Every finding on record at Wyndridge Health and Rehab CTR

Based on facility policy review, facility report review, and interview, the facility failed to notify the Long-Term Care (LTC) Ombudsman of resident discharges from the facility timely for 152 residents discharged from 9/3/2025-3/25/2026.The findings include: Review of the facility's policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), dated 5/2025, revealed .The facility's transfer/discharge notice will be provided to the LTC [Long Term Care] Ombudsman .The facility will maintain evidence that the notice was sent to the Ombudsman . Review of a resident discharge report from 9/3/2025-3/25/2026 revealed 152 residents had been discharged from the facility. During an interview on 3/25/2026 at 8:10 AM, the Social Worker stated she had been unable to send resident discharge notifications to the LTC Ombudsman because the new Ombudsman had not provided contact information. During a telephone interview on 3/25/2026 at 8:20 AM, the LTC Ombudsman stated she had not received notifications of resident discharges from the facility since starting the role in 11/2025. The LTC Ombudsman stated she had provided contact information to the facility and had informed the facility of the need to be notified of resident discharges. During an interview on 3/25/2026 at 11:00 AM, the Social Worker confirmed she had not notified the LTC Ombudsman of resident discharges since 9/3/2025.

Based on facility policy review, observations, and interview, the facility failed to properly store refrigerated food items, which had the potential to affect 77 out of 85 residents.The findings include:Review of the facility's undated policy titled, Food Storage Guidelines, revealed .'Open Dating' .on a food product .can .help .to know the time limit to .use the product at its best quality .'Use by' date is the last date recommended for the use of the product .The date has been determined by the manufacturer .If a product has a 'use by' date, follow that date .During an observation of the walk-in refrigerator on 3/23/2026 at 9:57AM, with the Certified Dietary Manager (CDM), revealed a turkey breast (approximately 5 pounds) with a manufacturer use by date of 3/20/2026. Further observation revealed an opened 32 fluid ounce bottle of lemon juice (approximately 3/4 full) with no manufacturer use by date or open date. During an interview on 3/23/2026 at 10:04 AM, the CDM confirmed the turkey breast was expired according to the manufacturer use by date and was available for resident use. The CDM further confirmed the 32 fluid ounce bottle of lemon juice was opened, had no manufacturer use by date, or an opened date on the bottle and was available for resident use.

Based on facility policy review, observation, and interview, the facility failed to maintain a clean, comfortable, homelike environment for 2 of 4 units observed for a clean, comfortable, homelike environment. Review of the facility's undated policy titled, Housekeeping Services, revealed thorough scrubbing will be used for all environmental surfaces that are being clean in patient care areas .due to the nature of the ventilator unit .cleaning is to be done daily on each shift from housekeeping, nursing staff, and respiratory therapy .Review of the facility's undated policy titled, Housekeeper Job Description, revealed .clean, wash, sanitize, and/or polish bathroom fixtures. Ensure that water marks are removed from fixtures .clean floors, to include sweeping, dusting, damp/wet mopping .remove dirt, dust .film from surfacesReview of the facility's undated policy titled, Housekeeping Department: Routine Cleaning of Equipment, revealed .environmental equipment is cleaned on a daily schedule and as needed such as: sinks, commodes, floors .Review of Pest Control Invoice #23745 dated 3/5/2026, revealed .sprayed kitchen + dining .room [ROOM NUMBER] .room [ROOM NUMBER] .During observations on 3/23/2026 at 12:34 PM and 3/25/2026 at 3:58 PM in room [ROOM NUMBER], revealed a significant amount of broken drywall material and drywall dust in the floor behind Bed A, adjacent to the resident's respiratory equipment. Continued observation revealed the drywall behind the bed near the baseboard was damaged with numerous visible penetrations. During observations on 3/24/2026 at 10:30 AM, 3/25/2026 at 10:41 AM, and 3/25/2026 at 3:22 PM in room [ROOM NUMBER], revealed pink, brown, and gray streaks in the bathtub, brown, black and pink stains around the bathtub drain. Further observation revealed a paper towel was present in the drain, caulking around the tub had brown, green, and gray discoloration, black debris was present at the edge of the faucet, and the faucet appeared to be leaking. Continued observation revealed, the vinyl baseboard was detached from the wall below the sink. During an observation on 3/24/2026 at 10:33 AM in room [ROOM NUMBER], revealed an orange and brown substance splattered on tiles surrounding the bathtub faucet and in the bathtub. Further observation revealed pink and brown streaks in the bathtub and brown, green, and gray stains near the drain. Continued observation revealed four rolls of toilet paper, two wrapped in paper, and two unwrapped, situated on the outer rim of the bathtub which was stained with a light brown substance. During an observation of the 100 Hall Shower Room on 3/24/2026 at 2:51 pm, revealed numerous cracked, chipped, and broken tiles in the front left shower stall with pink and brown staining and a black spotted substance present on and around tiles near the floor. Further observation revealed the shower head in the front left shower stall appeared to be leaking. A blue, plastic razor was noted on the floor between the shower stalls.During an observation on 3/25/2026 at 10:32 AM in room [ROOM NUMBER], revealed brown staining in a ring-shaped pattern on the interior of the toilet bowl. Further observation revealed the toilet seat was damaged with broken, stained plastic on the left side of the hinge, chipped plastic at the left edge, and yellow staining to the underside of the toilet seat. Continued observation revealed a foul and pervasive odor in the bathroom and the presence of several flying insects around the toilet. During an interview on 3/25/2026 at 10:41 AM, Housekeeper I stated, .the residents' rooms are cleaned every day .During an observation and interview on 3/25/2026 at 3:17 PM, in the 100 Hall Shower Room with Certified Nursing Assistant (CNA) G, revealed numerous cracked, chipped, and broken tiles in the front left shower stall with pink and brown staining and a black spotted substance present on and around tiles near the floor. Further observation revealed the shower head in the front left shower stall appeared to be leaking. A blue, plastic razor was noted on the floor between the shower stalls and a black to brown insect was noted on the floor near the drain of the rear left shower stall. CNA G stated, .there really shouldn't be bugs in the shower room .the razor is not supposed to be in the floor .During an observation on 3/25/2026 at 3:20 PM in room [ROOM NUMBER], revealed an orange and brown substance splattered on tiles surrounding the bathtub faucet and in the bathtub. Further observation revealed pink and brown streaks in the bathtub and brown, green, and gray stains near the drain. Continued observation revealed two rolls of toilet paper, one wrapped in paper, and one unwrapped, situated on the outer rim of the bathtub which was stained with a light brown substance. During an observation on 3/25/2026 at 3:29 PM in room [ROOM NUMBER], revealed brown staining in a ring-shaped pattern on the interior of the toilet bowl. Further observation revealed the toilet seat was damaged with broken, stained plastic on the left side of the hinge, chipped plastic at the left edge, and yellow staining to the underside of the toilet seat. Continued observation revealed a foul and pervasive odor in the bathroom and the presence of several flying insects around the toilet. During an interview on 3/25/2026 at 3:31 PM, Licensed Practical Nurse (LPN) G stated, .the facility has had intermittent issues with insects in the secure unit the past few months .During an interview on 3/25/2026 at 3:35 PM, the Administrator viewed photos of the above observations, and confirmed the facility failed to provide a clean, comfortable, and home-like environment on the 100 Hallway. During an interview on 3/25/2026 at 4:00 PM, the Assistant Director of Nursing (ADON) confirmed the drywall damage and debris in room [ROOM NUMBER] needed to be reported to the maintenance director and corrected immediately. During an interview on 3/25/2026 at 4:05 pm, the Maintenance Director confirmed the facility failed to maintain a clean, comfortable, and homelike environment on the 400 hallway.

Based on facility policy review, medical record reviews, observations, and interviews, the facility failed to ensure Physician's Orders were obtained for ventilator (a machine or device used to support or replace the breathing of a person who has difficulty breathing on their own) use for 1 resident (Resident #1) of 3 residents reviewed for ventilators, and for tracheostomy (a surgically created opening in the front of the neck leading into the windpipe/trachea) use for 2 residents (Residents #8 and #9)) of 3 residents reviewed for tracheostomies, the facility failed to ensure oxygen was administered according to Physician's Orders for 1 resident (Resident #65) of 23 residents reviewed for oxygen therapy, and failed to safely secure portable oxygen tanks in residents' rooms for 2 residents (Residents #88 and #69) of 23 residents reviewed for oxygen therapy. The findings include: Review of the facility's undated policy titled, Oxygen Use, General revealed Oxygen therapy is administered .upon written order of a licensed physician .must be inspected before oxygen is turned on to assure .proper working order .Oxygen Safety .Oxygen cylinders must be stored in racks .sturdy portable carts and/or approved stands .Oxygen cylinders may not be left free standing. They must be securely fastened at all times . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Epilepsy (seizure disorder), Acute on Chronic Respiratory Failure, Tracheostomy, and Dependence on Ventilator. Review of the comprehensive care plan for Resident #1 revealed a problem dated 11/25/2025, .ventilator dependent . and .has a tracheostomy . with appropriate goals and interventions. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During observations on 3/23/2026 at 11:15 AM and 3/24/2026 at 2:00 PM, Resident #1 was observed lying in bed with a tracheostomy connected to a mechanical ventilator. Review of a Respiratory Care assessment for Resident #1 dated 3/25/2026, revealed the resident used a mechanical ventilator and the settings were documented, the resident was suctioned 4 times on 3/25/2026, and the resident had a tracheostomy with the size and type documented. Review of the Physician's Orders for Resident #1 dated 3/25/2026, revealed no orders were present for ventilator use or ventilator settings to guide care such as mode (type), rate (number of breaths delivered per minute), tidal volume (amount of air delivered in each breath), FiO (Fraction of Inspired Oxygen-the percentage of oxygen delivered), or PEEP (Positive End-Expiratory Pressure-pressure kept in the lungs at the end of breathing out). Further review revealed no Physician's Orders were present for resident suctioning, or for tracheostomy use and tracheostomy care, type, and size, and there were no Physician's Orders authorizing respiratory therapy to manage ventilator settings. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Traumatic Brain Injury, Quadriplegia, Acute Respiratory Failure, and Tracheostomy. Review of the comprehensive care plan for Resident #8 revealed a problem dated 5/13/2025, .has a tracheostomy . with appropriate goals and interventions. Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. During observations on 3/23/2026 at 11:25 AM and 3/24/2026 at 2:15 PM, Resident #8 was observed lying in bed with a tracheostomy in place. Review of a Respiratory Care assessment for Resident #8 dated 3/25/2026, revealed the resident was suctioned 6 times on 3/25/2026, and the resident had a tracheostomy with the size and type documented. Review of the Physician's Orders for Resident #8 dated 3/25/2026, revealed no orders were present for resident suctioning, or for tracheostomy use and tracheostomy care, type, and size. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Dependence on Ventilator, and Tracheostomy. Review of the comprehensive care plan for Resident #9 revealed a problem dated 11/21/2025, .dependent on vent [ventilator] has tracheostomy . with appropriate goals and interventions. Review of a quarterly MDS assessment dated [DATE], revealed Resident #9 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. During observations on 3/23/2026 at 11:33 AM and 3/24/2026 at 2:35 PM, Resident #9 was observed lying in bed with a tracheostomy in place connected to a mechanical ventilator. Review of a Respiratory Care assessment for Resident #9 dated 3/25/2026, revealed the resident had a tracheostomy with the size and type documented. Review of the Physician's Orders for Resident #9 dated 3/25/2026, revealed the resident's orders did not include the tracheostomy type or size. During an interview on 3/25/2026 at 2:50 PM, Registered Nurse Assistant Director of Nursing (RN/ADON) confirmed no Physician Orders were present for Resident #1's ventilator use, ventilator settings, suctioning, tracheostomy use, or tracheostomy type or size. The ADON also confirmed there were no Physician Orders for Resident #8's tracheostomy use, type, or size, and the Physician Orders for Resident #9's tracheostomy did not include the type or size. During an interview on 3/25/2026 at 3:00 PM, the Director of Nursing (DON) confirmed Physician Orders were required to direct resident care, including respiratory support with tracheostomy and ventilator use.

