Every finding on record at Wheeler Nursing & Rehabilitation

Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systemically organized for 1 of 5 residents (Resident #1) reviewed for medical records. The facility failed to ensure RN A accurately documented the ordered care of suprapubic catheter care for Resident #1 on 03/18/2026, and 04/04/2026. This failure could place residents at risk of having records that did not reflect their current status or needs.Findings included: Record review of Resident #1's admission record, dated 04/23/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, but were not limited to Quadriplegia, C1-C4 (spinal cord injury resulting in paralysis of all four limbs), cognitive communication deficit (communication and memory impairment) and personal history of urinary tract infections. Record review of Resident #1's Quarterly MDS Assessment, dated 03/05/2026, revealed a BIMS of 15 out of 15, which indicated cognition was intact. In Section H of the MDS it reflected Resident #1 has an indwelling catheter (including suprapubic catheter). Record review of Resident #1's care plan, dated 04/03/2026, revealed the resident had an indwelling catheter due to neuromuscular dysfunction of bladder, quadriplegic with goals to show no signs or symptoms of urinary infection and catheter care every shift.The resident was resistive to care related to adjustment of nursing home with goals for the resident to cooperate with care. Record review of Resident #1's active physician's orders reflected the following:Clean suprapubic foley catheter site and pat dry, apply split gauze every day shift for preventative and catheter care. Record review of Resident #1's Wound Administration Record for 03/01/2026 through 03/302026, reflected the following:Clean suprapubic foley catheter site and pat dry, apply split gauze every day shift for preventative and catheter care.03/01/2026-03/17/2026, reflected day shift conducted the care, 03/18/2026, no documentation of care was recorded. 03/19/2026 through 03/30/2026, documentation reflected day shift conducted the care. Record review of Resident #1's Wound Administration Record for 04/1/2026-04/23/2026, reflected the following:Clean suprapubic foley catheter site and pat dry, apply split gauze every day shift for preventative and catheter care: 04/01/2026-04/03/2026, reflected day shift conducted the care, 04/04/2026, no documentation of care was recorded. 04/05/206-04/23/2026, documentation reflected day shift conducted the care. During an interview on 04/23/2026 at 9:45 AM, Resident #1 reported no concerns regarding care. Resident #1 was unable to confirm whether care had been provided but stated everything was going ok. During an attempted interview on 04/23/2026 at 4:45 PM, Resident #1 did not acknowledge or respond to questions related to care and did not engage with this writer. During an interview on 04/24/2026 at 11:50 AM, RN A stated she worked on the day shift on 03/18/2026, and 04/04/2026. RN A stated Resident #1 intermittently declined care when it was offered so she would leave her documentation window open until the care was provided. RN A stated on those two dates she failed to close the documentation window after the care was provided. RN A stated if a resident refused care by the end of her shift, she should have documented that the care was refused. RN A stated she received a verbal counseling and reeducation for failing to complete documentation. RN A stated failure to accurately document care could result in staff being unaware the care was completed. During an interview with MDS LVN, on 04/24/2026 at 12:00 PM, the MDS LVN, who also served as the Assistant Director of Nursing, stated RN A should have documented the care provided. The MDS LVN stated Resident #1 would decline care when offered, requiring staff to reattempt care throughout their shift. The MDS LVN stated RN A left the documentation window open in the clinical record and failed to return to complete the entry. The MDS LVN stated the negative outcome of incomplete documentation was the staff may not be aware of the residents' current status. The MDS LVN further stated, if it was not documented, then it would be considered that it didn't happen. During an interview with the DON on 04/24/2026 at 12:04 PM, the DON stated RN A should have documented the care provided. The DON stated Resident #1 would decline care when it was offered and it would cause the nursing staff to continually return to reattempt care until completed. The DON stated RN A should have closed out her documentation once care was provided or document the care was refused. The DON stated nurses were responsible for ensuring their documentation was complete, and she was responsible for ensuring documentation was accurate. Record review of the facility's policy Documentation, dated 02/13/2007, reflected the following:The facility will maintain complete and accurate documentation for each resident on all appropriate clinical records sheets.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure proper hand hygiene and glove use was practiced. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include:In an observation and interview on 8/26/25 at 12:05 pm [NAME] A was observed with gloved hands to touch food trays, the kitchen prep table, and serving utensils. [NAME] B picked up a tortilla with tongs, placed it on the plate filled the tortilla with meat and then folded the tortilla over using her hand. [NAME] B then continued to pick up serving utensils and plated the rest of the foods. [NAME] A did not wash her hands or change her gloves. [NAME] A stated she realized she had used her hand and stated she had just forgotten to use the tongs. She stated the consequence of touching food was food borne illness.In an interview on 6/24/24 at 2:20 PM, the DM stated she expected all staff to use tongs to serve bread products. The DM stated this could cause cross contamination. The DM stated she was responsible for training staff, and she would retrain them. Record Review of the facility policy and procedure, dated 2016, titled Sanitation/Infection Control documented employees are to wash hands prior to handling food, between handling cooked and uncooked food, after touching objects that may be a source of contamination. Record Review of the facility policy and procedure, dated 2016, titled Food Production and Meal Service documented serving utensils should be used to handle all foods as appropriate.

Based on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #2) of 12 residents reviewed for accuracy of assessments. On Resident #2's MDS the facility inaccurately coded Resident #2 as receiving anticoagulant medication. This failure could place residents at risk of not receiving necessary care. Findings Included: Record review of Resident #2's admission record dated 08/27/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hyperlipidemia (high cholesterol), orthostatic hypotension (form of low blood pressure that happens when standing after sitting or lying down), dysphagia (difficulty producing speech), and chest pain. Record review of Resident #2's quarterly MDS assessment revealed a completion date of 08/25/25. Section C (Cognitive Patterns) revealed a BIMS score of 15 which indicated the resident's cognition was intact. Section N revealed Resident #2 was receiving anticoagulant medication. Record review of Resident #2's care plan completed on 8/21/25 revealed Resident #2 was on anticoagulant therapy.Record review of Resident #2's active order summary report dated 08/26/25 revealed no order for anticoagulant medication. The report did reveal the following order: Aspirin Tablet EC (enteric coated) 81 MG Give 1 tablet by mouth one time a day for Preventative .During an interview on 08/28/25 at 09:54 AM, the MDS LVN stated she was responsible for completing MDS assessments. She stated she used the RAI manual as her policy when completing MDS assessments. When asked if aspirin should be coded as an anticoagulant in section N of the MDS she said yes it should. When she was shown a passage in the RAI which indicated aspirin was not to be coded as anticoagulant, she said, Huh, well ok! I did not know that. The MDS LVN could not think of a negative outcome for residents if aspirin was inaccurately coded as an anticoagulant. During an interview on 08/28/25 at 10:06 AM, the DON stated that the MDS LVN was responsible for MDS assessments. She stated a negative outcome of an inaccurate MDS could be reduction in funding and it could impact improper care for residents because the care plan was based on the MDS.During an interview on 08/28/25 at 10:08 AM, LVN A stated that she was the charge nurse for hall where Resident #2 resided. LVN A stated that the MDS LVN was responsible for MDS assessments and if a MDS was incorrectly coded, a resident's care plan could be affected which could negatively impact the residents' medications. During an interview on 08/28/25 at 10:10 AM, the ADM stated the MDS LVN was responsible for completing MDS assessments. She stated MDS assessments affected facility funding as well as direct resident care plans. The ADM stated having an inaccurate MDS could therefore negatively impact the care a resident received.Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . N041 5: High-Risk Drug Classes: Use and Indication . N041 5E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Coding Tips and Special Populations . Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as NO41 5E, Anticoagulant.

Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #2) of12 residents reviewed for care plans. The facility inaccurately care planned that Resident #2 was receiving Anticoagulant therapy. This failure could place residents at risk of not receiving desired and necessary care and treatmentFindings Included: Record review of Resident #2's admission record dated 08/27/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, hyperlipidemia (high cholesterol), orthostatic hypotension (form of low blood pressure that happens when standing after sitting or lying down), dysphagia (difficulty producing speech), and chest pain. Record review of Resident #2's quarterly MDS assessment revealed a completion date of 08/25/25. Section C (Cognitive Patterns) revealed a BIMS score of 15 which indicated the resident's cognition was intact. Section N revealed Resident #2 was receiving anticoagulant medication. Record review of Resident #2's care plan completed on 8/21/25 revealed Resident #2 was on anticoagulant therapy.Record review of Resident #2's active order summary report dated 08/26/25 revealed no order for anticoagulant medication. The report did reveal the following order: Aspirin Tablet EC (enteric coated) 81 MG Give 1 tablet by mouth one time a day for Preventative .During an interview on 08/28/25 at 9:54 AM, the MDS LVN stated that she was responsible for completing care plans along with the DON. When asked to look at Resident #2's care plan, she stated that it was wrong based on the RAI manual, that she should not have coded him as using an AC, but she thought aspirin was an AC. She stated a possible negative outcome for not having a correct care plan could be improper care. During an interview on 08/28/25 at 10:08 AM, the DON stated it was her and the MDS LVN's responsibility to ensure care plans were completed accurately. She stated that a possible negative outcome for not having the correct information in the care plan would be wrong treatment for residents and improper care. During an interview on 08/28/25 at 10:10 AM, the ADM stated that the MDS LVN and the DON were responsible for making sure the care plans were accurate. She stated a possible negative outcome for not having a care plan that was correct would be that care would not be right for that resident. Record review of the facility's policy titled 'Comprehensive Care plans' dated February 13, 2007, revealed in part the following.The facility will develop a comprehensive care plan for each resident that includes measurable short-term and long-term objectives and timetables to meet a residents medical, nursing and mental and psycho-social needs that are identified in the comprehensive assessment. 5. The comprehensive care plan will be maintained on the resident's clinical record and will be made available to all direct care staff. Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.18.11 dated October 2023 revealed the following: . N041 5: High-Risk Drug Classes: Use and Indication . N041 5E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Coding Tips and Special Populations . Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel as NO41 5E, Anticoagulant.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure the freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure refrigerator and pantry foods were properly stored, labeled, and dated. These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings include: Observation of the freezer on 7/8/24 at 10:20 am revealed the following: 1. (1) box of country fried steak, open to air. 2. (1) box of sweet roll dough, open to air. 3. (1) plastic bag of frozen meat patties, not in original box with no label. 4. (1) plastic bag of frozen sausage patties, not in original box with no label. 5. (1) plastic bag of frozen okra, not in original box with no label. Observation of the kitchen pantry area on 7/8/24 at 10:30 am revealed the following: 1. (3) white plastic bins holding packaged foods with crumbs of food in the bottom. Observations of the kitchen refrigerator on 7/9/24 at 7:10 am revealed there were: 1. (1) ziplock baggie of hardboiled eggs, no label or date 2. (1) box of bacon, open to air. 3. (1) bowl of onions, no label or date 4. (4) glasses of milk, on a plastic tray, not covered, labeled or dated. Observations of the kitchen freezer on 7/9/24 at 7:15 am revealed there were: 1. (1) box of sweet roll dough, open to air. 2. (1) box of biscuits, open to air. 3. (1) bag of hamburger patties, no label, not in original box. Observations of the kitchen freezer on 7/10/24 at 8:55 am revealed there were: 1. (1) box of sweet roll dough, open to air. 2. (1) box of biscuits, open to air. 3. (1) bag of hamburger patties, no label, not in original box. In an interview with the DM on 7/10/24 at 9:00 am, the DM stated she had been in the facility for 4 days and had been working on getting the kitchen in shape. She stated she had trained staff on what to do when cleaning, serving and storing food. She stated all foods should be covered, labeled and dated. She stated foods should be closed to air. The DM stated the consequences of crumbs in the bin, not refrigerating foods appropriately or not labeling and dating the foods would cause cross contamination and could possibly make the residents sick if consumed. Record Review of the policy dated 2/2016 titled Leftover Foods documented: Leftover foods shall be dated, labeled and properly stored in airtight containers after food service. The label should include an expiration or use by date. Record Review of the policy dated 2/2016 titled Leftover Foods documented: Milk must be covered with disposable material, stored in ice in a drainable container, and stored in the refrigerator. Opened packaged food or leftover food is to be tightly wrapped, or covered in clean airtight containers, labeled and dated and stored in refrigerator. Record Review of the policy dated 2/2016 titled Food Storage-Refrigerated and Frozen Foods documented: Food must be stored in a properly covered container with a label and date identifying it. Any foods removed from the [NAME] box must be dated and labeled. Record Review of the policy dated 2/2016 titled Dry Food and Supply Storage documented: Containers are to be cleaned regularly.

Based on interview and record review the facility failed to ensure within 14 days after the facility determined, or should have determined, that there was a significant change in the resident's physical or mental condition for 2 of 14 residents (Residents #1 and #25) reviewed for comprehensive assessments . 1. The facility failed to complete a significant change MDS for Resident #1 within 14 days of 01/23/24-the date he elected to receive hospice care. 2. The facility failed to complete a significant change MDS for Resident #25 within 14 days of 03/27/24-the date she tested positive for COVID 19. These failures could place residents at risk of not receiving the necessary care/treatment. Findings Include: 1. Record review of Resident #1's admission record reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, but were not limited to, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), hemiplegia and hemiparesis (partial paralysis following stroke) following cerebral infarction affecting left non-dominant side, acute respiratory failure (sudden failure of lungs to deliver oxygen to the body), altered mental status (change in brain function) and cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning). Hospice Medicaid was listed as primary payer. The name and phone number of Resident #1's hospice was listed under the external facilities section of his admission record. Record review of Resident #1's significant change MDS reflected it was signed as completed on 02/19/24 by the DON. Section C reflected a BIMS of 9, which indicated moderately impaired cognition. Section O reflected Resident #1 was receiving hospice care while a resident. Record review of Resident #1's care plan, completed on 01/30/24, reflected Resident #1 had a terminal prognosis and was admitted to hospice care. Record review of Resident #1's care plan, completed on 04/23/24 , reflected Resident #1 had a terminal prognosis and was admitted to hospice care. The care plan reflected Resident #1 was receiving pain medication related to hospice end of life care. Record review of Resident #1's active orders as of 07/08/24 reflected the following order with a start date of 01/23/24: All hospice related meds must be re-ordered through hospice pharmacy. Record review of Resident #1's discontinued or completed orders reflected the following order with a start date of 01/23/24: Admit to [name of hospice] Record review of Resident #1's form titled Texas Medicaid Hospice Program Individual Election/Cancellation/Update and dated 01/23/24 reflected Resident #1 elected hospice care and was signed by a hospice representative, Resident #1, and the hospice physician. 2. Record review of Resident #25's admission record reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included, but were not limited to, heart failure (heart muscle fails to pump blood as it should), altered mental status (change in brain function), cognitive communication deficit (difficulty with one or more of the following: attention, memory, perception, language, problem-solving, and reasoning), and COVID-19. Record review of Resident #25's significant change MDS reflected it was signed as completed on 04/17/24 by the DON. Section C reflected a BIMS of 4, which indicated severely impaired cognition. Section I reflected COVID 19 under Additional active diagnoses. Section O reflected Resident #25 was on Isolation or quarantine for active infectious disease while a resident. Record review of Resident #25's care plan, completed on 07/03/24, reflected Resident #25 was positive for COVID 19 on 03/27/24. Record review of Resident #25's discontinued, completed, or struck out orders reflected the following orders with start date of 03/27/24: Zinc Oral Tablet 50 MG (Zinc) Give 2 tablet by mouth one time a day for covid for 10 Days Quercetin Oral Tablet 250 MG (Quercetin) Give 1 tablet by mouth one time a day for covid for 10 days Nac 600 Oral Capsule (Acetylcysteine [Nutrient]) Give 1 capsule by mouth one time a day for COVID for 10 Days Droplet precautions: Resident will remain in room for isolation at all times including meals, bathing, and therapy. Signing indicates that resident has received all care in room this shift. Resident has not left room. Every shift for Covid/Covid Exposure During an interview on 07/10/24 at 09:55 AM, the MDS LVN stated she worked for the facility for 2 weeks. She stated she had one year of experience from 2015 as an MDS coordinator. She stated the RAI was the policy she followed for completing MDS assessments. She stated according to the RAI a significant change MDS had to be completed 14 days after the significant change occurred. The MDS LVN stated there was probably a negative outcome of a significant change MDS not being completed timely. She stated she was not employed when the significant change MDS' were completed for Resident #1 and Resident #25 . During an interview on 07/10/24 at 09:59 AM, the DON stated the policy used in completing MDS assessments was the RAI. She stated she was not familiar with the time frame for completing a significant change MDS as MDS LVN was responsible for completing the assessments timely. The DON stated the former MDS nurse would call her or send her an email when it was time for her to sign off on an MDS assessment. She stated she could not think of a negative outcome of a significant change MDS not being completed timely. During an interview on 07/10/24 at 10:04 AM, the ADM stated the MDS LVN was responsible for completing MDS assessments. She stated the RAI was the policy for MDS'. The ADM stated she did not know the timing for completing a significant change MDS. She stated she could not think of a negative outcome of a significant change MDS not being completed timely . Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual version 1.18.11, dated October 2023, reflected the completion date of a significant change MDS assessment was to be No Later Than 14th calendar day after determination that significant change in resident's status occurred (determination date + 14 calendar days).

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 staff (LVN A) reviewed for infection control. -LVN A did not wash her hands or change her gloves while performing wound care. This deficient practice could place residents at risk for the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene. Findings include: During an observation on 07-09-2024 at 12:49 PM LVN A was observed performing wound care on Resident #5's left decubitus heel wound. LVN A was observed washing her hand and donning gloves. LVN A then removed the old dressing, cleaned the wound with gauze wet with wound cleanser, dried the wound with gauze, cleaned the resident's left foot toes with a gauze pad soaked with betadine. LVN A then packed the left heel decubitus ulcer with collagen powder, covered the decubitus wound with a dry gauze, then wrapped the wound to include the ankle with Kerlex/Kling wrap. LVN A then removed her gloves and washed her hands. LVN A did not change her gloves or wash her hands any time after starting the wound care and before finishing the wound care. During an interview on 07-09-2024 at 01:28 PM LVN A reported that she should have changed her gloves and washed her hands after she removed Resident #5's old dressing because when you remove the old dressing you could have drainage on your hands or gloves that could be passed on to the new dressing and result in cross contaminating the resident which would negatively affect the resident. During an interview on 07-09-2024 at 01:59 PM the DON reported that with wound care and incontinent care she expects staff to change their gloves and wash their hands anytime they removed the old dressing, before they put on the new dressing, complete the incontinent care, before they put on the new brief, basically between the dirty and clean portion of the care. The DON reported that staff should also wash their hands when their hands or gloves become soiled. The DON reported that following this process keeps the infections down and will prevent cross-contamination with the residents. Record review of the competency assessment titled When Hand Washing Should be Performed Check List undated, revealed the following. -After contact with blood, body secretions, excretions, mucous membranes, or non-intact skin. (marked yes-in compliance) -After handling items potentially contaminated with blood, body fluids, excretions, or secretion. (marked yes-in compliance) Signed by LVN A 11-7-2023. Record review of the facility provided policy titled Infection Control Policy and Procedure Manual 2018 undated, revealed the following: Gloving: Gloves are worn for three important reasons. 1. To provide protective barrier and prevent gross contamination of the hands when touching blood, body fluids, excretions, mucous membranes, and non-intact skin. The wearing of gloves is . mandatory for all employees. 2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to another resident during invasive or other resident care procedures . 3. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite (objects or materials which are likely to carry infections such as cloths, utensils, and furniture) can transmit these microorganisms to another resident; in this situation, gloves must be changed between resident contacts, and hands washed after gloves are removed. -Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. -Failure to change gloves between resident contacts is an infection control hazard.

Based on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 6 residents (Resident #1) reviewed for accommodation of needs. Resident #1's call light was not within her reach. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life. Findings include: Record review of Resident #1's face sheet, dated 05/01/2024, revealed that a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses that included but not limited to Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left dominant side (weakness following a stroke), contracture of muscle-multiple sites, dysphagia (difficulty in swallowing), muscle wasting and atrophy, cognitive communication, gastro-esophageal reflux disease without esophagitis, shortness of breath, other abnormalities of gait and mobility, Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15 out of 15 which indicated Resident #1 was cognitively intact. Resident #1 required two-person staff assistance with bed mobility and dressing, total two-person staff dependence with chair/bed transfer, upper and lower body dressing, and personal hygiene. Resident #1 required full assistance with rolling from left to right. Record review of Resident #1's care plan, dated 05/01/2024, revealed, in part, [Resident #1] has a communication problem r/t hearing deficit, pain, respiratory impairment, stroke, weak or absent voice with interventions to ensure and provide a safe environment with call light in reach. Care plan also indicated that Resident #1 has ADL Self-care performance deficit r/t limited mobility with interventions for Resident #1 to use call light to call for assistance. During an observation and interview on 05/01/2024 at 10:01 AM Resident #1 was lying in her bed, her blanket was on top of her. Resident #1 asked the surveyor to get an aide because she needed her call light. Observation of the call light revealed it hanging on wall behind resident's head out of reach of the resident. During an observation and interview on 05/01/2024 at 10:05 AM, LVN A was asked to come to Resident #1's room as the resident was requesting help. LVN A asked Resident #1 what she needed, and Resident #1 stated she needed her call light. LVN A put the call light on Resident #1's blanket within the resident's reach. During an interview on 05/01/2024 at 10:07 AM, LVN A stated two CNA's put Resident #1 to bed and that the negative outcome for not having the call light in reach would be that the resident may need help and could get hurt. During an interview on 5/01/2024 at 10:15 AM, CNA B stated she and another aide forgot to put the call light in Resident #1's reach. CNA B said that a possible negative outcome for not having a call light in reach was that the resident could get hurt. During an interview on 5/01/2024 at 10:20 AM, CNA C stated she and another aide had forgotten to put the call light in Resident #1's reach. CNA C said the resident was a choking risk and couldn't get up on her own; and that a possible negative outcome for not having a call light in reach was that Resident #1 could be in trouble and not be able to call for help. During an interview on 5/01/2024 at 11:20 AM, the DON stated that a possible negative outcome for a resident not having their call light in reach would be that they wouldn't be able to call for help if they needed it. During an interview on 5/01/2024 at 11:20 AM, the DON was asked for a policy regarding accommodation of needs. During an interview on 5/01/2024 at 12:10 PM, the ADM stated that she called the Owner of the facility and said that they do not have a call light or accommodation of needs policy and that it was just common sense.

