Every finding on record at Wesley Woods Health & Rehabilitation

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation The facility failed to label, date, and seal food items in the pantry, refrigerator, and chest freezer on 3/19/2026. This failure could place residents at risk for health complications and foodborne illnesses.Findings included: During an observation on 3/19/2026, between 10:29 a.m. and 10:47 a.m., the following observations were made in the kitchen area: 1) an opened bag of cocoa was sitting on the pantry shelf with the top of the bag rolled down.2) an opened bag of cake mix was in a zip bag, but not labeled or dated on the pantry shelf3) an opened bag of lettuce mix was not sealed, labeled or dated on the fridge shelf4) a plastic container of a jello and fruitlike substance was not labeled or dated on the fridge shelf5) a metal container of cooked eggs was not labeled or dated on the fridge shelf6) a metal container of cooked breakfast meat was not labeled or dated on the fridge shelf7) an open zip bag of ground turkey was not labeled or dated on the fridge shelf8) an opened, unlabeled, undated bag of hashbrowns was on the freezer shelf9) an open box with an open bag of frozen egg products was on the freezer shelf10) an opened, unlabeled, undated bag of frozen potatoes was on the freezer shelf.11) an opened, unlabeled, undated bag of frozen chicken breasts was on the freezer shelf During an interview on 3/19/2026 at 10:45 a.m., DM identified all opened, unlabeled food items. He stated the food items were not stored properly. During an interview on 3/19/2026 at 3:15 p.m., DM stated staff know they should store food properly which included labeling and dating open items. He stated he typically did daily checks on food storage but was not at work yesterday so he did not get to check yet this morning. DM stated his expectation was that opened food would have been sealed in the appropriate container then labeled and dated. He stated his concern for food items not being stored properly was cross contamination or food born illnesses due to food getting spoiled or rotten. He stated he had staff fix all the food items that were improperly stored from the morning's inspection. He stated the residents were an at-risk population for food borne illnesses due to age and other health issues and this could make the residents more prone to illnesses. During an interview on 3/19/2026 at 3:45 p.m., DC stated she had received training on how to properly store food. She stated she had seen food improperly stored and would either fix it herself or let the DM know about it. She stated they were supposed to put food in a sealed container or bag, label and date it before putting it away. She stated not properly storing food could make residents sick. During an interview on 3/19/2026 at 4:00 p.m., DA stated she worked at the facility since January 2026 and had seen food improperly stored. She stated staff should have covered it up or put it in a container or bag, then labeled and dated it. The DA stated some shifts were better than others about storing food items. She stated if food was not stored properly there could have been cross-contamination and the residents could get sick. During an interview on 3/19/2026 at 4:15 p.m., ADM stated her expectation was that food be stored properly including making sure it was sealed, labeled and dated. The ADM stated her concerns with improper storage would have expired food. She stated if it had been left open it could have been open to bacteria and it could have been an infection control issue, and this could have made residents sick. She stated the facility population was an at-risk population. During a record review of an email, dated 3/19/2026 at 12:44 p.m., ADM stated, We do not have any residents who are tube fed. All 113 residents eat from the kitchen. Record review of an undated facility policy titled, Dry Storage and Supplies, reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.3. Dry bulk foods (e.g. flour, sugar) are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Scoops should not be left in food containers or bins. Containers are cleaned regularly.4. Open packages of food are stored in closed containers with tight covers and dated as to when opened. Record review of an undated facility policy titled, Storage of Food in Refrigeration, reflected:3. Food being returned to storage after cooking or prep must be covered4. All containers must be labeled with the contents and date food item was placed in storage.

Based on observations, interviews, and record review, the facility failed to provide each resident with a nourishing, attractive, palatable, temperature appropriate diet that met his or her dietary needs or preferences for 5 (Resident #13, #37, #53, #58, and #79) of 13 residents reviewed for dietary services.1. The facility failed to serve food that was appetizing.2. The facility failed to ensure food was served according to expected food temperatures.3. The facility failed to serve food that was adequately cooked in that residents were served raw and/or undercooked chicken, ground meat, and potatoes These failures placed residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings include:Record review of Resident #13's face sheet on 12/31/2025 reflected an [AGE] year-old female with an original admission date of 4/8/2025 and readmission on [DATE] with diagnoses including Enterocolitis (inflammation in the inner lining of the small intestine and colon) from Clostridium Difficile (a bacterium that causes an infection of the colon), moderate protein-calorie malnutrition (insufficient intake of protein and calories needed for maintaining health and bodily functions), and Major Depressive Disorder with Psychotic symptoms (depression with loss of touch with reality).Record review of Resident #13's quarterly MDS assessment dated [DATE] reflected a BIMS score of 09, which indicated moderately impaired cognition.Record review of Resident #13's comprehensive care plan initiated on 4/18/2025 reflected the resident was at risk for weight changes related to a diagnosis and history of mild protein calorie malnutrition and prefers hamburgers for meals and eggs for breakfast.Record review of Resident #37's face sheet on 12/31/2025 reflected a [AGE] year-old female with an original admission date of 4/20/2023 and readmission on [DATE] with diagnoses including Hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), lumbosacral spinal fusion (connecting two or more vertebrae in the lumbar and sacral regions to provide stability and relieve pain), bone density disorder (fragile bones), Hyperlipidemia (high cholesterol or fats in the blood), and Hypertension (high blood pressure).Record review of Resident #37's quarterly MDS assessment dated [DATE] reflected that the resident had a BIMS score of 13, which indicated normal cognitive function. Record review of Resident #37's comprehensive care plan initiated on 6/5/2023 reflected the resident was at risk for skin breakdown due to fragile skin and complications related to her diagnoses of Hyperthyroidism and Hyperlipidemia, which required providing a diet and fluids as ordered. The resident was also at risk for significant weight changes, which required offering food preferences and encouraging snacks within dietary restrictions.Record review of Resident #53's face sheet on 12/31/2025 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Dementia (a decline in cognitive function affecting memory, thinking, and behavior) with Anxiety, Hypertensive Chronic Kidney Disease (kidney damage caused by long-term high blood pressure), and iron deficiency anemia (when the body doesn't have enough iron to produce red blood cells.Record review of Resident #53's quarterly MDS assessment dated [DATE] reflected that the resident had a BIMS score of 14, which indicated normal cognitive function.Record review of Resident #53's comprehensive care plan initiated 2/9/2024 reflected the resident was at risk for weight changes, nutritional/appetite changes, dehydration and malnutrition, which required a therapeutic diet and fluids as ordered.Record review of Resident #58's face sheet on 12/31/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Paroxysmal atrial fibrillation (irregular heartbeat that start and stop spontaneously), morbid obesity due to excessive calories (significant amount of excess weight), Hyperlipidemia (high cholesterol or fats in the blood), and Hypertension (high blood pressure).Record review of Resident #58's quarterly MDS assessment dated [DATE] reflected that the resident had a BIMS score of 15, which indicated normal cognitive function.Record review of Resident #58's comprehensive care plan initiated on 3/9/2025 reflected that the resident was at risk for weight changes, dehydration, and malnutrition related to a therapeutic diet, medication side effects, dietary likes and dislikes, impaired cognition, and morbid obesity. The resident was also at risk of skin breakdown due to her nutritional status.Record review of Resident #79's face sheet on 12/31/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including mild dementia (mild cognitive impairment), Type 2 Diabetes (high levels of sugar in the blood), BMI of 40.0-44.9 (very severe obesity), and GERD (acid reflux).Record review of Resident #79's quarterly MDS assessment dated [DATE] reflected the resident had a BIMS score of 09, which indicated moderately impaired cognition.Record review of Resident #79's comprehensive care plan initiated on 10/27/2023 reflected that the resident was at risk for weight changes, dehydration, and malnutrition related to a therapeutic diet. The resident was to be provided with a diet and fluids as ordered including food preferences and food alternatives within dietary restrictions.Record review of facility Grievance Report Forms for December 2025 revealed several resident complaints regarding late meal service and dietary preferences.Observation of lunch service on 12/29/2025 at 12:30 PM revealed each unit of the facility had their own dining room and meals were transported to each unit via tray carts at consecutive times. Meal service times were observed to be varied and delayed during this observation in relation to the meal times conveyed upon entrance by ADM and. the posted mealtimes for each unit. In an interview on 12/29/2024 at 12:04 PM, Resident #79 stated the food at the facility was horrible. She stated the taste of the food was not as you would expect for the food items served and the menu items were not to her liking. The resident stated that the quality of the food prepared was bad and was typically served cold due to slow service. The resident stated that she was supposed to have received a diet soda with her meals, which was indicated on her meal tickets, but on several occasions that was not provided because it was overlooked which forced her to go into the kitchen herself to get the soda. The resident stated she observed a bunch of horseplay in the kitchen. The resident stated that they were never served fresh fruit even though she had expressed a desire for some. In an interview on 12/29/2025 at 1:40 PM, Resident #53 stated the taste and temperature of the food served at the facility was not good in that the resident stated that she would like to have 1-2 cups of coffee with her meals but there was rarely enough coffee to have even 1 cup. The resident stated when the coffee ran out no more was made.In a group interview during a resident council meeting held on 12/30/2025 at 10:00 AM, the following was reported: Resident #53 stated they were unaware there were snacks available for residents. Resident #13 complained about the taste and temperature of food served. Resident #58 complained about taste of the food consistently being unappetizing in its taste and appearance. Food substitutions were offered but rarely provided as requested. Food was not received according to the service times and that meals were served late. Fresh fruit was never served. The only fruit received was canned fruit and that was not often. Kitchen staff failed to read their food preference requests. Residents #37, #57, and #79 were served raw chicken and ground meat. Residents were served raw potatoes that were cut in half.In an interview on 12/31/2025 at 1:16 PM, the ADM stated she was aware of some of the resident complaints regarding the facility's food and dietary services. The ADM stated that the DM was new to the position and had been hired 2 months prior. The ADM stated the former dietary manager was fired due to food complaints. The ADM stated that the kitchen was down 2 dietary aides and was not fully staffed. The ADM stated that all dietary staff were properly trained and were regularly in-serviced on job duties and expectations. That included food preparation, taste, and temperatures. The ADM stated her expectation for the kitchen and dietary services would be that foods were palatable and served at preferred temperatures or temperatures that met temperature regulations. The ADM stated she had received a complaint approximately 3 months prior that chicken was served raw but was not aware of ground meat or potatoes served raw or undercooked. The ADM stated that she observed and confirmed the raw chicken that was served and stated that it had been cooked too fast, so it was burnt on the outside but raw on the inside. The ADM stated that the cook that prepared that chicken was no longer employed with the facility for that reason.Review of the facility's Dietary and Food Service policy on 12/31/2025 reflected: The facility will provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. MENU The Facility menu will meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences.FOODEach resident will receive, and the facility will provide: food prepared in accordance with established professional food preparation practices and by methods that conserve nutritive value, flavor, and appearance. adequate amounts of food that is palatable, attractive, and at the proper temperature. food prepared in a form designed to meet individual needs. substitutes of similar nutritive value to residents who refuse food served, and food that is prepared and served on schedule.

Based on observations, interviews, and record reviews, the facility failed to store food, serve food at the correct temperatures, and sanitize equipment correctly in accordance with professional standards for foodservice safety in the reviewed 1 of 1 kitchen. The findings included:- Food items were not labeled and/or dated. - Food items were out of date. - Food items were not correctly sealed. - Dirty kitchen equipment. - Staff food items were kept with residents' food items. The failures could cause foodborne illness, particularly among vulnerable populations.Findings include:Observation on 12/29/2025 at 9:15 AM of the walk-in cooler reflected the following:- Heavy cream was in the original container, with an expiration date of 12-10-2025.- A plastic bucket of pickled eggs was uncovered and exposed.- A plastic bucket of pickles was uncovered and exposed.- Celery in a container with plastic wrap dated 12-23 with no expiration date. - A bag of greens was left open and exposed. - A box containing green squash had a moldlike substance on one of the squashes. - A package of strawberries with a mold-like substance was on the strawberries. - There was an open personal-sized bottle of coffee in the cooler. Observation on 12/29/2025 at 9:25 AM of the kitchen reflected the following:- A container bin of cereal was left open and exposed with no label and not dated. - A large container of powdered sugar was left open and not dated. - A large container of sugar was not labeled with the expiration date. - The dispenser had lots of old juice residue under the machine where the juice was dispensed. - The coffee maker had lots of old coffee residue under the machine. - Several loaves of bread on a rack were not dated with the expiration date. Observation on 12/29/2025 at 10:46 AM in the kitchen reflected the following:- While CKH was taking temperatures of the food on the warming table, CKH used a paper towel to clean off the food on the thermometer before taking the temperature of another food item. Observation on 12/30/2025 at 10:15 AM in the kitchen reflected the following:- CK D did not sanitize the puree blender between each food item pureed. CK D wore the same gloves throughout the puree process and did not change them at any time. [NAME] touched multiple items, including the oven handle and a container of thickening powder, in the kitchen while wearing the same gloves during the puree process. Observation on 12/30/2025 at 10:47 AM in the kitchen reflected the following:- While CK D was taking temperatures of the food on the warming table, CK D used the rubber gloves on his hand to wipe off the food before taking the temperature of another food item. - CK D took the temperature of the meat loaf, which read 126.1degrees Fahrenheit. CK D did not record the temperature and did not bring the meat loaf to the required 140-degree Fahrenheit internal temperature and it was served to the residents. An interview on 12/30/2025 at 9:35 PM with CK D. CK D said that everyone was responsible for checking the dates on food in the kitchen. CK D said that if an item was out of date, it should be discarded. CK D said that all food items in the kitchen should be sealed. CK D said that the kitchen was thoroughly cleaned daily. CK D said all staff were required to clean the kitchen. Depending on the staffs' position in the kitchen determined what they were supposed to clean. CK D said that it was the aide's responsibility to clean the juice and coffee machines. CK D said there was no checklist for cleaning. CK D said he was required to sanitize the puree blender after each food item was pureed, but he did not do so because he forgot. CK D said that he did not record the food temperatures because he had taken them 2 hours before lunch service. CK D said the meatloaf should be held at 135 degrees and reheated because it was 126 degrees Fahrenheit. CK D said that he needed to sanitize the thermometer after each food item, but he did not do that. CK D said he was not supposed to clean the thermometer with a glove. CK D said that he was supposed to use an alcohol pad to clean the thermometer before taking the temperature of another item. CK D said that staff were not supposed to keep personal food items in the kitchen cooler. CK D said that not sanitizing properly and not keeping food at the correct temperature could cause residents to get sick and lead to cross-contamination.An interview on 12/31/2025 at 1:20 PM with CK F. CK F said that everyone was responsible for labeling items with the correct date. CK F said that if there was no date, the item was discarded. CK F said that the cooler was checked every 3 days. CK F said that food items placed in the cooler should be labeled with today's date and the date three days past the expiration date. CK F said that all opened food items should be resealed. CK F said that all items should be labeled and dated. CK F said that the kitchen should be cleaned daily. CK F said there was a cleaning check-off chart, but it was being revised. CK F said it was everyone's responsibility to clean the kitchen. CK F said that when making purees, the blender should be sanitized before proceeding to the next food item. CK F said that food temps were taken 10 minutes before serving. CK F said she would wipe the thermometer with alcohol, then move on to the next food item. CK F said that staff were not to keep their personal food items in the kitchen cooler. CK F said residents could be exposed to contaminated food and become sick if proper sanitation was not followed.An interview on 12/31/2025 at 1:32 PM with DA E. DA E said he was not sure about there being a checklist in the kitchen for cleaning. DA E said that it was everyone's responsibility to clean the kitchen and check for out-of-date food. DA E said that all opened food should be sealed, labeled, and dated. DA E said staff were not to store personal food items in the kitchen cooler. DA E said residents could become sick from contaminated machines or from eating out-of-date food. An interview on 12/31/2025 at 1:36 PM with DA D. DA D said everyone was responsible for checking out-of-date items. DA D said all food items in the kitchen should be labeled with the correct date. DA D said that if an item was out of date, it should be discarded. DA D said it was everyone's responsibility to clean the kitchen, and that they use a list to guide them. DA D noted the cooks washed their own dishes. DA D said that staff were not to keep their personal food items in the kitchen cooler. DA D said residents could become sick from contaminated machines or from eating out-of-date food. An interview on 12/31/2025 at 1:36 PM with the DM. The DM said that everyone was responsible for checking dates in the kitchen. The DM said that all outdated items should be reported to him and discarded. The DM said that the cooler should be checked every 2 days. The DM said that all open items should be labeled and dated. The DM said it was the responsibility of all staff to label and date items placed in the cooler. The DM said that there should be an expiration date on all food items. The DM said there was a checklist on the cleaning responsibilities of kitchen staff. The DM said that during the puree process, the blender should be sanitized between each food item. The DM said that when the cook should take the temperatures of food items, write down the temperature, and sanitize the thermometer before taking the temperature of the next food item. The DM said that the juice and coffee machines should be cleaned every few days. The DM said staff were not to keep their personal food items in the kitchen cooler. The DM said that residents could become ill if proper sanitation was not maintained or if they are served out-of-date food. An interview on 12/31/2025 at 1:36 PM with the ADM. The ADM said all opened food items should be sealed, labeled, and dated. The ADM said that during the puree process, the blender should be sanitized between each food item. ADM said that when temperatures are being taken, the thermometer should be sanitized between each food item and the temperature recorded. The ADM said that it is the responsibility of all kitchen staff to clean the kitchen. The AMD said there should be a checklist showing which staff are responsible for which cleaning tasks. The DM stated that staff are not to keep their personal food items in the kitchen cooler. The ADM said the DM has been in the kitchen for only two months and has been working to get everything in place. The ADM said that if a resident ate out-of-date food, they could get sick. The ADM said that improper sanitation could lead to cross-contamination.Record review: Reviewed the facility's food storage policy was not dated. Policy: Daily Food Temperature ControlProcedure: We will assure that food is served at a safe temperature. Temperatures of all hot and cold food shall be taken prior to every meal service and recorded on the Temperature Log. This is done to help ensure that food is safe and is served within acceptable ranges.1. There is a thermometer available for use in the department to test the temperature of foods, which is sanitized between food testing.2. Prior to meal service, the cook shall take the temperature of all hot and cold foods.3. Temperatures are recorded on the Temperature Log form.4. All hot foods shall be cooked and held for service at temperatures of 140 degrees F or above.5. Any hot or cold food which does not meet the minimum acceptable temperature shall be heated to a temperature of 165 degrees Fahrenheit and held at least 15 seconds. Policy: Cleaning was not datedProcedure: 1. All equipment, food contact surfaces, and utensils shall be cleaned:2. All food surfaces will be cleaned at the end of each food preparation session.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 1 laundry room. The facility failed to ensure laundry staff handled and stored linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life. Findings were: Observation on 12/30/2025 at 3:35 pm revealed 1 shelf of clean linen (resident gowns) stored on the dirty side of the laundry room. Resident gowns were folded, stacked neatly and appeared ready for use. The gowns were not covered or protected on the dirty side of the laundry. There was no signage giving directions on the use of the gowns. In an interview with 12/30/2025 at 3:40 pm LA C stated the laundry stored on the shelf which was located in the dirty side of the laundry, was clean laundry. She did not know why it was stored on the dirty side or why the gowns were uncovered. She requested the surveyor to speak with the ESD for that information. In an interview with ESD on 12/30/2025 at 3:45 pm she stated the laundry on the shelf located in the dirty side was clean laundry but that anything on the shelf would need rewashing before use because it was stored on the dirty side. She stated the reason it was important to protect clean linen is to prevent it from getting bacteria contamination which could cause infections for residents. She stated that she thought everyone would know to rewash linens on that shelf before use. In an interview on 12/31/25 at 1:31 pm CNA A stated, the policy for laundry/linens was to never mix clean and dirty laundry. She stated that was important to prevent cross-contamination and that mixing clean and dirty laundry could result in the residents' getting infections. In an interview on 12/31/25 at 1:35 pm LVN B stated, the policy for laundry/linens was definitely not mix clean and dirty laundry. She stated keeping the laundry separate was important to prevent laundry from getting germs and bacteria which could cause residents infections. She stated mixing the laundry could create cross-contamination and make residents ill. In an interview on 12/31/25 at 1:45 pm the DON stated the policy for laundry/linens was dirty and clean laundry had to be kept separate and transported in a bag or closed cart. She stated separating the laundry was important to prevent cross-contamination which could result in infections for residents. She stated there could be feces on the dirty laundry and it could get transferred on the clean laundry and to the resident if the laundry was mixed. In an interview on 12/31/25 at 1:52 pm the ADM stated she just learned that the policy for laundry/linens was to keep dirty and clean laundry stored separately. She stated that it was important to keep it separate to prevent cross-contamination which could cause residents to get infections.Record review of the facility's undated policy titled Laundry and Linen Services reflected the following:Soiled laundry is a significant and important source of microbial contamination. To reduce the possibility of infection transmission, soiled laundry must be kept separate from clean laundry and handled carefully with minimum agitation. Record review of the facility's undated policy titled Standard Precautions-Laundry and Linen reflected the following:Contaminated laundry and all other laundry shall be kept separated.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 Medication Storage rooms (Hall 300 Room) reviewed for drug storage. The facility failed to ensure expired medications were removed from the medication storage room on Hall 300 and that used dressings that were no longer sterile were also removed from the room. This failure could place residents at risk of receiving ineffective medication treatments and contaminated wound care that could result in unnecessary infections.Findings include: Observation on 12/30/25 at 2:37 pm of the 300 Hall Medication Storage Room revealed:2 Packages of 4x4 Sterile Wound Dressings opened but still in stock for use.1 Package of 4x4 Sterile Silver Wound Dressing opened but still in stock for use.1 Bottle of Zinc 50 milligram tablets expired 11/30/2025 In an interview on 12/31/25 at 1:31 pm CNA A stated, the policy for expired medications and expired/opened medical supplies was to throw them away. She stated that it was important to discard expired or open medications because residents could get sick from them or they may not work correctly. She stated, if expired items were accidentally used, the residents could get poisoned, or they may not work effectively. In an interview on 12/31/25 at 1:35 pm LVN B stated, the policy for expired medications and expired/opened medical supplies was to place them in the overflow bin where the ADON would remove them. She stated that it was important to discard expired or opened medications because they could make residents sick or they could be ineffective for the resident's treatment. She stated the negative outcome to residents if expired medication was given could be illness for a resident or it could be ineffective treatment, and she stated using previously opened sterile dressings would create a risk for infections in the resident's wounds. In an interview on 12/31/25 at 1:45 pm the DON stated that the policy for expired medications and expired/opened medical supplies was to discard them. She stated that it was important to discard expired or opened medications because opened and expired items could be contaminated and this could result in stomach upsets or infections for residents. She stated nursing is responsible for removing expired items. In an interview on 12/31/25 at 1:52 pm the ADM stated the policy for expired medications and expired/opened medical supplies was to discard them. She stated that it was important to discard expired or open medications because if they were used, residents could get less medication than they needed if the medication had lost its potency. She stated that opened sterile dressings could cause infections for the residents if used accidentally. Record Review on 12/31/25 of the facility's undated Storage of Medications policy reflected: No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are destroyed. Ensure that medications are stored in a safe, secure, and orderly manner.

