Every finding on record at Wellington Rehabilitation and Healthcare

Based on observations, interviews, and record reviews, the facility failed to ensure that staff used correct assistive devices to prevent accidents for 1 of 8 residents (Resident #34) reviewed for quality of care.On 07/27/2026 CNA A and CNA B transferred Resident #34 from her bed to chair, using the incorrect transfer method identified in Resident #34's profile, which resulted in an assisted fall.This failure could place residents at risk of falls, injuries and hospitalization. Findings included:Record review of Resident #34's face sheet revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #34 had current diagnoses of sepsis (a life-threatening medical emergency that happens when your body has an extreme, runaway response to an infection), radiculopathy (a medical condition caused by the pinching, compression, or irritation of a nerve root in the spine), morbid obesity, and muscle weakness.Record review of Resident #34's MDS assessment record dated 07/21/2026 indicated Resident #34 was dependent (the helper does all of the effort, resident does no effort, and/or the assistance of 2 person help) on staff complete the task for chair/bed-to-chair transfers (the ability to transfer to and from a bed to a chair or wheelchair).Record review of Resident #34's care plan dated 07/21/2026 indicated that Resident #34 required maximum assistance x2 with mechanical lift of staff participation with transfers related to chair/bed to chair, toilet transfer as of 07/17/2026.An interview conducted on 08/05/2026 at 11:00AM with Resident #34 revealed she had sustained a fall during a transfer to or from her wheelchair; she cannot recall which. She stated that the staff members transferred her without a mechanical lift and she fell to the floor. She denied any injuries being sustained during the transfer. She stated it made her feel unsafe and scared.An interview conducted on 08/05/2026 at 11:20AM with Resident #34's family member revealed Resident #34 was going to therapy when staff had lifted her her, attempted to transfer the resident to her chair when she fell down. He said that she had been in the facility for a week and a half. He said that she had been out of bed only with the mechanical lift. He said that it was just that 1 time where the staff did not use a hoyer for transfer. He stated that Resident #34's care plan said that she would be a hoyer transfer.An interview conducted on 08/05/2026 at 11:33AM with the DON, revealed Resident #34 was admitted to the facility with a transfer status to use a mechanical lift. The DON stated that the facility was planning to change Resident #34 to a 2- person transfer for goals to return home with her family. The DON said that she talked to the staff and told them that they were working toward 2- person gait belt transfer discharge. She said that therapy was using 2 person gait belt to gain mobility and transfer.An interview conducted on 08/05/2026 at 12:11PM with the DOR revealed the goal for Resident #34 was to get the resident to her prior level of functions regarding transfer status. The DOR stated the PT goal was to improve bed mobility, sit to stand, bilateral strength, and ambulation up to 20 feet. The DOR stated that CNA A and CNA B were in the room when therapy transferred Resident #34 with a gait belt and potentially felt that they could use the gait belt as well. The DOR stated if the staff are not aware of the transfer status of a resident, the rule of thumb would be to follow what the Kardex says. The DOR stated she would not do a gait belt transfer on a resident if she was not trained.An interview conducted on 08/05/2026 at 12:20 PM with CNA A, revealed she received training on transferring residents to and from their bed which included mechanical lift transfers and gait belt transfers. CNA A stated that CNA B asked her to assist with the transfer for Resident #34, and saw CNA B have a gait belt with her. CNA A stated that she believed Resident #34 was a mechanical lift transfer, but did not check the Kardex as she was just assisting with the transfer. CNA A stated that when her and CNA B went to transfer the resident with a gait belt to her wheelchair, Resident #34's legs buckled. CNA A stated her and CNA B lowered Resident #34 to the ground to assist with the fall. CNA A stated that they typically worked with the same residents, but if they don't, they are expected to check the Kardex for the Resident's transfer status. CNA A stated that if staff do not follow the Kardex, a resident and/or staff member could get hurt. CNA A stated the resident did not sustain any injuries related to the assisted fall. An interview conducted on 08/05/2026 at 2:40PM with CNA B revealed she had received training regarding transfers which included mechanical lift transfer, gait belt transfer, and 2- person transfers of residents. CNA B stated that she believed Resident #34 had been comfortable with standing and was able to complete a 2- person gait belt transfer. She said that the resident had been standing for maybe 2 minutes before CNA A and CNA B assisted to her knees. She said that as Resident #34 was falling, she grabbed the gait belt and her pants and lowered her to her knees. CNA B stated she did not check the Kardex that day because she ran out of time. CNA B stated the Kardex indicated that the resident was a hoyer transfer, not a 2 person gait belt assist. CNA B stated she saw therapy transfer Resident #34 with a gait belt and assumed she was a 2 person gait belt transfer. She stated that her not checking the Kardex could have resulted in the resident getting seriously injured. Record review of Resident #34's nurse note dated 07/17/2026 noted to continue mechanical lift transfers for all transfers per resident preference and interdisciplinary team recommendation until reassessed by therapy. Interdisciplinary team will continue to monitor anxiety, mobility status, and transfer safety and update interventions as indicated. Record review of Resident #34's nurse note dated 07/17/2026 noted upon assessment, resident was a x2 maximum assist and hoyer with transfers. Record review of education provided by the facility revealed that staff received training on the following:Reported Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment onNursing Staff CompetencyQuality of CareStandard TransferMechanical TransferHoyer Transfer Record review of transfer skills checklist for all staff members dated 07/27/2026.

Based on record review and interviews, the facility failed to ensure that the resident received adequate supervision and assistance with devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents and hazards.The facility failed to ensure Resident #1 did not elope from the facility on 1/10/2026, Resident #1 eloped was found in the alley behind the facility, attempting to get to the end of the alley where a coffee shop was located.This failure could result in serious injuries to residents and potentially death.The noncompliance was identified as PNC. This failure resulted in an identification of an (IJ) Immediate Jeopardy on January 10th, 2026, at 11:06 am. The IJ template was provided to the ADM and DON on February 17th, 2026, at 05:05 pm. The IJ was removed on January 11th, at 08:30 am, due to the facility implementing interventions to ensure the safety of the residents A record review on February 17th, 2026, of Resident #1's face-sheet reflected that Resident #1 was a 60year-old-male who was admitted to the facility on [DATE] and re-entered on 11/06/2025 with diagnoses of cerebral infarction, chronic obstructive pulmonary disease, mild intermittent asthma, hemiplegia and hemiparesis, aphasia, and depression. Record review of Resident #1's quarterly MDS dated [DATE], reflected that Resident #1's BIMS score was a 01 and he was not interview able due to severe cognitive impairment. Record review of Resident #1's care plan dated 11/12/2025 reflected that Resident #1 had potential for behavioral problems and impulsiveness. The care plan also reflected that Resident #1 was an elopement risk with history of elopement from previous nursing facility. Interventions were assessing fall risk, redirect, document wandering behaviors, and provide structured activities. During an observation on February 17th, 2026, of the back patio, it was noted that the entire back is in a secure locked area with a long alleyway directly in the back. Interview on 02/12/26 at 12:56 p.m., the DON revealed that Resident #1 is a special resident. She stated that staff previously brought him coffee from the local coffee shop (across the street). On January 10th, 2026 (a Saturday), there was a fill-in receptionist who forgot to get Resident #1, coffee and he became agitated. She stated that she was told that while the facility housekeeper was outside throwing trash out, Resident #1 caught the door and rolled his wheelchair out of the gate towards the alley. The DON stated that he did not make it to the coffee shop and had not left the premises. A psych eval was completed by ADON who also completed an elopement, skin and pain assessment. No harm or injury was found. The DON stated that Resident #1 was on 1 on 1 until psych was able to see him. (48hours later) In-services on making sure the door is closed and locked, emergency drill, elopement risk (Code pink), and where the elopement binder is kept and the nurse station. Interview on 02/17/26 at 09:52 a.m., the facility's housekeeper revealed after taking some trash out to the dumpster she failed to ensure that the gate locked behind her. She stated once she returned to the 100 hall another resident told her that a resident had escaped she stated she immediately yelled code Pink and ran outside. She stated once she arrived outside, she noticed a nurse was already outside talking with Resident #1. She stated she was in-serviced on what to do if a resident escapes, personnel counseling and making sure she was aware of what code to yell out if she sees a resident elope. She stated that she was informed to stay with a resident if she was to see one trying to elope and to call for the aid. She also stated the facility had the gate lock repaired so that it would click once closed. Interview on 02/17/26 at 2:23 p.m., LVN A revealed that on 1/10/2026 when she arrived outside, she noticed Resident #1 attempting to cross the alley. She stated she attempted to redirect Resident # 1 and have him return to the facility. She stated he then became agitated and aggressive and hit her in the face. She stated she called for other staff to assist and Med Aid A came to help, and they returned Resident # 1 to the facility without injury. LVN A stated she completed a range of motion assessment but was unable to complete a head-to-to-toe assessment due to his previous aggression with her. He was then placed on 15min checks until he was cleared by a psych doctor on 01/12/2026. Record review on 02/17/26 of progress note completed on 1/10/2026 by the ADON reflected that on 1/10/2026 she completed a head- to -toe assessment, change in condition, smoking evaluation and elopement risk assessment for Resident #1. Interview on 02/17/26 at 2:43 p.m., CMA A revealed that a resident told her that Resident #1 had gone out of the back gate. She stated that she then went outside to see which resident it was. CMA A stated that she saw Resident #1 in the back alley. She then said that she went after him, when she and LVN A made it to him, he locked his chair and became combative. She said that Resident #1 was upset because the staff could not get him coffee. She stated that he was swinging and he hit LVN A in the mouth on accident. She said that Resident #1 cannot use words, so he was angry and trying to explain himself. She said that her and LVN A tried to calm him down, eventually Resident #1 allowed them to push him back into the building. CMA A said that after the incident all staff completed abuse and neglect, elopement, making sure that the gates are closed and locked and deescalation in-service. Interview on 02/17/26 at 2:59 p.m., the Maintenance Manager revealed that he was on the 300 hallway when he was told that while the housekeeper was throwing away garbage, she did not lock the gate behind her. Due to this Resident #1 was able to get out of the gate and found in the alley. The maintenance manager stated that he in-serviced the housekeeper on elopement and making sure the gate was locked behind her. He revealed that he also gave the housekeeper verbal counseling. He said that the housekeeper has never left the gate open before or since the incident. The maintenance manager stated that he also called a company to ensure that the gate was secure and that it would close right behind the person and lock. Review of the Elopement Policy dated 06/2018 indicated:It is the policy of this facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement[TW15] . A record review on 02/17/26 of the facilities self-report revealed that the wander guard system had been approved to be installed in the facility.Record review revealed that the facility completed the following in-services:- De-escalation, elopement, elopement binder location and ensure that the gate closes completely and locks signed by all staff.- Door checks come out documented by the maintenance manager once a week.-Quiz on elopement behavior.-Positioned a staff to sit at the back door 7 days a week from 7am to 7pm.-In the process of having a wander guard installed

