Every finding on record at Truman W Smith Children's Care Center

Based on observation, interview, and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 2 of 6 residents reviewed for feeding tube management. (Resident #1 and Resident #2)The facility failed to follow the physician's orders for Resident #1's feeding tube (medical device to deliver nutrition, hydration, and medication directly to the stomach) rate (how fast it was given) of delivery on 3/16/26 and 3/17/26.The facility failed to follow the physician orders for Resident #2's feeding tube duration of administration and total volume (amount) of feeding on 3/17/26.These failures placed residents at risk for vomiting, aspiration (accidental breathing in food, liquid, or foreign material into airway/lungs which increased the risk of pneumonia (lung infection), malnutrition, and weight gain or loss.Findings included:1. Record review of Resident #1's face sheet dated 3/17/26 indicated Resident #1 was an [AGE] year-old male admitted to the facility initially on 6/16/15 and re-admitted on [DATE]. Resident #1 had diagnoses including chronic respiratory failure, gastrostomy (feeding tube placed through the abdomen into the stomach, used to deliver nutrition, fluids, and/or medication), developmental disorder of speech and language, and congenital hydrocephalus (rare, birth-present condition characterized by excess fluid buildup in the brain).Record review of Resident #1's quarterly MDS assessment dated 2/2326 indicated Resident #1 did not complete the BIMS questionnaire due to the resident being rarely or never understood. Resident #1 had unclear speech. Resident #1 was totally dependent on staff for all ADLs. Resident #1 had a feeding tube.Record review of Resident #1's undated care plan indicated Resident #1 required gastrostomy tube related to unable to take anything by mouth with interventions including Resident #1 was total assistance with tube feeding . see MD orders for current feeding orders. Resident #1 had a potential for nutritional problem requiring gastrostomy feedings with interventions including providing and serving diet as ordered.Record review of Resident #1's Order Summary Report dated 3/17/26 indicated he received Pediasure Peptide (nutrition) at 150 ml/hr for a total volume of 240 ml twice daily through his gastrostomy tube, with a start date of 11/25/25.Record review of Resident #1's Enteral (nutrition delivered directly into stomach or small intestine) TAR dated 3/1/26-3/31/26 indicated he was administered Pediasure peptide 150 ml/hr for a total volume of 240 ml twice daily at 9:00 AM and 4:00 PM from 3/01/26 through 3/17/26.Record review of Resident #1's weights indicated he weighed 57.4 pounds on 2/6/26 and 58.1 pounds on 3/6/26 indicating weights were stable.During an observation on 3/17/26 at 2:30 PM, Resident #1 was sitting up in a high back wheelchair watching television in the common area. Resident #1 was alert, awake, and constantly moving his hands and making verbal noises, but was unable to speak. There was a feeding pump attached to a pole on his wheelchair, and it was turned off. The feeding pump tubing was hanging on the pole and was not connected to Resident #1.During an observation and interview on 3/17/26 beginning at 2:45 PM, LVN A said she had worked at the facility for 17 years. LVN A said Resident #1 had returned from school today (3/17/26) and he went to school Tuesday through Friday. LVN A said she set up the feeding pump with the rate of administration and the total volume to be given, and the school should not be changing the settings on the feeding pump. LVN A said the school administered a feeding at 9:00 AM daily when the resident was at school. LVN A said the nurse would administer the 9:00 AM feeding when Resident #1 was not at school and the feeding at 4:00 PM daily. LVN A said Resident #1's feeding pump would still be set on what she had previously set the feeding pump to administer before Resident #1 went to school the morning of 3/17/26. Resident #1 was sitting in the common area watching television. LVN A went to Resident #1 and turned on his feeding pump, and she said the feeding pump was set wrong. LVN A said a staff member made pre-printed labels instead of them having to write on the feeding bags for each resident's feedings. The feeding pump was set at 240 ml/hr and 240 ml had been administered. There was a pre-printed label on the feeding bag that read 240 ml/hr with a total volume of 360 ml. LVN A said she had set the feeding pump for 240 ml/hr with a total volume of 360 ml per the pre-printed label. LVN A said the feeding pump showed Resident #1 received the right volume of 240 ml over an hour. LVN A said if the enteral feeding order was correct at 150 ml/hr with volume of 240 ml total and it was given at 240 ml/hr then Resident #1 received the feeding faster than what the physician ordered. LVN A if a resident received an enteral feeding too fast, it could cause him to throw up. LVN A said it was her second day in Resident #1's section in a while. LVN A said she should have checked her orders and not just gone by the pre-printed label because it did not come from a pharmacy. LVN A said she would have set Resident #1's feeding pump yesterday (3/16/26) to the same setting as printed on the pre-printed label. LVN A said she would have administered Resident #1's enteral feeding 3/16/26 at 9:00 AM and 4:00 PM at the 240 ml/hr with a total volume of 360 ml as printed on the pre-printed label. LVN A said the school would have administered Resident #1's enteral feeding 3/17/26 at 9:00 AM at the 240 ml/hr with a total volume of 360 ml because she had set the feeding pump prior to Resident #1 going to school and the school was not allowed to change the feeding pump settings. LVN A said there was a binder in their medication room with the pre-printed labels in it. LVN A said, The nurse putting the milk in the bag would be responsible for ensuring the labels matched the orders. LVN A said administering a resident an enteral tube feeding faster than the MD's order could cause vomiting or maybe make them poop, and would be the only negative things she could think of.During an interview on 3/17/26 at 3:15 PM, LVN B said she had worked at the facility for about 12 years. LVN B said she checked her MAR against the pre-printed labels to ensure the was correct. LVN B said the MAR was always accurate with any changes, where the pre-printed label was not. LVN B said if a resident was ordered enteral feedings at 150 ml/hr and it was given at 240 ml/hr, it could cause the resident abdominal discomfort and could cause them to vomit (throw up).2. Record review of Resident #2's face sheet dated 3/17/26 indicated Resident #2 was a [AGE] year-old female and admitted to the facility initially on 6/08/21 and readmitted on [DATE]. Resident #2 had diagnoses including spastic quadriplegic cerebral palsy (damage to the brain usually occurring before, during or shortly after birth), gastrostomy, protein-calorie malnutrition (lack of protein and energy to meet nutritional needs), feeding difficulties, dependent on a ventilator (machine that breathes for resident), and dysphagia (difficulty swallowing).Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2 did not complete the BIMS questionnaire due to the resident being rarely or never understood. Resident #2 had no speech. Resident #2 was totally dependent on staff for all ADLs. Resident #2 had a feeding tube.Record review of Resident #2's undated care plan indicated Resident #2 gastrostomy tube related to unable to take anything by mouth with interventions including Resident #1 was dependent with tube feeding . see MD orders for current feeding orders. Resident #2 had a potential for nutritional problem requiring gastrostomy feedings with interventions including providing and serving diet as ordered.Record review of Resident #2's Order Summary Report dated 3/17/26 indicated her Enteral Feed Order was Compleat Pediatric Reduced Calorie at 68 ml/hr by gastrostomy tube for 18 hours with a total volume of 1174 ml administered with a start date of 3/04/26.Record review of Resident #2's Enteral TAR dated 3/1/26-3/31/26 indicated she was administered Compleat Pediatric Reduced Calorie at 68 ml/hr for 18 hours for a total volume of 1174 ml daily at 9:00 AM from 3/04/26 through 3/17/26 with a start date of 3/04/26.Record review of Resident #2's weights indicated she weighed 73.2 pounds on 2/6/26 and 72.9 pounds on 3/6/26 indicating there was no significant weight loss.During an observation and interview on 3/17/26 beginning at 4:17 PM, LVN C said she had worked at the facility since December 2025. LVN C accompanied the surveyor into Resident #2's room. Resident #2 was lying in bed with the head of bed elevated and her feeding pump was infusing into her gastrostomy tube at 68 ml/hr for 17 hours. The printed label on the feeding bag read 68 ml/hr for 17 hours with a total volume of 1156 ml and had a handwritten date of 3/17 with a time of 6:00 AM and initials of RN D. LVN C said Resident #2 was not her resident that day (3/17/26) and she would have to check to see what her feeding was ordered at. LVN C went to the nurse's station briefly and returned and stated Resident #2's order was for 68ml/hr for 18 hours, but the total volume was wrong on the order. LVN C the order had a total volume of 1174 ml, but it should had been a total volume of 1224 ml. LVN C said the duration of the feeding and the total volume was incorrect. LVN C said they had pre-printed labels made by the nurses, but they should check the label with the orders to make sure the order had not changed. LVN C said Resident #2 would not have received 68 ml of her feeding with the feeding pump set to deliver 68 ml/hr over 17 hours instead of the ordered 18 hours. LVN C said if the feeding pump had been set to deliver 68 ml/hr over 18 hours and the total volume was entered as the order read 1174 ml, Resident #2 would not have received 50 ml of nutrition. LVN C said the nurse who transcribed the order did not figure the total volume correctly and it should have read 1224 ml. LVN C said if the resident was not receiving the correct feeding dose as ordered, it could affect the resident's nutrition and output. LVN C said if a tube feeding was given faster than it was ordered, it could cause the resident to have nausea and vomiting.During an interview 3/17/26 at 4:30 PM, RN D said she had worked at the facility for a little over a year. RN D said she did not work yesterday (3/16/26) but was scheduled for today (3/17/26) and tomorrow (3/18/26). RN D said she set up Resident #2's feeding the morning of 3/17/26. RN D said the night shift nurse set up their feeding bags with the pre-printed labels already on the feeding bag for them to use on day shift. RN D said she set up the feeding pump to whatever was on the label. RN D said sometimes the feeding orders did change and would have to look at the MAR. RN D said they knew when changes occurred based on what was written on the Kardex (centralized, quick-reference tool) where they sit at the nurse's station. RN D said they would also tell them in report if something changed. RN D said there were new orders written on the Kardex, but the pre-printed label was not updated, but she was not sure what happened, but that was what she was guessing if there was a new order and the label was not correct. RN D said the nurse was responsible for ensuring what she was administering was what was ordered. RN D said Resident #2 could get less feeding than what was ordered and then she could possibly lose weight. RN D said the nurse should be following the MD orders at all times to provide the best outcome for the resident.During an interview on 3/17/26 at 4:40 PM, ADON E said she was the ADON for the [NAME] wing. ADON E said she had worked at the facility for about 30 years. ADON E said they made their feeding bags up every 24 hours. ADON E said Resident #2 had gone to a doctor's visit and came back with a new order to increase her feedings to 18 hours and the nurse did not put the total volume in correctly. ADON E said the nurse who received the new order, would have also put it on the Kardex. ADON E said if Resident #2 did not receive 68 ml/hr for a total of 18 hours it could have cheated her out of 68 ml daily. ADON E said if the total volume was not correct, Resident #2 still would have missed calories. ADON E said the nurses should still be checking the pre-printed labels against the Enteral MAR/orders. ADON E said she checked Resident #2's weights and she had not lost weight, and they had corrected the order to read total volume of 1224 ml. ADON E said the staff should be following the physician orders and not the pre-printed label. ADON E said it was the law to follow the MD ordersorders, and it was for the benefit of the resident.During an interview on 3/17/26 at 4:53 PM, the DON said Resident #1's feeding rate was incorrect, and the feeding was given too fast, but the total volume was correct. The DON said administering the feeding too fast could make the resident feel sick to his stomach. The DON said it could cause nausea and vomiting. The DON said it was important to check the orders to ensure the orders had not changed. The DON said new orders were supposed to be put on the 24-hour report also. The DON said she was not sure how that got messed up with Resident #2's label not being updated when there was a new order put in for her feedings. The DON said Resident #2 could lose weight if she was not receiving the prescribed amount of feeding/calories. The DON said she believed if Resident #2's feeding rate was correct, and the total volume was incorrect then Resident #2 would not have gotten the correct amount of feeding and could affect her nutritional status. The DON said she had her ADONs currently doing a full sweep and checking the feeding orders and pumps as we spoke. The DON said she was not sure where the breakdown was, but she would get it corrected. The DON said they had a meeting every Monday with the NP, RD, and ADONs at 12:15 PM to address any issues with feedings, weight loss, weight gains, possible feeding changes, etc. The DON said the RD came on Saturdays or Sundays and she (DON) received the report on Mondays. The DON said she verified the RD recommendations/orders were inputted in the software correctly, but she did not check the feeding pumps to ensure the staff were setting them correctly. The DON said the ADONs ran their [NAME], but you can bet I will now. During an interview on 3/17/26 at 5:23 PM, ADON F said she was the ADON for the East wing. ADON F said she had worked at the facility for 21 years. ADON F said Resident #1's feeding pump was set at a rate of 240 ml/hr with total volume of 240 ml. ADON F said Resident #1's rate of infusion was wrong. ADON F said if Resident #1 was getting his feeding at 240 ml/hr instead of the 150 ml/hr as ordered, it could cause Resident #1 to have gastro-intestinal (stomach) disturbance, such as reflux (when stomach contents come up into the throat) or vomiting (throwing up). ADON F said the pre-printed label on Resident #1's bag was incorrect, but the staff should be going by the Enteral orders. ADON F said it was important to follow MD orders to ensure the residents got what they were supposed to receive.During an interview 3/17/26 at 5:27 PM, the ADM said they had already done an Ad Hoc (urgent, to solve an issue) Quality Assurance meeting and had addressed the issue with the feedings. The ADM said it was her expectation of her staff to follow MD orders because the MD knew what was best for the resident.Record review of a facility's Enteral Nutrition policy reviewed on 3/03/26 indicated . Adequate nutritional support through enteral nutrition was provided to residents as ordered . 4. Enteral nutrition was ordered by the provider based on the recommendations of the dietician . 7. The dietician monitored residents who were receiving enteral nutrition and made appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings . 11. The Nurse confirmed that orders for enteral nutrition were complete. Complete orders included: the enteral product . volume and rate of administration . Staff caring for residents with feeding tubes were trained on how to recognize and report complications related to the administration of enteral nutrition products, such as nausea, vomiting, diarrhea and abdominal cramping, inadequate nutrition, . aspiration (food/drink inhaled into lungs) .

Based on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 24 residents (Resident #63) reviewed for resident rights. The facility failed to ensure RT C acknowledged Resident #63 while providing care on 11/16/25. This failure could place residents at an increased risk of anxiety and a diminished quality of life.The findings included: Record review of the order summary report, dated 11/18/25, reflected Resident #63 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of obstructive hydrocephalus (buildup of fluid in cavities called ventricles deep within the brain, which increases the size of the ventricles and puts pressure on the brain), neuromuscular scoliosis (sideways curvature of the spine), chronic respiratory failure with hypoxia (condition where you don't have enough oxygen in the tissues in your body), anoxic brain injury (damage to the brain due to a loss of oxygen supply), spastic quadriplegic cerebral palsy (brain condition caused by damage or abnormal development of the brain before, during, or shortly after birth, which causes tight stiff muscles to all four limbs [arms and legs]), and obstructive sleep apnea (characterized by repeated interruptions in breathing during sleep due to a blockage in the airway). Record review of the annual MDS assessment, dated 10/20/25, reflected Resident #63 had no speech, was rarely/never understood, and was rarely/never to understand others. Resident #63 had poor long and short-term memory, no recall ability and had severely impaired decision making skills. The MDS reflected Resident #63 had no behavior or refusal of care and he liked to participate in his favorite activities. Resident #63 was totally dependent on staff for his ADLs. Record review of the comprehensive care plan, initiated on 11/13/23, reflected Resident #63 required total assist from the staff for meeting emotional, intellectual, physical, and social needs. The interventions included: all staff converse with resident while providing care. Record review of the comprehensive care plan, revised on 12/11/24, reflected Resident #63 had a tracheostomy. The interventions included: provide means of communication and procedural information, reassure that help is available immediately, provide paper and pencil if needed, work with resident to develop a communication system that will work in an emergency, and reassure resident to decrease anxiety. During an observation on 11/16/25 beginning at 10:46 AM, Resident #63's oxygen and heart rate monitor started beeping while a respiratory therapist was in the room with his roommate. The respiratory therapist yelled from the doorway for RT C's assistance. RT C entered the doorway and was looking at Resident #63's machine while she was putting on her isolation gown and gloves. RT C immediately walked to Resident #63's bed, swiftly lifted him up, shoved a pillow under his back, then laid him back down. RT C then proceeded to provide tracheal suctioning. RT C completed the tracheal suctioning, then rolled the suctioning tubing, placed it under Resident #63's pillow. Resident #63's oxygen and heart rate monitor returned to normal. RT C removed her PPE, left the room, then returned with a new pulse oximeter that attached to Resident #63 and replaced it. RT C did not speak or explain the care she was providing to Resident #63 during the observation. During an interview on 11/18/25 beginning at 9:48 AM, RT C interrupted an interview with the Respiratory Director. RT C stated generally upon going into a patient's room, the staff should knock, introduce themselves, and then explain the care that was going to be provided. RT C stated in an emergency situation, she did not always think about explaining what she was doing or talking to the resident. RT C explained Resident #63 was desaturating [his oxygen level was decreasing] and his pulse rate was elevated. RT C stated he was unable to cough so she had to perform the tracheal suctioning. RT C stated immediate action was needed to intervene and she said she just did not think about talking to him while providing care. During an interview on 11/18/25 at 10:23 AM, the DON stated facility staff should have knocked, introduced themselves, and talked to the residents while providing care. The DON stated talking to the residents while providing care was hard for the staff to remember because a lot of the kids were not able to respond back. The DON stated in-service education was provided regularly to the staff, specifically on dignity and making sure the staff was talking to the residents while providing care. She said it was important to ensure the staff were talking to the residents while providing care because it helped put them at ease. During an interview on 11/18/25 at 1:32 PM, the Administrator stated she expected staff to always acknowledge the residents while providing care. The Administrator stated she had not identified any issues with staff failing to acknowledge the residents' while providing care and did not have a system for monitoring. The Administrator stated it was important to ensure staff were acknowledging and talking to the residents while providing care to maintain dignity. During an interview on 11/18/25 at 2:18 PM, the Administrator stated she had gathered more evidence regarding Resident #63. The Administrator stated both Resident #63 and his roommate were crashing at the same time. The Administrator stated Resident #63 was relatively stable as he had an established airway, so RT C was trying to provide care quickly to help the other respiratory therapist with Resident #63's roommate. The Administrator stated RT C still should have communicated with Resident #63 while providing care, but it was more understandable why RT C did not provide Resident #63 with communication while she was providing care. Record review of the Resident Rights policy, revised 04/2017, reflected .Facility policies and procedures must be in compliance with these rights. Residents shall: . be treated as individuals in a manner that supports their dignity. The policy did not address communicating with the residents during care.

Based on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 11 residents (Resident #18) reviewed for enteral nutrition. The facility failed to ensure Resident #18's head of the bed was elevated while receiving a tube feeding (delivers liquid nutrition through a flexible tube that goes directly into your stomach or small intestine) on 11/16/25. This failure could place residents with gastrostomy tube at risk for complications from feeding tube administration such as aspiration and pneumonia. The findings included: Record review of order summary report, dated 11/17/25, reflected Resident #18 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and gastrostomy status (surgical procedure that creates an artificial opening through the stomach wall and abdominal wall, allowing for the insertion of a gastrostomy tube that provides a conduit between the stomach and the outside of the body). The order summary report further reflected Resident #18 had an order, which started on 06/26/23, to elevate the head of the bed to 30 degrees every shift. Record review of the quarterly MDS assessment, dated 10/08/25, reflected Resident #18 had no speech and was rarely/never understood by others. Resident #18 had poor short and long-term memory, no recall ability, and severely impaired decision-making skills. He had no behaviors or refusal of care. The MDS reflected Resident #18 had a feeding tube and received 51 % or more of total calories through the feeding tube. Record review of the comprehensive care plan, revised 10/13/23, reflected Resident #18 required tube feeding. The interventions included: Resident #18 needed the head of the bed elevated 45 degrees during and thirty minutes after tube feeding. Record review of Resident #18's MAR, dated November 2025, reflected the nurses were signing off and checking Resident #18's head of the bed was elevated to 30 degrees every shift, including 11/16/25 for day and evening shift. During an observation on 11/16/25 at 10:27 AM, Resident #18 was lying flat on his mattress that was positioned on the floor. There were no wedges to lift the head of the bed observed under the mattress. He had a tube feeding that was going at 100 milliliters per hour from kangaroo pump. During an interview on 11/18/25 at 9:28 AM, RN D stated she had worked at the facility for 6 years. She stated residents who received feedings from a feeding tube should have the head of the bed, elevated at least 35 degrees. RN D stated elevating the head of the bed at least 35 degrees was the standard general rule unless the residents had issues where the head of the bed was unable to be elevated. RN D stated none of the residents on her side had issues that would prevent the head of the bed from being elevated. She stated if residents' mattresses were on the ground, the staff used wedge pillows under the bed to keep the head of the bed elevated. RN D stated Resident #18 would have kept the head of the elevated and did not move around much. She stated she was unsure why Resident #18 did not have the wedges under his mattress. RN D stated it was important to ensure the head of the bed was elevated while the residents received tube feedings to prevent aspiration. During an interview on 11/18/25 at 10:23 AM, the DON stated the head of the bed should have been elevated while residents received tube feedings. She stated the nurses were responsible for ensuring the head of the bed was elevated. The DON stated residents with mattresses on the ground should have wedges under the mattress to ensure the head of the bed was elevated. She stated she was unaware Resident #18 had no wedges under his mattress. The DON said she expected the staff to ensure wedges were utilized. The DON stated she did not know what the facility policy was on positioning residents during feeding, but she looked it up. She said the policy did not specifically address how residents with a feeding tube should have been positioned. The DON stated that residents who received tube feedings should not have been laid flat because it placed them at risk for aspiration. During an interview on 11/18/25 at 1:32 PM, the Administrator stated she expected staff to ensure the head of the bed was elevated while residents received tube feedings. The Administrator stated that any clinical staff were responsible for monitoring to ensure the head of the bed was elevated. The Administrator stated it was important to ensure the head of the bed remained elevated while residents received tube feedings to prevent aspiration. Record review of the Enteral Nutrition policy, reviewed 06/25/25, reflected Adequate nutritional support through enteral nutrition is provided to residents as ordered. The recommendation to initiate the use of enteral nutrition is based on the results of the comprehensive nutritional assessment, and is consistent with current standards of practice. the provider will consider the need for supplemental orders, included: .head of bed elevation.Risk of aspiration may be affected by: . improper positioning of the resident during feeding. Record review of the Guidelines for Preventing Health-Care-Associated Pneumonia, 2003, accessed from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5303a1.htm reflected 2. Prevention of aspiration associated with enteral feeding a. In the absence of medical contraindication(s), elevate at an angle of 30 - 45 degrees of the head of the bed of a patient at high risk for aspiration (e.g. a person receiving mechanically assisted ventilation and/or who has an enteral tube in place) .