Based on interviews and record review the facility failed to report the findings of all investigations of abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property, in accordance with state law, including the state survey agency, within 5 working days of the incident for 1 out 1 reviewed for reporting.The facility failed to submit a Provider Investigation Report (Form 3613-A) to HHSC for a reported incident on 07/18/2025 involving an allegation of misappropriation of property.This failure could place all residents at risk of incidents not being investigated by or reported to HHSC. Findings included: Record review of an incident with an allegation of misappropriation of property involving Resident #1 reflected the incident was reported to HHSC on 07/18/2025. Record review of TULIP reflected no provider investigation report submitted. During an interview with ADM on 08/15/2025 at 11:10am, the ADM stated she was responsible for completing a thorough investigation for ANE. The ADM stated she had a provider letter that stated if you report ANE online then you do not have to complete a Provider Investigation Report (Form 3613-A. The ADM stated that all of the investigation information was submitted within the allotted timeframe therefore she did not believe there was a negative outcome from the 3613-A not being completed. Record review of facility policy Prevention and Reporting of Suspected Resident Abuse and Neglect, undated, reflected, Policy: Prevention and Reporting of Suspected Resident Abuse and Neglect - This facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The Administrator and Director of Nursing are responsible for the implementation and ongoing monitoring of abuse policies and procedures. Implementation and ongoing monitoring consist of the following policies: Screening, Training, Prevention, Identification, Protection, Investigation and Reporting. Procedure: 6. Investigation (The Administrator and Director of Nursing are responsible for investigation and reporting)A. Investigation of all alleged violations will be done under the direction of the DON and/or Administrator. This may utilize a Compliant Form, Initial Investigation for Possible Abuse Violations form, or other written documentation. 7. Reporting Requirements and Definitions:H. Misappropriation of Resident Property - the pattered or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without a resident's consent. Record review of Long-Term Care Regulation Provider Letter Number: PL 18-20 (ALL) (Revised), dated January 19, 2023, reflected, Providers can report incidents to CII: online through the TULIP (Texas Unified Licensure Information Portal) system at https://txhhs.force.com/TULIP/ (preferred method); by calling [PHONE NUMBER] (live agents are available Monday - Friday, 7 am-7 pm); or via email: ciicomplaints@hhs.texas.gov. In addition to reporting an incident, a provider must investigate, or ensure that an investigation was completed, to determine why it occurred, what actions the provider will take in response to the incident and what changes will be made to help prevent a similar incident from occurring.4 A provider must submit a PIR to CII using HHSC Form 3613-A (for use by an ALF, DAHS facility, ICF/IID, NF or PPECC) or HHSC Form 3613 (for use by a HCSSA). Please ensure you use the correct form for your provider type. The PIR must include all information from the initial incident report and any additional information the provider has obtained since making the initial report, including witness statements. The provider must submit the PIR within the applicable required time frame, as follows: Five working days for an ICF/IID, NF or skilled NF;.

Based on observation, record review, and interviews, the facility failed to ensure a resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 computers.On 08/14/2025 LVN A left the facility's computer open and unattended at the nurse's station with residents' personal medical information visible to anyone who passed by. The failure could place residents at risk of having their private information changed, viewed, and not kept secure. Findings include: During an observation on 08/14/2025 at 12:17pm reflected that LVN left her computer unlocked/opened and unsupervised, vaguely visible in an open area for resident and other individuals/guest of the facility passing by the nurse's station. At the time of the observation LVN was passing medication and approximately 35 feet away from the computer at the nurse station. During an interview with LVN A on 08/14/2025 at 12:17pm, the LVN A stated she was told it was ok to leave the computer screen unlocked with the resident's information displayed. The LVN A stated she did not remember who told her it was ok and then stated that's how she was trained. The LVN A stated a negative outcome of leaving a computer with resident information display would be a HIPAA violation or someone could have access to the resident information. During an interview with ADON on 08/15/2025 at 10:00am, the ADON stated the nurse using the computer was responsible for ensuring residents' information was not displayed on the unattended computer. The ADON stated a negative outcome of an unattended computer was resident's information could be accessed by anyone. The ADON stated her expectations were for staff to ensure resident information was not displayed on unattended computer screens. During an interview with DON on 08/15/2025 at 10:20am, the DON stated whoever was using the computer would be responsible for ensure the computer was locked prior to leaving the computer. The DON stated that a negative outcome would be a HIPAA violation. The DON stated that a family member, visitor, or another resident could have access to the computer if it was not locked when unattended. The DON stated that the facility immediately begun inservicing nurses and aides on locking computers and kiosk. The DON stated her expectation were for all computers to be locked when unattended. During an interview with ADM on 08/15/2025 at 11:10am, the ADM stated it was the staff who was using the computer was responsible for ensuring the computer screen was locked when unattended. The ADM stated a negative outcome could be that someone would have access to a resident's personal information. The ADM's expectation moving forward was for staff to ensure their computer screens were locked when unattended. The ADM provided this investigator with the HIPAA Privacy Notice Acknowledgment and Standards of Compliance with Related Policies and Agreements. Record review of the facility's HIPAA Privacy Notice Acknowledgment, undated reflected, By signing below, I acknowledge receipt of the facilities NOTICE OF PRIVACY PRACTICES FOR PERSONAL HEALTH INFORMATION. I understand the content and intent of the Notice and agree to abide by its instructions. I further understand that as an employee or volunteer of this facility that I am subject to the Articles of the Employee Handbook I have received. Specifically, I understand the progressive discipline program. By signing this document acknowledging the Privacy Notice, I am expressly acknowledging the modification, by addition of this document, to the Employee Handbook. I also understand that ANY VIOLATION of the Privacy Notice which results in Protected Information being released in violation of this policy will result in my termination and reporting of the Employee Misconduct Registry as a violation of Resident Rights. Please read this carefully as violation of this policy modifies the progressive discipline program listed in the Employee Handbook .

Based on observations, record reviews and interviews, the facility failed to provide each resident at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for three (Resident #1, Resident #3, and Resident #5) of 5 reviewed for timely meals. The facility failed to provide breakfast, lunch, and dinner according to the designated meal service schedules on multiple occasions. This deficient practice could place residents at risk of low blood sugar levels, increased stress levels, slowed metabolism rates, weakened immune systems, malnutrition, weakened hearts, and organ failures. Findings include: Interview on 06/24/2025 at 10:47AM with OMB revealed that lunch had been served late to the residents as late as 2PM while OMB was at the facility. OMB stated late meals had been served to residents more than once in the month of May and June. Observation on 06/24/2025 at 12:11PM revealed that lunch trays had been served in the dining room. Record review of Resident #1's admission record revealed Resident #1 is a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis of Hereditary and Idiopathic Neuropathy (inherited conditions that affect the peripheral nervous system, leading to progressive nerve damage) and Essential Hypertension (most common type of high blood pressure). Record Review of Resident #1 MDS record dated 05/14/2025 revealed that Resident #1 has a BIMs of 15 which indicates no cognitive impairment. Interview on 06/24/2025 at 1:30PM with Resident #1 revealed that mealtimes are often served late. Resident #1 stated that the meals are served later than designated mealtimes approximately 3 times per week. Resident #1 described late as 9:00AM for breakfast when scheduled breakfast is from 7:30-8:30AM, and 2:00 PM for lunch when scheduled lunch is from 11:30AM-12:30PM. Resident #1 stated being served meals late makes her feel hungry and unpleased. Resident #1 believed late meals are a result of disorganization in the kitchen with staff. Record review of Resident #3's admission record revealed Resident #3 is a 89- year-old female who admitted to the facility on [DATE] with diagnosis of Hypertensive Chronic Kidney Disease with Stage 1 through Stag 4 Chronic Kidney Disease (high blood pressure and kidney damage occur together, progressing through stages 1 to 4) and Mixed Hyperlipidemia (genetic condition where a person has elevated levels of both cholesterol and triglycerides in their blood). Record Review of Resident #3 MDS record dated 03/27/2025 revealed that Resident #3 has a BIMs of 15 which indicates no cognitive impairment. Interview on 06/24/2025 at 1:40PM with Resident #3 revealed that they are used to meals coming late due to it happening so often. Resident #3 stated that lunch has often been served at 2:00PM when it is scheduled for 11:30AM-12:00PM. Resident #3 stated that dinner had once been served at 8:00PM due to lunch being served late. Resident #3 stated this made them feel like the staff/facility had forgotten about them. Resident #3 stated this made them feel disgusting. Resident #3 believed late meals are a result of disorganization. Interview on 06/24/2025 at 2:00PM with Resident #5 revealed that mealtimes are disorganized. Resident #5 stated that meals are often late. Resident #5 could not explain why meals could be late . Interview on 06/24/2025 at 2:25PM with DM revealed that DM had been employed at the facility for 2 months. The DM stated mealtimes are 7:00AM, 11:10AM, and 4:45PM. The DM stated there have been times where meals are late. The DM stated residents were served lunch at 2:00PM approximately 4 weeks prior, due to the head cook walked out of the kitchen and did not return. The DM stated this could negatively impact a resident's capability to receive their medications. DM stated snacks are offered 3x a day and is delivered to the units. Interview on 06/24/2025 at 2:45PM with LVN A revealed that LVN A had been employed at the facility for 14 years. LVN A stated mealtimes are 5:00PM-6:00PM for dinner. LVN A stated that they had entered the evening shift to work at 1:30PM, and hall carts had still been on the unit. LVN A stated this was because lunch was served late, resulting in dinner being served after 6:00PM. LVN A stated something like this had happened approximately 3 times. LVN A stated this could negatively impact a resident who is diabetic and cause residents to be hungry. Interview on 06/24/2025 at 03:36PM with DON revealed that DON had been employed at the facility for almost 1 year. The DON stated that mealtimes are to be served at 8:00AM, 12:00PM and 5:00PM. The DON stated the expectation is timeliness for meal preparation and times. The DON stated this could negatively impact a resident by causing low blood sugar for diabetics, potential for missing medications that are required to be taken with meals and could cause GI issues . DON reported they provide snacks to residents. Interview on 06/24/2025 at 4:08PM with ADM revealed that ADM had been employed at the facility for almost 2 years. The ADM stated that the expectation as far as mealtimes, should be served on time. The ADM stated if meals are going to be late, they offer snacks to residents. The ADM stated this could negatively impact residents by being hungry and potentially weight loss. The ADM stated changes that have been made to avoid late mealtimes have been to hire new kitchen staff. The ADM stated the day that meals were served extremely late were due to the head chef quitting and walking out without notice. The ADM stated the facility did not know the staff member had left, resulting in late meals. ADM stated she had helped in the kitchen that day. Record review of document titles Resident Meal Service and Snacks provided by the facility revealed the following: 1. Resident meals will be served at regular hours with a maximum of fourteen hours between the evening meal and breakfast the following day.

Based on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 5 residents (Resident #2) observed for resident rights. The facility failed to ensure Resident #2 was treated with respect and dignity when providing personal care for this resident. This failure could place residents at risk of lowered self-esteem, depression, and frustration. Findings included: Record Review of Resident #2's admission record revealed Resident #2 is an [AGE] year-old woman. Resident #2 was admitted to the facility on [DATE] with diagnosis of Alzheimer's Disease (a progressive brain disorder that slowly destroys memory and thinking skills, eventually impacting the ability to conduct even the simplest tasks), Depression and Anxiety Disorder. Record Review of Resident #2's care plan revealed. 1. Focus Area dated 07/10/2023, indicating Resident #2 has a history of resisting/refusing care and can become physically and verbally aggressive during care. 2. Focus Area dated 07/23/2023, indicating Resident #2 has difficulty communicating needs due to history of Alzheimer's diagnosis. 3. Focus Area dated 07/29/2023, indicating Resident #2 has anxiety. Observation on 06/24/2025 at 1:15PM of Resident #2 sitting in her wheelchair at the front of the unit. Resident #2 appeared calm and relaxed during this observation. Resident #2 began crying when this HHSC Investigator approached her. Resident #2 was unable to voice what was wrong with her. Record Review of Resident #2 MDS record dated 03/31/2025 revealed that Resident #2 has a BIMS of 00, which indicate severe cognitive impairment. Record Review of facility's Investigation Report #regarding Resident #2 revealed the following: 1. Staff member provided a written summary stating they had been frustrated with Resident #2 while providing care due to the unusually demanding workload, resulting in frustration, and stated unprofessional works and statements to Resident #2. 2. Resident #2's informed the facility that the staff member told Resident #2 don't touch me, there is no one here to help you. 3. In-services on Abuse, Neglect, Resident Rights and Electronic Monitoring was provided to the facility staff. Record Review of Nursing Note dated 06/08/2025 by LVN revealed Resident #2's family member called and stated the night aide was rough with Resident #two. Skin assessment was completed with no visuals of marks or bruises. Interview on 06/24/2025 at 3:26PM with DON revealed that the ADM provides training on Resident Rights to staff members upon hire and anytime there is suspected abuse or neglect. The DON stated Resident Rights training includes the differences between abuse and neglect, steps to take during a suspected abuse claim as well as to whom to report. The DON stated the expectation on how residents are treated is with dignity and respect. The DON stated the steps the facility takes during an abuse investigation is to suspend the suspected employee, complete interviews, and review footage if available. The DON stated during the investigation with the suspected employee, they confirmed that they did not speak to Resident #2 with respect, and dignity while providing personal care. The DON stated the suspected employee was terminated upon completion of the investigation. The DON stated the result of the investigation was founded. Interview on 06/24/2025 at 4:08PM with ADM revealed that ADM provides Resident Rights trainings to staff upon hire and quarterly. The ADM stated this training includes screening of abuse, different types of abuse, and to whom to report suspected abuse or neglect. The ADM stated the expectation on how residents are treated is to treat them fairly and ensure they are free from abuse or neglect. The ADM stated the typical result of abuse/neglect investigation is to terminate employment with the employee. The ADM stated the result of Resident #2's investigation was that the staff member was witnessed on camera mistreating Resident #1 therefore resulting in termination of employment. Record Review of facility undated policy titled Resident Rights revealed: 1. The purpose of this policy is to ensure that resident rights are respected and protected, and to inform residents of their rights and provide an environment in which they can be exercised. 2. The resident has the right to: a. A dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. b. Exercise their rights as a resident of the facility and as c. Be treated with respect and dignity. d. To be free from abuse, neglect, and misappropriation of resident's property. Record Review of Resident #2 MDS record dated 03/31/2025 revealed that Resident #2 has a BIMS of 00, which indicate severe cognitive impairment. Record Review of facility's Investigation Report #regarding Resident #2 revealed the following: 1. Staff member provided a written summary stating they had been frustrated with Resident #2 while providing care due to the unusually demanding workload, resulting in frustration and stated unprofessional works and statements to Resident #2. 2. Resident #2's daughter informed the facility that the staff member told Resident #2 don't touch me, there is no one here to help you. 3. In-services on Abuse, Neglect, Resident Rights and Electronic Monitoring was provided to the facility staff. Record Review of Nursing Note dated 06/08/2025 by LVN revealed Resident #2's family member called and stated the night aide was rough with Resident #2her mother. Skin assessment was completed with no visuals of marks or bruises. Interview on 06/24/2025 at 3:26PM with DON revealed that the ADM provides training on Resident Rights to staff members upon hire and anytime there is suspected abuse or neglect. The DON stated Resident Rights training includes the differences between abuse and neglect, steps to take during a suspected abuse claim as well as who to report to. The DON stated the expectation on how residents are treated is with dignity and respect. The DON stated the steps the facility takes during an abuse investigation is to suspend the suspected employee, complete interviews, and review footage if available. The DON stated during the investigation with the suspected employee, they confirmed that they did not speak to Resident #2 with respect, and dignity while providing personal care. The DON stated the suspected employee was terminated upon completion of the investigation. The DON stated the result of the investigation was founded. Interview on 06/24/2025 at 4:08PM with ADM revealed that ADM provides Resident Rights trainings to staff upon hire and quarterly. The ADM stated this training includes screening of abuse, different types of abuse, and who to report suspected abuse or neglect to. The ADM stated the expectation on how residents are treated is to treat them fairly and ensure they are free from abuse or neglect. The ADM stated the typical result of abuse/neglect investigation is to terminate employment with the employee. The ADM stated the result of Resident #2's investigation was that the staff member was witnessed on camera mistreating Resident #1 therefore resulting in termination of employment. Record Review of facility undated policy titled Resident Rights revealed: 1. The purpose of this policy is to ensure that resident rights are respected and protected, and to inform residents of their rights and provide an environment in which they can be exercised. 2. The resident has the right to: a. A dignified existence, self-determination, and communication with and access to persons and services inside and outside eth the facility. b. Exercise their rights as a resident of the facility and as c. Be treated with respect and dignity. d. To be free from abuse, neglect and misappropriation of resident's property.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for three (Resident #1 and Resident #3) of five residents reviewed for pharmaceutical services. On 5/2/2025, two (2) medication cards - one from Resident #1 and one from Resident #3 - were observed with white tape on the reverse side of the card. The tape on the reverse side of the medication card indicated the potential for tampering. Administrative and nursing staff failed to be aware of patch use, failed to verify that the patches used were from the pharmacy, and failed to be trained on the use of patches to include when patches were acceptable for use in the facility policies and procedures. On 4/30/2025 during shift overlap, LVN-A and LVN-B discovered a narcotic count sheet reconciliation error. LVN-A noted on the count sheet the medication had been wasted, when it had not been wasted. The deficient practice could place residents at risk of medication overdoses or medication errors leading to adverse reactions, loss of consciousness, loss of breathing function and death. Findings included: Resident #1 Review of Resident #1's face sheet dated 5/2/2205 reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Dementia (memory disorder), seizures, low back pain, delusional disorders, osteoarthritis of bilateral knees (chronic joint disease resulting in breakdown of cartilage). Review of Resident #1's significant change MDS dated [DATE] indicated she had a BIMS score of 8 suggesting moderate cognitive impairment. Review of Resident #1's current care plan revealed she was at risk for pain related to her history of back injuries/surgeries, history of a left knee replacement, and arthritis of the knees with interventions that included provide medications as ordered. Review of Resident #1's progress notes dated 4/30/2025 revealed no note about the medication error and no note that resident had been assessed. Review of Resident #1's progress notes for 5/1/2025 at 6:30 am reflected VS 97.7,78,18,118/68, 96% RA 0 -10 PAIN alert and oriented x 2 per normal base line. confused per normal baseline. resident is able to voice needs and has no s/s of distress noted. Residents awake and alert sitting in bed with HOB elevated. PO fluids encouraged and provided. Review of Resident #1's orders dated 10/16/2024 reflected a physician order as follows: Endocet Oral Tablet 5-325MG (Oxycodone w/Acetaminophen), Give 1 tablet by mouth every 4 hours for chronic pain. Further review of Resident #1's orders revealed an order as follows: HYDROcodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth one time only for pain until 04/30/2025. Review of Resident #1's pain assessment on the MAR on 4/30/2025 reflected a pain level of 4. Review of Resident #1's narcotic count sheet for Endocet Oral Tablet 5-325MG (Oxycodone w/Acetaminophen) revealed an entry on 4/30/2025 at 7:40 pm with a count of 36 tablets that had a line drawn threw it and initialed by LVN-A and another entry on 4/30/2025 at 9:40 pm stating correct count 37 signed by LVN-A. Resident #2 Review of Resident # 2's face sheet dated 5/3/2025, reflected she was a [AGE] year-old female admitted on [DATE] with diagnoses that include: Dementia (memory disorder), history of brain cancer, benign neoplasm of ascending color (tumor in the colon), major depressive disorder, bipolar disorder, anxiety disorder, contractures of bilateral lower legs, left hip pain, and chronic pain (other). Review of Resident #2's quarterly MDS dated [DATE] indicated she had a BIMS score of 12 suggesting mild cognitive impairment. Resident #2's face sheet indicated a FM was her RP. Review of Resident #2's current care plan revealed she has a diagnosis of chronic pain with interventions that included provide PRN medications as indicated. Review of Resident #2's orders reflected a physician order dated 8/11/2024 as follows: Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth four times a day for Pain. Review of Resident 2's narcotic count sheet for Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) indicated it was administered on 4/30/2025 as follows: one table given at 4:00 pm, one tablet given at 7:36 pm and one tablet wasted at 9:30 pm. The line with the wasted comment was signed by LVN-A and DON. Resident #3 Review of face sheet dated 5/6/2025 reflected Resident #3 was an [AGE] year-old female admitted on [DATE] with diagnoses that include: Alzheimer's Disease (a progressive disease that destroys memory), Dementia (memory disorder), chronic pain, hypertension (high blood pressure) heart disease and cognitive communication deficit. Review of Resident #3's significant change MDS dated [DATE] indicated she had a BIMS score of 10 suggesting moderate cognitive impairment. Review of Resident #3's orders reflected an order dated 5/11/2024 as follows: Ultram Oral Tablet 50 MG (Tramadol HCl), Take 1 tablet by mouth every 8 hours as needed. During an observation on 5/2/2025 at 12:10 pm a blister card of Oxycodone medication for Resident #1 was noted to have two pieces of white tape on the back of the card. Further review of the blister card and pharmacy label revealed no labeling to indicate the blister pack had been modified by the pharmacy. The blister card observed did not have any deficits on the front side of the card where the tape had been observed on the reverse side. During an observation on 5/2/2025 at 1:11 pm a blister card of Tramadol medication for Resident #3 was noted to have two pieces of white tape on the back of the card. Further review of the blister card and pharmacy label revealed no labeling to indicate the blister pack had been modified by the pharmacy. The blister card observed did not have any deficits on the front side of the card where the tape had been observed on the reverse side. During an interview on 5/2/2025 at 12:32 pm, LVN-C stated she had not noticed the tape on the back of the cards when she counted the cart this morning. She stated if she was checking in medications from the pharmacy and saw that tape on the back, she would not accept it and would tell the DON in case there was tampering. She stated she had never received any training that covered getting medications cards from the pharmacy with tape on the back was allowed. During an interview on 5/2/2025 at 12:35 pm, MA-D stated she had never seen any medication cards with tape on the back and that she was very anal about checking the back of the cards. She stated if she did see a card with tape on the back, she would tell the DON if she saw they were tampered with. She stated they have plain white labels for use on the plastic med card dividers and the tape looked very similar so she would suspect tampering. She stated she had never received any training about accepting medication cards from the pharmacy with tape on the back. During an interview on 5/2/2025 at 1:01 pm, LVN-E stated she did sign for medications from the pharmacy and they were not supposed to accept the cards if that were tampered with. She stated if she saw the tape on the back, she would not accept the medications and she would tell the DON. She also stated if she saw card with tape on the back while she was counting with another nurse, she would not accept the keys to the cart and would tell the DON. She stated she had never had training about medication cards with tape on the back and what to do. During an interview on 5/2/2025 at 1:10 pm, MA-F stated she had not noticed the tape on the back of the card this morning and she had never seen it before. She stated if she had, she would report to the DON and would not accept the keys to the cart. She stated she had never had training about medication cards with tape on the back and what to do. During an interview on 5/2/2025 at 1:36 pm, the ADM stated she had a conversation with the pharmacy rep and they informed her they will put tape consistent with what was observed on the back of the medication cards if there is a pharmacy error made. She stated she was unsure if the facility policy allowed them to accept cards like that from the pharmacy. She stated probably not but she would pull the policy. During an interview on 5/2/2025 at 4:10 pm, the DON stated they had received a letter from the pharmacy today regarding tape on the back of medication cards but was not aware of a policy in place prior to today that allowed pharmacy to send cards with tape on the back and for staff to accept med cards with tape on the back. She stated to her knowledge there had never been in services with the staff on acceptable use of patches for medication cards from the pharmacy. She stated the tape on the back could appear as if the cards had been tampered with. During an interview on 5/2/2025 at 5:06 pm, the Pharmacy Director stated I don't know that anything exists in writing for the nursing facility to use patches. He stated there was nothing between the parties and they had come up with new ways of doing corrections so there were no problems in the future. He stated going forward they will have stickers that can be used for corrections that can be printed. Record review of pharmacy letter received 5/2/2025 from the Pharmacy Director stated Any blister cards containing medications with blister errors (i.e. incorrect number of pills in a bubble, etc.) may be corrected by the pharmacy staff so long as the correct patch is placed over the appropriate bubble(s). All instances will be verified by a [pharmacy name] pharmacist to assure accuracy prior to being send out. Appropriate patches to be used can be ordered from [supplier] and include, but are not limited to plain white, white with yellow and foil. Note that foil patches many only be sued for blister cards that can be heat sealed while other patches may be used for blister cards that cannot be heat sealed. Record review of facility policies revealed there was no policy that addressed the use of tape patches by the pharmacy to correct pharmacy errors or that medication card with patches were allowed to be accepted by nursing staff for resident use. Review of facility audit completed 5/2/2025 reflected an additional 13 blister cards were identified as having tape on the back of the card and had been re-ordered from the pharmacy if an additional blister card was not already available. Review of the undated facility policy on Receiving Medications from the Pharmacy states: It is the policy of this facility to assure all medications are correctly delivered and errors rectified as soon as possible to assure proper handling of all medications and to assure a system is adhered to at all times. #8 - Any discrepancies found in the acceptance of the medications should be IMMEDIATELY notified to the technician making the delivery. Review of the undated facility policy on Shift Change and Medication Cart Responsibility states: It is the policy of this facility to ensure the transition from one shift to the next is appropriate, ensure proper handling of all medications and minimize risk. #7 - Any discrepancies found in the acceptance of the medications should be IMMEDIATELY notified to the charge nurse and Director of Nurses and Administrator. During an interview on 5/3/2025 at 12:05 pm, LVN-A stated she had worked on 4/30/2025 and discovered a narcotic count discrepancy at shift change when she was counting narcotics with the oncoming nurse for evening shift, LVN B. She realized the count was off and called the DON. The DON told LVN-A to mark on Resident #2's narcotic count sheet that one tablet was wasted to make the count correct. She stated she had called the NP and received an order for a one-time dose of hydrocodone. She stated on her drive home, she realized she should not have falsified the information on the narcotic count sheet and marked wasted on Resident #2's sheet because it had not been wasted. She stated she had a lapse in judgement at the moment because she has been a nurse [AGE] years and this had never happened before, and it scared her. She stated she had received training on narcotic count sheets, and they were supposed to notify the DON when there was a discrepancy. She stated falsifying narcotic count sheets could lead to med errors and could cause potential harm to residents like a bad reaction, an overdose, they could end up in the hospital, or over sedated that could lead to respiratory depression. During an interview on 5/3/2025 at 2:08 pm, LVN-B stated she had come in to work night shift on 4/30/2025 and was counting narcotics with LVN-A the nurse going off shift. She stated they discovered the count was off for Resident #2's Hydrocodone. She stated LVN-A noted in writing by the count discrepancy wasted and initialed it but LVN-B did not initial it. During an interview on 5/3/2025 at 1:06 pm, the DON stated she was aware of the narcotic count discrepancy that occurred on 4/30/2025 by LVN-A. The DON stated she told LVN-A to mark the narcotic count sheet that the medication had been wasted and she knew it had not been wasted but had actually been given to Resident #1. She stated LVN-A and herself both signed the correction. She stated she realized it was wrong and I really don't have an explanation for why I told her to do that. DON was asked if the direction to mark that the medication has been wasted on the narcotic count sheet she had given LVN-B was the appropriate decision and she stated, absolutely not - it was not the right decision. During an interview on 5/3/2025 at 1:54 pm, the NP stated a facility nurse had called her on 4/30/2025 about a one-time order for Resident #2 to have hydrocodone. She stated she was not aware of any documentation falsification on the narcotic count sheet and said, I would not let anyone falsify documents She stated she did not normally have problems with this facility and the staff were fairly consistent and they don't have a lot of agency staff. She stated her concerns with false narcotic count sheet documentation would be patient safety as it could lead to a bad patient outcome. During an interview on 5/3/2025 at 1:25 pm, the ADM stated she was not aware of the falsification of the narcotic count sheet documentation. She stated her expectation was that staff would fill out the narc sheet correctly to show it was given or not given. She stated LVN-A should not have marked the narcotic count sheet as wasted if the medication had not been wasted.

