Every finding on record at Stephenson Nursing Center

Based on observation, interview, and record review, the facility failed to ensure pressure relieving interventions were in place for 3 of 4 residents (R1, R2, R4); failed to perform and document a wound assessment for a resident (R3); and failed to identify pressure ulcers prior to advancing to a stage 2 for 2 residents (R1,R3). These failures apply to 4 of 4 residents reviewed for pressure ulcers in the sample of 4.The findings include: 1) R1's electronic face sheet dated 7/7/26 showed R1 has diagnoses including but not limited to Alzheimer's disease, severe sepsis, gastrostomy, pressure ulcer right heel stage 3, pressure ulcer right ankle stage 4, pneumonia, and dementia without behaviors. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and has pressure ulcers. R1's weight log dated 7/1/26 showed R1's current weight is 153.8lbs. R1's care plan dated 4/28/26 showed, Has stage 1 pressure ulcer on right medial great toe related to disease process, history of ulcers, immobility .Has pressure ulcer on right lateral ankle .Has stage 3 pressure ulcer on R medial heel . R1's patient risk profile dated 7/6/26 showed R1 is at high risk for skin breakdown. R1's wound assessment dated [DATE] showed, stage 2 pressure wound of the right lateral ankle .duration >1 days .2.0x1.1x0.1cm(centimeters), open areas with exposed dermis . R1's wound assessment dated [DATE] showed, stage 2 pressure wound of the right distal medial foot .duration >8 days .0.6x0.6cm . On 7/7/26 at 9:28AM, R1 was lying on her left side in her bed. R1's air mattress was turned on with the weight setting at 250lbs. (96.2lbs over R1's weight). A sticker on the air mattress pump showed, 3/11/26 159. On 7/7/26 at 1:42PM, V3 (Registered Nurse) stated, Central supply goes around and checks all of the air mattress settings to ensure they are correct. I don't know when they do it or how often, but they are the ones that do it. There is a sticker on the air mattress pump that shows the resident's weight. When a new wound is identified we measure it and do an assessment and then inform the wound care nurse so she can do an assessment and get the resident on the list for the wound doctor.On 7/7/26 at 1:50PM, V5 (Wound Care Nurse) stated, The air mattress is used to prevent ulcers from residents lying in bed all the time. Anyone that has a wound gets an air mattress to take pressure off the wound. The purpose of the resident's weight setting being correct is that the right amount of pressure needs to be applied. If it's too high or too low, then it's not going to function correctly for that resident. I monitor the settings most of the time, we should all be keeping track of the settings. Most of the wounds are daily except for one or 2 so I should be checking the settings almost every day. We started putting the weights on the pump so that staff knew what the settings should be. It should be the resident's current weight that is shown on their air mattress pump. When residents come back from the hospital there should be a full skin assessment performed, and I should be notified as soon as possible so that we can get treatment in place. Staff are good at letting me know if something comes up with a resident. There would be signs on a resident's skin prior to a stage 2 that should be identified such as red, non-blanchable skin that we could be putting preventative measures in place to prevent it from developing into a more severe stage. I would say yes a wound should be identified prior to a stage 2.2) R2's electronic face sheet dated 7/7/26 showed R2 has diagnoses including but not limited to osteomyelitis, pressure ulcer buttocks stage 4, pressure ulcer of sacral region stage 4, pressure ulcer right hip stage 4, and paraplegia.R2's facility assessment dated [DATE] showed R2 has 4 stage 4 pressure ulcers.R2's patient risk profile dated 7/1/26 showed R2 is a high risk for skin breakdown.R2's physician's orders dated 7/1/26 showed, Ensure air mattress is on, plugged in, and set at correct weight.R2's weight record dated 7/5/26 showed R2's current weight is 124lbs.On 7/7/26 at 11:18AM, R2 was getting out of bed for the day. R2's air mattress was on and set at 180lbs. (56lbs more than R2's current weight). At 1:30PM, R2 stated, Feel this mattress, something isn't right. It seems too hard and it's not comfortable.3) R3's electronic face sheet dated 7/7/26 showed R3 has diagnoses including but not limited to respiratory failure with hypoxia, dysphagia, and dementia with agitation.R3's facility assessment dated [DATE] showed R3 has no cognitive impairment and is at risk for pressure ulcers.R3's physician's orders dated 7/6/26 showed, Coccyx: apply skin prep and Duoderm three times weekly.R3's nursing progress notes dated 7/5/26 showed, Observed skin opening on right buttock. Area cleansed and applied Duoderm until seen by wound nurse.On 7/7/26 at 11:40AM, R3 stated, They found a sore on my bottom the other day. It doesn't hurt, just annoying to have a patch on it. I have a cushion in my wheelchair that is supposed to help and I'm supposed to try and lay down a few times a day.R3's wound report dated 7/6/26 showed, stage 2 pressure wound coccyx, duration >7 days, 1x1.4x0.1cm, open areas with exposed dermis.On 7/7/26 at 1:50PM, V5 (wound care nurse) stated, I wasn't sure what (R3's) wound was so I put her on the list for (wound physician), I thought maybe it was MASD (Moisture Associated Skin Damage) but (wound physician) assessed it yesterday and said it's a stage 2 pressure ulcer. The floor nurse notified me last Thursday, so I sent a message to (wound physician) for him to see her. I skin prepped it and put a Duoderm on it on Thursday. I assessed it but I must not have documented it. There are no assessments for (R3's) wound prior to 7/6/26.4) R4's electronic face sheet dated 7/7/26 showed R4 has diagnoses including but not limited to dysphagia, pressure ulcer stage 4, hypertension, and tracheostomy.R4's facility assessment dated [DATE] showed R4 has severe cognitive impairment and 1 stage 4 pressure ulcer.R4's patient risk profile dated 6/5/26 showed R4 is a high risk for skin breakdown.R4's weight record dated 7/2/26 showed R4's current weight is 110lbs. On 7/7/26 at 1:30PM, R4 was lying in his bed with his air mattress set at 80lbs. (30lbs less than R4's current weight).The facility's policy titled, Pressure Injury Prevention & Management dated 4/6/26 showed, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection, and the development of additional pressure ulcers/injuries .2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment .c. Licensed nurses will conduct a full body skin assessment on all residents after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements, other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented .

Based on observation, interview, and record review, the facility failed to wear personal protective equipment (PPE) for a resident (R1) on Enhanced Barrier Precautions. This applies to 1 of 3 residents reviewed for infections in the sample of 4. The findings include:R1's electronic face sheet dated 7/7/26 showed R1 has diagnoses including but not limited to Alzheimer's disease, severe sepsis, gastrostomy, pressure ulcer right heel stage 3, pressure ulcer right ankle stage 4, pneumonia, and dementia without behaviors.R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment, has pressure ulcers, and utilizes tube feedings. R1's care plan dated 11/18/24 showed, Resident requires enhanced barrier precautions due to urinary catheter device and jejunal tube appliance. On 7/7/26 at 12:01PM, V3 (Registered Nurse) entered R1's room to administer medications via R1's feeding tube. V3 applied gloves but no gown and administered R1's medications and feeding tube flushes. V3 stated, I should have worn a gown and gloves with (R1) due to her being on enhance barrier precautions due to wounds and having tube feedings. On 7/7/26 at 12:42PM, V1 (Administrator/Registered Nurse) stated, (V3) told me she didn't wear a gown in (R1's) room. She should have worn and gown and gloves when she was administering medications and providing care to (R1) because she is on enhanced barrier precautions and she is at a high risk for infections. The facility's policy titled, Enhanced Barrier Precautions dated 5/2/26 showed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .

Based on interview and record review the facility failed to supervise a resident at risk for falls. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 6. This failure resulted in R1 sustaining a left hip fracture. This past compliance occurred from 2/22/26 to 2/23/26. Past noncompliance-no plan of correction required. The findings include:R1's admission Record (Face Sheet) showed an Original admission date of 11/18/25 with diagnoses to include but not limited to Alzheimer's dementia, unsteadiness of feet, weakness, and rheumatoid arthritis. R1's 2/28/26 Minimum Data Set (MDS) showed she was unable to complete the Brief Interview for Mental Status test, and she has both short and long-term memory problems. R1's 2/10/26 Restorative Note from 9:08 AM showed, On 2/5 (2/5/26) staff in (locked memory care) unit informed me that occasionally when [R1] is tired or not walking well in general she tends to walk too far behind her rollator (walker). I observed her ambulating (walking) with it and did not notice any concerns at that time. I called her husband. to discuss this with him. He said at night when he is visiting, he has noticed the rollator 'gets away from her sometimes.' R1's 2/22/26 Post Fall Observation showed, This nurse was off unit to complete scheduled facility treatments. At appx 1320 (1:20 PM), [V5 Certified Nursing Assistant, CNA] gestures from down the hall to come quick. When asked, resident states there's someone on the floor down here. This nurse responds immediately. Upon entering common area of unit, observed this resident lying on her back, LLE (left lower extremity) is bent at the knee, external rotation observed. Affected area immobilized. (Note was authored by V4 Registered Nurse, RN) R1's 2/22/26 Nurses' Note from 3:40 PM, showed R1 was admitted to the local area hospital with a left hip fracture. On 3/17/26 at 8:54 AM, V5 (CNA) stated she was taking R1 (a locked memory care unit resident) to the toilet shortly after lunch on 2/22/26. V5 stated the other CNA was in a room providing care for a resident and the nurse was off the unit. V5 said, I noticed she was getting away from the walker and her butt was sticking out. I asked if she was okay, so I went for a chair a few steps away and when I stepped away and turned around, she fell. She was using a 4-wheel walker. Her walker being away from her, that means her arms were stretched out and her butt was sticking out. I was trying to get her to stand upright with the walker, so I did what I thought was right and grabbed the chair, and as soon as I saw her leaning, she started to fall. I was holding the walker steady and put my hand on her back and trying to coach her to move towards the walker and she didn't understand, she was confused. I went to get the chair because she was so far from the walker, and I didn't think she was going to make it to the bathroom. Sometimes her hips go out, but I was told that afterwards; I didn't know that at the time. I thought she needed the chair, she would sit down, collect herself, then we would try again. I did not have gait belt on her. She needs some help going from seated to standing with the walker. She was in a lot of pain. I should have stayed side by side with her and called for help instead of leaving her. If I had stayed with her and called for help instead of leaving, and I had a gait belt on her, I could have possibly lowered her to the floor. On 3/17/26 at 10:56 AM, V4 (RN) stated, I was her (R1) nurse that day (2/22/26). V4 stated at that time, the memory care nurse was responsible for wound care on the other units, and she was attending those duties at the time of R1's fall. V4 stated V5 had called for her to come to the unit. V4 said she could tell right away it was broken. V4 stated she believed the leg was broken based on R1's pain and the rotation of the leg. V4 said she knows R1, and she doesn't typically have pain, and she was experiencing a significant amount of pain, especially when her left leg was touched. V4 said, I have never seen her this uncomfortable before. V4 said R1 requires assistance with ambulation, transfers, and a gait should be used. V4 said the assistance with ambulation and gait is for safety. V4 said the CNA should have stayed with R1 and not left for the chair. V4 said the CNA should have called for help and then if no help came and it was needed, she should have lowered R1 to the floor with the gait belt. On 3/17/26 at 9:55 AM, V8 (CNA) stated R1 requires assistance with ambulation as well as a gait belt. V8 said if R1's walker was getting away from her, she would call for help, and if there was a chair within reach, she would grab it. V8 said she would not take her hands off R1, and if needed, she would utilize the gait belt to lower R1 to the floor. On 3/17/26 at 10:03 AM, V9 (RN) (memory care) stated R1 requires assistance with ambulation, and she is definitely a fall risk when walking by herself. V9 said R1 can be weak when walking. V9 said if R1's walker was getting away from her, she would call for assistance, and if a chair was nearby, she would grab it. V9 said, If the chair was several steps away, I would not go get the chair. V9 said, if needed she would use the gait belt and lower R1 to the floor. On 3/17/26 at 1:55 PM, V2 (Director of Nursing) stated R1 had a tendency of getting away from her walker, which required her to have assistance and gait belt when she walked. V2 said, The gait belt is due to the unsteadiness, it will assist with steadying her. V2 stated V5 said, .she was assisting her (R1) and she (R1) was unable to advance her left leg forward, she (V5) went to grab the wheelchair and she went down on her left side. My understanding is she was walking her to the bathroom, and the wheelchair was right there. V5's description of the sequence of events leading to R1's fall was relayed to V2; R1's walker getting in front of her, R1's buttocks sticking out, V3 leaving R1 to get a chair, then R1 falling. In response, V2 stated V5 should not have left R1, she should have called for assistance, and if needed use a gait belt to lower R1 to the floor. On 3/17/25 at 12:25 PM, V11 (R1's Physician) stated, R1 has dementia, and she requires assistance with care. V11 stated if person is standing and their hip breaks because of a medical condition and not a fall, the person will typically fall immediately after the fracture occurs. V5's description of the sequence of the events leading to R1's fall was relayed to V11; R1's walker getting in front of her, R1's buttocks sticking out, V5 leaving R1 to get a chair, then R1 falling. V11 stated, based on V5's sequence of events, he couldn't say for certain; however, it sounds likely that the fall did cause the fracture. The facility's Safe Resident Handling/Transfers policy (Reviewed/Revised 11/1/25) showed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy continued, Compliance Guidelines:. 5. Proper hands-on assistance during ambulation. 8. Never leave a resident unsupported when balance is compromised or when the resident stops walking. Prior to the survey date of 3/17/26, the facility had taken the following action to correct the noncompliance:On February 22, 2026 the facility conducted gait belt training.On February 23, 2026 the facility conducted Safe Handling of Resident training.The facility terminated the offending employee.

Based on observation, interview, and record review the facility failed to ensure a safe mechanical lift transfer for a resident (R11) dependent upon staff for transfers. This failure resulted in R11 sustaining a right fracture. The facility also failed to ensure a stable chair was provided for a resident (R16) to prevent falls. These failures apply to 2 of 5 residents reviewed for safety and supervision in the sample of 38. The findings include:1. R11's face sheet showed she was admitted to the facility 11/27/2017 with diagnoses to include spastic hemiplegic cerebral palsy, major depressive disorder, hypertension, and primary generalized osteoarthritis. R11's facility assessment dated [DATE] showed she has moderate cognitive impairment and is dependent upon staff for transfers. R11's care plan initiated 1/27/26 showed, Resident wears sling to right arm due to right arm injury. Will wear sling to improve pain. R11's care plan initiated 11/28/2017 showed, Resident is at risk for falls. Approaches. Date Initiated: 1/24/26, Ensure resident is all the way back in the wheelchair before unhooking the (mechanical lift) sling. On 2/25/26 at 2:30 PM, R11 was lying in bed with her arm in a sling. R11 said, I'm wearing this sling because I broke some bones. They were putting me in a sling thing to get me out of bed; I just slid down and right onto the floor. It doesn't hurt very much, and the doctor said it should be healed up by Easter. They came in here and took some x-rays, that is how we found out it was broken. It's never happened like that before. There was just one girl was in here working the machine and there is supposed to be two to use it. They came right in and asked me questions; I told them there was only one girl when it happened. R11's Fall Report dated 1/24/26 at 11:30 AM showed, Resident was sliding out of her wheelchair and that was unsuccessful. Resident was lowered to the floor with two CNAs. (Certified Nursing Assistants). Resident does not have any noted injuries. Stated she was lowered to the floor. CNA reported that resident was sliding out of her wheelchair. She called for another CNA to assist her and the two of them lowered her to the floor.Witnessed by [V7 CNA] . Notes 1/26/26 (entered by V2 Director of Nursing): Resident experienced a fall after sliding out of her wheelchair. Has a diagnosis of CP (cerebral palsy), generalized osteoarthritis, edema of right arm, and obesity. After investigation with staff working that day, it was determined that the fall was unavoidable. She has poor trunk control and despite appropriate interventions her positioning in the wheelchair contributed to a loss of stability causing the fall. R11's Radiology Reported showed, . Date of Service: 1/24/26. Shoulder Complete. Right. Conclusion: . Acute anterior medial lateral humeral shoulder dislocation. This document showed it was reported to the facility 1/25/26 at 1:14 AM. R11's Post Fall Observation dated 1/24/26 showed, . she was sliding, and the CNA was unable to lift her back into the chair and she just kept sliding so it was safer to lower her to the floor. R11's Orthopedic Physician Note dated 1/27/26 showed, . Closed fracture of proximal end of right humerus. This is an elderly lady unfortunately had a fall out of a (mechanical lift) lift at the nursing home on Saturday (1/24/26). She was taken to the emergency room on Monday x-rays were taken yesterday which showed a proximal humerus fracture. She was put in a sling. On physical exam she has some pain in around her shoulder, no significant redness or swelling. X-ray show a small crack through the proximal humeral head area, undisplaced. On 2/26/26 at 8:40 AM, V7 CNA (Certified Nursing Assistant) said, It wasn't really a fall, she was in a chair, and she needed to be moved up. She wanted me to push her back in the chair. I took the (mechanical lift) sling and (V6 CAN), and I used the (mechanical lift) sling and a pillow and slid her out of the chair onto the floor. Then we used the (mechanical lift) to get her up off the floor. When the situation happened, they said she already complains about that arm. They were saying her arm got sprained because me and the other CNA and sliding her down with the (mechanical lift) sling. This happened in her room. I was getting her up for lunch. It was never a fall; we slid her down. [V6] was not helping me get her up out of the bed. This happened when she was in her chair. She is a lift for transfers. I did that transfer myself. That workload there is pretty heavy. A lot of people there would do that (1 assist lift transfers) because they are so busy. The hall I was working that day with [R11] there were 4-5 residents who were (mechanical lift) transfers. I was on the hall by myself. Some bigger residents I wouldn't do without the help of a second person but [R11] is usually an easier person, I'll be honest with you, I did that plenty of times, but I really don't think her arm has anything to do with that. Look at this, I got her in the chair, but she slid out. On 2/26/2026 at 12:39 PM, V6 CNA said, [V7] asked for help because [R11] was almost sitting on her wheelchair pedals. She was positioned with her butt on the pedals, so I don't know if she was trying to scoot or something. The sling was up behind her above her head, and she was sliding down. Her arms were up in the air; she was not holding onto anything. She was not complaining of pain at that time. We lowered her to the floor. I knew we couldn't get her back up because she is too big of a person, so we used the (mechanical lift) to get her back up off the floor. We slid her down using the (mechanical lift) sling then used the (mechanical lift) to get her back up. She is too heavy we could have never picked her up to get her back in the chair without the lift. [V7] was getting her up for lunch by herself. There should always be two people to use the (mechanical lift) so one can run the lift, and the other one can assist the resident into the chair. We use the lift because it is easier. We use the thing on the (mechanical lift) to scoot them up and get them positioned decent in the chair. It just works better when there is two, they just sit better. On 2/26/26 1:26 PM, V2 DON (Director of Nursing) said V7 was an agency CNA, and she would not have her back. I was informed shortly after she fell. The nurse called me and said that she had a fall, she told me that she slid out of the wheelchair. Everything seemed fine at that point but later in the afternoon. I got a phone call stating that [R11] was making a comment that she was transferred with one aide. I came in early that evening to speak with her and she told me that she had been transferred with just one person. The investigation was started then. [V7] was supposed to work the next day again so I called the agency and told them I was investigating and to DNR (do not return) her. I continued with the investigation, she contacted me and asked why she was DNR'ed (sic) and she swore up and down that she didn't do it by herself. I asked [V6] who was working that same day and she said she did not help her. [V6] had gone in with her when she had fallen to see what the positioning was. [V6] that she was right in front of the wheelchair but the whole thing was how did she get into the wheelchair in the first place? There was a (mechanical lift) in the room per [V6]. [V7] gave me the name of an employee who said she helped her, and that employee denied helping. [R11] was complaining of some discomfort to her right arm, which was not abnormal for her, but we did an x-ray that showed a dislocation. When that report came back, we let [R11's physician] know and he sent her to the ER. When [R11] came back she had a sling and an order to follow up with orthopedics, which we did. Orthopedics said there was a questionable subtle nondisplaced fracture. The aides are supposed to use two people when doing transfers with the (mechanical lift), and an in-service was completed afterwards. The reason they have to use two is for safety reasons, safety of the resident, for positioning, and for prevention of falls. The facility's undated policy and procedure showed, Safe Resident Handling/Transfers. Policy: It is the policy of this facility to ensure that residents are handled and transferred safety to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred. Compliance Guidelines: . 10. Two staff members must be utilized when transferring residents with a mechanical lift. 2. R16's face sheet showed she was admitted to the facility 6/24/25 with diagnoses to include encephalopathy, lack of coordination, hypothyroidism, Type 2 Diabetes, dementia with other behavioral disturbance, bipolar disorder, major depressive disorder, obstructive sleep apnea, chronic pain, muscle weakness, disorders of muscle, fibromyalgia, unsteadiness on feet, and abnormalities of gait and mobility. R16's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires supervision and touch assistance for most cares. R16's Care Plan initiated 10/7/25 showed, Resident is at risk for falls. The resident has impaired cognition and impaired safety awareness. Approaches. Date Initiated 12/18/25 Provide new stable dining chair. R16's Care Plan initiated 10/7/25 showed, Is above ideal body weight range and confounding factors include Diagnoses Diabetes and arthritis with weight gain making mobility more difficult. R16's Fall Report showed, . Patient fell after the chair broke while sitting down. Patient sat in the chair which broke making the patient fall to the floor. On 12/16/25, resident [R16] had a fall in the dining room. Contributing factors include BMI 40-44.9. dining room chairs were inspected immediately. R16's medical record showed, 12/16/25 at 1:36 PM, Patient fell after the chair broke while sitting down for dinner. Patient fell landing on the left side of her body. Patient denies any distress; however, she voiced pain to her lower back 3/10. Patient voiced that she hit her head. On 2/26/26 at 8:16 AM, V8 CNA said, I witnessed it (R16's fall), she was going to sit down in the chair, and it broke. She flopped back and hit the floor. It was one of our dining room chairs and she is a wider lady. When she was sitting in those chairs it was a tight fit.On 2/26/2026 at 1:39 PM, V2 DON said, [V1] and I went down to check the rest of the chairs to make sure they were stable, and we gave her a different chair to use. Her weight with the other chair was just too much. I don't think it was that the chair was in disrepair, I think all chairs down there would have done the same thing. Staff help her into the chair that is for her. she doesn't have safety awareness.The facility's policy and procedure dated 9/1/25 showed, Fall Prevention Program. Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care.

Based on observation, interview, and record review, the facility failed to ensure dietary staff covered their facial hair while preparing food for the residents, and while cleaning dishes. The facility failed to ensure staff used chemical sanitation to disinfect a food preparation table and equipment; failed to ensure staff were knowledgeable about the concentration level that was needed when testing the chemical sanitation; and failed to ensure cold desserts were maintained below 41 degrees Fahrenheit. This failure has the potential to affect all the residents in the facility.The findings include:The CMS 671 form completed by the facility on 2/24/26 showed 70 residents resided in the facility on 2/24/26.The document provided by the facility on 2/26/26, showed the only resident residing in the facility that does not receive nutrition by mouth is R21.On 2/24/26 at 9:17 AM, In the dish washing area of the facility, V17 (Dietary Cook) was doing the breakfast dishes. No gloves and no hair net covering his beard. V17 went across to the kitchen area to the hand washing station, to wash his hands. At 9:23 AM, V16 (Dietary Manager-DM) told V17 to make sure he puts his hair net on to cover his beard before doing the food. V17 said he only took it off to do the dishes because it was so hot in there. V17 had sweat dripping down his face and wiped the sweat off with his right arm. V17 was asked if facial hair could fall onto the clean dishes, and he said yes. Both V16 and V17 agreed that he should have been wearing the hair net over his beard in the dish wash area. On 2/24/26, between 10:35 AM-11:05 AM, this surveyor observed V17 do the pureed food for the lunch meal. V17 checked the consistency of the pureed spaghetti with meat sauce several times, pulling his hair net below his chin and resting in his facial hair. V17 continued this process several times until the spaghetti was the correct consistency. At 10:55 AM, V17 poured the food from the food processor into a smaller pan. V17 pulled the hair net under chin to taste, nodded his head, left the hair net under his chin while he took the pan across the kitchen and placed it in the oven. After putting the food in the oven, V17 pulled the hair net back over his beard. V17 put the cooked carrots into the food processor to puree them for the residents that required a pureed diet. V17 poured the pureed carrots into a smaller pan and pulled the hair net down under his chin (again resting on his facial hair) to test the consistency. V17 did not cover his facial hair again when he carried the pan over to the oven and placed the pan in the oven. At 11:13 AM while watching V17 do the pureed foods, V18 (dietary aide) was wiping down a large mixing bowl machine with a cloth used from green bucket. V18 covered the equipment with plastic, then cleaned the prep counter across from where V17 was working. V18 placed paper down on the prep table, laid out several slices of bread and started putting cheese on the bread. V18 was asked what was in the green cleaning bucket. V18 said dawn dish soap and water. V18 was asked if the prep areas should be cleaned with sanitizer instead of soap and water. V18 said she cleans them with soap and water. V16 (DM) was present during the conversation and said the prep areas should be cleaned with sanitizer and not soap and water. V18 grabbed a red bucket and filled it with quaternary solution from the three-sink area. V18 was asked to test the chemical solution. As she was dipping the test strip into the red bucket, V18 was reading the container the test strips were in. V18 held the strip next to the container to see what the results were. V18 said she thinks it should be between 400-500 ppm (parts per million). V16 said it should be 200 ppm. V16 said the facility does not keep any logs to record the results for testing the sanitation buckets. At 11:40 AM, V16 tested the temperature of some of the desserts in the roll in cooler. V16 said the pumpkin dessert was made last night and put in the cooler. The pureed pumpkin desserts temperatures were 51degrees Fahrenheit, 50 degrees Fahrenheit, and 51 degrees Fahrenheit. The regular pumpkin dessert was 46 degrees Fahrenheit, and the cottage cheese was 41.1 degrees Fahrenheit.On 2/26/26 at 10:47 AM, V15 (Registered Dietitian) said dietary staff should be wearing a hair net to cover facial hair when preparing foods. V15 said it is possible for facial hairs to fall onto clean dishes, so staff should probably wear one to cover their facial hair while doing the dishes. V15 said it is important to use chemical sanitation to wipe down the equipment and clean food prep areas to prevent food-borne illness. V15 said it is important for staff to be aware of the chemical concentration level needed for sanitation. V15 said the cold dessert temperatures should be under 41 degrees Fahrenheit if came out of the cooler to puree and cold milk was added.The facility's 2025 Dietary Employee Personal Hygiene policy showed 4. Hair Restraints. A. All dietary staff must wear hair restraints (e.g. hairnet, hat and/or beard restraint) to prevent hair from contacting food.The facility provided the information for the (Broad Range Quaternary Sanitizer). The document showed it was an EPA-registered broad range, liquid quaternary sanitizer. The document showed it was EPA approved for food contact sanitizing from 150-400 ppm. The document also showed the target range was 200 ppm.