Based on observations, interviews, and record reviews, the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 (Resident #1) of 3 residents reviewed for PASARR services. The facility failed to submit an NFSS request within 20 business days of Resident #1's IDT meeting held on 04/23/25. This failure could place residents at risk of not receiving the required care and services to attain and maintain their highest, practicable, physical, mental, and psychosocial well-being. Findings include: Review of Resident #1's admission Record, dated 08/27/25, reflected she was a [AGE] year old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had medical diagnoses that included osteitis deformans of multiple sites (a chronic metabolic disorder where bone turnover is accelerated and disordered), epilepsy (a brain disorder causing recurring, unprovoked seizures), paraplegia (the inability to voluntarily move the lower body parts), vascular dementia (brain damage), cognitive communication deficit, and spina bifida (the spinal cord and backbones do not close completely).Review of Resident #1's Comprehensive MDS Assessment, dated 07/02/25, reflected she had no BIMS indicated and she was considered by PASARR level II to have a serious mental illness, intellectual disability, or a related condition. Review of Resident #1's Care Plan, revised on 08/05/25, reflected Resident #1 was PASARR positive. Nursing and Social Services were responsible for ordering specialized services for Resident #1 as determined by the IDT care plan review meeting. Nursing and Therapy were responsible for ordering therapy services for Resident #1. Review of Resident #1's IDT Care Plan Review, dated 04/23/25, reflected, Therapy Services Plan of Care: .Therapy services were recommended by DOR and specialized wheelchair. Review of Resident #1's PCSP, dated 04/23/25, reflected the IDT met on 04/23/25 and confirmed Resident #1's need for a CMWC. IDD also visited the facility, reviewed, confirmed and signed on 04/28/25 that Resident #1's need for specialized services were agreed by the IDT and reflected, Resident #1 will receive PASARR Services of.CMWC . Review of Resident #1's Order Summary Report, dated 08/27/25, reflected no orders related to her CMWC. Review of Resident #1's Progress Notes, April-August 2025, reflected no notes related to her CMWC. Review of the facility's Email Thread, from 05/02/25 through 08/27/25, reflected the wheelchair vender notified the DOR on 05/02/25 that the facility had 28 days from Resident #1's IDT care plan review meeting to input Resident #1's PASARR into the SA's online portal and how to process Resident #1's PASARR. The DOR notified the wheelchair vender on 05/14/25 that he was working/waiting on processing Resident #1's PASARR due to Resident #1 needing a new IDT care plan review meeting. There were no email threads from 05/14/25 through 08/04/25. The ADM followed-up on Resident #1's CMWC status with the wheelchair vender on 08/05/25. The wheelchair vender notified the ADM and DOR on 08/05/25 to input Resident #1's PASARR into the SA's online portal and to send Resident #1's approval to them to have Resident #1's CMWC ordered. An observation of the facility's front entrance area on 08/27/25 at 11:10 a.m. reflected Resident #1 was sitting in a wheelchair. An attempt to interview Resident #1 was made on 08/27/25 at 11:10 a.m., but Resident #1 was unable to maintain focus during the interview. During an interview on 08/27/25 at 11:19 a.m., the SW stated she was unsure who was responsible for identifying PASARR positive residents prior to and after admission to the facility, who was responsible for making the referral to the appropriate state-designated authority when a PASARR positive resident was identified, what the facility's process was for referring PASARR positive residents to the appropriate state-designated authority, and why a referral to the appropriate state-designated authority would not be made for a PASARR positive resident. The SW stated the MDS Coordinator oversaw the PASARR process. The SW stated facility had a resource who was responsible for the PASARR process because the former MDS Coordinator left the faciity on [DATE]. The SW stated she knew the importance of referring identified PASARR positive residents to the appropriate state-designated authority and said, Referrals should be made to the appropriate state-designated authority. Residents should be able to get specialized services in order to help their well-being. Residents would not get the services that they should have if they were not referred to the appropriate state-designated authority. During an interview on 08/27/25 at 11:30 a.m., LVN A stated nurses were responsible for identifying PASARR positive residents prior to and after admission to the facility. LVN A stated the SW was responsible for making the referral to the appropriate state-designated authority when a PASARR positive resident was identified. LVN A stated the nurses identified PASARR positive residents prior to and after admission to the facility, nurses notified the DON, SW and physician, and the SW made the referral to the appropriate state-designated authority. LVN A stated she did not know why a referral to the appropriate state-designated authority would not be made for a PASARR positive resident. LVN A stated the ADON oversaw the PASARR process. LVN A stated she knew the importance of referring identified PASARR positive residents to the appropriate state-designated authority and said, Residents must receive appropriate care for their needs. We must ensure residents were not dismissed for those services they require. Residents could decline or not receive appropriate care from the staff. During an interview on 08/27/25 at 11:40 a.m., LVN B stated the DON was responsible for identifying PASARR positive residents prior to admission to the facility. LVN B stated the nurses were responsible for identifying PASARR positive residents after admission to the facility. LVN B stated the Physician was responsible for making the referral to the appropriate state-designated authority when a PASARR positive resident was identified. LVN B stated the DON identified PASARR positive residents prior to admission to the facility, the nurses identified PASARR positive residents after admission to the facility, the nurses notified the DON, the DON or the nurses notified the physician, and the physician made the referral to the appropriate state-designated authority. LVN B stated a referral to the appropriate state-designated authority would not be made for a PASARR positive resident if the resident had a change in condition that resulted in them no longer meeting PASARR positive criteria. LVN B stated the ADON and DON oversaw the PASARR process. LVN B stated she knew the importance of referring identified PASARR positive residents to the appropriate state-designated authority and said, Residents could get treated according to their diagnoses and to ensure residents get the services they need. Resident could develop mental psychosis, become suicidal, and worsen psychosis condition if they did not receive the appropriate care.During an interview on 08/27/25 at 11:51 a.m., the ADON stated the BOM was responsible for identifying PASARR positive residents prior to admission to the facility. The ADON stated the nursing, therapy, and social services departments were responsible for identifying PASARR positive residents after admission to the facility. The ADON stated the SW was responsible for making the referral to the appropriate state-designated authority when a PASARR positive resident was identified . The ADON stated she did not know what the facility's process was for referring PASARR positive residents to the appropriate state-designated authority and why a referral to the appropriate state-designated authority would not be made for a PASARR positive resident. The ADON stated the SW and DOR oversaw the PASARR process. The ADON stated she knew the importance of referring identified PASARR positive residents to the appropriate state-designated authority and said, Residents need to receive the best care they could tolerate and get the best quality of life in which they are able to function. We do not want anyone to be able to do something and not have special service, equipment or assistance for the condition. Residents could potentially decline if they do not get what they need.During an interview on 08/27/25 at 12:11 p.m., the DON stated the MDS Coordinator was responsible for identifying PASARR positive residents prior to and after admission to the facility and making the referral to the appropriate state-designated authority when a PASARR positive resident was identified. The DON stated she did not know why a referral to the appropriate state-designated authority would not be made for a PASARR positive resident and said, There shouldn't be a reason a referral is not sent out. The DON stated the MDS Coordinator oversaw the PASARR process. The DON stated the MDS Coordinator sent Resident #1's PASARR referral to the wheelchair vender and did not follow-up on the status. The DON stated the SA notified the facility that Resident #1 did not receive her CMWC for her PASARR positive condition. The DON stated Resident #1's CMWC was ordered and the facility was waiting for it to arrive at the time of the interview. The DON stated the MDS Coordinator left the facility at unknown date. The DON stated she knew the importance of referring identified PASARR positive residents to the appropriate state-designated authority and said, Residents quality of life is better when they receive specialized services. Resident could develop a decrease in quality of care and not have needs met if they did not receive specialized services. During an interview on 08/27/25 12:28 p.m., Resident #1's POA stated Resident #1 had PASARR positive conditions before her admission to the facility. Resident #1's POA stated Resident #1 requested specialized equipment for her PASARR positive condition. Resident #1's POA stated Resident #1 told her that the facility told her that they were getting her CMWC. Resident #1's POA stated the nursing department helped transfer Resident #1 using a mechanical lift and therapy department helped Resident #1 strengthen her ADLs to address her PASARR positive condition as the CMWC order was pending. Resident #1's POA stated she was concerned with Resident #1 having not received the CMWC. During an interview on 08/27/25 at 12:50 p.m., the ADM stated the facility's resource was responsible for identifying PASARR positive residents prior to and after admission to the facility. The ADM stated the DOR was responsible for making the referral to the appropriate state-designated authority when a PASARR positive resident was identified. The ADM stated he did not know why a referral to the appropriate state-designated authority would not be made for a PASARR positive resident and said, I can't imagine that there would be any reason for a referral not being sent out. The ADM stated the MDS Coordinator oversaw the PASARR process. The ADM stated the MDS Coordinator left the faciity on [DATE]. The ADM stated the DOR left the faciity on [DATE]. The ADM stated Resident #1's IDT care plan review meeting was on 04/23/25, the DOR sent Resident #1's PASARR referral to the wheelchair vender on 05/02/25, the wheelchair vender told him on 05/14/25 that the IDT care plan review meeting was too far from when the DOR sent Resident #1's PASARR referral and requested a new IDT care plan review meeting, Resident #1's new IDT care plan review meeting was on 07/23/25, he did not know when Resident #1's PASARR referral was sent out again, he followed up with the wheelchair vender on 08/05/25 and the vender confirmed the request Resident #1's referral request was completed on 08/15/25. The ADM stated the DOR did not meet the timeframe for submitting and following up on Resident #1's PASARR referral for a CMWC. The ADM stated he was told the timeframe to submit the referral was within 30 business days. The ADM stated he knew the importance of referring identified PASARR positive residents to the appropriate state-designated authority and said, Residents have a right to receive specialized services. The ADM said, It depends on the resident and their condition for what could happen to a resident if they did not receive specialized services. During an interview on 08/27/25 at 1:42 p.m., the surveyor requested the ADM and DON provide the facility's PASSAR policy. During an interview on 08/27/25 at 1:43 p.m., the ADM stated the facility's PASARR Resident Assessment policy was the facility's PASARR policy. During an interview on 08/27/25 at 2:43 p.m., the DON stated the facility's PASARR Resident Assessment policy was the facility's PASARR policy. Review of the facility's In-Services, April-August 2025, reflected staff were not given any reeducation related to PASSAR. Review of the facility's PASARR Resident Assessment policy, reviewed 05/2021, reflected, Policy: It is the policy of this facility to ensure that each resident is properly screened using the PASARR specified by the State. Procedures: The facility will refer to the state's Pre-admission Screening and Resident Review policy.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 was transferred safely, with a gait belt, correct positioning and with at least two staff, by CNA B when Resident #1 fell and sustained a femur (thigh bone) fracture which required surgery on 06/10/2025. An Immediate Jeopardy (IJ) was identified on 06/13/2025. While the IJ was removed on 06/15/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the of the corrective systems . This failure could place residents at risk of unsafe transfers, falls, injuries, hospitalizations and/or death. Findings include: Record review of Resident #1's face sheet, dated 06/16/2025, reflected an [AGE] year-old man who was admitted to the facility on [DATE]. Resident #1 discharged on 06/10/2025. Resident #1 had with diagnoses which included vascular parkinsonism (disease that is caused by damage to blood vessels in the brain that leads to movement and balance problems that particularly affect the lower body), unspecified atrial fibrillation (irregular or rapid heartbeat), dysphagia (difficulty swallowing), need for assistance with personal care (need for help with activities of daily living), unsteadiness on feet (being unbalanced or unstable while standing or walking), other abnormalities of gait and mobility (abnormal walking pattern), weakness, unspecified intellectual disabilities, developmental disorder of scholastic skills, muscle weakness and dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Record review of Resident #1's fall risk evaluation, dated 02/04/2025, reflected Resident #1 was a high fall risk with no falls in the past three months. Resident #1 had balance problems while standing / walking. Record review of Resident #1's BIMS assessment, dated 02/22/2025, reflected a score of 6 which indicated severe cognitive impairment. Record review of Resident #1's MDS, dated [DATE], reflected Resident #1 required substantial/ maximal assistance (helper does more than half the effort, 2-staff requred) for chair/bed-to-chair transfers. Resident #1 had no falls since the prior assessment or admission. Resident #1 was 228 lbs and 74 inches tall. Record review of Resident #1's care plan, dated 05/31/2015, reflected Resident #1 had impaired cognitive function with interventions to remember one/two step instructions. Review of Resident #1's care plan, dated 12/21/2021, reflected he had a self-care deficit and required substantial/maximal assist staff participation with transfers. Resident #1 was at risk for falls related to gait/balance problems. Review of care plan reflected no information regarding use of gait belt when transferring Resident #1. Review of Resident #1's chart reflected Kardex was unable to be reviewed due to Resident #1 being discharged from the facility. Record review of incident report, dated 06/10/2025 at 5:00 AM, reflected CNA B stated she helped Resident #1 get ready for the day and she tried to use the stand and pivot method to transfer but while doing so Resident #1's leg slid, and she helped the resident slowly to the ground and Resident #1 tried to support himself with his knees. Resident #1 was transferred to the ER for evaluation and treatment. Record review of progress note, dated 06/10/2025, by LVN A, reflected Resident #1 was assisted by CNA B when LVN A saw Resident #1 on the floor. LVN A completed an assessment and completed vitals. Resident #1 was transferred to bed. Resident #1 was repositioned and had right hip tenderness noted with limited range of motion and pain level of 10/10. Resident #1 screamed when his right foot was moved but was calm when the right leg was at rest. Resident #1's right thigh appeared to be swollen. Reached out to the on-call provider and advised Resident #1 be sent to the hospital via EMS. Record review of hospital records, dated 06/13/2025, reflected Resident #1 sustained a right femoral shaft fracture. Procedure performed was an open reduction and internal fixation of right femur shaft fracture with a cephalomedullary nail (surgically exposing fracture and realigning bone fragments and stabilizing the fracture with a nail inserted in the femur). During an interview on 06/13/2025 at 2:11 PM and 3:05 PM, CNA B stated she assisted Resident #1 with getting ready for the day on 06/10/2025. CNA B stated she attempted to transfer Resident #1 and she did not use a gait belt because the nurse did not tell her she needed to use one with Resident #1. CNA B stated she positioned Resident #1's wheelchair close to his bed and she was to the side and behind him. CNA B stated Resident #1 stood and then fell forward to his knees during the transfer. CNA B stated Resident #1 went straight down to the floor. CNA B stated Resident #1 usually stepped and then pivoted to the chair and he usually did most of the work. CNA B stated she usually stood behind Resident #1 for transfers and Resident #1 was the only resident she transferred from behind. CNA B stated she could find information on the Kardex (nursing tool for patient information) for what the resident needed for assistance during transfers. CNA B stated her hands were on Resident #1's pants or back. CNA B stated she did not remember if she was on his left or right side but stated she was behind him. CNA B stated Resident #1 sat on the edge of the bed and she usually told him to stand but that day (06/10/2025) he did not stand as usual and when she tried to help him, he felt like he was going down. CNA B stated Resident #1 fell forward after he lifted off the bed and he was standing and then went down with CNA B behind him. CNA B did not state if she checked the Kardex prior to the transfer . CNA B stated she usually got Resident #1 up for the day on her shift and he was usually able to stand and take a step and pivot . During an interview on 06/13/2025 at 2:23 PM, CNA D stated staff could find transfer requirements on the Kardex. CNA D stated the Kardex told staff if a resident needed a 1 or 2 person transfer or minimum or maximum assistance. CNA D stated there was not a transfer that would occur where the CNA stood behind a resident. CNA D stated she stood in front of residents when she assisted them from bed to chair and chair to bed. CNA D stated gait belts should be used during transfers. During an interview on 06/13/2025 at 2:28 PM, the OT stated Resident #1's transfers fluctuated and sometimes Resident #1 needed more help, but it depended on the day . The OT stated Resident #1 was on therapy services because of the fluctuation in his transfers. The OT stated there were not one-person transfers in which the staff would stand behind a resident . The OT stated the staff would only stand behind the resident if there was another staff member present. The OT stated a gait belt should be used for all transfers for safety reasons. During an interview on 06/13/2025 at 2:48 PM, CNA E stated staff were supposed to always use a gait belt when they transferred a resident . CNA E stated staff was supposed to stand in front of residents during a transfer. CNA E stated unless there was another staff member then she would not be behind the residents. CNA E stated staff viewed the Kardex to show whether a resident needed a 1 or two person transfer or a mechanical lift. CNA E stated substantial / maximal assistance usually meant to bring another staff member with you. During an interview on 06/13/2025 at 2:51 PM, CNA C stated with a little muscle from the CNA Resident #1's wheelchair was positioned on the side of his bed at an angle with his bed rail in reach because Resident #1 utilized them to push up. CNA C stated Resident #1 needed guidance during the transfer and this included verbal cueing. CNA C stated a gait belt was required for every transfer with Resident #1. During an interview on 06/13/2025 at 3:31 PM, LVN F stated during a one-person transfer the staff would be facing the resident and be knee-to-knee or feet-to-feet. LVN F stated there were no transfers that occurred when a staff was behind the resident. LVN F stated a gait belt should be used at all time during a transfer. LVN F stated the purpose of a gait belt was to ensure you had a good grip on the resident and you did not have to grab the resident's clothing or skin. LVN F stated the risk of transferring a resident without a gait belt was losing balance or grip and a potential fall. LVN F stated it was important to have the correct positioning (being in front of the resident) during a transfer to prevent the resident from losing balance or the staff hurting themselves. During an interview on 06/13/2025 at 3:27 PM, the DON stated during a transfer the first thing was for staff to use a gait belt. The DON stated staff were positioned in front of the resident with the staff's foot in between the resident's legs. The DON stated it was best practice to have a gait belt because staff never knew what could happen. The DON stated a resident who required maximum assistance definitely needed a gait belt to be used. The DON stated the purpose of a gait belt was for extra support or caution during transfers. The DON stated if staff transferred without a gait belt a lot of injuries could happen. The DON stated there were no transfers where a staff would be behind a resident and every single transfer had the staff in front of the resident. The DON stated if staff were behind a resident they could not see what they were doing. The DON stated staff were observed often and assessed for their transfer skills. The DON stated staff were assessed after hire and from time-to-time and if a concern was raised someone completed a transfer incorrectly. The DON stated after the aide transferred Resident #1 and fell, they started re-education of staff. The DON stated when incidents like that happened management wanted to educate so incidents were not repeated. The DON stated she expected staff to use a gait belt when indicated. The DON stated a gait belt would not be used for a resident who required only supervision and could transfer themselves or walk without assistance from staff, otherwise a gait belt was expected to be used. The DON stated most CNAs had a gait belt provided to them and after Resident #1 fell staff were informed a gait belt was a part of their uniform. The DON stated she expected staff to have proper positioning during transfers and if they were not sure they needed to ask questions. The DON stated the Kardex told the staff what a resident's transfer status was and how many staff were required. The DON stated staff were reminded to use the Kardex almost daily during the stand-down meeting. The DON stated she was out on 06/10/2025 and reviewed the progress note on 06/11/2025 about Resident #1's fall and stated initially she read the aide helped Resident #1 slide down to the floor and she thought that's good she helped him. The DON stated CNA B stated she (CNA B) transferred Resident #1 and he slid down to the floor. The DON stated after the initial assessment Resident #1 was transferred to his bed and he started to scream and LVN A saw his leg was swollen and she reached out to the supervisor and on-call. The DON stated after she learned Resident #1 had a fracture she began re-education with staff. The DON stated she reviewed what each transfer was and proper transfer and body mechanics. The DON stated she did not ask CNA B if she had a gait belt and did not ask where CNA B was positioned during the transfer. The DON stated she was only able to speak with LVN B. The DON stated Resident #1 had not had any falls prior to this incident. During an interview on 06/13/2025 at 3:40 PM, the ADM stated he expected staff to transfer residents correctly and there was zero tolerance for incorrect transfers. The ADM stated he was not aware of the specific details of Resident #1's transfer. The ADM stated he expected staff to use a gait belt 100 percent of the time when indicated. The ADM stated the IDT reviewed Resident #1's fall and discussed what could have been done better. The ADM stated he was not aware of the details regarding whether CNA B had a gait belt or where she was positioned when she transferred Resident #1. The ADM stated he and the DON stressed to staff they should never be without supplies (including gait belts) and staff could call or text anytime they needed something. During an interview on 06/13/2025 at 4:12 PM, the NP stated she expected staff to utilize safe transfer techniques. She stated Resident #1 did have intermittent confusion and other diagnoses that made him a fall risk. The NP stated not utilizing a gait belt or proper positioning during transfers could obviously result in a fall leading to a fracture. During an interview on 06/23/2025 at 1:47 PM, the DON stated substantial/maximal assistance meant that two staff were required during the transfer. The DON stated when staff reported a resident had a change in level of assistance needed then care plans or Kardex was updated right away. The DON stated skills checks were observed upon hire. The DON stated she came to the building during off hours to check in with staff and observe care. The DON stated staff also had skills check three months after hire. The DON stated if staff expressed concerns or area where they needed more training during their new hire training their training would be extended. The DON stated if a resident required two people for their care then she expected two staff to provide that care. The DON stated the risk of not having another staff if a resident required two people for care was a fall that resulted in an injury. The DON stated staff were trained by a train the trainer method and new staff were paired with another staff and trained by the other staff through on the job training. The DON stated she checked in with staff at the end of their training to ask if they felt comfortable and if they needed any additional training in any area. The DON stated she or the ADON would complete the final skills check before staff were released to work independently . During an interview on 06/23/2025 at 3:45 PM, LVN A stated she was the charge nurse when Resident #1 fell. She stated it was considered a witnessed fall and from what she was told by CNA B, CNA B tried to transfer Resident #1, he missed a step and fell. LVN A stated she was not sure why CNA B transferred Resident #1 by herself. LVN A stated based on what the Kardex had and other the CNA said Resident #1 was a two-person transfer. LVN A stated substantial / maximal assistance was required a two people in the transfer. Record review of in-service, dated 06/11/2025, reflected substantial/maximal assistance required two people for transfers. Record review of in-service, dated 06/11/2025, with subject GGS (functional abilities and goals) reflected it reviewed types of assistance needed for transfer and staff required and reflected CNA B did not complete the in-service as of 06/13/2025. Record review of in-service, dated 06/11/2025, with subject Kardex reflected CNA B did not participate in the in-service as of 06/13/2025. The in-service included the purpose of Kardex and how it was used . Record review of in-service, dated 06/11/2025, with subject of body mechanics reflected CNA B did not participate in the in-service as of 06/13/2025. The in-service included body positioning during transfers . Record review of in-service, dated 06/11/2025, with topic safe resident transfers and handling reflected proper techniques, correct use of patient handing equipment and devices with the goal to ensure resident safety and reduce injury for both residents and staff. Review reflected CNA B completed this in-service as verified by signature and date of 06/11/2025. Record review of the facility's schedule / sign-in sheets for 06/11/2025 and 06/12/2025 reflected CNA B was not scheduled to work at the facility. Review of facility scheduled, dated 06/13/2025, reflected CNA B was scheduled to return to the facility from 10:00 pm - 6:00 am on 06/13/2025. Record review of the facility's policy titled Quality of Care Transfer of a Resident, Safe with revision, date of 05/2025, reflected use good body mechanics at all times .use a gait belt for all transfer if gait belts is indicated for the resident. The policy reflected for one-person transfers, apply gait belt around resident's waist, provide necessary assistance to help the resident stand up. The policy reflected two-person transfers using a gait belt required to apply the gait belt around the resident's wait, use good body mechanics at all times and provide the necessary help for the resident to stand up with caregivers on both sides of the resident and staff holding the gait belt. This was determined to be an Immediate Jeopardy (IJ) on 06/13/25 at 4:57 PM. The ADM and DON were notified . The ADM was provided with the IJ template on on 06/13/2025 at 4:57 PM. The following Plan of Removal submitted by the facility was accepted on 06/14/2025 at 4:01 PM : Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified, on 6/13/2025. Identification of Others Affected by Alleged Deficient Practice: All admissions and re-admissions have the potential to be affected by this alleged deficient practice. Summary: On 6/13/2025 an abbreviated survey was initiated at the facility. On 6/13/2025 the surveyor provided an Immediate Jeopardy (IJ) that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Jeopardy (IJ) states as follows: F689 - The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident #1 was transferred safely (with gait belt and correct positioning) by CNA B on 06/10/2025. Resident #1 is an [AGE] year-old man admitted on [DATE] with diagnoses of vascular parkinsonism, dysphagia, need for personal assistance with care, unsteadiness on feet, weakness, other abnormalities of gait and mobility, dementia, and muscle weakness. Resident has a BIMS of 6. Resident #1 sustained a fall on 06/10/2025 resulting in injury to right hip. CNA B reported that resident slid down to knees while helping resident get out of bed after personal care. Resident #1 was admitted to the hospital and underwent subsequent open reduction internal fixation of right hip fracture on 06/10/2025. CNA B reported to surveyor on 06/13/2025 that she did not utilize gait belt and was standing behind the resident during the transfer. Resident #1 returned to the facility on [DATE]. Action: Resident #1 was re-admitted on [DATE] at 6:53 PM, at the time of readmission-these assessments were completed: Initial admission assessment, pain assessment, fall risk assessment, skin assessment, elopement, Braden scale (assessment to evaluate a resident's risk for developing pressure ulcers), functional observation GG assessment (resident's functional goals and abilities), and initial care plan. Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: DON/Designee Action: Individual in-service with CNA B on transfer policy and understanding the Kardex. CNA B provided return demonstration competency on use of gait belt and a safe resident transfer. CNA B suspended effective 6.14.2025. Start Date: 06/13/2025 Completion Date: 06/14/2025 Responsible: Director of Nurses/Designee Action: Review of CNA B personnel file for skill competency for safe transfer. Competency check off for safe transfer completed upon hire on 04/09/2025. Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: Director of Nursing (DON) Action: Thorough investigation of Resident #1 fall on 06/10/2025 conducted with root cause analysis identification of CNA B isolated error in performance of resident transfer. CNA B suspended effective 6.14.2025. Start Date: 6/13/25 Completion Date: 6/14/25 Responsible: Executive Director, IDT, DON, Clinical Resource, MSN/Ed, RN Action: Medical Director and Nurse Practitioner notification of immediate jeopardy. Details of incident, root cause analysis, resident status, and plan of removal discussed. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Executive Director Action: Inservice Leadership Team, including but not limited to: Executive Director, Administrators in Training, Therapy Program Manager, Director of Nurses, Assistant Director of Nurses, and Staffing Coordinator on immediate jeopardy, details of incident, root cause analysis, resident status, plan of removal. Inservice Leadership Team on the following: Fall assessment performed by nursing staff will include: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: Clinical Resource, MSN/Ed, RN Action: Audit 100% care plans of all active residents to confirm resident transfer status includes number of staff members required for safe transfer on the care plan and Kardex. No changes to care plans were indicated. All Kardex were up to date and current for resident transfer needs. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: DON/Designee/Clinical Resource, MSN/Ed, RN Action: Inservice DON on the following: Fall assessment: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation. Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex. Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Clinical Resource, MSN/Ed, RN Action: Inservice 100% nursing and nursing leadership staff on the following: Fall assessment: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 6/13/25 Completion Date: 6/16/25 Responsible: DON/Designee Action: Inservice 100% CNA and therapy staff (including all PRN staff, new hires, and agency staff) on the following: Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 6/13/25 Completion Date: 6/16/25 Responsible: DON/Designee Action: Ad hoc QA meeting. Attendees will include ED , DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and inventions. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Executive Director Systemic Change to Prevent Re-Occurrence: DON/Designee and IDT will ensure safe transfer requirements are assessed upon admission and added to the care plan and Kardex for all residents. DON/Designee and IDT will ensure safe transfer requirements are updated on the care plan and Kardex for any resident that has had a change in transfer status. Start Date: 6/13/25 Completion Date: Ongoing Monitoring of the POR from 06/14/2025 to 06/15/2025 included the following: During an interview with the ADM and the DON on 06/14/2025 at 10:29 AM, they stated Resident #1 returned to the facility on [DATE] at 6:49 PM. A telephone call was attempted to CNA B on 06/14/2025 at 3:08 PM with message requesting for call back. No message was returned by CNA B . During an interview with the ADM and the DON on 06/14/2025 at 10:29 AM, it was stated CNA received in-service and skills check off prior to her shift on 06/13/2025. CNA B was suspended at 2:00 PM on 06/14/2025 after the ADM and DON decided to suspend CNA B until a formal corrective action plan could be developed and implemented . Observation and interview with Resident #1 on 06/14/2025 at 1:15 PM revealed Resident #1 laid in bed with the call light in reach. Resident #1 responded to simple questions with garbled speech. Resident #1 denied any pain and that it was controlled . During interviews conducted from 06/14/2025 to 06/15/2025 with 6 CNAs, 2 LVNs, ADM, DON and 2 AITs reflected staff received in-service either on 06/14/2025 or 06/15/2025 prior to their shifts. Interviewed staff stated they were trained on how to safely transfer a resident from bed-to-chair/chair-to-bed, how to access the Kardex to review transfer status of a resident , use of gait belts (required to have as part of uniform) and to use when indicated when transferring a resident. Interviewed staff stated they took a posttest and demonstrated skills check off on transfers. During an interview on 06/15/2025 at 11:53 AM, the ADM stated the Medical Director and Nurse Practitioner were notified of the IJ. Review of phone logs reflected MD was contacted at 6:05 PM on 6/13/2025 and NP was contacted on 06/13/2025 at 5:45 PM. During an interview on 06/15/2025 at 11:57 AM, the ADM and the DON, stated they were at 90% completion of staff in-servicing. The ADM stated they had reached out to all staff who had not received the in-service and staff were not allowed to work until the training was completed. Review of the spread sheet of in-serviced staff reflected almost all staff were in-serviced as of 06/15/2025. During an interview on 06/15/2025 at 11:56 AM, the DON stated the audit was completed and no changes were identified during the audit. Record review of in-service sign-in sheets, dated 06/13/2025, reflected CNA B participated in the in-service on transfer policy and understanding the Kardex. CNA B provided return demonstration competency on use of gait belt and safe resident transfer and knowledge demonstrated via post-test, dated 06/13/2025. Review of CNA B's employee file reflected a skills competency was completed on 04/09/2025. Record review of counseling/disciplinary notice, dated 06/14/2025, reflected CNA B was suspended pending investigation and CNA B was informed via phone call. Record review of the QAPI meeting sign in sheet and agenda, dated 06/13/2025, reflected MD and NP were notified and meeting was held. Record review of root cause analysis, dated 06/13/2025, reflected the incident with CNA B was an isolated incident after she transferred Resident #1 alone and without a gait belt. CNA B was suspended on 06/14/2025. Record review of care plan resident roster audit documentation, dated 06/13/2025, reflected all resident's charts were audited and Kardex and care plan were updated as needed. Record review of in-service sign-in, dated 06/13/2025, reflected transfer policy and procedure was reviewed, understanding the Kardex, fall management was completed with DON by clinical resource. Record review of in-service sign-in sheets, dated 06/13/2025, reflected transfer policy and procedure was reviewed and understanding the Kardex reflected 19 staff participated. Record review of in-service sign-in sheet, dated 06/13/2025, reflected fall management in-service was completed with 6 nurses and 1 ADON. Record review of in-service sign-in sheet, dated 06/13/2025, reflected IJ, details of incident, root cause analysis, resident status and plan of removal was completed with ADM, 2 AITs , ADON and DON by clinical resource. Record review of 11 post-tests and 11 skills check-offs sheets, dated 06/13/2025, reflected staff demonstrated proper transfer skills and returned demonstration of knowledge from in-services. Record review of Resident #1's fall assessment, dated 06/13/2025, reflected Resident #1 was a high risk for falls and regularly incontinent. Record review of Resident #1's pain assessment, dated 06/13/2025, reflected Resident #1 had a dull pain and rated 4/10 at incision site. Record review of Resident #1's re-admission asking assessment reflected Resident #1 had outer right knee had 2 intact sutures, lateral right thigh had 2 intact sutures and right trochanter had 3 intact sutures. Review of Resident #1 elopement assessment, dated 06/13/2025, reflected Resident #1 was a low risk for elopement. Record review of Resident #1's Braden scale assessment, dated 06/13/2025, reflected the resident was a moderate risk for developing pressure sores. Record review of Resident #1's Kardex, dated 06/14/2025, reflected Resident #1 required substantial / maximal assistance staff participation with transfers . The ADM was informed the Immediate Jeopardy was removed on 06/15/2025 at 4:00 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place .

Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skill and techniques necessary to care for resident's needs, as identified through resident assessments, and described in the plan of care for 1 of 4 (Resident #1) related to safe transfers. The facility failed to ensure CNA B used the accurate technique to transfer Resident #1 safely (with gait belt, correct positioning and/or two-people) on 06/10/2025. An Immediate Jeopardy (IJ) situation was identified on 06/23/2025. While the IJ was removed on 06/24/2025, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of avoidable falls, injuries, hospitalization and/or death. Findings include: Review of Resident #1's face sheet dated 06/16/2025 reflected an [AGE] year-old man admitted on [DATE] with discharge day of 06/10/2025 with diagnoses of vascular parkinsonism (disease that is caused by damage to blood vessels in the brain that leads to movement and balance problems that particularly affect the lower body), unspecified atrial fibrillation (irregular or rapid heartbeat), dysphagia (difficulty swallowing), need for assistance with personal care (need for help with activities of daily living), unsteadiness on feet (being unbalanced or unstable while standing or walking), other abnormalities of gait and mobility (abnormal walking pattern), weakness, unspecified intellectual disabilities, developmental disorder of scholastic skills, muscle weakness, and dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Review of Resident #1's fall risk evaluation dated 02/04/2025 reflected Resident #1 was a high fall risk with no falls in the past three months. Resident #1 had balance problems while standing / walking. Review of Resident #1's BIMS assessment dated [DATE] reflected a score of 6 which indicated severe cognitive impairment. Review of Resident #1's MDS dated [DATE] reflected Resident #1 required substantial/ maximal assistance (helper does more than half the effort) for chair/bed-to-chair transfers. Further review reflected Resident #1 had no falls since the prior assessment or admission. Review reflected Resident #1 was 228 lbs and 74 inches tall. Review of Resident #1's care plan dated 05/31/2015 reflected Resident had impaired cognitive function with interventions to remember one/two step instructions. Review of Resident #1's care plan dated 12/21/2021 reflected he had a self-care deficit and required substantial/maximal assist staff participation with transfers. Further review reflected Resident #1 was at risk for falls related to gait/balance problems. Review of care plan reflected no information regarding use of gait belt when transferring Resident #1. Review of incident report dated 06/10/2025 at 5:00 AM reflected CNA B stated she helped Resident #1 get ready for the day and she tired to use stand and pivot method to transfer but while doing so Resident #1's leg slid, and she helped the resident slowly to the ground and Resident #1 tried to support himself with his knees. Resident #1 was transferred to the ER for evaluation and treatment. Review of progress note dated 06/10/2025 by LVN A reflected Resident #1 was assisted by CNA B when LVN A saw Resident #1 on the floor. LVN A completed an assessment and completed vitals. Review reflected Resident #1 was transferred to bed. Resident #1 was repositioned and had right hip tenderness noted with limited range of motion and pain level of 10/10. Resident #1 screamed when his right foot was moved but was calm when right leg was at rest. Resident #1's right thigh appeared to be swollen. Reached out to the on call provider and advised Resident #1 be sent to the hospital via EMS. Review of hospital records dated 06/13/2025 reflected Resident #1 sustained a right femoral shaft fracture. Procedure performed was an open reduction and internal fixation of right femur shaft fracture with a cephalomedullary nail (surgically exposing fracture and realigning bone fragments and stabilizing the fracture with a nail inserted in the femur). During an interview on 06/13/2025 at 2:11 PM and 3:05 PM, CNA B stated that she assisted Resident #1 with getting ready for the day on 06/10/2025. CNA B stated that she attempted to transfer Resident #1 and that she did not use a gait belt because the nurse did not tell her she needed to use one with Resident #1. CNA B stated she positioned Resident #1's wheelchair close to his bed and she was to the side and behind him. CNA B stated Resident #1 stood and then fell forward to his knees during the transfer. CNA B stated that Resident #1 went straight down to the floor. CNA B stated that Resident #1 usually stepped and then pivoted to the chair and he usually did most of the work. CNA B stated she usually stood behind Resident #1 for transfers and Resident #1 was the only resident she transferred from behind. CNA B stated that she could find information on the Kardex (nursing tool for patient information) for what the resident needed for assistance during transfers. CNA B stated that her hands were on Resident #1's pants or back. CNA B stated she did not remember if she was on his left or right side but stated she was behind him. CNA B stated Resident #1 sat on the edge of the bed and she usually told him to stand but that day (06/10/2025) he did not stand as usual and when she tried to help him he felt like he was going down. CNA B stated that Resident #1 fell forward after he lifted off the bed and he was standing and then went down with CNA B behind him. CNA B did not state if she checked the Kardex prior to the transfer. CNA B stated she usually got Resident #1 up for the day on her shift and he was usually able to stand and take a step and pivot. During an interview on 06/13/2025 at 2:23 PM, CNA D stated that staff could find transfer requirements on Kardex. CNA D stated that the Kardex told staff if a resident needed a 1 or 2 person transfer or minimum or maximum assistance. CNA D stated that there was not a transfer that would occur where the CNA stood behind a resident. CNA D stated that she stood in front of residents when she assisted them from bed to chair and chair to bed. CNA D stated gait belts should be used during transfers. During an interview on 06/13/2025 at 2:28 PM, the OT stated that Resident #1's transfers fluctuated and sometimes Resident #1 needed more help, but it depended on the day. The OT stated that Resident #1 was on therapy service because of the fluctuation in his transfers. The OT stated that there were not one-person transfers in which the staff would stand behind a resident. The OT stated that the staff would only stand behind the resident if there was another staff member present. The OT stated that a gait belt should be used for all transfers for safety reasons. During an interview on 06/13/2025 at 2:48 PM, CNA E stated that staff were supposed to always use a gait belt when they transferred a resident. CNA E stated staff was supposed to stand in front of residents during a transfer. CNA E stated unless there was another staff member then she would not be behind the residents. CNA E stated that staff viewed the Kardex to show whether a resident needed a 1 or two person transfer or a mechanical lift. CNA E stated substantial / maximal assistance usually meant to bring another staff member with you. During an interview on 06/13/2025 at 2:51 PM, CNA C stated with a little muscle from the CNA Resident #1's wheelchair was positioned on the side of his bed at an angle with his bed rail in reach because Resident #1 utilized them to push up. CNA C stated that Resident #1 needed guidance during the transfer and this included verbal cueing. CNA C stated that a gait belt was required for every transfer with Resident #1. During an interview on 06/13/2025 at 3:31 PM, LVN F stated that during a one-person transfer the staff would be facing the resident and be knee-to-knee or feet-to-feet. LVN F stated that there were no transfers that occurred when a staff was behind the resident. LVN F stated a gait belt should be used at all times during a transfer. LVN F stated the purpose of a gait belt was to ensure you had a good grip on the resident and you did not have to grab the resident's clothing or skin. LVN F stated the risk of transferring a resident without a gait belt was losing balance or grip and a potential fall. LVN F stated it was important to have the correct positioning (being in front of the resident) during a transfer to prevent the resident from losing balance or the staff hurting themselves. During an interview on 06/13/2025 at 3:27 PM, the DON stated that during a transfer that first thing was for staff to use a gait belt. The DON stated that staff were positioned in front of the resident with the staff's foot in between the resident's legs. The DON stated that it was best practice to have a gait belt because staff never knew what could happen. The DON stated that a resident that required maximum assistance definitely needed a gait belt to be used. The DON stated the purpose of a gait belt was for extra support or caution during transfers. The DON stated if staff transferred without a gait belt a lot of injuries could happen. The DON stated there were no transfers that a staff would be behind a resident and every single transfer had the staff in front of the resident. The DON stated if staff were behind a resident they could not see what they were doing. The DON stated staff were observed often and assessed for their transfer skills. The DON stated staff were assessed after hire and from time-to-time and if a concern was raised that someone completed a transfer incorrectly. The DON stated after the aide transferred Resident #1 and fell, they started re-education of staff. The DON stated that when incidents like that happened management wanted to educate so incidents were not repeated. The DON stated that she expected staff to use a gait belt when indicated. The DON stated a gait belt would not be used for a resident who required only supervision and could transfer themselves or walk without assistance from staff, otherwise a gait belt was expected to be used. The DON stated that most CNAs had a gait belt provided to them and after Resident #1 fell staff were informed a gait belt was a part of their uniform. The DON stated that she expected staff to have proper positioning during transfers and that if they were not sure they needed to ask questions. The DON stated the Kardex told the staff what a resident's transfer status was and how many staff were required. The DON stated that staff were reminded to use the Kardex almost daily during the stand-down meeting. The DON stated that she was out on 06/10/2025 and reviewed the progress note on 06/11/2025 about Resident #1's fall and stated that initially she read the aide helped Resident #1 slide down to the floor and she thought that's good she helped him. The DON stated that CNA B stated she (CNA B) transferred Resident #1 and he slid down to the floor. The DON stated that after the initial assessment Resident #1 was transferred to his bed and he started to scream and LVN A saw that his leg was swollen and she reached out to the supervisor and on-call. The DON stated that after she learned Resident #1 had a fracture she began re-education with staff. The DON stated she reviewed what each transfer was and proper transfer and body mechanics. The DON stated she did not ask CNA B if she had a gait belt and did not ask where CNA B was positioned during the transfer. The DON stated she was only able to speak with LVN B. The DON stated that Resident #1 had not had any falls prior to this incident. During an interview on 06/13/2025 at 3:40 PM the ADM stated that he expected staff to transfer residents correctly and there was zero tolerance for incorrect transfers. The ADM stated he was not aware of the specific details of Resident #1's transfer. The ADM stated he expected staff to use a gait belt 100 percent of the time when indicated. The ADM stated the IDT reviewed Resident #1's fall and discussed what could have been done better. The ADM stated he was not aware of the details regarding whether CNA B had a gait belt or where she was positioned when she transferred Resident #1. The ADM stated that he and the DON stressed to staff that they should never be without supplies (including gait belts) and staff could call or text anytime they needed something. During an interview on 06/13/2025 at 4:12 PM, the NP stated that she expected staff to utilize safe transfer techniques. She stated Resident #1 did have intermittent confusion and other diagnoses that made him a fall risk. NP stated not utilizing a gait belt or proper positioning during transfers could obviously result in a fall leading to a fracture. During an interview on 06/23/2025 at 1:47 PM, the DON stated substantial/maximal assistance meant that two staff were required during the transfer. The DON stated when staff reported a resident had a change in level of assistance needed then care plans or Kardex was updated right away. The DON stated skills checks were observed upon hire. The DON stated she came to the building during off hours to check in with staff and observe care. The DON stated staff also had skills check three months after hire. The DON stated if staff expressed concerns or area where they needed more training during their new hire training their training would be extended. The DON stated if a resident required two people for their care then she expected two staff to provide that care. The DON stated the risk of not having another staff if a resident required two people for care was a fall that resulted in an injury. The DON stated staff were trained by a train the trainer method and new staff were paired with another staff and trained by the other staff through on the job training. The DON stated she checked in with staff at the end of their training to ask if they felt comfortable and if they needed any additional training in any area. The DON stated she or the ADON would complete the final skills check before staff were released to work independently . During an interview on 06/23/2025 at 3:45 PM, LVN A stated she was the charge nurse when Resident #1 fell. She stated it was considered a witnessed fall and from what she was told by CNA B, CNA B tried to transfer Resident #1, he missed a step and fell. LVN A stated she was not sure why CNA B transferred Resident #1 by herself. LVN A stated based on what the Kardex had and other the CNA said Resident #1 was a two-person transfer. LVN A stated substantial / maximal assistance was required a two people in the transfer. Record review of CNA B's employee file reflected skills check off was completed for CNA B on 01/10/2025 and 04/09/2025 and included one-person, two-person and hoyer transfers. Record review of in-service, dated 06/11/2025, with subject GGS (functional abilities and goals) reflected it reviewed types of assistance needed for transfer, staff required and reflected CNA B did not complete the in-service as of 06/13/2025. Record review of in-service, dated 06/11/2025, with subject Kardex reflected CNA B did not participate in the in-service as of 06/13/2025. The in-service included the purpose of Kardex and how it was used. Record review of in-service, dated 06/11/2025, with subject of body mechanics reflected CNA B did not participate in the in-service as of 06/13/2025. The in-service included body positioning during transfers. Record review of in-service, dated 06/11/2025, reflected substantial/maximal assistance required two people for transfers. Record review of in-service, dated 06/11/2025, with topic safe resident transfers and handling reflected proper techniques, correct use of patient handing equipment and devices with the goal to ensure resident safety and reduce injury for both residents and staff. Review reflected CNA B completed this in-service as verified by signature and date of 06/11/2025. Record review of the facility's schedule / sign-in sheets for 06/11/2025, 06/12/2025 reflected CNA B was not scheduled to work at the facility. Review of the facility schedule dated 06/13/2025 reflected CNA B was scheduled to return to the facility from 10:00 pm - 6:00 am on 06/13/2025. Record review of the facility's policy titled Quality of Care Transfer of a Resident, Safe with revision date of 05/2025 reflected use good body mechanics at all times and use a gait belt for all transfer if gait belts is indicated for the resident. The policy reflected for one-person transfers, apply gait belt around resident's waist, provide necessary assistance to help the resident stand up. The policy reflected two-person transfers using a gait belt required to apply the gait belt around the resident's wait, use good body mechanics at all times and provide the necessary help f or the resident to stand up with caregivers on both sides of the resident and staff holding the gait belt. This was determined to be an Immediate Jeopardy (IJ) on 06/23/2025. The ADM and DON were notified on 06/23/2025 at 3:45 PM and a template was given. The following Plan of Removal submitted by the facility was accepted on 06/24/2025 at 7:48 AM: Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified, on 6/23/2025. Identification of Others Affected by Alleged Deficient Practice: All admissions and re-admissions have the potential to be affected by this alleged deficient practice. Summary: On 6/13/2025 an abbreviated survey was initiated at the facility. On 6/13/2025 the surveyor provided an Immediate Jeopardy (IJ) that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. On 6/23/2025 after review by enforcement, an additional Immediate Jeopardy (IJ) has been cited. The notification of Immediate Jeopardy (IJ) states as follows: F726 - The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facility failed to ensure CNA B used the accurate technique to transfer Resident #1 safely (with gait belt, correct positioning and/or two-people) on 06/10/2025. Resident #1 is an [AGE] year-old man admitted on [DATE] with diagnoses of vascular parkinsonism, dysphagia, need for personal assistance with care, unsteadiness on feet, weakness, other abnormalities of gait and mobility, dementia, and muscle weakness. Resident has a BIMS of 6. Resident #1 sustained a fall on 06/10/2025 resulting in injury to right hip. CNA B reported that resident slid down to knees while helping resident get out of bed after personal care. Resident #1 was admitted to the hospital and underwent subsequent open reduction internal fixation of right hip fracture on 06/10/2025. CNA B reported to surveyor on 06/13/2025 that she did not utilize gait belt and was standing behind the resident during the transfer. Resident #1 returned to the facility on [DATE]. Action: Resident #1 was re-admitted on [DATE] at 18:53 PM , at the time of readmission-these assessments were completed: Initial admission assessment, pain assessment, fall risk assessment, skin assessment, elopement, Braden scale, functional observation GG assessment, and initial care plan Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: DON/Designee Action: Individual in-service with CNA B on transfer policy and understanding the Kardex. CNA B provided return demonstration competency on use of gait belt and a safe resident transfer. CNA B suspended effective 6.14.2025 and subsequently terminated on 6.18.2025. Start Date: 06/13/2025 Completion Date: 06/18/2025 Responsible: Director of Nurses/Designee Start Date: 6/13/25 Completion Date: 6/14/25 Responsible: Executive Director, IDT, DON, Clinical Resource, MSN/Ed, RN Action: Medical Director and Nurse Practitioner notification of immediate jeopardy. Details of incident, root cause analysis, resident status, and plan of removal discussed. Start Date: 6/13/25 and 6/23/25 Completion Date: 6/13/25 and 6/23/25 Responsible: Executive Director Action: Inservice Leadership Team, including but not limited to: Executive Director, Administrators in Training, Therapy Program Manager, Director of Nurses, Assistant Director of Nurses, and Staffing Coordinator on immediate jeopardy, details of incident, root cause analysis, resident status, plan of removal. Inservice Leadership Team on the following: Fall assessment performed by nursing staff will include: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 06/13/2025 Completion Date: 06/13/2025 Responsible: Clinical Resource, MSN/Ed, RN Action: Audit 100% care plans of all active residents to confirm resident transfer status includes number of staff members required for safe transfer on the care plan and Kardex. No changes to care plans were indicated. All Kardex were up to date and current for resident transfer needs. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: DON/Designee/Clinical Resource, MSN/Ed, RN Action: Inservice DON on the following: Fall assessment: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Clinical Resource, MSN/Ed, RN Action: Inservice 100% nursing and nursing leadership staff on the following: Fall assessment: completion of SBAR, not moving resident if injury suspected, activation of 911, provider notification, DON notification, representative notification, change of condition completion, progress note documentation Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test and return demonstration Start Date: 6/13/25 Completion Date: 6/16/25 Responsible: DON/Designee Action: Inservice 100% CNA and therapy staff (including all PRN staff, new hires, and agency staff) on the following: Transfer policy, use of gait belt, safety with transfers, identification of resident transfer requirements through use of Kardex Understanding the Kardex: how to access Knowledge retention demonstrated with post-test and return demonstration Start Date: 6/13/25 Completion Date: 6/16/25 Responsible: DON/Designee Action: Ad hoc QA meeting. Attendees will include ED , DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and inventions. Start Date: 6/13/25 Completion Date: 6/13/25 Responsible: Executive Director Action: Ad hoc QA meeting. Attendees will include ED, DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and interventions. Start Date: 6/23/25 Completion Date: 6/23/25 Responsible: Executive Director Systemic Change to Prevent Re-Occurrence: DON/Designee and IDT will ensure safe transfer requirements are assessed upon admission and added to the care plan and Kardex for all residents. DON/Designee and IDT will ensure safe transfer requirements are updated on the care plan and Kardex for any resident that has had a change in transfer status. Start Date: 6/13/25 Completion Date: Ongoing Monitoring of the POR on 06/24/2025 included the following: A telephone call was attempted to CNA B on 06/14/2025 at 3:08 PM with message requesting for call back. No message was returned by CNA B . During an interview with the ADM and the DON on 06/14/2025 at 10:29 AM, it was stated CNA received in-service and skills check off prior to her shift on 06/13/2025. CNA B was suspended at 2:00 PM on 06/14/2025 after ADM and DON decided to suspend CNA B until a formal corrective action plan could be developed and implemented. During an interview on 06/15/2025 at 11:56 AM, the DON stated the audit was completed and no changes were identified during the audit. Observation and interview with Resident #1 on 06/14/2025 at 1:15 PM revealed Resident #1 laid in bed with call light in reach. Resident #1 responded to simple questions with garbled speech. Resident #1 denied any pain and that it was controlled. During an interview on 06/24/2025 at 12:59 PM, the ADM stated he was not able to get ahold of the 3 suspended staff to in-service them . The ADM stated they were not on the floor until they got the in-service. The ADM stated he had not been able to contact the staff to terminate them. During interviews conducted from 06/14/2025 - 06/15/2025 and on 06/23/2025 with 8 CNAs, 3 LVNs, ADM, DON and 2 AITs reflected staff received in-services either 06/14/2025 or 06/15/2025 prior to their shifts. Interviewed staff stated they were trained on how to safely transfer a resident from bed-to-chair/chair-to-bed, how to access the Kardex to review transfer status of a resident, use of gait belts (required to have as part of uniform) and to use when indicated when transferring a resident . Interviewed staff stated they took a posttest and demonstrated skills check off on transfers. During interviews with staff in-training on 06/24/2025, 3 CNAs stated they were currently in-training. CNAs stated they started at the facility between 06/19/2025 and 06/21/2025. CNAs stated they received in-services on using the Kardex, levels of transfer status and how many staff are involved in each transfer and to use a gait belt for each transfer . Interviewed staff were able to stated a gait belt should be used for each transfer, that staff should stand in front of the resident for transfers (except for mechanical lift transfers) and the Kardex was where to find how many staff were needed for a transfer, how much assistance was needed for a transfer and if a resident required a mechanical lift for a transfer. Staff stated they received the in-service after they started, but before they started their shift working on the floor at the facility over the phone and again in-person. During an interview with the DON on 06/24/2025 at 12:37 PM, the DON stated when a new admission arrived an initial assessment was conducted by the nurse or therapy to determine transfer status. The DON stated the nurse completed the assessment until therapy was able to come in and assess the resident. The DON stated periodically information was gathered by staff when they observed a change in a resident's care needs or abilities to participate in transfer during care. The DON stated if a staff reported a resident required more help, transfer status was changed to reflect assistance needed immediately in the Kardex. During an interview with the ADM on 06/24/2025 at 12:50 PM, the IDT was responsible to ensure transfer needs were updated in the Kardex for any changes and new admission . The ADM stated leadership staff were responsible to train any new hires on transfer required and the Kardex. Record review of in-service sign-in sheets, dated 06/13/2025, reflected CNA B participated in the in-service on transfer policy and understanding the Kardex. CNA B provided return demonstration competency on use of gait belt and safe resident transfer and knowledge demonstrated via post-test, dated 06/13/2025. Review of CNA B's employee file reflected a skills competency was completed on 04/09/2025. Record review of counseling/disciplinary notice, dated 06/14/2025, reflected CNA B was suspended pending investigation and CNA B was informed via phone call. Record review of the QAPI meeting sign in sheet and agenda, dated 06/23/2025, reflected MD and NP were notified and meeting was held. Record review of text message from ADM to MD and NP, dated 06/23/2025, reflected MD and NP were notified of IJ. Record review of root cause analysis, dated 06/13/2025, reflected the incident with CNA B was an isolated incident after she transferred Resident #1 alone and without a gait belt. CNA B was suspended on 06/14/2025. Record review of care plan resident roster audit documentation, dated 06/13/2025, reflected all resident's charts were audited and Kardex and care plan were updated as needed. Record review of in-service sign-in, dated 06/13/2025, reflected transfer policy and procedure was reviewed, understanding the Kardex, fall management was completed with DON by clinical resource. Record review of in-service sign-in sheets, dated 06/13/2025, reflected transfer policy and procedure was reviewed and understanding the Kardex reflected 19 staff participated. Record review of in-service sign-in sheet, dated 06/13/2025, reflected fall management in-service was completed with 6 nurses and 1 ADON. Record review of in-service sign-in sheet, dated 06/13/2025, reflected IJ, details of incident, root cause analysis, resident status and plan of removal was completed with ADM, 2 AITs , ADON, and DON by clinical resource. Record review of 11 post-tests and 11 skills check-offs sheets, dated 06/13/2025, reflected staff demonstrated proper transfer skills and returned demonstration of knowledge from in-services. Record review of Resident #1's fall assessment, dated 06/13/2025, reflected Resident #1 was a high risk for falls and regularly incontinent. Record review of Resident #1's pain assessment, dated 06/13/2025, reflected Resident #1 had a dull pain and rated 4/10 at incision site. Record review of Resident #1's re-admission asking assessment reflected Resident #1 had outer right knee had 2 intact sutures, lateral right thigh had 2 intact sutures and right trochanter had 3 intact sutures. Review of Resident #1 elopement assessment dated [DATE] reflected Resident #1 was a low risk for elopement. Record review of Resident #1's Braden scale assessment, dated 06/13/2025, reflected resident was a moderate risk for developing pressure sores. Record review of Resident #1's kardex, dated 06/24/2025, reflected Resident #1 required mechanical lift transfer with 2 person assistance . Record review of Resident #1's care plan and 5 other resident care plans reflected transfer status included