Based on interview and record review, the facility failed to maintain accurate and timely medication records to minimize the potential for medication related adverse consequences or events for three (Resident #1, Resident #2 and Resident #3) of five residents reviewed for med errors. A medication error occurred on 11/28/2024 where residents # 1, #2 and #3 all received a double dose of their scheduled narcotic pain medication. Residents #1, #2 and #3 received their first dose at 7pm and the second dose at 8:30 pm. The nursing facility failed to: o follow their policy for medication administration to avoid errors. o document and monitor Residents #1, #2, and #3 after the medication errors to ensure no adverse effects o notify the Responsible Parties of Residents #1, #2, and #3 after medication errors An Immediate Jeopardy (IJ) was identified on 04/4/2025 at 5:50 pm and the facility was notified and given an IJ template. A revised template was provided on 4/7/2025 at 2:05 pm. While the IJ was removed on 04/8/2025 at 3:55 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. The deficient practice could place residents at risk of medication overdoses leading to loss of consciousness, loss of breathing function and death. Findings include: Resident #1 Review of Resident # 1's face sheet dated 4/4/2025 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: Dementia (memory disorder), history of brain cancer, benign neoplasm of ascending colon (tumor in the colon), major depressive disorder, bipolar disorder, anxiety disorder, contractures of bilateral(both) lower legs, left hip pain, and chronic pain (other). Resident #1's face sheet indicated a FM was her RP. Resident #1's quarterly MDS dated [DATE] indicated she had a BIMS of 12 suggesting mild cognitive impairment. Review of Resident #1's orders on 4/4/2025 reflected a physician's order dated 8/11/2024 as follows: Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth four times a day for pain. Review of Resident #1's narcotic count sheet for Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen) indicated it was administered on 11/28/2024 at 7 am, 11 am, 3pm, 7pm and 8:30 pm Resident #2 Review of Resident #2's face sheet dated 4/4/2025 reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Dementia (memory disorder), seizures, low back pain, delusional disorders, osteoarthritis of bilateral knees (chronic joint disease resulting in breakdown of cartilage). Resident #2's face sheet indicated a FM was her RP. Resident #2's quarterly MDS dated [DATE] indicated she had a BIMS of 11 suggesting mild cognitive impairment. Review of Resident #2's orders on 4/4/2025 reflected a physician's order dated 10/16/2024 as follows: Percocet Oral Tablet 5-325MG (Oxycodone w/Acetaminophen), Give 1 tablet by mouth four times a day for pain. Review of Resident #2's narcotic count sheet for Percocet Oral Tablet 5-325MG (Oxycodone w/Acetaminophen) indicated it was administered on 11/28/2024 at 7 am, 11 am, 3pm, 7pm and 8:30 pm. Resident #3 Review of Resident #3's face sheet dated 4/4/2025 reflected an [AGE] year-old female admitted on [DATE] with diagnoses that included: Dementia (memory disorder), chronic kidney disease, chronic pain, hypertension (high blood pressure) and cognitive communication deficit. Resident #3's face sheet indicated a FM was her RP. Resident #3's quarterly MDS dated [DATE] indicated she had a BIMS of 12 suggesting mild cognitive impairment. Review of Resident #3's orders on 4/4/2025 reflected a physician order dated 8/11/24 as follows: HYDROcodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen), Give 1 tablet by mouth four times a day for pain. Review of Resident #3's narcotic count sheet for HYDROcodone-Acetaminophen Oral Tablet 10-325 MG indicated it was administered on 11/28/2024 at 5 am, 11 am, 3pm, 7pm and 8:30 pm. Record Review of a facility medication error form dated 11/29/2024 revealed a med error had occurred on 11/28/2024 that included resident #1, resident #2, and resident #3 and involving MA-A and LVN B and that the Physicians' statement or orders: continue to monitor, no changes and action taken was education on med rights, write up. During an interview on 4/4/2025 at 12:45 pm, the DON stated on 11/28/24 there was a medication error involving resident #1, resident #2 and resident #3 where they received a double dose of their narcotic pain medication. She stated that occurred because MA -A had not signed off the medications in the EMR and LVN B saw they were due on the EMR and gave them again. She did one on one in-services with the staff involved in the med error but not the rest of the nursing staff. She stated she probably should have included all nursing staff on the in-service training for medication errors. She stated the facility did fill out a med error form, but there were no progress notes indicating the RPs had been notified or that the residents had been monitored for adverse effects after the med error. During an interview on 4/4/2025 at 2:20 pm the Administrator stated there was no follow up monitoring done for resident' #1, resident #2, and resident #3, the med errors were not documented in the EMR progress notes, the RPs were not notified and the med errors were not noted on the 24-hour report to pass information to the next shifts. During an interview on 4/4/2025 at 3:16 pm the facility Medical Director stated he had concerns because there was no follow up monitoring done on the residents with the narcotic med errors. He stated he would have expected staff to monitor for altered mental status, clinical sedation, and respiratory depression. He stated at a minimum vital signs should have been checked to include monitoring oxygen saturation and respirations as an overdose of narcotic could cause a resident to stop breathing. During an interview on 4/5/2025, MA-A stated she had given scheduled narcotic pain meds on 11/28/2024 to resident #1, resident #2, and resident #3 and had signed them off on the narcotic count sheet. She stated she did not sign them off in the EMR, because she was just helping the nurse out before she left at the end of her shift and did not have time. MA-A stated it was her responsibility to sign off the medications in the EMR because she was the one that had actually given the medications to the residents. She stated she had been trained on medication administration and the person that gave the medication is the one responsible for signing off the EMR and the narcotic count sheets. She stated she had written the medication administration on a piece of paper and had given it to the LVN B before she left. She stated she found out later LVN B had forgotten about her note and had also given resident #1, resident #2, and resident #3 the same medications and as a result the residents got a double dose of narcotics. She stated a double dose of narcotics could cause residents to become sleepy, their blood pressure could drop, they could fall, stop breathing and lose consciousness, or even die. During an interview on 4/7/2025 at 1:19 pm, LVN B stated she worked the night shift on 11/28/2024 and gave resident #1, resident #2, and resident #3 their evening dose of narcotic medication because it was showing due in the EMR. She stated she also signed the medications out on the narcotic count sheet. She stated she had forgotten that MA-A told her the medications had already been given but not signed off in the EMR and had not noticed the previous administration on the narcotic count sheet. She stated she had been trained on medication administration and the person that gave the medication is the one responsible for signing off the EMR and the narcotic count sheets. She stated residents that got a double dose of narcotic medications could stop breathing, they could have a cardiac arrest, they could die depending on what else they have going on [a resident] could die pretty fast. Review of the undated facility policy on Medication errors and Drug Reactions revealed: 1) All medication errors and drug reactions must be promptly reported to the Director of Nursing Services, attending physician and the pharmacist. 2. A detailed account of the incident must be recorded and should include documentation of: a. Time and date of the incident b. Name, strength, and dosage of medication administered c. Resident's reaction to the medication d. Condition of the resident e. Any treatment administered; and f. Date and time the physician was notified, and instructions given. 3. Monitor closely any resident who has received incorrect medication or is having a drug reaction. Immediately report to the Director of Nursing Services and attending physician any change in the resident's condition. The ADM was notified on 04/4/2025 at 5:50 pm that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 04/07/2025 at 4:54 pm: On 4/4/25 an abbreviated survey was initiated at [Facility name]. On 04/04/25, the surveyor provided an Immediate Jeopardy Template notification. that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. Complaint Survey regarding Medication Errors. Failure is as follows: Residents #1, 2, and 3 o on 11/28/24 a medication error occurred and there was not documentation by facility staff of a medication error in the progress notes. Responsible parties for Residents # 1, 2, and 3 were contacted and made aware of the med errors on 4/4/2025. The Medical Director was made aware of past med error. o All residents have the potential to be affected by deficient practices of medication administration. o Missed Medication Report was pulled for the past 6 months to ensure no other residents were administered narcotics twice. o Review of all Narcotic sheets for the past 6 months was reviewed to ensure that there were no double doses of narcotics based on the sign out sheets and comparing to nurse notes and EMARs. o To prevent from occurring, the ADONs are reviewing count sheets daily to ensure no double doses have been administered. Training Topic: Administering Medications, Medication Errors, and Notification to Physicians, Family, and others. The Chief Operating Officer and Director of Clinical Operations educated the DON and Administrator with a posttest to show understanding The Director of Nurses Provided training to the nurses and medication aides on duty Training started on 4/4/25 at 2:50pm for nurses and med aides on duty with a post test to show understanding Training was concluded at 6:15 for all staff on-site Training will be concluded for those not present, they will be educated and required to pass a post test before they take their next assignment New Hire's will receive training from the DON or designee during new hire orientation The facility does not utilize agency staff Notification Chief Operating Officer was notified at 2:31 on 4/4/25 Director of Clinical Operations was notified at 2:31 on 4/4/25 Medical Director was notified by the administrator on 4/4/25 at 2:43 pm. Immediate Action The person who made the error(s) received an in-service and a disciplinary action. Residents with med errors on 11/28/24 were assessed on 4/4/25 and 4/5/25 and all notifications were made and documented on 4/4/25 and 4/5/25 by the ADON and CHARGE NURSE AD-HOC QA meeting Ad-Hoc QAPI meeting was held on 4/4/25 at 3:30PM -attendance was Medical Director via email and phone contact - COO via email and phone contact - ADON in person - DON in person - Administrator in person preparing the meeting Recurrence Prevention Missed Medications report will be ran during daily stand-up meeting to review medications that were missed. Any medication errors, the staff member will be contacted and an in-service and disciplinary action (where necessary) will be initiated. All nursing staff who administer medications will be given reminder. education over the policy and procedures by the DON or Nurse Managers that will be initiated immediately following the med error until all staff who administer medications has received re-education. The ADONs are reviewing count sheets to ensure no one has been doable dosed or that a dose has been missed and not documented in the EMAR. This is part of their morning routines. Monitoring for effectiveness Missed Medication Report will be ran prior to daily stand-up meeting by the DON This will be an ongoing process. The Surveyor monitored the POR on 4/8/2025 as followed: During interviews on 4/8/2025 from 12:22 pm - 3:45 pm with two LVNs, two MAs, DON and AD all stated they had been in-serviced on medication errors, policies on administering medications, appropriate notifications, post med error monitoring and completing a post test on all topics. Observations of two different medication administrations with a nurse and a MA on 4/8/2025 between 12:22 pm - 12:51 pm revealed no medication errors. Review of an Ad Hoc QAPI Agenda, dated 4/4/2025, reflected the Medical Director, Administrator, Chief Operating Officer, ADON, Business Office Manager, Maintenance Director, Housekeeping Director, Director of Nursing, Human Resource Coordinator, Social Worker, and the Admission/Marketing Coordinator were in attendance where they discussed medication errors and failure to document; In-services over administering medications, medication errors, and notifications and reviewed post test for administering medications. Review of an in service dated 4/4/2025 conducted by the Chief Operating Officer reflected the Administrator and Director of Nursing were in services on administering medications, medication errors and drug reactions, notifications to family, and posttest on medication administrations. Review of an in service dated 4/1/2025 conducted by the Director of Clinical Services reflected the DON and both ADONs were in serviced on the following: compliance concern, training and medication errors. Review of an in service dated 4/4 - 4/5/2025 conducted by the Director of Nursing reflected all staff from all shifts were in serviced on the following topics: med error policy, administering medication policy, notification to family, MD & others and the post test. Review of missed medication audit report dated 4/6/25 - 4/8/25 reflected no missed meds and no new med errors. While the IJ was removed on 04/8/2025 at 3:55 pm, the facility remained at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care and treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for one of nine residents (Resident #1) reviewed for resident rights . The facility failed to notify Resident #1's responsible party when his labs result on 2/25/2025 indicated his lithium levels were out of range. This failure could place residents at risk of a lack of a dignified existence, self-determination and quality of life. Findings include: Record review of Resident # 1's face sheet, dated 3/28/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Traumatic Subarachnoid Hemorrhage (Brain bleed), Type 2 Diabetes (a blood sugar regulation disorder), bipolar disorder (mood disorder), Depression, Hypertension (high blood pressure), Kidney Disorder, and history of Stroke (brain attack). The face sheet further reflected that a family member was Resident #1's responsible party. Record review of Resident #1's admission MDS assessment, dated 2/25/2025, reflected a BIMS of 10, which indicated moderate cognitive impairment. Record review of Resident #1's orders reflected a lab order, dated 2/21/2025, for a Lithium level. Record review of Resident #1's lab results, dated 2/25/2025, reflected a lithium level of 1.4 H [high] with a reference range of 0.6 to 1.2 Record review of Resident #1's progress notes, dated 2/26/202, reflected the following: Labs received and reviewed by nursing, copy of labs placed in folder for MD review. During an interview on 3/28/2025 at 3:13 pm, Nurse A stated she was the charge nurse on the unit on 2/25/2025 when Resident #1's lab results had come back. She stated she did not know the results had come back or had been placed in the folder. She said usually one of the ADONs would print out the lab results and bring them directly to the charge nurse and then the charge nurse would call the RP. She stated if they were put right in the folder, she would not be aware the lab results were back, and the RP needed to be called. She stated for Resident #1's lithium level result, if she had known, she would have called the NP or MD first, then called the family or RP. She stated she did not call Resident #1's RP and that's why there was no progress note about this in the EMR. She stated by not calling Resident #1's RP, the RP could lose trust in the nursing staff and not feel comfortable with resident's being at the facility . During an interview on 3/28/2025 at 1:08 PM, the ADON B stated it was the charge nurses on the unit's responsibility to call the RP or family members about out-of-range lab results. She stated she had received the lithium level results for Resident #1 and reviewed them and put them in the practitioner folder at the nurse's station but the charge nurse on the unit should have called Resident #1's RP . She stated it was not unusual to leave lab results in the folder for the practitioner to review, that was the facility's normal practice. She stated she was unaware the other ADON was printing out the results and handing them to the charge nurses on the unit. She stated she had concerns because there was no documentation that the charge nurse had called Resident #1's RP in the EMR. If the RP was not notified, there could be allegations that the facility wasn't taking care of their family member and there would be no progress notes for continuity of care. She stated, we probably should have taken extra time for the lithium levels and called the RP, then added we probably should have done a little bit better . During an interview on 3/28/2025 at 1:50 PM, the DON stated the out-of-range lab results for Resident #1 should have been communicated to the RP by the charge nurse. The DON stated her concerns would have been that Resident #1 had only been in the facility a week and the RP would not have known what was going on with the resident's care and the resident had rights to have this information. She stated one of the ADON's would print out lab results for the nurses and take them to the unit. She stated they recently made a change and split the units between two ADONs and the ADON for the unit Resident #1 was on may not have been aware the results needed to be printed out and taken to the charge nurse . During an interview on 3/28/2025 at 5:00 PM, the AD stated her expectation was the out-of-range lithium results be communicated to the RP by the charge nurse on the unit. She stated the RP had a right not know what was going on with the residents. During an interview on 3/28/2025 at 1:34 PM, the MD stated his expectation was that he would receive a phone call for any lab results that were a critical level, but out of range level results could just go in the folder at the nurse's station for him or the NP to review. He stated Resident #1 was clinically he was doing pretty fine and was not aware of any clinical concerns. When asked if the RP should have been called for the out of range lithium level, the MD stated probably so noting Resident #1 had only been in the facility a week at that point and there should have been notification to the POA or RP - whoever is the decision maker - that he had some abnormal lab values. Record review of the facility's, undated, Policy Resident Rights reflected the following: The resident has the right: - to be informed of, and participate in, his or her treatment, including the right to: Be fully informed in a language they can understand of their total health status. Be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish the care.

Based on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in one of one kitchen reviewed for kitchen and food sanitation. The facility failed to ensure DA A wore a beard restraint while preparing food for residents. These failures could have placed residents at risk for food contamination and foodborne illness. Findings included: Observation on 3/4/2025 at 12:30 PM of the kitchen revealed DA A was near the serving table and was not wearing a beard guard when near the food. DA A had a visible sideburns, mustache, and beard no more than one half inch in length. Observation on 3/4/2025 at 4:20 PM of the kitchen revealed DA A was in the kitchen and moving about the serving, drink and dessert tables with the beard net pulled down underneath their chin. In an interview on 3/4/2025 at 4:25 PM, DA A stated they were supposed to wear hair and beard nets when in the kitchen. They said it was important to wear hair and beard nets to prevent resident illness. In an interview on 3/4/2025 at 4:35 PM, the DM stated all dietary staff were aware of the policy that required them to wear beard nets when in the kitchen. They cited negative outcomes were food contamination and risk of illness for residents. During an interview on 2/24/2024 at 5:27 PM, the DON stated her expectation was anyone who entered the kitchen should have worn the appropriate hair/beard nets to prevent hair from falling into the food. During an interview on 2/24/2025 at 5:45 PM the ADM stated anyone who was in the kitchen should have been wearing the required hair/beard nets to prevent food contamination. Review of the facility's undated policy titled Section 9 - Dietary and Food Service reflected the following: Policy: Hair Nets Procedure: It is MANDATORY that all Dietary Staff wear hairnets while on duty in any food preparation area this facility. Any person with a beard must wear a beard net. Bald persons are excluded from wearing hair nets and clean-shaven persons are excluded from wearing beard nets.

Based on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards. The facility failed to ensure CNA B and CNA C appropriately utilized the mechanical lift on 9/25/24 while transferring Resident #1 to his bed causing him to hit his head on the wall. This failure could place residents at risk of harm, injury, and hospitalization . Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory), cognitive communication deficit disorder (a brain injury that affects a person's ability to communicate effectively), and ADL self-care performance deficit. Review of Resident #1's quarterly MDS assessment, dated 9/24/2024, a BIMS was not conducted due to him rarely/never being understood. Section GG (Functional Abilities and Goals) reflected he required a mechanical lift for transferring. Review of Resident #1's care plan, undated, reflected a focus, undated, of ADL self-care performance in bed mobility and transfers and a goal revised on 07/16/24 for Resident #1 to maintain current level of function in bed, mobility, and transfers with an intervention dated 10/10/23 that reflected Resident #1 required mechanical lift for transfers and provide 2 person for transfer, provide reassurance as needed, observe extremities and devices during transfer and position for comfort, encourage and remind resident to use handles as able during transfers. Observation of video footage provided by Resident #1's RP D, dated 09/25/2024 at 7:44 PM, revealed CNA B and CNA C, who were moving the resident from Geri-chair back to his bed using a mechanical lift. Resident #1's bed was against the wall. CNAs B and C moved the lift quickly and did not line up the sling to his bed or lock the lift. Resident #1's head hit the wall and he immediately grabbed his head with his left hand in pain and shock. During an interview on 03/04/2025 at 2:51 PM, CNA A stated she recalled placing Resident #1 in the Geri-chair, but did not recall any injuries on Resident #1, and if she had, she would have reported it to the charge nurse. She stated, I knew the family have video cameras in the resident's room, but I was never shown the video. She said she was trained on abuse and neglect and mechanical lifts. During an interview on 03/04/2025 at 3:05 PM, Resident #1's RP D revealed the same details viewed in the video. She stated, The staff act like they simply do not care about the residents, and some should not have jobs working directly with human beings. A telephone interview was attempted on 3/4/2025 at 4:10 PM with CNA C. A returned call was not received prior to exit. During an interview on 3/4/2025 at 5:20 PM, CNA B stated she did not recall the incident with Resident #1. She recited the necessary steps to safely transfer a resident in and out of bed. She said the mechanical lift should have been parallel with the bed. She said effective communication with the other CNA's was what ensured a safe transfer; making sure all staff were coordinated. She provided examples of abuse and neglect and to whom suspected abuse should be reported. She stated she was unaware of facility staff who were rough or disrespectful with residents. During an interview on 3/4/2025 at 5:45 PM the ADM stated CNA B immediately told a nurse about Resident #1 hitting his head during the transfer on 09/25/24. She stated CNA C retired and CNA B was counseled, retrained on mechanical lift procedures, and remained employed by the facility. Review of the CNA B's personnel file, on 03/04/24, reflected she was re-trained on proper mechanical lift techniques and received a written warning on 10/02/24. A performance evaluation dated 10/31/2024 reflected CNA B had consistently performed above acceptable levels of performance. Comments on the performance evaluation stated, Employee works well with others and provides excellent care to residents. She is very interactive with the residents, on top of her CNA duties. Employee is ambitious and has a lot of drive to further her nursing career. Review of the facility's undated Resident Abuse and Neglect Policy, reflected the following: . D. Neglect Allegation - Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness .

Based on observation, interview, and record review, the facility failed treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #1) of six residents reviewed for resident rights. The facility failed to ensure CNA C treated Resident #1 with dignity while in his room prior to providing care on 09/25/24 as she was observed talking about non-sensical information. This failure could place residents at risk of intimidation, psychosocial harm, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease (a brain disorder that slowly destroys memory), cognitive communication deficit disorder (a brain injury that affects a person's ability to communicate effectively), and ADL self-care performance deficit. Review of Resident #1's undated care plan reflected a focus revised on 11/20/19 of impaired cognition/thought process as evidenced by long/short memory deficits and needs supervision assistance with decisions and a goal revised on 07/16/24 of Resident #1 will be able to communicate basic needs on a daily basis with interventions revised on 11/20/19 of face the resident when speaking and make eye contact and introduce self to resident and explain care/procedure to be performed prior to beginning. Review of Resident #1's quarterly MDS assessment, dated 9/24/2024, a BIMS was not conducted due to him rarely/never being understood. Section GG (Functional Abilities and Goals) reflected he was dependent for ADLs. Review of Resident #1's quarterly care plan, dated 7/16/2024, reflected he had an ADL Self Care Performance Deficit and required extensive, total assistance with all ADL areas. Observation of video footage provided by Resident #1's RP D, dated 9/25/2024 at 7:48 PM, revealed CNA C in Resident #1's room, grabbing a brief from a cabinet and other various items while Resident #1 was in bed. CNA C was heard saying (directed to no one in particular), You aren't going to be doing anything to me. Trust me, I ain't scared. The way I found this one, I'll find another. Doesn't scare me one little bit. I can guarantee you that. During an interview on 03/04/2025 at 3:05 PM, Resident #1's RP D revealed the same details viewed in the video. She stated, The staff act like they simply do not care about the residents, and some should not have jobs working directly with human beings. A telephone interview was attempted on 3/4/2025 at 4:10 PM with CNA C. A returned call was not received prior to exit. During an interview on 03/04/2025 at 5:45 PM, the ADM stated she was shown the video of CNA C in Resident #1's room by RP D. She stated it was inappropriate for her to be talking about other things while in a resident's room. She stated staff should be focused solely on the resident and making them feel comfortable. Review of the facility's undated Resident Rights Policy reflected the following: The resident has the right: - To a dignified existence, self-determination . - To be treated with respect and dignity.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning juice machine dispenser nozzles, cleaning sides of juice machine, dumping juice machine overflow tray, cleaning the deep fat fryer, clean stainless-steel shelving where clean sheet pans are stored, storing, and stacking wet dishes on top of each other, ensure dish machine sanitizer levels are within the required range, utilization of a ice scoop with a handle, having hair restraints readily available without having to walk completely thru kitchen before obtaining a hair restraint, ensuring staff utilize hair restraints while in kitchen) for facility annual survey 9/30/24-10/2/24. 2. The facility failed to ensure food temperature logs were being completed. 3. The facility failed to ensure all items were covered and stored properly for facility annual survey 9/30/24-10/2/24. 4. The facility failed to label and date all food items in kitchen for facility annual survey 9/30/24-10/2/24. 5. The facility failed to label and date food items in nourishment room refrigerators for facility annual survey 9/30/24-10/2/24. 6. The facility failed to cover beverages while transporting from kitchen to neighborhood dining rooms for facility annual survey 9/30/24-10/2/24. 7. The facility failed to have floor drain covers secured to prevent tripping hazard for facility annual survey 9/30/24-10/2/24. 8. The facility failed to have 3 compartment sink pipes free from leaks for facility annual survey 9/30/24-10/2/24. These failures could place residents at risk of foodborne illness. Findings included: Initial observation on 9/30/24 at 9:20 AM of kitchen entrance revealed signage to wear hair restraints when entering but no container of hair restraints available. Observation on 9/30/24 at 9:26 AM revealed the ice machine scoop to be stored in the storage bin attached to the ice machine. Ice machine scoop was broken without handle and gaping hole where handle had been. No other ice scoop was located. Further observation revealed ice machine to have what appeared to be black and brown buildup of dirt, debris, and mold on upper inside of ice machine door and all-around entrance seal. Observation included a of gallon container of food grade ice machine cleaner on top of ice machine. Observation on 9/30/24 at 9:29 AM revealed the floor drain cover adjacent to the 3-compartment sink was not secured and completely came off drain when walked over. Further observation revealed a [NAME] tub was full of dirty water under the washing side of the 3-compartment sink. The pipes under the 3-compartment sink washing area and wall behind pipes had caked on black debris. Observation on 9/30/24 at 9:31 AM revealed juice machine sides to be dirty with debris caked on, dispenser nozzles to have what appeared to be sticky red, orange, and brown substance caked on them, and juice overflow tray full of red liquid. Observation on 9/30/24 at 9:33 AM revealed reach in beverage refrigerator had individual containers of what appeared to be salad dressings without a preparation date and use by date, container of what appeared to be chocolate pudding without a preparation date and use by date, a 1-gallon pitcher on a light brown liquid without a preparation date and use by date, a container of thickened milk without a lid on it. Observation on 9/30/24 at 9:37 AM of dry storage revealed an opened bag of penne pasta without an open date and use by date and an opened bag of rigatoni pasta without an open date and use by date. Both bags off past a were sealed shut by tying the ends of the bag closed. Observation on 9/30/24 at 9:38 AM of kitchen shelving revealed an opened bag of panko breadcrumbs without an open date and use by date and not closed securely to keep pests out. Further observation of kitchen counters revealed storage containers of dry cereal without a label and use by date. Observation on 9/30/24 at 9:42 AM of kitchen deep fat fryer revealed fryer to have buildup of food particles on inside surfaces and food debris floating on surface of oil. Further observation revealed stainless steel shelving where clean sheet pans were stored to have crumbs and food debris on surface of shelving. Observation on 9/30/24 at 9:46 AM of walk-in refrigerator revealed a container of what appeared to be scrambled eggs without a use by date, a container of what appeared to be sausage patties without a use by date, a container of what appeared to be gravy without a use by date, a container of applesauce without a use by date. Observation on 9/30/24 at 9:49 AM of dish machine area revealed dish racks of clean drinking glasses stacked together while still wet. Observation on 9/30/24 at 9:53 AM of kitchen work desk revealed container of hair restraint sitting on desk. Kitchen work desk was located across kitchen adjacent to convection oven. Observation on 9/30/24 at 11:40 AM of lunch meals being delivered to the magnolia neighborhood (hall) revealed rolling utility cart of drinks delivered to unit without lids or covering of utility cart to prevent contaminants. Observation on 10/1/24 at 10:44 AM of dish area revealed dish machine had to be ran and sanitizer levels tested 7 times before adequate sanitization levels were reached for the dish machine. Observation on 10/1/24 at 10:44 AM of DA J running dish machine without beard guard hair restraint on. DA J had small amount of chin hair present upon observation. Observation on 10/2/24 at 9:43 AM of nourishment refrigerators revealed on neighborhood 3 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms) tray of sandwiches without production date or use by date, pitcher of red liquid without production date or use by date, container of leftover food from local restaurant without resident name or discard date, grocery bag with container of what appeared to be some type of leftover food items bag of chips and a lunchable without resident name and discard date, container of cream cheese fruit dip without resident name or discard date, in crisper of refrigerator gallon Ziploc bag with half sandwiches in without production date or use by date, bottle of oreo coca cola without resident name or discard date, jar of pickles without resident name or discard date, gallon jug of tea without resident name or discard date. Observation on 10/2/24 at 9:45 AM of nourishment freezer revealed on neighborhood 3 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms ) a bag of peas and carrots without resident name or discard date, half pint container of vanilla ice cream without resident name or discard date, half pint container of chocolate ice cream without resident name or discard date, box of breaded chicken sandwich without resident name or discard date, 4 frozen dinners without resident name or discard date. Observation on 10/2/24 at 9:58 AM of nourishment refrigerator on neighborhood 1 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms ) revealed a container of spaghetti without resident name or discard date, a container of yogurt without a resident name or discard date, a container of cream cheese without a resident name or discard date, a bottle of hot sauce without a resident name or discard date, a tray of sandwiches with a label dated 10/5/24 unsure of production date. Observation on 10/2/24 at 9:59 AM of nourishment freezer on neighborhood 1 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms ) revealed a hot pocket with resident name or discard date, a bottle of sport drink without a resident name or discard date, a disposable glass with what appeared to be frozen milkshake in it without a resident name or discard date. Observation on 10/2/24 at 10:12 AM revealed [NAME] H with beard guard hair restraint pulled down under chin. [NAME] H had full beard present upon observation. [NAME] H was taking the skins off the baked sweet potatoes. When [NAME] H saw surveyor, he used gloved hand to pull beard guard back up to cover beard then proceeded to go back to removing potato skins without removing gloves or washing hands. [NAME] H then proceeded to puree baked sweet potatoes while pureeing potatoes [NAME] H proceeded to touch face 2 times without removing gloves or performing hand hygiene before going back to touching food. [NAME] H did not wash and sanitize puree machine but rinsed it under hot running water. [NAME] H did not wash or sanitize but rinsed the spatula used under hot running water. [NAME] H then removed gloves and put on new pair and proceeded to puree baked ham during puree process [NAME] H touched face again with gloved hands and did not remove gloves or perform hand hygiene prior to touching food again. [NAME] H then did not wash or sanitize puree machine or spatula used but just rinsed it under hot running water before handing machine off to [NAME] I to puree to buttered peas. Observation on 10/2/24 at 10:18 AM revealed [NAME] I receive puree machine and spatula from [NAME] H. [NAME] I then proceeded to puree buttered peas. After puree process was complete [NAME] I, then proceeded to rinse puree machine and spatula under hot running water. [NAME] I did not wash or sanitize puree machine or spatula. Observation on 10/2/24 at 12:22 PM of lunch meals being delivered to neighborhood 2 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms ) revealed rolling utility cart of drinks delivered to unit without lids or covering of utility cart to prevent contaminants. Observation 10/2/24 at 12:24 PM of nourishment refrigerator on neighborhood 2 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms ) revealed a reusable purple drink cup with lid and straw without resident name or discard date, a bottle of sugar free pancake syrup without resident name or discard date, a tray with sandwich halves without production date or use by date, a personal lunch bag Gatorade drinks and a pudding cup without resident name or discard date, a to go container of what appeared to be leftovers without a resident name or discard date. Observation on 10/2/24 at 12:25 PM of nourishment freezer on neighborhood 2 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms ) revealed a frozen meatloaf meal without resident name or discard date, 2 biohazard bags with ice in freezer. Interview on 10/1/24 at 10:44 AM with DA J who stated and insisted the dish machine had the proper sanitizer levels and said the test strips must be bad. When asked DA J said he did not wear a beard guard because he did not have a beard. Interview on 10/2/24 at 9:45 AM with LVN E who said the snacks are brought by the kitchen staff after the nursing staff call the kitchen requesting snacks. LVN E said the snacks are supposed to be labeled and dated when received from the kitchen, but they are not. LVN E said the nursing staff are responsible for taking the temperatures of the nourishment refrigerators. LVN E said nursing staff was responsible for labeling and dating food items brought by resident family members to be put in the refrigerator. Interview on 10/2/24 at 9:45 AM with MA G who said the snacks are supposed to be delivered at 10 am,2pm, and 7pm. MA G said the only snacks the unit receives are sandwiches or cookies and it is only after nursing calls the kitchen or goes down to the kitchen to get snacks. MA G said the snacks are supposed to be labeled and dated but are not. Interview on 10/2/2/4 at 10:05 AM with LVN F who said all food items in the refrigerator are supposed to be labeled and dated when staff put them in the fridge. LVN F said snacks brought from the kitchen are supposed to be labeled and dated upon arrival to the neighborhood. LVN F said the food items in the refrigerator can be kept for 3 days then discarded. LVN F said the refrigerator temperature log is to be completed by nursing staff daily. Interview on 10/2/24 at 11:30 AM with DM who said snacks are delivered 3 times a day to the different neighborhoods (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms ) at 10 am, 2pm, and 7pm. DM said the snacks are supposed to be labeled and dated upon delivery and it was nursing responsibility to clean the refrigerators on each neighborhood (hall) and take and log the temperature daily. Interview on 10/2/2/24 at 1:40 PM with DM who said the weekly cleaning list for staff was posted on the side of the reach in refrigerators. DM said they ensure cleaning tasks are completed by walking around the kitchen and checking to see if tasks have been done. DM said if the kitchen was not kept clean it has the potential to make resident sick. DM said all food items are supposed to have an open/preparation date and a discard date which was 7 days after the open/preparation date. DM said all food items are to be dated upon being received in the kitchen. DM said all kitchen staff are to always wear hair restraints while in the kitchen. DM said staff can wear hair nets or hair bonnets and men are required to wear beard guards if they have facial hair. DM said if hair restraints are not worn then there would be possible contamination of hair in the food. DM said the cooks are responsible for taking and recording food temperatures at every meal. DM said if the temperatures are not taken and recorded of the food then there was the potential for the residents to receive cold food. DM said they were aware of the issue with the dish machine and the sanitizer levels, and they had made a call to their chemical supplier to come out the next day to inspect the machine and chemicals to ensure everything was in good working order. The DM said the dietary services has their own specific in-services completed and all their in-services are recorded in their in-service binder. Interview on 10/2/24 at 3:10 PM with ADM who said their expectations concerning kitchen sanitation were that the dietary staff would be cleaning after every meal and that it was the DM responsibility to ensure that the kitchen remained clean and sanitary. The ADM said if the kitchen was not kept clean and sanitary that a negative outcome for residents could be infections, pests at the facility, and mold in the kitchen. The ADM said their expectation concerning labeling and dating of food items in the kitchen was that they expected all food items to be labeled and dated. The ADM said not labeling and dating food items could result in infections to the residents and poor sanitation in the kitchen. The ADM said her expectation of temperature logs being completed would be that they were completed daily at all meals. The ADM said if the temperature logs were not completed that this could result in unpalatable food items and resident weight loss. The ADM said their expectation of hair restraints in the kitchen would be that the staff were always wearing hair restraints in the kitchen. The ADM said if the staff were not wearing hair restraints this could result in contamination of food products with hair. The ADM said their expectation concerning in-services being completed in the dietary department would be that the in-services are mandatory, and it is the DM responsibility to conduct the in-services. The ADM said dietary has specific dietary related in-services that are to be completed monthly and the DM has a list of specific topics The ADM said if in-services are not conducted with staff, then the potential outcome could be staff not being prepared, lack of knowledge, and poor sanitation practices. The ADM said their expectation concerning nutrition refrigerators and freezers would be that nursing staff take temperatures and log daily, label and date all food items, and dispose of any expired food items. The ADM said the housekeeping staff clean the refrigerators. The ADM said if the temperatures were taken or if food items were not labeled and dated the possible outcomes could be infections and poor sanitation practices. Record review of daily food temperature logs for week 4 of the spring summer menus and week 1 of the fall winter 2024 menus reviewed reflected 14 breakfast meals (Day 17,18,19,20,21,22,23,24,25,26,27,28 of spring/summer menu cycle and day 1,2 of fall/winter menu cycle) without temperatures recorded, 12 lunch meals ( Day 17,18,20,21,22,23,24,25,26,27,28 of spring/summer menu cycle and day 1 of fall/winter menu cycle) without temperatures recorded, and 11 dinner meals (Day 18,19,20,22,23,24,25,26,27,28 of spring/summer menu cycle and day 1 of fall/winter menu cycle) without temperatures recorded. Record review of nourishment refrigerator temperature logs from June of 2024 through October of 2024 reflected 28 days had not been completed. Record review of Dietary Services policy undated reflected under heading Staff: -The designated Director of food service is responsible for the overall operation of the dietary service. Under heading Food Each resident will receive, and the facility will provide -food prepared in accordance with established professional food preparation practices and by methods that conserve nutritive value, flavor, and appearance. Record review of Daily Food Temperature Control policy undated reflected under heading Procedure We will assure that food is served at a safe temperature. Temperature of all hot and cold food shall be taken prior to every meal service and recorded on Temperature log. This is done to help ensure that food is safe and served within acceptable ranges. 2. Prior to meal service, the cook shall take the temperature of all hot and cold foods. 3. Temperature are recorded on the Temperature log form. Record review of Dry Storage and Supply policy undated reflected under heading Procedure 4. Open packages of food are stored in closed containers with tight covers and dated as to when opened. Record review of Equipment Sanitation policy undated reflected under heading Policy The facility will provide clean and sanitized equipment for food preparation. The facility will clean all food service equipment in a sanitary manner. Under heading Procedure -Equipment must be thoroughly sanitized between use in different food preparation tasks (ex.: salad preparation, raw meat cutting and cooked meat cutting) -Blenders and food processor bows will be inverted after cleaning to drain on shelved or trays with vented slots of bar netting -Large equipment is to be sanitized by spraying or wiping with a chemical sanitizing solution at the minimum strength of solutions needed for immersion sanitization Under heading Pots Pans and Dishes Where available, facility will use the designated dish washing machine according to the manufacturers specifications. If the machine is out-of-order for any time period it is recommended to use paper goods, where possible. A Manual dishwashing of pots, pans, dishes, and equipment may be completed using a three (3) compartment sink -- Step #1: Pre-Wash o Before submerging a dish into the first sink/compartment, prepare the dish for the first sink or washing by scraping off any excess food into the trash can to minimize introducing large amounts of soiling to the water. If an overhead sprayer hose is present it may be used for easy removal of the food soils before the first sink. - Step #2: Wash (Sink Compartment 1) o The first compartment should contain a solution of water and one of the following cleaning agents: detergent, soap, degreaser, abrasive cleaner or acid or alkaline cleaner, as the first compartment is meant for washing the dishes. o The temperature of the water used for washing must be at or above 110 degrees F. However, some local codes might require different temperatures. The temperature can also depend on the detergent manufacturer's specifications. o The washing step might include scrub brushes, dish cloths or glass brushes depending on the type of washware and how soiled the dishes are. o The wash water should be drained, and the sink refilled with a solution of clean water and detergent when the water becomes too dirty or the suds are gone. - Step #3: Rinse (Sink Compartment 2) o Transfer the dishes to the second compartment for rinsing. The exact temperature of the rinse water depends on the local health codes, but the absolute minimum is 120 degrees F. o The purpose of this step is to use clean water to rinse the soap, detergent or other cleaning agents that remained on the dishes during the washing step. Since the soapy dishes are being submerged in the rinsing compartment, the water in it will pretty soon become too soapy. As soon as it does, replace it with fresh water to ensure the soap doesn't enter the last compartment. - Step #4: Sanitize (Sink Compartment 3) o Soak rinsed dishes in a chemical sanitizing solution or hot water. Ensure the dishes are completely submerged. o If using a chemical sanitizer, follow the directions from the manufacturer to know how long the dishes must stay in the solution. o MINIMUM of 50 ppm of available chlorine at a temperature not less than 75 degrees Fahrenheit, OR; o MINIMUM of 12.5 ppm of available iodine in a solution have a pH higher than 5.0 and a temperature of not less than 75 degrees Fahrenheit, OR; o Any other approved chemical-sanitizing agent containing at least 150-400 ppm of quaternary ammonia at a temperature of approximately 70 degrees Fahrenheit o Facilities will use an approved test kit to measure the parts per million (ppm) of the chemical solutions in compartment sinks on a daily basis and will record the results of these tests on a temperature/chemical log or other formalized log o All abnormal test results will be reported to the Dietary Manager or designee and the solution will not be used until corrections can be made. Record review of Hair Restraint policy undated reflected under heading Procedure -It is MANDATORY that all dietary staff wear hairnets while on duty in any food preparation area in this facility. -Any person with a beard must wear a beard net. -Bald persons are excluded from wearing hair nets and clean-shaven persons are excluded from wearing beard nets. Record review of Nutrition Center policy undated reflected under heading Procedure: 2. All foods will be covered with clear plastic wrap and dated or will be in original sealed individual serving containers. 4. The refrigerator will be cleaned out weekly. Record review of Storage of Food in Refrigeration policy undated reflected under heading Procedure 4. All containers must be labeled with the contents and date food item was placed in storage. 5. Previously cooked foods can be held in refrigeration of 41 degrees F or lower for up to 7 days and then must be discarded. 6. Food items that remain sealed from the supplier may be held until the expiration date if unopened. Record review of Weekly Cleaning Assignment Schedule reflected morning dietary aide was responsible for deep cleaning the juice machine, table, and connections. Juice machine is scheduled to be cleaned every Tuesday. Morning dietary aide is responsible for deep cleaning both reach in refrigerators and making sure everything is labeled and dated this is scheduled to occur on Wednesdays. Morning dietary aide is responsible for cleaning dry storage and checking all storage items for dates on Mondays. Evening cook is responsible for changing the grease in the fryer on Mondays. Evening cook is responsible for polishing the outside of the fryer on Fridays. Evening dietary aide is responsible for cleaning the juice machine table and all connections on Monday. Record review of Refrigerator Storage policy undated reflected under heading Procedure 5. Food must be covered when stored, with a label identifying what is in the container. Record review of Resident meal Service and Snacks policy undated reflected under heading Procedure: 6. The dietary department shall prepare nightly snacks (and other in-between mealtime snacks) for all residents. These will be served in bulk and offered to all residents, following the constraints of the ir specific diet order, by nursing personnel. A variety of snacks will be offered. Any snack items that contain potentially hazardous food items will be left at room temperature for less than 4 hours or stored on ice or in the refrigerator. Record review of dietary in-services binder revealed only 3 in-services had been conducted in 2024. On 2/2024 an in-service was conducted titles Don't Cause infections. On 3/27/24 an in-service was conducted titles Resident rights, falls/fall prevention, abuse, neglect, exploitation, and reporting. On 9/26/24 an in-service was conducted titled behavior management, safe environment, and managing aggressive behaviors.