Based on facility policy reviews, medical record reviews, observations, and interviews, the facility failed to ensure practices to prevent the potential spread of infection were maintained by not following Enhanced Barrier Precautions (EBP) and not adhering to appropriate hand hygiene during respiratory care for 2 residents (Residents #1 and #8) of 4 residents with a ventilator and/or tracheostomy, and during medication administration for 1 resident (Resident #22) of 4 residents observed during medication pass, failed to offer hand hygiene assistance prior to meals for 3 residents (Residents #47, #31, and #66) of 23 residents observed during dining, and failed to secure a urinary catheter bag off the floor for 1 resident (Resident #15) of 10 residents observed for urinary catheters.The findings include: Review of the facility's undated policy titled, Enhanced Barrier Precautions (EBP), revealed .EBP are implemented to reduce the transmission of Multi-Drug Resistant Organisms (MDRO's) in residents who require high-contact care activities .this policy applies to all staff providing direct care, including .Nursing .Therapy staff .EBP .a set of targeted infection-control practices requiring gloves and gowns during high-contact resident care activities .including .device care (catheters, feeding tubes, trachs [tracheostomies-a surgically created opening in the front of the neck leading into the windpipe/trachea], drains) .During high-contact care activities, staff must wear .gowns .gloves .procedure: .perform hand hygiene .review signage for EBP requirements .don gown and gloves prior to beginning high-contact care .avoid touching environmental surfaces unnecessarily .remove gloves and gown before leaving the resident's room or care space .perform hand hygiene immediately . Review of the facility's undated policy titled, Handwashing, revealed .may use waterless handwashing such as alcohol gels .when hands are not visibly soiled .hands should be washed after 3 times of using waterless cleaner . Review of the facility's policy titled, Handwashing Policy (Residents), dated 2/2025, revealed .Staff must offer hand hygiene before meals . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Epilepsy (seizure disorder), Acute on Chronic Respiratory Failure, Tracheostomy, and Dependence on Ventilator (a machine or device used to support or replace the breathing of a person who has difficulty breathing on their own). Review of the comprehensive care plan for Resident #1 revealed a problem dated 11/25/2025, .ventilator dependent . and .has a tracheostomy . with appropriate goals and interventions. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Traumatic Brain Injury, Quadriplegia, Acute Respiratory Failure, and Tracheostomy. Review of the comprehensive care plan for Resident #8 revealed a problem dated 5/13/2025, .has a tracheostomy . with appropriate goals and interventions. Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. During an observation on 3/25/2026 at 8:38 AM, Respiratory Therapist (RT) E entered Resident #1's room to provide tracheostomy care. There was a sign on Resident #1's door for EBP, including gown and gloves for high-contact activity. RT E reached into her uniform pocket for a small bottle of hand sanitizer and sanitized hands, donned gloves, but did not don a gown or mask. RT E gathered and opened a gauze package, moistened the gauze with Hydrogen Peroxide, and lay the moistened gauze on top of the package wrapping on the resident's abdomen. RT E opened the split gauze package and lay the split gauze on top of the package wrapping on the resident's abdomen. RT E removed used split gauze from under Resident #1's trach collar and lay it on the package on the resident's abdomen. RT E performed cleaning of the site under the collar, then placed the new split gauze under the trach collar. RT E then removed the tracheostomy inner canula (portion of the tracheostomy tube that fits into the outer canula tube, which is in the windpipe/trachea), and laid the inner cannula on one of the gauze packages on the resident's abdomen, where it promptly rolled off the resident's abdomen onto the linens. RT E gathered the used supplies and discarded them. RT E grabbed a box (still with the same gloves) and left the room, walked down the hall to the RT office, and laid the box down on the desk. RT E then went to the RT supply cart, discarded her gloves, and reached into her uniform pocket for a small bottle of hand sanitizer, sanitized hands, and replaced it in her pocket. Further observation revealed RT E entered Resident #8's room to perform tracheal suctioning. There was a sign on Resident #8's door for EBP, including gown and gloves for high-contact activity. RT E donned gloves but did not don a gown or mask. RT E used the in-line suction catheter to suction Resident #8 via tracheostomy several times, and Resident #8 did have reflex coughing (can be normal during suctioning). After suctioning was complete, RT E discarded gloves, pulled the hand sanitizer from her pocket, sanitized hands, and replaced it in her pocket. During an interview on 3/25/2026 at 9:05 AM, RT E confirmed supplies were not set up appropriately for tracheostomy care by laying them on the resident's abdomen, confirmed she did not discard used gloves and perform hand hygiene before leaving Resident #1's room, and did not follow EBP for high-contact resident care. RT E stated .I don't know why they .[Residents #1 and #8] .had signs on their doors for EBP .we only have to do that [EBP precautions] if the resident has an active infection . RT E confirmed she did not follow the EBP for Residents #1 and #8. Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Quadriplegia, Tracheostomy Status, and Gastrostomy Status (tube placed through the abdomen into the stomach for nutrition and hydration). Review of the comprehensive care plan for Resident #22 revealed a problem dated 10/10/2025, .has a feeding tube for all nutrition, fluids, medications . with appropriate goals and interventions. Review of a quarterly MDS assessment dated [DATE], revealed Resident #22 had long-term and short-term memory deficits, and severely impaired cognitive skills for daily decision making. During an observation on 3/25/2026 at 8:30 AM, Registered Nurse (RN) C entered Resident #22's room to administer medications via gastrostomy (feeding) tube. RN C donned gloves but did not don a gown. RN C used the piston syringe (large syringe used to draw up and administer medications via feeding tube) to flush the tube with water, administered medications, and flushed with water again as ordered. RN C, with used gloves still on, took the piston syringe to the sink in the room, rinsed it, and set it on paper towels to dry. With the same gloves on, RN C proceeded to perform the OcuSoft eye lid scrub to both eyes. When completed, RN C discarded gloves and performed hand hygiene with hand sanitizer. During an interview on 3/25/2026 at 8:45 AM, RN C confirmed Resident #22 had a sign for EBP on the door. RN C confirmed she did not don a gown while performing feeding tube medication administration, and RN C confirmed she did not perform hand hygiene or change gloves between administering medications through the feeding tube and performing the eye lid scrub. During an interview on 3/25/2026 at 3:11 PM, the Infection Preventionist (IP) confirmed EBP was to be used with high-contact resident care, including tracheal care, suctioning, and feeding tube care, confirmed used gloves should be discarded before leaving a resident's room and hand hygiene should be performed every time gloves are discarded. The IP confirmed hand hygiene and changing of gloves was expected between administering medications by a different route. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Epilepsy, Atrial Fibrillation, and Chronic Pulmonary Edema. Review of the comprehensive care plan for Resident #47 dated 9/17/2025, revealed the resident was dependent for hygiene, dressing, mobility, and feeding assistance/supervision with meals. Review of a quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 12 on the BIMS assessment which indicated the resident had moderate cognitive impairment. During an observation on 3/23/2026 at 11:55 AM, Certified Nursing Assistant (CNA) J delivered the lunch meal tray to Resident #47. CNA J assisted Resident #47 to set up the meal tray and exited the room without offering hand hygiene assistance to the resident. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, and Morbid Obesity. Review of a quarterly MDS assessment dated [DATE], revealed Resident #31 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan for Resident #31 dated 3/17/2026, revealed .partial to moderate assistance with hygiene . During an observation on 3/23/2026 at 11:53 AM, CNA A delivered the lunch meal tray to Resident #31. CNA A set up the meal tray and exited the room without offering hand hygiene assistance to the resident. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, and Generalized Muscle Weakness. Review of a quarterly MDS assessment dated [DATE], revealed Resident #66 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the comprehensive care plan for Resident #66 dated 2/26/2026, revealed the resident required substantial to maximal assistance with ADLs and assistance when needed with meals. During an observation on 3/23/2026 at 11:48 AM, CNA J delivered the lunch meal tray to Resident #66. CNA J set up the resident's lunch tray and exited the room without offering hand hygiene assistance to the resident. During an interview on 3/23/2026 at 11:55 AM, CNA J confirmed residents were to be offered hand hygiene assistance prior to meals. CNA A confirmed she had not offered hand hygiene assistance to residents today and stated .I did not .if the resident mentions it, I will offer . During an interview on 3/25/2026 at 3:05 PM, the Infection Preventionist confirmed staff were to offer hand hygiene assistance to all residents prior to meals. Review of the medical record revealed Resident #15 was admitted on [DATE] with diagnoses including Chronic Osteomyelitis, Depression, Anxiety, and Paraplegia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #15 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the care plan for Resident #15 dated 1/16/2026 revealed the resident requires assistance with ADLs. Further review revealed . Provide care for urinary care per orders and per protocol including changing of urinary catheter, providing urinary care q shift and PRN, emptying drainage bag q [every] shift and PRN [as needed], monitoring for complications with urine as noted above . During an interview and observation on 3/23/2026 at 12:17 PM, revealed Resident #15 lying in bed with urinary catheter bag lying beside bed on the floor. LPN B confirmed the catheter bag should be hung from the resident's bed. During an interview on 3/25/2026 at 03:05 PM the Infection Preventionist confirmed urinary catheter bags were to be suspended off the ground to prevent infection.

