Every finding on record at Willowbrook Post Acute

Based on interview and record review, the facility failed to notify the resident's representative of the resident's transfer from the facility for 1 of 3 residents reviewed for change of condition (#3). This placed residents and residents' representatives at risk for not being able to contact each other. Findings include:Resident 3 admitted to the facility in 2/2026 with a diagnosis including respiratory failure.On 3/28/26 at 7:46 AM, Staff 14 (LPN) documented a progress note that Resident 3 was sent to the hospital at his/her request for not feeling well. There was no documented evidence that Resident 3's representative was notified of the transfer.On 4/21/26 at 10:08 AM and 2:52 PM, attempts to interview Staff 14 were unsuccessful.On 4/20/26 at 2:39 PM, Witness 1 (Family Member) stated the facility did not notify her of Resident 3's transfer to the hospital. She stated they were notified on 3/29/26 by a neighbor, who was contacted by the hospital.On 4/21/26 at 3:02 PM, Staff 2 (DNS) stated the facility did not notify Resident 3's representative of her/his transfer to the hospital and should have.The deficient practice was identified as past noncompliance based on the following: On 3/30/26 the deficient practice was identified by the facility when the facility completed a root cause analysis of the incident and determined the notification was not completed. Correction included: 1. Staff educated on notification policy for changes of condition; 2. All staff were educated on the use of an approved phone script to ensure accurate and appropriate communication; and 3. The phone script was posted by all phones for ease of use.

Based on observation, interview, and record review it was determined the facility failed to ensure a resident did not self-administer non-prescribed medications for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk for incorrect medication administration. Findings include:Resident 2 admitted to the facility in 5/2024 with diagnoses including hemiplegia (one-sided paralysis).Resident 2's 11/13/25 Self-Medication Administration Evaluation indicated she/he was not appropriate to self-administer any medications.Observation on 3/19/26 at 7:50 AM, with Staff 7 (RNCM) observed open tubes of antifungal cream, anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) located in Resident 2's bedside table drawer. Review of Resident 2's clinical record found no physician orders for the anti-itch cream, hydrocortisone cream or DMSO. Resident 2 did not have an order to self-administer the medications.On 3/19/26 at 7:50 AM, Staff 7 stated Resident 2 did not have an order to for any of the medications observed in the resident's bedside table drawer. On 3/19/26 at 8:10 AM, Resident 2 stated she/he did self-administer the medications found in her/his room.

Based on observation, interview, and record review it was determined the facility failed to ensure the resident was adequately monitored, had an adequate indication for use, and physician orders for medications for 1 of 3 sampled residents (#2) reviewed for medications. This placed residents at risk for adverse medication side effects of unnecessary medications. Findings include:Resident 2 admitted to the facility in 5/2024 with diagnoses including hemiplegia (one-sided paralysis). Resident 2's 11/13/25 Self-Med Administration evaluation indicated she/he was not appropriate to self-administer any medications. An observation on 3/19/26 at 7:50 AM, with Staff 7 (RNCM) observed an open tube of anti-itch cream, hydrocortisone cream, and a medicated pain roll-on (DMSO) in Resident 2's bedside table drawer. Review of Resident 2's clinical record found no evidence of physician orders, indication of use, or monitoring for the anti-itch cream, hydrocortisone cream and the DMSO. On 3/19/26 at 7:50 AM and 9:03 AM, Staff 7 stated Resident 2 did not have an order for the anti-itch cream, hydrocortisone cream or DMSO, and staff did administer or monitor for the medications. On 3/19/26 at 8:10 AM, Resident 2 stated she/he self-administered the medications found in her/his room.

Based on observation, interview and record review it was determined the facility failed to store and handle food in a sanitary manner in 1 of 1 kitchen and 2 of 2 snack refrigerators. This placed residents at risk for food borne illness. Findings include:The facility's Personal Hygiene, Food Handling and Storage Policy dated 8/2024 revealed the following:- Individuals handling food must practice good personal hygiene to minimize the risk of contaminating food and causing foodborne illness. Food storage areas shall be maintained in a clean, safe, and sanitary manner.- Hairnets, hats, or coverings are required at all times, [including] beard guards/masks for facial hair longer than trimmed eyebrows. Hair must be fully contained; only functional accessories allowed.- Food Services, or other designated staff, will maintain clean food storage areas at all times. - Food shall be rotated as delivered and used in a First In, First Out method. Items will be dated on receipt to facilitate this procedure.- Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will be tightly sealed with plastic wrap, foil, or a lid.- Cold foods will be maintained at temperatures of 40*F or below. Hot foods or potentially hazardous food will leave the kitchen or steam table at 140*F or above. Frozen foods will be stored at 0*F or below at all times.- The Food Services Manager, or his/her designee, will check refrigerators and freezers daily for proper temperatures. The Food Services Manager will maintain records of such information.The facility's Resident Food from Outside Source Policy dated 8/2024 revealed the following: - Refrigerated food items from an outside source is stored in a container with the following information on it: date product received, name of product, resident name and room number. - Refrigerated foods that are unlabeled or undated, when noted, is discarded. 1. The following items were observed in the facility's kitchen and pantry areas from 8/18/25 at 9:00 AM and 9:56 AM:Freezers:- Unlabeled lightly colored patties with no date.- Two empty dinner plates.- Unlabeled and undated frozen waffles in bags. - Multiple bags of unlabeled and undated orange vegetable sticks.- Unlabeled and undated yellow patties in a bag. - A bag of opened corn, not labeled or dated.- Garlic toast with plastic bag twisted, not labeled or dated.- Freezer burn on a frozen piece of meat, partially opened out of its plastic wrap.- A product labeled turkey leg, dated 4/19, with a hole in its plastic wrap with freezer burn.- Freezer temperature logs were reviewed from 8/1/25 through 8/17/25 and there were 28 instances where the temperature logs were blank. Refrigerators: - Empty apple juice pitcher dated 8/15.- Refrigerator temperature logs were reviewed from 8/1/25 through 8/17/25 and there were 11 instances where the temperature logs were blank.Pantry:- Four bags of rice crispy cereal in a plastic container with no date or expiration on the bags. The label on container read: R. Bran 5/29 and Cheerio 5/29. - Two bags of rice crispy cereal sat on a shelf with no label, date, or label of expiration.- One dented can of tomato sauce was on a shelf.General kitchen: - Stainless-steel container partially filled with cornbread sitting on kitchen counter. The foil did not completely cover the product and was not labeled or dated. On 8/18/25 at 9:45AM, Staff 12 (Dietary Manager) stated she did not know what the unlabeled items in the freezers were. She acknowledged the freezer burned items and stated she expected staff to wrap meat properly for storage and any items with freezer burn to be thrown out. Staff 12 acknowledged the empty pitcher in the refrigerator and stated she expected for empty pitchers that formerly contained juice to be cleaned and sanitized before the next fill and not stored in refrigerators. Staff 12 acknowledged the unlabeled bags of rice crispy cereal and dent in the can of tomato sauce. She stated she expected all items to be labeled upon receipt, labeled when opened, and expiration date to be visible. She stated the dented can was expected to be taken out of the pantry. Staff 12 stated the unlabeled and undated cornbread sitting on the kitchen counter was not served with breakfast on 8/18/25 and was not sure how long it had been sitting on the counter and acknowledged it should have been thrown away. Staff 12 acknowledged the lack of recorded temperature logs for the freezers and refrigerators and stated she expected for temperature logs to be recorded twice a day in order to maintain appropriate food temperatures for residents. Staff 12 stated there was no system in place to audit the refrigerators, freezers, and pantry for cleanliness and quality. She stated staff had taken items out of boxes and placed them into refrigerators, freezers, and onto shelves with no labeling system in place.2. On 8/18/25 at 9:42 AM, the snack refrigerator in the pantry area contained a partially filled pitcher of liquid dated 7/20.On 8/19/25 at 2:58 PM, the snack refrigerator in the ice machine room had a container of wrinkled, unlabeled and undated cherub tomatoes. There were no temperature logs on or around the refrigerator.On 8/18/25 at 9:45 AM, Staff 12 (Dietary Manager) acknowledged the pitcher of liquid dated 7/20 and stated she expected for dietary staff to remove pitchers from the refrigerator within five days of the labeled date. She stated there was no system in place to clean out and inspect quality for the snack refrigerator in the pantry. On 8/21/25 at 10:40 AM, Staff 12 acknowledged the lack of a temperature log for the snack refrigerator in the ice machine room. Staff 12 stated she was not aware of any systems in place for staff to audit, clean, or ensure quality of the snack refrigerator in the ice machine room.3. On 8/19/25 at 2:58 PM and 8/20/25 at 9:25 AM, the inside of the ice scoop holster located on the ice machine was observed to have a 2-inch by 1/4-inch black and slimy substance where the ice scoop rested.On 8/19/25 at 3:05 PM, Staff 48 (CNA) stated she had never looked inside of the ice scoop holster. She confirmed the inside of the holster was not clean and stated housekeeping staff usually took care of cleaning the holster.On 8/20/25 at 9:22 AM, the ice machine cleaning sheet had the following information: - January: 1/20/25 (blank comments)- February: 2/27/25 (Deep clean)- March: 3/26/25 (blank comments)- April: 4/30/25 (blank comments)- May: 5/23/25 (Deep cleaned)- June: 6/16/25 (blank comments)- July: 7/30/25 (Deep cleaned)- August: 8/19/25 (blank comments)On 8/20/25 at 9:25 AM, Staff 49 (Maintenance Aide) looked inside of the ice scoop holster, confirmed it was not clean and didn't look good. He stated it was the responsibility of maintenance staff to clean the machine each month, which included ensuring the inside of the ice scoop holster was clean. Staff 49 observed the cleaning sheet and acknowledged the ice machine was cleaned on 8/19/25, but was not sure why the holster was not checked.4. On 8/18/25 at 9:08 AM, Staff 36 (Dietary Aide) was observed to have a hairnet on which did not cover her bangs. Her bangs were long enough to cover her forehead.On 8/19/25 at 2:30 PM, Staff 36 was observed whisking powder into a gravy. She had a hairnet on that did not cover her bangs. Staff 36 adjusted her hairnet to cover her bangs and stated she thought the expectation was to just have the hairnet on top of her head but was unaware the hair net was to cover her bangs.On 8/20/25 at 8:44 AM, Staff 37 (Dietary Aide) was observed using a knife to chop cauliflower on the counter. He was wearing a cap to cover his hair, but had no beard covering on his face. His beard hair appeared to be approximately half an inch long.On 8/20/25 at 9:02 AM, Staff 12 (Dietary Manager) stated she was aware of the requirement to wear hairnets but did not have beard restraints for staff who had facial hair. Staff 12 stated Staff 37 just started working the morning of 8/20/25 and she did not go over expectations of the kitchen with him. She stated Staff 1 or Staff 11 would have gone over kitchen expectations with new employees.On 8/20/25 at 9:10 AM, Staff 11 (Human Resources) stated she did not go over duty-related expectations with employees based on their job classification.On 8/20/25 at 10:29 AM, Staff 1 (Administrator) stated he expected for Staff 12 to explain and enforce kitchen expectations with dietary staff, including hair and beard restraints.5. On 8/20/25 at 11:42 AM, Staff 36 (Dietary Aide) was observed serving food from the steam table. At 12:06 PM, the cooked foods temperature log on 8/20/25 for breakfast and lunch were observed to be blank.On 8/21/25 at 11:34 AM, the cooked foods temperature log on 8/21/25 for breakfast and lunch were completed. Staff 36 was observed plating and serving food from the steam table. The temperature logs for leaving the steam table could not be located.On 8/20/25 at 12:06 PM, Staff 12 (Dietary Manager) acknowledged the cooked foods temperature had not been logged for 8/20/25 for breakfast and lunch. She stated when food was cooked, the temperatures were checked but staff had forgotten to keep record.On 8/21/25 at 11:35 AM, Staff 12 stated kitchen staff only checked temperatures immediately after cooking before being placed on the steam table and leaving the kitchen. When asked how staff ensured temperatures on the steam table remained appropriate, she did not provide an answer.6. On 8/20/25 at 12:04 PM, clean dishes were observed to be on a rack directly underneath a vent which had dark dust and cobwebs. A fan was observed to be blowing toward the dishes and dishwashing area. The fan also had dark dust and cobwebs.On 8/20/25 at 12:04 PM, Staff 12 (Dietary manager) stated it was the responsibility of the maintenance team to clean the vents and fans. She acknowledged the unclean vent directly above the clean dishes and the dirty fan blowing towards the sink and clean dishes. She stated she expected staff to inform maintenance when vents and fans needed to be cleaned. Staff 12 stated she was unaware of a system in place to ensure the vents and fans were clean.On 8/21/25 9:21 AM, Staff 1 (Administrator) stated he expected the vent and fans in the kitchen to be clean and free from dust and cobwebs.

Based on observation, interview, and record review it was determined the facility failed to ensure proper storage temperatures were logged and maintained for 1 of 1 medication refrigerator reviewed for medication storage. This placed residents at risk for degradation and reduced efficacy of biologicals and medication. Findings include:The 7/2025 and 8/2025 medication refrigerator temperature logs indicated the temperatures were to be logged twice daily and the temperatures were to be between 36 F and 46 F. The temperature logs indicated the following:-15 occasions when the temperature was checked one time or less.-12 occasions when the temperature was less than 36 F. On 8/19/25 at 2:53 PM Staff 17 (RN) stated refrigerator temperatures should be checked and documented on the log by a nurse twice daily to ensure it was completed and temperatures were in the appropriate range. On 8/20/25 at 8:04 AM Staff 15 (RN) stated refrigerator temperatures should be checked and recorded on the log by a nurse every shift. Staff 15 stated if the temperature was out of range, she/he would adjust the thermometer and recheck later. On 8/20/25 at 10:29 AM Staff 7 (Environmental Services Director) stated the medication refrigerator temperatures should be monitored and recorded by nurses each shift and they were to notify him of readings that were out of range. Staff 7 stated the refrigerator temperature was running low over the past couple of weeks and acknowledged there were multiple temperature readings below 36 F.On 8/20/25 at 11:21 AM Staff 2 (DNS) acknowledged the identified dates on the logs when the temperatures were out of range and the temperatures were not checked twice daily.