Based on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 laundry room reviewed for environment. The facility failed to ensure the air filters in the laundry room were clean, the air filters were dirty with a thick dark gray substance. This failure could place the residents at risk of living and working in an unsafe, unsanitary and uncomfortable environment. Findings included: During an observation and interview on 11/17/25 at 2:24 P.M., the laundry room had dirty air filters on the ceiling on the dirty and clean side of laundry room. The air filters had a thick dark gray substance on them. Laundry Aide B said the facility kept the air filters clean. She said the air filters were usually changed once a week. She said the maintenance man usually changed the air filters; she said she thought he changed the air filters last Thursday. She said the air filters got dirty, because the staff opened and closed the doors all the time and the area she worked in had a lot of lint. During an interview on 11/18/25 at 12:34 P.M., with Laundry Aide B, said Maintenance Man A came once a week, brought a new air filter and pulled the old air filter down, then put a new air filter in vent. She said that Maintenance Man A changed the air filters yesterday. She said she thought Maintenance Man A was responsible for changing the air filters as far as she knew. She said a negative effect of the dirty air filters would be improper air flow throughout the building. During an interview on 11/18/25 at 12:43 P.M., Maintenance Man A said the air filters were changed in the laundry room every Thursday; unless the staff told him the air filters were getting clogged, then he would change them as needed. He said he changed the air filters by taking the dirty air filter down and cut the material off the roll to fit the bracket, then slid the filter back into place. He said he was the primary person responsible for changing the air filters. He said a negative effect of the dirty air filters was if they got too dirty or clogged it would cause the air conditioning unit to freeze. During an interview on 11/18/25 at 12:51 P.M., with the DON she said she does not know how often the air filters were changed in the laundry room. She said the air filters in the laundry room looked like they needed to be changed. She said she does not know the process of changing the air filters in the laundry room. She said her guess was the maintenance man or housekeeping were responsible for changing the air filters. She said a negative effect of the dirty air filters was it would make everything in the laundry room dusty. During an interview on 11/18/25 at 2:30 P.M., with the Administrator she said due to the amount of laundry the facility had to do there the air filters may look like they had not been changed in a while or not within a reasonable timeframe, because the amount of lint that was on the air filters. She said the air filters were changed once a week. She said she had not observed the air filters changed in the laundry room. She said Maintenance Man A was responsible for changing the air filters in the laundry room and throughout the facility, but the laundry aides or anyone should notify Maintenance Man A if the air filters were dirty. She said a negative effect of a dirty air filter had potential for clogging the air conditioner unit. Record review of Homelike Environment Policy dated February 2021 provided by the Administrator indicated: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .2.The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized homelike setting . a. Clean, sanitary and orderly environment. e. clean bed and bath linens that are in good conditions.

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 food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the freezers, and dry pantry were not kept past their expiration dates and did not contain employee personal items. These failures could place residents at risk of foodborne illness and food contamination. Findings included: During an observation of the freezer on [DATE] at 9:20 AM, the following items were observed: (1) 32-ounce bag of frozen hashbrowns that was opened with approximately ,d+[DATE] of the bag remaining, wrapped in a plastic shopping bag with no label or date opened. During an observation of the dry pantry on [DATE] at 9:20 AM, the following items were observed: (1) Gallon container of distilled white vinegar that was approximately half full with an open date of [DATE] and an expiration date of [DATE]. During an observation and interview on [DATE] at 9:20 AM, the [NAME] said the open bag of hashbrowns in the refrigerator was her personal food. She took the bag out of the freezer and disposed of them. She said she should not have put them in the refrigerator, and she took responsibility for them. She said she knew she was not supposed to put personal food items in the refrigerators. She said she was supposed to keep personal food items in the employee refrigerator. During an interview on [DATE] at 9:15 AM, the Dietary Aide said the cooks were supposed to check the walk-in refrigerators and freezers for expired foods and the dietary aides were supposed to check the dry pantry area for expired foods on Wednesdays. She said she last checked the dry pantry area last week on Wednesday, but she was very busy that day and did not make it to the top shelf where the vinegar was, so she just missed it. She said the resident could get sick by a food borne illness by consuming expired foods. During an interview on [DATE] at 1:12 PM, the DM said that there was a cleaning schedule for both the cooks and the dietary aides. She said the cooks were responsible for checking the walk-in refrigerators and freezers for expired foods on Fridays of every week. She said the dietary aides were responsible for checking the dry pantry area on Wednesdays for expired foods. She said it was her responsibility to check behind them to make sure everyone is performing their job functions. She said the residents could get sick by a food borne illness by consuming expired foods. During an interview on [DATE] at 1:23 PM, the [NAME] said she was responsible for checking the refrigerators and walk in for expired food. She said the Dietary Aide was responsible for checking the dry pantry for expired foods. She said the DM was responsible for making sure that all the kitchen employees did their jobs. She said it could cause the residents to get sick by a food borne illness by consuming expired foods. During an interview on [DATE] at 2:25 PM, the Administrator said all foods should be used or disposed of by the use by date. She said food borne illness was a potential risk to the resident for consuming expired foods. Record review of facility policy titled Dry Storage dated [DATE], indicated: 5. All expired foods must be removed from the store room . Record review of facility policy titled Food Storage dated [DATE], indicated: Safe and sanitary conditions shall be maintained in storage, preparation, and distribution of food.Staff shall not store personal items within the food preparation and storage areas .

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 2 residents observed for incontinent care infection control practices (Resident #79), and 3 of 3 residents observed for medication administration control practices. (Resident #'s 27, 91, 71). 1.CNA A did not change her gloves or sanitize her hands after performing incontinent care on the front perineal area for Resident #79 and touched clean areas. 2. The facility failed to ensure RN G performed hand hygiene before and after administering medications to 3 different residents. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1.Record review of the undated face sheet indicated Resident #79 was a [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 1/14/25 indicated Resident #79 had diagnoses that included: Seizures (uncontrolled jerking, blank stares, loss of consciousness caused by abnormal electrical activity in the brain), failure to thrive (not growing as expected), Cerebral Palsy (a congenital disorder of movement, muscle tone, or posture due to abnormal brain development before birth), and gastrostomy (tube inserted into the abdomen and stomach to provide a route for feeding). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #79 had no speech, rarely or never understood others, and was rarely or never understood by others. She had short- and long-term memory problems. The MDS indicated Resident #79 was dependent for toileting hygiene. Record review of the undated care plan indicated Resident #79 was totally dependent on one staff for incontinent care due to Cerebral Palsy. The care plan indicated she had impaired cognitive function and required tube feeding. During an observation on 1/14/25 at 9:06 AM, revealed CNA A and CNA B provided incontinent care to Resident #79. They sanitized their hands and donned (put on) PPE for EBP. CNA A cleaned Resident #79's front perineal area and did not change her gloves or sanitize her hands before rolling the resident to her side and touching Resident #79's shoulder, bed pad, and bed. She then cleaned the resident's back side before changing her gloves and sanitizing her hands. During an interview on 1/14/25 09:17 AM, CNA A said she was nervous and forgot to change her gloves after cleaning Resident #79's front before cleaning her backside. She said she did not realize she touched the resident's shoulder, bed, and bed pad with her dirty gloves. She said that could cause cross-contamination and spread infection. She said she was taught to always change her gloves and wash her hands after a dirty procedure and she should have changed them. During an interview on 1/14/25 at 9:18 AM, CNA B said she did not realize CNA A had not changed her gloves after cleaning Resident #79's front area, before going to her backside. She said they were taught to change their gloves and clean their hands when going from a dirty procedure to a clean area. She said CNA A should have changed her gloves. During an interview on 1/14/25 at 9:49 AM, LVN F said she was the Staff Coordinator/Trainer and she signed off that CNA A and CNA B had met the requirements for Pericare-Incontinent Care. She said they were taught to change gloves when going from dirty to clean. She said after CNA A cleaned Resident #79's front area, she should have changed her gloves and cleaned her hands before she cleaned her back side and before touching anything clean. She said not doing that was a risk of infection to staff and the residents, that could make staff and resident's sick. She said she would be reteaching both CNAs. During an interview on 1/14/25 10:32 AM, CNA C said during incontinent care, he always changed his gloves and cleaned his hands when going from dirty to clean. He said after cleaning a resident's front part staff would need to clean their hands and change their gloves because their gloves would be dirty. He said not changing gloves from a dirty procedure to a clean one could cause infections to staff and residents. During an interview on 1/14/25 at 1:28 PM, LVN D said staff should always change their gloves and clean their hands when going from dirty to clean. She said during incontinent care, after cleaning the front of a resident, staff should change their gloves and clean their hands before touching anything clean including the resident. She said if they did not change their gloves, it was a cross-contamination issue that could cause infection to residents and staff. During an interview on 1/14/25 at 1:31 PM, ADON E said staff must always change their gloves and clean their hands when they go from dirty to clean. She said during incontinent care staff should change their gloves and clean their hands after cleaning the front perineal area and before going to the back because their gloves would be dirty. She said if staff touched clean areas with dirty gloves that was cross -contamination which could cause infection to residents and staff. During an interview 01/14/25 2:19 PM, the DON said staff should always change their gloves and sanitize their hands when going from dirty to clean. She said when staff were performing incontinent care they should change their gloves and clean their hands after cleaning the front perineal area and before touching anything clean, or going to the back area. She said if they did not change their gloves or clean their hands, they were risking cross-contamination and infections to residents and staff. During an interview on 1/14/25 at 2:48 PM, the ADM said staff should change their gloves anytime they were moving from dirty to clean. She said during incontinent care staff should change their gloves after cleaning the front perineal area and before touching anything clean. She said touching anything clean with dirty gloves was cross-contamination and had the potential to cause infection to residents and staff. Record review of a Pericare-Incontinent Care competency dated 10/2/24 indicated CNA A had met the requirements. The competency was signed by evaluator, LVN F. Record review of a Pericare-Incontinent Care competency dated 10/2/24 indicated CNA B had met the requirements. The competency was signed by evaluator, LVN F. Record review of a Perineal Care Policy with a revised date of 4/16/24indicated: Perineal Care Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 2. Record review of Resident #27's face sheet, dated 01/14/25, indicated she was a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included dependence on respiratory (ventilator) status (breathing machine), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), Chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs cannot exchange oxygen and carbon dioxide properly), personal history of pneumonia (a medical record that indicates a person has had pneumonia in the past) and gastrostomy status (the presence of a surgical opening in the abdomen that allows for nutritional support or gastric decompression). Record review of Resident #27's quarterly MDS assessment, dated 12/26/24, indicated she did not perform a BIMS assessment (a 15-point cognitive screening measure that evaluates memory and orientation and includes free and recall items), because she was rarely/never understood and rarely/never understood others. Record review of Resident #27's care plan, dated 01/13/25, indicated eating and nutrition the resident needs total assistance with tube feeding and water flushes, see MD orders for current feeding orders. Check for tube placement and gastric contents/residual volume per facility protocol and record. The resident is totally dependent on one staff for nutrition via G-Tube. The resident is dependent with tube feeding and water flushes, see MD orders for current feeding orders. Interventions: review infection control techniques with resident such as frequent handwashing and use of hand sanitizer. Remind the resident and caregivers to refrain from physical contact. For example, practice social distances with no handshaking or hugging and remaining six feet apart when possible. 3. Record review of Resident #71's face sheet, dated 01/14/25, indicated she was a [AGE] year-old female was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pseudomonas (is a [NAME] of bacteria commonly found in wet environments like soil and water), acute respiratory distress (condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen) and cystic fibrosis (an inherited life-threatening disorder that damages the lungs and digestive system). Record review of Resident #71's quarterly MDS assessment, dated 10/17/24, indicated she did not perform a BIMS assessment, because she was rarely/never understood and rarely/never understood others. Record review of Resident #71's care plan, dated 04/17/24, indicated provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection. 4. Record review of Resident #91's face sheet, dated 01/14/25, indicated he was a [AGE] year-old male was admitted to the facility on [DATE]. His diagnoses included chronic respiratory failure (a long-term condition that makes it difficult to breathe because the lungs cannot exchange oxygen and carbon dioxide properly), pseudomonas (is a [NAME] of bacteria commonly found in wet environments like soil and water) and encounter for attention to tracheostomy (a medical appointment specifically focused on managing and caring for a patient's tracheostomy). Record review of Resident #91's quarterly MDS assessment, dated 12/25/24, indicated he did not perform a BIMS assessment, because he was rarely/never understood and rarely/never understood others. Record review of Resident #91's care plan, dated 04/17/24, indicated his level of staff assistance during care during transfer assistance and feeding assistance. Interventions enhanced barrier precautions (EBP). Follow facility fall protocol. Seizure precautions: Do not leave residential one during a seizure, protect from injury, if resident is out of bed, help to the floor to prevent injury, remove or loosen tight clothing, do not attempt to restrain resident during a seizure as this could make the convulsions more. During an observation on 01/13/25 at 7:29 A.M., revealed RN G did not wash or sanitize her hands before preparing medication for Resident #71. RN G did not wash or sanitizer her hands prior to administering Resident #71's meds and administered Resident #71's G-Tube feeding and did not wash or sanitizer hers hands afterwards. During an observation on 01/13/25 at 7:49 A.M. revealed RN G did not wash or sanitize her hands before preparing medication for Resident #27. RN G did not wash or sanitizer her hands prior to administering Resident #27's meds and did not wash or sanitizer hers hands afterwards. During an observation on 01/13/25 at 8:04 A.M. revealed RN G did not wash or sanitize her hands before preparing medication for Resident #91. RN G did not wash or sanitizer her hands prior to administering Resident #91's eyedrops. During an interview on 01/13/25 at 8:06 A.M., RN G said it was normally a habit for her to wash or sanitize her hands during med pass and between residents. She said she was nervous, so she forgot to sanitize her hands. She said staff should sanitize their hands between residents unless their hands were soiled, then they should wash their hands with soap and water. She said she should have sanitized her hands before giving meds and after she gave the meds to reduce the spread of infection rate. During an interview on 01/13/25 at 10:43 A.M., LVN M said before a nurse started giving a medication, they should wash their hands. She said the nurse should wash their hands before and after administering meds. She said nurses' hands played a part to the chain of infection. She said not washing her hands could had made her and the residents more susceptible to infections. During an interview on 01/14/25 at 9:00 A.M., LVN I said nurses should be washing their hands before and after a med pass to prevent cross contamination. During an interview on 01/14/25 at 9:46 A.M., RN J said when a nurse administered medications, they should wash their hands before and after giving the medications. She said hand hygiene between residents should be performed. She said hand hygiene was the number one infection control prevention. During an interview on 1/14/25 at 12:48 P.M., RN N said when a nurse administered meds they should wash their hands before a med pass, after the mad pass and before going to another resident. She said it was infection control and they could carry infections to another resident with their hands. She said nurses should always start fresh by washing their hands. During an interview on 1/14/25 at 1:15 P.M., the DON said during med pass she expected the nurses to wash their hands. She said handwashing was for infection control measures. She said the nurses should wash their hands during med pass and between each resident. She said a negative effect of improper hand hygiene was the spread of infection. During an interview on 1/14/25 at 3:17 P.M., the ADM said she excepted the nurses to wash their hands during med pass and between residents. She said a negative effect of improper hand hygiene was the risk of infection. Record review of RN G Nurses: GT Med/Feeding administration check-off sheet dated 12/2/24 indicated RN G had met the requirements. The competency was signed by evaluator, RN N. Record review of the facility's Handwashing/ Hand Hygiene Residents policy, last revised 1/25/23, indicated: this facility considers hand hygiene the primary means to prevent the spread of infections . 2. Residents may be trained and encouraged on the importance of hand hygiene in preventing the transmission of infections . 4. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, wipes etc.) shall be readily accessible and convenient for resident use to encourage compliance with hand hygiene policies . Record review of the facility's Infection Prevention and Control Program policy. Last revised 01/01/24, indicated: an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable disease and infection. 48958

