Every finding on record at Winston County Nursing Home

Based on observations, interviews, record reviews, facility document review, and facility policy review, the facility failed to develop and implement care plans to address a physician-ordered fluid restriction for two (2) of five (5) dialysis residents, Resident #43 and Resident #58. Findings include: Record review of the facility policy titled Care Plan, revised 2/1/23, revealed under Purpose: To direct resident care from admission to discharge. Resident #43 Record review of Resident #43's dialysis Care Plan revealed Hemodialysis – I am at increased risk for complications related to I have diagnosis of: ESRD (end stage renal disease) with hemodialysis. There was no mention of fluid restrictions on the care plan. Record review of Resident #43's orders revealed, Hemodialysis at (Proper Name) Monday-Wednesday-Friday with active date 4/30/25. Record review of Resident #43's orders revealed, 1000 milliliters (mL) fluid restriction every 24 hours with active date 8/12/25. Record review of Resident #43's Nutritional Risk assessment dated [DATE], revealed, .Oral intake: Fluids.Consumes 1000-1499 mL/day. Record review of Progress Note dated 5/25/2026, revealed, .Resident stated that he will be going back to dialysis tomorrow (5/26/26) due to having too much fluid . Record review of Progress Note dated 5/28/2026, revealed, .Resident is in bed at this time.Reported not feeling the best this AM due to going to dialysis back-to back the past three (3) days. During an interview on 6/17/2026 at 9:21 AM, the Administrator confirmed that Resident #43 was on a 1000 mL per day fluid restriction. During an interview on 6/17/2026 at 4:58 PM, the Minimum Data Set (MDS) nurse confirmed Resident #43's dialysis care plan had not been fully developed to include fluid restrictions related to dialysis. MDS nurse stated that because the care plan did not include the resident's fluid restriction, staff could be unaware of the restriction and provide more fluids than allowed. She further verbalized that this practice could lead to fluid excess and even fluid overload that could lead to hospitalization. Record review of Resident #43's admission Record revealed the facility admitted the resident on 4/30/2025 with diagnoses including End Stage Renal Disease. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/26 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 15 which indicated Resident #43 was cognitively intact. Resident #58Record review of Resident #58's Care Plan Report revealed under Focus: I hemodialysis – I am at increased risk for complications R/T (related to) I have dx (diagnosis) of: ESRD (end stage renal disease) w/(with) hemodialysis. Record review also revealed under Interventions: I am on a 1200 cc (cubic centimeter) fluid restriction.During an observation with Resident #58 on 6/15/26 at 12:30 PM, she was lying in bed and a 32-ounce water pitcher full of water was sitting on the bedside table. Further observation revealed a case of bottled water and Diet Mountain Dew stored in her room.An interview with Licensed Practical Nurse (LPN) #1 on 6/17/26 at 8:18 AM revealed Resident #58's water intake provided during medication administration was not documented on the MAR.During an interview with Certified Nurse Aide (CNA) #1 on 6/17/26 at 12:35 PM, she revealed Resident #58's family brought beverages into the room; however, she only documented fluids consumed during meals.An interview with the MDS Nurse on 6/18/26 at 12:15 PM revealed the purpose of the care plan was to ensure staff were aware of the care Resident #58 was supposed to receive. She confirmed the plan of care was not followed because fluids were not tracked and the resident exceeded the prescribed limit on several occasions.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #58 on 12/20/23 with medical diagnoses that included Anemia, Dependence on Renal Dialysis, and chronic kidney disease.Record review of the MDS with an ARD of 4/12/26 revealed under Section C, a BIMS summary score of 15, indicating Resident #58 was cognitively intact.

Based on observations, interviews, record review, facility document review, and facility policy review, the facility failed to ensure a physician-ordered fluid restriction was implemented and monitored for three (3) of five (5) dialysis residents. Resident #12, #43, and #58. Findings Include: Record review revealed that the facility does not have a policy and presented a statement on facility letterhead dated 06/17/26, that stated, (Proper name) nursing home does not have a policy specific to fluid restrictions on dialysis residents, signed by the Administrator. Resident #12An observation and interview with Resident #12 on 6/16/26 at 8:30 AM revealed she was lying in bed. A 32-ounce water pitcher full of ice water was located on the bedside table. The resident stated she attended dialysis three times weekly and was not aware of a fluid restriction.Record review of Resident #12's Order Summary Report revealed an order dated 2/20/26, Hemodialysis with 'proper name of dialysis company' Mon (Monday), Wed (Wednesday), Fri (Friday) @ (at) 11:30.Record review of Resident #12's Order Summary Report revealed no physician order for a fluid restriction was present in the facility medical record.An interview with the Quality Assurance (QA) Nurse on 6/17/26 at 9:38 AM revealed Resident #12 had never been on a fluid restriction since she started dialysis in February 2026.An interview with the Registered Dietitian (RD) on 6/17/26 at 10:32 AM confirmed she was aware Resident #12 was supposed to have a physician order for a fluid restriction, stating, Yes she has a 1200 milliliter (ml) fluid restriction, dialysis has already told me. She confirmed she did not relay this information to the nursing staff and stated it must have been a miscommunication. Record review of the RD Fluid Restriction Tracking Record revealed Resident #12 was documented as having a daily 1200 milliliter fluid restriction.A telephone interview with Proper name of the dialysis company RD on 6/17/26 at 10:54 AM revealed every dialysis resident should have a 1200 milliliter fluid restriction unless notified otherwise. She stated Resident #12's fluid restriction had been communicated to the facility on numerous occasions. The RD confirmed the resident should not have a water pitcher in her room because she could easily exceed her fluid limit.Record review of Resident #12's June 2026 Medication Administration Record (MAR) revealed an order dated 6/3/24, Glucerna one-time daily HS (bedtime) snack.Record review of Resident #12's Nutrition/Fluids Task Summary and June 2026 MAR revealed no evidence nursing staff were monitoring or documenting fluid intake to ensure the resident did not exceed the prescribed fluid restriction.Record review of the admission Record revealed the facility admitted Resident #12 on 1/16/18 with medical diagnoses that included Chronic Kidney Disease, Dependence on Renal Dialysis, and Unspecified Sequela of Cerebral Infarction.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/24/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, indicating Resident #12 was cognitively intact. Resident #43 Record review of Resident #43's orders revealed, Hemodialysis at (Proper Name) Monday-Wednesday-Friday with active date 4/30/25. Record review of Resident #43's orders revealed, 1000 milliliters (mL) fluid restriction every 24 hours with active date 8/12/25. Record review of Resident #43's Nutritional Risk assessment dated [DATE], revealed, .Oral intake: Fluids.Consumes 1000-1499 cc (cubic centimeters) /day. Record review of Resident #43's MARs for May 2026 and June 2026 revealed no documentation of monitoring related to the resident's physician-ordered fluid restriction. Record review of Progress Note dated 5/25/2026, revealed, .Resident stated that he will be going back to dialysis tomorrow (5/26/26) due to having too much fluid . Record review of Progress Note dated 5/28/2026, revealed, .Resident is in bed at this time.Reported not feeling the best this AM due to going to dialysis back-to-back the past three (3) days. Record review of Resident #43's Communication Form with Dialysis dated 6/1/26, revealed, .was heavy with fluid. Did not reach Estimated Dry Weight (EDW). Remains 2.0 kilograms (kg) over EDW. Plan to bring patient back on Thursday for another treatment depending on how much fluid he has on Wednesday. Record review of Resident #43's Communication Form with Dialysis dated 6/8/26, revealed, .Please help patient with fluid restriction control, patient shouldn't have over 32 ounces (oz) daily. Record review of Progress Note dated 6/12/2026, revealed, Pharmacy Recommendations to reduce Ativan and Medical Director (MD) disagrees at this time due to resident having severe anxiety associated with dialysis. Record review of Resident #43's Nutrition-Fluids Intake Amount flowsheet for dates 5/19/2026 through 6/16/2026 revealed oral fluid intake exceeded the physician-ordered 1000 mL fluid restriction on the following dates: 5/19/26 - 1400 mL 5/21/26 - 1660 mL 5/22/26 - 1560 mL 5/23/26 - 1760 mL 5/24/26 - 1280mL 5/27/26 - 1440 mL 5/28/26 - 1880 mL 5/29/26 - 1520 mL 5/30/26 - 1920 mL 5/31/26 - 1080 mL 6/1/26 - 1400 mL 6/2/26 - 1440 mL 6/3/26 - 1380 mL 6/4/26 - 1560 mL 6/5/26 - 1328 mL 6/6/26 - 1740 mL 6/7/26 - 1930 mL 6/8/26 - 1810 mL 6/9/26 - 1440 mL 6/10/26 - 1440 mL 6/11/26 - 2030 mL 6/12/26 - 2390 mL 6/13/26 - 1940 mL 6/14/26 - 1940 mL 6/15/26 - 1540 mL 6/16/26 - 1750 mL During an interview on 6/17/2026 at 9:21 AM, the Administrator confirmed that Resident #43 was on a 1000 mL per day fluid restriction. During a phone interview on 6/17/2026 at 10:00 AM, the Dialysis Nurse stated Resident #43 has had too large of a gain recently. She also confirmed Resident #43 has required extra treatments in the past few weeks for fluid. During a phone interview on 6/17/2026 at 10:49 AM, the Dialysis Registered Dietitian stated that her review of recent dialysis treatments showed fluid removal ranging from 2.6 liters to 3.10 liters, depending on the day. She also stated that she did not feel Resident #43 was purposefully non-compliant with his fluid intake, however, she stated, He's going to drink what he's given. During an interview on 06/17/2026 at 12:35 PM, the Administrator stated that Dialysis Communication Forms were received from dialysis by fax to the facility after the treatment and then placed in a notebook near the fax machine. She confirmed they were not always reviewed by the nurse. Record review of Resident #43's admission Record revealed the facility admitted the resident on 4/30/2025 with diagnoses including End Stage Renal Disease. A record review of the MDS with an ARD of 4/12/26 revealed under section C, a BIMS summary score of 15 which indicated Resident #43 was cognitively intact. Resident #58An observation and interview with Resident #58 on 6/15/26 at 12:30 PM revealed she was lying in bed and a 32-ounce water pitcher full of water was sitting on the bedside table. She stated she attended dialysis and was not aware of having a fluid restriction. Further observation revealed a case of bottled water and soft drinks stored in her room.Record review of Resident #58's Order Summary Report revealed an order dated 7/11/25, Dialysis @ (at) 'proper name of dialysis company' Monday, Wednesday, Friday @ (at) 7:00 AM. Record review also revealed an order dated 6/4/25 for a 1200 milliliter per day fluid restriction.Record review of Resident #58's Nutrition/Fluids Task on the MAR revealed the resident exceeded the 1200 milliliter per day fluid restriction on the following dates:6/4/26 - 1680 milliliters6/7/26 - 1314 milliliters6/9/26 - 1680 milliliters6/11/26 - 1440 milliliters6/13/26 - 1680 milliliters6/14/26 - 1680 millilitersAn interview with Licensed Practical Nurse (LPN) #1 on 6/17/26 at 8:18 AM revealed she had never known Resident #58 to exceed her fluid restriction and stated, We usually have to stay on her to drink. She revealed she provided the resident Glucerna twice daily and approximately 120 milliliters of water with medications but did not document the water intake on the MAR. She confirmed a water pitcher at the bedside was not appropriate for a dialysis resident and stated fluid intake should be closely monitored to prevent excess fluid accumulation.An interview with the Administrator on 6/17/26 at 9:12 AM revealed residents on fluid restrictions were only allowed what the nurse provided and what dietary provided at meals. She confirmed all fluids should be documented and tracked for accurate accounting of fluid intake.An interview with Certified Nurse Aide (CNA) #1 on 6/17/26 at 12:35 PM revealed every resident received a water pitcher full of ice water unless they were on thickened liquids, even if they were on a fluid restriction. She stated Resident #58's family also brought beverages into the room, but she only documented what was consumed during meals.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #58 on 12/20/23 with medical diagnoses that included Anemia, Dependence on Renal Dialysis, and chronic kidney disease.Record review of the MDS with an ARD of 4/12/26 revealed under section C, a BIMS summary score of 15, indicating Resident #58 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to store foods in kitchen refrigeration that was maintained in a clean, sanitary condition and good repair for one (1) of two (2) kitchen tours. Findings Include:Review of the facility policy titled Food Handling Guidelines: Cooling Process and Cold Holding, revised 4/26, revealed under, Policy: . An effective preventative maintenance plan is in place for each piece of food service equipment. All refrigeration is maintained in good working order and is calibrated, serviced, or tested per the manufacturer's instructions .During the initial kitchen tour on 6/15/26 at 11:00 AM, observation of the tray line cooler revealed the interior lower metal surface contained an excessive amount of moisture and was covered with a greenish-black substance in spotty patches. The interior lower door gasket was covered with a black substance, and the gasket was dangling from the refrigerator door, visibly preventing a proper seal.An observation and interview with Dietary Staff #3 on 6/15/26 at 11:06 AM confirmed the refrigerator was unclean and contained a black substance that she stated, Looks like mold. She stated the refrigerator was supposed to be cleaned weekly and confirmed, based on its appearance, that it had not been cleaned in some time. She confirmed the condition of the refrigerator could contaminate food and make someone sick. She also confirmed the seal (gasket) was loose and hanging, preventing a proper seal and potentially affecting the temperature inside the refrigerator.An observation and interview with the Dietary Manager on 6/15/26 at 11:14 AM confirmed the refrigerator was unclean and that the lower gasket was dislodged from the door, creating an improper door seal. She stated the lack of a proper seal could result in improper food storage temperatures inside the refrigerator, which could make someone sick.

