Every finding on record at St Annes Nursing Center, St Annes Residence Inc

Based on record and staff interviews, it was determined that the facility did not ensure medications were administered according to professional standards, resulting in a significant medication error for one resident (Resident #1) out of three sampled. As evidence by Staff C, a Registered Nurse, administered three medications that were not prescribed to Resident #1 (one antibiotic medication, one seizure/nerve pain medication and a high blood pressure/heart failure medication). This failure increased the risk of adverse drug reactions or medication toxicity that could potentially cause serious harm to Resident #1. At the time of the survey, 187 residents were residing at the facility.The findings included:Review of Resident #1's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Aftercare Following Joint Replacement Surgery, Presence of Artificial Hip Joint. Resident #1 was discharged on 05/26/2026. Review of Resident #1's Physician's Orders Sheet for May 2026 revealed Resident #1 had orders that included but not limited to: Tylenol 325 Milligrams (mg), Two tablets for mild pain, scale one to three as needed every six hours. Tramadol 50 mg, one tablet for moderate pain scale four to six every eight hours as needed for 30 days. Evening Medications included: Famotidine 20 mg two tabs by mouth at bedtime for Gastroesophageal Reflux Disease. Robaxin 500 mg one tablet by mouth every 12 hours for Musculoskeletal pain. Flomax 0.4 mg one capsule by mouth at bedtime for Benign Prostatic Hypertrophy. Atorvastatin 20 mg one tablet by mouth at bedtime for Hyperlipidemia. Melatonin 5 mg one tablet by mouth at bedtime for Insomnia.Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] showed the resident was cognitively intact according to a Brief Interview for Mental Status Score (BIMS) score of 14 out of 15, dependent for care, had no behavioral issues, was occasionally incontinent, received pain medications, had no shortness of breath or falls, has a surgical wound, was prescribed antidepressant, hypnotic, anticoagulant, and opioid medications, and received no special treatments.Review of Resident #1's progress notes dated 05/14/2026 timestamped 08:59 PM documented: Incident Note-Medication error identified 05/14/2026 at 6:30 PM, patient assessed, vital signs stable and within normal limits along shift. No signs and symptoms of distress, protocols followed. Physician and family notified. New orders received from Physician (MD) to continue to monitor the resident closely. Orders carried out. Resident request to be taken care of by a different nurse, Charge nurse will be taking over care of the resident. 10:48 PM -12:18 AM resident continued to be assessed, vital signs completed, no concerns observed. Progress note dated 05/15/2026 timestamped 12:19 AM -at 8:01 AM: resident assessed, vital signs completed, no distress reported. Pain 3 out of 10, patient requested Tylenol 650 Milligrams at 12:00 AM, Call received from resident's daughter stating not to administer any evening medications other than Tylenol because of the medication error that occurred but to continue treatment tomorrow. 12:19 AM-06:37 AM Resident continued to be monitored, no concerns. 6:50 AM Vital signs completed.7:13 AM Resident slept well during the night, easy to wake up, alert and oriented times three, no shortness of breath or complaint of pain. Resident continues to be monitored closely. 12:34 PM: Follow up call placed to resident's daughter. Gave update on resident's status, alert and oriented times three, resting in bed, denies any discomfort or needs at this time. Provided a report of all morning medications the resident received, tolerated well. Ongoing monitoring for the resident in effect, seen and evaluated by wound care, physical therapy and occupational therapy, vital signs within normal limits. During an interview on 08/13/2026 at 11:21 AM the Director of Nursing (DON) and Risk Manager reported that on 05/14/2026 at approximately 06:30 PM Staff, C, Registered Nurse (RN) reported to the Staff D,RN that a mistake was made with medication administration for Resident #1. The DON revealed that Staff D, RN reported going into Resident #1's room with medications and had three tablets for the resident in bed number two, got confused and gave the medications to the resident in bed number one (Resident #1) and that Resident#1 took the medications. Resident #1's Physician was called and both DON and Risk Manager were notified. Resident #1's family was notified. The medications that were administered to Resident #1 in error were Amoxicillin (an antibiotic) 500 milligrams (mg) one tablet, Coreg ( a medication for heart failure and high blood pressure) 12.5 mg one tablet, Gabapentin (a medication used to treat partial seizures and nerve pain) 100 mg one tablet. Orders were received from the Physician/Medical Doctor to monitor the resident's vital signs, monitor for any adverse effects of the medications-respiratory distress, difficulty breathing, rashes etc. Resident #1 was notified regarding receiving the wrong medication, resident requested care to be provided by another nurse, request was granted, resident received his evening pain medication, resident continued to be monitored closely, slept well through the night, no shortness breath, no complaint of pain, vital signs repeated at 12:00 AM, 2:00 AM, 4:00 AM and 6:00 AM were within Resident#1's normal limits. On 05/15/2026 vital signs continued to be monitored, no adverse effects were identified from the medication error the previous day. On 05/22/26 Staff C, RN received and signed disciplinary action pertaining to substandard work performance. One to one education was provided to the Staff C, RN on medication errors and how to prevent medication errors from occurring. On 05/14/2026 the DON and Risk Manager spoke with Staff C, RN via telephone about the medication error event and what actions will be taken. The DON stated that the nurse is a per diem nurse and came to the facility on [DATE] and received disciplinary action and education. In a telephone interview on 08/13/2026 at 3:33 PM, Staff C,RN who worked the 3:00 PM to11:00 PM shift, stated that on 05/14/2026 at approximately 6:30 PM [Resident #1] was a new admission and by mistake staff C, RN had administered the wrong medications to the resident. I cannot remember what patient the medications belonged to or the type of medications, it was probably two medications. After I looked again at the computer and saw the file for [Resident #1] medications was blank and realized I gave the medications to the wrong resident. I immediately told [Staff D, RN] what happened, notified the resident's family members.[Staff D, RN] and I notified the resident's Physician and orders were received to continue to monitor the resident. The resident had requested another nurse to provide care so Staff D, RN was assigned to Resident #1 and Staff C, RN, continued to take care of other assigned residents for the remainder of the shift. After the incident Staff C, RN reported in person to the facility days later for training and education on medication administration, medication rights and was written up for the medication error. During an interview on 08/13/2026 at 3:49 PM, Staff D, RN reported having received notification from Staff C, RN regarding the medication error involving Resident #1 on 05/14/2026 and obtained a list of medications that had been administered to Resident #1. Staff D, RN stated that the Director of Nursing was informed; the physician was contacted and orders received to monitor the resident closely. Staff D, RN and Staff C, RN assessed Resident #1 together. Staff D, RN spoke with the resident's two daughters who were present at the facility, and at their request, also spoke with the other daughter via telephone. Staff D, RN explained the medication error incident and outlined the steps that would be taken to ensure the resident's care. The regular evening medications for Resident #1 were withheld as requested by the family, except for the pain medication requested by the resident. Staff D, RN assessed the resident and recorded vital signs throughout the night. The resident's vital signs remained within normal limits; Resident #1 interacted with family and responded appropriately. Review of the facility's policy and procedures titled, Medication Errors revision date 10/18/25 documented: The organization has a process to respond to actual or potential medication errors. All actual or potential errors identified will be documented through the facility's risk management system. All significant medication error reports will be reviewed by the Quality Management Committee/QAPI Committee. The Quality Assurance and Performance Improvement Team will review all medication error data as part of the facility's improvement process. All adverse medication events requiring notification through external state, federal, USP, FDA or ISMP channels, will be reported according to the requirements of the specific organization.Review of the facility's policy and procedures titled, Medication Precautions revision date 10/18/25 indicates: The purpose is to ensure the safe administration of medications by ensuring that the rights are followed for every medication given to every resident, every time. It is the policy of this facility to administer medications to residents in accordance with the rights of the Medication administration. All medications will be administered in a safe, accurate, and timely manner in compliance with federal, state, and facility regulations.

Based on record review, and interview, the facility did not follow medication administration procedures for one (Resident #1) out of three sampled residents. The Registered Nurse (RN) exited Resident #1's room and did not ensure that the medication administered was taken. There were 187 residents residing in the facility during the survey. The findings included: A review of the facility's grievance logs, covering the period from January 2026 through August 2026, indicated that Resident #1 was noted in the log on 05/19/26 regarding a report that pain medication had not been administered as requested.During an interview on 08/13/2026 at 1:30 PM the Director of Nursing (DON) stated that on 05/19/2026 Resident #1's daughter reported that she found a pill in a medication cup in the resident's bedside drawer. The Director of Nursing revealed that Staff B, RN reported administering the resident's pain medication, observed the resident lift the cup to his mouth, provided water, watched the resident drink the water, and then exited the room. Review of Resident #1's medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Aftercare Following Joint Replacement Surgery, Presence of Artificial Hip Joint. Resident #1 was discharged on 05/26/2026 Review of the Physician's Orders Sheet for May 2026 revealed Resident #1 had orders that included but not limited to: Tylenol 325 Milligrams (mg), Two tablets for pain, scale (one to three )as needed every six hours. Tramadol 50 mg, one tablet for moderate pain scale (four to six) every eight hours as needed times 30 daysRecord review of Resident #1 's admission Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) 14 on a 0-15 scale indicating the resident is cognitively intact.In an interview on 08/13/2026 at 4:46 PM the Director of Nursing (DON)/Risk Manager stated that an investigation was conducted and resolved related to the grievance initiated on 05/19/2026 after Resident #1's daughter reported that the resident had not received as needed pain medication when requested and when the resident was given pain medication, Staff B, Registered Nurse (RN) did not explain to the resident what medication was given and did not wait until the resident took the medication before exiting the room. The DON explained that Staff B, RN, received disciplinary action and was educated on medication administration procedures. Resident #1 received a pain management consultation and was started on routine pain medication, and the family expressed satisfaction. During an interview conducted on 08/13/ 2026, at 3:03 PM, Staff B, RN reported that on 05/ 19/2026, during the 7:00 AM to 3:00 PM shift, Resident #1 asked for pain medication; and specifically requested Tramadol instead of Tylenol, which had been previously discussed. walked into Resident #1's room, the resident was lying in bed, his wife was in the room standing next to the bed. I let [Resident #1] know that I am bringing him his pain medication Tramadol. The resident speaks some English, and he asked in English and Spanish what medication he was getting. I told the resident; this is your Tramadol. I got his water from the pitcher on the bedside table and gave him pain medication (Tramadol) and the water. The wife started asking me what pain medication I was giving the resident, I turned in the direction where the wife was standing and stated Tramadol. I then turned back to the resident; the medication cup was empty and had been placed on the bedside table, my assumption was he had taken the medication, I then proceeded out of the room. I went back to the unit and continued taking care of my other assigned residents. Within the hour my supervisor (Staff E, RN) approached me stating that the [Resident #1's] daughter called and stated that her father was not aware of what medication the nurse had given him. The supervisor went to the resident's room, spoke with the resident and the resident presented the pain medication from his bedside drawer and gave the medication to [Staff E, RN]. The same day the DON and Assistant Director of Nursing (ADON) spoke with me, I received a written disciplinary notice/write up, education and teaching on the policies and procedures of medication administration. I was reassigned from the resident's care as per family request. The training included the five rights of medication-right patient, right dose, right time, right route, right quantity, do not leave any medications with the residents, make sure the residents consume the medications in your presence, dispose of the medication cups before leaving the room, hand hygiene, follow up with residents. On 08/13/26 at 3:59PM during a telephone interview Staff E, RN stated: On 05/19/2026 I spoke to the [Resident#1s] daughter on the telephone, she stated that her father did not know what kind of pill [Staff B,RN] gave him, so he did not take the medication, he put it in his drawer. I went to the room and [Resident #1] took a white pill out of his drawer and showed it to me. I took the pill and showed it to the DON, ADON and [Staff B, RN]. The pill was disposed of in a liquid that dissolves medications. When I went into [Resident #1's] room, his wife was at his bedside. The resident was given medication for pain after giving me the pill from his drawer, I am not sure if it was Tylenol or Tramadol.Review of the facility policy and procedures titled, Medication Precautions revision date 10/18/25 indicated: The purpose is to ensure the safe administration of medications by ensuring that the rights are followed for every medication given to every resident, every time. It is the policy of this facility to administer medications to residents in accordance with the rights of the Medication administration. All medications will be administered in a safe, accurate, and timely manner in compliance with federal, state, and facility regulations.

