Every finding on record at The Grove

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a safe environment and implement interventions to prevent accidents for two (2) of six (6) residents reviewed with a history of falls. Resident #1 and Resident #2.Findings include:A review of the facility's Fall Protocol Policy, dated 2/2011, revealed, It is the policy of this facility that the fall protocol will be as follows.Fall review.Evaluate possible alternative interventions to help prevent falls.Resident #1A record review of the facility's document, Fall During Staff Assist, dated 4/3/26, revealed Resident #1 fell during a chair-to-bed transfer when Certified Nurse Aide (CNA) #1 used a sit-to-stand lift. A review of the facility's Staffing Disciplinary, dated 4/3/26 revealed .CNA.noted to not follow proper transfer status for resident (Resident #1).This write did a phone interview with CNA who states that she asked the resident how she transferred.Made CNA aware that the care profile and transfer status are to be looked at prior to the start of every shift.A record review of the Nurse Notes dated 4/3/26 at 7:46 AM for Resident #1, revealed .CNA reported to this nurse that resident was on the floor.Fall was witnessed by CNA. CNA asked resident if she was a total and resident reported, 'I can stand.' While using sit to stand lift, resident let go of handles on her way down and slid onto the floor.A record review of the Order Summary Report revealed a Physician's Order, dated 2/16/26 for TOTAL LIFT X2 (with two person) ASSIST.A record review of the Care Profile Report, dated 4/20/26, revealed Resident #1 had Special Instructions including TOTAL LIFT X2 CNAs FOR TRANSFERS.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated her cognition was moderately impaired. A record review of the Face Sheet revealed the facility admitted Resident #1 on 2/1/25 and she had diagnoses including Chronic Obstructive Pulmonary Disease.On 4/20/26 at 10:30 AM, during an observation and interview, Resident #1 was seated in her wheelchair in her room with the call light within reach. She was unable to recall the fall and denied complaints.Resident #2A record review of the facility's document Un-witnessed Fall with Head Injury, dated 3/16/26, revealed Resident #2 was found on the floor of her room and the bed alarm was not sounding to alert staff. Prior to the fall, the resident was lying in the bed.A record review of the Order Summary Report revealed Resident #2 had a Physician's Order, dated 10/29/24 for BED/CHAIR ALARM.CHECK EVERY SHIFT FOR PROPER OPERATION & PLACEMENT.A record review of the Care Profile Report revealed Resident #2 had Special Instructions including Bed Alarm to bed.A record review of the Comprehensive MDS with an ARD of 4/8/26 revealed Resident #2 had a BIMS score of five (5), which indicated her cognition was severely impaired.A record review of the Face Sheet revealed the facility admitted Resident #2 on 10/24/24 with diagnoses including Dementia. On 4/20/26 at 10:10 AM, during an observation and attempted interview, Resident #2 was seated in her wheelchair at the nurses' station with a chair alarm in place. She was alert and responsive but unable to recall the fall incident.On 4/20/26 at 2:25 PM, during an interview with the Director of Nursing (DON), she reported Resident Care Profiles were available to all nursing staff and confirmed Resident #1 required two (2) staff and a full mechanical lift for transfers. She reported she was not as familiar with Resident #2's fall.On 4/20/26 at 3:10 PM, during an interview with the Quality Assurance (QA) Nurse, he reported the root cause of Resident #1's fall was failure to follow the care profile requiring two (2) staff and a full mechanical lift. He reported Resident #2's fall occurred when the resident got out of bed without assistance and the bed alarm was not engaged, which could have alerted staff through the call light system and allowed for intervention.On 4/20/26 at 4:30 PM, during an interview with the Administrator, he reported the expectation was for staff to provide a safe environment and prevent accidents and confirmed the facility investigated both incidents.

Based on staff interview, record review, and facility policy review, the facility failed to implement individualized care plan interventions for two (2) of six (6) sampled residents. Resident #1 and Resident #2.Findings include:A review of the facility's Total Care Plan Policy, undated, revealed, It is the policy of this facility that the Interdisciplinary care plan will be done as follows.Reminders.Care Plan must be followed by all staff included in resident's care.Resident #1A record review of the facility's document, Fall During Staff Assist, dated 4/3/26, revealed Resident #1 fell during a chair-to-bed transfer when Certified Nurse Aide (CNA) #1 used a sit-to-stand lift.A record review of the facility's Staffing Disciplinary, dated 4/3/26, revealed, .CNA.noted to not follow proper transfer status for resident (Resident #1).This write did a phone interview with CNA who states that she asked the resident how she transferred.Made CNA aware that the care profile and transfer status are to be looked at prior to the start of every shift.A record review of the Nurse Notes, dated 4/3/26 at 7:46 AM, revealed, .CNA reported to this nurse that resident was on the floor.Fall was witnessed by CNA. CNA asked resident if she was a total and resident reported, 'I can stand.' While using sit to stand lift, resident let go of handles on her way down and slid onto the floor.A record review of the Order Summary Report revealed a physician's order dated 2/16/26 for TOTAL LIFT X2 (with two person) ASSIST.A record review of the Care Plan Report revealed Resident #1 had a focus of fall risk with interventions including d/c sit to stand. Total lift x 2 assist.A record review of the Care Profile Report, dated 4/20/26, revealed Resident #1 had special instructions including TOTAL LIFT X2 CNAs FOR TRANSFERS.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/26 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident's cognition was moderately impaired.A record review of the Face Sheet revealed the facility admitted Resident #1 on 2/1/25 with diagnoses including Chronic Obstructive Pulmonary Disease.Resident #2Record review of the Care Plan Report revealed Focus: Falls-I have a history of falls prior to admission to facility with potential for reoccurrence to tremors, deconditioning, weakness, cognition. I require the use of bed and chair alarms related to fall risk. Date Initiated 10/24/24A record review of the facility's document, Un-witnessed Fall with Head Injury, dated 3/16/26, revealed Resident #2 was found on the floor of her room and the bed alarm was not sounding to alert staff.A record review of the Order Summary Report revealed Resident #2 had a physician's order dated 10/29/24 for BED/CHAIR ALARM.CHECK EVERY SHIFT FOR PROPER OPERATION & PLACEMENT.A record review of the Care Profile Report revealed Resident #2 had special instructions including use of a bed alarm.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/8/26 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated the resident's cognition was severely impaired.A record review of the Face Sheet revealed the facility admitted Resident #2 on 10/24/24 with diagnoses including Dementia.On 4/20/26 at 10:10 AM, during an observation and attempted interview, Resident #2 was seated in her wheelchair at the nurses' station with a chair alarm in place. She was alert but unable to recall the fall incident.On 4/20/26 at 10:30 AM, during an observation and interview, Resident #1 was seated in her wheelchair in her room with the call light within reach and denied complaints.On 4/20/26 at 2:25 PM, during an interview with the Director of Nursing (DON), she reported care plans were communicated to staff through Resident Care Profiles and confirmed Resident #1 required two (2) staff and a full mechanical lift for transfers.On 4/20/26 at 3:10 PM, during an interview with the Quality Assurance (QA) Nurse, he reported the root cause of Resident #1's fall was failure to follow the care plan requiring two (2) staff and a full mechanical lift. He reported Resident #2's fall occurred when the resident got out of bed and the bed alarm was not engaged, which could have alerted staff through the call light system.On 4/20/26 at 4:30 PM, during an interview with the Administrator, he reported staff were expected to implement care plans to meet resident needs and provide a safe environment.

Based on observation, interview, record review, and facility policy review, the facility failed to sanitize pots and pans according to manufacturer's guidelines and failed to calibrate food thermometers to ensure food remained hot for one (1) of four (4) kitchen observations.Findings include:A review of the facility's Calibration of Thermometers Policy, revised 10/17, revealed, .Facility shall ensure that a thermometer gives accurate recordings. Procedure: 1. All thermometers are to be calibrated: a. Before each use b. After being dropped c. When experiencing an extreme change in temperature. A review of the facility's Manual Warewashing Policy, dated 10/17 revealed, .Food service pots and pans that cannot fit in the dish machine or cleaned and sanitized in a three-compartment sink.Procedure.5) Third Compartment Sink a) Fill the third sink with water and sanitizer to the correct concentration. Hot water can be used as an alternative. B) Immerse items in the third sink in hot water or chemical sanitizing solution. I)If hot water immersion is used, the water must be a minimum of 171 F and items must be immersed for 30 seconds. Ii) If chemical sanitizing is used, the sanitizer must be mixed to the proper concentration. Follow manufacturers' recommendations. The following are published guidelines. (1) Chlorine-Immerse for 7 seconds in water temperature 100 degrees F (Fahrenheit) (2) Iodine-Immerse for 30 seconds in water temperature 68 degrees F. (3) Quats-Immerse for 30 seconds in water temperature 75 degrees F. (6) The concentration of the sanitizing solution is checked with an appropriate test kit when the sink is filled and again if the solution is used for an extended period of time.On 2/10/26 at 10:35 AM, during an observation, the Dietary Manager (DM) checked food temperatures on the steam table using a manual thermometer and failed to calibrate the thermometer prior to testing the food.On 2/10/26 at 10:48 AM, during an observation and interview, Dietary Aide (DA) #2 washed pots and pans in the three-compartment sink. Pots and pans were observed air drying on a table next to the sink. The third sink contained warm water, and a test strip did not register sanitizer concentration. DA #2 stated the sanitation equipment was not working. The sanitation container was observed to be under the sink without the sanitation tubing connected.On 2/10/26 at 10:48 AM, during an interview, the DM confirmed she failed to calibrate the thermometer because it had been calibrated previously by another cook and confirmed thermometers were not calibrated before each meal. The DM also confirmed the sanitation tubing had been disconnected from the three-compartment sink and was later reconnected to allow sanitizer to dispense into the sink.On 2/10/26 at 11:54 AM, during a follow up interview, DA #2 explained that while washing the pots and pans in the three-compartment sink, she did not initially add sanitizing solution to the sink and believed sanitizer may have already been present from earlier use.On 2/12/26 at 11:28 AM, during an interview, the Administrator stated staff are expected to calibrate thermometers and use sanitation equipment according to manufacturer guidelines.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to dignity, as evidenced by standing over the resident while assisting to feed for one (1) of (18) sampled residents. Resident #34.Findings include:A review of the facility's Dignity Policy, undated, revealed, .Dignity means that staff carry out activities which assist the resident to maintain and enhance his/her self-esteem and self-worth as follows.Promoting resident independence and dignity in dining.A record review of Resident #34's Face Sheet revealed the facility admitted Resident #34 on 7/16/12 with diagnoses including Hemiplegia and Hemiparesis.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25 revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident's cognition was severely impaired.On 2/9/26 at 11:54 AM, during an observation, Certified Nursing Aide (CNA) #1 was observed assisting Resident #34 with feeding in the resident's room. She was standing over the resident during lunch. CNA #1 tilted her arm downward to place food into the resident's mouth. Two vacant chairs were present in the resident's room, and three chairs were located in the hallway adjacent to the resident's door.On 2/9/26 at 12:05 PM, during an interview, CNA #1 acknowledged she assisted Resident #34 with feeding while standing over the resident. She reported she was aware she was expected to feed residents while seated at eye level. She reported she was aware two chairs were available in the room, and three chairs were located in the hallway near the resident's door. She reported she did not sit because she had been told the chairs were for family members and affirmed no family members were present during the meal.On 2/11/26 at 11:29 AM, during an interview, the Director of Nursing (DON) reported the importance of sitting during feeding assistance was to improve positioning and reduce the likelihood of aspiration. She reported her expectation was for staff to sit when assisting residents with feeding.On 2/12/26 at 10:40 AM, during an interview, the Administrator reported standing over a resident during feeding was a dignity concern and disrespectful and stated his expectation was for staff to sit during assisted feedings.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy and confidentiality by posting personal care information in the resident's room for one (1) of two (2) residents sampled for privacy. Resident #8.Findings include:A review of the facility's Privacy of Health Information Policy, undated, revealed, . It is the policy of this facility that resident's health information will be protected as follows: . No health information allowed on counter tops or in areas visible to unauthorized persons . - Posting notes and reminders in the residents' rooms by staff members will be prohibited (unless resident and/or responsible party has given us permission to do so AND it has been added to the resident's care plan) .A record review of Resident #8's Face Sheet revealed the facility admitted Resident #8 on 2/7/24 with diagnoses including Encounter for Attention to Gastrostomy.A record review of the Order Summary Report with active orders as of 2/10/26 revealed Resident #8 had physician orders for . All Oral Meds to Be Given Via percutaneous endoscopic gastrostomy (Peg) Tube as Previously Ordered (dated 1/2/26) . NPO (nothing by mouth) Status (dated 1/7/26) . Diet: Nutren 2.0 at 30 ml (milliliters) per hour continuous via PEG tube (dated 12/15/25) . Keep Head of Bed Elevated 30 Degrees or Greater at All Times R/T (related to) Peg Tube and Risk of Aspiration (dated 12/15/25) .On 2/11/26 at 9:31 AM, during an observation and interview, Licensed Practical Nurse (LPN) #3 was observed administering medications via PEG tube to Resident #8. Two (2) signs were observed posted on the wall above the resident's headboard indicating to Keep Head of Bed elevated at 30-45 degrees to prevent aspiration and Nutren 2.0 at 30 ml/hr (milliliters/hour) continuous via PEG tube and All meds given via PEG tube. LPN #3 confirmed the signs and reported the information reflected private health information contained in the resident's medical record and care plan.On 2/11/26 at 10:19 AM, during an interview, the Director of Nursing (DON) confirmed signage containing resident personal care information should not be posted in resident rooms. She reported Resident #8 recently received a new PEG tube due to decreased appetite and weight loss. She confirmed the information posted above the resident's headboard included personal care information and should not have been posted due to privacy concerns. She reported the information was available in the resident's medical record for staff access. She reported she was not aware the signs were posted and did not know who posted them or how long they had been posted. She stated her expectation was for staff to honor resident privacy and not post personal care information unless requested by the family.On 2/12/26 at 1:27 PM, during an interview, the Administrator reported he expected staff to honor resident privacy and not post personal care information in resident rooms.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical restraints by failing to identify and document the use of a lap belt as a restraint for one (1) of eighteen (18) sampled residents. Resident #55.Findings include:A review of the facility's Restraint Policy, undated, revealed, .Physical restraints are defined as any manual method or physical mechanical device, material, or equipment attached.to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.On 2/9/26 at 3:55 PM, during an observation, Resident #55 was observed with a soft belt secured across her lap while up in a wheelchair.On 2/10/26 at 11:46 AM, during an observation, Licensed Practical Nurse (LPN) #1 asked Resident #55 three (3) times to remove the belt. Resident #55 stared at the nurse and did not respond to the request.On 2/11/26 at 11:32 AM, during an interview, the Director of Nursing (DON) reported the facility failed to identify the resident's lap belt as a restraint. She reported the importance of properly identifying the belt as a restraint as a way to ensure staff were aware of required monitoring, including releasing it every thirty (30) minutes and checking for proper fit. She reported that the Quality Assurance (QA) nurse was responsible for ensuring restraints were identified properly and stated she would ensure proper assessment for restraint use and reduction.On 2/11/26 at 11:36 AM, during an interview, LPN #2, QA nurse, reported he did not identify Resident #55's lap belt as a restraint. He reported he was under the impression the resident could remove the belt and stated he would ensure residents were properly assessed for restraint use in the future.On 2/12/26 at 10:42 AM, during an interview, the Administrator reported Resident #55's lap belt should have been identified as a restraint. He reported the resident had previously been able to remove the belt, but her cognition had declined and she should have been evaluated more frequently. He reported his expectation was for the lap belt to be properly identified and monitored for continued need.A record review of Resident #55's Face Sheet revealed the facility admitted Resident #55 on 2/26/24 with diagnoses including Unspecified Dementia.A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/21/26 revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of zero (0), which indicated the resident's cognition was severely impaired.A record review of Resident #55's medical record revealed there was no documentation identifying the use of a lap belt as a restraint.

