Every finding on record at Willow Creek Retirement Center

Based on observations, record review, facility policy review, and interviews the facility failed to provide an environment that was free from accident hazards to prevent an avoidable elopement for one (1) of four (4) sampled residents. Resident #1. Findings Included:Record review of the facility policy titled, Incidents and Accidents Investigating and Reporting with Revision Date 5/25/24 revealed the policy stated, It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident .Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. Record review of the Incident Report dated 7/28/26 revealed Resident #1 exited through the D unit dining room exit door at approximately 1:00 PM, the door closed and locked behind her and while staff members observed her, another staff member retrieved the resident.Record review of the Facility Investigation revealed that on 7/28/26 at approximately 1:15 PM the resident exited through the dining room exit door, staff members observed Resident #1 and another staff member went out of another exit and retrieved Resident #1, and the resident was back inside the facility at 1:18 PM. The Investigation included documentation that the resident was assessed with no injury noted, the door magnet and keypad were inspected with the magnet cleaned and the keypad replaced.Record review of the weather history for 7/28/26 via www.weatherunderground.com revealed the temperature at approximately 1:16 PM on 7/28/26 was ninety-two degrees Fahrenheit with no precipitation and clear conditions. On 8/03/26 at 1:07 PM, observation and interview with Resident #1 in the Unit D common day/dining room revealed the resident was alert and oriented to self with a calm and friendly demeanor and stated that she was watching a soap opera, which was on television. She denied complaint. On 8/03/26 at 1:15 PM, observation revealed Unit D, locked Dementia Unit at the facility had two doors that exited into hallways, one door at the end of E Hall that exited to a fenced in outdoor area on the west end of the facility and one three (3) foot wide glass door with a two (2) foot wide side light (window next to the door) that exited to the parking lot on the north side of the facility; all doors could be unlocked by entering a numeric code into a wall-mounted keypad next to each door. At the time of observation all doors were locked, and the locks were working properly without problem. Observation revealed there was a 12X20 foot covered area with flat cement flooring that led to a (3) feet wide cement sidewalk that ran parallel to the building from front to back. The surfaces were clean, flat, well-maintained and free from trip hazards. Past the sidewalk were delineated parking spaces past which was the cement driveway. The surfaces were clean, flat, well-maintained and free from trip hazards.On 8/03/26 at 1:30 PM, observation of security camera footage of the Unit D common day/dining room date/time stamped 7/28/26 at 12:40 PM the Maintenance Supervisor exited the facility through the Unit D exit door on the north side of the facility and reentered at 12:41 PM (video revealed he pulled the door after entrance), then at 1:14 PM Resident #1 walked unassisted into the room, at 1:16 PM she walked to the exit door and pushed the door open and walked out and the door closed behind her. The footage showed that Certified Nursing Assistant (CNA) #1 and Licensed Practical Nurse (LPN) #1 immediately went to the exit door, attempted to enter the code into the wall-mounted exit door and the door did not open. LPN #1 ran from the room as CNA #1 remained and watched through the glass door. At 1:17 PM the Unit D exit door opened, CNA #1 went out and almost immediately thereafter, at 1:18 PM, CNA #1, Resident #1, LPN #1 and the Maintenance Supervisor entered the Unit D Day/dining room.On 8/03/26 at 1:55 PM, interview with CNA #1 revealed that she had assisted Resident #1 with toileting immediately prior to the elopement, and that they had just walked back into the Unit D common day/dining room. She stated that she had never observed Resident #1 engage in any exit seeking behavior before and said she was shocked as she observed the resident walk over to the exit door and push it open and walk out. She stated she immediately ran to the door which had closed and locked behind the resident to retrieve her but that the code she entered failed to unlock the door and LPN #1 took off running. CNA #1 reported that she never allowed Resident #1 out of her sight as the resident began to walk down the sidewalk toward the back of the building and was joined by LPN #1 who accompanied the resident back into the facility through the same door. She stated that Resident #1 and LPN #1 were met at the door by the Maintenance Supervisor who had entered the code into the keypad on the outside and opened the door. She reported the resident was dressed in pants, a shirt and shoes. She confirmed that it was hot and dry with no rain. On 8/03/26 at 2:15 PM, interview with the Minimum Data Set (MDS) Nurse revealed that on 7/28/26 at 1:16 she observed LPN #1 run past saying that Resident #1 was outside and she ran after LPN #1, out of the side exit door on the north side of the building near her office. She stated that once outside she observed Resident #1 walking down the sidewalk toward the rear of the building just past the Unit D exit door. She stated that the Maintenance Supervisor arrived and that she could see CNA #1 inside, through the glass door. She said that she and LPN #1 approached Resident #1 and spoke with her and convinced her to return inside without problem. She stated that the Maintenance Supervisor had posted himself at the exit door and entered the numeric code into the wall-mounted keypad outside upon their arrival at the door, CNA #1 came out and all staff ushered Resident #1 into the facility without further incident. She confirmed that it was hot and dry with no rain and the resident was dressed in pants, a shirt and shoes. On 8/03/26 at 2:40 PM, interview with LPN #1 revealed she confirmed that she was at the Unit D nurses' station at 1:16 PM on 7/28/26 and observed Resident #1 push the common day/dining room exit door open and walk out. She stated that she and CNA #1 had immediately ran to the door and were unable to unlock the door. She stated she ran out of the interior locked memory care unit (Unit D) next to the MDS office, then out of the exit door and down the sidewalk to where she had observed Resident #1 outside the Unit D exit door walking towards the rear of the building. She confirmed she was accompanied by the MDS Nurse and that the Maintenance Supervisor had arrived in the parking lot. She stated that she and the MDS Nurse were able to calmly redirect Resident #1 into return into the facility. She confirmed that the Maintenance Supervisor had met them, along with Resident #1 at the Unit D exit door, entered the numeric code into the wall-mounted keypad outside the door and opened the door and they had all entered into the common Unit D day/dining room. She stated that she had assessed Resident #1 and noted no injury and confirmed that the Director of Nurses (DON), Resident #1's primary healthcare provider, and her Resident Representative (RR) had been notified of the incident. She confirmed that it was hot and dry with no rain and Resident #1 had been dressed in pants, a shirt and shoes. On 8/03/26 at 3:45 PM, interview with the Assistant Director of Nurses (ADON) revealed that she had not been at the facility on 7/28/26 and that the Director of Nursing (DON) was not at the facility on 8/03/26. She confirmed that she was notified by the DON on 7/29/25 that on 7/28/26, Resident #1 had exited through the Unit D exit door. On 8/03/26 at 3:50 PM, interview with the Maintenance Supervisor, he confirmed that he had exited the facility at approximately 12:40 PM on 7/28/26, through the Unit D exit door and returned through the same door approximately one minute later and that at approximately 1:16 PM he had returned to the area outside the Unit D exit door and observed Resident #1 on the sidewalk near the Unit D exit door and saw LPN #1 and the MDS Nurse run to the resident. He said he went to the Unit D exit door and waited until Resident #1 with the two nurses arrived at the door, entered the numeric code into the wall-mounted keypad outside the door and opened the door and the resident and staff reentered the facility at approximately 1:17 PM. He confirmed that he checked all exit doors and locks for proper functioning daily Monday through Friday and had checked the Unit D exit door earlier in the day. He stated that he did not know for certain why the lock failed on 7/28/26 and recalled pulling the door behind him when he reentered at approximately 12:41 PM and noted no problem, and that he had inspected the door and lock following the elopement, cleaned the hardware and replaced the interior wall-mounted keypad next to the door. On 8/03/26 at 4:00 PM, interview with the Administrator revealed he was notified on the afternoon of 7/28/26 that at 1:16 PM, Resident #1 had exited the facility through the Unit D exit door on the north side of the facility. He confirmed that the facility had immediately initiated an investigation, reported the elopement, and that Resident #1 had been assessed by LPN #1 with no indication of injury, the resident's primary healthcare provider and resident representative had been notified. He reported that the Maintenance Supervisor had inspected the door, locking mechanism and magnet immediately after the resident reentered the facility, cleaned the hardware and replaced the wall-mounted keypad. He reported that he had scheduled the facility contracted service responsible for maintenance of the wander-guard system and door locks for inspection of all doors, locks, magnets, the wander-guard system and they had visited the facility following the incident. Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 11/28/22 with diagnoses that included dementia, diabetes, atrial fibrillation and heart failure.Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/20/26 revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment and was independent with walking (150) feet.

Based on observation, record review, facility policy review and interviews, the facility failed to ensure that residents were free from the misappropriation of resident property and exploitation when a licensed nurse signed for and took scheduled medication delivered by the pharmacy for one (1) of four (4) residents reviewed for medication administration. (Resident #1). Findings Included:Record review of the facility policy, Abuse, Neglect and Exploitation with a revised date of 05/25/24 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Record review of the Facility Investigation dated 4/20/26 revealed that on 4/17/26, Registered Nurse (RN) #1 received for two (2) bubble packages of Tramadol 50 milligram (mg) from the pharmacy courier, failed to log the packages/medication into the Narcotics Accountability form, took the packages/medication out of the facility in her bag/purse and four (4) days later returned one of the packages with (30) tablets in a damaged condition and failed to return the other package of seven (7) tablets.On 6/01/26 at 11:50 AM, an interview with the Administrator revealed that he had been notified by the Director of Nurse's (DON) on 4/21/26 that Resident #1's Tramadol was missing. He stated that he and the DON were able to determine with cooperation with the pharmacy services and review of security camera footage that RN #1 received and signed for delivery of thirty-seven (37) Tramadol packaged in two (2) bubble package cards, placed them on the Back Hall Nurses Station desk (counter top), covered them with papers and later placed both packages in her bag/purse, threw away the pharmacy manifest, which was supposed to be turned into the DON and left the facility with the medication. He said that when the resident requested pain mediation on 4/21/26 the misappropriation was discovered. He said that RN #1 was on duty on 4/21/26 and was taken to her home via the facility van and returned to the facility with one (1) damaged package of thirty (30) Tramadol (verified by pharmacist) but not the remaining package of seven (7). He stated that RN #1 had been immediately placed on suspension upon determination that she was on duty and responsible for the resident's medications at the time of the incident and that her employment at the facility had been terminated for theft of resident property.On 6/04/26 at 11:20 AM, observation and interview with the DON revealed she was on direct care duty on the 3:00 PM through 11:00 PM shift on 4/21/26 when Resident #1 requested pain medication, which led to the discovery that the resident did not have any of her physician ordered Tramadol in the locked scheduled medication box in the Back Hall medication cart. She confirmed the investigation details as provided by the Administrator. The DON confirmed that RN #1 was driven via facility van to her home and returned with one damaged package of (30) Tramadol 50 mg, but not the second package of seven (7) Tramadol 50 mg. Observation revealed one bubble packed card of round white tablets labeled with the name of Resident #1 with the foil backing behind tablets numbered 1,3,5,8,12,22,23,24,25 and 28 punctured/torn. The DON reported that the facility did not have a copy of the pharmacy manifest for 4/17/26 because, based on security camera footage, RN #1 had thrown it away.On 6/03/26 at 2 PM, during an interview with Resident #1 revealed that she had pain in her legs that she described as occasional and pretty bad to sometimes severe. She explained that prior to admission by the facility she had fall while living at home and suffered a fracture which required surgical intervention and was at the facility for therapy with plans to return home following completion of therapy. She said that pain interfered with her ability to participate with therapy and her goal was to recover from surgery, gain strength through therapy and return home. She reported that requested PRN pain medication that was administered by facility nurses in a timely manner. Record review of the Order Summary Report for Resident #1 revealed a physician order dated 4/18/26 Ultram Oral Tablet 50 MG (milligrams) (Tramadol HCL) Give 50 mg by mouth every 6 hours as needed for Pain. Record review of the Face Sheet for Resident #1 revealed the facility admitted the resident on 4/14/26 with diagnoses that included displaced fracture of greater trochanter of left femur, subsequent encounter for closed fracture with routine healing, polyneuropathy and rheumatoid arthritis.Record review of the admission Minimum Data Set (MDS) with Assessment Reference Date of 4/20/26 for Resident #1 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Further MDS review revealed the facility assessed Resident #1's primary medical condition was fracture and other multiple traumas and that she reported frequent pain that occasionally limited day-to-day activities that she rated 5 on a 0-10 pain scale following surgical repair of fracture.

