Every finding on record at Stevens Nursing and Rehabilitation Center of Halle

Based on observation, interview and record review, the facility failed to ensure residents received services in the facility, 1 of 4 residents (Resident #2), reviewed for reasonable accommodation. The facility failed to ensure the call light was within reach for Resident #2. This failure could place residents at risk of not being able to call for help as needed. Findings included: Record review of Resident #2's face sheet, dated 06/02/2026, revealed she was admitted [DATE], re-admitted on [DATE] and again on 5/22/2026 diagnoses included: spinal stenosis (narrowing of the space in the spine), encephalopathy (disturbance of brain function), and major depressive disorder (persistent depressed mood). Record review of Resident #2's MDS assessment, dated 5/13/2026, revealed the resident's BIMS score was 11, which indicated moderate cognitive impairment. Record review of Resident #2's care plan, dated 6/2/2026, revealed Resident #2 is at risk for falls d/t impaired balance, incontinence, psychotropic med use, amputation of toes and Be sure the resident's call light is within reach. During an observation on 6/2/2026 at 10:30 am -Resident #2's call light was wrapped around the head of the bed frame, out of sight and out of reach of the resident. During an interview on 6/2/2026 at 10:33 am - Resident #2 stated she could not reach the call light nor could she see it. During an observation and interview on 6/2/2026 at 3:30 pm the ADON observed the call light wrapped around the residents' bed frame and she stated it was out of the residents' sight and reach. She stated if the resident can't reach the call light, then she can't call for help, which may put the resident at risk. During an interview on 6/2/2026 at 3:33 pm LVN A stated the call light should be within residents reach so the resident could call for help. She stated it may impact the residents' care if the call light was not within reach. Record review of the facility's policy titled Call Lights: - Accessibility and Timely Response, dated 10/13/2022, indicated, Staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview, and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food and nutrition services. The facility failed to ensure dietary staff maintained proper hand hygiene during meal service. These failures could place residents at risk for food borne illness. Findings included: During an observation on 04/30/2026 at 11:54 a.m. Dietary Aide A was observed to assist with tray preparation for the secure unit. When the trays were ready to leave the kitchen on the meal cart Dietary Aide A was observed opening the kitchen door, picking up the phone on the kitchen wall, and paged out letting staff know the trays were ready for the secure unit. Dietary Aide then pushed the tray cart out into the dining room; after grabbing a chair from the dining room to hold the door up as he pushed the trays out Dietary Aide A was then observed to wipe his nose with his hand and returned to the kitchen and did not wash his hands before returning to the line and began assisting with prepping the trays for rest of the halls. While preparing the trays, Dietary Aide A was observed placing butter packets/drinks on the trays and grabbing plates that had been prepared placing on trays and placing the insulated lids on the plates. During an observation on 04/30/2026 at 12:02 p.m. Dietary Aide A while he continued to prepare trays was observed to scratch the side of his nose and did not wash his hands. During an interview on 04/30/2026 at 12:53 p.m. Dietary Aide A stated he was not aware he had wiped his nose, while he was holding the door of the kitchen after taking the secure unit trays out of the kitchen. Dietary Aide A further stated after he paged using the phone, opening the door, moving the chair to prop the door so he could get out of the kitchen with the meal he should have washed his hands when he came back in the kitchen due to it could cause cross contamination. Dietary Aide A stated someone could possibly get sick from cross contamination. During an interview on 04/30/2026 at 5:40 p.m. the Dietary Manager stated the Dietary Aide should have gone to the sink and washed his hands because from the dining room to the kitchen that was cross contamination. The Dietary Manager stated cross contamination could have occurred because he could have picked up germs from something he touched, and it could be passed on to the trays which could possibly make the residents sick. Record review of kitchen staff food handlers revealed all staff with their food handlers with Dietary Aide A having completed his 11/20/2025 with effective date of 11/20/2025 expiring 2 years after the effective date. Record review of facility's policy, Hand Washing, approved October 1, 2018, read, Policy: The facility recognized that food-borne illness has the potential to harm elderly and frail residents. All Nutrition and Foodservice employees will practice good hand-washing practices in order to minimize the risk of infection and food borne illness. Procedure: 2. Hands should be washed after the following occurrences: c. Touching the hair, face, or body. k. Touching un-sanitized equipment, work surfaces. Record review of facility's policy, Employee Sanitation, approved date October 1, 2018, read Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness. Procedure: 5. Hand washing a. Employees must wash their hands and exposed portions of their arms at designated hand-washing facilities at the following times: i. After touching bare human body parts other than clean hands and clean, exposed portions of arms. v. During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. vii. After engaging in other activities that contaminate the hands.

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained that were complete and accurately documented for 1 of 8 residents (Resident #8) reviewed for clinical records. The facility failed to ensure Resident #8's diagnosis of major depression was updated in the residents medical record. This deficient practices could result in errors in care and treatment. The findings were: Record review of Resident #8's face sheet, dated 05/01/2026, revealed a 90-years-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included dementia (loss of memory and thinking ability), muscle wasting and atrophy (loss of skeletal muscle mass), and type 2 diabetes mellitus (a condition where the body has trouble regulating blood sugar levels, leading to persistently high blood glucose levels). Record review of Resident #8's significant change in status MDS assessment, dated 04/14/2026, revealed the resident's BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment and was receiving antidepressant in Section N (Medications). Record review of Resident #8's comprehensive care plan, dated 04/19/2026, revealed the resident had the care plan of [Resident #8] uses psychotropic medications Citalopram and Rexulti for Anxiety. For intervention - Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every-shift. Record review of Resident #8's physician order, start dated 01/07/2026, revealed the resident had the order of Citalopram Hydrobromide Oral Tablet 10 MG (Citalopram Hydrobromide) Give 2 tablet by mouth one time [NAME] for Depression related to Major Depressive Disorder, Recurrent, Moderate. Give 2 tabletsto equal 20mg. Record review of Resident #8's Psychiatric Periodic Evaluation, dated 01/07/2026, revealed Resident #8's psychiatric doctor gave the diagnosis of Major depressive disorder to the resident and started Citalopram Hydrobromide for the major depression. Record review of Resident #8's medical record from 04/23/2025 to 05/01/2026 revealed there was no diagnosis of Major depression disorder in the resident's medical record. Interview on 05/01/2026 at 11:00 a.m., the DON said Resident #8 received her Citalopram Hydrobromide for major depression disorder, and the facility nurses should have updated the diagnosis into the resident's medical record when it was changed and added, and inaccurate medical record might affect incorrect care to the resident, and the facility did not have a policy regarding medical record accuracy, but medical records should be accurate and reflect the resident's current status.

Based on observation, interview and record review the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 of 8 residents (Residents #57) reviewed for food and nutrition services. The facility failed to ensure foods stored in Resident #57's personal refrigerator were labeled and dated. The failure could place residents at risk for food borne illness. The findings include:Record review of Resident #57's face sheet, dated 05/01/2026, revealed a 92-years-old male who was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Resident #57 had diagnoses which included chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), muscle wasting and atrophy (loss of skeletal muscle mass), and Alzheimer's disease (progressive disease that destroy memories and other important mental functions). Record review of Resident #57's quarterly MDS assessment, dated 01/21/2026, revealed the resident's BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment and required Partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand, chair to bed, and toilet transfer. Record review of Resident #57's comprehensive care plan, dated 04/27/2026, revealed the resident had the care plan of [Resident #57] has potential nutritional problem and is at risk for complications related to history of weight loss. Risk for malnutrition related to impaired cognition and Poor appetite, refuses some meals. Diet: Regular diet Regular texture,Regular Liquids. For intervention - Offer substitute if dislikes meal served and provide and serve diet as ordered. Observation on 04/28/2026 at 11:51 a.m. revealed there was a personal refrigerator in the room, and inside the refrigerator there was food wrapped in plastic wrap for food, but no date and no label on the wrap. Interview on 04/28/2026 at 12:39 p.m., LVN-B stated the food inside Resident #57's refrigerator was bread, and the resident's family might bring the food, but the food did not have any label and date. LVN-B said she did not know how long the food was inside the refrigerator because there was no label and date, and the nurse said the facility night nurses had the responsibility regarding checking it every day to prevent possible food-born illness. Interview on 04/30/2026 at 5:18 p.m., the DON stated the facility nurses were responsible for overseeing Resident #57's personal refrigerator and also responsible for monitoring it daily and should have dated and labeled to the food that the family member brought. The DON stated the resident might have food illness. Record review of the facility's policy, titled Use and Storage of Food Brought in by Family or Visitors, dated 01/27/2023, revealed . 2. All food items that are already prepared by the family or visitors brought in must be labeled with content and dated.

Based on interview and record review the facility failed to ensure any irregularities reported by the pharmacist to the attending physician, the facility's medical director , and the director of nursing were acted upon for 1 of 5 residents (Resident #35) reviewed for medications. The facility failed follow the facility's Pharmacy Consultant Recommendation for Resident #35's lipid panel (a blood test that measures the amount of fat molecules called lipid in the blood) order due to Simvastatin for high cholesterol. The resident's physician agreed with the recommendation on 04/06/2026. This failure could place residents at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition. The findings were: Record review of Resident #35's face sheet, dated 05/01/2026, revealed a 64-years-old female who was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Resident #35 had diagnoses which included pure hypercholesterolemia (lipid disorder in which low-density lipoprotein, or bed cholesterol, is too high), moderate intellectual disorder (a person has certain limitation in cognitive functions and skills including conceptual, social and practical skills, such as language, social, and self-care skills), and bipolar disorder (a mental health condition that causes extreme mood swings). Record review of Resident #35's annual MDS assessment, dated 04/16/2026, revealed the resident's BIMS score was 3 out of 15, which indicated the resident had severe cognitive impairment. Resident #35 had a diagnosis of hyperlipidemia (high cholesterol). Record review of Resident #35's comprehensive care plan, dated 11/04/2019, revealed the resident had the care plan of [Resident #35] has hypercholesterolemia. For intervention - Give medication for hypertension and document response to medication and any side effects, Give meds to control cholesterol level as ordered by the physician, and lab work to be done as ordered by physician. Record review of Resident #35's physician orders, dated 06/18/2025, revealed the resident had the order of Simvastatin Oral Tablet 40 MG (Simvastatin) - Give 1 tablet by mouth one time a day related to pure hypercholesterolemia. Record review of Resident #35's medication administration record from 04/01/2026 to 04/30/2026 revealed the resident was receiving her Simvastatin Oral Tablet 40 MG (Simvastatin) 1 tablet by mouth one time a day at 7:00 PM as ordered. Record review of Resident #35's Consultant Pharmacist/Physician Communication, dated 04/03/2026, revealed the facility pharmacist recommended [Resident #35] has an order for Simvastatin. Please consider a Lipid Panel. Further record review of the Consultant Pharmacist/Physician Communication revealed the resident's primary care physician agreed on 04/06/2026. Record review of Resident #35's medical record from 04/06/2026 to 05/01/2026 revealed there was no record regarding the facility conducted Resident #35's blood test for Lipid Panel. Interview on 05/01/2026 at 9:58 a.m., the ADON said Resident #35's pharmacist recommended a Lipid Panel on 04/03/2026, and the resident's physician agreed on 04/06/2026, but the facility did not conduct the resident's Lipid Panel because she forgot , and it was her mistake. Making sure the follow-ups regarding pharmacist and physician recommendations was ADON and DON's responsibility, and at this time there was no potential negative harm because the resident was taking Simvastatin every day as ordered and no complications about high cholesterol, such as heart attack or stokes. Interview on 05/01/2026 at 1:00 p.m., the DON said the facility should have conducted Resident #35's Lipid Panel because the pharmacist recommended it and the physician agreed. The DON stated she contacted the resident's physician and received the order for conducting the Lipid Panel on 05/20/2026, and the facility did not have the policy regarding follow-up to the pharmacist and physician recommendations.

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication room (main medication room) and 1 of 3 medication carts (100-hall nursing cart) reviewed and 1 of 1 Resident (Resident #20) reviewed for medication storage. 1. The facility failed to ensure an expired packet (total 15 tablets) of gas relief (simethicone 125 mg) was not stored inside the main medication room on 04/29/2026. The medication expired on 02/2025. 2. The facility failed to ensure an expired bottle of cream compound (Ketamine 10%, Diclofenac 5%, and Gabapentin 6% cream) was not stored inside the 100-hall nursing cart on 04/29/2026. The medication expired on 02/11/2026. 3. The facility failed to ensure the blood pressure instructions on Resident #20's blister packet of Lisinopril, for high blood pressure, matched the resident's primary care physician order. These failures could place residents at risk of not receiving therapeutic doses of their medication. Findings include:1. Observation on 04/29/2026 at 4:17 p.m. revealed inside the main medication room, there was one packet (total 15 tablets) of Simethicone 125 mg for gas relief on the shelf, and the medication was expired 02/2025. Interview on 04/29/2026 at 4:19 p.m., the ADON stated there was one packet (total 15 tablets) of gas relief (simethicone 125 mg) inside the main medication room, and it was expired on 02/2025. The ADON said the facility nurse removed the medication from residents and put the medication on the shelf inside the main medication room, and it was wrong because the facility nurses should have discarded it to the discontinued medication box. The ADON stated facility nurses had responsibility regarding discarding all expired medications immediately to prevent possible use and adverse effects. 2. Observation on 04/29/2026 at 4:34 p.m. revealed inside 100-hall nursing cart, there was one bottle of cream compound, and the cream compound was made up with Ketamine 10%, Diclofenac 5%, and Gabapentin 6% cream, and the cream had the label, and the label said, Do not use beyond 02/11/2026. Interview on 04/29/2026 at 4:41 p.m., the ADON said there was one bottle of cream compound (Ketamine 10%, Diclofenac 5%, and Gabapentin 6% cream) inside the 100-hall nursing cart, and it expired on 02/11/2026. The ADON said this medication belonged to the resident who was already discharged from the facility, so all facility nurses should have discarded this medication to the discontinued medication box to prevent possible use and adverse effects. 3. Record review of Resident #20's face sheet, dated 05/01/2026, revealed an [AGE] year-old female who was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Resident #20 had diagnoses which included spinal stenosis (the narrowing of one or more spaces within the spinal canal), hypertension (high blood pressures), and dementia (loss of memory and thinking ability). Record review of Resident #20's quarterly MDS assessment, dated 03/30/2026, revealed the resident's BIMS score was 13 out of 15, which indicated the resident's cognition was intact. Resident #20 had hypertension (high blood pressures) as an active diagnosis. Record review of Resident #20's comprehensive care plan, dated 08/01/2025, revealed the resident had the care plan of [Resident #20] has altered cardiovascular status related to hypertension (high blood pressures). For intervention - Monitor vital signs. Notify physician of significant abnormalities. Record review of Resident #20's physician order, start dated 02/17/2026, revealed the resident had the order of Lisinopril Oral Tablet 20 MG (Lisinopril) Give 1 tablet by mouth one time a day related to essential (primary)hypertension and Hold for Blood Pressure less than 110. Record review of Resident #20's medication administration record, from 04/01/2026 to 04/30/2026, revealed the resident was receiving her Lisinopril Oral Tablet 20 MG (Lisinopril) 1 tablet by mouth one time a day for hypertension at 8:00 AM as ordered. Observation on 04/30/2026 at 8:38 a.m. revealed MA-C measured Resident #20's blood pressure before giving the resident's Lisinopril, and the resident's blood pressure was 149/73 and heart rate was 54 per minute (normal range for blood pressure was 120/80 and pulse was from 60 to 100 per minute). MA-C hold Resident #20's Lisinopril and notified the charge nurse because the label on the resident's Lisinopril blister packet indicated Hold if blood pressure was less than 110 or heart rate was less than 60 per minute. Interview on 04/30/2026 at 8:40 a.m., MA-C stated she held Resident #20's Lisinopril because the resident's heart rate was 54 per minutes, and the label on the medication blister packet said, Hold if blood pressure less than 110 or heart rate less than 60 and notified the charge nurse regarding holding the medication and the resident's heart rate. Further interview on 05/01/2026 at 10:31 a.m. with the MA-C said she knew Resident #20's physician order said, Hold if blood pressure less than 110, but the label on the medication blister packet said, Hold if blood pressure less than 110 or heart rate less than 60, but she followed the label, instead of following the physician order. MA-C stated she should have asked the difference between the physician order and the label on the blister packet to the charge nurse and followed the physician order, but she said she did not report it to the nurse because Resident #20's heart rates were usually more than 60 per minutes. Interview on 04/30/2026 at 11:11 a.m., LVN-D said she contacted Resident #20's primary care physician and reported regarding the difference between the physician order (hold Lisinopril if blood pressure less than 110) and label on the blister packet (hold Lisinopril if blood pressure less than 110 or heart rate less than 60), and the physician said the facility nurse and MA should hold Resident #20's Lisinopril if only the resident's blood pressure was less than 110, not heart rate. LVN-D said she gave Lisinopril to Resident #20 because the resident's blood pressure was more than 110 as ordered and contacted the pharmacy and said the label on the blister packet was incorrect. Interview on 04/30/2026 at 11:16 a.m. with the DON said if the facility nurse or MA already knew the difference between the physician order (hold Lisinopril if blood pressure less than 110) and label on the blister packet (hold Lisinopril if blood pressure less than 110 or heart rate less than 60), they should have asked the resident's primary care physician and pharmacy and should have tried to fix the inaccurate label to prevent confusion and the resident might not take the medication as ordered and should have returned or destroyed the items per the facility policy. Record review of the facility's policy, titled Medication Storage and Disposal - expiration dating and expired medications, revised 10/01/2019, revealed . 8. It is the responsibility of all nurses who administer medications to monitor the expiration dates of the medications. Expired medications will not be administered in the facility. All expired medications will be disposed of per facility policy.

Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 8 residents (Resident #57) reviewed for medication storage and labels. 1. The facility failed to ensure nurses put a normal saline 10 cc syringe in the cart, instead of leaving it unattended on the nightstand inside Resident #57's room. This failure could place residents at risk of not having medications as ordered due to diversion of medication and incorrect instructions. Findings include: 1. Record review of Resident #57's face sheet, dated 05/01/2026, revealed a 92-years-old male who was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Resident #57 had diagnoses which included chronic obstructive pulmonary disease (common lung disease causing restricted airflow and breathing problems), muscle wasting and atrophy (loss of skeletal muscle mass), and Alzheimer's disease (progressive disease that destroy memories and other important mental functions). Record review of Resident #57's quarterly MDS assessment, dated 01/21/2026, revealed the resident's BIMS score was 5 out of 15, which indicated the resident had severe cognitive impairment and required Partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) to sit to stand, chair to bed, and toilet transfer. Record review of Resident #57's comprehensive care plan, dated 01/26/2026, revealed the resident had the care plan of Needs structured environment in secure unit related to cognitive deficit for Alzheimer's disease. For intervention - Provide low stimulation environment. Observation on 04/28/2026 at 11:51 a.m. revealed there was one 10 cc syringe of normal saline on the nightstand inside Resident #57's room unattended. Interview on 04/28/2026 at 12:39 p.m., LVN-B said there was one 10 cc syringe of normal saline on the nightstand inside Resident #57's room unattended, and it was unacceptable because it should have been stored inside the nursing cart. LVN-B stated she did not know what reason the 10 cc normal saline syringe was on the nightstand inside the resident's room unattended, and the resident and other residents with Alzheimer's disease or dementia might eat it because they were confused. Interview on 04/30/20206 at 5:15 p.m., the DON said the facility nurse should have stored 10 cc normal syringe inside the nursing carts to prevent possible use from confused residents, and it was the facility nurses' responsibilities. Record review of the facility's policy, titled Medication Ordering, Receiving, and Storage, dated 05/01/2020, revealed . 3. If medication containers have missing, incomplete, improper or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 3 resident hallways (Hallway 100), and 1 of 1 kitchen reviewed for environmental concerns, in that: 1. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired 3 and 5 foot wall scrapes near bed-A and had removed dust and lint from the bathroom ceiling vent. 2. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a 3x3 inch bathroom door penetration and had repaired an unsecured bathroom wall vent. 3. There was a 4.5- foot piece of floor baseboard molding under the prep table on the right side of the main kitchen that was missing. 4. There was a 7.0- foot piece of floor baseboard molding behind the ice machine and juice bar on the left side of the main kitchen that was not attached to the wall. 5. There were 2 broken 1x1 ft floor tiles in the main kitchen area that were cracked. 6. There were 2 eight- foot florescent ceiling lights in the main kitchen area that did not have protective sleeve covers. 7. There were 4 three- foot florescent ceiling lights in the dry storage room that did not have protective sleeve covers. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. Findings included: 1. During observation rounds with the Maintenance Director and Administrator on 03/7/25 from 12:50 pm - 12:55 pm revealed the following: a. In room [ROOM NUMBER] on hallway 100 there were two wall scrapes near Bed-A with one scrape measuring 3 ft in length and the other measuring 5 foot in length. b. In room [ROOM NUMBER] on hallway 100 there was a bathroom ceiling vent that was covered with dust and lint. c. In room [ROOM NUMBER] on hallway 100 there was a 3x3 inch penetration on the bathroom door. d. In room [ROOM NUMBER] on hallway 100 there was a bathroom ceiling vent was not fully attached to the ceiling wall surface. 2. During observation rounds in the kitchen with the Administrator and Maintenance Director on 3/5/25 from 1:40 pm -2:00 pm the following was noted a. There was a 4.5- foot piece of floor baseboard molding under the prep table on the right side of the main kitchen that was missing. b. There was a 7.0-foot piece of floor baseboard molding behind the ice machine and juice bar on the left side of the main kitchen that was not attached to the wall. c. There were 2 broken 1x1 ft floor tiles in the main kitchen area that were cracked. d. There were 2 eight- foot florescent ceiling lights in the main kitchen area that did not have protective sleeve covers. e. There were 4 three- foot florescent ceiling lights in the dry storage room that did not have protective sleeve covers. During an interview with the Maintenance Director and Administrator on 3/7/25 at 1:00 pm the Maintenance Director stated that he makes monthly rounds on all of the resident rooms. He stated that staff communicate the need for repairs on the work order TELS system and he was not aware of the needed repairs in rooms [ROOM NUMBERS]. The Administrator stated that making the noted repairs would improve the homelike environment for the residents. The Maintenance Director further stated that he made monthly rounds in the kitchen and was aware of the noted areas needing repaired. The Maintenance Director stated the kitchen light bulbs without sleeves could allow glass spillage onto the kitchen floor if the ceiling light bulbs break. The Administrator stated that all of the noted areas needing repair in the kitchen could affect employee safety and general food preparation. Record review of the undated TELS weekly, bi-weekly, and monthly maintenance task form revealed that there was not a resident room inspection task listed, and there was not a kitchen inspection task listed.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. There was a paper bag containing personal food items from an unapproved source on a cart in the kitchen. 2. Cook A had facial hair and was not wearing a facial hair restraint while engaged in food preparation and service in the kitchen. 3. Cook B wore jewelry on her right wrist while engaged in food preparation and service in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 01/23/2023 at 11:20 AM in the kitchen next to the steam table revealed a white paper bag on a rolling cart. The bag was open and inside were a container of French fries and a wrapped sandwich. Next to the paper bag was a closed disposable cup filled with a beverage. During an interview on 01/23/2023 at 11:21 AM with Cook A he stated the bag containing the French fries and sandwich and disposable cup with the beverage were his personal food items and did not come from the facility's food supplier. Cook A further stated he forgot to store the bag in the proper place and it should not have been on a cart in the middle of the kitchen. Interview on 01/23/2023 at 11:22 AM with the DM revealed Cook A should not have had his personal food items in the kitchen. 2. Observation on 01/23/2023 at 11:22 AM in the kitchen revealed Cook A stood in front of the steam table using serving utensils to place food onto plates for the residents' noon meal. Cook A had facial hair on his upper lip approximately 1 in length and hair on is chin that was approximately 1 in length. Cook A was not wearing a facial hair restraint. During an interview on 01/23/2023 at 11:23 AM with Cook A he stated he knew he should have worn a facial hair restraint over his mustache and beard but, They didn't have any. During an interview on 01/23/2023 at 11:23 AM with the DM she stated Cook A could have used the type of hair net used to cover hair on one's head for his facial hair. The DM further stated that Cook A received training on employee sanitation upon his hire and she and the consultant RD conducted training on a monthly basis. 3. Observation on 01/23/2023 at 11:54 AM in the kitchen revealed Cook B wore a bracelet made of colored strings and beads on her right wrist. Cook B was standing in front of the steam table where food was being plated for the residents' noon meal. During an interview on 01/23/2023 at 11:54 AM with Cook B she stated the consultant RD told her it was okay to wear the bracelet in the kitchen. During an interview on 01/23/2023 at 1:05 PM with the consultant RD, he stated he never told Cook B she could wear a bracelet in the kitchen. The consultant RD further stated he conducted inservices frequently with the staff in the dietary department on employee hygiene. Record review of facility policy 03.002 Food Deliveries approved 10/01/2018 revealed, 1. All foods delivered will be from an approved source, which includes commercial vendors and grocery stores. Record review of facility policy 04.001 Employee Sanitation approved 10/01/2018 revealed, b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. f. No jewelry can be worn on the arms and hands while preparing food except for a single plain ring such as a wedding band. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-401.11, revealed, Eating, Drinking or Using Tobacco Products. (A) Except as specified in (B) of this section, an employee shall eat, drink, or use any form of tobacco products only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 2-303.11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

Based on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, for 4 of 10 residents (Residents #1, #7, #10, #34) reviewed for allegations of abuse, neglect, exploitation, and mistreatment, in that: 1. The Administrator, the DON and the Physical Therapy Director did not report to the state agency and or investigate Resident #34's Representative's allegations of mistreatment on 11/22/2023. 2. The Administrator and the DON did not report to the state agency and or investigate Resident #10's allegation of mistreatment on 12/05/2023. 3. The Administrator and the DON did not report to the state agency and or investigate Resident #1's allegation of neglect on 12/13/2023. 4. The Administrator and the DON did not report to the state agency and or investigate Resident #7's allegation of neglect on 12/18/2023. These failures could place residents at risk for abuse, neglect, exploitation, and/ or mistreatment. The findings included: 1. Record review of Resident #34's admission record dated 01/24/2024 revealed an admitted [DATE] with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #34's allegations of neglect and/or mistreatment for the allegations made on 11/21/2023 and 11/22/2023. A record review of the facility's in-service record, dated 11/22/2023, revealed 15 nursing staff were inserviced specifically for resident #34 for Topic: Resident #34; contents or summary of training session: When providing care for Resident #34 we should be mindful. staff should always communicate what they are doing when providing care. there must be two staff members when transferring resident #34 (gate belt or lift transfer). if resident is agitated allow him time to calm down. let the nurse know so she can assist with care if needed. all residents must be turned and repositioned every two hours. incontinent care should be given at this time During an interview on 01/23/24 at 02:48 PM Resident #34's Representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's Representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's Representative stated Resident #34 had a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on Sunday 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's Representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning 11/21/2023 and further reported to the Administrator and the DON with an email on 11/22/2023 at 12:33 PM. Resident #34's Representative stated the DON replied with an email, on 11/22/2023 at 12:47 PM, and stated she would look into the issues and in-service the staff. A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:33 PM sent to the DON and the Administrator, revealed, Sunday 11/19 at 7 pm (Resident #34) Room (***) (Resident #34) and the aide had a very rough time with just a one person transfer where he hit his femur area on his right leg with the wheelchair arm. This was not safe for her either as she was struggling to get (Resident #34) in position to transfer. (Resident #34) has osteoporosis and is susceptible to fractures easily. Please provide two people for his bed transfers for the safety of the aide and for (Resident #34). After she did finally get him in bed she didn't check his diaper. He had been changed at 4:30 pm before supper and was not changed then until 4:30 am. He went 12 hours without a diaper change and was not turned every two hours as he should have been for circulation and hygienic purposes. He didn't receive his breathing treatments as ordered on Sunday as well. He needs to receive his breathing treatments with assistance three times a day during waking hours. Sent from my (name brand cell phone). A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:47 PM sent by the DON and received by Resident #34's Representative and the administrator, revealed, Thanks, (Resident #34's Representative) I will look into these issues and inservice staff. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report allegations of abuse, neglect, and exploitation to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's Representative had reported to him, on the morning of Tuesday 11/21/2023, a review of the in-room camera footage on the evening of Sunday 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on Tuesday 11/21/2023, the Physical Therapy Director stated the meeting included the Social Worker, The DON and the Administrator. The Physical Therapy Director stated he had not documented a grievance report nor reported the allegation to the state agency since he reported the complaint to the Administrator. During an interview on 11/24/2024 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The DON stated she had received a complaint about Resident #34 on 11/22/2023 from Resident #34's representative and documented the complaint on a grievance report. The DON stated she had also provided additional training for the nursing staff regarding transfers and respiratory treatments. The DON stated she had not reported the allegations of neglect and or mistreatment to the state agency. The DON stated the Administrator was aware of the complaint regarding Resident #34. During an interview on 11/26/2023 at 04:30 PM the Administrator stated he could not recall the stand-up meeting on 11/21/2023 and/ or the complaint from Resident #34's Representative but could state if an allegation of mistreatment was identified it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The Administrator was asked if an allegation of a CNA was rough with a Resident during transfers, allegation a Resident did not receive medications, and/or an allegation of neglect to provide incontinent care or hygiene care became known to him would it rise to the level of reporting the allegation to the state agency, the Administrator stated it would depend on the details and circumstances. 2. Record review of Resident #10's admission record dated 01/24/2024 revealed an admitted [DATE] with diagnoses which included hypokalemia (a lower than normal potassium level in your bloodstream) and Gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). A record review of Resident #10's admission MDS assessment, dated 11/20/2023, revealed Resident #10 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 15 out of a possible 15 which indicated no cognition impairment. A record review of Resident #10's care plan dated 1/23/2024, revealed, Problem: (Resident #10) has a potential nutritional problem r/t new admission, recent hospital stay, Obesity, vascular disorder of intestine. Diet: Low Fat - Reg with no fried food and gravies diet Regular texture, Regular Liquids consistency, NAS---large protein portions at all meal Snacks BID (twice a day) .Revision on: 12/06/2023 .The resident will maintain adequate nutritional status as evidenced by maintaining weight, no s/sx of malnutrition, and consuming meals daily through review date A record review of Resident #10's grievance report dated 12/10/2023 revealed, (Resident #10) .12/05/2023 .name of person contacted: DON .nature of complaint: Staff concerned because CNA's slid a residents snack down the hall on the floor .date resolved .spoke to CNA involved - stated this will not happen again .signature of person resolving concern/grievance DON Further review revealed the Administrator signed the grievance form on 12/15/2023. A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #10's allegations of abuse and/or mistreatment for the allegations made on Resident #10's grievance report dated 12/10/2023. 3. Record review of Resident #1's admission record dated 01/26/2024 revealed an admitted [DATE] with diagnoses which included Gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). A record review of Resident #1's quarterly MDS assessment, dated 12/18/2023, revealed Resident #1 was a [AGE] year-old male admitted for long term care and was assessed with a BIMS score of 10 out of a possible 15 which indicated mild cognition impairment. A record review of Resident #1's care plan dated 1/23/2024, revealed, Problem: (Resident #1) has a potential for dehydration related to episodes of nausea and vomiting A record review of Resident #1's grievance report dated 12/13/2023 revealed, (Resident #1) .12/13/2023 .name of person contacted: DON .nature of complaint: it was reported to the social worker that the Resident threw up and it remained in his room for several hours before being cleaned up .date resolved 12/15/2023 .spoke to spoke to the nurse regarding this and how she should have taken care of this and how to deal with this in the future .signature of person resolving concern/grievance DON Further review revealed the Administrator signed the grievance form on 12/15/2023. A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #1's allegations of neglect for the allegations made on Resident #1's grievance report dated 12/13/2023.4 . Record review of Resident #7's admission record dated 01/24/2024 revealed an admitted [DATE] with diagnoses which included dysphagia (Difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage) and Gastro-esophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). 4. A record review of Resident #7's admission MDS assessment, dated 11/20/2023, revealed Resident #7 was a [AGE] year-old female admitted for long term care and was assessed with a BIMS score of 03 out of a possible 15 which indicated severe cognition impairment. A record review of Resident #7's care plan dated 1/23/2024, revealed, Problem: (Resident #7) is at risk for complications due to GERD and hx (history) of Gastrointestinal hemorrhage .The resident will remain free from discomfort, complications or s/symptoms (signs and symptoms) related to dx (diagnosis) of GERD through review date .Avoid lying down for at least 1 hour after eating. Keep HOB elevated. Encourage to stand/sit upright after meals A record review of Resident #7's grievance report dated 12/18/2023 revealed, (Resident #7) .12/18/2023 .name of person contacted: DON .nature of complaint: Resident was not up for breakfast per ST (Speech Therapist) .date resolved 12/19/2023 . this was discussed with (the physical therapist regional supervisor) plan was to have therapy assist with out of bed transfer if short handed .signature of person resolving concern/grievance DON Further review revealed the Administrator signed the grievance form on 12/19/2023. A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #7's allegations of neglect and/or mistreatment for the allegations made on Resident #7's grievance report dated 12/18/2023. A record review of the facility's Abuse, Neglect, and Exploitation policy dated 8/15/2022, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .'neglect' means failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . reporting response the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, . within required time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

Based on interviews, and record reviews the facility failed to ensure residents' rights to voice grievances to the facility or other agencies or entities that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal for 2 of 8 residents (Resident #34, and #56) reviewed for grievances, in that; 1. The facility failed to ensure the Physical Therapy Director initiated a grievance report on behalf of Resident #34's grievance on 11/21/2023. 2. The facility failed to ensure the Physical Therapy Director, The DON, and the Administrator initiated a grievance report on behalf of Resident #56's grievance on 11/17/2023. This failure could place residents at risk by denying their right to make and have grievances heard and contributed to ill feelings of not being heard and unresolved issues. The findings included: 1. Record review of Resident #34's admission record dated 01/24/2024 revealed an admitted [DATE] with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . During an interview on 01/23/24 at 02:48 PM Resident #34's representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's representative stated Resident #34 has a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning of 11/21/2023. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report complaints to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's representative had reported to him, on the morning of 11/21/2023, a review of the in-room camera footage on the evening of 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on 11/21/2023, the meeting included the Social Worker, The DON and the Administrator at a minimum. The Physical Therapy Director stated he had not documented a grievance report since he reported the complaint to the Administrator. During an interview on 11/24/2023 at 11:20 AM the ADON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation. During an interview on 11/24/2023 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation. During an interview on 11/24/2023 at 01:50 PM the Administrator stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation. A record review on 01/12/2024 of the facility's November 2023, December 2023, and January 2024's grievance records revealed no grievance report for Resident #34. 2. Record review of Resident #56's admission record dated 01/26/2024 revealed an admitted [DATE] with diagnoses which included Post Traumatic Stress Syndrome (PTSD a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #56's quarterly MDS assessment, dated 12/30/2023, revealed Resident #56 was an [AGE] year-old female admitted for long term care and assessed with a BIMS score of 12 out of a possible 15 which indicated moderate cognition impairment. A record review of Resident #56's care plan, dated 01/25/2024, revealed, Problem: (Resident #56) uses psychotropic medications .for PTSD, .Presents in angry mood at times, hard to re-direct .Revision on: 01/07/2024 .Problem: Discharge planning has been discussed with the resident/RP. Discharge to the community is not expected .Revision on: 07/03/2023 .Interventions: Assist resident with adjusting to the facility . Encourage family to visit as often as possible .Encourage resident to become involved in facility activities of choice, to attend resident council, and to socialize with others .Follow up as needed to see if there are changes to the discharge plan .Monitor resident for difficulty adjusting to the facility During a record review and interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report complaints to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy director stated on 11/17/2023 he began to report Residents' grievances by sending group text messages to the facility's Social Worker, the DON, and the Administrator because he felt the verbal reports were not addressed. The Physical Therapy Director stated residents would voice their grievances to him when he rounded on residents in the mornings. The Physical Therapy Director demonstrated his cell phone with the group text message on 11/17/2023 at 07:55 AM. The Physical Therapy Director stated Resident #56 had complained to him on Friday 11/17/2023 that she was upset at the care she received from a CNA and wanted to go home. The Physical Therapy Director stated no one responded to the group text message. Physical Therapy Director stated he did not document a grievance for Resident #56 because he believed he had met the requirement for reporting complaints by alerting the Administrator, the DON, and the Social Worker. During an interview on 11/24/2023 at 11:20 AM the ADON stated for a period in November and December 2023 the Physical Therapy Director had reported grievances on behalf of residents on group text messages to which she was included. The ADON could not recall the group text message on behalf of Resident #56 on 11/17/2023. The ADON stated she could not recall if she had documented a grievance report for Resident #56 complaint from 11/17/2023 and stated, if I didn't then I believed (Physical Therapy Director) would have. During an interview on 11/24/2023 at 01:38 PM the DON stated for a period in November and December 2023 the Physical Therapy Director had reported grievances on behalf of residents on group text messages to which she was included. The DON could not recall the group text message on behalf of Resident #56 on 11/17/2023. The DON stated she could not recall if she had documented a grievance report for Resident #56 complaint from 11/17/2023 and stated, I could have documented a grievance report for Resident #56 when I received the text message from (the Physical Therapy Director) .but I though he already had and was just alerting us (the group) of the complaint. The DON stated the risk for harm to residents who have not had their grievances heard and resolved could be diminished self-esteem. During an interview on 11/24/2023 at 01:50 PM the Administrator stated he had been receiving group text messages from the Physical Therapy Director in November and December 2023 as well as January 2024. The Administrator stated the Physical Therapy Director had received instructions to document grievance reports on behalf of residents when he received a complaint. The Administrator stated he believed the Physical Therapy Director was documenting grievance reports for all reported complains on the group text messages. The Administrator stated he was responsible for reviewing the grievance reports and had not recognized the Physical Therapy Director had not documented the grievance for Resident #56 complaint on 11/17/2023. The Administrator stated the grievance reports should be documented by the staff who received the grievance. A record review on 01/12/2024 of the facility's November 2023's grievance records revealed no grievance report for Resident #56's complaint on 11/17/2023. A record review of the facility's Resident and Family Grievances policy dated August 2022, revealed, It is the policy of this facility to support each resident and family members right to voice grievances without fear of discrimination or reprisal. Definition: prompt efforts to resolve. include facility acknowledgement of a complaint and or grievance and actively working towards resolution of that complaint and or grievance . Administrator has been designated as the grievance official . the grievance official is responsible for overseeing the grievance process; receiving tracking grievances through their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the Resident; and coordinating with state and federal agencies as necessary in light of specific allegations .grievances may be voiced in the following forms: verbal complaint to a staff member or grievance official . the staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form . forward the grievance form to the grievance official as soon as practicable. the grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form . all staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the grievance official. prompt efforts include acknowledgement of complaint and or grievances and actively working towards a resolution of that compliance and or grievance . the grievance official or designee will keep the resident appropriately apprised of progress towards the resolution of the grievances.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and establish policies and procedures to investigate any such allegations for 1 of 1 resident (Resident #34) reviewed for reporting and investigations of alleged abuse, neglect, exploitation, and mistreatment and 14 of 19 staff (RN C, RN D, RN E, LVN G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, the FSS and the AD) reviewed for employee misconduct registry screenings, in that: 1. The facility failed to screen, through the employee misconduct registry, 14 staff, which included; RN C, RN D, RN E, LVN G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, CNA O, the FSS and the AD. 2. The Administrator, the DON and the Physical Therapy Director did not report to the state agency and or investigate Resident #34's Representative's allegations of mistreatment on 11/22/2023. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The findings were: Record review of the staff roster provided on 01/23/2024 by the facility for RN C revealed a hire date of 01/09/2023. Record review of the personnel file for RN C revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for RN D revealed a hire date of 12/19/2022. Record review of the personnel file for RN D revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for RN E revealed a hire date of 04/05/2022. Record review of the personnel file for RN E revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for LVN G revealed a hire date of 10/29/2013. Record review of the personnel file for LVN G revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for CNA H revealed a hire date of 12/29/2017. Record review of the personnel file for CNA H revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA I revealed a hire date of 09/09/2022. Record review of the personnel file for CNA I revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA J revealed a hire date of 03/30/2016. Record review of the personnel file for CNA J revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA K revealed a hire date of 03/17/2022. Record review of the personnel file for CNA K revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA L revealed a hire date of 08/01/2003. Record review of the personnel file for CNA L revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/24/2024 after staff records were requested by surveyor on 01/24/2024. Record review of the staff roster provided on 01/23/2024 by the facility for CNA M revealed a hire date of 11/03/2022. Record review of the personnel file for CNA M revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for CNA N revealed a hire date of 11/29/2021. Record review of the personnel file for CNA N revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for CNA O revealed a hire date of 10/28/2022. Record review of the personnel file for CNA O revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for the FSS revealed a hire date of 07/22/2008. Record review of the personnel file for the FSS revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. Record review of the staff roster provided on 01/23/2024 by the facility for the AD revealed a hire date of 05/30/1989. Record review of the personnel file for the AD revealed the annual Employee Misconduct Registry (EMR) check was completed on 01/09/2023. In an interview with the HRC on 01/25/2024 at 6:05 p.m., the HRC revealed she checked annual EMRs for all facility staff every January. The HRC stated she had been out the previous week and had not had a chance to finish. The HRC confirmed she had performed EMR checks for 7 of the 14 staff whose records were requested on 01/24/2024. In an interview with the Administrator on 01/26/2024 at 4:15 p.m., the Administrator confirmed all EMRs are checked on hire and annually to protect the residents. Record review of the facility's policy titled, Abuse, Neglect and Exploitation Policy, revised December 2017, revealed, Abuse Prevention: Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting or mistreating individuals. 2. Record review of Resident #34's admission record dated 01/24/2024 revealed an admitted [DATE] with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #34's allegations of neglect and/or mistreatment for the allegations made on 11/21/2023 and 11/22/2023. a record review of the facility's in-service record, dated 11/22/2023, revealed 15 nursing staff were in-serviced specifically for resident #34 for Topic: Resident #34; contents or summary of training session: When providing care for Resident #34 we should be mindful. staff should always communicate what they are doing when providing care. there must be two staff members when transferring resident #34 (gate belt or lift transfer). if resident is agitated allow him time to calm down. let the nurse know so she can assist with care if needed. all residents must be turned and repositioned every two hours. incontinent care should be given at this time During an interview on 01/23/24 at 02:48 PM Resident #34's Representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's Representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's Representative stated Resident #34 had a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on Sunday 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's Representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning 11/21/2023 and further reported to the Administrator and the DON with an email on 11/22/2023 at 12:33 PM. Resident #34's Representative stated the DON replied with an email, on 11/22/2023 at 12:47 PM, and stated she would look into the issues and in-service the staff. A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:33 PM sent to the DON and the Administrator, revealed, Sunday 11/19 at 7 pm (Resident #34) Room (***) (Resident #34) and the aide had a very rough time with just a one person transfer where he hit his femur area on his right leg with the wheelchair arm. This was not safe for her either as she was struggling to get (Resident #34) in position to transfer. (Resident #34) has osteoporosis and is susceptible to fractures easily. Please provide two people for his bed transfers for the safety of the aide and for (Resident #34). After she did finally get him in bed she didn't check his diaper. He had been changed at 4:30 pm before supper and was not changed then until 4:30 am. He went 12 hours without a diaper change and was not turned every two hours as he should have been for circulation and hygienic purposes. He didn't receive his breathing treatments as ordered on Sunday as well. He needs to receive his breathing treatments with assistance three times a day during waking hours. Sent from my (name brand cell phone). A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:47 PM sent by the DON and received by Resident #34's Representative and the administrator, revealed, Thanks, (Resident #34's Representative) I will look into these issues and in-service staff. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report allegations of abuse, neglect, and exploitation to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's Representative had reported to him, on the morning of Tuesday 11/21/2023, a review of the in-room camera footage on the evening of Sunday 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on Tuesday 11/21/2023, the Physical Therapy Director stated the meeting included the Social Worker, The DON and the Administrator. The Physical Therapy Director stated he had not documented a grievance report nor reported the allegation to the state agency since he reported the complaint to the Administrator. During an interview on 11/24/2024 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The DON stated she had received a complaint about Resident #34 on 11/22/2023 from Resident #34's representative and documented the complaint on a grievance report. The DON stated she had also provided additional training for the nursing staff regarding transfers and respiratory treatments. The DON stated she had not reported the allegations of neglect and or mistreatment to the state agency. The DON stated the Administrator was aware of the complaint regarding Resident #34. During an interview on 11/26/2023 at 04:30 PM the Administrator stated he could not recall the stand-up meeting on 11/21/2023 and/ or the complaint from Resident #34's Representative but could state if an allegation of mistreatment was identified it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The Administrator was asked if an allegation of a CNA was rough with a Resident during transfers, allegation a Resident did not receive medications, and/or an allegation of neglect to provide incontinent care or hygiene care became known to him would it rise to the level of reporting the allegation to the state agency, the Administrator stated it would depend on the details and circumstances. A record review of the facility's Abuse, Neglect, and Exploitation policy dated 8/15/2022, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .'neglect' means failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . reporting response the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, . within required time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