Based on interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for four (4) of nine (9) residents (Residents #66, #75, #27, #77) reviewed for food preferences. The facility kitchen failed to serve menu substitution items as requested by the residents and approved by facility staff. The facility kitchen failed to make residents aware of menu substitutions available to them. This failure could affect the residents that are provided daily meals by the facility, by placing them at risk for dissatisfaction, frustration, poor intake, weight loss, and decline in health. The findings included: During an interview on September 30, 2024, at 11:07 AM, Resident #66 expressed anger about the food at the facility. The resident stated that he always gets cold food. The resident stated that the residents were provided with tuna fish sandwiches in the recent past and the smell of the tuna was horrific. The resident stated that the residents were unable to eat the tuna. The resident stated that he did report his concerns with the food to the head boss (ADM). On October 2, 2024, a record review of Resident #66's care plan dated 09/07/23 reflected Resident #66 was at risk for weight changes related to recent weight change REGULAR DIET, THIN LIQUIDS SERVED. Goal: Resident #66's nutritional status will remain stable AEB no further reports of significant weight change through next review date. Interventions included Assess reports of S/S of aspiration/difficulty chewing or swallowing, implement appropriate interventions within code status. Notify MD and refer to ST as appropriate. During an interview on September 30, 2024, at 12:14 PM, Resident #75 stated the food at the facility was terrible. The resident stated that on that day (September 30, 2024) the food was cold, but it tasted good. She stated that sometimes the food was good, but most of the time it was not. She stated she has no concerns, but she would like the food to be better. During an interview on October 1, 2024, at 2:00 PM, Resident #27 stated they were not made aware of the substitutions available or the process in which to request a substitution. On October 1, 2024, at 2:00 PM in an interview, Resident #77 stated that the food at the facility is terrible. The resident stated that what is listed on the menu is not served. For example, the menu on October 1, 2024, listed asparagus (as requested by the residents), but greens were served instead. On October 2, 2024, at 9:39 AM, a record review of Resident #27's admission record reflected a seventy-seven (77) year old female, admitted to the facility on [DATE]. The resident's diagnoses included sacroiliitis (an inflammation of the sacroiliac joint, which connects the spine to the pelvis), spinal stenosis (an abnormal narrowing of the spinal canal or neural foramen that results in pressure on the spinal cord or nerve roots), Type 2 Diabetes Mellitus with hyperglycemia (a condition in which an excessive amount of glucose circulates in the blood plasma, which can produce noticeable organ damage over time), and hypokalemia (a low level of potassium in the blood serum). On October 2, 2024, at 9:40AM, a record review of Resident #27's care plan reflected that the resident was at risk for/has a history of weight changes, dehydration and malnutrition related to impaired cognition and DM. The goal was to encourage and assist the resident to consume greater that 50% of meals daily through the next review period. On October 2, 2024, at 9:41 AM, a record review of Resident #27's MDS assessment dated [DATE], reflected the resident had a BIMS score of 11, which indicated intact cognition, and Resident #27 required limited assistance and one-person physical assistance with eating. On October 2, 2024, at 9:41 AM, a record review of Resident #77's MDS assessment dated [DATE], reflected a BIMS score of 15, which indicated intact cognition. The assessment also reflected that the resident required supervision and setup help only with bed mobility, transfer, eating, and toilet use. Resident #77's assessment showed the resident had received chemotherapy while a resident at the facility and within 14 days of the assessment. On October 2, 2024, a record review was conducted of Resident #75's face sheet reflected that she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included hypothyroidism (a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormones), transient ischemic attack (a brief stroke like attack that, despite resolving within minutes to hours, still requires immediate medical attention to distinguish from an actual stroke), aphakia (the absence of the lens of the eye), and hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood). Record review of Resident #75's significant change MDS assessment, dated 09/03/24, reflected she had a BIMS score of 15, which indicated intact cognition. Resident #75 required setup or clean-up assistance with eating, toileting, showering and personal hygiene. On October 2, 2024, at 9:43 AM a record review of Resident #77's admission record reflected a sixty-seven (67) year old male, admitted to the facility on [DATE]. The resident's diagnoses included multiple myeloma not having achieved remission (a type of blood cancer), morbid (severe) obesity due to excessive calories, and anemia (a blood disorder in which the blood has reduced ability to carry oxygen). On October 2, 2024, at 9:44 AM, a record review of Resident #77's latest completed Care Plan revised on February 21, 2024, reflected the resident has an alteration in hematological status r/t Anemia, Cancer with the goal being the resident will remain free of complications related to altered hematological status ., and interventions included Encourage intake of foods high in iron, vitamin C. The care plan also indicated that the resident has an altered Endocrine system and that required monitoring of the resident's food intake and output and nutritional status. In an interview with DM on October 2, 2024, at 2:42 PM, when in the presence of ADM, DM was asked if asparagus was served on this day as stated on the menu and as specifically requested by the residents. DM stated that it was not. DM stated that was because [NAME] H does not know how to prepare the vegetable so [NAME] H omitted it from the menu. DM stated that she planned to teach [NAME] H how to prepare the asparagus this week, but she had not done so yet. DM was asked how asparagus typically prepared. DM stated that it could be boiled or baked in the oven. DM was asked what technique she planned to teach [NAME] H. DM stated that she did not know as this item was added to the menu because the residents requested it, but it was not something she that was planned for. DM stated that she planned to consult with DT for a recipe, but she had not done so at the time of this interview. A review of the facility's grievance log on October 2, 2024, at approximately 3:00 PM, reflected the following grievances in relation to food preferences and dietary services: Grievance dated July 22, 2024, which stated on this date, no role provided with lunch, menu received was not what was listed on the tray ticket (brussel sprouts instead of corn on the cob, mixed fruit instead of peach crisp). Grievance dated July 22, 2024, which stated the evening meal received did not match the posted menu. Grievance dated July 21, 2024, which stated that mixed fruit was served instead of peach cobbler. Grievance dated July 31, 2024, which stated, Resident shared that facility needs a food cop to monitor things. He added how water, tea, and juices are not offered. Grievance dated July 31, 2024, which stated in part: .meals are atrocious at times. Grievance dated July 31, 2024, which stated in part: The lunch meal today wasn't good, per resident. The menu was updated, and item of concern was removed. Grievance dated July 31, 2024, which stated in part: The lunch today was horrible: turkey meat was very thin, sandwich meat---processed---and cold. The grievance stated that an item listed on the menu was not served, the same desserts are served over and over again, meal served in Styrofoam plate over the weekend, and one meal was ham and cheese sandwiches-the same as snacks offered. Grievance dated July 31, 2024, which stated lunch on this date was something you would serve a child, and that the turkey meat was sandwich meat and not to be served as the main entrée. Grievance report dated July 31, 2024, regarding food preferences and food preparation. Grievance dated July 31, 2024, regarding items listed on the menu not being served and a lack of variety in the menu. A memo dated August 1, 2024, signed by the administrator, dietary manager and social worker, which stated, Due to the amount of grievances regarding the menu and recipes, the dietary manager, social worker and administrator discussed how to overcome the complaints. 1. Menu was reviewed and turkey crunch will be removed, and a substitute will be added in its place to the menu. 2. Dietary Manager will review menu and recipes as the cooks are preparing meals. 3. Administrator to receive a test tray for the next 14 business days to verify menu, recipe, and portion sizes are correct. 4. Social Worker to inform Dietary manager and administrator of any other concerns voiced regarding the meals. Grievance dated August 1, 2024, and attached Meal Satisfaction Survey Form which stated in part: Are you given a choice at meals? Never. Are you given enough time to finish eating without feeling rushed? Never. Grievance dated August 1, 2024, which stated in part: .Resident added that ice is not offered. Resident stated strong concerns about the lack of pies or cakes option. Attached Meal Satisfaction Survey Form stated, Are hot foods such as coffee, meats, and vegetables served hot enough? No .How would rate the overall taste of the food? Poor. How would you rate the variety of menu items? Poor. How would you rate the overall appearance of the meal? Poor .Are you given a choice at meals? Never .Are you assisted when necessary, during meal service? Never. Are you given a snack at bedtime? Never .[DM] has lied to us about pie & cake. Grievance dated August 1, 2024, and attached Meal Satisfaction Survey Form which stated in part: Are you given a snack at bedtime? Never. Grievance dated August 1, 2024, and attached Meal Satisfaction Survey Form which stated in part: .food portions are inadequate as served with other sides. The menu slips that accompany the meals should match what we truly receive. The sides need more help .chicken is served too much. Grievance dated August 1, 2024, and attached Meal Satisfaction Survey Form which stated in part: Are hot foods such as coffee, meats, and vegetables served hot enough? No. Are chilled foods such as milk, juice and salads served cold enough? No. How would you rate the overall taste of the food? Poor. Are you given snacks at bedtime? Never. Grievance dated August 1, 2024, which stated in part, .chocolate is listed as one of his dislikes on his meal ticket, however, he likes chocolate. Attached Meal Satisfaction Survey Form which stated in part: Are chilled foods such as milk, juice and salads served cold enough? No .How would you rate the overall taste of the food? Fair/Poor .How would you rate the overall appearance of the meal? Poor .Are you given a snack at bedtime? Never. Grievance dated August 2, 2024, which stated, Resident stated that foods are not served hot enough. She also shared that she is never given a choice at meals or snack at bedtime . The attached Meal Satisfaction Survey stated in part: Are hot foods such as coffee, meats, and vegetables served hot enough? No .Are you given a choice at meals? Never .Are you given a snack at bedtime? Never. In the additional comments section, the resident wrote, The kitchen staff cannot [sic] understand that the only thing I need to have 'ground' is my meat. I can eat vegetables-tater tots, etc. I was served mashed potatoes [sic] for both lunch and dinner; three days in a row. Grievance dated August 2, 2024, and attached Meal Satisfaction Survey Form which stated in part: Are hot foods such as coffee, meats, and vegetables served hot enough? No .Are you given a choice at meals? Never .Are you given a snack at bedtime? Never. In the additional comments section, the resident stated, I am diabetic. Diabetics are always supposed to get a bedtime snack to keep their blood sugar from tanking during the night. Grievance dated August 2, 2024, and attached Meal Satisfaction Survey Form which stated in part: Are you given a choice at meals? Never .Are you given a snack at bedtime? Never. Grievance dated August 2, 2024, which stated, Resident stated that foods are not hot enough. Resident stated the variety of the menu items are poor. Resident stated that she is never given a choice at meals or snacks at bedtime. The action taken stated, Looking at ways to improve food distribution. Nursing staff was educated to remember & offer choices @ mealtime. Nursing staff in-serviced on times of day to offer snacks. The attached Meal Satisfaction Survey Form stated in part: How would you rate the variety of menu items? Poor .Are you given a choice at meals? Never .Are you given a snack at bedtime? Never. Grievance dated August 2, 2024, and attached Meal Satisfaction Survey Form which stated in part: Are hot foods such as coffee, meats and vegetables served hot enough? No .Are chilled foods such as milk, juice and salads served cold enough? No .How would you rate the overall appearance of the meal? Poor .Are you given a choice at meals? Never .Are you given a snack at bedtime? Never. Grievance dated August 2, 2024, and attached Meal Satisfaction Survey Form which stated in part: Are hot foods such as coffee, meats, and vegetables served hot enough? No .Are you given a snack at bedtime? Never. Grievance dated August 2, 2024, which stated .aids do not take enough to assist those who require assistance, such as cutting up their food or opening packets for residents who need the help. She stated that residents are not offered water during the day. Meal Satisfaction Survey Form attached stated in part: Are hot foods such as coffee, meats, and vegetables served hot enough? No. Milk is served to [sic] early .Are chilled foods such as milk, juice, and salads served cold enough? No .How would you rate the overall taste of the food? Poor .How would you rate the variety of menu items? Poor .How would you rate the overall appearance of the meal? Poor .Are you given a choice at meals? No .Are you given a snack at bedtime? Never. Inservice dated August 2, 2024, regarding Hydration, and Nutrition and Hydration Care Tips. Grievance dated September 3, 2024, which stated that the meal tickets continue to not match the meal being served. On August 5, 2024, a Meal Satisfaction Survey was completed by an anonymous resident. When asked, Are you given a choice at meals? the resident responded with Never. Additional comments stated, There needs to be a pot of coffee on the counter all day. Grievance dated August 5, 2024, which stated, Resident stated that the hot foods are not served hot enough, variety of menu items are poor, choice at meals are never given, and never given snack at bedtime. See resident comments on meal satisfaction survey . The attached Meal Satisfaction Survey Form attached stated in part: Are hot foods such as coffee, meats, and vegetables served hot enough? No. How would you rate the variety of menu items? Poor. Are you given a choice at meals? Never. Are you given a snack at bedtime? Never. Grievance dated August 5, 2024, which stated, Resident shared hot foods are not served hot enough and chilled foods are not cold enough. Milk is room temperature per resident. She added that they [are] never given a choice at meals and a snack at bedtime . The attached Meal Satisfaction Survey Form attached stated in part: Are hot foods such as coffee, meats, and vegetables served hot enough? No .Are chilled foods such as milk, juice, and salads served cold enough? No .Are you given a choice at meals? Never .Are you assisted when necessary, during meal service? Never .Are you given a snack at bedtime? Never. The resolution/action taken was to bring the corporate dietary manger down on August 7th and August 8th to provide training, and Dietary Manager handed out every day menu items to all residents. Snacks are given to units @10, 2, & 7. Grievance dated August 5, 2024, which stated, Resident shared that she's sometimes given a choice at meals and a snack at bedtime. Grievance dated August 5, 2024, which stated, Resident stated that hot foods are not served hot enough and chilled foods are not cold enough. She stated the variety of menu items and overall appearance of the meals are poor. She added that she is never given a choice at meals or a snack at bedtime. The attached Meal Satisfaction Survey Form attached stated in part: How would you rate the variety of the menu? Poor .How would you rate the overall appearance of the meal? Poor .Are you given a choice at meals? Never .Are you given a snack at bedtime? Never. Grievance dated August 5, 2024, which stated, Resident stated that hot foods are not served hot enough and chilled foods are not served cold enough. She added that there are not a variety of menu items .she stated she is not given a snack at bedtime. The attached Meal Satisfaction Survey Form stated in part: How would you rate the variety of menu items? Poor .Are you given a snack at bedtime? Never. Inservice dated August 6, 2024-HS snacks for all residents. HS snacks for diabetic residents. Resident Council Grievance meeting notes dated August 15, 2024, from residents on the Bluebonnet/Willow hallways and the facility's response which stated the following in part: Water not always passed out. Response: Please see in-service training form, then encourage; Still receiving too many pudding [sic], vanilla ice-cream [sic], and fruit cups for dessert. Response: Menus are being followed; Jell-O was warm/melty recently. Response: Made incorrectly, has been educated for proper making; Breads aren't offered. Response: If not on menu, it is not being handed out; No real butter -just oil-used to get butter in little, square containers. Response: I have a strict order format that I am aloud [sic] to order. Grievance dated August 27, 2024, which stated that a family member shared their concerns regarding soggy foods, temperature issues with the food, and being served the same foods. Also, the resident would've like vegetables and more of them. Grievance dated August 27, 2024, which stated in part that the resident was requesting more vegetables, fresh fruits, and bigger salads with a variety of vegetables. The resident would also prefer thicker deli meats and cheese. Grievance dated September 5, 20024, which stated that a resident's sister shared concerns regarding food being served in that the eggs are watery sometimes, there was not always ice in the drinks, and diverse veggies were still not being offered. Grievance dated September 6, 2024, which stated that resident shared concerns with ongoing lunch and dinner meals. Resident stated that he continued to have vegetables on his plate, and he continued to not have bananas for his meals. Grievance dated September 6, 2024, in which a resident stated that 90% of her meals are not warm/hot, that no butter, sugar or salt is offered for oatmeal, her egg was burnt and had a piece of un-melted cheese on top, and that the dish was overall uninviting. The resident also requested milk and cereal, and more coffee for lunch and dinner. Grievance dated September 11, 2024, from Resident group meeting to discuss the upcoming menu which stated snacks aren't provided 3x a day, potatoes need to be cooked longer, coleslaw was dry, more deli meat sandwiches and for them to be cut in half, more saltine cracker packets, more dinner rolls, gravies on the side, larger servings for some dishes, more dinner rolls, less salt for some items, more tomato sauce for pasta dishes, and condiments readily available for meals. A review of the facility's Food Substitutions policy reflected: Residents' likes and dislikes are considered when making substitutions.

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed. 1. The kitchen test tray of the lunch meal on 10/2/24 foods was burnt, unappealing, and inedible. The kitchen test tray lacked silverware, condiments, dessert, and a beverage. Kitchen staff had to bring missing items after test tray was received and utensils were requested. 2. The facility failed to follow the puree diet recipe. The pureed baked ham, baked sweet potatoes, and buttered peas were all mixed with water during the puree process for the lunch meal on 10/2/24 instead of something with nutritive value such as broth, milk, or juice. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included: Observation on 10/2/24 at 10:12 AM of [NAME] H revealed [NAME] H pureed the baked sweet potatoes with water instead of broth or milk. [NAME] H pureed the baked ham with water instead of cooking juices or broth. [NAME] H did not have any recipe out for the pureed food. Observation on 10/2/24 at 10:18 AM of [NAME] I revealed [NAME] I pureed the buttered green peas with water instead of the cooking juices or broth. [NAME] I did not have any recipe out for the pureed foods. Observation on 10/2/24 at 12:30 PM of kitchen test tray revealed the kitchen test tray was delivered to the Bluebonnet neighborhood (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms). Nursing staff passed meal trays to residents then passed kitchen test tray to surveyor. Kitchen test tray did not have utensils, condiments, dessert, or beverage on tray. Surveyor took tray back to private dining room for observation and tasting, surveyor requested utensil from passing kitchen staff. Kitchen test tray revealed to have slice of baked ham, one half of a baked sweet potato, and scoop of buttered peas. Kitchen staff member brought utensils, 2 containers of butter, and dessert covered with paper towel. Observation of kitchen test tray revealed slice of baked ham, one half of baked sweet potato, scoop of buttered peas, and chess pie. Initial observation of meal tray looked unappealing as several items were missing and had to be requested (utensils, condiments, beverage, dessert). Baked ham was cooked well and had a good flavor temperature was warm. Baked sweet potato half was bland had no flavor was unseasoned. Buttered peas were mushy and not buttered no seasoning. Mini chess pie was burnt and dried out very tough and inedible. In an interview on 10/2/24 at 10:10:15 AM revealed [NAME] H, when asked about what liquids are used in the puree process [NAME] H said sometimes, they use milk for the puree desserts but for all the other foods they said they use water. In an interview on 10/2/24 at 10:20 AM with [NAME] I who, when asked about what liquids are used in the puree process, [NAME] I said they always use water to get the foods to the right consistency and if the food was to thin then they add thickener. In an interview on 10/2/24 at 1:40 PM with the DM who said the cooks were having difficulties with the puree process and corporate came down and conducted a training on the proper ways to puree foods. The DM said the corporate dietary person led a hands-on training of the puree process using water to thin foods. The DM could not give a specific date as to when this training had occurred when asked. The DM said ever since then the cooks use water to thin all foods as instructed by corporate. In an interview on 10/2/24 at 3:10 PM with the ADM who said their expectation would be for the kitchen to follow recipes to ensure the nutritive value of the food prepared was not compromised. The ADM said if the recipes are not followed this could have the potential to negatively affect the residents with weight loss or choking. Record review of puree recipes undated for chess pie buttered peas, baked sweet potato no skin, and baked ham reflected the following: 1. If product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth pudding or soft mashed potato consistency. 4. Top pureed foods with appropriate sauces or gravies as needed to ensure adequate moisture for safe consumption and enhance flavor. Record review of Dietary Service policy undated reflected under heading of Policy: The facility will provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs for each resident. Under heading Food: Each resident will receive, and the facility will provide -Food prepared in accordance with established professional food preparation practices and by methods that conserve nutritive value, flavor, and appearance -Adequate amounts of food that is palatable, attractive, and at the proper temperature -Substitutes of similar nutritive value to residents

Based on observations, interviews, and record reviews, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed for all residents for 2 of 2 meals observed. The facility failed to follow the posted menus for two lunch services served at the facility on Wednesday, 09/30/24 and Thursday, 10/2/24. These failures could place residents that eat food from the kitchen at risk of poor intake, chemical imbalance, and/or weight loss. The findings included: Observation of the kitchen preparing lunch meal trays on 10/2/24 at 11:20 AM revealed pureed meal trays having applesauce put on tray for dessert. Observation of neighborhood 1 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms) dining room on 9/30/24 at 11:40 AM revealed the meal trays were being checked by the LVN to ensure accuracy with preferences and diet ordered. All regular texture meal trays served had spaghetti w/ meat sauce, tossed salad or mixed vegetables depending on diet order, garlic bread, and pudding. All pureed meal trays had pureed spaghetti w/ meat sauce, pureed mixed vegetables, and pudding. The cycle menu called for spaghetti w/ meat sauce, mixed green salad, garlic breadstick, and cheesecake. No menu posting on neighborhood 1 was observed. Observation of the neighborhood 1 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms) dining room on 10/2/24 at 11:50 AM revealed the meal trays were being checked by the LVN for accuracy with preferences and diet orders. All pureed trays served had pureed baked ham, pureed baked sweet potatoes, pureed buttered peas, and applesauce. The cycle menu called for baked ham, baked sweet potatoes, buttered peas, and chess pie. No menu posting on neighborhood 1 observed. Observation of neighborhood 2 (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms) dining room on 10/2/24 at 12:10 PM revealed the meal trays were being checked by the LVN to ensure accuracy with preferences and diets ordered. All pureed trays served had baked ham, baked sweet potatoes, buttered peas, and applesauce. The cycle menu called for baked ham, baked sweet potatoes, buttered peas, and chess pie. In an interview with LVN F on 10/2/24 at 10:05 AM LVN F said that each neighborhood (The building is broken down into 4 neighborhoods or units. Each neighborhood or unit consists of a central nurse station, dining room, medication room, shower room, and 2 hallways with resident rooms) keeps cases of pudding and applesauce on hand to provide to residents. LVN F said the pureed resident's desserts are frequently different than the other residents. LNV F said the pureed residents get pudding, ice cream, or applesauce for dessert. In an interview [NAME] I on 10/2/24 at 10:18 AM [NAME] I said the dessert for today was chess pie except for the puree's they will get applesauce as I do not have enough to make pies for them. In an interview with DM on 10/2/24 at 1:40 PM DM said that sometimes the menu changes if the kitchen was out of a product or only has enough for some of the residents then the mechanical and pureed diets would receive something different. When asked if the facility uses a substitution log the DM responded we have those logs and the procedure I follow is when the kitchen must make a substitution then I write down the change on the log and put the log on the meal cart to inform the nursing staff of the change. DM said they do not keep copies of the substitution log and they do not have the RD sign off on the log. DM said they were unaware they were required to keep the log or have it signed off from the RD. DM said the facility currently has 12 pureed diets and 31 mechanical soft diets. In an interview with the ADM on 10/2/24 at 3:10 PM ADM said their expectation was for the menus to be followed and any changes to be communicated to residents and staff prior to the meal. The ADM said if the menus are not followed, and the substitutions are not communicated to the staff and residents this could potentially lead to weight loss in the residents. Record review of Food Substitutions policy undated reflected under heading Procedure: 3. The dietary manager will consult the dietitian as necessary prior to making a substitution. 5. All substitutions are noted on the menu and filed in accordance with established dietary policies. Record review of production records for the fall/winter 2024 lunch day 2 menu cycle reflected the production records called for 10 servings of pureed cheesecake, 10 servings of pureed garlic breadstick, and 77 servings of cheesecake slices. Pudding was not on the production records for lunch day 2 menu cycle. Record review of substitution log clipboard revealed no substitution logs had been kept on file. Record review of production records for the fall/winter 2024 lunch day 4 menu cycle reflected the production records called for 10 servings of pureed chess pie. Applesauce was not on the production records for lunch day 4 menu cycle. Record review of Dietary Service policy undated reflected under heading Menu: The facility menu will meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences. -vary from week to week, taking the general age-group of residents into consideration; and be followed. Any substitutions must be documented as required in subsection (d) of this section. (Subsection D of this section was not provided prior to exit) -any substitution of menu items will be recorded on the day of use. -substitutes of similar nutritive value to residents Record review of Subsection D of the Dietary Service policy attempted however Subsection D not provided prior to exit.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 5 residents (Resident #43) reviewed for PASARR Level I screenings. 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #43. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (bipolar disorder with an onset date of 01/24/18 and schizoaffective disorder, bipolar type with an onsite date of 02/23/24) was present upon Resident #43's admission date on 02/15/24. The facility did not complete a 1012 form to update the PASARR Level 1 with the new diagnosis until surveyor intervention on 10/02/24. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Record review of Resident #43's face sheet, dated 10/02/24, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks) with an onset date of 01/24/18 and schizoaffective disorder, bipolar type (a mental health condition including schizophrenia and mood disorder symptoms) with an onsite date of 02/23/24). Record review of Resident #43's quarterly MDS assessment, dated 08/19/24, reflected she had a BIMS score of 13, which indicated intact cognition. Resident #43 also took an antipsychotic medication during the assessment window. The MDS assessment reflected Resident #43 was independent with eating, required substantial/maximal assistance for toileting, required partial/moderate assistance with showering, and required set-up/clean-up assistance with personal hygiene. Record review of Resident #43's PASARR Level 1 Screening, dated 02/15/24, reflected that in Section C Mental Illness was marked as no, which indicated Resident #43 did not have a mental illness. Record review of Resident #43's care plan dated 02/21/24 and revised on 03/06/24 reflected Resident #43 had a diagnosis of bipolar disorder and was at risk for side effects to antipsychotic medications. Goal: No report of injury to self or other due to behaviors through next review date. Interventions included Approach in calm manner, introduce self, explain procedure/care to be provided. Provide reassurance as needed, do not rush. Refer to psychological services as indicated. In an interview on 09/30/24 at 12:29 PM, Resident #43 stated she was doing fine, and staff treated her great. She stated she used her call light if she needed help and staff got to her quickly when she called. She stated she felt safe in the facility, and she had no concerns. In an interview on 10/02/24 at 11:21 AM, the MDS who stated the MDS assessment for Resident #43, was completed incorrectly by the hospital when Resident #43 admitted . She stated she should have noticed the form was incorrect when Resident #43 admitted , and she should have put in another form to correct it. She stated there should have been a Y for yes placed in the PASARR Level 1 Screening where the form asks if the resident has evidence or an indicator of a mental illness. She stated she was responsible for the PASARR's for Resident #43, and she had been trained on how to accurately ensure PASARR screenings were completed correctly and for completing them correctly as well herself. She stated she should have done the correction form for Resident #43 because her PASARR screening was incorrect. She stated if a PASARR screening was not completed correctly, residents may not receive the services there were entitled to. In an interview on 10/02/24 at 1:15 PM, the ADM who stated the MDS nurses were responsible for ensuring the accuracy of or completing the PASARR evaluations when a resident admits to the facility. She stated the MDS nurses had been trained on completing and ensuring the accuracy of PASARR evaluations. She stated if a PASARR evaluation was done incorrectly it could have caused a resident to not receive the services they needed. In an interview on 10/02/24 at 1:19 PM, the DON who stated the MDS nurses were responsible for ensuring the accuracy of PASARR evaluations and they should have filled out another form to correct the PASARR if it was not correct. She stated she also checked the PASARR's to ensure accuracy. She stated the MDS nurses were trained on completing and ensuring accuracy of the PASARR evaluations. She stated if a PASARR was completed incorrectly a resident could have missed out on benefits or services that they deserved. Record review of the facility's undated policy, Preadmission Screening and Resident Review (PASARR) stated: It is the policy of this facility to ensure that all residents are screen and appropriately addressed via the PASARR process as outlines by regulations. The results of this process will be used to develop, review, and revise the residents care plan. This facility will not admit any new resident with: 1. A mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, a. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and b. If the individual requires such level of services, whether the individual requires specialized services; or 2. Intellectual disability, unless the State intellectual disability or developmental disability authority has determined prior to admission, a. That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and b. If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. Procedure: 1. The facilities designated staff will review all potential admission for possible positive PASARR conditions and ensure that CMS Preadmission guidelines are followed. 2. The PL1 (PASARR) is to be entered into TMHP or Simple LTC the next business day by designated staff. 3. If Resident is PASARR positive, the facility will monitor daily for the PE (PASARR Evaluation) from the Local Authority on TMHP or Simple LTC. Once PE has been submitted by the LA the designated staff will print the PE for IDT review to ensure the facility can provided recommended services.

