Every finding on record at The Highlands Guest Care Center

Based on interview and record review, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs used without adequate indications for its use for 1 of 3 Residents (Resident #1) whose records were reviewed for unnecessary drugs Nursing staff failed to obtain a consent from Resident #1's RP for the use of divalproex (psychotropic medication used for anxiety). This failure could place residents at risk of the use of unnecessary medications.Findings inlcuded: Record review of Resident #1's Quarterly MDS assessment, dated 06/16/26, reflected Resident #1 was a [AGE] year-old female, admitted to the facility on [DATE], diagnoses included unspecified mood affective disorder (a mental health diagnosis used when a person shows clear signs of significant emotional distress, but their symptoms do not match the exact rules for a specific condition like major depression or bipolar disorder) and cognitive communication deficit (trouble with talking and listening caused by problems with thinking skills). Resident #1's BIMS score of 07 indicated that Resident #1's cognition was severely impaired. Record review of progress notes reflected Resident #1 was sent to the hospital on 7/17/26, related to different concerns. Resident #1 still at the hospital. Record review of Resident #1's physician orders for January 2026 revealed an order Divalproex (psychotropic medication used for anxiety) sodium Oral Tablet delayed release 250 mg. Give 250 mg by mouth three times a day related to unspecified mood affective disorder. Start date: 01/07/2026 Record review of Resident #1's MARs for January 2026, February 2026, March 2026, and April 2026 revealed Resident #1 received Divalproex 250 mg from 01/07/26 to 04/21/26. Record review revealed there was no written consent and no documentation that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and was able to choose the option he or she preferred as the written documentation in the record about being informed,During an interview on 7/23/26 at 11:23 AM with the DON, the consent for Divalproex 250 mg was requested. The consent was not provided prior to exit. Interview on 07/23/26 at 11:35 AM with the DON said consent for the use of psychotropic medication had to be signed by the RP prior to administration. The DON stated the potential outcome was that the representative did not agree with the medication administration and the resident would receive medication unnecessarily. The DON stated ADON and the DON were responsible to do periodic audit for monitoring for all necessary consents. Record review of facility policy, Psychotropic Medication use, revised on 02/2025 read in relevant part . Informed Consent or Refusal: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal:a. non-pharmacological alternatives;b. the indications and rationale for the recommendation;c. the potential risks and benefits (including possible side effects, adverse consequences, and black boxwarnings); andd. the resident's/representative's right to accept or decline the treatment.

Based on observation, interview, and record review, the facility failed to provide food prepared that conserved nutritive value, flavor, and appearance for one of one kitchen, reviewed for nutritive value, in that:Cook A did not follow the recipe for the pureed (cooked food, usually vegetables, fruits, or legumes, that has been ground, pressed, blended, or sieved to the consistency of a creamy paste or liquid) BBQ Brisket served for lunch service on 07/14/26.This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings included:Observation and interview on 07/15/26 at 11:00 AM, [NAME] A prepared puree meal for lunch. [NAME] A took about one-sixth pan of regular texture BBQ brisket that was on the buffet steam table, ready to be served, to the blender, added all the regular texture BBQ brisket to the blender jar, and started the blender. After about one minute of blending the BBQ brisket, [NAME] A walked to the kitchen sink and took water in a pitcher, that was about 1/4 full, and added the water to the BBQ brisket mixture in the blender. [NAME] A stated, I added an unknown amount of water to make it thin. [NAME] A stated she did not look at the recipe. During a follow-up interview on 07/15/26 at 11:15 AM with [NAME] A, she stated she did not look at the standardized recipe binder. She stated that she added water instead of other liquid to adjust the consistency of the pureed BBQ brisket. [NAME] A stated that the risk of not following standardized recipe was decreasing the nutritional content of the meal.Interview on 07/15/26 at 11:20 AM with the Dietary Manager revealed his expectation was all the cooks followed standardized recipes to cook all meals. The Dietary Manager stated that if the recipe was for using broth or milk, for pureed foods, then [NAME] A should have used it. The Dietary Manager stated she provided an in-service to the cook on following recipes for all meals, in the past. The Dietary Manager stated that the risk of not following recipes was diluting the nutritional content and compromising on the quality of foods. Interview on 07/15/26 at 12:20 PM with the ADM revealed the facility did not have a policy on standardized recipes, the expectation was for the dietary staff to use the individual recipe accordingly. Review of facility's Diet Type Report dated 07/14/26 revealed a total of four residents listed with a diet texture of pureed. Review of the facility's recipe for Pureed BBQ brisket undated indicated .Spring/Summer 2026-Day 3-Lunch .1. Remove portions needed from regular prepared recipe and place in sanitized food processor. Blend until smooth. Place prepared noodles in a sanitized food pressor. Blend until smooth. NOTE: .if product needs thinning, gradually add appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plan development. The facility failed to ensure Resident #1's comprehensive care plan included a plan of care for ADLs. This failure could place residents at risk of not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health. The findings included: Record review of the MDS dated [DATE] indicated Resident #1 was a 70-years-old female and was admitted on [DATE] with diagnoses including hypertension (elevated blood pressure), non-Alzheimer's dementia (a broad group of progressive brain disorders that cause cognitive decline severe enough to impact daily life, but are not caused by Alzheimer's disease), stroke, and muscle weakness. Resident #1 had BIMS score of 00/15, indicating her cognition was severely impaired. Section GG (Functional Abilities) reflected Resident #1 required partial/moderate assistance for personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, washing/drying face and hands (excludes baths, showers, and oral hygiene). Record review of Resident #1's care plan last reviewed 04/28/26 revealed there was no plan of care that identified measurable objectives, goals, interventions and time frames for ADLs. During an interview on 06/10/26 at 11:21 AM, the DON stated every resident should have a plan of care that reflected their likes, dislikes, everyday routine, and anything that affected the residents. She stated the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. She stated it was the responsibility of the nursing staff, (charge nurses, ADON, MDS Coordinator nurse and DON) to update residents care plan. The DON stated that since the aides (CNAs) follow care plans to do their task, if the care was not care planned, the aides would not know what to do for the resident. During an interview on 06/10/26 at 12:02 PM, ADON A stated every resident should have a plan of care that reflected their needs, everyday routine, and anything that affected the residents. She stated the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. She stated it was the responsibility of the nursing staff, (charge nurses, ADON, MDS Coordinator nurse and DON) to update residents care plan. The ADON stated the care plan was not updated if would place residents at risk of not receiving care and services to meet their needs. During an interview on 06/10/26 at 12:48 PM, the MDS nurse stated the residents' care plan update was the responsibility of all IDT (nurses, ADON, physical therapy, SW) according to their discipline. She stated the care plan was to be generated so everyone will know how to collectively care for the residents. The MDS nurse deflected questions regarding the missing plans or risk to residents. Record review of the facility policy titled Care Plans-Baseline) revised on March 2022 revealed: The base line care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

Based on observation, interview and record review, the facility failed to ensure the residents' right to be treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #38) reviewed for respect and dignity in that: The facility failed to ensure RN A provided privacy by leaving the door open and not pulling privacy curtain, exposing Resident #38's abdomen while administering the medications through gastroenterology tube (feeding tube). This failure could place residents at risk of emotional distress and low self-esteem. Findings included: Record review of Resident #38's significant change MDS assessment, dated 12/19/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #38 had diagnoses which included: Cancer (destroying tissue), multiple sclerosis (neuromuscular disease), aphasia (unable to speak), dysphagia (unable to swallow), and hypertension (high blood pressure). Resident #38 was cognitive impaired and unable to make decisions and required assistance from one staff for activities of daily living. Record review of Resident #38's physician orders dated 10/29/2025 reflected, all medications are to be given by the feeding tube. Record review of Resident #38's care plan dated 09/28/2025 reflected that the resident had problems with swallowing from Multiple Sclerosis and required receiving medications through the feeding tube to maintain nutritional status. An observation on 12/29/2025 at 12:23 p.m., revealed RN A entered room of Resident #38 while she was in her bed. RN A did not close the door or pull the privacy curtain of Resident #38's room during the entire process of administering medications through her feeding tube. Resident #38's abdomen was visible to the hallway and to her roommate, who was in the room eating her lunch. Further observation revealed the floor technician outside of the room in the hallway cleaning the floors and a CNA wheeling a male resident down the hallway to his room after eating his meal. In an interview on 12/28/2025 at 1:15 p.m., RN A revealed she forgot to close the door or pull the privacy curtain. RN A stated she did guess she was more nervous than she thought and did not think about it, until she had completed her task. When asked about the training she received on resident's rights, RN A stated, by not closing the door and the curtain, the privacy and dignity of Resident #38 was compromised as the roommate could see her abdomen and anyone who passed by the room could see the abdomen of the resident. RN A was fully aware of resident rights to have privacy, dignity, and respect and received in-service on resident's rights at least once a year. In an interview on 12/29/2025 at 7:45 a.m., Administrator revealed that the nursing staff should always provide privacy when providing care to the residents. The Administrator stated that it means shutting the door and closing the blinds in the room and pulling the privacy curtain. In an interview on 12/29/2025 at 9:15 am Resident #38 revealed the staff usually does close the door and close the curtain. Resident #38 stated RN A had told her she was nervous because the surveyor was in the room with her. Resident #38 stated she liked RN A and she always talks to her and she is very nice and helps her, but she would have liked the door to be closed and the curtain pulled. In an interview on 12/29/2025 at 9:30 a.m. the roommate, Resident #68, revealed that Resident #68 never looked when they were taking of her roommate, and they almost always pulled the curtain, and closed the door. Resident #68 stated her biggest concern was getting past the curtain and opening the door when she wanted to leave the room. During an interview on 12/30/2025 at 11:51 a.m., the DON stated privacy and dignity must be provided during nursing care and the door and privacy curtain to Resident #38's room should have been closed completely and the curtain pulled by RN A. He said the training was an ongoing process and resident rights was one of them. The DON stated the facility ensured all the new hires had gone through skill checks. Every nursing staff member also had to complete an annual evaluation to ensure their nursing skills and knowledge including competency in respecting residents' rights. Review of facility's policy Resident Rights revised dated February 2021, reflected: It is the policy of this facility that all residents be treated with kindness, respect, and dignity Policy Interpretation and Implementation. a, a dignified existence. b. be treated with respect, kindness, and dignity.

Based on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift for 1 of 1 facility reviewed for nurse staffing. The facility failed to update and post the daily nurse staffing information from 12/27/2025-12/28/2025. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census.The findings included: During an observation on 12/28/25 at 9:00 a.m., the daily staffing posting was hanging at the receptionist desk dated 12/26/2025. During an interview on 12/29/2025 at 10:42 a.m., the Staffing Coordinator stated that she created the staff posting on Friday and placed it in the 24-hour turnover binder for the Weekend Supervisor to post on weekends. The Staffing Coordinator said the night shift nurses completed the daily staffing posting. Record review of the 24-hour turnover binder revealed there was daily staff posting for 12/27/25 and 12/28/25. During an interview on 12/30/25 at 11:45 a.m., the DON stated that the Staffing Coordinator was responsible for filling out the facility's daily posting. The Weekend Supervisor was in charge to put up the staff posting on Saturday and Sunday. The DON was not aware that the staff posting had not been posted. The DON stated that the purpose of the daily staff posting was for the transparency of the facility to family members. The DON said the staff posting informs each family member how many staff members are assigned each shift to provide care for their loved one. The DON stated the negative effect of not posting would be that visitors would not have the nursing staff hours for that day. During an attempted interview on 12/30/2025 at 11:55 a.m., the Weekend Supervisor did not answer the phone. Record review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised August 2022, indicated, Our facility will post on a daily basis for each shift staffing data, including the number of nursing personnel responsible for providing direct care to residents. 1. Within two hours of the beginning of each shift, the number of licensed nurses (RN, LPNs, LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in clear and readable format.