Based on observation, interview, and record review the facility failed to ensure resident dignity was maintained during personal care for 2 of 2 residents (R13, R48) reviewed for dignity in the sample of 38. The findings include:1. R13's face sheet printed on 2/26/26 showed diagnoses including but not limited to traumatic subdural hemorrhage, speech and language deficits, autistic disorder, and left side paralysis. R13's facility assessment dated [DATE] showed moderate cognitive impairment. The same assessment showed total staff assistance required for bathing, dressing, personal hygiene, and transfers. On 2/25/26 at 9:10 AM, V6 (CNA-Certified Nurse Aide) performed morning hygiene care for R13. V6 removed R13's clothing and did a bed bath. R13's face, chest, groin area, and buttocks were washed during the process. R13 was rolled repeatedly from side to side during the process. The window curtain was not closed and R13 was visible to the neighboring wing windows. R13 was dressed and transferred to the wheelchair. At no time was the window curtain closed. 2. R48's face sheet printed on 2/26/26 showed diagnoses including but not limited to transient cerebral attack, chronic heart failure, palliative care, and anxiety. R48's facility assessment dated [DATE] showed severed cognitive impairment. The same assessment showed staff assistance required for bathing, dressing, and personal hygiene. On 2/24/26 at 10:56 AM, V5 (CNA) removed R48's incontinence brief and began peri care. During the process, V5 exited the room to get more gloves. R48 was naked from the waist down and the room door was left open. R48 was visible to the hallway. On 2/26/26 at 9:49 AM, V2 (Director of Nurses) stated resident room doors and window curtains should be closed during personal care. It is to ensure privacy and dignity. It is required for all residents, regardless of mental cognition or level of alertness. The facility's Promoting/Maintaining Resident Dignity policy revision dated 12/1/25 states under the compliance section: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 12. Maintain resident privacy.

Based on observation, interview, and record review, the facility failed to develop a care plan for a resident with a diagnosis of post-traumatic stress disorder (PTSD) for 1 of 1 resident (R79) reviewed for PTSD in the sample of 38.The findings include:R79's admission Record, provided by the facility on 2/26/26, showed she had diagnoses including post-traumatic stress disorder, unspecified, bipolar disorder, in partial remission, major depressive disorder, and generalized anxiety disorder. All of these diagnoses had an onset date of 12/29/23. R79's facility assessment dated [DATE] showed she has moderate cognitive impairment and partial to moderate assistance from staff for dressing, bathing, and toilet hygiene. The assessment showed R79 is independent with bed mobility and transfers.On 02/24/2026 at 12:51 PM, R79 was alert, oriented. Cognitively intact. Well-groomed. R79 was smiling and pleasant. No signs of withdrawal, anger, depression. R79 interacted with staff and other residents. R79 said she likes it in the facility. Staff are nice. They take good care of me. R79 said she feels her needs are being met.On 2/26/26 at 12:06 PM, V11 (RN) said R79 had some relationship issue in the past that caused her PTSD. Emotional and Verbal abuse. V11 said she knows this from working with R79 previously and talking with R79 and her family. V11 was asked to look in R79's electronic medical record for a PTSD care plan. V11 said she did not see a care plan for R79's PTSD diagnosis and does not know where to reference the cause of her PTSD diagnosis. V11 said R79 has been stable. V11 said it is important for staff to know the cause of a resident's PTSD, what the triggers are and how to manage the resident's symptoms.On 2/26/26 at 1:03 PM, R79 said she talks with someone that comes to the facility twice a week about how she feels and things that make her sad. She does not know what the person's name is, or who she works for. R79 said she feels her emotional needs are being met at the facility.On 2/26/26 at 1:30 PM V1 (Administrator) verified that there was no care plan for R79's PTSD prior to this surveyor asking. V1 said it is important to have a care plan in place, so staff know how to take care of R79. V1 provided the updated care plans with the PTSD included.R79's 2/26/26 PTSD care plan showed her PTSD was due to past falls that caused injuries.On 2/26/26 at 3:28 PM, V2 (Director of Nursing) was asked where the information was obtained regarding the cause for R79's PTSD. V2 said R79's PTSD was probably because she had a fall with a fracture in the past. V2 said R79 is receiving psychiatric services from a (behavioral health service). V2 was informed of the information provided to this surveyor by V11 (RN). V2 said she (V2) was not sure that R79's falls caused her PTSD or if it is due to something else. V2 said she called the behavioral health service that sees R79 and has not received a return call yet. V2 agreed that it is important to identify the reason for the diagnosis and make sure a care plan is in place.The facility's 2025 Comprehensive Care Plans policy showed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Trauma-informed care is an approach to delivering care that involves understanding, recognizing, and responding to the effects of all types of trauma. A trauma-informed approach to care delivery recognizes the widespread impact, and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization. The policy showed the care plan will be developed within 7 days after the completion of the comprehensive assessment.The comprehensive care plan will describe, at a minimum, the following: A. The services that are to be furnished are to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. B. Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment. C. Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of screening recommendations.f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. G. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident. Identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for 1 of 5 residents (R26) reviewed for pressure ulcers in the sample of 38. The findings include: R26's face sheet printed on 2/26/26 showed diagnoses including but not limited to paralysis of upper limb following cerebral infarction affecting right dominate side, right hip/buttock stage 3 pressure ulcer, right and left knee stiffness, and muscle weakness. R26's facility assessment dated [DATE] showed partial to moderate staff assistance required for bed rolling. The assessment showed total staff assistance required for putting on footwear. The same assessment showed R26 had no cognitive impairment. R26's pressure ulcer risk assessment dated [DATE] showed risk for pressure ulcer development. R26's most recent weight dated 2/12/26 showed 193.4 pounds. On 2/24/26 at 2:25 PM, R26 was seated in a wheelchair in his room. R26 wore black socks and both feet were resting directly on the floor. Blue heel protectors were lying on the bottom shelf of his nightstand. R26 had a low air-loss mattress on his bed, and the dial was set to the firmest level, way beyond the 400-level mark. This surveyor pushed on the mattress and R26 stated, That is super hard, right? R26 said he had a sore on his hip, and the mattress is supposed to help. R26 said the mattress is hard and he can't get comfortable on the hard ridges. On 2/25/26 at 9:40 AM, R26 was seated in a wheelchair in his room. The heel protectors were still on the bottom shelf of the nightstand, and his heels were directly on the floor. The air mattress setting was still set beyond the 400-level mark. At 2:27 PM, R26 was in the wheelchair in his room. The boots and bed setting were the same. His feet were flat on the ground. R26 stated the boots come off when he is in bed and staff do not attempt to put them back on him. On 2/26/26 at 10:13 AM, R26 was seated in a wheelchair in his room. The boots and bed setting were the same. His feet were flat on the ground. R26 stated staff do not float his heels or reposition him in bed. R26 repeated, That bed is so hard I can't move around on it. The ridges on the mattress make it hard for me to roll. R26's care plan showed a focus area related to stage 4 pressure of right hip. Interventions included: Apply pressure relieving device as ordered by MD (SPECIFY: pressure relieving device/reducing device) on (SPECIFY: bed/chair). Date initiated 10/6/25. Encourage turn and repositions every 2 hours and as needed. Date initiated 1/9/26. R26's wound report dated 2/23/26 showed a stage 4 right lateral hip wound measuring 1.5 x 0.4 x 1.0 centimeters. The report showed the wound was chronic and greater than 364 days in duration. The report showed it was decreasing in size and surface area. The report showed the objective was to prevent deterioration. Recommendations included limit sitting to 60 minutes, offload wounds, turn side-to-side in bed and reposition per facility protocol. On 2/26/26 at 10:29 AM. V2 (Director of Nurses) stated pressure ulcer air mattresses are based on resident weight. Settings are monitored by both the aides and nurses. The dial is set per each resident's weight. The settings are monitored every shift. It is reflected on the physician order report and TAR (treatment administration record). R26 is high risk for more skin breakdown and he already has a wound on his hip. V2 said staff should be attempting to get R26 to wear heel protectors or floating his heels in bed. V2 stated there is the potential for slower wound healing and more open areas to develop if interventions are not done correctly. At 10:40 AM, V2 and this surveyor observed R26's air mattress settings and feet directly on the floor. V2 said nurses should be documenting in the medical record that they are checking for both interventions. R26's February 2026 TAR showed documentation of the heel boots in place on 2/24, 2/25 and 2/26 (start dated 10/1/25). The same TAR showed to check air mattress for correct weight setting every shift (start dated 2/26/26-day of survey). The facilities Pressure Ulcer Prevention and Management policy dated 9/1/25 states: 4.c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure ulcer injury present.

Based on observations, interview and record review, the facility failed to ensure catheter tubing was positioned in a manner to prevent it from dragging across the floor as a resident was propelling his wheelchair for 1 of 1 resident (R46) reviewed for catheters in the sample of 38.The findings include:R46's admission Record provided by the facility on 2/26/26, showed he had diagnoses including, but not limited to chronic kidney disease, stage 3A, disorder of prostate, unspecified, urine retention, benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy (urine flow is blocked or flows backward into the kidneys), vesicoureteral-reflux with bilateral reflux nephropathy with hydroureter (the backward flow of the urine from the bladder to the kidneys leads to scarring, infection, and potential chronic failure). R46's facility assessment dated [DATE] showed he had moderate cognitive impairment, Requires supervision or touch assistance for toileting, bathing, bed mobility and transfers. The assessment showed R46 uses a wheelchair for mobility and has a urinary drainage catheter.On 2/24/2026 at 1:33 PM, R46 was observed propelling himself down the hall in his wheelchair. R46 had a urinary drainage bag placed inside a privacy bag that was attached to the wheelchair. The tubing for R46's urinary drainage bag was dragging on the floor as R46 was propelling down the hallway. On 2/25/26 R46 was seen propelling himself down a hall with the tubing to his urinary drainage device dragging on the floor at 8:30 AM, at 9:34 AM, and at 9:46 AM. As he was propelling his wheelchair past the nurses' station at 9:34 AM, he went past V14 (RN) and a Certified Nursing Assistant that was sitting at the nurses' station documenting in the facility's electronic medical system.On 2/26/2026 at 8:45 AM R46 was observed propelling himself down the hall. Again the tubing for R46's urinary drainage device was dragging on across the floor as he was propelling down the hall. On 2/26/26 at 11:41 AM, V2 (Director of Nursing-DON) was informed about the daily observations of R46's catheter tubing dragging across the floor as he propelled through the facility. V2 said the tubing should not be touching the floor for infection control reasons. To prevent infection.On 2/26/26 at 12:38 PM, V11 (Registered Nurse-RN) said a resident's catheter tubing should not be dragging on the floor for infection control reasons and dignity reasons. R46's care plan initiated 12/4/25 showed he had a indwelling urinary catheter. Position catheter bag and tubing below the level of the bladder. Collection bags have backflow prevention devices which are effective for short periods such as during transfers and bed mobility.The document provided by the facility on 2/26/26, titled (R46) UTI dates showed since his admission on [DATE], R46 has had 3 urinary tract infections.The facility's 2025 Indwelling Catheter Use and Removal policy showed Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination.and increase the risk of urinary tract infections. The policy showed 7. Additional care practices include.e. Securement of the catheter to facility flow of urine, prevention of kinks in the tubing and position below the level of the bladder. The policy does not address ensuring the tubing does not come into contact with the floor.The facility's 9/1/2025 Catheter Care policy does not address ensuring the catheter tubing does not come in contact with the floor.

Based on observation, interview, and record review the facility failed to ensure a gradual dosage reduction was attempted for a resident prescribed multiple psychotropic medications. This applies to 1 of 5 residents (R16) reviewed for unnecessary medications in the sample of 38.The findings include:R16's face sheet showed she was admitted to the facility 6/24/25 with diagnoses to include encephalopathy, lack of coordination, hypothyroidism, Type 2 Diabetes, dementia with other behavioral disturbance, bipolar disorder, major depressive disorder, obstructive sleep apnea, chronic pain, muscle weakness, disorders of muscle, fibromyalgia, unsteadiness on feet, and abnormalities of gait and mobility. R16's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires supervision and touch assistance for most cares. This same assessment showed R16 exhibited no behaviors. On 2/24/26 at 12:00 PM, R16 was in the common area during the lunch meal. On 2/25/26 at 9:30 AM, R16 was in the common area during an activity. On 2/26/26 at 8:11 AM, R16 was in the common area sitting at the dining table. No behaviors were observed. R16's February 2026 Physician Order Sheet showed orders for psychotropic medications as follows: clonazepam (antianxiety medication) 0.25 mg every evening; duloxetine (antidepressant medication) 60 mg daily; Quetiapine Fumarate (antipsychotic medication) 200 mg every evening; Quetiapine Fumarate 50 mg every afternoon; Quetiapine Fumarate 100 mg daily (scheduled in the morning). R16's complete Care Plan was reviewed with no mention of resident exhibiting behaviors. R16's Care Plan initiated 7/6/25 showed, Resident is at risk for adverse consequences related to receiving antipsychotic, antidepressant, antianxiety medications. History of behavioral symptoms. Access if the resident's behavioral symptoms present a danger to the resident and/or others. Attempt to give the lowest dose possible. Monitor for effectiveness.R16's last 3 months of CNA Behavior Charting was reviewed and showed no behaviors exhibited. R3's last 3 months of nursing notes showed no documentation of resident adverse behaviors. On 2/26/26 at 8:16 AM, V8 CNA said, [R16] does not really have behaviors. She can get kind of snippy maybe, she has no yelling out, she is not combative at all, she does not refuse care for me.On 2/26/26 at 8:11 AM V 9 CNA said, [R16] doesn't have behaviors really, maybe trying to walk by herself when she needs assistance, otherwise, not really.On 2/26/26 at 8:40 AM, V7 CNA said, I worked regularly on [R16's] hall for 5 months until last month, so I'm very familiar with her. [R16] has no behaviors. She would try and tell other residents what they need to do sometimes, but she has never had a bad behavior. She had no yelling out, no combative behaviors at all.On 2/26/2026 at 9:54 AM, V2 DON (Director of Nursing) provided R16's behavior monitoring documentation. V2 said R16's behaviors include being easily irritated. V2 said this behavior is exhibited by swearing at times and using a different tone of voice. V2 said R16 will also at times kind of push her walker away. R16's Pharmacy Consultation Report signed 2/28/26 showed, The resident has been receiving duloxetine 60 mg every day since 6/24/25; clonazepam 0.25 mg every day since 6/24/25; Quetiapine 100 mg at 9:00 AM, 50 mg at 12:00 PM, and 200 mg at 6:00 PM since 6/24/25. Per CMS guidelines if used to manage behavior, stabilize mood, or treat a psychiatric disorder, thee medications are subject to dose reduction regulations twice within the first year in two separate quarters and annually thereafter, unless clinically contraindicated. If appropriate at this time, may I suggest the following GDR: QUETIAPINE 100 MG AT 9:00 AM, 50 mg AT 12:00 PM, and 150 mg AT 6:00 PM. If a gradual dose reduction is contraindicated, please review the following and check if appropriate: 1. The resident's target symptoms returned or worsened after the most recent attempt at a tapering dose. 2. Past reduction attempts have resulted in problematic behavior and/or staff inability to provide care. 3. Past reduction attempts have resulted in psychiatric instability by exacerbating an underlying medical or psychiatric disorder. 4. Past reduction attempts have caused the resident to post danger to self or others. Please provide in the space below a CMS required patient specific rationale describing why a Gradual Dosing Reduction attempt is clinically contraindicated. (R16's physician wrote in) 'No change due to continued behaviors'. The facility's policy and procedure implemented 9/1/25 showed, Gradual Dose Reduction of Psychotropic Drugs. Policy: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless, clinically contraindicated, in an effort to be managed at a lower dose or to discontinue these drugs. For any individual who is receiving a psychotropic medication, a GDR may be considered clinically contraindicated for reasons that include, but that are not limited to, the following: a. The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder; or b. The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at this time would be likely to impair the resident's function, exacerbate an underlying medical condition or psychiatric disorder or increase distressed behavior.

Based on observation, interview, and record review, the facility failed to ensure staff wore the required personal protective equipment when providing high-contact resident care activities for 1 of 7 residents (R9) reviewed for infection control in the sample of 38.The findings include:R9's admission Record, provided by the facility on 2/26/26, showed diagnoses of moderate protein-calorie malnutrition, muscle weakness, paraplegia, cachexia (a complex, progressive syndrome characterized by severe weight loss, muscle atrophy, and fat depletion), ataxia (a lack of muscle coordination affecting gait, speech, eye movements, and swallowing), degenerative disease of nervous system, neuropathy, stage 4 pressure ulcers on his buttocks sacrum, left and right lower back, and an unstageable pressure ulcer right heel. All the pressure ulcers were present on admission. The admission Record showed R9 had a colostomy on admission, and a gastrostomy tube was initiated on 12/26/25. R9's 1/31/26 facility assessment showed he is cognitively intact, is dependent on staff for all activities of daily living.R9's care plan initiated on 11/26/26, showed he requires Enhanced Barrier Precautions due to wounds and catheter. The care plan showed, Sign will be posted outside resident door to notify staff and visitors of protocol for enhanced barrier precautions. The care plan showed, Staff will wear gown and gloves when performing activities listed on posted signage.On 2/24/26 at 12:09 PM, V12 (staffing coordinator/scheduler) was in R9's room. V12 let R9 know she needed to reposition him in bed. V12 was only wearing gloves, no gown. V12 was touching R9's blankets, pillow, R9, and his catheter bag. R9 was agitated and said he wanted his pants on first. V12 put R9's sweatpants on him. At 12:18 PM, V13 (Certified Nursing Assistant-CNA) entered R9's room and let R9 know she informed the nurse that his colostomy bag needed changed. V13 told R9 they (V12 and V13) need to reposition him in bed. V13 did not have gloves or a gown on. V13 touched R9's bed frame, his wheelchair, then his bed remote to raise the bed. After raising R9's bed, V13 said she needed to put gloves on. V13 put gloves on. V12 and V13 repositioned R9 in bed. At 12:24 PM, V14 (Registered Nurse-RN) entered R9's room. Both V13 and V14 were only wearing gloves. V14 (RN) touched R9's colostomy bag, then touched the tubing on R9's feeding tube to move it to the side. V14 removed R9's colostomy bag. Both V13 and V14 cleaned stool from around R9's stoma site. Both only had on gloves. V13 wiped stool from stoma because it was still coming out. While leaning over resident to perform care both V13 and V14's clothing was touching R9's bedding. V14 put a new colostomy pouch on R9, then helped V13 roll R9 onto right side. V13 informed V14 that R9's dressing needed changed on his bottom. V14 removed one of the large dressings, looked at R9's wound and said she would be right back with supplies. V14 returned and informed R9 that V1 (Administrator/RN) would be right in to do the dressing change so she could finish the medication pass. At 12:50 PM, V1 entered R9's room, washed her hands and put clean gloves on. V13 (CNA) was still in R9's room to assist with wound care. This surveyor observed 5 pressure wound dressing changes for R9. No gown was worn by V1 or V13 during the wound care for R9. During the wound care, both V13 and V1's clothing were touching the resident and his bedding. V1 and V13 applied a brief to R9 after care.On 2/25/26 at 9:24 AM, V14 (RN) was in R9's room with the door closed. This surveyor knocked on the door. V14 was flushing R9's feeding tube after stopping the feeding. V14 was only wearing gloves and no gown.On 2/26/26 at 9:59 AM, V2 (Director of Nursing-DON) said if a resident is on Enhanced Barrier Precautions and staff are going in to provide care, they should have a gown and gloves on to prevent the resident from getting an infection. V2 said this includes doing anything with the feeding tube and during wound care.On 2/26/26 at 12:38 PM, V11 (RN) said if a resident is on enhanced barrier precautions and staff are going in to do direct care such as repositioning, toileting, wound care, V11 would wear a gown and gloves for infection control reasons.The signage posted outside R9's room showed, Stop. Enhanced Barrier Precautions. Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must also: Wear gloves and a gown for the following High-Contact resident care activities: Dressing, Bathing/showering, Transferring, changing linens, providing Hygiene, changing briefs or assisting with toileting, Device Care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound Care: Any skin opening requiring a dressing.The facility's 2025 Enhanced Barrier Precautions policy and procedure showed It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs).Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown, and gloves use during high-contact resident care activities.1. a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.2. B. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g. chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous statis ulcers) and/or indwelling medical devices (e.g. central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. The policy showed 4. High contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters, and Wound care: Any skin opening requiring a dressing.