Based on observation, interview, record review, and state board of nursing information review the facility failed to follow professional standards by permitting an unlicensed Certified Nursing Aide (CNA) to apply a medicated product, zinc oxide, during incontinent care for one (1) of three (3) residents observed for care. Resident #10.Findings include:A review of the Mississippi Board of Nursing website (www.msbn.ms.gov) revealed, Can a RN (Registered Nurse) delegate the administration of medicated ointments, lotions, and protective skin barriers to unlicensed personnel? .The registered nurse may .2. Assign duties of administration of patient medications to other licensed nurses only.On 2/11/26 at 12:35 PM, during an observation, CNA #2 provided catheter and incontinent care to Resident #10 and applied zinc oxide to the perineal folds.A record review of the Order Summary Report for Resident #10 revealed a Physician's Order, dated 2/2/26, for Zinc Oxide skin protection.CNA may apply per nurses' direction for skin protection only.On 2/11/26 at 12:45 PM, during an interview, Resident #10 reported staff routinely applied zinc oxide after catheter and incontinent care.On 2/11/26 at 12:50 PM, during an interview, CNA #2 reported she was instructed by the Director of Nursing (DON) to apply zinc oxide after incontinent episodes to prevent skin breakdown.On 2/12/26 at 2:00 PM, during an interview, the DON reported she instructed CNAs to apply zinc oxide to incontinent residents for skin protection and stated she was unaware zinc oxide was considered a medicated product.On 2/12/26 at 2:12 PM, during an interview, the Administrator reported he was unaware zinc oxide was considered a medicated product and stated he was seeking a non-medicated barrier cream alternative.A record review of the Face Sheet revealed the facility admitted Resident #10 on 11/25/25 with diagnoses including Heart Failure.A record review of Resident #10's Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/26 revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to act upon a pharmacist-identified medication irregularity related to crushing an extended-release medication for one (1) of three (3) residents reviewed for medication administration. Resident #8.Findings include:A review of the facility's Pharmacy Consultant Policy, undated, revealed, . It is the policy of this facility that a licensed pharmacist will provide consultation . A monthly report of any irregularities found is made to the resident's physician (placed on the medical record) The Director of Nursing (DON) . Action taken based on the report will be documented . A file of monthly reports will be maintained by the Director of Nursing .A record review of the Pharmacy Recommendations for Nursing for Resident #8, dated 11/12/25 revealed, . Medication Administration Alert: Crushing of Meds. This resident's record indicates that their meds are (or can be) crushed. The following meds SHOULD NOT be crushed, (change to another form of therapy): . Toprol XL (metoprolol succinate ER) - Extended Release - can not be crushed or chewed .A record review of the Order Summary Report with active orders as of 2/10/26 revealed Resident #8 had a Physician's Order, dated 12/15/25 for Toprol XL Oral Tablet Extended Release 24 Hour 50 mg (milligram) (Metoprolol Succinate) Give 1 tablet via PEG-Tube one time a day for Hypertension.A record review of Resident #8's Medication Administration Record (MAR) for November 2025 revealed Toprol XL Extended Release 50 mg was administered by mouth daily (start date 2/8/24). A record review of the December 2025 MAR revealed Toprol XL Extended Release 50 mg was administered daily via percutaneous endoscopic gastrostomy (PEG) tube beginning 12/16/25. A record review of the January and February 2026 MARs revealed the medication continued to be administered daily via PEG-Tube through 2/12/26.On 2/11/26 at 9:31 AM, during an observation and interview, Licensed Practical Nurse (LPN) #3 was observed preparing and administering medications to Resident #8 via PEG tube. LPN #3 crushed Toprol XL Extended Release 50 mg and administered the medication via PEG tube. LPN #3 reported she was not aware the medication should not be crushed.On 2/11/26 at 2:22 PM, during a phone interview, the Pharmacy Consultant reported Toprol XL Extended Release should not be crushed and explained crushing could result in altered absorption, decreased effectiveness, and release of the full dose at one time, increasing potential side effects. She reported she issued a nursing consult on 11/12/25 identifying medications that should not be crushed for Resident #8 and explained recommendations are sent to the Director of Nursing (DON) for follow-up and correction.On 2/11/26 at 3:00 PM, during an interview, the DON reported when pharmacist recommendations include medications that should not be crushed, she typically posts a list of medications that cannot be crushed but did not ensure the medication was changed to an appropriate formulation for PEG administration. She reported Resident #8 received the PEG tube in 12/2025 and medications should have been converted to an appropriate form.On 2/12/26 at 12:30 PM, during a follow-up interview, the DON reported it was her responsibility to follow through on pharmacist recommendations and ensure timely completion. She reported the recommendation for Resident #8 was missed and confirmed several months was not a timely response.On 2/12/26 at 12:59 PM, during an interview, the Nurse Practitioner reported Toprol XL Extended Release should not be crushed due to its extended-release formulation. She reported the medication should have been changed to an appropriate formulation after PEG placement and stated the issue was missed.On 2/12/26 at 1:27 PM, during an interview, the Administrator reported nursing staff were expected to follow through timely on pharmacist recommendations and correct identified irregularities.A record review of the Face Sheet revealed the facility admitted Resident #8 on 2/7/24 with diagnoses including Essential (Primary) Hypertension and Encounter for Attention to Gastrostomy.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/25 revealed Resident #8 required a Staff Assessment for Mental Status indicating memory problems with short- and long-term memory. Section K revealed the resident had a feeding tube.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff demonstrated competency in sanitation procedures for the three-compartment sink for one (1) of three (3) kitchen observations.Findings include:A review of the facility's Manual Warewashing Policy, dated 10/17 revealed, .Food service pots and pans that cannot fit in the dish machine or cleaned and sanitized in a three-compartment sink.Procedure.5) Third Compartment Sink a) Fill the third sink with water and sanitizer to the correct concentration. Hot water can be used as an alternative. B) Immerse items in the third sink in hot water or chemical sanitizing solution. I)If hot water immersion is used, the water must be a minimum of 171 F and items must be immersed for 30 seconds. Ii) If chemical sanitizing is used, the sanitizer must be mixed to the proper concentration. Follow manufacturers' recommendations. The following are published guidelines. (1) Chlorine-Immerse for 7 seconds in water temperature 100 degrees F (Fahrenheit) (2) Iodine-Immerse for 30 seconds in water temperature 68 degrees F. (3) Quats-Immerse for 30 seconds in water temperature 75 degrees F. (6) The concentration of the sanitizing solution is checked with an appropriate test kit when the sink is filled and again if the solution is used for an extended period of time.On 2/10/26 at 10:48 AM, during an observation and interview, Dietary Aide (DA) #2 washed pots and pans in the three-compartment sink. Pots and pans were observed air drying on a table next to the sink. The third sink contained warm water, and a test strip did not register sanitizer concentration. DA #2 aide added sanitizing solution directly from the container into the sink without measuring the amount. After adding the solution, the test strip registered between 200 and 400 parts per million (PPM). DA #2 confirmed the sanitation equipment was not working and she added sanitizer based on estimation. During an interview at this time, the Dietary Manager (DM) stated she had washed pots and pans earlier using what she believed was correct sanitation and confirmed the sanitation tubing had been disconnected. The DM stated she did not know who disconnected the solution tubing.On 2/11/26 at 11:51 AM, during an interview, the Maintenance Director stated she contacted the sanitation vendor after being notified the sanitation equipment was not working.On 2/11/26 at 12:06 PM, during an interview, the Sanitation Vendor Representative stated the sanitation equipment was functioning properly and explained sanitizer should not be manually poured into sinks, as the equipment is designed to dispense the correct concentration, confirming staff were not utilizing the equipment as designed.On 2/12/26 at 11:28 AM, during an interview, the Administrator stated staff are expected to use sanitation equipment according to manufacturer guidelines.

Based on observation, interview, record review, and facility policy review, the facility failed to follow Enhanced Barrier Precaution (EBP) requirements by not wearing required personal protective equipment (PPE), specifically a gown, during percutaneous endoscopic gastrostomy (PEG) tube care for one (1) of five (5) residents observed for care. Resident #8.Findings include:A review of the facility's Enhanced Barrier Precautions Policy, dated 4/30/25, revealed, .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms to residents .Policy Interpretation and Implementation EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply.Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include.device care or use.feeding tube.Communication -Staff are trained prior to caring for residents on EBP and annually with PPE (Personal Protective Equipment) in-service.An orange sign will be placed on the resident door frame and a green dot on the name tag next to the door indicating the need for EBP.On 2/11/26 at 10:14 AM, an observation of Resident #8's, Enhanced Barrier Precaution signage, including an orange sign and green dot, was observed on the resident's door. During the same observation, Licensed Practical Nurse (LPN) #4 performed PEG tube dressing care and did not wear a gown while providing the care.On 2/12/26 at 1:00 PM, during an interview with LPN #4, she confirmed she did not wear a gown during PEG tube care for Resident #8 and stated she forgot to put it on. She reported she had been trained to wear personal protective equipment (PPE) when providing care to residents with medical devices and Enhanced Barrier Precaution signage.On 2/12/26 at 1:03 PM, during an interview with Registered Nurse (RN) #1/Infection Preventionist, she stated staff are trained to wear PPE when caring for residents identified with Enhanced Barrier Precaution signage and medical devices.On 2/12/26 at 1:04 PM, during an interview with the Director of Nursing (DON), she stated she expects staff to follow Enhanced Barrier Precaution policies to prevent infection transmission.On 2/12/26 at 1:05 PM, during an interview with the Administrator, he stated he expects staff to follow infection control and Enhanced Barrier Precaution policies when providing resident care. A record review of training documentation from Long-Term Care Consultant, LLC, dated 8/03/25, revealed Licensed Practical Nurse (LPN) #4 received training on Enhanced Barrier Precautions.A record review of the Face Sheet revealed the facility admitted Resident #8 on 2/7/24 with diagnoses including Essential (Primary) Hypertension and Encounter for Attention to Gastrostomy.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/25 revealed Resident #8 required a Staff Assessment for Mental Status indicating memory problems with short- and long-term memory. Section K revealed the resident had a feeding tube.A record review of the Order Summary Report with active orders as of 2/10/26 revealed Resident #8 had a Physician's Order, dated 12/15/25 for NPO (nothing by mouth) status and included PEG care orders.