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 23 residents reviewed for environment. (Resident #48) 1. The facility failed to remove a green sputum filled suction canister over 3/4 full in the room of Resident #48 a timely manner. This failure placed resident at risk of exposure to growing bacteria from another resident, living in an uncomfortable environment and a decrease in quality of life and self-worth. Findings included: 1. Record review of the face sheet 01/14/25 indicated Resident #48 was a [AGE] years old male and was admitted on [DATE] with diagnoses including disease of upper respiratory tract ( a common viral infection that affects the nose, throat and airways), major depressive disorder (a mental illness that causes a persistent low mood and loss of interest in activities) and other specified disorders of white blood cells (a category of blood conditions that affect white blood cell function). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #48 was usually understood and usually understood others. The MDS indicated a BIMS score of 14 indicating Resident #48's cognition was intact. The MDS indicated Resident #48 was dependent on staff for ADL's. During an observation on 01/12/25 at 10:04 A.M., near bed A on entrance of room revealed a suction canister filled with a green sputum substance dated 1/3/25. Further observations revealed on 01/13/25 at 8:14 A.M., near bed A at the entrance of the room was a suction canister filled with a green sputum substance dated 1/3/25. On 01/13/25 at 10:24 A.M., near bed A at the entrance of the room was a suction canister filled with a green sputum substance dated 1/3/25. On 01/14/25 at 8:43 A.M., near bed A at the entrance of the room was a suction canister filled with a green sputum substance dated 1/3/25. During observation and interview on 01/12/25 at 12:06 P.M., revealed Resident #48 returned to the facility via ambulance on droplet precautions due mycoplasma pneumonia (bacteria cause respiratory tract infections) stated by LVN I. During an interview on 01/12/25 at 2:03 P.M., Resident #48 said he did not notice the sputum in suction container at the entrance of the room. During an interview on 01/14/25 at 9:00 A.M., LVN I said respiratory staff was responsible for removing and replacing the dirty suction canisters. She said the canister belonged to a discharged Resident #69 that went to the hospital. She said the suction canister in Resident #48's room looked nasty. She said she thought the canister should have been removed when the previous resident went to the hospital. She said the resident had been gone for 6 days and it looked nasty. LVN I clarified the previous resident was admitted to the hospital on 1/8/25. During an interview on 01/14/25 at 9:05 A.M., LVN H said respiratory staff was responsible for removing and replacing the suction canisters by putting them in a biohazard bag and placing them in the biohazard room and as needed, but since it had been several days since the Resident #69 was admitted to the hospital the suction canister should have been removed. She said she was not sure on the number of days the canister was to be removed after a resident had left. She said but if a resident was in the room, when the canister got up to 1100ml they were supposed to remove the canister. She said some of the negative effects of the canister in the room was it was nasty to look at and it could have a potential to grow mold. During an interview on 01/14/25 at 9:46 A.M., RN J said respiratory staff was responsible for ensuring that the suction canisters were changed when they were dirty. She said she felt like if a resident was sent to the hospital and admitted the canister should have been removed. She said the suction canister could start to stink and grow bacteria since the resident had been gone for 6 days. She said the suction canister with green sputum was not nice to look at. During an interview on 01/14/25 at 9:55 A.M., RT K said respiratory staff were responsible for making sure suction canisters were changed out. He said normally they changed the suction canisters out when they were 3/4's full, 1200ml or at least once a month. He said the suction canister could grow mold in it. He said it was nasty to look at and it would not have been a bad idea to have removed the canister. He said he would not like to look at the green sputum filled canister in his home if it was not in use. During an interview on 1/14/25 at 12:48 P.M., RN N said respiratory staff were responsible for changing out the suction canisters. She said she thought the canister should have been changed and removed. She said she felt like when the resident came back to the facility the canister would have been changed. She said there was bacteria in secretions, and they were growing and sitting in the suction canister. She said she would not want that green sputum filled canister sitting in her house. During an interview on 1/14/25 at 1:15 P.M., the DON said respiratory staff were responsible for making sure the suction canisters were changed. She said she felt like if a resident had been gone for 6 days and had a suction canister was filled with green substance, it should have been removed. She said she would not want to look at that in her home if it was not in use. During an interview on 1/14/25 at 3:37 P.M., the ADM said she could definitely see the suction canister with a green substance of a resident had been gone for 6 days a homelike environment issue. She said respiratory staff were responsible in changing the suction canisters and the suction canister should have been removed immediately after the resident left the facility. She said the canister was filled to the point that it should have been deposed of. She said she would not want to look at that in her home and there was a stigma attached to [NAME] and sputum, no one wanted to look at that. She said if Resident #48 had visitors they probably would not want to look at the dirty suction canister upon entrance of the resident's room. Record review of a facility policy revision date of February 2021 and titled, Homelike Environment Indicated that, Residents are provided with a safe, clean, comfortable and homelike environment and encourage to use their personal belongings to the extent possible . Record review of a facility policy dated of 12/07/23, Policy and Procedure Manual, Titled, Change-Out Supplies, Indicated that, Suction canisters will be changed out every month or when 3/4 full. New canisters will be labeled with the date of change out. Used canisters will be placed in a red biohazard bag disposed of properly in the biohazard room.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Residents #1) reviewed for infection control. 1. While in outbreak status for COVID-19, CNA A, LVN B, and Sitter C failed to wear N-95 masks as identified as a requirement in the facility policy. 2. While removing Resident #1's speaker valve, RT D did not wash, sanitize her hands, or wear gloves during the procedure. These deficient practices could place residents at-risk for infection due to improper care practices. The findings included: 1.During an observation and interview on 02/10/2024 at 10:00 a.m., a sign on the front entrance door stated, Masks must be worn in all areas of the facility at all times. CNA A answered the door not wearing a mask. After waiting in the lobby, LVN B entered the lobby not wearing a mask. LVN B instructed the state surveyor that the facility was in outbreak status for COVID-19 and it was a requirement to wear N-95 masks. LVN B stated there were no cases of COVID-19 on the west wing, but the facility had some employees that tested positive requiring them to stay in outbreak status. During an observation and interview on 02/10/2024 at 11:00 a.m., Sitter C was sitting less than 2 feet from a resident on the west wing and had no mask on. Sitter C stated she was not sure if she had to wear a mask because several people were not wearing one. During an interview on 02/10/2024 at 2:30 p.m., the DON stated masks had to be worn in all areas of the building as the sign on the door stated. The DON stated the staff knew they needed to wear the mask, that they had been in-serviced on wearing masks when the outbreak began 3 weeks prior. The DON stated there were no residents in the facility that had COVID-19, but they had several staff that had been affected by the virus and the facility continued to be in outbreak status. The DON stated not wearing the masks could lead to the spread of COVID-19 to the residents by an infected employee or visitor. 2. Record review of Resident #1's face sheet, dated 02/10/2024, revealed an admitted [DATE] with diagnoses which included: DiGeorge's Syndrome ( a condition where a small part of chromosome 22 was missing. This resulted in several developmental problems of the body systems), pulmonary hypertension ( characterized by high blood pressure in the pulmonary arteries, which are the blood vessels that carry oxygen-poor blood from the heart to the lungs), and tracheostomy status (a tracheostomy provides an air passage to help you breathe when the usual route for breathing is somehow blocked or reduced). Record review of Resident #1's quarterly MDS assessment, dated 11/16/202, revealed Resident #1 did not have a BIMS score and had short- and long-term memory impairment. Resident #1 was indicated to always be incontinent of bladder and bowel and needed dependent assistance with her activities of daily living. The MDS revealed Resident #1 had a tracheostomy. Review of Resident 1's care plan dated 11/25/2020 revealed Resident #1 had a tracheostomy related to impaired breathing mechanics. The intervention to maintain infection control was to use universal precautions as appropriate. During an observation on 02/10/2024 at 12:20 p.m., Resident #1 was done eating and wanted her speaker valve removed. RT D approached Resident #1 and attempted to remove the speaker valve without washing or sanitizing her hands and without wearing gloves. RT D was unable to loosen the speaker valve at that time. RT D retrieved a glove and removed the speaker valve with the glove without putting the glove on her hand. RT D disposed of the single glove and went back to evaluating other residents without washing her hands after removing the speaker valve. During an interview on 02/10/2024 at 12:30 p.m., RT D stated gloves should be worn when removing speaker valves and during all tracheostomy care. RT D stated hand hygiene was important when touching the tracheostomy to prevent infections. RT D stated poor hand hygiene and not following universal precautions could lead to serious infection of the tracheostomy site. During an interview with the DON on 02/10/2024 at 2:30 p.m., she confirmed the staff should wash and/or sanitize hands prior to wearing gloves when caring for a tracheostomy. The DON reveled the staff received training on infection control annually. The staff skills were checked yearly. The DON stated not following the infection control policy could cause the spread of infections that could lead to death in the compromised population of children at the facility. During an interview on 02/10/2024 at 2:40 p.m., the ADM stated the facility staff knew they were to wear masks throughout the facility and she felt they were not abiding by that rule because it was the weekend. The ADM stated she would immediately start in- servicing on wearing masks and hand hygiene with tracheostomy care. The ADM stated not wearing masks during an outbreak status increased the risk of spreading COVID-19 to the residents. The ADM stated not washing hands or wearing gloves during tracheostomy care provided an increased risk for infection at the tracheostomy site. Review of facility policy, titled Core Principles of COVID-19 Infection Program dated 09/15/2023, revealed Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, and other applicable facility practices (e.g., use of face covering or masks, . hand hygiene) .Appropriate use of Personal Protective Equipment (PPE). Review of facility policy, titled PASSY-MUIR TRACHEOSTOMY & VENTILATOR SWALLOWING AND SPEAKING VALVES dated 02/10/2024 revealed, thorough hand washing and the use of gloves are necessary when working with the tracheostomy tube and when handling the PMV (including placement and removal of the PMV on/off the tracheostomy tube).

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerated foods were properly labeled and dated. 2. The facility failed to ensure the fryer was clean and free of food debris. These failures could place residents at risk for food-borne illness. Findings included: During an observation of the kitchen refrigerators on [DATE] beginning at 08:50AM these items were found: *1 bag of white sliced cheese without a label or date marked on the package *1 bag diced bell peppers dated [DATE] - found underneath a metal bowl that contained 1 - package breakfast sausage and 1 - package turkey breast thawing *1 - container of guacamole dated [DATE] During an observation on [DATE] at 8:58 AM, the fryer in the kitchen was dirty and covered with splattered chicken fry batter. During an interview on [DATE] at 9:00AM, the Dietary Manager said the ready to eat foods were good for 3 days from the labelled date. She said she expected the staff to put the date the food was placed in the refrigerator when it was placed in there. She said the cheese was good for two weeks from the date it is labelled. She said all the above items this surveyor found she threw away after they were found. She said the kitchen used the fryer to fry chicken the previous night on [DATE] and she expected the fryer to be cleaned after each use. During an interview on [DATE] at 10:28 AM, the Dietary Manager said she had reviewed the facility's policy and would inservice her staff on adding the use-by date to the labels for the food stored in the refrigerator. She said the bell peppers should not have been placed underneath the thawing meat. She said she threw them away along with the other foods this surveyor found and she inserviced her staff on proper thawing. She said she has worked in the facility about 1 month. She said she expected her staff to follow the facility policies. She said she expected her staff to clean the deep fryer each time it was used, when it was safe to do so. She said they also drain and deep-clean the fryer once a week. She said the residents that eat food from the kitchen could suffer food-borne illness. During an interview on [DATE] at 10:46 AM, the Administrator said she expected the staff to follow the facility's policy for dietary services. She said the residents could potentially get sick or suffer food-borne illness if served expired, or improperly thawed food. Record review of the facility's policy, kitchen and equipment cleaning and sanitation, last revised [DATE], stated: .The kitchen and dining service equipment and food contact surfaces shall be maintained in a clean and sanitized condition . .Equipment food contact surfaces and utensils shall be clean to sight and touch . .Food contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other accumulations . .nonfood contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . Record review of the facility's policy, food receiving and storage, last revised [DATE], stated: .7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . .12. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables, and other ready-to-eat foods .

Based on observation, interview, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 4 of 23 residents reviewed for range of motion. (Resident #6, Resident #21, Resident #67, and Resident #68) The facility failed to provide restorative therapy for contractures or contracture prevention for Resident #6, Resident #21, Resident #67, and Resident #68. This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being. Findings included: 1. Record review of a face sheet dated 12/06/23 revealed Resident #6 was a [AGE] year-old male that admitted to the facility on [DATE]. Resident #6 had diagnoses of cerebral palsy (a group of disorders that affect a person's ability to move and maintain balance and posture), cerebral vascular accident (stroke happens when there is a loss of blood flow to part of the brain), and paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease). Record review of a MDS dated [DATE] revealed Resident #6 was rarely/never understood and had a BIMS of 99, which indicated severe cognitive impairment. Resident #6 required continuous oxygen administration, required tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care, and required mechanical ventilation (a type of therapy that helps you breathe or breathes for you when you can't breathe on your own). Resident #6 was dependent for all ADLs and was receiving restorative therapy for passive range of motion for at least 15 minutes 7 days per week. Record review of a care plan last updated 10/27/23 revealed Resident #6 had limited physical mobility related to cerebral palsy and required a daily restorative passive range of motion program to promote joint mobility and decrease pain. Record review of consolidated physician's orders dated 12/2023 revealed Resident #6 had an order dated 10/11/23 for bilateral lower extremity ROM for 15 reps an each joint daily. Resident #6 had a physician's order dated 1/23/2023 for bilateral upper extremity ROM for 15 reps on each joint daily. Record review of ADL task document dated 11/07/23 to 12/06/23 revealed Resident #6 had not received passive range of motion exercises as prescribed on 11/08/23, 11/21/23, 11/25/23, 11/26/23, 11/27/23, 12/01/23, 12/02/23, nor 12/02/23. 2. Record review of a face sheet dated 12/06/23 revealed Resident #21 was a [AGE] year-old male that admitted to the facility on [DATE]. Resident #21 had diagnoses of quadriplegia (paralysis of all four limbs), hypertension (high blood pressure), and seizure disorder. Record review of a MDS dated [DATE] revealed Resident #21 was rarely/never understood and had a BIMS of 99, which indicated severe cognitive impairment. Resident #21 required continuous oxygen administration and required tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck) care. Resident #6 was dependent for all ADLs and was receiving restorative therapy for passive range of motion for at least 15 minutes 7 days per week. Record review of a care plan last updated 10/16/23 revealed Resident #21 had limited physical mobility related to anoxic brain injury (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation) and required a daily restorative passive range of motion program to promote joint mobility and decrease pain. Record review of consolidated physician's orders dated 12/2023 revealed Resident #21 had an order dated 11/11/23 for bilateral upper extremity ROM for 15 reps an each joint daily. Record review of ADL task document dated 11/07/23 to 12/06/23 revealed Resident #21 had not received passive range of motion exercises as prescribed on 11/13/23, 11/14/23, 11/15/23, 11/18/23, 11/20/23, 11/21/23, 11/25/23, 11/26/23, 11/27/23, 12/01/23, 12/02/23, nor 12/02/23. 3. Record review of a face sheet dated 12/06/23 revealed Resident #67 was [AGE] years old and was admitted on [DATE] with diagnoses including [NAME]-Chiari Syndrome with Spina Bifida (a malformation in the brain along with when the neural tube does not close all the way, the backbone that protects the spinal cord does not form and close as it should), unspecified joint contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and neuromuscular scoliosis (one of three main types of scoliosis that cause an irregular curvature of the spine). Record review of a MDS dated [DATE] revealed Resident #67 was rarely/never understood. A BIMS was not conducted due to the resident was rarely/never understood. The MDS indicated Resident #67 had limited range of motion and was impaired on both sides of the upper and lower extremities. The MDS indicated Resident #67 was dependent on staff for all ADLs and received passive range of motion therapy as part of the Restorative Nursing Program. Record review of a care plan last updated 11/09/23 revealed Resident #67 had spastic quadriplegic cerebral palsy (characterized by paralysis of both arms and both legs, with muscle stiffness) affecting mobility. There were interventions to use braces and splints as ordered. The care plan indicated Resident #67 had limited physical mobility and was part of the restorative therapy program. Record review of consolidated physician's orders dated 12/05/23 revealed Resident #67 had an order dated 06/13/23 for bilateral upper extremity ROM for 15 repetitions at each joint every day related to contracture. There was an order dated 06/10/23 for bilateral lower extremity ROM for 15 repetitions every day. Record review of ADL task document dated 11/07/23 to 12/06/23 revealed Resident #67 had not received passive range of motion exercises as prescribed on 11/17/23, 11/21/23, 11/25/23, 11/26/23, 11/28/23, 12/01/23, 12/02/23, and 12/03/23. Record review of progress notes from 11/07/23 - 12/06/23 did not indicate Resident #67 did not tolerate therapy, was not available for therapy, or had refused therapy. 4. Record review of a face sheet dated 12/06/23 revealed Resident #68 was [AGE] years old and was admitted on [DATE] with diagnoses including anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), unspecified joint contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), and chronic pain. Record review of a MDS dated [DATE] revealed Resident #68 was rarely/never understood. A BIMS was not conducted due to the resident was rarely/never understood. The MDS indicated Resident #68 had limited range of motion and was impaired on both sides of the upper and lower extremities. The MDS indicated Resident #68 was dependent on staff for all ADLs and received passive range of motion therapy as part of the Restorative Nursing Program. Record review of a care plan last updated 11/01/23 revealed Resident #68 was dependent on staff for physical needs. The care plan indicated Resident #68 had limited mobility related to anoxic brain damage and the resident was part of the restorative nursing passive ROM program. Record review of consolidated physician's orders dated 12/05/23 revealed Resident #68 had an order dated 07/06/23 for passive range of motion to left hip, knee, and ankle for 15 repetitions every day. There was an order dated 07/06/23 for passive range of motion to right knee and ankle, avoiding right hip, for 15 repetitions every day. There was an order dated 10/28/23 for gentle passive range of motion to bilateral lower extremities for 15 repetitions every day. There was an order dated 11/08/23 for passive range of motion to bilateral upper extremities for 15 repetitions every day. Record review of ADL task document dated 11/07/23 to 12/06/23 revealed Resident #68 had not received passive range of motion exercises as prescribed on 11/13/23, 11/17/23, 11/21/23, 11/22/23, 11/25/23, 11/26/23, 11/27/23, 11/28/23, 11/29/23, 12/02/23, and 12/03/23. Record review of progress notes from 11/07/23 - 12/06/23 did not indicate Resident #68 did not tolerate therapy, was not available for therapy, or had refused therapy . Record review of a green splint binder kept on the restorative aides' cart revealed there was no documentation of any resident not tolerating restorative therapy. During an interview on 12/04/2023 at 9:30 a.m., LVN C stated there were splint aides that did all of the range of motion and splint applications for the facility. LVN C stated the splint aides were aware of the time requirements of 15 minutes or more and the therapy needing to be done 7 days a week to be effective. LVN C stated the regular CNAs did some passive ROM for the children but were not specially trained like the splint aides were. LVN C stated not getting the prescribed ROM could lead to further contractures and joint pain. During an interview on 12/05/23 at 1:11 p.m., the MDS Coordinator said she was responsible for the restorative therapy program. She said the split aides provided restorative therapy to the residents. She said according to the documentation residents had not received restorative therapy. She said the splint aide should document in progress notes any days the resident did not tolerate the restorative therapy. She said there was a binder that was kept at the wing that contained documentation. During an interview on 12/06/23 at 9:03 a.m., the MDS Coordinator said she had not found any further documentation concerning restorative therapy. She said she felt the residents had received the ordered therapy and it just had not been documented. During an interview on 12/06/23 at 9:17 a.m., Splint Aide H said restorative therapy was documented in the electronic medical record of each resident. She said each therapy session should be documented daily. She said there were days when she was working on the floor and could not do her restorative aide duties. She said those days were documented as a zero since the task was not done. She said if residents had refused, the refusal would be documented on a handwritten form and placed in the splint binder. During an interview on 12/06/23 at 9:20 a.m., Splint Aide J said there were days the splint aides had to work the floor and may not apply splints to residents and/or provide range of motion exercises. She said on the days she had to work the floor she does try to provide range of motion exercises but may not be able to provide it to all residents. She said there were times when someone had called off and she had to work the floor by herself and could not provide therapy to every resident. She said if a resident could not tolerate the restorative therapy it would have been documented on a handwritten paper and placed in the splint binder. During an interview on 12/06/23 at 10:04 a.m., the DON said the splint aides were responsible for providing restorative therapy to the residents. She said restorative therapy should be charted in the electronic medical record of each resident. She said she would expect the therapy to be provided unless the resident was out of the building or if something was going on with the resident, such as being out of the building. She said if the resident was out of the building she would expect it to be documented in the progress notes. She said the purpose of restorative therapy was to prevent contractures or to maintain mobility. She said should like for it to be documented so she would know the therapy had been done. She said the therapy was needed, it was ordered, and it should be done. She said if the aide was unable to do their duty they should have made the MDS Coordinator aware . During an interview on 12/06/23 at 10:36 a.m., the Administrator said she felt as the residents were being gotten up they were receiving range of motion exercises. She said she felt it had just not been documented. She said she would expect all completed task to be documented in the resident electronic medical record. She said a resident not receiving restorative therapy could cause stiffing of the joints. Review of a Restorative Nursing Services facility policy dated January 2023 indicated, .Residents will receive restorative nursing care as needed to help promote optimal safety and independence . Review of an article titled Contractures and Splinting, https://www.advanced-healthcare.com/wp-content/uploads/2011/07/August-2014-Inservice.pdf, dated August 2014 indicated, . Contractures - Joint movement is similar to the hinge on a door. Regularly moving the door keeps it working properly, so the door opens and closes easily. When the door isn't moved regularly, the hinge may rust from lack of use, making the door harder to open and close. Similarly, the structures in and around the joints stretch, flex, and move all day long keeping them functional. If the joint is not moved, it shrinks, becomes stiff, and loses the ability to stretch and move. This causes changes in fluids that lubricate the inside of the joint. Movement squeezes and pushes the fluid around, lubricating the joint. When a joint stops moving, so does the fluid. Now both the outside and inside of the joint are immobile. Contractures are joint deformities caused by immobility. Keeping residents active and moving is the best way to prevent contractures . 44596 Resident #6 FTag Initiation Resident #21 FTag Initiation

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Residents # 5) reviewed for infection control practices. The facility failed to ensure that a urine sample was removed from Resident # 5's dresser. These failures placed residents at risk for cross contamination and infection. Findings include: Record review of an undated face sheet revealed Resident # 5 was a [AGE] year-old male admitted on [DATE] with diagnoses including Autistic Disorder (a developmental disability caused by differences in the brain), Epilepsy (Epilepsy is a disorder of the brain characterized by repeated seizures), Hypo Osmolality (condition where the levels of electrolytes, proteins, and nutrients in the blood are lower than normal). Record review of a quarterly MDS dated [DATE] revealed Resident # 5 was rarely or never understood and rarely or never understood others. The MDS revealed Resident # 5 had a BIMS (cognitive/mental status) of 00 which indicated severe cognitive impairment and that Resident # 5 required limited assistance for all activities of daily living. Record review of a care plan dated 09/05/2023 revealed Resident # 5 has bladder incontinence. It revealed that staff will monitor/document for signs or symptoms of a urinary tract infection. During an observation on 12/04/2023 at 9:47 a.m., in Resident # 5's bathroom there was a dresser with the top drawer open. Inside the dresser drawer was a urine sample in a cup that was not labeled or dated. There was no information to indicate who this urine belonged to or when the sample was taken. Resident # 5 presented as non-verbal. During an interview on 12/06/2023 at 8:02 a.m., CNA F said she does not know what the cup with yellow liquid is in Resident # 5's bathroom. She said it looks like a urine sample cup which may have urine in it. She said urine samples should not be stored in this manner and should be taken by a nursing staff. During an interview on 12/06/2023 at 8:06 a.m., LVN G said that it appears to be a urine sample cup in Resident # 5's top dresser drawer. She said urine samples should be placed in a cooler after they are labeled and dated . She said that they are placed into a cooler until the lab picks up the samples. She said residents could be placed at risk for infection and disease or may possibly swallow the urine if they came into contact. During an interview on 12/6/2023 at 9:45 a.m., the Director of Nursing said nursing staff should take a urine sample to the nurse's station, place the sample in a biohazard bag, label the sample, then put in the refrigerator for lab collection. She said a urine sample should not be placed in a resident's dresser. She said residents could be placed at risk for infection or disease if they came into contact with or drank urine. During an interview on 12/06/2023 at 9:05 a.m., the Administrator said urine sample cups should not be left in a resident's dresser drawer. She said a urine sample cup should be labeled, dated, and placed in a refrigerator to go to a lab. She said residents could potentially be placed at risk for infection. She said she expects facility staff to follow their infection control policies. Review of a facility Infection Prevention and Control policy revised January of 2023 indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections 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.