Based on record review, facility policy review and interviews, the facility failed to ensure that a resident was protected from physical abuse when the Resident Representative (RR) struck the resident in the face. for one (1) of seven (7) sampled residents. (Resident #2).Findings Included:Record review of the facility policy Abuse, Neglect and Exploitation with a revision date 5/25/24, revealed .Mistreatment means inappropriate treatment or exploitation of a resident.Physical Abuse includes, but is not limited to hitting, slapping.It also includes controlling behavior through corporal punishment.The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves.III. Prevention of Abuse. E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives.Record review of the Facility Investigation dated 6/02/26 revealed that on 6/2/26 at approximately 8:30 AM, Certified Nursing Assistant (CNA)# 1 and the RR for Resident #2 was assisting Resident #2 with changing his shirt as he sat in his recliner. Resident #2 became agitated and struck out at CNA #1 and his RR. Resident #2's RR slapped the resident's face two times and told him to stop. CNA #1 went to the nurse and reported the incident, and the RR had left the facility. Resident #2 was assessed by the nurse and Nurse Practitioner (NP)#1 with no injuries noted. On 6/02/26 at 10:30 AM during an interview, the Administrator reported that on 6/2/26 at approximately 8:30 AM, CNA #1 and the RR were assisting Resident #2 to change his shirt. Resident #2 became agitated and began striking out at CNA #1 and the RR. The RR struck Resident #2 on his face twice and told him to Stop it. He stated that he had reported the incident to the local police department, the State Agency (SA) and the State Attorney General's Office.On 6/02/26 at 11:55 AM, during an interview CNA #1 reported that on 6/02/26 at approximately 8:30 AM Resident #1 was seated in a recliner in his room and his RR visited and said that she wanted to help him with his breakfast in the common dining area. CNA #1 stated that she and the RR were trying to assist the resident with dressing (to change his shirt) and he began to strike out at both. She said that she was shocked when the RR struck Resident #2 twice on the face and sternly told him to Stop it. She stated that the resident's behavior changed immediately.On 6/02/26 at 12:30 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated that during breakfast she was assisting/supervising residents in the dining room with breakfast when CNA #1 reported to her that a RR had struck Resident #2 twice while assisting him with dressing. She stated that she immediately assessed Resident #2 who was in the dining room for breakfast and noted no injury then reported the incident to the Director of Nurses (DON) and Administrator.On 6/04/26 at 11:20 AM, during an interview the DON stated that after she had spoken with LPN #1 and CNA #1, she felt Resident #2's RR had struck the resident to control his behavior through corporal measures. On 6/04/26 at 3:00 PM, an interview with the Administrator revealed the facility had completed the investigation into the visitor (RR) on resident abuse allegation that was reported on 6/02/26 and involved Resident #2 and had submitted final report to the SA.On 6/04/26 at 3:04 PM, during a telephone interview the RR for Resident #2 confirmed that her hand contacted the face of Resident #2 at approximately 8:30 AM on 6/02/26 after he became combative toward her and CNA #1while they were trying to assist him with dressing. She confirmed that she told him to Stop it and said that afterward he stopped striking out at them and allowed them to assist him to change his shirt. She said she did it to get his attention to get him to stop being combative and cooperate.Record review of the Face Sheet for Resident #2 revealed the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, metabolic encephalopathy and anxiety.Record review of the discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/07/26 revealed Resident #2 had a memory problem and moderately impaired cognitive skills for daily decision making and that he required substantial/maximal assistance for upper body dressing.

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control practices during resident care by failing to perform hand hygiene during incontinent care (Resident #66), failing to implement Enhanced Barrier Precautions during catheter care (Resident #13), and contaminating environmental surfaces with soiled gloves during wound care (Resident #36) for three (3) of four (4) care observations.Findings include: A review of the facility's policy, Infection Prevention and Control Program, revised 3/23/23, revealed, .It is the policy of this facility to.maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the facility's policy, Hand Hygiene, revised 6/12/22, revealed, .Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection.Policy Explanation and Compliance Guidelines.1. Staff will perform hand hygiene when indicated.6. Additional considerations: The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.Hand Hygiene Table.When, during resident care, moving from a contaminated body site to a clean body site.Either Soap and Water or Alcohol Based Hand Rub. A review of the facility's policy, Enhanced Barrier Precautions, revised 9/29/25, revealed, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or. discontinuation of the indwelling medical device. Resident #66 A record review of the Face Sheet revealed the facility admitted Resident #66 on 3/10/21 with diagnoses including chronic kidney disease. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/25 revealed Resident #66 had a Brief Interview for Mental Status (BIMS) score of (15), which indicated the resident was cognitively intact. On 3/3/26 at 9:56 AM, during an observation, Certified Nursing Aide (CNA) #3 provided incontinent care to Resident #66. CNA #3 explained the procedure to the resident and provided privacy. CNA #3 donned gloves and began peri-care without performing hand hygiene prior to initiating care. During the care, CNA #3 removed gloves and applied new gloves multiple times but did not perform hand hygiene between glove changes. CNA#3 continued peri-care, including cleaning fecal material, while changing gloves several times without performing hand hygiene. On 3/3/26 at 10:29 AM, during an interview, CNA #3 confirmed she did not perform hand hygiene between glove changes during Resident #66's care. CNA #3 stated she washed her hands after completing care but acknowledged she should have performed hand hygiene when removing gloves and before donning clean gloves. On 3/3/26 at 3:21 PM, during an interview, the Director of Nursing (DON) stated staff should perform hand hygiene upon entering the resident room and each time gloves are removed during care. The DON stated hand hygiene is required to prevent the spread of infection between residents and environmental surfaces. Resident #13 A record review of the Face Sheet revealed the facility admitted Resident #13 on 2/10/21 with diagnoses including Retention of Urine. A record review of the Order Summary Report revealed Resident #13 had a physician order dated 1/15/25 for urinary catheter care which instructed staff to provide catheter care with soap and water every shift and as needed. A record review of the Quarterly MDS with an ARD of 2/2/26 revealed Resident #13 had a BIMS score of six (6), which indicated the resident's cognition was severely impaired. On 3/3/26 at 2:14 PM, during an observation, CNA #1 assisted by CNA #2 provided Foley (indwelling catheter) care to Resident #13. CNA #1 gathered supplies, entered the room, explained the procedure, performed hand hygiene, and applied clean gloves. During the catheter care observation, the staff did not don a gown while providing care to a resident with an indwelling urinary catheter. On 3/4/26 at 2:34 PM, during an interview, CNA #2 confirmed she did not put on a gown prior to providing catheter care. CNA #2 stated the purple dot next to the resident's name served as a reminder that staff should wear a gown when providing care and acknowledged she forgot to don the gown. On 3/4/26 at 2:40 PM, during an interview, CNA #1 confirmed staff did not wear a gown while providing catheter care to Resident #13. CNA #1 stated gowns should be worn during care to reduce the risk of spreading infection between residents. On 3/4/26 at 4:15 PM, during an interview, the DON stated staff should wear gowns when providing direct care to residents who require Enhanced Barrier Precautions. The DON stated the purpose of Enhanced Barrier Precautions is to reduce the spread of infection between residents and staff. Resident #36 A record review of the Face Sheet revealed the facility admitted Resident #36 on 11/10/17 with diagnoses including Dementia. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/3/26 revealed Resident #36 required a staff assessment for mental status and had long-term memory impairment. A record review of the Order Summary Report revealed Resident #36 had a physician order dated 2/11/26 for wound care to a pressure ulcer on the left great toe. On 3/4/26 at 12:16 PM, during an observation, Licensed Practical Nurse (LPN) #4 performed wound care to Resident #36's pressure ulcer on the left great toe. During the procedure, while wearing the same gloves used during wound care, LPN #4 picked up a dressing from the floor to discard and then used the same gloves to touch the bed remote control to lower the bed. On 3/4/26 at 12:21 PM, during an interview, LPN #4 confirmed she touched the wound site, the floor, and the bed remote control while wearing the same gloves. LPN #4 acknowledged she should have removed her gloves and performed hand hygiene before touching environmental surfaces in the room. On 3/5/26 at 9:59 AM, during an interview, the DON stated staff should remove contaminated gloves and perform hand hygiene before touching other surfaces during resident care. The DON stated failure to follow infection control practices could result in contamination of environmental surfaces and the spread of infection.