Based on observation, staff interview, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals in one (1) of four (4) shower rooms observed during the annual survey. Findings Include: A review of the facility policy titled Hazardous Materials/Chemicals and Waste-Storage, revised on 11/7/23, revealed, Purpose: To provide a policy whereby hazardous materials/chemicals and waste can be stored in a safe manner to prevent injury to patients, personnel, or visitors. Policy: It is the policy of this facility that all hazardous materials are received into the department by appropriate personnel and stored in a supply closet suitable for chemicals . Storage areas are kept locked and secured from the public at all times to prevent injury to patients, personnel, or visitors . Hazardous waste storage and processing areas will be free of clutter and effectively separated from patient care . All Hazardous Waste is to be kept in a locked and secure area inaccessible to the general public . An observation of the south shower room on 8/26/24 at 10:30 AM revealed two (2) spray plastic containers of Clorox cleaner and one (1) spray plastic container of Medco Rinse Agent sitting on the top of a shelf, unattended and not secured. A second observation of the south shower room on 8/26/24 at 11:40 AM revealed the same two (2) spray plastic containers of Clorox cleaner and one (1) spray plastic container of Medco Rinse Agent sitting on top of a shelf, still unattended and unsecured. On 8/26/24 at 4:00 PM, during an observation and interview the Director of Nursing (DON) confirmed that the chemicals were sitting on top of a shelf in the shower room, unattended. The DON stated that both the Clorox cleaner and Medco Rinse Agent should have been locked inside a cart, as they are biohazard chemicals. She confirmed that there were no wandering residents in the facility and that there had been no incidents involving chemicals in the last 12 months. During an interview on 8/26/24 at 4:20 PM, the Administrator confirmed that chemicals should not be left unattended anywhere in the facility and should always be securely locked. The Administrator acknowledged that the chemicals could be harmful if residents accessed them. A review of the Medco Rinse Agent Material Safety Data Sheet (MSDS), prepared on 2/2/09, revealed that exposure to the eyes, skin, respiratory tract, or gastrointestinal tract could be irritating. A review of the Clorox Germicidal Bleach Safety Data Sheet (SDS), revised on 12/11/20, revealed that in case of eye or skin contact, inhalation, or ingestion, immediate medical attention is required.

Based on observations, interviews, and facility policy review, the facility failed to ensure proper sanitation procedures were utilized during dishwashing, as evidenced by, the minimum water temperature of the low-temperature dishwasher machine was not reached during two dishwasher observations for two (2) of four (4) dietary tours. Findings Include: A review of the facility's policy titled Machine Warewashing, revised on 09/12/11, revealed, Chemical Sanitizing Machines use a low temperature to clean and sanitize. Follow the dishwasher manufacturer's guidelines. Suggested temperature = 120 degrees. If the dish machine cannot be used, dishes should be washed according to the procedures for washing pots and pans in the three-compartment sink. During an observation on 08/28/24 at 12:01 PM, Dietary [NAME] #2 demonstrated how the low-temperature dishwasher worked. It was noted that the chemical sanitizer was within the recommended manufacturer's guidelines, however, the thermometer of the machine only measured 60 degrees Fahrenheit (F). At that time, the Dietary Supervisor ran the machine three (3) more times, but the temperature remained at 60 degrees F. Dietary Worker #3, who normally checked the dishwasher temperature, used an analog thermometer to manually check the water temperature. The temperature was 110.6 degrees F. On 08/28/24 at 12:43 PM, the Administrator observed the rinse cycle of the dishwasher and confirmed the dishwashing thermometer was not working. On 08/29/24 at 9:09 AM, the Dietary Supervisor was observed running the dishwasher. She stated that they continued to use the dishwasher as the temperature, manually checked that morning, revealed it reached 114 degrees F. She added that chemicals were also used in the dishwasher. The Dietary Supervisor stated that she was also pre-rinsing the dishes with hot water and dishwashing liquid. The policy was reviewed with the Dietary Supervisor, and it stated that if the dishwasher could not be used, dishes should be washed according to the procedure used for washing pots and pans in the three-compartment sink. The Dietary Supervisor confirmed that she had not been following this procedure. On 08/29/24 at 9:45 AM, Dietary [NAME] #2 was observed testing the three-compartment sink with test strips and demonstrated that the chemical levels were within the manufacturer's recommended guidelines. On 08/29/24 at 9:57 AM, during an interview, the Maintenance Supervisor stated that the dishwasher servicing company had arrived the previous afternoon around 4:00 PM and informed the facility that the part for the dishwasher had to be obtained from a nearby town, and they should be back later that day. On 08/29/24 at 11:10 AM, the Administrator confirmed that the dishwasher servicing company had been in the building earlier that morning and was in the process of obtaining a part to ensure that the dishwasher's temperature reached and recorded the recommended temperature. On 08/29/24 at 12:27 PM, the kitchen staff were observed washing dishes in the three-compartment sink.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure resident rights were honored by prohibiting residents from group activities and restricting resident use of common areas of the facility without clinical justification for three (3) of 18 sampled residents, with the potential to affect 62 residents. Residents # 3, #4, and #45 Findings include: Record review of the facility's policy, Resident Rights Policy, updated 9/5/15, revealed, It is the policy of this facility that resident rights will be addressed as follows: .Exercise rights .Each resident will be able to exercise his/her rights as follows: As a resident in this facility . 2. To voice grievances to: .State Department of Health . Resident #3 On 1/08/23 at 11:25 AM, during an observation and interview with Resident #3, he was dressed and sitting in his room with the door open. Resident #3 revealed that because his unit of the facility has COVID-19 positive residents, the facility has prohibited the COVID-19 negative residents from having group activities by restricting the use of common areas. A record review of the Face Sheet of Resident #3 revealed the resident was admitted by the facility on 5/27/22 with diagnoses including Rheumatoid Arthritis, Heart Disease, and Type 2 Diabetes Mellitus. A record review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/21/22, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #4 On 1/08/23 at 11:45 AM, during an interview with Resident #4, the State Agency (SA) observed Resident #4 dressed and sitting in her room. She confirmed that since her unit has COVID-19-positive residents, the facility has restricted the COVID-19 negative residents from entering the common areas in the facility. A record review of the Face Sheet revealed the facility admitted Resident #4 on 3/22/19, with diagnoses including, Acute kidney Failure, Type 2 Diabetes Mellitus, and Heart Failure. A record review of Resident #4's Quarterly MDS with an ARD of 11/21/22, revealed a BIMS score of 15, which indicated she was cognitively intact. Resident #45 On 1/08/23 at 11:55 AM, during an interview with Resident #45, she revealed that the facility has required that she remain on her unit and not enter the common areas in the facility, because there are COVID-19 positive residents on her hall. A record review of the Face Sheet revealed the facility admitted Resident #45 on 11/19/17 with diagnoses including Essential hypertension, Chronic Kidney Disease, and Type 2 Diabetes Mellitus. A record review of Resident #45's Quarterly MDS with an ARD of 10/10/22, revealed she had a BIMS score of 15, which indicated she was cognitively intact. On 1/08/23 at 12:05 PM, an interview with Certified Nurse Assistant (CNA) #1, working on the south unit of the facility, confirmed the facility had restricted both COVID-19 positive and negative residents from exiting the unit and going to any common areas in the facility. On 1/09/23 at 9:25 AM, during an interview with License Practical Nurse (LPN) #1 confirmed the south unit has several residents that are COVID-19-positive. LPN #1 revealed she was informed by the Director of Nursing (DON) and Infection Preventionist (IP) that the residents that are COVID-19 negative, as well as the COVID-19 positive residents were to remain on the unit and not allowed to exit to common areas in the facility. On 1/09/23 at 12:15 PM, an interview with the IP confirmed there were both COVID-19-positive and negative residents on the south unit. The IP revealed to keep COVID-19 from spreading throughout the facility, she felt it would be best to prevent the negative residents on that unit from entering the common areas. On 1/09/23 at 12:25 PM, an interview with the DON revealed she had requested the residents in the south unit, who are COVID-19 negative to remain within the unit, to avoid the spread of COVID-19 to other areas of the facility. The DON confirmed she informed her staff that COVID-19 negative residents should avoid the common areas within the facility. On 1/09/23 at 12:30 PM, an interview with the Administrator revealed his expectation is that COVID-19 negative residents are allowed to enter the common areas in the facility.

Based on interviews, record review, and facility policy review, the facility failed to implement its protocol for antibiotic use and thereby failed to prevent the unnecessary and inappropriate antibiotic use for one (1) of five (5) residents reviewed for unnecessary medications. Resident #78. Findings Include: Review of the facility's, Antibiotic Stewardship Policy revised 9/9/22, revealed, It is the policy of this facility to observe the practice of Antibiotic Stewardship to monitor antibiotic use in the care and treatment of our residents. It is our goal to promote appropriate selection and use of antibiotics . Monitoring for accountability of provider and staff for following acceptable criteria (McGreer criteria) for initiation and continued treatment with an antibiotic . As part of the Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP) . Review of the facility's, ESBL (Extended-Spectrum Beta-Lactamases) or VRE (Vancomycin Resistant Enterococci) in Urine Protocol, updated 3/28/22, revealed, In the event a urinalysis is positive for ESBL or VRE the facility will follow the steps of this protocol. Implement contact precautions and complete antibiotic treatment as ordered by the provider. Communicate current or recent treatment to provider and no follow-up urinalysis . Record review of the Physicians Orders for Resident #78, revealed a physician's order dated 12/20/22, for Macrobid 100 mg (milligrams) by mouth twice a day for ten days related to urinary tract infection (UTI). Record review of the result of the facility's, Urine Culture, dated 12/22/22, revealed Escherichia Coli (ESBL). Record review of the Resident # 78's Physicians Orders dated 12/22/22, revealed the Nurse Practitioner ordered Augmentin 500-125 mg by mouth twice a day for seven (7) days related to UTI. Record review of the facility's, December 2022 Medication Administration Record (MAR) confirmed Resident #78 received Macrobid 100 mg twice a day for 10 days for UTI and Augmentin 500-125 mg twice a day for seven (7) days for UTI. Record review of the Departmental Notes, revealed a nurses note dated 12/20/22, at 10:18 AM, of a monthly telemedicine visit with the Medical Doctor, in which a Licensed Practical Nurse (LPN) reviewed the U/A (Urinalysis) results for Resident #78 and received a new order for Macrobid 100 mg to be given twice a day for 10 days for UTI. Record review of the Departmental Notes, revealed a nurses note dated 12/23/22, at 2:31 PM, of documentation by a LPN that Resident #78 continued to receive both Augmentin 500-125 mg and Macrobid 100 mg orally twice a day. Record review of the facility's, Revised McGeer Criteria for Infection Surveillance Checklist, dated 12/29/22, revealed Resident #78 met UTI criteria. Registered Nurse (RN) #2 reviewed the checklist nine (9) days after Resident #78 began taking antibiotics. During an interview on 1/11/23, at 10:00 AM with RN #2, she confirmed she is the Infection Preventionist (IP) for the facility. The IP revealed that she was off during the time Resident #78 was on antibiotic therapy. The IP said she is responsible for initiating the McGee's tool when a resident is placed on an antibiotic. She stated the Director of Nursing (DON) monitors the antibiotics when she's off. The IP confirmed she initiated the tool when she returned. She stated she thought the Macrobid was discontinued, and the Augmentin was started. During an interview on 1/11/23, at 10:20 AM, with the Director of Nurses (DON), she confirmed she was responsible for covering for the IP when she's on vacation. The DON confirmed she failed to follow the facility's antibiotic protocol while the IP was on vacation. During an interview on 1/11/2023, at 11:00 AM, the Nurse Practitioner (NP) confirmed on 12/22/22, he ordered Augmentin 500-125 mg po (by mouth) twice a day times seven (7) days related to UTI for Resident #78. The NP revealed he unaware the physician had ordered Macrobid on 12/20/22. The NP said the nurse called him with the culture results. He was not told the resident was receiving Macrobid. The NP confirmed receiving both antibiotics at the same time was unnecessary, as the Macrobid could have managed the infection. The NP also confirmed any time several antibiotics are given, it could result in the resident developing a Multi Dose Resistant Organism (MDRO). During an interview on 1/11/23, at 2:00 PM, RN #1 confirmed she received the order for Augmentin 500-125 mg. RN #1 said she doesn't know why she didn't tell the NP about the Macrobid. The nurse stated she normally checks the residents' medications for allergies and other medications. RN #1 confirmed she is familiar with the facility's antibiotic stewardship protocol and normally looks at the resident's medication and the culture for sensitivity. Record review of the Face Sheet, revealed the facility admitted Resident #78 on 1/13/22. The resident's diagnoses included Urinary Tract Infection, Dysuria, Urine Retention, and Depression. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/14/22, revealed Resident # 78 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to notify the resident/Resident Representative in writing of the reason for transfer to the hospital for two (2) of three (3) hospital transfers reviewed. Residents #20 and #37. Findings include: A review of the facility's policy titled, Family Notification Policy, without a date, revealed the facility would notify the family with any transfer to another health care setting such as a hospital. The policy did not specify as to how the family would be notified. A review of Resident #20 physician's orders [REDACTED]. A review of Resident #20's medical record did not reveal a letter notifying the Resident's Representative of a transfer to the hospital. An interview on 08/15/19 at 10:02 AM, with Social Services (SS) #1 revealed she was responsible for notifying the family and the Ombudsmen of facility initiated transfers/discharges. SS #1 said the nurses notified the family only by telephone at the time of Resident #20's transfer. Review of the Face Sheet revealed Resident #20 was admitted by the facility, on 9/29/11, with the included [DIAGNOSES REDACTED]. Resident #37 A review of Resident #37's physician's orders [REDACTED]. Review of Resident #37's medical record revealed no documentation was provided to the resident or the Resident's Representative regarding the hospital transfer on 7/28/19. An interview, on 08/15/19 at 10:02 AM, with SS #1 revealed she said she was responsible for notifying family and the ombudsmen of the facility initiated transfers/discharges. SS #1 said she started emailing the notifications of bed hold to the Resident Representatives, but it did not include the written notification of the reason for transfer. She said the nurses notified the family by telephone at the time of Resident #37's transfer. Review of the Face Sheet revealed Resident was admitted by the facility, on 11/13/15, with the included [DIAGNOSES REDACTED].