Based on observations, record review and interviews, the facility failed ensure one (Resident #1) out of three sampled residents received higher level of care and treatment in a timely manner, as evidenced by Resident # 1 who has bilateral contracted upper extremities was noted on 10/24/2025 with swelling to her left arm that progressively got worst with swelling and discoloration throughout the inner portion of the left arm and was no longer contracted. Resident #1 was eventually transferred to a local hospital on [DATE] (two days after changes were noted). Hospital Xray of Resident #1's left arm revealed an acute mid humerus spiral fracture with displacement. There were 197 residents residing in the facility at the time of the survey. The findings include. Observation on 11/13/2025 at 09:52 AM, revealed Resident #1 in bed awake and alert in in no apparent distress and stated she was okay, a sling was noted on the left arm. Record review of Resident #1 clinical records revealed an admission date of 06/19/2023 with diagnoses including Degenerative Disease of the Nervous System and Palliative Care status. Record review of a nursing progress note created by Staff O, Registered Nurse (RN) on 10/24/2025 at 10:07 PM documented: Patient observed with mild edema to the left arm, area was assessed, skin warm and intact no signs of discoloration.Hospice nurse was notified regarding the finding and order to continue monitoring the affected area.Will continue to observe and document any changes. Review of progress note dated 10/25/2025 at 11:35 PM created by Staff O, RN indicated: During the 3-11 shift Tylenol was administered to the resident regarding the edema in case of pain. The oncoming nurse was informed for follow-up Record review revealed statements on 10/25/25 [Staff F, Registered Nurse] 7-3 shift received in report that the resident had slight edema of the left arm, when doing rounds the edema was noted very minimal, her arms were contracted towards her body as usual and no bruising was seen. I was told hospice was made aware and to continue to monitor. I gave report to the 3-11 nurse. Statement on 10/25/25 [Staff G, RN] 3-11 shift: The morning shift gave me report of the edema to the left arm. The arm was elevated on a pillow and to monitor. Around 8:00 PM I decided to give Tylenol in case of pain. The resident is nonverbal. I gave report to the night nurse. There is no documentation of bruising or discoloration. Documented 10/26/25 statement from the 11-7 shift Nurse [Staff H, RN]: The resident was noted with edema to the left arm. Upon assessment the resident left arm was noted with swelling throughout the arm along with discoloration to the inner portion of the arm. The arm is a contracted arm that was observed to not be contracted at that moment. The supervisor was immediately called to come evaluate the resident. Hospice was then called at 12:50 AM and as per Hospice Triage Nurse [Staff B, RN] she will send a local hospice nurse to come evaluate the resident. At 2:25 AM the local hospice nurse, [Staff C, Licensed Practical Nurse] arrived to evaluate the resident. After the evaluation the family was called for permission to send out the resident, in which she was sent out to [local hospital]; [ambulance service] was called at 3:35 AM with an ETA (Estimated Time of Arrival) of 20 minutes; [local hospital] was called at 3:40 AM in which I spoke to the charge nurse to make them aware of the resident going to their facility. The [ambulance company] arrived at 3:58 AM and left with the resident at 4:05 AM. On 10/26/25, 3-11 nurse [Staff H, RN] The resident returned to the facility at 5:21 PM.The resident was noted with her left arm in a splint and sling.Will continue to monitor. Record review revealed:10/25/25 statement, Staff A, Hospice Certified Nursing Assistant Bathe the patient around 8:00 AM. Normal as usual her arms were contracted had no complaints. I didn't see anything unusual in her arms or elbows. She (Resident #1) seemed fine, and we left her comfortable in bed. Review of statement dated 10/25/25- Staff B, Hospice CNA: At approximately 8:00 AM. I was in [Resident #1] room to give her a bath at that time the patient seemed in normal she didn't look agitated or that she was in pain. I finished given the bath and left the patient comfortable.Review of statement dated:10/25/25 Staff L, CNA 3-11; During my shift I noticed the arm more swollen the shift before I report it to nurse. The arm was elevated on a pillow. She had pain and the nurse gave her Tylenol. Review of documented statement -10/26/25 Staff D, CNA 11-7 shift: On 10/26/25 while assisting a nurse (Staff H, RN] from the night shift with a resident, we went to [room number] so the nurse could assess the resident's left arm. I received report from the previous shift instructing me to keep to the resident's left hand elevated due to edema. During the nurse's assessment. I observed bruising and noted that the resident 's arm was not contracted as it had previously been. I informed the nurse that the arm condition appeared abnormal since the resident is typically contracted, and her arm was not supposed to be moving that manner. The nurse and I were both very concerned by the finding, and she proceeded to contact the supervisor for further evaluation/instructions. Review of the Physician Orders include but not limited to: Two staff to provide personal care every shift daily (11/04/2025). Transfer with total assistance using a mechanical lift (01/25/2024). Application of sling and swathe to the left arm daily (10/27/2025); Tylenol 650 milligrams PRN (as needed) every 4 hours (02/17/2025); Apply bilateral hand rolls; may remove for hygiene (03/06/2025).Record review of the Minimum Data Set (MDS) Quarterly dated 07/28/2025 Section for cognitive Status indicate Resident #1 is severely impaired cognitively; Section functional status revealed upper extremity impairment, with the resident dependent on staff for eating, oral hygiene, toileting hygiene, bathing, upper and lower body dressing, and personal hygiene. Section J-Health Conditions indicated the resident received scheduled and PRN pain medications with no shortness of breath and no history of falls. Section P- Restraints and Alarms indicated no restraints or alarms were used. On 11/13/2025 at 12:30 PM, Resident #1 was observed in bed grimacing, the surveyor asked the resident if she was in pain and the resident stated her arm was hurting, and she had not eaten lunch. At 12:32 PM, the surveyor pressed the call light to alert the staff. At 12:44 PM, Staff P, a Registered Nurse, entered Resident #1's room and assessed her, who reported a pain level of 7 on a scale of 0-10. Shortly thereafter, Resident #1's assigned nurse Staff Q, RN entered the room and went to get the pain medication.During an interview on 11/13/2025 at 10:54 AM, Hospice CNAs Staff A and B revealed they did not notice anything abnormal on 10/24/2025, the resident did not exhibit any signs of pain. They mentioned that her arm was contracted, had no color difference, no swelling.Interview on 11/13/2025 at 11:52 AM, Hospice Staff C, a Licensed Practical Nurse (LPN) revealed a report was received from Staff O, Registered Nurse (RN) about swelling on the left arm and went to the facility to perform an assessment. Hospice Staff C, LPN reported she arrived at the facility at around dawn and entered the resident's room accompanied by the facility Staff O, RN; the resident was lying on the bed facing upward, the left shoulder appeared swollen, with bruising noted on the inner arm, and the area was warm to touch and the resident grimaced when the arm was touched. Hospice Staff C, LPN revealed she contacted Resident #1's son to inform him that the resident would be transferred to [Local Hospital] as the physician could not be reached and the son requested the transfer. Interview on 11/13/2025 at 2:35 PM Staff D, Certified nurse assistant (CNA) night shift reported receiving a shift handoff from the previous shift's CNA, who reported that the resident had edema and to keep arm elevated on a pillow. During rounds, the resident was observed to have bruising and was able to move her arm, although she had previously been unable to move her hand. Staff D, CNA then stated that she immediately notified the nurse, who went into the room to assess the resident. When the nurse assessed the arm around 12:00-12:30 AM, the resident grimaced or cried. Staff D, CNA indicated that when assisting the resident, she uses a draw sheet and requests help from another staff member as needed. Interview on 11/13/2025 at 2:40 PM, Staff F Registered Nurse (RN) 7:00 AM to 3:00 PM shift stated: I worked the 7:00 AM to 3:00 AM shift on October 25th with her (Resident #1) on that day she was as normal as she usually is with her arms contracted. The report I received from night shift was that she had slight edema of her left arm; and when I rounded on her and gave her medications and took her blood sugar everything looked normal there was no bruising that I noticed or any pitting edema she also didn't seem to be in any pain. The CNA was able to change and reposition her there was no complaints. Staff F, RN was asked about the facility's policy and procedure if a resident that receives hospice services that is not on Crisis Care has a change in condition; Staff F, stated: We call Hospice to come and see the resident. When asked if Hospice staff came to the facility on that day to provide any type of care for Resident #1; Staff F stated: During my shift no. I was told by the night shift that Hospice was already made aware at the time and that there were no new orders that was on the 25th, that was from the report I received from the night shift on the 25th.During an interview on 11/13/2025 at 2:50 PM the Director of Nursing (DON) revealed the facility is primarily responsible for all residents residing in the facility including the residents receiving hospice services (not Crisis Care) that has a change in condition: We call to make the Hospice Nurse aware of any situation and [healthcare company] first for orders to go through with the doctor as well. From my understanding I believe we would go to the Hospice nurses because they're on the same floor, and if not, we would reach out to the physician. The DON was asked if she would reach out to the Hospice physician or the Primary Care Physician. The DON stated: I believe it's the primary physician that we have here. The DON was asked if it was acceptable for a resident noted with swelling and pain to touch in a contracted extremity that gradually worsened over a 24-hour period not to be transferred and or receive emergency services for more than 36 hours from onset. The DON stated: if it was me I would notify [healthcare company] first and then if I'm made aware that we should notify the family, then I would go ahead and notify the family and if they had requested to send her to the hospital I think I would communicate with [healthcare company] or Hospice first and the physician to try to get everyone on the same page and then go through with sending the patient to the hospital if necessary. Regarding the need for a physician order to transfer a resident to receive higher level of care. The DON revealed: If it's an emergency case I don't believe so we would just notify the physician if it's a sudden change in the patient status, I believe we're able to go ahead and request emergency services and let the physician know. Most of the time if it's a gradual decrease in the patient's physical awareness or anything of that sort, usually we're always in contact with the physicians through the phone and they will usually order us to call emergency services or transport for the patient to go to a hospital. The DON was asked If the facility is primarily responsible for all the residents including residents receiving hospice services why hadn't the facility taken the initiative to seek higher level of care in a timely manner for Resident #1's change in condition that started on 10/24/25. The DON stated: In my in my opinion with Hospice patients it's important to kind of keep an eye on the patient; especially this specific patient, she's very weak, bedbound and she has contractures especially in her arms and they stay in fist like position close to her chest, and if I do notice that there is something that seems off with the patient or an injury of sorts especially with this patient, I think it would be necessary to get her to emergency services as quickly as we can considering she is on Hospice and pain management is probably our number one priority.On 11/13/2025 at 3:09 PM, Staff E, Attending Physician revealed the usual process is for the nurse to inform the doctor, who then provides orders, and to also notify the Hospice nurse as part of the communication protocol. Staff E, Attending Physician reported he was on vacation during the time of the incident and the Physician on call was informed of the situation and authorized the resident's transfer to the hospital.During an interview on 11/13/2025 at 3:31 PM, the Risk Manager revealed 10/25/2025 swelling was noted in the resident's arm, but no bruising was observed. The wound care nurse assessed the resident that day and documented edema in the upper and lower extremities without distress, bruising, or other signs of trauma. Between 3:00 PM and 11:00 PM, swelling was noted, and the arm was elevated. The CNA observed that the resident's hand was no longer contracted and was lying flat. The hospice runner evaluated the resident and contacted the physician. An X-ray was initially planned at the facility, but the son requested that she be transferred to the hospital. A fracture was subsequently diagnosed at the hospital. The primary care physician was notified the following morning upon the resident's return. A root cause analysis was conducted, concluding that the fracture likely occurred during routine care or while placing a pillow under the arm. The analysis noted that the injury may not have been preventable given the resident's history of stiffness and contracted arms. On 11/13/2025 at 4:22 PM the DON revealed the resident sustained a fracture but has never experienced a fall and always remain in bed. She is a hospice patient and receives care from both hospice and facility staff. Edema was first noted in the resident's arm on 10/24/2025, at which time hospice was notified and a nurse assessed edema in the upper and lower extremities without distress, bruising, or other signs of trauma. On 10/25/2025, between 7:00 AM and 3:00 PM, slight edema was observed on the left side with no bruising, and the arm was elevated per physician orders. Later that day, between 3:00 PM and 11:00 PM, the resident remained non-verbal, and the arm continued to be elevated. On 10/26/2025, between 11:00 PM and 7:00 AM, staff noted swelling throughout the arm with discoloration; the arm, previously contracted, was no longer contracted. The supervisor was notified, and hospice was contacted to evaluate the resident. At 2:25 AM on 10/27/2025, the resident's family was informed, and she was transferred to the hospital.