Based on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of four residents (Resident #1) reviewed for abuse and neglect. The facility failed to thoroughly investigate a fall in which Resident #1 sustained a femur (thigh bone) fracture on 06/10/2025 during a transfer by CNA B. This failure could place residents at risk of further abuse, physical harm, mental anguish and emotional distress. Findings include: Review of Resident #1's face sheet dated 06/16/2025 reflected an [AGE] year-old man admitted on [DATE] with discharge day of 06/10/2025 with diagnoses of vascular parkinsonism (disease that is caused by damage to blood vessels in the brain that leads to movement and balance problems that particularly affect the lower body), unspecified atrial fibrillation (irregular or rapid heartbeat), dysphagia (difficulty swallowing), need for assistance with personal care (need for help with activities of daily living), unsteadiness on feet (being unbalanced or unstable while standing or walking), other abnormalities of gait and mobility (abnormal walking pattern), weakness, unspecified intellectual disabilities, developmental disorder of scholastic skills, muscle weakness, and dementia (loss of memory, language, problem-solving and other thinking abilities that interfere with daily life). Review of Resident #1's BIMS assessment dated [DATE] reflected a score of 6 which indicated severe cognitive impairment. Review of Resident #1's MDS dated [DATE] reflected Resident #1 required substantial/ maximal assistance (helper does more than half the effort) for chair/bed-to-chair transfers. Further review reflected Resident #1 had no falls since the prior assessment or admission. Review reflected Resident #1 was 228 lbs and 74 inches tall. Record review of Resident #1's care plan, dated 05/31/2015, reflected the resident had impaired cognitive function with interventions to remember one/two step instructions. Review of Resident #1's care plan, dated 12/21/2021, reflected he had a self-care deficit and required substantial/maximal assist staff participation with transfers. Resident #1 was at risk for falls related to gait/balance problems. Review of incident report dated 06/10/2025 at 5:00 AM reflected CNA B stated she helped Resident #1 get ready for the day and she tired to use stand and pivot method to transfer but while doing so Resident #1's leg slid, and she helped the resident slowly to the ground and Resident #1 tried to support himself with his knees. Resident #1 was transferred to the ER for evaluation and treatment. Review of progress note dated 06/10/2025 by LVN A reflected Resident #1 was assisted by CNA B when LVN A saw Resident #1 on the floor. LVN A completed an assessment and completed vitals. Review reflected Resident #1 was transferred to bed. Resident #1 was repositioned and had right hip tenderness noted with limited range of motion and pain level of 10/10. Resident #1 screamed when his right foot was moved but was calm when right leg was at rest. Resident #1's right thigh appeared to be swollen. Reached out to the on call provider and advised Resident #1 be sent to the hospital via EMS. There was no documentation of statements by CNA B or LVN A related to Resident #1's fall. No PIR was provided by the facility for Resident #1's fall. Review of hospital records dated 06/13/2025 reflected Resident #1 sustained a right femoral shaft fracture. Procedure performed was an open reduction and internal fixation of right femur shaft fracture with a cephalomedullary nail (surgically exposing fracture and realigning bone fragments and stabilizing the fracture with a nail inserted in the femur). During an interview on 06/13/2025 at 2:11 PM and 3:05 PM, CNA B stated she assisted Resident #1 with getting ready for the day on 06/10/2025. CNA B stated she attempted to transfer Resident #1 and she did not use a gait belt because the nurse did not tell her she needed to use one with Resident #1. CNA B stated she positioned Resident #1's wheelchair close to his bed and she was to the side and behind him. CNA B stated Resident #1 stood and then fell forward to his knees during the transfer. CNA B stated Resident #1 went straight down to the floor. CNA B stated Resident #1 usually stepped and then pivoted to the chair and he usually did most of the work. CNA B stated she usually stood behind Resident #1 for transfers and Resident #1 was the only resident she transferred from behind. CNA B stated she could find information on the Kardex (charting tool that provide care needs for a resident) for what the resident needed for assistance during transfers. CNA B stated her hands were on Resident #1's pants or back. CNA B stated she did not remember if she was on his left or right side, but stated she was behind him. CNA B stated Resident #1 sat on the edge of the bed and she usually told him to stand but that day (06/10/2025) he did not stand as usual and when she tried to help him, he felt like he was going down. CNA B stated Resident #1 fell forward after he lifted off the bed and he was standing and then went down with CNA B behind him. During an interview on 06/13/2025 at 3:27 PM, the DON stated she was out on 06/10/2025 and reviewed the progress note on 06/11/2025 about Resident #1's fall and stated initially she read CNA B helped Resident #1 slide down to the floor and she thought that's good she helped him. The DON stated CNA B stated she (CNA B) transferred Resident #1 and he slid down to the floor. The DON stated after the initial assessment Resident #1 was transferred to his bed and he started to scream and LVN A saw his leg was swollen and she reached out to the supervisor and on-call. The DON stated after she learned Resident #1 had a fracture she began re-education with staff on transfers. The DON stated she reviewed what each transfer was and proper transfer and body mechanics. The DON stated she did not ask CNA B if she had a gait belt and did not ask where CNA B was positioned during the transfer. During an interview on 06/13/2025 at 3:40 PM, the ADM stated he expected staff to transfer residents correctly and there was zero tolerance for incorrect transfers. The ADM stated he was not aware of the specific details of Resident #1's transfer. The ADM stated he expected staff to use a gait belt 100 percent of the time when indicated. The ADM stated the IDT reviewed Resident #1's fall and discussed what could have been done better. The ADM stated he was not aware of the details regarding whether CNA B had a gait belt or where she was positioned when she transferred Resident #1 . The ADM stated he and the DON stressed to staff they should never be without supplies (including gait belts) and staff could call or text anytime they needed something. During an interview on 06/16/2025 at 1:37 PM, the ADM stated the IDT was responsible to review incident reports after falls after the morning meetings. The ADM stated incidents were determined to have a need for investigation on a case-by-case basis. The ADM stated any concerns related to an incident or falls were brought up then, he immediately started to talk with staff for more information. The ADM stated CNA B was interviewed on the specifics of the fall prior to 06/13/2025 but he was unsure who interviewed CNA B. The ADM stated he did not recall information regarding gait belt use or positioning of CNA B during the transfer being reported to the DON. The ADM stated an investigation included a focus on the root cause analysis and focus to prevent something to happen again to any residents. The ADM stated investigations were trigged by something the facility did not want to happen and how to prevent them from happening again. The ADM stated there was not a specific policy on investigating incidents and information was in the abuse policy. During an interview on 06/16/2025 at 1:46 PM, the DON stated LVN A stated CNA B reported Resident #1 slide down during the transfer. The DON stated she was out on 06/10/2025 and when she returned, she reviewed the notes and something did not add up. The DON stated after she talked to CNA B, she started to in-service the staff on body mechanics and transfers. The DON stated CNA B then reported she was behind Resident #1 during the transfer and the posture was not good. The DON stated CNA B did not mention the gait belt during the interview. The DON interviewed CNA B on 06/11/2025. The DON stated she and ADM discussed with the IDT about the fall and everyone felt something was off. During an interview on 06/16/2025 at 1:50 PM, the ADM and the DON stated they discussed with the IDT to be more vocal about any concerns and discussing an incident was more than just saying an incident or fall happened but needed to brainstorm why it happened and how to move forward. Record review of the facility's policy titled Abuse: Prevention of and Prohibition Against, with revision date of 04/2024, reflected an adverse event was an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. Investigation included that all identified events should be reported to the ADM immediately. Investigation would include interview with the residents, interviews with any witnesses to the incident, including the alleged perpetrator and review of staff members on all shifts who may have information regarding the alleged incident. At the conclusion, the facility with attempt to determine if abuse, neglect, misappropriation or exploitation has occurred. Further review reflected the results of the investigation would be documented.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #36) reviewed for PASARR Level 1 screenings. The facility failed to notify the local authority of the PASARR I screen for Residents #36. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Record review of a Face Sheet dated 06/05/25 for Resident #36 revealed a [AGE] year-old female admitted initially to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included post-traumatic stress disorder (is a mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it), bi-polar disorder, in full remission, most recent episode depressed (is a serious mental illness characterized by severe mood swings. Remissions refers to a state where mood symptoms are absent or minimal), Parkinson's disease without dyskinesia, without mention of fluctuations (the condition in its state where these involuntary movements are not present), other insomnia (sleep difficulties that do not link to any other health conditions. It can be acute or chronic). Record review of Resident #36's diagnosis report revealed that she was diagnosed with post-traumatic stress disorder upon admission and bi-polar disorder, in full remission on 03/13/23. Record review of Resident #36's Quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated cognitive intact in section C. Record review of Resident 36's care plan dated 03/24/2025 revealed a focus that Resident #36 had a trauma r/t history of PTSD; she had mood problems related to the disease process; and she has the potential to demonstrate physical behaviors related thx of PTSD. With a goal of no evidence of emotional, physical, and psychological problems; improved mood state and happier, calmer, appearance, no s/sx of depression, anxiety, or sadness; effective coping skills through the review date. Interventions in place were to administer mediations as ordered, monitor/document for side effects and effectiveness, behavioral health consults as needed, encourage resident to attend care conference to express preferences and participate in care plan process, monitor/record/report to MD mood patterns s/sx of depression, anxiety, or sad mood. Record review of Resident #36's PASARR Level 1 Screening dated 03/13/23 revealed the resident did have a Mental Illness, Intellectual Disability, or Developmental Disability in section C. During an interview with the MDS Coordinator on 06/06/2025 at 2:25 PM, reflected she does the MDS for the residents and the resource nurse reviews it to make sure it is correct. She stated if it is done incorrectly, she can go in, complete the modification, and sign it. She stated failure to enter the PASARR request in a timely manner could result in the resident not receiving the psych services and not get some DME they may have qualified for. She has submitted a Negative PASARR Level 1 form 1012 for resident dated 6/6/2025. During an interview with the ADM on 06/06/2025 at 2:40 PM, reflected his expectation is to clarify and place his trust in his team to meet the expectations and communicate any needs. He expected them to communicate with the family on how the resident are doing. He stated the MDS Coordinator and the MDS clinical resource is responsible for making sure the MDS are accurate. He stated not submitting the PASARR in a timely manner to the local authorities, this failure could result in the resident not receiving services. Record review of the facility's policy, PASRR Policy and Procedure undated reflected: Policy: The facility will designate as individual to follow up on ALL residents have receive a PASARR Level I screening. If the facility serves a resident with a positive PASARR Level I screening, the facility MUST have obtained a PASARR Level II evaluation from the Local Authority or have documented attempts to follow up with the Local Authority to obtain the PASARR Level II evaluation.

Based on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 10 residents (Resident #1) reviewed for accidents and supervision. The facility failed to prevent Resident #1 from eloping on 09/27/2024. The non-compliance was identified as PNC. The facility had corrected the non-compliance on 9/27/2024 before the investigation/complaint began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death. The findings were: During an interview on 11/20/24 at 12:23 PM with Resident #1, he stated he didn't remember what he was going to HEB for. He stated he was going for a machine for his head. Resident #1 was advised there were no machines for his head there and he stated well he doesn't know what he was there for. Record review of Resident # 1's face sheet, dated 11/27/2024, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis that includes Nontraumatic Intracerebral Hemorrhage In Hemisphere, Subcortical (a bleeding into the brain that can occur in the cerebral cortex or basal ganglia), Essential (Primary) Hypertension ( a type of high blood pressure that doesn't have an identifiable cause), Contusion and Laceration of Cerebrum, Unspecified, Without Loss of Consciousness, Sequela (a medical diagnosis indicating a brain injury where there was bruising and tearing of the cerebral tissue, but the person did not lose consciousness), Cerebral Infarction, Unspecified (a medical condition where a blood vessel supplying blood to the brain is blocked, resulting in brain tissue damage), Hyperlipidemia, Unspecified (a common condition where there are too many fats in the blood. It's usually asymptomatic but can lead to serious health problems if left untreated), Other Psychoactive Substance Abuse, Uncomplicated, Dysphasia, Unspecified, Personal History of Other Mental and Behavioral Disorders (Mental and behavioral disorders due to psychoactive substance use. Overview . - Mental and behavioral disorders due to multiple drug use and use of other), Cerebral aneurysm, Nonruptured (a bulge in a brain artery that hasn't burst yet), Hemiplegia and Hemiparesis following other Nontraumatic Intracranial Hemorrhage Affecting Right Dominant Side (a person has experienced weakness or paralysis on the left side of their body due to a brain bleed that occurred on the right side of the brain, specifically in the dominant hemisphere). Record review of Resident's # 1 Admission MDS assessment, dated 10/15/2024 revealed a BIMS score of 05 means sever cognitive impairment. Review of Resident #1's care plan dated 11/21/2024 revealed no evidence of wandering or risk for elopement. Record review of witness statement from LVN A dated 9/27/2024 stated she saw Resident #1 all day and he seemed normal. Around noon she noticed that Resident #1 wasn't in the dining room for lunch like he normally is. LVN A stated she didn't see him in his room or in the back patio, so she let the DON and Administrator know that she did not know where Resident #1 is. LVN B told LVN A that she received a call from her family member that someone got kicked out of the store for trying to shoplift a bunch of steaks. CNA A advised LVN A she heard Resident #1 talking about getting some steak and asking his roommate for directions. LVN A advised the DON and the Administrator about the conversation she had with CNA regarding Resident #1. LVN A stated when Resident #1 returned to the building she completed an assessment on him and provided the report to EMS when they came and picked Resident #1 up around 2 PM. Record review of witness statement from LVN B dated 9/27/2024 stated she saw Resident #1 moving around the building as normal. She stated she did not see him trying to leave the building at all. She stated after they started the code pink to search the building for him, she received a call from her family member around 12:45pm that someone got kicked out of the store for trying to shoplift some steaks and she mentioned it to LVN A and CNA A. That is when CNA A stated she overheard Resident #1 asking his roommate how to get to the local grocery store so he can get some steaks. She notified the DON and the Administrator immediately about the information. During an interview on 11/21/24 at 9:35 am with CNA A stated Resident #1 took a shower, and she heard him say he was going to get him some steaks. She stated Resident #1's roommate can come and go, and she figured the roommate was going to get the steak. She went and got the iron, and she asked him where he was going looking all sharp. And he said he was going to get him some steaks. Once Resident #1 finished dressing for the day, she made his bed, and then she went looking for him to give him his tray. She stated he waited until someone came in and snuck out the front door. Resident #1 went to the local grocery store and stole $230 worth of steaks. She stated that LVN B's family member worked at the local grocery store, and she called her and stated someone was in there trying to steal steaks. When LVN B's family member described him, CNA A realized it was him. CNA A said when he got back, Resident #1 was evaluated, and they sent him to the hospital to make sure he was alright. CNA A stated they were in-serviced on Elopement and what to do in case of an elopement, what code pink means and who to notify as soon as they realize the resident is missing. During an interview on 11/20/24 at 12:15 PM with Reception stated Resident #1 got out in the front while she was helping someone else. She stated she did not realize he slipped out. She stated there was a lot going on that day. Receptionist stated a code pink was called. An unknown staff member brought him back from the local grocery story. After Resident #1 returned, EMS was called to bring him to the hospital to have him checked out. Resident #1 was checked out and he was fine. Receptionist denies he tried to get out since being back. She stated he only goes by the door when he is going to a doctor's appointment. The ADM and DON added him to the elopement binder, they went over the elopement process, and they have been doing training every week. During an interview on 11/20/24 at 2:55 PM with DON stated Resident #1 was sitting in the building and a nurse stated she could not find him. DON stated a code pink was called. DON stated she and the ADM went driving around to find him. DON stated someone called and stated they saw someone that looked like a resident. She stated she and the ADM drove by the local grocery store and picked him up. Resident #1 stated he fell while he was out there. Resident #1 denied wanting to go to the hospital, but he was sent anyway to ensure he was alright. Resident #1 returned to the facility from the emergency room with no injuries noted on the paperwork. The DON was advised Resident #1 walking out the door when hospice walked in. DON stated he knows when people come in and out. He was able to get out with the little crack in the door. DON stated he has not tried to escape since. DON stated his family was called and they came down and had a care plan. During an interview on 11/20/2024 at 2:38pm with ADM stated there were two hospice staff that were waiting at the front door. Resident #1 was able to get out the front door when they were coming in. Resident #1 walked to the local grocery store. Resident #1 said that he went to the store to get some steaks. Staff found Resident #1 about an hour later and returned Resident #1 to the facility. Staff were in-serviced on elopement of residents. Resident #1 has not tried to elope since then. Record review of policy Wandering/ Elopement revised December 2023 revealed: It is policy of the facility to provide a safe environment, as free of accidents as possible, for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement. The facility course of action prior to surveyor entrance included: Search of facility and surrounding areas. Checked and accounted for all residents. Staff in the daytime will make rounds every two hours and at nighttime, the staff will make rounds every four hours to ensure the residents are counted for and safe. Observed all exit doorways and alarms in complete working order. Resident #1 was sent to the hospital for ER for evaluation after being located. Medical records review reveled Resident #1 returned to the facility with no issues or follow up appointments. Resident placed on 1:1 supervision after being located. CNA A was assigned to do 1:1 with Resident #1. The staff was in-serviced on Elopement policies and procedures process; ensure residents sign in/out; how to fill out an elopement assessment; informed elopement binders are located at each nurses station on 9/27/2024. Elopement drill was performed. The faculty and staff performed a drill showing they can perform the elopement protocol. The staff stated when a resident is missing, a code pink is called. Then they will start a search of all rooms and once that room is checked, they will place the garbage can outside the door to confirm that room was already checked. Faculty and staff search inside and outside the facility. The facility contacted the alarm company, which a test operation was perform on the doors, locks, and alarms on 09/27/2024. Observation was done by observing the doors which were pushed and left open for 15 seconds and the alarm sounded. The code for the doors were changed. Pink binders were placed at the nurses stations. Once they cannot find the resident, they will call the police and file a missing report. Doors were checked. The alarm company came. Prior to the survey the facility implemented: 1:1 monitoring of the resident until further assessment (target date 1/13/2025). Assess for fall risk. Provided structured activities walking inside and outside, toileting, reorientation, strategies including signs, pictures, and memory boxes. Psych evaluation. There was another resident listed in the elopement binder, but I did not collect information for that resident. Everything was completed on 09/27/2024. Upon admission Resident #1 was considered a low risk. (4) but after the elopement, his score is now at a high risk (11). Resident #1 score is currently an 11. He is in the pink binder along with another resident. The 2 residents are in the pink elopement binder and the care plan for Resident #1 is updated. Interviews were conducted with employees who consisted of LVN's (2), Staffing Coordinator/Med Aide (1), CNAs (9), Receptionist (1), and Resident #1 on 11/20-21/2024 from 10:00 am to 11:30 am and revealed they had received in-services on Elopement Response, all were able to state the key elements of the Emergency response plan and elopement policy which was included.

