toe assessments were documented as a progress note and under observations on the Resident's chart. She stated that she would have written a progress note about what happened to the resident and who was notified. LVN F viewed Resident #7's chart and stated that Resident #7 did not have a progress note for the incident and did not have skin assessment for the incident either . During an interview on 10/17/24 at 10:33 AM LVN G stated you [NAME] supposed to ensure residents were okay. LVN G stated that this included to check lung sounds and a head-to-toe assessment. LVN G stated that these should be documented under a progress note. LVN G stated that she would have monitored the resident at least every shift after incident for 3 days as this was procedure for after an incident. LVN G stated that the potential risk for not assessing the resident [NAME] that the resident could potentially get a respiratory infection from inhaling smoke or staff could miss an injury. During an interview on 10/17/24 at 10:37 AM CNA H stated that the incident happened between 9:30 AM and 10:00 AM on 10/14/2024. CNA H stated that she smelled a smokey smell and described it as when you first turn on heater for first time in the year. CNA H stated that there was a lot of smoke in Resident #7's room and the smoke came out of the room when she opened the door. CNA H stated that she was coughing heavily and had a headache the rest of her shift. CNA H stated that she believed the DON checked on Resident #7 following the incident. LVN H stated the following day Resident #7 complained about his chest and throat hurting and she notified his nurse. She stated the nurse was LVN F. During an interview on 10/17/24 at 11:08 AM the NP stated that she saw Resident #7 on 10/14/2024 because he was nauseous and stated that he drank too much water with his medication. The NP stated that other than that everything was okay. The NP stated that she did not take his vitals and reviewed the vitals from his chart, and they appeared okay. The NP stated she saw Resident #7 again this morning (10/17/2024) and he was doing therapy. The NP stated that Resident #7 had issues with acid refluex. The NP stated that a GDR was recommend for his PPI and this could have been why he felt pain in his throat. The NP stated that Resident #7 did not complain of a cough this morning. The NP stated that earlier this week staff notified her that Resident #7 complained of a cough. The NP stated that when she assessed him on 10/15/2024 his lungs were clear. She stated that his chest pain was in the center and when he ate it felt like it burned and that his nurse mentioned that his chest pain happened before the smoke exposure . During an interview on 10/17/24 at 11:13 AM LVN I stated she worked on the hall with the unit smoking. LVN I stated that after she and the CNA smelled smoke, they pulled the fire alarm, and removed residents off the hall. LVN I stated initially that she did not recall Resident #7. LVN I stated that she was assigned to that room during that shift on 10/14/2024. LVN I stated that staff went one by one and checked the residents to make sure they were okay. LVN I stated that this included checking the residents vitals and asking if they were okay. LVN I stated that the vitals were not documented. LVN I stated that she did not believe Resident #7 had a head- to- toe assessment completed after the incident. LVN I stated she did not know why an assessment was not done. said Shethen stated it was not completed because it was chaotic. LVN I's vitals [NAME] documented in the vitals tab in the residents' charts. LVN I stated that usually after an incident residents were followed for 72 hours . During an interview on 10/17/24 at 11:29 AM the DON stated that LVN I worked the hall when Resident #7's unit began to smoke. The DON stated she notified the NP that he needed to be evaluated and that the NP went and evaluated him. The DON stated that she was not sure what was done during the NP's evaluation. The DON stated that she did not see that LVN I completed an assessment with Resident #7 or vitals. The DON stated that the NP stated Resident #7's vitals needed to be checked. The DON stated that vitals [NAME] documented in a resident's chart, under the vitals tab, and by progress note. The DON stated that she doe didoes not think anyone completed a head- to- toe assessment with Resident #7. The DON stated it was a lack of education for new nurses and the nurse should have been educated on what to do in the situation. The DON stated that she was only made aware that Resident #7 had been complaining of chest pain on 10/15/2024 and she asked the NP to reach out to the nurse. The DON stated that if a resident [NAME] not assessed after an incident there was potential risk for infection, bronchitis, and pneumonia. The DON stated that she asked the NP to order a chest x-ray the day of the incident on 10/14/2024 and again 10/17/2024. The DON stated that the NP denied and stated that his lungs were clear and did not feel an x-ray was needed at this time. The DON stated she was not aware of the Resident complaining daily of GERD issues prior to the incident. The DON stated that she expected nurses to monitor a resident for three days or 9 shifts after any incident. The DON stated that she expected the staff to gather vitals, watch for new symptoms, new cough or headache, and new chest pain. The DON stated that vitals included gathering blood pressure, respiratory rate, and pulse. The DON stated that CNAAN H had a cough and shortness of breath after the incident, and she was unsure if Resident #7 had a cough. The DON stated that she was unsure if Resident #7 was assessed for emotional or psychosocial distress since the facility did not have a social worker and she thought the ADM may be responsible to for completed that assessment. During an interview on 10/17/24 at 11:53 AM Resident #7 stated that he stated that he has not been feeling well since he had all the smoke in his room. Resident #7 stated he has been having pain in his chest and motioned in the middle of his chest. Resident #7 stated that he has not had pain in his chest before the exposure to smoke. Resident #7 stated that the nurse told him he has bronchitis. Resident #7 stated that he has pain mainly when he swallows, and did not associate a number with it, just stated it was the same since the incident and not getting worse. During an interview on 10/17/24 at 12:17 PM: LVN F checked Resident #7's vitals temperature 98.7 Fahrenheit, 76 was his heart rate, 99% O2, and 142/68. LVN F stated Resident #7 was going to start taking Carafate for his GERD. During an interview on 10/17/24 at 12:21 PM the MD stated that she expected for a routine assessment which included vital signs and oxygen level to be completed after exposure to smoke inhalation. The MD stated that if a resident has COPD, inhalation could have exacerbated it. The MD stated smoke inhalation could cause a cough or chest pain like any other irritant. During an interview on 10/17/24 at 03:07 PM the ADM stated that there was not a social worker and stated that the nurse would complete the psychosocial assessment for any emotional distress. He is unsure if this was completed and who assessed the resident for emotional or psychosocial distress. He stated if there was distress the resident would be referred to psychology. The ADM stated that the NP assessed Resident #7 right away after the incident. He stated that if she would not have been here, he would have expected that the charge nurse assessed him. The ADM stated that CNA H had a headache and sat in the lobby for a few hours after the incident. The ADM stated that he expected the NP to check Resident #7's lung sounds. The ADM stated that he didoes not know what else the NP would check, and he knew the NP talked to staff after, but he was unsure what happened with Resident #7's assessment . Review of facility in-service dated 07/14/2024 included topic of skin and pain assessments. Comments included for any new incident, a skin assessment must be done to document injuries and a pain assessment should be completed to ensure resident has no pain from new events. Skin and pain assessments should be completed for any admission, any change in condition or event. Review of facility policy titled Resident Examination and assessment dated [DATE] revealed the purpose of this procedure is to examine and assess the resident for any abnormalities in health status. Further review revealed the physical exam should include vital signs such as blood pressure, pulse, respirations, temperature, heart rate and rhythm, lung sounds, and cough. Documentation of the exam should be recorded in the resident's medical record and include the date and time the procedure was performed, name and title of the individuals who performed the procedure, and assessment data obtained during the procedure. Staff should notify the physician for worsening pain as reported by the resident and other information in accordance with facility policy and professional standards of practice. Review of facility quality of care policy titled Change in a Resident's Condition or Status dated May 2017 revealed the nurse will notify the resident's attending physician if there has been any accident or incident involving the resident. Further review revealed that prior to notification, the nurse will make detailed observations and gather relevant information including information prompted by the interact SBAR communication form. The policy revealed the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on observations, interviews, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for all the residents reviewed for infection control, as indicated by: 1. LVN F, LVN I, and CMA N did not clean and disinfect the blood pressure monitor while using it on Resident #11, Resident #1, Resident #54, Resident #50, Resident #5, Resident #25, and Resident #46. 2. LVN F did not perform hand sanitizing before preparing medications and handling blood pressure monitor. 3. IP M handled clean items with soiled gloves while providing peri care to Resident #230 These failures could place the residents at risk of transmission of disease and infection. Findings included: Record review of Resident #230's face sheet on 10/16/24 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. His diagnoses were, constipation, nausea with vomiting, gastro-esophageal reflux disease, and anxiety disorder, Record review on 10/16/24 of Resident #230's care plan dated 10/01/24 reflected the resident had alternation in his bowel elimination and constipation. The relevant intervention was monitoring bowel movements every shift and record. Record review on 10/16/24 of Resident #230's initial MDS assessment, dated 10/04/24 revealed a BIMS score of 13 indicating his cognition was intact. Further review of the MDS revealed Resident #230 was occasionally incontinent with bowel and bladder. During an observation on 10/16/24 at 9:30am IP M provided peri care to Resident #230 while he was lying in his bed. IP M did not change her soiled gloves before handling the clean wet wipe packet. IP M washed her hands and donned gloves. She removed some wet wipes from the packet for using at that time. She then opened the diaper and cleaned the front and back of Resident #230 with the wipes. When she needed more wipes, without changing the soiled gloves, she handled the wet wipe packet, removed more wipes, and continued to clean. She changed the old diaper with the new one. After the completion of the task, she left the contaminated wet wipe packet with remaining wipes stored on the side table and left the room. During an interview on 10/16/24 at 9:50am IP M stated she was an LVN and the IP at the facility. She stated she understood the mistake that she did not change the dirty gloves while handling clean items. She stated, though peri care was done by CNA's, she gave helping hands to them so that resident did not have to wait for long. She stated she was in a hurry and missed many steps in the procedure for peri care. She said such omissions leads to spreading diseases. Record review of Resident #50's face sheet on 10/16/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were acute congestive heart failure, shortness of breath, hypertensive heart, chronic kidney disease, and hyperlipidemia (excessive fat in blood). Record review on 10/16/24 of Resident #50's care plan dated 08/08/24 stated Resident #50 required monitoring as she was on diuretics for congestive heart failure. Record review on 10/16/24 of Resident #50's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating her cognition was intact. Record review of Resident #25's face sheet on 10/16/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were hyperlipidemia (excessive fat in blood), dizziness, giddiness, pain, and hypertension. Record review on 10/16/24 of Resident #25's care plan dated 09/05/24 reflected the resident was at risk for decreased cardiac output related to reduced myocardial contractility. The relevant intervention was giving anti-hypertensive medications as ordered and monitoring the side effects such as orthostatic hypotension (low blood pressure) and increased heart rate. Record review on 10/16/24 of Resident #25's quarterly MDS assessment, dated 09/03/24 revealed a BIMS of 11 indicating a moderate level of cognition. An observation on 10/16/24 at 8:25am, revealed LVN F failed to sanitize the blood pressure monitor before using it on Resident #25, in between Resident #25 and Resident #50, and after Resident #50. LVN F took the blood pressure monitor from the top of the med cart and without sanitizing it, she took the blood pressure of Resident #25. LVN F then moved on to Resident #50 and took her blood pressure with the same blood pressure monitor without sanitizing it. After completing the measurement on Resident #50, without cleaning the blood pressure monitor, she kept it on the top of the med cart. During an interview on 10/16/24 at 8:45am, LVN F stated she was working at the facility for about [AGE] years. She said it was essential to minimize the risk of spreading contagious diseases by sanitizing the blood pressure cuff in between the residents. LVN F stated she was aware of the importance of sanitizing medical equipment, and she received training; however, did not know exactly when it was. Record review of Resident #5's face sheet on 10/16/24 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were dementia, congestive heart failure, atrial fibrillation (irregular heartbeat), and hypothyroidism (low thyroid hormone). Record review on 10/16/24 of Resident #5's care plan dated 07/25/24 reflected the resident was at risk for fluid retention and activity intolerance related to congestive heart failure. The relevant intervention was administering diuretics as ordered and monitoring effectiveness and notify the provider of side effects/no changes in edema. Record review on 10/16/24 of Resident #5's quarterly MDS assessment, dated 10/04/24 revealed a BIMS score of 10 indicating moderate cognitive impairment. Record review of Resident #46's face sheet on 10/16/24 revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses were altered mental status, pain, cerebral infarction (stroke), hyperlipidemia (high fat level in blood), and hypertension. Record review on 10/16/24 of Resident #46's quarterly MDS assessment, dated 07/11/24 revealed a BIMS score of 05 indicating her cognition was severely impaired. The MDS indicated hypertension as one of her active diagnoses. Record review on 10/16/24 of Resident #46's care plan dated 10/03/24 had not indicated for the management of hypertension. During an observation on 10/17/24 at 8:50am LVN I did not sanitize the blood pressure monitor before, in between and after using it on Resident #5 and Resident #46. She took the monitor from the med cart and measured the blood pressure of Resident #5 who was sitting in the dining area. After taking the blood pressure of Resident #5, she approached Resident #46 and applied the same monitor without sanitizing. After the completion, she kept it above the med cart and started dispensing medication for the residents. During an interview on 10/17/24 at 9:05am, LVN I stated she was working at the facility for about a month. LVN I said she was concentrating on administering medications for the residents and forgot to sanitize the blood pressure cuff before and after using it on Resident #5 and Resident #46. She stated it was important to follow infection control protocol and sanitize the blood pressure cuffs before using it on the residents. She added, this was essential to minimize the risk of spreading contagious diseases. LVN I stated she was aware of the importance of sanitizing medical equipment and received training on this during her 3 day orientation training when she started working at the facility. Review of the in-service records from 06/01/24 to 10/17/24 revealed there was no in-services on sanitizing medical devices. 2. Observation on 10/16/2024 at 7:48 AM revealed LVN F coughed and grabbed a blood pressure cuff and proceeded to enter a resident room without performing hand hygiene. Observation on 10/16/24 07:52 AM revealed LVN F prepared medications and did not perform hand hygiene prior to preparing these medications. Further observation revealed hand sanitizer was on the medication cart. Observation on 10/16/24 at 08:00 AM revealed LVN F coughed and proceeded to prepare medications for resident without performing hand hygiene. During an interview on 10/17/24 at 10:05 AM LVN F stated that hand hygiene should have been performed before and after direct care with patients. LVN F stated that hand hygiene should have been performed before medication pass and periodically during medication pass. LVN F stated that hand hygiene should have also been performed before trays were passed during meals. LVN F stated that if staff coughed or blew their nose, they should have used hand sanitize after. LVN F stated that if staff blew their nose and did not wash their hands and pass medications it could cause cross contamination and an infection control issue which could get the resident sick. LVN F stated she received training on hand hygiene and infection control but does not recall how long ago. LVN F stated that hand hygiene was reviewed monthly during in-services. LVN F stated that blood pressure cuffs were supposed to be sanitized before use of each patient and before the next. During an interview on 10/17/24 at 09:50 AM CNA O stated she has worked at the facility for a few years. CNA O stated staff should perform hand hygiene before, during and after resident care, and it depended on what the staff was doing. She stated that if staff go from one room to another, hand hygiene should be performed. CNA O stated that if staff worked with the resident, they should perform hand hygiene before they worked with another resident. During an interview on 10/17/24 at 09:53 AM CMA O stated that when she passed medications she knocked, introduced herself, washed her hands, and then prepared medication. She stated she used hand sanitizer after she prepared the medication and after she administered the medication, she washed her hands again. CMA O stated it was not okay to skip hand sanitizer and not wash hands because it was contamination. CMA O stated if she needed to blow her nose, she should wash her hands so that way nothing was contaminated. During an interview on 10/17/24 at 09:59 AM CNA T stated that she has worked at the facility for a few months. CNA T stated she has not had any training for hand hygiene. CNA T stated that staff were supposed to perform hand hygiene before and after working with residents. She stated that hand hygiene should have been performed before putting on gloves and after taking gloves off. She stated that if staff touched their face or blow their nose, they were supposed to wash their hands. 3. Record review of Resident #11's face sheet dated 10/17/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but were not limited to cerebral palsy (a condition that affects movement and posture caused by damage to the brain, most often before birth), hypertension (high blood pressure), and chronic pain. Review of Resident #1's face sheet dated 10/17/2024 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to diabetes mellitus (a disorder in which the body has high blood sugar levels for prolonged periods of time), cerebral infarction (a conditions where the blood flow to the brain is compromised), hypertension (high blood pressure), and hypothyroidism (a condition where the thyroid gland does not produce enough hormones). Review of Resident #54's Face Sheet dated 10/17/2024 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hyperlipidemia (high amount of cholesterol in the blood), anxiety, and CVA with right sided weakness (a conditions where blood flow to a part of the brain is stopped causing right sided weakness). An observation on 10/16/24 at 08:59 AM revealed CMA N sanitized her hands, then took blood pressure cuff off top of medication cart and wiped it down with a sanitizing wipe, and then walked into Resident #54's room. She applied the wrist blood pressure cuff to resident #54's wrist and checked his blood pressure. She took the blood pressure cuff off his wrist and proceeded to return it to the medication cart in the hallway. She set the blood pressure cuff down on top of the cart, sanitized her hands, then began documenting Resident #54's vital signs in the computer and pulling medication to administer. She proceeded to administer Resident #54's medication. An observation on 10/16/24 at 08:28 AM revealed CMA N pushed the medication cart down the hall and outside of Resident #11's room. She sanitized her hands, then picked up the blood pressure cuff off the top of the medication cart and approached Resident #11. She applied the blood pressure cuff to Resident #11's wrist and checked Resident # 11's blood pressure. CMA N removed the blood pressure cuff from Resident #11's wrist and returned it to the medication cart in the hall. CMA N laid the blood pressure cuff down on top of the medication cart, sanitized her hands, and proceeded to document the vital signs in the computer, then pull the medication for Resident #11. She administered the medication to Resident #11. CMA N sanitized hands and pushed medication cart down call to Resident #1's room. An observation on 10/16/24 at 08:39 AM revealed CMA N picked up the blood pressure cuff off the top of the medication cart and approached Resident #1. She proceeded to apply the blood pressure cuff to Resident #1's wrist. She then checked Resident # 1's blood pressure. CMA N then returned to the medication cart in the hallway and sat the blood pressure cuff on top of the cart. She sanitized her hands and proceeded to document the vital signs for Resident #1. CMA N then pulled medications for Resident #1. She administered the medications to Resident #1 and returned to the cart and sanitized her hands. An interview on 10/17/24 at 10:10 AM with CMA N, revealed she had been employed at this facility about 5 years off and on. CMA N acknowledged only sanitizing blood pressure cuff a total of 1 time between 3 residents whom she assessed blood pressure. She further stated that not sanitizing the wrist blood pressure cuff between using on different residents could cause contamination. An interview on 10/17/24 at 01:50 PM with LVN F revealed blood pressure cuffs were to be cleaned between residents. She stated not cleaning the blood pressure cuffs between residents can cause cross contamination. An interview on 10/17/24 at 03:55 PM with the DON revealed her expectation for checking vital signs during medication administration included disinfecting any shared vital sign machines including blood pressure cuffs. She stated failing to disinfect the blood pressure cuff between residents could result in infection. The DON stated it was her expectation that all the staff at the facility should follow infection control protocols while providing care to residents that included peri care. She said the staff were monitored for infection control compliance through annual skill checks and regular and frequent observation by the DON and the IP. She stated the staff with deficient practices were retrained and reevaluated for their skills and proficiency in controlling the infections at the facility. An interview on 10/17/24 at 03:12 PM with ADM revealed the blood pressure cuff should be disinfected between resident use, and it could pass an infection between residents if not done. The ADM stated he was not aware that the hand sanitizer dispenser in the satellite kitchen was not functional. He said hand sanitizing in the kitchen was important since the food for all the residents were dispatched from there and improper infection control practices could lead to spreading diseases to all the residents at the facility. Review of facility's policy titled Cleaning and disinfection of Resident care Items and Equipment revised in October 2018 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The purpose of this procedure is to provide guidelines for disinfection of non-critical resident care items. . 1.The following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care. a. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue (e.g., urinary catheters) or the vascular system (e.g., intravenous catheters) are considered critical items and must be sterile. b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. (Note: Some items that may come in contact with non-intact skin for a brief period of time (e.g., hydrotherapy tanks, bed side rails) are usually considered non-critical surfaces and are disinfected with intermediate-level disinfectants.) c. Non-critical items are those that come in contact with intact skin but not mucous membranes. (1)Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers. (2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) . Review of facility's policy titled Influenza, prevention and control seasonal revised in August 2014 reflected: Infected Healthcare Workers: 1. The Infection Preventionist and/or designee will monitor and manage ill healthcare personnel. Staff who develop fever and respiratory symptoms will be: a. Instructed not to report to work, or if at work, to stop resident-care activities, don a facemask, and promptly notify their supervisor and the Infection Preventionist and/or designee before leaving work. b. Reminded that adherence to respiratory hygiene and cough etiquette after returning to work is always important. (1) If symptoms such as cough and sneezing are still present, staff will wear a facemask during resident-care activities. (2) The importance of performing frequent hand hygiene (especially before and after each resident contact and contact with respiratory secretions) will be reinforced . Standard Precautions: 1. During the care of any resident, all staff shall adhere to standard precautions, which are the foundation for preventing transmission of infectious agents in all healthcare settings. Hand hygiene: a. Staff will perform hand hygiene frequently, including before and after all resident contact, contact with potentially infectious material, and before putting on and upon removal of personal protective equipment, including gloves. b. Hand hygiene in healthcare settings will be performed by washing with soap and water or using alcohol-based hand rubs. If hands are visibly soiled, soap and water, not alcohol-based hand rubs, will be used. c. Supplies for performing hand hygiene are available throughout the facility. 45070 50872