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 resident personal refrigerators reviewed for food safety (Resident # 51). The facility failed to ensure the refrigerator for Resident # 51 did not contain expired foods. This failure could place resident at risk for food borne illnesses. Findings include: Record review of a face sheet dated [DATE] indicated Resident # 51 was an [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including Muscle Wasting and Atrophy (Muscular atrophy is the decrease in size and wasting of muscle tissue), Morbid Obesity (A disorder involving excessive body fat that increases the risk of health problems), Acute Embolism and Thrombosis (Thrombosis is a clot in a blood vessel. An embolism or thromboembolism is a clot that moves through your bloodstream). Record review of a Quarterly MDS dated [DATE] indicated Resident # 51 understood others and made himself understood. The MDS indicated Resident #51 cognition was intact with a BIMS score of 15. The MDS indicated Resident #51 was totally dependent for transfer and bed mobility. Record review of a care plan for Resident #51 dated [DATE] revealed Resident # 51 has an ADL self-care performance deficit and requires assistance with staff for most activities of daily living. During an observation and interview on [DATE] at 10:17 a.m., Resident # 51 said he did not know if anyone cleans out his refrigerator. Resident #51 used his electric wheelchair to leave the room. It was observed that a pickled okra jar, labeled and dated [DATE], was in his room on top of his personal refrigerator. The Okra inside the glass jar had been decomposing, turned black, and was now falling apart. Inside the refrigerator for Resident # 51 was an unknown food item in an undated and unlabeled zip lock bag. The unknown food appeared moldy, falling apart, and had black and blue spots on it. During an interview on [DATE] at 8:15 a.m., CNA F said Housekeeping was responsible for cleaning out personal refrigerators. She said that she, as a CNA, can prep food and pull food out of the refrigerator as well. She said if there was spoiled food that she found in a personal refrigerator she would tell the resident and then throw the food away. She said if she found a food that was not labeled or dated, she would also throw that food out. She said food in the personal refrigerators are supposed to be labeled and dated as this is how she was trained. She said she had not seen the decomposing Okra in Resident #51's room. She said she did not know there was expired cheese in the fridge as well. She said that residents are placed at risk of illness if they eat expired food. During an interview on [DATE] at 8:45 a.m., with the Director of Nurses she said it is the responsibility of all staff to ensure that resident's personal foods are checked to ensure there is no out of date or expired foods. She said residents could be placed at risk for foodborne illness if they eat expired foods. She said food that is decomposing or moldy should be discarded and not consumed. During an interview on [DATE] at 9:05 a.m., the Administrator said it is the responsibility of the Dietary Manager to ensure that resident's personal refrigerators are clean and free from expired foods or foods that are not labeled or dated. She said decomposing okra should have been thrown away by facility staff. She said the Dietary Supervisor is ultimately responsible to ensure this is completed . She said that residents are placed at risk of illness if they eat expired foods. She said she expects her staff to follow facility policy. During an interview on [DATE] at 9:38 a.m., the Dietary Manager said it is the dietary staff that are responsible to clean out the refrigerators in resident's rooms. She said expired food should be discarded and all foods should be labeled and dated. She said the okra that is decomposing should have been thrown away and not left in the room. She said residents are placed at risk of illness if they eat expired foods. Record Review of facility policy titled, Personal Refrigerators Policy revised [DATE]. The policy revealed, Residents of the facility may place a personal refrigerator in their room if space permits and under Life Safety Code regulations, that the resident room has an adequate electrical system, such as proper outlets, to allow the connection of a refrigerator without overloading the electrical system. The care and maintenance of any refrigerator is the responsibility of the resident and/or responsible party. It is also the responsibility of the resident and/or resident representative to properly store non-facility supplied foods that require refrigeration in their personal refrigerator. If food is expired or appears spoiled or moldy, the facility reserves the right to discard it. Housekeeping can assist the resident and/or family member by inspecting the refrigerators at least weekly and assist with removal of outdated food items and cleanliness.

Based on observations, record review and interviews, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent accidents for 1 of 24 residents (Resident # 25) reviewed for accidents. The facility failed to protect Resident #25 when CNA A shook off the metal hook from the mechanical lift with her hands causing the metal hook to fall and hit Resident #25 in the chest and fall to her lap. This failure could place residents at risk for injury or harm. Findings included: Record review of Resident # 25's Admission Record indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses include Cerebral Palsy (Cerebral palsy (CP) is a group of disorders that affect a person's ability to move and maintain balance and posture), Anoxic Brain Damage (Anoxic brain injuries are caused by a complete lack of oxygen to the brain), Convulsions (A sudden, violent, irregular movement of a limb or of the body, caused by involuntary contraction of muscles and associated especially with brain disorders such as epilepsy, the presence of certain toxins or other agents in the blood, or fever in children). Record review of Resident # 25's MDS dated [DATE] revealed that Resident # 25 was rarely or never understood and rarely or never understood others. The MDS revealed Resident # 25 had a BIMS (cognitive/mental status) of 00 which indicated severe cognitive impairment. The MDS also revealed, Resident # 25, was totally dependent for transfers. Record review of Resident #25's Care Plan dated 9/26/2023, revealed a problem initiated on 1/08/2020, the resident has an ADL self-care performance deficit Cerebral palsy. Resident requires two staff for transfer. During interview on 12/05/2023 at 11:30 a.m., with CNA B she said that she was working on 11/28/2023 with Resident # 25 and CNA A. She said an incident occurred between herself, Resident # 25 and CNA A. She said that Resident # 25 was being weighed using the mechanical lift. After Resident # 25 was finished being weighed she would be placed into her wheelchair. She said that she had CNA A assist her with the Transfer. She said that CNA A was in a hurry and wanted to go to her lunch break. She said Resident # 25's right foot came off the wheelchair footrest. She said she asked CNA A to help keep her feet on the wheelchair footrest while she lowered Resident # 25 down into her wheelchair. This further agitated CNA A and she said, That is what I was already doing. She said she stopped lowering the mechanical lift to show CNA A what she needed her to do with Resident # 25's leg and then went back to lowering the lift. She said this is when CNA A threw her hands in the air and walked back. She said then CNA A came back to assist with lowering Resident # 25 into the chair. She said CNA A was bent over and keeping Resident # 25's legs in the proper place. She said she was staring at Resident # 25 and did not notice that the mechanical lift had lowered and hit CNA A in the head. She said after they had Resident # 25 secured in her chair and her weight was not being supported by the mechanical lift CNA A screamed at me, You hit me in the head! She said then CNA A grabbed the mechanical lift's metal hooks that the sling was attached to and began shaking it out of anger. She said Resident # 25 was still under the mechanical lift in her wheelchair when this occurred. She said that one of the metal hooks came off the mechanical lift and fell a few inches down onto Resident # 25's chest and into her lap. She said that this was the end of the incident. She said that Resident # 25 did not notice anything had happened, was unharmed, and was smiling during the incident. She said that RRT D witnessed the incident occur. She said that she reported the incident immediately. During an interview on 12/5/2023 at 12:48 p.m., with LVN E. she said she did not witness the incident between CNA A and CNA B. She said she did hear CNA B tell CNA A to, Be careful with the leg. CNA B was later crying after the incident as I think she was shook by what happened. She said that RRT D was with them when this occurred and witnessed everything. During an interview on 12/5/2023 at 1:00 p.m., with the Director of Nursing she said she remembers the incident between CNA A and CNA B. She said that she did not witness the incident but was told what happened. She said that while lowering Resident # 25 into her wheelchair CNA A was hit in the head by the mechanical lift the CNA B was lowering. She said that CNA A was reported to have been angry from having the lift hit her head. She said she was told that a part of the mechanical lift fell into the lap of Resident # 25. She said that she assessed Resident # 25 and she was unharmed. She said there was no injury, no bruising, and no need for medical attention. She said Resident # 25 did not show any signs of distress. During an interview on 12/5/2023 at 1:13 p.m., with CNA A she said she was working on 11/28/2023 when the incident occurred with Resident # 25 and CNA B. She said she was helping CNA B weigh Resident # 25. She said after she was weighed and was being lowered back into her chair, she bent over to keep Resident # 25's leg on her footrest of her wheelchair. She said she could see the lift coming down onto her head. She said she told CNA B that she was lowering the lift onto her and to stop. She said she lifted her head and hit the mechanical lift. She said she was angry and stood up pushed the mechanical lift away and said, That was my head! She said CNA B just looked at her and did not say anything. She said the mechanical lift hook fell to the floor and did not hit Resident # 25. She said Resident # 25 was never touched by the metal hook. She said Resident # 25 did not react in any way while this was occurring. She said she did not yell at CNA B and she went to her lunchbreak immediately afterwards. During an interview on 12/5/2023 at 1:30 p.m., with the Administrator she said CNA B told her that CNA A shook off the metal hook from the mechanical lift and that she shook it off using her hands. She said CNA B is very passionate and was very worked up this day, 11/28/2023. She said CNA B came to her and said she wanted to apologize to CNA A for hitting her in the head with the mechanical lift. She said that it would not be professional for CNA A to hit or shake the mechanical lift for any reason while the resident was present. She said that no harm came to Resident # 25. She said there was a head to toe assessment completed immediately after and this incident was reported immediately after to the proper authorities. She said that during the assessment Resident # 25 was smiling and laughing. During an interview on 12/5/2023 at 1:53 p.m. with RRT D. she said she was working on 11/28/2023 and she witnessed the incident between CNA A, CNA B, and Resident # 25. She said both CNAs were weighing Resident # 25. She said after she was weighed, she was being let down into her wheelchair. She said she was waiting for them to finish so she could provide care to Resident # 25. She said CNA B had lowered the mechanical lift down and hit CNA A in the head with it. CNA A became angry, and she shook the mechanical lift. She said Resident # 25 was directly below the mechanical lift while CNA A was shaking the lift. While CNA A was shaking the lift she said to CNA B, CNA B you hit me on purpose! CNA B said, I didn't. I was watching her feet. She said that at this time a metal hook that is a part of the mechanical lift mechanism that attaches the sling to the machine shook loose and fell right past Resident # 25's face missing her face, then falling onto Resident # 25's chest, and then sliding down into her lap. CNA B said to CNA A to be careful, and CNA B started to cry. She said she did not think CNA B lowered the lift down onto CNA A's head on purpose. She said that CNA A's shaking of the mechanical lift is what caused the hook to fall. During an observation on 12/5/2023 at 2:18 p.m. Female Surveyor (RN) Observation: Resident # 25 with LVN E. Resident # 25 had no bruising, marks or discoloration on her chest, abdomen, or thighs, including inner thighs. She had a g-tube on her left abdomen and an old scar on her left upper to mid quadrant. During an interview on 12/5/2023 at 2:53 p.m. with the Administrator she said that CNA A was suspended pending the investigation. She said she was suspended on the 28th of November and returned on the 4th of December as there were inconclusive findings. Record Review of Nurses Assessment for Resident # 25 dated, 11/28/2023 shows that the Director of Nurses assessed Resident # 25, On November 28th in response to an incident involving possible resident injury. This nurse assessed Resident bodily for any sign of injury. No evidence was found of bodily injury. Record Review of facility policy titled, Resident Incident and Visitor Accident Report revised January 2023. The policy revealed, The facility will conduct an investigation of all incidents involving residents of the facility. The facility will conduct an investigation of all non-resident accidents that occur on the property of the facility. The investigation will be conducted by designated personnel and reported to the Administrator/designee. Incidents/Accidents of Unknown Origin will be reported in accordance with state and federal regulations.

Based on observation, interview, and record review the facility failed to ensure Residents were free of accidents for 1 of 4 Residents reviewed for accidents. (Resident #1) The facility did not ensure staff repositioned Resident #1 safely resulting in a fracture to Resident #1's left Femur. This failure could place Residents at risk for injury. Findings included: A face sheet dated 01/09/23 showed Resident #1 was an [AGE] year-old admitted on [DATE] with diagnoses of Spastic Quadriplegic cerebral Palsy, (CP affecting all four limbs, the trunk, and the face), adult failure to thrive (A decline seen in adults - typically those with multiple chronic medical conditions), Intellectual disabilities, contracture, chronic pain, Subluxation (partial dislocation) of left hip, personal history of COVID19, Ileus (lack of the normal muscle contractions of the intestines), malnutrition, and cerebral palsy. A MDS dated [DATE] showed Resident #1 was rarely or never able to make himself understood or understand others. required total dependence for all ADLs, required one person assistance for bed mobility and two-person assistance for transfers. He was always incontinent to bowel and bladder. Resident #1 had unclear speech, rarely or never understood or able to understand others. A care plan dated 08/19/22 showed Resident #1 had potential for pain related to contractures and spastic quadriplegic cerebral palsy. Staff were to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Staff were to monitor/document for probable cause of each pain episode, remove/limit causes where possible. A care plan dated 08/30/22 showed Resident #1 was totally dependent on one staff for bed mobility, turning and repositioning as needed. Resident is totally dependent on two staff for transferring. A video surveillance tape dated 12/31/22 at 1:14 PM provided by the Administrator showed Resident #1 laying sideways with Resident #1's hips and legs on a mattress, foot against the wall and the upper torso on a mat and head on a pillow. There was a pillow between Resident #1's legs. The mattress and mat were directly on the floor in the lowest position possible. Resident #1 was alert with no signs of destress. Two staff identified by the administrator as RN-A and CNA-A entered the room. CNA-A spoke to Resident #1 in a pleasant tone of voice. CNA-A placed his left hand on Resident #1's left shoulder and with a twisting motion turned Resident #1 to the right. There was an audible pop. Resident #1 immediately started to cry out as if in pain. CNA-A turned Resident #1 on to left side and RN-A conducted some type of treatment to Resident #1 buttock. Resident #1 stopped crying while lying on the left side while the treatment was administered. Resident #1 started to cry again and had a grimacing expression. RN-A finished the treatment and left the room. CNA-A remained in the room kneeling beside Resident #1 when the video ended. A patient report from local x-ray provider dated 01/01/23 at 12:41 AM showed an x-ray was conducted on 01/01/23 of Resident #1's left femur. Findings showed the bilateral acetabula are dysplastic (an abnormally shallow hip socket) and there are bilateral age-indeterminate superior dislocated femoral heads. An oblique fracture of the left proximal femoral shaft. (A fracture is a straight line that's angled across the width of your bone.) Interview on 01/04/23 at 3:21 PM, RN-A said he was the nurse on duty 12/31/22 when Resident #1's leg was broken. RN-A said the CNA had notified him that Resident #1 had been scratching behind his scrotum and needed treatment. RN-A said he went to provide the treatment. RN said then CNA-A bent over to move Resident #1 over in the bed, he heard a pop. RN-A said he thought it was either CNA-A's back or a toy hitting the floor. RN-A said he had never heard a bone break and did not recognize the pop as a bone breaking. RN-A said he did not tell the oncoming nurse or contact the family, because he did not know Resident #1 leg was broken. He said he did not hear Resident #1 crying after he had calmed down. Interview on 01/04/23 at 3:33 PM, CNA-A said he was the aide on duty 12/31/22, when Resident #1's leg broke. CNA-A said when he and RN-A went into the room, Resident #1 had slid off his mattress. CNA-A said he moved Resident #1 back on his mattress and heard a pop. CNA-A said RN-A asked him if that was his back or something. CNA-A said he told RN-A it was not him and they thought it was a toy that had fell to the floor. CNA-A said Resident #1 does not like to be touched or bothered so he thought Resident #1 was fussing because he did not want to be changed or repositioned. CNA-A said Resident #1 did not make much noise while being changed but became upset when he placed the pillows between Resident #1's legs. CNA-A said he did not know Resident #1's leg was broken. Interview on 01/08/23 at 1:35 PM the Administrator said she was investigating the incident with Resident #1 fractured femur. Administrator said she had an emergency QUPI meeting on 01/02/23 to develop a plan of correction. The Administrator said RN A and CNA A were immediately suspended pending investigation. The Administrator said all nursing staff received training on bed mobility and transfer assistance, reporting abuse and neglect, and administering pain medications. The Administrator said all nursing staff were tested on skills for transfer mobility, and repositioning techniques, starting on 01/01/23 and completed on 01/08/23. The Administrator said an audit was conducted that included bed mobility and transfer needs for all residents. The Administrator said the DON/designee and Rehabilitation Director will monitor three times a week for four weeks, then two times a week for eight weeks and then weekly thereafter. The Administrator said the QAPI committee will provide oversight monthly for 3 months and every 6 months until resolved. Interview on 01/09/23 at 10:18 AM, the DON said she had reviewed the video of the incident with Resident #1. The DON said CNA-A failed to use the proper technique when he repositioned Resident #1. The DON said because of the angel Resident #1 was lying in at the time, CNA-A should have asked RN-A to assist with repositioning Resident #1. The DON said because of the improper way Resident #1 was repositioned by CNA-A, Resident #1's left femur was fractured. The DON said both staff, CNA-A and RN-A were terminated for failing to assess Resident #1's condition and for failing to report an injury of a Resident to the Administrator and/or DON. The DON said on 01/01/23 at 3:00 AM the charge nurse notified the ADON that there was swelling to Resident #1's left leg and x-rays had been ordered. The DON said Resident #1 received pain medication on 12/31/22 at 2:00 PM and again on 01/01/22 after the swelling was discovered. The DON said it was hard to know how Resident #1 was feeling because he yelled out and makes a lot of noise when he is mad, happy, or just in general. Interview on 01/09/23 at 10:47 AM, LVN A said she was working on 12/31/22 5:00 AM to 5:00 PM. LVN-A said that afternoon around 2:00 PM, LVN A went in to see Resident #1. LVN A said Resident #1 was crying, but that was not unusual. LVN A said she fed him some pudding with pain medication. LVN said after feeding him the pudding, she stayed with Resident #1 for about twenty minutes and left the room. LVN A Resident #1 had stopped crying. LVN A said later she saw Resident #1 on his way to get a shower. LVN A said he was not crying when she saw him. Interview on 01/09/23 at 11:25 AM, CNA-B said he was working on the afternoon on 12/31/22. CNA-B said Resident #1 did not appear to be any more upset then normal. CNA-B said Resident #1 always yelled out during care and he did not notice Resident #1 yelling out more than normal and did not notice Resident #1 was having problems with his left leg. CNA-B said the shower was about the same as always with nothing unusual. Interview on 01/08/23 CNA-B, CNA-C, LVN-A and RN-B said they had received training on abuse/neglect and transferring and repositioning residents. Observations on 01/08/23 from 1:00 PM to 1:15 PM showed 3 residents being repositioned by staff. Staff used proper technique and provided appropriate support when repositioning residents in their beds. Inservice record from 01/01/23 through 01/08/23 showed documentation that nursing staff had received training on Reporting Abuse and Neglect, Skills Assessments on transfer, and bed mobility/positioning techniques. Facility policy revised 07/18/18 showed The QA Committee will ensure implementation of this policy to identify, assess, and develop strategies to control risk of injury to residents and nursing staff associated with the lifting, transferring, repositioning or movement of a resident. 1. A. Orientation & Training: Nursing staff will receive in-service training for the criteria used to assess for appropriate level of assistance required. Transfer training refers to the teaching techniques and use of equipment involving in moving patient/resident from one surface to another (e.g., bed to wheelchair) or the moving or repositioning of a patient/resident on one surface (e.g., bed, mat table) Bed Mobility/Repositioning .All motion is slow, specific, and methodical. More than one caregiver may be needed in the event the resident is dependent, bariatric, brittle, rigid, resistant, and so on. Great care should be taken to keep the body as a unit during rolling and repositioning and keeping arms and legs aligned and visible during the care.