Based on interviews,observation and record reviews, the facility failed to ensure resident has the right to be free from neglect for one (Resident #1) of eight residents reviewed for abuse neglect. On 2/21/2025, CNA A transferred Resident #1 without a gait belt from the shower chair to the bed. As a result, Resident #1 suffered a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Oversight and monitoring of direct care staff (nurse aides), was not addressed. CNA A transferred Resident #1 inappropriately on 2/21/25 causing a left lower extremity fracture, was not retrained and or monitored, and then CNA A transferred Resident #1 inappropriately on 04/07/25 causing a right lower extremity fracture. CNA A was aware Resident #1 required two staff to transfer but transfered the resident alone. This failure resulted in an Immediate Jeopardy situation on 04/10/2025. While the IJ was removed on 4/14/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm due to staff needing more time to monitor the effectiveness for the plan of removal for accidents and hazards. These failures could place residents at risk of serious harm, pain, and serious injury. Findings included: 1. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 15 (indicated no cognitive impairment). Section GG of the assessment revealed Resident #1 was dependent on staff to provide all the effort when toileting, showering, and when changing positions from sitting to standing. Section I of the MDS indicated Resident #1 had diagnoses of a left tibia (shin bone) fracture, multiple sclerosis (a disease that affects the nervous system and causes muscle weakness), and lack of coordination. Record review of Resident #1's care plan with a revision date of 4/08/2025 revealed Resident #1 sustained a fracture to the lower left extremity (left leg) on 2/26/2025 and sustained an additional fracture to the right lower extremity (right leg) on 4/07/2025. Resident #1's care plan was updated on 4/08/2025 and indicated a mechanical lift should be used for transfers. No transfer information prior to 4/08/2025 was found on the care plan. Record review of Resident #1's progress note dated 2/21/2025 at 10:51 a.m. by RN B revealed Resident #1 had stated she bumped her knee against the shower chair, and an order was received for an x-ray. Record review of Resident #1's incident report dated 2/21/2025 completed by RN B revealed CNA A notified RN B that Resident #1 hit her knee against the shower chair during a transfer in the shower room. Record review of Resident #1's x-ray dated 2/21/2025 revealed Resident #1 had a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Record review of Resident #1's hospital orthopedic progress note dated 2/28/2025 revealed pain had improved and was better controlled since the splint (a medical device designed to immobilize the leg) was applied to the left leg while in the hospital. 2. Record review of Resident #1's progress note dated 4/07/2025 at 1:07 p.m. by RN B revealed Resident #1 had reported that she hit her right foot against the shower chair when transferred from the shower chair to the bed and an x-ray had been ordered. Record review of Resident #1's incident report dated 4/07/2025 completed by RN B revealed Resident #1 reported right foot pain and had reported she hit her right foot against the shower chair when being transferred from the shower chair to the bed. Record review of Resident #1's x-ray dated 4/07/2025 revealed an oblique fracture (a bone break that occurs at an angle to the bone's long axis) to the right distal diaphysis of the tibia (lower area of the shin bone) that was reported to the facility on [DATE] at 11:17 p.m. Record review of Resident #1's progress note dated 4/08/2025 at 10:18 a.m. by RN B revealed an order was received from NP JJ to send Resident #1 to the hospital. Record review of Resident #1's progress note dated 4/08/2025 at 10:36 a.m. by RN B revealed Resident #1 was transported to the hospital via ambulance. Record review of Resident #1's hospital history and physical dated 4/08/2025 revealed Resident #1 was being seen for right lower extremity pain. Resident #1 reported she was being moved to transfer from her wheelchair and got her leg stuck and twisted. The hospital notes also revealed an oblique fracture through the distal tibial shaft (a bone break that occurs at an angle to the lower area of the shin bone). In an interview and observation on 4/09/2025 at 11:04 a.m., Resident #1 reported that both of her legs had been broken. Resident #1 stated that her left leg had been broken over a month ago when CNA A transferred her from the shower chair to the bed. Resident #1 reported that her right leg had been broken a few days ago when she was transferred again by CNA A from the shower chair to the bed. Resident #1 stated that both times her foot had gotten caught between the shower chair and the bed. Resident #1 reported that she was not sent to the hospital immediately after fracturing the first leg and did not remember how long it took before she was sent to the hospital. Resident #1 stated she was in pain after both fractures until she was sent to the hospital because the facility was not able to administer strong enough pain medications. Resident #1 stated they did not send her to the hospital until the next day after the second fracture. Resident #1 reported when she fractured her right leg a few days ago that she had felt it pop in the right leg when CNA A transferred her from the shower chair to the bed. Resident #1 reported her right leg got caught behind the shower chair, and CNA A transferred her from the shower chair to the bed by herself. Resident #1 reported the facility sent her to the emergency room the next day after breakfast. Resident #1 stated she was in pain before they sent her to the hospital, and they gave her pain medication. Resident #1 reported the pain medication did not work, and she was still in pain. Resident #1 stated before her legs were fractured that she only got out of bed for therapy and showers but was unable to do therapy since the injuries occurred. Resident #1 lifted her blanket and revealed both of her legs were wrapped with soft gauze and ACE wrap. The right leg appeared bigger than the left. Resident #1 reported her pain was currently well managed. In an interview on 4/09/2025 at 12:42 p.m., CNA A reported she was transferring Resident #1 from the shower chair to the bed on 2/21/2025. CNA A stated Resident #1's left leg did not pivot with the resident when transferring her, and her foot stayed stuck to the floor in the same position. CNA A reported the leg twisted when she transferred Resident #1, and Resident #1 reported that she heard her leg pop. CNA A stated Resident #1's left leg also bumped the bed during the transfer. CNA A stated she did not use a gait belt and was by herself during the transfer. CNA A reported no training was completed before or after this incident, and she had been working at the facility for around six months. CNA A reported when she transferred Resident #1 on 4/07/2025 that she had CNA C with her, but stated CNA C did not know what she was doing. CNA A reported CNA C leaned Resident #1 forward in the shower chair, and Resident #1 bumped her right leg on the shower chair. CNA A reported Resident #1 complained of pain to her right leg, but CNA A transferred Resident #1 to the bed anyway because the shower chair was hurting her. CNA A reported CNA C did not know to get on the other side of Resident #1 to help with the transfer, so CNA A did the transfer by herself. CNA A reported that Resident #1 complained of pain when she was transferred to the bed, and CNA A notified RN B. CNA A reported a gait belt was not used for the second transfer because Resident #1 did not like gait belts. In an interview on 4/09/2025 at 12:59 p.m., RN B stated that Resident #1 complained of pain to her left leg on 2/21/2025. RN B stated Resident #1 had told him that her left leg got caught in the shower chair, and Resident #1 reported she heard it pop. RN B stated x-rays were ordered, and Resident #1 did have a fracture. RN B stated the fracture to the right leg occurred when CNA A transferred Resident #1 back to bed from the shower chair. RN B stated Resident #1 told him she bumped her leg on the shower chair, and RN B was unsure if CNA A was by herself during the transfer. RN B stated x-rays were ordered which revealed a fracture to the right leg. RN B reported he had not received any training over transfers since either incident. In an interview on 4/09/2025 at 1:35 p.m., CNA C reported she did not assist CNA A when Resident #1 was transferred. CNA C stated she was in training and did not work with CNA A on 4/07/2025. CNA C reported she was not in the room when Resident #1 was transferred, and she was working a different hall. In an interview and observation on 4/09/2025 at 2:02 p.m., the DON stated Resident #1 told her she hit her foot when she was transferred on 2/21/2025 from the shower chair to the bed. The DON stated she thought Resident #1 was a two-person transfer prior to this incident. The DON confirmed by looking at her computer that Resident #1's care plan did not contain any information regarding transfers until 4/08/2025. The DON reported that the CNAs would know how to transfer residents because they were orientated to their hall and received report from each other. The DON stated she did not know if CNA A was by herself after the first incident. The DON stated they were still investigating the incident that occurred on 4/07/2025, and she was not sure of what happened yet. The DON stated that CNA A told her there was another CNA assisting with the transfer, but the DON was not sure who the other CNA was. The DON stated CNA A knew she was not supposed to transfer Resident #1 by herself. The DON confirmed Resident #1 sustained a fracture to her right leg after being transferred from the shower chair to the bed on 4/07/2025. In an interview on 4/09/2025 at 2:54 p.m., Resident #1 confirmed that CNA A was alone when she was transferred from the shower chair to the bed both times. Resident #1 reported no one had offered to use a gait belt, but that was a good idea. In an interview and observation on 4/10/2025 at 1:54 p.m., ADON D reported a mechanical lift should have been used to transfer Resident #1 prior to the first incident on 2/21/2025. ADON D stated there was a list of residents that required a mechanical lift for transfers that was located in the CNA assignment book at the nurse's station. ADON D then obtained the assignment book and revealed a list of residents that required the use of a mechanical lift. ADON D confirmed Resident #1 was the last name on the list, but the list was not dated. Record review of facility in-service regarding Turning and positioning, dated 3/15/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. Record review of facility in-service regarding Positioning resident with a fracture, dated 02/27/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. A record review of the facility's policy titled Accidents and Incidents - Investigating and Reporting, dated 2001, revealed All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator . Incident/Accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. A record review of the facility's policy titled Lifting Machine Policy and Procedure, dated 11/01/2016, revealed Review the resident's care plan to assess for any special needs of the resident . Two (2) clinical person who have been trained to use this lifting device are required to perform this procedure. A record review of the facility's policy titled Abuse, Neglect and Exploitation, revised on 7/01/2020, revealed neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 12 (indicated mildly impaired cognition). Section I of the MDS revealed Resident #2 had diagnoses of muscle weakness, severe morbid obesity (overweight), and anxiety disorder. Record review of Resident #2's care plan with a revision date of 3/31/2025 revealed Resident #2 indicated she was a fall risk and had poor safety awareness. In an observation on 4/11/2025 at 12:02 p.m., CNA FF and CNA GG were preparing to transfer Resident #2 from the bed to the wheelchair using a mechanical lift. The top of the sling was placed under the shoulders of Resident #2. The bed was not locked. The wheelchair was not locked. CNA FF positioned the lift over Resident #2. CNA FF placed two blue sling loops on two of the mechanical lift hooks. CNA GG placed two green sling loops on two of the mechanical lift hooks. CNA FF began lifting the resident in the sling using the mechanical lift. Resident #2 was lying flat in the sling as she was lifted. CNA FF positioned Resident #2 over the wheelchair using the mechanical lift while CNA GG guided Resident #2 in the sling. CNA GG attempted to position Resident #2 over the wheelchair, but Resident #2 remained in a laying position. The surveyor requested the CNAs stop the transfer and called for assistance. CNA EE entered the room and assisted CNA GG in positioning Resident #2 in more of a sitting position over the wheelchair. Resident #2 was lowered into the wheelchair without injury. In an interview on 4/11/2025 at 12:44 p.m., CNA FF reported they had trouble transferring Resident #2 using the mechanical lift because the sling was too small. CNA FF reported they had additional slings but was unsure if they had the right size for Resident #2. CNA FF was unable to continue with the interview because she had to feed a resident. In an observation and interview on 4/11/2025 at 1:42 p.m., CNA EE and CNA FF were in Resident #2's room, and CNA FF stated they were going to transfer Resident #2 with the mechanical lift from the wheelchair to the bed. CNA FF reported the sling under Resident #2 was too small, and they would look for a new sling after transferring Resident #2. The surveyor requested the CNAs not to transfer the resident. The surveyor notified the ADM, and the ADM told the CNAs not to transfer Resident #2. The ADM brought the DOR to the room. The DOR checked the sling and reported it was the appropriate size because two inches of the sling was visible on each side of Resident #2. The DOR reported he would assist CNA FF with transferring Resident #2 from the wheelchair to the bed using the mechanical lift. CNA FF positioned the mechanical lift over Resident #2. The DOR connected the sling loops to the mechanical lift in the following order: left upper hook had a green sling loop, right upper hook had a black loop, the right lower hook had a green loop, the lower left hook had 3 loops (green, purple, and black). The wheelchair was not locked, and the bed was not locked. CNA FF lifted Resident #2 in the sling using the mechanical lift. Resident #2 was lying flat in the sling as she was lifted. CNA FF positioned Resident #2 in the sling over the bed and lowered the resident to the bed. CNA FF and the DOR pulled the resident up in the bed. The bed was not locked and moved as they repositioned Resident #2. The DOR reported that the colored loops do not have to match when using the lift. The DOR reported the most important thing is that the resident is comfortable. Review of the mechanical lift sling's owner manual, with a print date of December 2023, revealed The top edge of the sling should be slightly above the resident's head . Place the straps of the sling over hooks of the swivel bar or cradle and be sure to match the corresponding strap and/or strap colors on each side of the sling for an even lift of the resident . Colored straps make it easy to connect both side of the sling equally. Always ensure there is sufficient head support when lifting a resident . WARNING: Wheelchair wheel locks MUST be in a locked position before lowering the resident into the wheelchair for transport . When the resident is lifted from the surface, they will be raised to a sitting position. In an interview on 4/11/2025 at 3:12 p.m., the ADM was notified of concerns regarding transfer observations. The ADM reported PT HH was coming to the facility to provide individual training to the DON and ADONs. The ADM reported all staff would be retrained on safe transfers and complete a competency test after completing the training. In an interview on 4/11/2025 at 4:32 p.m., PT HH reported that the ADM had tasked her with training the DON and ADONs concerning safe transfers with mechanical lifts and transfers with a gait belt. PT HH stated that the DON and ADON performed a safe transfer using her as the patient. PT HH stated that she watched the DON and the ADON train two sets of CNAs. PT HH stated that the CNA's then performed safe transfers using her as the patient for each team of CNAs. PT HH stated they performed the transfers safely and stated that until further notice CNAs were to be observed by a nurse every time that they perform a mechanical lift transfer. The ADM, the DON, ADON D, ADON E, and the MDS Nurse were provided the IJ template on 4/10/2025 at 3:13 p.m. and notified that an Immediate Jeopardy situation had been identified due to the above failures. The plan of removal was approved on 4/12/2025 at 3:19 p.m. and reflected: Problem: Failure of safety during transfer for resident # 1. Interventions: On 4/10/2025 the center will in-service nursing staff on where to find the resident's care plan to determine how to care for the resident. This care plain is found on the electronic screen system on each hall and general area. The resident transfer section on the care plan will tell the Nursing tea member how the resident is to be transferred. On 4/10/2025 the center will educate nursing team members on the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both residents and staff. On 4/10/2025 the center will complete a skills check-off tool on the nursing team members so they can demonstrate the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both resident and staff. The following in services were immediately initiated by . Chief Nursing Officer on 4/10/2025. Any nurse not present or in-serviced by 4/12/2025 by 12pm, will not be allowed to assume their duties until in-serviced. ADM . will ensure these team members are removed from the time clock and PCC access removed, this will be monitored until 100% complete or the team members are terminated. On going in-service will be completed by . the DON; ADON D and ADON E until all staff, Weekend, and PRN are completed by 4/12/2025 at 12:00pm. Systemic Change 4/11/2025: On 4/11/2025 it was found that identified CNAs were not following the education and Skills check-off they had completed before they started their shift. . (IDT Team - I) decided to bring in a Licensed Physical Therapist to educate, complete a skills check-off list, and post-test on transferring a resident. On 4/12/2025 PT educated, completed a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with .DON; ADON D and ADON E. After they completed and passed their education, PT observed DON; ADONs educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with 3 CNAs. Moving forward only DON; ADONs, and PT will be able to in-service, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices. Moving forward a resident can only be transferred using a Hoyer lift with a licensed nurse present. This practice will continue until the (IDT Team - I) decides the CNAs are able to complete this transfer without supervision. The following in services were immediately initiated by Chief Nursing Officer on 4/10/2025. Any nurse not present or in-serviced by 4/12/2025 by 12pm, will not be allowed to assume their duties until in-serviced. ADM and HR will ensure these team members are removed from the time clock and PCC access removed, this will be monitor until 100% complete or the team members are terminated. On going in-service will be completed by DON and ADONs until all staff, Weekend, and PRN are completed by 4/12/2025 at 12:00pm. The following in-services were initiated by Chief Nursing Officer on 4/10/2025: Nursing Department (CNAs): - In-service nursing staff on where to find the resident's care plan to determine how to care for the resident. (See in-service 600-1) - Educate nursing team members on the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both residents and staff. (See in-service 600-2) (See Check-off list 600-2) (See Post-test 600-2). The medical director was notified of the immediate jeopardy situation on 4/10/2025 by the DON. The Ombudsmen was notified of this Immediate Jeopardy situation on 4/10/2025 by the Administrator. Monitoring as of 4/11/2025: The DON and ADONs will monitor resident transfers by CNA every shift for 7 days. Administrator will monitor this process daily for the next 7 days. The DON and ADONs will test nursing staff on where to find the resident's care plan every shift for 7 days. The ADM will monitor this process daily for the next 7 days. QAPI: 1. Ad Hoc QA meeting held on 4/10/2025 to discuss causes, in-services and review interventions. 2. Any negative findings in the monitoring and/or auditing system will be reviewed and addressed by the QAPI committee for a potential systemic change. Monitoring of the plan of removal included: In an interview on 4/14/2025 at 1:48 p.m., ADON D reported CNA A had come into the facility and completed training and then was placed on suspension. ADON D stated she was not sure if CNA A would be returning to work after the investigation. ADON D reported RN B was out of the country on vacation but would receive training before returning to work on the floor. ADON D reported that she received training from PT HH. In an interview on 4/14/2025 at 4:13 p.m., the DON reported the ADONs and herself received individual training from PT HH and trained every CNA and nurse themselves. The DON reported that a nurse would be required to be in the room with two CNAs every time a mechanical lift was used, indefinitely. The DON reported that herself and the ADONs would continue to monitor transfers on every shift for the next seven days. The DON reported that herself and the ADONs would also continue to monitor the CNAs and ensure they were able to access care plans for the next seven days. Interviews were conducted with 27 employees from 4/12/2025 starting at 3:55 p.m. and continued through 4/14/2025 at 4:13 p.m. All employees interviewed were able to verify how to access the residents' care plans and identify patients that required a mechanical lift, how to properly transfer residents, and reported they had received hands on training on how to transfer a resident using a mechanical lift, a sit-to-stand lift, and a gait belt. All interviewed staff reported they had received in-services concerning safe transfers, accessing resident care plans, and completed training hands-on transfer training by the DON or ADONs. Interviewed staff members and shifts included: ADON D - worked all shifts ADON E - worked all shifts RN F - worked 2:00 p.m. to 10:00 p.m. RN G - worked all shifts RN H - worked weekend shift 6:00 a.m. to 10:00 p.m. LVN I - worked 6:00 a.m. to 2:00 p.m. LVN J - worked all shifts LVN K - worked 10:00 p.m. to 6:00 a.m. LVN L - worked weekend shift 6:00 a.m. to 10:00 p.m. LVN M- worked 2:00 p.m. to 10:00 p.m. LVN N- worked 2:00 p.m. to 10:00 p.m. LVN O- worked 6:00 a.m. to 2:00 p.m. CNA P - worked 2:00 p.m. to 10:00 p.m. CNA Q - worked 2:00 p.m. to 10:00 p.m. CNA R - worked 6:00 a.m. to 2:00 p.m. CNA S - worked 2:00 p.m. to 10:00 p.m. CNA T - worked 2:00 p.m. to 10:00 p.m. CNA U - worked 10:00 p.m. to 6:00 a.m. CNA V - worked 6:00 a.m. to 2:00 p.m. CNA W - worked 2:00 p.m. to 10:00 p.m. CNA X - worked 2:00 p.m. to 10:00 p.m. CNA Y - worked 10:00 p.m. to 6:00 a.m. CNA Z - worked all shifts CNA AA - worked 2:00 p.m. to 10:00 p.m. CNA BB - worked 10:00 p.m. to 6:00 a.m. LVN CC - worked 8:00 a.m. to 5:00 p.m. CNA DD - worked 6:00 a.m. to 2:00 p.m. Record review of facility in-service titled Where to find a resident's care plan, dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. Record review of facility in-service titled Abuse and Neglect, dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. Record review of facility in-service titled Safety with Hoyer Lift and Transfers with Gait Belt, Check-Off, Post Test dated 4/11/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A completed training and the post-test on 4/12/2025. In an observation on 4/13/2025 at 8:20 p.m., CNA T and CNA S transferred a resident from a wheelchair to the bed using a mechanical lift. RN G was present and assisted during the transfer. Proper techniques and safety precautions were observed. In an observation on 4/14/2025 at 11:43 a.m., CNA V transferred a resident from the bed to a wheelchair using a gait belt. Proper techniques and safety precautions were observed. In an observation on 4/14/2025 at 1:55 p.m., CNA DD transferred a resident from the bed to the wheelchair using a gait belt. Proper technique and safety precautions were observed. Review of Punch detail report for CNA A dated 04/30/25 for dates 04/06/25 to 04/30/25 reflected the CNA A last full day of work was on 04/08/25 and the CNA A came to the facility for inservice training 04/13/25. CNA A did not return to work at the facility for the remainder of the month. On 04/30/25 at 2:43 PM the facility Administrator provided the following clarification via email: . The facility will ensure that all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transfering is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist due to their extensive knowledge of body mechanics and emphasis on safety for both staff and residents during transfers. On 04/14/2025 CNA A, was terminated for failure to follow company policies and procedures while providing resident care The ADM was informed the Immediate Jeopardy was removed on 4/14/2025 at 5:15 p.m. The facility remained out of compliance at a severity level of that was not Immediate Jeopardy and a scope of pattern, due to staff needing more time to monitor the effectiveness of the plan of removal for accidents and hazards.

