CASS VALLEY HEALTHCARE CENTER

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure each residents' environment remained free of accident hazards for one (Resident #1) of four residents reviewed for accidents and hazards. <BR/>The facility failed to ensure CNA A did not unlock the wheels and move Resident #1's bed during peri care, causing Resident #1 to fall. This resulted in Resident #1 being sent to the hospital with fractures and lacerations.<BR/>An Immediate Jeopardy (IJ) existed from 05/31/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.<BR/>This failure could result in residents experiencing accidents, injuries, and diminished quality of life. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 06/10/2025, reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: history of falling ( person experienced past falls), muscle wasting and atrophy, not elsewhere classified (decrease in size and strength of muscle tissue), lack of coordination (the inability to smoothly and accurately control body movements), hypertensive heart disease without heart failure (the heart conditions caused by long-term high blood pressure- a condition where the force of blood against the artery walls is consistently too high, making the heart work harder to pump blood- that do not involve heart failure).<BR/>Review of Resident #1's MDS Assessment, dated 05/28/2025, reflected Resident #1 was unable to complete brief interview for mental status. Resident #1 had poor short- and long-term memory recall. Her decision-making ability was severely impaired. She was dependent on staff for the following: eating, oral hygiene, toileting hygiene, showers, upper and lower dressing, personal hygiene, and transfers. She was incontinent of bowel and bladder. <BR/>Review of Resident #1's Comprehensive Care Plan, revision date of 05/31/2025, reflected Resident #1 had an actual fall. Interventions: Bed mobility and toileting use two person assist. Inservice staff on amount of assist needed and update Kardex. Continue interventions on the at-risk plan. Monitor/document/report as needed to MD for signs and symptoms of pain, bruises, and change of mental status. New Onset of the following: confusion, sleepiness, inability to maintain posture, and agitation. Resident #1 had an ADL self-care performance deficit. She was dependent on staff for bed mobility, eating, toileting, oral hygiene, showers, dressing (upper and lower body), personal hygiene, and transfers. <BR/>Review of Resident #1's hospital records, dated 05/31/2025, reflected Resident #1 was transferred to the emergency room at local hospital on [DATE]. She had x-rays and was assessed by medical doctors. Resident #1 was discharged back to the facility on [DATE] with diagnosis of right anterior superior iliac spine fracture (a break in the bony projection on the front and upper part of the right hip bone), forehead laceration (a jagged or irregular tear or cut in the skin or other soft body tissue), right elbow soft tissue foreign body (refers to the presence of an object, like a splinter, thorn or, metal, that has entered the skin and become embedded in the soft tissues) and right pulmonary nodule (a small, discrete spot or growth in the right lung that appears denser than the surrounding lung tissue). <BR/>Review of written statement by CNA A reflected on 05/31/2025 at 9:50 AM, Resident #1 was lying in bed receiving peri care from CNA A. There was a lot of loose BM everywhere on the bed. CNA A began to provide peri-care to Resident #1. CNA A had cleaned Resident #1 on one side and needed to be on the side of the bed located against the wall. CNA A moved the bed away from the wall to have easy access to Resident #1. When CNA A was moving the bed, Resident #1 fell off the bed. CNA A confirmed there was loose stool on the alternating air mattress causing the air mattress to be slick. <BR/>An Immediate Jeopardy (IJ) existed from 05/31/2025-06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented the following actions prior to investigation start: <BR/>Review of facility's Inservice records, dated 05/31/2025, reflected all nursing staff received in-services on abuse/neglect policies and fall with injury protocol. <BR/>Review of the facility's accident hazards/supervision devices quiz, completed on 05/31/2025 and was ongoing, reflected all nursing staff completed this quiz and passed. <BR/>Review of the facility's safe peri care and bed mobility for high-risk resident's quiz, completed on 05/31/2025, reflected all nursing staff had completed the quiz and passed. <BR/>Review of the facility's interviews with interviewable residents, dated 06/01/2025, reflected 9 residents had received care from CNA A and they all knew CNA A. The following was asked of the residents:<BR/>1. <BR/>Do you know CNA A- Yes<BR/>2. <BR/>Do you know who to report to if you had problems with any staff? - Yes.<BR/>3. <BR/>Has CNA A provided you with care- Yes.<BR/>4. <BR/>Do you feel safe when CNA A provided care for you? Yes<BR/>5. <BR/>Do you feel safe at this facility? Yes<BR/>Review of the facility's skin assessments, on 06/10/2025, of all Residents after the incident on 05/31/2025. There were no new skin concerns. <BR/>Review of the facility's maintenance records, on 06/10/2025, reflected all beds were checked for any issues such as locking the bed or any malfunction of the beds. There were no concerns of all Residents beds. <BR/>Review of Resident #1's medical records, on 06/10/2025, reflected Resident #1 was being monitored for signs of pain post-incident. There was no concerns of pain. <BR/>Review of Resident #1's Kardex, on 06/10/2025, reflected peri care assistance was added to her Kardex on 05/30/2025.<BR/>Review of the facility's investigation, on 06/10/2025, reflected all residents Kardex was updated on 05/30/2025 to reflect peri-care assistance. <BR/>Review of CNA A's personnel record, on 06/10/2025, reflected she was suspended on 05/31/2025 until investigation was completed. CNA A returned to work on 06/06/2025. CNA A's misconduct was up to date and no concerns noted. <BR/>Observation on 06/10/2025 at 9:05 AM, Resident #1 was lying in bed. She was not interviewable. Resident #1 was lying in bed. She was in a fetal position facing the wall. She made eye contact and did mumble. Resident did not exhibit signs of being in pain such as: grimacing, tense body posture, restlessness, moaning, etc. Resident #1's bed was in lowest position. <BR/>Interview on 06/10/2025 at 9:18 AM, CNA B stated she did receive in-service on abuse and neglect within the past 2 weeks. She stated she did not recall the exact date. She stated examples of abuse was yelling at a resident, hitting a resident, or can be sexual abuse. CNA B stated neglect was when staff refused to give resident food, water and/or assist resident to the bathroom. CNA B stated she had been in-service on fall protocol. She stated never move a resident when they fall. She stated a nurse was required to assess the resident and give instructions to the CNA after she completed her assessment. CNA B stated she did take a quiz on falls and peri care. She stated she was reminded if a resident was a one person assist, to always ask for assistance if there was a safety issue. CNA B stated staff was never to move a bed during peri-care. She stated if a bed needed to be move this was expected to be completed prior to beginning peri-care and to ask another staff for assistance. CNA B stated peri care assistance was not on the Kardex until after the incident with Resident #1. <BR/>Interview on 06/10/2205 at 9:40 AM, CNA C stated she had received in-service on abuse and neglect, fall protocol, and peri care end of May. She stated she did not recall the exact date; however, it was the last weekend of May 2025. She stated the following was types of neglect: refusing to give resident a shower, feeding a resident, give resident water, etc. CNA C stated abuse was when someone hit, cussed, or yelled at a resident. She stated she did take quizzes on falls and peri care. She stated she was a new CNA and she learned to always ask for assistance with a resident required one person assist, if there was any safety concerns. She stated she would never move a bed during peri-care. She stated if a bed needs to be moved to reach one side of the resident, the bed was expected to be moved prior to peri-care and it was always in good practice to have two staff in the room when moving a bed. CNA C stated assistance with peri-care was not on the Kardex until after the incident with Resident #1. <BR/>Interview on 06/10/2025 at 10:58 AM, CNA D stated she was walking by Resident #1's room and opened the door to check on Resident #1. She stated CNA A was giving peri-care to Resident #1. CNA D stated Resident #1 was on her right side while lying in bed. She stated she exited the room and did not witness Resident #1 fall. She stated she was given quizzes on pericare and falls. CNA D stated she had been in-service on fall protocol and abuse/neglect. She stated abuse was when a staff kicked or yelled at a resident. She stated touching resident in private areas was also considered abuse. CNA D stated neglect was not changing a resident brief, not giving resident food, or not assisting a resident to the bathroom. She stated if a resident fell or was found on the floor only the nurse was trained to assess the resident. She stated the CNA was not to move the resident until the nurse completed all her assessments and gave directions to the CNA of what to do after the assessments. She stated when giving peri care the bed was to remain locked. She stated during the in-service the DON explained if a staff needed assistance for the staff to use call light and walkie talkies would be provided to the staff to use whenever they may need assistance with a resident. CNA D stated if a resident is a one person assist and a staff felt the resident may need more than one person the staff was expected to call for assistance. She stated peri care assistance was not on the Kardex prior to the incident with Resident #1. She stated after the incident with Resident #1 peri care assistance was on all residents Kardex. <BR/>Interview on 06/10/2025 at 10:35 AM, CNA A stated she began peri-care and cleaning Resident #1 on 05/30/2025 around 9:30 AM. She stated there was a lot of feces and some of it was loose stools. She stated feces were all over the bed. CNA A stated Resident #1 was lying on her back. She stated she needed to be on the right side of Resident #1 to finish cleaning the feces off Resident #1. She stated she rolled Resident #1 to the right side of the bed facing the wall. CNA A stated after she rolled Resident #1 to the right side she walked to the end of the bed and unlocked the bed. CNA A stated she began to move the bed away from the wall and this is when Resident #1 fell off the bed. She stated Resident #1 fell between the bed and the wall. CNA A stated she was at the end of the bed and attempted to catch Resident #1 prior to her falling. CNA A stated she was trained not to move the bed during peri-care. She stated the training was prior to the incident, however, she did not recall the date. CNA A stated she was required to unlock the bed prior to peri care and ask for assistance if there was any issues with giving peri-care. CNA A stated Resident #1 peri care was not on the Kardex. She stated she had given care to Resident #1 several times and she was a one person assist with peri-care. She stated she did ask a nurse a few months ago and this was the nurse's instructions of peri care on Resident #1 being 1 person assist. CNA A did not recall the name of the nurse or the date she questioned Resident #1's peri care. She stated she was in-service on peri-care, fall protocol, abuse, and neglect, prior to her returning from her suspension. CNA A stated neglect was when a staff refused to change a resident dirty brief, refused to feed a resident, refused to give resident water, etc. She stated slapping, yelling, or cussing a resident was abuse. CNA A stated she learned to always ask for assistance when needing to move a bed and never to move a bed during peri-care. She stated only move a bed prior to peri-care and ensure another staff was in the room for any assistance. CNA A stated she was the only witness to the fall of Resident #1. <BR/>Interview on 06/10/2025 at 2:17 PM, the Director of Nurses stated her expectations for peri care was for each CNA to gather their supplies before they enter a resident's room. She stated the CNAs were expected to position the resident in bed according to what type of peri-care is needed. The Director of Nurses stated the staff may raise the bed to the height level of the staff to provide peri-care. She sated the CNAs were expected to follow PPE guidance during peri-care. The Director of Nurses stated if the staff needed to unlock the bed, the CNA was expected to ensure the resident was stable in the bed. She stated the bed was to be moved prior to giving peri care and it was safe practice to have two staff in the room when moving a bed as a precaution. The Director of Nurses stated one staff would be on the left side of the bed and the other staff would be on the right side of the bed. She stated moving a bed when staff was at the foot of the bed was not best practice. She stated CNA A did not follow the correct protocol when moving the bed. The Director of Nurses stated CNA A was not to move the bed when standing at the foot of the bed and during peri-care. She stated the facility had purchased walkie-talkies for all staff to use when they may need assistance. The Director or Nurses stated she expected the walkie-talkies to be always with the staff and to use them when they are needing assistance with anything related to a resident care. She stated random checks was being completed with CNA A and the other CNAs during peri-care. The Director of Nurses stated the training and in servicing was ongoing. She stated they were beginning unannounced abuse drills, and this would be follow-up in QAPI. <BR/>Interview on 06/10/2025 at 3:02 PM, the Administrator stated her expectations for peri-care was for staff to ask for assistance, if there was any question about safety concerns. She stated the bed was required to be locked during peri-care. The Administrator stated CNA A was not to move Resident #1's bed during peri-care. She stated if Resident #1's bed needed to be moved, CNA A was expected to move it prior to beginning peri-care. She stated moving Resident #1's bed when CNA A was standing at the end of the bed may have contributed to Resident #1's fall. The Administrator stated the facility's investigation was inconclusive. <BR/>Facility Policy on Perineal Care, revised 04/16/2024, reflected The Purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. <BR/>Preparation:<BR/>1. <BR/>Review the resident's care plan to assess for any special needs of the resident.<BR/>2. <BR/>Assemble the equipment and supplies as needed.<BR/>(note: Enhanced Barrier Precautions would be used during peri care if resident has any qualifying condition).<BR/>Equipment and Supplies<BR/>The following equipment and supplies will be necessary when performing this procedure:<BR/>1. <BR/>Wash basin.<BR/>2. <BR/>Towels<BR/>3. <BR/>Washcloth<BR/>4. <BR/>Soap (or other authorized cleansing agent) or cleaning wipes and <BR/>5. <BR/>Trash bag and personal protective equipment (gowns, gloves, mask, etc., as needed)<BR/>Steps in the Procedure<BR/>1. <BR/>Place the equipment on the beside stand. Arrange the supplies so they can be easily reached.<BR/>2. <BR/>Explain the procedure to resident.<BR/>3. <BR/>Provide privacy.<BR/>4. <BR/>Wash hands and apply gloves. Toilet resident if on the toileting program and or remove brief.<BR/>5. <BR/>Place bed protector under resident's buttocks. <BR/>6. <BR/>Position resident with legs apart (if possible) avoid unnecessary exposure. Use wet washcloth/ cleaning wipes and apply soap/peri wash.<BR/>For a Female resident:<BR/>a. <BR/>Wet washcloth and apply soap or skin cleansing agent.<BR/>b. <BR/>Wash perineal area (between the anus and the vagina), wiping from front to back.<BR/>(1) <BR/>Separate labia (the fleshy folds of skin that make up the external female genitalia) and wash area downward from front to back (Note: if the resident has an indwelling catheter, gently wash the juncture tubing from the urethra (the tube that lets urine leave your bladder) down the catheter about three inches. Gently rinse and dry the area.)<BR/>(2) <BR/>Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in the same directions, using fresh water and a clean washcloth. <BR/>(3) <BR/>Gently Dry perineum.<BR/>c. <BR/>Ask the resident to turn on her side with her top leg slightly bent, if able. <BR/>d. <BR/>Rinse wash cloth and apply soap or skin cleansing agent.<BR/>e. <BR/>Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. <BR/>f. <BR/>Rinse and dry thoroughly.<BR/>Facility Policy on Fall Prevention Program, reviewed on 06/10/2024, reflected a fall can be defined as: when a resident is found on the floor; a resident slides to the floor unassisted; a resident rolls off the bed/chair onto the floor, including bedside mat; and a resident fall off any apparatus/equipment used for transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement comprehensive care plans that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for one (Resident #27) of three residents reviewed for care plans. <BR/>The facility failed to implement a comprehensive care plan for Resident #27. <BR/>This failure could place residents at risk of not meeting their immediate needs, long term and or short-term goals, and and interventions.