Based on interviews, and record reviews, the facility failed to ensure that Residents are free from abuse for 6 of 6 residents (Residents #3, #5, #13, #14, #26, #29) reviewed for abuse. 1. The facility failed to prevent Resident #29 from being verbally abused by a facility staff member. 2. The facility failed to keep Residents #3, #5, #13, #14, #26, #29 free from verbal abuse from a facility staff member for extended periods of time resulting in an unsafe and hostile environment. These failures place Residents at risk for psychosocial harm, fearful of retaliation, being uncomfortable, impaired quality of life and abuse as a result of the verbal abuse. An Immediate Jeopardy (IJ) was identified on 7/19/2023 at 5:08PM. While the immediate jeopardy was lifted on 7/21/2023 at 2:35PM, the facility remained out of compliance at a severity of actual harm with potential for more than minimal harm: and scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Plan of removal of IJ will be included in findings. Findings included: Record review of Resident #3's face sheet revealed a [AGE] year old female with an admitted [DATE] with diagnoses including: chronic obstructive pulmonary disease, emphysema and acute kidney failure. Record review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 13. Record review of Resident #5's face sheet reflected a [AGE] year old female with an admitted [DATE] and with diagnoses including chronic kidney disease, altered mental status, hyperparathyroidism, morbid (severe) obesity, unspecified dementia, moderate, with psychotic disturbance, delirium due to known physiological condition, schizophrenia, unspecified, delusional disorders, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, unspecified, major depressive disorder, recurrent, moderate anxiety disorder, unspecified, insomnia, unspecified, essential (primary) hypertension. Record review of Resident #5's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #13's face sheet reflected a [AGE] year old female with an admitted [DATE] and with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, alcohol use unspecified with alcohol-induced persisting dementia, essential (primary) hypertension, major depressive disorder, recurrent, unspecified, unspecified atrial fibrillation. Record review of Resident #13's MDS assessment dated [DATE] reflected a BIMS score of 8. Record review of Resident #14's face sheet reflected a [AGE] year old male with an admitted [DATE] and with diagnoses including acute upper respiratory infection, obesity, major depressive disorder, chronic obstructive pulmonary disease, dementia, unspecified severity, without behavioral, disturbance, psychotic disturbance, mood disturbance, and anxiety, schizoaffective disorder, bipolar type, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, current episode manic without psychotic features. Record review of Resident #14's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #26's face sheet reflected a [AGE] year old male with an admitted [DATE] and with diagnoses including chronic obstructive pulmonary disease, hypertensive chronic kidney disease with stage 1 through stage chronic kidney disease, or unspecified chronic kidney disease, other psychotic disorder not due to a substance or known physiological condition, bipolar disorder, unspecified, major depressive disorder, recurrent, moderate, anxiety disorder, unspecified, other seizures, essential (primary) hypertension, atherosclerosis of coronary artery bypass graft(s), unspecified with unstable angina pectoris, pneumonia due to coronavirus disease, gastro-esophageal reflux disease with esophagitis. Record review of Resident #26's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #29's face sheet revealed a [AGE] year old female with an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, pressure ulcer of other site, stage 2, dysphagia, oral phase, diabetes mellitus, essential (primary) hypertension, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified, unspecified mood [affective] disorder, anxiety disorder. Record review of Resident #29's MDS assessment dated ,d+[DATE]//2023 reflected a BIMS score of 14. During an interview on 7/19/2023 at 10:18AM with CNA F was asked when you see abuse and neglect who do you report it to and how soon do you report it and CNA F replied report it as soon as you see it, the abuse coordinator is Admin, if she isn't there you go up the chain of command. When asked if they have seen staff yell at residents before, CNA F stated yes, one in particular, she has a high-pitched voice, she doesn't yell at residents, but she talks loudly. When asked who, CNA F stated, Charge RN. CNA F was asked if they have any concerns about abuse and neglect in the facility at this time and CNA F replied, not right now. Interview with Resident #13 on 7/19/2023 at 10:32AM: Resident #13 was asked what occurred before, during and immediately after the incident and Resident #13 stated Charge RN was in there yelling at Resident #29 like always. All of the employees know. Charge RN told her to quit her damn yelling. Charge RN looks mean, she's intimidating. Very stern. When she goes past the line, I can recognize it. When asked what the tone of the perpetrator was Resident #13 replied she was ugly and horrible. When asked if they think retaliation has occurred, Resident #13 stated not that I know of. They take Resident #29 to her room to eat now. Its better now because of that. As for me, I've been getting some looks from some nurses. Nurse glares at me all the time. One of them ignored me when I tried to speak to her. Resident #13 was asked if this was reported to who and when, and Resident #13 stated to Admin, the administrator. I've gone to her before about issues that have happened, she just says that she knows, and she'll take care of it. When asked how the resident and the perpetrator interacted before and after the incident, Resident #13 stated just yelling like always since she got here and always at Resident #29. After- she's just a weekend nurse so she's only here 2 days a week. She doesn't interact with me at all now. Not everyone is Charge RN's favorite. On the weekend we all stay in our rooms, so we don't make her mad. Resident #13 was asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care and Resident #13 stated no, no one else, just Resident #29. In an Interview on 7/19/2023 at 10:42AM with family member of Resident #13: Family member was asked while here have they seen any concerns about abuse and neglect and the family member of Resident #13 stated Resident #13 has had issues with Charge RN because of how she talks to the residents. She (Charge RN) just rubs people the wrong way. In an Interview on 7/19/2023 at 10:58AM with Charge LVN was asked when they see abuse and neglect who do they report it to and how soon do they report it and Charge LVN replied Admin and immediately. Charge LVN was asked how they watch the staff to ensure they are caring for residents and Charge LVN stated I watch them providing care at times. When asked if they seen staff yell at residents before, Charge LVN stated Charge RN, but she's just loud, I wouldn't consider it abuse, it's almost like she's hard of hearing. When asked if they have any concerns about abuse and neglect in the facility at this time, Charge LVN replied no. Interview with Resident #26 on 7/19/2023 at 11:05AM: Resident #26 was asked if they like it here and Resident #26 replied it's alright. When asked if staff treat them with dignity and respect, Resident #26 stated mostly. Resident #26 was asked if they ever see staff yell at residents and Resident #26 replied they yell at Resident #29, it happens all the time, Resident #29 yells at people and staff yells back. When asked what the tone of the staff when they yell, Resident #26 stated I don't think it's in a mean or rude way. When asked if they have a problem or concern, who would they talk to, Resident #26 stated well the staff I would guess. Resident #26 asked if they feel comfortable going to staff to talk to them about your concerns and Resident #26 replied not extremely and said, well I don't want to get yelled at. Resident stated that they are familiar with Charge RN and when asked if they see her yell at residents Resident #26 responded sure, she yells at people. Staff and residents, mostly Resident #29. When asked if they are afraid of her, Resident #26 replied it's impossible not to be, she has a voice that says I'm right. Interview with Resident #5 on 7/19/2023 at 12:13PM: Resident #5 was asked if they see interactions between their roommate Resident #29 and staff and Resident #5 stated all the time. When asked how staff treat Resident #29, Resident #5 replied Charge RN yells at her and gets tough with her, but Resident #29 just takes it. Resident #5 stated it makes me feel bad for her. When asked if they have seen staff yell at any other residents, Resident #5 stated no. Interview with Resident #3 on 7/19/2023 at 12:20PM: Resident #3 was asked how they like living there and Resident #3 replied I like it here. When asked if the staff treat them with dignity and respect, Resident #3 stated yes they treat me good, but not everyone is treated well and it only happens on the weekends with Charge RN. When asked if they have seen it happen, Resident #3 replied yes, I've seen her yell at Resident #29, I've seen her yell at staff and stated, sometimes I'm afraid of Charge RN. When asked if they are afraid of retaliation Resident #3 stated yes I am. Resident #3 stated she's verbally abusive and it goes on all the time. When asked if this has been reported to staff, Resident #3 replied lots of people have, everyone knows about it, I don't think they'll ever do anything about it. When asked how the weekend is at the facility, Resident #3 stated I try to stay out of their way or stay in my room. In an Interview on 7/19/2023 at 12:33PM with Resident #15: When asked if they have any concerns about abuse and neglect in the facility right now, Resident #15 replied I don't like how some of the staff holler at the residents. Resident #15 stated Charge RN, she gets mad at Resident #19 or Resident #29 and yells at them. When asked if they are afraid of Charge RN, Resident #15 replied I'm not afraid of her, I'll stand up for myself but I'm afraid if I say something they'll take it out on me. Charge RN yells at people that can't help themselves and that's not right. When asked how the weekend is at the facility, Resident #15 stated I stay in my room, so I don't get yelled at or caught up in it. Interview with Resident #14 on 7/19/2023 at 12:41PM: When asked if they could describe the incident that happened between Resident #29 and RN Charge RN in the dining room earlier this month, Resident #14 stated I was there. Charge RN kept yelling the louder Resident #29 got. It happens a lot. When asked if they have any concerns about abuse and neglect in the facility at this time, Resident #14 responded no concerns, just Charge RN and Resident #29. When asked if they are afraid of Charge RN, Resident #14 stated no I'm not. When asked if they are afraid of retaliation if they were to tell someone, Resident #14 stated well there's no one to tell because everyone see is, but no I'm not afraid of retaliation. Charge RN just isn't using any common sense, she's mean. When asked how the weekend is at the facility, Resident #14 stated it's ok. In an Interview on 7/19/2023 at 12:49PM with CNA B stated, Charge RN yells at Resident #29 only, it happens often. When asked what they think the tone of Charge RN is when this happens, CNA B responded, it's aggressive, it makes the other residents uncomfortable. Interview with Resident #29 on 7/19/2023 at 12:54PM: When asked if they remember the incident, Resident #29 stated not really. When asked if they like it here, Resident #29 stated it's ok. Resident #29 was asked if the staff treat them with dignity and respect and Resident #29 replied I guess so. When asked how Charge RN treat them, Resident #29 replied sometimes she yells but that's just Charge RN doing her thing. When asked how that makes them feel, Resident #29 responded sometimes bad or sad. When asked if they are afraid of Charge RN, Resident #29 replied I'm not afraid of her, she's a good nurse. Resident #29 was asked if they feel safe here and Resident #29 stated yeah. When asked if they remember if there have been past occurrences like this, Resident #29 replied no I don't. In an interview on 7/19/2023 at 1:01PM DON: DON was asked to describe the incident that occurred on 7/9/2023 and DON stated, Charge RN called me when it happened and told me that another resident was yelling 'abuse, abuse', so she called me to tell me that I needed to come and relieve her. When asked if the resident/perpetrator exhibited any behaviors that would provoke one another and if so, what actions were being taken to address this, DON stated no, but we interviewed Charge RN and issued her an EDR, it's like a write up. When asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care, DON stated no. When asked if DON did a psychosocial assessment on all the residents the DON replied, only Resident #29. When asked if they were aware that some of the residents are afraid of Charge RN, DON replied no, I did not know that. In an interview on 7/19/2023 at 1:06PM Admin: When asked how long Charge RN was suspended, Admin stated she was suspended on Sunday and was allowed to come back on Tuesday, but she only works on the weekends. When asked how long the investigation lasted, Admin stated 2 days on Sunday and Monday. Admin was asked to describe the incident and Admin replied Resident #29 yells a lot and Charge RN was trying to tell her not to yell. You do have to raise your voice when talking to Resident #29. Charge RN is loud, and Resident #13 felt like the situation was out of hand. When asked if there were discrepancies and how this was investigated, Admin stated there were, yes. I went and spoke with each of them and none of them had the same story. Resident #13 has a thing against Charge RN. When asked did the resident/perpetrator exhibit any behaviors that would provoke one another and if so, what actions were being taken to address this, the Admin responded yes. I counseled with Charge RN and explained to her to tone it down. Admin was asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care and Admin responded no. When asked if annual performance reviews identified issues with the provision of care, treatment or other concerns the Admin stated Charge RN's always been this way. I constantly tell her to be quiet. When asked what the result of your investigation was, Admin stated my result was she was not abusive. She was just trying to make the resident understand. Admin was asked if their previous warnings or incidents at the facility and Admin replied, yes it was between Resident #13 and about Charge RN yelling. When asked if they came up to the facility on the weekends to check in on Charge RN to see how she was doing after the incident the Admin stated, no I did not. When asked how they assure retaliation does not occur when a staff or resident reports an allegation of abuse the Admin stated, I go visit with the residents and assure them that door is always open. Admin was asked if anyone talked to all of the residents and the Admin responded no, we did not. When asked if they were aware that some of the residents are afraid of Charge RN, Admin responded no I was not aware of that. We did have a mention in our full book survey that the residents were afraid of retaliation, but we talked to the residents and did in-services with staff. Admin as asked what the EDR done for on Charge RN and Admin stated, it was for the incident about her voice and demeaner on that day. When asked if it was for the incident on 7/9/23 the Admin stated yes. Interview on 7/19/2023 at 1:31PM with Admin stated: When asked what they are doing on the weekends to ensure that the situation with Charge RN is no longer happening, the Admin replied I talked with Charge RN and let Residents know to come talk to me. When asked if the Admin has been up there on the weekends the Admin replied no. Interview on 7/19/2023 at 1:50PM with CNA : When asked if they have seen staff yell at residents before CNA B stated yes, all the time and Charge RN yells at Resident #29 all the time. She is loud but there's a difference between yelling at residents and being loud. When asked if they have intervened when they saw this happen, CNA B stated yes, I have, and we've had words about it. I'm very vocal with how she treats Resident #29. Interview on 7/19/2023 at 1:55PM with Admin: When asked on the EDR that was given to Charge RN on 7/12/2023 shows that there are 2 write ups in the last 12 months, Admin responded Oh no, there's no other write ups, that was a mistake, I had used a template to do that and forgo to erase it. When asked what the Admin did about the grievance filed on 5/29/2023 about Charge RN, Admin stated I counseled with her on her demeaner and voice tones. When asked if there were any other investigations about Charge RN the Admin stated no, I always talked to her about her voice and her demeanor with the residents. When asked if the Admin felt like they conducted an effective investigation of this incident on 7/9/2023, Admin stated I know she's a good nurse, she's good to the patients, she takes care of the residents. I don't see her as being abusive, but I know it comes across that way. Admin was asked why Charge RN is still employed, the Admin responded, I don't believe she's abusive. Admin was asked how they know that and Admin stated, Well I asked the residents. When asked if they understand that if the residents are afraid do they think they would be honest and Admin stated, they know Charge RN, but I didn't know anyone was afraid of her. Interview on 7/19/2023 at 2:14PM with Charge RN: Charge RN described the incident and stated I was at the nurse station charting, Resident #29 she was yelling for me at the top of her lungs as I was going down the hall. Resident #29 didn't have her hearing aids. I told her to stop yelling. When asked how they usually respond to the Residents behaviors requests for assistance, Charge RN stated I usually do it right away. I was caring for another Resident at the time. I tried to tell her that I would be back. Charge RN was asked to describe what contact they have with Resident #29 since the investigation and Charge RN replied I worked last weekend with her. When asked what type of training Charge RN had related to abuse and neglect they have received and Charge RN replied we had in-services about it and who to contact. Charge RN stated during the incident that there was a Resident yelling abuse going down the hall so I called the DON to relieve me and she called the Admin. When asked if they have any other information they wish to share in regards to the investigation, Charge RN stated Resident #29 is very hard of hearing. I wasn't being ugly to her. The kitchen supervisor was right there cleaning tables when it happened. Interview on 7/19/2023 at 2:25PM with LVN D: When asked if they have worked with RN Charge RN on the weekends, LVN D stated yes. When asked how Charge RN interacts with residents, LVN D replied I've known her a long time, we work together on Saturdays. She comes off very gruff and she's just loud. I don't think that she means harm or is bad. She just doesn't have any tone control. She's not mean spirited, she just doesn't have elderly gloves and she needs restraint. Interview on 7/19/2023 at 2:39PM with LVN A: When asked if they have worked with RN Charge RN on the weekends, LVN A stated yes. When asked how Charge RN interacts with residents, LVN A stated, I've heard more complains than what I've seen, the main thing is she's just loud, nothing physical. LVN A stated, she's loud and residents don't like it. Interview on 7/19/2023 at 2:47PM with LVN I: When asked if they have worked with RN Charge RN on the weekends, LVN I stated, I'm coming in as she's leaving. When asked how Charge RN interacts with residents, LVN I replied, I haven't seen any interactions, I haven't heard any complaints from the residents. When asked if they have any concerns about abuse and neglect in the facility at this time, LVN I stated I haven't seen anything, I've just heard stuff. I've heard that Charge RN yelled at a few resident, Resident #13 on the other side of the hall, other than that I heard she's always yelling back and forth with Resident #29. Interview on 7/19/2023 at 2:37PM with LVN J: When asked if they have worked with RN Charge RN on the weekends, LVN J responded, yes I do sometimes. When asked how Charge RN interacts with residents, LVN J stated, she's mean, and she yells at them. When asked if they have any concerns about abuse and neglect in the facility at this time, LVN J stated, just that but everyone knows about it, and they don't do anything about it. Interview on 7/19/2023 at 2:50PM with CNA G: When asked if they have seen any staff yell at residents, CNA G replied, Charge RN, yes she has and she has a rude attitude and a loud voice with residents. When asked if they have ever reported it, CNA G stated, well the residents haven't complained to me. When asked if they have seen Charge RN yell at residents, CNA G stated, I haven't seen it, but I always hear her. When asked if they have any concerns about abuse and neglect in the facility at this time, CNA G replied yes, it's degrading for the residents. This is their home. In an interview on 7/21/2023 at 11:31AM Admin: Admin was asked if there are other investigations on Charge RN and Admin stated, there are no other investigations, what's in her file is what I have. When asked if their investigation prevented further abuse, neglect or mistreatment of the resident, Admin replied well, yes because when I did interviews and tried to find out more information, I didn't get the same answers that you guys got. When asked if they felt that the investigation was adequate the Admin stated, yes I do. The Admin was asked if they think that they took appropriate corrective action as a result of the findings and Admin stated yes, I think I did. If I would have got different information, I would have done it differently. When asked if they interviewed other residents to ask them how the yelling/verbal abuse made them feel the Admin responded no. Admin was asked if they monitored Resident #29 and other residents at risk such as conducting unannounced management visits at different times and shifts and Admin replied Yeah, me and DON come in at different times, DON is good at popping up. When asked if on the weekends did the Admin specifically come in to monitor Charge RN's interactions with residents the Admin stated no, I did not come in to observe her. Admin was asked what actions were taken to protect the residents and the Admin replied, well we did the plan of removal after. Admin was asked if they felt that the facility's ANE policies and procedures are implemented well within the staff and the Admin replied they are now, but before it's hard to say really. I don't know. Admin was asked if they are conducting ongoing oversight and supervision of staff to assure that the ANE policies and procedures are implemented as written and Admin responded, I am now yes. When asked if they feel that the staff is able to identify, correct and intervene in situations in which abuse, neglect and exploitation is more likely to occur and the Admin stated now, yes. Record Review of staff in-services indicate that Charge RN was in-serviced on Abuse and Neglect on the following dates: 6/14/2023, 7/7/2023, and 7/19/2023. Record Review of staff in-services indicate that Charge RN was in-serviced on Resident Rights on 7/10/2023. Record review of facility's Grievance Log shows a grievance filed on 5/30/2023 by Resident #13 describes the incident as follows: Charge RN yells at Residents causing Resident #13 to feel uncomfortable. Resident #13 feels Charge RN yells at her and others. The Disposition of Complaint states: talk to RN about her loud voice dealing with Residents. The findings of the incident as follows: Charge RN has a very loud demeanor when dealing with anyone or anything. The Recommendations/Corrective Action states: Counsel with Charge RN on her demeanor and voice tones. Record Review of Facility Grievance Investigation Report dated 5/30/2023 shows a written statement as follows: Resident #13 states they feel like Charge RN verbal abusive to her and the other Residents. Resident #13 states that Charge RN yells at other Residents and makes them feel uncomfortable. Resident #13 states that Charge RN yelled at them for going into the dining room for smoke break and Charge RN yelled at them stating they were in the dining room too early for smoke break. Resident #13 states that sometimes in the dining room Charge RN is so loud that it makes them uncomfortable so they go back to their room. Record Review of Facility Notice of Disciplinary Action for Charge RN is dated 10/13/2022 is detailed as follows: Arguing with Resident in a non-professional manner in a loud tone. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from DON that states: Charge RN was in lobby and Resident #29 was yelling out at staff to come here. Charge RN went over to Resident and told them to stop yelling and Resident #29 told Charge RN that she was not their boss and to not tell them what to do. Charge RN continued to argue with Resident about this but I was talking to someone else at the time and didn't hear the whole conversation. MDS LVN stepped out of their office and told Charge RN to walk away and they did so. After Charge RN got back to their office, Resident #29 then yelled at Charge RN to come back over there. Charge RN did not do so. Earlier in the shift I was asking Resident #29 to stop yelling out and at the same time Charge RN came over and interrupted me to tell Resident #29 the same thing. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from Bus Office that states: This is what I heard but did not see from my office. Resident #29 was in the living area, requesting different things from everyone in a loud tone. Charge RN went up to Resident #29 and in their very loud voice tone told them that they needed to stop yelling and that someone would get to them. I'm not sure if Resident #29 told Charge RN she was not her boss, but Charge RN told Resident #29 you are not by boss, that they worked at the nursing home and cared for them. I then heard MDS LVN tell Charge RN to walk away. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from MDS LVN that states: Charge RN was working 6-2 as RN coverage. Resident #29 was in the lobby after breakfast, and they were wanting to go to bed. Charge RN was yelling at her tell her she had to stay up for 30 min. Charge RN kept arguing with Resident #29. DON told them that the yelling needs to stop and that they couldn't handle it anymore. Resident #33 was getting anxious and restless because of all the yelling. At lunch Resident #29 yelled for me to come there. Charge RN said just keep walking. I did ask them what they needed, and they wanted me to move Resident #17 to their table. I told them to give me a minute and I will. About 10 minutes later, Resident #29 was yelling for LVN G and Charge RN told them to keep going. LVN K did not listen, and Resident #29 wanted a pain pill. LVN G gave her the medicine. After lunch, Resident #29 told Charge RN to come here. Resident #29 wanted to be laid down. Charge RN told her that she had to wait 30 minutes. Resident #29 told Charge RN something I could not hear. Charge RN leaned over the table and to tell Resident #29 you are not by boss. Resident #29 said loudly I am your boss. Charge RN said no you are not my boss and you will not talk to me that way. I immediately got out of my chair and told Charge RN that they needed to walk away. Charge RN went to walk away, and Resident #29 was asking them something and Charge RN put her hand in the air and walked to the middle office up front. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from LVN G that states: I LVN G was working as a LVN at [facility] on 10/13/22. My RN supervisor was Charge RN. Charge RN has really stern assertive voice and sometimes yells a lot. On this particular day Charge RN was on a roll, Resident #29 was in the dining room yelling at me as I went to walk by them and Charge RN yelled at me and told me to keep walking however I stopped to see what they wanted and they asked me for Tylenol. So I went and got them medication. Then in about 30-45 minutes later Resident #29 was in the lobby and just sitting there in a wheelchair and they yelled at me again. I was at the computer doing my charting and I told Resident #29 it would be just a minute. I could visibly see that Resident #29 was not in any harm where I was sitting and they just wanting to talk to me or ask me something. Charge RN heard her from a office and Charge RN stormed out of that office and yelled at Resident #29 saying what do you need. Resident #29 said she wants to lay down Charge RN told it would be 30 minutes then they said I need to talk to my nurse. Charge R said your nurse is busy what do you need? Resident #29 looked at Charge RN and said just go back to your office and leave me alone and Charge RN stormed closer to Resident #29 and said you are not my boss. Charge RN said yes I am your boss. You could tell in the tone of Charge RN voice that the statement Resident #29 made Charge RN really mad. MDS LVN also heard the commotion going on and they stepped out of their office and they told Charge RN you need to step away this is getting out of hand you just need to go take a minute. Chare RN just stared at MDS LVN and then Resident #29 and MDS LVN and then just turned around and walked back into their office. After Charge RN went back to their office Resident #29 started yelling for Charge RN again. Resident #29 is always yelling at nurses for things and Charge RN always yells back. Record Review of Facility Provider Investigation for Charge RN dated 7/9/2023 is detailed as follows: Provider Investigation Report indicates that Charge RN has a history of similar allegations for abuse. Description of the incident is described as Resident #13 accused Charge RN of verbal abuse of Resident #29. Investigation summary states: All staff must raise voice with Resident #29 so they can hear us. Charge RN has a very loud personality and when they raise their voice to talk to Resident #29 it is louder than other staff. Resident #29 will holler after she is done eating until they are put to bed. They have an order to be up after meals for at least 30 minutes. Staff try to expl [TRUNCATED]

