Every finding on record at The Homestead of Denison

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A, CNA B, and RN C used the required PPE for Resident #1, who was on EBP due to his tube feeding, foley catheter, and open wound, while performing wound care on 07/19/26. This failure could place the residents at risk of cross-contamination and development of infection.Findings included: Record review of Resident #1's Comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included hypertension (elevated blood pressure), neurogenic bladder (a loss of bladder control caused by brain, spinal cord, or nerve damage), type 2 diabetes mellitus (elevated blood sugar), and Cerebrovascular Accident (occurs when blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients) ( pressure ulcer of sacral region, and local infection of the skin. Resident had no BIMS score documented and was coded under section C1000- Cognitive Skills for Daily Decision Making at 3 which indicated Severely impaired - never/rarely made decisions. Review of section K: Swallowing/Nutritional Status indicated resident had a feeding tube. Record review of Resident #1's comprehensive care plan initiated on 02/03/26, reflected, [Resident #1] required EBP related to feeding tube, wounds, foley catheter. Goal: EBP care should be maintained for the residents entire stay or until wounds have healed or indwelling medical device is no longer needed. Interventions: . Provide patient standard precautions using gowns and gloves during Dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. Record review of Resident #1's Physician Orders Report on 07/19/26 reflected: Nursing intervention: implement and maintain enhanced barrier precautions when performing high contact care activities. Related to indwelling catheter with start dated 11/03/25. Record review of Resident #1's Physician Orders Report on 07/19/26 reflected: Wound Prevention: Apply Triad Cream to Masserated Coccyx Area Cover With Foam Dressing Every Three Days Until Resolved with start date of 07/16/26. Observation on 07/19/26 at 09:45 AM, revealed Resident #1 was on Enhanced barriers precautions. There was signage on the room door that informed visitors/staff he was on enhanced barriers precautions, perform hand hygiene before and after leaving room, necessary PPE to wear in room, and donning/doffing (put on/remove) information. There was a PPE supplies holder hanging over the room door. CNA A and CNA B entered Resident #1's room. Both CNAs washed hands, donned gloves and procced to provide incontinent care for Resident #1 without wearing gowns. Interview with CNA A on 07/19/26 at 10:21 AM, revealed she knew she was supposed to wear a gown for the Resident #1's peri care, but she forgot. She stated she was nervous. She stated she was in-serviced regarding different type of infection control during orientation. She stated the risk of not wearing proper PPE in enhanced barriers precautions residents' rooms was exposing herself and others to the development of infection and spreading germs from one resident to another resident. Interview with CNA B on 07/19/26 at 10:29 AM, revealed she knew that she supposed to wear a gown for the Resident #1's peri care, but she forgot, because she did not pay attention to the signage in front of the room. She could not recall the last time she had in service on infection control. She stated the risk to residents' cross contamination and development of infection. Observation on 07/19/26 at 09:50 AM, revealed RN C got all supplies ready outside Resident #1's room. RN C entered Resident #1's room, washed hands put on gloves, no gown, explained the procedure to Resident #1 and provided wound care to the sacral area.Interview with RN C on 07/19/26 at 10:21 AM, revealed he was supposed to wear proper PPE (gown and gloves) while performing wound care for Resident #1. He stated failure to follow proper infection control including putting on proper PPE would cause cross contamination and spread of infection. He stated he had done training on infection control, and wound care. In an interview with the DON on 07/19/26 at 1:12 PM, she stated they had in serviced the staff that for anyone with a catheter or tube feeding they were required to wear a gown when performing direct care. She stated the risk was potential spread of multi-drug-resistant organism (MDRO) from resident to resident. She stated he DON and the ADON were responsible for doing routine rounds to monitor staff following proper infection control policy. Record review of the facility's policy, Infection control Policy and Procedure Manual revised August 2007-, dated 3/2024, reflected, Precaution: Enhanced Barrier Precautions- Applies to all residents with any of the following: infection control with an MDRO when contact precautions do not otherwise apply: Wounds and /or indwelling medical devices (e.g. central line, urinary catheter, feeding tube.PPE potential exposure to: during high-contact resident care activities: .changing briefs or assisting with toileting.wound care: any skin opening requiring a dressing. Required PPE: Gloves and gowns prior to the high contact care activity.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #4 and Resident #54) of 5 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #4's care plan reflected changes with oxygen being continuous to PRN and failed to reflect Resident #4's non-compliance with wearing her oxygen.2. The facility failed to ensure Resident #54's care plan reflected Resident #54 changing the oxygen settings from the physician's ordered 4lpm. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health. Findings Include: Resident #4 Review of admission Record for Resident #4 dated 03/26/2026 revealed Resident #4 was an [AGE] year-old female who was admitted to the facility originally on 11/21/2024 and readmitted on [DATE]. Resident #4 was diagnosed with Acute and Chronic Respiratory Failure (long term condition where the lungs cannot maintain adequate oxygen levels or remove carbon dioxide effectively, leading to progressive health complications), Dysphagia following Cerebral Infarction (difficulty swallowing from a complication of a stroke), Chronic Obstructive Pulmonary Disease (chronic airflow blockage, making it difficult to breath), and Alzheimer's Disease (progressive neurodegenerative disorder that primarily affects memory, thinking and behavior, and is the most common cause of dementia). Review of Resident #4's MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 3 which indicated she was severely cognitively impaired. Resident #4 had received oxygen therapy in the past 14 days. Resident #4 was noted to experience shortness of breath or trouble breathing when lying flat. Review of Resident #4's care plan dated 12/04/2024 revealed Focus [Resident #4] has dx [diagnosis] of COPD.Goal.Will be free of s/sx [signs and symptoms] of respiratory infections through review date .Interventions.OXYGEN SETTINGS per orders.every shift. NOTE: There was no information related to Resident #4's noncompliance with wearing oxygen or changes to her physician's orders for oxygen use. Review of Resident #4's Physician Order Summary Report dated 03/25/2026 revealed Resident #4 was ordered Oxygen Administer continuous oxygen at 2-4L [liters] per NC [nasal cannula], Keep sats > 92% (Per nasal cannula or mask type); may remove for ADLs; Keep HOB [head of bed] elevated for sob [shortness of breath] while laying [sic] flat. The order began on 10/22/2025 and was discontinued on 03/25/2026. Review of Resident #4's Physician Order Summary Report dated 03/26/2026 revealed Resident #4 was ordered Oxygen: Administer oxygen at 2-4 Liters per minute related to SOB SpO2<92% (shortness of breath or with oxygen saturations below 92%) as needed. The order began on 03/26/2026. Review of Resident #4's March MAR revealed Oxygen Administer continuous oxygen at 2-4L [liters] per NC [nasal cannula], Keep sats > 92% (Per nasal cannula or mask type); may remove for ADLs; Keep HOB [head of bed] elevated for sob [shortness of breath] while laying [sic] flat every shift. 03/01/2026-03/25/2026 were signed off by a nurse as oxygen was administered continuously at 2-4liters per minute. Order was discontinued on 03/25/2026. Review of Resident #4's March MAR revealed Oxygen: Administer oxygen at 2-4 Liters per minute related to SOB SpO2<92% (shortness of breath or with oxygen saturations below 92%) as needed. On 03/26/2026 on evening/night shift was signed off as having administered 2-4lpm of oxygen as needed. Observation on 03/24/2026 at 9:55 AM revealed Resident #4 was out of her room. Resident #4's oxygen concentrator was running on 3 1/2 lpm. Resident #4 was not wearing the oxygen. Observation on 03/24/2026 at 10:19 AM revealed Resident #4 was in the activity room putting puzzles together with other residents. Resident #4 had a rollator and no oxygen was attached or with Resident #4. Observation on 03/24/2026 at 11:09 AM revealed Resident #4 was in the dining room waiting for lunch to be served. Resident #4 had a rollator and no oxygen was attached or with Resident #4. Observation on 03/25/2026 at 11:00 AM revealed Resident #4 was in the dining room waiting for lunch to be served. Resident #4 had a rollator and no oxygen was attached or with Resident #4. Observation on 03/26/2026 at 9:41 AM revealed Resident #4 was in the sitting area at the front of the building, with other residents. Resident #4 had a rollator and no oxygen was attached or with Resident #4. Observation on 03/26/2026 at 9:45 AM revealed Resident #4 up walking into her room with her rollator. No oxygen was noted with Resident #4. There were no signs or symptoms of shortness of breath. Interview with DON on 03/26/2026 at 9:43 AM revealed Resident #4 used her oxygen mostly when she was in bed. DON stated there was a time Resident #4 required the oxygen continuously but Resident #4 was non-compliant with wearing her oxygen due to her cognitive status. DON stated there had been no concerns with Resident #4 being short of breath due to being non-compliant with wearing her oxygen or no longer using the oxygen continuously. DON stated she reviewed care plans and stated it was noted as Oxygen per orders under the diagnosis of COPD. DON stated there was no additional information in the care plan regarding Resident #4's non-compliance with wearing her oxygen or the changes in her physician's order for oxygen use. Review of Progress Notes for Resident #4 dated 01/01/2026-03/25/2026 revealed no documentation regarding Resident #4's non-compliance with wearing her oxygen. Resident #54 Review of admission Record for Resident #54 dated 03/24/2026 revealed Resident #54 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 was diagnosed with Chronic Obstructive Pulmonary Disease (chronic airflow blockage, making it difficult to breath), Acute and Chronic Respiratory Failure with Hypercapnia (critical condition where the lungs fail to eliminate carbon dioxide), Emphysema (chronic, progressive lung disease, typically caused by smoking, where air sacs are destroyed, causing severe shortness of breath), Nicotine Dependence (chronic, relapsing brain addiction to tobacco products, driven by nicotine's stimulation of dopamine), Obstructive Sleep Apnea (common, serious disorder where throat muscles relax during sleep, causing the airway to collapse and breathing to repeatedly stop and start) and Type 2 Diabetes Mellitus with Diabetic Autonomic Polyneuropathy (chronic complication where prolonged high blood sugar damages multiple peripheral nerves). Review of Resident #54's MDS assessment dated [DATE] revealed Resident #54 had a BIMS score of 12 which indicated she was moderately cognitively impaired. Resident #54 had received oxygen therapy in the past 14 days. Resident #54 was noted to experience shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat. Review of Resident #54's care plan dated 12/26/2024 updated on 01/29/2026 revealed Focus [Resident #54] has oxygen therapy and bipap at hs [night] r/t [related to] resp [respiratory] failure, pulmonary emphysema/COPD, pulmonary nodules. Removes O2 on her own. Educated to place in bag, but is noncompliant.Goal.[Resident #54] will have no s/sx [signs and symptoms] of poor oxygen absorption through the review date.Interventions.For resident who should be ambulatory, provide extension tubing or portable oxygen apparatus.Observe for s/sx of respiratory distress and report the MD PRN [doctor as needed]: Respirations, Pulse, oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis [excessive, generalized sweating unrelated to heat or exercise], Headaches, Lethargy, Confusion, Atelectasis [partial or complete collapse of a lunching], Hemoptysis [coughing up of blood or blood-stained mucus from lungs or airways often caused by infections like bronchitis or tuberculosis], Cough, Pleuritic pain [sharp, stabbing or burning pain that intensifies with breathing, coughing or sneezing, caused by inflammation of lung lining], Accessory muscle usage, Skin color.OXYGEN SETTINGS per orders.Focus.[Resident #54] has altered respiratory status/difficulty breathing r/t COPD, resp failure, Multiple pulmonary nodules, Pulmonary emphysema .Goal.[Resident #54] will have no complications related to SOB though [sic] the review date. OXYGEN SETTINGS: Oxygen: Administer continuous oxygen at [4 LPM] Liters per (PER NASAL CANNULA; MAY REMOVE FOR ADLS; KEEP HOB ELEVATED FOR SOB WHILE LAYING FLAT).NOTE: There was no information regarding Resident #54 changing the oxygen settings. Review of Resident #54's Physician Order Summary Report dated 03/24/2026 revealed Resident #54 was ordered Oxygen Administer continuous oxygen at (4LPM) Liters per (PER NASAL CANNULA; MAY REMOVE FOR ADLS; KEEP HOB [head of bed] ELEVATED FOR SOB [shortness of breath] WHILE LAYING [sic] FLAT every shift. The order began on 11/30/2024. Review of Resident #54's March MAR revealed Oxygen: Administer continuous oxygen at (4LPM) Liters per (PER NASAL CANNULA: MAY REMOVE FOR ADLS; KEEP HOB ELEVATED FOR SOB WHILE LAYING FLAT) every shift. March 1, 2026-March 24, 2026 were signed off by a nurse as oxygen was administered continuously at 4liters per minute. Review of Resident #54's Progress Notes from 02/01/2026 to 03/25/2026 revealed no information regarding Resident #54 being educated over oxygen concentrator settings or the oxygen settings being changed by the resident. Observation on 03/24/2026 at 9:50 AM revealed Resident #54 sitting in her recliner in her room. Resident #54 was receiving oxygen via nasal cannula at 6lpm. Resident #54 stated she should have her oxygen on 5 1/2lpm but stated she turns the oxygen up to 6lpm to catch her breath. Observation on 03/25/2026 at 11:33 AM revealed Resident #54 had come inside from smoking. Resident #54 stated she was waiting for the nurse to come to administer her nebulizer treatment. Resident #54's oxygen concentrator was set on 5lpm. Observation and interview with LVN B on 03/25/2026 at 11:44 AM revealed she had worked at the facility since September 2025. LVN B stated the facility's policy was to check the concentrator setting one time per shift. LVN B stated she randomly checked each resident on oxygen concentrator settings throughout her shift (6:00 AM to 6:00 PM). LVN B stated she had not checked Resident #54's oxygen settings that day. LVN B stated Resident #54's physician's order was for 4lpm but Resident #54 would change the settings several times throughout the day. LVN B stated Resident #54 had to be re-educated and the oxygen settings turned down. LVN B checked the EHR and verified Resident #54 was ordered 4lpm via nasal cannula. Together with LVN B observation was made of Resident #54's oxygen concentrator's settings. LVN B stated Resident #54's concentrator was set to almost 5lpm. LVN B turned down the setting to 4lpm and explained to Resident #54 that she needed to make sure the oxygen settings remained on 4lpm. As LVN B was leaving Resident #54's room she explained Resident #54 liked to turn her oxygen up to 6lpm. LVN B stated this was a concern because turning the oxygen concentrator settings up too high could cause Resident #54's blood to be over oxygenated and could cause Resident #54's breathing to be altered. Interview with DON on 03/25/2026 at 12:02 PM revealed nurses should be checking the oxygen settings on each resident's oxygen concentrators each shift. DON stated Resident #54 liked to turn up their oxygen settings. Each time this was found DON stated she expected the nurse to educate the resident and turn it back down. DON stated Resident #54 had been educated on numerous occasions, including having the hospice chaplain meet with Resident #54. DON stated oxygen settings should follow physician's order because there was a risk of causing respiratory distress. DON stated there should be a care plan for Resident #54's non-compliance with oxygen settings. DON stated she thought she updated the care plan at the same time it was documented that Resident #54 was non-compliant with bagging her nasal cannula when it was not in use. DON reviewed the care plans in the EHR and confirmed there was no mention in the care plan regarding Resident #54's known behavior of changing her oxygen settings. Review of Goals and Objectives, Care Plans dated 03/20/2025 revealed Policy StatementCare plans shall incorporate goals and objectives that lead to the residents' highest obtainable level of independence.Policy Interpretation and Implementation1. Care plan goals and objectives are defined as the desired outcome for a specific resident problem.2. When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly.3. Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment and:a. Are resident oriented.b. Are behaviorally stated.c. Are measurable; andd. Contain timetables to meet the residents' needs in accordance with the comprehensive assessment.4. Goals and objectives are entered into the resident's care plan so that all disciplines have access to such information and can report whether or not the desired outcomes are being achieved.5. Goals and objectives are reviewed and/or revised:a. When there has been a significant change in the residents' condition.b. When the desired outcome has not been achieved.c. When the resident has been readmitted to the facility from a hospital/ rehabilitation stay; andd. At least quarterly.6. The residents have the right to refuse to participate in establishing care plan goals and objectives. When such refusals are made, appropriate documentation will be entered into the resident's clinical records in accordance with established policies.

Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility dietary staff failed to ensure temperatures were taken of all hot and cold foods before serving them to residents during lunch meal service on 3/24/26.The facility dietary staff failed to ensure the potato salad was at the proper holding temperature for lunch service on 3/24/26.The facility dietary staff failed to ensure all seasonings used for food preparation were not past the used by date. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination.Record review of the facility recipe Apple Crisp dated 10/22/25 reflected .May serve warm or cold. Critical Control Point - Maintain at an internal temperature of less than 41 Fahrenheit. Critical Control Point - Reheat: To an internal temperature of 165 Fahrenheit held for 15 seconds, within 2 hours one time only. Record review of the facility recipe Potato Salad dated 10/22/25 reflected .serve cold, 1/2 cup each. Critical Control Point - Maintain at an internal temperature of less than 41 Fahrenheit. An observation and interview with the Dietary Manager in the kitchen on 03/24/2026 at 9:00 a.m. revealed Dill Weed spice container about 1/3 full, with a written date of 1/4/25 and a used by date of 6/30/25. The Dietary Manager revealed the written date on the container was the date the dietary staff opened Dill Weed. The used by date was the date the item should have been used by and discarded. The Dietary Manager stated if the item was past the used by date she would check the color and smell to determine if it should have been used. The Dietary Manager immediately threw the Dill Weed away. The Dietary Manager stated she had kept the spice in case she needed it, but it was only being used for a recipe they no longer had. The Dietary Manager stated she had not used Dill Weed in a long time. An observation and interview of Dietary Aide A in the kitchen taking food temperatures on 3/24/26 at 10:33 a.m. revealed the Potato salad was 103.2 Fahrenheit. Dietary Aide A proceeded to put the potato salad on the steam table in a bed of ice. Dietary Manager intervened and stated the salad should have been cold and would put it back in the freezer until it was time to serve at 11:00 a.m. to give it an opportunity to cool down. The Dietary Manager took the salad and placed it in the freezer. At 10:48 a.m. the Dietary Manager took some okra out of the fryer and poured them onto the steam table without temping them. At 10:56 a.m. the Dietary Manager took the temperature of the potato salad again and it was at 92.6 Fahrenheit. The Dietary Manager then put the potato salad in the serving area on ice and Dietary Aide A stated she was ready to serve. The Surveyor intervened and told Dietary Aide A they should not serve the potato salad because it was not held at the appropriate temperature. Dietary Aide A told the Dietary Manager they could not serve the potato salad and the Dietary Manager stated they would substitute it out for potato chips. The Dietary Manager removed the potato salad from the service area then got the potato chips and began portioning them out to serve the trays. At 11:03 a.m. Dietary Aide A served the first tray with the fried okra and an unknown staff put the plate of food on a tray with a covered apple dessert. The apple desserts were not temped prior to serving and had been on the racks since 10:33am. An observation of the lunch test tray on 03/24/2026 at 12:31p.m. revealed the following items: water, tea, potato chips, apple cobbler, sloppy joe with bun and fried okra. The Dietary Manager and 2 surveyors tasted the food. The apple cobbler was cool and at room temperature. The okra was hot. Interview with the Dietary Manager on 03/24/2026 at 12:33 PM revealed all foods should have been temped including hot and cold foods prior to serving. The Dietary Manager stated hot foods should have a temperature higher than 160 degrees and cold foods should have a temp lower than 40 degrees. The Dietary Manager stated the cobbler should have been hot, but she had no way to keep it hot after cooking it that morning. The Dietary Manager stated she temped the apple cobbler when she cooked it that morning but had not temped it prior to food service. The Dietary Manager recalled temping the okra but noted she had made several batches of okra and did not temp all of the batches of okra that day. The Dietary Manager stated if foods were not temped appropriately the food could have been cold or too hot. The Dietary Manager stated not having had the potato salad at the right temperature could have resulted in residents getting sick. The Dietary Manager was unsure of the reason the potato salad was so hot, as she typically made it the day of and was usually cold at lunch. The Dietary manager stated she had thrown out the potato salad and the Dill Weed seasoning. The Dietary Manager stated the risk to the residents of possibly using expired seasoning would have been it could have made them sick. An interview with the Administrator on 03/26/2026 at 11:26 AM revealed the expectation was all food should have been temped prior to serving and any food in the danger zone should have not been served. The Administrator stated hot food should have been hot and cold foods should have been cold. The risk to the residents of foods not having been at the appropriate temperature was food borne illness. The Administrator stated the expectation for seasonings used for food preparation was they should have been labeled on the outside with the expiration date and the dietary staff should have been checking the seasonings every time they use it to ensure it had not passed the used by date. The Administrator stated the risk to the residents of using expired seasonings could haveaffected the quality and taste of the food. The Administrator stated he frequently tasted the food to ensure quality and planned on in-servicing the dietary staff on food temps, following recipes and ensuring all fried foods were temped. Requested facility policy related to expiration dates and used by date from the Administrator on 3/24/26 but was informed they did not have a policy specifically related to it. The facility did not submit a policy by the date and time of exit. Record review of the facility policy Food Preparation and Service revised July 2014 reflected .1. The danger zone for food temperatures is between 41 Fahrenheit and 135 Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, potentially hazardous food must be maintained below 41 Fahrenheit or above 135 Fahrenheit. Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) may cause foodborne illness. 5. The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms: Poultry and stuffed foods - 165 Fahrenheit. Ground meat, ground fish and eggs held for service - at least 115 Fahrenheit. Fish and other meats - 145 Fahrenheit for 15 seconds. Fresh, frozen or canned fruits/vegetables - 135 Fahrenheit. Unpasteurized eggs - until all parts of the egg (yolks and whites) are completely firm (160 Fahrenheit) Foods cooked in a microwave - 165 Fahrenheit in all parts of the food. It is critical to measure the food temperature at multiple sites and allow the food to stand covered for two (2) minutes after microwave heating.6. Previously cooked food must be reheated to an internal temperature of 165 Fahrenheit for at least 15 seconds. Re-heated foods that are not consumed within 2 hours will be discarded . 3. The temperature of foods held in steam tables will be monitored by food service staff.9. Snacks will not be left on trays or countertops beyond the established safe time and temperature requirements.

Based on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for two of four residents (Resident #4 and #54) reviewed for quality of care. The facility failed to ensure the supplemental oxygen was provided at the physician ordered rate for Residents #4 and #54. This failure could place residents who received oxygen therapy at risk of oxygen toxicity.Findings included: Resident #4 Review of admission Record for Resident #4 dated 03/26/2026 revealed Resident #4 was an [AGE] year-old female who was admitted to the facility originally on 11/21/2024 and readmitted on [DATE]. Resident #4 was diagnosed with Acute and Chronic Respiratory Failure (long term condition where the lungs cannot maintain adequate oxygen levels or remove carbon dioxide effectively, leading to progressive health complications), Dysphagia following Cerebral Infarction (difficulty swallowing from a complication of a stroke), Chronic Obstructive Pulmonary Disease (chronic airflow blockage, making it difficult to breath), and Alzheimer's Disease (progressive neurodegenerative disorder that primarily affects memory, thinking and behavior, and is the most common cause of dementia). Review of Resident #4's MDS assessment dated [DATE] revealed Resident #4 had a BIMS score of 3 which indicated she was severely cognitively impaired. Resident #4 had received oxygen therapy in the past 14 days. Resident #4 was noted to experience shortness of breath or trouble breathing when lying flat. Review of Resident #4's care plan dated 12/04/2024 revealed Focus [Resident #4] has dx [diagnosis] of COPD.Goal.Will be free of s/sx [signs and symptoms] of respiratory infections through review date .Interventions.OXYGEN SETTINGS per orders.every shift. Review of Resident #4's Physician Order Summary Report dated 03/25/2026 revealed Resident #4 was ordered Oxygen Administer continuous oxygen at 2-4L [liters] per NC [nasal cannula], Keep sats > 92% (Per nasal cannula or mask type); may remove for ADLs; Keep HOB [head of bed] elevated for sob [shortness of breath] while laying [sic] flat. The order began on 10/22/2025 and was discontinued on 03/25/2026. Review of Resident #4's Physician Order Summary Report dated 03/26/2026 revealed Resident #4 was ordered Oxygen: Administer oxygen at 2-4 Liters per minute related to SOB SpO2<92% (shortness of breath or with oxygen saturations below 92%) as needed. The order began on 03/26/2026. Review of Resident #4's March MAR revealed Oxygen Administer continuous oxygen at 2-4L [liters] per NC [nasal cannula], Keep sats > 92% (Per nasal cannula or mask type); may remove for ADLs; Keep HOB [head of bed] elevated for sob [shortness of breath] while laying [sic] flat every shift. 03/01/2026-03/25/2026 were signed off by a nurse as oxygen was administered continuously at 2-4liters per minute. Order was discontinued on 03/25/2026. Review of Resident #4's March MAR revealed Oxygen: Administer oxygen at 2-4 Liters per minute related to SOB SpO2<92% (shortness of breath or with oxygen saturations below 92%) as needed. On 03/26/2026 on evening/night shift was signed off as Resident #4 received 2-4 liters per minute of oxygen as needed. Observation on 03/24/2026 at 9:55 AM revealed Resident #4 was out of her room. Resident #4's oxygen concentrator was running on 3 1/2 lpm [liters per minute]. Resident #4 was no wearing the oxygen Observation on 03/24/2026 at 10:19 AM revealed Resident #4 was in the activity room putting puzzles together with other resident. Resident #4 had a rollator and no oxygen was attached or with Resident #4. Observation on 03/24/2026 at 11:09 AM revealed Resident #4 was in the dining room waiting for lunch to be served. Resident #4 had a rollator and no oxygen was attached or with Resident #4. Observation on 03/25/2026 at 11:00 AM revealed Resident #4 was in the dining room waiting for lunch to be served. Resident #4 had a rollator and no oxygen was attached or with Resident #4. Observation on 03/26/2026 at 9:41 AM revealed Resident #4 was in the sitting area at the front of the building, with other residents. Resident #4 had a rollator and no oxygen was attached or with Resident #4. Observation on 03/26/2026 at 9:45 AM revealed Resident #4 up walking into her room with her rollator. No oxygen was noted with Resident #4. There were no signs or symptoms of shortness of breath. Interview with DON on 03/26/2026 at 9:43 AM revealed Resident #4 used her oxygen mostly when she was in bed. DON stated there was a time Resident #4 required the oxygen continuously but Resident #4 was non-compliant with wearing her oxygen due to her cognitive status. DON stated due to Resident #4 being non-compliant and Resident #4 doing better than she had been the order was changed to as needed instead of continuous on the evening of 03/25/2026. DON stated there had been no concerns with Resident #4 being short of breath due to being non-compliant with wearing her oxygen or no longer using the oxygen continuously. Review of Progress Notes for Resident #4 dated 01/01/2026-03/25/2026 revealed no documentation regarding Resident #4's non-compliance with wearing her oxygen. Interview with DON on 03/26/2026 at 10:24 AM revealed Resident #4's oxygen orders were changed on 03/25/2026 to reflect her need for oxygen on an as needed basis. DON stated she reviewed the care plan which indicated oxygen was per physician orders. Resident #54 Review of admission Record for Resident #54 dated 03/24/2026 revealed Resident #54 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #54 was diagnosed with Chronic Obstructive Pulmonary Disease (chronic airflow blockage, making it difficult to breath), Acute and Chronic Respiratory Failure with Hypercapnia (critical condition where the lungs fail to eliminate carbon dioxide), Emphysema (chronic, progressive lung disease, typically caused by smoking, where air sacs are destroyed, causing severe shortness of breath), Nicotine Dependence (chronic, relapsing brain addiction to tobacco products, driven by nicotine's stimulation of dopamine), Obstructive Sleep Apnea (common, serious disorder where throat muscles relax during sleep, causing the airway to collapse and breathing to repeatedly stop and start) and Type 2 Diabetes Mellitus with Diabetic Autonomic Polyneuropathy (chronic complication where prolonged high blood sugar damages multiple peripheral nerves). Review of Resident #54's MDS assessment dated [DATE] revealed Resident #54 had a BIMS score of 12 which indicated she was moderately cognitively impaired. Resident #54 had received oxygen therapy in the past 14 days. Resident #4 was noted to experience shortness of breath or trouble breathing with exertion, when sitting at rest and when lying flat. Review of Resident #54's care plan dated 12/26/2024 updated on 01/29/2026 revealed Focus [Resident #54] has oxygen therapy and bipap at hs [night] r/t [related to] resp [respiratory] failure, pulmonary emphysema/COPD, pulmonary nodules. Removes O2 on her own. Educated to place in bag, but is noncompliant.Goal.[Resident #54] will have no s/sx [signs and symptoms] of poor oxygen absorption through the review date.Interventions.For resident who should be ambulatory, provide extension tubing or portable oxygen apparatus.Observe for s/sx of respiratory distress and report the MD PRN [doctor as needed]: Respirations, Pulse, oximetry, Increased heart rate (Tachycardia), Restlessness, Diaphoresis [excessive, generalized sweating unrelated to heat or exercise], Headaches, Lethargy, Confusion, Atelectasis [partial or complete collapse of a lunching], Hemoptysis [coughing up of blood or blood-stained mucus from lungs or airways often caused by infections like bronchitis or tuberculosis], Cough, Pleuritic pain [sharp, stabbing or burning pain that intensifies with breathing, coughing or sneezing, caused by inflammation of lung lining], Accessory muscle usage, Skin color.OXYGEN SETTINGS per orders.Focus.[Resident #54] has altered respiratory status/difficulty breathing r/t COPD, resp failure, Multiple pulmonary nodules, Pulmonary emphysema .Goal.[Resident #54] will have no complications related to SOB though [sic] the review date. OXYGEN SETTINGS: Oxygen: Administer continuous oxygen at [4 LPM] Liters per (PER NASAL CANNULA; MAY REMOVE FOR ADLS; KEEP HOB ELEVATED FOR SOB WHILE LAYING FLAT). NOTE: There was no information regarding Resident #54 changing the oxygen settings.Review of Resident #54's Physician Order Summary Report dated 03/24/2026 revealed Resident #54 was ordered Oxygen Administer continuous oxygen at (4LPM) Liters per (PER NASAL CANNULA; MAY REMOVE FOR ADLS; KEEP HOB [head of bed] ELEVATED FOR SOB [shortness of breath] WHILE LAYING [sic] FLAT every shift. The order began on 11/30/2024. Review of Resident #54's March MAR revealed Oxygen: Administer continuous oxygen at (4LPM) Liters per (PER NASAL CANNULA: MAY REMOVE FOR ADLS; KEEP HOB ELEVATED FOR SOB WHILE LAYING FLAT) every shift. March 1, 2026-March 24, 2026 were signed off by a nurse as oxygen was administered continuously at 4liters per minute. Observation on 03/24/2026 at 9:50 AM revealed Resident #54 sitting in her recliner in her room. Resident #54 was receiving oxygen via nasal cannula at 6lpm. Resident #54 stated she should have her oxygen on 5 1/2lpm but stated she turns the oxygen up to 6lpm to catch her breath. Observation on 03/25/2026 at 11:33 AM revealed Resident #54 had come inside from smoking. Resident #54 stated she was waiting for the nurse to come to administer her nebulizer treatment. Resident #54's oxygen concentrator was set on 5lpm. Observation and interview with LVN B on 03/25/2026 at 11:44 AM revealed she had worked at the facility since September 2025. LVN B stated the facility's policy was to check the concentrator setting one time per shift. LVN B stated she randomly checked each resident on oxygen concentrator settings throughout her shift (6:00 AM to 6:00 PM). LVN B stated she had not checked Resident #54's oxygen settings that day. LVN B stated Resident #54's physician's order was for 4lpm but Resident #54 would change the settings several times throughout the day. LVN B stated Resident #54 had to be re-educated and the oxygen settings turned down. LVN B checked the EHR and verified Resident #54 was ordered 4lpm via nasal cannula. Together with LVN B observation was made of Resident #54's oxygen concentrator's settings. LVN B stated Resident #54's concentrator was set to almost 5lpm. LVN B turned down the setting to 4lpm and explained to Resident #54 that she needed to make sure the oxygen settings remained on 4lpm. As LVN B was leaving Resident #54's room she explained Resident #54 liked to turn her oxygen up to 6lpm. LVN B stated this was a concern because turning the oxygen concentrator settings up too high could cause Resident #54's blood to be over oxygenated and could cause Resident #54's breathing to be altered. Interview with DON on 03/25/2026 at 12:02 PM revealed nurses should be checking the oxygen settings on each resident's oxygen concentrators each shift. DON stated Resident #54 liked to turn up their oxygen settings. Each time this was found DON stated she expected the nurse to educate the resident and turn it back down. DON stated Resident #54 had been educated on numerous occasions, including having the hospice chaplain meet with Resident #54. DON stated oxygen settings should follow physician's order because there was a risk of causing respiratory distress. Review of Oxygen Administration dated revised February 2025 reflected Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration, and infection prevention associated with respiratory therapy tasks, Preparation1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess any special needs of the resident.3. Assemble the equipment and supplies as needed.General Guidelines1. Oxygen therapy is administered by an oxygen mask, nasal cannula, and/or nasal catheter.a. The oxygen mask is a device that fits over the resident's nose and mouth. It is held in place by an elastic band placed around the resident's head.b. The nasal cannula is a tube that is placed into the resident's nose. It is held in place by an elastic band placed around the resident's head.c. The nasal catheter is a piece of tubing inserted through the resident's nostrils into the back of his/her mouth. It is held in place by a piece of skin tape attached to the resident's forehead and/or cheek.AssessmentBefore administering oxygen, and while the resident is receiving oxygen therapy, assess for the following:1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes);2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion).3. Signs or symptoms of oxygen toxicity (i.e., tracheal irritation, difficulty breathing, or slow, shallow rate of breathing).4. Vital signs.5. Lung sounds.6. Oxygen saturation, if applicable; and7. Other laboratory results, if applicable.ReportingNotify the Physician or Nurse Practitioner if the resident refuses the procedure.

Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #71) of 3 observed for infection control. The facility failed to ensure CNA D changed gloves and completed hand hygiene during incontinent care for Resident #71 on 3/25/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness.Record review of Resident #71's Comprehensive MDS assessment dated [DATE] reflected Resident #71 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cerebral infarction (a condition caused by a blockage in blood vessels supplying the brain, resulting in tissue death), hemiplegia (paralysis that affects one entire side of the body causing severe loss of muscle function, strength, and control) affecting left side, and elevated blood pressure. Resident #71's BIMS score was 99, which indicated Resident #71 was unable to complete the interview. The MDS assessment indicated Resident #71 required maximal assistance with toileting hygiene. Observation on 03/25/26 at 1:24 PM revealed CNA D and CNA F entered Resident #71's room to provide incontinence care. Both CNAs washed their hands and donned gloves, CNAD unfastened Resident #71's brief, she then provided peri-care to the resident, wiping across the resident's pubis bone and then down each groin. She rolled resident on her side, CNA E supported resident when she was on her side. CNA D wiped the resident's buttock area with peri-wipes, front to back, she then removed the soiled brief and with soiled gloves, placed the clean brief under the resident. She rolled the resident on her back onto the clean brief. Once finished, she fastened the resident's brief. Without changing gloves CNA D covered resident and she lowered the resident's bed to low position. Both CNAs removed and discarded gloves and washed their hands. In an interview on 03/25/26 at 1:47 PM, CNA D stated she should change her gloves and perform hand hygiene when she went from dirty to clean. CNA D stated failing to provide proper care exposed the residents to infections. In an interview on 03/26/26 at 9:18 AM, the DON stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. She stated CNAs were trained to perform hand hygiene between change of gloves. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated she would educate all nursing staff and she would do random rounds for monitoring. Record review of the facility's policy, Hand Washing/Hand Hygiene, revised December 2023, reflected, .Use an alcohol-based hand rub or water for the following situations . Before moving from a contaminated body site to a clean body site during resident care .