Based on observations, record review, and interviews, the facility's staff neglected to use a mechanical lift to transfer one (Resident #1) of the three sampled residents who required transfers with a mechanical lift. Staff G, a Certified Nursing Assistant, did not use a mechanical lift as ordered to transfer Resident #1 from the bed to the wheelchair. This deficient practice resulted in Resident #1 sustaining multiple fractures to the right lower extremity. Ninety-three residents in the facility required transfer using a mechanical lift.The findings include: Observation on 10/22/2025 at 10:22 AM, revealed Resident #1 receiving a bed bath without any apparent distress. The right leg was completely covered with a bandage wrap dressing. Record review revealed documentation indicating that on 10/9/2025 at 6:00 AM, Staff G, a Certified Nursing Assistant, informed Staff J, a Registered Nurse (RN) that Resident #1 had complained of leg pain after being transferred from bed to wheelchair. Review of the Nurses Notes created by Staff J, RN dated 10/09/2025 timestamped 6:58 AM indicated: Change in condition- while the patient was being transferred to her wheelchair to go to dialysis, the patient started complaining about pain on her right lower extremity. [provider] was called and a new order for a STAT X-Ray on the patient's right hip, knee, ankle, and foot was placed. When Resident #1 returned, Staff I, Advanced Practice Registered Nurse (APRN), assessed the resident due to the reported pain and noted a light green discoloration below the knee. The resident reported pain to touch and movement, with no swelling noted and no fall reported; Staff I ordered an X-ray to rule out fracture or dislocation. On 10/10/2025, the X-ray results revealed a proximal right tibia fracture with diffuse osteopenia. Staff I, ARNP had the resident transferred to the hospital for further evaluation. The resident's hospital record showed acute comminuted fractures of the right fibular shaft and an acute oblique fracture of the right proximal tibia shaft. Review of Resident # 1's clinical records revealed the resident was admitted to the facility on [DATE], clinical diagnoses included but not limited to End Stage Renal Disease and Dependence on Renal Dialysis. Review of Resident #1's Physician's Orders Sheet for October 2025 revealed an order for fall precautions, safety precautions and to transfer patient with use of mechanical lift. Record review of Resident #1 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score 03, on a 0-15 scale indicating the resident is cognitively impaired. Section GG for Functional Abilities documented supervision for eating, dependent on toileting, showering, lower body dressing, sit to lying for substantial assistance and upper body dressing for partial assistance. Record review of Resident #1's Care Plans Annual Review dated 09/12/25 revealed the resident is at risk of falls due to: Decreased mobility and unsteady gait. Interventions include but not limited to keeping floor clean, dry and free of debris: encourage use of non-skid soles and use of appropriate device with assistance for ambulation and transfers. Interview on 10/22/25 at 11:06 AM. Staff C, Certified Nursing Assistant (CNA) stated: I work with [Resident #1] and I was informed that she has a broken leg. I always have assistance from another CNA when transferring her to the wheelchair. We place a pillow under her leg and use the [mechanical lift] to transfer her safely to the chair. I have never transferred residents who requires a [mechanical lift] without using it. Interview on 10/22/2025 at 12:02 PM, the Risk Manager revealed that on 10/09/2025 Resident #1 started complaining of pain in the long bone of the lower leg. An X-ray was attempted on the first day, but completed the following day, which revealed a fracture. The CNA had transferred the resident without using a lift, during which the resident's leg was twisted. The CNA admitted she is at fault and was suspended facing termination. The resident was sent to the hospital but did not undergo surgery due to age and overall health; an immobilizer was applied instead. The resident has since returned to the facility.Observation on 11/12/2025 at 12:35 PM, revealed Resident #1 sitting in a chair eating lunch, a cast was noted on Resident #1's right lower leg and a dressing on her left foot.Interview on 11/12/2025 at 11:20 AM, Staff G, CNA stated: In the early morning I entered the resident's room to prepare her for dialysis. I cleaned her up, and while turning her, she began screaming in pain. I had used proper body mechanics to transfer her from the bed to the wheelchair by holding the resident and placing one leg between the resident and twisting the resident into the chair. When I lifted her feet to place them on the footrests, she cried out in pain and kept moving her feet off the rests. I repositioned her feet and took her to the nurse . When I returned the following night, I made it clear that I had never dropped a resident. The resident was supposed to be transferred using a mechanical lift; however, I was only trained to transfer her from the bed to the wheelchair without using the lift. I understand that using the mechanical lift is a two-person procedure. I received my CNA license in December 2024. The facility has a document that provides instructions for each resident's care, but I did not review that paper for [Resident #1] at the time because I usually only read it for new residents. This was not my first time working with [Resident #1], and I was aware that she required a mechanical lift. Although the resident has dementia, she was usually compliant with care. I did not notice any discoloration or visible changes in her condition after the transfer. After the incident, I was sent home and asked to return the following week to complete an incident report. I was later given a 15-day suspension and subsequently terminated. I believe this incident could have been avoided if I had received proper training. Interview on 11/12/2025 at 12:40 PM Staff H, Registered Nurse (RN) Unit Manager stated: I have been the Unit Manager for three years. We do have patients who require the use of a mechanical lift for transfers. The CNAs are responsible for checking each patient's transfer order, which specifies how the patient should be transferred, whether by mechanical lift, minimal assistance, or other methods. If a patient normally transfers without the lift but feels tired or weak on a particular day, staff are instructed to use the lift for safety. The mechanical lift transfers always require two staff members. During change-of-shift rounds, CNAs are informed about each patient's transfer status, and there is also a transfer sheet available for reference. CNAs are expected to review the transfer sheet at the start of every shift. We conduct frequent in-service trainings and always encourage staff to use the lift whenever it is ordered. A return demonstration is required during training to ensure proper technique. We also held transfer training not long ago. The transfer form has always been in place.Interview on 11/12/2025 at 2:46 PM Staff I, APRN (Advanced Practice Registered Nurse) stated: I saw the resident after the incident was reported. An X-ray was performed, which showed a fracture, and the resident was sent to the hospital for further evaluation. I was informed that the resident had swelling and reported pain. I am not certain what specifically caused the fracture. I did not speak with the CNA involved, as she was not present at the time. The resident was prescribed Tylenol for pain, which she only experienced during movement. The resident was recently seen by orthopedics and now has a cast. The hospital decided not to perform surgery; the resident initially had a splint, which was later replaced with a cast.and is not receiving therapy due to the cast.Telephone interview on 12/18/2025 at 2:11 PM Staff J, RN revealed on 10/09/2025 at around 6:00 AM before Resident #1 left for dialysis; Staff G, CNA had the patient in the wheelchair and reported the patient was complaining of pain in the right leg and because Resident #1 was wearing pants she did not see the legs but gave Tylenol for pain, and the resident left for dialysis. I called [company] and reported the change in condition, and a stat X-ray was ordered.Review of the facility's policy and procedure regarding Suspected Adult, Disabled Person or Elderly Abuse/Neglect/ Exploitation 12/03/2004.Purpose: Residents have the right to be free from mental, physical, sexual, and verbal abuse, neglect, misappropriation of resident's property, corporal punishment, involuntary seclusion and exploitation. It is the policy of this facility to protect residents from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, consultants, other residents, staff of other agencies serving the residents, visitors, friends. family members or legal guardians, or other individuals.Policy: The facility will implement processes for screening and training employees on protection of neglect, mistreatment and misappropriation of property. This facility mandates that, under residents and for the prevention, identification, investigation, and reporting of abuse, the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency and necessary corrective action will be implemented.Review of the facility's policy titled- Subject; Patient Mechanical Lift - Proper Use in Resident Transfer; Effective: 4/6/2005.POLICY: It is the policy of CHS [Catholic Health Systems) Facilities that all resident transfers/lifting is done safely and appropriately to protect the employee and patient from injury. All patient lifting, shifting or transferring will be done with Mechanical Lifting Equipment when appropriate. Failure to follow the guidelines established by this policy will result in disciplinary action being taken.PURPOSE: An injury to a health care professional from patient transfer/lifting activities directly affects the quality of life for our staff members and patients. Therefore, it is crucial that healthcare professionals practice safe lifting, transporting and proper body mechanics at all times. Mechanical Patient Lifts are a key component in this effort.PROCEDURES: Patients who require a mechanical lifting device for transfers will be identified in the CNA module of the Facility's EMR (Electronic Medical Records) system.Throughout the facility there are certain patients who have been determined to require assistance for all moves. For the protection of the staff member as well as the patient a mechanical lifting device will be used in transferring these patients. The designated mechanical lifting device will be designated MANDATORY for use in moving the patient, due to their inability to assist effectively and safely during transfers.

Based on observations, record reviews and interviews, the facility failed to create comprehensive, resident-centered individualized care plans for two (Resident #1 and Resident #4) out of two sampled residents as evidenced by their care plans containing generic interventions not tailored to their specific health needs and functional status. The findings include: Review of the facility document_ Subject: Care PlanningEffective: 12/3/2004Revised: 2/22/2006Reviewed: 10/16/2024POLICY:Care, treatment and services are planned to ensure that they are appropriate to the residents' needs. Therefore, it is the policy of this Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, limitations and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable.PROCEDURE: Item 3- The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family. Item 6 -Developing a plan for care, treatment and services that includes resident care goals that are reasonable and measurable. Item 15 Monitoring the effectiveness of care planning and the provision of care, treatment and services. Item 16 The plan of care will be individualized to the needs of the resident. Item 17 The plan of care will be evaluated at 90-day intervals or more frequently, based on the resident's clinical condition, care goals and the plan for treatment, care and services, and revised as needed to meet the needs of the resident's changing condition. Resident #1On 09/18/2025 at 9:19 AM and 11:15 AM Resident #1 was observed in bed with eyes closed. Bed in lowest position and bilateral safety mats on floor.Review of resident #1's clinical records revealed an initial admission dated 6/26/2023 and readmitted on [DATE] (resident was hospitalized from [DATE] to 8/30/2025). Clinical diagnoses include but not limited to Dementia.Record review of Resident #1's Care plans revealed:PROBLEM: 07/05/2023 [Resident #1] has the potential for falls related to decreased safety awareness09/28/2023: Quarterly Review-Resident has impaired mobility, mostly bed/chair bound12/19/2023: Quarterly Review02/14/2024 Update: The resident was observed as per nurse's documentation on floor lying on the right side, head at the foot of the bed, no injury noted, see orders/nurses' notes.03/14/2024- Update: clarification about the fall 2-14-2024. The resident was observed after the fall with skin tear to the right hip, wound care nurse evaluation ordered also XRAY to bilateral hip see nurse notes.03/15/2024Quarterly Review 06/03/2024 Significant Change Review.Resident # 1's Problem remained the same from 08/19/2024 to the Quarterly Review dated 08/03/2025.Problem dated 08/26/2025 Update: On 8/25/2025-Resident noted with fall from bed, hematoma noted to occipital area. Neuro checks initiated. See nurse's notes. Transferred to hospital for further evaluation.GOALInjuries related to falls will be minimized with daily intervention, re-directing and the use of assistive devices during the next 90 days.Estimated Date: 11/04/2025INTERVENTIONS:Evaluation as needed by rehab and nursing for safety equipmentand interventions to reduce fall risk. Monitor clinical concerns that may contribute to poor safety awareness such as: UTI (Urinary Tract Infections), hydration, medications, acute anemia, physical limitation and coping methods. Evaluate the effectiveness and continual need for safety equipment on a quarterly basis and/or as condition changes. Staff to anticipate and prioritize needs: reduce time in room alone, encourage activities, one of the last residents put to bed, reduce naps in daytime hours, personal items within reach, call light within reach, report poor sleeping patterns, etc. Follow code star protocol, keep floor clean, dry and free of debris: encourage use of non-skid soles and use of appropriate device with assistance for ambulation and transfers. Keep call light within reach and remind resident not to get up unassisted. Resident #4Observation on 09/18/2025 at 9:25 AM of Resident #4's morning care provided by Certified Nursing Assistants Staff C and D and revealed the resident was confused at times and communicated in English and Spanish at the same time.Record review of Resident #4's clinical records revealed the resident was initially admitted on [DATE] and readmitted [DATE]; clinical diagnoses included but not limited to: Alzheimer's disease, Chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, Review of Resident # 4 Care Plans indicated:PROBLEM:- Review dated 05/25/2022 [Resident #4] has the potential for falls related to decreased safety awareness, use of psychotropic medications, impaired mobility. Dx (diagnoses)includes anxiety, Alzheimer's, and dementia.Resident # 4's Care Plan Problems remained the same from 08/18/2022 to 01/31/2023.On 03/02/2023 Update: late entry for 2/21/2023- Resident observed on floor in room. See nurses' notes. No apparent injuries noted at the time. Neuro checks started. She continues to be monitored.Record review revealed no changes on Resident #4's Care Plans' section for Problem from 03/2023 until the Quarterly Review dated 09/04/2025 noting: Resident is not on psychotropic meds at this time. GOAL:-Injuries related to falls will be minimizedwith daily intervention, re-directing andthe use of assistive devices during thenext 90 days.Estimated Date: 12/05/2025 INTERVENTIONS:- Evaluate as needed by rehab and nursing for safety equipmentand interventions to reduce fall risk.-Monitor clinical concerns that may contribute to poor safetyawareness such as: UTI, hydration, medications, acute anemia, physical limitationand coping methods.-Evaluate the effectiveness and continual need for safetyequipment on a quarterly basis and/or as condition changes-Staff to anticipate and prioritize needs: reduce time in room alone,encourage activities, one of the last residents put to bed, reduce naps in daytimehours, personal items within reach, call light within reach, report poor sleepingpatterns, etc.-Follow code star protocol.-Keep floor clean, dry and free of debris: encourage use of non-skid soles and use of appropriate device with assistance for ambulation and transfers*Keep call light within reach and remind resident not to get up unassisted.-1/4 side rails up as needed to assist with positioning and personal care tasks.-Monitor at least q2-3 (every 2 to 3) hours and PRN (as needed) when in room for safety andcomfort.-Maintain low bedMonitor psychotropic drug use for side effects related to falls such as over sedation, hypotension, increased restlessness and notify MD of abnormalFalling Star Program per facility protocolINTERVENTION: 5/8/2023-Bilateral floor mats when in bed as ordered Interview on 09/18/2025 at 3:02 PM, the Care Plan Coordinator was asked what interventions were implemented for Resident # 1 after the fall on 02/14/2024 and 3/14/2025 she stated: I don't know what interventions were implemented and I need to check with [Risk Manager]; the Care Plan Coordinator left the room and returned at 3:34 PM. The Care Plan Coordinator stated that the goals and interventions in care plans for residents at risk of falls are centered around the residents. Although the goals and interventions may be similar and include regular evaluations and monitoring .On 09/19/2025 at 3:36 PM, the Care Plan Coordinator, Director of Nursing, and Risk Manager informed staff about the identified concerns related to the lack of individualized care plans. Interview on 09/18/2025 at 4:54 PM Resident # 1's Physician was asked what interventions were expected after Resident #1's fall that occurred on 2/14/2024 with no interventions implemented until the fall that occurred on 08/25/2025; he stated: After the first fall she should have had fall precaution such as the floor mats and low bed in place to prevent fall with injuries even though she was bedbound.

