Every finding on record at The Bridges at Ankeny

Based on observations, interviews, and record review, the facility failed to ensure diversion of narcotics did not occur. Staff found that a Roxicodone (narcotic for pain) pill was missing and was replaced with a Spironolactone (diuretic (removes water)) pill for 1 of 3 residents reviewed (Resident #2). The facility reported a census of 94 residents. The facility corrected the noncompliance prior to the beginning of the survey on July 27, 2026 by doing the following;a. Director of Nursing (DON) completed an audit of all medication cardsb. Education was completed with all nurses and certified medication aides regarding proper handling and storage of narcotic medications.c. An assessment of pain for all residents who received a narcotic was completed.d. Audits were completed daily for three weeks following the incident.e. Results were by the QAPI team and a sustained monitoring frequency will be continued.Findings include:A Minimum Data Set, dated [DATE], documented diagnoses for Resident #2 included arthritis, diabetes, and acquired absence of left and right leg below the knees. A Brief Interview of Mental Status for this resident revealed a score of 15 out of 15, indicating intact cognition. It documented that this resident received pain medication. The MDS documented that the resident required total assistance of staff for activities of daily living including; toileting hygiene, shower/bathing, dressing, and transfers from surface to surface (for example bed to chair). A Care Plan revised on 9/2/25, directed staff that Resident #2 was at risk for pain/discomfort and increased risk for injury from decreased function related to diagnosis of osteomyelitis (painful bone infection), TMA, and partial Calcanectomy (surgical removal of part or all of the heel bone), and left below the knee amputation. It directed that staff were to administer pain medications as ordered. A Medication Administration Record (MAR) for the month of July 2026, directed that Roxicodone 5 mg (milligrams), was to be given by mouth two times a day for pain. It documented that this order for Roxicodone had a start date of 4/3/26. In a 5 day Investigation Summary for Self-Report with a report date of 7/14/26, documented that on 7/14/26, Staff A, Registered Nurse (RN), reported that Resident #2's Roxicodone tablet had been replaced with a Spironolactone tablet, which had been taped into the bubble pack in place of the Roxicodone tablet. On 8/4/26 at 8/4/26 at 1:56 p.m., Staff A stated that she noticed there was a card that had a piece of tape over it. It was the last tablet for the Roxicodone for Resident #2. Staff A stated that she counted narcotics with Staff B, Licensed Practical Nurse (LPN), when Staff B arrived at the facility. Staff A said that Staff B caught that the pill looked different than the others. Staff B told Staff A she noticed right away the pill was different because of the size difference. The tablet/pill was taped in (the narcotic card). Staff A stated she didn't have any clue who would do such a thing. On 7/28/26 at 10:45 a.m., the Director of Nursing and the Administer confirmed that a Roxicodone was punched out of the bubble in the card it came in and a Spironolactone was placed into the bubble then taped into the card. This DON and Administrator stated they were not definitively able to prove who had done this nor account for where the Roxicodone had went. A Controlled Substance Administration & Accountability policy copyrighted in 2025, directed that: it is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure.

Based on observations, interviews and documentation review, the facility failed to provide grooming for 1 of 3 residents reviewed (Resident #7). Resident #7 was noted to have caked dried on food in his mustache and beard on 2 separate days. Refusals of care were not documented. The facility reported a census of 96. Findings include:A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #7 included stroke, hemiplegia (loss of strength/movement on one side of the body), and non-Alzheimer's dementia. A Brief Interview for Mental Status (BIMS), documented this resident had a score of 3 out of 15, indicating that this resident had a sever cognitive deficit. Resident #7 required substantial to maximal assistance for personal hygiene, bathing, and transfers. On 6/8/26 at 3:45 p.m., Resident #7 was lying in bed. His beard and facial hair were crusted all around mouth with reddish dried on matter (food). This Resident did not answer when asked if staff help him with cleaning his beard. He looked away. On 6/9/26 at 10:20 a.m., this Resident was lying in bed. Lights were off in room. Had a container of scrambled eggs and toast on his tray table next to his bed. Resident appeared to have food/matter still dried on to his beard and facial hair. Resident would not answer questions and looked the other way. On 6/9/26 at 1:15 p.m., Resident #7 was lying in bed. Food was noted to be on his facial hair. On 6/9/26 at 2:05 p.m., this resident was lying in bed. The food remained on his beard and facial hair. On 6/9/26 at 3:31 p.m., The Lead Housekeeper was outside of his room. She stated she planned to clean his room next. She stated normally she has a male housekeeper clean his room because the resident can be so inappropriate. She said it's not the things he says, she said she can deal with that. She says it's what he does that is so inappropriate. Resident lying in bed. Food remained caked on his facial hair.On 6/9/26 at 3:45 p.m., The above observations were shared with the Director of Nursing (DON). She stated that this resident refuses cares all the time. This DON will look for documentation of the refusals. The DON asked Staff A, Licensed Practical Nurse (LPN), to go in to this resident's room with her for cares in pairs. This LPN responded he refuses all the time. The LPN was asked if this was documented and the LPN repeated that this resident refuses care all the time. Upon entrance to this resident, the DON asked Resident #7 if she could wash off his mustache and beard. DON started to wash the food of his beard. She stated It (the food) is stuck on there pretty good. The resident did not resist but stuck his hand underneath the covers and appeared to be pleasuring himself. This resident propositioned the DON sexually while she was washing his face. She was able to wash his mustache and beard with soap and water and then rinse with water using wash cloths. She asked if she could dry and he pushed her hand away and said no. She asked if there was anything else she could do for him before she left the room. Following the above observation the DON acknowledged that this resident's refusals to have his face washed had not been documented.On 6/29/26 at 10:18 a.m., Administrator and DON acknowledged that this resident had food dried on his beard and mustache after meals, which was not cleaned off. On 6/10/26 at 11:58 a.m., Staff B, Certified Nurse Aide (CNA), stated that yesterday morning, he had tried to wash Resident #7's face off. He stated he tried to wash his face off right before breakfast. He said that there had been debris in his beard for a long time. Staff B had tried to use a wash cloth to try and moisten it (the day before), but it was so hard that he couldn't get the debris off. He stated that later on he had tried to use wipes and tried using soapy water and the resident started pushing Staff B away. Staff B stated he tries to do as much for Resident #7 as he can because Resident #7 has behaviors toward women. Staff B stated that this resident doesn't have the sexual behavior toward men. Staff B stated that multiple female staff have asked Staff B to care for Resident #7 as they don't feel comfortable with him. On 6/10/26 at 12:30 p.m., the Administrator stated they know they need to document refusals and they are going to follow up with more education regarding how to care for Resident #7.An Activities of Daily Living policy copyright date of 2025, directed the following: Policy:The facility will, based on the resident's comprehensive assessment and consistent with the resident'sneeds and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration isunavoidable.Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming and oral care;2. Transfer and ambulation;3. Toileting;4. Eating to include meals and snacks; and5. Using speech, language or other functional communication systems.Policy Explanation and Compliance Guidelines:1. Conditions which may demonstrate unavoidable decline in ADLs include:a. Natural progression of the resident's disease state with known functional decline.b. Deterioration of the resident's physical condition associated with the onset of an acutephysical or mental disability while receiving care to restore or maintain functional abilities.c. Refusal of care and treatment by the resident or his/her representative to maintain functionalabilities after efforts by the facility to inform and educate about the benefits/risks of theproposed care and treatment; counsel and/or offer alternatives to the resident or representative.2. The facility will provide a maintenance and restorative program to assist the resident in achieving andmaintaining the highest practicable outcome based on the comprehensive assessment.3. A resident who is unable to carry out activities of daily living will receive the necessary services tomaintain good nutrition, grooming, and personal and oral hygiene.4. The facility will identify resident triggers through the Care Area Assessment (CAA) process to assesscausal factors for decline, potential decline or lack of improvement.5. The facility will maintain individual objectives of the care plan and periodic review and evaluation.

Based on resident interview, staff interview and policy review, the facility failed to notify a qualified staff member of an intravenous (IV) pump that was not working properly resulting in a delay of the resident's continuous IV medication for 1 of 5 residents reviewed for medication administration (Resident #12). The facility reported a census of 96 residents. The facility corrected the noncompliance prior to the beginning of the survey on 6/9/26 by doing the following; a. The scheduler was immediately educated on the need to ensure a registered nurse (RN) or licensed practical nurse (LPN) with IV certification was on the schedule at all times while an IV is in the building. b. The master schedule was reviewed to identify and areas of concern that may not have IV staff. c. Staff education to LPN's who are not certified included the purpose as follows; to ensure safe resident care and prevent delays in treatment, all nursing staff must understand expectations for IV-related issues when and IV-certified nurse is not immediately available. d. The scheduler will review daily schedules to ensure there are no gaps. e. In addition RN staffing and regulations were reviewed. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognition. The MDS further revealed the resident had diagnoses of sepsis (life threatening response to an infection) and osteomyelitis (infection of the bone). Review of the June Medication Administration Record (MAR) for Resident #12 revealed an order for continuous Nafcillin (antibiotic) sodium IV solution reconstituted with a start date of 5/6/26. Review of the Care Plan initiated 5/1/26 for Resident #12 revealed the resident had an acute infection of osteomyelitis of the thoracic vertebrae (middle spine) with sepsis and directed staff to administer antibiotics as ordered. During an interview 6/10/26 at 9:45 AM, Resident #12 revealed on 6/9/26 at approximately 4:00 AM he had utilized his call light to alert staff that the IV pump had an error code and was not operating. A staff member responded and stated they would notify the nurse however no one arrived for approximately 30 minutes. The resident stated he then walked to the nurse's station to notify staff of the IV pump not working and was told he would have to wait until shift change because there was currently no one at the facility that was IV certified. The resident stated he then waited until approximately 6:30 AM following the 6:00 AM shift change report to notify staff of the malfunctioning IV pump and a Registered Nurse (RN) adjusted the IV pump so that it was in working order. Review of the facility incident report dated 6/9/26 at 6:00 AM, Resident #12 reported the IV malfunctioned at approximately 4:00 AM the IV started to beep indicating it needed to be reset and the nurse was not able to reset the IV. This resulted in the resident missing 2 hours of the antibiotic. On 6/10/26 at 10:25 AM, the Administrator confirmed that Resident #12 did not receive his IV antibiotic as ordered on the morning of 6/9/26. The Administrator revealed a RN that usually covered the shift had been on leave at the time. The Administrator further revealed the Assistant Director of Nursing (ADON) had been on-call and covered 6/9/26 however the ADON left the facility around 3:30 AM. On 6/10/26 at 2:15 PM, the Administrator clarified that a Licensed Practical Nurse (LPN) with IV therapy certification had been on duty during the time Resident #12's IV pump malfunctioned on 6/9/26. However, the Administrator confirmed that facility personnel failed to notify the certified LPN of the malfunctioning IV pump after being alerted by the resident.Review of facility policy titled, Nursing Services and Sufficient Staff, dated 2025 revealed it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.