Based on interview and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of four residents reviewed for indwelling urinary catheters, in that: The facility failed to implement a batch order for daily catheter care when Resident #1 was admitted on [DATE] and failed to provide daily catheter care for Resident #1 from 7/2/2024 until 7/10/2024. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain. Findings included: Review of Resident #1's face sheet dated 7/14/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Cellulitis (bacterial skin infection), Chronic Kidney Disease, Morbid Obesity (severely overweight), Hypertension (high blood pressure), Congestive Heart Failure, Major Depressive Disorder (type of depression), Borderline Personality Disorder (mental health disorder), Tobacco use, Alcohol use and anxiety disorder. Review of Resident #1's MDS admission assessment dated [DATE] reflected a BIMS score of 9 suggesting mild cognitive impairment. Review of MDS Section H - Bladder and Bowel reflected resident had an Indwelling catheter and urinary continence was not rated, resident had a catheter Review of Resident #1's care plan dated 7/3/2024 reflected no Focus Area, Goal, or Interventions for an indwelling catheter. Review of Resident #1's care plan dated 7/12/2024 reflected a Focus Area for Indwelling Catheter with a goal of Will remain free of catheter related trauma through review date and Interventions to include position catheter bag below the level of the bladder and away from entrance room door, monitor and document input and output and monitor for signs and symptoms of pain, burring, blood-tinged urine .change in behavior, change in eating patterns. Review of nursing progress note dated 7/2/2024 at 5:37 p.m., by LVN B reflected Resident has a 16F Foley cath. Resident Foley is patent and draining properly. Review of NP admission assessment progress note with a date of service of 7/3/24 reflected under the heading Physical Exam, Genitourinary: no tenderness, Foley Indicating Resident #1 had a Foley Catheter in place. Review of Resident #1's progress notes dated from 7/2/2024 until 7/11/2024 reflected no progress notes indicating any catheter care was attempted or performed. Review of Resident #1's orders dated 7/12/2024 reflected an order dated 7/10/2024 to start 7/11/2024 Catheter care every shift. Monitor urethral site for s/s of skin breakdown, pain/discomfort, unusual odor, urine characteristic or secretions, catheter pulling causing tension. During an interview on 7/12/2024 at 1:20 p.m., the DON stated the facility uses batch orders for Foley catheter care. The DON stated the nurse that does the admission is responsible for making sure they are completed. The DON stated she did not put in the catheter care batch orders for Resident #1 until 7/10/2024 I should have done it but I didn't get to it. The DON further stated the nurses are still learning how to do batch orders but ultimately is responsible for making sure they get in and done. She stated she believed catheter care was being done even though there was no order, but she cannot prove this as there are no progress notes from the nurses to reflect the care was being done. She stated if catheter care is not done residents can get infections and become very sick. During an interview on 7/15/2024 at 9:10 a.m., the AAD stated he was not aware Resident #1 did not have orders put in at admission for catheter care and stated, that is unacceptable. During an interview on 7/15/2024 at 11:58 a.m., the AD stated her expectation is that staff will make sure new admissions are followed up on immediately as far as orders including Foley catheters. She stated it is the DON's responsibility to follow up and make sure orders are being done. She stated she is not sure how this was missed because she is currently out on maternity leave. When asked what could happen if catheter care is not provided, AD stated a plethora of things - infection control first and foremost, it could lead to infections a UTI could be the first thing. If it is not documented then the care didn't happen. During an interview on 7/15/2024 at 12:43 p.m., the Medical Director (MD) stated he came on as MD for the facility in January of 2024 and has reviewed the facility batch orders and is familiar with the orders. He stated he was not aware the batch orders for catheter care for Resident #1 were not done until 10 days after Resident #1 was admitted . He stated his expectations around indwelling catheters is nursing should ensure residents have Foley catheter care orders at admission. He stated he believed it was an oversight and does not believe there have been any issues with any other residents pertaining to catheter care. He stated if catheter care is not performed a resident could potentially get an infection or some other complication from their catheter; a resident could also get skin breakdown from it not being cleaned or if the catheter is leaking. During an interview on 7/15/2024 at 12:50 p.m., LVN B stated she was the nurse that completed the admission orders on Resident #1. LVN B stated the nurses were typically responsible for the medication orders and the ADON or DON were responsible for the batch orders. She stated they have not had an ADON since the end of June, so the DON would have been responsible for the batch orders. She stated she has never received any training on how to input batch orders which would include orders for Foley catheter care. LVN B stated if catheter care is not done a Resident could potentially get an infection, have compromised skin integrity, the catheter could be dislodged and could not be patent. During an interview on 7/16/2024 at 1:16 p.m., the AAD stated they were not able to locate any in-service records for nursing staff on completing batch orders in EMR to include orders for catheter care, but they would be rectifying that right away. Review of facility policy Indwelling Urinary Catheter Care dated 12/2023 reflected Policy - it is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and as needed (PRN) to promote hygiene, comfort and decrease the risk of infection.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by facility staff for one (Resident #2) of ten residents reviewed for abuse, in that: The facility failed to protect Resident #2 from physical abuse by LVN A on 6/3/2024 when LVN A pulled on Resident #2's wheelchair causing him to fall to the ground. This failure placed residents at risk of not being protected from abuse, neglect, or exploitation. Findings included: Review of Resident #2's face sheet dated 7/14/2024 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: Alzheimer's Disease (progress memory loss disease), Type 2 Diabetes (blood sugar disorder), Asthma (breathing disorder), Dementia (memory loss disorder), Hypertension (high blood pressure) and Osteoporosis (bone density disorder). Review of Resident #2's quarterly MDS assessment reflected a BIMS score of 11 suggesting mild cognitive impairment. Further review of the MDS reflected Resident used a wheelchair for ambulation ad could ambulate independently with his wheelchair. Review of Resident #2's care plan with a canceled date of 6/27/2024 reflected the focus: Potential for injury as [Resident #2] was moved back and fell to his left knee, a goal of: [Resident #2] will have no adverse effects from being moved backward and falling to his knee thru next review; and interventions: Complete head to toe assessment if possible - Resident has decline, Monitor for any changes in behavior or mood, Monitor for pain to knees, Refer to psychology and psychiatry for services for follow up. Review of Resident #2's progress notes dated 6/3/2024 at 6:44 p.m. by the DON., reflected Observed [LVN A] talking loudly to resident [Resident #2] saying you cannot be back here; you cannot tell me what to do. and pulling on resident's wheelchair. Resident was seen resisting and fell down on his knees. NP notified. Record review of a progress note dated 6/3/24 at 6:53 p.m., reflected Resident # 2 refused a skin assessment, denied pain and said he wanted to rest. Resident #2 refused to allow staff to touch him at all. During an interview on 7/12/2024 at 12:00 p.m., the AAD stated on 6/3/2024, Resident #2 was behind the nurses station. LVN A attempted to remove Resident #2 from behind the nurse's station by yanking on his wheelchair from behind. As a result of the yanked force, Resident #2 fell out of his wheelchair and landed on his knees. Nursing staff attempted to assess Resident #2, but he refused. The AAD stated Resident #2 did not have any injuries and did not go to the ED. The AAD stated LVN A was suspended immediately, and an investigation was started. The AAD stated later when they went back and viewed the facility video of the event the decision was made to terminate LVN A. When the Investigator asked to see the video, the AAD notified investigator that the recording device only saved 7 days' worth of video, and they no longer had the video. The AAD stated he and his corporate nurse both reviewed the video and would supply statements as to what they witnessed on the video. Multiple attempts made to contact LVN A to be interviewed were not successful . Review of the Facility investigation report reflected LVN A was suspended on 6/3/2024. There was no statement from LVN A in the facility report. Review of facility Counseling notice dated 6/6/2024 reflected reasons why counseling action is necessary: On 6/3/24 after review of the video, it was determined that the employee physically removed resident from behind the desk causing the resident to fall out of his wheelchair to the ground. Employee then proceeded to yell at the resident Review of witness statement dated 7/24/2023 by AAD reflected in the video, the resident [Resident #2] was viewed seated in his wheelchair and propelling his wheelchair behind the 1-00 hall nurse' station. The staff member [LVN A] seated behind the desk stated You can't be back here the resident did not respond and remained behind the nurses' station. The staff member then walked behind the resident's wheelchair and began pulling on the chair from behind. The resident continued to try and move forward. The resident came out of the chair and fell on to his left knee. Review of witness statement dated 7/24/2023 by CN reflected Resident #2 was behind the nurse's station. The resident [Resident #2] was seen in a wheelchair, leaning forward, his right foot was in front and his left knee was flexed as he was wheeling into the nurses' station area. The nurse [LVN A] was then seen holding the wheelchair from behind and pulling the patient backward, as the patient was trying to move forward. As the employee was pulling the chair backward, the resident was noted to come out of his wheelchair onto his left knee and then the resident stood up. Review of facility onboarding records reflected a form indicating LVN A received training on Resident Rights which was signed by LVN A on 9/26/2023. Review of facility onboarding records/employee file reflected a form indicating LVN A received training on Resident Rights & Protections, Reporting and Preventing Abuse, Neglect and Mistreatment Notice and Texas Senate [NAME] 9 Advisement which was signed by LVN A on 9/24/2023 The date of hire for LVN A was 9/25/2023. All appropriate background checks were completed on 8/31/2023 including license check, criminal background checks and employability registry. The employee file reflected LVN A's date of termination as 6/6/2024. Review of facility policy Abuse: Prevention of and Prohibition Against dated 4/2024 reflected: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of Facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic devices) to take, keep, or distribute inappropriate photographs or recordings on social media. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility.

Based on interview and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for resident rights, in that: The facility failed to ensure Resident #1's NP was notified until the 5th day of her experiencing constipation. This failure placed residents at risk of illness, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including irritable bowel syndrome, chronic pain, morbid obesity, and panic disorder. Review of Resident #1's quarterly MDS assessment, dated 04/22/24, reflected a BIMS score of 15, indicating no cognitive impairment. Section H (Bowel and Bladder) reflected she was always incontinent of her bowels. Review of Resident #1's quarterly care plan, dated 04/11/24, reflected she had bowel/bladder incontinence r/t impaired mobility with an intervention of changing as soiled. Review of Resident #1's bowel movement tracking sheet, from 04/09/24 - 05/08/24, reflected she did not have a bowel movement from 04/21/24 until 04/25/24. Review of Resident #1's progress notes, dated 04/25/24 at 5:00 AM and documented by LVN A, reflected the following: [Resident #1] verbalized not having BM for couple of days. Previous shift offered her some stool softeners and MiraLAX, so we continue to monitor and will advance treatment as per HCP orders when need arises. Review of Resident #1's progress notes, dated 04/25/24 at 6:50 AM and documented by LVN B, reflected the following: . [Resident #1] stated that she had not had a BM in 6 days and had received PRN medications enema, stool softener, lactulose, and prune juice. None were effective. Sent to ER per resident request. Review of Resident #1's progress notes, dated 04/25/24 at 6:45 PM and documented by LVN B, reflected the following: Called (hospital) to check on [Resident #1]. Nurse informed this nurse that [Resident #1] was admitted with SIRS. 2 enemas given in ED and medications were effective . Review of Resident #1's hospital records, dated 04/25/24, reflected she was diagnosed with SIRS, Cellulitis of left leg, and wheezing. The issues resolved during hospitalization were cellulitis of left lower leg, constipation, and SIRS. During an interview on 05/08/24 at 10:38 AM, Resident #1 stated she had gone many days back in April without having a bowel movement. She stated none of the medications or interventions were working so she requested to go to the hospital. During an interview on 05/08/24 at 10:49 AM, LVN B stated they had been administering Resident #1 stool softeners, laxatives, and giving her prune juice but nothing had worked. She stated she could not remember if she had notified the NP regarding her constipation prior to her requesting to go to the hospital, but she did notify her after she went to the hospital. During an interview on 05/08/24 at 11:43 AM, the NP stated she had not been notified of Resident #1's constipation prior to the day she went to the hospital. She stated it was her expectation that she be notified any time a resident had a change in condition, even if it was constipation. She stated other interventions could have been tried, such as a suppository. During a telephone interview on 05/08/24 at 12:25 PM, LVN A stated when she got report from LVN B on the evening of 04/24/24, and she was informed Resident #1 had not had a BM in a few days and she had recently given her stool softener and prune juice. She stated she spoke to Resident #1 who did not complain of pain and told her she wanted to wait until the morning to see if she had a BM before thinking about going to the hospital. She stated the next morning around 5:00 AM, Resident #1 stated she was in a lot of pain and wanted to go to the hospital. She stated she told her the NP would be at the facility soon and she agreed to wait for her. She stated she texted the NP at that time. She stated she was not sure if the NP had been aware of her constipation before that time. She stated before the NP arrived, Resident #1 voiced she wanted to go to the hospital, so she was sent out at that time. During an interview on 05/08/24 at 1:59 PM, the DON stated it was her expectation that she and the NP were notified any time a resident had a change-in-condition. She stated she had not been notified of Resident #1's constipation until the night before she requested to go to the hospital, 04/24/24. She stated it was the nurses' responsibility to notify the NP of any changes to ensure she was involved in all aspects of the residents' care. Review of the facility's Change of Condition Policy, revised 12/2023, reflected the following: Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. 1. If, at any time, it is recognized by any of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): . - Change in output (bowel or bladder) including amount, color, consistency, odor, or frequency. . 7. The Interdisciplinary team (IDT) shall collaborate with the attending physician .

Based on observation, interview and record review the facility failed ensure residents had the right to a safe, clean, comfortable, and homelike environment, in that: 1. The facility failed to ensure resident room floors in halls 200 and 300 didn't have a buildup of stains and physical dirt, scratches, peeling and chipping paint on the walls. 2. The facility failed to ensure the furniture wood was not chipping. 3. The facility failed to ensure there was not a strong urine odor in the facility upon entrance to the building. 4. The facility failed to ensure there were no dirty clothes on the floors of residents closets. 5. The facility failed to ensure the community showers on the halls didn't have soap scum. 6. The facility failed to ensure the toilets were not leaking in the residents rooms. These failures could place residents at risk of a diminished quality of life. Findings included: During an observation on 04/23/2024 at 8:30 AM revealed upon entrance in the door, there was a strong urine odor in the entrance way. The Admission Coordinator stated it was an old building and residents sat in the front of the building and the urine smell had just been there. She had housekeeping mop the area, but the urine smell was still there . An Observation of rooms 221A, 219, 214, 307, 309 and 311B on 4/23/24 at 10:10 AM revealed chipped, peeling, two-toned paint coming off the walls. An Observation of rooms 221, and 219 on 4/23/24 at 10:16 AM revealed floor trim and baseboards were hanging off the wall. An Observation of rooms [ROOM NUMBERS] on 4/23/24 at 10:16 AM revealed there were clothes on the floor in the closets. The closets doors would not close. The door was dragging against the floor which caused scratches on the floor. Observation of room [ROOM NUMBER] on 4/23/24 at 10:51 AM revealed the toilet was leaking and it had a tile lifted from the floor. Observation of the community shower rooms of halls 200 and 300 on 4/23/24 at 10:59 AM revealed white soap scum on the walls. In an interview on 04/25/24 at 10:23 AM, with the Housekeeper she stated the CNAs were usually responsible for cleaning the closets . She is not sure how often the task is completed. In an interview on 04/25/24 at 10:30 AM with Maintenance he stated the evening housekeepers were responsible for cleaning the shower rooms . He stated if he didn't clean the walls then it didn't get done. The Maintenance man stated he was not aware of any leaking toilets or rooms that needed immediate attention. He stated there were notifications for maintenance for immediate needs to be filled out by the staff kept at the nurse's station. In an Interview on 04/25/24 at 12:49 PM with LVN A revealed anyone was responsible for straightening the closets and rooms. She stated the facility had a program within the PCC system that allows staff to place a maintenance request , if the problem continues, we notify the admin. In an interview on 04/25/24 at 12:54 PM with LVN B revealed maintenance was notified for any environmental concerns. There was a chart in the PCC system that communicated with maintenance for issues such as leaking toilets, wet floors, mold, or water damage. The expectation was dirty clothing be bagged and placed in barrel outside the residents' room , and clean clothing be hung up correctly in the closet. CNA's, nurses, and laundry would all be responsible for cleaning up a room. The risk for residents having an unkept room would be not having a homelike environment leading to depression . In an Interview on 04/25/24 at 01:22 PM, Admin stated every employee was responsible for straightening and cleaning rooms. The Administrator stated department heads have daily room rounds to check all resident rooms for deep scratches in paint, chipping wood on doors, and leaking water pipes. The administrator currently stated the facility only has a maintenance assistant. The Administrator stated have The Facility had a system called TELS, this is a system to report work orders for completion. She stated The Facility was in between maintenance supervisors and were in the process of renewing and renovating the rooms. The Facility had someone assigned to paint the rooms when needed. She stated she was not sure how the building aesthetics would negatively affect a resident. The ADM stated there was always a risk for slipping on wet tile. Record review of the facility's, undated, policy on Residents Rights reflected You have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely .

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 2 medication carts (Medication Cart #1) reviewed for medication storage . The facility failed to ensure Medication Cart # 1 was not left unattended and unlocked. This failure could place residents at risk of obtaining access to prescription and over-the-counter medication, that could cause overdose, allergic reactions, poisoning or exacerbation of illness and symptoms. Findings include: Observation on 04/24/2024 at 4:32 PM revealed Medication Cart #1 was against a wall in a resident hallway. Three residents walked by the unattended and unlocked medication cart. There were no visible facility staff on the hallway at that time. Observation on 04/24/2024 at 4:34 PM revealed Medication Cart #1 remained unattended and unlocked. There were no visible facility staff on the hallway at that time . Residents were in the hallway. Observation on 04/24/2024 at 4:37 PM revealed Medication Cart #1 remained unattended and unlocked. There were no visible facility staff on the hallway at that time . Residents were in the hallway. Interview on 04/25/2024 at 4:00 PM, the DON stated the expectation was for medication and treatment carts to be locked anytime someone was not physically with the cart. When asked about potential negative outcomes for residents, she said, Residents may not realize what is in there. They might hold onto the cart to scoot themselves. The heavy drawers could come open and they could pinch a finger or hurt themselves. Interview on 04/25/2024 at 4:25 PM, the ADM stated her expectation was for the medication carts to be locked when not in use. She said leaving it unlocked placed the residents at risk of taking unprescribed medications. Record review of the facility's policy titled Medication Storage in the Facility, revised November 13, 2018, reflected the following: 1. Storage of Medications Policy Medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications.

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 5 residents (Resident #14, Resident #34, and Resident #153 ) reviewed for accommodation of needs. The facility failed to ensure resident call lights were placed within their reach. This failure could place residents at risk of injuries and unmet needs. Findings include: 1. Record review of Resident #153's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #153 had diagnoses which included protein calorie malnutrition, abnormal weight loss, dysphagia (difficulty swallowing), aphasia (a language disorder that affects a person's ability to communicate), and vascular parkinsonism (a condition which presents difficulty walking and maintaining balance caused by several small stokes within the brain). Record review of Resident #153's care plan, dated 12/17/23, reflected Resident #153 had an actual fall and was at risk for falls. Resident #153's goal was to resume usual activities without further incident through the review date. Interventions in place within the care plan included to keep call light within reach and encourage resident to use it to call for assistance as needed. Record review of Resident #153's quarterly MDS, dated [DATE], reflected a BIMS score of 12, which indicated the resident was cognitively impaired. Resident #153 was Dependent for ADL care such as showers grooming and toileting. In an observation on 04/23/24 at 10:07 AM revealed Resident #153 was lying in bed with his call light on the floor to the left of his bed out of reach. In an observation on 04/23/24 at 02:50 PM revealed Resident #153 was lying in his bed and the call light remained out of reach on the left-hand side of the bed on the floor. Resident #153 was asked if he was able to reach his call light and he felt up to right shoulder but was not able to obtain his call light. Resident #153 had a sign on his room wall which stated, call don't fall which indicated a reminder to use his call light. 2. Record review of Resident #14's face sheet reflected Resident #14 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #14 had a diagnosis which included Hemiplegia and Hemiparesis following Cerebral Infarction (a condition where one side of the body is paralyzed and the other side is weak, but not completely paralyzed). In an observation/interview on 04/23/2024 at 10:22 AM revealed Resident #14 was lying in his bed and the call light was within reach. Resident #14 stated, Sometimes I wait 2-3 hours to be changed. It happens mostly during the day shift. I don't need to be changed much as night. Sometimes I slip through the cracks. 3. Record review reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident had a diagnosis which included Unspecified Sequelae of Cerebral Infarction (a condition referred to as a stroke) and has a BIMS of 15. In an observation/interview on 04/23/2024 at 12:24 PM revealed Resident #34 call-push pad was not within reach or visible. The resident had limited range of motion and was unable to turn his head. The resident stated he did not know where the call-push pad was located or how long he was unable to reach it. A CNA was summoned from the hallway to locate the call light for Resident #34. The CNA found the residents call-push pad located on top of the roommates over-the-bed light. In an interview on 04/25/24 at 12:54 PM with LVN A, she stated call lights should always be available and within reach of the residents. LVN A stated everyone was responsible for making sure residents had their call lights within reach. She stated the resident could fall and that may cause an injury. In an interview on 04/25/24 at 01:10 PM with the DON, she stated residents needed to be able to always push the call button. Everyone was responsible for making sure all residents had their call lights. The negative effects to the residents for not having their call light within their reach was the resident may not be able to communicate their needs; it could lead to falls. A record review of the facility's policy titled Call Light/Bell, dated 4/2024, reflected Procedure #5 was to Leave the resident comfortable. Place the call device within the resident's reach before leaving room.