Based on observations records reviewed and interviews, the facility failed to provide adequate supervision and safety measures for two (Resident #1 and Resident #4) out of four sampled residents as evidence by Resident #1 has severe cognitive impairment experienced a fall out of bed due to lack of supervision during personal care, resulting in a head injury. 2)During Resident #4's personal care, staff failed to use fall prevention devices properly, leaving the resident at risk of falling. There were 186 residents residing in the facility at the time of the survey. The findings include:Review of the facility's organization's policy titled, Accident Hazards/Supervision/Devices revised February 2025 documented: Policy Statement: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1) Identifying hazards and risks, 2) Evaluating and analyzing hazards and risks, 3) Implementing interventions to reduce hazards and risks and 4) Monitoring effectiveness and modifying interventions. Resident #1On 09/18/2025 at 9:19 AM and 11:15 AM Resident #1 was observed in bed with eyes closed. Bed in lowest position and bilateral safety mats on floor.Review of resident #1's clinical records revealed an initial admission dated 6/26/2023 and readmitted on [DATE] (resident was hospitalized from [DATE] to 8/30/2025). Clinical diagnoses include but not limited to Dementia, Pressure-induced deep tissue damage of right heel and Constipation, unspecified.Review of Resident #1's Physician Order (POS) for August to September 2025 included but not limited to Eliquis 2.5 mg (milligrams) 1 tablet BID (twice daily) ASA (aspirin) 81 mg QD (daily) and Lactulose 10gm/15 ml (10 milligrams per 15 milliliters) -20gm/30ml QD for constipation.Review of nurse's notes dated 8/27/2025 timestamped 01:02:04 incident dated 08/25/2025time of incident: 03:50 incident type-Fall: CNA reported while providing morning care, patient rolled over the bed and fell, striking the back of the head large hematoma to the occipital area noted. Large amount of blood noted. CNA remain at the bedside throughout the event. Patient remained alert able to speak to staff and 911 no s/s of distress noted or loss of consciousness observed patient was transferred to [NAME] south via 911Review of Resident #1's Quarterly Minimum Data Set (MDS) dated [DATE] cognitive Section's Brief Interview for Mental Status (BIMS) documented a score of 00 on a scale of 0 to 15, which indicates severe cognitive impairment.Review of Resident #1's Care Plan dated 08/03/2025 Quarterly Review updated 08/26/2025 documented: On 8/25/2025-Resident noted with fall from bed, hematoma noted to occipital area. Neuro checks initiated. Transferred to hospital for further evaluation. Interventions added on 9/12/2025 indicated: Bilateral bed wedges when in bed as ordered and an intervention added on 9/16/2025 indicated Bilateral floor mats when in bed as ordered. Review of Resident #1's hospital records documented: pt (patient) brought by [local rescue] for fall or rollover from St [NAME] Nsg. (Nursing) Home today about 30 minutes ago, pt has hx. (history) of dementia. It was noticed on arrival that pt was on blood thinners Eliquis once she was in the ED (Emergency Department) room. Code resuscitation called on arrival after pt was bedded. (Emergency Services) asked St [NAME]'s staff multiple times if she was on anticoagulants. Staff at St [NAME]'s told them no but once she arrived at ED it was on her med rec. Pt arrived with scalp laceration and bleeding. General: .Scalp: puncture woundCT (Computerized Tomography) Brain:1. No acute intracranial hemorrhage, midline shift, or mass effect.2. There is a right posterior parietal laceration, contusion and hematoma.Discharge Patient, 08/30/2025 06:27:00 EDT (Eastern Daylight Time), Fall I Syncope I Atrial fibrillation I GIB (gastrointestinal bleeding).Interview on 09/08/2025 at 2:41PM The Risk Manager revealed Resident #1's first fall in the facility happened in 2024 and no staff was involved. The second fall occurred on 08/25/2025, the resident rolled from the bed when the CNA (Certified Nursing Assistant) went to change gloves, the resident fell from the bed, the fall was just a normal hematoma. The CNA was working alone, it depends on the patient, then they work in pairs. At that time the resident did not have wedges on the side of the bed and the CNA said she had her in the middle of the bed. On average each CNA is assigned 10-12 patients at night (11:00PM to 7:00AM shift) and they work in pairs. The resident was in the hospital for a little over a week. When asked if the fall could have been prevented; the Risk Manager stated: She (Resident #1) is not a very active maybe the fall could not have been prevented. The Risk Manager revealed the incident was reported as an adverse incident and not negligence.Interview on 09/08/2025 at 2:29 PM the Assistant Director of Nursing (ADON) revealed: As far as I know the CNA was providing care and turned around to change gloves and the resident fell of the bed. The staff had the bed at required level. I was not here so I only went by what the staff said and from the reports.Telephone Interview on 09/08/2025 at 4:01 PM, Staff B, Licensed Practical Nurse (LPN) stated: Around 3:00 in the morning on a Monday morning I was charting at the nursing station and around 4:00 AM the CNA was giving care and she ran to the nursing station the CNA was shaking she said she was giving care the patient had a large BM (Bowel Movement) when I went to the room the sheet everything was full of BM; the patient was on the floor and I called my supervisor. I tried to reach the family.and made several calls. We sent her to the hospital and the son called back and we told him what happened [Resident #1] was talking to everybody. I did not see what happened.the room and in the hallway was smelling bad. The only thing I saw was the patient on the floor.On 09/18/2025 at 4:06 PM, telephone interview with Staff A,CNA assigned to Resident #1 on the night of the incident stated: During patient care I had everything set up with me she had a large stool, it got on the sheet and was all over and it got on my gloves and I turn and took off the gloves and throw it in the garbage to put on new gloves while I was putting on the new gloves she was on her side and she fell off the bed; I go towards her on the other side of the bed and asked if she was ok and she said yes. I immediately went to get the nurse and told her the patient fell, and she pretty much took care of her I did see a little bit of blood on the floor. It was revealed that Staff A started working in the facility in June 2025 and had only been a CNA for a few months and after training for seven (7) days she worked alone. Staff A stated: It is hard to work in pairs because sometimes I have 15 to 20 residents to care for by myself.During telephone interview on 09/18/2025 at 4:54 PM, Resident # 1's Physician was asked about the incident involving Resident # 1's fall with injury and expectation as far as the required interventions for a resident such as Resident # 1 who had fallen before; the doctor stated: They called me, and I sent her to the hospital for CT scan. Normally after the first fall the interventions include the bed to be placed in the lowest position and floor mats, no order is needed, this is the standard protocol; they do not need to call me. After the first fall and patients at risk for fall, including bedbound, should have floor mats including bed in lowest position to prevent another fall that could cause injury. The doctor was asked about Resident #1's fall that occurred on 2/14/2024 that documented: The resident was observed after the fall with skin tear to the right hip; and no interventions were implemented until the fall that occurred on 08/25/2025. He stated: After the first fall she should have fall precaution such as the floor mats and low bed in place to prevent fall with injuries even though she was bedbound.During an interview on 09/18/2025 at 5:09 PM with the Nursing Home Administrator, Director of Nursing and the Risk Manager, the identified concerns were discussed including the staffing schedule on the night Resident # 1 fell and sustained injuries. The DON revealed, from the first fall Resident #1 should have floor mats and a physician's order is needed for floor mats and from a professional standard it would be considered as a gap in communication. Root Cause Analysis (RCA) has not made recommendations, but we could have a standing order for everyone that falls. The DON revealed the fall was unavoidable. When asked why the incident was not reported as neglect, the DON indicated the incident was not intentional and neglect would be considered as being intentional. The Risk Manager revealed on the night Resident # 1 fell and was injured each CNA had 14 residents to care for. Resident #4Observation on 09/18/2025 at 9:25 AM of Resident #4's morning care provided by Certified Nursing Assistants Staff C and D revealed Staff D left the room to get a pair of socks for the resident while Staff C continued providing care. At 10:22AM Staff C, went to the left side of the bed leaving the right side padding/wedge used for fall prevention down, the resident was noted laying on the bed closer to the edge Staff C, returned to the right side of the bed and provided care; then at 10:28 AM Staff C, went to the right side of the bed leaving the left side padding/wedge down.Record review of Resident #4 clinical records revealed the resident was initially admitted [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Alzheimer's disease, Chronic obstructive pulmonary disease, Unspecified atrial fibrillation and Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene.Review of Resident #4's Physician Orders Sheet for September 2025 documented orders that include: Tradjenta (linagliptin) S mg (milligrams) 1 tablet/ 5mg) by mouth daily for Diabetes; [Eliquis]Apixaban 2.S mg 1 tablet 12.5 mg by mouth twice a day for Atrial Fibrillation.Care Plan Goal indicated Injuries related to falls will be minimized with daily intervention, re-directing and the use of assistive devices during the next 90 days. Estimated Date: 12/05/2025.Interview on 09/18/2025 at 2:12 PM Staff C, Certified Nursing Assistant, revealed she started working in the facility August of 2024. I am supposed to put the side up when I am not at the side, but I forgot, and I was nervous. The resident should be in the middle of the bed when I position the resident. On 09/18/2025 at 2:21 PM RN, Unit Manager, was informed of the identified concerns during Resident #4's morning care the unit manager acknowledged the concern and indicated the staff should not have left the side wedge down while on the opposite side of the bed and for bed mobility the resident should be in the middle of the bed and if help is needed call for help.

Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct an identified quality deficiency in the problem area related to repeated deficient practice for F 880-Infection Prevention & Control. As evidenced by: F 880 was cited during a Recertification survey ending 11/09/23 when the facility failed to implement infection control procedures for one (Resident #430) as evidenced by Respiratory equipment (Nebulizer and tubing) stored uncovered on bedside table next to a live plant. There were 190 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during a recertification conducted on November 06, 2023, through November 09, 2023, at the facility. F 880 Infection Prevention & Control was cited as the facility failed to implement infection control procedures for one (Resident #430) as evidenced by Respiratory equipment (Nebulizer and tubing) stored uncovered on bedside table next to a live plant. Review of the facility policy and procedures titled Quality Assurance and Performance Improvement (QAPI) revision date 10/25/24 states: As part of catholic Health Services, Our Mission is to provide health care and services to those in need, to minimize human suffering, to assist people to wholeness and to nurture an awareness of their relationship with God. Our vision is to strive to improve the health, independence and spiritual life of the elderly, the poor, and the needy in the archdiocese, through innovative and proactive approaches to: Managing care and providing services. Facilitating transitions across levels of care. Community partnerships and collaboration. Advocacy efforts. The primary objective of Quality Assurance & Performance Improvement (QAPI) is to monitor, assess and improve the performance of critical focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors on a continuous basis throughout the facility. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 01/15/2025,2/19/25, and 3/19/25 documented the facility have QAA Committee meetings monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Control Preventionist/Risk Manager, Dietary Manager, Clinical Dietician, Director of Housekeeping, Director of Maintenance, Director of therapy, Director of Human resources, Director of admissions, Director of Business office, Director of Social Services, Director of Activities, MDS (Minimum Data Set) Coordinator. Interview on 04/10/2025 at 5:56 AM with Administrator (NHA) stated the QAA Committee meets every month on the last Thursday of the month, the last meeting was held in the month of 03/2025. The committee consists of the Medical Director, Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist and all interdisciplinary team members. The purpose of QAA is looking at processes to implement improvements, monitoring what we can improve to benefit our residents, knowing what our residents' needs are and meeting them. Continuously updating the facility assessment based on the care needs of the residents.

Based on observations, interviews and record review the facility failed to implement infection prevention and control practices and standards for three (Resident #84, Resident #41 and Resident #73) out of seven sampled residents as evidenced by Incentive Spirometer was observed on Resident #84's nightstand bedside with no protective covering. Staff failed to clean the cuff on the vital signs machine between residents. There were 190 residents residing in the facility at the time of the survey. The findings included: Resident #84 On 4/07/25 at 8:19 AM Resident #84 was observed in bed. An incentive Spirometer that was not in use at that time with no protective covering was observed on the nightstand next to the resident. (photographic evidence). Staff B, Registered Nurse (RN) was asked if Resident #84 uses an incentive Spirometer; Staff B stated: Yes, this resident (Resident #84) uses the Spirometer for respiratory issues since she came from the hospital. Staff B, RN was asked about the protocol for storing respiratory supplies when not in use; stated: It should be stored in a plastic bag and dated when not in use. Staff B, RN was notified about the observation and entered the room with the surveyor and observed the Incentive Spirometer that was not bagged on nightstand. Record review of a demographic sheet revealed Resident#84 was admitted to the facility on [DATE] with diagnosis that include COPD (Chronic Obstructive Pulmonary Disease) with acute exacerbation and other pulmonary embolism without acute Cor pulmonale. Record review of a Minimum Data Set (MDS) reference dated 3/9/25 revealed Resident #84 is moderately impaired cognitively, required set up clean up assistance for eating/oral hygiene, had no impairment of upper extremities. Record review of a care plan dated 10/02/24 revealed Resident #84 had the potential for shortness of breath, alteration in respiratory status due to S/P (Status Post) hospitalization due to chest pain and SOB (Shortness of Breath), noted pneumonia and pulmonary embolism, suggestive atelectasis on the right and left lower lobe, needs continuous oxygen. Interview on 4/10/25 at 9:01 AM, the Director of nursing (DON) was interviewed about the protocol for proper storage of respiratory devices while not in use; the DON stated: we don't have a protocol for storing the incentive Spirometer but is to be stored in a plastic when not in use for infection control, but is kept not in bag so it can be readily available to the resident. Resident#41 On 4/07/25 at 9:15 AM Resident #41 was observed seated in a wheelchair in the room. Staff B, RN entered the room with a vitals machine and was observed while Resident # 41's blood pressure (B/P)was measured, Staff B, RN placed the B/P cuff on the resident's right arm and measured the blood pressure then removed the cuff and placed it on the vitals machine and performed hand hygiene and exit the room. Staff B, RN then re-entered room with a handheld sphygmomanometer (Blood Pressure machine) and placed the cuff on Resident #41's arm and measured the B/P. Staff B, RN then administered medications, performed hand hygiene and exited room. Staff, RN did not disinfect either cuff. There were no disinfectant wipes on the machine. Resident#73 On 4/07/25 at 9:35 AM Staff B, RN entered Resident#73's room with the same vitals machine and explained to resident the procedure to measure B/P, performed hand hygiene and proceeded to place cuff on Resident #73's left arm and was stopped by the surveyor and asked to step outside the resident's room. Staff B, RN was asked about the protocol for cleaning/disinfecting the shared blood pressure cuff; Staff B, RN stated: I usually disinfect the B/P cuff after each use, but I was nervous. During an interview on 4/10/25 at 9:13 AM, the DON revealed: Staff are to clean the vitals machine with bleach wipes between residents to prevent infection. Record review of a Policy Subject: Infection Control Surveillance Policy#4011 Effective: 12/3/2004 Revised: 5/25/2016 Reviewed: 10/25/2024 revealed INTRODUCTION: The intent of any surveillance method is to measure outcomes and processes of care as a component of an overall resident safety and the Performance Improvement Program. Surveillance requires an integrated, collaborated effort throughout the organization to achieve the goals of the Infection Control Program. These goals are: To reduce the risk of infection between healthcare personnel and residents. Reduce the risk of nosocomial infections developing in residents related to the use of devices and required procedures.