Based on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitization. 1. The facility failed to ensure food in the freezer, refrigerator and dry storage room were properly stored, dated and labeled. 2. The facility failed to ensure kitchen staff performed hand hygiene while preparing food. 3. The facility failed to maintain kitchen equipment in clean operating condition. 4. The facility failed to ensure refrigerators in satellite kitchens maintained appropriate temperatures. 5. The facility failed to ensure clean dishes were stored away from food preparation area and cleaning cloths were stored away from food preparation areas. These failures could place residents who were served from the kitchen at risk of food-borne illness. Observation of the freezer on 10/15/2024 at 7:06 AM revealed an undated package of molded raspberries . Observation of the dry storage on 10/15/2024 at 7:07 AM revealed jalapenos with a label that revealed refrigerate after opening with an open date of 10/7/2024. Observation of the freezer on 10/15/2024 at 7:11 AM revealed undated Ozempic (a prescription injectable medication used to treat type 2 diabetes in adults). Observation on 10/15/2024 at 7:16 AM revealed ice maker in satellite kitchen had rust and white build up on dispenser and rust on tray. Observation on 10/15/2024 at 7:17AM revealed thermometer reading 50 degrees in satellite kitchen refrigerator. There were lemon glycerin swab sticks in freezer of satellite kitchen. Further observation revealed instructions to protect from freezing. Observation on 10/15/2024 at 7:19 AM revealed drinking cups stored in cabinets of satellite kitchen-stained brown at bottoms. Observation on 10/15/2024 at 7:20 AM revealed four plastic containers of various kinds of cereal stored in cabinet of satellite kitchen with no label or date. Observation on 10/15/2024 at 11:07 AM revealed a non-functioning hand sanitizer dispenser in the satellite kitchen. Observation on 10/15/2024 at 7:23 AM revealed satellite kitchen refrigerator temperature read 70 degrees. Observation on 10/15/2015 at 12:38 PM revealed DA T wore gloves while serving dining service. Further observation revealed that DA T opened refrigerator with gloves on and proceeded to serve without changing gloves or performing hand hygiene. DA T proceeded to open Ziploc bag of small potato chips and did not perform hand hygiene before returning to serve. Observation on 10/16/2024 at 12:07 PM revealed [NAME] K prepared pureed food over exposed clean bowls. Further observation revealed clean bowls were uncovered. Observation on 10/16/2024 at 12:11 PM revealed [NAME] L touched his face mask with his gloves. [NAME] L was observed then touching the cooking utensil without performing hand hygiene. Observation on 10/16/2024 12:14 PM revealed [NAME] L removed his left glove and grabbed a thermometer. [NAME] L proceeded to put on the same used glove and did not perform hand hygiene and proceeded to take the temperature of the fried chicken. Observation on 10/16/2024 12:17 PM revealed a small red and green filled with a liquid on food preparation table while [NAME] L prepared food. Observation on 10/16/2024 at 12:19 PM revealed [NAME] K grabbed used spoon from food preparation area and added scoop of chicken base paste into measuring cup. [NAME] K proceeded to add water to existing left-over water in measuring cup. She proceeded to mix the chicken base with used spoon. Observation on 10/16/2024 at 12:21 PM revealed [NAME] K grabbed wet rag from water bucket on food preparation area and proceeded to clean food preparation area while blending pureed rice. Observation revealed clean bowls open and under food preparation area. [NAME] K placed rag into green bucket and did not perform hand hygiene before she continued to prepare puree. Observation on 10/16/2024 at 12:23 PM revealed [NAME] K grabbed blending mechanisms with her bare hands and removed it from the blender and scrapped it with the spatula. During an interview on 10/17/24 at 01:40 PM [NAME] K stated has worked at the facility for four years. [NAME] K stated she should wash her hands before preparing food, if she were to leave the food preparation area, she would grab what she needs, leave the supply and wash her hands before she begins prepping food again. [NAME] K stated clean dishes were supposed to be stored on the halls and plates as well but in the warmers. [NAME] K stated cups are stored in a container and stored upside down on halls. [NAME] K stated small dessert bowls were supposed to be covered with something over them so nothing could get on them. She stated the bowls were not covered that day and food could have gotten on them. [NAME] K stated the temperature for the freezer should be below 20 degrees and the refrigerator should stay around 36 degrees. [NAME] K stated in the satellite kitchens the refrigerator should be 32 degrees and the freezer should be 10 degrees. [NAME] K stated the freezers in the satellite kitchens usually do not go below zero. [NAME] K stated only food should be stored in the freezer in the kitchen and Ozempic should not be stored in there. [NAME] K stated if the food label stated refrigerator after opening then the food item should not be stored in dry storage because it was perishable. [NAME] K stated everyday fruits and vegetables are checked daily. [NAME] K stated if they were bad, they were thrown out. [NAME] K stated the staff that served the halls was responsible for cleaning and sanitizing the ice makers in the satellite kitchen. [NAME] K state there should not be white calcium build up or rust on the ice makers. [NAME] K stated any food stored in the satellite kitchens should have a label and expiration date. During an interview on 10/17/24 at 02:00 PM the DM stated she has been the dietary manager for about 2 years. The DM stated the cooks were responsible for checking temperatures of the refrigerator and freezers in main kitchen. The DM stated whoever goes to the satellite kitchen to serve in the hall for breakfast and dinner are responsible for checking the temperature in the refrigerator and freezers. The DM stated the temperature should be 41 or below for the refrigerator and the freezer was supposed to be at 32 or below. The DM state if staff saw temperate above what was supposed to be, they should have taken out any food and brought to the main kitchen. It was important to maintain the correct temperature, so it does not reach danger zone. The DM stated if the refrigerator or freezer was outside the correct temperature, it could cause microorganisms to grow which could make anyone who consumed the food stored in there sick. The DM stated staff were not supposed to store personal items in any of the refrigerators or freezer and only food for the residents should be stored. The DM stated food should have the date it was opened and a date to use by date. The DM stated if the label on the items has to refrigerate after opening, she would not expect that to be stored in dry storage. The DM stated hand hygiene should be performed when you come into the kitchen, change duties, and before you put gloves on and take gloves. The DM stated if staff removed a glove, they should not put it back on. The DM stated staff should not touch their face mask when they are cooking. The DM stated it could make someone sick or could cause cross contamination if not performing hand hygiene correctly. The DM stated cleaned dishes should be stored on the halls and food should not be prepared over clean dishes. The DM stated this could cause cross contamination and physical contamination if you prepare food over dishes that are cleaned. The DM stated that the ice make in satellite are maintained by maintenance and they were responsible for cleaning them. The DM stated ice makers should not have rust on them. During an interview on 10/17/24 at 02:14 PM [NAME] L stated he had worked at the facility for four days. [NAME] L stated that anything that was opened should have a date on it with oldest in front and newest in back. [NAME] L stated the cooks were responsible for labeling but anyone can label food when its opened. [NAME] L stated that cooks were responsible for labeling food in the satellite kitchens. [NAME] L stated that cleaned dishes were supposed to be stored upside down to dry and then stored downward. [NAME] L stated that food should not be prepared over cleaned dishes. [NAME] L stated if you were preparing food over clean dished staff could drop food it could dirty clean dishes. [NAME] L stated the temperature for freezer should be below 32 degrees and the refrigerator should be 68 degrees. [NAME] L state this is for the satellite kitchens as well. He stated the cooks were responsible for checking the temperatures and writing it on the log. [NAME] L stated hand hygiene should be performed all the time. [NAME] L stated you should wash your hands after touching a face mask and when change gloves. [NAME] L stated gloves should not be reused and if they were it could cause cross contamination and could spread germs and cause someone to get sick. [NAME] L stated if staff are cooking and needed to grab something else hand hygiene should be performed in between grabbing them item and starting to cook again. During an interview 10/17/24 at 03:11 PM the ADM stated the DM was responsible for checking labeling in kitchen. He stated they were supposed to do it as shipment comes in. The ADM stated that an opened date were supposed to be put on any food that was opened. The ADM stated that the facility goes through a lot of cereal and not having a label when the cereal was put in the satellite kitchens or opened would not hurt. The ADM stated temperature for the refrigerator was supposed be at 40 degrees or below and the freezer was supposed to be at 0 degrees or below. The ADM stated that this was the same for the satellite kitchen. The ADM stated that the kitchen staff was responsible for checking the satellite kitchen. The ADM stated that if the temperature is above what it should be the food would have to be disposed of. The ADM stated that he expected for hand hygiene in the kitchen to be performed before staff touched food and after they touched anything else. The ADM stated staff were not supposed to reuse gloves in the kitchen. The ADM stated reusing gloves could cause cross contamination. The ADM stated that staff should wash their hands after touching their face masks in the kitchen. Review of facility policy titled Handwashing/Hand Hygiene dated August 2015 revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Further review revealed to use alcohol-based hand rub or soap after removing gloves, before donning gloves, before and after eating or handling food. Review of facility policy titled Refrigerators and Freezers dated December 2014 revealed this facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Acceptable temperature ranges are 35 degrees Fahrenheit to 40 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers. The food service supervisor will take immediate action if temperatures are out of range. Supervisors will inspect refrigerators and freezers monthly for presence of rust, excess condensation and any other damage. Review of facility policy titled Food Receiving and Storage dated July 2014 revealed food shall be received and stored in a manner that complies with safe food handling practices. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit and kept clean. Functioning of refrigeration will be monitored at designated intervals throughout the day by food and nutrition services manager or designed. Food items and snacks kept on the nursing units must be maintained at temperate of 41 degrees Fahrenheit or below and labeled with a use by date. Further review revealed toxic substances and drugs will not be stored in the kitchen area or in storerooms for food.

Based on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 31, Resident #38, Resident #43, and Resident #58) reviewed quality of life. 1. The facility failed to ensure Resident #31's facial hair was removed. 2. The facility failed to ensure Resident # 38's, Resident #43's and Resident #58's nails were cleaned and smooth around the edges. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: Resident #31 Record review of Resident # 31's Face Sheet, undated, reflected a 75 -year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses of Alzheimer's disease, unspecified ( a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest task), unspecified lack of coordination ( the inability to control the position of one's limbs or posture), and unspecified osteoarthritis ( a joint disease that occurs when the cartilage in a joint breaks down over time- joint pain, stiffness, and restricted movement). Record review of Resident #31's Quarterly MDS Assessment, dated on 07/25/2024, reflected the resident had a BIMS score of 0 indicating her cognition was severely impaired. Resident #31 required staff to complete more than half the effort with personal hygiene, dressing, and bathing. Record review of Resident #31's Comprehensive Care Plan , revised on 09/25/2024 , reflected Resident #31 had ADL self -care performance deficit related to impaired memory. Intervention: Resident #31 required assistance with showers and with personal hygiene. Observation on 10/15/2024 at 9:12 AM revealed Resident #31 was sitting in her wheelchair in the dining area with other residents. She had facial hair on the right side, middle and underneath her chin. The hair was approximately 1 inch long. Observation on 10/16/2024 at 8:40 AM revealed Resident # 31 was sitting in her wheelchair in the dining area with other residents. The facial hair on and underneath her chin had not been removed. Interview on 09/17/2024 at 9:13 AM with Resident #31 she was not interview able. Resident #38 Record review of Resident #38's Face Sheet , not dated, reflected a 87 -year-old female admitted on [DATE] and readmitted on [DATE] with diagnoses of vascular dementia, unspecified, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a chronic condition that occurs with the brain doesn't receive enough blood flow, which damages brain tissue and impairs thinking, and memory) and Alzheimer's disease, unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest task). Record review of Resident #38's Quarterly MDS Assessment, dated 07/24/2024, reflected Resident #38 was not capable of completing brief interview for mental status related to Resident #38 was rarely or never understood. Resident #38 was dependent on staff for the following: personal hygiene, dressing, bathing, and toileting hygiene. Record review of Resident #38's Comprehensive Care Plan, revised on 09/24/2024, reflected Resident #38 ADLs was not care planned. Resident #38 had a communication problem related to Alzheimer's and Dementia disease. Intervention: monitor/ document for nonverbal indicators of discomfort or distress, and follow-up as needed. Observation on 10/15/2024 at 9:22 AM revealed Resident #38 was in her room lying in bed. Resident # 38 had blackish/ brownish substance underneath the forefinger, ring finger and middle fingernails on her right hand. Her fore fingernail and her ring fingernail were not smooth around the edges. An attempted interview on 10/15/2024 at 9:24 AM with Resident #38 revealed she was not interview able. Resident #43 Record review of Resident # 43's Face Sheet dated, not dated, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of Alzheimer's disease with late onset (developed in people at the age of 65 and older- a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest task), osteoarthritis left shoulder (occurs when the cartilage in the shoulder joint wears down), and age related physical debility (a symptom of frailty such as weakness, inactivity, and depression). Record review of Resident #43's Quarterly MDS Assessment, dated 09/22/2024, reflected the resident had a BIMS score of 0 indicating his cognition was severely impaired. Resident # 43 required more than the helper's assistance with personal hygiene. Resident #43 required moderate assistance helper does half the assistance with the following: upper and lower dressing and toileting hygiene. Record review of Resident #43's Comprehensive Care Plan dated, 09/25/2024, reflected Resident #43 had impaired memory and inattention related to diagnosis of Alzheimer's and BIMS score of 0. Intervention: Administer medication as ordered. Assess Resident #43 overall cognitive function and memory. Resident #43 had an ADL self-care performance deficit. Intervention: Resident #43 required assistance with personal hygiene. Observation on 10/15/2024 at 9:43 AM revealed Resident #43 was sitting in his wheelchair watching tv in the common area of the memory care unit. He had blackish substance underneath all fingernails on his right hand. Resident #43's middle finger, ring finger and fore fingernails on his right hand was rough around the edges. In an attempted interview on 10/15/2024 at 9:45 AM Resident #43 was not interview able. Resident # 58 Record review of Resident # 58's Face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses vascular dementia, unspecified severity, with anxiety ( symptoms changes in personality, behavior, and mood, such as depression, agitation, and anger. Vascular dementia is a type of dementia that occurs when blood flow to the brain is interrupted, damaging brain cells and impairing thinking, memory, and behavior), cerebrovascular disease, unspecified (condition that affect blood flow to your brain. Conditions include stroke, brain aneurysm, and brain bleed), and age-related physical debility ( a symptom of frailty symptoms: weakness, fatigue, slowness, poor balance, decreased physical activity, and cognitive impairment). Review of Resident #58's quarterly MDS assessment dated [DATE] reflected Resident #58 was assessed to have a BIMS score of 00 indicating severe cognitive impairment. Resident #58 was assessed to be dependent on staff for the following: personal hygiene, dressing, bathing, and toileting hygiene. Review of Resident #58's comprehensive care plan, revised on 10/13/2024 reflected ADLs was not care planned. Resident #58 had cognitive loss. She had impaired decision-making ability related to severe cognitive impairment. Intervention: Avoid use of restraints. Allow Resident #58 practice problem solving techniques. Observation on 10/15/2024 at 9:55 AM revealed Resident #58 was in her room lying in bed Resident #58's right hand forefinger, middle finger, and ring fingernails were not even around the edges and also had a blackish substance underneath the nails. In an attempted interview on 10/15/2024 at 9:58 AM Resident #58 was not interview able. In an interview on 10/17/2024 at 10:26 AM, RN D stated the nurses and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all residents' nails with a diagnosis of diabetes (a disease in which the body's ability to produce or respond to the hormone insulin was impaired) . RN D stated it was the CNA's responsibility to clean and trim all other residents' nails. She stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria underneath the residents' nails. She stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. RN D stated she was not aware of, Resident #43, Resident #58 or Resident #38 refused nail care. She stated if resident has rough nails there was a possibility the resident may scratch themselves or other residents. She stated there was a possibility the resident may develop a skin tear. RN D stated if a female resident had facial hair on their chin, there was a possibility the resident may become embarrassed with their appearance and may isolate themselves in their room. In an interview on 09/17/2024 at 10:47 AM, the ADON stated it was a joint effort between the CNAs and the nurses to complete nail care on the residents. She stated the nurses was responsible for residents with diagnosis of diabetes. The ADON stated nail care was given during showers and as needed. She stated if a resident had blackish substance underneath their nails there was a possibility the substance may be some type of bacteria. The ADON stated a resident may have symptoms of vomiting, nausea, or diarrhea. She stated if a resident had rough edges around the tip of the nails a resident could scratch their eye or develop a skin tear if the resident scratched themselves. She stated if a female resident had facial hair there was a possibility the female resident may not want to leave their room due to embarrassment of the hair on their face. The ADON stated it was the nurse supervisor to monitor personal hygiene on residents. In an interview on 10/17/2024 at 11:11 AM, CNA E stated the nurses completed all diabetic fingernails and the CNAs were responsible for all other residents' nails. She stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails. CNA E stated if a resident's nails needed to be cleaned, trimmed, or filed, and it was not their shower day, the staff were expected to do any type of nail care as needed. She stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria. She stated if a resident swallowed bacteria it was a potential the resident may become ill with major stomach problems such as diarrhea. CNA E stated she had given care to Resident #43, Resident #58, and Resident #38 , and she was not aware of them refusing nail care. CNA E stated if a female resident had facial hair on their chin, a resident may become embarrassed over their appearance and there was a possibility the resident may isolate themselves in their room. CNA E stated it was the CNAs or nurses' responsibility to remove facial hair from the female's chin in the resident's room or during showers. CNA E stated she was not aware of any female resident refusing to allow staff to remove unwanted facial hair from their face. She stated if a resident had nails not filed correctly and had rough edges around the fingernails, there was a possibility the resident may scratch themselves or another resident. She stated she had been in-service on personal hygiene, however, did not recall the date of the in-service. Record review of the facility's Policy on Care of Fingernails revised October 2010 reflected The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Review the resident's care plan to assess any special needs of the resident. Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual (s) who administered the nail care. 3. The condition of the resident's nails and nail bed, including: a. Redness or irritation of skin of hands. b. Breaks or cracks in skin. c. Bluish or dark color of nail beds. d. Ingrown nails; e. Bleeding; and or f. Pain 4. Any difficulties in cutting the resident's nails 5. Any problems or complaints made by the resident with his/her hands. 6. If the resident refused the treatment, the reasons why and the intervention taken. 7. The signature and title of the person recording the data.

Based on interview and record review, the facility failed, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 12 of 12 residents on the secure unit. The facility failed to provide activities on the secured unit as scheduled on 10/05/24, 10/06/24, 10/12/24, and 10/13/24, These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. Findings include: Record review of the Activity Calendar for the month of October 2024 revealed the following scheduled activities: *10/05/24 10:00 AM: Coffee Social, 11:00 AM Sensory Station, 2:00 PM: TV TIME, 3:00 PM: Coffee Social, 4:00 PM: Resident Activity Choice. *10/06/24 10:00 AM: Coffee Social, 11:00 AM: Sensory Station, 2:00 PM: Grandbaby Love, 2:30 PM Corn Hole/Basket toss, 4:00: PM Resident Activity Choice. *10/12/24 10:00 AM: Coffee Social, 11:00 AM Sensory Station, 2:00 PM: TV TIME, 3:00 PM: Coffee Social, 4:00 PM: Resident Activity Choice. *10/13/24 10:00 AM: Coffee Social, 11:00 AM: Sensory Station, 2:00 PM: Grandbaby Love, 2:30 PM Corn Hole/Basket toss, 4:00: PM Resident Activity Choice. Record Review of the resident participation records from 10/05/24 to 10/13/24 revealed activities did not occur on 10/05/24, 10/06/24, 10/12/24, and 10/13/24. In an interview on 10/17/2024 at 9:29 AM CNA C stated she did work sometimes on the weekends. She stated no one had in-service her on how to document on the participation records. She stated she did not know if the other staff worked on the memory care unit had been in-service by the activity staff. CNA C stated it was difficult sometimes to do activities with residents on weekends. She stated there was a lot to do on the memory care unit with all the residents giving ADL care. She stated she does talk to the residents on weekends and during the week. She will sit with them when they watch tv and talk to the residents but she was never told during the week to document on any type of participation record of activity being done during the week or weekends. CNA C stated she did not remember if she worked 10/05/2024 - 10/06/2024. In an interview on 10/17/2024 at 9:40 AM the Activity Director A stated anytime an activity was conducted with the residents she expected the activity to be documented on the participation record including on the memory care unit. She stated attendance records were the same as participation records. She stated if any residents attended an activity or had an in-room activity it was to be documented. Activity Director A stated she had not in-serviced all of the staff on the secure unit about documenting activity programs on the weekends. She stated if residents on the secure unit was not receiving routine activities there was a potential the residents may have a decline in cognition, increase social isolation, increase behaviors, etc. She stated it was her and the Activity memory care Coordinator duty to ensure the residents on the secure unit received activities according to the calendar and every day. She stated she had been the Activity Director at this facility more than 5 years. Activity Director A stated sometimes the activities on the calendar changes. She stated they do not make the changes on the current activity calendar on the memory care unit. In an interview on 10/17/2024 at 10:08 AM the Activity Memory Care Coordinator B stated she does leave activity items out for the staff to use on the weekends. She stated she did not recall if all the staff on the secure unit had been in-serviced on how to document on the participation record and how to do the activities on the memory care unit calendar. She stated if it was not documented on the memory care participation records of any resident attending an activity, the activity for that day did not occur on the memory care unit. Activity Memory Care Coordinator B stated if the residents did not receive routine activities every day there was a potential a resident may become bored, wander, become restless and/or have a decline in cognition. She stated it was her responsibility to ensure the residents received activities on the memory care unit and the Activity Director A was her supervisor. She stated she had been an employee at the facility approximately 1 year. She stated attendance records were the same as participation records. Record review of the Facility Policy on Documentation, Activities, revised December 2009, reflected The Activity Director/ Coordinator is responsible for maintaining appropriate departmental documentation. Recordkeeping is a vital part of the activity programs. The following records, at a minimum, are maintained by Activity Department personnel: a. Activity Assessment b. Attendance records. Record review of the Facility Policy on Group Programs and Activities Calendar, revised April 2009, reflected Group activities are available in this facility and an activities calendar is completed to inform residents, families, and staff of the activity opportunities available. Both large and small group activities are part of our activity programs. The activities calendar states all activities available for the entire month, which may also include scheduled room visits. Modifications, time changes, cancellations or substitutions are reflected on all large, posted calendars.

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 2 of 2 medication storage rooms and 1 of 3 medication carts. A) The facility failed to ensure expired supplies were removed from the medication storage room for Halls 100 and 200 including 1 box of Colostomy (a surgical opening for the colon in the abdomen) supplies that expired 2/5/2018, 3 bisacodyl suppositories that expired 8/2024, and chlorhexidine wipes that expired 7/2/2023. B) The facility failed to ensure expired supplies were removed from the medication storage room for halls 300 and 400 including a foley catheter insertion tray with expiration date of 5/31/2023 and Normal Saline IV flush with expiration date 4/30/2023. C) The facility failed to ensure that all medication were secured in the medication cart when it was unattended by CMA N. These failures could place residents at risk of contamination causing illness, decreased effectiveness of medication, and risk of injury to other residents if medications left out were consumed. Findings included: A. Observation on 10/16/2024 at 3:10 PM of the medication storage room for Halls 100 and 200 with LVN G in attendance revealed Colostomy (a surgical opening for the colon in the abdomen) supplies that expired 2/5/2018, 3 bisacodyl suppositories that expired 8/2024, and chlorhexidine wipes that expired 7/2/2023. B. Observation on 10/16/2024 at 4:50 PM of the medication storage room for Hall 300 and 400 with LVN S in attendance revealed 1 vanilla pudding that expired on 7/28/2024, 8 Luer slip disposable syringes that expired 8/6/2024, and a closed IV catheter system (needle to start an IV) that expired 2/28/2022. In an interview on 10/17/2024 at 3:43 PM the DON stated a pharmacist checked 1 medication room and 2 medication carts each month rotating around. She stated all nurses were trained to look at expiration dates of supplies and medication prior to use and if the medication or supplies were expired to not use them. Expired supplies were to be thrown away and medications were to be given to the ADON for destruction. The DON stated that using expired medications and supplies could cause a harmful effect or have a decrease in effectiveness. In an interview on 10/17/2024 at 3:12 PM the ADM stated the pharmacist came out in July-ish and checked for expirations in the medication carts and medication rooms. He stated, I've taken expired medications myself they just might not be as effective. Review of Resident #54's undated Face Sheet reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of hyperlipidemia (high amount of cholesterol in the blood), anxiety (feeling of dread, fear, and uneasiness), and CVA with right sided weakness (a conditions where blood flow to a part of the brain is stopped causing right sided weakness). A. Observation on 10/16/2024 at 08:57 AM revealed MA N locked the medication cart and walked down 200-hall out of line of sight of the medication cart. 3 medication cards with medications remained on top of the cart face down. The card on top indicated it contained Lisinopril 20mg (a medication to lower blood pressure). B. Observation on 10/16/2024 at 09:10 AM revealed MA N locked the cart and walked into a room and out of line of sight of the medication cart with Resident #54. The 3 cards of medication remained on top of the cart face down. In an interview on 10/17/2024 at 10:10AM MA N stated she has been working at the facility for about 5 years. MA N stated she later realized she left the medication cards on top of the medication cart unattended. She stated that anyone could have walked up to the cart and taken the medications. MA N stated it could be very bad. Review of a facility policy and procedure titled Storage and Expiration Dating of Medications, Biologicals dated 2008 and revised in June 2023 reflected, 3.3 The community should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room, inaccessible by unauthorize staff, residents, and visitors. 4. The community should ensure that medications and biologicals that: (1) have an expired date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. Review of grievances indicated no complaint or concerns voiced by residents about expired supplies, food, or medication being given/used.