Based on observation, interview, record review, and facility policy review, the facility failed to implement a resident's comprehensive care plan intervention related to Enhanced Barrier Precautions for one (1) of (18) care plans reviewed. Resident #13.Findings include:A review of the facility's policy, Care Plans, updated 2/20/20, revealed, Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provide care.Procedure.Staff approaches are to be developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention.A record review of the Care Plan Report revealed Resident #13 had a Focus of The resident has indwelling foley catheter. with Interventions that included Enhanced Barrier Precautions.On 3/3/26 at 2:14 PM, during an observation, Certified Nursing Aide (CNA) #1 assisted by CNA #2 provided Foley catheter care to Resident #13. Staff did not wear a gown while providing catheter care despite the care plan intervention requiring Enhanced Barrier Precautions.On 3/4/26 at 2:34 PM, during an interview, CNA #2 confirmed she did not wear a gown during Resident #13's catheter care and stated she forgot to put it on. CNA #2 stated the purple dot by the resident's name served as a reminder that staff should wear a gown when providing care.On 3/4/26 at 2:40 PM, during an interview, CNA #1 confirmed staff did not wear a gown while providing care to Resident #13. CNA #1 stated she was responsible for ensuring Enhanced Barrier Precaution supplies were stocked outside the resident's room and acknowledged the care plan intervention requiring a gown was not followed.On 3/4/26 at 4:15 PM, during an interview, the Director of Nursing (DON) stated staff should wear gowns when providing direct care to residents who require Enhanced Barrier Precautions and confirmed staff are expected to follow care plan interventions.On 3/4/26 at 4:33 PM, during an interview, Registered Nurse (RN) #1, the care plan nurse, stated the care plan is intended to guide staff in providing resident care and should be followed when delivering care. RN #1 explained staff are expected to follow the care plan interventions.A record review of the Face Sheet revealed the facility admitted Resident #13 on 2/10/21 with diagnoses including Retention of Urine.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/26 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident's cognition was severely impaired.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to ensure proper infection control practices related to hand hygiene during Percutaneous Endoscopic Gastrostomy (PEG) tube site care during an annual recertification survey on 11/7/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F880Findings include:A review of the facility's policy, Quality Assurance Performance Improvement, revised 5/7/18, revealed .Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life.Record review of the Provider History Profile revealed the facility received a citation for F880 - Infection Prevention and Control that had a Plan/Date of Correction of 12/4/2024. Record review of the Centers for Medicare and Medicaid Services (CMS)-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 11/7/24 revealed, .Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure proper infection controls practices were implement.for two (2) of (19) sampled residents.During the current recertification survey, the facility failed to follow infection prevention and control practices during resident care by failing to perform hand hygiene during incontinent care (Resident #66), failing to implement Enhanced Barrier Precautions during catheter care (Resident #13), and contaminating environmental surfaces with soiled gloves during wound care (Resident #36) for three (3) of four (4) care observations.In an interview on 3/6/26, at 1:17 PM, the Director of Nursing (DON) explained that, based on current information from the State Agency (SA), the lack of hand hygiene during patient care has been a recurring issue since the last survey. The facility has not monitored this issue or implemented any performance improvement plans since the previous plan of correction, such as tracking and measuring outcomes. The DON emphasized that it is important for staff to maintain hand hygiene during care to prevent the spread of infections.At 1:30 PM on 3/6/26, in an interview with the Administrator, he revealed that he has been working at the facility since January 2026. During this time, he has been conducting Quality Assurance Performance Improvement (QAPI) meetings monthly. In those meetings, he does not recall identifying or addressing the continued tracking or monitoring of hand hygiene during resident care since the last plan of correction was implemented for the facility. However, he confirmed that this monitoring should occur, as required by their current policy.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were stored securely when medications were left unattended at a resident's bedside for one (1) of two (2) medication storage observations. Resident #33.Findings include:A review of the facility's policy, Medication Storage, undated, revealed, .Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments and biologicals must be stored securely.On 3/3/26 at 9:00 AM, during an observation and interview, Resident #33 pointed to a medication cup sitting on the bedside table. The medication cup contained six (6) pills described as three round pills, two pink pills, and one white oblong pill. Resident #33 stated she did not know why she had to take so many medications.On 3/3/26 at 9:10 AM, during an observation, Licensed Practical Nurse (LPN) #3 entered the room and spoke with Resident #33 regarding the medications. LPN #3 stated to the resident that when she previously left the room the resident had the pills in her hands. Resident #33 stated she had told the nurse she wanted to eat first. LPN #3 then handed the medication cup to the resident, and the resident took the medications.On 3/3/26 at 9:12 AM, during an interview, LPN #3 stated she should not have left the medications in the resident's room and should have remained with the resident to ensure the medications were taken. LPN #3 stated leaving medications unattended could result in the resident discarding the medications or another resident entering the room and taking them.On 3/3/26 at 3:21 PM, during an interview, the Director of Nursing (DON) stated nurses should not leave medications at the bedside. The DON stated physician orders require medications to be administered as ordered and leaving medications unattended could allow another resident access to them.A record review of the Face Sheet revealed the facility admitted Resident #33 on 9/12/24 with diagnoses including Essential (Primary) Hypertension and Hyperlipidemia.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/16/25 revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.A record review of the Order Summary Report revealed Resident #33 had active physician orders for Ativan Oral Tablet 0.5 mg (milligrams) by mouth one time a day dated 6/2/25, Losartan Potassium Tablet 100 mg by mouth daily dated 9/12/24, Aspirin Chewable 81 mg by mouth daily dated 9/12/24, Mobic Oral Tablet 15 mg by mouth daily dated 4/2/25, Cholecalciferol Oral Tablet 2000 units by mouth daily dated 9/29/25, and Cyanocobalamin Oral Tablet 1000 units by mouth daily dated 9/29/25.A record review of the Medication Administration Record (MAR) revealed Licensed Practical Nurse (LPN) #3 documented Ativan, Losartan, Aspirin, Mobic, Cholecalciferol, and Cyanocobalamin as administered during the 8:00 AM medication pass on 3/3/26.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to a clean, comfortable, and homelike environment when the air conditioning vent in the resident's room contained excessive dust and debris for one (1) of (18) sampled residents. Resident #9.Findings include:A review of the facility's policy, Resident Rights, revised 10/24/22, revealed, .Resident rights.8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment.A record review of the Face Sheet revealed the facility admitted Resident #9 on 6/3/25 with diagnoses including Alzheimer's Disease.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/25, revealed Resident # 9 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated his cognition was severely impaired.On 3/2/26 at 12:37 PM, during an observation, the air conditioning vent in Resident #9's room contained visible dust and debris.On 3/3/26 at 1:58 PM, during an observation and interview, the air conditioning vent in Resident #9's room continued to be visibly dirty with dust and debris. Resident #9's wife stated she had notified Licensed Practical Nurse (LPN) #1 approximately one month earlier that the air conditioning vent was dusty when the resident moved into the room. She stated she was told maintenance had been notified and the vent would be cleaned, but it had not been addressed.On 3/3/26 at 4:03 PM, during an interview, LPN #1 stated she had spoken with maintenance staff approximately one month earlier about the condition of Resident #9's air conditioning vent and explained it contained dust, dried debris, and what appeared to be food particles. LPN #1 stated she did not submit a maintenance request ticket because she had spoken with maintenance staff directly.On 3/3/26 at 4:20 PM, during an interview, the Maintenance Director stated he had not received a maintenance request regarding the air conditioning vent in Resident #9's room. The Maintenance Director stated maintenance requests should be entered into the maintenance request log so the issue can be tracked and completed. The Maintenance Director reviewed the maintenance request log for D Hall and confirmed no request had been logged regarding cleaning the air conditioning vent in Resident #9's room.On 3/5/26 at 9:06 AM, during an interview, the Director of Nursing (DON) stated nursing staff should document maintenance issues using a maintenance request form or report the issue through the facility's maintenance request process to ensure repairs are completed in a timely manner.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to reasonable accommodation of communication needs when a functioning bedside telephone was not provided for one (1) of (18) sampled residents. Resident #9.Findings include:A review of the facility's policy, Resident Rights, revised 10/24/22, revealed, .Resident rights.The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.A record review of the Face Sheet revealed the facility admitted Resident #9 on 6/3/25 with diagnoses including Alzheimer's Disease.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/25, revealed Resident # 9 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated his cognition was severely impaired.On 3/2/26 at 12:37 PM, during an observation and interview, Resident #9 had a telephone sitting at the bedside which was not functioning. Resident #9's wife stated she had been attempting for approximately three months to have an incoming-call-only telephone set up at the resident's bedside because the resident had forgotten how to use his cell phone due to dementia. She stated she had spoken with the Social Worker regarding assistance with setting up the phone. She explained the Social Worker instructed her to purchase the phone and contact the phone company. The wife stated she had purchased the phone and brought it to the facility; however, she was told to contact the phone company to activate the line. She reported the phone company did not understand what was needed and stated the facility had not followed up to assist with ensuring the phone was working even though the phone remained at the resident's bedside.On 3/3/26 at 2:00 PM, during an observation and follow-up interview, the bedside telephone for Resident #9 remained in the room but was not operational. Resident #9's wife stated the bedside telephone was still not functioning. She confirmed she had previously spoken with the Social Worker about getting the phone set up but stated the issue had not been resolved and the phone remained in the resident's room without being operational.On 3/4/26 at 9:15 AM, during an observation, Resident #9 continued to have a telephone at the bedside which was not functioning.On 3/4/26 at 9:35 AM, during an interview, the Social Worker stated the typical process for setting up a landline telephone was for the resident's family to contact the phone company to establish service in the resident's room. The Social Worker stated Resident #9's wife had approached her approximately one month earlier about setting up a phone and she instructed the wife to contact the phone company. The Social Worker stated she believed the phone had been set up but acknowledged she did not follow up with the family to confirm the phone was working or to request a demonstration.On 3/4/26 at 9:49 AM, during an interview, the Maintenance Director stated the resident's family had not notified him that a phone had been brought to the facility to be installed at the resident's bedside. He stated the facility does not typically provide phones for residents and indicated he was unaware the phone needed to be set up.On 3/4/26 at 9:50 AM, during an interview, the Administrator stated it was not the facility's responsibility to follow up with the resident's family regarding the setup of the bedside phone. The Administrator stated families typically contact the phone company directly to arrange for telephone service in the resident's room.On 3/5/26 at 9:06 AM, during an interview, the Director of Nursing (DON) stated the facility should have followed up with the resident's family regarding the request for a bedside phone. The DON stated residents have the right to communicate with individuals of their choosing and acknowledged the facility failed to ensure the phone was operational for Resident #9.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a Foley (indwelling catheter) was properly secured with a leg strap to prevent catheter movement and trauma for one (1) of two (2) residents reviewed for urinary catheters. Resident #13.Findings include:A review of the facility's policy, UTI (Urinary Tract Infection) Prevention with Indwelling Catheter Use, undated, revealed, .A resident with an indwelling catheter is susceptible to urinary tract infections.Policy Explanation.7. Catheter tubing should be secured to the resident's leg or bed clothing to prevent pulling and irritation of the urinary meatus.On 3/3/26 at 2:14 PM, during an observation, Certified Nursing Aide (CNA) #1 assisted by CNA #2 provided Foley catheter care to Resident #13 and the catheter tubing was not secured with a leg strap. On 3/4/26 at 2:34 PM, during an interview, CNA #2 confirmed Resident #13 did not have a leg strap in place and stated she forgot to obtain one. CNA #2 stated the purpose of the leg strap was to keep the Foley catheter from being pulled out and believed it was the nurse's responsibility to ensure the leg strap was in place.On 3/4/26 at 4:15 PM, during an interview, the Director of Nursing (DON) stated the leg strap was used to keep the Foley catheter secured and maintain proper flow. The DON stated all nursing staff were responsible for ensuring a leg strap was in place and that any staff member could obtain a leg strap and secure the catheter. The DON stated the purpose of the leg strap was to prevent trauma.A record review of the Face Sheet revealed the facility admitted Resident #13 on 2/10/21 with diagnoses including Retention of Urine.A record review of the Order Summary Report revealed Resident #13 had a Physician's Order, dated 1/15/25, for Urinary Catheter Care: nurse is to ensure that catheter care is provided with soap and water every shift and as needed. Leg strap secured.every shift.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/26 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident's cognition was severely impaired.