Based on observations, interviews and record review the facility failed to provide appropriate respiratory care consistent with professional standards of practice, for one ( Resident #95) out of two sampled residents receiving oxygen as evidenced by observations of oxygen in progress at 1.25 liters per minute despite a physician's order for 2 liters per minute for Resident #95. The findings included: On 4/08/25 9:40 am Resident #95 was observed in bed with eyes closed, oxygen in progress at 1.25 Liters per minute via nasal cannula. (Photographic evidence). On 04/08/25 at 11:40 AM Resident #95 was observed in bed with no apparent distress, oxygen was in progress at 1.25 Liters per minute via nasal cannula (photo). Staff C, Registered Nurse (RN) was asked what the prescribed rate for oxygen delivery for Resident #95 and stated, It should be at 2 Liters per minute as needed. Staff C, Registered Nurse (RN) entered the room with surveyor, visualized the oxygen level and adjusted to the prescribed rate. Staff C, Registered Nurse (RN) checked Resident #95's oxygen saturation, and it was 76%. Staff C, Registered Nurse (RN) revealed Hospice would be notified. On 4/08/25 at 12:00 PM Staff D, Hospice Registered Nurse (RN) evaluated Resident #95 and revealed a new oxygen saturation rate of 96%. Staff C, Registered Nurse (RN) stated, I did round this morning, but I did not visualize if the oxygen was at the ordered level. Record review of a demographic sheet revealed Resident #95 was admitted on [DATE] with diagnosis that included: Acute chronic diastolic congestive heart failure (CHF) and nonrheumatic aortic valve stenosis. Record review of a Quarterly Minimum Data Set (MDS) reference dated 3/9/25 revealed Resident #95 had a Brief Interview of Mental Status (BIMS) score of 7, indicating severe cognitive impairment, dependent on ADLs (Activities of Daily Living), received hospice care and oxygen therapy. Record review of a Care Plan dated 03/12/2023 and revised 4/08/25 revealed Resident #95 had the potential for shortness of breath, alteration in respiratory status due to Chronic Obstructive Pulmonary Disease, CHF, End stage of Cardiac disease with interventions that included: Administer oxygen and nebulizer treatments as ordered, apply oxygen via nasal cannula Oxygen 2.0 liter per min continuous as ordered. Record review of a Physicians Order Sheet revealed Resident #95 had orders dated 10/30/24 to apply humidified oxygen via nasal cannula at 2.0 liter per min as needed and an order dated 4/08/25 to apply humidified oxygen via nasal cannula at 2.0 liter per min continuous. On 4/10/25 at 9:08 AM The Director of Nursing was interviewed about the oxygen protocol and stated, Oxygen is to be delivered at the prescribed rate whether it is continuous or as needed. Record review of a Policy Subject: Oxygen Concentrators, Policy#2012, Effective: 3/1/2008, Revised: 9/6/2013, Reviewed: 10/16/2024 revealed Policy: Oxygen Concentrators will be used for patients and residents that require oxygen with a liter flow rate of 1 to 5 liters per minute. PURPOSE: The device is a means of delivering oxygen to the patients and residents in small mobile units that extract oxygen from room air and provides continuous supply of oxygen without refilling. PROCEDURES: This equipment is to be used on all patients and residents that require oxygen with a liter flow rate of 1 to 5 liters per minute. Turn the knob of the flowmeter until the ball is centered on the line that indicates the prescribed flow rate. To increase the flow, turn the knob counterclockwise; to decrease the flow rate, turn the knob clockwise.

Based on observations, interviews and record reviews, the facility failed to provide appropriate treatment and services to prevent Urinary Tract Infection (UTI) for one (Resident #182) out of one resident reviewed for an indwelling urinary catheter, a evidenced by inappropriate placement of the urinary drainage bag anchored on the side rail above the resident's head increasing the risk for UTI and dislodgement. The findings included: On 4/07/25 at 9:46 AM Resident#184 observed lying in bed. An indwelling urinary catheter drainage bag was observed anchored to the side rail above near the resident's head. The surveyor requested to speak with the supervisor in the room. Staff A, Registered Nurse (RN) Supervisor entered the room and was asked if the indwelling urinary device drainage bag was positioned correctly. Staff A, Registered Nurse (RN) Supervisor stated, The drainage bag should be lower than the bladder. Staff A, RN Supervisor then performed hand hygiene and donned gloves, adjusted the indwelling urinary drainage bag and secured it below the bladder level to the bed frame. Staff A, RN stated, I don't know why as that high because haven't done rounds in this room yet. Record review of a demographic sheet revealed Resident#182 was admitted on [DATE] with diagnosis that included: Benign Prostate Hyperplasia (BPH) with lower urinary tract symptoms. Record review of physician order sheet revealed Resident#184 had order dated 2/7/25 to provide indwelling urinary catheter care every shift . Record review of an Admission Minimum Data Set (MDS) reference dated 2/13/25 revealed Resident#184 is cognitively intact. Requires partial/moderate assistance for toileting hygiene/personal hygiene/transfers, has an indwelling catheter, diagnosis of BPH and obstructive uropathy, has a PU (Pressure Ulcer) injury Record review of care plan dated 2/25/25 reveled Resident #184 was at an increased risk for infection related to indwelling catheter due to urinary retention with interventions that included: Maintain anchoring device to prevent dislodgement of catheter or pulling against meatus and monitor site of anchor for skin integrity. Interview on 4/7/25 at 10:18 AM Staff B, RN was notified of the identified concern and asked about the protocol for positioning of the urinary drainage bag. Staff B, RN stated: When I come on shift, I do rounds in each room on my assignment and do frequent rounds throughout shift. This morning [Resident#184's] indwelling urinary catheter was in place. The [] bag should be below the body. The purpose is to facilitate urine flow because it could cause the urine to back flow and cause infection. On 4/10/25 at 8:59 AM, the Director of Nursing stated: If a resident is in bed the drainage bag is hung below the level of the bladder. Staff are educated about how to position drainage bags. Record review of a Policy Subject: [brand] Catheter Care, Policy # 2032, Effective: 4/6/2005, Revised: 8/12/2019, Reviewed: 10/16/2024 revealed Policy: It is the policy of this facility that catheter care will be provided to all residents with indwelling catheters at least daily and more often as needed due to soiling with feces or when it is deemed necessary by the nurse .The purpose of catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. BASIC PROCEDURES: The catheter and drainage bag should be kept as a closed system with the drainage bag kept at a level lower than the bladder to allow drainage by gravity.

Based on observations, interviews and record reviews, the facility failed to develop and implement a fall care plan for two (Resident #25 and Resident #52) out of 13 residents who have orders for floor mats. record review revealed no interventions for floor mats for Resident#25, observations revealed one floor mat in place for Resident#52; and failed to implement a respiratory care plan for one (Resident #95) out of two sampled residents receiving oxygen, as evidenced by Resident #95 oxygen flow rate note in progress at 1.25 Liters Per Minute (LPM) instead of the ordered rate of 2 LPM. The findings included: Resident#25 Observation on 4/07/25 at 10:00 AM, Resident #25 was in bed; one floor mat was noted on the floor at the left side of the bed. Staff A, Registered Nurse (RN) Supervisor revealed: This Resident need two floor mats. Staff A, RN Supervisor, was unable to find another floor mat in the room. Staff E, Certified Nursing Assistant (CNA) approached the surveyor and was interviewed about floor mats and protocol. Staff E stated: I am the Certified Nursing Assistant assigned to [Resident #25] today. [Resident #25] usually only has one floor mat in place. My responsibility is to make sure the floor mats are placed on each side and the bed is low because they have tried to get out or have fallen. Record review of a demographic sheet revealed Resident #25 was admitted on [DATE] with diagnosis that include: Presence of Right artificial hip joint; End stage renal disease, S/P-operative repair of hip fracture; Muscle Weakness (generalized and Alzheimer disease. Record review of nursing notes dated 7/31/24 revealed Resident #25 was found on the floor and on 10/22/24 revealed Resident#25 was found on the floor. Record review of a Quarterly Minimum Data Set (MDS) reference dated 2/1/25 revealed Resident#52 is severely cognitively impaired; dependent for Activities of Daily Living (ADL), has impairment on upper and lower extremities . Record review of a physician order sheet (POS) revealed Resident#25 had order dated 4/6/25 for bilateral floor mats when in bed every shift. Record review Resident#25's care plan dated 8/6/24 and reviewed on 2/7/25 revealed Resident#25 complained of pain to right leg after a fall on 7/31/24 and X-ray results were positive for a fracture to femur. Further review revealed interventions included: maintain bed in lowest position, monitor every 2-3 hours and as needed (PRN) when in room for safety and comfort, keep call light within reach and remind the resident not to get up unassisted. No interventions for floor mats were included. On 4/7/25 at approximately 11:00 AM, Staff F, MDS Coordinator, was asked if floor mats should be included in the care plan; Staff F went to check then returned and presented a care plan to that now included intervention floor mat as ordered (4/7/25). Resident#52 On 4/07/25 at 9:46 AM Resident#52 observed in bed with eyes closed, no apparent distress, bed low, one floor mat was in place on resident's right side and the other floor mat was folded up and leaning against the nightstand (Photographic evidence). Staff E, Certified Nursing Assistant (CNA) entered the room and was asked how many floor mats are required for Resident #52. Staff E stated: [Resident #52] is supposed to have two floor mats down, when I assisted the resident, I put one up. Record review of a demographic sheet revealed Resident #52 was admitted on [DATE] with diagnosis that include: Fracture unspecified part of neck of femur, Vitamin D deficiency and muscle weakness. Record review of a Physician Order Sheet (POS) revealed Resident #52 had an order dated 2/29/24 directions: Bilateral floor mats when in bed every shift. Record review of a Nursing note dated 3/22/25 revealed at 3:15 AM Resident #52 was found by CNA on the floor mat in the bedroom. Further review of nursing notes revealed on 3/14/25 Resident #52 was found on the floor next to the bed on the floor mattress. During an interview on 4/7/25 at 10:18 AM, Staff B, Registered Nurse (RN) revealed: I am the nurse for this resident. When I come on shift, I do rounds in each room on my assignment. I do frequent rounds. They have floor mats because they try to get out of bed without assistance. I did not communicate with the assigned CNA this morning the amount of floor mats needed. In general, I communicate with the CNAs. During an interview on 4/10/25 at 8:54 AM, the DON was asked about the protocols for floor mats. The DON stated: The falling star program to identify how a fall was caused and to help prevent further falling. Some interventions include floor mats to prevent them from hitting a hard surface. If a resident has floor mats there is a physician order for it and during huddles at the end of each shift staff discuss the fall prevention interventions . The residents are supposed to have two floors mats the only time the floor mat should be removed is during care. The staff are to fold it up during care, so they are not standing on it and place it back before they walk away. Resident #95 On 4/08/25 9:40 am Resident #95 was observed in bed with eyes closed, oxygen in progress at 1.25 Liters per minute via nasal cannula. (Photographic evidence). On 04/08/25 at 11:40 AM Resident #95 was observed in bed with no apparent distress, oxygen was in progress at 1.25 Liters per minute via nasal cannula (photo). Staff C, Registered Nurse (RN) was asked what the prescribed rate for oxygen delivery for Resident #95 and stated, It should be at 2 Liters per minute as needed. Staff C, Registered Nurse (RN) entered the room with surveyor, visualized the oxygen level and adjusted to the prescribed rate. Staff C, Registered Nurse (RN) checked Resident #95's oxygen saturation, and it was 76%. Staff C, Registered Nurse (RN) revealed Hospice would be notified. On 4/08/25 at 12:00 PM Staff D, Hospice Registered Nurse (RN) evaluated Resident #95 and revealed a new oxygen saturation rate of 96%. Staff C, Registered Nurse (RN) stated, I did round this morning, but I did not visualize if the oxygen was at the ordered level. Record review of a demographic sheet revealed Resident #95 was admitted on [DATE] with diagnosis that included: Acute chronic diastolic congestive heart failure (CHF) and nonrheumatic aortic valve stenosis. Record review of a Quarterly Minimum Data Set (MDS) reference dated 3/9/25 revealed Resident #95 had a Brief Interview of Mental Status (BIMS) score of 7, indicating severe cognitive impairment, dependent on ADLs (Activities of Daily Living), received hospice care and oxygen therapy. Record review of a Care Plan dated 03/12/2023 and revised 4/08/25 revealed Resident #95 had the potential for shortness of breath, alteration in respiratory status due to Chronic Obstructive Pulmonary Disease, CHF, End stage of Cardiac disease with interventions that included: Administer oxygen and nebulizer treatments as ordered, apply oxygen via nasal cannula Oxygen 2.0 liter per min continuous as ordered. Record review of a Physicians Order Sheet revealed Resident #95 had orders dated 10/30/24 to apply humidified oxygen via nasal cannula at 2.0 liter per min as needed and an order dated 4/08/25 to apply humidified oxygen via nasal cannula at 2.0 liter per min continuous. On 4/10/25 at 9:08 AM The Director of Nursing was interviewed about the oxygen protocol and stated, Oxygen is to be delivered at the prescribed rate whether it is continuous or as needed. Record review of a Policy Subject: Care Planning Policy#2046 Effective: 12/3/2024 Revised: 2/22/2006 Reviewed: 10/16/2024 POLICY: Care, treatment and services are planned to ensure that they are appropriate to the resident's needs. Therefore, it is the policy of this Facility to provide an individualized, interdisciplinary plan of care for all residents that is appropriate to the resident's needs, strengths, limitations and goals. Care planning will be implemented through the integration of assessment findings, consideration of the prescribed treatment plan and development of goals for the resident that are reasonable and measurable. The plan of care will be documented through the use of computerized care planning. PROCEDURE: The plan of care shall be individualized, based on the diagnosis, resident assessment and personal goals of the resident and his/her family. The planning for care, treatment and services will include the following: The plan of care will be individualized to the needs of the resident.