Based on interview and record review the facility failed to ensure discharge services were in place prior to discharging a resident to independent senior housing who requires assistance with activities of daily living. This failure resulted in R1 being found in her apartment soiled in urine and feces and unable to get out of bed. This applies to 1 of 3 (R1) residents reviewed for discharge in the sample of 3. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnosis including osteoarthritis left hip, abnormalities of gait and mobility, type 2 diabetes unspecified dementia and cognitive communication deficit. R1's face sheet shows she was admitted to the facility on [DATE] and discharged on 5/30/25. R1's care plan initiated March 17, 2025 shows R1 has difficulty understanding others, hard of hearing, cognitive and memory deficits. R1 is a fall risk and requires staff assistance with ambulation, has urinary incontinence and requires staff to provide incontinence care. R1's current care plan does not show a discharge plan. On 6/4/25 at 9:33 AM, V3 (Social Service Director) said prior to discharge home health services should be set up and medical equipment should be delivered to their home prior to discharge. If the resident needs a caregiver, V3 facilitates this process through the senior resource center prior to discharge. The day of R1's discharge V3 found out that R1's apartment was independent living. V3 said, V10 (Property Manager of Senior Housing) said she would let V11 (Social Service Manager of Senior Housing) know of R1's discharge. V11 came to the facility the day before R1's discharge and talked to R1. V3 said, V11 asked V3 how R1 was doing in therapy and asked if R1 was more independent. The following day after R1's discharge, everything fell apart. V3 said V11 expressed concerns that R1 was not stable enough to return to her apartment and R1 should have not been discharged because R1 needed long term care and was not appropriate for independent living. V3 said, This is the first time that this problem has come up. R1 is her own decision maker, and she is still at her apartment. If V3 knew R1 had a case worker she would have reached out to her prior to R1's discharge. V3 said today V3 was going to call the senior resource center to see if the caregiver services were set up for R1 as R1 had this service prior to coming to the facility and it should have been set up prior to discharge. V3 said, Our staff assisted R1 back to her apartment, and it was discovered R1 lost her cell phone when R1 arrived in her apartment. V3 delivered the walker to her apartment on 5/30/25. V3 said R1's apartment does not have caregivers and V3 was not aware of the type of setting where R1 was being discharged to. V3 said, During the discharge meeting, we only talked about how R1 was doing in therapy, and we did not discuss her discharge needs. R1 was alert, had periods of confusion, she was a standby assist with ambulation. R1 was referred to home health services for therapy. V3 said V3 sent the referral but is not sure if R1 is receiving those services. V3 said R1 was calling her throughout the weekend. R1 reported she was doing okay, and V3 has not heard from her since Monday. On 6/4/25 at 9:59 AM, V4 (Restorative Nurse) said she was part of R1's discharge meeting. V3 coordinates the equipment and home health services, and V4 coordinates with therapy and assesses a residents mobility prior to discharge. V4 said, R1 was alert with forgetfulness. By the time of discharge, she (R1) could walk with her walker and required supervision with transfers and was incontinent. V4 said the day of R1's discharge V4 felt uncomfortable about R1's discharge. V4 asked V1 (Administrator) if she could meet R1 at her apartment. V4 said R1 had the facility's walker and did not have her own walker with her prior to discharge. A senior bus picked up R1 to transport her to her apartment and V4 met R1 at her apartment. V4 said she was concerned about R1 getting to her apartment safely so that's why V4 met R1 there. V4 said she assisted R1 off the bus and sat her on a bench and went to get a wheelchair because it was a long walk to her apartment and R1 did not have her walker. V4 said before she left R1's apartment, V4 asked the facility about visiting hours and was told visitors are buzzed in on the phone. R1 did not have a phone with her. V4 said she left R1 and bought a cell phone for her and dropped it off at her apartment. V4 said she was told the independent living center does not have any staff to assist with any care needs. V4 said V11 expressed concerns about R1's discharge but stated, well she (R1) was already there, what are we supposed to do. V4 said she reassured V11 that R1 is capable of doing what she needs to do. R1 can transfer herself, ambulates with walker, and was incontinent of urine. On 6/4/25 at 10:35 AM, V6 (Registered Nurse-RN) said prior to discharge there should discharge planning in place to ensure a resident's needs are set up, the floor staff gets a discharge list about one week prior to discharge. V6 said R1 was alert with forgetfulness. R1 could get up and transfer herself, she self-propelled in the wheelchair and was incontinent. V6 said sometimes R1 would refuse therapy or assistance from staff at times. V6 said V6 thought R1 was being discharged to assisted living setting. V6 said, I don't know if R1 was safe to be discharged to independent living. On 6/4/25 at 12:47 PM, V5 (Director of Therapy) said R1 had multiple refusals with therapy and was non-compliant, R1 was strong-willed and worked with therapy when she allowed us to. V5 said R1 made progress initially in therapy and then she flat lined. R1 lacks safety awareness of her deficits, poor safety, she could ambulate with the walker with standby by assist and would self-propel herself in the wheelchair. V5 said R1 had not practiced going up and down stairs, R1 would refuse services to work with stairs. V5 said, We had concerns about her safety to go home to an independent setting. I'm not sure if any staff reached out to her (R1's) family. R1 would be more appropriate for assisted living or long term care. On 6/4/25 at 1:06 PM, V3 (SSD) said she did not communicate with home health services of R1's new phone number so they could call R1 to set up the service. She does not know if R1's caregiver service has been reinstated and did not know she needed assistance with meals. On 6/5/25 at 10:00 AM, V10 said senior housing apartments are for elderly residents ages [AGE] years old and above. V10 said, They should be independent for all their activities of daily living, including cooking, dressing, transfers, ambulating, and housekeeping needs. V11 (Senior Housing Social Worker) expressed concerns to the facility regarding R1 not being fully independent with activities of daily living. The facility asked if we could pick up R1 to transport her home, we explained we do not provide transportation services. They asked if we could assist R1 off the senior bus, we explained we do not have caregivers to assist with cares. We do not have staff or provide services for residents we only provide housing. V11 re-instated R1's caregiver service through the senior center and the caregiver arrived on 6/3/25. On 6/3/25, R1 would not answer the door so she (V11) went to open R1's door with the caregiver and found R1 soiled in bed (appeared to be in bed from the previous day). On 6/5/25 at 10:15 AM, V11 (Senior Housing Social Worker) said she went to the facility on 5/28/25 (two days prior to R1's discharge) to talk to R1. V11 asked R1 how therapy was going and how R1 was doing with her activities of daily living. V11 said she spoke with V3 and told V3 the senior housing facility does not offer any assistance with activities of daily living. There are no staff to assist R1 with ADL's, cooking or housekeeping services. V11 asked V3 about R1's transfer status and was told R1 was being discharged on Friday 5/30/25. V11 said the facility was aware of R1's home setting. V11 reminded V3 they only offer housing and no other services. Residents should be independent, and any outside services should be set up prior to discharge. V11 said V3 asked if someone one could assist R1 off the bus the day of discharge and V11 questioned R1's ability getting in and out of the bus. V11 said the day of R1's discharge, the facility asked for assistance to get R1 into her apartment and V11 told the facility again they cannot provide hands on assist with cares. V11 said the facility was well aware of R1's living situation and expressed V11's concerns to V3. On 6/3/25, R1 was found in her apartment soiled with urine and feces (appeared she had been in bed from the previous day) and unable to get out of bed. V11 said the facility should communicate with us the services a resident needs and should be set up prior to discharge. V11 said R1 required meals on wheels, caregiver services and had not been seen by PT/OT. R1's Communication/Order Sheet dated 5/23/25 shows orders including discharge home with current medications, in home PT (Physical Therapy)/OT (Occupational Therapy) services, and four wheeled walker. R1's Discharge Meeting Care Plan Record dated 5/29/25 shows V3 (Social Service Director), V4 (Restorative Nurse) and R1 in attendance. R1's Discharge Plan Notice Form dated 5/30/25 shows R1's discharge date of 5/30/25 to her home apartment and a standard walker has been ordered. R1's Care Conference Report provided on 6/4/25 shows on 5/28/25 faxed documents to set up PT/OT services. On 5/29/25, R1's discharge meeting was held. On 5/29/25, V3 called to inform V10 and V11 that R1 would be discharging on 5/30/25 and asked if they could be looking out for R1 to get off the bus. V10 shared V11 would call V3. On 5/30/25, V4 followed R1 home to assist her off the bus and into her apartment. On 5/30/25, V3 called case manager to inform her R1 had been discharged home in the community so that her care giver service could be reinstated. The facility's Discharge Instructions Policy states, Upon admission and throughout the resident admission, the Social Service Representative, with the involvement of the interdisciplinary team, will review the discharge needs of each resident, and develop a discharge plan, and communicate and finalize discharge instructions.

Based on observation, interview, and record review the facility failed to ensure staff applied a gait belt for a resident who is high risk for falls. This failure resulted in R1 falling on the floor while ambulating without a gait belt and sustained a left femur fracture requiring surgical repair. This applies to 1 of 3 (R1) residents reviewed for falls in the sample of 3. The findings include: R1's Final Serious Injury Incident Report dated 5/8/25 shows R1 is an [AGE] year-old female, alert and oriented x3. On 5/5/25 at 10:00 PM, (R1) sustained a fall while exiting the bathroom. V5 (Certified Nursing Assistant-CNA) was assisting (R1) back to the recliner after toileting. (R1) became weak and began to fall .(R1) complained of leg pain and was assessed by the nurse and sent out to the local hospital. R1 sustained a left femur fracture requiring surgical repair. R1's Fall Risk assessment dated [DATE] shows she is high risk for falls. R1 has balance problems while standing and walking, requires the use of assistive device, impaired mobility requires assist with toileting, and has a history of three or more falls in the last three months. On 5/27/25 at 9:05 AM, R1 was observed in her room lying in her bed. Dark and light purple and greenish bruising noted to R1's left forehead and bruising throughout her left forearm to above her elbow. A leg brace and ace wrap was in place to her left lower leg. R1 said she was coming out of the bathroom and fell down trying to get into her wheelchair. R1 said staff was with her but could not recall who. R1 said her legs gave out and once in a while her legs give out. R1 said she did not have a gait belt on and does not remember if she was lowered to the floor. R1 said she has a broken femur and cannot bear weight on her left leg; she is getting therapy in her room and now the staff use a mechanical lift to transfer her out of the bed. On 5/27/25 at 10:37 AM, V3 (Licensed Practical Nurse-LPN) said on 5/5/25, she was alerted by V5 (CNA) R1 fell after toileting. When she entered the room, R1 was laying on the floor outside of the bathroom, her head was partially under the wheelchair touching the top left wheel. R1 did not have a gait belt on, she had a hematoma on the outer side of her left knee with bruising. V5 asked me for a gait belt to assist R1 off the floor. R1's gait is not the greatest, she transfers with one person, walker, and gait belt. V3 does not recall where R1's walker was located. On 5/27/25 at 10:43 AM, V6 (CNA) said she was in another resident's room when V5 reported R1 was on the floor, and she needed help with transferring her. When she entered R1's room, R1 was lying on the floor in between the bathroom and her recliner chair. R1's wheelchair was positioned behind her, and she does not recall seeing R1's walker. R1 was not wearing a gait belt and V5 was trying to find a gait belt to use to assist R1 from the floor. R1 is a one person assist and transfers with a gait belt and walker. R1's gait is unsteady and uses her walker when up. R1 is a fall risk, staff should use a gait belt on residents when transferring and ambulating. Anybody who walks should have a gait belt on. V5 reported to her, R1 said she thinks her leg is broken. On 5/27/25 at 9:28 AM, V4 (Registered Nurse-RN) said R1 is alert and oriented but can be forgetful at times. She was recently admitted from home after having falls at home. R1 was admitted to the facility with bruising to her face and body. Prior to the fall R1 transferred with one person assist, gait belt and walker. Staff should ensure R1 has a gait belt on and walker because her gait is unsteady. On 5/27/25 at 11:51 AM, V2 (Director of Nursing-DON) said V5 (CNA) reported she was assisting R1 from the bathroom and R1 seemed a little off and tired while ambulating. V5 went to get the wheelchair and placed it behind R1 and when she tried to sit sat on the edge of the wheelchair and was lowered to the floor. V3 (LPN) and V6 (CNA) both said R1 did not have a gait belt on when they entered the room. V2 said when she questioned V5 about the gait belt and V5 said she removed the gait belt after R1 fell and she was sticking to her statement. V2 said it does not make sense to remove a resident's gait belt after falling. Staff should ensure to use gait belts when transferring and ambulating residents. R1's X-ray report dated 5/5/25 shows acute markedly displaced and angulated fracture mid shaft femur. (Severe break in the femur where the fracture pieces are significantly shifted and angled away from their normal position. These types of fractures are caused by trauma, like a fall). R1's current care plan initiated on 5/2/25 shows R1 is at risk for falls due to history of falling at home and general weakness. R1's interventions include observe for fatigue when ambulating, offer and provide toileting assistance, encourage to assume a standing position slowly, and personal items within reach. R1's Fall Program Policy dated 2020 states, All residents will be evaluated for falls .Upon completion of the fall evaluation; if the resident is identified at risk for falls; the following may occur: a care plan is developed or updated, new fall interventions are reviewed .education regarding the resident's risk for falls and interventions to prevent falls is provided.

Based on interview and record review the facility failed to apply a narcotic pain patch in an inaccessible location for a resident with a history of removing narcotic pain patches. This applies to 1 of 3 residents reviewed for medications in the sample of 5. The findings include: R1's Face Sheet showed she was admitted to the facility on [DATE] with diagnoses including scoliosis and dementia. R1's 1/23/25 Minimum Data Set (MDS) showed the resident was not able to complete the Brief Interview for Mental Status and she had both short and long-term memory problems. R1's MDS showed she was dependent upon staff for functional abilities except eating which she required substantial/maximal assistance. R1's MDS showed she had frequent pain. The facility's 3/1/25 incident report submitted to the state health department showed R1's fentanyl (schedule II narcotic pain medication) patch, which was on her body, had gone missing. The report showed a replacement patch was applied. R1's fentanyl order history showed she had been on varying doses of fentanyl beginning on 11/19/24. The order history showed the patches are to be changed every 72 hours. R1's fentanyl order history showed a change beginning on 2/18/25, which her previous orders did not show. The change on 2/18/25 was, Place patch on res (resident) back only and cover with [transparent film dressing]. This change carried through to her most recent order as of 4/3/25. R1's current fentanyl patch order (started on 3/9/25) was for a 25 microgram per hour patch to be applied to R1's back every 72 hours. R1's February 2025 and March 2025 Medication Administration History (also known as Medication Administration Record, or MAR) showed an order to verify the placement of R1's fentanyl patch once a shift (every 8 hours). The MAR showed, beginning on 2/27/25 for the 3:00 PM to 11:00 PM shift, the nurse documented the fentanyl patch was on R1's chest. (At this time, R1's fentanyl order showed it should be applied to her back.) Prior to this entry, R1's patch was documented as being on her back. The nurses continued to document R1's fentanyl patch was on her chest until 3/1/25 during the 3:00 PM to 11:00 PM shift. The entry for this shift showed R1's patch was missing. R1's 3/1/25 9:06 PM nursing note, (Authored by V6 Registered Nurse) showed, At bedtime, unable to find the resident's fentanyl patch. I asked for assistance from another CNA (Certified Nursing Assistant) to put her in bed, change her clothes, and do a skin check. Patch still missing .sweep of the room done with 2 CNAs, unable to find the detached patch . On 4/3/25 at 12:25 PM, V6 Registered Nurse stated she was the nurse who noted R1's fentanyl patch was missing from R1's body. V6 said herself and a CNA performed a head-to-toe skin assessment to try and find the patch; however, they were unsuccessful. V6 said, R1 had a linen change earlier in the shift and they were unable to locate the patch in any of the laundry; however, they were not certain if all laundry had been searched. V6 said R1 does have a history of picking at dressings and pain patches. R1's March 2025 MAR showed, on 3/7/25, R1's patch was applied to her chest. R1's MAR showed the fentanyl patch verification entries, beginning on 3/7/25 for the 11:00 PM to 7:00 AM shift, showed R1's patch was on her chest. The nurses continued to verify patch placement to R1's chest until the 3:00 PM to 11:00 PM shift on 3/9/25. During this shift the nurse documented in the MAR, Found in resident's mouth. R1's 3/9/25 9:22 PM nursing note showed, Resident found with fentanyl patch in her mouth at 5:15 PM. Removed by CNA and given to myself to dispose of . On 4/3/25 at 10:10 AM, V2 Director of Nursing stated R1 has a history of picking at her dressings and fentanyl patches. V2 stated R1's order was changed to have it placed on her back and covered with a dressing to prevent the patch from coming off and to make it inaccessible to R1. V2 said, while reviewing R1's MAR in the electronic charting, the nurse documented the patch was placed to R1's chest on 2/27/25. V2 said the patch should have been applied to R1's back. V2 said the patch applied to R1's chest on 3/7/25 should have been applied to her back. V2 said fentanyl is a potent narcotic and can be dangerous if ingested. Medication Administration policy (effective 4/2020) showed, Medication preparation/Administration .Follow special directions .

Based on observation, interview, and record review, the facility failed to ensure a residents' pain regimen was adequate to relieve her pain for one of 13 residents (R14) reviewed for pain in the sample of 13. This failure resulted in R14 experiencing unrelieved pain for three days. The findings include: R14's Physician Order Report dated January 3, 2025-February 3, 2025 shows she was admitted to the facility on [DATE] with diagnoses including nonrheumatic aortic valve stenosis, acute diastolic congestive heart failure, depression, gastrointestinal stromal tumor of stomach, age related osteoporosis, scoliosis thoracic region, muscle weakness, and abnormalities of gait and mobility. R14's medications orders show an order for ibuprofen 200 mg two tablets every four hours as needed to start on December 6, 2024, an order for ibuprofen 200 mg three tablets twice a day for pain to start on December 10, 2024, and morphine liquid 10 mg every two hours as needed to start January 30, 2025. R14's Care Plan created December 17, 2024 shows, Resident has complaints of chronic back pain. History of fall with minor injury. Assess past effective and ineffective pain relief measures, monitor and record any nonverbal signs of pain. R14's Care Plan created December 3, 2024 shows, Pain: evaluation of pain will be performed routinely to address pain management needs. I will receive pain medication per physician/nurse practitioner orders. Pain medication effectiveness will be documented and reported as needed. R14's Progress Notes dated December 2, 2024 shows, Spoke to doctor in regard to residents fall and complaints of back pain. Order received and noted. R14's Progress Note dated December 10, 2024 shows, Reports general aches and pains this morning. Ibuprofen administered as now scheduled . R14's Progress Note dated January 9, 2025 shows, Resident is alert and oriented. Refuses all medications except ibuprofen. States pain is related to her skin tear on her right upper arm. R14's Progress Note dated January 26, 2025 shows, Resident has very poor appetite only taking a few bites at each meal. Also only wanting to take ibuprofen and no other medications. Requesting to stay in bed or go back to bed quickly after getting up in chair. MD (medical doctor) and power of attorney notified of general decline . January 29, 2025 shows, Daughter (V20) here to meet with hospice. Daughter upset stating that she does not feel that residents pain is adequately controlled . January 30, 2025 shows, Need for comfort meds communicated to doctor and new orders morphine and Ativan received. Power of Attorney notified. February 2, 2025 shows, Resident putting on call light several different times requesting to have morphine and be repositioned, she was repositioned every single time, this nurse gave her ibuprofen and am waiting on morphine to arrive from pharmacy. I informed her as soon as we receive her morphine, I will bring it in. She stated, 'so I am just supposed to suffer until then?' I reassured her I gave ibuprofen to help for now. On February 2, 2025 at 10:23 AM, R14 was lying in bed. R14 said that the had pain in her heart and pain in her back. R14 said she was waiting for her morphine. R14 said before her ibuprofen was administered, her pain was rated a 9/10. After the ibuprofen, R14's said her pain is rated at 8/10. R14 was thin and frail. R14 had 4-5 blankets on. On February 3, 2025 at 10:15 AM, V20 (R14's Daughter/power of attorney) was sitting at R14's bedside. R14 was pale and barely breathing. R14 was unresponsive. V20 began crying and stated her mom was actively dying. V20 became tearful when interviewed in regard to R14's pain. V20 said her mom always had chronic pain. V20 said she has been asking for something stronger for pain for R14 since R14 was admitted to the facility. V20 said R14 took ibuprofen at home for pain, but always took more than the recommended amount. V20 said that V4 RN (Registered Nurse) got the process started for a stronger pain medication for R14 but then V20 said she did not know what happened after. Someone dropped the ball.V20 said it took the facility three days to get an order for morphine. V20 said she was very upset. V20 said R14 has aortic stenosis, no stomach due to stomach cancer, was a post-polio baby, and shrunk five inches in height. V20 said that she was told by the facility that staff could not take the morphine out of the emergency box because their pharmacy said the morphine was already on its way to be delivered. V20 said she was very upset when she came in to visit on February 2, 2025 and the morphine still was not in the facility for R14. R14's Medications Administration History dated January 1, 2025-January 31, 2025 shows that R14 asked for her ibuprofen early 17 times. On February 4, 2025 at 9:07 AM, V2 DON (Director of Nursing) said there was an order for hospice for R14 on January 26, 2025. V2 said R14 was refusing to eat and only wanted to take her ibuprofen. V2 said on January 27, 2025 R14's daughter (V20) was upset that R14 did not have morphine for pain. On January 29, 2025 V20 came and talked to V2 again and stated, she just needs to relax so she can die. V2 said that R14 was saying she wanted ibuprofen. V2 said on January 30, 2025, V4 RN contacted R14's doctor to get something stronger for pain because V4 could see that R14 was declining so V4 wanted to get the pain medications so R14 did not have to go through the weekend with no pain medications. V2 said the problem was that the doctor did not call in the morphine prescription into the pharmacy. On February 2, 2025, R14's nurse came to V2 and V4 and said R14 was still asking for morphine. The nurse called the pharmacy and the pharmacy said they did not have a prescription for morphine. So, the nurse called the doctor again and the doctor put the order in to the pharmacy. At 5:18 PM, V2 said the morphine was delivered on February 2, 2025 but did not know why R14 did not get morphine until February 3, 2025. V2 said if R14 was asking for more ibuprofen or asking for it early, then that meant that R14 was in pain. On February 4, 2025 at 9:16 AM, V4 RN said she called the doctor on Thursday night January 30, 2025. V4 said she asked the doctor to get the medication on board because she knows R14 would need them. V4 said she felt that R14 was declining rapidly. V4 said she put the order in the computer, and she knew the medication would not be at the facility until later the next day. V4 said R14's nurse came to her on Sunday February 2, 2025 and said R14 did not have morphine yet. V4 said she told the nurse that V4 would come help the nurse take the morphine out of the emergency box. V4 said staff was not able to take the morphine out of the emergency box because the pharmacy said the morphine was already on the delivery truck. R14's Medications Administration History dated February 1, 2025-February 4, 2025 shows an order for morphine was ordered to start January 30, 2024. This same document shows that R14 did not receive morphine until February 3, 2025 at 7:41 AM. This document also shows that R14 was actively dying at 7:41 AM, 10:05 AM, and 12:06 PM. R14 passed away at 12:30 PM. The facility's Pain Management Policy dated April 2020 shows, The goal is to facilitate resident independence, promote comfort and preserve resident dignity. Residents will be encouraged to report pain early so that pain management can be more effective. Nursing will address pain management issues as soon as they are brought to their attention. Physician or extender notification of inadequate pain management will occur. Nursing will inform the physician or extender about the admission, current pain medications and the need for potential supplemental pain medications if appropriate.

Based on observation, interview, and record review the facility failed to maintain their kitchen in a clean and sanitary manner. The facility failed to ensure staff handled kitchen utensils in a manner to prevent cross contamination. These failures have the potential to affect all 46 residents in the facility. The findings include: The facility's Long-Term Application for Medicare and Medicaid form dated 2/2/25 showed a resident census of 46. On 2/2/25 at 9:26 AM, an initial tour of the facility's kitchen was conducted. During the tour, the following observations were noted: 1. Dried grease and food debris noted across the top of the stove, down the front of the ovens, and down the sides of the steamers. 2. Four, individual plastic quart containers, each containing dried cereal, were noted on one of the kitchen counters. Each lid, on the containers, appeared dirty and were sticky to the touch. A brown, sticky substance was noted on the side of one of the containers. 3. A plastic milk crate, noted on the bottom shelf of a rack next to the stove, was covered with grease and sticky food debris. On 2/2/25 at 10:25 AM, a second tour of the facility's kitchen was conducted. During this time, the following observations were noted: 1. Dried liquid and food debris was noted on the bottom shelf of the food prep table. 2. The lid and sides of the facility's commercial grade food processor were covered with a greasy substance. 3. The shelf under the facility's plate warmer rack was covered with salt packets and napkins. The packages of salt were opened with salt lying all over the shelf. 4. Dried liquid and food debris was noted down the front and sides of the facility's steam table. 5. A dirty oven mitt was on the floor under the steam table. On 2/2/25 at 11:22 AM, V3 Dietary Manager began placing food items on the steam table in the kitchen. Without washing her hands, V3 then walked over to a plastic bin containing miscellaneous scoops and kitchen utensils and began rummaging through the bin with her bare hands. V3 picked up multiple scoops with her bare hands and carried the scoops over to the kitchen steam table. V3 placed a scoop (each) into the containers of spinach, sweet potatoes, pureed spinach, pureed sweet potatoes, pureed ham, and mechanical soft ham. On 2/2/25 at 1:15 PM, V3 Dietary Manager stated kitchen staff are to wear gloves when handling kitchen utensils and/or dishes to prevent cross contamination. V3 stated the last time the facility's kitchen was deep cleaned was probably over a month ago. The facility's Food: Preparation policy dated 9/2017 showed, All staff will practice proper hand washing techniques and glove use. Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful, physical, biological, and chemical contamination. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use .

Based on interview and record review the facility failed to ensure certified nursing assistants (CNA) working in the facility received their annual abuse and dementia care training/education. This failure has the potential to affect all 46 residents in the facility. The findings include: The facility's Long-Term Application for Medicare and Medicaid form dated 2/2/25 showed a resident census of 46. The facility's nursing schedule showed the following agency CNA's provided cares to residents in the facility: V7 CNA on 2/2/25 V8 CNA on 1/20/25-1/24/25 V9 CNA on 1/20/25, 1/23/25-1/31/25 On 2/4/25 at 7:39 AM, V2 Director of Nursing stated V7-V9 CNA's had not completed any abuse or dementia trainings in the last year. V2 stated V7-V9 are agency CNA's. I called their agency. They said (V7-V9 CNA's) had not received the trainings. They didn't attend our abuse or dementia trainings here. The facility's assessment (originally dated 8/18/2017; revised 2025) showed, We accept residents with the following diagnosis, diseases, and condition . Alzheimer's disease, dementia . Human Resources and Nursing Department strive to hire staff that have related health care experience. Training and education are provided upon orientation and throughout the year. The following areas are in the staff education and topics list: . abuse, neglect, exploitation . caring for persons with Alzheimer's or other dementia .