Based on record review, interview and facility policy review the facility failed to provide necessary behavioral services by qualified staff to ensure residents' dignity, privacy, and safety and failed to promote mental and psychosocial well-being for five (5) of (5) residents. Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5. Findings include:Record review of the Facility Policy titled, Dementia Care with an implementation date of 1/04/26 revealed, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia, to meet his or her highest practicable physical, mental and psychosocial well-being.4. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. 5. Individualized, non-pharmacological approaches will be utilized, to include meaningful activities aimed at enhancing the resident's well-being.Resident #1 Record review of the Progress Notes and Incident Report for Resident #1 revealed:On 10/27/25 at 1:15 AM, Resident #1 entered the room of Resident #2 and Resident #5 and got into bed with one of the residents and yelled at her. He pushed her in her bed to the middle of the room and hit and growled at staff and was transferred to the emergency room.On 11/05/25 Nurse Practitioner (NP) #1 visited Resident #1 related to emergency room transfer on 10/27/25 for agitation and aggressiveness. He returned to the facility on [DATE] and had an unwitnessed fall in the early morning hours of 11/05/25. The NP noted a plan that included ongoing monitoring.On 11/10/25 at 11:40 AM, Resident #1 was in Room D10A where there was an incident between him and Resident #4. (Incident Report)On 11/21/25 at 6:16 PM, Resident #1 punched an unnamed staff member at the nursing station.On 12/19/25 at 7:04 AM, Resident #1 went to sleep in another resident's room.On 12/24/25 at 7:43 PM, Resident #1 required frequent redirecting due to going into other resident's rooms.On 12/25/25 at 3:45 AM, Resident #1 removed personal items from a female resident's room and at 4:22 AM Resident #1 was asleep on a couch in a different female resident's room.On 12/25/25 at 7:08 AM, Resident #1 was described as aggressive and hostile and physically attacked another resident and threatened staff. The NP was notified with new orders noted to transfer the resident out of the facility for assessment and treatment related to behavior. The female resident yelled at him to get out of her things and there was an incident between the two residents.On 12/26/25 at 6:25 PM, Resident #1 was on one-on-one supervision and noted lying in another resident's bed following failed attempt at redirection and becoming agitated, yelling profanities and attempting to kick staff.On 12/26/25 at 7:02 PM, Resident #1 took another resident's walker and started pushing into a chair next to its owner, he then urinated in the hallway.On 12/29/25 at 4:40 PM, Resident #1 attempted to get other residents' food.On 1/05/25 at 4:31 PM, Resident #1 urinated in another resident's room on a chair.Resident #1Record review of the admission Record for Resident #1 revealed the facility admitted the resident on 6/03/25 with diagnoses that included Pick's Disease, Alzheimer's Disease, anxiety and history of falling.Record review of the admission Minimum Data Set (MDS) for Resident #1 with an Assessment Reference Date (ARD) of 12/17/25 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. MDS review revealed Resident #1 was assessed as able to walk independently indoors.Record review of the physician orders for Resident #1 revealed the resident had order for Monitor for the following behaviors.restlessness, agitation, hitting biting, kicking, spitting, foul language, elopement, stealing.aggression.every shift with a start date of 12/11/25 and Observe closely for significant side effects of Anti-Depressant medication including.unusual changes in mood or behavior.every shift with a start date of 12/11/25.Resident #2Record review of the Progress Note for Resident #2 with an effective date of 12/25/25 at 6:30 AM revealed following incident with another resident, Resident was shaken up originally but was able to calm down.Record review of the Progress Note for Resident #2 dated 12/30/25 at 3:55 PM the DON contacted the resident's Resident Representative (RR) regarding condition and no bodily injuries.Record review of the admission Record for Resident #2 revealed the resident was admitted on [DATE] and the resident had diagnoses of Alzheimer's Disease, depression and difficulty in walking and falling and restlessness and agitation.Record review of the Annual MDS with an ARD of 12/08/25 for Resident #2 revealed the resident had a BIMS score of 6, which indicated severe cognitive impairment. The MDS review revealed Resident #2 was independent with walking.Resident #3Record review of the Progress Note for Resident #3 dated 12/24/25 at 2:29 PM, revealed Resident #3 had a fall during intrusion of another resident as her daughter called for assistance with removing the other resident.Record review of the admission Record for Resident #3 revealed the facility admitted the resident on 5/02/23 and the resident had diagnoses of Alzheimer's Disease, hemiplegia and hemiparesis following cerebral infarction (stroke) affection left non-dominant side and difficulty walking.Record review of the Quarterly MDS with an ARD of 10/20/25 for Resident #3 revealed Resident #3 had a BIMS score of 3, which indicated severe cognitive impairment. The MDS review revealed the resident used a walker or wheelchair and required partial/moderate assistance for walking.Resident #4Record review of the Progress Note for Resident #4 dated 11/11/25 at 12:59 AM revealed documentation of an incident between her and Resident #1 in her room. Record review of the admission Record for Resident #4 revealed the facility admitted the resident on 8/05/16 and the resident had diagnoses of dementia, need for assistance with personal care, and depression.Record review of the Quarterly MDS with ARD 10/17/25 for Resident #4 revealed the resident had a BIMS score of 13, which indicated no cognitive impairment. The MDS review revealed Resident #4 was able to walk without assistance.Resident #5Record review of the admission Record for Resident #5 revealed the facility admitted the resident on 8/19/25 and the resident had diagnoses of Alzheimer's Disease, history of falling.Record review of the Quarterly MDS with an ARD of 11/24/25 for Resident #5 revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. The MDS review revealed the facility assessed Resident #5 used a walker or wheelchair. On 1/05/25 at 10:00 AM, telephone interview with the Complainant for CI#2704690 revealed she visited the dementia unit at the facility regularly as a visitor and had observed staff give Resident #1 time and space to keep him calm, including allowing him to wander or stay in other residents' rooms, but that approach had not worked at all. She stated that during a visit she observed Resident #1 get into Resident #5's bed while she was not in the room. Complainant states she feared what would have happened if Resident #5 had been in her bed in her room. She stated she was not sure if a linen changed was accomplished before Resident #5 got into her bed. The Complainant said that on 12/24/25 she visited Resident #3 and observed the resident and her daughter go into the bathroom and was waiting in the bedroom for them to come out of the bathroom when Resident #1 begin to come to the room and she got her foot behind the room door and held the door closed so he could not enter the room as he continued pushing against the door and she kept telling him he needed to go to his room, that was not his room. The Complainant stated at the time resident pushed with force to open the door all the way, even as she tried to hold it as Resident #3's daughter was bringing her from the bathroom into the room, and they (Resident #3 and her daughter) stepped back into the bathroom to pull the red emergency cord for staff to come. She stated that Resident #1 refused to leave the room and was becoming increasingly agitated. The Complainant stated she was not sure if Resident #3 was frightened or off balance due to change of course, but she fell to the floor of the bathroom while Resident #1 was in the room going towards the bathroom. The Complainant confirmed that staff did respond to the red call light and were able to redirect him to leave Resident #3's room. The Complainant confirmed she was leaving one-night last week, and a female resident (she did not know the resident's name) was in the hall and summoned to her to come to her room and when she looked in the room, Resident #1 was in the lady's room, and the resident was terrified and would not go into her room due to it. The Complainant confirmed she had observed Resident #1 enter the common dining room for a meal and reach for food items from other resident's trays/plates.On 1/05/25 at 12:35 PM, during an interview the Administrator confirmed that he was familiar with Resident #1 and his care. He confirmed that all incidents were reviewed by the Interdisciplinary Team (IDT) with review of the resident's care plan. He confirmed that nursing staff were responsible for providing adequate supervision for residents and included strategically placed staff and keeping hallway lights on during the evening hours. He confirmed that, while wandering and disorientation were common symptoms of dementia, it was the responsibility of staff to ensure safe wandering and provide a sense of safety and security for all residents.On 1/05/26 at 2:00 PM, during an interview with Certified Nursing Assistant (CNA) #1 stated she had picked up an extra shift on the night shift on or around 11/10/25. While answering Resident #4's call light, Resident #4 was standing at her bedside and Resident #1 was exiting her bathroom door. She stated that she attempted to redirect Resident #1 to exit the room, but he walked toward Resident #4 instead and the residents' hands bumped. She stated that the nurse came into the room and assessed both residents and Resident #1 was sent out via ambulance for assessment and treatment due to wandering and difficulty with redirection. She said that all the residents on the Dementia Unit went into and out of each other's rooms. She stated she was aware that care instructions for Resident #1 included supervision and monitoring for safe wandering.On 1/05/26 at 3:00 PM, an interview with Social Services Director, (SSD) she confirmed that the facility IDT discussed issues with the residents' behaviors during morning meetings Monday through Friday to determine root cause of adverse or aggressive behaviors and resultant interventions to provide for the physical, mental, emotional and psychosocial well-being of all residents.On 1/05/25 at 4:47 PM, a telephone interview with the RR for Resident #1 revealed she was concerned about the amount of supervision provided considering several and repeated incidents involving Resident #1, specifically on the evening/night shift. She stated that Resident #1 had sundowning, which is frequently associated with dementia and could result in increased confusion and disorientation during evening/night hours. On 1/06/26 at 12:50 PM, an interview with the Assistant Director of Nursing (ADON) revealed she was responsible for providing in-service training for nursing staff. She stated that In-Service Training was provided for nursing staff monthly. She stated that In-Service Training for nursing staff on the dementia unit included environmental accommodations that the evening hours the hallway lights should remain on and there should be a staff member positioned at the end of the hallway to provide full coverage of the hall, which she confirmed meant that all resident room doors and the entire hall would be in view of the staff. She confirmed she was on duty on the Dementia Unit on 12/25/25 as the direct care nurse for all residents including Resident #1 on the 3:00 PM to 11:00 PM and stayed over as direct care provider from 11:00 PM to 7:00 AM. She explained that the resident returned to the facility from a local acute care hospital where he had been transferred because of an episode of wandering during which Resident #1 had entered the room of Resident #2. She stated that the Administrator had instructed staff to place Resident #1 on one-on-one (1:1) for (24) hours