Based on observations, resident interviews, staff interviews, record review, and facility policy review, the facility failed to promote dignity and maintain independence during meal service by failing to provide a table knife to residents who were capable of independently cutting their own food for six (6) of eight (8) residents reviewed during a dining observation in the Cypress Cottage. Residents #6, Resident #16, Resident #34, Resident #49, Resident #70, and Resident #90Findings Include:Review of the facility policy titled Resident Rights revised 2/1/23 revealed under, Policy: It is the nursing home's policy to provide the kind of care that will maintain and enhance dignity, respect individuality and quality of life .An observation of the lunch meal and resident interviews in the Cypress Cottage on 6/17/26 at 12:31 PM revealed residents were served pork chop with gravy, rice, squash and zucchini, and a roll. During the observation, Resident #6 was observed attempting to cut her pork chop with a fork without success. She then used a spoon to attempt to cut the meat while holding it in place with a fork. When asked whether she had a table knife to cut the meat, she stated, We are not allowed to have a knife, and stated the facility only allowed them to have a plastic knife. Residents #16, #34, #49, #70, and #90 were also observed unable to cut their meat due to not having a knife. Resident #90 stated he was not sure why the facility would not provide knives and stated they all had to wait for an aide to cut up their meat. The residents were observed to be independent with eating but were required to request assistance and wait for the staff to help them to cut their meat. This resulted in residents being unable to independently consume their meals in a manner consistent with their assessed abilities.An interview with the Ambassador of Food Service #2 on 6/17/26 at 12:48 PM revealed she had been told residents could not have a butter knife and must wait for nursing staff or aides to assist with cutting their meat. She confirmed the residents were independent and capable of performing this task and stated residents should be treated with dignity and respect in a home-like environment.An interview with the Administrator on 6/17/26 at 3:49 PM revealed she was not aware residents were not receiving a knife at meals and confirmed residents who were capable should be allowed to independently cut up their own meat.An interview with the Interim Director of Food Services on 6/19/26 at 8:45 AM revealed she was not aware residents were not receiving a knife with meals. She stated every meal tray should be provided with a spoon, fork, and knife to promote a dignified dining experience.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #6 on 11/14/25 with medical diagnoses that included Age-Related Osteoporosis, Hypokalemia, Vitamin B-12 Deficiency Anemia, Hypo-Osmolality and Hyponatremia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 10, indicating Resident #6 was moderately cognitively impaired. Additionally, review of Section GG revealed the resident required set up or clean-up assistance with meals.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #16 on 5/14/25 with medical diagnoses that included chronic kidney disease and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 4/19/26 revealed under Section C, a BIMS summary score of 11, indicating Resident #16 was moderately cognitively impaired. Additionally, review of Section GG revealed the resident required set up or clean-up assistance with meals.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #34 on 10/10/19 with medical diagnoses that included Hyperlipidemia, Vitamin D Deficiency, and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 6/14/26 revealed under Section C, a BIMS summary score of 15, indicating Resident #34 was cognitively intact. Additionally, review of Section GG revealed the resident required set up or clean-up assistance with meals.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #49 on 3/20/20 with medical diagnoses that included Hypokalemia, Vitamin D Deficiency, and Essential (Primary) Hypertension.Record review of the MDS with an ARD of 6/7/26 revealed under Section C, a BIMS summary score of 15, indicating Resident #49 was cognitively intact. Additionally, review of Section GG revealed the resident required set up or clean-up assistance with meals.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #70 on 3/5/26 with medical diagnoses that included Hypokalemia and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 5/31/26 revealed under Section C, a BIMS summary score of 10, indicating Resident #70 was moderately cognitively impaired. Additionally, review of Section GG revealed the resident required set up or clean-up assistance with meals.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #90 on 6/9/25 with medical diagnoses that included Essential (Primary) Hypertension and Atrial Fibrillation.Record review of the MDS with an ARD of 5/17/26 revealed under Section C, a BIMS summary score of 9, indicating Resident #90 was moderately cognitively impaired. Additionally, review of Section GG revealed the resident required set up or clean-up assistance with meals.

Based on record review, observations, resident interviews, staff interviews, and facility policy review, the facility failed to make prompt efforts to resolve resident grievances related to food quality, food preferences, alternative menu selections, meal variety, food temperature, and food palatability as evidenced by unresolved concerns identified during six (6) of 12 months of Resident Council meetings reviewed. Resident #6, #13, #25, #28, #34, #38, #42, #49, #69, #81, and #99 Findings Include:Review of the facility policy titled Grievances-Family and Resident Grievances revealed under, Policy: It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal, or fear of discrimination. Additionally revealed under, Policy Explanation and Compliance Guidelines: . 12. The facility will make prompt efforts to resolve grievances.Record review of Resident Council meeting minutes dated 12/1/25, 1/5/26, 3/2/26, 4/1/26, 5/4/26, and 6/1/26 revealed repeated resident complaints regarding food quality, alternative menu requests not being honored, food temperature, lack of variety, tough meats, poor food preparation, excessive seasoning, insufficient seasoning, and repetitive menu items.An interview with Resident #34 on 6/15/26 at 12:30 PM revealed the food was awful. She stated the facility frequently served string beans and the food lacked flavor due to insufficient seasoning. She reported these concerns had been ongoing.An interview with Resident #49 on 6/15/26 at 4:30 PM revealed the facility frequently served the same foods, including green beans, sometimes twice daily. She stated foods were often overly spicy or salty and indicated these concerns continued.An interview with Resident #6 on 6/16/26 at 4:48 PM revealed the food was terrible. She stated the food lacked seasoning, meats were frequently too tough to chew, and repetitive menu items remained a concern.An interview with Resident #81 on 6/17/26 at 11:45 AM revealed food quality had significantly declined. She stated meats were tough, menu items were repeatedly served, fruit and desserts were not regularly available, and residents had repeatedly voiced these concerns without improvement.An interview with Resident #13 on 6/17/26 at 11:52 AM revealed food concerns had been discussed in resident council numerous times. He stated residents had been told concerns would be corrected; however, the concerns continued.An interview with Licensed Practical Nurse (LPN) #1 on 6/17/26 at 8:16 AM revealed food quality had been a concern among residents for an extended period. She stated residents frequently complained about food quality, appearance, repetitive menu items, and foods they did not like.An interview with the Dietary Meal Server on 6/17/26 at 8:38 AM revealed residents constantly complained about the foods served and the taste of the food. She stated the concerns had been discussed during Resident Council meetings and stated, nothing gets done.An observation of the lunch meal on 6/17/26 at 12:48 PM revealed residents continued to voice concerns regarding tough meats, excessive seasoning, repetitive menu items, and alternative meal requests not being honored. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #6 on 11/14/25 with medical diagnoses that included Age-Related Osteoporosis, Hypokalemia, Vitamin B-12 Deficiency Anemia, Hypo-Osmolality and Hyponatremia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 10, indicating Resident #6 was moderately cognitively impaired. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #13 on 8/10/22 with medical diagnoses that included Irritable Bowel Syndrome and Type 2 Diabetes Mellitus without Complications. Record review of the MDS with an ARD of 4/26/26 revealed under Section C, a BIMS summary score of 14, indicating Resident #13 was cognitively intact. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #34 on 10/10/19 with medical diagnoses that included Hyperlipidemia, Vitamin D Deficiency, and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 6/14/26 revealed under Section C, a BIMS summary score of 15, indicating Resident #34 was cognitively intact. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #49 on 3/20/20 with medical diagnoses that included Hypokalemia, Vitamin D Deficiency, and Essential (Primary) Hypertension.Record review of the MDS with an ARD of 6/7/26 revealed under Section C, a BIMS summary score of 15, indicating Resident #49 was cognitively intact. Record review of the Transfer/Discharge Report revealed the facility admitted Resident #81 on 1/25/19 with medical diagnoses that included Anemia, Magnesium Deficiency, Type 2 Diabetes Mellitus without Complications. Record review of the MDS with an ARD of 6/14/26 revealed under Section C, a BIMS summary score of 12, indicating Resident #81 was moderately cognitively impaired. On 6/17/2026 3:28 PM, during a Resident Council meeting, multiple residents voiced ongoing concerns regarding food quality, menu variety, food temperature, food palatability, and alternative meal selections. Residents reported the concerns had been discussed previously without improvement. During the meeting, Resident #25 stated the food tasted bad and that residents would like more variety in menu selections. Resident #28 stated, We always have chicken. Then he stated, I take that back, we had pork chops today, and you would have to be an alligator to eat it because it was so tough! Resident #38 stated bread products such as muffins, toast, and biscuits were frequently unavailable at breakfast and that breakfast meals often lacked a meat option. Resident #42 stated residents had repeatedly discussed food concerns with staff and during Resident Council meetings; however, no improvements had been made. Resident #42 stated food was frequently overcooked, cold, overly bland, or excessively seasoned. Resident #69 stated she did not like the food served and would like additional menu choices. Resident #99 stated the food quality was poor and that the alternative meal option was not any better than the regular meal selection. Resident #99 stated changes to the food service program were needed. They all confirmed that they had voiced their grievances, but they had gone unresolved. An interview with the Administrator on 6/17/26 at 3:49 PM revealed awareness of resident concerns regarding food quality, seasoning, menu selections, and dietary services. She confirmed residents had expressed dissatisfaction with the current dietary services provider and acknowledged resident grievances regarding food had not been addressed and resolved.An interview with the Interim Director of Food Services on 6/19/26 at 8:45 AM revealed ongoing concerns related to food quality, food preferences, communication failures, and alternative menu requests. She acknowledged there had been significant breakdowns in communication regarding resident food preferences and stated resident preferences and disliked foods were not consistently being reflected on meal tickets. She confirmed the food should be better and acknowledged the facility had ongoing problems related to food quality and resident food preferences. Record review of Resident #25's admission Record revealed the facility admitted the resident on 2/17/2023 with diagnoses including Unspecified Dementia. A review of the MDS with an ARD of 5/17/2026 revealed under section C, a BIMS summary score of 06 which indicated Resident #25 had severe cognitive impairment. Record review of Resident #28's admission Record revealed the facility admitted the resident on 6/20/2023 with diagnoses including End Stage Renal Disease. A review of the MDS with an ARD of 4/23/2026 revealed under section C, a BIMS summary score of 15 which indicated Resident #28 was cognitively intact. Record review of Resident #38's admission Record revealed the facility admitted the resident on 7/02/2025 with diagnoses including Anxiety Disorder, Unspecified. A review of the MDS with an ARD of 6/07/2026 revealed under section C, a BIMS summary score of 15 which indicated Resident #38 was cognitively intact. Record review of Resident #42's admission Record revealed the facility admitted the resident on 6/07/2013 with diagnoses including End Stage Renal Disease. A review of the MDS with an ARD of 6/07/2026 revealed under section C, a BIMS summary score of 15 which indicated Resident #42 was cognitively intact. Record review of Resident #69's admission Record revealed the facility admitted the resident on 7/24/2025 with diagnoses including Unspecified Dementia. A review of the MDS with an ARD of 4/05/2026 revealed under section C, a BIMS summary score of 15 which indicated Resident #69 was cognitively intact. Record review of Resident #99's admission Record revealed the facility admitted the resident on 3/21/2024 with diagnoses including Unspecified Atrial Fibrillation. A review of the MDS with an ARD of 4/19/2026 revealed under section C, a BIMS summary score of 10 which indicated Resident #99 had moderate cognitive impairment.

Based on observations, resident interviews, staff interviews, test tray review, and facility policy review, the facility failed to ensure food was palatable and consistent with resident food preferences and dislikes for nine (9) of 23 residents reviewed for food services in the Elm and Cypress cottages (Residents #6, #8, #16, #34, #49, #58, #70, #81, and #90). Findings included repetitive menu items, tough meats that were difficult to chew, food that was excessively salty, spicy, undercooked, or otherwise unpalatable, and failure to honor resident food preferences and alternative meal requests. Findings Include:Review of the facility policy titled Guidelines for Patient Food Service revised 8/22 revealed under, Policy/Purpose: To ensure that all food served from the FNS (Food and Nutrition Service) is of the highest quality, prior to each serving period. Additionally revealed under, Procedure: . Prior to meal service, a designated team member will taste each prepared food item on the patient serving line. The following criteria will be used for testing food items: . Is food properly seasoned? Does the food have eye appeal? Is the food overcooked or undercooked? .An observation of Resident #8 on 6/15/26 at 12:45 PM revealed she ate her meal in her room and received a puree diet of pork chop, lima beans, and sweet potatoes. The resident stated, I wish you could do something about serving a lot of green beans. She stated green beans were served morning, noon, and night. Further observation revealed there was no dessert or fruit provided with the meal.An interview with Resident #34 on 6/15/26 at 12:30 PM revealed the food was awful. She stated the facility frequently served green beans and that the food lacked flavor due to insufficient seasoning. She reported her family kept snacks available because she became hungry between meals.An interview with Resident #49 on 6/15/26 at 4:30 PM revealed the facility frequently served the same foods, including green beans, sometimes twice daily. She stated foods were sometimes spicy and that sauce or gravy was frequently added to meats, making them overly salty.An observation of the lunch meal in the Elm and Cypress cottages on 6/16/26 at 11:36 AM revealed the residents were served meatloaf, mashed potatoes, carrots, and green beans, which corroborated resident concerns regarding the frequent serving of green beans. No dessert or fruit was provided with the meal.Observation of Resident #8's lunch meal on 6/16/26 at 12:10 PM revealed she received pureed meatloaf, mashed potatoes, pureed green beans, pureed carrots, and lemonade. No fruit or dessert was observed.On 6/16/26 at 2:36 PM, a telephone interview with a family member who wished to remain anonymous voiced concerns regarding food quality. She stated residents were not receiving a balanced diet, frequently did not receive desserts or fruit, and were often served foods they did not like. She reported meats were often difficult to chew and expressed concern regarding the overall quality and variety of foods served.An interview with Licensed Practical Nurse (LPN) #1 on 6/17/26 at 8:16 AM revealed food quality had been a concern among residents. She stated residents frequently reported the food did not taste good and she had personally observed concerns regarding food appearance. She stated residents frequently reported dissatisfaction with foods served by the kitchen and often refused certain menu items. She further stated residents were repeatedly served the same vegetables, including broccoli, green beans, and spinach, and reported meals were frequently served without fruit or dessert.An interview with the Ambassador of Food Service #2 on 6/17/26 at 8:38 AM revealed residents frequently complained about food quality and taste. She confirmed green beans were served frequently and stated they had been served twice the previous day for lunch and dinner. She reported residents frequently complained that meat was tough. She further stated food was sometimes brought from the dietary department and placed in warming equipment in the cottages well before meal service, causing food to become dry, overcooked, and less palatable. She reported that many residents contacted family members to bring them food from outside the facility.An interview with Resident #81 on 6/17/26 at 11:45 AM revealed food quality had significantly declined. She stated the food tasted old, meats were tough, vegetables lacked variety, and menu items were repeatedly served. She stated vegetables such as spinach, potatoes, rice, and green beans were frequently repeated. She further stated fruit and desserts were not regularly available and that dinner meals were often unappealing.An interview with Resident #6 on 6/17/26 at 12:04 PM revealed desserts were frequently replaced with gelatin products. She stated the food either lacked flavor or was excessively spicy. She reported green beans were frequently served and stated she did not receive fruit regularly. She stated meats were frequently difficult to chew and that she had repeatedly informed staff she disliked oatmeal; however, she continued to receive oatmeal despite documenting this preference on her meal ticket. She further stated she had requested alternative meal selections on multiple occasions but did not receive them.An interview with Resident #16 on 6/17/26 at 12:14 PM revealed food quality had been a concern for an extended period. She stated salads appeared old and unappetizing and expressed a desire for more fruit options.Observation of the lunch meal on 6/17/26 at 12:31 PM revealed residents were served pork chops with gravy, rice, squash and zucchini, and a roll. Residents #6, #16, #34, #49, #70, and #90 reported the pork chop was excessively tough and difficult to cut or chew. Residents also reported the vegetables were overly spicy and the meat was salty, rendering the food as not palatable. Observation of Resident #58's lunch meal on 6/17/26 at 12:55 PM revealed she received pork chops with gravy, rice, squash and zucchini, and a roll. She stated the pork chop was too tough and required excessive effort to chew. She further stated the vegetables were salty.A test tray reviewed on 6/17/26 at 12:59 PM revealed the regular diet meal consisted of pork chops with gravy, zucchini and squash, and rice. The pork chop was difficult to cut and chew. The squash and zucchini were firm, appeared undercooked, and lacked flavor other than excessive black pepper seasoning. The pureed pork chop and gravy were excessively salty. The pureed squash and zucchini were not palatable and had an unpleasant flavor. Overall, the meal was not palatable.An interview with the Administrator on 6/17/26 at 3:49 PM revealed awareness of resident concerns regarding food quality, seasoning, and menu selections. She confirmed residents had expressed dissatisfaction with the current dietary services provider and acknowledged resident concerns regarding food quality and menu selections remained unresolved.An interview with the Interim Director of Food Services on 6/19/26 at 8:45 AM revealed she identified significant concerns regarding food appearance, preparation, and communication of resident food preferences. She confirmed residents should receive food that was pleasing to the palate and consistent with their food preferences. She confirmed resident food preferences and dislikes should be reflected on meal tickets to help ensure residents received foods that were acceptable and palatable to them. She further confirmed the Registered Dietitian was responsible for updating meal tickets to ensure resident preferences and disliked foods were reflected and stated, This is not being done. She acknowledged there were ongoing concerns related to food quality and communication regarding resident food preferences.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #6 on 11/14/25 with medical diagnoses that included Age-Related Osteoporosis, Hypokalemia, Vitamin B-12 Deficiency Anemia, Hypo-Osmolality and Hyponatremia.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 10, indicating Resident #6 was moderately cognitively impaired.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #8 on 8/28/19 with medical diagnoses that included Anemia, Vitamin D deficiency, and Type 2 Diabetes Mellitus with Diabetic Neuropathy.Record review of the MDS with an ARD of 5/6/26 revealed under section C, a BIMS summary score of 7, indicating Resident #8 was severely cognitively impaired.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #16 on 5/14/25 with medical diagnoses that included Chronic Kidney Disease and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 4/19/26 revealed under section C, a BIMS summary score of 11, indicating Resident #16 was moderately cognitively impaired.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #34 on 10/10/19 with medical diagnoses that included Hyperlipidemia, Vitamin D Deficiency, and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 6/14/26 revealed under section C, a BIMS summary score of 15, indicating Resident #34 was cognitively intact.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #49 on 3/20/20 with medical diagnoses that included Hypokalemia, Vitamin D Deficiency, and Essential (Primary) Hypertension.Record review of the MDS with an ARD of 6/7/26 revealed under section C, a BIMS summary score of 15, indicating Resident #49 was cognitively intact.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #58 on 12/20/23 with medical diagnoses that included Anemia, Dependence on Renal Dialysis, and Chronic Kidney Disease.Record review of the MDS with an ARD of 4/12/26 revealed under section C, a BIMS summary score of 15, indicating Resident #58 was cognitively intact.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #70 on 3/5/26 with medical diagnoses that included Hypokalemia and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 5/31/26 revealed under section C, a BIMS summary score of 10, indicating Resident #70 was moderately cognitively impaired.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #81 on 1/25/19 with medical diagnoses that included Anemia, Magnesium Deficiency, Age-Related Osteoporosis and Type 2 Diabetes Mellitus without Complications.Record review of the MDS with an ARD of 6/14/26 revealed under section C, a BIMS summary score of 12 indicating Resident #81 was moderately cognitively impaired.Record review of the Transfer/Discharge Report revealed the facility admitted Resident #90 on 6/9/25 with medical diagnoses that included Essential (Primary) Hypertension and Atrial Fibrillation.Record review of the MDS with an ARD of 5/17/26 revealed under section C, a BIMS summary score of 9 indicating Resident #90 was moderately cognitively impaired.