Based on record review, policy review and staff interviews, the facility failed to ensure all residents received medication as ordered by a physician and failed to prevent potentially serious medication errors when staff administered the wrong medications or dosage for 3 of 3 residents reviewed (Residents #103, #105 and #102). Resident #103 received the wrong medications, transferred to the hospital where he was admitted to the hospital and had bradycardic episodes (temporary or sustained drop in heart rate below 60 beats per minute). The facility reported a census of 90 residents.The facility corrected the immediate concern prior to the survey on 3/9/26 when the facility staff implemented the following corrective actions: The facility conducted a root cause analysis of how and why the medication errors occurred. The facility did evaluations of medication pass with staff that are responsible for giving residents medications. The facility provided medication pass education, and review of the policy for medication pass to all staff responsible for distributing medications to the residents. The facility developed a Room Change Medication Safety Checklist for staff to ensure safe and accurate medication administration following any resident room change, in accordance with CMS medication safety and profession standards. The scope and severity was lowered from a G to a D at the time of the survey after ensuring the facility implemented the corrective actions. Findings include: 1. Resident #103's admission Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score as a 14, indicating intact cognition. The MDS listed diagnoses of stroke, cognitive communication deficit, and a urinary tract infection. Resident #103's Incident Report for 1/31/26 documented the following; the resident had received the wrong medications, and a short while later was pale with head drooping and not able to speak at this time. The nurse assessed him and his blood pressure and heart rate were low. He was sent to the hospital. Review of the facility's Investigation Summary documented Staff A, Registered Nurse (RN) noted resident #103's blood pressure and heart rate were low. Staff A was called to the Medication Cart by Staff B, Certified Medication Aide (CMA) and at that time it was noted Staff A gave Resident #103 another resident's medications that morning. Staff A then called the on-call doctor and the doctor ordered to send the resident to the hospital for fluids and to be monitored. The medications Resident #103 received were as follows; Losartan (used to treat high blood pressure) 100 milligrams (mg), Carvedilol (used to treat high blood pressure by relaxing blood vessels and slowing the heart) 25 mg, Diltiazem (used to treat high blood pressure) 180 mg extended release, Hydroxyzine ( antihistamine which can cause drowsiness) 25mg, Eliquis (blood thinner)5 mg, Donepezil (used to treat confusion and memory loss in Alzheimer's disease) 10mg, Ezetimbe (used lower cholesterol) 40 mg, Fluoxetine (used to treat depression) 40mg, and Rosuvastatin (used to lower cholesterol) 40mg, all of which were not prescribed to him. Resident #103 had moved rooms and Staff A pulled the medications from the wrong room spot in the medication cart. The investigation documented Staff A had taken the medications out of the cart, crushed them and gave them to the resident. The facility investigation lacked documentation of staff or resident interviews to determine if there were any concerns noted in the past or present with medication administration. Review of the hospital records for Resident #103 documented he had episodes of bradycardic, down to 35 beats per minute for his heart rate. He had intravenous fluid boluses (rapid dose of fluids). The half-life (time required for the body to reduce concentration of the drug by 50%) of the medications that were given range from 2 to 20 hours. In addition, he was not supposed to be on Eliquis (blood thinner) until he had a repeat scan of the brain due to his stroke. He was admitted to the hospital to for monitoring due to half life of medications. On 3/10/26 at 11:25 AM Staff A, RN reported on 1/31/26 she had a CMA that day working with her. Staff A reported at 8:00 AM she went to do Resident #103's meds. She grabbed the last person's meds in 115 spot in the medication cart since Resident #103 was in 115. Staff A reported at the time the CMA was on the computer at the cart so she just popped the medications and gave them. Staff A reported she did not look to see if it was Resident #103's name on the medication packs and did not compare the medications to the Medication Administration Record (MAR). A short while later at breakfast she noted Resident #103's head was down and seemed off so she checked his blood pressure twice with the automatic cuff and it was low. Staff A reported she went to get a manual blood pressure cuff. When she was looking for a cuff, Staff B, CMA came and said she gave the wrong medications. Staff A reported she went to the cart to verify that yes it was the wrong medication she gave to Resident #103. Staff A then went back to Resident #103 in the dining room and the daughter was with the resident. The daughter asked what was wrong with him. Staff A told the daughter at that time that she gave him the wrong medication. Staff A took him to his room and aides assisted him and she called the doctor and the doctor said to send him out. Staff A called 911 at that time. Staff A reported it is not her normal practice to give medications without verifying with the MAR or checking the name. Staff A reported I would never do that again. On 3/10/26 at 12:54 PM Staff B, CMA reported she worked on 1/31/26 as the medication aide. Staff B reported she gave Staff A, RN the keys to the medication cart to let her do the g-tube residents first since she cannot do them. Staff B reported she went to do other things and when she came back to the cart Staff A gave the keys back. Staff B reported a short while later she saw Staff A and she was looking around. Staff B then asked Staff A what she was looking for. Staff A reported a manual blood pressure cuff due to Resident #103 having a low blood pressure Staff B reported Resident #103 was doing good prior to this incident when she saw him go by for breakfast. Staff B reported that as long as she knew Resident #103 she never had heard of him having a low blood pressure that she was aware of, so she wondered about his medications. Staff B reported then looked into her medication cart and she noticed Staff A gave the wrong medications to Resident #103. Staff B reported she is not sure how Staff A made the error. Staff B reported she informed Staff A of the medication error and showed her whose meds she gave. Staff B then called for the Certified Nurses Aides to come help with Resident #103 so Staff A could do all the stuff she needed to for him. Staff B reported the daughter was here at the time of the incident and was upset. Staff B stayed in the dining room with the other residents while Staff A was working with Resident #103. Staff B reported she was not told to write a statement of what happened that day at all by the facility. On 3/10/26 at 3:30 PM the Administrator and Director of Nursing (DON) reported Staff A was verbally educated that day about the 6 rights of medication administration (the right of medication administration to ensure resident safety by verifying: right resident, right dose, right medication, right dose, right route, right time and right documentation). The DON reported the staff are trained on the 6 rights in orientation on the checklist during training. On 3/11/2026 at 10:35 AM the Medical Direct reported he filled out the he filled out Major Injury Determination Form on Resident #103 because he required hospitalization. The Medical Director reported the medications that were given could drop the resident's blood pressure and heart rate. He reported the medication error could have been prevented. The facility policy titled Medication Administration revised 2025 documented staff are to ensure the 6 rights of medication administration are followed, review the MAR to identify the medication to be administered, and compare the medication bubble pack with the MAR to verify resident name, medication name, form, dose, route and time. It further directed staff to sign the MAR after administration of the medication. 2. Resident #105's admission MDS assessment dated [DATE] identified a BIMS score as a 15, indicating intact cognition. The MDS listed diagnosis of dementia. Resident #105's Incident Report dated 2/1/26 documented Staff A, RN received Donepezil 10 mg from pharmacy, the medication was administered by Staff A upon receiving it. Staff B had the cart keys so the medication was placed in the computer on the medication cart and Staff A then went to the DON's office as requested. Upon Staff A returning to the floor Staff B reported she gave the pill that came from the pharmacy and Staff A then reported she had already given it. On 3/10/26 1:20 PM Administrator reported Staff A, RN gave the medication for the 2/1/26 med error but didn't sign it out when she gave it, left the meds at the cart and went to the DON because she was asking for her. Staff A reported Staff B saw the medication and didn't see it signed out so gave the medication and signed it off. Staff A reported to the Administrator when she came back to the floor, Staff B reported she started the medication for the resident. Staff A then reported to Staff B that she already gave it. An assessment done on the Resident #105 and no concerns noted. The Administrator reported the family, physician and DON notified of the medication error. On 3/10/26 at 1:49 PM Staff A, RN reported there was a medication that Resident #105 didn't have a certain medication at the time Staff B, CMA gave him his morning medications. Staff A reported when the medication came from the pharmacy and Staff A gave it to him. Staff A reported she didn't sign it out that she gave it to him on the MAR. Staff A reported she put the medication between the computer. Staff A reported she had compared it to the MAR but forgot to sign it out. Staff A reported she does not normally leave the medications out on the med cart they should be locked. Staff A reported it is not her normal process to not sign the medication once given. Immediately she was educated on the medication error. 3. The admission MDS assessment dated [DATE] revealed Resident #102 admitted to facility on 1/13/26 from the hospital and required after care following surgery on her digestive system. The resident also had diagnoses of cancer, anemia and diabetes. The MDS revealed the resident had a surgical wound and took opioid (narcotic) pain medication. The MDS documented the resident rated her pain at an 8 during the look-back period. The Care Plan initiated 1/14/26 revealed Resident #102 had a risk for pain related to rectal cancer. The resident had a surgical incision to the rectum and to the abdomen due to a colostomy site and JP drain. The Care Plan directed staff to administer scheduled/PRN (as needed) pain medications as ordered and monitor for medication effectiveness and side effects. The Order Summary Report dated 1/14/26 revealed Tramadol 100 milligrams (mg) by mouth (PO) every 6 hours PRN for pain management started on 1/13/26. The Order Summary Report also revealed to give 2 tablets of Tramadol 50 mg PO every 6 hours PRN for pain with a note in capital letters: ORDER IS FOR 100 MG SO GIVE 2 TABS started on 1/19/26. A Medication Error report dated 1/19/26 at 11:00 AM revealed Resident #102 received Tramadol 50 mg PO every 6 hours on 1/16/26, 1/17/26, 1/18/26, and part of 1/19/26. The Order for Tramadol was for 100 mg every 6 hours. The resident did not know that she only received half the dose of the Tramadol. Nurse Practitioner (NP) was notified. New orders were written regarding the discrepancy. The Controlled Drug Receipt Form revealed 12-Tramadol 50 mg tablets received on 1/13/26. The label contained directions to take 1 tablet PO every 6 hours as needed but a line was drawn through hours as needed. Tramadol 50 mg was documented as removed and administered on 1/16 at 6 PM and 11:28 PM, on 1/17 at 5:05 AM, 11:45 AM, 6 PM, and 10:05 PM, on 1/18 at 5:05 AM, 12 PM, 5:10 PM and 11:05 PM and on 1/19 at 5 AM. A Controlled Drug Receipt Form revealed 60-Tramadol 50 mg tablets received on 1/17/26 and a 2 had been written over the 1 in the typed directions (to administer tablet PO every 6 hours). Documentation revealed that 2 tablets was documented as removed starting on 1/19 at 10:30 AM. The Medication Administration Record (MAR) dated 1/1/26 to 1/31/26 revealed the following: a.Tramadol 100 mg PRN administered on 1/13 and 1/14. b. Tramadol 100 mg (but only 50 mg was administered) documented as given 1/16 (6 PM dose), 1/17 x 4 (scheduled times: 12 AM-8AM-12PM-6PM), 1/18 x 4 (at scheduled times), 1/19 x 2 (for 12 AM and 6 AM dose) (but only 50 mg was administered). c. Two - Tramadol 50 mg tablets administered 1/19/26 (at 10:30 AM). d. Dilaudid 2 mg was administered on 1/19/26 starting at the 3:00 PM dose. Pain rated at 6. Progress Notes revealed: a. On 1/19/26 at 8:52 AM, the resident complained of her bottom hurting. Nurse and charge nurse assessed the area. Resident was originally admitted to the facility with absorbent sutures in place to the rectum. Suture site on admission was scabbed over and in the healing process. Upon assessing area this AM, sutures dehisced and exposed wound site about 4-5 cm (centimeter) in length and 2-3 cm in width. Call placed to the doctor. b. On 1/19/26 at 11:00 AM, charge nurse reported to nurse manager that a medication error had occurred on the resident. Hospital discharge orders on admit stating the following:Tramadol 100 mg (1-2 tablets) po every 6 hours PRN for pain management.Lower dose of Tramadol 100mg (1 tablet) po every 6 hours PRN was initiated on admission on [DATE]. On 1/16/26, a family member approached nurse to see about scheduling resident's pain medications due to increased discomfort because the resident will not ask for pain medication if she needed it. Tramadol order was changed to the following:Tramadol 100mg (1 tablet) po every 6 hours scheduled for pain management. Pharmacy was notified. Upon pharmacy delivery on 1/16/26, Tramadol 50 mg tablets were delivered to the facility. Scheduled Tramadol 50mg (1 tablet) was given every 6 hours on 1/16/26, 1/17/26, 1/18/26, and part of 1/19/26. Tramadol 100 mg was supposed to be given on these days, however, half the dose was given. Staff did not compare the bubble pack order to the order in the computer prior to giving the medication to the resident. Staff education provided. NP saw resident on rounds today and gave new orders regarding the discrepancy. c. On 1/19/26 at 1:32 PM, the NP documented that nursing requested her to visit the resident for reports of pain and rectum wound dehiscence. Resident reported pain 10/10 that is not relieved by current tramadol orders. Resident is on scheduled tramadol 100 mg every 6 hours. In an interview on 3/10/26 at 2:03 PM, Staff A, Registered Nurse (RN), reported the nurses and the Unit Manager entered the orders in the computer and processed the orders. In an interview on 3/10/26 at 2:35 PM, Staff D, certified medication aide (CMA), reported she clicked on the resident's name on the MAR in the computer whenever she planned to pass medications. Staff D reported she pulled the medication card bubble pack and checked the name, medication and dose on the card. In an interview on 3/11/26 at 10:05 AM, Staff K, Assistant Director of Nursing (ADON), reported she expected staff who passed medications followed the 6 Rights of medication pass. She also expected staff to always compare the bubble pack to the physician's order. She expected the staff to come to her if they had any question or concern about a medication order so they could trouble shoot it. She also encouraged staff to look at the actual order. Staff K reported the nurse entered the physician's order and another nurse on duty or on the following shift double checked the orders. In an interview on 3/12/26 at 10:34 AM, Staff L, NP, reported she saw Resident #102 for an open rectal wound on 1/19/26. The resident had problems with pain during the course of her stay. The resident was getting PRN Tramadol, and then changed to getting Dilaudid in-between the doses of Tramadol. Staff L reported she made a lot of changes in the resident's medications, including changes from PRN to scheduled pain medication. In an interview on 3/12/26 at 10:57 AM, Staff M, RN, reported Resident #102 had colon cancer and a colostomy. She had a lot of pain. The wound to her rectum dehisced and the nurses packed the wound. The resident originally was not honest about the pain. It was like she was always in pain and just dealt with it. Staff M reported she was aware there had been some mix up with the Tramadol. Resident #102 was started on one dose and changed to another dose to help with the pain. They eventually got her pain manageable. Staff M reported new orders entered by the ADON but the nurses also entered the physician's orders. Another nurse had to double check and note the orders. In an interview on 3/12/26 at 12:37 PM, Staff K, ADON, reported Resident #102's daughter came to her and said her mom felt like the pain medications were not working. Staff K reported she called the on-call Dr. The daughter wanted staff to give scheduled medication not PRN. Staff K got an order for the pain medication to be on scheduled times and an order to increase the Tramadol to 100 mg every 6 hours. The pharmacy had to call the on-call doctor because they wanted verbal verification on the dose because they thought the dose of 100 mg was kind of high on the Tramadol. Pharmacy wanted to make sure that the dose is what the provider wanted. At that time, Staff L, NP, said to go ahead and send the Tramadol but to make it into 50 mg tablets. The pharmacy sent the 100 mg tablets but cut the pill in half and placed the pills into the bubble pack. Staff K reported she told the nurses and CMA's to go by what the computer order showed not what the bubble pack says to do but the nurses followed the bubble pack directions not the order in the computer. Staff K reported she had called the doctor on a Friday to get orders for pain medication. The resident got 50 mg instead of 100 mg dose over the weekend. She got a 1/2 tab of the 100 (which was 50 mg) but the resident should have gotten 2 tablets of the 1/2 tab to make the 100 mg. Staff K reported the order was correct but the label on the bubble pack from pharmacy was different. The person who got the bubble pack from pharmacy should have put an alert such as check the MAR on the bubble pack. The nurses thought the tablets in the bubble pack was a full tablet not 1/2 tablet of the 100 mg tablet. Staff K reported the pharmacy delivered the medication. The nurse received the medication and signed off on the phone that the medication was received. Staff K stated she provided education to staff to make sure the order matched the computer and the bubble pack. If the bubble pack did not match the order in the computer, then a note or alert shall be placed on the bubble pack. During an interview on 3/17/26 at 3:21 PM, the Administrator reported the QA team had worked on a Performance Improvement Projects (PIP) related to medication errors. The PIP included the staff education completed with all of the nurses and CMA's that passed medication, audits by the unit nurse manager of staff during medication pass ensuing the 6 Rights were followed, and staff education about communication amongst the nurses and CMA's. Two weeks prior to an incident with a medication error, the facility began to schedule 1 nurse, 1 CMA, and 1 CNA on the skilled units. Before that time, they staffed 1 nurse and 2 CNA's on the unit but the nurses had difficulty getting assessments and the things that needed to be done. A CMA was added to help take the load off of the nurse. When they switched to 1 nurse and 1 CMA, they continued to use 1 medication cart for the nurse/ CMA to run off. After an medication error incident, a second cart was obtained and added on the unit. In addition to the Medication Error PIP, an audit on medication carts was done to ensure that the resident's medications were put in the correct place behind the room placard (in the medication cart). A medication error incident happened when the placard for 114 was placed in 115. Staff needed to make sure the placard was kept in the correct location in the medication cart. A room checklist was also implemented and included for staff to make sure the resident's picture was updated, and the room label had an updated resident's name. The facility also provided training on where staff can access policies. An undated Medication Administration policy revealed medication are administered as ordered by the physician in accordance with professional standards of practice. The following steps should be followed whenever a medication administered: 1.Review MAR to identify medication to be administered.2.Compare medication source (bubble pack, vial, etc.) with MAR to verify the resident's name, medication name, form, dose, route, and time.3. Ensure that the six rights of medication administration are followed:a. Right residentb. Right drugc. Right dosaged. Right routee. Right timef. Right documentation

Based on observation, interview, and facility policy review, the facility failed toEnsure sanitary and safe conditions in the three kitchenettes and six service areas in the facility maintained for food services. These failures posed the risk of food borne illness to the residents receiving food from the kitchenettes and service areas.Maintain best practices in accordance with professional standards of food service safety. The deficient practice has the potential to result in food borne illness among the residents that consumed food from the kitchen. The facility reported a resident census of 90. Findings include: Observation on 3/10/2026 at 12:35 p.m. of the 100 hall and 200 hall kitchenette revealed a stainless steel prep counter that had a coffee maker and toaster placed on it with crumbs on top of the toaster and a white dried substance on the counter with debris on the counter and the stainless steel shelf above the counter with debris on it. Observation and interview on 3/10/2026 at 2:15 p.m. of the 300 hall and 400 hall kitchenette revealed the reach-in freezer with dried juice on the bottom, and the steam table with dried calcium deposits on the front and its lower shelf with calcium deposit buildup. Staff O, Dietary Aide and Cook, stated she had worked at the facility for two years and when asked regarding cleaning schedules, she was not aware of any posted cleaning schedules. Observation on 3/10/2026 at 2:53 p.m. of the 500 hall and 600 hall kitchenette revealed a fan on the floor with debris on the front guard of the fan. The lower shelf of the center island was covered with a whitish residue, and contained a carboard box with a garbage liner and used meal slips inside, serving trays had been placed to the side of the box. Above the shelf there were dried drips of residue on the front of the stainless steel drawer beneath the counter of the center island. During an interview on 3/11/2026 at 9:50 a.m. with the Dietary Director revealed she had no cleaning schedules for the facility's kitchenettes and stated They [the dietary staff] are pretty good about cleaning up. Observation on 3/11/2026 in the 500 hall and 600 hall kitchenette of the noon meal service with Staff O, Dietary Aide/Cook revealed at: 12:27 p.m., Staff O, put on a pair of disposable gloves and took 12 plates from a warmer and the meal slips and placed them on the steam table's counter and began plating the food for the noon meal with the same pair of gloves. With that pair of gloves on, she touched a spatula to serve the lasagna, a pair of tongs to place pieces of garlic bread, the sides of a salad bowl, and the individual resident's meal slip to place on a tray for serving. She then opened the fridge and took out a tray of individual salad dressings, placed the tray on the kitchenette's center island, and took one of the individual salad dressings and placed it on the resident's tray. 12:30 p.m., she took off both of her gloves and put on another pair of gloves. She had not sanitized her hands after removing the gloves, or prior to putting on the clean pair of gloves. With those gloves on she served several meals, touching the plate, the handle of a spatula or a scoop to plate the lasagna, the tongs for the garlic bread, the resident's meal slip, and the sides of the salad bowl for each meal served. 12:33 p.m., she removed that pair of gloves to review the meal slips and used a pair of scissors to cut some of the meal slips and placed one of the meal slips on the tray with the meal to be served. She then put on a clean pair of gloves, without sanitizing her hands, and plated several more resident meals for serving. 12:36 p.m., she removed the pair of gloves, reviewed the meal slips and used the scissors to cut one of the meal slips and placed it on the tray with the meal to be served. 12:37 p.m., she put on a clean pair of gloves, without sanitizing her hands, and plated more resident meals for serving. 12:49 p.m., she took off her gloves, washed her hands in the kitchenette's hand sink rubbing her hands with antibacterial soap for approximately five seconds before rinsing off the soap and drying her hand and then put on a clean pair of gloves. With those same gloves on she touched a meal slip, a plate, the handle of the scoop to plate lasagna, the tongs to plate a piece of garlic bread, the sides of the lettuce bowl, and placed the plate on a tray for serving. She then touched the handles of the cart to reposition it in the doorway. She then continued to plate another meal with those same gloves on. She handled another plate, meal slip, scoop for the lasagna, tongs for the garlic bread, the sides of the lettuce bowl and placed the prepared plate and meal slip on a tray. With the same pain of gloves on, she prepared another plate, touching the plate, meal slip, scoop for lasagna, tongs for garlic bread, and lettuce bowl. She then, with the same pair of gloves on, unwrapped a package of hot dog buns and handled a ready-to-eat hot dog bun, removing the bun from the package and placed it on a plate and open the bun with those same gloved hands and used a scoop to place ground hot dog on the bun, and placed garlic bread on the plate and placed the plate on a tray to be served. She then continued to plate other resident meals for serving with the same gloved hands. 12:56 p.m., she removed the pair of gloves, but failed to sanitize her hands. During an interview on 3/11/2026 at 1:02 p.m. with Staff O, Dietary Aide/Cook, the observations of her glove use were reviewed including her failure to wash her hands thoroughly after taking off a pair of gloves, and before putting on a clean pair of gloves, touching multiple surfaces that contaminated the gloves before handling the ready-to-eat hot dog bun, and not limiting glove use to only one task. Staff O, Dietary Aide/Cook, stated that she had been trained to wear gloves while she was plating resident meals for meal service, and agreed that she had touched multiple surfaces prior to handling the hot dog bun. During an interview on 3/11/2026 at 1:06 p.m. with the Dietary Director revealed she stated she encouraged dietary staff not to wear gloves when preparing and serving resident meals. Review of Staff O, Dietary Aide/Cook's Employee Personnel File revealed she had been hired on 7/9/2024 and had signed the facility's Ready to Eat (RTE) Foods and Glove Use policy on 6/27/2024 that stated The FDA Food Code prohibits handling of RTE foods with bare hands. This applies during food preparation. A glove may be used to handle RTC foods if absolutely necessary. The following steps must be taken with GLOVE USE: 1. You MUST wash your hands thoroughly before putting on the glove(s): this is a Food Code Rule!!! 2. A glove must be limited to one task only- thus the term Single Use. Once you don the glove(s) and leave the task to open a refrigerator, oven , box, bag, etc., the glove(s) is contaminated and must be removed/replaced before returning to handling the RTE food item(s). Wash hands again before donning a new glove. I have read and understand that I cannot touch any ready to eat (RTE) foods with my bare hands and must follow the above procedures for glove usage.   Observation on 3/12/2026 at 11:38 a.m. of the 500 hall Dining Room Serving Area revealed the microwave with food debris in it and the ice scoop's plastic holder affixed to a wall was dirty. During an interview on 3/12/2026 at 11:54 a.m. with the Dietary Director, the lack of cleanliness of the facility's kitchenettes and dining room serving areas, including dried juice spills on the bottom of fridges in the serving area, debris in the microwaves, shelves noted to have dried substances and debris, ice machines with dried substances was discussed. She stated that she had scheduled a staff person to work every other week on a cleaning list she compiled. During an interview on 3/12/2026 at 1:10 p.m. with the Administrator revealed her expectation that the dietary staff should have, and follow cleaning schedules. She agreed that dietary staff should use a clean pair of one-use gloves prior to handling a ready-to-eat food items. Review of the facility policy Sanitization, revised November 2022 revealed The food service area is maintained in a clean and sanitary manner: All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris,. All. counters, shelves and equipment are kept clean. 2. A direct, continuous observation of the 600 hall dining room on 03/10/2026 beginning at 12:06 PM and ending at 12:55 PM revealed the following:At 12:06 PM Staff P, CNA, was observed touching various unsanitary surfaces including the wheels of a wheel chair and then, without hand hygiene, serving food to residents. At 12:12 PM Staff P continuously served meals to residents with her thumb on the eating surfaces of a residents dishware as she served food to residents. Again no hand hygiene was observed. At 12:17 PM Staff P was observed direct bare-skin contact with what was later identified as a Turkey Rueben Sandwich, this was served to the resident and consumed. A direct, continuous observation of the 600 hall dining room on 03/11/2026 beginning at 12:08 PM and ending at 12:34 PM revealed the following:At 12:32 PM Staff Q, CNA, was observed to be making direct bare-skin contact with a residents garlic bread, it was then served to the resident and consumed. At 12:33 PM Staff P was observed to be again making direct bare-skin contact with a residents food, it was then served to the resident. In an interview on 03/12/2026 at 11:28 AM with Staff D, CNA, she stated facility staff are not allowed to touch a resident's food, and staff should wash their hands in between each resident. In an interview on 03/12/2026 at 11:45 AM with Staff H, CNA, she stated staff should not touch food when serving it to residents. She stated staff should also keep their fingers and thumb away from the top of the dish so as to avoid the serving areas of the plates and bowls. In an interview on 03/12/2026 at 11:34 AM with Staff I, Licensed Practical Nurse (LPN), she stated staff members cannot touch a residents food with their bare hands. She added staff should also avoid touching the tops of a residents plate to avoid cross contamination. In an interview on 03/12/2026 at 11:12 AM with Staff J, RN, she stated staff members should avoid touching a resident's food when serving them. Review of a facility provided document titled Food Preparation and Service, with a last revised date of November 2022, stated in the section labeled General Guidelines Cross-contamination can occur when harmful substances, ie chemicals or disease-causing microorganisms are transferred to food by hands. In the section labeled Food Distribution and Service it documents Bare hand contact with food is prohibited.