Based on observations, interviews, and record reviews the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion, for 1 of 1 resident (Resident #34) reviewed for abuse, in that: CNA P was identified in a recorded video transferring Resident #34 from a wheelchair to a bed, against Resident #34's will; evidenced by his calling out Owww! and simultaneously grabbing the wheelchair he was seated in and attempting to stop CNA P from the transfer. This failure could place residents at risk for abuse by denying residents of their rights. The findings included: A Record review of Resident #34's admission record dated 01/24/2024 revealed an admitted [DATE] with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #34's allegations of neglect and/or mistreatment for the allegations made on 11/21/2023 and 11/22/2023. A record review of the facility's in-service record, dated 11/22/2023, revealed 15 nursing staff were in-serviced specifically for resident #34 for Topic: Resident #34; contents or summary of training session: When providing care for Resident #34 we should be mindful. staff should always communicate what they are doing when providing care. there must be two staff members when transferring resident #34 (gate belt or lift transfer). if resident is agitated allow him time to calm down. let the nurse know so she can assist with care if needed. all residents must be turned and repositioned every two hours. incontinent care should be given at this time During a record review and interview on 01/23/24 at 02:48 PM Resident #34's Representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's Representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's Representative stated Resident #34 had a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on Sunday 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's Representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning 11/21/2023 and further reported to the Administrator and the DON with an email on 11/22/2023 at 12:33 PM. Resident #34's Representative stated the DON replied with an email, on 11/22/2023 at 12:47 PM, and stated she would look into the issues and in-service the staff. A record review of the video provided by Resident #34's representative revealed CNA P and Resident #34 were in a bedroom. Resident #34 was dressed in a button-down shirt and pants and wore a gait belt. Resident #34 was seated in his wheelchair. CNA P positioned Resident #34 by the bed and stood in front of Resident #34 and attempted to grab the gait belt and lift Resident #34 while Resident #34 grabbed the arm rests of the wheelchair and began to loudly complaint and verbalize Owww!. Further review revealed this was attempted three times with the same results to include CNA P's insistence with the transfer by removing the wheelchair armrest adjacent to the bed. With continued insistence Resident was lifted by his gait belt and swung over to his bed by CNA P while he continued to call out Oww!. The recording terminated after the transfer. A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:33 PM sent to the DON and the Administrator, revealed, Sunday 11/19 at 7 pm (Resident #34) Room (***) (Resident #34) and the aide had a very rough time with just a one person transfer where he hit his femur area on his right leg with the wheelchair arm. This was not safe for her either as she was struggling to get (Resident #34) in position to transfer. (Resident #34) has osteoporosis and is susceptible to fractures easily. Please provide two people for his bed transfers for the safety of the aide and for (Resident #34). After she did finally get him in bed she didn't check his diaper. He had been changed at 4:30 pm before supper and was not changed then until 4:30 am. He went 12 hours without a diaper change and was not turned every two hours as he should have been for circulation and hygienic purposes. He didn't receive his breathing treatments as ordered on Sunday as well. He needs to receive his breathing treatments with assistance three times a day during waking hours. Sent from my (name brand cell phone). A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:47 PM sent by the DON and received by Resident #34's Representative and the administrator, revealed, Thanks, (Resident #34's Representative) I will look into these issues and in-service staff. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report allegations of abuse, neglect, and exploitation to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's Representative had reported to him, on the morning of Tuesday 11/21/2023, a review of the in-room camera footage on the evening of Sunday 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on Tuesday 11/21/2023, the Physical Therapy Director stated the meeting included the Social Worker, The DON and the Administrator. The Physical Therapy Director stated he had not documented a grievance report nor reported the allegation to the state agency since he reported the complaint to the Administrator. During an interview on 11/24/2024 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The DON stated she had received a complaint about Resident #34 on 11/22/2023 from Resident #34's representative and documented the complaint on a grievance report. The DON stated she had also provided additional training for the nursing staff regarding transfers and respiratory treatments. The DON stated she had not reported the allegations of neglect and or mistreatment to the state agency. The DON stated the Administrator was aware of the complaint regarding Resident #34. The DON reviewed a still frame of the video and identified CNA P as the CNA who transferred Resident #34 in the video record. The DON stated CNA P was terminated 12/20/2023 for lack of attendance. During an interview on 11/26/2023 at 04:30 PM the Administrator stated he could not recall the stand-up meeting on 11/21/2023 and/ or the complaint from Resident #34's Representative but could state if an allegation of mistreatment was identified it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The Administrator was asked if an allegation of a CNA was rough with a Resident during transfers, allegation a Resident did not receive medications, and/or an allegation of neglect to provide incontinent care or hygiene care became known to him would it rise to the level of reporting the allegation to the state agency, the Administrator stated it would depend on the details and circumstances. A record review of the facility's Abuse, Neglect, and Exploitation policy dated 8/15/2022, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .'neglect' means failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . reporting response the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, . within required time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

Based on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 2 of 8 residents (Resident #2 and #37) reviewed for advanced directives, in that: 1. Resident #2's attending physician had not printed his name on the OOHDNR when it was signed on [DATE], rendering the document invalid. 2. Resident #37's attending physician had not dated the OOHDNR when it was signed by the family on [DATE] or when the order was written on [DATE], rendering the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes. The findings include: 1. Record review of Resident #2's face sheet, dated [DATE], revealed an admitted [DATE] and diagnoses which included: dementia, with other behavioral disturbance, other malaise (general feeling of being unwell), anemia and essential hypertension (high blood pressure that has no clearly identifiable cause). Further review of Resident #2's face sheet, revealed under the section, ADVANCE DIRECTIVE: DNR (Do Not Resuscitate). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident #2's Care Plan, with last review completed on [DATE], revealed, Resident is a DNR. Date initiated: [DATE]. Review of the Care Plan revealed an intervention to include the DNR in Resident #2's medical record. Review of Resident #2's Order Summary Report, Active Orders as of [DATE], revealed an order, DNR, dated [DATE] with no end date. Record review of Resident #2's electronic clinical record revealed an OOH-DNR for Resident #2, signed by Resident #2's RP, two witnesses, a notary and physician all dated [DATE]. Further review revealed the physician had not printed his name in the Physician's Statement section of the OOH-DNR. 2. Record review of Resident #37's face sheet, dated [DATE], revealed an initial admitted [DATE] with a recent admission of [DATE] and diagnoses which included: focal/partial symptomatic epilepsy (affect initially only one hemisphere of the brain), mild intellectual disabilities, dysphasia with oral and oropharyngeal phase (swallowing problems occurring in the mouth and the throat), acute kidney failure. Further review of Resident #37's face sheet, revealed under the section, ADVANCE DIRECTIVE: DNR (Do Not Resuscitate). Record review of Resident #37's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment. Record review of Resident #37's Care Plan, with last review completed on [DATE], revealed, [Resident] is a DNR. Date initiated: [DATE]. Review of the Care Plan revealed an intervention to include the DNR in Resident #37's medical record. Review of Resident #37's Order Summary Report, Active Orders as of [DATE], revealed an order, DNR (Do Not Resuscitate), dated [DATE] with no end date. Record review of Resident #37's electronic clinical record revealed an OOH-DNR for Resident #37, signed by Resident #37's family member and two witnesses and dated on [DATE]. Further review revealed the physician had signed the OOH-DNR however had not dated his signature in the Physician's Statement section of the OOH-DNR. In a record review and interview with the SSD on [DATE] at 2:05 p.m., the SSD confirmed Resident #2's OOH-DNR was missing the physician's printed name and Resident #37's OOH-DNR was missing the date for when the physician signed the document. The SSD stated all sections of the OOH-DNR must be fully completed to be valid. The SSD revealed she and the contract SW had recently reviewed the OOH-DNRs on file, including Resident #2's and must have overlooked the physician's name missing. The SSD stated an incomplete or invalid OOH-DNR could put a resident at risk of not having their wishes followed in the event of an emergency. In an interview with the Administrator and RRN on [DATE] at 3:23 p.m., the Administrator stated the SSD and contract SW were responsible for ensuring all OOH-DNR were completed correctly. The RRN stated there had been confusion among the staff regarding when a resident was considered DNR. The RRN stated the corporate SW had educated staff that residents were DNR upon making their wishes known even prior to obtaining the OOH-DNR. The RRN stated she was not aware the completed OOH-DNR had to in the facility with the physician's signature before the resident's code status could change. Record review of the facility's policy titled, Resident' Rights Regarding Treatment and Advance Directives, date implemented [DATE], revealed, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive.

Based on observations, interviews, and record reviews the facility failed to have evidence that all alleged violations are thoroughly investigated; Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress; and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 1 Resident (Resident #34) reviewed for an investigation of allegations of abuse and neglect, in that: The facility failed to investigate to the state agency allegations of abuse and neglect received on 11/22/2023 for Resident #34. This failure could place residents at risk for abuse and neglect by not investigating and reporting the results of their investigation. The findings included: A Record review of Resident #34's admission record dated 01/24/2024 revealed an admitted [DATE] with diagnoses which included dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #34's admission MDS assessment, dated 12/11/2023, revealed Resident #34 was a [AGE] year-old male admitted for long term care and could not be assessed with a BIMS due to cognitive impairment. A record review of Resident #34's care plan dated 1/23/2024, revealed, Problem: (Resident #34) has an ADL self-care performance deficit r/t Impaired balance, impaired vision, behaviors. Known to resist care .TRANSFER: The resident requires total assistance by 2 staff to move between surfaces. May use (brand name) lift when uncooperative .Revision on: 11/17/2023 .Encourage the resident to participate to the fullest extent possible with each interaction . A record review on 01/12/2024 of the Texas Unified License Information Portal website, accessed 01/24/2024, revealed no facility related report for Resident #34's allegations of neglect and/or mistreatment for the allegations made on 11/21/2023 and 11/22/2023. A record review of the facility's in-service record, dated 11/22/2023, revealed 15 nursing staff were in-serviced specifically for resident #34 for Topic: Resident #34; contents or summary of training session: When providing care for Resident #34 we should be mindful. staff should always communicate what they are doing when providing care. there must be two staff members when transferring resident #34 (gate belt or lift transfer). if resident is agitated allow him time to calm down. let the nurse know so she can assist with care if needed. all residents must be turned and repositioned every two hours. incontinent care should be given at this time During a record review and interview on 01/23/24 at 02:48 PM Resident #34's Representative stated on Sunday 11/19/2023 Resident #34 was ambulating in his wheelchair without any complaints of pain. Resident #34's Representative stated on 11/20/2023 Resident #34 was complaining of pain with transfers from bed to wheelchair. Resident #34's Representative stated Resident #34 had a camera in his room. Resident #34's representative stated she reviewed the camera recordings and discovered an unidentified CNA was attending to Resident #34 around 08:45 PM on Sunday 11/19/2023 and was forcing Resident #34 from his wheelchair to his bed while Resident #34 was refusing and calling out in pain. Resident #34's Representative stated she reported the mistreatment to the facility's Physical Therapy Director on Tuesday morning 11/21/2023 and further reported to the Administrator and the DON with an email on 11/22/2023 at 12:33 PM. Resident #34's Representative stated the DON replied with an email, on 11/22/2023 at 12:47 PM, and stated she would look into the issues and in-service the staff. A record review of the video provided by Resident #34's representative revealed CNA P and Resident #34 were in a bedroom. Resident #34 was dressed in a button-down shirt and pants and wore a gait belt. Resident #34 was seated in his wheelchair. CNA P positioned Resident #34 by the bed and stood in front of Resident #34 and attempted to grab the gait belt and lift Resident #34 while Resident #34 grabbed the arm rests of the wheelchair and began to loudly complaint and verbalize Owww!. Further review revealed this was attempted three times with the same results to include CNA P's insistence with the transfer by removing the wheelchair armrest adjacent to the bed. With continued insistence Resident was lifted by his gait belt and swung over to his bed by CNA P while he continued to call out Oww!. The recording terminated after the transfer. A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:33 PM sent to the DON and the Administrator, revealed, Sunday 11/19 at 7 pm (Resident #34) Room (***) (Resident #34) and the aide had a very rough time with just a one person transfer where he hit his femur area on his right leg with the wheelchair arm. This was not safe for her either as she was struggling to get (Resident #34) in position to transfer. (Resident #34) has osteoporosis and is susceptible to fractures easily. Please provide two people for his bed transfers for the safety of the aide and for (Resident #34). After she did finally get him in bed she didn't check his diaper. He had been changed at 4:30 pm before supper and was not changed then until 4:30 am. He went 12 hours without a diaper change and was not turned every two hours as he should have been for circulation and hygienic purposes. He didn't receive his breathing treatments as ordered on Sunday as well. He needs to receive his breathing treatments with assistance three times a day during waking hours. Sent from my (name brand cell phone). A record review of the email provided by Resident #34's Representative, dated 11/22/2023 at 12:47 PM sent by the DON and received by Resident #34's Representative and the administrator, revealed, Thanks, (Resident #34's Representative) I will look into these issues and in-service staff. During an interview on 01/24/2024 at 10:26 AM The Physical Therapy Director stated his training was to report allegations of abuse, neglect, and exploitation to the abuse, neglect, and exploitation prevention coordinator who was also the Administrator. The Physical Therapy Director stated he assessed Resident #34 on Sunday 11/19/2023 without any complaints of pain with ambulation in his wheelchair. The Physical Therapy Director stated on Monday 11/20/2023 Resident #34 had pain with transfers and wheelchair ambulation. The Physical Therapy Director stated Resident #34's Representative had reported to him, on the morning of Tuesday 11/21/2023, a review of the in-room camera footage on the evening of Sunday 11/19/2023 revealed an unidentified CNA was rough with Resident #34 while transferring Resident #34 from his wheelchair to his bed. The Physical Therapy Director stated he reported the allegation of mistreatment to the Administrator during the 08:30 AM stand-up meeting on Tuesday 11/21/2023, the Physical Therapy Director stated the meeting included the Social Worker, The DON and the Administrator. The Physical Therapy Director stated he had not documented a grievance report nor reported the allegation to the state agency since he reported the complaint to the Administrator. During an interview on 11/24/2024 at 01:38 PM the DON stated she could not recall the stand-up meeting on 11/21/2023 but could state if an allegation of mistreatment was identified at the meeting it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The DON stated she had received a complaint about Resident #34 on 11/22/2023 from Resident #34's representative and documented the complaint on a grievance report. The DON stated she had also provided additional training for the nursing staff regarding transfers and respiratory treatments. The DON stated she had not reported the allegations of neglect and or mistreatment to the state agency. The DON stated the Administrator was aware of the complaint regarding Resident #34. The DON reviewed a still frame of the video and identified CNA P as the CNA who transferred Resident #34 in the video record. The DON stated CNA P was terminated 12/20/2023 for lack of attendance. During an interview on 11/26/2023 at 04:30 PM the Administrator stated he could not recall the stand-up meeting on 11/21/2023 and/ or the complaint from Resident #34's Representative but could state if an allegation of mistreatment was identified it would have been acted upon at a minimum with a documented grievance report with a follow up investigation and report to the state agency. The Administrator was asked if an allegation of a CNA was rough with a Resident during transfers, allegation a Resident did not receive medications, and/or an allegation of neglect to provide incontinent care or hygiene care became known to him would it rise to the level of reporting the allegation to the state agency, the Administrator stated it would depend on the details and circumstances. A record review of the facility's Abuse, Neglect, and Exploitation policy dated 8/15/2022, revealed, it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property .'neglect' means failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . reporting response the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, . within required time frames: immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