Based on observation, record review and interview, the facility failed to accurately complete a Level I Preadmission Screening and Resident Review (PASRR) for one (Resident #166) out of 5 residents investigated for Level I PASRR. There were 190 residents residing in the facility at the time of the survey. The findings included. Record review of a demographic sheet for Resident #166 revealed an admitted [DATE] with diagnosis that included: Depression, unspecified. Further review revealed Admissions Minimum Data Set (MDS) reference dated 3/18/25 Section A1500. Preadmission Screening and Resident Review (PASRR), Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? - No. Section I revealed anxiety disorder, and Depressive Disorder. Section N revealed Resident#166 was taking antipsychotic and antianxiety medications and Section O revealed Resident#166 received no Psychological Therapy. Record review of a physician's order sheet revealed orders dated 3/12/25 directions: Lorazepam one (1) milligram (mg) tablet dose via Percutaneous Endoscopic Gastrostomy (PEG) tube every twelve (12) hours for anxiety, and 3/21/25 Seroquel 25 mg tablet via PEG tube for Psychosis. Further review revealed a Psychiatric evaluation note dated 3/14/25 indicated medication included: Seroquel 25 mg at bedtime and the chief complaint included depression, anxiety and a history of psychosis. Record review of Resident #166's PASRR dated 3/11/25 revealed Section I: PASRR Screen Decision- Making A. MI or suspected MI (check all that apply): no diagnosis was checked. On 4/10/2025 at 4:34 PM, review of the most recent PASRR provided by the Social Services Director for Resident#166, dated 3/11/2025 revealed: Section I: PASRR Screen Decision- Making A. MI or suspected. MI (check all that apply): no diagnosis was checked. During an interview on 4/10/2025 at 5:00 PM, the Social Services Director, revealed Resident #166 was admitted on [DATE] and received a psychiatric evaluation on 3/14/25 and a resident review was scheduled to occur within 30 days of the psychiatric evaluation to assess any changes in the patient's condition. The Social Services Director acknowledged the discrepancies. During an interview on 4/10/2025 at 5:32 PM, the Director of Care Coordination stated: Any significant changes in a resident's condition are typically evident through behavioral changes and the facility continuously reviews the PASRRs within 30 days for further evaluation. If I was aware of these circumstances for earlier, I would have initiated a new resident review for [Resident#166] to include all the mental illness diagnosis to ensure appropriate care and documentation. Record review of a Policy and Procedure titled, Subject: Pre-Admission Screening and Resident Review (PASRR) Program revealed It is the policy of the facility to ensure compliance with Federal Regulation (CFR)483.100-483.138, which requires completion of the Pre-Admission Screen and Resident Review (PASRR) screen prior to admission to the facility. Purpose: The Level | and II PASRR Screening and Determination process is mandated by Federal Regulation (CFR) 483.100-483.138. The PASRR evaluation is designed to prevent inappropriate placement of residents/patients in a Skilled Nursing Facility (SNF). Level | Pre-Admission Screen and Determination applies to ALL new admissions and must be completed prior to resident admission by the acute care hospital or transferring

Based on observation, record review and interview, the facility failed to accurately the code Minimum Data Set (MDS) for one (Resident #200) out of five sampled residents; as evidenced by the resident was discharged to an Assisted Living Facility, and the MDS was coded to indicate that the resident was discharged to a Short-Term General Hospital. The findings included. Review of Resident #200's clinical records revealed the resident was admitted to the facility on [DATE] from a Short-Term General Hospital (acute hospital) Medical diagnosis included but not limited to: Other specified injuries of head, subsequent encounter. Review of orders dated 01/17/2024 noted Resident #1 to be discharged to the St. [NAME] Residence. Assisted Living Facility (ALF. The discharge/transfer was scheduled for January 18, 2025. Review of Resident # 200's discharge Assessment MDS reference dated 01/18/2025 indicated in the section for cognitive pattern that the resident is cognitively intact. The entry/discharge reporting section indicated: Discharge Assessment-return not anticipated. Type of discharge: Planned. The section for discharge status coded resident was discharged to a Short-Term General Hospital (acute hospital). Review of a Nurses Notes dated 01/18/2025 at 10:52:00 documented: Resident discharged to Adult Living Facility St. [NAME] ALF, on 01/18/2025 transported via wheelchair. During an interview on 04/10/2025 at 3:40 PM, Staff F, MDS Coordinator revealed, the Social Services department is responsible for inputting the discharge information, while the MDS department is tasked with verifying that the information is submitted in a timely manner. Staff F acknowledged that an error had occurred in this process and accepted responsibility on behalf of the department. Review of the facility policy and procedure effective April 6, 2005, regarding resident assessments stated, it is the policy of this facility that each resident admitted to the institution shall receive a complete head-to-toe admission observation/assessment by a qualified individual so that plan of care can be developed to best meet the needs of the resident. The observation/ assessment of the care or treatment required to meet the needs of the resident will be ongoing throughout the resident's facility stay, with the observation/assessment process individualized to meet the needs of the resident population.

Based on observation, record review and interview, the facility failed to implement infection control procedures for one (Resident #430) out of 35 sampled residents. As evidenced by Respiratory equipment (Nebulizer and tubing) stored uncovered on bedside table next to a live plant. There were 191 residents residing in the facility at the time of the survey. The Findings Included: During Observation on 11/06/23 at 09:45 AM, Resident #430 was sitting on the side of the bed in the residents room, the Oxygen (02) running at 2 Liters per minute (LPM) via Nasal canula (NC), Resident #430 stated he is waiting on his extra food. The nebulizer mask was stored on the residents bedside table uncovered next to a live plant (Photo Obtained). The 02-tubing with water dated 10/30/23 was stored in bag hanging from the wall. (Photo Obtained) During Observation on 11/07/23 at 09:24 AMm Resident #430 was in the wheelchair in the residents room eating breakfast. The 02 was running at 3lpm via NC, the nebulizer mask was on bedside table uncovered next to a live plant. (Photo Obtained). On 11/08/23 08:17 AM Resident#430 observed in bed awake, 02 running at 3 LPM via NC, nebulizer mask stored on bedside table uncovered next to live plant (photo). Review of the medical records for Resident #430 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but werenot limited to: Cough, Unspecified. Review of the Physician's Orders Sheet for November 2023 revealed, Resident #430 had orders that included but were not limited to: Oxygen (O2) at 2-4 liters /minute (LPM) via NC continuously for shortness of breath, Albuterol Sulfate 0.083% nebulization solution dose. (2.5mg/3ml) inhalation via nebulizer every 4 hours as needed for coughing and wheezing and Atrovent 0.02% solution-give 2.5ml via nebulizer every 4 hours as needed for cough and wheezing. Record review of Resident #430's Electronic Medication Administration Record (EMAR) revealed, the resident did not receive nebulizer treatments for the last 7 days (11/2/23-11/9/23). Record review of Resident #430 's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score of 15, on a 0-15 scale indicating the resident is cognitively intact. Section GG for Functional Abilities and Goals documented supervision for oral hygiene and eating, Partial assistance for personal hygiene and upper body dressing, Dependent for lower body dressing. Section J for Health Conditions documented shortness of breath or trouble breathing with exertion and when sitting at rest and Section O for special Treatments and Procedures documented resident received oxygen therapy and hospice care in the last 14 days while a resident. Record Review of Resident # 430's Care Plans Reference Date 08/31/23 revealed, the resident has the potential for Shortness of breath, alteration in respiratory status due to impaired mobility, end stage heart failure, and wheezing. Interventions include-Administer oxygen and nebulizer treatments as ordered. Document as needed use and effectiveness. Interview on 11/08/23 at 08:22 AM, Registered Nurse, D/E wing (Staff A) stated, I have been working here for 6 years, when I do my rounds, I check every room and resident assigned, make sure anything the resident has/needs are in place. The nurses do the respiratory treatment for the residents assigned, we change the mask once a week and if needed or if the mask is soiled. When the mask is not is used, the mask is stored in the dated bag on the wall for tubing supplies. If the mask is found on the floor or exposed, we will replace the mask. Interview on 11/08/23 at 08:39 AM, Registered Nurse, G wing (Staff B) stated, I have been working here for almost 1 year, I work all over the facility, I really do not have a specific assignment. During rounds and constantly during the shift we check on the residents to make sure the safety precautions are in place. The nurses do the respiratory treatments for the residents, once a week or as needed we change the respiratory supplies, after we do the nebulizer treatments, we clean the mask and store the nebulizer mask and tubing in the plastic bag on the wall that is dated until next use. Interview on 11/09/23 at 09:15 AM, the Assistant Director of Nursing (ADON) stated, I have been the ADON since last December 2022, the nurses have been educated to change the oxygen tubing once a week and as needed, the nebulizer mask and tubing are to be stored in the clear bag provided that is dated, when not in use. During rounds and throughout their shift the nurses are educated to check on the residents and make sure all fall, and safety precautions are in place, all respiratory equipment is stored correctly and to make sure that the residents are in no discomfort. Review of the facility's policy titled, Infection Control-Nursing revision date 8/22/2022 states-Nursing Staff are responsible for functions essential to the prevention, recognition, and management of infections. Prevention of infection is the main goal of the staff. This is accomplished by practicing good aseptic techniques, observing infection control policies and procedures, and recognizing the potential risks associated with invasive procedures.

Based on observations, interviews, and record reviews, the facility failed to provide maintenance/ repair services for wheelchair arm trays for one resident (#88) out of 35 sampled residents as evidenced by Resident(#88) reported armrest in disrepair for two weeks. The findings included: On 11/08/23 at 12:28 PM, in an observation and interview with Resident #88. The resident stated, My arm tray needs a screw. This has been going on for two weeks. I've told nurses and certified nursing assistants (CNA's). It was observed that Resident #88's left arm was wrapped in a towel and resting on the arm tray. When Resident #88 moved her arm, the tray fell loosely from the hinge. One out of two screws were missing from the arm tray that was attached to the wheelchair. On 11/09/23 at 08:46 A, in an interview with Resident #88. When asked, Have you told anyone about your arm tray to be fixed? Resident #88 stated, There was an administrator that called maintenance before, and it was fixed. Now, it's broken again. (See Photographic evidence) On 11/9/23 at 10:35 AM, it was observed that Resident #88 was sitting in a wheelchair at the nursing station heading to the salon. The wheelchair lap desk was missing one out of two screws. On 11/09/23 at 10:41 AM, in an interview with Staff D, NM (Nurse Manager). When asked, How does the staff report to maintenance that a wheelchair is broken or needs to be fixed? Staff D stated, When equipment is broken. We write it in the binder called wheelchair repair / broken equipment. We also notify the purchasing department. Review of the equipment work order request dating from 11/2/2022 revealed, that a work order was placed on 4/10/23 for Resident #88 stating, Arm tray is broken. Left side. The latest work order for the facility was from 8/3/2023. ( See photographic evidence) On 11/09/23 at 10:41 AM, in an interview with Staff D, when asked, Has Resident #88 reported to you that her arm tray had a missing screw or to be fixed? Staff D stated, On 4/10/23, I placed a work order to be done for the arm tray broken on the left side. Resident #88 sees me every day. She didn't tell me that the arm tray was broken. On 11/09/23 at 10:56 AM, in an interview with the Director of Maintenance. When asked, How is your department informed about maintenance and repairs of wheelchairs? Resident #88 said her arm tray needs a screw. The Director of Maintenance stated, Whatever issues with the wheelchair, the staff are to place it in the book. The maintenance department can fix it. We also can make adaptations like a full rest to the wheelchair for rehabilitation. I'm going to fix the wheelchair now for Resident #88. On 11/09/23 at 12:27 PM, in an interview with Staff E, LPN (Licensed Practical Nurse). When asked, How is Resident's #88s mobility in the wheelchair and were you aware or told of the arm tray being broken? Staff E stated, Resident #88 is non-ambulatory, uses a wheelchair, and receives assistance in/out of the wheelchair. Resident #88 has left-sided weakness and receives assistance to propel in a wheelchair. The wheelchair has a left armrest tray to assist with left-sided weakness. I am not aware that the armrest tray is broken. No one has informed me the appliance was broken. When there is a broken appliance. I notify the supervisor and maintenance using radio or work hub, which is a computer system where maintenance orders are placed. On 11/09/23 at 12:34 PM, in an interview with Staff C, CNA, When asked, How is Resident's #88 mobility in the wheelchair and were you aware or told about the armrest tray being broken? Staff C stated, Resident #88 needs assistance into the wheelchair. The staff or resident propels the wheelchair. I became aware of the armrest tray being broken three weeks ago. Resident #88 told me that the armrest tray was broken again, and I did not inform any other staff due to maintenance not working that day. Record review of Resident #88 revealed, a medical diagnosis of Hemiplegia (paralysis of one side of the body) and Hemiparesis (one-sided muscle weakness) following cerebral infarction (stroke) affecting the left arm non-dominant side. Record review of physician orders revealed, occupational therapy evaluation and treatment for wheelchair and positioning dated 03/21/2023. Record review of the minimum data set date(MDS) dated [DATE] revealed, in Section C (cognitive patterns), a brief interview of the mental status score was a 15 on a scale of 0-15 indicating the resident was cognitively intact. In Section GG (Functional Abilities and Goals), the resident needed some help from staff for indoor mobility and transfer, uses a manual wheelchair, requires moderate assistance to wheel 50 feet, and is non-ambulatory. In Section I (Diagnosis), the residents medical diagnoses of Cerebrovascular Accident (stroke), Transient Ischemic Attack (Stroke), Hemiplegia or Hemiparesis. Record review of the care plan dated 2/24/2023 revealed, Resident #88 had a mobility deficit as evidenced by decreased balance endurance safety awareness strength and requires maximum assistance with bed mobility, maximum assistance with transfers, and total assistance with wheelchair mobility. Interventions were to assist in transfers to and from bed, toilet, and chair observing safety measures. Maintain safety precautions. Encourage the resident to participate in bed mobility and praise efforts. Review of the facility's policy titled, Patient equipment/ bed repairs. Effective 4/1/2019. Last reviewed 8/14/23. The policy states the engineering department intends to place all patient-related equipment back in service as soon as possible. If the equipment is classified as clinical equipment, proper documentation will be provided to the biomedical department for their equipment history. In the section titled Procedure, 1. Upon either being notified or discovering that a patient's bed is inoperative, the bed, if there is no patient involved, will be transported to a maintenance shop for needed repairs or if possible fixed in the room. A. a repairs/service request describing the repairs to be done will be generated. Documentation of corrective repairs and equipment repair history will be maintained in the engineering department.