Based on observation, staff interview, record review, and facility policy the facility failed to follow the Resident #15's Comprehensive Care Plan related to falls, and Resident #33's Comprehensive Care Plan for Foley catheter care, for two (2) of 23 resident care plans reviewed for one (1) of 23 resident care plans reviewed. Findings include: A review of the facility's policy titled Total Care Plan Policy, without a date, revealed the facility would identify the problems that would affect the resident and his/her care needs. The Care Plan would identify problems that affect the resident and his/her care needs, and address areas identified on the Minimum Data Set MDS, and the Care Area Trigger (CAT)s. Resident #15 A review of the Resident #15's Comprehensive Care Plan revealed the Problem/Need, dated 10/23/12, for the risk of falls due to an unsteady gait and a [DIAGNOSES REDACTED]. Review of Resident #15's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/22/19, revealed in section J1900B the resident fell two or more times since the prior assessment with injury (not major). A review of Resident 15's, Resident Incident Report, dated 6/11/19, revealed Resident #15 was assisted by Certified Nursing Assistant (CNA) #1 to the bathroom. CNA #1 removed the resident's walker from the bathroom. While Resident #15 was standing in front of the commode pulling her down pants and brief, Resident #15 started to fall, but CNA #1 was not able to break the fall. Resident #15 fell to the floor hitting her face and forehead and knee. The incident report noted an abrasion to the forehead and right side of neck and lip. Resident #15 was sent to emergency room (ER) for evaluation without any orders on return for treatment on her medical record. Review of a handwritten statement, dated 6/11/19, by CNA #1, on the facility's Written Statement on Accident/incident was attached to Resident #15's incident report. CNA #1 stated, she turned her back to Resident #15 to move the walker out of the way of the resident, and when she turned around the resident was falling. A review of Resident 15's Resident Incident Report, dated 4/11/19, revealed the resident was found in front of bathroom door by Licensed Practical Nurse (LPN) #1 with a laceration to the right brow, and was sent to to the ER for evaluation. The documentation noted on the incident report revealed the fall was not witnessed. A review of Resident 15's Resident Incident Report, dated 2/11/19, revealed the resident was in the bathroom and stood up by herself, and lost her balance, leaned against the wall and then slid to the floor. LPN #4 documented the CNAs were reminded that Resident #15 cannot be left alone in the bathroom and discussed with the Director of Nursing (DON). No injuries were reported on the incident report. The incident was documented as non-witnessed. An interview, on 8/14/19 at 2:43 PM, with LPN #1 revealed Resident #15 had a history of [REDACTED]. LPN #1 said she did help when Resident #15 fell , on 4/11/19, but was not her nurse and couldn't recall who the aide was that day. An interview, on 8/14/19 at 3:28 PM, with LPN #4, revealed she was present when Resident #15 fell on [DATE]. She said she completed the incident report and said CNA #2 assisted Resident #15 to the bathroom, but left Resident #15 in the bathroom to answer another call light. LPN #4 said when CNA #2 came back to the bathroom, the resident was on the floor. LPN #4 said Resident #15 had no injuries. LPN #4 also said she was aware the resident's care plan said to stay with the resident while in the bathroom. LPN #4 said the expectation for nurses and aides was to follow the care plan. An interview, on 8/14/19 at 2.51 PM, with CNA #2, revealed she said she was Resident #15's CNA when she fell on [DATE]. CNA #2 said she helped Resident #15 to the toilet in the bathroom and had heard a call light that had been going off for about 5 minutes and went to answer it. CNA #2 said she asked Resident # 15 to not get up and that she would return. CNA #2 said when she got back, Resident #15, was leaning on the wall by the hand rail on the floor. CNA #2 said she was aware Resident #15's care plan said the resident needed to have someone to stay with her in the bathroom, but she knew the other staff members were busy with other residents and wanted to answer the light. CNA #2 said she had received education and had not left the resident by herself anymore. An interview, on 8/15/19 at 8:36 AM, with Resident # 15 revealed she always was helped and that no one has left her alone in the bathroom. Resident #15 said this place was a good home. She also said she was getting in her recliner this mooring from her wheelchair, and a nurse walked by and reminded her not to get up without calling for help. An interview, on 8/15/19 at 9:31 AM, revealed the DON said the expectation was to follow the care plan specific to Resident #15. An interview, on 8/15/19 at 2:13 PM, with LPN # 2/MDS Nurse revealed the expectation of the staff was to follow the care plan specific to each resident. She confirmed Resident #15's care plan stated to stay with the resident while in the bathroom. Resident #33 Review of Resident #33's Comprehensive Care Plan, revealed the Problem/Need, dated 2/15/2014, for a history of [MEDICAL CONDITION] and inability to void. At risk for Urinary Tract Infections, and the presence of a Foley catheter. Interventions included Foley catheter care every shift. On 8/14/19 at 9:35 AM, an observation revealed, CNA #6 assisted by CNA #7 performed Resident #33's catheter care. CNA #6 had already set up her barrier and supplies. Both CNA #6 and CNA #7 washed their hands and applied clean gloves. CNA #6 set up two (2) basins, one was to wash Resident #33, and one was to rinse the resident. When CNA #6 was cleaning Resident #33's penis she wiped the resident's penis three times (x3) without rotating her washcloth, then placed that washcloth in the soiled linen bag. CNA #6 retrieved another washcloth and wiped the resident's penis again twice (x2). When CNA #6 rinsed the resident's penis area she wiped two times (x2) without rotating the washcloth and placed that washcloth in the soiled linen bag. CNA #6 retrieved another washcloth and wiped the resident's penis area three time (x3) without rotating the washcloth. CNA #6 then dried the resident's penis area, and while drying the area she used a patting motion times five (x5 ) without rotating the towel, then patted the area dry again three times (x3 ) and again four times (x4) without rotating the towel. On 8/14/19 at 3:00 PM, an interview with CNA #6 revealed she stated she, wiped too many times. CNA #6 stated she should have wiped one time and folded her washcloth before she wiped again. She also stated wiping too many times causes germs to spread. On 8/15/19 at 2:13 PM, an interview with Licensed Practical Nurse (LPN) #2/MDS Nurse, revealed she would expect the staff to follow the comprehensive care plan. Review of the physician's orders [REDACTED]. A record review of the most recent Quarterly Minimum Data set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/3/19, revealed Resident #33 was coded for an indwelling catheter.

Based on staff interviews, record reviews, and facility policy review, the facility failed to accurately complete the Preadmission Screen (PAS) for one (1) of four (4) resident PASs reviewed. Resident #44. Findings include: A review of the facility's policy titled, Preadmission Screening Resident Review (PASRR) Policy, undated, revealed it is the policy of this facility that the PASRR will be completed as follows: Completed on Long Term care residents only for admission, according to the guidelines from Medicaid, and faxed to Medicaid once completed following admission (long term care residents only). A review of the Resident Assessment Manual, dated (MONTH) (YEAR), revealed all individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level 1 Preadmission Screening Resident Review (PASRR) completed to screen for possible mental illness (MI), intellectual disability (ID), (mental [MEDICAL CONDITION]/MR) in federal regulation)/developmental disability (DD), or related condition. Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. A record review of the most recent comprehensive Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 3/26/19, revealed the MDS was coded to indicate Resident #44 had not been evaluated by a Level II PASRR. The most recent Admission comprehensive MDS assessment was also coded to include a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan revealed a Focus for [MEDICAL CONDITION] Drug - [MEDICATION NAME] for [MEDICAL CONDITION] and Delusional Disorder. At risk for side effects. The Onset Date was 3/19/19. Review of the PAS dated, 3/20/19, indicated the resident did not have a [DIAGNOSES REDACTED]. A review of the [DIAGNOSES REDACTED]. On 8/15/19 at 10:30 AM, an interview with the Director of Nursing (DON), revealed the resident had a [DIAGNOSES REDACTED]. On 8/15/19 at 3:31 PM, an interview with the Licensed Social Worker (LSW) #1, revealed, the resident was admitted on [DATE] and a Level II referral should have been done. She also stated the PAS was not completed accurately. A review of the facility's Face Sheet revealed, the facility admitted Resident #44 on 3/19/19 with a [DIAGNOSES REDACTED].

Based on record review, staff interview, and facility policy review, the facility failed to make a Level II referral related to Resident #49's change in status for one (1) of four (4) residents reviewed for Preadmission Screening Resident Reviews (PASRR). Findings include: Review of a typed statement provided by the facility, on the facility's letterhead, no date or signature, revealed the facility followed the policies and procedures of (Name of Management Company) to complete PASRRs. A review of the (Name of the Management Company), Provider Manual, revised 7/3/13, revealed when a resident experienced a significant status change, a PASRR Level II Change in Status Request form must be completed by the provider and faxed to (Name of Management Company). Significant changes included a resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a [DIAGNOSES REDACTED]. A review of the Diagnosis/History List, for Resident #49, revealed a [DIAGNOSES REDACTED]. A review of Resident #49's Department of Mental Health Level II letter, dated 2/11/16, indicated the resident did not require specialized services because the resident was ruled out due to there was not sufficient evidence of serious mental illness. An interview, on 8/14/19 at 12:04 PM, revealed Social Services (SS) #1 said the referral for the Level II for Resident #49 had not been submitted, and she was unaware a referral was to be sent for residents with added mental disorder or [DIAGNOSES REDACTED]. SS #1 said she had a training planned about the PASSRs next week. She also said they use (Name of Management Company) for their policy to complete the PASSRs. Because the facility had no Level II designated as a major mental illness, no trigger was in place when the resident had a significant change. Therefore, the facility failed to notify (Name of Management Company) when Resident #49 had added diagnoses. A review of Resident #49's Pre-Admission Screening (PAS), provided by the facility, revealed the PAS was dated 2/2/16 with No indicated for a [DIAGNOSES REDACTED]. Therefore, the facility failed to notify (Name of Management Company) of the mental illness.