Based on clinical record review, observation, staff interviews and policy review, the facility failed to implement Transmission Based Precautions (TBP) for 1 of 2 residents reviewed for TBP (Resident #5). The facility also failed to demonstrate proper mechanical lift sanitation practices and Personal Protective Equipment (PPE) use to prevent cross contamination for 3 of 6 units reviewed for infection control (Units #100, #500 and #600). The facility failed to provide filter changes/cleaning to a non-invasive device (BiPAP) machine for 1 of 1 residents reviewed for BiPAP use (Resident#1). The facility reported a census of 90.Findings include:1.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of pneumonia, sepsis and obstructive sleep apnea. It also indicated that she did not have a BiPAP or had used it in the last 14 days. She had a Brief Interview for Mental Status (BIMS) score of 15. The Care Plan initiated on 2/27/26 indicated that Resident #1 had an altered respiratory status and diagnoses of pneumonia and obstructive sleep apnea. It lacked documentation of BiPAP use. The Nursing Admission/readmission assessment dated [DATE] indicated under the respiratory assessment that Resident #1 used a BiPAP and had a diagnoses of sepsis, pneumonia and obstructive sleep apnea. During an observation on 3/09/26 at 2:37 PM Resident #1 had a BiPAP device on her face and the machine was running when the surveyor entered the room. She removed the device to talk with the surveyor. During an observation on 3/11/26 at 1:20 PM Resident #1 had a BiPAP machine in her room on the bedside table. In an interview on 3/11/26 at 1:20 PM Resident #1 stated she was on a BiPAP that she takes care of. The staff only fills the water tank for it. She added that the facility ordered a tubing replacement for her. In an interview on 3/11/26 at 2:15 PM Staff F, Registered Nurse (RN) stated that a resident on a BiPAP should have an order for it that would include washing the mask and refilling the water reservoir. There should also be a place to document when the BiPAP is on and off as well. In an interview on 3/11/26 at 2:45 PM with the Assistant Director of Nursing (ADON), Administrator and the Regional Director of Clinical Services, the Regional Director of Clinical Services stated that Resident #1 was not using her BiPAP. The ADON agreed. The surveyor informed them of an observation of her using her BiPAP as well as Resident #1 stating that staff fill the water for her BiPAP. All stated they were unaware she was using her BiPAP. In an interview on 3/12/26 at 12:10 PM the ADON stated that Resident #1 should have had orders for her BiPAP but she was not aware she had one as the family brought in over the weekend. She stated that she has an order template that she uses that says to obtain in home settings and to assist with water in the reservoir. She spoke with Resident #1 and saw her BiPAP. Resident #1 told her that the staff were filling her water reservoir. A policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy™) dated 2025 indicated that the facility will obtain an order for the use of a CPAP, BiPAP, AVAPS or Trilogy™ device and settings from the practitioner. It also indicated that: a. A personal CPAP/BiPAP/AVAPS/Trilogy™ device may/may not be brought into the facility for the resident's use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use. b. The facility will follow the manufacturer's instructions for use of the machine. c. Nursing will assess the skin integrity around the mask site daily to ensure there is no impairments to the skin. Treat as per physician's orders if noted. d. Document use of the machine, resident's tolerance, any skin, respiratory or other changes and response(s). e. Follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. Only the supplier may service the machine. f. Replace equipment immediately when it is broken or malfunctions, or if visible soiling remains after cleaning. The residents clinical record lacked documentation of cleaning/replacement of filters to the BiPAP machine for Resident#1. 2. Resident #19's Electronic Health Record revealed: Clinical Orders for a respiratory panel and a portable chest x-ray for cough, shortness of breath and wheezing ordered on 3/2/26. Droplet isolation precautions started on 3/3/26. This order was revised on 3/11/26 to include Contact/Droplet isolation (Airborne N-95 use required) due to highly contagious pathogen COVID-19). Progress Notes for Resident #19 revealed: a. On 3/2/26 at 2:50 PM, the resident had a cough and expiratory wheezes bilaterally, and complained of a headache. b. On 3/3/26 at 12:04 PM, the resident was positive for COVID and in droplet precautions. The Care Plan initiated on 3/3/26 revealed Resident #19 tested positive for COVID-19 and was placed on droplet isolation. The Care Plan directed staff to follow Center for Disease Control (CDC) recommendations and the facility's protocol. Observations revealed the following: a. On 3/9/26 at 12:16 PM, a Droplet Precautions sign hung on the wall by the resident's door. A date of 3/13/26 indicated the end date of the isolation. A plastic bin with drawers was by the door outside the room and contained face shields, gloves, and masks.b. On 3/9/26 at 12:18 PM, a female staff member donned a yellow gown, donned a N95 mask over the surgical mask she already had on her face, and donned a pair of gloves. The staff member entered the room. At 12:21 PM, the female staff member exited the resident's room without the N95 mask, gown and gloves but continued to wear the surgical mask and walked down the hall. In an interview on 3/12/26 at 10:06 AM, Staff C, IP, stated that staff should not be wearing a surgical mask under an N95 mask. A COVID-19 Policy Guidelines revealed the facility had established protocol for the prevention and spread of COVID-19 in accordance with the CDC, CMS and State agencies. A Donning and Doffing PPE sign on the wall by the resident's room revealed: To [NAME] (put on the gear) -a. Perform hand hygiene.b. [NAME] isolation gown.c. Put on N95 facepiece. Do not wear facemask under your chin or store in pocket between residents. d. [NAME] a face shield or goggles. e. Put on gloves. f. Enter the resident's room. To Doff (take off the gear) - a. Remove gloves and gown.b. Exit the room.c. Perform hand hygiene.d. Remove face shield.e. Remove respirator / face mask.f. Perform hand hygiene. 3. During a direct observation on 03/10/2026 at 01:46 PM an unknown staff member was observed taking a mechanical lift from room [ROOM NUMBER] and moving to it room [ROOM NUMBER] without sanitation. During a direct observation on 03/11/2026 at 11:38 AM, a mechanical lift was removed from room [ROOM NUMBER]. Without sanitation it was carried down the hallway by Staff Q, Certified Nurses Aide (CNA), to room [ROOM NUMBER] and used to transfer the resident. In an interview on 03/12/2026 at 11:45 AM with Staff H, CNA, she stated you have to wipe down mechanical lifts after leaving a residents room and before entering the residents room. During the interview her coworker, Staff R, CNA, took the mechanical lift from room [ROOM NUMBER] and without sanitizing it took it into room [ROOM NUMBER] to transfer the resident. In an interview on 03/12/2026 at 11:28 AM with Staff D, CNA, she stated mechanical lifts have to be cleaned before and after transferring each resident. In an interview on 03/12/2026 at 11:34 AM with Staff I, Licensed Practical Nurse (LPN), she stated mechanical lifts have to be sanitized before use with either purple top cleaning wipes or a spray that is maintained by the facility. In an interview on 03/12/2026 at 11:12 AM with Staff J, Registered Nurse (RN), she stated mechanical lifts should be cleaned in between each resident with cleaning supplies stored at all of the nurses stations. In a interview on 3/12/26 at 10:06 AM Staff C, Infection Preventionist (IP) stated that mechanical lifts should be cleaned between different residents. Purple top wipes are available at each nurse's station. Review of a facility provided document titled Cleaning and Disinfection of Resident-Care Equipment, with a copyright date of 2025, documented the following: Staff shall follow established infection control principles for cleaning and disinfecting reusable, noncritical equipment. General guidelines include: a. Verify whether the equipment is single-use or reusable. Discard single-use items after use. b. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable). d. Multiple-resident use equipment shall be cleaned and disinfected after each use

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to obtain orders and accurate settings for a Bilevel Positive Airway Pressure (BiPAP) to ensure safe and accurate delivery of respiratory therapy for 1 of 2 resident reviewed for respiratory care (Resident #1). The facility reported a census of 90 residents.Findings include:The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had diagnoses of pneumonia, sepsis and obstructive sleep apnea. It also indicated that she did not have a non-invasive mechanical ventilator (BiPAP) or had used it in the last 14 days. She had a Brief Interview for Mental Status (BIMS) score of 15.The Care Plan initiated on 2/27/26 indicated that Resident #1 had an altered respiratory status and diagnoses of pneumonia and obstructive sleep apnea. It lacked documentation of BiPAP use.The Nursing Admission/readmission assessment dated [DATE] indicated under the respiratory assessment that Resident #1 used a BiPAP and had a diagnoses of sepsis, pneumonia and obstructive sleep apnea.During an observation on 3/09/26 at 2:37 PM Resident #1 had a BiPAP device on her face and the machine was running when the surveyor entered the room. She removed the device to talk with the surveyor.During an observation on 3/11/26 at 1:20 PM Resident #1 had a BiPAP machine in her room on the bedside table.In an interview on 3/11/26 at 1:20 PM Resident #1 stated she was on a BiPAP that she takes care of. The staff only fills the water tank for it. She added that the facility ordered a tubing replacement for her.In an interview on 3/11/26 at 2:15 PM Staff F, Registered Nurse (RN) stated that a resident on a BiPAP should have an order for it that would include washing the mask and refilling the water reservoir. There should also be a place to document when the BiPAP is on and off as well.In an interview on 3/11/26 at 2:45 PM with the Assistant Director of Nursing (ADON), Administrator and the Regional Director of Clinical Services, the Regional Director of Clinical Services stated that Resident #1 was not using her BiPAP. The ADON agreed. The surveyor informed them of an observation of her using her BiPAP as well as Resident #1 stating that staff fill the water for her BiPAP. All stated they were unaware she was using her BiPAP.In an interview on 3/12/26 at 12:10 PM the ADON stated that Resident #1 should have had orders for her BiPAP but she was not aware she had one as the family brought in over the weekend. She stated that she has an order template that she uses that says to obtain in home settings and to assist with water in the reservoir. She spoke with Resident #1 and saw her BiPAP. Resident #1 told her that the staff were filling her water reservoir.A policy titled Noninvasive Ventilation (CPAP, BiPAP, AVAPS, Trilogy(tm)) dated 2025 indicated that the facility will obtain an order for the use of a CPAP, BiPAP, AVAPS or Trilogy(tm) device and settings from the practitioner. It also indicated that:a. A personal CPAP/BiPAP/AVAPS/Trilogy(tm) device may/may not be brought into the facility for the resident's use. If brought in, the nurse/respiratory therapist will verify the settings on the machine prior to use. b. The facility will follow the manufacturer's instructions for use of the machine. c. Nursing will assess the skin integrity around the mask site daily to ensure there is no impairments to the skin. Treat as per physician's orders if noted. d. Document use of the machine, resident's tolerance, any skin, respiratory or other changes and response(s). e. Follow manufacturer instructions for the frequency of cleaning/replacing filters and servicing the machine. Only the supplier may service the machine. f. Replace equipment immediately when it is broken or malfunctions, or if visible soiling remains after cleaning.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure the daily nurse staffing information was posted for 18 days of the 31 days reviewed (February 10 to March 12, 2026). This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's current staffing levels. The facility reported a census of 90 residents. Findings include: Observation on 3/10/2026 at 1:43 p.m. revealed the daily staff posting, located at the front of the building, to the right of the administrator's office was dated 2/28/2026. Previous postings were behind the 2/28/2026 form and included postings for February 10th, 12th through 19th, 24th through 26th, and 28th. There were no postings found for February 11th, 20th, 21st, 22nd, 23rd, 27th and after the February 28th posting. Observation on 3/11/2026 at 7:20 a.m. revealed the daily staff posting by the administrator's office remained the 2/28/2026 posted form. Observation on 3/12/2026 at 7:35 a.m. revealed the daily staff posting by the administrator's office remained the 2/28/2026 posted form. During an interview on 3/12/2026 at 12:34 p.m., Staff N, Staffing Coordinator, stated she had worked at the facility since September 2025 and was responsible for posting the daily nurse staffing information which she posted beside the administrator's office. Staff N stated the payroll system she had used gave her the option to print a computerized Daily Nurse Staffing form that she posted. She stated she worked Monday through Friday and on Friday she would print the Daily Nurse Staffing forms for Friday, Saturday, Sunday, and Monday. She would then post those forms with the Friday form facing out. She stated that occasionally she noticed on Tuesday morning that the Friday posting from the prior week was still posted and had not been changed daily by the staff. She was not aware of who was responsible to change the form on the weekends. Staff N revealed that a new payroll system had been implemented by the facility on March 1st, 2026 and she was not sure how to post the required Daily Nurse Staffing form. She stated the new payroll system did not have option to print a Daily Nurse Staffing form. During an interview on 3/12/2026 at 1:05 p.m. with the Administrator regarding the required posting of the Daily Nurse Staffing report, she was not aware the Daily Nurse Staffing Report had not been posted daily since March 1, 2026 and was unaware that the new payroll system had no option to print the report. After reviewing the postings by her office, she agreed that the Daily Nurse Staffing had not been posted since February 28, 2026. Review of the facility's policy Posting Direct Care Daily Staffing Numbers, revised July 2016 revealed Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. The daily posting would be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The form must be legible so that staffing data can be easily seen and read by residents, staff, visitors or others who are interested in our facility's daily staffing information.