Based on observation, record review and interview, facility failed to ensure the kitchen dish machine was operating properly and maintaining the proper wash and rinse temperatures. There were 179 residents out of 195 residents who used the facility's eating utensils and dishes. Findings included: A follow up visit to the kitchen was conducted on 10/27/22 at 2:33 PM to observe the mechanical dishwashing process. Dishwashing was in progress with a multi tank dish machine in use that used high temperature sanitization. The dish machine had three temperature gauges on the front of the machine. The temperatures on these gauges were: Wash temperature: 145 degrees Fahrenheit (F) Rinse temperatures: 158 F Final rinse temperature: 191 F The hot water pressure gauge was 20 PSI (pounds per square inch). The data specification plate on the dish machine documented the following minimum dish machine temperatures and water pressure: Wash temperature: 150 degrees F Rinse temperatures: 165 degrees F Final rinse temperature: 180 degrees F. Pressure: 20 to 25 PSI The surveyor informed the evening Food and Nutrition Services supervisor, Staff A (contract food service staff) about the wash and rinse temperatures that were not reaching the minimum required temperatures. Staff A took a photo of the gauges. The gauge temperatures were still not reaching the proper temperatures at 2:43 PM, as the wash temperature and rinse temperature were 149 degrees F and 158 degrees F, respectively (Photographic evidence obtained). There were two Food and Nutrition Services staff working the machine at each end of dish machine. The surveyor asked the porter working on the soiled end of the dish machine (Staff D, contract food service staff), how often he checks the temperatures on the machine. He stated a couple of times. He stated that the wash temperature was not reaching the minimum required temperature. At the same time, there was a pipe near the pressure gauge was that was leaking water. On 10/27/22 at 2:46 PM, a maintenance associate, Staff E arrived, and the surveyor told him about the leaking pipe. He was not aware of the leaking pipe. According to the Weekly High Temperature Mechanical Ware Washing Machine Log, the staff were recording the wash temperatures and final rinse temperatures. The staff were not recording the rinse temperature of the middle gauge, as there was no place on the form to record these temperatures. The temperatures were recorded to be above the minimum required temperatures for the wash and final rinse temperatures on the Weekly High Temperature Mechanical Ware Washing Machine Logs. The dishes were observed to be clean by sight after washing through the dish machine. At 2:47 PM, the surveyor informed the evening Food and Nutrition Services Supervisor, Staff A about the leaking pipe and the wash temperature that was not reaching 150 degrees F, as it was 145 degrees F at the time. On 10/28/22 at 8:22 AM, the Director of Food and Nutrition Services (contract food service staff) stated that the leaking pipe was fixed. The contract food service Food Safety Policies and Procedures, revised on 4/01/22 included the following: Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 8, Cleaning and Sanitizing Food Contact Surfaces - .Washing, rinsing, and sanitizing procedures must be posted and adhered to at all manual and mechanical ware washing equipment in use .

Based on observation, record review and interviews, the facility failed to ensure that clean equipment was protected from contamination; clean eating utensils were stored to prevent contamination; Time/Temperature for Safety (TCS) foods were held at proper temperature; and equipment was properly sanitized. This has the potential to affect 179 residents out of 195 residents who consume the facility's food. Findings included: During a follow up visit to the kitchen on 10/26/22 at 4:21 PM, there was a caddy of eating utensils, containing forks and spoons that were stored with their handles down (photographic evidence obtained). Staff would have to touch the lip- or food-contact surface of the eating utensil to remove them from the caddy. The Director of Food and Nutrition Services (contract food service staff) stated that the Food and Nutrition staff use these utensils when they need for the tray line service. The Director of Food and Nutrition Services said these utensils should be stored handle side up. On 10/26/22 at 4:34 PM, a black insulated jacket (used for the walk-in freezer) was stored near clean equipment in food preparation area on the table with the stand mixer. Photographic evidence obtained. At 4:30 PM, on 10/26/22, the underside surface of the shelf over a steam table was coated with a brown substance (Photographic evidence obtained). The Director of Food and Nutrition Services observed the shelf in this condition. The surveyor asked for the equipment cleaning schedule. The equipment cleaning schedule was provided on 10/27/22 and it showed that the supervisor was supposed to clean the tray line after each use. Interview with the Director of Food and Nutrition Services on 10/28/22 at 8:22 AM, confirmed that the supervisor is supposed to clean shelf on the steam table as part of the cleaning the tray line after each use. During the beginning of the evening meal service on 10/26/22 at 4:44 PM, the surveyor asked about the scope sizes being used for the pureed beef and macaroni. One of the cooks had removed them and put them at the 3 compartment sink to be washed. The porter, Staff B (contract food service staff), who was manually washing dishes at the three-compartment sink, cleaned the scoops very quickly in soapy water; rinsed the scoops quickly under running water from the faucet; then dipped them in the sanitizer solution; and finally put them on the drain board. He did this twice. The scoops were not immersed for at least 30 seconds in the quaternary ammonium sanitizer solution to properly sanitize them. The porter, Staff B spoke Spanish and one of the cooks translated from English to tell him that he must leave the scoops in the sanitizing solution for at least 30 seconds. The porter Staff B still did not understand, so the cook had to explain it again and he understood. The surveyor asked the porter, Staff B if he could demonstrate testing the sanitizer level in the 3-compartment sink, and he said in basic English words that he does not speak English (his primary language was Spanish) and did not know how to test the sanitizer level (the surveyor knew basic Spanish). On 10/26/22 at 4:49 PM, the Food and Nutrition Services staff were taking holding temperatures of the hot food on the steam table before the evening meal. The holding temperature of the pureed beef was 124 degrees Fahrenheit (F). The host foods on the steam table were well ranged from 140 to 191 degrees F. The evening cook, Staff C (contract food service staff) took the temperatures of the pureed beef several times, and stirred the pureed beef, but the food temperature did not reach the minimum of 135 degrees F. She used a different digital thermometer to check the temperature and the pureed beef temperature was not above 126 degrees F. The surveyor asked the evening cook, Staff C what was the minimum temperature she was looking for and she replied 160 [degrees F]. The Director of Food and Nutrition Services came along and said, you know what to do - you take it out and reheat it. You're allowed mistakes. The surveyor asked evening cook, Staff C if she checked the final internal cooking temperature of the pureed beef and she said she did but didn't record it. She stated that the pureed beef was 170 degrees F when she finished cooking it. The evening cook, Staff C removed the pan of pureed beef from the steam table to reheat the food. At 5:07 PM, the evening Food and Nutrition Services supervisor, Staff A (contracted food services staff) was taking the holding temperatures of the cold food. She had a digital thermometer in a cup of ice water. It initially read 33 degrees F (rather than 32 degrees F). The surveyor advised Staff A that the cup needed more ice. She added more ice and the digital thermometer read 30 F. The surveyor asked the Staff A what temperature she was looking for when checking the accuracy of the thermometer and she was not able to say that it was supposed to be 32 degrees F. Review of the HACCP (Hazard Analysis and Critical Control Point) Critical Control Points Daily Temperature Log for the evening meal of 10/26/22, the Food and Nutrition Services staff were recording the hot and cold holding temperatures under the section for Cooking Internal Temperatures on the temperature log, rather recording them in the section on the log for Holding Temperatures (Photographic evidence obtained). The Food and Nutrition Services staff were not recording any internal cooking temperatures of hot food on the log for the month of October 2022. The Director of Food and Nutrition Services was made aware of this at the time. The evening cook, Staff C did not record the reheating temperature of the pureed beef on the temperature log for 10/26/22, and there was a section on the temperature log for recording reheated food. The Food and Nutrition Services staff were also not recording cooling temperatures of food on the temperature log for the month of October 2022. During the evening meal service on 10/26/22 at 5:29 PM, the surveyor observed a pan of pureed bread on a counter next to the steam table. The pureed bread was not on a heat or cold source to control the temperature of the food. The surveyor asked the Director of Food and Nutrition Services if the pureed bread should be hot or cold. The Director of Food and Nutrition Services said that it felt cold to him when he touched the side of the pan with his hand. The surveyor touched the side of the pan of pureed bread as well, and it was not cold like 41-degree F. The surveyor asked the Director of Food and Nutrition Services if the pureed bread was a TCS (Time/Temperatures Control for Safety) food (a food that requires time/temperature control for safety (TCS) to limit pathogenic microorganism growth or toxin formation) and he said he thought it was. The pureed bread was not under temperature control and the facility was not using time instead of temperature for public health control. The surveyor asked the Director of Food and Nutrition Services how the pureed bread was made. He said it was made with bread, water, and a thickener. The surveyor asked what bread was used for the pureed bread and the Director of Food and Nutrition Services said whole wheat bread. The surveyor and the Director of Food and Nutrition Services looked at the ingredient label on the commercially prepared fresh loaf bread package. The pan of pureed bread remained on the counter. The surveyor requested a recipe for the pureed bread. The Director of Food and Nutrition Services provided a recipe for the pureed bread on 10/27/22. However, the pureed bread recipe doesn't match the observed pureed bread product and the Director of Food and Nutrition Services' description of the pureed bread preparation. The pureed bread recipe called for a commercially manufactured pureed bread mix. On 10/28/22 at 8:13 AM, the Director of Food and Nutrition Services said they use the recipe but use fresh bread rather than a commercial pureed bread mix. The surveyor told the Director of Food and Nutrition Services that the commercially manufactured pureed bread mix might be formulated to ensure the product was not a TCS food when made, so it did not require temperature control. The Director of Food and Nutrition Services provided a copy on 10/27/22 of the Food and Nutrition Services staff in-service training for sanitizing/dish machine/3 compartment sink, which was completed on 9/30/22. On 10/28/22 at 8:21 AM, the Director of Food and Nutrition Services and the head Chef (contract food services staff) indicated that the porter, Staff B's signature was not included in the sign-in sheet for the in-service training conducted on the three-compartment sink on 09/30/22. The contracted porter, Staff B was hired on 2/08/22. The contract food service Food Safety Policies and Procedures, revised on 4/01/22 included the following: Section C - FDA Food Code, Chapter 3, C - 23 Cooling and Chilling - . Cooling and chilling temperatures must be taken with a calibrated thermometer and recorded on the HACCP Cooling and Chilling log. Section C - FDA Food Code, Chapter 3, C - 24 Hot and Cold Holding - . Cold foods must be held and served at a temperature of 40 degrees F (4 degrees Celsius) or below [The FDA Food Code standard is TCS cold food must be held at 41 degrees F or below] . Hot foods must be held and served at a temperature of 140 degrees F (60 degrees Celsius) or above [The FDA Food Code standard is TCS hot food must be held at 135 degrees F or above . Hot and Cold food service temperatures must be taken with a calibrated thermometer and record on the HACCP log . Temperatures must be taken and recorded at the time of service set up and at a minimum once every two hours during service. If service time is less than two hours a final hold temperature must be recorded if the food is not discarded. Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 3, Food and Equipment Temperature Measuring Devices - . Accurate food and equipment thermometers (cleaned, sanitized, and calibrated) are available and used by all food employees during storage, preparation, display, service and transportation . Thermometers must be accurate to at least +/- 2 degrees F from 32 degrees F (+/- 0.5 degrees Celsius from 0 degrees Celsius) . Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 8, Cleaning and Sanitizing Food Contact Surfaces - .Washing, rinsing, and sanitizing procedures must be posted and adhered to at all manual and mechanical ware washing equipment in use . Contact time with chemical sanitizer solution must meet manufacturer's instructions including water temperature requirements . Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D-9, Cleaning and Sanitizing Frequency - . Nonfood contact surfaces must be cleaned at a frequency necessary to preclude accumulation of soil residues . A cleaning schedule must be created and utilized. Identifying what is to be cleaned, frequency, and what equipment/cleaning agents . Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 10, Storage of Soiled Linens, Clean Equipment, and Utensils - . Clean equipment, utensils, and linens must be stored in a clean, dry location, where they are not exposed to splash, dust, or other contamination and at least 6 inches off the floor. Section D - Equipment and Utensils, FDA Food Code, Chapter 4, D - 11, Kitchen and Tableware - . Single service and cleaned/sanitized utensils must be handled, displayed, and dispensed so the contamination of food and lip contact surfaces is prevented .

Based on observation, record review and interview, facility failed to follow the menu for pureed diets for the evening meal on 10/26/22. There were 79 residents who were served pureed diets in the facility. Findings included: On 10/26/22 at 4:21 PM, observation revealed there was a pan of pureed pasta and a pan of pureed beef held stored on the steam table for the evening meal. Review of the facility Week 6, Day 4 menu indicated 6 ounces (oz). pureed beef and macaroni were to be served for the evening meal for pureed diets (the menu did not indicate that the beef and macaroni was to be served separately). The Director of Food and Nutrition Services stated that they made the pureed beef and pureed macaroni separately, because some residents do not like macaroni. The surveyor asked to see the recipe, and the evening Food and Nutrition Services supervisor, Staff A (contract food service staff) could not find the recipe in the recipe book. She stated that they serve 3 oz. of pureed macaroni and 3 oz. of pureed beef. The Director of Food and Nutrition Services provided a recipe for beef, macaroni, and tomatoes for regular consistency diets; however, the recipe did not include instructions on how to prepare the pureed beef and macaroni.

