Every finding on record at St Patrick's Residence

Based on interview and record review, the facility failed to ensure a resident did not fall out of bed after being turned during incontinence care. This failure resulted in the resident slipping off the bed and experiencing bilateral distal femur fractures requiring bilateral femoral retrograde rodding. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. Findings Include:Review of R1's care plan shows R1's diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting her left side, osteoarthritis, and dementia with impaired thought processes. R1 was at increased risk for falls related to her weakness, hemiplegia, poor balance/coordination, and medications. R1 utilized a pressure-relieving mattress on her bed, had altered functional range of motion of her left side, required a mechanical lift and two staff for transfers, used 1/4 side rails to enable bed mobility, and prior to her fall required the maximal assistance of one staff but may need two staff at times for bed mobility. MDS (Minimum Data Set), dated 4/14/26, shows R1's cognitive status was intact and R1 required substantial and maximum assistance (more than half the effort provided by staff including lifting or holding trunk or limbs) to roll right and left in bed. On 5/15/26 at 9:49 AM, V4 (Certified Nursing Assistant/CNA) stated he was performing incontinence care and told R1 he was going to turn her to her left side. V4 stated R1 was lying on her back in the middle of her bed. Without moving R1 further to right in her bed, V4 turned R1 from the middle of her bed by pushing R1 away from V4. R1 held the left bed rail with her right hand and V4 turned his head back to retrieve wipes from her table which was behind V4. As V4's head was turned, R1 slid off the bed and landed the floor on her knees while still holding the rail. V4 stated R1 complained of pain in her knees throughout his shift. V4 stated he was provided education after the fall regarding gathering his supplies in front and close to him when performing incontinence care as well as turning a resident toward him instead of away from him. Witness statement written by V4, dated 4/29/26, shows V4 told R1 he would turn her to her left to clean her bottom and V4 reached for wipes on the table. The statement shows when V4 turned his head back for the wipes, R1 fell off the bed and he rushed to the other side to help her. V4 saw R1 on her knees and was holding the side rail of the bed and V4 called for help. The statement shows two nurses assessed R1 and the staff assisted R1 back to bed. Hospital physician note, dated 4/30/26, shows R1 apparently landed on her knees while getting in or out of bed. She does have a large bruise on the inside of her left knee. Hospital X-ray results of her left knee, dated 4/30/26, show R1 had an acute, complex fracture of the distal femoral metaphysis with displacement and apex anterior angulation at the fracture site. Hospital Xray results of R1's right knee, dated 4/30/26, show mildly comminuted fractures of the distal right femur with impaction and angulation with mild displacement of multiple fragments. Nurse Practitioner Progress notes, dated 5/11/26, shows, .Patient suffered a fall while staff was repositioning her in bed which resulted in bilateral distal femur fractures. Patient subsequently underwent bilateral distal femoral retrograde rodding on 5/5/26. Orthopedic surgery discussed goals of care and treatment options extensively with family members. Patient has now returned to facility for continued skilled nursing care and PT/OT (Physical and Occupational Therapy) rehabilitation services as tolerated. On 5/15/26 at 9:23 AM, V3 (Director of Nursing) stated V4 (CNA) turned R1 in bed and then turned around to the table to grab wipes when R1's feet started to slide off the bed, her body followed, and R1 landed on the floor in a kneeling position on her knees. R1 was assessed by nurses and reported knee pain, was transferred back to bed by staff using a mechanical lift, and V3 assessed her knees approximately 30 minutes after the fall. V3 stated she saw no redness or swelling of R1's knees, R1 still reported pain in her left knee, and an X-ray was ordered. V3 stated the X-ray did not arrive until the next morning and R1 continued to report pain in her knees, so R1 was sent to the hospital where X-rays were performed, the fractures were identified, and surgery was performed. At 10:31 AM, V3 stated R1 should have had all of his supplies prepared and in front of him so he did not have to look away from R1. At 2:32 PM, V3 stated the facility recently implemented procedures to have all staff turn residents toward them when turning residents in bed. V3 stated she was not sure if there were specific instructions for turning residents on air mattresses. V3 stated R1 was utilizing an air mattress at the time she fell. Developmental Feedback Worksheet, dated 5/4/26, shows V4 was educated to ensure residents were turned toward him for safety while providing incontinence care to reduce the risk of falls or injury. Facility Education Document, undated, shows, During incontinence care always turn the resident towards you. Turning the resident toward you allows you to maintain control and balance, reducing the risk of falls or injury to both the resident and staff member. Air mattress manufacturers' information, undated and provided on 5/15/26 by the facility, shows the mattress dynamically adjusted pressure to the patient profile using air cells. On 5/15/26 at 9:55 AM, V5 (Agency Registered Nurse) stated V4 was changing R1's incontinence brief when V4 reached for wipes and R1's legs slid from the bed followed by her body. V5 stated R1 landed on her knees with her buttocks on her feet and when V5 arrived R1 was attempting to remove her feet from under her buttocks. R1 was verbalizing she was in pain/agony by saying Ow.ow! loudly while the staff used the mechanical lift to put R1 in bed. R1 was guarding her knees after the fall and staff assessed R1 for injuries. V5 stated she provided medication for pain and did not suspect injuries at that time. R1 was ordered an in-facility X-ray to assess for injuries and was sleeping when V5 finished her shift. Witness statement written by V5, dated 4/29/26, shows V5 entered the room and R1 was on the floor screaming in pain. V5 assessed R1 and R1 reported pain of 8 on a scale of 10 with 10 being the worst pain. The statement shows V5 assisted staff using a mechanical lift placing R1 back into bed. On 5/15/26 at 11:11 AM, V6 (CNA) stated when she arrived in R1's room after her fall, R1 was kneeling on the floor with her buttocks on her feet and R1 was screaming in pain when being moved. V6 stated V5 instructed the staff to place R1 in bed using a mechanical lift and once R1 was in bed she did not verbalize pain unless her legs were touched. V6 stated prior to the fall, R1's legs were never straight and were slightly bent. Witness statement written by V6, dated 4/29/26, shows V6 entered R1's room and saw R1 on her knees with her thighs touching her calves. On 5/15/26 at 1:45 PM with V8 (Nurse Practitioner), V7 (Physician) stated R1's fall from bed caused fractures and resulted in her surgeries to repair the fractures.Interdisciplinary Progress note, dated 5/1/26, shows, Resident experienced fall on 4/29/2026 during provision of incontinence care by staff. During care staff briefly turned away from resident, at which time slid out of bed onto floor while holding on to siderail. Resident was assessed by 2 nurses before being transferred back to bed via [mechanical] lift per policy. Resident remained in the facility for continued monitoring. POA (Power of Attorney) and Medical NP (Nurse Practitioner) informed. Resident was subsequently transferred to [hospital] on 4/30/26 for further evaluation after compliant of pain even after medication was administered. POA and Medical NP notified. [Hospital] update injury: Closed fracture of distal end of right and left femur, unspecified fracture morphology, initial encounter. At time of incident, resident had underlying medical conditions including pneumonia and anemia, which likely contributed to the increased weakness and fatigue. These factors significantly increased the resident's risk for instability during care.

Based on interview and record review, the facility failed to conduct a thorough and impartial investigation of resident abuse by a staff member. The facility also failed to maintain documentation from the witnesses of the abuse. R1 experienced pain and was crying following the incident. The alleged perpetrator was allowed to return to work another two shifts with R1. A reasonable person would experience fear and anxiety having the alleged perpetrator provide care for a dependent resident with a history suffering from abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3.The findings include: The facility failed to conduct a thorough and impartial abuse investigation. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 5:40 PM when CNA (Certified Nursing Assistant) students reported to V9 (Wound Nurse/Nurse Supervisor) that they witnessed V8 (CNA) abuse R1. V9 then conducted witness interviews in a coercive manner, failed to substantiate the abuse allegation, and allowed V8 to return to work another two shifts with R1. V1 (Administrator), V2 (Assistant Administrator), and V15 (Corporate Nurse Consultant) were notified of the Immediate Jeopardy on [DATE] at 2:30 PM and the template was provided.V1 provided an Immediacy Removal Plan at 5:58 PM on [DATE], which was rejected and returned to V1 on [DATE] at 9:30 AM. The facility's second Immediacy Removal Plan was provided by V1 at 10:43 AM on [DATE] which was rejected and returned to V1 at 11:05 AM. The facility's third Immediacy Removal Plan was provided by V1 at 11:21 AM on [DATE] which was rejected and returned to V1 at 11:35 AM. The facility's fourth Immediacy Removal Plan was provided by V1 at 11:49 AM on [DATE] and it was accepted at that time. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.R1's Face sheet dated [DATE], shows R1's diagnoses included metabolic encephalopathy, dementia with psychotic disturbance, adult failure to thrive, major depression disorder, pain in left and right knee and low back pain, cervicalgia, muscle weakness, noncompliance with other medical treatment, psychosis not due to a substance, anxiety, hemiplegia, and legal blindness. The face sheet shows R1 was admitted to the facility on [DATE] and expired at the facility on [DATE]. R1's MDS (Minimum Data Set), dated [DATE], shows R1's cognition was severely compromised. Psychology note dated [DATE], shows Resident was cooperative. Resident is making stable progress on goals listed above. Ongoing psychotherapy could help improve symptom management. The resident's cognitive functioning seems sufficient at this time. The note shows R1 had the capacity to participate meaningfully and benefit from psychotherapy. R1's care plan initiated [DATE], shows R1 had a history of financial abuse/exploitation alleged toward her son and was considered a vulnerable adult due to poor and compromised health/mental health status, cognitive issues, physical decline, and need for 24-hour care. The care plan shows R1 experienced a significant trauma during her lifetime, and she is a trauma survivor. The care plan also shows R1 exhibited manipulative behavior and makes accusations against staff and other residents related to her diagnosis of dementia with psychotic disturbance and anxiety. The interventions include having two staff present during care in R1's room and during showers as of [DATE]. On [DATE] at 3:50 PM, V5 (Student CNA) stated she witnessed V8 (CNA) hitting R1's left shoulder hard with an open hand and pushing her shoulder down forcefully into the mattress, holding R1 down. V5 stated V8 also shoved R1's knee down forcefully into the mattress and pushed the right side of R1's body toward the wall with force. V5 stated R1 was dressed in a gown and was screaming, saying she was being hurt and asking for help and asking V8 to stop. V5 stated V9 (Wound Nurse/Nurse Manager on Duty) asked her to provide a written statement describing what she witnessed, and she gave it to V9. On [DATE] at 3:53 PM, V7 (Student CNA) stated she fed R1 dinner with V14 on [DATE]. V7 stated R1 said V8 pushed her chest and knee and hit her, and then R1 called V8 a liar. V7 stated she and the other students (V5 and V14) reported the allegations to V9 (Wound Nurse/Nurse Manager on Duty) and V10 (Quality Assurance) and then provided handwritten statements. V7 stated V9 and V10 asked if the students were sure about their report because V8 had a child and V8 was a mother and they were attempting to make the students feel guilty. On [DATE] at 3:09 PM, V14 (CNA Student) stated she and V5 (CNA Student) witnessed V8 (CNA) pushing R1 on her left side while R1 was lying in bed and using a lot of unnecessary force - it looked like she was hurting her. V14 stated R1 was telling V8 to stop and she was being hurt. V14 stated V8 was pressing very hard on R1's shoulder while leaning over her and putting her weight onto R1. V14 stated she and V7 (CNA Student) were then sent into R1's room to feed R1. V14 stated R1 began sobbing and stated V8 hurt her. V14 stated R1 attempted to show V14 and V5 her knee where it hurt and R1 grabbed V14's shoulder and told V14 and V7 not to be like V8. V14 stated V14, V5, and V7 notified V4 (CNA Student Instructor), V9 (Wound Nurse/Nurse Manager on Duty) and V10 (Quality Assurance). V14 stated V9 seemed really mad for us saying anything. V14 stated V9 talked over the students when they tried to talk - including V9 stating R1 is combative, R1 often behaves the way they reported, and that the students needed to think about what they were reporting because [V8] was a single mother. V14 stated, Honestly that made me feel really uncomfortable and I wanted to leave, and I was just doubting myself for saying something. V14 stated V7 tried to talk to V9 and V10 but had a very hard time speaking English, and V9 and V10 would not listen to V7. V14 stated during the discussion, V9 tried to tell her that V8 was giving R1 a bed bath but she wasn't. V14 stated all three students provided written statements to V9 as requested by the facility. V14 stated the students were also asked to demonstrate on V10 (Quality Assurance) what V8 did to R1. V14 stated she told V10 she would not use the same force she saw V8 use because she would hurt V10, but she demonstrated how V8 leaned onto R1. V14 stated V7 was then asked to demonstrate what she saw, but V7 was not present during the abuse. V14 stated that after the demonstrations, V9 commented that all the students demonstrated different versions of the allegation. On [DATE] at 10:22 AM, V5 (CNA Student) stated while reporting the allegation on [DATE], V9 (Wound Nurse/Nurse Manager on Duty) told the students multiple times that V8 was a single mother, had no husband, and could lose her job if she were accused of abuse. V5 stated V9 made the students feel like they were lying about the allegation, and they started to regret their decision to report the abuse. V5 stated she gave V9 her written witness statement on [DATE], and she physically demonstrated V8's actions on V10 (Quality Assurance). V5 stated V10 then asked for V7 (CNA Student) to come in and physically demonstrate V8's abuse, even though V7 was not present when it occurred. On [DATE] at 10:30 AM, V1 (Administrator) stated V9 (Wound Nurse/Nurse Manager on Duty) and V10 (Quality Assurance) completed R1's abuse investigation and the investigation documents provided on [DATE] were all the documents included in R1's completed investigation. V9's typed document dated [DATE] showed the students provided written statements and then were asked to demonstrate the abuse they witnessed. On [DATE] at 10:33 AM, V4 (CNA Student Instructor) stated she was shocked by V9's behavior toward the students and V9's line of questioning when the students reported the abuse allegations. V4 stated V9 (Wound Nurse/Nurse Manager on Duty) interrupted the students as they tried to explain what they saw. V4 stated V9 abruptly said V8 would lose her certificate and not be able to work again. V4 stated V9 told them that V8 was a single mother, and she would not be able to feed her child as a single parent if she was accused of abuse. V4 stated, I have never seen so much heated debate about what was going to happen to the CNA and how she would lose her job. V4 stated V9 and V10 then took V5, V7 and V14 away from V4 and told the students to physically demonstrate on V10 what they saw V8 do to R1. V4 stated the students were also asked to write statements describing what they saw, and those written statements were provided to V9. On [DATE] at 10:41 AM, V13 (Licensed Practical Nurse) stated she was present when V9 (Wound Nurse/Nurse Manager on Duty) asked the students to describe what they witnessed. V13 stated V9 told the students that V8 (CNA) had a daughter and could lose her job if accused of abuse. V13 stated the students were asked to write statements to describe what they saw. The facility's Final Abuse Investigation Report, submitted to the state surveying agency on [DATE], showed the facility determined the allegation of abuse regarding R1 and V8 was not substantiated. Under the Brief Description of Incident, it showed The nursing students reported to the nursing instructor who reported to the nurse manager that [R1] reported to them during meal assistance, that the CNA hit her. The Final Report does not include any reference to or consideration of the witness statements made by V14 and V5 (CNA Students) that describe what they saw V8 do with R1.The facility's Daily Staffing schedules and Time Detail showed V8 was again assigned to R1 on [DATE] and [DATE].Review of the final abuse investigation included no handwritten statements provided by V5, V7 or V14 (CNA Students), and the only handwritten statements included were those written by V8 (alleged perpetrator) and V4 (CNA Student Instructor). A [DATE] typed document signed by V10 (Quality Assurance) and not by the students they refer to, was included in the investigation. V10's document showed a different and less aggressive version of the statements the students reported, and not the actual written statements. A second typed but undated document written by V9 (Wound Nurse/Nurse Manager on Duty) and not by the students they refer to, also showed a less aggressive interpretation of their statements and re-enactments.On [DATE] at 12:42 PM, V10 (Quality Assurance) stated she did not know where the written statements from the students were. On [DATE] at 11:54 AM, V9 (Wound Nurse/Nurse Manager on Duty) stated she gave the written statements from the students to V12 (Director of Nursing). On [DATE] at 10:51 AM, V12 stated she gave the statements back to V9 and was unable to locate them. V12 also stated she never interviewed R1 because she trusted V9 and V10 to do it. V12 stated she never received any statements with R1's interview.Facility policy, Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident property, effective [DATE], shows, Residents, families, visitor, and Nursing Home Staff will receive education on reporting concerns, incidents and grievances without the fear of retribution. member facilities strictly prohibit any retaliation, discrimination, harassment or any other adverse action taken against an employee who reports or participates in the investigation audit in good faith. Nursing Home Staff who are asked to provide a statement for the purpose of the investigation will comply by providing a written statement or dictating the statement to the Nursing Supervisor/Designee and acknowledging the statement made by their signature. Upon receiving a report of an allegation or suspicion of abuse, neglect, mistreatment, misappropriation, or exploitation, the Supervisor shall immediately ensure that the resident is protected from any further violation from occurring and contact the Administrator or Director of Nursing. When the investigation is complete, the Director of Nursing/Designee will present all relative documentation to the Administrator. The Administrator will: . b. Review that investigation is complete including: 1) All statements from staff, residents and any other person deemed necessary to complete the investigation. Ensure Director of Nursing/designee provides CMA (Central Management Services) with a complete written investigation with conclusion. Either the witness will write his/her statement and sign and date it, or the investigator may obtain the witness statement, read it back to the witness and have him/her sign and date it.The Immediate Jeopardy began on [DATE]. The immediacy was removed on [DATE] when the facility took the following actions to remove the immediacy:V8 (CNA) was suspended on [DATE] at 6:41pm and returned to work on [DATE] and then terminated on [DATE] at 5:30pm.Investigating nurse (V9) was suspended on [DATE] at 10:20am and terminated [DATE].On [DATE], V15 (Corporate Nurse Consultant) reviewed all abuse allegations dated [DATE] to [DATE] to identify any improper investigations.On [DATE], residents with a BIMS (Brief Interview for Mental Status) score of 10 or above were interviewed for care concerns, witnessing or experiencing abuse or any abuse that was reported, and they felt was not handled correctly.On [DATE], skin assessments were performed on residents with a BIMS score of 9 or lower to identify any signs or symptoms of abuse or neglect.On [DATE], staff were interviewed for any knowledge of any abuse not reported or any abuse that was reported that they felt was not handled properly or with coercion.Education provided to all staff regarding Abuse and reporting by [DATE] by Director of Mission Integration. Staff not educated will be taken off the schedule until the abuse education is completed.Abuse policy reviewed and/or updated on [DATE].On [DATE], the Investigation Checklist was updated to include senior level review by Corporate Nurse, validation of interviews confirming their statements by the Abuse Coordinator or designee, Director of Mission Integration, Director of Nursing or Infection Preventionist/Nurse Educator.On [DATE], education was provided to the Administrator, Director of Nursing, Director of Mission Integration and Nurse Educator/IP Nurse Manager on conducting an objective and impartial investigation and investigation checklist.On [DATE], the Corporate Nurse Consultant provided education to the Administrator and nurse managers on preventing abuse, neglect and misappropriation, abuse policy, abuse reporting procedure, and abuse investigation protocol.Ad-hoc Quality Assurance and Root Cause Analysis was completed with the Interdisciplinary Team and Medical Director on [DATE].Twenty interviewable residents will be interviewed three times a week for four weeks, then twenty residents twice weekly for four weeks, and then twenty residents weekly for four weeks.On any residents with BIMS scores of 9 and below, twenty skin check audits will be conducted three times a week for four weeks, then twenty residents twice weekly for four weeks, and then twenty residents weekly for four weeks.Twenty staff members will be given a post test on abuse and coercion to validate understanding and report any incidents of abuse three times a week for four weeks, then twenty staff twice weekly for four weeks, and twenty staff weekly for four weeks.All state reportable events will be reviewed by the Corporate Nurse Consultant to ensure investigations are thorough, accurate, and uncoerced. This will be done weekly for twelve weeks.

