Every finding on record at Winfield Rehab & Nursing

Based on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 2 of 3 months reviewed. (July 2025 and August 2025)The facility did not have RN coverage for 2 days in July 2025 (7/26/2025 and 7/27/2025).The facility did not have RN coverage for 2 days in August 2025 (8/02/2025 and 8/03/2025).This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters. Findings included:Record review PBJ Staffing Data Report fiscal year Quarter 4 2025 (July 1 - September 30) indicated No RN Hours 07/01 (TU); 07/02 (WE); 07/03 (TH); 07/04 (FR); 07/05 (SA); 07/06 (SU); 07/07 (MO); 07/08 (TU); 07/09 (WE); 07/10 (TH); 07/11 (FR); 07/12 (SA); 07/13 (SU); 07/14 (MO); 07/15 (TU); 07/16 (WE); 07/17 (TH);07/18 (FR); 07/19 (SA); 07/20 (SU); 07/21 (MO); 07/22 (TU); 07/23 (WE); 07/24 (TH); 07/25 (FR); 07/26 (SA); 07/27 (SU); 07/30 (WE); 07/31 (TH) 08/02 (SA); 08/03 (SU); 08/04 (MO); 08/05 (TU); 08/07 (TH); 08/08 (FR); 08/11 (MO); 08/13 (WE); 08/14 (TH); 08/15 (FR); 08/16 (SA); 08/17 (SU); 08/23 (SA); 08/24 (SU); 08/30 (SA); 08/31 (SU) 09/01 (MO); 09/02 (TU); 09/13 (SA); 09/14 (SU); 09/20 (SA); 09/21 (SU).Record review of facility time punch report dated from 7/01/2025 to 9/30/2025 indicated the facility had RN coverage in the facility on all dates except 7/26/2025, 7/27/2025, 8/02/2025, and 8/03/2025.During an interview on 12/10/2025 at 2:18 pm the Regional Nurse Consultant said she was the RN coverage from July 2025 to September 2025 due to no DON in the facility at that time and she was responsible for staffing. She said she was unsure why there was no RN coverage on 7/26/25, 7/27/25, 8/02/25 and 8/03/25. The current DON assumed the staffing role in September 2025. She said if there was no RN coverage 7 days a week 8 hours a day then oversight of situations could be affected. During an interview on 12/10/2025 at 2:25 pm the Administrator said that the DON was responsible for staffing and during that time the DON was covered by the regional nurse and was not aware that there were days an RN was not in the facility for the required 8 hours. She said she expected the RN coverage to occur daily as regulated to prevent any care issues. Record review of a facility policy titled Nursing Services and Sufficient Staff dated 4/10/2022 indicated, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. 8.Except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2025 for the fourth quarter July 2025 to September 2025).The facility failed to submit accurate RN hours for:07/01 (TU); 07/02 (WE); 07/03 (TH); 07/04 (FR); 07/05 (SA); 07/06 (SU); 07/07 (MO); 07/08 (TU); 07/09 (WE); 07/10 (TH); 07/11 (FR); 07/12 (SA); 07/13 (SU); 07/14 (MO); 07/15 (TU); 07/16 (WE); 07/17 (TH);07/18 (FR); 07/19 (SA); 07/20 (SU); 07/21 (MO); 07/22 (TU); 07/23 (WE); 07/24 (TH); 07/25 (FR); 07/26 (SA); 07/27 (SU); 07/30 (WE); 07/31 (TH) 08/02 (SA); 08/03 (SU); 08/04 (MO); 08/05 (TU); 08/07 (TH); 08/08 (FR); 08/11 (MO); 08/13 (WE); 08/14 (TH); 08/15 (FR); 08/16 (SA); 08/17 (SU); 08/23 (SA); 08/24 (SU); 08/30 (SA); 08/31 (SU) 09/01 (MO); 09/02 (TU); 09/13 (SA); 09/14 (SU); 09/20 (SA); 09/21 (SU).These failures could place residents at risk for personal needs not being identified and met. Findings:Record review PBJ Staffing Data Report fiscal year Quarter 4 2025 (July 1 - September 30) indicated No RN Hours 07/01 (TU); 07/02 (WE); 07/03 (TH); 07/04 (FR); 07/05 (SA); 07/06 (SU); 07/07 (MO); 07/08 (TU); 07/09 (WE); 07/10 (TH); 07/11 (FR); 07/12 (SA); 07/13 (SU); 07/14 (MO); 07/15 (TU); 07/16 (WE); 07/17 (TH);07/18 (FR); 07/19 (SA); 07/20 (SU); 07/21 (MO); 07/22 (TU); 07/23 (WE); 07/24 (TH); 07/25 (FR); 07/26 (SA); 07/27 (SU); 07/30 (WE); 07/31 (TH) 08/02 (SA); 08/03 (SU); 08/04 (MO); 08/05 (TU); 08/07 (TH); 08/08 (FR); 08/11 (MO); 08/13 (WE); 08/14 (TH); 08/15 (FR); 08/16 (SA); 08/17 (SU); 08/23 (SA); 08/24 (SU); 08/30 (SA); 08/31 (SU) 09/01 (MO); 09/02 (TU); 09/13 (SA); 09/14 (SU); 09/20 (SA); 09/21 (SU).Record review of facility time punch report dated from 7/01/2025 to 9/30/2025 indicated facility had RN coverage in the facility on all dates except 7/26/2025, 7/27/2025, 8/02/2025, and 8/03/2025.During an interview on 12/10/2025 at 2:17 PM the Administrator said that she completed the spreadsheet for the RN hours worked and submitted them to an offsite person at the corporate office to input the data into PBJ. She said she was not aware that he had inaccurately reported the hours. She said inaccurate reporting could affect the facility's quality measures.Attempted phone call on 12/10/2025 at 2:40 pm to corporate office regarding PBJ reporting with no answer and voicemail left. Record review of a facility policy titled Nursing Services and Sufficient Staff dated 4/10/2022 indicated, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. 7.The facility is responsible for submitting timely and accurate staffing data through the CMS Payroll Based Journal (PBJ) system .

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in 1 of 1 kitchen reviewed for kitchen sanitation in that:The facility failed to ensure the dish machine reached recommended minimal 50-100 parts-per-million, (PPM), of hypochlorite (chlorine) during the final rinse cycle of the facility dish machine on 12/8/2025.This failure could place the residents at risk of foodborne illnesses. Findings included:During an observation and interview on 12/8/2025 at 9:41 AM the dish machine was checked by the DM. She tested the hypochlorite (chlorine) after the final rinse cycle, and it registered at 10 ppm. She said it should be at least 50-100 ppm of hypochlorite. She said she would contact the technician contracted for the dish machine for service. She said she would shut the dish machine down and use disposable plates and utensils until it was repaired. She said if the dish machine did not have the proper amount of sanitization chemicals the dishes might not be clean enough and could make someone sick.During a follow up observation on 12/8/2025 at 4:34 PM in the kitchen, the dish machine was tested, and the hypochlorite was 50 ppm meeting regulation and policy.During an interview on 12/10/2025 at 2:30 PM, the Administrator said the technician for the dish machine repaired it and increased the sanitizer for the dish machine. She said the dish machine should be checked daily by the kitchen staff. She said if the dish machine did not have the correct amount of sanitizer chemical, then the dishes would not get cleaned or sanitized properly and there could be a risk for spreading infections. Record review of a service report from the contract company for the kitchen on 12/8/2025 indicated a tech went to the facility to service the dish machine not sanitizing properly. A micro pump motor was replaced, and sanitizer solution was increased. Record review of a facility policy titled Ware Washing revised 5/2018 indicated, .The purpose of ware washing is to clean and sanitize utensils and equipment used during the preparation and service of food from the dietary department. Proper ware washing is an essential component in the prevention of food borne illnesses. 4. Improper temperatures and/or sanitizer strength will be reported to the person in charge immediately and manual ware washing and/or paper products will be implemented until the problem is corrected. 2. Low temperature dish machines: a: 120 degrees= minimum water temperature for both wash and rinse cycles, b. chemical: chlorine sanitizer=50-100 ppm (parts per million) .

Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove reviewed for food service in that:The facility did not ensure the gas stove was in working order. Two of six gas stove burners (left front and left back) did not light properly when the knob was turned. This failure could place residents who eat out of the kitchen at risk of injury and undercooked food. Findings include:During an observation and interview on 12/8/2025 at 9:36 AM, the gas stove had six burners total, two burners on the left front and left back did not light completely when the knob was turned and only half of the burner was lit. The DM said the stove had been that way for 2 years since she started at the facility and the kitchen staff does not use those two burners. She could not answer what could happen if they did not light properly. She said she would let the Administrator know about the stove.During an interview on 12/10/2025 at 2:30 PM, the Administrator said the burners on the stove were reported to the Maintenance Supervisor and someone was going to come to the facility that day. She said if the burners did not light properly, it could take longer to cook or have a gas leak. She said she was not aware of the burners on the stove prior to Monday 12/8/2025.During an interview on 12/10/2025 at 2:25 PM, the Maintenance Supervisor said he was not made aware of the burners on the stover not working properly until yesterday 12/9/2025. He said someone was coming to the facility that day to look at it. He said sometimes the kitchen staff would report issues to him but not all the time. He said if the burners did not light properly, he did not know of a risk and what could happen.On 12/9/2025 Surveyor requested a policy for the stove, and none was provided by the time of Surveyor exit on 12/10/2025.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 2 of 12 residents (Resident #16 and #29) reviewed for ADL care.1.The facility failed to ensure Resident #16 did not have a thick, black substance under his nails on 12/8/2025 and 12/9/2025. 2. The facility failed to ensure Resident #29 had clean clothing on 12/08/2025.These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.Findings included:1.Record review of an admission Record for Resident #16 dated 12/9/2025 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of dementia (loss of mental ability that can interfere with normal activities of daily living), schizophrenia (mental condition that affects how people think, feel, and behave), blindness in right eye and hypertension. Record review of a task documentation for Resident #16 dated 12/10/2025 indicated he received a bath on 12/7/2025.Record review of an admission MDS Assessment for Resident #16 dated 10/1/2025 indicated he had severe impairment in thinking with a BIMS score of 3. He required partial/moderate assistance where the helper does less than half the effort with personal hygiene. He required substantial/maximal assistance with shower/bathing.Record review of a care plan for Resident #16 revised on 10/31/2025 indicated he had an ADL self-care performance deficit and was at risk of not having his needs met in a timely manner. Interventions included to provide showers, shave, oral care, hair care, and nail care per schedule and when needed.Record review of an undated shower schedule for Resident #16 indicated his shower days were on Tuesday, Thursday, and Saturday. During an observation and interview on 12/8/2025 at 10:37 AM, Resident #16 was in bed awake and dressed. He said he had not been at the facility long and things were going well. His fingernails had a thick, black substance underneath them and he said he was not sure what days his showers were scheduled for. He said his last shower was one day last week but did not remember the day.During an observation on 12/8/2025 at 4:12 PM, Resident #16 was in bed resting with his eyes closed. His fingernails still had a thick, black substance underneath them.During an observation on 12/9/2025 at 8:07 AM, Resident #16 was in his room in bed. His fingernails still had a thick, black substance underneath them.During an interview on 12/9/2025 at 2:51 PM, CNA E said she gave Resident #16 a shower earlier that day. She said his fingernails had been trimmed and cleaned before she gave him a shower. She said if residents were diabetic, the nurse aides could not trim the resident's nails, but they could clean them. She said nails should be cleaned as needed and on their shower days.2. Record review of Resident #29's facility face sheet dated 12/09/2025 indicated Resident #29 was a [AGE] year-old male that was originally admitted to the facility on [DATE] and readmitted on [DATE] for diagnosis of Alzheimer's. Record review of Resident #29's comprehensive care plan dated 09/11/2023 revealed Resident #29 had an ADL self-care performance deficit and was at risk of not having their needs met in a timely manner and for him to maintain a sense of dignity by being clean, dry, odor free, and well-groomed. Record review of Resident #29's quarterly MDS assessment dated [DATE] revealed Resident #29 had a BIMS of 99 indicating inability to complete the interview. A SAMS was completed and indicated Resident #29 had severe cognitive impairment for daily decision making.During an observation on 12/08/2025 at 10:54 AM Resident #29 was sitting in a geriatric chair in the dining room and his shirt and pants were soiled with food. During an observation on 12/08/2025 at 11:56 AM Resident #29 was in the dining room for lunch with same shirt and pants soiled with food.During an observation on 12/08/2025 at 2:11 pm Resident #29 was asleep in bed and continued to wear the same soiled shirt and pants. During an interview on 12/08/2025 at 2:33 pm CNA A said she was assigned to Resident #29. She said that residents that could not change their clothes themself, the CNA did it for them. She said that when a resident's clothes were soiled then the CNA was to change them. She said if a resident's clothes were left soiled then it looked bad. During an observation on 12/08/2025 at 4:32 pm Resident #29 was in the dining room for dinner and continued to have on the same soiled shirt and pants. During an interview on 12/08/2025 at 4:36 pm CNA A said she should have changed Resident #29's clothes when they got soiled and especially before she got him back up for dinner. She said leaving residents in soiled clothes could affect them but could not say how. During an interview on 12/09/2025 at 8:30 am LVN B said that the CNA's care was overseen by the charge nurses and residents that are dependent should have their soiled clothes changed and then as needed. She said residents that were left soiled could affect their well-being and dignity. During an interview on 12/09/2025 at 8:45 am the DON said that the CNAs were responsible for providing ADL care to the residents, but all staff should be aware of any issues and ensure residents received care. She said she expected no resident to be left in soiled clothes as it was a dignity issue. During an interview on 12/9/2025 at 2:56 PM, the DON said she had been employed at the facility since August 2025. She said she conducted a nail inspection in the facility last night (12/8/2025) and she trimmed and cleaned Resident #16's nails that morning. She said the staff clean the resident's nails whenever they take a shower and that it was at least 3 days a week. She said it would make her feel nasty if she was dependent on staff to clean her nails. During an interview on 12/10/2025 at 2:20 PM, the Administrator said nail care and ADL care were the responsibility of the nurses and nurse aides. She said nail care should be done as needed and on shower days. She said she would not like it if she was dependent on staff to clean her nails.During an interview on 12/10/2025 at 2:25 pm the administrator said the DON was responsible for resident care but the charge nurses were to ensure the CNAs were providing care as the residents needed. She said she expected each resident to receive ADL care as they need it and residents that were left in dirty clothes could affect their dignity. Record review of a facility policy titled Clinical Practice Guideline Activities of Daily Living dated 1/23/2016 indicated, residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene .Record review of a facility policy titled Nail Care dated 4/25/14 indicated, .To provide for personal hygiene needs and prevent infection

Based on observations, interviews, and record review, the facility failed to incorporate recommendations from a PASARR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for 2 of 9 (Resident # 7 and Resident #9) residents reviewed for PASARR services.The facility failed to submit a complete and accurate request for NF specialized services in the LTC online portal within 20 business days after the date of the Interdisciplinary Team (IDT) meeting on [DATE]. This failure could place residents at risk of not receiving specialized PASARR services which would enhance their highest level of functioning and could contribute to residents' decline in physical, mental, and psychosocial well-being.Findings included:1.Record review of an admission Record for Resident #7 dated [DATE] indicated she admitted to the facility [DATE] and expired on [DATE]. She was [AGE] years old with diagnoses of adult failure to thrive (a decline in health with weight loss), polyneuropathy (a condition when the nerves outside the brain or spinal cord are damaged), cerebral infarction (stroke) and GERD (acid reflux). Record review of a Significant Change MDS Assessment for Resident #7 dated [DATE] indicated she did not have any impairment in thinking with a BIMS score of 15. Record review of a Care plan for Resident #7 dated [DATE] and revised on [DATE] indicated she was PASARR positive with ID. Interventions included that the facility would maintain the PL1, PE, and IDT minutes in the resident's medical record.Record review of a PASARR Comprehensive Service Plan (PCSP) for Resident #7 dated [DATE] indicated she had an initial meeting and Specialized OT was new. All services were agreed upon at the meeting for initial services. Record review of a PASARR Evaluation for Resident #7 dated [DATE] indicated she had ID.Record review of a PASARR Level 1 Screening for Resident #7 following a readmission into the facility dated [DATE] indicated dementia was her primary diagnosis but she also had an intellectual disability.Record review of SIMPLE (an online portal for long term care facilities) for Resident #7 revealed there was not a NFSS form that was submitted for the resident following the PCSP meeting held on [DATE] for OT services.2. Record review of an admission Record dated [DATE] for Resident #9 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of end stage renal disease, intellectual disabilities (a disability that involves limitations on thinking, learning and tasks of daily living) and down syndrome.Record review of a Quarterly MDS assessment dated [DATE] for Resident #9 indicated she had severe impairment in thinking with a BIMS score of 6. She used a wheelchair for mobility. During the 7 day look back period she received OT and PT services at least 15 minutes a day on one or more days.Record review of a NFSS therapy signature page dated [DATE] for Resident #9 was signed by the Therapist and the Administrator at that time. Record review of a PCSP for Resident #9 dated [DATE] indicated it was an annual meeting that was held. Specialized OT was a new service requested, and services were agreed upon. Record review of a PE for Resident #9 dated [DATE] indicated she had ID, DD.Record review of a PASARR Level 1 Screening for Resident #9 dated [DATE] indicated she was positive for ID and DD. Record review of a care plan revised [DATE] for Resident #9 indicated she had been deemed PASARR positive on the PASARR evaluation which may place her at risk for not having the ordered specialized services provided. Interventions included specialized services determined to be necessary by the IDT will be initiated and request submitted to DADS within 20 days after date of IDT.During an observation and interview on [DATE] at 3:46 PM, Resident #9 was in her room sitting on the side of her bed looking at her phone. She was alert to person and place. She said she had received therapy but was not receiving therapy at that time. During a phone interview on [DATE] at 3:57 PM, the RP for Resident #9 said she was the contact person for the resident but did not make any decisions for her. She said she had known the resident for many years, and the facility contacted her when there were changes but had not been involved in any care plan meetings and was not aware of what services were agreed upon during the care plan meetings.During a phone interview on [DATE] at 1:43 PM, CNA F said she had been employed at the facility for 3 years but was recently demoted from a case manager position where she helped with admissions and PASARR. She said she was trained by the MDS Coordinator and the SW on PASARR. She said she attended the IDT meetings for PASARR and helped with entering in the IDT meeting in the portal after the meetings. She said she had been asleep and could not recall a meeting in [DATE] and was not aware of any email that was sent by the PASARR following a meeting in [DATE]. During an interview on [DATE] 2:02 PM, the Habilitation Coordinator was in the facility. She said she visited the facility monthly and checked on each resident that was PASARR positive. She said the facility had meetings for the residents after their initial evaluation and then annually and some had quarterly meetings between times. She said she has been the Habilitation Coordinator for the facility since late [DATE]. She said she was not the coordinator for the facility in [DATE]. She said Resident #7 had a PE on [DATE] and an initial meeting on [DATE]. She said if a resident had an initial meeting, then the nursing facility staff should have entered in the meeting information into Simple after the IDT. She said during the initial meeting that PT was pending, and OT was a new service that was requested. She said Resident #9 had an annual meeting on [DATE] and OT was a new service that was requested. She said after the meeting the facility should have entered an NFSS for both residents with new therapy services requested. She said if services were not provided the residents would not get the therapy they were requesting. During an interview on [DATE] 2:22 PM, the SW said the NFSS forms should be entered by therapy into the online portal. She said she worked at the facility in [DATE] and left for a short time and was rehired in [DATE]. She said she was not aware of the PASARR unit reaching out to the facility requesting information. She said she was not sure how long the facility had to submit the NFSS form for therapy into the portal. She said she was responsible for all things PASARR now and worked in the facility 2 days a week. During an interview on [DATE] 3:05 PM, the DOR said she started at the facility [DATE]. She said the facility had been without a DOR for about 3 months prior to her starting at the facility. She said she had just attended her first PASARR meeting that day and Resident #9 was discussed. She said the NFSS form would be completed by therapy and was not sure of the timeframe that they had to be entered into the portal. She said services could be denied or residents might not get the requested services if the forms were not submitted in a timely manner. She said Resident #9 had an evaluation for PASARR and received therapy from [DATE] to [DATE] for OT services. She had a recertification on [DATE] for OT and could not find a NFSS form in Simple for [DATE]. She said Resident #7 admitted to the facility on [DATE] and they billed her Medicare part B for therapy services. She said on [DATE] they started an initiation through PASARR for PT, OT, and ST. She said Resident #9 had an NFSS form that was submitted on [DATE] into SIMPLE that was returned due to the signatures and was not resubmitted. She said Resident #7 did not have an NFSS form that she could see in SIMPLE for her. During a follow up interview on [DATE] at 3:45 PM, the Administrator said she started at the facility [DATE]. She said she missed the email that was sent by the PASARR unit in [DATE] and it was an oversight. She said she was not aware the facility should have been checking the online portal for updates to approval for PASARR services. She said at that time CNA F was standing in doing PASARR and was told she had been trained, but when she found she was not a social worker she decided the facility needed a social worker in that position. She said the MDS Coordinator would be responsible for PASARR now and the SW would help with it as well. She said she would check SIMPLE and TMHP for updated information and would be providing oversight. She said residents could miss requested services if the information was not submitted in a timely manner. She said she was not aware that Resident #7 and Resident #9 had a service that was requested but did not receive it.Record review of a facility policy titled Preadmission Screening Resident Review revised 7/2023 indicated, .The purpose of this guideline is to direct the user through the PASRR procedures. Facility initiated Specialized Services by submitting request to DADS within 20 days of PCSP meeting .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #59) reviewed for infection control.The facility failed to ensure staff did not place dirty towels on the floor of Resident #59's bathroom from 12/8/2025 to 12/9/2025.This failure could place residents at risk for cross contamination and infection. Findings included:Record review of an admission Record for Resident #59 dated 12/9/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of congestive heart failure (heart's inability to pump effectively), COPD (a group of lung disease that affect breathing), type 2 diabetes, and fusion of spine (a surgical procedure that permanently connects to or more bones in the spine).Record review of a Quarterly MDS Assessment for Resident #59 dated 11/28/2025 indicated she had moderate impairment in thinking with a BIMS score of 12. She required partial/moderate assistance with personal hygiene, which the helper does less than half the effort. She was always incontinent of urine/bowel.Record review of a care plan for Resident #59 dated 10/10/2025 and revised on 10/14/2025 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. Interventions included for toileting: extensive assistance.During an observation and interview on 12/8/2025 at 10:15 AM, Resident #59 was in bed awake and said she had been a resident in the facility since May or June 2025. A dirty towel was on the floor in the bathroom with a brown substance on it. Resident #59 said she had a small bowel movement that morning and the staff had cleaned her up.During an observation on 12/8/2025 2:30 PM, Resident #59 was in bed awake, and the dirty towel was still on the floor in her bathroom.During an observation on 12/9/2025 at 8:09 AM, Resident #59 was in bed awake, and the dirty towel was still on the floor in the bathroom.During an observation and interview on 12/9/2025 at 2:42 PM, CNA E went in the room of Resident #59 and observed a dirty towel on the floor. She said the nurse aides were responsible for picking up dirty linens and the dirty linens should be placed in a plastic bag. She said residents could be at risk for cross contamination and biohazard along with infection control if staff did not place the dirty linens appropriately. CNA E put gloves on her hands and picked up the dirty towel, placed it in a plastic bag, and removed it from the room. During an interview on 12/10/2025 at 11:32 AM, the DON said dirty linens should be placed in a closet in a barrel for the linens. She said linens should be bagged and not stored on the floor. She said there was a risk for infection control and harboring bacteria if dirty linens were placed on the floor.During an interview on 12/10/2025 at 2:20 PM, the Administrator said dirty linens should be placed in the dirty linen barrel in the soiled linen closet. She said whoever was handling the dirty linens was responsible for putting the dirty linens in a bag and in the barrel. She said there was a risk of infection control issues or a tripping hazard if linens were left on the floor. Record review of a facility policy titled Infection Prevention and Control Program revised 11/6/24 indicated, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national standards and guidelines. 12. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. f. Environmental services staff shall not handle soiled linens unless it is properly bagged

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 4 resident's personal refrigerators reviewed for food safety (Resident #59).The facility failed to ensure the refrigerator for Resident #59 did not contain a bottle of Miracle Whip that expired on 9/23/2025. This failure could place residents at risk for food borne illnesses. Findings included:Record review of an admission Record for Resident #59 dated 12/9/2025 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of congestive heart failure (heart's inability to pump effectively), COPD (a group of lung disease that affect breathing), type 2 diabetes, and fusion of spine (a surgical procedure that permanently connects to or more bones in the spine).Record review of a Quarterly MDS Assessment for Resident #59 dated 11/28/2025 indicated she had moderate impairment in thinking with a BIMS score of 12. She required partial/moderate assistance with personal hygiene, which the helper does less than half the effort. She was always incontinent of urine/bowel.Record review of a care plan for Resident #59 dated 10/10/2025 and revised on 10/14/2025 indicated she had an ADL self-care performance deficit and was at risk for not having her needs met in a timely manner. Interventions included for toileting: extensive assistance. There was no record to indicate the resident would not allow staff to check her personal refrigerator.During an observation and interview on 12/8/2025 at 10:15 AM, Resident #59 was in bed awake. She had a personal refrigerator that had a bottle of Miracle Whip that expired 9/23/2025. Resident #59 was asked about the bottle of Miracle Whip and said she had not used it in a long time and was not aware it was expired.During an observation and interview on 12/9/2025 at 2:39 PM, Resident #59's personal refrigerator still had the bottle of expired Miracle Whip. She said the lady that just brought her ice water was the person who checked her refrigerator daily. She said she ate food out of her refrigerator and did not know the Miracle Whip was expired. During an observation and interview on 12/9/2025 at 2:40 PM, MA D said she had been employed at the facility since 2019 and was told recently in November 2025 that she would be responsible for checking the personal refrigerators once during the shift, and all the MA's were responsible. She said they checked the temperatures and was not told to check the refrigerators for expired or old foods. She observed the refrigerator for Resident #59 and removed the bottle of miracle whip. She said residents could get sick or get food poisoning from eating foods that expired.During an interview on 12/10/2025 at 11:32 AM, the DON said all the department heads in the facility conducted angel rounds with each resident in the facility and they checked the personal refrigerators. She said they checked for cleanliness, temperatures of the refrigerators and expiration dates of food items daily. She said the medication aides in the facility checked the temperatures and logged them daily. She said residents could get sick if they ate food that was beyond the expiration date. During an interview on 12/10/2025 at 11:47 AM, the BOM said she conducted angel rounds daily and Resident #59 was one of the rooms she checked daily. She said she checked the personal refrigerators for temperatures, spills, and expired food items. She said Resident #59 would not allow staff to clean her refrigerator and Resident #59 would tell her she would do it herself. She said she had tried many times in the past, but the resident will not allow her to check her refrigerator. She said she was not aware she had a bottle of miracle whip that had expired. She said if residents ate food items that were expired, they could get sick.During an interview on 12/10/2025 at 2:30 PM, the Administrator said the staff and resident families helped with monitoring of the personal refrigerators. She said the MA's checked the temperatures daily. She said the department heads conducted angel rounds daily and they checked the refrigerators for expired food items. She said the BOM had told her before that Resident #59 did not like for the staff to remove items from her refrigerator. She said she would have the MA's help to monitor the refrigerators going forward for expired food. She said residents could be at risk of illnesses if they ate food that expired.Record review of a facility policy titled Resident Refrigerators revised 8/23/2023 indicated, .This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary use of any resident-owned refrigerators. 3. Staff shall inspect the refrigerator weekly, clean as needed, and discard any foods that are out of compliance. b. Foods with use-by dates shall be discarded accordingly .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (nurse cart for 300 hallway) reviewed for labeling and storage. The facility did not document when insulin was opened from the nurse medication cart for the 300 hallway. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings included:Record review of the Physician Summary of orders dated 12/09/2025 indicated Resident #48 was a [AGE] year-old male admitted on [DATE]. His diagnosis included type 2 diabetes. An order dated 05/03/2025 indicated Resident #48 was to have Insulin Aspart Flex pen 100 unit/millimeter (Insulin) solution Inject as per sliding scale (amount of insulin given per level of blood sugar at time of testing): if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 and greater notify physician, before meals subcutaneously for Type 2 Diabetes. Record review of the Physician Summary of orders dated 12/09/2025 indicated Resident #48 had an order dated 11/25/2025 for Lantus Solostar Subcutaneous Solution Pen-injector100 unit/millimeter (Insulin Glargine) Inject 25 unit subcutaneously in the morning related to type 2 Diabetes.During an observation of the nurse medication cart for the 300 hall on 12/08/2025 at 10:45 AM with LVN C revealed the following:Lantus Solostar Solution 100 unit per milliliter flex pen with no open date documented on label or container, with an issue from pharmacy date of 11/26/2025. Pharmacy directions indicated to discard medication 28 days after the open date.During an interview on 12/08/2025 at 09:00 AM, the DON said she did not know the medication cart had unlabeled insulins (no date when opened). She discarded the unlabeled insulin, and she obtained a new pen of insulin and placed it in the cart for use. She said most insulins were to be replaced 28 days after opening. She said all insulins should have an open date on them since they were only good for so many days after opening. She said the number of days depended on the insulin. She said if a resident was given medications that were expired, the medications may not provide an effective result. She said the nurses and medication aides were responsible for ensuring their carts did not have expired medications. She said going forward she would provide education on multi-dose vial usage and more frequent monitoring of the medication carts for expired medications. During an interview on 12/09/2025 at 2:30 PM, the Administrator said the DON was responsible for ensuring medications were labeled and stored as required by regulations. She said she expected all insulins and multi-dose vials to be dated when opened and expired medications to be removed from medication carts. The Administrator said if a resident was given medications that were expired, the medications may not provide an effective result.Record review of a facility policy titled Vials and Ampules of Injectable Medications Storage of Medications in the Home, dated 09/2018, with revision date 09/2020 indicated: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal.Nursing policies developed by the facility may supersede the procedures outlined in this policy.1.Vials and ampules dispensed by the pharmacy are maintained in the box or container with the pharmacy label in which they are dispensed.2. Unopened vials expire on the manufacturer's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to record on multi-dose vials. At a minimum, the date opened must be recorded. These labels are not required on single-use vials or ampules. Triggered expiration dates may be found in the manufacturer's package insert, on the package provided, or on a reference chart by the pharmacy, or by contacting the pharmacist.3. Ampules and single-use vials (containing no preservative) are discarded immediately after use.4. The solution in multi-dose vials (MDV) is inspected prior to each use for unusual cloudiness, precipitation, or foreign bodies. The rubber stopper is inspected for deterioration. If an MDV is opened and does not indicate the date opened, the date opened reverts to the date of dispensing on the container, and the use period is determined from that date. If the dispensing date cannot be determined, the product should not be used and should be discarded according to the facility's policy.5. If an unused/unopened multi-dose vial shows visible evidence of precipitation or contamination or the rubber stopper is deteriorating, it is not to be used but should be returned to the provider pharmacy. A replacement vial is ordered from the provider pharmacy. The pharmacy provider determines the need for reporting a defective solution to the manufacturer and/or filing a Drug Product Problem Report with the Food and Drug Administration (FDA) MedWatch program.6. Medication in multi-dose vials may be used until the manufacturer's recommended expiration date if inspection reveals no problems during that time. USP <797> guidelines recommend discarding multi-dose vials 28 days after opening. The date opened and the triggered expiration date should be recorded on a label for such purpose affixed to the vial. Expiration date triggered by opening should be available either in the manufacturer's labeling or package insert, on a chart provided by the pharmacy, or from the pharmacist.Record review of the package insert for Lantus Solostar (insulin aspart flex pen) accessed at https://www.lantus.com .pdf on 12/08/25 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 28 days.Record review of the package insert for insulin glargine (insulin flex pen) accessed at https://insulins.lilly.com on 12/08/25 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 28 days.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (nurse cart for 300 hallway) reviewed for pharmacy services. The facility failed to dispose of expired insulin pens from the nurse medication cart for the 300 hall. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization. Findings included:Record review of the Physician Summary of orders dated 12/09/2025 indicated Resident #48 was a [AGE] year-old male admitted on [DATE]. His diagnosis included type 2 diabetes. An order dated 05/03/2025 indicated Resident #48 was to have Insulin Aspart Flex pen 100 unit/millimeter (Insulin) solution Inject as per sliding scale (amount of insulin given per level of blood sugar at time of testing): if 150 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units; 401 and greater notify physician, before meals subcutaneously for Type 2 Diabetes. Record review of the Physician Summary of orders dated 12/09/2025 indicated Resident #48 had an order dated 11/25/2025 for Lantus Solostar Subcutaneous Solution Pen-injector100 unit/millimeter (Insulin Glargine) Inject 25 unit subcutaneously in the morning related to type 2 Diabetes.During an observation of the nurse medication cart for the 300 hall on 12/08/2025 at 10:45 AM with LVN C revealed the following:Insulin Aspart Flex pen (Insulin) solution 100 unit per milliliter flex pen with no open date with issue date of 08/08/2025. Pharmacy directions indicated to discard medication 28 days after the open date.During an interview on 12/08/2025 at 09:00 AM, the DON said she did not know the medication cart had expired insulins. She discarded the expired insulin, and she obtained two new pens of insulin and placed them in the cart for use. She said most insulins were to be replaced 28 days after opening. She said all insulins should have an open date on them since they were only good for so many days after opening. She said the number of days depended on the insulin. She said if a resident was given medications that were expired, the medications may not provide an effective result. She said the nurses and medication aides were responsible for ensuring their carts did not have expired medications. She said going forward she would provide education on multi-dose vial usage and more frequent monitoring of the medication carts for expired medications. During an interview on 12/09/2025 at 2:30 PM, the Administrator said the DON was responsible for ensuring medications were labeled and stored as required by regulations. She said she expected all expired medications to be removed from medication carts. The Administrator said if a resident was given medications that were expired, the medications may not provide an effective result.Record review of a facility policy titled Vials and Ampules of Injectable Medications Storage of Medications in the Home, dated 09/2018, with revision date 09/2020 indicated: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal.Nursing policies developed by the facility may supersede the procedures outlined in this policy.1.Vials and ampules dispensed by the pharmacy are maintained in the box or container with the pharmacy label in which they are dispensed.2. Unopened vials expire on the manufacturer's expiration date. Opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to record on multi-dose vials. At a minimum, the date opened must be recorded. These labels are not required on single-use vials or ampules. Triggered expiration dates may be found in the manufacturer's package insert, on the package provided, or on a reference chart by the pharmacy, or by contacting the pharmacist.3. Ampules and single-use vials (containing no preservative) are discarded immediately after use.4. The solution in multi-dose vials (MDV) is inspected prior to each use for unusual cloudiness, precipitation, or foreign bodies. The rubber stopper is inspected for deterioration. If an MDV is opened and does not indicate the date opened, the date opened reverts to the date of dispensing on the container, and the use period is determined from that date. If the dispensing date cannot be determined, the product should not be used and should be discarded according to the facility's policy.5. If an unused/unopened multi-dose vial shows visible evidence of precipitation or contamination or the rubber stopper is deteriorating, it is not to be used but should be returned to the provider pharmacy. A replacement vial is ordered from the provider pharmacy. The pharmacy provider determines the need for reporting a defective solution to the manufacturer and/or filing a Drug Product Problem Report with the Food and Drug Administration (FDA) MedWatch program.6. Medication in multi-dose vials may be used until the manufacturer's recommended expiration date if inspection reveals no problems during that time. USP <797> guidelines recommend discarding multi-dose vials 28 days after opening. The date opened and the triggered expiration date should be recorded on a label for such purpose affixed to the vial. Expiration date triggered by opening should be available either in the manufacturer's labeling or package insert, on a chart provided by the pharmacy, or from the pharmacist.Record review of the package insert for Lantus Solostar (insulin aspart flex pen) accessed at https://www.lantus.com .pdf on 12/08/25 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 28 days.Record review of the package insert for insulin glargine (insulin flex pen) accessed at https://insulins.lilly.com on 12/08/25 indicated unopened and stored at room temperature was good for 28 days, unopened and refrigerated was good until the expiration date, and opened was good for 28 days.

Based observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #1) of six residents reviewed for pharmaceutical services.The facility failed to ensure an unknown staff did not leave Resident #1's medications inside the resident's room for the resident to take unsupervised which resulted in her dropping one Colace pill and one Amlodipine pill on an unknown date.This failure could place the residents at risk of not receiving medications as ordered by the physician for 1 of 6 residents (Resident #1) reviewed for pharmaceutical services.Findings included: Record review of the face sheet dated 10/25/2025 indicated that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure, which is when the heart cannot pump blood throughout the body efficiently, generalized edema, which is swelling caused by fluid build-up, myocardial infarction, which is a blockage in the heart, chronic obstructive pulmonary disease, which is when airflow gets trapped in your lungs making it feel difficult to breath, constipation which is when you cannot have regular bowel movements, essential hypertension which is high blood pressure with no clear cause. Record review of the MDS dated [DATE] indicated that Resident #1 had a BIMS score of 15. Her score indicated that she had normal cognition, and no major memory or cognition issues. Record review of Resident #1's Medication Review, dated 10/16/25, revealed an order for amlodipine 10mg, give 1 tab by mouth one time a day in the morning and Colace 100mg by mouth every 12 hours. Record review of the MARs dated 10/16/2025 revealed that Resident #1 was prescribed amlodipine 10mg, one tablet in the morning by mouth and Colace 100mg one capsule every 12 hours by mouth as part of her daily medication regimen. Record review of the facility police entitled Medication Storage and dated 1/20/2021 which indicated that It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. During an observation on 10/15/25 at 4:33 p.m. Resident #1's previous bedroom (room [ROOM NUMBER]) revealed two pills on the ground; one orange and one white, which were identified by the DON as Colace, a stool softener, and amlodipine which is a blood pressure medication. During an interview on 10/15/2025 at 12:50 p.m. Resident #1 stated that she found little white pills on the floor in her previous room which was room [ROOM NUMBER] and that the med aides or nurses did not wait for her to take her medication and she thought she dropped some of her pills. Resident #1 stated that the staff got in a hurry and that she didn't have time to ask them what she was taking. During an interview on 10/15/25 at 4:40 p.m. LVN C stated that the pills could have gotten on the floor from the resident spitting them out when the staff was not looking, or the staff dropped the pills and did not pick them up. She stated that the pills should not have been on the floor and that there was a risk of another resident finding the medication. LVN C said taking it could cause adverse health effects and there was a risk of the resident whose medication it was missing a dose, as it could have also caused them adverse health effects. During an interview on 10/15/25 at 4:43 p.m. MA A stated that the pills could have gotten on the floor from the resident spitting them out when the staff is not looking. She stated that the staff could have dropped the pills and did not pick them up. She stated that the pills should not have been on the floor and that there was a risk of another resident finding the medication. MA A stated taking the medication if it was not prescribed to you could have caused adverse health effects and there was a risk associated with missing a dose of the medication if it was prescribed to you, as it might have caused adverse health effects. During an interview on 10/15/25 at 4:50 p.m. the DON stated that the pills could have gotten on the floor from the resident spitting them out when the staff is not looking, or the staff could have dropped the pills and not picked them up. She stated that the pills should not be on the floor and that there is a risk of another resident finding the medication. The DON said taking the medication if it was not prescribed to you for your specific medical condition it could have caused adverse health effects. She stated that there is a risk of the resident whose medication it was missing a dose, as it can also cause them adverse health effects. During an interview on 10/16/25 at 12:08 p.m. MA B stated that the pills could have gotten on the floor from the resident spitting them out when the staff was not looking, or the staff could have dropped the pills and did not pick them up. She stated that the pills should not be on the floor and that there was a risk of another resident finding the medication as taking medication that does not belong to you could have caused adverse health effects. MA B stated that taking medication that does not belong to you could have caused adverse health effects. She stated that there is a risk of the resident whose medication it was when they missed a dose, as it could have also caused them adverse health effects. During an interview on 10/16/25 at 1:30 p.m. the ADM stated that the policy for medications is to always be kept safe and always secured. The administrator stated that they moved Resident #1 from room [ROOM NUMBER] to room [ROOM NUMBER] last week. The ADM stated that the risk of leaving medications in the room is the resident not taking the medication or another resident taking a medication that they do not need. She stated that the resident could have dropped the pills and the staff member was not there to see it but that the medication, if administered properly should not be on the floor. During an interview on 10/16/25 at 2:10 p.m. the ADON stated that the pills could have gotten on the floor from the resident spitting them out when the staff is not looking, or by the staff dropping the pills and not picking them up. She stated that the pills should not have been on the floor and that there was a risk of another resident finding the medication. The ADON stated taking medication that is not prescribed to you could have caused adverse health effects. She stated that there was a risk of the resident whose medication it was in missing a dose, as it also could have caused them adverse health effects. During an interview on 10/16/25 at 2:17 p.m. CNA D stated that the pills could have gotten on the floor from the resident spitting them out when the staff was not looking, or the staff dropped the pills and did not pick them up. She stated that the pills should not have been on the floor and that there is a risk of another resident finding the medication and taking it. CNA D stated that taking medication that is not prescribed to you could cause adverse health effects and there was also a risk of the resident whose medication it was when they missed a dose, as it also could have caused them adverse health effects.