on 12/26/25 through 12/27/25. She confirmed Resident #1 attempted to take food items from other residents as she documented on 12/29/25.On 1/06/25 at 3:50 PM, during an interview the Director of Nurses (DON) confirmed that one of the main focuses for a resident that was ambulatory and had wandering behaviors and dementia was to have eyes on them and provide the level of assistance and supervision needed by each resident. She stated staff were trained to intervene if a resident attempted to enter another resident's room uninvited, invaded their privacy or take their belongings. She stated that it was the responsibility of the staff to ensure residents in the dementia unit had a safe, homelike environment with their belongings, and provided a sense of safety and security. She stated that adequate staffing and supervision for residents in the dementia unit was very important ant that they required close monitoring. The DON confirmed that the IDT reviewed all incidents, attempted to determine root cause analysis and nonpharmacologic interventions to decrease aggressive and disruptive behaviors, therefore she was aware of the repeated incidents of interactions between Resident #1 and other residents on the dementia unit. She stated that staff were aware that Resident #1 had behavior of wandering into other residents' rooms resulting in incidents between himself and other residents, urinating in their rooms, and taking their belongings. She confirmed she expected nursing staff to provide adequate supervision, monitoring and interventions to ensure the highest practicable well-being for all residents and report to her if there were any problems or need for additional assistance. The DON identified individualized, non-pharmacological interventions to attain or maintain the resident's well-being for Resident #1 could include, but had not been incorporated, confirmation that the residents television and electronic drum set were operating correctly for activities and entertainment, provide radio (or television capability) for music for the resident, work with resident and family regarding visual aides to help the resident identify his room and bathroom.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure proper infection control practices were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube site care and wound care for two (2) of (19) sampled residents. Residents #14 and #30 Findings Include: A review of the facility's policy titled Hand Hygiene, dated 06/12/22 revealed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . If your task requires gloves, perform hand hygiene prior to donning gloves, and sanitize or wash hands after removing gloves . Resident #14 On 11/06/24 at 1:08 PM, during an observation of wound care, Licensed Practical Nurse (LPN) #1/Wound Care Nurse, performed a dressing change on Resident #14's right elbow. After removing the soiled dressing from the resident's arm, she placed it on the resident's bedside table without using a barrier and did not use a red biohazard bag for disposal. LPN #1 then proceeded to apply a new dressing without removing her soiled gloves. On 11/06/24 at 1:10 PM, LPN #1 admitted that she did not use a barrier or a red biohazard bag for the soiled dressing, acknowledging failure to do so could lead to infection. During an interview with the Infection Preventionist on 11/07/24 at 9:55 AM, she stated that all staff are expected to follow infection control guidelines, including using appropriate containers for disposing of soiled dressings to prevent the spread of infection. During an interview on 11/07/24 at 10:00 AM, the Director of Nursing (DON) emphasized her expectation that staff adhere to infection prevention protocols when performing wound care. She stated that failure to change gloves or using clean surfaces for soiled dressing could increase the risk of the spread of infection. A record review of Resident #14's Admission Record revealed the facility admitted the resident on 07/16/24. The resident had diagnoses that included Dementia, and Pressure Ulcer of Right elbow, Stage 3. Resident #30 On 11/06/24 at 1:25 PM, during an observation of LPN #1 providing PEG tube site care for Resident #30 revealed LPN #1 entered the room without washing her hands or using hand sanitizer. She held one pair of clear gloves upon entry and did not perform hand hygiene before donning the gloves. After lowering the head of the bed with her bare hands, she applied gloves, removed the soiled split gauze from the PEG site, placed it in a red bag, and cleaned the site with gauze and normal saline and applied a new split gauze to the site. During the procedure, she did not wash her hands, use hand sanitizer, or change gloves. During an interview with LPN #1 at 1:35 PM on 11/06/24, she admitted that she failed to wash her hands or use hand sanitizer upon entering the room and acknowledged she should have performed hand hygiene and changed gloves at different stages of the care. She recognized that her actions could lead to cross-contamination and infection. At 12:48 PM on 11/06/24, the DON confirmed that LPN #1 should have performed hand hygiene before and during the procedure. The DON noted that failure to follow these infection control protocols could lead to the spread of infection. A record review of the Admission Record revealed the facility admitted Resident #30 on 03/22/19. The resident had diagnoses that included Dysphagia, Oropharyngeal Phase and Encounter for Attention to Gastrostomy. 48669 50751

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the physician orders were followed related to the care of a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube for one (1) of (19) sampled residents. Resident #30. Findings Include: A review of the facility's policy titled, Dressing Change, policy (undated) revealed, A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment. On 11/06/24 at 1:25 PM, during an observation of PEG tube site care, Licensed Practical Nurse (LPN) #1 lowered the head of the bed to a flat position while Resident #30's feeding pump was infusing Glucerna 1.2 at 50 cubic centimeters (cc) per hour. LPN #1 then proceeded to clean the PEG site with gauze in a circular motion without drying the site afterward. On 11/06/24 at 1:35 PM, during an interview with LPN #1 , she admitted she forgot to place the feeding pump on hold before positioning the bed flat to conduct care. She acknowledged that she should have dried the site before applying a split gauze. During an interview on 11/07/24 at 12:48 PM, the Director of Nursing (DON), stated that LPN #1 should have stopped the pump. She explained that Resident #30 could aspirate if the pump continues infusing while the bed is flat. She also noted that failing to dry the site could increase the risk of infection. A record review of the Admission Record revealed the facility admitted Resident #30 on 03/22/19. The resident had diagnoses that included Dysphagia, Oropharyngeal Phase and Encounter for Attention to Gastrostomy. A record review of the Order Summary Report, revealed Resident #30 had active orders as of 11/07/24 that included an order dated 1/13/24 to keep the head of the bed elevated 30-90 degrees while tube feeding was infusing and an order dated 1/31/24 to clean the PEG site with normal saline, and pat dry with gauze before applying a split gauze to the PEG site daily for skin protection. A record review of Resident #30's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/24 revealed a Brief Interview for Mental Status (BIMS) score of (99), indicating severely impaired cognition. Section K was coded for PEG tube use.

Based on observation, interviews, record review, and facility policy review, the facility failed to prevent significant medication errors for one (1) of six (6) residents observed for medication administration. Resident #9 Findings Include: A review of the facility's policy titled Medication Administration Guidelines, (undated), revealed, Medications are administered as prescribed .18. Prior to administration, the medication and dosage schedule on the resident's MAR/TAR or EMAR/ETAR is compared with the medication label. Information on the medication should be checked against the MAR/ETAR at least three times during the med preparation and administration process . During an observation on 11/04/24 at 8:35 AM, Licensed Practical Nurse (LPN) #3 pulled medications for Resident #9. While pulling medications for an order of Lorazepam Oral Tablet 0.5 mg (milligram) that was to be given once daily for Anxiety Disorder, LPN #3 instead pulled a tablet for Alprazolam 1 mg, 1.5 tablets (to equal 1.5 mg) to be given at bedtime. This medication was placed into the medication cup with the resident's other medications to be administered. LPN #3 confirmed she intended to administer the medication to Resident # 9. The State Agency (SA) questioned whether the Alprazolam medication was due at that time and LPN #3 confirmed that the medication was not due and verified it as the incorrect medication for that time. LPN #3 called LPN #5, and together, they wasted the medication. During an interview on 11/07/24, the Director of Nursing (DON) stated that her expectation was for staff to ensure residents receive the correct medications as prescribed. She emphasized that administering incorrect medications, especially narcotics, could result in adverse outcomes, including lethargy or oversedation, and expressed concern regarding the observed error. A record review of the Admission Record revealed the facility admitted Resident #9 on 01/21/15. The resident had diagnoses that included Anxiety Disorder, Depression, and Insomnia. A record review of the Order Summary Report, with active orders as of 11/07/24 revealed Resident #9 and order for the Lorazepam Oral Tablet 0.5 mg (to be given once daily for Anxiety Disorder, unspecified), with an order start date of 10/02/24 and Alprazolam 1 mg, with an order for 1.5 tablets (to equal 1.5 mg) to be given at bedtime, with an order start date of 10/01/24.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure the comprehensive care plan interventions were implemented during Percutaneous Endoscopic Gastrostomy (PEG) tube care for one (1) of 19 care plans reviewed. Resident #30 Findings Include: A review of the facility's policy titled Care Plans, dated 02/20/20 revealed, Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the interdisciplinary team will provides care . PROCEDURE: . 6. Staff approaches are to developed for each problem/strength/need. Assigned disciplines will be identified to carry out the intervention . A record review of Resident #30's Comprehensive Care Plan with a start date of 4/4/2019 revealed Adequate fluid/nutritional intake .Intervention .Keep head of bed elevated at all times .Cleaning peg site with normal saline. Pat the site dry with gauze .for skin protection. On 11/06/24 at 1:25 PM, during an observation of PEG site care, Licensed Practical Nurse (LPN) #1 lowered the head of the bed to a flat position while the pump continued to infuse the feeding. After cleaning the PEG site, LPN #1 did not dry the PEG tube site prior to applying the split gauze dressing. During an interview with LPN #1 on 11/06/24 at 1:35 PM, she acknowledged that she did not follow the care plan for Resident #30 when she lowered the bed of Resident #30 while the feeding continued to infuse and did not dry the PEG site before applying the split gauze dressing. On 11/07/24 at 12:48 PM, during an interview with the Director of Nursing (DON), she stated that she expects staff to follow the care plan when providing care. On 11/07/24 at 3:00 PM, during an interview with LPN #2, the Minimum Data Set (MDS)/Care Plan Nurse, she explained that staff are expected to adhere to the plan of care, as the purpose of the care plan is to guide the staff in providing appropriate care. A record review of the Admission Record revealed the facility admitted Resident #30 on 03/22/19. The resident had diagnoses that included Dysphagia, Oropharyngeal Phase and Encounter for Attention to Gastrostomy. A record review of Resident #30's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/16/24 revealed a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), indicating severely impaired cognition. Section K was coded for PEG tube usage.