Based on observation, record review and staff interview, the facility failed to administer medications according to the Physician's order and in a timely manner for 4 of 4 residents reviewed. (Res #1, #2, #4 and #8 ) The facility identified a census of 84 residents. Findings include: 1. Review of the facilities Medication Administration Audit Report form dated 5.9.25 at 10:19 a.m. revealed the facility staff failed to administer the following resident medications according to their Physician's orders: Resident #1 - a. Morphine Sulfate (for pain) 20 milligrams (mgs) per milliliter (ml) 0.5 ml by mouth (po) every four (4) hours for pain, air hunger and/or shortness of breath (sob). On 4.15.25 the physician ordered time of admission had been 12 p.m. and 8 p.m. however staff actually administered the medication at 4:46 p.m. and 9:56 p.m. b. Magic mouthwash (thrush) 5 ml po every day (qd). On 4.16.25 the medication had been ordered at 7 a.m. but administered at 12:28 p.m. c. Ativan (anti-anxiety) 0.5 mg tablet po every 4 hours. On 4.16.25 the medication had been ordered at 8 a.m. and 12 p.m. but administered at 12:27 p.m. and 4:57 p.m. Resident #2 - a. Midodrine Hydrochloride (HCL) (orthostatic hypotension (low blood pressure) tablet 10 mgs one (1) tablet po three times a day (tid). On 4.20.25 the medication had been ordered at 12 p.m. but administered at 1:18 p.m. b. Enoxaparin Sodium Injection Solution (aftercare of a femur fracture) 40 mg/0.3 ml one syringe subcutaneously (sq) two times a day (bid). On 4.20.25 the medication had been ordered at 7 p.m. and administered 4.21.25 at 12:09 a.m. c. Acetaminophen 325 mg two tablets po TID. On 4.20.25 the medication had been ordered at 7 p.m. but administered on 4.21.25 at 12:09 a.m. d. Lidocaine External Patch 4 % applied topically to areas of concern bid for pain. On 4.20.25 the medication had been ordered at 7 p.m. but administered on 4.21.25 at 5:39 a.m. Resident #4 - a. Atrovastatin Calcium (cholesterol) 1 tablet po at bedtime (hs) and Sucralfate (recent gastrointestinal bleed) 1 gram tablet four times a day (qid). On 5.6.25 the medication had been ordered at 7 p.m. and administered at 11:10 p.m. Resident #8 - a. Lidocaine External Cream 3% applied to buttocks topically qd. On 5.6.25 the medication had been ordered at 7 a.m. and administered at 11:06 a.m. b. Insulin Glargine injection 25 units sq bid. On 5.6.25 the medication had been at 7 p.m. and administered at 11:02 p.m. 2. An observation 5.8.25 at 10:18 a.m. revealed Staff F, Certified Medication Aide CMA as she passed medications to Resident #8. Review of the Medication Admin Audit Report form dated 5.8.25 at 10:40 p.m. revealed the resident received the following medications ordered for 7 a.m. but administered as documented below: a. Lispro insulin 10 units tid and Glargine Insulin 25 units bid for Hyperglycemia - administered at 9:06 a.m. b. Lidocaine external cream 3 % to buttocks qd, Senna S 8.6-50 mg two tablets po qd for constipation and Ropinirole HCL 0.5 mg tablet po qd for restless leg syndrome - 10:16 a.m. c. Lasix 60 mg po bid for congestive heart failure, Ferrous Sulfate 325 mg qd for anemia, Clopidogrel Bisulfate 75 mg tablet po qd related to Paraxysmal Atrial Fibrillation, Aspirin 81 mg po qd of heart health, Finasteride 5 mg po qd for Benign Prostatic Hyperplasia and Hydrocodone/Acetaminophen 7.5-325 mg po qd for pain - 10:14 a.m. d. Amiodarone HCL 100 mg po qd for paraxysmal atrial fibrillation - 10:13 a.m. i. Clopidogrel Bisulfate 75 mg tablet po qd related to Paraxysmal Atrial Fibrillation, Aspirin 81 mg po qd of heart health Finasteride 5 mg po qd for Benign Prostatic Hyperplasia and Hydrocodone/Acetaminophen 7.5-325 mg po bid for pain - 10:14 a.m. 3. During an email 5.13.25 at 5:46 p.m. the Director of Nursing (DON) confirmed the above documented medications from the Medication Administration Audit Report as administered late. 4. During an interview 5.9.25 at 11:01 a.m. Staff E, CMA indicated she had been aware of a families concern with medication administration times. Staff F, CMA had administered medications late however she had been new to the facility and when Staff E asked her about the medications administered late she confirmed she ran behind the day in question but failed to tell anyone and administered the medications for Resident #2, 20 minutes late on an unknown date in question.

Based on observation, a call light audit report, resident, family and staff interview, Resident Council Notes and facility policy review, the facility failed to answer resident call lights in a timely manner (within 15 minutes) for 2 of 7 residents reviewed. (Resident #1, #6 ) The facility identified a census of 84 residents. Findings include: 1. An observation 5.8.25 revealed the call monitor located at the nurse's station on the 300 hallway with the following: The call light on for Resident #10 for 16 minutes so far. The time on the monitor itself read 10:13 a.m. on the bottom right hand corner. Now the monitor read the call light on for 17 minutes then staff responded and turned the call light off. A Location Event Report form dated 5.8.25 included the following late call light response times: a. 9:56 a.m. until 10:13 a.m. - 17 minutes. 2. An observation 5.8.25 at 1:33 p.m. revealed the call light monitor at the nurse's station on the 600 hall with a call light on for Resident #9 for 18 minutes which had been turned on at 1:15 p.m. The time on the upper right hand corner of the computer monitor itself read 1:33 p.m. A Location Event Report form dated 5.8.25 included the following late call light response times: a. 1:15 p.m. until 1:33 p.m. - 18 minutes. b. 4:17 a.m. until 4:38 a.m. - 21 minutes. 3. During an interview 5.7.25 at 2:38 p.m. a family member of Resident #1 confirmed family timed the resident's call light on for an average time of 32 minutes as they used a stop watch on their cell phones. The family member indicated one (1) time the family timed the call light on for three (3) hours. 4. During an interview 5.7.25 at 3:53 p.m. a family member for Resident #6 confirmed she timed her call light as on for 1 hour as she used the clock in the room which caused the resident to have felt disappointed so the family provided cares rather than the facility staff. The resident and the family member confirmed the call lights had been an issue since she admitted to the facility plus she fell without injury recently on a date unknown but at approximately 4 a.m. because the facility staff failed to answer her call light timely and she had to go to the bathroom so she stood up on her own and fell . The resident indicated this issue caused feeling of having been sorry, sad, angry and anxious. 5. During an interview 5.9.25 at 9 a.m. Staff A, Licensed Practical Nurse (LPN) confirmed staff as unable to answer resident call lights within 15 minutes due to staffing issues and their inability to meet the needs of all of the individual residents. During an interview 5.9.25 at 9:56 a.m. Staff B, Certified Nursing Assistant (CNA) confirmed staff as unable to answer resident call lights within 15 minutes as she described the staff as to busy and the facility failed to provide enough staff to have met the individual resident needs. 6. Review of the facilities Resident Council Notes revealed the following as dated: a. 1.7.25 - Call lights took to long. Several residents in attendance indicated they waited over 1/2 hour. b. 12.3.24 - Call lights not answered timely. c. 11.5.24 - Residents waited to long for the call lights, especially on the evening shift. 7. During an interview 5.9.25 at 11:15 a.m. the Administrator confirmed he had been aware of continued problems with call lights. 8. An Answering Call Light policy and procedure dated 3.2021 indicated the purpose as the following: The purpose of this procedure included an assurance of timely responses to the residents' requests and needs.

Based on observation, clinical record review, staff and resident interview and facility policy review, the facility staff failed to follow appropriate infection control practices during an outbreak status and when 1 of 3 residents (Resident #4, #5) presented on barrier precautions. The facility identified a census of 84 residents. Findings include: 1. According to a Minimum Data Set (MDS) assessment dated 5.8.25 Resident #4 had diagnosis that included Renal Insufficiency, Anxiety, Chronic Respiratory Failure, muscle weakness and required assistance with personal cares. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (moderately impaired cognitive skills) and required substantial/maximum assistance with toileting hygiene. A Care Plan addressed a Problem area and Interventions as stated and dated below: a. Self-care deficit as evidence by required assistance with activities of daily living (adl's), impaired balance during transitions and required assistance with ambulation. (revised 4.22.25) 1. Assistance of one (1) with a front wheeled walker (FWW) and provision of perineal care with every incontinence and as needed (prn). (revised 4.23.25) b. Required enhanced barrier precautions related to the presence of a pressure area on her left heel. (initiated 4.23.25 and revised 5.13.25) 2. Staff adhered to enhanced barrier precautions related to the presence of a pressure area to the left heel. (initiated 4.23.25 and revised 5.13.25) An observation 5.8.25 at 9:22 a.m. revealed Staff D, Certified Nursing Assistant (CNA) as she dropped her name tag in the middle of the resident's bathroom floor. An observation 5.8.25 at 9:20 a.m. Staff G, CNA went into the resident's bathroom and told Staff D her name tag fell on the floor in the bathroom so Staff D picked up the name tag at 9:22 a.m. and clipped it to her scrubs but failed to sanitize the name tag. According to an email 5.16.25 at 12:58 p.m. the Director of Nursing (DON) indicated in the event as stated above she would have expected the staff member to have sanitized her name tag with a registered disinfectant for the required contact time per manufacturer's instruction or throw it away and have asked for a new one. During an interview 5.8.25 at approximately 9:25 a.m. following staff's provision of perineal cares the resident asked, what had been going on because staff wore gowns during cares and they never wore gowns. The resident described the situation as just crazy. An observation 5.8.25 at 9:40 a.m. revealed Staff H, Certified Medication Aide (CMA) as she entered the resident's room, checked the resident's temperature, dropped the thermometer on the floor in the room, picked up the device and set it on the resident's oxygen concentrator which had been in use and attempted to check the resident's blood pressure with a wrist device but without success. At 9:43 a.m. Staff H left the resident's room with the blood pressure device and thermometer and placed them on top of a medication cart without a barrier and/or sanitization of the devices. During a interview 5.8.25 at 9:48 a.m. Staff H confirmed the above documented observation. An observation at 9:49 a revealed the staff member as she placed the blood pressure machine on her left wrist to have checked it functionality as it failed to register when she attempted to check the resident's blood pressure just prior. The staff member confirmed the device as functional so at 9:52 a.m. she returned to the resident's room and checked the resident's blood pressure which measured 131/71, left the room and again placed the device on top of the medication cart but again failed to have sanitized the device. 2. An observation 5.8.25 at 12:16 p.m. revealed Staff, Registered Nurse (RN) as she entered the resident's room DONNED (put on) in Personal Protective Equipment (PPE) and with med cups which contained medications set up at the medication cart at the nurse's station along with three (3) separate eye drop boxes/containers. The staff member placed the eye drop boxes and medication cups on the resident's bedside stand/table without a barrier. The staff checked for proper gastrostomy tube placement and stomach content's residual, flushed the tube, administered crushed meds diluted in water, followed by liquid meds and flushed the device again. With the same gloved hands the staff member reached into her scrub pockets and removed a sharpie to have dated the items in the resident's room. (i.e .tube feeding bags, tube feeding water bags and etc) At this point, Staff C, RN and the Assistant Director of Nursing (ADON) picked up the resident's call light device/button, positioned on the ground/floor and attached it to his bed but failed to sanitize the device prior. 3. According to an email 5.16.25 at 1 p.m. the DON confirmed the facility had been in outbreak status from 4.9.25 thru 5.7.25. According to an email 5.7.25 at 11:53 a.m. during the facilities outbreak status 4.2025 the facility had 10 residents who tested positive, and seven (7) staff members. During an interview 5.14.25 at 12:48 p.m. Staff C, Registered Nurse (RN) and Assistant Director of Nursing (ADON) confirmed during the time of the outbreak there had been multiple times staff had been redirected related to proper mask placement and especially with the laundry staff . During an interview 5.9.25 at 9:56 a.m. Staff B, CNA confirmed she went into resident rooms without proper PPE when the facility had been in an outbreak status in April 2025. 4. According to an email 5.16.25 at 12:39 p.m. the DON confirmed she expected staff to have placed a barrier when the placed an item down in a resident's room such as eye drops and etc. 5. During an interview 5.9.25 at 11:15 a.m. the Administrator confirmed he had been aware of continued problems with infection control. The facilities Enhanced Barrier Precautions sign included the following directives the providers and staff must have performed: a. Wore gloves and gowns for the following high contact resident care activities: 1. Dressing, bathing, transfers, linen change, personal hygiene, change of brief and/or toileting assistance, device care with items such as catheters, central lines, feeding tube, tracheostomy and etc and wound care. 6. An Infection Prevention and Control Program policy dated 10.1.22 included the following Policy Statement: An infection prevention and control program had been established and maintained for provision of a safe, sanitary and comfortable environment and to have helped in the prevention and development of transmission of communicable diseases and infections. The Prevention of Infection section included the following directives: a. Important facets of infection prevention included: 1. Education of staff for assurance that they adhered to proper techniques and procedures. 2. Implementation of appropriate isolation precautions when necessary. 3. Established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). The Monitoring Employee Health and Safety section included the following directives: a. Those with potential direct exposure to blood or body fluids had been trained in and equipped to have used appropriate precautions and personal protective equipment. 1. The facility provided personal protective equipment and checked for proper usage.

Based on clinical record review and staff interview the facility failed to maintain a complete and accurate Care Plan for 1 of 3 residents reviewed. (Res #1) The facility identified a census of 84 residents. Findings include: On an Encounter Note for Resident #1 dated 3.26.25 the Physician typed an addendum dated 5.14.25 with information that included the following: a. The patient was admitted to the facility under hospice care, with the diagnosis of a malignant neoplasm of the brain and lung. Part of the treatment included oral inhalers for breathing assistance. She was instructed to rinse her mouth after each dose of the inhalers. She refused to rinse her mouth after each inhaler treatment and she unfortunately developed stomatitis (a condition that caused painful swelling and sores inside the mouth.) It had been the Physician's opinion, within a reasonable degree of medical certainty, that the cause of the stomatitis was the patient's refusal of the oral rinses after the inhaler treatment. Review of the resident's Care Plan (not dated) revealed the facility failed to have addressed the stomatitis and the resident's continued refusal to have rinsed her mouth post inhaler usage.

Based on observation, clinical record review, resident and staff interview and facility policy review, the facility failed to provide proper perineal care for 1 of 3 residents reviewed. (Res #4 ) The facility identified a census of 84 residents. Findings include: According to a Minimum Data Set (MDS) assessment dated 5.8.25 Resident #4 had diagnosis that included Renal Insufficiency, Anxiety, Chronic Respiratory Failure, muscle weakness and required assistance with personal cares. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (moderately impaired cognitive skills) and required substantial/maximum assistance with toileting hygiene. A Care Plan addressed a Problem area and Interventions as stated and dated below: a. Self-care deficit as evidence by required assistance with activities of daily living (ADL's), impaired balance during transitions and required assistance with ambulation. (revised 4.22.25) 1. Assistance of one (1) with a front wheeled walker (FWW) and provision of perineal care with every incontinence episode and as needed (PRN). (revised 4.23.25) An observation 5.8.25 at 9:08 a.m. revealed Staff D, Certified Nursing Assistant (CNA) and Staff G, CNA as they entered the resident's room. The resident requested no male assistance so Staff G went into the resident's bathroom. While positioned in bed Staff D assisted the resident onto her right side, removed bed pan positioned under the residents buttocks (full of urine) and cleansed the resident's mid-gluteal region with one (1) swipe only but failed to cleanse the resident's vaginal area, her buttocks and/or thighs. The staff member removed a brief positioned under the the resident and replaced it with a clean brief. During an interview at the same time Staff D had been asked if the brief presented soiled/wet, the staff member mumbled and ignored the question. Staff G had then been asked if the brief removed from under the resident had been soiled/wet at which time he responded a little wet. Both staff members then repositioned the resident while Staff G noted another pad positioned under the resident appeared soiled/wet so he removed the pad. During another interview at 9:18 a.m. Staff D confirmed she failed to have cleansed the resident's vaginal area and proceeded to pull back clean brief anteriorly, cleansed the resident anteriorly and replaced the same soiled brief. Staff proceed to position the resident for comfort, provided for her current needs and exited the room. During an interview just after all the staff had left the resident's room, the resident indicated last week when she asked for the bed pan an unknown staff member directed her to have peed in her depends which pissed off the resident as she stated, who said things like that, I would have liked to have seen her pee her pants. A Perineal Care policy dated 2.2018 indicated the purpose as follows: The purposes of this procedure included the provision of cleanliness and comfort to the residents, prevention of infections and skin irritation and observance of the resident's skin condition. The Steps in the Procedure for a female resident included the following: a. Wash the perineal area as they wiped front to back. 1. Separation of the labia and to have washed downward from front to back. 2. To have washed the perineum as staff moved from the inside outward to the thighs. 3. Position the resident on her side with the top leg slightly bent, if able. 4. To have washed the rectal area thoroughly from the base of the labia with the extention over the buttocks.