Based on observation , interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 3 residents (Residents #7, #40 and #104) reviewed for ADL care. The facility failed to ensure Residents #7, #40 and #104 received their bath/showers three times a week as per their shower schedule. This failure could place residents at risk of skin breakdown, infection, and loss of self-esteem. Findings include: 1. Record review of Resident #7's face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included Type 2 Diabetes Mellitus with Unspecified Complications (a problem in the way the body regulates and uses sugar as a fuel), Stage 3 Pressure Ulcer Of Sacral Region (involves the full thickness of the skin and may extend into the subcutaneous tissue layer; granulation tissue and epiboly rolled wound edges are often present), Stage 3 Pressure Ulcer of Right and Left Buttock (The skin now develops an open, sunken hole called a crater or ulcer. The tissue below the skin is damaged), Neuromuscular Dysfunction of Bladder, Unspecified (the nerves and muscles don't work together very well), Colostomy Status (A colostomy is an operation that creates an opening for the colon, or large intestine, through the abdomen). Also, the resident needed Assistance with Personal Care. Record review of Resident #7's Comprehensive MDS, dated [DATE], reflected he had a BIMS score of 14, which indicated intact cognitive status. His functional abilities reflected he required substantial/maximal assistance for tub/shower transfer. Record review of Resident #7's facility shower schedule reflected Resident #7 was scheduled to receive a shower three times a week on Tuesdays, Thursdays and Saturdays on the 6AM-2 PM shift . 2. Record review of Resident #40's face sheet reflected she was a [AGE] year-old female who was admitted to the facility 03/13/2023. Resident #40 had diagnoses which included Dysarthria and Anarthria (is a motor speech disorder resulting from impaired neuromuscular control over speech production), Post-Traumatic Stress Disorder, Unspecified (a mental health condition that's triggered by a terrifying event - either experiencing it or witnessing it), Lymphedema, not Elsewhere Classified (swelling caused by a buildup of lymph fluid in the body between the skin and muscle), Parkinson's Disease without Dyskinesia, without mention of fluctuations (A disorder of the central nervous system that affects movement, often including tremors). Record review of Resident #40's Comprehensive MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated intact cognitive status. Her functional abilities reflected she required substantial/maximal assistance for tub/shower transfer. Record review of Resident #40's facility shower schedule reflected Resident #40 was scheduled to receive showers on Mondays, Wednesdays, and Fridays on the 2PM -10PM 3. Record review of Resident #104's face sheet reflected 04/23/2024 at [AGE] year-old male who was admitted to the facility on [DATE]. Resident #104 had diagnoses which included Anemia, Unspecified (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues), Muscle Weakness (Generalized) (Generalized weakness or decreased strength of the muscles, affecting both distal and proximal musculature), Unsteadiness on Feet (a pattern of walking that's unstable. This can increase your risk of injury if left unmanaged), Unspecified Abnormalities of Gait and Mobility (an injury, sore, an inner ear balance issue or nerve damage), Need for Assistance with Personal Care (helps clients with everyday tasks. These tasks are called activities of daily living). Record review of Resident #104's Comprehensive MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated intact cognitive status. Her functional abilities reflected she required substantial/maximal assistance for tub/shower transfer. Record review of Resident #104's facility shower schedule reflected Resident #104 was scheduled to receive showers on Tuesdays, Thursdays, and Saturdays on the 2PM-10PM shift . In an interview on 04/24/2024 at 4:35 PM, Resident #7 stated he was not getting his showers on the days he was supposed to receive showers. He stated the staff did not want to give him a shower and he would ask them for a shower. He stated he felt neglected, and it caused stress and depression . In an interview on 04/24/2024 at 4:55 PM, Resident # 40 advised a VA representative she was not getting her showers. She stated she was supposed to get a shower on 4/20/2024 and 4/23/2024 and she did not get one . In an interview on 04/23/2024 at 11:40 AM, Resident #104 stated he was not getting his showers. He stated he had one on 04/23/2024 and the last time he had it was on 4/11/2024. He stated he was supposed to get one every other day. He spoke with the DON, and she advised him they were getting new staff and they would have the shower dates set up. He stated he asked to have one every day, and he wasn't getting one. He was scheduled for morning shower's and did not get one and the evening staff would tell him they did not have enough staff, or they did not have time. A CNA, unknown, advised him to let her know he wanted a shower, and she would give him one. During an interview with the DON on 4/25/2024 at 4:00 PM, she stated the CNA's were to give showers to the residents. She stated she was made aware and told the staff they were to accommodate the resident needs. She would go watch the floor or assist with the showers if needed . During an interview with the ADM on 4/25/2024 at 4:25 PM, she stated the CNA's and then the nurse reviewed the shower sheets. She stated they reviewed the situation and made sure the residents did not refuse a shower, we educate and in-service our staff and the residents were showered immediately. During an interview with the VA representative on 4/25/2024 at 9:22AM, she stated the reason why she was in the building was due to concerns of VA residents. She stated she spoke with Residents #40 and #14 and one of their concerns was they were not receiving showers as they should.

Based on interview and record review the facility failed to ensure a drug regimen review for each resident was reviewed at least once a month by a licensed pharmacist for five of five reviewed for drug regimen review. The facility failed to document an MRR for Residents# 1, 15, 8, 34 and 22 for the months of January, February and March 2024. This failure could place residents at risk of adverse drug consequences and a decline in their physical and mental health status. Findings include: 1. Record review of the facility's pharmacy monthly review reports for Resident #15, reflected Resident is given Buspirone HCl for anxiety. There is no MRR documentation the doctor has conducted a monthly or frequent review of the residents medical record January, February and March 2024. Record review for Resident #15 medical diagnosis sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #15 had diagnoses which included Chronic Obstructive Pulmonary Disease, Unspecified (refers to a group of diseases that cause airflow blockage and breathing-related problems), Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified (is a type of nerve damage that can occur if you have diabetes. High blood sugar glucose can injure nerves throughout the body), Generalized Anxiety Disorder (Persistent worrying or anxiety about several areas that are out of proportion to the impact of the events), Chronic Kidney Disease, Stage 3 Unspecified (you have an eGFR between 30 and 59 and mild to moderate damage to your kidneys), Atherosclerotic Heart Disease Of Native Coronary Artery Without Angina Pectoris (is the buildup of fats, cholesterol and other substances in and on the artery walls. This buildup is called plaque) and had a BIMS of 08. 2. Record review of the facility's pharmacy monthly review reports dated January-March 2024 for Resident #1, reflected there is no MRR documentation the doctor has conducted a monthly or frequent review of the residents medical record. He is prescribed Benztropine Mesylate for Tremors, Depakote Seizures, Duloxetine Mood Disorder, HCl Risperidone for Schizophrenia. Record review of Resident #1 medical diagnosis sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Schizophrenia, Unspecified (A disorder that affects a person's ability to think, feel, and behave clearly), Cognitive Communication Deficit (Acquired cognitive-communication deficits may occur after a stroke, tumor, brain injury, progressive degenerative brain disorder, or other neurological damage), Spinal Stenosis, Thoracolumbar Region (he spinal canal, located in the mid-region or thoracic spine, can narrow with age), Parkinsonism, Unspecified (a term used to describe the collection of signs and movement symptoms associated with several conditions - which included Parkinson's disease PD and had a BIMS of 10. 3. Record review of the facility's pharmacy monthly review reports dated January - March of 2024 for Resident #8, reflected no documentation of monthly MMRs were conducted in January, February and March 2024. Record review of Resident #8's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Diabetes Type 2 (elevated blood sugar), Intermittent Asthma (bronchial spasms), Heart Failure (a condition where the heart doesn't pump blood as well as it should), shortness of breath and weakness. Record review of Resident #8's care plan, dated 8/01/21, reflected Resident #8 was receiving anticoagulant therapy. Interventions on the care plan included to monitor and report to the medical doctor immediately any signs or symptoms of unusual bleeding, pale skin, weakness, black tarry stool and head injury related to falls or trauma. Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated the resident was cognitively intact. Resident #8 was Dependent for ADL care such as showers grooming and toileting. Section N (Medications) was coded that the resident was receiving an anticoagulant daily. Record review of Resident #8's Physicians order summary report, dated 4/23/24, reflected Resident #8 had an order for Apixaban (a blood thinner used to reduce the chances of stroke) by mouth two (2) times daily for clot prevention. 4. Record review of the facility's pharmacy monthly review reports dated January - March 2024 for Resident #34, reflected no documentation of monthly MMRs were conducted in January, February and March 2024. Record review of Resident #34's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34 had diagnosis which included Unspecified Sequelae of Cerebral Infarction (a condition referred to as a stroke) and has a BIMS score of 15. 5. Record review of the facility's pharmacy monthly review reports dated January - March 2024 for Resident #22, reflected no documentation of monthly MMRs were conducted in January, February, and March 2024. Record review of Resident #22's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #22's had a diagnosis which included Neurocognitive Disorder with Lewy Bodies (a progressive dementia affecting movement, thinking skills, mood, memory and behavior). There were no BIMS score available. Interview on 4/25/2024 at 4:00 PM, the DON stated a representative from the pharmacy conducted monthly reviews for a sample of residents and the facility physician conducted a medication review in PCC quarterly or as needed, if there is an adverse reaction. Interview on 4/25/2024 at 4:25 PM, the ADM stated, The facility conducts MRRs quarterly and as needed, and the ADM stated the have the physician look at meds monthly. She also stated, We hold GDR meetings monthly with the psychiatrist, psychologist and our physician. Record review of the Medication Administration Record for April 2024 reflected Resident #8 received Apixaban two times daily for clot prevention. There was no monitoring in place for unusual bleeding. Record review of the facility's policy, titled medical diagnosis sheet Unnecessary Drugs, revised April 2014, reflected: Purpose: The purpose of this requirement is that each resident's entire drug/medication regimen be managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. 47926 49048 4. Record review of the facility's pharmacy monthly review reports for Resident #34, reflected no documentation of monthly MMRs were conducted in January, February and March 2024. Record review of Resident #34's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #34 had diagnosis which included Unspecified Sequelae of Cerebral Infarction (a condition referred to as a stroke) and has a BIMS score of 15. 5. Record review of the facility's pharmacy monthly review reports for Resident #22, reflected no documentation of monthly MMRs were conducted in January, February, and March 2024. Record review of Resident #22's, undated, face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #22's had a diagnosis which included Neurocognitive Disorder with Lewy Bodies (a progressive dementia affecting movement, thinking skills, mood, memory and behavior). There was no BIMS score available. Interview on 4/25/2024 at 4:00 PM, the DON stated a representative from the pharmacy conducted monthly reviews for a sample of residents and the facility physician conducted a medication review in PCC quarterly or as needed, if there is an adverse reaction. Interview on 4/25/2024 at 4:25 PM, the ADM stated, The facility conducts MRRs quarterly and as needed, and we have the physician look at meds monthly. She also stated, We hold GDR meetings monthly with the psychiatrist, psychologist and our physician. Record review of the Medication Administration Record for April 2024 reflected Resident #8 received Apixaban two times daily for clot prevention. There was no monitoring in place for unusual bleeding. Record review of the facility's policy, titled Unnecessary Drugs, revised April 2014, reflected: Purpose: The purpose of this requirement is that each resident's entire drug/medication regimen be managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 1 of 5 residents (Residents #8) reviewed for respiratory care. The facility failed to ensure Resident #8's oxygen concentrator had a clean filter in place, humidifier was filled and dated, and tubing was changed as ordered by physician. This failure could place residents at risk for respiratory infections . Findings include: Record review of Resident #8's, undated, face sheet reflected [AGE] year-old female who was admitted to the facility on [DATE]. Resident #8 had diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Diabetes Type 2 (elevated blood sugar), Intermittent Asthma (bronchial spasms), Heart Failure (a condition where the heart doesn't pump blood as well as it should), shortness of breath and weakness. Record review of Resident #8's care plan, dated 2/21/24, reflected Resident #8 had shortness of breath. Interventions on the care plan included to apply oxygen via nasal cannula. Resident #8's goals included not to have a rehospitalization within the next 30 days and no complications related to shortness of breath through the review date. Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated the resident was cognitively intact. The MDS also reflected that The Resident was dependent for ADL care such as showers grooming and toileting. Section O (special treatments) of the MDS indicated Resident #8 used oxygen therapy continuously. Record review of Resident #8's Physicians order summary report, dated 4/23/24, reflected Resident #8 had an order for Oxygen at 2 -3 liters per minute continuously for treatment of COPD. The orders also reflected an order to change oxygen tubing and humidifier bottle every night shift every Sunday. Record review of Resident #8's Medication Administration Record for April 2024 reflected a task to change oxygen tubing and humidifier bottle every Sunday and was signed off as completed on 4/21/24. In an observation and interview on 04/23/24 at 10:19 AM revealed Resident #8 was lying in bed with her oxygen on her nose. The oxygen tubing was dated for 4/16/24. The oxygen concentrator had no filter in place. The humidifier was dated 4/16/23 and was empty of water. Resident #8 stated she used her oxygen continuously because she was short of breath without it . In an interview with LVN A on 04/25/24 at 12:54 PM, she stated she was not sure why Resident #8's oxygen was not changed. She stated the oxygen policy was for the night shift nurse to change all oxygen tubing, humidifiers, and filters weekly every Sunday. LVN A said the risk to Resident #8 for not having her oxygen filter in place and tubing unchanged was respiratory infection . In an interview with the DON on 04/25/24 at 01:10 PM, she stated it's her expectation that the oxygen tubing, filter, and humidifiers be changed weekly on Sundays. The oxygen tubing and humidifiers should be dated, and initialed when changed. She stated the task was delegated to the night shift nurse and they were responsible for ensuring it was completed. The DON monitors the Medication Administration Record to ensure the oxygen task had been completed. The DON stated not having clean tubing, filters in place on the oxygen concentrator, and humidification could place Resident #8 at risk for infection and feeling uncomfortable. A record review of the facility policy titled Disposition of Respiratory equipment Disposables, dated 04/2024, reflected It is the policy of this facility that certain disposable respiratory equipment will allow utilization of resources at responsible levels and with the highest quality care and treatment of our patients. Each facility will stock disposable supplies adequate to provide safe respiratory care to respiratory patients. Supplies will be clearly dated when initially setup or changed. All disposable change outs are performed per facility requirements.

Based on observation, interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 5 residents (Resident #8) reviewed for physician orders. The facility failed to obtain a physician's order prior to providing treatment for an open wound to the right lower forearm for Resident #8. This deficient practice could place residents at-risk of inadequate monitoring and treatment of medical conditions and an infection of the skin wound. The findings were: Record review of Resident #8's, undated, face sheet reflected [AGE] year-old female who readmitted to the facility from the hospital 04/14/24. Resident #8 had diagnoses which included Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Diabetes Type 2 (elevated blood sugar), Intermittent Asthma (bronchial spasms), Heart Failure (a condition where the heart doesn't pump blood as well as it should), shortness of breath, and weakness. Record review of Resident #8's quarterly MDS, dated [DATE], reflected a BIMS score of 15, which indicated the resident was cognitively intact. Resident #8 was Dependent for ADL care such as showers grooming and toileting. Record review of Resident #8's care plan, dated 3/19/24, reflected Resident #8 had an actual skin tear to her right extremity related to trauma. Resident #8's goal was the skin injury would be healed by the review date. Interventions included to monitor and document location, size and treatment of the skin injury. Report abnormalities, failure to heal, signs and symptoms of infection or maceration to the medical doctor. Record review of Resident #8's medication administration record for April 2024 reflected Resident #8 had an order to clean skin tear to right lower arm with normal saline, pat it dry, and cover with a dry bordered dressing daily and as needed for loose or soiled dressing. The order was dated 3/29/24 and discontinued 4/11/24. In an interview and observation on 04/23/24 at 10:19 AM with Resident #8 revealed the resident had a brown colored dressing in place with hard deep brown dried fluid around the boarders of the dressing. Resident #8 stated she received a skin tear 3 weeks ago. She stated the dressing was changed three (3) times by the nurse. The Resident stated she did not know when the dressing had last been changed. The dressing had no date or initials on it . In an interview on 04/25/24 at 12:54 PM with LVN A, she stated she was not aware of any skin tear on Resident #8's right lower arm. She stated nurses were responsible for obtaining orders from the physician to treat any skin issues as they were needed. LVN A stated skin assessments were completed weekly. LVN A stated the negative effects for not addressing an open wound or skin tear would be infection . In an interview on 04/25/24 at 01:10 PM with the DON, she stated she would expect the nurse to investigate assess and clean wounds and provide treatment as they happen. This would have included obtaining a physician's order for treatment. She stated the dressing should have been dated and initialed. The DON stated the nurses were responsible for obtaining a physician's order to treat any skin issues. The DON stated the risk to the resident for not obtaining an order would be lack of communication, treatment of the injury or wound leading to infection. A record review of the facility policy titled Quality of Care, dated 03/2015 reflected that residents who enter the facility with a wound would not develop signs and symptoms of infection, unless the residents clinical condition makes the development unavoidable. The policy also reflected Procedure #1 a treatment order will be obtained from the attending physicians for areas requiring treatment including open skin tears.