Based on interviews, record review, and facility investigation review, the facility failed to provide adequate supervision to prevent an accidental coffee burn for one (1) of the four (4) sampled residents. Resident #1 Findings included: Record review of the Facility Investigation with completion date 9/06/24 revealed the facility reported the incident of coffee spill with burn injury of Resident #1 to the State Agency (SA) and appropriate agencies in accordance with state and federal guidelines initially on 9/03/24 with final report submitted on 9/06/24. According to the Facility Investigation, the resident was served coffee on the morning of 9/03/24 at approximately 7:00 AM, observed capably drinking the coffee without assistance, then at 7:08 AM the resident rested the covered coffee cup on his stomach and it fell and tumbled toward the resident's left thigh, spilling and causing a burn injury to the resident, unobserved by facility staff. Further record review of the Facility Investigation included hospital progress notes and discharge instructions which revealed that Resident #1 was transported to a local acute care hospital for assessment and treatment of a twenty centimeter (cm) by sixteen cm (20cm X 16cm) partial thickness burn of left thigh of unspecified degree burn from hot coffee on 9/03/24 and was taken to surgery for debridement with application of skin substitute on 9/04/24 and was stable and ready for discharge on 9/05/24. Discharge instructions included deep wound clean and dry and reinforce dressing as needed. On 9/11/24 at 2:50 PM an interview with the Dietary Manager (DM) revealed that he was notified by the Administrator on 9/03/24 that Resident #1 had a burn injury that had been determined to be from the coffee. He said he notified the local vendor and was instructed to immediately remove the commercial coffee maker from service, which he did. He said the Administrator procured non-commercial coffee makers from a local vendor to provide coffee for residents over the weekend until the local vendor delivered a new commercial coffee machine. He stated that he was instructed to immediately begin measuring the temperature of coffee before it was served to residents and cool the coffee to one hundred forty (140) degrees Fahrenheit or below before being sent out in carafes or served in cups to residents. He confirmed that he attended a meeting of QAPI committee on 9/05/24, during which the facility Hot Liquids Policy was revised to prevent further injury. The DM confirmed that the temperature of all coffee sent out in carafes or served in cups to residents since the afternoon of 9/03/24, had been checked and none of the coffee was above one hundred forty (140) degrees Fahrenheit. Record review of the Hot Liquids Evaluation, dated 6/17/24 for Resident #1, revealed the resident was assessed by Registered Nurse (RN) #1 as able to manage hot liquids independently with a cup with lid when drinking hot liquids and had no previous history of hot liquid spills. On 9/12/24 at 2:00 PM an interview with the Director of Nurses (DON) revealed she was made aware that Resident #1 had a skin injury on his left hip/thigh area on 9/03/24 at approximately 1:30 PM. She said she immediately assessed the resident in his bed in his room and described the injury as an open area of skin with healthy looking pink subcutaneous tissue exposed. She said that while in the resident's room she had observed a light coffee colored stain on the pad from his Geri recliner. She confirmed that she had observed security camera footage of the activity room on the morning of 9/03/24 during which the resident sat a cup of coffee on his stomach, rubbed his eyes, the coffee cup turned over and tumbled toward the side of the Geri recliner. She said that after watching the rest of the footage of the Resident for 9/03/24, it was determined that the resident had experienced a burn from the coffee from the toppled coffee cup based on the determination that there was no contact with any other hot or heated objects or substances. The DON confirmed that all residents received Hot Liquids Evaluations, with care plans updated as needed. She confirmed that In-Service Training's on hot liquid services and the proposed changes to the Hot Liquid Policy were provided to all dietary and nursing staff on 9/04/24 through 9/05/24. She confirmed that she attended a meeting of the QAPI committee on 9/05/24 during which the incident and the facility's Hot Liquid Policy was reviewed, and the proposed policy revision was approved. On 9/12/24 at 2:30 PM an interview with the Administrator revealed he was notified by the DON that Resident #1 had a skin injury on 9/03/24 at approximately 1:30 PM. He said that as part of the facility investigation he observed security camera footage of the activity room on the morning of 9/03/24 during which the resident sat a cup of coffee on his stomach, rubbed his eyes, the coffee cup turned over and tumbled toward the side of the Geri recliner. He said that after watching the rest of the footage of the Resident for 9/03/24, it was determined that the resident had experienced a burn from the coffee from the toppled coffee cup, based on the determination that there was no contact with any other hot or heated objects or substances. The Administrator reported that all staff involved in the care of the resident on 9/03/24 were interviewed and that none of them had noted wetness or stain of the resident's clothes or signs and symptoms of distress or discomfort. He reported that after the resident's security was ensured, coffee temperatures were measured with the injury reported to the local vendor, who issued instructions for the coffee maker be removed from service. The commercial coffee maker was immediately removed from service and with non-commercial coffee makers were obtained to provide coffee for residents over the weekend, until a new machine could be delivered from the local vendor. All residents were assessed for the ability to manage hot liquids, with care plans updated as needed. He reported that upon observation of the injury, Resident #1's Resident Representative (RR) requested the resident be assessed and treated at an acute care facility, which was reported to the resident's primary healthcare provider with new orders noted for transport via ambulance to local acute care hospital. The Administrator confirmed that the mandatory In-Service Training was provided on 9/04/24 and 9/05/24 for all nursing and dietary staff related to resident safety with hot liquids and introduction of the proposed changes in the Hot Liquids Policy and was attended by one hundred percent (100%) of the required personnel. The Administrator stated that following discovery of Resident #1's injury, he reviewed the resident's Hot Liquids Evaluation dated 6/17/24, in which Resident #1 was determined to be able to manage hot liquids independently. The evaluation was repeated on 9/03/24, revealed the resident was unsafe for hot liquids. He reported that Hot Liquid Evaluations were conducted for all residents on 9/03/24 with care plans updated as needed. He reported that a case conference with QAPI committee members on 9/05/24 during which the facility's Hot Liquids Policy was reviewed, which resulted in an update of the policy to include measurement of coffee temperatures prior to serving to residents and that the temperature of coffee served must not exceed one hundred forty (140) degrees Fahrenheit when served to resident's at risk for burns from hot liquids. Record review of the Face Sheet for Resident #1 revealed the facility admitted the resident on 3/12/21. The resident had diagnoses that included Vascular Dementia, Type 2 Diabetes, Peripheral Vascular Disease, and Acquired Absence of Right and Left Legs Above the Knee. Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 8/26/24 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. Further MDS review revealed the resident had no impairment of his functional range of motion of upper extremities and required supervision for eating. Validation: The SA validated on 9/12/24, through interview and record review that all corrective actions had been implemented as of 9/5/24, prior to the SA entrance on 9/11/24.

Based on observations, record review, interviews, and facility policy review, the facility failed to provide care and services to promote healing and prevent infection for one (1) of four (4) residents that required wound care. Resident #2 Findings Include: Record review of the facility policy titled DRESSING CHANGE, (undated), revealed, A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment. On 5/23/24 at 3:50 PM, an observation of Resident #2 revealed she was lying on her back in bed. The resident's incontinence brief was wet and had fecal matter present. There were two small open areas on her sacral area, with no bandage present. On 5/23/24 at 4:55 PM, an interview with the Assistant Director of Nurses (ADON) revealed she was assigned to the care of Resident #2 on 5/23/24. She stated she had not provided wound care to Resident #2. She explained that she intended to wait because evening meal trays had just been delivered to the hall and she had to assist with meal deliveries. She stated, when trays come out, everyone stops doing what they're doing and passes trays, as she continued to retrieve meal trays from the cart. On 5/23/24 at 5:25 PM, an interview with the ADON revealed that Resident #2 had not yet had wound care to her sacral area on . She confirmed that the resident had not had a dressing in place from 3:50 PM until 5:25 PM. She also confirmed that Resident #2 was always incontinent of bowel and bladder. On 5/24/24 at 5:55 PM, in an interview with the ADON, she revealed Resident #2 received sacral wound care and her sacral dressing had been replaced after 5:30 PM, by Registered Nurse (RN) #1. On 5/24/24 at 2:00 PM, an interview with RN #1 revealed that she had performed wound care for Resident #2 on 5/23/24 after 5:30 PM. She confirmed that the resident had not had a dressing in place at the time, however, she did not know why. The nurse confirmed that it was important for incontinent residents, with open wounds, to have dressings in place according to physician orders to reduce the risk of infection. On 5/24/24 at 2:10 PM, an interview with Medical Doctor (MD) #1 revealed he it was important for physician orders for dressings to open areas to the sacral area be followed to provide a barrier to prevent exposure to urine and fecal matter in residents that are incontinent of bowel and bladder. He stated that this was important to prevent infection. On 5/24/24 at 2:30 PM an interview with the facility Administrator revealed he expected physician orders for wound care to be carried out in a manner to protect residents' skin and prevent infection. He stated that there was no facility policy in place that stated resident needs could not be provided during meal times. Record review of the Face Sheet for Resident #2 revealed the facility admitted the resident on 2/10/21. The resident had diagnoses of Chronic Kidney disease, Venous Insufficiency, and Stage 2 pressure Ulcer of Sacral Region. Record review of the Physician Orders, dated May 2024, for Resident #2, revealed an order, dated 4/16/24, to Cleanse stage 2 pressure injury to sacrum with normal saline. Pat dry with gauze. Apply foam dressing. Change daily and PRN until healed. Record review of the Electronic Treatment Administration Record (ETAR), for May 2024, revealed RN #1 performed wound care for Resident #2 on 5/23/24.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide care and services for a resident with an indwelling urinary catheter in a manner to prevent the potential for a urinary tract infection (UTI) for one (1) of two (2) sampled residents with indwelling urinary catheters. (Resident #6) Finding include: Record review of the facility policy titled, UTI Prevention with Indwelling Catheter Use, dated 1/27/2015, revealed, Policy: A resident with an indwelling catheter is susceptible to urinary tract infections . Policy Explanation . 3. Urinary drainage tubing should be positioned so as not to touch the floor . On 3/12/24 at 12:40 PM, an observation revealed Certified Nursing Assistant (CNA) #1 answered the call light for Resident #6, who was seated on the toilet in her room. The resident's catheter drainage bag and approximately three (3) inches of drainage tubing were lying on the floor next to the toilet. On 3/12/24 at 12:45 PM, in an interview with CNA #1, she confirmed the catheter drainage bag and tubing should not have been on the floor due to the risk of urinary tract infection. On 3/13/24 at 4:20 PM, an interview with Medical Doctor (MD) #1, he confirmed that catheter drainage bag and tubing should be kept off of the floor due to the risk of urinary tract infection. On 3/13/24 at 4:55 PM, during an interview the Director of Nurses (DON) confirmed that catheter drainage bags and drainage tubing should not be on the floor and that bags and tubing laid on the floor could increase the risk of a urinary tract infection. Record review of the Face Sheet for Resident #6 revealed the facility admitted the resident to the facility on [DATE], with diagnoses that included Unspecified Hydronephrosis and Cognitive Communication Deficit. Record review of the March 2024 Physician Orders revealed, an order dated 11/21/23 Insert 16F (French, size of catheter) 10cc (centimeter) bulb indwelling foley catheter r/t (related to) hydronephrosis.