Based on interview and record review, the facility failed to protect a resident from physical and mental abuse from staff. These failures caused R1 to sob and experience pain following the episode of witnessed abuse. This applies to 1 (R1) of 3 residents reviewed for abuse in a sample of 3. A reasonable person would experience fear and anxiety of the alleged perpetrator to provide care for a dependent resident with a history of suffering from abuse and has experienced significant trauma during their lifetime as stated in the care plan. The findings include: R1's Face sheet dated 4/10/26, shows R1's diagnoses included metabolic encephalopathy, dementia with psychotic disturbance, adult failure to thrive, major depression disorder, pain in left and right knee and low back pain, cervicalgia, muscle weakness, noncompliance with other medical treatment, psychosis not due to a substance, anxiety, hemiplegia, and legal blindness. The face sheet shows R1 was admitted to the facility on [DATE] and expired at the facility on 4/3/26.R1's MDS (Minimum Data Set), dated 1/9/26, shows R1's cognition was severely compromised. Psychology note dated 3/23/26, shows Resident was cooperative. Resident is making stable progress on goals listed above. Ongoing psychotherapy could help improve symptom management. The resident's cognitive functioning seems sufficient at this time. The note shows R1 had the capacity to participate meaningfully and benefit from psychotherapy. R1's care plan initiated 4/22/24, shows R1 had a history of financial abuse/exploitation alleged toward her son and was considered a vulnerable adult due to poor and compromised health/mental health status, cognitive issues, physical decline, and need for 24-hour care. The care plan shows R1 experienced a significant trauma during her lifetime, and she is a trauma survivor. The care plan also shows R1 exhibited manipulative behavior and makes accusations against staff and other residents related to her diagnosis of dementia with psychotic disturbance and anxiety. The interventions include having two staff present during care in R1's room and during showers as of 11/25/24. On 4/2/26 at 1:54 PM, V5 (Certified Nursing Assistant/CNA Student) stated on 3/25/26 at approximately 5:40 PM she and V14 (CNA Student) delivered a dinner tray to R1's room and witnessed R1 lying on her back in her bed, the right side of the bed was against the wall, and the right side of R1 body positioned close to the wall. V8 (CNA) was standing on the left side of R1's bed, hit R1 several times with an open hand on R1's left shoulder and forcefully pushed R1's shoulder downward in the mattress holding her shoulder down for several seconds. V8 also forcefully shoved R1's left knee down on the bed. V5 stated V8 also put her left hand on R1's left knee and her right hand on R1's left shoulder and forcefully push R1 against the wall. V5 stated R1 was already close and almost touching the wall when the CNA began pushing R1 further into the wall. V5 stated R1 was screaming asking for help the entire time and asking V8 to stop because V8 was hurting her. V5 stated V8 did not notice the students were in the room. V5 and V14 reported what they saw to V4 (CNA Instructor) and then to V9 (Wound Nurse/Manager on Duty) and V10 (Quality Assurance). On 4/2/26 at 3:53 PM, V7 (CNA Student) stated she met V8 (CNA) and V14 outside R1's room to feed R1 and V8 told the students she did not care if R1 ate because R1 was going to die. V7 stated they entered the room together and R1 was asleep. V8 touched R1's chest using force with the palm of her hand and shook her palm on R1's chest without saying anything prior. V7 stated R1 woke up and V8 told the students to give the dinner to R1. V7 stated when V8 left R1's room, R1 cried and stated V8 was a liar, that V8 pushed R1's knee, and V8 pushed and hit R1 in the chest. R1 told the students she was still in pain. V7 stated V14 (CNA Student) and V5 (CNA Student) told her they saw V8 pushing R1 when they delivered R1's tray. V7 stated R1 told the students not to act like V8, that the students were good girls, and that V8 was a liar. V7 stated V8 reentered the room and removed R1's tray saying R1 did not want to eat any more. V7 stated they were still assisting R1 to drink her milk and R1 did not say she was finished with her tray. V7 stated the students reported the information to V9 (Wound Nurse/Manager on Duty) and V10 (Quality Assurance). On 4/6/26 at 10:30 AM, V1 (Administrator) stated V9 and V10 completed the abuse investigation and the abuse investigation file provided on 4/6/26 (which did not include the written witness statements from V5, V7, and V14) was the full and complete investigation.On 4/6/26 at 11:54 AM, V9 (Wound Nurse/Manager on Duty) stated V5, V7 and V14 (CNA Students) were interviewed and all wrote statements and provided them to the facility at the time they alleged abuse by V8 (CNA) on R1. V9 stated V5 reported V8 pushed R1 into the wall while R1 said stop hurting me while having her gown changed. V9 stated the students demonstrated the incident by pushing V10's shoulder and holding her shoulder as well as V5 demonstrating V8 holding R1's knee. V9 stated she was unable to locate the students' written statements. On 4/6/26 at 2:45 PM, V8 (CNA) stated she was replacing R1's gown that R1 removed after a prior bed bath V8 gave her earlier. V8 stated R1 did not want the gown replaced and kept moving her arms but V8 continued to put the gown on. V8 stated she did not push on R1's knee and only touched her arms while R1 continued to say, No, it hurts, it hurts. V8 denied having to roll R1 in the bed and denied the students delivered R1's dinner tray when V8 was in the room. V8 stated she walked R1's dinner tray from the dining room to R1's room with the student CNAs.On 4/6/26 at 3:09 PM, V14 (CNA Student) stated she and V5 were passing dinner trays from a meal cart located in the hallway when they delivered R1's tray to her room. V14 stated, We walked in the room to put the tray down and we saw V8 (CNA) pushing the resident from her left side using a lot of unnecessary force - it looked like she was hurting her. V14 stated R1 was lying on her back and V8 was leaning over R1 and putting her weight on R1. V14 stated R1 had a gown completely on. V8 was pressing on R1's left shoulder, and V14 could see V8 leaning over R1 and putting most of her weight down on R1 into the bed. V14 stated she was clear that the CNA was not trying to prevent R1 from hitting her because R1's hand was not coming up toward V8 or trying to hit V8. V14 stated R1 told V8 to stop and that V8 was hurting R1 but V8 continued. V14 stated V8 did not see the students drop off the dinner tray. V14 stated when they left R1's room she and V5 were surprised, questioned themselves and were unsure what to do. V14 stated the students walked to the dining room and she and V7 (CNA Student) were then assigned to feed R1 her meal. V14 stated when they returned to R1, R1 was sobbing and stated V8 was really hurting her. V14 stated R1 was trying to show her and grabbed V14's shoulder and told her not to be like V8. V14 stated V8 then returned to the room, asked the students if R1 drank anything and the students replied no. V14 stated V8 responded that didn't matter because she was on hospice anyway and told the students stop giving R1 her milk and go back to the dining room. V14 stated she reported the abuse to her supervisor. V14 stated V9 (Wound Nurse/Manager on Duty) and V10 (Quality Assurance) asked the students to provide handwritten statements and physically demonstrate the abuse they witnessed on V10. On 4/7/26 at 7:21 AM, V5 (CNA Student) stated she was interviewed, asked to provide a written statement, and asked to physically demonstrate what she witnessed by V9 and V10. V5 stated she tried to use the same force she witnessed V8 use on R1 when she demonstrated on V10. On 4/7/26 at 10:51 AM, V12 (Director of Nursing) stated she was told the CNA students reported V8 pushed R1 during care. V12 stated she did not interview R1 and received a verbal account of what R1 stated from V9 and V10. V12 stated she interviewed V8 who stated she tapped R1 and R1 was hitting V8 while V8 was putting a gown on R1. V12 stated she was not confident regarding the allegations the students were making. V12 stated she received the written statements which conflicted but could not locate their written statements again. V12 stated they concluded the abuse was unsubstantiated. On 4/7/26 at 12:42 PM, V10 (Quality Assurance) stated V5, V7, and V14 (CNA Students) all provided written statements regarding the abuse they witnessed. V10 stated she went to R1's room when the abuse was reported and R1 was in her room, was very confused and moving around, and stated she wanted to sleep. V10 stated when she asked R1 if she felt safe at the facility, R1 replied she wanted to go to sleep. V10 stated the students told her they saw V8 push R1 against the wall and push her leg because R1 kept moving her body. V10 stated the students reported R1 was moving in the bed and said don't hurt me but V8 kept holding R1. V10 stated she asked the students to physically demonstrate what they witnessed - including V7 who did not witness the abuse. V10 stated the students' physical accounts of the abuse differed. V10 stated she was unable to locate the students' written statements.Initial abuse report, dated 3/25/26 and provided 4/6/26, shows while being assisted with a meal, R1 reported to nursing students that a CNA hit her. Final abuse report, dated 3/27/26 and provided 4/6/26, shows the allegation of abuse was unsubstantiated. The report shows R1 misrepresented staff simple cues and had medication changes which caused delusional thoughts and visual hallucinations. The report shows R1 was described as restless, combative, manipulative, and preferred not to be touched. The report shows V8 (CNA) reported she was providing simple cues and touched the resident's leg and shoulders when she repositioned R1 during a gown change. The report shows R1 was moving her arms during care and told the CNA not to hit her, and V8 reassured R1 she was providing care. The final report fails to show any references to the CNA student eye-witness accounts during interviews or in written statements. On 4/8/26 at 12:11 PM, camera footage from 3/25/26 was reviewed with V1 (Administrator), V2 (Assistant Administrator) and V12 (Director of Nursing). The video showed at 5:07 PM V5 and V14 were working with a CNA taking a food tray cart into R1's hall. At 5:14 PM, V8 exited R1's hall and at 5:15 PM, the students exited R1's hall and then entered the dining room. At 5:21 PM, V14 and V7 left the dining room and entered R1's hall with V8 with no meal tray. V8 leaves and returns to R1's hall/room twice without a meal tray and later exits the room with a meal tray.Facility Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property, effective 8/18/22, shows the facility will provide an environment for residents that is safe and free from abuse, neglect, exploitation, mistreatment and misappropriation. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes, but is not limited to, hitting, slapping, punching and kicking. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment, deprivation or abuse.

Based on interview and record review, the facility failed to notify the local law enforcement agency regarding allegations of resident abuse per the facility policy. This applies to 2 (R1 and R2) of 3 residents reviewed for abuse allegations in the sample of 3.The findings include: 1.Initial abuse report dated March 25, 2026, and final report dated March 27, 2026, shows an allegation of physical abuse was reported to the facility regarding R1. On 4/6/26 at 3:09 PM, V14 (Certified Nursing Assistant/CNA Student) stated she and V5 (CNA Student) witnessed V8 (CNA) pushing R1 on her left side while lying in bed and using a lot of unnecessary force - it looked like she was hurting her. V14 stated R1 was telling V8 to stop, and she was being hurt and V8 was pressing very hard on R1's shoulder while leaning over her and putting her weight into R1. V14 stated she and V7 (CNA Student) were then sent into R1's room to feed R1. V14 stated R1 began sobbing and stated V8 hurt her. V14 stated R1 attempted to show V14 and V7 her knee where it hurt and R1 grabbed V14's shoulder and told V14 and V7 not to be like V8. The record showed an abuse allegation was submitted to the state surveying agency. However, review of the abuse investigation showed no evidence of the facility notifying the local law enforcement agency. 2.Initial and final abuse reports both dated December 9, 2025, and final report dated show an abuse allegation was submitted to the state surveying agency regarding R2. R2 alleged that someone pulled her arm during care, someone was rough during oral care and people were laughing at her. A skin assessment was completed, and bruising was observed on front and back of both arms. Review of the abuse investigation showed no evidence of the facility notifying the local law enforcement agency. On April 9, 2026, at 2:13 PM, V12 (Director of Nursing) stated the police should be notified of any allegations of abuse. The facility's August 18, 2022 Prevention, Identification, Investigation and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident or Misappropriation of Resident Property showed 3. Reporting/ Response: the facility will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required. The policy continued .The Administrator.shall also report to the local police if such allegation meets the requirements.