Based on interviews and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) out of seven reviewed for abuse. The facility failed to prevent abuse by failing to ensure Resident #1 was not pushed by CNA A resulting in a fall in his room on 5/27/2024. This failure placed residents at risk for abuse with potential for injuries, pain, trauma, and hospitalization . Findings included: Review of Resident #1's face sheet dated 6/12/2024 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Osteoarthritis left knee (arthritis of the knee), Alzheimer's Disease (progressive brain disorder that destroys memory and thinking skills), Age-related Macular Degeneration (degenerative condition of the eye affecting sight), Psychophysical visual disturbances (auditory/visual hallucinations/delusions), Hearing loss, Hypertension (high blood pressure), and Cerebrovascular Disease (problem with blood flow in the brain). Review of Resident #1's admission MDS dated [DATE] reflected a BIMS score of 3 suggesting severe cognitive impairment. Section D for mood indicated no mood problems at that time. Section E for behavior indicated Resident #1 had delusions, verbal behaviors/symptoms directed toward others and had refusal of care behaviors 1 to 3 days in the last week. Review of Resident #1's care plan dated 6/12/2024 reflected Resident #1 had a witnessed fall and aggressive/combative behaviors on 5/27/2024 with an intervention of Resident had a witnessed fall related to aggressive and combative behaviors. Resident was assessed for injury and was found to have no injury at this time. Resident refused vitals and all other interventions. Redirection was ineffective. Resident was assisted back to bed. Fall and safety precautions maintained. Review of Resident #1's progress notes dated 5/27/2024 at 10:00 AM by RN B reflected: Resident was being assisted to his room by this nurse and aides while showing combative behavior with staff and housekeeping. This nurse and aide walked resident to room and let go of resident when resident tried to swing again at this nurse and lost balance and fell on his bottom against his bed. This nurse and aides attempted to help resident up and resident continued with combative and aggressive behavior, but we were able to get resident backup and resident still attempted to swing at this nurse and aides when on his feet. This nurse and aides exited residents room to prevent resident from injuring staff or himself. Resident refused any VS check. Further review of progress notes on 5/28/2024 at 7:29 PM skin assessment completed and noted healing scratch to left lower back and left side of neck, no open areas noted, no s/s pain noted to areas. Review of neurological flow sheet dated 5/27/2024 for Resident #1 indicated an initial assessment was completed at 10:03 AM on 5/27/2024 by RN B with a note refused by resident. Review of PA progress note dated 5/27/2024 reflected 5/27 More agitation recently will add hydroxyzine to 75mg QID, was on this at home. Has been swinging at staff. Has done this before at home. Was able to speak to [FM]. Doing well with therapy. Family concerned about oral intake, seems good to me, but will follow up with BMP. PA progress notes further revealed that Resident #1's vital signs were taken at 10:27 AM on 5/27/2024. Under Assessment and Plan: 5/27 Increase hydroxyzine [anti-anxiety medications] to 75 mg QID. During an interview on 6/12/2024 at 11:34 AM, Resident #1 stated he was doing good and felt safe at the facility. He stated he remembered falling a while back and got some scratches, but it wasn't too bad. Resident #1 denied having any issues with staff or other residents but appeared confused at times and was not able to answer a question posed, but paused and shrugged his shoulders. During an interview on 6/12/2024 at 1:16 PM, the FM stated they were contacted by the facility on 5/27/2024 and informed that Resident #1 had fallen but had no injuries. The FM stated they went up to the facility on [DATE] and arrived about 30 minutes after the facility called. Resident #1 was in his room in bed. The FM stated about 5 to 10 minutes later the facility PA came in and spoke to Resident #1 and assessed him for increased agitation and stated he would increase his anxiety medication. The FM stated they later reviewed video footage of the incident and could see Resident #1 being pushed by CNA A and fell in his room, then staff left him alone. The FM stated no one ever asked Resident #1 if he was okay or attempted to check him out to see if he was hurt. The FM stated they did not see anyone enter his room again until they arrived approximately 30 minutes later. The FM stated she was very upset and was crying by what they had witnessed being done to Resident #1 in the video. The FM stated they had a care plan meeting the next day, 5/28/2024, at the facility to discuss Resident #1's behaviors and aggressiveness towards staff. The FM stated at the meeting they showed the video footage of the fall incident from 5/27/2024 to the AD. The FM stated the AD watched the video several times and immediately took action. The FM stated a head-to-toe skin assessment was completed for Resident #1. Resident #1 was noted to have a scratch on his left lower back and an abrasion to the left collar bone area. During an interview on 6/12/2024 at 2:24 PM the AD stated the facility had a care plan meeting with Resident #1's FM on 5/28/2024 about 3:00 PM. After the meeting the FM showed her and the DON the video footage from the fall incident on 5/27/2024 in Resident #1's room. The AD stated, in the video I see her [CNA B] push the resident to the ground; the nurse tries to jump in front of him to catch him, but she does not. The AD stated she could see the resident being combative with staff as they tried to help him up but Resident #1 was not assessed immediately due to aggressiveness. She stated in the video she could see staff assist Resident #1 to his feet, assist him to the bed where he sat down, and then staff left the room and closed the door behind them. The AD stated they immediately suspended the CNA and RN involved and notified the police, and the MD. The AD stated the DON had an immediate head to toe skin assessment completed on Resident #1 where a scratch on his lower back and an abrasion on his collar bone area were discovered. The AD stated the police arrived the next morning, 5/29/2024, and Resident #1 was interviewed by her with the police present. Resident #1 was able to recall that he fell and that someone pushed him from behind causing him to fall. Resident #1 showed his injuries to the police officer. During an interview on 6/12/2024 at 2:24 PM, the DON stated on 5/27/2024 she had received a call from RN B that Resident #1 had fallen. RN B had assessed him and had no injuries. She stated she was told the facility PA was on the unit at that time and saw the resident and also assessed him. She stated this was what RN B stated in the statement that she had given about the incident. She stated she was not aware Resident #1 had not been assessed until 5/28/2024 when the FM showed them the video. She stated on 5/28/2024, she watched the video of the fall incident provided by the FM and it showed CNA A pushing Resident #1 from the back. He fell hitting his bed on the way down and landed on his bottom. She stated she could not see RN B assess Resident #1 in the video nor hear her ask if he was okay or if she could take his vital signs. She stated CNA A was terminated after the incident and on 5/30/2024, RN B was provided 1:1 education on proper transfers, had to take a test, and complete a return demonstration before she was cleared to return to work on 5/31/2024. The DON stated Resident #1 was not assessed immediately because of his aggressive behavior. She stated the facility PA was on the unit and about 30 minutes after the fall the AP went to see Resident # 1. There were no new orders, no injuries noted, and no complaints from Resident #1 at that time. The DON stated on 5/30/24 Resident #1 indicated he had pain to his knees and ankles and was observed guarding his left shoulder. Xray images were ordered and ruled out any fractures. During an interview on 6/13/2024 at 10:37 AM, RN B stated she was with Resident #1 and CNA A on 5/27/2024 when Resident #1 fell . RN B stated she did not see CNA A push the resident. She stated she did see him fall and tried to catch him but was not able to and he hit the bed and then landed on the floor on his bottom. She stated they immediately tried to help Resident #1 back up, but he was fighting with them and trying to hit them. She stated she thought she asked him if he was okay and if she could do vitals on him right after he fell . She stated she watched the video and could not hear herself ask if he was ok over CNA A talking. She stated she did not hear herself ask him if she could do vital signs and did not hear Resident #1 say no. She stated she has been trained on falls and stated they were supposed to assess residents after the fall to see if there were any injuries. She stated they left the room because Resident #1 was so agitated, and they wanted to give him time to calm down. She stated the next staff that went in Resident #1's room was the facility PA and that was about 30 minutes or so later and the FM was already in the room. During an interview on 6/13/2024 at 11:42 AM, the Medical Director (MD) stated he was aware of the fall incident with Resident #1 on 5/27/2024 where he was pushed by CNA A. He stated his expectations after a fall was for the resident to be assessed to see if there were any injuries. If there were any major injuries needing emergency care, these should be taken care of and address any reasons for the fall to prevent a recurrence. The MD stated he would have concerns about waiting 30 minutes or more to assess a resident, That is concerning if nobody asks him if he is okay or looks at him for 30 minutes. He stated his understanding was that Resident #1 had been assessed and had no injuries. He stated Resident #1 has been a very challenging resident that they had managed as well as they could until he started becoming more violent. Review of video provided by the FM revealed on 5/27/2024 at 9:38 am Resident #1 was being assisted to his room by CNA A and RN B. Resident #1 was seen walking through the doorway with both staff and was struggling with staff. RN B lets go of his left hand and then CNA A lets go of his right hand and was seen taking her left hand and pushing it against Resident #1's back causing him to fall to the ground, striking the bed, and landing on the floor on his bottom. Staff was then seen trying to assist Resident #1 up and he was resisting. The staff gets Resident #1 to his feet and assisted him to the bed where he sat down. Staff then left the room and closed the door. Audio review does not indicate if any staff asked him if he was okay after the fall or if any staff asked him if they could check his vitals and Resident said 'no'. Review of statement dated 5/29/2024 at 10:05 AM, CNA A revealed she denied doing anything to Resident #1 and that he had been forcefully pulling away. In an attempt not to hurt [Resident #1[ due to his pulling from us, [RN B] and I let him go, at which time I began to fall and was able to break my fall. I attempted to brace [Resident #1] from falling but it was too late. Review of statement dated 5/29/2024 at 8:52 AM, RN B stated CNA A had come to help her get Resident #1 to his room and we both help him to his room while he is still trying to hit us, we let go of his arms when we enter the room and at that point [Resident #1] attempts to hit us again and tumbles over his feet and falls to the ground with his back on the bed I ask him is he okay and can I take his vitals. {Resident #1] replies to me no and begins to cuss at us again. We finally were able to get him up and he tells us get the *** out so we leave the room. Review of facility self-report dated 5/29/2024 that included Plan of Correction and steps taken reflected: o Reviewed footage from the family multiple times and then reviewed footage from the facility cameras and it Is almost definite that the resident was pushed by CNA [CNA A] resulting in him becoming unsteady and falling. He fell on to his left side brushing against the bed frame and the overbed table. o Interview with resident with officer [name omitted] present-resident able to recall that he fell . He was not able to recall the day, but he recalls someone pushing him from behind causing him to lose his balance and he fell . He pulled up his sweater and showed the officer the area on his left clavicle and the scratch on his left lower back. Review of CNA A onboarding folder reflected she had received training on ANE on 9/16/2002 and the form was signed by CNA A. Further review reflected a document Senate [NAME] 9. Legislation on curbing abuse was signed on 9/16/2020 by CNA A indicating CNA A had been made aware of how to curb abuse. Review of background check information provided by facility on 6/13/2024 reflected appropriate background checks (employability, criminal and license checks) were performed prior to hire and yearly as required for CNA A and RN B. Review of facility in-service training sheet dated 5/21/2024 with topics Abuse and Neglect, who to report allegations of abuse to, Resident Rights, Customer Service reflected the printed name and signature of CNA A. The in-service sheet had a copy of the facility Abuse and Neglect Policy attached, copy of the Resident Rights hand out attached, as well as hand out with the Abuse Coordinator's information and phone number. Review of undated facility Policy Prevention and Reporting of Suspected Abuse and Neglect reflected This facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The Administrator and Director of Nursing are responsible for the implementation and ongoing monitoring of abuse policies and procedures. Implementation and ongoing monitoring consist of the following policies: Screening, Training, Prevention, Identification, Protection, Investigation, and Reporting.

Based on observation, interview and record review, the facility failed to respect the residents' right for 3 (Resident #1, Resident #27, and Resident #42) of 3 residents to send and promptly receive unopened mail, letters, and packages each postal delivery day. The facility failed to ensure Residents #1, #27, and #42 had the right to receive unopened packages. The failure could affect the rights of the facility's residents by opening their packages. Findings included: Review of Resident #1's face sheet dated 08/02/2023 revealed a [AGE] year-old-female with an admitted [DATE]. Diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, bipolar disorder, unspecified, and personal history of malignant neoplasm of brain (a fast-growing cancer that spreads to other areas of the brain and spine). Review of Resident #1's most recent MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 14 suggesting Resident #1 is cognitively intact. Review of Resident #27's face sheet dated 08/02/2023 revealed a [AGE] year-old-female with an admitted [DATE]. Diagnoses included Alzheimer's disease, unspecified, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, and other symptoms and signs involving cognitive functions and awareness. Review of Resident #27's most recent MDS assessment dated [DATE] revealed Resident #27 had a BIMS score of 99 suggesting resident was unable to complete the interview. Review of resident #42's face sheet dated 08/02/2023 revealed a [AGE] year-old-male with an admitted [DATE]. Diagnoses included vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), mild cognitive impairment of uncertain or unknown etiology, personal history of transient ischemic attack (a stroke that lasts only a few minutes), and cerebral infarction without residual deficits. Review of Resident #42's most recent MDS assessment dated [DATE] revealed Resident #42 had a BIMS score of 13 suggesting the resident is cognitively intact. Interview with Resident #42 on 08/02/2023 at 10:06 a.m., revealed that he had received packages two times at the facility and both times the packages came to his room fully opened. When he asked the receptionist, who brought him the packages, why there were opened, he revealed she said the facility had to make sure he was not getting anything he should not have. He revealed it felt like it was an evasion of his privacy for them to be opened before he even had a chance to see what was in them. Interview on 08/02/2023 with the facility receptionist at 1:03 p.m., revealed that she opened the residents' packages and took the opened boxes to the residents. When asked why she opened them, she revealed she did not know why she opened them then said she felt like it was a courtesy to them because often they are taped and might have difficulties opening them. She said that there is no facility policy requiring her to open resident packages and no one from the facility administration told her to open resident packages. When asked why she opened Resident #42's package she revealed that she was not sure if he has scissors and if he did, he might hurt himself with the scissors. She revealed she did try to tape his package shut after opening it to make it look like it had not been previously opened. When asked how she would feel if she received a package delivered to her home opened, she said she would feel like she had her privacy invaded. She revealed she opened Resident #1's package that contained books, Resident #27's packages that contained clothing, and Resident #47's packages that contained books. She revealed she was not trained in resident's rights but had received an in-service on residents' rights. Interview on 08/02/2023 with the ADM at 2:25 p.m., revealed she had no idea that the receptionist was opening residents' packages and was surprised. ADM revealed that the receptionist had been both trained and in-serviced resident rights and residents' packages should never be opened without their permission. ADM revealed if her packages were delivered to her opened, she would be unhappy and feel like it was an invasion of privacy. Review of HHSC (Health and Human Services Commission) Nursing Facility Resident Rights', undated, revealed Residents of Texas nursing facilities have all the rights, benefits, responsibilities, and privileges granted by the Constitution and laws of this state and the United States. They have the right to be free of interference, coercion, discrimination, and reprisal in exercising these rights as citizens of the United States. Residents have the right to be treated with dignity, courtesy, consideration, and respect. Residents of the right to privacy and confidentiality and residents have the right to receive unopened mail.

Based on interviews and record review the facility failed to ensure residents had the right to be free from abuse for 1 of 7 residents (Resident #1) reviewed for abuse. The facility failed to ensure a safe environment free from abuse for Resident #1 when CNA A pulled a taser out to scare Resident #1 on 04/29/2023. An Immediate Jeopardy (IJ) was identified to have occurred from 04/29/23 to 05/06/23. This was determined to be a Past Noncompliance IJ due to the facility having to implemented actions that corrected the noncompliance prior to the investigation. The failure could place residents at risk for abuse. Findings included: Review of Resident #1's face sheet reflected the resident was a [AGE] year-old male and was admitted to the facility on [DATE]. The diagnoses included Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may include personality changes, and emotional problems), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (feeling of fear, dread, and uneasiness), glaucoma in diseases classified elsewhere (disease of the eye and adnexa), and insomnia (sleep disorder in which you have trouble falling and/or staying asleep). Review of Resident #1's MDS, dated [DATE] revealed Resident #1's BIMS score was 03 (out of 15) which indicated cognitive severe impairment. Review of Resident #1's Care Plan, dated 04/06/23, addresses a history of insomnia, resisting/refusing care, Alzheimer/Dementia, depression, and potential of demonstrate physical behaviors related to dementia/poor impulse control. Resident #1's interventions for history of insomnia were assess daytime sleeping patterns, assess for causes of insomnia and document in the clinical record, dim light and provide quiet environment during the night, and collaborate with in-house nurse practitioner/medical director and psych nurse, as warranted. Resident #1 interventions for resisting/refusing care are do not rush resident when providing care, encourage and allow them to perform all cares as able, introduce self to resident, explain all care to be provided, use simple direct communication, 1-2 step instructions, offer 1-2 item choices as needed. If the resident is combative, aggressive of refuse care, provide for safety, offer alternative time for car, back away, seek assistance as needed, notify nurse of behaviors of refusal. Resident #1 interventions for Alzheimer/Dementia are if resident behaviors are affecting other residents, remove from common area and place in calmer setting. Do not isolate, provide music, tv, and other appropriate activity, introduce self to resident and explain care/procedure to be performed prior to beginning, encourage and assist resident to attend activities of interest, and encourage and allow resident to verbalize needs and concerns. Resident #1 interventions for depression are social worker will visit and provide emotional support and reassurance through a comforting presence as needed, approach in calm manner, introduce self and explain procedure/care to be provided, provide positive interaction with resident, observe for side effects to include but not limit to: headache, weakness change in appetite, nervousness, change in appetite, dry mouth and document findings and notify medical director. Resident #1 interventions for demonstrating physical behaviors related to dementia/poor impulse control are communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated, document observed behavior and attempted interventions in behavior log, when Resident #1 becomes agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, to staff walk calmly away and approach later. Interview with the DON on 05/16/23 at 12:41 p.m. the DON stated she was not in the building when CNA A pulled the taser on Resident #1 but stated that she was notified by Charge Nurse A. The DON stated that no weapon such as a taser were allowed in the facility. The DON stated CNA A could have injured the residents, herself, or other staff members by having a taser in the facility. The DON stated that the resident could have suffered mental anguish for the incident. CNA A was placed in the Do Not Return list from the facility and exited from the agency. DON stated she has been in-serviced on abuse and neglect and workplace violence. Interview with the Administrator on 05/16/23 at 1:25 p.m. the Administrator stated that Charge Nurse A called and stated that CNA A pulled out a taser on Resident #1. Charge Nurse A removed CNA A, ensured the resident was ok and then called the administrator. The Administrator then immediately notified the [staffing agency name] Agency and police. Facility staff were in-serviced on facility policies and procedures. The Administrator stated that the Account Representative for stated that the agency does not require agency staff to be in-serviced on abuse or neglect. The agency only required agency staff to receive a background check, verification of licenses/certifications and drug test. The Administrator stated weapons were not allowed in the facility. The Administrator said that the resident or staff could have been hurt during this incident. Interview with the Charge Nurse A on 05/26/23 at 10:20 a.m., Charge Nurse A stated she was on the other side of the dining area and heard flickering sounds, like something electrical. Charge Nurse A then started walking around to find where the noise was coming from. Charge Nurse A then saw CNA A with the taser by her side pointed at the ground setting it off. CNA A was telling Resident #1 to get back and don't mess with me. Charge Nurse A then told CNA A to stop and had a staff remove CNA A while Charge Nurse A stayed with Resident #1. Charge Nurse A and Resident #1 walked to his room. Charge Nurse A asked Resident #1 was he ok and he stated yes. Resident #1 then stated he wanted to stay in his room, but he wasn't upset. Charge Nurse A stated Resident #1 had no injuries from the incident. Charge Nurse A then reached out to the Administrator and DON regarding the situation. Charge Nurse A was told to get a statement from CNA A but CNA A refused. CNA A stated to Charge Nurse A that she was going to leave because she was told she could come back. Charge Nurse A stated that CNA A did state that Resident #2 went into Resident 1's room and that upset him. CNA A stated that's when Resident #1 began to yell and ball up his fist at her in a threatening way. Charge Nurse A stated she did not call the Police because the Administrator stated she would do it. Charge Nurse A stated that she was in-serviced on preventing abuse, abuse coordinator (ADM) and Violence Free Workplace. Interview with CNA B on 05/26/23 at 11:25 a.m., CNA B stated that she and CNA A was assisting to change a resident when they overheard a resident talking in a loud aggressive tone. Once they left out the room CNA A went to see what was going on. CNA B stated that Resident #1 appeared to be upset but she didn't know why. CNA B stated she doesn't know what a taser looks like, but she did hear a noise that sounded like electricity. CNA B stated she has never seen the item that was making the electricity noise. CNA B stated that she was an agency staff and has not been back to the facility since the incident. CNA B stated she did not witness any resident harmed doing the incident. A record of review of the facility's Prevention and Reporting of Suspected Resident Abuse and Neglect policy not dated, reflected, the facility has designed and implement processes, which strive to ensure the prevention and reporting of suspected or alleged resident abuse and neglect. This facility has implemented the following processes in an effort to provide residents and staff a comfortable and safe environment. The Administrator and Director of Nursing are responsible for the implementation and ongoing monitoring of abuse policies and procedures. Implementation and ongoing monitoring consist of the following policies: Screening, Training, Prevention, Identification, Protection, Investigation and Reporting. Reporting, Requirements and Definitions: C. Abuse Allegation - define as the willful infliction of injury, unreasonable confinement intimidation, or punishment with resulting physical harm, pain or mental anguish. A record of review of the facility's policy titled Violence-Free Workplace not dated, reflected, It is facility policy to provide a workplace that is safe and free from all threatening and intimidating conduct. Therefore, facility will not tolerate violence or threats of violence of any form in the workplace, at work related functions, or outside of work if it affects the workplace. This policy applies to facility employees, clients, customers, guests, vendors and persons doing business with Senior Care. It will be a violation of this policy for any individual to engage in any conduct, verbal or physical, which intimidates, endangers, or creates the perception of intent to harm persons or property. Examples include but are not limited to: Physical assaults or threats of physical assault, whether made in person or by: other means (i.e., in writing, by phone, fax, or email). Verbal conduct that is intimidating and has the purpose or effect of threatening the health or safety of a coworker. Possession of firearms or any other lethal weapon on company property, in a vehicle being used on company business, in any company owned or leased parking facility, or at work-related function. Any other conduct or acts which management believes represents an imminent or potential danger to workplace safety/security. Anyone with questions or complaints about workplace behaviors, which fall under this policy, may discuss them with a supervisor or a Human Resources representative. The facility will promptly and thoroughly investigate any reported occurrences or threats of violence. Violations of this policy will result in disciplinary action, up to and including immediate termination of employees. Where such actions involve non-employees, facility will take action appropriate for the circumstances. Where appropriate and/or necessary, facility will also take whatever legal actions are available and necessary to stop the conduct and protect facility employees and property. This noncompliance was identified as Past Noncompliance (PNC). The noncompliance began on 04/29/2023 and ended on 05/06/2023. The facility had corrected the noncompliance before the survey began. The facility took the following actions to correct the non-compliance: 1. 04/29/23 Administrator immediately removed CNA A from the facility, and they were not allowed to return to the facility. 2. 04/29/23 DON has been in-serviced on abuse and neglect and workplace. 3. 04/29/23 The Administrator then immediately notified the [staffing agency name] Agency and police department. 4. 04/29/23 The facility self-reported the incident to HHS. 5. 04/29/23 The facility gave the resident a head-to-toe assessment. No injuries were noted. 6. 04/29/23 The facility gave the resident a psychological assessment. No psychological harm was noted. 7. 04/29/23 The facility notified family. 8. 04/29/23 The facility notified the facility's medical director. 9. 04/29/23 The facility placed the CNA A the do not return list. 10. 04/29/23 The Staffing Agency terminated the CNA A for their agency. 11. 04/29/23 The facility implemented a procedure for in-servicing agency staff. 12. 04/29/23 The facility in-serviced staff on Preventing Abuse, Abuse Coordinator & Violence Free Workplace. 13. 04/29/23 The Staff Agency implemented in-serving for agency staff. Agency staff are receiving an abuse, neglect and misappropriation in-servicing prior to them receiving an assessment. 14. 05/26/23 interview with Agency Staff and Facility Staff revealed they had been in-serviced from the facility on Abuse, Neglect Exploitation, Workplace violence. 15. 05/31/23 QAPI met in reference to the incident on 04/29/23. 16. 06/09/23 interviews with AD, CNA D, CNA F and CNA G revealed they had been in-serviced from the facility on Abuse, Neglect Exploitation, Workplace violence.