Based on observation, interviews, record review, and facility policy review, the facility staff failed to provide treatment and services in a manner to promote the healing and prevent complications of a pressure ulcer for one (1) of three (3) sampled residents with pressure ulcers. (Resident #2) Findings include: Review of the facility's policy, titled Dressing Change undated, revealed, Policy: A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment . Review of the facility's policy, titled Hand Hygiene, reviewed 6/12/22, revealed Policy: All staff will perform hand hygiene procedures to prevent the spread of infection .Policy Explanation and Compliance Guidelines: 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. On 3/13/24 at 11:55 AM, an observation revealed the facility Treatment Nurse provided wound treatment for a Stage 2 pressure ulcer, with non-intact skin on the left upper back of Resident #2. After the Treatment Nurse removed the dressing from the wound, she removed her gloves and donned (put on) clean gloves without performing hand hygiene. During the procedure, the Treatment Nurse dropped the sterile calcium alginate dressing on the mattress, picked the dressing up and applied the dressing to the wound. The Calcium Alginate dressing was larger than the wound. The adhesive and edge of the Calcium Alginate bordered dressing used to cover the wound protruded past the wound margins. Record review of the Instructions For Use on the Calcium Alginate dressing package revealed .Make sure the dressing DOES NOT overlap the wound margins . On 3/13/24 at 12:30 PM, during an interview with the Treatment Nurse, confirmed she had not performed hand hygiene after removal of the dressing from the resident's wound and removing her gloves, prior to donning fresh gloves and applying the calcium alginate dressing. The Treatment Nurse stated that she did not perform hand hygiene because the hand sanitizer was in a wall mounted dispenser, located next to the door, and she did not want to leave her clean field to use the hand sanitizer or the bathroom sink. The Treatment Nurse did not respond regarding the application of the Calcium Alginate dressing to the resident's wound, after being dropped on the mattress, nor did she respond to the Calcium Alginate dressing overlapping the wound margins. On 3/13/24 at 4:55 PM, in an interview the Director of Nurses (DON) confirmed that the facility policy on hand hygiene stated that hand hygiene was to be performed upon removal of used gloves and prior to the donning of clean gloves. A record review of the Face Sheet for Resident #2 revealed the facility admitted the resident on 9/15/23. The resident had diagnoses that included Pressure Ulcer of Unspecified Part of Back, Stage 2, Venous Insufficiency, and Type 2 Diabetes Mellitus. A record review of the March 2024 Physician Orders, for Resident #2 revealed an order dated 3/05/24 Clean Left upper back Stage 2 pressure ulcer with normal saline, apply Aquacel AG (Calcium Alginate) and cover with outer dressing. Change daily and PRN (as needed).

Based on interview, record review, policy review, and review of the facility reported incident investigation, the facility failed to ensure residents were free from abuse and neglect for two (2) of four (4) residents reviewed for abuse and neglect. Residents #1 and #2. Findings include: Review of the facility's policy, Abuse Program, revised May 23, 2017, revealed, It is the policy of this facility to take all steps necessary to maintain an environment free of abuse and neglect. Each resident has the right to be free from verbal, sexual, physical and mental abuse, .Abuse means the will infliction of injury .intimidation, or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, irrespective of any mental or physical condition .cause physical harm, pain or mental anguish. It includes verbal abuse .and mental abuse .Willful, as used in the definition of abuse, means the individual must have acted deliberately, not the individual must have intended to inflict injury or harm .Verbal Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms .Neglect is the failure of the facility, its employees or services providers to provide goods and services necessary to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. Neglect occurs when facility staff fail to monitor and/or supervise the delivery of resident care and services to assure that care is provided as needed by residents. Neglect occurs when a facility fails to provide necessary care for residents, such as situations in which residents are left to lie in urine or feces . Resident #1 Record review of the Facility Investigation dated 6/19/23, revealed that on 6/16/23, it was determined that Certified Nurse Aide (CNA) #1 yelled and used derogatory language toward Resident #1 during routine care. On 8/10/23 at 10:00 AM, in an interview with Housekeeper #1, she revealed that on 6/16/23, she was working in the hallway on B Hall. The Housekeeper confirmed at approximately 10:30 AM, while she was outside the door of Resident #1, she could hear CNA #1 cursing and yelling. The Housekeeper verified that she recognized the voice as that of CNA #1. On 8/11/23 at 11:55 AM, a telephone interview with the former Human Resource (HR) Coordinator revealed that on 6/16/23, CNA #3 had verbally reported that CNA #1 had a filthy mouth. The former HR Coordinator revealed that CNA #1 had a history of using foul language and had received disciplinary action regarding her inappropriate language prior to 6/16/23. On 8/11/23 at 12:08 PM, in a telephone interview with CNA #3, she revealed that on 6/16/23, she had been assigned to work with CNA #1 for the 6:00 AM to 2:00 PM shift. She stated that at approximately 10:30 AM, she and CNA #1 entered the room of Resident #1, to provide care for the resident. She stated that after CNA #1 explained the procedure (dressing) to the Resident #1, he swung his legs off the bed. CNA #1 said the resident had kicked her. CNA #3 stated at that time, CNA #1 began to yell at the resident and tell him that she wasn't going to help him anymore. CNA #3 said that CNA #1 got a shirt to dress the resident in and the resident expressed that he did not want to wear that shirt. CNA #3 stated that at that time, CNA #1 threw the shirt down and used derogatory language speaking to the resident. She stated that CNA #1 yelled at the resident, (Expletive) this! I'm not putting up with this today! CNA #3 reported that Resident #1 then told CNA #1, You aren't supposed to talk to me that way. CNA #1 revealed during a break at approximately 3:30 PM, she had reported the verbal abuse of Resident #1 by CNA #1, to the former HR Coordinator. Record review of the Face Sheet for Resident #1 revealed the facility admitted the resident on 5/13/22. The resident's current diagnoses included Unspecified Dementia, Type 2 Diabetes Mellitus, Paroxysmal Atrial Fibrillation, and Essential Hypertension. Record review of the Annual Minimum Data Set (MDS) for Resident #1, with Assessment Reference Date (ARD) of 5/15/23, revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) and received a score of 99. The staff assessment revealed the resident had both a short-term and long-term memory problem and the resident's cognitive skills, for daily decision making, were moderately impaired to poor. Resident #2 Record review of the Facility Investigation dated 6/29/23, revealed that on 6/24/23, CNA #2 had not entered the room of Resident #2 or provided any type of care for the resident during her shift. The resident had not received incontinence care from 5:46 AM through 2:48 PM on 6/24/23, and was not repositioned, bathed, dressed, or provided with any type of personal hygiene during that time. On 8/10/23 at 11:24 AM, during a telephone interview with the Resident Representative (RR) for Resident #2, she revealed that on 6/24/23, at approximately 2:30 PM, she had visited Resident #2 and observed that the resident and her bed were wet with urine and the resident had a strong odor of urine and feces. She stated the resident's incontinence brief was saturated and the bed sheets were wet with urine, and the resident was soiled. On 8/10/23 at 2:09 PM, during a telephone interview with Licensed Practical Nurse (LPN) #1, she confirmed that on 6/24/23, she had been assigned to care for Resident #2, and to supervise CNA #2 during the 7:00 AM to 7:00 PM shift. The LPN stated she had entered the room of Resident #2 and provided nursing care to the resident at least three (3) times during the day. LPN #1 denied noting that the resident had not been repositioned during that time and had not noted any foul orders. The LPN revealed that later that afternoon, when the family of the Resident #2 went into the room to visit the resident, they requested that LPN #1 step into the resident's room. LPN #1 revealed that it was at that time that she noted a foul odor and discovered that the Resident #2's brief was saturated with urine, as well as her bed sheets. LPN #1 stated that CNA #2 should have made rounds every two (2) hours to reposition the resident and provide incontinent care as needed. On 8/11/23 at 9:35 AM, during an interview with the Administrator, she confirmed that the facility conducted a thorough investigation and substantiated the allegation of verbal abuse by CNA #1 towards Resident #1 on 6/16/23. During the same interview, the Administrator also confirmed that she had viewed the facility security camera footage from the ceiling mounted camera in the hallway outside the room of Resident #2 and that CNA #2 had not entered the room of Resident #2 during the 6:00 AM shift to 2:00 PM shift on 6/24/23. The Administrator stated that an investigation was conducted which resulted in neglect begin substantiated for Resident #2 on 6/24/23. On 8/11/23 at 1:25 PM, during a telephone interview with CNA #2, she revealed that on 6/24/23, she forgot that she had been assigned to care for Resident #2. She stated, I forgot to go in there, and confirmed she didn't provide the care to Resident #2 that she was supposed to provide. Record review of the Facesheet for Resident #2 revealed the resident was admitted by the facility on 3/22/19, and had diagnoses that included Unspecified Dementia, Encounter for Attention to Gastrostomy, and Dysphagia. Record review of the Quarterly MDS for Resident #2, with an ARD of 7/26/23, revealed that the resident was unable to participate in a BIMS and assessed as having short term and long-term memory problems and the resident's cognitive skills for daily decision making were moderately impaired to poor. The MDS review revealed that Resident #1 required extensive assistance for dressing, eating, toilet use and personal hygiene.