Based on record review, staff interviews, resident interviews, and facility policy review, the facility failed to initiate an investigation regarding an allegation of misappropriation of the Resident #61's Trust Fund, for one (1) of four (4) Resident Trust Funds reviewed. Findings include: A review of the facility's policy titled, Abuse, Neglect, or Exploitation Policy, undated, revealed any report of abuse, neglect, or exploitation will be investigated by the Administrator, Director of Nursing, Social Services, Quality Assurance Committee, and Facility Security. Investigation shall include but is not limited to, questioning of the resident involved when appropriate. Questioning all staff members working in that area at the time of the incident suspected of abuse, neglect, or exploitation, who might have knowledge of the reported complaint. Questioning any family or visitors who might have knowledge of the incident. Written statements by all staff questioned and signed by staff member. The resident's statement may be written by facility staff. Written statements by family questioned and by visitors questioned. An interview, on 8/15/19 at 11:00, revealed Administrator #1 stated nothing had been reported to him. An interview, on 8/15/19 at 11:01 AM, revealed Administrator #2 stated nothing had been reported to her. On 8/15/19 at 11:05 AM, an interview with the Assistant Administrator (AA), revealed she was not aware of anyone handling the resident roughly, but rather it was Certified Nursing Assistant (CNA) #5 (CNA #5 was also Resident #61's relative) taking the resident to the bathroom. The AA stated the resident had stated CNA #5 had not been talking to her. The AA also stated she asked CNA #5 to take someone with her when she went in to care for Resident #61. The AA stated Resident #61 reported to her that CNA #5 did not want to work with her (Resident #61) and that CNA #5 was acting like her daddy. The AA stated Resident #61 and CNA #5 just did not get along. The AA stated CNA #5 had started swapping out when she had to care for Resident #61. She also stated she had talked with the Resident #61's Resident Representative (RR) and the RR stated she gets along with her cousin, CNA #5. The AA stated Resident #61 thinks transferring on the sit to stand lift is handling her rough because she is unable to hold onto one side of the lift, and she thinks the staff is doing something to her. She stated Resident #61 feels she can do more than what she is able to do for herself. She also stated she does know it was the sit to stand lift that Resident #61 was referring to. The AA stated Resident #61 never reported to her that CNA #5 was handling her roughly. She stated she did not do an investigation because she did not feel there was anything to investigate because this happened before the last survey. She also stated Resident #61 stated she had some money missing but Resident #61 had found her money. The AA stated, Resident #61 had $105.00 or $106.00. She stated she was off from work the next day. She also stated, Resident #61 had given the Licensed Social Worker (LSW) $100.00 and had gotten $50.00 of it the other day from the LSW. She stated Resident #61 signed off on it in her (AA) office and she (AA) had the money in a little locked box. The AA stated that was the day Resident #61's son had come to the facility. She also stated Resident #61 has $50.00 left. The AA stated she usually does not hold money. She stated the resident had money missing last month and had brought some money to the office to the LSW and Front Office Worker #1 which was $100.00. She stated Wednesday morning when she returned to work, the LSW gave her $100.00 for Resident #61 and this was last week, but her days are kind of running together. The AA also stated when the resident's son was at the facility, Resident #61 had gotten $50.00 of her money. She stated she rolled the camera back, and she did not see anyone go in or out of Resident #61's room. She also stated the next day Resident #61 brought the money to her office because she did not want to hold that amount of money. She stated she does not know the policy on when a resident has missing money. She also stated she generally handles it by telling the residents if they have any problems to let her know about it and she will roll the camera back. She stated she did not tell Administrator #1. She also stated she told the Director of Nursing (DON), but at that time, the money came back. She stated to her, the situation was over with because she (Resident #61) brought money to the office. She also stated, she asked the resident when she has that kind of large sums of money, she needs to have it locked up. She stated Resident #61 had not had that type of money before. The AA also stated she did not write anything down regarding the CNA situation or the money situation. She stated it is the facility's policy to investigate the resident's concerns, but she did not investigate because it was an issue that was resolved. She also stated other than the nurse that was standing in the hallway, no one knew about the situation. She stated she does not remember who that nurse was. She stated she should have gone to the Director of Nurses (DON) and the DON should take the next step, but she kind of handled it herself. She stated she thought everything was okay. She stated Resident #61 wants to go home tonight if she could. She also stated the resident was here previously, had gone to a facility in another town, and eventually returned to this facility. She stated the resident was wanting to go home before all of this occurred. She also stated if she failed to do something it was because of the relationship that she and Resident #61 has. This interview was conducted by speaker phone in the presence of another surveyor. On 8/15/19 at 11:35 AM, an interview with the Licensed Social Worker (LSW) revealed, Resident #61 had not reported anything to her about being unhappy with a CN[NAME] She also stated the resident had not personally reported to her that she had some money missing. The LSW stated she had witnessed the AA giving the resident some money ($50.00) this week out of $100.00. She stated the rest of the $50.00 is in the AA's office. The LSW stated Resident #61 always goes to the AA and does not open up to her (LSW). She stated the resident had not mentioned anything to her. She stated if a resident came to her with a concern regarding how a CNA for example, is caring for them, she would go through the chain of command. She stated she would go to Licensed Practical Nurse (LPN) #5. On 8/15/19 at 11:50 AM, an interview with the DON, revealed the resident had not mentioned anything to her regarding any CN[NAME] She also stated the resident had not told her about any missing money. On 8/15/19 at 12:00 PM, an interview with Resident #61, revealed she had gone to the AA because CNA #5 had stopped speaking to her. She stated she had not had a chance to talk to the AA about CNA #5 handling her roughly. She stated she had not told anyone about that. She also stated the AA came to her and gave her $50.00, and she had $50.00 left in the office. Resident #61 stated she wanted to draw half of the $100.00 out. She stated the $100.00 she had missing was about one month ago. She also stated a staff member brought her $50.00 of the $100.00 that was missing a month ago. Resident #61 also stated she told the AA and the AA said she would roll the camera back. Resident #61 stated she had another $100.00 after the first $100.00 went missing. She stated she had $100.00 twice, but not at the same time. She stated she had the first $100.00 about a month ago. Resident #61 stated the whole $100.00 came up missing. She stated she had nine $10.00 bills and two $5.00 bills. She stated she had another $5.00 and $1.00 bill. She stated she did not tell anyone until one of the workers came into her room. Resident #61 told this worker that $100.00 was taken out of her purse and her purse was taken from underneath her pillow. Resident #61 does not want to state the worker's name. She stated the first person she told was Resident #23, and then she told the AA and the AA told her (Resident #61) she was going to roll the camera back. She stated the AA told her that a woman was coming to talk to her and would want to know where the money came from. She stated the woman never came. She stated the AA stated she would have to get someone else to come. She stated that same worker (the worker that Resident did not want to give her name) came into her room that night and put $50.00 in the envelope. She stated the worker was going through her things and she saw the worker lift her hand and handed the envelope to her which had the $50.00 in it. She stated the worker told her it was not $100.00 but it was $50.00. The resident stated she asked the worker where was her other $50.00 at. She stated she never heard anymore from the A[NAME] On 8/15/19 at 12:30 PM, an interview with Administrator #1 revealed, he would expect the Assistant Administrator to handle issues and does not expect her to bring everything to him. He stated the policy on misappropriation is to go through the proper chain of command. He stated anyone in the facility can go to Quality Assurance (QA). He also stated he would expect the staff to report abuse to the administrator. He stated if someone reported to him that a resident had money missing, he would conduct an investigation. A review of the facility's Face Sheet revealed, the facility admitted Resident #61, on 7/20/18, with [DIAGNOSES REDACTED]. A review of the most recent Yearly comprehensive Minimum Data Set (MDS) revealed, Resident #61 had a Brief Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on resident interviews, staff interviews, record reviews, and facility policy review, the facility failed to ensure the resident funds were free from misappropriation, for one (1) of four (4) Resident Trust Funds reviewed. Resident #61. Findings include: A review of the facility's Abuse and Neglect-Consumer Information Sheet, undated, revealed, according to the Nursing Home Reform Act of 1987, all residents in nursing homes are entitled to receive quality care and live in an environment that improves or maintains the quality of their physical and mental health. This entitlement includes freedom from abuse and misappropriation of funds. Review of the facility's policy titled, Abuse, Neglect, or Exploitation Policy, no date, revealed: Definition: Misappropriation of Resident Property- The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of resident's belongings or money without the resident's consent. Reporting: The complaint must be reported as soon as possible to the Administrator, Director of Nurses, and Facility Contact Person. Investigation: Any report of abuse, neglect or exploitation will be investigated by the Administrator, Director of Nurses, Social Services, Quality Assurance Committee, and Facility Security. Action: Any employee suspected of abuse, neglect or exploitation will be investigated and actions taken will at the discretion of administration. On 8/15/19 at 11:00 AM, an interview with Administrator #1, revealed nothing had been reported to him. On 8/15/19 at 11:01 AM, an interview with Administrator #2, revealed nothing had been reported to her. On 8/15/19 at 11:05 AM, an interview with the Assistant Administrator (AA), revealed she was not aware of anyone handling the resident roughly, but rather it was Certified Nursing Assistant (CNA) #5 (CNA #5 was also Resident #61's relative) taking the resident to the bathroom. The AA stated the resident had stated CNA #5 had not been talking to her. The AA also stated she asked CNA #5 to take someone with her when she went in to care for Resident #61. The AA stated Resident #61 reported to her that CNA #5 did not want to work with her (Resident #61) and that CNA #5 was acting like her daddy. The AA stated Resident #61 and CNA #5 just did not get along. The AA stated CNA #5 had started swapping out when she had to care for Resident #61. She also stated she had talked with the Resident #61's Resident Representative (RR) and the RR stated she gets along with her cousin, CNA #5. The AA stated Resident #61 thinks transferring on the sit to stand lift is handling her rough because she is unable to hold onto one side of the lift, and she thinks the staff is doing something to her. She stated Resident #61 feels she can do more than what she is able to do for herself. She also stated she does know it was the sit to stand lift that Resident #61 was referring to. The AA stated Resident #61 never reported to her that CNA #5 was handling her roughly. She stated she did not do an investigation because she did not feel there was anything to investigate because this happened before the last survey. She also stated Resident #61 stated she had some money missing but Resident #61 had found her money. The AA stated, Resident #61 had $105.00 or $106.00. She stated she was off from work the next day. She also stated, Resident #61 had given the Licensed Social Worker (LSW) $100.00 and had gotten $50.00 of it the other day from the LSW. She stated Resident #61 signed off on it in her (AA) office and she (AA) had the money in a little locked box. The AA stated that was the day Resident #61's son had come to the facility. She also stated Resident #61 has $50.00 left. The AA stated she usually does not hold money. She stated the resident had money missing last month and had brought some money to the office to the LSW and Front Office Worker #1 which was $100.00. She stated Wednesday morning when she returned to work, the LSW gave her $100.00 for Resident #61 and this was last week, but her days are kind of running together. The AA also stated when the resident's son was at the facility, Resident #61 had gotten $50.00 of her money. She stated she rolled the camera back, and she did not see anyone go in or out of Resident #61's room. She also stated the next day Resident #61 brought the money to her office because she did not want to hold that amount of money. She stated she does not know the policy on when a resident has missing money. She also stated she generally handles it by telling the residents if they have any problems to let her know about it and she will roll the camera back. She stated she did not tell Administrator #1. She also stated she told the Director of Nursing (DON), but at that time, the money came back. She stated to her, the situation was over with because she (Resident #61) brought money to the office. She also stated, she asked the resident when she has that kind of large sums of money, she needs to have it locked up. She stated Resident #61 had not had that type of money before. The AA also stated she did not write anything down regarding the CNA situation or the money situation. She stated it is the facility's policy to investigate the resident's concerns, but she did not investigate because it was an issue that was resolved. She also stated other than the nurse that was standing in the hallway, no one knew about the situation. She stated she does not remember who that nurse was. She stated she should have gone to the Director of Nurses (DON) and the DON should take the next step, but she kind of handled it herself. She stated she thought everything was okay. She stated Resident #61 wants to go home tonight if she could. She also stated the resident was here previously, had gone to a facility in another town, and eventually returned to this facility. She stated the resident was wanting to go home before all of this occurred. She also stated if she failed to do something it was because of the relationship that she and Resident #61 has. This interview was conducted by speaker phone in the presence of another surveyor. On 8/15/19 at 11:35 AM, an interview with the Licensed Social Worker (LSW) revealed, Resident #61 had not reported anything to her about being unhappy with a CN[NAME] She also stated the resident had not personally reported to her that she had some money missing. The LSW stated she had witnessed the AA giving the resident some money ($50.00) this week out of $100.00. She stated the rest of the $50.00 is in the AA's office. The LSW stated Resident #61 always goes to the AA and does not open up to her (LSW). She stated the resident had not mentioned anything to her. She stated if a resident came to her with a concern regarding how a CNA for example, is caring for them, she would go through the chain of command. She stated she would go to Licensed Practical Nurse (LPN) #5. On 8/15/19 at 11:50 AM, an interview with the DON, revealed the resident had not mentioned anything to her regarding any CN[NAME] She also stated the resident had not told her about any missing money. On 8/15/19 at 12:00 PM, an interview with Resident #61, revealed she had gone to the AA because CNA #5 had stopped speaking to her. She stated she had not had a chance to talk to the AA about CNA #5 handling her roughly. She stated she had not told anyone about that. She also stated the AA came to her and gave her $50.00, and she had $50.00 left in the office. Resident #61 stated she wanted to draw half of the $100.00 out. She stated the $100.00 she had missing was about one month ago. She also stated a staff member brought her $50.00 of the $100.00 that was missing a month ago. Resident #61 also stated she told the AA and the AA said she would roll the camera back. Resident #61 stated she had another $100.00 after the first $100.00 went missing. She stated she had $100.00 twice, but not at the same time. She stated she had the first $100.00 about a month ago. Resident #61 stated the whole $100.00 came up missing. She stated she had nine $10.00 bills and two $5.00 bills. She stated she had another $5.00 and $1.00 bill. She stated she did not tell anyone until one of the workers came into her room. Resident #61 told this worker that $100.00 was taken out of her purse and her purse was taken from underneath her pillow. Resident #61 does not want to state the worker's name. She stated the first person she told was Resident #23, and then she told the AA and the AA told her (Resident #61) she was going to roll the camera back. She stated the AA told her that a woman was coming to talk to her and would want to know where the money came from. She stated the woman never came. She stated the AA stated she would have to get someone else to come. She stated that same worker (the worker that Resident did not want to give her name) came into her room that night and put $50.00 in the envelope. She stated the worker was going through her things and she saw the worker lift her hand and handed the envelope to her which had the $50.00 in it. She stated the worker told her it was not $100.00 but it was $50.00. The resident stated she asked the worker where was her other $50.00 at. She stated she never heard anymore from the A[NAME] On 8/15/19 at 12:30 PM, an interview with Administrator #1 revealed, he would expect the Assistant Administrator to handle issues and does not expect her to bring everything to him. He stated the policy on misappropriation is to go through the proper chain of command. He stated anyone in the facility can go to Quality Assurance (QA). He also stated he would expect the staff to report abuse to the administrator. He stated if someone reported to him that a resident had money missing, he would conduct an investigation. A review of the facility's Face Sheet revealed, the facility admitted Resident #61, on 7/20/18, with [DIAGNOSES REDACTED]. A review of the most recent Yearly comprehensive Minimum Data Set (MDS) reveaintact.led, Resident #61 had a Brief Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to safely transfer Resident #1 with a Hoyer Lift resulting in a fall with major injuries for one of three (1 of 3) residents reviewed. Findings include: Review of the facility's policy entitled, Total Lift Policy (undated) revealed It s the policy of this facility that a resident lift will be utilized as follows: To enable two individuals to lift and move a resident safely. Procedure: 8. Determine which color loops are to be used and then attach them in the hooks. Ensure that the loops are secured in the hooks. 9. Ask the resident to cross arms and keep hands inside the lift. 10. Slowly raise the resident. 11. Check again to ensure lift-pad loops are properly secured in lift hooks. 12. Be sure the resident is balanced. 13. If everything checks out, continue with lifting resident completely. Review of the facility's Report of Unexplained or Serious Incident 4/25/15 at 9:15 AM, revealed Resident #1 was transferred with a Total Sling (Hoyer) lift with CNA #1 and CNA #2's assistance, and sustained bilateral hip fractures, and left arm fractures during the transfer with the Total Sling lift (Hoyer Lift) and the two (2) CNA's assistance. The facility's investigation concluded one of the sling straps was not properly placed into the lift's hook causing the strap to loosen during the transfer, and Resident #1 fell forward out of the sling onto the floor. Review of the Emergency Department (ED) notes and X-rays 4/25/15 at 3:46 PM, revealed the following Diagnoses: [REDACTED]. Attempted to call CNA #1 for interview and phone was not working when called. Review of the facility's Statement on Incident/Accident 4/25/15 written by CNA #1 revealed at about 9:15 AM she was getting Resident #1 ready for dialysis and asked CNA #2 to help her put him in the chair. They started lifting him and he slid out of the sling from the Hoyer lift face first. Other staff was summoned to the room, and they waited for the ambulance to arrive. An interview with CNA #2 on 5/14/15 at 11:40 AM revealed on 4/25/15 CNA #1 had asked her to help transfer Resident #1 from the bed to the wheelchair because it was time for him to go to dialysis. She went in the room to assist CNA #1 to transfer Resident #1 from the bed to the wheelchair with the Hoyer Lift. She stated the lift pad was already attached to the lift when she entered the room, and when she got the remote and started lifting him up, he fell forward head first onto the floor, and onto the legs of the lift. She stated the right side lift pad strap was down on the floor, and the other three straps were still attached to the lift. CNA #2 reported they had inservices since the incident on how to use the lifts. Review of the facility's In-Service Meeting Minutes November 5, 2014 at 1:30 PM addressed Total Lift Sling - remove sling immediately if damaged/broken and take to the DON/QA/Administration revealed CNA #1 and CNA #1's signtures on the sign in sheet. Review of the facility's Skills Check List for Total Lift for CNA #1 and CNA #2 on 11/4/14 revealed both had satisfactory checked for using the lift. A sentence typed after the title of the sheet stated, Before and during the lift/transfer procedure, observe all sling hooks to ensure the sling is securely attached to the lift bar. Each CNA signed and dated the bottom of the forms. An interview on 5/14/15 at 10:05 AM with the Quality Assurance (QA) Nurse revealed the investigation regarding the fall for Resident #1 on 4/25/15 determined one of the straps to the Hoyer lift had not been applied properly by Certified Nursing Assistant (CNA) #1, which resulted in Resident #1 falling forward out of the lift. She verified Resident #1 sustained multiple fractures from this fall. The QA Nurse stated any resident that required a lift was automatically a two (2) person assist. An interview with the facility's Administrator on 5/14/15 at 10:30 AM, verified Resident #1 fell from the lift on 4/25/15, when one of the straps slid off indicating the strap had not been correctly placed inside the lift hook. He stated CNA #1 was terminated after the investigation. The Administrator reported all staff had been in-serviced prior to using the lift, and another in-service has been conducted to all staff after the incident. An interview with the Medical Director and Resident #1's Primary Care Physician on 5/14/15 at 3:30 PM revealed the facility notified him of the fall for Resident #1 on 4/25/15. He validated the facility Administrator went over with him the findings of the investigation, and they attempted to re-enact the incident to find the cause, and ruled the strap to the lift had not been put completely in place resulting in the fall for Resident #1. The facility's Face Sheet revealed the facility admitted Resident #1 on 12/21/12 with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/24/15 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 and was cognitively intact. Further review of the MDS revealed Resident #1 required two (2) person assistance with transfer d/t total dependence, extensive one person assistance with bed mobility, dressing, bathing, and personal hygiene.