Based on observation, interview and record review, the facility failed to prohibit neglect when: 1. CNA C failed to provide services necessary to avoid physical harm to one of three residents reviewed for neglect (resident #1). Resident #1 required assistance of two persons for transfers to and from the wheelchair and bed. CNA C transferred resident #1 from the wheelchair to the bed without the assistance of another person. During the transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. This deficient practice placed one of one resident (resident #1) who required assistance of two persons for transfers on Unit 424 at risk of physical harm. 2. The facility failed to maintain all patient care equipment in safe operating condition. Resident #1 had an assist bar attached to her bed for repositioning. During a transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. One of the two ends at the bottom of the assist bar did not have a rubber [MEDICATION NAME] and the metal edge was exposed. This deficient practice placed 11 residents with assist bars attached to their beds on three of four units at risk of physical harm. Findings include: 1. Review of the Admission Record dated 04/11/17 revealed resident #1 was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 60-day assessment dated [DATE] revealed resident #1 was readmitted to the facility on [DATE] after discharge from the acute hospital with [DIAGNOSES REDACTED].#1 had a BIMS score of 4 (severe impairment) and required extensive physical assistance of two or more persons for transfers to and from the bed and wheelchair. Review of the care plan dated 12/09/15 and updated on 12/17/17 read in part: Transfers: Assist x 2 extensive assist (with) gait belt. During an interview on 04/10/17 at 2:10 p.m. the director of rehabilitation stated resident #1 was a two-person transfer with a gait belt, and all the certified nurse aides had been trained on the two-person transfer. During an interview on 04/10/17 at 9:25 a.m. the administrator stated resident #1 was a two-person transfer. The administrator further stated CNA C's employment was terminated due to performing the transfer by herself. Review of the nursing progress note for resident #1 signed by RN D, dated 04/02/17 and timed 7:25 p.m: Called in to resident's room at approx. 1925 (7:25 p.m.) by CNA to assess a wound caused during transfer. CNA stated that while she attempted to transfer resident from chair to bed resident obtained skin tear to left lateral lower extremity. CNA stated that she did not see any available staff prior to transfer for assistance. CNA is unsure of exact cause or object that caused injury, but was visibly upset that injury occurred during transfer. Resident was lying in bed when nurse entered room, did not appear to be in pain or discomfort. Resident asked if she was in any pain and resident stated 'I'm fine'. Resident denied complaints of pain or discomfort during wound care. Further review of the nursing progress note dated 04/02/17 revealed resident #1 had a wound on the left lateral lower extremity that was approximately 9.5 cm in length, 4 cm wide, and 0.3 cm deep, and emergency medical services transported resident #1 to the hospital for possible sutures. Review of the emergency medicine record dated 04/02/17 and timed 9:42 p.m. revealed resident #1 presented to the emergency room via emergency medical services with a laceration of the left lower leg that measured 8 cm in length, the left leg was reportedly cut by a bed rail as the resident was being transferred from her wheelchair to a bed, and the injury mechanism was a metal edge. The hospital record further reflected resident #1 experienced moderate pain and was given local anesthetic, and the laceration was closed using 26 sutures. Review of the emergency department record dated 04/02/17 and timed 11:35 p.m. revealed resident #1 was stable for discharge back to the nursing facility. Review of the provider investigation report dated 04/07/17: On the evening of 04/02/17, (resident #1) was ready to go to bed and her CNA (CNA C) was assisting her to bed. The CNA positioned (resident #1's) wheelchair next to the bed, locked the wheels, placed the gait belt around (resident #1) and transferred her to the bed. (Resident #1) did not call out in pain or grimace during the transfer. When the CNA reached down to help (resident #1) get her legs onto the bed, she noticed a large laceration on the outside of her lower left leg. (CNA C) hurried to get the nurse who came to assess the injury. He cleaned the wound and applied steri strips. After consulting with the DON and the physician, the decision was made to send (resident #1 to the emergency room ). Review of the provider investigation report dated 04/07/17: There were drops of blood directly under the assist bar on the ground, a drop on the assist bar, and some drops directly next to the bed, presumable from when the CNA lifted (resident #1's) legs onto the bed. The laceration was not evident earlier in the evening, and it would be extremely unlikely that anything associated with the wheelchair could have caused the injury (the leg extensions were removed during the transfer). The CNA used a gait belt to stand (resident #1), turned to pivot (resident #1) so that she could sit on the bed, and eased (resident #1) into a sitting position on the bed. In all likelihood, (resident #1's) leg was in contact with the assist bar after she was in the standing position, and the skin tear was obtained during the pivot rotation. Review of the provider investigation report dated 04/07/17: The CNA (CNA C) should have asked another CNA or a nurse to assist with the transfer. (Resident #1) has an order to be transferred with the assistance of 2 people. (CNA C) was very aware of this, but did not see a staff member immediately available when (resident #1) wanted to get into bed. There were 2 other CNA's and 2 nurses present on the unit at the time of the injury. This injury may or may not have been prevented if two people had performed the transfer, but (CNA C) should not have done it by herself. During an interview on 04/10/17 at 2:15 p.m. CNA C stated she knew resident #1 was a two-person transfer, and on the evening of 04/02/17 she transferred resident #1 from the wheelchair to the bed by herself. CNA C stated when she helped resident #1 put her legs on the bed she saw a gash on the resident's left leg and immediately reported it to the nurse. CNA C stated she should have gotten help from another CNA on the unit. Further, CNA C stated resident #1 had a sign on the wall by her bed stating resident #1 was a two-person transfer. During an interview by telephone on 04/10/17 at 5:56 p.m. RN D stated resident #1 was a two-person transfer with a gait belt, and CNA C reported to him that she had transferred resident #1 by herself. Observation on 04/11/17 at 7:35 a.m. with CNA E revealed resident #1 lying in bed in no apparent distress with a V-shaped suture line on the outer aspect of her left lower leg that was approximately 8 cm in length. Further observation revealed the suture line was clean and dry, and there were no signs of infection. There was a sign on the wall by her bed stating resident #1 was a two-person transfer. During an interview on 04/10/17 at 9:50 a.m. RN H stated resident #1 was the only resident on Unit 424 that required assistance of two persons with a gait belt for transfers. RN H further stated the wound on resident #1's left lower leg was healing, and there were no signs of infection. 2. During an interview on 04/10/17 at 9:25 a.m. the administrator stated one of two ends on resident #1's assist bar did not have a rubber [MEDICATION NAME] and the metal edge was exposed. The administrator stated there were drops of blood directly under the assist bar on the ground and a drop of blood on the assist bar. The administrator further stated the facility's routine maintenance schedule did not include checking the assist bars, and the facility had implemented weekly checks of the assist bars on residents' beds starting on 04/03/17. During an interview on 04/10/17 at 9:25 a.m. the maintenance manager stated one of two ends on resident #1's assist bar did not have a rubber [MEDICATION NAME] and metal edge was exposed. The maintenance manager stated 11 residents had assist bars attached to their beds, and during an inspection on 04/03/17 he found that three assist bars were missing a rubber [MEDICATION NAME] and he replaced the rubber [MEDICATION NAME]. The maintance manager further stated that the routine maintenance inspection schedule did not include checking the assist bars on residents' beds and he is now checking the assist bars weekly. Review of the provider investigation report dated 04/07/17: The ends of the assist bars that face down when in the upright position have exposed metal. These ends are intended to have a rubber [MEDICATION NAME]. One of the two ends at the bottom of the assist bar on (resident #1's) bed did not have a rubber [MEDICATION NAME]. This may have contributed to the injury, as a rubber [MEDICATION NAME] may or may not have prevented the metal from penetrating (resident #1's) skin. There had been no reports to maintenance about repairing these ends, and no staff had ever recalled noticing that an end is unprotected (again, the ends are not visible when the bar is upright). All other assist bars in the building were evaluated and 2 of the ten assist bars needed to have one [MEDICATION NAME] added each. Review of the document dated 04/03/17 and provided by the maintenance manager on 04/10/17 revealed three of 11 resident beds with assist bars on three of four units (Units 424, 410, and 416) had an assist bar that was missing a rubber [MEDICATION NAME] and the rubber [MEDICATION NAME] were replaced immediately. The facility policy titled Abuse Policy dated 02/2005 and revised 12/05/16 read in part: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.

Based on observation, interview and record review, the facility failed to maintain all patient care equipment in safe operating condition. Resident #1 had an assist bar attached to her bed for repositioning. During a transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. One of the two ends at the bottom of the assist bar did not have a rubber [MEDICATION NAME] and the metal edge was exposed. This deficient practice placed 11 residents with assist bars attached to their beds on three of four units at risk of physical harm. Findings include: Review of the Admission Record dated 04/11/17 revealed resident #1 was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 60-day assessment dated [DATE] revealed resident #1 was readmitted to the facility on [DATE] after discharge from the acute hospital with [DIAGNOSES REDACTED].#1 had a BIMS score of 4 (severe impairment) and required extensive physical assistance of two or more persons for transfers to and from the bed and wheelchair. Review of the care plan dated 12/09/15 and updated on 12/17/17: Transfers: Assist x 2 extensive assist (with) gait belt. Review of the nursing progress note for resident #1 signed by RN D, dated 04/02/17 and timed 7:25 p.m: Called in to resident's room at approx. 1925 (7:25 p.m.) by CNA to assess a wound caused during transfer. CNA stated that while she attempted to transfer resident from chair to bed resident obtained skin tear to left lateral lower extremity. CNA stated that she did not see any available staff prior to transfer for assistance. CNA is unsure of exact cause or object that caused injury, but was visibly upset that injury occurred during transfer. Resident was lying in bed when nurse entered room, did not appear to be in pain or discomfort. Resident asked if she was in any pain and resident stated 'I'm fine'. Resident denied complaints of pain or discomfort during wound care. Further review of the nursing progress note dated 04/02/17 revealed resident #1 had a wound on the left lateral lower extremity that was approximately 9.5 cm in length, 4 cm wide, and 0.3 cm deep, and emergency medical services transported resident #1 to the hospital for possible sutures. Review of the emergency medicine record dated 04/02/17 and timed 9:42 p.m. revealed that resident #1 presented to the emergency room via emergency medical services with a laceration of the left lower leg that measured 8 cm in length, the left leg was reportedly cut by a bed rail as the resident was being transferred from her wheelchair to a bed, and the injury mechanism was a metal edge. The hospital record further reflected resident #1 experienced moderate pain and was given local anesthetic, and the laceration was closed using 26 sutures. Review of the emergency department record dated 04/02/17 and timed 11:35 p.m. revealed that resident #1 was stable for discharge back to the nursing facility. During an interview on 04/10/17 at 9:25 a.m. the administrator stated one of two ends on resident #1's assist bar did not have a rubber [MEDICATION NAME] and the metal edge was exposed. The administrator stated there were drops of blood directly under the assist bar on the ground and a drop of blood on the assist bar. The administrator further stated the facility's routine maintenance schedule did not include checking the assist bars, and the facility had implemented weekly checks of the assist bars on residents' beds starting on 04/03/17. During an interview on 04/10/17 at 2:15 p.m. CNA C stated she knew resident #1 was a two-person transfer, and on the evening of 04/02/17 she transferred resident #1 from the wheelchair to the bed by herself. CNA C stated when she helped resident #1 put her legs on the bed she saw a gash on the resident's left leg and immediately reported it to the nurse. During an interview on 04/10/17 at 9:25 a.m. the maintenance manager stated one of two ends on resident #1's assist bar did not have a rubber [MEDICATION NAME] and metal edge was exposed. The maintenance manager stated 11 residents had assist bars attached to their beds, and during an inspection on 04/03/17 he found that three assist bars were missing a rubber [MEDICATION NAME] and he replaced the rubber [MEDICATION NAME]. The maintance manager further stated that the routine maintenance inspection schedule did not include checking the assist bars on residents' beds and he is now checking the assist bars weekly. Review of the provider investigation report dated 04/07/17: On the evening of 04/02/17, (resident #1) was ready to go to bed and her CNA (CNA C) was assisting her to bed. The CNA positioned (resident #1's) wheelchair next to the bed, locked the wheels, placed the gait belt around (resident #1) and transferred her to the bed. (Resident #1) did not call out in pain or grimace during the transfer. When the CNA reached down to help (resident #1) get her legs onto the bed, she noticed a large laceration on the outside of her lower left leg. (CNA C) hurried to get the nurse who came to assess the injury. He cleaned the wound and applied steri strips. After consulting with the DON and the physician, the decision was made to send (resident #1 to the emergency room ). Review of the provider investigation report dated 04/07/17: There were drops of blood directly under the assist bar on the ground, a drop on the assist bar, and some drops directly next to the bed, presumable from when the CNA lifted (resident #1's) legs onto the bed. The laceration was not evident earlier in the evening, and it would be extremely unlikely that anything associated with the wheelchair could have caused the injury (the leg extensions were removed during the transfer). The CNA used a gait belt to stand (resident #1), turned to pivot (resident #1) so that she could sit on the bed, and eased (resident #1) into a sitting position on the bed. In all likelihood, (resident #1's) leg was in contact with the assist bar after she was in the standing position, and the skin tear was obtained during the pivot rotation. Review of the provider investigation report dated 04/07/17: 1) The ends of the assist bars that face down when in the upright position have exposed metal. These ends are intended to have a rubber [MEDICATION NAME]. One of the two ends at the bottom of the assist bar on (resident #1's) bed did not have a rubber [MEDICATION NAME]. This may have contributed to the injury, as a rubber [MEDICATION NAME] may or may not have prevented the metal from penetrating (resident #1's) skin. There had been no reports to maintenance about repairing these ends, and no staff had ever recalled noticing that an end is unprotected (again, the ends are not visible when the bar is upright). All other assist bars in the building were evaluated and 2 of the ten assist bars needed to have one [MEDICATION NAME] added each. Review of the document dated 04/03/17 and provided by the maintenance manager on 04/10/17 revealed three of 11 resident beds with assist bars on three of four units (Units 424, 410, and 416) had an assist bar that was missing a rubber [MEDICATION NAME] and the rubber [MEDICATION NAME] were replaced immediately.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prohibited neglect when: 1. CNA C failed to provide services necessary to avoid physical harm to one of three residents reviewed for neglect (resident #1). Resident #1 required assistance of two persons for transfers to and from the wheelchair and bed. CNA C transferred resident #1 from the wheelchair to the bed without the assistance of another person. During the transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. This deficient practice placed one of one resident (resident #1) who required assistance of two persons for transfers on Unit 424 at risk of physical harm. 2. The facility failed to maintain all patient care equipment in safe operating condition. Resident #1 had an assist bar attached to her bed for repositioning. During a transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. One of the two ends at the bottom of the assist bar did not have a rubber [MEDICATION NAME] and the metal edge was exposed. This deficient practice placed 11 residents with assist bars attached to their beds on three of four units at risk of physical harm. Findings include: 1. Review of the Admission Record dated 04/11/17 revealed resident #1 was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 60-day assessment dated [DATE] revealed resident #1 was readmitted to the facility on [DATE] after discharge from the acute hospital with [DIAGNOSES REDACTED].#1 had a BIMS score of 4 (severe impairment) and required extensive physical assistance of two or more persons for transfers to and from the bed and wheelchair. Review of the care plan dated 12/09/15 and updated on 12/17/17 read in part: Transfers: Assist x 2 extensive assist (with) gait belt. During an interview on 04/10/17 at 2:10 p.m. the director of rehabilitation stated resident #1 was a two-person transfer with a gait belt, and all the certified nurse aides had been trained on the two-person transfer. During an interview on 04/10/17 at 9:25 a.m. the administrator stated resident #1 was a two-person transfer. The administrator further stated CNA C's employment was terminated due to performing the transfer by herself. Review of the nursing progress note for resident #1 signed by RN D, dated 04/02/17 and timed 7:25 p.m: Called in to resident's room at approx. 1925 (7:25 p.m.) by CNA to assess a wound caused during transfer. CNA stated that while she attempted to transfer resident from chair to bed resident obtained skin tear to left lateral lower extremity. CNA stated that she did not see any available staff prior to transfer for assistance. CNA is unsure of exact cause or object that caused injury, but was visibly upset that injury occurred during transfer. Resident was lying in bed when nurse entered room, did not appear to be in pain or discomfort. Resident asked if she was in any pain and resident stated 'I'm fine'. Resident denied complaints of pain or discomfort during wound care. Further review of the nursing progress note dated 04/02/17 revealed resident #1 had a wound on the left lateral lower extremity that was approximately 9.5 cm in length, 4 cm wide, and 0.3 cm deep, and emergency medical services transported resident #1 to the hospital for possible sutures. Review of the emergency medicine record dated 04/02/17 and timed 9:42 p.m. revealed resident #1 presented to the emergency room via emergency medical services with a laceration of the left lower leg that measured 8 cm in length, the left leg was reportedly cut by a bed rail as the resident was being transferred from her wheelchair to a bed, and the injury mechanism was a metal edge. The hospital record further reflected resident #1 experienced moderate pain and was given local anesthetic, and the laceration was closed using 26 sutures. Review of the emergency department record dated 04/02/17 and timed 11:35 p.m. revealed resident #1 was stable for discharge back to the nursing facility. Review of the provider investigation report dated 04/07/17: On the evening of 04/02/17, (resident #1) was ready to go to bed and her CNA (CNA C) was assisting her to bed. The CNA positioned (resident #1's) wheelchair next to the bed, locked the wheels, placed the gait belt around (resident #1) and transferred her to the bed. (Resident #1) did not call out in pain or grimace during the transfer. When the CNA reached down to help (resident #1) get her legs onto the bed, she noticed a large laceration on the outside of her lower left leg. (CNA C) hurried to get the nurse who came to assess the injury. He cleaned the wound and applied steri strips. After consulting with the DON and the physician, the decision was made to send (resident #1 to the emergency room ). Review of the provider investigation report dated 04/07/17: There were drops of blood directly under the assist bar on the ground, a drop on the assist bar, and some drops directly next to the bed, presumable from when the CNA lifted (resident #1's) legs onto the bed. The laceration was not evident earlier in the evening, and it would be extremely unlikely that anything associated with the wheelchair could have caused the injury (the leg extensions were removed during the transfer). The CNA used a gait belt to stand (resident #1), turned to pivot (resident #1) so that she could sit on the bed, and eased (resident #1) into a sitting position on the bed. In all likelihood, (resident #1's) leg was in contact with the assist bar after she was in the standing position, and the skin tear was obtained during the pivot rotation. Review of the provider investigation report dated 04/07/17: The CNA (CNA C) should have asked another CNA or a nurse to assist with the transfer. (Resident #1) has an order to be transferred with the assistance of 2 people. (CNA C) was very aware of this, but did not see a staff member immediately available when (resident #1) wanted to get into bed. There were 2 other CNA's and 2 nurses present on the unit at the time of the injury. This injury may or may not have been prevented if two people had performed the transfer, but (CNA C) should not have done it by herself. During an interview on 04/10/17 at 2:15 p.m. CNA C stated she knew resident #1 was a two-person transfer, and on the evening of 04/02/17 she transferred resident #1 from the wheelchair to the bed by herself. CNA C stated when she helped resident #1 put her legs on the bed she saw a gash on the resident's left leg and immediately reported it to the nurse. CNA C stated she should have gotten help from another CNA on the unit. Further, CNA C stated resident #1 had a sign on the wall by her bed stating resident #1 was a two-person transfer. During an interview by telephone on 04/10/17 at 5:56 p.m. RN D stated resident #1 was a two-person transfer with a gait belt, and CNA C reported to him that she had transferred resident #1 by herself. Observation on 04/11/17 at 7:35 a.m. with CNA E revealed resident #1 lying in bed in no apparent distress with a V-shaped suture line on the outer aspect of her left lower leg that was approximately 8 cm in length. Further observation revealed the suture line was clean and dry, and there were no signs of infection. There was a sign on the wall by her bed stating resident #1 was a two-person transfer. During an interview on 04/10/17 at 9:50 a.m. RN H stated resident #1 was the only resident on Unit 424 that required assistance of two persons with a gait belt for transfers. RN H further stated the wound on resident #1's left lower leg was healing, and there were no signs of infection. 2. During an interview on 04/10/17 at 9:25 a.m. the administrator stated one of two ends on resident #1's assist bar did not have a rubber [MEDICATION NAME] and the metal edge was exposed. The administrator stated there were drops of blood directly under the assist bar on the ground and a drop of blood on the assist bar. The administrator further stated the facility's routine maintenance schedule did not include checking the assist bars, and the facility had implemented weekly checks of the assist bars on residents' beds starting on 04/03/17. During an interview on 04/10/17 at 9:25 a.m. the maintenance manager stated one of two ends on resident #1's assist bar did not have a rubber [MEDICATION NAME] and metal edge was exposed. The maintenance manager stated 11 residents had assist bars attached to their beds, and during an inspection on 04/03/17 he found that three assist bars were missing a rubber [MEDICATION NAME] and he replaced the rubber [MEDICATION NAME]. The maintance manager further stated that the routine maintenance inspection schedule did not include checking the assist bars on residents' beds and he is now checking the assist bars weekly. Review of the provider investigation report dated 04/07/17: The ends of the assist bars that face down when in the upright position have exposed metal. These ends are intended to have a rubber [MEDICATION NAME]. One of the two ends at the bottom of the assist bar on (resident #1's) bed did not have a rubber [MEDICATION NAME]. This may have contributed to the injury, as a rubber [MEDICATION NAME] may or may not have prevented the metal from penetrating (resident #1's) skin. There had been no reports to maintenance about repairing these ends, and no staff had ever recalled noticing that an end is unprotected (again, the ends are not visible when the bar is upright). All other assist bars in the building were evaluated and 2 of the ten assist bars needed to have one [MEDICATION NAME] added each. Review of the document dated 04/03/17 and provided by the maintenance manager on 04/10/17 revealed three of 11 resident beds with assist bars on three of four units (Units 424, 410, and 416) had an assist bar that was missing a rubber [MEDICATION NAME] and the rubber [MEDICATION NAME] were replaced immediately. Review of the facility policy titled Abuse Policy dated 02/2005 and revised 12/05/16: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility must prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.