Based on interviews, and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents for 6 of 6 residents (Residents #3, #5, #13, #14, #26, #29) reviewed for abuse. The facility failed to implement written abuse and neglect policies to prohibit and prevent abuse for Residents #3, #5, #13, #14, #26 and #29. These failures place Residents at risk for psychosocial harm, fearful of retaliation, being uncomfortable, impaired quality of life and abuse as a result of the verbal abuse. An Immediate Jeopardy (IJ) was identified on 7/19/2023 at 5:08PM. While the immediate jeopardy was lifted on 7/21/2023 at 2:35PM, the facility remained out of compliance at a severity of actual harm with potential for more than minimal harm: and scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. Plan of removal of IJ will be included in findings. Findings included: Record review of Resident #3's face sheet revealed a [AGE] year old female with an admitted [DATE] with diagnoses including: chronic obstructive pulmonary disease, emphysema and acute kidney failure. Record review of Resident #3's MDS assessment dated [DATE] reflected a BIMS score of 13. Record review of Resident #5's face sheet reflected a [AGE] year old female with an admitted [DATE] and with diagnoses including chronic kidney disease, altered mental status, hyperparathyroidism, morbid (severe) obesity, unspecified dementia, moderate, with psychotic disturbance, delirium due to known physiological condition, schizophrenia, unspecified, delusional disorders, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, unspecified, major depressive disorder, recurrent, moderate anxiety disorder, unspecified, insomnia, unspecified, essential (primary) hypertension. Record review of Resident #5's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #13's face sheet reflected a [AGE] year old female with an admitted [DATE] and with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, alcohol use unspecified with alcohol-induced persisting dementia, essential (primary) hypertension, major depressive disorder, recurrent, unspecified, unspecified atrial fibrillation. Record review of Resident #13's MDS assessment dated [DATE] reflected a BIMS score of 8. Record review of Resident #14's face sheet reflected a [AGE] year old male with an admitted [DATE] and with diagnoses including acute upper respiratory infection, obesity, major depressive disorder, chronic obstructive pulmonary disease, dementia, unspecified severity, without behavioral, disturbance, psychotic disturbance, mood disturbance, and anxiety, schizoaffective disorder, bipolar type, unspecified psychosis not due to a substance or known physiological condition, bipolar disorder, current episode manic without psychotic features. Record review of Resident #14's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #26's face sheet reflected a [AGE] year old male with an admitted [DATE] and with diagnoses including chronic obstructive pulmonary disease, hypertensive chronic kidney disease with stage 1 through stage chronic kidney disease, or unspecified chronic kidney disease, other psychotic disorder not due to a substance or known physiological condition, bipolar disorder, unspecified, major depressive disorder, recurrent, moderate, anxiety disorder, unspecified, other seizures, essential (primary) hypertension, atherosclerosis of coronary artery bypass graft(s), unspecified with unstable angina pectoris, pneumonia due to coronavirus disease, gastro-esophageal reflux disease with esophagitis. Record review of Resident #26's MDS assessment dated [DATE] reflected a BIMS score of 15. Record review of Resident #29's face sheet revealed a [AGE] year old female with an admitted [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, pressure ulcer of other site, stage 2, dysphagia, oral phase, diabetes mellitus, essential (primary) hypertension, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety bipolar disorder, unspecified, major depressive disorder, recurrent, unspecified, unspecified mood [affective] disorder, anxiety disorder. Record review of Resident #29's MDS assessment dated ,d+[DATE]//2023 reflected a BIMS score of 14. During an interview on 7/19/2023 at 10:18AM with CNA F was asked when you see abuse and neglect who do you report it to and how soon do you report it and CNA F replied report it as soon as you see it, the abuse coordinator is Admin, if she isn't there you go up the chain of command. When asked if they have seen staff yell at residents before, CNA F stated yes, one in particular, she has a high-pitched voice, she doesn't yell at residents, but she talks loudly. When asked who, CNA F stated, Charge RN. CNA F was asked if they have any concerns about abuse and neglect in the facility at this time and CNA F replied, not right now. Interview with Resident #13 on 7/19/2023 at 10:32AM: Resident #13 was asked what occurred before, during and immediately after the incident and Resident #13 stated Charge RN was in there yelling at Resident #29 like always. All of the employees know. Charge RN told her to quit her damn yelling. Charge RN looks mean, she's intimidating. Very stern. When she goes past the line, I can recognize it. When asked what the tone of the perpetrator was Resident #13 replied she was ugly and horrible. When asked if they think retaliation has occurred, Resident #13 stated not that I know of. They take Resident #29 to her room to eat now. Its better now because of that. As for me, I've been getting some looks from some nurses. Nurse glares at me all the time. One of them ignored me when I tried to speak to her. Resident #13 was asked if this was reported to who and when, and Resident #13 stated to Admin, the administrator. I've gone to her before about issues that have happened, she just says that she knows, and she'll take care of it. When asked how the resident and the perpetrator interacted before and after the incident, Resident #13 stated just yelling like always since she got here and always at Resident #29. After- she's just a weekend nurse so she's only here 2 days a week. She doesn't interact with me at all now. Not everyone is Charge RN's favorite. On the weekend we all stay in our rooms, so we don't make her mad. Resident #13 was asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care and Resident #13 stated no, no one else, just Resident #29. In an Interview on 7/19/2023 at 10:42AM with family member of Resident #13: Family member was asked while here have they seen any concerns about abuse and neglect and the family member of Resident #13 stated Resident #13 has had issues with Charge RN because of how she talks to the residents. She (Charge RN) just rubs people the wrong way. In an Interview on 7/19/2023 at 10:58AM with Charge LVN was asked when they see abuse and neglect who do they report it to and how soon do they report it and Charge LVN replied Admin and immediately. Charge LVN was asked how they watch the staff to ensure they are caring for residents and Charge LVN stated I watch them providing care at times. When asked if they seen staff yell at residents before, Charge LVN stated Charge RN, but she's just loud, I wouldn't consider it abuse, it's almost like she's hard of hearing. When asked if they have any concerns about abuse and neglect in the facility at this time, Charge LVN replied no. Interview with Resident #26 on 7/19/2023 at 11:05AM: Resident #26 was asked if they like it here and Resident #26 replied it's alright. When asked if staff treat them with dignity and respect, Resident #26 stated mostly. Resident #26 was asked if they ever see staff yell at residents and Resident #26 replied they yell at Resident #29, it happens all the time, Resident #29 yells at people and staff yells back. When asked what the tone of the staff when they yell, Resident #26 stated I don't think it's in a mean or rude way. When asked if they have a problem or concern, who would they talk to, Resident #26 stated well the staff I would guess. Resident #26 asked if they feel comfortable going to staff to talk to them about your concerns and Resident #26 replied not extremely and said, well I don't want to get yelled at. Resident stated that they are familiar with Charge RN and when asked if they see her yell at residents Resident #26 responded sure, she yells at people. Staff and residents, mostly Resident #29. When asked if they are afraid of her, Resident #26 replied it's impossible not to be, she has a voice that says I'm right. Interview with Resident #5 on 7/19/2023 at 12:13PM: Resident #5 was asked if they see interactions between their roommate Resident #29 and staff and Resident #5 stated all the time. When asked how staff treat Resident #29, Resident #5 replied Charge RN yells at her and gets tough with her, but Resident #29 just takes it. Resident #5 stated it makes me feel bad for her. When asked if they have seen staff yell at any other residents, Resident #5 stated no. Interview with Resident #3 on 7/19/2023 at 12:20PM: Resident #3 was asked how they like living there and Resident #3 replied I like it here. When asked if the staff treat them with dignity and respect, Resident #3 stated yes they treat me good, but not everyone is treated well and it only happens on the weekends with Charge RN. When asked if they have seen it happen, Resident #3 replied yes, I've seen her yell at Resident #29, I've seen her yell at staff and stated, sometimes I'm afraid of Charge RN. When asked if they are afraid of retaliation Resident #3 stated yes I am. Resident #3 stated she's verbally abusive and it goes on all the time. When asked if this has been reported to staff, Resident #3 replied lots of people have, everyone knows about it, I don't think they'll ever do anything about it. When asked how the weekend is at the facility, Resident #3 stated I try to stay out of their way or stay in my room. In an Interview on 7/19/2023 at 12:33PM with Resident #15: When asked if they have any concerns about abuse and neglect in the facility right now, Resident #15 replied I don't like how some of the staff holler at the residents. Resident #15 stated Charge RN, she gets mad at Resident #19 or Resident #29 and yells at them. When asked if they are afraid of Charge RN, Resident #15 replied I'm not afraid of her, I'll stand up for myself but I'm afraid if I say something they'll take it out on me. Charge RN yells at people that can't help themselves and that's not right. When asked how the weekend is at the facility, Resident #15 stated I stay in my room, so I don't get yelled at or caught up in it. Interview with Resident #14 on 7/19/2023 at 12:41PM: When asked if they could describe the incident that happened between Resident #29 and RN Charge RN in the dining room earlier this month, Resident #14 stated I was there. Charge RN kept yelling the louder Resident #29 got. It happens a lot. When asked if they have any concerns about abuse and neglect in the facility at this time, Resident #14 responded no concerns, just Charge RN and Resident #29. When asked if they are afraid of Charge RN, Resident #14 stated no I'm not. When asked if they are afraid of retaliation if they were to tell someone, Resident #14 stated well there's no one to tell because everyone see is, but no I'm not afraid of retaliation. Charge RN just isn't using any common sense, she's mean. When asked how the weekend is at the facility, Resident #14 stated it's ok. In an Interview on 7/19/2023 at 12:49PM with CNA B stated, Charge RN yells at Resident #29 only, it happens often. When asked what they think the tone of Charge RN is when this happens, CNA B responded, it's aggressive, it makes the other residents uncomfortable. Interview with Resident #29 on 7/19/2023 at 12:54PM: When asked if they remember the incident, Resident #29 stated not really. When asked if they like it here, Resident #29 stated it's ok. Resident #29 was asked if the staff treat them with dignity and respect and Resident #29 replied I guess so. When asked how Charge RN treat them, Resident #29 replied sometimes she yells but that's just Charge RN doing her thing. When asked how that makes them feel, Resident #29 responded sometimes bad or sad. When asked if they are afraid of Charge RN, Resident #29 replied I'm not afraid of her, she's a good nurse. Resident #29 was asked if they feel safe here and Resident #29 stated yeah. When asked if they remember if there have been past occurrences like this, Resident #29 replied no I don't. In an interview on 7/19/2023 at 1:01PM DON: DON was asked to describe the incident that occurred on 7/9/2023 and DON stated, Charge RN called me when it happened and told me that another resident was yelling 'abuse, abuse', so she called me to tell me that I needed to come and relieve her. When asked if the resident/perpetrator exhibited any behaviors that would provoke one another and if so, what actions were being taken to address this, DON stated no, but we interviewed Charge RN and issued her an EDR, it's like a write up. When asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care, DON stated no. When asked if DON did a psychosocial assessment on all the residents the DON replied, only Resident #29. When asked if they were aware that some of the residents are afraid of Charge RN, DON replied no, I did not know that. In an interview on 7/19/2023 at 1:06PM Admin: When asked how long Charge RN was suspended, Admin stated she was suspended on Sunday and was allowed to come back on Tuesday, but she only works on the weekends. When asked how long the investigation lasted, Admin stated 2 days on Sunday and Monday. Admin was asked to describe the incident and Admin replied Resident #29 yells a lot and Charge RN was trying to tell her not to yell. You do have to raise your voice when talking to Resident #29. Charge RN is loud, and Resident #13 felt like the situation was out of hand. When asked if there were discrepancies and how this was investigated, Admin stated there were, yes. I went and spoke with each of them and none of them had the same story. Resident #13 has a thing against Charge RN. When asked did the resident/perpetrator exhibit any behaviors that would provoke one another and if so, what actions were being taken to address this, the Admin responded yes. I counseled with Charge RN and explained to her to tone it down. Admin was asked if the perpetrator exhibited inappropriate behaviors to the resident or other residents in the past such as derogatory language, rough handling or ignoring residents while giving care and Admin responded no. When asked if annual performance reviews identified issues with the provision of care, treatment or other concerns the Admin stated Charge RN's always been this way. I constantly tell her to be quiet. When asked what the result of your investigation was, Admin stated my result was she was not abusive. She was just trying to make the resident understand. Admin was asked if their previous warnings or incidents at the facility and Admin replied, yes it was between Resident #13 and about Charge RN yelling. When asked if they came up to the facility on the weekends to check in on Charge RN to see how she was doing after the incident the Admin stated, no I did not. When asked how they assure retaliation does not occur when a staff or resident reports an allegation of abuse the Admin stated, I go visit with the residents and assure them that door is always open. Admin was asked if anyone talked to all of the residents and the Admin responded no, we did not. When asked if they were aware that some of the residents are afraid of Charge RN, Admin responded no I was not aware of that. We did have a mention in our full book survey that the residents were afraid of retaliation, but we talked to the residents and did in-services with staff. Admin as asked what the EDR done for on Charge RN and Admin stated, it was for the incident about her voice and demeaner on that day. When asked if it was for the incident on 7/9/23 the Admin stated yes. Interview on 7/19/2023 at 1:31PM with Admin stated: When asked what they are doing on the weekends to ensure that the situation with Charge RN is no longer happening, the Admin replied I talked with Charge RN and let Residents know to come talk to me. When asked if the Admin has been up there on the weekends the Admin replied no. Interview on 7/19/2023 at 1:50PM with CNA : When asked if they have seen staff yell at residents before CNA B stated yes, all the time and Charge RN yells at Resident #29 all the time. She is loud but there's a difference between yelling at residents and being loud. When asked if they have intervened when they saw this happen, CNA B stated yes, I have, and we've had words about it. I'm very vocal with how she treats Resident #29. Interview on 7/19/2023 at 1:55PM with Admin: When asked on the EDR that was given to Charge RN on 7/12/2023 shows that there are 2 write ups in the last 12 months, Admin responded Oh no, there's no other write ups, that was a mistake, I had used a template to do that and forgo to erase it. When asked what the Admin did about the grievance filed on 5/29/2023 about Charge RN, Admin stated I counseled with her on her demeaner and voice tones. When asked if there were any other investigations about Charge RN the Admin stated no, I always talked to her about her voice and her demeanor with the residents. When asked if the Admin felt like they conducted an effective investigation of this incident on 7/9/2023, Admin stated I know she's a good nurse, she's good to the patients, she takes care of the residents. I don't see her as being abusive, but I know it comes across that way. Admin was asked why Charge RN is still employed, the Admin responded, I don't believe she's abusive. Admin was asked how they know that and Admin stated, Well I asked the residents. When asked if they understand that if the residents are afraid do they think they would be honest and Admin stated, they know Charge RN, but I didn't know anyone was afraid of her. Interview on 7/19/2023 at 2:14PM with Charge RN: Charge RN described the incident and stated I was at the nurse station charting, Resident #29 she was yelling for me at the top of her lungs as I was going down the hall. Resident #29 didn't have her hearing aids. I told her to stop yelling. When asked how they usually respond to the Residents behaviors requests for assistance, Charge RN stated I usually do it right away. I was caring for another Resident at the time. I tried to tell her that I would be back. Charge RN was asked to describe what contact they have with Resident #29 since the investigation and Charge RN replied I worked last weekend with her. When asked what type of training Charge RN had related to abuse and neglect they have received and Charge RN replied we had in-services about it and who to contact. Charge RN stated during the incident that there was a Resident yelling abuse going down the hall so I called the DON to relieve me and she called the Admin. When asked if they have any other information they wish to share in regards to the investigation, Charge RN stated Resident #29 is very hard of hearing. I wasn't being ugly to her. The kitchen supervisor was right there cleaning tables when it happened. Interview on 7/19/2023 at 2:25PM with LVN D: When asked if they have worked with RN Charge RN on the weekends, LVN D stated yes. When asked how Charge RN interacts with residents, LVN D replied I've known her a long time, we work together on Saturdays. She comes off very gruff and she's just loud. I don't think that she means harm or is bad. She just doesn't have any tone control. She's not mean spirited, she just doesn't have elderly gloves and she needs restraint. Interview on 7/19/2023 at 2:39PM with LVN A: When asked if they have worked with RN Charge RN on the weekends, LVN A stated yes. When asked how Charge RN interacts with residents, LVN A stated, I've heard more complains than what I've seen, the main thing is she's just loud, nothing physical. LVN A stated, she's loud and residents don't like it. Interview on 7/19/2023 at 2:47PM with LVN I: When asked if they have worked with RN Charge RN on the weekends, LVN I stated, I'm coming in as she's leaving. When asked how Charge RN interacts with residents, LVN I replied, I haven't seen any interactions, I haven't heard any complaints from the residents. When asked if they have any concerns about abuse and neglect in the facility at this time, LVN I stated I haven't seen anything, I've just heard stuff. I've heard that Charge RN yelled at a few resident, Resident #13 on the other side of the hall, other than that I heard she's always yelling back and forth with Resident #29. Interview on 7/19/2023 at 2:37PM with LVN J: When asked if they have worked with RN Charge RN on the weekends, LVN J responded, yes I do sometimes. When asked how Charge RN interacts with residents, LVN J stated, she's mean, and she yells at them. When asked if they have any concerns about abuse and neglect in the facility at this time, LVN J stated, just that but everyone knows about it, and they don't do anything about it. Interview on 7/19/2023 at 2:50PM with CNA G: When asked if they have seen any staff yell at residents, CNA G replied, Charge RN, yes she has and she has a rude attitude and a loud voice with residents. When asked if they have ever reported it, CNA G stated, well the residents haven't complained to me. When asked if they have seen Charge RN yell at residents, CNA G stated, I haven't seen it, but I always hear her. When asked if they have any concerns about abuse and neglect in the facility at this time, CNA G replied yes, it's degrading for the residents. This is their home. In an interview on 7/21/2023 at 11:31AM Admin: Admin was asked if there are other investigations on Charge RN and Admin stated, there are no other investigations, what's in her file is what I have. When asked if their investigation prevented further abuse, neglect or mistreatment of the resident, Admin replied well, yes because when I did interviews and tried to find out more information, I didn't get the same answers that you guys got. When asked if they felt that the investigation was adequate the Admin stated, yes I do. The Admin was asked if they think that they took appropriate corrective action as a result of the findings and Admin stated yes, I think I did. If I would have got different information, I would have done it differently. When asked if they interviewed other residents to ask them how the yelling/verbal abuse made them feel the Admin responded no. Admin was asked if they monitored Resident #29 and other residents at risk such as conducting unannounced management visits at different times and shifts and Admin replied Yeah, me and DON come in at different times, DON is good at popping up. When asked if on the weekends did the Admin specifically come in to monitor Charge RN's interactions with residents the Admin stated no, I did not come in to observe her. Admin was asked what actions were taken to protect the residents and the Admin replied, well we did the plan of removal after. Admin was asked if they felt that the facility's ANE policies and procedures are implemented well within the staff and the Admin replied they are now, but before it's hard to say really. I don't know. Admin was asked if they are conducting ongoing oversight and supervision of staff to assure that the ANE policies and procedures are implemented as written and Admin responded, I am now yes. When asked if they feel that the staff is able to identify, correct and intervene in situations in which abuse, neglect and exploitation is more likely to occur and the Admin stated now, yes. Record Review of staff in-services indicate that Charge RN was in-serviced on Abuse and Neglect on the following dates: 6/14/2023, 7/7/2023, and 7/19/2023. Record Review of staff in-services indicate that Charge RN was in-serviced on Resident Rights on 7/10/2023. Record review of facility's Grievance Log shows a grievance filed on 5/30/2023 by Resident #13 describes the incident as follows: Charge RN yells at Residents causing Resident #13 to feel uncomfortable. Resident #13 feels Charge RN yells at her and others. The Disposition of Complaint states: talk to RN about her loud voice dealing with Residents. The findings of the incident as follows: Charge RN has a very loud demeanor when dealing with anyone or anything. The Recommendations/Corrective Action states: Counsel with Charge RN on her demeanor and voice tones. Record Review of Facility Grievance Investigation Report dated 5/30/2023 shows a written statement as follows: Resident #13 states they feel like Charge RN verbal abusive to her and the other Residents. Resident #13 states that Charge RN yells at other Residents and makes them feel uncomfortable. Resident #13 states that Charge RN yelled at them for going into the dining room for smoke break and Charge RN yelled at them stating they were in the dining room too early for smoke break. Resident #13 states that sometimes in the dining room Charge RN is so loud that it makes them uncomfortable so they go back to their room. Record Review of Facility Notice of Disciplinary Action for Charge RN is dated 10/13/2022 is detailed as follows: Arguing with Resident in a non-professional manner in a loud tone. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from DON that states: Charge RN was in lobby and Resident #29 was yelling out at staff to come here. Charge RN went over to Resident and told them to stop yelling and Resident #29 told Charge RN that she was not their boss and to not tell them what to do. Charge RN continued to argue with Resident about this but I was talking to someone else at the time and didn't hear the whole conversation. MDS LVN stepped out of their office and told Charge RN to walk away and they did so. After Charge RN got back to their office, Resident #29 then yelled at Charge RN to come back over there. Charge RN did not do so. Earlier in the shift I was asking Resident #29 to stop yelling out and at the same time Charge RN came over and interrupted me to tell Resident #29 the same thing. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from Bus Office that states: This is what I heard but did not see from my office. Resident #29 was in the living area, requesting different things from everyone in a loud tone. Charge RN went up to Resident #29 and in their very loud voice tone told them that they needed to stop yelling and that someone would get to them. I'm not sure if Resident #29 told Charge RN she was not her boss, but Charge RN told Resident #29 you are not by boss, that they worked at the nursing home and cared for them. I then heard MDS LVN tell Charge RN to walk away. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from MDS LVN that states: Charge RN was working 6-2 as RN coverage. Resident #29 was in the lobby after breakfast, and they were wanting to go to bed. Charge RN was yelling at her tell her she had to stay up for 30 min. Charge RN kept arguing with Resident #29. DON told them that the yelling needs to stop and that they couldn't handle it anymore. Resident #33 was getting anxious and restless because of all the yelling. At lunch Resident #29 yelled for me to come there. Charge RN said just keep walking. I did ask them what they needed, and they wanted me to move Resident #17 to their table. I told them to give me a minute and I will. About 10 minutes later, Resident #29 was yelling for LVN G and Charge RN told them to keep going. LVN K did not listen, and Resident #29 wanted a pain pill. LVN G gave her the medicine. After lunch, Resident #29 told Charge RN to come here. Resident #29 wanted to be laid down. Charge RN told her that she had to wait 30 minutes. Resident #29 told Charge RN something I could not hear. Charge RN leaned over the table and to tell Resident #29 you are not by boss. Resident #29 said loudly I am your boss. Charge RN said no you are not my boss and you will not talk to me that way. I immediately got out of my chair and told Charge RN that they needed to walk away. Charge RN went to walk away, and Resident #29 was asking them something and Charge RN put her hand in the air and walked to the middle office up front. Record Review of Facility Notice of Disciplinary Action dated 10/13/2022 includes a witness statement from LVN G that states: I LVN G was working as a LVN at [facility] on 10/13/22. My RN supervisor was Charge RN. Charge RN has really stern assertive voice and sometimes yells a lot. On this particular day Charge RN was on a roll, Resident #29 was in the dining room yelling at me as I went to walk by them and Charge RN yelled at me and told me to keep walking however I stopped to see what they wanted and they asked me for Tylenol. So I went and got them medication. Then in about 30-45 minutes later Resident #29 was in the lobby and just sitting there in a wheelchair and they yelled at me again. I was at the computer doing my charting and I told Resident #29 it would be just a minute. I could visibly see that Resident #29 was not in any harm where I was sitting and they just wanting to talk to me or ask me something. Charge RN heard her from a office and Charge RN stormed out of that office and yelled at Resident #29 saying what do you need. Resident #29 said she wants to lay down Charge RN told it would be 30 minutes then they said I need to talk to my nurse. Charge R said your nurse is busy what do you need? Resident #29 looked at Charge RN and said just go back to your office and leave me alone and Charge RN stormed closer to Resident #29 and said you are not my boss. Charge RN said yes I am your boss. You could tell in the tone of Charge RN voice that the statement Resident #29 made Charge RN really mad. MDS LVN also heard the commotion going on and they stepped out of their office and they told Charge RN you need to step away this is getting out of hand you just need to go take a minute. Chare RN just stared at MDS LVN and then Resident #29 and MDS LVN and then just turned around and walked back into their office. After Charge RN went back to their office Resident #29 started yelling for Charge RN again. Resident #29 is always yelling at nurses for things and Charge RN always yells back. Record Review of Facility Provider Investigation for Charge RN dated 7/9/2023 is detailed as follows: Provider Investigation Report indicates that Charge RN has a history of similar allegations for abuse. Description of the incident is described as Resident #13 accused Charge RN of verbal abuse of Resident #29. Investigation summary states: All staff must raise voice with Resident #29 so they can hear us. Charge RN has a very loud personality and when they raise their voice to talk to Resident #29 it is louder than other staff. Resident #29 will holler after she is done eating until they are put to bed. They have an order to be up after meals for at least 30 minutes. Staff try to explain that to them and try to get them to stop hollering staff names out but [TRUNCATED]

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods was properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. These failures could place residents who ate the food from the kitchen at risk for food-borne illness. Findings included: Observation of the refrigerator on [DATE] at 9:54AM revealed the following: 1. 3 loose fresh tomatoes in a box, no date. 2. 1 5-pound chub of hamburger meat with an expiration date of [DATE]. 3. 1 food service bag of boiled eggs, no date Observation of the freezer on [DATE] at 10:12AM revealed the following: 1. 3 food services bags of frozen, chopped spinach, no date. 2. 2 2-pound bags of frozen cauliflower, no date. 3. 1 food service bag of frozen meat pies, no date. 4. 20 pounds of frozen peas, open to air, no date. 5. 1 food services container of frozen King Ranch Chicken, no date. 6. 4 ,d+[DATE] extra-large frozen pepperoni pizzas, no date. 7. 1 food service bag of frozen French toast, no date. 8. 1 4-pound bag of frozen fajita vegetable mix, no date. 9. 2 food service bags of frozen hamburger patties, no date. 10. 2 food service bags of frozen cinnamon rolls, no date. 11. 1 food service bag of frozen chicken wings, no date. 12. 30 pounds of frozen mixed vegetables, open to air, no date. 13. 3 food service bags of frozen waffles, no date. 14. 1 food service bag of frozen turkey chunks, no date. 15. 1 food service bag of frozen hushpuppies, no date. 16. 1 food service bag of frozen carrot rings, no date. 17. 1 frozen beef brisket, no date Observation of the dry pantry on [DATE] at 10:44AM revealed the following: 1. One 4 ,d+[DATE] pound container of pureed rice, open to air, no date. 2. 3 food service containers of protein powder, no date. 3. 1 food service bag of tortilla chips, no date 4. 5 food service bags of Mexican rice seasoning, no date. 5. 1 food service bag of strawberry Jell-O, no date. In an interview on [DATE] at 11:07AM, the Dietary Supervisor, [NAME] stated she had been cooking in facilities for [AGE] years. She stated she was in charge of making sure that food was labeled and dated and was unsure why some of the items in the kitchen had been missed. She stated that staff were also responsible for letting her know when they found something expired and were to throw it out immediately. She stated she in-serviced all the staff on the procedures for food labeling and storage but was still working to ensure it was being done on a regular basis. She stated the negative outcome of open containers and expired food in all parts of the kitchen would be pests could get into the dry foods and residents could become sick if they were served expired foods. Dietary Supervisor stated that there should be labels and dates on all food items in the refrigerator, freezer, and pantry. Record review of the facility's Dietary Services Policy and Procedure Manual for Sanitation and Infection Control: Food Storage, dated ,d+[DATE] revealed the following: Food must be stored in a properly covered container with a date and label identifying with is in the container. Food may remain in the [NAME] box as long as contents and date are easily visible on the box. Any foods removed from the [NAME] box must be dated and labeled. All of the following terms will be considered expiration dates for cold food products: Expires by date Best by date Use by date Sell by date Hard cooked eggs may be kept in the refrigerator for 1 week. Raw Hamburger, Ground and Stew Meat may be kept in the refrigerator for 1 to 2 days Record review of the facility's Dietary Services Policy and Procedure Manual for Sanitation and Infection Control: Food Safety, dated ,d+[DATE], revealed the following: Open packaged food, or leftover food is to be tightly wrapped or covered in clean air-tight containers, labeled, and dated, and stored in the refrigerator. Do not keep leftovers in the refrigerator over 3 days (72 hours).

Based on interview, and record review, the facility failed to 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 by failing to assure rights of residents, dignity and respect were provided for 2 of 15 residents (Resident #18 and Resident #31) reviewed for resident's rights, dignity and respect issues. Resident #18 stated that if a complaint is made, staff will ignore her or be rude to her for the remainder of the staff member's shift. Resident #18 could not give a specific date, due to it being a daily occurrence. Resident #31 stated that staff have been intimidating to Resident #31 since the resident council meeting on 06/13/2023. Staff have been short tempered, rude, giving dirty looks to Resident #31. This failure could cause residents to feel uncomfortable, disrespected, and unsafe in their home environment. Findings include: Record review of Resident #18's clinical record revealed Resident #18 is a [AGE] year-old female, who was admitted to facility on 01/18/2022. Resident has a Brief interview of mental status (BIMS) of 15 and functional status requires no set up or physical assistance from staff. Resident #18 has the diagnosis included but not limited to the following: CONGESTIVE HEART DISEASE HYPERTENSION CHRONIC OBSTRUCTIVE PULMONARY SIDEASE During an interview 06/13/23 02:35 PM, Resident #18 stated that sometimes the nurses and CNAs will ignore you, especially if you have made a complaint about something. Resident #18 was asked if a complaint had been made and Resident #18 stated No, it would just make things worse. During an interview 06/15/23 08:17 AM, Resident #18 stated that if you make a complaint the nurses and CNAs will just be rude to you. Resident #18 stated There is one nurse on the weekend, and if you ask her something she is short tempered and will yell at you and is extremely rude. The bad attitudes by nurses and CNAs happen every weekend. Nurses and CNAs are not keeping the times for smoke breaks for residents but have no issue taking their own smoke breaks. Resident #18 stated that because of this, RN (Resident #18 would not identify) that works on the weekends, a few nurses aides have walked out of facility due to this RN's negative attitude towards them and the residents. Resident #18 stated that she did not mention this to the DON or ADM because Resident #18 will just avoid contact with RN while she was on duty. Resident #18 stated that by making a complaint about the weekend RN's behavior would just make the situation worse. Record review of Resident #31's clinical record revealed Resident #31 is a [AGE] year-old female who was admitted on [DATE]. Resident has a Brief interview of mental status (BIMS) of 12 and a functional status that requires 1-person physical assist from staff. Resident #31 has the diagnosis included but not limited to the following: ATRIAL FIBRILLATION HYPERTENSION PERIPHERAL VASCULAR DISEASE CHRONIC OBSTRUCTIVE PULMONARY DISEASE During an interview 06/15/23 09:15 AM, Resident #31 stated that nurses and CNAs have been being rude, giving dirty looks, short tempered to Resident #31 since the resident council meeting on 06/13/2023. Resident #31 is a smoker. Resident #31 stated that the weekend RN and CNAs will let smoke time pass for the residents and then when residents ask when the smoke break will be the weekend Nurse stated to Resident #18 that smoke break will happen when I am ready for it to happen. Resident #31 was asked who was the weekend nurse that stated this, and Resident #31 would not give nurse's name. Resident #31 stated after the meeting on Tuesday Resident #18 and Resident #31 had spoken to one another and stated that they would be on the shit list for months to come. Resident #31 was asked, if she had asked the DON or ADMIN could address the behavior of the weekend nurse, Resident #31 stated that by making a complaint it would just make the behaviors from the weekend nurse and CNAs worse. Record Review of policy Texas State [NAME] of Rights of the Elderly-Resident/Family copy, not dated, states the following. An elderly individual is encouraged and assisted in the exercise of an individual's rights. An elderly individual may voice grievances or recommend changes in policy or service without restraint, interference, coercion, discrimination, or reprisal. The person providing services shall develop procedures for submitting complaints and recommendations by elderly individuals and for assuring a response by the person providing services. Record Review of policy Private Notice-Uses and disclosures of health information Resident/Family copy, not dated, states the following: Complaints: A complaint will not result in retaliation. Record Review of policy Smoking policy Resident/Family copy, not dated, states the following: The facility is responsible for informing residents, staff, visitors and other affected parties of smoking policies through distribution and/or posting.