Based on observation, interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for lack of ADL care needs. Findings include: On 8/18/25 the facility had a census of 53 residents. On 8/20/25, Staff 1 (Administrator) provided a list of residents who:-Required two-person mechanical lift transfers: 12;-Required two-person extensive or total assistance for bathing: 1; -Required two-person extensive or total assistance for toileting: 10;-Required two-person extensive or total assistance for dressing: 1;-Required one-to-one feeding assistance: 7;-Were considered high fall risks: 30;-Were considered at risk for elopement: 4 and -Required bariatric care (body mass index greater than 40): 10. 1. Resident 3 was admitted to the facility in 3/2025 with diagnoses including a stroke and dysphagia (difficulty swallowing foods and liquids). Resident 3's 3/18/25 admission MDS indicated the resident had severe cognitive impairment and was dependent for all care needs including toileting and bed mobility. Resident 3's 6/7/25 fall investigation report indicated the resident had a fall on 6/7/25, night shift and only two CNA staff were on shift when Resident 3 fell. On 8/18/25 at 3:54 PM and 8/19/25 at 2:22 PM, Witness 2 (Family Member) stated the facility did not usually have enough staff scheduled and on 6/7/25 night shift, when Resident 3 fell, the facility was short-staffed. On 8/20/25 at 8:58 AM, Staff 27 (CNA) reported he worked on 6/7/25 with Staff 26 (CNA) and stated two CNAs were not enough staff to meet the needs of the residents because the facility is big and the acuity of the residents was too high for only two CNA staff. On 8/20/25 at 9:10 AM, Staff 26 stated on 6/7/25 there were only two CNAs working in the facility for 50 residents thus they were not able to meet the acuity needs of the residents. On 8/21/25 at 11:12 AM, Staff 2 (DNS) and Staff 3 (RNCM) verified on 6/7/25, the facility only had two CNA staff on night shift, and confirmed the facility was short-staffed. 2. Random observations from 8/18/25 through 8/22/25 between the hours of 7:30 AM and 10:00 PM revealed the following: -No call light monitors were observed in the residents' units/hallways. There was one call light monitor located at the nurses' station which was inaudible. On 8/19/25 at 2:54 PM, the call light monitor at the nurses' station was not functioning. -On 8/19/25 at 2:54 PM, room [ROOM NUMBER]'s call light was activated for 34 minutes and room [ROOM NUMBER]'s call light was activated for 30 minutes. -CNA staff were to carry electronic call light activation devices, and some CNAs did not have electronic call light activation devices on their person when randomly asked to produce the device.-On multiple occasions during day and evening shift observations, CNA staff were difficult to find. -On 8/19/25 at 3:01 PM, a resident on the 200 unit was visible from the hallway, naked and was hollering, gotta moment? Multiple staff walked by the resident's room without stopping to assist the resident. -On 8/20/25 at 8:22 PM, a resident was outside in the parking lot with a CNA, yelling help me, help me, help me. -On 8/20/25 at 8:33 PM, room [ROOM NUMBER]'s call light was activated for 47 minutes, room [ROOM NUMBER]'s call light was activated for 30 minutes, room [ROOM NUMBER]'s call light was activated for 28 minutes and room [ROOM NUMBER]'s call light was activated for 22 minutes. -On 8/20/25 at 8:55 PM, two residents were in wheelchairs on the 300 unit and verbalized they were waiting for assistance to go to bed for at least 45 minutes. On 8/18/25 at 9:45 AM, Resident 26 stated she/he required two staff to assist with all ADL care. Resident 26 stated it took anywhere from 30 minutes to two hours to find two staff available to assist with her/his ADL care. Resident 26 stated the night shift was the worst shift. On 8/18/25 at 11:03 AM, Resident 20 stated she/he was incontinent and sometimes it took what feels like hours before staff were available to assist her/him. On 8/18/25 at 1:13 PM, Resident 4 stated call light response times were frequently slow, especially during mealtimes. Resident 4 stated she/he sometimes waited up to two hours for assistance. Resident 4 stated she/he feared something might happen to her/him and nobody would be available to help. On 8/18/25 at 1:21 PM, Resident 18 stated last week it took staff 58 minutes to assist her/him. Resident 18 stated staff often answered her/his call light, said they would be right back and never returned. On 8/20/25 at 9:41 AM, Staff 22 (CNA) stated the facility had many CNA staff who called off, frequently. Staff 22 stated the facility was chronically low staffed which resulted in residents' not receiving proper care. Staff 22 stated during times when the facility was short staffed, residents' showers were missed, call light response times were longer, and staff had to stay past their shift to complete all of their work. On 8/20/25 at 10:18 AM, Staff 15 (RN) stated there were often days when CNAs called off or were habitually late which resulted in inadequate staffing. Staff 15 stated the facility did not staff according to the acuity needs of residents. On 8/20/25 at 10:45 AM, Staff 28 (CNA) stated staffing was horrible and there was often not enough staff scheduled to meet the acuity needs of the residents. Staff 28 stated there was a resident with behavioral needs who often tried to get out of the facility or tried to kiss other residents so the resident required a lot of time to supervise. Staff 28 stated there were times when showers were missed, CNA staff could not complete their rounds or turn residents every two hours and staff were unable to take lunches or breaks. On 8/20/25 at 8:43 PM, Staff 32 (CNA) stated care was difficult at times due to the number of bariatric residents. On 8/20/25 at 9:30 PM, Staff 35 (CMA) stated staffing on the weekends was the worst. Staff 35 stated call light response times were often long because CNAs were unable to get to them timely. Staff 35 stated there were a lot of behavioral need residents and residents at a high risk for falls. Staff 35 stated showers were missed, at times. On 8/21/25 at 10:01 AM, Staff 25 (Regional Director of Rehabilitation) confirmed some residents did not receive SLP and OT rehabilitation services timely or at the frequency determined to be necessary because they did not have adequate SLP and OT staff coverage. On 8/21/25 at 11:35 AM, Staff 11 (Human Resources/Payroll/Staffing) stated she was responsible for staffing and staffing needs were based on the State mandatory minimum CNA staffing ratios and not according to the acuity needs of residents. Staff 11 stated she was aware the facility resident acuity levels were high. Staff 11 stated many staff called off and it was difficult to get agency coverage. Staff 28 confirmed the facility was not able to staff to the acuity needs of the residents because they did not have enough employees and agency staff were not available. Staff 28 also verified weekend staffing was especially difficult. 3. Resident 30 was admitted to the facility in 2024 with diagnoses including a stroke and anxiety. A 5/13/25 Annual MDS revealed Resident 30 had a BIMS score of 15, which indicated she/he was cognitively intact, had an indwelling catheter and an ostomy (an appliance worn over the stoma, which is a surgically created opening on the abdomen surface to collect feces). On 8/18/25 at 2:16 PM, Resident 30 stated she/he required assistance with ostomy care and on multiple occasions, her/his ostomy bag had blown out due to insufficient staffing, resulting in a mess on her/him and while in bed. Resident 30 stated she/he was upset and frustrated because there is never enough staff on evening shift. On 8/19/25 at 10:02 AM, Staff 18 (CNA) stated Resident 30 required assistance with the resident's ostomy care and at times the resident's ostomy bag had blown out due to staffing shortages. On 8/20/25 at 1:51 PM, Staff 23 (CNA) stated Resident 30 required assistance with ostomy care and there had been instances when staff were unable to get to respond in a timely manner, resulting in the resident's bag exploding. Staff 23 stated the resident voiced concerns within the past two weeks regarding inadequate ostomy care during evening shift. On 8/20/25 at 7:00 PM, Staff 19 (RN) stated Resident 30 was particular about her/his ostomy care due to concerns about odor and fear of leakage or bursting. Staff 19 stated within the past last two weeks, the resident's ostomy bag exploded during the evening shift due to lack of staff. Staff 19 stated Resident 30 was very upset after experiencing a bowel movement all over herself/himself and in her/his bed. Staff 19 stated this was a direct result of inadequate staffing based on resident acuity. a. On 8/20/25 at 8:36 PM, Resident 30 was observed in her/his motorized wheelchair just outside her/his doorway and stated her/his call light was on for approximately 20 minutes and the resident was waiting for assistance to go to bed. Resident 30 stated there never was enough staff on evening shift. At 9:11 PM (approximately 60 minutes later) Staff 33 (CNA) assisted the resident to bed. On 8/21/25 at 2:42 PM, Staff 3 (RNCM) stated she was unaware of Resident 30's concerns regarding timely ostomy care. Staff 3 stated staff were expected to answer call lights within five to 10 minutes. Staff 3 acknowledged ongoing staffing challenges and confirmed the facility had residents with high acuity needs. On 8/22/25 at 9:34 AM, Staff 2 (DNS) stated she expected all staff to respond to call lights within 15 minutes and acknowledged the facility struggled to maintain appropriate staffing levels. Staff 2 acknowledged many residents with high acuity care needs. 4. Resident 9 was admitted to the facility on 6/2025 with diagnosis including Parkinsons and difficulty walking. The Dementia Cognitive Loss CAA dated 6/11/25 revealed Resident 9 had severe cognitive impairment and metabolic encephalopathy (the brain is not functioning properly due to a chemical imbalance.) On 8/20/25 at 2:32 PM, Staff 24 (CNA) and Staff 28 (CNA) both stated Resident 9 was a fall risk, experienced confusion, required two-person assistance with transfers and was dependent on staff for all ADL care needs. Staff 24 and Staff 28 indicated the facility was often severely understaffed during evenings and weekends and both were assigned beyond the state minimum staffing ratios. On 8/20/25 at 8:33 PM, Resident 9 was observed up in her/his wheelchair sitting outside her/his room. At 8:45 PM, Staff 31 (LPN) spoke with Resident 9 who stated she/he needed to use the bathroom and wanted to go to bed. Staff 31 requested assistance for Resident 9 and was informed the assigned CNA was providing a shower to another resident. At 9:16 PM, two staff members assisted Resident 9 into her/his bedroom and closed the door. At 9:33 PM, (approximately 45 minutes later), the resident was in bed, with the bed in the lowest position and call light within reach. On 8/20/25 at 9:36 PM Staff 47 (CNA) stated evening shifts were rough. Staff 47 stated it was difficult assisting residents and responding to call lights in a timely manner. Staff 47 stated residents were upset due to long wait times and inadequate staffing. Staff 47 stated multiple residents in the facility required two-person assistance or were fully dependent on staff for ADL care needs. On 8/21/25 at 2:42 PM, Staff 3 (RNCM) stated staff were expected to answer call lights within five to 10 minutes. Staff 3 acknowledged staffing concerns and the facility had residents with high acuity needs. On 8/22/25 at 9:34 AM, Staff 2 (DNS) stated she expected all staff to answer call lights within 15 minutes and acknowledged the ongoing challenges in maintaining appropriate staffing levels. Staff 2 acknowledged the facility had many residents with high acuity care needs. 5. During a Resident Council meeting on 8/20/25 at 1:05 PM, attendees expressed concerns regarding long response times from staff during the evening shift. Resident Council meeting minutes from 5/22/25 concerns with call lights not being answered and staff not coming back after initial response. Resident Council meeting minutes from 6/2025 revealed concerns with staff taking two hours to answer call lights. On 8/22/25 at 9:34 AM, Staff 2 (DNS) stated she expected all staff to answer call lights within 15 minutes and acknowledged the ongoing challenges in maintaining appropriate staffing levels. Staff 2 acknowledged the facility had many residents with high acuity care needs.

Based on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5 percent. There were eight errors out of 30 opportunities resulting in a 26.67 percent error rate. This placed residents at risk for adverse medication side effects and pain. Findings include: Resident 9 was admitted to the facility in 6/2025 with diagnoses including Parkinson's Disease (a disorder of the central nervous system). Resident 9's 6/11/25 admission MDS indicated the resident had significant cognitive impairment.Resident 9's 8/2025 MAR indicated Resident 9 was to receive:- Carbidopa/levodopa (a medication for Parkinson's Disease) 25-100 mg TID - Allopurinol (medication for gout) 300 mg in the morning- Aspirin (medication for irregular heart rate) 81 mg in the morning- Cholecalciferol (a vitamin) 25 mcg in the morning- Finasteride (medication for an enlarged prostate) 5 mg in the morning- Senna (a laxative) 8.6 mg BID- Furosemide (medication for fluid retention) 40 mg in the morning- Metoprolol (medication for irregular heart rate) ER 100 mg in the morningThe 8/20/25 MAR indicated the morning medications were due at 7:00 AM and were not administered until 9:06 AM. On 8/20/25 at 9:06 AM Staff 15 (RN) was observed to administer the morning doses of carbidopa/levodopa, allopurinol, aspirin, cholecalciferol, finasteride, senna, furosemide and metoprolol to Resident 9. On 8/20/25 at 9:12 AM Staff 15 acknowledged the late administration of carbidopa/levodopa, allopurinol, aspirin, cholecalciferol, finasteride, senna, furosemide and metoprolol for Resident 9. On 8/20/25 Staff 2 (DNS) acknowledged the identified medication errors due to the late administration of morning medications for Resident 9 on 8/20/25.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 3 of 3 sampled residents (#'s 31, 35 and 46) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration and adverse medication side effects. Findings include: 1. Resident 35 was admitted to the facility in 5/2023 with diagnoses including dementia. Resident 35’s 5/19/25 Annual MDS indicated the resident had moderate cognitive impairment. Observations on 8/18/25 at 11:02 AM and 8/19/25 at 8:45 AM revealed Resident 35 had antifungal powder and antifungal lotion on her/his bedside table. Review of Resident 35’s health record revealed no self-administration of medication assessment was completed to determine the resident’s ability to safely self-administer antifungal powder or antifungal lotion. On 8/19/25 at 1:28 PM Staff 18 (CNA) confirmed Resident 35 had both antifungal powder and lotion on her/his bedside table and removed the medicated powder and lotion from the room for disposal. Staff 18 stated residents should not have medications at the bedside. On 8/19/25 at 1:38 PM Staff 19 (RN) stated residents were assessed and needed physician orders in place for self-administration of medications. Staff 19 acknowledged medications should not be kept at the bedside for self-administration without an assessment. On 8/19/25 at 2:22 PM Staff 3 (RNCM) acknowledged residents required an assessment for safe self-administration of medications and treatments. Staff 3 confirmed Resident 35 was not assessed to safely self-administer medications, and the medications were not left in her/his room. 2. Resident 46 was admitted to the facility in 2/2025 with diagnoses including bipolar disorder (a mood disorder). Resident 46’s 5/21/25 Quarterly MDS indicated the resident had moderate cognitive impairment. Observations on 8/18/25 at 9:40 AM and 8/19/25 at 1:10 PM revealed Resident 46 had antifungal powder on her/his bedside table. Review of Resident 46’s health record revealed no self-administration of medication assessment was completed to determine the resident’s ability to safely self-administer antifungal powder. On 8/19/25 at 1:13 PM Staff 20 (CNA) confirmed Resident 46 had antifungal powder on her/his bedside table. Staff 20 stated the facility kept antifungal powder at the bedside for residents who needed it, and staff helped them apply the powder as part of their care. On 8/19/25 at 1:38 PM Staff 19 (RN) stated residents were assessed and needed physician orders in place for self-administration of medications. Staff 19 acknowledged medications should not be kept at the bedside for self-administration without an assessment. On 8/19/25 at 2:22 PM Staff 3 (RNCM) acknowledged residents required an assessment for safe self-administration of medications and treatments. Staff 3 confirmed Resident 46 was not assessed to safely self-administer medications, and the medications were not left in her/his room. 3. Resident 31 was admitted to the facility in 12/2021 with diagnoses including dementia and gastroparesis (a stomach disorder that significantly slows or stops the movement of food from the stomach to the small intestine). Resident 31's 12/30/24 Annual MDS indicated she/he had moderate cognitive impairment. No evidence was found in Resident 31's health record to indicate she/he had a doctor's order or was approved to self-administer medications. On 8/18/25 at 10:15 AM a plastic cup containing a white powder was observed on Resident 31's bedside table. The words, Gold Bond medicated powder were written on the outside of the cup. On 8/18/25 at 10:15 AM Resident 31 stated she/he did not know who left the powder on her/his table. 8/18/2025 10:55 AM Staff 19 (RN) acknowledged the cup of powder at Resident 31's bedside and stated she was aware Resident 31 had an order for the powder but stated she/he did not have an order to self-administer the medicated powder. On 8/19/25 at 1:20 PM Staff 41 (CNA) stated she notified the medication aide or the nurse if she saw medications at a resident's bedside. Staff 41 stated she didn't usually see pills, but she did see nystatin powder (a topical antifungal medication used to treat skin and mucocutaneous fungal infections) and barrier creams on residents' bedside tables. On 8/19/25 at 1:38 PM Staff 19 stated residents were not allowed to keep medications in their rooms without having a physician's order and without being evaluated to self-administer the medication. Staff 19 stated it was unsafe because residents might use them incorrectly or ingest them. On 8/19/25 at 1:46 PM Staff 3 (RNCM) stated it was a safety concern for Resident 31 to have medications in their rooms without a physician's order and without an evaluation to ensure the resident was able to self-administer the medication safely. Staff 3 stated if she found medications in Resident 31's room she would remove the medications, request an order from the physician and complete a self-administration evaluation.

Based on interview and record review it was determined the facility failed to protect the resident's right to be free from abuse by another resident for 1 of 7 sampled residents (#17) reviewed for abuse. This placed residents at risk for abuse. Findings include:Resident 17 was admitted to the facility in 12/2017 with diagnoses including vascular dementia (impaired reasoning, planning, judgment, memory and other thought processes caused by impaired blood flow to the brain) and peripheral vascular disease (a condition that affects the blood vessels outside of the heart and brain and primarily involves the narrowing or blockage of arteries that supply blood to the legs, arms, stomach, or kidneys).Resident 17's 12/31/24 annual MDS indicated a BIMS was not completed due to her/his refusal to participate in the assessment.Resident 17's cognition care plan indicated she/he refused to participate in a standardized cognitive evaluation and staff were unable to assess her/his level of cognition.Resident 63 was admitted to the facility in 3/2025 with diagnoses including a femur fracture and Alzheimer's disease.Resident 63's 3/13/25 admission / Medicare - 5 Day assessment revealed she/he had severe cognitive impairment and exhibited physical and verbal behaviors on a daily basis. A cognitive loss / dementia CAA completed with her/his admission assessment indicated she/he scratched and hit staff members and her/his goal was to return to a memory care facility after completing her/his therapy goals.A review of Resident 63's care plan revealed staff were to monitor her/him for acts of physical aggression toward staff.A FRI completed on 3/31/25 revealed Resident 63 wandered into Resident 17's room on 3/30/25 and told her/him to get out of her/his bed then pinched Resident 17 on the wrist which caused two small bruises to Resident 17's wrist. The FRI concluded the facility substantiated abuse of Resident 17 by Resident 63.On 4/1/25 Staff 5 (Social Services Director) submitted a written statement with a summary of the incident. In her statement, Staff 5 indicated Resident 17 pointed to the bruises on her/his wrist and stated, Look what that crazy [resident] did and Just keep [her/him] away from me. In her statement, Staff 5 concluded resident-to-resident abuse occurred. On 8/21/25 at 7:45 AM Staff 38 (CNA) stated he remembered the incident and Resident 17 showed him the bruises on her/his wrist the day after the incident. Staff 38 stated he and other CNAs kept Resident 17 and Resident 63 separate after the incident on 3/30/25 to avoid any other incidents.On 8/21/25 at 8:17 AM Staff 5 stated she remembered the incident and staff placed a temporary stop sign on Resident 17's door to discourage Resident 63 from entering without permission and possibly having another incident.On 8/21/25 at 2:57 PM Staff 32 (CNA) stated she remembered the incident and said Resident 63 was pretty aggressive and wandered into Resident 17's room, grabbed her/him and wouldn't let her/him go.On 8/22/25 at 9:09 AM Staff 40 (CNA) stated he remembered the incident on 3/30/25 and heard Resident 17 hollering out and found her/him crying in her/his doorway with Resident 63. Staff 40 stated he helped Resident 63 back to her/his room while a nurse assessed Resident 17. Staff 40 stated Resident 63 swatted at but never hit other residents when she/he was uncomfortable with them. Staff 40 stated Resident 63 did not have a one-on-one at the time of the incident and he did not know if she/he ever had a one-on-on after the incident.On 8/22/25 at 11:32 AM Staff 1 (Administrator) acknowledged the incident on 3/30/25 with Resident 17 and Resident 63. Staff 1 stated all residents should be free from aggressive behaviors, including pinching. Staff 1 stated he expected staff to monitor residents who demonstrate behaviors to limit the possibility of them escalating to the level of abuse.

