Every finding on record at The Mildred & Shirley L. Garrison Geriatric Educat

Based on observation, interviews and record reviews, the facility failed to treat residents with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality for 1 of 7 residents (Resident #1) reviewed for dignity in that: The facility failed to ensure Resident #1's call light was answered in a timely manner. This could place residents at risk for falls, diminished quality of life and loss of dignity and self-worth.Findings include: Record review of the admission record for Resident #1, dated 06/16/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: encounter for attention to colostomy (alternate route for bowel movements), viral pneumonia (lung infection), and depression (mood disorder). Record review of the comprehensive MDS assessment for Resident #1, dated 06/05/26 revealed Resident #1's BIMS score was 12, indicating his cognition was intact. During an interview with a confidential family member on an undisclosed date at an undisclosed time, the family member stated they were unhappy with the care received at the facility. The family member stated it took the staff a long time to answer the call lights, sometimes over 15 minutes. The family member stated sometimes staff were seen sitting around the nurse's station while call lights were ringing. During an observation on 06/16/26 at 10:53 AM, Resident #1's call light was observed ringing and a light was observed over room [ROOM NUMBER] and at the nurse's station. RN A was observed sitting at the nurse's station on the computer. During an observation and interview on 06/16/26 at 11:03 AM revealed RN A continued sitting at the nurse's station and stated she did not know why room [ROOM NUMBER]'s call light had not been answered. RN A stated she was trained to answer the call lights as soon as possible. RN A stated she was last trained to answer the call lights during her orientation to the facility when she was hired. RN A stated she did not answer the call light for room [ROOM NUMBER] because she wanted to finish a note. RN A stated a potential negative outcome to the residents was there could be something really wrong. During an observation on 06/16/26 at 11:05 AM, RN A answered the call light for Resident #1. During an interview on 06/16/26 at 1:25 PM, Resident #1 stated sometimes it took the staff 20 minutes to answer his call light. Resident #1 stated he had a colostomy bag that needed frequent changing and sometimes the bag would bust before staff answered his call light. Resident #1 stated his bag needed to be burped but did not bust earlier when his call light was ringing. Resident #1 stated ever since he was admitted to the facility, the call light wait times have been long. During an interview on 06/16/26 at 2:37 PM, the DON stated he expected any of the staff members to answer the call lights. The DON stated he did not know why RN A did not answer the call light for room [ROOM NUMBER] in a timely manner and stated she was probably depending on the CNAs to answer the call light. The DON stated part of the training he did monthly with the staff was related to answering the call lights in a timely manner. The DON stated if a staff member was sitting at the nurse's station, then the call light should have been answered right then and there. The DON stated a potential negative outcome for the residents was they were at risk for falls or an overall delay in care. During an interview on 06/16/26 at 2:55 PM, the ADM stated he expected the staff to answer the call lights in a timely manner. The ADM stated if a staff member was not doing anything else and they did not answer the call light in a timely manner, that's wrong. The ADM stated the staff were provided training regarding call lights during orientation on hire and then as needed. The ADM stated he thought the DON went over answering call lights in his monthly meeting with the nursing staff. The ADM stated a potential negative outcome to the residents was not meeting their needs. Record review of the facility document titled, Resident Advisory Council Agenda and Minutes, dated 05/27/26 reflected the following: .Nursing ReviewNews/Announcements: Call lights response time is too long. Record review of the facility document titled, Education/Training Record, dated 04/10/26 reflected the following: .Topics: Abuse and Neglect, Resident Rounds, Call light safety.In-Service: Call Light Safety & ResponsibilityPurpose: To ensure resident safety, timely assistance, and dignity by maintaining proper access to call lights and responding promptly to resident needs.Who This Applies To:All Staff: Nursing, CNAs, therapy, housekeeping, dietary, and ancillary departments.Answering Call lights is everyone's responsibility.Staff must make every effort to answer call lights as quickly as possible.Call lights should never be allowed to ring for an extended period of time. Record review of the facility policy titled Resident Rights, undated reflected the following: As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility as a resident of the facility and as a citizen of the United States.

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 of 7 residents (Resident #2 and Resident #3) reviewed for care plans. The facility failed to develop a care plan for Resident #2's and Resident #3's enhanced barrier precautions (EBP). These failures could place residents at risk of not receiving the care required to meet their individual needs. Findings included: Resident #2 Record review of the face sheet for Resident #2, dated 06/16/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified protein-calorie malnutrition (poor nutrition), gastroenteritis and colitis (bowel disorder), and pain. Record review of Resident #2's quarterly MDS assessment, dated 04/28/26, revealed Resident #2 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS further revealed Resident #2 had a feeding tube while a resident. Record review of Resident #2's physician's orders, dated 06/16/26, revealed an order: Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: Implanted feeding device every shift with a start date of 06/16/26. Record review of the current comprehensive care plan for Resident #2, undated, revealed there was no specific care plan regarding when EBP would be required for the resident. Resident #3 Record review of the face sheet for Resident #3, dated 06/16/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: metabolic encephalopathy (brain dysfunction), urinary tract infection (bladder infection), and anxiety (mood disorder). Record review of the significant change MDS assessment for Resident #3, dated 05/21/26, revealed Resident #3 had a BIMS score of 07 indicating his cognition was severely impaired. The MDS further revealed Resident #3 had an unhealed Stage 4 pressure ulcer ( the most severe and deepest type of skin injury) and an indwelling catheter. Record review of Resident #3's physician orders, dated 06/16/26, revealed an order: ENHANCED BARRIER PRECAUTIONS: PPE required for high resident contact care activities. Indication: wounds, foley [catheter] every shift with a start date of 05/22/26. Record review of the current comprehensive care plan for Resident #3, undated, revealed there was no specific care plan regarding when EBP would be required for the resident. During an interview on 06/16/26 at 2:37 PM, the DON stated the Interdisciplinary Team was responsible for ensuring a resident's care plan was completed. The DON stated the MDS Nurses, ADONs and himself were a part of the Interdisciplinary Team. The DON stated some things could have been missed when Resident #2 went in and out of the hospital. The DON stated Resident #3 had not always been on EBP but was now due to him having a Foley catheter, so it should have been caught. The DON stated training for care plans was as needed at the facility. The DON stated a potential negative outcome to the residents was that the care plan was not comprehensive to them. During an interview on 06/16/26 at 2:55 PM, the ADM stated the nursing managers were responsible for ensuring a resident's care plan was completed. The ADM stated the nursing managers were provided care plan training as they went and things came up. The ADM stated he did not know why Resident #2 and Resident #3 were missing a care plan for EBP. The ADM stated the residents were at risk for [staff] potentially not doing EBP. Record review of the facility's policy titled, Comprehensive Person-Centered Care Planning, with a revised date of 04/25, reflected the following: Policy: It is the policy of this facility that the interdisciplinary team shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to establish and 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 7 residents (Resident #2) reviewed for infection control. The facility failed to ensure PTA B followed EBP by wearing a gown while assisting Resident #2 in his room. This failure could place residents at risk for cross contamination and infection. The findings included: Record review of the face sheet for Resident #2, dated 06/16/26 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: unspecified protein-calorie malnutrition (poor nutrition), gastroenteritis and colitis (bowel disorder), and pain. Record review of Resident #2's quarterly MDS assessment, dated 04/28/26, revealed Resident #2 had a BIMS score of 12, indicating his cognition was moderately impaired. The MDS further revealed Resident #2 had a feeding tube while a resident. Record review of Resident #2's physician orders, dated 06/16/26, revealed an order: Enhanced Barrier Precautions: PPE required for high resident contact care activities. Indication: Implanted feeding device every shift with a start date of 06/16/26. Record review of the current comprehensive care plan for Resident #2, undated, revealed there was no specific care plan regarding when EBP would be required for the resident. During an observation on 06/16/26 at 10:54 AM, PTA B was observed from the hallway assisting Resident #2 with putting the blankets over Resident #2's feet and pushing the bed back against the wall. PTA B was not wearing a gown when she was assisting Resident #2. An EBP sign was noted on the door to Resident #2's room with indications for wearing PPE to include transferring a resident and changing linens. A PPE box was observed sitting outside of Resident #2's room and no gowns were observed in the box. During an interview on 06/16/26 at 10:57 AM, PTA B stated she did not think about putting on a gown to assist Resident #2. PTA B stated the reason she did not wear a gown for Resident #2 was because he asked for help getting into bed and she thought he was going to fall out of his chair. PTA B stated she knew she was supposed to wear a gown. PTA B stated she was last trained sometime last week regarding EBP. PTA B stated a potential negative outcome to the resident was he was at risk for infection. During an interview on 06/16/26 at 2:37 PM, the DON stated the therapy staff receive training for EBP annually and as needed if anything changes. The DON stated he expected the staff to follow the EBP protocol and if they had questions, they asked for clarification. The DON stated he was not sure if putting covers on a resident required EBP and that may be why she did not wear a gown. The DON stated the staff should ask for more gowns if none were available in the PPE box. The DON stated the residents had a risk for infection without wearing the proper PPE for a resident on EBP. During an interview on 06/16/26 at 2:55 PM, the ADM stated he expected the staff to follow the policies and procedures for EBP. The ADM stated he did not know the last time PTA B had been trained on EBP. The ADM stated he did not know why PTA B was not wearing a gown when assisting Resident #2. The ADM stated the resident had a risk for possible infection. Record review of the facility's policy titled, IPCP Standard and Transmission-Based Precautions with a revised date of 04/25 reflected the following: Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable disease and conditions.Procedure:.3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (.residents with.indwelling medical devices are especially high risk of both acquisition of colonization with MDROs) .c. Examples of high-contact resident care activities requiring gown and gloves use for Enhanced Barrier Precautions include:.iii. Transferring.v. Changing linens6. Implementation:.b Make PPE, including gowns and gloves, available immediately outside of the resident room.

Based on interviews and record reviews, the facility failed to treat residents with respect, dignity, and care in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of 12 confidential residents in that: The facility failed to ensure staff were not utilizing their personal cell phones while providing care, which included assisting residents with their showers and performing peri-care. This could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings include: At an undisclosed date and time twelve confidential residents stated the use of cell phones by CNAs while performing care made them feel ignored, not a priority, embarrassed, concerned the CNA could make a mistake due to distraction by the cell phone conversation, and, most of all, their privacy was violated. The fifteen confidential residents stated the use of cell phones by CNAs occurred on every shift. Confidential residents stated staff utilize their cell phones while performing showers, when performing care in resident rooms, and while performing peri-care. The confidential residents stated the staff text and talk on their phones while walking down hallways, at the nurses' stations, and while in the dining area during meals. The fifteen residents stated they did not know the names of the CNAs who utilized their cell phones while performing care. The confidential residents stated cell phone usage of the CNAs while performing care happened in the facility often, they said every CNA in the facility utilized their cell phone while performing care. During an interview on 06/04/26 at 2:25pm, the DON stated residents should be provided with privacy during resident care; the staff should provide residents with their full attention. He stated all staff were trained in privacy, resident rights, dignity, and cell phone usage during orientation and through continuous education by department heads and the DON. He stated staff were monitored by sporadic rounds completed by the DON and the ADON. He stated cell phones should never be used in patient care areas, cell phones should not be utilized anywhere Residents are visible. He stated the potential negative outcome would be a HIPPA violation. During an interview on 6/04/2026 at 3:20pm, the ADM stated staff should provide residents with their undivided attention while performing care. The ADM stated all staff are trained in resident rights, dignity, and cell phone usage during the on boarding process, continuous online training, and in-services. He stated cell phones should only be used during breaks; personal calls are not allowed while staff are performing care or in patient care areas. He stated cell phones should be kept in breakroom lockers. Staff are monitored for cell phone use by rounding completed by the ADON and the DON. The ADM stated the potential negative outcome for residents, if staff are using their cell phones, was residents could feel disrespected and a loss of dignity. Record review of the facility policy dated April 2025 titled Resident Rights and Responsibilities revealed the following: Policy: It is policy of this facility to inform the residents both orally and in writing of their rights as a resident, as well as the rules and regulations governing the resident's conduct and responsibilities during their stay in the facility. Policy Interpretation and ImplementationAt admission residents will be provided with a copy of their rights and a copy of all rules and regulations. The residents will be required to sign a statement acknowledging they were informed of their rights. To assure our residents, staff, and visitors are continually informed and aware of resident rights, grievance procedures, and responsibilities, large print copies may be posted in a prominent area in the facility.

Based on observation, interview and record review, the facility failed to provide food and drink that was palatable, attractive and at a safe and appetizing temperature for 4 of 19 residents (Residents #10, #30, #80, #93, and 15 confidential residents) reviewed for food palatability. A. Resident #10, #30, #80, #93 voiced concerned of cold food.B. Six of the 8 foods sampled on the meal tray were cold. These failures could result in a decline in residents' consumption of food and residents to have unwanted weight loss. The findings included: In interviews at an undisclosed date and time, 15 of 15 confidential residents stated the food was cold, the food was cold for all three meal forms, approximately 85% of the time the food was served cold. The food served in the dining area as well as in resident rooms was served cold. During an interview on 06/02/2026 at 8:34 a.m., Resident # 93 voiced that the food is mostly cold, like this morning my eggs were cold. She stated that she ate at the dining and in her room. During an interview on 06/02/2026 at 9:25 a.m., Resident #10 voiced that the food is hit or miss, most of the time the food was okay. Resident #10 voiced the food could be warmer. During an interview on 06/02/2026 at 9:38 a.m., Resident #30 voiced that the food was okay, but could be hotter. During an interview on 06/02/2026 at 12:20 p.m., Resident #80 voiced that the food is cold sometimes. Resident #80 voiced he ate in his room and not at the dining. During an interview on 06/02/2026 at 6:31 a.m., the DM was informed of a request for a test tray. During an observation on 06/02/2026 at 12:31 p.m., the sample trays were delivered to the survey room. Sample tray findings found by the survey team and DM were the following: FOOD ITEMS TemperatureMechanical Corn/Peas ColdMechanical Meat/Spaghetti ColdMechanical Mixed Vegetables ColdPuree Italian Vegetables ColdPuree Meat/Spaghetti ColdPuree Bread Cold During an interview on 06/04/2026 at 12:54 p.m., DA stated, monitoring of food temperatures depends on who is serving or making it, basically anyone handling the meals, including myself. He added, we do not have external heat for the cart, the plate warmer would have kept the plates warm and if you were not serving quickly enough, the food cooled down. DA stated he had seen the food palatability policy and received training. He stated that no resident had complained about the cold food personally but could not speak for other colleagues. He further stated that residents would get food borne illness and might not be willing to eat the food resulting in loss of weight. During an interview on 06/04/2026 at 1:23 p.m., the DM stated, myself, as well as the cooks' responsibilities for monitoring that all meals were palatable, and I feel that our plate warmer is not functioning correctly, currently in the process of looking for a new one to order. She stated, yes, I had come across the food palatability policy and been trained but I had to refresh my mind on it. I had received complaints from two residents and had spoken with them, and I did remake the food or ask them if they wanted something different. She stated serving such cold meals, that would result to residents getting sick. During a telephone interview on 06/04/2026 at 2:04 p.m., the RD stated that all the kitchen staff would be responsible for monitoring and ensuring that all meals were palatable. She added that, since she was not in the building that day, she does not know why the meals were cold. That would be a question for the DM, when asked about kitchen staff training. The RD added again that it would be something the DM would address, as regards residents' complaints about cold meals. The RD stated, I am a consultant and not in the kitchen every day when asked the potential negative outcome on the residents. During an interview on 06/04/2026 at 2:47 p.m., the ADM stated, that will be all the kitchen staff responsibilities, for monitoring and ensuring that all meals were palatable, and the meals were cold If the tray transportation took too long or using cold plates instead of the warmer. He further stated that the kitchen staff had been trained in food palatability and had come across such a policy. The ADM added that there were no widespread complaints from the residents, only one or two, and those were addressed regarding cold meals. He further stated, residents may not eat, leading to weight loss. Record review of the facility's policy and procedure titled, Food Palatability, undated, reflected the following: POLICY: Food PalatabilityPurposeTo ensure all residents receive food that: Is appealing in taste, temperature, and presentation. Policy GuidelinesFood Quality & Palatability Food shall be served at proper temperatures: Hot foods: hot and freshCold foods: appropriately chilled.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in facility 1 of 1 kitchen reviewed for food safety. 1) The facility failed to ensure food items in the refrigerator (x1), and freezer (x1), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to ensure the leaking drainage pipe from the ice machine was fixed. 3) The facility failed to ensure the kitchen ceiling vents were clean. These failures could place residents at risk for food-borne illness and cross contamination.The findings included: During kitchen tour observations on 06/02/2026 that began at 5:58 a.m. and concluded at 6:41 a.m., revealed the following: - Leaking drainage pipe from the Ice machine, next to the prepping table. -Dirty & dusty ceiling vents. Walk-in Freezer -What resembled garlic bread (no label), corn filters, and noodles in different clear plastic bags, all with no use by date. Walk-in Refrigerator -What resembled pork, [NAME] lettuce, grapes, American blend lettuce, and strawberry in different clear plastic bags, all with expired date. -What resembled cheese (no label), pork, and chicken thighs in different clear plastic bags, all with no use by date. During an interview on 06/04/2026 at 12:54 p.m., DA stated, Any of the kitchen staff including myself or whoever places items in the freezer or refrigerator is responsible for putting the labels and dating (use by date) of all food items, as well as removing of any expired food items. He stated that he had brought up the issue of the leaking ice machine drainage pipe to the DM, but was not sure what happened afterwards, and added he was not certain who was responsible for cleaning the dirty vents because the kitchen staff had no tall ladder. The DA stated, I don't know why those food items were not labeled/dated, and for the expired food items, that would be the kitchen staff members not following policy and I have been trained on labelling and dating of food items, equally seen both the food storage and kitchen sanitation policies. He further stated that all the kitchen staff members, including himself, were responsible for monitoring the dating, labelling and discarding of all expired food items. The DA stated, the above deficiencies could lead to possible food borne illness. During an interview on 06/04/2026 at 1:23 p.m., the DM stated, Every kitchen staff is responsible for putting the date (use by date) and labeling of all food items alongside discarding all expired food items. She added, MM was responsible for the leaking ice machine drainage pipe, the dirty dusty vents, and honestly it skipped my mind to put in an order, and I am not sure if I needed to put in one. The DM added, we have been going through a lot of changes in the kitchen, when asked why food items were not labeled or dated. She stated, I have been trained on that and have come across food storage and kitchen policies, it would be my responsibility for monitoring the dating and labelling of all the food items and discarding all expired food items in the kitchen, the residents are capable of getting food sickness. During a telephone interview on 06/04/2026 at 2:01 p.m., the RD stated that the people who work in the kitchen were responsible for those tasks, labeling/dating and discarding all expired food items. She stated, I have not seen any leakage from the ice machine and again, people working in the kitchen were responsible, and same was applicable for the dusty dirty ceiling vents. When asked why the food items were not labeled, dated and expired food items not discarded, she stated that is something the DM would address, again I was not there in the kitchen the day you people were there, so I can't answer this question. She further added that the DM should be the one to answer the question on who is responsible for monitoring those tasks, for the potential negative outcome on the resident, she stated that it was something surveyor should ask the DM. During an interview on 06/04/2026 at 2:47 p.m., the ADM stated, all the kitchen staff were responsible for the mentioned task - dating, labelling and discarding all expired food items in the kitchen, and monitoring these tasks and added residents could get sick from expired and unlabeled food items. He stated that anyone in the kitchen should report that ice machine drainage concern and such was not brought to his attention, and there should be regular cleaning of the dusty/dirty vents, that was not made known to him. He further added, I am not sure why the food items were not labelled/dated, expired food items not discarded and all kitchen staff were responsible for monitoring all such tasks. The ADM stated that all the kitchen staff have been trained on the identified tasks and have come across both kitchen and sanitation policy(s). Record review of the facility's policy and procedure titled, Food Storage, undated, reflected the following: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: 12. Refrigerated food storage:All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.13. Frozen Foods:All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. Record review of the facility policy and procedure titled, Cleaning and Sanitation of Dining and Food Service Areas, undated, reflected the following: Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Procedure: The director of food and nutrition services will determine all cleaning and sanitation tasks. Staff will be trained on the frequency of cleaning as necessary.The methods and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. (See sample forms on the following pages.)A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. (See Sample Cleaning Schedule on the following pages.)Staff will be held accountable for cleaning assignments.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (dumpsters #1 and #2), in that: -The doors for dumpsters #1 and #2 were left open.-Garbage was left outside of the dumpster. These failures could place residents at risk of exposure to germs and diseases carried by vermin and rodents.Observation on 06/02/2026 at 7:10 a.m., revealed the facility's dumpster area, which was in the lot next to the loading dock had commercial-size dumpsters (#1 and #2), with open doors. Further observations revealed improperly trashed recliner chair on the ground behind both dumpsters (#1 and #2). During an interview on 06/04/2026 at 2:22 p.m., the HKS stated that MM was responsible for keeping the dumpster area clean and closing the door and she helped sometimes. HKS further added that the MM was responsible for monitoring such tasks. She further stated, he forgot to close the doors and maybe the dumpsters were full, that was why the recliner was left out. She stated, no I have not had any training on such task but could do one and have not come across waste disposal policy. Such failure would make the area look bad and could cause falls for anyone including the residents assessing the place, equally led to bad smell due to those open doors. During an interview on 06/04/2026 at 2:35 p.m., the MM stated, I am responsible for trashing the recliner chair properly and closing the doors of both dumpsters, equally responsible for monitoring of such task. Because I am the only MM right now and there is a lot of work for me.He further stated, yes, I have been trained and have come across the waste disposal policy. He stated, it could be bad for the residents such as trash getting out of the dumpsters which could lead to environmental pollution. During an interview on 06/04/2026 at 2:47 p.m., the ADM stated, anyone who throws away trash is responsible for keeping the dumpster area clean and closing the door, while the MM will be monitoring that task. He stated that he was not sure why the recliner on the ground was not properly trashed and equally why the dumpster doors were kept open. The ADM added that all the staff have been trained on such task and had come across the waste disposal policy. He further stated, trash could spill out causing environmental pollution. Record review of the facility policy and procedure titled, Waste Management, undated, reflected the following: Policy: External Dumpster Use and Door Control. Procedures: 2. Dumpster Use The dumpster shall only be opened for the time necessary to deposit waste. Waste must be placed fully inside the dumpster; no bags or debris may be left outside.3. Door/Lid Requirements Dumpster doors/lids must remain closed at all times when not in active use. After each use, staff must verify:o Lids are fully shuto Side doors (if applicable) are secured Failure to close doors is considered a safety and infection control risk.6. Maintenance & Monitoring The Maintenance or Environmental Services Department will:o Inspect dumpster areas routinely for cleanliness and complianceo Ensure dumpster doors/lids function properlyo Coordinate vendor pickups to prevent overflow.

Based on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 6 residents (Residents #9 and #35) reviewed for advanced directives. The facility failed to ensure Residents #9 and #35 who were listed as DNR (Do Not Resuscitate), had Do Not Resuscitate forms that did not have missed required information. This failure could place residents at risk of not having their end-of-life wishes honored and incomplete records. Findings include: Resident #9 Record review of Resident #9's, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included Chronic Respiratory Failure (lungs cannot get enough oxygen into the blood), Heart Failure (the heart does not pump blood as effectively as it should), and Type 2 Diabetes (high blood sugar). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #9's physician order summary, dated 06/04/26, reflected the following order: DNR-Do Not Resuscitate dated 04/20/2026. Record review of Resident #9's care plan, dated 03/06/26, reflected a care plan for DNR. Record review of Resident #9's DNR form dated 11/20/25 reflected the resident's signature was signed on the wrong signature line. The resident's signature was signed on the signature line for a Guardian/Agent/Proxy/Relative Signature. The signature line for Person's Signature was blank. In addition, the physician's signature was not dated. Resident #35 Record review of Resident #35's, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included Renal Disease (damage to the kidneys that result in the inability to filter waste and excess fluid) and Type 2 Diabetes (high blood sugar). The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #35's physician order summary, dated 06/04/26, reflected the following order: DNR-Do Not Resuscitate dated 06/23/25. Record review of Resident #35's care plan, dated 05/27/26, reflected a care plan for DNR. Record review of Resident #35's DNR form dated 06/19/25 reflected the DNR reflected the resident's signature was signed on the wrong signature line. The resident's signature was signed on the signature line for a Guardian/Agent/Proxy/Relative Signature. The signature line for Person's Signature was blank. During an interview on 06/04/26 at 2:45PM with the DON, he stated the DNR was not valid if not filled out correctly. He stated the SW was responsible for making sure the DNR was completed accurately. He stated quarterly audits of DNRs are completed for accuracy. He verified the missing information on the DNR for Residents #9 and #35. He stated he did not know why the information was missing. He stated the potential negative outcome was the residents' end of life wishes may not be followed. He stated he was trained in how to complete DNRs and his expectations were for them to be filled out completely and be correct. During an interview on 06/04/26 at 3:35pm with the SW, she stated the DNR was not valid if it's not filled out correctly. She stated she and the resource nurses were responsible for ensuring DNRs were completed correctly. She verified the missing information on DNR for Residents #9, and #35. She stated she completed quarterly audits of DNRs for accuracy. She stated the reason the DNR's were not complete was human error. She stated she was trained on DNRs. The SW stated the potential negative outcome for residents if a DNR was not completed correctly was the resident's end of life wishes may not be honored. Record review of the Social Services Policies and Procedures Advanced Directives (Revised April 2025) reflected the following: Advance Directives will be recognized and respected. The facility recognizes the resident's rights to choose their treatment and make decisions about care to be received at the end of their life. It is the policy of this facility to implement the residents' decisions and directives that are in compliant with state and federal law and the policies of this facility.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 2 of 4 medication carts (Sage and Oak medication carts) reviewed for medication storage. The facility failed to ensure there was not a loose pill in the Oak medication cart. The facility failed to ensure there was not two loose pills in the Sage medication cart. These failures could place residents at risk for medication errors and adverse drug reactions. The findings include: 1. During an observation with LVN A on [DATE] at 8:59am of the Oak Medication Cart, one loose white pill, scored (a shallow groove or debossed line across the surface) with a number 3 and letter L was found in the second drawer unlabeled. During an interview with LVN A he stated medication carts were checked upon arriving to shift. He stated they are trained monthly and yearly on checking medication carts. He stated the medication arts were checked for cleanliness, organization, loose pills and expired medication. He stated he had not seen that pill when he arrived on shift. He stated the potential negative outcome of a loose pill being in the medication cart could be medication error, or residents not getting their medication. He stated if a pill was dropped into the medication drawer, they were trained to identify the pill and discard it in the appropriate receptacle. During an interview with the DON on [DATE] at 9:20am, the DON identified the white loose pill as Trazadone (a medication used for sleep insomnia, and in higher doses to treat major depressive disorders). 2. During an observation and interview of the Sage Medication cart on [DATE] at 10:15am with CMA B, one white round pill with a number 113, and a tan pill with a number 34 on one side and an E on the other side, were found loose in the second drawer. CMA B stated medication carts are checked throughout the shift and if any loose pills are found, they are disposed of. During an interview on [DATE] at 10:25am with the DON, he stated medication carts should be checked at the start of each shift. He stated the last time the medication carts had been checked were that morning. The DON identified the white pill as Losartan (medication used to treat high blood pressure) and the tan pill as Clopidogrel (medication use to prevent blood clots). He stated the facility policy was to keep the medication carts clean and free of clutter. During an interview on [DATE] at 1:54pm with the ADM, he stated medication cart checks should be done at the beginning of every shift. He stated medication carts were checked for cleanliness, expired medication, loose pills and medication stock. He stated a potential negative outcome of loose pills in the medication cart could be medication error or missing medication. He stated training was conducted annually and as needed for medication cart checks. He stated if there were loose pills identified in any cart, they should be brought to the DON for identification and disposal. Record review of undated facility policy titled Medication Access and Storage revealed: Procedure: 1. The provider pharmacy dispenses medication in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medication are kept and stored in these containers.