Based on observation , interview and record review, the facility failed to ensure that PRN (as needed) orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication, for 3 of 20 (Resident #20, #26, #54) reviewed for the sample. Resident #26 had a PRN order for [MEDICATION(S)] ([CONDITION(S)] medication) for more than 14 days without physician documentation re-evaluating the medication to continue its use PRN. Resident #20 had a PRN order for [MEDICATION(S)] (anti-anxiety medication) since 8/3/2019. The facility failed to limit Resident #54's [CONDITION(S)] prn medication, Lorazepams to 14 days and the prescribing practitioner did not provide rationale for extended use. This deficient practice could place residents at risk of receiving unnecessary medications. Findings include: 1. Record review of Resident #26's admission record dated 10/12/22, indicated that Resident #26 was a 32year old[AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses which included Chronic [CONDITION(S)], [CONDITION(S)], Hypertension (high blood pressure), and Brain damage. Record review of Resident #26's quarterly MDS dated [DATE] indicated Resident #26 required total assistance of 1 person for bed mobility, transfers, dressing, eating toilet use, and bathing. The MDS also indicated that Resident #26 had a BIMS score of 0 indicating severe cognitive impairment. The MDS also indicated Resident #26 had no behavioral symptoms and the resident received anxiety medications 7 days in the 7-day look back period. Record review of Resident #26's care plan revised on 07/25/22 indicated Resident #26 had depression and had a goal that he would remain free from signs and symptoms of depression, anxiety, or sad mood. Interventions included to administer medications as ordered, monitor/document/report as needed signs and symptoms of depression, including: hopelessness, anxiety, sadness, [CONDITION(S)] Record review of Resident #26's quarterly Material Data Sheet (MDS) dated [DATE] indicated Resident #26 required total assistance of 1 person for bed mobility, transfers, dressing, eating toilet use, and bathing. The MDS also indicated that Resident #26 had a BIMS score of 0 indicating severe cognitive impairment. MDS also indicated that Resident #26 had no behavioral symptoms, and MDS indicated that resident received anxiety medications 7 days in the 7-day look back period. Record review of Resident #26's order summary report dated 10/12/22 included the following medications:revealed an order for [MEDICATION(S)] Tablet 1 MG ([MEDICATION(S)]) Give 1 tablet via G-tube every 6 hours as needed for breakthrough spasms dated 12/14/21 [MEDICATION(S)] Tablet 1 MG ([MEDICATION(S)]) Give 1 tablet via G-tube every 6 hours as needed for breakthrough spasms dated 12/14/21 Record review of Resident #26's mMedication administration records for January 2022-October 2022 indicated [MEDICATION(S)] was administered: on 1/22/22 twice, 1/23/22 twice, 2/6/22, 2/9/22, 2/15/22, 2/19/22, 3/10/22, 3/13/22, 3/15/22, 3/16/22, 3/20/22, 3/24/22, 4/6/22, 4/10/22, 5/2/22, 6/11/22, 7/3/22, 7/31/22, and 9/26/22. 1/22/22 twice, 1/23/22 twice, 2/6/22, 2/9/22, 2/15/22, 2/19/22, 3/10/22, 3/13/22, 3/15/22, 3/16/22, 3/20/22, 3/24/22, 4/6/22, 4/10/22, 5/2/22, 6/11/22, 7/3/22, 7/31/22, and 9/26/22 Record Review of an uncompleted Physician Notification Letter (no physician signature, nor response to letter) printed 6/29/22 indicated that Resident #26 had the order for [MEDICATION(S)] 1mg tablet every 6 hours PRN (as needed). During an interview on 10/13/2022 at 10:58 AM with the Pharmacy Consultant for the facility she said that she was aware that Resident #26 had the order for the [MEDICATION(S)] for spasms. She said she had placesd a reminder to the physician and the facility every month that the PRN [CONDITION(S)] medications are good for 14 days and need to be monitored. The Pharmacy Cconsultant said she had sent out a note to the physician in July 2022 about the [MEDICATION(S)]. 2. A record review of the undated face sheet for Resident #20 indicated Resident #20 admitted to the facility on [DATE] and was [AGE] years old. A record review of the consolidated physician's orders dated October 2022 indicated he had diagnoses that included: unspecified convulsions (irregular movement of a limb or of the body), anxiety disorder (worry, fear, increased heart rate, restlessness, rapid breathing), heart failure, chronic [CONDITION(S)] (airways are damaged requiring long term treatment), [CONDITION(S)] (a surgical opening in the neck area through an incision in the trachea for breathing), dependence on ventilator (use of a machine to be able to breathe), contracture (permanent shortening of a muscle or joint), gastrostomy (artificial external opening into the stomach for feeding), and [CONDITION(S)] (movement disorders with stiff muscles, weak muscles and tremors). The physician's orders indicated: 6/25/19 [MEDICATION(S)] ([MEDICATION(S)]) Tablet, 1 mg , Give 1 tablet via G-tube three times a day related to anxiety. 8/3/19 [MEDICATION(S)] ([MEDICATION(S)]) tablet, 1 mg , Give 1 tablet via G-tube every 6 hours as needed for anxiety. A record review of Resident #20's most recent MDS dated [DATE] indicated Resident #20 had no speech, rarely or never understood others, and was rarely or never understood by others. The MDS indicated he had short and long-term memory problems. The MDS indicated he had other behavioral symptoms and indicated these other behavioral symptoms were observed daily for the 7-day look back period. The MDS indicated Resident #20 required the total assistance of 2 or more staff for bed mobility and transfer. The MDS indicated Resident #20 had a diagnosis of anxiety. A record review of Resident #20's care plan dated 3/31/21 indicated Resident #20 was dependent on staff for meeting emotional, intellectual, physical and social needs related to cognitive deficits, immobility, and physical limitations. The care plan indicated he was dependent on one staff for bed mobility and 2 staff with a mechanical lift for transfer. The care plan revised on 10/12/22 indicated Resident #20 used antianxiety medication related to an anxiety disorder. The care plan indicated he had a mood problem with a goal of a calmer appearance with no signs or symptoms of anxiety. The care plan indicated he had a [CONDITION(S)] disorder, [CONDITION(S)], gastrostomy tube, [CONDITION(S)], and altered respiratory status. A record review of Resident #20's MAR indicated Resident #20 received prn [MEDICATION(S)]: 1/3/22, 1/10/22, 1/13/22, 1/20/22, 1/27/22, 2/28/22, 3/11/22, 3/17/22, 3/24/22, 3/29/22, 4/30/22. The MAR indicated no PRN [MEDICATION(S)] was given to Resident #20 in May, June, July, or October of 2022. The MAR's were reviewed for 2022. A record review of Resident #20's physician's progress notes dated 1/28/22, 3/4/22, 3/29/22, 4/15/22, 5/20/22, 6/25/22, 7/15/22, and 8/13/22 revealed the note did not address PRN [MEDICATION(S)] for Resident #20. During an interview on 10/13/22 10:31 AM, the NP said Resident #20 was not given [MEDICATION(S)] PRN for anxiety. She said he was given [MEDICATION(S)] for seizures or muscle spasms. She said she was not sure exactly why he was given the [MEDICATION(S)] because she did not have the chart in front of her. She said they could not assess anxiety with Resident #20 because he did not communicate. She said the reason for the prn [MEDICATION(S)] was not anxiety. She said it was put in the computer wrong. During an interview on 10/13/22 at 12:45 PM, RN C said Resident #20 took [MEDICATION(S)] routinely and [MEDICATION(S)] PRN for anxiety. He looked in the computer, saw the documentation, and said Resident #20's last dose of [MEDICATION(S)] PRN was 4/30/22. He said the PRN [MEDICATION(S)] was not given for muscle spasms or for seizures. He said it was ordered for anxiety. He said he checked Resident #20 for anxiety and knew he had anxiety when his heart rate went up and he was moving a lot. He said he had not given him any PRN [MEDICATION(S)]. During an interview on 10/13/22 at 12:56 PM, ADON A said Resident #20 had [MEDICATION(S)] ordered as a routine medication and as a PRN medication. She said both were ordered for anxiety. She said he has episodes of a high heart rate, and his arms would move in jerking motions when he had anxiety. She said his legs did not move much but when he was anxious; his arms would move a lot. She said they gave routine [MEDICATION(S)] and the PRN [MEDICATION(S)] when he had signs of anxiety. ADON A said they could not give the PRN [MEDICATION(S)] for a [CONDITION(S)] because it was not ordered for seizures. She said the PRN [MEDICATION(S)] could only be given for anxiety. She said when he had the anxiety episodes she would try to reposition first then if that did not work, she said she might try Tylenol or ibuprofen. She said she thought the physician should relook at PRN orders. She said the PRN order for [MEDICATION(S)] for Resident #20 should have had a stop or discontinue date of 14 days. She said Resident #20 was ordered the PRN [MEDICATION(S)] medication in 2019. She said it was not acceptable that the medication and order for the medication had not been reevaluated. She said the pharmacist checked the medications monthly and would send the reports to the DON, then the DON gives the copies to the ADON's. She said she gets a copy for her side of the building (West) and the other ADON gets a copy for her side of the building (East). She said she had received something from the pharmacist indicating that the medication ([MEDICATION(S)] prn) should be looked at. She said she did not remember when she got that recommendation. She said she did not remember what she did with it. A record review of the pharmacy recommendations book on 10/13/22 indicated from January 2022 to present date there were no recommendations regarding Resident #20's PRN [MEDICATION(S)]. A record review of Resident #20's progress notes put in by LVN D, dated 4/30/22 for Resident #20 indicated: -7:39 PM [MEDICATION(S)] 1 tablet via G-tube every 6 hours as needed for anxiety. -8:43 PM .Resident was very agitated when first came on shift. Appears to be a tiny better. -9:07 PM Patient tolerated well. Patient is no longer restless and heart rate has decreased to 102 from 138. PRN administration was effective. During an interview on 10/13/22 at 1:16 PM, the DON said she learned today that PRN orders for psychotropics had to have a stop date of 14 days or a rationale from the MD as to why the medication should continue. She said she did not know that until today. She said she talked to the NP again and the NP said the medication for Resident #20 was for a neurostorm. She said the NP discontinued the PRN [MEDICATION(S)] and kept the routine [MEDICATION(S)]. She said she was not sure what could be given to Resident #20 at this time for a neurostorm or for anxiety. She said she would have to check the orders. During an attempted interview on 10/13/22 at 1:29 PM, this surveyor called LVN D. She did not answer, and this surveyor left a message to return the call. She did not return the call. During an interview and record review on 10/13/22 at 1:33 PM, ADON A said she went through the pharmacy recommendations book and did not find anything for January through today of 2022 as far as a recommendations for Resident #20's PRN [MEDICATION(S)]. She said she found one dated 7/29/21-7/30/21 that indicated: 7/29/21-7/30/21 Resident has an order for the following PRN [CONDITION(S)] medication, please follow-up on stop date/rationale for use of DC (discontinue) at this time. [MEDICATION(S)] 1 mg G-Tube every 6 hours, PRN anxiety on 8/3/19. ADON A said she did not remember if she or anyone addressed the recommendation. During an interview on 10/13/22 at 1:56 PM, ADON A said it was the DON's responsibility to make sure the pharmacy recommendations were addressed. During an interview on 10/13/22 01:58 PM, the DON said it was the responsibility of the ADON for that wing to address the pharmacy recommendations. She said ADON A was the ADON for the West Wing, Resident #20's wing. She said it was up to the ADON to put the pharmacy recommendations on the log for the NP and then turn the log in to the DON after the NP reviewed it and made the recommendations. She said she talked to the NP again a few minutes ago and the NP said Resident #20 did not need a PRN order for [MEDICATION(S)] because they had [MEDICATION(S)] in their emergency E-kit. During an interview on 10/13/22 at 2:09 PM, ADON A said she got the West Wing pharmacy recommendations. She said she would go in and look at the pharmacy recommendations and make sure the NP received them for review. She said she was supposed to make sure the NP addressed all pharmacy recommendations and when she did that, she would initial them. She said she would then give them back to the DON. She said the DON took care of all the GDR's. 3. Record review of Resident #54's Admission Record dated 10/12/22 indicated he was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #54's diagnoses included: Psychological Development (focuses on how people grow and change over the course of a lifetime), [CONDITION(S)] (a serious condition that makes it difficult to breathe on your own), malnutrition (lack of proper nutrition), and [CONDITION(S)] status (an opening surgically created through the neck into the trachea (windpipe) to allow direct access to the breathing tube). Record review of Resident #54's MDS dated [DATE] indicated he never made himself understood and never understood others. Resident # 54's cognitive skills for daily decision making revealed he was severely impaired. The MDS indicated Resident #54 required total assist of 1 person with bed mobility, dressing, toileting, bathing and two assist with transfers. The MDS did not indicate any behavior problems. The MDS did reveal resident #54 received a dose of anti-anxiety medication. Record review of Resident #54's revised care plan on 10/12/22 indicated the use of anti-anxiety medication of [MEDICATION(S)] PRN for agitation and the intervention was to give medication as ordered by the physician. Record review of Resident #54's Order Summary Report dated 10/12/22 indicated the resident had an order dated 09/15/22 for [MEDICATION(S)] 1mg, give 1 tablet via J-Tube every six hours as needed for PRN agitation. Record review of Resident #54's MAR dated 10/01/22-10/31/22 revealed [MEDICATION(S)] 1MG, give 1 tablet every six hours via J-tube for agitation started on 09/15/22 was documented as given on 09/18/22, 09/26/22 and 10/07/22. Record review of Resident #54's individual controlled substance record revealed [MEDICATION(S)] 1mg was signed out on 10/07/22 at 9:45p.m. Reviewed Resident #54's physician progress note dated 09/16/22 to start [MEDICATION(S)] 1mg every six hours as needed for agitation on 09/15/22. No further physician progress notes were noted regarding extending [MEDICATION(S)] administration after the 14-day period. During an interview on 10/13/22 at 10:02 a.m., LVN B said she was unaware Resident #54 received a prn dose of [MEDICATION(S)] 1mg longer than the allotted 14 days. LVN B said she knew prn [CONDITION(S)] medication should only be given for 14 days but did not realize it included this population of residents. LVN B said she could see where this could be polypharmacy since Resident #54 had an order for [MEDICATION(S)] and [MEDICATION(S)] and they were both benzodiazepines but was unaware of any harms it could cause. During an interview on 10/13/22 at 12:49 p.m., the Administrator said she was not aware of prn [CONDITION(S)] usage after 14 days, as she was not a nurse. The ADM said she expected the DON, ADON and charge nurses to be responsible for any indication of medication and to ensure they had appropriate diagnosis. Record review of Medication management policy dated 10/01/09, indicated PRN orders for [CONDITION(S)] drugs are limited to 14 days, if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Based on observation, interview and record review the facility failed to ensure the resident had the right to make choices about aspects of his or her life in the facility that were significant for 1 (Resident #19) of 20. The facility failed to honor Resident #19's wishes to have anyone entering her room wear a mask. This failure could place residents at risk for not having the opportunity to exercise their rights of autonomy. Findings included: Record review of a face sheet dated 10/12/22 indicated Resident #19 was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #19's most recent quarterly MDS dated [DATE] indicated Resident #19 was understood and understands. Resident #19's BIMS score was a 13 indicating she was cognitively intact. Record review of Resident #19's most recent comprehensive care plan dated 10/12/22 indicated Resident #19 used anti-anxiety medication [MEDICATION(S)] for an anxiety disorder. The goal of the care plan was the resident would be free from discomfort or adverse reactions related to anti-anxiety therapy. The interventions included monitoring occurrences of target behavior symptoms and documents them per facility protocol. The care plan did not address her preference regarding people wearing a face mask in her room. During an observation on 10/10/22 at 10:06 a.m. revealed Resident #19's large glass window of her room revealed a sign on red paper that indicated for those entering her room to put on a mask due to Resident #19's request; even if the person was were vaccinated. Outside of Resident #19's room were two different sizes of masks available for use. During an observation and interview on 10/11/22 at 8:29 a.m. revealed Housekeeper E entered Resident #19's room and began cleaning the room. Resident #19 was asleep when Housekeeper E entered her room. Housekeeper E cleaned the entire room without a mask on. Housekeeper E stated she was told today they did not have to wear masks due to the Covid 19 virus case numbers in their county. When the surveyor pointed out the sign on red paper on the large window of Resident #19's room, Housekeeper E stated she had not seen the sign. Housekeeper E stated she had worked at the facility for 1 year and 4 months. Housekeeper E stated she could pass on the flu or other infections to Resident #19. Housekeeper E stated she should have respected Resident #19's wishes. During an interview on 10/12/22 at 9:44 a.m., Resident #19 stated there were staff who entered her room without their mask on . Resident #19 said she had to tell them to please put on a mask. Resident #19 said reminding the staff to wear their masks made her upset. Record review of an in-service dated 09/28/22 indicated per Resident #19's request all staff were to wear a mask when in her room. The in-service was not signed by Housekeeper E. During an interview on 10/13/22 at 1:29 p.m., the DON stated the first-time staff could go without their masks Resident #19 became anxious. The DON indicated Resident #19 had requested a sign be put up for anyone to wear a mask when they entered Resident #19's room. The DON stated not wearing a mask was not respecting Resident #19's rights. The DON stated monitoring occurred with the company neighbor program. The company neighbor program ensures resident needs were met by doing monitoring rounds on assigned residents each day. The DON indicated all department heads were given rooms to monitor. The DON she expected the ADON assigned to this wing make rounds routinely throughout the day. During an interview on 10/13/22 at 1:40 p.m., the Administrator stated anyone who entered Resident #19's room should wear a mask. The Administrator stated wearing the mask protected Resident #19's rights. The Administrator stated she was responsible for ensuring Resident #19's rights were protected. Record review of a Resident Rights policy and procedure dated 2016 indicated Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: b. Be treated with respect, kindness, and dignity. e. Self-determination h. Be supported by the facility in exercising his or her rights.