Based on observation, interview and record review the facility failed to ensure that residents were free from physical and chemical restraints imposed for purposes of discipline or convenience and were not required to treat the resident's medical symptoms for 1 of 11 residents (Resident #8) reviewed for restraints. The facility failed to ensure Resident #8 was free from physical restraint when CNA A physically restrained him during incontinence care on 4/27/25. An Immediate Jeopardy (IJ) situation was determined to have existed between 4/27/2025 to 4/28/25. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for physical restraint. Findings include: Record review of Resident #8's admission record, dated 5/1/25, indicated Resident #8 was a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #8 had a primary diagnosis which included Alzheimer's Disease (progressive brain disorder that slowly damages memory, thinking, and behavior) and secondary diagnoses which included Ataxia (lack of muscle coordination and control) and cognitive communication deficit (difficulty communicating). Record review of Resident #8's MDS, dated [DATE], revealed he had a BIMS of 3, which indicated severe cognitive impairment. He was dependent on staff for toileting hygiene, shower/bath, putting on/taking off footwear, and lower body dressing; he required maximum assistance with oral hygiene and personal hygiene. He was able to eat independently. He was always incontinent of bowel and bladder. Record review of Resident #8's comprehensive care plan, revision on 11/15/23 , indicated Resident #8 had impaired cognition and was at risk for further decline related to a diagnose of Alzheimer's Disease. Interventions were in place which indicated identifying yourself at each interaction, provide clear instructions using simple sentences, and stopping personal care to return later if he became agitated. Record review of a witness statement, dated 4/27/25 given by RN C, indicated she saw CNA B leave Resident #8's room crying. RN C said CNA B told her Resident #8 was swinging his arms and CNA A grabbed Resident #8's hands and pushed them into resident's chest. The same witness statement indicated RN C removed CNA A from Resident #8's room and notified the ADM. During an observation on 4/29/25 at 12:00 p.m. revealed Resident #8 was sitting in a geri chair (specialized recliner) in the day room watching television; he appeared to be clean and well groomed, with no offensive odors. There were no visible skin tears, marks, or bruising on his skin. Resident #8 became agitated in response to attempted interview as indicated by fidgeting in his chair and raising his voice shouting no. Observation of a video recording (8 seconds long with no visible time stamp or date) from Resident #8's in-room camera showed CNA A physically restraining Resident #8 by pushing Resident #8's hands into his chest and holding him down on the bed. Resident #8 can be heard crying out in the video clearly stating Ow. During an interview on 4/30/25 at 11:20 a.m., the ADM said CNA A was agency staff and completed all his required training through that agency. The ADM said CNA A had not worked at the facility previously and Resident #8 was his first interaction with a resident at the facility. The ADM said CNA B went into Resident #8's room to assist CNA A with incontinent care. The ADM said CNA B left the room and reported to RN C that CNA A was being rough with Resident #8. The ADM said RN C notified him of alleged abuse and he suspended CNA A immediately pending investigation. The ADM said he requested video from the camera in Resident #8's room but Resident's RP (responsible party) was unable to send the video. The ADM said RP sent a video clip that would not open. The ADM said CNA A was sent home immediately pending investigation and would not be allowed back at the facility. During an interview on 4/30/25 at 6:15 p.m., CNA B said she went into Resident #8's room with CNA A to assist with incontinent care. She said Resident #8 was sleeping, and CNA A yanked his blankets off him. She said Resident #8 woke up startled and grabbed her hand and started squeezing it. She said CNA A grabbed Resident #8's hands, pushed them down into his chest, and held him down on the bed. CNA B said she told CNA A they wouldn't be able to change the resident right now because he was upset, but CNA A insisted they could and told her to go get the Hoyer lift so they could transfer Resident #8 to his chair. CNA B said she left the room and reported to the charge nurse, RN C, that CNA A was being rough with Resident #8. During a telephone interview on 5/1/25 at 8:19 a.m., CNA A said he and CNA B went into Resident #8's room to assist with incontinent care. CNA A said he woke Resident #8 up, introduced himself, and explained the care he was going to provide. CNA A said when he attempted to roll Resident #8 onto his side Resident #8 became combative and grabbed CNA B's hand and squeezed it. CNA A said CNA B told him they wouldn't be able to change Resident #8 right now because of his behaviors. CNA A said he continued to try and change Resident #8's brief and Resident #8 began swinging his fists around. CNA A said he grabbed Resident #8's hands and held them down to the resident's chest to avoid injuries. CNA A said he knew he was not supposed to physically restrain a resident; he said he should have left the room and come back later to provide care . CNA A said RN C told him to leave the resident room and informed he was being suspended pending investigation. He did not know why he did not leave the room to return later. During an interview on 5/1/25 at 9:10 a.m. Resident #8's RP said she was notified on 4/27/25 of the alleged abuse and watched the video recording from the camera in Resident #8's room. The RP said CNA A and CNA B went into Resident #8's room and CNA A yanked the blankets off him. The RP said Resident #8 was scared and became combative with staff, grabbing CNA B's hand. The RP said CNA A grabbed Resident #8's hands and pushed them down into his chest, holding him down on the bed. She said CNA B told CNA A she was going to get the nurse and left the room. The RP said she did not know how to send the entire video of the incident from the in-room camera, but was able to send an 8 second clip to the ADM. Record review of CNA A personnel file indicated all required background checks and abuse, neglect, and exploitation training had been completed by CNA A's staffing agency. Record review of the facility policy titled Restraint Free Environment, dated 10/24/22, indicated It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which resident has medical symptoms that warrant use of restraints It was determined these failures placed residents in an IJ situation on 4/27/25 to 4/28/25. The facility corrected the noncompliance on 4/28/2025 by the following: CNA A was immediately removed from resident care and suspended then terminated. Appropriate notifications to abuse coordinator, RP and providers were made Began ongoing in-service on 4/27/25 for all staff which covered abuse/neglect and required reporting to the facility abuse coordinator. Began ongoing in-service for all staff dated 4/27/25 which covered using no force or minimal force with residents and reporting any pain during personal care to charge nurse . The in-service was provided to all-staff members. Completed QAA Resident Questionnaires, dated 4/28/25, indicated 10 of 10 residents interviewed had not experienced any physical or verbal mistreatment, were treated with dignity and respect, and felt safe in the facility. Staff interviews conducted with staff of varying disciplines on two separate shifts including LVN (3), RN (1), CNA (7), CMA (1), LCSW (1) revealed all staff interviewed were had received abuse and neglect training upon hire, annually, and had additional in-services covering abuse, neglect, mandatory reporting, and using minimal force with residents.

Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 11 residents (Resident #1) reviewed for accidents. The facility failed to keep Resident #1 in a safe environment to prevent an elopement on 4/24/2025 when she followed a visitor out of the facility. An Immediate Jeopardy (IJ) situation was determined to have begun on 4/24/2025 and ended on 4/28/25. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents at risk for serious injury and accidents. Findings include: Record review of Resident #1's admission record, dated 5/1/2025, indicated a [AGE] year-old female who was readmitted to the facility on [DATE]. Resident #1 had diagnoses which included unspecified dementia (decline in cognitive function), anxiety disorder , and senile degeneration of brain (mental deterioration associated with aging). Record review of Resident #1's MDS, dated [DATE], indicated she had a BIMS of 6, which indicated severe cognitive impairment. She required moderate assistance with eating; she required maximum assistance with oral hygiene, upper body dressing, and personal hygiene; she was dependent on staff assistance for showering/bathing, putting on/taking off clothes, putting on/taking off footwear, and toileting hygiene. She was frequently incontinent of bowel and bladder. She had no history of wandering behavior. Record review of Resident #1's comprehensive care plan, dated 4/5/25, indicated she was at risk for falls and further cognitive decline. Interventions were in place which included identify yourself at each interaction, reduce distractions, and ensuring resident was wearing appropriate footwear when ambulating. Record review of Resident #1's elopement assessments, dated 3/15/25 and 3/22/25, indicated she had an elopement risk score of 0 which indicated lowest risk. Record review of incident report #1122 for an elopement dated 4/24/25 indicated the facility was notified of Resident #1's elopement at approximately 8:35 p.m. The same incident report indicated ADM was notified of the elopement at 8:42 p.m. and staff were sent to escort Resident #1 back to the facility. Post-incident assessment completed on 4/24/25 at 9:00 p.m. indicated resident was alert and oriented to person, place, time, and situation, and had no injuries noted. Record review of a progress note, dated 4/24/25 at 6:30 p.m. by LVN G, indicated resident was noted behind the nurse's station trying to use the phone to go home; education and redirection was ineffective. Record review of progress note, dated 4/24/25 at 7:26 p.m. by LVN G, indicated resident asked her what would happen if she opened the door. LVN G noted resident standing up by the door and walking back and forth; education and redirection was ineffective. During an observation and interview on 4/29/25 at 11:00 a.m., Resident #1 was in her room sitting on the bed, she appeared clean and well-groomed with no offensive odors; she had no visible skin tears, marks, or bruising. Resident #1 said she left the facility because she wanted to go home. Resident #1 said she asked a nurse to open the door for her to go home and the nurse refused, so when she saw people exiting the facility and she followed them out. During an interview on 4/30/25 at 11:00 a.m., Regional Consultant Nurse (RNC) said the facility first learned of the elopement when staff at the nursing facility next door called to ask if Resident #1 was a resident at their facility. She said Resident #1 used to work as a CNA and had gone to the nursing facility next door thinking she was going to work. The RNC said Resident #1 had no previous history of wandering or exit-seeking behaviors and her prior elopement scores were all 0. The RNC said the first time Resident #1 exhibited wandering or exit-seeking behaviors was on 4/24/25, the day of the elopement. The RNC said LVN G had identified these behaviors and charted them in Resident #1's medical record but did not notify any other staff or do anything to intervene. The RNC said two staff members assisted Resident #1 back to the facility and she was immediately assessed for injuries with non noted and placed on 1-to-1 observation . The RNC said Resident #1 would remain on 1-to-1 observation until psychiatric services evaluated the resident. She said all resident's had new elopement assessments completed and placed into the elopement binder at the nurses' station. She said LVN G was suspended pending the investigation. During an interview on 4/30/25 at 11:20 a.m., the ADM said the facility was unable to determine how Resident #1 exited the facility. The ADM said Resident #1 stated she saw visitors exiting the facility and asked them to hold the door for her and followed them out. The ADM said when the facility was notified of the elopement maintenance tested all the door magnetic locks and alarms and they were functioning correctly. The ADM said Resident #1 was immediately placed on 1-to-1 supervision and the facility in-serviced all staff on abuse, neglect, exploitation and missing resident policies and held elopement drills with staff . During an interview on 4/30/25 at 2:00 p.m., the Maintenance Director said following the elopement on 4/25/24 he verified all door locks and alarms were functioning and hung signs on the exit doors to alert visitors that residents may try to follow them out. He said he was responsible for completing regular weekly checks of door locks and alarms and recording the inspections in a logbook. He said he had not identified any concerns related to the door locks or alarms. During an observation on 4/30/25 from 2:15 p.m. - 2:45 p.m. revealed the Maintenance Director checked all door magnetic locks and alarms; the locks functioned properly, and alarms were audible . Each exit door had a sign posted, prominently displayed at eye-level, indicating a resident could attempt to follow visitors out. Interview attempted for LVN G - phone calls were not returned. Record review of an elopement incident report, dated 4/24/25, indicated at 8:35 PM a CNA at the next-door nursing facility called and reported Resident #1 was at their facility asking to use a phone to call her family to go home. The incident report indicated Resident #1 was alert and oriented to person, situation, place, and time and had no noted injury . Record review of the facility's policy titled Missing Resident Policy, last revised 8/15/23, indicated .This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk It was determined these failures placed residents in an IJ situation on 4/24/25 to 4/28/25. The facility corrected the noncompliance on 4/28/2024 by the following: Resident #1 placed on 1-to-1 supervision pending psychiatric evaluation to determine safe placement. Resident head counts conducted on 4/24/25 following elopement accounted for all residents. New elopement assessments completed for all residents and placed in elopement binder located at nurse's station. All exit doors locks and alarms were checked by facility maintenance staff and verified to be functioning. Each exit door had a sign posted, prominently displayed at eye-level, indicating a resident could attempt to follow visitors out. An associate disciplinary memo dated 4/25/25 indicated LVN G was suspended pending investigation. QAA Staff questionnaire dated 4/25/25 concerning resident's following staff out of building. Ad Hoc QAPI meeting held to develop a performance improvement plan and ensure safety of resident's going forward. Performance Improvement Plan, dated 4/24/25, titled Exit Seeking/Missing Resident indicated the following action items: 1.) The facility maintenance director and/or designee completed environmental assessments to include checking the function of all the facility exit doors to ensure proper function. 2.) Complete head to toe physical assessment performed by facility staff nurse and telehealth physician assistance, no injuries noted. 3.) Educate facility direct care staff on Missing Resident Policy. Document education using in-service sign in sheet so that compliance can be validated. 4.) Complete a missing resident drill with facility direct care staff. Document drill using drill sign in sheet so that compliance can be validated. 5.) All facility residents were reassessed using the Elopement/Wandering Risk Assessments. No other like residents were identified. 6.) The DON /Designee will conduct weekly random missing resident drills two (2) times a week for six (6) weeks to ensure facility staff know the proper procedure for locating missing residents. Results of weekly observations will be reviewed in the facility morning meeting by the Administrator and/or designee. 7.) Review findings monthly at QAPI meeting for three months to ensure compliance. 8.) Conduct an AdHOC QAPI meeting regarding the facility resident exiting the facility and the facility's plan to follow up to sustain compliance. Physician progress notes, dated 4/25/25, indicated Resident #1 was seen by telehealth provider indicated exit-seeking behavior was an acute new problem and Resident #1's condition was stable. Review of a comprehensive care plan dated 4/25/25 showed care plan was updated to reflect wandering/exit seeking behavior with appropriate interventions in place to redirect resident from restricted areas and use verbal redirection to dissuade exit-seeking behavior. Completed in-service for all staff dated 4/24/25, topic discussed Do Not let any residents out the door without the charge nurse's permission. Completed in-service for all staff dated 4/25/25, topic discussed Missing Resident for all staff. Emergency Response Drill for missing resident, dated 4/25/25, a drill took place between 5:00 p.m. and 5:13 p.m . Emergency Response Drill for missing resident, dated 4/28/25, a drill took place between 3:22 p.m. and 3:25 p.m . Emergency Response Drill for missing resident, dated 4/28/25, a drill took place between 7:07 p.m. and 7:12 p.m . Record review of Elopement Binder indicated all residents had new elopement assessments completed on 4/24/25 . Record review of QAPI minutes from Ad Hoc meeting held on 4/25/25 at 1:15 p.m. to discuss facility's notification regarding Resident #1's elopement and plan to sustain compliance. Record review of a logbook titled Doors Mag Lock for April and March of 2025 indicated all weekly checks were completed and no problems were identified. Observations on 4/30/25 between 2:00 p.m. and 2:45 p.m. of facility exits revealed all magnetic locks and door alarms were functioning. Signs were prominently displayed at each door at eye-level notifying people exiting the facility to not allow residents to follow them out the door. Interviews with staff of various disciplines on two (2) different shifts were interviewed. All staff members said they attended in-service training after the elopement and topics covered not allowing residents to exit the facility without permission from the charge nurse and missing resident response. All staff were all able to verbalize appropriate action to take in the event of a missing resident including identifying exit-seeking behavior, immediately responding to door alarms, looking for missing resident inside the building, outside the building, and notifications including to local police. Staff were able to verbalize to be wary of residents following staff or visitors out of the building and not to allow residents to exit the building without permission from the charge nurse. Staff interviews included LVN (3) RN (1) CNA (7) CMA (1) LCSW (1).

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #1). The facility failed to properly secure Resident #1 during a mechanical lift transfer on 3/4/25 when she fell out of the mechanical lift and there was a potential for severe injury due to the neglectful actions of NA B. These failures could place residents at risk for serious injury and accidents. The noncompliance was determined to be past noncompliance (PNC). The past noncompliance began on 3/4/25 and ended on 3/7/25. The facility had corrected the noncompliance before the survey began. Findings included: Record review of undated admission record printed on 3/08/25 indicated Resident #1 was an [AGE] year-old female who admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy that can significantly interfere with daily life), cognitive communication deficit (difficulty communicating due to brain damage), arthropathy (any disease or condition that affects the joints) and dementia (an umbrella term for a group of diseases that cause a decline in mental ability severe enough to interfere with daily life, encompassing memory, thinking, and behavior). Record review of quarterly MDS dated [DATE] indicated Resident #1 had difficulty communicating some words or finishing thoughts but was but was able if prompted or given time and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment in thinking with a BIMS score of 00 and was totally dependent on staff for transfers. Record review of a care plan for Resident #1 revised on 01/11/2024 indicated she had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner. Interventions included: Transfers: dependent: mechanical lift x 2 NA. Record review of a care plan for Resident #1 revised on 1/14/25 indicated she had the potential for falls related to cognitive impairment, incontinence, gait/balance problems and confusion. Interventions included: Staff education/assist with transfers dated 8/12/2024. Record review of progress note for Resident #1 indicated the following: -3/4/25 at 6:10pm Completed by LVN C- Called to room by [NA B]. [Resident #1] [was] lying on her right side on the floor. She is positioned between the mechanical lift legs. [NA B] reported [Resident #1] was sliding off sling when [NA B] was transferring [Resident #1] from Geri-chair (reclining chair) to bed. [NA B] grabbed [Resident #1s] shirt and mechanical lift sling and assisted [Resident #1] to the floor. Action: Head to toe assessment completed. [Resident #1] moved all extremities within normal limits for this resident. No knots [NAME] on scalp. No pain when pressure applied to all joints. [Resident #1] stated I'm ok. -3/4/25 at 8:01pm Completed by LVN C: Data: [virtual medical visit] provider, and doctor notified of event and [Resident #1's] assessment. Action: Provider given details of incident and resident's assessment. Provider video chatted with resident. Response: Orders received for fall precautions, neuros per facility protocol, notify clinician for any change in condition. -3/4/25 at 8:41pm_[Virtual Medical Visit] note - Date of Service: 3/4/25 @ 7:59pm, Details: Nurse Name: [LVN C], Patient Name: [Resident #1] Primary Chief Complaint: Fall Without Injury History Present Illness: [AGE] year-old female who had a fall that evening. [NA B] was transferring [Resident #1] from Geri chair to bed using a mechanical lift. [Resident #1] started sliding out of sling and the [NA B] was able to grab [Resident #1's] shirt and mechanical lift sling and lowered [Resident #1] to the ground. [Resident #1] denied pain or injuries. [Resident #1] had good ROM without c/o pain. No deficits noted - at [Resident #1] baseline. No obvious injuries, lacerations, abrasions, bleeding. [Resident #1] did not hit her head. Witnessed. Neuro was checks started and were normal. Record review of 72-hour neuro checks report dated effective 3/4/25 indicated Resident #1 had no change in neuro status. [Resident #1] did not follow finger with her eyes and her neuro remain at baseline and voiced no pain complaints. During an observation and attempted interview on 3/9/25 at 2:03pm, Resident #1 was in her room lying in bed resting, she did not respond to questions asked. Resident #1 did was clean, well-groomed with no unpleasant odor. There was no visible bruising, skin tears or marks to Resident #1's upper body area. Record review of witness statement form dated 3/4/25 completed by NA B indicated the following: [NA B] used mechanical lift, connected all 4 loops on mechanical lift, and pushed the button. [Resident #1] was in the air, she leaned forward, and [NA B] saw [Resident #1] coming out of the [mechanical lift] swing. [NA B] immediately grabbed both the sling and [Resident #1] shirt, brought [Resident #1] close to [NA B] while supporting [Resident #1] back and head; once safely on the floor [NA B] got help. Record review of a skills validation checklist for transfers dated 1/24/2025 indicated NA B was in attendance by her signature and was observed by the DON on mechanical lift transfer. Record review of Administrator's typed statement dated 3/4/25 regarding the incident indicated the following: At 6:27 pm [the Administrator] received a call from DON stating there had been an accident involving the mechanical lift. [NA B] was putting [Resident #1] to bed BY HERSELF using the mechanical lift. [Resident #1] was not injured and did not hit the floor, per [NA B]. [NA B] stated she knew she was not to use the mechanical lift without a partner, but that she was trying to get her residents in bed. She stated when [the facility] is short, we just do what we have to do sometimes. [NA B] also stated she used blue hooks on one side and green hooks on the other side when she put [Resident #1] in the mechanical lift sling. She stated [Resident #1] was facing her as she steered the mechanical lift and as she got close to the bed, [Resident #1] started to fall toward her, she grabbed her shirt and wrapped her arm around her causing [Resident #1] to turn in the sling. She stated at no time did [Resident #1] hit the floor. [NA B] stated she lowered [Resident #1] to the floor . During an attempted interview on 3/12/2025 at 9:11am, the NA B was called but she did not answer, and it went to voice mail and a message was left to return the call related to the investigation. During a phone interview on 3/12/25 at 9:17am, LVN C said she had been employed at the facility for about [AGE] years and worked the 6pm-6am as a charge nurse. She said she was the nurse on duty the day Resident #1 was involved in the mechanical lift fall incident on 3/4/25. She said NA B ran out into the hall and yelled for help, LVN C said herself, the DON who no longer worked there and several others who she could not recalled ran and assisted. LVN C said she saw Resident #1 laying on the floor between the legs of the lift and NA B explained what happened. She Said NA B explained she was transferring Resident #1 from chair to bed using the mechanical lift and Resident #1 started slipping or coming out the mechanical lift sling, and NA B explained to her she grabbed Resident #1 by her shirt and guided Resident #1 to the floor. LVN C said she could tell NA B did grab Resident #1 by the shirt because Resident #1's shirt did appear to be gathered as if used as described by NA B. LVN C said the resident was assessed by her, they moved the lift out of the way, checked her vital signs, and talked to Resident #1 and she voiced she was okay and they assisted Resident #1 back into bed. LVN C said Resident #1 did not appear distressed, no injuries and did not appear to be in pain so she was not sent out to the hospital. LVN C said she notified the appropriate people and doctor ordered fall precautions and initiate the 72-hour neuro checks post fall. Record review of the state agency reporting system revealed from 3/4/25 -3/9/25 there were no self-reported incidents submitted regarding Resident #1's mechanical lift fall incident. During an interview on 3/9/25 at 2:27pm The Administrator indicated the mechanical lift fall incident that occurred on 3/4/25 with Resident #1 was not reported to HHSC due to not meeting HHSC reportable criteria of neglect. The incident involving [Resident #1] did not meet the neglect reportable criteria as [Resident #1] did not have any evidence of an injury, emotional harm, pain and/or death. During an interview on 3/9/25 at 4:20pm Regional Nurse Consultant said she was not an employee of the facility when the incident occurred with Resident #1 and replied No, the incident was not reported to HHSC, the incident was investigated by the facility, and it was determined that the incident did not meet HHSC criteria of neglect. [Resident #1] did not have any injury, emotional harm, pain, and/or death due to the mechanical lift incident. Therefore, it was determined that this incident did not meet the reportable criteria defined in HHSC provider letter. It is [Regional Nurse Consultant] expectation that the facility staff are to use the mechanical lift in accordance with the facility mechanical lift and the clinical manufacturer guidelines. During an interview on 3/9/25 at 5:33pm, the Administrator said all allegations of abuse and neglect was reportable to the state agency, but it just depended on each situation, and she determined what allegations were reported to state agency by following the guidelines in the Long-Term Care Regulation Provider Letter issued 8/29/24 and followed the facility's Abuse Policy. Administrator said it was her responsible for making reports of allegations to the state agency, but according to the most recent provider letter she felt the letter did not indicate potential for severe injury due to the neglectful actions of a staff member was a reportable incident and especially since Resident #1 was not hurt. The Administrator said she was the Abuse Coordinator. The Administrator said Resident #1's family has electronic monitoring in her room, and she had reached out the day of the incident to Resident #1's family requesting to see the video footage or for the family member to review it and also reached a couple of times during family member's visit and she said the family member had not followed up and said they was satisfied with care provided. She said the previous DON had started in-servicing staff and began an investigation and determined that it was an accident. Record review of an undated associate disciplinary memorandum for NA B indicated on 3/4/25 she was suspended for transferring a resident using the mechanical lift without assistance resulting in an unsafe transfer of resident. Effective 3/7/25 after completion of investigation NA B discharged [terminated] due to failure to follow policy of two-person transfer using the mechanical lift. Record review of termination form dated 3/7/25 indicated NA B was terminated involuntary on 3/7/25 due to a safety violation. Her hired date was 3/20/23 and NA B last day worked was on 3/4/25. NA B transferred a resident using the mechanical lift without assistance resulting in an unsafe transfer of a resident. Record review of a Validation Checklist Mechanical List undated indicated, .Purpose: To determine if the staff is performing mechanical lift procedure in accordance with the facility's standard of practice. 1. Employee understands the maximum weight for each lift. 2. Employee understands to inspect sling for tears or loose stitching and report any findings to DON or designee. 3. Employee understands to not use any plastic back incontinence pad or seat cushion between resident and sling that could cause sliding. 4. Lifting the Resident: must have two staff members when using a lift. 5. Explain procedure to resident. 6. The adjustable legs must be in the maximum opened position and always locked while resident is in the lift. 7. Make sure the arms of the sling (leg sections) are crossed under the resident's legs and attach on the opposite side hook. 8. Match the corresponding colors on each side of the sling for an even lift of the resident. 9. When the sling is elevated a few inches, check to make sure that all hooks are connected to lift. 10. Do not lock the rear casters of the lift, this could cause tipping of the lift. 12. Use the steering handle when moving the lift. 13. When moving the resident lift away from the bed or chair, turn the resident so that he/she faces the employee transferring from or to a wheelchair, shower or bed is locked. 14. Employee understands how to activate the emergency release. 15. Employee understands to inspect lift for wear, tear, and broken parts: reporting any findings to DON or designee . Record review of a facility policy titled Incident/Accident Policy revised on 11/17 indicated, .It is the policy of this facility to report and investigate all incidents and accidents that occur in the facility or on facility property in a timely manner. 9. The Administrator and Director of Nursing will review the incident/accident to determine if investigation is required . Record review of a mechanical lift policy last reviewed on 9/13/24 indicated Policy: To enable one individual to lift and move a resident safely, with as little effort as possible. Record review of a facility policy titled Fall Management System revised on 1/3/17 indicated, .Fundamental Information: A fall occurs when there is an unintentional coming to rest on the floor, ground, or other lower level but not as a result of an overwhelming external force (ex: resident pushes another resident) .A fall without injury is still a fall . It was determined these failures resulted in Resident #1's mechanical lift fall on 3/4/25. Facility took the following actions to correct the noncompliance: Record review of Administrator's typed statement dated 3/4/25 indicated in-services was conducted on 3/4/25 [Name of Virtual Medical Visit Provider] with staff regarding mechanical lift usage and gave a return demonstration. [Name of Virtual Medical Visit Provider] was called and did a Facetime visit, doctor was notified and a QAPI meeting was had. All nursing staff was in-serviced that are on the facility employee roster. During interviews with 7 CNA s and 4 LVNs covering day and night shifts indicated they were In-serviced by the previous DON and ADON who showed them the proper way to use the lift with a return demonstration. During an observation on 3/9/25 at 1:52pm, NA D and NA E provided a return demonstration with no issues or concerns. Record Review of [NA B] provided a written statement and was suspended on 03/04/2025 during investigation and later terminated involuntary on 3/7/25 due to a safety violation. Record review of an undated typed note provided by the Administrator indicated the following: An off-cycle QAPI meeting was held on March 4, 2025, at approximately 8:13 pm via phone conversation with medical director to discuss an incident in which [Resident #1] was lowered from the mechanical lift by a [NA B] as [Resident #1] started to fall from the sling. We discussed the facility's follow up plan to sustain compliance. The following individuals were in attendance: Facility Medical Director - via phone, Facility Administrator, and the Facility Interim DON.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but , but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 5 (Resident #1) residents reviewed for abuse and neglect. The facility did not report to the state agency within 24 hours when NA B dropped Resident #1 during a mechanical lift transfer on 3/4/25. These failures could place residents at risk for serious injury and accidents. Findings included: Record review of undated admission record printed on 3/08/25 indicated Resident #1 was an [AGE] year-old female who admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy that can significantly interfere with daily life), cognitive communication deficit (difficulty communicating due to brain damage), arthropathy (any disease or condition that affects the joints) and dementia (an umbrella term for a group of diseases that cause a decline in mental ability severe enough to interfere with daily life, encompassing memory, thinking, and behavior). Record review of quarterly MDS dated [DATE] indicated Resident #1 had difficulty communicating some words or finishing thoughts but was but was able if prompted or given time and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment in thinking with a BIMS score of 00 and was totally dependent on staff for transfers. Record review of a care plan for Resident #1 revised on 01/11/2024 indicated she had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner. Interventions included: Transfers: dependent: mechanical lift x 2 NA. Record review of a care plan for Resident #1 revised on 1/14/25 indicated she had the potential for falls related to cognitive impairment, incontinence, gait/balance problems and confusion. Interventions included: Staff education/assist with transfers dated 8/12/2024. Record review of progress note for Resident #1 indicated the following: -3/4/25 at 6:10pm Completed by LVN C- Called to room by [NA B]. [Resident #1] [was] lying on her right side on the floor. She is positioned between the mechanical lift legs. [NA B] reported [Resident #1] was sliding off sling when [NA B] was transferring [Resident #1] from Geri-chair (chair that reclines) to bed. [NA B] grabbed [Resident #1s] shirt and mechanical lift sling and assisted [Resident #1] to the floor. Action: Head to toe assessment completed. [Resident #1] moved all extremities within normal limits for this resident. No knots [NAME] on scalp. No pain when pressure applied to all joints. [Resident #1] stated I'm ok. -3/4/25 at 8:01pm Completed by LVN C: Data: [virtual medical visit] provider, and doctor notified of event and [Resident #1's] assessment. Action: Provider given details of incident and resident's assessment. Provider video chatted with resident. Response: Orders received for fall precautions, neuros per facility protocol, notify clinician for any change in condition. -3/4/25 at 8:41pm_[Virtual Medical Visit] note - Date of Service: 3/4/25 @ 7:59pm, Details: Nurse Name: [LVN C], Patient Name: [Resident #1] Primary Chief Complaint: Fall Without Injury History Present Illness: [AGE] year-old female who had a fall that evening. [NA B] was transferring [Resident #1] from Geri chair to bed using a mechanical lift . [Resident #1] started sliding out of sling and the [NA B] was able to grab [Resident #1's] shirt and mechanical lift sling and lowered [Resident #1] to the ground. [Resident #1] denied pain or injuries. [Resident #1] had good ROM without c/o pain. No deficits noted - at [Resident #1] baseline. No obvious injuries, lacerations, abrasions, bleeding. [Resident #1] did not hit her head. Witnessed. Neuro was checks started and were normal. Record review of 72-hour neuro checks report dated effective 3/4/25 indicated Resident #1 had no change in neuro status. [Resident #1] did not follow finger with her eyes and her neuro remain at baseline and voiced no pain complaints. During an observation and attempted interview on 3/9/25 at 2:03pm, Resident #1 was in her room lying in bed resting, she did not respond to questions asked. Resident #1 did was clean, well-groomed with no unpleasant odor. There was no visible bruising, skin tears or marks to Resident #1's upper body area. Record review of witness statement form dated 3/4/25 completed by NA B indicated the following: [NA B] used mechanical lift , connected all 4 loops on mechanical lift , and pushed the button. [Resident #1] was in the air, she leaned forward, and [NA B] saw [Resident #1] coming out of the [mechanical lift ] swing. [NA B] immediately grabbed both the sling and [Resident #1] shirt, brought [Resident #1] close to [NA B] while supporting [Resident #1] back and head; once safely on the floor [NA B] got help. Record review of a skills validation checklist for transfers dated 1/24/2025 indicated NA B was in attendance by her signature and was observed by the DON on mechanical lift transfer. Record review of Administrator's typed statement dated 3/4/25 regarding the incident indicated the following: At 6:27 pm [the Administrator] received a call from DON stating there had been an accident involving the mechanical lift. [NA B] was putting [Resident #1] to bed BY HERSELF using the mechanical lift . [Resident #1] was not injured and did not hit the floor, per [NA B]. [NA B] stated she knew she was not to use the mechanical lift without a partner, but that she was trying to get her residents in bed. She stated when [the facility] is short, we just do what we have to do sometimes. [NA B] also stated she used blue hooks on one side and green hooks on the other side when she put [Resident #1] in the mechanical lift sling. She stated [Resident #1] was facing her as she steered the mechanical lift and as she got close to the bed, [Resident #1] started to fall toward her, she grabbed her shirt and wrapped her arm around her causing [Resident #1] to turn in the sling. She stated at no time did [Resident #1] hit the floor. [NA B] stated she lowered [Resident #1] to the floor. [NA B] gave us a written statement and was suspended investigation. Staff presents were in-serviced on mechanical lift usage and gave a return demonstration. [Name of Virtual Medical Visit Provider] was called and did a Facetime visit, doctor was notified and a QAPI meeting was had. All nursing staff will be in-serviced that are on the facility employee roster. Record review of an undated typed note provided by the Administrator indicated the following: An off-cycle QAPI meeting was held on March 4, 2025, at approximately 8:13 pm via phone conversation with medical director to discuss an incident in which [Resident #1] was lowered from the mechanical lift by a [NA B] as [Resident #1] started to fall from the sling. We discussed the facility's follow up plan to sustain compliance. The following individuals were in attendance: Facility Medical Director - via phone, Facility Administrator and the Facility Interim DON. During an attempted interview on 3/12/2025 at 9:11am, the NA B was called but she did not answer, and it went to voice mail and a message was left to return the call related to the investigation. During a phone interview on 3/12/25 at 9:17am, LVN C said she had been employed at the facility for about [AGE] years and worked the 6pm-6am as a charge nurse. She said she was the nurse on duty the day Resident #1 was involved in the mechanical lift fall incident on 3/4/25. She said NA B ran out into the hall and yelled for help, LVN C said herself, the DON who no longer worked there and several others who she could not recalled ran and assisted. LVN C said she saw Resident #1 laying on the floor between the legs of the lift and NA B explained what happened. She Said NA B explained she was transferring Resident #1 from chair to bed using the mechanical lift lift and Resident #1 started slipping or coming out the mechanical lift sling, and NA B explained to her she grabbed Resident #1 by her shirt and guided Resident #1 to the floor. LVN C said she could tell NA B did grab Resident #1 by the shirt because Resident #1's shirt did appear to be gathered as if used as described by NA B. LVN C said the resident was assessed by her, they moved the lift out of the way, checked her vital signs, and talked to Resident #1 and she voiced she was okay and they assisted Resident #1 back into bed. LVN C said Resident #1 did not appear distressed, no injuries and did not appear to be in pain so she was not sent out to the hospital. LVN C said she notified the appropriate people and doctor ordered fall precautions and initiate the 72-hour neuro checks post fall. Record review of the state agency reporting system revealed from 3/4/25 -3/9/25 there were no self-reported incidents submitted regarding Resident #1's mechanical lift fall incident. During an interview on 3/9/25 at 4:20pm Regional Nurse Consultant said she was not an employee of the facility when the incident occurred with Resident #1 and replied No, the incident was not reported to HHSC, the incident was investigated by the facility, and it was determined that the incident did not meet HHSC criteria of neglect. [Resident #1] did not have any injury, emotional harm, pain, and/or death due to the mechanical lift incident. Therefore, it was determined that this incident did not meet the reportable criteria defined in HHSC provider letter. It was [Regional Nurse Consultant] expectation that the facility staff are to use the mechanical lift in accordance with the facility mechanical lift and the clinical manufacturer guidelines. During an interview on 3/9/25 at 5:33pm, the Administrator said all allegations of abuse and neglect was reportable to the state agency, but it just depended on each situation, and she determined what allegations were reported to state agency by following the guidelines in the Long-Term Care Regulation Provider Letter issued 8/29/24 and followed the facility's Abuse Policy. Administrator said it was her responsible for making reports of allegations to the state agency, but according to the most recent provider letter she felt the letter did not indicate potential for severe injury due to the neglectful actions of a staff member was a reportable incident and especially since Resident #1 was not hurt. The Administrator said she was the Abuse Coordinator. The Administrator said Resident #1's family has electronic monitoring in her room, and she had reached out the day of the incident to Resident #1's family requesting to see the video footage or for the family member to review it and also reached a couple of times during family member's visit and she said the family member had not followed up and said they was satisfied with care provided. Record review of an undated associate disciplinary memorandum for NA B indicated on 3/4/25 she was suspended for transferring a resident using the mechanical lift without assistance resulting in an unsafe transfer of resident. Effective 3/7/25 after completion of investigation NA B discharged [terminated] due to failure to follow policy of two-person transfer using the mechanical lift . Record review of termination form dated 3/7/25 indicated NA B was terminated involuntary on 3/7/25 due to a safety violation. Her hired date was 3/20/23 and NA B last day worked was on 3/4/25. NA B transferred a resident using the mechanical lift without assistance resulting in an unsafe transfer of a resident. Record review of a revised facility policy titled Abuse, Neglect and Exploitation dated 9/6/24 indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Policy Explanation and Compliance Guidelines: .2) The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law . VII) Reporting/Response: A) The facility reports abuse and abuse allegations that include: 1)Reporting allegation involving staff to-resident abuse . 2)Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes: a)Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse (with or without bodily injury) . c) Not later than 24 hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury but that involves any of the following: -Neglect . B) The Administrator will follow up with government agencies, during business hours, to confirm the initial repot was received, and to report the results of the investigation when final withing 5 working days of the incident, as required by state agencies .