Based on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of resident property for 1 of 1 sampled resident (#26) reviewed for misappropriation of controlled pain medication. This placed residents at risk for unmanaged pain. Findings include:Resident 26 was admitted to the facility in 6/2024 with diagnoses including infection of the abdominal wall.Resident 26's 6/11/25 Annual MDS indicated the resident was cognitively intact.Resident 26's 11/2025 MAR indicated the resident was to have oxycodone 2.5 mg (a Schedule II controlled pain medication) every four hours as needed for pain. The facility's investigation dated 11/20/24 included the following:- During a routine narcotic count it was discovered a card of oxycodone belonging to Resident 26 was missing.- It was determined the CMAs and nurses on the night shift were not counting the narcotic drawer properly.- The facility took immediate action to ensure narcotics were counted correctly.- The facility determined misappropriation of Resident 26's personal property occurred, and the claim was substantiated.On 8/19/25 at 9:39 AM Resident 26 stated she/he had not missed any needed oxycodone doses since admission to the facility, and she/he was not aware of any missing oxycodone. On 8/20/25 at 11:03 AM Staff 16 (CMA) stated while performing a narcotic count at shift change, he noticed a card of oxycodone was missing for Resident 26. Staff 16 stated they had reported the incident to a nurse, and the card was not found. On 8/20/25 at 12:17 PM Staff 3 (RNCM) stated a card of Resident 26's oxycodone was missing and not found. Staff 3 stated an investigation was conducted and concluded the narcotic drawer was not counted properly, and the card was likely thrown away by mistake. Staff 3 stated a corrective plan was implemented over the following six weeks. The deficient practice was identified as Past Noncompliance based on the following:On 11/21/24 the deficient practice was identified and corrected with the following actions:1. Education and demonstration regarding proper narcotic counting was given to all CMAs. 2. All CMAs and nurses attested to having reviewed the PharMerica instruction manual regarding the procedure for pulling controlled medications for administration and maintaining the narcotic record book.3. Weekly narcotic count audits were completed by the DNS for six weeks.

Based on observation, interview and record review it was determined the facility failed to ensure residents were appropriately assessed for the use of a physical restraint for 1 of 1 sampled resident (#30) reviewed for restraints. This placed residents at risk for restricted freedom of movement and a decline in physical functioning. Findings include:Resident 30 was admitted to the facility in 2024 with diagnoses including a stroke.The facility's Physical Restraints and Enablers/Devices Policy and Procedure dated 8/1/24 indicated restraints were used only to treat a resident's medical symptom, protect the resident' safety, and assist the resident in attaining or maintaining the highest practicable level of physical and psychosocial well-being. If determined a resident had symptoms necessitating the use of a physical or mechanical device, an evaluation was completed prior to the device being initiated, annually and upon a change of condition. The effect, not the intent is evaluated to determine if the device was a restraint or an enabler. Devices may include but not limited to, self-releasing seatbelts.A 5/13/25 Annual MDS revealed Resident 30 was impaired on one side and utilized a motorized wheelchair. A review of Resident 30's electronic medical record revealed no assessment was completed regarding the use of a self-releasing seatbelt when Resident 30 used her/his motorized wheelchair.Random observations from 9:00 AM to 4:30 PM on 8/18/25 through 8/28/25 revealed Resident 30 moved throughout the facility in her/his motorized wheelchair and wore a seatbelt positioned across her/his lower abdomen.On 8/18/25 at 2:16 PM, Resident 30 stated she/he used her/his motorized wheelchair at all times to maneuver around the facility and had a seatbelt. Resident 30 stated she/he was unsure whether anyone assessed her/him for the safety of the seatbelt.On 8/20/25 at 1:51 PM, Staff 23 (CNA), and at 2:44 PM, Staff 24 (CNA) both stated Resident 30 had a seatbelt for safety when in her/his wheelchair. Both stated the resident could not latch the seatbelt independently but could safely unlatch/release the seatbelt latch on her/his own.On 8/20/25 at 7:00 PM, Staff 19 (RN) and on 8/21/25 at 11:53 AM, Staff 15 (RN) both stated Resident 30 used a motorized wheelchair to maneuver around the facility and had a seatbelt for safety. Both stated an assessment was required because the seatbelt could be considered a restraint if Resident 30 was unable to latch and unlatch it independently. Both were unsure if an assessment was completed.On 8/21/25 at 2:42 PM, Staff 3(RNCM) stated Resident 30 required the seatbelt for safety when she/he was in her/his motorized wheelchair and no assessment was completed until requested on 8/18/25. Staff 3 stated the assessment was to ensure the seatbelt was not considered a restraint and the resident was able to latch and unlatch it independently. On 8/22/25 at 9:34 AM, Staff 2 (DNS) stated she was unaware Resident 30 utilized a seatbelt in her/his wheelchair, and she completed an assessment on 8/19/25 to ensure the resident was able to latch and unlatch the seatbelt safely. Staff 2 stated she expected staff to complete assessments quarterly to ensure the seatbelt was not functioning as a restraint.

Based on interview and record review the facility failed to ensure a clinical rational for administering a psychotropic medication for 1 of 5 sampled residents (#9) reviewed for medications. This placed residents at increased risk for adverse consequence of antipsychotic medication. Findings include:Resident 9 was admitted to the facility on 6/2025 with diagnosis including Parkinsons and difficulty walking.A review of Drugs.com - Prescription Drug Information revealed the following common side effects of trazodone included drowsiness, dizziness and tiredness. After a single dose in a healthy adult, trazadone was mostly eliminated from the system within one to three days. The half-life of trazadone was approximately five to 13 hours, meaning every five to 13 hours, the blood concentration of the drug decreased by 50 percent. The elimination half-life of a medication referred to the time required for its blood levels to be reduced by half. Factors such as metabolism, age, health status, weight and the amount and frequency of the drug taken influenced the rate at which the body cleared the medication. The Psychotropic Drug Use, Dementia Cognitive Loss and Fall CAA dated 6/11/25 revealed Resident 9 was administered trazodone (an antidepressant) 50 mg at bedtime. No diagnosis was documented in the orders or located in the hospital records and clarification was needed. Witness 4 (Family Member) signed consent for the use of trazodone and indicated the medication was being used for sleep; however, no diagnosis was associated with the order. The resident was a fall risk and had severe cognitive impairment and metabolic encephalopathy (a condition in which the brain was not functioning properly due to a chemical imbalance.) A physician order dated 6/10/25 directed staff to administer trazodone 50 mg at bedtime for.A review of Resident 9's 6/2025 and 7/2025 MARs revealed the resident received trazodone at bedtime from 6/10/25 through 7/10/25 (29 days).A review of Resident 9's clinical record and Un-Witnessed Fall event investigations from 6/20/25 through 7/8/25 revealed the following:-6/20/25 at 2:10 PM Resident 9 experienced an unwitnessed fall in the bathroom due to self-transferring. No injury was sustained.-6/22/25 at 6:08 AM Resident 9 rolled out of bed and was found on the floor after attempting to self-transfer. No injuries were sustained.-6/26/25 at 3:14 AM Resident was found on the floor. The bed was in the highest position, although it had been in the lowest position 15 minutes earlier. A fall mat was in place and the resident had non-skid socks on. Resident 9 complained of right hip pain, had a bruise on the head and sustained a small skin tear. The resident was sent out to the hospital and returned later that shift with no major injuries or new orders.-6/27/25 at 2:20 PM Resident 9 was found sitting on the bathroom floor with her/his back against the wheelchair, positioned as if attempting to self-transfer. No injuries were sustained.-7/6/25 at 1:30 PM Resident 9 was found on the floor, she/he slid out of bed. No injuries were sustained.-7/8/25 at 4:20 PM Resident 9 was found on the floor, next to her/his bed. No injuries were sustained.A Progress Note dated 6/25/25 at 1:27 PM, by Staff 3 (RNCM) revealed she reviewed the hospital records for proper diagnosis for use of trazodone and no new diagnosis was located. The note indicated, Given to med records to upload.A 7/10/25 Order Note revealed a verbal order from the provider to discontinue the trazodone related to no diagnosis for use of the medication and to monitor. A review of Resident 9's clinical record revealed trazadone was discontinued on 7/10/25 (29 days later).On 8/20/25 at 10:17 AM, Staff 38 (CNA) and at 2:32 PM, Staff 24 (CNA) and Staff 28 (CNA), all stated Resident 9 was a fall risk, experienced confusion, required two-person assistance for transfers and was dependent for ADL care. Staff stated while on the 200 hall, the resident had fallen multiple times. Staff 24 and Staff 28 stated the resident was difficult to monitor on the 200 hall because where the resident was located. Staff further stated Resident 9 had not fallen since being moved to the 100 hall. On 8/21/25 at 3:08 PM Staff 3 (RNCM) stated she reviewed orders upon admission to ensure all medications had appropriate diagnosis and indications for use. She used a drug manual or google to research potential side effects. Staff 3 sated the 6/25/25 note created was intended to alert the provider the resident lacked a diagnosis or clinical rational for trazadone use. Staff 3 confirmed this was overlooked and not followed up on. Staff 3 acknowledged Resident 9 continued to receive trazadone until it was discontinued on 7/10/25 and acknowledged the resident experienced multiple falls from 6/20/25 through 7/8/25. Staff 3 recognized the potential correlation of between trazadone and the resident's unwitnessed falls.On 8/21/25 at 8:35 PM Staff 45 (LPN) stated she worked with Resident 9 on the 200 hall and confirmed the resident was a fall risk. Staff 45 stated the trazodone was administered but was unsure whether there was an appropriate diagnosis or an order for its use. Staff 45 stated it was the responsibility of office people to ensure residents had appropriate diagnoses for psychotropic medications. Staff 45 stated trazodone could cause drowsiness and potentially contribute to falls if the resident attempted to get out of bed or into a wheelchair. Staff 45 stated the RNCM and pharmacist should monitor clinical diagnoses and medication side effects.On 8/22/25 at 8:33 AM and 10:28 AM, Staff 39 (Pharmacist) stated residents were reviewed monthly to ensure appropriate clinical diagnoses supported all medications, including psychotropics. Staff 39 confirmed Resident 9 lacked an appropriate diagnosis or clinical rationale for trazodone use. She explained trazodone, due to its low dosage and histamine antagonist effects, could cause sedation and dizziness, which could have increased the resident's fall risk.On 8/22/25 at 9:46 AM and 11:00 AM, Staff 2 (DNS) acknowledged a lag in ensuring residents had clinical rationales or diagnoses for medications, including psychotropics. Staff 2 confirmed Resident 9 received trazodone from 6/10/25 through 7/10/25 without an appropriate diagnosis or rationale. When asked about the resident's multiple unwitnessed falls between 6/20/25 and 7/8/25 and whether medication side effects were considered, Staff 2 stated a root cause analysis had been completed. During the time, the resident had a new suprapubic catheter placed and was adjusting to a new environment. Staff 2 confirmed no discussion occurred regarding medication use or side effects. She acknowledged the potential correlation between trazodone and the resident's multiple unwitnessed falls.

Based on interview and record review it was determined the facility failed to complete a person-centered care plan related to ostomy care for 1 of 1 sampled resident (#30) reviewed for bowel and bladder. This placed residents at risk for infections and lack of ADL care. Findings include:Resident 30 was admitted to the facility in 2024 with diagnoses including a stroke and anxiety.A Care Plan dated 5/6/24 revealed Resident 30 had an alteration in gastro-intestinal status including colostomy. Interventions included bowel-colostomy, give medications as ordered, monitor and document effectiveness. The care plan did not include monitoring for signs/symptoms of potential infection, leakage, or how to clean the stoma (surgically created, opening on the surface of the abdomen) and peristomal (area of skin surrounding an ostomy stoma, where the artificial appliance is attached to collect bodily waste) skin.A 5/13/25 Annual MDS revealed Resident 30 had a BIMS score of 15 which indicated she/he was cognitively intact. The resident had an indwelling catheter and an ostomy (an appliance worn over the stoma which is a surgically created opening on the abdomens surface to collect feces).A review of the 7/2025 and 8/2025 TARs revealed Resident 30 was to have her/his colostomy bag and wafer (an adhesive backed disc with a hole for the stoma that sticks to the skin around it, creating a seal) changed every five to seven days and as needed. On 8/18/25 at 2:16 PM, Resident 30 stated she/he required assistance with her/his ostomy care and some staff did not know what to do or were slow to respond. This resulted in the ostomy bag exploding and caused irritation to the stoma, which the resident found concerning.On 8/20/25 at 1:51 PM, Staff 23 (CNA) and at 2:44 PM, Staff 24 (CNA) both stated Resident 30 required one-person assistance with ostomy care and it was important to clean around the stoma. Staff stated she/he was very particular about her/his ostomy care and directed how often the ostomy bag should be changed or cleaned. Both indicated CNAs were to review the care plan prior to starting their shift. On 8/20/25 at 7:00 PM, Staff 19 (RN) stated she provided Resident 30's ostomy care because the resident was cautious and concerned about infection and leakage. Staff 19 stated CNAs were expected to report signs or symptoms of leakage or other concerns related to the resident's ostomy care. Staff 19 stated CNAs were responsible for reviewing the care plan to ensure appropriate care and monitoring of the ostomy.On 8/21/25 at 11:53 AM, Staff 15 stated she provided Resident 30's ostomy care every seven days because the residents skin became irritated easily. Staff 15 stated CNAs were to report any concerns related to leakage or signs and symptoms of infection to the nurse. Staff 15 indicated all staff were responsible for reviewing the resident's care plan.On 8/21/25 at 2:42 PM, Staff 3 (RNCM) stated she was responsible for the care plan and was unaware Resident 30 had concerns related to her/his ostomy care. Staff 3 reviewed the care plan and acknowledged interventions related to Resident 30's ostomy care were lacking. On 8/22/25 at 9:34 AM, Staff 2 (DNS) stated she reviewed Resident 30's colostomy care plan and expected staff to ensure the care plan reflected appropriate interventions for ostomy care.

Based on interview and record review the facility failed to prevent an avoidable fall for 1 of 4 sampled residents (#3) reviewed for falls. This placed residents at risk for injury. Findings include:Resident 3 was admitted to the facility in 3/2025 with diagnoses including a stroke and dysphagia (difficulty swallowing foods and liquids). Resident 3's 3/18/25 admission MDS indicated the resident had severe cognitive impairment and was dependent for all care needs including toileting and bed mobility. Resident 3's 6/7/25 fall investigation report indicated at approximately 4:00 AM, the nurse was on a break when Resident 3 was found in her/his room, on the floor, between the bed and the wall. The report indicated Staff 27 (CNA) changed Resident 3's brief around 3:30 AM and at 4:00 AM, Staff 26 (CNA) heard the resident yelling and crying and found Resident 3 on the floor. Resident 3's bed was not pushed back against the wall as it should have been, and the facility only had two CNAs scheduled for 50 residents. There were no reported injuries and Resident 3 refused to be transported to the hospital for an evaluation. On 8/18/25 at 3:54 PM and 8/19/25 at 2:22 PM, Witness 2 (Family Member) stated on 6/7/25, Resident 3 was found between the bed and wall and the resident had to beat her/his head against the wall to get the attention of staff. Witness 2 stated Resident 3 fell because a CNA did not push the resident's bed back against the wall after providing care. Witness 2 stated the facility did not usually have enough staff and on 6/7/25 night shift, when Resident 3 fell, the facility was short-staffed. On 8/20/25 at 8:58 AM, Staff 27 reported around 3:30 AM, he changed Resident 3's brief and about a half hour later, I was told of a STAT [immediately] fall regarding Resident 3. Staff 27 stated there were two CNA staff working and two CNAs were not enough to meet the needs of the residents because the facility is big and the acuity of the residents was too high for only two CNA staff. On 8/20/25 at 9:10 AM, Staff 26 stated Resident 3 was considered a high fall risk. She reported Staff 27 changed Resident 3's brief around 3:30 AM and upon finishing, Staff 27 did not push the resident's bed back against the wall. Staff 26 stated about a half hour later, she heard Resident 3 yelling and crying and found her/him on the floor between the bed and wall, in a fetal position. Staff 26 stated there were only two CNAs working in the facility for 50 residents thus they were not able to meet the acuity needs of the residents. On 8/21/25 at 11:12 AM, Staff 2 (DNS) and Staff 3 (RNCM) confirmed Resident 3 had a fall on 6/7/25 because CNA staff did not push her/his bed back against the wall after providing care. Staff 2 and Staff 3 verified the facility only had two CNA staff on night shift and the facility was short-staffed. Refer to F725.