Based on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 5 residents reviewed for full code status. The facility failed to ensure staff were able to perform CPR, according to standard protocol, when RN J and LVN S were unable to provide timely rescue breaths to Resident #1 during a code, due to the Ambu bag (a device used to provide manual ventilation) not being readily available on the crash cart. Resident #1 was pronounced deceased at the facility. An Immediate Jeopardy was identified on [DATE] at 5:05 PM. The IJ template was provided to the facility Administrator on [DATE] at 5:07 PM. While the immediate jeopardy was removed on [DATE] at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. This failure could place residents at risk of hospitalization, brain damage, and untimely death. Record review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female admitted the facility on [DATE]. Resident #1 had medical diagnoses to include: displaced intertrochanteric fracture of left femur (hip fracture), chronic kidney disease (irreversible loss of kidney function), Type II Diabetes Mellitus (condition characterized by the body's inability to use insulin properly), dementia, and anemia. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 01, which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's Comprehensive Care Plan dated initiated on [DATE] revealed Resident #1 elected Full Code status (a formal choice to receive all possible medical interventions and life-saving measures to revive a person, including CPR, if their breathing or heart stops) with the following intervention: Initiate full code measures in case of cardiac arrest, to include CPR and AED use. Record review of Resident #1's Physicians orders, dated [DATE] revealed an order for Full Code status with a start date of [DATE]. Record review of Resident #1's progress report dated [DATE] had the following entry dated [DATE] at 06:21 (6:21 AM) Upon giving report to oncoming nurse, charge nurse was alerted that resident was not breathing and appeared to be unresponsive. Upon entering room resident was unresponsive and did not respond to verbal commands, or physical stimuli at this time resident was moved from bed to floor and CPR began, EMS was called. CPR was continued by staff until EMS arrived and took over Code. Nephew was called, did not answer, left voicemail for him to return call. ADON and Nurse Practitioner notified as well.Author: [Name] LVN S [e-SIGNED] During an interview on [DATE] at 10:41 AM, SP stated she went to Resident #1's room on [DATE] at approximately 6:15 AM to get her for therapy and the resident was observed to be breathing but unresponsive. She stated she went to the station to notify the nurses, LVN S and RN J, who were at the station for change-of-shift report. SP stated she returned to the room and Resident #1 was no longer breathing and she again notified the nurses. SP stated LVN S and RN J both responded to the room with the crash cart that was designated for Magnolia and Sage halls, while another day-shift nurse [name not given] called EMS. SP stated CNA U and CNA T also came to the room to assist. She stated Resident #1 was assessed by both nurses and determined to have no pulse or respirations and was lowered to the floor. SP stated the AED pads were applied to Resident #1 and chest compressions were started at 6:31 AM. She stated she did not recall which nurse started compressions. She stated one of the CNAs who responded to the room was asked to retrieve the Ambu bag from the cart, but she did not recall which CNA it was. SP stated the Ambu bag could not be located on the cart by the CNA who then ran to retrieve an Ambu bag from the facility's supply room. SP stated she was holding Resident #1's head while LVN S and RN J rotated with performing chest compressions. SP stated the resident began foaming at the mouth and had greenish-brown secretions coming from her mouth during compressions and RN J began suctioning the resident. She stated the CNA returned from the supply room with an Ambu bag after approximately 4-5 minutes. SP stated staff were unable to use the Ambu bag at that point, due to the amount of secretions and emesis (vomit) coming from Resident #1's mouth. She stated RN J and LVN S continued compressions and suctioning until EMS arrived. SP stated EMS took over CPR upon arrival to the facility and pronounced Resident #1 deceased at 7:06 AM. During an interview on [DATE] at 11:08 AM, RN J stated she worked the previous day on [DATE] and was involved in the resuscitative efforts for Resident #1, along with LVN S who was also on duty at the time of the emergency. RN J stated she and LVN S were in morning report on [DATE] at approximately 6:15 AM when the SP notified them that Resident #1 did not look good and was unresponsive. RN J stated she grabbed the crash cart for Magnolia and Sage halls and ran to Resident #1's room with LVN S. She stated the AED was connected and chest compressions were initiated but the Ambu bag could not be immediately located on the cart and one of the CNA's ran to grab an Ambu bag from the supply room, which took several minutes. RN J stated the AED did not advise a shock and mouth-to-mouth breathing was not given. She stated the resident had to be suctioned due to the amount of stomach contents that was coming from her mouth. She stated EMS arrived approximately 8-10 minutes later and compressions were still being done and care was turned over to EMS. She stated the resident was pronounced deceased a short time later. RN J stated notifications were made to the family and physician. During an interview on [DATE] at 1:38 PM, CNA U stated she was on duty on the 6 AM-6 PM shift on [DATE], when Resident #1was found unresponsive and she responded to the room to provide assistance. CNA U stated she looked for an Ambu bag on the cart but did not find one and she ran to the supply room to retrieve another bag. She stated she thought she was gone maybe 2 minutes and returned with another Ambu bag. She stated RN J and LVN S were alternating performing chest compressions. She stated she did not recall whether the Ambu bag was used but she did recall the resident being suctioned. CNA U stated EMS arrived approximately 10 minutes after CPR was initiated and she realized the Ambu bag was on the cart. CNA U stated she was unsure why she did not initially locate the Ambu bag on the crash cart. During an interview on [DATE] at 3:37 PM, CNA T stated she was on duty on the 6 AM-6 PM shift on [DATE], when Resident #1 coded. She stated she was in and out of the room while other staff performed chest compressions. She stated RN J, LVN S and CNA U alternated performing chest compressions. She stated LVN S asked CNA U for the Ambu bag from the crash cart, but it could not be located so CNA U was sent to retrieve a bag from the supply room. CNA T stated during the time CNA U was gone to get a bag, she looked through the drawers of the cart and found an Ambu bag. She stated once the Ambu bag was made available to the nurses, a few rounds of CPR had already been performed and staff had switched out a time or two on chest compressions. CNA T stated she believed staff would have utilized the Ambu bag sooner if it had been available. During a follow-up interview on [DATE] at 6:01 PM, RN J stated she was notified of Resident #1 being unresponsive by the SP and she immediately responded to the room with the crash cart and assisted LVN S to lower Resident #1 to the floor. She stated she put AED pads on the resident then immediately began chest compressions. She stated she asked for the Ambu bag at that point, but it was not immediately available. RN J stated she had been trained in CPR, and the steps included the following: 1st - check pulse and determine the resident is unresponsive. 2nd- open the airway and deliver 2 rescue breaths with the Ambu bag. 3rd - begin chest compressions with a ratio 30 compressions to 2 breaths. RN J stated she began with compressions because the Ambu bag was not available. She stated the Resident #1 started having emesis (vomit) after compressions were performed and required suctioning. RN J stated she would have delivered rescue breaths according to the 30:2 ratio, if the Ambu bag had been available because that's just the standard. She stated she did not know the facility policy for CPR, but she assumed it was the same as current CPR protocol. RN J stated not having rescue equipment readily available on the cart could prolong the time it takes to be resuscitated and could result in resident death. During an interview on [DATE] at 11:07 AM, LVN S stated she had worked the night shift and at approximately 6:15 AM she was giving report to the oncoming nurse, RN J, when the SP notified the nurses that Resident #1 was breathing but not responding. SP then notified the nurses that Resident #1 was no longer breathing. LVN S stated she ran to Resident #1's room and RN J got the crash cart. She stated CNA U and CNA T were also present. LVN S stated Resident #1 was assessed and had no pulse and no respirations and was lowered to the floor and chest compressions were initiated and staff rotated performing compressions for a few rounds. She stated the Ambu bag could not be located initially but she believed she was still doing the first round of compressions when the bag was found. LVN S stated Resident #1 started having emesis and suctioning was performed by RN J. She stated EMS arrived and took over the care of the resident, but the resident expired and was pronounced at 7:06 AM. LVN S stated it was the responsibility of the charge nurses to make sure the crash cart was ready for use and not having essential equipment readily available on the cart during an emergency could result in a poor outcome for the resident. During an interview on [DATE] at approximately 12:45 PM, the ADM stated he was notified of Resident #1's passing at the facility. He stated he was not aware that there was any difficulty locating resuscitative equipment from the crash cart for Magnolia and Sage halls. The ADM stated his expectation was that residents wishing to receive CPR be provided with proper CPR, including rescue breathing, according to policy. During an interview on [DATE] at approximately 12:51 PM, the DON stated he was notified of Resident #1's passing at the facility. He stated he was not aware that any resuscitative items had not been readily available during CPR. He stated residents should receive CPR, to include rescue breaths, per protocol and standard of care when a full code status is elected. Record review of the facility policy titled Policy/Procedure - Nursing Clinical, revised 10/2018 revealed: Section: Emergency ProceduresSubject: Cardiopulmonary Resuscitation (CPR)Procedures:1. Check for responsiveness, quality of breathing and pulse simultaneously.2. If unresponsive, not breathing (occasional gasps are not breathing) and no pulse, activate EMS system:Page or yell loudly for Code Blue to the areaCall 9113. Position the resident face-up, on firm, flat surface, supporting the head, neck and back in a straight line.4. Start chest compressions.Perform 30 chest compressions at a rate at least 100- 120/ minuteCompression depth of at least 2 inches (5 cm) for an average adult, while avoiding excessive chest compression depths (greater than 2.4 inches [6 cm]) 5. Open airway (tilt the head back and lift the chin up), give 2 rescue breaths.May use a bag valve mask (BVM) or Ambu bag to give rescue breathsBlow in for about I second to make the chest clearly rise. If chest does not risewith rescue breaths, retilt head, look for and remove object if seen and give another rescue breath.6. Continue cycles of CPR, 30 chest compressions : 2 rescue breaths. Do not stop CPR except in one of these situations:Sign of breathing and pulse activityAn Automated External Defibrillator AED is ready to use (if available)Another trained responder or EMS personnel take over . This was determined to be an IJ on [DATE] at 5:05 PM. The administrator and DON were notified on [DATE] at 5:08 PM an IJ situation was identified due to the above failure and the IJ Template was provided. The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:06 PM. Record review of the facility Plan of Removal reflected the following: [Facility Name]F-678Plan of Removal [DATE]Per the information provided in the IJ template given on [DATE] at 5:07 PM, the facilityfailed to provide goods and services related to life saving measures and available equipment/suppliesThe Medical Director was notified of IJ on [DATE] by the Executive Director. Crash cart for Magnolia/Sage hall was cleaned, replenished, and verified by ADON- 1, ADON-2, and Clinical Resource on [DATE] at approximately 1:43 PM.Education completed on [DATE] with licensed nurses, certified medication aides and certified nursing assistants on:Emergency code names (i.e. code blue) Policies and Procedures for crash carts Regular auditing of crash carts [Facility Name] CPR Policy requirements This training was completed on [DATE] with current nursing staff (licensed nurses, certified medication aides-CMA, certified nursing assistants-CNA) on shift. A member of management will be at the facility at each shift change to ensure remaining nursing staff (licensed nurses, certified medication aides-CMA, certified nursing assistants-CNA) complete training prior to starting their work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation with new nursing staff (licensed nurses, certified medication aides-CMA, certified nursing assistants-CNA) hires not being allowed to work the floor until training is completed.An ad hoc QAPI meeting regarding items in the 1J template was completed on [DATE] with complete policy review. CPR policy and crash cart auditing policy with required contents were specifically reviewed. Attendees included the Medical Director, Executive Director-[Facility], DON-[Facility], ADON x2-[Facility], and Clinical Resource.The DON, ADON, or designee will verify nursing staff {licensed nurses, certified medication aides-CMA, certified nursing assistants-CNA) competency weekly via quiz.Crash carts will be reviewed daily by licensed nurse floor staff and verified by DON, ADON or designee daily and after each usage. Once a day audit and after each use audit by licensed nurse floor staff is required indefinitely. DON, ADON, or designee daily auditing is required for 90 days.Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance On [DATE] the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on [DATE] at 10:55 AM, the ADM stated all staff from the previous night shift on [DATE] and all staff who were working today, [DATE] had been in-serviced according to the POR topics prior to going on duty today. He stated ADM and nursing administration were calling staff members who were not assigned to work today to give an in-service over the phone. He stated all crash carts were clean, stocked and audited with verification of auditing by nursing administration. Observation on [DATE] at 11:12 AM of crash cart #1 revealed the cart was clean and stocked, and the audit logbook had been signed for the daily audit. Observation on [DATE] at 11:17 AM of crash cart #2 revealed the cart was clean and stocked, and the audit logbook had been signed for the daily audit. Observation on [DATE] at 11:19 AM of crash cart #3 revealed the cart was clean and stocked, and the audit logbook had been signed for the daily audit. Record review of an in-service training for clinical staff dated [DATE] revealed, Topic: Facility Codes, Code Blue, CPR Policy, Crash Cart Expectations (Crash cart audit items).Facility Emergency Preparedness Codes - red, gray, orange, green, yellow, white; with emphasis on - Code Blue=a life-threatening medical emergency involving a patient who is unresponsive, not breathing, or without a pulse. Current CPR policy was reviewed with staff. Crash carts should be audited daily for the listed supplies on the crash cart log and initialed.Signed by 76 staff members. During an interview on [DATE] at 1:49 PM, LVN L stated she was assigned to verify that licensed staff were auditing crash carts daily. LVN L stated she had been in-serviced on the location and daily auditing of all crash carts in the facility, emergency preparedness codes and reviewed on the proper steps of CPR, according to current facility policy. During an interview on [DATE] at 1:51 PM, RN M stated she was assigned to verify that licensed staff were auditing crash carts daily. RN M stated she had been in-serviced on the location and daily auditing of all crash carts in the facility, emergency preparedness codes and reviewed on the proper steps of CPR, according to current facility policy. During a phone interview on [DATE] at 3:39 PM, the Medical Director stated he was informed by the ADM of the delay in rescue breathing during CPR for Resident #1 due to the Ambu bag not being located timely from the crash cart. He stated he spoke with the ADM a little yesterday but mainly today. He stated he and the ADM reviewed the crash cart policy and CPR policy. The Medical Director stated that he agreed with the facility training that a delay in any component of CPR, even seconds, could adversely affect the outcome of a resident. Record review of ad hoc QAPI meeting summary sheet. Meeting was held on [DATE] with discussion of CPR policy and crash cart policy and weekly competencies for licensed staff. In attendance were - ADM, DON, ADONs, MD On [DATE] between 1:31 PM and 5:15 PM interviews were conducted with the following staff members: CNAs A, C, D, E, G, K, N, O, Q; LVNs B, F, H, I, L P, R, S; RNs J, M; Housekeeper, OT, DS, MDS Coordinator, and COTA. All staff members stated they were in-serviced on [DATE] or [DATE] on Facility Emergency Preparedness Codes - red, gray, orange, green, yellow, white; with emphasis on - Code Blue=a life-threatening medical emergency involving a patient who is unresponsive, not breathing, or without a pulse. If witness to a resident who is unresponsive, notify the charge nurse immediately; CPR policy - Basic Life Support is to be provided to any resident who has elected full code status, prior to EMS arrival. Crash cart expectations: cart will be clean and fully stocked (according to the audit log) at all times and immediately following the use in an emergency situation. The 3 crash carts are located at each of the 3 nurses stations. The carts are to be audited by the charge nurse daily and initialed on the daily log. If any item is missing from the cart or is not able to be located in the facility supply, notify the ADM immediately. LVNs and CNAs were also given competency quizzes with the following questions: 1. What is the code for a medical emergency at [Facility Name]? 2. Where are the crash carts located at the facility? 3. How often should the crash cart be audited? 4. After use, how soon should the crash cart be cleaned and replenished? 5. If crash cart items are missing or need to be replaced, when and who should you inform? On [DATE] at 6:00PM, the ADM was informed the IJ was removed however the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 27 residents reviewed for quality of care. 1. The facility failed to ensure that the crash cart shared for Magnolia hall, housing Resident #1, and Sage Hall (which housed a total of twenty-seven residents who had elected Full Code status) was audited daily, sanitized, and had all resuscitative equipment readily available and easily located to deliver life-saving measures in the event of a medical emergency. 2. During a medical emergency on [DATE] at approximately 6:30 AM for Resident #1, RN J and LVN S were unable to timely locate an Ambu bag (a device used to provide manual ventilation) from the crash cart for Magnolia and Sage halls, resulting in delayed ventilation during resuscitative efforts. Resident #1 was pronounced deceased at the facility. 3. The crash cart for Magnolia and Sage halls was utilized on [DATE] at approximately 6:30 AM for Resident #1. RN J and LVN S failed to clean and replenish the cart after use for Resident #1. An Immediate Jeopardy was identified on [DATE] at 5:05 PM. The IJ template was provided to the facility Administrator on [DATE] at 5:08 PM. While the immediate jeopardy was removed on [DATE] at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more that minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. This failure could place residents who have elected Full Code status (a formal choice to receive all possible medical interventions and life-saving measures to revive a person, including CPR, if their breathing or heart stops) at risk of death by not being provided CPR in a timely mannerRecord review of Resident #1's face sheet dated [DATE] revealed an [AGE] year-old female admitted the facility on [DATE]. Resident #1 had medical diagnoses to include: displaced intertrochanteric fracture of left femur (hip fracture), chronic kidney disease (irreversible loss of kidney function), Type II Diabetes Mellitus (condition characterized by the body's inability to use insulin properly), dementia, and anemia. Record review of Resident #1's admission MDS dated [DATE] revealed a BIMS score of 01, which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's Comprehensive Care Plan dated initiated on [DATE] revealed Resident #1 elected Full Code status(a formal choice to receive all possible medical interventions and life-saving measures to revive a person, including CPR, if their breathing or heart stops) with the following intervention: Initiate full code measures in case of cardiac arrest, to include CPR and AED use. Record review of Resident #1's Physicians orders, dated [DATE] revealed an order for Full Code status with a start date of [DATE]. During an observation and interview on [DATE] at 10:55 AM, the crash cart for 2 of 5 resident halls (Magnolia and Sage halls) was observed to be in unusable condition with dirty/contaminated suction tubing, suction canister and Yankauer suction device (a rigid, bulb-tipped instrument used to clear secretions from the mouth to maintain a clear airway during emergency care), which were observed to contain green colored fluid. The AED pads had been used and remained connected to the AED device. RN J conducted an audit with state surveyor of the contents of the crash cart for Magnolia and Sage halls, according to the facility's crash cart inventory log. The following items were missing from the cart upon inspection: O2 mask, suction canister, suction tubing, Yankauer suction device, and AED pads. RN J stated it was the responsibility of the charge nurses to audit the cart daily for supplies. She stated the audits were usually conducted by the night shift nurses. RN J stated the cart had not been cleaned since a code (resuscitation efforts including chest compressions and suctioning) was initiated on [DATE] at 6:30 AM on Resident #1. She stated during the code for Resident #1, all the necessary equipment was on the cart, with the exception of an Ambu bag which was not readily located on the cart for Magnolia and Sage halls, resulting in a delay in providing rescue breaths for the resident. She stated the cart could not be used in the current condition due to contamination from previous use during the code for Resident #1. RN J stated the cart was missing multiple vital pieces of equipment such as the O2 mask, suction equipment and AED pads that would be necessary to initiate a code. RN J stated she and LVN S should have cleaned and replenished the cart following the use of single-use equipment during the previous code for Resident #1 on [DATE]. She stated there were multiple Full Code residents on Magnolia and Sage Halls and the crash cart, in its current condition, would not be able to be used timely in the event of a life-threatening emergency. During an interview on [DATE] at 11:07 AM, LVN S stated she was on duty during code for Resident #1 on [DATE] and she participated in CPR efforts. She stated there was a delay in locating an Ambu bag from the cart for Magnolia and Sage halls, but all other necessary equipment was in place on the cart. She stated immediately following the code for Resident #1, the contaminants on the cart should have been emptied and the cart should have been cleaned and restocked. She stated she did not know whose responsibility it was to get the cart back in order when it was shift change but she had to leave to pick up her kids. She stated she did not know offhand how many residents were Full Code status on Magnolia and Sage Halls. She stated the cart would not have been usable in the condition it was left in following the code for Resident #1 on [DATE]. She stated the cart is to be audited daily by the charge nurses and it could be done by either shift. Record review of the [DATE] and February 2026 Crash Cart Checklist for the crash cart for Magnolia and Sage Halls revealed the following items to be checked daily and initialed:O2 tank levelO2 tubing-maskSuction machine-working orderSuction CanisterSuction YankauerAmbu bagStethoscopeBP cuffPen light-working Y/N?BackboardGlovesAED pads in date- Y/N?AED battery in date- Y/N?AED working? The following dates were blank, indicating a staff member did not sign for an audit being conducted, on the [DATE] checklist: 1/9, 1/10, 1/11, 1/12, 1/13, 1/14, 1/15, 1/16, 1/17, 1/18, 1/19, 1/20, 1/21, 1/22, 1/23, 1/24, 1/25, 1/26, 1/27, 1/28. 1/29, 1/30 and 1/31. The following dates were blank, indicating a staff member did not sign for an audit being conducted, on the February 2026 checklist: 2/1, 2/5, 2/8, 2/9, 2/12, 2/13, 2/15, 2/24, 2/26, and 2/27. Record review of the Full Code Order Listing Report for Magnolia Hall, dated [DATE] revealed sixteen residents had elected Full Code status. Record review of the Full Code Order Listing Report for Sage Hall, dated [DATE] revealed eleven residents had elected Full Code status. During an interview on [DATE] at approximately 12:45 PM, the ADM stated he was not aware that the crash cart for Magnolia and Sage halls was missing any resuscitative items, and his expectation was that the cart was audited for readiness in an emergency situation. He stated nursing administration was responsible to ensure crash carts were audited regularly, according to policy.During an interview on [DATE] at approximately 12:51 PM, the DON stated he was not aware that the crash cart for Magnolia and Sage halls was missing any resuscitative items and nurses on night shift were assigned to audit the crash cart for proper supplies every shift, then initial the log. He stated the logbook contained on each cart had a list of each item the cart should have at all times and a check-off for the items to be in working order, such as the suction machine, and AED machine. The DON stated all disposable items needed for the crash carts were kept in the central storage. Record review of the facility policy titled Policy/Procedure - Nursing Clinical, revised 05/2007 revealed: Section: EmergencySubject: Crash Cart, ModifiedPolicy:It is the policy of this facility that a modified crash cart will be maintained at each nurse's station for use during emergency situations.Procedures:1. The modified crash cart will routinely be stored at each nurse's station2. Person or Persons identified by each facility will check the crash cart every day and restock as necessary.3. After each use, supplies will be re-stocked as needed. This was determined to be an IJ on [DATE] at 5:05 PM. The administrator and DON were notified on [DATE] at 5:08 PM and the IJ Template was provided. The following Plan of Removal submitted by the facility was accepted on [DATE] at 7:06 PM. Record review of the facility Plan of Removal reflected the following: [Facility Name]F-684Plan of Removal[DATE]Per the information provided in the IJ template given on [DATE] at 5:07 PM, the facilityfailed to provide goods and services related to life saving measures and available equipment/suppliesThe Medical Director was notified of IJ on [DATE] by the Executive Director. Crash cart for Magnolia/Sage hall was cleaned, replenished, and verified by ADON- 1, ADON-2, and Clinical Resource on [DATE] at approximately 1:43 PM.Education completed on [DATE] with licensed nurses, certified medication aides and certified nursing assistants on:Emergency code names (i.e. code blue) Policies and Procedures for crash carts Regular auditing of crash carts [Facility Name] CPR Policy requirements This training was completed on [DATE] with current nursing staff (licensed nurses, certified medication aides-CMA, certified nursing assistants-CNA) on shift. A member of management will be at the facility at each shift change to ensure remaining nursing staff (licensed nurses, certified medication aides-CMA, certified nursing assistants-CNA) complete training prior to starting their work on the floor. Staff will not be allowed to work unless they have completed the training. This training will also be included in the new hire orientation with new nursing staff (licensed nurses, certified medication aides-CMA, certified nursing assistants-CNA) hires not being allowed to work the floor until training is completed.An ad hoc QAPI meeting regarding items in the 1J template was completed on [DATE] with complete policy review. CPR policy and crash cart auditing policy with required contents were specifically reviewed. Attendees included the Medical Director, Executive Director-[Facility], DON-[Facility], ADON x2-[Facility], and Clinical Resource.The DON, ADON, or designee will verify nursing staff {licensed nurses, certified medication aides-CMA, certified nursing assistants-CNA) competency weekly via quiz.Crash carts will be reviewed daily by licensed nurse floor staff and verified by DON, ADON or designee daily and after each usage. Once a day audit and after each use audit by licensed nurse floor staff is required indefinitely. DON, ADON, or designee daily auditing is required for 90 days.Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance On [DATE] the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview on [DATE] at 10:55 AM, the ADM stated all staff from the previous night shift on [DATE] and all staff who were working today, [DATE] had been in-serviced according to the POR topics prior to going on duty today. He stated ADM and nursing administration were calling staff members who were not assigned to work today to give an in-service over the phone. He stated all crash carts were clean, stocked and audited with verification of auditing by nursing administration. Observation on [DATE] at 11:12 AM of crash cart #1 revealed the cart was clean and stocked, and the audit logbook had been signed for the daily audit. Observation on [DATE] at 11:17 AM of crash cart #2 revealed the cart was clean and stocked, and the audit logbook had been signed for the daily audit. Observation on [DATE] at 11:19 AM of crash cart #3 revealed the cart was clean and stocked, and the audit logbook had been signed for the daily audit. Record review of an in-service training for clinical staff dated [DATE] revealed, Topic: Facility Codes, Code Blue, CPR Policy, Crash Cart Expectations (Crash cart audit items).Facility Emergency Preparedness Codes - red, gray, orange, green, yellow, white; with emphasis on - Code Blue=a life-threatening medical emergency involving a patient who is unresponsive, not breathing, or without a pulse. Current CPR policy was reviewed with staff. Crash carts should be audited daily for the listed supplies on the crash cart log and initialed.Signed by 76 staff members. During an interview on [DATE] at 1:49 PM, LVN L stated she was assigned to verify that licensed staff were auditing crash carts daily. LVN L stated she had been in-serviced on the location and daily auditing of all crash carts in the facility, emergency preparedness codes and reviewed on the proper steps of CPR, according to current facility policy. During an interview on [DATE] at 1:51 PM, RN M stated she was assigned to verify that licensed staff were auditing crash carts daily. RN M stated she had been in-serviced on the location and daily auditing of all crash carts in the facility, emergency preparedness codes and reviewed on the proper steps of CPR, according to current facility policy. Record review of ad hoc QAPI meeting summary sheet. Meeting was held on [DATE] with discussion of CPR policy and crash cart policy and weekly competencies for licensed staff. In attendance were - ADM, DON, ADONs, MD On [DATE] between 1:31 PM and 5:15 PM interviews were conducted with the following staff members: CNAs A, C, D, E, G, K, N, O, Q; LVNs B, F, H, I, L P, R, S; RNs J, M; Housekeeper, OT, DS, MDS Coordinator, and COTA. All staff members stated were in-serviced on [DATE] or [DATE] on Facility Emergency Preparedness Codes - red, gray, orange, green, yellow, white; Code Blue=a life-threatening medical emergency involving a patient who is unresponsive, not breathing, or without a pulse. If witness to a resident who is unresponsive, notify the charge nurse immediately; CPR policy - Basic Life Support is to be provided to any resident who has elected full code status, prior to EMS arrival. Crash cart expectations: cart will be clean and fully stocked (according to the audit log) at all times and immediately following the use in an emergency situation. The 3 crash carts are located at each of the 3 nurses stations. The carts are to be audited by the charge nurse daily and initialed on the daily log. If any item is missing from the cart or is not able to be located in the facility supply, notify the ADM immediately. LVNs and CNAs were also given competency quizzes with the following questions: 1. What is the code for a medical emergency at [Facility Name]? 2. Where are the crash carts located at the facility? 3. How often should the crash cart be audited? 4. After use, how soon should the crash cart be cleaned and replenished? 5. If crash cart items are missing or need to be replaced, when and who should you inform? On [DATE] at 6:00PM, the ADM was informed the IJ was removed however, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to establish and 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 5 residents (Resident #1) reviewed for infection control.The facility failed to ensure LVN A followed Enhanced Barrier Precautions (EBP) when flushing the central line for Resident #1. This failure could place residents at risk for cross contamination and infection. The findings include: Record review of the face sheet for Resident #1, dated 02/23/26 revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: cerebral infarction (stroke), hemiplegia and hemiparesis following cerebral infarction affecting right dominate side (right sided weakness/paralysis), and dementia (lasting, progressive decline in mental abilities). Record review of the significant change MDS assessment for Resident #1, dated 02/13/26 revealed Resident #1 received IV medications while a resident at the facility. Record review of the order summary report for Resident #1, dated 02/23/26, revealed an order: Enhanced Barrier Precautions: PPE required for high resident contact activities. Indication: implanted IV access.every shift with a start date of 02/21/26. During an observation on 02/23/26 at 9:35 AM, LVN A flushed the central line on Resident #1 with normal saline. LVN A did not wear a gown when providing care to Resident #1. A box with PPE inside was noted outside of Resident #1's room and a sign was noted on Resident #1's door stating, Enhanced Barrier Precautions. During an interview on 02/23/26 at 10:50 AM, LVN A stated she should have worn a gown when flushing the central line for Resident #1. LVN A stated she was not thinking about it and that was why she forgot. LVN A stated she was last trained on EBP during the last skills fair at the facility which happened sometime around October 2025. LVN A stated a potential negative outcome to the resident was a potential for infection or the spread of bacteria. During an interview on 02/23/26 at 10:54 AM, the DON stated he expected the nurses to follow EBP when flushing an IV line. The DON stated the staff were trained regularly on EBP at the facility and the last training was set for 2/20/26 but state walked into the building and the training was rescheduled. The DON stated the risk to the residents was possible infection. During an interview on 02/23/26 at 11:11 AM, the ADM stated he expected the staff to follow EBP if a resident was on it. The ADM stated the facility had signs and PPE boxes all around the facility to ensure staff were able to follow EBP. The ADM stated the risk to the residents with not following EBP was spreading infection. Record review of the facility education/training document, dated 12/17/25, revealed a topic regarding Enhanced Barrier Precautions. LVN A's name and signature were noted on the form. Record review of the facility policy titled, Infection Prevention and Control Program, with a revised date of 04/25 reflected the following: Policy: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.Goals: Decrease the risk of infection to residents and personnel.3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. Record review of the facility policy titled, IPCP Standard and Transmission-Based Precautions, with a revised date of 04/25 reflected the following: Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions.Procedure:.3. Enhanced Barrier Precautions (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident to resident. (e.g., resident with wounds or indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).PPE: The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with:Wounds or indwelling medical devices regardless of known MDRO infection or colonization.Indwelling medical devices include, but are not limited to central lines.c. Examples of high-contact resident care activities requiring a gown and glove use for Enhanced Barrier Precautions include: .device care or use: central vascular line.