Based on observation, interview and record review the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 8 (Resident #1) residents reviewed for abuse and neglect. The facility did not implement their policy to report to HHSC within 24 hours when a fall incident to Resident #1 occurred on 3/04/2025. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings included: Record review of undated admission record printed on 3/08/25 indicated Resident #1 was an [AGE] year-old female who admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy that can significantly interfere with daily life), cognitive communication deficit (difficulty communicating due to brain damage), arthropathy (any disease or condition that affects the joints) and dementia (an umbrella term for a group of diseases that cause a decline in mental ability severe enough to interfere with daily life, encompassing memory, thinking, and behavior). Record review of quarterly MDS dated [DATE] indicated Resident #1 had difficulty communicating some words or finishing thoughts but was but was able if prompted or given time and usually understood others. The MDS indicated Resident #1 had severe cognitive impairment in thinking with a BIMS score of 00 and was totally dependent on staff for transfers. Record review of a care plan for Resident #1 revised on 01/11/2024 indicated she had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner. Interventions included: Transfers: dependent: mechanical lift x 2 NA. Record review of a care plan for Resident #1 revised on 1/14/25 indicated she had the potential for falls related to cognitive impairment, incontinence, gait/balance problems and confusion. Interventions included: Staff education/assist with transfers dated 8/12/2024. Record review of progress note for Resident #1 indicated the following: -3/4/25 at 6:10pm Completed by LVN C- Called to room by [NA B]. [Resident #1] [was] lying on her right side on the floor. She is positioned between the mechanical lift legs. [NA B] reported [Resident #1] was sliding off sling when [NA B] was transferring [Resident #1] from Geri-chair to bed. [NA B] grabbed [Resident #1s] shirt and mechanical lift sling and assisted [Resident #1] to the floor. Action: Head to toe assessment completed. [Resident #1] moved all extremities within normal limits for this resident. No knots [NAME] on scalp. No pain when pressure applied to all joints. [Resident #1] stated I'm ok. -3/4/25 at 8:01pm Completed by LVN C: Data: [virtual medical visit] provider, and doctor notified of event and [Resident #1's] assessment. Action: Provider given details of incident and resident's assessment. Provider video chatted with resident. Response: Orders received for fall precautions, neuros per facility protocol, notify clinician for any change in condition. -3/4/25 at 8:41pm_[Virtual Medical Visit] note - Date of Service: 3/4/25 @ 7:59pm, Details: Nurse Name: [LVN C], Patient Name: [Resident #1] Primary Chief Complaint: Fall Without Injury History Present Illness: [AGE] year-old female who had a fall that evening. [NA B] was transferring [Resident #1] from Geri chair to bed using a mechanical lift . [Resident #1] started sliding out of sling and the [NA B] was able to grab [Resident #1's] shirt and mechanical lift sling and lowered [Resident #1] to the ground. [Resident #1] denied pain or injuries. [Resident #1] had good ROM without c/o pain. No deficits noted - at [Resident #1] baseline. No obvious injuries, lacerations, abrasions, bleeding. [Resident #1] did not hit her head. Witnessed. Neuro was checks started and were normal. Record review of 72-hour neuro checks report dated effective 3/4/25 indicated Resident #1 had no change in neuro status. [Resident #1] did not follow finger with her eyes and her neuro remain at baseline and voiced no pain complaints. During an observation and attempted interview on 3/9/25 at 2:03pm, Resident #1 was in her room lying in bed resting, she did not respond to questions asked. Resident #1 did was clean, well-groomed with no unpleasant odor. There was no visible bruising, skin tears or marks to Resident #1's upper body area. Record review of witness statement form dated 3/4/25 completed by NA B indicated the following: [NA B] used mechanical lift, connected all 4 loops on mechanical lift, and pushed the button. [Resident #1] was in the air, she leaned forward, and [NA B] saw [Resident #1] coming out of the [mechanical lift ] swing. [NA B] immediately grabbed both the sling and [Resident #1] shirt, brought [Resident #1] close to [NA B] while supporting [Resident #1] back and head; once safely on the floor [NA B] got help. Record review of a skills validation checklist for transfers dated 1/24/2025 indicated NA B was in attendance by her signature and was observed by the DON on mechanical lift transfer. Record review of Administrator's typed statement dated 3/4/25 regarding the incident indicated the following: At 6:27 pm [the Administrator] received a call from DON stating there had been an accident involving the mechanical lift. [NA B] was putting [Resident #1] to bed BY HERSELF using the mechanical lift. [Resident #1] was not injured and did not hit the floor, per [NA B]. [NA B] stated she knew she was not to use the mechanical lift without a partner, but that she was trying to get her residents in bed. She stated when [the facility] is short, we just do what we have to do sometimes. [NA B] also stated she used blue hooks on one side and green hooks on the other side when she put [Resident #1] in the mechanical lift sling. She stated [Resident #1] was facing her as she steered the mechanical lift and as she got close to the bed, [Resident #1] started to fall toward her, she grabbed her shirt and wrapped her arm around her causing [Resident #1] to turn in the sling. She stated at no time did [Resident #1] hit the floor. [NA B] stated she lowered [Resident #1] to the floor. [NA B] gave us a written statement and was suspended investigation. Staff presents were in-serviced on mechanical lift usage and gave a return demonstration. [Name of Virtual Medical Visit Provider] was called and did a Facetime visit, doctor was notified and a QAPI meeting was had. All nursing staff will be in-serviced that are on the facility employee roster. Record review of an undated typed note provided by the Administrator indicated the following: An off-cycle QAPI meeting was held on March 4, 2025, at approximately 8:13 pm via phone conversation with medical director to discuss an incident in which [Resident #1] was lowered from the mechanical lift by a [NA B] as [Resident #1] started to fall from the sling. We discussed the facility's follow up plan to sustain compliance. The following individuals were in attendance: Facility Medical Director - via phone, Facility Administrator and the Facility Interim DON. During an attempted interview on 3/12/2025 at 9:11am, the NA B was called but she did not answer, and it went to voice mail and a message was left to return the call related to the investigation. During a phone interview on 3/12/25 at 9:17am, LVN C said she had been employed at the facility for about [AGE] years and worked the 6pm-6am as a charge nurse. She said she was the nurse on duty the day Resident #1 was involved in the mechanical lift fall incident on 3/4/25. She said NA B ran out into the hall and yelled for help, LVN C said herself, the DON who no longer worked there and several others who she could not recalled ran and assisted. LVN C said she saw Resident #1 laying on the floor between the legs of the lift and NA B explained what happened. She Said NA B explained she was transferring Resident #1 from chair to bed using the mechanical lift and Resident #1 started slipping or coming out the mechanical lift sling, and NA B explained to her she grabbed Resident #1 by her shirt and guided Resident #1 to the floor. LVN C said she could tell NA B did grab Resident #1 by the shirt because Resident #1's shirt did appear to be gathered as if used as described by NA B. LVN C said the resident was assessed by her, they moved the lift out of the way, checked her vital signs, and talked to Resident #1 and she voiced she was okay and they assisted Resident #1 back into bed. LVN C said Resident #1 did not appear distressed, no injuries and did not appear to be in pain so she was not sent out to the hospital. LVN C said she notified the appropriate people and doctor ordered fall precautions and initiate the 72-hour neuro checks post fall. Record review of the state agency reporting system revealed from 3/4/25 -3/9/25 there were no self-reported incidents submitted regarding Resident #1's mechanical lift fall incident. During an interview on 3/9/25 at 4:20pm Regional Nurse Consultant said she was not an employee of the facility when the incident occurred with Resident #1 and replied No, the incident was not reported to HHSC, the incident was investigated by the facility, and it was determined that the incident did not meet HHSC criteria of neglect. [Resident #1] did not have any injury, emotional harm, pain, and/or death due to the mechanical lift incident. Therefore, it was determined that this incident did not meet the reportable criteria defined in HHSC provider letter. It was [Regional Nurse Consultant] expectation that the facility staff are to use the mechanical lift in accordance with the facility mechanical lift and the clinical manufacturer guidelines. During an interview on 3/9/25 at 5:33pm, the Administrator said all allegations of abuse and neglect was reportable to the state agency, but it just depended on each situation, and she determined what allegations were reported to state agency by following the guidelines in the Long-Term Care Regulation Provider Letter issued 8/29/24 and followed the facility's Abuse Policy. Administrator said it was her responsible for making reports of allegations to the state agency, but according to the most recent provider letter she felt the letter did not indicate potential for severe injury due to the neglectful actions of a staff member was a reportable incident and especially since Resident #1 was not hurt. The Administrator said she was the Abuse Coordinator. The Administrator said Resident #1's family has electronic monitoring in her room, and she had reached out the day of the incident to Resident #1's family requesting to see the video footage or for the family member to review it and also reached a couple of times during family member's visit and she said the family member had not followed up and said they was satisfied with care provided. Record review of an undated associate disciplinary memorandum for NA B indicated on 3/4/25 she was suspended for transferring a resident using the mechanical lift without assistance resulting in an unsafe transfer of resident. Effective 3/7/25 after completion of investigation NA B discharged [terminated] due to failure to follow policy of two-person transfer using the mechanical lift . Record review of termination form dated 3/7/25 indicated NA B was terminated involuntary on 3/7/25 due to a safety violation. Her hired date was 3/20/23 and NA B last day worked was on 3/4/25. NA B transferred a resident using the mechanical lift without assistance resulting in an unsafe transfer of a resident. Record review of a Validation Checklist Mechanical List undated indicated, .Purpose: To determine if the staff is performing mechanical lift procedure in accordance with the facility's standard of practice. 1. Employee understands the maximum weight for each lift. 2. Employee understands to inspect sling for tears or loose stitching and report any findings to DON or designee. 3. Employee understands to not use any plastic back incontinence pad or seat cushion between resident and sling that could cause sliding. 4. Lifting the Resident: must have two staff members when using a lift. 5. Explain procedure to resident. 6. The adjustable legs must be in the maximum opened position and always locked while resident is in the lift. 7. Make sure the arms of the sling (leg sections) are crossed under the resident's legs and attach on the opposite side hook. 8. Match the corresponding colors on each side of the sling for an even lift of the resident. 9. When the sling is elevated a few inches, check to make sure that all hooks are connected to lift. 10. Do not lock the rear casters of the lift, this could cause tipping of the lift. 12. Use the steering handle when moving the lift. 13. When moving the resident lift away from the bed or chair, turn the resident so that he/she faces the employee transferring from or to a wheelchair, shower or bed is locked. 14. Employee understands how to activate the emergency release. 15. Employee understands to inspect lift for wear, tear, and broken parts: reporting any findings to DON or designee . Record review of a revised facility policy titled Abuse, Neglect and Exploitation dated 9/6/24 indicated, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Policy Explanation and Compliance Guidelines: .2) The facility's abuse prevention coordinator is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law . VII) Reporting/Response: A) The facility reports abuse and abuse allegations that include: 1)Reporting allegation involving staff to-resident abuse . 2)Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specific timeframes: a)Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse (with or without bodily injury) . c) Not later than 24 hours after the incident occurs or is suspected. An incident that does not result in serious bodily injury but that involves any of the following: -Neglect . B) The Administrator will follow up with government agencies, during business hours, to confirm the initial repot was received, and to report the results of the investigation when final withing 5 working days of the incident, as required by state agencies .

Based on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 24 residents reviewed for accidents. (Resident #20) The facility failed to properly secure Resident #20 during a mechanical lift transfer on 8/30/2024 when she fell out of the mechanical lift and hit her head and left shoulder on the door in her room resulting in a subdural hematoma and a left shoulder separation. On 9/10/2024 at 10:00 AM an Immediate Jeopardy (IJ) situation was identified. While the IJ was removed on 9/10/2024 at 3:53 PM, the facility remained out of compliance at a potential for harm with a scope identified as isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures could place residents at risk for serious injury and accidents. Findings included: 1.Record review of an Admission Record dated 9/9/2024 for Resident #20 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of ID (limitation in metal abilities that affect thinking, learning and everyday life skills), DD (a group of conditions due to an impairment in physical, learning, language, or behavior areas), hypertension and unspecified convulsions (involuntary contraction of the muscles that result in uncontrollable shaking). Record review of a Quarterly MDS assessment dated [DATE] for Resident #20 indicated she had severe impairment in thinking with a BIMS score of 3. She was totally dependent on staff for transfers. Record review of a care plan for Resident #20 revised on 9/1/2024 indicated she had an ADL self-care performance deficit and is at risk for not having their needs met in a timely manner. Interventions included: left arm splint/sling to immobilize left shoulder. She is non-complaint refusing to wear it at times. Transfers: dependent: hoyer lift x 2 CNA. Record review of a care plan for Resident #20 revised on 10/5/2023 indicated she had the potential for falls related to cognitive impairment secondary to intellectual disabilities. Interventions included: hoyer lift x2 CNA for transfers from bed to chair/gurney or chair/gurney to bed dated 8/24/2024. Staff training on hoyer lift transfers dated 8/31/2024. Record review of an incident report for Resident #20 dated 8/30/2024 at 8:25 PM by LVN W indicated a witnessed fall occurred in the resident's room during a transfer with a mechanical lift. Statements by witnessed staff NA A and CNA B indicated, .they were getting the resident ready to put her back in bed after her shower. As they were in the door frame putting the straps on the mechanical lift, they started pushing the lift into the room and one of the straps came off and her head and shoulder hit the door . The Administrator, DON, and responsible party were notified. Record review of an X-ray report dated 8/20/2024 for Resident #20 indicated she had a widening of the AC joint seen measuring approximately 6 mm suggesting AC joint separation (collarbone separated from the shoulder blade) of unknown acuity. Record review of a CT scan of head dated 8/30/2024 for Resident #20 indicated she had a small subdural hematoma and a soft tissue trauma. Record review of TULIP for the facility did not indicate a self-report was submitted to report the serious bodily injury of Resident #20. During an observation and interview on 9/9/2024 at 9:22 AM, Resident #20 was in her bed awake, alert to person and coloring on a piece of paper. Her Best Friend was present and said she had been with the resident since February 2024 and worked Monday-Friday with her from 8 am-11 am. She said Resident #20 had a fall about a week ago when she fell from the lift and had a left shoulder bruise and pain in her head. Resident #20 was very hard to understand when she spoke and pointed to her left shoulder and said it hurt. During an observation and interview on 9/9/2024 at 1:10 PM, CNA C and CNA D were in the room of Resident #20 to provide care. Resident #20 was transferred from her wheelchair to her bed using a mechanical lift. CNA D was operating the lift, the legs were widened, and the lift was positioned over the wheelchair. The lift sling straps were placed on the lift using the last strap which was a faded purple in color, and they connected the sling to all 3 hooks on both sides of the lift for a total of 6 straps. The wheelchair was checked and locked, the resident was lifted and positioned over the bed, and the staff did not lock the legs on the lift. The mechanical lift was taken back into the hallway and locked. Observation of the lift sling for the resident was faded in color and no manufacturer's tag was present. Both staff said the sling looked like one of the old ones. During an interview on 9/9/2024 at 1:35 PM, CNA D said she had been employed at the facility for 2 1/2 years and worked all over the facility and was not specifically assigned to a hall. She said she was supposed to be off that day on 9/9/2024 but came in to help. She said on the day Resident #20 had a fall from the mechanical lift, she was not working, and the incident occurred on the night shift. She said following the incident, they were taught how to properly use a mechanical lift, how to lift properly, and how to secure the lift pad along with safe transfers. She said when operating the mechanical lift, they should widen the base, apply the brakes so it does not move, apply straps, and make sure they do not move, make sure straps were intact, proceed with lifting with another person helped to guide and double checked that everything was good. She said they would then proceed to unlock the brakes and continue with the transfer. She said during the transfer with Resident #20, she did not apply the brakes when she moved her to the bed. She said the other CNA (CNA C) that helped her made her nervous and it was too late to apply the brake. She said she was watching the resident's legs and wanted to make sure they were on the bed. She said it was never too late to apply the brakes, but she did not. She said residents could be at risk for falls, breaking something, or a head injury if they were not transferred properly using the mechanical lift. During a phone interview on 9/9/2024 at 6:33 PM, CNA B said she had been employed at the facility since July 2024 and worked 6 pm-6 am on hall 200. She said the incident involving Resident #20 on 8/30/2024, she was helping NA A. She said the resident had a shower and they were taking her back to her room. She said Resident #20 was on a shower bed and they placed the lift sling underneath her in the shower room. She said the mechanical lift had 6 rings (3 on each side) and the straps were placed on all 6 rings. She said NA A was operating the lift and she was helping to guide the resident. She said the resident was in the hallway in front of her room door and they were in the process of lifting Resident #20 with the lift and one of the straps by her left leg came off and was not sure why. She said the resident began to lean to the left side and NA A started trying to lower the resident down and she could not catch her. She said Resident #20 fell on her left side in the doorway hitting her head and left shoulder on the door. She said the resident fell to the floor. She said they immediately called the nurse, who was across the hall in another resident's room. She said the nurse came in and assessed the resident taking vital signs and called 911. She said following the incident that same night, they had an Inservice provided by a therapist who showed them the proper way to use the lift with a return demonstration. She said she was suspended pending investigation for 2 days and came back to work on 9/1/2024. She said prior to the incident, she had a check off at a previous facility but not since returning to work in the facility. She said since being employed at the facility this time, she only had skills check off that included mechanical lift transfers on the night of the incident. Record review of a Nursing Assistant Skills Review Checklist dated 7/10/2024 for CNA B indicated she was successful with mechanical lift transfers. Record review of a skills validation checklist for transfers dated 8/30/2024 indicated CNA B was in attendance by her signature and was observed by the PTA on mechanical and gait belt transfer. Record review of an Associate Disciplinary Memorandum dated 8/30/2024 for CNA B indicated she was suspended for transferring a resident using the mechanical lift and a strap slipped off causing the resident to fall and hit her head and shoulder. During a phone interview on 9/9/2024 at 6:52 PM, NA A said she was not certified as a nurse aide and would be testing on tomorrow 9/10/2024. She said she had been employed at the facility for almost a year and worked 6 pm-6 am and assigned to work hall 300 where Resident #20 resided. She said on 8/30/2024 she needed help with Resident #20 since she was a 2-person transfer and had CNA B to help with her shower and transfer. She said they put the straps on the lift and got her ready to take her in the room. She said the resident was on a shower bed. She said one of the lift straps came off and the resident was dangling and hit her head and left shoulder on the middle of the door. She said she tried to lower the lift and the resident fell to the floor. She said prior to the incident, she had a skills check off that included lift transfers. She said the nurse came in and checked on the resident and she stayed with her until she was transferred out to the hospital. She said she was suspended for a 1 1/2 days and she did what she had been taught to do and was not sure how the strap came off. Record review of a Nursing Assistant Skills Review Checklist dated 7/2/2024 for NA A indicated she was successful with mechanical lift transfers. Record review of a skills validation checklist for transfers dated 8/30/2024 indicated NA A was in attendance by her signature and was observed by the PTA on mechanical and gait belt transfer. Record review of an associate disciplinary memorandum dated 8/30/2024 for NA A indicated she was suspended for transferring a resident using the mechanical lift and a strap slipped off causing the resident to fall and hit her head and shoulder. During a phone interview on 9/9/2024 at 7:02 PM, LVN U said she had been employed at the facility for [AGE] years and worked 6 pm-6 am as a charge nurse. She said the day of the incident on 8/30/2024 with Resident #20, she was down hall 300 where Resident #20 resided. She said she was aware the staff had taken her to the shower room. She said at the time of the incident, she was in across the hall checking a resident's blood sugar. She said she heard a noise like something hit the wall or something. She said she looked across the hall and saw Resident #20 on the floor between the legs of the lift. She said the resident was assessed by her, they moved the lift out of the way, checked her vital signs, and talked to her. She said shortly after, her arm and legs started jerking for a few seconds and they placed her on her side. She said it happened again and after that she was ok, was comfortable. She said the resident left and went to the hospital. She said she had never seen the resident had any seizure activity before and did not recall if the resident was taking any medications for seizures either. She said the staff were in-serviced on how to use a mechanical lift and someone from therapy demonstrated the proper way to use it with return demonstration that same night. Record review of a skills validation checklist for transfers dated 8/30/2024 indicated LVN U was in attendance by her signature and was observed by the PTA on mechanical and gait belt transfer. During an observation and interview on 09/10/24 8:36 AM, the Maintenance Supervisor was in the hallway of hall 300. Shown a picture of the Hoyer lift sling that was on Resident yesterday and he said they had checked all the slings on 8/31/2024 after the incident when she fell from the sling. He said they inspected all the slings in the facility after the incident with Resident #20 and they were in working order. Resident #20 was propelling herself down the hall in a wheelchair and he observed the sling that was in use for her on 9/9/2024 and said he did not see anything wrong with the sling the resident was using. He checked the straps and said they were good, but the color was the only thing that was faded. He said the binding was intact. During an interview on 9/10/2024 at 8:45 AM, the Administrator was shown a picture of the sling that was in use for Resident #20 and said the sling looked ok, stitching was ok on the straps, and the color was faded. She said following the fall with Resident #20, they checked all the slings in the facility but was unsure about that particular sling. She said the sling should not be in use for the resident. She said new slings had been ordered but had not arrived at the facility yet and they ordered the full body ones. During an observation and interview on 9/10/2024 at 11:05 AM, the Laundry staff said she had been employed at the facility for [AGE] years. She said she washed the lift slings with personal clothes and hung them to air dry. She said she checked the slings first to make sure they were not damaged and completed a checklist for the slings. She said on the checklist they would sign their name and date it when a sling came into the laundry room. She said once the slings were dry, they were taken back to the supply room on hall 400. The lift slings were observed in the supply room and the manufacturer label warning that indicated: do not wash with bleach. Slings can suffer damage during washing and drying. Check sling before each use. Bleached, torn, cut, frayed or broken slings are unsafe, and could result in serious injury or death to patient. Destroy and discard worn slings. She said they started completing a checklist back in May 2024 for the slings and prior to that they did not have one. She said the nurse aides were responsible for checking the lift slings prior to use. She said if a worn or damaged lift sling was in use, residents could be at risk for slipping or falling along with injuring any body part. Record review of a sling inventory check list undated indicated laundry staff started the checklist on 5/6/2024. The checklist had a box for staff to complete for the resident's name or number and date. The checklist did not have any resident's name listed on the checklist and only had staff signatures with dates and a check mark by the in column. During an interview with the interim DON on 9/11/24 at 8:10AM she said she had been employed at the facility since July 20, 2024. She said she was not at the facility on the evening when Resident had a fall from the mechanical lift. She said the Administrator called to notify that they had started in-servicing staff along with the ADON and began an investigation and determined that it was an accident. She said she was not directly involved in the investigation of the incident with Resident . She said yesterday 9/10/2024, CNA C had been informed by the Administrator that she would be suspended and would be able to return to work today after completing a skills check off on the proper use of a mechanical lift and a return demonstration. During an interview on 9/11/2024 at 9:20 AM, CNA C said she had been employed for [AGE] years and worked 6 am-6 pm shift. She said she had a mechanical lift transfer check off in the past. She said she was suspended yesterday (9/10/2024) following the incident and before she could return to work today, she had to complete a competency check off on proper use of a mechanical lift. She said residents could hurt themselves with the lift moving if they were left unattended. During an interview on 9/11/2024 at 11:42 AM, the Administrator said she was notified by staff on 8/30/2024 about Resident #20 falling out of the mechanical lift. She said she went to the facility and started an investigation with talking to the nurse aides involved, had them perform a demonstration on how they connected the lift sling, and what they did. She said after the investigation, it was determined the incident was an accident as the staff were not aware of how the strap came off. She said she sent all the information to her regional support team who then informed her that it was an accident and was witnessed by staff that it did not need to be reported to the state agency. She said they informed her that it did not meet the guidelines for reporting as there were not any problems with the sling or lift. Requested a mechanical lift policy/transfer and the Administrator said the facility did not have a policy and used a mechanical lift checklist as a policy for staff. Record review of a Validation Checklist Mechanical List undated indicated, .Purpose: To determine if the staff is performing mechanical lift procedure in accordance with the facility's standard of practice. 1. Employee understands the maximum weight for each lift. 2. Employee understands to inspect sling for tears or loose stitching and report any findings to DON or designee. 3. Employee understands to not use any plastic back incontinence pad or seat cushion between resident and sling that could cause sliding. 4. Lifting the Resident: must have two staff members when using a lift. 5. Explain procedure to resident. 6. The adjustable legs must be in the maximum opened position and always locked while resident is in the lift. 7. Make sure the arms of the sling (leg sections) are crossed under the resident's legs and attach on the opposite side hook. 8. Match the corresponding colors on each side of the sling for an even lift of the resident. 9. When the sling is elevated a few inches, check to make sure that all hooks are connected to lift. 10. Do not lock the rear casters of the lift, this could cause tipping of the lift. 12. Use the steering handle when moving the lift. 13. When moving the resident lift away from the bed or chair, turn the resident so that he/she faces the employee transferring from or to a wheelchair, shower or bed is locked. 14. Employee understands how to activate the emergency release. 15. Employee understands to inspect lift for wear, tear, and broken parts: reporting any findings to DON or designee . Record review of a facility policy titled Incident/Accident Policy revised on 11/17 indicated, .It is the policy of this facility to report and investigate all incident and accidents that occur in the facility or on facility property in a timely manner. 9. The Administrator and Director of Nursing will review the incident/accident to determine if investigation is required . This was determined to be an Immediate Jeopardy (IJ) on 9/10/2024 at 10:00 AM. The facility's Administrator and Interim DON were notified. The Administrator was provided the IJ template on 9/10/2024 at 10:29 AM. The following Plan of Removal (POR) submitted by the facility was accepted on 9/10/2024 at 4:02 PM. Tag Cited: F-689 Issue Cited: Free of Accidents/Hazards/Supervision Failure to ensure a safe transfer of resident using a Mechanical Lift. 1. Immediate Action Taken A. Resident # 20 was sent to the ER for evaluation/treatment on 8/30/2024 B. Resident #20 returned to facility on 9/1/2024; head to toe physical assessment was completed upon return to the facility and documented; new diagnosis Acute Right Subdural Hematoma, no midline shift; Left Shoulder Separation Grade 1 C. On 9/10/2024 The DON and/or designee trained all facility nurses and nurse aides on the use of mechanical lift. All facility nurses and nurse aides were trained prior to their next shift. D. On 9/10/24 The DON and/or designee completed a skills validation with return demonstration on all facility nurses and nurse aides on the use of Hoyer lifts to ensure knowledge and understanding of training. All facility nurses and nurse aides were trained prior to their next shift. E. The MDS Coordinator and/or designee reviewed the care plans for each resident who requires the use of a mechanical lift to ensure resident specific interventions were present. F. On 9/10/2024, the facility discarded the mechanical lift sling that was faded in color without a manufacturer's tag. G. On 9/10/24, CNA A was suspended pending retraining and will not be reinstated until CNA A is able to demonstrate competency with Hoyer lift skills validation. H. On 9/10/24, CNA B was suspended pending retraining and will not be reinstated until CNA B is able to demonstrate competency with Hoyer lift skills validation. This was completed on 9/10/2024 by 10:00 pm. 2. Identification of Residents Affected or Likely to be Affected: A. No other residents identified, on 9/10/24 the DON/Designee completed an audit on all facility resident's requiring Hoyer lift transfers to ensure interventions currently in place are appropriate for resident's receiving required care and transfer interventions. This will be completed on 9/10/24 by 10:00 pm. 3.Actions to Prevent Occurrence/Recurrence: A. As of 9/10/2024, any staff member hired for facility nurse and/or nurse aide positions will be provided the following by the facility DON and/or designee: o In-service education on the Mechanical Lift will be completed by the facility DON and/or designee during orientation. o Skills Validation with Return Demonstration will be completed by facility DON and/or designee during orientation. B. The DON/Designee will conduct weekly random observations two (2) times a week for eight (8) weeks to ensure staff are transferring residents who require Hoyer lift properly. C. Results of weekly observations will be reviewed in the morning meeting by the Administrator or designee On 9/10/2024 the facility's Administrator notified the Medical Director to conduct an Ad Hoc QAPI meeting regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: _____9/10/2024____________ Surveyors monitored the Plan of Removal as follows: Record review of hospital record for Resident #20 dated 8/30/2024 at 11:27 PM indicated she was admitted to the facility following a fall from a mechanical lift at the nursing home. Record review of a late entry admit/readmit progress note dated 9/1/2024 at 5:00 PM for Resident #20 indicated she arrived at the facility from a hospital with an admitting diagnosis of subdural hematoma. Record review of an in-service program attendance record dated 9/10/2024 indicated training was provided to RN N, LVN U, ADON L, CNA Q, CNA X, and CNA Y on mechanical lift transfers. Record review of a Transfer Skills Validation dated 9/10/2024 indicated ADON L, MDS Coordinator, DON, LVN U, CNA B, RNA, RN N, CNA X, CNA F, and CNA Y were observed performing a transfer with a mechanical lift. Record review of the care plans for residents who require a mechanical lift for transfers indicated 12 out of 66 residents were care planned appropriately with interventions for mechanical lift transfers. Record review of an attestation dated 9/10/2024 by the Administrator indicated she discarded in the dumpster at the back of the facility, the mechanical sling that was faded in color without a manufacturer's tag. Record review of an Associate Disciplinary Memorandum for CNA D dated 9/10/2024 was suspended for improper use of a mechanical lift. Record review of an Associate Disciplinary Memorandum for CNA C dated 9/10/2024 was suspended for improper use of a mechanical lift. Record review of an Ad Hoc QAPI meeting dated 9/10/2024 indicated at approximately 3:30 PM the facility discussed with the medical director the mechanical lift incident with Resident #20 and the facility's follow-up plan to sustain compliance. The Administrator, the Interim DON, the MDS Coordinator, and the Regional Nurse were in attendance. Observations and interviews on 9/11/2024 from 2:00 PM to 3:19 PM included: During an observation on 9/11/2024 at 2:00 PM, RNA and CNA C were in the room of Resident #61 to transfer him from his wheelchair to his bed using a mechanical lift. Resident #61 was transferred properly and safely without any issues or concerns noted by RNA and CNA C. During an interview on 9/11/2024 at 2:21 PM, RNA said he had been employed at the facility for 3 years. He received training on the proper of use of a mechanical lift and the MDS Coordinator and the DON showed them how to use the lift with a return demonstration. He said he was taught all steps on how to properly attach the straps for residents' safety. During an interview on 9/11/2024 at 2:24 PM, CNA C said she had been employed at the facility for [AGE] years. She said she had training on proper use of use of the mechanical lift, was instructed to make sure the wheels were locked, and positioned correctly. She said she did a check off with a return demonstration. During an interview on 9/11/2024 at 2:29 PM, CNA T said she had been employed at the facility for 3 years. She said she had a training on how to use the mechanical lift and the ADON conducted a demonstration on the use of the mechanical lift. She said the DON had another demonstration this morning and she had to complete a return demonstration. During an interview on 9/11/2024 at 2:45 PM, CNA D said she had been employed at the facility for 2 1/2 years. She said she was suspended after the incident on 9/10/2024 and came back to work today after lunch. She said she had to complete an in-service on proper use of a mechanical lift before she was allowed to return. She said she was taught the correct operation of the lift by the DON with a return demonstration. During an interview on 9/11/2024 at 2:49 PM, CNA S said she had been employed at the facility for 6 months. She said she had an in-service training on the mechanical lift and the DON showed them how to properly use it and had to complete a return demonstration. During an interview on 9/11/2024 at 2:52 PM, CNA V said she had been employed at the facility since 2019. She said she had an in-service training on the mechanical lift and was shown how to properly use it and had to complete a return demonstration. During an interview on 9/11/2023 at 3:01 PM, CNA F said she had been employed at the facility for 2 years. She said she received training on the use of the mechanical lift with the MDS Coordinator. She said they discussed the different sling sizes and demonstrated how to use it. She said they must make sure the wheels were locked and did a return demonstration. She said they were also shown a video on how to properly use the lift. During an observation on 9/11/2024 at 3:07 PM, CNA S and CNA T both transferred Resident #20 from her wheelchair to her bed using a mechanical lift properly and safely. During an interview on 9/11/2024 at 3:09 PM, CNA R said she worked and had been employed at the facility for 1 1/2 years. She said she received training on the use of the mechanical lift with a return demonstration. She said you must make sure it was locked. During an interview on 9/11/2024 at 3:15 PM, ADON L said she received training on the mechanical lift and provided training to the staff in the facility. She said she had a return demonstration on proper use and safety of the mechanical lift. During an interview on 9/11/2024 at 2:17 PM, LVN P said she received training on the mechanical lift with proper use, which required 2 people to operate, how to use the slings, and which colors on the sling straps to use on the lift. She said she completed a return demonstration. During an interview on 9/11/2024 at 2:19 PM, MA O said she received training on the mechanical lift with proper use, weight limits, and make sure it was locked. She said she completed a return demonstration with the DON. All above staff were able to appropriately answer questions regarding the proper use of the mechanical lift and had return demonstrations to show knowledge of training. The Administrator was informed the Immediate Jeopardy was removed on 9/11/2024 at 3:53 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observations, interviews, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relayed the call directly to a centralized staff work area for 3 of 24 residents (Resident #7, Resident #65, and Resident #38) reviewed for call lights. The facility failed to ensure Resident #7, #65, and #38's emergency call light string in the bathroom were not tied in knots or wrapped around the grab bar on 9/9/2024-9/11/2024. These failures could place residents at risk of injury, pain, hospitalization , and a diminished quality of life. Findings included: 1. Record review of an Admission Record dated 9/10/2024 for Resident #7 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of ID (limitation in metal abilities that affect thinking, learning and everyday life skills), down syndrome (a genetic disorder caused by an extra chromosome), end stage renal disease (kidneys do not function normally), and type 2 diabetes. Record review of a Quarterly MDS assessment dated [DATE] for Resident #7 indicated she did not have any impairment in thinking with a BIMS score of 14. She was independent with ADLs except for showering/bathing. She was always continent of bladder and bowel. Record review of Resident #7's care plan dated 4/20/2023 and revised on 9/10/2023 indicated he was at risk for falls related to gait/balance problems. Interventions included to place her call light within reach and encourage her to use it for assistance as needed. During an observation and interview on 9/9/2024 at 9:45 AM, Resident #17 was in her room and said she had been at the facility for a long time. She said she was able to use her bathroom. Her call light string in the bathroom was not long enough to reach the floor. During an observation on 9/10/2024 at 1:52 PM, Resident #17 was not in her room and the bathroom call light string was not long enough to reach the floor. 2. Record review of an Admission Record dated 9/10/2024 for Resident #65 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of fracture of upper and lower end of left fibula (the leg bone that forms the calf and ankle), anxiety disorder, and depression disorder. Record review of a Quarterly MDS assessment dated [DATE] for Resident #65 indicated she did not have any impairment in thinking with a BIMS score of 15. She was independent with toileting hygiene and always continent of bladder and bowel. Record review of a care plan for Resident #65 revised on 5/28/2024 indicated she had the potential for falls related to gait/balance problems. Interventions included to place the resident's call light in reach and encourage the resident to use it for assistance as needed. During an observation and interview on 9/9/2024 at 11:35 AM, Resident #65 said she had been at the facility for 4 months. She said she was able to go to the bathroom on her own and did not realize the call light string in the bathroom was not long enough. The call light string in the bathroom was not long enough to reach the floor. During an observation and interview on 9/10/2024 at 1:49 PM, Resident #65 was in her room. She said she has never seen anyone check the call lights in the bathroom. She observed the call light in the bathroom and said if she fell , she would not be able to reach the call light in the bathroom because it was too short. 3. Record review of an Admission Record dated 9/10/2024 for Resident #38 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, ID (limitation in metal abilities that affect thinking, learning and everyday life skills), and hypertension. Record review of an Annual MDS assessment dated [DATE] for Resident #38 indicated she had severe impairment in thinking with a BIMS score of 6. She was independent with toileting hygiene and was always continent of bladder and bowel. During an observation and interview on 9/9/2024 at 11:45 AM, Resident #38 was in her room sitting up in a wheelchair and said she had been at the facility for [AGE] years. Her call light string in the bathroom was wrapped around the grab bar and she said she did not wrap the string around the grab bar, and it had always been that way. During an observation and interview on 9/10/2024 at 1:47 PM, Resident #38 was in her room sitting in a wheelchair. Her call light string was at an appropriate length close to the floor. She said the call light string in the bathroom unwrapped on its own fell . She said there had not been anyone in the room to check the call light string in the bathroom. During an observation and interview on 9/10/2024 at 1:53 PM, CNA F said she was assigned to hall 300 today 9/10/2024 where Resident #65, #38, and #7 resided. She said she had been employed at the facility for 2 years. She said the nurse aides were responsible for checking the call light strings in the bathrooms and if there was a problem, then they would let the Maintenance Supervisor know. She observed the call lights in the bathrooms of Resident #7 and #65 and said the strings were tied in a double knot and the residents would not be able to reach them if they fell . She said residents could not reach them and could be lying on the floor for a long period of time. During an observation and interview on 9/11/2024 from 9:57 AM-10:05 AM, the Maintenance Supervisor said he was responsible for checking the call light strings in the resident bathrooms. He said he had a checklist that he went by and checked the facility weekly for call light strings. He said normally staff would let him know if there was a problem with the call light strings. He said the facility had problems with them being wrapped around the grab bars in the bathrooms at times. He observed the call light string in the bathroom of Resident #65 and said her string had knots in it and needed to be longer. He untied the string, and the call light string was the appropriate length and not touching the floor. He went into the room of Resident #7 and said her call light string in the bathroom was too short, was tied in knots, and untied it. He said residents might not be able to reach the strings if they fell and could be there for a long time. Record review of a Tasks in Use dated 8/19/2024 indicated there were not any tasks assigned for maintenance to check the call lights. During an interview on 9/11/2024 at 11:42 AM, the Administrator said no one was responsible for checking the call lights in the resident bathrooms and was not aware that the Maintenance Supervisor was checking them. She was aware that the call lights in the bathroom needed to be close to the floor. She said going forward she would add them to the quality-of-life rounds checks where the department heads had assigned rooms they checked daily. She said residents could be at risk for lying in the floor for a while until someone came in. Record review of a facility policy titled Call Light Response dated 2/10/2021 indicated, .The purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance. 1. All staff shall be educated on the proper use of the resident call system, including how the system works, and ensuring resident access to the call light. 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed.

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 10 staff (CNA F, Medication Aide H, Medication Aide M, and ADON L) observed for compliance to infection control standards during meal and medication pass. 1. The facility failed to ensure CNA F washed or sanitized her hands before and after resident contact when passing out meal trays to residents on Hall 100. 2. The facility failed to ensure Medication Aide H washed or sanitized before and after resident contact during medication pass. 3. The facility failed to ensure Medication Aide M washed or sanitized before and after resident contact during medication pass. 4. The facility failed to ensure reusable equipment was sanitized. These failures could place residents at risk of exposure to communicable diseases and infections. Findings included: 1.During observation of meal service on 09/09/2024 at 12:30 PM to 12:48 PM, CNA F did not wash or sanitize hands prior to exiting rooms or handling meal trays for the next room for the following rooms: room [ROOM NUMBER] took meal tray into room, repositioned resident linens, adjusted bed using bed controller and moved bedside table in position with tray on top of table; room [ROOM NUMBER] opened milk, used bed controller to adjust bed, repositioned bedside table; room [ROOM NUMBER] opened health shake and soda can then pushed residents wheelchair up to table; room [ROOM NUMBER] turned on light switch, pushed bedside table to resident; room [ROOM NUMBER] opened door and placed meal tray on table; room [ROOM NUMBER] placed meal tray on table; room [ROOM NUMBER] placed meal tray on table; room [ROOM NUMBER] placed meal tray on table; room [ROOM NUMBER] placed meal tray on table; room [ROOM NUMBER] placed meal tray on table and pushed bedside table to resident; room [ROOM NUMBER] opened door and placed tray on table; room [ROOM NUMBER] opened door and placed tray on table; room [ROOM NUMBER] moved remote from bedside table, moved wallet from table, set up meal tray, turned on room light; room [ROOM NUMBER] removed personal items from bedside table, removed drink from personal refrigerator, opened drinks, applied residents personal spices to soup. During an interview on 09/09/2024 at 1:32 PM CNA F said that she was the transportation aide but would work on the floor as a CNA when needed. She said that she did not have an assigned hall but worked where she was needed. She said that when she was passing trays on hall 100, she did not sanitize her hands after exiting rooms when passing out the trays. She said that not sanitizing or washing hands could spread germs to the residents. She said that she has had hand hygiene training and that skills check off included hand hygiene. She said that the facility provided hand sanitizer and that sanitizer stations were located down each hall. 2. Record review of a face sheet dated 9/10/2024 for Resident #66 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cancer of the liver, blindness of the right eye, and weakness. Record review of an Admission MDS assessment dated [DATE] for Resident #66 indicated she had no impairment in thinking with a BIMS score of 15. During an observation and interview on 09/10/2024 at 7:30 AM Medication Aide H sprayed her hands with an aerosol disinfectant spray and rubbed them together then administered medications to Resident #66. Medication Aide H said that she did not like the way the alcohol hand rubbed felt on her hands and she chose to use the spray. After administration of medications to Resident #66, Medication Aide H went in the bathroom and washed her hands then returned to her medication cart. Medication Aide H said that she would use the spray before and then she only washed her hands afterward between residents, but she did not use alcohol hand gel when prepping medications, taking blood pressures, or entering her cart. Medication Aide H said that she was aware the facility policy for hand hygiene specified the use of alcohol hand gel for sanitizing her hands, but she chose to use the spray and thought that the spray would kill any germs she potentially came into contact with. 3.Record review of a face sheet dated 9/10/2024 for Resident #20 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of cerebrovascular disease (disease of the brain circulatory system), knee pain, and weakness. Record review of a Quarterly MDS assessment dated [DATE] for Resident #20 indicated he had moderate impairment in thinking with a BIMS score of 11. During an observation on 09/11/24 at 07:45 AM Medication Aide M did not sanitize with alcohol-based sanitizer or wash her hands before or after taking Resident # 8's blood pressure with a wrist cuff that was wrapped with tape to keep the battery cover plate in place. Medication Aide M then entered medication cart for hall 100 and prepared medications for Resident #8. Medication Aide M did not sanitize her hands before or after medication administration to Resident # 8. Medication Aide M said that she should have sanitized before and after each resident contact and not doing so, could spread infections. Medication Aide M said that the tape would not allow proper sanitizing of her wrist cuff and that using it could spread infection resident to resident. 4. During an observation and interview on 09/10/24 at 11:25 AM of the 200/300 Nurse medication cart an electronic thermometer sticky paper tape with brown edges with debris attached in the top medication drawer. The thermometer was sitting beside gauze pads and alcohol pads. ADON L said that the broken thermometer should not be in use due to it not being cleaned properly due to the tape. ADON L said the broken cuff with the dirty tape wrapped around it could transmit infection resident to resident. During an interview with the Interim DON on 9/11/2024 at 9:00 AM she stated that the facility policy was that staff was to use hand sanitizer each time they exit a resident room regardless of the reason why they were in the room. She said that she expected the staff to use hand sanitizer and wash hands according to the facility policy. She stated that the residents and staff were at risk when hand hygiene was not performed. She said that germs can be spread to other rooms if staff do not sanitize their hands when exiting a resident room. She said that she would be reviewing the hand hygiene policy with all staff. During an interview on 09/11/24 at 1:00 PM with ADON L she said that all staff had been in-serviced on hand hygiene and the requirement to use alcohol-based sanitizer. ADON L said that not using correct hand hygiene could result in the spread of infections. During an interview on 09/11/24 at 2:13 PM with the Interim DON, she said that all staff had been in-serviced on hand hygiene and the requirements to use alcohol-based sanitizer if not using soap and water. The Interim DON said that using reusable equipment with tape on it would impede the sanitization of the medical device between residents. The DON said the staff should be removing any broken items from use and not applying tape to keep it together. The DON said that not sanitizing the equipment could spread infections. During an interview on 09/11/24 at 02:30 PM with the Administrator, she said that all staff had been in-serviced on hand hygiene and the requirements to use alcohol-based sanitizer of not using soap and water between resident interventions. She said that not using correct hand hygiene could result in the spread of infections. The Administrator said that the staff could not clean and sanitize equipment that had tape applied and by doing so they could spread infections. Record Review of nurse aide skills review checklist indicated that handwashing procedural guideline demonstration was completed correctly for CNA F on 7/15/2024. Record Review of a staff in-service dated 8/12/2024 titled Infection Control Quarterly Training Guidelines that included review of the hand hygiene policy was signed by CNA F. Record Review of a staff in-service dated 8/13/2024 titled Infection Control Quarterly Training Guidelines that included review of the hand hygiene policy was signed by ADON L. Record Review of a staff in-service dated 8/14/2024 titled Infection Control that was signed by Medication Aide H. Record review of a facility policy titled Hand Hygiene with a revised date of 2/11/2022 indicated .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub. A condition listed on the hand hygiene table included between resident contacts. Record Review of a Facility Policy: Infection Prevention and Control Program dated 10/24/2022- revised 3/26/2024 Indicated . This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . 10. Equipment Protocol: a. all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be sanitized. 49017

Based on interviews and record review, the facility failed to develop, implement, and maintain an effective training program for 3 of 17 employees (Interim DON, Dietary Manager, and CNA S) new and existing staff reviewed for training. The facility failed to ensure the Interim DON was trained on HIV, dementia, and restraint reduction on hire. The facility failed to ensure the Dietary Manager was trained on dementia annually. The facility failed to ensure CNA S was trained on HIV, dementia, and restraint reduction on hire. This failure could place residents at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training. Findings included: Record review of the personnel file for the Interim DON indicated she was hired at the facility on 7/30/2024 by contract and did not have on hire training on HIV and restraint reduction until 8/14/24 and had no training for dementia. Record review of the personnel file for the Dietary Manager indicated she was originally hired at the facility on 06/26/2012 and now was an employee by contract. The personnel file indicated the Dietary Manager did not have annual training on dementia. Record review of the personnel file for CNA S indicated she was hired at the facility on 3/15/2024 and did not receive training on HIV and dementia until 4/17/24. CNA S did not receive restraint training until 8/28/24 after a reprimand for non-completion by the Administrator. During an interview on 9/11/2024 at 9:24 AM, HR said she was responsible for completing the orientation and other paperwork. She said she was not aware of the required trainings for employees on hire had to be completed before they started resident care until the State Surveyor requested the trainings for selected employees. HR said she usually gave the new employees two weeks to complete the new hire training before they were released to work on their own. HR said going forward she will make sure all training is completed before resident care is started. She said going forward she would complete a checklist for the required trainings. She said staff could be at risk of lack of information and residents could be at risk of harm for a multitude of things if staff did not receive the training they needed. During an interview on 9/11/2024 at 9:32 AM, the Administrator said the staff were watching videos on trainings by logging into a website and have continued to watch them that included abuse/neglect, blood borne pathogens, misuse of resident property, resident rights, dementia, and fall prevention. She said she was ultimately responsible for ensuring the staff received the required trainings during orientation prior to employment and annually. She said if staff were not receiving the training, they would not know how to care for residents, and it may have a negative impact on their care. She said there was a system in place and a check list for the trainings.