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) during medication administration for one (1) of four (4) care areas observed. Resident #9Findings Include:Review of the facility policy titled Infection Control-EBP with an effective date of 4/01/2024 revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .2. Initiation of Enhanced Barrier Precautions: i .indwelling medical devices (e.g . feeding tubes .)On 6/16/26 at 4:15 PM, an observation during medication administration with Licensed Practical Nurse (LPN) # 2 revealed, she administered medications to Resident #9 via a Percutaneous Endoscopic Gastrostomy (PEG) tube and did not don a gown, required for EBP.An interview on 6/16/26 at 4:30 PM with LPN #2, confirmed she did not don a gown to administer Resident #9's medications and stated she forgot to wear the gown.An interview with the Director of Nursing (DON) on 6/17/2026 at 5:08 PM, confirmed LPN #2 should have donned a gown to administer Resident #9 's PEG medications to prevent the spread of infection to another resident.Record review of Resident #9's admission Record revealed the facility admitted the resident on 1/25/2022 with diagnoses including Cerebral Infarction.A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 03 which indicated Resident #9 had severe cognitive impairment.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure medications were stored in a properly secured refrigerator for one (1) of four (4) medication storage rooms. C Hall Findings include:Review of the facility's policy titled Medication Storage-Controlled Medication Storage revised 2/1/23, revealed: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations .An observation on 6/16/2026 at 10:05 AM with Licensed Practical Nurse (LPN) #2, revealed the medication storage room on C Hall contained 44 Lorazepam syringes prescribed to Resident #50, and were maintained on the center shelf of the refrigerator rather than within the locked, affixed controlled-substance storage box.During an interview conducted with LPN #2 at 10:06 AM, she stated the syringes would not fit in the locked storage drawer in the refrigerator. During an observation and interview conducted on 6/16/2026 at 11:01 AM with the Director of Nursing (DON), she confirmed the syringes were not in the drawer that locks because they would not all fit in the drawer but confirmed that they should have been locked and secured.Record review of Resident #50's admission Record revealed the facility admitted Resident #50 on 1/09/2025 with diagnoses including Anxiety Disorder, Unspecified.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/05/2026 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 00 which indicated Resident #50 had severe cognitive impairment.

Based on observations, resident and staff interviews, facility document review, and facility policy review, the facility failed to provide an effective system for residents to summon staff assistance when the call light system was nonfunctional for two (2) of 24 residents residing on one (1) nursing unit, Unit C. (Resident #52 and #95)Findings include:Review of facility policy titled, Answering and Responding to Call Lights with revision date: 2/1/23, revealed, Purpose: To ensure that resident's needs are responded to and met in a timely manner .During initial rounds on 6/15/2026 at 12:39 PM, observation of the call light system was not functioning, and residents were using handbells to request assistance.During an interview on 6/15/2026 at 12:42 PM, Licensed Practical Nurse (LPN) #3 confirmed the call light system was down yesterday (6/14/2026) and today. During an interview on 06/15/2026 at 12:43 PM, the Director of Nursing (DON) revealed the call system went out midday Friday. She stated maintenance was working on the roof Friday, and something caused the call system to go down. She further stated that the Maintenance Director had called in to the company to have the system repaired and stated they are supposed to be here tomorrow to fix it. During an observation and interview on 06/15/2026 at 12:56 PM, Resident #52 revealed she was not aware the call system wasn't working properly and she was not given a handbell to ring for assistance. She stated she had just moved to this room on Friday, 6/12/26. Resident #52 stated, It normally takes a good while for someone to answer my call light. During an observation on 06/15/26 at 1:10 PM, surveyor walked down the hall and around to the nurse's station to inquire about the call light system. Registered Nurse (RN) #1 confirmed the call light system did not light up or alarm for Resident #52. She verbalized that she worked yesterday and the system was down then too. When asked how residents were to notify staff they needed assistance, she stated, they all have handbells at bedside. The RN walked to Resident #52's room with surveyor and confirmed Resident #52 did not have a handbell to ring for assistance. She stated, Maintenance had passed out bells to everyone this morning, before lunch, and had informed the nurse that he had enough for everyone.An interview with Maintenance Staff #1 on 06/15/2026 at 1:12 PM, he stated, We had a few bells. Some got one and some didn't. He further stated he got the bells on Friday when the system first went down. He confirmed that some of the residents received a handbell to use and some did not, but he did not know which residents did and which ones didn't. During an interview on 6/15/2026 at 1:25 PM with Resident #95, she confirmed that she did not have a handbell to ring for assistance and she was not aware that the call system was not working properly. Record review of Resident #52's admission Record revealed the facility admitted the resident on 4/1/2026 with diagnoses including Encounter for other Orthopedic Aftercare and Other Fracture of T9-T10 Vertebra, Subsequent Encounter for Fracture with Routine Healing.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/7/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 10 which indicated Resident #52 had moderate cognitive impairment.Record review of Resident #95's admission Record revealed the facility admitted the resident on 8/28/2025 with diagnoses including Encounter for Surgical Aftercare following Surgery on the Digestive System and Acute Gastric Ulcer with Perforation.A record review of the MDS with an ARD of 5/10/26 revealed under section C, a BIMS summary score of 5 which indicated Resident #95 had severe cognitive impairment.

Based on observation, staff interview, facility policy review, the facility failed to ensure items in the kitchen refrigerator, freezer and dry good spices were labeled and dated on one (1) of two (2) kitchen tours during survey. Findings include: A review of the facility policy revised on 1/22, titled Food and Supply Storage revealed: Procedures: Cover, label and date unused portions and open packages . An interview on 03/26/24 at 10:15 AM, with the Assistant Dietary Director (ADD) revealed that the Dietary Director is off this week, and she oversees the kitchen. An observation and interview on 03/26/24 at 10:18 AM, of the walk-in freezer in the kitchen with ADD revealed four (4) clear gallon size Ziploc bags with some type of meat inside them. The ADD confirmed that it was fish inside two (2) of the gallon Ziploc bags and some type of red meat inside of the other 2 gallon size Ziploc bags. The ADD confirmed that the Ziploc bags should have been labeled and dated when the meat was placed in the bag and stored in the refrigerator. An observation on 03/26/24 at 10:35 AM, of the spice rack located on the stainless steel preparation table revealed an opened 28 ounce container of Nutmeg that was unlabeled, a 28 ounce container of Montreal Steak seasoning, a 28 ounce container of Cinnamon, a 28 ounce container of Onion Powder, a 28 ounce container of Garlic Powder, a 28 ounce container of Rubbed Sage, a 28 ounce container of Rotisserie Chicken Seasoning, a 28 ounce container of Lemon Pepper Salt, and a 28 ounce container of Ground Cumin that were all opened and unlabeled. There was a stainless steel four (4) inch container with a creamy white substance inside of it with a piece of clear plastic wrap over the top of it with no label or date. An interview on 03/26/24 at 10:45 AM, with the cook confirmed that the creamy white substance in a 4-inch stainless steel container was bacon grease that she used it to season the food with sometimes and that she did not know how old it was. The cook confirmed that when any item was opened that it was supposed to have a label identifying what was inside and when it was opened but she was busy and didn't have time to do it. An interview on 03/26/24 at 10:50 AM, with the ADD confirmed that there were nine (9) 28-ounce seasoning containers opened without dates on the labels. The ADD stated All the staff knows to label anything that they open with the contents and the date opened on a sticker. An observation on 03/26/24 at 11:05 AM, of the kitchen in Oak Cottage revealed a tray with eight (8) 8-ounce glasses of a brown liquid and three (3) 8-ounce glasses of a white liquid that did not have a label on them. An interview on 03/26/24 at 11:35 AM, with the Dietary Aide confirmed that all items prepared and placed in the refrigerator or stored as dry goods should be labeled and dated. Dietary worker confirmed that not labeling food and drink items could result in someone getting sick. An interview on 03/27/24 at 2:15 PM, with the Administrator confirmed that any food or drink that is opened is supposed to be labeled and dated. The Administrator confirmed that not labeling and dating food items could result in someone getting something that they might have an allergy to or someone getting sick if the food item is old.

Based on staff interviews, record review, and facility policy review, the facility failed to submit criminal background checks on four (4) of five (5) new employee personnel records reviewed during survey. Employee #1, #2, #3, and #5. Findings include: Review of the facility policy titled, Hiring with no revision date revealed under Comments #3e. If the drug test is negative, a Criminal History Record Check (CHRC) will be performed. Employees will be fingerprinted, and fingerprints will be submitted to the (Proper Name State Agency) . An interview on 03/28/24 at 12:45 PM, with the Administrator confirmed that background checks were completed with the Human Resource Director who also oversees the hospital. The Administrator confirmed that she was not aware that the fingerprint letters were not on the employee files. An interview on 03/28/24 at 12:55 PM, with the Human Resource Director and the Administrator revealed that criminal background checks have not been performed on any employee that has been hired since the first week of January 2024. The Human Resource Director stated, I'm just going to be honest with you, I don't have any background letters. I have the fingerprint cards filled out, but I haven't sent them in to be checked. I got behind on them and I just haven't managed to catch up. The Human Resource Director confirmed that the purpose of the background checks is to make sure the residents are safe and that nobody is hired with a criminal background. A record review of License Verification for the five (5) employee files that did not have a background check letter did not reveal any discipline activity on their license. Employee #1, #2, #3 and #5 were all hired within the last four (4) months and serve in the role of Certified Nursing Assistant (CNA) and Registered Nurse (RN). The employees have had a Nurse Aid Registry search that showed no disqualifying events, but they do not have a fingerprint letter from the state that would show any criminal charges in the last two years. An interview on 03/28/24 at 1:40 PM, with the Chief Executive Officer (CEO) of the hospital/nursing home confirmed that he was not aware that the Human Resource Director had not been submitting the fingerprint cards for a criminal background check. The CEO confirmed that not submitting and receiving the background check information could result in someone being hired and working with the residents that could put the residents at risk.

Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident's choice for end of life care was indicated accurately on medical records for one (1) of 24 residents reviewed for advance directives. Resident #56 Findings include: Record review of facility's resident rights pamphlet titled, A Matter of Rights, undated, revealed, As a resident in a long term care facility, you have many rights guaranteed by law. Your rights include . freedom to make your own decisions. You have a right to expect care and a residential setting that: promotes your quality of life, and reflects your individual needs and preferences . Record review of facility policy titled, Policy for Advanced Directives, undated, revealed, (proper name of facility) and the Medical Staff will comply with the 1990 Patient Self Determination Act by: 1. Inquiring upon admission if the patient has an advance directive (Living Will or Durable Power of Attorney), 2. Providing information related to advance directives to the patient. Within the confines of medical/ethical practices, we will honor your advance directive with consultation with you and your family . Record review of facility policy titled, Understanding Advance Directives, undated, revealed, You have the right to make health care decisions, including decisions about nursing home care, for yourself . Record review of Resident #56's Advance Directive Acknowledgement Review dated 12/19/23, revealed, This update on (proper name of Resident #56) took place on 12/19/2023 with the responsible party. This update documents that this resident will be: DNR (do not resuscitate) and was signed by the Licensed Social Worker (LSW). This document was located in the resident's paper medical chart as the front page. Record review of Advance Directive Acknowledgement revealed on admission to the facility, Resident #56 chose a full code status. This document was signed by the resident and witnessed by the LSW and dated 12/2/22. This form was located in the resident's paper chart behind the Advance Directive Acknowledgement Review form that was dated 12/19/23. Record review of Resident #56's electronic Physician Orders dated 12/12/22, revealed an order for full code. An interview and chart review with the Director of Nursing (DON) on 3/27/24 at 4:00 PM, revealed if Resident #56 experienced a cardio-pulmonary arrest, the staff would check the resident's medical record and would note the first page which indicated a DNR status, and if no additional review of medical records or orders was done, no life-saving measures would be initiated. She confirmed the advance directive signed by the resident on admission and the physician's electronic order indicated a full code status. She confirmed the facility failed to ensure the accuracy of documentation of the resident and/or the resident's representative choice for end of life care which could have led to the resident's wishes not being honored. During an interview on 3/27/24 at 4:05 PM, the Administrator confirmed the electronic physician's order as well as the initial advance directive signed by the resident on admission indicated a full code status, but the Advance Directive Review dated 12/19/23 indicated a Do Not Resuscitate status. She confirmed the facility failed to accurately indicate the resident and/or resident's representative choice for end of life care in the medical record which could have led to the resident's wishes not being honored. An interview with the LSW on 3/27/24 at 4:40 PM, revealed she was responsible for discussing the advance directive with the residents and/or resident representatives annually. She revealed if a resident or representative had no request for change from the previous advance directive acknowledgement, the acknowledgement review would be signed to indicate this information was reviewed but no changes were made. If the resident or representative requested a change from the previously made choice, a new Advance Directive Acknowledgement Review form would be completed to indicate the decision made and would be signed by the resident or representative to indicate this new decision. She and Resident #56's representative discussed this during the annual review, but no decision to change from the full code status was determined. The LSW confirmed she mistakenly marked DNR rather than full code on the review form, which was not indicative of the resident's or the representative's wishes. She stated it is important for this information to be accurate since it does determine what end of life care would be provided for the resident. Record review of Resident #56's Face Sheet revealed the resident was admitted to the facility on [DATE], with medical diagnoses that included chronic obstructive pulmonary disease with acute exacerbation, heart failure, type 2 diabetes mellitus, atrial fibrillation, and congestive heart failure. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/17/23, revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident was severely cognitively impaired.

Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to ensure a resident received the necessary care and treatment of a nephrostomy for one (1) of three (3) residents with urinary catheter systems. Resident #78 Findings include: Record review of the facility policy titled Application of Urostomy pouch and bedside drainage bag with a revision date of 2/1/23, revealed, Purpose: Care of a Resident with a urostomy and pouch system for collection of urine. To promote the dignity and cleanliness of a Resident who has a urostomy Record review of Progress note, (Proper name of facility) dated 03/19/2024 at 4:03 AM, revealed, This nurse received report from emergency room (ER) Resident also needs a new bag ordered since his is leaking. An interview and observation on 3/26/24 at 10:57 AM, Resident #78 revealed his urinary catheter bag leaks, and he has to put the catheter bag inside of a zip-lock bag, so it doesn't leak into his privacy bag. An observation of a clear zip-lock bag with the nephrostomy bag inside of it with approximately 75 cc of yellow urine in the bottom of the zip-lock bag. The resident revealed the urinary bag had been leaking for quite some time. An interview and observation on 3/27/24 at 2:00 PM, Resident #78 revealed he had told the nurses that his catheter bag leaked and that's what he is using the zip-lock bags for, they just give me more zip-lock bags. He revealed I just want this fixed, so I don't have to use these extra bags. An interview and observation on 3/27/24 at 2:45 PM, the Registered Nurse (RN) Supervisor revealed it is the responsibility of the nurses to inspect Resident #78's catheter bag each shift and to notify her or the Director of Nurses (DON) if there is a problem. She revealed she had not been notified of any issues with his urinary bag. The RN Supervisor confirmed that Resident #78's urinary catheter bag was inside a zip-lock bag and revealed it looked like there was approximately 75-100 cc of urine in the bottom of the zip-lock bag. She revealed the ball was dropped and confirmed he did not have a new catheter bag ordered at this time and stated, I feel like we failed the resident for this. An interview on 3/27/24 at 3:05 PM, RN #1 revealed Resident #78 asked for a zip lock bag a few days after he came back from the ER and I gave him two or three zip-lock bags to use to put his catheter bag in. RN #1 revealed she looked at the catheter bag and it looked as if the seam on the catheter bag was leaking. She confirmed she did not notify anyone about ordering the resident a new catheter bag and confirmed the resident's primary physician had not been notified about the leaking nephrostomy bag. An observation and interview on 03/27/24 at 3:45 PM, the DON revealed she was unaware of any issues with Resident #78's nephrostomy catheter needing to be replaced. Resident #78 stated to the DON that his bag had been leaking before he went to the ER last week and he has been using zip-lock bags for quite some time. An interview on 3/27/24 at 3:55 PM, the DON confirmed the issue of his catheter bag leaking has gone through several staff members and it should have been taken care of immediately. She confirmed they failed to address the necessary care needed for the resident's nephrostomy. Record review of Resident #78's Face Sheet with an admission of 3/15/23 revealed medical diagnoses that included Retention of urine, and Benign Neoplasm of Prostate. Record review of Resident #78's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/18/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #78 is cognitively intact.

Based on record review, resident and staff interviews, and facility policy review, the facility failed to ensure a resident was free of accidents and or hazards during transfer when two (2) staff physically lifted the resident under her arms and transferred her from her chair to the bed without using a mechanical lift resulting in a distal femur fracture for one (1) or six (6) residents reviewed for accidents. Based on implementation of the facility's corrective actions on 2/20/23, this was determined to be Past Non-Compliance. (Resident # 1) Findings include: The facility policy titled USE OF HYDRAULIC LIFT, HOYER LIFT, revised 9/9/2014, revealed Purpose: To reduce the risk of injury to residents and or staff related to transfer of dependent or obese residents . Special Considerations: Hydraulic lifts are designed to be operated by one person but, for the safety of residents and staff members, it is this facility's policy for two staff members to be present when hydraulic lift is in use. One to operate the lift and the other to stabilize and support the resident during transfer . A review of the facility's self-reported investigation of Resident # 1's fracture of unknown cause, revealed, Description of incident: On 2/18/23 family of the resident noted swelling and redness on the right leg and reported to the nurse, upon assessment the Licensed Practical Nurse (LPN) on duty observed the redness and swelling and reported to the Registered Nurse (RN) Supervisor who confirmed the assessment and notified the provider. Resident #1 was sent to Emergency Department (ED) for evaluation and radiology reported a mildly angulated nondisplaced fracture to distal femur and severe tri-compartmental osteoarthritic disease with severe joint space loss. Resident returned from ED with an immobilizer to right leg and medication for pain and to follow up with primary physician as surgery is not an option. The primary physician referred to an orthopedic doctor of choice. The RN Supervisor reported that during the assessment, the family indicated the resident was transferred from the recliner to bed on 2/17/23 in the P.M. without the use of the lift and that her knee was twisted during the transfer. The family indicated they did not witness the transfer but was informed by someone about the incident. The family declined to identify the source of information. Upon notification of the fracture on 2/18/23 the Director of Nursing (DON) reported the incident via phone to Licensure and Certification at approximately 11:30 PM on 2/18/23. A review of the findings of the investigation revealed: 1.) On 2/17/23 Certified Nursing Assistant (CNA) # 1 was assigned to resident and approximately 5:30 PM went in to move resident from the recliner to the bed for the night, stepped out into the hall and asked CNA # 2 to assist . 2.) Resident's care plan and instructions for specific resident care are maintained on cards located at the nurse's station and CNAs are instructed to check the card every day for specific instructions or changes in the care plan and initial the card to indicate understanding of the instructions . 3.) Review of the records indicated CNA # 1 did not read the card prior to her shift on 2/17/23. CNA # 1 admitted during an interview that she did not read the care plan which specifically calls for residents to be transferred with a Hoyer lift. 4.) Review of the record indicated CNA # 2 had not previously been assigned and had no knowledge of the resident's specific needs. An interview with CNA # 2 stated she relied on CNA # 1's knowledge of the resident's care plan and assisted CNA # 1 with a two-person manual transfer from the recliner to the bed. 5.) During separate interviews with both CNA's, they indicated they did not observe anything unusual or remarkable about the transfer and the resident did not indicate any pain during or after the transfer . 6.) CNA # 1 and CNA # 2 were suspended pending findings of investigation on 02/18/23. A review of the conclusion of the investigation revealed, 1.) Both CNAs were placed on leave pending the investigation. 2.) Investigators believe the injury was sustained during the transfer on 2/17/23 and CNAs did not follow the proper protocol by not familiarizing themselves with the care plan instructions on the card system. 3.) Investigators did not find intentional abuse or rough handling of resident. 4.) All residents care planned for a Hoyer Lift was reviewed and no deficiencies noted. An observation of Resident # 1 on 3/27/23 at 3:00 PM, revealed resident lying in bed facing the door, eyes closed with no nonverbal signs of pain observed. An interview and observation on 3/28/23 at 10:00 AM, revealed Resident # 1 lying in bed watching the television, State Agency (SA) spoke to the resident and asked if she was hurting, and Resident # 1 smiled and shook her head no. On 3/28/23 at 11:00 AM, during an interview via phone with CNA # 1, revealed she was assigned to Resident # 1 on 2/17/23, and knew she was supposed to use the Hoyer Lift for Resident #1. She was supposed to review the Kardex every day before caring for residents to make sure there is no changes but verified, she did not review Resident # 1's Kardex on 2/17/23 prior to the transfer. CNA # 1 stated she got CNA # 2 to help her, we lifted the resident gently under her arms and transferred her to the bed, lifted her legs in the bed and made her comfortable. The resident never complained. CNA #1 confirmed transferring her incorrectly possibly fractured Resident #1's leg. A phone interview with CNA # 2 on 3/28/23 at 3:00 PM, revealed she did assist with the two- person transfer for Resident # 1 but she was not assigned to the resident just assisted, and trusted that CNA #1 who was assigned to her knew the care she needed. On 3/29/23 at 8:45 AM, during an interview with the Quality Assurance (QA)/Nurse Educator, she stated she was a part of the investigation for Resident #1's fracture. She confirmed that the fracture was most likely sustained during the improper transfer of Resident # 1. An interview with the Director of Nursing (DON) on 3/29/23 at 8:55 AM, revealed she investigated the fracture for Resident # 1 and confirmed she believed that Resident # 1 being transferred incorrectly resulted in the fracture of her leg and confirmed that other possible concerns from an incorrect transfer are falls, and further injuries. An interview with the Administrator on 3/29/23 at 9:10 AM, revealed that the investigation of Resident # 1 is clear, the resident had no other incidents or injuries until she was transferred incorrectly on 2/17/23 by CNA #1 and CNA #2. A record review of the Progress notes dated 2/18/2023, revealed family of Resident # 1 was visiting and reported Resident # 1 was complaining of knee pain, that Resident # 1 was assessed by the LPN and RN Supervisor on duty and assessment revealed the right knee swelling, redness, and warm to touch. The provider was notified and ordered to be sent to the emergency room for an outpatient x-ray. Review of the x-ray report revealed Impression: Acute nondisplaced distal femoral condyle fracture extending from lateral to medial. A review of the Transfer assessment dated [DATE] revealed under Mode of Transfer: Lift mechanically. A review of CNA # 1's personnel file revealed she was educated on the Kardex (care plan) on 6/27/22 and 7/1/22 on the Lifts. A review of CNA # 2's personnel file revealed she was educated on the Kardex (care plan) and Lifts on 9/27/22. Record review of the Face Sheet revealed that the facility admitted Resident #1 on 2/10/23 with diagnoses of Disorder of the Bone density and structure unspecified, Chronic Pain syndrome and Peripheral vascular disease. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 2/19/23, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 06 which indicated that she was severely cognitively impaired. Section GG of the MDS for chair/bed-to chair transfer Resident # 1 was coded Dependent. The SA validated through record review and staff interview that the following occurred: 1. Investigators believe the injury was sustained during the transfer on 2/17/23 and CNA'S did not follow the proper protocol by not familiarizing themselves with the care plan instructions on the card system. 2. Both CNAs were immediately placed on leave pending investigation. 3. An Ad Hoc Quality Assurance meeting was held on 2/20/23. 4. Immediate in-person education was conducted 2/20/23 with all staff to reiterate protocols regarding information about care plans, the card system acknowledgement, Resident Rights and abuse and neglect. 5. All Resident's care planned for a Hoyer Lift were reviewed. No additional deficiencies were noted. 6. Investigators did not find intentional abuse or rough handling of resident. 7. Kardex will be checked for completion beginning 2/20/23, three (3) times a week for 3 weeks, then 2 times a week for 3 weeks, then weekly times 3 weeks. Any CNA failing to read and acknowledge Kardex assignments will be subject to disciplinary actions. 8. If either of the two CNA's involved in the incidents are found to be out of compliance within 90 days, immediate dismissal will result. Record review revealed the facility emailed the Investigative summary to the State Agency on 2/23/23 and to the Attorney General's Office on 3/22/23.

Based on staff interview, record review and facility policy review the facility failed to implement the care plan related to transfers for one (1) of nine (9) care plans reviewed. Based on implementation of the facility's corrective actions on 2/20/23, this was determined to be Past Non-Compliance. (Resident #1) Findings include: A record review of the facility's policy titled Care Plan, revealed, Purpose: To direct resident care from admission to discharge . Procedure: 10.) Customize the care plan to address the resident's individual concerns and needs . A record review of the facility's policy titled Care Plan Kardex for CNA, Purpose: To ensure that the Certified Nurse Assistants (CNA) identify particular needs of each resident related to activities of daily living .Procedure: 1.) Certified Nurse Assistants will utilize the Plan of Care Kardex daily to ensure continuity of care to assigned residents . 2.) The Certified Nurse Assistants will review the Plan of Care Kardex of each assigned resident daily . 6.) The plan of Care Kardex will identify the Residents' needs to Nurses and Certified Nurse Assistants regarding he is following ADL'S (Activities of Daily Living): Hearing, speech, vision, ambulation, bathing, restraints, bed mobility, and transfer, personal hygiene, dressing, eating, bowel and bladder function, and any adaptive equipment. A review of the comprehensive care plan with a start date of 2/16/23 titled, I FALLS- I am at risk for falls w(with)/injuries R/T (related to): I have a HX (history) of falls, I am not walking, I have increased weakness. I have a DX (diagnosis) of osteopenia; I am dependent for transfers. Intervention: .Transfers- I am dependent x (times) 2 (two) staff using hoyer lift . A record review of the Plan of Care Kardex for February 2023 for Resident #1, revealed under Transfers/ROM(Range of Motion): Mechanical Lift: Hoyer/Ceiling Lift for transfers. A review of the findings of the investigation revealed: 1.) On 2/17/23 Certified Nursing Assistant (CNA) # 1 was assigned to resident and approximately 5:30 PM went in to move resident from the recliner to the bed for the night, stepped out into the hall and asked CNA # 2 to assist . 2.) Resident's care plan and instructions for specific resident care are maintained on cards located at the nurse's station and CNAs are instructed to check the card every day for specific instructions or changes in the care plan and initial the card to indicate understanding of the instructions . 3.) Review of the records indicated CNA # 1 did not read the card prior to her shift on 2/17/23. CNA # 1 admitted during an interview that she did not read the care plan which specifically calls for residents to be transferred with a Hoyer lift. 4.) Review of the record indicated CNA # 2 had not previously been assigned and had no knowledge of the resident's specific needs. An interview with CNA # 2 stated she relied on CNA # 1's knowledge of the resident's care plan and assisted CNA # 1 with a two-person manual transfer from the recliner to the bed. 5.) During separate interviews with both CNA's, they indicated they did not observe anything unusual or remarkable about the transfer and the resident did not indicate any pain during or after the transfer . 6.) CNA # 1 and CNA # 2 were suspended pending findings of investigation on 02/18/23. A review of the conclusion of the investigation revealed, 1.) Both CNAs were immediately placed on leave pending the investigation. 2.) Investigators believe the injury was sustained during the transfer on 2/17/23 and CNAs did not follow the proper protocol by not familiarizing themselves with the care plan instructions on the card system. 3.) Investigators did not find intentional abuse or rough handling of resident. 4.) All residents care planned for a Hoyer Lift was reviewed and no deficiencies noted. An interview via phone with CNA # 1 on 3/28/23 at 11:00 AM, revealed she knew she was supposed to use the Hoyer Lift for Resident #1 and knows she was supposed to review the Kardex every day before caring for residents to make sure there is no changes but verified, she did not review Resident # 1's Kardex on 2/17/23 prior to the transfer. CNA #1 confirmed she was assigned to Resident # 1 and knew she was supposed to use the Hoyer Lift for her. CNA # 1 stated I got CNA # 2 to help me, we lifted resident gently under her arms and transferred resident to the bed, lifted her legs in the bed and made her comfortable, and the resident never complained. CNA #1 confirmed transferring her incorrectly possibly fractured Resident #1's leg. An interview with the Quality Assurance (QA)/Nurse Educator on 3/29/23 at 8:45 AM, revealed she was a part of the investigation for Resident #1's fracture and confirmed that the injury Resident # 1 sustained was related to CNA's not following the Kardex care plan for Resident # 1. An interview with the Director of Nursing (DON) on 3/29/23 at 8:55 AM, she revealed she investigated the fracture on Resident # 1 and confirmed she believed that staff not following the care plan for transfers resulted in the fracture of Resident # 1's leg. An interview with the Administrator on 3/29/23 at 9:10 AM, he revealed that the CNAs did not follow the plan of care resulting in the fracture. A review of the comprehensive care plan with a start date of 2/16/23 titled, I desire to have my needs anticipated and met by staff in a timely manner through next review .Interventions: Transfers- I am dependent x 2 staff using Hoyer lift. Record review of the Face Sheet revealed that the facility admitted Resident # 1 to the facility on [DATE] with diagnoses of Disorder of the Bone density and structure unspecified, Chronic Pain syndrome and Peripheral vascular disease. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 2/19/23, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 06 which indicated that she was severely cognitively impaired. Section GG of the MDS for chair/bed-to chair transfer Resident # 1 was coded Dependent. A review of CNA # 1's personnel file revealed she was educated on the Kardex (care plan) on 6/27/22 and 7/1/22 on the Lifts. A review of CNA # 2's personnel file revealed she was educated on the Kardex (care plan) and Lifts on 9/27/22. The SA validated through record review and staff interview that the following occurred: 1. Investigators believe the injury was sustained during the transfer on 2/17/23 and CNA'S did not follow the proper protocol by not familiarizing themselves with the care plan instructions on the card system. 2. Both CNAs were immediately placed on leave pending investigation. 3. An Ad Hoc Quality Assurance meeting was held on 2/20/23. 4. Immediate in-person education was conducted 2/20/23 with all staff to reiterate protocols regarding information about care plans, the card system acknowledgement, Resident Rights and abuse and neglect. 5. All Resident's care planned for a Hoyer Lift were reviewed. No additional deficiencies were noted. 6. Investigators did not find intentional abuse or rough handling of resident. 7. Kardex will be checked for completion beginning 2/20/23, three (3) times a week for 3 weeks, then 2 times a week for 3 weeks, then weekly times 3 weeks. Any CNA failing to read and acknowledge Kardex assignments will be subject to disciplinary actions. 8. If either of the two CNA's involved in the incidents are found to be out of compliance within 90 days, immediate dismissal will result. Record review revealed the facility emailed the Investigative summary to the State Agency on 2/23/23 and to the Attorney General's Office on 3/22/23.