Based on observations, interviews, and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must include the minimum healthcare information necessary to properly care for a resident for 1 of 8 residents (Resident #269) reviewed for healthcare information necessary to properly care for a Resident, in that: The facility failed to care plan Resident #269's need for a peripherally inserted central catheter (also known as a PICC line - percutaneous indwelling central catheter, is a form of intravenous access that can be used for a prolonged period for administration of intravenous in the vein medications). This failure could place residents at risk for harm by not receiving care for their indwelling intravenous catheters. The findings include: A record review of Resident #269's admission record dated 01/24/2024 revealed an admitted [DATE] with diagnoses which included sepsis (a life-threatening complication of an infection). A record review of Resident #269's admission MDS assessment, dated 01/16/2024, revealed Resident #269 was an [AGE] year-old male admitted for short term care. A record review of Resident #269's Initial Baseline / Advanced Care Plan, dated 01/16/2024, revealed an admitting diagnosis of severe sepsis with septic shock (Septic shock is a life-threatening condition caused by a severe localized or system-wide infection that requires immediate medical attention) and medications ordered - antibiotics. Further review revealed the question regarding IV Medications / fluids was left unanswered. A record review of Resident #269's physicians orders, dated 01/24/2024, revealed the physician ordered nursing staff to care for Resident #269's PICC line daily and as needed, monitor midline (PICC) site for redness, tenderness, edema, excessive bleeding outside, chest/neck/ear pain, numbness or tingling of affected arm/and. notify MD of abnormal findings every shift . no blood pressure checks or veiny puncture to midline arm 'left arm'. During an observation and interview on 01/23/2024 at 03:10 PM Resident #269 stated demonstrated a PICC line on his left upper arm covered by a clear bandage. The PICC line was accessed by 2 lumens (small tubes covered with screw on/off caps). Resident #269 stated he received the PICC line while at the hospital and the facility nursing staff used the lumens to inject his antibiotic medications. During an interview on 01/24/2024 at 02:23 PM the DON stated Resident #269 was admitted for short term care related to a severe infection, was currently receiving intravenous antibiotics through a PICC midline on Resident #269's left arm. The DON stated she was the RN who signed off on Resident #269's baseline care plan. The DON stated Resident #269 was not care planned supports and interventions for his intravenous antibiotics and/or his midline PICC line. The DON stated she was responsible for ensuring the accuracy of residents care plans and had made a mistake and overlooked Resident #269's midline intravenous access. The DON stated the lack of care plan interventions could have placed resident #269 at risk for not caring for his intravenous access. A record review of the facility's Care Plans- Baseline policy , dated March 2022, revealed, a baseline plan of care to meet the residents' immediate health and safety needs is developed for each resident within 48 hours of admission. the baseline care plan includes instructions needed to provide effective, person centered care of the resident that meet professional standards of quality care and must include the minimum health care information necessary to properly care for the resident including, but not limited to the following: .physicians' orders

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 8 residents (Residents #2 and #49) for care plan revisions, in that: 1. Resident #2's care plan was not revised to reflect fall interventions after a fall on 12/27/2023 and had not been updated to address Resident #2's new respiratory needs. 2. Resident #49's care plan was not revised to reflect smoking interventions identified in an updated smoking assessment on 10/26/2023. This failure could place residents at risk of receiving inappropriate care. The findings were: 1. Record review of Resident #2's face sheet, dated 01/26/2024, revealed an admitted [DATE] and diagnoses which included: dementia, with other behavioral disturbance, other malaise (general feeling of being unwell), anemia and essential hypertension (high blood pressure that has no clearly identifiable cause). Record review of Resident #2's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 03, which indicated severe cognitive impairment. Review revealed in Section J: Health Conditions; resident did not have a history of falls or respiratory conditions. Record review of Resident #2's Care Plan, with last review completed on 12/27/2023, revealed, [Resident] is at risk for falls r/t impaired balance, impaired cognition, wandering with poor safety awareness. Date initiated 11/03/2021. Further review revealed interventions for falls listed were dated 11/03/2021. An additional intervention for start tx for Respiratory infection dated 12/27/2023 was included in problem area. No problem area for Respiratory Care was noted on the care plan. Review of Resident #2's Order Summary Report, Active Orders as of 01/26/2024, revealed an order for Albuterol Sulfate Inhalation Nebulization Solution, every 6 hours as needed for wheezing, with a start date 12/27/2023 and D/C date 01/18/2024. Record review of Resident #2's electronic medical record revealed an MD notification document, dated 12/28/2023 completed by the DON. Notification provided regarding resident's unwitnessed fall with laceration above Rt eye and wheezing. Orders received from MD for Albuterol Neb Q6 hours PRN. Record review of Resident #2's electronic medical record revealed a Nursing Quarterly/PRN Nursing Evaluation, dated 12/29/2023. Review revealed in Section F: Respiratory, Type of respiratory treatments ordered: Nebulizer. Record review of Resident #2's Skilled Administration Record dated 12/1/2023-12/31/2023, revealed Resident #2 received nebulizer treatments on 12/27/2023 and 12/28/2023. 2. Record review of Resident #49's face sheet, dated 01/25/2024, revealed an initial admitted [DATE] and a most recent admission of 05/12/2023 with diagnoses that included: end stage renal disease, acquired absence of right leg below knee, lack of coordination, and legal blindness. Record review of Resident #49's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 15, which indicated the resident's cognition to be intact. Further review of Section GG: Functional Abilities revealed Resident #49 required anywhere from substantial/maximal to setup assistance for self-care ADL's. Record review of Resident #49's Care Plan, with last review completed on 11/09/2023, revealed, [Resident] is a smoker. Date initiated: 11/09/2023. Review revealed the interventions included to instruct resident on smoking risks, instruct on policy, monitor hygiene, notify charge nurse for violations, and observe clothing and skin for burns. Care plan did not indicate Resident #49's need for smoking apron and one to one supervision. Record review of Resident #49's electronic medical record revealed a Smoking Safety Screen, dated 08/30/2022, that noted Resident #49 as non-smoker. Further review revealed a Smoking Safety Screen, dated 10/26/2023, that indicated Resident #49's adaptive equipment needs were a smoking apron and one-on-one assistance. In an interview with the CMP on 01/26/2024 at 12:43 p.m., the CMP stated Resident #49 was initially not a smoker when admitted to the facility. The CMP revealed that Resident #49's status changed later to smoker and when the assessment was completed, the care plan should have been updated to include all safety interventions. The CMP stated the care plan was very important so that all staff are aware of each resident's specific needs. The CMP further stated she would have been the one to update the care plan and other than human error is unsure how it was overlooked. In an interview with the DON on 01/26/2024 at 12:55 p.m., the DON revealed revisions were to be made as changes occurred and were the responsibility of all disciplines. The DON reviewed Resident #2 care plan and Resident #2 had not had any falls prior to the fall on 12/27/2024 and due to Resident #2 wheezing at the time we thought the respiratory infection was probably the reason for her fall so we put the treatments under fall risk in care plan. The DON added that instead of the respiratory treatment, some other intervention specific for falls should have been to the problem of fall risk and a new respiratory problem added with the nebulizer treatments as an intervention. A policy was requested regarding Care Plan Revisions however a policy was not provided prior to exit.

Based on interviews and record reviews the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the Resident for 1 of 8 residents (Resident #56) reviewed for surviving trauma, in that: The facility failed to provide care in a manner to eliminate and/or mitigate triggers for Resident #56's Post Traumatic Stress due to a rape assault. This failure could place residents at risk for triggering re-traumatization. The findings included: A record review of Resident #56's admission record dated 01/26/2024 revealed an admitted [DATE] with diagnoses which included Post Traumatic Stress Syndrome (PTSD a disorder that develops in some people who have experienced a shocking, scary, or dangerous event) and dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A record review of Resident #56's quarterly MDS assessment, dated 12/30/2023, revealed Resident #56 was an [AGE] year-old female admitted for long term care and assessed with Post traumatic stress syndrome with a BIMS score of 12 out of a possible 15 which indicated moderate cognition impairment. A record review of Resident #56's hospital discharge documents dated 07/02/2022, revealed Resident #56 was diagnosed with Post Traumatic Stress Syndrome as evidenced by a 2002 sexual assault, rape. A record review of Resident #56's care plan, dated 01/25/2024, revealed, Problem: (Resident #56) uses psychotropic medications .for PTSD, .Presents in angry mood at times, hard to re-direct .Revision on: 01/07/2024 .Problem: Discharge planning has been discussed with the resident/RP. Discharge to the community is not expected .Revision on: 07/03/2023 .Interventions: Assist resident with adjusting to the facility . Encourage family to visit as often as possible .Encourage resident to become involved in facility activities of choice, to attend resident council, and to socialize with others .Follow up as needed to see if there are changes to the discharge plan .Monitor resident for difficulty adjusting to the facility During an interview on 01/24/2024 at 04:05 PM Resident #56 stated she did not want to participate in conversations about her past. Resident became silent when asked if she had male care givers and would return to participating in the interview when the conversation turned away from male care givers. Resident #56 stated she was happy with the care, the girls are good to me. During an interview on 01/25/2024 at 02:23 PM the DON stated there were no interventions and or supports in place to eliminate and/or mitigate any potential triggers for Resident #56 diagnosis for PTSD related to a past sexual assault. The DON stated Resident #56 was at risk for being reminded and possibly trigged for negative feelings related to her past rape. A record review of the facility's Trauma Informed Care policy, dated 10/13/2022, revealed, it is the policy of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and or re-traumatization, . the facility will use multi pronged approach to identifying residents history of trauma, as well as his or her cultural preferences. this will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the resident assessment instrument, admission assessments, the history of physical, the social history assessments and others.

44903 Based on observations, interviews, and record reviews, the facility failed to provide food that was palatable, attractive, and prepared by methods which conserved the nutritive value, flavor, and appearance for 1 of 1 meal (noon meal) reviewed for food palatability and nutritive value, in that: 1. The facility served Resident #40 a hamburger with a greenish-gray color substance on the bottom bun. 2. The facility failed to follow the recipe for Resident #32's tuna salad sandwich. This failure could place all residents who ate meals prepared from the kitchen at risk of food borne illness, possible weight loss, altered nutritional status, and diminished quality of life. The findings were: 1. Record review of Resident #40's face sheet, dated 01/26/2024, revealed an initial admitted [DATE] with a most recent admission of 08/06/2020 and diagnoses which included: chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), cognitive communication deficit (difficulty paying attention to a conversation, staying on topic, remembering information, responding accurately or following directions), hypothyroidism (underactive thyroid, thyroid gland doesn't make enough thyroid hormones to meet the body s needs which control how the body uses energy. Affects breathing, heart rate, weight, digestion, and moods) and hypokalemia (low levels of potassium in the blood). Record review of Resident #40's Quarterly MDS, dated [DATE], revealed the resident's BIMS score was 10 (out of 15) indicative of moderate cognitive impairment and he required supervision and set up with meals. During an observation of the noon meal on 01/23/2024 at 12:17 p.m., Resident #40 motioned this surveyor to his table. Resident #40 had been served a hamburger and fries which was the alternate meal for the day. Resident #40 had pulled a small piece of the hamburger bun off and placed it on his table pointing at the greenish-gray color substance on the bun. Resident #40 asked, is that pepper or something else? LVN F walked to Resident #40's table and stated, oh, that's mold! Resident #40 was holding the remaining two-thirds of his hamburger down near his lap and as he picked up the hamburger, this surveyor and LVN F saw the bottom of the hamburger bun was covered in the greenish-gray colored substance. During an interview with the LVN F on 01/23/2024 at 12:43 p.m., LVN F revealed the floor nurses had identified a total of 7 potential residents served hamburger buns. LVN F stated she had checked allergies for those residents and that none of the residents served hamburger buns were allergic to penicillin. During an interview with the DON on 01/23/2024 at 12:47 p.m., the DON revealed all the resident's physicians would be notified and the residents monitored closely for any symptoms. During an interview with the RD and Administrator on 01/23/2024 at 3:00 p.m., the RD stated the hamburger bun with the greenish-gray area should not have been served as it would pose a risk for food borne illnesses to residents. During an interview with the FSS on 01/23/2024 at 3:23 p.m., the FSS revealed the hamburger buns used for today's meal were the last bag in the box. The FSS stated she had not checked the expiration date prior to serving however does routine storage checks to determine if food is within expiration dates. 2. A record review of Resident #32's admission record, dated 01/24/2024, revealed an admitted [DATE] with diagnoses which included muscle wasting and atrophy (a reduction of muscle mass) and vitamin deficiency. A record review of Resident #32's quarterly MDS assessment, dated 12/13/2023, revealed Resident #32 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 15 out of a possible 15 which indicated no cognitive impairment. A record review of Resident #32's physicians orders, dated 01/24/2025, revealed Resident #32 was prescribed fish oil capsules daily for vitamin deficiency. A record review of Resident #32's care plan, dated 01/24/2024, revealed, (Resident #32) has anemia (a common cause of anemia worldwide is iron deficiency. Iron is needed to form hemoglobin, part of red blood cells that carry oxygen and remove carbon dioxide (a waste product) from the body) . The resident will remain free of s/symptoms (signs and or symptoms) or complications related to anemia through review date .Encourage intake of foods high in iron, vitamin C .(Resident #32's) has a potential for nutritional problems as evidenced by weight variances r/t (related to) obesity and vitamin deficiency, hx (history) of constipation, Hypernatremia (too much salt in the blood), Dysphagia (difficulty swallowing foods and or drinks) with coughing during meals. Diet: Regular, mechanical soft texture, Nectar liquids. HS (hour of sleep) snack x30 days .Provide and serve diet as ordered .Provide and serve supplements as ordered A record review of the facility's Quantified Recipe 1418, dated 03/14/2023, revealed, tuna salad sandwich on wheat 3 ounces .serving utensil: #8 scoop / spatula .assemble filling and bread using a #8 scoop .3 ounces .sandwich . is equal to #8 scoop . During an observation and interview on 01/23/2024 at 12:10 PM revealed Resident #32 was served his meal which included a tuna salad sandwich on wheat bread. Resident #32 called out to surveyor and demonstrated the sandwich by spreading apart the slices of bread to reveal a scant, difficult to recognize, smear of tuna salad. Resident #32 stated is there any tuna in this sandwich? Resident #32 gave the Surveyor permission to collected photographic evidence of the sandwich. During an interview on 01/24/2023 at 2:01 PM the dietician viewed the photo of the tuna salad sandwich and stated it was difficult to see the tuna salad in the sandwich from the photo shown. The dietician stated the expectation for the kitchen was to follow recipes for all foods prepared including a tuna salad sandwich. The dietician stated the risk to residents who received foods prepared without following recipes could be residents not receiving the calories needs and recommended. During an interview on 01/25/2024 the Food Service Supervisor stated she was unsure if there was a recipe for tuna salad sandwiches and stated usually the staff prepared the tuna salad sandwich with a knife and not a scoop. A record review of the facility's Tray Service policy, dated 10/2018, revealed, the facility believes that accurate trade service and act adequate portion sizes are essential to the resident's well-being and safe. the facility will ensure that diets are served accurately and in the correct portions and that residents' preferences are met . for trade line service, nutrition and food service staff will check each residence tray card prior to service to ensure that preferences and dislikes are honored, the correct diet is served, portion sizes are accurate A record review of the facility's Portion Control policy, dated 10/2018, revealed, the facility will use standard portion control procedures and utensils to ensure that adequate portions are served to residents . standardize recipes should be used to prevent overproduction . for each food item should follow the specific portion sizes listed on the menus food items should be served using standard sized ladles, scoops, spoondles, and spoons. standard scoop and ladle sizes are listed in the following tables: . scoop #8 half cup 4 ounces .

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 3 residents (Resident #1) reviewed for infection control, in that: CNA A did not wash or sanitize her hands between change of gloves during incontinent care for Resident #1. These deficient practices could place residents at-risk for infection due to improper care practices. The findings include: 1 .Record review of Resident 1's face sheet, dated 11/28/2023, revealed an admitted [DATE] and, a readmitted [DATE], with diagnoses which included: Dementia (decline in cognitive abilities), Anemia (Blood disorder in which the blood has a reduced ability to carry oxygen), Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypertension (High blood pressure) and, Bipolar disorder (Mental disorder characterized by periods of depression and periods of abnormally elevated mood). Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 99, she was coded as having severe impairment and memory problems. Resident #1 required extensive assistance and was always incontinent of bowel and bladder. Review of Resident #1's care plan dated 08/19/2021 revealed a problem of Resident #1 has FUNCTIONAL bladder incontinence r/t (related to) impaired cognition and impaired mobility with an intervention of Monitor/document for s/sx (signs and symptoms)UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Observation on 11/30.2023 at 1:15 p.m. revealed, while providing incontinent care for Resident #1, CNA A, after cleaning the genital area and front of Resident #1, changed her gloves but did not sanitize or wash her hands before putting new gloves on. CNA A changed her gloves after she finished cleaning the resident's buttocks but did not sanitize or wash her hands. During an interview with CNA A on 11/30/2023 at 1:30 p.m., CNA A verbally confirmed she should have washed or sanitized her hands between change of gloves but forgot. She confirmed the staff received infection control training. Review of CNA A's CNA orientation skills checklist, dated 01/11/2023, revealed she met proficiency in infection control and incontinent care. During an interview with the DON on 11/30/2023 at 5:30 p.m., the DON confirmed the staff should have washed or sanitized her hands between change of gloves. The DON confirmed the staff received training on infection control. The facility did annual skill checklists with the staff. The ADON did spot checks on different staff to check their knowledge and skills. Review of the facility policy titled, Perineal care, dated 10/24/2022, revealed 16. Remove gloves and discard. Perform hand hygiene. Review of the facility's Incontinent care proficiency checklist, undated, revealed Use hand gel between glove changes. If heavily soiled, wash hands with soap and water.