Based on observation, interview, and record review, the facility failed to provide assistance to residents who were identified as needing assistance with feeding, positioning, and incontinence care. This applies to 4 of 6 (R45, R100, R107, R121) residents reviewed for activities of daily living in the sample of 33. Findings include: 1.R45's face sheet showed R45 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's Disease, Alzheimer's Disease, hypertension, localized edema, osteoarthritis, major depressive disorder, allergic rhinitis, and anxiety. R45's MDS (Minimum Data Set) dated January 26, 2026, showed R45 has severe cognitive impairment and is always incontinent of bowel and bladder. R45's MDS also showed that R45 requires setup assist and cleanup assist for feeding. R45's current care plan showed that R45 had an ADL (Activities of Daily Living) self-care performance deficit related to weakness, unsteady gait, dementia, and Parkinson's Disease. R45 required setup, cleanup, supervision and touching at times for eating assistance. R45 required maximal assistance and was dependent upon staff for toileting. R45's care plan also showed R45 is at risk for pressure injuries/ulcers related to altered nutrition, decreased mobility, impaired cognition, use of antidepressants and incontinence. R45's interventions included Provide prompt incontinence care and to place resident back to bed after lunch. R45's bowel and bladder care plan showed that R45 should be checked for incontinence during rounds, when requested, and as needed. R45's current active physicians order form showed a treatment orders for moisture associated skin breakdown due to incontinence care. On March 23, 2026, at 11:26 AM R45 was observed sitting in dining room asleep in her wheelchair just before lunch. Staff presented R45 with meal at 12:00PM and R45 began to eat the entire meal with R45's fingers. R45 did not pick up utensils, and staff did not assist R45 with utensils. R45 was then taken into the tv room after lunch where R45 fell asleep in the wheelchair and not to bed as care plan instructed. On March 24, 2026, at 8:40 AM, R45 was sitting at breakfast table with staff. Staff were assisting other residents. R45 had weighted utensils on plate but continued to eat with hands. Staff did not assist or redirect. R45 was taken into the TV room following breakfast. On March 24, 2026, at 2:30 PM, V6 (Certified Nursing Assistant/CNA) said that R45 does not require any assistance with eating. V6 confirmed that she observed R45 eating with her fingers but did not believe R45 needed assistance. V6 said that staff provide incontinence care for R45 just twice per shift. V6 said that R45 was toileted at the start of shift. On March 25, 2026, at 8:49 AM R45 was sitting in dining room eating breakfast with her hands. R45 was not assisted by staff and did not have weighted utensils on her tray. On March 25, 2026, at 9:20 AM V25 (CNA) said that R45 should not have weighted utensils, and staff is supposed to set up her tray. On March 25, 2026, at 9:26 AM V26 (Licensed Practical Nurse/LPN) said that R45 does not require assistance or weighted utensils for meals. 2. R100's EMR (Electronic Medical Record) showed R100 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's disease and dementia. R100's MDS (Minimum Data Set) dated February 4, 2026, showed R100 had severe cognitive impairment, was always incontinent of bowel and bladder, and was dependent on staff for toileting, transfers, and mobility. R100's care plan showed R100 had an ADL (Activity of Daily Living) self-care performance deficit related to weakness, impaired cognition secondary to Alzheimer's dementia, poor balance/coordination. R100 was at risk for pressure injury/ulcers related to decreased mobility, impaired cognition, incontinence, use of diuretic, and failure to thrive. Interventions included provide prompt incontinence care, turn and reposition as frequently as possible. 3. R107's EMR showed R107's most recent admission was on February 10, 2024. R107 was admitted with diagnoses that included unspecified dementia, and polyarthritis. R107's MDS dated [DATE], showed R107 had severe cognitive impairment and was dependent on staff for toileting, sitting to a standing position and chair/bed to chair transfers. R107 was always incontinent of urine and sometimes incontinent of bowel. R107's care plan showed R107 has an ADL self-care performance deficit related to cognitive deficit secondary to dementia, polyarthritis, and activity intolerance. R107 is at risk for pressure injury/ulcers related to decreased mobility, impaired cognition, and incontinence. Interventions include provide prompt incontinence care, turn and reposition every 2 hours when in bed, and shift position hourly when in the wheelchair. 4. R121's EMR showed R121's most recent admission to the facility was on July 3, 2022. R121's diagnoses included unspecified dementia and other specified peripheral vascular diseases. R121's MDS dated [DATE], showed R121 had severely impaired cognitive skills for decision making, and was dependent on staff for toileting, transfers, and mobility. R121 was frequently incontinent with bowel and bladder. R121's care plan showed R121 has an ADL self-care performance deficit related to dementia. R121 has peripheral vascular disease and interventions included changing position frequently, not sitting in one position for long periods of time. R121 is at risk for pressure injuries/ulcers related to decreased mobility, impaired cognition, and incontinence. Interventions included prompt incontinence care, frequently reposition every two hours when in bed and shift hourly when in high backed wheelchair. On March 24, 2026, continuous observation was made of R100, R107, and R121 from 10:30 AM to 3:00 PM to show R100, R107, and R121 had not been repositioned or provided incontinence care for approximately four hours. At 10:28 AM, R100 was sitting at a table in the dining room with a book in front of her, R107 was asleep in her wheelchair, sitting at the same table with a busy board in front of her. and R121 was asleep in her high-backed wheelchair at the same table. At 11:05 AM, Activity staff removed the activity items from the tables and announced to the residents that they were going to get ready for lunch. At 12:10 PM, R100, R107, and R121, were sitting and waiting for lunch, R107 was still asleep. At 12:16 PM, V7 (CNA) brought R107 her tray. R100 was being assisted with her lunch by another staff member, and R121 was waiting for her tray. At 12:19 PM, R100 was done eating and staff member went and washed her hands and came back and assisted R121 with her lunch. R107 went back to sleep at the table. At 12:22 PM, V27 (Registered Nurse) came and woke up R107 and assisted her with her lunch. At 1:10 PM, R107 asleep at the same table. R100 moved to a table with other residents for activities. R121 being fed by a staff member. At 1:18 PM, R121 was done eating, R107 asleep at table, R100 was sitting at activity table in the dining room. At 1:27 PM, R107 was moved to another table to sit with another resident. R107 woke and looked around. At 1:31 PM, R121 was moved to a table with R107 and another resident for activities. At 1:42 PM, R107 was asleep at the table, R100 and R121 remained sitting at a table in the dining room. At 2:18 PM V4 (CNA) came and took R121 to her room to toilet her. V4 said she had toileted R121 last and 12:00 PM. V5 (CNA) was helping V4 with transfer R121 with a mechanical lift. When R121 was raised to a standing position, R121's entire buttock area was saturated with urine and had soaked through her clothing. When V4 opened R121's incontinence brief, the brief was saturated with urine. At 2:36 PM, V7 (CNA) was asked when R107 had been changed last. V7 said she checked and changed R107 around 10:30 AM, before lunch and checked and changed her at 1:15 PM. At 2:38 PM, V5 said she toileted R100 around 10:30 AM before lunch. Surveyor asked to have R100 toileted now. V5 was assisted by V6 (CNA). R100 was transferred from her wheelchair to the toilet using a mechanical lift. R100's incontinence brief was soaking wet. At 2:53 PM, V7 was asked to toilet R107. V7 was assisted by V6 and R107 was transferred from her wheelchair to the toilet using a mechanical lift. V7 removed R107's incontinence brief which was soaked with urine. On March 25, 2026, at 9:45 AM, V2 (Director of Nursing) said the residents are to be checked and changed every two hours and be repositioned every 2 hours. For residents in wheelchairs, if they toilet them every two hours, they are changing the residents' position and relieving the pressure areas they have been sitting on. The facilities Activities of Daily Living Policy's explanation and compliance guidelines showed 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The facility provided their policy titled, Activities of Daily Living dated November 1, 2025. The policy showed, Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care, 2. Transfer and ambulation, 3. Toileting, 4. Eating to include meals and snacks. The facility provided their policy, Turning and Repositioning dated November 11, 2025. The policy showed, 1. All residents at risk of, or with existing pressure injuries, will be turned and repositioned. 3.It also included assisting the resident to stand or making small shifts of position, if in chair.7. Repositioning techniques in chair:.If the resident is unable to make position changes, reposition every hour.

Based on observation, interview and record review, the facility failed to ensure their staff performed hand hygiene and gloving when providing perineal care and failed to ensure that the proper PPE (Personal Protective Equipment) was donned prior to providing urinary catheter care and perineal care for residents identified on (EBP) Enhanced Barrier Precaution. This applies to 4 of 7 residents (R4, R89, R144, R169) reviewed for infection control in a sample of 33. The findings include:1. According to the Electronic Medical Record (EMR), R144 had multiple diagnoses, including vascular dementia, unspecified osteoarthritis, and unspecified symptoms and signs involving cognitive functions following cerebral infarction. R144's Minimum Data Set (MDS) dated [DATE], showed R144 had severe cognitive impairment and required maximum assistance from staff for toileting hygiene and lower-body dressing. On March 24, 2026, at 11:29 AM, R144 had an EBP sign on the door that says staff must wear gloves and a gown for high-contact resident care activities, including dressing, transferring, providing hygiene, and urinary catheter care. V22 (Certified Nursing Assistant/CNA) pushed R144 in the wheelchair to the room, wore gloves, and did not wear a gown. V22 applied a gait belt around R144's waist and held R144 while R144 walked from the bedside to the bathroom. V23 pulled down R144's pants and incontinent brief and provided perineal care to R144 in the bathroom. R144 had an indwelling urinary catheter, a leg drainage bag strapped to her right leg, and V22 emptied the urine into a urinal. V22 removed her gloves, washed her hands, and put on clean gloves. V22 assisted R144 with transferring back into the wheelchair. On March 24, 2026, at 1:07 PM, V2 (Director of Nursing/DON) said CNAs should always wear gloves and a gown for any personal care, such as perineal care or assisting in the bathroom, for residents with an indwelling urinary catheter with EBP precautions. On March 25, 2026, at 11:15 AM, R144 had an EBP sign on the door stating that staff must wear gloves and a gown for high-contact resident care activities, including dressing, transferring, providing hygiene, and urinary catheter device care. V23 (CNA) was assisting R144 with toileting. V23 pushed R144 in the wheelchair to the room. V23 wore gloves and did not wear a gown. V23 applied a gait belt around R144's waist and assisted R144 to transfer from the wheelchair to the toilet. V23 pulled down R144's pants and incontinent brief. V23 disposed of the soiled incontinence brief soiled with stool in the trash bag. V23 removed the soiled glove, washed her hands, and wore clean gloves. R144 had an indwelling urinary catheter with a leg drainage bag strapped to her right leg. V23 emptied the urine from the catheter drainage bag into a urinal. V23 assisted R144 with perineal care while R144 was standing over the toilet, holding on to the bar. V23 wiped R144 with disposable wipes, and brown stains were on the wipes. V23 pulled up R23's clean incontinence brief and pants using the same soiled gloves used to wipe R144's stool. V23 also touched R144's wheelchair bars and sweater with the same soiled gloves. On March 25, 2025, at 11:35 AM, V23 said she should have worn a gown before assisting R144 with toileting because R144 had an indwelling urinary catheter and was in EBP precaution. On March 25, 2025, at 12:51 PM, V2 (DON) said the CNA should have removed the soiled gloves, performed hand hygiene, and worn clean gloves after cleaning the R144's stool. V2 also said that the CNA should have reapplied clean gloves before touching R144 or touching clean surfaces to prevent cross-contamination and ensure infection control. 2. R169's EMR (Electronic Medical Record) shows R169 was admitted to the facility on [DATE], with multiple diagnoses including epilepsy, altered mental status, dysphagia, vascular dementia, and coronary artery disease. R169's POS (Physician Order Sheet) shows R169 has a current order dated March 17, 2026, for EBP (Enhanced Barrier Precautions) in place due to enteral feeding and chronic open area to right hip. R169's current care plan with initiated date of March 13, 2026, shows R169 is care planned to be on enhanced barrier precautions related to gastric feeding tube and chronic wound. In the same care plan, one of the approaches/interventions is direct care staff to utilize gowns and gloves for all personal care. On March 24, 2026, at 1:33 PM, R169's door had an EBP sign. The EBP sign showed staff must wear gloves and a gown for the following high-contact resident care activities including changing linens, changing briefs, and providing hygiene. V9 (CNA) and V10 (CNA) entered R169's room to provide incontinence care and to weigh R169. V9 and V10 wore gloves but no gowns. V9 and V10 provided R169 with incontinence care and weighed R169. During the incontinence care, loose stool was present on the incontinence pad and bed sheet. V9 and V10 changed the soiled incontinence pad and bed sheet without wearing gowns. 3. R4's EMR shows R4 was admitted to the facility on [DATE], with multiple diagnoses including morbid obesity, congestive heart failure, chronic kidney disease, atrial fibrillation, chronic respiratory failure, overactive bladder, diabetes. The same EMR shows R4 has an ileostomy. R4's MDS (Minimum Data Set) shows R4 is moderately cognitively impaired and is dependent on staff for toileting. R4's POS shows R4 has a current order dated March 9, 2026, for EBP due to a chronic wound (surgical wound). R4's current care plan with initiated date of April 11, 2024, shows R4 is care planned to be on enhanced barrier precautions related to a chronic abdominal wound and one of the approaches/interventions for this is staff to wear gown and gloves throughout high/close contact resident care activity such as dressing, bathing/showering, transferring, changing briefs, or assisting with toileting, providing hygiene, and changing linens. On March 24, 2026, at 1:55 PM, R4's door had an EBP sign. V9 and V10 entered R4's room to provide R4 with incontinence care. V9 and V10 entered R4's room and washed their hands with soap and water. They both wore gloves but no gowns. V9 and V10 provided R4 with incontinence care. On March 24, 2026, at 3:25 PM, V10 stated she should have worn a gown during R4's and R169's incontinence care since they were on EBP. On March 24, 2026, at 3:27 PM, V9 stated she did not wear a gown because she was not emptying R4's ileostomy bag and R169 does not have any bacterial issues in her urine or saliva. V9 continued to say a gown is worn if any bodily fluids would splatter on her since she did not think any bodily fluids would splatter on her, she did not wear a gown with either R4 or R169. On March 24, 2026, at 3:42 PM, V2 (DON) stated for residents on EBP, she expects her nursing staff to wear gloves and a gown during personal care. V2 continued to say incontinence care is personal care. The facility's policy titled, Infection Control-Enhanced Barrier Precautions Policy dated May 21, 2025, shows the policy of the facility is to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. In the same policy, under the subsection, Policy Explanation and Compliance Guidelines, shows PPE (Personal Protective Equipment) for EBP is only necessary when performing high-contact care activities and high-contact resident care activities include changing briefs, providing hygiene, assisting with toileting, dressing, bathing, transferring, changing linens, device care or use such as with urinary catheters, and wound care. 4. R89's EMR (Electronic Medical Record) showed R89 was admitted to the facility on [DATE], with diagnoses that included vascular dementia, intercranial injury with loss of consciousness, major depressive disorder, and poly-osteoarthritis. R89's MDS (Minimum Data Set) dated January 26, 2026, showed R89 had severe cognitive impairment, was always incontinent of bowel and bladder, and was dependent on staff for incontinence care. R89's care plan showed R89 has functional incontinence of bowel and bladder related to severely impaired cognition and impaired physical mobility/strength secondary to TBI (traumatic brain injury). Interventions included provide incontinence care when incontinent. On March 24, 2026, at 11:33 AM, V7 (CNA) gathered supplies to change R89's incontinence brief. V7 washed her hands and put on gloves, opened R89's incontinence brief, cleaned R89 in the front, turned R89, and with the same gloves cleaned that buttock area, grabbed the clean incontinence brief, the clean linen, and placed them under R89. She continued to pull out the wet incontinence brief and linen from under R89 and pull through the clean incontinence brief and clean linen. V7 fastened the incontinence brief and then grabbed a clean gown and put it on R89. On March 25, 2026, at 9:45 AM, V2 (DON) said when performing incontinence care, you clean from front to back, clean to dirty. The staff would first open the incontinence brief, clean the front area then turn the resident and clean the back side from front to back, remove gloves, hand hygiene, and put on new gloves before touching the clean incontinence brief and clean linen. After doing hand hygiene and putting on new gloves, place the clean incontinence brief, and clean linen under the resident and turn them the other way and pull the dirty linen/incontinence brief out and then pull the clean linen through. The facility provided their policy titled, Perineal Care that was dated January 2, 2025, showed, .6. Perform hand hygiene and put on gloves. Apply other personal protective equipment as appropriate.8. If perineum is grossly soiled, turn resident on side and remove any fecal material.a. Cleanse buttocks and anus, front to back, vagina to anus in females, and scrotum to anus in males, using a separate washcloth or wipes. c. remove gloves and wash hands. d. dry hands and put on new gloves. 9. re-position resident in supine position. Continue with perineal care.13. remove gloves and wash hands, dry hands and put on new gloves.15. Reposition as desired and cover resident.

Based on observation, interview, and record review, the facility failed to follow a doctor's order for monitoring daily weight for a resident with history of congestive heart failure. This applies to 1 of 2 residents (R160) reviewed for daily weights in the sample of 33.The findings include:R160's EMR (electronic medical records) showed multiple diagnoses which included chronic diastolic (congestive) heart failure, chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic respiratory failure with hypoxia, hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, vascular dementia, mild, with anxiety, generalized anxiety disorder, unspecified dementia, unspecified severity, with psychotic disturbance, moderate protein-calorie malnutrition, bipolar disorder. R160's 5-day MDS (minimum data set) dated March 13, 2026, showed that R160 was moderately impaired in cognition.R160's POS (Physician Order Summary) showed to monitor weight daily. Notify Registered Dietitian and provider for weight gains/loss of more than 3 pounds. Obtain re-weight for confirmation and document progress note (revised order date February 26, 2026).R160's weight history in EMR showed as follows recorded in lbs (pounds):95.8 lbs (March 1, 2026), 102.5 lbs (February 26, 2026), 102.5 lbs (February 23, 2026), 102.5 lbs (February 6, 2026), 102.5 lbs (January 27, 2026), 105.7 lbs (January 7, 2026), 101.8 lbs (December 31, 2025), 103.0 lbs (December 24, 2025). No further weights after March 1, 2026, were recorded. Physician (V19) progress notes dated March 3, 2026, included:Assessment and Plan: 2. Acute-on-chronic congestive heart failure exacerbation with preserved ejection fraction: Status post inpatient stay at hospital on December 13, 2025, through December 16, 2025. Clinical presentation with worsening shortness of breath and chest pressure. Evaluated by Cardiology. [R160] received IV diuresis and transitioned to oral diuretics. Continue furosemide [diuretic medication] 40 mg [milligram] daily. Spironolactone [diuretic medication] discontinued due to recurrent hyperkalemia. Repeat echocardiogram showed LV [left ventricular] function, normal EF [ejection fraction] and moderate-to-severe aortic valve stenosis. Continue current management with metoprolol succinate [medication for management of hypertension], furosemide and spironolactone. Continue to monitor daily weight and volume status. On March 23, 2026, at 10:39 AM, R160 was in the dining room and stated I have lost weight. I don't remember how much.On March 24, 2026, at 12:37 PM, V14 (Registered Nurse/RN) stated that she is not aware of any daily weight monitoring orders. The POS was checked in V14's presence, and the orders for daily weight monitoring were verified. V14 stated that she did not request daily weights as it does not show in MAR (Medication Administration Records). V14 stated that whoever put in the orders did not put an order scheduling time for it to show up in the MAR.On March 24, 2026, at 2:33 PM, when a weight was requested for R160, V11 (RN) stated that she just took R160's weight and it showed 106.8 lbs. V11 stated that she took R160's weight with R160 standing up and initial weight showed 110 lbs and so R160 was reweighed again. V11 added that she may have put in the orders for daily weight monitoring on readmission from one of R160's hospital stays, but overlooked scheduling it so that it pops up in the MAR for nursing to follow up. R160's weight change from 95.8 lbs (March 1, 2026) to 106.8 lbs (March 24, 2026) showed that R160 had gained 11 pounds.On March 24, 2026, at 3:08 PM, V15 (RN/MDS Coordinator) stated that R160 was seen by V19 (Physician) after one of R160's hospital stays and V19 wrote a progress note (dated March 3, 2026) that R160 was evaluated by cardiology in the hospital and to continue daily weight monitoring. On March 25, 2026, at 10:00 AM, V16 (Dietitian) stated that she was aware of the daily weight monitoring as she saw that an order for the same was put in on February 26, 2026. V16 stated that she did not follow up further on the subject as she was focused on R160's weight loss and nutrition interventions. V16 stated that even though R160 is admitted to Hospice on March 24, 2026, they are still planning to do daily weight monitoring for R160's comfort level. On March 25, 2026, at 12:51 PM, V2 (Director of Nursing) stated that nursing should put in a physician's order as soon as they receive it and it should be implemented. V2 stated that weight changes should be notified to the Physician, POA (Power of Attorney) and Dietitian as needed. Facility policy titled Physician Orders (revised December 9, 2025) included: Policy: This facility shall use uniform guidelines for carrying out physician orders. Policy explanation and compliance guidelines: Orders should be received only by licensed nurses. Elements of order: Orders must be carried out timely. Documentation of Medications Orders: h. Enter the new order on MAR or ensure the new order is in the electronic MAR.