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#9) reviewed for unnecessary medications. This placed residents at risk for adverse side effects of medications. Findings include:Resident 9 was admitted to the facility on 6/2025 with diagnosis including Parkinsons and difficulty walking. Resident 9's 6/2025 and 7/2025 Pharmacy Recommendation and Review indicated Resident 9 a new order for trazodone (an antidepressant medication) with an unknown diagnosis. The recommendation was given to provide a diagnosis for the new psychotropic medication.A review of Resident 9's 6/2025 and 7/2025 MARs revealed the resident received trazodone at bedtime from 6/10/25 through 7/10/25 (29 days).On 8/22/25 at 8:33 AM and 10:28 AM, Staff 39 (Pharmacist) stated residents were reviewed monthly to ensure they had appropriate clinical diagnoses for use of all medications, including psychotropics. Staff 39 stated Resident 9 did not have an appropriate diagnosis or clinical rationale for the use of trazodone. On 8/22/25 at 9:46 AM, 11:00 AM, and 11:47 AM, Staff 2 (DNS) stated she noticed a lag in ensuring clinical rationales were documented for the use of medications, including psychotropics. Staff 2 acknowledged the pharmacy recommendation regarding Resident 9 was not followed up on in a timely manner. Staff 2 stated she expected RNCMs to follow up with the physician to ensure recommendation were implemented.

Based on observation, interview and record review it was determined the facility failed to provide physical, occupational and speech therapy services as ordered for 3 of 3 sampled residents (#s 3, 26 and 60) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life. Findings include: The Stroke Foundation, What to Expect From a Stroke, dated 2023, explained stroke rehabilitation (PT, OT and SLP) was the therapy and activities that drive recovery by helping to re-learn ways of doing things affected by a stroke. It aimed to stimulate the brain to change and adapt. By creating new pathways, a person could learn to use other parts of the brain to recover function of those parts affected by the stroke. Improvement after a stroke can continue for years but for many people it's quickest in the first six months. 1. Resident 3 was admitted to the facility in 3/2025 with diagnoses including a stroke, hemiparesis/hemiplegia (the loss of ability to move part or most of the body) and dysphagia (difficulty swallowing foods and liquids). Resident 3's 3/12/25 Hospital Discharge Summary indicated the resident had a stroke which resulted in a prolonged hospitalization complicated by dysphagia. On 3/7/25, Resident 3 had a PEG tube (a type of feeding tube inserted into the stomach and used for individuals when unable to swallow food or liquids) surgically placed due to her/his inability to swallow. Resident 3's 3/12/25 Discharge to Facility Physician Order's prescribed SLP and OT evaluations and treatment upon admission to the facility. The resident continued to require PEG tube feedings for nutrition. Resident 3's 3/18/25 admission MDS indicated the resident had severe cognitive impairment, was unable to eat by mouth and was dependent for all needed care. Resident 3's Speech Therapy Medicare SLP Evaluation and Treatment revealed the resident was evaluated on 3/28/25, 16 days after the resident was admitted to the facility. The evaluation determined Resident 3 needed SLP treatment two times a week. Resident 3's 3/2025 and 4/2025 SLP Service Matrix Log (a record used to track therapy visits) indicated the resident did not receive her/his twice weekly SLP therapy on 4/5/25 through 4/11/25 and 4/12/25 through 4/18/25. The resident was not provided the prescribed SLP treatments on two of four weeks during 4/2025. Resident 3's Occupational Therapy Medicare OT Evaluation and Treatment revealed the resident was evaluated on 3/31/25, 19 days after the resident was admitted to the facility. The evaluation determined Resident 3 needed OT treatment two times a week. Resident 3's 3/2025 and 4/2025 OT Service Matrix Log indicated the resident did not receive her/his twice weekly OT therapy on 4/6/25 through 4/13/25 and 4/14/25 through 4/20/25. The resident was not provided the prescribed OT treatments on two of four weeks during 4/2025. Multiple random observations from 8/17/25 through 8/22/25 between the hours of 7:30 AM and 10:00 PM revealed Resident 3 had right-sided hemiparesis with reduced functional movement of her/his right arm or hand and reduced movement of her/his right leg. Resident 3 had a PEG tube in place. On 8/18/25 at 3:54 PM, Witness 2 (Family Member) reported Resident 3 did not receive timely SLP or OT services as ordered because the facility lacked therapy staff. On 8/21/25 at 10:01 AM, Staff 25 (Regional Director of Rehabilitation) reviewed Resident 3's SLP and OT therapy services for 3/2025 and 4/2025. Staff 25 confirmed the resident did not receive SLP and OT services in a timely manner and at the frequency determined to be necessary because they did not have adequate SLP and OT staffing. On 8/22/25 at 10:09 AM, Staff 1 (Administrator) confirmed Resident 3's SLP and OT services were not provided as prescribed, and he expected therapy to be provided as ordered and in a timely manner. 2. Resident 26 was admitted to the facility in 6/2025 with diagnoses including chronic pain syndrome and bilateral hip arthritis. Resident 26's 6/11/25 Annual MDS indicated the resident had no cognitive impairment. Resident 26 required substantial/maximal assistance for toileting, dressing, personal hygiene, bed mobility and was dependent for chair to bed transfers. A 7/6/25 Progress Note indicated Resident 26 was transferred to the hospital due to nausea, a headache and shoulder pain. A 7/11/25 Progress Note indicated Resident 26 returned from the hospital. Resident 26's 7/11/25 Skilled Nursing Facility Transfer Orders prescribed PT and OT evaluation and management. A review of Resident 26's electronic health record revealed no evidence PT and OT evaluations were completed. On 8/18/25 at 9:45 AM, Resident 26 stated she/he was supposed to receive therapy services, did not receive them and was unsure why no therapy was provided. On 8/21/25 at 10:01 AM, Staff 25 (Regional Director of Rehabilitation) confirmed Resident 26 had PT and OT orders written on 7/11/25 and no PT or OT services were provided. Staff 25 was unsure why the PT and OT orders were missed. 3. Resident 60 was admitted to the facility in 2/2024 with diagnoses including hemiplegia (paralysis of one side of the body) and aphasia (loss of the ability to speak or understand spoken language as a result of brain damage). Resident 60's 2/29/24 admission MDS revealed he was cognitively intact, usually understood speech, sometimes made herself/himself understood, received 26-50% of her/his nutrition and hydration via feeding tube, used a wheelchair for ambulation and was dependent for transfers. Resident 60's signed orders dated 2/26/24 revealed she/he was to be evaluated and treated as necessary by Physical Therapy (PT) and Occupational Therapy (OT). Orders dated 3/5/24 also revealed she/he was to be evaluated and treated as necessary for diet advancement by a Speech-Language Pathologist (SLP). Resident 60's care plan included a goal dated 2/23/24 to work with therapies to increase strength and reinforce cognitive strategies. Resident 60's therapy evaluation notes revealed she/he was evaluated by PT, OT and SLP who recommended the following therapy schedules:-PT: three days per week-OT: five days per week-SLP: three days per week Resident 60's therapy schedule for the week of 2/25/24 through 3/2/24 revealed the following:-Received two of three PT sessions-Received one of five OT sessions-Received two of three SLP sessions Resident 60's therapy schedule for the week of 3/3/24 through 3/9/24 revealed the following:-Received one of three PT sessions Resident 60's therapy schedule for the week of 3/10/24 through 3/16/24 revealed the following:-Received two of three PT sessions On 8/20/25 at 10:29 AM Staff 13 (Administrative Assistant / Director of Rehabilitation) acknowledged the missed therapy dates and stated PT was out sick during the weeks of 2/25/24 through 3/2/24 and 3/10/24 through 3/16/24 and was not able to complete the scheduled sessions. Staff 13 was unaware of the reason for the other missed therapy sessions. On 8/21/25 at 10:12 AM Staff 25 (Regional Director of Rehabilitation) acknowledged the missed therapy sessions and lack of documentation regarding the reason the sessions were missed. He stated therapists sometimes documented in the electronic record and sometimes they did not. On 8/21/25 at 3:09 PM Witness 6 (Family Member) stated Resident 60 was supposed to receive therapy every day and the staff guaranteed Resident 60 would receive therapy three to four days a week. On 8/22/25 at 11:32 AM Staff 1 (Administrator) acknowledged Resident 60's missed therapy sessions and stated he expected all residents to receive skilled therapy as ordered. Refer to F725.

Based on observation, interview, and record review it was determined the facility failed to ensure enhanced barrier precautions were implemented for 1 of 3 sampled residents (#9) reviewed for infection control. This placed residents at risk for transmission of infection. Findings include: The facility's Transmission Based Precautions Policy and Procedure dated 8/1/24 indicated the following:-To implement Transmission-Based Precautions for residents known to be, or suspected of being, infected with infectious agents.-Enhanced Barrier Precautions (EBP) when a person is colonized with a Multi-Drug-Resistant Organism or the status of colonization is unknown, enhanced barrier precautions are utilized, per CDC guidance, to reduce the risk of spread of and MDRO (actual colonized or potential). -Personal caring for a resident on EBP wears gloves and a gown. Prior to leaving the resident's room, gown and gloves are removed and hand hygiene performed. EBP is used with residents with a urinary catheter during the following situations: dressing, transferring, providing hygiene and changing briefs or assisting with toileting.Resident 9 was admitted to the facility in 6/2025 with diagnosis including Parkinsons and difficulty walking.A 6/11/25 admission MDS indicated the resident was dependent on staff for all ADL care needs and had a catheter.On 8/20/25 at 9:49 AM, Resident 9's door was observed to have a sign which indicated she/he was on EBP. The resident was sitting in her/his wheelchair when Staff 38 (CNA) escorted resident to her/his room because she/he needed to use the commode. Staff 38 left and returned with the sit-to-stand device, which was positioned in front of the resident. Staff 38 did not perform hand hygiene or don gloves or gown. Staff 38 placed the resident's catheter bag on the floor, then picked it up and hung it on the side of the commode. Staff 38 requested assistance and Staff 16 (CMA/CNA) entered the room donned gloves but no gown. Both staff assisted the resident to the commode. Staff 16 removed his gloves and performed hand hygiene at the sink. Staff 38 left the room without performing hand hygiene.On 8/20/25 at 10:03 AM, Staff 16 stated when a resident was placed on EBP, staff were required to don gown and gloves before providing ADL care. Staff 16 acknowledged he did not don a gown. On 8/20/25 at 10:17 AM, Staff 38 stated Resident 9 had a catheter, required two-person assistance for transfers and was on EBP. Staff 38 acknowledged he did not don gown or gloves prior to assisting the resident onto the commode and had not performed appropriate hand hygiene. Staff 38 stated the catheter bag should not have been placed on the floor. On 8/22/25 at 9:46 AM, and 11:00 AM, Staff 2 (DNS) stated all residents who were placed on EBP required staff to follow appropriate infection control practices, hand hygiene and confirmed Resident 9's catheter bag was not to be placed on the floor.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate and complete for 13 of 77 days reviewed for staffing. This placed residents and the public at risk for inaccurate staffing information. Findings include:A review of the facility's DCSDRs revealed the following: From 6/1/25 through 8/18/25, 77 days were reviewed and revealed 13 days when licensed nurse staff hours were inaccurate or the postings had missing/incomplete information on 6/5/25, 6/6/25, 6/15/25, 7/6/25, 7/8/25, 7/25/25, 8/1/25, 8/3/25, 8/4/25, 8/11/25, 8/12/25, 8/16/25 and 8/17/25. On 8/21/25 at 11:25 AM, Staff 11 (Human Resources/Payroll/Staffing Coordinator) reviewed the 6/1/25 through 8/18/25 DCSDRs and verified the reports were inaccurate or incomplete on the days identified.

Based on observation, interview and record review it was determined the facility failed to prevent loss of range of motion and development of contractures for 1 of 1 sampled resident (#23) reviewed for contractures. This failure resulted in Resident 23 developing bilateral (both) hand contractures and experiencing significant pain in her/his hands. Findings include: The facility's 2/2018 Restorative Nursing Policy and Procedure revealed the following: -Based on a comprehensive assessment of the resident's current functional status related to communication, mobility, range of motion, performance of ADLs, eating and toileting, the RCM (Resident Care Manager) will determine appropriateness for participation in restorative nursing programs. -Ongoing assessment of each resident's functional status occurs no less often than quarterly with the completion of the MDS. -If the resident expresses a desire to improve in one or more area of communication, mobility, range of motion, ADL performance, eating or toileting, a therapy referral or restorative nursing referral will be initiated. -If the RCM or licensed staff determines the resident has a need to maintain current function in communication, mobility, range of motion, ADL performance, eating or toileting, a restorative nursing referral will be initiated. -Residents with the need to improve functional status will be re-evaluated monthly to determine effectiveness of the current interventions and need to revise goals or interventions. -Residents with the need to maintain current functional status will be re-evaluated at least quarterly to determine effectiveness of the current interventions and need to revise goals or interventions. Resident 23 was admitted to the facility in 6/2023 with diagnoses including spinal stenosis (narrowing of the spinal column that can cause pressure on the spinal cord). Resident 23's 6/8/23 Admission and 9/8/23 Quarterly MDS revealed the resident was severely cognitively impaired and she/he had no upper extremity (shoulder, elbow, wrist or hand) impairment. Resident 23's 10/23/23 Neurology Clinic Note indicated the resident developed weakness of her/his arms since she/he admitted to the facility. Resident 23's 12/9/23 Quarterly MDS revealed the resident was severely cognitively impaired and she/he experienced upper extremity impairment on both sides. Resident 23's 12/22/23 Neurosurgery Clinic Evaluation Note indicated the resident's arm strength was progressively worsening. Resident 23's 12/28/23 OT Evaluation and Plan of Treatment revealed the following: -The resident experienced problems with immobility and weakness in all extremities. -The resident's right and left upper extremity strength and range of motion was impaired. -No pain was present per resident verbal and nonverbal communication. -The resident's goal for therapy was to return home. -The resident could benefit from skilled therapy to return home. Resident 23's 1/2/24 Potential for Harm due to Substance Use Care Plan indicated the resident was to utilize a carrot (an alternative nonsurgical solution for management of contractures of the hand) in the right hand and an edema glove (used to push excess fluid out of the hand) on the left hand during the day. Resident 23's 3/10/24 Quarterly MDS indicated the resident was moderately cognitively impaired and she/he experienced upper extremity impairment on both sides. Resident 23's 5/2024 Physician Orders directed the following: -The resident was to wear an edema glove to her/his left hand during the day and it was to be removed at night PRN. -PT and OT evaluation and treatment as indicated. No evidence was found in Resident 23's clinical record to indicate the resident's upper extremity impairments were comprehensively assessed, ongoing monitoring of her/his upper extremity impairments was being provided or exercises were being completed to maintain or improve the resident's range of motion/mobility or to prevent further declines. No rationale was found as to why range of motion services were not being provided. Additionally, no evidence was found to indicate care plan interventions were implemented as directed or that the care plan was reviewed or revised to determine if interventions were effective. On 5/13/24 at 1:53 PM Resident 23 was observed in her/his room in bed visiting with Witness 1 (Spouse). Resident 23's middle, ring and little fingers on both of her/his hands curled into the palm of her/his hands. No carrot was observed in either of the resident's hands. Resident 23 stated she/he was unable to extend any of those fingers on either hand, her/his hands were not too good and they caused her/him a great deal of pain. Witness 1 stated she was at the facility three times daily to assist Resident 23 at meal times. Witness 1 stated Resident 23 was supposed to use a carrot in her/his right hand to prevent her/his contracture from worsening but stated staff had not offered it to Resident 23 in months. Witness 1 stated Resident 23 rarely received any restorative therapy for either of her/his hand contractures as there was only one CNA in the building who provided any sort of stretching or range of motion exercises and Resident 23 was often not assigned to that particular CNA. Witness 1 further stated Resident 23 did not have a carrot for her/his left hand or anything else to prevent further decreases in her/his range of motion in that hand. Resident 23 stated she/he was interested in receiving restorative therapy for her/his hands. Witness 1 stated she thought staff were aware of the resident's interest. On 5/15/24 at 10:10 AM Staff 21 (CNA) stated Resident 23 was not care planned to receive any type of restorative therapy or stretching exercises for her/his hands. Staff 21 stated the resident had a carrot for one of her/his hands but he only offered it to the resident when he remembered. Staff 21 stated Resident 23 regularly complained of pain in her/his hands and stated the resident would scream in pain when he barely brushed her/his finger. On 5/15/24 at 11:53 AM Staff 15 (CNA) stated Resident 23 did not receive any restorative therapy. Staff 15 stated Resident 23 did not have hand contractures when [she/he] first came here and her/his hand contractures have gotten worse. Staff 15 further stated Resident 23 regularly complained about pain in her/his hands. On 5/15/24 at 1:12 PM Staff 22 (CNA) stated Resident 23 had contractures in both of her/his hands, and she was unsure if anything was being done to prevent the contractures from worsening. Staff 22 stated Resident 23 was cooperative with care, she had not seen the resident ever use a carrot in either of her/his hands and the resident frequently complained about pain in her/his hands. On 5/15/24 at 1:35 PM Staff 14 (LPN) stated Resident 23 should have restorative stuff for [her/his] upper body and hands because of [her/his] contractures. Staff 14 reviewed Resident 23's electronic record and stated the resident did not have a restorative plan in place. Staff 14 further stated she had never seen the resident use a carrot in either of her/his hands, and she was not aware of anything being done to prevent her/his contractures from worsening. On 5/16/24 at 12:51 PM Staff 3 (RNCM) stated residents with contractures required assessments and monitoring, and she would initiate an RA program for any resident who experienced a functional decline. Staff 3 stated she was unsure of when Resident 23's contractures started and could not explain the change in MDS coding that occurred in 12/2023 which indicated the resident had bilateral upper extremity impairments. Staff 3 stated the resident's bilateral hand contractures were not being monitored, had not been assessed and she was unsure if her/his current care plan for contractures was appropriate. Staff 3 further stated she was unsure if the carrot for the resident's right hand was effective or being utilized, nothing was in place for contracture prevention for her/his left hand and the resident was appropriate for an RA program but she had not initiated such a program for the resident. On 5/16/24 at 1:46 PM Staff 2 (Regional RN) acknowledged the lack of assessing and monitoring of Resident 23's contractures to ensure they didn't worsen, and expected this in place for the resident. Staff 2 stated she was surprised they don't have a restorative program in place for [her/him].