Based on observation, interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as is possible for 2 of 8 residents (#2 & #5) whose records were reviewed for falls. 1. a. Resident #2 required a 2 person assist with all transfers. b. CNA A transferred Resident #2 via sit to stand mechanical lift without using a second person. c. Resident #2 fell during the transfer and sustained a 3 x 4 cm hematoma on center of forehead with a .1 cm x .1 cm superficial open area in the center; 2 cm x 2 cm discoloration to left lower leg. The Resident was sent to the ER for further evaluation and treatment as needed. 2. Resident #2's wheel casters did not lock which contributed to her fall. The ADM, the DON and the previous M.S. were aware or should have been aware that the wheel casters did not lock. 3. The ADM and the M.S. did not ensure that the wheel casters on Resident #5s bed locked. Resident had multiple falls since his admission and was a high risk for falling. These deficient practices could affect 2 residents who used the sit to stand mechanical lift for transfers; 10 residents whose wheel casters were determined not to lock during (MONTH) (YEAR) and 15 residents who were a fall risk and it could cause avoidable accidents. The findings were: 1. & 2. Review of Resident #2s admission record dated 8/2/18 revealed she was originally admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2s quarterly MDS dated [DATE] revealed her BIMS was 6 which meant she had severe cognitive impairment; she had impaired vision; she required extensive assistance by 2 persons with bed mobility and transfers; was not steady moving from seated to standing position and did not have a history of falls. Review of Resident 2s Care Plan updated on 2/28/18 revealed she required extensive assistance by 2 persons with transfers and she was at risk for injury reason to improper transfer. Review of a Fall Risk assessment dated [DATE] revealed Resident 2s grand total was 11 with 10 or greater indicating the Resident was a high risk for potential falls. Review of incident report dated 4/22/18 read that at 6:05 a.m., CNA (A) was transferring Resident (#2) from bed to wheelchair using a (lift). Resident let go of straps and slid to the floor striking the center of forehead with a .1 cm superficial open area in the center; 2 cm x 2 cm discoloration to left lower leg. Resident immediately assessed for injury and pain, ice applied to forehead. Review of incident follow up dated 4/24/18 revealed Resident #2 had dark reddened discoloration to under eyes bilateral, less [MEDICAL CONDITION] noted to hematoma to forehead. Area dry no active bleeding. No increased confusion noted. Denies headache. Review of ADL Assistance and Support worksheets dated (MONTH) through (MONTH) (YEAR) revealed that only 1 staff was assisting Resident #2 for transfers on multiple occasions on all 3 shifts; day, evening and night on the following dates: 1/6/18, 1/7/18, 1/12/18, 1/21/18, 1/27/18, 1/29/18, 2/4/18, 2/7/18, 2/9/18, 2/11/18, 2/14/18, 2/25/18, 2/26/18, 3/1/18. 3/3/18, 3/4/18, 3/5/18, 3/6/18, 3/10/18, 3/18/18, 3/22/18, 3/25/18, 3/27/18, 3/28/28, 3/30/18, 3/31/18, 4/1/18, 4/2/18, 4/3/18, 4/4/18, 4/7/18, 4/8/18, 4/9/18 4/10/18/ 4/11/18, 4/12/18, 4/14/18, 4/15/18, 4/16/18, 4/17/18, 4/19/18, 4/20/18, 4/21/18 4/22/18, 4/26/18, 4/27/18, 4/29/18, 5/4/18, 5/8/18, 5/9/18, 5/16/18, 5/27/18 and 5/29/18. Review of Resident 2s Care Plan updated on 5/27/18 revealed she required extensive assistance by 2 persons with transfers and that she was at risk for injury reason to improper transfer. Further review revealed staff was to use a mechanical lift for transfers. Review of Resident #2s annual assessment dated [DATE] revealed her BIMS was 6 indicative of severe cognitive impairment; she had impaired vision; she required extensive assistance by 2 persons with bed mobility and total assistance by 2 persons for transfers; was not steady moving on and off the toilet. Further review revealed she had not moved from a seating to standing position during this review period. Review of ADL Assistance and Support worksheets dated (MONTH) and (MONTH) (YEAR) revealed Resident #2 was being transferred by 1 staff on multiple occasions on the following dates: 6/5/18, 6/15/18, 6/23/18, 6/25/18, 7/2/18, 7/6/18, 7/9/18, 7/21/18, 7/27/18 and 7/29/18. Interview on 7/31/18 with CNA A revealed she had been a tenured employee of about [AGE] years at the facility. CNA A stated she usually worked on Station II, Resident #2 was on Station I. CNA A stated she was working alone on the morning Resident #2 fell . CNA A stated another CNA was scheduled to come in at 7:00 a.m. She stated she looked on the computer program to check if Resident #2 required more than 1 person for transfers. She stated she did not find the information, but had seen other aids transfer the Resident with a sit to stand mechanical lift on their own. However, she remembered they had just advised them a few days prior that 2 persons were required anytime a mechanical lift was used. CNA A stated she set up the sit to stand mechanical lift and looked for someone to help her with the transfer, but could not find any other staff that was available. She stated the charge nurse was giving report and counting medications with the on-coming nurse and there were no other CNAs available; none that she could see. CNA A stated the usual argument that administrative staff would give them was to find a charge nurse or another CNA to assist as needed. CNA A stated she proceeded to transfer Resident #2 with the sit to stand mechanical lift because she felt pressured to get the Resident up because the Resident kept asking to get up. She stated the Resident's family member was very particular and she did not want the Resident to complain to the family member and then she would get into trouble. CNA A stated during the transfer everything was going fine and then the Resident suddenly looked at her and stated, I'm sorry, but I have to let go. Resident #2 let go of the straps fell back onto the bed, the bed rolled backwards and she fell to the floor hitting her forehead on the bottom metal frame of the bed landing on her right side/shoulder. CNA A stated she immediately went to get the charge nurse. She stated she was so upset and crying because she did not mean to hurt the Resident. CNA A stated she had tried to lock the bed, but it did not lock; the brakes were not working. She stated the bed was closer to the middle of the room and not against the wall. Interview 8/1/18 at 1:42 p.m. with LVN I revealed she worked 6 a.m. to 6 p.m. LVN I stated the only time when it was difficult to manage the load was when someone called in and there was not a replacement then everyone had to help each other out. She stated that the CNAs usually work well together, but confirmed the halls were long and it was a lot of area to cover. In addition, there was no visibility; the aids could not see each other's whereabouts and there was no call light intercom on Station I. Interview on 8/2/18 at 8:15 a.m. with Resident #2 revealed she was sitting in recliner; there was a rolling walker by the recliner and a wheelchair in front of the bathroom door. The wheelchair was not locked. Resident #2 did not have any visible bruising. She remembered incident/fall very clearly, but could not remember all the details. Resident #2 stated she fell and hit her head on the floor. She stated she had a knot on her forehead and bruising under both eyes. Resident #2 stated the doctor and everybody else came to see her. She commented she was doing much better. The Resident #2 then commented she fell at home in Hallettsville; she was not sure who had assisted her. Resident #2 stated she did not ambulate and used a wheelchair. Observation at this same time revealed Resident #2s bed rolled from side to side after engaging the casters on the wheels. Further observation revealed the bed was against the wall adjoined to the wall on the right side upon entering the room Interview on 8/2/18 with CNA B revealed she worked Station I on a regular basis. CNA B stated she agreed to work and made arrangements to report to work at 7:00 a.m. on the morning Resident #2 fell . She stated she was familiar with Resident #2s fall and knew the brakes on the bed did not work and had reported it to the previous M.S. He told her he was working on getting new beds for the residents, but would change out Resident #2s bed. She commented she made sure the beds were against the wall to be safe. CNA B stated the M.S. did not change out the bed and commented, he had too much work to do. She stated many of the beds had mechanical problems; the cranks did not work, the brakes did not work and they had nails sticking out of them where the cranks were attached. She commented they were old beds. CNA B confirmed staff was using a sit to stand mechanical lift to transfer Resident #2. She stated that the ADL worksheet stated Resident #2 required extensive assistance, but it did not state the Resident required 2 persons for transfers before the fall. CNA B stated the Resident would yell out and call out for help until she got what she wanted. She stated CNA A was very upset about the incident and felt very bad that the Resident fell . CNA B stated they were using a Hoyer mechanical lift and commented the was afraid of falling. She would get anxious during transfers because she was afraid of falling. Interview on 8/2/18 at 2:40 p.m. with CNA C revealed she worked primarily on Station I. She stated she arrived at 2:00 p.m. on the day Resident #2 fell . She stated she knew the brakes on to the bed did not work so she made sure to keep the bed against the wall. She stated the bed moved, skated on the floor. She stated the head of the bed would also not stay up when she positioned it up in the sitting position for Resident #2. CNA C stated she talked to the previous M.S. several times and told him that the brakes did not work; she verbally reported the problem and wrote it on the maintenance log. She presented the maintenance log and there were several entries she made and one of the entries was dated 8/1/16 which read in part: does not lock. CNA C also confirmed staff was using a sit to stand mechanical lift when transferring Resident #2 and now were strictly using the Hoyer mechanical lift. CNA C stated Resident #2 was afraid since the fall when transferred and did not like being transferred via the Hoyer mechanical lift. CNA C proceeded to go to Resident #2's room; she demonstrated that the bed did not lock into position. Observation at this same time revealed the wheel casters did not lock the wheels into place. The bed moved even though the casters were in a locked position. Observational Rounds with the M.S. on 8/2/18 at 3:15 p.m. in resident rooms determined to be a fall risk as of (MONTH) (YEAR) revealed the wheels on the following beds did not lock: room [ROOM NUMBER] B, 215 B, 315 A and 407 [NAME] Note: Resident #2 was assigned to one of the rooms. Interview on 8/2/18 at 5:01 p.m. with the previous M.S. revealed he worked at the facility for about 1 year before resigning from his position. He stated the biggest problem he had was the age of the beds. He stated he talked with the V.P. and requested to buy 3 to 5 beds a month and the V.P. told him the census was too low. The previous M.S. commented he did the best he could with the materials he had because the beds were not being produced any longer. He stated he talked with the ADM about purchasing new beds, but at the time, she and the V.P. both did not approve the purchase of new beds. He stated he had a budget of about $7000 a month, but the maximum he was allowed to spend at one time was $500 without approval from corporate. The previous M.S. stated he was aware that Resident #2 had a fall and stated he knew the brakes on the bed did not work. He stated he changed the bed out the day after she fell , but then that bed broke so he put the same bed back in her room. The M.S. stated he let the ADM know the brakes were not working, but again stated he was expected to fix the beds with used parts. He confirmed he did not work on the Resident's bed because he had too much work and did not have an assistant. Interview on 8/2/18 at 5:19 p.m. with LVN J revealed she had worked at facility for [AGE] years on a part time basis. She stated she was running late the morning Resident #2 fell and stated the fall took place right before she arrived. LVN J stated she understood CNA A was using the sit to stand mechanical lift to transfer Resident #2; the Resident let go of the straps or handle and fell . LVN J stated both the aid and the Resident reported this to her and stated Resident #2 hit her head on the bottom rail of the bed. She stated she did not know anything about the brakes not locking; it had not been brought to her attention. LVN J stated nursing staff had been using the sit to stand mechanical lift or the Hoyer mechanical lift to transfer Resident #2, but they used the sit to stand more regularly. LVN J further stated it was usually one 1 aid who would transfer the Resident using the sit to stand mechanical lift. Interview on 8/2/18 at 8:36 p.m. with LVN D revealed she had worked at the facility 4 years on the 6:00 p.m. to 6:00 a.m. shift. She stated she was the charge nurse on the morning Resident #2 fell and confirmed she and the on-coming nurse were counting medications and she was passing on report. LVN D stated that CNA A notified her that Resident #2 had fallen. She walked into the room and saw Resident #2 lying on the floor next to the bed. The bed was along the wall. LVN D stated she assessed the Resident and noted a bump on her forehead. CNA A reported Resident #2 hit her head on the bottom rail of the bed. Resident #2 kept apologizing stating, I let go. CNA A was visibly upset and crying. CNA A further stated Resident #2 slipped out of the sit to stand mechanical lift and that the Resident's knees gave out. LVN D stated she could not tell if the bed moved. She did not check to see if the wheelchair or the bed were in the locked position. She stated the bed was in the low position. LVN D stated CNA A reported to work at 2:00 a.m.; she was helping out because they had limited help that morning. LVN D stated that normally there were 3 CNAs assigned to work Station I and II; one CNA was coming in at 7:00 a.m. She stated the sit to stand mechanical lift had been used in the past to transfer Resident #2, but they had quit using it 3 or 4 months prior because it was leaving pinch marks on the Resident's breasts. She stated she had advised the aids to use the Hoyer mechanical lift. LVN D stated she was not sure how they would communicate with the aids other than verbally tell them of any changes. She stated they did not have a communication book for the aids, she was not sure how the aids charted and where the information would be available for the aids. LVN D confirmed that CNA A typically worked Station II, but mentioned she had worked Station I before. She stated she did not know if CNA A knew they were using a Hoyer mechanical lift instead of the sit to stand mechanical lift for transfers and further stated she had not told CNA A of the change. LVN D stated CNA A did not tell her anything about the brakes not locking, but stated she was aware there had been mechanical problems with several of the beds. LVN D stated CNA A did not ask her for assistance and did not know if she asked another aid for assistance. She commented in her opinion there were not enough aids that day; there were 2 aids and 2 nurse's working at the time of the incident. She stated she had worked numerous times when there were only 2 aids working Station I and Station II. She mentioned they used to have 4 aides working both stations. LVN D stated the lay out of the building made it difficult to find another staff to help because the halls were long and separated; an aid was not able to look down the hall to see if anyone was available. The aid would have to walk down and go around the hall to find help. LVN D confirmed the limited aids and the lay out of the building made it difficult to manage the workload for all nursing staff. Observational Rounds with the M.S. on 8/3/18 at 8:40 a.m. in resident rooms determined to be a fall risk as of (MONTH) (YEAR) revealed the wheels on the following beds did not lock: room [ROOM NUMBER] B, 417 B, 407 A and 103 B ( the head of the bed did not lock). Resident #2 was assigned to one of the rooms. Interview on 8/3/18 at 9:30 a.m. with the ADM revealed she was out of town when Resident #2 fell . She stated her understanding after completing the investigation was that CNA A was transferring Resident #2 using a sit to stand mechanical lift on her own. Then she learned Resident #2 let go, slipped and fell . The ADM stated CNA A knew to use 2 persons when using a mechanical lift. She stated administrative staff would conduct random checks/rounds on direct care staff while providing care and they provided staff with in-servicing to make sure they understood 2 persons were required when using a mechanical lift. The ADM stated she was the M.S.'s direct boss and she was responsible for ensuring the M.S. completed his tasks and maintained the building and equipment in safe operating conditions. She stated she learned of problems/issues to be addressed during morning meetings. The ADM stated the previous M.S. rarely attended morning meetings and did not always communicate well with her. She stated he did not always let her know when there were major mechanical problems in the building. The ADM stated the previous M.S. did not let her know the brakes were not working on some of the beds. She stated she did not review the maintenance log to find out what was going on; whether or not the M.S. was completing the work orders. The ADM stated she was aware the previous M.S. would use pieces from retired beds to repair the beds being used. At times he reported he could not order parts due to the age of the bed, but again stated she did not know the brakes on some of the beds were not working. The ADM stated the M.S. had a monthly budget, but any major purchases required corporate's approval. She stated she and the M.S. discussed buying new beds; they provided the numbers to corporate and stated that purchasing new beds at the time was not approved. However, she stated that corporate had not made a final decision one way or another. The ADM stated the current M.S. reported to her after making rounds with the Surveyor that some of the brakes on the beds did not work and they would be ordering new casters. She stated that some of the beds were also designed with inner posts that would keep the bed in a stationary position when the wheels were cranked off the floor. The ADM stated that in-servicing had not been provided for staff regarding the dual functionality of the bed and she stated she was not sure if staff was aware. The ADM stated that after Resident #2s fall, PT screened all residents on their current level of function regarding transfers and anyone who was using the sit to stand mechanical lift was assessed to be more appropriate to use the mechanical lift. She stated they provided staff with in-servicing on how to properly transfer residents via a mechanical lift after Resident #2s fall. The ADM stated they did not provided in-servicing on how to use the sit to stand mechanical lift; however, they had retired this lift. Interview on 8/3/18 at 9:03 a.m. with the DON revealed she and the ADM lead the investigation after Resident #2 fell . She stated it was also her understanding that CNA A used a sit to stand mechanical lift to transfer Resident #2. She did not find a second person; during the transfer Resident #2 let go , slid and hit her head on the rail. The DON stated the bed was along the right wall upon entering the room She confirmed CNA A stated the bed moved which the DON stated would be an indicator of the brakes not working, but commented it was after the incident that she learned the brakes were not working. The DON stated she did not check the bed herself, but thought the ADM instructed the previous M.S. to check the bed. The DON stated the ADON and the MDS Coordinator audited the charts to determine the level of ADL assistance the residents required when asked who audited the charts to ensure the aids were providing care according to the resident's ADL flowsheet. The DON stated she was not aware that the aids were not using 2 persons at all times when transferring Resident #2. Interview on 8/3/18 at 9:18 a.m. with the ADON F revealed she audited charts for new admissions to ensure everything was completed per policy. She stated nursing staff was to communicate with each other during shift change regarding the level of ADL assistance the resident's required. The ADON also stated the information was available in the computer program the aids used to chart the resident's care needs. She stated if in question, an aid should defer to the charge nurse. Interview on 8/3/18 at 10:16 a.m. with the D.O.R. revealed he had worked at the facility for 8 years. He stated he attended morning meetings regularly and the complaint about faulty beds was always a subject matter during morning meetings. He stated the handles to the cranks were always broken and it was common knowledge that the brakes on some of the beds were not working. He stated the previous M.S. did not have an assistant and he often complained that he had too much work. When he was approached about a faulty bed his response was the ADM knows about it and will not order any new beds. The D.O.R. stated the previous M.S. was expected to fix the beds whatever that meant. The M.S. expressed a lot of frustration to him. The D.O.R. stated that in the [AGE] years he had worked he knew of only a hand full of new beds that had been purchased. He stated during the time that Resident #2 fell PT had been working with her and confirmed she required assistance by 2 persons for transfers. He stated the ADM asked him to screen all of the residents who used the stand to assist mechanical lift, but could not remember the resident's on the list other than Resident #2. He stated he did not have the list of residents who were screened. The D.O.R. reported that each department head was assigned a number of rooms to monitor and one of the areas that they had to check was the functionality of resident equipment. Interview on 8/3/18 at 11:21 a.m. with CNA A revealed that Resident #2s bed was along the right wall upon entering the room. However, it was not up against the wall. The head board was against the wall adjacent to the wall on the right side; there was a night stand between the head board and the wall upon entering the room. A recliner was on the left side by the headboard and closer to the window. The window was on the far back wall of the room. CNA A stated Resident #2 was in a sitting position on the bed facing the window. She positioned the stand to assist mechanical lift in front of the Resident. The wheelchair was on the right side by the foot board. CNA A stated as she started to lift the Resident, the Resident let go and landed in a sitting position on the bed, but then the bed rolled back towards the wall and the Resident fell to the floor landing sideways. CNA A stated both nurse's; on-coming and the one ending her shift came into the room and she told them that the bed rolled backwards. She stated she was asked to write a statement, but was told to be vague. CNA A stated when the DON called her she told the DON that the bed rolled backwards and then she learned from talking with other staff that the brakes had not worked for some time. Interview on 8/3/18 at 1:18 p.m. with ADON [NAME] revealed she was also the staffing coordinator. She stated that on the morning Resident #2 fell there was only 1 aide working Station I, CNA A; she had agreed to come in early to help out because there were 2 to open CNA shifts to cover that morning. The 2nd aid, CNA B, who also agreed to fill in, stated she would report to work about 6:30 a.m. or soon after. The plan was that CNA A would start dressing the residents and then when CNA B arrived they would get them up from bed. ADON [NAME] stated that everyone knew that it took 2 staff to transfer a resident when using a mechanical lift. She stated CNA A told her that the Resident kept asking CNA A to get her up from bed; CNA A thought she was helping. ADON [NAME] mentioned that CNA A had worked with Resident #2 several times before and was familiar with the Resident's care needs. In addition, nursing staff was supposed to pass on report any changes regarding care needs during shift change. She confirmed that CNA A had not worked Station I in some time and she worked a staggered shift; reported to work about 2:00 a.m. so ADON [NAME] stated she was not sure if anyone passed on report to CNA [NAME] ADON [NAME] stated she learned the brakes were not working on the day Resident #2 fell . She stated other aids knew, but did not tell her about it. Interview on 8/3/18 at 3:20 p.m. with Resident #2s RP revealed he understood the CNA was standing Resident #2 up, the CNA let go and then the Resident fell . He commented he did not know anything about the bed rolling backwards due to faulty breaks and did not know the CNA should have asked for assistance to use the mechanical lift. Resident #2s RP stated he was not happy about the incident at all. He commented he visited afterwards and the Resident had extensive black and blue bruising to the forehead and around her eyes. Interview on 8/3/18 at 4:20 p.m. with the DON revealed she was not in the facility on the day Resident #2 fell . She stated she probably checked the bed the Monday after upon returning to work. She stated the bed did not move for her, but stated she did not check to make sure the brakes were working. The DON stated she told the M.S. to look at the bed and make sure it was working. She confirmed that she did not identify the bed rolling backwards as a determining factor leading to the fall. Interview on 8/3/18 with ADON [NAME] revealed she conducted CNA classroom training's including using a mechanical lift. She stated during the last in-service, she primarily informed the aids that 2 persons were required while using a mechanical lift. She stated she did not demonstrate how to use the mechanical lift and stated she had not provided any training on using the sit to stand mechanical lift. Interview on 8/6/18 at 11:23 a.m. with LVN G revealed she had approached the previous M.S. and the ADM multiple times about mechanical issues with the bed's. She stated she was aware and administrative staff was aware that some of the beds did not lock. She stated corporate was not supportive with getting repairs completed, getting new equipment, getting more staff etc. LVN G commented it was hard to keep staff morale up because she had nothing to work with. Interview on 8/6/18 at 2:25 p.m. with the ADM revealed they had a Guardian Angel program. She assigned a number of resident rooms to department heads. Staff was to go in every morning, talk with the staff, look for any housekeeping and maintenance problems. Observation on 8/7/18 at 10:09 a.m. revealed CNA K and LVN G transferring Resident #2 using a Hoyer mechanical lift. During the transfer Resident was visibly jumpy and anxious every time staff moved the lift. Her eyes were observed to be wide open and she kept trying to clutch on to the straps. Interview on 8/7/18 at 3:30 p.m. with CNA H revealed she worked primarily Station I. She stated she was familiar with the fall Resident #2 had and confirmed the bed was not up against the wall; there was a night stand between the bed and the wall closest to the door upon entering the room. She also confirmed that the brakes on Resident #2s bed did not lock and the cranks were also broken. Interview on 8/7/18 at 4:06 p.m. with the D.M. revealed she was Resident #2s Guardian Angel. She confirmed that she was responsible for making morning rounds and was supposed to check in on the resident; check for any housekeeping and maintenance problems. The D.M. stated she did not always make her morning rounds when she had to cook breakfast. She stated she had two kitchen positions open; cook and dietary aid. The D.M. stated she was not always able to attend morning meetings either. She further stated she was not sure whether she was supposed to check if the wheels locked on the beds. The D.M. presented a Guardian Angel check list and it included to check that the bed was locked and in the lowest position. She confirmed she had not been checking the brakes. Interview on 8/8/18 at 10:28 a.m. with the previous M.S. revealed he was really pushing for getting the residents new beds because he believed they deserved a new bed. He stated he did not think about replacing the casters so much and then stated some of the casters could not be replaced because of the design of the beds. Interview on 8/8/18 at 12:15 p.m. with ADON [NAME] revealed they audited all charts and updated all information after Resident #2 fell during (MONTH) (YEAR). She stated she was not certain whether Resident #2s ADL information was on the computer program the aids were using at the time. ADON [NAME] commented she did remember updating the Resident's Care Plan after her fall to reflect that staff was to use a Hoyer mechanical lift for all transfers. 3. Review of Resident #5s admission record dated 8/8/2018 revealed he was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that Resident #5 had two listed family contacts. Review of Resident #5s admission MDS revealed it was completed on 6/26/18. His BIMS score was 12 indicative of moderately impaired cognition; he had minimal difficulty hearing; had vision impairment, required limited assistance by 1 person for bed mobility and transfers; was not steady, and only able to stabilize with staff assistance when moving from surface to surface; was occasionally incontinent of bladder and frequently incontinent of bowel. Review of Resident #5s comprehensive care plan revealed it was initiated on 6/20/18 and revised on 7/4/18 revealed he had ADL self-care performance deficit reason to Dementia and [MEDICAL CONDITION] and required assistance from staff to go to/from sitting to standing and he required limited extensive assistance by one staff to move between surfaces. Further review revealed he had a history of [REDACTED]. Review of incident/accidents for Resident #5 revealed he had multiple falls including on: 1. 7/2/18: Another resident saw the resident on the floor. Staff checked on him and he was walking to his chair with his rolling walker. The Resident reported he slipped and fell backwards. No injuries noted. 2. 7/6/18: Staff heard a loud noise and upon entering his room he was sitting on his buttocks; legs straight out in front of him with the wheelchair behind him. The Resident stated he was going to the bathroom; his legs just fell out from under. No injuries noted. 3. 7/8/18: Another resident called staff. Staff checked in on Resident and noted he was sitting on the toilet. Resident confirmed he fell , but was unable to state how he fell ; no injuries noted. 4. 7/8/18: Staff witness Resident falling to the floor in the bathroom; he landed on his buttocks. Resident stated just fell . No injuries noted. 5. 7/10/18: Staff reported Resident was in the bathroom; he held on to the sink while he sat himself down on the floor. No injuries noted. 6. 7/13/18: CNA noted skin tear on Resident's left thumb. The Resident reporte