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 disease and infection including incontinent care and hand hygiene for 2 of 20 residents (Resident #22 and Resident #72) reviewed for infection control, in that: The facility failed to ensure CNA F provided proper incontinent care for Resident #22. The facility failed to ensure LVN B provided proper Foley catheter care for Resident #72. These deficient practices could place residents at risk for infection due to improper care practices. Findings include: 1. Record review of Resident #22's Admission Record dated 10/13/22 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #22's MDS dated [DATE] indicated he never made himself understood and never understood others. Resident #22's cognitive skills for daily decision making revealed he was severely impaired. The MDS indicated Resident #22 required total assist of 1 person with bed mobility, dressing, toileting: two persons assist with bathing and transfers. The MDS indicated Resident #22 was always incontinent of bowel and bladder. Record review of Resident #22's care plans for the problem area of ADL's revealed the resident had an ADL self-care performance deficit r/t profound intellectual disability. Interventions reflected the resident was totally dependent on one staff for incontinent care During an observation and interview on 10/10/22 at 10:31 a.m. revealed the surveyor walked in on CNA G and CNA F providing incontinent care to Resident #22. CNA F was attempting to clean bowel from Resident #22's buttock area. CNA F started wiping front to back, then side to side and back to front without changing wipes or changing gloves with soiled bowel noted on her gloves. The Surveyor asked about incontinent care and CNA G said CNA F did not wipe the right way, CNA F wiped side to side, back to front and used her wipe more than 1 time before changing her gloves. CNA G said she should have stopped CNA F when she saw she was not doing proper incontinent care, but she did not think about it till CNA F had completed incontinence care. CNA F said she could have done the wiping better because she used the wipe twice and did not wipe front to back. CNA F said she was trying to hurry and get the resident clean and did not change her gloves when they were soiled. CNA F said wiping incorrectly or not changing gloves properly can cause infection. During an interview on 10/12/22 at 9:33 a.m., CNA G said wiping back to front during incontinent could cause infection and UTIs. During an interview on 10/12/22 at 10:58 a.m., LVN B said incontinent care should be done from front to back to keep bacteria away. LVN B said if incontinent care was not preformed properly it could lead to UTIs or some type of infection. During an interview on 10/13/22 at 1:02 p.m., the Administrator said she expected staff to do incontinent care the right way every time. The ADM said she expects staff to change their gloves and wash their hands during care. The ADM said she expected the Education Coordinator, the ADON and the DON to follow up on any incontinent care education. The ADM said not washing hands, changing gloves, or wiping properly could cause an infection During an interview on 10/13/22 at 1:57 p.m., the ADON said staff should wipe front to back when providing incontinent care and change their gloves when going from dirty to clean to prevent infections or UTIs. The ADON said the Education Coordinator was the person responsible for making sure staff were properly trained on incontinence care and the DON was the overseer. 2. A record review of the undated face sheet indicated Resident #72 admitted to the facility on [DATE] and readmitted on [DATE]. The face sheet indicated he was a [AGE] year old. A record review of Resident #72's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #72's most recent MDS dated [DATE] indicated Resident #72 had long and short-term memory problems. The MDS indicated he required the total assistance of one staff for bed mobility and two or more stuff for transfer. The MDS indicated he required the total assistance of one staff for toilet use and had a catheter. A record review of Resident #72's undated care plan indicated Resident #72 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, immobility, and physical limitations. The care plan indicated Resident #72 was dependent on one staff for bed mobility and toilet use and 2 staff for transfer, and had a catheter. During an observation and interview on 10/12/22 at 2:05 PM revealed LVN B provided supra pubic catheter care for Resident #72 with ADON A assisting. LVN B did not change her gloves once they were dirty. She used the same gloves throughout care. After providing catheter care, LVN B put her dirty gloves on Resident #72's clean brief and on the underpad (bed pad under Resident #72) on the bed. She said she should have used her hand sanitizer and changed her dirty gloves after cleaning the catheter. She said she put her dirty gloves on Resident #72's underpad and his brief. During an interview on 10/12/22 at 2:15 PM, ADON A said LVN B should have changed her gloves and washed her hands after cleaning the catheter and before touching Resident #72's brief and underpad. She said the risk of using dirty gloves on clean areas was infection transmission. During an interview on 10/12/22 at 2:55 PM LVN B said the risk of using dirty gloves to touch clean items was cross-contamination, transfer of infection to residents or staff and it was an infection control issue. During an interview on 10/13/22 8:16 AM, the Administrator said she expected staff to change their gloves when they switched from clean to dirty and back to clean. She said after the resident was prepped for catheter care the staff should wash their hands and change gloves. She said then the staff would clean the catheter tube and the resident's stomach then change gloves again before repositioning the resident. She said the risk of using dirty gloves to reposition the resident and touching clean things was transmitting infections. The Suprapubic Catheter Care Policy dated October 2010 indicated: 6. Wash around the catheter site with soap and water .Wash the outer part of the catheter tube with soap and water . 10. Remove gloves and discard in designated container. Wash and dry your hands thoroughly . 13. Reposition the bed covers. Make the resident comfortable. Record review of the Perineal Care policy dated February 2018 did not revealed when to change gloves or wash hands during the actual perineal care procedure.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen. 1. The facility did not label and date all food items stored in the refrigerator and freezer. 2. The facility did not ensure compromised food items with fuzzy green areas were discarded from the refrigerator. 3. The facility did not close and seal the large storage bin's lid tightly. 4. The facility did not ensure stored food items were not exposed to air. 5. The facility did not ensure food items and paper goods were not stored on the floor. 6. The facility did not ensure food service equipment was cleaned. 7. The facility did not ensure chlorine test papers was not expired. 8. The facility did not ensure meat was not stored on top of non-meat food items. These failures could place the residents at risk of foodborne illness. Findings included: 1. During an observation on [DATE] at 10:15 a.m., two bags of frozen meat were not labeled. During an observation on [DATE] at 10:15 a.m., eight bags of what appeared to be chicken breast were not labeled. During an observation on [DATE] at 10:16 a.m., two bags of what appeared to be chopped chicken breast were not labeled. During an observation on [DATE] at 10:16 a.m., one bag of what appeared to be hot dogs or sausage links was not labeled. During an observation on [DATE] at 10:16 a.m., two bags of what appeared to breaded chicken nuggets were not labeled. During an observation on [DATE] at 10:17 a.m., one bag of what appeared to be bread shrimp was not labeled. During an observation on [DATE] at 10:17 a.m., one large box of powdered food thickener was not dated. During an observation on [DATE] at 10:20 a.m., one large plastic jar of yellow mustard was not dated. During an observation on [DATE] at 10:20 a.m., five small, clear containers of yellow pudding were not dated. During an observation on [DATE] at 10:21 a.m., seventeen cups of liquid were not dated or labeled. During an observation on [DATE] at 10:21 a.m., one clear bag with 6 what appeared to be bagels were not labeled. During an observation on [DATE] at 10:22 a.m., two boxes of strawberry yogurt were not dated. During an observation on [DATE] at 10:22 a.m., one large tub of mustard potato salad was not dated. 2. During an observation on [DATE] at 10:45 a.m., six bags of 12 count hot dog buns stored in the refrigerator had fuzzy green areas on the bottom part of the buns. 3. During an observation on [DATE] at 10:20 a.m., a lid on one large container of powdered cheese sauce was not tightly sealed. During an observation on [DATE] at 10:20 a.m., a lid on one large container of cornbread meal was not tightly sealed. 4. During an observation on [DATE] at 10:15 a.m., one box of sausage patties was exposed to air. The patties were in a bag that was not sealed. During an observation on [DATE] at 10:15 a.m., one box of sausage rolls was exposed to air. During an observation on [DATE] at 10:16 a.m., one frozen opened bag of French fries had small tears in the bag, causing exposure to air. 5. During an observation on [DATE] at 10:20 a.m., three stacked boxes of chips were stored directly on the floor of a freezer that was not in use. During an observation on [DATE] at 10:20 a.m., one large box of cups was stored directly on the floor of a not in use freezer. 6. During an observation on [DATE] at 10:21 a.m., the deep fryer was visualized with dark brown grease and beige/ brown floating particles around the perimeter. 7. During an observation on [DATE] at 3:00 p.m., Dietary Aide/ Cook H performed final rinse chemical sanitization test with expired precision Chlorine test paper. 8. During an observation on [DATE] at 10:16 a.m., one box of frozen hamburger patties was stored on top of a box of waffles and two boxes of egg rolls. During an interview on [DATE] at 12:24 p.m., the assistant dietary supervisor said she has been working at this facility for [AGE] years. The assistant dietary supervisor said she expected food items to be labeled and dated appropriately. She said the facility writes the date when the product is received and should label items removed from its original packaging. The assistant dietary supervisor said all dietary staff know how to label and date appropriately, some of the new staff members chose not to. She said they have been working with a skeleton crew due to illnesses. The assistant dietary supervisor said she returned to work yesterday, and the dietary supervisor could not return until Saturday. She said she noticed the unlabeled and undated items and corrected the non-compliance. The assistant dietary supervisor said the dietary staff have received in-services on storage and labeling. She said it was important to date and label food items to know when it was received and when it needs to be discarded. The assistant dietary supervisor said it was her and dietary supervisor responsibility to ensure proper labeling and storage was done. She said things probably got missed due to short staffing and illnesses among the regular staff. The assistant dietary supervisor said the dietary aides were responsible for checking the expiration date on the test strips. She said it was the dietary supervisor responsibility to ensure dietary aides used non expired chlorine test papers. During an interview on [DATE] at 12:47 p.m., dietary aide/cook H said she has been working for the facility for 5 years. She said they date and label food items when they receive them. The dietary aide/cook said they label food items not in the original packaging. She said it was important to label and dated food items to ensure spoiled items were not getting served to the residents. She said she knew food items and paper goods should not be stored on the ground. The dietary aide/cook said she knows to tightly seal lids on containers after use. She said it was all dietary staff responsibility to ensure the policies and guidelines were being followed. The dietary aide/cook H said it was the dietary aide's job to manage the dishwasher and test paper. She said the dietary supervisor normally makes sure the chlorine test papers were not expired but she has been out sick. During an interview on [DATE] at 12:55 p.m., dietary aide J said she has been working at the facility for 2 years. She said it was her responsibility to clean and label and date food. Dietary aide J said she knew food items should be labeled when not stored in its original packaging. She said she knew things should not be stored on the floor. Dietary aide J said the dietary supervisor normally oversee the dietary aides to ensure labeling and dating food was happening. She said it was not getting done because so many staff members were out sick and the other staff members could only do some much. She said it was important to label and date food so old food was not getting served. Dietary aide J said she knew to securely close lids on containers so food would not go bad. She said it probably did not get done because someone got busy and forgot to tightly close the lid. Dietary aide J said it was the dietary aide's responsibility to check the expiration date on the chlorine test paper. She said the dietary supervisor normally makes sure they are not using expired chlorine test paper. During an interview on [DATE] at 1:07 p.m., the DON said she expected the dietary staff to date food items when it was received and opened. She said she expected the staff to securely seal lids on containers. The DON said she expected food to not have green fuzzy areas stored in the refrigerator. She said she expected the chlorine test papers to not be expired. The DON said she did not want the residents to receive compromised food. She said the residents deserved quality food and service from the facility. The DON said it was primarily the dietary supervisor then the administrator responsibility to ensure quality food and service to the residents. She said she would attempt to locate the dietary staff's in-service training, but the dietary supervisor normally monitored and kept records of their training. During an interview on [DATE] at 1:31 p.m., the administrator said she expected the dietary staff to follow the policy and procedure concerning dry and refrigerator and freezer storage. The administrator said she was not happy to hear about the hot dog buns with fuzzy green areas in refrigerator. She said the deep fryer had old grease from last Friday. The administrator said it was cleaned yesterday and new grease was bought today. She said the dietary staff was short staffed due to positive COVID-19 members. The administrator said she expected the dietary aides to maintain current test papers to ensure adequate results and clean dishes. Record review of a undated facility dry storage policy revealed .no food, paper goods or chemicals can be stored on the floor .all items must be dated with the date that the food was delivered .if a food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated .if an item is opened, the food must be tightly sealed .lids on spices should be closed . Record review of a undated facility refrigerator and freezer storage policy revealed no food can be stored on the floor .all items must be dated with the date that the food was delivered . if a food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated .food is dated so that the food delivered first can be used . if an item is opened, the food must be tightly sealed . Record review of a sanitization policy dated ,d+[DATE] revealed the food service are shall be maintained in a clean and sanitary manner .all utensils, counters, shelves, and equipment shall be kept clean .all equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils .

Based on observation, record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental and psychosocial needs for 5 of 18 residents (Residents #81, #82, #68, #38 and #55) reviewed for care plans The facility did not ensure Resident #81's care plan indicated the use of a privacy bag or cover for the urine collection bag. The facility failed to implement care plans that addressed triggered areas on the Care Area Assessment (CAA) Summary and/or areas for the individual needs for Resident's #81,#82, #68, #38 and #55. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental and psychosocial outcome. Findings included: 1. A record review of a face sheet dated 8/25/2021 at 9:00am revealed Resident # 81 was a [AGE] year-old-male that admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of order summary report dated 8/25/2021 at 9:00am revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also revealed Resident #81 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of an MDS dated [DATE] indicated Resident #81 was rarely to never understood and rarely to never understood others. The MDS indicated Resident #81 was unable to complete the Brief Interview of Mental Status, had short- and long-term memory impairment, and had severely impaired cognitive skills for daily decision making. The MDS indicated that Resident #81 required dependent assistance with ADLs and had an indwelling catheter. A record review of a care plan with a revision date of 7/27/2021 revealed a care plan for Resident #81's suprapubic catheter with an intervention to position catheter bag away from door for privacy. There was no mention of a privacy bag or cover for the urine collection bag. During an observation from the doorway on 8/23/2021 at 10:40am, Resident #81's urine collection bag was positioned at the foot of the bed and revealed 200 cc of dark amber urine to collection bag. During an observation on 8/23/2021 at 1:55 pm, Resident #81's urine collection bag was positioned on the frame on the left side toward the foot of the bed with no privacy bag or cover. During an observation on 8/24/2021 at 3:19 pm, Resident #81's urine collection bag was positioned on the frame on the left side toward the foot of the bed with 400 cc of amber urine to collection bag. During an interview on 08/25/20 at 10:40 a.m., LVN B revealed she looked at care plans anytime there is a change with a resident and for new admissions. She said she expected for interventions to be followed by the nursing staff. She said Resident #81 did normally have a catheter bag cover. She was unaware that he did not have one the past two days. She stated CNA's are responsible for placing catheter's in the bags. During an interview on 08/25/2021 at 11:00 a.m., RN E, the nurse assigned to the resident, revealed he looked at the care plans daily. He said he always looks at the interventions and the interventions should be followed by all staff. He said he did not know why there had not been privacy covers on the urine collection bag of Resident #81. He stated it was the responsibility of all nursing staff to ensure that interventions listed on the care plans are carried out. During an interview on 8/25/2021 at 1:00 pm the DON stated it was the responsibility of the MDS nurse to create the care plan and the nursing staff to read and communicate the interventions needed for each resident that are listed on the care plan to the entire team that is carrying for the resident. The DON stated the care plans were one of the tools used to know the individual needs of each resident and they must be followed to ensure the highest quality of care. During an interview on 8/25/2021 at 1:15 pm the Administrator stated it was the responsibility of the nurses to read the care plans and follow the listed instructions to ensure the residents are cared for as they should be. The Administrator stated it was the nursing department's responsibility to make sure all areas were communicated to one another. The 24-hour report was the communication tool used to ensure this happened. 2. Record review of consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #82 was sometimes understood and sometimes understood others. A BIMS (Brief Interview for Mental Status) was not conducted due to Resident #82 being rarely understood. The MDS indicated Resident #82 was totally dependent on staff for all ADLs. Record review of the care plan dated 07/27/2021 indicated Resident #82 was dependent on staff for meeting emotional, intellectual, physical and social needs. Resident #82 had an ADL self-care performance deficit. The care plan indicated Resident #82 had an indwelling catheter related to a [CONDITION(S)] (damage in the nervous system causing the bladder to not function properly). An intervention dated 11/12/2020 indicated the catheter bag should be positioned away from the door. An observation on 08/23/2021 at 10:39 a.m., revealed Resident #82 resting his left side in bed. The urine catheter collection bag was hanging on the left side of the bed with approximately 300 milliliters of urine present in the bag. The urine collection bag was not covered with a privacy bag. An observation on 08/24/2021 at 10:05 a.m., revealed Resident #82 resting in his bed. The urine catheter collection bag was hanging on the right side of the bed facing the doorway. The collection bag was visible from outside of the room. The collection bag had approximately 100 milliliters of urine present in the bag. The urine collection bag was not covered with a privacy bag. During an interview on 08/25/20 at 10:40 a.m., LVN B revealed she looks at care plans anytime there is a change with a resident and for new admissions. She said she does expect for interventions to be followed by the nursing staff. She said she hadn't taken care of Resident #82 and she wasn't sure why he didn't have a privacy bag. During an interview on 08/25/2021 at 11:00 a.m., RN E revealed he looks at the care plans daily. He said he always looks at the interventions and the interventions should be followed by all staff. He said he did not know why there had not been privacy covers on the urine collection bag of Resident #82. 3. The consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicate Resident #68 required the total assistance of two or more staff for bed mobility and transfer. The MDS, section H0100 was marked None of the above. Indwelling catheter was a choice in section H0100 and was not selected. The care plan dated 7/8/21 indicated Resident #68 required the assistance of one staff for bed mobility and required 2 staff with a hoyer lift for transfer. The care plan indicated Resident #68 had a potential for bladder incontinence. The care plan did not indicate he had foley catheter. (A device placed in the penis for urine flow.) During a record review on 8/25/21 at 10:48 a.m. revealed Resident #68's foley catheter was not on his care plan. During an interview on 8/25/21 at 10:52 a.m., RN A said Resident #68 was not care planned for a foley catheter. (A device placed in the penis for urine to flow from.) She said she checked the care plan and there was nothing on the care plan regarding a foley, but since he had a foley it should be on the care plan. During an interview on 8/25/21 at 10:56 a.m., LVN B said Resident #68 was not care planned for a foley catheter. She said he had a foley catheter so he should have been care planned for one. During an interview on 8/25/21 at 11:11 a.m., MDS C nurse said she did not care plan Resident #68's foley catheter. She said she should have known he got the foley from the 24-hour report, or from the Clinical Standards meeting that was held weekly, or from the nurse that placed the foley catheter telling her. During an interview on 8/25/21 at 12:22 p.m., ADON D said Resident #68 got the foley on 7/2/21. She said his care plan did not indicate he had a foley catheter and it should have indicated he had a foley catheter. She said the MDS nurse should have seen the information on the 24-hour report, or the nurse that took the order could have told her, or she, herself should have told her. The ADON said she Resident #68 should have been care planned for the foley catheter because that is how the staff knows what is going on with the resident. During an interview on 8/25/21 at 12:26 p.m., RN E said he received the order to place the foley for Resident #68 on 7/2/21. He said he did not tell the MDS nurse about the order for the foley catheter. He said he wrote it on the 24-hour report. During an interview on 8/25/21 at 12:40 p.m., the DON said Resident #68 should have been care planned for the foley catheter because that is staff's way of knowing how to care for the resident. A record review on 8/25/21 revealed RN E indicated in the nurse's notes Resident #68 had gotten a foley catheter. During an interview on 8/25/21 at 1:06 p.m., the DON said the information regarding the foley catheter did not get communicated to the MDS nurse. She said the MDS nurse could have viewed the 24-hour report or heard them talking about it at the stand-up meeting they all attend in the mornings. She said the day and night nurse wrote on the 24-hour report. She said the day nurse that wrote on the 24-hour report was RN E who placed the foley catheter and indicated on the 24-hour report Resident #68 had gotten a foley catheter. During a record review of the 24-hour report dated 7/2/21 indicated Resident #68 had a foley placed. The 24-hour report indicated Resident #68 and foley placed and flushed at 4:30 p.m. During an interview on 8/25/21 at 1:09 p.m., the MDS nurse said she was at the morning meeting when the discussion took place about Resident #68 getting the foley. She said there must have been a miscommunication or something because she did not write that information down and she usually wrote down new information. She said she did not know how she had missed it. She said the MDS she did on 7/16/21 for #68 was not coded for a foley catheter and it should have been. During an interview on 8/25/21 at 1:38 p.m., the DON said LVN F, the night nurse had written on part of the 24-hour report dated 7/2/21 and RN E had written on part of it. 4. A record review of the face sheet dated 8/25/2021 indicated Resident #38 was an 8-year-old female that admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of an MDS dated [DATE] indicated Resident #38 was rarely to never understood and rarely to never understood others. The MDS indicated Resident #38 was unable to complete the Brief Interview of Mental Status, had short- and long-term memory impairment, and had severely impaired cognitive skills for daily decision making. The MDS indicated that Resident #38 required dependent assistance with ADLs and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated Resident #38 received 7 days of antianxiety medications. The Care Area Assessment (CAA) portion of the MDS indicated a care area trigger for [CONDITION(S)] medication use related to the use of antianxiety medications. A record review of a comprehensive care plan dated 6/21/2021 for Resident #38 revealed no care plan was created for the triggered CAA for [CONDITION(S)] medication usage. A record review of order summary report dated 8/25/2021 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with the MDS nurses on 8/25/2021 at 12:10 pm, she stated when she created a comprehensive care plan, she care planned any CAA area triggered, as well as, diagnosis, medications and acute conditions that may occur such as infections. She stated she updated the care plans when she was informed of new orders or condition changes in daily stand up meeting or weekly standards of care meeting. The MDS nurse stated it was important to care plan all areas of the Resident's care because it was the main source of care instruction for the staff to provide quality care to the residents. She stated she must have been going too fast and overlooked that CAA. The MDS nurse stated for a [CONDITION(S)] medication care plan the interventions would include side effects of the medications to monitor the resident for, as well as, adverse effects of the medications to monitor for. During an interview on 8/25/2021 at 1:00 pm the DON stated the care plans were one of the tools used to know the individual needs of each resident and they must be followed to ensure the highest quality of care. The resident could be at risk for not receiving proper care without the proper care plan. During an interview on 8/25/2021 at 1:15 pm the Administrator stated it was the responsibility of the interdisciplinary team to ensure all care plans are created that ensure the highest quality of care for each resident. The facility has weekly standards of care meetings and quarterly care plan meetings to ensure all areas are covered in the care plan for each resident. 5. A record review of the face sheet dated 8/25/2021 indicated Resident #55 was a 4-year-old female that admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of an MDS dated [DATE] indicated Resident #55 was rarely to never understood and rarely to never understood others. The MDS indicated Resident #55 was unable to complete the Brief Interview of Mental Status, had short- and long-term memory impairment, and had severely impaired cognitive skills for daily decision making. The MDS indicated that Resident #55 required dependent assistance with ADLs. The MDS indicated the application of ointments/medications other than to feet occurred for Resident #55. A record review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the care plan dated 7/6/2021 on 8/25/2021 for Resident #55 revealed no care plan was created for skin infection, impaired skin integrity, rash ,antibiotic usage or anything pertaining to the skin to guide staff in providing quality resident specific care for Resident #55's individual needs. During an observation on 8/23/2021 at 10:33 am, Resident #55 was noted to have a medium brown complexion and have a visible rash to bilateral forearms and cheeks. The rash on the forearms was red with a mixture of weeping and crusted [CONDITION(S)] (6-8 [CONDITION(S)] approximately 0.1 to 0.2 cm in diameter to each arm). The rash to Resident #55's face was red and fine with no [CONDITION(S)] noted. During an observation on 8/24/2021 at 11:10am, Resident #55 was noted with the rash to the bilateral forearms and cheeks. The rash to the forearms remained red with areas of weeping and crust noted to the tiny [CONDITION(S)]. The face rash was red with no [CONDITION(S)] noted. During an interview on 8/24/2021 at 11:16 am, LVN B stated Resident #55 got the rash on and off. LVN B stated they were not sure what caused the rash. She stated when it became red or started to weep, they would call the doctor and report the change and he would order a treatment or antibiotics for it. During an interview with the MDS nurses on 8/25/2021 at 12:10 pm, she stated when she created a comprehensive care plan, she care planned any CAA area triggered, as well as, diagnosis, medications and acute conditions that may occur such as infections. She stated she updated the care plans when she was informed of new orders or condition changes in daily stand up meeting or weekly standards of care meeting. The MDS nurse stated it was important to care plan all areas of the Resident's care because it was the main source of care instruction for the staff to provide quality care to the residents. She stated she must have been going too fast and overlooked that CAA. The MDS nurse stated for a [CONDITION(S)] care plan the interventions would include side effects of the medications to monitor the resident for, as well as, adverse effects of the medications to monitor for. During an interview on 8/25/2021 at 1:00 pm the DON stated the care plans were one of the tools used to know the individual needs of each resident and they must be followed to ensure the highest quality of care. During an interview on 8/25/2021 at 1:15 pm the Administrator stated it was the responsibility of the interdisciplinary team to ensure all care plans are created that ensure the highest quality of care for each resident. The facility has weekly standards of care meetings and quarterly care plan meetings to ensure all areas are covered in the care plan for each resident. A comprehensive Assessments and the Care Delivery Process dated December 2016 provided by the DON on 8/25/21 indicated: Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Based on observation, interview and record review, the facility failed to complete an accurate assessment to reflect the status for 1 of 19 residents reviewed for assessments. (Residents #68) The facility did not ensure Resident #68's assessment was completed accurately. He was not marked for his Foley catheter. This failure could place residents at risk for decreased quality of care due to inaccuracy of assessments. Findings included: The consolidated physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] indicate Resident #68 required the total assistance of two or more staff for bed mobility and transfer. The MDS, section H0100 was marked None of the above. Indwelling catheter was a choice in section H0100 and was not selected. The care plan dated 7/8/21 indicated Resident #68 required the assistance of one staff for bed mobility and required 2 staff with a hoyer lift for transfer. The care plan indicated Resident #68 had a potential for bladder incontinence. The care plan did not indicate he had foley catheter. During an interview on 8/25/21 at 11:11 a.m., MDS C nurse said she did not care plan Resident #68's foley catheter. She said she should have known he got the foley from the 24-hour report, or from the Clinical Standards meeting that was held weekly, or from the nurse that placed the foley catheter telling her. During an interview on 8/25/21 at 12:26 p.m., RN E said he received the order to place the foley for Resident #68 on 7/2/21. He said he did not tell the MDS nurse about the order for the foley catheter. He said he wrote it on the 24-hour report. During a record review of a nursing note dated 7/2/21 completed by RN E indicated Resident #68 received a Foley catheter. During an interview on 8/25/21 at 1:06 p.m., the DON said the information regarding the foley catheter did not get communicated to the MDS nurse. She said the MDS nurse could have viewed the 24-hour report or heard them talking about it at the stand-up meeting they all attend in the mornings. She said the day and night nurse wrote on the 24-hour report. She said the day nurse that wrote on the 24-hour report was RN E who placed the foley catheter and indicated on the 24-hour report Resident #68 had gotten a foley catheter. During a record review on 8/25/21 at 1:08 p.m. the 24-hour report dated 7/2/21 indicated Resident #68 had a Foley placed. The 24-hour report indicated the resident's name and foley placed and flushed at 4:30 p.m. During an interview on 8/25/21 at 1:09 p.m., the MDS nurse said she was at the morning meeting when the discussion took place about Resident #68 getting the foley. She said there must have been a miscommunication or something because she did not write that information down and she usually wrote down new information. She said she did not know how she had missed it. She said the MDS she did on 7/16/21 for Resident #68 was not coded for a Foley catheter and it should have been. During an interview on 8/25/21 at 1:38 p.m., the DON said LVN F, the night nurse had written on part of the 24-hour report dated 7/2/21 and RN E had written on part of it. A comprehensive Assessments and the Care Delivery Process dated December 2016 provided by the DON on 8/25/21 indicated: Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents were provided for 1 of 7 residents reviewed for accidents. (Resident #1) The facility did not implement the care plan for Resident #1 regarding transfers. CNA A transferred Resident #1 with a Hoyer lift from bed to shower gurney without two-person assistance as indicated in the plan of care. Resident #1 was sent to the emergency room after she fell off the shower gurney during the transfer where she received a staple (used to close wound too complex to close with traditional stitches) to a laceration to her right forehead. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents who required assistance for transfers at risk of further injury. Findings included: A face sheet dated 06/12/2020 indicated Resident #1 was [AGE] years old, admitted [DATE] with diagnoses including [CONDITION(S)], symptomatic [CONDITION(S)] and epileptic syndromes, unspecified convulsions, unspecified intellectual disabilities, and [CONDITION(S)]. An MDS dated [DATE] indicated Resident #1 required total assistance with ADLs and required two-person physical assistance with transfers. A care plan dated 03/09/2020 Resident #1 had an activities of daily living self-care performance deficit related to [CONDITION(S)] and required a Hoyer lift with two staff members assistance for transfers. During an observation on 06/12/2020 at 10:55 a.m., Resident #1 was in her room lying in bed. Resident #1 was unable to answer questions and was unable to be interviewed. An Incident note dated 03/13/2020 at 12:30 a.m., written by LVN B, indicated Resident #1 was on the floor. CNA stated she was going to take the resident to the shower and put her on the gurney. The gurney side rail was noted to be down. There was blood coming from Resident #1's head area and approximately 1 cm laceration to the right frontal area. EMS was called to transport to the hospital for evaluation. A hospital discharge record dated 03/13/2020 indicated Resident #1 had a laceration with foreign body of scalp due to a fall from bed and had a suture to her scalp. Nurses notes dated 03/13/2020 at 5:52 p.m. written by LVN C indicated Resident #1 returned from the hospital at 7:00 a.m. by ambulance with one staple to the right top area of her head. A witness statement dated 03/13/2020 written by RT D indicated she saw Resident #1 on the floor and CNA A about 3 to 4 feet away near the mechanical lift. The note indicated RT D moved the shower gurney and noted the side rail was down. A witness statement dated 03/13/2020 written by RN E indicated she saw Resident #1 on the floor. CNA A told her she transferred Resident #1 by herself. A provider investigation report dated 03/13/2020 completed by the DON indicated on 03/13/2020 CNA A transferred Resident #1 with a Hoyer lift from bed to shower gurney with no assistance. CNA A said Resident #1 rolled off the shower gurney when she removed the Hoyer lift straps from the lift. CNA A said she could not stop Resident #1 from falling. CNA A said she transferred Resident #1 with the Hoyer lift without assistance. The provider investigation report indicated after investigation the findings were confirmed. A disciplinary report dated 03/13/2020 indicated CNA A failed to follow the resident transfer policy and did not have two staff members for a mechanical lift transfer that resulted in a resident fall. CNA A was suspended pending the outcome of the investigation. CNA A's suspension was lifted on 03/20/2020. A disciplinary report signed and dated on 03/23/2020 by CNA A indicated a final disciplinary action notice. Corrective actions to be taken included resident transfer policy and procedure education and competency. During an interview on 06/12/2020 at 3:38 p.m., the DON said Resident #1 could not walk and required a two-person Hoyer lift when transferred. The DON said CNA A transferred Resident #1 with a Hoyer lift without two staff members and the resident fell . The DON said Resident #1 sustained a laceration to her forehead, the resident was sent to the hospital and returned with one staple to her forehead. She said a care plan was used to promote safety when providing care to a resident and Resident #1's care plan indicated she required a two-person Hoyer lift during transfers when the injury occurred. The DON said CNA A did not follow the facility policy and care plan when she transferred Resident #1. The DON said Resident #1 would not have been injured if the policy and care plan were followed. The DON said CNA A was suspended and they conducted a QAPI meeting on 03/13/2020 following the incident. The DON said the facility staff, including CNA A, were in-serviced on operating a Hoyer lift, following residents' care plan to prevent injury, how and where to access a resident's care plan and staff demonstrated how to operate a Hoyer lift. During a phone interview on 06/12/2020 at 4:39 p.m., CNA A said Resident #1 could not walk and required two-person assistance when transferred. CNA A said she could not find a staff member to assist her with Resident #1's transfer because they were busy assisting other residents. CNA A said she became impatient waiting for staff to assist her and transferred Resident #1 with a Hoyer lift from her bed to a shower gurney without two staff members. CNA A said she transferred Resident #1 to the shower gurney and unhooked her from the Hoyer Lift. CNA A said one of the side railing was down and Resident #1 rolled off the side of the gurney where the side rail was down. CNA A said Resident #1 fell on the floor and sustained a laceration. CNA A said the resident was sent to the hospital and returned with one staple to her forehead. CNA A said a care plan was used to promote safety when providing care to a resident. Resident #1's care plan indicated she required a two-person Hoyer lift during transfers when the injury occurred. CNA A said she did not follow the facility policy and care plan when she transferred Resident #1. CNA A said Resident #1 would not have been injured if the policy and care plan were followed. CNA A said following the incident she was suspended, in-serviced on operating a Hoyer lift, following a residents' care plan to prevent injury, how and where to access a resident's care plan. CNA A was able to identify where to find a residents' care plan. An undated Transfer Techniques policy indicated .It is important to remember that each resident is different; transfer techniques may need to be modified for the particular resident to meet their individual needs .transfer training refers to the teaching techniques and use of equipment involved in moving a patient/resident from one surface area to another .Mechanical lift to be utilized when transferring residents who are non-weight bearing and unable/unsafe to be transferred by alternate methods . The surveyor determined the facility was in non-compliance from 03/13/2020 to 03/23/2020. The facility took the following actions to correct the non-compliance: *An in-service dated 03/13/2020 for nursing staff indicated staff were in-serviced on operating a Hoyer lift, following a resident's care plan to prevent injury and how and where to access a resident's care plan. *A Competency Skills Check Off sheet dated 03/13/2020 for nursing staff indicated staff demonstrated transferring techniques including mechanical lift transfers. *An in-service dated 03/23/2020 for CNA A indicated she was in-serviced on operating a Hoyer lift, following a resident's care plan to prevent injury and how and where to access a residents' care plan. *A Competency Skills Check Off sheet dated 03/23/2020 for CNA A indicated she demonstrated competency transferring techniques including mechanical lift transfers. During interviews on 06/12/2020 LVNs F, G, H, CNAs J, K, and L said they were in-serviced on operating a Hoyer lift, following a resident's care plan to prevent injury and how and where to access a resident's care plan. They said they were checked off on how to operate a Hoyer lift. They were able to identify the in-services.