Based on observation, clinical record review, document review, resident, family, and staff interviews, the facility failed to provide sufficient staff to ensure call lights were answered within a reasonable amount of time (within 15 minutes) to provide needed care and supervision to residents. Family members and residents reported having to wait thirty to sixty minutes for the call light to be answered numerous times during the week. Observation of the call light system revealed the call lights were answered between one to sixty four minutes. The facility reported a census of 83 residents. Findings include: Observations revealed the following: On 2/19/25 at 7:37 AM, the Palatium Care Monitor located at the nurse's station revealed call lights had been on for the following rooms and the amount of time the call light had been on at that time: room [ROOM NUMBER] - 21 minutes room [ROOM NUMBER] - 32 minutes room [ROOM NUMBER] - 24 minutes room [ROOM NUMBER] - 27 minutes On 2/19/25 at 7:45 AM, the Palatium Care monitor located at the nurse's station revealed the following call lights remained on and the amount of time the call light had been activated. room [ROOM NUMBER] - 30 minutes room [ROOM NUMBER] - 35 minutes On 2/19/25 at 9:08 AM, the Palatium Care monitor located at the nurse's station revealed call lights on for the following rooms and the amount of time the call light had been on at that time: room [ROOM NUMBER] - 24 minutes On 2/19/25 at 9:21 AM, room [ROOM NUMBER]'s call light had been activated and on for 37 minutes. On 2/19/25 at 9:27 AM, room [ROOM NUMBER]'s call had been activated for 21 minutes prior to the call light being answered by the Social Worker. On 2/19/25 at 9:27 AM, room [ROOM NUMBER]'s call light had been activated and on for 20 minutes. In an email on 2/19/25 at 10:32 AM, the surveyor requested call light reports from 2/10/25 to 2/20/25. An email received from the Administrator on 2/19/25 at 10:51 AM revealed he could only obtain call light reports that were available for the past 2 days. There had been a switchover with who manages the call light system, and the facility had lost some functionality. The Administrator provided call light reports for the dates he could see. what I can see. The Location Event Reports dated 2/18/25 to 2/20/25 revealed call light response times greater than 15 minutes for the following: room [ROOM NUMBER] - 2/19/25 8:15 AM - 16 minutes 2/19/25 8:40 AM - 21 minutes 2/19/25 10:09 AM - 16 minutes room [ROOM NUMBER] - 2/19/25 7:12 AM - 31 minutes 2/20/25 9:24 AM - 16 minutes room [ROOM NUMBER] - 2/19/25 9:47 AM - 21 minutes room [ROOM NUMBER] - 2/18/25 11:40 AM - 26 minutes 2/18/25 6:41 PM - 25 minutes 2/19/25 9:29 AM - 22 minutes room [ROOM NUMBER] - 2/18/25 9:41 AM - 18 minutes 2/19/25 7:44 AM - 23 minutes room [ROOM NUMBER] 2/19/25 7:05 AM - 39 minutes room [ROOM NUMBER] 2/18/25 5:23 PM - 24 minutes 2/18/25 9:41 PM - 17 minutes 2/19/25 6:43 AM - 21 minutes room [ROOM NUMBER] 2/19/25 7:15 AM - 38 minutes 2/19/25 5:29 PM - 16 minutes room [ROOM NUMBER] 2/19/25 7:10 AM - 44 minutes room [ROOM NUMBER] 2/18/25 5:35 PM - 64 minutes room [ROOM NUMBER] 2/19/25 8:44 AM - 45 minutes 2/19/25 11:21 AM - 29 minutes 2/20/25 5:56 AM - 19 minutes room [ROOM NUMBER] 2/19/25 1:50 AM - 19 minutes 2/19/25 5:24 AM - 30 minutes 2/19/25 6:25 AM - 16 minutes During an observation on 2/17/25 at 11:03 AM, Staff N, CNA, had asked Staff O, LPN what a resident was at the facility for, this resident had been admitted to the facility on [DATE], Staff O, LPN, informed Staff N, CNA she wasn't sure as she hadn't even had a chance to look at the hospital discharge paperwork. During confidential resident and family interviews starting on 2/17/25 at 10:15 AM, seven of ten residents reported concerns there were not enough staff and it took up to an hour for staff to respond and assist the residents after the call light had been activated. Four of four family members reported it took a while for staff to respond to the call light to see what was needed, but then it took another 30-60 minutes for staff to return and provide assistance and address the needs of the resident. A family member voiced concern the facility had trimmed back staff, especially on the weekend. During a confidential family interview on 2/19/25 at 2:40 PM, a family member reported that the resident waited 20 minutes. A Certified Nursing Assistant (CNA) from another hall had come to this unit looking for another CNA to assist in the other hall. This CNA assisted the resident to the restroom. Family member stated she had informed the resident to turn on her call light as soon as she felt any need for assistance or if it had been some time since she had been to the restroom due to the long wait time. The family member also told resident when she was transferred to the restroom, after she is situated to turn on the call light so the CNA would respond by the time she was done using the restroom. During a confidential family interview on 2/19/25 at 3:30 PM, a family member reported that the facility staff have all been really good to their loved one, the staff engage with the residents and care. The family member stated concerns with new ownership trimming back the number of staff and seem to be even shorter on the weekends. In an interview, on 2/18/25 at 10:53 AM, Staff M, CNA, reported picking up multiple shifts due to the amount of call ins and low number of staff working on the floor, many times the CNA that is assigned to be the float for each unit is pulled to other units to pass medications, leaving them short or having to wait long periods of time for two CNAs to be available to assist those who need two people. Staff M, CNA informed the increase of resident admissions has made it harder, the CNAs have not been able to get a full report on the needs for these newly admitted residents due to Nurses not having enough time to fully complete the admission. During an interview, on 2/17/25 at 12:47 PM, Staff O, Licensed Practical Nurse (LPN) reported an increased number of admissions, the previous week in one day a unit had 5 new residents admitted to the facility and today this unit was to expect two more new residents being admitted to the facility. Staff O, LPN stated it is a lot to complete with no help, the CNA's are needing help from the nurses at times as well as the Certified Medication Aide (CMA's). There are multiple things the nurse is responsible for and when having that many admission at once there is not enough support or time in the day to thoroughly complete it all. In an interview, on 2/19/25 at 9:35 AM, Staff E, CNA, reported she was the only CNA on the 300 and 400 hall with 27 residents. Six residents required the assistance of two staff for transfers with a mechanical lift but they also had residents that needed the assistance of 1-2 for pivot transfers. In an interview, on 2/19/25 at 3:35 PM, Staff L, LPN, reported there is never enough staff, CNAs or Nurses, there had been a huge change in staffing with the Facility's change in ownership and management doesn't seem to care. Management Staff are never on the floor to help and the social worker never answers call lights, as they had been this week. There are a lot of two assist residents, which means when both CNAs are caring for a resident, another resident will have to wait. Staff L, LPN, stated the night shift wait times are even worse for residents. During an interview, on 2/20/25 at 12:55 PM, Staff Q, LPN, reported weekends are difficult with staffing. If there is even one call in it gets hard to take care of everything, two nurses are needed for each unit. Staff Q, LPN stated it is too much for one nurse to cover the 500 and 600 hall. When 100-200 halls (Residents on skilled level of care) had a lower census one nurse was enough, but now with the increased admissions it is too much for only one nurse. Staff Q, LPN, reported the census on the 500-600 hall is currently 36 residents that alone can be hard to handle, if there are any incidents or new admissions it is extremely hard for one nurse to complete everything and properly care for the residents. In an interview on 2/20/25 at 1:10 PM, Staff R, CNA, stated they do have staff but when people call in they have to work short. They used to have two nurses for the halls, but don't anymore, the nurses get busy which makes it hard when the nurses help is needed. During an interview on 2/20/25 at 1:22 PM, Staff I, CNA, stated even with full staffing it can be really difficult, the CNA ' s can handle the resident ' s cares but being on time is hard. The 600 hall has a lot of residents that require assistance to two and that can take forty minutes to complete their cares, which makes other residents have to wait for help. The nurses are usually busy, if there is a fall and there is only one nurse for the unit it can take a long time for them to respond. In an interview on 2/20/25 at 1:39 PM, Staff P, CNA, reported there are a lot of residents that need two people to assist them, so when both CNAs are helping one resident other residents may have to wait thirty to forty minutes. Residents have complained to Staff P, CNA and they (residents) think the CNAs don't want to help. It is hard on the CNAs and residents. On 2/20/25 at 3:10 PM, the DON, (Director of Nursing) stated she would expect call lights to be answered within fifteen minutes. Review of The Bridges at [NAME] Facility Assessment, review date September 2024, revealed the following: The facility will have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by the facility assessment, resident assessments and individualized plan of care. The facility will provide these services by sufficient number of each of the following types of personnel on a 24- hour basis to provide nursing care to all residents in accordance with the resident care plans and state regulations: 1. The facility will designate licensed nurses to serve as a charge nurse/s on each shift 2. The facility will use the services of a registered nurse for at least 8 hours consecutively a day, 7 days a week. 3. The facility will designate a registered nurse to serve as the director of nursing on a full time basis. 4. The facility will designate certified nursing assistance and certified medication assistants for daily cares/services.

Based on record review, family and staff interview, the facility failed to involve the resident and/or resident's representative in care conferences and ensure care conferences held at least quarterly for one of three residents reviewed for care conferences (Resident #63). The facility reported a census of 83 residents. Findings include: The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had diagnoses of cerebrovascular accident (CVA)(stroke), cancer, and dementia. The MDS revealed the resident admitted to the facility on [DATE]. The MDS indicated the resident had severely impaired decision making skills. The MDS indicated the resident's preferences for the family or significant other to be involved in care discussions The Progress Notes dated 8/28/24 at 10:11 AM revealed a Care Conference was held on 8/28/24. In an interview on 2/17/25 at 1:29 PM, a family member reported only two care conferences held in the past year, and only one care conference held since the new company took ownership. In an interview 2/20/25 at 10:07 AM, the Social Worker (SW) reported she set up the residents' care conferences. The SW reported care conferences held quarterly or more often if the family requested one. She notified the resident's representative via phone to let them know when a care conference would be held. The SW reported care conferences were documented in the electronic health record in the progress note. At the time, the SW confirmed Resident #63's last care conference held in 8/2024. The SW stated she was not sure why Resident #63 had not had a care conference since 8/2024.

Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to follow accepted professional standards and practices regarding medication being left in the open. The facility reported a census of 83. Findings include: 1. The Quarterly Minimum Data Set (MDS) for Resident #20, dated 02/06/2025, documented the resident was rarely or never understood. It documented the following relevant diagnoses: Hypertension (high blood pressure), Renal Insufficiency (kidney failure), Hyperlipidemia (high cholesterol), Alzheimer's disease, Non-Alzheimer's dementia, Malnutrition, Anxiety disorder, Depression, and hypokalemia (low potassium). The Care Plan for Resident #20, last revised on 12/03/2024, instructed staff members to administer medication as ordered and to monitor the resident for side effects and effectiveness. The Medication Administration Record (MAR) documented the resident was to receive Potassium Chloride ER 20 milliequivalents, once a day for low potassium. It also documented the resident was to receive a probiotic capsule by mouth once daily in the morning. A direct observation on 02/17/2025 at 10:10 AM revealed a medication cup sitting on a dining room table with two medication tablets in the cup while a dietary staff (Staff S) cleaned. Upon noticing the medication cup, Staff S picked up the medication cup containing the medication and took it to the nurse on duty, Staff K, Licensed Practical Nurse (LPN). She informed Staff K that the medication had been left on the table near Resident #20. Staff K disputed this, stating she had witnessed Resident #20 swallow her meds and that they could not be hers. Staff S countered that Resident #20 was sitting alone and the medications were found next to her plate. Staff K took the medication and walked to the medication cart. She poured a glass of water and began to walk towards Resident #20's room when the surveyor asked if she intended to pass the medication. Staff K stated she did intend to pass the medication, and the surveyor stated she should contact her nurse manager for guidance on how to proceed. Staff K questioned the surveyor as to why she shouldn't pass the medication, and became agitated when she was again instructed to contact her nurse manager before passing unidentified medication to a resident. Staff K returned to the medication cart where she was able to confirm the medication in the cup matched a potassium oral tablet and probiotic pill, both of which were prescribed to Resident #20. Staff K stated the resident must have regurgitated the medication, but the medication in the cup showed no signs of moisture damage as of 10:23 AM. Staff K then took the medication and left the floor. In a conversation on 02/17/2025 at 11:24 AM, Staff K informed the surveyor she had contacted the provider and was informed she should hold the medication and not pass them to the resident. In an interview on 02/19/2025 at 01:04 PM with Staff K, LPN, she insisted the resident must have swallowed the pills and regurgitated them or spit them out at a later date. That she witnessed the resident swallow the medication. She noted she had never had medication brought to her by another staff member before, and she acknowledged she was unsure of the procedure for when that happens. When asked she had attempted to pass the medication to the resident without first verifying what the medications were, she stated she knew at a glance what medications they were. As they were clearly identifiable. She stated the resident struggles to take medication and that she requires close monitoring while giving medication, so she was positive she saw the resident swallow the medication. She did not answer when asked why the medication did not appear to have moisture damage consistent with having been in a mouth. In an interview on 02/19/2025 at 01:51 PM with the Director of Nursing (DON), she stated the expectation was for staff to contact nurse management when pills are discovered untaken to report the medication error. She stated the expectation is for staff to never attempt to pass medication without a positive identification to residents. At this time she presented the cup of medication from the incident on 02/17/2025 and informed the surveyor Staff K had not brought the medication to their attention until approximately 05:00 PM on 02/17/2025. The two medication in the cup still did not appear to have damage consistent with having been regurgitated or in a mouth, the DON agreed with that assessment. Review of a facility provided document titled Administering Medications, with a last revised date of December 2012, instructs staff members to verify a residents identify before administering medication, as well as to verify the medication is the right dose, right medication, and is being administered at the right time. 49698 2. Review of Resident #230's MDS dated [DATE] revealed Resident #230 was admitted to the facility on [DATE] with a BIMS of 14, indicating cognition is intact and diagnoses of atrial fibrillation, heart failure, hypertension, renal insufficiency, depression, asthma, respiratory failure and oxygen dependency. Review of Resident #230's Admission assessment dated [DATE] indicated Resident #230 does not want to self-administer medications. Observation on 2/17/25 at 11:36 AM revealed a bottle of Zyrtec (Allergy medication) and a medication cup with two pills, one blue oval tablet with imprinted identification L2X2 and one orange and white oblong capsule with imprinted identification APO 015, sitting on Resident #230 ' s bedside table. During an interview with Resident #230 and Resident's Husband on 2/17/25 at 3:55 PM, Resident #230 and her husband acknowledged the medications still sitting on Resident #230's bedside table. Resident #230's husband stated he had brought the Zyrtec from home and had been notified by facility staff, for safety reasons he is not to bring medications from home. Resident #230 acknowledges the medications sitting at bedside and thought they might be her bedtime meds and was not certain why she had not taken them or how long they had been there. On 2/17/25 medications that were found on Resident #230's bedside table were identified as Diltiazem 180mg and Guaifenesin ER (Mucinex DM) 600mg, via Drugs.com using the medications imprinted identification IDs. Review of Resident #230's Order Summary Report revealed, orders for Mucinex DM 12 hour 30-600 mg tablet, give one tablet by mouth two times daily for congestion. Start date 2/13/25 and discontinued on 2/14/25 at 10:52 PM per provider's order. Diltiazem 180mg Extended Release Capsule, give one capsule by mouth one time a day for hypertension start date 2/12/25. Review of Resident #230's MAR dated February 2025, revealed the following: 1. 2/13/25 Mucinex DM bedtime dose had been administered. 2/14/25 Mucinex DM morning dose had been administered. 2/14/25 Mucinex DM bedtime dose had been administered. 2/14/25 at 10:52 PM Mucinex DM was discontinued. 2. 2/12/25 Diltiazem morning dose had been held due to blood pressure measuring outside of recommended parameters. 2/13/25 Diltiazem morning dose had been administered. 2/14/25 Diltiazem morning dose had been administered. 2/15/25 Diltiazem morning dose had been administered. 2/16/25 Diltiazem morning dose had been administered. 2/17/25 Diltiazem morning dose had been held due to blood pressure measuring outside of recommended parameters. 2/18/25 Resident #230 refused Diltiazem morning dose. 2/19/25 Resident #230 refused Diltiazem morning dose. On 2/17/25 at 4:00 PM, the Facility's Regional Director of Clinical Services was notified of medications sitting on Resident #230's bedside table. During an interview on 2/20/25 at 3:10 PM, the Director of Nursing (DON) revealed she was not aware how long these medications had been sitting at Resident #230 ' s bedside or when they had been administered as the last time the Diltiazem had been administered with the Mucinex was on the morning of 2/14/25 and the Mucinex was discontinued the night of 2/14/25. The DON stated it is expected for the nurses or CMA's (Certified medication Aide) to monitor and watch residents take their medications and not leave medication alone at bedside or anywhere else unattended. Review of facility provided, Administering Medications Policy, Revised December 2012, stated, medications shall be administered in a safe and timely manner and as prescribed.