Based on observations, interviews, and record reviews the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of nine residents reviewed for accidents and supervision. On 2/21/2025, CNA A transferred Resident #1 without a gait belt from the shower chair to the bed. As a result, Resident #1 suffered a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Oversight and monitoring of direct care staff (nurse aides), was not addressed. CNA A transferred Resident #1 inappropriately on 2/21/25 causing a left lower extremity fracture, was not retrained and or monitored, and then CNA A transferred Resident #1 inappropriately on 04/07/25 causing a right lower extremity fracture. This failure resulted in an Immediate Jeopardy situation on 4/10/2025. While the IJ was removed on 4/14/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm due to staff needing more time to monitor the effectiveness for the plan of removal for accidents and hazards. These failures could place residents at risk of serious harm, pain, and serious injury. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 15 (indicated no cognitive impairment). Section GG of the assessment revealed Resident #1 was dependent on staff to provide all the effort when toileting, showering, and when changing positions from sitting to standing. Section I of the MDS indicated Resident #1 had diagnoses of a left tibia (shin bone) fracture, multiple sclerosis (a disease that affects the nervous system and causes muscle weakness), and lack of coordination. Record review of Resident #1's care plan with a revision date of 4/08/2025 revealed Resident #1 sustained a fracture to the lower left extremity (left leg) on 2/26/2025 and sustained an additional fracture to the right lower extremity (right leg) on 4/07/2025. Resident #1's care plan was updated on 4/08/2025 and indicated a mechanical lift should be used for transfers. No transfer information prior to 4/08/2025 was found on the care plan. 1. Record review of Resident #1's progress note dated 2/21/2025 at 10:51 a.m. by RN B revealed Resident #1 had stated she bumped her knee against the shower chair, and an order was received for an x-ray. Record review of Resident #1's incident report dated 2/21/2025 completed by RN B revealed CNA A notified RN B that Resident #1 hit her knee against the shower chair during a transfer in the shower room. Record review of Resident #1's x-ray dated 2/21/2025 revealed Resident #1 had a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Record review of Resident #1's hospital orthopedic progress note dated 2/28/2025 revealed pain had improved and was better controlled since the splint (a medical device designed to immobilize the leg) was applied to the left leg while in the hospital. 2. Record review of Resident #1's progress note dated 4/07/2025 at 1:07 p.m. by RN B revealed Resident #1 had reported that she hit her right foot against the shower chair when transferred from the shower chair to the bed and an x-ray had been ordered. Record review of Resident #1's incident report dated 4/07/2025 completed by RN B revealed Resident #1 reported right foot pain and had reported she hit her right foot against the shower chair when being transferred from the shower chair to the bed. Record review of Resident #1's x-ray dated 4/07/2025 revealed an oblique fracture (a bone break that occurs at an angle to the bone's long axis) to the right distal diaphysis of the tibia (lower area of the shin bone) that was reported to the facility on [DATE] at 11:17 p.m. Record review of Resident #1's progress note dated 4/08/2025 at 10:18 a.m. by RN B revealed an order was received from NP JJ to send Resident #1 to the hospital. Record review of Resident #1's progress note dated 4/08/2025 at 10:36 a.m. by RN B revealed Resident #1 was transported to the hospital via ambulance. Record review of Resident #1's hospital history and physical dated 4/08/2025 revealed Resident #1 was being seen for right lower extremity pain. Resident #1 reported she was being moved to transfer from her wheelchair and got her leg stuck and twisted. The hospital notes also revealed an oblique fracture through the distal tibial shaft (a bone break that occurs at an angle to the lower area of the shin bone). In an interview and observation on 4/09/2025 at 11:04 a.m., Resident #1 reported that both of her legs had been broken. Resident #1 stated that her left leg had been broken over a month ago when CNA A transferred her from the shower chair to the bed. Resident #1 reported that her right leg had been broken a few days ago when she was transferred again by CNA A from the shower chair to the bed. Resident #1 stated that both times her foot had gotten caught between the shower chair and the bed. Resident #1 reported that she was not sent to the hospital immediately after fracturing the first leg and did not remember how long it took before she was sent to the hospital. Resident #1 stated she was in pain after both fractures until she was sent to the hospital because the facility was not able to administer strong enough pain medications. Resident #1 stated they did not send her to the hospital until the next day after the second fracture. Resident #1 reported when she fractured her right leg a few days ago that she had felt it pop in the right leg when CNA A transferred her from the shower chair to the bed. Resident #1 reported her right leg got caught behind the shower chair, and CNA A transferred her from the shower chair to the bed by herself. Resident #1 reported the facility sent her to the emergency room the next day after breakfast. Resident #1 stated she was in pain before they sent her to the hospital, and they gave her pain medication. Resident #1 reported the pain medication did not work, and she was still in pain. Resident #1 stated before her legs were fractured that she only got out of bed for therapy and showers but was unable to do therapy since the injuries occurred. Resident #1 lifted her blanket and revealed both of her legs were wrapped with soft gauze and ACE wrap. The right leg appeared bigger than the left. Resident #1 reported her pain was currently well managed. In an interview on 4/09/2025 at 12:42 p.m., CNA A reported she was transferring Resident #1 from the shower chair to the bed on 2/21/2025. CNA A stated Resident #1's left leg did not pivot with the resident when transferring her, and her foot stayed stuck to the floor in the same position. CNA A reported the leg twisted when she transferred Resident #1, and Resident #1 reported that she heard her leg pop. CNA A stated Resident #1's left leg also bumped the bed during the transfer. CNA A stated she did not use a gait belt and was by herself during the transfer. CNA A reported no training was completed before or after this incident, and she had been working at the facility for around six months. CNA A reported when she transferred Resident #1 on 4/07/2025 that she had CNA C with her, but stated CNA C did not know what she was doing. CNA A reported CNA C leaned Resident #1 forward in the shower chair, and Resident #1 bumped her right leg on the shower chair. CNA A reported Resident #1 complained of pain to her right leg, but CNA A transferred Resident #1 to the bed anyway because the shower chair was hurting her. CNA A reported CNA C did not know to get on the other side of Resident #1 to help with the transfer, so CNA A did the transfer by herself. CNA A reported that Resident #1 complained of pain when she was transferred to the bed, and CNA A notified RN B. CNA A reported a gait belt was not used for the second transfer because Resident #1 did not like gait belts. In an interview on 4/09/2025 at 12:59 p.m., RN B stated that Resident #1 complained of pain to her left leg on 2/21/2025. RN B stated Resident #1 had told him that her left leg got caught in the shower chair, and Resident #1 reported she heard it pop. RN B stated x-rays were ordered, and Resident #1 did have a fracture. RN B stated the fracture to the right leg occurred when CNA A transferred Resident #1 back to bed from the shower chair. RN B stated Resident #1 told him she bumped her leg on the shower chair, and RN B was unsure if CNA A was by herself during the transfer. RN B stated x-rays were ordered which revealed a fracture to the right leg. RN B reported he had not received any training over transfers since either incident. In an interview on 4/09/2025 at 1:35 p.m., CNA C reported she did not assist CNA A when Resident #1 was transferred. CNA C stated she was in training and did not work with CNA A on 4/07/2025. CNA C reported she was not in the room when Resident #1 was transferred, and she was working a different hall. In an interview and observation on 4/09/2025 at 2:02 p.m., the DON stated Resident #1 told her she hit her foot when she was transferred on 2/21/2025 from the shower chair to the bed. The DON stated she thought Resident #1 was a two-person transfer prior to this incident. The DON confirmed by looking at her computer that Resident #1's care plan did not contain any information regarding transfers until 4/08/2025. The DON reported that the CNAs would know how to transfer residents because they were orientated to their hall and received report from each other. The DON stated she did not know if CNA A was by herself after the first incident. The DON stated they were still investigating the incident that occurred on 4/07/2025, and she was not sure of what happened yet. The DON stated that CNA A told her there was another CNA assisting with the transfer, but the DON was not sure who the other CNA was. The DON stated CNA A knew she was not supposed to transfer Resident #1 by herself. The DON confirmed Resident #1 sustained a fracture to her right leg after being transferred from the shower chair to the bed on 4/07/2025. In an interview on 4/09/2025 at 2:54 p.m., Resident #1 confirmed that CNA A was alone when she was transferred from the shower chair to the bed both times. Resident #1 reported no one had offered to use a gait belt, but that was a good idea. In an interview and observation on 4/10/2025 at 1:54 p.m., ADON D reported a mechanical lift should have been used to transfer Resident #1 prior to the first incident on 2/21/2025. ADON D stated there was a list of residents that required a mechanical lift for transfers that was located in the CNA assignment book at the nurse's station. ADON D then obtained the assignment book and revealed a list of residents that required the use of a mechanical lift. ADON D confirmed Resident #1 was the last name on the list, but the list was not dated. Record review of facility in-service regarding Turning and positioning, dated 3/15/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. Record review of facility in-service regarding Positioning resident with a fracture, dated 02/27/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. A record review of the facility's policy titled Accidents and Incidents - Investigating and Reporting, dated 2001, revealed All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator . Incident/Accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. A record review of the facility's policy titled Lifting Machine Policy and Procedure, dated 11/01/2016, revealed Review the resident's care plan to assess for any special needs of the resident . Two (2) clinical person who have been trained to use this lifting device are required to perform this procedure. A record review of the facility's policy titled Abuse, Neglect and Exploitation, revised on 7/01/2020, revealed neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 12 (indicated mildly impaired cognition). Section I of the MDS revealed Resident #2 had diagnoses of muscle weakness, severe morbid obesity (overweight), and anxiety disorder. Record review of Resident #2's care plan with a revision date of 3/31/2025 revealed Resident #2 indicated she was a fall risk and had poor safety awareness. In an observation on 4/11/2025 at 12:02 p.m., CNA FF and CNA GG were preparing to transfer Resident #2 from the bed to the wheelchair using a mechanical lift. The top of the sling was placed under the shoulders of Resident #2. The bed was not locked. The wheelchair was not locked. CNA FF positioned the lift over Resident #2. CNA FF placed two blue sling loops on two of the mechanical lift hooks. CNA GG placed two green sling loops on two of the mechanical lift hooks. CNA FF began lifting the resident in the sling using the mechanical lift. Resident #2 was lying flat in the sling as she was lifted. CNA FF positioned Resident #2 over the wheelchair using the mechanical lift while CNA GG guided Resident #2 in the sling. CNA GG attempted to position Resident #2 over the wheelchair, but Resident #2 remained in a laying position. The surveyor requested the CNAs stop the transfer and called for assistance. CNA EE entered the room and assisted CNA GG in positioning Resident #2 in more of a sitting position over the wheelchair. Resident #2 was lowered into the wheelchair without injury. In an interview on 4/11/2025 at 12:44 p.m., CNA FF reported they had trouble transferring Resident #2 using the mechanical lift because the sling was too small. CNA FF reported they had additional slings but was unsure if they had the right size for Resident #2. CNA FF was unable to continue with the interview because she had to feed a resident. In an observation and interview on 4/11/2025 at 1:42 p.m., CNA EE and CNA FF were in Resident #2's room, and CNA FF stated they were going to transfer Resident #2 with the mechanical lift from the wheelchair to the bed. CNA FF reported the sling under Resident #2 was too small, and they would look for a new sling after transferring Resident #2. The surveyor requested the CNAs not to transfer the resident. The surveyor notified the ADM, and the ADM told the CNAs not to transfer Resident #2. The ADM brought the DOR to the room. The DOR checked the sling and reported it was the appropriate size because two inches of the sling was visible on each side of Resident #2. The DOR reported he would assist CNA FF with transferring Resident #2 from the wheelchair to the bed using the mechanical lift. CNA FF positioned the mechanical lift over Resident #2. The DOR connected the sling loops to the mechanical lift in the following order: left upper hook had a green sling loop, right upper hook had a black loop, the right lower hook had a green loop, the lower left hook had 3 loops (green, purple, and black). The wheelchair was not locked, and the bed was not locked. CNA FF lifted Resident #2 in the sling using the mechanical lift. Resident #2 was lying flat in the sling as she was lifted. CNA FF positioned Resident #2 in the sling over the bed and lowered the resident to the bed. CNA FF and the DOR pulled the resident up in the bed. The bed was not locked and moved as they repositioned Resident #2. The DOR reported that the colored loops do not have to match when using the lift. The DOR reported the most important thing is that the resident is comfortable. Review of the mechanical lift sling's owner manual, with a print date of December 2023, revealed The top edge of the sling should be slightly above the resident's head . Place the straps of the sling over hooks of the swivel bar or cradle and be sure to match the corresponding strap and/or strap colors on each side of the sling for an even lift of the resident . Colored straps make it easy to connect both side of the sling equally. Always ensure there is sufficient head support when lifting a resident . WARNING: Wheelchair wheel locks MUST be in a locked position before lowering the resident into the wheelchair for transport . When the resident is lifted from the surface, they will be raised to a sitting position. In an interview on 4/11/2025 at 3:12 p.m., the ADM was notified of concerns regarding transfer observations. The ADM reported PT HH was coming to the facility to provide individual training to the DON and ADONs. The ADM reported all staff would be retrained on safe transfers and complete a competency test after completing the training. In an interview on 4/11/2025 at 4:32 p.m., PT HH reported that the ADM had tasked her with training the DON and ADONs concerning safe transfers with mechanical lifts and transfers with a gait belt. PT HH stated that the DON and ADON performed a safe transfer using her as the patient. PT HH stated that she watched the DON and the ADON train two sets of CNAs. PT HH stated that the CNA's then performed safe transfers using her as the patient for each team of CNAs. PT HH stated they performed the transfers safely and stated that until further notice CNAs were to be observed by a nurse every time that they perform a mechanical lift transfer. The ADM, the DON, ADON D, ADON E, and the MDS Nurse were provided the IJ template on 4/10/2025 at 3:13 p.m. and notified that an Immediate Jeopardy situation had been identified due to the above failures. The plan of removal was approved on 4/12/2025 at 3:19 p.m. and reflected: Problem: Failure of safety during transfer for resident # 1. Interventions: On 4/10/2025 the center will in-service nursing staff on where to find the resident's care plan to determine how to care for the resident. This care plain is found on the electronic screen system on each hall and general area. The resident transfer section on the care plan will tell the Nursing tea member how the resident is to be transferred. On 4/10/2025 the center will educate nursing team members on the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both residents and staff. On 4/10/2025 the center will complete a skills check-off tool on the nursing team members so they can demonstrate the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both resident and staff. The following in services were immediately initiated by . Chief Nursing Officer on 4/10/2025. Any nurse not present or in-serviced by 4/12/2025 by 12pm, will not be allowed to assume their duties until in-serviced. ADM . will ensure these team members are removed from the time clock and PCC access removed, this will be monitored until 100% complete or the team members are terminated. On going in-service will be completed by . the DON; ADON D and ADON E until all staff, Weekend, and PRN are completed by 4/12/2025 at 12:00pm. Systemic Change 4/11/2025: On 4/11/2025 it was found that identified CNAs were not following the education and Skills check-off they had completed before they started their shift. . (IDT Team - I) decided to bring in a Licensed Physical Therapist to educate, complete a skills check-off list, and post-test on transferring a resident. On 4/12/2025 PT educated, completed a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with .DON; ADON D and ADON E. After they completed and passed their education, PT observed DON; ADONs educate, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices with 3 CNAs. Moving forward only DON; ADONs, and PT will be able to in-service, complete a skills check-off list, and post-test on transferring a resident with body techniques and mechanical devices. Moving forward a resident can only be transferred using a Hoyer lift with a licensed nurse present. This practice will continue until the (IDT Team - I) decides the CNAs are able to complete this transfer without supervision. The following in services were immediately initiated by Chief Nursing Officer on 4/10/2025. Any nurse not present or in-serviced by 4/12/2025 by 12pm, will not be allowed to assume their duties until in-serviced. ADM and HR will ensure these team members are removed from the time clock and PCC access removed, this will be monitor until 100% complete or the team members are terminated. On going in-service will be completed by DON and ADONs until all staff, Weekend, and PRN are completed by 4/12/2025 at 12:00pm. The following in-services were initiated by Chief Nursing Officer on 4/10/2025: Nursing Department (CNAs): - In-service nursing staff on where to find the resident's care plan to determine how to care for the resident. (See in-service 600-1) - Educate nursing team members on the process of transferring residents by using their proper body mechanics or using a transfer device for the safety of both residents and staff. (See in-service 600-2) (See Check-off list 600-2) (See Post-test 600-2). The medical director was notified of the immediate jeopardy situation on 4/10/2025 by the DON. The Ombudsmen was notified of this Immediate Jeopardy situation on 4/10/2025 by the Administrator. Monitoring as of 4/11/2025: The DON and ADONs will monitor resident transfers by CNA every shift for 7 days. Administrator will monitor this process daily for the next 7 days. The DON and ADONs will test nursing staff on where to find the resident's care plan every shift for 7 days. The ADM will monitor this process daily for the next 7 days. QAPI: 1. Ad Hoc QA meeting held on 4/10/2025 to discuss causes, in-services and review interventions. 2. Any negative findings in the monitoring and/or auditing system will be reviewed and addressed by the QAPI committee for a potential systemic change. Monitoring of the plan of removal included: In an interview on 4/14/2025 at 1:48 p.m., ADON D reported CNA A had come into the facility and completed training and then was placed on suspension. ADON D stated she was not sure if CNA A would be returning to work after the investigation. ADON D reported RN B was out of the country on vacation but would receive training before returning to work on the floor. ADON D reported that she received training from PT HH. In an interview on 4/14/2025 at 4:13 p.m., the DON reported the ADONs and herself received individual training from PT HH and trained every CNA and nurse themselves. The DON reported that a nurse would be required to be in the room with two CNAs every time a mechanical lift was used, indefinitely. The DON reported that herself and the ADONs would continue to monitor transfers on every shift for the next seven days. The DON reported that herself and the ADONs would also continue to monitor the CNAs and ensure they were able to access care plans for the next seven days. Interviews were conducted with 27 employees from 4/12/2025 starting at 3:55 p.m. and continued through 4/14/2025 at 4:13 p.m. All employees interviewed were able to verify how to access the residents' care plans and identify patients that required a mechanical lift, how to properly transfer residents, and reported they had received hands on training on how to transfer a resident using a mechanical lift, a sit-to-stand lift, and a gait belt. All interviewed staff reported they had received in-services concerning safe transfers, accessing resident care plans, and completed training hands-on transfer training by the DON or ADONs. Interviewed staff members and shifts included: ADON D - worked all shifts ADON E - worked all shifts RN F - worked 2:00 p.m. to 10:00 p.m. RN G - worked all shifts RN H - worked weekend shift 6:00 a.m. to 10:00 p.m. LVN I - worked 6:00 a.m. to 2:00 p.m. LVN J - worked all shifts LVN K - worked 10:00 p.m. to 6:00 a.m. LVN L - worked weekend shift 6:00 a.m. to 10:00 p.m. LVN M- worked 2:00 p.m. to 10:00 p.m. LVN N- worked 2:00 p.m. to 10:00 p.m. LVN O- worked 6:00 a.m. to 2:00 p.m. CNA P - worked 2:00 p.m. to 10:00 p.m. CNA Q - worked 2:00 p.m. to 10:00 p.m. CNA R - worked 6:00 a.m. to 2:00 p.m. CNA S - worked 2:00 p.m. to 10:00 p.m. CNA T - worked 2:00 p.m. to 10:00 p.m. CNA U - worked 10:00 p.m. to 6:00 a.m. CNA V - worked 6:00 a.m. to 2:00 p.m. CNA W - worked 2:00 p.m. to 10:00 p.m. CNA X - worked 2:00 p.m. to 10:00 p.m. CNA Y - worked 10:00 p.m. to 6:00 a.m. CNA Z - worked all shifts CNA AA - worked 2:00 p.m. to 10:00 p.m. CNA BB - worked 10:00 p.m. to 6:00 a.m. LVN CC - worked 8:00 a.m. to 5:00 p.m. CNA DD - worked 6:00 a.m. to 2:00 p.m. Record review of facility in-service titled Where to find a resident's care plan, dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. Record review of facility in-service titled Abuse and Neglect, dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. Record review of facility in-service titled Safety with Hoyer Lift and Transfers with Gait Belt, Check-Off, Post Test dated 4/11/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A completed training and the post-test on 4/12/2025. In an observation on 4/13/2025 at 8:20 p.m., CNA T and CNA S transferred a resident from a wheelchair to the bed using a mechanical lift. RN G was present and assisted during the transfer. Proper techniques and safety precautions were observed. In an observation on 4/14/2025 at 11:43 a.m., CNA V transferred a resident from the bed to a wheelchair using a gait belt. Proper techniques and safety precautions were observed. In an observation on 4/14/2025 at 1:55 p.m., CNA DD transferred a resident from the bed to the wheelchair using a gait belt. Proper technique and safety precautions were observed. The ADM was informed the Immediate Jeopardy was removed on 4/14/2025 at 5:15 p.m. The facility remained out of compliance at a severity level of that was not Immediate Jeopardy and a scope of pattern, due to staff needing more time to monitor the effectiveness of the plan of removal for accidents and hazards. In an observation on 4/14/2025 at 1:55 p.m., CNA DD transferred a resident from the bed to the wheelchair using a gait belt. Proper technique and safety precautions were observed. Review of Punch detail report for CNA A dated 04/30/25 for dates 04/06/25 to 04/30/25 reflected the CNA A last full day of work was on 04/08/25 and the CNA A came to the facility for inservice training 04/13/25. CNA A did not return to work at the facility for the remainder of the month. On 04/30/25 at 2:43 PM the facility Administrator provided the following clarification via email: . The facility will ensure that all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transfering is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist due to their extensive knowledge of body mechanics and emphasis on safety for both staff and residents during transfers. On 04/14/2025 CNA A, was terminated for failure to follow company policies and procedures while providing resident care The ADM was informed the Immediate Jeopardy was removed on 4/14/2025 at 5:15 p.m. The facility remained out of compliance at a severity level of that was not Immediate Jeopardy and a scope of pattern, due to staff needing more time to monitor the effectiveness of the plan of removal for accidents and hazards.