Based on review of a facility policy, facility investigation, medical record review, observation and interview, the facility failed to prevent abuse of 1 resident (#2) of 5 residents reviewed for abuse. The findings included: Review of a facility policy Abuse, Neglect, Misappropriation Protocol revised 2/2018 showed .policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .abuse is the willful inflection of injury .willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident #2 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Dysphagia, Neurocognitive Disorder with Lewy Bodies, Dementia, Alzheimer's Disease, and Schizoaffective Disorder. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. Staff interview showed both short- and long-term memory problems. The resident had behaviors of physical behavioral symptoms directed toward others 1 to 3 days, verbal behavioral symptoms directed toward others 1 to 3 days, other behavioral symptoms not directed toward others 1 to 3 days, rejection of care 1 to 3 days during the assessment period. The resident was dependent with 2-person assist with dressing, toilet use, personal hygiene, dependent with 1-person assist with eating, extensive assistance with 2-person assist with bed mobility, transfer, extensive assist 1-person assist with locomotion, walking did not occur, and always incontinent of bowel and bladder Review of a Facility Investigation Report dated 3/20/2023 showed Certified Nursing Assistant (CNA) #2 was assisting Resident #2 with his breakfast when Resident #3 was brought to the table beside Resident #2. Within a couple of minutes Resident #3 hit Resident #2 in the face with a washcloth. The CNAs immediately separated the residents and moved Resident #3. Emotional support was given to Resident #2. Staff was instructed that if Resident #3 became sick again to move him to the other side of his room to clean room as he did not have a roommate and would rather have been in his room. Summary of Incident Investigation Resident #2 experienced unprovoked slap in the face with a dry washcloth by another resident who was sitting next to him in the dining room. Emotional support was given. Patient with no change in his behavior unable to recall event a few minutes later. Patients separated immediately. Abuse policy reviewed with staff. Do not place other resident near Resident #2 when in dining room. Move Resident #3 to the other side of his room when housekeeping is cleaning his room. Avoid sitting him too close to other residents when up in dining room as much as possible. Review of Resident #2's Nurses' Progress Note dated 3/20/2023 showed .Pt. [patient] was sitting beside another resident in the dining room when [Resident #2] experienced an unprovoked slap in the face with a dry washcloth. Other resident stated, 'he was looking at me.' No injury noted no red [NAME]. Pt.'s [patients] separated immediately. Emotional support given. No change in [Resident #2's] behavior and unable to recall event a few minutes later . Review of Resident #2's comprehensive care plan revised on 3/20/2023 showed .incident with another resident. No injury noted. Residents separated .emotional support was given to [Resident #2] . Review of Resident #2's Nurses' Progress Note dated 3/21/2023 at 12:00 AM, showed .no c/o [complain of] pain or s/s [signs/symptoms] injury or emotional distress noted at this time d/t [due to] recent R/R [resident to resident] incident . Review of Resident #2's Nurses' Progress Note dated 3/21/2023 at 9:00 AM, showed .no c/o pain/discomfort or distress noted or emotional distress at this time d/t recent R/R incident . Review of Resident #2's Nurses' Progress Note dated 3/22/2023 at 9:00 AM, showed .no c/o pain or discomfort noted . Review of Resident #2's Nurses' Progress Note dated 3/23/2023 12:00 AM showed .no behavior issues noted this past shift no s/s of distress .no s/s of any pain or discomfort at this time . Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Malignant Neoplasm of Prostate, Spinal stenosis, Polyarthritis, Cerebral Infarction, Dementia, Dysphagia, Gastrointestinal Hemorrhage, Esophagitis, Adult Failure to Thrive, Nausea with Vomiting, Diverticulum of Esophagus, and Diaphragmatic Hernia. Review of Resident #3's comprehensive care plan showed the care plan was revised on 1/2/2023 and showed .continues to verbally and physically abusive towards staff and attempts with residents, intervened by staff. Refuses meds showers, care often . Review of Resident #3's quarterly MDS dated [DATE] showed a BIMS score of 7 indicating severe cognitive impairment. The resident exhibited behavioral symptoms of physical behavioral symptoms toward others 1 to 3 days, verbal behavioral symptoms toward others 1 to 3 days, rejection of care 4 to 6 days during the assessment period. The resident required limited assistance with 1-person assist with bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, supervision with set up for eating, and was occasionally incontinent of bladder, frequently incontinent of bowel. Review of Resident #3's Nurses Note dated 3/20/2023 showed .this nurse spoke with resident prior to following incident resident was pleasant. Res. [resident] had been moved out of his room for housekeeping to clean his room. Res was placed beside another resident. [Resident #3] became unexpectedly upset and struck another resident in the face with a dry washcloth that [Resident #3] was holding in his hand. Stated he became 'mad' because the other res was 'looking at him' also stated he 'didn't like being moved out of his room.' Res was separated and emotional support. No injury, new order move Res to other side of room when housekeeping is cleaning [Resident #3's] room. Avoid setting Res to close to other Res. When up in day room as much as possible . Review of Resident #3's comprehensive care plan showed the care plan was revised on 3/20/2023 and showed .incident with another resident .new interventions from incident .move [Resident #3] to the other side of room when housekeeping is cleaning his room .avoid sitting to close to other residents when up in day room as much as possible . During an interview with Licensed Practical Nurse (LPN) #1 on 6/26/2023 at 7:50 AM, she stated .I was passing medications .I didn't see him actually hit him .they used to be roommates when [Resident #2] was first admitted .[Resident #2] was in the dining room .the housekeeper was cleaning [Resident #3]'s room .he did vomit often due to his esophagus, in the past he had to go out to get his esophagus stretched .the CNA brought him to the dining room, before she took him in, I asked her to wait and let me rub his feet with lotion. He was in a good mood he wasn't combative or agitated .he raised both feet up for me and let me take his socks off with ease. Not even 5 minutes of him being in the dining room .the CNA came to me and said she had parked [Resident #3] by [Resident #2] in the dining room, and [Resident #3] had a dry rag in his lap, [Resident #2] was setting there and [Resident #3] accused [Resident 2] of looking at him and [Resident #3] took his dry rag and swatted [Resident #2] in the face. [Resident #2] was declining and sadly he didn't even realize what had happened .we removed [Resident #3] away from [Resident #2] when I asked [Resident #3] why he had done that he stated he was mad because he had been removed from his room. I took him back to his room, and told him he could eat in his room if he liked and we kept them separated for the rest of the time before [Resident #2] passed away .there were no [NAME], no redness on his face and no response at all from [Resident #2] .there was no change in his mood or demeanor after the incident . During an interview with CNA #2 on 6/26/2023 at 8:10 AM, she stated .it happened shortly before [Resident #2] passed away .initially [Resident #2] was aggressive and he was [Resident #3's] roommate. I am not aware of any incidents occurring between them but [Resident #3] just didn't like [Resident #2] .The CNA was not a regular on the unit so she brought him to the table where I was assisting [Resident #2] with his breakfast .it had been so long since they were roommates and honestly I didn't think anything about it .[Resident #2] had been out to Geri-psych, he was no longer aggressive, he had declined mentally and physically and I didn't think about anything happening .[Resident #3] was rolled to the side of the table .he had a rag in his lap and he just took his rag and flung his arm out with the rag in his hand and hit [Resident #2] in the face .I said [Resident #3] why did you do that and he said because I don't like him .we immediately separated them .[Resident #3] was taken back to his room .[Resident #2] didn't act like he even knew anything had happened .we told the nurse and she assessed him there were no red [NAME], scratches or anything .he didn't ever get any bruising or it didn't ever turn red, he was never upset, there were no changes in his behaviors .we had been sitting there laughing but he didn't really know what he was laughing about but on his good days everything was funny to him, after the incident he stayed in a good mood and kept laughing .yes he hit [Resident #2] on purpose . During an interview with CNA #1 on 6/26/2023 at 8:35 AM, she stated .I don't know if anything was said between them before or not, but I did see [Resident #3] [NAME] the rag at [Resident #2] hitting him in the face .yes he meant to hit him it was deliberate .I didn't talk to either resident immediately after the incident .I didn't see any changes in him after the incident .I didn't see any [NAME] on [Resident #2] after the incident .he didn't act like he knew anything had happened .[Resident #3] could get hateful with residents he didn't like to be called buddy and he would get mad .he would call staff names and say stuff out in general but it wouldn't be directed to a particular resident . During an interview with CNA #3 on 6/26/2023 at 11:50 AM, she stated .I am not aware of [Resident #3] ever making contact with any other resident .he would toss things like empty bowls in a resident's direction, but he never hit anyone and it was more of a toss than a throw with an intention to hit someone .he didn't like having a roommate but I never saw him be physically aggressive to any resident only staff until he hit [Resident #2] . Observation and interview of Resident #3 on 6/26/2023 at 12:30 PM, in his room showed the resident lying in bed turned toward the wall, laying with his legs drawn up midway to his chest. No odor or signs of incontinence or apparent distress were noted. Attempted interview with Resident #3 was unsucessful. During an interview with CNA #5 on 6/27/2023 at 12:00 PM, she stated .I wasn't here the day it happened but I was told about it and was told not to seat [Resident #3] at the table with any other resident .he moved to .real soon after it happened maybe the next day .he could get aggravated at the staff and other residents and say stuff like shut up .some days he was nice and told us he loved us then other days he would be aggressive and combative with care .he has hit me a few times .there was something with these two before .I remember it was right after [Resident #2] came back from Geri-psych .I think that was maybe October .I don't remember exactly what happened but I remember having to sign an in-service paper .I don't think it was an altercation . During an interview with the Director of Nursing (DON) on 6/27/2023 at 2:40 PM, the DON confirmed the facility substantiated the resident to resident incident as abuse.

Based on review of a facility policy, facility investigation, medical record review, observation and interview, the facility failed to report the results of an abuse investigation within the required time period for 1 resident (#2) of 5 residents reviewed for abuse. The findings included: Review of a facility policy Abuse, Neglect, Misappropriation Protocol revised 2/2018 showed .policy and procedure designed to prohibit abuse, neglect, exploitation, involuntary seclusion of residents and/or misappropriation of resident property .6 .there are two time limits for reporting of reasonable suspicion of a crime .allegation of abuse and/or serious bodily injury-2 hour time limit .8 .the results of the investigative findings are to be reported in 5 working days . Resident #2 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Dysphagia, Neurocognitive Disorder with Lewy Bodies, Dementia, Alzheimer's Disease, and Schizoaffective Disorder. Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. Staff interview showed both short- and long-term memory problems. The resident had behaviors of physical behavioral symptoms directed toward others 1 to 3 days, verbal behavioral symptoms directed toward others 1 to 3 days, other behavioral symptoms not directed toward others 1 to 3 days, rejection of care 1 to 3 days during the assessment period. Review of a Facility Investigation Report dated 3/20/2023 showed Certified Nursing Assistant (CNA) #2 was assisting Resident #2 with his breakfast when Resident #3 was brought to the table beside Resident #2. Within a couple of minutes Resident #3 hit Resident #2 in the face with a washcloth. The CNAs immediately separated the residents and moved Resident #3. Summary of Incident Investigation Resident #2 experienced unprovoked slap in the face with a dry washcloth by another resident who was sitting next to him in the dining room. Emotional support was given. Patient with no change in his behavior unable to recall event a few minutes later. Patients separated immediately. Review of Resident #2's Nurses' Progress Note dated 3/20/2023 showed .Pt. [patient] was sitting beside another resident in the dining room when [Resident #2] experienced an unprovoked slap in the face with a dry washcloth. Other resident stated, 'he was looking at me.' No injury noted no red [NAME]. Pt.'s separated immediately. Emotional support given. No change in [Resident #2's] behavior and unable to recall event a few minutes later . Resident #3 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses including Malignant Neoplasm of Prostate, Spinal stenosis, Polyarthritis, Cerebral Infarction, Dementia, Dysphagia, Gastrointestinal Hemorrhage, Esophagitis, Adult Failure to Thrive, Nausea with Vomiting, Diverticulum of Esophagus, and Diaphragmatic Hernia. Review of Resident #3's quarterly MDS dated [DATE] showed a BIMS score of 7 indicating severe cognitive impairment. The resident exhibited behavioral symptoms of physical behavioral symptoms toward others 1 to 3 days, verbal behavioral symptoms toward others 1 to 3 days, rejection of care 4 to 6 days during the assessment period. Review of Resident #3's Nurses Note dated 3/20/2023 showed .this nurse spoke with resident prior to following incident resident was pleasant. Res. [Resident] Had been moved out of his room for housekeeping to clean his room. Res was placed beside another resident. [Resident #3] became unexpectedly upset and struck another resident in the face with a dry washcloth that [Resident #3] was holding in his hand. Stated he became 'mad' because the other res was 'looking at him' also stated he 'didn't like being moved out of his room.' Res was separated and emotional support. No injury, new order move Res to other side of room when housekeeping is cleaning [Resident #3's] room. Avoid setting Res to close to other Res. When up in day room as much as possible . Review of Resident #3's comprehensive care plan revised on 3/20/2023 showed .incident with another resident .new interventions from incident .move [Resident #3] to the other side of room when housekeeping is cleaning his room .avoid sitting to close to other residents when up in day room as much as possible . During an interview with the Director of Nursing (DON) on 6/27/2023 at 2:40 PM, she confirmed the facility substantiated abuse occurred and the facility had not submitted the required 5-day investigation follow up to the State Survey Agency.