Based on record review, family interview and policy review the facility failed to provide oral hygiene cares as directed in the care plan for 3 of 3 residents reviewed for oral cares (Resident # 63 and #25). The facility reported a census of 83 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had diagnoses of cerebrovascular accident (CVA) (stroke), hemiplegia (paralysis on one side of the body), cancer, and non-Alzheimer's dementia. The MDS revealed the resident had impaired memory and severely impaired decision-making skills. The MDS documented the resident dependent for oral hygiene. The MDS assessment under Section L left blank, indicated the resident did not have broken or loosely fitting dentures or mouth pain. The Care Plan revised 2/27/24 revealed the resident had a history of CVA with left sided hemiplegia and required assistance with Activities of Daily Living (ADL's). The resident had her own teeth. The Care Plan directed staff to encourage and provide oral cares in the AM (morning), afternoon and HS (evening), and observe, document and report any signs or symptoms of oral or dental problems. The Occupational Therapy (OT) Discharge Summary signed by OT on 11/15/23 revealed the resident required assistance for all self-cares and needed encouragement to complete oral cares. The resident's prognosis was good with consistent staff follow through. The Documentation Survey Report dated 12/1/24 to 1/31/25 revealed oral hygiene completed: 12/2024: 22 of 31 times on the 6 AM-2 PM (day shift) 9 of 31 times on the 2 PM-10 PM (evening shift) 1/2025: 24 of 31 times on the 6 AM-2 PM shift 3 of 31 days on the 2 PM-10 PM shift The electronic health record (EHR) Task Care Record revealed oral hygiene completed In 2/2025: 7 of 18 times on the 6 AM - 2 PM shift 0 of 18 times on the 2 PM - 10 PM shift In an interview 2/17/25 at 1:25 PM, a family member stated the resident was unable to move her left arm because she had a stroke. The resident required assistance for ADL's. The family member reported sometimes the resident's breath smelt bad as if facility staff had not brushed her teeth. In an interview 2/20/25 at 9:50 AM, Staff E, Certified Nursing Assistant (CNA), reported Resident #63 got combative during cares, but she tried to reapproach the resident and talked the resident through whatever they needed to do. She brushed the resident's teeth usually when she got the resident up or after breakfast. In an interview 2/20/25 at 9:58 AM, Staff F, CNA, reported oral cares done whenever she got the resident up. The CNA's assisted the resident or provided oral cares for the resident. A Supporting Activities of Daily Living policy revised 3/2018 revealed residents provided with cares to maintain their ability to carry out ADL's. Residents unable to carry out ADL's independently will receive the services necessary to maintain good oral hygiene in accordance with the care plan. 49990 2. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 had diagnoses of anxiety disorder, depression, and non-Alzheimer's dementia. The MDS revealed the resident had impaired memory and severely impaired decision-making skills. The MDS documented the resident required partial or moderate assistance for oral hygiene. The MDS assessment under Section L noted the resident had obvious cavities or broken natural teeth. The Care Plan revised 2/05/25 revealed the resident had a history of non-Alzheimer's dementia and required assistance with activities of daily living. The resident had her own teeth. The Care Plan directed staff to encourage and provide oral cares in the AM (morning), afternoon and HS (evening), and observe, document and report any signs or symptoms of oral or dental problems. Review of the Plan of Care response history for oral hygiene, it documented Resident #25 only had documented oral hygiene on: 10/26/2024 12/20/2024 01/03/2025 01/07/2025 01/26/2025 01/31/2025 There was no documentation for the month of February. In an interview on 02/20/2025 at 01:32 PM with Staff P, Certified Nursing Assistant (CNA), she stated it was the CNAs responsibility to document oral hygiene and it was required to be documented every shift, once in the morning and once in the evening. She noted if the resident refused oral cares she should document refused. She stated she was familiar with Resident #25, she required assistance to perform oral care. She stated you should sit with her and encourage her to brush her teeth otherwise she forgets and won't do it. In an interview on 02/20/2025 at 01:22 PM with Staff I, CNA, she stated the CNAs are responsible for documenting all ADLs in the electronic health record (EHR), she stated documentation is required during the morning and afternoon shift. She stated she was familiar with Resident #25, and she requires assistance with oral hygiene. She stated she was unaware of Resident #25 refusing oral hygiene so long as you sat with her and encouraged her. In an interview on 02/20/2025 at 09:35 AM with the Director of Nursing (DON), she stated she was unsure why there were only two documented instances of oral hygiene in the last thirty days for Resident #25. She acknowledged the expectation is for oral hygiene to be documented twice a day for the resident.

Based on record review, observations, and family and staff interviews, and policy review the facility failed to carry out therapy recommendations and provide restorative exercises for 3 of 4 residents reviewed for restorative services and/or limited range of motion (Resident #36, #54 and #63). The facility reported a census of 83 residents. Findings include: 1. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had diagnoses of cerebrovascular accident (CVA) (stroke), hemiplegia (paralysis on one side of the body), Alzheimer's Disease, dementia, and weakness. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. The MDS documented Physical Therapy (PT) and Occupational Therapy (OT) services started on 4/4/24 The MDS indicated the resident had impaired Range of Motion (ROM) to the upper and lower extremities on one side. The resident required partial to moderate assistance for eating, substantial to maximum assistance for dressing, and partial to moderate assistance for bed mobility and transfers and toileting. The MDS assessment dated [DATE] revealed the resident had a BIMS score of 0 indicating severely impaired cognition. The MDS documented the resident required substantial to maximum assistance for eating and bed mobility, dependent for toileting hygiene. The MDS documented the resident had PT and OT services again 12/11/24 -1/20/25. The Care Plan revised 10/22/24 revealed Resident #36's had a risk of contractures and a risk for falls due to impaired balance, CVA and dementia. The resident required assistance with Activities Of Daily Living (ADL's) and unable to perform ROM independently. The Care Plan directed staff to provide assistance of one for bed mobility, toileting, transfers and eating, and a refer to PT/OT to evaluate and treat. Notify the charge nurse and therapy of declines in ability to complete Passive Range Of Motion (PROM) tasks or if the resident had complaints of pain during or after performing PROM. The nurse assigned to review the restorative program routinely and addressed progress towards the goals. A Restorative Aide Exercise Prescription dated 6/1/24 revealed the resident's restorative exercise program frequency 3 to 6 times per week. The program included 4 pound (lb) weights to the left upper extremity for 10 repetitions, PROM to the right upper extremity, and ambulate 100-150 feet with a platform walker and assistance of one staff. The Documentation Survey Report revealed restorative exercises performed: 12/2024: 1 of 31 days 1/2025: 2 of 31 days The Restorative Nursing Service Progress Notes revealed the following: On 2/12/25, major cueing needed for Active Range Of Motion (AROM) and PROM. On 2/17/25, resident tolerated sit to stand during toileting. The progress notes lacked the restorative exercises performed. A Electronic Health Record (EHR) Task Care Record dated 2/2025 revealed: Restorative AROM lower extremity exercised completed 5 of 18 days. Restorative AROM upper extremities completed 5 of 18 days Ambulated 100-150 feet using a front wheeled walker with a platform and assistance of one staff one to two times daily documented 3 of 18 days (on 2/1, 2/4, and 2/8/25). In an interview 2/18/25 at 9:15 AM, Staff H, PT, reported the facility had a restorative program but he was unsure who did the restorative exercises with the residents as staffing had been hit and miss for a while. He recommended the surveyor check the schedule to see who was assigned to do the restorative. Staff H reported therapy made recommendations such as a restorative program when a resident discharged from the therapy services as needed. In an interview 2/18/25 at 9:40 AM, Staff I, Certified Medication Aide (CMA) and restorative aide reported she worked with residents for restorative. Staff I reported she had not been able to do the resident's restorative program because the restorative aide had been pulled to work as a CNA on the unit, or pulled to work on the medication cart as a CMA. She had not done restorative with the residents for a couple of weeks due to the facility had been short- handed and the restorative aide got pulled to work other areas. The restorative aide is the first to get pulled when they had a call in or were short staffed. This occurred greater than 80 percent of the time. Staff I confirmed Resident #36, #54, and #63 were on a restorative program. She had seen a decline in some of the residents in their ADL's. When a resident had a decline, they often referred the resident to therapy for an evaluation. She documented restorative activities in POC (Point of Care) but also had a book to log if a resident had refused to do the exercises. In an interview 2/20/25 at 9:58 AM, Staff F, Certifed Nursing Assistant (CNA), reported she had worked at the facility for 2 1/2 year. She started working as a restorative aide in the past couple of weeks because she had incurred an injury and required light duty tasks. Staff F reported each hall had a binder with the residents who were on a restorative exercise program and what exercises to do. Staff F reported the restorative activity and number of minutes completed with the resident was documented in the EHR. Staff F reported the facility pulled the restorative aide when they were unable to cover staffing needs. Staff F did not think any residents in the 500 hall had a decline in their ADL's. In an interview 2/20/25 at 12:15 PM, the Director of Nursing (DON) reported there had been several staff call-ins in the past couple of weeks, and they had to pull the restorative aide to work as a CNA or CMA. The DON stated she had not noticed any decline in resident ADL's, but she started a Performance Improvement Plan (PIP) because she had identified a concern for restorative. A Restorative Nursing Services policy revised 7/2017 revealed residents received restorative nursing care to help promote optimal safety and independence. Residents may be started on a Restorative Nursing Program (RNP) during the course of their stay or when discharged from rehabilitative care. Restorative goals are outlined in the resident's care plan. Restorative assisted the resident in development, maintenance, or strengthening physiological and psychological resources and helped to maintain the resident's independence. 2. The Annual MDS assessment dated [DATE] revealed Resident #54 had diagnoses of stroke, hemiplegia, arthritis, and Alzheimer's disease. The resident had impaired ROM to the upper and lower extremity on one side. The MDS documented the resident required set up assistance for eating, dependent for toileting and bathing, and substantial to maximum assistance for bed mobility and transfers. The resident had OT service 2/10/23 - 2/27/23 and PT services starting on 9/12/24. The MDS documented RNP AROM for 1 day during the look-back period. The MDS assessment dated [DATE] revealed the resident dependent for transfers. The MDS recorded RNP AROM and PROM for 0 days during the look-back period. The Care Plan initiated 4/3/24 and revised 1/25/25 revealed the resident had a self-care deficit and required assistance with ADL's. The Care Plan also revealed the resident had a risk for decline in her ability to complete AROM due to decreased strength. The Care Plan directed staff to provide assistance of one person for bed mobility and toileting, and assistance of two and a Hoyer (mechanical device) for transfers. The Care Plan also directed staff to notify the nurse if the resident had any declines in her ability to complete AROM tasks or had complaints of pain during AROM, review the restorative program and progress toward meeting goals routinely, and refer to PT and OT for evaluation and treatment as ordered. The Restorative Exercise Prescription dated 6/1/24 revealed upper extremity theraband exercise for 10 repetitions and AROM to the hip, knees and feet for 10 repetitions to be completed 3 to 6 times per week. The Documentation Survey Report revealed restorative exercised completed: 12/2024 - 1 of 31 days 1/2025 - 2 of 31 days The Restorative Nursing Service Progress Notes document dated 2/2025 was blank. The EHR Task Care Record dated 2/2025 revealed the following: a. Restorative AROM to the left upper extremity using one pound hand held weights including left shoulder flexion, chest press, shoulder abduction, and bicep curl for 15 repetitions completed 2 of 18 days. b. Restorative AROM to the right upper extremities using three pound weights including right shoulder flexion, chest press, shoulder abduction, and bicep curl for 15 repetitions completed 1 of 18 days. c. Restorative AROM using the arm bike was refused by the resident 1 of 18 days, and arm bike AROM completed 0 of 17 days. d. Lower Extremities sitting exercises-using 2.5 pound weight (hip flexion, ankle pumps, hip abduction and adduction, and knee flexion for 10 repetitions completed 2 of 18 days. 3. The Annual MDS assessment dated [DATE] revealed Resident #63 had diagnoses of CVA, hemiplegia, cancer and non-Alzheimer's dementia. The resident had impaired ROM to the upper and lower extremities on one side. The MDS recorded the resident required set up assistance for eating, dependent for bathing, dressing, hygiene, bed mobility and transfers. The MDS documented the resident had no therapy and had RNP for zero days during the look-back period. The MDS assessment dated [DATE] revealed Resident #63 required substantial to maximum assistance for eating. The MDS documented the resident had no therapy and had RNP for zero days during the look-back period. The Care Plan revised 2/27/24 revealed the resident had a history of CVA with left sided hemiplegia and required assistance with ADL's. The Care Plan directed staff to provide assistance of two persons for bed mobility and toileting, and use a Hoyer and assistance of two staff for transfers. The Care Plan also recorded the the resident unable to independently perform ROM and had a risk for developing contractures related to a history of CVA. The resident had a risk for declines in ability to complete AROM. The Care Plan also directed staff to notify the nurse if she had any decline in her ability to complete AROM tasks or had complaints of pain during AROM, and review the restorative program and progress toward meeting goals routinely. A Restorative Aide Exercise Prescription dated 7/1/24 revealed PROM exercises to the upper and lower extremities for 10 repetitions with a frequency 3 to 6 times per week. The Restorative Nursing Service Progress Notes for 2/2025 were blank. The Progress Notes dated 7/1/24 to 2/18/25 revealed: a. On 8/6/24 at 4:35 PM, a Restorative Nursing Program Evaluation note: The resident required a PROM restorative program. Resident required restorative nursing program due to hemiparesis and hemiplegia on the left side. The resident participates in PROM program occasionally. Resident meeting current goal for completion of PROM program. No barriers to progress noted. Will continue current program as written. Care plan has been reviewed. b. On 2/8/25 at 2:43 PM, a Monthly Nursing Assessment revealed the resident required assistance of 1 to 2 (staff) for all ADL's. The PT Discharge Summary signed by the Staff H, PT, revealed a restorative nursing program (RNP) recommended to maintain the resident's current level of performance and prevent decline. A RNP for active range of motion (AROM) and passive range of motion (PROM) instructions completed with the IDT (interdisciplinary team). The OT Discharge Summary signed by OT on 11/15/23 revealed the OT recommended RNP PROM to the LUE and AROM to the RUE with 2 lb resistance band, and peg board and close pin tree manipulations. The resident required assistance for all self-cares. The resident's prognosis good with consistent staff follow through. The Documentation Survey Report revealed PROM restorative exercises to the upper extremity and to all joints on the left upper extremity completed: 12/2024: a total of 2 times in 31 days 1/2025: restorative AROM and PROM a total of 2 times in 31 days. A EHR Task Care Record dated 2/2025 revealed restorative PROM to the upper extremities and lower extremities documented 3 of 18 days, and restorative AROM to the right upper extremity using a theraband for 10 repetitions twice completed 2 of 18 days. In an interview 2/20/25 at 9:50 AM, Staff E, CNA, reported she had worked at the facility one year. Staff E reported she had not seen a decline in Resident #63's ability to do ADL's. The resident got combative with cares, but she tried to reapproach the resident and tried to talk her through whatever they needed to do.

Based on observations, record review, staff interview, and policy review the facility staff failed to ensure a resident's bed was placed in a low position to ensure the resident's safety for one of five residents reviewed for transfers (Resident #12). The facility reported a census of 83 residents. Findings include: The Admission Minimum Data Set (MDS) assessment dated revealed 12/27/24 revealed Resident #12 had diagnoses of dementia, osteoporosis, and anxiety disorder. The MDS recorded the resident had a Brief Interview for Mental Status score of 10, indicating moderately impaired cognition. The MDS indicated the resident dependent on staff for bed mobility and transfers. The Care Plan revised on 12/23/24 revealed the resident had impaired cognitive function and impaired thought processes as evidenced by short and long term memory deficit and impaired decision-making related to diagnosis of dementia. The resident also had a risk of falls related to poor safety awareness, functional impairment, and use of medications that increased the resident's fall risk. The Care Plan directed staff to supervise the resident as needed and provide a safe environment. Observations revealed the on 2/19/25 at 7:20 AM, Resident #12 lying in bed on her back with clothes on and a sling under her. The resident's bed was left in the high position. No staff were observed in the resident's room, the hallway area or at the nurse's station. At 7:46 AM, the resident continued to [NAME] in bed on her back and the bed remained in a high position. No staff observed in the resident's room, hallway area or at the nurse's station. At 7:55 AM, the surveyor requested Staff D, Assistant Director of Nursing (ADON) to check the resident's room with the surveyor. Staff D entered the room with the surveyor. Staff D reported the resident's bed left in a higher position than what she would like to see. At the time, Staff D thought maybe staff got the resident dressed and staff were coming back to get the resident up for breakfast. Staff D took the bed control and lowered the bed toward the floor. The facility's Fall Prevention Program Policy updated 12/23/01 revealed falls were a significant concern and many falls resulted in injury. The fall prevention strategies to promote resident safety and prevent falls included maintaining beds at the lowest position at all times. The policy directed staff not to leave cognitively impaired residents at high risk for falls or had a history of falls in a room by themselves, as the resident may try to transfer themselves.