Based on staff interview, record review, and facility policy review the facility failed to follow the plan of care to transfer Resident #1 using the Hoyer Lift in a safe manner, resulting in a fall with major injuries for one (1) of three (3) residents reviewed. Findings include: A review of the facility's policy entitled, Total Care Plan Policy (undated), revealed the facility would complete a Total Care Plan for all residents within twenty-one days of admission and would address problems and identify interventions for each resident to include measurable and attainable goals. This plan of care would include ongoing updates as they occur in the resident's change in condition. Resident #1 Review of the facility's Report of Unexplained or Serious Incident 4/25/15 at 9:15 AM, revealed Resident #1 sustained bilateral [MEDICAL CONDITION], and left arm fractures during a transfer with the Total Sling lift (Hoyer Lift) and two (2) CNAs assistance. The facility's investigation concluded one of the sling straps was not properly placed into the lift's hook causing the strap to loosen during the transfer, and Resident #1 fell forward out of the sling onto the floor. Reveiw of Resident #1's Care Plan 12/21/12 revealed he was at risk for falls d/t dependence on a lift for transfers. Further review of the Care Plan revealed an approach to use the Total Sling lift with two (2) Certified Nurse Aides (CNAs) to transfer. The Care Plan did not address approaches to ensure the sling and straps was properly placed and secured prior to the transfer. Review of the Emergency Department (ED) notes 4/25/15 at 3:46 PM, revealed the following Diagnoses: [REDACTED]. An interview with CNA #2 on 5/14/15 at 11:40 AM, revealed each resident's care sheet has if a lift is to be used for them. CNA #2 stated she assisted CNA #1 on 4/25/15 to transfer Resident #1 with the lift. When she entered the room, the sling straps was already in place across Resident #1, she got the remote and began to lift Resident #1 up, and then he went head first onto the floor. The sling pad was still in the lift, and the right front strap was down on the floor. CNA #2 revealed she did not think the strap was all the way in the hook, maybe just on top of the hook. CNA #2 reported they have had inservices since the incident on using the lifts. An interview on 5/14/15 at 10:05 AM, with the Quality Assurance (QA) Nurse, revealed the use of a lift for any resident was addressed in the resident's Care Plan. She confirmed Resident #1 had a fall from the lift pad with major injuries on 4/25/15 when CNA #1 failed to properly put the lift pad strap onto the lift hook. The facility's Face Sheet revealed the facility admitted Resident #1 on 12/21/12 with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 3/24/15 indicated Resident #1 had a Brief Interview for Mental Status (BIMS) of 15 and was cognitively intact. Further review of the MDS revealed Resident #1 required two (2) person assistance with transfer d/t total dependence, extensive one person assistance with bed mobility, dressing, bathing, and personal hygiene.