Based on interview, record review, and facility policy review the facility failed to report an unwitnessed fall to the physician and family for one (1) of the three (3) fall reports reviewed. Resident #1 Review of the facility policy titled, Reporting of Incidents with an effective date of 10/2014 and a revision date of 9/10/2014 revealed its purpose was to address incidents in a timely, effective manner. To maintain a record of incident and related assessments and interventions. Number 6 under procedure revealed notify responsible party and physician of occurrence. A telephone interview, on 12/20/22 at 10:36 AM with Licensed Practical Nurse (LPN) #1 revealed that a Certified Nurse Aide (CNA) came and got her because Resident #1 was in the floor. LPN #1 stated that the resident was sitting in the bathroom floor and told her that she went to the bathroom and did not feel like walking back. LPN #1 stated Resident #1's call light was on her bed. She stated that Resident #1 said she was not hurt so she didn't think much about it. LPN #1 stated that she looked Resident #1 over from head to toe and got her vital signs. She stated she did not call the doctor or family concerning the incident. She stated she did talk to the doctor when he made rounds, but she thought it was the next day. She stated that the doctor questioned her about the incident and said it should have been considered a fall. LPN #1 stated that she did what the Director of Nursing (DON) had told her to do. An interview, on 12/20/22 at 1:30 PM with the Director of Nursing (DON) revealed LPN #1 had called her at home to report Resident #1 was found in the bathroom floor. She stated that Resident #1 told them she sat down in the floor. The DON confirmed she told LPN #1 to do a thorough skin assessment. She stated that she just believed what the resident said when she told the staff that she had just sat down in the floor. The DON confirmed that due to the fact that Resident #1 had previous falls and a Brief Mental Status (BIMS) score of five (5), the incident should have been written up as a fall and reported to the doctor and responsible party. The DON confirmed the Medical Director (MD) and the Responsible Party (RP) were not notified, but the MD did come that afternoon and made rounds. A telephone interview on 12/21/22 at 2:30 PM with the physician revealed that he was not called concerning Resident #1's fall, he just happened to find out during his rounds. He stated that Resident #1 is a Medicare Part A resident, so he tries to see those residents weekly. He stated that he was not sure if the staff knew he was coming around that day. He stated that sometimes the reporting is hit or miss. An interview with Administrator on 12/21/22 at 3:00 PM revealed that if a resident had an incident, it should be written up as a fall and this would include notification of the physician and the family. Record review of the fall dated 12/23/22 where Resident #1 was found in the bathroom floor by a staff member revealed that the resident did not sustain any injuries. Record review revealed Resident #1 was admitted to the facility on [DATE] with Unspecified Dementia, Essential hypertension, Type 2 Diabetes Mellitus, Syncope and Collapse, Hemiplegia following Cerebral Infarct affecting left nondominated side, difficulty in walking, and Unspecified lack of coordination. Review of section C of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/28/22 revealed a Brief Interview for Mental Status (BIMS) score of five (5) which indicated Resident #1 was severely cognitively impaired.

Based on observation, staff interviews, and facility policy review the facility failed to ensure items in the kitchen refrigerator and refrigerated cooler were labeled and dated, expired food items were removed and that food bins were covered for one (1) of two (2) kitchen tours. Findings include: A review of the facilities' policy titled, Food and Supply Storage. Policy #BOO3, revised ,d+[DATE], revealed, All food, non-food items, and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .Dry Storage .Foods that must be opened must be stored in approved containers that have tight-fitting lids .Hang scoop. The food level must be no closer than one inch below the handle of the scoop .Refrigerated storage life of foods .Use the manufacturer's expiration date for products before they are opened .Label when the product is opened. The initial brief tour of the kitchen on [DATE] at 10:20 AM with the Dietary Manager (DM) revealed: 1. Kitchen refrigerator #1 an observation and interview revealed three (3) metal containers not labeled, and not dated. The Dietary Manager revealed that one container was pimento and cheese, the second was pears, and the third was lettuce and tomato. The Dietary Manager was unsure of how long the items had been in the refrigerator. A large gallon-sized bag of ham was not labeled or dated. A large gallon-sized bag of turkey was not labeled or dated. The Dietary Manager revealed it is everyone's responsibility to keep things labeled and expired items discarded. She confirmed this had not been done. 2. Refrigerated cooler observation and interview with the DM revealed three (3) five-pound white plastic containers with a manufactured label of sweet potatoes. Each container was labeled with today's date [DATE], good through [DATE]. Observed a plastic 7.6-ounce container of red liquid substance with no label or date and a brown, opened box, with no date or label. The Dietary Manager stated, These are omelets, I think they opened these this morning. There were three white 12 lb. plastic containers labeled baked potato salad with an expiration date of [DATE] and a white 11 lb. plastic container labeled coleslaw with an expiration date of [DATE]. An oblong metal container which the dietary manager revealed was spaghetti with an expiration date of [DATE]. The Dietary Manager confirmed a white container was sliced strawberries with an expiration date of [DATE]. 3. An observation of the storage shelf revealed four (4) 5 lb boxes of Butter flake artificially flavored buttermilk biscuit mix with a manufactured expiration date of [DATE]. 4. An observation and interview with the Dietary Manager revealed the sugar storage bin lid was off and the scoop was lying inside on the sugar. The flour bin revealed a square plastic container lying down in the flour. The third bin used for storing brownie mix was noted with the lid off. The Dietary Manager stated the lid is to always be kept on and the scoop is not to be stored inside the bins on the food. She revealed this could cause contamination and could make someone sick. An interview on [DATE] at 11:05 AM, with the Dietary Manager revealed that all food was supposed to be labeled and dated when opened. She revealed it is everyone's responsibility to ensure that expired foods are discarded and she confirmed that the dietary department has failed to complete this task. An interview on [DATE] at 2:10 PM, with the Infection Control Nurse confirmed that any expired foods or uncovered foods could cause an infection or food poisoning in a resident if food is not discarded timely.

Based on observation, resident and staff interviews, record review and facility policy review the facility failed to change, date, and label and store oxygen tubing and to post oxygen signage at the entrance to residents' rooms for three (3) of four (4) residents reviewed with oxygen. Residents #2, Resident #42 and Resident #184. Findings Include: Review of facility policy Oxygen Therapy with revision date of 02/09/18 revealed under Policy Explanation and Compliance Guidelines: .4. NO SMOKING and/or OXYGEN IN USE signs will be posted at the entrance of the resident's room. Facility Policy also revealed under Oxygen Concentrator the following: .3. Change humidified bottle and tubing weekly. Resident #184 An observation on 10/11/22 at 11:03 AM, revealed Resident #184 lying in bed with Oxygen (O2) via biprong nasal cannula at 5 (five) Liters Per Minute (LPM), O2 tubing was not dated or labeled and there was no O2 signage on the resident's room door. An observation on 10/11/22 at 2:00 PM, revealed Resident #184 lying in bed receiving O2 via nasal cannula at 5 LPM, O2 tubing was not dated or labeled and there was no O2 signage on the resident's room door. An observation on 10/12/22 at 9:00 AM, revealed Resident #184 was in her bed receiving O2 via nasal cannula at 5 LPM, the O2 tubing was not labeled or dated and there was no O2 signage on the resident's door. An observation and interview on 10/12/22 at 1:30 PM, with Licensed Practical Nurse (LPN) #1 confirmed that Resident #184's O2 tubing was not labeled and dated and there was no O2 signage on the door. She revealed there was a plastic bag with new O2 tubing with a date of 10/10/22 lying on top of the air conditioner in the resident's room and that the nurse was supposed to have changed the resident's tubing on Sunday 10/10/22 so it must have not been done. She revealed it is the policy of the facility that resident's O2 tubing has to be changed once per week, labeled, and dated and O2 signage needs to be put on the door. She revealed that if a resident's O2 tubing is not labeled and dated then no one knows when it was changed and that could lead to an infection for the resident. An interview on 10/12/22 at 1:45 PM, with the Director of Nurses (DON) confirmed it is the policy of the facility that O2 tubing is changed, dated, and initialed on Sunday's each week. She revealed that if the O2 tubing is not dated then you can assume it was not changed. She revealed the reason the resident's O2 tubing would need to be changed is to prevent the buildup of bacteria. Record review of Resident #184's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 5 L/M per NC (nasal cannula) cont. (continuous) decrease O2 levels and an order dated 9/23/22, Change NEB(nebulizer)/O2 tubing q (every) Sunday, date tube and storage bag, clean NEB/O2 concentrator and filter @ (at) this time. Record review of Resident #184's Face Sheet with an admitted [DATE] and medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #184's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicates the resident is severely cognitively impaired, Resident #2 An observation and interview on 10/11/22 at 11:00 AM, with Resident #2 revealed that he used his oxygen every night and that he put it on and removed it himself. The oxygen tubing and water humidifier bottle were not labeled and dated and there was no oxygen signage on the door. An observation on 10/11/22 at 3:00 PM, revealed that there was no date on the oxygen tubing or on the humidified water bottle and there was no oxygen signage on the door outside of his room. An interview with Licensed Practical Nursing (LPN) #1 on 10/13/22 at 8:30 AM, revealed that the oxygen tubing and humidified water bottles are supposed to be changed every seven days and that the nurses on night shift are responsible for this. An interview with Licensed Practical Nurse (LPN) #4 on 10/12/22 at 1:30 PM, revealed that the night shift nurses take care of changing the oxygen tubing and water humidifier bottles. She revealed that the tubing and the humidifier bottles are supposed to be dated and that the nasal cannulas are to be placed in a plastic bag. She also revealed that oxygen signs are to be on the wall outside of the resident's room as well. LPN #4 confirmed that there was no date on the oxygen tubing, nasal cannula, or humidified water bottle and that there was no oxygen sign outside the resident's door. She also revealed that this could cause issues including being unable to determine the last time this tubing was changed which could lead to infection. On 10/13/22 at 9:45 AM, an interview with Registered Nurse (RN) #2, revealed that the oxygen tubing and humidified bottles are scheduled to be changed every Sunday and as needed. She also revealed that the nurses on night shift are responsible for getting them changed and dated. Record review of Resident #2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . SOB (shortness of breath) and an order dated 6/22/20 to Change NEB/O2 Tubing every Sunday, Date Tube and Storage Bag . A record review of the Face Sheet revealed that Resident #2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2022, for Resident #2, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #2 is cognitively intact. Record review of the September and October 2022 Electronic Treatment Administration Records (E-TARs), revealed in the description column to Change Nebulizer/Oxygen Tubing Every Sunday, Date Tube and Storage Bag. There were no initials or check marks by staff present on the E-TAR that would indicate that this task was completed. Resident #42 An observation and interview with Resident #42 on 10/11/22 at 3:45 PM, revealed the resident sitting in her wheelchair with an oxygen concentrator at her side. There was no date on the tubing or bag for tubing storage and there was no oxygen signage on the resident's room door. Resident #42 revealed she wears oxygen every night. An observation of Resident #42 on 10/12/22 at 9:26 AM and at 9:55 AM, revealed no date on the oxygen tubing, no storage bag, and no oxygen signage on the entry door. An observation and interview on 10/12/22 at 1:20 PM, with LPN #5 revealed the oxygen tubing and storage are to be changed weekly on Sunday night. She revealed the oxygen tubing is also supposed to be labeled, dated, and placed in a plastic bag. LPN #5 confirmed there was no tubing storage bag in the room and that it should be. LPN #5 confirmed there was no oxygen signage on the door. An interview on 10/12/22 at 2:00 PM, with the Infection Control Nurse revealed the oxygen tubing is to be changed out each Sunday night and kept in a bag when not in use. She revealed it must be labeled and dated each week and oxygen signage should be on the resident's door. Record review of the Face Sheet for Resident #42 revealed that she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . SOB and an order dated 10/31/19 Change NEB/O2 Tubing every Sunday. Date Tube and Storage Bag . Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/22, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 12, indicating that the resident is moderately impaired.