Based on observation, interviews and record reviews, the facility failed to provide pain management consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of eight residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 did not experience additional pain after sustaining a fracture on 2/21/2025 to the left distal diaphysis of the tibia (lower area of the shin bone) and was not transferred to the hospital until 2/26/2025 (five days later). 2. The facility failed to ensure Resident #1's pain was accurately assessed and documented. This failure resulted in an Immediate Jeopardy situation on 04/10/2025. While the IJ was removed on 04/14/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm actual harm due to staff needing more time to monitor the effectiveness for the plan of removal for neglect. This failure could place residents at risk of pain, emotional distress, and mental anguish. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 15 (indicated no cognitive impairment). Section GG of the assessment revealed Resident #1 was dependent on staff to provide all the effort when toileting, showering, and when changing positions from sitting to standing. Section I of the MDS indicated Resident #1 had diagnoses of a left tibia (shin bone) fracture, multiple sclerosis (a disease that affects the nervous system and causes muscle weakness), and lack of coordination. Record review of Resident #1's care plan with a revision date of 4/08/2025 revealed Resident #1 sustained a fracture to the lower left extremity (left leg) on 2/26/2025 and sustained an additional fracture to the right lower extremity (right leg) on 4/07/2025. Resident #1's care plan was updated on 4/08/2025 and indicated a mechanical lift should be used for transfers. 1. Record review of Resident #1's progress note dated 2/21/2025 at 10:51 a.m. by RN B revealed Resident #1 had stated she bumped her knee against the shower chair, and an order was received for an x-ray. Record review of Resident #1's x-ray dated 2/21/2025 revealed Resident #1 had a fracture to the left distal diaphysis of the tibia (lower area of the shin bone) that was reported to the facility on [DATE] at 4:13 p.m. Record review of Resident #1's progress notes dated 2/22/2025 at 6:57 a.m. by RN II revealed NP was notified of the x-ray results, and RN II was awaiting a response. The progress note did not reveal how the NP was notified. In an interview on 4/09/2025 at 1:32 p.m., RN II stated he did not think he was the nurse that received the x-ray results for Resident #1 on 2/22/2025. RN II stated he did not remember notifying the NP J. RN II stated he always called or texted NP J with any abnormal lab or x-ray results. RN II reported if the NP did not respond to the text message, then he would have called them. Record review of Resident #1's progress notes dated 2/25/2025 at 2:09 p.m. by RN B revealed NP J was notified of the x-ray results received on 2/21/2025 (four days later) and an order for an orthopedic consult was received. Record review of Resident #1's progress notes dated 2/26/2025 at 6:46 a.m. by RN II revealed NP J was notified of the x-ray results and the morning nurse was briefed for follow up with DON, because there finding of acute fracture by the x-ray. In an interview on 4/09/2025 at 12:59 p.m., RN B stated that Resident #1 complained of pain to her left leg on 2/21/2025. RN B reported Resident #1 complained of pain, so he notified the pain doctor. RN B reported the pain doctor ordered the x-rays. RN B stated Resident #1 had told him that her left leg got caught in the shower chair, and Resident #1 reported she heard it pop. RN B stated x-rays were ordered, and Resident #1 did have a fracture. RN B reported he ordered the x-ray before he left around 2pm and gave report to the oncoming nurse. RN B stated the x-ray results came on the next shift, and the night nurse called the NP. RN B stated he was told in report that the resident had a fracture and he also followed up with the NP. RN B stated the NP told him to send her to the emergency room , and he sent her to the hospital. RN B stated he does not remember exactly when the x-ray results were received or when Resident #1 was sent to the hospital. RN B stated he knows he got an order for an orthopedic consult and an order to send to the emergency room . RN B stated he was unsure when he notified the NP or when he received new orders. In an interview on 4/10/2025 at 1:11 p.m., the DON reported the nurses should call NP JJ 24 hours a day, 7 days a week with lab results and x-ray results. The DON stated if she did not answer then they would call the answering service. The DON stated NP JJ had never given them instructions not to call her after hours. The DON stated they stopped using the answering service about six months ago, and just started calling NP JJ. The DON stated she expected the nurses to call her depending on the emergency and how many times they had called the NP. The DON stated she did not know how many times they should call the NP before calling her and that the nurses should use their own judgement. The DON stated she did not know what happened with Resident #1's x-ray results, and why the doctor was not followed up with. The DON reported she was aware the x-rays were obtained for Resident #1 on 2/21/2025. The DON stated she did not remember if she knew about the results and thought maybe she was off work at that time. In an interview and observation on 4/09/2025 at 2:02 p.m., the DON reported Resident #1 told her she hit her foot when she was transferred from the shower chair to the bed on 2/21/2025. The DON reported she did not remember what happened concerning the x-ray results and would have to check the notes. The DON reported Resident #1 complained of pain after the incident on 2/21/2025, but Resident #1 did have pain medicine. The DON reviewed Resident #1's notes on her computer and confirmed x-rays were ordered for Resident #1 on 2/21/2025, and the NP was notified on 2/22/2025 by RN II, but no response was received. The DON reported RN B received an order for an orthopedic consult on 2/25/2025, but an order to send Resident #1 to the hospital was not received until 2/26/2025. The DON stated she was confused about the incident and did not know why Resident #1 was not sent to the hospital until 2/26/2025. In an interview on 4/09/2025 at 3:56 p.m., NP J reported she was on-call Monday thru Friday from 8am to 5pm. NP J stated any calls or messages after 5pm should have been called in to their call system. NP J stated she did not remember waiting days to send Resident #1 to the hospital and did not remember when she was notified by the facility of the x-ray results from 2/21/2025. NP J stated she did remember giving an order for an orthopedic consult but did not remember waiting to send Resident #1 to the hospital. NP J stated she would have sent Resident #1 to the hospital if she had a fracture because a broken bone in the elderly could delay their healing. NP J stated she expected staff to notify her immediately of changes when she was on-call, and they could send a text if it was not critical. NP J stated if a critical result was received in the middle of the night then they should call the on-call provider. NP J stated the risk to the residents if she was not notified timely was that it could jeopardize the residents' health or life. 2. In an interview and observation on 4/09/2025 at 11:04 a.m., Resident #1 reported that both of her legs had been broken. Resident #1 stated that her left leg had been broken over a month ago when CNA A transferred her from the shower chair to the bed. Resident #1 reported that her right leg had been broken a few days ago when she was transferred again by CNA A from the shower chair to the bed. Resident #1 stated that both times her foot had gotten caught between the shower chair and the bed. Resident #1 reported that she was not sent to the hospital immediately after fracturing the first leg and did not remember how long it took before she was sent to the hospital. Resident #1 stated she was in pain after both fractures until she was sent to the hospital because the facility was not able to administer strong enough pain medications. Resident #1 stated they did not send her to the hospital until the next day after the second fracture. Resident #1 reported when she fractured her right leg a few days ago that she had felt it pop in the right leg when CNA A transferred her from the shower chair to the bed. Resident #1 reported her right leg got caught behind the shower chair, and CNA A transferred her from the shower chair to the bed by herself. Resident #1 reported the facility sent her to the emergency room the next day after breakfast. Resident #1 stated she was in pain before they sent her to the hospital, and they gave her pain medication. Resident #1 reported the pain medication did not work, and she was still in pain. Resident #1 stated before her legs were fractured that she only got out of bed for therapy and showers but was unable to do therapy since the injuries occurred. Resident #1 lifted her blanket and revealed both of her legs were wrapped with soft gauze and ACE wrap. The right leg appeared bigger than the left. Resident #1 reported her pain was currently well managed. Record review of Resident #1's February MAR indicated Resident #1 had a pain level of zero (meaning no pain) out of 10 (meaning severe pain) for every shift (day, evening, and night) except for the following: 2/15/2025 - day shift pain level was listed as a one (mild, barely noticeable pain) 2/16/2025 - day shift pain level was listed as a three (noticeable pain) 2/22/2025 - day shift pain level was listed as a five (moderate pain) All shifts for 2/21/2025, 2/23/2025, 2/24/2025, and 2/25/2025 indicated a pain level of zero (meaning no pain). The February MAR also revealed as needed pain medication was administered twice on 2/22/2025 and 2/23/2025. As needed pain medicationmedication, which was one tablet of hydrocodone 5/325 mg, was not administered on 2/21/2025, 2/24/2025, or 2/25/2025. The MAR revealed Resident #1 did have a Fentanyl pain patch that was changed every 72 hours. Record review of Resident #1's hospital orthopedic progress note dated 2/28/2025 revealed pain had improved and was better controlled since the splint (a medical device designed to immobilize the leg) was applied to the left leg while in the hospital. In an interview on 4/10/2025 at 1:11 p.m., the DON stated a fractured leg wasis painful, but no one told her Resident #1 was having pain. The DON reported that Resident #1 had pain medication that prevented her from being in excruciating pain and was seen regularly by a pain doctor. The DON stated she expected pain levels to be documented and treated according to the physician's orders. The DON reported the floor nurses monitored the residents' pain levels and were responsible for documenting them. Record review of facility in-service regarding Turning and positioning, dated 3/15/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. Record review of facility in-service regarding Positioning resident with a fracture, dated 02/27/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. CNA A signature not found. A record review of the facility's policy titled Abuse, Neglect and Exploitation, revised on 7/01/2020, revealed neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. A record review of the facility's policy titled Pain - Clinical Protocol, revised on 10/2022, revealed The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain . The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated. A record review of the facility's policy titled Pain Assessment and Management, revised on 7/01/2020, revealed Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals . Assess the resident whenever there is a suspicion of new pain or worsening of existing pain . Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: . (4) fractures. The ADM, the DON, ADON D, ADON E, and the MDS Nurse were provided the IJ template on 4/10/2025 at 3:13 p.m. and notified that an Immediate Jeopardy situation had been identified due to the above failures. The plan of removal was approved on 4/12/2025 at 3:19 p.m. and reflected: Interventions: All residents were immediately assessed on 4/10/2025 for any change in condition from their baseline including pain assessment. Any resident who verbalized or showed nonverbal signs of pain, was addressed at that time following that resident's physician orders for pain management. On 4/12/2025 either DON; ADON D; ADON E; and LVN CC; will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions, these rounds will be documented on the resident 24-hour report for the next 7 days. The ADM will monitor this process daily for the next 7 days. The following in services were immediately initiated by the Chief Nursing Officer on 4/10/2025. Any nurse not present or in-serviced by 4/12/2025 by 12pm, will not be allowed to assume their duties until in-serviced. The ADM and HR will ensure these team members are removed from the time clock and PCC access removed, this will be monitor until 100% complete or the team members are terminated. On going in-service will be completed by DON; ADON D; ADON E until all staff, Weekend, and PRN are completed by 4/12/2025 at 12:00pm. Post Test will be completed to evaluate team members understanding of in-services covered. The passing score will be 80% - 100%. (See Post-test POR-1) The following in-services were initiated by CNO: Licensed Nurses: How to assess residents for signs and symptoms of pain using a pain scale appropriate for them. (See In-service 600-I1) How to reassess pain after medication administration for effectiveness and process for if not effective. (See In-service 600-I2) Each resident will have a pain management treatment plan as part of their plan of care. (See In-service 600-I3) The medical director was notified of the immediate jeopardy situation on 4/10/2025 by the DON. The Ombudsmen was notified of this Immediate Jeopardy situation on 4/10/2025 by the ADM. Monitoring as of 4/10/2025: All residents were immediately assessed on 4/10/2025 for any change in condition from their baseline including pain assessment. Any resident who verbalized or showed nonverbal signs of pain, was addressed at that time following that resident's physician orders for pain management. On 4/12/2025 either DON; ADON D; ADON E; and LVN CC; will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions, these rounds will be documented on the resident 24-hour report for the next 7 days. The ADM will monitor this process daily for the next 7 days. The following in services were immediately initiated by the Chief Nursing Officer on 4/10/2025. Any nurse not present or in-serviced by 4/12/2025 by 12pm, will not be allowed to assume their duties until in-serviced. The ADM and HR will ensure these team members are removed from the time clock and PCC access removed, this will be monitor until 100% complete or the team members are terminated. On going in-service will be completed by DON; ADON D; ADON E until all staff, Weekend, and PRN are completed by 4/12/2025 at 12:00pm. Monitoring of the plan of removal included: Interviews were conducted with 27 employees from 4/12/2025 starting at 3:55 p.m. and continued through 4/14/2025 at 4:13 p.m. All employees interviewed were able to verify how to assess residents' pain levels, who to notify, where to document pain levels, and how to identify indicators of pain. All interviewed staff reported they had received in-services concerning signs of pain, using pain scales, and all nurses were in-serviced on reassessing pain after pain medication administration. Interviewed staff members and shifts included: ADON D - worked all shifts ADON E - worked all shifts RN F - worked 2:00 p.m. to 10:00 p.m. RN G - worked all shifts RN H - worked weekend shift 6:00 a.m. to 10:00 p.m. LVN I - worked 6:00 a.m. to 2:00 p.m. LVN J - worked all shifts LVN K - worked 10:00 p.m. to 6:00 a.m. LVN L - worked weekend shift 6:00 a.m. to 10:00 p.m. LVN M- worked 2:00 p.m. to 10:00 p.m. LVN N- worked 2:00 p.m. to 10:00 p.m. LVN O- worked 6:00 a.m. to 2:00 p.m. CNA P - worked 2:00 p.m. to 10:00 p.m. CNA Q - worked 2:00 p.m. to 10:00 p.m. CNA R - worked 6:00 a.m. to 2:00 p.m. CNA S - worked 2:00 p.m. to 10:00 p.m. CNA T - worked 2:00 p.m. to 10:00 p.m. CNA U - worked 10:00 p.m. to 6:00 a.m. CNA V - worked 6:00 a.m. to 2:00 p.m. CNA W - worked 2:00 p.m. to 10:00 p.m. CNA X - worked 2:00 p.m. to 10:00 p.m. CNA Y - worked 10:00 p.m. to 6:00 a.m. CNA Z - worked all shifts CNA AA - worked 2:00 p.m. to 10:00 p.m. CNA BB - worked 10:00 p.m. to 6:00 a.m. LVN CC - worked 8:00 a.m. to 5:00 p.m. CNA DD - worked 6:00 a.m. to 2:00 p.m. Record review of facility in-service titled Following Physician Orders to Address Pain dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses. Record review of facility in-service titled Assessing the effectiveness of pain medication given dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. Record review of facility in-service titled Comprehensive Pain Management Treatment Plan dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses and CNAs. Review of Punch detail report for CNA A dated 04/30/25 for dates 04/06/25 to 04/30/25 reflected the CNA A last full day of work was on 04/08/25 and the CNA A came to the facility for inservice training 04/13/25. CNA A did not return to work at the facility for the remainder of the month. On 04/30/25 at 2:43 PM the facility Administrator provided the following clarification via email: . The facility will ensure that all mechanical transfer train-the-trainer sessions, center random skill checks, and instances where transfering is found to be done incorrectly, will be supervised, monitored, and approved by a licensed physical therapist due to their extensive knowledge of body mechanics and emphasis on safety for both staff and residents during transfers. On 04/14/2025 CNA A, was terminated for failure to follow company policies and procedures while providing resident care The ADM was informed the Immediate Jeopardy was removed on 4/14/2025 at 5:15 p.m. The facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated, due to staff needing more time to monitor the effectiveness of the plan of removal for accidents and hazards.