Based on observation, interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with the resident's comprehensive assessment and plan of care for three of six residents (Residents #1, #2 and #3) reviewed for quality of life. The facility failed to answer Resident #1, Resident #2 and Resident #3 call lights in a timely manner. The failure could place residents at risk for complications associated with delayed care such as skin breakdown and dignity issues. Findings include: 1. Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Acute Respiratory Failure with Hypoxia, Dysarthria and Dysphagia Following Cerebral Infarction, Type 2 Diabetes Mellitus with Other Circulatory Complications, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Dysphasia Following Cerebral Infarction, Aphasia Following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Unspecified, Unspecified Dementia, Mild, With Mood Disturbance, Unsteadiness on Feet, Weakness. Observation on 9/19/2023 at 9:30 AM revealed a call light signal going off for about 4 minutes. The State Surveyor stepped outside the conference room to see what resident call light was buzzing. It was a resident on the 300 hallways. The State Surveyor went to the residents room opened door and stood inside the doorway and looked inside the room to ensure neither resident was in immediate danger. It was observed there was not a nurse on the 300 hallway. About 5 to 7 minutes later, two CNAs came from down the hall. They then assisted the resident(s). Observation on 09/19/2023 at 12:10 PM revealed Resident #1's call light going off for about 2 minutes. Resident #1 was in his room and was sitting in his wheelchair. Resident #1 did not speak English, but he pointed to the briefs sitting in the chair. The DON, ADON, and an unknown worker were observed coming outside of an office. They walked passed Resident#1's door while the call light had already been signaling for at least 5 minutes. The DON continued standing at the door and eventually walked back into the room. CNA# 2 went down the hallway with the food cart and she stated she needed some help passing trays. There was no one else on the floor to assist her. Resident #1's call light was still going off at this time as she passed him by. She pushed the cart to the side and went to get some help. Two other CNAs came to assist her with passing out the trays. Resident #1 call light was still going off. No one went into the room, but the call light stopped for about a minute then it began to go off again. CNA#1 who also worked the 300 hallways came out a resident room and sanitized and began to pass out trays. Then one of the CNAs went in Resident #1 room and advised him to give her a minute. She then went and spoke with another CNA to assist her with the resident. Both went inside the room and assisted him. 2. Record review of Resident #2's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included Type 2 Diabetes Mellitus with Hyperglycemia, Unspecified Injury At C4 Level of Cervical Spinal Cord, Sequela, Weakness, Contracture, Unspecified Joint, Constipation, Unspecified, [NAME] Syndrome, Other Muscle Spasm, Edema, Unspecified, Morbid (Severe) Obesity Due to Excess Calories, Obstructive Sleep Apnea (Adult) (Pediatric), Type 2 Diabetes Mellitus with Unspecified Complications, Hyperlipidemia, Unspecified, Major Depressive Disorder, Single Episode, Unspecified, Quadriplegia, Unspecified, Atherosclerotic Heart Disease Of Native Coronary Artery without Angina Pectoris. Observation and interview on 09/19/2023 at 10:10 AM revealed Resident #2 was in his room, lying in bed. He stated staff did not answer the call light for over 2 hours. The resident stated the staff would answer the call light on a Monday and then by Friday they were back to not answering the call light. Resident #2 stated he felt neglected, it was causing him stress and depression. Resident #2 stated he had bedsores from the staff not answering the light. Once or twice a week they did not respond to his call light. It took the staff on average 20 to 25 minutes. He stated the issue happened day and night, they could be sitting at the desk, and he would go up to the desk at the nursing station and ask why no one was answering the call light. The staff would ask him what he needed, and he told them he was dirty. He stated the nurses didn't want to anything. At night the aid must wait on somebody. Then by the time they came it was over 2 hours. He stated it was the same issue in the daytime. Record review of grievances revealed Resident #2 filed the following grievances with the facility: -On 9/5 at 1:30 AM, Resident #2 filed a grievance because the nurse and CNA did not answer the call lights on 9/4-day shifts. The document stated they did not answer the call light all day. -On 7/31 at 9:40 AM, Resident #2 filed a grievance because it took too long for the call light to be answered. The resident needed pain medication for his foot. He stated another resident went to assist with finding a staff to assist him. Staff finally came to turn off the light and left without checking on him. It occurred on 7/30 on 4 to 5PM. -On 7/25 at 2:00 PM, Resident #2 filed a grievance because he had to wait for staff to change his briefs for three hours (11PM to 2AM). He stated staff came and turned off the light and said they would be back. He stated he finally went to check the nursing station and saw staff sitting and laughing with each other. He stated he was disappointed that there are painting the walls but not fixing anything with staff. He stated if this continued, he will have to tell his son and file a claim. He stated he had a friend that works for the federal government. He also stated he had a bedsore now. -07/10/2023 at unknown time, Resident #2 filed a grievance because he had to wait for his call light to be answered and for him to be changed for over two hours. He also stated he had not been receiving his scheduled showers. 3. Record review of Resident #3's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included Parkinson's Disease, Other Obesity Due to Excess Calories, Bipolar Disorder, In Full Remission, Most Recent Episode Depressed, Post-Traumatic Stress Disorder, Unspecified, Essential (Primary) Hypertension, Lymphedema, Not Elsewhere Classified, Interstitial Pulmonary Disease, Unspecified, Dysphagia, Oropharyngeal Phase, Unspecified Convulsions, Anemia, Unspecified, Hypothyroidism, Unspecified, Unspecified Protein-Calorie Malnutrition. Observation and interview on 09/19/2023 at 5:35 PM, Resident #3 stated it depended on the time of day and what was going on to determine when the call light was answered. She stated it could be 30 to 40 minutes if they were short staff. People who didn't work the floor, like the kitchen staff and administration would come and try and help her if they could. During an interview on 9/19/2023 at 2:00 PM with LVN #1, he stated it shouldn't take to long for staff to respond to a call light, less than 30 seconds. LVN stated if a call light is not answered timely a resident could fall, they could be on the floor, they could be having chest pain, cardiac arrest, choking, aspirating, and calling for staff help. During an interview on 9/19/2023 at 2:38 PM with CNA #3, she stated staff should respond to call lights as soon as possible or at least 2 to 5 minutes and it depends if they were in the middle of doing something. CNA stated if call lights were not answered in a timely manner it could be an emergency; they may try to get up, and not able to do for themselves and fall. During an interview on 9/19/2023 at 2:55 PM with CNA #1, she stated staff should respond to a call light immediately. She stated she personally tried to respond to a call light within seconds. She stated there was a person behind that call light and if the call light was not answered, the resident would get agitated and impatient. There was no excuse why a call light should not be answer timely. She stated everyone was responsible for answering the call light. During an interview on 9/19/2023 at 3:25 PM with CNA #2, she stated she tried to respond as soon as she could to call lights. She stated every light belonged to all staff. No one should not pass a light and not answer. She stated anything could happen if a call light was not answered in a timely manner. She stated a person could be choking, slid out the bed, fell in the bathroom, someone could get hurt. She stated a resident could have woken up and on the edge of the bed and fall. During an interview on 9/19/2023 at 4:15 PM with the ADON, she stated how long it took to respond to a call light really depended. She stated they had a team effort, and they worked together, 5 to 10 minutes not to exceed over that. She stated if the call light was not answered in a timely manner a resident could have a fall; they could be in distress. She stated everybody was responsible for answering call lights. The ADON, DON, Administrator and all other staff members were responsible for answering call lights. The ADON stated she stated she was not paying attention when she walked past Resident #1's door as the call light was active. During an interview on 9/19/2023 at 5:08 PM with the DON, she stated on an average, response to a call light should be no longer than 10 minutes. She stated the resident could be pain or he may have had to go to the bathroom. She stated everyone in the facility was responsible for answering call lights. She stated if the staff was not able to fulfill the task, they needed to get someone who was capable to assist. During an interview on 9/19/2023 at 5:45 PM with the ED, she stated staff answered call lights as they come on, there was no specific time. She stated if there was a 2 person assist, they would answer the call light and let them know they needed to get help to assist and return to the resident. The ED stated everyone in the building was responsible for answering call lights. All staff members. Record review of facility in-service, dated 09/08/2023, revealed the topic included: Efficient Response to Call Lights. It stated it is not just the CNAs responsibility to answer call lights. nurses and CMAs are able to assist with call lights .24 employees sign the in-service sign in sheet. Record review of the facility policy for Call Lights reflected It is the policy of this facility to provide the resident a means of communication with nursing staff.

Based on interview and record review the facility failed to ensure a comprehensive assessment was completed within 14 calendar days after admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition, for one of one resident record reviewed for comprehensive assessments. Resident #1 did not have a completed admission/comprehensive MDS assessment within 14 days following his admission to the facility. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental and psychosocial well-being. Findings include: Record review of Resident #1's admission record, dated 07/18/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His admitting diagnoses included Acute Respiratory Failure with Hypoxia, Dysarthria and Dysphagia Following Cerebral Infarction, Type 2 Diabetes Mellitus with Other Circulatory Complications, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Dysphasia Following Cerebral Infarction, Aphasia Following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Unspecified, Unspecified Dementia, Mild, With Mood Disturbance, Unsteadiness on Feet, Weakness. Record review of Resident #1's MDS summary screen in the Electronic Health Record, on 09/19/23, revealed the resident's admission MDS was still in progress. His MDS had an ARD date of 09/01/23. In an interview on 09/19/23 at 6:35 PM, the ED stated the MDS Nurse was responsible for the MDS. She stated she was not aware Resident #1's MDS was incomplete and late. The ED stated they did not have a fulltime MDS nurse. In an interview on 09/19/23 at 4:55 PM, the MDS Nurse stated she could not speak as to why Resident #1's MDS was not completed by the ARD date of 09/01/2. The MDS Nurse stated she traveled from different facilities that needed help. She stated they hadn't had an actual MDS coordinator since June 2023. She stated she went to the facility for ten days out of a month. She stated it was her job to complete the MDS. The MDS coordinator stated the MDS was due every 92 days at least. She stated the MDS was due 14-days after admission. She stated the MDS policy they used was the RAI manual. She stated it was important for the MDS to be completed on time so the resident had the care they needed, and the actual care of the resident's needs. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.17.1, dated October 2019, reflected, The RAI[S(1] process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status.

Based on observation, interview, and record review the facility failed to ensure residents were free from abuse for 1 (Resident #1) of 5 residents on 200 Hall. On 2/23/2023 at approximately 11:00pm Resident # 1 was physically assaulted (choked) by staff causing a skin tear to Resident # 1's neck that required medical treatment. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 2/24/2023. The IJ Immediate Jeopardy template was provided to the ADM on 2/25/2023 at 5:45pm. While the (IJ) Immediate Jeopardy was removed on 2/25/2023 at 4:30pm, the facility remained out of compliance at a scope of actual harm with potential for more than minimal harm that is Immediate Jeopardy because all staff had not been trained on Abuse/Neglect This failure placed all residents at risk for abuse. Findings included: Review of Resident #1's face sheet dated 2/25/2023, reflected Resident # 1 was a 78- year- old man, admitted to the facility on [DATE]. Resident # 1 was diagnosed with acute respiratory failure (difficulty breathing on own), Atherosclerotic Heart disease (build- up of cholesterol plaque in the arteries causing obstruction of blood flow), Emphysema (lung condition that causes shortness of breath), Esophageal obstruction (the malformation in which the esophagus is interrupted and forms a blind-ending pouch rather than connecting normally to the stomach), Chronic pulmonary disease (lung disease that block the airflow making it difficult to breathe). Review of Resident #1's Quarterly MDS dated [DATE], reflected Resident # 1 had a BIMS score of 04, not cognitive to understand and answer questions, section G of MDS reflected Resident # 1 was total dependent for bathing and toileting one person assist. Review of Resident # 1's care plan dated 1/17/2023, reflected Resident # 1 had the following goal: Resident # 1 will remain free from skin breakdown due to incontinence and brief use through the review date. The facility had the following interventions in place: 1. Intervention: Check as required for incontinence, wash, rinse, and dry perineum and change clothing PRN (as needed) after each episode. 2. Toilet use: totally dependent on staff for toilet use Review of progress note dated 2/23/2023 by LVN A, reflected the following: This nurse was called by CNA stating that this resident was wanting to speak to the nurse. When I walked into the room, I could see that the resident was bleeding on the right side of his neck. Resident is stating that the CNA had choked him with both hands and that she had scratched the side of his neck when she let him go. Resident with a large skin tear on the right side of his neck which is approximately 2 inches by 1 which continued to bleed for about 5 minutes. S/T (skin tear) is cleaned with Wound cleaner and triple antibiotic ointment placed on S/T (skin tear) and covered with dressing. Resident is extremely upset. He states that she cursed him out d/t (due to) resident asking can A to change his brief. Resident asking for us to call the police, so that he may press charges. During an interview on 2/24/2023 at 3:25pm with Resident # 1. Resident # 1 stated, last night Resident # 1 unable to give specific time of incident, CNA A had just changed his brief and was providing care to his roommate. He stated before CNA A left the room he asked if she could change him again, because he had another bowel movement. Resident # 1 stated CNA A got upset and started hitting him with his call light, he stated he had to put his arm up to shield his face from getting hit. Resident # 1 stated CNA A then grabbed him by the throat, he stated he could not breathe, he stated she grabbed him with both hands. Resident # 1 stated CNA A scared the hell out of him he stated he had never had anything like this ever happen to him. Resident # 1 stated the facility called the police and he made a report about the incident. He stated he has had problems with CNA A before but stated he let it go, when he asked her to do something. Resident # 1 stated he did let staff know when this incident happened. He stated CNA A caused the injury to the right side of his neck. Resident # 1 stated he told the nurse that was on duty and asked her to call the police so he could file charges. Resident # 1 stated LVN A contacted the police, and he made a report. Resident # 1 stated LVN A cleaned his neck and put a bandage on his neck. Observation on 2/24/2023 at 3:30pm of Resident #1's injury. LVN C, completed wound care for Resident #1. Resident # 1 was observed to have an open skin tear to the right side of his neck, the wound was open, red and bloody, the skin around that side of the neck appeared to be purplish in color. LVN C, cleaned the wound and placed a bandage back over the wound. The left side of Resident # 1's neck was observed and front of neck, the neck was red however did not show any bruising or injuries. LVN C, stated he was not on duty when the incident occurred, he stated he heard about the incident when he arrived at work the following day. LVN C stated he had been trained on Abuse/Neglect and reported the ADM was the abuse/neglect coordinator. During a phone interview on 2/24/2023 at 2:30pm with CNA A, stated she worked the 6pm to 6am shift the night of 2/23/2023. CNA A stated was could not remember the time she provided care for Resident # 1and his roommate. CNA A stated Resident # 1 continued to ring his call light stating that he needed his brief changed. She stated she reminded Resident # 1 that he did not need his brief changed, she denied yelling, cursing, or hurting Resident # 1. She stated after she advised Resident # 1 that he did not need his brief changed, she stated he requested she get the nurse on duty. CNA A stated she could not remember the time she provided care for Resident # 1 and his roommate she stated she just remembers she was advised by the other charge nurse of duty LVN B that she needed to leave. During a phone interview on 2/24/2023 at 2:40pm with POA(Power of attorney), stated Resident # 1 contacted him very upset and was not able to speak because he was so upset. He stated Resident # 1 stated CNA A went off on him when he asked to be changed, he stated they had a verbal confrontation. POA (Power of attorney) stated Resident # 1 stated CNA A, started choking him and he could not breathe, yell out and thought he was going to die. POA (Power of attorney) stated the facility called the police and a report was filed. POA (Power of attorney) stated the ADM contacted him and apologized and advised him that CNA A had been terminated. During a phone interview on 2/24/2023 at 4:59pm with LVN A, stated she was on duty the night of the incident 2/23/2023. When asked LVN A stated she could not remember the exact time of the incident. LVN A stated there was a commotion in the hall and stated CNA A advised her that Resident # 1 wanted to speak with a nurse. She stated when she went into Resident # 1's room she noticed that Resident # 1 was bleeding on the right side of his neck. LVN A stated Resident # 1 stated to her that CNA A choked him, and he could not breathe she stated Resident # 1 was very shook-up. LVN A stated the resident wanted to call the police and file charges, so she called the police, ADM, and DON. LVN A stated she advised CNA A that she could not go back into Resident # 1's room. LVN A, stated while she provided care to Resident # 1 cand calmed him down, she stated LVN B spoke with ADM via phone, and she terminated CNA A. LVN A reported that she had been previously trained on Abuse/Neglect she stated the ADM was the abuse/neglect coordinator. LVN A stated she was advised that once she returned to work that she would be re in serviced on abuse/ neglect. In an interview on 2/24/2023 at 3:55pm with SW, stated she spoke with Resident # 1 regarding the incident. SW stated Resident # 1 advised her that CNA A put her hands around his neck and choked him, he stated he was scared. SW stated she had been checking on Resident #1 since the incident occurred. SW stated she had been trained on abuse/neglect previously and stated the ADM was the abuse/neglect coordinator. During an interview on 2/24/2023 at 6:20pm with Resident # 2, stated he was the roommate of Resident # 1 before he was moved the next morning. Resident # 2 stated Resident # 1 and CNA A got into it some kind of way, and she ended up with her hands on Resident # 1. Resident # 2 stated he could not see that well and it happened so fast. He stated Resident # 1 had marks on his neck. Resident # 2 stated CNA A had never hit or hurt him. During an interview on 2/24/2023 at 6:30pm with Resident #3, stated her room is across the hall from Resident # 1. Resident #3 stated Resident # 1 wanted to be changed and CNA A stated, I already changed you MF (mother fucker), she stated CNA A was yelling, she stated CNA A got fired. Resident # 3 stated CNA A never yelled, hurt, or hit her. During an interview on 2/24/2023 at 7:00pm with Resident # 4, stated she heard CNA A yelling and cursing at another resident, but never at her. Resident # 4 stated when she asked CNA A to close her window blinds, she stated CNA A told her to close them herself. She stated CNA A had never hit, hurt or yelled at her. During an interview on 2/24/2023 at 4:45PM with ADM, stated he got the call about the incident the nurse on duty immediately sent CNA A home and was advised that she was terminated. ADM stated, they had not started their investigation of the incident because it had just happened. ADM stated he did speak with Resident # 1 and his POA (Power of attorney) and apologized and advised them that CNA A had been terminated. ADM stated all staff are trained on abuse/neglect when they are hired. ADM stated he had been trained on abuse/neglect and reported that CNA A must have a bad day. ADM stated no Review of facility Abuse/Neglect policy dated 11/28/2017, reflected Each Resident has the right to be free from abuse, neglect. Abuse -willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, or mental anguish. Review of QAPI - (Quality Assurance and Performance Improvement) dated November 2022- February 2023 completed monthly. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 2/24/2023. The IJ Immediate Jeopardy template was provided to the ADM on 2/25/2023 at 5:45pm. While the (IJ) Immediate Jeopardy was removed on 2/25/2023 at 4:30pm, the facility remained out of compliance at a scope of actual harm with potential for more than minimal harm that is Immediate Jeopardy because all staff had not been trained on Abuse/Neglect A Plan of Removal was first submitted by the ADM on 2/24/2023 at 8:34pm. The Plan of removal accepted on 2/25/2023 at 1:24pm. Plan of Removal Immediate Plan of Removal The facility submits this Plan of Removal to address the Immediate Jeopardy identified on 2/24/23. Identification of Others Affected by Alleged Deficient Practice: All residents have the potential to be affected by this alleged deficient practice. Summary: Per the IJ (Immediate Jeopardy) template, the facility failed to ensure the resident was free from abuse. Immediate Action Taken: 1. The Medical Director was notified on 2/24/23. 2. In-service on Abuse, Neglect, and Exploitation and Resident Rights and quiz started on 2/24/23 with staff in the facility by Administrator, DON, or designee. Quizzes are given after the in-service is conducted. Before taking assignment after clocking in, each employee will be in-serviced prior to resident care. Completion of training will be 2/25/23 and those on leave have been contacted and instructed to complete training prior to shift. HR/designee will be responsible for monitoring compliance. Monitoring to take place daily by reconciling the schedule with the employee roster. 3. Social Services will be responsible for evaluating resident for emotional trauma with completion date of 2/25/23. Social Services will complete trauma assessment and complete social services UDA (trauma assessment). If trauma is noted, psychology services will be offered within seven days and any interventions they deem appropriate will be implemented immediately. DON/designee will ensure this happens by conducting a chart review and reviewing orders to ensure interventions are in place. 4. Social worker/designee will conduct safe surveys (a tool used to determine if resident feels safe in a facility) on all residents with a BIMs score of 12 or greater with completion date of 2/25/23. DON/designee will review all safe surveys and compare against roster of residents to ensure completeness. 5. Social worker scheduled psychology services ervices provider] for Resident #1 that took place on 2/25/23 at 10 am. DON/designee will verify it is completed by reviewing chart notes from psychology. 6. Charge nurse to perform skin assessments for all residents on 200 hall with a BIM of 11 or less and these will be completed by 2/25/23. DON/designee will review all skin assessments and compare against roster of residents to ensure completeness. Systemic Change to Prevent Re-Occurrence 1. Administrator and DON in-serviced all staff on Abuse, Neglect and Exploitation and Resident Rights. Staff to be in-serviced on Abuse, Neglect and Exploitation and Resident Rights upon hire, periodically with any allegation of abuse and annually starting on 2/24/23 as a permanent part of the new hire training and will be ongoing. In-services began on 2/24/23 and will be completed on 2/25/23. All staff on leave have been contacted and instructed to complete training prior to working assigned shift. HR will ensure compliance with in-servicing. 2. The regional RN resource in-serviced and quizzed Administrator and DON on Abuse, Neglect and Exploitation and Resident Rights on 2/24/23. Monitoring to Ensure Ongoing Compliance 1. All staff will be in-serviced regarding Abuse, Neglect, Exploitation and Resident Rights upon hire, annually, and as needed by administrator/DON/designee starting on 2/24/23 and will be ongoing. 2. The Abuse Coordinator will provide a summary of any investigations related to Abuse, Neglect and Exploitation and Resident Rights monthly at the QAPI meeting for review for 90 days. Monitoring of Plan of removal on 2/25/2023 is as follows: 1. 2/25/2023 - Interview with ADM at 3:00pm reported he texted the MD (medical director) regarding the incident on 2/24/2023 and advised of the Immediate Jeopardy. 2. 2/25/2023- Reviewed in-service and quizzes regarding: Abuse/Neglect and Exploitation and Resident Rights 73 staff have completed this training and taken the skills test. List verified against staff roster. 3. 2/25/2023- Review of psychologist progress note dated 2/25/2023, reflected she completed assessments for the resident and other residents today. She stated her information has not been entered into the system at this time but should be entered tomorrow. The resident accepted the psychological services. 4. 2/25/2023 - Review of safe surveys completed and reviewed in binder to assess if the resident has been threatened, mistreated by staff, if they feel safe, do they feel comfortable reporting their concerns, and if they know who to report abuse/neglect to. Verified against resident roster surveys completed. 5. 2/25/2023- Interview with social worker at 3:10pm stated she continues to follow-up with the resident since the incident. She stated her assessment is in Point Click Care under the progress notes. 6. 2/25/2023- Reviewed all skin assessments completed for residents on 200 hall with a BIMS of 11 or less. Verified using roster and Point Click Care system completed. Systematic Change to Prevent Re-Occurrence monitoring completed 2/25/2023: 1. 2/25/2023- reviewed Administrator and DON in-serviced staff currently working. 2. 2/25/2023- reviewed - Administrator and DON were in-serviced on Abuse/Neglect, Exploitation and Resident Rights, skills test completed by RN, Clinical Resources Monitoring to Ensure Ongoing Compliance completed on 2/25/2023: 1. Reviewed in-services dated 2/24/2023 completed by staff Abuse, Neglect, Exploitation and Resident Rights 2. Reviewed of QAPI (Quality assurance performance improvement) dated 2/25/2023. In an interview on 2/25/2023 at 12:00pm with Resident # 5, reported the night of the incident, he asked CNA A if she could move his roommate over because he was blocking the door and he could not get his wheelchair through the door. Resident # 5 stated, CNA A got upset with him and cursed at him and called him some names, he stated she also threw a cup of water on him. Resident # 5 stated he did let the staff on duty know and the ADM contacted him that night and advised him that CNA A was terminated. Resident # 5 stated he does feel safe now that she is gone. In an interview on 2/25/2023 at 12:15pm with Resident #1, stated he felt safe, now that the staff is no longer at the facility. He stated he just never had anything like that happen to him before and it scared him. In an interview on 2/25/2023 at 12:20pm with Resident # 6, stated things have been going ok with him. Stated the staff had been nice and helpful to him, stated he did feel safe. Resident # 6 stated no one has ever hit or hurt him. In an interview on 2/25/2023 at 1:00pm with CNA B, stated she had been trained on Abuse/Neglect/ and Exploitation. CNA B stated who the abuse/neglect coordinator was and when to report. CNA B stated she understood the expectation of client care. In an interview on 2/25/2023 at 1:10pm with CNA C, stated she had been trained on Abuse/Neglect/ and Exploitation. CNA C stated who the abuse/neglect coordinator was and when to report. CNA C stated she understood the expectation of client care. In an interview on 2/25/2023 at 1:20pm with LVN B, stated she had been trained on Abuse/Neglect/ and Exploitation. LVN B stated who the abuse/neglect coordinator was and when to report. LVN B stated she understood the expectation of client care. In an interview on 2/25/2023 at 1:30pm with LVN C, stated she had been trained on Abuse/Neglect/ and Exploitation. LVN C stated who the abuse/neglect coordinator was and when to report. LVN C stated she understood the expectation of client care. In an interview on 2/25/2023 at 3:00pm with ADM, he expected that all staff would provide quality care to each resident at facility. He stated he expected all staff to adhere to the abuse/ neglect policy and procedures at all times. He stated as the ADM, when abuse/neglect is reported he would address it immediately and ensure the safety of all residents.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate assistance devices to prevent accidents for 1 of 4 residents (#1) reviewed for transfers in that: CNA A and CNA B did not utilize a mechanical lift as directed in resident's care plan while transferring Resident #1 which resulted in acute, nondisplaced transverse left tibial metaphyseal fracture and an acute, nondisplaced left fibular metaphyseal fracture. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This deficient practice affected 1 resident and put an additional 19 residents who required a mechanical lift during transfers at risk of discomfort, pain, and/or injury. Findings included: Review of Resident #1's face sheet revealed an [AGE] year old male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 indicating a severe cognitive impairment. Further review of MDS assessment revealed Resident #1 was totally dependent on two+ people for transfers. Review of Resident #1's most recent Care Plan revealed resident had an ADL self-care performance deficit related to Parkinson's disease. Interventions included: Transferring: requires 2 staff and Hoyer lift for transfers d/t fragile skin. Review of progress note dated 9/17/17 and signed by LVN A revealed LVN A heard Resident #1 yell out from down the hallway. Shortly thereafter LVN A observed Resident #1 being propelled in his Geri chair to the dining room; resident showed no signs of distress at this time. CNA A and CNA B were questioned as to if something had occurred to cause resident to yell out and both stated they did not know why he yelled out like that. CNAs further stated his legs were not hit on anything or twisted in anyway. A few minutes later in the dining room Resident #1 complained of his left leg hurting stating, Oh, my leg hurts! Upon inspection, swelling was noted below left knee and was slowly increasing in swelling as the minutes passed. Resident #1's doctor was phoned and order was given to get an X-ray of left knee/tibia/fibula by a local mobile imaging company. Ice pack was applied to resident's knee and resident had very limited movement to lower extremity. Resident was showing distress only when left leg palpated just below the knee. Review of progress note dated 9/17/17 and signed by LVN A revealed the ice pack was removed with significant less edema noted to lower leg but faint hematoma to area just distal to knee and another faint hematoma noted approximately 20cm below previously mentioned hematoma. Further review of notes revealed a second round of ice packs were applied. Ice pack was removed after 20 minutes; resident had only consumed 50% of meal which was unusual for him as he usually consumes 100%. Swelling was noted to continue but no longer increasing. Resident was treated with pain medication as needed throughout the day. Review of radiology report dated 9/17/17 revealed no acute findings of the left knee, left tibia or left fibula. Review of progress notes dated 9/18/17 revealed Resident #1's hematoma just distal to left knee had darkened in color and enlarged in size, also noted with 3 serous fluid filled blistered noted within border of hematoma, distal pulses palpable, swelling remains about the same. Resident only had pain to movement of lower left extremity or palpation. Review of progress note dated 9/19/17 revealed Resident #1 continued with ice pack to lower left leg for 20 minutes every 4 hours. Resident was noted to show discomfort if touching left leg in that area but relief with ice pack. Skin has noted blisters and bruising below the left knee. Review of notes further revealed NP A was notified of resident's condition. NP A ordered Tramadol 50 MG for pain and Venous Doppler Ultrasound to check for blood clot. Review of progress note dated 9/19/17 and signed by NP A revealed an order for [REDACTED]. Review of progress note dated 9/13/17 - 9/16/17 revealed no recent history of left knee pain or swelling. Review of medical records from the emergency room dated 9/19/17 revealed Resident #1 presented with low blood pressure, swelling and warmth in left lower leg. Physical exam of lower left leg revealed [DIAGNOSES REDACTED] and edema with bulla present on anterior tibia. CT of left knee revealed acute, nondisplaced transverse left tibial metaphyseal fracture and an acute, nondisplaced left fibular metaphyseal fracture. X-ray of left knee revealed findings consistent with CT findings. Resident was treated with compression dressing and discharged back to the facility. Review of medical records dated 9/25/17 and signed by NP B revealed Resident #1 presented for evaluation and treatment of [REDACTED]. The injury occurred about a week ago around 9/17/17 according to chart review and ED record. Resident responded in pain with movement of lower left extremity. Resident's knee was wrapped in an ACE brand elastic bandage with knee immobilizer. Imaging revealed stable nondisplaced left proximal tibial and left fibular head fractures. During interview on 10/11/17 at 1:15 p.m. DON stated that CNA A and CNA B failed to use a Hoyer lift while transferring Resident #1 on 9/17/17; instead, they only used a gait belt. DON further stated CNA A should have known better as she regularly worked on Resident #1's hall and knew he required a Hoyer lift to be transferred. DON further stated that CNA B came from another hall way to assist CNA A and was following the instructions of CNA A. DON further stated it was her understanding that LVN A heard Resident #1 yell out while being improperly transferred by CNA A and CNA B. About 15 minutes later LVN A noticed swelling with pain. DON further stated the mobile X-ray company came out and completed X-rays of left knee which were negative. Staff monitored left knee for a day or two and noticed the appearing of purple blisters. Resident #1 was sent to theER on [DATE] and received a CT scan of left knee which showed a fracture. DON further stated that CNA A was terminated and CNA B was written up and retrained on always confirming with a residents care plan before performing a transfer. During interview on 10/12/17 at 3:15 p.m. CNA B stated she was asked by CNA A on 9/17/17 to help transfer Resident #1 from his bed to his chair so that he could go eat breakfast. CNA B further stated she worked on a different hall and wasn't as familiar with the needs of residents on CNA A's hall. CNA B further stated when she entered Resident #1's room CNA A had already got resident up to a sitting position on his bed. He was sitting up and his legs were dangling off the bed. CNA B further stated she had a suspicion at this point that something was wrong as she knew Resident #1 required two staff to get him to a sitting position. CNA B further stated that Resident #1 was complaining of leg pain prior to them performing the two person gait-belt transfer. CNA B further stated they examined his leg and didn't notice anything wrong. CNA B further stated they transferred Resident #1 from his bed to his wheelchair with a gait belt. She further stated the transfer was fine and resident did not appear to bump his knee on anything or twist his knee. CNA B further stated that Resident #1 was complaining of leg pain prior to the transfer and may have sustained injury while CNA A assisted resident from a lying position to a sitting position on the bed. She further stated she was retrained on always looking at a resident's care plan prior to performing a transfer to ensure the care plan is being followed. During interview on 10/13/17 at 10:30 a.m. LVN A stated he heard Resident #1 yell out on the morning of 9/17/17. LVN A further stated it was a different type of yell than usual; it sounded more like a yell from pain. He further stated a few minutes later he made his way down the hall to check it out and observed CNA A and CNA B wheeling Resident #1 down the hall to the dining room for breakfast. LVN A questioned CNA A and CNA B as to what happened but both staff stated they didn't know why resident yelled out like that. LVN A further stated initially resident wasn't grimacing or showing any signs of discomfort. LVN A further stated about 15 minutes later he went to check on Resident #1 in the dining hall and resident told him his left leg hurts. LVN A further stated resident's left leg appeared swollen. He further stated he could see resident's leg swelling more and more by the second. He further stated resident's leg swelled about 30% bigger in approximately 20 minutes. LVN A further stated he questioned CNA A and CNA B again as he was confident something must have happened during the transfer but both staff maintained that nothing had happened to his leg during the transfer. LVN A then called resident's doctor regarding the swelling and a mobile X-ray was ordered. LVN A further stated the X-ray came back negative. Resident #1 was treated with pain medication and ice packs to help with the swelling. LVN A further stated he observed resident's leg again later that evening and noticed blisters around the swollen area. LVN A stated he believes the injury was acute based on Resident #1 yelling out, an improper transfer being performed, the severity of resident's leg pain and the rate at which the swelling occurred. LVN A further stated Resident #1 had not had any left knee pain/swelling in the days leading up to 9/17/17. During interview on 10/13/17 at 11:25 a.m. DON stated that she expects residents who are non-weight bearing to be transferred with a Hoyer lift. She further stated she expects staff to transfer residents according to their care plan. During interview on 10/13/17 at 11:55 a.m. Administrator stated he expects staff to use a Hoyer lift to transfer residents who are non-weight bearing. Review of facility policy titled Quality of Care revised on 11/2007 revealed Passive - Hoyer Lift (2 Person Lift) 1. Resident should be in anatomical body alignment. 2. Roll to right, position Hoyer sling under left side, then roll left and position sling under right side. 3. Attach sling to Hoyer and slowly raise resident up off floor and guide direction on Hoyer. Widen base of lift and lock brakes prior to lifting resident with lift. 4. Place resident into chair or onto bed. It was determined these failures caused harm to Resident #1 on 9/17/17. The facility took the following actions to correct the non-compliance: 1. On 9/20/17 all nursing staff were in-serviced on abuse and neglect policies and procedures. 2. On 9/20/17 all nursing staff were in-serviced on proper resident transfers. 3. On 9/20/17 all nursing staff received Hoyer lift and gait belt video training. 4. CNA A was subsequently terminated. 5. CNA B was in-serviced on reviewing residents care plans prior to performing a transfer. This investigator interviewed six CNAs, two LVNs and two RNs on 10/11/17 - 10/13/17 and all were knowledgeable of abuse/neglect policies/procedures, proper resident transfer techniques and of reviewing residents' care plans prior to performing transfers on residents with whom they are unfamiliar. Additionally, all staff were aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. This investigator interviewed four residents who required the use of a Hoyer lift for transfers on 10/11/17 - 10/13/17. All residents stated that staff always use a Hoyer lift when transferring them from bed to wheelchair or from wheelchair to bed. All residents stated they have never been injured or hurt from a transfer. None of the residents had any complaints related to transfers. This investigator observed two resident transfers who required a Hoyer lift on 10/11/17 - 10/13/17. All transfers were performed correctly and without injury. The DON provided a list that indicated 20 residents required Hoyer lift for transfers.