<BR/>Findings included:<BR/>Record review of Resident #27's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Hemiplegia (paralysis) affecting the left side, Diabetes Mellitus (high blood sugar), and Hyperlipidemia (high cholesterol). With a BIMs of 15 (cognitively intact). Resident #27 is visually impaired, with verbal behavioral symptoms towards others, she requires limited to extensive assistance with ADLs, she requires set up and supervision during meals, and has occasional incontinence. <BR/>Record review of Resident #27's Care Plans revealed there was a total of three care plans initiated on 6/20/23. The care plans available were the use of antidepressant (Sertraline), the use of antipsychotic (Keppra), and the use of anti-anxiety (Hydroxyzine). Further investigation revealed there were no person-centered comprehensive care plans available. <BR/>Record review of Resident #27's Fall Scale Evaluation dated 6/11/23 revealed she was a high fall risk. <BR/>Record review of Residents #27's care plans dated 6/20/23 revealed there was no short-term or long-term fall care plan was available.<BR/>Interview with LVN E on 07/13/23 at 11:46 AM revealed the MDS nurse was the one responsible for doing the person-centered comprehensive care plans. MDS nurse does care plans for new admissions and updates them for short-term and long-term issues. She stated the charge nurses do not do any care plans; they only do the baseline care plan assessment upon admission. She stated that the risk of not having up to date care plans could be that the nurses would not know the right interventions for the residents, and they would not get adequate care. <BR/>Interview with MDS F on 07/13/23 at 12:52 PM revealed MDS was responsible for completing all care plans with the help of the DON. She stated the DON opened the care plans on admission, and she completed them within 7 days of completing the MDS assessment. She stated she was responsible for both short term and long-term care plans. She stated the short-term care plans were updated during morning meetings and long-term care plans were updated with MDS assessments. She cannot recall any breakdown or issues with care plans being missed. <BR/>Interview and record review with MDS F on 07/13/23 at 2:09 PM revealed Resident #27 did not have comprehensive care plans and there were only three medication care plans available. She stated there should be more care plans to include other areas for the residents such as medical care, behavioral care, activities, dietary, fall prevention, and they should be person centered, she was not sure how they were missed. She stated the risk of not having up to date care plans could lead to complications and further decline of the resident. To avoid missing care plans she stated she will bring her laptop to their morning meetings to assess any short-term and long-term changes of the residents and discuss with IDT. <BR/>Record review of Resident #27's Care Plan dated 06/20/2023, revealed person-centered comprehensive care plans were initiated and created on 07/13/23. Comprehensive care plans were provided at the conclusion of the survey. <BR/>Interview with ADON/Staffing Coordinator on 07/13/23 at 2:13 PM revealed MDS F and DON were responsible for care plans, which also included the comprehensive person-centered care plans. MDS F also was responsible to complete the short-term and long-term care plans. She stated the CNAs could see the interventions for the residents based on the [NAME]. She stated her expectation was that the care plans would be completed according to the facility policy. She also stated the risk for the care plans not being up to date would be the CNAs and nurses would not know how to properly care for the resident. <BR/>Interview with CNA G on 07/13/23 at 2:18 PM revealed she would be able to see how to care for the residents by looking in the [NAME]. This is where she would be able to see if the resident had specific interventions like if they are a fall risk. <BR/>Interview with DON on 07/13/23 at 2:22 PM revealed MDS nurse was responsible to complete short-term and long-term person-centered comprehensive care plans. She stated that she opened them on admission and MDS F completed them within 7 days of completing the MDS assessment. She stated her expectation was that the care plans should be documented within the patient chart that includes goals and interventions. Her expectation was that MDS F would update care plans quarterly and as needed. Missing care plans for Resident #27 would be reviewed along with all residents moving forward to ensure completion. Risks to residents of gaps in care plans would be they would not be cared for properly. <BR/>Record review of policy titled Care Plans, Comprehensive Person-Centered with a revision date of [DATE] revealed comprehensive, person-centered care plans will be developed within 7 days of the completion of the required comprehensive assessment (MDS). It also revealed that comprehensive, person-centered care plans that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored, individual activities, independent activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident , encouraging both independence and interaction in the community for 3 of 8 residents ( Resident #10, Resident #19, and Resident #25) reviewed for activities. <BR/>The facility failed to develop an activity program based on preferences of Resident #10, Resident #19, Resident #25 during the months of July to August 2024. <BR/>These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. <BR/>Findings include:<BR/>1. Record review of Resident #10's Face Sheet, dated 08/22/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis depression unspecified (used when a person's symptoms do not clearly align with a specific mental disorder or where there is insufficient information for a more definitive diagnosis), other secondary parkinsonism ( caused by brain injuries or brain disorders), and cognitive communication deficit (can effect both verbal and nonverbal communication, such as speaking, listening, reading, writing, and social interaction skills).<BR/>Record review of Resident #10's Annual MDS Assessment, dated 01/30/2024, reflected Resident #10 was rarely/never understood. She had poor short (unable to recall after 5 minutes and long (unable to recall long past memories) term memory recall. Resident #10 does not have speech (absence of spoken words). Resident #10 activity preferences was listening to music and participating in religious activities or practices. <BR/>Record review of Resident #10s Quarterly MDS Assessment, dated 07/30/2024, reflected Resident #10 had poor short (unable to recall events after 5 minutes) and long-term memory recall (unable to recall past events). Resident #10 was rarely/ never understood or rarely/never understands others. <BR/>Record review of Resident 10's Comprehensive Care Plan, dated 08/14/2024, reflected Resident #10 required staff assistance for meeting emotional, intellectual, physical, and social needs related to disease process and immobility. Intervention: Resident #10 needed in-room visits and activities. <BR/>Record review of Resident #10's in room activity participation record in the electronic medical record reflected Resident #10 did not have any documentation of receiving in room activities or attending group activities. The record review was completed with the Activity Director M. She stated she did not have any participation records on Resident #10.<BR/>Observation on 8/20/2024 at 10:31 AM. Resident #10 was sitting in the lobby asleep. <BR/>Observation on 08/20/2024 at 4:00 PM, Resident #10 was in bed. Her door to her room was slightly opened. Resident #10 was awake there was no lights on in her room. Television was not on and did not observe any radio in her room which music was her favorite activity. Resident #10's room was dark and she was moving her eyes side to side. Resident had sad expression (forehead wrinkled and eyebrows were brought together -signs of sad expression). <BR/>In an interview on 8/20/2024 at 4:05 AM, Resident #10 was not interview able. <BR/>Observation on 08/21/2024 at 7:45 AM, Resident #10 was in bed. Her door to her room was slightly opened. Resident #10 was awake and there were no lights on in her room and no stimulation such as a radio in her room which is her favorite activity listening to music. Resident #10 did not have television on in room. <BR/>In an interview on 8/21/2024 at 8:15 AM, Activity Director M stated she did not have any in room or group participation records for the month of July 2024 and August 2024 for Resident #10. She stated she would print all of the in-room participation records for the months of July 2024 and August 2024<BR/>In an interview on 08/21/2024 at 8:45 AM, Activity Director M stated after the activity in room participation records were printed Resident #10 did not have any in room or group participation records for the months of July 2024 or August 2024. She stated she did not know if she received in room activities or attended group activities during the months of July 2024 and August 2024. Activity Director M stated if a resident had a diagnosis of depression and was not physically able to do activities without assist from another person, there was a possibility Resident # 10 may become more depressed and may become very lonely. She stated Resident #10 quality of life may decrease. She stated Resident #10 does sit in the lobby but sleeps most of the time and she was not receiving any activities in the lobby. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. <BR/>2. Record review of Resident #19's Face Sheet, dated 08/22/2024, reflected a 94- year-old female admitted to the facility on [DATE] with diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition in which a person loses the ability to think and solve problems. Unspecified severity- a medical classification for dementia that does not have a specific diagnosis and does not have a specified severity), major depressive disorder ( feelings of guilt or worthlessness, lack of energy, agitation ( unable to stay calm) and /or sleep disturbances), and unspecified glaucoma (a group of eye diseases that cause increased pressure in the eye, which can damage vision). <BR/>Record review of Resident #19's admission MDS Assessment, dated 10/18/2024, reflected Resident #19 had a BIMS score of a 15 indicated her cognition was intact. Resident #19's activity preferences were the following: go outside and get fresh air when weather permitted, participate in religious services or practices, listen to music, reading such as: books, newspapers, and magazines. Participating in groups activities was not very important to Resident #19. <BR/>Record review of Resident #19's Quarterly MDS Assessment, dated 07/17/2024, reflected Resident #19 had a BIMS score of 15 indicated her cognition was intact. Resident #19 had moderately impaired vision- not able to see newspaper headlines but can identify objects. She was assessed to feel down, depressed, or hopeless. Resident #19 also felt tired and bad about herself, had difficulty concentrating on things such as: reading or watching television. <BR/>Record review of Resident #19's Comprehensive Care Plan, dated 07/31/2024, reflected Resident #19 required staff assistance for meeting emotional, intellectual, physical, and social needs related to immobility. Intervention Resident #19 needed in room visits and activities if unable to attend out of room events. Resident was resistive to care related to adjustment to nursing home and dementia (a condition in which a person loses the ability to think and solve problems). Resident #19 refused to get out of bed. Intervention: All Resident #10 to make decisions about treatment regime, to provide sense of control. Resident #19 had impaired cognitive function/dementia (a condition in which a person loses the ability to think and solve problems). Intervention: Reminisce with Resident #19 using photos of family and friends. <BR/>Observation on 8/20/2024 at 11:30 AM, Resident #19 was in her room lying in bed. The door to her room was barely opened and she did not have television on and did not see a radio or other stimulation in her room. Resident #19 had sad expression on her face such as (forehead wrinkled, and eyebrows were brought together -signs of sad expression). Resident #19 was staring toward the ceiling. <BR/>In an interview on 08/202/2024 at 11:33 AM, Resident #19 stated she was lonely and there was not anything for her to do except watch television and she was tired of television. She stated she did not receive in room visits or activities from anyone and she did not know what in room visits or in room activities was until now. Resident #19 stated she never heard of in room activities. Resident #19 stated she did not prefer to attend group activities it made her feel uncomfortable being around others in a group. She stated if someone would just bring her a radio or something for her to listen to music. Resident #19 stated she loved Gospel music and liked country music. She stated if there was gospel or country music on television she never knew about it or ever saw it on television. Resident #19 stated music was her favorite thing to do. She stated she never liked to read very much due to her vision. Resident #19 stated her neighbor had books on tape and her neighbor would listen to different types of books. Resident #19 stated she might enjoy listening to books but she would need to try it before she made decision if she liked to listen to books. Resident #19 stated no one had ever offered her anything to read and with her poor vision it would need to be very large print. Resident #19 stated she did like to go outside in the spring and fall sometimes. She stated she did not recall anyone assisting her to sit outside. Resident #19 stated that would be nice sometimes not every day or every week but maybe once or twice a month when weather was cooler. She stated she did like to listen to devotionals. She stated it would be nice if someone read the bible to her or a devotional to her once a week. Resident #19 stated there is never anything to do and no one comes by and will sit and talk to me. She stated do you think you can talk to someone and ask them if they would visit with me sometimes and bring me something to do instead of watching television all the time. <BR/>In an interview on 08/21/2024 at 8:15 AM, Activity Director M stated Resident #19 was not on the in-room activity program. She stated she did not realize Resident #19 was not getting out of bed very often. The Activity Director M stated she did not have any participation records for Resident #19 during months of July 2024 and August 2024. She stated she had not been reminiscing using photos of Resident #19's family and friends. Activity Director M stated if Resident #19 did not want to attend group activities she needed to be receiving in room activities. Activity Director M stated she did not realize it was on Resident #19's care plan she was to receive in room activities reminiscing about family or friends' photos. She stated Resident #19 had a potential of becoming bored and depressed if she was not doing the activities she preferred or not doing any type of activities in her room. Activity Director M stated she had not been offering her large print books to read, books on tape or a radios. She stated if music, religious activities and going outside was her favorite activities these type of activities was expected to be provide to Resident #19. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. <BR/>3. Record review of Resident #25's Face Sheet, dated 06/17/2024, reflected a [AGE] year-old male admitted on [DATE] with a diagnoses of lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), age-related physical debility ( frail patients often present with symptoms including weakness, fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), and anxiety disorder due to known physiological condition ( when anxiety symptoms (startle easily and can't relax) are a direct result of a physical health problem).<BR/>Record review of Resident #25's admission MDS Assessment, dated 06/21/2024, reflected Resident #25 had a BIMS score of 9 indicated Resident cognition was moderately impaired. Resident#25's activity preference was the following: have books, newspaper, and magazines to read, listen to music, watching news, go outside to get fresh air when the weather was good, and participating in religious services or practices.