Based on review of facility policy, medical record review, facility investigation, observation and interview, the facility failed to prevent abuse of 1 resident (#1) of 5 residents reviewed for abuse. The findings included: Review of a facility policy Abuse, Neglect, Misappropriation Protocol revised on 10/20/2022 showed .the facility has a zero-tolerance policy for abuse, involuntary seclusion, neglect, exploitation and misappropriation of resident property .Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment .willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Resident #1 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Ocular Hypertension, Glaucoma, and Type 2 Diabetes Mellitus. Review of Resident #1's quarterly Minimum Data Set (MDS) showed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of a facility investigation dated 1/21/2023 showed .Resident [Resident #1] was in her room with her roommate. Her roommate [Resident #2] did not want her talking and told her to shut up then slapped her on the mouth. Resident incident was witnessed by staff and immediately separated. [Resident #2] who slapped [Resident #1] was moved to another room without a roommate and placed on 1:1 observations when out of her room throughout the night for cooling off period .Report of Resident Incident .staff heard yelling et [and] came to room to see [Resident #2] slap resident [Resident #1] .Resident Statement: [Resident #2] she wouldn't shut up, so I gave her a little pop in the mouth .Resident Statement: [Resident #1] She's crazy yelling at me . Observation of Resident #1 on 2/8/2023 at 7:45 AM, in her room, showed the resident seated in a wheelchair, she was awake, alert, well-groomed and dressed appropriately for the inside temperature. No fearful or anxious behaviors were observed. During an interview with Resident #1 on 2/8/2023 at 7:45 AM, Surveyor asked the resident if she recalled an incident with another resident hitting her and Resident #1 stated .she just popped me in the mouth. I think she just didn't want me in there .it hurt at the moment, but that was all .I wasn't used to people doing me like that, so I didn't respond. I just thought she was an ignorant woman .I was raised a Christian, so I didn't do anything back to her . The resident was smiling and chuckling while speaking to Surveyor. The resident stated .I'm okay now . she stated she was not afraid and felt safe in the facility. Resident #2 was admitted to the facility on [DATE] with diagnoses including Anemia, Severe Protein-Calorie Malnutrition, Dementia with Behavioral Disturbance, Anxiety Disorder, Adjustment Disorder, Alzheimer's Disease, Cerebral Ischemia, and Adult Failure to Thrive. Review of Resident #2's comprehensive care plan dated 9/5/2022 showed .impaired mood behavior/psychosocial .wants shoes on before she gets out of bed .daughter reports resident will get angry if she doesn't have footwear provided prior to getting up .has exhibited episodes of wandering .provide consistent care givers and routine .if resisting care, have another staff member attempt and attempt at a later time .provide diversional activities .ensure adequate lighting both day and night-she does not like to be in the dark . The care plan was revised on 1/23/2022 and showed .incident involving another resident .residents were separated .[Resident #2] was moved to room .her safety was ensured, and emotional support provided. Staff provided 1:1 when out of room [ROOM NUMBER] hours .Redirect as needed .monitor when in dining room. Do not leave unattended . Observation with Resident #2 on 2/8/2023 at 7:55 AM, in the dining room, showed the resident seated in a wheelchair at a dining room table, no other residents were seated with the resident, but other residents were in the dining room. No anxious, agitated, or aggressive behaviors were noted. Resident #2 was awake, alert, well-groomed, dressed appropriately for the inside temperature and location. During an interview with Resident #2 on 2/8/2023 at 7:55 AM, the resident was asked if she recalled an incident where she hit another resident she stated .we are still friends .I'm going to take my Bible back to my room, you watch my stuff, that's my water . During the interview the Surveyor was unable to determine if the resident could recall the incident with Resident #1. Resident #2 was not observed to have any aggression or agitation. Resident #2 was admitted to the facility on [DATE] with diagnoses including Anemia, Severe Protein-Calorie Malnutrition, Dementia with Behavioral Disturbance, Anxiety Disorder, Adjustment Disorder, Alzheimer's Disease, Cerebral Ischemia, and Adult Failure to Thrive. Review of Resident #2's comprehensive care plan dated 9/5/2022 showed .impaired mood behavior/psychosocial .provide consistent care givers and routine .if resisting care, have another staff member attempt and attempt at a later time .provide diversional activities .ensure adequate lighting both day and night-she does not like to be in the dark . The care plan was revised on 1/23/2022 and showed .incident involving another resident .residents were separated .[Resident #2] was moved to room .her safety was ensured, and emotional support provided. Staff provided 1:1 when out of room [ROOM NUMBER] hours .Redirect as needed .monitor when in dining room. Do not leave unattended . During an interview with Certified Nursing Assistant (CNA) #1 on 2/8/2023 at 8:10 AM, she stated .I've been told [Resident #2] will push staff's arm away during care but she hasn't done that to me. She will sometimes get upset if another resident disagrees with her, but she would just roll away. I had never seen her be aggressive toward any resident .I heard hollering, so I went into [Resident #1 and Resident #2's] room, [Resident #2] was going to the bathroom, [Resident #1] wasn't upset she was just sitting in her chair. I didn't see anything wrong, so I left the room. It was just a little bit later, I heard yelling again, I went in the room and about the time I walked in the room, I saw [Resident #2] pop [Resident #1] on the mouth. [Resident #1] said 'she hit me', and she was pouting. [Resident #2] said 'I didn't hit do it hard'. [CNA #2] was in the room by then, and then the nurse came in we immediately took [Resident #2] out of the room to an empty room .they bickered like sisters, [Resident #2] wanted to tell [Resident #1] what to do. [Resident #1] would say 'stop telling me what to do' but they wanted to sit together, they would talk, I never saw any aggressive behaviors between them before . During the interview CNA #1 stated .it was just a pop like a mother would pop their child for having a smart mouth .yes she did it willfully and said she didn't do it that hard . During an interview with Licensed Practical Nurse (LPN) #1 on 2/8/2023 at 8:30 AM, she stated .I was the dayshift nurse and it happened at the end of my shift .[Resident #2] would come out in the hall and say that [Resident #1] needed to go to the bathroom and when we would go check [Resident #1] would say 'I didn't tell her that. I don't have to go to the bathroom.' They wanted the chairs beside each other, and they would watch television together .it had been an uneventful day there hadn't been any sharp words or anything like that between them .It happened suddenly .I guess [Resident #2] told [Resident #1] to shut up and then popped her in the mouth .We moved [Resident #2] to a private room across the hall. We had a staff member in the dining room so she could watch both room doors, neither resident tried to go to the other resident's room .[Resident #2] seemed to remember what had happened because she wanted to apologize, and we let her .[Resident #2] can get aggravated but I have never seen her aggressive toward any other resident, and I have not had any reports of her being aggressive with residents .she is very particular and set in her ways, she gets focused on things .I assessed both residents. [Resident #1] took out her dentures and let me look in her mouth with a flashlight, there was no redness, no swelling, bleeding, scrapes or any sign of injury in her mouth or her face and she denied pain. I didn't see any injuries on [Resident #2] . During an interview with the Administrator on 2/8/2023 at 1:20 PM, she stated .the policy and regulation says willful .in the moment I think she reacted without thinking . but according to the definition of abuse there was a willful intent . During the interview the Administrator confirmed the facility failed to prevent abuse of Resident #1.

Based on facility policy review, observation, interview, and temperature log review, the facility failed to ensure expired and molded food items were not available for resident use and failed to ensure dry goods were properly stored in 1 of 1 kitchen, and failed to properly store and label food items and maintain a temperature log in 1 of 4 nourishment refrigerators which had the potential to effect 66 of 72 residents. The findings include: Review of the facility's policy titled, Use and Storage of Foods Brought to Residents by Family and Visitors, dated ,d+[DATE], showed .The facility provides safe and sanitary storage and handling of foods brought in from the outside by family and visitors .Food item(s) will be labeled with the resident's name, content, the date it was prepared, if known, and a discard/use by date .All refrigeration units will have internal thermometers to monitor for safe food temperatures, in accordance with state and federal standards. Designated staff .will monitor and document unit refrigerator temperatures daily . Review of the facility's undated policy titled, Expiration date policy, showed .All Store Bought Food Or Food delivery Service items should be disposed of by Manufactures Expiration date . Review of the facility's undated policy titled, Policy: Scoops, showed .Any food item .that Requires scoops, will be placed in zip lock bag. Placed on top of the container . Review of the facility's undated and untitled policy showed .Practices to maintain safe refrigerated storage include .Monitoring food temperatures and functioning of the refrigeration equipment daily .Labeling, dating, and monitoring refrigerated food .Additional strategies to prevent foodborne illness include .Preventing cross-contamination of foods . Review of the facility's undated and untitled policy showed .The refrigerators are intended for storage of patient food supplies only .Nursing will monitor and record temperatures of refrigerator .daily .All snacks/nourishment stored in refrigerator/freezer must be labeled . Observation of the kitchen with the Dietary Manager on [DATE] at 10:08 AM, showed the following items on the bread shelf: -1 package of 8 hot dog buns with a best if used by date of [DATE] (25 days past expiration date). -1 package of 8 hot dog buns with a best if used by date of [DATE] (20 days past expiration date). -1 package of 6 hoagie rolls undated and with mold on 2 of the hoagie rolls. During an interview on [DATE] at 10:15 AM, the Dietary Manager confirmed the package of 8 hot dog buns with the best by date of [DATE] and the package of 8 hot dog buns with the best by date of [DATE] were out of date and available for resident use. Further interview with the Dietary Manager confirmed the package of hoagie rolls were undated, molded, and available for resident use. It was the facility's expectation that bread was dated on the date of delivery and discarded 1 week later. Observation and interview of the kitchen with the Dietary Manager on [DATE] at 10:21 AM, showed a container of sugar located under the tea table. The container of sugar was open to air with the scoop stored inside the container. The Dietary Manager confirmed the sugar container was open to air with the scoop stored inside the container and it was the facility's expectation that the container was covered when not in use to prevent contamination and the scoop was to be stored in a zip lock bag on top of the container. Observation and interview of the kitchen with the Dietary Manager on [DATE] at 10:29 AM, showed a container of salt stored under a food preparation table. The container of salt was open to air with the scoop stored inside the container. The Dietary Manager confirmed the salt container was open to air with the scoop stored inside the container and it was the facility's expectation that the container was covered when not in use to prevent contamination and the scoop was to be stored in a zip lock bag on top of the container. Observation of the 300-unit nourishment refrigerator with Certified Nursing Assistant (CNA) #3 on [DATE] at 8:53 AM, showed the following items: -1 10-ounce glass jar of apple butter open,unlabeled, and undated. -1 32-ounce container of coffee creamer opened and undated. -1 24-fluid ounce bottle of ranch dressing open, unlabeled, and undated. During an interview on [DATE] at 8:55 AM, CNA #3 stated the nourishment refrigerator was for storage of resident items only and staff were to store their food items in a separate location. Food items placed in the nourishment refrigerator were to be labeled with the resident's name and dated. CNA #3 confirmed the jar of apple butter and the bottle of ranch dressing were not labeled or dated and was unaware what residents the items belonged to. CNA #3 confirmed the name on the container of the coffee creamer was the name of a nurse at the facility. Review of the 300-unit nourishment refrigerator temperature log dated ,d+[DATE], showed a temperature reading of 42 degrees Fahrenheit on [DATE]. The log showed no nourishment refrigerator temperature readings from [DATE] - [DATE]. During an interview on [DATE] at 8:59 AM, CNA #3 stated .I believe temperatures are obtained once a day . and .if I'm being honest, I don't know who is responsible for doing that . CNA #3 confirmed the entry on [DATE] was the only temperature recorded on the ,d+[DATE] 300-unit nourishment refrigerator temperature log. During an interview on [DATE] at 9:48 AM, the DON confirmed nourishment refrigerators were to contain resident food items only and staff food items were to be stored in the break room refrigerator. Resident food items stored in nourishment refrigerators were to be labeled with the resident's name and dated. The DON confirmed the ,d+[DATE] 300-unit nourishment refrigerator temperature log had only 1 temperature reading on [DATE] and it was the facility's expectation that temperature was documented daily by unit staff according to each unit's plan. During an interview on [DATE] at 9:58 AM, the Administrator stated nurses are responsible for documenting nourishment refrigerator temperatures daily and .We need to do a solid reboot of our plans, policy, and expectations for temperature logs with the staff .