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. The facility administered expired insulin medication to resident #24 on 9 different occasions. The facility had two expired medications in their e-kit. This deficient practice had the potential to affect all resident in the facility resulting in them receiving medication that could not be affective resulting in exacerbation of their condition and deterioration in their health. Finding include: Record review of Resident #24's face sheet dated 6-14-2023 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), muscle weakness (a lack of muscle strength), malnutrition (lack of proper nutrition), borderline intellectual functioning (characterized by intelligence wherein a person has below average cognitive ability), post-traumatic stress disorder (disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) and legal blindness (visual acuity less than 20/200). Record review of Resident #24's 4-17-2023 quarterly MDS revealed she had a BIMS of 15 indicating she was cognitively intact, and she had a functionality of being independent with some of her activities of daily living to requiring one-person assistance with dressing and eating. Record review of Resident #24's Order Summary Report with Active Orders as of 6-14-2023 revealed the following order: Humalog Solution (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10, subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) - start date of 10-4-2022 Record review of Resident #24's MAR (Medication Administration Record) for June 2023 revealed the following: Humalog Solution (Insulin Lispro) Inject as per sliding scale: if 150 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10, subcutaneously three times a day related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (E11.65) 6-10-2023 at 06:30 AM Blood Sugar was 312 with 8 units of Humalog administered 6-10-2023 at 04:30 PM Blood Sugar was 337 with 8 units of Humalog administered 6-11-2023 at 06:30 AM Blood Sugar was 311 with 8 units of Humalog administered 6-11-2023 at 11:30 AM Blood Sugar was 257 with 6 units of Humalog administered 6-11-2023 at 04:30 PM Blood Sugar was 281 with 6 units of Humalog administered 6-12-2023 at 07:30 AM Blood Sugar was 168 with 2 units of Humalog administered 6-12-2023 at 11:30 AM Blood Sugar was 218 with 4 units of Humalog administered 6-12-2023 at 04:30 PM Blood Sugar was 311 with 8 units of Humalog administered 6-13-2023 at 07:30 AM Blood Sugar was 252 with 6 units of Humalog administered During an observation and interview on 06-13-2023 at 02:24 PM of the A&B medication cart with LVN B Resident #24's Humalog was noted to be marked on the insulin bottle with a date of opened 5-12-2023 and an expiration date of 6-9-2023. LVN B reported after reviewing Resident #24's Humalog insulin bottle that the medication was expired and would need to be replaced. LVN B verified Resident #24's Humalog insulin bottle was 1/3 full and was currently being used. That Resident #24's Humalog insulin was given per sliding scale. LVN B verified that she had administered Resident #24's Humalog insulin the previous afternoon on her shift. LVN B reported that giving an expired medication such as insulin can result in a resident receiving a medication that is not effective, that could have side effects. LVN B reported that insulins should be discarded 28 days after being opened and this insulin was just missed. During an observation and interview on 06-13-2023 at 09:53 AM of the medication room with the DON present noted were two expired medications. Risperidone 1mg tablets (antipsychotic medication used to treat schizophrenia, bipolar disorder, and irritability cause by autism) expired 06/09/2023 Humulin N 100U/ml vile (used to treat diabetes) expired 05/31/2023 When questioned the DON reported that any expired medications should be placed in a lock box located in the medication room, a new medication should be reordered or refilled, and the expired medication is then picked up once a month by the pharmacy and destroyed. During an interview on 06-15-2023 at 08:57 AM the DON reported that all insulins should be marked when they are opened with an expiration date of 28 or 30 days. The DON reported that if an insulin is given after it expired then the residents blood sugars will not be treated as it should, that the blood sugar will not go down. The DON reported that the resident's condition and treatment could be affected. During an interview on 06-15-2023 at 09:24 AM the MDS Coordinator reported that the facility did not have a policy specially on medication safety, but they did have a policy on Medications that Must be Dated When Opened or Storage Condition Changes and Subcutaneous Injection Administration. During an interview on 06-15-2023 at 09:59 AM the DON presented the last training completed on medication safety to include 5 rights, eye, ear, inhaler, etc. administration presented by the MDS coordinator on 2-16-2023. The DON also presented Relias Trainings that she reported all staff are required to take annually titled Minimizing Medical Errors. During an interview on 06-15-2023 at 10:17 AM the MDS Coordinator reported that all insulins should be marked on the bottle when they are opened and when they should expire. The MDS Coordinator reported the all the nurses have an instruction card in their narcotic book on each medication cart that lists the types of insulin and when they expire after opening. All other OTC medications should be marked when they are opened and have an expiration date. The medications in the e-kit should be reviewed each month by the pharmacy and all medications close to expiration should be replaced. If a resident is given an expired medication, then the resident will not receive the full effects of the medication and it could make them sick. The MDS Coordinator reported that giving an expired medication could affect a resident's care. Record review of the facility provided instruction card the MDS Coordinator provided as part of the nursing narcotic book on each medication cart revealed the following: Humalog Inulin Lispro - Vial expires 28 days after opening or removing from refrigerator. Record review of the facility provided training titled Subcutaneous Injection Administration provided by the facility on 2-16-2023 revealed the following 1-Check expiration date of medication . Record review of the facility provided policy titled Medications that Must be Dated When Opened or Storage Condition Changes revealed no information related to this deficiency. 47854

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 2 (#10, #26) of 30 Residents 1. ADON broke sterile field during a sterile procedure. 2. LVN C failed to use proper hand hygiene techniques when preparing and administering medication to Resident. 3. Admin and Maintenance Supervisor was unable to provide any information regarding the process followed testing for Legionella which is bacteria that promotes pneumonia by inhaling water droplets. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases. Findings included: During an observation 06/13/23 10:55 AM Observed ADON perform a straight catheter on Resident #26. The ADON provided privacy for Resident #26, ADON washed hands before putting on new clean gloves. ADON proceeded to take an empty syringe and drain the catheter balloon of the catheter that was currently in place. 15 milliliters of saline was drawn out of the catheter balloon. Resident #26 stated that he didn't believe that he had dislodged the catheter but could not be certain. Catheter was not secured to Resident #26's leg. Once catheter was removed, ADON washed hands with hot water and soap. ADON went to open the sterile gloves that are in the straight catheter packaging. ADON proceeded to break the sterile field by touching the sterile side of the packaging. ADON donned sterile gloves and then proceeded to take the sterile drape and place it on Resident #26. ADON went to remove the residents brief with the sterile gloves and proceeded with opening the sterile swabs to clean Resident #26 penis, after cleaning the resident's penis. the ADON then reached under her arm to reach back behind her to retrieve the catheter for insertion into the resident's penis. The ADON did not lubricate the catheter before inserting the straight catheter into Resident #26's penis. The resident did not vocalize any pain and discomfort when the ADON asked if this was giving him any bladder relief. No urine was seen in the straight catheter. Resident #26 asked ADON for a drink of water, ADON handed resident his cup from his nightstand and then the ADON advanced the catheter further into resident's bladder. Then took the cup back from the resident and returned it to the nightstand. The ADON then placed her right hand on the Resident #26's bed sheets and then reached back to the catheter to readjust the catheter line. This was done a total of 2 times. ADON proceeded to sit resident up in his bed to see if this adjustment would assist with the emptying of his bladder. ADON then takes the bed control and adjust the head of the bed, so resident is sitting up. This procedure takes place with the same pair of sterile gloves the ADON started the procedure with. ADON the proceeds to attach the foley catheter bag to the straight catheter with no security device attached to resident. ADON never changed or washed hands during this process and went from sterile field to dirty area often. When ADON was finished with sterile procedure she removed sterile gloves and washed hands and disposed into trash can in Resident #26's room. During and interview 06/14/23 08:30 AM Interview with ADON to ask what why sterile technique was broken during a straight catheter procedure. ADON stated that she was unaware that she had broken the sterile process. During an observation 06/14/23 07:56AM Medication was being prepared by LVN C for Resident #10. Hand Hygiene was performed with hand sanitizer. Resident #10 was scheduled to receive 1.5 tablets of Sertraline 100mg to equal 150mg. LVN C proceeded to remove 2-100mg tablets from Resident #10's pill packet, LVN C took one of the tablets and proceeded to break pill in half with LVN C's fingernail and proceeded to administer pill to Resident #10. During an interview 06/14/23 08:27 AM Interview with LVN C was asked what the reasoning was for breaking the pill with her bare hand and not cutting pill with a pill cutter. LVN C did not answer the question but did state that her hands were clean. LVN C was asked what a negative outcome from this type of practice would be, LVN C stated that it could be a cause for infection. During an interview 06/14/23 08:54 AM Interview with DON on who performs the training for infection control and sterile techniques. DON stated that she was the infection preventionist and the ADON assisted with this type of training. DON was asked what a negative outcome could be from a break in a sterile field, DON stated that it could lead to infection. During an interview 06/14/23 09:08 AM Interview with ADMIN regarding Legionella and facility testing. ADMIN did not know what Legionnaires was or if there was a policy. Maintenance was not available for questioning. During an interview 06/15/23 09:50 AM Interview with Maintenance Super stated that he did not know what Legionnaires was and stated that he did not know of a process to test for this within the facilities water system and did not know of a policy to address this. Record review of facility policy Infection Control Policy & Procedure Manual-Surveillance dated 2019 states that following: Ensures that appropriate sterile techniques are followed; for example, that staff: Use sterile gloves, fluids, and materials, when indicated, depending on the site and the procedure Avoid contaminating sterile procedures; and Ensure that contaminated/non-sterile items are not placed in a sterile field Record review of facility policy Pharmacy Policy & Procedure Manual-Oral Solid Medication Administration dated 2003 states the following: 6. If it is necessary to divide or split the medication prior to administration, use an approved device or gloved hands. Devices must be cleaned with an alcohol wipe between uses. Any unused portion may not be retained for later use and, must be discarded in a manner so that no one has access to the unused portion. Record Review of facility policy Nursing Policy & Procedure Manual-Catheter insertion, Male/Female dated 2003/revised February 13, 2007, states the following: Perform male urethral catheterization: a) Put on gloves. b) Place the sterile drape over the legs below the penis. c) Hold the penis and retract the foreskin (if present) with the nondominant hand and cleanse from the meatus outward in a circular motion with antiseptic swabs or cotton balls with an antiseptic held with a forceps. d) Pick up the catheter four inches from the tip. Place the end in the basin to collect the urine and while holding the penis forward and upward with the nondominant hand, insert the lubricated catheter about seven inches. Avoid using any force during the insertion if resistance is met. e) Pinch catheter and collect a specimen if needed and then allow the urine to continue to flow into the basin until the bladder is empty if a single catheterization is being informed. f) If an indwelling catheter is being inserted, test it with the injection of the proper amount of distilled water into the balloon inflation port before insertion into the meatus. Withdraw the fluid and proceed to insert he catheter as above but with an additional 3/4 inch inserted to prevent pressure at the neck of the bladder. g) Reinflate the balloon when the catheter is in place through the port with a syringe filled with the proper amount of distilled water for balloon capacity. h) Gently tug on the catheter to insure secure placement. Attach the end to a closed drainage system. i) Remove the gloves and dispose with other used articles according to Universal Precautions. j) Place the catheter over the leg and position to not put pressure on the urethra. k) Place in a position of comfort

Based on interview, and record review, the facility failed to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means of other than a postal service. This failure effected 2 (Resident #18 and Resident #23) of 15 residents. Resident #18 and Resident #23 both have received mail that has been opened without their consent. Neither resident could remember the specific dates. This failure violates the resident's right to privacy and confidentiality, this could cause residents to feel uncomfortable, disrespected, and unsafe in their correspondence with others. Findings include: During Resident Council meeting held on 06/13/23 02:53 PM, the question was asked, do you get mail unopened, Resident #18 stated that she gets her boxes opened, and the staff does not open the boxes in front of her. Other residents in the meeting shook their heads yes to receiving mail already opened but would not elaborate on subject. During interview 06/15/23 08:13 AM, Resident #18 stated that she received a box of mail that was opened but could not give a specific date. Stated that the box was delivered by BOM. When Resident #18 asked BOM about the box being open, BOM stated that it was just easier to open in her office. During interview 06/15/23 08:29 AM, Resident #23 states that envelopes are not opened but boxes are opened but not opened in front of the Resident #23. Resident #23 does have contractures of bilateral arms and hands. But states that her packages should be opened in front of her, not in some random place. During interview 06/15/2023 09:43 AM BOM was asked if mail and packages were opened for residents. BOM stated that envelopes are not opened, and residents really don't receive boxes or packages. BOM stated that she will open packages/boxes only if the resident asks her for help, and that BOM is the only staff member to deliver mail to residents. Record review of Statement of Resident Rights-Resident/Family copy undated states the following: You have the right to: receive unopened mail and to receive assistance in reading and writing correspondence.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 12 residents (Resident #29) reviewed for accident hazards. CNA A transferred Resident #29 by herself from a wheelchair to a shower chair in preparation for bathing when Resident #29 required two staff participation with transfers. Resident #29 sustained a fall during the transfer resulting in a right leg fracture (broken bone in leg), right elbow fracture, and hematoma (bleeding outside of blood vessels, due to trauma.) Resident #29 was sent to the hospital and subsequently placed on hospice care (type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) when she returned to the facility. An Immediate Jeopardy (IJ) was identified on 04/26/22 at 5:30 PM. While the IJ was removed on 04/27/22 at 10:36 AM, the facility remained out of compliance at a severity level of actual harm that is not immediate and a scope of isolated due to the facility need to evaulate the effectiveness of their corrective systems. This failure could place residents that require two-person staff assistance with transfers at risk for falls, injury, and/or death. Findings include: Record review of Resident #29's Face Sheet, dated 4/26/22, indicated a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses that included a fracture of unspecified part of neck of the right femur initial encounter of a closed fracture (break of right leg bone), displaced fracture of olecranon process with intraarticular extension of the right ulna (bone in elbow broke in two places), unspecified fall, cognitive-communication deficit (comprehension and communication disorder resulting from damage or injury to the specific area in the brain), [CONDITION(S)], reduced mobility, [CONDITION(S)], diabetes (high sugar levels for prolonged periods of time), memory deficit, cerebral infarction (stroke), [CONDITION(S)] (difficulty with speech), lack of coordination, abnormalities of gait (walking) and mobility, [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting right dominate side (loss of strength in right arm, right leg, right side of face), [CONDITION(S)] (seizures), pain right hip, unspecified dementia (group of symptoms that affects memory, thinking and interferes with daily life), and hypertension (high blood pressure). Record review of Resident #29's 5-Day Medicare Part A MDS, dated [DATE], revealed she had a BIMS score of 7 out of 15 which indicated her cognition was severely impaired. Section G of the MDS revealed Resident #29 required two plus-person extensive physical assistance with transferring. The MDS defined a transfer as, how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . Section G also revealed Resident #29 was not steady, only able to stabilize with staff assistance during surface-to-surface transfers, which the MDS defined as a transfer between bed and chair or wheelchair. Record review of Physical Therapy Plan of Care dated 10/26/2021-12/20/21 indicated a referral reason of Patient is [AGE] year-old female who is current LTC (long-term care) resident of this facility who has been referred to PT due to recent sudden onset of severe pain right lower extremity about 2 weeks ago (X-rays on 10/20 were negative). She has declined in all her transfers-even requiring Hoyer lift for transfers or 2 person assist. She is having increased difficulty pivoting or moving her legs for transfers according to nursing. Record review of Resident #29's Care Plan, dated 02/15/22, indicated, in part: .Focus: The Resident has an ADL Self Care Performance Deficit related to confusion, [CONDITION(S)], impaired balance, limited mobility, limited ROM, stroke, unaware of safety needs, poor communication/comprehension, memory deficit, convulsions, vision problems, and psychomotor deficit .Interventions/Tasks: Transfer: The resident requires (2) staff participation with transfers. Record review of a progress note in Residents #29's electronic chart dated 02/23/22 at 1:01 AM indicated the following, res has had a decrease in activity due to swelling. She is requiring more help with transfers, needs assistance x2 due to increased weakness. Res continues to decline. Record review of a progress note in Residents #29's electronic chart dated 02/23/22 at 3:13 PM indicated the following, res has had a decrease in activity due to swelling. She is requiring more help with transfers, needs assistance x2 due to increased weakness. Res continues to decline. Record review of a progress note in Residents #29's electronic chart dated 02/26/22 at 8:40 AM indicated the following, Resident was assisted from bed to wheelchair with two CNAs for her bath, [CNA-A] assisted her to shower room, where she assisted her to stand holding to handrail, moved wheelchair and placed shower chair behind resident. CNA was assisting her to turn and sit down on shower chair, when her right leg gave out and she started to fall. CNA attempted to prevent fall, but unable to. Pulled on emergency call light. This nurse and LVN went to see what was wrong and found resident laying on floor between cabinet and the sink in shower room, assessed resident found 6cmX6cm hematoma on head, resident complain of pain to right hip area. Obtained orders to send to ER for X-Ray, Ambulance called, Family called, and ADM, and DON notified. Record review of incident report dated 02/26/22, completed by RN D, the RN called to assess Resident #29 after the fall, revealed an incident date and time of 02/26/22 at 8:26 AM. The section labeled, Incident Description revealed, Nursing Description: Called to shower room, noted resident on floor, assessed 6 cm x 6 cm hematoma on side of head, complain of right hip area hurting, order to send to ER for x-ray. Resident Description: States my right hip area is hurting, and side of my head hurting. In the section labeled, Agencies/People Notified, a family member was listed as well as the physician, DON and ADM. In the section labeled, Witnesses CNA A was the only person listed. The incident report only contained a description of events of the fall; it contained no documentation of actions taken to investigate why the incident occured or a collection of evidence that would allow the ADM to determine what actions were necessary (if any) for the protection of residents. During an observation and attempted interview on 04/25/22 at 11:14 AM, Resident #29 was lying in bed. When attempting to speak with Resident #29, resident would only grunt, no comprehensible language spoken. During an interview with ADON on 04/25/22 at 3:11 PM, ADON stated, she was not at the facility during the incident when Resident #29 fell during a transfer on 02/26/22. ADON stated, it was her understanding that Resident #29 had fallen during a transfer that occurred in shower room. During an interview with CNA A on 04/26/22 at 11:32 AM, she stated she was assisting Resident #29 in the shower room the day that she fell on [DATE]. CNA A stated Resident #29 was holding the grab bar and I moved the wheelchair and pulled the shower chair over to Resident #29 when resident's hand slipped and her leg went out. Resident #29 then fell and hit her head. CNA A was asked if she knew where to find Resident #29's transfer assistance requirements, she stated, I don't know I am just a CNA. Asked CNA A if she considered moving from a wheelchair to a shower chair a transfer and she stated yes. CNA A stated she was following transfer assistance requirements as I was told by staff. CNA A stated she pulled the call light for assistance with Resident #29 and multiple staff came. CNA A stated, the ambulance was called, and she was taken to the ER. CNA A stated she received no training or disciplinary action following Resident #29's fall. CNA A stated, I usually just transfer her [Resident #29] from wheelchair to the shower chair. CNA A stated she transferred residents like that, all the time and she did that with everyone except for a few residents who were totally dependent for assistance. According to CNA A, she was told by staff that if a resident can stand holding a grab bar, that it was ok to transfer residents without any help and Resident #29 was standing during physical therapy with a grab bar. During an interview with RN D on 04/26/22 at 11:43 AM, the RN who was called to assess Resident #29 after her fall, she stated, it was bath day, two aides got her to her wheelchair she (Resident #29) is paralyzed. RN D stated CNA A had stated that CNA A was assisting Resident #29 to the shower chair from the wheelchair. She stated Resident #29 was able to hold the grab bar and Resident #29's leg gave way and she fell . RN D stated, I assessed [Resident #29] and her leg was pointing out and [Resident #29] was complaining of pain to her right elbow. RN D stated, Therapy had been working with [Resident #29] and told us she could grab the bar, we go with what therapy says. RN D stated this statement by PT could be found, in the therapy notes. During an interview with PTA on 04/26/22 at 1:10 PM, she was asked if Resident #29 was on services with physical therapy, she stated Resident #29 was on a break from physical therapy. PTA stated a break from physical therapy meant, for one reason or another she was not on services with PT. PTA was then asked if it was acceptable practice to transfer residents that required two-person assistance to instead be transferred with only one-person assistance if a grab bar was available, to which PTA replied, max 2 assist means two staff are in the room with the resident. PTA was then asked if she would instruct staff differently and PTA stated, I am speaking for myself I would never tell them to use a bar as replacement person. During an interview with DON on 04/26/22 at 2:02 PM, when asked about Resident #29's fall on 02/26/22, DON stated she only knew what she had been told. DON stated she was told that when attempting to get Resident #29 to the shower chair from the wheelchair by CNA A, Resident #29 fell . DON stated, She (Resident #29) was a two-person assist with transfers. Regarding Resident #29's Care Plan which indicated she required two-person assistance with transfers, DON stated, 'I didn't necessarily write all of her care plan. If it's wrote in the care plan, that is what they should have been doing. DON stated, if it says two-person, it should have been two-person. When asked if moving from a wheelchair to a shower chair was considered a transfer, DON stated, of course it's a transfer. DON was asked if there was in-servicing or counseling done for CNA A after the incident, DON stated, I am not sure if in-servicing was done, and [CNA A] did not get counseling, per se. DON stated she did not think the incident was reported to the State Survey Agency since it was a witnessed incident. DON confirmed Resident #29 sustained a femur fracture and a small fracture in her right elbow from the incident. DON confirmed these would have been considered significant injuries, because it was a fracture. I consider anything more than a bruise a significant injury. DON stated she believed the incident caused Resident #29's admission to hospice to happen a little sooner. DON stated, I don't know [if it should have been reported]. During an interview with ADM on 04/26/22 at 2:32 PM, she stated, Some days she (Resident #29) she could help [with transferring herself], some days she could not help; she was getting weaker. ADM stated, regarding the incident on 02/26/22, Resident #29's leg just gave out before she made it to the shower chair. ADM stated she was told by CNA A Resident #29 was holding on to the grab bar and fell in the shower room. ADM stated if Resident #29's Care Plan indicated she required two-person assist with transfers, ADM would have expected her staff to transfer Resident #29 with two people assisting. When asked if ADM thought moving Resident #29 from her wheelchair to the shower chair was considered a transfer, ADM stated, Well yeah, that's a transfer. ADM stated there were no in-services in response to Resident #29's fall. ADM stated on the day of the incident, she was called and notified that Resident #29 had fallen in the shower room. She stated she had witness statements written. ADM stated, we sent her [Resident #29] out and all that. In my investigation, I came over here [to the facility] and got some stuff and went back to the house and did it on the computer. She stated she had a personal emergency and was unavailable two days after the incident. ADM stated, I normally have this big book of what happened [during an investigation] but I was out. ADM stated, since the incident was witnessed by a staff member, that is why she did not report it to the State Survey Agency. ADM stated there were times Resident #29 was doing well, and sometimes she was weaker. The morning of the fall, Resident #29 was doing better. ADM stated Resident #29 was seen by a physician on 02/22/22 or 02/24/22, he looked at Resident #29's right leg because she had been having pain and he thought she had been having nerve issues. ADM stated she was not sure if that was why Resident #29's leg gave out during the transfer. ADM stated CNA A tried to get the shower chair where it would help keep Resident #29 from falling but she could not. She again stated she did not report the incident, I kind of felt like it was witnessed. ADM was asked to provide the witness statements and any other documentation regarding an investigation of the incident at that time.The only documentation provided regarding an investigation into Resident #29's fall on 02/26/22 was the one witness statement previously referenced by CNA A and the incident report previously referenced. During an interview with PT Director on 04/26/22 at 3:13 PM, she stated Resident #29 was a max assist when transferring from her bed to wheelchair. PT Director stated that Resident #29 was doing good for a while but then started to decline. Asked PT Director when the decline started with Resident #29 PT Director stated, I cannot recall. PT Director was asked if she had told staff if a resident required two-person assistance for transferring, they would only need one-person assistance and PT Director stated, I don't tell them (staff) that they don't need to use a second person. When PT Director was asked if she would consider the grab bar a second person, PT Director stated, the grab bar did not count as a second person for transferring her (Resident #29) to the toilet or to the shower chair. During an interview with PTA on 4/26/22 at 3:25 PM, PTA was asked for clarification on what substantial/maximal assistance versus partial/moderate assistance during resident transfers. Per PTA, substantial/maximal assistance was when the therapist needed to use all their force to lift the resident. PTA was then asked if this decision was the RNs or CNAs to decide how many people to use for a resident transfer, PTA stated, it would be on physical therapy to decide if it was one-person, or two-person assist for transfers. During an interview on 04/27/22 at 10:00 AM, CNA A clarified that the incident with Resident #29 happened in the shower room, just prior to Resident #29's shower. She stated Resident #29 still had on her shoes and a robe and she had just unfastened her brief prior to transferring her from the wheelchair to the shower chair. CNA A stated, I did it like we've always done it. CNA A stated Resident #29 reached with one hand up as CNA A had the shower chair to the side so when Resident #29 had her balance, she could put the shower chair under her. CNA A stated Resident #29 was standing great when suddenly, her right leg buckled at the knee, I'm assuming it was the knee, that would have been her weak side. CNA A stated Resident #29 fell to the right, on her right side. She stated Resident #29 was a very heavy woman, you couldn't lift her if you tried. CNA A stated, I feel like I failed her. I tried really hard to catch her. She was really top heavy. During an interview on 04/27/22 at 2:27 PM with ADON, she stated there were no facility policies regarding preventing accidents and hazards. Record review of Physical Therapy notes dated 10/26/2021-12/20/21 revealed no documentation that Resident #29 was a one-person transfer if a grab bar was available, and no other documentation was provided by the facility which stated the same. Record review of a facility policy titled, Safe Patient Handling Policy and Procedure revised on 12/30/05, revealed, in part, Resident will be evaluated on admission and as needed for alternative means of lifting, transferring repositioning, and other movement to minimize risk of injury .Nurses will be educated regarding correct safe handling procedures, to report concerns or the inability to perform resident handling or movement that the nurse believe in good faith will expose a resident or nurse to an unacceptable risk of injury. The ADM and DON were informed on 04/26/22 at 5:30 PM that an Immediate Jeopary (IJ) was identified due to the above failures. A Plan of Removal was requested. The facility's Plan of Removal was accepted on 04/27/22 at 8:15 AM and included the following: Noncompliance: Facility failed to provide care based off their care plan and MDS. Both care plan and MDS required two persons assist for transfer however only one C.N.A assisted with transfer from wheelchair to shower chair. Resident fell and sustained multiple fractures and a hematoma. Root cause: Definition on care plan for bathing and transfers not clearly defined leading to C.N.A transferring resident to the shower chair alone. Necessary Changes: 1. Fall risk assessments are completed on all residents . 2. Incident reports monitored for falls; anyone who has falls will be care planned as a two-person transfer. 3. Gait belts will be used by nursing staff while transferring residents. 4. Resident Kardex will be updated and readily available to staff with updates to care planning . Training: 1. All staff will be in-serviced: a. Abuse and neglect b. Falls c. Fall prevention d. Safe Patient Handling 2. Nursing staff will be in-serviced: a. Gait belt use b. Transfers: use of two persons when indicated on Kardex/Care plan c. Resident Kardex use Employee of the facility will not be allowed to return to work until they have completed all in-serving required as stated above. RN staff are doing the fall risk assessments on 4/26/2022. ADON staff are in-servicing all staff via phone or in person on 4/26/2022. Therapy department will be doing transfer and gait belt training on 4/27/2022 for all nursing staff able to attend. Those not attending will have to be trained before being allowed to do patient care. Resident Kardex in PCC will be updated and available to staff on 4/26/2022. All in-servicing of staff will be done on 4/26/2022 unless unavailable therefore in-serviced before caring for residents. Nursing staff will know what bathing and transfers clearly mean on the care plan and Kardex system. Monitoring of the systems and trainings will be done by DON or designee twice weekly for 4 weeks. No further problems monitoring will be weekly for 8 weeks. Continued compliance will initiate random checks thereafter. Our QAPI committee will discuss the monitoring at our monthly meeting implementing an action plan. On 04/27/22 at 10:36 AM, the surveyors confirmed the facility implemented their Plan of Removal sufficiently to remove the Immediate Jeopardy by the following observations, interview and record reviews: During an observation on 04/27/22 at 8:40 AM, in-servicing was being conducted by physical therapists, ADM, ADON, and DON regarding Falls, Safe Handling, Abuse + Neglect, Gait Belts, Kardex/Care Plan, and Transfers. During an interview with on 04/27/22 at 8:44 AM with LVN E, she stated that in-servicing had been provided that morning and in the evening on 04/26/22 regarding two-person transfers for all residents that could not walk unassisted or have had an unsteady gait. During an interview on 04/27/22 at 8:46 AM, LVN E confirmed that she had attended an in-service on the evening of 04/26/22 on two-person transfers with the use of a gait belt. During an interview on 04/27/22 at 9:52 with DON, she was asked how she thought the IJ occurred, and DON stated, This probably occurred because of a communication issue, communication between nursing staff and the CNAs. DON was asked how they planned to prevent similar incidents in the future, and DON stated, We could have made it clearer on the care plan, updated care plans with better wording, In-services are being done and educating the staff that residents that are dependent should be transferred by two people at all times. During an interview on 04/27/22 at 9:55 AM with ADM, she was asked how she thought the IJ occurred, and she stated, I think it was the wording in the care plan; it (care plan) was not clear what was required for each of the residents. ADM was asked how they planned to prevent similar incidents in the future, and ADM stated, updated care plans with better wording, In-servicing, physical therapy showed staff how to correctly transfer and staff did re-demonstration, and phone in-servicing. During an interview on 04/27/22 at 10:20 AM with CNA C , she stated in-servicing had been provided that morning regarding how to properly transfer residents. She stated that to look up a resident's transfer status, it would be in the Kardex or the plan of care. During an observation on 04/27/22 at 10:30 AM, CNA A and CNA C transferred a resident from wheelchair to bed properly using a Hoyer-lift. During an interview and record review on 04/27/22 at 10:33 AM with ADON, she stated on 04/26/22, all staff were contacted either in person or by phone (except for one staff member they could not reach) and were in-serviced regarding, STAFF IS TO WEAR GAIT BELTS AT ALL TIMES AND USE WHEN TRANSFERRING RESIDENT .THERE IS A KARDEX UNDER THE POC UNDER EACH RESIDENT THAT WILL INFORM YOU OF THE ASSISTANCE THE RESIDENT NEEDS WITH ADLS .POLICY OVER ABUSE AND NEGLECT .POLICY OVER FALLS .SAFE HANDLING OF A RESIDENT. Reviewed in-service signed by most staff. ADON stated the in-service to be done that day was for nursing staff which included demonstration on safe transfers by PT. Review of that in-service, dated 04/27/22, revealed a subject of, Transfers, gait belt Training .Kardex/Careplan .safe handling .went back over falls .abuse .neglect .gait belts .safe handling. In-service contained multiple staff signatures. ADON stated all CNAs were informed about the Kardex system, which was to inform staff of a resident's transfer requirements. She stated CNAs were to look at the Kardex daily. ADON stated nurses had access to Care Plans and the Kardex for information regarding resident transfer requirements. During an interview on 04/27/22 at 11:05 AM with CNA B, she stated she was provided in-servicing on how to properly transfer residents that morning and she had to use two people when transferring residents. During an observation and interview on 04/27/22 at 11:45 AM, LVN E and CNA B were conducting a transfer in the shower room with a resident . CNA B stated, this is the new process, I would have gotten resident up on my own prior to today. Asked CNA B if, prior to in-service, she was transferring residents that required two-person assistance without help and CNA B stated, yes. When asked if a resident's Care Plan indicated two-person assistance was required for transfers, would CNA B still have got resident up on her own and CNA B stated, yes I would have got her up in the shower by myself because of the shower bar. Record review of a random sample of resident's fall risk assessments indicated resident fall risk assessments were completed on 04/26/22. The administrator was notified on 4/27/22 at 10:36 AM that the IJ was removed. The facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not immediate due to the facility need to evaluate the effectiveness of their corrective systems.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of 12 residents (Resident #29) reviewed for neglect. Resident #29 sustained a fall during a one-person transfer from a wheelchair to a shower chair which resulted serious bodily injury; a right femur fracture (thigh bone), right elbow fracture and head hematoma (bleeding outside of blood vessels, due to trauma). This incident was not reported to the State Survey Agency. Record review of TULIP did not reveal any self-reported incidents during the time of this incident. This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent serious bodily harm, or [MEDICATION(S)] physical impairment. Findings include: Record review of Resident #29's Face Sheet, dated 04/26/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #29's 5-Day Medicare Part A MDS, dated [DATE], revealed she had a BIMS score of 7 out of 15 which indicated her cognition was severely impaired. Section G of the MDS revealed Resident #29 required two plus-person extensive physical assistance with transferring. The MDS defined a transfer as, how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . Section G also revealed Resident #29 was not steady, only able to stabilize with staff assistance during surface-to-surface transfers, which the MDS indicated was a transfer between bed and chair or wheelchair. Record review of Resident #29's Care Plan, dated 02/15/22 revealed, in part: Focus: The resident has an ADL Self Care Performance Deficit r/t Confusion, [CONDITION(S)], Impaired balance, Limited Mobility, Limited ROM, Stroke Interventions/Tasks o TOILET USE: The resident requires (2) staff participation to use toilet . oTRANSFER: The resident has requires [sic] (2) staff participation with transfers . Record review of incident report dated 02/26/22, completed by RN D, the RN who was called to assess Resident #29 after the fall, revealed an incident date and time of 02/26/22 at 8:26 AM. The section labeled, Incident Description revealed, Nursing Description: Called to shower room, noted resident on floor, assessed 6 cm x 6 cm hematoma on side of head, complain of right hip area hurting, order to send to ER for x-ray. Resident Description: States my right hip area is hurting, and side of my head hurting. In the section labeled, Agencies/People Notified, a family member was listed as well as the physician, DON and ADM. In the section labeled, Witnesses CNA A was the only person listed. Record review of a progress note in Resident #29's electronic chart dated 02/26/22 at 8:40 AM revealed Resident was assisted from bed to wheelchair with two CNAs for her bath, [CNA A] assisted her to shower room, where she assisted her to stand holding to handrail, moved wheelchair and placed shower chair behind resident. CNA was assisting her to turn and sit down on shower chair, when her right leg gave out and she started to fall. CNA attempted to prevent fall, but unable to. Pulled on emergency call light. This nurse and LVN went to see what was wrong, and found resident laying on floor between cabinet and the sink in shower room, assessed resident found 6cmX6cm hematoma on head, resident complain of pain to right hip area. Obtained orders to send to ER for X-Ray, Ambulance called, Family called, and ADM, and DON notified. Record review of witness statement provided by CNA A, dated 02/26/22 at 9:00 AM revealed, Resident was transferred by 2 people from bed to w/c for shower. In shower room resident is usually good holding bar and w/asst [with assistance] stand up to place shower chair under resident. Resident right leg gave out and resident slide of shower chair falling on right side hitting her head on wall everything happened so fast I couldn't break her fall [sic]. During an interview on 4/25/22 at 11:14 AM, Resident #29 was lying in bed. When attempting to speak with Resident #29, Resident would only grunt, no comprehensible language spoken. During an interview with CNA A on 04/26/22 at 11:32 AM, she stated she was assisting Resident #29 in the shower room the day that she fell on [DATE]. CNA A stated Resident #29 was holding the grab bar and I moved the wheelchair and pulled the shower chair over to Resident #29 when resident's hand slipped and her leg went out. Resident #29 then fell and hit her head. CNA A was asked if she knew where to find Resident #29's transfer assistance requirements, she stated, I don't know I am just a CNA. Asked CNA A if she considered moving from a wheelchair to a shower chair a transfer and she stated yes. CNA A stated she was following transfer assistance requirements as I was told by staff. CNA A stated she pulled the call light for assistance with Resident #29 and multiple staff came. CNA A stated, the ambulance was called, and she was taken to the ER. CNA A stated she received no training or disciplinary action following Resident #29's fall. CNA A stated, I usually just transfer her [Resident #29] from wheelchair to the shower chair. According to CNA A, she was told by staff that if a resident can stand holding a grab bar, that it was ok to transfer residents without any help and Resident #29 was standing during physical therapy with a grab bar. During an interview on 04/26/22 at 2:02 PM, DON stated, I wasn't here [the day Resident #29 fell ], I only know what I was told. DON stated she did not think the incident was reported to the State Survey Agency since it was a witnessed incident. DON confirmed Resident #29 sustained a femur fracture and a small fracture in her right elbow from the incident. DON confirmed these would have been considered significant injuries, because it was a fracture. I consider anything more than a bruise a significant injury. DON stated she believed the incident caused Resident #29's admission to hospice to happen a little sooner. DON stated, I don't know [if it should have been reported]. During an interview with ADM on 4/26/2022 at 2:32 PM, she stated that since the incident on 02/26/22 with Resident #29 was witnessed by a staff member, that is why she did not report it to the State Survey Agency. Record review of facility policy titled, Abuse/Neglect, dated 11/15/16, revealed, in part, the following: .D. Identification .3. facility employees must report all allegation of abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility administrator or designee will report the allegation to HHSC. a) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation.