Based on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 (Med Cart Hall 400) of 2 medication carts reviewed for pharmacy services in that: The facility failed to ensure LVN F responsible for Nurses Cart Hall 400, removed medications in unsecure containers from the Nurses Cart. This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications, and place residents at risk of not having the medication available due to possible drug diversion.Record review and observation on 03/24/26 at 10:20 AM of Med Cart Hall 400, with LVN F revealed the blister pack for Resident #21's lorazepam 0.5 mg tablet (controlled medication used for anxiety) had 1 blister seal broken and the pill still inside the broken blister. Interview on 03/24/26 at 10:30 AM, LVN F stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken, and she was not aware of who might have damaged the blister. She stated the risk would be potential for drug diversion. She stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated when a broken seal was observed, she would waste the pill with another nurse. At an interview on 03/26/26 at 9:18 AM, the DON stated that if a blister pack medication seal was broken the pill would be discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. The DON stated the risk would be potential for drug diversion and infection control issues. She stated nurses were responsible for checking the medication blister packs for broken seals during the count on the change of shifts. The DON stated she was supposed to check the carts daily. The DON stated the pharmacy consultant checked the carts monthly and she would be doing random checks of the medication carts for monitoring. Record review of the facility's policy titled Storage of Medications, revised April 2019, revealed in part . Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy . Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 resident (Resident #2) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #2 had his fingernails trimmed on both hands on 03/24/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life.Record Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male with initial admission date of 11/20/2020 to the facility. His pertinent diagnoses included: hemiplegia (paralysis that affects one side of the body, causing severe or total loss of motor function in the arm, leg, and sometimes face) affecting right dominant side, hyperkalemia (elevated potassium), Diabetes mellitus (elevated blood glucose levels), cerebral infarction (is a condition caused by a blockage in blood vessels supplying the brain, resulting in tissue death). His cognitive skills for daily decision making were severely impaired. The BIMS score was 99, which indicated Resident #2 was unable to complete the interview. Resident #2 was dependent on staff for his personal hygiene. Review of Resident #2 's Comprehensive Care Plan, revised 11/17/2025 reflected, Focus: [Resident #2] requires assist with ADLs related to . CVA (cerebral infarction) with residual effects, right sided hemiplegia.Interventions: Hygiene: [Resident #2] requires total assistance with personal . In an observation on 03/24/2026 at 11:28 AM revealed Resident #2 had long and jagged nails on both hands measuring approximately 0.2 - 0.4 inches in length extending from the tip of his fingers. Resident #2 was not verbal. In an interview on 03/25/2026 at 9:20 AM with LVN C stated that Nurses and CNAs were responsible for clipping residents' fingernails. She stated that for residents with diabetes, Nurses were responsible for trimming fingernails as needed. LVN C stated the risks of long, dirty fingernails included skin tears, increased risk of infection and decreased quality of life. In an interview on 03/26/2026 at 9:18 AM, the DON stated her expectation was that ADL care be provided as needed, particularly during shower days. She stated that CNAs were responsible for providing nail care, including trimming fingernails, unless the resident had a diagnosis of diabetes. She stated that charge nurses were responsible for monitoring this care. The DON stated that residents having long, dirty fingernails could result in skin breakdown, potential of infections and dignity concerns. Record review of the facility policy Care of Fingernails/Toenails, revised in October 2010 reflected The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . Nail care includes daily cleaning and regular trimming .

Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of seven residents (Resident #1) reviewed for abuse. The facility failed to protect Resident #1 from physical abuse by CNA A on 03/30/25, which resulted in Resident #1 sustaining a head injury and contusion to her forehead. The noncompliance was identified as Past Noncompliance IJ. The noncompliance began on 03/30/25 at 6:40 p.m. and ended on 03/31/25. The facility had corrected the noncompliance before the incident investigation began on 07/15/2025. This failure could place residents at risk of serious abuse, injury and harm. Findings included: Record review of Resident #1's face sheet, dated 07/15/25, reflected she was a [AGE] year-old female, admitted to the facility on [DATE] with the diagnoses of Alzheimer's and cognitive communication deficit (communication difficulties stemming from impairments in cognitive skills like attention, memory, and problem- solving). Record review of Resident #1's Quarterly comprehensive MDS, dated [DATE], reflected a BIMS of 4, had continuous behaviors of disorganized thinking, no physical or verbal behaviors toward others, was ambulatory without assistive devices and required stand by assistance for ADLs. Record review of Resident #1's care plan, revised on 02/03/25, reflected [Resident #1] has impaired cognitive function or impaired thought process related Alzheimer's/dementia, mental disorder.Interventions.Use the resident's preferred name. Identity yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions.The resident understands consistent, simple, directive sentences. Provide the resident with necessary cues-stop and return if agitated.Keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Record review of Provider Investigation Report (Form 3613-A of Texas Health and Human Services) dated 04/04/2025 reflected, . on 03/30/25 at approximately 07:00 p.m. the DON notified the Administrator that CNA B alleged the CNA A pushed Resident #1 causing her to fall and bump her head. CNA A denied any such allegation claiming it was incidental contact. CNA A was immediately suspended pending investigation. There was no other known witness to the allegation. On 03/30/25 at 06:45 p.m. LVN C conducted a head-to-toe assessment of Resident #1, noting swelling to Resident #1's right forehead. On 03/30/25 Resident #1 was sent to the hospital where she received a CT scan which revealed no intracranial abnormalities (any deviation of typical structure or function of the brain). Resident #1 was returned to the facility later that evening. On 03/31/25 Resident #1 was seen by Psychiatric services that noted Resident #1 wasn't experiencing any emotional distress. On 03/31/25 The facility called the police and reported the incident to them. Officer D was the reporting officer, and the case number was [PHONE NUMBER]. On 03/31/25 Facility Social Worker conducted safe surveys with all Interviewalbe resident with no negative outcomes. On 03/31/25 The administrator visited Resident #1 who was asleep on the couch in the memory care unit. Resident #1 had a bruise and some swelling to her forehead.The investigation reveals through witness statements and resident statement that the allegation of abuse had been confirmed. The facility immediately suspended the alleged perpetrator once the allegation was made. The facility notified the family, physician, and ombudsman. The facility immediately sent Resident #1 out to the hospital to receive treatment which revealed no abnormalities of the intercranial space. The facility called and filed a report with the local police. The facility's social worker conducted safe surveys with all Interviewalbe residents with no negative outcomes. The facility terminated the alleged perpetrator. The facility conducted in-service with staff on abuse/neglect. Record review of CNA B's written statement dated 03/30/25 reflected, Resident #1 walked up to CNA A while she was sitting down eating a sandwich. [Resident #1] Was asking to call her son on the phone. CNA A told her that the phones were not working. [Resident #1] stated the was BS I know that they are working. CNA A stood up, got in [Resident #1's] face nose to nose and told [Resident #1] to get out of her face and she shoved her. [Resident #1] fell and hit her head on the floor. Record review of CNA A's written statement dated 03/30/25 reflected, I [CNA A] came to work on Sunday March 30th, 2025. I was sitting at table taking my daily meds I take every day after I get to work and eating a half of a sandwich before I get going. At that time, I was approached by [Resident #1] asking she could use the phone like she does every day, but today she was really aggressive and being really bossy and not trying to listen to our answers. She was yelling y'all are damn liars. I was just trying to calm her down and explain to her she can, we gotta [sic] clean up trays and all that and we will. I turned around in my chair she was standing at nurse desk. I get up and stood in front of her trying again to explain we will she got up on me put her face in my face and I said please give me my space. [Resident #1] was still talking and yelling at [Resident #2] She turned toward [Resident #2] and somehow, she lost her footing and I watched her leg cross over and she fell that fast. CNA B was sitting right there with us and witnessed it all. She immediately said I pushed her. I did not. I've been a CNA for 33 years. I would never hurt myself or anyone else. My job is to protect this resident. Record review of CNA A's clock in and out for pay period 03/23/25-04/05/25 reflected on 03/30/25 she had clocked in at 06:05 p.m. and clocked out 07:57 p.m. There were no other time entry's after 03/30/25 and she was listed as terminated. Record review of the Incident report for Resident #1 completed on 03/30/25 at 6:25 p.m. by LVN C reflected, Called to Memory care unit by CNA [B] stating resident was in the floor. Upon entering main room of memory care unit resident was observed to be sitting in the floor to the right of the nurse's station, with her legs straight out. She was noted to be wearing socks and tennis shoes with rubber soles. There is a large hematoma noted to the right forehead with no break in the skin. No loss of consciousness. Resident states she fell due to being pushed down by someone while pointing at CNA [A].VS obtained with assessment. No AMS noted. BP 140/51, P-89, R-20, T 97.9. DON of facility, MD and [family member] notified. Transferred to [hospital] ER via EMS for eval per MD recommendation. DON of facility notified administrator. Written statements obtained from both CNAs on memory care unit. Record review of Resident #1's hospital record dated 03/30/25 reflected an admission date of 03/30/25 at 7:29 p.m. and discharge back to the facility on [DATE] at 10:18 p.m. Resident #1 had a CT scan performed which revealed no intracranial hemorrhage (brain bleed). There was noted a small right frontal scalp hematoma (collection of blood underneath the skin of the forehead and scalp, often the resulting from trauma), No skull fracture. No acute intracranial abnormalities (any deviation from the typical structure or function of the brain or its surrounding structure). The discharge diagnosis was head injury and contusion (bruise) of scalp. Record review of the Police reported completed on 03/31/25 by Officer D, reflected he had attempted to interview Resident #1 who was not able to recall the events from the previous night, only that she had sustained an injury to her head. In addition, he spoke with Resident #1's family member who indicated he wished to press charges against CNA A. He interviewed CNA B, and her statement was consistent with the written statement she had made on 03/30/25. Officer D then made contact with CNA A which reflected, .contact was then made with [CNA A] via phone to gather her statement of what occurred the previous evening. [CNA A] advised that on the evening of March 30th, 2025, upon arrival to work the patients were sitting at their tables eating dinner. [CNA A] stated she takes a lot of medications that requires she eat food with, so with the patients busy, she decided to take her medication (did not state what medication) and sit down behind the nurse's desk to eat her food. [CNA A] had mentioned that there were four groups of women always wanted to use the phone to call family and causing issues and Resident #1 was the ringleader. [CNA A] had mentioned that the entire weekend [Resident #1] had been acting very aggressive, hitting people, and doing all kinds of crazy stuff. On this evening [CNA A] stated the [Resident #1] had come up to the desk asking to use the phone. [CNA A] stated that she informed [Resident #1] that once they get everyone settled that she would get the phone number from her nurse so she could make the call. Due to [Resident #1] being forgetful, [CNA A] stated that she had come up to the desk multiple times asking the same question. On roughly the fourth time, [CNA A] stated that [Resident #1] became agitated as she approached the nurse's desk with a large purse on her shoulder as she was followed by another patient only identified as [Resident #2]. [CNA A] stated, I then stood up to go wash my hands or do something. When she stood up, she stated that [Resident #1] was right there, but there was a taller desk in between the two of them. [CNA A] stated that [Resident #1] then leaned over the desk and began screaming in her face, calling her a damn liar and that she was holding them captive. [CNA A] stated that [Resident #1] then began turning back and forth between her and [Resident #2] stating they're not gonna let us out, [CNA A] stated as [Resident #1] turned back towards her, she observed her leg/foot twist and that is what caused her to fall to the ground and strike her head on the floor. [CNA A] stated that she tried to catch [Resident #1] as she was falling, but it happened to fast. [CNA A] stated she immediately got the nurse [LVN C]. [CNA A] had stated I've been an aid for 30 plus years, I don't do something like that. Those people are really aggressive. [CNA A] was advised that due to what had been informed to be up to this point and having a witness statement regarding the incident that the charge of Injury to a Child, Elderly Individual, or Disabled individual (PC 22.049f0) was going to be filed at large against her. She advised she understood. Record review of Resident #1's Psychiatric Subsequent Assessment note completed on 03/31/25 by NP F reflected, .Patient seen today for a new problem.Asked by facility DON to see patient via video telehealth for a recent altercation. Patient seen via telehealth with DON assisting. Pt is able to identify herself by her name and date of birth . Patient denies depressive and/or anxiety symptoms. Pt states I was pushed the other day however overall, I am okay. I know that it was not a resident who did it. It was an employee. I don't' know why they did that. I am not scare [sic] to be here and I feel very staff [sic] here. No overt psychosis detected.Mental Status examination.Short term memory: severely impaired.Long term memory.severely impaired. Observation of Resident #1 on 07/15/25 at 8:55 a.m. revealed her in her room in bed sleeping. In an interview with LVN E on 07/15/25 at 9:10 a.m. she stated she worked the 6 a.m. 6 p.m. shift on 04/01/25 following the incident with Resident #1 on 03/30/25. She stated the resident had a pretty good bruise and knot on her forehead which had also progressed to a black eye to her right eye. She stated the resident told her she had been pushed but was unable to identify who pushed her. She stated Resident #1 frequently request to use the phone and thinks her car is out in the parking lot and wants to call the police and report it stolen. She stated she was usually easily redirected, but at times can get very agitated. She stated they just keep reassuring her and re-directing and offering her another activity. Call placed to CNA A on 07/15/25 at 11:10 a.m. Message was left with a request for a return call. In an observation and interview with Resident #1 on 07/15/25 at 11:15 a.m. resident was observed ambulating in the hallway. Resident was asked if we could go to her room to talk, and resident stated yes. Resident #1 stated she was doing wonderful today. Resident was unable to recall any of the events that had occurred on 03/30/25 and stated she felt safe here and liked it here very much. Return call received from CNA A on 07/15/25 at 12:43 p.m. CNA A stated she had just come on duty on 03/30/25 for her 6 p.m. to 6 a.m. shift. She stated it was her 3rd day of her rotation. She stated it was a rough day. She stated Resident #1 had been aggressive all weekend. She stated she and the other residents all rushed the desk wanting to use the phone. She stated they usually kick in right after supper. She stated she was sitting behind the station eating her sandwich and taking her medications which was her usual routine when she came on duty. She stated Resident #1 kept coming up to the desk and asking to use the phone and she kept telling her to back up. She stated there was a resident behind Resident #1. She stated she stood up and Resident #1 was in her face, and she stated she told her again to back up and get out of her face. She stated Resident #1 went to turn around and got her feet tangled up and fell. She stated as soon as she fell, she yelled that I had pushed her. She stated she thinks in the resident's mind she thinks she pushed her. CNA A denied pushing the resident and denied putting her hands on the resident. CNA A stated CNA B went and got LVN C who came and assessed the resident and sent her to the hospital. She stated she was removed from the unit and asked to write a statement and was then sent home. She stated she tried to call the DON but was not able to reach her. She stated she had been terminated. She stated she was interviewed by the police and was told she would be getting a letter but stated she had not received anything yet. In an interview with Officer D on 07/15/25 at 1:05 p.m. he stated he did come to the facility on [DATE] to complete the report. He stated he spoke with the DON and met with Resident #1 and her family member. He stated Resident #1's family member wanted to press charges against CNA A. He stated he completed his investigation and handed it off to the District Attorney's office who will have the final say on what, if any charges were filed. In an interview with the DON on 07/15/25 at 1:10 p.m. stated she received a call from LVN C after the incident on 03/30/25 and was told about the fall and the allegation that Resident #1 had been pushed by CNA A. She stated she told LVN C to remove CNA A immediately from the unit, have her write her statement and then leave. She stated she then called the Administrator. She stated they also contacted the ADON who lives very close to the facility, to come and begin the investigation. She stated they started the Abuse and Neglect in-services that night and then on 03/31/25 they also in-serviced on Resident Rights, Dementia care, and recognizing and dealing with signs of burn out. She stated they sent the resident out to the hospital for evaluation, contacted the MD, family, police and reported the incident to the State. She stated they had NP F from Psychiatric services evaluate Resident #1 the next day and they monitored her for any changes in physical or emotional distress. She stated after they completed their investigation, they felt there was enough evidence to terminate CNA A. She stated she was very surprised at CNA A's action. She stated she had never had any complaints about her care toward the residents. She stated they try and keep consistent staff in the memory care, so they are familiar with the residents and familiar with what works with the resident for behavior management. She stated any time they place a new employee in the unit they go over each resident and review with them the interventions they had in place for re-direction. She stated asking for the phone and asking for her keys was Resident #1's normal behavior. She stated CNA A should have handed her the phone instead of putting her off, which only escalated the resident's behaviors. In an interview with LVN C on 07/15/25 at 4:19 p.m. she stated she had just come onto her 6 p.m. to 6 a.m. shift on 03/30/25. She stated she was responsible for hall 600 and hall 500 which is the locked unit. She stated she was still getting report from the off going nurse on hall 600 when she got a call from CNA B telling her she needed to come quick to the unit. She stated when she arrived on the unit, CNA B was on the floor by Resident #1 and CNA A was standing behind the resident. She stated CNA B was nervous. She stated CNA B was whispering to her that CNA A had pushed Resident #1. She stated Resident #1 was pointing to CNA A stating she had pushed her, and CNA A was stating she had not pushed her. She stated she evaluated the resident who had a large knot on her forehead. She stated she notified the MD who requested to send the resident out to the hospital for evaluation. She stated after she sent the resident out, she notified the DON about the situation. She stated the DON told her to send CNA A home after she completed her statement and to get a written statement from CNA B. She stated she took CNA A off the unit to the other nurse's station to complete her statement and then she went home. She stated she notified Resident #1's family member of the fall and her transport to the hospital. She stated she had worked with CNA A for several months and had not ever had any issues with her performance. She stated she could get a little overwhelmed at times, but stated she was very thorough with her work. She stated Resident #1 would often get close to you, but stated she thought it was because she was hard of hearing. She stated it was not unusual for her to want to use the phone, often stating she needed to call the police because someone had stolen her car. She stated they would re-direct her with activities or agree with her and she would often forget what she was wanting. She stated the facility started in-services on abuse and neglect that evening and the next day they had in-services on resident rights, dementia care and how to recognize burnout. In an interview on 07/15/25 at 4:36 p.m. with Resident #1's Family member, he said he had no concerns regarding the care of Resident #1. He stated the facility contacted him regarding the incident in March 2025 and that they had terminated the CNA. He stated when he saw Resident #1 the next day, she still had a big goose egg on her forehead and a black eye. He stated he regularly visited with Resident #1 and had not observed any change in behavior. He stated she still seemed to like it at the facility. He stated he does not hold the facility responsible for the actions of the CNA A, but stated he did hold her responsible and had told the police he wanted to press charges. He stated she had no business taking care of the elderly. In an interview with CNA B on 07/15/25 at 5:15 p.m. she stated she and CNA A had just come onto shift for their 6 p.m. to 6 a.m. shift on the memory care unit on 03/30/25. She stated the residents were finishing up with their supper. She stated the nurse's station sits in the middle of the large common/dining area and is L-shaped with the opening to the right side of the station. She stated behind the nurse's station was a small table against the wall. She stated she was sitting on the outside of the station at the L reviewing the assignment book and CNA A was sitting at the small table behind the nurse's station eating a sandwich. She stated Resident #1 had walked up behind CNA A requesting to use the phone and CNA A had told her the phone was not working. She stated Resident #1, again asked to use the phone. She stated when CNA A jumped up suddenly from her chair, was what caused her to look up. She stated CNA A turned around and put herself in Resident #1' face, nose to nose and screamed for her to back up and get out of her face and she stated all of sudden CNA A pushed the resident with both her hands open palmed. She stated Resident #1 stumbled backwards and tried to break her fall but could not and fell backwards outside of the nurse's station. She stated there was not another resident behind her. She stated CNA A did not try to catch the resident, but instead just put her hands down to her side. She stated she immediately jumped to run around the station to check on the resident. She stated she did not see her hit her head, but stated she heard the thump, which was very loud. She stated she took a very hard fall. She stated when she got to the resident, she could see the knot on her forehead. She stated she reached in her pocket to get her phone to call for the nurse. She stated she retrieved her phone, and CNA A reached down and grabbed her arm, which caused her phone to fly across the floor. She stated CNA A asked her what she was doing, and she stated she was calling the nurse, look at her head. She stated when CNA A grabbed her arm, Resident #1 flipped out yelling keep her away from me, she pushed me. She stated she retrieved her phone, called the nurse and stayed on the floor with the resident until LVN C got to the unit. She stated she informed LVN C about what she had witnessed. She stated LVN C assessed the resident and called 911. She stated she was asked to write a statement of what she witnessed, and CNA A was told to write her statement. She stated they removed CNA A from the unit immediately. She stated the ADON came to the facility shortly after the incident and she showed her what had happened. She stated the Administrator was on the phone listening to her describe what had occurred. She stated later that evening, maybe around 10:00 p.m. she received a call from CNA A. She stated she wanted her to write her statement that she witnessed the resident get her feet tangled up and that CNA A had tried to catch her. She stated she told CNA A, but you did not try and catch her, She stated CNA A wanted her to make sure she put in her statement the resident tripped over her feet and she wanted her to send her a screenshot of her statement. She stated she told CNA A OK so she could get her off the phone. She stated once she hung up, she immediately blocked her number. She stated she did not send her a screen shot of her statement. She stated she had no doubt CNA A pushed Resident #1 down. She stated she was interviewed by the police and told them the same thing. She stated she had worked with CNA A for a long time and never witnessed her being abusive toward any of the residents but stated she could be a bit explosive with staff at times. She stated the facility in-serviced them on Abuse and neglect that evening and the next day they were in-serviced on resident rights, dementia care and burn out. She stated she did not hesitate in reporting what she saw. In an interview with the ADON on 07/16/25 at 8:55 a.m. she stated the DON had called her on 03/30/25 after the incident with Resident #1. She stated she only lived about 10 minutes away from the facility, so she arrived probably around 8:00 p.m. She stated CNA A had already left the building. She stated CNA B was very distraught over the incident. She stated she did re-enact the incident with her and was very certain she saw CNA A push Resident #1. She stated she spoke with Resident #1 who was also adamant that she did not fall, but instead was pushed. She stated the resident could not name the person who pushed her. She stated she started in servicing the staff on Abuse and Neglect that evening and then onto to the next day. She stated they also in serviced on dementia care, resident rights, and signs of burnout and how to prevent it. She stated they do abuse and neglect in- services monthly or more frequently if an incident occurs. She stated she had not received any complaints or concerns about CNA A's performance before this incident. In an interview on 07/16/25 at 10:47 a.m. with the Social Worker she stated she was responsible for the safe surveys conducted after the incident with Resident #1. She stated none of the residents had abuse concerns. She stated she was familiar with Resident #1, and did not observe any psychosocial impacts such as change in emotional patterns or behavior since the incident. The Social Worker stated that the facility in-serviced on abuse routinely, was able to name types of abuse and who the abuse coordinator was including reporting requirements. In an interview with the Administrator on 07/16/25 at 11:15 a.m. he stated he was the abuse coordinator, and staff were in-serviced on abuse and neglect monthly and sometimes more often. He stated he was notified by the DON on 03/30/25 of the incident involving Resident #1. He stated they suspended CNA A immediately. He stated Resident #1 was assessed and sent to the hospital for further evaluation. He stated she was returned to the facility later the same day. He stated they immediately began in services on Abuse and neglect, Resident rights, dementia care and signs and symptoms of burn out. He stated he reported the incident to the State within 2 hours. He stated the family was notified as well as the MD. He stated they completed their investigation and determined abuse had occurred at the hands of CNA A. He stated they terminated her. He stated in his conversation with CNA A she did not show any remorse or concern for Resident #1, she just kept repeating how many years she had been a CNA and adamantly denied she had pushed her. He stated they held a QAPI meeting on 04/01/25 and put monitoring into place. He stated they interviewed and tested 3-5 random staff members on abuse and neglect, did skin assessments on 3 residents in the memory care unit, the DON reviewed all the weekly skin assessment, and randomly did 3 safe surveys on Interviewalbe residents weekly for 4 weeks and then monthly until June 2025. He stated in addition they were reviewing grievances daily with a resolution within 72 hours. He stated he also communicated frequently with the families, especially the families on the memory care unit. He stated he felt his staff had acted quickly and appropriately during this unfortunate incident and they had done everything in their power to prevent this from occurring. Interviews on 07/15/25 and 07/16/25 across both 12 hour shifts with various staff members, as well as new staff and agency staff (ADON, CNA B LVN C, LVN E, CNA G, CNA H, Staffing Coordinator, CNA I, Agency CNA J, LVN K, RN L, MA M, Agency CNA N, LVN O, CNA P, LVN Q, CNA R, Social Worker and the DON) revealed the facility had conducted abuse and neglect in-services immediately after the incident on 03/30/25 and on a routine basis. The above-mentioned staff members were able to verbalize abuse and different forms of abuse and neglect including reporting to the Administrator who was the facility's abuse coordinator. In addition, the facility had conducted training on Resident rights, dementia care and signs of burnout on 03/31/25. Staff were knowledgeable in re-direction, offering activities, snacks and residents centered activities to assist in behavior management as well as resident rights for refusal a care. Record review of CNA A's personnel file revealed she was hired on 04/01/24 with a last worked date of 03/30/25 and terminated from employment on 04/01/25. The facility had conducted Texas Department of Public Safety Criminal History verification and Employee Misconduct Registry Employability status checks as required and found no bars to employment. Record Review of abuse and neglect in-services conducted by the facility on 03/30/25 revealed that the facility staff was trained on abuse and neglect, types of abuse, who was the abuse coordinator and when abuse should be reported. Record Review of in-services on Resident rights, Dementia Care and Recognizing Burn out reflected the staff were in-serviced on the facility's protocols on 03/31/25. Record review of the facility policy titled, Abuse and Neglect-Clinical Protocol dated October 2022, reflected, The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect resident from abuse.Staff to Resident Abuse of any Types.The facility assumes the responsibility upon admission of ensuring safety and well-being of the resident.Education fro all staff will be ensured in how to react and reason appropriately to resident behaviors.Staff are expected to be in control of their behavior and behave professionally.The facility will not accept from an employee to claim his/her action was reflexive or knee-jerk reaction' and was not intended to cause harm.Definition.Abuse.the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Willful.the individual mush have acted deliberately, not that the individual mush have intended to inflict injury or harm. Record review of the facility's policy titled, Resident Rights, dated October 2022, reflected, Employee's will treat residents with kindness, respect, and dignity.be free from abuse.be supported by the facility in exercising his or her rights. Record review of the facility's policy titled, Dementia- Clinical Protocol, dated November 2018, reflected, .For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of [NAME] with interventions that are resident specific. Record review of the facility's policy titled, Recognizing and Dealing with Signs of Burnout, Frustration and Stress that May lead Abuse, dated December 2022, reflected, The facility will make every effort to prevent abuse.Training will be included on these topics in orientation of new employees and at least annually for education and awareness.Behaviors to avoid being accuse of abuse.Never get caught in a shouting match or shoving contest with a resident or staff that would be considered inappropriate.stay calm-maintain a soothing tone of voice.If necessary ask another person to intervene.Always report an incident to your supervisor.Understand resident with Cognitive deficits or Dementia for episode of action out and why they do this. The noncompliance was identified as PNC. The IJ began on 03/30/25 at 6:40 p.m. and ended on 03/31/25. The facility had corrected the noncompliance before the survey began. CNA A was terminated from employment and Resident #1 had no other incidents or signs of harm. The facility staff were reeducated regarding Abuse and Neglect on 03/30/25.