Based on interview and record review, the facility failed to promptly notify the ordering physician of results which fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #1) of eight residents reviewed for notification of changes. 1. The facility failed to notify and consult with Resident #1's physician on 2/21/2025 when x-ray results were received revealing Resident #1 had a fracture to the left distal diaphysis of the tibia (lower area of the shin bone). Resident #1 was not sent to the hospital until five days later, on 2/26/2025. 2. The facility failed to notify and consult with Resident #1's physician on 4/07/2025 when x-ray results were received revealing Resident #1 had an oblique fracture (a bone break that occurs at an angle to the bone's long axis) to the right distal diaphysis of the tibia (lower area of the shin bone). Resident #1 was not sent to the hospital until the next day on 4/08/2025. This failure resulted in an Immediate Jeopardy situation on 4/10/2025. While the IJ was removed on 4/14/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm due to staff needing more time to monitor the effectiveness for the plan of removal for notification of changes. This failure could place residents at risks of a delay in medical treatment, which could lead to worsening of their condition, hospitalization , or death. Findings included: Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 15 (indicated no cognitive impairment). Section GG of the assessment revealed Resident #1 was dependent on staff to provide all the effort when toileting, showering, and when changing positions from sitting to standing. Section I of the MDS indicated Resident #1 had diagnoses of a left tibia (shin bone) fracture, multiple sclerosis (a disease that affects the nervous system and causes muscle weakness), and lack of coordination. Record review of Resident #1's care plan with a revision date of 4/08/2025 revealed Resident #1 sustained a fracture to the lower left extremity (left leg) on 2/26/2025 and sustained an additional fracture to the right lower extremity (right leg) on 4/07/2025. Resident #1's care plan was updated on 4/08/2025 and indicated a mechanical lift should be used for transfers. 1. Record review of Resident #1's progress note dated 2/21/2025 at 10:51 a.m. by RN B revealed Resident #1 had stated she bumped her knee against the shower chair, and an order was received for an x-ray. Record review of Resident #1's x-ray dated 2/21/2025 revealed Resident #1 had a fracture to the left distal diaphysis of the tibia (lower area of the shin bone) that was reported to the facility on [DATE] at 4:13 p.m. Record review of Resident #1's progress notes dated 2/22/2025 at 6:57 a.m. by RN II revealed the NP was notified of the x-ray results, and RN II was awaiting a response. The progress note did not indicate how the NP was notified. In an interview on 4/09/2025 at 1:32 p.m., RN II stated he did not think he was the nurse that received the x-ray results for Resident #1 on 2/22/2025. RN II stated he did not remember notifying NP JJ. RN II stated he always called or texted NP JJ with any abnormal lab or x-ray results. RN II reported if the NP did not respond to the text message, then he would have called them. Record review of Resident #1's progress notes dated 2/25/2025 at 2:09 p.m. by RN B revealed NP JJ was notified of the x-ray results received on 2/21/2025 and an order for an orthopedic consult was received. Record review of Resident #1's progress notes dated 2/26/2025 at 6:46 a.m. by RN II revealed NP JJ was notified of the x-ray results and the morning nurse (6a-2pm) was briefed for follow up with DON, because there finding of acute fracture by the x-ray. In an interview on 4/09/2025 at 12:59 p.m., RN B stated that Resident #1 complained of pain to her left leg on 2/21/2025. RN B reported Resident #1 complained of pain, so he notified the pain doctor. RN B reported the pain doctor ordered the x-rays. RN B stated Resident #1 had told him that her left leg got caught in the shower chair, and Resident #1 reported she heard it pop. RN B stated x-rays were ordered, and Resident #1 did have a fracture. RN B reported he ordered the x-ray before he left around 2pm and gave report to the oncoming nurse. RN B stated the x-ray results came on the next shift, and the night nurse called the NP. RN B stated he was told in report that the resident had a fracture and he also followed up with the NP. RN B stated the NP told him to send her to the emergency room , and he sent her to the hospital. RN B stated he does not remember exactly when the x-ray results were received or when Resident #1 was sent to the hospital. RN B stated he knows he got an order for an orthopedic consult and an order to send to the emergency room . RN B stated he was unsure when he notified the NP or when he received new orders. In an interview and observation on 4/09/2025 at 2:02 p.m., the DON reported Resident #1 told her she hit her foot when she was transferred from the shower chair to the bed on 2/21/2025. The DON reported she did not remember what happened concerning the x-ray results and would have to check the notes. The DON reported Resident #1 complained of pain after the incident on 2/21/2025, but Resident #1 did have pain medicine. The DON reviewed Resident #1's notes on her computer and confirmed x-rays were ordered for Resident #1 on 2/21/2025, and the NP was notified on 2/22/2025 by RN II, but no response was received. The DON reported RN B received an order for an orthopedic consult on 2/25/2025, but an order to send Resident #1 to the hospital was not received until 2/26/2025. The DON stated she was confused about the incident and did not know why Resident #1 was not sent to the hospital until 2/26/2025. In an interview on 4/10/2025 at 1:11 p.m., the DON reported the nurses should call NP JJ 24 hours a day, 7 days a week with lab results and x-ray results. The DON stated if she did not answer then they would call the answering service. The DON stated NP JJ had never given them instructions not to call her after hours. The DON stated they stopped using the answering service about six months ago, and just started calling NP JJ. The DON stated she expected the nurses to call her depending on the emergency and how many times they had called the NP. The DON stated she did not know how many times they should call the NP before calling her and that the nurses should use their own judgement. The DON stated she did not know what happened with Resident #1's x-ray results, and why the doctor was not followed up with. The DON stated a fractured leg was painful, and she was aware of the x-rays were obtained for Resident #1 on 2/21/2025. The DON stated she did not remember if she knew about the results and thought maybe she was off work at that time. 2. Record review of Resident #1's progress note dated 4/07/2025 at 1:07 p.m. by RN B revealed Resident #1 had reported that she hit her right foot against the shower chair when transferred from the shower chair to the bed and an x-ray had been ordered. Record review of Resident #1's incident report dated 4/07/2025 completed by RN B revealed Resident #1 reported right foot pain and had reported she hit her right foot against the shower chair when being transferred from the shower chair to the bed. Record review of Resident #1's x-ray dated 4/07/2025 revealed an oblique fracture (a bone break that occurs at an angle to the bone's long axis) to the right distal diaphysis of the tibia (lower area of the shin bone) that was reported to the facility on [DATE] at 11:17 p.m. Record review of Resident #1's progress notes dated 4/08/2025 at 12:47 a.m. by LVN J revealed the x-ray results from 4/07/2025 had been sent to NP JJ, and LVN J was still awaiting response. In an interview on 4/09/2025 at 11:19 a.m., LVN J reported she received the x-ray results for the x-ray performed on 4/07/2025 and sent a text message to NP JJ. LVN J stated she did not receive a response from NP JJ, so she told the oncoming nurse in report to follow up. LVN J reported staff always notified NP JJ of changes and that it did not matter what day or time it was. LVN JJ reported she did not attempt to call NP JJ when she did not receive a response. Record review of Resident #1's progress note dated 4/08/2025 at 10:18 a.m. by RN B revealed an order was received from NP JJ to send Resident #1 to the hospital. Record review of Resident #1's progress note dated 4/08/2025 at 10:36 a.m. by RN B revealed Resident #1 was transported to the hospital via ambulance. In an interview on 4/09/2025 at 12:59 p.m., RN B stated that on 4/07/2025 Resident #1 reported to him that her right leg hurt. RN B reported that x-rays were ordered, and the results were received later that night. RN B reported the night nurse told him that she texted NP JJ and did not get a response. RN B stated he called NP JJ after receiving report, and NP JJ said she was on her way. RN B stated NP JJ came to the facility, checked Resident #1, and gave the order to send Resident #1 to the hospital. RN B stated he sent Resident #1 to the hospital as ordered on 4/08/2025. RN B reported Resident #1 did have pain and was given pain medicine until she was sent to the hospital. In an interview and observation on 4/09/2025 at 11:04 a.m., Resident #1 reported that both of her legs had been broken. Resident #1 stated that her left leg had been broken over a month ago when CNA A transferred her from the shower chair to the bed. Resident #1 reported that her right leg had been broken a few days ago when she was transferred again by CNA A from the shower chair to the bed. Resident #1 stated that both times her foot had gotten caught between the shower chair and the bed. Resident #1 reported that she was not sent to the hospital immediately after fracturing the first leg and did not remember how long it took before she was sent to the hospital. Resident #1 stated she was in pain after both fractures until she was sent to the hospital because the facility was not able to administer strong enough pain medications. Resident #1 stated they did not send her to the hospital until the next day after the second fracture. Resident #1 reported when she fractured her right leg a few days ago that she had felt it pop in the right leg when CNA A transferred her from the shower chair to the bed. Resident #1 reported her right leg got caught behind the shower chair, and CNA A transferred her from the shower chair to the bed by herself. Resident #1 reported the facility sent her to the emergency room the next day after breakfast. Resident #1 stated she was in pain before they sent her to the hospital, and they gave her pain medication. Resident #1 reported the pain medication did not work, and she was still in pain. Resident #1 stated before her legs were fractured that she only got out of bed for therapy and showers but was unable to do therapy since the injuries occurred. Resident #1 lifted her blanket and revealed both of her legs were wrapped with soft gauze and ACE wrap. The right leg appeared bigger than the left. Resident #1 reported her pain was currently well managed. In an interview and observation on 4/09/2025 at 2:02 p.m., the DON confirmed by looking at her computer that LVN J had notified NP JJ of the x-ray results just after midnight on 4/08/2025 but had not received a response. The DON reported the nurses should call the NPs if a response was not received. The DON reported they were still investigating the incident that occurred on 4/07/2025 and did not know why staff did not call NP JJ or the MD. In an interview on 4/09/2025 at 3:56 p.m., NP JJ reported she was on-call Monday thru Friday from 8am to 5pm. NP JJ stated any calls or messages after 5pm should have been called in to their call system. NP JJ stated she did not remember waiting days to send Resident #1 to the hospital and did not remember when she was notified by the facility of the x-ray results from 2/21/2025. NP JJ stated she did remember giving an order for an orthopedic consult but did not remember waiting to send Resident #1 to the hospital. NP JJ stated she would have sent Resident #1 to the hospital if she had a fracture because a broken bone in the elderly could delay their healing. NP JJ stated she expected staff to notify her immediately of changes when she was on-call, and they could send a text if it was not critical. NP JJ stated if a critical result was received in the middle of the night, then they should call the on-call provider. NP JJ stated the risk to the residents if she was not notified timely was that it could jeopardize the residents' health or life. In an interview on 4/10/2025 at 9:25 a.m., the DON reported staff notified NP JJ of changes or diagnostic results via text 24 hours a day, every day. The DON reported staff always notified NP JJ via text and did not have an on-call system. A record review of the facility's policy titled Lab and Diagnostic Test Results - Clinical Protocol, dated 2001, revealed 1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. 2. The staff will process test requisitions and arrange for tests. 3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility . a. if staff who first receive or review lab and diagnostic test results cannot follow the remainder of this procedure for reporting and documenting the results and their implications, another nurse in the facility (supervisor, charge nurse, etc.) should follow or coordinate the procedure . A nurse will identify the urgency of communicating with the Attending Physician based on physician request, the seriousness of any abnormality, and the individual's current condition . Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results: . whether the resident/patient's clinical status is unclear or he/she has signs and symptoms of acute illness or condition change and is not stable or improving, or there are no previous results for comparison . Direct voice communication with the physician is the preferred means for presenting any results requiring immediate notification . If the attending or covering physician does not respond to immediate notification within an hour, the nursing staff should contact the Medical Director for assistance. A record review of the facility's policy titled Change in a Resident's Condition or Status, revised 02/2021, revealed Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status . The nurse will notify the resident's attending physician or physician on call when there has been a (an): . significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; . g. need to transfer the resident to a hospital/treatment center . a significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff. The ADM, the DON, ADON D, ADON E, and the MDS Nurse were provided the IJ template on 4/10/2025 at 3:13 p.m. and notified that an Immediate Jeopardy situation had been identified due to the above failures. The plan of removal was approved on 4/12/2025 at 3:19 p.m. and reflected: Interventions: On 4/10/2025 at 7:00pm the DON; ADON D; ADON E immediately completed a change of condition assessment focusing on pain on each resident to determine if they are not at their baseline. Each resident was documented on the outcome of their assessment in their progress note in Point Click Care. For any residents that were found not to be at their baseline their physician was be notified and documented on. Any conditions noted after this immediate assessment, and it was found that the physician was not notified a re-education of physician notification will be completed. On 4/12/2025 either DON; ADON D; ADON E; and LVN CC; will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions, these rounds will be documented on the resident 24-hour report for the next 7 days. The ADM will monitor this process daily for the next 7 days. On 4/10/2025 at 7:00pm the following in-services were initiated by the Chief Nursing Officer: Any nurse not present or in-serviced by 4/12/2025 by 12pm, will not be allowed to assume their duties until in-serviced. The ADM and human resources will ensure these team members are removed from the time clock and PCC access removed, this will be monitor until 100% complete or the team members are terminated. On going in-service will be completed by the DON; ADON D; ADON E until all staff, Weekend, and PRN are completed by 4/12/2025 at 12:00pm. Post Test will be completed to evaluate team members understanding of in-services covered. The passing score will be 80% - 100%. (See Post-test POR-1) The following in-services were immediately initiated by Chief Nursing Officer: Licensed Nurses: - Notifying physicians during a change of condition in a resident. (See Inservice 580-I1). - Physician on-call schedule (See Inservice 580-I2). - Process on what to do if a physician cannot be reached. (See Inservice 580-I3). - Comprehensive Pain Management Treatment Plan for each resident. (See Inservice 580-I4). The medical director was notified of the immediate jeopardy situation on 4/10/2025 by the DON. The Ombudsmen was notified of this Immediate Jeopardy situation on 4/10/2025 by the ADM. Monitoring as of 4/10/2025: On 4/11/2025 the Corporate Nurse immediately audited the 24-hour facility resident summary to determine if there were any changes of conditions focusing on pain that were noted, and the physician was notified. These findings were sent to the DON; ADON D; ADON E for follow-up. On 4/12/2025 the chief nursing officer reviewed the administrative nurse's follow-up to ensure follow-up happened and will do this daily for 7 days. DON; ADON D; ADON E will monitor daily resident's current electronic records for a change of condition utilizing the Point Click Care Clinical Dashboard which includes resident's Change of Condition, 24 Hour Resident Report, Progress notes, Incidents & Accidents, Weights & Vitals, and Diagnostic reports on all residents daily. To ensure accuracy DON; ADON D; ADON E will round the center and observe each resident every 12 hours looking for indications of pain or change of conditions, these rounds will be documented on the resident 24-hour report for the next 7 days. The ADM will monitor this process daily for the next 7 days. Monitoring of the plan of removal included: Interviews were conducted with 13 nurses from 4/12/2025 starting at 3:55 p.m. and continued through 4/14/2025 at 4:13 p.m. All nurses interviewed were able to verify how to access the on-call physician number, how to notify the physician or NP, how to identify a change in condition, and verified they would contact the MD if unable to get a response from the attending or on-call physician. All interviewed nurses reported they had received in-services concerning changes in condition, documentation, and physician on-call schedules or contact information. Interviewed staff members and shifts included: ADON D - worked all shifts ADON E - worked all shifts RN F - worked 2:00 p.m. to 10:00 p.m. RN G - worked all shifts RN H - worked weekend shift 6:00 a.m. to 10:00 p.m. LVN I - worked 6:00 a.m. to 2:00 p.m. LVN J - worked all shifts LVN K - worked 10:00 p.m. to 6:00 a.m. LVN L - worked weekend shift 6:00 a.m. to 10:00 p.m. LVN M- worked 2:00 p.m. to 10:00 p.m. LVN N- worked 2:00 p.m. to 10:00 p.m. LVN O- worked 6:00 a.m. to 2:00 p.m. LVN CC - worked 8:00 a.m. to 5:00 p.m. Record review of facility in-service titled Notifying Physicians During a Change of Condition, dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses. Record review of facility in-service titled Physician On Call Schedule dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses. Record review of facility in-service titled What to do if a Physician cannot be reached dated 4/10/2025 revealed all nursing staff had signed indicating education was completed by all nurses. The ADM was informed the Immediate Jeopardy was removed on 4/14/2025 at 5:15 p.m. The facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of pattern, due to staff needing more time to monitor the effectiveness of the plan of removal for notification of changes.

Based on observation and interview the facility failed to ensure all patient care equipment was in safe operating condition for three (Resident #1, Resident #2, and Resident #3) of eight residents reviewed for safe operating patient care equipment. 1. The facility failed to ensure Resident #3 had brakes on the foot of his bed. 2. The facility failed to ensure one brake on Resident #1's bed was able to lock. 3. The facility failed to ensure Resident #2's bed had a working remote control. These failures could place residents at risk of living in an unsafe and un-homelike environment. Findings included: 1. Record review of Resident #3's Annual MDS revealed Resident #3 was a [AGE] year-old male admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 12 (indicated mildly impaired cognition). Section I of the MDS revealed Resident #3 had diagnoses of muscle weakness, morbid obesity (overweight), and anxiety disorder. Record review of Resident #3's care plan with a revision date of 4/09/2025 revealed Resident #3 had limited mobility and required extensive assistance with bed mobility. 2. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 15 (indicated no cognitive impairment). Section GG of the assessment revealed Resident #1 was dependent on staff to provide all the effort when toileting, showering, and when changing positions from sitting to standing. Section I of the MDS indicated Resident #1 had diagnoses of a left tibia (shin bone) fracture, multiple sclerosis (a disease that affects the nervous system and causes muscle weakness), and lack of coordination. Record review of Resident #1's care plan with a revision date of 4/08/2025 revealed Resident #1 sustained a fracture to the lower left extremity (left leg) on 2/26/2025 and sustained an additional fracture to the right lower extremity (right leg) on 4/07/2025. Resident #1's care plan was updated on 4/08/2025 and indicated a mechanical lift should be used for transfers. 3. Record review of Resident #2's Annual MDS assessment dated [DATE] revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Section C of the MDS assessment revealed a BIMs score of 12 (indicated mildly impaired cognition). Section I of the MDS revealed Resident #2 had diagnoses of muscle weakness, severe morbid obesity (overweight), and anxiety disorder. Record review of Resident #2's care plan with a revision date of 3/31/2025 revealed Resident #2 indicated she was a fall risk and had poor safety awareness. In an interview and observation on 4/09/2025 at 10:44 a.m., Resident #3 reported his bed did not work when he first admitted there a few weeks ago. Resident #3 stated the wheels on his bed did not lock. Resident #3 denied a history of falls and reported staff were aware that the brakes on his bed did not lock. Resident #3 stated he did not remember which staff knew that his brakes on his bed did not work. Observed bed easily moved and wheels rolled when minimal force was applied. In an interview and observation on 4/09/2025 at 11:04 a.m., Resident #1 reported her bed did not lock. Resident #1 stated she was unsure if staff knew her bed did not lock and denied any falls. Observed bed easily moved and wheels rolled when minimal force was applied. In an interview and observation on 4/10/2025 at 9:46 a.m., Resident #2 stated her remote control to her bed did not work. Observed Resident #2 press buttons on the bed remote, and the bed did not move except when Resident #2 pressed the button that indicated the bed would be lowered. When Resident #2 pressed that button, the head of the bed raised. Resident #2 stated staff were aware her bed did not work but was unsure who the staff were. In an interview and observation on 4/11/2025 at 10:30 a.m., the Maintenance Supervisor reported he was not aware of any issues with any beds, and if he had been then he would have fixed them. Observed the Maintenance Supervisor check Resident #3's bed, and the Maintenance Supervisor reported Resident #3's bed did not have locks on the wheels on the foot of the bed. The Maintenance Supervisor reported Resident #3's bed was not made to have brakes on the foot of the bed. Observed the Maintenance Supervisor move the foot of the bed with one hand. The Maintenance Supervisor reported he would change out the bed. The Maintenance Supervisor then went to Resident #1's room and checked the bed. The Maintenance Supervisor reported one brake on the foot of the bed would not lock and the other brake on the foot of the bed was not locked when he checked it. The Maintenance Supervisor reported he would change out the bed now since Resident #1 was at the hospital. The Maintenance Supervisor then went to Resident #2's room and checked the remote control for the bed. The Maintenance Supervisor pressed several buttons and checked the wires underneath the bed. The Maintenance Supervisor stated he was unable to fix the remote and would change out Resident #2's remote control to their bed. The Maintenance Supervisor stated he was responsible for monitoring the residents' bed and ensuring they worked properly. The Maintenance Supervisor stated the risk to the residents would be that the beds could move if the brakes did not work and that the residents would not be able to control their bed if the remotes did not work. The Maintenance Supervisor stated he expected staff to tell him when there were problems with equipment so he could fix them.