<BR/>Record review of Resident #25's Comprehensive Care Plan, dated 07/12/2024, reflected Resident #25 had a mood problem anxiety related to disease process of CVA ( a medical conditions that occurs when blood flow to the brain is suddenly cut off - this diagnosis was not listed on the face sheet) Intervention: Monitor/record/ report to medical doctor as needed acute episode feelings or sadness; feelings of worthlessness or guilt or change in psychomotor (movement-oriented activities that require practice and involved characteristics such as coordination, strength, speed and flexibility). Resident # 25 had impaired cognitive function/dementia or impaired thought process (a condition in which a person loses the ability to think and solve problems). Intervention Reminisce with Resident #25 using photos of family and friends. <BR/>Observation on 08/20/2024 at 11:30 AM, Resident #25 was lying in bed. The lights were off in his room and the door was slightly open leading into his room. He did not want to discuss anything about his nails. He made eye contact with Surveyor O when mentioned in room activities or in room visits. Resident #25 also clinched his mouth / jaw (sign of stress) when surveyor O mentioned if he received in room visits talking about pictures of his family and friends. Resident #25 did not have any stimulation in his room. <BR/>Interview on 08/20/2024 at 11:34 AM, Resident #25 stated no when asked if he received activities or visits in his room showing him pictures of his family and friends. Resident #25 stated no when asked if he liked to do anything with a group of people. <BR/>In an interview on 08/21/2024 at 8:15 AM, Activity Director M stated Resident #25 was on the in-room activity program due to Resident #25 did not attend group activities. She stated her schedule was to visit all in room residents Monday to Friday in the morning. Activity Director M stated according to Resident #25's participation records he only received two in room activities during the month of July 2024 and did not receive any in room activities during month of August 2024. She stated Resident #25 had a potential of becoming depressed, lonely and may have a decrease of quality of life. She stated she had not reminisced with Resident #25 with photos of his family and friends. She stated Resident #25 was expected to receive in room visits/ activities Monday thru Friday. Activity Director M stated she did not have any excuse why she did not visit Resident #25 to provide in room activities/ visits. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. <BR/>In an interview on 08/22/2024 at 2:05 PM, the Administrator stated all activities including in room visits was expected to be documented on the date the activity occurred with the residents. She stated if the Activity Director M did not document any activities, the activity did not occur with the resident or residents. The Administrator stated a resident may become depressed, lonely and have a diminish quality of life if they were not receiving activities of their preferences on a daily or weekly basis. She stated she had been in this facility approximately two weeks and would definitely be making observations of the activity programming. <BR/>Record review of the Facility's Policy on Activity Programs, revised on 06/2018, reflected activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident -centered assessment and the preferences of each resident. All activities are documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for 1 (Resident # 5) of 30 residents reviewed for medication storage and labeling The facility failed to ensure medication for Resident # 5 was stored and labeled as it was received. The facility failed to ensure that expired medication package was destroyed or sent back to the pharmacy. These failures could place the residents at risk for receiving the wrong medication or not receiving the therapeutic effect of the prescribed medication.Findings include: In observation of medication room refrigerator on [DATE] at 1400 with LVN A present, revealed a zip lock plastic bag with a prescription sticker label for Resident #5 for Lispro100 units/ML Pen from Pharmacy A with expiration date of [DATE]. The medication that was on the prescription sticker label on the zip lock bag for Lispro 100 units/ML Pen was not present in the zip lock bag. Inside the zip lock plastic bag was a box with a prescription label for Novolog flex pen (insulin aspart)100 U/ML INJ from Pharmacy B with use by date [DATE] on the prescription sticker for Resident #5. Medication packaging indicates that medication does not expire until the year 2026. In record review of Resident #5's physician orders revealed HumaLOG KwikPen (Insulin Lispro)100 UNIT/ML. Further review revealed Resident #5 was not prescribed Novolog (insulin aspart) while living in the facility. In an interview with LVN A on [DATE]at 1419 she stated she has worked in the facility for 2 years. She stated she was in-serviced frequently on abuse, neglect, exploitation, medication administration, and medication storage and labeling. LVN A stated that medication boxes should only be placed in packages they were received in. LVN A states that Resident #5 was on HumaLOG not Novolog. LVN A stated they have HumaLOG for his sliding scale. LVN A stated the medication was in the incorrect bag and it all should have been removed as the Resident was not on Novolog insulin and it was not from the facilities pharmacy. LVN A stated the medications are both rapid acting insulins, they have different absorption rates. LVN A stated she would need an order from the provider to give the alternate medication. LVN A stated it was not okay to place a medication box for one medication in the packaging for another medication. LVN A stated the medication being placed in the incorrect packaging could have led to a medication error. She stated medication errors can potentially harm the Residents. LVN A stated that all nurses are responsible for ensuring medication that is expired or discontinued are removed. In an interview with DON on [DATE] at 1426 she stated they frequently Inservice the staff on abuse, neglect, exploitation, medication administration, and medication labeling and storage. She stated medication should not be placed in packaging supplied for any other medication. They stated it was their expectation that all nurses who have access to the medication room and the medication carts to ensure all expired or discontinued medication are removed to prevent medication errors. The DON stated if medication such as insulin was put into a zip lock plastic bag labeled for a different insulin that was expired the medication could be given and cause harm to the Resident. The DON states t the medication discussed should have been placed in the destruction box and not left in the refrigerator. In an interview with the Administrator on [DATE] at 1430 she stated all staff are in-serviced frequently on abuse, neglect and exploitation. She stated the DON frequently in-serviced nurses on medication administration and medication storage and labeling. She states the nurses are responsible for following the Storage of medication policy. Record Review of facility policy titled Storage of medication last reviewed [DATE] reflected the following: The Facility stores all drugs and biologicals in a safe, secure and orderly manner. 2. Drugs and biologicals used in the facility are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 4 Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. 5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. <BR/>1. The facility failed to appropriately thaw frozen meant defrost on 08/20/2024. <BR/>2. The facility failed to store boxes of food off the floor, ensure the floor of the refrigerator was free of debris in the walk- in refrigerator on 08/20/2024.<BR/>3. The facility failed to ensure Dietary Aide P washed or sanitized her hands prior to placing new gloves on her hands when she was giving a resident some zip lock bags on 08/21/2024. <BR/>These failures placed residents at risk for health complications and foodborne illness. <BR/>Findings included: <BR/>Observation on 08/20/2024 at 9:05 AM, there was approximately 10 pound of frozen hamburger meat in a clear plastic round tube shape located in a pot sitting in the kitchen sink. The hamburger meat was not thawed and more than half was frozen. There was not any running water over the frozen hamburger meat. There was approximately half of the frozen hamburger meat not submerge in the water. Only half of the hamburger meat was submerged in the water. <BR/>In an interview on 08/20/2024 at 9:08 AM, Dietary Aide P stated all the hamburger meat was required to be in the water to be defrosted. She stated running water was also expected to be running over the hamburger meat while it was being defrosted. Dietary Aide P stated she forgot to run the water over the hamburger meat and place the hamburger meat in a larger pot. Dietary Aide P stated she was in a hurry and forgot. She stated if the hamburger meat was not defrosted properly there was a possibility the hamburger meat may be ruined from being defrosted at room temperature. She stated it was a possibility a resident may become ill with stomach issues if the resident ate ruined meat. <BR/>2. Observation on 08/20/2204 at 9:13 AM, there were four boxes of food stacked on top of one another located in the walk-in refrigerator floor. There were also some paper napkins on the floor and one was stuck to the surveyors shoe. In the corner of the walk-in refrigerator was some type of crumbled food. <BR/>3. Observation on 08/22/2024 at 11: 15 AM, Dietary Aide P removed gloves from her hand and placed them in garbage can. She did not wash or sanitize hands after removing the gloves. Dietary Aide P touched her clothes and picked up 2 new gloves from the glove container. She touched the outside of the gloves such as fourchettes (slender pieces of fabric or rubber that forms the sides of the finger). Dietary Aide P placed the gloves on her hands and picked up approximately 3 zip plastic bags and placed her fingers inside two of the plastic bags and gave it to a resident.<BR/>Interview on 08/22/2024 at 11:20 AM, Dietary P stated she did touch her shirt after she removed her gloves. She stated she did not sanitize or wash her hands prior to placing new gloves on her hands. Dietary aide stated she did pick up the gloves where the fingers go inside the gloves. She stated she was expected to wash her hands prior to placing new gloves on her hands. Dietary Aide P stated she had been in-serviced on hand hygiene and wearing gloves when changing tasks or touching anything not sanitary. <BR/>Interview on 08/22/2024 at 2:05 PM, the Administrator stated all boxes located in the walk-in refrigerator was expected to be on a crate or on the shelves. She stated no boxes was to be stored on the floor of the refrigerator. She stated the boxes may become damp and the food inside of the boxes had a potential of being wet or damp. She also stated it was a possibility of a safety hazard if the boxes were stacked on each other they could fall and injure a staff. The Administrator stated all frozen meat was required to be defrosted on a flat pan located in the refrigerator on the bottom shelf. She stated if the dietary staff was defrosting hamburger meat in the sink all of the hamburger meat was expected to be submerged in water with running water pouring over the frozen hamburger meat. She stated it was a possibility the meat may ruin if not defrosted correctly but there was a slight chance of this occurring when defrosting. The Administrator stated all staff was to wash and sanitize their hands when they removed gloves and prior to placing new gloves on their hands. She stated if the dietary aide P did not sanitize her hands and touched inside the zip plastic bags to give to a resident there was a possibility the bags could become cross contaminated. She stated there should not be any paper napkins on the floor in the walk-in refrigerator. The Administrator stated all areas of the kitchen including walk-in refrigerator was expected to be kept clean and organized. <BR/>In an interview on 08/22/2024 at 3:45 PM, Dietary Manager L stated all meat was required to be defrosted either in the refrigerator on a flat pan located on the bottom shelf of the refrigerator or in the sink in a container with running water pouring over the meat. She stated the hamburger meat was to be submerged in the pot and be defrosted with running water over the entire hamburger meat. Dietary Manger L stated there was a possibility the portion of the hamburger meat not submerged in the water would not be defrosted correctly and may cause illness with a resident if the hamburger meat was ruined. She stated any time dietary staff removes their gloves they were expected to wash their hands immediately before doing any other type of task including placing new gloves on their hands. Dietary Manger L stated if Dietary Aide P touched the outside of the new gloves with her contaminated hands there was a possibility bacteria could cross contaminated inside of the plastic bags. She stated if the resident was placing food inside of those bags there was a potential where bacteria touch the food. Dietary Manger L stated if a resident ate contaminated food the resident may become sick with any type of stomach issues such as vomiting and diarrhea. She stated the boxes located in the walk-in refrigerator was not to be stored on the floor. She stated they were expected to be stored on pallets or on the shelves in the refrigerator. Dietary Manager L stated this had a potential of becoming a safety hazard due to the boxes was stacked on top of each other and if they feel a staff may become injured. She stated there should never been any type of napkins or paper on the floor in the walk-in refrigerator or anywhere in the kitchen. Dietary Manager L stated this was not sanitary. She stated there should never be any type of food on the refrigerator floor. She stated this was also not sanitary. <BR/>Review of the facility policy on Food Preparation and Service, dated 10/2022, reflected Foods will not be thawed at room temperature. Thawing procedures include:<BR/>a. Thawing in the refrigerator in a drip-proof container.<BR/>b. Completely submerging the item in cold running water (70&deg;F or below) that is running fast enough to<BR/>agitate and remove loose ice particles.<BR/>c. Thawing in a microwave oven and then cooking and serving immediately; or<BR/>d. Thawing as part of a continuous cooking process<BR/>Facility policy of Refrigerators and Freezers, dated 10/2022, reflected This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on scheduled basis and more often as necessary.<BR/>Facility policy on Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, reviewed 06/12/2024, reflected Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (1) of one resident reviewed for transfer and discharge rights. (Resident #1)<BR/>The facility failed to make arrangements for a safe discharge for Resident #1.<BR/>This failure could place residents at risk for not receiving care and services to meet their needs upon discharge. <BR/>Findings included:<BR/>Review of Resident #1's Face Sheet reflected a [AGE] year-old male admitted [DATE] with diagnoses of unspecified systolic congestive heart failure (the left ventricle loses its ability to contract normally. The heart can't pump with enough force to push enough blood into circulation), essential primary hypertension (abnormally high blood pressure that not caused by a medical condition), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), and insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep).<BR/>Review of Resident #1's Quarterly MDS dated [DATE] reflected a BIMS score of 15 indicating no cognitive impairment. Resident #1 required set up or clean up assistance in the areas of eating, oral hygiene, upper body dressing, and personal hygiene, Resident #1 required partial/moderate assistance in the areas of lower body dressing and shower/bathe self. Resident #1 required substantial/maximal assistance in the areas of toileting hygiene and putting on/taking off footwear. <BR/>Review of Resident #1's care plan dated 12/10/24, revealed Resident #1 was care planned for the following: Resident #1 wished to be discharged to an apartment. <BR/>Review of Resident #1's 30-day discharge letter dated 10/09/24, revealed Resident #1 was given the 30-day discharge letter on the same date (10/09/24) he was discharged to the psych facility. <BR/>Review of Resident #1's Interdisciplinary Discharge Summary date 10/11/24, revealed Resident #1 was sent to the psychiatric facility for evaluation and treatment. <BR/>During an interview on 12/10/24 at 1:20 p.m., the SW stated that the resident was having several behaviors such as putting the remote to the tv in his pants, threatening other residents, and forced his roommate to watch gay porn. The SW stated Resident #1's former roommate was discharged from the facility as well but provided the investigator his face sheet with a phone number attached. The SW stated that the facility got an Application for Emergency Apprehension and Detention warrant for Resident #1 to be seen at a psychiatric facility. The SW stated that Resident #1 was given his 30-day discharge notice on 10/09/24 with a discharge date of 11/09/24. SW stated Resident #1 discharged from the psychiatric facility to another facility on 10/30/24. The SW stated that she nor anyone else was involved in the process of assisting with finding a new facility for Resident #1 once he left the psychiatric facility. <BR/>During an interview on 12/10/24 at 2:35 p.m., the BOM stated that she was not involved in the transfer process when Resident #1 was sent to the psychiatric facility. The BOM stated Resident #1 was aware that he was going to the psychiatric facility on 10/09/24. The BOM stated that she gave Resident #1 his 30-day discharge letter on 10/09/24 with a discharge date of 11/09/24. The BOM stated that she thought that the SW, the DON, and the ADM had placement for Resident #1 once he was discharged from the psychiatric facility. <BR/>During an interview on 12/10/24 at 4:00 p.m., Resident #1 stated that he was doing fine and was safe at his new facility. Resident #1 stated that the psychiatric facility referred him to the new facility. Resident #1 stated that he was very happy and pleased at his new facility and expected to get his own apartment after discharge. <BR/>During an interview on 12/10/24 at 4:30 p.m., the DON stated she was not working at the facility at the time of the incident. The DON stated that the facility should have coordinated a transfer for Resident #1 due to him coming from their facility. The DON stated that she was not sure who was responsible to assist with coordinating a safe transfer due to her being new at the facility. The DON stated the failure could affect the resident by not having a safe place to discharge after discharging from the psychiatric facility. <BR/>During an interview on 12/10/24 at 4:55 p.m., the ADM stated that Resident #1 was sent to the psychiatric facility on her first day working at the facility. The ADM stated that she thought the facility and coordinated a facility for Resident #1 to go to after he left the psychiatric facility. The ADM stated she was not involved in the discharge process for Resident #1. The ADM stated that IDT team was responsible for discussing the needs to ensure a safe discharge/transfer occurs and the SW was responsible for coordination with the psychiatric facility about finding a new placement for the resident. The ADM stated the failure could have affect the resident by not having a safe discharge. <BR/>Review of facility's Transfer or Discharge Notice policy dated Revised January 2023 reflected Residents and/or representatives are notified in writing, and in a language and format they understand, at least (30) days prior to a transfer or discharge.