Based on interview and record review, the facility failed to ensure that all alleged violations are thoroughly investigated and the results are reported to the State Survey Agency within 5 working days for one of 12 residents (Resident #29) reviewed for neglect, exploitation or mistreatment. The facility did not investigate or report to the State Survey Agency when Resident #29, who required two-person assistance with transfers, sustained a fall during a one-person transfer which resulted serious bodily injury This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent serious bodily harm, or [MEDICATION(S)] physical impairment. Findings include: Record review of Resident #29's Face Sheet, dated 04/26/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #29's 5-Day Medicare Part A MDS, dated [DATE], revealed she had a BIMS score of 7 out of 15 which indicated her cognition was severely impaired. Section G of the MDS revealed Resident #29 required two plus-person extensive physical assistance with transferring and toilet use. The MDS defined a transfer as, how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position . Section G also revealed Resident #29 was not steady, only able to stabilize with staff assistance during surface-to-surface transfers, which the MDS indicated was a transfer between bed and chair or wheelchair. Record review of Resident #29's Care Plan, dated 02/15/22 revealed, in part: Focus: The resident has an ADL Self Care Performance Deficit r/t Confusion, [CONDITION(S)], Impaired balance, Limited Mobility, Limited ROM, Stroke Interventions/Tasks o TOILET USE: The resident requires (2) staff participation to use toilet . oTRANSFER: The resident has requires [sic] (2) staff participation with transfers . Record review of an incident report dated 02/26/22, completed by RN D, the RN who was called to assess Resident #29 after the fall, revealed an incident date and time of 02/26/22 at 8:26 AM. The section labeled, Incident Description revealed, Nursing Description: Called to shower room, noted resident on floor, assessed 6 cm x 6 cm hematoma on side of head, complain of right hip area hurting, order to send to ER for x-ray. Resident Description: States my right hip area is hurting, and side of my head hurting. In the section labeled, Agencies/People Notified, a family member was listed as well as the physician, DON and ADM. In the section labeled, Witnesses, CNA A was the only person listed. The incident report was a description of events of the fall; it contained no documentation of actions taken to investigate why the incident occured or a collection of evidence that would allow the ADM to determine what actions were necessary (if any) for the protection of residents. Record review of a progress note in Resident #29's electronic chart dated 02/26/22 at 8:40 AM revealed Resident was assisted from bed to wheelchair with two CNAs for her bath, [CNA A] assisted her to shower room, where she assisted her to stand holding to handrail, moved wheelchair and placed shower chair behind resident. CNA was assisting her to turn and sit down on shower chair, when her right leg gave out and she started to fall. CNA attempted to prevent fall, but unable to. Pulled on emergency call light. This nurse and LVN went to see what was wrong, and found resident laying on floor between cabinet and the sink in shower room, assessed resident found 6cmX6cm hematoma on head, resident complain of pain to right hip area. Obtained orders to send to ER for X-Ray, Ambulance called, Family called, and ADM, and DON notified. Record review of witness statement provided by CNA A, dated 02/26/22 at 9:00 AM revealed, Resident was transferred by 2 people from bed to w/c for shower. In shower room resident is usually good holding bar and w/asst [with assistance] stand up to place shower chair under resident. Resident right leg gave out and resident slide of shower chair falling on right side hitting her head on wall everything happened so fast I couldn't break her fall [sic]. During an interview on 4/25/22 at 11:14 AM, Resident #29 was lying in bed. When attempting to speak with Resident #29, Resident would only grunt, no comprehensible language spoken. During an interview with CNA A on 04/26/22 at 11:32 AM, she stated she was assisting Resident #29 in the shower room the day that she fell on [DATE]. CNA A stated Resident #29 was holding the grab bar and I moved the wheelchair and pulled the shower chair over to Resident #29 when resident's hand slipped and her leg went out. Resident #29 then fell and hit her head. CNA A was asked if she knew where to find Resident #29's transfer assistance requirements, she stated, I don't know I am just a CNA. Asked CNA A if she considered moving from a wheelchair to a shower chair a transfer and she stated yes. CNA A stated she was following transfer assistance requirements as I was told by staff. CNA A stated she pulled the call light for assistance with Resident #29 and multiple staff came. CNA A stated, the ambulance was called, and she was taken to the ER. CNA A stated she received no training or disciplinary action following Resident #29's fall. CNA A stated, I usually just transfer her [Resident #29] from wheelchair to the shower chair. According to CNA A, she was told by staff that if a resident can stand holding a grab bar, that it was ok to transfer residents without any help and Resident #29 was standing during physical therapy with a grab bar. During an interview on 04/26/22 at 2:02 PM, DON stated, I wasn't here [the day Resident #29 fell ], I only know what I was told. DON stated she did not think the incident was reported to the State Survey Agency since it was a witnessed incident. DON confirmed Resident #29 sustained a femur fracture and a small fracture in her right elbow from the incident. DON confirmed these would have been considered significant injuries, because it was a fracture. I consider anything more than a bruise a significant injury. DON stated she believed the incident caused Resident #29's admission to hospice to happen a little sooner. DON stated, I don't know [if it should have been reported]. During an interview with ADM on 4/26/2022 at 2:32 PM, she stated, regarding the incident on 02/26/22, ADM stated, since the incident was witnessed by a staff member, that is why she did not report it to the State Survey Agency. ADM stated, we sent her [Resident #29] out [to the hospital] and all that. In my investigation, I came over here [to the facility] and got some stuff and went back to the house and did it on the computer. She stated she interviewed some staff members and asked what happened and she obtained witness statements. She stated she then had a personal emergency and was unavailable two days after the incident. ADM stated, I normally have this big book of what happened [during an investigation] but I was out. ADM was asked to provide the witness statements and any other documentation regarding an investigation of the incident. The only witness statement provided by ADM was the witness statement previously referenced by CNA A. The only documentation of an investigation provided by ADM was the incident report previously referenced that described the events of the incident Record review of facility policy titled, Abuse/Neglect, dated 11/15/16, revealed, in part, the following: .D. Identification .3. facility employees must report all allegation of abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility administrator or designee will report the allegation to HHSC. a) If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. . E. Investigation .3. The written report must be sent to HHSC no later than the fifth working day after the initial report. The facility will use the designated state reporting system.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and was developed within 48 hours of a resident's admission for two of two residents (Resident #88 and Resident #137) reviewed for baseline care plans. Resident #88 and Resident #137 did not have baseline care plans completed within 48 hours of admission. This failure could place newly admitted residents at risk for receiving improper or inadequate care. Findings include: Record review of Resident #88's face sheet, dated [DATE], revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #88's Admission MDS, dated [DATE], revealed it was still in process and was not completed. Record review of Resident #88's undated care plan revealed one focus area of Full code CPR order in place. There were no other focus areas in the care plan. Record review of Resident #137's face sheet, dated [DATE], revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #137's Admission MDS, dated [DATE], revealed it was still in process and was not completed. Record review of Resident #137's undated care plan revealed one focus area of Full code CPR order in place. There were no other focus areas in the care plan. During an interview and record review on [DATE] at 10:43 AM, ADON stated a baseline care plan should have been completed within 48 hours. She stated a baseline care plan should have included the resident's diagnosis, fall history, skin assessment, anything that triggers off of the MDS or admission sheet. She stated they also reviewed resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . ADON reviewed Resident #137's chart and stated the information in the care plan at that point did not reveal an adequate baseline care plan. She stated she did not know why it was not done. She stated the DON typically initiated the initial care plan. ADON stated a negative resident outcome for not having a baseline care plan could have been, we just don't have a plan of care for the resident. During an interview and record review on [DATE] at 11:25 AM, ADON verified that Resident #88 was admitted on [DATE]. ADON reviewed Resident #88's chart and stated there was no baseline care plan. She stated she did not know why it was completed. She stated she was responsible for completing care plans when she worked in the MDS office but then she left the facility for three months and the DON had been completing them. ADON stated she was trained to complete care plans by the previous DON. During an interview on [DATE] at 11:25 AM, ADON stated she had spoken with Owner and he said the facility followed the RAI manual when it came to care planning. ADON stated otherwise, the facility did not not have a policy for baseline care plans. During an interview on [DATE] at 1:40 PM, DON stated when she became the DON at the facility in [DATE], she began to help with care plans. She stated the minute a new resident was in the building, she would start a care plan. She stated when ADON returned to the facility a few months ago, ADON had said she would take over the care plans. DON stated she was under the impression an RN had to initiate a care plan, therefore ADON could not have initiated a care plan because she was an LVN. DON stated she did not initiate any care plans for Resident #88 or Resident #137. She stated a baseline care plan was to be completed within 48 hours of a resident's admission. DON stated a baseline care plan should have included the resident's code status, psychoactive medication, if any, diet details, whether the resident was continent or incontinent, and if they had a pacemaker, she would obtain the model number and put that in the care plan as well. DON stated she would also review the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the current care plans in Resident #88 and Resident #137's charts were not adequate baseline care plans. DON stated there would have been no negative outcomes for those two residents due to not having a baseline care plan. She stated she had hands on interaction with those residents every day. She stated they had their proper diets and there had not been any neglect. DON stated they used the RAI manual for instruction in completing care plans. DON stated she did not think the facility had another policy for baseline care planning.

Based on observation, interview and record review, the facility failed establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of four employees (LVN E) and one of six residents (Resident #7) reviewed for infection control practices. LVN E did not disinfect a wrist blood pressure cuff between use from Resident #137 to Resident #7. This failure could place residents at risk for transmissible diseases. Findings include: During an observation on 04/26/22 at 7:52 AM, LVN E obtained a blood pressure on Resident #137's left wrist with a wrist blood pressure cuff. LVN E then placed the blood pressure cuff on top of her medication cart. The blood pressure cuff was not disinfected after use. During an observation on 04/26/22 at 8:04 AM, LVN E obtained a blood pressure on Resident #7's right wrist with the same wrist blood pressure cuff used on Resident #137. The blood pressure cuff was not disinfected prior to use on Resident #7. During an interview on 04/26/22 at 8:24 AM, LVN E stated she should have cleaned off the blood pressure cuff between resident use and not doing so could have caused cross-contamination between residents. She stated, I know better than that. When we had COVID in the building, I cleaned it [wrist blood pressure cuff] all the time, but since there is no one sick down here . LVN E stated she often got in a hurry when administering medications. She stated she was sure there had been training or in-servicing regarding disinfecting multi-resident use equipment, but she could not remember. During an interview on 04/27/22 at 1:48 PM, DON stated that, glucometers and things like that needed to be cleaned between resident use. She stated regarding blood pressure cuffs, I don't know, honestly, if anywhere [sic] cleans those between. When we had COVID, they [residents] all had their own [blood pressure cuff]. She stated they cleaned thermometers between resident use; if they touch the residents, of course. She stated she did not think that blood pressure cuffs needed to be cleaned and stated, how do you clean a blood pressure cuff? They are fabric mainly. I guess you could use a spray. She stated if they had a resident that had a fever or someone that was sick, they would have had disposable blood pressure cuffs. DON stated if resident was healthy or without signs or symptoms of infection, I don't know. Even in the doctor's office, they grab that cuff off the wall and put it on your arm. DON stated she did not know how beneficial it would have been to disinfect blood pressure cuffs between resident use. She stated with shower chairs, they would have used a disinfectant and that any hard surface should have been disinfected. Record review of facility policy titled, Fundamentals of Infection Control Precautions, dated 2018, revealed, in part, A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility. These measures make up the fundamentals of infection control practices 6. Resident care equipment and articles .3. Non-invasive resident care equipment is cleaned daily or as need [sic] between use by the nursing assistant. Equipment that is visibly soiled with blood or body fluids will be cleaned immediately with an approved disinfectant by the nursing assistant. A documentation system will be maintained of the cleaning.