Based on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents, (Resident #1) reviewed for care plans. 1. The facility failed to follow the care plan dated 07/05/24 when staff failed to ensure a pillow was always under Resident #1's feet who had a DTI to the heel, while she was in the bed on 02/19/25. This failure could place residents at risk of not receiving the necessary care and services. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an initial admitted [DATE], and a re-admitted [DATE]. Resident #1 had a diagnosis of non-traumatic acute subdural hemorrhage (blood leaks between the brain and the skull), Type 2 Diabetes (body does not use insulin properly or produce enough insulin), Hypothyroidism (thyroid gland does not produce enough thyroid hormone), Muscle weakness, Chronic Kidney Disease, Wedge Compression Fracture (spinal fracture), Dementia (loss of memory and other mental capabilities), and Arthritis (joint inflammation and damage). Record review of Resident #1's Quarterly MDS Assessment, dated 12/26/24, reflected Resident #1 had a BIMS score of 3, which meant Resident #1 had a very low level of cognition. The MDS also noted Resident #1 did not display any behavioral symptoms like threatening others, screaming, cursing at others, hitting, scratching, pacing, or rummaging. The MDS noted Resident #1 did not display and rejection of care. Pressure ulcers were listed under skin conditions on the MDS quarterly assessment. Record review of an active physician's order, dated 08/05/25 reflected the following: Order Summary: Off load both heels with pillow while patient in bed at all time Every shift for promoting wound healing Record review of Resident #1's Care Plan, with an initial date of 03/17/24, and a revision date of 07/05/24, reflected the following: Resident #1 required ADL assistance such as Bed Mobility. It noted an extensive assist from staff to turn and reposition in bed when necessary. Resident #1 required total dependency for transfers, dressing, eating, hygiene, and toileting. Resident #1 had potential for pressure ulcers due to immobility. Resident #1 had a DTI to the heel. Revision noted on 08/07/24, Resident #1, Off load both heels with a pillow at all times while patient is in bed to promote wound healing. Resident #1 was resistive to care (refuses baths and medications) Record review of the progress notes on Resident #1's electronic record did not reflect any notations of Resident #1's refusal of the pillow used for her feet or any notes on Resident #1 moving the pillow from under her feet. In an interview and observation on 02/19/25 at 2:05 PM, Resident #1 was observed, as she laid in her bed and watched television. Resident #1's heels were not propped up on a pillow or anything else. There was no pillow observed at the end of Resident #1's bed. Resident #1 stated she was fine. She stated she did not have any concerns or issues at the facility. In an interview on 02/19/25 at 2:25 the Nurse Practitioner stated she saw Resident #1 a few times, and she had no concerns for the facility's care of Resident #1. The Nurse Practitioner stated there was a wound care doctor that handled Resident #1's wound care. The Nurse Practitioner stated she had not seen any concerns with Resident #1's wounds when she completed her general care. In an observation on 02/19/25 at 4:35 PM, Resident #1 was observed as she laid in her bed. There was no pillow observed at the foot of her bed. Resident #1's feet were not offloaded. A telephone interview was attempted on 02/19/25 at 4:55 PM to Resident #1's Wound Care Doctor, but there was no answer. In an observation on 02/19/25 at 5:54 PM, Resident #1's feet hung off the side of the bed. There was no pillow at the foot of the bed. In an interview on 02/19/25 at 5:59 PM, the DON stated Resident #1 made small movements, like adjusting her cover, but did not get out of bed on her own. The DON stated Resident #1 was not able to swing her feet around to get out of the bed. The DON stated Resident #1 usually had a pillow at the foot of the bed to offload her feet. In an observation and interview on 02/19/25 at 6:03 PM, the DON observed Resident #1 as she laid in bed with no pillow at the foot of the bed, and Resident #1's feet were not offloaded. The DON pointed to a pillow that sat on Resident #1's wheelchair and stated that was the pillow that was used to offload Resident #1's feet. The DON stated she was not sure why the pillow was not on the bed. In a follow up interview on 02/19/25 at 6:19 PM, the DON stated a staff member just changed Resident #1's sheet and put the pillow back at the foot of the bed to offload Resident #1's heels. The DON stated that was the first time she noticed Resident #1 without the pillow at the foot of the bed and feet offloaded. The DON stated she would update the care plan and note interventions to ensure Resident #1's heels were always offloaded. The DON stated she would also have the ADONs check to ensure Resident #1's feet were offloaded. The DON stated the risk of Resident #1 heels not offloaded was pressure that would lead to skin breakdown and a lower level of care. In an interview on 02/19/25 at 7:01 PM, the MDS Coordinator stated she ensured the care plans were completed and reflected all concerns. She stated she was unaware of Resident #1's feet not being offloaded. The MDS Coordinator stated she was taught that a general note of a refusal of care on the care plan would cover all concerns. The MDS Coordinator confirmed there was not a specific mention of any concerns with not offloading or Resident #1 interfering with offloading of her heels. The MDS Coordinator stated she was not aware of a risk, since a general note of refusal was on the care plan. In an interview on 02/19/25 at 7:16 PM, the Administrator stated before today, he was not aware of the issue with Resident #1's heels not offloaded. The Administrator stated he was not a medical practitioner, so he would have to ask Resident #1's doctor if there were risks associated with her heels not offloaded. The Administrator stated Resident #1's overall care plan should have addressed all care concerns. He stated interventions should have been listed on Resident #1' care plan if there were concerns of her interfering with the offload of her heels. Record review of the facility's policy titled, Care Plans Comprehensive Person-Centered, dated 2001, revised 03/2022, reflected the following: Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation I. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. 3. The care plan interventions are derived from a thorough analysis of the information gathered as pai1 of the comprehensive assessment. 4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: a. participate in the planning process; b. identify individuals or roles to be included; c. request meetings; d. request revisions to the plan of care; e. participate in establishing the expected goals and outcomes of care; f. participate in determining the type, amount, frequency and duration of care; g. receive the services and/or items included in the plan of care; and h. see the care plan and sign it after significant changes are made. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (I) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (3) d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. l0. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on observation, record review and interview, the facility failed ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers from developing 1 (Resident #1) of 6 residents reviewed for pressure ulcers. The facility failed on 02/19/25 to use a pillow under Resident #1's heels, at all times, to offload Resident #1's heels to prevent pressure ulcers or skin breakdown. This failure could affect residents at risk for pressure ulcers of developing new or worsening existing pressure ulcers. Findings included: Record review of Resident #1's face sheet reflected a [AGE] year-old female, with an initial admitted [DATE], and a re-admitted [DATE]. Resident #1 had a diagnosis of non-traumatic acute subdural hemorrhage (blood leaks between the brain and the skull), Type 2 Diabetes (body does not use insulin properly or produce enough insulin), Hypothyroidism (thyroid gland does not produce enough thyroid hormone), Muscle weakness, Chronic Kidney Disease, Wedge Compression Fracture (spinal fracture), Dementia (loss of memory and other mental capabilities), and Arthritis (joint inflammation and damage). Record review of Resident #1's Quarterly MDS Assessment, dated 12/26/24, reflected Resident #1 had a BIMS score of 3, which meant Resident #1 had a very low level of cognition. The MDS also noted Resident #1 did not display any behavioral symptoms like threatening others, screaming, cursing at others, hitting, scratching, pacing, or rummaging. The MDS noted Resident #1 did not display and rejection of care. Pressure ulcers were listed under skin conditions on the MDS quarterly assessment. Record review of an active physician's order, dated 08/05/25 reflected the following: Order Summary: Off load both heels with pillow while patient in bed at all time Every shift for promoting wound healing In an interview and observation on 02/19/25 at 2:05 PM, Resident #1 was observed, as she laid in her bed and watched television. Resident #1's heels were not propped up on a pillow or anything else. There was no pillow observed at the end of Resident #1's bed. Resident #1 stated she was fine. She stated she did not have any concerns or issues at the facility. In an observation on 02/19/25 at 4:35 PM, Resident #1 was observed as she laid in her bed. There was no pillow observed at the foot of her bed. Resident #1's feet were not offloaded. A telephone interview was attempted on 02/19/25 at 4:55 PM to Resident #1's Wound Care Doctor, but there was no answer. In an observation on 02/19/25 at 5:54 PM, Resident #1's feet hung off the side of the bed. There was no pillow at the foot of the bed. In an interview on 02/19/25 at 5:59 PM, the DON stated Resident #1 made small movements, like adjusting her cover, but did not get out of bed on her own. The DON stated Resident #1 was not able to swing her feet around to get out of the bed. She stated she and the staff were aware that Resident #1's feet needed to be offloaded. The DON stated Resident #1 usually had a pillow at the foot of the bed to offload her feet. In an observation and interview on 02/19/25 at 6:03 PM, the DON observed Resident #1 as she laid in bed with no pillow at the foot of the bed, and Resident #1's feet were not offloaded. The DON pointed to a pillow that sat on Resident #1's wheelchair and stated that was the pillow that was used to offload Resident #1's feet. The DON stated she was not sure why the pillow was not on the bed. In a follow up interview on 02/19/25 at 6:19 PM, the DON stated a staff member just changed Resident #1's sheet and put the pill back at the foot of the bed to offload Resident #1's heels. The DON stated that was the first time she noticed Resident #1 without the pillow at the foot of the bed and feet offloaded. The DON stated the risk of not offloading Resident #1's feet was skin breakdown and a lower level of care. In an interview on 02/19/25 at 7:16 PM, the Administrator stated before today, he was not aware of the issue with Resident #1's heels not offloaded. The Administrator stated Resident #1's heels should have been offloaded to prevent further health issues. Record review of the facility's policy titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, dated 2001 with a revision date of 04/2018, reflected the following: Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five (Resident #13, Resident #39, Resident #49, Resident #70, and Resident #71) of twenty-seven residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light was in reach and accessible for Resident #13, Resident #39, Resident #49, Resident #70, and Resident #71. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #13 Review of Resident #13's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #13's pertinent diagnoses included paraplegia (paralysis of the legs and lower part of the body) and muscle weakness. Review of Resident #13's Quarterly MDS Assessment, dated 07/10/2024, reflected the resident had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident was dependent on staff for toileting hygiene, shower, dressing, and personal hygiene. Review of Resident #13's Comprehensive Care Plan, dated 08/27/2024, reflected the resident had an actual fall and the goal was the resident will resume usual activities without further incident. In an interview with Resident #13 on 10/08/2024 at 11:06 AM, Resident #13 stated she was looking for her call light earlier but was not able to find it. She said she had been waiting for somebody to come and give the call light to her. She said her call light should be secured beside her so she did not have to yell if she needed something. Observation and interview with LVN D on 10/08/2024 at 11:15 AM revealed LVN D was about to provide wound care to Resident #13. LVN D went inside the room and told the resident she would be cleaning her wound to her right heel. She picked-up the foam wedge that was on the floor. She did not notice the resident's call light was also on the floor. After the wound care, LVN D saw the call light, picked it up, and handed it over to Resident #13. She said the call light should be in a place accessible to the residents because the residents needed them to call the staff. LVN D said if the call lights were not within reach, the residents would not be able to call the staff and their needs would not be met. Resident # 39 Review of Resident #39's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #39 was diagnosed with muscle weakness and muscle spasm. Review of Resident #39's Comprehensive MDS Assessment, dated 08/27/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 09. Resident #39 was dependent on staff for toileting, shower, and personal hygiene. Review of Resident #39's Comprehensive Care Plan, dated 07/03/2024, reflected the resident had an actual fall last 04/03/2024 and the goal for the resident would resume usual activities without further incident. Observation and interview with Resident #39 on 10/08/2024 at 10:01 revealed the resident was in his bed awake. His call light was observed on the floor. When asked where his call light was, the resident looked for his call light and said he could not find it. Resident #49 Review of Resident #49's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #49 was diagnosed with dizziness and cerebrovascular disease (blood supply to the brain was interrupted). Review of Resident #49's Comprehensive MDS Assessment, dated 09/30/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 06. Resident #49 required moderate assistance in toileting, dressing, and personal hygiene. Review of Resident #49's Comprehensive Care Plan, dated 10/07/2024, reflected the resident had a risk for fall and one of the interventions was to be sure the call light was within reach. Observation and interview with Resident #49 on 10/08/2024 at 9:30 AM revealed the resident was in his bed, awake. It was observed that Resident #49's call light was on the floor. Resident #49 stated he was trying to look for his call light because he wanted to get up but cannot find it. He said he cannot even find the cord of his call light. He said several staff already went inside his room and did not notice his call light was on the floor. Observation and interview with LVN A on 10/08/2024 at 10:06 AM, LVN A stated call lights should be with the residents all the time, because they use the call lights to call for help or assistance if needed. He said the residents used the call lights to communicate to the staff that they needed something. He added that if the call lights were not with the residents, the residents might fall trying to do things by themselves or get frustrated because they could not call the staff. He said all the staff were responsible in making sure the call lights were within reach of the residents. LVN A said the call light were for all residents, whether dependent or independent. LVN A went inside Resident #39's room, picked up the call light and placed it where the resident could reach it. LVN A then went to Resident #49's room, picked up the call light, and handed it to Resident #49. Resident #70 Review of Resident 70's Face Sheet, dated 10//08/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #70 was diagnosed with hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) affecting right dominant side. Review of Resident #70's Comprehensive MDS Assessment, dated 08/16/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 02. Resident #70 required substantial assistance in transfer, bed mobility, shower, dressing and personal hygiene. Review of Resident #70's Comprehensive Care Plan, dated 08/29/2024, reflected the resident had an actual fall on 07/25/2024 and one of the goals was the resident will have no complications related to fall. Observation on 10/08/2024 at 9:16 AM revealed that Resident #70 was in his bed with eyes closed. His call light was observed to be on the floor under the bed. Observation and interview with Resident #70's 10/08/2024 at 12:34 PM revealed Resident #70 was still in his bed. His call light was still on the floor. The resident did not respond when asked if he had his call light. Resident #71 Review of Resident #71's Face Sheet, dated 10/10/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #71 was diagnosed with muscle weakness and lack of coordination. Review of Resident #71's Comprehensive MDS Assessment, dated 08/21/2024, reflected the resident had a severe cognitive impairment with a BIMS score of 00. Resident #71 required set-up assistance for eating, toileting, shower, and dressing. Review of Resident #71's Comprehensive Care Plan, dated 08/11/2024, reflected the resident had potential for falls and the goal was the resident will be free of minor injuries. Observation on 10/08/2024 at 9:20 AM revealed Resident #71 was sitting in his bed. It was observed that the resident's call light was on the floor. Observation and interview with Resident #71 on 10/08/2024 at 12:38 PM revealed the resident came back from lunch and went straight to his bed. His call light was still on the floor. The resident did not respond when asked if he had his call light. Observation and interview with CNA G on 10/08/2024 at 12:44 PM, CNA G stated the call light was accessible to the residents in case they needed something. She said the call lights were important because the resident use them to let the staff know that they need assistance. Without the call light, the needs of the resident will not be known. CNA G went inside Resident #70's room and tried to pull the call light from beneath the resident's bed. CNA G said the call light was stuck under the bed. CNA G looked for the remote, raised the bed, and pulled the call light from beneath the bed. CNA G then went to Resident #71's room, picked-up the call light from the floor, and clipped it on Resident #71's bed. In an interview with the Administrator on 10/10/2024 at 7:36 AM, the Administrator stated the call lights should not be on the floor because the residents needed them to call the staff. The Administrator said the residents might be having an emergency and staff would not know. The Administrator said the staff should be make sure the call lights were within reach. The Administrator said he would coordinate with the DON regarding call lights and would constantly remind them that before leaving the room, make sure the call lights were with the resident. The Administrator concluded that they would re-educate the staff about privacy, monitor them closely weekly for four weeks and monthly thereafter. In an interview with the DON on 10/10/2024 at 8:12 AM, the DON stated call lights were important for the residents and they should be placed where the residents could access them without difficulty. The DON said the call lights were the residents' mode of communication so they could tell the staff they needed something. She said even if the residents seldom use them, the call lights should still be placed somewhere accessible. She said the call lights were for the dependent residents, as well for the independent residents. She said all the staff, from nurses, CNAs, therapy, housekeeping, and management, were responsible in ensuring that the call lights were within reach. The DON said the expectation was for the staff would be mindful that every time they leave the residents' room, the call lights were within reach. The DON said she would conduct an in-service and check-off about the call lights for all the staff of the facility. She said she would personally monitor that all the residents' call lights were within reach. Record review of facility's policy Call Lights: Accessibility and Timely Response revealed Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside . to allow residents to call for assistance . Policy Explanation and Compliance Guidelines . 5. Staff will ensure the call light is within reach of resident and secured.