Based on interviews and record review, the facility failed to notify the residents physician and representative regarding a change in the resident's condition, for 1 of 6 residents (Resident #1) reviewed for changes in condition - The facility failed to immediately consult with Resident #1's physician when Resident #1 sustained a fall with complaints of pain to the knee on the evening of 08/07/2025 until the next morning 08/08/2025, because CNA C failed to inform nursing staff. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 2:23 PM. The IJ template was provided to the facility on [DATE] at 2:51 PM. While the IJ was removed on 8/22/2025 at 2:51pm, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, because all staff had not been trained on 08/22/2025. This failure could place residents at risk of not having their family and physicians notified of changes resulting in a delay in decision making for medical interventions.The Findings include:Record review of Resident #1's undated face sheet revealed an [AGE] year-old female admitted on [DATE]. Resident #1 had a medical history of periprosthetic fracture around internal prosthetic right knee joint (a bone break that occurs around a knee replacement implant), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), gout (a painful form of inflammatory arthritis that happens when uric acid crystals build up in the joints), and age-related osteoporosis (a bone disease that makes bones weak and brittle, leading to an increased risk of fractures). Record review of Resident #1's quarterly MDS dated [DATE], Section C-Cognitive Patterns revealed Resident #1 had a BIMS of 4 which indicated Resident #1 had severe cognitive impairment. Record review of Section GG- Functional Abilities revealed Resident #1 required Supervision or touching assistance with chair/bed-to chair transfers and sit to stand.Record review of Resident #1's care plan revealed a focus initiated on 4/29/2025 [Resident#1] is at risk for acute/chronic pain r/t [related to] gout with an intervention to anticipate need for pain relief and respond immediately to any complaint. The care plan also revealed a focus initiated on 8/21/2025, [Resident #1] has a fracture of the right distal femur (the lower end of the thigh bone (femur), specifically the area just above the knee joint) related to hearing a pop during transfer and interventions initiated on 8/21/2025 revealed Anticipate and meet needs, be sure call light is within reach and respond promptly to all request for assistance, change surgical incision dressing as per order and PRN(as needed), follow weight bearing orders per MD order, reposition as necessary to prevent skin breakdown, therapy evaluation and treatment per orders. Record review of Resident #1's document titled Physical Therapy Treatment Encounter Note(s) dated 8/7/2025 at 4:00pm, revealed Pt (patient) STS (sit to stand) and stand pivot with CGA ( Contact Guard Assist, describes a level of assistance where a therapist or caregiver has their hands on the patient to provide physical support and balance for tasks like walking or standing, even though the patient performs most of the activity) /[NAME] (minimum assistance)Record review of Resident #1's progress note dated 8/8/25 at 7:10AM revealed X ray to the Right Knee to R/O Dislocation. pt Stated she heard a loud pop when transferring to bed last HS, she c/o to this nurse this morning that she was in pain, and she couldn't move her leg. This nurse medicated pt for pain level 10 and notified NP. requested X ray to R/O Dislocation of the RT knee. STAT signed by RN H. Progress note dated 8/8/25 at 10:56 AM revealed Per [MD] sent pt to [hospital] to get tx and evaluate for the rt knee fx signed by RN H. Record review of Resident #1's radiology report dated 8/8/2025 10:02AM revealed Impressions: 1. Osteoporosis 2. The knee arthroplasty is aligned (the specific way the new knee joint components are positioned during surgery to restore function and balance) 3. The acute distal femoral metaphyseal [the wider portion of a bone] fracture is visualized with posterior displacement (distal femoral metaphyseal fracture with posterior displacement is a serious injury to the thigh bone, just above the knee. Posterior displacement means the broken end of the thigh bone has shifted backward towards the back of the knee). Record review of Resident #1's hospital records revealed Date of admission: [DATE]; History of present illness: presents to [hospital] ED (emergency department) via EMS (emergency medical services) with complaints of right knee pain. Patient states that she fell yesterday when trying to transfer to the shower with the assistance of nurse aide and lost balance causing her to fall and hit the right side of her body. Patient denies pain to her remaining extremities. Denies hitting her head. Denies blood thinner use. Denies blurry vision or headache. Denies numbness or tingling. States that her functional status prior to injury was ambulatory with assistive device and occasional wheelchair use. Diagnostic Studies: [X-ray] acute distal femoral fracture.Date: 08/08/25, open reduction internal fixation of right periprosthetic supracondylar distal femur fracture (surgical repair of distal femur).During an interview with Resident #1's family member on 8/20/2025 at 7:10pm, she stated Resident #1 had a fall on 8/7/2025 and had sustained a broken distal femur. She stated Resident #1 had called her on 8/8/2025 about the fall and that Resident #1 told her during the night a CNA was attempting to take her to the shower and during the transfer Resident #1 fell and her knee popped. Resident #1's family member stated she was not sure if the CNA was unable to handle Resident #1's weight or why they had only sent one person to assist Resident #1 but she was upset that the incident had happened on 8/7/2025 but nothing was done until 8/8/2025. She stated she was notified by the facility around 10AM on 8/8/25 that Resident #1 had notified the morning nurse of her knee popping and they obtained an x-ray showing a fracture to the right knee. She stated Resident #1 was sent out to the hospital where she had to have surgery to the right knee to repair the fracture. She stated she did speak to the morning nurse and she was made to feel as though it was Resident #1's fault because she was told this occurred due to Resident #1 attempting to self-transfer. She stated she wanted to know what had actually happened because she did not believe Resident #1 would be lying about having a fall. She stated Resident #1 also complained of being in pain and not having received any pain medication through the night to alleviate the pain in her knee. During an interview with Resident #1 on 8/20/2025 at 8:45PM, she stated she didn't remember when the incident occurred or with who, but she remembers it was at night and the CNA had come to help her into her wheelchair. She stated she is not sure what happened, but the CNA was unable to hold her weight and they both fell together onto the floor. She stated she heard her knee pop after they fell. She stated the CNA went to get help and returned with another CNA and between both of them they assisted her back into bed. She stated she does not remember anyone checking on her through the night and she complained of her right knee hurting. Resident #1 stated she did not want any of the CNAs to get in trouble. She stated she told them her knee had popped and the morning nurse gave her pain medication, called the doctor and they sent her to the hospital. She stated at the hospital she had surgery on her right knee. She stated she really cares for the staff and did not want anyone to get in trouble and understood it was an accident. During a second interview with Resident #1 on 8/21/2025 at 1:20pm, she stated the night of the incident, she had been in pain the entire night and does not remember getting any pain medication. She stated the incident made her feel bad and in pain. She stated prior to the incident she had no issues with the staff and since she has been back, all her needs are being met. During an interview with LVN A on 8/20/2025 at 9:29pm, she stated she was working 8/7/2025 and worked with Resident #1. She stated on 8/7/2025, no report of an injury or fall had been reported to her by anyone. She stated the CNAs were usually really good about reporting any minor event or any falls. She stated if she knew someone had a fall, she would go assess and notify the physician and family. She stated she does remember checking in on Resident #1 during the night of 8/7/2025 but does not remember giving her any pain medication. She stated she does not remember who called her on 8/8/2025 but they asked if Resident #1 had any injuries or falls during the night shift, and she stated she was not aware of any events for that night. She stated the week of 8/11/2025, she had heard from CNA K, that CNA C had mentioned falling with Resident #1 prior to her going to the hospital. She stated she did not report that to the DON or ADM because Resident #1 was already at the hospital, and she believed it had already been addressed. During an interview with CNA B on 8/20/2025 at 9:42AM, she stated she was working on 8/7/2025 with LVN A. She stated she usually works with Resident #1. She stated on 8/7/2025 she did report that Resident #1 mentioned having a fall, to LVN A. She stated LVN A said no one had mentioned a fall to her. She stated she also mentioned to LVN A that Resident #1's knee was hurting. CNA B stated she did check on Resident #1 through the night and she complained about her knee and Resident #1 stated something feels wrong. CNA B stated Resident #1 did not detail how she fell only that her knee hurt. CNA B stated she did see LVN A go into Resident #1's room but did not know for what. CNA B stated she never went into Resident #1's room to assist her from any fall or assist her back into bed. CNA B stated she did hear from CNA K that Resident #1 had a fall with another CNA, but did not know what CNA. She stated she heard this the week after Resident #1 had been sent to the hospital. She stated she did not report that because she believed it had been addressed already. She stated she had been trained on reporting falls and accidents to her nurse. She stated she did let LVN A know about Resident #1 stating she had a fall.During an interview with the ADM on 8/20/2025 at 10:20pm, he stated no staff member had reported a fall with Resident #1 on 8/7 or 8/8. He stated on 8/8/2025 he learned of Resident #1's fracture and he spoke to Resident #1 himself. He stated at that time, Resident #1 told him, she had attempted to self-transfer into her wheelchair and heard her knee pop and sat back down in bed. He stated he did ask the night staff from 8/7/2025 if there had been any incidents or injuries with Resident #1 and no one reported any falls or injuries. He stated this was his first time learning of a potential fall. He stated if the CNAs working that night were aware Resident #1 had any form of change in condition, injury or had an incident, it should have been reported to the nurse and addressed that night with the physician and notified family. He stated at the time of the incident, there was no DON at the facility. He stated the current DON began his role on 8/15/2025. During an interview with CNA C on 8/21/2025 at 8:48AM, she stated she had been working at the facility for the past two months and she was responsible for showers. She stated on 8/7/2025, she was assisting Resident #1 from the bed to the wheelchair to take her for her shower at approximate 9pm. She stated Resident #1 is a minimum assistance transfer and usually does very well pivoting from bed to her wheelchair. She stated she noticed Resident #1 appeared to be struggling so she got behind her and tried to hold her, but she heard Resident #1's knee pop. She stated she pulled Resident #1 towards her, and they both slid down to the floor together. She stated after they were both on the floor, Resident #1 was complaining about her right knee hurting. She stated she had been trained not to move residents after a fall and had gone to look for a nurse. She stated she was unable to find a nurse, and Resident #1 pushed her call light. She stated Resident #1 wanted to get back in to bed. She stated she went and grabbed CNA B to help her get Resident #1 back in bed and they both assisted Resident #1 back to her bed. She stated her shift ended at 10pm and she went home. She stated she did not see any nurses on her way out and did not report the incident to anyone except CNA B. She stated she was trained to report these incidents so the residents can have the proper assessments. She stated, I feel like I could have done something different in this case, I would have tried to find a different nurse on a different hallway. CNA C stated she was not aware Resident #1 had been sent to the hospital for a broken femur and required surgery. During an interview with CNA K on 8/21/2025 at 9:09AM, she stated she had heard about Resident #1 having a fall from report. She stated she did not remember who told her but she was making sure to pass the information down during report. She stated she does not usually work the hall Resident #1 is on, but that she had worked with her in the past. She stated when she asked where she was, that is when she was told Resident #1 had a fall and was at the hospital. She stated she was here on 8/7/2025 but did not know of any fall that day but if a fall had occurred it should have been reported as soon as possible. She stated she was not present for a fall, and did not know any details about the fall, only that Resident #1 had a fall. During an interview with the MD on 8/22/2025 at 11:00AM, he stated he had been made aware of Resident #1's knee hurting after a bed to wheelchair transfer [8/8/2025]. He stated from his understanding Resident #1 was transferring and heard a pop and was sat down in the wheelchair. He stated he had not been aware the incident occurred the night before and staff should have notified him that night [8/7/2025]. He stated he expects staff to notify him of any incidents or injuries as soon as possible. Record review of facility policy titled Change in Condition, last revised 4/2025 revealed .1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The nurse will perform and document an assessment of the resident and identity need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using telephone or similar process to obtain new orders or interventions. Record review of facility policy titled Fall Management System last revised 4/2025 revealed; Fall refers to unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force.3. When a Resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record.a. The Attending Physician and Resident Representative shall be notified of the fall and the resident status. B. Follow-up documentation will be completed for a minimum of 72 hours following the incident.5. The investigation will be reviewed by the interdisciplinary Team. The ADM and DON were notified an IJ situation was identified due to the above failures on 08/21/25 at 2:51 PM and the IJ template was provided. The following Plan of Removal was accepted on 8/21/25 at 6:13 PM: F-580-Failure to NotifyPlan of Removal8/21/25Per the information provided in the IJ template given on 8/21/25 at 2:51. The facility failed to properly notify the charge nurse, and MD of an incident with Resident #1 when resident #1 heard her knee pop and had to be guided down to the floor. Immediate Actions Taken:1. Head to toe assessment was completed on resident #1.2. Suspension of C.N.A. C on 8/20/253. Safe Surveys completed on 8/21/25Others who have the potential to be affected by this deficient practice: All residents have the potential to be affected by this deficient practice.1. The Medical Director was notified of IJ on 8/21/25 by the Executive Director [ADM].2. Education initiated with licensed nurses and certified nursing assistants [NAME]. Reporting any change of condition to the charge nurseb. Abuse and Neglect3. Quiz was completed on 8/21/25 to C.N.A's currently on shift to indicated competency.4. All quizzes and competencies for C.N.A.'s will be completed by 8/22/25.5. This training and competencies have been completed with current C.N.A staff on 8/21/25. A member of management will be at the facility at each change of shift. C.N.A will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the nursing new hire orientation and C.N.A's will not be allowed to work unless they have received their training and knowledge check.6. An ad hoc (as needed) meeting regarding items in the IJ template was completed on 8/21/25 with complete policy review. Attendees included the Medical Director, Executive Director­[facility] [ADM], Executive Director [corporate], Director of Nursing-[facility], Director of Nursing [corporate], Clinical Market Leader and Clinical Resource.7. The DON, ADON will verify C.N.A competency with C.N.A's weekly.8. All residents with new complaints of pain or injury will be reviewed by DON, ADON ordesignee every week in the clinical meeting to ensure that all parties have been notified of a new injury or new complaint of pain.9. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance.On 08/22/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. Record Review of document tiled Skin Evaluation dated 8/21/2025 1500 [3pm] for Resident #1 revealed: Resident noted resting in bed upon enter. Skin assessment completed by this DON. Post surgical wound noted to right thigh, dressing CDI (clean, dry, intact).Full head to toe assessment completed and no other concerns or issues noted at this time, signed by DON on 8/22/2025. 2. Record review of document titled View Event revealed: For [CNA C].last day of work: 8/20/2025, first day of leave: 8/21/2025.leave type: Suspension.3. Record review revealed Safe Surveys dated 8/20/2025 had been conducted with 83 Residents in the facility. Safe Survey documents revealed all 83 residents stated yes they felt safe at the facility, and they report abuse to the administrator. They all stated yes, staff treated them with dignity and respect, and they felt their needs and concerns were reported to the appropriate parties. Record review revealed Pain evaluation in Advanced Dementia assessments were completed for 31 Residents in the facility on 8/20/2025. All 31 Resident assessments revealed breathing normal, no negative vocalization, facial expressions; smiling or inexpressive, body language; relaxed and consolability; no need to console. 4. During an interview with the MD on 8/22/2025 at 11:00AM he stated he was notified of the IJ templates, and the facility had a QAPI meeting, and they had implemented a plan of removal. He stated the facility would be implementing more training and education on abuse and neglect and on reporting any changes in condition. He stated they would continue to review through QAPI meetings for effectiveness. 5. Record review of facility document titled Inservice Title: Reporting Allegations and Suspicions of abuse or neglect and change of condition dated 8/20/2025-8/21/2025 revealed 119 staff signatures out of 169. The in-service document revealed .Any change in condition should be reported to the Provider as well as the DON and ADON immediately. 6. During interview on 8/22/2025 between 9:30AM-11:26 AM with CNA D, K, L ,M ,N ,P, Q, R, S ,T, GVN F, CMA G, LVN E, I,J, O, and RN H revealed all staff members had been trained on reporting any changes in conditions such as falls, injuries or incidents. All CNAs, and CMAs stated they would report any changes in condition to the charge nurse or the DON. All licensed nursing staff stated they would report any changes in conditions to the physician, family and to the DON. They all stated they had been in-serviced prior to their shift on 8/22/2025. All staff members stated the potential negative outcome of not reporting injuries, falls or incidents could be delay in medical care, neglect, and potential death depending on the situation. 7. Record review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI. 8. Record review of Untitled Document, undated, revealed Competencies will be completed via written quiz with all nursing staff once a week times 4 weeks. Trainings will be available on Tuesdays and Thursdays Signed by the DON.9. Record review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by the DON. 10. Record review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025. On 8/22/2025 at 2:51pm the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure residents were free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect in that: 1. CNA C neglected to notify LVN A or any licensed nurse of Resident #1's incident on 8/7/2025, that resulted in a broken distal femur. 2. The facility neglected to ensure Resident #1's pain was adequately assessed and treated for approximately 12 hours on 8/7/2025-8/8/2025, after Resident #1 reported having pain to her right knee following an incident with CNA C. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 2:23 PM. The IJ template was provided to the facility on [DATE] at 2:51 PM. While the IJ was removed on 8/22/2025 at 2:51pm, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, because all staff had not been trained on 08/22/2025. This failure placed residents at risk for neglect, mental anguish, pain and emotional distress.The Findings include:Record review of Resident #1's undated face sheet revealed an [AGE] year-old female admitted on [DATE]. Resident #1 had a medical history of periprosthetic fracture around internal prosthetic right knee joint (a bone break that occurs around a knee replacement implant), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), gout (a painful form of inflammatory arthritis that happens when uric acid crystals build up in the joints), and age-related osteoporosis (a bone disease that makes bones weak and brittle, leading to an increased risk of fractures). Record review of Resident #1's quarterly MDS dated [DATE], Section C-Cognitive Patterns revealed Resident #1 had a BIMS of 4 which indicated Resident #1 had severe cognitive impairment. Section GG- Functional Abilities revealed Resident #1 required Supervision or touching assistance with chair/bed-to chair transfers and sit to stand.Record review of Resident #1's care plan revealed a focus initiated on 4/29/2025 [Resident#1] is at risk for acute/chronic pain r/t [related to] gout with an intervention to anticipate need for pain relief and respond immediately to any complaint. The care plan also revealed a focus initiated on 8/21/2025, [Resident #1] has a fracture of the right distal femur (the lower end of the thigh bone (femur), specifically the area just above the knee joint) related to hearing a pop during transfer and interventions initiated on 8/21/2025 revealed Anticipate and meet needs, be sure call light is within reach and respond promptly to all request for assistance, change surgical incision dressing as per order and PRN(as needed), follow weight bearing orders per MD order, reposition as necessary to prevent skin breakdown, therapy evaluation and treatment per orders. Record review of Resident #1's document titled Physical Therapy Treatment Encounter Note(s) dated 8/7/2025 at 4:00pm, revealed Pt (patient) STS (sit to stand) and stand pivot with CGA ( Contact Guard Assist, describes a level of assistance where a therapist or caregiver has their hands on the patient to provide physical support and balance for tasks like walking or standing, even though the patient performs most of the activity) /[NAME] (minimum assistance)Record review of Resident #1's progress note dated 8/8/25 at 7:10AM, revealed X ray to the Right Knee to R/O Dislocation. pt Stated she heard a loud pop when transferring to bed last HS, she c/o to this nurse this morning that she was in pain, and she couldn't move her leg. This nurse medicated pt for pain level 10 and notified NP. requested X ray to R/O Dislocation of the RT knee. STAT signed by RN H. Progress note dated 8/8/25 at 10:56 AM revealed Per [MD] sent pt to [hospital] to get tx and evaluate for the rt knee fx signed by RN H. Record review of Resident #1's radiology report dated 8/8/2025 at 10:02AM, revealed Impressions: 1. Osteoporosis 2. The knee arthroplasty is aligned (the specific way the new knee joint components are positioned during surgery to restore function and balance) 3. The acute distal femoral metaphyseal [the wider portion of a bone] fracture is visualized with posterior displacement (distal femoral metaphyseal fracture with posterior displacement is a serious injury to the thigh bone, just above the knee. Posterior displacement means the broken end of the thigh bone has shifted backward towards the back of the knee). Record review of Resident #1's physician orders revealed Tramadol 50mg. Give 50mg by mouth two times a day for pain 0800 and 1800 [8am and 6pm] with a start date of 4/28/2025 and end date of 8/8/2025. Resident #1's physician orders also revealed Gabapentin Capsule 100mg. Give 1 capsule by mouth two times a day related to pain. 7am and 15 [3pm] with a start date of 4/29/2025 and an end date of 8/8/2025. Physician order to monitor and assess level of pain using the 0-10 scale, 0=no pain, 1-2 mild pain, 4-6 moderate pain, 7-10- severe pain with start date of 4/28/2025 per shift.Record review of Resident #1's medication administration record revealed Gabapentin was administer[PH1] [CO2] on 8/7/2025 at approximately 1500 [3pm] and 8/8/2025 at approximately 7AM. The document also revealed Tramadol 50mg was administered 8/7/2025 at 17:28 (5:28pm) and again on 8/8/2025 at 9:46AM. The document did not reveal any other pain medication administered between 8/7/2025 9pm and 8/8/2025 9AM. The document revealed an assessment of pain was completed on 8/8/2025 at 1:38AM by LVN A, and a score of 0 indicating no pain was documented. Record review of Resident #1's hospital records revealed Date of admission: [DATE]; History of present illness: presents to [hospital] ED (emergency department) via EMS (emergency medical services) with complaints of right knee pain. Patient states that she fell yesterday when trying to transfer to the shower with the assistance of nurse aide and lost balance causing her to fall and hit the right side of her body. Patient denies pain to her remaining extremities. Denies hitting her head. Denies blood thinner use. Denies blurry vision or headache. Denies numbness or tingling. States that her functional status prior to injury was ambulatory with assistive device and occasional wheelchair use. Diagnostic Studies: [X-ray] acute distal femoral fracture.Date: 08/08/25, open reduction internal fixation of right periprosthetic supracondylar distal femur fracture (surgical repair of distal femur).During an interview with Resident #1's family member on 8/20/2025 at 7:10 pm, she stated Resident #1 had a fall on 8/7/2025 and had sustained a broken distal femur. She stated Resident #1 had called her on 8/8/2025 about the fall and that Resident #1 told her during the night a CNA was attempting to take her to the shower and during the transfer Resident #1 fell and her knee popped. Resident #1's family member stated she was not sure if the CNA was unable to handle Resident #1's weight or why they had only sent one person to assist Resident #1 but she was upset that the incident had happened on 8/7/2025 but nothing was done until 8/8/2025. She stated she was notified by the facility around 10AM on 8/8/25 that Resident #1 had notified the morning nurse of her knee popping and they obtained an x-ray showing a fracture to the right knee. She stated Resident #1 was sent out to the hospital where she had to have surgery to the right knee to repair the fracture. She stated she did speak to the morning nurse and she was made to feel as though it was Resident #1's fault because she was told this occurred due to Resident #1 attempting to self-transfer. She stated she wanted to know what had actually happened because she did not believe Resident #1 would be lying about having a fall. She stated Resident #1 also complained of being in pain and not having received any pain medication through the night to alleviate the pain in her knee. During an interview with Resident #1 on 8/20/2025 at 8:45 PM, she stated she did not remember when the incident occurred or with who, but she remembers it was at night and the CNA had come to help her into her wheelchair. She stated she is not sure what happened, but the CNA was unable to hold her weight and they both fell together onto the floor. She stated she heard her knee pop after they fell. She stated the CNA went to get help and returned with another CNA and between both of them they assisted her back into bed. She stated she does not remember anyone checking on her through the night and she complained of her right knee hurting. Resident #1 stated she did not want any of the CNAs to get in trouble. She stated she told them her knee had popped and the morning nurse gave her pain medication, called the doctor and they sent her to the hospital. She stated at the hospital she had surgery on her right knee. She stated she really cares for the staff and did not want anyone to get in trouble and understood it was an accident. During a second interview with Resident #1 on 8/21/2025 at 1:20pm, she stated the night of the incident, she had been in pain the entire night and does not remember getting any pain medication. She stated the incident made her feel bad and in pain. She stated prior to the incident she had no issues with the staff and since she has been back, all her needs are being met. During an interview with LVN A on 8/20/2025 at 9:29 pm, she stated she was working 8/7/2025 and worked with Resident #1. She stated on 8/7/2025, no report of an injury or fall had been reported to her by anyone. She stated the CNAs were usually really good about reporting any minor event or any falls. She stated if she knew someone had a fall, she would go assess and notify the physician and family. She stated she does remember checking in on Resident #1 during the night of 8/7/2025 but does not remember giving her any pain medication. She stated she does not remember who called her on 8/8/2025 but they asked if Resident #1 had any injuries or falls during the night shift, and she stated she was not aware of any events for that night. She stated the week of 8/11/2025, she had heard from CNA K, that CNA C had mentioned falling with Resident #1 prior to her going to the hospital. She stated she did not report that to the DON or ADM because Resident #1 was already at the hospital, and she believed it had already been addressed. During an interview with CNA B on 8/20/2025 at 9:42AM, she stated she was working on 8/7/2025 with LVN A. She stated she usually worked[PH3] [CO4] with Resident #1. She stated on 8/7/2025 she did report that Resident #1 mentioned having a fall, to LVN A. She stated LVN A said no one had mentioned a fall to her. She stated she also mentioned to LVN A that Resident #1's knee was hurting. CNA B stated she did check on Resident #1 through the night and she complained about her knee and Resident #1 stated something feels wrong. CNA B stated Resident #1 did not detail how she fell only that her knee hurt. CNA B stated she did see LVN A go into Resident #1's room but did not know for what. CNA B stated she never went into Resident #1's room to assist her from any fall or assist her back into bed. CNA B stated she did hear from CNA K that Resident #1 had a fall with another CNA, but did not know what CNA. She stated she heard this the week after Resident #1 had been sent to the hospital. She stated she did not report that because she believed it had been addressed already. She stated she had been trained on reporting falls and accidents to her nurse. She stated she did let LVN A know about Resident #1 stating she had a fall.During an interview with the ADM on 8/20/2025 at 10:20pm, he stated no staff member had reported a fall with Resident #1 on 8/7 or 8/8. He stated on 8/8/2025 he learned of Resident #1's fracture and he spoke to Resident #1 himself. He stated at that time, Resident #1 told him, she had attempted to self-transfer into her wheelchair and heard her knee pop and sat back down in bed. He stated he did ask the night staff from 8/7/2025 if there had been any incidents or injuries with Resident #1 and no one reported any falls or injuries. He stated this was his first time learning of a potential fall. He stated if the CNAs working that night was aware Resident #1 had any form of change in condition, injury or had an incident, it should have been reported to the nurse and addressed that night with the physician and notified family. He stated at the time of the incident, there was no DON at the facility. He stated the current DON began his role on 8/15/2025. During an interview with CNA C on 8/21/2025 at 8:48AM, she stated she had been working at the facility for the past two months and she was responsible for showers. She stated on 8/7/2025, she was assisting Resident #1 from the bed to the wheelchair to take her for her shower at approximate 9pm. She stated Resident #1 is a minimal assistance transfer and usually does very well pivoting from bed to her wheelchair. She stated she noticed Resident #1 appeared to be struggling so she got behind her and tried to hold her, but she heard Resident #1's knee pop. She stated she pulled Resident #1 towards her, and they both slid down to the floor together. She stated after they were both on the floor, Resident #1 was complaining about her right knee hurting. She stated she had been trained not to move residents after a fall and had gone to look for a nurse. She stated she was unable to find a nurse, and Resident #1 pushed her call light. She stated Resident #1 wanted to get back in to bed. She stated she went and grabbed CNA B to help her get Resident #1 back in bed and they both assisted Resident #1 back to her bed. She stated her shift ended at 10pm and she went home. She stated she did not see any nurses on her way out and did not report the incident to anyone except CNA B. She stated she was trained to report these incidents so the residents can have the proper assessments. She stated, I feel like I could have done something different in this case, I would have tried to find a different nurse on a different hallway. CNA C stated she was not aware Resident #1 had been sent to the hospital for a broken femur and required surgery. During an interview with CNA K on 8/21/2025 at 9:09AM, she stated she heard about Resident #1 having a fall from report. She stated she did not remember who told her but she was making sure to pass the information down during report. She stated she does not usually work the hall Resident #1 is on, but that she had worked with her in the past. She stated when she asked where she was, that is when she was told Resident #1 had a fall and was at the hospital. She stated she was here on 8/7/2025 but did not know of any fall that day but if a fall had occurred it should have been reported as soon as possible. She stated she was not present for a fall, and did not know any details about the fall, only that Resident #1 had a fall. During an interview with the MD on 8/22/2025 at 11:00AM, he stated he had been made aware of Resident #1's knee hurting after a bed to wheelchair transfer [8/8/2025]. He stated from his understanding Resident #1 was transferring and heard a pop and was sat down in the wheelchair. He stated he had not been aware the incident occurred the night before and staff should have notified him that night [8/7/2025]. He stated he expects staff to notify him of any incidents or injuries as soon as possible. The MD stated if any resident is experiencing pain, he expects the nursing staff to provide what is ordered for pain and if those orders do not alleviate the pain, to call for further orders. Record review of facility policy title Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment original date: 11/2017 revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers. Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.Record review of facility policy titled Change in Condition, last revised 4/2025 revealed .1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The nurse will perform and document an assessment of the resident and identity need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using telephone or similar process to obtain new orders or interventions. Record review of facility policy titled Rounds undated, revealed; It is the policy of this facility to ensure the safety ad comfort of the resident and to assist in continuity of care and to identify potential change in condition. 1. Resident will be checked by the certified nursing assistants during rounds. 2. Observe resident for privacy, dignity and safety. 3. Note positioning of the resident and comfort level.The ADM and DON were notified an IJ situation was identified due to the above failures on 08/21/25 at 2:51 PM and the IJ template was provided. The following Plan of Removal was accepted on 8/21/25 at 6:13 PM: Plan of Removal 8/21/25Per the information provided in the IJ template given on 8/21/25 at 2:51. CNA C failed to properly notify the charge nurse, and/or the MD that resident #1 heard a pop and had to be guided to the floor on 8/7 /25.1. The Medical Director was notified of IJ on 8/21/25 by the Executive Director [ADM].2. Head to toe Assessment completed by DON on Resident #1 on 8/21/25.3. Suspension of CNA C on 8/20/254. Safe survey completed on all residents on 8/21/25.5. Education completed on 8/21/25 with licensed nurses and certified nursing assistance on:a. Reporting any change of condition to the charge nurseb. Abuse and Neglect6. Quiz was completed on 8/21/2025 to the certified nursing assistants currently on shift to indicate competency. All quizzes and competencies for CNAs to be completed by 8/22/25.7. This training and competencies were completed on 8/21/25 with current staff on shift. A member of management will be at the facility at each change of shift to ensure remaining staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will not be allowed to work unless they have received their training and knowledge check.8. An ad hoc (as needed) meeting regarding items in the IJ template was completed on 8/21/25 with complete policy review. Attendees included the Medical Director, Executive Director­[facility] [ADM], Executive Director [corporate], Director of Nursing-[facility], Director of Nursing [corporate], Clinical Market Leader and Clinical Resource.9. The DON, ADON will verify staff competency with staff weekly.10. All residents with new complaints of injury or pain will be reviewed by DON, ADON or designee every week in clinical meetings to assure assessments have been completed timely.11. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance.On 08/22/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. During an interview with the MD on 8/22/2025 at 11:00AM he stated he was notified of the IJ templates, and the facility had a QAPI meeting, and they had implemented a plan of removal. He stated the facility would be implementing more training and education on abuse and neglect and on reporting any changes in condition. He stated they would continue to review through QAPI meetings for effectiveness. 2. Record review of document titled Skin Evaluation dated 8/21/2025 at 1500 [3pm] for Resident #1 revealed: Resident noted resting in bed upon enter. Skin assessment completed by this DON. Post surgical wound noted to right thigh, dressing CDI (clean, dry, intact).Full head to toe assessment completed and no other concerns or issues noted at this time, signed by DON on 8/22/2025. 3. Record review of document titled View Event revealed: For [CNA C].last day of work: 8/20/2025, first day of leave: 8/21/2025.leave type: Suspension.4. Record review revealed Safe Surveys dated 8/20/2025 had been conducted with 83 Residents in the facility. Safe Survey documents revealed all 83 residents stated yes they felt safe at the facility, and they report abuse to the administrator. They all stated yes, staff treated them with dignity and respect, and they felt their needs and concerns were reported to the appropriate parties. Record review revealed Pain evaluation in Advanced Dementia assessments were completed for 31 Residents in the facility on 8/20/2025. All 31 Resident assessments revealed breathing normal, no negative vocalization, facial expressions; smiling or inexpressive, body language; relaxed and consolability; no need to console. 5. Record review of facility document titled Inservice Title: Reporting Allegations and Suspicions of abuse or neglect and change of condition dated 8/20/2025-8/21/2025 revealed 119 staff signatures out of 169. The in-service document revealed [ADM] is the facilities abuse and neglect coordinator. All suspicions and allegations of abuse or neglect must be reported directly to the abuse coordinator immediately. If anyone reports suspicious or witness abuse of any kind, it must be reported directly [ADM] per our policy.We must do everything we can to protect our residents. All allegations will be investigated per facility and state policy. 6. Record review of facility quiz titled Assessing and Reporting pain dated 8/21/-8/22 revealed 71 staff members had completed the quiz. The quiz revealed the following questions were asked to staff Give me an example of when you would assess for and report pain? Who would you report pain to? What are the non-verbal signs of pain? How would you communicate pain to the nurse?. Further review of the documents revealed staff stated they would assess for pain if a resident expressed pain at any time, or if they had facial or physical signs of pain. The staff stated they would report pain to the charge nurse and provider. The staff stated non verbal signs of pain would be frequent moaning, facial expressions, and elevated vital signs. The staff stated they would communicate the residents pain verbally to the nurse or provider and detail where the pain was expressed to be. 7. During interview on 8/22/2025 between 9:30AM-11:26 AM with CNA D, K, L, M, N, P, Q, R, S, T, GVN F, CMA G, LVN E, I, J, O, and RN H revealed all staff members had been trained on reporting abuse and neglect. All staff members stated they would report abuse and neglect to their ADM immediately. All staff members stated they would report any falls, injuries or incidents to the charge nurse, physician, and DON. They all stated they had been in-serviced prior to their shift on 8/22/2025. All staff members stated the potential negative outcome of not reporting abuse or neglect could be decrease in quality of life for the residents, decrease in care, and emotional anguish. 8. Record review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI. 9. Record review of Untitled Document, undated, revealed Competencies will be completed via written quiz with all nursing staff once a week times 4 weeks. Trainings will be available on Tuesdays and Thursdays Signed by the DON.10. Record review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by the DON. 11. Record review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025.On 8/22/2025 at 2:51pm the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Resident #1) reviewed for neglect.1. The facility failed to ensure staff followed the abuse policy by not preventing neglect for Resident #1 on 8/7/2025 when CNA C failed to notify a licensed nurse of an incident that resulted in a broken distal femur for Resident #1. 2. The facility failed to ensure staff followed the abuse policy by not preventing neglect for Resident #1 on 8/7/2025 when staff failed to adequately assess and treat Resident #1's report of pain, for approximately 12 hours, to her right knee following an incident with CNA C. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 2:23 PM. The IJ template was provided to the facility on [DATE] at 2:51 PM. While the IJ was removed on 8/22/2025 at 2:51pm, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated, because all staff had not been trained on 08/22/2025. These failures could place residents at risk for injury and neglect. The Findings include:Record review of facility policy title Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment original date: 11/2017 revealed: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers. Neglect is the failure of the Facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.Record review of facility policy titled Change in Condition, last revised 4/2025 revealed .1. If at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. 2. The nurse will perform and document an assessment of the resident and identity need for additional interventions, considering implementation of existing orders or nursing interventions or through communication with the resident's provider using telephone or similar process to obtain new orders or interventions. Record review of facility policy titled Rounds undated, revealed; It is the policy of this facility to ensure the safety ad comfort of the resident and to assist in continuity of care and to identify potential change in condition. 1. Resident will be checked by the certified nursing assistants during rounds. 2. Observe resident for privacy, dignity and safety. 3. Note positioning of the resident and comfort level. Record review of Resident #1's undated face sheet revealed an [AGE] year-old female admitted on [DATE]. Resident #1 had a medical history of periprosthetic fracture around internal prosthetic right knee joint (a bone break that occurs around a knee replacement implant), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), gout (a painful form of inflammatory arthritis that happens when uric acid crystals build up in the joints), and age-related osteoporosis (a bone disease that makes bones weak and brittle, leading to an increased risk of fractures). Record review of Resident #1's quarterly MDS dated [DATE], Section C-Cognitive Patterns revealed Resident #1 had a BIMS of 4 which indicated Resident #1 had severe cognitive impairment Section GG- Functional Abilities revealed Resident #1 required Supervision or touching assistance with chair/bed-to chair transfers and sit to stand.Record review of Resident #1's care plan revealed a focus initiated on 4/29/2025 [Resident#1] is at risk for acute/chronic pain r/t [related to] gout with an intervention to anticipate need for pain relief and respond immediately to any complaint. The care plan also revealed a focus initiated on 8/21/2025, [Resident #1] has a fracture of the right distal femur (the lower end of the thigh bone (femur), specifically the area just above the knee joint) related to hearing a pop during transfer and interventions initiated on 8/21/2025 revealed Anticipate and meet needs, be sure call light is within reach and respond promptly to all request for assistance, change surgical incision dressing as per order and PRN(as needed), follow weight bearing orders per MD order, reposition as necessary to prevent skin breakdown, therapy evaluation and treatment per orders. Record review of Resident #1's document titled Physical Therapy Treatment Encounter Note(s) dated 8/7/2025 at 4:00pm, revealed Pt (patient) STS (sit to stand) and stand pivot with CGA ( Contact Guard Assist, describes a level of assistance where a therapist or caregiver has their hands on the patient to provide physical support and balance for tasks like walking or standing, even though the patient performs most of the activity) /[NAME] (minimum assistance)Record review of Resident #1's progress note dated 8/8/25 at 7:10AM revealed X ray to the Right Knee to R/O Dislocation. pt Stated she heard a loud pop when transferring to bed last HS, she c/o to this nurse this morning that she was in pain, and she couldn't move her leg. This nurse medicated pt for pain level 10 and notified NP. requested X ray to R/O Dislocation of the RT knee. STAT signed by RN H. Progress note dated 8/8/25 at 10:56 AM revealed Per [MD] sent pt to [hospital] to get tx and evaluate for the rt knee fx signed by RN H. Record review of Resident #1's radiology report dated 8/8/2025 10:02AM revealed Impressions: 1. Osteoporosis 2. The knee arthroplasty is aligned (the specific way the new knee joint components are positioned during surgery to restore function and balance) 3. The acute distal femoral metaphyseal [the wider portion of a bone] fracture is visualized with posterior displacement (distal femoral metaphyseal fracture with posterior displacement is a serious injury to the thigh bone, just above the knee. Posterior displacement means the broken end of the thigh bone has shifted backward towards the back of the knee). Record rview of Resident #1's physician orders revealed Tramadol 50mg. Give 50mg by mouth two times a day for pain 0800 and 1800 [8AMand 6pm] with a start date of 4/28/2025 and end date of 8/8/2025. Resident #1's physician orders also revealed Gabapentin Capsule 100mg. Give 1 capsule by mouth two times a day related to pain. 7AM and 15 [3pm] with a start date of 4/29/2025 and an end date of 8/8/2025. Physician order to monitor and assess level of pain using the 0-10 scale, 0=no pain, 1-2 mild pain, 4-6 moderate pain, 7-10- severe pain with start date of 4/28/2025 per shift.Record review of Resident #1's medication administration record revealed Gabapentin was administer on 8/7/2025 at approximately 1500 [3pm] and 8/8/2025 at approximately 7AM. The document also revealed Tramadol 50mg was administered 8/7/2025 at 17:28pm(5;28pm) and again on 8/8/2025 at 9:46AM. The document did not reveal any other pain medication administered between 8/7/2025 9pm and 8/8/2025 9AM. The document revealed an assessment of pain was completed on 8/8/2025 at 1:38am by LVN A, and a score of 0 indicating no pain was documented. Record review of Resident #1's hospital records revealed Date of admission: [DATE]; History of present illness: presents to [hospital] ED (emergency department) via EMS (emergency medical services) with complaints of right knee pain. Patient states that she fell yesterday when trying to transfer to the shower with the assistance of nurse aide and lost balance causing her to fall and hit the right side of her body. Patient denies pain to her remaining extremities. Denies hitting her head. Denies blood thinner use. Denies blurry vision or headache. Denies numbness or tingling. States that her functional status prior to injury was ambulatory with assistive device and occasional wheelchair use. Diagnostic Studies: [X-ray] acute distal femoral fracture.Date: 08/08/25, open reduction internal fixation of right periprosthetic supracondylar distal femur fracture (surgical repair of distal femur).During an interview with Resident #1's family member on 8/20/2025 at 7:10pm, she stated Resident #1 had a fall on 8/7/2025 and had sustained a broken distal femur. She stated Resident #1 had called her on 8/8/2025 about the fall and that Resident #1 told her during the night a CNA was attempting to take her to the shower and during the transfer Resident #1 fell and her knee popped. Resident #1's family member stated she was not sure if the CNA was unable to handle Resident #1's weight or why they had only sent one person to assist Resident #1 but she was upset that the incident had happened on 8/7/2025 but nothing was done until 8/8/2025. She stated she was notified by the facility around 10AM on 8/8/25 that Resident #1 had notified the morning nurse of her knee popping and they obtained an x-ray showing a fracture to the right knee. She stated Resident #1 was sent out to the hospital where she had to have surgery to the right knee to repair the fracture. She stated she did speak to the morning nurse and she was made to feel as though it was Resident #1's fault because she was told this occurred due to Resident #1 attempting to self-transfer. She stated she wanted to know what had actually happened because she did not believe Resident #1 would be lying about having a fall. She stated Resident #1 also complained of being in pain and not having received any pain medication through the night to alleviate the pain in her knee. During an interview with Resident #1 on 8/20/2025 at 8:45PM, she stated she did not remember when the incident occurred or with who, but she remembers it was at night and the CNA had come to help her into her wheelchair. She stated she is not sure what happened, but the CNA was unable to hold her weight and they both fell together onto the floor. She stated she heard her knee pop after they fell. She stated the CNA went to get help and returned with another CNA and between both of them they assisted her back into bed. She stated she does not remember anyone checking on her through the night and she complained of her right knee hurting. Resident #1 stated she did not want any of the CNAs to get in trouble. She stated she told them her knee had popped and the morning nurse gave her pain medication, called the doctor and they sent her to the hospital. She stated at the hospital she had surgery on her right knee. She stated she really cares for the staff and did not want anyone to get in trouble and understood it was an accident. During a second interview with Resident #1 on 8/21/2025 at 1:20pm, she stated the night of the incident, she had been in pain the entire night and does not remember getting any pain medication. She stated the incident made her feel bad and in pain. She stated prior to the incident she had no issues with the staff and since she has been back, all her needs are being met. During an interview with LVN A on 8/20/2025 at 9:29pm, she stated she was working 8/7/2025 and worked with Resident #1. She stated on 8/7/2025, no report of an injury or fall had been reported to her by anyone. She stated the CNAs were usually really good about reporting any minor event or any falls. She stated if she knew someone had a fall, she would go assess and notify the physician and family. She stated she does remember checking in on Resident #1 during the night of 8/7/2025 but does not remember giving her any pain medication. She stated she does not remember who called her on 8/8/2025 but they asked if Resident #1 had any injuries or falls during the night shift, and she stated she was not aware of any events for that night. She stated the week of 8/11/2025, she had heard from CNA K, that CNA C had mentioned falling with Resident #1 prior to her going to the hospital. She stated she did not report that to the DON or ADM because Resident #1 was already at the hospital, and she believed it had already been addressed. During an interview with CNA B on 8/20/2025 at 9:42AM, she stated she was working on 8/7/2025 with LVN A. She stated she usually works with Resident #1. She stated on 8/7/2025 she did report that Resident #1 mentioned having a fall, to LVN A. She stated LVN A said no one had mentioned a fall to her. She stated she also mentioned to LVN A that Resident #1's knee was hurting. CNA B stated she did check on Resident #1 through the night and she complained about her knee and Resident #1 stated something feels wrong. CNA B stated Resident #1 did not detail how she fell only that her knee hurt. CNA B stated she did see LVN A go into Resident #1's room but did not know for what. CNA B stated she never went into Resident #1's room to assist her from any fall or assist her back into bed. CNA B stated she did hear from CNA K that Resident #1 had a fall with another CNA, but did not know what CNA. She stated she heard this the week after Resident #1 had been sent to the hospital. She stated she did not report that because she believed it had been addressed already. She stated she had been trained on reporting falls and accidents to her nurse. She stated she did let LVN A know about Resident #1 stating she had a fall.During an interview with the ADM on 8/20/2025 at 10:20pm, he stated no staff member had reported a fall with Resident #1 on 8/7 or 8/8. He stated on 8/8/2025 he learned of Resident #1's fracture and he spoke to Resident #1 himself. He stated at that time, Resident #1 told him, she had attempted to self-transfer into her wheelchair and heard her knee pop and sat back down in bed. He stated he did ask the night staff from 8/7/2025 if there had been any incidents or injuries with Resident #1 and no one reported any falls or injuries. He stated this was his first time learning of a potential fall. He stated if the CNAs working that night were aware Resident #1 had any form of change in condition, injury or had an incident, it should have been reported to the nurse and addressed that night with the physician and notified family. He stated at the time of the incident, there was no DON at the facility. He stated the current DON began his role on 8/15/2025. During an interview with CNA C on 8/21/2025 at 8:48AM, she stated she had been working at the facility for the past two months and she was responsible for showers. She stated on 8/7/2025, she was assisting Resident #1 from the bed to the wheelchair to take her for her shower at approximate 9pm. She stated Resident #1 is a minimum assistance transfer and usually does very well pivoting from bed to her wheelchair. She stated she noticed Resident #1 appeared to be struggling so she got behind her and tried to hold her, but she heard Resident #1's knee pop. She stated she pulled Resident #1 towards her, and they both slid down to the floor together. She stated after they were both on the floor, Resident #1 was complaining about her right knee hurting. She stated she had been trained not to move residents after a fall and had gone to look for a nurse. She stated she was unable to find a nurse, and Resident #1 pushed her call light. She stated Resident #1 wanted to get back in to bed. She stated she went and grabbed CNA B to help her get Resident #1 back in bed and they both assisted Resident #1 back to her bed. She stated her shift ended at 10pm and she went home. She stated she did not see any nurses on her way out and did not report the incident to anyone except CNA B. She stated she was trained to report these incidents so the residents can have the proper assessments. She stated, I feel like I could have done something different in this case, I would have tried to find a different nurse on a different hallway. CNA C stated she was not aware Resident #1 had been sent to the hospital for a broken femur and required surgery. During an interview with CNA K on 8/21/2025 at 9:09AM, she stated she had heard about Resident #1 having a fall from report. She stated she did not remember who told her but she was making sure to pass the information down during report. She stated she does not usually work the hall Resident #1 is on, but that she had worked with her in the past. She stated when she asked where she was, that is when she was told Resident #1 had a fall and was at the hospital. She stated she was here on 8/7/2025 but did not know of any fall that day but if a fall had occurred it should have been reported as soon as possible. She stated she was not present for a fall, and did not know any details about the fall, only that Resident #1 had a fall. During an interview with the MD on 8/22/2025 at 11:00AM, he stated he had been made aware of Resident #1's knee hurting after a bed to wheelchair transfer [8/8/2025]. He stated from his understanding Resident #1 was transferring and heard a pop and was sat down in the wheelchair. He stated he had not been aware the incident occurred the night before and staff should have notified him that night [8/7/2025]. He stated he expects staff to notify him of any incidents or injuries as soon as possible. The MD stated if any resident is experiencing pain, he expects the nursing staff to provide what is ordered for pain and if those orders do not alleviate the pain, to call for further orders. The ADM and DON were notified an IJ situation was identified due to the above failures on 08/21/25 at 2:51 PM and the IJ template was provided. The following Plan of Removal was accepted on 8/21/25 at 6:13 PM: Plan of Removal 8/21/25Per the information provided in the IJ template given on 8/21/25 at 2:51. CNA C failed to properly notify the charge nurse, and/or the MD that resident #1 heard a pop and had to be guided to the floor on 8/7 /25.1. The Medical Director was notified of IJ on 8/21/25 by the Executive Director [ADM].2. Head to toe Assessment completed by DON on Resident #1 on 8/21/25.3. Suspension of CNA C on 8/20/254. Safe survey completed on all residents on 8/21/25.5. Education completed on 8/21/25 with licensed nurses and certified nursing assistance on:a. Reporting any change of condition to the charge nurseb. Abuse and Neglect6. Quiz was completed on 8/21/2025 to the certified nursing assistants currently on shift to indicate competency. All quizzes and competencies for CNAs to be completed by 8/22/25.7. This training and competencies were completed on 8/21/25 with current staff on shift. A member of management will be at the facility at each change of shift to ensure remaining staff complete training prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will not be allowed to work unless they have received their training and knowledge check.8. An ad hoc (as needed) meeting regarding items in the IJ template was completed on 8/21/25 with complete policy review. Attendees included the Medical Director, Executive Director­[facility] [ADM], Executive Director [corporate], Director of Nursing-[facility], Director of Nursing [corporate], Clinical Market Leader and Clinical Resource.9. The DON, ADON will verify staff competency with staff weekly.10. All residents with new complaints of injury or pain will be reviewed by DON, ADON or designee every week in clinical meetings to assure assessments have been completed timely.11. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for 4 weeks or until substantial compliance is established and continue monthly for 90 days to ensure ongoing compliance.On 08/22/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:1. During an interview with the MD on 8/22/2025 at 11:00AM he stated he was notified of the IJ templates, and the facility had a QAPI meeting, and they had implemented a plan of removal. He stated the facility would be implementing more training and education on abuse and neglect and on reporting any changes in condition. He stated they would continue to review through QAPI meetings for effectiveness. 2. Record review of document tiled Skin Evaluation dated 8/21/2025 1500 [3pm] for Resident #1 revealed: Resident noted resting in bed upon enter. Skin assessment completed by this DON. Post surgical wound noted to right thigh, dressing CDI (clean, dry, intact).Full head to toe assessment completed and no other concerns or issues noted at this time, signed by DON on 8/22/2025. 3. Record review of document titled View Event revealed: For [CNA C].last day of work: 8/20/2025, first day of leave: 8/21/2025.leave type: Suspension.4. Record Review revealed Safe Surveys dated 8/20/2025 had been conducted with 83 Residents in the facility. Safe Survey documents revealed all 83 residents stated yes they felt safe at the facility, and they report abuse to the administrator. They all stated yes, staff treated them with dignity and respect, and they felt their needs and concerns were reported to the appropriate parties. Record review revealed Pain evaluation in Advanced Dementia assessments were completed for 31 Residents in the facility on 8/20/2025. All 31 Resident assessments revealed breathing normal, no negative vocalization, facial expressions; smiling or inexpressive, body language; relaxed and consolability; no need to console. 5. Record review of facility document titled Inservice Title: Reporting Allegations and Suspicions of abuse or neglect and change of condition dated 8/20/2025-8/21/2025 revealed 119 staff signatures out of 169. The in-service document revealed [ADM] is the facilities abuse and neglect coordinator. All suspicions and allegations of abuse or neglect must be reported directly to the abuse coordinator immediately. If anyone reports suspicious or witness abuse of any kind, it must be reported directly [ADM] per our policy.We must do everything we can to protect our residents. All allegations will be investigated per facility and state policy. 