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 11 of 18 residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) reviewed for abuse policies. The facility failed to protect Resident #1 from verbal abuse from Housekeeper A on 10/25/23 when Housekeeper A called Resident #1 a Nasty MF. The facility failed to protect Resident #1 from abuse from Resident #6 on 8/6/23 when Resident #6 hit Resident #1 on her back. The facility failed to protect Resident #1 from abuse from Resident #3 on 12/19/23 when Resident #3 hit Resident #1 on the arm. The facility failed to protect Resident #2 from abuse from Resident #3 on 2/4/24 when Resident #3 hit Resident #2 on her left shoulder. The facility failed to protect Resident #4 from abuse from Resident #5 on 10/6/23 when Resident #4 slapped Resident #5 because he grabbed her breast. The facility failed to protect Resident #7 from abuse from Resident #6 on 8/16/23 when Resident #6 hit Resident #7 on the head because he asked her to stop pulling on his wheelchair. The facility failed to protect Resident #11 from abuse from Resident #8 on 11/7/2023 when Resident #8 hit Resident #11 in the stomach with his hand. The facility failed to protect Resident #9 from abuse from MA B on 11/1/2023 when MA B pushed Resident #9 roughly in her wheelchair into her room. The facility failed to protect Resident #9 from abuse from Resident #8 on 12/30/2023. On 12/30/2023 when he was observed in the room by staff with his hands under the covers feeling of Resident #8's breasts. The Administrator failed to report an incident of abuse on 12/30/2023 when Resident #8 was found in the room of Resident #9 when he was observed in the room by staff with his hands under the covers feeling of Resident #8's breasts. The facility failed to protect Resident #8 from abuse from Resident #10 between 2/26/2024 to 3/27/2024. On 2/26/2024 Resident #10 hit Resident #8 on his left arm in the dining room. On 3/25/2024 Resident #10 hit Resident #8 on his left shoulder and hand in the dining room. On 3/27/2024 Resident #10 hit Resident #8 on the hand in the dining room. The facility failed to protect Resident #8 from abuse from Resident #9 on 4/21/2024 when she was observed hitting Resident #8 on the left shoulder with a closed fist in the dining room. An Immediate Jeopardy (IJ) situation was identified on 6/25/24 at 6:30 PM. While the IJ was removed on 6/28/24 at 5:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk of abuse which could lead to further abuse and neglect of other residents. Findings included: 1.Record review of the face sheet dated 6/24/24 indicated Resident #1 was an [AGE] year-old female admitted to the facility originally on 11/14/17 with the most recent readmission on 1/26/23, with diagnoses rheumatoid arthritis without rheumatoid factor (inflammation in lining of joints), hypertension (elevated blood pressure), and dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1's BIMS score was 15 indicating no cognitive impairment. Section E behavior of the MDS indicated Resident #1 did not have any physical, verbal or other behavioral symptoms. Record review of Resident #1's care plan dated 11/1/23 and revised on 4/23/24 indicated Resident #1 had a behavior problem as evidenced by verbal outbursts at times with interventions that included: 1. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. 2. When she becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. 3. Intervene as necessary to protect the rights and safety of others. Remove her to an alternate location when needed to protect the rights and safety of others. 4. Psychiatric consult per indication of physician's order. Record review of provider investigation report dated 8/11/23 indicated Resident #1 and Resident #6 were in a physical altercation on 8/6/23 at 5:45 PM. The provider investigation report indicated Resident #1 and Resident #6 were sitting near the TV when apparently Resident #6 hit Resident #1, Resident #1 said stop and hit Resident #6 on the arm. This was originally reported that Resident #6 hit Resident #1 and Resident #1 hit Resident #6 in the head. The provider investigation report indicated the residents were kept separated until evaluated by the Psychologist and felt they were not a threat to each other or others. Record review of facility incident report dated 8/6/23 for Resident #1, indicated Resident #1 hit Resident #6 on the hand/arm. Resident #1 then approached nursing staff and said I sure did hit her. She kicked me and I have the right to defend myself. Record review of witness statement provided by RN EE undated indicated I noticed the resident (Resident #6) sitting in front of another resident (Resident #1), in her wheelchair. The other resident (Resident #1) was reaching her arms towards Resident #6, and I relocated Resident #6 to the nurse's station. Signed by RN EE. Record review of witness statement provided by Dietary Helper Z undated indicated On Sunday August 6,2023 I was in the dish room and Dietary Helper told me to look at Resident #6 and Resident #1. I didn't see Resident #6 hit Resident #1, but I did see Resident #1 tap Resident #6 on the arm. The nurse moved Resident #6 away from Resident #1 to the nurse/s station. Signed by Dietary Helper Z. Record review of witness statement provided by Dietary Helper undated indicated On Sunday August 6, 2023, I was picking up dishes in the dining room when I heard Resident #1 tell Resident #6 to stop! I saw Resident #6 hit Resident #1 and then Resident #1 hit Resident #6 back on the arm. Then the nurse moved Resident #6 away from Resident #1. Signed by the Dietary Helper. Record review of behavioral health organization diagnostic assessment dated [DATE] at 2:49 PM indicated the reason for the referral was: conflict with another resident. Record review of Resident #1's clinical record revealed Resident was seen by behavioral health on 8/7/23 and not again until 11/6/23. Record review of provider investigation report dated 11/1/23 indicated that Resident #1 was in a verbal altercation with Housekeeper A on 10/25/23. The report indicated Resident #1, and Housekeeper A were cussing at each other. The provider investigation report indicated Housekeeper A was allowed to return to work on 10/31/23. Record review of Resident #1's progress notes dated between 10/23/23 through 10/27/23 revealed there was not a incident documented in the progress notes that occurred on 10/25/23. Record review of written witness statement undated provided by Housekeeper A indicated I went to help the resident off the floor. The blood was everywhere. I was cleaning up the blood off the floor. There was a towel already there. I picked up the towel to put it in the dirty laundry. The resident (Resident #1) started cursing me, calling me a mother fucker and saying I didn't know how to do my job, because she didn't like me putting the towel in laundry. She continued cursing me calling me a nasty MF and I said no you're the nasty MF, you need to go to your room and let me do my job, but she continued calling me MF and cursing me. I just walked off. Signed by Housekeeper A. Record review of typed witness statement undated provided by Resident #1 indicated I told Housekeeper A not to put that towel with blood on it in the laundry. Put it in a plastic bag first. He then said to me, shut up you F*****g b***h! signed by Resident #1. Record review of typed witness statement undated provided by Resident #2 indicated I didn't hear everything that was said, but I heard Resident #1 say F**K you. And I heard Housekeeper A say, F**k you I heard lots of curse words. Record review of Employment Action/Disciplinary Notice Form dated 10/31/23 indicated Housekeeper A was cleaning up biohazard accident (blood) on the floor with some towels and a resident (Resident #1) started to have a verbal altercation with Housekeeper A, profanities were used by both Resident #1 and Housekeeper A during the exchange. Action to be taken: Final written action to be given to Housekeeper A as agreed upon with Administrator. Signed by Housekeeper A on 10/31/23. Record review of in-service dated 10/31/23 titled Inappropriate behavior/Language in the workplace signed by Housekeeper A. Record review of provider investigation report dated 12/26/23 and signed by the Administrator indicated Resident #1 was involved in a physical altercation with Resident #3 on 12/19/23. The provider investigation report indicated Resident #3 went into Resident #1's room and was picking up some of her stuff. Resident #1 told her to put her stuff down and to get out of her room. Resident #3 put down what she had, and slapped Resident #1 on the arm. Resident #1 slapped her back on the arm. Record review of facility incident report for Resident #1 dated 12/19/23 at 5:45 PM indicated This resident (Resident #1) witnessed asking another resident (Resident #3) to leave her room and put her belonging back. When other resident (Resident #3) exited Resident #1's room she proceeded to hit Resident #1 on her arm. This resident (Resident #1) seen hitting other resident (Resident #3) back on her arm. Resident #1 told nursing staff I told her to come out my room and put my stuff back and she come out and hit me. I sure did hit her back. She need to stay out my room messing with my stuff. The incident report indicated the immediate action taken: Residents separated and redirected. This resident (Resident #1) assessed and no apparent injuries noted at this time. Resident #1 then taken into her assigned room. Record review of Resident #1's progress notes dated between 12/7/23 and 12/20/23 revealed there was no documentation regarding the resident-to-resident altercation that occurred on 12/19/23. Record review of witness statement provided by MA CC undated indicated I heard Resident #1 yell for Resident #3 to get out of her room. I ran to hurry Resident #3 out of her room. Resident #3 told her no and was picking up Resident #1's stuff off of her table and I'm unsure of what else she had. Resident #1 told her to put her stuff down, stop touching my stuff and to get out. I'm still trying to get Resident #3 to come out but she kept saying no this is mine, Resident #3 said no it isn't and to get out again. Resident #3 look at her and then just hit her and Resident #1 hit her back I stepped in and told them both to stop hitting. Resident #3 finally left her room. Record review of Psychological Services Progress Note for Resident #1 dated 12/21/23 at 6:21 PM indicated nursing home staff requested her to be seen due to a conflict with another residents. Signed by Psychologist. Surveyor was not provided with requested behavior monitoring and interventions report for Resident #1 by the time of surveyor exit on 7/1/24. 2. Record review of the face sheet dated 6/26/24 indicated Resident #2 was a [AGE] year-old female admitted to the facility originally on 2/3/22 with the most recent readmission on 6/7/23, with diagnoses metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), epilepsy (seizures), and generalized anxiety disorder (constant worry). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2's BIMS score was 15 indicating that Resident #2 was cognitively intact. Section E behavior of the MDS indicated Resident #2 did not have any physical, verbal or other behavioral symptoms. Record review of Resident #2's care plan dated 6/14/23 and revised on 2/20/24 indicated Resident #2 had a communication problem due to a hearing deficit with interventions that included: 1. Ensure/provide a safe environment: call light in reach, adequate low glare light, bed in the lowest position and wheels locked, avoid isolation. 2. Monitor for/record confounding problems: decline in cognitive status, mood, decline in ADL . Record review of provider investigation report dated 2/8/24 and signed by the Administrator indicated on 2/4/24 at 12:45 PM: Resident #3 hit Resident #2 across the back with a wet pair of pants. The provider investigation report revealed Resident #3 was taken to her room, and Resident #2 went to her room. The provider investigation report revealed the provider action taken was: continue to monitor residents for well being and safety. 2. Inservice staff on dealing with difficult behaviors and Resident #3 was transferred to another facility with a secured unit on 2/6/24. Record review of facility incident report dated 2/4/24 indicated Med aide reported to this nurse that Resident #3 hit Resident #2 on her back. The incident report indicated Resident #2 said .she was trying to help Resident #3 get back to her room and Resident #3 started yelling at her and hit her across the back just below the left shoulder. Record review of progress note dated 2/5/23 at 9:21 AM written by LVN R indicated Resident #3 hit Resident #2 on her back below her left shoulder. Record review of typed witness statement provided by Resident #2 undated indicated On Sunday, February 4, 2024 @ about 1:00 PM, I was coming down Hall 1 and Resident #3 was in the hallway between our rooms, I told Resident #3 where her room was and she told me to shut up, then hit me on my left shoulder and back. The med aid then took Resident #3 to her room. A short time earlier, my husband and I were visiting in my room and Resident #3 opened my door, and then shut it without incident. Signed by Resident #2. Record review of written witness statement provided by MA GG undated indicated On the date of February 4, 2024, about or between 12:15 PM - 12:30 PM, I was on hall 1 on a med pass. I saw Resident #2 coming down the hall in her wheelchair, I was close to her room waiting for her so I could give her meds. She was halfway down the hall when Resident #3 walked out of another resident room, Resident #2 was passing Resident #3 swung a wet pair of pants and hit Resident #2 across the back of her shoulders and in back of her head, I stepped in and walked Resident #3 to the nurses station and reported it to the nurse on duty LVN R. Resident #2 went to her room and LVN R went in to do an assessment, and normal activities were resumed. Signed by MA GG. Record review of a behavioral health solution psychological services progress note dated 2/5/24 indicated Resident #2 had been receiving psychiatric services weekly since 6/19/23. The psychological progress note dated 2/5/24 did not address the resident-to-resident altercation on 2/4/24. Record review of behavior monitoring, and interventions report dated 2/1/24-2/29/24 revealed one day of documentation with no behaviors observed on 2/29/24. 3. Record review of the face sheet dated 6/25/24 indicated Resident #3 was a [AGE] year-old female admitted to the facility originally on 5/3/21 with the most recent readmission on 5/12/22, with diagnoses Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3's BIMS score was 3 indicating severe cognitive impairment. Section E behavior of the MDS indicated Resident #3 did not have any physical, verbal or other behavioral symptoms. Record review of Resident #3's care plan dated 12/19/23 and revised on 3/4/24 indicated Resident #3 had a behavior problem as evidenced by resident-to-resident conflict with interventions that included: 1. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. 2. When she becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. 3. Intervene as necessary to protect the rights and safety of others. Remove her to an alternate location when needed to protect the rights and safety of others. 4. Psychiatric consult per indication of physician's order. Record review of Resident #3's progress note dated 2/5/23 at 12:45 PM written by LVN R revealed: Resident #3 hit Resident #2 on her back below her left shoulder, Resident #3 unable to explain what happened and stated, she made me mad. Resident #3 denied hitting Resident #2. Record review of provider investigation report dated 2/8/24 and signed by the Administrator indicated on 2/4/24 at 12:45 PM: Resident #3 hit Resident #2 across the back with a wet pair of pants. The provider investigation report revealed Resident #3 was taken to her room, and Resident #2 went to her room. The provider investigation report revealed the provider action taken was: continue to monitor residents for wellbeing and safety. 2. Inservice staff on dealing with difficult behaviors and Resident #3 was transferred to another facility with a secured unit on 2/6/24. Record review of facility incident report dated 2/4/24 indicated on 2/4/24 .Resident #3 hit Resident #2 on her back just below her left shoulder. Record review of a behavioral health solution psychological services progress note dated 2/5/24 indicated Resident #3 had been receiving psychiatric services weekly since 2/6/23. The psychological progress note dated 2/5/24 did not address the resident-to-resident altercation on 2/4/24. Record review of Resident #3's clinical record indicated Resident #3 discharged from the facility to another nursing facility with a secured unit on 2/6/24. Surveyor was not provided with requested behavior monitoring and interventions report for Resident #3 by the time of surveyor exit on 7/1/24. 4. Record review of the face sheet dated 6/25/24 indicated Resident #4 was a [AGE] year-old female admitted to the facility originally on 4/12/22 with the most recent readmission on 5/18/22, with diagnoses dementia with behavioral disturbances (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems accompanied by agitation, depression, and psychosis), dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4's BIMS score was 6 indicating severe cognitive impairment. Section E behavior of the MDS indicated Resident #4 had delusions. Section E behavior of the MDS indicated Resident #4 had physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others that occurred 1 to 3 days. Section E wandering of the MDS indicated Resident #4 had that type of behavior daily. Record review of Resident #4's care plan dated 6/1/23 and revised on 11/1/23 indicated Resident #3 had a behavior problem as evidenced by: clothing items thrown on the floor creating increased risk for slip, trip, or falls with interventions that included: 1. When she becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. 2. Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others. Record review of Resident #4's progress notes dated 10/4/23 through 10/7/23 revealed there was no documentation of the resident-to-resident altercation that occurred on 10/6/23. Record review of provider investigation report dated 10/13/24 signed by the Administrator indicated on 10/6/23 at 3:22 PM: .Resident #4 had told Resident #5 to quit following her, and when he continued to stand there, she slapped him. The provider investigation report revealed alternate placement was being looked at and the residents were on 1:1 supervision and staff were educated on resident-to-resident altercations. Record review of incident report dated 10/6/23 for Resident #4 revealed .Resident slapped another resident in the face/neck area. Resident #4 stated he grabbed my boob so I slapped him. Record review of staffing schedules dated 10/8/23 through 10/17/23 indicated: 10/6/23- no staffing schedule provided to show 1 on 1 monitoring of Resident #4. 10/7/23- no staffing schedule provided to show 1 on 1 monitoring of Resident #4. 10/9/23-Showed staffing 1 on 1 coverage for Resident #4 unknown hours. 10/11/23-Showed staffing 1 on 1 coverage for Resident #4 from 7:00 AM to 4:30 PM and 6:00 PM to 6:00AM. 10/12/23-Showed staffing 1 on 1 coverage for Resident #4 from 7:00 AM to 4:30 PM and unknown after that. 10/15/23- Showed staffing 1 on 1 coverage for Resident #4 from 7:00 AM to 4:30 PM, and 6:00 PM to 6:00 AM. 10/17/23- No 1 on 1 staffing coverage for Resident #4 shown. Record review of Resident #4's clinical record indicated she had been receiving behavioral health solution psychological services weekly from 8/18/23 to 10/23/23. Record review of behavioral health solution psychological services progress note dated 10/9/23 at 3:05 PM indicated: Patient's Response to Intervention: Discussed the issue she had with another resident and she has no memory of the incident. The progress note did not indicate when the incident occurred or with who. The progress note did not address 1 on 1 monitoring with Resident #4. Record review of behavioral health solution psychological services progress note dated 10/16/23 did not address the resident-to-resident altercation or 1 on 1 monitoring with Resident #4. Record review of behavioral health solution psychological services progress note dated 10/23/23 did not address the resident-to-resident altercation or 1 on 1 monitoring with Resident #4. The progress note revealed Resident #4 was not seen by the psychologist due to Resident #4 being transferred to another facility. Record review of Resident #4's clinical record indicated Resident #4 discharged from the facility on 10/16/23. Surveyor was not provided with requested behavior monitoring and interventions report for Resident #4 by the time of surveyor exit on 7/1/24. 5. Record review of the face sheet dated 6/25/24 indicated Resident #5 was a [AGE] year-old male admitted to the facility originally on 1/20/23, with diagnoses benign neoplasm of meninges (brain tumor), type 2 diabetes (high blood sugar), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5's BIMS score was 00 indicating severe cognitive impairment. Section E behavior of the MDS indicated Resident #5 did not have any physical, verbal or other behavioral symptoms. Record review of Resident #5's care plan dated 1/25/23 and revised on 3/1/24 indicated Resident #5 wanders related to cognitive impairment and is at risk for injury. He wanders around facility attempting to go in other residents rooms. Interventions included: 1. Redirect if he enters a restricted area. 2. Monitor him for tailgating when visitors are in the building or on the unit. Record review of Resident #5's progress notes dated between 10/2/23 through 10/7/23 revealed there was no documentation of the resident-to-resident altercation that occurred on 10/6/23. Record review of provider investigation report dated 10/13/24 signed by the Administrator indicated on 10/6/23 at 3:22 PM: .Resident #4 had told Resident #5 to quit following her, and when he continued to stand there she slapped him. The provider investigation report revealed alternate placement was being looked at and the residents were on 1:1 supervision and staff were educated on resident-to-resident altercations. Record review of incident report dated 10/6/23 for Resident #5 revealed .another resident slapped him across the face neck area. Resident #5 stated I was walking down the hall and then she hit me and pointed to the left side of his face. Record review of staffing schedules dated 10/8/23 through 10/17/23 (no staffing schedules provided prior to 10/8/23 or after 10/17/23) indicated: 10/6/23- no staffing schedule provided to show 1 on 1 monitoring of Resident #5. 10/7/23- no staffing schedule provided to show 1 on 1 monitoring of Resident #5. 10/9/23-Showed staffing 1 on 1 coverage for Resident #5 from 6-12. 10/12/23- Staffing showed 1 on 1 coverage for Resident #5 from 6:40 AM to 5:00PM and 6:00 PM to 6:00AM. 10/13/23- Showed staffing 1 on 1 coverage for Resident #5 7:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. 10/14/23-Showed staffing 1 on 1 coverage for Resident #5 11:00am to 6:00 PM and 6:00 PM to 6:00 AM. 10/17/23- Showed staffing 1 on 1 coverage for Resident #5 6-?. Record review of behavioral health solution psychological services progress note date 10/16/23 did not address 1 on 1 monitoring or the resident-to-resident altercation that occurred on 10/6/23. Surveyor was not provided with requested behavior monitoring and interventions report for Resident #5 by the time of surveyor exit on 7/1/24. 6. Record review of the face sheet dated 6/25/24 indicated Resident #6 was a [AGE] year-old female admitted to the facility originally on 4/24/18 with the most recent readmission on 12/5/22, with diagnoses Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia without behavioral disturbances (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6's BIMS score was 3 indicating severe cognitive impairment. Section E behavior of the MDS indicated Resident #6 had physical behavioral symptoms directed toward others that occurred 1 to 3 days. Record review of Resident #6's care plan dated 1/29/23 and revised on 6/20/23 indicated Resident #6 had a behavior problem as evidenced by: Incident occurring on 1/29/23 with resident-to-resident altercation with interventions that included: 1. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. 2. When she becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. 2. Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others. Record review of Resident #6's progress notes dated 8/14/23 through 8/16/23 revealed there was no documentation of the resident-to-resident altercation that occurred on 8/16/23. Record review of provider investigation report dated 8/21/23 signed by the Administrator indicated on 8/16/23 at 2:00 PM: While Resident #7 was sitting in the TV room watching tv Resident #6 grabbed hold of his chair to pull herself forward. Resident #7 told her to stop and Resident #6 hit him on the back of the head. The provider investigation report revealed Resident #6 was placed on 1 on 1 supervision since the incident and the doctor ordered Rexulti to see if it would help with Resident #6's behaviors. Record review of incident report dated 8/16/23 for Resident #6 revealed Resident #6 was sitting in dining room in wheelchair when she wheeled over to another resident and started pulling on his wheelchair. Resident #7 told Resident #6 not to pull on his chair and then Resident #6 hit resident #7 on the back of the head with her hand. Surveyor was not provided staffing schedule sheets showing staffing schedule for 1 to 1 monitoring for Resident #6 by the time of surveyor exit on 7/1/24. Record review of behavioral health solutions psychologists progress note dated 8/7/23, 11/6/23 and 2/27/24 revealed Resident #6 was not seen by psychiatric services in reference to the resident-to-resident altercation involving Resident #7. Record review of Resident #6's clinical record indicated Resident #6 was discharged to another nursing facility on 10/14/23. Surveyor was not provided with requested behavior monitoring and interventions report for Resident #6 by the time of surveyor exit on 7/1/24. 7. Record review of the face sheet dated 6/27/24 indicated Resident #7 was a [AGE] year-old male admitted to the facility originally on 8/4/23, with diagnoses transient cerebral ischemic attack (stroke), acute respiratory failure with hypoxia (problems breathing), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated Resident #7's BIMS score was 9 indicating moderate cognitive impairment. Section E behavior of the MDS indicated Resident #7 did not have any physical, verbal, or other behavioral symptoms. Record review of Resident #7's care plan dated 8/5/23 and revised on 9/1/23 indicated Resident #7 had fragile skin related to the aging process and was at risk for bruising easily and skin tears with intervention that included: 1. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against sharp or hard surfaces. Record review of provider investigation report dated 8/21/23 signed by the Administrator indicated on 8/16/23 at 2:00 PM: While Resident #7 was sitting in the TV room watching tv Resident #6 grabbed hold of his chair to pull herself forward. Resident #7 told her to stop and Resident #6 hit him on the back of the head. The provider investigation report revealed Resident #6 was placed on 1 on 1 supervision since the incident and the doctor ordered Rexulti to see if it would help with Resident #6's behaviors. Record review of Resident #7's progress note dated 8/16/23 written by LVN HH at 6:25 PM revealed Resident reported to this nurse that while he was sitting in the dining room watching TV. Another resident began pulling on his wheelchair. He reported that when he told her no, the other resident hit him in the back of his head . Record review of incident report dated 8/16/23 for Resident #7 indicated: Resident #7 was hit in [TRUNCATED]

Based on interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 11 of 18 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) reviewed for abuse and neglect. The facility failed to protect Resident #1 from verbal abuse from Housekeeper A on 10/25/23 when Housekeeper A called Resident #1 a Nasty MF. The facility failed to protect Resident #1 from abuse from Resident #3 on 12/19/23 when Resident #3 hit Resident #1 on the arm. The facility failed to protect Resident #1 from abuse from Resident #6 on 8/6/23 when Resident #6 hit Resident #1 on her back. The facility failed to protect Resident #2 from abuse from Resident #3 on 2/4/24 when Resident #3 hit Resident #2 on her left shoulder. The facility failed to protect Resident #4 from abuse from Resident #5 on 10/6/23 when Resident #4 slapped Resident #5 because he grabbed her breast. The facility failed to protect Resident #7 from abuse from Resident #6 on 8/16/23 when Resident #6 hit Resident #7 on the head because he asked her to stop pulling on his wheelchair. The facility failed to protect Resident #11 from abuse from Resident #8 on 11/7/2023 when Resident #8 hit Resident #11 in the stomach with his hand. The facility failed to protect Resident #9 from abuse from MA B on 11/1/2023 when MA B pushed Resident #9 roughly in her wheelchair into her room. The facility failed to protect Resident #9 from abuse from Resident #8 on 12/30/2023. On 12/30/2023 when he was observed in the room by staff with his hands under the covers feeling of Resident #8's breasts. The facility failed to protect Resident #8 from abuse from Resident #10 between 2/26/2024 to 3/27/2024. On 2/26/2024 Resident #10 hit Resident #8 on his left arm in the dining room. On 3/25/2024 Resident #10 hit Resident #8 on his left shoulder and hand in the dining room. On 3/27/2024 Resident #10 hit Resident #8 on the hand in the dining room. The facility failed to protect Resident #8 from abuse from Resident #9 on 4/21/2024 when she was observed hitting Resident #8 on the left shoulder with a closed fist in the dining room. An Immediate Jeopardy (IJ) situation was identified on 6/25/24 at 6:30 PM. While the IJ was removed on 6/28/24 at 5:00 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. These failures could place residents at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: 1.Record review of the face sheet dated 6/24/24 indicated Resident #1 was an [AGE] year-old female admitted to the facility originally on 11/14/17 with the most recent readmission on 1/26/23, with diagnoses rheumatoid arthritis without rheumatoid factor (inflammation in lining of joints), hypertension (elevated blood pressure), and dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1's BIMS score was 15 indicating no cognitive impairment. Section E behavior of the MDS indicated Resident #1 did not have any physical, verbal, or other behavioral symptoms. Record review of Resident #1's care plan dated 11/1/23 and revised on 4/23/24 indicated Resident #1 had a behavior problem as evidenced by verbal outbursts at times with interventions that included: 1. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. 2. When she becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. 3. Intervene as necessary to protect the rights and safety of others. Remove her to an alternate location when needed to protect the rights and safety of others. 4. Psychiatric consult per indication of physician's order. Record review of facility incident report dated 8/6/23 for Resident #1, indicated Resident #1 hit Resident #6 on the hand/arm. Resident #1 then approached nursing staff and said I sure did hit her. She kicked me and I have the right to defend myself. Record review of provider investigation report dated 8/11/23 indicated Resident #1 and Resident #6 were in a physical altercation on 8/6/23 at 5:45 PM. The provider investigation report indicated Resident #1 and Resident #6 were sitting near the TV when apparently Resident #6 hit Resident #1, Resident #1 said stop and hit Resident #6 on the arm. This was originally reported that Resident #6 hit Resident #1 and Resident #1 hit Resident #6 in the head. The provider investigation report indicated the residents were kept separated until evaluated by the Psychologist and felt they were not a threat to each other or others. Record review of witness statement provided by RN EE undated indicated I noticed the resident (Resident #6) sitting in front of another resident (Resident #1), in her wheelchair. The other resident (Resident #1) was reaching her arms towards Resident #6, and I relocated Resident #6 to the nurse's station. Signed by RN EE. Record review of witness statement provided by Dietary Helper Z undated indicated On Sunday August 6,2023 I was in the dish room, and Dietary Helper told me to look at Resident #6 and Resident #1. I did not see Resident #6 hit Resident #1, but I did see Resident #1 tap Resident #6 on the arm. The nurse moved Resident #6 away from Resident #1 to the nurse/s station. Signed by Dietary Helper Z. Record review of witness statement provided by Dietary Helper undated indicated On Sunday August 6, 2023, I was picking up dishes in the dining room when I heard Resident #1 tell Resident #6 to stop! I saw Resident #6 hit Resident #1 and then Resident #1 hit Resident #6 back on the arm. Then the nurse moved Resident #6 away from Resident #1. Signed by the Dietary Helper. Record review of behavioral health organization diagnostic assessment dated [DATE] at 2:49 PM indicated the reason for the referral was: conflict with another resident. Record review of Resident #1's clinical record revealed Resident was seen by behavioral health on 8/7/23 and not again until 11/6/23. Record review of provider investigation report dated 11/1/23 indicated that Resident #1 was in a verbal altercation with Housekeeper A on 10/25/23. The report indicated Resident #1, and Housekeeper A were cussing at each other. The provider investigation report indicated Housekeeper A was allowed to return to work on 10/31/23. Record review of Resident #1's progress notes from 10/23/23 through 10/27/23 revealed there was no documentation of the resident to staff incident that occurred on 10/25/23. Record review of written witness statement undated provided by Housekeeper A indicated I went to help the resident off the floor. The blood was everywhere. I was cleaning up the blood off the floor. There was a towel already there. I picked up the towel to put it in the dirty laundry. The resident (Resident #1) started cursing me, calling me a mother fucker and saying I didn't know how to do my job, because she didn't like me putting the towel in laundry. She continued cursing me calling me a nasty MF and I said no you're the nasty MF, you need to go to your room and let me do my job, but she continued calling me MF and cursing me. I just walked off. Signed by Housekeeper A. Record review of typed witness statement undated provided by Resident #1 indicated I told Housekeeper A not to put that towel with blood on it in the laundry. Put it in a plastic bag first. He then said to me, shut up you F*****g b***h! signed by Resident #1. Record review of typed witness statement undated provided by Resident #2 indicated I didn't hear everything that was said, but I heard Resident #1 say F**K you. And I heard Housekeeper A say, F**k you I heard lots of curse words. Record review of Employment Action/Disciplinary Notice Form dated 10/31/23 indicated Housekeeper A was cleaning up biohazard accident (blood) on the floor with some towels and a resident (Resident #1) started to have a verbal altercation with Housekeeper A, profanities were used by both Resident #1 and Housekeeper A during the exchange. Action to be taken: Final written action to be given to Housekeeper A as agreed upon with Administrator. Signed by Housekeeper A on 10/31/23. Record review of in-service dated 10/31/23 titled Inappropriate behavior/Language in the workplace signed by Housekeeper A. Record review of Employment Action/Disciplinary Notice Form dated 3/27/24 for Housekeeper A revealed Housekeeper A received a written verbal warning for Professionalism in Workplace. Record review of in-service sign in sheet titled Professionalism, Inappropriate languages, Inappropriate Behaviors dated 3/27/24 signed by Housekeeper A and 1 other employee. During an interview on 6/24/24 at 10:45 AM LVN R Said she was on duty the day that Housekeeper A and Resident #1 were arguing. LVN R said she heard Housekeeper A and Resident #1 yelling and saying cuss words and went over and separated them. She said she told Housekeeper A to get off the hall and he left. She said she does not remember anything that Housekeeper A said. She said she called and reported the incident to the Administrator. She said Housekeeper A was suspended for at least 3 days. Said she never witnessed Housekeeper A talk like that to any other resident. During an interview on 6/24/24 at 10:52 AM Resident #1 said another resident had a stroke and fell on the floor and busted her head open. Resident #1 said she told Housekeeper A to get something to mop up the blood. She said Housekeeper A told her Fuck that you don't tell me what to do you don't work here. Resident #1 said Housekeeper A told her That is why you are in the nursing home because you have AIDS. Resident #1 said her, and Housekeeper A had made up and were friends now. Resident #1 said Housekeeper A still worked at the facility. During an interview on 6/24/24 at 11:00 AM Resident #2 said she remembers when Resident #1's room flooded and Housekeeper A and Resident #1 got into a rather heated argument, she said she can't remember what all was said but that they were screaming and cussing at each other. Resident #2 said Housekeeper A still worked at the facility. During an interview on 6/24/24 at 12:00 PM Housekeeper A said he had worked at the facility for about 4 years. He said there was a resident that had fallen, and blood was on the floor, so he got a towel to clean up the blood. Housekeeper A said Resident #1 said to him you can't clean up the blood with the towel. Housekeeper A said Resident #1 was going off and he told Resident #1 to leave me the hell alone. Housekeeper A said he apologized to Resident #1 but said he didn't like blood and he was trying to hurry up and get away from it. He said Resident #1 just stirs him up. Housekeeper A said he did not think he told Resident #1 to shut up, he said he might have been wrong and slipped and said it. Housekeeper A said he never told Resident #1 shut up you fucking bitch. Housekeeper A said himself and Resident #1 have not had any incidents since. Housekeeper A said he was trained on abuse before the incident. Housekeeper A said he was trained on forms of abuse after the incident. Housekeeper A said he had never had a verbal altercation with any other resident. Housekeeper A said his written statement that he had given at the time of the incident was true and correct and was signed by him. Record review of provider investigation report dated 12/26/23 and signed by the Administrator indicated Resident #1 was involved in a physical altercation with Resident #3 on 12/19/23. The provider investigation report indicated Resident #3 went into Resident #1's room and was picking up some of her stuff. Resident #1 told her to put her stuff down and to get out of her room. Resident #3 put down what she had, and slapped Resident #1 on the arm. Resident #1 slapped her back on the arm. Record review of facility incident report for Resident #1 dated 12/19/23 at 5:45 PM indicated This resident (Resident #1) witnessed asking another resident (Resident #3) to leave her room and put her belonging back. When other resident (Resident #3) exited Resident #1's room she proceeded to hit Resident #1 on her arm. This resident (Resident #1) seen hitting other resident (Resident #3) back on her arm. Resident #1 told nursing staff I told her to come out my room and put my stuff back and she come out and hit me. I sure did hit her back. She need to stay out my room messing with my stuff. The incident report indicated the immediate action taken: Residents separated and redirected. This resident (Resident #1) assessed, and no apparent injuries noted at this time. Resident #1 then taken into her assigned room. Record review of Resident #1's progress notes from 12/7/23 through 12/20/23 revealed there was no documentation regarding the resident-to-resident altercation that occurred on 12/19/23. Record review of witness statement provided by MA CC undated indicated I heard Resident #1 yell for Resident #3 to get out of her room. I ran to hurry Resident #3 out of her room. Resident #3 told her no and was picking up Resident #1's stuff off of her table and I'm unsure of what else she had. Resident #1 told her to put her stuff down, stop touching my stuff and to get out. I'm still trying to get Resident #3 to come out but she kept saying no this is mine, Resident #3 said no it isn't and to get out again. Resident #3 look at her and then just hit her and Resident #1 hit her back I stepped in and told them both to stop hitting. Resident #3 finally left her room. Record review of Psychological Services Progress Note for Resident #1 dated 12/21/23 at 6:21 PM indicated nursing home staff requested her to be seen due to a conflict with another residents. Signed by Psychologist. Surveyor requested behavior monitoring and interventions report for Resident #1 on 6/27/24 at 10:15 AM from Regional Nurse Consultant HH and Regional Nurse JJ. The Surveyor had not received requested documentation by the time of surveyor exit on 7/1/24. 2. Record review of the face sheet dated 6/26/24 indicated Resident #2 was a [AGE] year-old female admitted to the facility originally on 2/3/22 with the most recent readmission on 6/7/23, with diagnoses metabolic encephalopathy (problem in the brain caused by a chemical imbalance in the blood), epilepsy (seizures), and generalized anxiety disorder (constant worry). Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated Resident #2's BIMS score was 15 indicating that Resident #2 was cognitively intact. Section E behavior of the MDS indicated Resident #2 did not have any physical, verbal, or other behavioral symptoms. Record review of Resident #2's care plan dated 6/14/23 and revised on 2/20/24 indicated Resident #2 had a communication problem due to a hearing deficit with interventions that included: 1. Ensure/provide a safe environment: call light in reach, adequate low glare light, bed in the lowest position and wheels locked, avoid isolation. 2. Monitor for/record confounding problems: decline in cognitive status, mood, decline in ADL . During an interview on 6/24/24 at 11:00 AM Resident #2 said the medication aide was giving her medication and said Resident #3 walked up to them and said she was going to get her medication too. Resident #2 said Resident #3 just hit her on her left shoulder and back for no reason. Resident #2 said when Resident #3 hit her it did not hurt but it startled her. She said she was not afraid of Resident #3, and said she saw Resident #3 in the dining room later that evening, but she just stayed away from her. Resident #2 said the medication aide witnessed the incident but cannot remember who it was. Record review of provider investigation report dated 2/8/24 and signed by the Administrator indicated on 2/4/24 at 12:45 PM: Resident #3 hit Resident #2 across the back with a wet pair of pants. The provider investigation report revealed Resident #3 was taken to her room, and Resident #2 went to her room. The provider investigation report revealed the provider action taken was: continue to monitor residents for well being and safety. 2. Inservice staff on dealing with difficult behaviors and Resident #3 was transferred to another facility with a secured unit on 2/6/24. Record review of facility incident report dated 2/4/24 indicated Med aide reported to this nurse that Resident #3 hit Resident #2 on her back. The incident report indicated Resident #2 said .she was trying to help Resident #3 get back to her room and Resident #3 started yelling at her and hit her across the back just below the left shoulder. Record review of progress note dated 2/5/23 at 9:21 AM written by LVN R indicated Resident #3 hit Resident #2 on her back below her left shoulder. Record review of typed witness statement provided by Resident #2 undated indicated On Sunday, February 4, 2024 @ about 1:00 PM, I was coming down Hall 1 and Resident #3 was in the hallway between our rooms, I told Resident #3 where her room was and she told me to shut up, then hit me on my left shoulder and back. The med aid then took Resident #3 to her room. A short time earlier, my [family member] and I were visiting in my room and Resident #3 opened my door, and then shut it without incident. Signed by Resident #2. Record review of written witness statement provided by MA GG undated indicated On the date of February 4, 2024, about or between 12:15 PM - 12:30 PM, I was on hall 1 on a med pass. I saw Resident #2 coming down the hall in her wheelchair, I was close to her room waiting for her so I could give her medications. She was halfway down the hall when Resident #3 walked out of another resident room, Resident #2 was passing Resident #3 swung a wet pair of pants and hit Resident #2 across the back of her shoulders and in back of her head, I stepped in and walked Resident #3 to the nurses station and reported it to the nurse on duty LVN R. Resident #2 went to her room and LVN R went in to do an assessment, and normal activities were resumed. Signed by MA GG. Record review of a behavioral health solution psychological services progress note dated 2/5/24 indicated Resident #2 had been receiving psychiatric services weekly since 6/19/23. The psychological progress note did not address the resident-to-resident altercation on 2/4/24. Record review of behavior monitoring, and interventions report dated 2/1/24-2/29/24 revealed one day of documentation on with no behaviors observed on 2/29/24. 3. Record review of the face sheet dated 6/25/24 indicated Resident #3 was a [AGE] year-old female admitted to the facility originally on 5/3/21 with the most recent readmission on 5/12/22, with diagnoses Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #3's quarterly MDS assessment dated [DATE] indicated Resident #3's BIMS score was 3 indicating severe cognitive impairment. Section E behavior of the MDS indicated Resident #3 did not have any physical, verbal, or other behavioral symptoms. Record review of Resident #3's care plan dated 12/19/23 and revised on 3/4/24 indicated Resident #3 had a behavior problem as evidenced by resident-to-resident conflict with interventions that included: 1. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. 2. When she becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. 3. Intervene as necessary to protect the rights and safety of others. Remove her to an alternate location when needed to protect the rights and safety of others. 4. Psychiatric consult per indication of physician's order. Record review of Resident #3's progress note dated 2/5/23 at 12:45 PM written by LVN R revealed: Resident #3 hit Resident #2 on her back below her left shoulder, Resident #3 unable to explain what happened and stated, she made me mad. Resident #3 denied hitting Resident #2. Record review of facility incident report dated 2/4/24 indicated on 2/4/24 .Resident #3 hit Resident #2 on her back just below her left shoulder. Record review of a behavioral health solution psychological services progress note dated 2/5/24 indicated Resident #3 had been receiving psychiatric services weekly since 2/6/23. The psychological progress note did not address the resident-to-resident altercation on 2/4/24. Record review of Resident #3's clinical record indicated Resident #3 discharged from the facility to another nursing facility with a secured unit on 2/6/24. Surveyor requested behavior monitoring and interventions report for Resident #3 on 6/27/24 at 10:15 AM from Regional Nurse Consultant HH and Regional Nurse JJ. The Surveyor had not received requested documentation by the time of surveyor exit on 7/1/24. 4. Record review of the face sheet dated 6/25/24 indicated Resident #4 was a [AGE] year-old female admitted to the facility originally on 4/12/22 with the most recent readmission on 5/18/22, with diagnoses dementia with behavioral disturbances (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems accompanied by agitation, depression, and psychosis), dementia without behavioral disturbance (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4's BIMS score was 6 indicating severe cognitive impairment. Section E behavior of the MDS indicated Resident #4 had delusions. Section E behavior of the MDS indicated Resident #4 had physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others that occurred 1 to 3 days. Section E wandering of the MDS indicated Resident #4 had that type of behavior daily. Record review of Resident #4's care plan dated 6/1/23 and revised on 11/1/23 indicated Resident #3 had a behavior problem as evidenced by: clothing items thrown on the floor creating increased risk for slip, trip, or falls with interventions that included: 1. When she becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. 2. Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others. Record review of provider investigation report dated 10/13/24 signed by the Administrator indicated on 10/6/23 at 3:22 PM: .Resident #4 had told Resident #5 to quit following her, and when he continued to stand there she slapped him. The provider investigation report revealed alternate placement was being looked at and the residents were on 1:1 supervision and staff were educated on resident-to-resident altercations. Record review of incident report dated 10/6/23 for Resident #4 revealed .Resident slapped another resident in the face/neck area. Resident #4 stated he grabbed my boob so I slapped him. Record review of Resident #4's progress notes dated 10/4/23 through 10/7/23 revealed there was no documentation of the resident-to-resident altercation that occurred on 10/6/23. Record review of staffing schedules dated 10/8/23 through 10/17/23 indicated: 10/6/23- no staffing schedule provided to show 1 on 1 monitoring of Resident #4. 10/7/23- no staffing schedule provided to show 1 on 1 monitoring of Resident #4. 10/9/23-Showed staffing 1 on 1 coverage for Resident #4 unknown hours. 10/11/23-Showed staffing 1 on 1 coverage for Resident #4 from 7:00 AM to 4:30 PM and 6:00 PM to 6:00AM. 10/12/23-Showed staffing 1 on 1 coverage for Resident #4 from 7:00 AM to 4:30 PM and unknown after that. 10/15/23- Showed staffing 1 on 1 coverage for Resident #4 from 7:00 AM to 4:30 PM, and 6:00 PM to 6:00 AM. 10/17/23- No 1 on 1 staffing coverage for Resident #4 shown. Record review of Resident #4's clinical record indicated she had been receiving behavioral health solution psychological services weekly from 8/18/23 to 10/23/23. Record review of behavioral health solution psychological services progress note dated 10/9/23 at 3:05 PM indicated: Patient's Response to Intervention: Discussed the issue she had with another resident and she has no memory of the incident. The progress note did not indicate when the incident occurred or with who. The progress note did not address 1 on 1 monitoring with Resident #4. Record review of behavioral health solution psychological services progress note dated 10/16/23 did not address the resident-to-resident altercation or 1 on 1 monitoring with Resident #4. Record review of behavioral health solution psychological services progress note dated 10/23/23 did not address the resident-to-resident altercation or 1 on 1 monitoring with Resident #4. The progress note revealed Resident #4 was not seen by the psychologist due to Resident #4 being transferred to another facility. Record review of Resident #4's clinical record indicated Resident #4 discharged from the facility on 10/16/23. Surveyor requested behavior monitoring and interventions report for Resident #4 on 6/27/24 at 10:15 AM from Regional Nurse Consultant HH and Regional Nurse JJ. The Surveyor had not received requested documentation by the time of surveyor exit on 7/1/24. 5. Record review of the face sheet dated 6/25/24 indicated Resident #5 was a [AGE] year-old male admitted to the facility originally on 1/20/23, with diagnoses benign neoplasm of meninges (brain tumor), type 2 diabetes (high blood sugar), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #5's quarterly MDS assessment dated [DATE] indicated Resident #5's BIMS score was 00 indicating severe cognitive impairment. Section E behavior of the MDS indicated Resident #5 did not have any physical, verbal, or other behavioral symptoms. Record review of Resident #5's care plan dated 1/25/23 and revised on 3/1/24 indicated Resident #5 wanders related to cognitive impairment and is at risk for injury. He wanders around facility attempting to go in other residents rooms. Interventions included: 1. Redirect if he enters a restricted area. 2. Monitor him for tailgating when visitors are in the building or on the unit. Record review of Resident #5's progress notes dated between 10/2/23 through 10/7/23 revealed there was no documentation of the resident-to-resident altercation that occurred on 10/6/23. Record review of provider investigation report dated 10/13/24 signed by the Administrator indicated on 10/6/23 at 3:22 PM: .Resident #4 had told Resident #5 to quit following her, and when he continued to stand there she slapped him. The provider investigation report revealed alternate placement was being looked at and the residents were on 1:1 supervision and staff were educated on resident-to-resident altercations. Record review of incident report dated 10/6/23 for Resident #5 revealed .another resident slapped him across the face neck area. Resident #5 stated I was walking down the hall and then she hit me and pointed to the left side of his face. Record review of staffing schedules dated 10/8/23 through 10/17/23 (no staffing schedules provided prior to 10/8/23 or after 10/17/23) indicated: 10/6/23- no staffing schedule provided to show 1 on 1 monitoring of Resident #5. 10/7/23- no staffing schedule provided to show 1 on 1 monitoring of Resident #5. 10/9/23-Showed staffing 1 on 1 coverage for Resident #5 from 6-12. 10/12/23- Staffing showed 1 on 1 coverage for Resident #5 from 6:40 AM to 5:00PM and 6:00 PM to 6:00AM. 10/13/23- Showed staffing 1 on 1 coverage for Resident #5 7:00 AM to 6:00 PM and 6:00 PM to 6:00 AM. 10/14/23-Showed staffing 1 on 1 coverage for Resident #5 11:00am to 6:00 PM and 6:00 PM to 6:00 AM. 10/17/23- Showed staffing 1 on 1 coverage for Resident #5 6-?. Record review of behavioral health solution psychological services progress note date 10/16/23 did not address 1 on 1 monitoring or the resident-to-resident altercation that occurred on 10/6/23. Surveyor requested behavior monitoring and interventions report for Resident #5 on 6/27/24 at 10:15 AM from Regional Nurse Consultant HH and Regional Nurse JJ. The Surveyor had not received requested documentation by the time of surveyor exit on 7/1/24. 6. Record review of the face sheet dated 6/25/24 indicated Resident #6 was a [AGE] year-old female admitted to the facility originally on 4/24/18 with the most recent readmission on 12/5/22, with diagnoses Alzheimer's disease (progressive disease that destroys memory and other important mental functions), dementia without behavioral disturbances (mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and cognitive communication deficit (difficulty communicating effectively). Record review of Resident #6's quarterly MDS assessment dated [DATE] indicated Resident #6's BIMS score was 3 indicating severe cognitive impairment. Section E behavior of the MDS indicated Resident #6 had physical behavioral symptoms directed toward others that occurred 1 to 3 days. Record review of Resident #6's care plan dated 1/29/23 and revised on 6/20/23 indicated Resident #6 had a behavior problem as evidenced by: Incident occurring on 1/29/23 with resident-to-resident altercation with interventions that included: 1. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behaviors and interventions in behavior log. 2. When she becomes agitated intervene before the agitation escalates by guiding away from source of distress, engaging calmly in conversation, or attempting to other interventions. If response is aggressive then approach at a later time after ensuring the safety of the resident and nearby residents. 2. Intervene as necessary to protect the rights and safety of others. Remove resident to an alternate location when needed to protect the rights and safety of others. Record review of Resident #6's progress notes dated 8/14/23 through 8/16/23 revealed there was no documentation of the resident-to-resident altercation that occurred on 8/16/23. Record review of provider investigation report dated 8/21/23 signed by the Administrator indicated on 8/1 [TRUNCATED]