Based observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for eight (Resident #10, Resident #13, Resident #44, Resident #49, Resident #56, Resident #61, Resident #80, and Resident #84) of eighteen residents observed for Infection Control. 1. The facility failed to ensure that CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #49. 2. The facility failed to ensure that CNA E changed her gloves and performed hand hygiene while providing incontinent care to Resident #80. 3. The facility failed to ensure that LVN B sanitized the blood pressure cuff in between Resident #44, Resident #56, Resident #61, and Resident #84. 4. The facility failed to ensure that LVN C sanitized the blood pressure cuff in between Resident #10 and Resident #13. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #49's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #49 was diagnosed with cerebrovascular disease (blood supply to the brain was interrupted) and kidney failure. Review of Resident #49's Comprehensive MDS Assessment, dated 09/30/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 06. The Quarterly MDS Assessment indicated the resident was always incontinent for bladder and bowel. Review of Resident #49's Comprehensive Care Plan, dated 10/07/2024, reflected Resident #49 was incontinent for bladder and bowel r/t kidney failure and one of the interventions was clean peri-area with each incontinent care. Observation and interview with CNA D on 10/08/2024 at 9:39 AM revealed CNA D was about to provide incontinent care to Resident #49. CNA D raise the bed and lowered the head of the bed. She washed her hands, put on a pair of gloves, put a brief on the resident's right-side table, and positioned the wipes beside the resident. She reached for the trash can and placed it near her. She did not change her gloves after touching the trash can. CNA D unfastened the brief on both sides and pushed the front part of the brief between the legs of the resident. CNA D pulled some wipes and started to clean the front part of the resident. She did it four times. CNA D rolled the resident towards the wall and cleaned the bottom of the resident. After cleaning the resident's bottom, CNA D rolled the soiled brief and the bed padding altogether towards the middle of the bed, pulled them, and put them in the trash can. After putting the soiled brief and padding on top of the trash can, CNA D took the new brief and put it at the bottom of the resident and fixed it. CNA D did not change her gloves nor sanitize her hands before touching the new brief. CNA D rolled the resident back, fixed the new brief, and taped the brief on both sides. CNA D went to the bathroom and washed her hands. CNA D stated she washed her hands before and after doing incontinent care. She said she did roll the soiled brief and padding altogether and put it on top of the trash can. CNA D said she did not change her gloves nor did hand hygiene before touching the new brief. She said she should have changed her gloves after pulling the soiled brief and padding because her gloves were considered soiled after they came in contact with the soiled brief. She also said she should have changed her gloves after touching the trash can. She said not doing hand hygiene and not changing the gloves could cause transfer of contaminants from dirty to clean. She said cross contamination could eventually cause infection. She said she had an in-service for hand hygiene and incontinent care but still forgot to do the right procedure. 2. Review of Resident #80's Face Sheet, dated 10/08/2024, reflected the resident was an [AGE] year-old female admitted on [DATE]. Resident #80 was diagnosed with muscle weakness and kidney failure. Review of Resident #80's Quarterly MDS Assessment, dated 10/02/2024, reflected the resident was cognitively intact with a BIMS score of 15. Resident #80's Quarterly MDS Assessment indicated the resident was incontinent for bowel and bladder. Review of Resident #80's Comprehensive Care Plan, dated 07/13/2024, reflected the resident was incontinent of bowel and bladder r/t kidney failure and one of the interventions was clean peri-area with each incontinent care. Observation and interview with CNA E on 10/08/2024 at 2:43 PM revealed CNA E was about to provide incontinent care to Resident #80. After letting the resident know that she would change her, CNA E started to prepare the items needed for incontinent care. She put on a pair of gloves, opened a brief and put it on the side of the resident's pillow, and put the wipes near the brief. CNA E pulled the hospital gown of the resident up, unfastened the brief on both sides, and pushed the brief on both sides. CNA E pulled some wipes and cleaned the resident from front to back. After cleaning the front part of the resident, the resident was instructed to roll to her left side. CNA E cleaned the bottom of the resident, pulled the soiled brief, and threw it on the trash can. CNA E grabbed the brief near the resident's head, put it under the resident, and fixed it. CNA E took did not change her gloves after pulling the soiled brief or before touching the new brief. After fixing the brief, CNA E lowered the resident's gown and pulled up the light blanket up to the resident's chest. She did not wash her hands after incontinent care. CNA E stated she should do hand hygiene before and after doing incontinent care for a resident. She said she was not aware that she did not wash her hands before and after cleaning Resident #80. She said she should have changed her gloves after cleaning the bottom of the resident because her gloves were already dirty. She said she was not aware she needed to sanitize her hands in between changing of the gloves. She said, if it was mandatory to sanitize her hands when she changed her gloves, she would do it. She said they had in-services and check-off about hand hygiene but cannot recall about sanitizing in between changing the gloves. 3. Review of Resident 61's Face Sheet, dated 10/09/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #61 was diagnosed with hypertension. Review of Resident #61's Quarterly MDS Assessment, dated 07/16/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated hypertension as one of Resident #61's active diagnosis. Review of Resident #61's Comprehensive Care Plan, dated 09/09/2024, reflected the resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #61's Physician's Order for amlodipine, dated 07/23/2024, reflected Amlodipine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 1 tablet by mouth one time a day for HTN HOLD IF SBP <100 OR HR <60. Review of Resident #61's Physician's Order for lisinopril, dated 07/23/2024, reflected Lisinopril Tablet 20 MG. Give 1 tablet by mouth one time a day for HTN. Hold if SBP < 100 or DBP < 60. Observation on 10/09/2024 at 7:07 AM revealed LVN B was preparing Resident #61's medication. He picked up the blood pressure cuff from the medication cart, went inside the resident's room, and placed the blood pressure cuff on Resident #61's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #61. He did not sanitize the blood pressure cuff. Review of Resident 84's Face Sheet, dated 10/09/2024, reflected the resident was a [AGE] year-old male admitted on [DATE]. Resident #61 was diagnosed with hypertension. Review of Resident #84's Quarterly MDS Assessment, dated 09/27/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated hypertension as one of Resident #84's active diagnosis. Review of Resident #84's Comprehensive Care Plan, dated 09/30/2024, reflected the resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #84's Physician's Order for lisinopril, dated 09/30/2024, reflected Lisinopril Oral Tablet 10 MG (Lisinopril). Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if SBP <110 or DBP <60. Observation on 10/09/2024 at 7:15 AM revealed LVN B was preparing Resident #84's medication. He picked up the blood pressure cuff from the medication cart, went inside the resident's room, and placed the blood pressure cuff on Resident #84's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #84. He did not sanitize the blood pressure cuff. The cuff was the same one used on the previous resident(s) which was not sanitized. Review of Resident 56's Face Sheet, dated 10/09/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #56 was diagnosed with hypertension. Review of Resident #56's Quarterly MDS Assessment, dated 09/30/2024, reflected the resident was cognitively intact with a BIMS score of 14. The Quarterly MDS Assessment indicated hypertension as one of Resident #56's active diagnosis. Review of Resident #56's Comprehensive Care Plan, dated 09/30/2024, reflected the resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #56's Physician's Order for amlodipine, dated 10/01/2024, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if SBP <100 or DBP <60. Review of Resident #56's Physician's Order for metoprolol, dated 10/01/2024, reflected Metoprolol Succinate ER Tablet Extended Release 24 Hour 100 MG. Give 1 tablet by mouth one time a day for HTN Hold for SBP <100, DBP <60, or HR <60. Observation on 10/09/2024 at 7:59 AM revealed LVN B was preparing Resident #56's medication. He picked up the blood pressure cuff from the medication cart, went inside the resident's room, and placed the blood pressure cuff on Resident #56's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart. He said the resident's blood pressure was low so he would re-check Resident #56's blood pressure before the resident go to her appointment. He did not sanitize the blood pressure cuff. The cuff was the same one used on the previous resident(s) which was not sanitized. Review of Resident 44's Face Sheet, dated 10/09/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #44 was diagnosed with hypertensive heart disease. Review of Resident #44's Quarterly MDS Assessment, dated 09/30/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated hypertension as one of Resident #44's active diagnosis. Review of Resident #44's Comprehensive Care Plan, dated 08/09/2024, reflected the resident had hypertension (HTN) r/t hypertensive heart disease and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #44's Physician's Order for tadalafil, dated 07/27/2024, reflected Tadalafil Oral Tablet 20 MG (Tadalafil). Give 2 tablet by mouth one time a day for Hypertension Hold if SBP <100 or DBP <60. Observation and interview with LVN B on 10/09/2024 at 7:59 AM revealed LVN B was preparing Resident #44's medication. He picked up the blood pressure cuff from the medication cart, went inside the resident's room, and placed the blood pressure cuff on Resident #44's arm. After the blood pressure reading was completed, LVN B placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #44. He did not sanitize the blood pressure cuff. The cuff was the same one used on the previous resident(s) which was not sanitized. LVN B stated he obtained the blood pressure of the residents before giving the medication for hypertension to know if the medication needed to be held or not. LVN B said he sanitized his hands after he gave the medications of a resident. LVN B said the blood pressure cuff should be sanitized as well after using it or before using it on another resident. LVN B said he forgot to sanitize the blood pressure cuff in between residents when he passed the medications. LVN B stated not sanitizing the blood pressure cuff in between residents could cause infection to transfer from one resident to another. LVN B added if a resident already had an infection, that infection could be transferred to another resident because the reusable item was not sanitized. He said he would make sure that he sanitized the blood pressure cuff everytime he would use it. 4. Review of Resident 13's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #13 was diagnosed with hypertension. Review of Resident #13's Quarterly MDS Assessment, dated 09/30/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated hypertension as one of Resident #13's active diagnosis. Review of Resident #13's Comprehensive Care Plan, dated 08/27/2024, reflected the resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #13's Physician's Order for amlodipine, dated 10/01/2024, reflected Amlodipine Besylate Tablet 10 MG. Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if SBP <100 or DBP <60. Observation on 10/09/2024 at 8:25 AM revealed LVN C was preparing Resident #13's medication. She picked up the blood pressure cuff from the medication cart, went inside the resident's room, and placed the blood pressure cuff on Resident #13's arm. After the blood pressure reading was completed, LVN C placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #13. She did not sanitize the blood pressure cuff. The cuff was the same one used on the previous resident(s) which was not sanitized. It was observed that a container of sanitizer was on top of the nurse's cart, beside a laptop. Review of Resident 10's Face Sheet, dated 10/09/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #10 was diagnosed with hypertension. Review of Resident #10's Quarterly MDS Assessment, dated 09/17/2024, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated hypertension as one of Resident #10's active diagnosis. Review of Resident #10's Comprehensive Care Plan, dated 09/17/2024, reflected the resident had hypertension and one of the interventions was give anti-hypertensive medications as ordered. Review of Resident #10's Physician's Order for lisinopril, dated 09/17/2024, reflected Lisinopril Oral Tablet 20 MG (Lisinopril). Give 1 tablet by mouth one time a day for hypertension related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD SBP LESS THAN110 DBP LESS THAN 60. Observation and interview with LVN C on 10/09/2024 at 8:57 AM revealed LVN C was preparing Resident #10's medication. She picked up the blood pressure cuff from the medication cart, went inside the resident's room, and placed the blood pressure cuff on Resident #10's arm. After the blood pressure reading was completed, LVN C placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #10. She did not sanitize the blood pressure cuff.This was the same one used on the previous resident(s) which was not sanitized. LVN C stated she forgot to sanitize the blood pressure cuff after using it for Resident #13 and before using it for Resident #10. She said the blood pressure cuff should be sanitized after using it or before using it to another resident to prevent cross contamination and infection. In an interview with the Administrator on 10/10/2024 at 7:36 AM, the Administrator stated not washing the hands nor sanitizing them could contribute to cross contamination. He said not changing the gloves after touching soiled items could contribute to the development of infection as well. He said if the blood pressure cuff was used for a resident, it should be sanitized before using it to another resident to prevent transfer of germs. He said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said he would collaborate with the DON to in-service the staff about infection control. The Administrator concluded that they would re-educate the staff about privacy, monitor them closely weekly for four weeks and monthly thereafter. In an interview with the DON on 10/10/2024 at 8:12 AM, the DON stated she always do in-services for infection control, hand washing, and infection control. She said the hands should be washed before and after incontinent care, or any care for that matter. She said gloves should be changed after touching any soiled items, like the trash can and the soiled brief. She said gloves should be changed after cleaning the resident's bottom. She said hands should be sanitized in between changing of gloves. She said the blood pressure cuff should be sanitized after every use. She said not washing the hands, not sanitizing the hands, not changing the gloves after touching soiled items, and not sanitizing the blood pressure cuff after each use could result to cross contamination and infection. She said the expectation was for the staff to be mindful in following the procedures pertaining to infection control. The DON said she would do a one-on-one in-service with the concerned staff and then would do an in-service about infection control for all the staff. She concluded that he would continually remind the staff to be attentive to the procedures for infection control and that she would personally monitor infection control. Review of facility policy, Perineal Care Nursing Policy and Procedure Manual for Long-Term Care rev. February 2018 revealed Purpose: the purpose of this procedure are to provide cleanliness . to prevent infection . Steps in the procedure . 2. Wash and dry hands thoroughly . 7. Put on gloves . 8. Female resident . e. Wash rectal area . Male resident . e. Wash rectal area . 10. Remove gloves . 11. Wash and dry hands . 12. Make resident comfortable . 16. Wash and dry hands thoroughly. Record review of facility policy Routine Cleaning and Disinfection Centers of Disease Control updated July 2019 revealed It is the policy of this facility to ensure the provision of routine cleaning and disinfection . c. Clean and disinfect any equipment that enters the room before use in another. Review of facility policy Hand Washing/Hand Hygiene Nursing Policy and Procedure Manual for Long-Term Care rev. August 2019 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 2. All personnel shall follow the hand-washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and after direct contact with residents . After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves.

Based on observations, interviews, and record review, the facility failed to provide the right to personal privacy which includes accommodations during personal care for one (Resident #13) of thirteen residents reviewed for Privacy. The facility failed to ensure LVN D closed Resident #13's door while performing wound care. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment. Findings included: Review of Resident #13's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #13's pertinent diagnoses included paraplegia (paralysis of the legs and lower part of the body) and injury to Achilles tendon (connective tissue that connects the calf to the heel bone). Review of Resident #13's Quarterly MDS Assessment, dated 07/10/2024, reflected the resident had an intact cognition with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had an injury to Achilles tendon. Review of Resident #13's Care Plan, dated 08/27/2024, reflected the resident had potential for pressure ulcer development r/incontinence, obesity, limited mobility and paraplegia. Review of Resident #13's Physician Order, dated 10/03/2024, reflected STAGE 3 PRESSURE WOUND OF THE RIGHT, lateral HEEL full THICKNESS-clean with wound cleanser, pat dry apply Santyl calcium alginate, ABD pad and wrap with kerlix (white gauze dressing) every day shift for Wound care. Review of Resident #13's Physician Order, dated 10/03/2024, reflected Stage 2 pressure wound OF THE RIGHT, medial HEEL partial THICKNESS-clean with wound cleanser, pat dry apply skin prep ABD pad and wrap with kerlix every day shift for Wound care. Observation and interview with LVN D on 10/08/2024 at 11:15 AM revealed LVN D was about to provide wound care to Resident #13. LVN D said the resident had wounds to the medial and lateral aspect of the right heel. She said treatment to the outward wound would be Santyl and calcium alginate while treatment for the inner wound would be skin prep. LVN D went inside the room and told the resident she would be cleaning her wound to her right heel. She washed her hands, put on a pair of gloves, prepared the things needed for wound care, and then removed her gloves. She then took the overbed table from inside the room, sanitized it, put paper towels on top of it, and transferred the items for wound care on the overbed table. LVN D went back inside the room and placed the table at the end of the bed. She washed her hands and put on a pair of gloves. LVN D proceeded with wound care. LVN D did not close the door or pulled the privacy curtain while doing wound care. LVN D stated she forgot to close the door before she did wound care. She said the door should be closed every time wound treatment was done to provide privacy and give dignity to the resident. She said she would make sure she would close the door or pull the privacy curtain every time she would do wound care. In an interview with Resident #13 on 10/08/2024 at 11:31 AM, Resident #13 stated she did not notice the door was open during wound care. She said, not that I mind, but it would be decent if the door was closed if they were treating me. In an interview with the Administrator on 10/10/2024 at 7:36 AM, the Administrator stated the staff must make sure that the residents were provided privacy when providing care to prevent embarrassment. He said the expectation was for the staff to close the door, not only during wound care, but during all care provided. He said he would collaborate with the DON to do an in-service about privacy during treatment. The Administrator concluded that they would re-educate the staff about privacy, monitor them closely weekly for four weeks and monthly thereafter. In an interview with the DON on 10/10/2024 at 8:12 AM, the DON stated the door should be closed or the privacy curtain should be drawn during wound care to provide privacy. She said providing privacy was true as well in the provision of any treatment to avoid other residents, staff, or visitors in seeing what treatment were being done to a particular resident or what the resident's wounds look like. The DON said all the staff, including her, were responsible in providing privacy to the residents. The DON said the expectation was for the staff to make sure that when they were providing care, the residents' door should be closed, or the privacy curtain should be pulled. She said she was made aware by LVN D about the issue and she already made a one-on-one in-service with LVN D. She said she would also do an in-service to all staff to continually remind the staff the importance of providing privacy and dignity through an in-service. Record review of facility's policy, Dignity 2001 MED-PASS, Inc. revised February 2021 revealed Policy Statement: Each resident shall be cared for a manner that promotes and enhances his or her sense of well-being feelings of self-worth and self-esteem . Policy implementation . 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #13) of eight residents reviewed for Respiratory Care. The facility failed to ensure that Resident #13's BiPAP (Bilevel Positive Airway Pressure: machine used to deliver pressurized air through a mask to keep airways open) mask was stored properly. This failure could place the resident at risk for respiratory infection and not having her respiratory needs met. Findings included: Review of Resident #13's Face Sheet, dated 10/08/2024, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #13 was diagnosed with acute respiratory failure and obstructive sleep apnea (a sleep disorder where breathing is interrupted repeatedly during sleep). Review of Resident #13's Quarterly MDS Assessment, dated 07/10/2024, reflected the resident was cognitively intact with a BIMS score of 15. Resident #13's Quarterly MDS Assessment indicated the resident was on non-invasive mechanical ventilation. Review of Resident #13's Comprehensive Care Plan, dated 08/27/2024, reflected the resident was wearing Bi-pap r/t respiratory failure and sleep apnea and one of the interventions was use BiPAP as ordered. Review of Resident #13's Physician Order, dated 01/26/2024, reflected BIPAP ON AT 2100 (9PM) OFF AT 0900(9AM) Attach O2 @ 2 LPM via (through) BIPAP MACHINE two times a day. Observation and interview with Resident #13 on 10/08/2024 at 10:56 AM revealed resident was in her bed, awake. The resident had a BiPAP machine mounted on a mobile BIPAP stand. A full mask BiPAP mask was attached to the BiPAP machine. The mask was not bagged. Resident #13 stated the nurses were the one putting the mask on at night and taking it off in the morning. She said sometimes the nurses put it on a bag but sometimes they do not. She said she would put it on a bag if she could but she said her movements were limited. Observation and interview with LVN C on 10/10/2024 at 12:08 PM, LVN C stated Resident #13 was using a BiPAP at night. She said the BiPAP mask should not be exposed nor touching anything because it could cause cross contamination and respiratory infection. She went inside the room and saw the BiPAP mask was hanging beside the BiPAP machine and was not bagged. LVN C looked for a plastic bag, found one on top of the resident's left-side table, and put the mask inside the bag. She said she did not notice that the mask was not bagged when she made her morning round. LVN C said she would clean the BiPAP mask and put in a new plastic bag. In an interview with the Administrator on 10/10/2024 at 7:36 AM, the Administrator stated the mask for BiPAP should be bagged to prevent infection. He said he would coordinate with the DON on how to go forward about the issue of respiratory care. The Administrator concluded that they would re-educate the staff about privacy, monitor them closely weekly for four weeks and monthly thereafter. In an interview with the DON on 10/10/2024 at 8:12 AM, the DON stated the BiPAP mask should be bagged when not in use to keep it clean. She said if the BiPAP mask was exposed or touching surfaces that were not clean, there could be a probability of cross contamination, respiratory infection, and oxygen administration could be compromised. The DON said the staff taking it off should put it in a bag. She said the expectation was for the staff to be mindful in making sure that the BiPAP mask of the resident would be bagged when not in use. The DON said she would conduct an in-service and check-off about the respiratory care and would personally monitor if the staff were bagging BiPAP mask. She also said the policy only stated to bag the nasal cannula but the policy also applied to the BiPAP mask. Record review of facility's policy, Departmental (Respiratory Therapy) - Prevention of Infection MED-PASS, Inc. revised November 2011 revealed Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy . Steps . 8. Keep the oxygen cannula and tubing . in a plastic bag when not in use.