Based on interviews and record review the facility's Arbitration Agreement failed to have a process for selecting a neutral arbitrator. The facility also failed to provide a selection of venues that is suitable for residents or their representatives. This applies to all 170 residents residing the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. On January 14, 2025, at 3:03 PM, the facility's Admission Packet which included the facility's Arbitration Agreement showed under General (q) Alternative Dispute Resolution: (i) Arbitration Agreement: .The Parties will cooperate with one another in selecting an arbitrator from the arbitration company panel of arbitrators and pursue diligently the arbitration . (Name of Association) Dispute Resolution Service will Administer the arbitration . If (Name of Association) or it's successor is not available to administer the arbitration, then the Facility will select another arbitration service to administer the arbitration . The arbitration hearing will be in the county in which the facility is located. On January 13, 2025 at 9:32 AM, during entrance conference, V1 (Administrator) said the arbitration agreement is part of the admission packet. V1 said she has not had any new admissions or their representative refuse to sign the arbitration agreement. On January 14, 2025, at 3:53 PM, V3 (Assistant Administrator) said the current admission packet with the arbitration agreement in it, is from 2018.

Based on interview and record review, the facility failed to follow their Water Management Plan for Legionella. The facility also failed to perform hand hygiene during provisions of care. This applies to all 170 residents residing in the facility. The findings include: 1. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. The facility's Water Management Plan dated September 17, 2024, showed Overview: Scope: The Water Management Plan (WMP) outlines procedures for minimizing the risk of Legionnaires' disease for persons at [the facility] site. The water systems on the site are described in tables and flow diagrams; the systems requiring control measures are noted in the Hazard Analysis . Objective: The objective of the WMP is to minimize the risk of Legionnaires' disease by managing certain building water systems for the control of Legionella bacteria. Organization: The WMP will be overseen by the team leader and members listed in the 'Team' section. The team's duties are listed in the 'Management' section . Cooling Towers: Sample cooling towers for Legionella testing within two weeks of start-up following shutdown (whether shutdown for the season or for maintenance) and at least once every three months (ideally monthly) during operation . Decorative Fountains: Test decorative fountains for Legionella at least once every three months during operation . Risk Assessment Per Hazard Analysis: The risk assessment report is based on an analysis of the building water systems for the hazards outlined in the Overview (Cope) of the WMP. The 'Significant Risk' column shows the team's determination as to whether the system/device presents a significant risk potential for one of the hazards outlined in the WMP scope . The Water Management Plan continued to show multiple areas at significant risk for Legionella growth, including: the cooling tower systems, the domestic hot water systems, and the decorative fountain. The Water Management Plan showed, Control Measures: Cooling Tower Maintenance: Monitoring: .4. Test for Legionella before fans are started following a shutdown (whether shut down for the season or for maintenance)-no less than one hour and no more than 14 days after water has been circulating with routine chemical treatment-and at least once every 90 days during operation. Test sample(s) of water from the cooling tower basin or water returning to the cooling tower from the load per the WMP validation program and any applicable regulations . Control Measure: Domestic Water System Maintenance. Monitoring: Check the hot water return pumps to make sure they are running. Log date and time of inspection. Frequency of control measure task: Every one day . Control Measure: Domestic Water System Maintenance. Monitoring: Record hot water temperatures at a few faucets annually. For each measurement, record the number of seconds it took to reach the peak temperature. Log temperature complaints. Frequency of control measure task: Every one day . Control measure: Domestic Water System Maintenance. Monitoring: Record thermostatic mixing valve outlet temperature gauge readings at least once weekly, preferably daily .Control Measures: Domestic Water System Maintenance. Monitoring: Record water heater and hot water storage tank outlet temperature gauge readings at least once weekly, preferably daily . On January 15, 2025, at 9:38 AM, V10 (Chief Engineer) provided the facility's documentation of control measures for the facility's Water Management Plan for Legionella. V10 said the decorative fountain was cleaned and started on March 13, 2024, and shut down on October 8, 2024. V10 said the cooling tower was started on June 10, 2024. V10 said the only maintenance on the cooling tower at that time was cleaning and chemicals were added. V10 provided a calendar and said calendar included the dates the cooling tower was cleaned and started, when the fountain was cleaned and started, when the cooling tower was shut down and drained, when the decorative fountain was shut down and drained, and hot water temperatures from a few residents' rooms on Mondays through Fridays. V10 said the facility tested for Legionella once in 2024, on August 15, 2024. The facility does not have documentation to show Legionella testing was performed every three months on decorative fountain, Legionella testing was performed on the cooling tower within 14 days of the cooling tower starting for the year, daily hot water temperature readings including the time to reach the temperature, weekly readings of the thermostatic mixing valve outlet temperature gauge, weekly readings of the water heater and hot water storage tank outlet temperature gauge, or daily monitoring of the hot water return pumps. On January 15, 2025, at 12:55 PM, V1 (Administrator) said it is the expectation V10 perform the monitoring listed in the control measures of the facility's Water Management Plan. 41855 2. R34's EMR (Electronic Medical Record) showed R34 was admitted to the facility on [DATE], with diagnoses that included fracture of left pubis, history of falling, weakness, and overactive bladder. R34's MDS (Minimum Data Set) dated January 2, 2025 showed R34 had severely impaired cognition and R34 required substantial/maximal assistance with toileting and showering. R34's care plan showed R34 had functional bowel and bladder incontinence related to impaired mobility and staff are to clean R34's perineal area with each incontinence episode. On January 15, 2025, at 9:27 AM, V8 (CNA/Certified Nurse Assistant) and V9 (Nurse Manager) assisted R34 to the bathroom. Both V8 and V9 put on clean gloves. V8 positioned R34's wheelchair so R34 was facing the wall with the grab bar. R34 held onto grab bar and V8 and V9 assisted R34 to stand and pivot so the toilet was behind her. V8 pulled down R34's pants and soiled incontinence brief. While R34 was sitting on the toilet, with the same gloves, V8 combed R34's hair and then put a new brief on R34 and loosely fastened it. When R34 said she was done, V8 and V9 assisted R34 to stand there was a small amount of stool on the toilet seat. V8 cleaned R34 from front to back. V8 sprayed the toilet seat with the same cleaner used to clean R34. V8 wiped the toilet seat clean and then pulled R34's incontinence brief and pants up. V8 and V9 assisted R34 back into her wheelchair. V8 sprayed R34's hands with the spray. V9 asked V8 to help R34 wash her hands with soap and water. V8 moved R34 in front of the sink and R34 washed her hands with soap and water. R34 was wheeled out of the bathroom and into her room. V8 had the same gloves on during the entire incontinence care. On January 15, 2025, at 10:46 AM, V2 (Director of Nursing) said the staff need to clean from dirty to clean. The staff should wash hands, put on gloves, assist resident to bathroom, once standing in front of the toilet, the staff can pull the resident's pants and incontinence brief down and remove the soiled brief. While the resident is using the bathroom, the staff needs to remove gloves, sanitize their hands, and put on new gloves. When resident is done, the staff need to clean both the front groin area especially if the incontinence brief was soiled and gloves need to be changed after cleaning the front area and before moving to the back area. The back area (buttock) needs to be cleaned from front to back. After cleaning the staff needs to remove their gloves, perform hand hygiene (soap and water or hand sanitizer), and put on new gloves before putting on and pulling up the incontinence brief and pants. 43389 3. R168's face sheet showed her to be a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include Heart Failure, Chronic Kidney Disease, Major Depressive Disorder, Pain in Left and Right Legs, and Adult Failure to Thrive. On January 14, 2024 at 10:20 AM during wound rounds with V7 (Wound Care Doctor), V6 (Certified Nursing Assistant) and V4 (Wound Care Nurse), V4 removed dressing from R168's right ankle, and sprayed the wound with wound cleaner, and dried it with a 4x4 gauze. While the V6 held R168 on her right side, V4 then pulled the foam dressing off R168's left ischium and sacrum. V4 pulled up R168's buttocks up to visualize and clean part of the left ischium wound. V4's gloves were touching between R168 buttocks on the white barrier cream substance. V4 then sprayed the left ischium wound with wound cleaner and wiped it with 4X4. Without removing her gloves or performing hand hygiene, V4 applied skin prep and grabbed alginate and tore it with her hands, placed it on the left ischium wound, and then a foam dressing on top of that. V4 then sprayed the sacral wound and wiped it with a 4x4 gauze. Without removing her gloves or performing hand hygiene, V4 applied skin prep, tore another piece of alginate, and put it on the sacral wound then put a foam dressing on top of that. On January 14, 2024 at 11:45 AM, during wound care, R168 had a right heal wound covered in black necrotic tissue right bunion wound covered in black necrotic tissue, a right inner ankle wound covered in grayish slough, and a sacral wound covered in grayish slough. V4 (Wound Care Nurse) sprayed the right foot wounds with wound cleanser and wiped dry with 4x4 gauze. Without removing her gloves, and performing hand hygiene, V4 applied skin prep to the 2 right foot wounds and the right inner ankle wound. V4 then place alginate and a new foam dressing on top of the right inner ankle wound. V4 then removed the dressing from R168's sacrum and right ischium, sprayed the wound with wound cleaner, wiped the wounds with 4x4 gauze, and then without removing her gloves or performing hand hygiene, V4 placed alginate and foam dressing on to R168's sacral wound. On January 15, 2025 at 10:32 AM, V4 stated she should remove her gloves and perform hand hygiene when moving from dirty to clean areas during wound care. V4 stated she probably forgot to remove gloves and perform hand hygiene because she was nervous. On January 16, 2025 at 10:26 AM, V2 stated when performing wound care and moving from dirty to clean areas, the staff should remove gloves and perform hand hygiene. V2 stated not removing gloves and performing hand hygiene could contaminate the wound and increase the risk of infection. The facility's hand hygiene policy dated May 2024 showed the following: 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to the attached table. When, during resident care, moving from a contaminated body site to a clean body site.

Based on interview and record review the facility's Arbitration Agreement failed to have the required language in the Arbitration Agreement Contract. This applies to all 170 residents residing in the facility. The findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated January 13, 2025, by V1 (Administrator) showed the facility census was 170 residents. The facility provided their Facility's Admission Contract Between Resident and [Facility] (Short-Term Rehabilitation Care and Long-Term Care Services) contract. On pages 17-18, the contract explained the arbitration agreement, but failed to let the resident and /or the resident representative know that signing this contract was not a condition of their admission to this facility or that after signing the agreement, that they had 30 days to rescind the agreement. On January 13, 2025 at 9:32 AM, during entrance conference, V1 (Administrator) said the arbitration agreement is part of the admission packet. V1 said she has not had any newly admitted resident or their representative refuse to sign the Admission/Arbitration agreement. On January 14, 2025, at 3:53 PM, V3 (Assistant Administrator) said the current admission packet with the arbitration agreement in it, is from 2018.

Based on observation, interview, and record review, the facility failed to assess, identify, and document a resident's skin lesion. The facility also failed to follow physician orders to consult a dermatologist for skin lesions. This applies to 1 of 4 residents (R18), reviewed for skin conditions in the sample of 34. The findings include: R18's face sheet showed her to be a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that include Vascular Dementia with mild anxiety, Chronic Diastolic Heart Failure, Chronic Kidney Disease, Personal history of Cerebral infarction, and Long Term Use of Anticoagulants. On January 13, 2025 at 10:21 AM, R18 was observed with a red lesion on the top of her nose and forehead. On January 14, 2025 at 2:27 PM, R18 was in the dining room and the red lesions to her nose and forehead were still present. V19 (Registered Nurse/RN) stated the lesions to R18 nose and forehead were skin cancer. V19 stated there are no treatments for the lesions. V19 stated they are applying A & D ointment to the area and keeping the areas from getting dry. On January 15, 2025 at 1:07 PM, V13 (Family member of R18) stated that he saw R18 yesterday and last week on Tuesday or Friday and R18 had the same lesion to her nose last week and yesterday. V18 stated that he is not aware of his mother going to the Dermatologist while residing at the facility. R18 stated she has reoccurring lesions to her nose. On January 14, 2025 at 4:25 PM, V2 (Director of Nursing) stated she wasn't aware of any wound on R18's nose and was only aware of the wound to R18's forehead. On January 15, 2025 at 10:37 AM, V7 (Wound Care Doctor) stated she was just made aware of the wound to R18's nose. V7 stated she is not sure what the wound was on R18's nose. V7 stated she saw that R18 had an order for a Dermatology consult in 2023, but she was not sure if R18 saw the Dermatologist. V7 stated she recommends that R18 visit a Dermatologist. V7 stated the Dermatologist can do a biopsy to determine if the lesions are cancerous. V7 stated in the meantime, they will keep it moist with Vaseline, and A & D ointment. V7 stated that reoccurring wounds might be suspicious for cancer. R18's Initial Wound Evaluation & Management Summary dated January 15, 2025 by V7, showed the following: Diagnosis: Nodular lesion of skin or subcutaneous tissue, Location: nose and face, Duration at least 7 days. History: scabby lesion on tip of nose, staff reports that it comes and goes, patient has been observed scratching the lesion at times. There is verbal history that the lesion on the forehead was previously diagnosed as a skin cancer (no known details). Patient was advised to go to dermatology in 2023, unclear per records if she saw a Dermatologist. No reported pain, pruritus, or drainage from nose lesion. Lesion measures 0.5 x 0.9 x 0.2 cm (centimeter). Treatment recommend referral to Dermatology. Additional Treatment information: Recommend Vaseline ointment to lesion daily. Recommend dermatology consult for biopsy if family is agreeable due to the thin skin and location of the lesion. R18 has an order dated July 8, 2023 that showed the following: Dermatology consult for nose lesion. Another order dated November 9, 2024 showed the following. Monitor skin on shower days. Document abnormal findings in progress notes. R18's care plan, shower sheets, and progress notes were reviewed for last week and this week, and there was no documentation of R18's nose lesion as of January 14, 2025 at 4:30 PM. On January 15, 2025 at 1:00 PM, V2 stated she has no knowledge of R18 seeing a Dermatologist. On January 15, 2024 at 2:35 PM, V20 (Medical Records) stated she is responsible for making doctor appointments for residents. V20 stated she was not aware of any appointment for Dermatology being made for R18 before today. On January 16, 2025 at 10:26 AM and 11:08 AM, V2 stated if the staff notices a new skin issue, the nurse should assess the skin, update the doctor and family, and document it in the medical record. V2 stated the staff should be documenting new skin tear or skin issues in the nursing progress note and detailing the assessment, who they notified, and any ordered treatments. V2 stated that she expects the staff to follow the doctor's orders. The facility's Wound and Skin Care-Wound Assessment and Documentation policy dated June 5, 2024 showed the following: 14. Progress note should be completed initially when a new wound is identified and whenever there is a change in the wound that indicates potential infection or deterioration, and as needed.

Based on interview and record review, the facility failed to follow their policy to notify the physician of a resident's significant weight loss and to consult the dietitian to evaluate a resident with significant weight loss. This applies to 1 of 5 residents (R98) reviewed for nutrition in the sample of 34. The findings include: The EMR (Electronic Medical Record) showed R98 was admitted to the facility on [DATE], with multiple diagnoses including chronic kidney disease, congestive heart failure, dementia, and major depressive disorder. R98's Weights and Vitals Summary dated January 16, 2025, showed on July 13, 2024, R98 weighed 158 pounds and on January 13, 2025, R98 weighed 127.7 pounds resulting in a 19.18 % (percent) weight loss in six months. The documentation continued to show on October 1, 2024, R98 weighed 138.6 pounds and on November 2, 2024, R98 weighed 128.2 pounds resulting in a 7.5% weight loss in one month. As of January 15, 2025, at 10:00 AM, the facility does not have documentation to show R98 was evaluated by the dietitian for R98's significant weight loss in November 2024, or January 2025. On January 14, 2025, at 4:21 PM, V12 (Dietitian) said V12's last evaluation documented for R98 was in August 2024. V12 continued to say R98 has not been on V12's radar for weight loss monitoring. V12 said R98 needs to be evaluated to see if she needs fortified foods or supplements. V12 continued to say R98 is not currently receiving supplements. On January 14, 2025, at 4:38 PM, V5 (Unit Manager) said she reviewed R98's progress notes and does not see any progress notes regarding staff notifying R98's physician regarding R98's significant weight loss. V5 said facility staff are expected to document a progress note when a physician is notified of significant weight loss. On January 15, 2025, at 9:46 AM, V2 (Director of Nursing) said when a resident experiences significant weight loss, the physician and dietitian should be notified. V2 continued to say the dietitian would complete a nutrition evaluation for the resident. V2 said V12 had not completed an evaluation for R98's significant weight loss in November or in January. V2 said it should be documented in the medial record. On January 16, 2025, at 10:21 AM, V2 said a significant weight loss is a 5% or greater weight loss in one month and a 10% or greater weight loss in six months. V2 continued to say V12's standard of practice for significant weight loss is to document and care plan on a monthly basis. The facility does not have documentation to show R98 has had monthly care plan updates or documentation since R98's significant weight loss in November 2024. R98's Nutrition Comprehensive assessment dated [DATE], by V12 showed R98 weighed 165.8 pounds and R98's goal weight was to maintain weight. The documentation continued to show the goal for R98 was for no unplanned weight changes and R98 was at risk for malnutrition. R98's nutrition care plan dated July 26, 2024, showed [R98] is at risk for inadequate intake of nutrition and/or hydration related to diuretic therapy and diagnosis including diabetes mellitus type 2, congestive heart failure, chronic kidney disease stage 4, depression and dementia . The care plan continued to show multiple interventions dated February 15, 2024, including Registered Dietitian to evaluate and make recommendations as needed. The facility's policy titled Weight Monitoring dated October 6, 2024, showed Policy: Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem . 7. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. b. The physician should be encouraged to document the diagnosis or clinical that may be contributing to weight loss . e. The Registered Dietitian or Dietary Manager should be consulted to assist with interventions; actions are recorded in the nutrition progress notes. f. Observations pertinent to the resident's weight status should be recorded in the medical record as appropriate. g. The interdisciplinary plan of care communicates care instructions to staff.