Based on observation, interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 3 of 4 Residents (Resident #13, Resident #14 and Resident #15) reviewed for pressure injuries. The facility failed to implement interventions to prevent pressure ulcer or injury development for Resident #13 and Resident #14. The facility failed to provide ongoing skin assessments causing undiscovered wounds for Resident #13 and Resident #14 to go untreated. The facility failed to implement the wound care physicians' recommendations for Resident #13. The facility failed to identify and treat wound to Resident #13's right outer ankle. The facility failed to identify and treat wound to Resident #14's left heel. The facility failed to ensure preventative equipment was in working order for Resident #15 on 6/27/24 when Resident #15 was lying on a deflated low air loss mattress for an undetermined amount of time. An IJ was identified on 6/27/24 at 5:24 PM. The IJ template was provided to the facility on [DATE] at 5:24 PM. While the IJ was removed on 6/28/24 at 5:22 PM, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because all staff had not been trained on pressure ulcer prevention and management. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life. Findings included: 1. Record review of the face sheet dated 6/26/24 indicated Resident #13 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes, hypertension (elevated blood pressure), and congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should). Record review of the MDS dated [DATE] indicated Resident #13 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 0 and had severe cognitive impairment. The MDS indicated Resident #13 required substantial/maximum assistance with toileting hygiene, showering/bathing, moving from sitting to lying, and moving from lying to sitting on the side of the bed. The MDS indicated Resident #13 was dependent with transfers. The MDS indicated Resident #13 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #13 had 1 stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough (any yellowish material noted in the wound bed) or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The MDS indicated the 1 stage 4 pressure ulcer was present upon admission to the facility. Record review of the care plan last revised on 6/9/24 indicated Resident #13 had a pressure ulcer and was at risk for infection, pain, and a decline in functional abilities with interventions that included:1. Notify physician and responsible party of changes in status. 2. Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling. 3. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. 4. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. 5. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. 6. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Record review of the physician orders dated 6/26/24 indicated Resident #13 had an order to: 1. left distal foot: cleanse wound with normal saline, pat dry, apply leptospermum honey, and alginate calcium, then cover with gauze island with border daily. 2. left lateral foot wound: cleanse with normal saline, apply betadine, and cover with gauze island with border daily. 3. left distal lateral foot wound: cleanse with normal saline, pat dry with gauze, apply betadine, leave open to air. 4. Right distal medial foot: cleanse with normal saline, pat dry, apply leptospermum honey, and alginate calcium, then secure with gauze island with border daily. 5. Perform head to toe skin assessment. Document any changes in skin integrity in the medical record. Every day shift every FRI for wound prevention/early identification notify the physician of any changes in skin integrity. Record review of Braden Scale for Predicting Pressure Sore Risk dated 5/23/24 revealed Resident #13's score of 17 which indicated Resident #13 was at low risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 5/16/24 revealed Resident #13's score of 17 which indicated Resident #13 was at low risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 5/9/24 revealed Resident #13's score of 14 which indicated Resident #13 was at moderate risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 5/2/24 revealed Resident #13's score of 13 which indicated Resident #13 was at moderate risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 4/19/24 revealed Resident #13's score of 13 which indicated Resident #13 was at moderate risk for developing a pressure sore. Record review of the TAR for June 2024 indicated Resident #13 was scheduled to have wound care to his left distal medial foot (site 1), left lateral foot (site 3), left distal lateral foot (site 4), and right distal medial foot (site 5). Resident #13 had a physician's order to Perform head to toe skin assessment. Document any changes in skin integrity in the medical record. Every day shift every Fri for wound prevention/early identification notify the physician of any changes in skin integrity. The June TAR indicated the head-to-toe skin assessment had been completed on 6/20/24. Record review of Resident #13's clinical record revealed Resident #13 did not have a documented skin assessment with wound measurements or description of wound. Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/3/24 indicated Resident #13 had: 1. Stage 4 pressure wound to the Left, Distal, Medial Foot Full Thickness measuring 1.1 x 1.2 x 0.1 centimeter. with recommendations to Float Heels in Bed; Pressure off-loading boot. 2. Unstageable of the Left, Lateral Foot Full Thickness measuring 1.8 x 1.5 x not measurable centimeters with recommendations to Reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. 3. Stage 3 pressure wound of the left, distal, lateral foot full thickness measuring 0.5 x 0.5 x not measurable centimeters with recommendations for Pressure off-loading boot; off-load wound; reposition per facility protocol. Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/13/24 indicated Resident #13 had: 1. Stage 4 pressure wound to the Left, Distal, Medial Foot Full Thickness measuring 1.1 x 1.2 x 0.1 centimeter. with recommendations to Float Heels in Bed; Pressure off-loading boot. 2. Unstageable of the Left, Lateral Foot Full Thickness measuring 1.8 x 1.5 x not measurable centimeters with recommendations to Reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. 3. Stage 3 pressure wound of the left, distal, lateral foot full thickness measuring 0.5 x 0.5 x not measurable centimeters with recommendations for Pressure off-loading boot; off-load wound; reposition per facility protocol. Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/19/24 indicated Resident #13 had: 1. Stage 4 pressure wound to the Left, Distal, Medial Foot Full Thickness measuring 0.8 x 0.7 x 0.1 centimeter. with recommendations to Float Heels in Bed; Pressure off-loading boot. 2. Unstageable of the Left, Lateral Foot Full Thickness measuring 0.8 x 0.7 x not measurable centimeters with recommendations to Reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. 3. Stage 4 pressure wound of the left, distal, lateral foot full thickness measuring 1.3 x 0.8 x not measurable centimeters with recommendations for Pressure off-loading boot; off-load wound; reposition per facility protocol. 4. Stage 4 pressure wound of the right, distal, medial foot full thickness measuring 1.5 x 1.5 x 0.3 with recommendations off-load wound; reposition per facility protocol; pressure off-loading boot. Investigations: Recommended And/Or Reviewed: Arterial Doppler Pending as of 6/19/2024. Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/26/24 indicated Resident #13 had: 1. Stage 4 pressure wound to the Left, Distal, Medial Foot Full Thickness measuring 0.8 x 0.7 x 0.1 centimeter. with recommendations to Float Heels in Bed; Pressure off-loading boot. 2. Unstageable of the Left, Lateral Foot Full Thickness measuring 0.8 x 0.7 x not measurable centimeters with recommendations to Reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. 3. Stage 4 pressure wound of the left, distal, lateral foot full thickness measuring 1.3 x 0.8 x 0.2 centimeters with recommendations for Pressure off-loading boot; off-load wound; reposition per facility protocol. 4. Stage 4 pressure wound of the right, distal, medial foot full thickness measuring 1.5 x 1.5 x not measurable centimeters with recommendations off-load wound; reposition per facility protocol; pressure off-loading boot. Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/27/24 indicated Resident #13 had: had: 1. Stage 4 pressure wound to the Left, Distal, Medial Foot Full Thickness measuring 0.8 x 0.7 x 0.1 centimeter. with recommendations to Float Heels in Bed; Pressure off-loading boot. 2. Unstageable of the Left, Lateral Foot Full Thickness measuring 0.8 x 0.7 x not measurable centimeters with recommendations to Reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. 3. Stage 4 pressure wound of the left, distal, lateral foot full thickness measuring 1.3 x 0.8 x 0.2 centimeters with recommendations for Pressure off-loading boot; off-load wound; reposition per facility protocol. 4. Stage 4 pressure wound of the right, distal, medial foot full thickness measuring 1.5 x 1.5 x not measurable centimeters with recommendations off-load wound; reposition per facility protocol; pressure off-loading boot. 5. Arterial wound of the right, posterior ankle full thickness measuring 1.2 x 1.5 x not measurable centimeters Depth is unmeasurable due to presence of nonviable tissue and necrosis. With recommendations off-load wound; reposition per facility protocol; pressure off-loading boot. Record review of Resident #13's nursing progress notes dated 6/1/24 to 6/27/24 revealed Resident #13 did not have documentation of wound measurements, description of wounds, or weekly skin assessments. 2. Record review of face sheet dated 6/28/24 indicated Resident #14 was a [AGE] year-old male that admitted to the facility on [DATE] with the most recent admission of 5/15/24 with diagnoses that included: urinary tract infection (infection in the urine), pressure ulcer of sacral region stage 4, acquired absence of right leg above knee (right leg amputation above the knee). Record review of the MDS dated [DATE] indicated Resident #14 understood others and was understood by others. The MDS indicated Resident #14 had a BIMS score of 15 and was cognitively intact. The MDS indicated Resident #14 required substantial/maximum assistance with showering/bathing, tub/shower transfer, and lower body dressing. The MDS indicated Resident #14 required partial/moderate assistance for upper body dressing. The MDS indicated Resident #14 was dependent for putting on/taking off footwear. The MDS indicated Resident #14 required set up or clean up assistance with eating, personal hygiene, and oral hygiene. The MDS indicated Resident #14 was independent with rolling left and right, sit to lying, lying to sitting on side of bed, and chair/bed to chair transfer. The MDS indicated Resident #14 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #14 had 1 stage 4 (full thickness tissue loss with exposed bone, tendon or muscle. Slough (any yellowish material noted in the wound bed) or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. The MDS indicated the 1 stage 4 pressure ulcer was present upon admission to the facility. Record review of the care plan last revised on 5/2/24 indicated Resident #14 had a pressure ulcer and was at risk for infection, pain, and a decline in functional abilities with interventions that included:1. Notify physician and responsible party of changes in status. 2. Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling. 3. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. 4. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. 5. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. 6. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. 7. Pressure relieving/reducing devices on bed/chair. 8. Low air loss mattress. Record review of the physician orders dated 6/28/24 indicated Resident #14 had an order to: 1. (site 14) Skin tear wound of the left ischium: cleanse with normal saline, pat dry, apply leptospermum honey then cover with gauze island with border daily. 2. (skin 1) Sacrum wound: Cleanse wound with normal saline, pat dry, with gauze, apply collagen sheet to wound bed, then negative pressure wound therapy on Monday, Wednesday, and Friday weekly. Record review of Resident #14's nurse progress notes dated 6/1/24 through 6/27/24 revealed no documentation of weekly skin assessment or wound assessment with updated measurements, description of wound, or treatment order. Record review of Braden Scale for Predicting Pressure Sore Risk dated 6/5/24 revealed Resident #14's score of 20 which indicated Resident #14 was not at risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 5/29/24 revealed Resident #14's score of 20 which indicated Resident #14 was not at risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 5/22/24 revealed Resident #14's score of 20 which indicated Resident #14 was not at risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 5/15/24 revealed Resident #14's score of 17 which indicated Resident #14 was at low risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 4/10/24 revealed Resident #14's score of 14 which indicated Resident #14 was at moderate risk for developing a pressure sore. Record review of Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/3/24 indicated Resident #14 had: 1. Stage 4 pressure wound sacrum full thickness measuring 1.6 x 0.6 x 0.4 centimeters with recommendations of limit sitting to 60 minutes; upgrade offloading chair cushion; reposition per facility protocol; low air loss mattress; off-load wound. 2. Skin tear wound of the left ischium full thickness measuring 1.2 x 0.6 x not measurable centimeters with recommendations of reposition per facility protocol; off-load wound. Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/13/24 indicated Resident #14 was not seen by the wound care doctor due to declined to be seen because he has to go smoke. Record review of Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/19/24 indicated Resident #14 had: 1. Stage 4 pressure wound sacrum full thickness measuring 1.6 x 0.5 x 0.4 centimeters with recommendations of limit sitting to 60 minutes; upgrade offloading chair cushion; reposition per facility protocol; low air loss mattress; off-load wound. 2. Skin tear wound of the left ischium full thickness measuring 1.0 x 0.6 x 0.1 centimeters with recommendations of reposition per facility protocol; off-load wound. Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/26/24 indicated Resident #14 had: 1. Stage 4 pressure wound sacrum full thickness measuring 1.3 x 0.5 x 0.4 centimeters with recommendations of limit sitting to 60 minutes; upgrade offloading chair cushion; reposition per facility protocol; low air loss mattress; off-load wound. 2. Skin tear wound of the left ischium full thickness measuring 1.0 x 0.6 x 0.1 centimeters with recommendations of reposition per facility protocol; off-load wound. Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/27/24 indicated Resident #14 had: 1. Stage 4 pressure wound sacrum full thickness measuring 1.3 x 0.5 x 0.4 centimeters with recommendations of limit sitting to 60 minutes; upgrade offloading chair cushion; reposition per facility protocol; low air loss mattress; off-load wound. 2. Skin tear wound of the left ischium full thickness measuring 1.0 x 0.6 x 0.1 centimeters with recommendations of reposition per facility protocol; off-load wound. 3. non-pressure wound of the left heel undetermined thickness measuring 0.5 x 1.2 x not measurable centimeters with recommendation to pad the wheelchair. 3. Record review of the face sheet dated 6/28/24 indicated Resident #15 was an [AGE] year-old male admitted to the facility on [DATE] with the most recent admission on 4/4/24 with diagnoses including severe protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function), pressure ulcer of left heel, unstageable, muscle weakness, and abnormal weight loss. Record review of the MDS dated [DATE] indicated Resident #15 understood others and was understood by others. The MDS indicated Resident #15 had a BIMS score of 0 and had severe cognitive impairment. The MDS indicated Resident #15 required substantial/maximum assistance with rolling left and right, moving from sitting to lying, and moving from lying to sitting on the side of the bed. The MDS indicated Resident #15 was partial/moderate assist with eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident #15 was dependent with transfers. The MDS indicated Resident #15 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #15 had 1 unstageable (slough and/or eschar: known by not stageable due to coverage of wound bed by slough and/or eschar). The MDS indicated the 1 unstageable pressure ulcer was present upon admission to the facility. Record review of the care plan last revised on 3/11/24 indicated Resident #15 had an unstageable pressure ulcer to his left heel and was at risk for infection, pain, and a decline in functional abilities with interventions that included:1. Notify physician and responsible party of changes in status. 2. Provide wound care per physician's order. Keep dressing clean, dry, and intact. Replace the dressing as needed for soiling. 3. Monitor dressing to ensure it is intact and adhering. Report loose or soiled dressings to treatment or charge nurse. 4. Routinely evaluate and document the wound dimensions, drainage, and condition of surrounding tissue. Notify the physician as needed for changes. 5. Monitor and document for signs and symptoms of infection such as foul-smelling drainage, redness, swelling, tenderness, fever, and red lines or streaking originating at the wound. Notify the physician when detected. 6. Weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Record review of the physician orders dated 6/28/24 indicated Resident #15 had an order to: (site 1) left heel wound: cleanse with normal saline gauze, pat dry, apply leptospermum honey, then cover non-sterile gauze, secure with gauze island with border daily. Record review of Resident #15's nurse progress notes dated 6/1/24 through 6/27/24 revealed no documentation of weekly skin assessment or wound assessment with updated measurements, description of wound, or treatment order. Record review of Braden Scale for Predicting Pressure Sore Risk dated 4/28/24 revealed Resident #15's score of 12 which indicated Resident #15 was at high risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 4/21/24 revealed Resident #15's score of 12 which indicated Resident #15 was at high risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 4/18/24 revealed Resident #15's score of 12 which indicated Resident #15 was at high risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 4/11/24 revealed Resident #15's score of 14 which indicated Resident #15 was at moderate risk for developing a pressure sore. Record review of Braden Scale for Predicting Pressure Sore Risk dated 4/4/24 revealed Resident #15's score of 12 which indicated Resident #15 was at high risk for developing a pressure sore. Record review of Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/3/24 indicated Resident #15 had: 1. Stage 4 pressure wound of the left heel full thickness measuring 2.3 x 2.3 x 0.2 centimeters with recommendations to reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. Record review of Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/13/24 indicated Resident #15 had: 1. Stage 4 pressure wound of the left heel full thickness measuring 2.3 x 2.3 x 0.2 centimeters with recommendations to reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. Record review of Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/19/24 indicated Resident #15 had: 1. Stage 4 pressure wound of the left heel full thickness measuring 2.3 x 2.3 x 0.2 centimeters with recommendations to reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. Record review of Record review of Wound Evaluation & Management Summary completed by the wound care physician dated 6/26/24 indicated Resident #15 had: 1. Stage 4 pressure wound of the left heel full thickness measuring 2.1 x 2.0 x 0.2 centimeters with recommendations to reposition per facility protocol; float heels in bed; pressure off-loading boot; off-load wound. During an interview and observation on 6/24/24 at 10:33 AM Resident #13 was lying in bed awake and alert with bilateral feet uncovered with bilateral feet not floated, and no dressing to the left distal medial foot or the left lateral foot. Resident #13 did not have feet off loaded or pressure off loading boots in place. Resident #13 did not have a low air loss mattress on his bed. Resident #13 was not able to answer questions appropriately due to cognition. During an interview on 6/27/24 at 9:17 AM the Regional Nurse Consultant HH said weekly skin assessments were signed off on in the ETAR and documented in a nurse progress note that they were completed. She said if a wound was identified then it was documented in a system called Gentell and in a progress note. She said the wound care physician usually came to the facility on ce a week and documents on a wound evaluation and management summary note and if needed a nurse from Gentell comes to the facility to see the residents. She said if it was a wound that does not require the wound care doctor or the Gentell nurse then it would be documented in the progress notes in the medical record. During an observation on 6/27/24 at 11:01 AM of wound care provided by the Treatment Nurse and LVN DD, on Resident #13 sitting in geri chair to bilateral feet, resident had on gripper socks with no other preventative measures in place. Wounds observed were: stage 4 pressure ulcer of lateral medial left foot, Stage 3 of left lateral distal foot, unstageable of left lateral foot, and stage 4 right distal medial foot. Also observed undocumented wound to the right posterior ankle open with thick adherent black necrotic tissue (eschar) in the center measuring 1.2cm x 1.5cm x not measurable due to eschar with light serous exudate with no treatment applied. During an interview on 6/27/24 at 11:01 AM the Treatment Nurse said he had worked at the facility PRN for about 2 years, he said he performs wound care Monday through Friday for the last 2 years but was not full time. He said he and LVN DD were responsible for completing weekly skin assessments. He said he signs off the TAR for the weekly skin assessments but does not document the skin assessment anywhere else. He said the wound care doctor comes in once a week usually on Wednesdays and sees all pressure wounds in the facility. He said the next day after the wound care doctor came, LVN DD enters the new orders in the medical record and documents the wound assessment from the wound care doctor into the Gentell report. The Treatment Nurse said he did not measure any wounds in the building, he said the wound care doctor is the only person that measures wounds that he is aware of. He said if he did a skin assessment that revealed a new wound, he would usually text the wound care doctor for orders. He said he would sometimes let the charge nurse know of a new wound but the charge nurse did not notify the family or the doctor of the wound. He said he did not document the wound anywhere else and did not measure the wound. He said the next time the wound care doctor was in the facility he would see the resident and determine the type of wound, measure the wound, and document the description of the wound on the Wound Evaluation & Management Summary. The Treatment Nurse said he did not do any other documentation on the wound except enter the new order for wound care. He said he did not notify the families of any new wounds or updates on existing wounds. He said Resident #13 had seen the wound care doctor the day before and did not know how the wound care doctor had missed the new undocumented wound to his right posterior ankle. He said he would notify the doctor and get new orders to treat the new wound. When surveyor asked if anyone assessed wounds or documented wound measurements between 6/3/24 and 6/13/24 when the wound care doctor did not come, he said no one. During an interview on 6/27/24 at 11:01 AM LVN DD said she had worked at the facility as needed usually on Wednesdays when the wound care doctor came in and the day after the wound care doctor came to the facility. She said she enters in all new orders from the wound care doctor the following day after he made rounds. She said she enters the information from the wound care doctor on the Gentell report. She said weekly skin assessments were signed off on the TAR but there was no other documentation that they do. She said the wound care doctor measures all pressure wounds weekly when he comes, and the Treatment Nurse does not measure the wounds. She said she only does wound care if the Treatment Nurse wanted a day off. She said Resident #13 rubbed his feet back and forth a lot and if they put pillows under his feet Resident #13 would usually kick them around. She said she had never seen a pressure relieving boot for Resident #13. During an observation and interview on 6/27/24 at 2:40 PM Resident #14 was observed sitting up in a wheelchair in his room, awake and alert. Resident #14 had a above the knee right leg amputation. Resident #14's left leg was discolored with redness and purple blueish color below the knee and foot. He said on his left heel he had a spot that the wheelchair peg had rubbed, and it had been there for about 1 1/2 years. Observed an undocumented dime size spot that was not open but has a brown scab like area that was hard to the left heel with dry skin surrounding the area. He said he had a rash in the peri area that the night aide usually puts a cream on. Observed residents' bed was a low air loss mattress. Observed black rolled up sock to Resident 14's left wheelchair footrest. Resident #14 said he rolled up a sock and rubber banded it to the footrest of his wheelchair to keep the peg from rubbing on his left heel. Resident #14 said the facility staff had not treated or looked at his left foot. Resident #14 said no one ever came in to assess his skin. He said once a week or every other week the wound care doctor came in and looked at his buttocks for about 2 minutes and leaves but did not ever look at any other part of his skin. During an observation and interview on 6/27/24 at 2:52 PM Resident #15 was observed lying in bed awake and alert. Resident #15 had a dressing to the left heel dated 6/27/24. Resident #15 was observed laying on a deflated low air loss mattress in his room. Upon further inspection it was determined that resident's bed frame was able to be felt due to resident's low air loss mattress being deflated. Resident #15 said he did not know for how long the mattress had been deflated. When surveyor asked Resident #15 if he was having any pain at that time Resident #15 responded yes. Resident #15 was not able to tell where the pain was or how long he had the pain. During an observation and interview on 6/27/24 at 2:52 PM The Wound Care Consultant said she had come to the facility on [DATE] at the request of the facility. She said if the facility needed advice on a wound she would come to the facility if they requested her to. She said she did not normally come to the facility very often. Upon the request of the surveyor, the Wound Care Consultant observed Resident #14's left heel wound and said in her opinion Resident #14's left heel wound was an arterial wound (painful, deep sore or wound that doesn't heal due to decrease blood flow to the area). She said she would order betadine to the wound daily and at the least the wound should be monitored daily. The Wound Care Consultant observed Resident #15's low air loss mattress to be deflated on 6/27/24 at 2:52 PM and said with Resident #15's air mattress being flat it was not providing pressure relief for Resident #15. The Wound Care Consultant said the purpose of the low air loss mattress was for pressure relief of boney prominences of a resident that was at risk for skin breakdown or that had skin breakdown. The Wound Care Consultant said lying on a deflated low air loss mattress could cause further deterioration of Resident #15's skin. The Wound Care Consultant did not assess Resident #15 [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 14 residents (Resident #12) reviewed for accidents. The facility failed to properly secure Resident #12 during transport in the facility van on 3/2/2024 when he fell out of his wheelchair into the facility van. On 4/4/2024 his wheelchair lifted off the floor from defective floor straps. An Immediate Jeopardy (IJ) situation was identified on 6/26/2024 at 2:40 PM. While the IJ was removed on 6/27/2024 at 1:35 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk for serious injury and accidents. Findings included: Record review of an Admission Record for Resident #12 dated 6/26/2024 indicated he admitted to the facility on [DATE] and was discharged on [DATE]. He was [AGE] years old with diagnoses of type 2 diabetes, orthopedic after following surgical amputation (surgery after following removal of a bone), acquired absence of left leg above the knee (surgical removal of the left leg above the knee), hypertension, and end stage renal disease (kidney failure). Record review of a Quarterly MDS Assessment for Resident #12 dated 4/25/2024 indicated he had moderate impairment in thinking with a BIMS score of 12. He required partial/moderate assistance to supervision with ADL's and used a wheelchair for mobility. He had two falls since admission with no injury and 1 fall with injury. Special Treatment, Procedures, and Programs while a resident included dialysis during the 14 day look back period. Record review of a care plan for Resident #12 revised on 6/24/2024 indicated he had an ADL self-care performance deficit with interventions of wheelchair independent. He has the potential for falls related to incontinence, gait/balance problems with interventions to educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Record review of an incident report for Resident #12 dated 3/2/2024 by RN FF indicated, Resident slide out of wheelchair per transport driver. Dressing change completed to left BKA due to dressing saturated with serosanguineous fluid (thin, watery fluid). Resident assessed for any other injuries at this time. Resident asked if he was having pain, resident denied. Resident not taken to the hospital. No injuries observed at time of incident. Record review of an incident report for Resident #12 dated 4/4/2024 by RN FF indicated, 1430 (2:30 PM) was reported to this nurse that this resident en route back to the facility fell backwards in the transportation van est. time 1225 (12:25 PM). When resident arrives to facility, resident to have assessment performed. 1535 (3:35 PM) Resident to facility. Resident received in wheelchair taken to room. Resident AAOx's 4, no new raised areas on back of head no injuries noted, resident denied hitting back of head and/or LOC. No N/V, no dizziness, no blurry vision, [NAME] well, resp. even and unlabored. Abd soft with positive bowel sounds. Resident informed resident that should he have N/V, dizziness, any changes in vision. He is to let nursing staff be aware. No injuries observed at time of incident. Not taken the hospital. He was oriented to person, place, and time. During a phone interview on 6/25/2024 at 9:13 PM, RN FF said she had been employed at the facility for 2 years and was full time on the 6a-6p shift and worked halls 200 and 300. She said Resident #12 was discharged to the hospital after an appointment. She said some time back in April 2024, she was working and was called to go outside of the facility by CNA C who was the driver of the van. She said CNA C entered the facility and told her Resident #12 had fallen in the van. She said she went outside and asked him if he was hurt and if he had hit his head, she said he denied hitting his head, but did fall on his knee. She said his wheelchair was present. She said he told her he just went down on his knee and was not complaining of anything at that time. She said CNA C took him to dialysis and she notified dialysis of the fall. She said later on she had heard he had fallen another time. During an interview on 6/26/2024 at 8:22 AM, ADON D said she had been employed at the facility for 3 years. She said she was responsible for scheduling the resident's appointments. She said she scheduled the appointments for the residents and placed them on the calendar and then scheduled the transportation. She said some of their residents were Medicaid transports and they received transportation from an outside company. She said Resident #12 admitted in January 2024 and initially was transported to dialysis via the facility van and his dialysis days were Tuesday, Thursday, and Saturday. She said they stopped sometime in mid-February providing transport to dialysis and then began with an outside company for transport. She said the Transport Aide and CNA C were the staff assigned to provide transport. She said CNA C had not been assigned transport in quite some time since February 2024. She said she was aware of the incidents with Resident #12 where he fell out of his wheelchair during transport in the facility van. She said if the transport were local then there would only be the driver, if longer distance then they would send two people for the transport. During an interview on 6/26/2024 at 8:39 AM, CNA C said she had been employed at the facility for 2 years, currently was on back up for transport and started driving in January 2024. She said she was involved with one of the 2 incidents with Resident #12. She said the incident involved transport in the facility van. She said Resident #12 was loaded in the van and they were driving through the parking lot, she felt something warm on her leg and got on the brakes, stopped the van, looked back and saw that Resident #12 was on the floor of the van down on one knee. She said she got out to check on him, backed the van up and came inside and got the nurses. She said the nurses came outside, picked him up and placed him back in his chair She said the nurse rewrapped his leg which had been leaking from the night before and they proceeded to go to dialysis. She said on the way, Resident #12said he was not feeling well and did not want to go and they went to the facility. She said the Transport Aide taught her how to load residents into the van and basically went by a checklist for transports. She said Maintenance at that time went over the skills and checked her off, but no longer worked at the facility. She said following the incidents they had in-services on safety and protocols with using the safety harnesses. She said she did not use the safety harnesses during the transport of Resident #12. She said she was trained on using the safety harness-lap belt but said Resident #12 did not want to wear it. She said she would drive slowly to ensure he did not fall. She said he did not want to wear the seat belt. She said before scheduled transports, she only checked the mileage and did not do any type of inspection of the van and was not sure if she had to do any type of inspection before transports. During an observation and interview on 6/26/2024 at 8:58 AM, CNA C was observed showing the facility van to the State Surveyor in the back parking lot. She said the facility van was out of service and needed repairs on the wheelchair ramp lift. She said there was one strap for the ramp that was placed at the back of the wheelchair, no lap belt, said it never had a lap belt. Inside the van, she demonstrated how the floor harness connected to the seat belt across their lap. She said Resident #12 did not want the lap belt across him during transport. Record review of a disciplinary memorandum for CNA C dated 3/4/2024 by the Administrator indicated a formal written disciplinary action that indicated anytime driving a resident, must be secured, if they refuse to be secured by the seatbelt, the resident will not be transported. Record review of a checklist for community driver van-bus for CNA C dated 12/27/2023 indicated she demonstrated competency on safe transfers and application of seat belt. During an interview on 6/26/2024 at 9:20 AM, the Transport Aide said she had been employed at the facility for a year and was full time as the transport driver. She said there was an incident that occurred in April 2024 while she transported Resident #12 to a doctor's appointment out of town on the way back. She said they used the facility van for transport that day. She said they were leaving a doctor appointment and headed back. She said she was at a stop light, and it turned green and went to turn and Resident #12 was heard saying whoa whoa whoa, put on the hazard lights, and noticed that his wheelchair was leaning backwards. She said he was still strapped by the wheels, and she had RA with her to help check on him and said everything was still locked. She said she parked, and they both checked on him and unstrapped him and re-strapped. She said she called the DON to inform her about what happened and about 5-10 minutes later, the Administrator called and asked how he was leaning backwards if he was strapped. She said they arrived back to the facility, met with the Maintenance Supervisor, and went to check the straps in the van and started realizing that some of the straps were worn. She said the straps when in the locked position, if pulled hard enough would release. She said they found a total of four that were worn, and they were ordered the same day. She said Resident #12 never fell out of his wheelchair. She said she received training by the previous Maintenance Supervisor initially but had not had one since then. She said the straps she chose to check that day were ok, but she did not check all the straps that morning before they left and only checked the ones she was using. She said following the incident, she had an in-service on the safety of the straps and had one previously with another incident. She said she would check with the Maintenance Supervisor to see if he had a copy of the manufacturer's guidelines for the straps. Record review of an orientation checklist for community driver van-bus for the Transport Aide dated 12/23/2021 indicated she was able to work all securement properly. Request for the manufacturer's guidelines for the straps in the van by the Transport Aide and none was provided. During an observation and interview on 6/26/2024 at 10:00 AM, the Transport Aide said the facility was not using a rental wheelchair accessible van for transports as of Friday 6/21/2024 because of issues with the lift. She provided a return demonstration with a staff member in a wheelchair on how to properly load into the van: she demonstrated the proper way to load, secure and unload safely. She said the rental company did not show the staff how to properly secure a resident into the rental van. She said if a new van driver were hired, the Maintenance Supervisor would do a check off with them. During an observation and interview on 6/26/2024 at 10:10 AM, the Maintenance Supervisor was outside in the back parking lot where the facility van was located. He said he had been employed at the facility for 3 months. He said he was not sure who would train new drivers at the facility, and he had never been trained at the facility since being employed for van safety. He said he was not sure who would do it. He said he conducted a monthly check of the van of the tires and oil, but the mechanics inside of the vehicle he did not check. He said if there was a problem with the lift, they would send it out for repairs. He demonstrated how to load a wheelchair in the van, backed it onto the ramp and positioned the wheelchair in the van with the front of the wheelchair facing the side door entrance. He secured the wheelchair by the back wheels and the front wheels. He had difficulty securing the seat belt around the wheelchair where a resident would be positioned. During an interview on 6/26/2024 at 10:20 AM, the Regional Director of Operations said most likely the Maintenance Supervisor would be the person responsible for training a new person hired for transport for the facility. Attempted a phone interview on 6/26/2024 at 11:00 AM with Resident #12, voicemail box was full and was unable to leave a message. During a phone interview on 6/26/2024 at 11:07 AM, the Wheelchair Rental Van representative said when the rental van was dropped on 6/21/2204, no training was provided to the facility staff on how to properly secure a wheelchair in the van or how to use the ramp. He said the facility was responsible for ensuring their staff were trained. He said he would assume that the facility would train their staff and all of their vans had q-straints (wheelchair securement system) and shoulder seat belts inside of the vehicles for safety. During an interview on 7/1/2024 at 1:31 PM, the Administrator said she had been employed at the facility for 6 1/2 years. She said the transport drivers were responsible for ensuring the residents were secure and wore safety belts. She said the Maintenance Supervisor had a list for the drivers to check the overall function of the van. She said she was unaware that the drivers were not using the checklist. She said the facility van was out of service because the lift mechanism was not working properly and had been out of service for about 4 weeks. She said they had used the facility next door van and last week rented a van and used an outside transport company for the residents. She said currently the facility was not transporting anyone because the rental had some issues, and they were having to change to a different one because there were some straps that did not work. She said Maintenance should be doing a check of the van monthly or weekly. She said the Maintenance Supervisor received an in-service. She said if a resident refused to wear a seat belt, then the driver should refuse to take them and report it to her. She said there was a risk for resident safety if residents were not properly secured in the van. Record review of a facility policy titled Transportation Policy and Procedure for Facility Based Vehicle (Van) revised 3/13 indicated, .In order for our residents to maintain the highest practical, physical, mental and psychosocial well being it is the policy of this facility to utilize the Facility vehicle (van) for residents who because of medical or special needs, require transportation. Driver Responsibilities: d. Maintain the cleanliness of the vehicle and assure that the vehicle is in good repair and in full compliance with all recommended maintenance as per vehicle operating manual. e. Maintain a current log notebook to include: 1. Vehicle maintenance log, which will include but not limited to, a recommended routine maintenance as per the vehicle's operating manual. 3. Vehicle utilization log, which will include for each use if the vehicle; the date, the driver's name, the mileage at the beginning and end of use, purpose and destination of use, and the initials of the facility Administrator authorizing the use. F. Complete daily facility-based vehicle maintenance log and follow instructions accordingly. G. Keep a copy of this transportation policy and Procedure in the vehicle at all times. H. Must call 911 immediately should a resident become unresponsive or sustain a fall. Record review of facility in-service for March and April 2024 did not indicate a training was provided to any staff in the facility on safety during transport. Record review of the weekly vehicle maintenance logs for the facility van indicated no weekly log since 2022. This was determined to be an Immediate Jeopardy (IJ) on 6/26/2024 at 2:40 PM. The facility's Regional Director of Operations, Regional Nurse Consultant JJ, Regional Nurse Consultant HH and DON were notified. The Regional Director of Operations was provided the IJ template on 6/26/2024 at 3:12 PM. The following Plan of Removal (POR) submitted by the facility was accepted on 6/27/2024 at 10:46 AM. Plan of Removal - F 689 Free of Accidents and Hazards/supervision/devices Tag Cited: F-689 Issue Cited: Free of Accidents/Hazards/Supervision Failure to in-Service staff on safety precautions during transport and the use of seat belts. 1. Immediate Action Taken A. Resident # 12 is currently out of the facility on 6/20/2024 B. The facility's van immediately stopped all van transport on 6/26/2024 at 8:00am C. The Regional Director of Operations or designee completed the following with the three facilities designated van drivers: o In-service education on the Transportation Policy which provides direction on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, how to transport more than 1 wheelchair o In-service education on weekly maintenance log that van drivers complete and provides to administrator/designee o Completed a skills validation check list on van drivers to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system. Completed a return demonstration. o All van drivers sign job description duties o Facility will decline transport to any resident who refuses to comply with Texas laws to wear a seat belt. The expectation is that all residents riding in facility van will wear a seat belt and have proper wheelchair securement if applicable. Facility will assist with alternate methods of transportation (ambulance, community ride and share vans, family members etc.) This was completed on 6/27/2024. 2. Identification of Residents Affected or Likely to be Affected: A. No other residents identified, all scheduled van transports for the remainder of the week will be transported by an outside vendor. This will allow the facility time for training all van drivers, complete skills competencies and return demonstration, with all van drivers. 3.Actions to Prevent Occurrence/Recurrence: A. As of 6/26/2024, any staff member hired for van transports will be provided the following by the facility maintenance supervisor o In-service education on the Transportation Policy which provides direction on duties of driver, driving of the van, how to operate the wheelchair lift and the wheelchair securement system, how to transport more than 1 wheelchair prior to driving the van o In-service education on weekly maintenance log that van driver completes and provides to administrator/designee o Completed a skills validation check list on van driver to acknowledge skills competence on how to operate the wheelchair lift and the wheelchair securement system. Completed a return demonstration. o Have van driver sign job description duties o Understand that in the event a resident refuse to wear a seatbelt or have wheelchair securement if applicable, that the administrator or designee will be notified immediately to schedule alternate transportation o Understand, that in the event of an emergency, pull over immediately as soon as it is safe to do so and call 911which is stated in the facility's Van Transportation policy B. The weekly maintenance log will be reviewed in the morning meeting by the Administrator or designee On 6/26/2024 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance Surveyors monitored the Plan of Removal as follows: Record review of the Admission Record for Resident #12 indicated he discharged from the facility on 6/20/2024. Record review of a Weekly Vehicle Maintenance Log dated 6/26/2024 by the Maintenance Supervisor and Regional Director of Operation for the rental van indicated the van was out of service for two straps not working, to be returned. Record review of an in-service on the Transportation Policy dated 6/26/2024 indicated training was provided to the Transport Aide, CNA C, and the Maintenance Supervisor. Record review of an in-service on the weekly vehicle maintenance log dated 6/26/2024 indicated training was provided to the Transport Aide, CNA C, and the Maintenance Supervisor. Record review of an orientation checklist for community driver dated 6/26/2024 indicated the Transport Aide, CNA C and the Maintenance Supervisor had a skills validation check off with return demonstration. Record review of a signed van drivers job description duties dated 6/26/2024 indicated training was provided to CNA C, the Transport Aide, and the Maintenance Supervisor. Record review of an in-service on declining transport for any resident who refuses to comply with Texas laws to wear a seat belt dated 6/26/2024 indicated training was provided to CNA C, the Transport Aide, and the Maintenance Supervisor. Record review of an appointment reminder for Resident #16 indicated he had an appointment scheduled for 6/27/2024 and the facility would contact EMS for transport. Record review of an appointment reminder dated 6/28/2024 and 6/29/2024 indicated no transports were scheduled. Record review of an appointment reminder for Resident #12 indicated he had an appointment scheduled for 7/1/2024 but was in the hospital. Record review of an appointment reminder for Resident #17 indicated she had an appointment scheduled for 7/1/2024 and the transport was scheduled with a contract transport company. Record review of an appointment reminder for Resident #18 indicated she had an appointment scheduled for 7/2/2024 and the transport was scheduled with a contract transport company. Record review of an in-service on in the event of an emergency dated 6/27/2024 indicated training was provided to CNA C, the Transport Aide, and the Maintenance Supervisor. Record review of an AdHoc QAPI dated 6/26/2024 indicated the Regional Nurse Consultant JJ, Regional Director of Operations, Regional Nurse Consultant HH, DON and the Medical Director were in attendance. Interviews on 6/27/2024 from 1:09 PM to 1:19 PM included: CNA C Transport Aide Maintenance Supervisor During an interview on 6/27/2024 at 1:09 PM, CNA C said she received in-service training on their job descriptions as a van driver, safety precautions, how to properly put on seatbelts, check straps, driving and maintenance logs, and loading onto ramp and lift. She said she had skills check off on 6/26/2024. She said if a resident refused to wear a seatbelt, then they were not able to transport as it was against the law to not wear one and let the resident know they would not be able to transport them. She said in the event of an emergency, dial 911. During an interview on 6/27/2024 at 1:13 PM, the Transport Aide said she had in-service training and went over job duties, how to load, unload, basic necessities in the van, and emergency precautions during transport. She said she had skills check off on 6/26/2024. She said if a resident refuses to wear a seatbelt, let them know they cannot transport, and in the event of an emergency pull over and call 911, then call to the facility. She said they were currently not using the van as of 6/26/2024 and they have arranged alternate transport for residents scheduled. She said they discussed their job descriptions and to have necessities on the van for the resident. During an interview on 6/27/2024 at 1:19 PM, the Maintenance Supervisor said he had in-service training and discussed how to secure a resident in the van, where to put seat belts, and how to secure wheelchairs. He said if a resident refused to wear a seatbelt, then they do not go anywhere. He said to check maintenance logs weekly and when they were transporting take them snacks, blankets and etc. He said in the event of an emergency pull over and call 911. He said he had a skills check off on 6/26/2024. He said the van was currently out of service because they found two straps that were defective as of 6/26/2024. All above staff were able to appropriately answer questions. The Regional Nurse Consultant JJ was informed the Immediate Jeopardy was removed on 6/27/2024 at 1:35 PM; however, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review, the facility failed to notify and consult with the resident's physician when there was a need to alter treatment for 1 of 8 residents (Resident #1) reviewed for notification of changes. The facility failed to ensure the physician was notified of a change in condition when Resident #1 did not have a bowel movement for 14 days. Resident #1 had contained fecal perforation in her rectum and expired at the hospital on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving appropriate medical treatments, deterioration of health, hospitalization , and death. Findings included: Review of face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis and weakness to one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, adjustment disorder with mixed disturbance of emotions and conduct, feeding difficulties, cognitive communication deficit, contracture to right and left hand and wrists, and visual loss. Review of quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment and a score of 03 for bowels, indicating always incontinent. Review of care plan revised [DATE], revealed Resident #1's had interventions in place for not eating food to include providing supplements, monitor bowel movements, notify physician as needed for constipation, administer stool softeners/laxatives as ordered PRN and document effectiveness, and report to nurse any changes in loss of appetite and constipation. Review of MARS between [DATE] through [DATE] for Resident #1 indicated routine pain medication of Tylenol 650 mg three times a day, Biscadoyl 5 mg every other day for constipation, and hydrochlorothiazide 12.5 mg once a day as diuretic were administered as ordered and a PRN order for MiraLax every 24-hours as needed for constipation was not administered for the month of [DATE]. Review of hospital records, dated [DATE], reflected Resident #1 was sent to the hospital with labored breathing and change in mental status. Hospital records reflected she had diagnoses of respiratory failure, altered mental status, hypotension, sepsis, hyperkalemia, and hyponatremia. Review of x-ray dated [DATE] reflected Resident #1 had a CT of abdomen and pelvis and included findings of a large stool likely to reflect stercoral colitis (chronic constipation leading to stagnation of fecal matter, increase in volume, impaction, and eventual deformation of the colon). Review of facility investigation synopsis, dated [DATE], revealed the following: Tuesday, [DATE] 08:00 am: Facility [CNA] reported to facility nurse that [Resident #1] was acting different, resident was not drinking out of a straw like she normally does. Resident was unable to verbalize what was wrong when asked by facility nurse. MD was notified of above orders and orders were received for stat UA, CBC, and CMP. Lab notified of new order, awaiting results. 12:10 pm: Resident noted with a decline in condition; Resident was noted by facility nurse as having labored breathing and facility nurse was unable to obtain )2 sat; 911 notified and MD [MD] was notified of transfer via EMS to ER for evaluation and treatment. RP notified of transfer to the ER for evaluation and treatment. Wednesday, [DATE] 3:00 pm: [RP C] arrived at the facility requesting to visit with the facility administrator, he presented the administrator with a written letter from the resident's [RP D] requesting the following information under the open records act: o A copy of resident's medical record chart for the last 30 days reflecting when resident had a bowel movement o Policy and procedures on what the proper channels are for when a patient doesn't have a bowel movement in three days. o When was the last time resident has been examined by a licensed physician? o What time and what's the staff member or nurse that found resident in medical distress and what happened at that point? An investigation was initiated by facility administrator and director of nursing. An in service was conducted with facility staff on bowel monitoring clinical practice guidelines with post test. facility staff completed bowl assessment on all residents identified with no bowel movements x 3 days; residents identified as no bowel movement x 3 days were placed in monitoring for signs/symptoms of Constipation and MD notified of any abnormal symptoms. Upon completion of bowel assessments on all facility residents, there were no residents identified with no bowel movements x 3 days. A QAPI meeting was held with this facility's medical director by phone conversation to discuss above mentioned incident and facility follow up to sustain compliance. Review of in-service, dated [DATE], revealed education was provided to nursing staff on bowel movement monitoring and to report when a resident has no bowel movement for three days. Review of in-service, dated [DATE], revealed education was provided to nursing staff on notification of changes and when and how to report a resident that had a change in condition. Review of in-service, dated [DATE], revealed education was provided to supervisory staff on obtaining bowel monitoring reports. Review of task sheet for bowel incontinence for Resident #1, dated [DATE], revealed no bowel movement was recorded for 14 days between [DATE] and [DATE]. During an interview on [DATE] at 10:15 AM, the Administrator, DON, and MDS Nurse said the DON said Resident #1 was sent out to the hospital because she was starting to have a change in condition with her mental and breathing status. The Administrator said Resident #1's hospital diagnosis was sepsis. The Administrator, DON, and MDS Nurse said there were concerns reviewed for fecal impaction and the hospital ER records revealed Resident #1's abdomen was soft, non-distended with no swelling but that there were concerns reviewed for fecal impaction and in-services were provided to nursing staff on notification of residents not going to the bathroom over 3 days on [DATE] and [DATE]. During an interview on [DATE] at 12:20 PM, CNA A said that she had been employed at the facility for two years and that CNA's are responsible for monitoring and documenting bowel movements. CNA A said she had received training on bowel monitoring during in-services yesterday and that she would notify her nurse if a resident had not had a bowel movement after 3 days. She said she normally did not work with Resident #1. During an interview on [DATE] at 12:42 PM, CNA B said she had been employed at the facility for two years. CNA B said she last took care of Resident #1 on Friday, [DATE] and that she had no bowel movement on her shift while she was taking care of her. CNA B said she had received training of bowel monitoring and that she would report to the nurse if a resident had not had a bowel movement for 3 days. During an interview on [DATE] at 1:01 PM, CNA E said she had been employed at the facility for [AGE] years and provided care for Resident #1 on a routine basis. CNA E said CNA's were responsible for recording resident bowel movements and would report to the nurse if someone did not go to the bathroom for three to four days. CNA E said the only resident with a concern for bowel monitoring on her hall was Resident #1 and that she had two bowel movements the day she was sent out to the hospital but no bowel movements for several days prior. CNA E said she did not report to the nurse that she had missed a bowel movement for over 3 days because she was not made aware during report that it was a concern during shift change. CNA E said on the day Resident #1 got sent out to the hospital after she gave her a bed bath in the morning, she was very weak and she had two small putty (clay like) stools, but the day before she was okay and did a 180 degree turnaround. CNA E said she notified the ADON of her change in condition and that Res #1's stomach was swelling on the Friday or Sunday before she was sent out and thought she had to have a bowel movement because her stomach was cramping. CNA E said that was the first time she reported cramping, has never had constipation, and goes to the bathroom. CNA E said the nurse tried to give her a laxative then around the weekend before she was sent to the hospital, but Resident #1 refused, and they also offered to send her to the hospital then and she refused. CNA E said sometimes Resident #1 would go a couple of days without a bowel movement at her baseline. CNA E said Resident #1 would only drink liquids ever since she last got Coronavirus Disease of 2019 (severe acute respiratory syndrome aka SARS-COV-2) and had not been eating food for months. CNA E said Res #1 would drink a health shake, soda, and water at every meal. CNA E said she felt bad Resident #1 declined rapidly that day and hoped she improved to come back to the facility. She said that ultimately CNA's were responsible for documenting and reporting bowel movements. She said it was important for staff to report a resident not having a bowel movement over 3 days because it could cause bowel blockage and possible hospitalization . She said she had received training by in-services yesterday and when to report changes in resident condition. During an interview on [DATE] at 1:23 PM, LVN G said she had been employed 2 years at the facility. LVN G said she did not normally provide care for Resident #1 but that she was the one that sent her out to the hospital. LVN G said on [DATE] at 8:00 AM she was notified by the CNA that Resident #1 could not drink anything through her straw, MD was notified and stat labs were ordered. LVN G said she continued to monitor Resident #1 and at noon she significantly declined and was struggling to breath before the stat labs were completed and LVN G sent her to the emergency room . LVN G said Resident #1 was not having any kind of pain or swelling in her abdomen during that time and was having a decline in her mental status. LVN G said the nurses are responsible for monitoring bowel movements that the CNA's document. LVN G said CNA's notify her if there are any concerns regarding residents not going to the bathroom for several days. LVN G said she had received training on bowel monitoring and that CNA's report to the nurse if it has been more that 3 days or if a resident complained of abdominal pain. LVN G said she did not review anything about Resident #1's bowel movements in her shift change reports. LVN G said she felt CNA's were documenting appropriately. LVN G said she had no concerns related to fecal impaction for Resident #1 the day she sent her to the hospital and that it was not her main concern when she assessed Resident #1. She said it was important for CNA's to notify her of any residents not using the bathroom after three days because it could prevent fecal impaction, sepsis, deterioration of health, hospitalization , or even death. During an interview on [DATE] at 2:24 PM, RN H said she had been employed since [DATE]. RN H said Res #1 was normally hers and last saw her on Sunday, [DATE] at baseline. RN H said she was not having any problems with constipation that was reported to her and nobody informed her Res #1 did not have a bowel movement for several days. RN H said CNA E did not tell her Resident #1 did not have a bowel movement the last two days she worked, Sunday and Monday. RN H said anytime the CNA's notify her of concerns with bowel movements her protocol would be to then pull up the task to see the last time it was documented and go to orders to see if the resident has a stool softener to administer, and if not she would call the doctor. RN H said if someone had told her Resident #1 was not having a bowel movement in those two days, Sunday and Monday ([DATE] and [DATE]), I would have done something about it. RN H said it would be important for CNA's to report the resident had not had a bowel movement because it could cause constipation, could rupture the intestine, and could cause fecal impaction. RN H said CNA E gave her fluids as normal and Res #1 had no complaints of anything, no facial grimacing or anything noted. RN H said she was not here the day Resident #1 was sent out to the hospital. RN H said since this was her first day returning to work, she was running a report of bowel movement records for all residents together. RN H said she was not aware of any additional resident's had constipation concerns and felt it was an isolated incident. RN H said Res #1's children would have called her if they knew she was constipated because they were very observant and involved and had placed a camera in her room. RN H said the facility has provided training on bowel movement monitoring and notification through in-services prior to returning to work since the incident. During a phone interview on [DATE] at 3:00 PM, the MD said LVN G texted him that Resident #1 was not looking good, and he sent her to the ER. MD said at that time he was not notified of any concerns with her bowel movements. The MD said he was not aware of any constipation or fecal impaction concerns with Resident #1 and that he was available by phone if there were any concerns, he needed to know about so that he could ensure residents were receiving proper care. During a phone interview on [DATE] at 3:16 PM, the MD said staff are usually good at letting him know if there was someone that did not have a bowel movement with ,d+[DATE] hours. The MD said if a resident had not a bowel movement for 14 days, he would order some lab work and abdominal x rays, review medication and order an enema. The MD said Resident #1 was on Biscadoyl already and had Miralax PRN, but she refused to take the Miralax. The MD said the NP saw her on [DATE] and she was not having a bowel movement and when you would talk to Resident #1, she would say everything was fine. The MD said he did not have any concerns with the facility believed Resident #1 was 4 days out from not having a bowel movement, but he was not in front of his computer and would talk to the Administrator about it. The MD said the facility usually notifies him and expects them to notify him within ,d+[DATE] hours of any concerns. The MD said some residents can go 3 to 4 days without a bowel movement at their baseline, but it depended on the resident and expected to be notified after 3 to 4 days. The MD said he was not sure why it was not reported to him for several days and was not aware she went 14 days without a bowel movement but that he was not in front of his computer. The MD said he met with the facility regarding Resident #1 and felt it was an isolated incident. He said today was the first time he had heard she did not have a bowel movement for 14 days and that if he would have known he would have ordered her an x-ray and reviewed medication. During an interview on [DATE] at 1:31 PM, the MD said he did not have a continued concern about the facility not notifying him of residents with no bowel movements. The MD said that it was a concern he was not notified about Resident #1 not having one for several days, but believed it was an isolated incident and protocols were put in place during the QAPI meeting to ensure it did not happen again. The MD said he had already discussed with the facility and put things in place after the meeting. The MD said there were no concerns moving forward and had discussed protocols to include staff training and contacts updated. The MD said the facility had since updated him of constipation concerns since the protocols were put in place. During a phone interview on [DATE] at 8:48 AM, RP D said Resident #1 had a severe case of sepsis and large ball of bowel that appeared to have punctured her colon and thought they might have to cut her colon out. RP D said Resident #1 was on life support and there was nothing they could do for her at the hospital. RP D said he had asked weeks ago when Resident #1 lost her appetite and was notified she was not eating. RP D said he had a camera in her room and his cousin visited Resident #1 and spoke to her this last Sunday before she expired. RP D said on Sunday, [DATE], she was not talking as much because about 2 weeks ago she said her side was hurting when the ADON was in the room. RP D said the facility then gave Resident #1 Tylenol and he spoke with the nurse, got notes from the nurse the night before and she did not have any complaints. RP D said staff informed the family they heard Resident #1 complain about her stomach, but they did not wish to be named. RP D said at the hospital Resident #1's stomach was hard and was told she would die instantly if they had the surgery. RP D said Resident #1 was paralyzed and legally blind and there was nothing wrong with her mind and did not have any medicine except for blood pressure medicine. RP D said Resident #1 expired from severe sepsis shock. During an interview on [DATE] at 10:46 AM, the ADM and DON said Resident #1 expired on Saturday, [DATE], at the hospital and that they have requested and refused hospital records. At 11:00 AM, the DON said she did not receive a report that Resident #1 having side pain or constipation but that the NP had ordered MiraLax PRN if she needed it. The DON said she provided in-services on bowel monitoring because of concerns brought to their attention from Resident #1's RP and started monitoring bowels to make sure that staff were documenting and reporting if they had not gone to the bathroom every 3 to 4 days. The DON said staff did not report Resident #1 not going to the bathroom and believed it may have been missed due to other nurse aides on the hall not communicating between shifts. The DON said Resident #1 had a bowel movement that morning before she was transported to the hospital. The DON said nurse aides report to their charge nurse and document if they have had a bowel movement so it will alert the nurse on electronic health record system to check the resident. The DON said now in their morning meetings, if there is an alert on the electronic health record staff review it in the morning meetings. The DON said that there were currently no additional residents since Resident #1 that had not had a BM in over three days. The DON said interventions were put in place to ensure it does not happen again to include pulling a full bowel movement report and completing in-services with our nursing staff to pull bowel movement report very shift. The DON said the charge nurses are pulling the bowel movement report and aides would be responsible for monitoring bowel movements. The DON said nurse aides could not see the history of bowel movements. The DON said she looked at Resident #1's bowel movement report with their computer and have had problems with internet outages and have contacted the help desk due to the weather. The DON said it was important to notify the charge nurses of a resident having no bowel movement within ,d+[DATE] days and know the resident's bowel schedule because of the different complications that can occur such as what happened to Resident #1. The DON said with the nurse aides, they know their residents well and if they do not have something ordered for constipation, staff are expected to notify the physician to ensure efforts are made to ensure the residents avoids complications or deterioration in health. During an interview on [DATE] at 11:08 AM, the HA said she had been employed at the facility for almost a year. The HA said the aides monitor bowel movements and that they have not provided training on bowel monitoring but that she has not returned to the facility since Resident #1 was sent out. The HA said Resident #1 was on the hall she last worked and the last time she saw her would be the prior Sunday before last, [DATE]. The HA said Resident #1 was talking to her like she always did and was not complaining. The HA said Resident #1 did not have a bowel movement with her for two weeks. The HA said she changed her at 8:00 PM, 12:00 AM, and 4:00 AM and would always ask for things. The HA said Resident #1 was never having any pain in her abdomen. The HA said she did not know that she should have notified someone about Resident #1 not having a bowel movement and said she was just being trained. The HA said nobody notified her that Resident #1 was not having a bowel movement. The HA said the computer system should have prompted a red flag and that made her think she was at least having a bowel movement during the day but come to find out it had been 2 weeks. The HA said she was not sure if Resident #1 was aware that she was not having a bowel movement. The HA said she acknowledged Resident #1 going over 4 days without a bowel movement should have been reported to avoid her being sent out to the hospital and that if they would have kept up with her bowel movement monitoring Resident #1 may still be alive today. The HA said she had not seen her eat food and that she would drink a shake and did not eat much since she has been there. During an interview on [DATE] at 12:21 PM, the Administrator said she received letter from an attorney the day Resident #1 expired on [DATE] with request to maintain all records possibly from RP D. The Administrator said it had been months since they talked to RP D. The Administrator said RP J asked the facility to comb her hair recently but that was her main concern and she informed her that she would get one of her staff down there to fix her hair. The Administrator said family for Resident #1 had a camera in her room to communicate with her and had a family friend visit that reported no concerns. The Administrator said she expected staff to report after three days of no bowel movement. The Administrator said for Resident #1 they had reviewed for weeks in morning meeting that her only intake was ensure and water and there was a concern with her not eating but not for her bowel movements. The administrator said the aides were responsible for monitoring bowel movements and reporting concerns and are making sure staff pulls the report every morning in meeting. The Administrator said Resident #1 had the ability to express what was going on with her and believed losing the internet due to weather was part of the problem for documenting and reporting. The Administrator said the facility lost power the weekend before she was sent to the hospital and on [DATE]st, 2024, that weekend it was down all weekend and was not notified until coming to work on Monday. During an interview on [DATE] at 1:00 PM, the ADON said she had been employed at the facility for 8 years. The ADON said she last saw Resident #1 on [DATE] and she was doing good. The ADON said she did not know when it was, but around last month Resident #1 was complaining about her side and the ADON listened to her bowel sounds at abdomen for movement. The ADON said Resident #1's family was on the camera and reported she was hurting so they offered her Tylenol and she refused. The ADON said her family wanted her to go out to the hospital and she refused to go and after the pain medication she did not complain anymore and had no tenderness to the area. The ADON said on that day, Resident #1 kept saying both sides were hurting and had a routine stool softener she would take but would not take the MiraLax. The ADON said she talked to CNA E the next day and reported she had a small bowel movement. The ADON said Resident #1 had not been eating for a while and ever since she had COVID-19 upon recovery she stopped eating food and would only eat a couple bites of food sometimes brought in from family. The ADON said the nurse aides were responsible for reporting if a resident had not had a bowel movement for over 3 days and said she thinks Resident #1's bowel movements were not reported due to a lack of communication and that they should have relayed that information during their shift report. The ADON said staff is expected to notify the nurse if a resident was not having a bowel movement in report and that it does prompt up on the electronic dashboard in their system if they had not had one for several days but with the weather causing internet failure staff may have not documented yet or seen the prompt. The ADON said paper charting was completed during internet outage. The ADON said the facility has provided training on bowel movement monitoring by conducting in-services with all staff. The ADON said they had reviewed this morning about pulling up reports on the computer to see if someone did not have a bowel movement for the last 3 days. The ADON said prior to Resident #1 being sent to the hospital they used to run the bowel movement sheet and go talk to that person or aide to see if they may have had one or was documentation accurate so they would go visit each person. The ADON said she has reviewed bowel movement reports and did not have any similar constipation concerns with any other residents. The ADON said CNA E was usually pretty good about reporting bowel movements and she may get busy but usually is good about reporting. The ADON said signs and symptoms of possible fecal impaction included nausea, abdomen hard or tender, and decreased appetite. The ADON said she had no changes other than Resident #1's side pain a couple of weeks ago and that was the last time she heard her complain and her family tried to send her out to the ER, and she refused to go. During a phone interview on [DATE] at 3:00 PM, the NP said she has been off for the last three weeks and visits the facility twice a month. The NP said if she had seen Resident #1 it would only be during one of those on-site visits and she could not recall when she last saw her. The NP said the nurses will tell her which residents have concerns when she is there. The NP said staff normally report residents not having any bowel movements and said she would assume they would report a resident not having one for over 3 days. The NP said if she was aware Resident #1 had not had a bowel movement for several days she would have assessed her medicines, prescribed stool softeners, and review medicine like MiraLax and most of the time there are already PRN orders in place to administer, and request to do an x-ray scan if medicine was not effective. The NP said she had no concerns with care and services provided by the facility and was not aware that Resident #1 had not had a bowel movement for that long. The NP said it would be important to report if a resident had not had a bowel movement for over 3 days because it could indicate a possible bowel blockage. The NP said staff they report concerns appropriately when she is at the facility. During an interview on [DATE] at 3:11 PM, the hospital ICU Nurse said Resident #1 was admitted on [DATE] at 5:37 PM with a diagnosis of septic shock, respiratory failure, septic shock that was first unclear on etiology and including UTI, pneumonia, and then abdominal because she showed colitis on her imaging. The hospital ICU Nurse said on [DATE] a CAT scan revealed she had a fecal contained severe constipation and contained perforation along the rectum. The hospital ICU Nurse said x-rays were showing severe colonic distension and constipation and the outside hospital (hospital she was transferred from) showed stercoral colitis. Review of facility policy, titled Clinical Practice Guideline: Bowel Monitoring, review date [DATE], revealed the following: Anticipated Outcome The aim of this guideline is [to] provide guidance to avoid constipation or fecal incontinence in order to achieve evacuation of the bowel. Fundamental information A stooling frequency of less than 3 times a week may still be considered normal if not associated with abdominal discomfort in the absence of bowel sounds. A daily bowel movement is not necessary, but a resident that has not had a bowel movement for ,d+[DATE] days should be monitored closely for signs and symptoms of Constipation. Stool softeners, suppositories and enemas may be used to assist the resident with rectal evacuation. Process o Bowel movements are monitored by nursing staff observation that a patient has had a bowel movement or a report from the patient that a bowel movement has occurred. o If the patient has not had a bowel movement for ,d+[DATE] days monitor for signs and symptoms of constipation; abdominal distension, pain, nausea/vomiting, loss of appetite, decrease bowel sounds o Notify the Physician of the abnormal symptoms o Provide the patient with fluids and juices as indicated. o Administer stool softener, suppositories, enemas and fibers as ordered. o Continue to monitor the patient during 4 to 7 days for bowel movement, adverse signs and symptoms. o Notify the physician if there is increased tenderness, rigidity, distinction, absence or decrease vowel sound for abnormal bowel movement e.g. blood or mucus in stool. o Monitor [EHR] reports Documentation Progress Notes, Medication Administration Record During an interview on [DATE] at 5:23 PM, the Administrator requested an IJ PNC and provided additional information to include a QAPI meeting and in-service documentation. Review of Performance Improvement Project Report, titled Bowel Movement Monitoring, start date of [DATE] revealed the following: .Goal: Establish a procedure for to avoid constipation or fecal impaction in order to achieve evacuation of the bowel that optimizes therapeutic benefits and minimizes associated risks . 4.) DON/Designee to pull no BM x 3 days report; resident is to be monitored for signs/symptoms of constipation and notify MD of any abnormal symptoms. 5.) Results of no BM x 3 days report will be discussed with admin/DON during morning clinical start up meeting. 6.) review findings monthly at QAPI meeting for three months to ensure compliance. Review of Clinical and Order Alerts Listing Report, dated [DATE] through [DATE], revealed bowel movement report was gerenated. Review of Daily Census Report, dated [DATE] and signed by the DON, revealed a bowel assessment validation was completed on all facility residents and no residents were identified [with] no bowel movements for 3 days. During a phone interview on [DATE] at 9:24 AM, CNA K said she had been employed for one to two years at the facility and had received in-service training on bowel monitoring and notification of changes yesterday, [DATE], and the week prior. CNA K said that if a resident does not have a bowel movement for 3 to 4 days, she would notify her nurse. CNA K said she had no residents she had that were going that long without a bowel movement. During a phone interview on [DATE] at 9:31 AM, CNA L said she had been employed as an aide at the facility for over a year. CNA L said the timeframe she would report bowel concerns was 3 days of a resident not going to the bathroom. CNA L said there were in-services over bowel monitoring and notifying staff of changes last week. She said all of her residents were going to the bathroom within the timeframe Resident #1 was documented as not going to the bathroom and that she works with the same residents every time she works. An IJ PNC was determined on [DATE] at 11:06 AM. The administrator was provided with updated template on [DATE] at 11:06 AM. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy by: o Completion of Investigation Synopsis Timeline of Events o Like Resident: bowel assessment validation completed on [DATE], on all facility residents; no residents identified with no bowel movements over 3 days; o Inservice completed on [DATE], on clinical practice guidelines: bowel movement monitoring and reporting no bowel movement for 3 days with post-test; o Inservice completed on [DATE], on notification of changes with post-test; o Inservice completed on J [TRUNCATED]