CI MS # Based on record review, policy review, review of personnel records, observation and staff interview, the facility failed to ensure that residents were transferred using the appropriate lift as identified by resident assessment and plan of care. This is for one (1) four (4) residents reviewed (Resident #1). Findings Include: Resident #1 Record review for Resident #1 revealed that the resident was [AGE] years old with a current date of admission of [DATE]. Review of the Diagnosis/History for this resident revealed that the resident's [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment for Resident #1, with the Assessment Reference Date of [DATE], revealed that the resident's score for the Brief Interview for Mental Status was coded as Moderately Impaired. This assessment documented that the resident's Functional Status for Transfer was "total dependence with two person physical assist". This assessment stated that the resident's balance for "Surface-to-surface transfer (transfer between bed and chair or wheelchair)" was "Not steady, only able to stabilize with staff assistance." The "Functional Limitation in Range of Motion" for this assessment was coded as impairment on both sides of the upper and lower extremity." Review of a written report from the facility to the state agency dated [DATE] revealed that "Administrative staff was notified on Friday evening, that Resident #1 had suffered a fracture." A detailed report of the facility's investigation was included. Review of the "Departmental Notes/Nurse Notes" for Resident #1 revealed the following: "On [DATE] 2:31 PM Resident in bed with HOB (head of bed) elevated, reported per CNA (Certified Nurse Aide) staff of left knee pain, CNA states "knee felt loose during care while turning her", pain on palpation, swelling and warm noted, RP (Responsible Party) Notified, (Name of Nurse Practitioner) notified, N.O. (new order) left knee x-ray, and labs, ... PRN (according to circumstances or as the situation demands) pain meds given per PEG (Percutaneous endoscopic gastrostomy or feeding tube), cold compress applied, will continue to monitor, red/purpulish bruise noted under left breast ... " "[DATE] 9:09 PM resident had an xray done of left leg, results indicated a spiral fx (fracture) of the distal shaft of the femur. N.O. to (Name of hospital) on [DATE] to treat fx ..." Review of the [DATE] final radiology report of an x-ray of the left knee of Resident #1 revealed the following: "Impression: There is a spiral fracture of the distal shaft of the femur. There is no other fracture dislocation or significant bone or joint abnormality. Spiral mildly displaced angulated fracture of the distal shaft of the femur." Interview with Registered Nurse (RN) #1 on [DATE] at 9:20 a.m., revealed that Resident #1 expired in the hospital on [DATE]. Review of the "Resident Lift/Transfer Assessment", with the completion date of [DATE] for Resident #1, revealed that the "Resident Level of Assistance Required" was "Dependent-Resident requires more than 50% assistance by staff or is unpredictable in amount of assistance requires" and that the question "Can the Resident bear weight" was answered "No Weight". "Does the Resident have upper extremity strength to support his/her weight" was answered "No". The "Select Equipment Required" section indicated "Total Lift with 2 staff assist". Review of the "ADL (Activities of Daily Living) Plan of Care" (used to direct the care for the Certified Nurse Aides) for Resident #1 dated [DATE] revealed that the resident was dependent with the assist of two (2) and that a total lift with two (2) staff was necessary for transfers. The facility provided a handwritten statement dated [DATE] from CNA #1 which was obtained during the facility's investigation of the fracture. The statement was as follows: "Resident #1 was transferred by (Name of CNA #2) and I with the stand up lift which did not have a stand up part at the bottom. She was twisting upper body and upper body dropped while in lift, lift straps held resident. Resident also yelled out. There were no complaints in shower. No complaints after shower or when put to bed, nor for the rest of the shift." Interview with CNA #1 on [DATE] at 10:50 a.m., confirmed that she and CNA #2 had used the Sit-to-Stand lift to transfer Resident #1. She stated that she was told after the incident that this was the wrong lift to use. When CNA #1 was asked if she had been trained to consult the ADL book to determine the type lift to use for each resident she stated that she did not remember. CNA #1 stated that CNA #2 noticed there was no "bottom" in the Sit-to-Stand lift after they had Resident #1 up in the lift and CNA #1 did not think to put the resident back to bed but continued to transfer her to the gerichair. CNA #1 stated that she did not know why the resident cried out. Then the resident slumped down. The resident was transferred to the gerichair and taken to the shower. CNA #1 continued, saying that she transferred the resident from the gerichair to the shower chair, using another Sit-to-Stand lift but this one had a "bottom". After the shower was completed the resident was transferred from the shower chair back to the gerichair using a Sit-to-Stand lift, returned to her room and transferred Resident #1 to the bed with a Sit-to-Stand lift. When questioned as to why the Sit-to-Stand lift was used the CNA gave no answer. The facility also provided a handwritten statement dated [DATE] from CNA #2, obtained during the investigation, which stated the following: "I helped CNA #1 with Resident #1 when she was in her room. I just changed Resident #1 diaper. When we used the lift, after we got her up, I realized it didn't have a foot stool. So, I just put her back in the chair. That was CNA #1 first time working that side, so she didn't know which lift to use. But I left out, after I changed her and put her back in the chair." Interview on [DATE] at 1:45 p.m. with CNA #2 revealed that CNA #1 and CNA #2 were going to transfer Resident #1 from the gerichair to the bed for incontinent care. CNA #1 went to get a lift and returned with a Sit-to-Stand lift. CNA #2 stated that she knew that Resident #1 needed a Total lift because the resident could not stand. She decided not to transfer the resident to the bed but to use the Sit-to-Stand lift only to hold Resident #1 up so that the incontinent care could be done. CNA #2 stated that she noticed when Resident #1 was lifted up that there was no "footstool" on the lift. The resident's feet were not touching the floor and she was hanging by the sling. CNA #2 stated that she had been taught that a resident had to be able to stand if a Sit-to-Stand lift was used. When asked why the Sit-to-Stand lift was used, CNA #2 stated "she just was not thinking". Review of an "Incident Investigation" provided by the facility revealed a "Narrative of investigation:" related to Resident #1's fracture revealed documentation as follows: "On [DATE] at approximately 3:00 P.M. I spoke with (Name of Responsible Party). She was visibly upset and when I asked what was wrong, she shared with me that CNA #1 had shared with her that Resident #1 did in fact get her foot lodged in the life (lift) on [DATE], that she(Resident #1) cried out and that she (CNA #1) had not reported it to anyone. As this was very obviously not what she (CNA #1) had stated previously, I immediately shared with (Name of Administrator)." This statement was signed by the Director of Nursing (DON) of the facility. Review of a report dated [DATE] and signed by the facility Administrator revealed that CNA #1 was interviewed and asked why she had not revealed, on her initial interview, that the foot of Resident #1 had gotten caught under the bar of the lift on [DATE]. CNA #1 stated "I don't know." The statement continued "When asked if she knew how serious this was keeping this from us, she replied, "I didn't know she was hurt." "I reminded her of earlier statement that Resident #1 cried out and I couldn't understand why she didn't think she was hurt. CNA #1 said, "she didn't complain any the rest of the shift ..." Review of the "General Orientation Checklist" from the personnel file for CNA #1 revealed that the "General Purpose: This checklist outlines the information which each new employee will want to become familiar with during his/her induction period. Orientation by Department Head or Director Include:". The "On-the-Job Training Includes Detailed Explanation of:" section was "Resident Transfer and Lift Program". This was dated [DATE]. The second page of this checklist included a statement that "I understand the Orientation Checklist and its requirements and that I am expected to complete the duties as assigned. I understand the job functions may be altered at any time." This was signed by CNA #1 on [DATE], two days before it was documented that the orientation was provided. Review of the "General Orientation Checklist" from the personnel file for CNA #2 revealed that the "General Purpose: This checklist outlines the information which each new employee will want to become familiar with during his/her induction period. Orientation by Department Head or Director Include:". The "On-the-Job Training Includes Detailed Explanation of:" section was "Resident Transfer and Lift Program". This was dated [DATE]. The second page of this checklist included a statement that "I understand the Orientation Checklist and its requirements and that I am expected to complete the duties assigned. I understand the job functions may be altered at any time." This was signed by CNA #2 on [DATE], 12 days before it was documented that the orientation was provided. Interview on [DATE] at 3:05 p.m., with the Human Resource staff, confirmed that the orientation checklist was signed by CNA #1 and CNA #2 prior to the date documented as the actual date that the orientation was provided. Interview on [DATE] at 9:25 a.m., with the CNA Supervisor, revealed that she had noticed a Sit-to-Stand lift without a foot plate. She remembered that it was the same lift that had a new wheel. She had shown it to the Environmental Supervisor and that together the two of them had taken the lift to the Maintenance Supervisor to have the foot plate replaced. The CNA Supervisor remembers the Maintenance Supervisor as saying "Oh, I forgot". The CNA Supervisor does not remember the date of this incident. On [DATE] at 3:48 p.m., with the assistance of the Maintenance Supervisor, all of the Sit-to-Stand lifts were observed and each had the foot plate in place. Interview on [DATE] at 9:45 a.m., with the Environmental Supervisor, confirmed that the CNA Supervisor had pointed out to her that the foot plate was missing from a lift and that the two of them took it to the Maintenance Supervisor for repair. This staff remembers the Maintenance Supervisor saying I'm going to fix that. She does not remember the date of this incident. Interview on [DATE] at 4:40 p.m., with the Maintenance Supervisor, revealed that he did remember someone pushing a Sit-to-Stand lift up to him and asking him to replace the foot plate. There was no record of the foot plate being replaced but the evidenced of a rear wheel being replaced on [DATE] on the #4 lift was provided by the Maintenance Supervisor. Review of the facility's policy "Sit-to-Stand Lifts", not dated, documented "The Sit to Stand Lift is to assist weight-bearing resident, when standing and toileting, and for use as a short distance resident transfer aid." Review of a "Personnel Termination/Leave Notice", dated [DATE], revealed that CNA #1 was discharged secondary to "Withheld information during course of incident investigation, did not adhere to policy & procedure; carelessness".