Based on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility refrigerator and freezer were dated or labeled. 2. The facility failed to use proper hand hygiene while handling and serving food to the residents. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed and food contamination. Findings Include: Observation of refrigerator 1 and interview with Dietary Manager on 12/10/24 revealed: At 8:40am an 8oz Cool Whip container with no open date or date received. At 8:46am an 46oz container of Ready Care thickened sweetened tea with about 2 ounces left dated 10/31/24. The Dietary Manager stated that it was empty and needed to be thrown out. She stated that she was unsure if there was potential harm to the resident because it was just tea. She then looked at the container observed the manufacture label that stated, must refrigerate and thrown out after 7 days of opening. At 8:48am a second 46oz Ready Care thickened sweetened tea almost full with a date of 10/31/24. The Dietary Manager threw that one out as well. Observation of Freezer 1 and interview with Dietary Manager on 12/10/24 revealed: At 8:48am an opened gallon sized Ziplock bag with about 1 gallon of 2-inch straw-like beige tubular items that the Dietary Manager identified as French Fries, with no label of what the item was or date opened. At 8:49am an unopened plastic clear bag of about 150 one-inch pink circular items with no label, that was identified by Dietary Manager as smoked sausage. At 8:50am a 2-gallon Ziplock bag with about a half-gallon of thin rigid 1-inch brown items without a label. The Dietary Manager was unable to identify what it was. Observation of Freezer 2 and interview with Dietary Manager on 12/10/24 revealed: At 8:50am a blue plastic bag closed by a knot, with about 2 gallons worth of green pea sized frozen items with no label, no date received or date opened. The Dietary Manager stated the items were California Vegetables. At 8:50am a blue plastic bag closed by a knot, with about a gallon of dime size green circular items with no label, no date received or date opened. The Dietary Manager stated that it was okra. At 8:50am a sealed a 2-gallon Ziploc bag with 10 tan 5-inch ovals 5-inch ovals. The Dietary Manager stated they were hashbrowns. At 8:51am a sealed plastic bag with 5-inch tan circular disc with no label or date received. The Dietary Manager stated they were waffles. At 8:51am a closed clear plastic bag with 8 white and yellow with green specks 7-inch oval items with no label or date received. The Dietary manager stated they were garlic breads. At 8:52am an clear blue plastic bag closed with a knot on top that had about 2 gallons of white, green, and orange different sizes and shapes of frozen items no label, date received or date opened. The Dietary Manager stated it was California mixed vegetables. At 8:52 am a sealed plastic bag of about 2 gallons of circular wedged orange, brown 1-inch oval items with no label or date received. The Dietary Manager stated they were sweet potato fries. At 8:54am a clear plastic bag of 8 foot long tannish textured 1 inch straw-like items with no label or date received. The Dietary Manager stated they were churros. At 8:54am 4 packages of sealed tannish brown 3-inch disk stacked by 3s. The Dietary Manager stated they were pancakes. At 8:55am a 2nd bag of a clear plastic bag of about a gallon of circular wedged orange, brown 1-inch items with no label or date received. The Dietary Manager identified them as sweet potato fries. At 8:56am a sealed clear plastic bag with about 2 gallons worth of textured green leafy items with no label or date received. The Dietary Manager stated they were collard greens. At 8:56am an unsealed clear plastic bag with 15 white and light brown, foot long circular 1-inch items with no label date received or date opened. The Dietary Manager stated they were bread sticks. At 8:58am a blue plastic bag closed with a knot on top, with about a gallon of white rigid 1/2 chunky items with no label, date opened or date received. The Dietary Manager was unable to identify what it was. Interview with Dietary Manager on 12/10/24 at 8:59am revealed that she did not know that items in freezer and refrigerator needed a label to identify them. She stated the expectation for dating items in the refrigerator and freezer were for all items to have a handwritten date received and if the items were opened then a date opened. She stated that she was the person who put the items in bags and took them out of their original boxes when they arrived to put them in the freezers. She stated she knew what every item was, and she could be called at any time if other staff had questions of what things were. She stated that if dietary staff didn't know what things were and they didn't have at date, then the risk to the resident would be that they may be given wrong food or bad food. Observation of [NAME] C on 12/10/24 at 11:35am pureeing lasagna rolls with gloves on. While pureeing her phone rang and she answered her phone and walked away to go to another room. The cook returned, threw away the gloves she had on, put new gloves on and resumed pureeing food. The cook did not wash her hands before putting new gloves on. The cook finished pureeing the lasagna rolls and walked to the dishwashing area with the food processor with her gloves on and returned to kitchen serving area and proceeded to touch the serving spoons on the heating table. Observation of [NAME] C on 12/10/24 at 11:50am grabbed two serving spoons with her bare hands hanging above her by the spoon instead of the handle then put the spoons in the hot food on the heating tray. Observation of [NAME] C on 12/10/24 at 12:01pm revealed removing the hot tray of lasagna roll out of the oven and placing it on the shelf, one of the pot mittens fell on the floor and the [NAME] picked it up and put it next to the stove. Interview with [NAME] C on 12/10/24 at 12:45am revealed that she should wash her hands before putting gloves and gloves should be worn anytime handling food like cooking and serving. She stated she should have washed her hands after coming from the back room after her phone call and then should have put gloves on. She stated that you need to wash your hands whenever you leave the serving area and go to another part of the kitchen. [NAME] C stated she should have not touched the part of the serving utensil that would go in the food and stated she should have been wearing gloves. She stated that she put the cooking mitten that fell on the floor on the cart on the side of the stove to put in in the laundry basket later. She stated that if she forgot to put it in the laundry basket it would potentially cause harm to the residents by exposing them to bacteria and cross contamination which could make them sick. Interview with Dietary Manager on 12/10/24 at 12:56pm revealed the expectation for kitchen staff was to wash their hands any time they go into a different part of the kitchen or changed tasks. She stated that [NAME] C should have washed her hands after she put the food processor in the dishwashing area. She stated that all kitchen staff should have worn gloves any time they are serving food or managing serving utensils. Dietary Manager clarified when they received food deliveries, she was responsible for labeling the food and putting it away. She stated that everything should have had a date received and a date opened once it was opened. Record review of Food Receiving and Storage revised July 2014 reflected, Policy Interpretation and Implementation . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) 10. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing Record review of Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices revised October 2008 reflected, .6. Employees must wash their hands: .c. Whenever entering or re-entering the kitchen; d. Before coming in contact with any food surfaces; .f. After handling soiled equipment or utensils; g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. After engaging in other activities that contaminate the hands . 10. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing . Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. 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 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety Review of the Food and Drug Administration Food Code, dated 2022, reflected .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: . (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands .

Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #9) of 6 residents reviewed for ADL's. The facility failed to ensure Resident #9 had her fingernails trimmed and cleaned. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: Record review of Resident #9's Quarterly MDS assessment dated [DATE] reflected Resident #9 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of heart failure, coronary artery disease (narrowing or blockage of your coronary arteries), Alzheimer's disease (brain disorder that causes a gradual decline in memory, thinking, and reasoning skills), dementia (neurological conditions that cause a decline in mental abilities that affect daily life), cerebral infarction (result of disrupted blood flow to the brain due to problems with blood vessels that supply it) and dementia. She had a BIMS of 13 indicating she was cognitively intact. She was total dependent with personal hygiene and showering ADLs. Record review of Resident #9's Comprehensive Care Plan last revised 11/25/24 reflected the following: -[Resident #9] is primarily bedfast all or most of the time and has potential for skin breakdown . Intervention included Provide assistance with ADL care as needed. -[Resident #9] has a history of CVA with the potential for a recurrence. Intervention included Assist with ADL's as needed and monitor for decline in functioning. -Bathing/dressing with interventions to include 1 person assist dressing and 2 person assist bathing and bed bath only. Observation on 12/10/24 at 9:18 AM revealed Resident #9 was lying in bed. She was observed with dirty long nails of approximately 0.5 cm on the right hand. Her left hand was contracted with splint in place. Surveyor attempted to interview Resident #9 but she was confused and unable to answer about her fingernails. Observation on 12/11/24 at 2:49 PM revealed Resident #9 was in bed. She was observed to have long fingernails of approximately 0.5 cm that were dirty. Interview on 12/11/24 at 2:51 PM with LVN A revealed Resident #9 did not leave the bed and was total dependent with ADLs. She stated everyone oversee cutting and cleaning fingernails as needed. LVN A stated Resident #9 left hand was hard to trim and clean because she will freak out. Observation with LVN A revealed Resident #9 had long dirty fingernails on both hands. LVN A stated Resident #9's fingernails were dirty. LVN A stated the risk to the resident of not getting her fingernails trimmed and cleaned was infection if they are dirty. In an interview on 12/11/24 at 3:30 PM with CNA B revealed Resident #9 had a contracted left hand. She stated Resident #9 is total dependent with ADLs and had no resistive to care behaviors when assisting her. CNA B stated CNAs were responsible to ensure resident nails cleaned or trim them unless resident is a diabetic in which nursing is responsible to trim the fingernails. Interview on 12/12/24 at 4:42 PM with the DON revealed CNAs were responsible to ensure fingernails are trimmed and cleaned. She stated the Charge Nurse was responsible for ensuring residents receive fingernail care. She stated the risk to the resident were infection, skin tears and potential risk of harm to resident with long fingernails. Review of the facility's policy titled Care of Fingernails/Toenails, revised October 2010, reflected to clean the nail bed, to keep nails trimmed, and to prevent infections . Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed .4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 2 medication carts (Nurses medication cart Hall 600, and Nurses medication cart 300/400 halls) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure medications in unsecured containers were immediately removed from stock. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: Record review and observation on 12/10/24 at 10:34 AM of the Nurses Medication Cart Hall 600, with LVN D revealed the blister pack for Resident #12's acetaminophen codeine. 300-30 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill was still inside the broken blister and tapped over. Interview on 12/10/24 at 10:41 AM, LVN D stated she was unaware when the blister pack seal was broken. She stated she did the count in the morning with the ongoing nurse, but she did not check the blisters for damage. She stated the risk of a damaged blister would be a potential for drug diversion. At that time, the surveyor checked the medication; the count was compared to the blister pack and the count was correct. Record review and observation on 12/10/24 at 10:49 AM of Nurses Medication Cart Hall 300/400, with LVN I revealed the blister pack for Resident #62's hydrocodone acetaminophen 5-325 mg tablet (controlled medication used for pain) had 1 blister seal broken and the pill still inside the broken blister. Interview on 12/10/24 at 10:54 AM, LVN I stated the count was done at shift change and the count was correct. She stated she did not check the blister packs during the count. She stated she was unaware when the blister pack seal was broken. She stated the risk would be a potential for drug diversion. She stated the nurses and med aides were responsible to check the medication blister packs for broken seals during the count of narcotics during the change of the shift. She stated when a broken seal was observed, she would report it to the DON and would discard the pill with another nurse. Interview on 12/12/24 at 4:42 PM, the DON stated if a blister pack medication seal was broken the pill should have been discarded. The DON stated it would not be acceptable to keep a pill in a blister pack that was opened. She stated the risk would be losing the medication because the seal was broken and potential for drug diversion. She stated nurses were responsible the check the medication packs for damaged blister during the count at the shift change. She stated the DON and the ADON were responsible to do random check of the medication carts for monitoring. Review of the facility's policy Storage of Medications, revised April 2019, reflected the following: .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to ensure quality of laboratory services to meet applicable requirements for laboratories by using expired glucometer control solution for 1 medication cart (Nurses medication cart Hall 600) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure an expired glucose control solutions (a liquid used to test the accuracy of a blood glucose meter and test strips) was removed from the nurses medication cart hall 600. This failure could affect diabetic residents resulting in diminished effectiveness, and not receiving the correct reading of the blood glucose level. The findings included: Record review and observation on [DATE] at 10:34 AM of the Nurses Medication Cart Hall 600, with LVN D revealed a glucose control solution with an expiration date of [DATE]. In an interview on [DATE] at 10:41 AM, LVN D stated the glucose control solution was expired. She stated she was responsible to check the cart for expired medication and expired solution. She stated she did not check the solution in the morning. She stated the risk for using expired solution would be a potential for wrong reading of blood glucose level. She stated 4 residents were on blood sugar check in 600 hall. She stated she would use a new solution to test the glucometer and check the blood glucose level for the 4 residents. Interview on [DATE] at 4:42 PM, the DON stated she expected nurses to check the medication carts, daily, for expiration and labeling of medication and expired solution. She stated the risk would be a wrong result of blood sugar level. She stated the pharmacy consultant checks the medication room and the medication carts monthly. Review of the facility's policy Storage of Medications, revised [DATE], reflected the following: .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of twenty-four residents (Resident #165) reviewed for medical records. LVN F and RT G failed to document physician notification about the Resident #165's trach dislodgement and change of condition on [DATE]. The noncompliance was identified as PNC from [DATE] to [DATE]. The facility had corrected the noncompliance before the survey began on [DATE]. This failure placed residents at risk for inaccurate medical records. Findings include: Record review of Resident #165's Comprehensive MDS assessment, dated [DATE], reflected a [AGE] year-old female admitted to the facility on [DATE] and a re-admission on [DATE]. Resident #165 had a BIMS of 15 which indicated her cognition was intact. Resident #165 required partial assistance with ADLs. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing breathing problems), respiratory failure (not enough oxygen in the blood). In Section O-Special Treatments, Procedures, and Programs it reflected she required tracheostomy (surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea) care and oxygen therapy. Record review of Resident #165's care plan, dated [DATE], reflected, [Resident #165] has a tracheostomy (related to respiratory failure .Goal .The resident will have no signs or symptoms of infection through the review date .Interventions .Ensure that trach ties are secured at all times . Monitor/document for restlessness, agitation, confusion, increased heart rate, and bradycardia (decreased heart rate) Record review of the Order Summary Report dated ,d+[DATE] for Resident #165 indicated orders: - change inner cannula daily and as needed, start date of [DATE]. - Change trach collar setup as needed, start date of [DATE]. - Change trach tube every 3 month on dayshift and as needed, start date of [DATE]. - Cleanse trach site and change dressing every shift and as needed, start date [DATE]. - Code status: full code, start date of [DATE]. Record review of the nursing progress note dated [DATE] for Resident #165 and completed by LVN F indicated: At 6:30 PM , RT G was in resident's room, resident's tracheostomy tube was not all the way in, it would not advance, RT G removed the tube to reinsert it properly, the trach tube would not advance, Residents O2 was 96%. resident was following commands and looking at nurse. at 6:38 PM resident saturations were decreasing, at 6:40 PM resident became unconscious and pulse was at 50, Pulse declined, and CPR was initiated at 6:40 PM, 911 was called at 6:40 PM. At 6:50 PM EMS has not arrived, recalled 911, Operator said EMT was on the way. 911 dispatched another [NAME] EMS, at 7:00 PM EMS arrived, CPR remained in progress, EMT continued CPR. At 7:13 PM EMS ceased CPR and stated resident was deceased . EMS left facility not removing the body. At 7:17 PM DON was notified, at 7:19 PM family member was notified, at 10:00 family arrived at facility. Record review of the nursing progress note dated [DATE] for Resident #165 and completed by RT G indicated: Around 6:30 PM pt called me in and asked if I could suction her. I tried to pass the suction tube but it would not pass. I checked her trach and found it part way out. I notified the nurse. I also notified RT director. He advised to take trach all the way out and add some lubricant and try to replace trach. Attempted to replace trach twice but could not get to go in. Nurse was holding trach collar trying to get her O2 up higher to try and insert trach again but pt started desatting (a drop I a person's oxygen saturation levels) quickly. I took out her ambu bag and hooked it up to e-tank and started bagging. we bagged pt for 10 minutes trying to get sats up. pt lost consciousness around 6:40 PM so the nurse called 911. CPR was started and we continued to bag pt and administer CPR until EMS arrived. PT lost pulse just as EMS arrived. EMS arrived around 7:00 PM. they took over CPR and placed AED leads on pt. they performed CPR for a few minutes and pronounced her deceased . In an interview with the RT Director on [DATE] at 3:24 PM he stated RT G called him and told him about Resident #165's trach partial dislodgement, he told her to pull the trach all the way-out and to reinsert it properly. He stated the insertion of the trach is part of the school education for respiratory therapists. He stated the RT G tried twice to reinsert the trach and she called 911. That was the expectation. In an interview with the physician on [DATE] at 4:10 PM he stated in general if a trach dislodged, respiratory therapist supposed to reinsert it that is why an extra trach by the bed side. He stated respiratory therapists were trained to replace the trach, if the trach was partially dislodged, they had to pull it to reestablish the air way. He stated the respiratory therapists were capable to replace the trach, it is not common to fail to replace it, but it happens because sometimes the opening of the stoma is not straight. It is unfortunate. He stated if a trach came out, first thing to do was to try to put it back in. It was the respiratory therapist scope of practice to replace the trach. He stated They did what I expected them to do. I am not expecting them to call me during a code. the protocol of the emergency is to call 911. I know from experience the RT change the trach. Is in their scope of practice. If not able to get it back - call 911. In an interview with LVN F on [DATE] at 1:45 PM she stated everything was very fast, when Resident #165 lost consciousness, she started CPR and told another staff to call 911. LVN F stated she called the physician after the code. She stated she forgot to document that she called the physician. Attempted to reach RT G on [DATE] at 1:50 PM by phone. No answer. Interview with LVN E on [DATE] at 1:35 PM she stated that Resident #165 had history of trach dislodgment. She stated on [DATE] Resident #165's trach was dislodged; RT H tried to reinsert it twice unsuccessfully. They called 911, they arrived to the facility and transferred the resident to the hospital. LVN E stated the difference between the two incidents was 911 arrived to the facility in less than 10 min on [DATE] instead of 20 min on [DATE]. Attempted to reach RT H on [DATE] at 1:42 PM by phone. No answer. Interview with the DON on [DATE] at 4:42 PM she stated she started working in the facility on [DATE], she stated LVN F called her after the code. She stated she did not expect staff to call her or call the physician during an emergency. She stated per protocol they called 911. The DON stated she expected LVN F to document that she called the physician. Record review of the facility's in-service initiated on [DATE] by the DON reflected 23 of nursing staff were in-serviced on change of condition, notifications, and documentation. Individual interviews with LVNs, RNs from all shifts (LVN D, LVN E, LVN I, LVN J, LVN K, LVN L, and RN M ) on [DATE] and [DATE] revealed they had received in-service training on change of condition, notifications, and documentation. Record review of the facility's policy Emergency Trach Care Procedures, not dated, reflected the following: .If you are unable to re-inset either the same size trach tube or a smaller size, call 911 and have the resident shipped to the ER. Review of the facility's policy Change in a Resident's Condition or Status, revised [DATE], reflected the following: .The nurse will notify the resident's Attending Physician, Nurse Practitioner or physician on call when there has been . significant change in the resident's physical/emotional/mental condition . Need to transfer the resident to a hospital/treatment center .

Based on interview and record review, the facility failed to ensure the QAA committee developed and implemented appropriate plans of action to correct identified quality deficiencies for change of condition concerns. The QAA committee failed to discuss and review Resident #165's change of condition after Resident #165 expired at the facility on [DATE] to determine any quality deficiencies at QAPI meeting in [DATE]. This failure could place residents at risk of quality of care concerns. Findings included: Record review of the nursing progress note dated [DATE] for Resident #165 and completed by RT G indicated: Around 1830 (6:30 PM) pt called me in and asked if I could suction her. I tried to pass the suction tube but it would not pass. I checked her trach and found it part way out. I notified the nurse. I also notified RT director. He advised to take trach all the way out and add some lubricant and try to replace trach. Attempted to replace trach twice but could not get to go in. Nurse was holding trach collar trying to get her O2 up higher to try and insert trach again but pt started desatting (decreasing oxygen saturation levels) quickly. I took out her ambu bag (device used to provide respiratory support to patients in an emergency situation) and hooked it up to e-tank and started bagging. we bagged pt for 10 minutes trying to get sats up. pt lost consciousness around 1840 (6:40 PM) so the nurse called 911. CPR was started and we continued to bag pt and administer CPR until EMS arrived. PT lost pulse just as EMS arrived. EMS arrived around 1900 (7:00 PM). they took over CPR and placed AED leads on pt. they performed CPR for a few minutes and pronounced her deceased . Interview on [DATE] with DON at 4:42 PM revealed she could not recall Resident #165's change of condition and death on [DATE] being discussed at an Interdisciplinary Meeting or at a QAPI meeting. Surveyor requested any documentation of discussion of Resident #165's death. She stated she was hired in [DATE]. She stated she could not recall the incident of Resident #165's change of condition and death. She stated in the QAPI meetings the facility discussed any clinical issues like incident/accidents and change of conditions. She stated the importance of having QAPI meetings were to discuss and review any clinical concerns to see if any changes need to be implemented. Interview on [DATE] at 2:38 PM revealed the Administrator stated he was not able to find any documentation of QAPI meeting for [DATE] and was unable to review documentation to see what was discussed. He stated they had a change of ownership in [DATE] and he took over as Administrator in [DATE]. Interview on [DATE] at 10:01 AM with the Administrator and Regional VP revealed the facility had a monthly QAPI meeting. Administrator stated in QAPI meetings they discuss resident weight loss, falls, change of conditions, hospitalization and tracking/trends. The Administrator stated if they identify concerns, discuss in in QAPI meetings and can come up with a plan for any identified concerns. He stated all department heads were invited to the QAPI meetings but the Medical Director, DON and wound care nurse participated in them. He stated the potential risk of not discussing resident change of conditions could place the facility at risk of not getting the opportunity to educate the employees in the event staff education needs were identified. Interview on [DATE] at 10:47 AM with MDS Coordinator revealed they meet monthly for QAPI meetings even in previous ownership and usually discuss about new admissions, discharge residents and deaths. The MDS Coordinator stated she cannot recall any discussion on QAPI meetings about Resident #165's death. She stated it was important to have QAPI meetings so they can collaborate together for patient safety and care concerns. She stated it can help us in things we can improve on and do better for resident quality of care. Review of QAPI Attendance Record for [DATE] meeting included Medical Director reflected MDS Coordinator was present at this meeting. The Infection Preventionist was not present during the meeting. Review of facility's policy Quality Assurance and Performance Improvement Program revised [DATE] reflected this facility shall develop, implement, and maintain and ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #54) reviewed for infection control. The facility failed to ensure LVN D used the required PPE for Resident #54, who was on enhanced barrier precautions due to his tube feeding and foley catheter, while administering resident medication through tube feeding on 12/10/24. This failure could place the resident at risk of cross-contamination and development of infection. Findings included: Record review of Resident #54's Comprehensive MDS assessment dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE] 3. Resident had a BIMS score of 9 which indicated he was moderately cognitively impaired. Diagnoses included pressure ulcer of sacral region, and local infection of the skin. Review of section K: Swallowing/Nutritional Status resident had feeding tube. Record Review of Resident #54's Physician Orders Report on 12/13/24 reflected: - Implement and maintain enhanced barrier precautions (EBP) when performing high contact care activities related to peg tube (tube feeding), foley catheter, with a start date of 10/04/24. - Alprazolam 0.25 mg, Give 1 tablet via PEG-Tube one time a day, with a start date of 10/16/24. - Hydrocodone-Acetaminophen 10-325 mg, Give 1 tablet via PEG-Tube every 6 hours, with a start date of 9/12/24. - Methocarbamol 750 mg, Give 1 tablet via PEG-Tube every 6 hours, with a start date of 9/12/24. Record review of Resident #54's comprehensive care plan initiated on 6/26/24, reflected, Resident is on Enhanced Barrier Precautions related to peg tube .Goal: Resident will remain in EBP until no longer meet criteria . Interventions .Enhanced barrier precautions until no longer required . Post appropriate enhanced barrier precautions signs. An observation of the medication pass on 12/10/24 at 1:41 PM revealed LVN D at the medication cart preparing Resident #54's medication and gathering supplies needed to administer medication through tube feeding. LVN D entered Resident #54's room, performed hand hygiene and put on gloves, but did not put on a gown. LVN D checked the placement of the tube feeding by checking the residual, she flushed the tube feeding with 60 ml of water. LVN D then administered medication ( Alprazolam 0.25 mg, Hydrocodone-Acetaminophen 10-325 mg, Methocarbamol 750 mg). LVN D returned to the medication cart and removed her gloves and performed hand hygiene. In an interview with LVN D on 12/10/24 at 2:04 PM she stated Resident #54 was on Enhanced Barrier Precautions because of his tube feeding, foley catheter and his sacrum wound. She stated she was supposed to wear a gown and gloves while providing care or medication administration to his tube feeding and failed to do so. She stated she just forgot. She stated she had been in serviced on the use of Enhanced Barrier Precautions and what PPE was required. She stated the risk to the resident would be potential spread of infections. In an interview with the DON on 12/12/24 at 04:42 PM, she stated they had in serviced the staff that for anyone with a catheter or tube feeding they were required to wear a gown when performing direct care . She stated the risk was potential spread of multi-drug resistant organism (MDRO) from resident to resident. She stated the DON and the ADON were responsible to do routine rounds to monitor staff. Record review of the facility's policy, Enhanced Barrier Precautions, dated 3/2024, reflected, Enhanced Barrier Precautions - expand the use of PPE and refer to the use of gown and gloves during high contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high contact care activities . Examples of EBP residents: Wounds . Indwelling medical devices: include central lines, urinary catheters, feeding tubes.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of 12 residents (Resident #1 and Resident #2) observed for infection control. 1. The facility failed to ensure that CNA A changed her gloves and performed hand hygiene while providing incontinence care to Resident #1 and transport dirty linens in a plastic bag on 11/05/24. 2. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinence care to Resident #2 and remove her gloves before leaving the room on 11/06/24. These failures could place the residents at risk of cross-contamination and development of infection. Findings included: 1. Record review of Resident #1's Face sheet dated 11/06/24 reflected a [AGE] year-old female with an admitted [DATE]. Her diagnoses included cerebral infarction (disrupted blood flow to the brain), hemiplegia affecting right side (paralysis) and diabetes. Record review of Resident #1's quarterly MDS dated [DATE] reflected the resident had a BIMS of 15 which indicated she was cognitively intact. She required partial to moderate assistance with toileting and was always incontinent of bladder and bowel. An observation on 11/05/24 at 09:40 a.m. revealed CNA A entered Resident #1 and Resident #3's room. CNA A went to Resident #3's unmade bed and proceeded to strip the linens from the bed without gloves on. CNA A stated to Resident #1, she would be back to provide her incontinent care. CNA A wadded up the dirty linens from Resident #3's bed, holding the linens against her uniform and left the room to deposit the linens in the soiled linen barrel. CNA A then went to the clean linen cart and retrieved a package of wipes, a plastic bag and gloves and re-entered Resident #1's room to provide incontinence care. CNA A put on gloves without performing hand hygiene and unfastened the resident's brief and cleaned down each groin, across the pubic area and down the middle. CNA A then went to the closet, wearing her soiled gloves, and retrieved a clean brief. CNA A then assisted the resident onto her side revealing she had a moderate bowel movement. CNA A cleaned the resident from front to back, removed the soiled brief and then reached into her pants pocket and retrieved a tube of barrier cream and applied the barrier cream while still wearing her soiled gloves. CNA A then wiped the excess barrier cream from her gloves onto the clean brief and had the resident roll back onto her back. CNA A then placed the tube of barrier cream back into her pants pocket and then retrieved a bottle of powder from another pocket and sprinkled the powder on the resident's pubic area and groin area. CNA A then fastened the resident's brief and repositioned the resident. CNA A removed her gloves, gathered the trash bag and left the room without performing hand hygiene. In an interview with CNA A on 11/04/24 at 09:50 a.m. she stated she was supposed to place dirty linens in a plastic bag. She stated she was behind this morning and just did not think when she stripped Resident #3's bed. She stated when she carried the linens against her uniform, she had cross contaminated herself. She stated she was supposed to perform hand hygiene before and after care, when her hands were soiled and was supposed to wash her hands after she entered the room and before she left. She stated she had failed to do that. She stated she had provided the tube of barrier cream herself, because she did not care for the small packets of barrier cream the facility had on hand. She stated she had been taking the tube of barrier cream from resident to resident. She stated she realized now how that could cause cross contamination between resident to resident. 2. Record review of Resident #2's Face sheet dated 11/06/24 reflected a [AGE] year-old male with an admitted [DATE]. His diagnoses included hemiplegia affecting left side (paralysis), epilepsy (seizure disorder) and acute cystitis (urinary tract infection that cause inflammation of the bladder). Record review of resident #2's quarterly MDS assessment, dated 09/25/24, reflected a staff assessment of mental status which indicated he was moderately cognitively impaired. He required substantial to maximum assistance for all ADL's and was frequently incontinent of bowel and always incontinent of urine. In an observation on 11/06/24 at 09:00 a.m. revealed CNA B entered Resident #2's room to provide incontinence care. CNA B washed her hands and put on gloves and went to the closet and gathered a shirt and pair of pants for the resident. CNA B unfastened the resident's brief and cleaned down each groin, across the pubic area and retracted the foreskin and cleaned the tip of the penis wiped down the shaft and changed the wipes with each pass. CNA B assisted the resident onto his side and cleaned the resident from front to back. CNA B placed a clean brief under the resident without changing her gloves and performing hand hygiene. CNA B repositioned the resident back onto his back and fastened the brief and put on his clean pants and shirt. CNA B then went to the resident's chest of drawers, wearing the soiled gloves, and searched for a pair of socks. CNA B stated she would have to go out of the room to retrieve some socks. CNA B removed her gloves, exited the room, and used the hand sanitizer on the hallway way and retrieved a pair of non-slip socks from the linen cart. CNA B re-entered the room, washed her hands and put on gloves. CNA B placed the socks on the resident and assisted him to the side of the bed and then transferred him from the bed to the wheelchair. CNA B gathered up the trash and bag of soiled linen and left the room, still wearing her gloves, and entered the soiled linen closet at the end of the hall. CNA B deposited the trash and soiled linens and then removed her gloves and performed hand hygiene. In an interview on 11/06/24 at 09:20 p.m. with CNA B she stated she was supposed to wash her hands before and after care and before going from dirty to clean. She stated she realized she had missed a step because she was nervous. She stated she was supposed to remove her gloves before leaving the room and had just forgot. She stated the risk of not changing her gloves and performing hand hygiene placed the resident at risk of infections. She stated gloves were never to be worn after leaving the resident's room, because they were considered contaminated and risked spreading germs. In an interview on 11/06/24 at 01:00 p.m. with DON she stated staff were supposed to wash hands and change gloves before, and after completion of cleaning a resident and after completion of care. She stated staff were never to wear gloves after leaving the resident's room since they were considered contaminated. She stated soiled linens were always to be placed in a plastic bag before removing them from the residents' room. She stated the facility provided individual packets of barrier cream for residents and tubes of barrier cream or powder should not be shared from resident to resident due to the risk of cross contamination and the spread of germs. She stated she had worked so hard with the staff on skills and stated they were all aware of what they were supposed to be doing. She stated the risk of failing to perform hand hygiene was increased infections and cross contamination. Record review of CNA A's competency check off for hand hygiene, infection control and peri-care revealed she was proficient in care as of 07/15/24. Record review of CNA B's competency check off for hand hygiene, infection control and peri-care revealed she was proficient in care as of 11/01/24. Record review of the facility's policy titled, Handwashing/Hand Hygiene, dated December 2022, reflected, The facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection .Wash hands with soap and water .when hands are visibly soiled .Use and alcohol-based hand rub .Before and after direct contact with residents .Before moving from a contaminated body site to a clean body site during resident care .After removing gloves .Hand hygiene is the final step after removing and disposing of personal protective equipment .The use of gloves does not replace hand washing/hand hygiene . Record review of the facility's policy titled, Laundry and Bedding, Soiled, dated September 2022, reflected, Soiled laundry/bedding shall be handled, transported and processed according to best practices for infection prevention and control .Contaminated laundry is bagged or contained at the point of collection (i.e., location where it was used) .Contaminated linen and laundry bags are not held close to the body or squeezed during transport .