F695 Based on observation, interviews, and record reviews, the facility failed to ensure professional standards of practice for respiratory care were followed. For all residents reviewed for respiratory care as indicated by: 1. The nasal cannula of Resident #34 and the CPAP of Resident #32 were not in a bag when unused. 2. The oxygen concentrator filters of Resident #32 and Resident #24 were covered in dust. These failures could place the residents at risk of infection. Findings included: Record review of Resident #34's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to Alzheimer's disease (a brain disorder that causes memory loss), venous insufficiency (the veins have trouble sending blood from arms and legs to the heart), congestive heart failure (the heart is unable to pump blood well enough to meet the body's need). Record review of Resident #34's quarterly MDS dated [DATE] revealed a BIMS score of 3 indicating significant cognitive impairment. An observation on 10/15/24 at 07:54 AM revealed Resident #34 lying in bed sleeping. A nasal cannula was laying across the top of the oxygen concentrator and not in a bag. An observation on 10/15/24 at 10:37 AM revealed Resident #34 lying in bed sleeping. A nasal cannula was laying across the top of the oxygen concentrator and not in a bag. An observation on 10/17/24 at 09:55 AM revealed Resident #34 sitting up in bed watching tv. A nasal cannula was laying across the top of the oxygen concentrator and not in a bag. Record review of Resident #32's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to chronic respiratory failure with hypercapnia (difficulty breathing with high levels of carbon dioxide in the blood), chronic congestive heart failure (the heart is unable to pump blood well enough to meet the body's needs), paroxysmal atrial fibrillation (irregular heart rhythm), and obstructive sleep apnea(repeated breathing interruptions during sleep). Record review of Resident #32's quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. Record review of Resident #32's Care Plan dated 12/26/2022 and edited on 9/4/2022 reflected I have altered respiratory status/difficulty breathing related to my diagnosis of acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia and obstructive sleep apnea (adult). I have an order yet refuse to use my CPAP machine while in bed or during naps. Interventions include: 1. CPAP ordered per home settings. 2. Oxygen settings: O2 via NC PRN (as needed) to maintain O2 > 90% An observation on 10/15/24 at 11:16 AM revealed Resident #32 lying in bed watching tv. The oxygen concentrator filter was covered in dust. Also observed Resident #32's CPAP on the floor near the oxygen concentrator with mask in a bag. An observation on 10/17/24 at 10:34 AM revealed Resident #32 remained in bed watching tv. The oxygen concentrator filter continued to be covered in dust. Also observed Resident #32's CPAP remained on the floor near the oxygen concentrator with mask in bag. Record review of Resident #24's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to vascular dementia (brain damage caused by impaired blood flow that has caused memory issues), chronic obstructive pulmonary disease (an ongoing lung disease that causes damage to the lungs), cerebral infarction due to thrombosis (blood flow was reduced or stopped to a portion of the brain due to a blood clot), and congestive heart failure (the heart is unable to pump blood well enough to meet the body's needs). Record review of Resident #24's MDS dated [DATE] revealed a BIMS assessment was not completed. Record review of Resident #24's Care Plan dated 8/5/2024 reflected Resident has shortness of breath and low oxygen sats related to COPD. Interventions included: 1. Administer oxygen at 2 liters via nasal cannula while awake and bipap while asleep. Observe oxygen precautions. 2. Keep room cool and free of irritants (smoke, dust, cleaning agents). Record review of Resident #24's orders from 10/17/2024 revealed orders clean concentrator filter monthly, once a day on the 5th of the month 11:00 PM-07:00 AM and Clean concentrator filter when it appears gray or dirty PRN, as needed. An observation on 10/16/24 at 09:46 AM revealed Resident #24 lying in bed sleeping. The oxygen concentrator filter was covered in dust. An observation on 10/17/24 at 09:50 AM revealed Resident #24 sitting up in bed. Oxygen concentrator continued with dust covering the filter. An interview on 10/17/24 at 10:48 AM with CNA O revealed the nurses were responsible for cleaning the oxygen concentrator filters. The oxygen tubing was to be kept in a bag when not in use or needs to be thrown away and a new one obtained. She stated that if a resident were to use the nasal cannula after it was just laying on top of the oxygen concentrator, it could cause the resident to develop a staph infection in their nose. An interview on 10/17/24 at 01:50 PM with LVN F stated there was an order to clean the back of all oxygen concentrators on the 11 PM-7 AM shift once a month. She stated that nasal cannulas were to be stored in a bag when not in use and all CPAP machines were supposed to be kept on the bedside table, and the mask was to be kept in a bag. If the CPAP machine was stored on the floor, it could get wet and be an electrical hazard or a fall risk. Also, if oxygen concentrator filters were covered in dust, it could be filtering unclean air and cause illness. An interview on 10/17/24 at 03:55 PM with the DON revealed she expected for the oxygen concentrator filters to be checked monthly by maintenance. She further stated that using an oxygen concentrator with a dirty filter could increase the risk of breathing in fungal spores and bacteria. She expected all nasal cannulas to be stored in a bag when not in use. The DON stated if a nasal cannula was not stored in a bag, it could increase the risk of inhaling microbes. She expected CPAP machines to be stored on the bedside table. She stated that storing a CPAP machine on the floor could cause a bug to enter the machine, could cause an infection, or even cause a tripping hazard. An interview on 10/17/24 at 03:12 PM with ADM revealed all nasal cannulas to be stored in bags when not in use and all CPAP machines to be stored on the resident's nightstand. He stated if the concentrator filters weren't cleaned, then the concentrator doesn't work sufficiently. Also, if the nasal cannulas and CPAP machines were not stored properly then it can cause contamination. Review of facility's policy titled Cleaning and disinfection of Resident care Items and Equipment revised in October 2018 reflected: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 10 residents (Resident #38, Resident #48, Resident #58 , and Resident #73) reviewed for care plans. 1. The facility failed to ensure the comprehensive care plans for Resident #38 and Resident #58 included ADLs. 2. The facility failed to ensure the comprehensive care plans for Resident #48 and Resident #73 included diagnosis of mental illness. This failure could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care. Findings included: Resident #38 Record review of Resident #38's Face Sheet , not dated, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnoses of vascular dementia, unspecified, without behavioral disturbance, and Alzheimer's disease, unspecified (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest task). Record review of Resident #38's Quarterly MDS Assessment, dated 07/24/2024, reflected Resident #38 was not capable of completing brief interview for mental status related to Resident #38 was rarely or never understood. Resident #38 was dependent on staff for the following: personal hygiene, dressing, bathing, shower transfer, and toileting hygiene. Resident #38 required moderate assistance (staff does less than half the effort) with oral hygiene. She required supervision with eating. Resident #38 required maximal assistance (helper does more than half the work) with transfers. Record review of Resident #38's Comprehensive Care Plan, revised on 09/24/2024, reflected Resident #38 ADLs was not care planned. Signed by the ADON. Resident # 48 Record review of Resident # 48's Face Sheet, not dated, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] with a diagnosis of delusional disorders (a mental illness- condition that causes a person to have false beliefs that are not based on reality), major depressive disorder ( a mental illness- persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts). Record review of Resident #48's MDS Annual Assessment, dated 09/03/2024, reflected Resident #48 had a BIMS score of one indicating Resident's cognition was severely impaired. Resident #48 was assessed to have a diagnosis of the following diagnoses: major depressive disorder, recurrent, severe with psychotic symptoms (mental illness- psychotic is a collection of symptoms that cause a person to lose touch with reality) and delusional disorders. Resident #48 was taking high-risk medications such as : anti-depressant (a common prescription medications that can help treat depression), and anti-psychotic (medications that treat psychosis-related conditions and symptoms). Record review of Resident #48's physician order, dated 10/16/2024, reflected Resident #48 had an order for Seroquel (quetiapine) 25 mg one tablet once a day for diagnosis of delusional disorders (order date 09/12/2024). Resident #48 had an order for Sertraline 100 mg one tablet every day for major depressive disorder, recurrent, severe with psychotic symptoms on 09/12/2024. Record review of Resident #48's Comprehensive Care Plan, dated 09/25/2024 reflected Resident #48's diagnosis of delusional disorders and major depressive disorders was not documented on the care plan. Signed by the ADON. Resident # 58 Record review of Resident # 58's Face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses vascular dementia, unspecified severity, with anxiety ( symptoms changes in personality, behavior, and mood, such as depression, agitation, and anger. Vascular dementia is a type of dementia that occurs when blood flow to the brain is interrupted, damaging brain cells and impairing thinking, memory, and behavior), cerebrovascular disease, unspecified (condition that affect blood flow to your brain. Conditions include stroke, brain aneurysm, and brain bleed), and age-related physical debility ( a symptom of frailty symptoms: weakness, fatigue, slowness, poor balance, decreased physical activity, and cognitive impairment). Review of Resident #58's quarterly MDS assessment dated [DATE] reflected Resident #58 was assessed to have a BIMS score of 00 indicating severe cognitive impairment. Resident #58 was assessed to be dependent on staff for the following: personal hygiene, dressing, bathing, and toileting hygiene. Review of Resident #58's comprehensive care plan, revised on 10/13/2024 reflected ADLs was not care planned. Resident #58 had cognitive loss. She had impaired decision-making ability related to severe cognitive impairment. Intervention: Avoid use of restraints. Allow Resident #58 practice problem solving techniques. Resident #73 Record review of Resident #73's Face Sheet, not dated, reflected a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of delusional disorders (a mental illness- condition that causes a person to have false beliefs that are not based on reality). Record review of Resident #73's Quarterly MDS, dated [DATE] reflected Resident #73 had a BIMS score of 8 reflected his cognition was moderately impaired. Resident #73 had active diagnoses of delusional disorders. Resident #73 was assessed to be taking antipsychotic medication. Record review of Resident #73's Physician Orders, dated 10/2024 reflected Resident #73 was ordered Sertraline 25 mg. one tablet daily for delusional disorders on 06/28/2024. Resident #73 was ordered Quetiapine 25 mg. one tablet daily in the evening. (5:30 PM). Record review of Resident #73's Comprehensive Care Plan, dated 09/25/2024, reflected Resident #73's diagnosis of delusional disorders was not documented on the care plan. Signed by the ADON. In an interview on 10/16/2024 at 10:45 AM MDS Coordinator stated ADLs including the following personal hygiene, transfers, toileting, showers, eating abilities, dressing, repositioning in bed and type of ambulation was required to be on the comprehensive care plan. She stated if a resident had a mental illness such as delusional disorder or major depression it was to be also care planned. The MDS Coordinator stated the staff would not know the type of physical or mental care a resident needed if it was not care planned and there was a possibility a resident may become injured if the improper ADL care was given to a resident. She stated if the resident did not have any recent delusions or depression these diagnoses there was a risk for symptoms. The MDS Coordinator stated there were risks for symptoms of these diagnoses and the symptoms and medications needed to be care planned. She stated all staff was to follow the care plan to know what type of care each resident needed. The MDS Coordinator stated she and the ADON was responsible for care plans. She stated she had been in serviced on care plans but did not recall the date and time. In an interview on 10/17/2024 at 10:47 AM The ADON stated a care plan was expected to be developed for any resident with a diagnoses of delusional disorder and major depression. She stated if any resident was on anti-psychotic medications or anti-depressants for a diagnoses these medications were expected to be an intervention on the mental illness care plan. She stated delusional disorder and major depression was a mental illness. The ADON stated if a resident was experiencing any symptoms of delusions or major depression, the staff would not know what type of interventions the resident required. She stated a resident may need a special intervention to use only for that resident. The ADON stated if the staff did not have access to the specific intervention for a resident, the resident may not receive the proper care when the resident was delusional and/or had major depression. The ADON stated all residents care plans was expected to have the ADLs on their care plans. She stated it would be difficult for the staff to know what type of ADL care to give if they did not know the resident and reviewed a resident's care plan and the ADLs was not documented. The ADON stated she and the MDS Coordinator was responsible for care plans. She stated if a staff name was on the care plan the staff was the one documenting on the care plan when the staff had care plan meetings. She stated she had been inserviced on care plans but did not recall the date or time. In an interview on 10/17/2024 at 11:11 AM CNA E stated she knew about care plans and what is documented on the care plan was the type of care a resident needed. She stated if any type of mental issues it was not documented it would be difficult to know the care a resident needed. CNA E stated if it was a new resident and the ADLs was not documented on the care plan, she would ask the nurse supervisor. In an email on 10/17/2024 at 11:48 PM requested the Comprehensive Care and in an interview on 10/17/2024 at 1:20 PM requested the Comprehensive Care Plan Policy. This was not provided at time of exit.

Based on observation, interview and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption in personal refrigerators for 1 of 1 residents. 1. The facility failed to conduct and/or document the temperature and contents of Resident #22's personal refrigerator. This deficient practice could place residents at risk for food-borne illness. Findings included: Review of undated face sheet for Resident #22 reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses include acquired absence of right leg below knee (below knee amputation), need for assistance with personal care, muscle weakness (lack of muscle strength), and major depressive disorder (a serious mental disorder that affects how a person feels, thinks, and acts). Review of Resident #22's quarterly MDS dated [DATE] reflected a BIMS score of 14 which indicated no cognitive impairment. Review of Resident #22's orders dated 10/17/2024 reflected assistance x 1 is required for toileting, transfers and eating. Observation and interview on 10/15/2024 at 1:40 PM revealed Resident #22 attempted to put a jar of peppers in his personal refrigerator. Further observation revealed the following: *Several uncovered drinks, *2 tomatoes that were shriveled with large black spots, *Dried food *Brown and yellow liquid spilled on bottom shelf and door of the personal refrigerator. *2 halves of a banana, *A bottle of mayonnaise with a best by date of [DATE], and * No thermometer was observed in the personal refrigerator. Resident #22 stated he did not know who, if anyone, checked his personal refrigerator. During an interview on 10/17/2024 with CNA O at 10:48 AM stated the refrigerators should be checked by dietary staff. CNA O stated if the personal refrigerators were not checked routinely by staff, then the resident could consume products and could end up with food borne illnesses. During an interview on 10/17/2024 at 1:50 PM LVN F stated she was unsure of who was supposed to check personal refrigerators. She stated if the personal refrigerators were not checked on a regular basis that the food can spoil and can cause food borne illness if consumed by residents. During an interview on 10/17/2024 at 3:12 PM the ADM stated housekeeping was supposed to check all personal refrigerators for spoiled food, but he was unsure of the frequency. The ADM stated he was unsure if personal refrigerator temperatures were being monitored at all. The ADM stated if a resident were to consume spoiled food, they could get food poisoning. During an interview on 10/17/2024 at 3:55 PM the DON stated there was not a policy for personal refrigerators at this time. She said that housekeeping was to clean and check temperatures daily in personal refrigerators for those residents with a low BIMS and incapable of checking the refrigerators themselves. She also stated that if the refrigerators were not checked it could lead to food spoilage, gastritis (an inflammation of the lining of the stomach) and illness if the food were to be ingested by the residents.

Based on observations, interviews, and record reviews the facility failed to ensure food was prepared in a form designed to meet individual needs for 6 of 6 residents (Resident #14, Resident #18, Resident #24, Resident #63, Resident #70, and Resident #75) reviewed for pureed diets. Cook K failed to ensure food prepared for residents receiving a pureed diet was in the proper consistency for this diet. This failure could place residents who received pureed diets at risk of not having nutritional needs met by consuming foods that could cause poor intake, choking and decreased meal intakes. Findings included: Observation on 10/15/2024 at 12:59 PM revealed pureed peas were served on plate and appeared to have a watery consistency. The pureed peas appeared to easily pour out of the serving spoon. During an interview on 10/15/2024 at12:59 PM, DA T stated that she thought the texture of the peas should be a little thicker. Observation on 10/16/2024 at 10:50 AM revealed the chicken base contained included instruaction revealed to add 1 teaspoon to 1 cup of boiling water. Observation on 10/16/2024 at 11:59 AM revealed chicken base separated from water in measuring cup. Further observation revealed [NAME] K added more water to the measuring cup. [NAME] K did not measure additional chicken base to add and did not measure the water added. Observation revealed [NAME] K added mixture while she pureed fried chicken. Observation and interview on 10/16/2024 at 12:03 PM revealed [NAME] K transferred the pureed chicken into serving dishes. Further observation revealed small pieces of unblended chicken in the mixture. [NAME] K stated the texture of the chicken puree was smooth. [NAME] stated again that the texture was smooth. During an interview on 10/16/2024 at 12:03 PM [NAME] K stated that the texture of the chicken puree was smooth. [NAME] K stated the puree texture should be thick like mashed potatoes and stated again that the texture was smooth and there were no chunks. During an interview on 10/16/2024 12:04 PM the DM stated there were small chunks in the chicken puree. DM stated that the cook needed to puree the chicken again. The DM stated the puree should be smooth like baby food and not have any chunks. During an interview on 10/16/24 at 03:01 PM RD V stated he visited the facility twice a month. RD V stated once a month there was a quality check on how the regular texture food was prepared and that the staff was using the correct ingredients. RD V stated he had no issues with food preparation. RD V stated he observed preparation of pureed food about every 4 to 5 months and was unsure of the exact timeframe. He stated pureed food should be smooth with no lumps. He stated if a fork was put through the pureed food, the food should not easily fall through the fork. RD V stated pureed fried chicken should be smooth. RD V stated when making pureed food the staff typically want to use high calorie liquids. RD V was not sure how to make broth with the chicken base. During an interview on 10/17/24 at 01:40 PM [NAME] K stated the pureed food was supposed to be a smooth texture with no grains or chunks. [NAME] K stated she should be able to put a fork through it and it slowly drops off the fork to ensure the resident do not choke. [NAME] K stated she could add chicken broth, beef broth and milk when she made pureed food. [NAME] K stated for pureed vegetables she could use water from the cooked vegetables. [NAME] K stated she was unsure about the amount of water she needed to make the chicken or beef broth with the chicken or beef bases. [NAME] K stated she measured 1/2 to a teaspoon of chicken base to mix into the water to make broth. [NAME] K stated they are not allowed to use just water for puree because it takes the taste away from the food. [NAME] K stated she should not add water to the measuring cup without adding additional chicken base and stated that if she did it could take away from the flavor. During an interview on 10/17/24 02:00 PM the DM stated she has been the dietary manager for about 2 years. The DM stated pureed food texture should not lose its form and should be smooth almost like consistency of mashed potatoes. The DM stated the pureed food should not just fall out of serving spoon. The DM stated depending on the diet the resident could choke if it was the incorrect texture. The DM stated for pureed foods the liquid you could add depended on the type of food that was being prepared. The DM stated vegetables juice from cooked vegetables could be added, chicken or beef broth to their respective meats could be added. The DM stated she did not think cooks should add more water to existing mixture and stated she expected cooks to mix base and water according to the instructions. The DM stated if the cooks did not follow the instructions on the chicken base, it could be too watery which would affect the flavor of the food. The DM stated the last in-service complete on pureed food may have been last year, but she was unsure. During an interview on 10/17/24 at 02:14 PM [NAME] L stated he has worked at the facility for 4 days. [NAME] L stated he received training on how to make pureed food. [NAME] L stated pureed food was supposed to be smooth and stated that someone could choke if there were chunks. [NAME] L stated pureed food should not be watery. [NAME] L stated if he were to scoop it, it should not just fall through the fork or out of the serving spoon. [NAME] L stated that staff can add milk but you cannot add water because it may not have the correct calories. During an interview on 10/17/24 at 03:11 PM the ADM stated he was unsure if pureed food was supposed to have chunks in it or what the texture was supposed to be. Record review of communication form dated 08/26/2024 revealed a dietician recommendation that sometimes pureed meats have some chunks in them. Review of undated facility list of residents with altered diets revealed Resident #14, Resident #18, Resident #24, Resident #63, Resident #70, and Resident #75 recieved pureed meals. Review of facility policy titled Therapeutic Diets dated October 2017 revealed a 'therapeutic diet' is considered a diet order by a physician, practitioner, or dietician as part of treat for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. Examples included an altered consistency diet.

Based on observations, interviews and record reviews the facility failed to ensure that proper care practices related to catheterization were maintained for one of one resident(s) reviewed for catheter care, as indicated by: 1. The foley catheter bag of Resident #70 was laying on the floor. These failures can place the resident at risk for infection, urethral (the tube that carries urine from the bladder exit the body) tears or dislodging the catheter. Record review of Resident #70's undated face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included but were not limited to retention of urine (inability to urinate), hypertension (high blood pressure), and muscle weakness. Record review of Resident #70's annual MDS dated [DATE] revealed a BIMS score of 4 indicating severe cognitive impairment. Record review of Resident #70's Care Plan dated 9/13/2024 reflected the resident was at risk for impaired urinary elimination related to recent urinary tract infection and antibiotic use, as well as a history of urinary retention (inability to urinate). The resident has a foley catheter for this diagnosis. The relevant interventions included: 1. Report signs/symptoms of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine). An observation on 10/15/24 at 07:51 AM revealed Resident #70 sitting in a recliner with the foley catheter bag on the floor under the bedside table legs. An observation on 10/15/24 at 08:41 AM revealed Resident #70 remained in the recliner and the foley catheter bag was on the floor to the right side of the recliner. An observation on 10/17/24 at 09:53 AM revealed Resident #70 sitting in a recliner with eyes closed. The foley catheter bag was laying on the floor in a dignity bag. An interview on 10/17/24 at 10:48 AM with CNA O revealed that she was responsible for ensuring all foley catheter bags are anchored below the level of the bladder but off the floor and have a dignity bag. An interview on 10/17/24 at 01:50 PM with LVN F revealed that if a foley catheter were on the floor then it should be picked up and put in a dignity bag. She stated that if a foley catheter bag were to touch the floor it could cause an infection. An interview on 10/17/24 at 03:55 PM with the DON revealed her expectation for foley catheters were to be kept at the lowest point possible without touching the floor. She stated that not doing so could cause contamination, cause a fall risk, or possible even be forcefully removed causing injury. An interview on 10/17/24 at 03:12 PM with ADM revealed foley catheters should be hung on the bed and if it touches the floor, it could cause cross contamination.