Based on observations, interviews and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 3 of 5 resident rooms (Resident #13, 29, and 84) observed for a clean environment. The facility failed to ensure that resident rooms were cleaned daily, and in accordance with the facility's Housekeeping Workers' Checklist. This deficient practice could negatively impact the facility's ability in preventing the spread of disease-causing organisms in residents' living areas. Findings include: Observation on 08/22/23 at 11:35 AM, in Resident # 84's room revealed the bathroom in the resident's room had dried up Fecal matter on the top left side of the toilet. The bottom portion of the toilet had dark dirt stains on around it. An interview with Resident # 84 (BIMS: 15) revealed, she had asked two CNAs (could not remember names) to clean the toilet earlier in the morning, after her roommate had messed it up and no one had yet to clean the toilet. Resident #84 stated the site of the toilet was gross. Observation on 08/22/23 at 11:43 AM, of Resident # 29's room revealed, the resident's bathroom was observed to had large dirt stains on the outer lower toilet and in the corner of the bathroom floors. Observation on 08/22/23 at 11:43 AM, Resident # 13's room revealed, the resident's room had some drywall of repaired completed and the area still had the dirt and dust from the repair. Interview with Resident # 13 (BIMS: 25) at 11:43 AM, revealed she had stated maintenance had made repairs to the wall a few months ago but she was not sure when. She stated she did not focus on the dirt because she kept the curtains closed in the area of the room. Interview with Housekeeping Services M on 08/22/23 at 11:51 AM, revealed she was assigned the 400 Hall and she stated that she cleaned rooms daily. She advised that she was not provided a checklist and just cleans whatever needs to be cleaned. She advised that she was also not trained on what areas to clean but to clean from top to bottom. She advised the risk of not cleaning room thoroughly could result in residents getting sick. Interview with Environmental Service Director on 08/24/23 at 12:00 PM revealed, he was shown pictures of concerns observed in the facility. He advised that he had trained his housekeeping staff on cleaning from top to bottom, which included wiping down the walls, cleaning the bathrooms thoroughly, and ensuring the entire floor was properly swept and mopped. He admitted to making the repairs to Resident #13's room wall and he stated he forgot to ensure it was cleaned up. He stated he had numerous discussions with Housekeeping Services M about not thoroughly cleaning rooms and she would be disciplined. He advised the risk of not properly cleaning the room could result in an Infection for residents. Interview with Assistant Administrator on 08/24/23 at 12:55 PM, revealed she was shown the pictures of the concerns observed in the facility for cleanliness. She advised she had met with the Environmental Services Director to discuss the concerns. She advised that for the most part, her housekeeping staff had an opportunity to improve in being more consistent with the cleanliness of the rooms. She advised the risk of not ensuring rooms were cleaned thoroughly is a sanitary concern and also infection control based on the health of the resident. Review of the facility's Housekeeping Workers' Checklist dated 7/2017, revealed that the residents' room were expected to be cleaned daily, including the cleaning of all fixtures and furniture, walls, and dusting and mopping floors.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure the Ice machine, Ice Scooper, and Ice Scooper Holder, located in the facility's only kitchen, was clean and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations on 08/22/23 at 09:15 AM in the facility's only kitchen include: Ice Machine was dirty on the inside of the ice machine and the machine was filled with ice. The top portion, over the ice, had dirt stands on the inner white plastic part of the machine that was over the ice and the Ice Machine door had a lot of old dirt particles in the springs of the door hinge. Ice Machine Scoop Holder was dirty on the inside and had a lot of dirt particles dried up on the bottom of the Ice holder. One 5 lb. tubing of what appeared to be ground beef was undated and unlabeled in the refrigerator. The tubing had no visible expiration date. Two small containers of Kosher meat were unlabeled and undated in the refrigerator. The containers had no visible expiration date. 6 containers of Kosher meals were unlabeled and undated in the refrigerator. The containers had no visible expiration date. Interview and observation with Kitchen Dietary Manager on 08/22/23 at 09:15 AM, revealed he was overall responsible for ensuring the kitchen was complying to Federal and State guidelines. He stated that he had the Ice machine, Ice Scooper, and Ice Scooper Holder cleaned at least once a month, but had not been checking for cleanliness recently, but would ensure that it was cleaned immediately. He was shown the foods that were unlabeled and undated, and he stated that when they got food delivered, he normally ensured his staff labeled and dated the foods as they are being stored, but his team had missed some items. He stated the risk of not ensuring all these concerns were addressed could result in residents getting ill as a result of food contamination. Interview with Assistant Administrator on 08/24/23 at 10:55 AM, revealed she was shown the pictures of the concerns discovered in the facility's only kitchen. She advised that the Dietary Manager had notified her of the concerns addressed with him. She advised that there was an opportunity for the Kitchen staff to ensure that the kitchen is thoroughly cleaned when scheduled. She stated that she had met with the Dietary Manager about ensuring that these concerns were corrected, and the staff was in-serviced on food storage, and cleaning the kitchen. She advised the risk of the concerns identified could result in food contamination, and residents getting ill. Record Review of the Facility's policy on Food Storage and Kitchen Sanitation dated 12/01/11, revealed All foods will be stored according to Federal and State guideline. All refrigerated food are labeled, dated, and tightly sealed. Scoops are stored covered in a protected area. Scoops are washed weekly or as needed. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. Processed reduced oxygen foods that exceed the use-by date or manufacturer's pull date cannot be sold in any form and must be disposed of in a proper manner. All equipment and utensils must be cleaned and sanitized.

Based observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Residents #60, #63, #16, and #30) of residents observed for infection control. The facility failed to ensure CMA C sanitized the blood pressure cuff between Resident #60, Resident #63, Resident #16, and Resident #30. These failures could place the residents at risk of cross-contamination and development of infections. Findings included: Review of Resident #60's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included hemiplegia and hemiparesis following cerebral infarction (interruption of blood flow to the brain), hyperlipidemia, essential (primary) hypertension. Review of Resident #60's Quarterly MDS dated [DATE] reflected that resident #60 was cognitively intact with a BIMS score of 15. Resident required limited assistance for bed mobility, transfer, walk in room, dressing, toilet use, and personal hygiene. Resident also needed supervision for walk in corridor, locomotion in unit, eating, and bathing. The quarterly MDS also indicated stroke as the primary reason for admission and hypertension as one of the primary medical condition. Review of Resident #60's Comprehensive Care Plan dated 06/06/2023 reflected that resident had hypertension (HTN). The Comprehensive Care Plan also disclosed that Resident #60 was taking lisinopril and carvedilol for hypertension. Review of Resident #60's Physician's order for lisinopril 10 mg dated 06/28/2023 reflected, Give 10 mg by mouth one time a day related to essential (primary) hypertension. Review of Resident #60's Physician's order for carvedilol 12.5 mg dated 08/08/2023 reflected, Give 1 tablet by mouth every 12 hours for HTN. Hold for SBP less than 100 or pulse less than 50. Review of Resident #63's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified hyperlipidemia, and vascular dementia. Review of Resident #63's Quarterly MDS dated [DATE] reflected that resident #63 was cognitively intact with a BIMS score of 15. Resident required supervision for bed mobility, transfer, walk in room, walk in corridor, locomotion in unit, locomotion off unit, eating, dressing, toilet use, and personal hygiene. The quarterly MDS also indicated hypertension as one of the primary medical condition. Review of Resident #63's Comprehensive Care Plan dated 08/14/2023 reflected that resident had hypertension (HTN). The Comprehensive Care Plan also disclosed that Resident #63 was taking amlodipine. Review of Resident #63's Physician's order for amlodipine besylate 5 mg dated 12/27/2022 reflected, Give 1 tablet by mouth one time a day related to essential (primary) hypertension. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Review of Resident #16's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified hyperlipidemia (an excess of fat particles in the blood), and unspecified encephalopathy (broad term for any brain disease that alters brain function or structure). Review of Resident #16's Quarterly MDS dated [DATE] reflected that Resident #63 was cognitively intact with a BIMS score of 15. Resident required extensive assistance for bed mobility, transfer, locomotion in unit, dressing, toilet use, and personal hygiene. Supervision required for eating. The quarterly MDS also indicated hypertension as one of the primary medical condition. Review of Resident #16's Comprehensive Care Plan dated 08/16/2023 reflected that resident had hypertension (HTN). The Comprehensive Care Plan also disclosed that Resident #16 was taking losartan, amlodipine, and clonidine H. Review of Resident #16's Physician's order for losartan potassium 100 mg dated 05/15/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Review of Resident #16's Physician's order for amlodipine besylate 10 mg dated 05/25/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Review of Resident #16's Physician's order for clonidine 0.1 mg dated 05/25/2023 reflected, Give 1 tablet by mouth every six hours as needed for HTN for systolic blood pressure greater than 170. Review of Resident #30's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included essential (primary) hypertension, unspecified hyperlipidemia, and type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateral. Review of Resident #30's Comprehensive MDS dated [DATE] reflected that resident #30 has severe impairment in cognition with a BIMS score of 07. Resident required supervision for bed mobility, transfer, walk in room, walk in corridor, locomotion in unit, locomotion off unit, dressing, eating, toilet use, bathing, and personal hygiene. The comprehensive MDS also indicated hypertension as one of the primary medical condition. Review of Resident #30's Comprehensive Care Plan dated 06/19/2023 reflected that resident had hypertension (HTN). The Comprehensive Care Plan also disclosed that Resident #30 was taking lisinopril, amlodipine, and atenolol potassium. Review of Resident #30's Physician's order for lisinopril 20 mg dated 05/26/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Review of Resident #30's Physician's order for amlodipine 10 mg dated 05/26/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Review of Resident #30's Physician's order for atenolol 100 mg dated 05/26/2023 reflected, Give 1 tablet by mouth one time a day for HTN. Hold all BP meds if SBP is less 100 or DBP less 60, or if pulse is less 55. If BP meds are held for 3 consecutive days, notify MD. Observation on 08/23/2023 at 8:02 AM, revealed that CMA C picked up the blood pressure cuff from the medication cart. The blood pressure cuff was not sanitized. CMA C placed the blood pressure cuff on Resident #60's arm. After the blood pressure reading was completed, CMA C went straight to Resident #63 and placed the blood pressure cuff on Resident #63's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on the medication cart and then prepared and gave the medications to Residents #60 and then prepared and gave the medications to Resident #63. Observation on 08/23/2023 at 8:37 AM, revealed that CMA C picked up the blood pressure cuff from the medication cart. The blood pressure cuff was not sanitized. CMA C placed the blood pressure cuff on Resident #16's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on the medication cart. CMA C prepared and gave the medications to Resident #16. Observation on 08/23/2023 at 8:43 AM, revealed that CMA C picked up the blood pressure cuff from the medication cart. The blood pressure cuff was not sanitized. CMA C placed the blood pressure cuff on Resident #30's arm. After the blood pressure reading was completed, CMA C placed the blood pressure cuff on the medication cart. CMA C prepared and gave the medications to Resident #30. Interview with CMA C on 08/23/2023 at 10:34 AM, CMA C stated she had been with the facility for two years. She said that she obtained the blood pressure of the residents before giving the medication for hypertension. CMA C stated that she washes or sanitizes her hands before and after giving medications. When asked what should be done after using the blood pressure cuff. She replied that it should be cleaned with a sanitizing wipe. She then acknowledged that she forgot to sanitize the blood pressure cuff in between residents when she passed medications that morning. She stated that this action could cause infection to transfer from one resident to another. Interview with LVN A on 08/23/2023 at 10:44 AM, LVN A stated that he had been with the facility for a year. LVN A stated that the blood pressure cuff should be sanitized in between residents. If the blood pressure cuff was not sanitized, it could cause cross contaminations and infection control issues. Interview with ADON N on 08/23/2023 at 11:50 AM, ADON N stated that the blood pressure cuff should be sanitized after every use or after every resident. ADON N said that if the blood pressure cuff is not sanitized, it could cause cross contamination and infection to spread. ADON N said that the expectation was for the blood pressure cuff would be sanitized in between residents. Interview with the DON on 08/24/2023 at 8:43 AM, DON stated that ADON N made her aware of the infection control issues. DON stated that the blood pressure cuff should be sanitized every after use. She said that not sanitizing the blood pressure cuff could cause cross contamination or development of new infections. Interview with the Assistant Administrator on 08/24/2023 at 10:01 AM, Assistant Administrator stated that the expectation was for the staff to follow the policies and procedures of the facility in general. She said the residents should feel safe and living to their full potential. The Assistant Administrator said that all staff should adhere to what is the best standard of care. Record review of facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment, Med-Pass Inc., rev. October 2018 revealed Policy Interpretation and Implementation . d. reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).

Based observation, interview, and record review, the facility failed to secure the catheter to facilitate flow of urine, prevent kinking of the tubing and position below the level of the bladder for 1 (Resident #57) of 1 resident observed for urinary catheter care. The facility failed to ensure CNA E kept the urine collection bag of Resident #57 below the level of the bladder. These failure could place the resident at risk for infection development. Findings included: Review of Resident #57's Face Sheet dated 08/23/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included unspecified neuromuscular dysfunction of bladder, cognitive communication deficit, and unspecified osteomyelitis. Review of Resident #57's Comprehensive MDS dated [DATE] reflected that Resident #57 has no BIMS score because resident was unable to complete the interview. Resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident was totally dependent for eating and bathing. The bladder and bowel section of the Comprehensive MDS also indicated the use of indwelling catheter. Review of Resident #57's Comprehensive Care Plan dated 05/26/2023 reflected that resident had an ADL self-care performance deficit r/t (relate to) Cerebral infarction. Review of Resident #57's Comprehensive Care Plan dated 05/26/2023 reflected that resident had (Indwelling) Catheter: Neurogenic bladder. 16FR 10ml Review of Resident #57's Physician's order dated 05/19/2023 reflected, Foley catheter size: 16fr with 10 ml balloon inflation and diagnosis. Observation on 08/22/2023 at 10:51 AM, revealed that Resident #57 was resting in her bed. The resident had an above the knee amputation to the right leg. The Hoyer lift sling was under the resident. The resident's urine collection bag was on top of the bed below the amputated leg. The catheter tubing was in a U-shaped formation. The urine in the tubing was in the direction towards the resident. Observation on 08/22/2023 at 11:22 AM, revealed that Resident #57 was still in the bed. The urine collection bag was still on top of the bed. Observation on 08/22/2023 at 11:31 AM, revealed that Resident #57 was to be transferred to the wheelchair via Hoyer lift. The urine catheter bag was on top of the bed prior to transfer. Interview with CNA E on 08/22/2023 at 11:32 AM, CNA E stated that she was the CNA for hall 200 for that day. She stated that she was the one who prepared Resident #57 that morning. CNA E said that she placed the urine collection bag on the bed to be able to put the pants on Resident #57. CNA E acknowledged that she should have hooked the urine collection bag back to the railing at the bottom of the bed if she was not yet to be transferred to the wheelchair. CNA E stated that leaving the urine collection bag on top of the bed could cause the urine to go back. This could cause urinary tract infection. Interview with LVN A on 08/23/2023 at 10:44 AM, LVN A said that Resident #57 is an amputee, a diabetic, with continuous feeding, and has an indwelling catheter. He added that the catheter bag should be hanged on the rail at the bottom of the bed. The catheter bag should be below the bladder so the flow of the urine will not be disrupted. LVN A further stated that if the urine flow is disrupted, it will not flow to the catheter bag and might go back. It could cause problems in the abdomen and infections such as urinary tract infection. Interview with ADON N on 08/23/2023 at 11:50 AM, ADON N stated that the catheter should not be on the bed because it could cause infection such as urinary tract infection. She stated that if the catheter bag was placed on the bed to facilitate dressing change, the catheter bag should not stay on the bed for a long time. ADON N said that the catheter bag should be hooked back to the bottom of the bed if the resident will not be transferred yet. It should not stay on the bed for a long time because it could result to urine backflow. Interview with the DON on 08/24/2023 at 8:43 AM, DON stated that the catheter should not be on the bed. She said that this action could cause the urine to flow back. The urine backflow could result to urinary retention and urinary tract infection. DON stated that this is not acceptable, and everybody must do better. DON said that all staff were expected to follow the infection control policy. She added that they did an in-service on 08/23/2023 to address the infection control issues. The in-service was to educate and remind the staff about the policy for infection control. Interview with the Assistant Administrator on 08/24/2023 at 10:01 AM, Assistant Administrator stated that the expectation was for the staff to follow the policies and procedures of the facility in general. She said the residents should feel safe and living to their full potential. The Assistant Administrator said that all staff should adhere to what is the best standard of care. Interview with CNA H on 08/24/2023 at 10:47 AM, CNA H stated that when transferring a resident with a catheter, the catheter should be hooked at the bottom of the wheelchair. The catheter bag should not be left on the left on the bed because it would cause the urine to go back and could cause infection. Interview with CNA D on 08/24/2023 at 10:52 AM, CNA D stated that the catheter bag should not be placed on top of the bed. The catheter bag should be hooked on the railing below the bed. CNA D said that the urine that is already contaminated will go back and could cause infection. Record review of facility policy, Catheter Care, Urinary, Med-Pass Inc., rev. September 2014 revealed Maintaining Unobstructed Urine Flow . 3. The urinary drainage bag must be held or positioned lower that the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.