Based on interview and record review, the facility failed to ensure adequate supervision and assistance was provided to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #1) Resident #1 required two people to assist with Hoyer lift transfers. CNA A did not transfer Resident #1 as described on the resident's care plan and MDS assessment. CNA A transferred Resident #1 with a Hoyer lift by herself. Resident #1 received a dislocation of the right hip. This failure contributed to Resident #1's right hip dislocation. This failure could place 90 residents dependent on staff for transfers at risk for injuries or harm. Findings Included: A consolidated physician order [REDACTED].#1, admitted [DATE] and readmitted on [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #1 had severe cognitive impairment and was totally dependent on staff for all activities of daily living. The MDS indicated Resident #1 required two person assistance for bed mobility and transfers. A care plan dated 05/20/15 indicated Resident #1 had a potential for injury and fracture due to osteopenia and chronic left hip dislocation. Interventions listed on the care plan indicated Resident #1 used a Hoyer lift for transfers with 2 person assistance. A Provider of Self-Reporting of Incidents submitted 8/31/15 indicated Resident #1 required total care, was not ambulatory, and was non-interviewable. The report indicated the resident was crying while being turned and repositioned. The report indicated the resident had swelling to the right upper thigh and the resident was given an as needed pain medication. The report indicated the dislocation of the right hip was determined by x-ray. A radiology report dated 08/31/15 indicated Resident #1 had a dislocation of the right hip. During an interview on 09/03/15 at 1:30 p.m., CNA A said on 08/31/15, she transferred Resident #1 from the bed to the wheelchair using a Hoyer lift. CNA A said she showered Resident #1 then took the resident back to her room. She said Resident #1 was not crying or making any facial grimacing at the time. She said RT B came out of Resident #1's room 2 hours later and asked her had she ever seen the resident cry. CNA A said she went into Resident #1's room and saw the resident crying. CNA A said LVN C touched Resident #1 on the right leg and the resident started crying. CNA A said this was her first time using the Hoyer lift during a transfer for Resident #1. CNA A said she used the Hoyer lift because the resident was too heavy for her to transfer by herself. CNA A said she usually transferred the resident with a sheet with help from another staff. CNA A said her last in-service on transfers was a couple of months ago. She said she was not retrained on transfers after the incident occurred with Resident #1. During an interview on 09/03/15 at 1:33 p.m., LVN C said on 08/31/15, RT B reported Resident #1 was crying. LVN C said she did a general assessment on the resident and when she touched the resident's right hip the resident frowned. LVN C said the right hip was not swollen or red but it was tender to touch. She said she got a telephone order for an X-ray to the right hip. LVN C said she administered Resident #1 Tylenol for pain. During an interview on 09/04/15 at 8:30 a.m., RT B said on 8/31/15, CNA B was going to give Resident #1 a shower. She said she did not notice Resident #1 crying or making any facial grimacing at that time. RT B said 2 hours later she noticed Resident #1 crying. RT B said she noticed the resident's heart rate was elevated, which usually indicated she was either in pain or incontinent. RT B said LVN C and CNA A repositioned Resident #1. She said when they touched Resident #1's right hip, she started crying. During an interview on 09/03/15 at 12:30 p.m., the DON said their policy and procedure regarding Hoyer lift transfers required two people perform the transfer. She said the last in-service on transfers was in June 2015. She said CNA A was not trained after the incident because they could not reach her. An incidents and accidents prevention system policy dated 11/02 indicated: .Mechanical or Electric Lift to be utilized when transferring residents who are non-weight bearing and unable/unsafe to be transferred by alternate methods .Mechanical and electric lift transfers must always be done with 2 staff members present. The CMS 672 dated 09/03/15 indicated 90 residents required assistance with transfers.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent the development and worsening of pressure sores for 1 of 5 residents reviewed for pressure sores. (Resident #4) Resident #4 developed a Stage II pressure sore to his right hip in December 2013. The pressure sore deteriorated to a Stage IV with tunneling to the bone as of August 2014. The wound care physician recommended surgical intervention on 08/11/14 and a change in treatment to prevent infection. Resident #4 did not see a surgeon for intervention to the Stage IV wound to his right hip. No change in treatment was documented. The ordered treatment was not completed according to physician orders [REDACTED].#4 was not provided pain medication prior to wound care treatments. This failure contributed to the worsening of an existing pressure sore for Residents #4. This failure could place 5 residents with pressure sores at risk for developing new pressure sores and decline in existing pressure sores. Findings included: Physician orders [REDACTED].#4, admitted [DATE], was [AGE] year old with [DIAGNOSES REDACTED]. Resident #4's orders documented to cleanse right hip (ischium) wound with mild soap and water, pack with nugauze ? inch coated with [MEDICATION NAME] gel and cover with dry, protective dressing every day and as needed. This wound care treatment was initiated on 05/27/14. An annual MDS assessment dated [DATE] said Resident #4 ' s cognition was severely impaired. He had no speech and was not able to make himself understood. Resident #4 required total assistance for transfers, bed mobility, dressing, bathing, and personal hygiene. Resident #4 was identified as having a Stage II pressure sore. The most recent quarterly MDS assessment dated [DATE] said Resident #4 ' s cognition was severely impaired. He had no speech and was not able to make himself understood. Resident #4 required total assistance for transfers, bed mobility, dressing, bathing, and personal hygiene. Resident #4 was identified as having a Stage III pressure sore with measurements of 0.2 cm in length, 0.2 cm in width, and 0.4 cm in depth. A nursing care plan dated 08/30/14 said Resident #4's Stage II pressure sore to his right hip was identified on 04/15/14. Interventions included the following: *Reposition every two hours and as needed * Assist with repositioning to avoid skin friction/shearing * Weekly evaluation of wound healing * Daily observation of skin with routine care * Adjust treatment plan if no healing within 2-4 weeks * Monitor for changes in skin status that may indicate worsening of pressure sore and notify the physician. *Cleanse wound to right hip with soap and rise with water, apply santyl to pressure sore, cover with absorptive dressing. Change daily and PRN soiling. * Monitor for pain prior to wound care and medicate per PRN orders. *Adjust my treatment plan if no healing within 2-4 weeks. A Braden scale assessment dated [DATE] said Resident #4 was at high risk for skin breakdown. A care plan dated 08/30/14 said Resident #4 was unable to communicate related to no speech, impaired hearing, [MEDICAL CONDITION], and severe cognitive impairment. Nursing notes for Resident #4 said on 08/28/14 at 2:30 p.m., LVN H spoke with Resident #4's mother related to wound clinic's wound reports which said Resident #4's wound tunnel is to the bone and "infection imminent if ordered treatment continues." Wound clinic physician suggested surgery. Resident #4's mother provided consent for surgery. Contact at the wound care clinic was notified by message of the consent. Wound care clinic notes dated 08/11/14 said bone was present in the wound bed. Documentation noted the physician requested Resident #4's mother be contacted and see if she wanted aggressive plan of care (such as surgery) or a palliative plan of care. The Stage III pressure sore to Resident #4's right hip was debrided and measured at 0.5 cm in length, 0.5 cm in width, and 3.7 cm in depth with moderate amount of drainage. Recommended treatment was clean with mild soap and water and change dressing every day. Coat ? inch of nugauze with silver gel and pack in wound. Cover with a dry protective dressing. Keep weight off the area of wound at all times. Wound care clinic notes dated 08/25/14 said Stage III pressure sore to Resident #4's right hip had large amount of drainage. Measurements of the pressure sore after debridement were 0.4 cm in length, 0.4 cm in width, and 3 cm in depth. Recommended treatments were clean wound with mild soap and water and change dressing daily. Coat ? inch of nugauze with silver gel and pack in wound. Cover with dry, protective dressing. Keep weight off area of wound at all times. Wound care clinic notes dated 09/15/14 said Resident #4's Stage III pressure sore to this right hip was debrided and measured at 0.4 cm in length, 0.4 cm in width, and 2.5 cm in depth. Recommended treatments were clean wound with mild soap and water and change dressing daily. Coat ? inch of nugauze with silver gel and pack in wound. Cover with dry, protective dressing. Keep weight off area of wound at all times. Wound care clinic notes dated 09/30/14 said surgical intervention was discussed as an option, and family interested in doing a flap but not amputation. Referral made to plastic surgeon. Measurements after debridement were 0.3 cm in length, 0.3 cm in width, and 2.1 cm in depth. Recommended treatments were clean wound with mild soap and water and change dressing daily. Coat ? inch of nugauze with silver gel and pack in wound. Cover with dry, protective dressing. Keep weight off area of wound at all times. Wound care clinic notes dated 10/13/14 said Resident #4 was referred to physician for flap. Wound measurements were 0.2 cm in length, 0.2 cm in width, and 0.2 cm in depth. Recommended treatments were clean wound with mild soap and water and change dressing daily. Coat ? inch of nugauze with silver gel and pack in wound. Cover with dry, protective dressing. Keep weight off area of wound at all times. The treatment administration record for October 2014 documented Resident #4's pressure sore to his right hip was ordered to be cleaned with mild soap and water, packed with nugauze ? inch coated with [MEDICATION NAME] gel, and covered with a dry protective dressing every day and as needed. Wound care was documented on the TAR as completed daily. Wound/Skin Healing Record said the following for Resident #4: *On 08/11/14, right hip pressure sore was a Stage 4 with dimensions measured at 0.2 cm in length, 0.4 cm in width, and 2.6 cm in depth with no drainage and no tunneling. Wound bed and surrounding skin color documented as normal for skin. Response to treatment documented as no change. *On 08/21/14, right hip pressure sore was a Stage 4 with dimensions of 0.2 cm in length, 0.2 cm in width, and 0.4 cm in depth with no drainage and no tunneling. Wound bed and surrounding skin color was normal for skin. Response to treatment documented as improved. *On 08/28/14, right hip pressure sore staging was not identified. Measurements were 2 cm in length, 0.1 cm in width, and 3 cm in depth with small amount of drainage. Surrounding skin color pink and wound bed normal for skin. Tunneling noted as 3 cm. Response to treatment documented as deteriorated. *On 09/02/14, pressure sore measurements were 1.4 cm in length, 0.1 cm in width, and 1.7 cm in depth with small amount of drainage. Wound bed and surrounding skin color documented as pink with 1.7 cm of tunneling. Response to treatment documented as improved. *On 09/16/14, pressure sore stage was not identified. Measurements were 0.3 cm in length, 0.1 cm in width, and 4 cm in depth with small amount of drainage. Surrounding skin color documented as pink with 4.0 cm of tunneling. Response to treatment said deteriorated. *On 09/23/14, pressure sore stage was not identified. Measurements were 0.2 cm in length and 3.2 cm in depth with small amount of drainage. Surrounding skin color was pink with 3.2 cm of tunneling. Response to treatment documented as improved. *On 09/30/14, pressure sore stage was not identified. Measurements were 0.3 cm in length, 0.3 cm in width, and 3.0 cm in depth with small amount of drainage. Wound bed noted as normal for skin; surrounding skin color noted as pink. Tunneling documented as 3.0 cm. Response to treatment documented as improved. *On 10/07/14, pressure sore stage was not identified. Measurements were 0.4 cm in length, 0.3 cm in width, and 4.0 cm in depth with small amount of drainage. Wound bed and surrounding skin color noted as normal for skin. Tunneling documented as 4.0 cm. Response to treatment documented as deteriorated. *On 10/14/14, pressure sore stage was not identified. Measurements were 0.3 cm in length, 0.2 cm in width, and 3.0 cm in depth with small amount of drainage. Wound bed and surrounding skin color documented as normal for skin. Tunneling noted as 3.0 cm. Response to treatment documented as improved. *On 10/21/14, pressure sore stage was not identified. Measurements were 0.6 cm in length, 0.6 cm in width, and 0.3 cm in depth with small amount of drainage and approximately 5 cm in tunneling. Wound bed and surrounding skin color was normal for skin. Response to treatment said deteriorated. *On 10/28/14, pressure sore stage was not identified. Measurements were 0.7 cm in length, 0.7 cm in width, and 0.3 cm in depth with small amount of drainage. Wound bed was [MEDICATION NAME] tissue with pink and gray surrounding skin color. Wound had approximately 4.6 cm in tunneling. Response to treatment said deteriorated. During an observation on 10/28/14 at 9:15 a.m., LVN H and LVN A performed wound care for a Stage IV pressure sore on Resident #4's right hip (ischium). LVN A said she held Resident #4's hands because he could get agitated during the treatment. LVN H removed the dressing to Resident #4's right hip. The LVN H then took the wooden portion of a sterile Q-tip and measured the wound by placing the wooden portion at the base of Resident #4's wound. LVN H used the wooden portion of the Q-tip to measure the tunneling of the wound. Wound dimensions were 0.7 cm in length, 0.9 cm in width, and 3.5 cm in depth. A small amount of bloody drainage was observed in the wound bed. LVN H packed Nugauze coated with [MEDICATION NAME] gel into the Stage IV pressure sore to Resident #4's hip and covered with a dry, protective dressing. LVN H did not clean Resident #4's wound with a soap and water. During an interview on 10/28/14 at 9:35 a.m., LVN H said Resident #4's pressure sore was to be cleaned with soap and water during the treatment. LVN H said she did not clean Resident #4's wound with soap and water during his treatment. During an interview on 10/28/14 at 9:40 a.m., LVN A said she did not give Resident #4 any pain medication prior to his wound care. LVN A said Resident #4's regular wound care was provided on the night shift (5 p.m.-5 a.m.). During an interview on 10/28/14 at 10:15 a.m., LVN A said Resident #4's agitation could "potentially" be due to pain. During an interview on 10/28/14 at 10:20 a.m., RN C said Resident #4's agitation could be an expression of pain. RN C stated, "I'd assume with the treatments there's some pain involved." RN C said he would have given Resident #4 [MEDICATION NAME] and Tylenol prior to his wound care treatments. During an interview on 10/28/14 at 10:30 a.m., the DON said agitation could be a sing of pain. She said a resident should be pre-medicated for a "painful " procedure, which included wound care to Stage II, III, or IV's. The DON said packing of a wound would be considered a "painful" procedure and should receive pain medication prior to the procedure. During an interview on 10/28/14 at 1:40 p.m., LVN A said Resident #4's Stage IV pressure sore to his right hip developed after his admission into the facility. During an interview on 10/28/14 at 2:10 p.m., the LVN H said Resident #4's wound to his right hip went to the bone. She said the pressure sore could be painful. The LVN H said aggressive behavior could be an indicator of pain. "You have to look at what is normal for each resident." During an interview on 10/28/14 at 4:10 p.m., LVN H said she notified Resident #4's mother in August 2014 after she was informed by the wound clinic Resident #4 required surgery and infection was imminent if his treatment was not changed. LVN H said she left a message for their contact at the wound care clinic regarding Resident #4's mother giving approval for surgery. LVN H said the wound care clinic then made a referral to a plastic surgeon. LVN H said no appointment was scheduled at this time with the plastic surgeon and Resident #4's treatment had not changed. During an interview on 10/29/14 at 1:30 p.m., the DON said she expected staff to follow the physician orders. The DON said if the orders were not clear, staff were to obtain a clarification order. During an interview on 10/29/14 at 10:00 a.m., LVN B said she was the transport nurse who went with Resident #4 to his wound care clinic appointments. LVN B said the physician at the wound care clinic suggested a skin flap (surgical procedure to remove skin from one part of the body to another) due to the nature of Resident #4's wound. During an interview on 10/30/14 at 3:50 p.m., the nurse at the wound care clinic said Resident #4's pressure sore was a "chronic condition " and Resident #4 went to the wound care clinic approximately every two weeks. During an interview on 10/31/14 at 12:10 p.m., the NP at the plastic surgeon ' s office said she had not seen Resident #4 yet. In-Service Training Report dated 10/29/14 on wound care treatments was performed by LVN H, who had failed to follow physician orders [REDACTED].#4. In-service training documented, " Always make sure that you review the treatment order prior to performing wound care. Follow the order as it is written for cleansing, what to cleanse with and what dressings are needed. When cleansing a wound you should be spraying the cleanser directly onto the wound as the pressure from the bottle aids in the cleansing process. " Wound care clinic communication report dated 10/29/14 said on 08/13/14, LVN H was notified of the plan of care and was going to discuss it with Resident #4 ' s mother. On 08/28/14, communication notes said LVN H requested progress notes from the previous visit be faxed to the facility. On 09/30/14, communication notes said referral to plastic surgeon was faxed. In-Service Training Report on Pain Assessments provided for CNAs, LVNs, and RNs dated 10/21/14 said pain assessments were to be completed on admission and quarterly and with any change of condition. Policy for Pressure Ulcer Treatment dated March 2005 said, " The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers ...Stage IV Pressure Ulcer: A Stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage exposing muscle, bone, or supporting structures. Undermining and sinus tracts may also be associated with Stage IV pressure ulcers. Interventions/Care Strategies: 1. Protect: a. Fill dead space including tunnels and undermining; b. Manage drainage; and c. Promote moist wound healing. 2. Debridement... 3. Treatment: a. Irrigate wound with normal saline or other designated wound cleaner. Use syringe to apply; b. Apply an alginate dressing, foam dressing or hydrogel to wound cavity; c. Cover with DSD, change daily; and d. Change per physician order [REDACTED]. Policy for Pressure Ulcer Treatment dated March 2005 indicated, "The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers ...A Stage IV pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis, or damage exposing the muscle, bone, or supporting structures. Undermining and sinus tracts may also be associated with Stage IV pressure ulcers. Interventions/Care Strategies: 1. Protect... 2. Debride Slough/Escher ... 3. Treatment... 4. Manage pain ... " The CMS Form 672 dated 10/27/14 indicated 5 residents had pressure sores.