Based on observations, interviews, and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #230) reviewed for privacy. The facility failed to ensure IP M provided privacy during peri care for Resident #230, by closing the door and fully drawing the privacy curtain. This failure could place residents at risk of having their bodies exposed to the public, resulting in low self-esteem and a diminished quality of life. The findings included: Record review of Resident #230's face sheet on 10/16/24 revealed a [AGE] year-old male who was initially admitted to the facility on [DATE]. His diagnoses were, constipation, nausea with vomiting, gastro-esophageal reflux disease (acid reflex), and generalized anxiety disorder. Record review on 10/16/24 of Resident #230's care plan dated 10/01/24 reflected the resident had alteration in his bowel elimination and constipation. The relevant intervention was monitoring bowel movements every shift and record. Record review on 10/16/24 of Resident #230's initial MDS assessment, dated 10/04/24 revealed a BIMS score of 13 indicating intact cognition. Further review of the MDS revealed Resident #230 was occasionally incontinent with bowel and bladder. During an observation on 10/16/24 at 9:30am IP M provided peri care to Resident #230 while he was lying in his bed. IP M did not close the door and drew the privacy curtain fully, of Resident #230's room during the entire process. If anybody passed by the hallway to Resident #230's room, they would see Resident #230's exposed body. During an interview on 10/16/24 at 10:00am Resident #230 stated he did not notice if the door and privacy curtain were closed properly. He said it would be embarrassing if anyone from the public observed him while receiving perineal care. During an interview on 10/16/24 at 9:50am IP M stated, by not closing the door and the curtain, the privacy and dignity of Resident #230 were compromised as anyone passed by the room could see resident's exposed body. When asked about the training she received on resident's rights, IP M stated she was fully aware of the resident's right to have privacy and received in-service on resident's rights at least once a year. During an interview on 10/17/24 at 4:35pm the DON stated privacy must be provided during nursing care and the door to Resident #230's room should have been closed completely by IP M. She said the training was an ongoing process and resident rights were one of them. The DON stated that the facility ensured all the new hires went through skill checks. Every nursing staff also had to complete an annual evaluation to ensure their nursing skills and knowledge including competency in privacy/confidentiality. During an interview on 10/17/24 at 3:30 pm the ADM stated that residents' privacy should be maintained during nursing care by closing the room door, pulling the curtains, and making sure the window blinds are closed. During the review of facility's policy Quality of Life -Dignity revised in August 2009, reflected: Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observations, interviews, and record review, the facility failed to ensure each resident was treated with respect and dignity by contracted staff for 1 (Resident # 69) of 1 resident reviewed for resident rights. The facility failed to ensure contracted staff did not check vital signs (blood pressure, heart rate, and temperature) while at the dining room table during meal service. This deficient practice placed the resident at risk of a decline in their sense of dignity and self-worth. Findings included: Review of Resident #69's undated face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included depression, dementia (memory, thinking, difficulty), dysphagia (difficulty swallowing), and anxiety. Review of Resident #69's Quarterly MDS dated [DATE] revealed Resident #69 had a BIMS score that was not completed but, indicated the resident could not understand and could not make self-understood. An observation of the 100-hall dining room lunch service on 10/15/24 at 01:07 PM revealed RN Q, approached the table with Resident #69 and another female resident. RN Q started assessing Resident #69, including putting a blood pressure cuff on Resident's left wrist while the resident was attempting to eat a hamburger with her right hand. An interview with LVN F on 10/17/2024 at 01:50 PM revealed that she had training on resident rights and dignity. She stated that all assessments on residents including checking vital signs should be done in the resident's room. She further stated that any type of assessment, including checking vital signs, could be a dignity issue and if she had witnessed this event, she would have asked RN Q to wait until the resident was done eating, then take her to her room [for further assessment]. A phone interview with RN Q on 10/17/24 at 03:08 PM revealed that she had been trained on resident rights. She stated, It was a big mistake, but I was in a hurry .as a hospice nurse I don't need to check her vitals if she appears comfortable. She further stated that checking vital signs while the resident was eating in the dining room could affect the resident's dignity. An interview with the ADM on 10/17/24 at 3:12 PM revealed staff, including contracted staff like hospice, had been trained on resident rights. He stated hospice was another set of eyes to monitor a resident. He stated that all assessments were to be performed in the resident's room and it could affect the resident's dignity/privacy if done in the dining room during a meal. An interview with the DON on 10/17/24 at 3:55 PM revealed all contracted staff were expected to respect the resident's rights. She stated residents should be taken to their room after they were done eating for any assessment. She stated that doing any assessment in the dining room while they were eating could be inaccurate due to movement and it could affect the resident's dignity. Record review of the Facility Policy on Quality of Life-Dignity dated August 2009 revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment process. Record review of undated Resident's [NAME] of Rights revealed 19.206-The facility ensures the resident's right to privacy in the following areas: 1. Medical treatment. The facility provides privacy to each resident during examinations, treatments, case discussions, and consultations. Staff treats these matters confidentially. 2. Personal care.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 6 residents (Resident #1) reviewed for safe requirements. The facility failed to provide a safe sling to be used for Resident #1 on [DATE]. On [DATE], Resident #1 was being transferred by Mechanical lift and the sling broke while Resident #1 was in the air, and she fell and hit her face on the legs of the Mechanical lift. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury, serious impairment, or death. Findings included: Record review of Resident #1's face sheet, dated [DATE], reflected Resident #1 was a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of nontraumatic intracerebral hemorrhage in cerebellum (primary, admission - a devastating condition whereby a hematoma ( swelling or clotted blood) is formed within the brain parenchyma ( functional part of an organ) with or without blood extension into the ventricles (cavities in the brain)- this is a new diagnosis after return from hospital on [DATE], the following are diagnosis prior to being admitted to hospital on [DATE]: hemiplegia and hemiparesis following cerebral infarction left non-dominant side ( paralysis or partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), lack of coordination (not able to move different parts of the body together easily), muscle wasting and atrophy ( thinning of the muscle mass), and type 2 diabetes mellitus with diabetic neuropathy, unspecified ( nerve damage caused by high blood sugars levels over time, leading to various complications in different parts of the body). Record review of Resident #1's Annual MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 15 indicated her cognition was intact. Resident #1 was assessed to have limited range of motion with upper and lower extremity on one side (left side). She required assistance with ADLs such as eating, all hygiene, upper and lower dressing including assist with footwear, toileting, all transfers, and repositioning in bed. Record review of Residents #1 Comprehensive Care Plan revised on [DATE], reflected Resident #1 had impaired physical mobility related to decreased in muscle strength and recent clavicle fracture (broken collar bone). Resident #1 required two person Mechanical lift transfer assistance. Intervention dated [DATE]: staff to provide a safe environment during transfers and will use a Mechanical lift with two assistance. Resident #1 had impaired physical mobility related to hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side. Intervention: Assess need for an provide as indicated adaptive devices, furniture, and clothing. She was assessed to be at risk for unstable blood glucose level related to Type 2 diabetes mellitus with diabetic neuropathy. Intervention: Assess blood glucose levels as ordered. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #1 was assessed to be at risk for falls related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Intervention dated [DATE]: Encourage to keep bed in low position. Keep call light in reach. Keep personal belongings in reach. Increased staff supervision with intensity based on resident need. Resident # 1 had ADL self-care performance deficit. Interventions: She was total dependent on staff for bathing/showering, toileting, transfers and required extensive assistance with personal hygiene and oral care. Record review of Resident #1's Nurses Note dated [DATE] at 9:10 AM reflected DON was called to the room at 0901 (9:01 AM), upon arrival to the room, resident was laying in supine position, stating 'help me'. Noted blood and skin tear to LUE and LLE. OTA with resident on the floor. CNA's present in the room. Statements received from 3 CNA's. ADON present and at resident's head holding steady and asking resident not to move. DON conducted partial assessment for visible injuries without moving resident. Resident complaining of neck pain. Resident alert and oriented to self only. Baseline is A&O X 4. Pupils reactive to light. Right cheek bone noted to be swollen along with orbital swelling around right eye. Petechiae ( small red or purple spot caused by bleeding into the skin) noted to right cheek bone and right bicep area. Top of right shoulder with abrasion and blue bruising noted. Blue discoloration and bruising noted to top right middle knuckle. Resident breathing WNL. Vitals obtained (did not see vital entered in documentation). ADON stated she would kept resident calm and talking until EMS comes and has the situation under control. DON left room with ADON and 2 aides present in room. Floor RN was on phone with 911 attempting to get EMS on the way. Signed by Director of Nurses. Record review of Resident #1's Nurses Note dated [DATE] at 9:49 AM reflected, called to room by CNA- upon entering room client in prone position with face and lower extremities laying across Mechanical legs non responsive during course of log roll to supine client started groaning started neuro checks pupils non responsive client groaning and grunting- sent CNA to get DON left OTA and two other CNAs in room started process to send out to hospital-unable to reach ( she named two persons names question of these people are at the time of reading the nurses note when in the facility determined after reviewing face sheet she was referring to two family members) One family member called back as EMS was entering room-report given to them along with transfer paperwork - spoke to family member concerning the incident: client being transferred by Mechanical, Mechanical sling broke client fell to floor informed of clients condition, other family member called also given same information and updated him on where they would be taking her. Signed by RN E. Record review of Hospital Records, dated [DATE], reflected Resident #1 had new diagnosis after her Computed Tomography scans. New diagnosis: back pain, brain bleed (bleeding between the brain tissue and the skull or inside the brain tissue), cerebellar hemorrhage (where the bleeding is located in a small space in the skull, found near the brainstem and cerebellum. The cerebellum is the part of the brain responsible for balance and coordinated movements. The brainstem is responsible for controlling vital body functions, such as breathing), closed head injury (rotational forces when the head twists or turns side to side or from the brain moving forward or backward inside of the skull), facial contusion (a bruise appears on your face after an injury), fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support), intraventricular hemorrhage (bleeding inside or around the ventricles-spaces in the brain that contain the cerebral spinal fluid. Bleeding in the brain can put pressure on the nerve cells and damage them. If the nerve cells are severely damaged, it can result in irreversible brain injury), right clavicle fracture (broken collar bone), right hip pain (injuries to your hip), subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it), traumatic intraventricular hemorrhage (an uncommon but important condition that may be a marker of severe injury in patients with blunt head trauma), traumatic subarachnoid hemorrhage (there is bleeding in the space that surrounds the brain), and traumatic subdural hemorrhage ( type of brain hemorrhage happens when blood is leaking out of a torn blood vessel and below the space of the brain and skull. This prevents the brain from getting enough oxygen). Record review of Resident #1's facility investigation dated ,[DATE], reflected a skin tear to left forearm and left upper thigh, bruising noted to right middle knuckle, right side of face on cheek bone with petechiae (round spots that form on the skin), along with petechiae on right upper extremity. Resident #1 complaining of neck pain. Resident #1 kept still on ground by ADON for prevention of further injury since complaining of neck pain . The sling to Mechanical lift ripped and caused the resident to fall to the ground. The investigation findings were confirmed. Signed by DON. Record review of written statement by CNA C, dated [DATE] reflected I was working halls 500 and 600, Hospitality Aide A and I went into Resident #1's room to get her up for a shower, to get her ready to go and see religious service., we put the sling underneath it, we noticed the blue hook was already ripped so we put it on the green hook, we got her ready her arms were on her chest like she always did. CNA D walked into the room because she needed the Mechanical lift for another resident. Hospitality Aide A was on one side of the bed and I was on the other side of the bed, as Hospitality Aide A began to move the Mechanical, I began my way by the shower chair because I was going to grab Resident #1, from behind to make sure that she was sitting properly in the shower chair, and as I got by the shower chair, that is when I saw her fall, the sling broke from under her. CNA D did not sign her statement. Record review of written statement by Hospitality Aide A, dated [DATE], reflected I went into Resident #1's room to give her a shower. We (does not specify who assisted Hospitality Aide A) prepared the water to the shower, her clean clothes on the chair, I went to her bed. CNA C and I put the sling under her (Resident #1). We went to hook the sling to the Mechanical. The blue hooks were ripped. We used the green hooks. At this point, I did not report the ripped blue hooks. I would have reported the sling to RN E. The green hooks looked good. We did look for other slings but were unable to locate one. I was using the remote for the sling. On the way up, everything looked went well. When I went to move Resident #1 to the shower chair, I heard the sling rip. It was really fast. Both hooks ripped. Resident #1 was holding her left arm, she flipped and landed face down on the Mechanical legs. CNA D went to call for help. I was trying to get Resident #1 to respond to me, but she was not responding at all. RN D came into the room with the therapy guy and they took over care for Resident #1. Signed by Hospitality Aide A Record review of written statement by CNA D, not dated, reflected I walked into Resident #1's around 9:00 AM on [DATE] (no year documented). When I walked in Resident #1's room I saw Hospitality Aide A had the Mechanical controller in her hand and Resident #1 was on the bed . CNA C was at the foot of the bed with the shower chair in front of her. I came in and shut the door. Hospitality Aide A moved it (did not specify in her statement) out to put in front of the shower chair. The back strap broke which cuz (do not know the meaning of cuz) Resident #1 to fall and hit the floor. She hit her eye/cheek on the leg of the Mechanical. She was on her stomach. I ran out in the hallway looking for RN E. There was not a signature of CNA D or a date when she wrote the statement. Record review of written statement by DON, dated [DATE], reflected the same information from nurses note dated [DATE] by the DON was documented on the top paragraph of the statement. The second paragraph reflected DON spoke with 3 CNAs to gather information on how incident occurred. 3 CNAs were standing near restroom with Mechanical lift in resident's room. DON asked each CNA to explain what occurred and exact details. Group statement received was that CNA C was standing on the window side of the bed, Hospitality Aide A was on the opposite side of the bed with the Mechanical lift and controls. CNA C was walking around the bed and as they began to move Resident #1 via Mechanical lift to the shower chair, the sling ripped, resident fell to the ground landing with her face on the legs of the Mechanical lift. They (did not specify in statement of who she was referring to as they) then called for help. CNA D was standing in the resident's room observing the transfer and witnessed the incident. CNAs called for help and floor RN E came. CNA (don't know which CNA did not specify) called for DON, Medical Records Coordinator F and the Receptionist G came to the conference room and informed DON and ADON that we were needed on hall 500. The sling was located by the door in Resident #1's room. Upon inspection, the 3 green hooks and 4 blue hooks were ripped and tore. Signed by the DON. Record review of maintenance of slings from the Mechanical lift manual reflected to check sling for wear; discard if worn. and to Ensure sling hardware is in good condition before each use. Observation on [DATE] at 3:30 PM of the sling used to transfer Resident #1 on [DATE] revealed there were four green loops, and three of the four green loops broke during the transfer. The bottom loops had already broken prior to using the sling. There were three out of four top purple loops frayed and was beginning to tear when the sling was used for Resident #1 transfer. In an interview on [DATE] at 10:45 AM Hospitality Aide A stated she knew the sling used on Resident #1 was not safe and it was tearing and ripped. She stated she did not look at the green hooks prior to placing them on the Mechanical lift when transferring Resident #1. Hospitality Aide A stated she was not qualified to perform a lot of skills a CNA performed. She stated she realized this when she took her skills test and failed. Hospitality Aide A stated she told staff that she became nervous but that was not the truth. She stated she guessed at a lot of the skills tasks during the test and passed but it was not because she knew what she was doing it was just luck. She stated she did not feel she was qualified to do any of the CNA ADL care. Hospitality Aide A stated she did it because she felt she could learn if she continued to do care with the residents. She stated she did not consider the residents safety when she was giving ADL care. Hospitality Aide A stated a resident may had a serious injury due to her lack of ability and knowledge on how to operate a Mechanical lift. She also stated she should not had been the one to operate the Mechanical lift the day of [DATE] due to not knowing what to do about the sling. She stated she did not know how to use that particular sling and was confused with the hooks torn and she always used the purple hooks and was afraid to use them because they were tattered and beginning to tear. She stated she discussed it with CNA C and they decided to go with the green hooks but they did not look at the green loops to determine if they were in good condition. She stated she did not request to be removed from the Mechanical lift. She stated when she and CNA B obtained the sling from the closet they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated she walked with CNA B into Resident #1's room with the sling and the Mechanical lift was already in the room. Hospitality Aide A stated CNA B was by the window and she was using the Mechanical lift. She also stated she had never used this type of sling before and one the blue hooks was broken and they couldn't use them and the purple hooks looked old and was frayed such as slightly tearing apart. She stated she discussed with CNA B of which hooks to use on the Mechanical lift. She also stated they had to use the purple that was frail and the green hooks. She stated she did not notice if the green hooks were tearing /frail looking like the purple hooks. Hospitality Aide A stated she placed the hooks on one side and CNA B placed hooks on the other side of Mechanical lift. She stated when she began to lift Resident #1 from the bed and was pulling the Mechanical lift away from the bed she heard a snap and Resident #1 fell to the floor when she was in the air on the Mechanical lift. She stated the green hooks broke. Hospitality Aide A stated she was aware it was not in her job description to do Mechanical lift transfers and she had been doing them for 5 months. She stated she did not know if the director of nurses knew she was doing the Mechanical lift transfers. She stated she had been in serviced on her job description when the facility got into trouble about her using Mechanical lift in March. She stated she did CNA care thinking she was helping the staff. She stated now she realizes without being qualified she caused a resident serious injury from not knowing how to properly use a Mechanical lift with a defected sling and she had never used that type of sling before until [DATE]. She stated a resident fell and had serious injuries as a result of her not being a CNA and not being qualified to use a Mechanical lift. She stated Resident #1 could have died or any resident could have been seriously injured or died with me not being qualified to give any type of hands-on care to the residents. She stated she should have followed the Hospitality Aide job description and never completed any type of CNA care to a resident. Hospitality Aide A stated she was placing all residents she assisted in danger of being harmed. In an interview on [DATE] at 12:04 PM CNA D stated she entered Resident #1's room (did not recall the time) and was waiting for Hospitality Aide A and CNA C to transfer Resident #1 because she needed to use the Mechanical lift on another resident. She stated when she entered Resident #1 room the resident lying on the bed and the Hospitality Aide A had the controller in her hand to maneuver Resident #1 in the air with the Mechanical lift to transfer her to the shower chair. She stated CNA C was standing behind the shower chair. When Resident #1 was being assisted in the air and Hospitality Aide A was beginning to maneuver her away from the bed this is when Resident #1 fell to the floor and hit her head on the legs of the Mechanical lift. She stated she immediately left the room to find RN E or any nurse. She stated Hospitality Aide A has been using Mechanical lifts before [DATE]. She stated she was not aware of any in-service being given of the Hospitality Aide job description. CNA D stated someone told her, but she did not recall who told her it was ok for Hospitality Aide A to do any type of ADL care including Mechanical lifts on residents since she passed her written test. She stated you do have to past written and skills test to be a CNA. She stated she did know Hospitality Aide A did not pass her skills test. CNA D stated she was not to touch the residents and give any type of care including Mechanical lift if she did not have her CNA certification. She also stated she is not qualified to do Mechanical lifts or any ADL care, but she had been doing this before [DATE]. CNA D stated she did not report any concerns about qualifications of Hospitality Aide A to anyone. She stated she knew of two nurse supervisors knowing Hospitality Aide A was assisting with Mechanical lift and doing ADL care. She did not give any names of the nurse supervisors and stated they were not working today ([DATE]). In an interview on [DATE] at 1:10 PM RN E stated Hospitality A and CNA C did not report to her about their concerns of the safety of the sling used on Resident #1. She stated if she had known the staff felt the sling was unsafe, she had new slings she could have given them. She stated she knew Hospitality Aide A was not to use a Mechanical lift. She stated she was not aware when she worked on the hall, she was assigned to that she was assisting with transfer via Mechanical lift or doing any CNA tasks without a CNA assisting her. RN E stated she has worked with Hospitality Aide A several times but did not recall how many times a week or a month. She stated Hospitality Aide A was not qualified to use Mechanical lift or to do any type of care on a resident. RN E stated on the day Resident #1 fell CNA D came out of the room and found me and immediately went to Resident #1's room. RN E stated Resident #1 was not responsive and within 3 minutes DON, ADON and OTA entered the room and took over while I went to make phone calls to 911, physician, and family. She stated it was her responsibility to monitor the nursing staff working under her on the floor she was assigned to. RN E also stated she knew Hospitality Aide A was working helping CNA C on [DATE] and she did not monitor Hospitality Aide A to ensure she was not doing hands on care. RN E stated Hospitality Aide A was only to pass out ice, answer call lights, assist residents to the dining room and make up beds and this was discussed in an in-service in [DATE]. She also stated she expected all staff to check the slings prior to entering the resident's room for safety of the sling. She stated if the sling was not safe the staff was to report to nurse supervisor and if the nurse supervisor was busy the staff was to go to the ADON or DON and report the sling was not safe to use. In an interview on [DATE] at 1:35 PM LVN I stated no one reported to her of sling not being safe to use on [DATE] when Hospitality Aide A and CNA C transferred Resident #1 via Mechanical lift and the sling broke, and Resident #1 fell to the floor hitting her face on the legs of the Mechanical lift. She stated if the Hospitality Aide A or the CNA C reported their concern safety of the sling, she could have given them a new sling. In an interview on [DATE] at 2:00 PM the DON stated there were three CNAs in Resident #1's room on [DATE] the day of the incident with Resident #1 was not correct . She stated there were two CNAs present (CNA C and CAN D). She also stated the other staff was present was Hospitality Aide A. She stated there were never 3 CNAs in Resident #1's room and she did interview the staff that was in the room at the time of Resident #1 falling from the Mechanical lift and she interviewed Hospitality Aide A, CNA C, and CNA D). She also stated after she inspected the sling the Hospitality Aide A and CNA C used on Resident #1 date of [DATE] she did confirm the sling was unsafe to use for the transfer of Resident #1. She stated the sling was tattered and the purple hooks was beginning to tear. She stated the sling was not in safe condition to use on any resident. The DON stated no one was inspecting the Mechanical lift slings used for mechanical transfer of residents and did not have a way of ensuring worn out slings were not in use. She also stated the maintenance supervisor did check the Mechanical lifts weekly, but no one was assigned to inspect the slings. She stated she in-service Hospitality Aide A after the state investigation in [DATE]. She stated she reviewed the Hospitality Aide job description and explained to Hospitality Aide A not to give any type of direct care including Mechanical lifts to any resident. Her job description was only to pass out ice, make beds, answer call lights, assist residents to the dining room in their wheelchairs, etc. She stated Hospitality Aide A signed the in-service. DON stated she was not aware Hospitality Aide was continuing to perform Mechanical lifts on residents or giving ADL care without another CNA assisting her. She stated no one had reported this to her. She stated the nurse supervisor was to monitor the staff on their halls. The DON also stated she did not follow up on monitoring or designate anyone to monitor Hospitality Aide A after the state investigation of Hospitality Aide A using Mechanical lift in [DATE] and this was part of the facilities plan of correction. She stated if someone had been monitoring Hospitality Aide A the incident with Resident #1 may not have occurred if there was another CNA using the Mechanical lift and reported to someone the sling was damaged. She also stated the sling should not have been used on Resident #1. The DON stated it was not a safe sling and should have been thrown away by staff. She stated that she and another administrator from sister facility completed a facility wide check on all slings. The staff had slings to use that was safe and the facility ordered more new slings on [DATE]. She stated in service began on [DATE] on how to inspect slings for any imperfections prior to every use. Who purchases new slings (DON or Medical supply), what to do if a sling is not in working condition-repot sling, the concerns of chain of command (floor nurse, DON, and then the Administrator), laundry to inspect slings each wash and all remaining slings in the facility was inspected by the DON. There were no further defected slings found in the facility. The DON stated it was not in the facility policy or protocol for Hospitality Aide to give direct care to any residents. She stated the investigation was confirmed that Hospitality Aide A was not qualified to do any Mechanical lift transfers. She also stated the staff coordinator did not report to her the Hospitality Aide A was using Mechanical lifts with another CNA or completing any type of ADL care without a CNA assistance. Record review of Sling inspection protocol, not dated, reflected inspect slings prior to each use. Report sling concerns to chain of command (floor nurse, DON, and then Administrator). Action: Record review on [DATE] of documentation of the investigation reflected on [DATE], the sling that was used on failed transfer was immediately removed from employee access by the DON at the time of the incident. The hall was delivered a new sling to begin using from this point forward. Record review on [DATE] of inspecting sling in-service dated [DATE] reflected the DON was in-serviced by sister facility DON and Administrator via zoom conference call regarding manufacturer recommendations on signs of deterioration for slings such as: sling faded, illegible tags, extreme curling or permanent wrinkles or creases, strap brittleness, stiffness, surface, and edge abrasions, decomposition of edge binding, surface abrasion and color loss. Record review on [DATE] of in-service regarding inspecting slings dated on [DATE] reflected the employees were educated one-on-one by the DON or designee, this in-service included a guideline for identifying signs of deterioration which include a guideline for identifying signs of deterioration which include completely faded, missing, illegible tags, extreme curling or permanent wrinkles or creases, strap brittleness, stiffness, surface, and edge abrasions, decomposition of edge binding, surface abrasion and color loss. She stated the staff was in serviced on chain of command the floor nurse was first in command, then DON and then the Administrator and how to report faulty equipment to appropriate supervisor. All resident care staff was informed new slings were readily available in the facility for replacement of unsafe or compromised equipment. The noncompliance was identified as PNC. The IJ began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began.