<BR/>Policy, Interpretation, and Implementation<BR/>1. <BR/>Transfers and discharge includes movement of a resident from a certified bed in the facility to a non-certified bed in another part of the facility, or to a non certified bed outside the facility. Transfer and discharge does not refer to movement to a bed within the same certified facility, Specifically:<BR/>a. <BR/>Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility; and<BR/>b. <BR/>Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility or other location in the community, when return to the original facility is not expected. <BR/> 3. Except as specified below, the resident and his or her representative are given a thirty (30) days advance written notice of the impending transfer or discharge from this facility. <BR/> 4. Under the following circumstances, the notice is given as soon as is it practicable but before the transfer or discharge: <BR/> a. The safety of individuals in the facility would be endangered;<BR/> b. The health of individuals in the facility would be endangered;<BR/> c. The resident's health improves sufficiently to allow a more immediate transfer or discharge;<BR/> d. An immediate transfer or discharge is required by the resident's urgent medical needs;<BR/> e. The resident has not resided in the facility for thirty (30) days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 6 residents (Resident #1) reviewed for a clean and homelike environment.<BR/>The facility failed to ensure Resident #1's urinal was emptied appropriately on 09/04/24. <BR/>This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life. <BR/>Findings included:<BR/>A record review of Resident #1's face sheet dated 09/04/24 reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1's diagnoses included personal history of traumatic brain injury (someone who had a previous traumatic brain injury), muscle wasting and atrophy (loss of muscle tissue), major depressive disorder (persistent low mood and loss of interest in activities that people enjoy), epileptic seizures (a sudden burst of electrical activity in the brain that cause symptoms such as jerking and shaking), primary essential hypertension (high blood pressure that doesn't have a known secondary cause), and muscle weakness (loss of muscle strength).<BR/>A record review of Resident #1's Quarterly MDS assessment, dated 08/12/24, reflected Resident #1 had a BIMS score of 13, which indicated cognitively intact. Resident #1's Quarterly MDS Section GG Functional Abilities and Goals reflected that Resident #1 required substantial/maximal assistance in the area of toileting hygiene and partial moderate assistance in the areas of eating, oral hygiene, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. <BR/>A record review of Resident #1's care plan, dated 09/04/24, reflected Resident #1 was care planned for ADL self-care performance deficit r/t disease process TBI, limited physical mobility r/t TBI, and impaired cognitive function/dementia or impaired thought process r/t neurological symptoms. <BR/>During an observation on 09/04/24 at 9:20am, Resident #1's urinal had yellowish liquid in it that appeared to be urine.<BR/>During an observation on 09/04/24 at 11:28am, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine.<BR/>During an observation on 09/04/24 at 1248pm, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine.<BR/>During an observation on 09/04/24 at 2:42pm, Resident #1's urinal appeared to have yellowish liquid in it that appeared to be urine.<BR/>During an interview on 09/04/24 at 9:20am, Resident #1 stated that the urinal had been on his nightstand for a long time. Resident #1 stated the CNAs only empty his urinal during the night shift. Resident #1 stated that his urinal was not emptied the night before. <BR/>During an interview on 09/04/23 at 1:00pm, LVN A stated that CNAs should make rounds at least every two hours. LVN A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. LVN A stated that it's anyone's responsibility that walked into the resident's room to ensure that the urinal was emptied appropriately. LVN A stated that if a resident's urinal was not emptied appropriately then that would be a resident's rights issue, the resident's room would have a foul smell, or the resident could knock over the urinal creating a slippery floor. <BR/>During an interview on 09/04/23 at 3:30pm, the DON stated that CNAs should ensure that the resident's urinals have been emptied when rounds were made. The DON stated anyone who entered the resident's room should ensure the resident's urinal was emptied appropriately. The DON stated if a resident's urinal was not emptied appropriately that would be a resident's right violation, and an infection control issue. <BR/>During an interview on 09/04/23 at 4:00pm, the ADM stated that CNAs should ensure that the resident's urinals have been emptied when rounds were made. The ADM stated anyone who entered the resident's room should ensure the resident's urinal was emptied appropriately. The ADM stated if a resident's urinal was not emptied appropriately that would be a resident's right violation, there would be an odor from the urinal, and an infection control issue. <BR/>Review of the facility's Bedpan/Urinal, Offering/Removing policy, revised February 2018, reflected, Purpose: The purpose of the procedure is to provide the resident with bedpan and/or a urinal assistance. Preparation<BR/>1. <BR/>Review the resident's care plan to assess for any special needs of the resident.<BR/>2. <BR/>Assemble the equipment and supplies as needed.<BR/>General Guidelines<BR/>1. <BR/>Check to see if the resident is on intake and output before discarding the urine and feces. <BR/>2. <BR/>Do not allow the resident to sit on a bedpan for extended periods. This is not only uncomfortable to the resident, it also causes skin breakdown. <BR/>3. If the resident prefers to keep a urinal at his bedside, check if frequently. Empty and clean it as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the communication system which allows residents to call for staff assistance was within reach for 5 (Resident #4, Resident # 21, Resident # 31, Resident #26, and Resident #20) out of 17 residents reviewed for call system placement. <BR/>The facility failed to ensure Resident #4, Resident #21, Resident #31, Resident #26 and Resident #20's call light was within reach. <BR/>The failure could place residents at risk for being unable to call for assistance from staff.<BR/>Findings include:<BR/>Review of Resident #4's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis or severe weakness in one side of the body) and cerebral infarction (stroke). <BR/>Review of Resident #4's Optional MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. MDS further reflected resident required substantial assistance with sitting on side of bed and transferring to the toilet. <BR/>Review of Resident #4's Care Plan, dated 05/13/2024, reflected resident requires staff assistance for meeting needs. Care plan reflected resident had an ADL self-care performance deficit and required extensive 2-person transfer and dependence for toileting needs. Interventions included to encourage resident to use call bell to call for assistance. <BR/>Observation and interview on 08/20/2024 at 09:15 AM, revealed Resident #4 lying in bed by the window with the call bell hanging from the back wall out of the resident's reach. Resident #4 stated he did not know where the call bell was and shrugged his shoulders when asked further questions.<BR/>2. Review of Resident #21 face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), personal history of traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), an anxiety disorder (feelings of worry, anxiety or fear). <BR/>Review of Resident #21's MDS, dated [DATE], reflected a BIMS score of 13 indicating resident was cognitively intact. MDS further reflected resident required moderate assistance with eating and substantial assistance with toileting. <BR/>Review of Resident #21's Care Plan, dated 05/13/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance. <BR/>Observation and interview on 08/20/2024 at 09:45 AM, revealed Resident #21 sitting in wheelchair alone in his room with call bell hanging against back wall and behind furniture. Resident #21 stated he did not know where the call bell was and that he never uses it. He stated he goes out of the room to get someone if he needs something.<BR/>3. Review of Resident #31's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with readmission on [DATE] with diagnoses of nontraumatic intracerebral hemorrhage (bleeding in the brain that occurs without surgery or trauma), encephalopathy (brain disease that alters brain function), hemiplegia and hemiparesis (weakness and paralysis on one side of the body). <BR/>Review of Resident #31's MDS, dated [DATE], reflected a BIMS score of 03 indicating severe cognitive impairment. MDS reflected resident was dependent on staff for toileting and hygiene needs.<BR/>Review of Resident #31's care plan, dated 07/08/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance.<BR/>Observation and interview on 08/20/2024 at 10:00 AM, revealed Resident #31 alone in the room, lying in bed with the call bell draped across the chair on the other side of the room. Resident # 31 was difficult to understand but stated he did not know about his call bell.<BR/>4. Review of Resident #26's face sheet reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy (brain dysfunction caused by a chemical imbalance in the blood from an underlying condition that affects metabolism), Alzheimer's disease (progressive disease that destroys memory and other mental functions), and transient cerebral ischemic attack (mini stroke). <BR/>Review of Resident #26's MDS, dated [DATE], reflected a BIMS of 10 indicating moderate cognitive impairment. MDS indicated resident required moderate assistance with toileting and showering. <BR/>Review of Resident #26's Care Plan, dated 07/09/2024, reflected resident had an ADL self-care performance deficit and required assistance with transfers, eating and toileting. Interventions included to encourage resident to use call bell to call for assistance.<BR/>Observation and interview on 08/20/2024 at 10:15 AM, revealed Resident # 26 alone in room lying in bed by the window with the call bell across the room out of reach. Resident #26 stated he never has a call bell where he can reach it.<BR/> 5. Review of Resident #20's face sheet reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease (progressive disease that destroys memory and other mental functions), Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and Dementia (impairment of brain functions such as memory loss and judgement). <BR/>Review of Resident #20's MDS, dated [DATE], reflected a BIMS of 04 indicating severe cognitive impairment. MDS reflected resident required supervision with toileting and shower. <BR/>Review of Resident #20's Care Plan, dated 06/09/2024 reflected resident had an ADL self-care performance deficit and required assistance with toileting and supervision/setup with eating and transfers. Interventions included to encourage resident to use call bell to call for assistance.<BR/>Observation on 08/2024 at 11:00 AM, revealed Resident #20 resting in bed with her call bell out of reach, hanging from back wall onto the floor. Resident was not interviewable. <BR/>In an interview on 08/22/2024 at 3:51 PM, CNA C stated it was the nursing staff's responsibility to ensure the residents call bell was within reach or it could place the resident at risk for falls. She stated the nurses at the nurses station would only be able to hear some of the residents if they were to cry out for help. <BR/>In an interview on 08/22/2024 at 4:10 PM, LVN A stated it was everyone's responsibility to ensure the call bells are within the residents reach and to tell the residents to call if they need anything. She stated a resident could fall while trying to get up and reach the call bell. She stated the nurses at the nurse station would only be able to hear some residents if they were to holler for help.<BR/>In an interview on 08/22/2024 at 5:30 PM, Interim DON stated the call bells should be within reach at all times. She stated the staff have received in-services on call bells and she has started making rounds in the facility to monitor compliance. She stated when the call bell is not within reach it places the resident at risk for injury and not being able to get what they need. <BR/>Review of in-service training, dated 03/27/2024, reflected call lights are everyone's responsibility and something anyone can help with. The training reflected the staff are to make sure call bells are within reach every time the staff enter and exit the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 4 of 8 (Resident #12, Resident #18, Resident #25, and Resident #28) residents reviewed for ADL care. <BR/>1. The facility failed to ensure Resident # 12, Resident #18, Resident #25, and Resident #28 nails were cleaned and did not have any rough edges. <BR/>These failures placed residents at risk of a decline in their hygiene, loss of dignity and decreased quality of life.<BR/>Findings included: <BR/>1. Record review of Resident # 12's Face Sheet dated, 08/22/2024, reflected a [AGE] year-old male admitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), anxiety disorder (worry endlessly over everyday issues such as health, money, family problems-even if the person realizes there's little cause for concern). <BR/>Record review of Resident #12's Quarterly MDS Assessment, dated 07/19/2024, reflected the resident had a BIMS score of 07 indicated his cognition was severely impaired. Resident #12 required assistance with personal hygiene, dressing, transfers, and showers/bathing. Resident #12 had a behavior problem of picking at skin on his hand. <BR/>Record review of Resident #12's Comprehensive Care Plan, dated 08/14/2024 reflected Resident #12 had an ADL self-care performance deficit. Intervention: Resident required assistance with personal hygiene, dressing, transfers, bed mobility, and toileting. <BR/>Observation on 08/20/2023 at 10:50 AM, Resident # 12's nails was rough around the edges on his right hand. He also had blackish substance underneath his nails on his middle and ring fingers on his right hand. Resident was sitting in wheelchair in his room. There was an odor of feces on residents' fingers. <BR/>In an interview on 08/20/3034 at 10:53 AM, Resident #12 stated he sometimes scratched his bottom at night and he got poop ( a word for feces) on my fingers. He stated he asked someone to clean it last night and the lady said she would come back and clean his fingers. Resident #12 said no one came back to his room. He did not respond to questions about his fingernails being rough around the edges. <BR/>2. Record review of Resident # 18's Face Sheet dated, 08/22/2024, reflected a [AGE] year-old female admitted on [DATE] and readmitted on [DATE] diagnoses of : type two diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), muscle weakness- generalized (loss of muscle strength), combined forms of age-related cataract, bilateral ( when the lens in both eyes becomes cloudy from age, injury or disease), other lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), hemiplegia , unspecified affecting left non dominant side ( left side paralysis- the loss ability to move).