Based on interview and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 10 residents (Resident #1) reviewed for neglect. CNA G failed to transfer Resident #1 with the assistance of another CNA and with the Hoyer lift which caused Resident #1 to fall on the floor. Resident #1's fall resulted in a compound fracture (a [MEDICAL CONDITION] where the broken end of the bone has penetrated the skin) of the left ankle. This fracture required Resident #1 to go to the hospital and ultimately have surgery to repair the left ankle. An Immediate Jeopardy was identified that existed from 09/15/2016 to 09/20/2016. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice has the potential to affect all 7 residents in the building who require assistance with transfers by 2 staff members using the Hoyer lift by causing resident injuries such as falls, fractures, and even death. Findings include: Record review of Resident #1's clinical record documented an [AGE] year old female who admitted to the facility on [DATE] with a readmission date of [DATE] (Resident #1 had been in the hospital for [MEDICAL CONDITION] and returned the same day of the fall) with the following Diagnoses: [REDACTED]. Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 13 out of 15 indicating no cognitive impairment. Resident #1's functional status reflected she required total assistance of 2 or more people with bed mobility, transfers, and toileting. Resident #1 required extensive assistance of 1 person with dressing, personal hygiene, and bathing. Resident #1 required supervision with locomotion in her wheelchair. Resident #1 had one sided upper extremity range of motion impairment and bilateral lower extremity impairments. Resident #1 required supervision while eating. Resident #1 was always incontinent of bladder and occasionally incontinent of bowel. Resident #1's MDS reflected she had not had any falls since her admission to the facility in 2014. Record review of Resident #1's care plan dated 07/28/2016, reflected Resident #1 required total assistance with bed mobility, toileting, and transfers using a mechanical (Hoyer) lift and assistance of 2 staff members due to Resident #1 being unable to assist with transfers. Record review of Resident #1's Nursing Assistance Care Plan dated, 04/26/2016, reflected Resident #1 required, Special Transfer Aids of a Hoyer Lift and Assist Transfer of 2. In an interview with Resident #1 on 09/28/2016 at 8:20 a.m. she stated when she was getting out of her recliner into her wheelchair, CNA G was helping her transfer. Resident #1 said CNA G was not using the Hoyer lift when she moved her. Resident #1 said she slipped and her foot went underneath her when she fell . Resident #1 stated when she landed, she landed on her foot and it broke. Resident #1 said CNA G always transferred her without the assistance of another CNA even when she was using a Hoyer lift. In an interview with the administrator on 09/26/2016 at 10:35 a.m., she stated Resident #1 had just gotten back to the facility from a previous hospital stay and LVN C told all of the CNAs that were here that day (CNA E, CNA F, and CNA G) that Resident #1 was a 2 person assist for transfers. The administrator stated CNA F asked CNA G for help with transferring Resident #1 as CNA F was taking another resident to the dining room. The administrator said CNA G went ahead and went to Resident #1's room without waiting for CNA F to transfer her. The administrator stated when CNA F got to Resident #1's room, Resident #1 was on the floor with an open fracture of her ankle; CNA G did not wait for assistance to transfer Resident #1. The administrator said Resident #1 required the use of 2 aides and a Hoyer lift for transfers. The administrator stated CNA G was terminated. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's Nursing documentation written by LVN C, dated 09/15/2016, reflected, Resident was being transferred from recliner to wheelchair by CNA G. CNA (G) stated that upon turning resident stated that her leg was giving out. This nurse was called to her room. I witnessed nurse (LVN A) and CNA (G) with resident. Resident was lying in floor. (L) Ankle bone was shaped in two and protruding skin. (L) Foot was contorted. 911, DR, and son notified. Resident sent out via ambulance. Record review of the Incident/Accident Report filled out by the DON dated, 09/15/2016, reflected Resident #1 was prone (face down) in the floor by the recliner. CNA G and LVN C at Resident #1's side. Resident #1's ankle bone was broken in two breaking through the skin. In this report CNA G stated that during Resident #1's transfer her leg gave out causing the resident to fall. CNA G stated she attempted to break the fall, but they both went down. The cause of the fall was documented on the form as: Resident is assist x2 with lift. The report reflected Resident #1 was sent to the emergency room . Record review of LVN A's statement dated, 09/15/2016 (no time), is as follows: CNA F came and got this LVN. When entering the room res (Resident #1) was on floor and CNA G was behind her sitting on floor. Res c/o (complained of) knee hurting and wanted (L) leg out from underneath her. When resident was raised slightly off of floor this LVN seen bone poking out. This LVN immediately called for help. LVN C came in and leg was removed from underneath resident. Area was being assessed, res. leg/foot was immediately stabilized. Ambulance called. Record review of LVN C's statement dated 09/16/2016 at 10:00 a.m., is as follows: On Sept. 15, 2016, Resident #1 had arrived back in the facility from hospital stay around 0900 (9:00 a.m.). (Resident #1 had been admitted to the hospital previously for [MEDICAL CONDITION] and returned the morning of 09/15/2016, the same morning of the fall). Assessment completed by this nurse with the assistance of CNA E. Resident was transferred from wheelchair to toilet to recliner with assist x 2 (assistance of 2 people). Resident was left in recliner, call light in hand, with feet elevated to rest. I (LVN C) told the CNAs on shift - CNA E, CNA F, and CNA G that resident's care was the same as before: assist x 2 with transfers may use Hoyer lift if needed. Around 11 a.m. CNA F asked me again about Resident #1's care. I told her 2 person. Around 11:30 a.m. I was paged from lunch duty to resident's room. Resident was lying in the floor in front of recliner CNA G and LVN A attending her. CNA G stated to me that when she was transferring resident the resident stated that her leg was giving out. Resident assessed. DR called orders to send to ER via ambulance. Son was called. CNA F was asked why resident was transferred x 1 (one person). CNA F stated that CNA G asked for assistance and CNA F told her that she would be there. When CNA F arrived to Resident #1's room the accident had already happened. I asked CNA F and CNA E again the care for Resident #1 and they both said 2 person assist. Can use lift. Record review of CNA F's statement dated 09/16/2016 at 11:02 a.m., is as follows: When CNA G got back from her lunch break I asked her to help me get Resident #1 up for lunch and she said yes so she went ahead and started to go to Resident #1's room and I told her I will be right down there I am going to take another resident to the dining room then I will be right there and as soon as I got done taking the resident to the dining room Resident #1's light was on so I went down there to see what happened and seen Resident #1 on the floor and there was blood in front of her so I called for help at the front and they came down to her room to help her. Record review of CNA G's statement dated 09/18/2016 (no time), is as follows: I knock on door came in and started telling Resident #1 it time for lunch. Resident #1 started raising her recliner. I ask do you want electric wheelchair or regular. She stated electric one so I put electric one in front of her recliner like with always to transfer her from recliner to electric she raise her electric chair up to it be easy for her to transfer she stood up had grab her electric chair arms to hold on she went walk around told me to raise her dress up from back so she won't get it wet she needed to go to the bathroom first. I said ok as we were chatting we started standing up to go around to sit down on her chair we started talking she mention how they were cooking fresh vegetables at hospital she was get with her meals I said alright that sounds good we tried to go around to sit in chair she I can't stand long I feel like I am falling I told hold on to me and chair. She said I can't so I am losing my strength I told her to hold onto chair. I was right beside her as we started to go around she then stated she couldn't move. She slid of my leg down to ground her left foot got caught up under her when she went down. But we never had no trouble before until now. Her leg gave out from under her. Record review of the patient health summary from the hospital dated 09/19/2016 (no time) reflected, Reason for Visit: OPEN LEFT TIB/FIB FRACTURE. (Tibia and Fibula) Record review of the Patient Registration Form dated 09/15/2016 documented that Resident #1 was admitted at 1613 (4:13 p.m.) with an Open left tib/fib fracture . CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS: Left lower extremity x-ray revealed an acute oblique [MEDICAL CONDITION] fibula as well as acute nondisplaced [MEDICAL CONDITION] malleolus and disruption of ankle mortise. During her stay in ER, she remained in [MEDICAL CONDITION] but did have intermittent episodes of rapid ventricular response which resolved prior to transfer to the floor where she was admitted for planned surgical repair of her acute open [MEDICAL CONDITION] distal shaft of the fibula. In an interview with the DON on 09/26/2016 at 2:30 p.m., she stated CNA G went to Resident #1's room to help CNA F. The DON said CNA G did not wait for CNA F to begin the transfer. The DON stated when CNA F got to Resident #1's room CNA G and Resident #1 were in the floor; the resident was on top of CNA G. The DON said CNA G had been a CNA for a long time and she knew to use 2 people for transfers on Resident #1 and that it is required to have 2 staff members for a Hoyer transfer. The DON referred to Hoyer training and stated the facility always does education about Hoyer transfers upon hire and periodically throughout the year. Record review of the in-service titled Pump Hoyer Lift led by RN B, dated 02/28/2016 (no time) reflected CNA G attended the training for Hoyer lifts. Record review of the in-service completed by the facility's rehab company on 04/22/ (no time) reflected CNA G received transfer training. In an interview with LVN A on 09/27/2016 at 9:55 a.m., she stated CNA F came to get her to go to Resident #1's room and when she got there Resident #1 was in the floor with her back against CNA G's chest leaning on her. LVN A said when Resident #1 was raised slightly off of the floor she could see the bone sticking out of Resident #1's ankle. When LVN A saw this she said she sent CNA F to go get LVN C. When LVN C arrived, LVN A said they stabilized Resident #1's ankle and placed it on a pillow. LVN A said Resident #1's foot was underneath her going the wrong direction and her bone was sticking out the opposite direction. In an interview with Resident #7 on 09/27/2016 at 11:59 a.m., she stated, CNA G has always transferred her with the Hoyer lift by herself. Resident #7 said it has been that way since I moved here until recently, when Resident #1 had her accident. In an interview with CNA E on 09/27/2016 at 2:36 p.m., she stated when Resident #1 came back from the hospital the morning of 09/15/2016, she took Resident #1 to weigh her and then to her room. CNA E stated Resident #1 needed to go to the restroom and then CNA E and LVN C put Resident #1 in her recliner and left. CNA E stated that was the only encounter she had with Resident #1 the day of her fall. In an interview with LVN C on 09/28/2016 at 9:45 a.m., she stated she was in the dining room helping the residents with lunch when LVN A yelled for help. LVN C stated she went to Resident #1's room and Resident #1 was in the floor and her foot was underneath her. CNA G was sitting behind Resident #1 so she could lean on her. LVN C said she and LVN A stabilized Resident #1's foot as best they could with a sheet and placed it on a pillow and waited for the paramedics to get to the facility. LVN C stated Resident #1 endured a horrible break; the only thing holding her foot on was the outer skin of her leg. In an interview with CNA F on 09/28/2016 at 9:50 a.m., she stated she asked CNA G to help her transfer Resident #1 after she assisted another resident to the dining room and when CNA F returned to Resident #1's room CNA G did not wait to transfer her. CNA F stated Resident #1 was in the floor on CNA G. CNA F said she saw blood in the floor and went to get LVN A. CNA F stated she hooks up the resident to the Hoyer and waits for help. CNA F said she never transfers by herself. In an interview with CNA G on 09/28/2016 at 2:55 p.m., she stated Resident #1 did not want to use the Hoyer for her transfer. CNA G said she had Resident #1 lift her recliner up so CNA G could transfer her to her wheelchair. CNA G stated Resident #1 stood up and began to pivot and her legs started giving out. CNA G said she tried to slide Resident #1 down to the floor, but it didn't work. CNA G stated she always transferred residents this way. CNA G said she did not wait for another staff even when the resident is supposed to be a 2 person transfer or if they require the use of a Hoyer because she didn't have time to wait. CNA G stated Resident #1's care plan said Resident #1 was supposed to be a 2 person transfer, but she transferred her all the time just herself. Record review of in-services the facility implemented were: An in-service was completed specific for Resident #1 on 09/15/2016: Always 2 person transfer when using the mechanical lift. All 9 CNAs and 10 nurses signed the in-service sheet. An in-service was completed specific for Transferring Residents on 09/15/2016: Use proper lifting and transferring techniques and make sure to check the nurse aide care plans. Use gait belts when applicable always times 2 person transfer when using the mechanical lift. All 9 CNAs and 10 nurses signed the in-service sheet. SUBJECT (S): Mechanical Lift DATE CONDUCTED: 09/16/2016 MINUTES ATTENDED: 30 MINS All 9 CNAs employed by the facility and all 10 nurses signed in attendance. The In-service regarding Mechanical Lift is as follows: Policy It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. Keep legs to lift in wide position when the resident is in it. Procedure 1. Have Hoyer lifter, canvas seat and back, as well as chains with S hooks on hand. 2. Explain procedure to resident and bring Hoyer Lift to bedside. 3. Roll resident onto his/her side. 4. Place wider seat part under resident's thighs so lower edge of seat is under knees. 5. Place narrow part just above small of back. 6. Roll resident to other side and pull sling through. 7. Position seat sling securely under resident. 8. Position lifter to open end of horseshoe base under side of bed. 9. Attach S hooks of the chains to the loops on seat hangers with hooks away from resident to outside of sling. 10. Attach chains to the swivel bar hooks. 11. Count links to be sure there are the same number on each side. Check to see that S hooks are hooked all the way into the chains and that the seat is close to the knees for safety. 12. Close release valves gently. 13. Resident's arms should be inside chains. 14. Check chains and S hooks to make sure they are properly positioned. 15. Hand may be placed on steering handle. Pump hydraulic pump handle. 16. Position wheelchair and lock brakes. Swing resident's feet off bed; when resident has been lifted clear of bed, grasp steering handles and move resident over chair. 17. Turn release valve slowly to lower resident gently. Guide resident's decent. 18. When resident is seated, detach S hooks from seat and back. Remove chains. Resident may remain on seat. 19. Return lift to designated area when not in use. 20. To return resident to bed, use the same procedure in reverse. Center resident over bed and lower gently. 21. Record in medical treatment any pertinent observations. SUBJECT (S): Transferring a Resident DATE CONDUCTED: 09/16/2016 All 9 CNAs employed by the facility and all 10 nurses signed in attendance. The In-service regarding Transferring a Resident is as follows: Procedure 1. Bed to Wheelchair. Wheelchairs with removable leg assemblies must be angled at a 35-degree angle on the resident's strongest side. Lock wheelchair, lift foot rests up out of the way. · Assist resident to a sitting position on the edge of the bed with feet flat on the floor. · Have resident lean forward at waist and, place strong hand on bed or arm of wheelchair and push up to a standing position. · Assist resident to take small steps toward chair, turning or pivoting on the uninvolved foot, until he/she feels the seats of the chair with the back of both legs. · Assist resident to bend forward at trunk and slowly lower body to chair. 2. Wheelchair to bed Same procedure as above is used. Process is reversed. The resident will slide body forward, pull feet back under body, lean forward, and push self up. 3. Getting Out of Chairs. Assist resident to place feet squarely on floor and pull under body, bend forward, and then push up with unaffected hand, keeping head forward over feet. 4. Toilet Transfer Position wheelchair as close to toilet seat as possible. Loosen and or lower clothes and move to edge of chair. An in-service was completed on 09/16/2016 regarding all, 7 residents in the facility who require 2 Person Transfer and are to use Mechanical Lift at all times. All 9 CNAs and 10 nurse signed the in-service sheet. Record review of an in-service completed by the administrator reflected: Effective immediately! 2 licensed or certified staff must sign off on 2 Person Assist and Hoyer Lift Residents. This should be done every shift. The sign off sheet will be located on the nurse's clipboard at the nurse's station. Nurse on duty will be responsible for checking the list to ensure that this is being done on their shift. Failure to comply will result in disciplinary action. Signed by the administrator and dated 09/20/2016 During observations of 5 different direct care staff members on 09/26-27/2016 they displayed competence in operating the Hoyer lift and safely transferred each resident with 2 staff members. In interviews with 5 different direct care staff members on 09/26-28/2016 they all stated it is required to have 2 staff members to operate the Hoyer lift when transferring a resident. Record review of the facility's Resident Neglect Policy dated 2014 is as follows: Any person who observes or becomes aware of an incident of resident abuse, neglect or mistreatment of [REDACTED]. This policy applies to incidents occurring anywhere in the Facility, on Facility grounds, at school or workshops, or away from the Facility. The Administrator or Department Head will initiate the procedure for incident investigation and reporting. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs. If a direct caregiver is observed, suspected or alleged to have engaged in abuse, neglect or mistreatment of [REDACTED]. In an interview with the administrator on 09/27/2016 at 8:52 a.m., she was notified an Immediate Jeopardy existed from 09/15/206 through 09/20/2016 prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 09/26/2016, 7 residents in the facility require the use of a Hoyer lift and 2 staff members when transferring; the facility had a census of 39.

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 10 residents (Resident #1) reviewed for neglect. CNA G failed to transfer Resident #1 with the assistance of another CNA and with the Hoyer lift which caused Resident #1 to fall on the floor. Resident #1's fall resulted in a compound fracture (a [MEDICAL CONDITION] where the broken end of the bone has penetrated the skin) of the left ankle. This fracture required Resident #1 to go to the hospital and ultimately have surgery to repair the left ankle. An Immediate Jeopardy was identified that existed from 09/15/2016 to 09/20/2016. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice has the potential to affect all 7 residents in the building who require assistance with transfers by 2 staff members using the Hoyer lift by causing resident injuries such as falls, fractures, and even death. Findings include: Record review of the facility's Resident Neglect Policy dated 2014 is as follows: Any person who observes or becomes aware of an incident of resident abuse, neglect or mistreatment of [REDACTED]. This policy applies to incidents occurring anywhere in the Facility, on Facility grounds, at school or workshops, or away from the Facility. The Administrator or Department Head will initiate the procedure for incident investigation and reporting. Neglect includes, but is not limited to, lack of care and supervision and unmet physical, social, emotional, spiritual or medical needs. If a direct caregiver is observed, suspected or alleged to have engaged in abuse, neglect or mistreatment of [REDACTED]. Record review of Resident #1's clinical record documented an [AGE] year old female who admitted to the facility on [DATE] with a readmission date of [DATE] (Resident #1 had been in the hospital for [MEDICAL CONDITION] and returned the same day of the fall) with the following Diagnoses: [REDACTED]. Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 13 out of 15 indicating no cognitive impairment. Resident #1's functional status reflected she required total assistance of 2 or more people with bed mobility, transfers, and toileting. Resident #1 required extensive assistance of 1 person with dressing, personal hygiene, and bathing. Resident #1 required supervision with locomotion in her wheelchair. Resident #1 had one sided upper extremity range of motion impairment and bilateral lower extremity impairments. Resident #1 required supervision while eating. Resident #1 was always incontinent of bladder and occasionally incontinent of bowel. Resident #1's MDS reflected she had not had any falls since her admission to the facility in 2014. Record review of Resident #1's care plan dated 07/28/2016, reflected Resident #1 required total assistance with bed mobility, toileting, and transfers using a mechanical (Hoyer) lift and assistance of 2 staff members due to Resident #1 being unable to assist with transfers. Record review of Resident #1's Nursing Assistance Care Plan dated, 04/26/2016, reflected Resident #1 required, Special Transfer Aids of a Hoyer Lift and Assist Transfer of 2. In an interview with Resident #1 on 09/28/2016 at 8:20 a.m. she stated when she was getting out of her recliner into her wheelchair, CNA G was helping her transfer. Resident #1 said CNA G was not using the Hoyer lift when she moved her. Resident #1 said she slipped and her foot went underneath her when she fell . Resident #1 stated when she landed, she landed on her foot and it broke. Resident #1 said CNA G always transferred her without the assistance of another CNA even when she was using a Hoyer lift. In an interview with the administrator on 09/26/2016 at 10:35 a.m., she stated Resident #1 had just gotten back to the facility from a previous hospital stay and LVN C told all of the CNAs that were here that day (CNA E, CNA F, and CNA G) that Resident #1 was a 2 person assist for transfers. The administrator stated CNA F asked CNA G for help with transferring Resident #1 as CNA F was taking another resident to the dining room. The administrator said CNA G went ahead and went to Resident #1's room without waiting for CNA F to transfer her. The administrator stated when CNA F got to Resident #1's room, Resident #1 was on the floor with an open fracture of her ankle; CNA G did not wait for assistance to transfer Resident #1. The administrator said Resident #1 required the use of 2 aides and a Hoyer lift for transfers. The administrator stated CNA G was terminated. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's Nursing documentation written by LVN C, dated 09/15/2016, reflected, Resident was being transferred from recliner to wheelchair by CNA G. CNA (G) stated that upon turning resident stated that her leg was giving out. This nurse was called to her room. I witnessed nurse (LVN A) and CNA (G) with resident. Resident was lying in floor. (L) Ankle bone was shaped in two and protruding skin. (L) Foot was contorted. 911, DR, and son notified. Resident sent out via ambulance. Record review of the Incident/Accident Report filled out by the DON dated, 09/15/2016, reflected Resident #1 was prone (face down) in the floor by the recliner. CNA G and LVN C at Resident #1's side. Resident #1's ankle bone was broken in two breaking through the skin. In this report CNA G stated that during Resident #1's transfer her leg gave out causing the resident to fall. CNA G stated she attempted to break the fall, but they both went down. The cause of the fall was documented on the form as: Resident is assist x2 with lift. The report reflected Resident #1 was sent to the emergency room . Record review of LVN A's statement dated, 09/15/2016 (no time), is as follows: CNA F came and got this LVN. When entering the room res (Resident #1) was on floor and CNA G was behind her sitting on floor. Res c/o (complained of) knee hurting and wanted (L) leg out from underneath her. When resident was raised slightly off of floor this LVN seen bone poking out. This LVN immediately called for help. LVN C came in and leg was removed from underneath resident. Area was being assessed, res. leg/foot was immediately stabilized. Ambulance called. Record review of LVN C's statement dated 09/16/2016 at 10:00 a.m., is as follows: On Sept. 15, 2016, Resident #1 had arrived back in the facility from hospital stay around 0900 (9:00 a.m.). (Resident #1 had been admitted to the hospital previously for [MEDICAL CONDITION] and returned the morning of 09/15/2016, the same morning of the fall). Assessment completed by this nurse with the assistance of CNA E. Resident was transferred from wheelchair to toilet to recliner with assist x 2 (assistance of 2 people). Resident was left in recliner, call light in hand, with feet elevated to rest. I (LVN C) told the CNAs on shift - CNA E, CNA F, and CNA G that resident's care was the same as before: assist x 2 with transfers may use Hoyer lift if needed. Around 11 a.m. CNA F asked me again about Resident #1's care. I told her 2 person. Around 11:30 a.m. I was paged from lunch duty to resident's room. Resident was lying in the floor in front of recliner CNA G and LVN A attending her. CNA G stated to me that when she was transferring resident the resident stated that her leg was giving out. Resident assessed. DR called orders to send to ER via ambulance. Son was called. CNA F was asked why resident was transferred x 1 (one person). CNA F stated that CNA G asked for assistance and CNA F told her that she would be there. When CNA F arrived to Resident #1's room the accident had already happened. I asked CNA F and CNA E again the care for Resident #1 and they both said 2 person assist. Can use lift. Record review of CNA F's statement dated 09/16/2016 at 11:02 a.m., is as follows: When CNA G got back from her lunch break I asked her to help me get Resident #1 up for lunch and she said yes so she went ahead and started to go to Resident #1's room and I told her I will be right down there I am going to take another resident to the dining room then I will be right there and as soon as I got done taking the resident to the dining room Resident #1's light was on so I went down there to see what happened and seen Resident #1 on the floor and there was blood in front of her so I called for help at the front and they came down to her room to help her. Record review of CNA G's statement dated 09/18/2016 (no time), is as follows: I knock on door came in and started telling Resident #1 it time for lunch. Resident #1 started raising her recliner. I ask do you want electric wheelchair or regular. She stated electric one so I put electric one in front of her recliner like with always to transfer her from recliner to electric she raise her electric chair up to it be easy for her to transfer she stood up had grab her electric chair arms to hold on she went walk around told me to raise her dress up from back so she won't get it wet she needed to go to the bathroom first. I said ok as we were chatting we started standing up to go around to sit down on her chair we started talking she mention how they were cooking fresh vegetables at hospital she was get with her meals I said alright that sounds good we tried to go around to sit in chair she I can't stand long I feel like I am falling I told hold on to me and chair. She said I can't so I am losing my strength I told her to hold onto chair. I was right beside her as we started to go around she then stated she couldn't move. She slid of my leg down to ground her left foot got caught up under her when she went down. But we never had no trouble before until now. Her leg gave out from under her. Record review of the patient health summary from the hospital dated 09/19/2016 (no time) reflected, Reason for Visit: OPEN LEFT TIB/FIB FRACTURE. (Tibia and Fibula) Record review of the Patient Registration Form dated 09/15/2016 documented that Resident #1 was admitted at 1613 (4:13 p.m.) with an Open left tib/fib fracture . CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS: Left lower extremity x-ray revealed an acute oblique [MEDICAL CONDITION] fibula as well as acute nondisplaced [MEDICAL CONDITION] malleolus and disruption of ankle mortise. During her stay in ER, she remained in [MEDICAL CONDITION] but did have intermittent episodes of rapid ventricular response which resolved prior to transfer to the floor where she was admitted for planned surgical repair of her acute open [MEDICAL CONDITION] distal shaft of the fibula. In an interview with the DON on 09/26/2016 at 2:30 p.m., she stated CNA G went to Resident #1's room to help CNA F. The DON said CNA G did not wait for CNA F to begin the transfer. The DON stated when CNA F got to Resident #1's room CNA G and Resident #1 were in the floor; the resident was on top of CNA G. The DON said CNA G had been a CNA for a long time and she knew to use 2 people for transfers on Resident #1 and that it is required to have 2 staff members for a Hoyer transfer. The DON referred to Hoyer training and stated the facility always does education about Hoyer transfers upon hire and periodically throughout the year. In an interview with LVN A on 09/27/2016 at 9:55 a.m., she stated CNA F came to get her to go to Resident #1's room and when she got there Resident #1 was in the floor with her back against CNA G's chest leaning on her. LVN A said when Resident #1 was raised slightly off of the floor she could see the bone sticking out of Resident #1's ankle. When LVN A saw this she said she sent CNA F to go get LVN C. When LVN C arrived, LVN A said they stabilized Resident #1's ankle and placed it on a pillow. LVN A said Resident #1's foot was underneath her going the wrong direction and her bone was sticking out the opposite direction. In an interview with Resident #7 on 09/27/2016 at 11:59 a.m., she stated, CNA G has always transferred her with the Hoyer lift by herself. Resident #7 said it has been that way since I moved here until recently, when Resident #1 had her accident. In an interview with CNA E on 09/27/2016 at 2:36 p.m., she stated when Resident #1 came back from the hospital the morning of 09/15/2016, she took Resident #1 to weigh her and then to her room. CNA E stated Resident #1 needed to go to the restroom and then CNA E and LVN C put Resident #1 in her recliner and left. CNA E stated that was the only encounter she had with Resident #1 the day of her fall. In an interview with LVN C on 09/28/2016 at 9:45 a.m., she stated she was in the dining room helping the residents with lunch when LVN A yelled for help. LVN C stated she went to Resident #1's room and Resident #1 was in the floor and her foot was underneath her. CNA G was sitting behind Resident #1 so she could lean on her. LVN C said she and LVN A stabilized Resident #1's foot as best they could with a sheet and placed it on a pillow and waited for the paramedics to get to the facility. LVN C stated Resident #1 endured a horrible break; the only thing holding her foot on was the outer skin of her leg. In an interview with CNA F on 09/28/2016 at 9:50 a.m., she stated she asked CNA G to help her transfer Resident #1 after she assisted another resident to the dining room and when CNA F returned to Resident #1's room CNA G did not wait to transfer her. CNA F stated Resident #1 was in the floor on CNA G. CNA F said she saw blood in the floor and went to get LVN A. CNA F stated she hooks up the resident to the Hoyer and waits for help. CNA F said she never transfers by herself. In an interview with CNA G on 09/28/2016 at 2:55 p.m., she stated Resident #1 did not want to use the Hoyer for her transfer. CNA G said she had Resident #1 lift her recliner up so CNA G could transfer her to her wheelchair. CNA G stated Resident #1 stood up and began to pivot and her legs started giving out. CNA G said she tried to slide Resident #1 down to the floor, but it didn't work. CNA G stated she always transferred residents this way. CNA G said she did not wait for another staff even when the resident is supposed to be a 2 person transfer or if they require the use of a Hoyer because she didn't have time to wait. CNA G stated Resident #1's care plan said Resident #1 was supposed to be a 2 person transfer, but she transferred her all the time just herself. Record review of in-services the facility implemented were: An in-service was completed specific for Resident #1 on 09/15/2016: Always 2 person transfer when using the mechanical lift. All 9 CNAs and 10 nurses signed the in-service sheet. An in-service was completed specific for Transferring Residents on 09/15/2016: Use proper lifting and transferring techniques and make sure to check the nurse aide care plans. Use gait belts when applicable always times 2 person transfer when using the mechanical lift. All 9 CNAs and 10 nurses signed the in-service sheet. SUBJECT (S): Mechanical Lift DATE CONDUCTED: 09/16/2016 MINUTES ATTENDED: 30 MINS All 9 CNAs employed by the facility and all 10 nurses signed in attendance. The In-service regarding Mechanical Lift is as follows: Policy It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. Keep legs to lift in wide position when the resident is in it. Procedure 1. Have Hoyer lifter, canvas seat and back, as well as chains with S hooks on hand. 2. Explain procedure to resident and bring Hoyer Lift to bedside. 3. Roll resident onto his/her side. 4. Place wider seat part under resident's thighs so lower edge of seat is under knees. 5. Place narrow part just above small of back. 6. Roll resident to other side and pull sling through. 7. Position seat sling securely under resident. 8. Position lifter to open end of horseshoe base under side of bed. 9. Attach S hooks of the chains to the loops on seat hangers with hooks away from resident to outside of sling. 10. Attach chains to the swivel bar hooks. 11. Count links to be sure there are the same number on each side. Check to see that S hooks are hooked all the way into the chains and that the seat is close to the knees for safety. 12. Close release valves gently. 13. Resident's arms should be inside chains. 14. Check chains and S hooks to make sure they are properly positioned. 15. Hand may be placed on steering handle. Pump hydraulic pump handle. 16. Position wheelchair and lock brakes. Swing resident's feet off bed; when resident has been lifted clear of bed, grasp steering handles and move resident over chair. 17. Turn release valve slowly to lower resident gently. Guide resident's decent. 18. When resident is seated, detach S hooks from seat and back. Remove chains. Resident may remain on seat. 19. Return lift to designated area when not in use. 20. To return resident to bed, use the same procedure in reverse. Center resident over bed and lower gently. 21. Record in medical treatment any pertinent observations. SUBJECT (S): Transferring a Resident DATE CONDUCTED: 09/16/2016 All 9 CNAs employed by the facility and all 10 nurses signed in attendance. The In-service regarding Transferring a Resident is as follows: Procedure 1. Bed to Wheelchair. Wheelchairs with removable leg assemblies must be angled at a 35-degree angle on the resident's strongest side. Lock wheelchair, lift foot rests up out of the way. · Assist resident to a sitting position on the edge of the bed with feet flat on the floor. · Have resident lean forward at waist and, place strong hand on bed or arm of wheelchair and push up to a standing position. · Assist resident to take small steps toward chair, turning or pivoting on the uninvolved foot, until he/she feels the seats of the chair with the back of both legs. · Assist resident to bend forward at trunk and slowly lower body to chair. 2. Wheelchair to bed Same procedure as above is used. Process is reversed. The resident will slide body forward, pull feet back under body, lean forward, and push self up. 3. Getting Out of Chairs. Assist resident to place feet squarely on floor and pull under body, bend forward, and then push up with unaffected hand, keeping head forward over feet. 4. Toilet Transfer Position wheelchair as close to toilet seat as possible. Loosen and or lower clothes and move to edge of chair. An in-service was completed on 09/16/2016 regarding all, 7 residents in the facility who require 2 Person Transfer and are to use Mechanical Lift at all times. All 9 CNAs and 10 nurse signed the in-service sheet. Record review of an in-service completed by the administrator reflected: Effective immediately! 2 licensed or certified staff must sign off on 2 Person Assist and Hoyer Lift Residents. This should be done every shift. The sign off sheet will be located on the nurse's clipboard at the nurse's station. Nurse on duty will be responsible for checking the list to ensure that this is being done on their shift. Failure to comply will result in disciplinary action. Signed by the administrator and dated 09/20/2016 During observations of 5 different direct care staff members on 09/26-27/2016 they displayed competence in operating the Hoyer lift and safely transferred each resident with 2 staff members. In interviews with 5 different direct care staff members on 09/26-28/2016 they all stated it is required to have 2 staff members to operate the Hoyer lift when transferring a resident. In an interview with the administrator on 09/27/2016 at 8:52 a.m., she was notified an Immediate Jeopardy existed from 09/15/206 through 09/20/2016 prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 09/26/2016, 7 residents in the facility require the use of a Hoyer lift and 2 staff members when transferring; the facility had a census of 39.