Based on medical record review and interviews, the facility failed to notify the responsible party and the medical provider timely of a change in skin condition for 1 resident (Resident #230) of 5 residents reviewed for pressure ulcers. The findings included: Resident #230 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Neuropathy, Difficulty in Walking, Acquired Absence of Left leg Above the Knee, Chronic Pain, Adult Failure to Thrive, Abnormalities of Gait and Mobility, and Need for Assistance with Personal Care. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #230 was cognitively intact, independent with bed mobility, locomotion on and off the unit, and eating. The resident had occasional urinary incontinence. Resident #230 was at risk for developing pressure ulcers with no pressure ulcers documented. Review of the discharge MDS assessment dated [DATE], showed Resident #230 had an unplanned discharge with return anticipated from the facility to an acute hospital. Since last assessment there was no skin conditions documented. Review of the comprehensive care plan showed Resident #230 required minimal assistance with activities of daily living, had occasional urinary incontinence, was at risk for fall related to impaired balance, unsteady gait, and left below the knee amputation. Resident #230 was at risk for skin breakdown related to impaired mobility and refusal of bathing at times. Interventions included to apply lotions, creams, ointments, and powders as needed; and to observe skin daily and report and treat any breaks in skin as indicated. Review of a handwritten witness statement dated 10/23/2022, showed Certified Nursing Assistant (CNA) #5 wrote after completion of Resident #230's shower on 10/23/2022 an open area was noticed on right buttock. The resident went out for a day pass with the family, the nurse and the wound care nurse were not notified until later after the resident had left the facility. During a telephone interview on 11/29/2022 at 5:22 PM, Family Member #1 of Resident #230 stated they were not informed of any change in skin conditions, until they had taken Resident #230 to the emergency room when the skin conditions were identified, and the resident was admitted with cellulitis of the buttocks. During an interview on 11/30/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #1 stated she cared for Resident #230 the Thursday prior to him leaving on 10/23/2022. He had reddened areas to entire buttock, but no open areas. During an interview on 11/30/2022 at 1:53 PM, the Administrator confirmed the Medical Director and family was not notified until 10/23/2022 of Resident #230's skin issues.

Based on facility policy review, medical record review, and interviews, the facility failed to complete weekly skin assessments to prevent the development of a skin condition for 1 resident (Resident #230) of 5 residents reviewed for pressure ulcers. The findings include: Review of the facility policy titled, Skin Care-Key Procedural Points Wound Management, undated showed .Nurses are to do a weekly skin assessment on each resident . Resident #230 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Neuropathy, Difficulty in Walking, Acquired Absence of Left Leg Above the Knee, Chronic Pain, Adult Failure to Thrive, Abnormalities of Gait and Mobility, and Need for Assistance with Personal Care. Review of the weekly skin assessments dated 9/2022, showed pink area to the buttocks. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #230 was at risk for developing pressure ulcers with no pressure ulcers documented. Review of the comprehensive care plan showed Resident #230 was at risk for skin breakdown related to impaired mobility and refusal of bathing at times. Interventions included to apply lotions, creams, ointments, and powders as needed; and to observe skin daily and report and treat any breaks in skin as indicated. Review of the Weekly Skin assessments dated 10/14/2022, Resident #230 had pink areas to buttocks. Skin assessments were not completed on the prior week of 10/7/2022 or 10/21/2022. Review of a handwritten witness statement dated 10/23/2022, showed Certified Nursing Assistant (CNA) #5 wrote after completion of Resident #230's shower on 10/23/2022 an open area was noticed on right buttock. The resident went out for a day pass with the family, the nurse and the wound care nurse were not notified until later after the resident had left the facility. Review of the hospital Wound Care Consult notes dated 10/24/2022, showed .Chief Complaint: Concern for pressure injuries to bilateral buttocks .On assessment there are no pressure injuries present. Bilateral buttocks with erosions and maceration consistent with moisture .No open wounds . During a telephone interview on 11/30/2022 at 8:16 AM, CNA #5 stated on 10/23/2022 after providing a shower to Resident #230 a sore was noted to the resident's right buttock. The skin condition was described as a quarter sized open area, .like a blister had busted and opened . and the left side of buttock was red. CNA #5 stated family had taken Resident #230 on a day pass before she could inform the wound care nurse, or the charge nurse. CNA #5 stated skin barrier protectant was applied to the areas, before the resident left the facility with the family. During an interview on 11/30/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #1 stated she cared for Resident #230 the Thursday prior to him leaving on 10/23/2022. He had reddened areas to entire buttock, but no open areas. She stated she was the primary nurse responsible for completion of the weekly skin assessments for Resident #230. She confirmed she only completed one skin assessment during the month of 10/2022, dated 10/14/2022, that showed the buttocks were pink. She confirmed the skin assessment for 10/7/2022 and 10/21/2022 were not completed. During an interview on 11/30/2022 at 1:53 PM, the Administrator (ADM) stated it was her expectation skin assessments were to be completed weekly. If a resident was not in the facility at the time of the weekly skin assessment, then the skin assessment was to be completed upon return to the facility. The ADM confirmed the weekly skin assessments were not completed for Resident #230 on 10/7/2022 and 10/21/2022. She stated the skin observation made by the CNA should have been reported immediately to the charge nurse or the wound care nurse. During an interview on 11/30/2022 at 3:50 PM, the Physician stated he was unable to recall Resident #230. He stated if one of the residents had a moisture associated skin condition, he would order some type of skin barrier, an ointment, or Nystatin and then would monitor for further breakdown. Treatments would be changed as needed for the resident's skin concern.

Based on the facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention for 1 resident (Resident #64) of 5 residents reviewed for falls. The findings include: Review of the facility's policy titled, Falls Management undated showed .Residents at risk for falls are identified to prevent future falls and maintain maximum level of function through use of interventions, as appropriate . Review of the facility policy titled, Accidents and Injuries-Resident, undated, showed .Accidents .incidents will be investigated, documented and reported .An incident report form will be competed on the shift that the accident .incident occurred. All incident .accident are reportable . Resident #64 was admitted to the facility on [DATE] with diagnoses including Lack of Coordination, Muscle Weakness, Hypertension, and Chronic Obstructive Pulmonary Disease. Review of Resident #64's quarterly Minimum Data Set assessment dated [DATE], showed Brief Interview for Mental Status score was 4 which indicated resident had severe cognitive impairment, and resident required limited assistance with ambulation, transfers, and toileting. Resident had documented 2 falls with no injury and 1 with injury not major. Review of Resident #64's care plan dated 6/15/2021 showed interventions to prevent falls non-skid socks, call light in reach, handrails to bed to assist resident with mobility, and assist with toileting. Care plan was updated on 9/7/2022 with added intervention impact mat to left side of bed after a fall with a skin tear to right arm on 9/7/2022. During an observation on 11/28/2022 at 10:30 AM, showed Resident #64 sitting up in bed no impact mat at the left side of the bed. During an observation on 11/29/2022 at 7:45 AM, showed resident sitting upon side of the bed feeding self-breakfast, no impact mat at the left side of the bed. During an observation on 11/29/2022 at 12:34 PM, showed resident had no impact mat to left side of the bed. During an observation on 11/30/2022 at 7:45 AM, showed resident lying in bed positioned on left side with top side rail up, no impact mat by the left side of the bed. During an interview and observation on 11/30/2022 at 7:52 AM, Licensed Practical Nurse (LPN) #4 confirmed no impact mat was in place to the left side of Resident #64's bed. During an interview on 11/30/2022 at 10:49 AM, the Director of Nursing confirmed the care plan was to be followed for Resident #64. The impact mat was an fall intervention and should have been placed on the left side of the resident's bed. 41291

Based on facility policy review, medical record review, observation, and interview, the facility failed to follow a physician order for a fluid restriction for 1 resident (Resident #20) of 2 residents reviewed for nutrition. The findings include: Review of the facility's undated policy titled, [Facility Name], showed .Residents Undergoing Hemodialysis [the process of purifying the blood of a person whose kidneys are not working normally] .Dietary management and fluid management per physician's orders . Resident #20 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease and Diabetes Mellitus. Review of the Physician's Orders dated 9/22/2022 showed .FLUID RESTRICTION 1000ML [milliliter] . Review of the admission Minimum Data Set (MDS) dated [DATE] showed Resident #20 had a Brief Interview for Mental Status score of 15, which indicated he was cognitively intact, needed limited assistance of 1 staff member for activities of daily living (ADL) and received dialysis. Review of a nurse's note dated 10/8/2022, showed .Fluids encouraged . Review of a nurse's note dated 10/20/2022, showed .Fluids encouraged . Review of a nurse's note dated 10/30/2022, showed .Fluids encouraged . An observation on 11/28/2022 at 10:33 AM, in Resident #20's room, showed a water jug with lid on the top. The resident stated there was water in the jug. During an observation and interview on 11/29/2022 at 12:15 PM, in Resident #20's room, Certified Nursing Assistant (CNA) #1 confirmed a white plastic jug with name of facility on it was on the resident's table, was full of water and available for consumption. The CNA stated she filled the jug whenever the resident asked and liquid volumes were not measured or documented by the nursing staff. During an interview on 11/29/2022 at 1:15 PM, the Registered Dietician (RD) revealed Resident #20 had a renal diet with a fluid restriction of 1800 ml, and the dietary department sends set amounts with each tray. The RD stated the remaining amounts allowed before restriction is reached should be measured, monitored, and documented by nursing. During an interview on 11/29/2022 at 1:30 PM, Central Supply stated that the white jugs with the facility's name on them were given with a welcome kit and had a volume of 32 ounces (oz), which was approximately 950 mls. During an interview on 11/29/2022 at 2:35 PM, CNA #2 stated she didn't have any residents on her hall with fluid restrictions. The CNA stated the nurse reported to her if there was a fluid restriction, and it was clearly marked on the diet card, which came on the tray at mealtime, if the resident had one. Review of an ADL report sheet (a sheet that indicates resident orders and needs) with the CNA showed no documentation of orders for fluid restriction for Resident #20. Review of the nurse's notes from 9/22/2022 to 11/29/2022, showed no documentation Resident #20 had any adverse outcome related to the staff's failure to monitor fluid intake. Review of the dialysis communication forms dated 11/15/2022, 11/17/2022, 11/19/2022, 11/23/2022 and 11/26/2022 showed pre and post-dialysis vital signs and weights. No respiratory difficulties or excessive weight removal were documented on those reports. During an observation and interview on 11/30/2022 at 9:22 AM, in Resident #20's room, CNA #2 confirmed the breakfast tray on the table had an empty coffee cup (240 ml) and a half full glass of juice (120 ml) sitting on the tray. The resident stated he drank all the coffee and half of the juice and was not educated on any fluid restriction. During an interview on 11/30/2022 at 9:46 AM, the Nurse Practitioner stated staff were to follow physician's orders, and it was expected a resident with fluid restriction would have fluids closely monitored and the resident's intake and output measured and documented. During an interview on 11/30/2022 at 12:15 PM, the Assistant Director of Nursing stated both dietary and nursing were to follow physician orders for fluid restrictions.