<BR/>Record review of Resident #18's Quarterly MDS Assessment, dated 07/18/2024, reflected Resident #18 had a BIMS score of 10 indicated her cognition was moderately impaired. She required assistance from staff with personal hygiene, dressing, transfers, eating and bathing. <BR/>Record review of Resident #18's Comprehensive Care Plan, dated 07/31/2024, reflected Resident #18 wished to have long fingernails. Intervention: keep fingernails smooth and clean. Monitor for any skin impairments related to long fingernails. Resident #18 makes poor safety choices. Intervention: Attempt to monitor Resident #18 in regard to safety choices that place resident at risk. Educate Resident #18 on risks associated with poor safety choices. Resident #18 had an ADL self-care performance deficit. Intervention: Resident #18 was dependent on staff for personal hygiene. <BR/>Observation on 08/20/2024 at 11:15 AM, Resident #18 was in her room sitting in wheelchair. Resident #18 nails were approximately 1-2 inches long on both hands. Resident #18's left hand had nails on her ring finger, middle finger, and fore finger rough around the edges. <BR/>In an interview on 08/202/2024 at 11:17 AM, Resident #18 stated she preferred her nails long but wanted her nails to be filed so they would not be so uneven and rough. She stated she always had a lot of pride in her fingernails and loved them long but did not prefer them to be unkept with not being filed. Resident #18 stated she was not able to file her nails any longer. She stated she asked someone on Saturday and on Sunday to file her nails and both of the ladies that worked at this facility told her that was not their job she would need to speak to the person who does activities she was the only staff that filed nails. Resident #18 stated she scratched her arm a little with one of her nails as she pointed to her right arm. <BR/>Observed on 08/20/2024 at 11:19 AM, Resident #18's right arm and there was a small scratch, however, it was not a skin tear. <BR/>3. Record review of Resident #25's Face Sheet, dated 06/17/2024, reflected a [AGE] year-old male admitted on [DATE] with a diagnoses of lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), age-related physical debility ( frail patients often present with symptoms including weakness, fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), and anxiety disorder due to known physiological condition ( when anxiety symptoms (startle easily and can't relax) are a direct result of a physical health problem).<BR/>Record review of Resident #25's admission MDS Assessment, dated 06/21/2024, reflected Resident #25 had a BIMS score of 9 indicated Resident cognition was moderately impaired. He required assistance with personal hygiene, showers, dressing and toileting hygiene. <BR/>Record review of Resident #25's Comprehensive Care Plan, dated 07/12/2024, reflected Resident #25 had an ADL self-care performance deficit. Intervention: Resident #25 required assistance with personal hygiene, toileting hygiene, showers, and dressing. Resident #25 was resistive to care related to anxiety (startle easily and can't relax) he will refuse turning and repositioning and repositioning to offload areas and therapy participation sometimes. Intervention: Allow Resident #25 to make decisions about treatment regimen, to provide sense of control. Resident #25 had a communication problem related to aphasia ( a language disorder that affects a person's ability to understand and express language, including reading and writing). Resident #25 had a mood problem anxiety related to disease process of CVA ( a medical conditions that occurs when blood flow to the brain is suddenly cut off - this diagnosis was not listed on the face sheet) Intervention: Monitor/record/ report to medical doctor as needed acute episode feelings or sadness; feelings of worthlessness or guilt or change in psychomotor (movement-oriented activities that require practice and involved characteristics such as coordination, strength, speed and flexibility).<BR/>Observation on 08/20/2024 at 11:30 AM, Resident #25 was lying in bed. His nails were approximately three inches long on all fingers on both hands. All of his fingernails on the left hand were rough around the edges. His right hand had blackish substance of a bowel movement (the process of moving waste through the intestines after eating or drinking) odor. There was a blackish substance on the tips of his middle and forefinger on his right hand. Resident #25 had a blackish substance underneath his nails on his fore finger, middle finger, and ring finger of the right hand. <BR/>Attempted interview on 08/20/2024 at 11:34 AM, Resident #25 did not want to be interviewed.<BR/>Attempted interview on 08/20/2024 at 3:05 PM, Resident #25 did not want to be interviewed. <BR/>4. Record review of Resident # 28's Face Sheet, dated, 08/22/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of type 2 diabetes mellitus without complications (high levels of blood glucose can damage the blood vessels and nerves that control the heart), lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), unspecified dementia, unspecified severity, with anxiety ( a condition in which a person loses the ability to think and solve problems. Unspecified severity- a medical classification for dementia that does not have a specific diagnosis and does not have a specified severity. Anxiety with dementia- often related directly to worries about coping with the condition and what the future holds).<BR/>Record review of Resident #28's admission MDS Assessment, dated 07/27/2024, reflected Resident #28 had a BIMS score of 6 indicated his cognitive status is severely impaired. He required assistance with bathing, dressing, personal hygiene, and transfers. <BR/>Record review of Resident #28's Comprehensive Care Plan, dated 08/14/2024, reflected Resident #28 needed had an ADL self-care performance deficit. Intervention: Resident #25 required assistance with personal hygiene, toileting hygiene, showers, and dressing.<BR/>Observation on 8/20/2024 at 1:03 PM, reflected Resident # 28 was sitting in his wheelchair in his room. He had approximately 2-3 inches of long nails on his right and left hand. Resident #28's forefinger nail had a sharp nail only in the corner of the finger on his left hand. Resident #28's ring finger, thumb, small finger, and middle fingernails on his left hand was rough around the edges. Resident #28 had a very long nail approximately 4 inches long on his right hand. Resident #28 right hand had a sharp nail and rough around the edges in the corner of his ring finger. His right-hand fingernails on his middle finger and fore finger had a blackish substance underneath these nails. There was an odor of bowel movement (the process of moving waste through the intestines after eating or drinking) odor. <BR/>In an interview on 08/20/2024 at 1:06 PM Resident #28 stated when he nails gets long and he can not find anyone to cut his nails, he will bend his nails until they break. He stated that is why you see that sharp nails in the corners. Resident #28 also stated when he bends his nails they don't break smoothly and causes a sharp point on some of his nails. He stated if someone does not want to cut his nails he will do it himself. Resident #28 stated he was a diabetic (high levels of blood glucose can damage the blood vessels and nerves that control the heart), and he knew his nails may become infected if his nails was not cut properly. Resident #28 stated he did have to use the bathroom last night and did have poop (a slang word for feces- waste matter from the bowels after food had been digested) to come out his bottom. Resident #28 stated he did scratch his bottom and got poop on his hands and he tried to get most of it off his hand (he raised his right hand when he was discussing where the poop was located). <BR/>In an interview on 08/22/2024 at 1:30 PM, ADON G stated if a resident had rough edges around the nail there was a possibility the resident may scratch themselves or someone else and develop a skin tear. She stated if a resident ingested blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria. She stated a resident may develop a stomach illness with symptoms of diarrhea and vomiting. ADON G stated it was according to what the bacteria was to determine if a resident would become ill. ADON G stated the nurses completed all nail care for residents with a diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart). She stated if a staff was not certain if they were to file someone nails the staff was expected to ask their nurse supervisor. ADON G stated all residents was expected to receive nail care during showers and as needed. She stated it was the nurse supervisor responsibility to monitor nail care. ADON G stated she would need to review the electronic medical record to determine if any residents refused nail care. <BR/>In an interview on 08/22/2024 at 4:45 PM, CNA K stated the nurses completed all diabetic (high levels of blood glucose can damage the blood vessels and nerves that control the heart) fingernails and the CNAs were responsible for all other residents' nails. CNA K stated the CNAs were responsible to complete nail care such as trimming, filing, and cleaning the nails during showers and as needed. CNA K stated if a resident had blackish substance underneath their nails, it was probably some type of bacteria such as bowel movements (the process of moving waste through the intestines after eating or drinking). She stated if a resident swallowed bacteria it was a potential the resident may become ill and may develop major stomach problems such as diarrhea or vomiting. CNA K stated if a resident became severely ill the resident may need to be transferred to emergency room for more care. She stated she worked with Resident #12, Resident #18, Resident #25, and Resident #28. CNA K stated the only resident she knew resisted care was Resident #25. CNA K stated Resident #25 resisted being turned or repositioned she was not aware of him refusing nail care. and Resident #31, and she was not aware of them refusing nail care. She stated if a resident's nails were rough around the edges there was a possibility the resident may scratch themselves and develop a skin tear, or possibly scratch their eye and cause a tear on their eyeball. CNA K stated she had been in-service on nail care but did not remember the date of the in-service. <BR/>In an interview on 08/22/2024 at 5:05 PM, CNA C stated the CNAs was responsible for cleaning, trimming, and filing all residents' nails except for the residents with diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart) and the nurses was responsible for residents with diabetes. CNA C stated the nurses was responsible for all residents' nails with diagnosis of diabetes. CNA C stated if a resident had a rough nails or their nails were dirty, nail care was expected to be completed as needed. CNA C stated if a resident nails was rough around the edges there was a possibility a resident may scratch themselves or another resident. CNA C stated the scratch may develop into a skin tear. CNA C stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill with stomach issues such as vomiting. She stated she worked at this facility as needed. CNA C also stated she had given care to Resident # 28, Resident #12, Resident #18, and Resident #25. She stated she was not aware of any of these residents refusing nail care. She stated she had been in-serviced on nail care but did not recall the date. <BR/>In an interview on 08/22/2024 at 5:35 PM, LVN A stated the nurses and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes (high levels of blood glucose can damage the blood vessels and nerves that control the heart). LVN A stated it was the CNAs responsibility to clean and trim all other residents' nails. She stated she was not aware of Resident #10, Resident #28, Resident #12 or Resident #25 refused nail care. She stated Resident # 25 would refuse to be turned or off load his heels but not nail care. LVN A stated if there was a blackish substance underneath the residents' nails, there was a possibility the substance had bacteria underneath the residents' nails. She stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea and vomiting. LVN A stated if a resident scratched themselves with rough nails there was a potential a resident may develop a skin tear and there was a possibility the resident may scratch another resident and cause a skin tear on another resident. She stated she had been in-serviced on nail care but did not recall the date of the in-service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored, individual activities, independent activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident , encouraging both independence and interaction in the community for 3 of 8 residents ( Resident #10, Resident #19, and Resident #25) reviewed for activities. <BR/>The facility failed to develop an activity program based on preferences of Resident #10, Resident #19, Resident #25 during the months of July to August 2024. <BR/>These failures placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life. <BR/>Findings include:<BR/>1. Record review of Resident #10's Face Sheet, dated 08/22/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis depression unspecified (used when a person's symptoms do not clearly align with a specific mental disorder or where there is insufficient information for a more definitive diagnosis), other secondary parkinsonism ( caused by brain injuries or brain disorders), and cognitive communication deficit (can effect both verbal and nonverbal communication, such as speaking, listening, reading, writing, and social interaction skills).<BR/>Record review of Resident #10's Annual MDS Assessment, dated 01/30/2024, reflected Resident #10 was rarely/never understood. She had poor short (unable to recall after 5 minutes and long (unable to recall long past memories) term memory recall. Resident #10 does not have speech (absence of spoken words). Resident #10 activity preferences was listening to music and participating in religious activities or practices. <BR/>Record review of Resident #10s Quarterly MDS Assessment, dated 07/30/2024, reflected Resident #10 had poor short (unable to recall events after 5 minutes) and long-term memory recall (unable to recall past events). Resident #10 was rarely/ never understood or rarely/never understands others. <BR/>Record review of Resident 10's Comprehensive Care Plan, dated 08/14/2024, reflected Resident #10 required staff assistance for meeting emotional, intellectual, physical, and social needs related to disease process and immobility. Intervention: Resident #10 needed in-room visits and activities. <BR/>Record review of Resident #10's in room activity participation record in the electronic medical record reflected Resident #10 did not have any documentation of receiving in room activities or attending group activities. The record review was completed with the Activity Director M. She stated she did not have any participation records on Resident #10.<BR/>Observation on 8/20/2024 at 10:31 AM. Resident #10 was sitting in the lobby asleep. <BR/>Observation on 08/20/2024 at 4:00 PM, Resident #10 was in bed. Her door to her room was slightly opened. Resident #10 was awake there was no lights on in her room. Television was not on and did not observe any radio in her room which music was her favorite activity. Resident #10's room was dark and she was moving her eyes side to side. Resident had sad expression (forehead wrinkled and eyebrows were brought together -signs of sad expression). <BR/>In an interview on 8/20/2024 at 4:05 AM, Resident #10 was not interview able. <BR/>Observation on 08/21/2024 at 7:45 AM, Resident #10 was in bed. Her door to her room was slightly opened. Resident #10 was awake and there were no lights on in her room and no stimulation such as a radio in her room which is her favorite activity listening to music. Resident #10 did not have television on in room. <BR/>In an interview on 8/21/2024 at 8:15 AM, Activity Director M stated she did not have any in room or group participation records for the month of July 2024 and August 2024 for Resident #10. She stated she would print all of the in-room participation records for the months of July 2024 and August 2024<BR/>In an interview on 08/21/2024 at 8:45 AM, Activity Director M stated after the activity in room participation records were printed Resident #10 did not have any in room or group participation records for the months of July 2024 or August 2024. She stated she did not know if she received in room activities or attended group activities during the months of July 2024 and August 2024. Activity Director M stated if a resident had a diagnosis of depression and was not physically able to do activities without assist from another person, there was a possibility Resident # 10 may become more depressed and may become very lonely. She stated Resident #10 quality of life may decrease. She stated Resident #10 does sit in the lobby but sleeps most of the time and she was not receiving any activities in the lobby. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. <BR/>2. Record review of Resident #19's Face Sheet, dated 08/22/2024, reflected a 94- year-old female admitted to the facility on [DATE] with diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition in which a person loses the ability to think and solve problems. Unspecified severity- a medical classification for dementia that does not have a specific diagnosis and does not have a specified severity), major depressive disorder ( feelings of guilt or worthlessness, lack of energy, agitation ( unable to stay calm) and /or sleep disturbances), and unspecified glaucoma (a group of eye diseases that cause increased pressure in the eye, which can damage vision). <BR/>Record review of Resident #19's admission MDS Assessment, dated 10/18/2024, reflected Resident #19 had a BIMS score of a 15 indicated her cognition was intact. Resident #19's activity preferences were the following: go outside and get fresh air when weather permitted, participate in religious services or practices, listen to music, reading such as: books, newspapers, and magazines. Participating in groups activities was not very important to Resident #19. <BR/>Record review of Resident #19's Quarterly MDS Assessment, dated 07/17/2024, reflected Resident #19 had a BIMS score of 15 indicated her cognition was intact. Resident #19 had moderately impaired vision- not able to see newspaper headlines but can identify objects. She was assessed to feel down, depressed, or hopeless. Resident #19 also felt tired and bad about herself, had difficulty concentrating on things such as: reading or watching television. <BR/>Record review of Resident #19's Comprehensive Care Plan, dated 07/31/2024, reflected Resident #19 required staff assistance for meeting emotional, intellectual, physical, and social needs related to immobility. Intervention Resident #19 needed in room visits and activities if unable to attend out of room events. Resident was resistive to care related to adjustment to nursing home and dementia (a condition in which a person loses the ability to think and solve problems). Resident #19 refused to get out of bed. Intervention: All Resident #10 to make decisions about treatment regime, to provide sense of control. Resident #19 had impaired cognitive function/dementia (a condition in which a person loses the ability to think and solve problems). Intervention: Reminisce with Resident #19 using photos of family and friends. <BR/>Observation on 8/20/2024 at 11:30 AM, Resident #19 was in her room lying in bed. The door to her room was barely opened and she did not have television on and did not see a radio or other stimulation in her room. Resident #19 had sad expression on her face such as (forehead wrinkled, and eyebrows were brought together -signs of sad expression). Resident #19 was staring toward the ceiling. <BR/>In an interview on 08/202/2024 at 11:33 AM, Resident #19 stated she was lonely and there was not anything for her to do except watch television and she was tired of television. She stated she did not receive in room visits or activities from anyone and she did not know what in room visits or in room activities was until now. Resident #19 stated she never heard of in room activities. Resident #19 stated she did not prefer to attend group activities it made her feel uncomfortable being around others in a group. She stated if someone would just bring her a radio or something for her to listen to music. Resident #19 stated she loved Gospel music and liked country music. She stated if there was gospel or country music on television she never knew about it or ever saw it on television. Resident #19 stated music was her favorite thing to do. She stated she never liked to read very much due to her vision. Resident #19 stated her neighbor had books on tape and her neighbor would listen to different types of books. Resident #19 stated she might enjoy listening to books but she would need to try it before she made decision if she liked to listen to books. Resident #19 stated no one had ever offered her anything to read and with her poor vision it would need to be very large print. Resident #19 stated she did like to go outside in the spring and fall sometimes. She stated she did not recall anyone assisting her to sit outside. Resident #19 stated that would be nice sometimes not every day or every week but maybe once or twice a month when weather was cooler. She stated she did like to listen to devotionals. She stated it would be nice if someone read the bible to her or a devotional to her once a week. Resident #19 stated there is never anything to do and no one comes by and will sit and talk to me. She stated do you think you can talk to someone and ask them if they would visit with me sometimes and bring me something to do instead of watching television all the time. <BR/>In an interview on 08/21/2024 at 8:15 AM, Activity Director M stated Resident #19 was not on the in-room activity program. She stated she did not realize Resident #19 was not getting out of bed very often. The Activity Director M stated she did not have any participation records for Resident #19 during months of July 2024 and August 2024. She stated she had not been reminiscing using photos of Resident #19's family and friends. Activity Director M stated if Resident #19 did not want to attend group activities she needed to be receiving in room activities. Activity Director M stated she did not realize it was on Resident #19's care plan she was to receive in room activities reminiscing about family or friends' photos. She stated Resident #19 had a potential of becoming bored and depressed if she was not doing the activities she preferred or not doing any type of activities in her room. Activity Director M stated she had not been offering her large print books to read, books on tape or a radios. She stated if music, religious activities and going outside was her favorite activities these type of activities was expected to be provide to Resident #19. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. <BR/>3. Record review of Resident #25's Face Sheet, dated 06/17/2024, reflected a [AGE] year-old male admitted on [DATE] with a diagnoses of lack of coordination (a problem with movement that can manifest in a variety of ways, such as difficulty with fine motor skills), age-related physical debility ( frail patients often present with symptoms including weakness, fatigue, medical complexity, and reduced tolerance to medical and surgical interventions), muscle weakness (loss of muscle strength), muscle wasting and atrophy, not elsewhere classified, other site ( muscle atrophy - the wasting or thinning of muscle mass, muscle wasting- weakening, shrinking, and loss of muscle caused by disease or lack of use), and anxiety disorder due to known physiological condition ( when anxiety symptoms (startle easily and can't relax) are a direct result of a physical health problem).<BR/>Record review of Resident #25's admission MDS Assessment, dated 06/21/2024, reflected Resident #25 had a BIMS score of 9 indicated Resident cognition was moderately impaired. Resident#25's activity preference was the following: have books, newspaper, and magazines to read, listen to music, watching news, go outside to get fresh air when the weather was good, and participating in religious services or practices.<BR/>Record review of Resident #25's Comprehensive Care Plan, dated 07/12/2024, reflected Resident #25 had a mood problem anxiety related to disease process of CVA ( a medical conditions that occurs when blood flow to the brain is suddenly cut off - this diagnosis was not listed on the face sheet) Intervention: Monitor/record/ report to medical doctor as needed acute episode feelings or sadness; feelings of worthlessness or guilt or change in psychomotor (movement-oriented activities that require practice and involved characteristics such as coordination, strength, speed and flexibility). Resident # 25 had impaired cognitive function/dementia or impaired thought process (a condition in which a person loses the ability to think and solve problems). Intervention Reminisce with Resident #25 using photos of family and friends. <BR/>Observation on 08/20/2024 at 11:30 AM, Resident #25 was lying in bed. The lights were off in his room and the door was slightly open leading into his room. He did not want to discuss anything about his nails. He made eye contact with Surveyor O when mentioned in room activities or in room visits. Resident #25 also clinched his mouth / jaw (sign of stress) when surveyor O mentioned if he received in room visits talking about pictures of his family and friends. Resident #25 did not have any stimulation in his room. <BR/>Interview on 08/20/2024 at 11:34 AM, Resident #25 stated no when asked if he received activities or visits in his room showing him pictures of his family and friends. Resident #25 stated no when asked if he liked to do anything with a group of people. <BR/>In an interview on 08/21/2024 at 8:15 AM, Activity Director M stated Resident #25 was on the in-room activity program due to Resident #25 did not attend group activities. She stated her schedule was to visit all in room residents Monday to Friday in the morning. Activity Director M stated according to Resident #25's participation records he only received two in room activities during the month of July 2024 and did not receive any in room activities during month of August 2024. She stated Resident #25 had a potential of becoming depressed, lonely and may have a decrease of quality of life. She stated she had not reminisced with Resident #25 with photos of his family and friends. She stated Resident #25 was expected to receive in room visits/ activities Monday thru Friday. Activity Director M stated she did not have any excuse why she did not visit Resident #25 to provide in room activities/ visits. She stated it was her responsibility to ensure all residents received activities according to their past and current interest. <BR/>In an interview on 08/22/2024 at 2:05 PM, the Administrator stated all activities including in room visits was expected to be documented on the date the activity occurred with the residents. She stated if the Activity Director M did not document any activities, the activity did not occur with the resident or residents. The Administrator stated a resident may become depressed, lonely and have a diminish quality of life if they were not receiving activities of their preferences on a daily or weekly basis. She stated she had been in this facility approximately two weeks and would definitely be making observations of the activity programming. <BR/>Record review of the Facility's Policy on Activity Programs, revised on 06/2018, reflected activity programs are designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident -centered assessment and the preferences of each resident. All activities are documented in the resident's medical record.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. <BR/>1. The facility failed to appropriately thaw frozen meant defrost on 08/20/2024. <BR/>2. The facility failed to store boxes of food off the floor, ensure the floor of the refrigerator was free of debris in the walk- in refrigerator on 08/20/2024.<BR/>3. The facility failed to ensure Dietary Aide P washed or sanitized her hands prior to placing new gloves on her hands when she was giving a resident some zip lock bags on 08/21/2024. <BR/>These failures placed residents at risk for health complications and foodborne illness. <BR/>Findings included: <BR/>Observation on 08/20/2024 at 9:05 AM, there was approximately 10 pound of frozen hamburger meat in a clear plastic round tube shape located in a pot sitting in the kitchen sink. The hamburger meat was not thawed and more than half was frozen. There was not any running water over the frozen hamburger meat. There was approximately half of the frozen hamburger meat not submerge in the water. Only half of the hamburger meat was submerged in the water. <BR/>In an interview on 08/20/2024 at 9:08 AM, Dietary Aide P stated all the hamburger meat was required to be in the water to be defrosted. She stated running water was also expected to be running over the hamburger meat while it was being defrosted. Dietary Aide P stated she forgot to run the water over the hamburger meat and place the hamburger meat in a larger pot. Dietary Aide P stated she was in a hurry and forgot. She stated if the hamburger meat was not defrosted properly there was a possibility the hamburger meat may be ruined from being defrosted at room temperature. She stated it was a possibility a resident may become ill with stomach issues if the resident ate ruined meat. <BR/>2. Observation on 08/20/2204 at 9:13 AM, there were four boxes of food stacked on top of one another located in the walk-in refrigerator floor. There were also some paper napkins on the floor and one was stuck to the surveyors shoe. In the corner of the walk-in refrigerator was some type of crumbled food. <BR/>3. Observation on 08/22/2024 at 11: 15 AM, Dietary Aide P removed gloves from her hand and placed them in garbage can. She did not wash or sanitize hands after removing the gloves. Dietary Aide P touched her clothes and picked up 2 new gloves from the glove container. She touched the outside of the gloves such as fourchettes (slender pieces of fabric or rubber that forms the sides of the finger). Dietary Aide P placed the gloves on her hands and picked up approximately 3 zip plastic bags and placed her fingers inside two of the plastic bags and gave it to a resident.<BR/>Interview on 08/22/2024 at 11:20 AM, Dietary P stated she did touch her shirt after she removed her gloves. She stated she did not sanitize or wash her hands prior to placing new gloves on her hands. Dietary aide stated she did pick up the gloves where the fingers go inside the gloves. She stated she was expected to wash her hands prior to placing new gloves on her hands. Dietary Aide P stated she had been in-serviced on hand hygiene and wearing gloves when changing tasks or touching anything not sanitary. <BR/>Interview on 08/22/2024 at 2:05 PM, the Administrator stated all boxes located in the walk-in refrigerator was expected to be on a crate or on the shelves. She stated no boxes was to be stored on the floor of the refrigerator. She stated the boxes may become damp and the food inside of the boxes had a potential of being wet or damp. She also stated it was a possibility of a safety hazard if the boxes were stacked on each other they could fall and injure a staff. The Administrator stated all frozen meat was required to be defrosted on a flat pan located in the refrigerator on the bottom shelf. She stated if the dietary staff was defrosting hamburger meat in the sink all of the hamburger meat was expected to be submerged in water with running water pouring over the frozen hamburger meat. She stated it was a possibility the meat may ruin if not defrosted correctly but there was a slight chance of this occurring when defrosting. The Administrator stated all staff was to wash and sanitize their hands when they removed gloves and prior to placing new gloves on their hands. She stated if the dietary aide P did not sanitize her hands and touched inside the zip plastic bags to give to a resident there was a possibility the bags could become cross contaminated. She stated there should not be any paper napkins on the floor in the walk-in refrigerator. The Administrator stated all areas of the kitchen including walk-in refrigerator was expected to be kept clean and organized. <BR/>In an interview on 08/22/2024 at 3:45 PM, Dietary Manager L stated all meat was required to be defrosted either in the refrigerator on a flat pan located on the bottom shelf of the refrigerator or in the sink in a container with running water pouring over the meat. She stated the hamburger meat was to be submerged in the pot and be defrosted with running water over the entire hamburger meat. Dietary Manger L stated there was a possibility the portion of the hamburger meat not submerged in the water would not be defrosted correctly and may cause illness with a resident if the hamburger meat was ruined. She stated any time dietary staff removes their gloves they were expected to wash their hands immediately before doing any other type of task including placing new gloves on their hands. Dietary Manger L stated if Dietary Aide P touched the outside of the new gloves with her contaminated hands there was a possibility bacteria could cross contaminated inside of the plastic bags. She stated if the resident was placing food inside of those bags there was a potential where bacteria touch the food. Dietary Manger L stated if a resident ate contaminated food the resident may become sick with any type of stomach issues such as vomiting and diarrhea. She stated the boxes located in the walk-in refrigerator was not to be stored on the floor. She stated they were expected to be stored on pallets or on the shelves in the refrigerator. Dietary Manager L stated this had a potential of becoming a safety hazard due to the boxes was stacked on top of each other and if they feel a staff may become injured. She stated there should never been any type of napkins or paper on the floor in the walk-in refrigerator or anywhere in the kitchen. Dietary Manager L stated this was not sanitary. She stated there should never be any type of food on the refrigerator floor. She stated this was also not sanitary. <BR/>Review of the facility policy on Food Preparation and Service, dated 10/2022, reflected Foods will not be thawed at room temperature. Thawing procedures include:<BR/>a. Thawing in the refrigerator in a drip-proof container.<BR/>b. Completely submerging the item in cold running water (70&deg;F or below) that is running fast enough to<BR/>agitate and remove loose ice particles.<BR/>c. Thawing in a microwave oven and then cooking and serving immediately; or<BR/>d. Thawing as part of a continuous cooking process<BR/>Facility policy of Refrigerators and Freezers, dated 10/2022, reflected This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on scheduled basis and more often as necessary.<BR/>Facility policy on Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, reviewed 06/12/2024, reflected Food and nutrition services employees will follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection and prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Resident #1, Resident #11, Resident #28, Resident #4, and Resident #17) of 35 residents reviewed for infection control. <BR/>1. LVN B failed to clean the reusable blood pressure (BP) cuff between resident use. <BR/>2. LVN A failed to perform hand hygiene and clean the catheter tip before performing catheter irrigation for Resident #17's suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen)<BR/>3. The facility failed to ensure LVN I sanitized or washed her hands after touching contaminated items when delivering meal trays to residents, when setting up Resident #1, Resident #11 and, Resident #28's meal trays and during feeding of Resident #11 on 08/20/2024.