Based on observations, staff interview, record review and facility policy review the facility failed to implement a comprehensive care plan for three (3) of 18 care plans reviewed. Resident #2, Resident #42 and Resident #184. Findings Include: Record review of the facility policy titled Care Plan with a revision date of 09/04/2014 revealed under Purpose .To direct resident care from admission to discharge. Resident #184 An observation on 10/11/22 at 11:03 AM, revealed Resident #184 lying in bed receiving Oxygen (O2)via biprong nasal cannula at five (5) Liters Per Minute (LPM). O2 tubing was not dated or labeled and there was no O2 signage on the resident's room door. Record review of Resident #184's care plans revealed the following care plan: I am at risk of respiratory complications related to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] @ 5 L/M (liters/minute) via nasal bi prong (NBP) with a goal of I will be free of signs and symptoms of respiratory distress and maintain optimal functioning within limitations imposed by disease process through next review and interventions that include Administer O2 as ordered @ 5 l/m via NBP. Change setup weekly and as needed (PRN). An observation and interview on 10/12/22 at 1:30 PM, with Licensed Practical Nurse (LPN) #1 confirmed that Resident #184's O2 tubing was not labeled and dated and there was no O2 signage on the door. She confirmed and revealed there was a plastic bag with new O2 tubing with a date of 10/10/22 lying on top of the air conditioner in the resident's room. She revealed the nurse was supposed to have changed the resident's tubing on Sunday 10/10/22 so it must have not been done and stated it is the policy of the facility that resident's O2 tubing has to be changed once per week, labeled, and dated and O2 signage needs to be put on the door. She confirmed the resident has a care plan that indicated that the O2 tubing needs to be changed weekly and as needed. An interview on 10/12/22 at 4:00 PM, with the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) #2 and LPN-MDS #3 revealed they are responsible for putting care plans on the resident's record on admission and after their MDS assessments if needed. LPN-MDS #3 revealed that the purpose of the care plan was to provide a guide for care to meet the resident's needs. LPN-MDS #2 revealed that the care plans go on the resident's paper chart and in the computer, which all nurses have access to and she confirmed that Resident #184's care plan was not followed related to changing the O2 tubing weekly. Resident #2 An observation and interview on 10/11/22 at 11:00 AM, Resident #2 revealed that he uses his oxygen every night. There was no date noted on the oxygen tubing, nasal cannula, or water humidifier bottle and there was no oxygen signage on the door. Record review of Resident #2's Care Plan with start date of 1/27/22 and review date of 10/20/2022, revealed the goal, I will be free of signs/symptoms of respiratory distress and maintain optimal functioning within limitations imposed by disease process through next review. The interventions in this Care Plan included the following: Administer Oxygen at 2 Liters per minute via nasal biprong as needed as ordered. Change setup weekly and as needed. On 10/12/22 at 1:30 PM, an interview with Licensed Practical Nurse (LPN) #4, revealed that the night shift nurses take care of changing the oxygen tubing, cannulas, and water humidifier bottles. She revealed that the tubing, cannulas, and the humidifier bottles are supposed to be dated and that the nasal cannulas are to be placed in a plastic bag. She also revealed that oxygen signs are to be on the wall outside of the resident's room as well. LPN #4 confirmed that there was no date on the oxygen tubing, nasal cannula, or humidified water bottle and that there was no oxygen sign outside the resident's door. Record review of Electronic Treatment Record for the months of September 2022 and October 2022, revealed that the oxygen tubing, nasal cannula, and humidified water bottle was not being changed and dated as ordered and care planned. Resident #42 An observation and interview on 10/11/22 at 3:45 PM, Resident #42 stated she wears oxygen at night. There was no date on the oxygen tubing or bag for tubing storage and there was no oxygen signage on the entry door. Record review of Resident #42's Care Plan with a start date of 1/27/22 and review date of 12/1/2022, revealed the goal, I will be free of signs/symptoms of respiratory distress and maintain optimal functioning within limitations imposed by disease process through next review. The interventions in this Care Plan included the following: Administer Oxygen at 4 Liters per minute via nasal biprong as ordered. Change setup weekly and as needed. An interview on 10/12/22 at 1:20 PM, with LPN #5 revealed the oxygen tubing and storage bags are to be changed weekly on Sunday night. She revealed the O2 tubing is supposed to be labeled and dated and placed in a plastic bag and she confirmed that it was not changed for Resident #42. An interview on 10/12/22 at 4:10 PM, with the Director of Nursing (DON) revealed that the importance of the care plans was to ensure the care is provided as needed. She revealed that if the staff did not implement the care plan, then a resident with O2 could have respiratory infections from the oxygen not being changed weekly.

Based on staff interviews, record review and facility policy review the facility failed to submit criminal background checks on three (3) of five (5) new employee personnel records reviewed. Findings include: Review of the facility policy titled, Hiring with no revision date revealed under Comments #3e. If the drug test is negative, a Criminal History Record Check (CHRC) will be performed. Employee will be fingerprinted, and fingerprints will be submitted to the MS State Department of Health. An interview on 10/12/22 at 9:45 AM with the Human Resources (HR) Director confirmed that the background checks had not been completed on Certified Nursing Assistant (CNA) #1, CNA #2, and Registered Nurse (RN) #1. She revealed she is the only one in her department and she covers the hospital new hires as well and stated that she just got behind. She revealed she did not realize how behind she had gotten until the State Agency (SA) asked for the records of the latest new employees hired in the last 120 days and it revealed that these employees did not have their criminal background check. She stated they were all direct care employees and that if an employee was working here they were required to have a criminal background completed. She revealed the facility has a policy that all employees will be fingerprinted and a criminal background check will be completed on every employee that works at the facility. An interview on 10/12/22 at 10:00 AM with the Administrator and the Director of Nurses (DON) confirmed it is the policy of the facility that all employees have a criminal background check. The DON confirmed that allowing someone to work here without a criminal background check being completed puts the resident at risk for the potential for abuse if that employee had a disqualifying factor on their criminal background check. Record review of new hire personnel records revealed that no criminal background check had been completed on CNA #1, CNA #2, and RN #1 that were hired in the last 120 days.

Based on observation, interview, record review and policy review, the facility failed to ensure that accidents did not occur due to environmental hazards for one (1) of four (4) sampled and two (2) unsampled residents reviewed, Resident #2. Resident #2's floor was uneven with a slope at the door threshold going into the resident's room. Resident #2 fell from her wheelchair on 3/1/13 while attempting to exit the doorway and was taken to the emergency room (ER). Resident #2 had a skin tear to the left hand. Resident #2 complained of unrelieved pain on 3/3/13 and x-rays of the thoracic spine revealed vertebral compression fractures that were old and recent. The facility had been aware of the uneven threshold prior to the incident. Resident #2 had increased pain and required the use of additional pain medications for approximately six (6) days and was confined to the bed and/or Geri-chair from 3/1/13-3/19/13. Findings include: Observation of room 44 with the Director of Nursing on 5/9/13 at 9:50 a.m. revealed that there was a slope in the floor threshold of the doorway to the inside of the room. Observation and measurement of the slope by the Maintenance Supervisor with a level and a tape measure on 5/10/13 at 9:40 a.m. revealed that the gradient slope to room 44 was seven-eights (7/8) of an inch at the highest level slanting into the room with the lowest level at one-fourth (?) of an inch. Observation and interview with Resident #2 on 5/9/13 at 11:45 a.m. revealed that she was alert and oriented to person and place but wasn't sure of the time. Resident #2 recalled falling out of the wheelchair over the past two (2) months. Resident #2 stated that there had been a hump in the doorway of her previous room (room 44) which was hard to get over with her wheelchair. Resident #2 stated that one day she had gotten a running start but the wheelchair got caught in the doorway and she had fallen out of the chair. Resident #2 stated that she was sent to the ER. Resident #2 stated that she had blood on her hand, didn't think that anything was broken, but that her back did hurt a lot. Resident #2 stated that the wheelchair had turned over on top of her. Resident #2 stated that she had moved to another room after the fall. Review of Resident #2's medical record revealed that she was admitted [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/13, revealed that she was cognitively intact with a Brief Interview for Mental Status of 13. A score of 13-15 is indicative of a cognitively intact resident. Review of a physician's orders [REDACTED].#2 to the ER for evaluation and treatment related to a fall and left hip pain. Review of a Resident Incident Report, dated 3/1/13 at 10:00 a.m. revealed that Resident #2 had fallen in her room while propelling self in the wheelchair. Resident #2 was noted sitting in the floor bedside the wheelchair with a complaint of left hip pain, left elbow pain and left hand pain. Resident #2 had a skin tear to the left knuckle area which measured approximately four (4) centimeters (cm) x two (2) cm. There was no documentation of the causative factors or resident statement of how the fall had occurred. Review of a nurse's note dated 3/1/13 at 10:00 a.m. revealed that the nurse was called to Resident #2's room and the resident was found sitting on the floor. Resident #2 complained of left hip, elbow and hand pain. The physician and Responsible Party (RP) were notified. Resident #2 was noted to have a skin tear to the left hand knuckle area which measured approximately 4 cm x 2 cm with first aide treatment provided. Resident #2 was transported per stretcher to the emergency room . Resident #2 returned at 3:00 p.m. with new orders for Lortab 5 milligram (mg) every four (4) hours as needed (prn) for four (4) days. Review of a nurse's note dated 3/3/13 at 2:55 p.m. revealed that the physician was notified due to Resident #2's complaint of back pain without relief from medication of Oxycontin 10 mg and Lortab 5 mg x 2. Resident #2 was ordered Motrin every eight (8) hours prn and ice packs to the back. Nurse's notes on 3/3/13 at 3:15 p.m. revealed that the physician was notified that Resident #2 could not take Motrin and X-rays of the lumbar and thoracic spine were ordered related to Resident #2's back pain. Review of a nurse's note dated 3/3/13 at 4:00 p.m. revealed that the X-ray report for Resident #2 was reported as scoliosis, arthritis, osteoporosis, degenerative disc disease, and multiple compression vertebral bodies some of which appear recent. At 4:20 p.m. the physician was notified of Resident #2's x-ray results and new orders were received for increased pain medications. Review of physician's orders [REDACTED]. 3/3/13- at 3:15 p.m. - x-rays of the thoracic Dorsal and lumbar lower spine related to back pain. 3/3/13 at 4:20 p.m.- discontinue (d/c) Motrin, Oxycontin 10 mg twice daily, and Lortab 5 mg every four (4) hours prn. New orders for Oxycontin 20 mg twice daily for pain and Lortab 10 mg every six (6) hours prn pain. 3/4/13- the order was changed from Lortab 10 mg to Narco 10/325 mg every six (6) hours prn pain. 3/11/13- get up in the Geri-chair for breakfast, lunch and supper, to d/c Oxycontin 20 mg twice daily and begin Oxycontin 10 mg every morning and 20 mg every evening. 3/13/13 -d/c Oxycontin 20 mg in the evening and begin 10 mg in the evening. 3/19/13- d/c the Geri-chair, resident may get up in the wheelchair when out of bed. Review of Resident #2's March Medication Administration Record (MAR) revealed that she was administered the following pain medication in addition to her routine pain medications: 3/2/13- Lortab 5 mg; 3/2/13 and 3/3/13; Lortab 10 mg on 3/3/13, Norco 10/325 mg- 3/5/13, 3/6/13 x 1 and 3/7/13 x 2. Resident #2's routine Oxycontin was increased from 10 mg twice daily to 20 mg twice daily from 3/3/13-3/11/13. Review of the Radiology report for Resident #2, dated 3/1/13, revealed a normal left hand with osteoporosis involving the bony structure with no acute traumatic changes and no evidence of trauma or change to the left hip. Radiology reports dated 3/3/13 revealed that Resident #2 had multiple compression fractures involving the lower thoracic vertebral bodies, some appear old and some appear new. The lumbar spine x-ray revealed compression fractures in the lumbar area which appeared old. Interview with Licensed Practical Nurse (LPN) #1 on 5/9/13 at 10:20 a.m. revealed that Resident #2 reported that she was trying to come over the hump in the doorway and her chair got caught and she fell out of the chair (3/1/13). LPN #1 stated that she observed Resident #2 on the floor on her side in the doorway and her wheelchair was inside the room (44). LPN #1 stated that Resident #2 was alert but upset and had a skin tear to the left hand. Resident #2 complained of pain in her back/side and was taken to the ER. LPN #1 stated that maintenance was notified and believed that maintenance had been told prior of the threshold being uneven. Interview with Resident #2's Responsible Party on 5/9/13 at 12:20 p.m. revealed that she had talked to some of the staff about the difficulty that Resident #2 had in trying to propel her wheelchair out of the room (44) because of the slope of the threshold but did not specifically report a complaint. Resident #2's RP stated that after the resident's fall there were some newer compression fractures and the resident had more pain which required her to take more pain medication. Interview with the Maintenance Supervisor on 5/9/13 at 10:15 a.m. and again at 12:50 p.m. revealed that there had been renovation in the past year on B and C units and because of the different concrete pours there was some unevenness in some of the doorways. The Maintenance Supervisor stated that he and the contractor had discussed some ways of building the areas up but could not guarantee the outcome. The Maintenance Supervisor stated that one of the ladies in a wheelchair had approached him while coming out of her room and stated that it sure was uneven at the doorway. The Maintenance Supervisor stated that he looked at the doorway and told the lady that it sure was, didn't recall the date or the resident. The Maintenance Supervisor stated that it had been discussed with the contractor about how the area could be fixed but that it had gotten dropped somewhere along the way when the floor guys didn't come back within a few weeks. Interview and observation with the Maintenance Supervisor, Maintenance Person #1, and Maintenance Person #2 on 5/10/13 at 9:40 a.m. revealed that three (3) rooms on C stations had a floor threshold that sloped and was considered accident hazards. Room #43, had a gradient of one -fourth (1/4) of an inch sloping to the inside of the room. Room #44 had a gradient of seventh-eight (7/8) of an inch and room #45 had a three-fourth (?) inch gradient into the room. Observation of maintenance staff attempting to propel a wheelchair across the thresholds of all three (3) rooms proved more difficult, with the wheelchair coming to a halt and requiring more pressure, than when the wheelchair was propelled over the threshold of other rooms. All three (3) maintenance staffs confirmed that the sloped thresholds could be an accident hazard. Interview with the Director of Nursing (DON) on 5/9/13 at 9:15 a.m. and again at 2:05 p.m. revealed that the Ombudsman had called the Administrator and reported there had been a concern about Resident #2's threshold in the doorway being uneven. The DON stated that several rooms on Station C had doorways that were uneven during renovation but there had been no issues except Resident #2 had slid out of her chair when she tried to cross the doorway in her wheelchair. The DON stated that she had gotten the incident report for Resident #2's fall on 3/1/13 and reviewed the nurse's notes/documentation and was not aware that the threshold was the problem that had caused the fall at the time. The DON stated that she did not have a written fall investigation report and that one was usually done. Interview with the Administrator on 5/9/13 at 3:50 p.m. revealed that she had been aware that some of the doorway floor thresholds were uneven on Station C but there had not been any problems. The Administrator stated that she had talked with the Mtc Spv about the issue but didn't know if anything could be done about fixing them. The Administrator stated that the first she had heard of any problem with Resident #2's door threshold was when the Ombudsman told her of the family's concern about the doorway the previous month. The Administrator stated that Resident #2's family never approached her with a complaint about the doorway and was not aware there had been any problems at the time of Resident #2's fall. Interview with Registered Nurse (RN) #1 on 5/10/13 at 8:50 a.m. revealed that she wasn't aware of Resident #2's fall (3/1/13) until the following Monday, 3/4/13. RN #1 stated that prior to Resident #2's fall the resident was up in the wheelchair and could propel the wheelchair in the room and right outside the room (Room 44). RN #1 stated that after the fall, Resident #2 stayed in bed due to pain/soreness, had to have increased pain medications for her back for breakthrough pain, and was gotten up in a Geri-chair for meals. RN #1 stated that she had looked at the incident report after the fall and what she had understood was that Resident #2 was trying to get out of the room and when she went to push herself over the hump the alarm pad slipped out of the chair and the resident was sitting on it. RN #1 stated that she thought the resident's fall had occurred because of trying to use her feet to propel outside the doorway over the hump. RN #1 stated that usually there was documentation of what the resident said happened but there was no documentation in the nurse's notes or incident report for Resident #2 of what the resident said the cause of the fall had been. Review of the standards requiring Barrier Free Accessibility, ICC A117.1-2009, Chapter 3, 303 Changes in Levels: 303.1 General. Changes in level in floor surfaces shall comply with Section 303. 303.2 Vertical. Changes in level of ? inch maximum in height shall be permitted to be vertical. 303.3 Beveled. Changes in level greater than ? inch in height and not more than ? inch maximum in height shall be beveled with a slope no steeper than 1:2. There was no specific policy provided by the facility that included safety hazards or accidents.