Based on interview and record review, the facility failed to follow physician orders for laboratory tests for a resident receiving intravenous hydration. This applies to 1 of 1 resident (R149) reviewed for laboratory services in the sample of 34. The findings include: The EMR (Electronic Medical Record) showed R149 was admitted to the facility on [DATE], with multiple diagnoses including hyperosmolality (fluid and electrolyte imbalance disorder) and hypernatremia (elevated sodium levels), Alzheimer's disease, dementia, and chronic kidney disease. On January 13, 2025, at 10:50 AM, R149 was sitting in her wheelchair. R149 had intravenous fluids infusing. R149's Order Summary Report dated January 15, 2025, showed an order dated January 12, 2025, for laboratory tests every Monday. The report continued to show an order dated January 12, 2025, Sodium Chloride Intravenous Solution 0.45% (percent), use 1000 mL (milliliters) intravenously one time a day every Monday for IVF (Intravenous Fluids), HANG AFTER MORNING LABS HAVE BEEN DRAWN! R149's January 2025 MAR (Medication Administration Record) showed R149 received the ordered intravenous fluids on January 13, 2025, at 6:00 AM. R149's Laboratory Results Report showed R149's laboratory tests were collected on January 14, 2025. On January 15, 2025, at 1:29 PM, V2 (Director of Nursing) said R149's laboratory tests were ordered to be drawn before the intravenous fluids were started on January 13, 2025, but the laboratory tests were performed the day after. V2 said it is the expectation for physician orders for laboratory tests to be followed as ordered.

Based on observation, interview, and record review, the facility failed to properly label, date, and store food items and maintain a clean kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 162 residents. On [DATE] at 12:24 PM, V18 (Diet Office Assistant) said there is only 1 NPO (Nothing by Mouth) resident, and the other 161 residents eat from the facility kitchen. On [DATE] from 9:14 AM through 10:21 AM, the facility kitchen was toured in the presence of V3 (Director of Food and Nutrition), and the following was found: In the Cook's refrigerator: 1. A small bin of pureed ham with expiration date of ,d+[DATE]. 2. A small bin of ground ham with expiration date of ,d+[DATE]. 3. An unlabeled and undated opened package of what V3 said was baloney. 4. A 4 Quart bin of processed ham dated opened on ,d+[DATE] and expiration on ,d+[DATE]. V3 said those dates were not correct, processed meats are not good for 11 days. 5. A medium sized plastic bin of tuna salad dated ,d+[DATE] and expiration of ,d+[DATE]. V3 said that expiration date was wrong, that tuna salad, or any salad mixed with mayonnaise is only good for 3 days. 6. A 2-quart bin of processed turkey labeled opened on ,d+[DATE] and expiration of ,d+[DATE]. In the Dry Storage: 7. Four 48-ounce glass jars of grape jelly with best by date of [DATE]. 8. Two 9-ounce taco seasoning mixes with expiration date of [DATE]. 9. A 1 quart bottle of foam free liquid oven cleaner spilled on the floor, with the contents white and dried up on the floor. V3 said she did not know how or when the cleaner spilled. In Walk-In refrigerator #2 10. A pink liquid spill on the floor under the chicken cutlets rack. 11. On [DATE] at 9:14 AM in the kitchen in front of the 3-compartment sink there was a sheet of plywood on the floor with a lot of dust surrounding it. V3 said a pipe in the floor was dug up on [DATE] because of a blockage. On [DATE] at 10:16 AM the kitchen floor was still dirty from the pipe work and the dust/dirt had shoe prints in it and was being tracked through the kitchen. V3 said we were going to mop it, but maintenance told us to leave it because they were coming back again tonight to continue repairs. We can mop it up, because we are tracking it through the kitchen. On [DATE] at 11:08 AM, V3 said the construction company was in the kitchen working on the pipe until [DATE] at 4:30 AM and they still had to concrete and re-tile the floor to finish the repair. 12. For the duration of the kitchen tour on [DATE] from 9:14 AM to 10:21 AM, V3's hairnet was only covering half of her head. V3's hair was not restrained from the top middle of her head forward. V3's hair net was only covering the top middle of her head back down to her neck. On [DATE] at 9:37 AM, V3 (Director of Food and Nutrition) said all food items in the kitchen should be labeled and dated to make sure the food is safe for the residents to eat. V3 said expired food items should be thrown away because they would be a health hazard if consumed by the residents. V3 said processed meats are good for 3 days once opened. V3 said the kitchen staff slice their own deli meats and she was not sure if deli meats sliced on site last longer than pre-sliced and packaged meats. V3 said she would refer to the facility policy for expiration of deli meats. V3 said the risk with serving expired processed meats is foodborne illness. V3 said prepared salads like tuna salad are good for 3 days in the refrigerator. V3 said hairnets need to be worn covering all hair on the head while in the facility kitchen because hair could potentially fall in the food and contaminate it. V3 said the floors in the kitchen and storage areas should be mopped after each meal. The facility's policy titled, Expired/Recalled Product revised ,d+[DATE] states, Procedure: .3. Outdated or recalled product will be discarded . The facility's policy titled, Food Storage and Expiration Dates revised ,d+[DATE] states, Policy: All opened food that is placed into storage shall be labeled with the product name, date opened and/or expiration, or use by date. If a product has a manufacturer expiration or use by date, follow that date unless removed from the original container .The day the product is opened is counted as day one. Procedures: Foods that expire 3 days after opening: leftover foods, prepared salads (egg, tuna, etc.), leftover deli meats .The dining service manager will: .2. Assure labeling guidelines are followed . The facility's policy titled, Labeling & Dating for Food Storage revised [DATE] states, Storage and packaging practices help assure proper ingredient usage and food safety. All foods that require time and temperature control (TCS) should be labeled with the following: common name of the food, date the food was made, and use by date . Any unopened items with a printed manufacturers use by date may be used until the date listed on the product . The facility's policy titled, Hair Restraints revised [DATE] states, Employees shall use effective hair restraints to prevent the contamination of food or food contact surfaces .Hair shall be covered at all times while in the kitchen and during service of food . The facility's policy titled, Cleanliness and Sanitation of Service Area effective ,d+[DATE] states, Policy: The cleanliness and sanitation of the serving area is to be maintained. Procedures: Employees involved in the service of food in the serving area must observe the following procedures to ensure safety: .After Service: 1 .Monitor racks, carts, and coolers, checking for any spillage. 2. Sweep and clean floors after meal service .

Based on observation, interview, and record review, the facility failed to ensure residents dependent upon staff for ADLs (Activities of Daily Living) received nail grooming for 4 of 38 residents (R18, R101, R139, & R146) reviewed for ADLs in a sample of 38. The findings include: 1. On 02/20/24 at 11:05 AM, R18 was observed with long jagged nails, with brown substances under the nails. R18 said that she didn't like them that way and wanted them cut and filed. R18 has diagnoses including, cerebral atherosclerosis, and polyarthritis osteoporosis. R18's 11/5/24 Care plan showed an ADL self-care performance deficit related to Activity Intolerance, Dementia, Impaired balance, Limited Mobility. She was admitted to hospice services and the goal is comfort with interventions including, check nail length and trim and clean on bath day and as necessary. R18's 12/28/23 Minimum Data Set (MDS) showed that R18 cognition is severely impaired, and in Section GG I. Personal hygiene R18 needs substantial/maximal assistance. 2. On 02/20/24 at 10:49 AM, R101 was observed with her fingernails long, jagged, and brown substances under nails. R101 said I asked about a month ago for them to cut them and nobody has helped me. R101 has diagnoses including, Parkinson's disease, osteoarthritis, and muscle weakness. R101's 1/3/24 MDS section C showed that her cognition is intact. Section GG I. of the MDS showed that R101 needs setup or clean up assistance for personal hygiene. R101's 1/3/24 care plan showed that R101 has an ADL self-care performance with interventions including, Check nail length and trim and clean on bath day and as necessary, and personal hygiene - supervision maximal 1 assist. 3. On 02/20/24 at 11:00 AM, R139 was observed with his fingernails long, jagged, and brown substances under nails. R139 said, The last time they cut them was a couple of weeks ago. I would rather they be cut short. R139's diagnoses include, Cerebral infarction, weakness, need for assistance with personal care, Dementia, and Alzheimer's disease. R139's 1/2/24 care plan showed he has an ADL self-care performance deficit related to a history of Cerebral Vascular Accident (CVA), dementia, and weakness. The care plan interventions included, check nail length and trim and clean on bath day and as necessary, and personal hygiene with moderate to maximal 1 person assistance. R139's MDS showed that his cognition is moderately impaired and in section GG I. He is to receive substantial maximal assistance with personal hygiene. 4. On 02/20/24 at 11:14 AM, R146 was observed with her fingernails long, jagged, and with brown substances under nails. R146 said that it was probably about a month since the last time they were cut, and that staff does not offer to cut them. On 02/21/24 at 10:58 AM, R146 was observed with her fingernails long, jagged, and with brown substances under nails. R146 has diagnoses including hemiplegia and hemiparesis, dementia, and weakness. R146's 1/23/24 care plan showed she has an ADL self-care performance deficit related to weakness, left hemiparesis post Cerebral Vascular Accident (CVA), osteoarthritis, and activity intolerance .with approaches including, personal hygiene - moderate to maximal to dependent 1 person assistance. R146's 1/29/24 MDS section GG I. personal hygiene showed that she needs substantial/maximal assistance. On 02/22/24 at 09:59 AM, V2 (Director of Nursing) said that the residents' nails should be clean and short, and staff should be providing ADL care routinely and as needed. V2 said this should be done for infection control, to prevent skin tears, cleanliness, and dignity. The facility's Activities of daily living (ADL) policy (1/18/2023) showed, that care and services will be provided for the following activities of daily living, bathing, dressing, grooming, and oral care. The policy's Explanation and Compliance guidelines showed, 3. a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to maintain infection control while entering isolation, while feeding residents, and during incontinent care. This applies to 10 of 10 residents (R1, R9, R59, R60, R76, R77, R89, R98, R104 and R109) reviewed for infection control in a sample of 38. The findings include: 1. On 2/22/24 at 10:39 AM, V6 (Social Services) was observed entering R59's room without gown and gloves. At 10:41 AM, V6 came out of R59's room. V6 said she went to issue R59 a notice of discharge. V6 only had on her N95 mask and goggles on when she entered the room. V6 said thought that all the PPE (Personal Protective Equipment) she was on was sufficient, she did not look at the isolation sign on the door. There was a sign for Contact Precautions and Droplet Precautions on the door. For the contact precaution sign, providers and staff must put on gloves and gown before entering the room, discard gloves and gown before exiting the room. R59's lab result of 2/14/24 showed that R59 tested positive for RSV (Respiratory Syncytial Virus). R59's EMR (Electronic Medical Record) showed that R59 was placed on contact/droplet precaution for RSV on 2/14/24 and end of isolation will be 2/23/24. On 2/22/24 at 10:43 AM, V9 (Agency LPN/Licensed Practical Nurse) said that R59 was on isolation for RSV and staff requires full PPE before going in the resident's room. On 2/22/24 at 10:47 AM, V2 (DON/Director of Nursing) said staff should have full PPE (gown, gloves, N95, face shield) prior to entering the room. On 2/22/24 at 12:15 PM, V10 (Infection Preventionist) said RSV is a respiratory infection and requires droplet isolation, staff are to wear full PPE to prevent possible spread of infection. 2. On 2/20/24 at 12:38 PM, during lunch on the 3rd floor, V8 (Volunteer) was observed feeding R104 and R109 at the same time. V8 used the same hand to feed both residents and did not perform any hand hygiene in between feeding both residents. R104's MDS (Minimum Data Set) of 1/5/24 shows that R104 requires assistance with meals. R109's MDS of 12/29/23 shows that R109 requires assistance with meals. 3. On 2/20/24 at 12:50 PM, V4 (MDS/Minimum Data Set Coordinator) was observed feeding R76 and R89 at the same time during lunch on the 3rd floor. V4 used the same hand to feed both residents and did not perform any hand hygiene while feeding both residents. On 2/21/24 at 12:15 PM, V7 (CNA/Certified Nurse Aide) was observed feeding R76 and R89 at the same time, using the same hand. V7 failed to perform any hand hygiene while feeding both residents. R76's MDS of 12/13/23, shows that R76 requires assistance with meals. R89's MDS of 2/1/24 shows that R89 requires assistance with meals. 4. On 2/20/24 at 12:57 PM, V5 (3rd floor Unit Manager) was observed feeding R60 and R77 at the same time during lunch on the 3rd floor. V5 failed to perform any hand hygiene while feeding both residents. R60's MDS of 1/3/24 shows that R60 requires assistance while eating. R77's MDS of 11/30/23 shows that R77 requires assistance while eating. On 2/22/24 at 9:18 AM, V2 (DON) said staff should wash their hands before, after, and in between feeding every resident. The facility's Infection Control- Management of Respiratory Syncytial Virus (RSV) policy (2/16/24) states that infection control principles will be followed to decrease the risk of transmission, based on federal, state or local guidance. The principle includes, hand hygiene, respiratory and cough etiquette, transmission-based precautions, appropriate personal protective equipment as indicated, cleaning and disinfecting of high-touched surfaces. 41384 5. On 02/20/24 at 12:30 PM, V17 (RN/Registered Nurse) was observed feeding 2 residents R98 and R1 at the same time. V17 was observed using only her right hand and used R98's and R1's spoons, forks, and cups, never cleaning her hands. At 12:39 PM, V16 (CNA) took over feeding R98 and R1. V16 was observed using only her right hand and using R98's and R1's spoons, forks, and cups, never cleaning her hands. On 02/20/24 at 12:32 PM, V17 said that she had cleaned her hands before she started serving the lunch trays and felt that should have been enough. V17 said that it is not ideal to keep cleaning your hands while feeding two people. V17 said that it is possible for cross contamination if you feed two people at the same time and don't clean your hands in-between. On 02/22/24 at 09:48 AM, V2 (Director of Nursing) said that staff should not be feeding two residents at the same time because there can be cross contamination, it is for infection control. 6. On 02/20/24 at 11:54 PM, V13 and V14 (CNAs) were observed providing incontinence care for R9. V14 removed R9's soiled brief, did not remove her gloves or clean her hands, and put her hands on R9's hip stabilizing R9 as V13 cleaned R9's buttock area. After V13 provided perineal care to R9, V13 removed her gloves but did not clean her hands before putting on clean gloves. V13 then assisted in putting on R9's new brief, and repositioning R9 in the bed. V14 also assisted with putting on R9's new brief, repositioned her in the bed, adjusting R9's sheet and blanket and touching the bed control to adjust R9's bed, still with the dirty gloved hands. On 02/20/24 at 12:03 PM, V13 (CNA) said she should have cleaned her hands before putting on new gloves. V13 said she should have cleaned her hands after going from a dirty area to clean for infection control. On 02/20/24 at 12:04 PM, V14 said she should have removed her gloves and cleaned her hands after going from a dirty area. V14 said she forgot to do it after removing the brief. V14 said this should be done for infection control. On 02/22/24 at 9:50 AM, V2 said that staff should clean their hands and change gloves when going from dirty to clean. V2 said this should be done for infection control to prevent the spread of infections. The facility's Infection Control - Hand Washing policy (11/30/2022) showed that the facility considers hand hygiene the primary means to prevent the spread of infections.

Based on observation, interview, and record review, the facility failed to provide a dignified dining experience to residents and failed to provide privacy during incontinence care. This applies to 3 of 3 residents (R9, R60, R77) reviewed for dignity in a sample of 38. The findings include: 1. On 02/20/24 at 11:50 AM, V13 (Certified Nursing Assistant/CNA) started to provide incontinence care for R9 when the state surveyor came into the room. V13 then stopped providing care and said, I need to get more help. She then left the room with the resident with her gown up over her chest, the sheet and blanket pulled down to the end of the bed, and the curtain and door open. R9 was left exposed to anyone walking in the hallway. At 11:54 AM, V13 return to the room with V14 (CNA). On 02/21/24 at 10:31 AM, R9 said it bothered her to be left exposed with the door and curtain open. I'm not for their show and tell. R9 said it has happened before and that staff should be more in tuned to what the patient is feeling and how leaving the door open makes them feel. On 02/20/24 at 12:03 PM, V13 said she should have closed the curtain and door before leaving the room for the residents' privacy. On 02/22/24 at 10:08 AM, V2 (Director of Nursing) said the staff should have pulled the sheets up and pulled the curtain before getting help. V2 said this should be done for dignity and privacy of the resident. The facility's Perineal Care policy (date 1/10/2023) showed, while providing perineal care provide privacy by pulling privacy curtain or closing the door in a private room. 44387 2. On 2/20/24 at 12:57 PM, V5 (3rd floor Unit Manager) was observed feeding R60 and R77 at the same time during lunch on the 3rd floor. V5 was standing while feeding both residents. R60's MDS of 1/3/24 shows that R60 requires assistance while eating. R77's MDS of 11/30/23 shows that R77 requires assistance while eating. On 2/22/24 at 9:18 AM, V2 said staff should sit or be at the same level while assisting with feeding residents for dignity reasons. The facility's Resident Rights Promoting and Maintaining Resident Dignity during Mealtimes (4/26/2023) states that all staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. All staff will be seated while feeding a resident.