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property and establish policies and procedures to investigate any such allegations for one of seven residents (Resident #1) reviewed for abuse and neglect. The facility failed to follow their policy for abuse and neglect by not reporting an allegation of abuse within 2 hours when Resident #1 alleged his spouse caused him to be sick on 11/24/23. This failure could place residents at risk for not having their allegations of abuse and neglect investigated. Findings include: Record review of the facility's policy titled, Abuse, Neglect, Molestation and Misappropriation, revised November 2022, reflected, .All allegations of abuse along with injuries of unknown origin are reported immediately to the charge nurse and /or administrator of the facility along with other officials in accordance with State law through established guidelines .The Administrator and/or DON .will notify state agencies according to their state reporting guidelines .All allegations are to be reported within the timeframe allotted by the appropriate state agency Record review of Resident #1's Admission MDS assessment , dated 11/24/23, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included heart failure, seizure disorder (burst of uncontrolled electrical activity between brain cells that causes abnormalities in muscle tone or movements), and respiratory failure. Resident #1 was able to make himself understood and understood others. Resident #1's brief interview for mental status had not been completed at the time of the assessment. Resident #1 had a feeding tube and received 51 % of intake by artificial means, was oxygen dependent with a tracheostomy ( an opening in the windpipe to help air and oxygen reach the lungs) and was on mechanical ventilation. Record review of Resident #1's 48-hour care plan, dated 11/24/23, reflected The resident requires tube feedings .Interventions .Provide local care to G-tube site as ordered .The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders .The resident has a tracheostomy .Monitor/document for restlessness, agitation, confusion, increased heart rate and bradycardia (slow heart rate) .Provide paper and pencil if needed. Work with resident to develop communication system that will work in an emergency Record review of Resident #1's progress note, written by Agency LVN A, dated 11/24/23 reflected .2143 [8:43 p.m.] .called to room by resident's wife, she stated that resident vomited, and she believes that he had aspirated. O2 saturation fluctuating between 90-94 % O2 at 3l per hour, RT suctioned resident's trach, wife insisting that resident be sent to hospital. Called EMS for transport, went to notify resident and wife that EMS was in route to transport, resident requested speaking valve, resident reported to this LVN, 'I'm not sick, it's her (pointing to wife) she's doing this to me' resident began looking at wife and stating, ' Quit lying, tell them what you're doing to me.' Staff stayed in room with resident, this LVN notified Administrator of resident statement, when EMS arrived to transport, notified lead EMT of resident's statement as well, resident transported to [hospital] at 2230 [9:30 p.m.] . In an interview with Agency LVN A on 01/03/24 at 3:45 p.m., she stated she had come on duty on 11/24/23 at 6:00 p.m. She stated Resident #1 required frequent suctioning and the Respiratory Therapist was working with him a lot during the shift. She stated Resident #1's family member asked about sending him to the hospital, but stated once they suctioned the resident his O2 sats were back in the normal range. She stated about 2 hours into her shift the family member called her to the room and reported Resident #1 had thrown up and she insisted he go to the hospital. Agency LVN A stated she had not seen any evidence the resident had thrown up. She stated she called Respiratory back in to suction the resident while she called for EMS since the family member insisted he go to the hospital. She stated when she returned to the room was when Resident #1 made the statements about his family member making him sick. She stated the family member kept talking over him. She stated the family member then stepped out of the room and she asked the resident what exactly the family member was doing to him, and he just kept saying ask her. She stated she had a staff member stay in the room with the resident until EMS arrived and she reported to them as well as called the hospital and told them what the resident had alleged. She stated she also contacted the Administrator and reported the allegation to her. She stated she treated the situation as an abuse allegation and reported it to the Abuse coordinator. In an interview with the Director of Operations on 01/03/24 at 4:00 p.m., he stated he was notified on 11/25/23 by the previous Assistant Administrator of the incident that had occurred on 11/24/23. He stated he was told by the Assistant Administrator the resident would not be returning to the facility. He stated he instructed her to report the incident to APS since the resident was no longer in the facility and it involved an allegation toward the family member. He stated he was informed today (01/03/24) by the SW that APS called her back in November 2023 and closed out the case and was told the facility needed to report the incident to the State Survey Agency. He stated had he been informed; he would have reported the incident to the State Survey Agency. He stated their policy required them to follow the Reporting guidelines so an allegation of abuse should had been reported within 2 hours. He stated the previous Assistant Administrator was responsible for reporting. He stated the Assistant Administrator had since been let go. In an interview with the Social Worker on 01/04/24 at 9:05 a.m., she stated she was first informed about the incident involving Resident #1 on 11/25/23. She stated the previous Assistant Administrator instructed her to notify APS of the allegation since the resident was no longer in the facility. She stated she reported the incident online and received a confirmation E-mail from APS the report was received. She stated sometime in the middle of the next week (11/27/23-12/01/23) she received a call from an APS worker ( name unknown) who stated the case had been closed and the facility needed to report the incident to the State Survey Agency. She stated she informed the Assistant Administrator of what the APS worker had said. She stated she was not sure what the previous Assistant Administrator had done. In an interview with the previous Assistant Administrator on 01/04/24 at 1:25 p.m., she stated she had worked at the facility from July 2023 through 12/19/23 when she was terminated. She stated she recalled the incident with Resident #1 and stated Agency LVN A called and reported the incident to her on 11/24/23. She stated she did not call in the allegation to the State Survey Agency. She stated she reached out to the Director of Operations the next day, and he told her he did not think it was a reportable incident, but she stated she felt something needed to be done, so she instructed the Social Worker to call and report it to APS. She stated the Social Worker did come to her the next week and told her APS closed out the case and said the facility needed to report the incident to the State Survey Agency. She stated she thought she reported this to the Director of Operations. She stated at the time a lot her responsibility's had been removed from her and were being done by the Director of Operations and the DON. She stated, once again she did not report the incident to the State Survey Agency. In a follow up interview with the Director of Operations on 01/04/24 at 2:40 p.m., he stated the previous Assistant Administrator was the designated Abuse Coordinator during the time the incident on 11/24/23 occurred. He stated anytime there was a change of Abuse Coordinator, the staff were informed, and postings were placed in numerous locations throughout the facility with the name of the coordinator and their contact number.

Based on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services were state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of seven residents (Resident #1) reviewed for abuse and neglect. The facility failed to report an allegation of abuse to the state survey agency when Resident #1's stated his spouse was making him sick on 11/24/23 within the 2-hour time frame. This failure could place residents at risk for unreported allegations of abuse, neglect, and injuries of unknown origin. Findings include: Record review of Resident #1's Admission MDS assessment , dated 11/24/23, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included heart failure, seizure disorder (burst of uncontrolled electrical activity between brain cells that causes abnormalities in muscle tone or movements), and respiratory failure. Resident #1 was able to make himself understood and understood others. Resident #1's brief interview for mental status had not been completed at the time of the assessment. Resident #1 had a feeding tube and received 51 % of intake by artificial means, was oxygen dependent with a tracheostomy ( an opening in the windpipe to help air and oxygen reach the lungs) and was on mechanical ventilation. Record review of Resident #1's 48-hour care plan, dated 11/24/23, reflected The resident requires tube feedings .Interventions .Provide local care to G-tube site as ordered .The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders .The resident has a tracheostomy .Monitor/document for restlessness, agitation, confusion, increased heart rate and bradycardia .Provide paper and pencil if needed. Work with resident to develop communication system that will work in an emergency Record review of Resident #1's progress note, written by Agency LVN A, dated 11/24/23 reflected .2143 [8:43 p.m.] .called to room by resident's wife, she stated that resident vomited, and she believes that he had aspirated. O2 sats fluctuating between 90-94 % O2 at 3l per hour, RT suctioned resident's trach, wife insisting that resident be sent to hospital. Called EMS for transport, went to notify resident and wife that EMS was in route to transport, resident requested speaking valve, resident reported to this LVN, ' I'm not sick, it's her (pointing to wife) she's doing this to me' resident began looking at wife and stating, 'Quit lying, tell them what you're doing to me.' Staff stayed in room with resident, this LVN notified Administrator of resident statement, when EMS arrived to transport, notified lead EMT of resident's statement as well, resident transported to [hospital] at 2230 [9:30 p.m. In an interview with Agency LVN A on 01/03/24 at 3:45 p.m. she stated she had come on duty on 11/24/23 at 6:00 p.m. She stated Resident #1 was requiring frequent suctioning and the Respiratory Therapist had been working with him a lot during the shift. She stated Resident #1's wife was asking about sending him to the hospital, but stated once they suctioned the resident his O2 sats were back in the normal range. She stated about 2 hours into her shift the wife called her to the room and reported that Resident #1 had thrown up and she was insisting that he go to the hospital. Agency LVN A stated she had not seen any evidence that the resident had thrown up. She stated she called Respiratory back in to suction the resident while she called for EMS since the wife was insisting, he go to the hospital. She stated when she returned to the room is when Resident #1 made the statements about his wife making him sick. She stated the wife kept talking over him. She stated the wife then stepped out of the room and she asked the resident what exactly the wife was doing to him, and he just kept saying ask her. She stated she had a staff member stay in the room with the resident until EMS arrived and she reported to them as well as calling the hospital and telling them what the resident had alleged. She stated she also contacted the Administrator and reported the allegation to her. She stated she treated the situation as an abuse allegation and reported it to the Abuse coordinator. In an interview with the Director of Operations on 01/03/24 at 4:00 p.m. he stated he was notified on 11/25/23 by the previous Assistant Administrator of the incident that had occurred on 11/24/23. He stated he had been told by the Assistant Administrator the resident would not be returning to the facility. He stated he instructed her to report the incident to APS since the resident was no longer in the facility and it involved an allegation toward the wife. He stated he was informed today (01/03/24) by the SW that APS had called her back in November 2023 and had closed out the case and was told the facility needed to report the incident to the State. He stated had he been informed; he would have reported the incident to the State. He stated their policy required them to follow the Reporting guidelines so an allegation of abuse should had been reported within 2 hours. He stated the previous Assistant Administrator was responsible for reporting. He stated the Assistant Administrator had since been let go. In an interview with the Social Worker on 01/04/24 at 9:05 a.m. she stated she was first informed about the incident involving Resident #1 on 11/25/23. She stated the previous Assistant Administrator instructed her to notify APS of the allegation since the resident was no longer in the facility. She stated she reported the incident online and received a confirmation E-mail from APS the report had been received. She stated sometime in the middle of the next week (11/27/23-12/01/23) she received a call from an APS worker ( name unknown) the case had been closed and the facility needed to report the incident to the State. She stated she informed the Assistant Administrator of what the APS worker had said. She stated she was not sure what the previous Assistant Administrator had done. In an interview with the previous Assistant Administrator on 01/04/24 at 1:25 p.m. she stated she had worked at the facility from July 2023 through 12/19/23 when she was terminated. She stated she recalled the incident with Resident #1 and stated Agency LVN A had called and reported the incident to her on 11/24/23. She stated she did not call in the allegation to the State. She stated she had reached out to the Director of Operations the next day, and he told her he did not think it was a reportable incident, but she stated she felt something needed to be done, so she instructed the Social Worker to call and report it to APS. She stated the Social Worker did come to her the next week and told her APS had closed out the case and told us we needed to report the incident to the State. She stated she thinks she reported this to the Director of Operations. She stated at the time a lot her responsibility's had been removed from her and were being done by the Director of Operations and the DON. She stated, once again she did not report the incident to the State. In a follow up interview with the Director of Operations on 01/04/24 at 2:40 p.m. he stated the previous Assistant Administrator was the designated Abuse Coordinator during the time the incident on 11/24/23 had occurred. He stated anytime there is a change of Abuse Coordinator the staff were informed, and posting were placed in numerous locations throughout the facility with the name of the coordinator and their contact number. Record review of the facility's policy titled, Abuse, Neglect, Molestation and Misappropriation, revised November 2022, reflected, .All allegations of abuse along with injuries of unknown origin are reported immediately to the charge nurse and /or administrator of the facility along with other officials in accordance with State law through established guidelines .The Administrator and/or DON .will notify state agencies according to their state reporting guidelines .All allegations are to be reported withing the timeframe allotted by the appropriate state agency .