CI MS # Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of four (4) residents reviewed was not neglected as evidenced by a Certified Nurse Aide (CNA) #1 transferred Resident #2 unassisted and Resident #2 received a [MEDICAL CONDITION] tibia during the transfer. Findings include: Resident #2 Observation and interview on 11/1/12 at 9:15 a.m. revealed Resident #2 was alert and oriented to person, place and time. Resident #2 stated that she did have a brace to her knee because of a fracture. Resident #2 stated that a girl had helped her to bed and kept her from falling but that her leg was twisted and she walked backward on it. Resident #2 stated that it didn't hurt too badly after she had gotten back to bed but then it started swelling and hurt more. Resident #2 stated that her leg was X-rayed and that's when they put the brace on. Resident #2 stated that two (2) people got her up and down from bed but that day the girl had bear hugged her and done it by herself. Resident #2 was not sure of the girl's name. Resident #2 complained of no pain. Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated that Resident #15 was cognitively intact. Review of the MDS, dated [DATE], revealed a BIMS of 15, which indicated that Resident #15 was cognitively intact. The MDS, dated [DATE], revealed that Resident #2 required extensive assistance and two (2) person assistance with transfers. Review of the care plan, dated 4/11/12, with an update on 5/22/12 and 6/29/12, revealed that Resident #2 required the assistance of two (2) to three (3) persons for transfers from the bed/wheelchair and chair to chair. Review of the plan of care Kardex, dated September 2012, which was used by the Certified Nurse Aides for care guidance, revealed that Resident #2 required two (2) people for assistance with transfers. (The Kardex was initialed by CNA #1 on 9/2/12 for care provided to Resident #2). Review of the Resident Incident Report, dated 9/2/12, revealed that Resident #2 stated that when she had gone back to bed with the assistance of the CNA (Certified Nurse Aide) the bed moved and when walking backward her right leg twisted and she had walked on her turned foot that was supported by the CNA. A two (2) centimeter bruise area was noted to the inner knee and she had complained of pain when the knee was touched (MD faxed/Responsible Party (RP) notified). Review of a nurse's note, dated 9/2/12 at 3:00 p.m., revealed the information from the incident report dated 9/2/12 with the addition of the right leg was elevated on a pillow and the responsible party was notified. Review of the nurse's note, dated 9/3/12 at 4:00 p.m., revealed that Resident #2 complained of no pain and was alert and oriented. A Bruise was noted to the right inner knee area with no open areas or bleeding noted. Review of a nurse's note, dated 9/4/12 at 2:00 p.m., revealed that Resident #2's right knee was swollen and tender when moved. Temperature 99.4 degrees, pulse 60, Respirations 21 and blood pressure 118/76. The Nurse Practitioner was on site and new orders were received. Review of Resident #2's physician's orders [REDACTED]. Review of an X-ray report, dated 9/4/12, of Resident #2's right knee revealed the following conclusion: Severe [MEDICAL CONDITION] is apparent; There is deformity of the proximal third of the shaft of the right fibula, consistent with an old healed fracture; The patient shows cortical irregularity involving the medial aspect of the tibial plateau, suggesting an impacted fracture in this area, which could be old or recent. Review of an X-ray report, dated 10/2/12, revealed that Resident #2's fracture involved the cortex of the medial aspect of the tibial plateau appeared to be healing in good alignment and position. Review of a note from the Certified Family Nurse Practitioner, dated 9/4/12, revealed that Resident #2's right knee had tenderness with palpation, warm to touch with moderate [MEDICAL CONDITION] medially and the neurovascular exam was intact to the right lower extremity. Further documentation included that the radiology report obtained 9/5/12 showed an impacted tibial plateau fracture, some question on X-rays as old versus acute, since we have a documented accident and swelling/tenderness over the area, clinically this is acute. Review of the facility's investigation report, dated 9/7/12, for the incident of Resident #2's tibial fracture revealed that the injury (to the right knee) resulted in CNA transferring resident without assistance. Resident is a two person transfer per her ADLs (activities of daily living) and Kardex. After talking with other CNAs on duty they say that you have to have two assist for transfer due to resident's inability to use the left side due [MEDICAL CONDITION](Cardiovascular Accident) and weakness. Resident acknowledges that CNA (Certified Nurse Aide) transferred her alone, that she told CNA her knee was hurting when she turned her foot over on its side and was attempting to walk on the foot in that position ...After interviewing (CNA #1), she admits to transferring resident alone and that resident hit knee on wheelchair that she did turn her feet under and she had trouble transferring her ...As a result of the investigation, CNA was terminated for not following the plan of care Kardex. Review of the handwritten statement, dated 9/7/12, with Certified Nurse Aide #1's signature, revealed the following statement: "I, (name CNA #1) was making rounds on patients and (name of Resident #2) asked me to put her to bed and she was about out of the chair at the time. So I went in to pull her back into the chair, but had no assistants at the time. I asked her to put her arm around my neck so I could pull her back into the chair but she insisted on going to bed and her foot bent and she went sideways toward the bed and she hit her knee on the wheelchair after she laid on the bed I just laid her on the bed after I got her situated I went and reported to (nurse)." An attempt was made to contact Certified Nurse Aide #1 by way of the telephone on 11/1/12 at 10:10 a.m. without success. Interview on 11/1/12 at 10:30 a.m. with the Director of Nurses (DON) revealed that Certified Nurse Aide (CNA) #1 had been in the hospital with illness. The DON stated that CNA #1 should have gotten assistance with the transfer of Resident #2 and had admitted that she transferred the resident without help. The DON stated that there had been plenty of staff available and that interviews with staff on duty revealed that CNA #1 hadn't asked anyone for help with the transfer. Interview with Certified Nurse Aide (CNA) #2 on 11/1/12 at 3:45 p.m. revealed that Resident #2 required two (2) person assist with transfers prior to breaking her knee and now required two person assist with the Hoyer Lift. CNA #2 stated that she always looked at the Kardex for the amount of assistance a resident needed and did not transfer anyone by herself that required more than one person assistance. Interview with Certified Nurse Aide (CNA) #3 on 11/1/12 at 11:30 a.m. revealed that she had taken care of Resident #2 one day and the resident complained of her knee hurting so she told the nurse and put the resident back in the bed so that they could X-ray her. CNA #3 stated that Resident #2 required two (2) people for transfers and that it was too risky to try to transfer her alone. Interview on 11/1/12 at 11:40 a.m. with Registered Nurse (RN) revealed that she had assessed Resident #2 the day that the incident had occurred (9/2/12) and did not recall her having pain. RN #1 stated that Resident #2's knee may have been a little red and they had elevated the knee. RN #1 stated that she was told that CNA #1 had transferred Resident #2 and the resident's knee had hit the chair. RN #1 stated that she did not really see any injury at the time and didn't think the resident really started complaining until a few days later. RN #1 stated that Resident #2 had been a two person assist with transfers. Interview with the Administrator on 11/2/12 at 10:30 a.m. revealed that CNA (Certified Nurse Aide) #1 had admitted to knowing that Resident #2 required two (2) persons for transfers and transferred Resident #2 without assistance because she was in a hurry. The Administrator stated that CNA #1 had been trained to review the follow the Kardex for resident care prior to the incident and was terminated because she didn't follow Resident #2's Kardex and the resident was injured. Review of the facility's "Abuse, Neglect and Mistreatment of [REDACTED]."

Based on observation, interview, record review and policy review, the facility failed to adequately supervise staff to prevent accidents for one (1) of four (4) residents reviewed (Resident #1). Resident #1, a bed bound resident, was transferred without the use of a Hoyer Lift and two (2) persons as required. Resident #1 sustained a fractured shoulder after the transfer had occurred. Findings Include: Observation on 1/25/11 at 9:45 a.m. revealed that Resident #1 was lying in bed with a sling in place to the right shoulder. Resident #1 was alert and confused. Resident #1 had no complaints of pain. Review of a written report from the facility dated 1/5/11 revealed that Resident #1 had sustained a fracture of the right humerus. The report revealed that CNA #1 performed an improper transfer, by not following the Kardex and instructions of the Nurses. Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/10 revealed that Resident #1 was cognitively impaired and required total assistance for care. Transfer and Ambulation had not occurred in the past seven (7) days from the ARD. Resident #1 was coded as being bed bound. Review of a Physician's Progress Note dated 12/18/10 revealed that Resident #1 was primarily restricted to the bed. Review of Resident #1's "Plan of Care Kardex" for November 2010 and December 2010 revealed documentation that the Resident was bed bound. The documentation revealed that if Resident #1 had to be transferred, it would require the use of a Hoyer Lift and two (2) person assist. CNA #1 had signed both Kardex's which indicated that she had followed the plan of care. Review of the Nursing Care Plan dated 7/22/10 revealed that Resident #1 was bedbound and if a transfer was required then a Hoyer lift with assistance of two (2) was required. Review of Resident #1's "ADL" "Activity of Daily Living" sheet for December 2010 had documentation that Resident #1 was bedbound every shift with exercise. CNA #1 signed the ADL sheet which indicated that she had provided the care as documented. Review of Nurse's Notes dated 11/3/10 at 10:00 p.m.; 11/10/10 at 8:00 a.m.; and 12/29/10 at 9:00 p.m. revealed that Resident #1 was bedbound. A note dated 11/17/10 at 9:00 p.m. revealed that she was transferred per Hoyer lift if needed. Review of a Nurse's note dated 1/1/11 at 5:50 a.m. revealed that CNA #3 reported that Resident #1 had pain when her right arm was lifted. A four (4) centimeter (cm) dark purple bruise with light green and yellow fading coloration was noted to the right upper arm and swelling at the right shoulder to the elbow. The arm was warm to the touch. The Physician was notified and Resident #1 was sent to the emergency room . Review of Resident #1's Weekly Skin assessment dated [DATE] revealed a 10 cm x 5 cm bruise to the right upper anterior arm from a fracture. Review of an X-ray of Resident #1's right shoulder dated 1/1/11 revealed severe osteoporosis and arthritis involving the bones of the shoulder and a comminuted fracture of the proximal humerus at the shoulder. Review of previous X-rays dated 11/16/09 and 11/16/10 revealed that Resident #1 had severe osteoporosis and arthritis involving the shoulders. Interview with the Director of Nursing (DON) on 1/25/11 at 9:00 a.m. revealed that Resident #1 was not supposed to get out of bed, that she was bedbound. The DON stated that everyone was told about that and it had been on the Kardex to only use the Hoyer lift. The DON stated that at the time of the investigation she had discovered that CNA #1 had transferred Resident #1 without the use of the Hoyer lift or assistance. The DON stated that CNA #4 admitted that she did not look at the Kardex. The DON stated that CNA #4 told CNA #1 not to get Resident #1 up, but that CNA #4 had done it anyway. The DON stated that the next day, 1/1/11, Resident #1 was diagnosed with [REDACTED].#1 being up. The DON stated that the LPN's did not know until the resident was already gotten up that day. Further interview with the DON on 1/25/11 at 3:00 p.m. revealed that she was not aware that LPN #2 told CNA #1 that it was okay for Resident #1 to be gotten up. The DON stated that if that occurred then LPN #2 was just as guilty as CNA #1 for not looking at the care plan. Interview with CNA #1 on 1/26/11 at 9:40 a.m. revealed that she got Resident #1 up unassisted and without the use of the Hoyer lift twice, once on 12/30/10 and once on 12/31/10. CNA #1 stated that she was unaware that Resident #1 couldn't get up at all. CNA #1 stated that she didn't want Resident #1 to lay in the bed all of the time. CNA #1 stated that she did not look at the Kardex plan of care prior to getting Resident #1 up. CNA #1 stated that she had been told before to look at the Kardex to determine the care that is needed for the Resident. CNA #1 stated that she did not mean to hurt Resident #1. CNA #1 stated that she placed Resident #1's arms on her shoulder and picked her up. CNA #1 stated that Resident #1 didn't yell out or complain of pain. CNA #1 stated that she had Resident #1 up in the gerichair when RN #1 had come by and said that Resident #1 wasn't supposed to be up. CNA #1 stated that after lunch she and CNA #5 put Resident #1 back to bed. CNA #1 stated that they paid close attention to the Resident's legs. CNA #1 stated that the Hoyer lift was not used either time during the transfers. CNA #1 stated that she told LPN #2 that she was going to get Resident #1 up and that LPN #2 told her that she didn't' think the Resident was supposed to get up. CNA #1 stated that she told LPN #2 that she had gotten the Resident up the day before, so, LPN #2 told her that is was okay. CNA #1 stated that she did not recall CNA #4 telling her not to get Resident #1 up. When questioned why she and LPN #1 didn't look at the care plan or Kardex before getting Resident #1 up, CNA #1 stated that she just didn't look at that section of the care plan. Interview with RN #1 on 1/25/11 at 9:15 a.m. revealed that she had saw Resident #1 sitting up in the Gerichair and asked when they had started getting her up. RN #1 stated that in the past, the Resident had not gotten up due to her knees and bones. RN #1 stated that she was told that CNA #1 had gotten Resident #1 up. RN #1 stated that she told staff as soon as the Resident finished eating to put her back to bed and to pay particular attention to her legs. RN #1 stated that she told CNA #1 to call her if they needed any assistance. RN #1 stated that she didn't notice if the lift pad was under the Resident at that time. RN #1 stated that she should have told the Charge Nurse at the station but told the staff to call her if they needed her. RN #1 stated that the next day Resident #1 was diagnosed with [REDACTED].#1 was transferred to or from the bed. RN #1 stated that staff were told during orientation to look at the Kardex for resident care. Interview with LPN #1 on 1/25/11 at 1:00 p.m. revealed that she was the assigned nurse on 12/31/10 to care for Resident #1. She stated that CNA #1 came to her and stated: "Look, I got my baby up". LPN #1 stated that when she looked around, she saw that Resident #1 was up. LPN #1 stated that RN #1 was there and said that Resident #1 was not supposed to be up. LPN #1 stated that both she and RN #1, told CNA #1, to let us know when she put Resident #1 back to bed so that she could oversee the transfer. LPN #1 stated that CNA #1 did not notify her of the transfer. LPN #1 stated that she was not aware that CNA #1 had gotten Resident #1 up by herself until later. LPN #1 stated that she did not notify the Charge Nurse, RN #2, because RN #1 had handled the situation. Interview with LPN #2 on 1/25/11 at 2:40 p.m. revealed that CNA #1 asked her about getting Resident #1 up. LPN #2 stated that she told CNA #1 that she wasn't aware that Resident #1 was supposed to get up because she hadn't seen the resident up in a long time. LPN #2 stated that CNA #1 replied that she had gotten the resident up before and had checked the Kardex so she had told the CNA she guessed that it would be okay to get the Resident up. LPN #2 stated that she did not look at Resident #1's care plan or Kardex and didn't recall anyone else saying that the Resident could not get up. Interview with RN #2 on 1/25/11 at 2:45 p.m. revealed that she was the charge nurse for 12/31/10 and did not know anything about Resident #1 being transferred/gotten up that day. RN #2 stated that Resident #1 was not supposed to be up. She stated that staff had been told prior to, and after the incident, to look at the Kardex for Resident care instructions. Interview with CNA #2 on 1/25/11 at 9:45 a.m. revealed that she was going to give Resident #1 a bath. CNA #2 stated that Resident #1 does not get up and that she had to be careful turning Resident #1. CNA #2 stated that the reason was because Resident #1 had brittle bones. CNA #2 stated that Resident #1 could only get up with the Hoyer lift and assistance of at least two (2) people. CNA #2 stated that the Kardex defined the care that a Resident was suppose to receive. CNA #2 stated that she had been in-serviced to review the Kardex daily for care of the residents. CNA #2 stated that she had been told prior to, and after the incident, not to get Resident #1 out of bed. Interview with CNA #3 on 1/25/11 at 12:50 p.m. revealed that she was repositioning Resident #1 on 1/1/11 when the Resident complained of pain when she pulled the gown sleeve down and lifted the Resident's right arm. CNA #2 stated that the Resident's arm was stiffer and that she saw that it was bruised, red, and swollen around the shoulder. CNA #3 stated that the staff were told to leave Resident #1 in the bed because of her brittle bones and bone disease. CNA #3 stated that she never got Resident #1 up. CNA #3 stated that they were always told to look at the Kardex daily for care. Interview with LPN #4 on 1/25/11 at 12:35 p.m. revealed that she had assisted CNA #1 to bathe Resident #1 on 12/31/10. LPN #4 stated that CNA #1 brought a geri-chair in the room and said that she was going to get Resident #1 up. LPN #4 stated that she told CNA #1 that Resident #1 was not supposed to get up. LPN #4 stated that she had not assisted in getting Resident #1 up, nor putting her back to bed. LPN #4 stated that she was told when she started work about seven (7) months ago that Resident #1 was bedbound and didn't get up. CNA #4 stated that she had gone to the nurse's station and told the two (2) nurses sitting at the desk, LPN #1 and LPN #2, that CNA #1 was getting Resident #1 up. LPN #4 stated that she thought CNA #1 would look at the Kardex and see that Resident #1 was not supposed to get up. LPN #4 stated that she didn't think CNA #1 would actually get Resident #1 up. LPN #4 stated that were in-services prior to, and after the incidents. The in-service was that CNAs were supposed to look at the Kardex for care. Interview with CNA #5 on 1/25/11 at 10:20 a.m. revealed that she had assisted CNA #1 to put Resident #1 back to bed on 12/31/10. CNA #5 stated that they had not used the Hoyer lift. CNA #5 stated that she held the Resident's legs while CNA #1 put her arms under the resident's arms and picked her up and placed her in the bed. CNA #5 stated that Resident #1 did not yell or make any sounds. CNA #5 stated that she had been trained prior to, and after the incident, to look at the Kardex for resident care. CNA #5 stated that she had taken care of Resident #1 before, and that the resident was bedbound. CNA #5 stated that the only way she was to get up was with a Hoyer lift and two (2) people were supposed to be present when using a mechanical lift. Review of the facility's policy and procedure for "Plan of Care Kardex" dated 11/15/05 revealed the purpose was to ensure that Certified Nurse Assistants identify particular needs of each resident related to activities of daily living. The procedure: "Certified Nurse Assistants will utilize the plan of care Karex daily to ensure continuity of care to assigned residents. The Nurse Assistant will review the plan of care Kardex of each assigned resident daily and initial in the appropriate space. The Nurse Assistant will sign full name, or at least first initial and last name, on the back of the Plan of Care Kardex for identification purposes. The plan of Care Kardex will be updated monthly or more frequently as the resident's mental and/or physical status changes. The Plan of Care Kardex will become part of the medical record. The Plan of Care Kardex will identify the residents' needs in the following ADL's: hearing, speech, vision, ambulation, bathing, restraints, bed mobility, transfer, personal hygiene, dressing, eating, bowel & bladder function, and any adaptive equipment." Review of the facility's policy and procedure for "Use of Hydraulic Lift (Hoyer) dated 3/2004 revealed that the Hydraulic Lifts can be operated by one person, but was better to have two staff members present during transfers to stabilize and support the resident.

Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of four (4) resident's reviewed was free from neglect (Resident #1). Resident #1, a bed bound resident, was transferred without the use of a Hoyer Lift and two (2) persons as required. Resident #1 sustained a fractured shoulder after the transfer had occurred. Findings Include: Observation on 1/25/11 at 9:45 a.m. revealed that Resident #1 was lying in bed with a sling in place to the right shoulder. Resident #1 was alert and confused. Resident #1 had no complaints of pain. Review of a written report from the facility dated 1/5/11 revealed that Resident #1 had sustained a [MEDICAL CONDITION] humerus. The report revealed that CNA #1 performed an improper transfer, by not following the Kardex and instructions of the Nurses. Record review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/10 revealed that Resident #1 was cognitively impaired and required total assistance for care. Transfer and Ambulation had not occurred in the past seven (7) days from the ARD. Resident #1 was coded as being bed bound. Review of a Physician's Progress Note dated 12/18/10 revealed that Resident #1 was primarily restricted to the bed. Review of Resident #1's "Plan of Care Kardex" for November 2010 and December 2010 revealed documentation that the Resident was bed bound. The documentation revealed that if Resident #1 had to be transferred, it would require the use of a Hoyer Lift and two (2) person assist. CNA #1 had signed both Kardex's which indicated that she had followed the plan of care. Review of the Nursing Care Plan dated 7/22/10 revealed that Resident #1 was bedbound and if a transfer was required then a Hoyer lift with assistance of two (2) was required. Review of Resident #1's "ADL" "Activity of Daily Living" sheet for December 2010 had documentation that Resident #1 was bedbound every shift with exercise. CNA #1 signed the ADL sheet which indicated that she had provided the care as documented. Review of Nurse's Notes dated 11/3/10 at 10:00 p.m.; 11/10/10 at 8:00 a.m.; and 12/29/10 at 9:00 p.m. revealed that Resident #1 was bedbound. A note dated 11/17/10 at 9:00 p.m. revealed that she was transferred per Hoyer lift if needed. Review of a Nurse's note dated 1/1/11 at 5:50 a.m. revealed that CNA #3 reported that Resident #1 had pain when her right arm was lifted. A four (4) centimeter (cm) dark purple bruise with light green and yellow fading coloration was noted to the right upper arm and swelling at the right shoulder to the elbow. The arm was warm to the touch. The Physician was notified and Resident #1 was sent to the emergency room . Review of Resident #1's Weekly Skin assessment dated [DATE] revealed a 10 cm x 5 cm bruise to the right upper anterior arm from a fracture. Review of an X-ray of Resident #1's right shoulder dated 1/1/11 revealed severe [MEDICAL CONDITION] and arthritis involving the bones of the shoulder and a comminuted [MEDICAL CONDITION] humerus at the shoulder. Review of previous X-rays dated 11/16/09 and 11/16/10 revealed that Resident #1 had severe [MEDICAL CONDITION] and arthritis involving the shoulders. Interview with the Director of Nursing (DON) on 1/25/11 at 9:00 a.m. revealed that Resident #1 was not supposed to get out of bed, that she was bedbound. The DON stated that everyone was told about that and it had been on the Kardex to only use the Hoyer lift. The DON stated that at the time of the investigation she had discovered that CNA #1 had transferred Resident #1 without the use of the Hoyer lift or assistance. The DON stated that CNA #4 admitted that she did not look at the Kardex. The DON stated that CNA #4 told CNA #1 not to get Resident #1 up, but that CNA #4 had done it anyway. The DON stated that the next day, 1/1/11, Resident #1 was diagnosed with [REDACTED].#1 being up. The DON stated that the LPN's did not know until the resident was already gotten up that day. Further interview with the DON on 1/25/11 at 3:00 p.m. revealed that she was not aware that LPN #2 told CNA #1 that it was okay for Resident #1 to be gotten up. The DON stated that if that occurred then LPN #2 was just as guilty as CNA #1 for not looking at the care plan. Interview with CNA #1 on 1/26/11 at 9:40 a.m. revealed that she got Resident #1 up unassisted and without the use of the Hoyer lift twice, once on 12/30/10 and once on 12/31/10. CNA #1 stated that she was unaware that Resident #1 couldn't get up at all. CNA #1 stated that she didn't want Resident #1 to lay in the bed all of the time. CNA #1 stated that she did not look at the Kardex plan of care prior to getting Resident #1 up. CNA #1 stated that she had been told before to look at the Kardex to determine the care that is needed for the Resident. CNA #1 stated that she did not mean to hurt Resident #1. CNA #1 stated that she placed Resident #1's arms on her shoulder and picked her up. CNA #1 stated that Resident #1 didn't yell out or complain of pain. CNA #1 stated that she had Resident #1 up in the gerichair when RN #1 had come by and said that Resident #1 wasn't supposed to be up. CNA #1 stated that after lunch she and CNA #5 put Resident #1 back to bed. CNA #1 stated that they paid close attention to the Resident's legs. CNA #1 stated that the Hoyer lift was not used either time during the transfers. CNA #1 stated that she told LPN #2 that she was going to get Resident #1 up and that LPN #2 told her that she didn't' think the Resident was supposed to get up. CNA #1 stated that she told LPN #2 that she had gotten the Resident up the day before, so, LPN #2 told her that is was okay. CNA #1 stated that she did not recall CNA #4 telling her not to get Resident #1 up. When questioned why she and LPN #1 didn't look at the care plan or Kardex before getting Resident #1 up, CNA #1 stated that she just didn't look at that section of the care plan. Interview with RN #1 on 1/25/11 at 9:15 a.m. revealed that she had saw Resident #1 sitting up in the Gerichair and asked when they had started getting her up. RN #1 stated that in the past, the Resident had not gotten up due to her knees and bones. RN #1 stated that she was told that CNA #1 had gotten Resident #1 up. RN #1 stated that she told staff as soon as the Resident finished eating to put her back to bed and to pay particular attention to her legs. RN #1 stated that she told CNA #1 to call her if they needed any assistance. RN #1 stated that she didn't notice if the lift pad was under the Resident at that time. RN #1 stated that she should have told the Charge Nurse at the station but told the staff to call her if they needed her. RN #1 stated that the next day Resident #1 was diagnosed with [REDACTED].#1 was transferred to or from the bed. RN #1 stated that staff were told during orientation to look at the Kardex for resident care. Interview with LPN #1 on 1/25/11 at 1:00 p.m. revealed that she was the assigned nurse on 12/31/10 to care for Resident #1. She stated that CNA #1 came to her and stated: "Look, I got my baby up". LPN #1 stated that when she looked around, she saw that Resident #1 was up. LPN #1 stated that RN #1 was there and said that Resident #1 was not supposed to be up. LPN #1 stated that both she and RN #1, told CNA #1, to let us know when she put Resident #1 back to bed so that she could oversee the transfer. LPN #1 stated that CNA #1 did not notify her of the transfer. LPN #1 stated that she was not aware that CNA #1 had gotten Resident #1 up by herself until later. LPN #1 stated that she did not notify the Charge Nurse, RN #2, because RN #1 had handled the situation. Interview with LPN #2 on 1/25/11 at 2:40 p.m. revealed that CNA #1 asked her about getting Resident #1 up. LPN #2 stated that she told CNA #1 that she wasn't aware that Resident #1 was supposed to get up because she hadn't seen the resident up in a long time. LPN #2 stated that CNA #1 replied that she had gotten the resident up before and had checked the Kardex so she had told the CNA she guessed that it would be okay to get the Resident up. LPN #2 stated that she did not look at Resident #1's care plan or Kardex and didn't recall anyone else saying that the Resident could not get up. Interview with RN #2 on 1/25/11 at 2:45 p.m. revealed that she was the charge nurse for 12/31/10 and did not know anything about Resident #1 being transferred/gotten up that day. RN #2 stated that Resident #1 was not supposed to be up. She stated that staff had been told prior to, and after the incident, to look at the Kardex for Resident care instructions. Interview with CNA #2 on 1/25/11 at 9:45 a.m. revealed that she was going to give Resident #1 a bath. CNA #2 stated that Resident #1 does not get up and that she had to be careful turning Resident #1. CNA #2 stated that the reason was because Resident #1 had brittle bones. CNA #2 stated that Resident #1 could only get up with the Hoyer lift and assistance of at least two (2) people. CNA #2 stated that the Kardex defined the care that a Resident was suppose to receive. CNA #2 stated that she had been in-serviced to review the Kardex daily for care of the residents. CNA #2 stated that she had been told prior to, and after the incident, not to get Resident #1 out of bed. Interview with CNA #3 on 1/25/11 at 12:50 p.m. revealed that she was repositioning Resident #1 on 1/1/11 when the Resident complained of pain when she pulled the gown sleeve down and lifted the Resident's right arm. CNA #2 stated that the Resident's arm was stiffer and that she saw that it was bruised, red, and swollen around the shoulder. CNA #3 stated that the staff were told to leave Resident #1 in the bed because of her brittle bones and bone disease. CNA #3 stated that she never got Resident #1 up. CNA #3 stated that they were always told to look at the Kardex daily for care. Interview with LPN #4 on 1/25/11 at 12:35 p.m. revealed that she had assisted CNA #1 to bathe Resident #1 on 12/31/10. LPN #4 stated that CNA #1 brought a geri-chair in the room and said that she was going to get Resident #1 up. LPN #4 stated that she told CNA #1 that Resident #1 was not supposed to get up. LPN #4 stated that she had not assisted in getting Resident #1 up, nor putting her back to bed. LPN #4 stated that she was told when she started work about seven (7) months ago that Resident #1 was bedbound and didn't get up. CNA #4 stated that she had gone to the nurse's station and told the two (2) nurses sitting at the desk, LPN #1 and LPN #2, that CNA #1 was getting Resident #1 up. LPN #4 stated that she thought CNA #1 would look at the Kardex and see that Resident #1 was not supposed to get up. LPN #4 stated that she didn't think CNA #1 would actually get Resident #1 up. LPN #4 stated that were in-services prior to, and after the incidents. The in-service was that CNAs were supposed to look at the Kardex for care. Interview with CNA #5 on 1/25/11 at 10:20 a.m. revealed that she had assisted CNA #1 to put Resident #1 back to bed on 12/31/10. CNA #5 stated that they had not used the Hoyer lift. CNA #5 stated that she held the Resident's legs while CNA #1 put her arms under the resident's arms and picked her up and placed her in the bed. CNA #5 stated that Resident #1 did not yell or make any sounds. CNA #5 stated that she had been trained prior to, and after the incident, to look at the Kardex for resident care. CNA #5 stated that she had taken care of Resident #1 before, and that the resident was bedbound. CNA #5 stated that the only way she was to get up was with a Hoyer lift and two (2) people were supposed to be present when using a mechanical lift. Review of the facility's policy and procedure for "Plan of Care Kardex" dated 11/15/05 revealed the purpose was to ensure that Certified Nurse Assistants identify particular needs of each resident related to activities of daily living. The procedure: "Certified Nurse Assistants will utilize the plan of care Karex daily to ensure continuity of care to assigned residents. The Nurse Assistant will review the plan of care Kardex of each assigned resident daily and initial in the appropriate space. The Nurse Assistant will sign full name, or at least first initial and last name, on the back of the Plan of Care Kardex for identification purposes. The plan of Care Kardex will be updated monthly or more frequently as the resident's mental and/or physical status changes. The Plan of Care Kardex will become part of the medical record. The Plan of Care Kardex will identify the residents' needs in the following ADL's: hearing, speech, vision, ambulation, bathing, restraints, bed mobility, transfer, personal hygiene, dressing, eating, bowel & bladder function, and any adaptive equipment." Review of the facility's policy and procedure for "Use of Hydraulic Lift (Hoyer) dated 3/2004 revealed that the Hydraulic Lifts can be operated by one person, but was better to have two staff members present during transfers to stabilize and support the resident. Review of the facility policy "Abuse, Neglect and Mistreatment of [REDACTED]."