Based on observation, interviews, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for three (Resident #1, and Resident #2) of five residents reviewed for accidents and hazards. Hospitality Aide A and CNA C observed the sling prior to entering Resident #1 room and determined at this time the sling was not safe to use. Hospitality Aide A and CNA C did not report this to anyone and used the unsafe sling on the Mechanical lift during transfer of Resident #1. Hospitality Aide A and CNA C observed the loops on the sling to be frayed. There were four green loops on the sling and three of the four green loops broke during the transfer. The bottom four blue loops were already torn and unable to use prior to hooking the sling to Mechanical lift. There were three of four purple loops frayed and was beginning to tear and these loops were used on the Mechanical lift during transfer of Resident #1. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:27 PM. While the IJ was removed on [DATE] at 7:50 PM, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of isolated. This failure could result in residents experience accidents, injuries, unrelieved pain, and diminished quality of life. Findings included: Record review of Resident #1's face sheet, dated [DATE], reflected Resident #1 was a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of: nontraumatic intracerebral hemorrhage in cerebellum (primary, admission - a devastating condition whereby a hematoma ( swelling or clotted blood) is formed within the brain parenchyma ( functional part of an organ) with or without blood extension into the ventricles (cavities in the brain)- this is a new diagnosis after return from hospital on [DATE], the following are diagnosis prior to being admitted to hospital on [DATE]: hemiplegia and hemiparesis following cerebral infarction left non-dominant side ( paralysis or partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), lack of coordination (not able to move different parts of the body together easily), muscle wasting and atrophy ( thinning of the muscle mass), and type 2 diabetes mellitus with diabetic neuropathy, unspecified ( nerve damage caused by high blood sugars levels over time, leading to various complications in different parts of the body). Record review of Resident #1's Annual MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 15 indicated her cognition was intact. Resident #1 was assessed to have limited range of motion with upper and lower extremity on one side (left side). She required assistance with ADLs such as eating, all hygiene, upper and lower dressing including assist with footwear, toileting, all transfers, and repositioning in bed. Record review of Residents #1 Comprehensive Care Plan revised on [DATE], reflected Resident #1 had impaired physical mobility related to decreased in muscle strength and recent clavicle fracture (broken collar bone). Resident #1 required two person Mechanical lift transfer assistance. Intervention dated [DATE]: staff to provide a safe environment during transfers and will use a Mechanical lift with two-person assistance. Resident #1 had impaired physical mobility related to hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side. Intervention: Assess need for an provide as indicated adaptive devices, furniture, and clothing. She was assessed to be at risk for unstable blood glucose level related to Type 2 diabetes mellitus with diabetic neuropathy. Intervention: Assess blood glucose levels as ordered. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #1 was assessed to be at risk for falls related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Intervention dated [DATE]: Encourage to keep bed in low position. Keep call light in reach. Keep personal belongings in reach. Increased staff supervision with intensity based on resident need. Resident # 1 had ADL self-care performance deficit. Interventions: She was total dependent on staff for bathing/showering, toileting, transfers and required extensive assistance with personal hygiene and oral care. Record review of Resident #1's Nurses Note dated [DATE] at 9:10 AM reflected DON was called to the room at 0901 (9:01 AM), upon arrival to the room, resident was laying in supine position, stating 'help me'. Noted blood and skin tear to LUE and LLE. OTA with resident on the floor. CNA's present in the room. Statements received from 3 CNA's. ADON present and at resident's head holding steady and asking resident not to move. DON conducted partial assessment for visible injuries without moving resident. Resident complaining of neck pain. Resident alert and oriented to self only. Baseline is A&O X 4. Pupils reactive to light. Right cheek bone noted to be swollen along with orbital swelling around right eye. Petechiae( a small red or purple spot caused by bleeding into the skin) noted to right cheek bone and right bicep area. Top of right shoulder with abrasion and blue bruising noted. Blue discoloration and bruising noted to top right middle knuckle. Resident breathing WNL. Vitals obtained (did not see vital entered in documentation). ADON states she will kept resident calm and talking until EMS comes and has the situation under control. DON left room with ADON and 2 aides present in room. Floor RN was on phone with 911attempting to get EMS on the way. Signed by Director of Nurses. Record review of Resident #1's Nurses Note dated [DATE] at 9:49 AM reflected, called to room by CNA- upon entering room client in prone position with face and lower extremities laying across Mechanical legs non responsive during course of log roll to supine client started groaning started neuro checks pupils non responsive client groaning and grunting- sent CNA to get DON left OTA and two other CNAs in room started process to send out to hospital-unable to reach ( she named two persons names question of these people are at the time of reading the nurses note when in the facility determined after reviewing face sheet she was referring to two family members) One family member called back as EMS was entering room-report given to them along with transfer paperwork - spoke to family member concerning the incident: client being transferred by Mechanical, Mechanical sling broke client fell to floor informed of clients condition, other family member called also given same information and updated him on where they would be taking her. Signed by RN E. Record review of Hospital Records, dated [DATE], reflected Resident #1 had new diagnosis after her CT scans. New diagnosis: back pain, brain bleed (bleeding between the brain tissue and the skull or inside the brain tissue), cerebellar hemorrhage (where the bleeding is located in a small space in the skull, found near the brainstem and cerebellum. The cerebellum is the part of the brain responsible for balance and coordinated movements. The brainstem is responsible for controlling vital body functions, such as breathing), closed head injury (rotational forces when the head twists or turns side to side or from the brain moving forward or backward inside of the skull), facial contusion (a bruise appears on your face after an injury), fall (to drop or descend under the force of gravity, as to a lower place through loss or lack of support), intraventricular hemorrhage (bleeding inside or around the ventricles-spaces in the brain that contain the cerebral spinal fluid. Bleeding in the brain can put pressure on the nerve cells and damage them. If the nerve cells are severely damaged, it can result in irreversible brain injury), right clavicle fracture (broken collar bone), right hip pain (injuries to your hip), subarachnoid hemorrhage (bleeding in the space between your brain and the membrane that covers it), traumatic intraventricular hemorrhage (an uncommon but important condition that may be a marker of severe injury in patients with blunt head trauma), traumatic subarachnoid hemorrhage (there is bleeding in the space that surrounds the brain), and traumatic subdural hemorrhage ( type of brain hemorrhage happens when blood is leaking out of a torn blood vessel and below the space of the brain and skull. This prevents the brain from getting enough oxygen). Record review of Resident #1's facility investigation dated ,[DATE], reflected skin tear to left forearm and left upper thigh, bruising noted to right middle knuckle, right side of face on cheek bone with petechiae (round spots that form on the skin), along with petechiae on right upper extremity. Resident #1 complaining of neck pain. Resident #1 kept still on ground by ADON for prevention of further injury since complaining of neck pain. The sling to Mechanical lift ripped and caused the resident to fall to the ground. The investigation findings were confirmed. Signed by DON. Record review of written statement by CNA C, dated [DATE] reflected I was working halls 500 and 600, Hospitality Aide A and I went into Resident #1's room to get her up for a shower, to get her ready to go and see religious service., we put the sling underneath it, we noticed the blue hook was already ripped so we put it on the green hook, we got her ready her arms were on her chest like she always did. CNA D walked into the room because she needed the Mechanical lift for another resident. Hospitality Aide A was on one side of the bed and I was on the other side of the bed, as Hospitality Aide A began to move the Mechanical, I began my way by the shower chair because I was going to grab Resident #1, from behind to make sure that she was sitting properly in the shower chair, and as I got by the shower chair, that was when I saw her fall, the sling broke from under her. CNA D did not sign her statement. Record review of written statement by Hospitality Aide A , dated [DATE], reflected I went into Resident #1's room to give her a shower. We (does not specify who assisted Hospitality Aide A) prepared the water to the shower, her clean clothes on the chair, I went to her bed. CNA C and I put the sling under her (Resident #1). We went to hook the sling to the Mechanical. The blue hooks were ripped. We used the green hooks. At this point, I did not report the ripped blue hooks. I would have reported the sling to RN E. The green hooks looked good. We did look for other slings but were unable to locate one. I was using the remote for the sling. On the way up, everything looked and went well. When I went to move Resident #1 to the shower chair, I heard the sling rip. It was really fast. Both hooks ripped. Resident #1 was holding her left arm, she flipped and landed face down on the Mechanical legs. CNA D went to call for help. I was trying to get Resident #1 to respond to me, but she was not responding at all. RN D came into the room with the therapy guy, and they took over care for Resident #1. Signed by Hospitality Aide A Record review of written statement by CNA D, not dated, reflected I walked into Resident #1's room [ROOM NUMBER] around 9:00 AM on [DATE] (no year documented). When I walked in Resident #1's room I saw Hospitality Aide A had the Mechanical controller in her hand and Resident #1 was on the bed. CNA C was at the foot of the bed with the shower chair in front of her. I came in and shut the door. Hospitality Aide A moved it (did not specify in her statement) out to put in front of the shower chair. The back strap broke which cuz (do not know the meaning of cuz) Resident #1 to fall and hit the floor. She hit her eye/cheek on the leg of the Mechanical. She was on her stomach. I ran out in the hallway looking for RN E. There was not a signature of CNA D or a date when she wrote the statement. Record review of written statement by DON, dated [DATE], reflected the same information from nurses note dated [DATE] by they DON was documented on the top paragraph of the statement. The second paragraph reflected DON spoke with 3 CNAs to gather information on how incident occurred. 3 CNAs were standing near restroom with Mechanical lift in resident's room. DON asked each CNA to explain what occurred in exact details. Group statement received was that CNA C was standing on the window side of the bed, Hospitality Aide A was on the opposite side of the bed with the Mechanical lift and controls. CNA C was walking around the bed and as they began to move Resident #1 by a Mechanical lift to the shower chair, the sling ripped, resident fell to the ground landing with her face on the legs of the Mechanical lift. They (did not specify in statement of who she was referring to as they) then called for help. CNA D was standing in the resident's room observing the transfer and witnessed the incident. CNAs called for help and floor RN E came. CNA (don't know which CNA did not specify) called for DON, Medical Records Coordinator F and the Receptionist G came to the conference room and informed DON and ADON that we were needed on hall 500. The sling was located by the door in the Resident #1's room. Upon inspection, the 3 green hooks and 4 blue hooks were ripped and tore. Signed by the DON. Record review on [DATE] of Hospitality Aide personnel file reflected she was a Hospitality Aide. She did receive one-on- one in-service by the DON of hospitality aide job description on [DATE] and was given a copy of the job description. She signed the original Hospitality Aide job description on [DATE]. She did not have another job description or any indication she was a CNA in her personnel file. The hospitality aide job description reflected the following: 1. Answer call lights in a timely manner; determine if request does not involve direct care and then carry out request. 2. Examples of non-direct care: helping with television, telephone, getting a personal item for a resident, giving a blanket or a pillow. 3. Be alert to resident's comfort and needs. Answer their requests promptly and report to nurse any need that exceeds your ability. 4. Uses tactful, appropriate communications in sensitive and emotional situations. 5. Observe all residents and report anything unusual or abnormal to Charge Nurse. 6. Offer fluids and encourage residents to drink (check with nurse for a list of residents with fluid restrictions or on thickened liquids). 7. Pass out meal trays and labeled snacks to residents 8. Clean and pick up rooms. 9. Stock gloves in rooms and notify housekeeping/maintenance if paper towels running low. 10. Pass ice and pick up meal trays from resident's room. 11. Empty bedside commodes. 12. Take laundry barrels to laundry room, get linens for beds, make unoccupied beds. 13. Bring residents to and from daily activities. 14. Perform other duties as assigned. 15. Treat all residents, visitors, and staff with courtesy. What you cannot do: 1. You cannot help feed residents (unless you have received training to be a feeding assistant). 2. No direct care (including changing, showering, transfers, shaving) 3. Cannot cut nails. 4. Cannot do vitals. Observation/Interview on [DATE] at 9:15 AM CNA B opened utility room door and reached for a Mechanical lift sling. Did not observe her inspecting the Mechanical lift sling. She began to walk down the hall with the staff coordinator was walking with her. Upon observation of his name tag noticed it stated staff coordinator. Asked the staffing coordinator to get two CNAs for observation of a Mechanical lift transfer. He stated he trained staff on how to transfer using Mechanical lift with the therapy department and he was qualified to do Mechanical lift transfers. It was explained to the staff coordinator preferred two CNAs to observe and not the training staff. The Staff Coordinator agreed and stated he would find another CNA. Observed someone walking down the hall and it was the same Hospitality Aide who was observed in [DATE] assisting with Mechanical lifts. Hospitality Aide A was walking toward CNA B. They entered Resident #2's room and Hospitality Aide A rolled Resident toward CNA B and placed the sling underneath Resident #2. CNA B rolled Resident #2 toward Hospitality Aide A and reached for the sling and pulled it under Resident #2. CNA B hooked the loops onto the sling and began to move resident. Hospitality Aide moved to Resident's wheelchair and assisted resident from behind as she was being lowered into the wheelchair. The legs of the Mechanical lift were widened, and the wheelchair was locked. The Hospitality Aide A and the CNA B did not inspect the sling prior to using it on the Mechanical lift. In an interview on [DATE] at 9:15 AM Hospitality Aide A stated she did not inspect the sling on the Mechanical lift, and she did not witness CNA B inspect the sling prior to using it on the Mechanical Lift. She stated her name tag was correct she was a Hospitality Aide and not a CNA. She stated she had taken written CNA test and past . Hospitality Aide A also stated she told everyone that she was nervous when she took the clinicals. Hospitality Aide A also stated she was not nervous she did not know how to do some of the clinicals, and she did not pass. She stated on most of the clinicals she guessed on how to the tasks including using Mechanical lift and transfers. She stated she does get confused on some of the slings especially which hooks to use to place on the Mechanical lift. She stated it depended on the resident which color to use and she does gets this confused sometimes. She also stated that she and CNA B obtained the sling from the closet they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated on that particular day ([DATE]) with the incident with Resident #1 she asked CNA C and they discussed which color to use because the blue hooks were broken the purple hooks was tattered and a little torn. She stated the only option was the green hooks and she had never used the green hooks before until that day. She also stated she was not qualified to do any type of transfers including Mechanical lifts. She stated she needed to do something and asked if she could finish this interview later today. In an interview on [DATE] at 9:35AM CNA B stated she did not inspect the sling prior to using it on the Mechanical lift to transfer Resident #2. She stated she had been in-service to inspect the sling prior to placing under the resident. CNA B stated she was in serviced in July the day of incident with Resident #1. She stated She was not aware that Hospitality Aide A was not allowed to do Mechanical Lift transfers. She stated Hospitality Aide A has been doing Mechanical lift transfers over 5 months. She agreed she remembered the incident when she was observed assisting with Mechanical lift during an investigation with a surveyor U in [DATE] and she continued to do Mechanical lift transfers after the surveyor U left the facility. She stated Hospitality Aide passed her written test and did not pass her clinicals. CNA B stated the staff coordinator H was aware she was completing Mechanical lift transfers and did not say it was not ok for her to bed completing this task. In an interview on [DATE] at 9:50 AM Staff Coordinator H stated he was aware Hospitality Aide A was doing Mechanical Lift transfers and did not believe it was a problem. He stated she passed her written test but did not pass her clinicals. He stated he believed since she had passed her written test, she was a Certified CNA. He stated he was aware of the incident with this same Hospitality Aide using Mechanical Lifts during an investigation in [DATE]. He stated she did continue to use Mechanical lift after [DATE]. He stated she had been trained by CNAs and also went through training with him and the therapy department after the investigation in [DATE]. He stated he did have her on the schedule but did not put what her duties would be on the schedule. He stated only CNAs were required to use Mechanical lift and if she did not pass her clinicals she was not a Certified Nursing Assistant. He also stated prior to entering a resident room with a sling the staff was expected to check the sling and if it was torn or looked unsafe the staff was to report this to their charge nurse and the charge nurse would obtain a new sling for the staff. In an interview on [DATE] at 10:15 AM CNA C stated she was aware Hospitality Aide A was not a certified nursing assistant. She stated she was not aware Hospitality Aide A was not to assist with any type of transfers. CNA C stated she did not recall who informed her of this information. She stated the Hospitality Aide A has been doing CNA work over 4 months. She also stated she had continued to assist CNAs with Mechanical lifts and also had been performing care on residents such as: showers, peri care, assisting residents to the bathroom and everything a CNA would do without another CNA with her doing these tasks except for Mechanical Lift transfers. She stated she did not report this to anyone. CNA C also stated she thought everyone knew it especially the floor nurses. She stated the day of the incident on [DATE] Resident #1 was wanting a shower to go to a religious activity. She stated she was working with Hospitality Aide A on [DATE]. She stated she walked with Hospitality Aide to the linen closet to get obtain a sling. She stated both of them looked at the sling and saw where the blue hooks were torn. She stated they noticed the purple hooks was a little torn and tattered. She stated she did not recall if they looked at the green hooks. CNA C also stated they had concerns of the safety of the sling and went to other linen closets trying to find another sling to use due to the one they had did not look safe. She stated they did not find another sling and did not report it to the nurse on duty (RN E). She stated they were in a hurry and decided to use the sling they did not believe was safe to use. CNA C stated she entered Resident #1 room with the Hospitality Aide A. She stated she went by the window and the Hospitality Aide A was behind the Mechanical lift. She stated during the time of the transfer prior to Resident #1 being lifted off the bed CNA C entered the room to wait for the Mechanical lift to be used on another resident. She stated the blue hoops were torn and was unable to use them and the some of the purple hooks was tearing and was tattered and they discussed if the green hooks were the appropriate hooks to use. She stated they did not look closely at the green hooks and used the green ones to hook to the Mechanical lift. She stated they placed the sling under Resident #1 and Hospitality Aide began to lift her off the bed and this is when I moved from the window area to the shower chair. She stated when she placed herself by the shower chair to assist with the transfer, she heard a noise and saw Resident #1 fall to the floor hitting her face on the legs of the Mechanical lift. CNA C stated CNA D left the room to find the nurse. She also stated the RN E entered the room and began to assess the resident and within 3 minutes the DON, OTA and ADON entered the room. She stated that particular sling was not safe to use due to some of the hooks being torn and some tattered and was tearing. She also stated the sling overall was worn and beginning to tear. should have never been used on Resident #1. She stated it was not safe to use and they (Her and Hospitality Aide A) should have reported it to RN D or to the DON. She stated they knew for a fact the sling was not safe and because they did not see another one, they decided to use the unsafe sling. She stated Resident #1 was not responsive when she fell and hit her head on the legs of the Mechanical lift. CNA C stated they did have an in-service in March after the investigation by surveyor U of the hospitality aides job description. She stated in the in-service it was discussed the hospitality aide could only pass out ice, make beds, answer call lights, and never do hands on care with a resident including Mechanical lift and any type of care to a resident with a CNA or alone. In an interview on [DATE] at 10:45 AM Hospitality Aide A stated she was in serviced in March after surveyor U had left completing investigation where she was observed using a Mechanical lift. She stated she was in-serviced one on one and within a group. She stated her job description of being a hospitality aide was reviewed with her. She stated she was informed by the DON to only pass out water, answer call lights, make up beds, assist residents to the dining room in their wheelchairs and she stated it was a lot more but could not recall the rest of it at this time. She stated she was also informed during the in-service never do any type of hands-on care such as Mechanical lift, any type of care that was hands on with a resident by herself or with a CNA present. She stated she had been doing everything the CNAs does during ADL care with the residents since before [DATE] but was in-serviced in [DATE] about only doing her job description of being Hospitality Aide. She stated she continued to do Mechanical lifts and gave care to residents after being in-service in [DATE]. She stated she gave the following care without any other staff with her such as: peri-care, assisting resident to the shower and giving showers, transfer residents to the toilet, transfer residents from their bed to wheelchair and to the shower chair, feeding residents, assisted CNAs using Mechanical lifts. She stated she had been doing everything the CNAs does during ADL care with the residents since before [DATE] but was in-serviced in [DATE] about only doing her job description of being Hospitality Aide. She stated she knew she was not qualified on [DATE] and any other time she assisted to do Mechanical lifts. Hospitality Aide A stated she knew the sling was not safe and it was tearing and ripped. She stated she did not look at the green hooks prior to placing them on the Mechanical lift when transferring Resident #1. Hospitality Aide A stated she was not qualified to perform a lot of skills a CNA performed. She stated she realized this when she took her skills test and failed. Hospitality Aide A stated she told staff that she became nervous but that was not the truth. She stated she guessed at a lot of the skills tasks during the test and passed but it was not because she knew what she was doing it was just luck. She stated she did not feel she was qualified to do any of the CNA ADL care. Hospitality Aide A stated she did it because she felt she could learn if she continued to do care with the residents. She stated she did not consider the residents safety when she was giving ADL care. Hospitality Aide A stated a resident may had a serious injury due to her lack of ability and knowledge on how to operate a Mechanical lift. She also stated she should not had been the one to operate the Mechanical lift the day of [DATE] due to not knowing what to do about the sling. She stated she did not know how to use that particular sling and was confused with the hooks torn and she always used the purple hooks and was afraid to use them because they were tattered and beginning to tear. She stated she discussed it with CNA C and they decided to go with the green hooks but they did not look at the green loops to determine if they were in good condition. She stated she did not request to be removed from the Mechanical lift when they used it on Resident #1 she did not want others to know she did not know what she was doing because she was afraid that she may be asked to resign from her job until she became a CNA. Hospitality Aide A stated the Staff Coordinator was aware she had continued to assist with Mechanical Lifts over the past 4 or 5 months. She stated he had observed her go into residents' rooms and ask if she was going to assist the CNA with Mechanical lift transfer and did not say she could not do this task. She stated when she and CNA B obtained the sling from the closet, they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated she walked with CNA B into Resident #1's room with the sling and the Mechanical lift was already in the room. Hospitality Aide A stated CNA B was by the window, and she was using the Mechanical lift. She also stated she had never used this type of sling before and one the blue hooks was broken, and they couldn't use them, and the purple hooks looked old and was frailed such as slightly tearing apart. She stated she discussed with CNA B of which hooks to use on the Mechanical lift. She also stated they had to use the purple that was frail and the green hooks. She stated she did not notice if the green hooks were tearing /frail looking like the purple hooks. Hospitality Aide A stated she placed the hooks on one side and CNA B placed hooks on the other side of Mechanical lift. She stated when she began to lift Resident #1 from the bed and was pulling the Mechanical lift away from the bed, she heard a snap and Resident #1 fell to the floor when she was in the air on the Mechanical lift. She stated the green hooks broke. Hospitality Aide A stated she was aware it was not in her job description to do Mechanical lift transfers and she had been doing them for 5 months. She stated she did not know if the director of nurses knew she was doing the Mechanical lift transfers. She stated she had been in serviced on her job description when the facility got into trouble about her using Mechanical lift in March. She stated she did CNA care thinking she was helping the staff. She stated now she realizes without being qualified she caused a resident serious injury from not knowing how to properly use a Mechanical lift with a defected sling and she had never used that type of sling before until [DATE]. She stated a resident fell and had serious injuries as a result of her not being a CNA and not being qualified to use a Mechanical lift. She stated Resident #1 could have died or any resident could have been seriously injured or died with me not being qualified to give any type of hands-on care to the residents. She stated she should have followed the Hospitality Aide job description and never completed any type of CNA care to a resident she was placing all residents she assisted in danger of being harmed. Observation and interview on [DATE] at 11: 20 AM with Resident #1. She was lying in bed. Resident #1 had bruises on her face and her shoulder. Resident #1 had burrowed eyebrows and a frown on her face. She stated she was afraid to get on that lift again. She stated she never wanted to be dropped again. Resident #1 had difficulty finishing her sentences but was able to when given time. This was not abnormal to her per staff and her medical records. Resident #1 stated she was sadder and more depressed. Resident #1 did not feel like talking about the incident and wanted to go to sleep. In an interview on [DATE] at 12:04 PM CNA D stated she entered Resident #1's room (did not recall the time) and was waiting for Hospitality Aide A and CNA C to transfer Resident #1 because she needed to use the Mechanical lift on another resident. She stated when she entered Resident #1 room the resident lying on the bed and the Hospitality Aide A had the controller in her hand to maneuver Resident #1 in the air to transfer her to the shower chair. She stated CNA C was stand [TRUNCATED]