Based on observation, interview and record review it was determined the facility failed to ensure foods were labeled and stored in a way to minimize food spoilage and cross contamination, failed to maintain a clean and sanitary environment for food preparation and failed to prevent potential contamination of the ice machine in 1 of 1 kitchen reviewed for sanitation. This placed residents at risk for potential infections related to foodborne pathogens. Findings include: 1. On 5/13/24 at 11:24 AM in the facility's kitchen, the following items were observed in the middle refrigerator: -A partially-consumed one-gallon plastic container of [NAME] Salad Dressing (labeled 8/1); -A partially-consumed one-gallon plastic container of pickle spears (labeled 11/16); -A partially-consumed one-gallon plastic container of dijon mustard (labeled 8/1); -A partially-consumed one-gallon plastic container of Ranch dressing (labeled 3/20); -A partially-consumed one-gallon plastic container of black olives (labeled 3/15); -A partially-consumed one-gallon plastic container of jalapenos peppers (labeled 3/15); -A stainless steel bin of individually-bagged ham and cheese sandwiches (none of the sandwiches were labeled or dated); and -An individually-bagged ham and cheese sandwich (unlabled and undated) on a tray with a package of string cheese. On 5/13/24 at 11:24 AM Staff 29 (Cook) commented on the sandwiches and stated, I think they were probably made yesterday. Should I write yesterday's date on it? On 5/13/24 at 11:48 AM Staff 11 (Dietary Manager) stated she did not know if the dates on the gallon containers of condiments were the open dates and she was unable to know when to discard them based on the way they were labeled. She stated the way they were labeled made it impossible to know if they were opened during the current year or a previous year. She stated, They should be labeled more clearly and the dates should include the year. I think it's better to have the open date and discard date just to be safe. On 5/13/24 11:58 AM Staff 11 stated dietary staff made a supply of sandwiches daily and she expected them to be individually labeled and dated. 2. On 5/13/24 at 11:24 AM a pork loin was observed to be thawing on a rack positioned directly above portions of thawing chicken in the thawing refrigerator located adjacent to the end of the food prep area and cook top. On 5/13/24 at 11:48 AM Staff 11 (Dietary Manager) stated she expected the meats to be positioned to thaw at the bottom of the refrigerator so they would not drip on other items. 3. On 5/15/24 at 12:07 PM the following unsanitary conditions were observed in the facility's kitchen: -Dust and grit on the supply shelves over the main food prep area; -Accumulated fuzz and dust on the ceiling support beam and shelving over the main food prep area and on the pipes over the steam table. Air circulated from the vents in the kitchen caused the fuzz to circulate over food trays and the steam table. On 5/15/24 at 12:07 PM Staff 11 (Dietary Manager) stated she expected these items to be clean so the dust did not land on the residents' food. 4. On 5/15/24 at 12:21 PM a test tray containing lunch was observed to have a weathered, oxidized and pitted dome covering the plate of food. The dome appeared grey despite its original color being maroon. The dome appeared unclean due to its worn nature. On 5/15/24 at 12:36 PM Staff 1 (Administrator) observed the test tray and stated the dome appeared weathered. He stated he expected the domes to be in better repair for the residents. 5. The Federal Food Sanitation Rules code 5-402.11 Backflow Prevention directed facilities to ensure a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. On 5/15/24 at 1:59 PM the facility's ice machine in the 200 hall was observed to drain directly into the floor plumbing without an air gap. The machine was also observed to have an ice scoop in a holster on the right side of the machine. There was standing water inside the holster and black dust particles floated on the surface of the water. Used PPE, black grime and debris were observed in a puddle of water under the ice machine. On 5/15/24 at 2:10 PM Staff 1 (Administrator) observed the ice machine and stated he understood the need for an airgap in the ice machine's drain plumbing to protect the ice from potential back flow from the sewar line. He also observed the unsanitary conditions in the ice scoop holster and under the ice machine. He stated he expected the ice machine and the area around it to be clean to protect the residents.

Based on interview and record review it was determined the facility failed to ensure residents were free from mental, verbal and physical abuse and intimidation for 3 of 3 residents (#s 1, 2 and 3) reviewed for abuse. This failure resulted in Resident 2's right to refuse care not being honored, resulting in mental anguish as evidenced by physically forcing care upon and mocking Resident 2. Additionally, this placed all residents at risk for abuse and intimidation. Findings include: 1. Resident 2 admitted to the facility in 5/2023 with COPD (chronic obstructive pulmonary disease), hemiplegia (paralysis on one side) and multiple cancer diagnoses. Resident 2 was on end of life, comfort care measures. Resident 2's 5/30/23 Communication Care reveled she/he had difficulty with speech. Resident 2's 11/15/23 Behavior Care Plan revealed Resident 2 would reject care. Staff were instructed to re-approach for care at a later time, explain the importance of care and to notify her/his family of rejection of care. The 12/3/23 Progress note revealed Resident 2 was given a bed bath in the afternoon. The progress note indicated the resident fought against staff when the care was provided. There was no evidence Resident 2's Care Plan was followed. The 12/7/23 Written Statements by Staff 5 (CNA) and Staff 6 (CNA) revealed on 12/3/23 around 4:30 PM Resident 2 refused oral care from Staff 5. Staff 5 informed Staff 3 (RN) who went to the room and decided a bed bath was needed. The resident said no, Staff 3 did not honor Resident 2's refusal and called Staff 6 to bring bed bath supplies into the room and to assist. The resident repeatedly said no, resisted care, clenched her/his legs, grabbed the bedrail and glared at Staff 3. Staff 3 instructed Staff 5 and Staff 6 to assist by unclenching her/his legs and to get her/his hand off the rail but Staff 5 and Staff 6 refused. At one point during the incident, Staff 3 laughed at Resident 2 while she stated the resident was very upset with her. The undated Facility investigation only included witness and nurse statements and a resident interview. The investigation did not include a summary of what happened or if abuse and neglect was ruled out. Review of the Licensed Nurse Staffing Schedule revealed Staff 3 remained on the schedule. On 12/3/23 at 2:36 PM Staff 6 stated he was pulled into Resident 2's room around 4:30 PM to do a bed bath with Staff 3 and Staff 5. Staff 6 stated the resident refused the bed bath but Staff 3 stated it had to be done. Resident 2 adamantly refused, said no and grabbed the bed rail. Staff 3 told Staff 6 to pry Resident 2's fingers and hand off the rail but Staff 6 refused, so she did it herself. Staff 3 then, chuckled, he is so mad at me. Staff 3 then threatened to turn Staff 5 in to turn for neglect. Staff 5 further stated Staff 3 always threatened the CNA's with neglect to force them to do what she wanted. On 12/6/23 at 3:25 PM Staff 5 stated on 12/3/23 at around 4:30 PM, Staff 3 approached her and instructed her to assist Resident 2 with oral care. Staff 3 stated she went to her/his room and offered the resident oral care to and she/he shook her/his head no. Staff 5 stated she waited and re-approached later and the resident declined again. Staff 5 stated she asked Resident 2 if she could do it later to which she/he agreed. Staff 5 then informed Staff 3 she/he refused but would return later to complete the care. Staff 3 replied, no and told her the care was to be provided right then. Staff 5 then requested Staff 3 to return to the room with her. Resident 2's bed sheets were dirty and Resident 2 had soiled her/himself and the bed since Staff 5 exited the room. Staff 5 stated, [name of resident], you are in such bad shape, sighed and further stated, we have to do everything. Staff 3 decided a full bed change and bed bath was needed. Staff 3 called Staff 6 (CNA) into the room to bring supplies. Resident 2 shook her/his head no and and verbalized, no. Staff 5 stated Staff 3 stripped the resident out of her/his clothing and stripped the bed which left the resident completely naked, and then started to wipe her/his body. Staff 3 was rough with the care. Resident 2 kept closing her/his legs really tight and she/he griped the bed rail really hard. Staff 3 talked the entire time about how Resident 2's family would be upset. Resident 2 glared at Staff 3 with her/his hand in a fist. Staff 5 stated anyone could tell Resident 2 did not want to receive the care provided. Staff 5 stated the written statement she submitted the day of the incident was accurate but management fully dismissed her concern of abuse. On 12/6/23 at 7:21 PM Staff 3 stated around 4:15 PM she checked in with Staff 5 to see if Resident 2's care was completed and it was not. Resident 2 stunk of body odor and urine so Staff 3 instructed the CNAs to bring in supplies. Staff 3 stated she completed a bed bath on one side of the body with no issues. The resident grabbed the rail and Staff 3 explained she needed to finish the bed bath so [she/he] allowed me to do it but did not like it. He allowed me to release her/his hand from the bar. Staff 3 stated she could not recall saying anything rude to the resident. Staff 3 stated on that day (12/6/23) the resident had a new order for morphine (narcotic pain medication), appeared more comfortable and was mostly accepting of cares. Staff 3 further stated it was a fine line between neglect of care and allowing the resident to refuse care and be soiled all day. On 12/6/23 at 4:15 PM and 7:16 PM Staff 1 (Administrator) verified he received Staff 5's written statement. Staff 1 stated within minutes it was clear to him Resident 2 was resistive to care and did not want to get cleaned up but was not hurt. Staff 1 verified a full and complete investigation was not done as he usually completed a timeline of events with a summary and abuse and neglect would be ruled out. Staff 1 verified Staff 3 remained on the nursing schedule. On 12/6/23 at 9:05 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 12/6/23 at 10:31 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *Staff 3 was placed on administrative leave pending further action(s). *All residents would be interviewed on 12/7/23 to identify if there were any further affected resident(s). *Staff would be trained on the definitions of Abuse, including all types of abuse. *Staff would be trained on reporting allegations, including when to report, how to report, who to report to, as well as how to report allegations without retaliation. *The Administrator would conduct audits with random staff members in the form of questions related to what was abuse, when do they report, and who do they report it to. Audits would occur weekly for four weeks, then monthly for two months. *Audits would be shared with facility QAPI team *Administrator and DNS would be responsible to ensure corrections. On 12/7/23 at 5:23 PM staff interviews verified re-education per the immediacy removal plan was completed. Four Facility Reported Incidents (FRIs) were reported to the State Agency as a result of the resident interviews. A review of facility documentation revealed all aspects of the immediacy removal plan were implemented. 2. Resident 1 was admitted to the facility in 2018 with diagnoses including stroke, behavioral disturbance and cognitive communication deficit. The April 2023 MARS, Physician Orders and Care Plan were reviewed. There was no physician order or instruction to force Resident 1 to take her/his medication. The 4/20/23 Facility Investigation revealed a 4/19/23 witness statement which indicated Staff 11 (CNA) was in Resident 1's room with Staff 19 (Former CNA) providing care when Staff 3 (RN) entered the room, interrupted the care and stated she needed to administer Resident 1's medications. Staff 3 raised Resident 1's head of bed to approximately 45 degrees and told Resident 1 I have some pills for you. Resident 1 replied, No, I don't want them. Staff 3 proceeded to spoon out crushed pills from the medication cup that were mixed with applesauce or pudding and then put the spoon in the resident's mouth. The resident spit the pills out and verbalized her/his displeasure. Staff 3 instructed Resident 1 not to spit the medication out as she scooped up the glob of meds off the resident's chest and placed them back into the resident's mouth. Staff 3 then instructed the resident to take a drink and swallow the pills, the resident continued to refuse but did swallow some of the medication. Resident 1 kept yelling no the entire time the medication was administered. Staff 3 had a second medication cup with whole pills in applesauce. Resident 1 again spit them out when administered and repeatedly told Staff 3 no, she/he did not want them. Staff 19 grabbed Resident 1's arm to keep her/him from hitting Staff 3. On 12/7/23 at 10:40 AM Staff 11 stated she and Staff 19 reported the incident to Staff 1 (Administrator) who dismissed it. Staff 11 stated Resident 1's daughter (Witness 3) worked at the facility in HR (Human Resources) and was also told about the incident. On 12/7/23 at 12:30 PM Staff 1 stated he ruled out any concerns quickly and talked to Resident 1's daughter who stated the resident had taken pills that way for years and had no concerns. Staff 1 acknowledged forcing a resident to take medications when they refused, spit them out and tried to hit the nurse, was abuse. On 12/8/23 at 12:45 PM Witness 3 stated she was horrified when she was notified of what happened and did not approve of the incident at all. Witness 3 stated Staff 1 did not handle the grievance well and did not hold a family meeting, which was policy. Witness 3 further stated when she pushed for more information on why the incident occurred, she was told Staff 11 blew everything out of proportion and he had taken care of it. Finally, Witness 3 stated at the time of the incident she worked at the facility in Human Resources and knew Staff 3 had nothing done in regards to her employment file but stopped complaining because she did not want to lose her job. 3. Resident 3 was admitted to the facility in 5/2023 with diagnoses including multiple sclerosis and chronic pain. On 12/6/23 at 4:05 PM Resident 3 stated she/he was only allowed to refuse care sometimes and that depended on who the nurse was. Resident 3 stated Staff 3 (RN) forced her/him to take medications and to get her/his weight checked when she/he had already refused. Resident 3 stated she/he understood why staff checked her/his weight but still wanted to check her/his weight only when it was convenient for her/him. On 12/6/23 at 1:50 PM Staff 7 (CNA) stated Staff 3 forced her to get Resident 3's weight when Resident 3 did not want it done and felt like Resident 3 had no rights. Staff 7 further stated Staff 3 was always rude to both residents and caregivers.

Based on interview and record review it was determined the facility failed to report allegations of abuse for 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for abuse. This failure to report past abuse allegations resulted in Resident 2's physical, verbal and mental abuse and placed all residents at increased risk of abuse and intimidation. Findings include: 1. Resident 2 admitted to the facility in 5/2023 with COPD (chronic obstructive pulmonary disease), hemiplegia (paralysis on one side) and multiple cancer diagnoses. Resident 2 was on end of life, comfort care measures. The 12/7/23 Written Statements of Staff 5 (CNA) and Staff 6 (CNA) revealed allegations that Staff 3 (RN) abused Resident 1. There was no evidence a FRI (Facility Reported Incident) was sent in to the State Agency. On 12/3/23 at 2:36 PM Staff 6 verified he turned in a written statement related to Staff 3's alleged abuse of Resident 1. On 12/6/23 at 3:25 PM Staff 5 verified she turned in a written statement related to Staff 3's alleged abuse of Resident 1. On 12/6/23 at 4:15 PM and 7:16 PM Staff 1 (Administrator) verified he received Staff 5's written statement. Staff 1 stated within minutes it was clear to him Resident 2 was resistive to care and did not want to get cleaned up but was not hurt. Staff 1 verified a full and complete investigation was not done and a FRI was not submitted to the State Agency. On 12/6/23 at 9:05 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On 12/6/23 at 10:31 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *The Administrator and DNS would be trained on the requirements of Facility Reported Incidents on 12/6/23. *All residents would be interviewed on 12/7/23 to identify if there were any further affected resident(s). If any further allegations were found, they would be reported as FRIs and an investigation would be immediately opened. *Staff would be trained on the definitions of Abuse, including all types of abuse. *Staff would be trained on reporting allegations, including when to report, how to report, who to report to, as well as how to report allegations without retaliation. *The Administrator would review all allegations to ensure they were reported as a FRI. *Administrator and DNS would be responsible to ensure corrections. On 12/7/23 at 5:23 PM staff interviews verified re-education per the immediacy removal plan was completed. Four Facility Reported Incidents (FRIs) were reported to the State Agency as a result of the resident interviews. A review of facility documentation revealed all aspects of the immediacy removal plan were implemented. See F600. 2. Resident 1 was admitted to the facility in 2018 with diagnoses include stroke, behavioral disturbance and cognitive communication deficit. The 4/20/23 Facility Investigation revealed a 4/19/23 allegation of abuse. Staff 11 (CNA) and Staff 19 (Former CNA) witnessed Staff 3 force Resident 1 to take medications. On 12/7/23 at 10:40 AM Staff 11 stated she and Staff 19 reported the incident to Staff 1 (Administrator) who dismissed it. Staff 11 stated Resident 1's daughter worked at the facility in HR (Human Resources) and was also told of the incident. On 12/7/23 at 12:30 PM Staff 1 acknowledged forcing a resident to take medications when they refused, spit them out and tried to hit the nurse ,was abuse and verified he did not submit a FRI to the State Agency. See F600.