Based on record review, observations, staff interview, and policy review the facility failed to provide complete incontinence care for one of four residents observed (Resident #27) for incontinence care. The facility reported a census of 83 residents. Findings include: The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had diagnoses of end stage renal disease, obstructive uropathy (a urinary tract disorder), and diabetes. The MDS indicated the resident had an indwelling catheter and had dependence on staff for toileting. The Care Plan revised 6/12/24 revealed the resident had a suprapubic catheter. The Care Plan directed staff to provide catheter care per facility policy. On 2/18/25 at 2:45 PM, Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA, washed their hands and donned a pair of gloves. Staff A and Staff B transferred Resident #27 from the broda chair to the bed using a mechanical lift. The cushion in the Broda chair was visibly wet. Staff A and Staff B washed their hands. Staff A obtained disposable wipes, a box of gloves, and a clean brief and placed the supplies by the bed. Staff A and Staff B donned a pair of gloves. Staff removed the resident's wet, urine saturated jeans and brief. The suprapubic catheter found disconnected from the leg bag. The leg bag was empty. Staff A removed the leg bag straps around the resident's thigh. Staff A used an alcohol swab and cleansed the end of the suprapubic catheter, then took another alcohol swab and cleansed the leg bag connection, and attached the catheter to the leg bag. Staff A changed her gloves and sanitized her hands. At 3:00 PM, Staff A told the resident she needed to clean him up. Staff A asked the resident to open his legs so she could clean the front. The resident did not respond. At 3:10 PM, the Director of Nursing (DON) entered the room. Staff A donned gloves, took disposable wipes and cleansed the resident's buttocks from front to back. The resident was incontinent of stool. Staff A continued to remove disposable wipes from the package with her soiled gloves, and cleansed between the resident's buttocks. Staff A removed additional wipes, cleansed between the resident's buttocks, folded the disposable wipe, and cleansed the area again. Staff A changed her gloves. Staff rolled the resident onto his right side. Staff B took disposable wipes and cleansed the resident's left outer buttock, then removed his gloves. Staff lowered the bed and placed a call light by the resident. Staff failed to cleanse the resident's groin, penis, scrotum, right hip and thighs. The DON stood in the room and observed staff with the surveyor present. In an interview 2/20/25 at 12:15 PM, the DON confirmed staff did not perform complete incontinence care on Resident #27 when she observed the CNA perform incontinence care on 2/18/24. The DON confirmed Staff A did not cleanse the resident's front, hips or thighs. The facility's Perineal Care policy revised 2/2018 revealed perineal care provided cleanliness to the resident and prevented skin irritation and infections. The procedural steps included the following: 1. Assemble supplies 2. Wash hands and don gloves. 3. For a male resident, wash perineal area starting with the urethra and working outward. If the resident had a catheter, gently wash the juncture of the tubing, rinse and dry the area. Retract the foreskin if resident uncircumcised. Continue to wash the perineal area including the penis, scrotum and inner thighs. Dry the perineum. 4. Position the resident onto the side. 5. Wash the rectal area thoroughly including the area under the scrotum, the anus, and the buttocks. Dry the area. 6. Remove gloves and wash hands.

Based on clinical record review, observation, resident and staff interview, and policy review the facility failed to ensure staff utilized a gait belt and safely transferred a resident on a weight chair, and failed to appropriately transfer residents using a mechanical lift for 3 of 5 residents reviewed for transfers (Resident #8, #10, and #4). The facility reported a census of 87 residents. 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had diagnosis of diabetes, congestive heart failure, and anemia. The MDS revealed the resident had a Brief Interview for Mental Status (BIMS) of 7, which indicated severely impaired cognition. The MDS documented the resident required substantial to maximum assistance for transfers and toileting. The Care Plan initiated 5/16/24 revealed the resident had a risk for falls related to impaired balance, poor safety awareness, and the use of medications that increased her fall risk. The Care Plan directed staff to encourage the resident to ask for assistance for transfers and ambulation, and provide assistance of one staff for transfers. The Progress Notes revealed the following: a. On 9/8/24 at 9:00 AM, a Certified Nursing Assistant (CNA) called Staff B, Registered Nurse (RN), over the walkie to go to the resident's room immediately. Upon entering the room, resident lying on the floor in front of the toilet face down on her left side with her head on the floor and her feet toward the sink. Blood was running from the right side of her head. Nurse instructed CNA to apply pressure as the nurse notified the Emergency Medical Technicians (EMT's) and the physician. Resident #8 sent to the hospital for treatment. b. On 9/9/24 at 1:07 AM, resident had six sutures placed to right forehead. c. On 9/9/24 at 11:21 AM, resident had limited movement to her right wrist and thumb. New order received from Advanced Registered Nurse Practioner (ARNP) to x-ray area. Tylenol (APAP) administered. Maintenance to fix the weight chair. At 6:35 PM, right wrist x-ray report received. Orders for a brace to the right wrist, and referral to Orthopedic physician. d. On 9/13/24 at 1:43 PM, resident returned from an Orthopedic appointment with a diagnoses of right scaphoid (wrist bone below the base of the thumb) fracture. A cast placed on her right arm/wrist. An incident report dated 9/8/24 at 9:01 AM revealed the CNA called Staff B, RN, to the room. Upon entering the bathroom, resident lying on her right side with her head in front of the toilet and her feet toward the sink. The resident had blood running from the right side of her forehead. Pressure applied to the right forehead as the EMT's, physician, and on-call manager notified. Resident oriented to person, place and situation, and ambulated with assistance of one and an assistive device at the time of the fall. Resident sent to the Emergency Department (ED) for treatment. Injuries included a right hand fracture and a laceration to the top of her scalp. The incident report revealed the environmental factors due to the equipment malfunctioned. The resident was in the weight chair when the leg of the weight chair came off, and she fell to the floor. The incident report revealed the box next to the gait belt on and in use left blank (not marked) on the form under the predisposing situational factors section. The Facility Investigation Summary for Self-Report revealed Resident #8 had a fall with fracture on 9/8/24. The resident had a BIMS of 7, and required the assistance of one for Activities of Daily Living (ADL's), transfers, and toileting. The investigation summary documented on 9/8/24 at approximately 9:00 AM, Resident #8 fell while being weighed on a weight chair in the bathroom with Staff A, CNA. Staff A stated she assisted Resident #8 onto the weight chair when the resident began to fall. The resident hit her forehead and right arm/wrist on the ground. Staff B, RN, evaluated the resident and sent the resident to the ED due to the fall. The resident had a right arm/wrist x-ray and was sent back to the facility. On 9/9/24 at approximately 4:00 PM, the facility received communication the resident had a right wrist fracture. The Medical Director reviewed the incident and determined it was not a major injury. Resident not admitted to a higher level of care and the injury had not changed her functional capacity. Staff A stated she had no indication something was wrong with the weight chair. The chair moved/rolled like normal. Upon review of the weight chair post fall, it was observed that a wheel had dislodged or dislocated from its caster. Other staff stated they had never had issues with the weight chair or noticed anything being off. One staff member mentioned they had put in a work order regarding the accuracy of the scale but had no issues otherwise. The weight chair was repaired by facility maintenance. Maintenance logs and work orders for the weight chair were reviewed. A work order to adjust the weight scale accuracy on the chair was received but no structural concerns were received. The investigation summary's conclusion revealed based on the investigation and interviews the facility believed the root cause to be the weight chair wheel spontaneously dislodged. The staff and facility had no knowledge the weight chair wheel was faulty as the chair had passed routine maintenance inspection. The weight chair wheel was repaired. A Weight Chair Checks documented revealed the weight chair on the 100/200 hall checked on 5/17, 6/14, 7/2, 8/23/24 and had passed inspections. During observation on 9/16/24 at 12:20 PM, Resident # 8 sat in a wheelchair by a counter in the dining room. The resident had a cast on her right arm, a yellowish bruise to the right side of her face, and a sore to her forehead. During an interview 9/17/24 at 12:55 PM, Staff B, RN, reported Resident #8 was modified independent in her room prior to her fall with a fracture. The resident got herself up and dressed, and took herself to the bathroom. The CNA helped put on her [NAME] hose and obtained her weight. The resident had just came back from the hospital a couple days prior to her fall. After she came back from the hospital, she required the assistance of one staff for dressing, toileting, and getting her weight. On the day of the resident's fall, Staff B stated she was on the 100 hall. She got a call to go to Resident #8's room quickly. She was on her way to the resident's room and got another call over the walkie to hurry. She walked into the room and saw the resident lying on the floor in the bathroom. Her head was in front of the toilet and her feet faced toward the sink. She asked what happened. The CNA told her she didn't know what happened but she was getting the resident's weight and the leg came off of the weight chair. She had the CNA apply pressure to the area (on her head). She left the room to get supplies and the Hoyer (mechanical lift). When she returned, she noted blood dripping from the rag. She decided to send the resident to the hospital and called 911. Staff A told her the front right wheel (of the weight chair) was on the floor. The wheel had just popped off and she didn't know why. She had never had any incidents with the weight chair before. Staff B reported the incident happened over a weekend, so she placed a tag on the weight chair and put the chair by the maintenance room. Resident #8 came back from the hospital and had six sutures in her head. They found out later her wrist was broken. During an interview 9/17/24 at 1:35 PM, Staff A, CNA, reported she was unsure what Resident #8's level of function was prior to her fall. Resident #8 had been in the hospital and had a catheter put in. Staff A stated as far as what she was told from (shift) report and what she witnessed, Resident #8 was able to independently move from her bed to the weight chair. She told the resident to wait for her because she had to leave the room to go get something. When she returned to the room, the resident had already moved herself from the bed to the weight chair. She had the wheels locked and the resident had moved herself over onto the weight chair. She unlocked the wheels on the weight chair, and moved her from the side of the bed (where the chair was parked) to the bathroom. As she turned the weight chair into the bathroom, the resident's right side was parallel to the sink and all of a sudden her body went to the left. She fell to the left, and did a 180 onto the floor. Her head ended up by the base of the toilet and her legs were toward the sink. She couldn't catch her in time. She then noticed a wheel on the ground. The wheel had came off of the weight chair. Staff A stated she didn't know if the resident hit her head on the toilet or something else. There was blood coming from her forehead. She did not lose consciousness. Staff A called for help. She asked Staff B if they should even move her. Staff B decided not to move Resident #8 and called the EMT's. Staff A stated she moved the towel she used to apply pressure, and there was a perfectly round hole to her right forehead. Another aide went and got her some more towels to apply to the resident's head wound, and then the EMT's showed up. Staff A stated this was the first time she had any issues with the weight chair. Whenever equipment malfunctioned or needed repaired, a Tag out /Lock out placed and the equipment, and the issue reported to maintenance. The incident happened on a Sunday AM. Maintenance wasn't in the facility at that time that she knew of. Somebody took care of the weight chair and pulled it out of service. In a follow up interview on 9/18/24 at 2:10 PM, Staff A, CNA, reported she did not have a gait belt on the resident on the day she pushed Resident #8 in the weight chair to the bathroom. The wheel came off but she did not see a bolt, a screw, or anything. Just the wheel lying on the floor. Staff A reported she used a pocket care plan to know what cares needed to be done or how a resident transferred. She got a new pocket care plan each day from the area she worked in. She checked the therapy book on how a resident transferred if the information not listed on the pocket care plan. Staff A unsure who updated the pocket care plan since the facility had changes in management. During an interview 9/18/24 at 10:40 AM, the Maintenance Director reported he checked all weight chairs monthly. He used the TELS system to know which equipment needed PM (preventative maintenance). Staff call him or his maintenance assistant when something needed repaired. Staff also could enter a work order into the TELS system. The maintenance director reported he heard a resident had a fall related to the weight chair when he came to work at 6:45 AM the day after the incident. He went down to the unit to get the chair. He checked the weight chair but the weight chair had already been adjusted. Someone had already screwed the wheel back in. A bolt goes up into the wheels but able to loosen the nut/bolt and adjust the chair up or down but the wheel had already been fixed. He didn't think the wheel fell off but it had been screwed down to the lower position. The weight chair had been checked on 7/28/24, and again on 8/23/24, and it passed inspection. The incident happened 1-2 weeks later. He thinks maybe one of the lug nuts on the front wheel was loose. The front left wheel (if sitting in the chair) was what reportedly had came off. During an interview on 9/18/24 at 10:55 AM, Resident #8 sat in a wheelchair in her room and had a cast on her arm. The resident reported she broke her arm when staff pushed her in a chair into the bathroom. The chair tipped, she fell out of the chair, and hit her head on the toilet. She had to have six stitches in her right forehead. The sutures and a dark bruise were visible to her forehead. During an interview on 9/18/24 at 11:10 AM, the Director of Nursing (DON) reported she had worked at the facility for 3 weeks. The DON stated she was notified when Resident #8 had a fall from the weight chair. The front wheel on the weight chair came loose and the chair tipped. The DON stated she didn't see the weight chair. The weight chair was taken off the floor and maintenance fixed it. During an interview 9/18/24 at 2:25 PM Staff C, certified medication aide (CMA), reported Resident #8 independent in her room and required stand by assistance (SBA) prior to her fall/fractured arm. Staff C stated a gait belt used even if a resident a SBA just to be ready. During an interview 9/18/24 at 3:00 PM, Staff D, Assistant Director of Nursing (ADON), reported she expected staff used a gait belt whenever a resident required assistance of one or two staff or used a mechanical lift. A gait belt always used unless the resident was independent. The ADON reported she wasn't at the facility at the time of the incident with Resident #8 but she heard the wheeled popped off of the weight chair. The weight chair was taken out of service and maintenance fixed the weight chair the next day. During an interview 9/18/24 at 3:35 PM, Staff I, CNA, reported she regularly worked the hall where Resident #8 resided and familiar with the resident. Resident #8 used a gait belt and a stand-by assistance of one for ambulation and transfers. Staff I confirmed a gait belt always used whenever a resident required the assistance of one staff. On 9/19/24 at 11:05 AM, the DON reported the facility didn't have a gait belt policy. A Safe Lifting and Movement of Residents policy revised 7/2017 revealed the facility used appropriate techniques and devices to move residents in order to protect the safety and well-being of staff and residents. 49990 2. The Quarterly Minimum Data Sample (MDS) for Resident #10, dated 06/24/24, which documented relevant diagnoses of heart failure, hypertension, renal failure, and respiratory failure. It documented Resident #10 is fully dependent for transfers, requiring two-person assistance and a mechanical lift device. The Care plan for Resident #10, last revised on 07/18/24, documented the resident requires two-person assistance with use of a mechanical lift device for all transfers. A direct observation on 09/17/24 at 12:20 PM revealed Staff K, Certified Nurses Aide (CNA), and Staff L, CNA, performing a mechanical lift transfer for Resident #10. During the transfer, Staff L failed to engage the stability legs to ensure the safety of the resident during the transfer. Additionally, Staff K failed to notice the stability legs were not engaged during the transfer. Additionally, staff members did not participate in a time-out to ensure safe strap placement for the resident before beginning to transfer. 3. In an interview on 09/18/24 at 11:14 AM with Resident #4, she stated she had previously been dropped out of a Hoyer (mechanical lift). She was unsure how it happened but said that the Hoyer tipped over, she landed on the ground and hit her head. She stated she is now afraid of transfers, as she worries she will be dropped again. Review of Resident #4's MDS, dated [DATE], documented a brief interview for mental status (BIMS) score of 14, which indicated intact cognition. Incident Report dated 8/26/24 at 6:50 PM documented during a Hoyer transfer the right sling strap slipped off the hook and the resident fell to the floor, hitting her head on the floor. Injury type described as follows; bruise on left side back of head. Review of a facility document titled N Fall investigation worksheet, dated 08/26/24, documented Resident #4 experienced a fall while being assisted with a mechanical lift transfer. It further documented she was not experiencing behaviors at the time of the incident, and that training and education had been provided to both CNAs regarding mechanical lift transfers, to make sure proper sling safety is used by conducting time-outs to insure all straps are secure. Progress Note dated 8/28/24 at 9:21 PM documented Resident #4 had complaints of head pain towards the back left of her head, and mid chest pain, ice pack applied and pain medicine given for pain control. In an interview on 09/18/24 at 04:01 PM with the Direct of Nursing (DON), she stated it was her expectation staff members perform a mechanical lift transfer in accordance with the standards of practice. She stated those standards of practice include a time-out to ensure proper strap placement as well as the use of the stability legs if present on mechanical lifts. Review of a facility provided document titled Lifting Machine, Using a Mechanical, last revised July 2017, documented staff members should ensure a mechanical lift is stabilized, as well as double check the placement of straps before a resident is moved away from a bed or chair.