Based on review of The Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0, medical record review, and interview, the facility failed to provide an accurate Minimum Data Set (MDS) assessment for 1 resident (#1) of 3 residents reviewed for a comprehensive assessment. The findings include: Review of the CMS's Resident Assessment Instrument (RAI) Version 3.0 Section H0400 Bowel Continence showed .Code 2, frequently incontinent .during the 7-day look back period, the resident was incontinent of bowel more than once, but had at least one continent bowel movement . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse's note dated 6/10/2021 at 1:35 PM, showed .Report from [name of nurse at the transferring facility] .Transferring Resident to this facility .Incont [incontinent] B/B [bladder and bowel] . Review of the Admission Minimum Data Set (MDS) dated [DATE] showed the resident was frequently incontinent of urine and always continent of bowel. Review of a Nurse Practitioner's Progress note dated 7/14/2021 showed .He does have urinary and fecal incontinency .Recent urinary tract infection . During an interview on 8/17/2021 at 11:00 AM, the Wound Nurse stated Resident #1 was admitted to the facility on [DATE] and was incontinent of bowel with frequent loose bowel movements. During an interview on 8/17/2021 at 2:30 PM, the Nurse Practitioner Resident #1 had frequent bowel incontinence. During a telephone interview on 8/18/2021 at 1:33 PM, Certified Nursing Assistant (CNA) #1 stated she was a regular caregiver for Resident #1. She stated Resident #1 was frequently incontinent of stool. During a telephone interview on 8/18/2021 at 1:40 PM, CNA #2 stated she was a regular caregiver for Resident #1. She stated the resident was frequently incontinent of stool. During an interview on 8/19/2021 at 1:15 PM, Licensed Practical Nurse (LPN) #1 stated she was Resident #1's nurse on the evening shift on 6/10/2021, when the resident was admitted to the facility. She stated the resident was incontinent of bowel and bladder. During a telephone interview on 8/24/2021 at 10:15 AM, the MDS Nurse stated Resident #1 had been frequently incontinent of bowel and the Admission MDS was not accurate. She stated she completed the MDS and care plan by chart review.

Based on review of the facility general guidelines, medical record review, and interview, the facility failed to follow policy to ensure physician services were provided for assessment and oversight of pressure ulcer care for 1 resident (#1) of 3 residents reviewed for pressure ulcers. The findings include: Review of the facility's General Guidelines for Skin Breakdown Prevented/Treatment Plan, undated showed .Upon admission to our facility, the following measures will be initiated .Complete skin assessment .Upon development of a wound .The physician/nurse practitioner will evaluate the wound on initial visit. They will document and oversee the plan of care . Medical record review showed Resident #1 was transferred from another nursing home and admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of wound documentation from the transferring nursing home dated 6/9/2021 at 9:54 AM showed Resident #1 had an unstageable pressure ulcer to the right heel which measured 3.0 centimeters (cm) x (by) 6.0 cm. Review of Resident #1's discharge plan of care from the transferring nursing home dated 6/10/2021 at 12:47 PM, showed .Pressure ulcer of right heel, unstageable . Further review showed no other pressure ulcers were identified from the transferring facility. Review of a Nurse's note dated 6/10/2021 at 1:35 PM, showed .Report from [name of nurse at the transferring facility] .Transferring Resident to this facility .Incont [incontinent] B/B [bladder and bowel]. Has unstageable .to R [right] heel . Review of a Nurse's note dated 6/10/2021 at 2:15 PM, showed .Resident arrived to facility .in w/c [wheelchair]. Transported to Rm [room] .and transferred to bed c [with] out incident . Review of a Braden scale (scale used to predict the risk of development of pressure ulcers) dated 6/10/2021 showed a score of 12, which indicated the resident was high risk for the development of pressure ulcers. Review of a skin assessment form dated 6/10/2021 (no time noted) showed the resident was combative and the skin assessment was not completed. Review of Resident #1's care plan dated 6/10/2021 showed the resident was at risk for skin breakdown and was admitted to the facility with pressure wounds to the sacrum and the left and right heels with interventions to float the resident's heels on pillows. Review of a Nurse's Admission note dated 6/11/2021 at 11:30 AM showed .Stage 2 [partial-thickness skin loss] wound is noted .to the right of the sacrum [triangular bone in the lower back] .0.4 x 0.5 cm. wound bed is red pink in color .Unstageable SDTI [suspected deep tissue injury] .to R posterior heel. Area is deep purple .measures 4.0 x 6.2 [centimeters] .Unstageable SDTI is noted to L [left] heel 3.5 x 4.0 [centimeters] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .S. [normal saline] Apply [MEDICATION(S)] [breathable dressing that adheres to skin] drg [dressing] [change] q [every] 3rd day & [and] prn [as needed] .Apply skin prep to unstageable SDTI to R [right] heel. Apply ABD [abdominal] & kerlix [gauze dressing] .[change] qd [every day] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply ABD & kerlix .[change] qd . Review of a Wound Report dated 6/14/2021 showed .ll [stage ll] .LEFT OF SACRUM .0.4 x 0.5 CM .G [granulation tissue/red tissue with bumpy appearance] .[MEDICATION(S)] DRESSING .Unstageable Suspected Deep Tissue .LEFT HEEL .3.5 x 4.0 CM .N [Necrotic/dead cells or tissue] .SKIN PREP AND DRY DRESSSING .Unstageable .Suspected Deep Tissue .RIGHT HEEL .4.0 cm x 6.2 cm .N .SKIN PREP AND DRY DRESSING . Review of the facility Physician's initial History and Physical (H&P) dated 6/17/2021 showed .SKIN .heels bandaged . Review of the Admission Minimum Data Set (MDS) dated [DATE] showed the resident was rarely or never understood, total dependance of 2 staff for bed mobility, transfer, dressing, and toilet use, total dependance of 1 staff for eating and personal hygiene, frequently incontinent of urine, always continent of bowel, and had 1 stage 2 pressure ulcer and 2 unstageable pressure ulcers present on admission. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APPLY POLYMEM [Polymeric membrane dressing/multifunctional used at different stages of healing] AND DRY DRESSING. CHANGE Q 3DAYS. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APPLY POLYMEM AND DRY DRESSING. CHANGE Q 3DAYS. Review of a Wound Report dated 6/21/2021 showed .ll [stage ll] .LEFT SACRUM .5.0 X 3.0 CM .G .[MEDICATION(S)] DRESSING .Unstageable .LEFT HEEL .3.0 X 4.5 CM .N .POLYMEM AND DRY DRESSING .Unstageable .RIGHT HEEL .3.7 X 7.0 CM .N .POLYMEM AND DRY DRESSING . Review of a Wound Report dated 6/28/2021 showed .ll [stage ll] .LEFT OF SACRUM .8.0 X 8.0 CM .G .[MEDICATION(S)] DRESSING .Unstageable .LEFT HEEL .6.0 X 5.0 CM .N .POLYMEM AND DRY DRESSING .Unstageable .RIGHT HEEL .6.5 X 6.0 CM .N .POLYMEM AND DRY DRESSING . Review of a Wound Report dated 7/5/2021 showed .ll [stage ll] .LEFT SACRUM .7.5 X 8.0 CM .G .[MEDICATION(S)] DRESSING .Unstageable .LEFT HEEL .5.4 X 6.5 CM .N .POLYMEM AND DRY DRESSING .Unstageable .RIGHT HEEL .5.5 X 7.0 CM .N .POLYMEM AND DRY DRESSING . Review of a Wound Report dated 7/12/2021 showed .ll [stage ll] .LEFT OF SACRUM .7.5 X 8.0 CM .S [Slough/ yellow, white material/ dead cells] .[MEDICATION(S)] DRESSING .Unstageable .LEFT HEEL .5.5 x 9.0 CM .N .POLYMEM AND DRY DRESSING .Unstageable .RIGHT HEEL .5.5 X 7.5 CM .N .POLYMEM AND DRY DRESSING . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nurse Practitioner (NP) Progress note dated 7/14/2021 showed .He came to our facility with bilateral heel wounds and also sacral wound. He is currently being followed by the staff wound care team. He recently had a catheter put in due to his sacral wounds. He does have urinary and fecal incontinency which puts him at an increased risk for wounds and there has been a continued decline in his mental status due to his Dementia .The patient requires max [maximum] assist with all ADLs [activities of daily living] .PHYSICAL EXAMINATION .SKIN .right heel and left heel .dressings are intact .ASSESSMENT .Bilateral heel decubitus wounds .The wound care consultant will be following wound as well . Review of a Wound Consultant Progress Report dated 7/15/2021 showed .seen at bedside on 7/15/2021 for the initial evaluation of a non-healing pressure ulceration of the right heel .Wound #1 .Right Heel .Pressure .Width: 4.0 cm .Length: 4.0 cm .Depth: Unable to Determine .Wound stage: Unstageable . Review of a Wound Consultant Progress Report dated 7/15/2021 showed .seen at bedside on 7/15/2021 for the initial evaluation of a non-healing pressure ulceration of the left heel .Wound #2 .Left Heel .Pressure .Width: 7.0 cm .Length: 4.0 cm .Depth: Unable to Determine .Wound stage: Unstageable . Review of a Wound Consultant Progress Report dated 7/15/2021 showed .seen at bedside on 7/15/2021 for the initial evaluation of a non-healing pressure ulceration of the sacrum .Wound #3 .Pressure .Width: 6.0 cm .Length: 7.0 cm .Depth: Unable to Determine .Wound stage: Unstageable . Review of a Wound Consultant Progress Report dated 7/22/2021 showed .for the evaluation of a non-healing pressure ulceration of the right heel .Wound #1 .Right Heel .Pressure .Width: 4.0 cm .Length: 4.0 cm .Depth: Unable to Determine .Wound stage: Unstageable . Review of a Wound Consultant Progress Report dated 7/22/2021 showed .for the evaluation of a non-healing pressure ulceration of the left heel .Wound #2 .Left Heel .Pressure .Width: 7.5 cm .Length: 4.0 cm .Depth: Unable to Determine .Wound stage: Unstageable . Review of a Wound Consultant Progress Report dated 7/22/2021 showed .for the evaluation of a non-healing pressure ulceration of the sacrum .Wound #3 .Sacrum .Pressure .Width: 6.0 cm .Length: 7.0 cm .Depth: Unable to Determine .Wound stage: Unstageable . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APPLY TETRACYTE [topical medication for wound healing] AND SANTYL [topical medication to break up and remove dead skin]. COVER WITH DURAFIBER [absorbent fibrous dressing] AND [MEDICATION(S)] [surgical dressing] FOLLOWED BY ALLEVYN [adhesive dressing] FOAM DRESSING. CHANGE THREE TIMES WEEKLY ON TUES [Tuesday], THURS [Thursday], AND SATURDAY . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APPLY TETRACYTE AND SANTYL COVER WITH DURAFIBER AND [MEDICATION(S)]. COVER WITH ABD PAD AND KERLIX. CHANGE Q DAY ON SUNDAY, MONDAY, WEDNESDAY, AND FRIDAY . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APPLY TETRACYTE AND THERAHONEY [wound gel used for healing of wounds]. COVER WITH [MEDICATION(S)] AND DURAFIBER. COVER ALL WITH ABD PAD AND KERLIX. CHANGE ON SUN [Sunday], MON [Monday], WED [Wednesday], AND FRIDAY . Review of a Physicians Order dated 7/22/2021 showed .CLEANSE UNSTAGEABLE WOUND TO SACRUM WITH NS AND WOUND CLEANSER. APPLY SANTYL AND TETRACYTE. APPLY [MEDICATION(S)] AND DURAFIBER. COVER WITH ALLEVYN LIFE FOAM DRESSING. CHANGE THREE TIMES WEEKLY ON TUES, THURS, AND SATURDAY . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . APPLY TETRACYTE AND THERAHONEY. COVER WITH [MEDICATION(S)] AND DURAFIBER. COVER ALL WITH ALLEVYN LIFE FOAM DRESSING. CHANGE 3 TIMES WEEKLY ON TUES, THURS, SAT . Review of a Nurse's note dated 7/29/2021 showed .report from 11-7 [11:00 PM to 7:00 AM] nurse that resident didn't look good .02 [oxygen] sats [saturation/ measurement of blood oxygen level] @ [at] 64% .a pulse of 43. 02 at 2 LPM [liters per minute] .Axillary [under the arm] temp .101.2 .Explained .to wife .concerns in regards to complications from unstageable wound on coccyx [triangular bone at the base of the spine] .a noxious [very unpleasant] .odor noted .MD [physician] notified . Review of a Nurse's note dated 7/29/2021 at 10:55 AM, showed .Exited facility via .EMS [emergency medical services] . Review of a Nurse's note dated 7/29/2021 at 6:50 PM, showed Resident #1 was admitted to the hospital. During a telephone interview on 8/17/2021 at 11:40 AM, Resident #1's physician stated he could not recall if he evaluated Resident #1's wounds. The physician stated he was not aware he was to evaluate the resident's wounds on his initial visit. He stated he usually just looked at the wounds that had worsened but was unable to recall if he looked at Resident #1's wounds. During an interview on 8/17/2021 at 2:30 PM, the NP stated she was not aware of the facility guidelines that the MD or NP must evaluate wounds on the initial visit of a resident. The NP stated she had not evaluated Resident #1's pressure ulcers on 7/14/2021. During an interview on 8/19/2021 at 2:15 PM, the Wound Care Nurse stated she had not requested the physician or NP assess Resident #1's worsening pressure ulcers. She stated she was unaware if the NP or MD had evaluated the wounds. She stated she called the physician on 7/13/2021 and requested Wound Consultants to evaluate Resident #1's wound due to the pressure ulcers worsening. She stated she verbally communicated wound progress to the NP or MD when they were in the building. During an interview on 8/19/2021 at 2:25 PM, the ADON stated there was no documentation the MD or NP evaluated Resident #1's pressure ulcers from 6/10/2021 until 7/29/2021. She stated on 7/15/2021 the Wound Consultants evaluated the wound and the pressure ulcers had declined. During an interview on 8/24/2021 at 3:20 PM, the NP stated she documented a progress note on 7/14/2021 that Resident #1's pressure ulcers had declined. She stated she based her progress note on review of the documentation by the wound care nurse and had not removed the dressings or assessed the resident's pressure ulcers.