Based on interview and record review it was determined Staff 3 (RN) failed to provide care and services which allowed residents the right to refuse care and physically forced personal care upon 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for abuse and nine unsampled residents, which did not meet professional standards of quality. This failure resulted in widespread refusal of care not being honored by Staff 3, provision of care against residents' wishes, mental anguish due to intimidation, mocking of Resident 2, potential of further vilation of resident rights, and care being forced upon all residents. Findings include: 1a. Resident 2 admitted to the facility in ,d+[DATE] with COPD (chronic obstructive pulmonary disease), hemiplegia (paralysis on one side) and multiple cancer diagnoses. Resident 2 was on end of life, comfort care measures. The [DATE] Written Statements of Staff 5 (CNA) and Staff 6 (CNA) revealed on [DATE] around 4:30 PM Resident 2 refused care which was reported to Staff 3 (RN). Staff 3 went to Resident 2's room and against the wishes of the resident, forced the resident to have a bed bath and full linen change although Resident 2 fought back. At one point during the incident, Staff 3 laughed at Resident 2 and stated the resident was very upset with her. On [DATE] at 7:21 PM Staff 3 acknowledged she completed a bed linen change and full bed bath when the resident said no. Staff 3 stated she could not recall saying anything rude to the resident. Staff 3 further stated it was a fine line between neglect of care and allowing the resident to refuse care and be soiled all day. On [DATE] at 4:15 PM and 7:16 PM Staff 1 (Administrator) verified Resident 2 was resistive to care and did not want to get cleaned up. b. The following staff interviews identified the following concerns related to Staff 3: *On [DATE] at 1:50 PM Staff 7 (CNA) stated she had been forced to weigh Resident 3 when the resident wanted her/his weight checked in the evening instead. Staff 7 further stated it felt like Resident 3 had no rights and Staff 3 was always rude to both residents and the CNAs. *On [DATE] at 1:53 PM Staff 8 (CNA) stated Staff 3 required her to get residents up for meals when they did not want to. Staff 8 further stated Staff 3 was rude to both residents and staff. *On [DATE] at 2:00 PM Staff 10 (CNA) stated Staff 3 forced her to get Resident 1 up for breakfast when she/he did not want to get up one time. Staff 10 stated after that incident she stood up to Staff 3 and refused to get the resident up when she/he did not want to get up. *On [DATE] at 2:13 PM Staff 11 (CNA) stated Staff 3 has ordered her many times to shower residents when the residents refused. However, she would advocate for her residents which resulted in retaliation by Staff 3 for the next several days. Staff 11 stated residents were scared of Staff 3, felt she was condescending, rude and pushy. Some residents would comply with her when they would not with other nurses because they were scared and intimidated by her. Staff 11 offered examples of one resident who would only wear her/his booties and compression hose when Staff 3 was their nurse and another resident who would come up to the medication cart, ask for her/his medications and Staff 3 would purposely make the resident wait and not administer the medications. *On [DATE] at 2:26 PM Staff 12 (CNA) stated there were three residents who liked to stay in bed but Staff 3 heavily pushed to ensure they got out of bed and into the cafeteria for meals. Staff 3 would use the words, have to when she spoke with the residents. The residents in turn would yell at her because they were forced to get out of bed. Staff 12 stated she had reported this concern three to four times in the past six months but nothing was done. Staff 12 further stated Staff 3 was the only nurse who forced the residents to get out of bed. *On [DATE] at 2:36 PM Staff 13 (CNA) stated there was one resident who always refused showers and Staff 3 forced her to get in the shower at least every week. Staff 13 further stated Staff 3 believed every resident should shower at least weekly. If they refused a second time during the week she would not allow them to refuse. *On [DATE] at 2:33 PM Staff 6 (CNA) stated he witnessed Staff 3 not honor a resident's right to refuse a bed bath. Staff 6 further stated he witnessed Staff 6 threaten Staff 5 by telling her she would turn her in for neglect of care if Staff 5 honored a resident's right to refuse care. Staff 6 stated Staff 3 frequently threatened staff with turning them in for neglect when they advocated for a resident and would frequently force staff to perform care against the residents wishes. *On [DATE] at 2:46 PM Staff 14 (CNA) stated Staff 3 had forced care on residents on many occasions and was rude to both residents and CNAs. Staff 14 stated Staff 3 had put her hands on CNAs and pulled them down the hall and/or into a resident room. Staff 14 re-stated Staff 3 frequently forced CNAs to provide care to residents who refused care. *On [DATE] at 12:51 PM Staff 15 (CNA) stated if a resident had a lower cognition and refused weight checks they would not allow the resident to refuse because Staff 3 would say, You will do what I want now. *On [DATE] at 2:59 PM Staff 16 (CNA) stated Staff 3 would use strong words when encouraging residents to comply with care and knew the residents felt pressured by her. *On [DATE] at 3:10 PM Staff 17 (CNA) stated she witnessed multiple occasions when a resident did not want to get out of bed or have a shower and was forced to by Staff 3. *On [DATE] at 3:19 PM Staff 18 (CNA) stated there were many instances when Staff 3 would talk to a resident who refused a shower and forced them into the shower although they still refused. *On [DATE] at 3:20 PM Staff 20 (CNA) stated she witnessed multiple occasions when Staff 3 forced residents into the shower or to get out of bed when they refused and did not want to. *On [DATE] at 3:25 PM Staff 5 stated she had witnessed Staff 3 force showers on residents on multiple occasions. Staff 5 stated she overheard Staff 3 state she hated her which was why she was rude to her. *On [DATE] at 8:37 PM Staff 20 re-approached this surveyor to report Staff 3 had lashed out and was extremely rude to Staff 5 that afternoon (Staff 5 was one of two main witnesses to the abuse of Resident 1). Staff 20 stated another staff member who also witnessed the incident told her she was being rude and Staff 3 replied, she should be nice to me then. Staff 20 says this behavior was not ok, it had been reported to the Administrator but when Staff 3 didn't like someone or something did not go her way she would just go off. Staff 20 stated when this occurred the CNAs did not know who to go to for assistance. On [DATE] at 9:05 PM the facility was notified of the Immediate Jeopardy (IJ) situation and an immediacy removal plan was requested. On [DATE] at 10:31 PM the facility submitted an acceptable immediacy removal plan which would abate the IJ situation. The immediacy removal plan included the following: *Staff 3 was placed on administrative leave pending further action(s). *All residents would be interviewed on [DATE] to identify if there were any further affected resident(s). *Staff would be trained on the definitions of abuse, including all types of abuse. *Staff would be trained on reporting allegations, including when to report, how to report, who to report to, as well as how to report allegations without retaliation. *The Administrator would conduct audits with random staff members in the form of questions related to what was abuse, when do they report, and who do they report it to. Audits would occur weekly for four weeks, then monthly for two months. *Audits would be shared with facility QAPI team *Administrator and DNS would be responsible to ensure corrections. On [DATE] at 5:23 PM staff interviews verified re-education per the immediacy removal plan was completed. Four Facility Reported Incidents (FRIs) were reported to the State Agency as a result of the resident interviews for allegations of abuse or intimidation by Staff 3. A review of facility documentation revealed all aspects of the immediacy removal plan were implemented. 2a. Resident 1 was admitted to the facility in 2018 with diagnoses include stroke, behavioral disturbance and cognitive communication deficit. The [DATE] Facility Investigation revealed on [DATE] Staff 3 (RN) forced Resident 1 to take medications when the resident repeatedly told Staff 3 she/he did not want the medications, repeatedly spit out the medications and hit Staff 3. On [DATE] at 12:30 PM Staff 1 acknowledged forcing a resident to take medications when they refused, spit them out and tried to hit the nurse, was abuse. b. Resident 3 was admitted to the facility in ,d+[DATE] with diagnoses including multiple sclerosis and chronic pain. On [DATE] at 4:05 PM Resident 3 stated Staff 3 (RN) forced her/him to take medications and to get her/his weight checked when she/he had already refused. Resident 3 stated she/he understood why staff checked her/his weight but still wanted to check her/his weight only when it was convenient for her/him. On [DATE] at 1:50 PM Staff 7 (CNA) stated Staff 3 forced her to get Resident 3's weight when Resident 3 did not want it done and felt like Resident 3 had no rights. Staff 7 further stated Staff 3 was always rude to both residents and caregivers. c. On [DATE] at 6:46 PM Resident 5 stated she/he was not always allowed to refuse care such as bathing or personal hygiene by Staff 3. d. On [DATE] at 4:35 PM Witness 2 (family) stated when Resident 4 first admitted she/he was not allowed to remain in her/his bed for meals and was forced to get up and go to the dining room. Witness 2 stated when she found out about it, she put a stop to it and now the resident was allowed to remain in bed. e. On [DATE] at 11:52 AM Staff 21 (CNA) stated she had multiple examples when Staff 3 was abusive and forced care upon the residents. Staff 21 stated one incident she witnessed, Staff 3 tried to force medications and water down the throat of a resident who was a choking risk and was actively coughing. On another day with the same resident the resident was flat in bed because she was dressing her/him and she/he was only partially dressed. Staff 3 entered the room and administered medications to the resident when the resident was completely flat without waiting for the resident to get dressed or to have the head of the bed raised. Staff 21 further stated on a different day, she assisted a resident with dressing in a double room with the curtain drawn, Staff 3 entered the room and demanded she come over to assist with a skin check on the other resident. Staff 20 told Staff 3 what she was doing but Staff 3 stated, I am not asking. I am telling you to help me with this. I am your nurse. Staff 20 stated she had to leave the resident who was only partially dressed and with her entire chest exposed. Staff 21 shared another example when an overweight resident in the dining room choked. The resident started to cough, stopped breathing and slumped in the wheelchair. Staff 21 stated she went behind the resident to initiate the Heimlich maneuver but Staff 3 pushed her away, started to put her arms around the resident but suddenly stood up and gave up. She said the resident was too big and did not even try. Staff 21 reported the resident revived her/himself and had no known negative outcome. Refer to F600

Based on observation, interview and record review the facility failed to follow physician orders [REDACTED].#103) reviewed for end of life care. This placed the resident at an immediate risk for aspiration. The failure of staff to implement the physician orders [REDACTED]. Findings include: Resident 103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/20/17 physician orders [REDACTED]. Resident 103 had a [MEDICAL CONDITION] for management of [MEDICAL CONDITION] and received medications including narcotics, food and fluids through a [DEVICE] ([DEVICE]). The 1/20/17 facility's Managing Acute Condition Changes Report (MACC) revealed the resident was a new admit, required monitoring every shift, had pain, anxiety [MEDICAL CONDITION]. The 1/20/17 In Room Care plan under the Swallowing Precautions indicated the resident was NPO and had a white board for communication. The resident understood English well and spoke words but with little to no sound. On 1/20/17 at 1:45 pm Staff 15 (RN) noted Arrived to facility, [MEDICAL CONDITION] in throat. On 1/20/17 Staff 2 (Interim DNS) completed the Diet Order and Communication form to the dietary staff revealing the resident was a new resident, had a [DEVICE] and was NPO. On 1/21/17 at 5:50 am the PN from Staff 6 (RN) noted [MEDICAL CONDITION] was clean and there was a creamy yellow mucous noted. On 1/22/17 at 11:09 pm Staff 11 (RN) noted the resident required tracheotomy care and suctioning due to increased secretions, the [MEDICAL CONDITION] tie was changed due to soiling and the resident was given [MEDICATION NAME] and an anti-anxiety medication for comfort. Observations on 1/23/17 at 10:22 am revealed the resident was in bed with the head of the bed elevated. Staff 2 was in the room and indicated the resident did her/his oral suctioning by mouth independently. The suction machine container of oral cavity secretions was pink in color. Staff 2 indicated the resident was admitted three days ago and they were still getting to know the resident. The resident was observed to suction her/his oral secretions and there was a pink water pitcher within her/his reach on the over the bed tray table. On 1/23/17 at 10:41 am, Resident 103 was observed to pick up the pink pitcher and put the straw to her/his mouth and suck on the straw. On 1/23/17 at 12:09 pm Resident 103 was observed to be in bed with the head of bed elevated. There was a pink pitcher with a straw on the bedside table within the resident's reach. The surveyor picked up the pitcher and there was fluid in the pitcher. On 1/23/17 at 12:51 pm there was a pink pitcher with a straw on Resident 103's bedside table and was within reach. On 1/23/17 at 1:43 pm the resident was awake laying on her/his back leaning towards his right side. Staff 5 (RN) entered the room and noticed the suction machine container of oral cavity secretions was pink in color. The resident wrote on the white board she/he had cranberry juice. Staff 5 indicated she was going to empty the container. The pink pitcher of fluids remained on her/his bedside table and was within Resident 103's reach. The facility's 1/23/17 MACC Report revealed the resident was palliative care for chronic [MEDICAL CONDITION], cancer of the larynx and status [REDACTED]. There was also a section on the MACC report for palliative care for staff to assess lung sounds. On 1/24/17 at 7:50 am the resident laid in bed on her/his back with the head of bed elevated. The resident had the pink cup of fluids on her/his bedside table within reach of the resident. On 1/24/17 at 8:17 am Staff 6 (RN) entered the resident's room to administer [MEDICATION NAME] through the resident's [DEVICE]. Staff 6 raised the resident's bed and the resident picked up the pink cup and the resident drank from the cup. The resident motioned for the oral suction and then suctioned her/his mouth. Staff 6 indicated they do [MEDICAL CONDITION] suctioning every six hours when the resident lets them because she/he did not like the suctioning. When Staff 6 left the room she did not remove the pink pitcher of fluids. The Progress Note for 1/24/17 at 12:32 PM noted the resident had copious amounts of greenish colored sputum from [MEDICAL CONDITION]. The assessment of lung sounds was not documented The 1/24/17 Speech Therapy Treatment Encounter Notes revealed the resident's swallowing abilities were profound or absent and had little to no attempts to initiate and participate. The resident was to be monitored for signs and symptoms of aspirations, was NPO and oral intake was only with one on one supervision. On 1/25/17 at 7:40 am there was a cup of water on the bedside tray table. On 1/25/17 at 8:09 am Staff 2 entered the room. The cup of water was on the resident's tray table and he did not remove it. On 1/25/17 at 9:01 am the resident was in bed and there was a cup of water on the bed side tray table. The suction machine container of oral cavity secretions had cloudy mucous and clot like debris and the resident was observed to suction her/his mouth. On 1/25/17 at 9:15 am Staff 3 (RNCM) indicated the resident was admitted with a NPO order. She got report from CNAs the resident had water in her/his room. She confirmed with Staff 12 (Director of Therapy Speech Language Pathologist) the resident should not have water in her/his room even if it was to wet her/his mouth and suction it out. Staff 3 indicated she updated the In Room Care Plan on 1/24/17 to reflect there should be no water at bedside. On 1/25/17 at 9:18 am Staff 12 (Director of Rehabilitation Speech Language Pathologist) indicated she evaluated the resident on 1/24/17 and did not observe the pink pitcher at bedside during the evaluation. Her recommendations were NPO and thought nursing agreed with those recommendations prior to her evaluation. During interview on 1/25/17 at 10:07 am Staff 5 (RN) indicated Staff 8 (CNA) reported the resident had water at her/his bedside on 1/24/17. Staff 5 stated she reviewed the care plan which indicated the resident was NPO. On 1/25/17 at 12:36 pm after consultation with the State survey supervisors the survey team informed Staff 1 (Administrator), Staff 2 (Interim DNS) and Staff 9 (Corporate RN) of the failure to follow the physician's orders [REDACTED]. On 1/25/17 at 12:45 pm the survey team requested a plan of correction to be developed and implemented by the facility to immediately follow the physician's orders [REDACTED]. On 1/25/17 at 2:45 pm a plan of correction was submitted by the facility which ensured Resident 103's physician's orders [REDACTED]. The Plan of Correction stated: -All free water was removed from bedside in affected residents' room. -Lung assessment completed immediately. -A sign stating NPO was placed above the residents bed, in addition to it being stated on the In Room Care Plan in residents room. -Nursing order initiated to Check resident ' s room QID to ensure no water, fluids or food are within reach of resident. -No other residents were potentially affected by this deficient practice based on; no other residents had a [MEDICAL CONDITION] and no other residents were NPO. -Staff were in-serviced regarding NPO status and what that means, and checking the In Room Care Plan prior to providing care to the resident. -Charge nurse will visually confirm there was not any water at bedside at the beginning and once during shift, every shift thereafter until discharge. -Resident's EMAR will be audited daily in MACC to ensure compliance with charge nurse rounds related to NPO status. Results of audits will be brought to the QA committee monthly X 3 months for review and further action as indicated. Saturday and Sunday DNS/Designee will review EMAR and follow up with the Charge nurse as indicated Qweek X 3 months or until the resident discharges. On 1/25/17 at 2:45 pm the survey team reviewed the updated care. Throughout the remainder of the survey Resident 103 was observed to have no beverages at bedside, and the facility placed a bright pink sign above the resident's bed indicating NPO. The plan of correction was accepted. The Immediate Jeopardy was abated. Further interviews of staff were conducted after the Immediate Jeopardy was abated and revealed: On 1/27/17 at 9:43 am Staff 11 (RN) was contacted by phone and indicated she was the night shift nurse. Staff 11 indicated the resident was supposed to be NPO and the resident requested water and the water was already in front of her/him so she gave it to the resident. She thought because the pitcher was on the resident's tray table it was accepted to give the resident water. She stated she assumed the resident was comfort care and if the resident wanted it she gave it to the resident. She indicated she should have clarified the NPO order with the physician. On 1/25/17 at 1:33 pm Staff 7 (CNA) was contacted by phone and indicated during the day shift on 1/23/17 she provided ice water in the pink pitcher and cranberry juice when the resident asked for it.