6. Record review of facility quiz titled Assessing and Reporting pain dated 8/21/-8/22 revealed 71 staff members had completed the quiz. The quiz revealed the following questions were asked to staff Give me an example of when you would assess for and report pain? Who would you report pain to? What are the non-verbal signs of pain? How would you communicate pain to the nurse?. Further review of the documents revealed staff stated they would assess for pain if a resident expressed pain at any time, or if they had facial or physical signs of pain. The staff stated they would report pain to the charge nurse and provider. The staff stated non verbal signs of pain would be frequent moaning, facial expressions, and elevated vital signs. The staff stated they would communicate the residents pain verbally to the nurse or provider and detail where the pain was expressed to be. 7. During interview on 8/22/2025 between 9:30AM-11:26 AM with CNA D, K, L ,M ,N ,P, Q, R, S ,T, GVN F, CMA G, LVN E, I,J, O, and RN H revealed all staff members had been trained on reporting abuse and neglect. All staff members stated they would report abuse and neglect to their ADM immediately. All staff members stated they would report any falls, injuries or incidents to the charge nurse, physician, and DON. They all stated they had been in-serviced prior to their shift on 8/22/2025. All staff members stated the potential negative outcome of not reporting abuse or neglect could be decrease in quality of life for the residents, decrease in care, and emotional anguish. 8. Record Review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI. 9. Record Review of Untitled Document, undated, revealed Competencies will be completed via written quiz with all nursing staff once a week times 4 weeks. Trainings will be available on Tuesdays and Thursdays Signed by the DON.10. Record Review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by the DON. 11. Record Review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025.On 8/22/2025 at 2:51pm the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #1) of 6 residents reviewed for medication administration. 1. The facility failed to ensure furosemide (Lasix) (used to treat conditions involving fluid retention) administered to Resident #1 as ordered from 5/9/2025-5/20/2025 (12 days). This failure could place residents at risk for not receiving medications as ordered by their physician. The findings include: Record review of Resident #1's undated face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a readmission date of 5/09/2025. Resident #1 had a medical history of cellulitis (a common bacterial skin infection) of right lower limb, essential hypertension (high blood pressure), and infection and inflammatory reaction due to internal fixation (infection and inflammation from a surgical procedure used to stabilize and heal fractures by using metal implants). Record review of Resident #1's annual MDS dated [DATE] Section C- Cognitive Patterns revealed a BIMS score of 11, which indicated Resident #1 had moderate cognitive impairment. Record review of Resident #1's hospital Discharge summary dated [DATE] revealed Discharge medications .unchanged medications .furosemide 40mg tablet, Take 1 tablet by mouth daily aka Lasix. Document also revealed Resident #1 was admitted to the hospital on [DATE] and discharged back to the facility on 5/09/2025. Record review of Resident #1's physician orders revealed the following: Furosemide tablet 40mg, Give 1 tablet by mouth one time a day with an order date of 5/22/2025 and Furosemide 20mg Give 2 tablets my mouth one time a day with a start date 9/26/2024 and a discontinue date of 5/5/2025. Record review of Resident #1's medication administration record revealed Resident #1 received the following: Furosemide 40mg (two 20 mg tablets) from 5/1/25-5/4/25 and Furosemide 40mg tablet on 5/21/25-5/30/25 and 6/1/25-6/3/25. The administration record did not reveal Furosemide 40mg was administered to Resident #1 between 5/9/2025-5/20/2025. Record Review of Resident #1's MD progress note dated 5/12/2025 revealed Daily subjective: She is awake, alert .Afebrile (no fever) vital signs stable .Lungs clear to auscultation (the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope)/heart regular rate and rhythm . no clubbing (physical change in the shape and appearance of the fingertips), cyanosis (a bluish color in the skin, lips, and nail beds caused by a shortage of oxygen in the blood), or edema (swelling caused by an abnormal buildup of fluid in the body's tissues). Record Review of Resident #1's NP progress note dated 5/14/2025 revealed . Daily subjective: She is awake, alert . Denies any chest pain or shortness of breath upon exertion .Afebrile vital signs stable .Lungs clear to auscultation/heart regular rate and rhythm .no clubbing, cyanosis, or edema. Record Review of Resident #1's NP progress note dated 5/19/2025 revealed . Daily subjective: She is awake, alert and sitting up in recliner . She voices no complaints of any pain or discomfort.Afebrile vital signs stable .Lungs clear to auscultation/heart regular rate and rhythm .no clubbing, cyanosis, or edema. Record Review of Resident #1's NP progress note dated 5/21/2025 revealed . Daily subjective: Patient is awake and alert and is up in her wheelchair. She is dressed and ready to go to her doctor's appointment. She will be going to see her wound care doctor. No acute distress noted .Afebrile vital signs stable .Lungs clear to auscultation/heart regular rate and rhythm .no clubbing, cyanosis, or edema. Record Review of Resident #1's progress notes dated 5/21/2025 revealed The ADON spoke with resident Infectious Disease provider regarding residents' concerns with Lasix. Providers office states they show on their end that resident (Resident #1) should be on 40mg daily . Head to toe assessment completed by this ADON. Resident continues with post-surgical wound to right ankle. Slight edema noted to bilateral lower extremities however normal for resident baseline. No c/o pain voiced at this time by resident (Resident #1) . Resident (Resident #1) received initial dose of Lasix as ordered. During an interview with LVN A on 6/3/2025 at 12:12pm, she stated she was here when Resident #1 was re-admitted from the hospital on 5/9/2025. She stated she reviewed the discharge paperwork and checked off one by one the medications on the list as she input them into the computer. She stated she was not sure what happened, or if she may have gotten distracted and checked off the Lasix order without inputting it into the system. She stated, the ADON and DON spoke to me about the missed medication, and I still don't know why that specific medication was missed. She stated the potential negative outcome of the residents not receiving their ordered medication could be an exacerbation of their illnesses, and increased swelling. She stated they are trained to have a second nurse double check the orders before signing them off. She stated she did not know if a second nurse verified the orders after she input them into the system. During an interview with the ADON on 6/3/2025 at 12:35pm he stated Resident #1 had gone to the wound care specialist appointment on 5/21/2025 and the clinic brought to the facilities attention that Resident #1 did not have Lasix on the medication list that had been sent over. He stated the clinic had explained that she had been on Lasix at the hospital. He stated he checked the discharge orders and the order for furosemide (Lasix) was there. He stated he spoke to LVN A and she was unable to explain what had happened or why it had been missed. He stated he did a head-to-toe assessment on the resident, notified the physician and family, and initiated the order. He stated during the 12 days she was without it there had been no change in condition and the resident had been stable. He stated due to this incident the facility had revised the way admission orders are verified. He stated two nurses will be verifying the orders together and administration will be going through each medication individually on the discharge orders and verifying they are in the system accurately. During an interview with PT on 6/3/2025 at 1:13pm, she stated she worked with Resident #1 on her physical therapy daily and Resident #1 did have some mild edema to both her legs. She stated Resident #1 often lays in bed during the weekend and the swelling increases but throughout the week it will get better due to her walking or moving more. She stated during the week the swelling was not very noticeable to her legs. She stated she did not notice any changes in Resident #1's level of function and even knowing now that Resident #1 was back on her Lasix, there had not been a change in her leg swelling. During an interview with Resident #1 on 6/3/2025 at 1:34pm, she stated she thought there was an issue with her water pill (furosemide/Lasix) but did not remember what or when. She stated everything was fine now and she was happy that they give her the water pill in the morning because she does not have to get up at night. She stated the facility had it all figured out and she did not have any concerns. Resident #1 was unable to recall having conversations with the wound care clinic, the ADM or ADON on 5/21/2025. During an interview with the DON on 6/3/2025 at 2:40pm, she stated the nursing staff was responsible for ensuring any resident orders are placed into the system upon admission. She stated during their morning meetings as a team, they would review all admissions for accuracy. She stated she was not sure how the furosemide order was missed for Resident #1. She stated due to the incident they (administration) had now implemented going through each medication on the discharge forms and making sure they are in the system correctly. She stated the potential negative outcome of the orders not being placed into the system could be the residents not having their medication regimen or reaching their therapeutic effect. During an interview with the ADM on 6/3/2025 at 2:47pm, he stated the floor nurses are responsible for initiating the admission procedure. He stated they have to input the medications, skin assessments, initial notes and on their next clinical meeting the ADON and DON review the admission paperwork for verification. He stated the potential negative outcome of residents not being given their ordered medications could be missing medication and pertinent treatments. He stated he is not sure what had happened and why the medication was missed but they had implemented a new intervention for verifying the orders during their clinical meetings. He stated the DON and ADON would be reviewing the medication list and going through each order individually to ensure they are in the system. Record review of facility policy titled Admission, Transfer, and Discharge Rights last revised 10/2007 revealed: POLICY: It is the policy of this facility to have written policies and procedures governing admissions to the facility that will be maintained on a current basis to ensure fair and impartial admission practices. PROCEDURES: . The primary purpose of our admission policies is to establish uniform guidelines for personnel to follow in admitting residents to the facility . 4. It shall be the responsibility of the administrator, through the admissions department, to assure that the established admission policies, as they may apply, are followed by the facility and resident. Record review of facility policy titled Pharmacy Services undated, revealed POLICY: It is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 30 confidential residents. The facility failed to ensure 12 of 30 confidential residents were provided, through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews during Resident Council on, 05/05/2025 at 2:00pm, 12 confidential residents, stated they did not have access to the Grievance form following the facility's remodel. The residents did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending Resident Council did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The 12 residents in attendance had all been Residents of the facility for 6 plus months. Observed prominent postings on 05/05/2025 at 4:15pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available and there was no access to submit a Grievance anonymously. Interview with the ADM on 05/06/2025 at 5:01pm; the ADM stated he was the Grievance Officer for the facility. The ADM stated he was responsible for the review of Grievances and assign them to department heads. The ADM stated the Grievance form was available for the Residents all the nurses' stations and the SW office. The ADM stated when residents present a Grievance issue to staff, the staff complete a Grievance form for the resident. The ADM stated there was no procedure for Residents to submit grievances anonymously. The ADM stated the facility should resolve grievances as soon as possible once they were submitted. The ADM stated he assigns the grievance to the appropriate department, that department addresses the grievance, resolved the grievance, and explained the resolution to the complainant. The resolution was documented on the original Grievance form. The ADM stated completed Grievances were kept in a notebook. The ADM stated he monitored the Grievance process for success by following up with the staff at morning meetings. The ADM stated the Interdisciplinary Team was responsible for ensuring staff were trained on the Grievance process. The ADM stated he was not aware the Grievance procedure was not being discussed in Resident Council. Record Review of the Grievance Policy: Policy: The facility will establish a grievance process that allows residents a way to execute their concerns or grievances to the facility without fear of discrimination or reprisal. The information on how to file a grievance will be available to the residents and make prompt efforts to resolve the grievance. Procedure: Information is made available to the resident and posted in designated locations throughout the facility. The resident or their representative have the right to file a grievance orally, in writing, or anonymously. The resident or their representative have the right to receive a written decision regarding their grievance. The decision regarding the grievance will be presented to the resident or their representative within three working days. The full grievances and the grievance log will be maintained by the facility for three years.

Based on Observations, Interviews, and Record Review the facility failed to ensure residents were free from involuntary seclusion for 5 of 32 (Residents #8, #24, #59, #89, and #96) residents reviewed for involuntary seclusion. The facility failed to obtain a physician order, documenting the clinical criteria met for placement in the secured/locked unit for Residents #8, #24, #59, #89, and #96. There was no update to the Care Plan for Resident #96 for placement in the secure/locked unit. This failure could place residents at risk of isolation, decreased quality of life, and psychosocial harm. Findings included: Resident #8 Record review of the face sheet, dated 05/05/2025, revealed Resident #8 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Alzheimer's disease (progressive, irreversible brain disorder), Chronic obstructive pulmonary disease (COPD (ongoing lung condition caused by damage to the lungs), cognitive communication deficit (difficulties in communication from impairments in cognitive processes), and need for assistance with personal care. Record review of Resident #8's MDS assessment, dated 08/10/2024, revealed Resident #8 had a BIMS score of 04, which indicated severely impaired cognition. Record review of the current care plan for Resident #8, date initiated 08/9/2023 and a revision date of 08/28/2023, revealed a focus area that stated, (Resident) is at risk for impaired cognitive function/Alzheimer or impaired thought processes r/t diagnosis of dementia alert, with a goal that stated, Will maintain current level of cognitive function through the review date., and the intervention and tasks that stated, Needs supervision/assistance with all decision making. family involved in decisions An additional focus area stated, (Resident) is an elopement risk/wanderer r/t history of attempts to leave facility unattended, and impaired safety awareness. Resident resides on a locked unit for optimal safety., with a goal that stated, Safety will be maintained through the review date. and interventions that stated, Assess for fall risk. Date Initiated: 07/14/2024, Created on: 07/14/2024, Document wandering behavior and attempted diversional interventions. Date Initiated: 07/14/2024 Created on: 07/14/2024, Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. An interview was attempted with Resident #8 on 05/04/2025 at 3:30 PM and Resident #8 was unable to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. During an observation on 05/05/2025 at 5:20 PM Resident #8 was observed walking to the door of the secure/locked unit to see if someone was there for her, and Resident #8 was unable to open the door. Resident # 24 Record review of the face sheet, dated 05/05/2025, revealed Resident #24 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety' (decline in cognitive abilities), Atrial fibrillation (AFib) (irregular and often very rapid heart rhythm), Anxiety Disorder (excessive worry about everyday issues and situations), and Major Depressive Disorder (mood disorder that causes persistent feelings of sadness and loss of interest). Record review of Resident #24's MDS assessment, dated 10/21/2024, revealed Resident #24 had a BIMS score of 00, which indicated severely impaired cognition. Record review of the current care plan for Resident #24, date initiated 09/22/2017 and a revision date of 09/14/2023, revealed a focus area that stated, (Resident) is an elopement risk/wanderer r/t Dementia. Resident is in a secure unit for safety and optimal well being d/t cognition., with a goal that stated, Safety will be maintained through the review date., and the intervention and tasks that stated, Assess for fall risk. Date Initiated: 10/05/2017 Created on: 10/05/2017; Document wandering behavior and attempted diversional interventions. Date Initiated: 10/05/2017 Created on: 10/05/2017; Monitor for fatigue and weight loss Date Initiated: 10/05/2017 Created on: 10/05/2017; RESIDENT REQUIRES A SECURED UNIT RELATED TO DX: UNSPECIFIED DEMENTIA WITHOUT BEHAVIORAL DISTURBANCE. Date Initiated: 10/05/2017 Created on: 10/05/2017. An interview was attempted with Resident #24 on 05/04/2025 at 4:01 PM and Resident #24 was unable to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. Resident #59 Record review of the face sheet, dated 05/05/2025, revealed Resident #59 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety' (decline in cognitive abilities), Generalized Anxiety Disorder (excessive worry about everyday issues and situations), Alzheimer's disease (progressive, irreversible brain disorder), Cognitive communication deficit, and Intermittent Explosive Disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts). Record review of Resident #59's MDS assessment, dated 04/08/2025, revealed Resident #59 had a BIMS score of 02, which indicated severely impaired cognition. Record review of the current care plan for Resident #59, date initiated 05/05/2025 revealed a focus area that stated, Elopement risk/wanderer r/t Impaired safety awareness, Resident wanders aimlessly. Resident is in a secure unit for safety and optimal well being, with a goal that stated, Safety will be maintained through the review date. Will not leave facility unattended through the review, and the intervention and tasks that stated, Document wandering behavior and attempted diversional interventions. Date Initiated: 05/05/2025 Created on: 05/05/2025; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 05/05/2025 Created on: 05/05/2025. An interview was attempted with Resident #59 on 05/05/2025 at 10;30 AM and Resident #59 was unable to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. Resident #89 Record review of the face sheet, dated 05/05/2025, revealed Resident #89 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses that included the following: Vascular dementia (decreased blood flow to areas of the brain, leading to damage to brain tissue and a decline in mental functions), Cognitive communication deficit, depression, and heart failure. Record review of Resident #89's MDS assessment, dated 02/27/2025, revealed Resident #89 had a BIMS score of 08, which indicated moderately impaired cognition. Record review of the current care plan for Resident #89, date initiated 02/25/2025 and a revision date of 05/05/2025, revealed a focus area that stated, Elopement risk/wanderer r/t Disoriented to place, Impaired safety awareness. (Resident) resides on a locked unit for optimal safety r/t cognition, with a goal that stated, Will not leave facility unattended through the review date., and the intervention and tasks that stated, Document wandering behavior and attempted diversional interventions. Date Initiated: 02/25/2025 Created on: 05/05/2025; Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Date Initiated: 2/25/2025 Created on: 05/05/2025; Monitor for fatigue and weight loss. Date Initiated: 02/25/2025 Created on: 05/05/2025; Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date Initiated: 02/25/2025 Created on: 5/05/2025. During an interview with Resident #89 on 05/05/2025 at 10:10 AM Resident #89 was unable to articulate where he was currently residing. Resident #89 stated he was working a shift at the EMS as a paramedic. Resident #89 was unable to state what the code to the door of the secure/locked unit was. The resident was confused by the question and stated he did not know there was a code for the door. Resident #96 Record review of the face sheet, dated 05/05/2025, revealed Resident #96 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included the following: Encephalopathy (brain disease, damage, or malfunction), Schizoaffective disorder (mental health condition marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder), Generalized Anxiety Disorder (excessive worry about everyday issues and situations), and Dementia in other diseases classified elsewhere, moderate, with mood disturbance (memory loss that deteriorates over time). Record review of Resident #96's MDS assessment, dated 04/07/2025, revealed Resident #96 had a BIMS score of 02, which indicated severely impaired cognition. Record review of the current care plan for Resident #96, date initiated 04/15/2025 and a revision date of 04/27/2025, revealed a focus area that stated, (Resident #96) is at risk for impaired cognitive function/dementia or impaired thought processes, with a goal that stated, Will be able to communicate basic needs on a daily basis through the review date., and the intervention and tasks that stated, Administer medications as ordered. Communicate with family/caregivers regarding resident's capabilities and needs. Discuss concerns about confusion, disease process and alternative placement with family/caregivers. Record review of Social Services Assessment/Evaluation for Resident #96, dated 04/11/2025 revealed the following: Strong desire to return home, requires Secured Unit. An interview was attempted with Resident #96 on 05/05/2025 at 5:20 PM and Resident #96 was unable to articulate where she was currently residing or if she knew the code to open the door to the secure/locked unit. An attempted telephone interview was made on 05/6/2026 at 12:35 PM to the physician for Resident #8, #24, #59, #89, and #96 with no response. During an interview with on 05/06/2025 at 2:20 PM the DON stated it was not the facility's policy to obtain a physician's order prior to placing a resident in a secured/locked unit. The DON stated she was not familiar with the State Operations Manual as it pertained to secure/locked units. The DON stated the Residents #8, #24, #59, #89, and #96 did not have the access code to enter or exit the secure/locked unit (Oak). The DON stated the Residents #8, #24, #59, #89, and #96 were on the secure/locked unit for their safety. The DON stated prior to placing a resident on the secure/locked unit, the resident was assessed to determine if they met the criteria for the unit, which included an assessment for elopement risk and monitoring for behaviors after admission and overall adjustment. The DON stated Residents #8, #24, #59, #89, and #96 were fully assessed and met the criteria for the secure/locked unit. The DON stated staff received orientation upon hire for the secure/locked unit. The DON stated the IDT team was responsible for ensuring documentation was completed for residents placed on the secure/locked unit. The DON stated she did not feel a resident being placed in a secure/locked unit was the same as a restraint. The DON stated if a resident was placed on a secure/locked unit without an adequate assessment or proper documentation, the resident's overall adjustment could have been negatively impacted. During an interview on 05/06/2025 at 2:45 PM the ADM stated the facility's policy did not state a physician's order was necessary for residents to be placed in a secure/locked unit. The ADM stated he had not seen this information in the State Operations Manual. The ADM stated the Residents #8, #24, #59, #89, and #96 did not have access to the door code to enter or exit the secure/locked unit (Oak). The ADM stated Residents #8, #24, #59, #89, and #96 were assessed for elopement risk. The ADM stated visual observations were made of the residents as well as assessing the residents' BIMS prior to placement on the secure/locked unit. The ADM stated the IDT team was responsible for ensuring residents met the criteria for placement on the secure/locked unit. The ADM stated the nursing staff, floor staff, and nurse management staff were responsible for ensuring all documentation and assessments were completed prior to placing a resident on a secure/locked unit. The ADM stated he did not feel there was a negative impact to a resident if they were placed on a secure/locked unit without a physician's order as no resident was placed on the secure/locked unit without an elopement assessment. Record Review of the facility's policy titled Restraints, dated 06/2017 revealed the following: Policy: It is the policy of this facility to refuse to restrain residents for any cause. PROCEDURE: Should a resident have cause for need of restraint, the physician will be notified immediately, and Texas state regulations will be followed. As soon as possible, residents with need for restraints will be transferred to an appropriate facility.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The facility failed to properly store, label. and date foods stored in the refrigerator and freezer. The facility failed to properly store, label, and date perishable food items stored in the dry storage. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations and interviews were made on [DATE] beginning at 10:15 AM during the initial observation of the kitchen: Observation on [DATE] at 10:15 AM of the dry storage, in the kitchen, revealed two 20 ounce bottles of Welch's grape jelly. The two bottles were observed to be opened and half-filled. According to the manufacturer's label, the bottles should have been refrigerated after opening. One of the two bottles of jelly did not contain a date to indicate when the bottle had been received by the facility. During an interview on [DATE] at 10:20 AM the DM stated she was unaware the bottles of jelly indicated they should have been refrigerated after opening. The DM stated the two bottles would be discarded and she planned to educate the dietary staff regarding the manufacturer's label instructions. Observation on [DATE] at 10:43 AM of the walk-in freezer, in the kitchen, revealed the following unlabeled and undated items: 2 bags of frozen spinach and 1 bag of frozen okra. The following items were not stored properly in the walk-in freezer; 1 box of opened and uncovered/unsealed cookie dough and 1 box of open and uncovered/unsealed breaded fish patties. Observation on [DATE] at 10:50 AM of the walk-in refrigerator in the kitchen, revealed the following unlabeled and undated items: 1 pitcher of prepared tea, 1 container of an unknown yellow liquid, and 1 container of vegetable soup. The walk-in refrigerator also contained the following outdated items: 1 container of tomato soup (expired [DATE]), and 1 container of chicken noodle soup (expired [DATE]). During an interview on [DATE] at 11:00 AM the DM stated she was unaware of the facility's policy regarding timeframes of holding prepared food in the refrigerator. The DM stated she had her staff throw out any prepared foods on Mondays unless the prepared food looked bad prior to that. The DM stated she believed the holding timeframe for prepared food was 4 to 5 days in the refrigerator. The following observations and interviews were made on [DATE] beginning at 11:22 AM during a follow-up observation of the kitchen: Observation on [DATE] at 11:22 AM of the walk-in refrigerator in the kitchen, revealed the following outdated item: 1 container of chicken noodle soup (expired [DATE]). The walk-in refrigerator also contained one unlabeled and undated container of a brown pudding-like substance. During an interview on [DATE] at 1:00 PM the DM stated all food in the kitchen refrigerators should have been dated with a prepared date or an expiration date. The DM stated all dietary staff were responsible for ensuring food was labeled and dated. The DM stated all dietary staff received training on food preparation and storage upon hire and again during in-service trainings. The DM stated it was her expectation that regulations were followed, and food items were labeled and dated properly. The DM stated all expired food should have been discarded each day. The DM stated she was not aware there was any expired food or food stored improperly in the refrigerator, freezer, or dry pantry. The DM stated she would complete an in-service with all dietary staff to educate them on proper food storage and holding timeframes for the refrigerator. The DM stated it was important for food items to be labelled and dated to ensure outdated food was not being served to prevent foodborne illness. The DM stated when food was not labelled and dated properly, residents were at risk of getting sick. During an interview on [DATE] at 2:20 PM the DON stated she was unsure of the facility's food storage policy. The DON stated all food in the refrigerators and freezers should have been labelled and dated. The DON stated she did not know what training dietary staff received. The DON stated all dietary staff were responsible for ensuring food was stored properly. The DON stated expired food should not have been stored in the refrigerators. The DON stated there was a risk that expired food could be served to residents if it was not stored properly. The DON stated residents were at risk of getting sick if they were served food that was not stored properly or expired. During an interview on [DATE] at 2:42 PM the ADM stated he was unsure of the facility's policy regarding food storage and holding times for prepared food. The ADM stated all food in freezers, refrigerators, and the dry pantry should have been labelled and dated and discarded promptly. The ADM stated it was his expectation that all food was served fresh and stored properly. The ADM stated all dietary staff were responsible for ensuring food was stored and dated properly, and the DM was responsible for overseeing dietary staff. The ADM stated the DM was responsible for checking all food storage areas to ensure food was stored properly. The ADM stated dietary staff received training upon hire and received in-service trainings if issues arose. The ADM stated if food was not labelled or dated properly, residents could have received food that was not fresh and outdated which could have potentially caused illness to the resident. Record review of the undated facility policy titled Food Storage did not contain any information pertaining to dating and/or labeling items. The facility stated they did not have any additional policies pertaining to food storage. The Food Storage policy revealed the following documentation: POLICY: It is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner. PROCEDURES: 8. The dietary manager, or his/her designee, will check refrigerators and freezers at least daily.