Based on review of facility policy, medical record review, review of facility investigation, observation, and interview, the facility failed to ensure 1 resident (#1) was free from abuse of 3 residents reviewed for abuse of 37 sampled residents. The findings include: Review of the facility policy, Definitions/Identification, undated, revealed .Abuse is the willful infliction of injury .with resulting physical harm, pain or mental anguish .It includes verbal abuse, sexual abuse, physical abuse .Willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0, indicating the resident had severe cognitive impairment. The resident required limited assistance for bed mobility, transfer, and dressing, and extensive assistance for toileting and ambulation. Medical record review of the resident's care plan dated 10/26/18, revealed the resident had a history of [REDACTED]. Medical record review of a Nurse's note dated 7/11/19 revealed, .Resident (increased) agitation, verbally toward others (staff and other residents) . Medical record review of a Nurse's note dated 8/7/19 revealed .Resident (#1) was in the dining room when a female resident (Resident #56) walked up to him. They were both conversing when he (Resident #1) suddenly leaned up in his w/c (wheelchair) and punched the female resident (Resident #56) in the mouth. They were both separated immediately . Medical record review of Resident #1's History and Physical dated 8/8/19 revealed .sent to the emergency room due to behavioral issues. Apparently he slapped a friend who was visiting .Patient has advanced dementia . Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #56's Annual MDS dated [DATE] revealed a BIMS score of 5, indicating the resident had severe cognitive impairment. Resident #56 demonstrated delusions, verbal behavior symptoms, and wandering. Review of the facility investigation report dated 8/7/19 revealed .(Resident #1) hit other resident (#56) on face causing small red area on side of face . Continued review revealed an interview with Registered Nurse (RN) #1, .Res (Resident #1) was in w/c in DR (dining room), resident .(#56) was walking by him. (Resident #1) thought resident (#56) said a 'smart ass remark' and (Resident #1) struck (Resident #56) with a closed fist . Continued review revealed an interview with Resident #1, I hit her because she made a smart ass remark . Observation of Resident #1 on 8/14/19 at 7:22 AM, in the residents room, revealed Resident #1 sleeping in bed. The bed was in low position with the call bell within reach. Observation of Resident #56 on 8/14/19 at 7:28 AM, on the secure unit, revealed the resident sitting in the activity/dining room in a chair. Observation of Resident #1 on 8/14/19 at 12:15 PM, in the secure unit activity room/dining room, revealed the resident sitting in a high back chair at a table with a staff member. Observation of Resident #56 on 8/14/19 at 12:20 PM, on the secure unit, revealed the resident ambulating in the hallway. Interview with RN #1 on 8/14/19 at 7:25 AM, at the secure unit nursing station, confirmed she was working on the secure unit on 8/7/19. Continued interview confirmed Resident #56 walked up to talk to Resident #1 in the dining room, and he suddenly hit her in the face. Further interview confirmed the residents were immediately separated. Further interview confirmed Resident #1 had a history of [REDACTED].#56 at a safe distance from Resident #1. Interview with Certified Nursing Assistant (CNA) #1 on 8/14/19 at 2:35 PM, by phone, confirmed she witnessed Resident #1 hit Resident #56 in the dining room on 8/7/19. Continued interview confirmed Resident #1 was sitting in the dining room and Resident #56 walked up to Resident #1 and struck Resident #56 in the face. Continued interview confirmed Resident #1 had a history of [REDACTED]. Interview with the Director of Nursing (DON) on 8/14/19 at 3:00 PM, in the DON's office, confirmed Resident #1 hit Resident #56. The facility failed to prevent abuse for Resident #56.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 1 resident was free from restraints (#77) of 7 residents reviewed for restraints. The findings include: Review of the facility policy Use of Chemical/Physical Restraints, undated, revealed .Restraints may be appropriate to manage emergency behaviors . Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations on 8/12/19 at 9:30 AM and 8/13/19 at 10:02 AM, on the secure unit hallway, revealed resident #77 was in a wheelchair with a Lap belt (type of physical restraint that lays across the resident's lap and attaches to back of wheelchair) in place. Continued observation revealed Resident self-propelling in the wheelchair on the secure unit. Medical record review of the current physician's recapitulation orders dated 7/29/19 revealed, .Lap belt while up in w/c (wheelchair) for safety . Medical record review of the resident's plan of care updated 7/15/19 revealed .Risk for Falls/Use of Restraint .is a high fall risk r/t (related to) hx (history) of falls . Interview with the Director of Nursing (DON) on 8/14/19 at 8:32 AM, in the DON office, confirmed the Lap Belt restraint was implemented to prevent falls and not to manage emergency behaviors.

Based on medical record review and interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments for 1 resident (#46) of 20 sampled residents. The findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #46's quarterly nursing documentation dated 9/29/18, 12/27/18, and 3/26/19 revealed .natural teeth .broken/carious . Medical record review of Resident #46's dental consult notes dated 3/8/19 and 6/13/19 revealed .decayed teeth .recommends extractions . Medical record review of Resident #46's Annual MDS dated [DATE] and Quarterly MDS dated [DATE] and 6/23/19 revealed no documentation of obvious or likely cavity or broken natural teeth. Interview with MDS Coordinator #1 on 8/14/19 at 1:07 PM, in the MDS office, confirmed she did not visually assess Resident #46's dental status. Continued interview confirmed she gathered information from the resident's medical record and .missed . the documentation which indicated Resident #46 had multiple cavities. Further interview confirmed Resident #46's Admission and Quarterly MDS assessments were inaccurate.

Based on review of facility policies, observation, and interviews, the facility failed to maintain a sanitary environment in 1 of 1 dish rooms; failed to ensure the dish machine was in proper working order in 1 of 1 dish rooms; and failed to maintain a sanitary environment in 1 of 1 dry food stock rooms, in 1 of 1 kitchens, in 1 of 1 walk in coolers, and in 1 of 1 walk in freezers observed; affecting 93 of 98 residents. The findings included: Review of facility policy Sanitation Inspection, not dated, revealed .All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects . Review of facility policy Food Safety Requirements, not dated, revealed .Food safety practices shall be followed throughout the facility's entire food handling process .Storage of food in a manner that helps prevent deterioration or contamination of the food .Dry food storage-keep foods/beverages in a clean, dry area .Refrigerated storage-foods that require refrigeration shall be refrigerated immediately upon receipt .Practices to maintain safe refrigerated storage include .Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by-date .keep foods covered or in tight containers .All equipment used in the handling of food shall be cleaned and sanitized .Staff shall follow facility procedures for dishwashing . Review of facility policy Monitoring of Cooler/Freezer Temperature, not dated, revealed .All food items will be stored at least 6 inches off the ground .Foods will never be stored directly above or in contact with ice .Refrigerated food shall be labeled, dated, and monitored so that it is used by the use by date . Review of facility policy Dishwasher Temperature, not dated, revealed .Manufacturer's instruction shall be followed for machine washing and sanitizing .The wash temperature shall be 120 degrees Fahrenheit .The sanitizing solution shall be 50 ppm (parts per million) .chlorine on dish surface in final rinse . Observation and interview with the Assistant Dietary Services Manager (ADSM) on 7/8/19 at 7:50 AM, of the dish room in the kitchen, revealed the following: *1 brown insect crawling up the back wall; identified by the ADSM as a roach *2 glasses, 3 bowls, various pieces of paper lying on the floor under the dish machine *buildup of food like debris on the floor and baseboard under the dish machine *4 dead insects on the floor under the dish machine; identified by the ADSM as roaches *buildup of a dark dusty type debris with particles loosely hanging down from the ceiling vent and blowing downward into the dish room *1 knife and 1 fork with visible dried debris stored on top of the dish machine Interview with the ADSM confirmed the dish room was not maintained in a sanitary manner. Observation and interview with the Dietary Manager (DM) on 7/8/19 at 8:00 AM, in the dish room, revealed the dish machine was in use and an empty 5 gallon bucket of sanitizer was connected to the dish machine. Further observation revealed the DM tested the concentration of the sanitizer in the dish machine. Interview with the DM confirmed no sanitizer was detected on the test strip and the facility failed to ensure dishes were sanitized. Observation and interview with the ADSM on 7/8/19 at 8:10 AM, of the dry food stock room in the kitchen, revealed the following: *1 brown insect crawling on the floor; identified by the ADMS as a roach *multiple dead brown insects on the floor behind the dry stock room door and under the dry food storage racks; identified by the ADSM as roaches *multiple packages of mustard, mayonnaise, and artificial sweeteners, and jelly, on the floor under the dry storage racks *8 bowl lids, 3 pieces of plastic, and a glass under the dry food storage racks *17 individual jelly packets with a sticky substance on the outside of the packet; stored on a shelf of the dry food storage racks *small dark brown elongated pellet type debris on 15 of 15 food storage rack shelves; identified by the ADSM as .mice turds . *a 10 pound bag of pasta approximately 1/3 full stored opened on a shelf Interview with the ADSM confirmed the dry food stock room was not maintained in a sanitary manner. Observation with the ADSM on 7/8/19 at 8:25 AM, in the kitchen, revealed the following: *multiple pieces of paper, dried food like debris, and a thick sticky debris on the kitchen floor *thick sticky substances on the floor, drain pipes, and wall under the 3 compartment sink *thick dark brown sticky debris on the back of the stove and on 2 of 2 power source boxes and the stove motor *dried debris and loose food-like particles on the bottom of the 3 sleeve plate warmer; which contained clean plates. *dark dusty type debris with particles loosely hanging down from the ceiling vent over the tray line *1 air conditioner with condensation dripping onto the floor beside the tray line *a utility cart which contained a 1 pound package of instant pudding approximately ½ full, 2 one pound bags of gravy mix each approximately ½ full, a 1 pound bag of brown sugar approximately ¾ full, a 1 pound package of cheese sauce mix approximately ½ full; all stored opened to air, not labeled with a use by date (UBD) Interview with the ADSM confirmed the kitchen was not maintained in a sanitary manner Observation with the ADSM on 7/8/19 at 8:50 AM, of a walk in cooler in the kitchen, revealed the following food items were stored opened to air and not labeled with a UBD: *1 ½ pound pack of provolone cheese approximately ½ full *2 ½ pound packs of sliced turkey approximately ¾ full *1 pound package of bologna approximately ½ full *12 quart open container containing a 5 pound package of sliced cheese approximately ¾ full *3 large blocks of cheese *a 1 gallon container of applesauce approximately ½ full *a 1 pound tub of pimento cheese approximately ¾ full *a 1 gallon container of pudding approximately ½ full *a 1 gallon container of a ground meat mixture approximately ½ full Continued observation revealed a 10 pound box of ground beef was stored on the floor in the walk in cooler. Interview with the ADSM confirmed the food items were not labeled and confirmed the ground beef was stored on the floor. Observation with the ADSM on 7/8/19 at 9:05 AM, of a walk in freezer in the kitchen, revealed 2 of 2 fans covered in a buildup of thick ice with ice cycles hanging downward and incasing a 3 gallon container of ice cream. Interview with the ADSM confirmed the walk in freezer had a buildup of ice. Observation and interview with the ADSM on 7/8/19 at 9:20 AM, of the kitchen, revealed 1 broom, 1 dust pan, and 1 mop stored in an alcove in the kitchen. Interview with the ADSM confirmed the mop head was dirty and the mop head was to be removed from the mop and stored outside of the kitchen. Continued interview confirmed brooms, dustpans, and mop handles were to be hung on wall pegs and stored off of the floor. Interview with the Housekeeping Supervisor on 7/8/19 at 9:40 AM, in the conference room, revealed .I was made aware of a mouse on the 300 hall and the 200 hall .we have caught 4 small mice .have out glue traps .every time the Dietary Manager reports any issues as far as mice in the kitchen I call pest control .we have a bait station outside of the kitchen door, at the receiving door, and at the end of the 200 hall . Interview with the Director of Nursing on 7/8/19 at 10:20 AM, in the conference room, revealed .last week there was a small mouse caught on a glue trap on the 200 hall .I was unaware of any concerns in the dietary department related to rodents . Interview with the ADSM on 7/8/19 at 12:45 AM, in the kitchen, confirmed the facility failed to maintain the kitchen, the dish room, the dry stock room, and food service equipment in a clean and sanitary manner and failed to provide a pest free environment. Interview with the ADSM on 7/22/19 at 6:40 AM, in the kitchen, confirmed .there is no logical explanation for us being out of sanitizer .