Based on interviews and record reviews the facility failed to provide residents treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 8 residents reviewed for quality of care. (Resident #1) The facility failed to monitor Resident #1's significant change of no bowel movements for 14 days between [DATE] through [DATE]. Resident #1 was sent to the emergency roiagnom on [DATE] and x-ray showed she had a contained fecal perforation in her rectum and expired at the hospital on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for deterioration of health, hospitalization , or death. Findings included: Review of face sheet dated [DATE] indicated Resident #1 was [AGE] years old, admitted on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis and weakness to one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, adjustment disorder with mixed disturbance of emotions and conduct, feeding difficulties, cognitive communication deficit, contracture to right and left hand and wrists, and visual loss. Review of quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS score of 15, indicating no cognitive impairment and a score of 03 for bowels, indicating always incontinent. Review of care plan revised [DATE], revealed Resident #1's had interventions in place for not eating food to include providing supplements, monitor bowel movements, notify physician as needed for constipation, administer stool softeners/laxatives as ordered PRN and document effectiveness, and report to nurse any changes in loss of appetite and constipation. Review of MARS between [DATE] through [DATE] for Resident #1 indicated routine pain medication of Tylenol 650 mg three times a day, Biscadoyl 5 mg every other day for constipation, and hydrochlorothiazide 12.5 mg once a day as diuretic were administered as ordered and a PRN order for MiraLax every 24-hours as needed for constipation was not administered for the month of [DATE]. Review of hospital records, dated [DATE], reflected Resident #1 was sent to the hospital with labored breathing and change in mental status. Hospital records reflected she had diagnoses of respiratory failure, altered mental status, hypotension, sepsis, hyperkalemia, and hyponatremia. Review of x-ray dated [DATE] reflected Resident #1 had a CT of abdomen and pelvis and included findings of a large stool likely to reflect stercoral colitis (chronic constipation leading to stagnation of fecal matter, increase in volume, impaction, and eventual deformation of the colon). Review of facility investigation synopsis, dated [DATE], revealed the following: Tuesday, [DATE] 08:00 am: Facility [CNA] reported to facility nurse that [Resident #1] was acting different, resident was not drinking out of a straw like she normally does. Resident was unable to verbalize what was wrong when asked by facility nurse. MD was notified of above orders and orders were received for stat UA, CBC, and CMP. Lab notified of new order, awaiting results. 12:10 pm: Resident noted with a decline in condition; Resident was noted by facility nurse as having labored breathing and facility nurse was unable to obtain )2 sat; 911 notified and MD [MD] was notified of transfer via EMS to ER for evaluation and treatment. RP notified of transfer to the ER for evaluation and treatment. Wednesday, [DATE] 3:00 pm: [RP C] arrived at the facility requesting to visit with the facility administrator, he presented the administrator with a written letter from the resident's [RP D] requesting the following information under the open records act: o A copy of resident's medical record chart for the last 30 days reflecting when resident had a bowel movement o Policy and procedures on what the proper channels are for when a patient doesn't have a bowel movement in three days. o When was the last time resident has been examined by a licensed physician? o What time and what's the staff member or nurse that found resident in medical distress and what happened at that point? An investigation was initiated by facility administrator and director of nursing. An in service was conducted with facility staff on bowel monitoring clinical practice guidelines with post test. facility staff completed bowl assessment on all residents identified with no bowel movements x 3 days; residents identified as no bowel movement x 3 days were placed in monitoring for signs/symptoms of Constipation and MD notified of any abnormal symptoms. Upon completion of bowel assessments on all facility residents, there were no residents identified with no bowel movements x 3 days. A QAPI meeting was held with this facility's medical director by phone conversation to discuss above mentioned incident and facility follow up to sustain compliance. Review of in-service, dated [DATE], revealed education was provided to nursing staff on bowel movement monitoring and to report when a resident has no bowel movement for three days. Review of in-service, dated [DATE], revealed education was provided to nursing staff on notification of changes and when and how to report a resident that had a change in condition. Review of in-service, dated [DATE], revealed education was provided to supervisory staff on obtaining bowel monitoring reports. Review of task sheet for bowel incontinence for Resident #1, dated [DATE], revealed no bowel movement was recorded for 14 days between [DATE] and [DATE]. During an interview on [DATE] at 10:15 AM, the Administrator, DON, and MDS Nurse said The DON said Resident #1 was sent out to the hospital because she was starting to have a change in condition with her mental and breathing status. The Administrator said Resident #1's hospital diagnosis was sepsis. The Administrator, DON, and MDS Nurse said there were concerns reviewed for fecal impaction and the hospital ER records revealed Resident #1's abdomen was soft, non-distended with no swelling but that there were concerns reviewed for fecal impaction and in-services were provided to nursing staff on notification and monitoring of residents not going to the bathroom over 3 days on [DATE] and [DATE]. During an interview on [DATE] at 12:13 PM, the Ombudsman said her of her main concerns during her visit was no documentation of bowel movements. During an interview on [DATE] at 12:20 PM, CNA A said that she had been employed at the facility for two years and that CNA's are responsible for monitoring and documenting bowel movements. CNA A said she had received training on bowel monitoring during in-services yesterday and that she would notify her nurse if a resident had not had a bowel movement after 3 days. She said she normally did not work with Resident #1. During an interview on [DATE] at 12:42 PM, CNA B said she had been employed at the facility for two years. CNA B said she last took care of Resident #1 on Friday, [DATE] and that she had no bowel movement on her shift while she was taking care of her. CNA B said she had received training of bowel monitoring and that she would report to the nurse if a resident had not had a bowel movement for 3 days. During an interview on [DATE] at 1:01 PM, CNA E said she had been employed at the facility for [AGE] years and provided care for Resident #1 on a routine basis. CNA E said CNA's were responsible for recording resident bowel movements and would report to the nurse if someone did not go to the bathroom for three to four days. CNA E said the only resident with a concern for bowel monitoring on her hall was Resident #1 and that she had two bowel movements the day she was sent out to the hospital but no bowel movements for several days prior. CNA E said she did not report to the nurse that she had missed a bowel movement for over 3 days because she was not made aware during report that it was a concern during shift change. CNA E said on the day Resident #1 got sent out to the hospital after she gave her a bed bath in the morning, she was very weak and she had two small putty (clay like) stools, but the day before she was okay and did a 180 degree turnaround. CNA E said she notified the ADON of her change in condition and that Res #1's stomach was swelling on the Friday or Sunday before she was sent out and thought she had to have a bowel movement because her stomach was cramping. CNA E said that was the first time she reported cramping, has never had constipation, and goes to the bathroom. CNA E said the nurse tried to give her a laxative then around the weekend before she was sent to the hospital, but Resident #1 refused, and they also offered to send her to the hospital then and she refused. CNA E said sometimes Resident #1 would go a couple of days without a bowel movement at her baseline. CNA E said Resident #1 would only drink liquids ever since she last got Coronavirus Disease of 2019 (severe acute respiratory syndrome aka SARS-COV-2) and had not been eating food for months. CNA E said Res #1 would drink a health shake, soda, and water at every meal. CNA E said she felt bad Resident #1 declined rapidly that day and hoped she improved to come back to the facility. She said that ultimately CNA's were responsible for documenting and reporting bowel movements. She said it was important for staff to report a resident not having a bowel movement over 3 days because it could cause bowel blockage and possible hospitalization . She said she had received training on bowel monitoring by in-services yesterday and when to report changes in resident condition. During an interview on [DATE] at 1:23 PM, LVN G said she had been employed 2 years at the facility. LVN G said she did not normally provide care for Resident #1 but that she was the one that sent her out to the hospital. LVN G said on [DATE] at 8:00 AM she was notified by the CNA that Resident #1 could not drink anything through her straw, MD was notified and stat labs were ordered. LVN G said she continued to monitor Resident #1 and at noon she significantly declined and was struggling to breath before the stat labs were completed and LVN G sent her to the emergency room . LVN G said Resident #1 was not having any kind of pain or swelling in her abdomen during that time and was having a decline in her mental status. LVN G said the nurses are responsible for monitoring bowel movements that the CNA's document. LVN G said CNA's notify her if there are any concerns regarding residents not going to the bathroom for several days. LVN G said she had received training on bowel monitoring and that CNA's report to the nurse if it has been more that 3 days or if a resident complained of abdominal pain. LVN G said she did not review anything about Resident #1's bowel movements in her shift change reports. LVN G said she felt CNA's were documenting appropriately. LVN G said she had no concerns related to fecal impaction for Resident #1 the day she sent her to the hospital and that it was not her main concern when she assessed Resident #1. She said it was important for CNA's to notify her of any residents not using the bathroom after three days because it could prevent fecal impaction, sepsis, deterioration of health, hospitalization , or even death. During an interview on [DATE] at 2:24 PM, RN H said she had been employed since [DATE]. RN H said Res #1 was normally hers and last saw her on Sunday, [DATE] at baseline. RN H said she was not having any problems with constipation that was reported to her and nobody informed her Res #1 did not have a bowel movement for several days. RN H said CNA E did not tell her Resident #1 did not have a bowel movement the last two days she worked, Sunday and Monday. RN H said anytime the CNA's notify her of concerns with bowel movements her protocol would be to then pull up the task to see the last time it was documented and go to orders to see if the resident has a stool softener to administer, and if not she would call the doctor. RN H said if someone had told her Resident #1 was not having a bowel movement in those two days, Sunday and Monday ([DATE] and [DATE]), I would have done something about it. RN H said it would be important for CNA's to report the resident had not had a bowel movement because it could cause constipation, could rupture the intestine, and could cause fecal impaction. RN H said CNA E gave her fluids as normal and Res #1 had no complaints of anything, no facial grimacing or anything noted. RN H said she was not here the day Resident #1 was sent out to the hospital. RN H said since this was her first day returning to work, she was running a report of bowel movement records for all residents together. RN H said she was not aware of any additional resident's had constipation concerns and felt it was an isolated incident. RN H said Res #1's children would have called her if they knew she was constipated because they were very observant and involved and had placed a camera in her room. RN H said the facility has provided training on bowel movement documentation and monitoring through in-services prior to returning to work since the incident. During a phone interview on [DATE] at 3:00 PM, the MD said LVN G texted him that Resident #1 was not looking good, and he sent her to the ER. MD said at that time he was not notified of any concerns with her bowel movements. The MD said he was not aware of any constipation or fecal impaction concerns with Resident #1 and that he was available by phone if there were any concerns, he needed to know about so that he could ensure residents were receiving proper care. During a phone interview on [DATE] at 3:16 PM, the MD said staff are usually good at letting him know if there was someone that did not have a bowel movement with ,d+[DATE] hours. The MD said if a resident had not a bowel movement for 14 days, he would order some lab work and abdominal x rays, review medication and order an enema. The MD said Resident #1 was on Biscadoyl already and had Miralax PRN, but she refused to take the Miralax. The MD said the NP saw her on [DATE] and she was not having a bowel movement and when you would talk to Resident #1, she would say everything was fine. The MD said he did not have any concerns with the facility believed Resident #1 was 4 days out from not having a bowel movement, but he was not in front of his computer and would talk to the Administrator about it. The MD said the facility usually notifies him and expects them to notify him within ,d+[DATE] hours of any concerns. The MD said some residents can go 3 to 4 days without a bowel movement at their baseline, but it depended on the resident and expected to be notified after 3 to 4 days. The MD said he was not sure why it was not reported to him for several days and was not aware she went 14 days without a bowel movement but that he was not in front of his computer. The MD said he met with the facility regarding Resident #1 and felt it was an isolated incident. He said today was the first time he had heard she did not have a bowel movement for 14 days and that if he would have known he would have ordered her an x-ray and reviewed medication. During an interview on [DATE] at 1:31 PM, the MD said he did not have a continued concern about the facility not notifying him of residents with no bowel movements. The MD said that it was a concern he was not notified about Resident #1 not having one for several days, but believed it was an isolated incident and protocols were put in place during the QAPI meeting to ensure it did not happen again. The MD said he had already discussed with the facility and put things in place after the meeting. The MD said there were no concerns moving forward and had discussed protocols to include staff training and contacts updated. The MD said the facility had since updated him of constipation concerns since the protocols were put in place. During a phone interview on [DATE] at 8:48 AM, RP D said Resident #1 had a severe case of sepsis and large ball of bowel that appeared to have punctured her colon and thought they might have to cut her colon out. RP D said Resident #1 was on life support and there was nothing they could do for her at the hospital. RP D said he had asked weeks ago when Resident #1 lost her appetite and was notified she was not eating. RP D said he had a camera in her room and his cousin visited Resident #1 and spoke to her this last Sunday before she expired. RP D said on Sunday, [DATE], she was not talking as much because about 2 weeks ago she said her side was hurting when the ADON was in the room. RP D said the facility then gave Resident #1 Tylenol and he spoke with the nurse, got notes from the nurse the night before and she did not have any complaints. RP D said staff informed the family they heard Resident #1 complain about her stomach, but they did not wish to be named. RP D said at the hospital Resident #1's stomach was hard and was told she would die instantly if they had the surgery. RP D said Resident #1 was paralyzed and legally blind and there was nothing wrong with her mind and did not have any medicine except for blood pressure medicine. RP D said Resident #1 expired from severe sepsis shock. During an interview on [DATE] at 10:46 AM, the ADM and DON said Resident #1 expired on Saturday, [DATE], at the hospital and that they have requested and refused hospital records. At 11:00 AM, the DON said she did not receive a report that Resident #1 having side pain or constipation but that the NP had ordered MiraLax PRN if she needed it. The DON said she provided in-services on bowel monitoring because of concerns brought to their attention from Resident #1's RP and started monitoring bowels to make sure that staff were documenting and reporting if they had not gone to the bathroom every 3 to 4 days. The DON said staff did not report Resident #1 not going to the bathroom and believed it may have been missed due to other nurse aides on the hall not communicating between shifts. The DON said Resident #1 had a bowel movement that morning before she was transported to the hospital. The DON said nurse aides report to their charge nurse and document if they have had a bowel movement so it will alert the nurse on electronic health record system to check the resident. The DON said now in their morning meetings, if there is an alert on the electronic health record staff review it in the morning meetings. The DON said that there were currently no additional residents since Resident #1 that had not had a BM in over three days. The DON said interventions were put in place to ensure it does not happen again to include pulling a full bowel movement report and completing in-services with our nursing staff to pull bowel movement report very shift. The DON said the charge nurses are pulling the bowel movement report and aides would be responsible for monitoring bowel movements. The DON said nurse aides could not see the history of bowel movements. The DON said she looked at Resident #1's bowel movement report with their computer and have had problems with internet outages and have contacted the help desk due to the weather. The DON said it was important to notify the charge nurses of a resident having no bowel movement within ,d+[DATE] days and know the resident's bowel schedule because of the different complications that can occur such as what happened to Resident #1. The DON said with the nurse aides, they know their residents well and if they do not have something ordered for constipation, staff are expected to notify the physician to ensure efforts are made to ensure the residents avoids complications or deterioration in health. During an interview on [DATE] at 11:08 AM, the HA said she had been employed at the facility for almost a year. The HA said the aides monitor bowel movements and that they have not provided training on bowel monitoring but that she has not returned to the facility since Resident #1 was sent out. The HA said Resident #1 was on the hall she last worked and the last time she saw her would be the prior Sunday before last, [DATE]. The HA said Resident #1 was talking to her like she always did and was not complaining. The HA said Resident #1 did not have a bowel movement with her for two weeks. The HA said she changed her at 8:00 PM, 12:00 AM, and 4:00 AM and would always ask for things. The HA said Resident #1 was never having any pain in her abdomen. The HA said she did not know that she should have notified someone about Resident #1 not having a bowel movement and said she was just being trained. The HA said nobody notified her that Resident #1 was not having a bowel movement. The HA said the computer system should have prompted a red flag and that made her think she was at least having a bowel movement during the day but come to find out it had been 2 weeks. The HA said she was not sure if Resident #1 was aware that she was not having a bowel movement. The HA said she acknowledged Resident #1 going over 4 days without a bowel movement should have been reported to avoid her being sent out to the hospital and that if they would have kept up with her bowel movement monitoring Resident #1 may still be alive today. The HA said she had not seen her eat food and that she would drink a shake and did not eat much since she has been there. During an interview on [DATE] at 12:21 PM, the Administrator said she received letter from an attorney the day Resident #1 expired on [DATE] with request to maintain all records possibly from RP D. The Administrator said it had been months since they talked to RP D. The Administrator said RP J asked the facility to comb her hair recently but that was her main concern and she informed her that she would get one of her staff down there to fix her hair. The Administrator said family for Resident #1 had a camera in her room to communicate with her and had a family friend visit that reported no concerns. The Administrator said she expected staff to report after three days of no bowel movement. The Administrator said for Resident #1 they had reviewed for weeks in morning meeting that her only intake was ensure and water and there was a concern with her not eating but not for her bowel movements. The administrator said the aides were responsible for monitoring bowel movements and reporting concerns and are making sure staff pulls the report every morning in meeting. The Administrator said Resident #1 had the ability to express what was going on with her and believed losing the internet due to weather was part of the problem for documenting and reporting. The Administrator said the facility lost power the weekend before she was sent to the hospital and on [DATE]st, 2024, that weekend it was down all weekend and was not notified until coming to work on Monday. During an interview on [DATE] at 1:00 PM, the ADON said she had been employed at the facility for 8 years. The ADON said she last saw Resident #1 on [DATE] and she was doing good. The ADON said she did not know when it was, but around last month Resident #1 was complaining about her side and the ADON listened to her bowel sounds at abdomen for movement. The ADON said Resident #1's family was on the camera and reported she was hurting so they offered her Tylenol and she refused. The ADON said her family wanted her to go out to the hospital and she refused to go and after the pain medication she did not complain anymore and had no tenderness to the area. The ADON said on that day, Resident #1 kept saying both sides were hurting and had a routine stool softener she would take but would not take the MiraLax. The ADON said she talked to CNA E the next day and reported she had a small bowel movement. The ADON said Resident #1 had not been eating for a while and ever since she had COVID-19 upon recovery she stopped eating food and would only eat a couple bites of food sometimes brought in from family. The ADON said the nurse aides were responsible for reporting if a resident had not had a bowel movement for over 3 days and said she thinks Resident #1's bowel movements were not reported due to a lack of communication and that they should have relayed that information during their shift report. The ADON said staff is expected to notify the nurse if a resident was not having a bowel movement in report and that it does prompt up on the electronic dashboard in their system if they had not had one for several days but with the weather causing internet failure staff may have not documented yet or seen the prompt. The ADON said paper charting was completed during internet outage. The ADON said the facility has provided training on bowel movement monitoring by conducting in-services with all staff. The ADON said they had reviewed this morning about pulling up reports on the computer to see if someone did not have a bowel movement for the last 3 days. The ADON said prior to Resident #1 being sent to the hospital they used to run the bowel movement sheet and go talk to that person or aide to see if they may have had one or was documentation accurate so they would go visit each person. The ADON said she has reviewed bowel movement reports and did not have any similar constipation concerns with any other residents. The ADON said CNA E was usually pretty good about reporting bowel movements and she may get busy but usually is good about reporting. The ADON said signs and symptoms of possible fecal impaction included nausea, abdomen hard or tender, and decreased appetite. The ADON said she had no changes other than Resident #1's side pain a couple of weeks ago and that was the last time she heard her complain and her family tried to send her out to the ER, and she refused to go. During a phone interview on [DATE] at 3:00 PM, the NP said she has been off for the last three weeks and visits the facility twice a month. The NP said if she had seen Resident #1 it would only be during one of those on-site visits and she could not recall when she last saw her. The NP said the nurses will tell her which residents have concerns when she is there. The NP said staff normally report residents not having any bowel movements and said she would assume they would report a resident not having one for over 3 days. The NP said if she was aware Resident #1 had not had a bowel movement for several days she would have assessed her medicines, prescribed stool softeners, and review medicine like MiraLax and most of the time there are already PRN orders in place to administer, and request to do an x-ray scan if medicine was not effective. The NP said she had no concerns with care and services provided by the facility and was not aware that Resident #1 had not had a bowel movement for that long. The NP said it would be important to report if a resident had not had a bowel movement for over 3 days because it could indicate a possible bowel blockage. The NP said staff they report concerns appropriately when she is at the facility. During an interview on [DATE] at 3:11 PM, the hospital ICU Nurse said Resident #1 was admitted on [DATE] at 5:37 PM with a diagnosis of septic shock, respiratory failure, septic shock that was first unclear on etiology and including UTI, pneumonia, and then abdominal because she showed colitis on her imaging. The hospital ICU Nurse said on [DATE] a CAT scan revealed she had a fecal contained severe constipation and contained perforation along the rectum. The hospital ICU Nurse said x-rays were showing severe colonic distension and constipation and the outside hospital (hospital she was transferred from) showed stercoral colitis. Review of facility policy, titled Clinical Practice Guideline: Bowel Monitoring, review date [DATE], revealed the following: Anticipated Outcome The aim of this guideline is [to] provide guidance to avoid constipation or fecal incontinence in order to achieve evacuation of the bowel. Fundamental information A stooling frequency of less than 3 times a week may still be considered normal if not associated with abdominal discomfort in the absence of bowel sounds. A daily bowel movement is not necessary, but a resident that has not had a bowel movement for ,d+[DATE] days should be monitored closely for signs and symptoms of Constipation. Stool softeners, suppositories and enemas may be used to assist the resident with rectal evacuation. Process o Bowel movements are monitored by nursing staff observation that a patient has had a bowel movement or a report from the patient that a bowel movement has occurred. o If the patient has not had a bowel movement for ,d+[DATE] days monitor for signs and symptoms of constipation; abdominal distension, pain, nausea/vomiting, loss of appetite, decrease bowel sounds o Notify the Physician of the abnormal symptoms o Provide the patient with fluids and juices as indicated. o Administer stool softener, suppositories, enemas and fibers as ordered. o Continue to monitor the patient during 4 to 7 days for bowel movement, adverse signs and symptoms. o Notify the physician if there is increased tenderness, rigidity, distinction, absence or decrease vowel sound for abnormal bowel movement e.g. blood or mucus in stool. o Monitor [EHR] reports Documentation Progress Notes, Medication Administration Record Review of facility policy, titled Resident Rights, revised [DATE], revealed the following: .Policy Explanation and Compliance Guidelines: . 11. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents . Resident Rights . 2. Planning and Implementing Care . b . iv. The right to receive the services and/or items included in the plan of care . During an interview on [DATE] at 5:23 PM, the Administrator requested an IJ PNC and provided additional information to include a QAPI meeting and in-service documentation. Review of Performance Improvement Project Report, titled Bowel Movement Monitoring, start date of [DATE] revealed the following: .Goal: Establish a procedure for to avoid constipation or fecal impaction in order to achieve evacuation of the bowel that optimizes therapeutic benefits and minimizes associated risks . 4.) DON/Designee to pull no BM x 3 days report; resident is to be monitored for signs/symptoms of constipation and notify MD of any abnormal symptoms. 5.) Results of no BM x 3 days report will be discussed with admin/DON during morning clinical start up meeting. 6.) review fidnings monthly at QAPI meeting for three months to ensure compliance. During a phone interview on [DATE] at 9:24 AM, CNA K said she had been employed for one to two years at the facility and had received in-service training on bowel monitoring and notification of changes yesterday, [DATE], and the week prior. CNA K said that if a resident does not have a bowel movement for 3 to 4 days, she would notify her nurse. CNA K said she had no residents she had that were going that long without a bowel movement. During a phone interview on [DATE] at 9:31 AM, CNA L said she had been employed as an aide at the facility for over a year. CNA L said the timeframe she would report bowel concerns was 3 days of a resident not going to the bathroom. CNA L said there were in-services over bowel monitoring and notifying staff of changes last week. She said all of her residents were going to the bathroom within the timeframe Resident #1 was documented as not going to the bathroom and that she works with the same residents every time she works. An IJ PNC was determined on [DATE] at 11:06 AM. The administrator was provided with updated template on [DATE] at 11:06 AM. The surveyor confirmed PNC had been implemented sufficiently to remove the Immediate Jeopardy by: o Completion of Investigation Synopsis Timeline of Events o Like Resident: bowel assessment validation completed on [DATE] [TRUNCATED]