Based on observation, interview and record review, facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 3 of 4 residents (Resident #32, Resident #35, Resident #67, and Resident #90) and 5 of 6 staff (LVN A, LVN D, CNA D, CNA E, and CNA F) reviewed for infection control. 1. LVN A failed to follow facility policy and procedure for handwashing while providing wound care for Resident #32, during observations of wound on 05/05/2025 at 2:33 PM. 2. CNA D and CNA E failed to follow facility policy and procedure for handwashing while providing incontinent care for Resident #35, during observations of incontinent care on 05/05/2025 at 10:34 AM. 3. The facility failed to provide an enhanced barrier precautions sign for Resident #67 while having a wound. LVN D, CNA D, and CNA E all provided direct care without PPE due to an enhanced barrier precaution sign not being posted. 4. CNA F failed to follow facility policy and procedure for handwashing while providing incontinent care for Resident #90, during observations of incontinent care on 05/05/2025 at 11:22 AM. These failures could place residents at risk for spread of infection and cross contamination. Findings included: Resident #32 Record review of Resident #32's face sheet undated revealed an [AGE] year-old female with an admitted [DATE] with the following diagnoses: Atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls), pressure ulcer of right buttock (stage 3), pressure ulcer of sacral region (stage 3), dysphagia (difficulty swallowing), cognitive communication deficit, anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), type 2 diabetes, vitamin deficiency, hyperlipidemia (a condition in which there are high levels of fat particles in the blood), high blood pressure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), heart failure, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), acid reflux, muscle weakness, osteoporosis (a condition in which bones become weak and brittle). Record review of Resident #32's Admission MDS dated [DATE] revealed a BIMS score blank and incomplete. The MDS under unhealed pressure ulcers, Resident #32 was listed as a 0, meaning that Resident #32 was not at risk of pressure ulcers at the time of the MDS. Under unhealed pressure ulcers/injuries Resident #32 was listed as a 0 meaning that Resident #32 was not listed as having a pressure ulcer/injury at the time of the MDS. Under current number of unhealed pressure ulcers/injuries at each stage was left blank and incomplete. Under skin conditions the section was left blank and incomplete. Record review of Resident #32's Care Plan dated 12/27/23, revealed that Resident #32 was listed as having a potential for pressure ulcer development with the interventions of: follow facility policies/protocols for the prevention/treatment of skin breakdown. Record review of Physician Orders for Resident #32, dated 02/24/25, stated: Wound care to stage 3 pressure injury to sacrum; cleanse with normal saline, pat dry, apply calcium alginate, cover with silicone super absorbent dressing. During an observation of wound care on 05/05/2025 at 2:33 PM, LVN A washed her hands for 10 seconds with soap/friction before rinsing her hands under running water. LVN A used a clean paper towel to dry her hands. LVN A used a clean paper towel to turn off the faucet and disposed in the trash. LVN A put on a pair of clean disposable gloves. LVN A used a disinfectant wipe to clean the tray to set up supplies. LVN A removed and disposed of gloves. LVN A washed her hands with hand sanitizer. LVN A put on pair of clean gloves. LVN A had used a disinfectant wipe to clean the bedside table. LVN A had not put on PPE when Resident #32 was listed as enhanced barrier precautions due to wounds. LVN A removed dirty gloves and disposed in the trash. LVN A washed her hands with soap/friction for 8 seconds prior to rinsing them under running water. LVN A used a clean paper towel to dry her hands. LVN A used a clean paper towel to turn off water faucet and disposed in the trash. LVN A set up all wound care supplies, specified in orders, on the bedside table. LVN A removed disposable gloves and disposed in the trash. LVN A used hand sanitizer to wash her hands. LVN A grabbed a PPE gown (yellow) and put it on. LVN A put on clean pair of disposable gloves. LVN A grabbed a biohazard bag and opened it to be ready to place trash in the bag. Resident #32 was sitting in her wheelchair and LVN A had Resident #32 stand up and bend over while holding onto the bed. Resident #32 did not seem stable. LVN A pulled Resident #32's pants down and removed the brief. LVN A removed the dirty bandage and disposed in the trash. LVN A removed her dirty disposable gloves and disposed of them into the trash. LVN A washed her hands with soap/friction for 9 seconds before rinsing them under running water. LVN A used a clean paper towel to dry her hands. LVN A used a clean paper towel to turn off the faucet and disposed in the trash. LVN A provided wound care according to physician orders. LVN A removed gloves and disposed in the trash. LVN A used hand sanitizer to wash her hands. LVN A put a clean pair of disposable gloves on. LVN A put calcium alginate and bandage on the wound. LVN A placed on new brief on Resident #32 and pulled up Resident #32's pants. LVN A used hand sanitizer to wash her hands. LVN A put on clean gloves. LVN A gathered the trash and disposed of the trash. LVN A did not wash her hands after disposing the trash. During an interview on 05/06/2025 at 3:25 PM, LVN A stated that the policy for handwashing states to wet hands, put soap on hands and scrub for 15 to 20 seconds, thoroughly rinse hands, use a clean paper towel to dry hands, and then use a clean paper towel to turn off the faucet. LVN A stated that by following the policy it helps to prevent contaminating any germs on the hands and transferring germs to the resident that may cause harm. LVN A stated that she had training in infection control and handwashing through in-services, monthly. LVN A stated that she had competency checks for handwashing, yearly. LVN A stated that it was the responsibility of the ADON and DON to oversee the training. Resident #35: Record review of Resident #35's face sheet dated 05/06/2025 revealed a [AGE] year-old female with an original admitted [DATE]/2020 and an initial admitted [DATE] with the following diagnoses: Chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), muscle weakness, need for assistance for personal care, dementia, dysphagia (difficulty swallowing), depression, diarrhea, chronic kidney disease, anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), atherosclerotic heart disease, attention and concentration deficit, osteoporosis, unsteadiness on feet, gastrointestinal hemorrhage. Record review of Resident #35's quarterly MDS dated [DATE] revealed a BIMS score of 2 meaning that Resident #2 had severe cognitive impairment. The MDS under bowel and bladder, Resident #35 was listed as a 3 meaning always incontinent. Record review of Resident #35's Care Plan dated on 09/10/2020, revealed that Resident #35 was listed as having bowel and bladder incontinence with the goal listed as: check as required for incontinence. Wash, rinse, and dry perineum. Change clothing as needed after incontinence episodes. During an observation of incontinent care on 05/05/2025 at 10:34 AM, CNA D washed hands with soap/friction for 8 seconds before rinsing hands thoroughly under running water. CNA D used a clean paper towel to dry hands and disposed in the trash. CNA D used a clean paper towel to turn off the water faucet and disposed in the trash. Helper CNA E had then washed her hands with soap/friction for 16 seconds before rinsing her hands under running water. CNA E used a clean paper towel to dry hands and disposed in the trash. CNA E used a clean paper towel to turn off the water faucet and disposed in the trash. CNA D gathered supplies for incontinent care. CNA D washed hands with soap/friction for 10 seconds before rinsing hands under running water. CNA D used a clean paper towel to dry hands. CNA D used the same paper towel that was used to dry her hands to turn off the water faucet. CNA E did not wash her hands. CNA D removed the resident's blankets. CNA D laid towel behind the resident. CNA E unfastened and removed Resident #35's brief. CNA D used one wipe to wipe the right crease of groin area and disposed in the trash. CNA D used one wipe to wipe the left crease of groin area and disposed in the trash. CNA D used one wipe to wipe across the top groin area and disposed in the trash. CNA D used one wipe to wipe center vagina and repeated this step three times due to bm. CNA D removed gloves and disposed in the trash. CNA D used hand sanitizer to wash her hands instead of using soap and water after having visible BM. CNA D put on pair of clean gloves. CNA E turned resident to the side. CNA D used one wipe to clean the right buttock and disposed in the trash. CNA D used a clean wipe to clean the left buttocks and disposed in the trash. CNA D used a clean wipe to clean the anus and there was a large amount of BM. CNA D only wiped one time and left BM on the resident. CNA D removed gloves and disposed in the trash. CNA D used hand sanitizer to wash her hands instead of using soap and water after wiping BM. CNA D put on a pair of clean disposable gloves. Surveyor intervened and asked CNA D to wipe to verify if the resident was clean. There was still a large amount of bm on the resident. CNA D had to clean with an additional four wipes until Resident #35 was clean. CNA D then placed a clean brief behind resident and laid her back. CNA D pulled up the front side of the resident's brief and fastened. CNA D dressed the resident, covered the resident, and gathered the trash. CNA D removed gloves and disposed in the trash. CNA D washed her hands with soap/friction for 10 seconds before rinsing her hands under water. CNA D used a clean paper towel to dry her hands and used the same paper towel to turn off the water faucet and disposed in the trash. CNA E did not wash her hands. During an interview on 05/06/2025 at 1:51 PM, CNA D stated that the policy for handwashing stated to scrub finger, hands, and nails for 15 to 20 seconds. CNA D stated that she had been trained in handwashing and infection control through company videos, and in-services. CNA D stated that she had competency checks monthly as well as all other training. CNA D stated that the DON and the ADON had been responsible for overseeing the training. CNA D stated that she was just nervous and in a hurry. CNA D stated that it was important to provide handwashing per policy because you could pass infections and germs to the residents. CNA D stated that the resident's immune system was fragile. CNA D stated that what she would have done different would be keep a steady pace, make sure to clean the resident, and wash hands as the policy stated. During an interview on 05/06/2025 at 3:47 PM, CNA E stated that the policy stated that you should wash your hands before, during, and after providing care for a resident for 15 to 20 seconds. CNA E stated that she had been trained in infection control practices and handwashing through in-services, Relias, and refreshers, every few weeks. CNA E stated that she was nervous, and her mind went blank. CNA E stated that the negative potential outcome of not providing handwashing as the policy stated could cause the spread of infections. Resident #67: Record review of Resident #67's face sheet undated revealed a [AGE] year-old male with an admitted [DATE] with the following diagnoses: stroke, muscle weakness, pressure ulcer of left buttock (stage 3), pressure ulcer of other site (stage 3), dysphagia (difficulty swallowing), need for assistance with personal care, major depressive disorder, hyperlipidemia, acid reflux, tinea unguium (nail fungus causing thickened, brittle, or ragged nails), retention of urine, Alzheimer's disease, atherosclerotic heart disease (the buildup of fats, cholesterol, and other substances in and on the artery walls), systolic heart failure, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #67's quarterly MDS dated [DATE] revealed a BIMS score listed as 3 meaning Resident #67 had severe cognitive impairment. The MDS under skin conditions showed that Resident #67 was not at risk, nor did he have a pressure ulcer. Record review of Resident #67's Care Plan dated 11/24/24, revealed that Resident #67 was listed as having actual impairment to skin integrity with stage three pressure injury to the sacrum. The goal listed was reduce risk for impairment to skin integrity through the use of wound care as ordered, offloading wound bed, supplements, frequent repositioning through the review date. Record review of Resident #67's Care Plan dated 05/21/24, had the potential for pressure injuries due to mobility. Record review of Resident #67's Physician Orders, dated 04/18/2025, stated: pressure wound to sacrum. Cleanse with normal saline or wound cleanser, pat dry, apply calcium alginate, cover with superabsorbent dressing as needed. Record review of Resident #67's Physician Orders, dated 04/18/2025, stated: pressure wound to sacrum. Cleanse with normal saline or wound cleanser, pat dry, apply calcium alginate, cover with superabsorbent dressing, day shift. Observation and interview during wound care on 05/05/2025 at 10:08 AM, Resident #67 did not have enhanced barrier precautions posted on the door, prior to observations of wound care. There was no hand sanitizer dispenser in Resident #67's room or outside of the door. Surveyor asked wound care nurse if Resident #67 was listed as enhanced barrier precautions. The Wound care nurse had stated yes and that all resident's with wounds or catheters were listed as enhanced barrier precautions. The Wound care nurse used the appropriate PPE to treat Resident #67. When asked about the enhanced barrier precautions that was supposed to be posted, wound care nurse stated that she was unsure why there was not a posting on the door. There was no PPE bin outside of Resident #67's room. During an observation on 05/06/2025 at 12:00 PM, Resident #67 still had no enhanced barrier precaution sign posted on the door. During an interview on 05/06/2025 at 12:10 PM, LVN D stated that she was not sure why Resident #67 did not have an enhanced barrier precautions sign posted on the door. LVN D stated that if Resident #67 was supposed to have a sign then he should have an enhanced barrier precaution sign posted. LVN D stated that she did not realize that Resident #67 was on enhanced barrier precautions. LVN D stated an enhanced barrier precaution sign shows that staff need to wear certain PPE to provide direct care to the resident in order to protect the resident and staff against infections. LVN D stated that by not taking precautions residents wounds could worsen or staff could give something to the resident. LVN D stated that she would ask ADON why Resident #67 did not have a sign. During an interview on 05/06/2025 at 12:10 PM, the ADON stated that Resident #67 had a wound on the coccyx. The ADON stated that Resident #67 should have had an enhanced barrier precaution sign posted. The ADON stated that he did not know why there was not one posted, but would make sure to get one posted, immediately. The ADON stated that if there was not a sign posted then that could have caused a spread of infection in the resident's wound. During an observation on 05/06/2025 at 1:48 PM, rooms #200, #202, #203, and #208 did not have hand sanitizer dispensers in the room or in the hall, all listed as enhanced barrier precautions. During an interview on 05/06/2025 at 1:51 PM, CNA D stated that she was not aware that Resident #67 was supposed to be on enhanced barrier precautions. CNA D stated that she was the caregiver on this hall and did provide care to Resident #67. CNA D stated that she knew that Resident #67 did have a wound but did not know that he was supposed to have been on enhanced barrier precautions. CNA D stated that she did not wear any PPE besides gloves to provide care to Resident #67 because she had not known that he was on enhanced barrier precautions. CNA D stated that by not wearing the appropriate PPE to provide care for Resident #67, it could have made wounds worse or spread infections. CNA D stated that no one had told her that Resident #67 was supposed to have been on enhanced barrier precautions. CNA D stated that she was not sure why there was not any hand sanitizer dispensers on this hall. CNA D stated that she had always brought her own hand sanitizer, so she had not paid any attention to the dispensers. During an interview on 05/06/2025 at 3;47 PM, CNA E stated that she was assigned to work hall 200 and had provided care to Resident #67. CNA E stated that she was not aware that he was supposed to be on enhanced barrier precautions. CNA E stated that she was aware that Resident #67 had a wound. CNA E stated that she had not worn PPE for enhanced barrier precautions because she had not known Resident #67 was on barrier precautions. CNA E stated that by not wearing PPE for residents on enhanced barrier precautions could cause the spread of infections. Resident #90: Record review of Resident #90's face sheet undated revealed a [AGE] year-old female with an admitted [DATE] with the following diagnoses: constipation, urinary tract infection, chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe), severe sepsis (a life-threatening complication of an infection), high blood pressure, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), acute diastolic heart failure, hemoperitoneum (a life-threatening condition that occurs when blood accumulates in the heart's pericardial sac), acute kidney failure with tubular necrosis, neuromuscular dysfunction of bladder, dysphagia (difficulty swallowing), need for assistance with personal care, anemia (condition in which the blood does not have enough healthy red blood cells and hemoglobin), pneumonia, overactive bladder. Record review of Resident #90's quarterly MDS dated [DATE] revealed a BIMS score listed as 5 meaning severe cognitive impairment. The MDS under bowel continence Resident #90 was listed as a 3 meaning always incontinent. During an observation of incontinent care on 05/05/2025 at 11:22 AM, CNA F did not wash her hands prior to gathering incontinent supplies. CNA F put on yellow gown for PPE due to enhanced barrier precautions. CNA F washed her hands after gathering incontinent supplies by using soap/friction for 11 seconds before rinsing her hands under running water. CNA F used a clean paper towel to dry her hands and disposed in the trash. CNA F used a clean paper towel to turn off the water faucet and disposed in the trash. CNA F laid out supplies on the bedside table using a towel as a barrier. CNA F removed her PPE (gown and gloves) and disposed in the trash to leave the resident's room to get hand sanitizer. CNA F came back into the resident's room after grabbing a bottle of hand sanitizer. CNA F washed hands with soap/friction for 6 seconds before rinsing her hands under running water. CNA F used a clean paper towel to dry her hands and disposed in the trash. CNA F used a clean paper towel to turn off the water faucet and disposed in the trash. CNA F uncovered Resident #90 and removed her pants. CNA F unfastened the resident's brief. Observed a large amount of BM on Resident #90. CNA F used the brief to wipe the majority of the bm off of the resident. Observed CNA F disposable gloves were soiled. CNA F removed disposable gloves and disposed in the trash. CNA F used hand sanitizer to wash her hands. CNA F put on clean pair of disposable gloves. CNA F used one wipe to wipe the center anus area and disposed of wipe in the trash. CNA F used another clean wipe to repeat this process and then proceeded to fold that same wipe and repeat the process of cleaning. CNA F then disposed of the wipe in the dirty brief by folding the dirty wipe into the dirty brief. CNA F then discarded the dirty brief into the trash bag. CNA F removed dirty gloves and discarded in the trash. CNA F washed hands with soap/friction for 4 seconds before rinsing hands under running water. CNA F used a clean paper towel to dry her hands and then disposed in the trash. CNA F used a clean paper towel to turn off faucet and disposed in the trash. CNA F put on a pair of clean disposable gloves. CNA F laid Resident #90 on her back and proceeded to provide peri care to the front area of the resident. CNA F noticed that there was also BM on the front side of the resident. CNA F wiped the vagina opening and noticed BM, wiped with a wipe, and discarded in the trash. CNA F removed gloves and discarded in the trash. CNA F used hand sanitizer to wash hands. CNA F put on a pair of clean disposable gloves. CNA F used a wipe to clean the vagina opening again and disposed of the wipe in the trash. CNA F used hand sanitizer to wash her hands. CNA F put on a clean pair of disposable gloves. CNA F used a wipe to clean the catheter tubing and discarded the wipe in the trash. CNA F removed her gloves and disposed in the trash. CNA F washed hands with soap/friction for 7 seconds before rinsing hands under running water. CNA F used a clean paper towel to dry hands and disposed in the trash. CNA F used a clean paper towel to turn off the water faucet and disposed in the trash. CNA F put on pair of clean disposable gloves. Surveyor noticed the Resident #90 had dried BM on the side of the resident's leg. CNA F turned resident back to the side to clean Resident #90 some more because CNA F realized that she did not clean all of the BM off of the resident. CNA F used 2 wipes to clean the backside of Resident #90. CNA F folded the dirty wipe and wipes continuously trying to get the dried BM off of the resident. CNA F used the same wipe to wipe 12 times. CNA F removed the dirty gloves and disposed of them in the trash. CNA F used hand sanitizer and put on a pair of clean disposable gloves. CNA F put a clean brief on Resident #90. Observed BM on sheets. CNA F grabbed a clean draw sheet and covered the soiled sheets with the clean draw sheet. CNA F dressed Resident #90. CNA F gathered dirty laundry and trash. CNA F washed hands for 9 seconds with soap/friction before rinsing her hands under running water. CNA F used a clean paper towel to dry her hands and disposed in the trash. CNA F used a clean paper towel to turn off the faucet and disposed in the trash. During an interview on 05/06/2025 at 2:29 PM, CNA F stated that the policy for handwashing had stated to sing happy birthday while washing hands and that should be sufficient. CNA F stated that she did not know a specific time limit of what the policy states for how long you should wash your hands. CNA F stated that she should have made sure to wash hands properly. CNA F stated that she should have made sure to verify that Resident #90 was completely clean from all BM and urine before competing care. CNA F stated that she did not do what the policy stated because she was nervous. CNA F stated that the importance of making sure that the procedure was done per the policy was that it prevents the spread of infections or cross contamination. CNA F stated that she had training for infection control practices and hand washing through in-services, modules, and skills checks, every three months. CNA F stated that it was the responsibility of the ADON and DON to oversee the training. During an interview on 04/15/2025 at 2:00 PM, The Administrator stated that the policy stated that we should wash hands long enough and per policy. The Administrator stated that it was the responsibility of the nurse managing team and DON to oversee the training. The Administrator stated that competency checks were completed monthly. The Administrator stated that his expectations were for staff to follow policy. The Administrator stated that the negative potential outcome for not following infection control practices was the spread of infections. During an interview on 05/06/2025 at 4:23 PM, The DON stated that her expectations for staff would be to follow policy for hand washing and infection control practices. The DON stated that staff should wash their hands before, during and after providing direct care for at least 15 seconds. The DON stated that the negative potential outcome for not following the handwashing and infection control policy would be the spread of infections. The DON stated that training was provided to the staff for infection control practices and handwashing through in-services, company, and competency checks, monthly. The DON stated that it was the responsibility of the DON and ADON to oversee the training. Record review of the facility-provided policy titled, Handwashing, dated 06/2016, revealed: Policy: It is the policy of this community to cleanse hands to prevent transmission of possible infectious material and to provide a clean, healthy environment for residents and staff. Hand washing is considered the most important single procedure for preventing the spreading of infections. Procedure: 1. Wet hands and apply soap to hands. 2. Rub hands in circular motion for not less than fifteen (15) seconds, using friction. 3. Rinse hands with warm water. 4. Dry hands with paper towel. 5. Tum off faucet with paper towel. 6. Discard paper towel in appropriate receptacle Waterless hand washing procedure: 1. Some situations require hand washing in areas where sinks are not readily available. In these limited circumstances, waterless hand washing products may be used. These products are not a substitute for good hand washing. Hand washing with soap and water should be done as soon as possible. 2. Waterless hand washing products are not used for skin care treatments or administration of eye drops. Record review of the facility-provided policy titled, Perineal Care, undated, revealed: Policy: It is the policy of this facility to: 1. Cleanse perineum 2. Eliminate odor 3. Prevent irritation or infection 4. Enhance resident's self-esteem Procedure: Equipment: Washcloth and towel Disposable wipes may be used as a substitute for soap and water. 1. Use privacy curtain for resident privacy. 2. Identify resident. 3. Explain procedure. 4. Gather necessary equipment. 5. Wash hands properly. Note: The basic infection control-concept for peri care is to wash from the cleanest area to the dirtiest area. 1. Rinse cloth and proceed with cleansing of the anal area, as described above. For all variations, complete procedure as follows: o Discard equipment or return it to the appropriate location. o Wash hands properly. o Document all appropriate information in medical record. Record review of the facility-provided policy titled, Wound Care, undated, revealed: Policy: It is the policy of this facility to provide excellent wound care to promote healing. Procedure: 1. Supplies are never placed on the bed. The soiled trash bag may be. 2. Supplies should be placed on a clean surface. A blue pad provides a nice clean barrier. 3. Hand washing must be done as outlined in the procedure. 4. The resident must not be soiled when the dressing change is done. Record review of the facility-provided policy titled, Infection Control, undated, revealed: Policy: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The program will be carried out by the facility infection preventionist. It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene based on accepted standards. Goals: o Decrease the risk of infection to residents and personnel. o Recognize infection control practices while providing care. o Identify and correct problems relating to infection control. o Ensure compliance with state and federal regulations related to infection control o Promote individual resident's rights and well-being while trying to prevent and control the spread of infection. o Monitor personnel health and safety. 3. The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection. Facility personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Policy for Enhanced Barrier Precautions was requested on 05/06/2025, the Administrator did not provide the policy and stated that he had not further documents to provide at that time.

Based on observations, interviews and record review, it was determined the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 5 residents (Resident #1) reviewed for care provided. The facility failed to notify Resident #1's physician, when the resident was found on the floor on 11/13/22, and she complained of pain to her right foot. On 11/17/22 (4 days later) the physician was notified Resident #1 continued to complain of pain and had bruising and swelling to her right foot. The physician ordered Resident #1 an X-ray and had her sent to the hospital, then she returned with a hard sole shoe and weight bearing as tolerated. This failure could place residents at risk for a delay in treatment or diagnosis of new symptoms, a decline in the resident's condition, and the need for hospitalization or death. Findings included: Record review of Resident #1's Admission Record indicated she was a [AGE] year-old female who admitted to the facility on [DATE]. Resident #1 had the following diagnoses: attention and concentration deficit following other cerebrovascular disease (problems with condition that affects blood flow and blood vessels in the brain), chronic respiratory failure with hypoxia (lack of oxygen in the blood), age related osteoporosis without current pathological fractures (loss of bone mass and strength), localization related symptomatic epilepsy and epileptic syndromes with simple partial seizures intractable with status epilepticus (seizures that originate from a localized cortical region), cognitive communication deficit (difficulty communicating because of injury to the brain that controls ability to think), unsteadiness on feet, need for assistance with personal care, other lack of coordination, difficulty in walking, abnormal posture, history of falling, muscle wasting and atrophy, and muscle weakness. In addition, Resident #1's current Admission Record included her Physician's contact information. Record review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 9 for cognitive awareness, which indicated she was moderately impaired. The MDS indicated Resident #1 required extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toileting, and personal hygiene, and walking in the room or corridor did not occur. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of Resident #1's Care Plan dated 10/25/22 included her diagnosis of Osteoporosis to be addressed by giving her medications as ordered; monitor and document risks of falls and educated resident, family/caregivers on safety measures that need to be takin to reduce risk of fall, and monitor, document, and report to physician signs and symptoms of complications related to osteoporosis, acute fracture, compression fractures, loss of height. The Care Plan Included Resident #1's limited physical mobility due to weakness that should be addressed by encouraging activities and physical mobility; use wheelchair for locomotion; monitor, document and report to physician signs and symptoms of immobility such as contracture forming or worsening, thrombus formation, skin breakdown, and fall related injury; provide supportive are, assistance with mobility as needed, document assistance as needed, and refer to therapy as ordered. Record review of Resident #1's Clinical and Order Alerts Listing Report written by CNA A and dated 11/13/22 at 11:57 p.m. indicated CNA C while conducting rounds when Resident #1 was found on the floor, while the charge nurse was on break. CNA C, with the assistance of a CNA, placed Resident #1 into a chair, and then onto her bed, while Resident #1 complained of foot (right) pain. Afterwards, the nurse (LVN B) was notified. Record review of Resident #1's Skin Evaluation written by Registered Nurse (RN A) on 11/14/22 at 12:51 P.M. indicated Resident #1 had MASD (moisture associated skin damage) to bilateral breast folds, and no other skin issues or concerns. Record review of Resident #1's Physical Therapy Treatment Encounter Note written by PTA A on 11/15/22 at 2:54 P.M. indicated PTA A Resident #1 complained of pain to her right toe/foot but showed no bruising or redness to any areas. Record review of Resident #1's Physical Therapy Treatment Encounter Note written by PTA A on 11/16/22 at 2:35 P.M. indicated Resident #1 had difficulty with weight bearing and ambulation with complaint of pain to her right foot, which had bruising noted to the toes, charge nurse was informed of pain and bruising. Record review of Resident #1's Physical Therapy Treatment Encounter Note written by PTA A on 11/17/22 at 1:56 P.M. indicated Resident #1complained of discomfort to the right foot. Resident #1 was able to put some weight to her foot; however, noted guarding and mostly putting weight on her heel. Gait training was stopped due to pain to her right foot. Resident #1's right foot had bruising to her toes and charged nurse was informed of pain and bruising. Record review of Resident #1's Change in Condition written by LVN A on 11/17/22 at 8:20 A.M indicated her right foot had bruising with swelling and pain with movement, and an order for x ray to the right toes to rule out a fracture and send to the emergency room . Record review of Resident #1's Progress Note dated 11/17/22 at 2:17 P.M. indicated CNA A and CNA B were informed by CNA C Resident #1 sustained a fall on 11/12/22 and bruising and swelling had been present since, and LVN A assessed Resident #1's right foot, which had bruising and swelling to her toe, and she complained of pain with movement. The Physician was notified and ordered a mobile unit X ray to the right toes that revealed a nondisplaced second proximal phalanx base fracture present. Physician was notified of the X ray results and ordered Resident #1 be sent to the hospital. Record review of Resident #1's Study (X ray report) dated 11/17/22 included impression as acute/subacute nondisplaced 2nd proximal phalanx (bone) base fracture, chronic posttraumatic deformities involving the 2nd, 3rd, and 4th metatarsals (long bones that connect ankle to toes) and osteopenia and osteoarthrosis. Record review of Resident #1's hospital's Final Report dated 11/18/22 included reason for exam as pain. Resident #1's findings included bones/joints were moderately advance generalized osteoarthritis through the foot and some degree of rheumatoid arthritis change may be present bilaterally. Old fracture deformities through the second through fifth metatarsals bones of the fight foot. Bony demineralization noted bilaterally, and no dislocation. Record review of Resident's Progress Note dated 11/18/22 indicated Resident #1 returned to facility from the hospital with a hard sole shoe (walking boot) and hospital's paperwork did include diagnosis of a fracture. Record review of Resident #1s Skin Evaluation written by Licensed Practicing Nurse (LPN A) on 11/21/22 at 12:51 P.M. indicated Resident #1 had bruising to right toes and foot and no other skin issues. During an interview on 11/30/22 at 9:46 A.M. LVN B indicated on 11/13/22 after midnight, she was notified by CNA C that Resident #1 said she attempted to go to the bathroom to take a bath, when she fell . LVN B indicated she assessed Resident #1, who was lying in her bed, and she had range of motion, no bruising or redness; however, she did complain of pain to her right food. LVN B said she had not seen Resident #1 walk independently but did received therapy for walking. After this incident, LVN B said she did not fill out a progress report, incident report, or contact the family or physician, because she was busy caring for her residents. LVN B said she typed a text to send to the physician but did not push the send button. LVN B indicated she had been in-serviced on fall prevention, including informing the physician, and documenting on appropriate reports. During an interview on 11/30/22 at 3:00 P.M. with Physician A indicated she was notified on 11/17/22 for an order to X ray Resident #1 due to sustaining a fall. After the mobile unit's X ray findings determine as fracture, Physician A had Resident #1 sent to the hospital for further evaluation. Physician A indicated per fall protocols; she should have been notified immediately after Resident #1 was found on the floor. During an interview on 11/30/22 at 10:10 P.M. CNA C indicated on 11/17/22 she was asked by CNA A if knew what caused the injury to Resident #1's right foot, and she replied that she found her on the floor on 11/13/22 at approximately 12:30 a.m. CNA C said was assisted by CNA E in placing Resident #1 back into her bed, and notified LVN B after she returned from her break. CNA C said she documented on Resident #1's fall on her Plan of Care noted by the CNAs. CNA C indicated she did not work on 11/14/22 and 11/15/22; however, she worked on 11/16/22 and observed Resident #1's right foot was purple, and she complained of pain. During an interview on 12/01/22 at 8:43 A.M. CNA A said on 11/16/22 the injury was brought to her attention by PTA A, who asked her what had happened to Resident #1's foot, because she had bruising, swelling, and was complaining of pain during her therapy session. CNA A and CNA B observed Resident #1's foot noting it was purple between the toes. CNA A said she reported her findings to LVN A, who reviewed Resident #1s' electronic file and found no documentation on a fall with injury. CNA A indicated she did not work on 11/14/22 or 11/15/22; however, she did work on 11/16/22 and was unaware Resident #1, who was found on the floor, had sustained an injury to her right foot. During an interview on 12/01/22 at 8:59 A.M. CNA B indicated he and CNA A observed Resident #1's foot was purple between the toes, and she was complaining of pain. CNA B said he witnessed CNA A report Resident #1's injury to LVN A. During an interview on 12/01/22 at 9:50 A.M. PT B indicated on 11/17/22 she stopped Resident #1's therapy session after observing Resident #1 guarding her foot and putting most of her weight on her heel when walking. PT B said she removed Resident #1's sock and observed she had purplish color between her toes and swelling to the ball of her right foot and toes. During an interview on 12/01/22 at 9:54 A.M. PTA A indicated she conducted therapy session with Resident #1 on 11/15/22, 11/16/22, and 11/17/22, and during these sessions Resident #1 complained of pain to her foot. PTA A indicated she removed resident #1's sock because she was complaining of pain and observed bruising and redness to her toes and foot. PTA A said she documented Resident #1's injury on her therapy notes. PTA A notified Resident #1's charge nurse, LVN A. PTA A indicated if she had been informed Resident #1 had pain to her right foot, she would not have conducted her therapy sessions. During an interview on 12/01/22 at 10:46 A.M. CNA D indicated on 11/13/22 at 6 A.M. CNA C informed her Resident #1 had fallen in the bathroom but did not mention she was in pain. Later that day, CNA D said she assisted Resident #1 from her bed, and she said her right foot was hurting. CNA D said she reported this to RN A, who replied he knew about this incident. On 11/15/22 CNA D was informed by CNA E that she assisted Resident #1 from her bed and observed the toes on her right foot were bruised and she complained of pain. CNA D informed CNA E on 11/14/22 she reported to RN A Resident #1's complained of pain to her right foot and witnessed RN A escort Resident #1 to her room to assess her foot, and he did not share his findings with her. During an interview on 12/01/22 at 10:52 A.M. CNA E indicated on 11/13/22 at approximately 6 A.M., CNA C informed her Resident #1 had a fall and she assisted CNA C in placing Resident #1 back into her bed. CNA E said on 11/14/22 Resident #1 had a small bruise on her right foot and she complained of pain when she stood her up from bed. CNA E said she reported this to RN A, who went towards Resident #1. During an interview on 12/01/22 at 2:55 P.M. Administrator (Operations Manager) indicated LVN B should have notified physician after Resident #1 was found on the floor. The staff are expected to follow fall prevention protocols to ensure interventions are implemented to prevent another fall. During an interview on 12/01/22 at 10:15 A.M. LVN A indicated on 11/16/22 CNA B and CNA C informed him CNA C had reported Resident #1 had an injury on her foot after she was found on the floor on 11/13/22. LVN A said he assessed Resident #1s right foot and obtained orders for X ray. LVN A indicated he worked on 11/16/22 and was unaware Resident #1 had bruising to her foot and was complaining of pain. During an on 12/01/22 at 10:44 A.M. RN A indicated he was not informed Resident #1 had sustained an injury and was complaining of pain before 11/16/22. During an interview on 12/01/22 at 2:39 P.M. DON indicated LVN B failed to notify physician after Resident #1 was found on the floor on 11/13/22. On 11/17/22 Resident #1's injury to her foot was brought to her attention, and that's when physician was notified. Record review of facility's Policy/Procedure for Fall Management System dated 06/2018 indicated the facility was committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted with attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices, and functional programs as appropriate to prevent accidents. It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. And when a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record. The attending physician and resident representative shall be notified of the fall and the resident status. Follow-up documentation will be completed for a minimum of 72 hours following the incident. A fall Risk Evaluations will be completed post fall. Review of the fall will include investigation to determine probable causal factors. Record review of facility's Policy/Procedure, Section: Resident Rights, undated but presented as current on 12/01/22, indicated the facility should notify the resident, his/her attending physician, and/or family/responsible party of changes in residents' condition. The nurse supervisor will notify the resident's attending physician when: the resident is involved in any accident or incident which results in an injury including injuries of an unknown source.