Based on observation, record review, staff interview, review of staff written statements, facility investigation report review, Physician interview, Medical Director interview, Responsible Party (RP) interviews, and facility policy and procedure reviews, the facility failed to ensure that one (1) of six (6) residents reviewed for falls/fractures was adequately assessed and treated when Resident #1 had signs and systems of pain. On 3/25/11, Resident #1 had facial grimaces, was yelling out when left leg was touched or repositioned, and had a change in her behavior. The facility failed to notify the Physician of the symptoms of pain and failed to notify the RP. The facility failed to document the continued assessment of Resident #1's pain after 3/25/11. The facility failed to ensure that the complaints of pain was passed on to the other shifts. There was no documented assessment of Resident #1 from 3/25/11 until 3/28/11, at which time an X-ray was ordered. Resident #1 had a [MEDICAL CONDITION] femur and left knee effusion. The facility did not receive an X-ray report until 3/30/11. There was documentation in the nursing notes that the X-ray report was still at the hospital until 3/30/11. Resident #1 was noted as being severely impaired in cognitive skills for daily decision making and required total assistance of staff for care. CNA staff reported that these behaviors of grimacing and yelling out was not the norm for Resident #1. The facility failed to ensure that Resident #1 received the care and services necessary for the prevention of pain due to a fracture. Findings include: Record review revealed that Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the The Minimum Data Sets (MDS) with Assessment Reference Dates (ARDs) of 04/08/2011, 01/10/2011, and 11/01/2011 revealed that Resident #1 was severely impaired in cognitive skills for daily decision making. Resident #1 required extensive assistance of two (2) or more persons to physically assist with bed mobility, transfers, dressing and toilet use. Review of the nursing notes on 3/25/11 at 3:30 p.m., written by Licensed Practical Nurse (LPN) #1 revealed the following: "CNA (Certified Nurse Assistant) reports resident screams and hollers when you touch L (left) leg or turns her. Eyes open. Does not voice if having pain in L (left) leg when asked, but frowns and moans when left leg is moved. Skin wet and dry. L (Left) leg warm to touch. Resident under blankets x 2 and spread and entire body warm. Extrem (Extremities) stiff. Calf of L (left) leg just as warm as rest of body to have med nurse give PRN (as needed) med. To cont (continue) to observe." The next notation was made on 3/25/11 at 11:00 p.m., which revealed the following: "Resting quietly, skin w/d (warm and dry) to touch. ES (Extra Strength) Tylenol (2) po (by mouth) for (increased) pain with no c/o pain noted. (No) s/s (signs and symptoms) of distress at this time." There were no other nursing notes documented until 3/28/11 at 2:35 p.m. "X-ray of (L) leg @ (name of hospital). Awaiting results." On 3/29/11 at 12:05 a.m. "ES Tylenol (2) given. CNA reports that Resident acts like (L) leg hurt when she touches it. Will cont. to observe." The next notation was a late entry made on 3/29/11 at 12:05 a.m. for 3/28/11 at 6:30 a.m., stating: "Whirlpool CNA @ (at) nurses station inform that resident (L) leg hurt when she touches it, inform CNA that his nurse was aware, will cont. to observe." At 7:30 a.m. "Informed on-coming nurse of pain in Resident (L) leg. Day nurse stated she would inform NP (Nurse Practitioner). On 3/29/11 at 12:30 .a.m., the next entry stated, "X-ray of (L) leg remains at (Name of Hospital). No complaints of pain voiced this shift." On 3/29/11 at 1:13 p.m., "X-ray left leg/hip remains at (Name of Hospital). C/o pain x 1 @ 12:25 p.m. - [MEDICATION NAME] 10 mg one po given." The next entry regarding the X-ray or the residents complaints of pain was on 3/30/11 at 11:45 a.m. "Called (Name of Hospital) r/t (related to) X-ray of (L) hip, talked to (Name of person) and she stated that (L) hip X-ray was unremarkable and asked if she would send a copy and will fax today." On 3/30/11 at 12:00 p.m., "X-ray of (L) hip received from (Name of hospital). X-ray placed in NP folder for review on tomorrow." On 3/30/11 at 3:30 p.m., "(Name of Physician's office) phoned. Res has fx (fracture) to (L) knew. New orders received. Cont immobilizer to (L) knee-copy of X-ray of (L) knee obtained from (Name of hospital). (The immobilizer was ordered on [DATE] for the resident). Review of the nursing notes and the 24 hour shift report revealed that there was no documentation after 3/25/11 at 11:00 p.m., about Resident #1 having left knee pain or an assessment of the resident 3/28/11 at 7:30 a.m., when the nurse reported to the on-coming shift of the resident's complaints of pain. There was no documentation that the Physician was notified of Resident #1's complaints of left knee pain on 3/25/11. There was no documentation that the RP was notified of Resident #1's complaints and/or change in condition. Interview on 6/7/11 at 4:40 p.m., with Licensed Practical Nurse (LPN #2), revealed that she administrated an Extra Strength Tylenol to Resident #1 at 4:30 p.m. on 3/25/11, per the instruction of the Charge Nurse (LPN #1). LPN #2 stated that she did not assess Resident #1 prior to administering the Extra Strength Tylenol. LPN #2 stated that she was the Medication Nurse on 3/25/11. LPN #2 stated that she did not assess Resident #1 after she had administered the medication. Review of the Medication Administration Record (MAR), dated March 2011, revealed the following: "Tylenol ES (an Extra Strength Tylenol)" was given to Resident #1 on 3/25/11 at 4:35 p.m., by LPN #2 for "c/o pain (complaints of pain)" and that at 5:35 p.m. on 3/25/11, LPN #2 documented that Resident #1 issued "NFC/resting (No Further Complaint/resting)." There was no other pain medications documented on the MAR for Resident #1 on 3/25/11, 3/26/11, and/or 3/27/11. The next documented pain medication administered to Resident #1 was documented on the MAR on 3/28/11 at 1:00 a.m. for Tylenol ES (Extra Strength Tylenol) "reason c/o (complaint of) leg pain" and at 3:00 a.m. on 3/28/11, it was documented with a result of "Some Relief." Review of Resident #1 printed Physician's orders for March 2011, revealed an order originating on 8/15/08 for [MEDICATION NAME] 10 MG. TAB 1 PO QID (four time daily) PRN (as needed) for Pain. There was no written order for Tylenol ES (Extra Strength Tylenol) printed on the March 2011 physician's orders. There was also an order originating on 12/31/08 for "[MEDICATION NAME] EC tab 1 bid (twice daily) prn pain." Record review revealed that Resident #1's last pain assessment form was completed on 1/10/11, with no changes indicated at that time. Review of the care plan revealed a problem stating: "Potential for pain related to DX ([DIAGNOSES REDACTED]." Approaches stated: "Assess for s/s (signs and symptoms) of pain q (every shift) and prn (verbal expressions of pain, grimacing, moaning). [MEDICATION NAME] 10 mg 1 po qid prn pain. [MEDICATION NAME] EC tab 1 po bid prn pain." Interview on 6/7/11 at 5:10 p.m., with LPN #1, revealed that she was the Charge Nurse on the evening shift (3:00 p.m.-11:00 p.m.) on 3/25/11. LPN #1 stated that she only works at the facility on an as needed basis on the 3:00 p.m. to 11:00 p.m. shift. LPN #1 stated that she passed the report about Resident #1's pain to the night shift (11:00 p.m.-7:00 a.m.) and that it was written in the 24 hour report by LPN #2. LPN #1 stated that she did not call the Physician or the RP about Resident #1's complaints of pain. LPN #1 stated that LPN #2 was the medication nurse that night and that LPN #2 would have been responsible for calling the RP and/or the treating physician. Review of the "Shift To Shift Daily Report" dated 3/25/11, 3/26/11, and 3/27/11 was blank for Resident #1. There was no documentation in the 24 hour report regarding Resident #1's complaints of pain for three (3) days after the initial report was verbally given to the Charge Nurse (LPN #1) on 3/25/11 at 3:30 p.m. Interview on 6/8/11 at 9:33 a.m., with Certified Nurse Assistant (CNA#1) revealed that she and CNA #2 were changing Resident #1's incontinent brief when the resident began to yell out in pain and grab at her left leg. CNA #1 stated that Resident #1 was also making facial grimaces. CNA#1 stated that she immediately reported the resident's unusual behavior and possible pain to the LPN #1. CNA #1 stated that LPN #1 told LPN #2 to give Resident #1 something for pain. CNA #1 stated that Resident #1 continued to yell out and make facial grimaces during the shift when they touched or moved Resident #1. Review of the hand written statement by CNA #1 signed and dated as 3/30/11 revealed the following: "Went in to do my 4:00 p.m. round try to turn (Name of Resident #1) she was complained (complaining) of pain in her left leg. I step to the door and call for the charge nurse to come to (name of Resident #1) room." Interview on 3/8/11 at 3:00 p.m., with CNA #2, revealed that Resident #1 was displaying pain through yelling out, facial grimace, and grabbing at her left leg. CNA #2 stated that she was partnered with CNA #1 on the evening shift on Friday 3/25/11, and that they reported Resident #1's pain to LPN #2 about 2:00 p.m. CNA #2 stated that on 3/26/11, on the evening shift (2:00 p.m.-10:00 p.m.), that she was assigned to Resident #1. CNA #2 stated that through out the evening shifts on 3/25/11 and on 3/26/11, that Resident #1 displayed signs of pain by her facial grimace, yelling out, and grabbing at her left leg. CNA #2 stated that this was unusual for Resident #1 and was not normal behavior. CNA #2 stated that Resident #1 had some noticed swelling to her left leg on 3/25/11 on the 2nd shift (2:00 p.m.-10:00 p.m.) and that the swelling was slightly more on 3/26/11 on the 2nd shift (2:00 p.m.-10:00 p.m.). Record review revealed that there was no written statements documented by CNA #2 in the original investigation that was conducted by the facility on 3/30/11. CNA #2 was assigned to Resident #1 during the evening shift (2:00 p.m.-10:00 p.m.) on 3/25/11 and 3/26/11. Review of the facility's investigation revealed that there were five (5) hand-written statements documented in the facility's original investigation dated 3/30/11-3/31/11. The statements were by employees that had not been assigned to work directly with Resident #1 from the evening shift (2:00 p.m.-10:00 p.m.) on 3/25/11 through the day shift (6:00 a.m.-2:00 p.m.) on 3/28/11. There were seven (7) employee written statements submitted for review during the survey that were dated 3/30/11-3/31/11. There were two (2) of the statements from employees that had worked directly with Resident #1 from the evening shift (2:00 p.m.-10:00 p.m.) on 3/25/11 through the day shift (6:00 a.m.-2:00 p.m.) on 3/28/11. Interview on 6/8/11 at 3:20 p.m., with CNA #3, revealed that she worked directly with Resident #1 on 3/26/11 on the night shift (10:00 p.m.- 6:00 a.m.). She stated that Resident #1 had an unusual expression of pain and grabbed at her left leg when she attempted to deliver care. CNA #3 stated that she reported the pain to the Charge Nurse. Record review revealed that the night nurse (10:00 p.m.-6:00 a.m.) on Saturday 3/26/11, never documented any pain and did not document any pain medications given to Resident #1. The record review of the facility's investigation revealed that there was no statement by the 3/26/11 night nurse (10:00 p.m.-6:00 a.m.). Interview on 6/8/11 at 4:10 p.m., with LPN #3, revealed that the third (3rd) shift night nurse had not been given a verbal and/or written report that Resident #1 had reported being in pain during the evening shift (2:00 p.m.-10:00 p.m.). LPN #3 stated that there was nothing written on the 24 hour report about Resident #1 when she came to work on 3/25/11 for the night shift (11:00 p.m.-6:00 p.m.). LPN #3 stated that she had no knowledge that Resident #1 was in need of assessing and monitoring for pain. Interview on 6/8/11 at 4:40 p.m., with Registered Nurse (RN #1), revealed that she was the first shift day nurse (7:00 a.m.-3:00 p.m.) on 3/25/11 and on 3/27/11. RN #1 stated that she always reads the 24 hour reports and that there was nothing written in the 24 hour reports for Resident #1. Interview on 6/8/11 at 5:20 p.m., with the Licensed Practical Nurse/Social Service Designee LPN #5/SSD, revealed that on Monday 3/28/11, after the lunch meal, she went to the dining room to assess Resident #1 and noticed that Resident #1 had facial grimaces and yelled out when touched on the left leg. LPN #5/SSD stated that the leg looked turned to the side, swollen, was warm to touch and "her leg just didn't look right." LPN #5/SSD stated that she immediately reported Resident #1's pain to the Director of Nursing (DON). Interview on 6/8/11 at 6:10 p.m., with Resident #1's Physician, revealed that he was not notified on 3/25/11 that Resident #1 was in pain, had leg swelling, or a change in her condition. The Physician stated that some nurses are better than others about notifying. Interview on 6/9/11 at 9:29 a.m., with RP #2 revealed that she was not notified about Resident #1's pain, leg swelling, or any changes in Resident #1's condition on 3/25/11. Interview on 6/9/11 at 9:44 a.m., with RP #1, revealed that he was not notified on 3/25/11, that Resident #1 had a change in her condition, complaints of pain, and/or leg swelling. Interview on 6/9/11 at 10:55 a.m., with LPN #4, revealed that she had no knowledge of Resident #1 reports of pain during the evening shift on 3/25/11. LPN #4 stated that she works each weekend (Saturday and Sunday) as a floor nurse on the day shift (7:00 a.m.-3:00 p.m.) and works as the Charge Nurse for the evening shift (3:00 p.m.-11:00 p.m.). LPN #4 stated that she only works for the facility on the two (2) days of each weekend. LPN #4 confirmed that on 3/26/11 and 3/27/11, she had no knowledge that Resident #1 was in pain, and she did not assess Resident #1 for pain. LPN #4 stated that there was nothing written in the 24 hour report that Resident #1 had complained of pain on the evening shift on 3/25/11. Interview on 6/9/11 at 11:10 a.m., with the Medical Director revealed that he was not contacted on 3/25/11 concerning Resident #1's pain, knee swelling or a change in condition. The Medical Director stated that the nurses must be an advocate for the residents. Interview on 6/9/11 at 11:20 a.m., with RN #2, revealed that she worked as the Charge Nurse on 3/26/11 on the day shift (7:00 a.m.-3:00 p.m.). RN #2 stated that she had no knowledge that Resident #1 reported any pain on 3/25/11. RN #2 stated that she did not assess Resident #1 and she never delivered any personal care to Resident #1 on 3/26/11 Interview on 6/9/11 at 1:20 p.m. with the Director of Nursing (DON), revealed that she was not notified of Resident #1's pain, leg swelling, or a change in condition on 3/25/11. The DON stated that the nurses should have contacted the treating Physician and should have reassessed and closely monitored Resident #1 after her report of pain on 3/25/11. The DON stated that the nurses should have written Resident #1's incident of pain in the 24 hour nurses report and passed it on to the other shifts on 3/25/11 and also reported the incident to the Physician. The DON stated that on 3/28/11, three (3) days after the initial report of pain for Resident #1, LPN #5/SSD reported that Resident #1 presented with pain, tender to touch on leg, warmth to leg, and facial grimace when she was moved and /or touched. The DON stated that at 2:30 p.m. on 3/28/11, she obtained an order to have an X-ray of Resident #1's leg which was done at the local hospital. The X-ray report arrived at the facility on 3/30/11 confirming a fracture to the left leg and left leg effusion. Review of the X-ray report revealed that Resident #1 was X-rayed on 3/28/11 at the local hospital and the X-ray report was transcribed and forwarded to the facility on [DATE]. The X-ray report stated: "There is a displaced fracture involving the distal femoral fracture. There is a fat fluid level indicating an effusion likely bloody given the fracture." "Impression: [MEDICAL CONDITION] femur with knee effusion." The X-ray report was signed and dated 3/30/11 at 1:52 p.m. Observation on 6/9/11 at 12:00 p.m., revealed that Resident #1 was not interviewable. Resident #1 was lying reclined in a geri-chair with a leg immobilizer that covered the left leg. keeping it in a straight position. Review of the facility policy and procedure entitled, "Physician Notification Policy", (with no date), revealed the following: "It is the policy of this facility that the Physician will be notified as follows: For any accident/incident involving the resident with injury to the resident has the potential for requiring physician intervention. With a significant change in the resident's Physical status Mental status Psychosocial status. With any need to alter treatment significantly, a need to discontinue an existing treatment, a need to commence a new form of treatment. With a decision to transfer the resident to another medical facility to another long term care facility. With a decision to discharge the resident. With the death of the resident. Document in the Nurse's Notes Date and time Reason for notification physician's response, Family notified Nurse's signature and title." Review of the facility policy and procedure, entitled, "Family Notification Policy", (with no date), revealed the following: "It is the policy of this facility that the resident's responsible party or other family members will be notified as follows: When an accident/incident involving the resident occurs; With a significant change in the resident's physical, mental, or psychosocial status; When there is a need to alter the resident's treatment (to discontinue a treatment or to commence a new treatment)." Review of the facility policy and procedure, entitled, "Fall Protocol Policy", (with no date), revealed the following: "It is the policy of this facility that the fall protocol will be as follows: Any fall with or without injury - Complete the Accident/Incident report; Follow falls policy. Document in the Nurse's Notes. Care Plan fall; Notify physician; Notify Family; Acute documentation for at least 72 hours; If a fall is unwitnessed or with a head injury, initiate Neuro-Checks-Fall review." Review of the facility policy and procedure, entitled, "Evaluating the Resident's Condition Policy", (with no date), revealed the following: "It is the policy of this facility that the resident's condition will be evaluation as follows: By licensed nurse assigned to the unit; By the R.N. as needed; According to the acute situation or emergency situation; Notify physician as needed; Notify family; Document evaluation of condition or situation in nurse's notes; Complete accident/incident report as indicated." Review of the facility policy and procedure, entitled, "Pain Protocol Policy", (with no date), revealed the following: "It is the policy of this facility that the pain protocol will be as follows: Complete Pain Assessment on Admission by day 21 At least quarterly With significant change in resident's condition; Complete Pain Management Evaluation on residents requiring routine pain medication each time medication is administered; Complete PRN Medication Sheet On all residents requiring PRN pain medication following the administration of pain medication to document PRN medication; To follow up on results of PRN pain medication." Review of the facility policy and procedure, entitled, "Abuse, Neglect, or Exploitation Policy", (with not date), documented the definition of the word neglect as "The failure of a caretaker to supply for the vulnerable adult food, clothing, supervision, or other services which are necessary to maintain his/her mental or physical health."