Based on observation, interviews, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #1 and Resident #2 .reviewed for Mechanical lift transfers. The facility failed to ensure Resident #1 was transferred with qualified staff. Hospitality Aide A knew the sling was not safe to use by observing the bottom loops were broken and three of the four top purple loops was frayed and beginning to tear. Hospitality Aide A did not report the unsafe sling to nurse prior to using the sling. Hospitality Aides were allowed to assist with resident transfers outside of the scope of their job description. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 6:27 PM. While the IJ was removed on [DATE] at 7:50 PM, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of isolated. This failure could place residents at risk for serious injury, serious harm, serious impairment, or death. Findings included : Record review of Resident #1's face sheet, dated [DATE], reflected Resident #1 was a [AGE] year-old-female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses of: nontraumatic intracerebral hemorrhage in cerebellum (primary, admission - a devastating condition whereby a hematoma ( swelling or clotted blood) is formed within the brain parenchyma ( functional part of an organ) with or without blood extension into the ventricles (cavities in the brain)- this is a new diagnosis after return from hospital on [DATE], the following are diagnosis prior to being admitted to hospital on [DATE]: hemiplegia and hemiparesis following cerebral infarction left non-dominant side ( paralysis or partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), lack of coordination (not able to move different parts of the body together easily), muscle wasting and atrophy ( thinning of the muscle mass), and type 2 diabetes mellitus with diabetic neuropathy, unspecified ( nerve damage caused by high blood sugars levels over time, leading to various complications in different parts of the body). Record review of Resident #1's Annual MDS Assessment, dated [DATE], reflected Resident #1 had a BIMS score of 15 indicated her cognition was intact. Resident #1 was assessed to have limited range of motion with upper and lower extremity on one side (left side). She required assistance with ADLs such as eating, all hygiene, upper and lower dressing including assist with footwear, toileting, all transfers, and repositioning in bed. Record review of Residents #1 Comprehensive Care Plan revised on [DATE], reflected Resident #1 had impaired physical mobility related to decreased in muscle strength and recent clavicle fracture (broken collar bone). Resident #1 required two person Mechanical lift transfer assistance. Intervention dated [DATE]: staff to provide a safe environment during transfers and will use a Mechanical lift with two-person assistance. Resident #1 had impaired physical mobility related to hemiplegia and hemiparesis following cerebral infarction affecting left-dominant side. Intervention: Assess need for an provide as indicated adaptive devices, furniture, and clothing. She was assessed to be at risk for unstable blood glucose level related to Type 2 diabetes mellitus with diabetic neuropathy. Intervention: Assess blood glucose levels as ordered. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Resident #1 was assessed to be at risk for falls related to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Intervention dated [DATE]: Encourage to keep bed in low position. Keep call light in reach. Keep personal belongings in reach. Increased staff supervision with intensity based on resident need. Resident #1 had ADL self-care performance deficit. Interventions: She was total dependent on staff for bathing/showering, toileting, transfers and required extensive assistance with personal hygiene and oral care. Record review of Resident #1's Nurses Note dated [DATE] at 9:10 AM reflected DON was called to the room at 0901 (9:01 AM), upon arrival to the room, resident was laying in supine position, stating 'help me'. Noted blood and skin tear to LUE and LLE. OTA with resident on the floor. CNA's present in the room. Statements received from 3 CNA's. ADON present and at resident's head holding steady and asking resident not to move. DON conducted partial assessment for visible injuries without moving resident. Resident complaining of neck pain. Resident alert and oriented to self only. Baseline is A&O X 4. Pupils reactive to light. Right cheek bone noted to be swollen along with orbital swelling around right eye. Petechiae( a small red or purple spot caused by bleeding into the skin) noted to right cheek bone and right bicep area. Top of right shoulder with abrasion and blue bruising noted. Blue discoloration and bruising noted to top right middle knuckle. Resident breathing WNL. Vitals obtained (did not see vital entered in documentation). ADON states she will kept resident calm and talking until EMS comes and has the situation under control. DON left room with ADON and 2 aides present in room. Floor RN was on phone with 911 attempting to get EMS on the way. Signed by Director of Nurses. Record review on [DATE] of Hospitality Aide personnel file reflected she was a Hospitality Aide. She did receive one-on- one in-service by the DON of hospitality aide job description on [DATE] and was given a copy of the job description. She signed the original Hospitality Aide job description on [DATE]. She did not have another job description or any indication she was a CNA in her personnel file. The hospitality aide job description reflected the following: 1. Answer call lights in a timely manner; determine if request does not involve direct care and then carry out request. 2. Examples of non-direct care: helping with television, telephone, getting a personal item for a resident, giving a blanket or a pillow. 3. Be alert to resident's comfort and needs. Answer their requests promptly and report to nurse any need that exceeds your ability. 4. Uses tactful, appropriate communications in sensitive and emotional situations. 5. Observe all residents and report anything unusual or abnormal to Charge Nurse. 6. Offer fluids and encourage residents to drink (check with nurse for a list of residents with fluid restrictions or on thickened liquids). 7. Pass out meal trays and labeled snacks to residents 8. Clean and pick up rooms. 9. Stock gloves in rooms and notify housekeeping/maintenance if paper towels running low. 10. Pass ice and pick up meal trays from resident's room. 11. Empty bedside commodes. 12. Take laundry barrels to laundry room, get linens for beds, make unoccupied beds. 13. Bring residents to and from daily activities. 14. Perform other duties as assigned. 15. Treat all residents, visitors, and staff with courtesy. What you cannot do: 1. You cannot help feed residents (unless you have received training to be a feeding assistant). 2. No direct care (including changing, showering, transfers, shaving) 3. Cannot cut nails. 4. Cannot do vitals. Record review on [DATE] of one-on one Inservice with the Hospitality Aide, dated [DATE] reflected Hospitality Aide A was aware and knowledgeable with which skills she was able to perform and which skills she was not to perform. Record review on [DATE] of the Inservice on the Hospitality Aide Job description given to the staff on [DATE] reflected the hospitality aides job description was reviewed with the staff. CNA B, CNA C and RN E signed the in-service. Observation/Interview on [DATE] at 9:15 AM CNA B opened utility room door and reached for a Mechanical lift sling. Did not observe her inspecting the Mechanical lift sling. She began to walk down the hall with the staff coordinator was walking with her. Upon observation of his name tag noticed it stated staff coordinator. Asked the staffing coordinator to get two CNAs for observation of a Mechanical lift transfer. He stated he trained staff on how to transfer using Mechanical lift with the therapy department and he was qualified to do Mechanical lift transfers. It was explained to the staff coordinator preferred two CNAs to observe and not the training staff. The Staff Coordinator agreed and stated he would find another CNA. Observed someone walking down the hall and it was the same Hospitality Aide who was observed in [DATE] assisting with Mechanical lifts. Hospitality Aide A was walking toward CNA B. They entered Resident #2's room and Hospitality Aide A rolled Resident toward CNA B and placed the sling underneath Resident #2. CNA B rolled Resident #2 toward Hospitality Aide A and reached for the sling and pulled it under Resident #2. CNA B hooked the loops onto the sling and began to move resident. Hospitality Aide moved to Resident's wheelchair and assisted resident from behind as she was being lowered into the wheelchair. The legs of the Mechanical lift were widened, and the wheelchair was locked. The Hospitality Aide A and the CNA B did not inspect the sling prior to using it on the Mechanical lift. In an interview on [DATE] at 9:15 AM Hospitality Aide A stated she did not inspect the sling on the Mechanical lift and she did not witness CNA B inspect the sling prior to using it on the Mechanical Lift. She stated her name tag was correct she was a Hospitality Aide and not a CNA. She stated she had taken CNA written test and past . Hospitality Aide A also stated she told everyone that she was nervous when she took the clinicals. Hospitality Aide A also stated she was not nervous she did not know how to do some of the clinicals, and she did not pass. She stated on most of the clinicals she guessed on how to the tasks including using Mechanical lift and transfers. She stated she does get confused on some of the slings especially which hooks to use to place on the Mechanical lift. She stated it depended on the resident which color to use and she does gets this confused sometimes. She also stated that she and CNA B obtained the sling from the closet they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated on that particular day ([DATE]) with the incident with Resident #1 she asked CNA C and they discussed which color to use because the blue hooks were broken the purple hooks was tattered and a little torn. She stated the only option was the green hooks and she had never used the green hooks before until that day. She also stated she was not qualified to do any type of transfers including Mechanical lifts. She stated she needed to do something and asked if she could finish this interview later today. In an interview on [DATE] at 9:35AM CNA B stated she did not inspect the sling prior to using it on the Mechanical lift to transfer Resident #2. She stated she had been in-service to inspect the sling prior to placing under the resident. CNA B stated she was in serviced in July the day of incident with Resident #1. She stated She was not aware that Hospitality Aide A was not allowed to do Mechanical Lift transfers. She stated Hospitality Aide A has been doing Mechanical lift transfers over 5 months. She agreed she remembered the incident when she was observed assisting with Mechanical lift during an investigation with a surveyor U in [DATE] and she continued to do Mechanical lift transfers after the surveyor U left the facility. She stated Hospitality Aide passed her written test and did not pass her clinicals. CNA B stated the staff coordinator H was aware she was completing Mechanical lift transfers and did not say it was not ok for her to bed completing this task. In an interview on [DATE] at 9:50 AM Staff Coordinator H stated he was aware Hospitality Aide A was doing Mechanical Lift transfers and did not believe it was a problem. He stated she passed her written test but did not pass her clinicals. He stated he believed since she had passed her written test she was a Certified CNA. He stated he was aware of the incident with this same Hospitality Aide using Mechanical Lifts during an investigation in [DATE]. He stated she did continue to use Mechanical lift after [DATE]. He stated she had been trained by CNAs and also went through training with him and the therapy department after the investigation in [DATE]. He stated he did have her on the schedule but did not put what her duties would be on the schedule. He stated only CNAs were required to use Mechanical lift and if she did not pass her clinicals she was not a Certified Nursing Assistant. He also stated prior to entering a resident room with a sling the staff was expected to check the sling and if it was torn or looked unsafe the staff was to report this to their charge nurse and the charge nurse would obtain a new sling for the staff. In an interview on [DATE] at 10:15 AM CNA C stated she was aware Hospitality Aide A was not a certified nursing assistant. She stated she was not aware Hospitality Aide A was not to assist with any type of transfers. CNA C stated she did not recall who informed her of this information. She stated the Hospitality Aide A has been doing CNA work over 4 months. She also stated she had continued to assist CNAs with Mechanical lifts and also had been performing care on residents such as: showers, peri care, assisting residents to the bathroom and everything a CNA would do without another CNA with her doing these tasks except for Mechanical Lift transfers. She stated she did not report this to anyone. CNA C also stated she thought everyone knew it especially the floor nurses. She stated the day of the incident on [DATE] Resident #1 was wanting a shower to go to a religious activity. She stated she was working with Hospitality Aide A on [DATE]. She stated she walked with Hospitality Aide to the linen closet to get obtain a sling. She stated both of them looked at the sling and saw where the blue hooks were torn. She stated they noticed the purple hooks was a little torn and tattered. She stated she did not recall if they looked at the green hooks. CNA C also stated they had concerns of the safety of the sling and went to other linen closets trying to find another sling to use due to the one they had did not look safe. She stated they did not find another sling and did not report it to the nurse on duty RN E. She stated they were in a hurry and decided to use the sling they did not believe was safe to use. CNA C stated she entered Resident #1 room with the Hospitality Aide A. She stated she went by the window and the Hospitality Aide A was behind the Mechanical lift. She stated during the time of the transfer prior to Resident #1 being lifted off the bed CNA C entered the room to wait for the Mechanical lift to be used on another resident. She stated the blue hoops were torn and was unable to use them and the some of the purple hooks was tearing and was tattered and they discussed if the green hooks were the appropriate hooks to use. She stated they did not look closely at the green hooks and used the green ones to hook to the Mechanical lift. She stated they placed the sling under Resident #1 and Hospitality Aide began to lift her off the bed and this is when I moved from the window area to the shower chair. She stated when she placed herself by the shower chair to assist with the transfer she heard a noise and saw Resident #1 fall to the floor hitting her face on the legs of the Mechanical lift. CNA C stated CNA D left the room to find the nurse. She also stated the RN E entered the room and began to assess the resident and within 3 minutes the DON, OTA and ADON entered the room. She stated that particular sling was not safe to use due to some of the hooks being torn and some tattered and was tearing. She also stated the sling overall was worn and beginning to tear. should have never been used on Resident #1. She stated it was not safe to use and they (Her and Hospitality Aide A) should have reported it to RN D or to the DON. She stated they knew for a fact the sling was not safe and because they did not see another one they decided to use the unsafe sling. She stated Resident #1 was not responsive when she fell and hit her head on the legs of the Mechanical lift. CNA C stated they did have an in-service in March after the investigation by surveyor U of the hospitality aides job description. She stated in the in-service it was discussed the hospitality aide could only pass out ice, make beds, answer call lights, and never do hands on care with a resident including Mechanical lift and any type of care to a resident with a CNA or alone. In an interview on [DATE] at 10:45 AM Hospitality Aide A stated she was in serviced in March after surveyor U had left completing investigation where she was observed using a Mechanical lift. She stated she was in-serviced one on one and within a group. She stated her job description of being a hospitality aide was reviewed with her. She stated she was informed by the DON to only pass out water, answer call lights, make up beds, assist residents to the dining room in their wheelchairs and she stated it was a lot more but could not recall the rest of it at this time. She stated she was also informed during the in-service never do any type of hands-on care such as Mechanical lift, any type of care that was hands on with a resident by herself or with a CNA present. She stated she had been doing everything the CNAs does during ADL care with the residents since before [DATE] but was in-serviced in [DATE] about only doing her job description of being Hospitality Aide. She stated she continued to do Mechanical lifts and gave care to residents after being in-service in [DATE]. She stated she gave the following care without any other staff with her such as: peri-care, assisting resident to the shower and giving showers, transfer residents to the toilet, transfer residents from their bed to wheelchair and to the shower chair, feeding residents, assisted CNAs using Mechanical lifts. She stated she had been doing everything the CNAs does during ADL care with the residents since before [DATE] but was in-serviced in [DATE] about only doing her job description of being Hospitality Aide. She stated she knew she was not qualified on [DATE] and any other time she assisted to do Mechanical lifts. Hospitality Aide A stated she knew the sling was not safe and it was tearing and ripped. She stated she did not look at the green hooks prior to placing them on the Mechanical lift when transferring Resident #1. Hospitality Aide A stated she was not qualified to perform a lot of skills a CNA performed. She stated she realized this when she took her skills test and failed. Hospitality Aide A stated she told staff that she became nervous but that was not the truth. She stated she guessed at a lot of the skills tasks during the test and passed but it was not because she knew what she was doing it was just luck. She stated she did not feel she was qualified to do any of the CNA ADL care. Hospitality Aide A stated she did it because she felt she could learn if she continued to do care with the residents. She stated she did not consider the residents safety when she was giving ADL care. Hospitality Aide A stated a resident may had a serious injury due to her lack of ability and knowledge on how to operate a Mechanical lift. She also stated she should not had been the one to operate the Mechanical lift the day of [DATE] due to not knowing what to do about the sling. She stated she did not know how to use that particular sling and was confused with the hooks torn and she always used the purple hooks and was afraid to use them because they were tattered and beginning to tear. She stated she discussed it with CNA C and they decided to go with the green hooks but they did not look at the green loops to determine if they were in good condition. She stated she did not request to be removed from the Mechanical lift when they used it on Resident #1 she did not want others to know she did not know what she was doing because she was afraid that she may be asked to resign from her job until she became a CNA. Hospitality Aide A stated the Staff Coordinator was aware she had continued to assist with Mechanical Lifts over the past 4 or 5 months. She stated he had observed her go into residents' rooms and ask if she was going to assist the CNA with Mechanical lift transfer and did not say she could not do this task. She stated when she and CNA B obtained the sling from the closet they noticed the sling was ragged and did not look safe to use. Hospitality Aide A stated she had concern about using the sling, however, she did check the storage closet on 500 and 600 hall and did not see any more slings. She stated she did not report this to the nurse or to anyone. She stated she walked with CNA B into Resident #1's room with the sling and the Mechanical lift was already in the room. Hospitality Aide A stated CNA B was by the window and she was using the Mechanical lift. She also stated she had never used this type of sling before and one the blue hooks was broken and they couldn't use them and the purple hooks looked old and was frayed such as slightly tearing apart. She stated she discussed with CNA B of which hooks to use on the Mechanical lift. She also stated they had to use the purple that was frail and the green hooks. She stated she did not notice if the green hooks were tearing /frail looking like the purple hooks. Hospitality Aide A stated she placed the hooks on one side and CNA B placed hooks on the other side of Mechanical lift. She stated when she began to lift Resident #1 from the bed and was pulling the Mechanical lift away from the bed she heard a snap and Resident #1 fell to the floor when she was in the air on the Mechanical lift. She stated the green hooks broke. Hospitality Aide A stated she was aware it was not in her job description to do Mechanical lift transfers and she had been doing them for 5 months. She stated she did not know if the director of nurses knew she was doing the Mechanical lift transfers. She stated she had been in serviced on her job description when the facility got into trouble about her using Mechanical lift in March. She stated she did CNA care thinking she was helping the staff. She stated now she realizes without being qualified she caused a resident serious injury from not knowing how to properly use a Mechanical lift with a defected sling and she had never used that type of sling before until [DATE]. She stated a resident fell and had serious injuries as a result of her not being a CNA and not being qualified to use a Mechanical lift. She stated Resident #1 could have died or any resident could have been seriously injured or died with me not being qualified to give any type of hands-on care to the residents. She stated she should have followed the Hospitality Aide job description and never completed any type of CNA care to a resident she was placing all residents she assisted in danger of being harmed. In an interview on [DATE] at 12:04 PM CNA D stated she entered Resident #1's room (did not recall the time) and was waiting for Hospitality Aide A and CNA C to transfer Resident #1 because she needed to use the Mechanical lift on another resident. She stated when she entered Resident #1 room the resident lying on the bed and the Hospitality Aide A had the controller in her hand to maneuver Resident #1 in the air to transfer her to the shower chair. She stated CNA C was standing behind the shower chair. When Resident #1 was being assisted in the air and Hospitality Aide A was beginning to maneuver her away from the bed this is when Resident #1 fell to the floor and hit her head on the legs of the Mechanical lift. She stated she immediately left the room to find RN E or any nurse. She stated Hospitality Aide A has been using Mechanical lifts before [DATE]. She stated she was not aware of any in-service being given of the Hospitality Aide job description. CNA D stated someone told her but she did not recall who told her it was ok for Hospitality Aide A to do any type of ADL care including Mechanical lifts on residents since she passed her written test. She stated you do have to past written and skills test to be a CNA. She stated she did know Hospitality Aide A did not pass her skills test. CNA D stated she was not to touch the residents and give any type of care including Mechanical lift if she did not have her CNA certification. She also stated she is not qualified to do Mechanical lifts or any ADL care but she had been doing this before [DATE]. CNA D stated she did not report any concerns about qualifications of Hospitality Aide A to anyone. She stated she knew of two nurse supervisors knowing Hospitality Aide A was assisting with Mechanical lift and doing ADL care. She did not give any names of the nurse supervisors and stated they were not working today ([DATE]). In an interview on [DATE] at 1:10 PM RN E stated Hospitality A and CNA C did not report to her about their concerns of the safety of the sling used on Resident #1. She stated if she had known the staff felt the sling was unsafe, she had new slings she could have given them. She stated she knew Hospitality Aide A was not to use a Mechanical lift. She stated she was not aware when she worked on the hall, she was assigned to that she was assisting with transfer via Mechanical lift or doing any CNA tasks without a CNA assisting her. RN E stated she has worked with Hospitality Aide A several times but did not recall how many times a week or a month. She stated Hospitality Aide A was not qualified to use Mechanical lift or to do any type of care on a resident. RN E stated on the day Resident #1 fell CNA D came out of the room and found me and immediately went to Resident #1's room. She stated Resident #1 was not responsive and within 3 minutes DON, ADON and OTA entered the room and took over while I went to make phone calls to 911, physician, and family. She stated it was her responsibility to monitor the nursing staff working under her on the floor she was assigned to. RN E also stated she knew Hospitality Aide A was working helping CNA C on [DATE] and she did not monitor Hospitality Aide A to ensure she was not doing hands on care. RN E stated Hospitality Aide A was only to pass out ice, answer call lights, assist residents to the dining room and make up beds and this was discussed in an in-service in [DATE]. She also stated she expected all staff to check the slings prior to entering the resident's room for safety of the sling. She stated if the sling was not safe the staff was to report to nurse supervisor and if the nurse supervisor was busy the staff was to go to the ADON or DON and report the sling was not safe to use. In an interview on [DATE] at 1:35 PM LVN I stated she was aware Hospitality Aide A was doing Mechanical lifts over 6 months. She stated she was also doing CNA care alone such as: peri care, showers, grooming, feeding residents, and transfer residents to the bathroom. LVN I stated Hospitality Aide A had been doing everything a CNA does and has been doing these tasks alone except for Mechanical lifts. She stated she was informed that the Hospitality Aide A could do anything that CNAs could do due to recently she passed her written test but failed her skilled test. She stated this does not make her a CNA if she did not pass the clinicals. LVN I stated she was the nurse supervisor and had been a supervisor when Hospitality Aide A worked on her hall. She stated she did not feel she was responsible for monitoring the staff as much as the ADON and DON. She also stated the correct proper chain of command with the CNAs was the nurse supervisor, the ADON and the DON. LVN I stated she did not report Hospitality Aide A was doing Mechanical lift transfers or any other hands-on care to the residents. She stated she assumed everyone knew since the Hospitality Aide had continued to do these tasks after the incident when surveyor U came in the facility around March. She stated the Hospitality Aide A never quit doing Mechanical lifts or any CNA care. She stated she realize after the incident with Resident #1 she should have reported it to upper management. LVN I also stated they had an in-service in [DATE] related to the Hospitality Aides job description. She stated the DON read the job description and explained that Hospitality Aides are only to pass out water, answer call lights, make up beds, can push residents in wheelchairs to activities and to the dining room. The Hospitality Aide was never to do hands on care with any resident. She also stated the staff was required to check the slings before entering the resident's room to ensure they were safe to use. She stated she received in-service on the checking the slings the day of the incident with Resident #1 on [DATE]. In an interview on [DATE] at 2:00 PM the DON stated there were three CNAs in Resident #1's room on [DATE] the day of the incident with Resident #1 was not correct . DON stated in her statement she put there were 3 CNAs in the room and this was not correct. There were 2 CNAs in the room and one Hospitality Aide. She stated there were two CNAs present (CNA C and CNA D). She also stated the other staff was present was Hospitality Aide A. She stated there were never 3 CNAs in Resident #1's room and she did interview the staff that was in the room at the time of Resident #1 falling from the Mechanical lift and she interviewed Hospitality Aide A, CNA C, and CNA D). She stated she in-service Hospitality Aide A after the state investigation in [DATE]. She stated she reviewed the Hospitality Aide job description and explained to Hospitality Aide A not to give any type of direct care including Mechanical lifts to any resident. Her job description was only to pass out ice, make beds, answer call lights, assist residents to the dining room in their wheelchairs, etc. She stated Hospitality Aide A signed the in-service. DON stated she was not aware Hospitality Aide was continuing to perform Mechanical lifts on residents or giving ADL care without another CNA assisting her. She stated no one had reported this to her. She stated the nurse supervisor was to monitor the staff on their halls. The DON also stated she did not follow up on monitoring or designate anyone to monitor Hospitality Aide A after the state investigation of Hospitality Aide A using Mechanical lift in [DATE] and this was part of the facilities plan of correction. She stated if someone had been monitoring Hospitality Aide A the incident with Resident #1 may not have occurred if there was another CNA using the Mechanical lift and reported to someone the sling was damaged. She also stated the sling should not have been used on Resident #1. The DON stated it was not a safe sling and should have been thrown away by staff. She stated that she and another administrator from sister facility completed a facility wide check on all slings. The staff had slings to use that was safe and the facility ordered more new slings on [DATE]. She stated in service began on [DATE] on how to inspect slings for any imperfections prior to every use. Who purchases new slings (DON or Medical supply), what to do if a sling is not in working condition-repot sling, the concerns of chain of command (floor nurse, DON, and then the Administrator), laundry to inspect slings each wash and all remaining slings in the facility was inspected by the DON. There were no further defected slings found in the facility. The DON [TRUNCATED]