Based on observation, interview and record review the facility failed to implement its policies and procedures that prohibit neglect of residents for 1 (Resident #1) of 4 residents reviewed for neglect in that: CNA A and CNA B did not utilize a mechanical lift as directed in resident's care plan while transferring Resident #1 which resulted in acute, nondisplaced [MEDICATION NAME] left tibial metaphyseal fracture and an acute, nondisplaced left fibular metaphyseal fracture. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure affected 1 resident and put an additional 19 residents who required a mechanical lift during transfers at risk of discomfort, pain, injury, and neglect. Findings included: Review of Resident #1's face sheet revealed an [AGE] year old male who was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 0 indicating a severe cognitive impairment. Further review of MDS assessment revealed Resident #1 was totally dependent on two+ people for transfers. Review of Resident #1's most recent Care Plan revealed resident had an ADL self-care performance deficit related to [MEDICAL CONDITION]. Interventions included: Transferring: requires 2 staff and Hoyer lift for transfers d/t fragile skin. Review of progress note dated 9/17/17 and signed by LVN A revealed LVN A heard Resident #1 yell out from down the hallway. Shortly thereafter LVN A observed Resident #1 being propelled in his Geri chair to the dining room; resident showed no signs of distress at this time. CNA A and CNA B were questioned as to if something had occurred to cause resident to yell out and both stated they did not know why he yelled out like that. CNAs further stated his legs were not hit on anything or twisted in anyway. A few minutes later in the dining room Resident #1 complained of his left leg hurting stating, Oh, my leg hurts! Upon inspection, swelling was noted below left knee and was slowly increasing in swelling as the minutes passed. Resident #1's doctor was phoned and order was given to get an X-ray of left knee/tibia/fibula by a local mobile imaging company. Ice pack was applied to resident's knee and resident had very limited movement to lower extremity. Resident was showing distress only when left leg palpated just below the knee. Review of progress note dated 9/17/17 and signed by LVN A revealed the ice pack was removed with significant less [MEDICAL CONDITION] noted to lower leg but faint hematoma to area just distal to knee and another faint hematoma noted approximately 20cm below previously mentioned hematoma. Further review of notes revealed a second round of ice packs were applied. Ice pack was removed after 20 minutes; resident had only consumed 50% of meal which was unusual for him as he usually consumes 100%. Swelling was noted to continue but no longer increasing. Resident was treated with pain medication as needed throughout the day. Review of radiology report dated 9/17/17 revealed no acute findings of the left knee, left tibia or left fibula. Review of progress notes dated 9/18/17 revealed Resident #1's hematoma just distal to left knee had darkened in color and enlarged in size, also noted with 3 serous fluid filled blistered noted within border of hematoma, distal pulses palpable, swelling remains about the same. Resident only had pain to movement of lower left extremity or palpation. Review of progress note dated 9/19/17 revealed Resident #1 continued with ice pack to lower left leg for 20 minutes every 4 hours. Resident was noted to show discomfort if touching left leg in that area but relief with ice pack. Skin has noted blisters and bruising below the left knee. Review of notes further revealed NP A was notified of resident's condition. NP A ordered [MEDICATION NAME] 50 MG for pain and Venous Doppler Ultrasound to check for blood clot. Review of progress note dated 9/19/17 and signed by NP A revealed an order for [REDACTED]. Review of progress note dated 9/13/17 - 9/16/17 revealed no recent history of left knee pain or swelling. Review of medical records from the emergency room dated 9/19/17 revealed Resident #1 presented with low blood pressure, swelling and warmth in left lower leg. Physical exam of lower left leg revealed [DIAGNOSES REDACTED] and [MEDICAL CONDITION] with bulla present on anterior tibia. CT of left knee revealed acute, nondisplaced [MEDICATION NAME] left tibial metaphyseal fracture and an acute, nondisplaced left fibular metaphyseal fracture. X-ray of left knee revealed findings consistent with CT findings. Resident was treated with compression dressing and discharged back to the facility. Review of medical records dated 9/25/17 and signed by NP B revealed Resident #1 presented for evaluation and treatment of [REDACTED]. The injury occurred about a week ago around 9/17/17 according to chart review and ED record. Resident responded in pain with movement of lower left extremity. Resident's knee was wrapped in an ACE brand elastic bandage with knee immobilizer. Imaging revealed stable nondisplaced left proximal tibial and left fibular head fractures. During interview on 10/11/17 at 1:15 p.m. DON stated that CNA A and CNA B failed to use a Hoyer lift while transferring Resident #1 on 9/17/17; instead, they only used a gait belt. DON further stated CNA A should have known better as she regularly worked on Resident #1's hall and knew he required a Hoyer lift to be transferred. DON further stated that CNA B came from another hall way to assist CNA A and was following the instructions of CNA A. DON further stated it was her understanding that LVN A heard Resident #1 yell out while being improperly transferred by CNA A and CNA B. About 15 minutes later LVN A noticed swelling with pain. DON further stated the mobile X-ray company came out and completed X-rays of left knee which were negative. Staff monitored left knee for a day or two and noticed the appearing of purple blisters. Resident #1 was sent to theER on [DATE] and received a CT scan of left knee which showed a fracture. DON further stated that CNA A was terminated and CNA B was written up and retrained on always confirming with a residents care plan before performing a transfer. During interview on 10/12/17 at 3:15 p.m. CNA B stated she was asked by CNA A on 9/17/17 to help transfer Resident #1 from his bed to his chair so that he could go eat breakfast. CNA B further stated she worked on a different hall and wasn't as familiar with the needs of residents on CNA A's hall. CNA B further stated when she entered Resident #1's room CNA A had already got resident up to a sitting position on his bed. He was sitting up and his legs were dangling off the bed. CNA B further stated she had a suspicion at this point that something was wrong as she knew Resident #1 required two staff to get him to a sitting position. CNA B further stated that Resident #1 was complaining of leg pain prior to them performing the two person gait-belt transfer. CNA B further stated they examined his leg and didn't notice anything wrong. CNA B further stated they transferred Resident #1 from his bed to his wheelchair with a gait belt. She further stated the transfer was fine and resident did not appear to bump his knee on anything or twist his knee. CNA B further stated that Resident #1 was complaining of leg pain prior to the transfer and may have sustained injury while CNA A assisted resident from a lying position to a sitting position on the bed. She further stated she was retrained on always looking at a resident's care plan prior to performing a transfer to ensure the care plan is being followed. During interview on 10/13/17 at 10:30 a.m. LVN A stated he heard Resident #1 yell out on the morning of 9/17/17. LVN A further stated it was a different type of yell than usual; it sounded more like a yell from pain. He further stated a few minutes later he made his way down the hall to check it out and observed CNA A and CNA B wheeling Resident #1 down the hall to the dining room for breakfast. LVN A questioned CNA A and CNA B as to what happened but both staff stated they didn't know why resident yelled out like that. LVN A further stated initially resident wasn't grimacing or showing any signs of discomfort. LVN A further stated about 15 minutes later he went to check on Resident #1 in the dining hall and resident told him his left leg hurts. LVN A further stated resident's left leg appeared swollen. He further stated he could see resident's leg swelling more and more by the second. He further stated resident's leg swelled about 30% bigger in approximately 20 minutes. LVN A further stated he questioned CNA A and CNA B again as he was confident something must have happened during the transfer but both staff maintained that nothing had happened to his leg during the transfer. LVN A then called resident's doctor regarding the swelling and a mobile X-ray was ordered. LVN A further stated the X-ray came back negative. Resident #1 was treated with pain medication and ice packs to help with the swelling. LVN A further stated he observed resident's leg again later that evening and noticed blisters around the swollen area. LVN A stated he believes the injury was acute based on Resident #1 yelling out, an improper transfer being performed, the severity of resident's leg pain and the rate at which the swelling occurred. LVN A further stated Resident #1 had not had any left knee pain/swelling in the days leading up to 9/17/17. During interview on 10/13/17 at 11:25 a.m. DON stated that she expects residents who are non-weight bearing to be transferred with a Hoyer lift. She further stated she expects staff to transfer residents according to their care plan. During interview on 10/13/17 at 11:55 a.m. Administrator stated he expects staff to use a Hoyer lift to transfer residents who are non-weight bearing. Review of facility policy titled Quality of Care revised on 11/2007 revealed Passive - Hoyer Lift (2 Person Lift) 1. Resident should be in anatomical body alignment. 2. Roll to right, position Hoyer sling under left side, then roll left and position sling under right side. 3. Attach sling to Hoyer and slowly raise resident up off floor and guide direction on Hoyer. Widen base of lift and lock brakes prior to lifting resident with lift. 4. Place resident into chair or onto bed. Review of facility policy titled Abuse Prevention revised on 11/28/16 revealed It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Further review of policy revealed the definition of Neglect to be is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. It was determined these failures caused harm to Resident #1 on 9/17/17. The facility took the following actions to correct the non-compliance: 1. On 9/20/17 all nursing staff were in-serviced on abuse and neglect policies and procedures. 2. On 9/20/17 all nursing staff were in-serviced on proper resident transfers. 3. On 9/20/17 all nursing staff received Hoyer lift and gait belt video training. 4. CNA A was subsequently terminated. 5. CNA B was in-serviced on reviewing residents care plans prior to performing a transfer. This investigator interviewed six CNAs, two LVNs and two RNs on 10/11/17 - 10/13/17 and all were knowledgeable of abuse/neglect policies/procedures, proper resident transfer techniques and of reviewing residents' care plans prior to performing transfers on residents with whom they are unfamiliar. Additionally, all staff were aware of the facility policy to transfer all residents who cannot bear weight with a Hoyer lift. This investigator interviewed four residents who required the use of a Hoyer lift for transfers on 10/11/17 - 10/13/17. All residents stated that staff always use a Hoyer lift when transferring them from bed to wheelchair or from wheelchair to bed. All residents stated they have never been injured or hurt from a transfer. None of the residents had any complaints related to transfers. This investigator observed two resident transfers who required a Hoyer lift on 10/11/17 - 10/13/17. All transfers were performed correctly and without injury. The DON provided a list that indicated 20 residents required Hoyer lift for transfers.