Based on observation, interview, and record review, the facility failed to provide an appropriate size wheelchair for a resident. This applies to 1 of 1 resident (R70) reviewed for wheelchairs in a sample of 38. The findings include: On 2/20/24 at 10:42 AM, during initial tour of the facility, surveyor asked R70 if she had any concerns. R70 stated, Yes, I do have a concern. I'm missing my wheelchair. This wheelchair here is not mine. Mine had my name on it and it was bigger. It was black. This wheelchair is too small. It's too low to the ground and too tight across my hips. I don't remember when it was exactly missing. I've told everyone that has come to my room that it's missing. I've told them the new wheelchair is uncomfortable, but no one is doing anything about it. I need my old one back. I can't use this one because it's just not the right size and it's uncomfortable. On 2/20/24 at 11:00 AM, surveyor tried to locate R70's Certified Nursing Assistant/CNA. V23 (CNA) stated R70's CNA was on her break. Surveyor asked V23 if R70 ever complained to her that her wheelchair was not the appropriate size. V23 stated no and said she doesn't normally work on the unit full time and that she floats all over the facility. Surveyor asked V23 if she could transfer R70 into her wheelchair. After transferring R70 in the wheelchair, surveyor was unable to slide a finger in between the sides of the wheelchair. It was too tight. R70 stated, It's too tight on the sides and it's causing pain. It's too low on the ground. This isn't going to work. On 2/20/24 at 11:13 AM, V22 (LPN/Licensed Practical Nurse/ 2nd floor Unit Manager) stated, Yes, I'm aware that (R70's) own wheelchair is missing. We are looking for it, but we can't find it. We did provide her with another one. She didn't mention it to me that it's too small. I did rounds this morning and she never said anything. I will go talk to (R70). On 2/20/24 at 11:17 AM, V22 came back to surveyor and stated, I talked to (R70), and she said her wheelchair causes pain. I told her she doesn't have to use it. We are looking for her wheelchair. I will try to find it. Thanks for telling me. On 2/21/24 at 10:08 AM, V21 (RN/Registered Nurse/Restorative Nurse) stated, I will have therapy evaluate (R70) today and get the correct wheelchair. We are actively looking for her old wheelchair. They personally didn't tell me it was missing. If we knew the wheelchair that we gave her was causing issues, therapy or the restorative nurse (me) would come and assess that new wheelchair. On 2/21/24 at 10:56 AM, V20 (Social Services) stated, We received an email from this family on Friday 2/16/24 stating that her wheelchair has been misplaced. On Monday, we started searching for her wheelchair. Yesterday, I was informed that she was uncomfortable in the new wheelchair that was provided. I talked with our supply manager, and we provided a new wheelchair to her. It was much more comfortable and suitable. V20's email from R70's son dated 2/16/24 documents: I did tell mom's (R70) nurse about this today, but I guess she was brought back to her room in the wrong wheelchair after her shower earlier this week. Her chair has special brake extensions, and it says (R70's last name) and (room number) on the white tag hanging off the back of the seat. Just wanted to help tracking it down and returning it to her room. Thank you. V20's email to R70's son dated 2/20/24 after surveyor brought it to the facility's attention documents: Your mom (R70) reported that the current wheelchair that she has was uncomfortable. Our supplies manager switched it out with one that she states is more comfortable until her chair has been located. On 2/21/24 at 1:55 PM, V19 (Director of Mission Integration) stated, When residents come in, they are given a wheelchair based on height and weight. If at any time, they are uncomfortable with their wheelchair, we will get physical therapy and/or occupational therapy involved and have them assess the resident with the wheelchair. Sometimes, they need longer footrests, or the wheelchair is too snug or too wide or we may have to provide them with different brake extenders. I don't have a policy regarding this. R70's face sheet shows diagnoses of cerebral infarction, chronic obstructive pulmonary disease (COPD), and wedge compression fracture of T5-T8 vertebra. R70's MDS (Minimum Data Set) dated 1/24/24) shows a BIM's (Brief Interview for Mental Status Score) of 14, which means she is cognitively intact. It also shows she uses a wheelchair. R70's care plan dated 11/3/23 shows a problem that she has limited physical mobility related to weakness, chronic back pain (Kyphoplasty due to compression fractures T5-T6 and T7-T8) in 12/2023, pathological fracture T12-L1), osteoporosis, COPD, and coronary artery disease. Approach: Locomotion: Wheelchair. Facility was unable to provide concerns/grievance form for R70's missing wheelchair and they were unable to provide a policy on wheelchairs.

Based on interview and record review, the facility failed to provide a resident and/or his family/power of attorney in writing for the reason of transfer to the hospital. They also failed to notify the ombudsman of the transfer. This applies to 3 of 3 residents (R41, R107, R208) reviewed for discharge in a sample of 38. The findings include: 1. On 2/22/24 at 11:56 AM, V19 (Director of Mission Integration) stated, We didn't inform (R41) or his representative of the reason for transfer in writing at the time of discharge to the hospital or afterwards. R41's face sheet shows an admitted [DATE] to the facility. R41's progress notes document the following: On 12/23/23 at 11:40 AM, (R41) had a scant amount of pink tinged sputum. On 12/23/23 at 3:48 PM, Spoke with nurse practitioner. Verbal order read back to send out (R41) to the hospital ER (emergency room ) Spoke with (R41's) POA. He is aware of the situation and transfer to the hospital. Left facility via 911 at 3:43 PM. On 12/23/23 at 9:02 PM, Spoke with staff at hospital ER. (R41) will be admitted with a diagnosis of pneumonia and hemostasis. On 12/28/23 at 7:40 PM, (R41) arrived with 2 ambulance personnels via stretcher from the hospital at 7:40 PM. (R41) was transferred to his bed. Review of R41's electronic medical record shows nothing was uploaded regarding the discharge letter to the resident/POA. Review of R41's January POS (Physician Order Sheet) does not show a physician's order to be transferred to the hospital. 2. On 2/22/24 at 12:01 PM, V19 (Director of Mission Integration) stated, We didn't inform (R208) or her representative of the reason for transfer in writing at the time of discharge to the hospital or afterwards. R208's face sheet documents an admitted [DATE]. R208's progress notes document the following: On 1/2/24 at 8:01 AM, (R208) observed on right side in his room at 6:55 AM. Noted with alarm sound in (R208's) room. (R208) stated, I was trying to hurry and go to the bathroom. I'm just humiliated that I have to use the bathroom by myself. Noted with stating again during assessment, I'm just clumsy and not careful. Encouraged to use call light to allow staff to assist with needs. She verbalized of having pain to left leg/hip. Bruise noted below the right elbow. Express with flexing extremities of having pain to left leg/hip. Notified medical doctor and informed. New orders received for x-rays of right arm and elbow, left hip, pelvis, and femur. Spoke with daughter and informed. On 1/2/24 at 10:00 AM, (R208) seen and evaluated by medical doctor with order to send (R208) to hospital (ER) due to pain on left lower trochanter post fall and irregular heartbeat. (R208)'s daughter at bedside. (R208) sent to emergency room for further evaluation and treatment. (R208)'s daughter to follow. Report given to nurse at emergency room . Informed of urine culture specimen result with positive UTI (Urinary Tract Infection). On 1/2/24 at 4:00 PM, (R208) sent back from the hospital. (R208) sent out due to pain after fall and irregular heartbeat. Per report, (R208) was administered with Rocephin IV while in hospital. New order for oral antibiotics for UTI from hospital received. (R208) is allergic to prescribed antibiotic. Medical doctor informed with order to change to Macrobid 500 MG (Milligrams) orally twice a day x 5 days. Noted and carried out. On 1/5/24 at 6:33 PM, CNA (Certified Nursing Assistant) alerted this nurse that (R208) is on the floor. Upon assessment, (R208) observed lying supine, both legs straight down with head tilted down with occiput against the bedside table next to her bed .Unable to recall how she fell on the floor. Complained of pain on left hip. Body assessment done and showed no break in skin. 911 called due to complaint of left hip pain without moving resident from the floor other than placing a pillow on head for comfort. (R208) has recent history of left hip fracture with displaced intertrochanteric fracture of left femur. Daughter (POA) informed and will follow resident in hospital. Medical doctor and supervisor informed. Report called into hospital and spoke with ER nurse. On 1/5/24 at 11:05 PM, (R208) returned from hospital via ambulance at 8:50 PM will continue to monitor. Review of R208's electronic medical record shows nothing was uploaded regarding the discharge letter to the resident/POA. R208's January 2024 POS does not show an order for transfer to the hospital on 1/5/24. V19 provided an email of a list residents that were discharged in December and emailed to the ombudsman. R208's name was not on the list. V19 stated that if R208's name is not on the list, then the ombudsman was not made aware of the discharge to the hospital. Facility's policy titled Discharge and Transfer from the Facility (10/15/22) documents: B. Timing of The Notice-1. Before the facility will transfer or discharge a resident, the facility will provide a written notice to the resident and resident representative in a manner and language understandable to the party. 2. For facility-initiated transfer or discharge of a resident, the facility will send a copy of the notice of transfer or discharge to the representative of the Office of the State Long Term care (LTC) Ombudsman. If information changes prior to the resident's discharge, the notice will be update and distributed to all required parties. 5. Emergency Transfers-When a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. 39182 3. R107's face-sheet showed, R107 was admitted to the facility on [DATE] and her diagnoses included inflammation of the gallbladder and laparoscopic cholecystectomy. R107's MDS (Minimum Data Set) dated 4/14/23 showed, R107 is cognitively intact (BIMS-Brief Interview of Mental Status-score of 15) and required extensive assist for ADLs (activities of daily living). R107's progress notes dated 4/17/23 at 7:51 PM showed R107 was sent to the hospital for investigation and confirmation of fracture of the right hip. Records lacked documentation to show that the notice of transfer or discharge was given in writing to the resident or her representative upon transfer or discharge or as soon as practicable. Records lacked documentation to show, the facility sent a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman within 30 days. On 2/22/24 at 12:15 PM, V19 (Director of Mission Integration) stated, notice of transfer or discharge was not given in writing, to the resident or her representative upon transferring R107 to the hospital on 4/17/23. On 2/22/24 at 12:18 PM, V1 (Administrator) stated, notice of transfer or discharge was not given in writing to a representative of the Office of the State Long-Term Care Ombudsman upon transferring R107 to the hospital on 4/17/23.

Based on interview, and record review, the facility failed to provide in writing to residents and their families/POA (Power of Attorney) regarding bed hold and return at the time of discharge to the hospital. This applies to 3 of 3 residents (R41, R107, R208) reviewed for discharge in a sample of 38. The findings include: 1. On 2/22/24 at 12:02 PM, V1 (Administrator) stated R41 was not given a bed hold notice at the time of discharge to the hospital. She stated that during the time of admission, the residents are given a contract regarding bed holds, but not at discharge. R41's face sheet shows an admitted [DATE] to the facility. R41's progress notes document the following: On 12/23/23 at 11:40 AM, (R41) had a scant amount of pink tinged sputum. On 12/23/23 at 3:48 PM, Spoke with nurse practitioner. Verbal order read back to send out (R41) to the hospital ER (emergency room ) Spoke with (R41's) POA. He is aware of the situation and transfer to the hospital. Left facility via 911 at 3:43 PM. On 12/23/23 at 9:02 PM, Spoke with staff at hospital ER. (R41) will be admitted with a diagnosis of pneumonia and hemostasis. On 12/28/23 at 7:40 PM, (R41) arrived with 2 ambulance personnels via stretcher from the hospital at 7:40 PM. (R41) was transferred to his bed. Review of R41's electronic medical record shows nothing was uploaded regarding the bed hold to the resident/POA. Neither was anything mentioned in the progress notes. 2. On 2/22/23 at 12:08 PM, V1 stated that R208 was not given a bed hold notice at the time of discharge to the hospital. R208's face sheet documents an admitted [DATE]. R208's progress notes document the following: On 1/2/24 at 8:01 AM, (R208) observed on right side in his room at 6:55 AM. Noted with alarm sound in (R208's) room. (R208) stated, I was trying to hurry and go to the bathroom. I'm just humiliated that I have to use the bathroom by myself. Noted with stating again during assessment, I'm just clumsy and not careful. Encouraged to use call light to allow staff to assist with needs. She verbalized of having pain to left leg/hip. Bruise noted below the right elbow. Express with flexing extremities of having pain to left leg/hip. Notified medical doctor and informed. New orders received for x-rays of right arm and elbow, left hip, pelvis, and femur. Spoke with daughter and informed. On 1/2/24 at 10:00 AM, (R208) seen and evaluated by medical doctor with order to send (R208) to hospital (ER) due to pain on left lower trochanter post fall and irregular heartbeat. (R208)'s daughter at bedside. (R208) sent to emergency room for further evaluation and treatment. (R208)'s daughter to follow. Report given to nurse at emergency room . Informed of urine culture specimen result with positive UTI (Urinary Tract Infection). On 1/2/24 at 4:00 PM, (R208) sent back from the hospital. (R208) sent out due to pain after fall and irregular heartbeat. Per report, (R208) was administered with Rocephin IV while in hospital. New order for oral antibiotics for UTI from hospital received. (R208) is allergic to prescribed antibiotic. Medical doctor informed with order to change to Macrobid 500 MG (Milligrams) orally twice a day x 5 days. Noted and carried out. On 1/5/24 at 6:33 PM, CNA (Certified Nursing Assistant) alerted this nurse that (R208) is on the floor. Upon assessment, (R208) observed lying supine, both legs straight down with head tilted down with occiput against the bedside table next to her bed .Unable to recall how she fell on the floor. Complained of pain on left hip. Body assessment done and showed no break in skin. 911 called due to complaint of left hip pain without moving resident from the floor other than placing a pillow on head for comfort. (R208) has recent history of left hip fracture with displaced intertrochanteric fracture of left femur. Daughter (POA) informed and will follow resident in hospital. Medical doctor and supervisor informed. Report called into hospital and spoke with ER nurse. On 1/5/24 at 11:05 PM, (R208) returned from hospital via ambulance at 8:50 PM will continue to monitor. Review of R208's electronic medical record shows nothing was uploaded regarding the bed hold to the resident/POA. Neither was anything mentioned in the progress notes. On 2/22/24, surveyor requested the policy regarding the bed hold notice and it was not provided. On 2/22/24 at 12:15 PM, V19 (Director of Mission Integration) stated she just created a policy on bed hold notice. She confirmed that the bed hold notice should be given at the time of discharge. 39182 3. R107's face-sheet showed, R107 was admitted to the facility on [DATE] and her diagnoses included inflammation of the gallbladder and laparoscopic cholecystectomy. R107's Minimum Data Set (MDS) dated [DATE] showed R107 is cognitively intact (BIMS-Brief Interview of Mental Status-score of 15) and required extensive assist for ADLs (activities of daily living). R107's progress notes dated 4/17/23 at 7:51 PM showed R107 was sent to the hospital for investigation and confirmation of fracture of the right hip. Records lacked documentation to show that the facility provided the resident and the resident representative written notice of bed-hold policy and return. On 2/22/24 at 12:25 PM, V1 (Administrator) and V19 (Director of Mission Integration) stated, notice of bed-hold policy was not given in writing, to the resident or her representative, when R107 was transferred to the hospital on 4/17/23.