<BR/>These failures could place residents at risk for cross contamination and infection.<BR/>Findings include:<BR/>1. Review of Resident #4's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis or severe weakness in one side of the body) and cerebral infarction (stroke). <BR/>Review of Resident #4's Optional MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Review of Resident #4's Care Plan reflected resident requires staff assistance for meeting needs and has hypertension requiring BP monitoring and medication. <BR/>Observation during med pass on 08/21/2024 at 08:30 AM, revealed LVN B checked the vital signs for Resident #6 and placed the BP cuff back on the medication cart without cleaning it. She then used the BP cuff to take vital signs for Resident #4 without cleaning the cuff first. <BR/>In an interview on 08/21/2024 at 08:36 AM, LVN B stated she should have cleaned the BP machine in between resident use but didn't. She stated it is policy to clean it before and after use because of the germs and risk for infection. <BR/>2. Review of Resident #17's face sheet reflected an [AGE] year old male admitted to the facility on [DATE] and again on 09/02/2022 with diagnoses of incomplete quadriplegia ( paralysis that affects a person's limbs and body from the neck down), chronic obstructive pulmonary disease (a group of lung disease that blocks airflow and makes it difficult to breathe), and overactive bladder (a problem with bladder function that causes the sudden need to urinate).<BR/>Review of Resident #17's care plan, dated 07/16/2024, reflected resident has a suprapubic catheter and foley care should be provided every shift and as needed. <BR/>Review of Resident #17's orders, date 07/17/2024, reflected an order to flush the catheter with 120-180 milliliters of sterile water every other day. <BR/>Observation on 08/21/2024 at 09:56 AM, during suprapubic catheter irrigation procedure for Resident #17 revealed LVN A sanitize her hands and don gloves and gown. She placed the irrigation tray and supplies on the bedside table, opened the kit and then disconnected the draining bag from Resident #17's catheter and handed it to the resident to hold. She then poured the sterile water into the container and drew up some in the syringe. She connected the syringe to the catheter without cleaning the catheter tip first. She then began attempting to flush the catheter. She was not able to flush the catheter and called for assistance. She then reconnected the old drainage bag to the catheter while waiting for assistance. <BR/>In an interview on 08/21/2024 at 11:10 AM, LVN A stated she forgot to clean the catheter before and after she attempted irrigation and reconnected the old bag. She stated not cleaning her hands and the catheter before irrigation placed the resident at risk for bladder infection. <BR/>In an interview on 08/22/2024 at 5:30 PM, the interim DON stated reusable medical equipment should be sanitized before every use to prevent the spread of infection. She stated she would expect staff to follow procedure for aseptic technique during catheter irrigation to prevent the spread of infection. <BR/>In an interview on 08/22/2024 at 5:50 PM, the Administrator stated the BP cuff should be cleaned in between residents for infection control. She stated she is not a nurse but would expect staff to follow procedure for catheter flushing to prevent the resident from getting an infection. <BR/>Review of facility policy for reusable medical equipment, dated 03/2023, reflected items that come in contact with intact skin but not mucous membranes, such as BP cuffs, should be cleaned and disinfected between residents. <BR/>Review of facility policy for catheter care, dated March 2024, reflected staff should use aseptic technique when there is a break in the closed system and clean technique when handling the catheter, tubing, or drainage bag. The policy does not specifically address the procedure for catheter irrigation. <BR/>3. Observation on 09/20/2024 at 12:13 PM to 12:35 PM, reflected LVN I entered the dining room from the hall. She touched her clothes and moved her hair away from her face. LVN I began to speak to residents and touched the residents' clothes and wheelchair handles. She began to look at the meal trays on the meal tray cart. LVN I picked up one lid of a meal tray and touched the tines ( the pointed prongs that allow you to spear and pick up the food) of the fork of Resident #28's meal tray. LVN I delivered Resident #28's meal tray to him in the dining room and did not change his fork. LVN I returned to the meal tray cart and did not sanitize her hands. She had the meal tray and touched the dirty dishwasher doorknob to enter the dishwasher room and placed meal tray on top of dirty plates and the middle finger, forefinger and ring finger touched dirty dishes in the dishwasher room. She exited the dishwasher room and proceeded to the meal cart without sanitizing or washing her hands. She picked up a meal tray off the meal cart and delivered the meal tray to Resident #1. When LVN I sat the meal tray on the table in front of Resident #1 she opened the thickened liquid water and the top part of her middle finger and fore finger on her right hand touched inside the container and touched the thickened water. LVN J asked LVN I to go into the hall and sanitize her hands. LVN I did not go into the hall to sanitize her hands or attempt to wash her hands. LVN I continued to pass out meal trays. LVN I delivered Resident #11's meal tray to her. She touched resident's hand and her specialty chair. LVN I opened Resident #11's thickened liquid and her forefinger and middle finger touched the thickened liquid and when she removed the lid off of Resident #11's plate of food she touched the green beans. After setting up the meal tray LVN I sat in a chair to begin to feed Resident #11. LVN I was given hand sanitizer and did sanitize her hands prior to feeding Resident #11. During feeding Resident #11, LVN I touched with her fore finger, ring finger and middle finger on her right hand the following: the arms of the chair she was sitting in, touched her own clothes and touched Resident #11's Hoyer lift sling to reposition the sling in Resident #11's chair. She also touched Resident #11's right hand. LVN I did not re-sanitize or wash her hands. LVN I picked up Resident #11's napkin to wipe off Resident #11's mouth. When LVN I wiped Resident #11's mouth she touched the side of Resident #11's upper lip with her fore finger and middle finger on her right hand. LVN J was sanitizing her hands every time she touched the table, chair or any object may be considered contaminated. She was feeding Resident #3.<BR/>In an interview on 08/20/2024 at 1:33 PM, LVN I stated she never sanitized her hands during the time she was passing out meal trays and setting up meal trays for the residents. LVN I stated she was expected to sanitize or wash her hands when passing out meal trays and when she was setting up meal trays for the residents. She stated she did not recall if she touched the tips of the fork, napkins, inside the thickened liquids container for Resident #1 and Resident #11. LVN I stated she did touch the door knob leading into the dishwashing room and she may have touched dirty dishes. She stated she did not recall touching her clothes, her hair, resident's wheelchair, or sling in Resident #11's specialty chair. She stated it was possible she did touch all of this but she was focused on delivering meal trays and feeding Resident #11 instead of what she was touching. LVN I stated it is impossible for staff to sanitize their hands if they touch anything may be contaminated. She stated the only time she sanitized her hands was when she sat on a chair to feed Resident #11. She stated she did touch arm of her chair; the sling Resident was sitting on in her specialty chair and possibly her own clothes. LVN I stated it is crazy to expect staff to sanitize their hands every time they touch an object that may be contaminated. She stated this was impossible. LVN I stated she did wipe Resident #11's mouth and she may have touched the side of her lip with her fingers. She stated if she had touched anything contaminated it was a possibility bacteria could cross contaminate onto the fluids, food, napkin, and Resident #11's mouth. LVN I stated she did not believe it was necessary to sanitize her hands every time she touched any type of object that may be contaminated. She stated staff would be sanitizing their hands every few seconds. LVN I stated she had been in-serviced on passing out meal trays and feeding the residents. She stated during in-service it was explained to wash or sanitize hands in between delivering meal trays to the residents and when feeding the residents. LVN I did not answer the question if a resident may become ill if they did ingest some type of bacteria that potentially transferred from her fingers or hands onto the resident's food or drink. <BR/>In an interview on 08/20/2024 at 00:00, LVN J stated she did ask LVN I to sanitize her hands. She stated LVN I did not sanitize her hands when she was passing out meal trays and setting up meal trays for residents. LVN J stated all staff was expected to sanitize or wash hands during each meal tray delivered to a resident. LVN J stated all staff was to sanitize their hands when they touch their hair, clothes or any object that was considered contaminated. She stated they had been in-serviced on hand hygiene during dining room service. LVN J stated she did not recall the date of the in-service. She stated if a resident did swallow some type of bacteria the resident had a potential of becoming physically ill such as vomiting or diarrhea. <BR/>In an interview on 08/22/2024 at 1:30 PM, ADON G stated all staff was expected to sanitize their hands prior to delivering meal trays and in between each meal tray delivered to a resident. She stated if staff touched any type of object such as doorknob, wheelchair, resident or staff clothes, hair, Hoyer sling, arms of a chair and/ or table, the staff was expected to sanitize or wash their hands after each contact with anything may be considered contaminated. ADON G stated if staff were not washing or sanitizing their hands during meal service and was touching residents' drinks, food or even plates it was a possibility bacteria may cross contaminate food, utensils such as fork and or the resident's plates. She stated if a resident ingested bacteria there was a possibility a resident may become sick with some type of food borne illness. She stated she had only been working at the facility about three weeks and she only knows about the in-services she had completed since she had been employed at this particular facility.<BR/>In an interview with the Administrator on 8/22/2024 at 2:05 PM, she stated all staff was expected to wash or sanitize hands prior and in between each meal tray delivered to the residents. She stated the staff was expected to sanitize or wash hands whenever they became in contact with anything considered contaminated such as: hair, clothes, dirty dishes, wheelchair, arms of a chair, etc. The Administrator stated there was a potential a resident may develop a food borne illness if a resident's food or drink was cross contaminated by bacteria on a staff fingers or hands. She stated she began working at this facility approximately two weeks ago and she was trying to look at a lot of things and the in-services been given in the past she had not looked at the in-services at this time and could not answer if an in-service had been given on dining room hand hygiene.<BR/>Review of facility policy for reusable medical equipment, dated 03/2023, reflected items that come in contact with intact skin but not mucous membranes, such as BP cuffs, should be cleaned and disinfected between residents. <BR/>Review of facility policy for catheter care, dated March 2024, reflected staff should use aseptic technique when there is a break in the closed system and clean technique when handling the catheter, tubing, or drainage bag. The policy does not specifically address the procedure for catheter irrigation. <BR/>Review of the Facility Policy of Hand Hygiene, revised on 10-2020 reflected This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare- associated infections. Use and alcohol-based hand rub containing at least 62 % alcohol; or , alternatively, soap and water for the following situations:<BR/>1. Before and after direct contact with residents.<BR/>2. After direct contact with a resident's intact skin.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 5 residents (Resident #4, Resident #14, Resident #31, Resident # 9, and Resident #8) out of 10 resident rooms reviewed for environment. <BR/>The facility failed to ensure walls and floors were clean and in good repair for Resident # 4, Resident #14, Resident #31, Resident #9, and Resident #8's room. <BR/>This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment. <BR/>Findings include: <BR/>Observation on 08/20/2024 at 03:10 PM in Resident # 4 and Resident # 14's room revealed large (approximately 2 ft) long holes in the wall behind Resident #14's bed. The bed was pushed up into the wall and there was a white powdery substance on the floor behind the bed. Observation in the room further revealed a cable outlet hanging from the wall next to the dresser. Behind Resident #4's bed there were holes in the wall, unable to see the size due to the bed. <BR/>In an interview on 08/20/2024 at 03:10 PM, Resident # 4 stated he did not know about the holes behind the bed, but he knew about damaged wall where the cable outlet was. He stated it had been that way for a while. Resident #14 was not interview able. <BR/>Observation on 08/20/2024 at 4:00 PM in Resident # 31's room revealed scratch marks and missing paint behind and next to the resident's bed. There was a brown substance on the floor and white debris on the floor. <BR/>Observation on 08/20/2024 at 4:10 PM, in Resident # 8 and Resident #9's room revealed missing trim and paint under the windowsill with exposed drywall. Resident # 8's bed was up against the wall under the window with pillows and bedding by the damaged wall. Observation behind Resident #9's bed revealed the bed pushed up into the wall with damaged drywall and white debris/powder on the floor. <BR/>In an interview on 08/20/2024 at 4:12 PM, Resident #9 stated she did not know about the holes behind her bed, but she knew they pushed the bed in the wall to get the door closed. <BR/>In an interview on 08/22/2024 at 4:45 PM, Housekeeping supervisor D stated debris falls on the floor every time the bed hits the wall. She stated they do their best to keep the floors clean, but she needs assistance from the nursing staff to move the resident's bed out of the way because she cannot do it herself. She stated they clean the rooms and floors everyday and try to deep clean often. She stated they do not have a floor crew anymore and she does the best she can with the staff they do have. <BR/>In an interview on 08/22/2024 at 5:00 PM, Maintenance supervisor E stated there have been damages to the walls since March of 2023. He stated he began working in the maintenance department in May of 2024 and started repairing the damaged walls using sheetrock that was previously ordered by someone else but realized it was the wrong material. He stated the administrator told him to hold off until they get the correct supplies. He stated the reason for the damaged walls was because there is no tolerance for door clearance if the bed is pulled away from the wall. He further stated the damaged walls were not homelike and could cause illness due to the drywall dust and could cause depression and make the residents feel unnoticed. He was not aware of the cable wire hanging from the wall and said he would take care of that immediately. <BR/>In an interview on 08/22/2024 at 5:50 PM, the Administrator stated they were working on fixing the holes in the walls. She stated she contacted a maintenance person from another building to assist. She stated they plan to replace the drywall and place some type of bumper on the walls to prevent further damage. She stated she is unsure how long the holes have been there and did not realize how big they were. She stated maintenance was scheduled to come back this week but delayed due to the survey. She further stated the damaged walls could cause potential harm or risk to the resident from the drywall dust and possible pest problem from the holes. She stated the damages are not homelike. Regarding the dirty floors she stated she has spoken with housekeeping already and expects the floors to be cleaned every day. <BR/>Review of facility Homelike Environment policy, dated February 2021, reflected residents are provided with a safe, clean, comfortable and homelike environment . the staff and management maximizes the characteristics of a homelike setting . including a clean, sanitary and orderly environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview, and record review the facility failed to ensure residents were free from abuse for 1of 8 residents (Resident #1) reviewed for Abuse.