Based on interview and record review the facility failed to ensure 2 of 4 sampled residents (#s 21 and 92) reviewed for hydration and [MEDICAL TREATMENT] were free from neglect of care. This resulted in Resident 21 sustaining an injured shoulder and Resident 92 sustaining a deep laceration to the left thigh during transfers. Findings include: The facility provided the following policies and procedures: 1. ABUSE: What is it? Who do you report to? Who is responsible to report abuse? The Definition of Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 2. The facility's 11/2016 Abuse screening, training, identification, investigation, reporting and protection revealed the following under the Prevention heading: 8) Caregivers are provided sufficient information to provide care for assigned residents utilizing the in-room-care plan and oral report from the licensed nurse. 9) Licensed nurses, nursing management staff, administrative staff are responsible for the supervision of facility staff to identify inappropriate behaviors such as use of derogatory language, rough handling, ignoring residents while providing care, providing privacy, providing care as identified on the residents plan of care. 17) Administrative personnel will immediately remove staff members involved in said incident from their duties. The staff member will be sent home until administrative personnel can complete a thorough investigation of reported incident. 18) If an allegation of abuse is substantiated the employee's employment will be terminated. If the employee is certified or a licensed professional their supervising agency will be notified. 19) Allegations of abuse, neglect or exploitation will be reported immediately to appropriate state survey agency. Results of the investigation will be reported to the state survey agency in a timely manner after initial reporting. 1. Resident 21 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The 6/7/16 admission MDS under Section C for Cognition revealed the resident had short term memory problems and was impaired for daily decision making, under Section G for Functional Status, the resident required extensive assistance with bed mobility, transfers, toileting, locomotion on and off the unit and grooming. The 6/13/16 CAA for Cognitive Loss indicated the resident was alert and oriented to self and place, no cognitive decline, the resident had shown no short term memory deficit but was unable to complete the BIMS (Brief Interview for Mental Status) related to dysphasia from a stroke. The CAA for ADLs and Functional Status revealed the resident had falls in the facility, had limited range of motion to her/his left side from a stroke, was a sit to stand lift and needed extensive staff assistance with all care. The 7/4/16 Comprehensive Care Plan revealed the resident had impaired mobility and ADL function related to stroke with left sided deficit. Staff were to assist the resident moving to and from lying position/scooting up in bed/turning side to side/positioning body while in bed. Staff were to perform a two person assist with the hoyer lift to bed, two person assist with the sit to stand lift to bedside commode and/or shower chair. The Progress Note (PN) for 7/14/16 at 5:07 pm revealed Staff 5 (RN) responded to a STAT call for assistance in Resident 21's room. Upon entering the room a CNA was found having difficulty with the resident in the sit to stand lift and the resident was falling downwards. Staff 5 assisted the CNA to help the resident safely to the floor. Resident 21 complained of left shoulder pain. Upon Staff 5's assessment there was no bruising noted and the resident was able to mover her/his left shoulder. She assisted the resident with the hoyer lift from the floor to the bed. The resident indicated she/he had no pain in the lower extremities just in her/his left shoulder. Vital signs were completed and staff would continue to monitor. The 7/14/16 facility Fall Investigation revealed the incident occurred during a transfer using the sit to stand lift to the commode, and suspected the sling was not applied correctly. Staff 10 (CNA) reported he was the only one in the room, the resident was in the sit to stand, the resident's legs gave out and he assisted the resident to the floor and called for assistance STAT. Two staff arrived to help Staff 10. On 7/18/16 the Clinical Management team determined the care plan interventions for two person assist transfers was not followed. Resident 21 was transferred with a (one person) assist which resulted in the injury to resident (increased shoulder pain). On 1/27/17 at 9:35 am Staff 10 (CNA) was contact by phone and he indicated he was unable to recall the incident. On 1/27/17 at 1:06 pm Staff 1 (Administrator) acknowledged Resident 21 was a two person transfer since it was reported in the incident investigation. 2. Resident 92 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. The 11/15/16 In Room Care Plan indicated the resident was a two person assist for transfers with a hoyer lift. The 11/18/16 Progress Notes (PN) from the Physical Therapist revealed the resident was a two person maximum assist for bed mobility, required the use of a hoyer lift for transfers, and had poor balance. The Occupational Therapist noted the resident was unable to follow simple one step commands. On 11/24/16 Staff 6 (RN) noted in the PN she was called to Resident 92's room at approximately 5:45 am and the CNA pointed to blood on the blue bootie of the resident's right lower extremity. Staff 6 removed the blue bootie and noticed a large V shape laceration approximately three inches in length and two inches in width and at the widest portion was 1/4 to 1/2 inch in depth. The blood and wound appeared dried and the resident was unable to say what happened. The wound was deep into the subcutaneous tissue and Staff 6 was unable to steri-strip the wound. The resident was transported to the hospital. The 11/24/16 investigation revealed Staff 19 (CNA) worked the swing shift on 11/23/16 and indicated she assisted with a transfer for Resident 92 from the wheelchair to the bed after dinner around 6:30-7:00 pm. She indicated nothing happened during the transfer after dinner that could have caused the skin tear. Staff 19 did not assist the resident with a transfer prior to dinner. The 11/24/16 facility investigation for the laceration revealed on 11/23/16 Staff 10 (CNA) was assigned to Resident 92's care during the swing shift. Staff 10 indicated the resident remained in bed throughout the shift and she/he did not get up into her/his chair due to fatigue. Staff 4's (RNCM) 11/24/16 evaluation of the incident revealed it seemed the skin tear occurred sometime on 11/23/16 probably on swing shift. The resident was not able to move in her/his bed or wheelchair enough to bump her/his leg on something so it must of happened during a transfer or cares. It seemed Resident 92's leg was bumped on something and staff did not notice or did not report it at the time of the occurrence. The 12/1/16 Clinical Management Team Review recommendations included the resident was now bed bound and transfers were no longer an issue. this raises a concern for safety with transfers with (Staff 10), since his story is inconsistent with the rest of the staff that was here that day. it appears that he transferred (Resident 92) prior to dinner without assistance, which is not per the care plan. when asked about transfers he denies transferring (Resident 92) at all. it is entirely possible that this skin tear occurred during the this transfer when (Staff 10) was by himself . (this is not the first time he has not followed the care plan and injured a resident). This was signed by Staff 4 (RNCM). On 1/26/17 at 1:05 pm Staff 1 (Administrator) verified Staff 10 failed to follow the care plan for Resident 92 for a two person transfer which resulted in a deep laceration to her/his lower extremity. On 1/27/17 at 9:35 am Staff 10 indicated by a phone conversation he found the laceration when he came on shift and reported it to the nurse because it was new. He was unable to recall the time he reported it or if he transferred the resident on 11/23/16 during the evening shift.

Based on interview and record review it was determined the facility failed to operationalize their policies and procedures to investigate, rule out abuse and report incidents for neglect of care as required for 3 of 4 sampled residents (#s 21, 92 and 102) reviewed for hydration, [MEDICAL TREATMENT] and injuries. As a result Resident 21 sustained a shoulder injury and Resident 92 sustained a deep laceration to her/his lower extremity during transfers. Findings include: The facility provided the following policies and procedures: 1. ABUSE: What is it? Who do you report to? Who is responsible to report abuse? The Definition of Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. 2. The facility's 11/2016 Abuse screening, training, identification, investigation, reporting and protection revealed the following under the Prevention heading: 8) Caregivers are provided sufficient information to provide care for assigned residents utilizing the in-room-care plan and oral report from the licensed nurse. 9) Licensed nurses, nursing management staff, administrative staff are responsible for the supervision of facility staff to identify inappropriate behaviors such as use of derogatory language, rough handling, ignoring residents while providing care, providing privacy, providing care as identified on the residents plan of care. 17) Administrative personnel will immediately remove staff members involved in said incident from their duties. The staff member will be sent home until administrative personnel can complete a thorough investigation of reported incident. 18)If an allegation of abuse is substantiated the employee's employment will be terminated. If the employee is certified or a licensed professional their supervising agency will be notified. 19) Allegations of abuse, neglect or exploitation will be reported immediately to appropriate state survey agency. Results of the investigation will be reported to the state survey agency in a timely manner after initial reporting. 1. Resident 21 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The In Room Care Plan for 3/6/15 which was updated 8/10/16 revealed the resident was a two person assistance with sit to stand to the bedside commode, and required a two person assist for transfers with a hoyer lift. The Progress Note (PN) for 7/14/16 at 5:07 pm revealed Staff 5 (RN) responded to a STAT call for assistance in Resident 21's room. Upon entering the room a CNA was found having difficulty with the resident in the sit to stand lift and the resident was falling downwards. Staff 5 assisted the CNA to help the resident safely to the floor. Resident 21 complained of left shoulder pain. Upon Staff 5's assessment there was no bruising noted and the resident was able to mover her/his left shoulder. She assisted the resident with the hoyer lift from the floor to the bed. The resident indicated she/he had no pain in the lower extremities just in her/his left shoulder. Vital signs were completed and staff would continue to monitor. The 7/14/16 facility Fall Investigation revealed the incident occurred during a transfer using the sit to stand lift to the commode, and suspected the sling was not applied correctly. Staff 10 (CNA) reported he was the only one in the room, the resident was in the sit to stand, the resident's legs gave out and he assisted the resident to the floor and called for assistance STAT. Two staff arrived to help Staff 10. On 7/18/16 the Clinical Management team determined the care plan interventions for two person assist transfers was not followed. Resident 21 was transferred with a (one person) assist which resulted in the injury to resident (increased shoulder pain). The facility started the investigation on 7/14/16 and completed the investigation on 7/18/16. Staff 10's employee time sheet revealed he worked on 7/17/16 and 7/18/16. The facility failed to follow their own Policy # 17 as above. The facility did not rule out abuse or neglect and did not report the incident to the local SPD unit. The facility failed to operationalize their own policy and procedures to rule out neglect of care and did not report the incident to the local SPD unit. On 1/26/17 at 1:05 pm Staff 1 indicated they were to report to the local unit if there was neglect, and administrative personal would immediately remove the staff member involved so they could investigate. If the allegation was unsubstantiated the staff would be reinstated. He indicated Staff 10 did not follow the care plan. Staff 1 was asked if they followed their own procedures, Staff 1 indicated evidently not. 2. Resident 92 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. The 11/15/16 In Room Care Plan revealed the resident was a two person assist for transfers with a hoyer lift. The Progress Note for 11/24/16 revealed Resident 92 sustained a V shape laceration approximately three inches in length and two inches in width and at the widest portion was 1/4 to 1/2 inch in depth to her/his left lower extremity. The resident had advanced dementia and was unable to say what happened and was transported to the hospital. The investigation started on 11/24/16 and the administrator review was completed on 12/9/16. On 12/1/16 The Clinical Management Team Review recommendations included the resident was now bed bound and transfers were no longer an issue. this raises a concern for safety with transfers with (Staff 10), since his story is inconsistent with the rest of the staff that was here that day. it appears that he transferred (Resident 92) prior to dinner without assistance, which is not per the care plan. when asked about transfers he denies transferring (Resident 92) at all. it is entirely possible that this skin tear occurred during the this transfer when (Staff 10) was by himself . (this is not the first time he has not followed the care plan and injured a resident). Abuse or neglect was not ruled out. On 12/1/16 the facility determined Staff 10 injured Resident 92 and another resident (Resident 21) during a transfer. On 12/9/16 Staff 1 (Administrator) reviewed and signed off on the incident. The Employee time sheet revealed Staff 10 worked on 12/2/16, 12/4/16 and 12/5/16 prior to the completion of the administrator review. On 1/26/16 at 11:26 am Staff 2 (DNS) indicated Staff 10 worked the previous swing shift and remained working at the facility. By allowing Staff 10 to remain at the facility after the 11/24/16 investigation revealed Staff 10 injured Resident 21 and Resident 92 while completing a one person transfer instead of a two person transfer. The facility could not ensure the residents were free from neglect of care. The facility did not follow their own policies of suspending Staff 10 during the investigation, ruling out abuse or neglect, and reporting the incident to the local SPD unit. By not following the policies, the facility could not ensure the residents were safe from neglect of care from Staff 10. On 1/26/17 at 1:05 pm Staff 1 indicated they were to report to the local unit if there was neglect, and administrative personnel would immediately remove the staff member involved so they could investigate. If the allegation was unsubstantiated the staff would be reinstated. He indicated they substantiated Staff 10 not following the care plan. Staff 1 was asked if they followed their own procedures, Staff 1 indicted evidently not. Refer to F 223 3. Resident 102 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing assessment dated [DATE] noted the resident had her/his left leg amputated above the knee and had 49 sutures in the incision. Resident Progress Note dated 7/27/16 at 4:49 am noted: the resident's left stump was oozing serosanguineous fluid from the lower lateral side of the incision line and had moderate amounts of drainage. The nurse noted the drainage started after a Hoyer lift transfer which may have placed pressure on the stump. Resident Progress Note dated 7/27/16 at 6:45 am noted: the licensed nurse was called to the resident's room and upon entrance blood observed blood spatter on the wall. The resident's left stump was bleeding out of two areas of the surgical incision. Possible dehiscence and was draining moderate amount of serangeous fluid. Multiple attempts to stop the bleeding were made by several nurses. The resident stated the night shift aids incorrectly used the Hoyer lift which caused the bleeding to start. The ambulance was called due to excessive bleeding and the resident was transported to the hospital. The Emergency Provider Record dated 7/27/16 noted the resident was at the emergency department due to a transfer lift at the nursing facility on 7/26/16 when the stump was hit. The lateral wound opened and had oozed since the incident. Resident Progress Note dated 7/27/16 at 8:54 am noted the resident had returned from the hospital. Resident Progress Notes from 7/27/16 through 7/29/16 included excessive bleeding from the left leg incision and noted multiple dressing changes. Resident Progress Note dated 7/30/16 noted the resident was concerned with drainage from the wound and a possible infection and was sent to the hospital. The resident refused to return to the facility and was discharged on [DATE]. On 1/25/17 at 4:13 pm, Staff 2 (DNS) stated the Resident 102 had a left leg amputation wound which had excessive bleeding while admitted to the facility. Staff 2 was informed of the complaint the resident was injured by staff when transferred with a Hoyer Lift (Machine to assist immobile residents). Staff 2 acknowledged the request for the facility investigation regarding the reported incident and stated the facility had no investigation which involved Resident 102. On 1/26/17 at 3:22 pm. Staff 13 (CNA) stated she worked the night shift with Resident 102 and witnessed the Hoyer lift incident. Staff 13 further stated we used a Hoyer lift to transfer her/him which ripped the incision on her/his leg. Staff 13 stated the resident yelled in pain and the stump was bleeding. On 1/30/17 at 10:36 am Staff 2 acknowledged the Resident Progress Notes indicated several nurses were aware an accident occurred which required emergency medical attention. Staff 2 stated the facility should have investigated the accident to rule out abuse and neglect.