Based on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 1 resident reviewed for medication errors (Resident #1). LVN C incorrectly administered Resident #2's evening medication regimen to her roommate, Resident #1, after Resident #1 had already been administered her regular evening medication. The significant medication errors caused Resident #1 to have an altered mental status requiring transfer to the local hospital for further evaluation. Due to the significant medication error, Resident #1 required admission to the hospital on [DATE]. Resident #1 remained in the hospital with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It's needed for the nerve cells and brain function. But too much serotonin causes signs and symptoms of shivering, diarrhea, muscle rigidity, fever, seizures and can cause death if not treated.) An Immediate Jeopardy (IJ) situation was identified on [DATE] at 11:27 am. While the IJ was removed on [DATE] at 4:39 pm, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The facility's failure placed Resident #1 at risk and could have placed other residents at risk for medication overdose, coma or death. Findings include: Record Review of Resident #1's clinical record revealed: Resident #1 an [AGE] year-old female with an admitted [DATE] and a readmitted [DATE]. She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record Review of Resident #1's MDS, dated [DATE], indicated: Under section B, labeled Hearing, Speech, and Vision indicated under section B0200: Ability to hear listed 2, meaning moderate difficulty. Under section B1000: Ability to see in adequate light listed 1, meaning vision impaired. Under section B1200: Corrective lenses listed 1, meaning yes. BIMS Score (Brief Interview for Mental Status), is listed at a 5 meaning Resident #1 has severe cognitive impairment. Record Review of the care plan for Resident #1, dated [DATE], stated: Resident #1 is at risk for signs and symptoms of dehydration r/t med usage. Goal listed: will be free of any discomfort or adverse side effects of diuretic therapy through the review date. Interventions listed: Administer medication as ordered. Record Review of the care plan for Resident #1, dated [DATE], stated: Resident #1 has impaired cognitive function/dementia. Goal listed: Will maintain current level of cognitive function through the review date. Interventions listed: Communication: Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any disturbances, turn off TV, radio, close door, etc. Use simple, directive sentences. Provide with necessary cues. Stop and return if agitated. Record Review of the care plan for Resident #1, dated [DATE], stated: Resident A is at risk for a communication problem r/t hearing deficit. Goal listed: Will be able to make basic needs known daily through the review date. Interventions listed: Anticipate and meet needs. Record Review of Resident #1's physician orders, dated [DATE] stated: [MEDICATION(S)] HCI 10mg, Famotidine 20mg, [MEDICATION(S)] 100 mg, Ibuprofen 200mg, [MEDICATION(S)] 20mg, [MEDICATION(S)] 75mg, [MEDICATION(S)] HCI 10mg, [MEDICATION(S)] 10mg, [MEDICATION(S)] Sublingual 0.4mg, Potassium Chloride 20 MEQ, [MEDICATION(S)] HCI 25mg. Record Review of Resident #1's MAR, dated [DATE] stated: On [DATE] at 6:19 p.m., LVN D documented she administered [MEDICATION(S)] HCI 10mg (treats Alzheimer's disease) by mouth at bedtime. Record Review of Resident #1's MAR, dated [DATE], stated: On [DATE] at 6:18 p.m., LVN D documented she administered [MEDICATION(S)] Capsule 100 mg (anticonvulsant and nerve pain medication) by mouth at bedtime. Record Review of Resident #1's MAR, dated [DATE], stated: On [DATE] at 6:19 p.m., LVN D documented she administered [MEDICATION(S)] HCI 10mg (treats Alzheimer's disease) by mouth at bedtime. Record Review of Resident #1's MAR, dated [DATE], stated: On [DATE] at 6:18 p.m., LVN D documented she administered [MEDICATION(S)] 10 meq (anti-[CONDITION(S)]) by mouth at bedtime. Record Review of Resident #1's MAR, dated [DATE], stated: On [DATE] at 6:18 p.m., LVN D documented she administered [MEDICATION(S)] HCI (anti-depressant/Selective Serotonin Reuptake Inhibitor SSRI that works by increasing the levels of a mood-enhancing chemical called serotonin in the brain) by mouth at bedtime. Record Review of the MAR dated [DATE] for Resident #2 (the MAR of Resident #1's roommate that revealed the medication and doses that LVN C incorrectly administered to Resident #1 ), stated: On [DATE] at 7:34 p.m., LVN C documented he administered [MEDICATION(S)] HCI (anti-depressant that works by increasing levels of a chemical called serotonin in the brain) 50 mg. On [DATE] at 7:35 p.m., LVN C documented he administered [MEDICATION(S)] 2mg (it is used to treat muscle spasms). On [DATE] at 7:34 pm., LVN C documented he administered [MEDICATION(S)] 100 mg (a stool softener). On [DATE] at 7:34 pm., LVN C documented he administered Iron ([MEDICATION(S)] Sulfate) 325 mg. On [DATE] at 7:34 pm., LVN C documented he administered [MEDICATION(S)] 20 mg (used to lower cholesterol and triglyceride). On [DATE] at 7:34 pm., LVN C documented he administered [MEDICATION(S)] HCI 500 mg (used to lower blood sugar). On [DATE] at 7:34 pm., LVN C documented he administered [MEDICATION(S)] 100 mg (it is used to treat nerve pain caused by different conditions like diabetes and shingles). On [DATE] at 7:34 pm., LVN C documented he administered [MEDICATION(S)] 5mg (used to treat sleep problems) On [DATE] at 7:34 pm., LVN C documented he administered [MEDICATION(S)] 0.5 mg (used to treat anxiety, [CONDITION(S)], or sleep difficulties). During an interview with LVN C on [DATE] at 10:47 a.m., LVN C confirmed he was the nurse that committed the medication error and was responsible for caring for Resident #1 on his shift. When asked how the error occurred, he stated, I gave the roommate (Resident #2's) medication to Resident #1 on an accident. I had asked her three times if that was her name (stating Resident #2's name) and she said yes three times. LVN C stated that he was not familiar with working with this resident. LVN C stated that he did verify Resident #1's room number and he did look at Resident #1's MAR picture, but it seemed a little blurry to him. LVN C stated that he had not worked on this hall before or with the residents on this hall. LVN C stated that he intended to give the medications to Resident #2 instead of Resident #1. LVN C stated that he has not made this mistake before. LVN C stated that he was also not familiar with the system of the bed set up, whether A bed was by the door, or the window or bed B was by the bed or window. LVN C stated that when he realized that he had made the mistake, he immediately notified DON via phone, and she instructed him to report to NP and to follow her instructions. LVN C stated that NP instructed him to monitor Resident #1 for cognitive changes and blood glucose levels/vital signs every three hours. LVN C stated that Resident #1's vitals remained stable, but she had cognitive changes. LVN C stated that at 12:52 am he contacted NP regarding the cognitive changes and contacted 911. LVN C stated that EMS arrived and transported Resident #1 to the hospital. During an interview with DON on [DATE] at 11:18 a.m., DON stated that she learned of the incident when LVN C had notified her via telephone and reported the incident to her. DON stated that she advised LVN C to do baseline vital signs and sugars and contact NP and follow her instructions. LVN C stated that NP gave orders to check vital signs every 3 hours, blood glucose checks, and check for cognitive changes for the night. DON stated that she DON stated that LVN C was administering medications that evening and accidentally administered Resident #2's medications to Resident #1 DON stated that her she expects all nurses and med aides to verify residents in several different ways to make sure that they have the correct resident before administering medications. DON stated the ways that LVN C could have verified Resident #1 would have been to verify the MAR picture with the resident, verify the bed with the resident, and to verify the resident's name. DON stated that if the nurse is unsure about the resident, then other staff members could be asked to help verify the resident. DON stated that LVN C stated to her that he was not familiar with the bed set up and that the two resident's pictures on the MAR were similar and Resident #1's picture seemed far away. DON stated that LVN C notified her approximately at 8pm. DON stated that LVN C had stated to her that he noticed that Resident #1 had been fatigued and drowsy, much different than previously and that her vitals were stable. DON stated that LVN C stated to her that when he tried to wake Resident #1, she was not responding so at that time 911 was called. DON stated that she had not notified pharmacy to let them know of medication error and no QAPI meeting had been initiated at this time. Physician and NP was notified. DON stated that to correct the issue from happening again she will in-service staff, make sure that all MAR pictures are updated, and do skills check with staff. DON stated that the negative potential outcome would be that Resident #1 got hurt from the medications and could have caused death or worse side effects from the medications. During an interview with administrator on [DATE] at 1:50 pm., Administrator stated that he learned of the incident the day that it happened and that he was waiting to get confirmation from the hospital for updates to see if it was the overdose that caused her cognitive changes or what specifically they were treating her for. Administrator stated that it was the side effects of the medication that caused the staff to become aware that a mistake had been made. Administrator stated that his expectations are that the staff know the 5 rights of medication, how to pass medications, and if something looks questionable then verify with another staff member. Administrator stated that all staff can go to DON or himself if they are unsure of how to do something or if they question the identity of the resident then they can figure it out together. Administrator stated that he expects staff to not rush through identifying a resident or passing medications to keep errors from happening. Administrator stated that he and the DON will be handling the staff on a one-on-one basis and making sure that all staff are aware of the correct ways to identify a resident and pass medications. Administrator stated that he or DON will get with LVN C to see where he is at in skills and see where he needs further training or education . Administrator stated that for new implementations for the facility they will do PCC training on the computer, training upon hire, and work with employees to get them all comfortable with skills. Administrator stated that it is important to get feedback from employees as well to see where they are or are not comfortable. Administrator stated that the negative potential outcome could be that the resident could have died from overdose. During an interview with family member of Resident #1 on [DATE] at 5:32 pm., Family member stated that Resident #1 was placed in medical ICU, was shaking so badly that it was a concern that Resident #1 may go into a [CONDITION(S)]. Family member stated that Resident #1 could not even communicate at that point, had high blood pressure, and had a high fever. Family member stated that Resident #1 was practically in a coma state. Family member stated that it was a scary ordeal, and the family was unsure if Resident #1 would make it through this. Family member stated that the hospital diagnosed Resident #1 with serotonin syndrome due to the symptoms and the types of medications that were incorrectly given to Resident #1. Family member stated that Resident #1 had always loved living in this facility, but it makes the family nervous that this kind of mistake may happen again, and the resident may not be able to pull through next time. Family member stated that she is aware that mistakes like this happen, but she would rather LVN C not treat Resident #1 again if she is unable to move Resident #1 from the facility. Family member stated that she hopes that the facility takes the necessary precautions so that this mistake does not happen to Resident #1or other residents again. An attempted interview was made to Nurse Practitioner on [DATE] at 4:27 pm via telephone. Left message with return contact, no return call. An attempted interview was made to Nurse Practitioner on [DATE] at 4:8:45 am via telephone. Left message with return contact, no return call. An attempted interview was made to Medical Director on [DATE] at 9:29 am via telephone. Left message with return contact, no return call. Record Review of the Resident #1 progress notes, dated [DATE]-[DATE], stated: -On [DATE] at 8:09 pm LVN C documented: Writer gave roommates medication. Writer asked resident name multiple times and stated she was Resident #2, and she stated yes three times. -On [DATE] at 3:20 pm LVN D documented: she (CNA) called to me said that patient fell into the floor. Patient assessed and she said she could not straighten her left leg. It was told by LVN D for her not to move and called 911. Patient family member notified. Ambulance transferred to ER. -On [DATE] at 5:52 am LVN B documented: Day shift nurse called hospital night nurse RN reported resident was admitted for serotonin syndrome. Nurse reported resident was still under monitoring and not stable. No other nurse needs at this time. Record Review of the facility's incident report labeled, Falls, dated [DATE] at 3:08 pm, stated: Incident Description: Upon assessment patient said she could not straighten her leg. Instructed her to not move. No severe pain noted upon palpation of left hip and femur. 911 called for transport. Granddaughter called and notified. She said she would let daughter know. Unable to reach daughter. Resident #1 taken to hospital: N for no was marked. On notes DON made comments on [DATE]: Resident #1 with fall related to weakness/[CONDITION(S)] related to adverse effect of medications received in error on [DATE]. Resident #1 had resulting serotonin syndrome which caused weakness and altered mental status which directly caused this fall. Prevention of future falls will be resolution of acute serotonin syndrome and strengthening back to baseline. Will frequently monitor for safety upon return to the facility and request therapies assist with strengthening and fall prevention. No acute injuries noted related to this fall. Record review of the Hospital's History and Physical, dated [DATE] at 7:45 pm, for Resident #1, stated: Chief Complaint EMS stated that Patient was given 10mg of [MEDICATION(S)] at the nursing home accidentally given someone else's medication. History of Present Illness Resident #1is an [AGE] year-old female with history of Alzheimer's, CHF, and TIA who initially presented last night after accidentally receiving her neighbor's medications at the nursing home (was given [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]). She was kept in the hospital overnight and returned back to her baseline and discharged this morning back to the nursing home .( Resident #1 was originally sent to the hospital for the medication error and released, this is when Resident #1 had a fall due to signs and symptoms from the medication error and was then sent back to the hospital). Later she attempted to get out of bed and fell , hitting her hip (incident happened in the nursing home). It was then reported that she got shortness of breath, diaphoretic, and spike a fever. Imaging of her hip was negative for fracture. Per the family she developed a temperature of 104, confusion, and intermittent clonus. Denied any rigidity. Home medication includes [MEDICATION(S)]. Currently she is confused and not at baseline. Vitals: Temp: 103.7 degrees, HR: 129, RR: 24, BP: ,d+[DATE], SpO2: 79% Diagnoses Serotonin Syndrome (Serotonin is a chemical that the body produces naturally. It's needed for the nerve cells and brain function. But too much serotonin causes signs and symptoms of shivering, diarrhea, muscle rigidity, fever, seizures and can cause death if not treated.) 1. Assessment/Plan: 1. Continuous Telemetry 2. Discontinue all serotonergic agents 3. IVF 4. Close monitoring for any acute changes in mental status that could cause compromise of airway 5. Head of the bed elevation to avoid aspiration 6. For the fever, although WBC normal, will follow up cultures. No physical evidence of infection. 7. Will hold [MEDICATION(S)] as this can mask [CONDITION(S)] that is used to help monitor effectiveness of treatment 8. Consult MICU 9. Observation unit transfer Record Review of LVN C disciplinary action labeled, Counseling/Disciplinary Notice, dated [DATE], signed and dated by DON, stated: Reason: LVN C received counseling for the medication error that occurred on [DATE] when LVN C confused the two roommates. Corrective Action: LVN C received Relias training for review of medication administration safety. Record Review of the facility's in-service labeled , Resident Photos, dated [DATE], stated: Resident photos should be taken up close, similar to the driver's license or passport photo. Should be clear and resident should look how they typically would (glasses, dentures, etc.). Residents should have face fully visible (no caps, sunglasses, or masks). Photo should show the resident's full face and have the top of collar bone/shoulders (no full body photos). Staff that received this training included: admissions staff, LVN's, CNA's, ADON, LMSW, DON. Record Review of the facility's policy labeled, Medication Administration, dated ,d+[DATE], stated: Policy: It is the policy of this facility to accurately prepare, administer, and document oral medications. Procedure: 1. Administer drug to resident. a). Identify resident b). Check the picture of the resident against the MAR. c). Ask his/her name. d). Verify with another staff member if any question in the above. Essential Points: 5. The resident must be identified before administering any medications. It was determined these failures placed Resident #1 in an Immediate Jeopardy situation from [DATE] to [DATE]. On [DATE] at 11:27 am the Operations Manager and DON were notified of the IJ situation was identified due to significant medication error. The facility's Plan of Removal was accepted on [DATE] at 3:47 pm and included C. Actions taken to prevent reoccurrence: 1. LVN C was immediately suspended until after facility investigation . 2. The DON and or ADON will conduct in-services for all licensed staff and medication aides regarding complete and accurate medication administration. 3. The DON and or ADON will conduct med pass skills check offs on all licensed staff and medication aides to include med pass skills during orientation process of newly hired licensed staff and medication aides. 4. Resident pictures were retaken and updated in PCC. 5. The IDT team will meet and review resident pictures weekly x6 weeks to review any changes. 6. LVN C was interviewed by DON and Operations Manager. 7. LVN C was provided education on medication administration, room layouts, and identifying residents in A/B bed and assigned additional on-line training titled, Avoiding common medication errors. As part of education, he was assigned to orientation on all medication carts prior to accepting assignment for that hall. 8. Pharmacy consultant was called to come conduct medication pass check offs. 9. Attending Physician's were notified of IJ status on [DATE] at 11:45 am. 10. Change of condition, and medication administration policies were reviewed. Medication administration will be completed according to the twelve rights of medication administration. Notifications to physicians will be made if medication errors occur. 11. The DON and ADON will monitor medication proficiency and safety weekly on eight residents to ensure all medication rights are being followed per physician orders. 12. QI meeting conducted [DATE]. Compliance Interviews: During an interview with Medication Aide I on [DATE] at 9:08 am. Medication Aide I stated that she had done the recent skills training on how to correctly identify a resident. Medication Aide I stated that there are a few different ways to identify a resident. Medication Aide I stated that she would look at the picture on the MAR to help identify, look at the resident name on the name tag listed on the door and know which bed is where and she can also ask the resident what their name is. Medication Aide I stated that if there is still confusion then she can ask another staff member. During an interview with Medication Aide J on [DATE] at 9:32 am. Medication Aide stated that she did have the required training on how to correctly identify a resident. Medication Aide J stated that first she would look at the picture that is list on the MAR and make sure that it is a good picture. Medication Aide J stated that she could become familiar with her residents. Medication Aide J stated that she can ask the resident what their name is and don't tell the resident what their name is but ask. Medication Aide J stated that she can look at the resident's name listed on the door and make sure to know the setup of which bed goes where so that you can correctly identify the resident. Medication Aide J stated that you want to use different forms of identification to make sure that you have the correct resident. During an interview with Medication Aide K on [DATE] at 10:01 am. Medication Aide K stated that she did attend the skills check offs and in-service training on how to correctly identify a resident. Medication Aide K stated that she would be able to correctly identify a resident by checking the MAR picture to see who she is looking for as well as asking the resident what their name is. Medication Aide K stated that she could ask another staff member to help identify if there was any confusion. Medication Aide K stated that she could also look at the name tags on the door to see what bed the resident that she is looking for is in. During an interview with ADON on [DATE] at 10:18 am. ADON stated that she did attend the required training for how to correctly identify a resident. ADON stated that she attended the training and skills check off was conducted after the training to make sure that staff knew how to correctly identify a resident. ADON stated that on the MAR you can blow up the picture to get a better look of the picture if you are unable to see the picture. ADON stated that you need to know your bed locations so that you can easily look at the name tags and know which resident belongs to which bed. ADON stated that you do not want to rely on just one form of identification to help avoid errors in identification process. ADON stated that if you are not sure of the identification of the resident at that point or you just need to make sure then you can always ask another staff member. During an interview with LVN E on [DATE] at 10:35 am LVN E stated that she did do the medication Error training and skills check off with the DON. In the training it was included how to zoom into the MAR pictures when pictures were not good enough or far away or blurry, how to identify a resident correctly how to learn the A, B bed lay out with matching the resident's name with the bed, ask resident the name do not tell them their name. Surveyor confirmed that the facility's plan of removal was implemented as evidenced by: 1) Interviews with all available licensed nurses and medication aides to confirm the additional training regarding medication administration had been performed. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 8 residents reviewed for pressure injuries. (Resident #278) Resident #278 was admitted to the facility with no pressure ulcers and developed 2 unstageable pressure ulcers to the sacrum/coccyx area. The facility was unaware of these ulcers and not providing any treatment. This failure could place the remaining 8 residents who had pressure injuries at risk for new development or worsening of existing pressure injuries. Findings included: Resident #278 Record review of face sheet for Resident #278 revealed a [AGE] year-old male admitted on [DATE]. Resident's [DIAGNOSES REDACTED]. Observation on 09/08/20 at 12:10 PM revealed Resident #278 lying on back in bed. Air mattress noted to bed. Observation on 09/08/20 at 2:16 PM revealed Resident #278 lying on back in bed. Air mattress noted to bed. Observation on 09/08/20 at 4:15 PM revealed Resident #278 lying on back in bed. Air mattress noted to bed. Observation on 09/09/20 at 8:30 AM revealed Resident #278 lying on back in bed. Air mattress noted to bed and appeared to have minimal air in mattress. Observation on 09/09/20 09:56 AM for central line dressing change for Resident #278 revealed resident lying on back in bed. Air mattress noted to bed and appeared to have minimal air in mattress. Observation on 09/10/20 at 09:40 AM of Resident #278 of incontinent care performed by CNA # 1 revealed Resident #278 was lying flat on back in bed. CNA #1 turned resident on left side and revealed 2 pressure ulcers to sacral area with eschar on wound bed. The skin around the pressure ulcers were bright red in color and was not blanchable. No dressing was covering the wound. The resident was laying on an air mattress that appeared to have minimal air in the mattress. Interview on 09/10/20 at 9:49 AM with CNA #1 revealed she was not aware of the pressure ulcer on the left side of the sacrum but was aware of the pressure ulcer to the right side of the sacrum. Stated she noticed it this morning and hasn't had time to report it to the charge nurse. CNA #1 stated she had not seen the pressure ulcer on the left side of the sacrum because she has a hard time turning the resident by herself and we got lucky that he helped turn himself this time. CNA #1 stated she reported to maintenance 3 days prior the air mattress was not working properly. Interview on 09/10/20 at 9:51 AM with LVN #2 regarding Resident #278's pressure ulcers revealed he knew the resident had redness on his bottom last week but was unaware of any pressure ulcers this week. LVN #2 denies any CNA's reporting pressure ulcers to his bottom. LVN #2 was unaware of the air mattress not working properly and stated he would report to maintenance. LVN #2 stated that the air mattress was important for pressure ulcer prevention due to Resident #278's immobility. Interview on 09/10/20 at 9:54 AM with LVN #3 regarding Resident #278's pressure ulcers revealed that she was unaware of the pressure ulcers. LVN #3 stated that the skin assessments are usually done every week by the wound care nurse, but the wound care nurse has been pulled to the floor a lot and the skin assessments were the responsibility of the floor nurses at that time. LVN #3 stated that the skin assessments may not be getting done at due to low staffing. Observation on 09/10/20 at 10:03 AM with LVN #3 and CNA #1 of Resident #278's pressure ulcers reveal the pressure ulcer on the left side of the sacrum measuring 6cm x 2cm by LVN #3. The pressure ulcer on the right side of the sacrum measuring 3cm x 1.5 cm by LVN #3, who confirmed these measurements. Interview on 09/10/20 at 11:59 AM with CNA #2 via phone regarding Resident #278's pressure ulcers revealed CNA #2 noted a skin tear to resident's tailbone a week ago. Stated she reported to LVN #2 when she saw it. CNA denies documenting the skin tear on any shower sheets. Interview on 09/10/20 at 12:20 PM with RN #1 via phone regarding skin integrity for Resident #278 revealed RN #1 had no knowledge of skin breakdown to resident's sacral area. RN #1 stated he knew about the surgical wound to the right knee but was never told about any skin breakdown to his bottom. RN #1 last worked on 09/08/20. Interview on 09/10/20 at 2:10 PM with CNA #4 regarding Resident #278's care revealed Resident #278 was very red on his buttocks. CNA #4 applied ointment to his buttocks during incontinent care. CNA #4 stated she reported this to the nurse but was could not remember which nurse she told. CNA #4 stated she last worked Oak unit on 09/07/20. Interview on 09/10/20 at 2:15 PM with CNA #5 regarding Resident #278's care revealed CNA #5 helped CNA #2 last week with incontinent care for Resident #278. CNA #5 stated that Resident #278 had some dark spots on his bottom and redness. CNA #5 stated she did not report to the nurse because she heard CNA #2 already reporting the skin to LVN #2. Interview on 09/10/20 at 5:08 PM with Interim DON revealed she expects to be notified immediately regarding pressure ulcers in the facility. Interim DON stated the floor nurses do their own wounds and skin assessments when the LVN #5 is pulled to the floor. Interim DON stated that the floor nurse's are told by word of mouth when they are responsible for their own weekly skin assessments. Interview on 09/10/20 at 5:32 PM with LVN #5 revealed she was unaware of the pressure ulcers to Resident #278's sacral area until that morning after the surveyor alerted the facility to the pressure ulcers. Record Review of Resident #278's active physician orders [REDACTED]. Record Review of Resident #278's weekly skin assessments reveal no documentation of weekly skin assessments. Record Review of LVN #5's progress note for Resident #278 with an effective date of 9/10/2020 at 11:09 AM reveal the facility verifies 2 unstageable pressure ulcers to the sacrum. Record Review of Resident #278's comprehensive MDS dated [DATE] Section C Cognitive Patterns reveal a BIMS score could not be assessed. Staff assessed Resident #278 as moderately cognitively impaired. Section G Functional Status reveals Resident #278 for bed mobility is coded extensive assistance with two+ person physical assist and for toilet use is coded extensive assistance with one-person physical assist. Section H Bladder and Bowel reveal Resident #278 is always incontinent of bowel and bladder. Section M Skin Condition reveal Resident #278 is at risk for developing pressure ulcers/injuries and does not have any pressure ulcers/injuries. Record Review of Resident #278's comprehensive care plan with a date initiated: 08/31/2020 reveal Focus: Has potential/actual impairment to skin integrity r/t (related to) Goal: Will be free from injury through the review date. Interventions: Encourage good nutrition and hydration in order to promote healthier skin, use caution during transfer and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The Comprehensive Care Plan did not document any interventions or treatment for [REDACTED].#278's right and left sacrum. Record Review of Resident #278's Hospital # 1 records reveal on 08/16/2020 Resident #278 was assessed by FNP. FNP documented Integumentary: Warm, dry, Intact, r knee drsg cdl with immobilizer in place. 'The hospital medical records did not document any pressure ulcers to resident # 278's sacrum. Record Review of Admission assessment with effective date 8/16/20 signed by LVN #6 Section 12. Skin Integrity 1. Any skin problems on admission? The question is unanswered with Yes and No left unchecked. Record review of admission assessment with effective date 08/19/2020 by RN #2 reveal Section 12. Skin Integrity 1. Any skin problems on admission? No was checked. Record review of first skilled nurse's note dated 08/20/2020 reveal skin is warm and dry with no changes and was documented by LVN #6. Record review of daily skilled nurse's notes dated 08/25/2020 to 09/09/20 reveal no changes to the skin. Record review of skilled nurses noted dated 09/10/20 with a time of 6:17 PM reveal x2 eschar pressure wounds to bottom and redness present Record review of facilities policy and procedure titled Policy/Procedure - Nursing Administration, Section: Care and Treatment, Subject: Pressure Ulcers Revised 05/2007 revealed: Policy: It is the policy of this facility that: 1. A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and 2. A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing Procedures: 1. Resident Assessment A. Complete admission assessment to identify risk and to identify present ulcer(s) - Impaired diffuse or localized blood flow, for example, generalized [MEDICAL CONDITION] or lower extremity arterial insufficiency - Resident refusal of some aspect of care and treatment - Cognitive impairment -Exposure of skin to urinary and fecal incontinence - Under nutrition, malnutrition, and hydration deficits - History of healed pressure ulcer and its stage (if known) - Skin assessment on admission B. Comprehensive Care C. Prevention - Stabilize, reduce or remove underlying risks, monitor impact of interventions and modify interventions as appropriate - Repositioning - Support surface, pressure relieving devices (heel/elbow protectors) - Friction and shear prevention (mechanical lift) - Incontinence and skin care (toileting) - Provide non-irritating surfaces - Maintain or improve nutrition and hydration status - Assess for adverse drug reactions (lethargy, anorexia, confusion) - Nutrition and Hydration management