Based on observation, interview, and record review, the facility failed to provide adequate hydration to a resident to prevent dehydration and failed to ensure residents receive tube feeding and water flushes as ordered by the physician. This failure resulted in R1 requiring hospitalization due to elevated sodium levels and dehydration. This applies to 2 of 3 residents (R1, R3) reviewed for improper nursing care in the area of tube feedings and hydration in the sample of 5. The findings include: 1. On December 20, 2022 at 11:02 AM, R1 was sitting in a high-back wheelchair in the activity room, near the nurse's station. R1 was not able to answer questions due to his cognitive status. R1 was not receiving tube feeding at the time of the observation. R1's tube feeding machine was in his room. The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE]. R1 has multiple diagnoses including Parkinson's Disease, dementia, dysphagia, gastrostomy, hypertension, insomnia, major depressive disorder, PVD (Peripheral Vascular Disease), cerebral infarction, history of falling, and osteoarthritis of the right shoulder. R1's MDS (Minimum Data Set) dated October 5, 2022 shows R1 has severe cognitive impairment, is totally dependent on facility staff for eating, and requires extensive assistance with all other ADLs (Activities of Daily Living). R1 uses a wheelchair for mobility. R1 is frequently incontinent of bowel and bladder. The MDS continues to show R1 is fed through an abdominal feeding tube and receives 51 percent or more of his total calories through tube feeding, and R1's average fluid intake by tube feeding is 501 cc (cubic centimeters) or more per day. Facility documentation of R1's CMP (Comprehensive Metabolic Panel) results dated December 5, 2022 shows R1's sodium level was 165 mEq/L (Milliequivalents/Liter) (Reference Range 138-147), and BUN (Blood Urea Nitrogen) level as 54 mg/dL (milligrams/deciliter) (Reference range 7-28). On December 5, 2022 at 7:02 PM, V4 (LPN-Licensed Practical Nurse) documented, Received critical lab result for CBC with diff (Complete Blood Count with differential) and CMP. Informed MD. MD order send resident out for ER (emergency room ) for further eval and treat. Order in place. On December 6, 2022 at 3:06 AM, V5 (RN-Registered Nurse) documented, [R1] admitted at [local hospital], diagnosis: Hypernatremia (elevated sodium level) and dehydration. At the time of R1's hospitalization , the EMR showed the following enteral feeding orders and water flushes for R1: An order dated October 13, 2022 for (Brand name of feeding) 1.5 at 90 ml/hour (milliliters/hour) for 17 hours to infuse a total of 1530 ml/day via G-tube (Start 3:00 PM, off 8:00 AM or until 1530 ml is infused). An order dated October 13, 2022 for flush G-tube with 350 ml of H2O (water) QID (four times a day) at midnight, 6:00 AM, 12:00 PM, and 6:00 PM. Hospital documentation dated December 5, 2022 at 8:31 PM shows R1's blood levels were checked upon admission to the hospital and R1's sodium level was 166 mEq/L and BUN was 57 mg/dL. On December 6, 2022 at 10:08 AM, V9 (Hospital Nephrologist) documented, Reason for Consultation: AKI (Acute Kidney Injury/Hypernatremia). Assessment/Plan: 1) Hypernatremia - due to minimal intake; PO (Oral) intake/GT (gastrostomy) intake/free water flushes unclear. Unlikely to have diabetes insipidus; no evidence of an osmotic diuretic; meds benign. Plan - adjust IVF (Intravenous Fluids) (hypotonic); start free water flushes via GT; evaluate urine electrolytes. On December 6, 2022 at 9:57 AM, V10 (Hospital Dietitian) documented, Patient status: [AGE] year-old male admitted on ,d+[DATE] presents from NH (Nursing Home) with hypernatremia. Patient screened due to consult for tube feeding. Per chart, patient is on (Brand name of feeding) 1.5 at 90 ml/hour for 17 hours (3:00 PM to 8:00 AM) with FWF (Free Water Flush) 350 ml QID (Four Times a Day).Also discussed the FWF regimen ordered would be more than enough to keep patient hydrated and patient was likely not receiving this fluid . On December 20, 2022 at 1:57 PM, V3 (Dietitian) said, This is a big red flag that [R1] got sent out for dehydration. I had no words when I saw that. I do not think he got his water flushes and that is why he was dehydrated. Also, when I calculate the tube feeding rate and amount, I make my calculations based on the needs of the resident. In addition to the water flushes, a large part of the tube feeding is also water, so my calculations for water flushes and tube feeding will calculate exactly what is needed by the resident to maintain their nutrition and hydration status. On December 21, 2022 at 8:40 AM, R1 was sitting in a high-back wheelchair in the activity room. R1 was not receiving tube feeding at the time of the observation. On December 21, 2022 at 8:45 AM, R1's tube feeding pump readings were checked with V6 (RN). V6 said R1's tube feeding was complete, and the pump was turned off after the feeding was completed. V6 turned on the pump. The pump showed the following readings: Rate: 80 ml/hr., water flush 325 ml every 6 hours, total volume to be infused 1530 ml. V6 reviewed the 24-hour history on the pump. The history showed R1 received 1156 ml of tube feeding in 24 hours (R1 should receive 1530 ml in 24 hours) and the 48-hour history showed R1 received 2734 ml (R1 should receive 3060 ml in 48 hours). The feeding pump did not show R1 received the 1530 ml of tube feeding daily as ordered by the physician. On December 21, 2022 at 9:20 AM, R1's tube feeding pump readings were reviewed with V2 (DON-Director of Nursing). V2 pressed buttons on the pump to display the history and confirmed the history showed R1 received 1156 ml of tube feeding in 24 hours and 2734 ml of tube feeding in 48 hours. V2 said the readings on the pump did not look correct since R1 should have received 1530 ml in 24 hours and 3060 ml in 48 hours. V2 continued to say she was going to check with the manufacturer of the pump regarding the readings on the feeding pump. V2 said she was not sure if the pump history was cleared out when the nurse cleared the pump settings. V2 cleared the pump settings, turned off the pump, and then turned the feeding pump power back on and the same history numbers of 1156 ml in 24 hours and 2734 ml in 48 hours. The amount fed history did not clear from the pump when the pump numbers were cleared, and the pump was turned off. A review of the EMR showed R1 had an order dated December 9, 2022 to flush the enteral feeding tube with 250 ml of water every four hours. Documentation shows the order was changed by V11 (LPN) on December 13, 2022 to 250 ml every 4 hours until December 14, 2022 and then discontinued. The facility does not have documentation to show R1 received water flushes from December 14, 2022 at 6:00 AM to December 20, 2022 at 12:00 PM. On December 22, 2022 at 2:18 PM, V2 (DON) said, A new nurse (V11) was told the water flush order was going to change and V11 discontinued the water flush order. V11 did not enter the new water flush order. At 2:44 PM, V2 continued to say, the new water flush order from December 13, 2022 should have been 325 ml every 6 hours via G-tube. On December 21, 2022 at 10:53 AM, V7 (Attending Physician) said, [R1's] BUN was elevated, and his sodium was off the charts. He went to the hospital and responded well to hydration, and I agree he was dehydrated. I assume he was not getting enough fluids and that is why he was dehydrated. The hospital did not change any of his medications or find other concerns such as a UTI (Urinary Tract Infection). He did not have vomiting, diarrhea, or fever to dehydrate him. He is a mouth breather and does drool at times but receives medication to dry up his secretions. It was either negative hydration or mouth breathing, though it was probably the former. His kidney function was fine. They just hydrated him, and he responded well. It is my expectation the facility staff give the tube feeding and water flushes as ordered. Also, I was not aware until I walked into the facility this morning that [R1] has not received water flushes since December 14. 2. On December 21, 2022 at 8:49 AM, R3 was lying in her bed. R3's (Brand name of feeding) 1.5 tube feeding was running at 75 ml/hour, and the tube feeding pump showed 150 ml of tube feeding had been fed to R3. The tube feeding pump also showed R3 was receiving 350 ml of water flush every 6 hours. R3 could not respond to questions due to her cognitive status. V4 (LPN) was standing just outside of R3's room and said she was assigned to care for R3. V4 said she asks the nurse from the previous shift how much tube feeding the resident received on the night shift and the nurse reports the number to her. V4 could not state how much tube feeding R3 had received during the night shift. V5 (RN) was standing at the nurse's station and said he was the night shift nurse assigned to R3 and had started at 7:00 PM the previous night. V5 continued to say R3's tube feeding was running when he started his shift the previous evening at 7:00 PM and the day shift nurse did not tell him when the tube feeding was started or how much tube feeding had infused. On December 21, 2022 at 9:27 AM, R3's tube feeding pump was turned off and no tube feeding was infusing to R3. V2 (DON) turned on R3's tube feeding pump. The tube feeding display window showed R3 would receive 350 ml of water flush every 6 hours, and tube feeding at 75ml per hour for a total volume of 1200 ml when the tube feeding pump is powered on. V2 reviewed the 24- and 48-hour history display. The 24-hour history showed R3 received 667 ml of tube feeding. The 48-hour display showed R3 received 1868 ml of tube feeding. V2 said R3 should have received 1200 ml of tube feeding in 24 hours and 2400 ml of tube feeding in 48 hours and V2 could not understand why the readings showed R3's tube feeding was short of the amount ordered by the physician and would have to check with the manufacturer. V4 (LPN) was at the nurse's station and was asked why the tube feeding pump was turned off. V4 said, I turned off the pump at 9:00 AM because the night shift nurse told me the resident needed 150 ml of tube feeding and then she would be finished. I do not know how to check if the resident got the total amount of tube feeding. I do not know how to work the pump or how to check the machine. The EMR shows R3 was admitted to the facility on [DATE] with multiple diagnoses including cerebral palsy, gastrostomy tube, dysphagia, anemia, adult failure to thrive, hypertension, major depressive disorder, encephalopathy, kidney stones, hydronephrosis, muscle spasm, UTI (Urinary Tract Infection), and chronic pain. R3's MDS dated [DATE] shows R3 is cognitively intact, is totally dependent on facility staff for transfers between surfaces, dressing, and personal hygiene, and requires extensive assistance with all other ADLs. R3 has an indwelling urinary catheter and is always incontinent of stool. The EMR shows an order dated December 6, 2022 for(Brand name of feeding) 1.5 tube feeding at 75 ml/hour for 16 hours or until 1200 ml is reached. The EMR shows an order dated December 6, 2022 for 350 ml water flush every 6 hours for hydration. The facility does not have documentation to show R3 received the water flush as ordered on December 13, 2022 at midnight and 6:00 AM. On December 20, 2022 at 1:57 PM, V3 (Dietitian) said, [R3's] calories are obtained 100 percent from her tube feeding. She does have an order for pleasure feeding. She cannot feed herself or give herself fluids. The Operation and Service Manual for the facility's enteral feeding pump, effective date February 28, 2007 shows, History: The totals of FEED mL and FLUSH mL will be shown for the requested history time. The manual continues to show the history can be displayed for a maximum of 72 hours past history and the 72-hour history includes time when the pump is powered off. The facility's policy entitled Enteral Nutrition, revised November 2018 shows, Policy Statement: Adequate nutritional support through enteral nutrition is provided to residents as ordered.3. The dietitian, with input from the provider and nurse: a. estimates calorie, protein, nutrient and fluid needs; b. determines whether the resident's current intake is adequate to meet his or her nutritional needs; c. recommends special food formulations; and d. calculates fluids to be provided (beyond free fluids in formula). 4. Enteral nutrition is ordered by the provider based on the recommendations of the dietitian. If a feeding tube is ordered, the provider and interdisciplinary team document why enteral nutrition is medically necessary.11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include a. the enteral nutrition product; b. delivery site (tip placement); c. the specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.; d. administration method (continuous, bolus, intermittent); volume and rate of administration; f. the volume/rate goals and recommendations for advancement toward these; and g. instructions for flushing (solution, volume, frequency, timing and 24-hour volume).

Based on record reviews, interviews, and observations, the facility failed to safely transfer a resident from a wheelchair to a standing scale. This failure resulted in R1 sustaining a left ankle fracture. This applies to one of three residents (R1) reviewed for falls in a sample of 6. Findings include: R1's EHR (Electronic Health Record) showed that R1 was admitted to the facility on [DATE] after a hospitalization due to a fall. R1's Face Sheet showed her diagnoses include [CONDITION(S)] of the knee, repeated falls, abnormalities of gait and mobility, weakness, severe [CONDITION(S)], [CONDITION(S)], pain in left knee, and a right artificial knee joint. The Facility's fall Occurrence Report dated 6/7/22 showed that on 6/7/22, R1 was being weighed on a standing scale with only one person assisting her when her left leg gave out, causing an injury. R1 was sent to the local community hospital for evaluation. R1's progress note dated 6/7/22, showed that on 6/7/22 a CNA was attempting to weigh R1 when her left knee buckled, and her left knee and ankle rotated internally and R1 verbalized pain. R1 was then sent to the local emergency room hospital. R1's hospital records for date of service 6/7/22, showed she presented to the emergency room with left ankle pain and deformity after a fall. R1's x-rays revealed a fracture/dislocation at the tibiotalar articulation with anterior dislocation of the fibula. The x-ray also showed that there is a displaced fracture of the distal fibula with distal fracture fragments. The hospital records showed under Assessment/Plan that the hospital did a reduction to R1's dislocation and R1 was placed on restrictions of NPO (Nothing by Mouth) as she awaits a consultation from an orthopedic doctor regarding possible surgery. On 6/29/22 at 9:38am, V11 CNA (Certified Nurse's Assistant) said that on 6/7/22 she was assigned to R1, and she was transferring R1 from her wheelchair to a standing scale when R1 became weak and fell on the base of the standing scale. V11 said that R1 ambulated with a wheelchair but felt that she could step up and stand on the scale with her assistance. V11 said that this day was the first time she had been assigned to R1 and she thought R1 was a 1 person assist and she did not need to use a gait belt. V11 said that she was informed by the previous shift that R1 was a 1 person assist and she did not check R1's records to verify this. V11 said that when R1 was getting on the scale, R1 put her left foot on the scale, then while lifting her right leg over the one-inch step, R1's left leg got weak and R1 began to fall. V11 said that she was the only person assisting R1 during this time. V11 said that there is a scale on another floor that is used to weigh residents that are in wheelchairs, but she thought R1 could stand on the scale by herself with her assistance. On 6/29/22 at 12:31pm V12 (Registered Nurse/RN) said that on 6/7/22 she was in a resident's room when she came out and saw V11 struggling with R1 on the standing scale. V12 stated she saw V11's arms around R1 as she was lowering her to the ground. V12 said that R1 ambulated with a wheelchair, and it is the facility's policy that if a resident is unable to stand then they are to be weighed in their wheelchair. On 6/28/22 at 12:32pm, V4 (Physical Therapist/PT) said that R1 is a 2 person assist. V4 said that on 6/7/22, R1 had just completed physical therapy, was tired/fatigued, had left knee weakness with pain, and because she was not weighed in her wheelchair or was assisted by two staff, it caused her to fall. V4 said that R1 had not yet received physical therapy for stepping because she was not physically ready, and R1 should not have use the standing scale because it requires you to step up on to the scale. On 6/29/22 at 10:48am V8 R1's (Primary Care Physician) said that R1 ambulates with a wheelchair and if R1 had been weighed while still in the wheelchair, she would not have fallen. V8 also said there should have been 2 staff and a gait belt used because this would have prevented R1 from falling and causing her to sustain a fracture. V8 said that R1 was morbidly obese, and this contributed to her fall. On 6/28/22 at 2:29pm V7 (Director of Nursing) said that R1 should have been weighed in her wheelchair for safety reasons and if she had been weighed in her wheelchair she would not had fallen and sustained injuries. R1's care plan dated 5/20/22 showed that R1 had a deficit in ADLs (Activities in Daily Living) related to a fall on 5/18/22 with left knee pain. R1's care plan showed under Approach, the resident requires extensive assistance by 2 staff to move between surfaces and as necessary. R1's Physical Therapy Plan of Care with Start of Care 5/20/22 and End of Care 6/7/22 showed that R1 was admitted with a prior history of falls, and on 5/18/22 had another fall, and was hospitalized until 5/19/22 when she was admitted to the facility. The Plan of care showed that R1 had complaints of left knee pain, weakness, and decreased activity tolerance with resulting impairments in bed mobility, transfers and gait. The care plan showed that R1's medical history related to her condition included obesity and chronic [CONDITION(S)] BLE (Bilateral Lower Extremities). R1's care plan showed that R1 used a wheelchair for mobility, and she needed maximum assistance with balance, and dynamic standing. Under Functional Deficits Section GG: Mobility D. sit to stand R1's current level was 02-Substantial/maximal assistance Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. R1's PT - Therapist Progress & Discharge Summary Start date 5/20/22 and End date 6/7/22 showed under section GG: Mobility, M 1 step (curb), not attempted due to medical condition or safety concerns. Under 6/7/22 note: V5 (Physical Therapist Aide) wrote R1 was given verbal cues to increase her step height on her (RLE) right lower extremity. The facility's Transfer policy (no date) showed under Policy, it is the policy to reduce the risk of injury to residents . Procedure- 1. Evaluate the situation. A. Identify and obtain the equipment and assistance needed. The facility's Weighing and Measuring the resident policy dated March 2011 showed under, Preparation 1. Review the resident's care plan to assess for any special needs of the resident, under, Equipment and Supplies - The following equipment and supplies will be necessary when performing this procedure: 1. Appropriate Scale: c. Platform scale (for non-ambulatory residents). 8. To measure the non-ambulatory resident's weight using the platform scale; b. weigh the wheelchair .c. assist the resident into the wheelchair. D. Transport resident to platform scale. e. Roll the resident onto the platform. Lock the wheels. The facility' Gait Belt Usage policy dated 1/1/2017 showed under Policy: To maximize safety for our patients and staff we require the use of a gait/transfer belt to be used while, lifting, transferring or ambulating patients. The facility's Fall - Clinical Protocol dated March 2018 showed under 3. The staff and practitioner will review each resident's risk factors for falling