Based on interview, observation, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one of six residents (Resident #1) reviewed for accidents in that: The facility failed to use a two-person assist for perineal care, as determined necessary by the comprehensive, during repositioning in bed to his side, resulting in the resident falling to the floor, sustaining a laceration requiring sutures. CNA A did not provide Resident #1 with a two person assist during perineal care on bed. This failure could place residents who require a two person assist during care at risk for accidents or injuries. Findings include: Record review of Resident #1's Admission Record, dated 3/1/2022, revealed he was an [AGE] year-old male, date of birth 7/02/1933, admitted on [DATE] with diagnoses including: repeated falls, lack of coordination, muscle weakness, unsteadiness on feet, muscle wasting and atrophy (overall loss of muscle mass), dementia (impairment of memory and/or judgement), and cataract( a cloudy area in the eye that leads to a decrease in vision). Record Review of Resident #1's MDS, dated [DATE], revealed his ADL Self Performance for bed mobility and toilet use was total dependence with provided support of two + persons physical assist and his bowel continence level revealed he was frequently incontinent. Record review of Resident #1's CAA Worksheet, dated 12/23/2021, revealed a selection for functional/mobility (G0110) or balance (G0300) problems; physical disability (G0300, G0400). Record review of Resident #1's Care Plan, revised 1/17/2022, revealed he had an ADL self-care performance deficit and was at risk for not having his needs met in a timely manner. He was non ambulatory and required two staff assist for bed mobility, transfer, dressing, toilet use & bathing with interventions to include providing the level of ADL assistance, per focus, to maintain good nutrition, grooming, personal & oral hygiene, and safety on a daily basis. In addition, he was a fall risk with the potential for falls related to cognitive and vision impairment, history of falls, debility, and muscle weakness. Record Review of Fall Risk Assessment, dated 2/25/2022, revealed Resident #1 was a Category: High Risk. Record review of Resident #1's Progress Notes, dated 2/6/2022, revealed CNA A was providing care to Resident #1 when he fell over bolsters (restraint free barriers for bed) and she could not catch him. Blood was noted to open area at left forehead and inside of mouth. Resident #1 sustained two sutures to left temple and swelling to upper lip. Record review of Resident #1's MD Progress Note, dated 2/8/2022, revealed MD was notified of Resident #1's fall in room on Sunday morning via video call and reported blood everywhere and bleeding from resident's mouth, resident mental status seemed at baseline and could move his head and extremities. MD recommended to get him in bed, clean him up, and reassess. MD was notified at 5:00 PM same day that the resident returned from emergency room with sutures in his forehead. MD diagnosis and assessment included a plan of: Fall prevention techniques. Staff aware. No suture removal required. No evidence of serious injury. Record review of incident report, dated 2/6/2022, revealed LVN A was called to Resident #1's room by CNA A at 12:15 PM. Resident #1 was lying on the floor next to bed on anterior side and able to bend knee with ease. Open area to left forehead was noted and blood inside mouth. CNA A said I was cleaning him and holding him up when he started to slip off the bolsters. CNA A tried to catch Resident #1 to prevent him from falling but she could not. MD said to give Resident #1 Tylenol and representative was notified and they requested he be sent to hospital. DON B was notified. Record review of Provider Investigation Report, revealed a disciplinary memorandum letter for CNA A, dated 2/7/2022, signed by Administrator and included the following: Suspension Pending investigation begins 2/7/2022 Description of incident: Giving care to resident requiring two persons bed not locked bed to be in low position Disciplinary Action Formal Written Description of violation: final warning Corrective action to be taken Suspend & Investigate State what corrective action the associate is to take: One on one education - turning & positioning Using 2 people, be aware of resident care tool Use a gait belt & wear a name tag Abuse & Neglect Policy Record review of Resident #1's PA Progress Note, dated 2/9/2022, revealed Resident #1 had a fall over the weekend, was transferred to the emergency room , and received 2 stitches to his forehead laceration. Staff reports on Sunday as care was being administered patient fell off of bed and hit head. PA noted laceration to left forehead and swelling around right eye and minimal swelling to left upper lip area. Responsible party expresses dissatisfaction with care. PA recommended care plan meeting to discuss goals of care. Record review of in-service, dated 2/9/2022, revealed CNA A attended training on topics including: Turning & Repositioning Program, CNA Assignment Sheet, and Use of gait belt Record review of Provider Investigation Report completed by administrator, dated 2/11/2022, revealed an investigation summary of the incident involving CNA A and Resident #1 that included the following: CNA A stated she went in to provide care for Resident #1. She did not request assistance. As she was caring for the resident, he rolled out of the bed and fell to the floor, causing a laceration to his forehead. The medical director was notified, the family was notified, and the DON was notified. Resident #1 was sent to hospital and CAN was suspended. Resident interviews were conducted and no resident reported feeling unsafe when care was provided by CNA A. Investigation Findings: Confirmed Provider Action Taken Post-Investigation: CNA A had a one-on-one in-service on turning and repositioning, use of gait belt, and using the CNA Assignment sheet, written final warning, with the understanding that she would be terminated if she provided care without assistance when it is care planned as such. She returned to work on 2/10/2022. All staff in-serviced on Abuse & Neglect. During an interview on 3/1/2022 at 11:46 AM, the Regional Nurse said she is in charge while the administrator is on vacation for the remainder of the week and the Director of Nursing was out sick. She said she was aware of CNA A providing a one person assist when a two-person assist was required during care for Resident #1 at the time he fell off the bed. Regional Nurse said Resident #1 rolled off the bed when CNA A turned him to his side. Regional Nurse said Resident #1 sustained a laceration to forehead and bleeding inside of his mouth and was sent out to hospital. She said CNA A was sincerely apologetic about the incident and did not consider at the time of the incident that he was a two person assist. She said CNA A had a good reputation with the facility for taking care of her residents. Regional Nurse said CNA A was suspended during the investigation, was provided re-education on ADL care, and was issued a disciplinary action letter. Regional Nurse said there was sufficient staff to provide a two-person assist and it was important for staff to adhere to providing necessary ADL support for the safety of all residents to prevent accidents or injuries. She said CNA's have had no further incidents in providing a two person assist when needed. Upon completion of incident investigation, CNA A was instructed to provide a two person assist when repositioning any resident. During an interview on 3/1/2022 at 3:53 PM, LVN A said CNA A was providing perineal care for Resident #1 by herself when he rolled off the bed. She said CNA A immediately notified her of the incident and she assessed him. She said nurses were ultimately responsible for ensuring the care plan was followed and that the care plan documentation on all residents were kept on file at the nurses station. She said she observes aides assisting residents to ensure they are following the care plan. She said aides know how many staff should assist a resident by referring to care plan documents kept on file at nurse station. She said Resident #1 was a two person assist and CNA A was providing a one person assist. She said it was important for nursing staff to adhere to care plan interventions and provide support necessary for the safety of all residents to prevent any accidental or avoidable injuries. During an interview on 3/1/2022 at 4:00 PM, CNA A said she provided a one person assist to Resident #1 while providing perineal care in bed. CNA A said Resident #1 kept going when she turned him, and he fell on the floor. CNA A said she tried to stop him from rolling off the bed but could not do it alone. She said it was a horrible accident and was fully responsible. She said she was suspended from the facility during the investigation, was re-educated on ADL assistance and now ensures a two-person assist is provided during repositioning of any resident for the safety of all residents. She said it was important to adhere to the care plan and provide two-person assistance when necessary for all residents to prevent accidents or injuries. She said CNA's were responsible for ensuring needed ADL support was provided and that the care plan adherence was overseen by the nurses. CNA A said she typically does a one person assist with perineal care and did not know a two person was required. She said providing a one person assist when a two person was required put all residents at risk for accidents or injuries and received in-services on ADL support that re-educated her on requirements. She said she had access to the care plan on paper records kept at the nurse's station that tell her how much assistance each resident needs and how many staff should help. CNA A said she knew how to get help if she needed it when providing care by asking other nursing staff. She said she reviews care plans at the beginning of her shift by referring to care plan documentation at nurse station. During an interview on 3/1/2022 at 11:30 PM, Resident #1's RP said she did not feel the resident was receiving proper care and services. RP said the CNA A notified her that he fell over the bed while she was providing care for him. RP said CNA A was very sweet and apologetic about the incident and that he usually has one person assist him. She said she had attended a care plan meeting but did not review the incident or review ADL support required during the meeting. During an observation and interview on 3/4/2022 at 1:15 PM, Hospitality Aides A and B said care plan information was in a book at nursing cart. They walked to nursing cart and opened a book with shower log and said the care plan information was not currently in the book and that it was available in a book at nursing station. Hospitality Aides A and B said they received verbal report from nurses on residents that require a two person assist at the start of their shift. During an observation and interview at 3/4/2022 at 1:30 PM, DON A said all CNA's can access care plan information by referring to care plan documentation located at the nursing station in a file container. She said there was no book for care plans only the file container, but that there was a book for shower logs. The file container was located at the nurse's station with care plan documentation. She said CNA's can take the care plan documentation to their nursing cart. DON A said CNA's were responsible for ADL support and ultimately it was the nurses or DON's responsibility to ensure the necessary ADL support was provided. DON A said nursing staff observes aides providing assistance to ensure they were following policy and that it was important for nursing staff to adhere to ADL support needed for the safety of all residents to prevent injuries and a failure to provide needed support put residents at risk for accidents. Record review Regional Nurse e-mail submitted by Regional Nurse on 3/4/2022 at 2:18 PM, revealed the fall had been QA'd (Quality Assurance). She said falls were discussed in QA and consists of the facility IDT (interdisciplinary team) members that include Admin, DON, ADONs, Dietary, Therapy, Housekeeping, Social Services, Medical Director, Activity Director, HR Director, and Recording Secretary. Record review of facility policy, titled Incident/Accident Policy, reviewed 2/10/2021, included the following: Definitions Incident: an unusual or unexpected event that is not consistent with the routine operation of the facility or the routine care of the resident. This includes incidents that occur involving resident, visitor, employee, volunteer, or other non-employee. Accident: an unexpected, unintended event that can cause a resident bodily injury. It does not include adverse outcomes associated as a direct consequence of treatment or care (e.g. drug side effects or reactions). Procedure 1. Immediately assess the condition of the person(s) involved in the incident/accident. 2. 2. Initiate emergency first aid and determine need for acute emergency care. 3. Notify the attending physician or medical director in the absence of the attending physician. 4. Notify family and other applicable health entities. 5. Notify the Administrator, Director of Nursing or Department Head on duty. 6. Document medical facts of the incident and follow up in the medical record. 7. Complete the Incident/Accident Report for incidents/accidents. 8. Do not file Incident/Accident Report in the resident's medical record. 9. The Administrator and Director of Nursing will review the incident/accident to determine if investigation is required. 10. Medical Director reviews, signs and provides recommendations on Incident/Accident trends and patterns. Record of facility policy, titled Fall Management System, reviewed 2/19/2021, included the following: Policy It is the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs. Fundamental Information A fall occurs when there is an unintentional coming to rest on the floor, ground, or other lower level but not as a result of overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. A fall is often the result of cumulative risk from both intrinsic (resident-related) and extrinsic (environmental) factors. Intrinsic risk factors for falls include changes that are part of normal aging as well as certain acute or chronic conditions and medications. The following are examples of common intrinsic risk factors: *Gait and balance disorder *Muscular weakness (particularly of lower extremities) *Dizziness or [CONDITION(S)] *Confusion *Incontinence *Stroke *Parkinson's disease *Vision and hearing impairment *Seizure Disorder *Depression *Previous falls . Procedure A. Identifying resident at risk for falls 1. On admission, quarterly, and with significant change in status, a licensed nurse will complete a Fall Risk Assessment for each resident. The risk areas that are assessed are: Mental status Ambulatory/elimination status Gait/balance Perceptual deficits Orthostatic blood pressure (systolic) Falls history Medications Predisposing diseases/conditions 2. The facility will also utilize the Minimum Data Set and Care Area Assessment (CAA) to assist in identifying resident's risk for falls. The MDS and CAAs are to be completed according to the Federal guidelines. 3. 3. A care plan is implemented for residents at risk for falls B. Analysis of Assessment and Implementation of Preventative Measures C. 1. Residents that score 10 or above per the Fall Risk Assessment, may represent high risk for falls. 2. The identifying factors will be provided to staff, and the individualized resident care plan will be developed with appropriate goals and interventions utilizing the Fall Management . 4. Resident's level of risk may be identified and communicated on tools like care plans and assignment sheets. 5. Preventative interventions are reviewed, evaluated and implemented to reduce the reoccurrence of falls 6. Nursing Administration/designee will be responsible for validation and re evaluation of residents at risk for falls and effectiveness of interventions for Fall Management Program. E. Investigation and follow-up of accidents involving falls. 1. the licensed nurse will initiate the Incident/Accident investigation immediately after each fall utilizing the Investigation follow-up guideline 2. Interventions will be implemented in an attempt to prevent the resident from sustaining further falls. Based on the investigation results, the licensed nurse will initiate intervention measures as soon as practicable . 4. The Director of Nursing or designee, Administrator and the Interdiscplinary Team (IDT) in the clinical meeting will review falls and may modify intervention to reduce the risk of future falls. 5. Falls data and reports are reviewed in QAA Meetings . Record review of facility policy, titled Abuse Policy, reviewed 2/1/2021, included the following: Procedure III. Prevention of Abuse E. A committee selected and chaired by the Administrator or designated representative will function as the Quality Assurance and Assessment committee and meet, at minimum quarterly, to: Analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences . 2. This includes an analysis of . -The deployment of staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned has knowledge of the individual residents care needs. -The assessment, care planning, and monitoring residents with needs and behaviors which might lead to conflict or neglect, such as residents .that require heavy nursing care and/or are totally dependent on staff.

Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and based on the comprehensive assessment for for 1 of 3 residents reviewed for quality of care. (Resident #65) The facility did not initiate cardiopulmonary resuscitation (CPR) for Resident #65 when she was found with no pulse or respirations. Resident #65 had no advance directive or code status. A resident without a code status was considered a full code. An Immediate Jeopardy situation was identified on [DATE] at 4:20 p.m. The Immediate Jeopardy was removed on [DATE] at 11:16 a.m. The facility remained out of compliance at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 51 residents who requested a full code-status (everything is done to keep a person alive) at risk of death. Findings included: Physician orders [REDACTED].#65 was a [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. The orders did not include a code status. The most recent MDS dated [DATE] did not address advance directives or code status for Resident #65. The care plan dated [DATE] for Resident #65 did not address advance directives or code status. The undated Advance Directive Acknowledgment form included Resident #65's name, facility name, and [DATE] as date of admission. The rest of the form was incomplete and not signed. The undated Out-Of-Hospital Do-Not-Resuscitate (DNR) Order form included Resident #65's name and date of birth. The rest of the form was incomplete and not signed. The closed medical record for Resident #65 dated [DATE] through [DATE] contained no information regarding her code status. The nursing documentation for Resident #65 indicated the following: - [DATE] at 4:00 a.m., .Resident resting in bed . - [DATE] at 7:05 a.m., .entered resident's room-observed resident with eyes half open-she was not moving-there were no respirations and she was unresponsive. Arms cool to touch. Called for assistance of RN. She came to room and saw there were no response and no respirations. She did sternal rub without response This was written by LVN A. - [DATE] at 7:09 a.m., .Called (physician's name) and informed him that resident was found unresponsive and no carotid pulse. He said no CPR since she was already gone . This was written by LVN A. A physician order [REDACTED]. May release body to (local funeral home) . This was written by LVN A. During an interview on [DATE] at 11:00 a.m., LVN A said on [DATE] at approximately 7:05 a.m., she walked in Resident #65's room and found the resident with no respirations and pale in color. She said the resident was expired. LVN A asked RN B to assist her with Resident #65 while she went to the nursing station to confirm Resident #65's code status and call her physician. LVN A said she thought Resident #65 was a full code, but did not see anything on her chart. LVN A said she was told in report that Resident #65 had been up most of the night hollering. LVN A said she told the physician that she thought the resident was a full code, and he said he was not sure either. LVN A did not know why code status was not addressed in the chart. She said code status was usually done by the social worker. She said a resident would be considered a full code if no code status was specified in the resident's chart. LVN A said she did not start CPR because she knew by Resident #65's color that she was gone. She said she did not check Resident #65's vital signs. During an interview on [DATE] at 11:15 a.m., RN B said she assessed Resident #65 and found no respirations. She said she did not know the resident's code status because she was not Resident #65's nurse. She said she did not start CPR because LVN A came in and reported that Resident #65's physician said not to do CPR since she was already expired. RN A said she was still completing her assessment. RN A stated, If I was to just walk in, I would have started CPR until EMS (emergency medical services) showed up. I think the other nurse should have started CPR. I don't know why CPR wasn't started. Not knowing code status, I would have started CPR. During an interview on [DATE] at 2:50 p.m., the administrator said he felt the staff did what Resident #65 physician told them to do which was not to start CPR. During an interview on [DATE] at 5:00 p.m., the Medical Director (MD), Resident #65's physician, said he received a call from a nurse on [DATE]. He said he did not know which nurse called him. The MD said the nurse said Resident #65 had no vital signs and there was no do not resuscitate (DNR) listed in her medical record he stated, I told her not to do CPR; it's a crime against the resident. He said the survival rate for CPR is 0% for residents in a nursing home. He said he overlooked the fact there was no DNR for Resident #65. During an interview on [DATE] at 2:00 p.m., BOM said she and the marketer explained the admission packet paper work with new admissions. She said the marketer was the one who initiated the paper work. The BOM said the advanced directive was not completed for Resident #65, but should have been. She said the red DNR and green full code forms were placed in the charts by the social worker. The BOM said resident closed records should also contain the red DNR and green full code forms. The BOM said the ADON told her if the DNR form was not filled out, the resident should be treated as a full code. During an interview on [DATE] at 2:30 p.m., the ADON said DNR status should be on all charts. A Cardiopulmonary Resuscitation Advanced Directives Policy dated [DATE] Indicated, .When a patient is found to be without heartbeat or respirations by any staff member the patient's medical record must be checked to ensure that the patient's wishes are followed. If there are no advanced directives or a Full Code status the licensed staff will start CPR . The administrator was notified on [DATE] at 4:20 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 11:16 a.m., and included: Immediate Action: All nurses will receive in service on CPR-Advanced Directives Policy with posttest. 100% chart audit of all charts to validate code status of all residents and the code status system by DON/designee. DON/Designee will validate code status paperwork is completed upon admission. All staff will receive in service on abuse and neglect with posttest. DON/Designee will validate CPR certification of all nurses The above in services and validation as well as posttest will begin [DATE] and will be completed [DATE] and no staff will be allowed to return to work until they have completed the required in services/posttests. Monitoring: DON/Designee will use the Advanced Directive QAPI tool for all new or readmissions to the center daily to validate that code status system is in place. DON/Designee will use QAPI Emergency Management Documentation Time Line to validate that CPR is initiated according to code status for any resident that expires. A QA & A meeting will be conducted by Administrator on [DATE] and weekly to validate that the facilities CPR/Advanced Directive System is sustained for 3 months. On [DATE] at 11:16 a.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with 4 RN, 3 LVNs, and 6 CNAs regarding the training they had received on CPR and the abuse policy. 13 nursing staff (4 RN, 3 LVNs, and 6 CNAs) members from all shifts, and 4 interdisciplinary staff members (dietary, maintenance, and housekeeping) were interviewed and said they received training regarding advanced directives, process for initiating CPR, what to do if there wa s no code status, symptoms of dependent lividity, process for DNR residents, the five types of abuse/neglect, and the process for reporting abuse. 60 resident records indicated the correct code status was included in the record. 21 nurse personnel files indicated current CPR training. On [DATE] at 11:16 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A report provided by the facility on [DATE] at 11:30 a.m. indicated there were 51 residents with a full code status.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for 1 of 3 residents reviewed for neglect. (Resident #65) The facility did not initiate cardiopulmonary resuscitation (CPR) for Resident #65 when she was found with no pulse or respirations. Resident #65 had no advance directive or code status. A resident without a code status was considered a full code. An Immediate Jeopardy situation was identified on [DATE] at 4:20 p.m. The Immediate Jeopardy was removed on [DATE] at 11:16 a.m. The facility remained out of compliance at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 51 residents who requested a full code-status (everything is done to keep a person alive) at risk of neglect and death. Findings included: An Abuse/Neglect prohibition policy dated [DATE], indicated .residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, corporal punishment, and involuntary seclusion Physician orders [REDACTED].#65 was a [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. The orders did not include a code status. The most recent MDS dated [DATE] did not address advance directives or code status for Resident #65. The care plan dated [DATE] for Resident #65 did not address advance directives or code status. The undated Advance Directive Acknowledgment form included Resident #65's name, facility name, and [DATE] as date of admission. The rest of the form was incomplete and not signed. The undated Out-Of-Hospital Do-Not-Resuscitate (DNR) Order form included Resident #65's name and date of birth. The rest of the form was incomplete and not signed. The closed medical record for Resident #65 dated [DATE] through [DATE] contained no information regarding her code status. The record also did not contain a red form indicating DNR or a green form indicating full code. The nursing documentation for Resident #65 indicated the following: - [DATE] at 4:00 a.m., .Resident resting in bed . - [DATE] at 7:05 a.m., .entered resident's room-observed resident with eyes half open-she was not moving-there were no respirations and she was unresponsive. Arms cool to touch. Called for assistance of RN. She came to room and saw there were no response and no respirations. She did sternal rub without response This was written by LVN A. - [DATE] at 7:09 a.m., .Called (physician's name) and informed him that resident was found unresponsive and no carotid pulse. He said no CPR since she was already gone . This was written by LVN A. A physician order [REDACTED]. May release body to (local funeral home) . This was written by LVN A. During an interview on [DATE] at 11:00 a.m., LVN A said on [DATE] at approximately 7:05 a.m., she walked in Resident #65's room and found the resident with no respirations and pale in color. She said the resident was expired. LVN A asked RN B to assist her with Resident #65 while she went to the nursing station to confirm Resident #65's code status and call her physician. LVN A said she thought Resident #65 was a full code, but did not see anything on her chart. LVN A said she was told in report that Resident #65 had been up most of the night hollering. LVN A said she told the physician that she thought the resident was a full code, and he said he was not sure either. LVN A did not know why code status was not addressed in the chart. She said code status was usually done by the social worker. She said a resident would be considered a full code if no code status was specified in the resident's chart. LVN A said she did not start CPR because she knew by Resident #65's color that she was gone. She said she did not check Resident #65's vital signs. During an interview on [DATE] at 11:15 a.m., RN B said she assessed Resident #65 and found no respirations. She said she did not know the resident's code status because she was not Resident #65's nurse. She said she did not start CPR because LVN A came in and reported that Resident #65's physician said not to do CPR since she was already expired. RN A said she was still completing her assessment. RN A stated, If I was to just walk in, I would have started CPR until EMS (emergency medical services) showed up. I think the other nurse should have started CPR. I don't know why CPR wasn't started. Not knowing code status, I would have started CPR. During an interview on [DATE] at 2:50 p.m., the administrator said he felt the staff did what Resident #65 physician told them to do which was not to start CPR. During an interview on [DATE] at 5:00 p.m., the Medical Director (MD), Resident #65's physician, said he received a call from a nurse on [DATE]. He said he did not know which nurse called him. The MD said the nurse said Resident #65 had no vital signs and there was no do not resuscitate (DNR) listed in her medical record he stated, I told her not to do CPR; it's a crime against the resident. He said the survival rate for CPR is 0% for residents in a nursing home. He said he overlooked the fact there was no DNR for Resident #65. During an interview on [DATE] at 2:00 p.m., BOM said she and the marketer explained the admission packet paper work with new admissions. She said the marketer was the one who initiated the paper work. The BOM said the advanced directive was not completed for Resident #65, but should have been. She said the red DNR and green full code forms were placed in the charts by the social worker. The BOM said resident closed records should also contain the red DNR and green full code forms. The BOM said the ADON told her if the DNR form was not filled out, the resident should be treated as a full code. During an interview on [DATE] at 2:30 p.m., the ADON said DNR status should be on all charts. A Cardiopulmonary Resuscitation Advanced Directives Policy dated [DATE] Indicated, .When a patient is found to be without heartbeat or respirations by any staff member the patient's medical record must be checked to ensure that the patient's wishes are followed. If there are no advanced directives or a Full Code status the licensed staff will start CPR . The administrator was notified on [DATE] at 4:20 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 11:16 a.m., and included: Immediate Action: All nurses will receive in service on CPR-Advanced Directives Policy with posttest. 100% chart audit of all charts to validate code status of all residents and the code status system by DON/designee. DON/Designee will validate code status paperwork is completed upon admission. All staff will receive in service on abuse and neglect with posttest. DON/Designee will validate CPR certification of all nurses The above in services and validation as well as posttest will begin [DATE] and will be completed [DATE] and no staff will be allowed to return to work until they have completed the required in services/posttests. Monitoring: DON/Designee will use the Advanced Directive QAPI tool for all new or readmissions to the center daily to validate that code status system is in place. DON/Designee will use QAPI Emergency Management Documentation Time Line to validate that CPR is initiated according to code status for any resident that expires. A QA & A meeting will be conducted by Administrator on [DATE] and weekly to validate that the facilities CPR/Advanced Directive System is sustained for 3 months. On [DATE] at 11:16 a.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with 4 RN, 3 LVNs, and 6 CNAs regarding the training they had received on CPR and the abuse policy. 13 nursing staff (4 RN, 3 LVNs, and 6 CNAs) members from all shifts, and 4 interdisciplinary staff members (dietary, maintenance, and housekeeping) were interviewed and said they received training regarding advanced directives, process for initiating CPR, what to do if there was no code status, symptoms of dependent lividity, process for DNR residents, the five types of abuse/neglect, and the process for reporting abuse. 60 resident records indicated the correct code status was included in the record. 21 nurse personnel files indicated current CPR training. On [DATE] at 11:16 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A report provided by the facility on [DATE] at 11:30 a.m. indicated there were 51 residents with a full code status.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for 1 of 3 residents reviewed for neglect. (Resident #65) The facility did not initiate cardiopulmonary resuscitation (CPR) for Resident #65 when she was found with no pulse or respirations. Resident #65 had no advance directive or code status. A resident without a code status was considered a full code. An Immediate Jeopardy situation was identified on [DATE] at 4:20 p.m. The Immediate Jeopardy was removed on [DATE] at 11:16 a.m. The facility remained out of compliance at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 51 residents who requested a full code-status (everything is done to keep a person alive) at risk of neglect and death. Findings included: Physician orders [REDACTED].#65 was a [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. The orders did not include a code status. The most recent MDS dated [DATE] did not address advance directives or code status for Resident #65. The care plan dated [DATE] for Resident #65 did not address advance directives or code status. The undated Advance Directive Acknowledgment form included Resident #65's name, facility name, and [DATE] as date of admission. The rest of the form was incomplete and not signed. The undated Out-Of-Hospital Do-Not-Resuscitate (DNR) Order form included Resident #65's name and date of birth. The rest of the form was incomplete and not signed. The closed medical record for Resident #65 dated [DATE] through [DATE] contained no information regarding her code status. The record also did not contain a red form indicating DNR or a green form indicating full code. The nursing documentation for Resident #65 indicated the following: - [DATE] at 4:00 a.m., .Resident resting in bed . - [DATE] at 7:05 a.m., .entered resident's room-observed resident with eyes half open-she was not moving-there were no respirations and she was unresponsive. Arms cool to touch. Called for assistance of RN. She came to room and saw there were no response and no respirations. She did sternal rub without response This was written by LVN A. - [DATE] at 7:09 a.m., .Called (physician's name) and informed him that resident was found unresponsive and no carotid pulse. He said no CPR since she was already gone . This was written by LVN A. A physician order [REDACTED]. May release body to (local funeral home) . This was written by LVN A. During an interview on [DATE] at 11:00 a.m., LVN A said on [DATE] at approximately 7:05 a.m., she walked in Resident #65's room and found the resident with no respirations and pale in color. She said the resident was expired. LVN A asked RN B to assist her with Resident #65 while she went to the nursing station to confirm Resident #65's code status and call her physician. LVN A said she thought Resident #65 was a full code, but did not see anything on her chart. LVN A said she was told in report that Resident #65 had been up most of the night hollering. LVN A said she told the physician that she thought the resident was a full code, and he said he was not sure either. LVN A did not know why code status was not addressed in the chart. She said code status was usually done by the social worker. She said a resident would be considered a full code if no code status was specified in the resident's chart. LVN A said she did not start CPR because she knew by Resident #65's color that she was gone. She said she did not check Resident #65's vital signs. During an interview on [DATE] at 11:15 a.m., RN B said she assessed Resident #65 and found no respirations. She said she did not know the resident's code status because she was not Resident #65's nurse. She said she did not start CPR because LVN A came in and reported that Resident #65's physician said not to do CPR since she was already expired. RN A said she was still completing her assessment. RN A stated, If I was to just walk in, I would have started CPR until EMS (emergency medical services) showed up. I think the other nurse should have started CPR. I don't know why CPR wasn't started. Not knowing code status, I would have started CPR. During an interview on [DATE] at 2:50 p.m., the administrator said he felt the staff did what Resident #65 physician told them to do which was not to start CPR. During an interview on [DATE] at 5:00 p.m., the Medical Director (MD), Resident #65's physician, said he received a call from a nurse on [DATE]. He said he did not know which nurse called him. The MD said the nurse said Resident #65 had no vital signs and there was no do not resuscitate (DNR) listed in her medical record he stated, I told her not to do CPR; it's a crime against the resident. He said the survival rate for CPR is 0% for residents in a nursing home. He said he overlooked the fact there was no DNR for Resident #65. During an interview on [DATE] at 2:00 p.m., BOM said she and the marketer explained the admission packet paper work with new admissions. She said the marketer was the one who initiated the paper work. The BOM said the advanced directive was not completed for Resident #65, but should have been. She said the red DNR and green full code forms were placed in the charts by the social worker. The BOM said resident closed records should also contain the red DNR and green full code forms. The BOM said the ADON told her if the DNR form was not filled out, the resident should be treated as a full code. During an interview on [DATE] at 2:30 p.m., the ADON said DNR status should be on all charts. An Abuse/Neglect prohibition policy dated [DATE], indicated .residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation, corporal punishment, and involuntary seclusion . A Cardiopulmonary Resuscitation Advanced Directives Policy dated [DATE] Indicated, .When a patient is found to be without heartbeat or respirations by any staff member the patient's medical record must be checked to ensure that the patient's wishes are followed. If there are no advanced directives or a Full Code status the licensed staff will start CPR . The administrator was notified on [DATE] at 4:20 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 11:16 a.m., and included: Immediate Action: All nurses will receive in service on CPR-Advanced Directives Policy with posttest. 100% chart audit of all charts to validate code status of all residents and the code status system by DON/designee. DON/Designee will validate code status paperwork is completed upon admission. All staff will receive in service on abuse and neglect with posttest. DON/Designee will validate CPR certification of all nurses The above in services and validation as well as posttest will begin [DATE] and will be completed [DATE] and no staff will be allowed to return to work until they have completed the required in services/posttests. Monitoring: DON/Designee will use the Advanced Directive QAPI tool for all new or readmissions to the center daily to validate that code status system is in place. DON/Designee will use QAPI Emergency Management Documentation Time Line to validate that CPR is initiated according to code status for any resident that expires. A QA & A meeting will be conducted by Administrator on [DATE] and weekly to validate that the facilities CPR/Advanced Directive System is sustained for 3 months. On [DATE] at 11:16 a.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with 4 RN, 3 LVNs, and 6 CNAs regarding the training they had received on CPR and the abuse policy. 13 nursing staff (4 RN, 3 LVNs, and 6 CNAs) members from all shifts, and 4 interdisciplinary staff members (dietary, maintenance, and housekeeping) were interviewed and said they received training regarding advanced directives, process for initiating CPR, what to do if there wa s no code status, symptoms of dependent lividity, process for DNR residents, the five types of abuse/neglect, and the process for reporting abuse. 60 resident records indicated the correct code status was included in the record. 21 nurse personnel files indicated current CPR training. On [DATE] at 11:16 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A report provided by the facility on [DATE] at 11:30 a.m. indicated there were 51 residents with a full code status.

Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 of 3 residents reviewed for advanced directives. (Resident #65) The facility did not initiate CPR for Resident #65 when she was found with no pulse or respirations. Resident #65 had no advance directive or code status. A resident without a code status was considered a full code. An Immediate Jeopardy situation was identified on [DATE] at 4:20 p.m. The Immediate Jeopardy was removed on [DATE] at 11:16 a.m. The facility remained out of compliance at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 51 residents who requested a full code-status (everything is done to keep a person alive) at risk of death. Findings included: Physician orders [REDACTED].#65 was a [AGE] year old female, admitted [DATE] with [DIAGNOSES REDACTED]. The orders did not include a code status. The most recent MDS dated [DATE] did not address advance directives or code status for Resident #65. The care plan dated [DATE] for Resident #65 did not address advance directives or code status. The undated Advance Directive Acknowledgment form included Resident #65's name, facility name, and [DATE] as date of admission. The rest of the form was incomplete and not signed. The undated Out-Of-Hospital Do-Not-Resuscitate (DNR) Order form included Resident #65's name and date of birth. The rest of the form was incomplete and not signed. The closed medical record for Resident #65 dated [DATE] through [DATE] contained no information regarding her code status. The record also did not contain a red form indicating DNR or a green form indicating full code. The nursing documentation for Resident #65 indicated the following: - [DATE] at 4:00 a.m., .Resident resting in bed . - [DATE] at 7:05 a.m., .entered resident's room-observed resident with eyes half open-she was not moving-there were no respirations and she was unresponsive. Arms cool to touch. Called for assistance of RN. She came to room and saw there were no response and no respirations. She did sternal rub without response This was written by LVN A. - [DATE] at 7:09 a.m., .Called (physician's name) and informed him that resident was found unresponsive and no carotid pulse. He said no CPR since she was already gone . This was written by LVN A. A physician order [REDACTED]. May release body to (local funeral home) . This was written by LVN A. During an interview on [DATE] at 11:00 a.m., LVN A said on [DATE] at approximately 7:05 a.m., she walked in Resident #65's room and found the resident with no respirations and pale in color. She said the resident was expired. LVN A asked RN B to assist her with Resident #65 while she went to the nursing station to confirm Resident #65's code status and call her physician. LVN A said she thought Resident #65 was a full code, but did not see anything on her chart. LVN A said she was told in report that Resident #65 had been up most of the night hollering. LVN A said she told the physician that she thought the resident was a full code, and he said he was not sure either. LVN A did not know why code status was not addressed in the chart. She said code status was usually done by the social worker. She said a resident would be considered a full code if no code status was specified in the resident's chart. LVN A said she did not start CPR because she knew by Resident #65's color that she was gone. She said she did not check Resident #65's vital signs. During an interview on [DATE] at 11:15 a.m., RN B said she assessed Resident #65 and found no respirations. She said she did not know the resident's code status because she was not Resident #65's nurse. She said she did not start CPR because LVN A came in and reported that Resident #65's physician said not to do CPR since she was already expired. RN A said she was still completing her assessment. RN A stated, If I was to just walk in, I would have started CPR until EMS (emergency medical services) showed up. I think the other nurse should have started CPR. I don't know why CPR wasn't started. Not knowing code status, I would have started CPR. During an interview on [DATE] at 2:50 p.m., the administrator said he felt the staff did what Resident #65 physician told them to do which was not to start CPR. During an interview on [DATE] at 5:00 p.m., the Medical Director (MD), Resident #65's physician, said he received a call from a nurse on [DATE]. He said he did not know which nurse called him. The MD said the nurse said Resident #65 had no vital signs and there was no do not resuscitate (DNR) listed in her medical record he stated, I told her not to do CPR; it's a crime against the resident. He said the survival rate for CPR is 0% for residents in a nursing home. He said he overlooked the fact there was no DNR for Resident #65. During an interview on [DATE] at 2:00 p.m., BOM said she and the marketer explained the admission packet paper work with new admissions. She said the marketer was the one who initiated the paper work. The BOM said the advanced directive was not completed for Resident #65, but should have been. She said the red DNR and green full code forms were placed in the charts by the social worker. The BOM said resident closed records should also contain the red DNR and green full code forms. The BOM said the ADON told her if the DNR form was not filled out, the resident should be treated as a full code. During an interview on [DATE] at 2:30 p.m., the ADON said DNR status should be on all charts. A Cardiopulmonary Resuscitation Advanced Directives Policy dated [DATE] Indicated, .When a patient is found to be without heartbeat or respirations by any staff member the patient's medical record must be checked to ensure that the patient's wishes are followed. If there are no advanced directives or a Full Code status the licensed staff will start CPR . The administrator was notified on [DATE] at 4:20 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 11:16 a.m., and included: Immediate Action: All nurses will receive in service on CPR-Advanced Directives Policy with posttest. 100% chart audit of all charts to validate code status of all residents and the code status system by DON/designee. DON/Designee will validate code status paperwork is completed upon admission. All staff will receive in service on abuse and neglect with posttest. DON/Designee will validate CPR certification of all nurses The above in services and validation as well as posttest will begin [DATE] and will be completed [DATE] and no staff will be allowed to return to work until they have completed the required in services/posttests. Monitoring: DON/Designee will use the Advanced Directive QAPI tool for all new or readmissions to the center daily to validate that code status system is in place. DON/Designee will use QAPI Emergency Management Documentation Time Line to validate that CPR is initiated according to code status for any resident that expires. A QA & A meeting will be conducted by Administrator on [DATE] and weekly to validate that the facilities CPR/Advanced Directive System is sustained for 3 months. On [DATE] at 11:16 a.m., the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: Interviews with 4 RN, 3 LVNs, and 6 CNAs regarding the training they had received on CPR and the abuse policy. 13 nursing staff (4 RN, 3 LVNs, and 6 CNAs) members from all shifts, and 4 interdisciplinary staff members (dietary, maintenance, and housekeeping) were interviewed and said they received training regarding advanced directives, process for initiating CPR, what to do if there wa s no code status, symptoms of dependent lividity, process for DNR residents, the five types of abuse/neglect, and the process for reporting abuse. 60 resident records indicated the correct code status was included in the record. 21 nurse personnel files indicated current CPR training. On [DATE] at 11:16 a.m., the administrator was informed the IJ was removed; however, the facility remained out of compliance at an isolated incident of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. A report provided by the facility on [DATE] at 11:30 a.m., indicated there were 51 residents with a full code status.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed for accidents. (Resident #1) The facility did not use the tie down strap or seatbelt to secure Resident #1 during transport resulting in Resident #1 falling out of her wheelchair, fracturing her hip when the van stopped abruptly. This failure could place 18 residents who used wheelchairs during van transportation at risk for an injury. Findings included: An Admission order dated December 2015 indicated Resident #1 was admitted on [DATE], and was [AGE] years old with [DIAGNOSES REDACTED]. Nursing notes dated 12/07/15 indicated Resident #1 arrived to facility at 7:20 p.m. in a wheelchair with two staff members. The notes indicated Resident #1 complained of severe left hip upon movement, left knee pain, and back pain. The notes indicated Resident #1 had a bruise to her left knee with edema and abrasion to her right shin, her left foot was externally rotated, and her left leg was shorter than her right leg. The notes indicated Resident #1 was unwilling to move her left lower extremity (LLE) and complained of extreme pain. Resident #1 was transported via Emergency Medical Services (EMS) to the hospital at 7:50 p.m. An Incident/accident report dated 12/07/15 indicated Resident #1 was being transported in facility van when the van driver hit the brakes. Resident #1 slid out of the wheelchair. The report indicated the type of injury was a hematoma, abrasion to the left knee and pain in the left hip. The report indicated Resident was transported to the hospital by (EMS) on 12/07/15 at 8:00 p.m. An undated Nursing Home to Hospital Transfer Form indicated Resident #1 ' s hospital admitted was 12/07/15. The form also indicated Resident #1 was sent from the facility to the hospital on [DATE] for left hip/knee pain. A hospital radiology record dated 12/09/15 indicated exam date for Resident 1's left hip was 12/07/15. The hospital record also indicated Resident #1 had a minimally displaced left hip fracture. During an interview on 12/16/15 at 2:03 p.m. the activity director said she and the van driver went to pick Resident #1 up from the hospital to transport her to the facility. She said the van driver fastened the straps to ensure the wheel chair was secure. She said the wheelchair was secured. She said the van driver slammed on the brakes. She said Resident #1 slid forward out of her wheelchair onto her knees, then over to her right side. She said she tried to stop her from sliding out of the chair, but she did not react in time. She said she did not realize Resident #1 was not wearing her seat belt or lap belt until after she had slid out of the chair. She said she and the van driver was unable to get Resident #1 up from the floor of the van. She said they saw a man in the parking lot where they had parked, and he assisted them with getting her back into the wheelchair. She said Resident #1 said her knee was hurting and her hip was tingling. During an interview on 12/16/15 at 2:28 p.m., the van driver said when she picked up Resident#1 from the hospital to transport her to the facility; she did not fasten the lap belt or the seat belts. She said she checked to ensure the wheelchair was secure, but failed to ensure Resident #1 was buckled in with the lap and seat belt. She said she had to come to a sudden stop and when she did, Resident #1 slid out of her wheelchair. She said she and the activity director were unable to get Resident #1 back into her wheelchair. She said they requested assistance from a man that was in the parking lot. She said Resident #1 was placed back in her wheelchair without any problems. She said Resident #1 said her knee was hurting, and her hip was tingling. She said she contacted the facility and asked if she needed to take Resident #1 to the hospital. The DON said to bring Resident #1 to the facility if she was not hurting. She said Resident #1 continued to deny pain. She said when she got Resident #1 to the facility and took her out of the van, she did not complain of pain until she was being transferred from the wheelchair to her bed. During an interview on 12/16/15 at 3:10 p.m., the DON said Resident # 1 was picked up by staff from the hospital and was being transported to the facility. The DON said she received a phone call around 6:08 p.m. from one of the nurses that Resident #1slid out of the wheelchair in the van, when the van driver had to slam on the brakes. She said she was informed the only thing hurt was Resident #1's knee. She said the van driver reported Resident #1 was not in any pain. She said she informed the van driver to proceed to the facility. She said she informed the van driver that if Resident #1 pain or condition changed to take Resident #1 to the closest hospital. She said when they returned to the facility and staff was transferring Resident #1 to the bed to assess her, she complained of severe pain of left hip/and knee. She said Resident #1 was immediately sent to the hospital. She said Resident #1 received a left hip fracture. She the van driver told her she did not fasten Resident #1's lap or seat belt to buckle her in. During an interview on 12/16/15 at 1:49 p.m., the administrator said the van driver had to stop suddenly causing Resident #1 to come out of the wheelchair. He said the wheel chair was secured. The administrator said the van driver said the belts were not secured to prevent her from falling out of the wheelchair. The administrator said the van driver had been transporting residents for about six months. He said she had previously received orientation and a checklist was completed showing she demonstrated competency in the use of the van before she was permitted to transport residents. He said she was suspended pending the outcome of the investigation. He said he did not terminate her, but did retrain and orient her. The administrator said all of the van drivers have been retrained since the incident. He said for three weeks the administration was checking to ensure all residents were secured before leaving the facility in the van. The undated Transportation policy and procedure for center-based vehicles indicated the authorized driver of the center's vehicle must be completed oriented as to the transportation policy and procedure as well as successful completion of competency training on all facets of van usage before being permitted to drive. An undated Orientation Checklist community Driver-Van-Bus indicated on 06/17/15, and again on 12/08/15, the van driver completed the orientation checklist of procedures of a wheelchair lift to include: able to inspect lift for proper function, required maintenance, or damage, secure safety belt/bar, and for Wheelchair and Occupant Securement system included to be able to apply front (2) and Back (2) securement belts to each wheelchair and floor pockets/anchorages, able to apply lap/shoulder belts, and to ensure that the wheelchair brakes are locked during transport. During an interview on 12/28/15 at 2:58 p.m., the administrator said 18 residents used a wheelchair in the van during transportation.

Based on observation, interview, and record review, the facility failed to provide supervision for the proper use of alarms to prevent injuries from falls for 12 of 12 residents sampled for falls. (Resident #s 1, 62, 46, 36, 63, 65, 21, 50, 16, 55, 8, and 48) 1. Resident #1, a [AGE] year old, totally dependent on staff for assistance with transfers, fell on [DATE] fracturing her hip. The resident fell again on 9/20/11 and received an avulsion (breaking and tearing away of the bone) to her prior hip fracture, a rib fracture, and a head laceration. The incident report indicated an alarm was on her wheelchair, but no cord was on the device to activate the alarm. She had other falls on 10/23/11 and 11/30/11. 2. Resident #62, an [AGE] year old who required assistance with transfers fell 8 times between 7/25/11 and 12/4/11. The incident/fall reports indicated the bed alarm was in use for the 8 falls and did not activate for 2 falls. His injuries included: skin tears to his ear and arm, an abrasion to his knee, bleeding from the right side of his head, bruising, and swelling to his right ear, a contusion and laceration above his right eye, and a laceration to his eyebrow that required sutures. 3. Resident #46, an [AGE] year old, sustained a lumbar spine fracture when he fell from his wheelchair. Resident #46 had 5 falls between 9/8/11 and 12/14/11. On 9/12/11, he was left unattended on the toilet and fell , resulting in a hematoma and abrasion to the forehead. An alarm was in use for 4 of 5 falls. It failed to activate and activated after he fell for 2 of those falls. 4. Resident #36, a [AGE] year old who required extensive assistance with ADLs and transfers, sustained a contusion when she fell from a chair. Bed and chair alarms were ordered to be used "as needed" beginning 9/21/10. Resident #36 had 5 additional falls between 9/25/11 and 11/26/11. Two of those 5 incident/fall reports did not indicate use of an alarm; 2 indicated an alarm was used, but did not note whether it activated; 1 indicated the alarm was turned off. 5. Nine residents had ineffective bed/chair alarms in use. (Resident #s 46, 63, 65, 21, 50, 16, 55, 8, and 48) The facility had no fall management program with the exception of applying bed/chair alarms to residents at risk for falls. Following falls, the facility did not implement new strategies or evaluate the use of bed/chair alarms for effectiveness. This failure contributed to Resident #1's fall, fractured hip, hip replacement surgery and a subsequent fall resulting in an avulsion of her prior hip surgery. This failure also contributed to Resident #46's fall and spinal compression fracture and placed 54 residents at risk for falls and serious injuries. Findings included: 1.) December 2011 physician orders [REDACTED]. She had no orders for bed or chair alarms. A fall potential care plan dated 9/21/09 indicated the goal for Resident #1 was to "receive no injury due to falling ongoing"; there were no updates documented. Approaches were to assess and observe for ongoing changes in status, assure the use of non-skid soles, "transfer per %%%% (sic) assistants", keep the room and paths lighted and clear, keep the bed in low position, and "staff to be alert to identify factors that may increase the potential for falls." A quarterly MDS dated [DATE] noted she was confused, required limited assistance with ADLs, and walked independently. The most recent MDS dated [DATE] noted Resident #1 was confused and totally dependent for ADLs and transfers. The number of falls noted was one with no injuries. A care plan dated 7/26/11 had no documentation for fall risk or prevention and was not updated following Resident #1's fall and hip fracture. An incident/fall reported dated 8/14/11 indicated Resident #1 had an unwitnessed fall at the nursing station sustaining a fractured hip. She returned on 8/24/11 from the hospital following a surgical hip repair. Nurse's notes dated 9/4/11 indicated Resident #1 used a bed alarm and nursing notes dated 9/7/11 noted the use of a wheelchair alarm. Nurse's notes dated 9/19/11 indicated Resident #1 was repeatedly standing up from her wheelchair. An incident/fall report dated 9/20/11 noted Resident #1 had an unwitnessed fall from her wheelchair and sustained an avulsion to her prior hip fracture, fractured a rib, and lacerated her head. RN A's written statement on the report indicated the alarm was on the resident's wheelchair, but no cord was on the device to activate the alarm. An acute fall care plan for Resident #1 dated 9/20/11 noted to: "1. Notify the MD 2. Monitor for 72 hours after the fall for injury 3. Neurological checks for 72 hours if warranted 4. Monitor vital signs 5. Encourage to use call light 6. Report changes in endurance, ambulation, and transfers 7. Assess for proper fitting clothing, if appropriate 8. Monitor at frequent intervals 9. Monitor for safe environment 10. ROM as warranted. 11. PT/OT to assess as warranted 12. Assess for medications as a contributing factor." An incident/fall report dated 10/23/11 indicated Resident #1 had an unwitnessed fall from a geri chair while sitting at the nursing station. The report indicated her chair alarm was attached to her, but was turned off. She sustained no injuries. An incident/fall report dated 11/30/11 noted Resident #1 had an unwitnessed fall in her room. She was found on the floor at 6:50 a.m. and had no injuries. The report indicated bed and chair alarms were in place, but did not note whether they were turned on or sounded. An acute fall care plan dated 11/30/11 contained the same twelve approaches for Resident #1 as on all acute fall care plans. A thirteenth approach was written in to "ensure alarms are activated ." During an interview on 12/13/11 at 11:15 a.m., CNA B said she did not remember when Resident #1 got an alarm, but she thought it was after her hip fracture. She said the resident walked independently and went to the bathroom without assistance prior to her fall, but she was incontinent and required total assistance with her ADLs following her hip fracture. During an interview on 12/13/11 at 11:20 a.m., RN D said when Resident #1 fell on [DATE], her alarm was off and no one saw her until she was already on the floor. During an interview on 12/13/11 at 2:50 p.m., restorative aide C said she did not know when Resident #1 got an alarm. She said sometimes the alarm was used and sometimes it was not. She also said that although the alarm was sometimes in place, it was not always turned on. During an interview on 12/13/11 at 3:31 p.m., the DON said prior to Resident #1's fall on 8/14/11, the intervention was just to observe the resident. After her fall, she said the interventions were for bed and chair alarms, therapy, and use of a geri chair. She said her care plan should have been updated by the MDS coordinator, but the DON did not check to see if it had been done. The DON said after Resident #1's 9/20/11 fall, she talked to the staff regarding turning off resident alarms, but no other interventions were implemented. The DON said following the 10/23/11 fall, she told the staff to make sure Resident #1's alarm was turned on. She said no other interventions were implemented. She said following the 11/30/11 fall, physical therapy was consulted to evaluate Resident #1, but no order was written until 12/6/11. The DON also said the nurse who documented incident/fall reports should fill out the acute fall care plan and indicate what approaches were used. 2.) December 2011 physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #62 was confused, could not speak, and required assistance with all ADLs and transfers. A fall potential care plan dated 7/27/11 noted approaches for Resident #62 were to assess for changes in status, assure non-skid shoes, "transfer per %%% (sic) assistants," keep room and paths clear and well lighted, keep bed in lowest position, and staff were to be alert to identify factors that increased fall potential. The only update indicated the staff was to continue the plan of care dated 10/26/11. An incident/fall report dated 7/25/11 indicated Resident #62 had an unwitnessed fall when he fell from his bed after the sitter closed her eyes. He sustained a skin tear to his right elbow. The report indicated the sitter said she moved the fall mat by his bed because she did not think it was needed since she was in the room. The report also noted a bed alarm was in use, but it did not indicate if the alarm was turned on or sounded. A fall investigation worksheet for Resident #62 dated 7/25/11 noted in the section for " ecommendations to prevent further falls" to "continue alarm; mattress to floor." An acute fall care plan dated 7/25/11 noted the twelve approaches for Resident #62 were the same as on all acute fall care plans. An incident/fall report dated 8/1/11 indicated Resident #62 had an unwitnessed fall from his bed.\, but sustained no injuries. The report noted a bed/chair alarm was in use, but did not indicate if it was on or sounded. CNA G's written statement indicated she found the resident on the floor. A fall investigation worksheet for Resident #62 dated 8/1/11 noted in the section for "recommendations to prevent further falls" to "continue bed/chair alarm, call light, assistive devices within easy reach, currently on skilled therapy services." An acute fall care plan dated 8/1/11 noted the twelve approaches for Resident #62 were the same as on all acute fall care plans. An incident/fall report dated 8/19/11 indicated Resident #62 had an unwitnessed fall from his bed, but sustained no injuries. The report indicated 1/2 side rails were used, but bed/chair alarm was not marked. LVN H's written statement indicated she heard Resident #62's bed alarm and found him on the floor by his bed. A fall investigation worksheet for Resident #62 dated 8/19/11 noted in the section for "recommendations to prevent further falls" to "have bed/chair alarm, frequent room checks, monitor during shifts, re-orientation prn need." An acute fall care plan dated 8/19/11 noted the twelve approaches for Resident #62 were the same as on all acute fall care plans. An incident/fall report dated 9/28/11 indicated Resident #62 had an unwitnessed fall from his bed and sustained no injuries. The report indicated a bed/chair alarm was in use, but "bed alarm did not activate" was documented. A fall investigation worksheet for Resident #62 dated 9/28/11 noted in the section for "recommendations to prevent further falls" and "bed/chair alarm, frequent monitoring." A therapy screen dated 9/28/11 noted Resident #62 had a "recent fall" and had no documentation in the "section to be completed by rehab." Resident #62 had no acute fall care plan dated 9/28/11. An incident/fall report dated 10/13/11 indicated Resident #62 had an unwitnessed fall in the dining room when he fell from his wheelchair. He sustained an injury, bleeding from the right side of his head. The report indicated resident supports, including bed/chair alarms, was marked "none ordered." The event summary read, "Chair alarm did not go off." An investigation report dated 10/14/11 for Resident #62 noted in the section "analysis (describe why incident occurred and how recurrence will be avoided)" noted, "Resident left by sitter who did not replace alarm after changing his jacket. Resident stood up from wheelchair and fell to the floor hitting his head. (No) loss of consciousness." An acute fall care plan dated 10/13/11 contained the same twelve approaches for Resident #62 as on the other acute fall care plans. Two approaches were checked: notify physician and neurological checks for 72 hours, if warranted. A therapy screen dated 10/14/11 noted Resident #62 had a "recent fall " and the "section to be completed by rehab" had no documentation. An incident/fall report dated 11/1/11 indicated Resident #62 had an unwitnessed fall from his bed sustaining a skin tear, bruising, and swelling to his right ear. There was no documentation regarding use of a bed/chair alarm. A therapy screen dated 11/1/11 noted Resident #62 had a "recent fall" and the "section to be completed by rehab" had no documentation. An incident/fall report dated 11/6/11 indicated Resident #62 had an unwitnessed fall from his wheelchair sustaining a laceration and contusion above his right eye. He was sent to the emergency room . Bed/chair alarm was marked on the report, but there was no documentation regarding the alarm being on or whether it sounded. An untitled document dated 11/6/11 noted Resident #62 returned from the emergency room with sutures. A therapy screen dated 11/7/11 noted Resident #62 had a "recent fall" and the "section to be completed by rehab" had no documentation. An incident/fall report dated 12/4/11 indicated Resident #62 had an unwitnessed fall from his wheelchair sustaining a head injury with a hematoma and laceration. He was sent to the emergency room . An investigation report for Resident #62 dated 12/5/11 noted "analysis (describe why incident occurred and how recurrence will be avoided)" noted, "Frequent checks on resident, attempt to reposition frequently." A therapy screen dated 12/5/11 noted Resident #62 had a "recent fall" and the "section to be completed by rehab" had no documentation. The incident/fall log dated July 2011 through December 2011 indicated Resident #62 sustained falls resulting in skin tears on 7/19/11, 9/25/11, and 11/1/11. The same log indicated Resident #62 had falls with no injuries on 10/6/11, 10/16/11, 10/27/11, 10/31/11 and 11/5/11. 3.) December 2011 physician orders [REDACTED]. He had orders for bed and chair alarms with a start date of 9/13/11. The most recent MDS dated [DATE] indicated Resident #46 was confused, dependent for ADLs, and had two falls, one with no injury, and one with a non-major injury. A fall risk care plan dated 3/9/10 noted a goal for Resident #46 of no injury due to ongoing falls. Continue plan of care was dated 7/13/11, 9/8/11, and 11/3/11. A bed/chair alarm care plan dated 3/22/11 had approaches for Resident #46 including, "...Assure alarm is maintained and in good working condition. Assure all staff are (sic) aware that resident should have alarm on ..." Continue plan of care was dated 7/13/11, 9/8/11, and 11/3/11. An incident/fall report dated 8/15/11 noted Resident #46 fell from his wheelchair while sitting at the nursing station and staff were unable to catch him prior to his fall. The report indicated he had a chair and bed alarm, but did not indicate whether it was turned on or sounded when he stood up. A hospital x-ray report dated 8/16/11 noted a lumbar spine compression fracture sustained following a fall on 8/15/11. Interventions noted in the report were to continue chair alarm and monitor him at shift change. A fall investigation worksheet for Resident #46 dated 8/15/11 noted in the section "recommendations to prevent further falls" were "bed/chair alarm to continue, reoriented per resident need, monitor during shift change." A fall risk assessment dated [DATE] noted Resident #46 had a score of 19; the form indicated a score of 10 or greater equaled high risk. An acute fall care plan dated 8/15/11 contained the same 12 approaches for Resident #46 as on all acute fall care plans. An incident/fall report dated 9/12/11 indicated Resident #46 sustained a hematoma and abrasion to his right forehead following a fall from his bathroom toilet after being left unattended. CNA E's written statement indicated she assisted him to the bathroom, told him not to get up, she would be right back. He was on the floor when she returned. A fall investigation worksheet for Resident #46 dated 9/12/11 noted in the section "recommendations to prevent further falls" were "bed/chair alarm in use, monitor during shift change." An acute fall care plan dated 9/12/11 contained the same twelve approaches for Resident #46 as on all acute care plans. A physician order [REDACTED]. An incident/fall report dated 9/29/11 noted Resident #46 had an unwitnessed fall in his room when CNA F heard a noise and found the resident on the floor at the foot of his bed. The report indicated the resident had a bed alarm, but it did not sound. He sustained redness and an abrasion to his right knee. There were no interventions documented. A fall investigation worksheet for Resident #46 dated 9/29/11 noted in the section "recommendations to prevent further falls" were "bed/chair alarm in use." A fall risk assessment dated [DATE] indicated Resident #46 had a score of 19. An incident/fall report dated 10/24/11 indicated Resident #46 had an unwitnessed fall in his room. RN A found the resident between the wheelchair and bed and noted the resident told her he slid out of his wheelchair. He did not sustain an injury. It was documented his wheelchair alarm was not attached. An investigation report for Resident #46 dated 10/25/11 noted in the section "analysis (describe why incident occurred and how recurrence will be avoided ...)" that "resident had pain medicine, sat on the side of the bed, fell asleep et (sic) slide to the floor stated per resident." A therapy screen dated 10/25/11 noted Resident #46 had no documentation in the section "To be completed by rehab." An incident/fall report dated 12/14/11 indicated Resident #46 had a witnessed fall while sitting in a wheelchair at the nursing station. A family member's witness statement indicated Resident #46 went to sleep and fell from his wheelchair, noting his alarm did not sound until he was "halfway on the floor." An acute fall care plan dated 12/14/11 indicated Resident #46's physician was notified, blood pressure meds could have been a contributing factor, and to send the resident to the ER for evaluation. A therapy screen dated 12/14/11 noted Resident #46 had a "recent fall 12/14/11" and had no documentation in the section "To be completed by rehab." The incident/fall log dated July 2011 through December 2011 indicated Resident #46 sustained an additional fall without injury on 9/8/11. No other falls were documented in the log. 4.) December 2011 physician orders [REDACTED]. She also had an order for [REDACTED]. The most recent MDS dated [DATE] noted Resident #36 was confused and required extensive assistance with ADLs, mobility, and transfers. It also indicated she had two or more falls with no injury and one fall with a non-major injury. An incident/fall report dated 9/15/11 indicated Resident #36 had a fall witnessed by a visitor where she fell from a chair (unknown type) and the chair fell on her. The ADON's written statement indicated she heard a loud noise and saw the chair on the resident. She sustained a contusion, undocumented site. There was no documentation of a chair alarm in use or of any interventions. A fall investigation worksheet for Resident #36 dated 9/16/11 noted the section "Recommendations to prevent further falls" was blank. A therapy screen dated 9/16/11 noted Resident #36 had a "recent fall" and had no documentation in the section "To be completed by rehab." A fall risk assessment dated [DATE] indicated Resident #36's score was 12. A care plan or potential for injury related to unsteady gait dated 10/16/07, updated 11/3/11, indicated to assess Resident #36's mobility and changes in status, assure non-skid shoes, transfer with assistance, paths clear, call light in reach, bed low position, and staff were to identify factors that may increase fall potential. An acute fall care plan dated 9/15/11 contained the same twelve approaches for Resident #36 as on all acute fall care plans. An incident/fall report dated 9/25/11 indicated Resident #36 had an unwitnessed fall where she was found lying in the doorway of another resident's room. She was sent to the ER, but had sustained no injuries. There was no documentation of an alarm in use. A fall investigation worksheet for Resident #36 dated 9/26/11 noted in the section "Recommendations to prevent further falls" were "frequent monitoring; monitor during shift." A PT screen dated 9/27/11 indicated therapy was not recommended for Resident #36 due to recent discharge from therapy; use a wheelchair when gait becomes unsteady. During an interview on 12/15/11 at 8:17 a.m., the COTA said Resident #36 was last discharged from therapy 7/28/11. A fall risk assessment dated [DATE] indicated Resident #36's score was 16. An acute fall care plan for Resident #36 dated 9/25/11 contained the same approaches as the acute fall care plan for her dated 9/15/11. An incident/fall report dated 10/3/11 indicated Resident #36 had a witnessed fall when she attempted to sit in a dining room chair, missed, and fell to the floor. She struck her back and ribs against the chair. She was sent to the ER; no injuries were sustained. There was no documentation of an alarm in use. A fall investigation worksheet for Resident #36 dated 10/7/11 noted in the section "Recommendations to prevent further falls" were "bed/chair alarm, monitor frequently, re-orientate (sic) per need." A therapy screen dated 10/18/11 indicated Resident #36 was at her baseline and ineligible for physical therapy. A fall risk assessment dated [DATE] noted Resident #36's score was 17. Resident #36 had an acute care plan for bruising dated 10/3/11; there was no acute care plan for the fall. An incident/fall report dated 10/10/11 indicated Resident #36 had an unwitnessed fall where she was found on the floor beside her bed. The report noted the bed alarm was on the bed, but it was turned off. An investigation report for Resident #36 dated 10/11/11 noted in the section "Analysis: Describe why incident occurred and recurrence will be avoided " was "Resident has bilateral lower extremity weakness; bed/chair alarm in use at all times ..." A fall risk assessment dated [DATE] noted Resident #36's score was 17. An acute fall care plan dated 10/10/11 was documented the same for Resident #36 as the acute fall care plans for her dated 9/15/11 and 9/25/11. An incident/fall report dated 11/14/11 indicated Resident #36 had an unwitnessed fall from her wheelchair in her room sustaining a bruise to her right elbow. The report noted a chair alarm but did not indicate whether it was turned on or sounded. The only intervention was "will monitor." A fall risk assessment for Resident #36 was with the incident/fall report dated 11/14/11. It was undated and blank. Resident #36 had no acute fall care plan with the 11/14/11 incident/fall report. A therapy screen dated 11/15/11 indicated Resident #36 had a "recent fall" and had no documentation in the "section to be completed by rehab." An incident/fall report dated 11/26/11 indicated Resident #36 had a witnessed fall at the nursing station while standing from her wheelchair sustaining a bruise to her left forearm. The report noted "chair alarm was in place." It did not indicate if he alarm was on or if it sounded. Resident #36 had no fall risk assessment, no acute fall care plan, and the therapy screen form with the incident/fall report dated 11/26/11 was blank. During an interview on 12/14/11 at 2:55 p.m., the DON said there was a problem with therapy screening residents. She did not know if Resident #36's care plans had been updated. She said after each of those falls, they brought Resident #36 to the nursing station, observed her, and the bed/chair alarms were used. 5.) During an observation and interview on 12/13/11 at 9:25 a.m., Resident #46's alarm cord was attached to the resident and his wheelchair. The cord was approximately two and a half feet long. CNA E and the activity director stood the resident and the alarm did not activate. The DON was present and said the alarm could not go off because the string connected to the alarm was too long. The undated owner's manual, directions for use for bed/chair magnet alarms noted: " ...Step 3: Attach the device to a wheelchair, chair, or bed ...Step 4: Attach the alligator clip to the resident's garment. Step 5: Adjust the length of the cord according to the placement of the device on the wheelchair, chair, or bed. Step 6: Adjust the string, allowing the resident to move naturally before the alarm is activated. If the resident moves beyond that distance, the magnet detaches from the face of the unit from any angle, producing an audible tone to cue the resident to sit back down, and alerts the caregiver that a resident may be at risk of falling. If possible, test the cord length by asking the resident to lean forward a comfortable distance ... " During an interview on 12/13/11 at 9:28 a.m., CNA E provided a list of 16 residents with alarms. During observations on 12/13/11, when the following five residents in wheelchairs were assisted to a standing position, the alarm cords were too long to activate: *9:30 a.m., Resident #46 *9:33 a.m., Resident #63 *9:37 a.m., Resident #65 *9:40 a.m., Resident #21 *10:00 a.m., Resident #50 *10:03 a.m., Resident #55 was sitting in chair with the chair alarm clipped to the resident and attached to the chair arm. When the resident stood, the alarm slid off the chair arm and did not activate. *10:05 a.m., Resident #16 was sitting in a wheelchair with a chair alarm clipped to the resident and attached to the wheelchair. When she stood, the alarm cord was too long and did not activate. *10:09 a.m., Resident #8 was sitting in a wheelchair with the alarm attached to the wheelchair, but it was not clipped to the resident. *10:12 a.m., Resident #48 was lying in bed with a bed alarm clipped to the resident and attached to the bed. The alarm was turned off. During an interview on 12/13/11 at 10:31 a.m., CNA E said she had never been in-serviced on how to attach or trouble-shoot bed/chair alarms. She said there was no list of residents with bed/chair alarms. CNA E said the list she provided was made when she went through the building looking at residents to see who had alarms. During an interview on 12/13/11 at 11:10 a.m., CNA B said there was no list of residents with alarms, staff knew by "word of mouth." CNA B also said she had never been in-serviced on bed/chair alarm use. During an interview on 12/13/11 at 11:25 a.m., CNA I said there was no list of residents with alarms, staff knew by "word of mouth." CNA I also said she had never been in-serviced on bed/chair alarm use. During an interview on 12/13/11 at 11:40 a.m., CNA J said she had never been in-serviced on bed/chair alarm use. She also said she did not know who was responsible to ensure alarms were working properly. During an interview on 12/13/11 at 11:45 a.m., the DON said CNAs should report to each other which residents had bed/chair alarms. The DON also said she now realized CNAs did not have training on use of bed/chair alarms. The DON said she had never conducted an in-service on use of bed/chair alarms. During an interview on 12/13/11 at 11:51 a.m., the DON said no prior problem with bed/chair alarms had been identified. During an interview on 12/13/11 at 12:10 p.m., CNA K said she had no training during orientation about bed/chair alarms. CNA K said she knew who had alarms from other CNAs. CNA K said she had an in-service on the bed/chair alarms that day but had no prior in-service on them. During an interview on 12/13/11 at 12:20 p.m., CNA L said she had never been in-serviced on bed/chair alarm use. During an interview on 12/13/11 at 12:25 p.m., CNA M said there was no list of residents at risk for falls. CNA M said nurse aides did not receive report. She said she would only knew who had falls if she "overheard" it. CNA M said she had never been in-serviced on bed/chair alarm use. During an interview on 12/13/11 at 12:38 p.m., the ADON said there had never been an in-service on bed/chair alarm use. The ADON said she had "no idea" how nurses would know how to correctly put a bed/chair alarm on a resident. She said the alarm cord should not be so long that when a resident stands, the alarm would not activate. During an interview on 12/13/11 at 12:52 p.m., RN A said she had shortened alarm cords because they were too long to activate when the resident stood. During an interview on 12/13/11 at 2:37 p.m., the DON said there was no policy for bed/chair alarms. The DON said a fall risk assessment was completed on new residents and if at risk, a bed/chair alarms would "automatically" be placed on the resident. She also said residents with an unsteady gait were given bed/chair alarms. During an interview on 12/13/11 at 2:50 p.m., restorative aide C said she learned use of bed/chair alarms on her own and she taught other aides. During an interview on 12/13/11 at 3:31 p.m., the DON said there was no fall management program. She said falls were discussed in daily morning meetings. During an interview and record review on 12/15/11 at 6:08 p.m., the DON said five additional residents were identified with bed/chair alarms and provided an amended list changing the total number to 21 residents with bed/chair alarms. Fall risk assessments dated 12/13/11 through 12/14/11 indicated 54 residents were at risk for falls.