Based on observation, record review, staff interview, review of staff written statements, facility investigation report review, Physician interview, Medical Director interview, Responsible Party (RP) interviews, and facility policy and procedure reviews, the facility failed to ensure that one (1) of six (6) residents reviewed for falls/fractures was not neglected by failing to adequately assess and treat Resident #1 when she exhibited signs and systems of pain. On 3/25/11, Resident #1 had facial grimaces, was yelling out when left leg was touched or repositioned, and had a change in her behavior. The facility failed to notify the Physician of the symptoms of pain and failed to notify the RP. The facility failed to document the continued assessment of Resident #1's pain after 3/25/11. The facility failed to ensure that the complaints of pain was passed on to the other shifts. There was no documented assessment of Resident #1 from 3/25/11 until 3/28/11 at which time an X-ray was ordered. Resident #1 had a [MEDICAL CONDITION] femur and left knee effusion. The facility did not receive an X-ray report until 3/30/11. There was documentation in the nursing notes that the X-ray report was still at the hospital until 3/30/11. Resident #1 was noted as being severely impaired in cognitive skills for daily decision making and required total assistance of staff for care. CNA staff reported that these behaviors of grimacing and yelling out was not the norm for Resident #1. The facility failed to ensure that Resident #1 received the care and services necessary for the prevention of pain due to a fracture. Findings include: Cross refer findings to F-309 for the facility's failure to ensure that Resident #1 received the necessary care and services to prevent neglect when she began to experience pain on 3/25/11. The CNA staff reported to the Nursing staff that Resident #1 was grimacing and complaining of pain. The Nursing staff had no documented evidence that Resident #1 was assessed for pain. She was given ES Tylenol for pain relief. The nursing staff failed to pass on to on-coming staff that Resident #1 was complaining of pain on 3/25/11.

Based on observations, record reviews, physicians interviews, staff interviews, handwritten employee statement reviews, Responsible Parties (RP) interviews, and facility policy and procedure reviews, the facility failed to immediately notify the RP and the treating physicians for Resident #1 concerning her pain, knee swelling, and change in condition for one (1) of six (6) resident's reviewed. The facility also failed to ensure that the RP was notified of the change in resident's status. This is for Resident #1. Resident #1 was noted to exhibit signs and symptoms of pain when her left leg was touched or repositioned by making facial grimaces and yelling out. These behaviors started on 3/25/11. Resident #1 was given ES Tylenol for pain. An X-ray on 3/30/11, revealed that Resident #1 sustained a [MEDICAL CONDITION] distal femur with knee joint effusion. Findings include: Cross refer findings to F- 309 for the facility's failure to ensure that the Physician was notified of the residents complaints of pain that began on 3/25/11. The RP was not notified of the change in resident's status related to complaints of knee pain.

Based on record review, resident interview, staff interview, personnel record review, policy review, and staff written statement review, the facility failed to prevent neglect by failing to ensure that Resident #1, one (1) of eight (8) patients reviewed, received adequate supervision of two (2) CNAs (Certified Nurses Assistants) and use of a lift as ordered for a transfer. The resident fell on [DATE] without injury during a transfer from a wheelchair to the commode. The resident fell again on 12/28/10 and sustained a fractured tibia/fibula when a CNA failed to use a Sit to Stand lift as ordered for a transfer from bed to wheelchair and failed to ask for assistance of another CNA as ordered. Findings Include: Cross Refer to F-224 for the facility's failure to prevent neglect during transfers and failure to follow physician's orders [REDACTED]. The resident also fell during a transfer on 12/28/10 and sustained a fractured tibia/fibula when a CNA failed to read and implement the resident's ADL Care Plan for use of a lift for a transfer from bed to wheelchair and failed to ask for assistance of another CNA as ordered.

Based on record review, resident interview, staff interview, personnel record review, policy review, and staff written statement review, the facility failed to ensure physician's orders were followed for transfers with a Sit to Stand Lift and assist of two (2) Certified Nurses Assistants (CNAs). This was for Resident #1, one (1) of eight (8) residents reviewed. Findings Include: Cross Refer to F-224 for the facility's failure to ensure Resident #1 was transferred with a Sit to Stand Lift with the assistance of two (2) CNAs as ordered. This resulted in the resident sustaining fractures of the left tibia and fibula

Based on record review, resident interview, staff interview, personnel record review, policy review, and staff written statement review, the facility failed to ensure that one (1) of eight (8) residents reviewed (Resident #1), was free from neglect. Resident #1 was transferred by CNA (Certified Nurses Assistant) #1 without the use of the Sit to Stand Lift as ordered and without assistance, resulting in a fall. Resident #1 was sent to the emergency room and diagnosed with [REDACTED]. Findings Include: Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's 12/13/10 Significant Change Minimum Data Set (MDS) revealed she had poor recall/memory. She was sad, depressed and lethargic. Resident #1 required total assistance for dressing, encouragement and cueing for eating, and was occasionally incontinent of bladder. She participated in activities some of the time. Observation on 01/27/11 at 3:30 p.m. revealed that Resident #1 was in her room seated in a recliner with her legs elevated. An immobilizer was noted to her left leg. The resident responded to her name being called. She was confused and only oriented to her name at this time. Resident #1 was unable to communicate as to what happened to her leg. Resident #1 did state that her leg still hurt. Review of the physician's orders [REDACTED]. Review of Resident #1's Care plan included: "Potential to fall related to Hx (history) of falls, [MEDICAL CONDITION], and [MEDICAL CONDITION] with History of fractures to wrist, femur, tibia, fibula" with a problem onset of 10/11/2005. The care plan also documented on "4/27 fall" and "12/28/10 fall fracture L (left) tibia/fibula" and "High risk for trauma/injury/fractures related to [MEDICAL CONDITION] (with) hx of fractures" with a problem onset of 02/13/07. There was also documentation stating: "12/26 fall resolved and 12/28 fall Fx L tibia/fibula." There was a handwritten order on 12/28/10 stating to discontinue sit to stand (with) 2 (two) CNAs and D/C (discontinue) "may transfer self to toilet." Review of the "Resident ADL (Activities of Daily Living) Record & Care Plan" for Resident #1 used by the facility CNAs revealed: "Transfers with help - a change documented on 12/26/10; Lift - Sit to Stand had a line drawn through it; Total Lift PRN (as needed) dated 12/26/10". Review of Nurses Notes (NN) Following Fall, faxes sent to the physician, and physician's orders [REDACTED]. The nurse found the resident sitting on the bathroom floor. The CNA stated that she lowered the resident to the floor when the Resident's legs gave way on her. An assessment revealed no injury and the resident had no complaints of pain. When report was given to the physician he gave no new orders. Review of the resident's physician's orders [REDACTED]." Review of the resident's December 2010 Medication Records revealed [MEDICATION NAME] 5 mg was administered on December 26, 28, 29, 30 and 31, 2010 for left leg pain. Review of NN following Fall, faxes to the resident's physician and physician's orders [REDACTED].#1 attempted to transfer Resident #1 from her bed to a wheelchair (w/c) without any assistance and without using the Sit to Stand lift as ordered. When the resident began complaining about left leg pain the CNA transferred her back to the bed. When the resident sat down, she sat on the very edge of the bed and began to slip down. The CNA attempted to help the resident move further back on the bed, but the resident had on a silky type nightgown which caused her to continue slipping off the edge of the bed. The CNA lowered the resident down to a sitting position on the floor beside the bed. The resident continued to complain of left leg pain. She stated that her left leg had been hurting ever since the incident on 12/26/10. Registered Nurse (RN) #1 assessed the resident and noted she had a raised area located just below her left knee. She assessed the resident's pain as moderate, sharp with facial grimaces. The resident was assisted back onto the bed by staff members X 3. Orders received from the physician to transfer the resident to the emergency room (ER) for X-rays. At 2:00 p.m. ER staff called the facility to report that the resident had a fracture to the left lower knee/leg area. A fax to the physician documented that the resident had complained of her left leg hurting since 12/26/10. The resident saw an orthopedic physician and received a left leg immobilizer. physician's orders [REDACTED]." December's computerized orders also showed this same order dated 06/16/09 with a line drawn through it and handwritten (changed) 12/26/10. Review of the facility's policy "Resident's Free From Abuse Policy" (with no date) signed by the Director of Nurses (DON) and CNA #1 revealed: "It is the policy of this facility that all residents will be free from physical, mental and/or verbal abuse. Facility Responsibility: (6). To protect the resident during the investigation. Action: Any employee suspected of abuse, neglect or exploitation shall be placed on suspension ...Shall remain on suspension until (1).A complete investigation has been conducted. (2). Evidence has proven that the employee is not guilty of abuse, neglect or exploitation. Shall not be assigned to work in the same area where the reported incident occurred." Review of in-services related to Abuse/Neglect that CNA #1 had received since her hire date of 05/27/09 revealed: "08/20/09 Abuse and Neglect; 10/05/09 Abuse, Resident Rights; and 12/04/09 Following ADL Sheets. Review of a 05/27/09 Orientation Check List for New Employees revealed the following items were initialed by CNA #1 as done: Discuss Abuse and Neglect; Abuse Video and Med Care Hoyer Lift video. Review of CNA #1's 06/01/09 Performance Evaluation check off sheet revealed the following skills were performed adequately: Transfer from bed to chair; Transfer from bed to chair with non-ambulatory resident; Mechanical lift; ADL Record; Wheelchair to commode; Uses proper number of people for transfers/assistance. On 11/09/10 CNA #1 received a skills check off for a Sit to Stand Lift and a Total Lift. A CNA Job Description signed on 06/09/10 by CNA #1 stated, "11. Read and follow resident ADL Care Plan. 17. Prevent abuse, neglect and exploitation in the elderly." During an interview on 01/28/11 at 9:15 a.m. the Administrator and the Director of Nurses (DON) stated that this resident did not fall on 12/26/10 or on 12/28/10, but was lowered to the floor by CNAs both times. The DON stated that Resident #1 had a [DIAGNOSES REDACTED]. The DON also stated that CNA #1 had been counseled about following ADL careplans, she had been written up and placed on suspension until their investigation was completed. She stated "There was a new order to use the Sit to Stand Lift. She (CNA #1) said she didn't use it because she didn't know about the order. Now we post each resident's ADL sheet on the inside of their closet door." CNA #1 schedule showed that she worked the 11pm to 7am shift and was not in the building during the survey and was unable to be reached by telephone until 01/28/11. During a 01/28/11 4:30 p.m. phone conversation CNA #1 stated, "I didn't know I was supposed to use the sit to stand lift. Nobody told me." She confirmed that she did not read the resident's ADL careplan prior to giving her care on the morning of 12/28/10. When asked about the 12/28/10 incident with Resident #1, CNA #1 stated that during the 12/28/10 5:30 a.m. transfer from the bed to a wheelchair the resident began to complain of left leg pain. "I told her to sit back down on the bed and she did, but she sat on the very edge. I told her to scoot back some but she couldn't so I put my knee between her legs and my arms under her arms and around her back to try to get her further back on the bed. She had on a silky gown and she just kept sliding down so I told her to hold on to me and I lowered her to the floor. A nurse and another CNA came into the room and we all got her (Resident #1) up and onto the bed. Later they told me her leg was broken. I never meant to hurt her." During exit conference on 02/11/11 at 7:30 p.m. the DON and the Assistant Administrator confirmed that the information gathered was correct.