Based on observation, interview and record review the facility failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident for 1 of 8 residents (#2) whose records were reviewed for falls. 1. Resident #2s wheel casters did not lock which contributed to her fall resulting in a 3 x 4 cm hematoma on center of forehead with a .1 cm x .1 cm superficial open area in the center; 2 cm x 2 cm discoloration to left lower leg. 2. The ADM, the DON and the previous M.S. were aware or should have been aware and failed to ensure Resident #2 was provided with a functional bed. These deficient practices could affect 2 residents who used the sit to stand mechanical lift for transfers and 10 residents whose wheel casters were determined not to lock during (MONTH) (YEAR) and could cause avoidable accidents. The findings were: Review of Resident #2s admission record dated 8/2/18 revealed she was originally admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of incident report dated 4/22/18 read that at 6:05 a.m., CNA (A) was transferring Resident (#2) from bed to wheelchair using a (lift). Resident let go of straps and slid to the floor striking the center of forehead with a .1 cm superficial open area in the center; 2 cm x 2 cm discoloration to left lower leg. Resident immediately assessed for injury and pain, ice applied to forehead. Review of incident follow up dated 4/24/18 revealed Resident #2 had dark reddened discoloration to under eyes bilateral, less [MEDICAL CONDITION] noted to hematoma to forehead. Area dry no active bleeding. No increased confusion noted. Denies headache. Interview on 8/2/18 at 8:15 a.m. with Resident #2 revealed she was sitting in recliner; there was a rolling walker by the recliner and a wheelchair in front of the bathroom door. The wheelchair was not locked. Resident #2 did not have any visible bruising. She remembered incident/fall very clearly, but could not remember all the details. Resident #2 stated she fell and hit her head on the floor. She stated she had a knot on her forehead and bruising under both eyes. Resident #2 stated the doctor and everybody else came to see her. She commented she was doing much better. The Resident #2 then commented she fell at home in Hallettsville; she was not sure who had assisted her. Resident #2 stated she did not ambulate and used a wheelchair. Observation at this same time revealed Resident #2s bed rolled from side to side after engaging the casters on the wheels. Further observation revealed the bed was against the wall adjoined to the wall on the right side upon entering the room Observational Rounds with the M.S. on 8/2/18 at 3:15 p.m. in resident rooms determined to be a fall risk as of (MONTH) (YEAR) revealed the wheels on the following beds did not lock: room [ROOM NUMBER] B, 215 B, 315 A and 407 [NAME] Note: Resident #2 was assigned to one of these rooms. Interview on 8/2/18 at 5:01 p.m. with the previous M.S. revealed he worked at the facility for about 1 year before resigning from his position. He stated the biggest problem he had was the age of the beds. He stated he talked with the V.P. and requested to buy 3 to 5 beds a month and he would tell him the census was too low. The previous M.S. commented he did the best he could with the materials he had because the beds were not being produced any longer. The previous M.S. stated he talked with the ADM about purchasing new beds, but at the time, she and the VP both did not approve the purchase of new beds. He stated he had a budget of about $7000 a month, but the maximum he was allowed to spend at one time was $500 without approval from corporate. The previous M.S. stated one of the biggest issues in trying to repair the beds because as he previously stated they were not being produced anymore. The previous M.S. stated he was aware that Resident #2 had a fall and stated he knew the brakes on the bed did not work. He stated he changed the bed out the day after she fell , but then that bed broke so he put the same bed back in her room. The M.S. stated he let the ADM know that the brakes were not working, but again stated he was expected to fix the beds with used parts. He confirmed he had not worked on the Resident's bed because he had too much work and did not have an assistant. Observational Rounds with the M.S. on 8/3/18 at 8:40 a.m. in resident rooms determined to be a fall risk as of (MONTH) (YEAR) revealed the wheels on the following beds did not lock: room [ROOM NUMBER] B, 417 B, 407 A and 103 B ( the head of the bed did not lock). Resident #5 was assigned to one of the rooms. The M.S. stated he was fairly new and had been in the the facility less then 2 weeks and had not had the opportunity to check the functionality of the beds. He stated he was not aware that the brakes on the aforementioned beds did not work. The ADM stated she was the M.S.'s direct boss and she was responsible for ensuring the M.S. completed his tasks and maintained the building and equipment in safe operating conditions. She stated she learned of problems/issues to be addressed during morning meetings. The ADM stated the previous M.S. rarely attended morning meetings and did not always communicate well with her. She stated he did not always let her know when there were major mechanical problems in the building. The ADM stated the previous M.S. did not let her know about the brakes were not working on some of the beds. Although, she confirmed she did not review the maintenance log to find out what was going on; whether or not the M.S. was completing the work orders. The ADM stated she was aware the previous M.S. would use pieces from retired beds to repair the beds being used. At times he reported he could not order parts due to the age of the bed, but again stated she did not know the brakes on some of the beds were not working. The ADM stated the M.S. had a monthly budget, but any major purchases required corporate's approval. She stated she and the M.S. discussed buying new beds; they provided the numbers to corporate and stated that purchasing new beds at the time was not approved. However, she stated that corporate had not made a final decision one way or another. The ADM stated the current M.S. reported to her after making rounds with the Surveyor that some of the brakes on the beds did not work and they would be ordering new casters. Interview on 8/3/18 at 9:03 a.m. with the DON revealed she and the ADM lead the investigation after Resident #2 fell . The DON stated the bed was along the right wall upon entering the room She confirmed CNA A stated the bed moved which the DON stated would be an indicator of the brakes not working, but commented it was after the incident that she learned the brakes were not working. The DON stated she did not check the bed herself, but thought the ADM instructed the previous M.S. to check the bed. Interview on 8/3/18 at 10:16 a.m. with the D.O.R. revealed he had worked at the facility for 8 years. He stated he attended morning meetings regularly and the complaint about faulty beds was always a subject matter during morning meetings. He stated the handles to the cranks were always broken and it was common knowledge that the brakes on some of the beds were not working. The D.O.R. stated when approached the previous M.S. about a faulty bed his response was the ADM knows about it and will not order any new beds. The D.O.R. stated the previous M.S. was expected to fix the beds whatever that meant. The M.S. expressed a lot of frustration to him. The D.O.R. stated that in the [AGE] years he had worked he knew of only a hand full of new beds that had been purchased. The D.O.R. reported that each department head was assigned a number of rooms to monitor and one of the areas that they had to check was the functionality of resident equipment. Interview on 8/3/18 at 4:20 p.m. with the DON revealed she was not in the facility on the day Resident #2 fell . She stated she probably checked the bed the Monday after upon returning to work. She stated the bed did not move for her, but stated she did not check to make sure the brakes were working. The DON stated she told the M.S. to look at the bed and make sure it was working. Interview on 8/6/18 at 11:23 a.m. with LVN G revealed she had approached the previous M.S. and the ADM multiple times about mechanical issues with the bed's. She stated she was aware and administrative staff was aware that some of the beds did not lock. She stated corporate was not supportive with getting repairs completed, getting new equipment, getting more staff etc. Interview on 8/8/18 at 10:28 a.m. with the previous M.S. revealed he was really pushing for getting the residents new beds because he believed they deserved a new bed. He stated he did not think about replacing the casters so much and then stated the casters could not be replaced on some of the beds because of the design. Review of the facility Job Description For Administrator revised on 10/09 read in part: The Administrator is responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting, and physical management of the facility, residents and equipment in a manner that the purpose of the facility shall be established and maintained in accordance with established policies. Review of the facility's Job Description for Maintenance Supervisor (undated) read in part: The Maintenance Supervisor will assist in supervising the day-to-day activities of the Maintenance Department in accordance with current federal, stated and local standards .and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner. Review of a document provided by the facility on 8/8/18 revealed there were 2 residents who used the sit to stand mechanical lift for transfers during (MONTH) (YEAR) and 10 residents whose wheel casters were determined not to lock during (MONTH) (YEAR).