Based on observation, interview, and record review the facility failed to ensure residents were not restrained from being able to exit their beds for 4 of 13 residents (R5, R11, R19 and R35) reviewed for restraints in the sample of 13. The findings include: 1. On 2/2/25 10:26 AM, R11 was lying in bed. R11 had siderails on the upper half of her bed in a raised position on both sides of her bed. R11 had bolsters (wedge shaped cushions) attached to each side of her bed measuring 33 inches long and 7 inches high. The bolsters were attached to the bed with two straps holding them in place. There was 23 inches from the end of the bolster to the end of her bed. On 2/4/25 at 9:40 AM, R11 was lying in bed and the siderails and bolsters were in the same position. On 2/4/25 at 9:40 AM, V15 (Certified Nursing Assistant) said R11 has the bolster in place so she does not get out of bed. V15 said R11 is not able to independently use her side rails for positioning herself. R11's Fall Care Plan dated 11/26/24 shows, [R11] is at risk for falls r/t (related to) the need for assistance with all transfers, a visual deficit requiring the use of glasses, a hx (history) of anxious behaviors bolster cushions on bed. R11's Informed Consent Regarding Physical Device Usage form dated 12/5/23 shows the device she uses is half side rails on both sides of bed. The form shows, I also understand that the reason/need for use of the physical device will be reassessed quarterly or if there is a change in resident's/my condition. I am aware that attempts may be made to reduce/remove the use of the physical device as the resident's/my condition warrants . On 2/4/25 at 1:00 PM, V2 (Director of Nursing) said she does not have any restraint assessments nor siderail assessments to provide for R11. On 2/3/25 at 2:48 PM, V2 (Director of Nursing) said side rails can be considered a restraint if the resident is not using them to help with positioning. V2 said R11 cannot use her siderails for self-assisted bed mobility. V2 said bolsters are not a restraint, they are a positioning device. 2. On 2/2/25 at 2:52 PM, R5 was lying in bed. R5 had bolsters (wedge shaped cushions) attached to the middle of each side of his bed measuring 33 inches long and 7 inches high. The bolsters were attached to the bed with two straps holding them in place. R5 had his left leg over the side of the right side of his bed resting on the bolster. On 2/2/25 at 2:52 PM, V15 (CNA) said R5 has bed bolsters because he tries to get out of bed and is at fall risk. On 2/4/25 at 11:53 AM, V15 said if R5 did not have the bolsters in place, he would be able to get out of bed but it is not safe for him to do it by himself. R5's Fall Care Plan dated 10/31/24 shows, [R5] is at risk for falling r/t (related to) dependent on staff with mobility, hx (history) of restlessness d/t dx (diagnosis) of anxiety and alz (Alzheimer's disease). Safety precautions diminished Ensure bolsters are in place and are attached properly. The facility's Restraint Device Evaluation Policy dated 4/2020 shows, Upon admission, quarterly and with a change in condition, every resident is evaluated for restraint use by completing the Device Observation, Education, and Consent form. Use of side rails for bed mobility/physical functioning is not considered a restraint .Make sure the restraint allows for freedom of movement. Do not attach any restraint to side rails or bed frame . 34506 3. R19's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, polyosteoarthritis, anxiety disorder, and depression. Transfer status: mechanical lift for all transfers. R19's Care Plan edited November 25, 2024 shows, R19 has arthritis and has pain with flexion of right and left shoulder joints past level of shoulders, dementia, unable to participate in active range of motion exercises. R19's Minimum Data Set, dated dated dated [DATE] shows she is not cognitively intact. R19 is dependent on staff to roll left and right in bed. On February 2, 2025 at 1:35 PM, V21 and V22 CNAs (Certified Nursing Assistants) transferred R19 into bed via a mechanical lift. There were tall barriers on each side of R19 while she was in bed. These barriers were about as long as R19's body was and went higher than R19's body when she was lying in bed. V22 CNA said the barriers are used so she doesn't get out of bed. Although she doesn't really need them anymore because she doesn't move as much as she used to. 4. R35's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses of congestive heart failure acute respiratory failure, altered mental status, adjustment disorder, and delusional disorder. R35's Care Plan created on January 2, 2025 shows, [R35] has a history of falling. Place bolsters on either side of bed. R35's Minimum Data Set (MDS) dated [DATE] shows he is not cognitively intact. On February 2, 2025 at 9:42 AM, R35 was in his bed. R35's top half of his body was out of bed near the floor. There were tall barriers noted under each side of R35's bed. At 11:56 AM, R35 was still in bed, there were tall barriers on each side of R35 while he was lying in bed. On February 4, 2025 at 1:16 PM, V28 CNA said the tall barriers are there so that R35 does not fall out of bed. V28 said that R35 cannot climb over the barriers, nor can he remove them. On February 3, 2025 at 7:51 AM, V2 DON (Director of Nursing) said there is no restraint assessment for R19 or R35. The facility's Restraint Device policy effective April 2020 shows, Restraint use requires an evaluation, recommendation and an order and resident/legal representative permission before application. Use of restraints will be in accordance with state/federal regulations. Make sure the restraint allows for freedom of movement, do not attach any restraint to side rails or bed frame.

Based on interview and record review, the facility failed to ensure misappropriation of residents' property did not occur for two of four residents (R41, R11) reviewed for misappropriation in the sample of 13. The findings include: 1. R41's Physician Order Report dated January 3, 2025-February 3, 2025 shows he was admitted to the facility on [DATE] with diagnoses including heart disease, dementia with agitation, dehydration, anxiety disorder, and urinary tract infection. There is an order for hydrocodone-acetaminophen (Norco) 5-325 one tablet for pain every four hours as needed. The facility's Preliminary Incident Investigation Report dated February 1, 2025 shows, January 31, 2025, during the shift to shift narcotic count it was noted that five Norco 5-325 tablets were missing from the bottle. Name of resident allegedly abused or neglected: [R41]. R41's Norco 5-325 Controlled Substance Record shows R41's bottle of Norco was not counted on the night shift of January 30, 2025. On January 31, 2025 at 3:00 AM, there were Norco 60 tablets signed by two nurses. On January 31, 2025 at 3:00 PM, there were 55 Norco tablets. V2 DON (Director of Nursing) investigation report shows she received a call from V19 LPN (Licensed Practical Nurse) stating that [R41's] pill bottle that contained Norco 5/325 was off by five tablets. V19 stated to V2 that V18 RN (Agency Registered Nurse) wanted to do a corrected count, but V19 said no and called V2. Upon speaking with V19 further, V19 told V2 that she counted the narcotic on January 29, 2025 (prior day that V19 worked) and the counted showed 60 Norco pills in R41's bottle. On February 4, 2025 at 11:18 AM, V19 said on January 31, 2025, she was counting the narcotics with an agency nurse [V18] that worked before her. V19 said that when she went to retrieve R41's bottle of Norco 5-325, V18 immediately said 'We didn't count that.' Meaning the previous shift did not count R41's bottle of Norco. V19 said she reached for a cup and a spoon and proceeded to count R41's bottle of Norco. V19 said she counted 55 when it should have been 60. V18 said, Oh I should have counted with the previous nurse to V19. V19 said V18 said this statement twice. V19 said she double counted and still got the same number. V19 said that V18 told V19 to sign the narcotic count sheet and to correct the narcotic count. V19 told V18 that V19 is not authorized to do that. V19 said V2 the director of nursing does that. V19 said that V18 kept saying, I should have counted it, I don't want anyone to think I took anything. V19 said that V18 was acting strange. On February 4, 2025 at 9:46 AM, V2 DON said she received a phone call shortly before midnight on Friday January 31, 2025 from V19. V2 said V19 told her that R41's bottle of Norco was missing five tablets. V2 said R41's family had brought in a bottle of Norco to the facility. V2 said 41 also had a bingo card of Norco from the facility's pharmacy. V2 said staff are supposed to count both the bottle of Norco and the bingo card of Norco at the end of every shift and at the beginning of every shift. V19 told V2 that V18 wanted V19 to just correct the count. V2 said she came in early the next morning on February 1, 2025 to begin the investigation. V2 said she reviewed the facility's cameras. The only thing that V2 noted from the cameras was V18 may have opened the narcotic box at 3:46 PM, 7:20 PM, and 7:41 PM. V2 said the actual narcotic box was obscured by another medication cart, but V18 made the arm motion like she was opening the narcotic box. V2 said V18 gave residents a narcotic medication during the 7:20 PM time and 7:41 PM time but could not find where V18 would have given a narcotic at 3:46 PM. V2 said she called and made a report to the local police department and called the agency where V18 worked. V2 said she did not talk with V18 after the incident but that V18 emailed V2 an unsigned statement. V2 said she still has not accounted for the Norco yet. V2 said the police came to the facility and they are doing their investigation. 2. R11's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and encounter for palliative care. R11's Physician Order Report dated December 1, 2024-December 31, 2024 shows an order for fentanyl patch 25 mcg every 72 hours. R11's Progress Note dated December 21, 2024 done by V24 RN (Registered Nurse) shows, Resident is due to have new fentanyl patch administered per order. This writer unable to locate current patch on left chest as indicated in electronic medical record. New patch applied early to right back related to no current transdermal pain relief present on resident body. An attempt was made to talk to V24 via phone on February 4, 2025. A message was left with no call back. On February 4, 2025 at 9:46 AM, V2 DON said she has not investigated any potential for misappropriation in the last three months regarding a missing fentanyl patch. V2 said she was not aware of the missing fentanyl patch on R11. V2 said V24 no longer works for the facility due to attendance issues. V2 said staff are supposed to notify her right away if the see that a fentanyl patch is missing off a resident. On February 4, 2025 at 11:18 AM, V19 LPN said she calls the director of nursing and administrator if a fentanyl patch is missing off a resident because it is a controlled substance and it could mean that someone took it. The facility's Medications-Controlled policy effective April 2020 shows, A count of controlled drugs is maintained by nurses of the off-going and oncoming shifts. The facility's Abuse policy effective April 2020 shows, This facility affirms the right of our residents to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment.

Based on interview and record review, the facility failed to ensure their abuse policy was implemented for one of four residents (R11) reviewed for abuse policy and procedures in the sample of four. The findings include: R11's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including anxiety disorder, Alzheimer's disease, depression, scoliosis, delusional disorder, and encounter for palliative care. R11's Physician Order Report dated December 1, 2024-December 31, 2024 shows an order for fentanyl patch 25 mcg every 72 hours. R11's Progress Note dated December 21, 2024 done by V24 RN (Registered Nurse) shows, Resident is due to have new fentanyl patch administered per order. This writer unable to locate current patch on left chest as indicated in electronic medical record. New patch applied early to right back related to no current transdermal pain relief present on resident body. An attempt was made to talk to V24 via phone on February 4, 2025. A message was left with no call back. On February 4, 2025 at 9:46 AM, V2 DON said she has not investigated any potential for misappropriation in the last three months in regard to a missing fentanyl patch. V2 said staff are supposed to notify her right away if the see that a fentanyl patch is missing off a resident. On February 4, 2025 at 11:18 AM, V19 LPN said she calls the director of nursing and administrator if a fentanyl patch is missing off a resident because it is a controlled substance and it could mean that someone took it. The facility's Abuse Policy effective April 2020 shows, The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of residents. This will be done by: orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse, neglect, exploitation, and misappropriation of property.

Based on observation, interview and record review the facility failed to ensure the safety of a resident (R1) during incontinence care. This applies to 1 of 3 (R1) residents reviewed for safety in the sample of 6. This failure resulted R1 sustaining a bruising/hematoma to the left forehead. The findings include: R1's Final Abuse Investigation dated 1/20/23 documents on 1/16/23 while care was being provided, his left forehead bumped the siderail sustaining injury as evidenced by hematoma to the left forehead. R1 reported to V15 (Physician) that R1 had been pinned by the black CNA identified as V9 (CNA) against the side rail. When the second CNA (V8) was questioned, V8 stated she did not witness any unusual occurrence. R1 informed V15 he was forcibly turned to be cleansed and isn't certain if he hit his head against the bed rail . R1 explained to police he had been held down while being changed We can't substantiate abuse occurred; however, the CNA's providing care were terminated due to providing care less than facility standards. Interviews with both CNA' (V8 & V9) deny any unacceptable practice occurred. R1's Physician Progress note dated 1/16/23 documents problem- traumatic ecchymosis of the forehead. R1 is seen for a bruise on the forehead. R1 was seen yesterday by me (V15) at that point R1 did not have a bruise on the forehead. According to R1 either last night or early this morning the patient was forcibly turned to be cleansed and suffered an injury to the forehead R1 is uncertain how this happened .He has a bruise on his forehead approximately 3 inches in length. R1's face sheet shows he is a [AGE] year-old male with diagnoses including congestive heart failure, COPD, hypertension, major depressive disorder on receiving hospice services. R1's Minimum Data Set assessment dated [DATE] shows he's cognitively intact, no behaviors, has no indicators of psychosis, requires extensive two person assist with bed mobility, total dependent on staff for toileting, and has limited range of motion affecting both lower extremities. On 1/19/23 at 8:58 AM, R1 was lying in his bed. A large dark purple bruise was observed from the left side of his forehead above his left eyebrow down to his temple. R1 said I remember they were changing me. He was turned on his side and V9 was being rough. On 1/19/23 at 2:22 PM, V9 (CNA) said she and V8 (CNA) were the only two CNAs on 2nd shift on 1/15/23. They went room to room to change residents. V9 said her and V8 went to change R1 about 9:00 PM, and she did not notice a bruise on him. V9 said they changed him and that was it, she said during cares she did not press his head on the rail. On 1/19/23 at 12:14 PM, V8 (CNA) said V8 and V9 were the only two CNA's working 2nd shift on 1/15/23 on R1's wing. R1 needs help repositioning. They went in his room to provide incontinence care. She did not notice anything happen during care. V8 said she did not see R1's head hit the side rail. On 1/19/23 at 7:00 AM, V7 (RN) said she was R1's nurse on 1/15/23 for 2nd and 3rd shift. V8 and V9 were the only two CNA's working on 2nd shift. V7 said she did not notice a bruise on R1's forehead until the next day on 1/16/23. On 1/16/23 there was a large bruise on the left side of his forehead. V7 said V8 and V9 did not report any occurrence during cares. If something happened, I'm not aware of it. On 1/19/23 at 10:00 AM, V10 (CNA) said she was R1's CNA on 1/16/23 during the day shift. She went into his room and noticed a very large bruise on his forehead. I asked him what happened, and he said some girls were cleaning him up and one of the girls was holding him down. V10 said R1 asked to speak to a manager on duty and she reported the bruise to V3 (Infection Control Nurse). V10 said R1 is alert and a total care with his activities of daily living. On 1/19/23 at 9:44 AM, V3 (ICP Nurse) said she was the manager on duty on 1/16.23. V10 reported to R1 wanted to talk to me. V10 said when she entered the room, she noticed a large bruise to the left side of his forehead. He said a couple of CNAs were rough with him the night before. On 1/19/23 at 10:18 AM, V11 (CNA) said R1 is alert and oriented he can communicate his needs and needs assistance with rolling in bed. He's pleasant. He said some CNA's he does not get along with because they are rough with him but did not tell me who. On 1/19/23 at 1:18 PM, V2 (DON) said R1 makes his needs own, he has not made any false allegations. On 1/15/23 there was only two CNA's (V8, V9) working on 1/15/23 during second shift. Something is not adding up on what caused the bruise to his forehead. On 1/19/23 at 1:45 PM, V1 (Administrator) said she went to talk to R1 again on 1/20/23. R1 said when during care he was being turned by V9 and she placed her hand under his knee and her other hand near his head, and he may have hit the rail but does now know what happened. He was very adamant he did not want V9 taking care of him. The way V9 had positioned R1 could have caused the bruise. V1 said V9 and V8 were both terminated for lack of facility standards. V6 (Police Officer) typed email submitted to the state agency dated 1/17/23 documents he was escorted to see R1. When asked R1 what happened he said V9 (CNA) was being rough with him but could not recall how he sustained the injury to his forehead. R1's nurses note dated 1/16/23 documents a 6.1 cm (centimeters) x 6.1 cm red/purple hematoma on the left outer side of his forehead. R1's care plan updated October 2022 documents R1 is unable to complete bed mobility independently, has weakness, diagnosis of CHF, on hospice services, needs training and skill practice in bed mobility. Interventions include for the CNA to cue the resident that staff need to assist him with repositioning. Ask R1 to reach and grab onto the side rail as staff turn him side to side, once he grabs onto the side rail cue him to hold onto and try to pull himself with staff assist. Then cue him to continue to hold onto the side rail as staff perform care .allow resident rest periods as needed.

Based on observation, interview, and record review the facility failed to ensure staff provided the appropriate care for a resident with a diagnosis of dementia with a history of behaviors. This applies to 1 of 3 (R2) residents reviewed for dementia care in the sample of 6. This failure resulted on R2 sustaining a hematoma and a small abrasion to the right forehead. The findings include: R2's face sheet shows he is a [AGE] year-old male with diagnoses including encephalopathy, dementia with agitation, delirium, major depressive disorder, acquired absence of the left leg above the knee and acquired absence of the right leg above the knee. R2's Minimum Data Set assessment dated [DATE] shows his cognition is mildly impaired, behaviors of delirium including inattention, disorganized thinking, physical and verbal behaviors towards others, and is total dependent with two people assist for transfers, toileting, and extensive assist with bed mobility. R2's Final Incident Report dated 1/20/23 documents on 1/16/23 while care was being provided R2 became combative and his right forehead bumped the side rail sustaining an injury as evidenced by a hematoma to the right forehead and a small abrasion the right siderail has dried blood on it consistent with siderail contact .R2 stated he was held down by a pillow over his face and was hit with an object .the CNA's providing care were terminated due to providing care less than facility standards. On 1/19/23 at 9:15 AM, R2 was lying in his bed. A hematoma was observed to his right forehead with a laceration near his eye and diffuse bruising under his right eye. R2 said he wasn't wrestling around with anyone. They said I hit my head on the side rail but I didn't, someone hit me on the head with something. On 1/19/23 at 12:14 PM, V8 (Certified Nursing Assistant) said on 1/15/23 she and V9 were the CNA's working the 2nd shift. They went in to change R2 and he was full of stool, he was being combative, cussing at us, and trying to hit us. We rolled him over too hard causing him to hit his head on the siderail and he started bleeding. We usually re-approach him when he has behaviors and report to nursing but we were in the mix of cleaning him and didn't want to leave him in stool. We should have left the room and came back when he was calmer. On 1/19/23 at 2:22 PM, V9 (CNA) said she was working on 1/15/23 with V8. They went to change R2, he was being combative and there was stool everywhere, it was nasty. R2 was in a rage it was like a tug of war, he didn't want to get cleaned up, we pushed him over and his head hit the side rail. V9 said she normally does not take of R2. R2 can be combative and has verbal behaviors but has not seen him like that before. On 1/19/23 at 10:54 AM, V13 (CNA) said R2 has dementia, gets combative and has verbal behaviors. Because of his behaviors we have two staff members go in his room for cares. If he gets combative you should stop providing care, leave the room, and reproach because it could aggravate him more if you continue when he has behaviors. On 1/19/23 at 10:44 AM, V12 (CNA) said R2 is a handful, he can be hostile and combative. There must be two staff for cares due to his behaviors. He is a total care. When he has behaviors, you should stop what you're doing, re-approach and notify nursing. On 1/19/23 at 1:18 PM, V2 (DON) said R2 has mental health issues and has accused staff in the past of things. He is a total care assist and has behaviors. When he has behaviors, staff should make sure he is safe and re-approach. R2's care plan dated through March 2023 shows he is at moderate risk for abuse and may present with physical and verbal behaviors due to his condition of health and dementia diagnosis. Interventions include avoid power struggles, continue to care for him with professionalism and dignity, and record behaviors in behavior logbook so departments will know what behaviors have occurred that day. R2's undated Social Services Behavioral Tracking Sheet shows the date, time, staff, behavior, interventions, outcome and care plan/update should be filled out. On 1/15/23 there was no behavior documented for R2. The facility's undated Behavioral Policy and Procedure states, to provide care for residents living with Dementia which is an integral part of the person-centered environment and necessary to support high quality of life with meaningful relationships and engagement. Fundamental principles of care for the persons living with behavior symptoms associated with Dementia or other mental health issues involve an interdisciplinary approach that focuses on the needs of the resident living with diseases, as well as the needs of the other residents in the facility. We strive to create a quality of life with and for the resident .The behavior and emotional state of people with Dementia often are the forms of communication because residents may lack the ability to communicate in other ways. Residents need opportunities and sufficient time to express themselves. Staff need training to identify potential triggers for a residents behavioral and emotional symptom such as agitation, mood change .when staff recognize these triggers, they can use environmental and behavioral strategies to modify the triggers .

Based on observation, interview, and record review the facility failed to implement interventions to prevent a resident with a history of falls from experiencing a fall with major injury for 1 of 2 residents (R7) reviewed for falls in the sample of 16. This failure resulted in R7 being left unsupervised in her wheelchair and experiencing a fall on 1/21/22. R7 sustained a facial laceration which required treatment at an acute care hospital and received 7 sutures to her left forehead. The findings include: R7's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include congestive heart failure, Alzheimer's disease with late onset, dehydration, hypertension, fatigue, personal history of [CONDITION(S)], and cerebral infarction without residual deficits. R7's facility assessment dated [DATE] showed R7 to be cognitively impaired and staff assistance for all cares. R7's care plan started 10/20/18 titled Falls showed, Resident at risk for falling related to history of falls, vision impairment, cognitive and memory deficits, history of noncompliance with care, history of refusal to wear gait belt and eyeglasses at times. Fall and safety precautions diminished due to diagnosis of dementia . Approach start date: 11/23/20 Apply sensor pad in char and bed and ensure they are working at all times . Approach start date: 4/16/21 Place resident in Falling Star Program . Approach start 10/3/21 Place resident on visual supervision when she is up in chair and when having increased behavioral symptoms . R7's fall record reviewed and showed R7 experienced falls 8/11/21, 8/30/21, 9/15/21, 9/21/21, 10/7/21, 10/16/21, 11/11/21, 11/22/21, 12/31/21, 1/21/22, and 2/19/22. R7's 8/30/21 fall event report showed R7 experienced an unwitnessed fall in her room when she got up out of her wheelchair and attempted to ambulate without assistance. R7's 9/21/21 fall event report showed R7 experienced an unwitnessed fall in her room when attempting to transfer herself from her wheelchair into her bed without assistance and was found sitting on the floor. R7's 9/15/21 fall event report showed R7 experienced a fall in the hallway when she attempted to transfer herself from her wheelchair without assistance. R7's care plan showed a new intervention on 10/3/21 to place resident on visual supervision when she is up in chair. R7's nursing progress notes showed a late entry entered on 10/9/21 at 5:15 PM which documented an unwitnessed fall for R7 which occurred on 10/7/21 and showed, Patient was noted to be sitting on the dining room floor in front of her wheelchair next to the dining room chair with her legs extended out in front of her. Patient attempted to transfer herself from the wheelchair to the dining room chair without assistance. R7's 10/16/21 fall event report showed R7 was in her wheelchair at the nurse's station when she attempted to transfer alone and fell . R7's nursing progress note dated 10/16/21 at 2:46 PM showed, Resident at nurse's station in wheelchair. Heard noise. Resident seen on floor on her back. Chair alarm did not go off, broken, replaced . R7's 11/22/21 fall event report showed R7 experienced an unwitnessed fall in the dining room when she leaned too far forward and fell out of her wheelchair. R7's 12/31/21 fall event report showed she attempted to get up from bed and take herself to the bathroom without assistance. The same report showed the alarm pad was in place but not plugged in. R7's 1/21/22 fall event report showed R7 experienced an unwitnessed fall from her wheelchair when she attempted to transfer without assistance. The same report showed R7's alarm was in place but not sounding. R7's nursing progress note dated 1/21/22 at 11:40 AM showed, Resident noted to be on floor in front of wheelchair. Moderate amount of blood noted next to head. Upon assessment noted laceration to left forehead above eye brow active bleeding present, direct pressure applied. Able to move extremities, noted left hip rotated outward. R7's nursing progress note entered 1/21/22 at 11:45 AM showed, .order received to send to [Acute Care Hospital Emergency Department] . R7's nursing progress note dated 1/22/21 at 4:05 PM showed, A call from [acute care hospital] stating that resident is coming back with stitches on her left forehead . R7's acute care hospital paperwork dated 1/21/22 showed R7 was seen for a fall, [MEDICATION(S)] head trauma, and a facial laceration. The same paperwork included instructions for caring for R7's sutures. The same packet from the acute care hospital included results of a CT Scan (diagnostic scan of R7's head to identify any injuries) which showed, . Moderate scalp hematoma is seen in the left lateral upper frontal region. R7's 2/19/22 fall event report showed R7 experienced another unwitnessed fall from her wheelchair in her room. On 3/03/22 at 1:36 PM, V3 RN (Registered Nurse Manager) said she is the one who handles the fall program at the facility. V3 said upon admission they do a fall risk assessment and then again quarterly. These assessments determine if a resident is in the fall star program. V3 said, Residents in the falling star program would get a little bit closer monitoring, safe positioning, stuff like that. We used to do fall meetings more regularly but that has kind of got put to the wayside. The nurse filling out the fall report at the time of the event should be putting a new intervention on a care plan. [R7] has had a lot of falls and was on the falling star program. She is a resident who should be in a supervised area, within arm's reach. She is someone you would have to have right next to you. She should not be in her wheelchair and unsupervised. She has been declining in the last few months though so maybe the nurse thought she was sleeping. We do not have a process to check the to ensure the alarms are working. The alarms are supposed to blink when the batteries are low, and the nurses would need to watch for that and replace the batteries. The facility's fall policy titled Falling Star Program Policy and Procedure with review date of 1/2022 showed, Purpose: The Falling Star Program is designed to prevent falls in our facility . Assessment: To identify residents on the Falling Star program a blue falling star is placed at the head of the bed, on their care plan, and on any wheelchairs or walkers. This alerts the staff to a potential risk for falls and interventions that may prevent the resident from falling 3. Implement a plan of care including the potential risk for falls, goals, and appropriate interventions based on the resident's assessment. If a fall occurs: . 8. IDT (interdisciplinary team) to meet daily in clinical meeting regarding any falls. Safety interventions will be reviewed, and the plan of care updated .

Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the Centers for Disease Control and Prevention (CDC) regarding isolation of new admissions to rule out COVID-19. This has the potential to effect all residents in the facility and has the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to residents. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 05/10/21 when V4 (Certified Nursing Assistant) entered R193's room without a N95 mask or eye protection on. The Immediate Jeopardy was identified on 5/11/2021. V1 (Administrator) was informed of the Immediate Jeopardy on 05/11/21. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 05/11/21; however noncompliance remains at a level two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The CMS (Centers for Medicare and Medicaid Services) Form 672, Resident Census and Conditions of Residents, completed by the facility on 05/10/21 showed the facility's census was 43. A facility provided list of residents that were vaccinated for COVID-19 indicated 81% of the facility's residents received the COVID-19 vaccination. The same list indicated R6 and R193 were not vaccinated and resided in the same hallway. On 05/11/21 at 10:40 AM, V3 (Infection Control Nurse) verified the unvaccinated residents on the list had not had COVID-19 within the last 90 days. R193's face sheet showed R193 was admitted to the facility on [DATE]. On 05/10/21 at 10:00 AM, on the door of R193's room was a pink sign. The sign indicated R193 was on quarantine. Outside of R193's room was a cart that contained personal protective equipment (PPE) of surgical masks, gloves, and gowns. On 05/10/21 at 01:05 PM, V4 (Certified Nursing Assistant- CNA) entered R193's room wearing an isolation gown, gloves, and surgical mask. V4 did not have a N95 mask or eye protection on. V4 handed R193 their call light and picked up R193's meal tray. On 05/10/21 at 3:13 PM, V3 (Infection Control Nurse) said new admissions, such as R193, are placed on, Quarantine isolation for 14 days. The 14 days on quarantine isolation creates a, Symptomatic lookback period to make sure the residents do not have COVID-19. V3 said staff should wear a surgical mask, gloves, and gown when entering a quarantine isolation room. V3 confirmed a N95 mask and eye protection were not required. V3 said the facility also had a Person Under Investigation (PUI) isolation that was for residents that had close contact with someone that tested positive for COVID-19. V3 said they follow the Center for Disease Control and Prevention guidelines regarding COVID-19. The facility's Explanation of Isolation Precautions Type and Duration policy with a revised date of 05/20 showed new admissions were placed on quarantine isolation and required staff to wear gown, mask, and gloves. The Center for Disease Control and Prevention website titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes & Long-Term Care Facilities updated 03/29/21 Showed under the section for New Admissions and Residents who Leave the Facility that, [Health Care Providers] should wear an N95 or higher-level respirator, eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for [quarantined] residents. The Immediate Jeopardy that began on 05/10/21 was removed on 05/11/21, when the facility took the following actions to remove the immediacy: The facility's infection control policy/procedure regarding new admissions was immediately reviewed and revised to reflect compliance with CDC guidance including but not limited to: PPE in use will include but not be limited to donning of N95 masks and protective eye wear upon entering the room of a newly admitted resident who meets the PUI criteria. On May 11, 2021, the facility immediately provided the required PPE supplies to the designated infection control cart for use by staff entering the involved resident's room. On May 11, 2021, the facility immediately and simultaneously initiated and completed re-education by the Infection Preventionist regarding modifications to the facility's infection control policy/procedure. Part time, PRN and remaining staff will be educated via Team Reach/phone with verbal confirmation to acknowledge that they have received and understand this education; they will be asked to sign an attestation upon their return to work their next scheduled day. Education of 100% staff completion by end of working day 5/13/2021. To ensure the policy/procedure are being followed, the Director of Nursing and Infection Preventionist, or designee will monitor staff utilizing appropriate PPE and to ensure appropriate PPE is available; audits will be conducted on isolation of PUIs 3 times per week for one month and then weekly for 3 months. Results of the audit findings will be reviewed and discussed at the QAPI meeting. The committee will evaluate and determine the need for adjustment and further monitoring. An emergency QA meeting with the Administrator, Director of Nursing, Infection Preventionist Nurse, Infection Control Consultant, and Medical Director will be conducted on 5/12/2021 to discuss the abatement plan and the audit for PUI monitoring.

Based on observation, interview, and record review, the facility failed to implement transmission based precautions for a resident experiencing COVID-19 symptoms, failed to implement appropriate hand hygiene and appropriate use of personal protective equipment (PPE), failed to implement their infection prevention control program and provide appropriate infection surveillance for staff, failed to provide continued staff education related to the COVID-19 pandemic, and failed to establish an effective isolation wing to prevent cross contamination between COVID-19 positive residents and persons under investigation. These failures resulted in an outbreak of COVID-19 among staff and residents that resulted in 49 residents being evacuated to an alternate long term care facility. This applies to all 85 residents in the facility reviewed for infection control. The Immediate Jeopardy began on September 29, 2020 when the facility failed to put isolation practices into effect after a staff member was tested for COVID-19. The Immediate Jeopardy was identified on 10/22/20. V1 Administrator was notified of the Immediate Jeopardy on 10/22/20 at 10:35AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 10/26/20, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training and revised COVID unit layout. The findings include: This facility data sheet dated 10/14/20 showed 85 residents residing in the facility. On 10/15/20, the facility provided a roster of residents evacuated which include R13-R61. 1) On 10/14/20 at 8:30AM, V2 (Director of Nursing) stated, We have 14 residents and 8 staff members currently positive for COVID-19. We are on our 3rd week of employee testing. We think our initial COVID-19 case came from a staff member. She just finished her 14 day quarantine. Last Friday (10/9/20) was the first positive COVID-19 case with residents. On 10/14/20 at 12:15PM, V1 (Administrator) stated, We have decided to evacuate. Our human resources department and office personnel are contacting the families to let them know that they either need to take their family member home or we have to transfer them to an alternate facility. This is an emergency transfer, there is no other choice besides home at this point. We are declaring an internal disaster. All staff have been separated. Staff have been pulled from the non-COVID unit to the COVID unit but then they must stay on COVID unit. They are not allowed to cross back over to the non-COVID unit. On 10/14/20 at 9:00AM, V5 (Certified Nursing Assistant) stated, Today is my first day working on the COVID unit. I am still learning all of the processes and what I'm supposed to be doing. I didn't get training for this unit, I usually work on the persons under investigation (PUI) unit. On 10/14/20 at 9:10AM, V3 (Infection Control Nurse/Licensed Practical Nurse) stated, The dietary staff are not required to wear PPE when delivering meal trays. The dietary staff deliver the meal cart to both the COVID and PUI unit. To get to the PUI unit, the dietary staff must first pass through the COVID unit (without PPE on). To retrieve the meal carts, dietary staff must go back through the COVID unit and wheel the cart back through the COVID unit to the kitchen. On 10/14/20 at 11:20AM, V3 (Infection Control Nurse/Licensed Practical Nurse) took off her dirty PPE, left the COVID unit and entered the non-COVID area of the facility where staff are not allowed to cross over after working on the COVID unit. On 10/14/20 at 11:30AM, V9 (housekeeping/maintenance director) was standing at the nurses station on the COVID unit with his bare hands touching surfaces on top of the nurses station. V9 did not have gloves or an isolation gown on. V9 left the COVID unit without performing any hand hygiene and proceeded out into the receptionist area of the facility. On 10/14/20 at 2:00PM, V4 (Registered Nurse) was applying PPE at the entrance of the COVID unit. V4 stated, I normally work on the non-COVID unit, that's where I am working today. I just came over here to draw blood on a resident then I'm heading back to finish my shift on the non-COVID unit. (Crossing from non-COVID unit to COVID unit and back to non-COVID unit). R5-R11 all reside on the COVID-19 positive unit. Progress notes for R5-R11 were reviewed and showed V4 (Registered Nurse) documented that she performed blood draws on R5-11 on 10/12/20. (while she was working the non-COVID unit) On 10/14/20 at 2:12PM, V5 (certified nursing assistant) came out of the soiled utility room on the COVID unit without a mask or PPE on. V5 walked around the nurse's station, made eye contact with surveyor, and then attempted to cover her mouth and nose with the edge of her shirt. On 10/15/20 at 10:55AM, V7 (admissions/marketing director) was observed at the nurses station on the COVID unit. V7 was leaning over the desk, putting her hands in direct contact with the desk and then proceeded to leave the unit. During this observation, V7 was wearing a surgical mask but no gown, gloves, or N95 mask. V7 did not perform hand hygiene upon exiting the COVID unit. On 10/15/20 at 3:00PM, V15 (registered nurse) was observed on the COVID unit putting on her N95 mask and commented to the surveyor, I have no idea how this mask goes on, does this look right? It feels weird. Oh well, I guess its right. I came in today and was told all of my residents moved to another facility. I'm not sure what I am going to be doing tonight because I have never worked over here (PUI unit). On 10/15/20 at 7:00PM, V6 (Registered Nurse) was observed sitting at the nurses station on the COVID unit. V6 did not have a mask, gloves, or gown on. V6 continued to sit at the nurse's station for 5 minutes without PPE on. V6 then stood up, went into the soiled utility room on the COVID unit, and walked out with a clean N95 mask and face shield in his hands. On 10/20/20 at 11:07AM, V12 (certified nursing assistant) stated, I tested positive for COVID-19 when I tested last week. I had a headache last Wednesday or Thursday and called the facility and they told me to come in and get a COVID test done. I walked into the facility with a surgical mask on and went down to the soiled utility room on the COVID unit and got my test done there. You have to walk through the reception area and down one hallway to get to the soiled utility room on the COVID unit. I got my positive results that Friday. The N95 masks that they gave us to wear didn't fit right. That bothers me because I didn't really feel 100% protected. Also, the COVID unit nurses station was deemed clean so we were told we could hang out and sit there with just a mask on. I don't feel comfortable with that because we have 2 overflow patients that are COVID positive in rooms near the nurse's station. I remember getting educated on the use of our personal protective equipment but I don't recall any recent in-services or updates on COVID-19. Once positive tests started rolling in everyone just kind of panicked. On 10/20/20 at 11:40AM, V13 (care plan coordinator/registered nurse) stated, I tested positive a week ago today. I had a few symptoms, cough and nasal congestion. I tested negative the day before that and the Friday before that as well. (The facility was unable to provide documentation of the 2 previous negative test results). Then I had a rapid test done on the 13th. I'm still having the cough. They told me that we could put our personal protective equipment on at the nurse's station on the COVID unit because it was brand new out of the package. We were tested weekly for a little bit, then had 2 weeks of negatives, so we went monthly. Then when we did that monthly test is when we ended up with a positive staff member on September 29th. It had really only been 2 weeks since we had done a weekly test. Then it started to be everybody testing positive. I'm not sure why. The last days I worked on the COVID unit were October 10th, 11th, 12th and 13th. I got sent home on October 13 after I tested positive. October 9th was the first time we made a COVID unit. It was just a regular unit prior to the 9th. On 10/20/20 at 11:10 AM, V11 (activity aide) stated, At the time of the test I was having a cough, body aches, sore throat, runny nose and loss of taste. I called in and asked if I could come in and be tested . On Monday the 12th I got tested at the facility and received positive results. I was working on the PUI unit. To my knowledge the outbreak is on the PUI unit. We were doing activities in small groups up until about a week or week and a half before the outbreak. It was rumored that there were a couple of people positive, so we stopped doing the small groups of 4-6 and went back to doing activities on the televisions. The last group was 3 weeks ago. I worked all day on October 9th. On 10/20/20 at 11:20AM, V14 (certified nursing assistant) stated, I was tested at the facility, I remember feeling chest tightness and congestion and had a really bad headache. I came in to work on 10/7/20 at 6:45AM and didn't feel well so I ended up going home at 8:00AM. They had me sit at the nurse's station because I wasn't feeling well. I tested positive for COVID-19 on 10/9/20. I was working on the PUI hall and we didn't have any positive cases besides staff so we just wore surgical masks. Only one staff member had tested positive on 9/29/20 so we thought we just had to wear the surgical masks and gloves when we were doing patient care. I don't recall hardly any in-services on infection control or COVID-19 except at the beginning of the pandemic. I remember administration started panicking about staffing because we were short on staff. On 10/14/20 at 1:06PM, V3 (Infection Preventionist) stated, At this time, we are treating the north and south units like 2 separate facilities. Our staff do not cross over from one wing to the other. For the non-COVID units the staff are wearing the blue surgical masks and if they would have someone on quarantine then yes they would do the conventional stuff like put on a mask, gown, and gloves. They wouldn't need a face shield because the residents are negative for COVID-19 and have assessments done every shift. On the COVID positive and persons under investigation (PUI) units we are wearing a gown, gloves, KN95 mask. We are not necessarily mandating eyewear because they are the monitored residents. On the COVID unit, staff are wearing N95 mask, gloves, gown, and goggles/face shield. There are 2 residents on the other side of the COVID positive hall with their doors open because that is their preference. I prefer to keep the personal protective equipment at the nurse's station so that way if I have to do something I can get my PPE on quicker. I started doing in-services on Monday and Tuesday (10/13/20 and 10/14/20, after positive COVID-19 test results have been received). I started doing infection control in-services. Prior to the outbreak we had a big flu thing (in-service). That was an all staff meeting and it was a big meeting. The last in-service I did was all about the influenza. They had a lot of questions about COVID. Before the in-services yesterday it was more monitoring, standing back and watching. For the quarantined residents that we've had here and there, I was just watching. Half the time they don't even know I'm paying attention. On 10/14/20 at 2:10PM, V3 stated, I do not have an employee infection control tracking form prepared, I have a few things written down but nothing formal. I'm not going to give you that because it's not anything formal. We don't really have staff call off for illnesses so it's not that much. Last week is when we really started seeing call offs due to COVID. On 10/21/20 at 10:45AM, V16 (Certified Nursing Assistant) stated, I worked on 9/28/20. When I went home I felt like I was getting a cold. I didn't feel well when I went in for my shift on 9/29/20 at 6:45AM. At 8:00AM, I reported to management (I can't remember who) that I didn't feel well. They contacted the administrator who then gave me a COVID test and sent me home. I found out on 10/1/20 that I had tested positive for COVID. The facility told me to contact anyone I had been in contact with for the past 48 hours and let them know I tested positive. They didn't ask me who I worked with or what residents I worked with. On 10/21/20 at 11:09AM, V3 stated, For reusable personal protective equipment (PPE) we are storing goggles and mask in our utility room. It's a clean room. We aren't using that room for anything else right now. When staff are at the COVID nurses station they should be wearing gowns, N95 mask, goggles/face shield, gloves. If staff are not working the staff can come in and get a rapid test in the community room right outside of the front lobby. If staff test positive they are taken off the roster, it is reported to the local health department and the administrator reports it to public health. I don't think there is anything else we do related to positive staff cases. I don't really deal with that part very much. I haven't heard of any staff getting their rapid test in the soiled utility room on the COVID unit. That would be unacceptable because they are walking through the building and could contaminate other people. COVID in-services have not occurred since I came here in July. Nothing formal has happened. I know the administrator has done nurse meetings every other Tuesday and I am off every Tuesday so I'm not sure what has been said in those meetings. The facility's in-service records for the year 2020 showed the facility provided all nurses with an in-service on COVID-19 resident assessments on 3/18/20. On 4/7/20 the facility provided an in-service to all staff on policies & procedures related to COVID-19 as well as current guidance from local and state authorities. The facility was unable to provide any further in-services from 4/7/20 to 10/15/20 related to COVID-19 guidance given to all staff. The facility's policy titled, COVID-19 Control Measures for Long Term Care revised 8/20/20 showed, It is the policy of [NAME] Nursing Center to develop a COVID-19 plan to minimize the spread of the virus. However, in the event the facility is affected with the virus, the following procedures will take effect: .Staffing: Managers shall ensure that all clinical and non-clinical staff members including housekeeping, laundry and dietary are familiar with the plan. Staff members will know the symptoms of COVID-19 and understand the transmission and preventative measures .Education/In-services will be provided for staff .The following guidance is to help prevent transmission of COVID-19 .d) consider that staff caring for positive or symptomatic patients do NOT care for negative or asymptomatic patients .Any residents identified with symptoms of fever and respiratory illness (cough, shortness of breath, sore throat) should be immediately placed in both Contact and Droplet transmission-based precautions .Facilities: Focus on decreased staff rotation and cohort staff who work with symptomatic residents whenever possible .Employees: All employees must wear a mask (universal masking) during their shift to protect residents. All staff must wear masks when entering the building. The guidance from the Centers for Disease Control updated 4/30/20 showed, Determine which residents received direct care from and which health care providers (HCP) had unprotected exposure to HCP who worked with symptoms consistent with COVID-19 or in the 48 hours prior to symptom onset. Residents who were cared for by these HCP should be restricted to their room and be cared for using all recommended COVID-19 personal protective equipment (PPE) until results of HCP COVID-19 testing are known. If the HCP is diagnosed with COVID-19, residents should be cared for using all recommended COVID-19 PPE until 14 days after last exposure and prioritized for testing if they develop symptoms. 2) R12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R12 was located on the COVID-19 positive unit on 10/14/20. R12's nursing progress notes for 10/5/20 showed, Fax sent out to physician. (R12) appears lethargic, keeps dozing off in between activity. Poor appetite. Observed with phlegm in his mouth thick and yellow in color. Bilateral lung sounds wheezing with expiration. R12's nursing progress notes for 10/9/20 showed, Physician notified of positive COVID test results. Quarantine measures initiated. The facility's daily health assessments for R6, R8, R11, and R12 dated 10/2/20 showed assessments were all within normal limits. The assessments dated 10/5/20 showed R12's lung sounds to be wheeze. The assessments dated 10/7/20 showed R8 and R11 as wheezes and R12 to have rhonchi (coarse lung sounds). On 10/20/20 at 11:40 AM, V13 said the COVID Isolation Unit was started on 10/9/20 which is when the PPE (Personal Protective Equipment) requirement changed from requiring a surgical mask to staff needed full PPE including the N95 mask and face shield. On 10/21/20 at 11:09AM, V3 stated, The symptoms related to COVID vary between each patient, some have been afebrile the entire time, some are running a temperature, some have respiratory symptoms such as rhonchi, wheezes. Audible wheezes are only in those patients with prior respiratory history. Daily monitoring of non-covid is temperatures, oxygen saturations, and respiratory assessments (lung sounds). If there were any changes we were writing that down and informing the director of nursing and possibly let the administrator know. Then they directed us on what to do. Whether or not we would isolate them depends on the situation. We would see if they have a fever, respiratory changes, or maybe it is related to something else. We then would contact the primary care provider to see what they wanted to do and usually they'll order a chest x-ray. If the x-ray came back as something like pneumonia the resident is cleared to come out of their room. Whether or not the resident is isolated is up to the physician. I don't know what our policy is related to residents with COVID symptoms. I don't want to quote the wrong thing. (R12) symptoms indicate he should have been isolated and tested immediately. If there is a roommate then that roommate is moved to another private room. (R62) experienced audible wheezing during my shift on 10/7/20. I know that I notified the physician-even if it's not charted. The physician said she does this randomly and didn't order anything additional. The facility's resident COVID testing log dated 10/7/20 showed R8, R11, and R12 all tested positive for COVID19. The Immediate Jeopardy that began on September 29, 2020 was removed on 10/26/20 when the facility took the following actions to remove the immediacy: Current Layout 10/17/2020- Staff have separate entrances. All Birchwood staff enter from the Dining Room and Oakwood enters from the East Parking lot door. 10/19/2020- All food, supplies, and linen carts are now transported outside to the Birchwood wing. 10/17/2020-Clocking in for work is now done on paper 10/10/2020-All Oakwood trays are disposable. 10/9/2020-Residents COVID positive residents are in private rooms and separated on another unit. 10/17/2020-Bathroom exhaust fans have been turned on and any window that may be opened are open to create airflow. 10/9/2020-All staff are screened at the beginning and middle of each shift - Tracking of employee illnesses will take place and recorded with the Infection Prevention Nurse 10/9/2020-PPE is readily available on all units. N95 Mask, gowns, gloves, and goggles. The PPE station is located in the middle of the hallway just before the Conference Room. 10/16/2020- Oakwood and Birchwood have separate break rooms and refrigerators. Handwashing supplies and ABHR are readily available and restocked frequently on all units and facility. Oakwood residents are being assessed for Temperature, Pulse Ox, and respiratory status every 4 hours and documented in the computer Birchwood residents are being assessed for Temperature, Pulse Ox, and respiratory status every shift and as needed. Any abnormal results are reported to the Administrator or the Director of Nursing. If symptoms exist then the resident will be isolated in a private room awaiting lab confirmation of COVID. In-service Training In-service training will occur via in-person or virtual depending on the circumstances. All in-services will be complete by 5pm 10/26/2020. All staff who are quarantined at home will be educated virtually. Administratory and Infection Preventionist or their designees are responsible for the education. Education will include: Proper donning and doffing of PPE Handwashing and hand hygiene COVID-19 sign and symptoms Social Distancing and Breaks Cleaning and disinfection of rooms and commonly used surfaces/items Isolation precautions Staff Screening On 10/26/20 at 4:00PM, In-service records were reviewed and showed 84% of staff have been provided in-service training on donning and doffing personal protective equipment, hand hygiene, COVID-19 response plan, COVID-19 signs and symptoms, social distancing and breaks, cleaning and disinfection of rooms and high touch areas, isolation precautions and staff screening. Staff that were not able to attend the in-service in person were given an electronic version and submitted responses that the information had been received and understood. V1 (Administrator) stated that all staff will need to have the training completed prior to working their next shift. At this time, there are several staff members out on medical leave and several staff members at home that are COVID positive. The layout of the COVID unit was evaluated by surveyors and showed to be an adequate layout of a COVID unit. Donning and doffing areas had been moved to non-patient care areas and alternate entrances and exits were in place for the COVID and non-COVID hallways.