Based on interview and record review the facility failed to have physician orders for the resident's immediate care, at the time each resident was admitted for one of three residents (Resident #1) reviewed for Admission Physician Orders. 1. The facility failed to have Physician orders to check residual prior to medication administration. 2. The facility failed to have physician ordered which indicated the proper use of Resident #1's Gastrojejunostomy tube for feeding and medication administration upon his admission to the facility on [DATE]. These failures could place residents at risk of nausea, vomiting and diarrhea. Findings include: Record review of Resident #1's Admission MDS assessment, dated 11/24/23, reflected Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included heart failure, seizure disorder (burst of uncontrolled electrical activity between brain cells that causes abnormalities in muscle tone or movements), and respiratory failure. Resident #1 was able to make himself understood and understood others. Resident #1's brief interview for mental status had not been completed at the time of the assessment. Resident #1 had a feeding tube and received 51 % of intake by artificial means, was oxygen dependent with a tracheostomy ( an opening in the windpipe to help air and oxygen reach the lungs) and was on mechanical ventilation. Record review of Resident #1's 48-hour care plan, dated 11/24/23, revealed The resident requires tube feedings .Interventions .Provide local care to G-tube site as ordered .The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders .The resident has a tracheostomy .Monitor/document for restlessness, agitation, confusion, increased heart rate and bradycardia (slow heart rate) .Provide paper and pencil if needed. Work with resident to develop communication system that will work in an emergency Record review of Resident #1 progress note, written by LVN B on 11/22/23, reflected Arriving via ambulance after discharge from [hospital] status post Aortic Valve Repair (heart valve), R Hemothorax (collection of blood between the chest wall and lung), CVA (stroke), Septicemia (blood poison), respiratory failure .G/J tube (a soft narrow tube that enters the stomach in the upper part of the abdomen and threaded into the small intestine. The gastric port sits in the stomach and is used to vent air and give medications. The jejunal port sits in the small intestines and is used for feeding) site with some redness, Glucerna 1.5 started at 80cc/Hour Record review of Resident #1's Physician Order Summary, dated from 01/03/24, reflected an admitted [DATE]. The orders reflected, .Glucerna 1.5 at 80 ml/hour every shift Resident may be disconnected from feeding for activities, ADLS, therapy and quality of life with a start date of 11/22/23 The order did not indicate which port of the G/J tube the feeding was to be administered. Record review of the physician's orders did not include to check for residual (amount remaining) prior to administration of medication through the gastric port, or how much residual required physician notification and when to hold the medication administration. Record review of the hospital discharge orders, dated 11/21/23, for Resident #1 reflected, Continue current Tube Feeding regimen: Promote (high protein supplement) at 80 ml/hr x 22 hours via J-tube water flushes per MD discretion In an interview with LVN C on 01/03/24 at 12:15 p.m. revealed she was the nurse who admitted Resident #1 on 11/22/23. She stated the admitting nurse was responsible for entering all the admission orders on any new admission. She stated they utilized the hospital discharge orders for their admitting orders, and if there was anything that needed clarifying they would contact the facility physician to obtain orders. She stated Resident #1 admitted with a G/J tube which was a specialty tube that had two separate ports. She stated the J tube was for feedings and the G tube was for medication administration. She stated they also had a standing protocol to check for residual prior to administering any medications. She stated the protocol was to hold medications for any residual over 100 ml and she stated she somehow missed putting it in the orders. She stated the G/J tube orders should have been specified on the orders as well to ensure the feedings were provided through the correct port. She stated failing to connect it to the J tube might cause some nausea. She stated she had no excuses, and stated she remembered having two admissions that day around the same time and guessed she just overlooked it. In an interview with the DON on 01/03/24 at 02:35 p.m., she stated all the nursing staff who were assigned to the ventilator hall had specialized training. She stated most of those residents had g-tubes and the nursing staff knew to always check residual prior to giving medications. She stated that was just standard nursing care. She stated however admission orders needed to be specific and indicate how much residual required physician notifications and when to hold the medications. She stated a specialty tube such a G/J tube should also have specified orders on which port to use for the feedings and which for the medications. She stated any concern or questions should be clarified with the physician. She stated failing to have specific orders for proper care of the G/J tube could result in tube occlusion, nausea and vomiting for the resident. Record review of the facility's policy titled, Enteral Feedings- Safety Precautions, dated November 2018, reflected, To ensure the safe administration of enteral nutrition .check the following information .Route of delivery .access site .Method (Pump, gravity, syringe) and Rate of administration (ml/hour) .Check enteral tube placement every 4 hours and prior to feeding or administration of medication .Check gastric residual volume as ordered

48122 Based on interview, and record review the facility failed to ensure the resident environment was free of accidents and hazards as was possible for one resident (Resident #33) of four residents reviewed for accidents and hazards, in that: CNA A, CNA B, CNA C and LVN D failed to lift Resident #33 with a mechanical lift twice on 01/05/23, which resulted in the resident having a broken leg. The noncompliance was identified as PNC. The IJ began on 01/05/23, and ended on 07/26/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of severe injury. Findings include: Review of Resident #33's face sheet, dated 11/15/23, reflected Resident #33 was a [AGE] year-old female, admitted on [DATE], and had a primary admitting diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right-sided weakness and paralysis following stroke), as well as stroke, generalized muscle weakness, and dysarthria following cerebral infarction (difficulty speaking following a stroke.) Review of Resident #33's annual MDS, dated [DATE], reflected Resident #33 was able to speak clearly, be understood by others, and was able to understand others. The resident had a BIMs of 12, indicating possible moderate cognitive impairment. The document reflected no behavioral issues or indicators of psychosis. The document reflected functionally Resident #33 used a wheelchair and required extensive two-person assistance for bed mobility (moving herself around in her bed), transfer, dressing, and toilet use. She was totally dependent on staff for bathing but was able to feed herself. Review of Resident #33's admission MDS, dated [DATE], reflected she required extensive two-person assistance with bed mobility, dressing, bathing, and toilet use, and was only transferred once or twice with one-person physical assist. Review of Resident #33's care plan, dated 11/20/22, reflected Transfers total assist x 2 with Mechanical lift . An interview on 11/07/23 at 3:27 PM with Resident #33 revealed that on her birthday this year, 01/05/23, the aide did not want to use the mechanical lift, and she and the other aide who assisted dropped her, and the nurse on duty, whose name she did not know, did not seem very worried about it. She said she had been visiting with her family member, and after shift change he noticed that her leg was swelling and said it looked like she had two knees on one leg. She said the nurse who had come on duty (LVN A) was alarmed and got X-rays for her and she had a broken leg. She said her leg had a knot which was discolored and as large as a fist. She said they fired a nurse and an aide over the incident. She was unable to identify the staff members by name. An interview on 11/09/23 at 11:01 AM with Asst. Administrator revealed she had been employed at the facility for about a week when the Administrator discovered the incident with Resident #33's leg during a mock survey. She said they immediately put a PIP in place and started doing training with staff on related issues. She said they did skills check-offs for all of the nurses and CNAs. She said at the time they discovered it, in July, the people involved in the transfer were not working at the facility. She had been told that day (11/09/23) initially that the staff involved in the incident were not working at the facility at the current time, and when she learned that they actually were still employees, she knew that was bad. An interview on 11/09/23 at 11:05 AM with the DON revealed the former DON had been terminated for not performing her job duties, which included not reporting things that should have been reported. She said the former DON was very avoidant of reporting and some other aspects of her job, and when she was at the facility she created a culture of similar attitudes among the staff, and they had worked very hard to change that since she had been there, including terminating some staff and hiring new, and a lot of training. She said their QAPI process included many PIPs due to the former DON's lack of performance, and the incident with Resident #33 was one of the things they QAPI'd. She said in July 2023, when they discovered the issue, the former DON (at that time the active DON) told them the staff involved were no longer employed at the facility. She said the Administrator had been at the facility for less than a week when they discovered the issue with Resident #33 and they felt absolutely sick about it and immediately began to re-train the direct care staff. An interview and record review on 11/09/23 at 3:18 PM with the ADON revealed she started around the time that they did the mock survey and discovered the incident with Resident #33. At that time she was not able to find skills check-offs for the direct care staff left by the former administrative staff, so she initiated new ones. She said she did them with all of the already existing staff, and when they hired new staff they had seven days to get all of their check-offs completed. At the time of this interview, she provided a binder with all of the skills check-offs she had done, organized by hallway, and including full time and PRN employees. An interview on 11/09/23 at 4:08 PM with CNA D revealed she had been the CNA who had an incident with Resident #33 during a transfer, but there had been one on the shift before hers, as well. She said she had come in for her 6PM to 6AM shift, and Resident #33 was complaining about pain in her leg when she got there. She said the resident was in her wheelchair, visiting with her when she got to work, and there was no sling under her, so she and LVN A attempted to transfer her with a gait belt. She said that they stood the resident up and when she went to push the wheelchair out of the way something was wrong, and it would not move. At that time Resident #33 started to drop, and she tried to stop her with the belt, but the way her arm was extended she was not able to, so she yelled at the nurse that she was falling, and she fell with the resident. She said she landed on the floor, partially on the leg of the wheelchair, and Resident #33 landed on top of her. She said LVN A also went down on the side, while slowing the fall. She said the fall happened very slowly and she cushioned Resident #33 from the floor and wheelchair, but it was scary. She said the nurse assessed Resident #33 and they got a sling and got the resident back into her bed. She said after that the resident was still complaining about pain in her leg, so she told LVN E, who said the CNAs had to set her on the floor earlier that day too, and that she had normal pain for her when she checked on her. She then told LVN A, because the resident kept complaining, and LVN A sent Resident #33 out to the hospital right away . CNA D said Resident #33 was new to her at that time, and she did not know the resident was lift, but had been trained since on how to know. She said she would look at the Kardex (information regarding care in the electronic chart) and talk to the nurse, and if there was not a sling under the resident, she would put one under them and use the mechanical lift to transfer them. She said the two CNAs who had the fall with the resident earlier that day did not work there anymore, and she thought she remembered their first names, but did not know their last names, and they had not worked there for a long time. An interview on 11/10/23 at 10:04 AM with the DON revealed there was a disciplinary notice for LVN E back in January, when this incident happened for not reporting the first of two incidents to administrative staff. At the time of this interview she provided an incident report for the second of the two falls the resident had that day, but said there was no incident report for the other one. An interview on 11/10/23 at 10:50 AM with Resident #33 revealed she had been a mechanical lift for years, before she even came to this facility. She said she only remembered one fall, and it was with a CNA and nurse who still worked at the facility. She said they did send her to the hospital after it happened, and she only remembered falling one time. She said she thought she remembered that the aide had not used the mechanical lift because there was something wrong with it, but she could not remember what. She said since that happened all the staff had done a good job transferring her with the mechanical lift. An observation on 11/10/23 at 11:34 AM of Resident #27 being transferred by mechanical lift ed by CNA I and CNA J. Correct procedures were followed by the CNAs and no concerns were noted. A telephone interview on 11/10/23 at 1:09 PM with LVN E revealed two CNAs (CNA B and CNA C) had lifted Resident #33 with a gait belt on her shift, but she talked to the CNAs at the time, and they said they had looked at the Kardex and it said to use a gait belt. She did not check at that time to see if the Kardex said the resident was a gait belt transfer. She said the resident did not really fall, but was slowly sat down on the floor by the CNAs and she assessed the resident. She was not in the room during that transfer, so she did not see it, but the resident was able to talk to her and tell her what happened. She said Resident #33 always had pain, to the point where you could touch her and she would say it hurt, and her pain was at her baseline when she assessed her . LVN E said there was no indication of injury at that time, and she told the resident's that if she started to have increased pain to let her know and she could contact the physician and get Xray orders, and he seemed like he was fine with that. After she assessed her, she and the CNAs put her back in her wheelchair using the gait belt, with no problems. She said after the incident the resident and her were outside talking and laughing, and she does not remember her acting like or saying she was in additional pain. She said she and the two CNAs involved were suspended related to the incident, and then terminated. Review of an incident report for Resident #33, dated 01/05/23, by LVN A, reflected Nursing Description: Pt was being transferred to bed from w/c using gait belt when her body became flaccid. CNA and this nurse low [missing text] floor. Resident Description: Pt stated that her leg was hurting and she wanted to sit. Description: Pt lowered to floor into seated position. VS taken at that time and WNL; Pt c/o pain in LLE; Mechanical lift and sling gathered and [missing text] from floor; EMS called and transported to (name of hospital); Family/DON/ADON/PCP notified of event. The report reflected bruising on the front of the resident's left lower leg, that the resident was alert and oriented, and had pain of eight on a scale from one to ten. Review of a nursing progress note for Resident #33, by LVN E, dated 01/05/23 at 4:00 PM, reflected resident wanted to get up in w/c chair, CNA;s was [sic] getting resident up using gait belt. had to assist resident to floor. this nurse assessed resident. No injuries are [sic] bruising noted at this time. resident stated she had little pain to left LLE asked her resident if pain was different from her normal pain stated no. gave resident pain pill. resident up there told him if she states pain is worse i will notify DR to get x ray. Review of a nursing progress note for Resident #33, by LVN A, dated 01/05/23 at 8:52 PM, reflected Pt lowered into floor after attempting to transfer her from the w/c to the bed; Gait belt in use; C/o pain in LLE prior to transfer; Bruise noted at site of pain after transfer; EMS contacted and transported to TMC for eval; Appropriate parties notified. Review of a nursing progress note for Resident #33, by LVN O, dated 11/07/23, reflected Resident #33's return to the facility from the hospital. Resident is readmitted from TMC ( .) Resident is happy to be back home, alert and oriented though feeling bad about her L tibia fracture that is nonsurgical. The patient is post fall, history of CVA, and left hemiparesis. The left leg is immobilized and in a non-weight bearing status. Interviews beginning at 8:00 AM on 11/09/23, and concluding at 4:00 PM on 11/10/23 with the following staff (covering all shifts and halls) revealed staff had been trained, and was knowledgeable about all aspects involved in the incident with Resident #33, including what to do if the mechanical lift did not work properly, what to do if a mechanical lift resident does not have a sling underneath them, where to find transfer information about a resident, how to do a proper mechanical lift transfer, and reporting incidents, accidents, or concerns. Interviewed staff were: CNA D, LVN E, ADON, LVN F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, CNA N, LVN P, CNA Q, CNA R, LVN Y, LVN Z, and CNA AA. The Former DON and LVN A were not available for interview on 11/10/23. Review of QAPI documents for a Performance Improvement Plan, dated 07/26/23, reflected plans which included training of all staff due to concerns regarding mechanical lift transfers and reporting incidents. Review of the binder of skills check-offs, which included all full time and PRN staff, reflected completed, correct skills check-offs and competency quizzes which included mechanical lift transfers, for a sample of CNAs covering all halls and all shifts (CNA D, CNA G, CNA I, CNA J, CNA K, CNA L, CNA M, and CNA N). Review of the policy Safe Lifting and Moving of Residents, revised 07/2017, reflected the following: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. ( .) 2. Manual lifting of residents shall be eliminated when feasible. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 6. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. 7. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. 8. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged. 9. Enough slings, in the sizes required by residents in need, will be available at all times. As an alternative, residents with lifting and movement needs will be provided with single-resident use disposable slings.