Based on interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse of residents for one (Resident #1) of three residents reviewed for abuse. The facility did not implement the Abuse and Neglect Policy when CNA C abused Resident #1 and CNA C was not immediately relieved of duty. This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm. An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. While the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: Record review of the Facility Policy of Resident Abuse/ Neglect, (not dated), reflected This facility will not tolerate resident abuse and neglect. Any reported of suspected abuse or neglect will be thoroughly investigated by administrative staff. The residents in this facility have the right to be free of verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, and/ or injury of unknown source. Definitions: 1. Allegations of Abuse/Neglect (Employees): After investigation is completed, and there is reason to believe that abuse, neglect, or mistreatment of a resident has occurred, the administrator or his/her designee will notify the family, attending physician, medical director, ombudsman, and the licensing agency. The administrator will relieve the employee of duty immediately. 2.Abuse- Any act, failure to act, or incitement to act done willingly, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. 3. Physical Abuse- Physical action within the definition of abuse including, but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 3. Verbal Abuse- The use of any oral, written, or gesture language that includes disparaging or derogatory terms to the resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. Record review of Resident #1's face sheet, dated 06/03/2024, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis with rheumatoid factor, unspecified (a chronic inflammatory disorder that affect more than just your joints), polyosteoarthritis, unspecified (have arthritis in five or more joints at the same time), and scoliosis, unspecified (spine deformity). Record review of Resident #1's BIMS assessment, dated 05/16/2024, reflected Resident #1 had a BIMS score of 15 which indicated her cognition was intact. Record review of Resident #1's Admission MDS Assessment, dated 05/22/2024, reflected Resident #1 had a BIMS score of 11 which indicated her cognitive status was moderately impaired. She required assistance with ADLs such as: bathing, dressing, hygiene, bed to chair transfer, sit to stand transfer, toilet transfer and shower transfer. Resident #1 was assessed to need PRN pain medication. She also had diagnosis of arthritis (joint inflammation) and medically complex conditions (usually involve multiple body systems and are often chronic in nature). Record review of Resident #1's Baseline Care Plan, dated 05/17/2024, reflected Resident #1 was alert and oriented to time, place, and person. She was risk for pain related to scoliosis and other diagnosis. Her bed mobility, dressing, transfers, and toileting required one staff person assist. Record review of Resident #1's Comprehensive Care Plan, dated 05/22/2024, reflected Resident #1 was at risk for injury from decrease in ADLs. Intervention: Administer medication as ordered per the physician. Assess and document pain level. She had impaired physical mobility related to rheumatoid arthritis, and polyarthritis. Intervention: Encourage participation in range of motion exercises and praise accomplishments. Evaluate and treat underlying causes. PT and OT evaluations as needed. Resident is at risk for falls due to impaired mobility. Interventions: Increased staff supervision with intensity based on resident need. Monitor resident's use of side rails when repositioning and resident's ability to safely enter/exit bed. Monitor resident's use / need of side rails per protocol. Record review of Resident #1's facility investigation report reflected the incident occurred on 05/16/2024 at 4:00 AM Resident #1 was interviewable and had capacity to make informed decisions. She had diagnosis of rheumatoid arthritis and polyosteoarthritis. CNA C was described as the perpetrator. Description of the allegation CNA C entered Resident #1's room to change her, CNA C was telling her to sit up, he grabbed Resident #1 by her hands and was assisting her up. Resident #1 asked him (CNA C) to stop because he was hurting her. Staff member (CNA C) kept pulling her up. Assessment of Resident #1 completed by the Director of Nurses reflected there were purple discoloration to the top of right hand between the thumb and index finger. The size of the bruise on Resident #1 right hand was 5.5 cm x 3.0 cm and was tender to touch. There was not treatment provided. The investigation reflected the investigation findings was confirmed. NP, DON, and Administrator was notified. CNA C received one-on-one counseling (date counseling was completed not indicated on the facility investigation report) and was to return to facility and reassigned to work on another hall where Resident #1 was not residing. CNA C was reeducated on resident rights, abuse, and neglect. Resident wanted to notify her family. Investigation was completed by the Administrator and Director of Nurses. Record review of CNA C's time sheet reflected he was allowed to return to work the night of 05/16/2024. Record review of CNA C's disciplinary action dated 05/22/2024 reflected CNA C had a final written warning for performance and policy violation. Details of the incident: see self-report (gave the intake number of this investigation). Methods by which the employee can correct the unsatisfactory behavior: No further C/O abuse by residents. Consequences: Termination. Time frame for improvement: Remaining Employment. Employee Signature: Via Phone date: -5/22/2024. Preparer's signature: Director of Nurses date: 05/22/2024. In an interview on 06/03/2024 at 2:00 PM Resident #1 stated she was happy someone was here to investigate what happened to her when she was admitted to this facility. She stated she had not seen CNA C and she hoped she never saw him for the rest of her life. Resident #1 stated if she saw him she did not know what she would do but try to get away from him. She also stated she was afraid that morning when he was pulling her hands and she kept asking him to stop. She stated her hand did hurt and she asked for a pain pill for her hand. She stated the nurse worked the same time as CNA C did not ask her anything what happened. She stated she wanted to look at her skin and did not understand what she was wanting to look at. She did not ask to look at her hands. Resident #1 stated if the nurse (LVN D) asked her to look at her hands she would have let her. Resident #1 stated she did not understand why the CNA C did not stop when she told him to stop he was hurting her hands. She stated she interviewed staff and asked them questions before she allows anyone to touch her. Resident #1 stated she was lying in bed asleep when CNA C came in the room and kept on wanting her to sit up on the bed and be changed. She stated she did not trust him by the way he talked to her in a loud tone and was not treating her like a human. Resident #1 stated he kept pulling on her hands and then told me he rather for me to hurt than from him to get hurt. She stated no one had ever treated me so bad like he did early that morning. She stated she had only been in the facility less than 24 hours. Resident #1 also stated when CNA C said to her he rather for her to hurt than for him to get hurt, she stated she felt he was the meanest person to say something like that to an elderly lady who could not care for herself. She stated it made her mad and she became more afraid of CNA C after he said he did not care if she hurt as long as he did not hurt. Resident #1 stated she did not see him again after that night he pulled on her hands. In an interview on 06/03/2024 at 3:10 PM the Director of Nurses stated she completed the investigation of the incident with Resident #1 and CNA G. She stated abuse was confirmed during the investigation. The Director of Nurses stated Resident #1 did have difficulty trusting staff and would talk to the staff before she agreed for any type of care given to her. She also stated LVN A reported the incident to her after LVN A assessed Resident #1. She stated she completed investigation on 05/16/2024 and determined abuse did occur with Resident #1 from CNA C. She stated Resident #1 was afraid CNA C was going to harm her such as: break her hand or pull her shoulder out of socket. Director of Nurses stated Resident #1 did not come out of her room approximately 1-2 weeks after the incident 05/16/2024. She stated she would speak to each staff who entered her room and would not allow them to give her care until she felt safe and the staff reassured her they would not hurt her. The Director of Nurses stated CNA C was counseled via phone on 05/22/2024. She stated the investigation was completed on 05/16/2024 and she did not counsel with him and give him a written disciplinary action until 05/22/2024 via phone. She stated she should have spoken to him face to face when she gave him the disciplinary action. The Director of Nurses stated she did not recall the reason the disciplinary action was not completed on 05/16/2024 after the investigation. She stated according to the facility policy he should have been terminated immediately and the abuse was violation of their abuse and neglect policy. In an interview on 06/03/2024 at 3:45 PM The Administrator stated he did sign the investigation report and it was confirmed Resident #1 was abused by CNA C. He stated CNA C had not been accused of abusing anyone in the facility until now. The Administrator also stated he believed CNA C had only been confirmed abuse one time and the Administrator did not agree with terminating him at that particular time. He stated according to the policy the facility was required to terminate CNA C immediately. The Administrator was notified on 06/03/2024 at 8:19 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 06/05/2024 at 06:01 PM: On 06/03/2024, an abbreviated survey was initiated at the facility. On 06/03/2024, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy states as follows: F607 The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents. CNA A- attempted to transfer Resident #1 from her bed by pulling her by her arms and hands causing bruising to the resident. The facility failed to follow their policy when physical abuse was confirmed. Action: On 6/04/2024, the DON designated an LVN to make a referral to Psychological Care, and Resident #1 was evaluated by their psychologist. The psychologist reported to the DON on 6/04/2024 that resident was doing great. The psychologist will continue to visit with resident until she discharges her from psychological services. On 6/04/2024, the DON assessed the resident's hands where injuries occurred during transfer. DON stated that the resident has no more pain and that the injuries are in the final stages of healing. No follow-up will be needed for the bruises on the resident's hands. The DON and administrator will be reeducated on pain and skin assessments and following proper policies & procedures by outside DON on 6/05/2024. Starting 6/04/2024, The Director of Nursing (DON) or designee will reeducate all nursing staff on triggers to notice when a resident is in pain and what steps need to be taken. C.N.A.'s will be trained by the DON or designee on how to observe a resident that is grimacing in pain. The C.N.A. must notify the charge nurse immediately. The charge nurse should evaluate the resident for pain and take appropriate measures including documenting under pain assessment. If the resident has orders in place for pain management, then the charge nurse is to follow orders and follow-up an hour after treatment is provided to determine if treatment was successful. If current orders do not seem to be effective, then the charge nurse is to call the attending physician for further treatment/recommendations. All of this will be documented in the resident's progress notes and chart reports. The ADON or designee will monitor all reported pain assessments, via the 24-hour reports 4-5 days per week, to ensure that policies and procedures are being followed appropriately by the nursing staff. The ADON will report her findings to the DON and/or administrator weekly unless she finds noncompliance. If noncompliance is found, she will report immediately to the DON and/or administrator. Starting 6/04/2024, The DON or designee will in-service all nursing staff on when providing a thorough skin assessment is necessary and expected, such as upon admission, if a bruise or skin tear is noticed for the first time on a resident, if resident complains of roughness or states they were abused. The charge nurse will be responsible for completing and documenting a thorough skin assessment, incident report and calling the physician for orders, if necessary. Along with a skin assessment, a pain assessment must always be performed to determine the pain level of the resident. If it is determined that the resident is in pain, then the procedures for pain treatment must be followed by the charge nurse. The ADON or designee will monitor all reported bruises / skin tears to ensure company policies and procedures are followed thoroughly. Findings will be reported weekly to the DON and/or administrator unless she discovers violation of policy. If violation of company policy is found, then she will report immediately to the DON and/or administrator. Starting 06/04/2024, The DON or designee will in-service and retrain staff on policy and procedures of transfers. Safe transfers must be performed by all staff who work in patient care areas. All CNA's and nurses are required to follow transfer procedures. Education will include stand by, one person assists, 2 person assist, sliding board, sit to stand (Sara lift), Hoyer lift, and the stand and pivot. Return demonstration will be provided by the trainee to confirm understanding. The ADON or designee will monitor 4-5 transfers per week for 3 months to verify company policies and procedures are followed thoroughly. Findings will be reported to the DON and/or administrator weekly unless noncompliance is observed. If noncompliance is observed, then she will report immediately to the DON and/or administrator. The facility administrator and DON will be reeducated by outside administrator on company policies and procedures regarding resident abuse. The administrator, who is the abuse coordinator, or designee will in-service all facility staff on company policies and procedures regarding resident abuse/neglect. Administrator and DON will thoroughly review company policy and procedures regarding resident abuse and neglect for retraining purposes. If an employee witnesses an abuse allegation or if an employee is told that a resident is abused/neglected by a resident/family member or visitor, the employee will be trained by the administrator or designee to report the allegation, immediately to the administrator. If the administrator is unavailable, then the employee is to report the allegation to their immediate supervisor. It is then the supervisor's responsibility to notify the administrator. It is then the administrator's responsibility to ensure that all of the proper steps are completed, and a thorough investigation is completed, after reporting the allegation(s) to HHSC. The administrator or designee are responsible for completing the investigation and sending in the final report to HHSC in accordance with state regulatory requirements. If any of the staff are unavailable for training sessions by 6/7/2024, then each employee, including agency staff will not be able to work on the floor until they have gone through the appropriate training. C.N.A. A has been terminated from employment by the administrator, effective 6/04/2024. Start Date: 06/04/2024. Completion Date: The above will be completed by 6/7/2024. Responsible: Administrator, DON and ADON Record review on 06/06/2024 of the inservice on Resident Abuse/Neglect Policy, dated 06/04/2024, reflected 67 staff was inserviced on the abuse and neglect policy by the Administrator and DON. Record review on 06/06/2024 of CNA C personnel record reflected he was terminated on 06/04/2024. Interview on 06/06/2024 at 11:03 am the DON stated she was reeducated on pain and skin assessments and the proper policies and procedures by DON K from a sister facility. She stated she was inserviced when pain and skin assessments were to be completed after an incident with a resident. The DON stated a pain and or skin assessment should be reported when any new skin findings or abnormalities are discovered, or resident has new complaints of pain or if resident falls. The DON stated if this occurred, a skin and pain assessment should be completed, and resident should be evaluated head to toe including any report of abuse or neglect. She also stated nurses were to evaluate pain, look at non-verbal grimacing, verbal screaming, the nurses had a scale of 0 - 10 to use on residents who are verbal. She also stated reporting should be completed when there was bruises from an unexplained injury within 2 hours of discovery. The DON also stated the nurses was expected to document in the chart any administration of pain medication as ordered or needed and to notify the physician. She also stated the CNAs was expected to immediately report any abuse/neglect, change of condition or pain to the charge nurse. She stated she was in-serviced on abuse and neglect and read over the policy. She stated she learned the facility had five days to complete investigation and send in the report to HHSC. She stated if anyone reported abuse or neglect to her or the Administrator they had 2 hours to resport it to HHSC. She sated the Administrator was the abuse and neglect coordinator. The DON also stated the staff was expected and had been in serviced to report any signs of abuse or neglect to the Abuse Coordinator, the Administrator. On 6/6/2024 at 1:57 am the Administrator revealed he was reeducated on pain and skin assessments and the proper policies and procedures by RN K DON and Administer M at a sister facility. He learned pain and skin assessment should be complete anytime anything is noticed on a resident that has not been seen before. If it is noticed by the CNA, it should be report to the nurse immediately. If the CNA sees something that is red on the resident's body, and it is new it needs to be reported to the charge nurse. The charge nurse should then do a head-to-toe assessment and a pain assessment. He was also in-serviced in abuse and neglect. If someone is dismissed for abuse or neglect, the facility needs to report it to the licensing authority within 5 days. He will report abuse and neglect to HHSC as soon as possible as soon as he can get his computer up and running. On 06/06/2024 at 6:50 PM, the Administrator was notified the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained at a level of with potential for more than minimal harm that is not immediate jeopardy at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure staff did not use physical abuse or corporal punishment on a resident for one of three residents (Resident #1) reviewed for abuse. CNA C pulled Resident #1's hands and refused to stop when Resident #1 repeatedly stated to stop and there was a bruise on Resident #1's right hand after CNA C pulled on her hand. Resident #1 stated CNA C was hurting her while attempted to transfer her from lying position in bed to sitting position on the side of bed. Resident #1 was afraid of CNA C and isolated self in room after the incident. An Immediate Jeopardy (IJ) situation was identified on 06/03/2024 at 8:19 PM. While the IJ was removed on 06/06/2024 at 6:50 PM, the facility remained out of compliance at a severity of no actual harm that is not immediate and a scope of isolated. This failure placed residents at risk for injury, harm, psychosocial harm, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 06/03/2024, reflected Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of rheumatoid arthritis with rheumatoid factor, unspecified (a chronic inflammatory disorder that affects more than just your joints), polyosteoarthritis, unspecified (have arthritis in five or more joints at the same time), and scoliosis, unspecified (spine deformity). Record review of Resident #1's BIMS assessment, dated 05/16/2024, reflected Resident #1 had a BIMS score of 15 which indicated her cognition was intact. Record review of Resident #1's Admission Assessment, dated 05/22/2024, reflected Resident #1 had a BIMS score of 11 which indicated her cognitive status was moderately impaired. She required assistance with ADLs such as: bathing, dressing, hygiene, bed to chair transfer, sit to stand transfer, toilet transfer and shower transfer. Resident #1 was assessed to need PRN pain medication. She also had diagnosis of arthritis (joint inflammation) and medically complex conditions (usually involve multiple body systems and are often chronic in nature). Record review of Resident #1's Baseline Care Plan, dated 05/17/2024, reflected Resident #1 was alert and oriented to time, place, and person. She was at risk for pain related to scoliosis and other diagnosis. Her bed mobility, dressing, transfers, and toileting required one staff person assist. Record review of Resident #1's Comprehensive Care Plan, dated 05/22/2024, reflected Resident #1 was at risk for injury from decrease in ADLs. Intervention: Administer medication as ordered per the physician. Assess and document pain level. She had impaired physical mobility related to rheumatoid arthritis, and polyarthritis. Intervention: Encourage participation in range of motion exercises and praise accomplishments. Evaluate and treat underlying causes. PT and OT evaluations as needed. Resident is at risk for falls due to impaired mobility. Interventions: Increased staff supervision with intensity based on resident need. Monitor resident's use of side rails when repositioning and resident's ability to safely enter/exit bed. Monitor resident's use / need of side rails per protocol. Record review of Resident #1's Nurses Notes, dated 05/15/2024 at 9:24 PM reflected Resident #1 was admitted to the facility. She had a bruise on top of her right-hand brown in color. (there was not a skin assessment completed on 05/15/2024). Signed by LVN F. Record review of Resident #1's facility Admission Record, dated 05/16/2024, reflected Resident #1 responded to commands. She was alert and oriented to person, place, time, and situation. Resident #1's right and left-hand grasp were weak. Her left and right foot press strength was also weak. Record review of Resident #1's facility investigation report reflected the incident occurred on 05/16/2024 at 4:00 AM Resident #1 was interviewable and had capacity to make informed decisions. She had diagnosis of rheumatoid arthritis and polyosteoarthritis. CNA C was described as the perpetrator. Description of the allegation CNA C entered Resident #1's room to change her, CNA C was telling her to sit up, he grabbed Resident #1 by her hands and was assisting her up. Resident #1 asked him (CNA C) to stop because he was hurting her. Staff member (CNA C) kept pulling her up. Assessment of Resident #1 completed by the Director of Nurses reflected there were purple discoloration to the top of right hand between the thumb and index finger. The size of the bruise on Resident #1 right hand was 5.5 cm x 3.0 cm and was tender to touch. There was not treatment provided. The investigation reflected the investigation findings was confirmed. NP, DON, and Administrator was notified. CNA C received one-on-one counseling (date counseling was completed not indicated on the facility investigation report) and was to return to facility and reassigned to work on another hall where Resident #1 was not residing. CNA C was reeducated on resident rights, abuse, and neglect. Resident wanted to notify her family. Investigation was completed by the Administrator and Director of Nurses. Record review on 06/03/2024 of Resident #1's nurses note dated 05/16/2024 at 4:24 AM reflected Resident #1 was in bed resting with eyes closed, unlabored breathing with no facial grimacing noted and arouses without difficulty. Resident #1 is alert and oriented. She is capable of verbalizing her needs. (has numbers for vitals but does not describe what type of vitals was completed). Unable to assess skin integrity at this time related to Resident #1 refusal. Signed by LVN D Record review of Resident #1's MAR reflected on 5/16/2024 LVN D administered PRN pain medication a 6:43 AM. Resident #1 pain was at an eight (on 1 being the lowest pain and 10 being highest in pain). Record review of Resident #1's nurses notes dated 05/16/2024 at 9:15 AM (recorded as a late entry on 05/22/2024 at 6:32 PM) reflected DON called to room for assessment. Resident voiced concerns with aide on previous shift. DON conducted assessment and found purple discoloration to top of right hand between the thumb and index finger. 5.5 cm x 3.0 cm. Tender to touch. Declined pain medication. NP notified of findings on exam. Signed by Director of Nurses. Record review of Resident #1's statement to the Director of Nurses on 05/16/2024 at 9:25 AM reflected he walked in and I've (Resident #1) had never done this before. He asked what do you need? Resident #1 stated she could probably go to the bathroom. He asked me if my clothes needed to be changed. Resident #1 stated if they need to. She also stated he changed my pants and got another pair of pants out of the closet. He was going to change my pants He stated to get up. He was very rude. Resident #1 stated her right wrist was sore. Resident #1 stated the CNA told her if I don't hurt you, I will hurt myself. She asked for someone else, the CNA stated he was the only one here. Record review of CNA C's written statement dated 05/16/2024 at 5:01 PM reflected CNA C went in Resident #1 room during normal rounds. She stated she wanted to get up for the day. She was trying to find her call light but was unable to locate the call light. He stated it was attached to her right-side rail and was within reach. He stated he asked her are you sure you want to get up and she stated yes. CNA C stated he picked out a pair of pants and a shirt. He stated her brief was wet and he changed her brief. He stated he was putting on her socks and she stated Owe. CNA C also stated he was putting her pants on her and rolled her to her side and she stated, 'Owe like something hurt. He stated this was his first time working with Resident #1 and he did not know if she was in actual pain. He stated he asked her if she still wanted to get up and she said yes. He stated he assisted her in sitting position on the side of the bed. Resident #1 stated she needed something to hold on to in order to sit up on her own. Resident #1 decided she did not want to get up and I assisted her to lay back down on the bed. CNA C stated he was in her room over 20 minutes and he ensured call light was within reach and he left the room. Record review of Resident #1's nurses note dated 05/16/2024 at 9:05 PM reflected Resident #1 continued to follow up for new admission from the assisted living. She is very pleasant and alert and oriented x 3 (person, place, and time). She is cooperative with care. Resident #1 had a small open area to her upper back with a band aid covering the area. When the band aid was removed prior to giving her a shower and a new band aid was applied to residents back after her shower. There was very minimal drainage noted to the area on her back. Resident #1 required extensive assistance of one staff for transfers. Resident's care remains ongoing. Written by LVN E. Record review of Resident #1's electronic medical record reflected incident/ accident report, pain assessment, skin assessment or nurses' notes was not completed on 5/16/2024 after the incident was first reported to LVN A by CNA I LVN A did document Resident #1's vital signs on 05/16/2024 at 10:03 AM. Record review of Resident #1's nurses note on 05/17/2024 at 1:56 PM reflected Resident #1 was a new admit. Resident #1 was assisted by one staff with transfers and toileting (incontinent of bladder). She was having difficulty adjusting to new environment and the need to ask for help. Resident #1 refused to come out of her room for activities and to eat in the dining room. Record review of Resident #1's nurses note from 05/17/2024 through 06/04/2024 did not mention her bruise or if she was in pain, having depression, or change in her emotional status from the incident on 05/16/2024. There were no follow-up notes to the incident with bruising on her hand on 05/16/2024. Record review of Resident #1's nurses note on 06/04/2024 at 1:24 PM reflected there was a referral for supportive care for emotional distress. Supportive services in the facility today and will visit the resident and will obtain consent for visits. Signed by LVN H. In an interview on 06/03/2024 at 8:45 AM the Director of Nurses stated she needed to ensure CNA C gave a more descriptive interview. She stated she did not want to use leading questions. The Director of Nurses stated she needed to have asked more questions to understand in detail how he assisted her from laying position to a sitting position. Record review of LVN A's written statement (not dated) reflected LVN A received a report from Resident #1 stated CNA C was rude and rough with her. Resident #1 stated CNA C entered her room to assist with toileting and dressing early this AM. (no date on the statement). Resident #1 stated during CNA C assisting her he was pulling on her hands and arms and telling her to get up. Resident #1 stated she expressed several times he was hurting her and CNA C stated he did not want to hurt his back. Resident #1 requested to be assisted by another staff and CNA C stated he would get someone for her and he left the room and did not get anyone else to come to my room at assist me. Resident #1 stated she had bruising on her hand and the bruise was not present last night when she fell asleep. Resident #1 requested a male aide not enter her room. LVN A stated she received a verbal report from LVN D. LVN A stated in the report LVN D stated Resident #1 voiced aide was moving too fast and was rough. LVN D stated she spoke to CNA C to be mindful of how he was providing assistance. In an interview on 06/03/2024 at 9:15 AM Resident #1 stated she was admitted to this facility from assisted living center owned by the same company. She stated she was admitted late afternoon on 05/15/2024. She stated during the early morning on 5/16/24 between around 3:00AM- 4:00 AM a male staff came into her room and asked her if she needed to be changed. She stated she explained to him she thought she needed to be changed but she would rather be changed later. Resident #1 stated he would not stop asking her and she finally told him to go ahead and change her. She stated he was standing at an angle by her bed and grabbed her hands and began pulling her from a laying position and attempted to pull her to sit on the side of the bed. Resident #1 stated she began to tell him he was hurting her and to stop. She stated she kept explaining to him he was hurting her and to stop. Resident #1 stated he continued to pull her hands attempting to sit her up on the side of the bed. She also stated when she kept saying you are hurting me please stop the CNA stated, I rather for you to hurt than for me to get hurt. She stated later he stated again I rather for you to hurt than for me to hurt my back. Resident #1 stated she was afraid of him. She stated she thought he was going to hurt her. Resident #1 stated she believed he was going to pull her arm out of socket he was pulling on her that hard. She also stated she was afraid he was going to break her wrist or bones in her hands or arm. Resident #1 stated she had been in hospitals and in nursing facilities but she had never experienced any type of treatment the CNA gave me. She stated she requested another aide to assist her and he explained he was the only one on duty. Resident #1 also stated he left her room and never sent anyone else in her room to assist her. She stated she described him to the Director of Nurses and another nurse worked the morning on 05/16/2024. She stated she found out CNA C was the one who hurt me. Resident #1 stated she had a bruise on her right hand and it was not there when she went to bed when she was admitted to the facility the day before. She also stated it was a new bruise and it was painful in the area where the bruise was located. Resident #1 stated a nurse came in before 7:00 AM and gave her some medication for pain. She stated the nurse who gave her the medication was the nurse that worked with CNA C. Resident #1 stated the nurse never came in her room until after the incident and wanted to see my skin. She stated she asked her why she needed to see her skin. She stated the nurse that worked the same time with CNA C stated it was something she did with everyone. Resident #1 stated she asked her about her furniture in her room. She also stated the nurse never looked at her hands. She was wanting to see her legs for something and I told her I did not have any of that on my legs. Resident #1 stated it had something to do with cells or something like that. She stated I never understood what she was wanting to look at my skin and not my hands where he had pulled on my hands. She stated she was not very clear of what she wanted to look at on her and she was afraid to let anyone touch her at that time due to being hurt by the aide. She stated she was not going to allow anyone that morning to touch her until she saw someone in charge. Resident #1 stated she was afraid to go to sleep and she did not know what the aide may do to her if he decided to move her again. She also stated she did not appreciate the tone of voice he used and making a statement he rather for me to hurt than for him to get hurt. Resident #1 stated that made me mad and she did not want to be around him. Resident #1 stated he is working on another hall and came back to work the very night this all happened to me. She stated she was afraid if she did see him in the hall and was afraid he would do something to her for reporting him. Resident #1 also stated she was so worried about the women he was taking care of on the other halls. She stated what if they cannot speak up for themselves and he hurts someone else. Resident #1 stated someone like him did not need to be taking care of anyone in a nursing home. She stated it has taken her 2 weeks or more to trust anyone in this facility. She stated when anyone comes in her room to give her care she begs them not to hurt her. She stated she asks them a lot of questions before she will agree for them to give her care. Resident #1 stated there were 2 or 3 staff that takes care of her now and she trusts them and one is a male. She said he was so gentle with her and was so good to her. She stated she did not trust not one person in the facility because she felt since they let him come back in that facility the management did not take this abuse seriously and she stated she did consider she was abused by the male aide that worked on her hall morning of 05/16/2024 and she stated his name was (she stated his name) and it was CNA C. In an interview on 06/03/2024 at 9:57 CNA J stated she had given care to Resident #1. CNA J stated Resident #1 did not trust anyone and would ask staff to please don't hurt her or give her a bruise (Resident #1). CNA J stated Resident # 1 would talk to the staff and ask the staff questions before she would allow any staff to give her care. CNA J also stated Resident #1 trusted most staff but it was approximately 2 weeks after she was admitted to the facility before she trusted anyone. She stated Resident #1 would state the male aide hurt my hands and gave me a bruise and don't hurt me like hurt me. In an interview on 06/03/2024 at 10:40 LVN A stated LVN D gave her verbal report at the change of shift the morning of 05/16/2024. She stated during the morning report LVN D stated Resident #1 stated CNA C was rough with her and moved too fast. LVN D stated if a staff is being rough with a resident during care that would be potential abuse. LVN D stated CNA I came to her and reported Resident #1 was making accusations of an aide hurting her hands and there were bruises on her hand. LVN A stated she went to Resident #1's room and observed a new bruise on top of her right hand between the thumb and index finger. She stated Resident #1 reported to her that the male aide worked last night and early this morning (05/16/2024) came into her room between 3:00 AM and 4:00 AM and asked her if she needed to be changed. She stated Resident #1 informed her CNA C grabbed her hands and attempted to transfer her from lying position to a sitting position by grabbing her hands and pulling on her hands. LVN A stated during interview with Resident #1 of what created the bruise on her hand, she stated CNA C would not stop when she asked him to stop pulling her hands because he was hurting her. She stated Resident #1 repeatedly stated you are hurting me and stop. LVN A also stated Resident #1 informed her CNA C stated, I rather for you to hurt than for me to get hurt. LVN A stated she did consider this physical and verbal abuse. She stated Resident #1 was afraid and stated she did not want any males in her room to give her care. LVN A also stated she was alert and oriented to person, place, time, and situation on the morning of 05/16/2024. She also stated Resident #1 did not trust staff in giving her care or come out of her room approximately 1-2 weeks after the incident with CNA C on 05/16/2024. LVN A stated Resident #1 would ask each staff who entered her room not to hurt her or give her a bruise. LVN A stated she did not trust anyone and would talk to the staff and question them before she would allow anyone to do any type of care for her. In an interivew with Resident #1's R/P on 06/03/2024 at 11:30 AM she stated Resident #1 was afraid of CNA C and she repeated the same report of what occurred when CNA C pulled on her hands the early morning of 05/16/2024. She stated her mother (Resident #1) had been in the facility less than 24 hours. She also stated Resident #1 would not come out of her room approximately 1 week or more due to being afraid of CNA C and was afraid he may retaliate against her for reporting the incident of abuse. In an interview on 06/03/2024 at 11:50 AM LVN D stated she was not aware any incident occurred with Resident #1 during her shift on 05/15/2024-05/16/2024. She stated CNA C did not report anything to her. LVN D stated she went to Resident #1 during her shift sometime after midnight to check on her. LVN D stated she could not remember her nurses note documented on 05/16/2024 at 4:24 AM. She stated (after her nurses note read to her) she went in Resident #1's room to check Resident #1's skin. LVN D stated she is expected to check residents' skin before 4:00 AM if it is required to be checked. She stated Resident #1 had diagnosis of cellulitis (a common skin infection caused by bacteria), and was ordered medication for the cellulitis. LVN D stated she was required to check the area of cellulitis. She stated this is what she meant in her note when it stated to assess skin integrity. She stated she went in Resident #1's room to check the area of cellulitis. She stated Resident #1 did refuse and she did not go back to her room to check her skin. LVN D stated she did not recall why she spoke to CNA C related to being mindful of the care he was giving to Resident #1. She stated later in the morning (05/16/2024) around 6:00 AM she spoke with Resident #1 about if she had been abused. She stated she did not know the reason she asked her that question and that was something they ask new admission residents. LVN D stated Resident #1 denied being abused and they talked about her personal items in her room. LVN D stated she did not ask Resident #1 if anything happened to her earlier in the morning. She stated she did not believe there was a reason to ask Resident #1 any questions about if anything occurred with her and CNA C due to nothing had been reported to her of any type of incident. LVN D stated she did give a verbal report to LVN A at the change of shift but did not recall what she reported to LVN A. She also stated she did not know why Resident #1 was in pain around 6:45 AM on 05/16/2024. She stated she did remember giving her a pill for pain but did not recall why Resident #1 was in pain. Record review of Resident #1's medical diagnosis in the electronic medical record revealed she does not have a diagnosis of cellulitis. In an interview on 06/03/2024 at 12:50 PM CNA I stated she was taking care of Resident #1 the day shift on 05/16/2024. She stated on 05/16/2024 when she entered Resident #1's room, she was not smiling and had a grimace expression on her face and immediately stated don't hurt me. CNA I stated when she spoke to Resident #1 she began saying please don't give me a bruise and hurt me. CNA I also stated Resident #1 expressed to her that she did not trust anyone in the facility. CNA I stated Resident #1 explained to her a male CNA was in her room between 3:00 AM-4:00 AM early in the morning (on 5/16/2024) and asked her if she needed assistance. CNA I stated Resident #1 kept rubbing her hands and explained the male CNA pulled on her hands when he tried to pull her up from lying in the bed to sit on the side of the bed. CNA I stated Resident #1 informed her she told the male aide to stop and he was hurting her and he would not stop pulling her hands. CNA I also stated Resident #1 explained the male aide told her I rather for you to hurt than for me to get hurt. CNA I stated she observed a bruise on her right hand on top of hand near her thumb and the finger beside the thumb. She stated Resident #1 told her it was hurting but she got something for pain. CNA I stated she reassured Resident #1 she would not hurt her and would be very slow giving her care. CNA I stated she found LVN A and reported to her what Resident #1 told her and LVN A went to Resident #1 and assessed her. CNA I stated for approximately 2 weeks after the incident on 05/16/2024 with Resident #1, she would state to every staff who entered her room please don't hurt me and give me a bruise and would repeat please don't hurt me. CNA I stated Resident #1 would talk with staff before she would allow them to do anything for her. She also stated Resident #1 did not come out of her room or interact with anyone but her family approximately 1-2 weeks after the incident on 05/16/2024. In an attempted interview with CNA C on 06/03/2024 at 1:20 PM attempted to call CNA C and left voice message. In an attempted interview with CNA C on 06/03/2024 at 3:00 PM attempted to call CNA C and left a voice message. In an interview on 06/03/2024 at 3:10 PM the Director of Nurses stated she completed the investigation of the incident with Resident #1 and CNA C. She stated abuse was confirmed during the investigation. She stated Resident #1 had a BIMS score of 15 which indicated her cognitive status was intact. She also stated Resident #1 reported the same event that occurred with CNA C each time she had spoke to her. The Director of Nurses stated Resident #1 did have difficulty trusting staff and would talk to the staff before she agreed for any type of care given to her. She also stated LVN A reported the incident to her after LVN A assessed Resident #1. She stated she completed investigation on 05/16/2024 and it was confirmed abuse did occur when CNA C pulled on Resident #1's hands when Resident #1 asked CNA C to stop numerous times. She stated Resident #1 was afraid CNA C was going to harm her such as: break her hand or pull her shoulder out of socket. Director of Nurses stated Resident #1 did not come out of her room approximately 1-2 weeks after the incident 05/16/2024. She stated she would speak to each staff who entered her room and would not allow them to give her care until she felt safe and the staff reassured her they would not hurt her. She stated she agreed Resident #1 was reporting exactly what happened early morning of 05/16/2024 and she was physically and verbally abused by CNA C. In an interview on 06/03/2024 at 3:45 PM The Administrator stated he did sign the investigation report and it was confirmed Resident #1 was abused by CNA C. He stated he did speak to Resident #1. The Administrator did not elaborate on the details of their conversation. He stated he was not aware of CNA C making a statement he rather for Resident #1 to hurt than for him to hurt. He stated he was not aware of this statement until 06/03/2024. Record review of the Facility's Resident Abuse/ Neglect Policy (not dated) reflected This facility will not tolerate resident abuse and neglect. Any reported of suspected abuse or neglect will be thoroughly investigated by administrative staff. The residents in this facility have the right to be free of verbal, sexual, physical, or mental abuse, corporal punishment, involuntary seclusion, and/ or injury of unknown source. Definitions: 1. Abuse- Any act, failure to act, or incitement to act done willingly, knowingly, or recklessly through words or physical action which causes or could cause mental or physical injury or harm or death to a resident. 2. Physical Abuse- Physical action within the definition of abuse including, but not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. 3. Verbal Abuse- The use of any oral, written, or gesture language that includes disparaging or derogatory terms to the resident or within the resident's hearing distance, regardless of the resident's age, ability to comprehend, or disability. The Administrator was notified on 06/03/2024 at 8:19 PM, that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 06/05/2024 at 06:01 PM: On 06/03/2024, an abbreviated survey was initiated at the facility. On 06/03/2024, the surveyor provided an Immediate Jeopardy (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. Plan of Removal for F600 The facility failed to ensure that the resident was free from Abuse. CNA C attempted to transfer Resident #1 from her bed by pulling her by her arms and hands causing bruising to the resident. The facility failed to assess and document the injuries of Resident #1 after advising staff her hand was tender to touch. The facility failed to immediately assess Resident #1 after the allegation of physical abuse was made to LVN A. Action: On 6/04/2024, the DON designated an LVN to make a referral to Psychological Care, and Resident #1 was evaluated by their psychologist. The psychologist reported to the DON on 06/04/2024 that resident was doing great. The psychologist will continue to visit with the resident until she discharges her from psychological services. On 06/04/2024, the DON assessed the resident's hands where injuries occurred during transfer. DON stated that the resident has no more pain and that the injuries are in the final stages of healing. No follow-up will be needed for the bruises on the resident's hands. Starting 06/04/2024, The DON or designee will in-service and retrain nursing staff on policy and procedures of transfers. Safe transfers must be performed by all staff who work in patient care areas. All CNA's and nurses are required to follow transfer procedures. Education will include stand by, one person assists, 2 person assist, sliding board, sit to stand (Sara lift), Hoyer lift, and the stand and pivot. Return demonstration will be provided by the trainee to confirm understanding. The ADON or designee will monitor 4-5 transfers per week for 3 months to verify company policies and procedures are followed thoroughly and report findings to the DON and/or administrator weekly. Starting 06/04/2024, The DON or designee will in-service and re-educate all nursing staff on when resident physical assessments should be completed, and appropriate documentation made. If a resident makes any type of physical abuse allegation, then a complete head-to-toe physical assessment must be completed by the charge nurse. If injuries are found on assessment, appropriate documentation in observations and progress notes should be made as well as documentation of provider informed. Progress notes should be made on each shift by the charge nurse stating a detailed update on the injury site. Staff will be educated on when families should be informed of injuries or findings in a timely manner. The DON and administrator will be reeducated on pain and skin assessments and following proper policies & procedures by outside DON on 06/05/2024. Starting 06/04/2024, The Director of Nursing (DON) or designee will reeducate all nursing staff on triggers to notice when a resident is in pain and what steps need to be taken. If a C.N.A. observes a resident grimacing in pain, then he/she must notify the charge nurse immediately. The charge nurse should evaluate the resident for pain and take appropriate measures. If the resident has orders in place for pain management, then the charge nurse is to follow orders and follow-up an hour after treatment is provided to determine if treatment was successful. If current orders do not seem to be effective, then the charge nurse is to call the attending physician for further treatment/recommendations. If a resident makes an allegation of physical abuse, then the charge nurse is to immediately complete a head-to-toe assessment on the resident and document his/her findings on the resident's skin. The ADON or designee will monitor all reported pain assessments, via the 24-hour reports 4-5 days per week, to ensure that policies and procedures are being followed appropriately by the nursing staff. The ADON will report her findings to the DON and/or administrator weekly unless she finds noncompliance. If noncompliance is found, she will report immediately to the DON and/or administrator. Start Date: 06/04/2024. Completion Date: The above will be completed by 06/07/2024. Responsible: Administrator, DON and ADON Monitoring: Record review on 06/06/2024 of the in-service on abuse/neglect reflected the Administrator and the Director of Nurses was in serviced by Administrator M and DON/RN K from a facility owned by the same company. They were in serviced on the following: 1. Types of Abuse and Neglect such as verbal, physical, mental, emotional, sexual, exploitation, and neglect. 2. Procedure for suspected abuse and/or neglect. 3. Signs of abuse and /or neglect 4. Training, reporting, response, investigation [TRUNCATED]