Based on facility policy review, medical record review, and interview, the facility failed to revise a comprehensive care plan for transfers for 1 resident (#19) of 6 residents reviewed for accidents of 31 sampled residents. The facility's failure to revise the comprehensive care plan for Resident #19 resulted in actual Harm when Resident #19 sustained a femur (long bone of upper leg) fracture during an improper transfer requiring surgery. The findings include: Review of the Facility Policy, Falls Management, undated, revealed, .Policy: Residents at risk for falls are identified to prevent future falls and maintain maximum level of function through use of interventions, as appropriate. Procedures: 1. A fall assessment will be completed on admission, quarterly (following the MDS (Minimum Data Set) schedule) and as needed. 2. The Care Plan will reflect measures implemented to prevent falls as appropriate. 3.) The Committee members will maintain/monitor as indicated . New interventions to Care Plan . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #19's Significant Change of Status MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired for daily decision making. Continued review revealed the resident required extensive assistance with activities of daily living (ADLs) and 2 person physical assist for transfers and toileting. Medical record review of Resident #19's care plan initiated 1/26/16 and last revised 10/4/17, revealed, the resident had interventions for assistance with transfers as needed and required assist of 1-2 persons and gait belt use. (A gait belt is a device used by caregivers to transfer care receivers with mobility issues from one position to another, from one location to another or while assistively ambulating patients who have problems with balance.) Medical record review of a Fall Risk assessment dated [DATE] revealed Resident #19 was a high risk for falls. Review of a facility fall investigation dated 1/5/18 at 12:50 PM revealed .CNA (Certified Nursing Assistant) was attempting to assist resident back to w/c (wheelchair) when legs went out & (and) resident fell to floor, resident sitting bullfrog legged on floor in bathroom. No gait belt was used. Medical Director and family notified . The interventions initiated after the fall were .staff education use of gait belts for all transfers & (and) to be 2 person assist . Review of the hospital records revealed the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED].#19 was transferred for orthopedic consult and subsequent surgical repair. Continued review revealed Resident #19 was discharged from the hospital on [DATE]. Interview with MDS Licensed Practical Nurse (LPN) #1 on 8/29/18, at 8:56 AM in the conference room revealed, LPN #19 had cared for the resident at times in the past and even though the care plan stated the resident was a 1-2 person assist for transfers, she would have asked for help transferring the resident and would consider the resident a 2 person assist. Interview with Risk Management LPN #3 on 8/29/18, at 9:40 AM, in the conference room, revealed the LPN was in charge of investigating falls and completing reports on falls. LPN #3 stated Resident #19 needed 2 persons to assist to ensure a safe transfer. Interview with the Director of Nursing (DON) on 8/29/18, at 11:45 AM, in the conference room revealed the comprehensive care plan revised 10/4/17 should have included a 2 person assist for a safe transfer of Resident #19. The DON confirmed the facility's failure to revise Resident #19's care plan to ensure a safe transfer resulted in a fall with Harm on 1/5/18 for Resident #19 when the resident suffered a femur fracture after an improper transfer. In summary, the investigative report identified the person performing the transfer for Resident #19 as a CNA, when actually the person was a Nurse Aide (NA), not certified, who had completed the facility's Nurse Aide Training program. The NA was training on the hall with another CNA on 1/5/17, and was instructed not to do anything without the CNA present. The CNA assigned to the NA was on break at the time of the fall. Refer to F689

Based on facility policy review, medical record review, and interview, the facility failed to ensure the safety of 2 residents (#19, #4) of 6 residents reviewed for accidents, of 31 sampled residents. The facility's failure to ensure a safe transfer resulted in actual Harm to Resident #19 when the resident received a fractured femur from an improper transfer. The findings include: Review of the Facility Policy, Falls Management, undated, revealed, .Policy: Residents at risk for falls are identified to prevent future falls and maintain maximum level of function through use of interventions, as appropriate. Procedures: 1. A fall assessment will be completed on admission, quarterly (following the MDS (Minimum Data Set) schedule) and as needed. 2. The Care Plan will reflect measures implemented to prevent falls as appropriate. 3.) The Committee members will maintain/monitor as indicated .New interventions to Care Plan . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #19's Significant Change of Status, MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating the resident was moderately cognitively impaired with decisions of daily care. Continued review revealed the resident required extensive assistance with activities of daily living (ADLs), and 2 person assist for transfers and toileting. Medical record review of Resident #19's care plan initiated 1/26/16 and revised 10/4/17, revealed an intervention for assistance for the resident of 1-2 persons with transfers as needed and the use of a gait belt. (A gait belt is a device used by caregivers to transfer care receivers with mobility issues from one position to another, from one location to another or while assistively ambulating patients who have problems with balance.) Medical record review of a Fall Risk assessment dated [DATE] revealed Resident #19 was a high risk for falls. Medical record review of the Nurses Note dated 1/5/18, timed 12:50 PM, revealed, Called to room by staff. Res (resident) found in bathroom, bullfrog legged on floor. CNA had attempted to transfer res back to wc (wheelchair) when res fell to floor .therapy transferred resident back to wc. Res c/o (complained of) pain to right leg. When back to bed, attempted to reposition res when she began to cry with pain to right leg/hip .(physician notified) .new order noted to transfer res to .ER (emergency room ) for eval (evaluation) and tx (treatment). Review of a facility fall investigation dated 1/5/18 at 12:50 PM revealed .CNA (Certified Nursing Assistant) was attempting to assist resident back to w/c (wheelchair) when legs went out & (and) resident fell to floor, resident sitting bullfrog legged on floor in bathroom. No gait belt was used. Medical Director and family notified . Interventions were implemented to include staff education on the use of gait belts, and all transfers to be 2 person assist. Medical record review of a discharge note from Erlanger Hospital 1/10/18 revealed .Primary discharge Diagnoses: [REDACTED].brought in by EMS (emergency management system) to the emergency room complaining of right thigh/leg pain status [REDACTED].initially taken to .(name of hospital) where x-ray showed fractured so she was transferred here .(a larger hospital) for orthopedic surgery consult .ortho .now stable . Interview with MDS Licensed Practical Nurse (LPN) #1 on 8/29/18, at 8:56 AM in the conference room revealed the LPN had cared for the resident in the past and although Resident #19's care plan stated the resident was a 1-2 person assist for transfers, she would have asked for help transferring the resident and would consider the resident a 2 person assist for transfers. Interview with LPN #2 on 8/29/18, at 9:24 AM, in the conference room confirmed LPN #2 had been working on Resident #19's hall on 1/5/18 when the fall occurred. The LPN stated to safely transfer Resident #19, you would need the assistance of 2 persons. Further interview revealed the Nurse Aide (NA) who transferred the resident in the bathroom on 1/5/18 was in training, and the CNA training her was on break at the time of the fall. Interview with Risk Management LPN #3 on 8/29/18, at 9:40 AM, in the conference room, revealed LPN #3 was in charge of investigating falls and completing reports on falls. The LPN stated Resident #19 required 2 persons to ensure a safe transfer on the day of the fall, and only had the assistance of 1 person for the transfer, a newly employed Nurse Aide, still in training with a CNA who was on a break at the time of the fall, which resulted in a fractured femur. Interview with the Director of Nursing (DON) on 8/29/18, at 10:20 AM, in the conference room confirmed the Nurse Aide trainee should not have been transferring the resident by herself on the day of the resident's fall. Continued interview confirmed the resident should have been transferred with 2 persons for a safe transfer. The DON confirmed the facility's failure to ensure a safe transfer for Resident #19 resulted in a fall with Harm on 1/5/18. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the MDS revealed the resident had a [DIAGNOSES REDACTED]. Medical record review of Resident #4's Fall Risk assessment dated [DATE] revealed a score of 6, with a 10 or above indicating high risk for falls. Medical record review of Resident #4's care plan dated 11/8/17 with revision date 6/6/18 revealed .Assist (Resident #4) with transfers .use assist of 1-2 . Review of a facility fall investigation dated 6/6/18 revealed .Resident (#4)being transferred to w/c (wheelchair) by staff became unstable et (and) fell to floor . Interview with Certified Nurse Assistant (CNA) #1 on 8/28/18 at 2:12 PM in the Conference Room revealed she went to the resident's room on 6/6/18 and observed CNA #2 and Resident #4 on the floor in the resident's room. Further interview with CNA #1 revealed the resident required a 2 person assist with transfers, and only CNA #2 was present for the transfer at the time of the fall. Interview with MDS Nurse #1 on 8/28/18 at 3:35 PM in the Conference Room confirmed the Resident (#4) required a 2 person assist to ensure a safe transfer.