Based on observation, interview, and record review, the facility failed to safely transfer a resident per the facility's policy and the resident care plan. As a result of this failure, R1 sustained a laceration to R1's head during a transfer. R1 was transferred to local hospital and received 3 staples to the back of R1's head. This applies to 1 of 3 residents (R1) reviewed for transfers. Findings include: On 4/26/22 at 11:24 AM, R1 was observed in her room sitting up in bed resting. R1 said after getting a shower, staff was attempting to transfer back to her bed, she fell from the mechanical lift. R1 said she does know what happened, something gave in, and she fell and hit her head. R1 said she was sent to the hospital and had three staples to the back of her head. R1 said there was only one staff with her during the transfer. R1 said she would prefer if there were two staff with mechanical lift transfers. R1's face sheet shows the following diagnoses of [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominant size, spinal stenosis lumbosacral region, abnormalities of gait and mobility and need for assistance with personal care. R1's MDS (Minimum Data Set) dated 2/8/22 shows R1's cognition is intact and R1 is total dependence with two or more staff assist with transfers. R1's care plan initiated on 8/13/21 and revised on 2/8/22 shows R1 requires a mechanical lift and two persons for transfers. The facility's incident report dated 4/19/2022 shows Resident sustained a laceration to the back of her head during a failed transfer using a mechanical lift. CNA (Certified Nurse Aide) notified nurse that resident was on the floor, he stated he was transferring the resident from the shower chair to her bed when she slipped through the opening in the sling to the floor. Sling was not properly positioned on the resident and was too large. 911 was called and resident was transported to hospital for treatment and evaluation. Resident received three staples to the back of her head. Resident returned to facility later that evening. According to V8 CNA witness statement states After the shower I put the sling back on her ready to put her to bed. After lifting her about two feet up and all of a sudden resident came out the hole from the sling. I thought the sling was oversized and I reported to my nurse. On 4/26/22 at 2:47 PM, V8 (CNA) said on the day of the fall, after giving R1 a shower, he took R1 back to her room. V8 said he had R1 lean forward in the shower chair and then slid the sling behind her back and then he crossed the straps of the sling under R1's legs and hooked the straps straight up to the bar of the mechanical lift. V8 said after he hooked the straps, he raised the lift, and R1 was suspended in the air and R1 fell through the hole. V8 said R1 fell back and hit the back of head on the leg of the mechanical lift. V8 stated that he was the only staff member in the room during R1's transfer. V8 said he did R1's transfer on his own before and after R1's shower. V8 said after R1 fell he told V3 (Registered Nurse/RN) he dropped R1 on the floor and the ambulance was called. V8 stated he did know he wasn't supposed to do mechanical lift transfers by himself. V8 stated he did not check the size of R1's sling prior to the transfer, but he thinks the hole in the sling where R1's butt went was too big. On 4/26/22 at 11:43 AM, V3 (RN) said on the day of the fall, V8 (CNA) informed her that R1 fell . V3 said when she got to R1's room, she observed her lying on the floor. V3 said there was blood on the floor and R1 said he dropped me. V3 said she did R1's vitals and called 911. V3 said V8 was alone with R1 during the mechanical lift transfer. V3 said V8 should have called her before putting R1 in sling to make sure it's the right sling. V3 said it always takes two people to help with transfers. On 4/27/22 at 11:35 AM, V11 (RN) via phone interview said R1 came back from the ER (emergency room ) and had three staples on the back of her head. On 4/27/22 at 9:14 AM, V6 (Physical Therapist/PT) said since admission, R1 has always required a mechanical lift for transfers. V6 said physical therapy assess and makes recommendation on transfer techniques for residents. V6 said there should always be two staff during mechanical lift transfer for safety reasons. On 4/27/22 at 11:58 AM, V1 (Administrator) said R1 injured her head during a mechanical lift transfer by V8 (CNA.) V1 said R1 was sent to the ER after the fall. V1 said it requires two staff for mechanical lift transfers. On 4/27/22 at 9:45 AM, V7 (R1's Physician) via phone said, he is aware that R1 went to the emergency room after the fall. V7 said per facility policy, there should always be two staff members with mechanical lift transfers. There was only one staff member when R1 was transferred. V7 said per facility protocol, residents should be assessed by PT for safe transfers, and recommendations should be followed. According to R1's hospital record dated 4/13/22 shows R1 had posterior head laceration and had three staples to the laceration. The facility's policy titled Mechanical Lifts/(Brand name lift) (October 2015), under Guidelines: 3. For safe operation of the (Brand name lift), always have two people to lift resident. Under Procedure: 1. Review the resident's plan of care and/or the resident's care guide. 3. For safety, make sure that two people are performing this procedure.

Based on record review and interview, the facility failed to follow their policy and procedure while transferring a resident using a mechanical lift. This failure resulted in R1 sustaining a comminuted fracture of the right clavicle. This applies to 1 of 6 residents (R1) reviewed for fall in the sample of 6. Findings Include: The EMR (Electronic Medical Record) shows R1 is an [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses including spinal stenosis, [CONDITION(S)], abnormalities of gait and mobility, morbid (severe) obesity and [CONDITION(S)]. On April 30, 2021 at 12:35 PM, R1 said she remembers landing on the floor. She was being transferred to her wheelchair from the bed. There was only one person doing the transfer and it was a male staff. Then staff came in and got her up and put her in her wheelchair. R1 also said she was then sent to the hospital. On May 4, 2021 at 9:35 AM, V7 (LPN, License Practical Nurse) said on March 22, 2021, V8 (CNA/Certified Nursing Assistant) was working alone while transferring R1 with a mechanical lift. V7 said that is when R1 fell causing a fracture to her clavicle. The facility's incident report sent to IDPH (Illinois Department of Public Health) shows that on March 22, 2021 at 5:15 AM, V8 (CNA/Certified Nursing Assistant) was transferring R1 from her bed to her wheelchair using a mechanical lift by himself. The Corrective Action Notice in the report showed under Employee's Comments V8 wrote, I responsible for last night's incident My co-worker was busy and resident kep (kept) holloring (hollering) that she wanted to get-up- that's why I tried to get-up alone. R1's care plan dated February 8, 2021 under ADLs (Activities of Daily Living) shows that R1 is to be transferred with a mechanical lift, with assistance of two staff members. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is totally dependent on at least two staff members for transfer. R1's progress notes shows on March 22, 2021 at 5:15 AM, R1 fell from a mechanical lift while being transferred. At 12:40 PM, the facility received results of R1's x-ray and R1 was then sent to the hospital for evaluation and treatment. At 10:44 PM, R1 returned from the hospital with a diagnosis of a fractured clavicle. R1's hospital documentation dated March 22, 2021 under the title Emergency Provider Notes shows R1 was lifted with a mechanical lift and she fell out of it and landed on her buttocks area, her right shoulder, and right side of her head. R1 stated most of her pain was in her shoulder. R1's Right clavicle x-ray result dated March 22, 2021 under conclusion shows Comminuted and midly angulated fracture mid to distal 3rd of the right clavicle is noted. The facility's policy and procedure titled Lifting Machine, Using a Mechanical dated July 2017 under the subtitle General Guidelines shows 1. At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . On April 30, 2021 at 1:50 PM, V1 (DON/Director of Nursing) said that all transfers with a mechanical lift should be done with two staff because residents are unpredictable, and it is the facility's policy.

Based on observation, interview and record review the facility failed to monitor and supervise a cognitively impaired resident who was left in the uncovered outside patio for three hours, being exposed to direct sunlight and heat. This failure resulted in R1 needing to be sent out to the local hospital emergency room for treatment of [REDACTED]. R1 was admitted to the local hospital with a [DIAGNOSES REDACTED]. This applies to 1 of 3 residents (R1) reviewed for incident reports. The findings include: According to the EHR (electronic health record), R1 has [DIAGNOSES REDACTED]. The MDS (minimum data set) dated 06/07/19 shows that R1 has moderately impaired cognition, requiring extensive assistance with bed mobility, transfer, dressing, toilet use, personal hygiene, bathing and locomotion on and off the unit. The same MDS showed that R1 has both lower extremities impairment in functional limitation in range of motion. The facility's incident report dated 07/25/19 showed that approximately 16:15 (4:15 PM), facility's CNA/certified nursing assistant went to get R1 for his shower. R1 was in the 2 east rooftop gardens where he often sits to enjoy the outdoors. R1 appeared flushed and slow to respond to the CNA. The CNA brought R1 inside and immediately notified the nurse. The nurse found R1 to be slow to respond, appeared flushed and warm to touch. Vital signs were obtained, ice packs applied for cooling and oxygen was administered. R1 was transported to hospital via EMS (emergency medical services). R1 was evaluated in the ER (emergency room ), diagnosed with [REDACTED]. Hospital record dated 07/25/19 showed: R1 was seen in ER (emergency room ) with heat exposure and fever. R1 was found outside the facility with 103.5 fever, hot dry skin, resident was not responsive to name. Hospital history and physical examination [REDACTED] The resident is an [AGE] year old male, nursing home resident, with multi system atrophy, dementia and parkinsonian features. Cannot give much history. Brought by EMS because of high fever from the nursing home. He was apparently in the sun for a couple of hours. In the ER, he was found to have pneumonia and possible UTI (urinary tract infection) and was further admitted because of [MEDICAL CONDITION]. Vital signs: ER temperature was 101.8 degrees. Blood pressure 156/88. Lactic acid was 2.1 and WBC (white blood count) 11.3 Assessment and Plan 1. Septi[DIAGNOSES REDACTED] because of high lactic acid. 2. History of heat exposure. [MEDICATION NAME] for burn areas. History of present illness: R1 is an [AGE] year old with [DIAGNOSES REDACTED]. R1 was poor historian so history is taken from chart review and staff report. Apparently R1 was found outside confused with fever of 103.5 outside his nursing facility. He does not remember this and just states he had planned to go out in the garden and does not recall anything further. He was taken to the hospital for evaluation and workup, revealed positive urinalysis (culture pending) negative head CT and CT abdomen/pelvis with question of LLL opacities. He was treated for [REDACTED]. Presently he denies any acute concerns. Denies any pain, dyspnea, wheezing, chest pain/pressure, nausea, emesis or abdominal pain. Nurse report he has sunburn areas on his face and BUE (both upper extremities). He was given [MEDICATION NAME] and [MEDICATION NAME] during admission. Nurse report the new development of hives on BLE. R1 endorses history of [MEDICATION NAME] allergy but unknown reaction. Physical examination Skin: positive [DIAGNOSES REDACTED] consistent with sunburn noted over face and BUE (both upper extremities) forearms. Positive [DIAGNOSES REDACTED]tous rash with appearance of hives noted on bilateral medial thighs. Assessment: -[MEDICAL CONDITION], hypovolemia- likely urosepsis given abnormal UA (urinalysis) pneumonia less likely - Hyperthermia - likely due to above, may have component of heat stroke - acute [MEDICAL CONDITION] - due to above, improved - acute [MEDICAL CONDITION] - due to above, improved - positive urinalysis - LLL opacities, dry cough - pneumonia less likely, may be due to atelectasis, poor secretion clearance, aspiration - Sunburn - prolonged exposure - history of dementia,[MEDICAL CONDITIONS] On 07/27/19 at 11:55 AM V3 CNA (certified nursing assistant) stated that on 07/25/19 he was working on second floor. V11 CNA (3pm-11 PM) was looking for R1 because he was not in his room. V3 said that V11(Certified Nurse Aide - CNA) asked him where R1 was. V3 said he told V11 that he did not know where R1 was and that R1 would usually go and play bingo. V3 continued and stated that the bingo game is usually done at 3pm. V3 said he helped V11 look for R1 and at around 4 PM he found R1 in the second-floor garden outside. R1 was sitting up in the wheel chair under the sun. R1 was not responding. R1 already passed out, his body was shaking, sweating, and his eyes were opened. V3 said he told V11 to call a nurse and brought R1 inside the building then to his room. V4 (nurse) took R1's vital signs. V3 further stated that it was very hot that day (07/25/19) and R1's face, neck and arms were very red. R1 was wearing short sleeves shirt, long pants, and regular glasses. R1 was not wearing hat or sunglasses. There were family members and residents outside, but they were under the tree. On 07/30/19 at 2:28 PM V11 CNA stated that on 07/25/19 he came to work at 3 PM. V11 said that she was doing her rounds and cannot find R1. V11 said that she asked a nurse (V11 did not know the name) where R1 was. The nurse told her to check the dining room, but R1 was not there. V11 said that she answered 2 call lights and after that she asked V3 if he saw R1. V3 said he might be in the dining room downstairs. V3 went to check on R1 in the first-floor dining room but R1 was not there. V11 said that at around 4 - 4:15 PM she was doing her charting on the second floor TV room. V3 was standing near the door of the TV room and he looked at the window outside the patio and saw R1. V11 said that V3 and her (V11) went outside the patio and saw R1's body was shaking. V11 continued and stated that R1 had sunburn on his face, forehead, and arms. V11 described the sunburn as deeply red. V11 said that they brought R1 inside the facility and told the nurse. The nurses applied cold compress to R1's body and 911 was called. On 07/27/19 at 3:35 PM V4 (nurse) stated on 07/25/19 at around 4 PM V11 CNA approached her, asking about R1 because he was schedule to have a shower that day. V4 said she told V11 that R1 might be in the dining room or in his room. At around 4:20 PM, V4 said she saw R1 being brought back by V3 and V11 from the patio garden. V4 said that while R1 was being wheeled back to his room she saw R1's eyes were opened, not moving, and that R1 was not verbally responsive. V4 said she knew something was not right with R1 and did quick assessment. V4 said that V14 and V15 (nurses) were following R1 to his room so she called 911 and informed V12 (supervisor). R1's skin was hot, skin was flushed and not verbally responsive. V4 said she went back to R1's room and the 2 nurses were already putting cold wet towels on R1's forehead, arms, armpit and groin area. R1's oxygen saturation was 89% and they put R1 on a non-rebreather mask and R1's oxygen saturation went up to 93 %. R1's pulse registered as 132 per pulse oximeter. V4 said they were trying to get R1's temperature, but the paramedics came already. On 07/29/19 at 11:20 AM, V6 (student CNA) stated that on 07/25/19 around 12:45 PM he walked in the TV room and met R1. R1 called him over and wanted to go outside. V6 said he responded to R1 and asked V8 CNA that R1 wanted to go outside and if he could bring him out. V6 said V8 responded yes and said, we will get him later. V6 said that he took that V8 knew and that she will follow up with R1. V6 said he pushed R1 outside of the patio and there were other people there in the patio. V6 said he asked R1 if he wanted to be in the shade, but R1 wanted to be under the sun. V6 said he positioned R1 in partial sun close enough to the other people and so he would be able to view R1 from the TV room. V6 said he talked to R1 for a few minutes and excused himself and walked back inside the TV room. V6 further stated at around 12:55 PM they took residents to the first floor for bingo game and left the building at 1:45 PM. V6 said that he was not aware that V8 left the building at 2 PM. V6 said he was not aware if V8 told anyone the location of R1. V6 said that R1 was lucid and alert. V6 further stated that when he brought R1 out when it was partially cloudy, while the clouds were passing by. Additionally, he was talking to R1 they were under the sun. V6 said that there was a slight breeze and it was comfortable for him (V6) outside. On 07/29/19 at 12:18 PM, V8 CNA stated that on 07/25/19 there were CNA students from 7AM to 2 PM. V8 said on that day (07/25/19) she was asked to come in early, so she came in at 6AM and worked until 2 PM. V8 said that R1 was not her resident that day, but she knew R1. V8 said that she was paired with 2 students CNA (V8 did not know their name but knew thet one was an Asian girl and the other a white male) and helped her toilet, transfer and give showers to the residents. R1 always went to bingo 3 times a week (Tuesday, Thursday and Saturday) and the bingo starts at 1:30 PM. V8 denies talking to anyone or V6 regarding bringing R1 outside the patio. V8 said that R1 was on the other wing (group 3) and she was in group 1. V8 further stated that R1 can have a conversation, but she does not think R1 can remember what you talk about. R1 is disoriented with time and he is declining physically. V8 said that day (07/25/19) it was sunny and in the lower 80's not like 95 or humid. On 07/27/19 at 4 PM V5 CNA (7A-3PM) stated that she was working that day (07/25/19) and resident was fine. V5 said the last time she saw R1 was during lunch time (12 PM- 12:45 PM). V5 said that R1 usually goes to the first floor to play bingo. V5 said that the volunteers take R1 down to play bingo because this was R1's routine since she (V5) was working in the facility for 3 years. V5 said that when she was doing her rounds R1 was not in his room, so she was thinking R1 was downstairs playing bingo. On 07/29/19 at 2:50 PM V9 (nurse practitioner) stated that she was informed by V4 that R1 was unresponsive. Skin was flushed and R1 was going to the hospital when 911 was called. V9 was asked what her expectation for the staff is in supervising a resident and how long to be safe to be under the sun. V9 said that a resident is alert or if not oriented can go outside, she/he has wear sunblock, take precaution or stay in the shaded area. They have to have somebody to monitor the residents because he is outside. Safe time for residents under the sun should be 10-15 minutes. On 07/30/19 at 1:20 PM V10 (nurse practitioner) stated that she saw R1 a month ago and he was stable. V10 said that she left the building that day (07/25/19) at 3 PM and heard about the incident. V10 was asked about the expectation for the resident to be under the sun. V10 said limited amount of time with supervision or monitor the resident. If the weather is 80 degrees, then the time duration should be 15 - 20 minutes outside. On 07/31/19 at 11:35 AM V13 (physician) stated that he did not see R1 in the hospital because he was out of the country. V13 was asked what expectation from the staff for supervising a resident or how long to be safe under the sun. V13 said that there is nothing written in the medical book to be safe under the sun, but they need to do a safety check for the resident. This includes frequent checks every 30 minutes, 45 minutes, or every hour. They should have common sense if the resident is safe to be outside. On 07/29/19 at 1:45 PM R1 was observed in bed. R1's face and arms were still red. R1's forehead, nose, and cheeks were peeling off. R1 stated that he asked a CNA to bring him outside to get fresh air. R1 denies any pain. The weather on 07/25/19 per time and date. com/weather report showed: - 12:52 PM 83 degrees F (Fahrenheit)- sunny with humidity of 41% - 1:52 PM 83 degrees F sunny humidity of 41 % - 2:52 PM 84 degrees F sunny humidity of 41 % - 3:52 PM 85 degrees F sunny humidity of 39 % - 4:52 PM 84 degrees F sunny humidity of 40 %