Based on observation, interview, and record review the facility failed to identify a pressure ulcer prior to becoming a stage 2, failed to initiate a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R1 developing a pressure ulcer, R1's pressure ulcer deteriorating to an unstageable wound with necrotic tissue and becoming infected, and R1's admission to the acute care hospital for surgical treatment. The findings include: 1. R1's Face sheet showed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility assessment dated [DATE] showed he is completely dependent upon staff for all cares and has a history of pressure ulcers. On 10/16/20 at 12:30 PM, V10 (R1's Power of Attorney for Healthcare) said R1 was transferred to the hospital on 10/10/20 and is very sick because of necrotic wounds. V10 said she went to the emergency department with R1 on 10/10/20 and was shocked to see he had 2 wounds. V10 said R1 had a wound the size of her fist on his left buttock and a wound near his coccyx. V10 said the hospital took him into surgery and removed the dead tissue. V10 said the facility never informed her of R1's wounds. R1's complete care plan was reviewed and showed a care plan for a pressure ulcer to his left buttock was created on 9/30/20 (53 days after the wound developed) with a problem start date of 8/31/20 (23 days after the wound was identified) which included an intervention to assess the pressure ulcer weekly. R1's nursing progress note entered on 8/8/20 showed, observed resident incontinence pad with smear of blood upon repositioning. Noted skin excoriation open approx 2.5 cm x 2 cm . [Physician informed]. R1's nursing progress notes from 8/8/20 to current showed no notification to R1's family regarding the onset of his left buttock wound. The first wound assessment for R1's left buttock was documented by V2 (DON/Wound Care Nurse) on 8/12/20 which showed, Left buttock ., stage 2, . 2.0 cm x 2.5 cm x 0.2 cm . barrier cream to buttocks and groin (an order which had been on R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's wound assessment documented by V2 on 8/19/20 showed the wound had increased in size to 6 cm x 6 cm x 0.2 cm and notes the treatment which was initiated on 8/16/20. R1's wound assessment for his left buttock entered by V3 and dated 8/26/20 showed the wound had increased in size again to 7.9 cm x 10.4 cm x UTD (unable to determine), was now unstageable, and the notes the tissue type to be necrotic/eschar. This same assessment notes that the same treatment is in place from the prior assessment. There was no weekly assessment for R1's left buttock wound documented for the week of 9/2/20. R1's treatment administration record for August 2020 showed the treatment to R1's left buttock was changed on 8/29/20 to .cleanse with wound cleanser daily, apply Santyl (enzymatic debridement cream) and cover with ABD (non-adhering gauze pad). R1's left buttock wound assessment entered by V3 on 9/9/20 showed the wound to measure 7.9 cm x 11 cm x UTD, to be unstageable, and the tissue type to be slough. R1's wound assessment dated [DATE] showed the wound had increased in size to 7.9 cm x 12 cm x UTD, to be unstageable, and the tissue type as necrotic/eschar again. This assessment notes no treatment change. R1's left buttock wound assessment dated [DATE] showed the wound to measure 7 cm x 12 cm x 0.2 cm. R1's treatment administration record for September 2020 showed the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no treatment changes made between 8/29/20 and 9/24/20 despite the wound continuing to increase in size. There was no documentation in R1's medical record between 8/29/20 and 9/24/20 showing notification to a physician regarding the left buttock wound. R1's left buttock wound assessment entered by V2 DON on 9/30/20 showed the wound to be 7 cm x 12 cm x UTD, stage 3, and the tissue type as slough. This assessment noted no changes to the wound treatment. The last documented assessment for R1's left buttock wound before his transfer to the acute care hospital on 10/10/20 was entered by V2 on 10/7/20 and showed the wound to be 6.8 cm x 12.9 cm x UTD, stage 3, and the tissue type to be necrotic/eschar. This assessment noted no change to the wound treatment orders. The wound treatment orders were not changed from 9/24/20 through 10/10/20 when he was transferred to the acute care hospital. R1's nursing progress notes from 9/24/20 through 10/10/20 do not include notification to the physician regarding the left buttock wound. R1's nursing progress note dated 9/29/20 showed, requested to have clear liquids to drink for lunch stated 'the food is balling up in his mouth not able to swallow it as his mouth is too dry not producing enough saliva'. R1's nursing progress note dated 10/7/20 entered by V4 RN (Registered Nurse) showed, Has been up in wheelchair by desk yelling help, when asked what he needed stated I can't breathe need drink of water. Water given. Within a few min he started yelling again that he couldn't breathe yet was able to talk and yell just fine. R1's nursing progress note dated 10/8/20 entered by V4 showed, told staff that he wanted to go to the ER. Writer entered room but refuses to answer when questions asked. Lungs clear yet diminished . R1's nursing progress note dated 10/9/20 showed, Resident states he can't breathe but speaking in full sentences . O2 (oxygen) at 5 LPM via [CONDITION(S)] . state he cannot swallow and drink but was able to take medications without problem and drank water offered after medications. R1's nursing progress note dated 10/9/20 showed, .chose to decline to eat breakfast .states I can't swallow and drink when I am lying down . R1's nursing progress note dated 10/9/20 at 11:01AM showed, Refused scheduled bath. State he wants to go to the hospital. PCP (Primary Care Physician) notified by fax, awaiting advise. R1's nursing progress note dated 10/9/20 at 1:51 PM showed, . still awaiting for PCP's advice R1's nursing progress note dated 10/9/20 at 10:27 PM showed, Fax received from [PCP], stated he would be in the facility to see this resident over the weekend. R1's nursing progress note dated 10/10/20 at 10:05 AM with an edit time of 11:59 AM showed, .Resident alert yet increased lethargy noted. Refused to eat. Did take meds with water no difficulty swallowing. Area to Lt (left) buttock has increase in eschar and active bleeding noted. Surrounding tissue is spongy. Resident request to go to the ER (emergency room ) states 'I'm dying'. Call placed to [PCP] update given states to send him to the ER. R1's nursing progress note dated 10/10/20 at 3:29 PM showed, [PCP] here stated resident is being admitted to the hospital. BGM (Blood Glucose Monitoring) was 407 and has infection. Will see the surgeon in the AM about left buttock. R1's treatment administration record for August 2020 showed no treatment orders started for R1's left buttock wound until 8/16/20. R1's nursing progress note dated 8/16/20 showed, [R1's Primary Care Physician] here on rounds. Treatment order received for left buttocks . R1's nursing progress note dated 8/23/20 showed, Observed resident left buttock wound is not healing . R1's emergency department note from the acute care hospital dated 10/10/20 showed, .stage IV pressure ulcer on the patient's coccyx, low back, buttocks area . R1's acute care hospital operative note dated 10/11/20 showed, .admitted to the hospital for large decubitus ulcer in the left buttock and sacrum. The decubitus ulcer measure 10 cm x 13 cm x 2 cm in size dimensions. Half of the surface area of the decubitus ulcer was necrotic and there was a 2nd ulcer over the sacrum measuring approximately 2 cm in diameter and 3 cm deep .there was a skin excoriation surrounding the decubitus ulcers covering the entire sacral area and the posterior surface of both thighs. The facility was unable to provide any documentation of the second wound to R1's sacrum. R1's surgical pathology report from the acute care hospital dated 10/11/20 showed . debridement tissue, left buttock, inflamed and necrotic soft tissue . it is a piece of necrotic tissue measuring 5.5 cm x 3 cm x 1.3 cm . R1's surgery progress note dated 10/13/20 showed . patient with fever. Infection Disease on consult. He is currently receiving [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] (all antibiotics) . R1's surgery progress note dated 10/14/20 from the acute care hospital showed, Chief Complaint: .large decubitus ulcer in the left buttock, stage 3 and a small sacral ulcer penetrating down to the bone, [CONDITION(S)] (infection into the bone) in similar circumstances requires bone debridement and coverage with muscle flap. Antibiotic treatment with exposed bone will not be adequate. Unfortunately this patient is not a candidate for any surgical procedure. On 10/22/20 at 1:00 PM, V2 DON (Director of Nursing) said she is only aware of R1 having one pressure wound (left buttock) but that it is a fairly large one. V2 stated, The nurses on the floor do the wound assessments, the report is turned into me and then I input it into the system. Typically the nurses tell me what is going on with the wound and then we discuss it, if they want me to look at it I will but I don't look at everyone's. Wounds are assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . As soon as the nurse sees that a wound is worsening and not responding to treatment, they should be notifying the physician. The nurses know what they want for orders so I'm ok with them just asking for what they want from the physician. If the nurse does not get a response from the physician by the end of their shift they should be contacting them again. Our medical director is always available to get orders from. A week is unacceptable to wait to get new wound care orders because a wound could become infected and become very serious. I'm trying to get a handle on the wounds again, I've been really busy with other positions so haven't had the time to really pay attention to them. The facility policy with revision date of March 2017 and titled, Pressure Ulcer Prevention Program Policy and Procedure showed, . Treatment Procedures . 3. Assessments of ulcer including staging, description, and measurements will be documented on the weekly Pressure Ulcer Report by the Wound Care Nurse, or assigned Registered Nurse/Licensed Practical Nurse . 6. The nurse will notify physician when pressure ulcers develop and inform him/her of treatment being currently used. 7. The nurse will notify resident's family . 12. Monitor pressure ulcer for signs of infection. 13. Report signs of infection to physician, such as, foul odor, excessive drainage, and unusual appearance. 2. R3's electronic face sheet printed 10/20/20 showed R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's facility assessment dated [DATE] showed R3 has one stage 3 pressure ulcer that was not present upon admission to the facility. R3's care plan dated 7/8/20 showed, Resident is at risk for infection and increased pain related to pressure ulcer on coccyx. Notify physician of any need to change treatment or worsening to wound bed. Perform weekly skin check and measure wound. Assess wound bed and surrounding skin. R3's wound assessment dated [DATE] showed, Observed Stage 2 pressure ulcer on 5/27/20, measuring 1.0cmx0.6cmx0.2cm. R3's weekly skin check dated 6/9/20 and 9/22/20 signed by V6 (registered nurse) showed, Skin clear; no open areas, bruises, skin tears, reddened areas, etc. R3's wound care assessment dated [DATE] showed, Stage 3 coccyx wound measuring 1.2cmx0.9cmx0.3cm. (increase in area and depth from 6/24/20 assessment) R3's nursing progress notes dated 7/6/20 showed, Communication to physician requesting new treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R3's wound assessment dated [DATE] showed, Stage 3 coccyx wound measuring 1.8cmx1.3cmx0.3cm. (increase in area and depth from 7/1/20 assessment). No call was placed to R3's physician requesting new treatment orders. R3's wound assessment dated [DATE] showed, Stage 3 coccyx wound measuring 2.1cmx1.4cmx0.2cm (increase in area from 7/15/20 assessment). No call was placed to R3's physician requesting new treatment orders until 7/27/20. New orders were received from R3's physician on 8/3/20. R3's wound assessment dated [DATE] showed, Stage 3 coccyx wound measuring 1.8cm x1.0cm unable to determine depth. Undermining (widening of the wound base) now present at 12:00 with a depth of 2.3cm. (worsening of the wound compared to 8/12/20 assessment and no new orders since 8/3/20). R3's wound assessment dated [DATE] showed, Stage 3 coccyx wound measuring 2.6cm x1.2cm x2.1cm. Undermining present at 12:00 with a depth of 2.1cm. (increase in area and depth from 8/19/20 assessment). New orders were not requested from R3's physician until 9/6/20 when a request was made to send R3 to local wound care clinic for evaluation due to R3's wound not responding to treatment. Order was not received until 9/15/20 to send R3 to the wound care clinic for evaluation. R3's wound assessment dated [DATE] showed, Stage 3 coccyx wound measuring 2.9cmx1.7cmx2.0cm. Undermining not present. R3's wound care clinic visit note dated 9/17/20 showed, Sacral ulcer stage 3 with black grey bases noted down to bone some undermining noted .Initial wound encounter measurements are 2.5cm length x 1cm width x 0.5cm depth, with an area of 2.5sq cm and a volume of 1.25cubic cm. Undermining has been noted at 11:00 and ends at 3:00 with a maximum distance of 2.5cm. There is a moderate amount of purulent drainage noted which has a mild odor. R3's wound care orders received by the facility on 9/17/20 showed, Cleanse area on coccyx with cytotoxic cleanser. Apply enzymatic [MEDICATION(S)] agent to wound bed. Butter enzymatic [MEDICATION(S)] agent onto ¼'' plain packing and pack into undermining from 11-3, and pack into wound. Cover and secure with foam dressing. This dressing to be changed daily. R3's treatment administration record dated 9/17/20 showed, Cleanse area on coccyx with cytotoxic cleanser, apply enzymatic [MEDICATION(S)] agent to wound bed and cover with dry dressing daily. R3's orders received by the facility from the wound care clinic on 9/17/20 were not initiated until 9/25/20. On 10/14/20 at 11:00AM, V21 (Licensed Practical Nurse) stated, (R3)'s wound started out as a small slit and just got worse. It's really advanced now. I think (V2-Director of Nursing) is the wound care nurse but I'm not sure. I just do the dressing changes like I'm supposed to. On 10/22/20 at 1:10PM, V2 stated, (R3) has an area on her coccyx, it was never reported to me or charted that her wound had progressed down to her bone. She goes to the wound clinic now because we weren't able to get the wound to respond to our treatments. R3's wound assessments dated 5/27/20 thru 9/30/20 showed V2 evaluated R3's wounds.

Based on observation, interview, and record review the facility failed to ensure the facility abuse policies and procedures were implemented by the administrator (abuse coordinator) after the physical abuse of R1. These failures resulted in the facility not recognizing R1's incident of 4/6/19 as physical abuse, and not recognizing that V5 (Certified Nurse Assistant) neglected to protect R1 from physical abuse. The facility did not notify R1's physician, family, medical director, or law enforement of the physical abuse. The Immediate Jeopardy started on (MONTH) 6, 2019 at approximately 9:00 PM, when the facility's video surveillance recorded V8 CNA (Certified Nursing Assistant) physically restraining R1 to a wheelchair for 20 minutes as R1 struggled to get up and stand. V8 repeatedly and forcibly made R1 sit in the wheelchair and wrapped his arm around the front of R1's neck to subdue her. On (MONTH) 19, 2019 at 1:30 PM, V1 Administrator was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on (MONTH) 25, 2019 at 3:00 PM. While the immediacy was removed, the facility still remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This has the potential to effect all facility residents. The findings include: The Facility Data Sheet dated (MONTH) 12, 2019 shows there were 97 residents in the facility. R1 is a [AGE] year old female admitted to the facility's dementia unit on (MONTH) 5, 2019 at 1:50 PM from home. R1's face sheet shows [DIAGNOSES REDACTED]. R1's Brief Interview for Mental Status (BIMS) dated (MONTH) 14, 2019 shows a score of 99 which indicates R1 was unable to complete the interview (cognitively impaired). Review of the video recording from (MONTH) 6, 2019 (day after admission) captured the incident with R1. During the 20 minute recording, V8 (Certified Nursing Assistant) physically restrained R1's arms behind her back, and restricted R1's movement forcing her to remain seated in the wheelchair. V8 tipped R1 backwards in the wheelchair; R1 landed on the floor with her head on V8's lap. V5 (CNA) was present watching V8 interact with R1 without intervening to protect R1. The facility's assignment schedules for (MONTH) 6-7, 2019 show V8 was the only CNA assigned to the dementia unit from 11:00 PM-3:00 AM on (MONTH) 6, 2019 (following the event) and the only CNA assigned to the unit from 11:00 PM-7:00 AM on (MONTH) 7, 2019. Time card reports from (MONTH) 6, 2019 show V8 worked from 2:38 PM until 7:24 AM on (MONTH) 7, 2019 and on (MONTH) 7, 2019 from 2:45 PM until 7:32 AM on (MONTH) 8, 2019. V5's time card shows V5 continued to work on (MONTH) 12, 13 and 15, 2019. The facility's record of warning showed V5 was disciplined on (MONTH) 22, 2019 (16 days after the incident) for failing to follow the facility's abuse prevention and reporting policies. The facility's record of warning shows V8 was discharged from employment on (MONTH) 22, 2019 for physically containing a resident causing multiple bruises to the resident (16 days after the incident). On (MONTH) 12, 2019 at 10:15 AM, V1 Administrator said (in regards to incident of (MONTH) 6, 2019), V8 made a bad decision and held her down. V8 said she did not notify law enforcement of the event because It's not as if he punched her. On (MONTH) 19, 2019 at 1:35 PM, V1 was notified of a plan to remove immediacy and V1 said What does immediacy mean?V1 said she would have a plan when someone explains what it is to me. On (MONTH) 12, 2019 at 8:35 AM, V2 DON (Director of Nursing) said abuse inadvertently occurred. I don't think V8 sought to cause her (R1) harm. On (MONTH) 12, 2019 at 2:40 PM, V7 (R1's physician) said the facility notified him R1 tipped back in her wheelchair (R1 is ambulatory) and fell on to a CNA. V7 said he was not notified there was an abuse investigation regarding R1. R1's Physician Fax Communication form dated (MONTH) 9, 2019 showed the facility notified V7 that R1 was in a wheelchair which was tipped backward onto a CNAs lap and it was being considered a fall. The time stamp on the fax communication form actually showed (MONTH) 10, 2019 at 9:54 AM as the time the fax was sent (a day after the videotaped incident was reviewed by Administration). R1's Physician Fax Communication form dated (MONTH) 9, 2019 showed the facility informed V7 of bruising on both arms, chest, neck and nose via fax and not by phone. This fax communication has a time stamp that showed the fax was actually sent (MONTH) 12, 2019 at 2:25 PM. The facility received acknowledgement back from V7 on (MONTH) 12, 2019 at 4:36 PM. V7did not assess R1's bruising until after this surveyor notified him of the extent of the injuries and video evidence of what really occurred on (MONTH) 6, 2019. R1's physician progress notes [REDACTED]. This note showed R1 has had no other trauma to explain the bruising (other than incident of (MONTH) 6, 2019). On (MONTH) 25, 2019 at 9:35 AM, V26 (Facility Medical Director) said V1 did not notify him of an abuse allegation. V26 said V7 unofficially mentioned it to me. I assumed that since they (the facility) did not say anything to me that it did not occur. On (MONTH) 19, 2019 at 2:30 PM, V22 (R1's spouse) said he was notified about a week ago that something happened between a CNA and his wife. I don't know if she was trying to get out or if a CNA grabbed her but she (R1) scratched him. V22 said he has not been notified of the investigation results. (The facility investigation was finalized on (MONTH) 17, 2019). On (MONTH) 25, 2019 at 8:30 AM, V22 said the facility notified him a CNA was fired after he held R1's hands down on the floor. They didn't give me any details or say the CNA abused my wife. They didn't give me much detail at all. I noticed she had bruises. On (MONTH) 25, 2019 at 12:30 PM, V1 said she is the facility's abuse coordinator. After viewing the video from (MONTH) 6, 2019 on (MONTH) 9, 2019, V1 was asked what she did and V1 responded I filed a report and sent it to public health. I had staff do skin assessments on the residents on the dementia care unit. If staff are found guilty of neglecting to report abuse and protecting the residents they need to be corrected, educated and / or disciplined. The facility's Abuse Prevention Program Policy dated (MONTH) (YEAR) showed employees of this facility who have been accused of abuse, neglect or mistreatment will be removed from resident contact immediately. Abuse is defined as any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident .The resident or resident's representative will be immediately informed of the occurrence of potential abuse, neglect or mistreatment and that an investigation is being conducted. Neglect means the failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, or mental anguish .The resident or resident's representative will be informed of the conclusions of the investigation . The facility shall also contact local law enforcement authorities if there is physical abuse involving physical injury inflicted on a resident by a staff member and when there is reasonable suspicion that a crime has been committed in the facilty by a person other than the resident . The facility's Nursing Home Administrator job description dated 2003 showed to ensure that all employees follow the facility's established policies and procedures. This job description shows the Administrator will inform the Medical Director of all suspected or known incidents of abuse. This also showed to make routine inspections of the facility to assure that established policies and procedures are being implemented. The Nursing Home Administrator must possess the ability to implement policies and procedures necessary for providing quality care and maintaining a sound operation. Through observation, interview, and record review on (MONTH) 25, 2019 at 3:00 PM surveyors confirmed the facility took the following actions to remove the immediacy of the situation: 1. All staff will be in-serviced on abuse, focusing on the identification of abuse, prevention, and reporting abuse provided by outside consultant. In-servicing began on (MONTH) 24, 2019 and will be ongoing until complete. As of (MONTH) 25, 2019, there was a plan to in-service the remaining 30 staff members. 2. The Administrator was in-serviced on abuse identification, prevention and reporting abuse by outside consultant. Completed on (MONTH) 19, 2019. 3. The facility implemented review of the video surveillance on a shift-by-shift basis until the staff in-services are complete. Then daily review of the video will be completed until regulatory compliance is restored. Then review of video surveillance will conducted at least weekly. 4. Social Services met with all residents on the dementia unit to assess emotional/psychological needs and care plan if applicable on (MONTH) 24, 2019. 5. The involved nurse and CNA have been suspended and assigned to another unit indefinitely. 6. The nurse and CNA will work with another nurse/CNA respectively for a probationary period during which supervisory staff will review/discuss with the nurse/CNA and their respective partner of any observations of care rendered and/or interaction with residents. 7. Supervisory staff on the routine basis will randomly conduct verbal testing with all staff regarding: types of abuse, how/when to intervene, when to report, and who to contact/report to.

Based on observation, interview, and record review the facility failed to ensure a resident (R1) on the dementia unit was not physically abused. The facility also neglected to intervene to keep a resident safe from abuse. These failures resulted in R1 being abused for over 20 minutes by V8 CNA (Certified Nursing Assistant) as V5 CNA looked on and did nothing. R1 sustained extensive bruising to the neck, nose, arms, chest and back after being held against her will and repeatedly abused by V8. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on (MONTH) 6, 2019 at approximately 8:17 PM when V8 forcibly removed R1 from the dementia unit vestibule. V8 continued to force R1 against her will into a wheelchair, down the hallway and making R1 sit at a table. R1 exhibited signs of distress such as kicking, hitting and attempting to resist V8's actions for approximately 20 minutes. On (MONTH) 19, 2019 at 1:30 PM, V1 Administrator was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on (MONTH) 25, 2019 at 3:00 PM. While the immediacy was removed, the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This applies to 1 of 5 residents (R1) reviewed for abuse in the sample of 5. The findings include: R1 is a [AGE] year old female admitted to the facility's dementia unit on (MONTH) 5, 2019 at 1:50 PM from home. R1's face sheet shows [DIAGNOSES REDACTED]. R1's Brief Interview for Mental Status (BIMS) dated (MONTH) 14, 2019 shows a score of 99 which indicates R1 was unable to complete the interview (cognitively impaired). Review of the video recording from (MONTH) 6, 2019 (day after admission) captured the incident as follows: At 8:16 PM, R1 was sitting in the vestibule at the dementia unit entrance. R1 flipped the light switch turning the hallway lights off. At 8:17 PM, V8 CNA (Certified Nursing Assistant) walked behind R1 and attempted to lift the resident and her four wheeled seated walker as the resident was sitting in it. R1 resisted, pushing her feet on the ground and leaning into V8. V8 put R1 into a choke hold-put his left arm around R1's neck and his right arm under her right arm extending it backwards. V8 then released the choke hold and grabbed R1 by both wrists and pulled them behind her back. At 8:18 PM, V5 CNA brought a wheelchair as R1 continued struggling with V8. At 8:19 PM, V8 took R1 by the right arm (as R1 attempted to back away). R1 stood up and V5 stepped in to assist R1 from the left side and R1 is forcibly sat into the wheelchair. R1's feet kicked up from the force of being sat in wheelchair. R1 continued to struggle against V8. V8 placed R1 in a choke hold with his left arm across her chest. V8 then grabbed R1's arms from behind and placed his arms in front of hers and held onto the arms of the chair, restricting her arm movement. During this struggle, R1's eyeglasses were knocked to the floor. V8 attempts to push R1 down the hallway in the wheelchair. R1 put both feet down and V8 then tilted the wheelchair on its back two wheels (R1's feet are now off the floor) and R1 is kicking both feet. R1 threw her arm back to strike V8 and V8 lost control of the wheelchair causing V8 to fall to the floor on his knees. R1 and the wheelchair landed on top of V8. R1 continued to strike at and struggle with V8. V5 steadied the wheelchair and V8 was able to stand up. At 8:20 PM, V8 put his hands firmly on R1's shoulders as she grabs at V8's hands. R1 could be seen grimacing and pulling at V8's hands as they exit the camera view in the hallway. In the dining room area, V8 pushes R1 in the wheelchair on the back two wheels. R1's feet are off the ground, hands reaching back towards V8. R1 was kicking. At 8:21 PM, V8 attempted to place R1 in a choke hold from behind. R1 fought against V8. R1 and V8's hands are locked and pressing on R1's face. V8 pushed R1 and the chair into the dining table. R1 attempted to turn around toward V8 and V8 reclined the wheelchair again restricting R1's movement. V8 put the front wheels of the chair on the ground. R1 grabbed the table and attempted to push it away from her. V8 then restrained R1 from behind by placing his arms on the chair armrests in front of her arms. At 8:22 PM, R1 attempted to wiggle her arms loose and V8 grabbed R1's left arm and extended it back behind her. V8 continued to stand behind R1 restraining her arms until 8:24 PM. At 8:24 PM, R1 strikes at V8. V8 grabs both of R1's arms at the bicep area and locked his arms and crouches, pulling R1 back in the chair with his weight. At 8:25 PM, V8 locked the brakes of the wheelchair and remained behind her. Ay 8:26 PM, V8 placed his right foot on the cross bar of the wheelchair from behind holding R1 and the chair against the table. At 8:29 PM, R1 pushed the table away and leaned forward attempting to stand and V8 tilted the wheelchair and forced R1 back into the wheelchair with his right hand. V8 reached his arm across R1's chest placing her into another hold from behind, keeping the wheelchair in a tilted position. R1 was kicking her legs and trying to free her hands. At 8:30 PM, V8 changed his position of restraint and placed his hands on the arm of the wheelchair again restraining R1's arm movements. At 8:37 PM, R1 stood up. V8 grabbed R1 firmly by the shoulders and pushed her back into the wheelchair. R1 attempted to stand again. V8 grabbed her hips and pulled R1 back down into the wheelchair. At 8:38 PM, R1 stood again. V8 unsuccessfully attempted to use his right hand to sit her down. V8 then grabbed R1's hips and forced her down into the wheelchair. R1 swung her right arm back towards V8. V8 placed R1 in a hold again. V8 used his right arm to push down on R1's neck forcing her head toward the chest while he held her right arm behind her head. At 8:39 PM, V8 pulled the wheelchair away from the table allowing R1 to stand. V8 then pushed the wheelchair back into her knees, bear hugged her from behind and forced her down into the wheelchair. R1 was wiggling side to side and kicking her feet. At 8:41 PM, V8 walked away from R1. R1 stood and ambulated out of view of the camera with her rolling walker. During the time the video captured, V5 can be seen looking on, taking a drink, assisting other residents and not intervening in any way to stop the abuse. On (MONTH) 12, 2019 at 9:30 AM, R1 had a dark colored bruise to the bridge of her nose and a circular dark bruise to the left side of her neck. There were at least six areas of yellow bruising across the top of R1's upper back. Both of R1's posterior upper arms had large dark purple bruises as well as the underside of R1's arms. There were numerous (at least six) separate bruised areas yellow/green in color across R1's upper chest. Both of R1's lower arms and wrists had various colored bruises. On (MONTH) 12, 2019 at 9:35 AM, R1 was asked how she got the bruising and replied I had a check up with a doctor, an assistant. He grabbed at ya. I think he was a young guy who didn't know much about what he was doing. On (MONTH) 12, 2019 at 8:20 AM, V1 Administrator said she became aware of the bruising on R1 the morning of (MONTH) 9, 2019. V1 said V11 CNA reported the bruising to V4 Dementia Unit Director. The video showed V8 restraining R1 with his arms behind her back and restraining her with his arms. The more R1 tried to scratch and claw, the more V8 held R1 down. R1 was turning the lights on and off. V8 persisted against R1's will. The nurse assigned to the dementia unit that evening was on another unit at the time of the incident. At 9:35 AM, V1 Administrator said I didn't see any reason why R1 had to be moved from the vestibule area on (MONTH) 6, 2019. The door was secure. R1 would have been safe even if she exited the wing door. In discussing the video footage of the (MONTH) 6, 2019 incident, V1 said, R1 was resisting being moved from inside the vestibule. R1 was struggling and fighting down the hallway. V8 had the wheelchair tilted on two wheels which is not safe. I don't think it's the resident's fault the wheelchair fell backwards. V8 did not allow R1 to do as she pleased. V8's foot was behind the wheelchair preventing R1 from getting up. V8 used force to keep R1 seated. The acceptable thing to do would be to supervise her. She was safe. At 10:20 AM, V14 RN (Registered Nurse) said if abuse is suspected you should call the Administrator right away and remove the employee from working and send them home. This removes the suspected cause of harm from the residents and protects them. I would consider it physical abuse if a resident was physically restrained to the point of bruising. At 10:25 AM, V9 RN said she was responsible for the dementia unit the evening of (MONTH) 6, 2019. V9 said on (MONTH) 6, 2019 around ,[DATE]:15 PM, she was told by V5 that V8 was being rough with R1. I had my coat on and was headed toward the door when she told me. At 10:42 AM, V10 CNA said if a resident is combative you should walk away, notify the nurse, and reapproach later. I would not force a resident to do something; it may cause them to lash out, punch or scratch you. It's never okay to physically restrain a combative resident. That's how you cause behaviors. If a resident was restrained to the point of causing bruising, I'd consider it abuse. At 2:12 PM, V2 DON (Director of Nursing) said R1's bruising could be explained by the actions from the video on (MONTH) 6, 2019. V5 CNA said on (MONTH) 6, 2019, R1 was between the double doors on the dementia unit and kept turning the lights off. V8 asked her to stop doing it, which she did for a short time. R1 started turning the lights out again and that's when everything started. V8 should have left R1 go after she was out from the double doors. V8 was aggressive with R1. V8 physically restrained R1. I told V9 about V8 putting his arm around R1's mouth and aggressive behavior toward R1. On (MONTH) 16, 2019 at 9:10 AM, V4 Dementia Unit Director said V8 didn't back off and leave R1 alone. V8 should have backed off right from the start. V8's actions would be considered abuse based on my knowledge and my teaching abuse here. The incident between V8 and R1 happened on (MONTH) 6, 2019 and we were not aware of it until (MONTH) 9, 2019. At 10:40 AM, V4 Dementia Unit Director said R1's extensive bruising could be explained by the actions of V8 recorded on the video on (MONTH) 6, 2019. When asked if V8 did anything wrong in the video, V4 said, V8 had R1's arms behind her back, put R1 in a wheelchair when she didn't want to be put there and tipped the wheelchair backwards. It looked like V8 used force and restrained her. This is not appropriate and normally causes a resident to be more upset.V8 should have backed off. V8 was making R1 do what he wanted not what R1 wanted. By continuing this R1 got more upset, combative and was striking out. At 9:00 AM, V11 CNA said she noticed bruising on R1's arms the night shift of (MONTH) 8, 2019. The bruising looked like hand and finger prints to both arms. I have never seen so much bruising on anyone. I knew something happened. I thought, who did this? Who could have done this? I asked R1 how she got the bruises and she said she didn't know. I asked if someone grabbed her and she said she didn't know. I asked if someone hit her and she said she didn't know. At 11:19 AM, V1 Administrator said (while viewing the video and asked to describe V8's actions)) I believe that's where the other CNA said, he was choking her out. At 12:52 PM, V1 was asked if there was additional video footage. V1 replied R1 and V8 went outside the building and there is no video from the outside. V1 said she has viewed the video a few times and it's just hard to watch. At 1:09 PM, V4 said based on the video and R1's bruises it was really inappropriate as we all know. V4 answered yes based on the seven kinds of abuse, this was abuse. At 1:18 PM, V4 said R1 wasn't hurting anybody. They should have backed off and given her some time and space. At 2:05 PM, V5 said I didn't attempt to intervene on R1's behalf to stop V8. It was wrong on my part. I was shocked by what was going on. V8 should have just let her go. V8 had his arm around R1's mouth. At 3:25 PM, V1 Administrator said some of the bruises found on R1 looked like hand prints and fingerprints. At 12:30 PM, V6 CNA said I helped the nurse do the skin check on R1 when she was admitted . There wasn't any bruises. On (MONTH) 9, 2019 at 2:00 AM, R1 was up and walking on the unit. I tried to give her a shower. R1 took her top off in the shower room and I saw all the bruises on her. I don't know if it was the look on my face but R1 refused the shower. R1 had bruises to the neck, chest, bridge of her nose, back, back of her arms and shoulders. I thought, What the hell, Who body slammed her? She didn't have those bruises on (MONTH) 5th. There were finger type bruising on her arm. I thought, Why is there a spot on her neck? Is that from someone's thumb? I was upset. R1 had a change in behavior since (MONTH) 5, 2019. On (MONTH) 5th, R1 was bossy and now (on (MONTH) 9, 2019) R1 is scared and anxious. R1's admission skin assessment dated (MONTH) 5, 2019 shows there were no issues. R1's skin assessment dated (MONTH) 9, 2019 shows at least 29 bruised /reddened areas to her arms, wrists, hands, chest, neck, nose and thigh. This assessment does not include at least six bruises noted to her back on (MONTH) 12, 2019. The facility's final investigative report into this event showed the events of [DATE] and the actions of V8 have been substantiated as a factor in the subsequent development of bruises to the resident. V8 chose to physically redirect the resident (R1) away from the exit door; this resulted in an observable escalation in the resident's (R1's) agitation including swinging her arms, striking out, etc. R1's physician progress notes [REDACTED]. This note showed R1 has had no other trauma (other than incident of (MONTH) 6, 2019). R1's care plan started (MONTH) 11, 2019 showed R1 is at risk for abuse/neglect. If/when R1 exhibits physical/verbal behaviors, provide her with a safe/secure environment and walk away until she calms down (monitor from a distance). The facility's Abuse Prevention Program dated (MONTH) (YEAR) shows abuse means any physical or mental injury inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. This assumes that all instances of abuse of residents, even those in a coma, cause physical harm or pain or mental anguish. Through observation, interview, and record review on (MONTH) 25, 2019 at 3:00 PM surveyors confirmed the facility took the following actions to remove the immediacy of the situation: 1. All staff will be in-serviced on abuse, focusing on the identification of abuse, prevention, and reporting abuse provided by outside consultant. In-servicing began on (MONTH) 24, 2019 and will be ongoing until complete. As of (MONTH) 25, 2019, there was a plan to in-service the remaining 30 staff members. 2. The Administrator was in-serviced on abuse identification, prevention, and reporting abuse by outside consultant. Completed on (MONTH) 19, 2019. 3. The facility implemented review of the video surveillance on a shift-by-shift basis until the staff in-services are complete. Then daily review of the video will be completed until regulatory compliance is restored. Then review of video surveillance will be conducted at least weekly. 4. Social Services met with all residents on the dementia unit to assess emotional/psychological needs and care plan if applicable on (MONTH) 24, 2019. 5. The involved nurse and CNA have been suspended and assigned to another unit indefinitely. 6. The nurse and CNA will work with another nurse/CNA respectively for a probationary period during which supervisory staff will review/discuss with the nurse/CNA and their respective partner of any observations of care rendered and/or interaction with residents. 7. Supervisory staff on a routine basis will randomly conduct verbal testing with all staff regarding: types of abuse, how/when to intervene, when to report, and who to contact/report to after in-servicing is complete.