Based on observation, interview and record review the facility failed to implement their policies and procedures to prohibit mistreatment and neglect for 1 of 2 residents reviewed for neglect. (Resident # 1) Resident #1 had a history of [REDACTED]. During repositioning, Resident #1 asked CNA A to "stop". The CNA continued and the residents arm was fractured. This failure contributed to the fracture of Resident #1's left arm. This failure could place 43 residents on East wing dependent on staff for turning/repositioning at risk for injury. Findings included: Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 had severe cognitive impairment and was totally dependent on two or more staff for all ADLs, including bed mobility. A care plan, dated 4/24/13 indicated Resident #1 had a potential for injury/fracture due to [MEDICAL CONDITION]. He required two plus staff for bed mobility. A nursing note dated 10/6/13 indicated the following for Resident #1: *11:05 a.m. Resident #1 was in the shower and verbalized a " burning pain " in upper left arm. Resident # 1 said his pain level was at a " ...6 or 7 ... " The resident refused pain medication. The note indicated during the assessment " popping on palpation " . Resident #1's arm was stabilized in a comfortable position for the remainder of the shower. The note indicated Resident #1 continued to verbalized pain at a 6. *11:30 a.m. physician notified and an x-ray of Resident #1's left arm/shoulder was ordered. *12:33 p.m. x-ray positive for a fracture *3:08 p.m. resident was transferred to the hospital for treatment A provider investigation report dated 10/7/13, indicated on 10/6/13 at 11:05 a.m., during care Resident #1 complained the arm he was lying on as " being uncomfortable " . CNA A said during his shower she heard a " pop " when she lifted Resident #1 ' s arm to wash it. Resident #1 had a fracture to his mid-left humerus (upper arm). The incident was reported to state agency on 10/7/13. The report did not identify a perpetrator. The provider investigation report indicated the allegation was confirmed. The section titled, "Provider Action Taken Post Investigation" said the facility would in-service staff on " abuse, neglect and reporting ... ensuring resident extremities properly positioned during repositioning." During an observation and interview on 10/18/13 at 11:30 a.m., Resident #1's left arm was in a sling. He said CNA A, RT B, and an LVN (unidentified) were in his room preparing him for a shower. Resident #1 said they turned him onto his left side. He said his left arm was underneath him. Resident #1 said it was uncomfortable and he told them to "hold on let me get my arm fixed". He said CNA A continued to turn him and he heard a " pop." Resident #1 said CNA A continued to work at the facility, but he no longer allowed her to work with him. He said his bones had broken before due to improper turning. During an interview on 10/18/13 at 12:15 p.m., RT B said he was in Resident #1's room, with CNA A and an LVN (unidentified) while they prepared the resident for a shower. He said they turned Resident #1 on his left side. RT B said Resident #1 complained his left arm was uncomfortable and asked CNA A to "stop." RT B said CNA A said Resident #1 was not rolled over far enough and she put pressure on his back pushed him over more. He said he heard a "pop" . He said Resident #1 asked if his arm made the "pop" sound. RT B said he told Resident #1 he did not know, but he thought the ventilator tubing had made the " pop" sound. RT B said later, in the shower, they heard Resident #1's arm "pop" again and asked the LVN to assess him. He said Resident #1 should have been rolled using the log rolling technique, onto his back, repositioned and scooted closer to the left side of his bed before rolling him over further. RT B said he was trained approximately one year ago on the log rolling technique. During an interview on 10/18/13 at 1:00 p.m., the administrator said the in-service regarding abuse, neglect; reporting or repositioning was not completed. He said he talked with the corporate office and was working with the therapy department to get an in-service scheduled. The administrator said Resident #1 should have been placed on his back, repositioned, and then rolled back to his side. He said CNA A was not suspended because neglect was not suspected. During an interview on 10/18/13 at 3:00 p.m., CNA A said she was in Resident #1's room, with RT B and LVN E, preparing him for a shower. CNA A said LVN E attempted to see a wound on Resident #1's back, but could not RT B pulled Resident #1 over more. She said at that time Resident #1 said, "oh, my arm". CNA A denied pulling Resident #1 over more for LVN E. She said they took him to the shower and when she went to wash his arm it felt, " limp and could feel something protruding " . She said LVN E assessed Resident #1. CNA A said she had been trained on the log rolling technique during orientation (5/13) but had not been re-trained since the incident. She said she was not suspended pending the investigation. During an interview on 10/18/13 at 9:00 a.m., the DON said Resident #1 had a [DIAGNOSES REDACTED]. She stated the incident occurred when staff turned Resident #1 during care. She said Resident #1 had said his arm was uncomfortable. She said he was sent for x-rays that confirmed he had a fracture of his left upper arm. During an interview on 10/18/13 at 10:00 a.m., the administrator said Resident #1 had a [DIAGNOSES REDACTED]. He said the incident occurred when staff turned Resident #1 during care. An in-service checklist titled "Transfer Techniques", dated 10/8/13, revealed nine employees met the requirements during demonstration of proper techniques. The nine staff checked off as meeting the requirements did not include CNA A, RT B, or LVN E. The Abuse/Neglect Prohibition Policy with a revised date of 5/10 indicated " ...Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse ... The facility will prohibit neglect ...Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." During a telephone interview on 10/24/13 at 2:30 p.m., the administrator said 43 residents on East wing were dependent on staff for turning and repositioning.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures to prohibit abuse, neglect and misappropriation of property for 1 of 2 residents reviewed for neglect. (Resident #1) Resident #1 had a history of [REDACTED]. During repositioning, Resident #1 asked CNA A to "stop". The CNA continued and the residents arm was fractured. This failure contributed to the fracture of Resident #1's left arm. This failure could place 43 residents on East wing dependent on staff for turning/repositioning at risk for injury. Findings included: The Abuse/Neglect Prohibition Policy with a revised date of 5/10 indicated " ...Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse ... The facility will prohibit neglect ...Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." Physician orders [REDACTED]. The most recent MDS assessment dated [DATE] indicated Resident #1 had severe cognitive impairment and was totally dependent on two or more staff for all ADLs, including bed mobility. A care plan, dated 4/24/13 indicated Resident #1 had a potential for injury/fracture due to [MEDICAL CONDITION]. He required two plus staff for bed mobility. A nursing note dated 10/6/13 indicated the following for Resident #1: *11:05 a.m. Resident #1 was in the shower and verbalized a " burning pain " in upper left arm. Resident # 1 said his pain level was at a " ...6 or 7 ... " The resident refused pain medication. The note indicated during the assessment " popping on palpation " . Resident #1's arm was stabilized in a comfortable position for the remainder of the shower. The note indicated Resident #1 continued to verbalized pain at a 6. *11:30 a.m. physician notified and an x-ray of Resident #1's left arm/shoulder was ordered. *12:33 p.m. x-ray positive for a fracture *3:08 p.m. resident was transferred to the hospital for treatment A provider investigation report dated 10/7/13, indicated on 10/6/13 at 11:05 a.m., during care Resident #1 complained the arm he was lying on as " being uncomfortable." CNA A said during his shower she heard a " pop " when she lifted Resident #1 ' s arm to wash it. Resident #1 had a fracture to his mid-left humerus (upper arm). The incident was reported to state agency on 10/7/13. The report did not identify a perpetrator. The provider investigation report indicated the allegation was confirmed. The section titled, "Provider Action Taken Post Investigation" said the facility would in-service staff on " abuse, neglect and reporting ... ensuring resident extremities properly positioned during repositioning." During an observation and interview on 10/18/13 at 11:30 a.m., Resident #1's left arm was in a sling. He said CNA A, RT B, and an LVN (unidentified) were in his room preparing him for a shower. Resident #1 said they turned him onto his left side. He said his left arm was underneath him. Resident #1 said it was uncomfortable and he told them to "hold on let me get my arm fixed". He said CNA A continued to turn him and he heard a " pop." Resident #1 said CNA A continued to work at the facility, but he no longer allowed her to work with him. He said his bones had broken before due to improper turning. During an interview on 10/18/13 at 12:15 p.m., RT B said he was in Resident #1's room, with CNA A and an LVN (unidentified) while they prepared the resident for a shower. He said they turned Resident #1 on his left side. RT B said Resident #1 complained his left arm was uncomfortable and asked CNA A to "stop." RT B said CNA A said Resident #1 was not rolled over far enough and she put pressure on his back pushed him over more. He said he heard a "pop" . He said Resident #1 asked if his arm made the "pop" sound. RT B said he told Resident #1 he did not know, but he thought the ventilator tubing had made the " pop" sound. RT B said later, in the shower, they heard Resident #1's arm "pop" again and asked the LVN to assess him. He said Resident #1 should have been rolled using the log rolling technique, onto his back, repositioned and scooted closer to the left side of his bed before rolling him over further. RT B said he was trained approximately one year ago on the log rolling technique. During an interview on 10/18/13 at 1:00 p.m., the administrator said the in-service regarding abuse, neglect; reporting or repositioning was not completed. He said he talked with the corporate office and was working with the therapy department to get an in-service scheduled. The administrator said Resident #1 should have been placed on his back, repositioned, and then rolled back to his side. He said CNA A was not suspended because neglect was not suspected. During an interview on 10/18/13 at 3:00 p.m., CNA A said she was in Resident #1's room, with RT B and LVN E, preparing him for a shower. CNA A said LVN E attempted to see a wound on Resident #1's back, but could not RT B pulled Resident #1 over more. She said at that time Resident #1 said, "oh, my arm". CNA A denied pulling Resident #1 over more for LVN E. She said they took him to the shower and when she went to wash his arm it felt, " limp and could feel something protruding " . She said LVN E assessed Resident #1. CNA A said she had been trained on the log rolling technique during orientation (5/13) but had not been re-trained since the incident. She said she was not suspended pending the investigation. During an interview on 10/18/13 at 9:00 a.m., the DON said Resident #1 had a [DIAGNOSES REDACTED]. She stated the incident occurred when staff turned Resident #1 during care. She said Resident #1 had said his arm was uncomfortable. She said he was sent for x-rays that confirmed he had a fracture of his left upper arm. During an interview on 10/18/13 at 10:00 a.m., the administrator said Resident #1 had a [DIAGNOSES REDACTED]. He said the incident occurred when staff turned Resident #1 during care. An in-service checklist titled "Transfer Techniques", dated 10/8/13, revealed nine employees met the requirements during demonstration of proper techniques. The nine staff checked off as meeting the requirements did not include CNA A, RT B, or LVN E. During a telephone interview on 10/24/13 at 2:30 p.m., the administrator said 43 residents on East wing were dependent on staff for turning and repositioning.

Based on observation, interview, and record review, the facility failed to ensure proper treatment and care was provided to prevent respiratory arrest for 1 of 11 residents reviewed for respiratory care. (Resident #3) On 2/23/13 staff did not respond promptly to Resident #3's ventilator alarm. The resident was found unresponsive and required manual ventilation to regain consciousness. This failure contributed to Resident 3's respiratory arrest. This failure created an Immediate Jeopardy situation. The Immediate Jeopardy was removed on 3/1/13. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 13 residents who were on ventilators at risk for respiratory arrest or death. Findings included: Physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #3 was alert and oriented, but was totally dependent on staff for all ADLs. An incident report dated 2/23/13 indicated CNA A summoned LVN B to Resident #3's room. The resident was unresponsive and in respiratory arrest. The report indicated manual ventilation was initiated and Resident #3 became alert and responsive. Resident #3 refused to be taken to the hospital for follow up. A grievance report dated 2/25/13 indicated Resident #3 was concerned about the length of time it took staff to answer his call light. The report indicated staff were not able to hear the ventilator alarm. The resolution to the grievance was to connect the ventilator alarm to the call light system, provide in-services and take disciplinary action regarding answering call lights. The date to be resolved was by 3/4/13. During an interview on 2/28/13 at 1:50 p.m., the administrator said he was working with the RT director to order an alarm system that would connect the both the ventilator alarm to the call light system. He said he had not conducted in-services regarding Resident #3's call light at this time. During an interview on 2/28/13 at 2:15 p.m. Resident #3 said on 2/23/13 his ventilator alarm sounded and staff did not respond. He said he turned his call light on and no one answered the call light. He said "I never been so scared in all my life" and, "they don't realize that this is our life." During an interview and observation on 2/28/13 at 6:15 p.m. Resident #3 had a baby monitor transmitter on the night stand next to his bed. He said a baby monitor was in his room so the nurse could hear the ventilator alarm if it sounded. He said he kept his door and blinds closed because the noise was so loud. During an interview on 2/28/13 at 2:28 p.m. CNA A said on 2/23/13 at approximately 6:00 p.m. during meal time she was in another resident's room providing care when she heard Resident #3's call light sounding. She said she washed her hands and went to Resident #3's room. She said Resident #3 was unresponsive and she called for a nurse. CNA A said she had not received any in-services regarding Resident #3's call light. During an interview on 2/28/13 at 3:48 p.m. LVN B said on 2/23/13 she was assisting with dinner when CNA A alerted her Resident #3 was unresponsive. She said she could not hear the ventilator alarm or the call light sounding until she went in the resident's room. She said manual ventilation with an Ambu-bag was initiated and he regained consciousness. LVN B said she was feeding residents away from the nursing station and did not hear the call light or alarm. She said Resident #3 wanted his door and blinds closed so a baby monitor was set at the nursing station and the RT desk. LVN B said at meal times the noise level was "super loud" and if she was not right by the monitor she could not hear the alarm. During an interview on 2/28/13 at 3:02 p.m. the director of respiratory therapy said Resident #3 wanted his door and blinds closed. She said with his door closed it was harder for the staff to hear the alarm on the ventilator, so a baby monitor was used. She said a baby monitor was placed at the nursing station and at the respiratory therapist's desk. She said as a result of the incident on 2/23/13, she was working to purchase a remote alarm system that would connect to the resident's call light and flash a red light when the ventilator alarm went off. She said until then, she told her staff to listen for the alarms and the call light. During an interview on 2/28/13 at 3:41, CRT C said the ventilators were equipped with alarms and lights that automatically initiated if there was a malfunction. He said Resident #3 wanted his door and blinds closed which made it hard to hear the alarm, so baby monitors were used. CRT C said the monitors were placed at the nursing desk and the RT desk. He said he could hear the monitor, unless he was in the medication room. During an interview on 2/28/13 at 4:11 p.m. the ADON for East Wing said Resident #3 wanted his door and blinds closed so they used 2 baby monitors to hear his ventilator alarm. She said a baby monitor was placed at the nursing station and at the respiratory therapist desk. She said if you were at the nursing station, the alarm could be heard on the baby monitor. She said if nurses were in resident rooms or it was loud in the facility, the monitor could not be heard. The ADON said Resident #3 requested the monitor in his room be turned off if he had visitors and sometimes staff forgot to turn it back on. During an interview on 2/28/13 at 4:17 p.m. LVN D said Resident #3 wanted his door and blind closed. She said a baby monitor was placed at the nursing station and at the respiratory therapist desk. LVN D said as long as she was around the nursing station and the volume on the baby monitor was turned up she could hear. She said at meal times the facility was very loud and it was difficult to hear the baby monitor. LVN D said the monitor's volume was not always up high which made it difficult to hear. During an interview on 2/28/13 at 4:31 p.m., the administrator said he was unaware the staff were having a difficult time hearing the baby monitors. During an interview on 2/28/13 at 4:48 p.m., CRT E said she checked on Resident #3 every two hours. She said Resident #3 kept his door and blinds shut so she had to rely on the baby monitor and the call light to determine if the resident required assistance. She said she could hear the baby monitor at the respiratory desk if the volume was turned up. She said the volume was not always turned up and it made it difficult to hear. CRT E said sometimes the monitor was turned off. She said at meal times the facility was loud and she could not hear the monitors or the alarm. During an interview on 2/28/13 at 5:46 p.m., LVN F said Resident #3 wanted his door and blinds closed. She said a baby monitor was placed at the nursing station and at the respiratory therapist's desk. LVN F said she could only hear Resident #3's baby monitor if she was sitting at the nursing desk. She said if she was in the medication room or in a resident's room she was unable to hear the baby monitor. The administrator and director of RT were notified on 2/28/13 at 4:31 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 2/28/13 at 6:06 p.m. and included: 1. Resident #3 would be provided with one on one staff until a new ventilator alarm was installed to the call light system. Charting would be done every hour on what the resident was doing for 8 hours, and then charted every 2 hours. 2. Resident #3's room door would not be closed until a new ventilator alarm was installed unless the resident was supervised or when patient care was being done. 3. Ventilator checks would be increased to every hour on Resident #3 until a new alarm was installed. 4. All staff would be in-serviced regarding call lights, reporting incidents and current action plan for Resident #3. 5. This action plan was begun immediately at 5:00 p.m. on 2/28/13: -1-1 supervision was started -Door open at all times except during resident care -Hourly ventilator checks done by RT -All staff in-serviced either by phone or in person The surveyor confirmed the Plan of Removal was implemented sufficiently to remove the Immediate Jeopardy by: -Two LVNs and one RN were interviewed and said they were in-serviced on 2/28/13. They said one-on-one supervision for Resident #3 must be provided and his door was to remain opened at all times until an alarm system was installed. They also said they were in-serviced regarding call lights. -Three CRTs were interviewed and said they were in-serviced on 2/28/13. They said one-on-one supervision for Resident #3 must be provided and his door was to remain opened at all times until an alarm system was installed. They said they were told to check Resident #3's ventilator every 1 hour. They said they were in-serviced regarding call lights. -Two CNAs were interviewed and said they were in-serviced on 2/28/13. They said one- on-one supervision for Resident #3 must be provided and his door was to remain opened at all times until an alarm system was installed. They said they were in-serviced regarding call lights. On 3/1/13 at 11:55 a.m., the administrator and director of RT were informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. During an interview on 2/28/13 at 4:31 p.m. the director of RT provided a list of 13 residents who were ventilator dependent.