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for three (Residents #21, #28, and #33) of six residents reviewed for transfers. 1. NA G and CNA F failed to transfer Resident #21 safely when they failed to use a gait belt and lifted the resident under his armpits when transferring him from the bed to the wheelchair. 2. CNA P failed to transfer Resident #33 safely when she attempted to transfer the resident from the bed to the wheelchair with one staff instead of 2 as indicated in her care plan. The resident fell and suffered a left femur (leg) fracture. 3. CNA R failed to use gait belt when transferring Resident #28, which resulted in a left, lateral, fourth rib fracture. These failures could place residents who require transfer assistance at risk for falls injury Findings included: 1. Record Review of Resident #21's quarterly MDS assessment, dated 05/29/21, reflected an admitted [DATE]. Resident #21 had a BIMS score of 7 indicating he was severely cognitively impaired. The resident had limited range of motion in both lower extremities and required extensive assistance with transfers. Resident #21's active diagnoses included [CONDITION(S)], heart failure, [CONDITION(S)], pneumonia, diabetes, hip fracture, anxiety disorder and chronic obstructive pulmonary disease with respiratory failure. Record review of Resident #21's care plan dated 07/12/21 reflected the resident required moderate assistance by 2 staff for transfers. In an observation and interview with Resident #21 on 07/27/21 at 10:08 a.m., revealed he had pulled his call light. Resident #21 stated he was wanting to get out of the bed and stated every time someone comes into his room; they tell him just a minute I need to get some help and then they leave and don't come back. He stated he does not know why they will not let him get out of the bed. An observation on 07/27/21 at 10:36 a.m., revealed NA G and CNA F were completing incontinence care and dressing Resident #21. Both CNAs assisted the resident onto the side of the bed. CNA F placed the wheelchair next to the bed facing toward the head of the bed and locked the wheels. NA G lowered the bed below the height of the wheelchair seat and placed her left arm under Resident #21's left armpit. CNA F leaned over the wheelchair and placed her right arm under the resident's right arm pit. Both staff lifted the resident to a standing position while NA G grabbed the back of his pants and pivoted him onto the wheelchair. The staff did not use a gait belt during the transfer. An interview with NA G on 07/28/21 at 11:00 a.m., revealed she should have used a gait belt when transferring Resident #21. She stated she had been trained to use a gait belt for any resident who required transfer assistance and knew that lifting a resident by their arms could injure them. She stated she was nervous, and the resident was already agitated and wanted to get up. An interview on 07/28/21 at 11:05 a.m., with CNA F revealed when she realized NA G was about to transfer Resident #21, she should have stopped her, because she was not positioned correctly to assist with the transfer. She said she had to quickly lean over the wheelchair to help. She stated she was aware they were supposed to use a gait belt with all transfers, but stated she was not sure there if a gait belt in the room. She stated she had not been assigned to that hall and was asked to come and assist NA G with Resident #21. She stated by not correctly transferring the resident they could injure the resident's shoulders and could also injure themselves. She stated she had received gait belt training by the facility when she started to work. An interview with LVN C on 07/28/21 at 2:05 p.m. revealed the facility had conducted facility wide gait belt training about 2 months ago. She stated all agency staff had to be checked off prior to working the floor. She stated all NAs had to be checked off and they had to work with another CNA. Record review of NA G's training record reflected she had completed the Temporary Nurse Aide course approved by the American Health Care Association on 05/28/21. In addition, she had completed and passed the Gait Belt Transfer Skill Assessment on 06/01/21. Record review of CNA F's training record reflected she had completed and passed the Gait Belt Transfer Skill Assessment on 05/13/21. 2. Record Review of Resident #33's quarterly MDS assessment, dated 03/17/21, reflected an admitted [DATE]. Resident #33 had a memory problem and her cognitive skills were moderately impaired. The resident was only able to transfer from surface to surface with staff assistance. Resident #33's active diagnoses included non-Alzheimer's dementia, diabetes, and [CONDITION(S)]. Record Review of Resident #33's care plan, dated 01/31/20, reflected the resident required extensive assistance by 2 staff for transfers. Record Review of Resident #33's Nurse Notes reflected: 04/27/2021 2:25 p.m., Nurse's Note: Late Entry: Note Text: Late entry for fall on 04/27/21 . Event: Fall - witnessed fall 04/27/21. Description of event: resident was being transferred by C.N.A and resident fell hitting her left knee and left shoulder. C/O leg, ankle and shoulder pain. Root Cause of Fall: C.N.A was transferring resident and resident fell . Record Review of Resident #33's Nurse Notes reflected: 5/4/2021 4:46 p.m., Nurse's Note: Note Text: Resident admitted from .hospital stay was related to left femur fx. Resident has 4 staples to left upper thigh, 5 staples intact to left knee (lateral), 10 staples to front of left knee (anterior) . Record Review of the Provider Investigation Report for Resident #33, dated 04/27/21, reflected that CNA P did a one-person transfer of Resident #33 and assisted the resident to ground. CNA P asked CNA Q to assist her to put the resident back in her wheelchair. The resident's nurse was not notified. The Roommate of Resident #33 told the nurse that CNA P dropped the resident. Resident #33 suffered a left leg fracture. CNA P was terminated from employment. The facility completed in-services with staff on abuse/neglect and transfers. Record Review of the Witness Statement for CNA P, not dated, reflected: .I let her (Resident #33) bed down and got her wheelchair. I slowly lifted her with her arms around my neck, she started to lose balance, that's when I slowly sit her down. She didn't fall. Record Review of the Witness Statement for CNA Q, not dated, reflected: CNA P came to the room I was in and asked me if I could help with (Resident #33.) When I entered the room, I seen the resident on the floor. CNA P stated that she had sat the resident on the floor. I helped transfer her to her wheelchair. Review of CNA P's training record reflected she had completed and passed Orientation Training including accident prevention training on 03/13/20. An observation and interview with Resident #33 on 07/28/21 at 12:45 p.m., revealed she was sitting in her wheelchair. She said she did not remember falling and getting a fracture. An observation and interview on 07/28/21 and 12:50 p.m., with Resident #15 (roommate to Resident #33) revealed she remembered the fall and that a CNA dropped Resident #33. CNA P was called for interview on 07/29/21 at 9:50 a.m. but did not return the call of the State Surveyor. CNA Q was called for interview on 07/29/21 at 9:55 a.m. but did not return the call of the State Surveyor. 3. Record Review of Resident #28's Quarterly MDS assessment, dated 02/15/21, reflected Resident #28 had a BIMS score of 12 which reflected her cognitive skills were moderately impaired. The resident required extensive assistance of two person with transfers. Resident #28's active diagnoses included Cerebral Infarction, Muscle Wasting, Major Depressive Disorder, Anxiety Disorder, Persistent Mood Disorder, [CONDITION(S)], and Chronic Obstructive Pulmonary Disease Review of Resident #28's Care Plan, dated 02/26/21, reflected the resident required a one person assist with transfers and toileting. Record Review of Resident #28's Nurse Notes written by reflected: Radiology results, dated 03/04/21 at 9:10 a.m., revealed, Procedure: Ribs Bi-Lat MIN 3V .Results: Acute left lateral fourth rib fracture. Multiple broken median sternotomy wires. Record Review of the Provider Investigation Report for Resident #28, dated 03/10/21, reflected, Today 03/04/2021 at 10:30 am, the Administrator was notified that [CNA R] was transporting resident [Resident #28] from her wheelchair to her bed but did not use a gait belt. [CNA R] grabbed the resident by her arms to lift her. it is possible that the resident's rib was cracked during this move, but the resident has had a cough post covid-19 infection. the resident mentioned to the nurse that her side felt funny. Resident was assessed and an x-ray was ordered. a cracked rib was found. [CNA R] was removed from the building and suspended pending investigation. Physical injuries were reported. treatment is needed, and in-house physician was notified. MD said it is cracked but not out of place. To prevent something like this from happening again, immediate education related to bed position and transfers with gait belt . An interview on 07/27/21 at 2:13 p.m. with Resident #28 revealed a staff member bear-hugged her to transfer her, without a gait belt, and she felt her rib pop. She stated she later told her nurse her side felt funny. CNA R was called for interview on 07/28/21 at 4:45 p.m. but did not return the call of the State Surveyor. An interview on 07/28/21 at 11:35 a.m. with the DON revealed following the transfer incident on 03/04/21 the facility did transfer training, gait belt policy training, mechanical lift checkoffs, and abuse training. The DON said for Resident #28 on 03/04/21, CNA R grabbed the resident in a bear hug which was not needed. The DON said CNA R was agency staff and was terminated from employment. The DON said the facility did transfer monitoring and continued the monitoring through April 2021. The DON said following the incident on 04/27/21 with Resident #33 the facility continued the same monitoring. The DON said CNA P transferred Resident #3 and did not tell anyone what had happened. The DON said the roommate of Resident #33 told the nurse what happened. An interview on 07/28/21 at 4:30 p.m. with the DON said the expectation for all staff was that they were supposed to use gait belts for all transfers. The DON said CNA R did not use a gait belt to transfer Resident #28. She said CNA R did not tell her why she did not use a gait belt. The DON said CNA P knew Resident #33 required a 2 person assist to transfer but she thought she could do the transfer herself. The DON said CNA P told her Resident #33 started slipping and so she lowered the resident to the ground. The DON said CNA P did not use a gait belt for the transfer, but she did not say why. The DON said CNA P said she did not report the incident to the nurse because the resident did not fall, she was lowered to the ground. CNA P did notify CNA Q who helped her following the fall. The DON said CNA Q did not notify the nurse about the incident because she did not want to get involved. An interview with the Medical Records Coordinator on 07/29/21 at 2:30 p.m., revealed she completed the check offs with the new staff on the use of gait belts, and was also responsible for doing spot checks and re-training if the staff was having trouble or found to not be using a gait belt properly. She stated all new staff, including agency staff had to be checked off on gait belts before working the floor. She stated she checked of both NA G and CNA F on the use of gait belts. An interview with OT D on 07/29/21 at 3:15 p.m., revealed since May 2021 the therapy department had placed gait belts with each resident's name in their room hanging on the back of the door for those residents who required transfer assistance. She stated if the gait belt was misplaced or lost the staff would let them know and they would replace the gait belts. She stated the therapy department had been involved in providing gait belt training and had provided a facility wide training in April or May of 2021. An interview with the Director of Rehabilitation on 07/29/21 at 3:25 p.m., revealed the resident's armpits were not to be used during transfers because that could cause injury to a resident's shoulders and increase the risk of dropping the resident. He stated they provided education to the CNAs during orientation and anytime the facility requested a refresher. He stated they had completed a facility wide gait belt training after an incident in April 2021. He stated they taught staff to use a gait belt for all transfers for safety and to prevent injury. Record Review of the Facility Policy for Bed Mobility and Transfers, not dated, reflected: Transfer Process. Before the initiation of a transfer, you must know resident's: diagnosis, involved or weak side, weight bearing status (if appropriate), ability to follow instructions, medical precautions or contraindications. The Facility's undated policy titled, Gait Belt Policy, reflected, As part of our ongoing efforts to provide a safe working environment for out employees, your employer provides all direct care staff with a git belt at not cost to the employee .It is the responsibility of all direct care staff to properly use the gait [NAME] and to use id during all appropriate transfers .Gait belt training and competency testing are conducted by nursing personnel at the time direct care employees are hired. The use of gait belts is mandatory as a way to protect you and our residents during the performance of your duties .

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for one (Resident #1) of six residents reviewed for abuse. CNA A failed to ensure he was familiar with Resident #1's required level of assistance for ADLs and to provide the required two people for assistance. CNA A provided Resident #1 incontinent care with no assistance, resulting in the resident rolling off the bed onto the floor and disconnecting her ventilator. The resident required emergency CPR and was transferred to the hospital, where she was diagnosed with [REDACTED]. It was determined an Immediate Jeopardy (IJ) past non-compliance existed from [DATE] to [DATE]. The IJ was determined to have been removed on [DATE] due to the facility's implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure placed residents at risk for serious injuries, a decline in the resident's condition, hospitalization or death. Findings included: Review of Resident #1's Minimum Data Set (MDS) Admission Assessment, dated [DATE], reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her active [DIAGNOSES REDACTED]. She was in a persistent vegetative state/no discernible consciousness, was totally dependent and required assistance of two staff for bed mobility, was incontinent of bowel, had a Foley catheter and was on a ventilator. Review of Resident #1's comprehensive care plan, dated [DATE], reflected she had a self-care performance deficit and required two staff to reposition and turn in bed. Review of the Provider Investigation report dated [DATE] reflected, .Incident date [DATE] at 5:54 a.m.description of incident .Resident rolled out of bed during incontinent care .Nurse assessed and found no pulse. CPR initiated. Pulse returned, and resident was transported to hospital by EMS in stable condition .CNA was suspended. MD and RP notified. Safe survey completed. In-service regarding abuse and neglect and fall prevention .Skin assessment performed on all resident who are unable to be interviewed. (CNA A) was terminated from employment. Staff educated regarding bed mobility . Review of the Witnessed Fall report completed by LVN D and dated [DATE] reflected, .Incident description .Entered residents room due to CNA calling for assistance. This nurse entered room resident lying parallel to right side of bed. Assessed resident vitals. Unable to feel pulse. Turned resident on back one round of CPR and being bagged by RT. Pulse picked up on pulse/O2 monitor .Immediate Action Taken .Assessed resident vitals. Unable to feel pulse. Turned resident on back and initiated a code. After one round of CPR/ RT. 911 notified. Pulse picked up on pulse/O2 monitor. BP ,[DATE] HR 86 O2 100% on vent. No visible injuries noted transported resident to (hospital name) ER for further evaluation .Witness statement .CNA A .I raised her bed and I rolled her on her back. I had her in the middle of the bed. I had a table with towels on it and I turned to get a towel and when I turned back around she was falling and I couldn't stop her . Review of Resident #1's hospital records, dated [DATE], reflected the following: .The patient present following fall .Per nursing home pt fell out of bed while being changed. Nurse couldn't find radio (sic) pulse and performed 1 min of CPR until pulse was detected .Differential Diagnosis: [REDACTED].Chest X-Ray .There is at least one right rib fracture of indeterminate age laterally .XR Pelvis .There is an abnormal appearance of the intertrochanteric region of the right hip, concerning for acute fracture . Review of the Resident #1's hospital discharge summary dated [DATE] reflected, .Diagnosis: [REDACTED].multiple fractures rib fractures .Comminuted right intertrochanteric [MEDICAL CONDITION] .The patient was not a good surgical candidate and was a high likelihood for mortality .Supportive care was continued .Present overall condition did not improve, she was evaluated by several people who recommended hospice placement. Today family has agreed on hospice arrangements. She will be transferred to hospice services . An interview with CNA A on [DATE] at 12:37 p.m. revealed he had worked on the ventilator hall for six months in the past but had been on other halls before [DATE]. He stated he was not familiar with Resident #1, as she was a new resident. He stated when he first rolled her she was in the rail, so he moved her toward the center of the bed and placed her on her back. He said he turned around to get a towel and she had flopped over on her side and started rolling and there was nothing he could do to stop her. He stated the resident could move her legs. He stated he did not ask for assistance when he went in to clean her up around the end of his shift. CNA A stated he had not checked the kiosk to determine what level of care Resident #1 required before providing care to her. He stated he had not done this because he only logged into the kiosk to complete his charting at the end of his shift. In an interview with LVN D on [DATE] at 6:15 p.m. she revealed on the morning of [DATE], she was down the hall making her last rounds, when she heard CNA A yell for help. She stated when she went to Resident #1's room, the resident was on the floor, detached from her vent. She assessed her and found no pulse and started CPR with assistance from the respiratory therapist. She stated they reconnected her vent, and after CPR and ventilation, were able to get a pulse and heart rhythm back. She stated the resident had no visible signs of injury. She stated 911 was called and the resident was transported to the hospital for evaluation. She stated CNA A had not asked her for any assistance with this resident. She stated they had two nurses to cover halls 100, 200, and 300, two CNAs and two RTs on duty that night, so he could have asked any one of those people for assistance. She stated she frequently assisted the CNAs, especially on the 200 hall, where almost all of the residents required two-person assistance. In an interview with the DON on [DATE] at 8:50 a.m. she revealed the incident occurred around the end of CNA A's shift on [DATE] and he had already clocked out when she had arrived at the facility. She stated she called him to ask about Resident #1's incident, and asked how a resident who could not move, lying on her back in the middle of the bed could roll of the bed. She stated CNA A insisted the resident could move her legs. She stated she asked CNA A if he had asked anyone to help him and he stated he did not. She stated she told the CNA he was suspended pending the investigation. She stated she had him come into the facility on [DATE] to re-enact exactly how the incident occurred. CNA A kept insisting he had the resident on her back, and he turned his back to get a towel and the next thing he knew, she was on the floor. The DON stated she had ADON B lay down on the bed on her back in the center of the bed and asked CNA A if this was the position he had Resident #1 in. He replied that it was. She stated ADON B crossed her right leg over her left and attempted to turn herself to the left side of the bed. She stated she was unable to turn herself without using her hands and arms to roll herself over. She said they immediately terminated CNA A for failure to ask for assistance in providing care to Resident #1. In an interview with LVN C on [DATE] at 2:00 p.m. she revealed Resident #1 was totally dependent for all care. She stated Resident #1 would not respond to verbal stimuli, open her eyes and her extremities were flaccid. She stated she had never seen Resident #1 move any of her limbs. Interviews conducted on [DATE] from 2:10 p.m. through 3:00 p.m. with CNA's K, M, N, I and O revealed all were aware each resident's level of care was found in the Kardex/plan of care system. They all stated they had been paired up with another CNA upon hire and were showed how to document in the care provided in the facility's Kardex/plan of care system. CNA M revealed on [DATE] at 2:30 p.m. if she had any question about a resident's level of care she would ask a co-worker or her charge nurse. Review of CNA A's training record reflected he had completed training on Position and Transfer Techniques and fall prevention on [DATE]. He had also signed an acknowledgment on [DATE] that he was to follow the resident's care plan to know who required a Hoyer lift or who was to be lifted by two persons. He stated if there were any questions about how a resident was to be transferred, he was to clarify with the nurse. In an interview with the DON on [DATE] at 9:00 a.m. she stated after the incident on [DATE] they immediately put a corrective action plan into place that included: Review of the Plan reflected: 1. Suspension and later termination of CNA A on [DATE]. 2. Reported incident to the State within 2 hours of incident. 3. Thorough investigation of the incident, which included re-enactment of the event to determine the plausibility of how the incident occurred, interviews with staff members and safe surveys with four alert residents on the 200 hall, three residents from the 100 hall and seven residents from the 300 hall was concluded on [DATE] 4. In serviced staff on Abuse and Neglect and fall prevention, and repositioning residents in bed/bed mobility on [DATE]. 5. Skin assessments on all non-verbal residents and Safe Surveys of interviewable residents on halls 100, 200 and 300 completed on [DATE] 6. Audited all resident's Kardex/care plan on [DATE] to ensure all resident's level of care was updated and accurate. 7. Educated and validated all staff understood the use of the Kardex/care plan system on [DATE] 8. Ongoing monitoring will include: Select 2 staff members a week x six week to demonstrate competency in locating Kardex and demonstrate transfers as well as bed mobility. 9. Review plan in QAPI monthly until resolved. Review of In-service records revealed the facility had completed in-services on Abuse and Neglect, repositioning residents in bed/bed mobility and Fall precautions on [DATE] and Use of the Kardex/care on [DATE] Review of competency checks for bed mobility and the use of the Kardex/plan of care revealed the facility completed competency checks prior to working on: [DATE]- 20 staff members [DATE]- 11 staff members [DATE]- 3 staff members [DATE]- 5 staff members [DATE]-3 staff members [DATE]- 3 staff members [DATE]- 2 staff members [DATE]- 2- staff members [DATE]- 1 staff member. Review of the facility's monitoring plan revealed: Week One- February [DATE]: Seven staff members were monitored for knowledge on the use of the Kardex/plan of care and bed mobility. Week two- February [DATE]: Two staff members were monitored for knowledge on the use of the Kardex/plan of care and bed mobility. These systems were implemented prior to the state investigation on [DATE]. Interviews conducted on [DATE] from 10:45 a.m. to 8:15 p.m. with CNA E, CNA F, LVN G, CNA H, CNA I, LVN J and CNA K, which represented all shifts revealed they would check the Kardex system or ask thier nurse to determine what level of care a resident required. Review of inservice records revealed they had been in serviced on the use of the Kardex/Plan of Care system and on bed mobility and transfers. On [DATE] at 2:00 p.m. The Interim Administrator and DON was informed an Immediate Jeopardy was determined to have existed from [DATE] to [DATE]. Review of the facility's undated Abuse and Neglect policy, reflected, .No resident will be deprived by any individual of goods or services necessary to attain or maintaining physical, mental and psychosocial well-being . Review of the facility's undated policy, Comprehensive Resident Care Plans, reflected, .All items or services orders to be provided or withheld shall be included in each resident's plan of care .In accordance with each resident's plan of care, all services provided or arranged by the facility meet profession standard of quality and are provided by qualified persons. The care plan will be made available to all direct care staff.