Based on observation, interview, and record review, the facility failed to ensure residents were protected from a CNA (Certified Nursing Assistant- V8) after an allegation of abuse was reported to the nurse in charge. This resulted in V8 continuing to work 10 more hours on the dementia unit and another 16 hours the next day on the dementia unit after witnessed aggressive behavior towards a resident was reported. Twelve of these hours, V8 was the only CNA assigned to provide care on the unit. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy started on (MONTH) 6, 2019 at approximately 9:00 PM, when V5 CNA reported to V9 RN (Registered Nurse) that V8 was being abusive to R1. V9 left the facility without assessing R1 or removing V8 from resident care. On (MONTH) 19, 2019 at 1:30 PM, V1 Administrator was informed of the Immediate Jeopardy. The Immediate Jeopardy was removed on (MONTH) 25, 2019 at 3:00 PM. While the immediacy was removed, the facility remains out of compliance at a level two. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementation. This has the potential to effect all 13 residents on the dementia care unit. The findings include: R1's face sheet shows she is [AGE] years old, and admitted to the facility's dementia unit on (MONTH) 5, 2019 at 1:50 PM from home. R1's face sheet shows [DIAGNOSES REDACTED]. R1's Brief Interview for Mental Status (BIMS) dated (MONTH) 14, 2019 shows a score of 99 which indicates R1 was unable to complete the interview (cognitively impaired). Review of the facility video recording (MONTH) 6, 2019 (day after admission) captured the incident as follows: At 8:16 PM, R1 was sitting in the vestibule at the dementia unit entrance. R1 flipped the light switch turning the hallway lights off. At 8:17 PM, V8 CNA (Certified Nursing Assistant) walked behind R1 while she was sitting on the seat of her four wheeled walker. V8 attempted to lift R1and the walker to move her. R1 pushed her feet on the ground and leaned into V8. V8 put his left arm around R1's neck and his right arm under her right arm, extending her arm backwards. V8 then released R1's neck, and grabbed R1 by both wrists and pulled them behind her back. At 8:18 PM, V5 CNA brought a wheelchair as R1 continued struggling to get away from V8. At 8:19 PM, V8 took R1 by the right arm (as R1 attempted to back away on her walker). R1 stood up and V5 stepped in to assist R1 from the left side and forcibly sat R1 into the wheelchair. R1's feet kicked up from the force of being sat in wheelchair. R1 continued to struggle against V8. V8 placed his arm around the front of R1's neck and placed his left arm across her chest, pulling her back towards him. V8 then grabbed R1's arms from behind and placed his arms in front of hers and held onto the arms of the chair, restricting her arm movement. During this struggle, R1's eyeglasses were knocked to the floor. V8 attempted to push R1 down the hallway in the wheelchair. R1 put both feet down and V8 then tilted the wheelchair on its back two wheels, raising R1's feet off the floor. R1 was kicking both feet and threw her arm back to strike V8. V8 lost control of the wheelchair causing V8 to fall to the floor on his knees. R1 fell backwards in the wheelchair, landing on her back and V8's legs. R1 continued to strike at and struggle with V8. V5 steadied the wheelchair and V8 pushed the wheelchair up from the floor. At 8:20 PM, V8 had his hands on the back of R1's neck and shoulders. R1 was grimacing and grabbing at V8's hand while he was pushing her down the hall, towards the dining room. V8 continued to tip R1 back in her wheelchair, and her feet were raised off the ground, and kicking in the air. At 8:21 PM, R1 reached for V8, and V8 attempted to hold R1 by placing his arm around her chest. R1 fought against V8. R1 and V8's hands were locked and pressing on R1's face. V8 pushed R1 and the chair into the dining table, moving the table away from R1. R1 attempted to turn around towards V8, and V8 reclined the wheelchair again restricting R1's movement. V8 put the front wheels of the chair on the ground, and R1 grabbed the table and attempted to push it away from her. V8 then restrained R1 from behind by placing his arms on the chair armrests in front of her arms. At 8:22 PM, R1 attempted to wiggle her arms loose and V8 grabbed R1's left arm and extended it back behind her. V8 continued to stand behind R1 restraining her arms until 8:24 PM. At 8:24 PM, R1 reached back with her arm towards V8. V8 grabbed both of R1's arms at the bicep area, locked his arms, crouched back, pulling R1 back in the chair with his weight. At 8:25 PM, V8 locked the brakes of the wheelchair, and put his right foot on the cross bar of the wheelchair, holding R1 against the table. At 8:29 PM, R1 pushed the table away and leaned forward attempting to stand and V8 tilted her wheelchair back. V8 forced R1 back into the wheelchair with his right hand. V8 reached his arm across R1's chest holding her towards him from behind, keeping the wheelchair in a tilted position. R1 was kicking her legs and trying to free her hands. At 8:30 PM, V8 changed his position and placed his hands on the arm of the wheelchair, restraining R1's arm movements. At 8:37 PM, R1 stood up. V8 grabbed R1 firmly by the shoulders and pushed her back into the wheelchair. R1 attempted to stand again and V8 grabbed her hips and pulled R1 back down into the wheelchair. At 8:38 PM, R1 stood again. V8 unsuccessfully attempted to use his right hand to sit her down. V8 then grabbed R1's hips and forced her down into the wheelchair. R1 swung her right arm back towards V8. V8 used his right arm to push down on R1's neck forcing her head toward her chest while he held her right arm behind her head. At 8:39 PM, V8 pulled the wheelchair away from the table allowing R1 to stand. V8 then pushed the wheelchair back into R1's knees, placed both arms around R1 from behind and forced her down into the wheelchair. R1 was wiggling side to side and kicking her feet. At 8:41 PM, V8 walked away from R1. R1 stood and ambulated out of view of the camera with her rolling walker. During the time the video captured, (from beginning to end), V5 can be seen looking on, taking a drink, assisting other residents, and not intervening in any way to stop the abuse. On (MONTH) 12, 2019 at 9:30 AM, R1 had a dark colored bruise to the bridge of her nose and a circular dark bruise to the left side of her neck. There were at least six areas of yellow bruising across the top of R1's upper back. Both of R1's posterior upper arms had large dark purple bruises as well as the underside of R1's arms. There were numerous (at least six) separate bruised areas yellow/green in color across R1's upper chest. Both of R1's lower arms and wrists had various colored bruises. On (MONTH) 12, 2019, (untimed) V5 said that on (MONTH) 6, 2019, V9 nurse was not on the dementia unit when V5 witnessed V8 being abusive to R1. When V9 returned to the unit, V5 said she told V9 about R1 falling in the wheelchair and V8 putting his arm around R1's mouth. V5 said she told V9 after the event happened, I think someone should call V1 Administrator and V9 responded, Oh my god, I don't know what to do. And then V9 left. On (MONTH) 18, 2019 at 10:45 AM, V5 said if abuse is witnessed she should call V1 immediately and remove the resident from the abusive situation and keep them safe. I should have made sure R1 was safe. I told V12 RN about the incident (MONTH) 7, 2019. V12's written statement dated (MONTH) 9, 2019 shows V5 told V12 on (MONTH) 7, 2019 (the day after the event) at the beginning of their shift (2:45PM-11:00 PM) about abuse involving V8 and R1. V5 told V12 the fall in the wheelchair was not reported and R1 was not assessed. V15 CNAs undated written interview shows that V5 told V15 on (MONTH) 7, 2019 about what occurred between V8 and R1 on (MONTH) 6, 2019. On (MONTH) 12, 2019 at 10:25 AM, V9 said she was the nurse assigned to the dementia unit the evening of (MONTH) 6, 2019. V9 said V5 did tell her (that same night) she thought V8 was rough with R1. V9 said she had her coat on and was headed toward the door when she was notified. V9 said she did not assess R1, did not remove V8 from resident care or tell the oncoming nurse. V9 said she left the building. On (MONTH) 16, 2019 at 3:25 PM, V1 Administrator said it's important to (suspend) the accused abuser to protect the resident and other residents from harm. Staff should make sure the resident is safe. On (MONTH) 16, 2019 at 2:57 PM, V2 DON reviewed the assignment schedules for (MONTH) 6 and 7, 2019. V2 said V8 worked as the only CNA on the dementia unit from 11:00 PM until 3:00 AM on (MONTH) 6, (YEAR). V8 also worked as the only CNA on the dementia unit from 11:00 PM until 7:00 AM on (MONTH) 7, 2019. The facility's assignment schedules for (MONTH) ,[DATE], 2019 show V8 was the only CNA assigned to the dementia unit from 11:00 PM-3:00 AM on (MONTH) 6, 2019 and the only CNA assigned to the unit from 11:00 PM-7:00 AM on (MONTH) 7, 2019. Time card reports from (MONTH) 6, 2019 show V8 worked from 2:38 PM until 7:24 AM on (MONTH) 7, 2019 and on (MONTH) 7, 2019 from 2:45 PM until 7:32 AM on (MONTH) 8, 2019. Through observation, interview, and record review on (MONTH) 25, 2019 at 3:00 PM surveyors confirmed the facility took the following actions to remove the immediacy of the situation: 1. All staff will be in-serviced on abuse, focusing on the identification of abuse, prevention, and reporting abuse provided by outside consultant. In-servicing began on (MONTH) 24, 2019 and will be ongoing until complete. As of (MONTH) 25, 2019, there was a plan to in-service the remaining 30 staff members. 2. The Administrator was in-serviced on abuse identification, prevention and reporting abuse by outside consultant. Completed on (MONTH) 19, 2019. 3. The facility implemented review of the video surveillance on a shift-by-shift basis until the staff in-services are complete. Then daily review of the video will be completed until regulatory compliance is restored. Then review of video surveillance will be conducted at least weekly. 4. Social Services met with all residents on the dementia unit to assess emotional/psychological needs and care plan if applicable. 5. The involved nurse and CNA have been suspended and assigned to another unit indefinitely. 6. The nurse and CNA will work with another nurse/CNA respectively for a probationary period during which supervisory staff will review/discuss with the nurse/CNA and their respective partner of any observations of care rendered and/or interaction with residents. 7. Supervisory staff on the routine basis will randomly conduct verbal testing with all staff regarding: types of abuse, how/when to intervene, when to report, and who to contact/report to.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a resident to resident altercation. The facility failed to lower a resident's bed prior to exiting the room for a resident with a history of falling out of bed. The facility failed to ensure a resident at high risk for falls had interventions in place and failed to review and revise interventions after each fall. This failure resulted in R92 being pushed by another resident, sustaining a right [MEDICAL CONDITION] that required surgical repair and an extensive hospitalization . This applies to 3 of 21 residents (R16, R18, R92) reviewed for safety and supervision in the sample of 21. 1. R92's face sheet shows she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R92's Minimum Data Set (MDS) assessment of 9/25/18 shows she is cognitively impaired, has behaviors that significantly disrupt care or living environment, and wandering that significantly intrudes on the privacy or activities of others. The MDS shows R92 requires assist of one staff member for transfers and has a history of falls. On 12/11/18 at 9:28 AM, R92 was sitting in a wheel chair in the hallway outside of her room. A wedge pillow was in between R92's legs. Other than stating her name, R92 was not able to be interviewed. At 11:51 PM, V30 (R92's family member) said R92 had a recent fall in which she was pushed down by another resident. V30 said R92 was in the hospital for several days due to having surgery for [REDACTED]. R92's fall report of 11/6/18 shows she was pushed by another resident resulting in a fall. R92 was last observed by staff ambulating in the hallway. The report shows R92's right lower extremity was externally rotated and R92's pain scale was determined to be a 10 out of 10 due to R92 screaming and facial grimacing. R92 was sent to the emergency room for evaluation. The 11/15/18 notes from the local hospital show R92 sustained a right femoral neck fracture ([MEDICAL CONDITION]) and was status [REDACTED]. The notes show R92 developed a fever due to aspiration pneumonia post surgery. R92's progress notes show she was sent to the hospital for evaluation on 11/6/18 and returned to the facility on [DATE]. On 12/11/18 at 1:46 PM, V1 Administrator said R23 was the resident who pushed R92 down on 11/6/18. Progress notes of 11/6/18 show Witnessed by staff. Pushed to floor by another resident .Right lower extremity externally rotated, pain indicated at 10 out of 10 due to screaming and facial grimacing. On 12/13/18 at 11:11 AM, V16 ( Environmental Services) said she witnessed R92's fall. V16 said R23 was walking towards the resident rooms and R92 was following R23. V16 said R92 tried to reach out for R23. R23 turned around and pushed R92. V16 said the incident occurred by the entrance to the dining room. V16 said the Nurses were not in the dining room at the time of the incident and a CNA (Certified Nursing Assistant) was behind the Nurse's desk. V16 said no staff were walking with R92 or R23 at the time of the incident. V16 said R23 can be aggressive. She get's agitated and she paces a lot. You can see the agitation in her face. V16 said V11 (Licensed Practical Nurse-LPN) and V12 (Registered Nurse-RN) were working the unit on 11/6/18 when the incident happened. On 12/12/18 at 2:31 PM, V6 (Social Service Assistant Director) said R23 has had behaviors of hitting at staff and other residents. On 12/13/18 at 12:53 PM V11 (RN /dementia unit director) said R23 does not like people touching her. R92 went up and grabbed R23's arm. V11 said she did not see the incident because she was in the Nurse's room doing paperwork. On 12/13/18 01:00 PM, V12 LPN said when the incident happened he was in another resident's room doing a treatment and he did not see the incident occur. V12 said R92 has a habit of reaching out to people. R23 does not like to be touched and has a history of pushing other residents and staff. V12 said with R23 you have to be very careful not to invade her personal space. V12 said he came out of the resident's room when he heard a commotion and saw R92 on the floor. V12 said when you have a resident that is aggressive you have to keep a close eye on them. On 12/13/18 at 1:14 PM, V14 CNA said she was working the shift R23 pushed R92 down. V14 said she did not witness the incident. I was in the dining room. I just saw (R92) laying on the floor after it happened. (R23) has a history of pushing other residents. If we see another resident walking in the hall when (R23) is there we keep an eye on them. I don't think (R23) likes to be touched. V14 said some residents will walk up to (R23) and try to talk to her but she does not like that. V14 said R92 used to be a CNA and she likes to reach out to other residents like she is helping them. V14 said when a resident has behaviors of hitting and pushing you need to keep a closer eye on them for their safety and for the safety of other residents. On 12/13/18 at 12:13 PM, V5 (Care Plan Nurse) said after one of R92's previous falls on 6/25/18, the intervention put in place was for staff to stand by and assist with transfers. V5 said R92 should have been a stand by assist since that time. R92's falls care plan shows on 10/02/18 an intervention of Use assist of one and a gait belt when ambulating or transferring resident was initiated. R23's Progress notes from 9/7/18 through the present were reviewed showing multiple incidents of agitation, aggression and resident to resident altercations. On 12/13/18 at 2:21 PM, V2 (Director of Nursing-DON) said she could not find a policy and procedure addressing supervision of residents with behaviors. V2 said she would look to see if she could find a policy and procedure regarding protecting other residents when a resident has behaviors. V2 said the only place that the facility has any policy and procedure addressing resident safety is in their Abuse Prevention Program Facility Policy which shows VI. Protection of Residents. The facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. On 12/14/18 08:19 AM, V2 (DON) said one assist with ambulation means a CNA or a Nurse should be walking with the resident. V2 said when R92 was on the dementia unit (the unit the incident occurred on) she was a one assist. V2 said R92's falls care plan says assist of one and a gait belt when ambulating or transferring resident. They should have had a gait belt on her whenever she was walking or transferring. Staff should have hands on gait belt to help keep her steady. No staff was walking with (R92) when she was pushed. V2 said if someone had been walking with R92 they could have possibly intervened or redirected her to prevent the incident. 2. R16's face sheet shows he was admitted to the facility with [DIAGNOSES REDACTED]. R16's Minimum Data Set (MDS) assessment of 9/11/18 shows he has severe cognitive impairment, can move to and from lying position, turn side to side, and position body while in bed. The MDS shows R16 has requires assistance of one staff member for transfers and walking in room. The MDS also shows R16 has had falls prior to the 9/11/18 assessment. On 12/122/18 at 9:44 AM, V12 (Licensed Practical Nurse-LPN) was performing a dressing change to the pressure injury on R16's left great toe. V12 raised the height of R16's bed to a high position-(approximately 3 foot 4 inches off of the ground) to do the treatment. Between 9:44 AM and 10:09 AM, V12 left the room two times in order to get supplies. Both times V12 left R16's bed in the higher position when V12 exited the room. 12/12/18 at 10:11 AM, V12 LPN said he should not have left R16's bed in the higher position when he left the room in case R16 tried to self transfer or get out of bed because he could fall. On 12/13/18 at 9:06 AM, V19 LPN said the resident's bed should be lowered because they could fall and if the bed is lowered it would not be as far. On 12/13/18 at 9:13 AM, V17 LPN said the resident's bed should be lowered for the resident's safety prior to leaving the wound for supplies. On 12/13/18 at 9:11 AM, V18 Certified Nursing Assistant (CNA) said it is not acceptable to leave the resident's room when the bed is in the high position. The bed should be lowered to the normal level just above the knees before leaving the room to get supplies. The list of R16's falls provided by V5 (Care Plan Nurse) on 12/13/18 shows R16 has a history of falling out of bed. The list shows R16 rolled out of bed on 3/25/16, slipped off side of bed on 3/31/18, was found sitting on the floor with his back against the night stand on 3/24/18, slid out of bed on 7/27/18 and fell out of bed on 11/18/18. On 12/13/18 at 12:18 PM, V5 said R16 had fallen out of bed reaching for a urinal on 11/18/18. he slid out of bed in (MONTH) 27, (YEAR). he slid off the side of the bed on 3/31/18 and he rolled out of bed on 3/25/16. V5 stated, For a resident who has had multiple falls out of bed I would not expect staff to walk out of the resident's room to get supplies with the resident's bed in the high position. Adding, (R16's) care plan shows keep the bed in the lowest position with the brakes locked. R16's falls care plan with a revision date of 7/11/18 shows Keep bed in lowest position with brakes locked. On 12/12/18 a policy and procedure was requested regarding keeping the resident's bed in the low position after providing care. On 12/13/18 at 3:08 PM, V2 DON said the facility did not have a policy and procedure that addresses bed height expectations when leaving the resident's room. V2 said the expectation is that staff will lower the residents bed to around knee high. 3. R18 is an [AGE] year old male resident with [DIAGNOSES REDACTED]. R18's MDS (minimum data set) dated (MONTH) 12, (YEAR) shows he has moderately impaired cognitive skills for daily decision making, needs extensive assistance with transferring, and is dependent on staff for dressing, hygiene and bathing, R18 was observed on (MONTH) 11 thru 13- (YEAR) wearing plain white socks when out of bed. R18 was not observed with shoes or non-skid socks. R18's fall intervention dated (MONTH) 22, (YEAR), shows to provide proper, well-maintained footwear. On (MONTH) 12, (YEAR) at 2:15 PM, R18 was assisted to a standing position from his reclining high back wheel chair by V27 RN (Registered Nurse) and V 28 CNA (certified nursing assistant). There was no sensor pad alarm or non-slip pad (Disomic) underneath him. R18's fall care plan dated (MONTH) 27, (YEAR) shows to use a non-slip pad (Disomic) in R18's reclining high back chair (Broda). The intervention dated (MONTH) 25, (YEAR) shows to use a non-slip pad in R18's high back wheel chair (Geri-chair). The intervention dated (MONTH) 10, (YEAR) shows to equip the resident with a device that monitors rising. Pad sensor alarm in place for reclining high back chair. R18's fall risk assessments dated (MONTH) 7, (MONTH) 5, and (MONTH) 6, (YEAR) show a high fall risk. R18's fall care plan has no new interventions since (MONTH) (YEAR). R18's fall reports show R18 had falls on (MONTH) 26, (MONTH) 6, (MONTH) 20, (MONTH) 2, (MONTH) 15, (MONTH) 18 and (MONTH) 11, (YEAR). Each of these 7 falls were from R18 self-transferring/ambulating. The facility's Fall Policy dated (MONTH) (YEAR) shows if a fall occurs, identify the cause of the fall and update the care plan to reflect appropriate interventions. On (MONTH) 13, (YEAR) at 9:28 AM, V5 Care Plan Nurse said I try to review falls once every one to two weeks when I'm in the office. During a month, I work on care plans 3-4 days per month, if it's a good month. I do the care plans for nursing. There should be reviews or revisions of the care plan with each fall incident. The care plan should be used by staff to understand the residents' needs and preferences to care for the resident. Staff won't know what needs to be done to prevent the next fall if interventions are not updated.