Based on observation, interview and record review, the facility failed to ensure the services provided by the facility were provided by a qualified person in accordance with each resident's written plan of care when: CNA C failed to provide services necessary to avoid physical harm to one of three residents reviewed for comprehensive care plans (resident #1). Resident #1 required assistance of two persons for transfers to and from the wheelchair and bed. CNA C transferred resident #1 from the wheelchair to the bed without the assistance of another person. During the transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. This deficient practice placed one of one resident (resident #1) who was care planned to receive assistance of two persons for transfers on Unit 424 at risk of physical harm. Findings include: Review of the Admission Record dated 04/11/17 revealed resident #1 was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 60-day assessment dated [DATE] revealed resident #1 was readmitted to the facility on [DATE] after discharge from the acute hospital with [DIAGNOSES REDACTED].#1 had a BIMS score of 4 (severe impairment) and required extensive physical assistance of two or more persons for transfers to and from the bed and wheelchair. Review of the care plan dated 12/09/15 and updated on 12/17/17 read in part: Transfers: Assist x 2 extensive assist (with) gait belt. During an interview on 04/10/17 at 2:10 p.m. the director of rehabilitation stated resident #1 was a two-person transfer with a gait belt, and all the certified nurse aides had been trained on the two-person transfer. During an interview on 04/10/17 at 9:25 a.m. the administrator stated resident #1 was a two-person transfer. The administrator further stated CNA C's employment was terminated due to performing the transfer by herself. Review of the nursing progress note for resident #1 signed by RN D, dated 04/02/17 and timed 7:25 p.m: Called in to resident's room at approx. 1925 (7:25 p.m.) by CNA to assess a wound caused during transfer. CNA stated that while she attempted to transfer resident from chair to bed resident obtained skin tear to left lateral lower extremity. CNA stated that she did not see any available staff prior to transfer for assistance. CNA is unsure of exact cause or object that caused injury, but was visibly upset that injury occurred during transfer. Resident was lying in bed when nurse entered room, did not appear to be in pain or discomfort. Resident asked if she was in any pain and resident stated 'I'm fine'. Resident denied complaints of pain or discomfort during wound care. Further review of the nursing progress note dated 04/02/17 revealed resident #1 had a wound on the left lateral lower extremity that was approximately 9.5 cm in length, 4 cm wide, and 0.3 cm deep, and emergency medical services transported resident #1 to the hospital for possible sutures. Review of the emergency medicine record dated 04/02/17 and timed 9:42 p.m. revealed resident #1 presented to the emergency room via emergency medical services with a laceration of the left lower leg that measured 8 cm in length, the left leg was reportedly cut by a bed rail as the resident was being transferred from her wheelchair to a bed, and the injury mechanism was a metal edge. The hospital record further reflected resident #1 experienced moderate pain and was given local anesthetic, and the laceration was closed using 26 sutures. Review of the emergency department record dated 04/02/17 and timed 11:35 p.m. revealed resident #1 was stable for discharge back to the nursing facility. Review of the provider investigation report dated 04/07/17: On the evening of 04/02/17, (resident #1) was ready to go to bed and her CNA (CNA C) was assisting her to bed. The CNA positioned (resident #1's) wheelchair next to the bed, locked the wheels, placed the gait belt around (resident #1) and transferred her to the bed. (Resident #1) did not call out in pain or grimace during the transfer. When the CNA reached down to help (resident #1) get her legs onto the bed, she noticed a large laceration on the outside of her lower left leg. (CNA C) hurried to get the nurse who came to assess the injury. He cleaned the wound and applied steri strips. After consulting with the DON and the physician, the decision was made to send (resident #1 to the emergency room ). Review of the provider investigation report dated 04/07/17: There were drops of blood directly under the assist bar on the ground, a drop on the assist bar, and some drops directly next to the bed, presumable from when the CNA lifted (resident #1's) legs onto the bed. The laceration was not evident earlier in the evening, and it would be extremely unlikely that anything associated with the wheelchair could have caused the injury (the leg extensions were removed during the transfer). The CNA used a gait belt to stand (resident #1), turned to pivot (resident #1) so that she could sit on the bed, and eased (resident #1) into a sitting position on the bed. In all likelihood, (resident #1's) leg was in contact with the assist bar after she was in the standing position, and the skin tear was obtained during the pivot rotation. Further review of the provider investigation report dated 04/07/17: 1) The ends of the assist bars that face down when in the upright position have exposed metal. These ends are intended to have a rubber [MEDICATION NAME]. One of the two ends at the bottom of the assist bar on (resident #1's) bed did not have a rubber [MEDICATION NAME]. This may have contributed to the injury, as a rubber [MEDICATION NAME] may or may not have prevented the metal from penetrating (resident #1's) skin. There had been no reports to maintenance about repairing these ends, and no staff had ever recalled noticing that an end is unprotected (again, the ends are not visible when the bar is upright). All other assist bars in the building were evaluated and 2 of the ten assist bars needed to have one [MEDICATION NAME] added each. 2) The CNA (CNA C) should have asked another CNA or a nurse to assist with the transfer. (Resident #1) has an order to be transferred with the assistance of 2 people. (CNA C) was very aware of this, but did not see a staff member immediately available when (resident #1) wanted to get into bed. There were 2 other CNA's and 2 nurses present on the unit at the time of the injury. This injury may or may not have been prevented if two people had performed the transfer, but (CNA C) should not have done it by herself. During an interview on 04/10/17 at 2:15 p.m. CNA C stated she knew resident #1 was a two-person transfer, and on the evening of 04/02/17 she transferred resident #1 from the wheelchair to the bed by herself. CNA C stated when she helped resident #1 put her legs on the bed she saw a gash on the resident's left leg and immediately reported it to the nurse. CNA C stated she should have gotten help from another CNA on the unit. Further, CNA C stated resident #1 had a sign on the wall by her bed stating resident #1 was a two-person transfer. During an interview by telephone on 04/10/17 at 5:56 p.m. RN D stated resident #1 was a two-person transfer with a gait belt, and CNA C reported to him that she had transferred resident #1 by herself. Observation on 04/11/17 at 7:35 a.m. with CNA E revealed resident #1 lying in bed in no apparent distress with a V-shaped suture line on the outer aspect of her left lower leg that was approximately 8 cm in length. Further observation revealed the suture line was clean and dry, and there were no signs of infection. There was a sign on the wall by her bed stating resident #1 was a two-person transfer. During an interview on 04/10/17 at 9:50 a.m. RN H stated resident #1 was the only resident on Unit 424 that required assistance of two persons with a gait belt for transfers. RN H further stated the wound on resident #1's left lower leg was healing, and there were no signs of infection.

Based on observation, interview and record review, the facility failed to ensure that: 1. Each resident received adequate supervision and assistance devices to prevent accidents when: CNA C failed to provide services necessary to avoid physical harm to one of three residents reviewed for accidents (resident #1). Resident #1 required assistance of two persons for transfers to and from the wheelchair and bed. CNA C transferred resident #1 from the wheelchair to the bed without the assistance of another person. During the transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. This deficient practice placed one of one resident (resident #1) who required assistance of two persons for transfers on Unit 424 at risk of physical harm. 2. The environment remained as free from accident hazards as possible when: Resident #1 had an assist bar attached to her bed for repositioning. During a transfer, resident #1 sustained a laceration to her left lower leg that required 26 sutures. One of the two ends at the bottom of the assist bar did not have a rubber stopper and the metal edge was exposed. This deficient practice placed 11 residents with assist bars attached to their beds on three of four units at risk of physical harm. Findings include: 1. Review of the Admission Record dated 04/11/17 revealed resident #1 was a [AGE] year-old female who was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 60-day assessment dated [DATE] revealed resident #1 was readmitted to the facility on [DATE] after discharge from the acute hospital with [DIAGNOSES REDACTED].#1 had a BIMS score of 4 (severe impairment) and required extensive physical assistance of two or more persons for transfers to and from the bed and wheelchair. Review of the care plan dated 12/09/15 and updated on 12/17/17 read in part: Transfers: Assist x 2 extensive assist (with) gait belt. During an interview on 04/10/17 at 2:10 p.m. the director of rehabilitation stated resident #1 was a two-person transfer with a gait belt, and all the certified nurse aides had been trained on the two-person transfer. During an interview on 04/10/17 at 9:25 a.m. the administrator stated resident #1 was a two-person transfer. The administrator further stated CNA C's employment was terminated due to performing the transfer by herself. Review of the nursing progress note for resident #1 signed by RN D, dated 04/02/17 and timed 7:25 p.m: Called in to resident's room at approx. 1925 (7:25 p.m.) by CNA to assess a wound caused during transfer. CNA stated that while she attempted to transfer resident from chair to bed resident obtained skin tear to left lateral lower extremity. CNA stated that she did not see any available staff prior to transfer for assistance. CNA is unsure of exact cause or object that caused injury, but was visibly upset that injury occurred during transfer. Resident was lying in bed when nurse entered room, did not appear to be in pain or discomfort. Resident asked if she was in any pain and resident stated 'I'm fine'. Resident denied complaints of pain or discomfort during wound care. Further review of the nursing progress note dated 04/02/17 revealed resident #1 had a wound on the left lateral lower extremity that was approximately 9.5 cm in length, 4 cm wide, and 0.3 cm deep, and emergency medical services transported resident #1 to the hospital for possible sutures. Review of the emergency medicine record dated 04/02/17 and timed 9:42 p.m. revealed resident #1 presented to the emergency room via emergency medical services with a laceration of the left lower leg that measured 8 cm in length, the left leg was reportedly cut by a bed rail as the resident was being transferred from her wheelchair to a bed, and the injury mechanism was a metal edge. The hospital record further reflected resident #1 experienced moderate pain and was given local anesthetic, and the laceration was closed using 26 sutures. Review of the emergency department record dated 04/02/17 and timed 11:35 p.m. revealed resident #1 was stable for discharge back to the nursing facility. Review of the provider investigation report dated 04/07/17: On the evening of 04/02/17, (resident #1) was ready to go to bed and her CNA (CNA C) was assisting her to bed. The CNA positioned (resident #1's) wheelchair next to the bed, locked the wheels, placed the gait belt around (resident #1) and transferred her to the bed. (Resident #1) did not call out in pain or grimace during the transfer. When the CNA reached down to help (resident #1) get her legs onto the bed, she noticed a large laceration on the outside of her lower left leg. (CNA C) hurried to get the nurse who came to assess the injury. He cleaned the wound and applied steri strips. After consulting with the DON and the physician, the decision was made to send (resident #1 to the emergency room ). Review of the provider investigation report dated 04/07/17: There were drops of blood directly under the assist bar on the ground, a drop on the assist bar, and some drops directly next to the bed, presumable from when the CNA lifted (resident #1's) legs onto the bed. The laceration was not evident earlier in the evening, and it would be extremely unlikely that anything associated with the wheelchair could have caused the injury (the leg extensions were removed during the transfer). The CNA used a gait belt to stand (resident #1), turned to pivot (resident #1) so that she could sit on the bed, and eased (resident #1) into a sitting position on the bed. In all likelihood, (resident #1's) leg was in contact with the assist bar after she was in the standing position, and the skin tear was obtained during the pivot rotation. Review of the provider investigation report dated 04/07/17: The CNA (CNA C) should have asked another CNA or a nurse to assist with the transfer. (Resident #1) has an order to be transferred with the assistance of 2 people. (CNA C) was very aware of this, but did not see a staff member immediately available when (resident #1) wanted to get into bed. There were 2 other CNA's and 2 nurses present on the unit at the time of the injury. This injury may or may not have been prevented if two people had performed the transfer, but (CNA C) should not have done it by herself. During an interview on 04/10/17 at 2:15 p.m. CNA C stated she knew resident #1 was a two-person transfer, and on the evening of 04/02/17 she transferred resident #1 from the wheelchair to the bed by herself. CNA C stated when she helped resident #1 put her legs on the bed she saw a gash on the resident's left leg and immediately reported it to the nurse. CNA C stated she should have gotten help from another CNA on the unit. Further, CNA C stated resident #1 had a sign on the wall by her bed stating resident #1 was a two-person transfer. During an interview by telephone on 04/10/17 at 5:56 p.m. RN D stated resident #1 was a two-person transfer with a gait belt, and CNA C reported to him that she had transferred resident #1 by herself. Observation on 04/11/17 at 7:35 a.m. with CNA E revealed resident #1 lying in bed in no apparent distress with a V-shaped suture line on the outer aspect of her left lower leg that was approximately 8 cm in length. Further observation revealed the suture line was clean and dry, and there were no signs of infection. There was a sign on the wall by her bed stating resident #1 was a two-person transfer. During an interview on 04/10/17 at 9:50 a.m. RN H stated resident #1 was the only resident on Unit 424 that required assistance of two persons with a gait belt for transfers. RN H further stated the wound on resident #1's left lower leg was healing, and there were no signs of infection. 2. During an interview on 04/10/17 at 9:25 a.m. the administrator stated one of two ends on resident #1's assist bar did not have a rubber stopper and the metal edge was exposed. The administrator stated there were drops of blood directly under the assist bar on the ground and a drop of blood on the assist bar. The administrator further stated the facility's routine maintenance schedule did not include checking the assist bars, and the facility had implemented weekly checks of the assist bars on residents' beds starting on 04/03/17. During an interview on 04/10/17 at 9:25 a.m. the maintenance manager stated one of two ends on resident #1's assist bar did not have a rubber stopper and metal edge was exposed. The maintenance manager stated 11 residents had assist bars attached to their beds, and during an inspection on 04/03/17 he found that three assist bars were missing a rubber stopper and he replaced the rubber stoppers. The maintance manager further stated that the routine maintenance inspection schedule did not include checking the assist bars on residents' beds and he is now checking the assist bars weekly. Review of the provider investigation report dated 04/07/17: The ends of the assist bars that face down when in the upright position have exposed metal. These ends are intended to have a rubber stopper. One of the two ends at the bottom of the assist bar on (resident #1's) bed did not have a rubber stopper. This may have contributed to the injury, as a rubber stopper may or may not have prevented the metal from penetrating (resident #1's) skin. There had been no reports to maintenance about repairing these ends, and no staff had ever recalled noticing that an end is unprotected (again, the ends are not visible when the bar is upright). All other assist bars in the building were evaluated and 2 of the ten assist bars needed to have one stopper added each. Review of the document dated 04/03/17 and provided by the maintenance manager on 04/10/17 revealed three of 11 resident beds with assist bars on three of four units (Units 424, 410, and 416) had an assist bar that was missing a rubber stopper and the rubber stoppers were replaced immediately.

Based on interview and record review, the facility failed to ensure 1 of 4 residents (Resident #1) reviewed for falls with injury/neglect received adequate supervision to prevent accidents. CNA B did not intervene after witnessing Resident #1 ambulating unassisted from Resident #1's room to the dining room. While in the dining room, CNA A did not provide adequate supervision while assisting Resident #1. CNA A walked away from Resident #1 and the resident fell , landed on her bottom, and sustained a fracture to the left hip. This failure resulted in actual harm to Resident #1 and could have also affected 32 residents in hall 100 for accidents or serious harm. The findings were: Record review of Resident #1's, Face Sheet revealed Resident #1 was a [AGE] year-old woman who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1's [DIAGNOSES REDACTED]. Record review of Resident #1's Order Summary Sheet dated 12/21/16, revealed Resident #1 should ambulate only with walker and aid/assistance due to fall risk/history of fractures. Order date was 8/02/15 and start date was 11/16/16. Record review of Resident #1's Care Plan, date initiated 12/09/15, revised on 12/22/16, indicated Resident #1: -Resident #1 has the potential for falls related to cognitive impairment, debility Interventions: - monitor for pain due to fall and medicate as necessary; - never leave resident alone in bathroom, or turn back to; -never leave Resident alone or out of sight or reach during transfer; -anticipate and meet the resident's needs. Place items frequently used by the resident within easy reach when in the room. -educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. -encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility; -ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair -fall risk screening upon admission and quarterly to identify risk factors. -keep bed in the lowest position when not providing care. Record review of the facility's Fall Incidents Log for the period of 10/01/16 to the present revealed on 12/25/16, Resident #1 had a witnessed fall in the dining area. Review of the facility's Provider Investigation Report (PIR) dated and submitted to the State Agency (SA) on 12/30/16 revealed that on 12/25/16 at around 7:10 a.m., Resident #1 was ambulating to the dining room for breakfast using her walker and being assisted by CNA A. Resident #1 became tired and wanted to sit down. CNA A reached to get a chair and as she did, Resident #1 fell backward landing her buttocks/left hip. Resident #1 was assessed and complained of mild pain to her left hip. Resident #1 was assisted to her wheelchair and taken to her bed. The PIR documented LVN A evaluated Resident # 1 noting mild let hip pain and possible rotation. LVN A recommended x-ray and transfer to the hospital. X-rays were completed at the hospital and the results showed an acute fracture. The PIR documented CNA A assisted Resident #1 with her walker on the way to the dining room. Resident #1's gait had slowed down and R#1 appeared fatigued. CNA A asked if Resident #1 was tired and Resident #1 replied yes. CNA A instructed Resident #1 to stay right there, I'll get you a chair. CNA A took a few steps to get a chair and as she was getting the chair, she noticed Resident #1 was falling backwards. Resident #1 landed on her bottom in a sitting position with her legs forward in front of her. According to the PIR, LVN A and Housekeeper witnessed Resident #1 as she was falling and noted that she fell on her buttock. The facility's PIR also documents The Physician orders [REDACTED]. The care plan shows Resident #1 is a one person assist. The facility concluded that the results of the investigation did not show that any neglectful action or inaction contributed to this injury. The PIR documented In hindsight, CNA A could have lowered Resident #1 to the floor if necessary. However, CNA A's judgment was to reach for a chair was consistent with the plan of care and Physician order [REDACTED]. Review of PIR revealed CNA B was not identified, listed or interviewed as a witness to Resident #1's fall on 12/25/16. PIR also did not list or reference an interview of Resident #1's physician to clarify or determine any facility violation of physician orders. In an interview on 1/26/17 at 1:15 p.m., Certified Nursing Assistant A (CNA A) said, I was walking Resident #1 to dining room from her room with her walker. We got the outside of the column by the dining room and about three (3) feet from the table she sits at. Her gait had slowed down and she appeared really tired. I asked her if she was tired and she said she was. I looked down the hallway and did not see anyone, so I made the decision to grab a chair about 3 feet way to get behind her so she could sit down. I told Resident #1 not to move, that I was going to get a chair for her to sit in. Just as I went to grab the chair, I notice Resident #1 starting to fall. There was no way I could get to her to prevent her from falling. She landed on her bottom in a sitting position. The nurse was coming down the hallway and examined Resident #1. Resident #1 was calm, but did tell the nurse her left hip was hurting. The nurse directed us to get her up and get her into the chair. She and I got her up, one on each side under her arm and leg so she did not bear any weight and CNA B put the chair under her. We got her up to the bed and used the same manner transferred her into the bed. CNA A said she was trained not to leave Resident #1's side. CNA A said she probably had other options, but did not think about that in the moment. CNA A said she had never been in a situation like this one before and was not trying to hurt Resident #1. CNA A said she was trying to help Resident #1, but everything happened so fast. In an interview on 1/26/17 at 1:00 p.m., Licensed Vocational Nurse A (LVN A) said she was down the hallway on the treatment cart reading and signing papers. LVN A said CNA A and Resident #1 walked out of Resident #1's room and they were using the walker. LVN A said she looked and saw Resident #1 falling in the dining room. LVN A said she could not see CNA A because her view was partially blocked by a column in the dining room. LVN A said CNA A was with Resident #1 when she responded to the dining room. LVN A said she saw Resident #1 when she was falling but did not see CNA A. LVN A said the incident happened so fast, she was focused on Resident #1 and not looking for CNA A, but when she ran to respond CNA A was with Resident #1. LVN A said when Resident #1 is ambulating; someone has to be physically touching her so she does not lose her balance. LVN A said when you walk a resident, you cannot leave their side or let go of them. LVN A said there were no circumstances or excuses for leaving a resident per the Resident 1's plan of care. LVN A said CNA B was behind her at a resident's door. LVN A said she was not sure where CNA B was when Resident #1 fell , but CNA #B could have seen the incident. In an interview on 1/26/17 at 10:55 a.m., the Housekeeper said he went to get supplies out of the closet of Bluebonnet and saw Resident #1 coming out of her room with CNA A. Housekeeper said as he was walking out of the door of Bluebonnet, he heard a fall and turned around and saw Resident #1 on the floor. Housekeeper said he did not see Resident #1 fall. Housekeeper said he turned around and saw Resident #1 on the ground. Housekeeper said CNA A must have moved her arm and Resident #1 fell . Housekeeper said CNA A was standing next to Resident #1 when he saw her, but he did not see the fall, he heard the crash. In an interview on 1/26/17 at 4:30 p.m., Physician said he had a standing order for over a year stating Resident #1 should have assistance with a walker and from an aide when ambulating. Physician stated to him leaving Resident #1 for even two (2) or three (3) seconds was a violation of the order. Physician said for every second Resident #1 was on her feet, someone should be there. Physician stated the CNA made a bad decision. Physician said he meant what he said in the standing order and Resident #1 should not have been left alone to protect Resident #1's best interest and he hoped the facility personnel had been properly trained to do so. Physician stated he wrote the Progress Note dated 12/30/16 at 12:55 p.m. for Resident #1. Record review of Progress Notes dated 12/30/16 at 12:55 p.m., for Resident #1 state, Here to check on Resident #1 discharged from hospital, status [REDACTED]. At this point, seems to have tolerated surgery well, but is as expected very weak. Review of the chart and current/signed orders prior to her fall on 12/25/16, clearly state the only circumstances she should be weight bearing is with her walker and aide/assistance due to fall risk and previous hip fracture. Apparently, Resident #1 was up with the walker but no aid/assistance when she fell which is/was a violation of a very clear order even if left for a second without aid. The note was dated and signed by the Physician. In an interview on 01/26/17 at 4:15 p.m., Director of Nurses (DON) said the physician Order Summary Report dated December 21, 2016 documented Resident #1 had mobility limitations and restrictions. The physician order [REDACTED]. The DON stated the physician order [REDACTED]. The DON indicated Resident #1 required staff assistance at all times while the resident was ambulating or standing with rolling walker. The DON stated the facility initiated and conducted a Provider Investigation Report (PIR) and reported to the State Agency (SA) on 12/26/16 due to Resident #1's fall on 12/25/16. The DON said CNA A assisted Resident #1 on 12/25/16 from the resident's room to the facility's dining room for breakfast. The DON said R#1 utilized a rolling walker. The DON stated CNA A then left R#1 unassisted for a brief period on 12/25/16 in the dining room. The DON indicated the facility's internal investigation revealed CNA A left Resident #1 unassisted in the dining room when the CNA recognized and confirmed from the resident she felt weak and the staff member made a poor judgment call to leave the resident to retrieve a chair located in the dining room. Resident #1 consequently fell and sustained a left hip fracture according to radiology report dated 12/25/16 and PIR dated 12/26/16. The DON confirmed CNA A did not follow the physician's orders [REDACTED].#1. In an interview on 01/26/17 at 1:45 p.m., Registered Nurse A (RN A) stated Resident #1 had a physician order [REDACTED]. RN A stated the physician order [REDACTED]. RN A stated R#1's chart identified the resident as [AGE] years old, with lower extremity weakness, prior history of non-facility right hip fracture, history of falls at the facility, high risk for falls and facility acquired left hip fracture from fall on 12/25/16. RN A also stated that nursing personnel who provided care for Resident #1 had knowledge of the resident's physician orders [REDACTED]. In an interview/written statement on 01/26/17 at 2:00 p.m., CNA B stated she witnessed Resident #1 exit her room and ambulate with rolling walker to the dining room unattended. CNA B said she was near Resident #1's room across the hallway in the doorway of another resident's room waiting for LVN A to finish wound care treatment for [REDACTED]. CNA B stated she stated to LVN A I hope she doesn't fall. She's walking by herself (referring to Resident #1). CNA B stated she had knowledge of the physician orders [REDACTED]. CNA B stated she had knowledge of Resident #1's history of previous hip fracture and resident's generalized lower extremity weakness. CNA B stated she witnessed Resident #1 ambulate from the resident's room through the hallway and into the dining room unattended with no staff member near her. CNA B said she then heard Resident #1 scream and saw the resident on the floor in the dining room. CNA B said she then notified LVN A that Resident #1 had fallen to the floor and both rushed to assist the resident. CNA B said that when she approached Resident #1 that CNA A yelled at CNA B and said I don't need your help. CNA B said she and LVN A still assisted Resident #1. When asked by this surveyor whether Resident #1 was neglected by the facility in providing care. CNA B stated Yes. CNA said CNA A should have been with her at all times. When asked by this surveyor why CNA B did not intervene to assist the resident when she first saw the resident exiting her room unattended. CNA B stated Resident #1 was not her assigned resident and that CNA A was rude and didn't like to be helped. When asked by this surveyor whether the decision to not initially intervene when she saw Resident #1 exit her room unattended could also be neglect. CNA B said I guess so. CNA stated she reported the incident to the facility Administrator and DON on 12/26/16. In an interview on 1/26/17 at 3:45 p.m., the Administrator said he was the facility's Abuse Coordinator. Administrator stated he reported Resident #1's fall to the SA on 12/26/16 as possible facility neglect. Administrator stated CNA A and CNA B were both interviewed through the facility's PIR of Resident #1 fall on 12/25/16. Administrator stated he initially did not consider CNA B's interview statement as credible and did not consider CNA B's statement in the decision to not intervene to assist Resident #1 as possible neglect. Administrator acknowledged the facility did not follow the physician's orders [REDACTED]. Administrator also confirmed that CNA B's decision to not initially intervene when she saw Resident #1 ambulating unattended was in violation of the facility's Neglect policy. Administrator indicated both CNA A and CNA B both had knowledge of Resident #1's ambulatory limitations and knowledge of the facility's Abuse, Neglect and Exploitation policy. During the Exit Conference on 01/27/17 the facility Administrator provided SA surveyors a document titled Client/Resident/Individual Information form for Resident #1 given to DADS Investigators by the Administrator on 1/27/17 which documents the following: On 12/25/16, Resident #1 fell on the way to the dining room. Resident #1 was ambulating with the assistance of CNA A. At the time, three witnesses were identified. The DON interviewed CNA B who stated she saw Resident #1 leaving her bedroom with her walker and heard CNA A say from behind Resident #1, don't stop, Keep walking. CNA B stated when she went into another residents room she heard a loud scream. CNA B looked down the hallway and saw Resident #1 falling to the ground with no other staff in sight. CNA B ran up to help Resident #1 and then saw CNA A come from out of nowhere to help Resident #1. CNA B was not identified as a witness to the incident. CNA B came to the aid of Resident #1 after the incident happened. On 12/26/16, DADS Surveyors interviewed CNA B and reportedly were told by CNA B that she stood in a resident's doorway and watched Resident #1 walk down the hall unassisted. CNA B reportedly told them that she knew Resident #1 was a fall risk and was afraid Resident #1 would fall. CNA B reportedly told them that she did not act to intervene until Resident #1 did actually fall. After the fall, CNA B reportedly called LVN A and rushed to the aid of Resident #1. This statement to the Surveyors is a different version of the story than was originally reported by CNA B and is in direct contradiction to the statements made by three other witnesses. If this version of the story is correct then CNA B did neglect to intervene on Resident #1's behalf while she ambulated by herself to the dining room. An investigation into this statement is being opened and CNA B will be suspended pending the result of that investigation. Review of the facility's resident roster on 1/25/17, indicated 32 residents in hall 100.