Based on observation, interview and record review the facility failed to ensure that the facility implemented written policies and procedures that prohibit neglect of residents for 1 of 8 residents (#2) whose records were reviewed for abuse and neglect. 1. a. Resident #2 required a 2 person assist with all transfers. b. CNA A transferred Resident #2 via sit to stand mechanical lift without using a second person. c. Resident #2 fell during the transfer and sustained a 3 x 4 cm hematoma on center of forehead with a .1 cm x .1 cm superficial open area in the center; 2 cm x 2 cm discoloration to left lower leg. The Resident was sent to the ER for further evaluation and treatment as needed. 2. Resident #2's wheel casters did not lock which contributed to her fall. The ADM, the DON and the previous M.S. were aware or should have been aware that the wheel casters did not lock. These deficient practices could affect 2 residents who used the sit to stand mechanical lift for transfers and it could cause avoidable falls. The findings were: Review of facility policy, Abuse, Neglect and Exploitation Policy revised on (MONTH) (YEAR) read in part: Comprehensive policies and procedures have been developed to aid our facility in preventing abuse/neglect or mistreatment of [REDACTED]. The help with recognition of incidents of abuse, the following definitions of abuse are provided by the State Operations Manual Appending PP Guidance to Surveyors: f. (Neglect) is defined as failure to provide goods and services necessary to avoid physical harm, mental aguish, or mental illness. Review of Resident #2s admission record dated 8/2/18 revealed she was originally admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2s quarterly MDS dated [DATE] revealed her BIMS was 6 which meant she had severe cognitive impairment; she had impaired vision; she required extensive assistance by 2 persons with bed mobility and transfers; was not steady moving from seated to standing position and did not have a history of falls. Review of Resident 2s Care Plan updated on 2/28/18 revealed she required extensive assistance by 2 persons with transfers and she was at risk for injury reason to improper transfer. Review of a Fall Risk assessment dated [DATE] revealed Resident 2s grand total was 11 with 10 or greater indicating the Resident was a high risk for potential falls. Review of incident report dated 4/22/18 read that at 6:05 a.m., CNA (A) was transferring Resident (#2) from bed to wheelchair using a (lift). Resident let go of straps and slid to the floor striking the center of forehead with a .1 cm superficial open area in the center; 2 cm x 2 cm discoloration to left lower leg. Resident immediately assessed for injury and pain, ice applied to forehead. Review of incident follow up dated 4/24/18 revealed Resident #2 had dark reddened discoloration to under eyes bilateral, less [MEDICAL CONDITION] noted to hematoma to forehead. Area dry no active bleeding. No increased confusion noted. Denies headache. Review of ADL Assistance and Support worksheets dated (MONTH) through (MONTH) (YEAR) revealed that only 1 staff was assisting Resident #2 for transfers on multiple occasions on all 3 shifts; day, evening and night on the following dates: 1/6/18, 1/7/18, 1/12/18, 1/21/18, 1/27/18, 1/29/18, 2/4/18, 2/7/18, 2/9/18, 2/11/18, 2/14/18, 2/25/18, 2/26/18, 3/1/18. 3/3/18, 3/4/18, 3/5/18, 3/6/18, 3/10/18, 3/18/18, 3/22/18, 3/25/18, 3/27/18, 3/28/28, 3/30/18, 3/31/18, 4/1/18, 4/2/18, 4/3/18, 4/4/18, 4/7/18, 4/8/18, 4/9/18 4/10/18/ 4/11/18, 4/12/18, 4/14/18, 4/15/18, 4/16/18, 4/17/18, 4/19/18, 4/20/18, 4/21/18 4/22/18, 4/26/18, 4/27/18, 4/29/18, 5/4/18, 5/8/18, 5/9/18, 5/16/18, 5/27/18 and 5/29/18. Review of Resident 2s Care Plan updated on 5/27/18 revealed she required extensive assistance by 2 persons with transfers and that she was at risk for injury reason to improper transfer. Further review revealed staff was to use a mechanical lift for transfers. Review of Resident #2s annual assessment dated [DATE] revealed her BIMS was 6 indicative of severe cognitive impairment; she had impaired vision; she required extensive assistance by 2 persons with bed mobility and total assistance by 2 persons for transfers; was not steady moving on and off the toilet. Further review revealed she had not moved from a seating to standing position during this review period. Review of ADL Assistance and Support worksheets dated (MONTH) and (MONTH) (YEAR) revealed Resident #2 was being transferred by 1 staff on multiple occasions on the following dates: 6/5/18, 6/15/18, 6/23/18, 6/25/18, 7/2/18, 7/6/18, 7/9/18, 7/21/18, 7/27/18 and 7/29/18. Interview on 7/31/18 with CNA A revealed she had been a tenured employee of about [AGE] years at the facility. CNA A stated she usually worked on Station II, Resident #2 was on Station I. CNA A stated she was working alone on the morning Resident #2 fell . CNA A stated another CNA was scheduled to come in at 7:00 a.m. She stated she looked on the computer program to check if Resident #2 required more than 1 person for transfers. She stated she did not find the information, but had seen other aids transfer the Resident with a sit to stand mechanical lift on their own. However, she remembered they had just advised them a few days prior that 2 persons were required anytime a mechanical lift was used. CNA A stated she set up the sit to stand mechanical lift and looked for someone to help her with the transfer, but could not find any other staff that was available. She stated the charge nurse was giving report and counting medications with the on-coming nurse and there were no other CNAs available; none that she could see. CNA A stated the usual argument that administrative staff would give them was to find a charge nurse or another CNA to assist as needed. CNA A stated she proceeded to transfer Resident #2 with the sit to stand mechanical lift because she felt pressured to get the Resident up because the Resident kept asking to get up. She stated the Resident's family member was very particular and she did not want the Resident to complain to the family member and then she would get into trouble. CNA A stated during the transfer everything was going fine and then the Resident suddenly looked at her and stated, I'm sorry, but I have to let go. Resident #2 let go of the straps fell back onto the bed, the bed rolled backwards and she fell to the floor hitting her forehead on the bottom metal frame of the bed landing on her right side/shoulder. CNA A stated she immediately went to get the charge nurse. She stated she was so upset and crying because she did not mean to hurt the Resident. CNA A stated she had tried to lock the bed, but it did not lock; the brakes were not working. She stated the bed was closer to the middle of the room and not against the wall. Interview 8/1/18 at 1:42 p.m. with LVN I revealed she worked 6 a.m. to 6 p.m. LVN I stated the only time when it was difficult to manage the load was when someone called in and there was not a replacement then everyone had to help each other out. She stated that the CNAs usually work well together, but confirmed the halls were long and it was a lot of area to cover. In addition, there was no visibility; the aids could not see each other's whereabouts and there was no call light intercom on Station I. Interview on 8/2/18 at 8:15 a.m. with Resident #2 revealed she was sitting in recliner; there was a rolling walker by the recliner and a wheelchair in front of the bathroom door. The wheelchair was not locked. Resident #2 did not have any visible bruising. She remembered incident/fall very clearly, but could not remember all the details. Resident #2 stated she fell and hit her head on the floor. She stated she had a knot on her forehead and bruising under both eyes. Resident #2 stated the doctor and everybody else came to see her. She commented she was doing much better. The Resident #2 then commented she fell at home in Hallettsville; she was not sure who had assisted her. Resident #2 stated she did not ambulate and used a wheelchair. Observation at this same time revealed Resident #2s bed rolled from side to side after engaging the casters on the wheels. Further observation revealed the bed was against the wall adjoined to the wall on the right side upon entering the room Interview on 8/2/18 with CNA B revealed she worked Station I on a regular basis. CNA B stated she agreed to work and made arrangements to report to work at 7:00 a.m. on the morning Resident #2 fell . She stated she was familiar with Resident #2s fall and knew the brakes on the bed did not work and had reported it to the previous M.S. He told her he was working on getting new beds for the residents, but would change out Resident #2s bed. She commented she made sure the beds were against the wall to be safe. CNA B stated the M.S. did not change out the bed and commented, he had too much work to do. She stated many of the beds had mechanical problems; the cranks did not work, the brakes did not work and they had nails sticking out of them where the cranks were attached. She commented they were old beds. CNA B confirmed staff was using a sit to stand mechanical lift to transfer Resident #2. She stated that the ADL worksheet stated Resident #2 required extensive assistance, but it did not state the Resident required 2 persons for transfers before the fall. CNA B stated the Resident would yell out and call out for help until she got what she wanted. She stated CNA A was very upset about the incident and felt very bad that the Resident fell . CNA B stated they were using a Hoyer mechanical lift and commented the was afraid of falling. She would get anxious during transfers because she was afraid of falling. Interview on 8/2/18 at 2:40 p.m. with CNA C revealed she worked primarily on Station I. She stated she arrived at 2:00 p.m. on the day Resident #2 fell . She stated she knew the brakes on to the bed did not work so she made sure to keep the bed against the wall. She stated the bed moved, skated on the floor. She stated the head of the bed would also not stay up when she positioned it up in the sitting position for Resident #2. CNA C stated she talked to the previous M.S. several times and told him that the brakes did not work; she verbally reported the problem and wrote it on the maintenance log. She presented the maintenance log and there were several entries she made and one of the entries was dated 8/1/16 which read in part: does not lock. CNA C also confirmed staff was using a sit to stand mechanical lift when transferring Resident #2 and now were strictly using the Hoyer mechanical lift. CNA C stated Resident #2 was afraid since the fall when transferred and did not like being transferred via the Hoyer mechanical lift. CNA C proceeded to go to Resident #2's room; she demonstrated that the bed did not lock into position. Observation at this same time revealed the wheel casters did not lock the wheels into place. The bed moved even though the casters were in a locked position. Observational Rounds with the M.S. on 8/2/18 at 3:15 p.m. in resident rooms determined to be a fall risk as of (MONTH) (YEAR) revealed the wheels on the following beds did not lock: room [ROOM NUMBER] B, 215 B, 315 A and 407 [NAME] Note: Resident #2 was assigned to one of the rooms. Interview on 8/2/18 at 5:01 p.m. with the previous M.S. revealed he worked at the facility for about 1 year before resigning from his position. He stated the biggest problem he had was the age of the beds. He stated he talked with the V.P. and requested to buy 3 to 5 beds a month and the V.P. told him the census was too low. The previous M.S. commented he did the best he could with the materials he had because the beds were not being produced any longer. He stated he talked with the ADM about purchasing new beds, but at the time, she and the V.P. both did not approve the purchase of new beds. He stated he had a budget of about $7000 a month, but the maximum he was allowed to spend at one time was $500 without approval from corporate. The previous M.S. stated he was aware that Resident #2 had a fall and stated he knew the brakes on the bed did not work. He stated he changed the bed out the day after she fell , but then that bed broke so he put the same bed back in her room. The M.S. stated he let the ADM know the brakes were not working, but again stated he was expected to fix the beds with used parts. He confirmed he did not work on the Resident's bed because he had too much work and did not have an assistant. Interview on 8/2/18 at 5:19 p.m. with LVN J revealed she had worked at facility for [AGE] years on a part time basis. She stated she was running late the morning Resident #2 fell and stated the fall took place right before she arrived. LVN J stated she understood CNA A was using the sit to stand mechanical lift to transfer Resident #2; the Resident let go of the straps or handle and fell . LVN J stated both the aid and the Resident reported this to her and stated Resident #2 hit her head on the bottom rail of the bed. She stated she did not know anything about the brakes not locking; it had not been brought to her attention. LVN J stated nursing staff had been using the sit to stand mechanical lift or the Hoyer mechanical lift to transfer Resident #2, but they used the sit to stand more regularly. LVN J further stated it was usually one 1 aid who would transfer the Resident using the sit to stand mechanical lift. Interview on 8/2/18 at 8:36 p.m. with LVN D revealed she had worked at the facility 4 years on the 6:00 p.m. to 6:00 a.m. shift. She stated she was the charge nurse on the morning Resident #2 fell and confirmed she and the on-coming nurse were counting medications and she was passing on report. LVN D stated that CNA A notified her that Resident #2 had fallen. She walked into the room and saw Resident #2 lying on the floor next to the bed. The bed was along the wall. LVN D stated she assessed the Resident and noted a bump on her forehead. CNA A reported Resident #2 hit her head on the bottom rail of the bed. Resident #2 kept apologizing stating, I let go. CNA A was visibly upset and crying. CNA A further stated Resident #2 slipped out of the sit to stand mechanical lift and that the Resident's knees gave out. LVN D stated she could not tell if the bed moved. She did not check to see if the wheelchair or the bed were in the locked position. She stated the bed was in the low position. LVN D stated CNA A reported to work at 2:00 a.m.; she was helping out because they had limited help that morning. LVN D stated that normally there were 3 CNAs assigned to work Station I and II; one CNA was coming in at 7:00 a.m. She stated the sit to stand mechanical lift had been used in the past to transfer Resident #2, but they had quit using it 3 or 4 months prior because it was leaving pinch marks on the Resident's breasts. She stated she had advised the aids to use the Hoyer mechanical lift. LVN D stated she was not sure how they would communicate with the aids other than verbally tell them of any changes. She stated they did not have a communication book for the aids, she was not sure how the aids charted and where the information would be available for the aids. LVN D confirmed that CNA A typically worked Station II, but mentioned she had worked Station I before. She stated she did not know if CNA A knew they were using a Hoyer mechanical lift instead of the sit to stand mechanical lift for transfers and further stated she had not told CNA A of the change. LVN D stated CNA A did not tell her anything about the brakes not locking, but stated she was aware there had been mechanical problems with several of the beds. LVN D stated CNA A did not ask her for assistance and did not know if she asked another aid for assistance. She commented in her opinion there were not enough aids that day; there were 2 aids and 2 nurse's working at the time of the incident. She stated she had worked numerous times when there were only 2 aids working Station I and Station II. She mentioned they used to have 4 aides working both stations. LVN D stated the lay out of the building made it difficult to find another staff to help because the halls were long and separated; an aid was not able to look down the hall to see if anyone was available. The aid would have to walk down and go around the hall to find help. LVN D confirmed the limited aids and the lay out of the building made it difficult to manage the workload for all nursing staff. Observational Rounds with the M.S. on 8/3/18 at 8:40 a.m. in resident rooms determined to be a fall risk as of (MONTH) (YEAR) revealed the wheels on the following beds did not lock: room [ROOM NUMBER] B, 417 B, 407 A and 103 B ( the head of the bed did not lock). Resident #2 was assigned to one of the rooms. Interview on 8/3/18 at 9:30 a.m. with the ADM revealed she was out of town when Resident #2 fell . She stated her understanding after completing the investigation was that CNA A was transferring Resident #2 using a sit to stand mechanical lift on her own. Then she learned Resident #2 let go, slipped and fell . The ADM stated CNA A knew to use 2 persons when using a mechanical lift. She stated administrative staff would conduct random checks/rounds on direct care staff while providing care and they provided staff with in-servicing to make sure they understood 2 persons were required when using a mechanical lift. The ADM stated she was the M.S.'s direct boss and she was responsible for ensuring the M.S. completed his tasks and maintained the building and equipment in safe operating conditions. She stated she learned of problems/issues to be addressed during morning meetings. The ADM stated the previous M.S. rarely attended morning meetings and did not always communicate well with her. She stated he did not always let her know when there were major mechanical problems in the building. The ADM stated the previous M.S. did not let her know the brakes were not working on some of the beds. She stated she did not review the maintenance log to find out what was going on; whether or not the M.S. was completing the work orders. The ADM stated she was aware the previous M.S. would use pieces from retired beds to repair the beds being used. At times he reported he could not order parts due to the age of the bed, but again stated she did not know the brakes on some of the beds were not working. The ADM stated the M.S. had a monthly budget, but any major purchases required corporate's approval. She stated she and the M.S. discussed buying new beds; they provided the numbers to corporate and stated that purchasing new beds at the time was not approved. However, she stated that corporate had not made a final decision one way or another. The ADM stated the current M.S. reported to her after making rounds with the Surveyor that some of the brakes on the beds did not work and they would be ordering new casters. She stated that some of the beds were also designed with inner posts that would keep the bed in a stationary position when the wheels were cranked off the floor. The ADM stated that in-servicing had not been provided for staff regarding the dual functionality of the bed and she stated she was not sure if staff was aware. The ADM stated that after Resident #2s fall, PT screened all residents on their current level of function regarding transfers and anyone who was using the sit to stand mechanical lift was assessed to be more appropriate to use the mechanical lift. She stated they provided staff with in-servicing on how to properly transfer residents via a mechanical lift after Resident #2s fall. The ADM stated they did not provided in-servicing on how to use the sit to stand mechanical lift; however, they had retired this lift. Interview on 8/3/18 at 9:03 a.m. with the DON revealed she and the ADM lead the investigation after Resident #2 fell . She stated it was also her understanding that CNA A used a sit to stand mechanical lift to transfer Resident #2. She did not find a second person; during the transfer Resident #2 let go , slid and hit her head on the rail. The DON stated the bed was along the right wall upon entering the room She confirmed CNA A stated the bed moved which the DON stated would be an indicator of the brakes not working, but commented it was after the incident that she learned the brakes were not working. The DON stated she did not check the bed herself, but thought the ADM instructed the previous M.S. to check the bed. The DON stated the ADON and the MDS Coordinator audited the charts to determine the level of ADL assistance the residents required when asked who audited the charts to ensure the aids were providing care according to the resident's ADL flowsheet. The DON stated she was not aware that the aids were not using 2 persons at all times when transferring Resident #2. Interview on 8/3/18 at 9:18 a.m. with the ADON F revealed she audited charts for new admissions to ensure everything was completed per policy. She stated nursing staff was to communicate with each other during shift change regarding the level of ADL assistance the resident's required. The ADON also stated the information was available in the computer program the aids used to chart the resident's care needs. She stated if in question, an aid should defer to the charge nurse. Interview on 8/3/18 at 10:16 a.m. with the D.O.R. revealed he had worked at the facility for 8 years. He stated he attended morning meetings regularly and the complaint about faulty beds was always a subject matter during morning meetings. He stated the handles to the cranks were always broken and it was common knowledge that the brakes on some of the beds were not working. He stated the previous M.S. did not have an assistant and he often complained that he had too much work. When he was approached about a faulty bed his response was the ADM knows about it and will not order any new beds. The D.O.R. stated the previous M.S. was expected to fix the beds whatever that meant. The M.S. expressed a lot of frustration to him. The D.O.R. stated that in the [AGE] years he had worked he knew of only a hand full of new beds that had been purchased. He stated during the time that Resident #2 fell PT had been working with her and confirmed she required assistance by 2 persons for transfers. He stated the ADM asked him to screen all of the residents who used the stand to assist mechanical lift, but could not remember the resident's on the list other than Resident #2. He stated he did not have the list of residents who were screened. The D.O.R. reported that each department head was assigned a number of rooms to monitor and one of the areas that they had to check was the functionality of resident equipment. Interview on 8/3/18 at 11:21 a.m. with CNA A revealed that Resident #2s bed was along the right wall upon entering the room. However, it was not up against the wall. The head board was against the wall adjacent to the wall on the right side; there was a night stand between the head board and the wall upon entering the room. A recliner was on the left side by the headboard and closer to the window. The window was on the far back wall of the room. CNA A stated Resident #2 was in a sitting position on the bed facing the window. She positioned the stand to assist mechanical lift in front of the Resident. The wheelchair was on the right side by the foot board. CNA A stated as she started to lift the Resident, the Resident let go and landed in a sitting position on the bed, but then the bed rolled back towards the wall and the Resident fell to the floor landing sideways. CNA A stated both nurse's; on-coming and the one ending her shift came into the room and she told them that the bed rolled backwards. She stated she was asked to write a statement, but was told to be vague. CNA A stated when the DON called her she told the DON that the bed rolled backwards and then she learned from talking with other staff that the brakes had not worked for some time. Interview on 8/3/18 at 1:18 p.m. with ADON [NAME] revealed she was also the staffing coordinator. She stated that on the morning Resident #2 fell there was only 1 aide working Station I, CNA A; she had agreed to come in early to help out because there were 2 to open CNA shifts to cover that morning. The 2nd aid, CNA B, who also agreed to fill in, stated she would report to work about 6:30 a.m. or soon after. The plan was that CNA A would start dressing the residents and then when CNA B arrived they would get them up from bed. ADON [NAME] stated that everyone knew that it took 2 staff to transfer a resident when using a mechanical lift. She stated CNA A told her that the Resident kept asking CNA A to get her up from bed; CNA A thought she was helping. ADON [NAME] mentioned that CNA A had worked with Resident #2 several times before and was familiar with the Resident's care needs. In addition, nursing staff was supposed to pass on report any changes regarding care needs during shift change. She confirmed that CNA A had not worked Station I in some time and she worked a staggered shift; reported to work about 2:00 a.m. so ADON [NAME] stated she was not sure if anyone passed on report to CNA [NAME] ADON [NAME] stated she learned the brakes were not working on the day Resident #2 fell . She stated other aids knew, but did not tell her about it. Interview on 8/3/18 at 3:20 p.m. with Resident #2s RP revealed he understood the CNA was standing Resident #2 up, the CNA let go and then the Resident fell . He commented he did not know anything about the bed rolling backwards due to faulty breaks and did not know the CNA should have asked for assistance to use the mechanical lift. Resident #2s RP stated he was not happy about the incident at all. He commented he visited afterwards and the Resident had extensive black and blue bruising to the forehead and around her eyes. Interview on 8/3/18 at 4:20 p.m. with the DON revealed she was not in the facility on the day Resident #2 fell . She stated she probably checked the bed the Monday after upon returning to work. She stated the bed did not move for her, but stated she did not check to make sure the brakes were working. The DON stated she told the M.S. to look at the bed and make sure it was working. She confirmed that she did not identify the bed rolling backwards as a determining factor leading to the fall. Interview on 8/3/18 with ADON [NAME] revealed she conducted CNA classroom training's including using a mechanical lift. She stated during the last in-service, she primarily informed the aids that 2 persons were required while using a mechanical lift. She stated she did not demonstrate how to use the mechanical lift and stated she had not provided any training on using the sit to stand mechanical lift. Interview on 8/6/18 at 11:23 a.m. with LVN G revealed she had approached the previous M.S. and the ADM multiple times about mechanical issues with the bed's. She stated she was aware and administrative staff was aware that some of the beds did not lock. She stated corporate was not supportive with getting repairs completed, getting new equipment, getting more staff etc. LVN G commented it was hard to keep staff morale up because she had nothing to work with. Interview on 8/6/18 at 2:25 p.m. with the ADM revealed they had a Guardian Angel program. She assigned a number of resident rooms to department heads. Staff was to go in every morning, talk with the staff, look for any housekeeping and maintenance problems. Observation on 8/7/18 at 10:09 a.m. revealed CNA K and LVN G transferring Resident #2 using a Hoyer mechanical lift. During the transfer Resident was visibly jumpy and anxious every time staff moved the lift. Her eyes were observed to be wide open and she kept trying to clutch on to the straps. Interview on 8/7/18 at 3:30 p.m. with CNA H revealed she worked primarily Station I. She stated she was familiar with the fall Resident #2 had and confirmed the bed was not up against the wall; there was a night stand between the bed and the wall closest to the door upon entering the room. She also confirmed that the brakes on Resident #2s bed did not lock and the cranks were also broken. Interview on 8/7/18 at 4:06 p.m. with the D.M. revealed she was Resident #2s Guardian Angel. She confirmed that she was responsible for making morning rounds and was supposed to check in on the resident; check for any housekeeping and maintenance problems. The D.M. stated she did not always make her morning rounds when she had to cook breakfast. She stated she had two kitchen positions open; cook and dietary aid. The D.M. stated she was not always able to attend morning meetings either. She further stated she was not sure whether she was supposed to check if the wheels locked on the beds. The D.M. presented a Guardian Angel check list and it included to check that the bed was locked and in the lowest position. She confirmed she had not been checking the brakes. Interview on 8/8/18 at 10:28 a.m. with the previous M.S. revealed he was really pushing for getting the residents new beds because he believed they deserved a new bed. He stated he did not think about replacing the casters so much and then stated some of the casters could not be replaced because of the design of the beds. Interview on 8/8/18 at 12:15 p.m. with ADON [NAME] revealed they audited all charts and updated all information after Resident #2 fell during (MONTH) (YEAR). She stated she was not certain whether Resident #2s ADL information was on the computer program the aids were using at the time. ADON [NAME] commented she did remember updating the Resident's Care Plan after her fall to reflect that staff was to use a Hoyer mechanical lift for all transfers. Review of facility policy, Safe Lifting and Movement of Residents revised (MONTH) (YEAR) read in part: Manual lifting of residents shall be eliminated when feasible. The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. Review of a document provided by the facility on 8/8/18 revealed there were 2 residents who used the sit to stand mechanical lift for transfers during (MONTH) (YEAR).