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for 1 of 10 residents (Resident #3) reviewed for neglect in that: Resident #3, who was diagnosed with [REDACTED]. Resident #3 fell and sustained a fractured right arm. This failure affected Resident #3 and placed the remaining 17 residents on the secured unit at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization . The evidence is as follows: Record review of Resident #3's clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -A quarterly MDS resident assessment, dated 11/11/16, documented the resident scored 5 of 15 on a mini-mental exam indicating severe cognitive impairment, required extensive assistance by one staff member for bed mobility, transfers, dressing, personal hygiene and toileting, totally dependent on one staff for bathing, frequently incontinent of bladder and bowel, 60 inches tall and 100 pounds. -A Screening for Fall Risk, dated 12/23/16, revealed Resident #3 scored 13, indicating a high risk for falls. -Review of Incident/Accident Reports for Resident #3 revealed she had three falls prior to her fall on 1/4/17. Resident #3 fell on [DATE], 9/24/16 and on 12/23/16. -Right Humerus x-ray, dated 1/4/17, documented interval appearance of a displaced and [MEDICAL CONDITION] arm. Review of the Provider Investigation Report, dated 1/4/17, documented the following: Description of the Allegation: Resident was up to the wheelchair, assisted to the bathroom by CNA (CNA A) and was about to be assisted to bed when an alarm in another room started to go off, CNA (CNA A) requested resident to wait to get in bed, and went to check alarm. Upon reentering resident's room, resident was noted to be on her right side. Resident assessed, pain noted to right shoulder, arm and rib areas, able to move lower extremities and left upper extremity without pain. Description of Injury: Report on x-ray revealed interval appearance of the comminuted and [MEDICAL CONDITION] arm, osteopenia and [MEDICAL CONDITION] joint disease. During an interview on 2/16/17 at 8:30 a.m., CNA A stated he worked the 10:00 p.m. to 6:00 a.m. shift at the nursing home. CNA A stated he assisted Resident #3 to the bathroom around 1:45 a.m. CNA A stated he assisted Resident #3 back to her wheelchair and was about to transfer her to bed when he heard another resident's alarm sounding. CNA A stated he instructed Resident #3 to stay in her wheelchair so he could go help another resident. CNA stated he was stuck between a rock and a hard place and it was a judgment call to leave the resident alone. During an interview on 2/16/17 at 8:45 a.m., MA B stated Resident #3 was forgetful but would try to do things by herself and does not ask for help. MA B stated Resident #3's dementia has progressed recently and if a CNA was helping her and told her to stay in her wheelchair while they answered a call light, Resident #3 would not stay in her wheelchair. During an interview on 2/16/17 at 9:20 a.m., the DON stated there were three Alzheimer's secured units at the facility. The DON stated Resident #3 resided on one of the secured Alzheimer's units where all the residents have dementia and required supervision and assistance with all activities of daily living. The DON stated Resident #3 has had four falls in the past 6 months. The DON stated prior to the fall on 12/23/17, Resident #3 was very independent and could transfer herself. The DON stated Resident #3 returned from a stay at the hospital on [DATE] and on 1/4/17 early in the morning, Resident #3 fell again. The DON stated CNA A assisted Resident #3 to the bathroom using a wheelchair and was assisting her back to bed when CNA A heard an alarm going off. The DON stated CNA A left Resident #3 by her bed to answer another resident's call light/Alarm. The DON stated, in hind sight, CNA A should have assisted Resident #3 to bed before he left her and that was when Resident #3 got a broken arm. The DON stated Resident #3 had just gotten back from the hospital and they were not aware she could not transfer herself. The DON stated she had already expressed to staff that if they have two alarms going off, to finish what they are doing before answering a second call light. Review of the facility's policy on Abuse Prevention, revised 11/28/16, documented the following: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: Neglect - is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the Resident Roster (CMS Form 802), received from the facility on 2/15/17, documented 87 residents with 18 residents residing on one of the secured Alzheimer's unit.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent neglect for 1 of 10 Residents (Resident #3) reviewed for abuse/neglect. Resident #3, who was [DIAGNOSES REDACTED].#3 unattended by CNA A to answer another resident's call light/alarm. Resident #3 fell and sustained a fractured right arm. This failure affected Resident #3 and placed the remaining 17 residents on the secured unit at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization . The evidence is as follows: Review of the facility's policy on Abuse Prevention, revised 11/28/16, documented the following: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Definitions: Neglect - is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Record review of Resident #3's clinical record revealed the following: -The face sheet documented an admitted [DATE], was [AGE] years of age with the following Diagnoses: [REDACTED]. -A quarterly MDS resident assessment, dated 11/11/16, documented the resident scored 5 of 15 on a mini-mental exam indicating severe cognitive impairment, required extensive assistance by one staff member for bed mobility, transfers, dressing, personal hygiene and toileting, totally dependent on one staff for bathing, frequently incontinent of bladder and bowel, 60 inches tall and 100 pounds. -A Screening for Fall Risk, dated 12/23/16, revealed Resident #3 scored 13, indicating a high risk for halls. -Review of Incident/Accident Reports for Resident #3 revealed she had three falls prior to her fall on 1/4/17. Resident #3 fell on [DATE], 9/24/16 and on 12/23/16. -Right Humerus x-ray, dated 1/4/17, documented interval appearance of the comminuted displaced and [MEDICAL CONDITION] arm. Review of the Provider Investigation Report, dated 1/4/17, documented the following: Description of the Allegation: Resident was up to the wheelchair, assisted to the bathroom by CNA (CNA A) and was about to be assisted to bed when an alarm in another room started to go off, CNA (CNA A) requested resident to wait to get in bed, and went to check alarm. Upon reentering resident's room, resident was noted to be on her right side. Resident assessed, pain noted to right shoulder, arm and rib areas, able to move lower extremities and left upper extremity without pain. Description of Injury: Report on x-ray revealed interval appearance of the comminuted and [MEDICAL CONDITION] arm, osteopenia and [MEDICAL CONDITION] joint disease. During an interview on 2/16/17 at 8:30 a.m., CNA A stated he worked the 10:00 p.m. to 6:00 a.m. shift at the nursing home. CNA A stated he assisted Resident #3 to the bathroom around 1:45 a.m. CNA A stated he assisted Resident #3 back to her wheelchair and was about to transfer her to bed when he heard another resident's alarm sounding. CNA A stated he instructed Resident #3 to stay in her wheelchair so he could go help another resident. CNA stated he was stuck between a rock and a hard place and it was a judgment call to leave the resident alone. During an interview on 2/16/17 at 8:45 a.m., MA B stated Resident #3 was forgetful but would try to do things by herself and does not ask for help. MA B stated Resident #3's dementia has progressed recently and if a CNA was helping her and told her to stay in her wheelchair while they answered a call light, Resident #3 would not stay in her wheelchair. During an interview on 2/16/17 at 9:20 a.m., the DON stated there were three Alzheimer's secured units at the facility. The DON stated Resident #3 resided on one of the secured Alzheimer's units where all the residents have dementia and required supervision and assistance with all activities of daily living. The DON stated Resident #3 has had four falls in the past 6 months. The DON stated prior to the fall on 12/23/17, Resident #3 was very independent and could transfer herself. The DON stated Resident #3 returned from a stay at the hospital on [DATE] and on 1/4/17 early in the morning, Resident #3 fell again. The DON stated CNA A assisted Resident #3 to the bathroom using a wheelchair and was assisting her back to bed when CNA A heard an alarm going off. The DON stated CNA A left Resident #3 by her bed to answer another resident's call light/Alarm. The DON stated, in hind sight, CNA A should have assisted Resident #3 to bed before he left her and that was when Resident #3 got a broken arm. The DON stated Resident #3 had just gotten back from the hospital and they were not aware she could not transfer herself. The DON stated she had already expressed to staff that if they have two alarms going off, to finish what they are doing before answering a second call light. Review of the Resident Roster (CMS Form 802), received from the facility on 2/15/17, documented 87 residents with 18 residents residing on one of the secured Alzheimer's unit.

Based on observation, interview, and record review the facility failed to provide and ensure 1 of 5 residents (#1) living in one of the facility's secure units received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to ensure Resident #1 was assessed to determine the cause of pain and failed to address the resident's pain. Resident #1 was admitted to the hospital the following day with a [MEDICAL CONDITION] of unknown origin and expired in the hospital several days after admission. The deficient practice affected 1 resident and could result in delayed [DIAGNOSES REDACTED]. Findings include: Review of Resident #1's Admission Record (closed record) dated [DATE] reflected the Resident was a [AGE] year old male with a legally authorized representative originally admitted to the facility on [DATE], re-admitted [DATE], and had the following [DIAGNOSES REDACTED]., unspecified sequelae of unspecified [MEDICAL CONDITION] disease, major [MEDICAL CONDITION], single episode, unspecified, chronic ischemic [MEDICAL CONDITION], unspecified, gastro-[MEDICAL CONDITION] reflux disease without esophagitis, and constipation, unspecified. Review reflected the resident lived in one of the facility's secure units (Unit A). In an interview with the ADON conducted on [DATE] at 8:40am, she stated Resident #1 was sent to the emergency room the morning of [DATE] because of left hip pain. He was diagnosed with [REDACTED]. He suffered a decline and expired in the hospital days after admission. Review of Resident #1's 5 day scheduled MDS assessment dated [DATE] reflected the resident had unclear speech with limited ability making concrete requests, and responded adequately to simple, direct communication only. The BIMS score was 00. The resident required extensive assistance from one staff to walk in room and limited assistance with walking in the corridor. The Resident did not have functional limitations in range of motion to any extremity. Review reflected Resident #1 did not display indicators of pain or possible pain during the 5 day look back period. Observation of Unit A conducted during initial tour on [DATE] at 9:08am revealed Resident #1's unit and the adjacent unit connected by a set of double doors were secure units requiring a code to exit each unit and to use the connecting double doors. In an interview with CNA #1 on [DATE] at 11:27am, she stated she worked the 6a-2p shift on [DATE]. She stated the resident appeared lethargic and slumped in his wheelchair during her shift. He required more assistance than usual with weight bearing and transfers. Normally the resident was alert, constantly mobilizing with his wheelchair within the unit and attempting to stand up unassisted. In an interview with CNA #2 on [DATE] at 11:43am she stated during the 6a-2p shift on [DATE], the resident grabbed his leg when she and CNA #1 performed a transfer and required more assistance than usual. He appeared to have no energy and was not mobilizing in his wheelchair. Normally the resident mobilized throughout the unit using his feet for propulsion. LVN #1 was aware the resident's behavior was different from baseline. In an interview with LVN #1 on [DATE] at 9:27am, she stated the morning of [DATE] staff reported Resident #1 exhibited signs of pain to the left leg when being provided ADLs. The resident had a communication deficit and could not describe the location of his pain. She checked the resident's limbs during breakfast and he did not show signs or symptoms of pain. She did not provide pain management to the resident. The resident did not normally complain of pain. Review of Resident #1's Order Summary Report dated [DATE] reflected the order to monitor his level of pain each shift and 2 orders to document non pharmacological interventions every shift for Monitoring. Review of Resident #1's Progress Notes printed by the facility on [DATE] at 4:26pm reflected: · LVN #1 entered a late Nursing Note on [DATE] at 4:49pm for [DATE]. LVN #1 documented she was notified by staff the resident was complaining of left leg discomfort. She noted the resident did not exhibit pain and was able to flex the leg. No redness or [MEDICAL CONDITION] observed. The note contained no documentation regarding pain intervention. · LVN #1's Daily Skilled Notes for [DATE] at 1:48pm and [DATE] at 2:45pm reflected the space to enter pain information in the review of systems was left blank for both entries. Review of Resident #1's Medication Administration Record, admitted [DATE], for dates of [DATE]-[DATE], printed by the facility on [DATE] reflected the order to monitor the resident's level of pain every shift on page 3. The resident experienced level 3 pain for 2 shifts on Saturday [DATE], level 4 pain for 2 shifts on Sunday [DATE], and level 7 pain on the first shift Monday [DATE]. Review of the MAR reflected prior to [DATE] reflected two other entries for pain on [DATE]. The other shifts were coded as 0 for pain level and one shift was blank. The MAR reflected no documentation Resident #1's pain was addressed with pharmacological or non-pharmacological interventions. In an interview with LVN #3 on [DATE] at 12:30pm, she stated she worked the night shift on [DATE] and [DATE]. She stated Resident #1 slept through the night on both shifts. She did not receive report the resident showed pain. In an interview with CNA #3 on [DATE] at 1:43pm, she stated she worked the 6a-2p shift on [DATE]. She stated at approximately 7:15am she entered Resident #1's room to provide incontinent care. He was lying in bed on his right side with his left leg drawn towards his chest. She placed her hands on the left side of his body to roll him onto his back. The resident yelled out, guarded his left leg and did not want to be moved. She reported her observations to LVN #2. In an interview with CNA #4 on [DATE] at 2:13pm, she stated she worked the night shift on [DATE]. She stated 2p-10p staff reported to her the resident had been in bed most of the day, an unusual behavior. The resident slept throughout her shift. She stated the resident was normally active during the night shift. In an interview with CNA #5 on [DATE] at 9:09am, she stated she worked the 2p-10p shift on [DATE]. She stated Resident #1 was in bed when she arrived on duty and spent the rest of the day in bed. He appeared lethargic which was not normal for the resident. She stated Resident #1 normally was alert and active. In an interview with the Director of Rehabilitation on [DATE] at 11:39am, she stated in review of Resident #1's therapy progress notes, the resident received therapy on [DATE] and showed no symptoms of pain. The resident had to engage his hips to participate in the session. She stated she reviewed his progress note for the session. No signs or symptoms of pain were documented in the therapy note. The progress note was electronically signed at 4:30pm by the therapist, but did not specify the time of service. The resident did not normally complain of pain. In an interview with CNA #4 on [DATE] at 11:11am, she stated she worked the 6a-2p shift on [DATE]. She stated the resident yelled out in pain at approximately 7:15am when she touched his legs to position him for incontinent care. The nurse was notified and instructed the CNAs to not move the resident and serve him breakfast in his bedroom. She stated she worked the 10p-6a shift for the first time on [DATE]. The resident slept throughout the shift. She was unaware the resident did not normally sleep throughout the night. In an interview with PTA #1 on [DATE] at 10:46am, she stated on [DATE] at approximately 8:30am, she stated she entered Resident #1's bedroom to take him to therapy. The resident was wearing his sleepwear and lying supine in bed. Normally the resident was out of bed and dressed by that time of morning. Each time she attempted to position the resident for dressing he would return to supine position. His behavior was unusual. She palpated his extremities and checked for range of motion. The resident showed pain only when she palpated the left hip. She reported her concern to LVN #2. LVN #2 notified PTA #1 the nurse practitioner was notified earlier in the morning the resident was in pain and the resident was soon to be transported to the emergency room . In an interview with LVN #2 on [DATE] at 12:43pm she stated she was the charge nurse for the 6a-2p shift on [DATE]. She received report from staff that Resident #1 appeared to have hip pain. She instructed the aides to not move the resident. The resident was lying on his right side with his left leg drawn up when she entered the room to assess him. She stated the resident's hip had range of motion and did not appear red or swollen. She notified the nurse practitioner who gave the order to transfer the resident via ambulance to the emergency room . She stated the resident did not usually exhibit signs of pain and she had not received report of pain from previous shifts. She stated a change of condition was anything different from the resident's baseline. Review of Resident #1's Progress Notes printed by the facility on [DATE] at 12:13pm reflected the document had 1 entry from LVN #2 dated [DATE], timed 10:00am. LVN #2 documented she was notified by the CNAs that the resident indicated pain to the left lower extremity. LVN #2 observed the resident had his leg drawn up and was grimacing. LVN #2 instructed the CNA to assist the resident with breakfast in bed, and she would notify the nurse practitioner. Review of Resident #1's hospital records received by the surveyor from the hospital on [DATE] reflected the resident was seen in the emergency roiagnom on [DATE] at 9:55am with left hip pain and swelling. He was admitted the same day to the hospital's geriatric trauma unit with a left femoral neck fracture. Review of Resident #1's hospital Discharge Documentation printed [DATE] reflected the resident expired on [DATE]. Review of Resident #1's untitled care plan provided by the facility on [DATE], admitted [DATE] reflected the resident had a focus area initiated [DATE] and revised on [DATE] for risk for falls r/t balance/weakness, vision problems, medications and impulsive behaviors secondary to dementia. One intervention was monitor/document/report to MD for s/sx: Pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Review reflected a focus area initiated [DATE] and revised [DATE] for a fall r/t unsteady gait, poor balance, psychoactive drug use, poor communication/comprehension and one intervention was a self-releasing seatbelt for his wheelchair to alert staff when he needed assistance. The plan did not have a focus area for pain. Review of the facility's Policy/Procedure - Nursing Administration revised ,[DATE], Section: Care and Treatment, Subject: Pain Management reflected it was policy to assess and manage resident pain for the purpose of developing and implementing a plan using pharmacologic and/or non-pharmacologic interventions to manage pain and/or try to prevent the pain consistent with the resident's goals.Review of procedures reflected the resident would be assessed for pain upon development of new symptoms of acute or chronic pain that has not been previously assessed. It was noted, Residents who are cognitively impaired may exhibit pain through new or changed behaviors. Step 4 of the assessment procedure was complete appropriate physical assessment to determine any physical changes or manifestations as needed. Review of step 2 of the management procedure reflected Document all finding(s) in Nursing Notesand step 4 included Medication(s) received, refused and response to medication will be documented on the Medication Administration Record (MAR). In an interview with CMA #1 on [DATE] at 11:01am, she stated she worked weekdays, 6a-2p. She stated Resident #1 did not normally complain of pain did not require scheduled pain medications. Review of Resident #1's 9 paged CMA Administration Record for [DATE]-[DATE], printed by the facility on [DATE] reflected the resident did not receive scheduled medications for pain. Review of Resident #1's Medication Review Report, pharmacy order dates [DATE], documented the resident had an order for [REDACTED]. Review reflected the resident did not require a pain medication regimen when readmitted . In an interview with the ADON on [DATE] at 3:06pm she stated LVN #1 reported to her she did not provide Resident #1 with pain relief medication on [DATE] because there was no physician's order. Review of Form CMS-802 Roster/Sample Matrix provided by the facility on [DATE] reflected 16 residents of the 2 secure units were identified by the facility as having communication deficits.

Based on observation, interview, and record review, the facility did not ensure 2 of 8 sampled residents (#3, 7) did not experience avoidable unplanned weight loss. Resident #7 lost 15.75 pounds (11% of body weight) in 2 1/2 months (7/5/11 - 9/28/11) due to the facility failing to implement interventions, monitor the interventions in place and identify the cause of the resident's weight loss. Resident #3 lost an undocumented amount of weight from 8/12/11 to 9/12/11. The facility did not revise resident #7 and #3's care plan to reflect their change in condition. This practice could affect the 26 residents identified by the facility with weight concerns being monitored. The findings include: 1. Review of resident #7's 7/5/11 face sheet revealed [DIAGNOSES REDACTED]. The 7/5/11 Clinical Admission Assessment documented non-[MEDICAL CONDITION] on the right leg. The "describe measurements (weight, circumference) or other [MEDICAL CONDITION] present" section was blank. The height and weight section were blank. The 7/6/11 Nutritional Assessment documented a height of 5 feet 4 inches and a weight of 143 pounds. A nutritional problem identified was "leaves 25% or more of food uneaten at most meals." The nutritional risk indicator evaluation ranked resident #7 as moderate risk. The care planning section documented "Will aim for general weight maintenance." The 8/5/11 11:52 AM progress note documented "significant weight loss from last month ... meal intake varies usually eats either a 50 - 100% at breakfast or lunch, but not both meals. Staff has difficulty waking her to eat at some meals. She is cued for meals ... Recommend begin supplement ..." Review of the non-dated weight sheet provided by the facility on 9/27/11 revealed resident #7's documented 8/11 weight was 133 pounds. The 10 pound loss in one month was 6.9% of her body weight which is categorized as severe. Resident #7's 9/16/11 chemistry profile lab revealed her sodium was 142 mMol/L (normal range 134 - 144). Her blood osmolarity was 279 (normal range 258 - 281). <http://www.MedicineNet.com> Plasma osmolarity: The osmolarity of blood plasma, which is a measure of the hydration status. The plasma osmolarity is sensitive to changes in hydration status. The labs suggest resident #7 was tending to dehydration on 9/16/11. 2. The 7/12/11 MDS was coded to indicate resident #7 required one person extensive physical assistance with the activities of eating. Section K confirmed the admission height of 64 inches and 143 pounds. The 7/14/11 Care Plan documented "Resident will have PO intake 75% of meals and nourishment over the next 90 days." Review of the 8/11 CNA flow sheet for resident #7 revealed the following food consumption: Breakfast blank for 9 meals, 25% for 4 meals, 50% for 10 meals, 75% of 6 meals and 100% for 2 meals. Lunch blank for 5 meals, 25% for 10 meals, 50% for 15 meals and 100% for 1 meal. Dinner blank or zero for 8 meals, 25% for 14 meals, 50% for 4 meals, 75% for 1 meal and 100% for 4 meals. Review of the 9/11 CNA flow sheet for resident #7 revealed the following food consumption: Breakfast blank or less than 25% for 6 meals, 25% for 12 meals, 50% for 8 meals. Lunch blank or less than 25% for 6 meals, 25% for 12 meals, 50% for 8 meals, 75% for 2 meals and 100% for 1 meal. Dinner blank or less than 25% for 8 meals, 25% for 4 meals, 50% for 5 meals, 75% for 8 meal and 100% for 3 meals. 3. Review of resident #7's current record revealed an 8/8/11 physician order [REDACTED]. During this time period resident #7 only lost 1.5 pounds. Review of the resident #7's current flow sheets revealed the supplement was not documented as being provided from 9/1/11 to 9/28/11. During this time period resident #7 lost an additional 4.25 pounds. Resident #7's total loss of 15.75 pounds was 11% of her body weight which is categorized as severe. 4. Interview with LVN #1 on 9/28/11 at 10:22 AM confirmed there was not any documentation for resident #7's supplement because it had been coded to dietary in the computer and those sheets were not printed out. LVN #1 did not know why, whoever checked the physician orders [REDACTED]. 5. Observation on 9/27/11 between 12:00 and 12:45 PM revealed resident #7 ate less than 50% of her meal because she kept rolling away. The nurse aide who was engaged in feeding 2 other residents at the table would tell resident #7 to come eat but was physically unable to bring resident #7 back to the table because she could not leave the 2 residents she was feeding. 6. During an interview with the DON and administrator on 9/28/11 at 5:15 PM, they stated resident #7's weight loss was fluid loss related to 3+ [MEDICAL CONDITION] in the lower extremities. On 9/29/11 at 3:29 PM, the DON confirmed there was not any care plan related to the severe weight loss because the facility did not know how to estimate how much weight would be lost. Resident #7's severe weight loss was considered avoidable because the facility did not establish a weight goal or monitoring process to ensure resident #7's weight changes were planned and consented to by her responsible party. 7. During a confidential interview (A) it was revealed that there was not enough staff to feed the residents. The person stated they had observed staff pick up plates at the end of the meal from residents who had only eaten a few bites of food. 8. On 9/30/11 at 9:27 AM, a family member revealed resident #7's usual weight prior to admission was in the 140's. The family member stated they were concerned with the weight loss experienced by resident #7. 9. Interview with the DON on 9/30/11 at 2:28 PM revealed the facility discussed resident weight concerns every Wednesday. On Wednesday, 9/28/11, the facility discussed 8 residents on the dementia side of the building and 18 residents on the skilled (traditional) side of the building.