Based on record review and interviews, the facility failed to respond to grievances for one (Resident #545) out of one resident reviewed for grievances. The resident's daughter established communication with the facility concerning complaints about the mother's care and was not informed of the results of the grievances. There were 191 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, Grievance Procedure (effective 12/03/2004, reviewed 8/22/2022) documented the following: Policy: It is the policy of the facility to provide a system whereby persons served and/or their significant others or representatives, can voice concerns about the quality of care received at the facility. Procedure: During the admission process, the Admitting Department staff will provide the resident or his/her representative with written information outlining how the resident, or his/her representative submits a grievance related to quality of care. The information provided to the resident includes Time frames for review and resolution of grievance; That the grievance will be followed-up on and he/she will be apprised of the grievance outcome. The resident will be informed of: The steps taken to resolve the grievance and the result of the grievance. A grievance log will be maintained by the Grievance Coordinator. Such log will indicate the number of grievances handled, a categorization of the cases underlying the grievances and the final disposition of the grievances. Review of the Demographic Face Sheet for Resident #545 documented the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 12/21/21. Review of the Minimum Data Set (MDS) Admission Assessment for Resident #545 dated 12/15/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 13 out of 15 indicating no cognitive impairment and the resident was able to make her needs known. The resident required extensive assistance with one-person physical assist for ADLs (Activities of Daily Living) and received oxygen therapy. Review of the concern/grievance/complaint log for Resident #545 documented the following: On 12/14/21, the daughter reported that she did not like the CNA (Certified Nursing Assistant) assigned to her mother. Reports that the CNA did not fix the bed after the mother went to therapy in the afternoon and states she was told she needed to wait until 3:30 PM for a new gown. Actions Taken: CNA was educated on proper customer service and will no longer be assigned to care for the patient; Complainant Advised: Yes; Type of Grievance: Staff; Final Disposition: Resolved. On 12/16/21, the daughter reported that staff informed her mother to urinate in the incontinent brief if the staff does not get to her in time. Actions Taken: Staff educated to attend patient's needs in a timely manner and toilet patient as requested. Complainant Advised: Yes; Type of Grievance: Other; Final Disposition: Resolved. On 12/17/21, the daughter reports her mom has been without oxygen for 8 hours and the order is continuous. Daughter wants to ensure that labs are monitored regarding sodium and that they were supposed to be drawn in the AM; Actions Taken: Administration spoke with daughter the same evening. Resident placed on every 2-hour rounds to ensure O2 (oxygen) is on and response to needs. Labs should be back tomorrow AM. Results informed; Complainant Advised: Yes; Type of Grievance: Other; Final Disposition: Resolved. Interview and record review with the Regional Director of Social Services on 10/28/22 at 10:18 AM, revealed that on the Concern/Grievance Form the section for the complainant advised of result and the resolution acceptable to the complainant was blank and not filled out for 12/14/21, 12/16/21 and 12/17/21. She stated, It was not documented that the daughter accepted what was done. She acknowledged the daughter should have been made aware of the grievance resolutions and sections should have been filled out. During an interview with the Administrator on 10/28/22 at 1:29 PM. She revealed that the resolution information is not documented on the grievance forms, and it should be, and the complainant should have been informed of the results of the grievance.

Based on record review and interview, the facility's quality assurance and assessment committee failed to identify quality concerns to implement effective plans of action for correcting deficiencies resulting in repeated deficient practice. The facility was cited for Food Procurement, Store/Prepare/Serve-Sanitary (F 812) during the survey with exit date of 03/05/ 2020 and again on this recertification survey with exit date of 10/28/2022. This repeated deficient practice has the potential to affect any of the 191 residents residing in the facility at the time of the survey. The findings included: Record view of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) written by the Administrator and the reviewed date was on 8/22/2022, the policy documented: The facility will form a QAPI Steering Committee, designed to meet monthly. The committee must include the Medical Director, Administrator, Director of Nursing, Infection Control Preventionist and at least two other members representing the facility staff. The primary objectives of Quality Assurance & Performance Improvement (QAPI) are to monitor, assess and improve performance of critical focus areas, improve healthcare outcomes, and reduce and prevent medical/health care errors on a continuous basis throughout the facility. Review of the Quality Assurance and Performance Improvement (QAA) Committee Meeting Sign-in Sheets dated 8/24/22, 9/21/22 and 10/19/22: documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON) and other department heads. On 10/28/22 at 1:33 PM, the Administrator stated, The QAA Committee meets monthly. Committee members are Administrator, Medical Director, DON, Department Heads, Pharmacy, Infection Control Preventionist and Contract Companies are in attendance. The purpose of QAA is for performance improvement, monitoring and evaluating opportunities of improvement. We look at satisfaction surveys, grievances, CASPER quality measures and any feedback from a family.

Based on record review and interview the facility failed to transfer a resident safely according to a physician order of using a mechanical lift for one (resident # 112) out of four residents reviewed for accidents which resulted in actual harm to the resident with a foot fracture. This practice has the potential to affect one-hundred and thirty residents who require one to two person transfer assistance during the time of the survey. The findings included: Record review of the face sheet revealed, resident # 112 was admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the quarterly assessment of the Minimum Data Set (MDS) for resident # 112 dated 4/16/2017 revealed section C for Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and section G for functional status for transfers was coded as one person physical assistance. Record review of the skin assessment for resident # 112 dated 06/05/2017 revealed, had no skin problems or lesions present. Had no foot problems or care. Record review of the nurse's note for resident # 112 dated 06/9/2017 at 11:23am revealed, required one aide assist to transfer to lift resident during transfers. On 06/11/2017 at 3:14 pm noted swelling, painful to touch left ankle / foot, edema to left foot. Foot elevated in pillow. Physician notified. Family notified. On 6/11/2017 at 6 pm, x-ray of left foot taken due to pain and swelling. As needed pain medication was given. On 06/11/2017 at 10:01 pm spoke with medical doctor - x-ray results of left foot showed multiple acute fractures with orders to transfer resident # 112 to hospital. Record review of the Physician Order Sheet (POS) for resident # 112 dated 09/30/2014 active through 06/11/2017 revealed, patient required total assistance with transfer via mechanical lift. This order was discontinued on 06/13/2017. Review of the the POS for resident # 112 dated 06/11/2017 revealed, transfer resident # 112 to hospital for evaluation of multiple acute fractures to the left foot. Record review of the care plan for Activities of Daily Living (ADL) for resident # 112 dated 2/2/2017 revealed, resident # 112 required extensive to total assistance with ADL tasks and mobility related to advanced dementia, impaired mobility and incontinence. Goal: Personal care needs will be anticipated and met by staff daily over the next 90 days. Interventions: Transfer with mechanical lift as ordered. Record review of the x-ray report for resident # 112 dated 06/11/2017 revealed subacute fractures of the distal left tibia and fibula as discussed. Record review of the adverse incident report for resident # 112 revealed date of incident 6/11/2017 and submitted on 06/26/2017. Interview on 11/16/2017 at 2:17 pm with the risk manager and Director of Nursing (DON) regarding resident # 112 revealed, during activities of daily living (ADL) on 6/11/2017 at approximately 2 pm a resident was noted with a left foot and ankle swollen and painful by Staff Z, a certified nursing assistant (CNA). An incident report was completed. An investigation was started. This was reported as an adverse incident within the required time frame. Upon investigation Staff Y, Certified Nursing assistance had improperly transferred resident # 112 from the bed to the wheel chair without using a mechanical lift. Staff Y, CNA had pivoted her. According to Staff Y, CNA the resident did not fall. Resident # 112 was alert to name, place and time, she could be guided and was able to move her extremities. Based on the Medical doctor order resident # 112 was supposed to be transferred with a mechanical lift. Staff Y, CNA was rushing and pivoted resident # 112 despite resident # 112 saying she was supposed to be transferred with a lift. Resident # 112 knew she needed to be transferred with a mechanical lift. The DON and the risk manager noted that resident # 112 upon review of the x-ray results from 06/11/2017 had sustained a fracture to the left distal fibula and distal tibia. Resident # 112 was transferred to the hospital on [DATE]. The risk manager and the DON noted that resident # 112 did not have a left foot fracture prior to the incident on 06/11/2017, however was at risk for a fracture due to a history of osteopenia and foot drop (Hallux Valgus). Staff Y, CNA had later stated that she knew resident # 112 was supposed to be transferred with a mechanical lift. The DON and the risk manager confirmed that the incorrect transfer of resident # 112 without using a physician ordered mechanical lift resulted in the fracture of the foot of resident # 112. Interview on 11/16/2017 at 6:17 pm with the administrator, the DON and the risk manager regarding resident # 112 revealed for transfer with a mechanical lift - A resident would be assessed by therapy, therapy gives the transfer mode and recommended with a person or mechanical lift. The facility policy was to transfer a resident manually with two people and if using a mechanical lift to ask for assistance. They confirmed that it was a huge concern that resident # 112 was not transferred with a mechanical lift by staff Y, a CNA on 06/11/2017 according to the physician order. Record review of the facility policy dated 2/8/2017 titled Patient Mechanical Lift - Proper use in Resident transfer revealed: Will ensure the availability of appropriate lifting and safety equipment for the staff and educate them on the use of those items. Ensure compliance with this lifting technique and moving policy by all staff members and will take appropriate action when failure to do so is determined which may include counseling or possible termination of employment. Staff: Be accountable for utilizing proper body mechanics, lifting techniques and patient safety. Understand that failure to use the proper lifting equipment when appropriate may result in disciplinary action being taken including counseling and up to possible termination. Ensure that each new patient is assessed to identify a need for mechanical lift equipment. Utilize the proper transfer / lift procedure for each patient. This includes the use of the patient transfer devices or other lifting equipment and applying proper body mechanics. Demonstrate an ability to perform all tasks related to the use of the lifts as required.

Based on record review and interview, the facility failed to follow the care plan for transferring a resident safely according to a physician order for [REDACTED]. The findings included: Record review of the face sheet revealed, resident # 112 was admitted on [DATE]. The [DIAGNOSES REDACTED]. Record review of the quarterly assessment of the Minimum Data Set (MDS) for resident # 112 dated 4/16/2017 revealed section C for Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 14 out of 15 and section G for functional status for transfers was coded as one person physical assistance. Record review of the skin assessment for resident # 112 dated 06/05/2017 revealed, had no skin problems or [MEDICAL CONDITION] present. Had no foot problems or care. Record review of the nurse's note for resident # 112 dated 06/9/2017 at 11:23am revealed, required one aide assist to transfer to lift resident during transfers. On 06/11/2017 at 3:14 pm noted swelling, painful to touch left ankle / foot, [MEDICAL CONDITION] to left foot. Foot elevated in pillow. Physician notified. Family notified. On 6/11/2017 at 6 pm, x-ray of left foot taken due to pain and swelling. As needed pain medication was given. On 06/11/2017 at 10:01 pm spoke with medical doctor - x-ray results of left foot showed multiple acute fractures with orders to transfer resident # 112 to hospital. Record review of the Physician Order Sheet (POS) for resident # 112 dated 09/30/2014 active through 06/11/2017 revealed, patient required total assistance with transfer via mechanical lift. This order was discontinued on 06/13/2017. Review of the the POS for resident # 112 dated 06/11/2017 revealed, transfer resident # 112 to hospital for evaluation of multiple acute fractures to the left foot. Record review of the care plan for Activities of Daily Living (ADL) for resident # 112 dated 2/2/2017 revealed, resident # 112 required extensive to total assistance with ADL tasks and mobility related to advanced dementia, impaired mobility and incontinence. Goal: Personal care needs will be anticipated and met by staff daily over the next 90 days. Interventions: Transfer with mechanical lift as ordered. Record review of the x-ray report for resident # 112 dated 06/11/2017 revealed subacute fractures of the distal left tibia and fibula as discussed. Record review of the adverse incident report for resident # 112 revealed date of incident 6/11/2017 and submitted on 06/26/2017. Interview on 11/16/2017 at 2:17 pm with the risk manager and Director of Nursing (DON) regarding resident # 112 revealed, during activities of daily living (ADL) on 6/11/2017 at approximately 2 pm a resident was noted with a left foot and ankle swollen and painful by Staff Z, a certified nursing assistant (CNA). An incident report was completed. An investigation was started. This was reported as an adverse incident within the required time frame. Upon investigation Staff Y, Certified Nursing assistance had improperly transferred resident # 112 from the bed to the wheel chair without using a mechanical lift. Staff Y, CNA had pivoted her. According to Staff Y, CNA the resident did not fall. Resident # 112 was alert to name, place and time, she could be guided and was able to move her extremities. Based on the Medical doctor order resident # 112 was supposed to be transferred with a mechanical lift. Staff Y, CNA was rushing and pivoted resident # 112 despite resident # 112 saying she was supposed to be transferred with a lift. Resident # 112 knew she needed to be transferred with a mechanical lift. The DON and the risk manager noted that resident # 112 upon review of the x-ray results from 06/11/2017 had sustained a fracture to the left distal fibula and distal tibia. Resident # 112 was transferred to the hospital on [DATE]. The risk manager and the DON noted that resident # 112 did not have a left foot fracture prior to the incident on 06/11/2017, however was at risk for a fracture due to a history of osteopenia and foot drop (Hallux Valgus). Staff Y, CNA had later stated that she knew resident # 112 was supposed to be transferred with a mechanical lift. The DON and the risk manager confirmed that the incorrect transfer of resident # 112 without using a physician ordered mechanical lift resulted in the [MEDICAL CONDITION] of resident # 112. Interview on 11/16/2017 at 6:17 pm with the administrator, the DON and the risk manager regarding resident # 112 revealed for transfer with a mechanical lift - A resident would be assessed by therapy, therapy gives the transfer mode and recommended with a person or mechanical lift. The facility policy was to transfer a resident manually with two people and if using a mechanical lift to ask for assistance. They confirmed that it was a huge concern that resident # 112 was not transferred with a mechanical lift by staff Y, a CNA on 06/11/2017 according to the physician order. Record review of the facility policy dated 2/8/2017 titled Patient Mechanical Lift - Proper use in Resident transfer revealed: Will ensure the availability of appropriate lifting and safety equipment for the staff and educate them on the use of those items. Ensure compliance with this lifting technique and moving policy by all staff members and will take appropriate action when failure to do so is determined which may include counseling or possible termination of employment. Staff: Be accountable for utilizing proper body mechanics, lifting techniques and patient safety. Understand that failure to use the proper lifting equipment when appropriate may result in disciplinary action being taken including counseling and up to possible termination. Ensure that each new patient is assessed to identify a need for mechanical lift equipment. Utilize the proper transfer / lift procedure for each patient. This includes the use of the patient transfer devices or other lifting equipment and applying proper body mechanics. Demonstrate an ability to perform all tasks related to the use of the lifts as required.