Based on record review, observations, staff and resident interview the facility failed to ensure the resident environment remained as free from accident hazards as possible for 1 of 2 resident's sampled (Residents #3). Specifically, the facility failed to ensure bed frame protective end caps were in place which resulted in the sharp edge of the bed frame coming in contact with the resident during transfer causing injuries for one resident on two separate occasions. The resident required assistance of two for tranfers and only person assist was done on 5/19/2019. The facility further failed to have a system in place to ensure that protective end caps were in place for 23 beds currently in use at the facility, placing resident's at risk for injury. The facility reported a census of 54. Findings include: A Minimum Data Set (MDS) assessment form dated 6/4/19 indicated Resident #3 had [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status (BIMS) score of 14, cognitively intact skills for daily decision making. The resident required extensive assistance of two staff members for transfers, bed mobility and toilet use and extensive assistance of one staff member for locomotion on and off the unit and as she was non-ambulatory. Resident #3's Care Plan included the following focus areas as dated: risk for skin breakdown due to needed assist with activities of daily living (ADL's) and transfer (initiated 3/23/19); [MEDICAL CONDITION] related to [MEDICAL CONDITION] Fibrillation (initiated 4/4/19); laceration on left knee (revised 5/30/19); risk for skin breakdown due to weakness and decreased mobility (revised 5/30/19); pain to left knee due to a laceration and stitches (revised 5/30/19); and at risk for falls due to a history of falls and weakness (initiated 5/11/19). The Care Plan approaches included the following: a. Administer diuretic as prescribed by my physician, initiated on 4/4/19. b. Encourage to elevate my legs when I am in bed a least a couple of hours per day, initiated on 4/4/19. c. Monitor [MEDICAL CONDITION] and report concerns to the physician, initiated on 4/4/19. d. Monitor pain level and report increase discomfort to the physician, initiated on 4/4/19. e. Treatment to left knee as ordered by my physician, initiated on 5/30/19. f. Monitor skin with cares, alert nurse of any red or open areas so she can contact my physician, initiated on 5/30/19. g. Notify the physician if my skin worsens, initiated on 5/30/19. h. I require assist of 2 staff members for a stand and pivot transfer using a pivot disk and Dysem (under the pivot disk to keep it from slipping). Provide verbal cues for hand placement during transfers, revised on 6/6/19. Review of an Incident Report dated 5/19/19 at 11:30 a.m. revealed the nurse was called into the resident's room by the caregiver. Resident #3 was sitting in the wheel chair and faced the head of the bed. The caregiver stated the residents leg was bleeding and didn't know what happened, we didn't hit anything The caregiver stated the resident had been really weak and didn't stand but she didn't fall. She had to go to the bathroom really bad. The wheel chair brakes were on and the pedals were off the wheel chair. The staff assisted the resident back to bed, assessed the area on the left knee, cleansed the area and noted a 6.5 centimeter (cm) by (x) 1 cm x 0.3 cm deep laceration. Staff covered the area with wet gauze and ice, wrapped the site and sent the resident to the emergency room . During an interview on 6/14/19 at 5:10 p.m. Staff E, Certified Nursing Assistant (CNA) confirmed the resident required 2 staff assistance with transfers per her care plan however he self transferred the resident himself on 5/19/19 which he agreed had been a poor judgement call. Staff [NAME] confirmed he self transferred the resident from her wheel chair to the toilet, from the the toilet to her wheel chair and then he wheeled her to the bed in her room. He then faced the wheel chair towards the bed and positioned himself in front of her, he stood her with the use of a gait belt and pivot transferred her as he turned to his right side and sat her on the edge of the bed. At that time he noted the skin tear on her left knee and he reported it right away to the nurse. Staff [NAME] confirmed there had been no question she hit her left leg on the bed and/or bed frame, however, he failed to look at either site to have observed any evidence of an impaction of her leg to the bed and/or frame. During this interview the staff member kept repeating over and over again he made a poor judgement call. During an interview on 6/21/19 at 11:34 a.m. Staff I confirmed she had been the charge nurse on duty on 5/19/19 when Staff [NAME] called her to the resident's room. As she entered the room the resident sat in her wheel chair positioned at the foot of her bed as it faced towards the head of her bed. Staff I noted blood on the pants of the resident's left leg. Staff I stated they needed to get her into bed so Staff [NAME] and herself transferred the resident to bed, removed her pants. Staff I felt she could not have repaired the area and sent the resident to the hospital. Both Staff [NAME] and the resident denied a fall or having hit the leg on anything. Staff I indicated Staff [NAME] self transferred the resident from her bed to the wheel chair because the resident had to go the bathroom really bad, however, the resident never got to the bathroom because Staff [NAME] noted the blood and went to report it. Staff I indicated she specifically remembered that because when they got the resident back into bed she kept stating that she had to go to the bathroom. Staff I offered the resident the bedpan because she had not wanted to move her due to the bleeding and the size of the laceration. Staff I confirmed she checked the area in and around the bed and failed to see anywhere she could of hit her leg as there were no rough or jagged edges. The staff member indicted she felt along the wheel chair and bed frame. When she felt along the bed frame it had been just random checks of the frame she did not recall lifting the sheet to visualize or feel the bed frame. Staff I offered that she never paid any attention to the black protective caps on the bed frame and she could not say if the caps were in place or not. During an interview on 6/19/19 at 3:55 p.m., the Director of Nursing (DON) indicated she had not conducted the investigation of the incident but Staff H, Quality Assurance (QA) nurse, at the time of the incident, followed through with the investigation. The DON indicated all she knew was Staff [NAME] transferred the resident from the bed to the wheel chair and then to the toilet. When they returned to the room Staff [NAME] observed the resident's leg bleeding so he never transferred the resident back to bed. During an interview on 6/19/19 at 4:11 p.m. Staff H stated she received a call from Staff I , LPN who informed her they planned to send Resident #3 to the emergency room due to a laceration. Staff H asked Staff I how it happened but the staff had been unaware of the cause. The staff member confirmed she documented on the 5 Why's form. Staff H indicated typically she did not lift the resident's bed sheets to observe the bed frame, however, she looked under the resident's bed and checked the resident's wheel chair but found nothing out of the ordinary Staff H thought Staff I informed her Staff [NAME] had transferred the resident from bed to wheel chair but Staff I had not been present with her investigation. Review of the 5 Why's form dated 5/19/19 at 12:30 p.m. revealed the following entry: Resident alert and oriented x 3, able to make needs known. Resident #3 bumped leg on unknown object during a transfer from bed to wheel chair. Staff in room believed the point of contact was on the edge of the wheel chair and with the resident's skin having been so frail, caused an open gash to the left knee. No sharp objects noted around the bed, the wheel chair or on her clothing. The resident was sent to the emergency room for further treatment. A Emergency Department Provider Note form dated 5/19/19 included the following documentation: Today she had been transferred into her wheel chair by staff, who used a gait belt. The patient reported she stood with the gait belt on and staff assist, but became to weak to stand and fell . Reportedly the staff caught her and she had not hit the floor but sustained a knee laceration. The area had been explored to its depth in a bloodless field with no sign of tendon nerve or vascular injury. No foreign bodies were identified. It was closed with continuous suture (given the patient's fragile skin) as well as 2 simple interrupted sutures which required removal in approximately 14 days. Review of an Incident Report form dated 5/30/19 at 10:51 p.m. indicated a CNA went and got the nurse and said Resident #3 had been uncooperative and when the staff tried to get her into bed her skin tore. The nurse walked into the room and found a large puddle of blood under the resident's right foot and a large skin tear under her right knee. The nurse placed gauze on the wound and wrapped it to try to stop the bleeding, cleaned the blood off of the floor, called the physician and sent the resident to the emergency room . A Progress Notes form with an entry dated 5/30/19 at 11:25 p.m. included the following: A CNA came and got me and described the resident as uncooperative when they tried to get her to bed and her skin tore. The nurse walked into the room and found a large puddle of blood under her right foot and a large skin tear under her right knee. The resident stated that one of the CNA's tried to get her to turn her foot and she stated she couldn't. When she told the CNA she couldn't move her foot he allegedly said yes you will and forcefully turned her and somehow caused the skin tear. The resident also stated he yelled at me, he is very aggressive. The nurse placed gauze and wrapped her leg to try to control the bleeding and sent the resident to the emergency room . After the resident left Staff D, CNA came and got the nurse and showed her a place on the resident's bed where there had been blood and a piece of skin on the metal frame of he bed. An observation of photos, taken by the nurse at the time of the incident, revealed a bed frame support pipe with rough jagged edges and no black protective cap present with a small amount of serosanginous blood on the inside of the support pipe and pieces skin hanging from the outside of the same site. During an interview on 6/18/19 at 5:10 p.m. Staff [NAME] confirmed for the 5/30/19 injury, himself and Staff D positioned the resident's wheel chair as it faced her bed and the staff members stood on each side of the resident and pivot transferred her onto the edge of the bed. Staff [NAME] was questioned several times as the direction of the pivot technique with this injury however he refused to comment and answer the question. During an interview on 6/13/19 at 11:15 a.m. Staff D confirmed herself and Staff [NAME] assisted the resident to go to the bathroom. Staff D stated anytime they did anything with Resident #3 she cried so they asked her to calm down. When they assisted the resident in the bathroom they utilized a pivot disk but she still resisted them during the transfer process. Upon completion the staff members transferred her from the toilet to the wheel chair and propelled her to her bed. As Staff [NAME] stood behind the resident, Staff D asked Staff [NAME] to stand to the side of the resident but he refused and continued to stand behind the resident. They placed a gait belt and stood the resident as she screamed due to the amount of room beside the bed during the transfer process. When the staff members attempted to pivot transfer the resident she refused to cooperate Staff [NAME] continued the transfer process anyway and the resident's leg got caught on the bed and she screamed my leg, my leg. The staff members then sat the resident on the edge of the bed and Staff D looked down and observed blood all over and she directed Staff [NAME] to inform the nurse of the incident. The nurse arrived and found the skin tear to the resident's right knee area and called the ambulance. Staff D offered that Staff [NAME] yelled at the resident during the transfer process and told her to sit down. During an interview on 6/13/19 at 1:32 p.m. Staff F, LPN confirmed she worked the night of 5/30/19. When she went to the resident's room for administration of medications Staff D and Staff [NAME] had been in the process of toileting the resident in the bathroom. Staff F chose to stand outside of the bathroom door because she had heard Staff [NAME] had a bad temper and reportedly rude to residents. While she stood outside the door she heard the resident as she said she could not stand much longer and she wanted to sit. Staff [NAME] replied to the resident with a snotty raised voice no you are not. Staff F knew they positioned the resident in the chair and planned to position the resident in bed however she left the room at that time to go to the bathroom herself. Staff G, RN then text her and informed her Staff [NAME] needed her. When she came back down the hallway Staff [NAME] met her at the nurse's station and seemed irritated. Staff [NAME] stated the resident had been uncooperative with the transfer process and refused to move her feet so she tore her skin. Staff F went straight to the resident's room and observed a puddle of blood on the floor about six inches around the resident's shoe as she sat on the edge of the bed. Staff F stated the resident had been off blood thinners but continued as an active bleeder. Staff F went and grabbed supplies and when she returned she noted a flap of skin split down the middle so she placed the skin back over the wound and placed gauze over the area as a means to stop the bleeding. When she asked what happened, Staff D said the resident's leg just popped and they never hit her leg on anything. The resident stated Staff [NAME] just yelled and pushed her to turn but her body refused to turn. When Staff F asked the resident her position she stated the staff placed the wheel chair up to the bed as it faced the wall and stood her but because she could not move Staff [NAME] shoved her while he had her left arm as he stood towards her back and Staff D had her right arm and stood towards the front of her body. Staff F left the room, called the ambulance and returned to the resident because she knew Staff [NAME] irritated the resident. The resident then informed her Staff D told Staff [NAME] not to push her on the bed but he refused to listen and continued anyway The ambulance arrived and transferred the resident to the hospital. Later Staff D showed her the resident's bed frame where she observed blood inside of a support bar of the bed frame and skin on the outside. When she felt the area she noted no protective cap on the support bar which revealed rough jagged edges. When the resident returned from the hospital they had steri strips on the area like crazy and the area had been wrapped real good. The physician ordered Keflex (an antibiotic) and increased her [MEDICATION NAME] (diuretic). During an interview on 6/13/19 at approximately 12:45 p.m. the Director of Nursing (DON) confirmed when a resident required 2 staff assistance with the transfer process she expected the staff members to have positioned themselves to the sides of the resident not in front and back. During an interview on 6/13/19 at 9:31 a.m. Staff A stated the next day when he arrived at work he asked Resident #3 what happened the night prior. The resident stated she did not know the names of the staff the night prior and she described the situation as terrible. She stated 2 aides came in and assisted her to the bathroom and as they positioned her in bed they argued amongst themselves about how to have completed the transfer process. The resident stated the guy (Staff E) had not wanted to listen to the girl (Staff D) because her feet refused to move due to her plastic slippers and her feet became tangled in the easy chair in her room and the guy said, move your feet damnit. When they positioned her on the edge of the bed they realized her leg was bleeding so they called the nurse. The resident indicated she could not remember her leg hitting anything and that the 2 staff members utilized a gait belt. A Emergency Department Provider Note form dated 5/30/19 at 10:06 p.m. included the following documentation: A non-toxic but chronically ill female presented in the ER with a right leg laceration. She bumped her leg while she got into bed. In regards to her leg laceration, it was a superficial skin flap, non amenable to sutures; steri-strips placed by nursing staff. Discharge orders included [MEDICATION NAME] (an antibiotic) 500 milligrams 1 capsule three times a day for seven days as the resident was a high risk for secondary infection. A Treatment Administration Record for Resident #3 form for 6/1/19-6/30/19 included the following treatment order; Place [MEDICATION NAME] and wrap in gauze to skin tear on the right calf. Change daily and as needed (PRN) with a start date of 6/1/19. A Treatment Administration Record for Resident #3 form for 6/1/19-6/30/19 included the following treatment order for Right leg laceration - cleanse gently with normal saline, applied Xeroform gauze and wrapped with conform, change daily until healed. The order had a start date of 6/4/19. A Treatment Administration Record for Resident #3 form for 6/1/19-6/30/19 included the following treatment order for Right leg laceration - cleanse gently with normal saline, applied Xeroform gauze and a large border gauze. Change daily until healed. The order had a start date og 6/12/19. Review of the 5 Why's form dated 5/30/19 at 10:51 p.m. revealed the following entry from the DON: had Aides demonstrate the transfer from the previous evening, one aide was in front of the wheel chair and the other aide in back of the wheel chair. The resident was not moving her feet to pivot and her right leg was to close to the bed. When the aides turned her and lowered her into bed her right leg got caught up on the bed frame. The resident's legs were very [MEDICAL CONDITION] and orders for her diuretics changed the previous evening. Both aides were educated on the proper way to transfer when having difficulties when a resident legs will not move. An environmental tour on 6/13/19 at 10:45 a.m. with Staff A, Assistant Director of Nursing (ADON) revealed the facility had 23 Joerms Easy Care Beds which were currently assigned to a resident that had one or more black protective bed support bar end caps missing. The bed had 3 sections, each section had two round metal hollow support bars (appeared like a pipe) that provided the base for the mattress which required 12 protective end caps (6 on each side). The diameter of the support bar measured 1.5 inches, the bed frame could be adjusted from 7 inches (to center of end cap) to 29.5 inches off the floor. When felt by the surveyor the unprotected end of a support bar felt rough and with a sharp edge. Staff A, ADON stated she was not sure who was responsible to check beds for safety concerns. She explained housekeeping cleaned the beds and nursing made the beds. Staff A confirmed the exposed areas posed a hazard and protective end caps should have been replaced. During an interview on 6/13/19 at 11:25 a.m., Staff B, housekeeper stated she cleaned the beds and was alert for something loose. She had not noticed anything with any of the beds. Had she noticed she would have reported to maintenance. Staff B specifically denied having noticed the black protective end cap missing from any bed frames when the Surveyor provided an example. Staff B further stated had not been trained on what to look for to ensure beds were safe and in good repair. In an interview on 6/13/19 at 11:40 a.m., Staff C, Certified Nursing Assistant (CNA) stated he removed the bedding and housekeeping cleaned the beds. Staff C, denied knowledge of expectation to inspect the beds for concerns. Staff C stated would report if had noted something obvious. In an interview on 6/13/19 at 2:20 p.m. the Director of Nursing (DON) acknowledged that during investigation into Resident #3's injury she became aware the missing black protective end cap could possibly have been the cause of the injury. After she viewed the photo, taken by a facility staff person, of exposed metal bed frame with what appeared to be blood and tissue, the DON confirmed it looked like the cause of injury. The DON stated they had replaced the black end cap on the Resident #3's bed but failed to inspect other beds at the facility for missing end caps, further stated, we should have. During an interview on 6/13/19 at 2:35 p.m. the Administrator confirmed there had not been an established expectation to routinely inspect bed frames. The Administrator stated a new checklist had been implemented to complete weekly inspections for safety concerns, which included: ensure all 12 end caps (black protective end cap) are accounted for and tight. During an interview on 6/12/19 at 4:21 p.m. the Administrator stated the situation with Staff [NAME] was an improper transfer. Due to the improper transfer and additional write ups Staff [NAME] had been terminated.