Based on observation, interview and record review the facility failed to ensure that residents were free from neglect for 1 of 8 residents (#2) whose records were reviewed for abuse and neglect. 1. a. Resident #2 required a 2 person assist with all transfers. b. CNA A transferred Resident #2 via sit to stand mechanical lift without using a second person. c. Resident #2 fell during the transfer and sustained a 3 x 4 cm hematoma on center of forehead with a .1 cm x .1 cm superficial open area in the center; 2 cm x 2 cm discoloration to left lower leg. The Resident was sent to the ER for further evaluation and treatment as needed. 2. Resident #2's wheel casters did not lock which contributed to her fall. The ADM, the DON and the previous M.S. were aware or should have been aware that the wheel casters did not lock. These deficient practices could affect 2 residents who used the sit to stand mechanical lift for transfers and it could cause avoidable falls. The findings were: Review of Resident #2s admission record dated 8/2/18 revealed she was originally admitted into the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2s quarterly MDS dated [DATE] revealed her BIMS was 6 which meant she had severe cognitive impairment; she had impaired vision; she required extensive assistance by 2 persons with bed mobility and transfers; was not steady moving from seated to standing position and did not have a history of falls. Review of Resident 2s Care Plan updated on 2/28/18 revealed she required extensive assistance by 2 persons with transfers and she was at risk for injury reason to improper transfer. Review of a Fall Risk assessment dated [DATE] revealed Resident 2s grand total was 11 with 10 or greater indicating the Resident was a high risk for potential falls. Review of incident report dated 4/22/18 read that at 6:05 a.m., CNA (A) was transferring Resident (#2) from bed to wheelchair using a (lift). Resident let go of straps and slid to the floor striking the center of forehead with a .1 cm superficial open area in the center; 2 cm x 2 cm discoloration to left lower leg. Resident immediately assessed for injury and pain, ice applied to forehead. Review of incident follow up dated 4/24/18 revealed Resident #2 had dark reddened discoloration to under eyes bilateral, less [MEDICAL CONDITION] noted to hematoma to forehead. Area dry no active bleeding. No increased confusion noted. Denies headache. Review of ADL Assistance and Support worksheets dated (MONTH) through (MONTH) (YEAR) revealed that only 1 staff was assisting Resident #2 for transfers on multiple occasions on all 3 shifts; day, evening and night on the following dates: 1/6/18, 1/7/18, 1/12/18, 1/21/18, 1/27/18, 1/29/18, 2/4/18, 2/7/18, 2/9/18, 2/11/18, 2/14/18, 2/25/18, 2/26/18, 3/1/18. 3/3/18, 3/4/18, 3/5/18, 3/6/18, 3/10/18, 3/18/18, 3/22/18, 3/25/18, 3/27/18, 3/28/28, 3/30/18, 3/31/18, 4/1/18, 4/2/18, 4/3/18, 4/4/18, 4/7/18, 4/8/18, 4/9/18 4/10/18/ 4/11/18, 4/12/18, 4/14/18, 4/15/18, 4/16/18, 4/17/18, 4/19/18, 4/20/18, 4/21/18 4/22/18, 4/26/18, 4/27/18, 4/29/18, 5/4/18, 5/8/18, 5/9/18, 5/16/18, 5/27/18 and 5/29/18. Review of Resident 2s Care Plan updated on 5/27/18 revealed she required extensive assistance by 2 persons with transfers and that she was at risk for injury reason to improper transfer. Further review revealed staff was to use a mechanical lift for transfers. Review of Resident #2s annual assessment dated [DATE] revealed her BIMS was 6 indicative of severe cognitive impairment; she had impaired vision; she required extensive assistance by 2 persons with bed mobility and total assistance by 2 persons for transfers; was not steady moving on and off the toilet. Further review revealed she had not moved from a seating to standing position during this review period. Review of ADL Assistance and Support worksheets dated (MONTH) and (MONTH) (YEAR) revealed Resident #2 was being transferred by 1 staff on multiple occasions on the following dates: 6/5/18, 6/15/18, 6/23/18, 6/25/18, 7/2/18, 7/6/18, 7/9/18, 7/21/18, 7/27/18 and 7/29/18. Interview on 7/31/18 with CNA A revealed she had been a tenured employee of about [AGE] years at the facility. CNA A stated she usually worked on Station II, Resident #2 was on Station I. CNA A stated she was working alone on the morning Resident #2 fell . CNA A stated another CNA was scheduled to come in at 7:00 a.m. She stated she looked on the computer program to check if Resident #2 required more than 1 person for transfers. She stated she did not find the information, but had seen other aids transfer the Resident with a sit to stand mechanical lift on their own. However, she remembered they had just advised them a few days prior that 2 persons were required anytime a mechanical lift was used. CNA A stated she set up the sit to stand mechanical lift and looked for someone to help her with the transfer, but could not find any other staff that was available. She stated the charge nurse was giving report and counting medications with the on-coming nurse and there were no other CNAs available; none that she could see. CNA A stated the usual argument that administrative staff would give them was to find a charge nurse or another CNA to assist as needed. CNA A stated she proceeded to transfer Resident #2 with the sit to stand mechanical lift because she felt pressured to get the Resident up because the Resident kept asking to get up. She stated the Resident's family member was very particular and she did not want the Resident to complain to the family member and then she would get into trouble. CNA A stated during the transfer everything was going fine and then the Resident suddenly looked at her and stated, I'm sorry, but I have to let go. Resident #2 let go of the straps fell back onto the bed, the bed rolled backwards and she fell to the floor hitting her forehead on the bottom metal frame of the bed landing on her right side/shoulder. CNA A stated she immediately went to get the charge nurse. She stated she was so upset and crying because she did not mean to hurt the Resident. CNA A stated she had tried to lock the bed, but it did not lock; the brakes were not working. She stated the bed was closer to the middle of the room and not against the wall. Interview 8/1/18 at 1:42 p.m. with LVN I revealed she worked 6 a.m. to 6 p.m. LVN I stated the only time when it was difficult to manage the load was when someone called in and there was not a replacement then everyone had to help each other out. She stated that the CNAs usually work well together, but confirmed the halls were long and it was a lot of area to cover. In addition, there was no visibility; the aids could not see each other's whereabouts and there was no call light intercom on Station I. Interview on 8/2/18 at 8:15 a.m. with Resident #2 revealed she was sitting in recliner; there was a rolling walker by the recliner and a wheelchair in front of the bathroom door. The wheelchair was not locked. Resident #2 did not have any visible bruising. She remembered incident/fall very clearly, but could not remember all the details. Resident #2 stated she fell and hit her head on the floor. She stated she had a knot on her forehead and bruising under both eyes. Resident #2 stated the doctor and everybody else came to see her. She commented she was doing much better. The Resident #2 then commented she fell at home in Hallettsville; she was not sure who had assisted her. Resident #2 stated she did not ambulate and used a wheelchair. Observation at this same time revealed Resident #2s bed rolled from side to side after engaging the casters on the wheels. Further observation revealed the bed was against the wall adjoined to the wall on the right side upon entering the room Interview on 8/2/18 with CNA B revealed she worked Station I on a regular basis. CNA B stated she agreed to work and made arrangements to report to work at 7:00 a.m. on the morning Resident #2 fell . She stated she was familiar with Resident #2s fall and knew the brakes on the bed did not work and had reported it to the previous M.S. He told her he was working on getting new beds for the residents, but would change out Resident #2s bed. She commented she made sure the beds were against the wall to be safe. CNA B stated the M.S. did not change out the bed and commented, he had too much work to do. She stated many of the beds had mechanical problems; the cranks did not work, the brakes did not work and they had nails sticking out of them where the cranks were attached. She commented they were old beds. CNA B confirmed staff was using a sit to stand mechanical lift to transfer Resident #2. She stated that the ADL worksheet stated Resident #2 required extensive assistance, but it did not state the Resident required 2 persons for transfers before the fall. CNA B stated the Resident would yell out and call out for help until she got what she wanted. She stated CNA A was very upset about the incident and felt very bad that the Resident fell . CNA B stated they were using a Hoyer mechanical lift and commented the was afraid of falling. She would get anxious during transfers because she was afraid of falling. Interview on 8/2/18 at 2:40 p.m. with CNA C revealed she worked primarily on Station I. She stated she arrived at 2:00 p.m. on the day Resident #2 fell . She stated she knew the brakes on to the bed did not work so she made sure to keep the bed against the wall. She stated the bed moved, skated on the floor. She stated the head of the bed would also not stay up when she positioned it up in the sitting position for Resident #2. CNA C stated she talked to the previous M.S. several times and told him that the brakes did not work; she verbally reported the problem and wrote it on the maintenance log. She presented the maintenance log and there were several entries she made and one of the entries was dated 8/1/16 which read in part: does not lock. CNA C also confirmed staff was using a sit to stand mechanical lift when transferring Resident #2 and now were strictly using the Hoyer mechanical lift. CNA C stated Resident #2 was afraid since the fall when transferred and did not like being transferred via the Hoyer mechanical lift. CNA C proceeded to go to Resident #2's room; she demonstrated that the bed did not lock into position. Observation at this same time revealed the wheel casters did not lock the wheels into place. The bed moved even though the casters were in a locked position. Observational Rounds with the M.S. on 8/2/18 at 3:15 p.m. in resident rooms determined to be a fall risk as of (MONTH) (YEAR) revealed the wheels on the following beds did not lock: room [ROOM NUMBER] B, 215 B, 315 A and 407 [NAME] Note: Resident #2 was assigned to one of the rooms. Interview on 8/2/18 at 5:01 p.m. with the previous M.S. revealed he worked at the facility for about 1 year before resigning from his position. He stated the biggest problem he had was the age of the beds. He stated he talked with the V.P. and requested to buy 3 to 5 beds a month and the V.P. told him the census was too low. The previous M.S. commented he did the best he could with the materials he had because the beds were not being produced any longer. He stated he talked with the ADM about purchasing new beds, but at the time, she and the V.P. both did not approve the purchase of new beds. He stated he had a budget of about $7000 a month, but the maximum he was allowed to spend at one time was $500 without approval from corporate. The previous M.S. stated he was aware that Resident #2 had a fall and stated he knew the brakes on the bed did not work. He stated he changed the bed out the day after she fell , but then that bed broke so he put the same bed back in her room. The M.S. stated he let the ADM know the brakes were not working, but again stated he was expected to fix the beds with used parts. He confirmed he did not work on the Resident's bed because he had too much work and did not have an assistant. Interview on 8/2/18 at 5:19 p.m. with LVN J revealed she had worked at facility for [AGE] years on a part time basis. She stated she was running late the morning Resident #2 fell and stated the fall took place right before she arrived. LVN J stated she understood CNA A was using the sit to stand mechanical lift to transfer Resident #2; the Resident let go of the straps or handle and fell . LVN J stated both the aid and the Resident reported this to her and stated Resident #2 hit her head on the bottom rail of the bed. She stated she did not know anything about the brakes not locking; it had not been brought to her attention. LVN J stated nursing staff had been using the sit to stand mechanical lift or the Hoyer mechanical lift to transfer Resident #2, but they used the sit to stand more regularly. LVN J further stated it was usually one 1 aid who would transfer the Resident using the sit to stand mechanical lift. Interview on 8/2/18 at 8:36 p.m. with LVN D revealed she had worked at the facility 4 years on the 6:00 p.m. to 6:00 a.m. shift. She stated she was the charge nurse on the morning Resident #2 fell and confirmed she and the on-coming nurse were counting medications and she was passing on report. LVN D stated that CNA A notified her that Resident #2 had fallen. She walked into the room and saw Resident #2 lying on the floor next to the bed. The bed was along the wall. LVN D stated she assessed the Resident and noted a bump on her forehead. CNA A reported Resident #2 hit her head on the bottom rail of the bed. Resident #2 kept apologizing stating, I let go. CNA A was visibly upset and crying. CNA A further stated Resident #2 slipped out of the sit to stand mechanical lift and that the Resident's knees gave out. LVN D stated she could not tell if the bed moved. She did not check to see if the wheelchair or the bed were in the locked position. She stated the bed was in the low position. LVN D stated CNA A reported to work at 2:00 a.m.; she was helping out because they had limited help that morning. LVN D stated that normally there were 3 CNAs assigned to work Station I and II; one CNA was coming in at 7:00 a.m. She stated the sit to stand mechanical lift had been used in the past to transfer Resident #2, but they had quit using it 3 or 4 months prior because it was leaving pinch marks on the Resident's breasts. She stated she had advised the aids to use the Hoyer mechanical lift. LVN D stated she was not sure how they would communicate with the aids other than verbally tell them of any changes. She stated they did not have a communication book for the aids, she was not sure how the aids charted and where the information would be available for the aids. LVN D confirmed that CNA A typically worked Station II, but mentioned she had worked Station I before. She stated she did not know if CNA A knew they were using a Hoyer mechanical lift instead of the sit to stand mechanical lift for transfers and further stated she had not told CNA A of the change. LVN D stated CNA A did not tell her anything about the brakes not locking, but stated she was aware there had been mechanical problems with several of the beds. LVN D stated CNA A did not ask her for assistance and did not know if she asked another aid for assistance. She commented in her opinion there were not enough aids that day; there were 2 aids and 2 nurse's working at the time of the incident. She stated she had worked numerous times when there were only 2 aids working Station I and Station II. She mentioned they used to have 4 aides working both stations. LVN D stated the lay out of the building made it difficult to find another staff to help because the halls were long and separated; an aid was not able to look down the hall to see if anyone was available. The aid would have to walk down and go around the hall to find help. LVN D confirmed the limited aids and the lay out of the building made it difficult to manage the workload for all nursing staff. Observational Rounds with the M.S. on 8/3/18 at 8:40 a.m. in resident rooms determined to be a fall risk as of (MONTH) (YEAR) revealed the wheels on the following beds did not lock: room [ROOM NUMBER] B, 417 B, 407 A and 103 B ( the head of the bed did not lock). Resident #2 was assigned to one of the rooms. Interview on 8/3/18 at 9:30 a.m. with the ADM revealed she was out of town when Resident #2 fell . She stated her understanding after completing the investigation was that CNA A was transferring Resident #2 using a sit to stand mechanical lift on her own. Then she learned Resident #2 let go, slipped and fell . The ADM stated CNA A knew to use 2 persons when using a mechanical lift. She stated administrative staff would conduct random checks/rounds on direct care staff while providing care and they provided staff with in-servicing to make sure they understood 2 persons were required when using a mechanical lift. The ADM stated she was the M.S.'s direct boss and she was responsible for ensuring the M.S. completed his tasks and maintained the building and equipment in safe operating conditions. She stated she learned of problems/issues to be addressed during morning meetings. The ADM stated the previous M.S. rarely attended morning meetings and did not always communicate well with her. She stated he did not always let her know when there were major mechanical problems in the building. The ADM stated the previous M.S. did not let her know the brakes were not working on some of the beds. She stated she did not review the maintenance log to find out what was going on; whether or not the M.S. was completing the work orders. The ADM stated she was aware the previous M.S. would use pieces from retired beds to repair the beds being used. At times he reported he could not order parts due to the age of the bed, but again stated she did not know the brakes on some of the beds were not working. The ADM stated the M.S. had a monthly budget, but any major purchases required corporate's approval. She stated she and the M.S. discussed buying new beds; they provided the numbers to corporate and stated that purchasing new beds at the time was not approved. However, she stated that corporate had not made a final decision one way or another. The ADM stated the current M.S. reported to her after making rounds with the Surveyor that some of the brakes on the beds did not work and they would be ordering new casters. She stated that some of the beds were also designed with inner posts that would keep the bed in a stationary position when the wheels were cranked off the floor. The ADM stated that in-servicing had not been provided for staff regarding the dual functionality of the bed and she stated she was not sure if staff was aware. The ADM stated that after Resident #2s fall, PT screened all residents on their current level of function regarding transfers and anyone who was using the sit to stand mechanical lift was assessed to be more appropriate to use the mechanical lift. She stated they provided staff with in-servicing on how to properly transfer residents via a mechanical lift after Resident #2s fall. The ADM stated they did not provided in-servicing on how to use the sit to stand mechanical lift; however, they had retired this lift. Interview on 8/3/18 at 9:03 a.m. with the DON revealed she and the ADM lead the investigation after Resident #2 fell . She stated it was also her understanding that CNA A used a sit to stand mechanical lift to transfer Resident #2. She did not find a second person; during the transfer Resident #2 let go , slid and hit her head on the rail. The DON stated the bed was along the right wall upon entering the room She confirmed CNA A stated the bed moved which the DON stated would be an indicator of the brakes not working, but commented it was after the incident that she learned the brakes were not working. The DON stated she did not check the bed herself, but thought the ADM instructed the previous M.S. to check the bed. The DON stated the ADON and the MDS Coordinator audited the charts to determine the level of ADL assistance the residents required when asked who audited the charts to ensure the aids were providing care according to the resident's ADL flowsheet. The DON stated she was not aware that the aids were not using 2 persons at all times when transferring Resident #2. Interview on 8/3/18 at 9:18 a.m. with the ADON F revealed she audited charts for new admissions to ensure everything was completed per policy. She stated nursing staff was to communicate with each other during shift change regarding the level of ADL assistance the resident's required. The ADON also stated the information was available in the computer program the aids used to chart the resident's care needs. She stated if in question, an aid should defer to the charge nurse. Interview on 8/3/18 at 10:16 a.m. with the D.O.R. revealed he had worked at the facility for 8 years. He stated he attended morning meetings regularly and the complaint about faulty beds was always a subject matter during morning meetings. He stated the handles to the cranks were always broken and it was common knowledge that the brakes on some of the beds were not working. He stated the previous M.S. did not have an assistant and he often complained that he had too much work. When he was approached about a faulty bed his response was the ADM knows about it and will not order any new beds. The D.O.R. stated the previous M.S. was expected to fix the beds whatever that meant. The M.S. expressed a lot of frustration to him. The D.O.R. stated that in the [AGE] years he had worked he knew of only a hand full of new beds that had been purchased. He stated during the time that Resident #2 fell PT had been working with her and confirmed she required assistance by 2 persons for transfers. He stated the ADM asked him to screen all of the residents who used the stand to assist mechanical lift, but could not remember the resident's on the list other than Resident #2. He stated he did not have the list of residents who were screened. The D.O.R. reported that each department head was assigned a number of rooms to monitor and one of the areas that they had to check was the functionality of resident equipment. Interview on 8/3/18 at 11:21 a.m. with CNA A revealed that Resident #2s bed was along the right wall upon entering the room. However, it was not up against the wall. The head board was against the wall adjacent to the wall on the right side; there was a night stand between the head board and the wall upon entering the room. A recliner was on the left side by the headboard and closer to the window. The window was on the far back wall of the room. CNA A stated Resident #2 was in a sitting position on the bed facing the window. She positioned the stand to assist mechanical lift in front of the Resident. The wheelchair was on the right side by the foot board. CNA A stated as she started to lift the Resident, the Resident let go and landed in a sitting position on the bed, but then the bed rolled back towards the wall and the Resident fell to the floor landing sideways. CNA A stated both nurse's; on-coming and the one ending her shift came into the room and she told them that the bed rolled backwards. She stated she was asked to write a statement, but was told to be vague. CNA A stated when the DON called her she told the DON that the bed rolled backwards and then she learned from talking with other staff that the brakes had not worked for some time. Interview on 8/3/18 at 1:18 p.m. with ADON [NAME] revealed she was also the staffing coordinator. She stated that on the morning Resident #2 fell there was only 1 aide working Station I, CNA A; she had agreed to come in early to help out because there were 2 to open CNA shifts to cover that morning. The 2nd aid, CNA B, who also agreed to fill in, stated she would report to work about 6:30 a.m. or soon after. The plan was that CNA A would start dressing the residents and then when CNA B arrived they would get them up from bed. ADON [NAME] stated that everyone knew that it took 2 staff to transfer a resident when using a mechanical lift. She stated CNA A told her that the Resident kept asking CNA A to get her up from bed; CNA A thought she was helping. ADON [NAME] mentioned that CNA A had worked with Resident #2 several times before and was familiar with the Resident's care needs. In addition, nursing staff was supposed to pass on report any changes regarding care needs during shift change. She confirmed that CNA A had not worked Station I in some time and she worked a staggered shift; reported to work about 2:00 a.m. so ADON [NAME] stated she was not sure if anyone passed on report to CNA [NAME] ADON [NAME] stated she learned the brakes were not working on the day Resident #2 fell . She stated other aids knew, but did not tell her about it. Interview on 8/3/18 at 3:20 p.m. with Resident #2s RP revealed he understood the CNA was standing Resident #2 up, the CNA let go and then the Resident fell . He commented he did not know anything about the bed rolling backwards due to faulty breaks and did not know the CNA should have asked for assistance to use the mechanical lift. Resident #2s RP stated he was not happy about the incident at all. He commented he visited afterwards and the Resident had extensive black and blue bruising to the forehead and around her eyes. Interview on 8/3/18 at 4:20 p.m. with the DON revealed she was not in the facility on the day Resident #2 fell . She stated she probably checked the bed the Monday after upon returning to work. She stated the bed did not move for her, but stated she did not check to make sure the brakes were working. The DON stated she told the M.S. to look at the bed and make sure it was working. She confirmed that she did not identify the bed rolling backwards as a determining factor leading to the fall. Interview on 8/3/18 with ADON [NAME] revealed she conducted CNA classroom training's including using a mechanical lift. She stated during the last in-service, she primarily informed the aids that 2 persons were required while using a mechanical lift. She stated she did not demonstrate how to use the mechanical lift and stated she had not provided any training on using the sit to stand mechanical lift. Interview on 8/6/18 at 11:23 a.m. with LVN G revealed she had approached the previous M.S. and the ADM multiple times about mechanical issues with the bed's. She stated she was aware and administrative staff was aware that some of the beds did not lock. She stated corporate was not supportive with getting repairs completed, getting new equipment, getting more staff etc. LVN G commented it was hard to keep staff morale up because she had nothing to work with. Interview on 8/6/18 at 2:25 p.m. with the ADM revealed they had a Guardian Angel program. She assigned a number of resident rooms to department heads. Staff was to go in every morning, talk with the staff, look for any housekeeping and maintenance problems. Observation on 8/7/18 at 10:09 a.m. revealed CNA K and LVN G transferring Resident #2 using a Hoyer mechanical lift. During the transfer Resident was visibly jumpy and anxious every time staff moved the lift. Her eyes were observed to be wide open and she kept trying to clutch on to the straps. Interview on 8/7/18 at 3:30 p.m. with CNA H revealed she worked primarily Station I. She stated she was familiar with the fall Resident #2 had and confirmed the bed was not up against the wall; there was a night stand between the bed and the wall closest to the door upon entering the room. She also confirmed that the brakes on Resident #2s bed did not lock and the cranks were also broken. Interview on 8/7/18 at 4:06 p.m. with the D.M. revealed she was Resident #2s Guardian Angel. She confirmed that she was responsible for making morning rounds and was supposed to check in on the resident; check for any housekeeping and maintenance problems. The D.M. stated she did not always make her morning rounds when she had to cook breakfast. She stated she had two kitchen positions open; cook and dietary aid. The D.M. stated she was not always able to attend morning meetings either. She further stated she was not sure whether she was supposed to check if the wheels locked on the beds. The D.M. presented a Guardian Angel check list and it included to check that the bed was locked and in the lowest position. She confirmed she had not been checking the brakes. Interview on 8/8/18 at 10:28 a.m. with the previous M.S. revealed he was really pushing for getting the residents new beds because he believed they deserved a new bed. He stated he did not think about replacing the casters so much and then stated some of the casters could not be replaced because of the design of the beds. Interview on 8/8/18 at 12:15 p.m. with ADON [NAME] revealed they audited all charts and updated all information after Resident #2 fell during (MONTH) (YEAR). She stated she was not certain whether Resident #2s ADL information was on the computer program the aids were using at the time. ADON [NAME] commented she did remember updating the Resident's Care Plan after her fall to reflect that staff was to use a Hoyer mechanical lift for all transfers. Review of facility policy, Abuse, Neglect and Exploitation Policy revised on (MONTH) (YEAR) read in part: Comprehensive policies and procedures have been developed to aid our facility in preventing abuse/neglect or mistreatment of [REDACTED]. The help with recognition of incidents of abuse, the following definitions of abuse are provided by the State Operations Manual Appending PP Guidance to Surveyors: f. (Neglect) is defined as failure to provide goods and services necessary to avoid physical harm, mental aguish, or mental illness. Review of facility policy, Safe Lifting and Movement of Residents revised (MONTH) (YEAR) read in part: Manual lifting of residents shall be eliminated when feasible. The use of a mechanical lift with residents requires the assistance of 2 staff members at all times. Review of a document provided by the facility on 8/8/18 revealed there were 2 residents who used the sit to stand mechanical lift for transfers during (MONTH) (YEAR).