Based on interview and record review, the facility failed to ensure residents remained free from accidents, hazards, and each resident received adequate supervision and assistance when transferring with a Hoyer lift for 1 of 7 residents (Resident #1) reviewed for accidents and hazards. CNA G failed to transfer Resident #1 with the assistance of another CNA and with the Hoyer lift which caused Resident #1 to fall on the floor. Resident #1's fall resulted in a compound fracture (a fracture of the bone where the broken end of the bone has penetrated the skin) of the left ankle. This fracture required Resident #1 to go to the hospital and ultimately have surgery to repair the left ankle. An Immediate Jeopardy was identified that existed from 09/15/2016 to 09/20/2016. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice has the potential to affect all 7 residents in the building who require assistance with transfers by 2 staff members using the Hoyer lift by causing resident injuries such as falls, fractures, and even death. Findings include: Record review of Resident #1's clinical record documented an [AGE] year old female who admitted to the facility on [DATE] with a readmission date of [DATE] (Resident #1 had been in the hospital for septicemia and returned the same day of the fall) with the following Diagnoses: [REDACTED]. Record review of Resident #1's most recent quarterly MDS assessment dated [DATE] reflected Resident #1 had a BIMS score of 13 out of 15 indicating no cognitive impairment. Resident #1's functional status reflected she required total assistance of 2 or more people with bed mobility, transfers, and toileting. Resident #1 required extensive assistance of 1 person with dressing, personal hygiene, and bathing. Resident #1 required supervision with locomotion in her wheelchair. Resident #1 had one sided upper extremity range of motion impairment and bilateral lower extremity impairments. Resident #1 required supervision while eating. Resident #1 was always incontinent of bladder and occasionally incontinent of bowel. Resident #1's MDS reflected she had not had any falls since her admission to the facility in 2014. Record review of Resident #1's care plan dated 07/28/2016, reflected Resident #1 required total assistance with bed mobility, toileting, and transfers using a mechanical (Hoyer) lift and assistance of 2 staff members due to Resident #1 being unable to assist with transfers. Record review of Resident #1's Nursing Assistance Care Plan dated, 04/26/2016, reflected Resident #1 required, Special Transfer Aids of a Hoyer Lift and Assist Transfer of 2. In an interview with Resident #1 on 09/28/2016 at 8:20 a.m. she stated when she was getting out of her recliner into her wheelchair, CNA G was helping her transfer. Resident #1 said CNA G was not using the Hoyer lift when she moved her. Resident #1 said she slipped and her foot went underneath her when she fell . Resident #1 stated when she landed, she landed on her foot and it broke. Resident #1 said CNA G always transferred her without the assistance of another CNA even when she was using a Hoyer lift. In an interview with the administrator on 09/26/2016 at 10:35 a.m., she stated Resident #1 had just gotten back to the facility from a previous hospital stay and LVN C told all of the CNAs that were here that day (CNA E, CNA F, and CNA G) that Resident #1 was a 2 person assist for transfers. The administrator stated CNA F asked CNA G for help with transferring Resident #1 as CNA F was taking another resident to the dining room. The administrator said CNA G went ahead and went to Resident #1's room without waiting for CNA F to transfer her. The administrator stated when CNA F got to Resident #1's room, Resident #1 was on the floor with an open fracture of her ankle; CNA G did not wait for assistance to transfer Resident #1. The administrator said Resident #1 required the use of 2 aides and a Hoyer lift for transfers. The administrator stated CNA G was terminated. Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's Nursing documentation written by LVN C, dated 09/15/2016, reflected, Resident was being transferred from recliner to wheelchair by CNA G. CNA (G) stated that upon turning resident stated that her leg was giving out. This nurse was called to her room. I witnessed nurse (LVN A) and CNA (G) with resident. Resident was lying in floor. (L) Ankle bone was shaped in two and protruding skin. (L) Foot was contorted. 911, DR, and son notified. Resident sent out via ambulance. Record review of the Incident/Accident Report filled out by the DON dated, 09/15/2016, reflected Resident #1 was prone (face down) in the floor by the recliner. CNA G and LVN C at Resident #1's side. Resident #1's ankle bone was broken in two breaking through the skin. In this report CNA G stated that during Resident #1's transfer her leg gave out causing the resident to fall. CNA G stated she attempted to break the fall, but they both went down. The cause of the fall was documented on the form as: Resident is assist x2 with lift. The report reflected Resident #1 was sent to the emergency room . Record review of LVN A's statement dated, 09/15/2016 (no time), is as follows: CNA F came and got this LVN. When entering the room res (Resident #1) was on floor and CNA G was behind her sitting on floor. Res c/o (complained of) knee hurting and wanted (L) leg out from underneath her. When resident was raised slightly off of floor this LVN seen bone poking out. This LVN immediately called for help. LVN C came in and leg was removed from underneath resident. Area was being assessed, res. leg/foot was immediately stabilized. Ambulance called. Record review of LVN C's statement dated 09/16/2016 at 10:00 a.m., is as follows: On Sept. 15, 2016, Resident #1 had arrived back in the facility from hospital stay around 0900 (9:00 a.m.). (Resident #1 had been admitted to the hospital previously for septicemia and returned the morning of 09/15/2016, the same morning of the fall). Assessment completed by this nurse with the assistance of CNA E. Resident was transferred from wheelchair to toilet to recliner with assist x 2 (assistance of 2 people). Resident was left in recliner, call light in hand, with feet elevated to rest. I (LVN C) told the CNAs on shift - CNA E, CNA F, and CNA G that resident's care was the same as before: assist x 2 with transfers may use Hoyer lift if needed. Around 11 a.m. CNA F asked me again about Resident #1's care. I told her 2 person. Around 11:30 a.m. I was paged from lunch duty to resident's room. Resident was lying in the floor in front of recliner CNA G and LVN A attending her. CNA G stated to me that when she was transferring resident the resident stated that her leg was giving out. Resident assessed. DR called orders to send to ER via ambulance. Son was called. CNA F was asked why resident was transferred x 1 (one person). CNA F stated that CNA G asked for assistance and CNA F told her that she would be there. When CNA F arrived to Resident #1's room the accident had already happened. I asked CNA F and CNA E again the care for Resident #1 and they both said 2 person assist. Can use lift. Record review of CNA F's statement dated 09/16/2016 at 11:02 a.m., is as follows: When CNA G got back from her lunch break I asked her to help me get Resident #1 up for lunch and she said yes so she went ahead and started to go to Resident #1's room and I told her I will be right down there I am going to take another resident to the dining room then I will be right there and as soon as I got done taking the resident to the dining room Resident #1's light was on so I went down there to see what happened and seen Resident #1 on the floor and there was blood in front of her so I called for help at the front and they came down to her room to help her. Record review of CNA G's statement dated 09/18/2016 (no time), is as follows: I knock on door came in and started telling Resident #1 it time for lunch. Resident #1 started raising her recliner. I ask do you want electric wheelchair or regular. She stated electric one so I put electric one in front of her recliner like with always to transfer her from recliner to electric she raise her electric chair up to it be easy for her to transfer she stood up had grab her electric chair arms to hold on she went walk around told me to raise her dress up from back so she won't get it wet she needed to go to the bathroom first. I said ok as we were chatting we started standing up to go around to sit down on her chair we started talking she mention how they were cooking fresh vegetables at hospital she was get with her meals I said alright that sounds good we tried to go around to sit in chair she I can't stand long I feel like I am falling I told hold on to me and chair. She said I can't so I am losing my strength I told her to hold onto chair. I was right beside her as we started to go around she then stated she couldn't move. She slid of my leg down to ground her left foot got caught up under her when she went down. But we never had no trouble before until now. Her leg gave out from under her. Record review of the patient health summary from the hospital dated 09/19/2016 (no time) reflected, Reason for Visit: OPEN LEFT TIB/FIB FRACTURE. (Tibia and Fibula) Record review of the Patient Registration Form dated 09/15/2016 documented that Resident #1 was admitted at 1613 (4:13 p.m.) with an Open left tib/fib fracture . CHIEF COMPLAINT HISTORY OF PRESENT ILLNESS: Left lower extremity x-ray revealed an acute oblique fracture of the distal fibula as well as acute nondisplaced fracture of the medial malleolus and disruption of ankle mortise. During her stay in ER, she remained in [DIAGNOSES REDACTED]but did have intermittent episodes of rapid ventricular response which resolved prior to transfer to the floor where she was admitted for planned surgical repair of her acute open fracture of the right distal shaft of the fibula. In an interview with the DON on 09/26/2016 at 2:30 p.m., she stated CNA G went to Resident #1's room to help CNA F. The DON said CNA G did not wait for CNA F to begin the transfer. The DON stated when CNA F got to Resident #1's room CNA G and Resident #1 were in the floor; the resident was on top of CNA G. The DON said CNA G had been a CNA for a long time and she knew to use 2 people for transfers on Resident #1 and that it is required to have 2 staff members for a Hoyer transfer. The DON referred to Hoyer training and stated the facility always does education about Hoyer transfers upon hire and periodically throughout the year. Record review of the in-service titled Pump Hoyer Lift led by RN B, dated 02/28/2016 (no time) reflected CNA G attended the training for Hoyer lifts. Record review of the in-service completed by the facility's rehab company on 04/22/ (no time) reflected CNA G received transfer training. In an interview with LVN A on 09/27/2016 at 9:55 a.m., she stated CNA F came to get her to go to Resident #1's room and when she got there Resident #1 was in the floor with her back against CNA G's chest leaning on her. LVN A said when Resident #1 was raised slightly off of the floor she could see the bone sticking out of Resident #1's ankle. When LVN A saw this she said she sent CNA F to go get LVN C. When LVN C arrived, LVN A said they stabilized Resident #1's ankle and placed it on a pillow. LVN A said Resident #1's foot was underneath her going the wrong direction and her bone was sticking out the opposite direction. In an interview with Resident #7 on 09/27/2016 at 11:59 a.m., she stated, CNA G has always transferred her with the Hoyer lift by herself. Resident #7 said it has been that way since I moved here until recently, when Resident #1 had her accident. In an interview with CNA E on 09/27/2016 at 2:36 p.m., she stated when Resident #1 came back from the hospital the morning of 09/15/2016, she took Resident #1 to weigh her and then to her room. CNA E stated Resident #1 needed to go to the restroom and then CNA E and LVN C put Resident #1 in her recliner and left. CNA E stated that was the only encounter she had with Resident #1 the day of her fall. In an interview with LVN C on 09/28/2016 at 9:45 a.m., she stated she was in the dining room helping the residents with lunch when LVN A yelled for help. LVN C stated she went to Resident #1's room and Resident #1 was in the floor and her foot was underneath her. CNA G was sitting behind Resident #1 so she could lean on her. LVN C said she and LVN A stabilized Resident #1's foot as best they could with a sheet and placed it on a pillow and waited for the paramedics to get to the facility. LVN C stated Resident #1 endured a horrible break; the only thing holding her foot on was the outer skin of her leg. In an interview with CNA F on 09/28/2016 at 9:50 a.m., she stated she asked CNA G to help her transfer Resident #1 after she assisted another resident to the dining room and when CNA F returned to Resident #1's room CNA G did not wait to transfer her. CNA F stated Resident #1 was in the floor on CNA G. CNA F said she saw blood in the floor and went to get LVN A. CNA F stated she hooks up the resident to the Hoyer and waits for help. CNA F said she never transfers by herself. In an interview with CNA G on 09/28/2016 at 2:55 p.m., she stated Resident #1 did not want to use the Hoyer for her transfer. CNA G said she had Resident #1 lift her recliner up so CNA G could transfer her to her wheelchair. CNA G stated Resident #1 stood up and began to pivot and her legs started giving out. CNA G said she tried to slide Resident #1 down to the floor, but it didn't work. CNA G stated she always transferred residents this way. CNA G said she did not wait for another staff even when the resident is supposed to be a 2 person transfer or if they require the use of a Hoyer because she didn't have time to wait. CNA G stated Resident #1's care plan said Resident #1 was supposed to be a 2 person transfer, but she transferred her all the time just herself. Record review of in-services the facility implemented were: An in-service was completed specific for Resident #1 on 09/15/2016: Always 2 person transfer when using the mechanical lift. All 9 CNAs and 10 nurses signed the in-service sheet. An in-service was completed specific for Transferring Residents on 09/15/2016: Use proper lifting and transferring techniques and make sure to check the nurse aide care plans. Use gait belts when applicable always times 2 person transfer when using the mechanical lift. All 9 CNAs and 10 nurses signed the in-service sheet. SUBJECT (S): Mechanical Lift DATE CONDUCTED: 09/16/2016 MINUTES ATTENDED: 30 MINS All 9 CNAs employed by the facility and all 10 nurses signed in attendance. The In-service regarding Mechanical Lift is as follows: Policy It is the policy of this home to utilize the Hoyer (or similar) lift when it is necessary to safely transfer a resident due to body weight or physical condition. Keep legs to lift in wide position when the resident is in it. Procedure 1. Have Hoyer lifter, canvas seat and back, as well as chains with S hooks on hand. 2. Explain procedure to resident and bring Hoyer Lift to bedside. 3. Roll resident onto his/her side. 4. Place wider seat part under resident's thighs so lower edge of seat is under knees. 5. Place narrow part just above small of back. 6. Roll resident to other side and pull sling through. 7. Position seat sling securely under resident. 8. Position lifter to open end of horseshoe base under side of bed. 9. Attach S hooks of the chains to the loops on seat hangers with hooks away from resident to outside of sling. 10. Attach chains to the swivel bar hooks. 11. Count links to be sure there are the same number on each side. Check to see that S hooks are hooked all the way into the chains and that the seat is close to the knees for safety. 12. Close release valves gently. 13. Resident's arms should be inside chains. 14. Check chains and S hooks to make sure they are properly positioned. 15. Hand may be placed on steering handle. Pump hydraulic pump handle. 16. Position wheelchair and lock brakes. Swing resident's feet off bed; when resident has been lifted clear of bed, grasp steering handles and move resident over chair. 17. Turn release valve slowly to lower resident gently. Guide resident's decent. 18. When resident is seated, detach S hooks from seat and back. Remove chains. Resident may remain on seat. 19. Return lift to designated area when not in use. 20. To return resident to bed, use the same procedure in reverse. Center resident over bed and lower gently. 21. Record in medical treatment any pertinent observations. SUBJECT (S): Transferring a Resident DATE CONDUCTED: 09/16/2016 All 9 CNAs employed by the facility and all 10 nurses signed in attendance. The In-service regarding Transferring a Resident is as follows: Procedure 1. Bed to Wheelchair. Wheelchairs with removable leg assemblies must be angled at a 35-degree angle on the resident's strongest side. Lock wheelchair, lift foot rests up out of the way. · Assist resident to a sitting position on the edge of the bed with feet flat on the floor. · Have resident lean forward at waist and, place strong hand on bed or arm of wheelchair and push up to a standing position. · Assist resident to take small steps toward chair, turning or pivoting on the uninvolved foot, until he/she feels the seats of the chair with the back of both legs. · Assist resident to bend forward at trunk and slowly lower body to chair. 2. Wheelchair to bed Same procedure as above is used. Process is reversed. The resident will slide body forward, pull feet back under body, lean forward, and push self up. 3. Getting Out of Chairs. Assist resident to place feet squarely on floor and pull under body, bend forward, and then push up with unaffected hand, keeping head forward over feet. 4. Toilet Transfer Position wheelchair as close to toilet seat as possible. Loosen and or lower clothes and move to edge of chair. An in-service was completed on 09/16/2016 regarding all, 7 residents in the facility who require 2 Person Transfer and are to use Mechanical Lift at all times. All 9 CNAs and 10 nurse signed the in-service sheet. Record review of an in-service completed by the administrator reflected: Effective immediately! 2 licensed or certified staff must sign off on 2 Person Assist and Hoyer Lift Residents. This should be done every shift. The sign off sheet will be located on the nurse's clipboard at the nurse's station. Nurse on duty will be responsible for checking the list to ensure that this is being done on their shift. Failure to comply will result in disciplinary action. Signed by the administrator and dated 09/20/2016 During observations of 5 different direct care staff members on 09/26-27/2016 they displayed competence in operating the Hoyer lift and safely transferred each resident with 2 staff members. In interviews with 5 different direct care staff members on 09/26-28/2016 they all stated it is required to have 2 staff members to operate the Hoyer lift when transferring a resident. In an interview with the administrator on 09/27/2016 at 8:52 a.m., she was notified an Immediate Jeopardy existed from 09/15/206 through 09/20/2016 prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 09/26/2016, 7 residents in the facility require the use of a Hoyer lift and 2 staff members when transferring; the facility had a census of 39.

Based on interview and record review, the facility failed to implement their policies and procedures to prohibit neglect for 1 of 5 residents (Resident #1) reviewed for neglect. RN A gave Resident #1 a cup of coffee with a temperature of 180 degrees Fahrenheit. Resident #1 spilled the coffee on her thighs, resulting in 2nd [MEDICAL CONDITION] both her left and right thighs. Resident #1 required emergency medical treatment and was hospitalized for [REDACTED]. An Immediate Jeopardy was identified that existed from 4/27/16 to 4/28/16. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice affected 1 resident (Resident #1) who received 2nd [MEDICAL CONDITION] her left and right thighs and had the potential to affect the remaining 20 residents in the facility who consume hot liquids such as hot chocolate, hot tea or coffee at risk of sustaining [MEDICAL CONDITION] by hot liquids. Findings include: Record review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's MDS quarterly assessment completed 2/12/16 documented a BIMS score of 13 (cognitively intact). This MDS indicated Resident #1 required limited to extensive 1 person assistance with activities of daily living with the exception of eating, which indicated supervision and set-up assistance required. Record review of the Incident/Accident Report dated 4/27/16 and completed by LVN B documented: Witnessed resident drop hot coffee onto lap. Noted large areas of reddened skin on top of right and left thighs with both intact and broken blisters of unknown depth. Resident assessed and immediately sent to hospital via orders from physician. Record review of RN A's written statement dated 4/27/16 documented: 6:30am - This RN gave cup of coffee to Resident #1. Instructed her to be careful due to coffee being hot. Turned around to get hot chocolate for another resident and heard Resident #1 yell. Ran over and noted that Resident #1 had spilled coffee in her lap. Lifted pants leg off of upper thigh. Called LVN on that side to take her to room and checked her out. Record review of Resident #1's Patient Chart Report from the local hospital where Resident #1 was a patient from 4/27/16 to 5/3/16 documented: Diagnosis: [REDACTED]. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin.) Record review of the facility's Coffee Daily Temperature Log for 4/27/16 documented the temperature of the coffee at breakfast was 180 degrees Fahrenheit. Record review of the Provider Investigation Report dated 5/2/16 documented: Description of the allegation: Resident dropped hot coffee on her lap. Description of injury:Areas of reddened skin measuring 10 inches x 6 inches on top of right and left thighs with both intact blister on right thigh 1cm x 1cm and broken blisters on left thigh with one blister being 7cm x 7cm and the other 12cm x 7cm of unknown depth. Investigation Summary: Resident was handed coffee, no restriction per doctor orders. Dietary was temping coffee on log sheet. Coffee was served too hot. During an interview on 5/10/16 at 10:35am, Resident #1 stated she was in the dining room for breakfast and staff poured her a cup of coffee from a freshly brewed pot of coffee. Resident #1 stated she has arthritis in her hands and she spilled the coffee on her legs. During an interview on 5/10/16 at 11:10am, DM stated that prior to Resident #1 being burned by the coffee, we didn't know we were doing it (coffee) wrong. We noticed it (coffee) was too hot but we never thought about it being dangerous. We just kept taking it (coffee) out. We never thought about a resident being burned. DM stated that on the day Resident #1 was burned, a nurse came into the kitchen and got coffee for Resident #1. DM stated she could not remember the nurse's name. During an interview on 5/10/16 at 1:36pm, DON stated the temperature of the hot coffee and other hot beverages should've been 160 degrees or below. DON stated staff would routinely go into the kitchen and pour coffee from the carafes on the coffee maker. During an interview on 5/11/16 at 12:54pm, Resident #1 stated she was doing better and that her legs were better. Resident #1 stated her right leg is still healing. During an interview on 5/11/16 at 1:27pm, RN A stated on 4/27/16 she was in the dining room getting the clothing protectors and other items ready for breakfast when Resident #1 came into the dining room and asked her for a cup of coffee. RN A stated, I went into the kitchen and poured her a cup and gave it to her. RN A stated she actually went into the kitchen and poured the coffee for Resident #1 from the glass carafe but she cannot remember if the carafe was sitting on the countertop or on the burner of the coffee maker. RN A stated that after giving the coffee to Resident #1, she turned to tend to another resident who had called out to her. RN A stated she heard Resident #1 call out and when she turned around, she saw that Resident #1 had spilled the coffee on her legs. RN A stated that prior to this incident, she was not aware the facility had a policy stating hot coffee must be at a temperature of 150-160 degrees before being served to residents. RN A stated, I didn't know the policy existed. During an interview on 5/11/16 at 11:55am, DON stated that prior to this incident, she had never seen the facility's policy addressing the temperature of hot beverages. DON stated that the following procedures were implemented on 4/28/16 as a result of the incident: 1. All staff were inserviced on 4/28/16 by the Administrator on Policy and Procedure: Precaution for Hot Beverages and procedure on getting coffee and hot chocolate from kitchen to dining room to residents. 2. A Handling of Hot Liquids Safety Evaluation was completed by the Occupational Therapist on the 21 residents who drink hot beverages and care plans were updated to address resident needs based on each resident's individual results. 3. Policy was implemented instructing staff that no one is allowed to get coffee/hot chocolate out of the kitchen to give to residents. Staff must wait until dietary places coffee in dining room to be served to residents. 4. All staff were also inserviced from 5/2/16 to 5/7/16 on the results of the resident evaluations related to the handling of hot liquids. Record review of inservice records indicated all facility staff were inserviced on 4/28/16 on the following: Policy and Procedure: Precaution for Hot Beverages and procedure on getting coffee and hot chocolate from kitchen to dining room to residents. Record review of the facility's Abuse Policy and Procedure dated 1/2008 and revised 3/2012 documented: Policy - It is the policy of this home to prohibit resident abuse or neglect in any form . Definitions - Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Record review of evaluations completed by the Occupational Therapist revealed 21 residents were evaluated using the Handling of Hot Liquids Safety Evaluation on 5/2/16 and care plans were updated to address resident needs based on the results of the evaluations. Record review of inservice records indicated all facility staff were inserviced from 5/2/16 to 5/7/16 on each resident's Handling of Hot Liquids Safety Evaluation and their updated care plans. Record review of the facility's policy and procedure titled Precautions for Hot Beverages dated 5/2015 and revised 1/2016 documented: Policy - This home shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. The temperature of any hot beverage or hot water used to make a hot beverage will be monitored regularly and will be individualized to each facility as dictated by the clientele served. Procedure - The coffee brewer in dietary will be set at brewing cycle above 170 degrees Fahrenheit and will dispense into an airpot or carafe. The Dietary department will allow the coffee to cool until it reaches 150-160 degrees Fahrenheit before setting the coffee or other hot beverage container into the dining room. Other Considerations - The chart below provides the estimated time it takes an individual to receive second and third degree burns. Water Temperature Time to receive 2nd degree burn/3rd degree burn 120 degrees 8 minutes/10 minutes 124 degrees 2 minutes/4 minutes 131 degrees 17 seconds/30 seconds 140 degrees 3 seconds/5 seconds 150 degrees <1 second/1 second Record review of the facility's Coffee Daily Temperature Log 12/15 documented: Directions: Allow coffee brewed into an airpot, insulated container or carafe to cool to 150-160 degrees F before setting out in to the dining room .Generally coffee dispenses into container between 160-180 degrees F. Allow to cool for 5-10 minutes, take temperature. Only set out in dining room once temperature reaches 160 degrees F or below. On 5/10/16 at 1:40pm, DON was notified that an Immediate Jeopardy situation had been identified that existed from 4/27/16 through 4/28/16. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 5/10/16, 21 residents in the facility consume hot beverages such as hot coffee or hot chocolate.