Based on observation, interview, and record review, the facility failed to develop individualized interventions for a resident with dementia who exhibits aggressive behaviors. This failure resulted in the resident's aggressive behaviors continuing and causing major injury to another resident. This applies to 1 of 4 residents (R23) reviewed for behaviors in the sample of 21. The findings include: On (MONTH) 11, (YEAR) at 9:15 AM, R23 was ambulating throughout the dementia unit. R23 was seen going into other resident's rooms while the other residents were in the main area and sitting on their beds. R23 was not interviewable. On (MONTH) 12, (YEAR), at 1:15 PM, R23 was sitting in the hall area between the resident rooms and the main living area in a chair. R23 would get up from the chair and pace the halls with her hands on her hips while looking into each resident room and then go back and sit down in the chair. On (MONTH) 13, (YEAR), at 8:50 AM, R22, R29, and R41 were sitting at the dining table watching down the hallway at R23 who was pacing the halls. R22 said, There she goes again. See her down there. R29 said, There she is, she is the one who pushed me, she just keeps going up and down there just like that. R23's electronic medical record showed on (MONTH) 6, (YEAR), at 1:16 PM an event was added for R23 which showed R23 pushed another resident but did not include any detail into the incident other than being aggressive toward others. On (MONTH) 11, (YEAR), at 1:46 PM, V1 (Administrator) stated R92 was pushed down by R23 on (MONTH) 6, (YEAR). R92's electronic nursing progress notes showed on (MONTH) 6, (YEAR) at 1:16 PM, witnessed by staff pushed to floor by another resident. Nursing staff responded immediately to ensure safety and assess. Resident on floor on back. RLE (right lower extremity) externally rotated, pain indicated at 10/10 due to resident screaming and facial grimacing . R92's nursing progress note dated (MONTH) 6, (YEAR) at 1:36 PM showed R92 was taken to acute care hospital by ambulance. R92's inpatient progress note summary from the acute care hospital dated (MONTH) 15, (YEAR) showed, .femoral neck fracture Developed fever due to aspiration pneumonia .family is very involved in care and expressed patient is in intractable pain . R23's face sheet showed she was admitted to the facility on (MONTH) 7, (YEAR) with [DIAGNOSES REDACTED]. R23's MDS (Minimum Data Set, dated dated dated (MONTH) 16, (YEAR) showed R23 exhibiting physical behavioral symptoms directed toward others and verbal behavioral symptoms directed toward others. R23's electronic nursing progress notes showed aggressive behaviors and pacing up and down the halls started shortly after admission. R23's nursing progress note dated (MONTH) 8, (YEAR) showed R23 was pacing, running down the hall, hitting staff and at 7:30 AM slapped another resident on the shoulder. R23's nursing progress note dated (MONTH) 19, (YEAR) at 7:00 AM showed R23 pushed another resident causing the resident to fall backwards onto the floor. R23's nursing progress note dated (MONTH) 20, (YEAR) showed R23 reached out and gave another resident a slight push on her upper arms. R23's nursing progress note dated (MONTH) 22, (YEAR) showed R23 hit another resident in the arm. R23's nursing progress note dated (MONTH) 26, (YEAR) showed a certified nursing assistant heard something fall to the floor and then saw another resident losing their balance backwards with R23 standing in front of them. The same (MONTH) 26, (YEAR) note showed the other resident stated she pushed me. R23's nursing progress notes did not include an entry for (MONTH) 6, (YEAR) when the incident occurred with R92. R23's behavior monitoring record showed no entries for behaviors which occurred on (MONTH) 6, (YEAR). R23's complete current care plan provided by the facility on (MONTH) 12, (YEAR) did not include a care plan for resident behaviors. As of (MONTH) 14, (YEAR) at 10:00 AM R23's plan of care did not include an individualized, person centered behavior care plan. On (MONTH) 14, (YEAR) at 9:00 AM, V2 DON (Director of Nursing) said R23 was put on a new [MEDICAL CONDITION] medication on (MONTH) 7, (YEAR) in response to the incident that occurred on (MONTH) 6, (YEAR). V2 said the facility staff had talked about starting a different medication to try and curb some of the anger and aggression R23 was exhibiting. V2 said she did not know if they increased supervision for R23 after the incident on (MONTH) 6, (YEAR). Evidence was requested of increased supervision of R23 after she was witnessed pushing another resident to the floor and none was received. V2 said all of the documentation for 15 minute checks for R23 was provided. V2 said R23 has been on 15 minute checks on and off for months now. V2 said they received an order to send R23 out to an acute care psychiatric hospital on (MONTH) 20, (YEAR). V2 said she was not made aware of any other incidents with R23 when she pushed any other residents down to the floor. When this surveyor discussed the four previous incidents that occurred with V2 regarding R23 she was surprised to see there had been a previous incident that R23 pushed a resident to the floor. On (MONTH) 12, (YEAR), at 2:50 PM V13 (Activity Aide) said she works on the dementia unit Monday through Friday from 9:00 AM until 5:00 PM. V13 said R23 does not like other people to be up close to her and sometimes she will push people for no reason. V13 said R23 had knocked another resident over on to the floor before the incident with R92. V13 said if a new employee were to come onto the unit they can ask other people who work here information regarding how to take care of the residents and what the residents are like. V13 said the report sheet she uses does not include an area to say if a resident has behaviors and what the behaviors are. V13 said she was on the dementia unit at the time of the (MONTH) 6, (YEAR) incident. V13 said she was with a group of residents who were listening to someone play guitar in the main dining area when she heard R92 yelling behind her. V13 said R92 was laying on the floor and R23 went out to the hallway and was just looking in the dining area as they were checking on R92. V13 said R23 was not any different after the incident. V13 said before the incident R23 was in the hall wandering just as she has been now. V13 said staff have to keep an extra close eye on R23. On (MONTH) 13, (YEAR), at 1:14 PM, V14 CNA (Certified Nursing Assistant) said she was working the day R23 pushed R92 down. V14 said R23 has a history of pushing other residents. V14 said, I don't think (R23) likes to be touched. When a resident has behaviors of hitting and pushing you need to keep a closer eye on them for the safety of other residents and the resident with behaviors. On (MONTH) 13, (YEAR), at 2:31 PM, V6 (Social Service Assistant) stated R23 has had behaviors of hitting other residents. V6 said a care plan should have been developed with interventions to deter her behaviors of striking out at other residents. V6 said there was no care plan developed. V6 said staff do track behaviors and document in behavior book and at the end of the month she takes the sheets out and reviews them. V6 said if she needs to at that time she will make an additional note in the resident's progress notes about the behavior. On (MONTH) 13, (YEAR), 3:21 PM, V6 said when residents are having hitting or throwing behaviors they are put on 1:1 supervision. R23's electronic medical record showed no evidence of 1:1 supervision. V6 said she tried to get her into an acute psychiatric hospital on (MONTH) 20, (YEAR) when they received the order to send her but they were having trouble with payer source. V6 said we tried four other facilities also but no one would take her. R23's medical record showed no evidence of multiple attempts at placement into an acute psychiatric setting. V6 said she does not recall what other facilities she tried to call for placement. V6 said she has no notes showing what facilities she contacted. On (MONTH) 13, (YEAR) policies were requested regarding dementia care, resident behaviors, 15 minute checks, and 1:1 supervision and V2 stated the facility does not have a policy for these. The only document the facility could provide that addressed residents with aggressive behaviors was provided as an untitled binder that was referred to as a behavior tool. Upon review of the binder page 45 included the behavior Aggression with possible interventions to include, 1. Remove resident from area, 2. Remove other residents from area that may be causing situation, 3. Remove anything that causes excess noise levels, 4. Distract resident by singing/dancing .

Based on observation, interview and record review the facility failed to supervise a resident while she was on the toilet to prevent injury. This failure resulted in R2 standing up from the toilet, falling and fracturing her right distal femur. The facility also failed to ensure that CNAs report a resident fall to the nurse for further assessment in a timely manner. This applies to 2 of 3 residents (R2, R1) reviewed for falls with injury in a sample of 3. The findings include: 1. R2 ' s physician's order [REDACTED]. The Minimum Data Set of 1/16/14 shows that R2 scored a 9 (Moderately Impaired Cognition) on her Brief Interview for Mental Status (BIMS). This same document shows that R2 requires extensive assist of 1 staff for toilet use. R2 ' s Fall Risk Evaluation dated 1/27/14 shows that R2 scored a 16 (a score of 10 or higher is at risk). The facility document entitled Notification of Alleged Abuse of a Resident, dated 2/2/14 states, " (R2) was taken to the bathroom and (was) handed the call light cord. She is able to and does use the call light when she is done. She was found on the floor in the doorway of the bathroom and complained (of) pain to her right n (knee). She was able to move all extremities except (her) right knee. Transferred to the ER. (R2) returned with a [DIAGNOSES REDACTED]. " The Radiology Report dated 2/1/14 states, " There is a comminuted fracture through the distal femur in the supracondylar region with very mild posterior angulation and displacement of the major distal fracture fragments. " The Facility Investigation Report dated 2/2/14 states, " After interviewing staff and residents and review of the chart and MDS, we are able to conclude that the resident requires assistance with all transfers and ambulation and with cognitive limitations should not have been left unattended in the bathroom. She should have been provided the privacy she needed to eliminate herself but with staff nearby to assist her with transferring from the commode with gait belt use to her wheelchair or to ambulate to her bed and the fall could have been avoided. " The Nurse ' s Notes dated 2/1/14 state, " Resident taken to the bathroom, found on floor in bathroom 3 minutes later. Resident (mechanically lifted) on to the bed. Complains of pain 9 out of 10 in the right hip and knee, Unable to straighten right leg. Foot strength on right side weaker than on left side. " On 3/13/14 at 1:30 PM, E10 (CNA) stated, " (R2) was somewhat ambulatory. She would try to go to the bathroom but she wasn ' t successful, she couldn ' t do it alone. She was not good on the toilet. I think she believed she could do it herself. I caught her one time trying to go to the bathroom,that was it. I didn ' t trust her after that. " On 3/13/14 at 2:00 PM, E11 (CNA) stated, " (R2) is always a 1-2 assist (for transfers). Occasionally she would try to transfer herself to the toilet, but she couldn ' t do it. I didn ' t leave her alone. I didn ' t trust her. " R2 ' s care plan dated 1/28/13 states, " Resident at risk for falling related to cognitive deficit, use of psychotropic meds, weakness and limited mobility. Occasional incontinence and unaware of safety. " This document also states, " 4/22/13- lowered to the floor- no injury- left knee gave out. , 11/4/13- non-injury- getting out of bed without assistance., 12/25/13- fall without injuries. " This same document shows, " Assist of 1 or 2 staff with transfers and transfer belt and give resident verbal reminders not to ambulate/transfer without assistance. " 2. The physician's order [REDACTED]. The Facility Incident Investigation Form dated 3/4/14 states, " On the evening of Tuesday, March 4th, (E5-CNA) came to this writer to complain about one of her coworkers. (E5) said, ' and I know I should have said something before now, but last week or so (E6-CNA) was working A/B hall and I was on C/D hall. At about 9:45PM- I was at the nurse ' s station and she waved me toward her and said quietly, ' come here, I need your help. ' (E5) said she followed (E6) to room 236 and went in and saw (R1) on the floor next to her bed with her legs out in front of her. (E5) said (E6) asked for help to get (R1) back on the bed and (E5) did. (E5) said she asked (E6) what happened and (E6) said she didn ' t know. (E5) said that (R1) was soiled with BM and had a sheet under her but she does not know why. E5 said, ' I guess maybe she was trying to get her up by herself before she came to get me, I don ' t know. ' (E5) said she returned to her assignment and said she did not mention anything to the nurse because she was working the other hall and this was (E6 ' s) resident. (E5) said she felt guilty when realized this had not been reported to the nurse, she didn ' t know how to handle the matter since no one had been told about it. So she came to report what she understood to have been a fall, she did not know if the resident fell out of bed or not. " This same document then states, " Nursing Management spoke with (E6) asking her if she knew anything about a fall involving, (R1) recently? ' Well, the way I see it, she almost fell . Well she was all twisted up in the bed, her legs were on the side and her feet were off the bed and almost touching the floor. (R1) was holding on, I think she was trying to get up out of the bed. ' " This same document continues with, " Regarding the resident, it does not matter how she came to be on the floor, staff are trained at CNA class and on the job that any and every resident on the floor must be assessed by a nurse before getting them up from the floor. It is believed that she avoided reporting this to a nurse and furthermore was keeping the information from being reported. Considering the CT results I believe there was a fall. This means that (E6) is willing (to) withhold information about the resident ' s well-being and to lie to protect herself. (E5) is also wrong for not recognizing that this had not been reported and has voiced remorse and apologies for her part. " On 3/12/14 at 1:30 PM, E5 stated, " (E6) asked me to come help her. (R1) was on the floor, covered in BM. (E6) said she had fallen out of bed. I checked her for bleeding. Me and (E6) assisted her to bed with the (mechanical lift). I thought it had already been reported. (R1) was in pain. I think it was about Feb. 28th. Looking back on it now, the nurse wasn ' t there- something was not right. In some ways I think (E6) was trying to keep it a secret. She wasn ' t frantic. I don ' t know how long (R1) was on the floor. " On 3/12/14 at 2:15 PM, E6 stated, " (R1) was half off the bed- she had poop on her. I heard her- she always yells. Her legs were off the bed, touching the floor. The bed was in a low position and her legs were bent like she was trying to get up. I used the pads to pull her up- (E5) helped. She complained of pain at the time- but she complains of pain so much. " The facility policy entitled Accident and Incident Reporting and Investigation Policy and Procedure dated 6/10/13 states, " Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department head and/or a nurse on duty as soon as such accident/incident is discovered or when information of such accident/incident is learned. "

Based on Observation, Interview and Record Review the facility failed to identify pressure ulcers for R107 at a stage I before progressing to stage I. This failure resulted in R107 having two pressure ulcers that were not identified until 5/11/11 when they were at a stage III. R107 developed a pressure ulcer to her right heel that was not identified until 10/28/11 at a stage II. This applies to 1 of 6 residents (R107) reviewed for pressure ulcers in a sample of 24. The findings include: The Wound Care Skin Integrity Evaluation form for R107 dated 5/11/11 showed, "Page 1: Wound 1 - Right 5th toe (lateral).; Onset date - 5/11/11.; Assessment date - 5/11/11.; Exudate: Minimum.; Thickness: Full thickness.; Etiology - Pressure ulcer stage III.; Size - 0.40 x 0.40.; Depth - 0.2.; Push score - 4.; Tunneling - none.; Undermining - none.; Drainage consistency - serous.; Acquisition - facility acquired.; Wound bed - 100% beefy red granulation tissue.; Periwound - [MEDICAL CONDITION] phase [DIAGNOSES REDACTED]. Some tannish crusts. Painful.; Evaluation comments: Social services obtaining new shoes. Social Services to get new shoes." The Wound Care Skin Integrity Evaluation form for R107 dated 5/11/11 showed, "Page 2: Wound 2 - Right 4th toe (lateral).; Onset date - 5/9/11.; Assessment date - 5/11/11.; Exudate - minimal.; Thickness - Full thickness.; Etiology - Pressure ulcer stage III.; Tunneling - none.; Undermining - none.; Drainage consistency - serous.; Size - 1.20 x 0.50.; Depth - 0.2.; Acquisition - Facility acquired.; Wound bed - 100% beefy red granulation tissue noted.; Periwound - [MEDICAL CONDITION] phase [DIAGNOSES REDACTED]; slight [MEDICAL CONDITION]; painful.; Evaluation comments: Social service obtaining new shoes. Social services to get new shoes." The Podiatrist Note for R107 dated 5/23/11 showed, "We advise staff to regularly monitor shoewear, or pressure reducing devices and transfer appliances such as wheelchairs, for signs of wear and increased pressure to bony prominences." On 1/26/12 at 12:50 PM, E12 (Registered Nurse - RN) stated, "I know after that (Pressure ulcers to R107's toes on 5/11/11.) R107 got a bigger pair of shoes." E12 stated R107's shoes had caused the pressure ulcers to her toes. On 1/26/12 at 12:10 PM, E11 (Certified Nursing Assistant - CNA) stated, "We do skin checks every day to check for skin breakdown. Today R107 had a shower and we make sure her heels are clean and then let the wound nurse know so she can put a dressing on her right heel." The Wound Care Assessment form for R107 dated 10/28/11 showed, "Size - 4.8 x 5.1.; Depth - unable to determine.; Color - pink/white.; Progress - new.; Moved to pressure sheet." The Weekly Pressure Ulcer Healing Assessment for R107 showed, "10/28/11 - Stage II.; Size - 3.5 x 7.0 x 0.2.; Drainage - serosanguinous.; Drainage amount - scant.; Drainage color - red.; Ulcer margins - open edge.; Surrounding skin - minimal peripheral tissue [MEDICAL CONDITION].; Wound bed - 100% red.; Pain - "Only when it hits the air it stings." The Weekly Pressure Ulcer Healing Assessment for R107 dated 1/11/12 showed, "Stage II.; Size - 1.0 x 1.0 x 0.1 open area at 0900.; Undermining/Tunneling - none.; Drainage - serosanguinous.; Drainage amount - small.; Drainage color - red.; Ulcer margins - open edge.; Surrounding skin - hyper and hypo pigmentation.; Wound bed - peri wound with indurated scalp scab = 2.0 x 2.0 x unable to determine." The Nurse Practitioner Progress Note dated 1/12/12 for R107 showed, "Subjective: R107 was seen today for a nonhealing pressure ulcer to the right heel. The wound nurse and I assessed the heel.; Objective: It has a black eschar in the center. The outer edges are pink. It does look like the wound has enlarged. We have been treating this probably for a couple of months. There is slight odor to the wound. This morning the patient had a temperature of 99. She does state that it hurts, especially when it is touched.; Assessment and Plan: Unstagable pressure ulcer to right heel." The Wound Care/Skin Integrity Evaluation form dated 1/18/12 for R107 showed, "Onset date: 10/28/11.; Wound 1 - Right heel.; Thickness - Full thickness.; Etiology - Pressure - unstagable.; Exudate - moderate.; Size - 1.50 x 2.00.; Depth: Unable to determine.; Tunneling - none.; Undermining - none.; Drainage Consistency - Serosanguinous.; Acquisition - Facility acquired.; Wound bed: 100% Tan eschar.; Periwound: Slight [DIAGNOSES REDACTED] indurated.; Treatment intervention: Apply Santyl/[MEDICATION NAME] ointment to eschar. Cover with non-bordered foam dressing. Wrap with stretch gauze and secure with tape every day. On 1/25/12 at 1:30 PM, E7 (Licensed Practical Nurse - LPN/Wound Care Nurse) stated, "R107's right heel was identified as a blister. A blister is a stage II pressure ulcer. It was healing well and then indurated around the scab and had some drainage around the scab. Her right heel pressure ulcer is a stage II now." E7 was observed giving care to R107's right heel pressure ulcer. E7 removed R107's guaze dressing from R107's right heel. E7 put a mirror under R107's right heel to observe her pressure ulcer. R107 had pressure ulcer to her right heel (medial) that was purple in the center with a white-yellow area around the purple area that appeared to have some drainage. E7 was asked what the caused R107's right heel pressure ulcer? E7 stated, "R107 had a spell when she was unconscious in bed and was moving her feet on her bed and got a blister on her heel." The Nurse Practitioner's Progress Notes dated 11/2/11 showed, "R107 was seen today for unresponsiveness. Staff reports when they tried to get her up this morning she was flaccid. They tried the use of a sit to stand lift. She could not bear weight. Did not open her eyes. Her vital signs have remained stable. She had some involuntary twitching of her bilateral upper extremities and her head. She does have a history of [MEDICAL CONDITION]." R107's Pressure Areas Care Plan dated 12/12/11 showed, "Updated on pressure: High risk for skin breakdown as evidence by pressure ulcer scale and some confusion. Occasional incontinence of the bladder.; 10/28/11 - Blister right heel.; Suspend heels when in bed. No shoe until right heel healed." The facility's Prevention of Decubitus Ulcers Policy and Procedure showed, "Philosophy - Recognizing that residents in long term care facilities have the potential to develop decubitus ulcers, the nursing center believes that this potential can be eradicated with proper preventative measures.; Recognizing the Signs and Symptoms of a Pressure Sore: Usually, the first signs of a bedsore forming on the resident's skin are; heat, reddened areas, tenderness, a feeling of burning at the site and discomfort.; Check the resident's skin condition daily for signs or symptoms of skin irritation or breakdowns.; Use skin protection devices as ordered.; Stages of Decubitus Ulcers: Stage I - A persistent area of skin redness that does not disappear within 30 minutes when pressure is relieved.; Stage 2 - A partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater.; Stage 3 - A full thickness is lost, exposing the subcutaneous tissue. Presents as a deep cavity with or without undermining adjacent tissue.; Stage 4 - A full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone." The facility's policy does not include definitions and/or descriptions of pressure ulcers that are unstagable or deep tissue injury. R107's Pain Care Plan dated 6/25/10 Showed, "Complains of intermittent pain to lower legs and arms. [DIAGNOSES REDACTED].; 10/20/11 - Continues to have pain and does not communicate pain.; Encourage change of position." R107's Care Plan dated 9/21/11 showed, "Resident prefers in room activities. Potential for social isolation.; Provide activity calendar in room and invite to activities daily. Provide and offer in room reading material. Respect residents rights and choices regarding activities." R107's Physician order [REDACTED].

Based on observation, interview and record review the facility failed to provide a full body sling for a resident (R4) for transfer. The facility failed to ensure the mechanical lift sling was properly positioned prior to transferring a resident. These failures contributed to R1 sliding out of the mechanical lift sling and striking her head on the floor. On 6/20/11, R1 was sent to a local hospital and was later sent to a trauma center for evaluation and treatment. R1 was diagnosed with [REDACTED]. This applies to 2 of 4 residents (R1, R4) reviewed for falls in the sample of 4. The findings include: 1. The facility incident report dated 6/20/11 at 12:45 PM for R1 documents, "R1 was in her room being transferred with a mechanical lift with the assist of 2 Certified Nursing Assistants, (CNA). A divided leg sling was used...... When R1 suddenly slipped through the bottom of the sling falling backward hitting her head on the floor. R1's legs remained held in place by the sling that was criss crossed in place as it should have been. If you picture a baby being born breech, that is what happened. R1 was assessed to have a laceration on the back of her head approx. 1 cm....At 12:50 PM, R1 was sent to the hospital emergency department....At 4:30 PM, the emergency department called and stated resident was being sent to (trauma hospital) with a [DIAGNOSES REDACTED]. On 6/27/11 at 10:50 AM, E4 (CNA) confirmed she assisted with the mechanical lift transfer for R1. E4 stated, "It all happened very suddenly. I had the leg straps of the sling hooked on the black strap and the top was hooked on the purple loops. It made too big of a hole and she fell right through it. I have always used the black loops to secure the sling." (The divided leg sling has 3 colored loops and a longer black strap at the end of the leg section of the sling.) On 6/27/11 at 12:40 PM, E3 (CNA) was asked how she determined what strap to use to secure the sling to the mechanical lift. E3 responded, "The smaller the person, the closer the strap should be to the person." On 6/27/11 at 1:35 PM, E2 (Restorative Therapy Nurse) stated, "I make the evaluation whether a resident should be transferred with a mechanical lift or not. I don't go any further than that as far as what type of sling should be used. I looked at the incident and R1 had slid through the opening in the split (divided leg) sling. R1 came all the way through and hit her head on the floor. The sling was still secured to the lift. The incident was probably a combination of two things, the sling had slipped up too high (on the resident's back) and the straps were too loose." A Medical Imaging Report dated 6/20/11 documents the CAT Scan results for R1 as "Subdural hematoma along the falx measuring 5 mm....Posterior scalp hematoma." The nutritional assessment dated [DATE] documents R1 is 62 inches tall, and weighs 140#. The care plan dated 9/29/10 states R1 is a mechanical lift transfer with 2 assists at all times into bed. The Owner's Operator and Maintenance Manual for Patient Slings, Invacare, Part No. 921, Section 5 - Using Divided Leg Slings, page 15, states, "For the Divided Leg Sling: The back of the sling should be parallel to the patient's upper arms and be positioned between the top of the patient's head and the base of the spine." The Manual/Electric Portable Patient Lift Owner's Installation and Operating Instructions, Invacare, Lifting the Patient, page 12, states "Warning: When elevated a few inches off the surface and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the swivel bar. If any of the attachments are not properly in place, lower the patient back onto the bed and correct this problem. Adjustments for safely and comfort should be made before moving the patient." 2. On 6/27/11 at 12:45 PM, E3 and E4 (Certified Nursing Assistants - CNA) were observed transferring R4 from the wheelchair to the resident's bed using a mechanical lift device. After the sling was removed from under the resident, E4 identified the type of sling as the split (divided leg) sling. The resident care plan posted on the door of the resident's bathroom states to use a "Full Body Sling" with the mechanical lift. On 6/27/11 at 12:40 PM, E3 (CNA) stated, "We always use a split (divided leg) sling for mechanical transfers unless therapy says they need a full body sling." On 6/27/11 at 12:50 PM, E4 (CNA) stated, "There must not have been enough full body slings, so they used a split (divided leg) sling." On 6/27/11 at 10:55 AM, the laundry storage in the clean utility room on the Redwood unit had no slings (either style) available. The Physical Therapy Evaluation dated 12/29/10 documents R4's [DIAGNOSES REDACTED]. The evaluation states R4 requires a full mechanical lift. On 6/27/11 at 1:45 PM, E2 (Restorative Nurse) stated the Physicial Therapy evaluation "Full Mechanical Lift" means to use the full body sling. The Nutritional Progress note dated 5/15/11 documents R4's weight as 217#. The facility's Total Lift Transfer Policy and Procedure states: Unless otherwise specified all residents will use the split leg sling. If a full body sling is to be used it will be noted on the face sheet of the care plan and a copy will be placed on the inside of the resident's bathroom door.