Based on interview and record review the facility failed to ensure 2 of 4 sampled residents (#s 21 and 92) reviewed for hydration and dialysis were free from accidents. This resulted in Resident 21 sustaining an injured shoulder and Resident 97 sustaining a deep laceration to the left extremity during transfers. Findings include: 1. Resident 21 was admitted to the facility in 5/2016 with [DIAGNOSES REDACTED]. The 6/7/16 admission MDS under Section C for Cognition revealed the resident had short term memory problems and was impaired for daily decision making, under Section G for Functional Status, the resident required extensive assistance with bed mobility, transfers, toileting, locomotion on and off the unit and grooming. The 6/13/16 CAA for Cognitive Loss indicated the resident was alert and oriented to self and place, no cognitive decline, the resident had shown no short term memory deficit but was unable to complete the BIMS (Brief Interview for Mental Status) related to dysphasia from a stroke. The CAA for ADLs and Functional Status revealed the resident had falls in the facility, had limited range of motion to her/his left side from a stroke, was a sit to stand lift and needed extensive staff assistance with all care. The 7/4/16 Comprehensive Care Plan revealed the resident had impaired mobility and ADL function related to stroke with left sided deficit. Staff were to assist the resident moving to and from lying position/scooting up in bed/turning side to side/positioning body while in bed. Staff were to perform a two person assist with the hoyer lift to bed, two person assist with the sit to stand lift to bedside commode and/or shower chair. The Progress Note (PN) for 7/14/16 at 5:07 pm revealed Staff 5 (RN) responded to a STAT call for assistance in Resident 21's room. Upon entering the room a CNA was found having difficulty with the resident in the sit to stand lift and the resident was falling downwards. Staff 5 assisted the CNA to help the resident safely to the floor. Resident 21 complained of left shoulder pain. Upon Staff 5's assessment there was no bruising noted and the resident was able to mover her/his left shoulder. She assisted the resident with the hoyer lift from the floor to the bed. The resident indicated she/he had no pain in the lower extremities just in her/his left shoulder. Vital signs were completed and staff would continue to monitor. The 6/7/16 admission MDS under Section C for Cognition revealed the resident had short term memory problems and was impaired for daily decision making, under Section G for Functional Status, the resident required extensive assistance with bed mobility, transfers, toileting, locomotion on and off the unit and grooming. The 7/14/16 facility Fall Investigation revealed the incident occurred during a transfer using the sit to stand lift to the commode, and suspected the sling was not applied correctly. Staff 10 (CNA) reported he was the only one in the room, the resident was in the sit to stand, the resident's legs gave out and he assisted the resident to the floor and called for assistance STAT. Two staff arrived to help Staff 10. On 7/18/16 the Clinical Management team determined the care plan interventions for two person assist transfers was not followed. Resident 21 was transferred with a (one person) assist which resulted in the injury to resident (increased shoulder pain). On 1/27/17 at 9:35 am Staff 10 (CNA) was contact by phone and indicated he was unable to recall the incident. Staff 10 failed to follow the Care Plan to utilize a two person transfer instead of a one person transfer using the sit-to-stand. This constituted an unsafe transfer which resulted in left shoulder pain for Resident 21. On 1/27/17 at 1:06 pm Staff 1 (Administrator) acknowledged Resident 21 was a two person transfer since it was reported in the incident investigation. Refer to 223 2. Resident 92 was admitted to the facility in 11/2016 with [DIAGNOSES REDACTED]. The 11/15/16 In Room Care Plan indicated the resident was a two person assist for transfers with a hoyer lift. The 11/18/16 Progress Notes (PN) from the Physical Therapist revealed the resident was a two person maximum assist for bed mobility, required the use of a hoyer lift for transfers, and had poor balance. The Occupational Therapist noted the resident was unable to follow simple one step commands. On 11/24/16 Staff 6 (RN) noted in the PN she was called to Resident 92's room at approximately 5:45 am and the CNA pointed to blood on the blue bootie of the resident's right lower extremity. Staff 6 removed the blue bootie and noticed a large V shape laceration approximately 3 inches in length and 2 inches in width and at the widest portion was 1/4 to 1/2 inch in depth. The blood and wound appeared dried and the resident was unable to say what happened. The wound was deep into the subcutaneous tissue and Staff 6 was unable to steri-strip the wound. The resident was transported to the hospital. The 11/24/16 investigation revealed Staff 19 (CNA) worked the swing shift on 11/23/16 and indicated she assisted with a transfer for Resident 92 from the wheelchair to the bed after dinner around 6:30-7:00 pm. She indicated nothing happened during the transfer after dinner that could have caused the skin tear. Staff 19 did not assist the resident with a transfer prior to dinner. The 11/24/16 facility investigation for the laceration revealed on 11/23/16 Staff 10 (CNA) was assigned to Resident 92's care during the swing shift. Staff 10 indicated the resident remained in bed throughout the shift and she/he did not get up into her/his chair due to fatigue. Staff 4's (RNCM) 11/24/16 evaluation of the incident revealed it seemed the skin tear occurred sometime on 11/23/16 probably on swing shift. The resident was not able to move in her/his bed or wheelchair enough to bump her/his leg on something so it must of happened during a transfer or cares. It seemed Resident 97's leg was bumped on something and staff did not notice or did not report it at the time of the occurrence. The 12/1/16 Clinical Management Team Review recommendations included the resident was now bed bound and transfers were no longer an issue. this raises a concern for safety with transfers with (Staff 10), since his story is inconsistent with the rest of the staff that was here that day. it appears that he transferred (Resident 97) prior to dinner without assistance, which is not per the care plan. when asked about transfers he denies transferring (Resident 97) at all. it is entirely possible that this skin tear occurred during the this transfer when (Staff 10) was by himself. (this is not the first time he has not followed the care plan and injured a resident). This was signed by Staff 4 (RNCM). On 1/26/17 at 1:05 pm Staff 1 (Administrator) verified Staff 10 failed to follow the care plan for Resident 97 for a two person transfer which resulted in a deep laceration to her/his lower extremity. On 1/27/17 at 9:35 am Staff 10 he was unable to recall if he transferred the resident on 11/23/16 during the evening shift. Refer to 223

Based on interview and record review it was determined two CNA staff failed to ensure a fall was promptly reported to nursing for 1 of 3 sampled residents (#1) who experienced falls. Resident 1 experienced delayed treatment of [REDACTED]. Findings include: Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 4/2/13 indicated the resident was a low fall risk with interventions including bed in the low position, fall mat at the bedside and non skid footwear. The resident required extensive assistance for transfers with two staff assist and a gait belt. The resident was noted to have full weight bearing status. A facility investigation dated 5/23/13 indicated the resident had an episode of unresponsiveness during a transfer, was lowered to the floor and subsequently sent to the hospital for evaluation. The resident was found to have a left shoulder and left femur fracture. Staff 1 (DNS) began an investigation and determined an unreported fall had occurred on 5/18/13. On 5/23/13 Staff 6 (CNA) came forward and reported the resident had fallen during a transfer on 5/18/13 while Staff 6 and Staff 3 (CNA) assisted. At the time of the fall the resident's wheelchair brake was not locked and the staff did not use a gait belt. The resident was placed on the floor. Staff 3 and Staff 6 did not report the incident. Staff 1's investigation further showed the resident had signs of increased pain from 5/18/13 to 5/23/13. NNs dated 5/18/13 at 3:11 am indicated the resident called out once during the shift then slept peacefully. On 5/19/13 the resident stated her/his left knee hurt. The resident was assessed by Staff 1 (DNS) and the leg showed no swelling, bruising, or heat. The resident was able to straighten the leg without complaint. The resident responded she/he sometimes had pain in the left leg. The resident was transferred to the wheelchair without any complaints of pain or visual signs of discomfort. A NN on 5/20/13 at 6:49 pm indicated the resident was medicated with Tylenol twice during the shift for complaints of leg/hip pain. The aide staff reported the resident had been increasingly hard to roll and transfer. The resident had also refused dinner related to increased pain. NNs on 5/21/13 indicated the resident continued to report left leg pain and was difficult to turn. There was no redness or swelling noted. The resident showed a decrease in appetite related to new pain to the left leg. NNs on 5/22/13 indicated the resident continued to complain of pain to the left knee, which was swollen and warm to touch. The resident was given Tylenol and offered ice which the resident declined. The resident was noted to rest quietly the remainder of the night shift. A NN on 5/22/13 at 9:49 am indicated after the resident was transferred out of bed she/he whimpered, told staff they were not nice and threw a hairbrush at staff. Staff 2 (RNCM) assessed the resident's left knee and found it to be swollen, warm to the touch and showed some yellowish faded bruising. The area was extremely tender. The resident jumped and winced when Staff 2 lifted up the resident's pant leg, this was noted as a change from the previous day. The resident's family and physician were notified and an order for [REDACTED]. Additional NNs on 5/22/13 indicated an order for [REDACTED]. On 5/23/13 the resident became unresponsive, possible [MEDICAL CONDITION] activity, and the resident was transported to the hospital for evaluation. In an interview on 5/30/13 at 3:00 pm Staff 2 (RNCM) indicated the resident was confused but could express needs such as pain. Staff 2 assessed the resident's leg on 5/22/13 after reports of increased behaviors and pain. The leg was swollen, discolored; no deformity noted and was tender to the touch. Staff 2 indicated the resident sometimes had complaints of pain but it was not as profound as it was on 5/22/13. The resident's physician was notified and there was some belief the pain was due to gout or arthritis. The resident's pain had been monitored since 5/18/13 when complaints increased but there were no physical signs, changes or sign of injury until 5/22/13. In an interview on 5/30/13 at 3:40 pm Staff 3 (CNA) indicated during a transfer on 5/18/13 the resident was lowered to the floor. Staff 3 stated the resident complained of pain during the transfer and after she/he was placed on the floor. Staff 3 stated she and Staff 6 did not have a gait belt in place on the resident and the wheelchair rolled out of place. Staff 3 further indicated the resident was transferred multiple times after the fall with no gait belt in place. The resident was placed in bed for the night with complaints of leg pain. Staff 3 worked with the resident the following day on 5/19/13 as well. The resident continued to have complaints of leg pain which were reported to the medication aide. However, Staff 3 did not at any point report the resident had fallen on 5/18/13. In an interview on 5/31/13 at 2:33 pm Staff 6 (CNA) indicated she had assisted Staff 3 to transfer the resident without a gait belt. The resident's wheelchair moved and they were unable to complete the transfer. Staff 6 and Staff 3 lowered the resident to the floor. Staff 6 stated during the transfer the resident complained of leg pain. The resident was transferred from the floor, to the wheelchair and then to bed without a gait belt and with continued complaints of pain. Staff 6 did not report the fall to nursing staff on 5/18/13. Staff 6 stated she was off work for the next two days. When she returned she heard the resident had two fractures. On 5/23/13 Staff 6 stated she reported to Staff 1 (DNS) the resident had fallen during the transfer on 5/18/13. Refer to F-323

Based on interview and record review it was determined the facility failed to ensure a resident was transferred according to the care plan for 1 of 3 sampled residents (#1) reviewed for accidents. Resident 1 experienced two falls with fractures and increased pain. Findings include: Resident 1 was a long term resident of the facility with [DIAGNOSES REDACTED]. The resident's care plan dated 4/2/13 indicated the resident was a low fall risk with interventions including bed in the low position, fall mat at the bedside and non skid footwear. The resident required extensive assistance for transfers with two staff assist and a gait belt. The resident was noted to have full weight bearing status. An update to the resident's care plan was made on 5/22/13 for staff to use a Hoyer lift and two staff assistance for transfers. A quarterly nursing assessment dated [DATE] indicated the resident had dementia with future declines expected. The resident was noted as currently stable with no changes. The resident was able to make choices when presented with simple questions and was able to make her/his needs known. The resident denied pain and was not observed with signs or symptoms of pain. The resident was assessed as a fall risk with interventions in place. a. A facility investigation dated 5/23/13 indicated the resident had an episode of unresponsiveness during a transfer, was lowered to the floor and subsequently sent to the hospital for evaluation. The resident was found to have a left shoulder and left femur fracture. Staff 1 (DNS) began an investigation and determined an unreported fall had occurred on 5/18/13. On 5/23/13 Staff 6 (CNA) came forward and reported the resident had fallen during a transfer on 5/18/13 while Staff 6 and Staff 3 (CNA) assisted. At the time of the fall the resident's wheelchair brake was not locked and the staff did not use a gait belt. The resident was placed on the floor. Staff 3 and Staff 6 did not report the incident. Staff 1's investigation further showed the resident had signs of increased pain from 5/18/13 to 5/23/13. NNs dated 5/19/13 the resident stated her/his left knee hurt. The resident was assessed by Staff 1 (DNS) and the leg showed no swelling, bruising, or heat. The resident was able to straighten the leg without complaint. The resident responded she/he sometimes had pain in the left leg. The resident was transferred to the wheelchair without any complaints of pain or visual signs of discomfort. A NN on 5/20/13 at 6:49 pm indicated the resident was medicated with Tylenol twice during the shift for complaints of leg/hip pain. The aide staff reported the resident had been increasingly hard to roll and transfer. The resident had also refused dinner related to increased pain. NNs on 5/21/13 indicated the resident continued to report left leg pain and was difficult to turn. There was no redness or swelling noted. The resident showed a decrease in appetite related to new pain to the left leg. NNs on 5/22/13 indicated the resident continued to complain of pain to the left knee, which was swollen and warm to touch. The resident was given Tylenol and offered ice which the resident declined. The resident was noted to rest quietly the remainder of the night shift. A NN on 5/22/13 at 9:49 am indicated after the resident was transferred out of bed she/he whimpered, told staff they were not nice and threw a hairbrush at staff. Staff 2 (RNCM) assessed the resident's left knee and found it to be swollen, warm to the touch and showed some yellowish faded bruising. The area was extremely tender. The resident jumped and winced when Staff 2 lifted up the resident's pant leg, this was noted as a change from the previous day. The resident's family and physician were notified and an order for [REDACTED]. The care plan was updated for staff to use a Hoyer lift for the resident's transfers. Additional NNs on 5/22/13 indicated an order for [REDACTED]. The resident requested Tylenol twice during the swing shift which was minimally effective. On 5/23/13 the resident became unresponsive, possible seizure activity, and the resident was transported to the hospital for evaluation. In an interview on 5/30/13 at 3:00 pm Staff 2 (RNCM) indicated the resident was confused but could express needs such as pain. Staff 2 assessed the resident's leg on 5/22/13 after reports of increased behaviors and pain. The leg was swollen, discolored; no deformity noted and was tender to the touch. Staff 2 indicated the resident sometimes had complaints of pain but it was not as profound as it was on 5/22/13. The resident's physician was notified and there was some belief the pain was due to gout or arthritis. The resident had previously been a two person stand pivot transfer with a gait belt. Staff 2 stated after her assessment she changed the resident's care plan to use of a Hoyer lift for transfers. In an interview on 5/30/13 at 3:40 pm Staff 3 (CNA) indicated during a transfer on 5/18/13 the resident was lowered to the floor. Staff 3 stated the resident complained of pain during the transfer and after she/he was placed on the floor. Staff 3 stated she and Staff 6 did not have a gait belt in place on the resident and the wheelchair rolled out of place. Staff 3 further indicated the resident was picked up off the floor, put in the wheelchair and then transferred to bed with no gait belt in place. Staff 3 knew a gait belt should have been in place. The resident was placed in bed for the night with complaints of leg pain. In an interview on 5/31/13 at 2:33 pm Staff 6 (CNA) indicated she had assisted Staff 3 to transfer the resident without a gait belt. Staff 6 knew a gait belt should have been in place. The resident's wheelchair moved and they were unable to complete the transfer. Staff 6 and Staff 3 lowered the resident to the floor. Staff 6 stated during the transfer the resident complained of leg pain. The resident was transferred from the floor, to the wheelchair and then to bed without a gait belt and with continued complaints of pain. Staff 6 stated she was off work for the next two days. When she returned she heard the resident had two fractures. b. A facility investigation dated 5/23/13 indicated the resident had an episode of unresponsiveness during a transfer, was lowered to the floor and subsequently sent to the hospital for evaluation. The resident was found to have a left shoulder and left femur fracture. The resident was transferred on 5/23/13 with a sit to stand lift when a care plan update on 5/22/13 indicated a Hoyer lift was to be used. In an interview on 5/30/13 at 10:00 pm Staff 5 (CNA) indicated she had not worked with the resident in several months. Staff 5 checked the care plan which indicated two staff assistance for the resident's transfers. Staff 5 stated she asked another staff, could not remember who, and they said use a lift. Staff 5 assumed it was a standing lift as she had seen the resident last use in January. The resident had complaints of leg pain and during the transfer became unresponsive. Staff 5 could not get the resident back into the wheelchair or into the bed. The resident began to slip out of the lift so Staff 5 unhooked the strap under the resident's arms, lowered the resident to the floor and called for help. Staff 5 stated she should have paid closer attention to what the care plan showed for the resident's care.