Based on interview and record review, the facility failed to implement their written policies and procedures to prohibit neglect for 1 of 5 residents (Resident #1) reviewed for neglect. RN A gave Resident #1 a cup of coffee with a temperature of 180 degrees Fahrenheit. Resident #1 spilled the coffee on her thighs, resulting in 2nd [MEDICAL CONDITION] both her left and right thighs. Resident #1 required emergency medical treatment and was hospitalized for [REDACTED]. An Immediate Jeopardy was identified that existed from 4/27/16 to 4/28/16. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice affected 1 resident (Resident #1) who received 2nd [MEDICAL CONDITION] her left and right thighs and had the potential to affect the remaining 20 residents in the facility who consume hot liquids such as hot chocolate, hot tea or coffee at risk of sustaining [MEDICAL CONDITION] by hot liquids. Findings include: Record review of the facility's Abuse Policy and Procedure dated 1/2008 and revised 3/2012 documented: Policy - It is the policy of this home to prohibit resident abuse or neglect in any form . Definitions - Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Record review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's MDS quarterly assessment completed 2/12/16 documented a BIMS score of 13 (cognitively intact). This MDS indicated Resident #1 required limited to extensive 1 person assistance with activities of daily living with the exception of eating, which indicated supervision and set-up assistance required. Record review of the Incident/Accident Report dated 4/27/16 and completed by LVN B documented: Witnessed resident drop hot coffee onto lap. Noted large areas of reddened skin on top of right and left thighs with both intact and broken blisters of unknown depth. Resident assessed and immediately sent to hospital via orders from physician. Record review of RN A's written statement dated 4/27/16 documented: 6:30am - This RN gave cup of coffee to Resident #1. Instructed her to be careful due to coffee being hot. Turned around to get hot chocolate for another resident and heard Resident #1 yell. Ran over and noted that Resident #1 had spilled coffee in her lap. Lifted pants leg off of upper thigh. Called LVN on that side to take her to room and checked her out. Record review of Resident #1's Patient Chart Report from the local hospital where Resident #1 was a patient from 4/27/16 to 5/3/16 documented: Diagnosis: [REDACTED]. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin.) Record review of the facility's Coffee Daily Temperature Log for 4/27/16 documented the temperature of the coffee at breakfast was 180 degrees Fahrenheit. Record review of the Provider Investigation Report dated 5/2/16 documented: Description of the allegation: Resident dropped hot coffee on her lap. Description of injury:Areas of reddened skin measuring 10 inches x 6 inches on top of right and left thighs with both intact blister on right thigh 1cm x 1cm and broken blisters on left thigh with one blister being 7cm x 7cm and the other 12cm x 7cm of unknown depth. Investigation Summary: Resident was handed coffee, no restriction per doctor orders. Dietary was temping coffee on log sheet. Coffee was served too hot. During an interview on 5/10/16 at 10:35am, Resident #1 stated she was in the dining room for breakfast and staff poured her a cup of coffee from a freshly brewed pot of coffee. Resident #1 stated she has arthritis in her hands and she spilled the coffee on her legs. During an interview on 5/10/16 at 11:10am, DM stated that prior to Resident #1 being burned by the coffee, we didn't know we were doing it (coffee) wrong. We noticed it (coffee) was too hot but we never thought about it being dangerous. We just kept taking it (coffee) out. We never thought about a resident being burned. DM stated that on the day Resident #1 was burned, a nurse came into the kitchen and got coffee for Resident #1. DM stated she could not remember the nurse's name. During an interview on 5/10/16 at 1:36pm, DON stated the temperature of the hot coffee and other hot beverages should've been 160 degrees or below. DON stated staff would routinely go into the kitchen and pour coffee from the carafes on the coffee maker. During an interview on 5/11/16 at 12:54pm, Resident #1 stated she was doing better and that her legs were better. Resident #1 stated her right leg is still healing. During an interview on 5/11/16 at 1:27pm, RN A stated on 4/27/16 she was in the dining room getting the clothing protectors and other items ready for breakfast when Resident #1 came into the dining room and asked her for a cup of coffee. RN A stated, I went into the kitchen and poured her a cup and gave it to her. RN A stated she actually went into the kitchen and poured the coffee for Resident #1 from the glass carafe but she cannot remember if the carafe was sitting on the countertop or on the burner of the coffee maker. RN A stated that after giving the coffee to Resident #1, she turned to tend to another resident who had called out to her. RN A stated she heard Resident #1 call out and when she turned around, she saw that Resident #1 had spilled the coffee on her legs. RN A stated that prior to this incident, she was not aware the facility had a policy stating hot coffee must be at a temperature of 150-160 degrees before being served to residents. RN A stated, I didn't know the policy existed. During an interview on 5/11/16 at 11:55am, DON stated that prior to this incident, she had never seen the facility's policy addressing the temperature of hot beverages. DON stated that the following procedures were implemented on 4/28/16 as a result of the incident: 1. All staff were inserviced on 4/28/16 by the Administrator on Policy and Procedure: Precaution for Hot Beverages and procedure on getting coffee and hot chocolate from kitchen to dining room to residents. 2. A Handling of Hot Liquids Safety Evaluation was completed by the Occupational Therapist on the 21 residents who drink hot beverages and care plans were updated to address resident needs based on each resident's individual results. 3. Policy was implemented instructing staff that no one is allowed to get coffee/hot chocolate out of the kitchen to give to residents. Staff must wait until dietary places coffee in dining room to be served to residents. 4. All staff were inserviced from 5/2/16 to 5/7/16 on the results of the resident evaluations related to the handling of hot liquids. Record review of inservice records indicated all facility staff were inserviced on 4/28/16 on the following: Policy and Procedure: Precaution for Hot Beverages and procedure on getting coffee and hot chocolate from kitchen to dining room to residents. Record review of evaluations completed by the Occupational Therapist revealed 21 residents were evaluated using the Handling of Hot Liquids Safety Evaluation on 5/2/16 and care plans were updated to address resident needs based on the results of the evaluations. Record review of inservice records indicated all facility staff were inserviced from 5/2/16 to 5/7/16 on each resident's Handling of Hot Liquids Safety Evaluation and their updated care plans. Record review of the facility's policy and procedure titled Precautions for Hot Beverages dated 5/2015 and revised 1/2016 documented: Policy - This home shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. The temperature of any hot beverage or hot water used to make a hot beverage will be monitored regularly and will be individualized to each facility as dictated by the clientele served. Procedure - The coffee brewer in dietary will be set at brewing cycle above 170 degrees Fahrenheit and will dispense into an airpot or carafe. The Dietary department will allow the coffee to cool until it reaches 150-160 degrees Fahrenheit before setting the coffee or other hot beverage container into the dining room. Other Considerations - The chart below provides the estimated time it takes an individual to receive second and third degree burns. Water Temperature Time to receive 2nd degree burn/3rd degree burn 120 degrees 8 minutes/10 minutes 124 degrees 2 minutes/4 minutes 131 degrees 17 seconds/30 seconds 140 degrees 3 seconds/5 seconds 150 degrees <1 second/1 second Record review of the facility's Coffee Daily Temperature Log dated 12/15 documented: Directions: Allow coffee brewed into an airpot, insulated container or carafe to cool to 150-160 degrees F before setting out in to the dining room .Generally coffee dispenses into container between 160-180 degrees F. Allow to cool for 5-10 minutes, take temperature. Only set out in dining room once temperature reaches 160 degrees F or below. On 5/10/16 at 1:40pm, DON was notified that an Immediate Jeopardy situation had been identified that existed from 4/27/16 through 4/28/16. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 5/10/16, 21 residents in the facility consume hot beverages such as hot coffee or hot chocolate.

Based on interview and record review, the facility failed to ensure the resident environment remained free from accident hazards for 1 of 5 residents (Resident #1) reviewed for accident hazards. RN A gave Resident #1 a cup of coffee with a temperature of 180 degrees Fahrenheit. Resident #1 spilled the coffee on her thighs, resulting in 2nd degree burns to both her left and right thighs. Resident #1 required emergency medical treatment and was hospitalized for [REDACTED]. An Immediate Jeopardy was identified that existed from 4/27/16 to 4/28/16. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. This deficient practice affected 1 resident (Resident #1) who received 2nd degree burns to her left and right thighs and had the potential to affect the remaining 20 residents in the facility who consume hot liquids such as hot chocolate, hot tea or coffee at risk of sustaining severe burns caused by hot liquids. Findings include: Record review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's MDS quarterly assessment completed 2/12/16 documented a BIMS score of 13 (cognitively intact). This MDS indicated Resident #1 required limited to extensive 1 person assistance with activities of daily living with the exception of eating, which indicated supervision and set-up assistance required. Record review of the Incident/Accident Report dated 4/27/16 and completed by LVN B documented: Witnessed resident drop hot coffee onto lap. Noted large areas of reddened skin on top of right and left thighs with both intact and broken blisters of unknown depth. Resident assessed and immediately sent to hospital via orders from physician. Record review of RN A's written statement dated 4/27/16 documented: 6:30am - This RN gave cup of coffee to Resident #1. Instructed her to be careful due to coffee being hot. Turned around to get hot chocolate for another resident and heard Resident #1 yell. Ran over and noted that Resident #1 had spilled coffee in her lap. Lifted pants leg off of upper thigh. Called LVN on that side to take her to room and checked her out. Record review of Resident #1's Patient Chart Report from the local hospital where Resident #1 was a patient from 4/27/16 to 5/3/16 documented: Diagnosis: [REDACTED]. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin.) Record review of the facility's Coffee Daily Temperature Log for 4/27/16 documented the temperature of the coffee at breakfast was 180 degrees Fahrenheit. Record review of the Provider Investigation Report dated 5/2/16 documented: Description of the allegation: Resident dropped hot coffee on her lap. Description of injury:Areas of reddened skin measuring 10 inches x 6 inches on top of right and left thighs with both intact blister on right thigh 1cm x 1cm and broken blisters on left thigh with one blister being 7cm x 7cm and the other 12cm x 7cm of unknown depth. Investigation Summary: Resident was handed coffee, no restriction per doctor orders. Dietary was temping coffee on log sheet. Coffee was served too hot. During an interview on 5/10/16 at 10:35am, Resident #1 stated she was in the dining room for breakfast and staff poured her a cup of coffee from a freshly brewed pot of coffee. Resident #1 stated she has arthritis in her hands and she spilled the coffee on her legs. During an interview on 5/10/16 at 11:10am, DM stated that prior to Resident #1 being burned by the coffee, we didn't know we were doing it (coffee) wrong. We noticed it (coffee) was too hot but we never thought about it being dangerous. We just kept taking it (coffee) out. We never thought about a resident being burned. DM stated that on the day Resident #1 was burned, a nurse came into the kitchen and got coffee for Resident #1. DM stated she could not remember the nurse's name. During an interview on 5/10/16 at 1:36pm, DON stated the temperature of the hot coffee and other hot beverages should've been 160 degrees or below. DON stated staff would routinely go into the kitchen and pour coffee from the carafes on the coffee maker. During an interview on 5/11/16 at 12:54pm, Resident #1 stated she was doing better and that her legs were better. Resident #1 stated her right leg is still healing. During an interview on 5/11/16 at 1:27pm, RN A stated on 4/27/16 she was in the dining room getting the clothing protectors and other items ready for breakfast when Resident #1 came into the dining room and asked her for a cup of coffee. RN A stated, I went into the kitchen and poured her a cup and gave it to her. RN A stated she actually went into the kitchen and poured the coffee for Resident #1 from the glass carafe but she cannot remember if the carafe was sitting on the countertop or on the burner of the coffee maker. RN A stated that after giving the coffee to Resident #1, she turned to tend to another resident who had called out to her. RN A stated she heard Resident #1 call out and when she turned around, she saw that Resident #1 had spilled the coffee on her legs. RN A stated that prior to this incident, she was not aware the facility had a policy stating hot coffee must be at a temperature of 150-160 degrees before being served to residents. RN A stated, I didn't know the policy existed. During an interview on 5/11/16 at 11:55am, DON stated that prior to this incident, she had never seen the facility's policy addressing the temperature of hot beverages. DON stated that the following procedures were implemented on 4/28/16 as a result of the incident: 1. All staff were inserviced on 4/28/16 by the Administrator on Policy and Procedure: Precaution for Hot Beverages and procedure on getting coffee and hot chocolate from kitchen to dining room to residents. 2. A Handling of Hot Liquids Safety Evaluation was completed by the Occupational Therapist on the 21 residents who drink hot beverages and care plans were updated to address resident needs based on each resident's individual results. 3. Policy was implemented instructing staff that no one is allowed to get coffee/hot chocolate out of the kitchen to give to residents. Staff must wait until dietary places coffee in dining room to be served to residents. 4. All staff were inserviced from 5/2/16 to 5/7/16 on the results of the resident evaluations related to the handling of hot liquids. Record review of inservice records indicated all facility staff were inserviced on 4/28/16 on the following: Policy and Procedure: Precaution for Hot Beverages and procedure on getting coffee and hot chocolate from kitchen to dining room to residents. Record review of evaluations completed by the Occupational Therapist revealed 21 residents were evaluated using the Handling of Hot Liquids Safety Evaluation on 5/2/16 and care plans were updated to address resident needs based on the results of the evaluations. Record review of inservice records indicated all facility staff were inserviced from 5/2/16 to 5/7/16 on each resident's Handling of Hot Liquids Safety Evaluation and their updated care plans. Record review of the facility's policy and procedure titled Precautions for Hot Beverages dated 5/2015 and revised 1/2016 documented: Policy - This home shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. The temperature of any hot beverage or hot water used to make a hot beverage will be monitored regularly and will be individualized to each facility as dictated by the clientele served. Procedure - The coffee brewer in dietary will be set at brewing cycle above 170 degrees Fahrenheit and will dispense into an airpot or carafe. The Dietary department will allow the coffee to cool until it reaches 150-160 degrees Fahrenheit before setting the coffee or other hot beverage container into the dining room. Other Considerations - The chart below provides the estimated time it takes an individual to receive second and third degree burns. Water Temperature Time to receive 2nd degree burn/3rd degree burn 120 degrees 8 minutes/10 minutes 124 degrees 2 minutes/4 minutes 131 degrees 17 seconds/30 seconds 140 degrees 3 seconds/5 seconds 150 degrees <1 second/1 second Record review of the facility's Coffee Daily Temperature Log dated 12/15 documented: Directions: Allow coffee brewed into an airpot, insulated container or carafe to cool to 150-160 degrees F before setting out in to the dining room .Generally coffee dispenses into container between 160-180 degrees F. Allow to cool for 5-10 minutes, take temperature. Only set out in dining room once temperature reaches 160 degrees F or below. On 5/10/16 at 1:40pm, DON was notified that an Immediate Jeopardy situation had been identified that existed from 4/27/16 through 4/28/16. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 5/10/16, 21 residents in the facility consume hot beverages such as hot coffee or hot chocolate.

Based on interview and record review, the administrator and DON failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being for 1 of 5 residents (Resident #1) reviewed for neglect and accident hazards, in that: The administrator and DON failed to ensure staff were trained on the facility's policy that specifies the procedures for preparing and serving hot beverages to residents. RN A gave Resident #1 a cup of coffee with a temperature of 180 degrees Fahrenheit. Resident #1 spilled the coffee on her thighs, resulting in 2nd [MEDICAL CONDITION] both her left and right thighs. Resident #1 required emergency medical treatment and was hospitalized for [REDACTED]. An Immediate Jeopardy was identified that existed from 4/27/16 to 4/28/16. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. The facility's failure to ensure staff were properly trained on the procedures for preparing and serving hot beverages to residents affected one resident (Resident #1) who received second [MEDICAL CONDITION] her left and right thighs and had the potential to affect the remainining 20 residents in the facility who consume hot liquids such as hot chocolate, hot tea or coffee by placing them at risk of sustaining [MEDICAL CONDITION] by hot liquids. Findings include: Record review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 is [AGE] years old. Record review of Resident #1's MDS quarterly assessment completed 2/12/16 documented a BIMS score of 13 (cognitively intact). This MDS indicated Resident #1 required limited to extensive 1 person assistance with activities of daily living with the exception of eating, which indicated supervision and set-up assistance required. Record review of the Incident/Accident Report dated 4/27/16 and completed by LVN B documented: Witnessed resident drop hot coffee onto lap. Noted large areas of reddened skin on top of right and left thighs with both intact and broken blisters of unknown depth. Resident assessed and immediately sent to hospital via orders from physician. Record review of RN A's written statement dated 4/27/16 documented: 6:30am - This RN gave cup of coffee to Resident #1. Instructed her to be careful due to coffee being hot. Turned around to get hot chocolate for another resident and heard Resident #1 yell. Ran over and noted that Resident #1 had spilled coffee in her lap. Lifted pants leg off of upper thigh. Called LVN on that side to take her to room and checked her out. Record review of Resident #1's Patient Chart Report from the local hospital where Resident #1 was a patient from 4/27/16 to 5/3/16 documented: Diagnosis: [REDACTED]. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin.) Record review of the facility's Coffee Daily Temperature Log for 4/27/16 documented the temperature of the coffee at breakfast was 180 degrees Fahrenheit. Record review of the Provider Investigation Report dated 5/2/16 documented: Description of the allegation: Resident dropped hot coffee on her lap. Description of injury:Areas of reddened skin measuring 10 inches x 6 inches on top of right and left thighs with both intact blister on right thigh 1cm x 1cm and broken blisters on left thigh with one blister being 7cm x 7cm and the other 12cm x 7cm of unknown depth. Investigation Summary: Resident was handed coffee, no restriction per doctor orders. Dietary was temping coffee on log sheet. Coffee was served too hot. During an interview on 5/10/16 at 10:35am, Resident #1 stated she was in the dining room for breakfast and staff poured her a cup of coffee from a freshly brewed pot of coffee. Resident #1 stated she has arthritis in her hands and she spilled the coffee on her legs. During an interview on 5/10/16 at 11:10am, DM stated that prior to Resident #1 being burned by the coffee, we didn't know we were doing it (coffee) wrong. We noticed it (coffee) was too hot but we never thought about it being dangerous. We just kept taking it (coffee) out. We never thought about a resident being burned. DM stated that on the day Resident #1 was burned, a nurse came into the kitchen and got coffee for Resident #1. DM stated she could not remember the nurse's name. During an interview on 5/10/16 at 1:05pm, LVN B stated that she does not know what the temperature of coffee is supposed to be and she didn't know prior to the incident involving Resident #1. During an interview on 5/10/16 at 1:36pm, DON stated the temperature of the hot coffee and other hot beverages should've been 160 degrees or below. DON stated staff would routinely go into the kitchen and pour coffee from the carafes on the coffee maker. During an interview on 5/11/16 at 1:12am, CNA C stated she always got coffee from the pot in the dining room. CNA C stated that prior to the incident with Resident #1, she was not aware of the facility's policy concerning the temperature of hot beverages served to residents. During an interview on 5/11/16 at 12:54pm, Resident #1 stated she was doing better and that her legs were better. Resident #1 stated her right leg is still healing. During an interview on 5/11/16 at 1:27pm, RN A stated on 4/27/16 she was in the dining room getting the clothing protectors and other items ready for breakfast when Resident #1 came into the dining room and asked her for a cup of coffee. RN A stated, I went into the kitchen and poured her a cup and gave it to her. RN A stated she actually went into the kitchen and poured the coffee for Resident #1 from the glass carafe but she cannot remember if the carafe was sitting on the countertop or on the burner of the coffee maker. RN A stated that after giving the coffee to Resident #1, she turned to tend to another resident who had called out to her. RN A stated she heard Resident #1 call out and when she turned around, she saw that Resident #1 had spilled the coffee on her legs. RN A stated that prior to this incident, she was not aware the facility had a policy stating hot coffee must be at a temperature of 150-160 degrees before being served to residents. RN A stated, I didn't know the policy existed. During an interview on 5/11/16 at 11:55am, DON stated that prior to this incident, she had never seen the facility's policy addressing the temperature of hot beverages. DON stated that the following procedures were implemented on 4/28/16 as a result of the incident: 1. All staff were inserviced on 4/28/16 by the Administrator on Policy and Procedure: Precaution for Hot Beverages and procedure on getting coffee and hot chocolate from kitchen to dining room to residents. 2. A Handling of Hot Liquids Safety Evaluation was completed by the Occupational Therapist on the 21 residents who drink hot beverages and care plans were updated to address resident needs based on each resident's individual results. 3. Policy was implemented instructing staff that no one is allowed to get coffee/hot chocolate out of the kitchen to give to residents. Staff must wait until dietary places coffee in dining room to be served to residents. 4. All staff were inserviced from 5/2/16 to 5/7/16 on the results of the resident evaluations related to the handling of hot liquids. Record review of inservice records indicated all facility staff were inserviced on 4/28/16 on the following: Policy and Procedure: Precaution for Hot Beverages and procedure on getting coffee and hot chocolate from kitchen to dining room to residents. Record review of evaluations completed by the Occupational Therapist revealed 21 residents were evaluated using the Handling of Hot Liquids Safety Evaluation on 5/2/16 and care plans were updated to address resident needs based on the results of the evaluations. Record review of inservice records indicated all facility staff were inserviced from 5/2/16 to 5/7/16 on each resident's Handling of Hot Liquids Safety Evaluation and their updated care plans. Record review of the facility's policy and procedure titled Precautions for Hot Beverages dated 5/2015 and revised 1/2016 documented: Policy - This home shall monitor, serve and hold hot beverages in a safe manner to prevent potential burns. The temperature of any hot beverage or hot water used to make a hot beverage will be monitored regularly and will be individualized to each facility as dictated by the clientele served. Procedure - The coffee brewer in dietary will be set at brewing cycle above 170 degrees Fahrenheit and will dispense into an airpot or carafe. The Dietary department will allow the coffee to cool until it reaches 150-160 degrees Fahrenheit before setting the coffee or other hot beverage container into the dining room. Other Considerations - The chart below provides the estimated time it takes an individual to receive second and third degree burns. Water Temperature Time to receive 2nd degree burn/3rd degree burn 120 degrees 8 minutes/10 minutes 124 degrees 2 minutes/4 minutes 131 degrees 17 seconds/30 seconds 140 degrees 3 seconds/5 seconds 150 degrees <1 second/1 second Record review of the facility's Coffee Daily Temperature Log dated 12/15 documented: Directions: Allow coffee brewed into an airpot, insulated container or carafe to cool to 150-160 degrees F before setting out in to the dining room .Generally coffee dispenses into container between 160-180 degrees F. Allow to cool for 5-10 minutes, take temperature. Only set out in dining room once temperature reaches 160 degrees F or below. On 5/10/16 at 1:40pm, DON was notified that an Immediate Jeopardy situation had been identified that existed from 4/27/16 through 4/28/16. Prior to entrance, the facility identified the deficient practice and took the necessary corrective actions. According to information provided by the facility on 5/10/16, 21 residents in the facility consume hot beverages such as hot coffee or hot chocolate.