Based on observation, record review, and interview, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one of three residents (Resident #49) reviewed for pain management. The facility failed to ensure Resident #49 was assessed, monitored, and received pain medication prior to wound care provided for a cancerous open lesion on the left side of her face. This failure could place all residents at risk for unnecessary pain and discomfort. Findings included: Review of the undated face sheet for Resident #49 reflected she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) exacerbation, Vascular Dementia (brain damage caused by multiple strokes, causes memory loss in older adults), Cognitive Communication Disorder (difficulty communicating because of injury to the brain that control ability to think) and Malignant Neoplasm (cancerous growth) of unspecified site of unspecified female breast. Resident # 49 was noted to be on hospice services (a type of health care that focuses on the palliation [to reduce the intensity or severity] of a terminally ill patients' pain and symptoms) and had a DNR - Do Not Resuscitate - order on file. Review of the quarterly MDS dated [DATE] for Resident #49 reflected a BIMS score of 99 as the resident was unable to complete the interview. Review of the Care Plan dated 08/16/2023 for Resident #49 reflected Problem: I am being seen by wound care for a malignant area on my left side of face. Current measurements as of 08/22/2023 5.0 X 3.0 X 1.5 cm. Goal: Wound to heal without complications, Approach: Wound care to be performed according to orders. Problem: 02/17/2023 I have impaired cognitive function r/t BIMS score less than 13 and my dx of Vascular Dementia. Approach: Ask yes/no questions in order to determine the resident's needs. Review of Physician's orders dated 08/22/2023 for Resident #49 reflected Acetaminophen [OTC] tablet; 500 mg; amt: 1 tab; oral Special instructions: 1 tab PO Q 6 hours prn for pain. Acetaminophen- codeine - Schedule III [controlled substance] tablet; 300-30 mg; amt: 1 tab; oral three times a day prn. Morphine Concentrate Schedule II solution; 100 mg/5 ml (20 mg/ml); amt 0.25-1 ml every 1 hour as needed for Pain/SOB. Observation and interview on 08/30/2023 at 10:52 AM revealed LVN A prepared wound care supplies for Resident #49's cancerous open lesion to the left side of her face. The dressing was noted to cover most of the residents left side of her face. LVN A removed the dressing after squirting NS to loosen the dressing and tugging as it was stuck to the wound on the left side of the resident's face. The dressing was pulled off and the resident grimaced, made some sounds of distress, and tried to pull her face away from the painful stimuli. Her wound was dripping blood and it dripped down her chin onto her chest. LVN A pressed the 4 X 4 gauze to the wound and the resident continued to flinch and make noises. When asked if the resident had been pre-medicated for pain LVN A stated she had not but she had Morphine available as she was on hospice. CA Alginate was then placed on the wound and a silicone dressing. In an Interview on 08/30/2023 at 11:10 AM LVN A stated Resident #49 winced and yes, she was in pain. She stated she could have consoled her, maybe she could have stopped the wound care and medicated her. She stated she does respond in an appropriate manner, and she could have asked if she was in pain. In an interview on 08/31/2023 at 10:11 AM the ADON stated pain meds should be given a 1/2 hour to 1 hour prior to the wound care procedures and a verbal and non-verbal assessment for pain should be conducted. He stated LVN A should have stopped the procedure to see if there were orders for pian medication. He stated, We can treat the pain. Interview on 08/31/2023 at 11:01 AM the DON stated prior to wound care Resident #49 should have been pre-medicated, or the nurse should have stopped the procedure and called the Doctor. She stated the nurse should be observant for signs of pain. She stated not pre-medicating for pain could cause the resident an increased pain level, emotional distress, and an increased stress level. Review of a facility policy and Procedure titled Pain Assessment and Management dated 2001 and revised October 2010 reflected Purpose: The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the residents' goals and needs that address the underlying causes of pain. General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary process that includes the following: A. Assessing the potential for pain B. Effectively recognizing the presence of pain C. Identifying the characteristics of pain D. Addressing the underlying causes of pain E. Developing and implementing approaches to pain management F. Identifying and using specific strategies for different levels and sources of pain; G. Monitoring for effectiveness of interventions; and H. Modifying approaches as necessary. Recognizing pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain. Possible behavioral signs of pain: A. Verbal expressions such as groaning, crying, or screaming. B. Facial expressions such as grimacing, frowning, clenching of the jaw, etc; C. Changes in gait, skin color, and vital signs. D. Behavior such as resisting care, irritability, depression, decreased participation in usual activities. 2. Ask the resident is he/she is experiencing pain. Be aware that the resident may avoid the term pain and use other descriptors such a throbbing, aching, hurting, cramping, numbness, or tingling. Review of a facility policy and procedure titled Pain - Clinical Protocol dated 2005 and revised April 2023, reflected Assessment and recognition: 1. The physician and staff will identify individuals who have pain or are at risk for having pain. 2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc. and severity of pain) A. Staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. B. The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed. 4. The nursing staff will identify any situations or interventions where and increase in the resident's pain may be anticipated; for example, wound care, ambulation or repositioning.

Based on observation, interview and record review the facility failed to investigate injuries of unknown origin for 3 of 4 residents (Residents #2, #3 and #4) when: A.) Resident #2 was discovered to have a dark purple bruise to her right upper lip on 5/25/12 at 4:15 AM. The resident was unable to tell staff what had caused the bruising. B.) Resident #3 was discovered on 4/16/12 at 10:30 PM to have redness and bruising to her left hand, 5th digit (pinkie finger). The resident was unable to tell staff what had caused the bruising. C.) Resident #4 was discovered on 4/16/12 at 12:30 PM to have a bruised area on the inside of her left palm, by her thumb. The resident was unable to tell staff what had caused the bruising. This deficient practice affected Residents #2, #3 and #4 and 1 additional resident that was reviewed for abuse/neglect when the facility failed to investigate the cause of injuries that were located in unusual areas and could place residents residing in the facility at risk of abuse/neglect. Findings include: A.) Review of the Facesheet reflected Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a History and Physical dated 10/5/11 reflected Resident #2 had a past history of: [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Review of an Incident/Accident report dated 5/25/12 at 4:15 AM reflected, "While nurse was making rounds she noted a purple bruise to Resident #2's top lip on the right side. Resident #2 does not recall how she got the bruise. " Under the section called "Additional comments and/or steps taken to prevent recurrence " : " Monitor until healed. " The physician and family member were notified. The Incident/Accident report was signed by the Charge Nurse, Licensed Vocational Nurse (LVN) A, the Director of Nurses (DON) and the Administrator. There was no further information on the Incident/Accident report. Review of a Faxed Transmission dated 5/25/12 reflected, "While doing rounds Resident #2 was noted to have a purple bruise on the upper right lip. Resident #2 was unable to tell how she got the bruise. Will continue to monitor. " Review of Nurses' Notes for Resident #2 reflected the following: 4/5/12-Resident #2 complained of tooth pain on upper left side of mouth. 4/9/12-Resident #2 went to the dentist and had one tooth extraction. 5/25/12-Upon doing rounds nurse noted resident to have a purple bruise on top lip on the right side. Etiology unknown. Resident #2 does not recall how she got bruise. 5/26/12-Follow up bruise to right upper lip. Purple discoloration still noted to area. 5/27/12-Follow up bruise to right upper lip continues to be purplish in color. 5/28/12-Bruising to upper right lip continues. Review of the Care Plan dated 5/25/12 reflected Resident #2 had bruising to her right upper lip. Review of the comprehensive Care Plan dated 4/25/12 reflected Resident #2 was moderately cognitively impaired. She was able to ambulate with her rolling walker. She shuffles her feet and tends to lean forward, which makes her gait unsteady. She exhibits involuntary movement to her hands at times. She requires assistance with Activities of Daily Living. Set up is needed at meals. She has a history of falls and needs to be reminded to call for assistance for toileting and transfers. She wears glasses and is able to read large print. She uses multiple medications and is at risk for side effects. She has the potential for excess bleeding related to anticoagulant therapy. In an interview on 6/1/12 at 6:15 AM LVN A stated that she worked the 11:00 PM to 7:00 AM shift. She stated that on 5/25/12 at approximately 4:00 AM she noted a " Dark, dark purple bruise " on Resident #2's right upper lip. She stated that Resident #2 was not able to tell her how she got the bruise. LVN A stated that she worked with Resident #2 the night before and the bruise was not there. She stated that when she started her shift that night she was not given any report that Resident #2 had the bruise on her lip. LVN A stated that the bruise must have occurred sometime between dinner the night before and 4:00 AM. She stated that it looked like it had only been there a few hours. She stated, she didn't know how Resident #2 got the purple bruise, she " might have bit it (her lip) during supper " but she really didn't know. She stated that she filled out an Incident/Accident report and documented the bruise on the 24 hour report sheet. She stated that Resident #2 was a very pleasant resident. She used a walker to get around and had a shuffling gait due to her [MEDICAL CONDITION] but had no behavior issues. She stated that Certified Nurses Aide (CNA) B was the aide taking care of Resident #2 that night. In an interview on 6/1/12 at 6:20 AM CNA B stated that she worked the night shift (11:00 PM to 7:00 AM). She stated that Resident #2 did not require much care on the night shift and she did not recall seeing a bruise on her lip. She stated that Resident #2 falls a lot but had not fallen in a long time. She was not aware of how Resident #2 could have gotten a bruise on her lip. In an interview on 6/1/12 at 6:25 AM LVN A stated that CNA B had just reported to her that LVN C recalled Resident #2 having dental work the day before the bruise was noted on her lip. In an interview on 6/1/12 at 6:28 AM LVN C stated that she was not sure when Resident #2 was seen by the dentist but she could look for it on the calendar. LVN C flipped through the calendar. On 5/18/12, " Dentist in chapel at 8:00 AM " was documented. She stated that she was not able to tell me if the Dentist examined Resident #2 that day. In an interview on 6/1/12 at 7:50 AM CNA D stated that she worked with Resident #2 on 5/24/12 and there was no bruise on her lip that day. She stated that she was then off for three days and returned to work on 5/28/12. She stated that on 5/28/12 she noticed the " Round, purple area, like when you get a pinch that makes a little blood blister " on Resident #2's right upper lip. She stated that she reported the area to the charge nurse and was told that the area had already been reported and it was being monitored. She stated that as the area healed, the purple color "sort of spread out along her lip. " CNA D stated that when she asked Resident #2 what had happened to her lip she said, "What's wrong with my lip?" She stated that Resident #2 did not remember what happened. Observation on 6/1/12 at 7:45 AM revealed Resident #2 sitting in a chair in the dining room waiting for breakfast. She had no visible bruising. In an interview on 5/31/12 at 2:45 PM the Director of Nurses (DON) stated that they look at all of the incident reports in morning meeting every day to determine which ones needed to be investigated or followed up on. He stated that he did not document an investigation because; we know the residents and the staff. He stated that Resident #2 had [MEDICAL CONDITION] and probably hit her lip with her cup while she was eating. B.) Review of the Facesheet reflected Resident # 3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of the Incident/Accident report dated 4/15/12 at 9:45 AM reflected Resident #3 resisted care and slapped a staff member on the face. Assessed by LVN F and found " no apparent injury " . Under Additional comments and/or steps taken to prevent recurrence: " monitor behavior closely, PRN (as needed) [MEDICATION NAME] increased " . Under Name, title of witness(es) was CNA G and H. The physician and family were notified. The report was signed by the DON, Administrator and LVN F. Review of an Incident/Accident report dated 4/16/12 at 10:30 PM reflected Resident #3 was noted to have redness and bruising to her left hand by her 5th digit. Etiology unknown. Under section labeled Additional Comments and/or steps taken to prevent recurrence: "likely due to altercation with staff member. Monitor closely until resolved." The physician and family were notified. The report was signed by the DON, Administrator, and Treatment Nurse E. There was no further information on the Incident/Accident Report. Review of a Fax Transmission dated 4/15/12 reflected, " Resident #3 slapped one CNA on the face, staff member walked away. " Review of the Physician's Telephone Orders dated 4/16/12 reflected, " FYI: Resident #3 noted to have bruising and redness to left hand 5th digit, etiology unknown, will monitor " . Review of the Nurse's Notes for Resident #3 reflected the following: 4/16/12 at 11:00 AM redness and bruising to left hand 5th digit, etiology unknown 4/18/12 at 6:00 AM bruise to the left 5th digit was, " purplish discoloration noted to bruised area " . 4/18/12 at 8:00 PM bruising improvement noted to left little finger. 4/20/12 bruising/redness to left hand 5th digit resolved. 4/20/12 (Late Entry for 4/15/12) resisting care of staff member, she had coffee cup and newspaper in hand and started saying things to staff, she slapped staff in the face and tried to strike her in the chest, and tried to hit " my left arm. " Review of the undated Care Plan reflected that Resident #3 had potential to be physically abusive towards others due to [DIAGNOSES REDACTED]. Approaches: 5. Maintain resident's personal space. In an interview on 6/1/12 at 8:00 AM LVN F stated that Resident #3 was resisting care on 4/15/12, she was striking at CNA's. She further stated she was not sure how Resident #3 got the bruise to her left hand. She stated that the CNA's were worried the resident would spill her coffee on herself. In an interview on 6/1/12 at 8:52 AM CNA H stated that on 4/15/12 CNA G was pushing Resident #3 ' s wheelchair down the hallway to her room to change her, when the resident began to put her feet down on the floor to stop the wheelchair. Resident #3 was refusing to go down hall with CNA G, she turned around in her wheelchair and slapped CNA G in her chest and tried to slap her in the face. CNA G attempted to continue to roll the wheelchair down the hall so Resident #3 put her hands on the wheels to stop it from rolling. CNA H intervened and took Resident #3 to her room to change her. In an interview on 6/1/12 at 9:00 AM CNA G stated that she was attempting to take Resident #3 to her room to change her, when the resident turned around in the wheelchair and began slapping at her. CNA G stated that she then placed her hands on Resident #3's arms and gently pushed them down onto the arms of the wheelchair. The resident was very agitated so CNA H took her to the room and provided the care for her. In an interview on 5/31/12 at 2:45 PM the DON stated that he did not investigate the incident because Resident #3's injury probably occurred because she was combative with care and was very mobile in her wheelchair. C.) Review of the Facesheet reflected Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Incident/Accident Report dated 4/16/12 reflected that Resident #4 was found with a bruised area to the inside of her left palm by her thumb, etiology unknown. It further stated that a CNA reported that the resident had previously been combative with her ADL care. Under the section of additional comments and/or steps taken to prevent recurrence: " probable occurred with combative behavior. Monitor until healed. " The physician and family were notified. The report was signed by the DON, Administrator, and Treatment Nurse E. Review of the Physician's Telephone Orders dated 4/16/12 reflected Resident #4 was noted to have bruising to the inside of her left palm by her thumb, etiology unknown, will monitor. Review of the Nurse's Notes dated 4/16/12 at 12:30 PM reflected that Resident #4 had a "bruised area to inside of left palm by the thumb area, etiology unknown, but CNA reports resident has previously been combative with ADL care". There was no other documentation in Nurse's Notes about the bruise to Resident #4's palm. In an interview on 6/1/12 at 8:35 AM CNA I stated that she did not know anything about Resident #4's bruise to the palm of her hand. She further stated she doesn't remember anything about the incident. In an interview on 6/1/12 at 8:40 AM the DON stated that the nurses are to always follow up on bruises for three days or until it is resolved. He further stated that the nurses should always document about the bruise every day. In an interview on 5/31/12 at 2:45 PM the DON stated that he looked at the bruise on Resident #4 and it was barely noticeable. He stated that the bruise was not something that he thought needed to be investigated. In an interview on 5/31/12 at 2:45 PM the Administrator stated no one would abuse anyone here. He stated that he knows his staff and that most of them had worked at the facility for many years. Review of the undated Policy titled RESIDENT ABUSE/NEGLECT POLICY reflected that any reported or suspected abuse or neglect will be thoroughly investigated by administrative staff. The residents have the right to be free from ...injury from an unknown source. Identification of Abuse or Neglect: The incident/accident reports will be monitored by administrative staff in an attempt to identify suspicious bruising of residents. These reports are brought to the management team meetings that are usually held five days each week. All incident/accident reports are then provided to the administrator. Our awareness for possible abuse or neglect will continue to be sharpened. The management staff will determine occurrences, patterns and trends when they exist. The same staff will determine when an investigation should occur. Allegations of Abuse/Neglect: Upon report of any allegation or violations, the administrator or designated representative will thoroughly investigate the situation in accordance with the law. Should there be any evidence that supports an allegation of abuse or neglect during the early phase of the investigation, the employee will be removed from direct care of the residents, while the investigation is in progress. The outcome of the investigation will be discussed with the accused employee upon completion of the investigation. Findings and Actions: The investigation will be conducted by interviewing staff, visitors and residents involved with or witnessing the incident and by documenting the facts. Contents of Investigation: An investigation will include, but not be limited to, the following facts: 1. Names of all individuals involved. 2. Witnesses that actually viewed this incident 3. The resident's statement concerning this incident. 4. When and where the incident occurred. 5. Any evidence of injury or abuse present on the resident's body or in the resident's actions. Review of the facility's CMS 672 form reflected a facility census of 72.

Based on observation, interview, and record review the facility failed to report to the state regulatory agency and investigate an injury of unknown source for 1 of 7 residents reviewed with injuries of unknown origin.(Resident #1) Resident #1 sustained bruises around her upper chest and right arm on or about on 03/08/12. No staff witnessed an incident that could have resulted in these injuries and the source of the injuries could not be explained by Resident #1. The bruises were suspicious due to the location and the extent of the bruises. The facility did not report the injuries to The Department of Aging and Disability Services (DADS). This failure affected Resident #1 and placed 72 residents at risk of abuse, neglect, or injuries of unknown source not being investigated and reported. Findings include: Review of Resident #1's face sheet reflected this [AGE] year old female resident was admitted to the facility on [DATE] with Diagnosis: [REDACTED]. Review of Resident #1's Significant Change Minimum Data Set ((MDS) dated [DATE] coded her cognitive skills for daily decision making as severely impaired. The MDS indicated she needed extensive one person physical assistance with transfers and activities of daily living. No falls last 6 months. Observation of Resident #1 on 03/22/12 at 9:10 AM at the local hospital revealed pleasantly confused thin lady resting with the head of the bed elevated, a urinary catheter in place, and an IV infusing Sodium Chloride via a pump at 70 cc an hour. When questioned how she obtained the visibly large bruise to the right arm, she stated "I don't know, don't remember." Observation on 03/22/12 at 9:30 AM with two hospital nurses on duty a visual inspection of all skin areas on Resident #1 revealed the following: 1. Front right arm from shoulder to just below the elbow a large area in various stages from purple/red to brown/yellow; 2. Back of upper right arm bruising a dark deep purple/red was seen; 3. Under both the breast across the chest; to just above the breast, various stages of bruises seen; 3. Front upper chest across both breast were bruises deep purple to yellow, with bruises around both nipple areas; and 4. Back bruising extended from the front all the way around Resident #1's bruising scattered purple areas with yellow. Upon movement Resident #1 cried out in pain. Review of Resident #1's "Behavior Monitoring Flow Record" dated 03/12 reflected no behavior documented and none in the Nurses Notes reviewed 02/25/12-3/20/12. Review of Nurses Notes reflected in February Resident #1 was being treated for [REDACTED]. She had used a rolling walker but due to an unsteady gait and appearing lethargic on 02/29/12 began using a wheelchair for mobility; and required transfer assistance with a gait belt with the assistance of two Certified Nurse Aides (CNA's) . Review of Nurses Notes reflected: "03/08/12 7 PM resident was undressed for shower and to put her to gown on. She cried out with pain, several times. CNA noticed resident was bruised from bottom of neck to below breast and across chest from armpit to armpit. The bruising is yellow already. On her right shoulder is a lump on the chest side about 6 centimeters and hard." DON notified. Physician notified. New orders to x-ray right shoulder. Son notified. "03/08/12 8 PM x-ray negative for fracture. Area painful when touched. Resident unable to say how she may have received bruising due to dementia" "03/09/12 1:30 PM resident is being monitored for bruising located on mid chest" "resident cried out in pain during ambulation from wheelchair to bed this morning." "03/10/12 2:25 AM CNA reported a large purplish bruise to residents upper right arm while getting ready to take vitals. Upon assessment large purplish bruise noted to upper right arm. no complaint of pain, no signs/symptoms distress or discomfort noted." Physician to be notified later in the morning. Will continue to monitor. "03/10/12 4:30 AM Follow up for bruising to mid- chest" "Cried out in pain during ambulation from bed to wheelchair". "03/10/12 continues follow up for bruise to mid chest and right upper arm" "03/10/12 called to patients room and CNA concern about bruising to chest and arm, tender to touch" "will call if pain continues" "03/11/12 3:30 AM" (time had been marked over so difficult to determine exact numbers) "follow up for bruising, cries out in pain when touched" "03/11/12 3 PM Resident continues follow up for bruising to right arm. Entire upper right arm is bruised.. Painful to touch". Continued Review of Nurses Notes reflected from 03/11/12 -03/18/12 follow up monitoring was done each shift on the bruising, a couple of notes indicate the chest was yellow and fading. Then on 03/18/12 Resident #1 had a elevated temperature, the physician was notified and she was sent to the local hospital for evaluation where she was admitted for a urinary track infection [MEDICAL CONDITION]. Review of Incident/Accident Report dated "03/08/12 7:00 PM" reflected this description "resident has yellow bruising across her chest under both arms and from base of neck to under breast". Area on the form for "additional comments and/or steps taken to prevent recurrence" was blank. The form has a place for the Medical Director and the Director of Nurses (DON) to sign just under this area and both areas were without these signatures. Review of Incident/Accident Reports from January 2012 to present reflected no other reports for Resident #1. None was found for the upper right arm reflected in the nurses notes dated 03/10/12. Review of Resident #1's "Acute Care Plan Bruising" was added on 03/09/12 Problem: Bruising (written on side of sheet "chest-upper abdomen area") Goal: Resident will have bruising resolved without complications. Approaches: 1. Monitor sites X 72 hours after reported occurrence or initial observation. Registered Nurse (RN) or Licensed Vocational Nurse (LVN). 2. Report and document observable changes in appearance.(RN or LVN) 3. Attempt to identify cause of bruising if no specific incident reported.(RN or LVN) 4. Notify MD as warranted.(RN or LVN) 5. Contact family member when bruising noted.(RN or LVN) 6. Remove clutter and any unnecessary items in residents' room to maintain safe environment. for resident.(CNA) 7. Assess possible resident need for appropriate protective, safety devices or garments.(RN or LVN) Review of a Occupation Therapy Evaluation dated 03/14/12 reflected treatment [DIAGNOSES REDACTED]. In an interview on 03/22/12 at 12:30 CNA F stated on 03/18/12 she saw Resident #1 was "shaking in bed and just didn't look right". She reported to the nurse and she was sent to the hospital. She further stated that Resident #1 had been declining, requiring two staff to transfer her, and that staff would get her up mostly around meals three times a day. CNA F further stated Resident #1 was a thin lady with very fragile skin. Interview on 3/21/12 at 1:50 PM DON stated he had spoke to Resident #1's physician and thinks the bruising on the 03/08/12 Incident/Accident Report "is from the gait belt used to transfer the resident, as she is on aspirin and had right arm bruised from the blood pressure cuff". Asked regarding the Incident/Accident Reports reviewed (12 resident reports from 01/06/12- 03/22/12 of unknown injuries) staff are documenting "etiology unknown" or "cause unknown" how these are investigated as the form had an area for documentation for "additional comments and/or steps taken to prevent recurrence" that mostly are left blank. The form has a place for the Medical Director and the Director of Nurses (DON) to sign just under this area and both areas were frequently without these signatures. He stated that in the morning meetings the staff discuss the incident reports. The DON further stated that he had no documentation of an investigation on Resident #1's unknown bruising and it was not reported to the state as abuse was not suspected. When questioned regarding the bruising documented just under and on the breast is this the proper placement for a gait belt? DON stated "a gait belt can be placed under the breast area, he was told by Physical Therapy/Occupational Therapy (PT/OT)". Interview on 3/21/12 at 2:10 PM Physical Therapy Assistant stated a gait belt is never put on the breast area and only in a couple of cases would you ever place the gait belt under the breast area; one would be if the person had abdominal surgery and if the person was a very obese person. Interview on 3/21/12 at 2:23 PM, PT B stated the gait belt can be place above the breast area on a very large lady whose breast may hang down where the belt would normally go at the waist area. She further stated it would never be place high on a thin person. Interview on 3/21/12 at 2:30 PM the DON stated he had not conducted any training on gait belt use following Resident #1's 03/08/12 incident. He stated that staff are to monitor a bruise for 72 hours after discovery. When questioned regarding the bruising on the right arm was any training provided regarding taking blood pressures and he stated if is common nursing knowledge that they should change arms. In an interview on 03/22/12 at 3:15 PM Resident #1's physician stated that she had received a call from the emergency room (ER) physician when the resident had arrived at the hospital as he was very concerned about the large areas of bruising. She further stated that the ER physician had called the facility and spoke with LVN D as to the cause of the bruising and was told she knew nothing about them; this had caused grave concern; so she was called. She further did not know the specifics of the bruising but had talked to the DON today. When the detail bruising was described from the observation this morning, she stated "I am at a loss to explain that". The physician discussed the aspirin and lab work being borderline as contributing factors to the bruising as well as Resident #1 having fragil skin. Review of Healthtech Transfer and Ambulation; The Gait Belt/Transfer Belt policy provided reflected the following: II. Procedures: A. Gait belt is applied snugly to the resident's waist or as noted in precautions. Precautions for use of belt: A. Position belt higher under armpits around chest. 1. Recent [MEDICAL CONDITION]/[MEDICAL CONDITION] surgery. 2. Recent abdominal or back surgery.