<BR/>The facility failed to ensure Resident # 1 was free from Abuse, as a result Resident #1 was assaulted by Resident #2 on two different occasions and was injured. <BR/>This failure placed all residents at risk for being assaulted by Resident # 2. <BR/>Findings included: <BR/>Review of Resident #1's face sheet reflected that he was a 62- year- old man, admitted to the facility on [DATE]. The face sheet reflected Resident # 1 had a diagnosis of Chronic Congestive heart failure (A chronic condition in which the heart doesn't pump blood as well as it should), Type 2 Diabetes with kidney complication ( a chronic condition that affects the way the body processes blood sugar), Chronic Kidney disease (A loss of kidney function) , Obesity (A disorder involving excessive body fat that increases the risk of health problems), age related cataract (when the lens you're the eyes start to break down and clump together), partial traumatic amputation ( when some of the soft tissue still remains) at knee level, left lower leg. <BR/>Review of Resident # 1's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15 which indicated Resident # 1 had the cognitive ability to make his wants and needs known. Section G functional status of the MDS reflected Resident # 1 required extensive assistance with toileting, bathing, dressing and transfers. <BR/>Review of Resident # 1's care plan dated 4/21/2023 reflected the following goal: Resident # 1 was at risk of loss of ROM (range of motion). Resident # 1 had the following goal: Resident # 1 will improve current level of function in ADL's. The plan had the following interventions<BR/>1. <BR/>Bed mobility: Supervision x1<BR/>2. <BR/>Transfer limited: Limited x1<BR/>3. <BR/>Toileting: Extensive x1<BR/>4. <BR/>Eating: Supervision with set up help<BR/>5. <BR/>Staff assist with ROM (range of motion) daily when direct care is provided to help prevent loss<BR/>Review of Resident # 2's face sheet reflected, a [AGE] year-old man, admitted to the facility on [DATE]. Resident # 2 had a diagnosis of Unspecified Dementia (A mental disorder in which a person loses the ability to think, remember, learn, make decisions, and sole problems) and Cognitive Communication deficit (difficulty with thinking and how someone uses language).<BR/>Review of Resident # 2's quarterly MDS, dated [DATE] reflected a BIMS score of 99 which indicated the interview was not able to be completed. Section G functional status of the MDS reflected Resident #2 required extensive assistance with dressing, total dependence with bathing, eating and some assistance with walking at least 50 feet with turns. <BR/>Review of Resident # 2's care plan dated 4/14/2023, focus Resident # 2 was evaluated as a wandering risk, decreased safety awareness, confusion, and wandering behavior. The care plan reflected the following goal. Resident # 2 will remain free of injuries associated with wandering behaviors. The plan had the following interventions: <BR/>1. <BR/>Encourage to participate in activities of preference <BR/>2. <BR/>Utilize a wander bracelet <BR/>3. <BR/>Observe fore signs/symptoms of agitation, pacing, repetitive verbalizations of wanting to leave, restlessness <BR/>4. <BR/>Provide re-orientation as needed<BR/>5. <BR/>Check wander guard by nurse for placement and function if wander guard is removed replace or place on increased <BR/>monitoring of resident's whereabouts <BR/> Resident # 2care plan reflected the following focus: Resident #2 has potential to be physically aggressive/Dementia. Goal: Resident # 2 will demonstrate effective coping skills. The care plan had the following interventions: <BR/>1. <BR/>Resident's triggers for physical aggression are loud noises.<BR/>2. <BR/>Administer medication as ordered<BR/>3. <BR/>Analyze times of day, places, circumstances, triggers<BR/>4. <BR/>Provide physical and verbal cues to alleviate anxiety, give positive feedback <BR/>5. <BR/>Family to provide sitters in the evenings to monitor resident 1:1<BR/>6. <BR/>Monitor resident every 15 min. continuously <BR/>7. <BR/>When resident becomes agitated: Intervene before agitation escalates<BR/>8. <BR/>Guide from source of distress <BR/>Resident # 2 care plan reflected the following focus: Resident # 2 has impaired cognitive function/dementia or impaired thought processes. Goal: To improve current level of cognitive function. The care plan has the following interventions: <BR/>1. <BR/>Cue, orient, supervise as needed<BR/>Record review of progress note dated 4/2/6/2023 by LVN reflected Resident # 1 was heard yelling help. The note reflected when the LVN got to Resident # 's room she found Resident # 1 hanging halfway off the right side of his bed and Resident # 2 standing at the foot of Resident # 1's bed. The LVN stated she assisted Resident # 1 back into his bed, and Resident # 1 was observed to have redness to the left side of his face. Resident # 1 stated Resident # 2 came into his room and when he asked him to leave, he started hitting him with both hands and with a closed fist. <BR/>Record review of progress note dated 4/30/2023 by LPN reflected there was screaming heard coming from Resident #1's room. LPN stated someone yelled that two Resident's hitting each other. LPN stated when she arrived at Resident # 1's room she observed another staff already in the room that had Resident # 2 from behind and directed him out of Resident # 1's room. The LPN stated Resident # 1 was assessed to have a scratch to the right side of his chest next to an old surgery wound, redness to the back of the neck, his gown was torn from where Resident # 2 had pulled and grabbed Resident # 1, and he complained of pain however, did not want to go to the hospital. The note reflected Resident # 1 reported that Resident # 2 came into his room and punched him multiple times. The note reflected Resident # 1 wanted to call the police and file charges against Resident # 2. <BR/>Record review of progress note dated 4/20/23 by LPN reflected Resident # 2 got behind another resident unknown in a wheelchair and gripped the back of the resident's chair. Resident # 2 was asked to let go of the resident's chair; Resident #2 became upset and gripped the chair tighter and started cursing and shaking his hand in the nurse's face. The note reflected Resident # 2 tried to hit the resident in the wheelchair. <BR/>Observation on 5/15/2023 at 3:30pm, revealed Resident # 2 observed wandering the halls by the nurse's station. Resident was observed going into the nurse's station where they were working. Resident was redirected by staff at the time. Resident was not on 1:1 supervision. Resident # 2 was not able to be formally interviewed by surveyor as he did not have the cognitive ability to understand. <BR/>Observation and interview conducted on 5/16/2023 at 11:00am, revealed Resident # 1's injuries. Resident # 1 had two scratches approximately 3inches long to his right leg, the skin was raised they appeared to be in the healing stage. Resident # 1 had a scratch to the center of his chest approximately 3 inches that was also in the healing stage. This scratch was on top of a previous surgery area on the chest. Resident # 1 stated the scratch to his chest hurt the most because the skin on his chest is thin from a previous surgery he had. Resident # 1 was observed with his left leg amputated. Resident # 1 reported he stayed in his room most of the time. <BR/>During an interview on 5/16/2023 at 11:00am with Resident #1, revealed there was more than one incident. Resident # 1 stated 4/26/2023 was the first incident when Resident # 2 wandered into his room. He stated he told Resident # 2 to get out of his room and stated Resident # 2 started hitting him; he stated he yelled for help. Resident # 1 stated Resident # 2 almost pulled him to the ground when he was hitting him. Resident # 1 stated he spoke with the ADM and stated the ADM assured him that he would take care of the problem and would not allow the resident to come back into his room. Resident # 1 stated the next incident happened on 4/30/2023. He stated Resident # 2 wandered back into his room, and again he stated he told Resident #2 to get out of his room and Resident # 2 started hitting him again. Resident # 1 stated again he yelled for help and staff came to assist. Resident # 1 stated he has welts on his legs from where Resident # 2 was hitting him and Resident # 2 had scratched him on his arm and on his chest. Resident # 1 stated he asked that they call the police, he wanted to file charges against Resident # 2 for his injuries. Resident # 1 stated when he made his report to the police; the police spoke with the facility. Resident # 1 stated the police advised him that the facility advised of Resident # 2's diagnosis and that they would monitor him more closely. Resident # 1 stated Resident # 2 was supposed to be supervised however, he is not because he had been down his hall several times the next day with no supervision, and he doesn't want Resident # 2 hitting on him anymore. <BR/>During a phone interview on 5/15/2023 at 8:42am a Facility visitor, revealed she had visited the facility on 4/30/2023 when the incident between Resident # 1 and Resident # 2 occurred. She stated she heard a resident yelling, and when she went to see what was going on she saw Resident # 2 shaking Resident #1 very aggressively. She stated she asked Resident # 2 if he would come out the room; She stated Resident # 2 grabbed Resident # 1 again and shook him she stated she called for help. The Facility visitor stated Resident # 2 would move all over the building and had caused problems with other residents, she stated she doesn't think he had the appropriate supervision. The Facility visitor stated Resident # 2 is strong and had grabbed her arm before in the past; So she knew how strong he was. Facility visitor stated Resident # 2 had gotten into with other residents and stated staff just sit behind the desk at the nurse's station.<BR/>During an interview on 5/15/2023 at 11:55am with the ADON, revealed when the incident initially happened between Resident # 1 and Resident # 2, they tried to monitor Resident # 2 they did not start the 1:1 monitoring of Resident # 2 until the 2nd incident between them happened that's when Resident # 2 was placed on 1:1 supervision. ADON stated they had a care plan meeting the next day on 5/1/2023 and Resident # 2 was taken off the 1:1 monitoring the staff and family would monitor Resident # 2 movements throughout the day. <BR/>Interview on 5/15/2023 at 1:30pm with LVN A, revealed Resident # 2 had a wander guard and they took turns monitoring the resident throughout the day. LVN A stated Resident # 2 was a wanderer and does wander into other resident's rooms. She stated Resident # 2 had shown aggressive behaviors when provoked by loud noises or if someone was physical with him first. <BR/>Interview on 5/16/2023 at 11:30am with the other State agency worker, who revealed she had spoken with Resident # 1 earlier today and stated that he was afraid that Resident # 2 would come back in his room and start hitting him again. She stated that she advised Resident #1 that Resident # 2 was on 1:1 supervision. <BR/>In an interview on 5/16/2023 at 1:15pm with CNA A, revealed she worked the day of the incident on 4/30/3034 between Resident #1 and Resident # 2. CNA A stated she worked on another hall that day and heard Resident # 1 yelling for Resident # 2 to get out of his room. She stated Resident # 2 got upset and started to swing at Resident # 1. CNA A stated Resident # 2 would often go into resident's rooms. She stated when Resident # 2 would get upset he would hit other residents and had hit staff before. CNA A stated they all tried to keep an eye on him and intervene before something happened. She stated Resident # 2 was on 15minute checks and everyone pitched in and monitored. <BR/>An interview on 5/16/2023 at 1:30pm with the House- keeping staff, revealed he worked the day on the 1st incident on 4/26/2023 between Resident # 1 and Resident # 2. He stated the heard Resident # 1 screaming. He stated he proceeded to Resident # 1's along with another staff member and stated Resident # 2 was standing at the end of Resident # 1's bed, Resident #1 stated Resident # 2 was hitting and beating on him. House- keeping staff stated he walked Resident # 2 out of Resident # 1 's room and Resident # 2 was very agitated. House- keeping staff stated Resident # 2 had wandered into other resident's rooms and stated they will just tell him to get out and he will leave.<BR/> An interview on 5/16/2023 at 3:30pm with the Activity Director, revealed she worked the day of the incident on 4/30/203. She stated she heard Resident #1 yelling for help and stated when she stood up she could see another staff had already approached Resident # 1's room. Activity Director stated when she made it down to Resident # 1's room she observed Resident # 1 hanging halfway off his bed almost to the floor. She stated she assisted Resident # 1 back up into his bed and stated he said, [Resident # 2] was hitting him. Activity director stated she also observed Resident # 1 left side of his face was red and Resident # 1 stated Resident # 2 had hit him in his face. <BR/>A phone interview on 5/16/2023 at 4:00pm with Resident # 2's Family member revealed, that there were two incidents of physical aggression that recently took place with Resident # 2. He stated the facility provided 1:1 supervision, moved his room and adjusted his medication. Family member stated the facility asked if he could assist with the supervision but stated he was not able to assist due to his work schedule, so the facility was providing the 1:1 supervision. <BR/>An interview on 5/16/2023 at 4:30pm with the DON, stated she started at facility about a week ago, she stated she expected staff would monitor all residents who are wanders to ensure their safety. She stated that she worked on a new training for staff to know what behaviors to look for and would intervene when residents get agitated before aggression occurred. The DON stated the 1:1 monitoring was the only intervention in place for Resident # 2, staff would monitor and redirect when needed.<BR/>An interview on 5/16/2023 at 4:45pm with ADM, revealed it was his expectation that staff intervene during any resident-to-resident altercations. He stated staff should separate the residents and keep them safe. The ADM stated when their numbers increased, they would increase staff. He stated all staff had been trained on abuse/neglect and understand the expectation if they see or suspect abuse/ neglect. The ADM stated it is his expectation that staff would monitor any residents who wander throughout the day and try to keep them within line of sight. <BR/>Record Review of policy report dated 4/30/2023, reflected the police responded to a simple assault at the facility. The report reflected that the facility would increase supervision of Resident # 2 by getting a sitter to provided 1:1 supervision throughout the day, and the facility would check to see if the wander guard alarm could be placed on the halls to alarm when he goes on certain halls of the facility. The report reflected Resident # 1 stated he just did not want Resident # 2 back him his room hitting on him. The report reflected the report was closed out due to Resident # 2's diagnosis and the facility put interventions in place. <BR/>Record Review of 1:1 monitoring reflected monitoring was started on 4/26/2023 and ended on 5/1/2023. <BR/>Record Review of the following in-services had been completed with staff: <BR/>5/8/2023- Interventions for Residents with agitation/behaviors<BR/>5/2/2023- 1:1 monitoring <BR/>4/27/2013- Resident # 2 behavior/agitation how to handle <BR/>4/27/2023- Resident to Resident altercation <BR/>Review of QAPI - (Quality Assurance and Performance Improvement) dated Feb. 2023 - April 2023 focusing on Resident Centered culture. <BR/>Record review of facility Abuse/Neglect policy dated 10/2022 stated the following:<BR/>Each resident has the right to be free from abuse. Mistreatment, neglect, and corporal punishment, involuntary seclusion and financial abuse. <BR/>The facility will prohibit neglect, mental or physical abuse including involuntary seclusion and the misappropriation of property or finances or residents. <BR/>The facility Quality Assurance /Improvement committee will review the abuse policy to assure effectiveness

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection and prevention control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (Resident #1, Resident #11, Resident #28, Resident #4, and Resident #17) of 35 residents reviewed for infection control. <BR/>1. LVN B failed to clean the reusable blood pressure (BP) cuff between resident use. <BR/>2. LVN A failed to perform hand hygiene and clean the catheter tip before performing catheter irrigation for Resident #17's suprapubic catheter (a flexible tube that drains urine from the bladder through a small incision in the lower abdomen)<BR/>3. The facility failed to ensure LVN I sanitized or washed her hands after touching contaminated items when delivering meal trays to residents, when setting up Resident #1, Resident #11 and, Resident #28's meal trays and during feeding of Resident #11 on 08/20/2024.<BR/>These failures could place residents at risk for cross contamination and infection.<BR/>Findings include:<BR/>1. Review of Resident #4's face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis or severe weakness in one side of the body) and cerebral infarction (stroke). <BR/>Review of Resident #4's Optional MDS, dated [DATE], reflected a BIMS score of 11 indicating moderate cognitive impairment. <BR/>Review of Resident #4's Care Plan reflected resident requires staff assistance for meeting needs and has hypertension requiring BP monitoring and medication. <BR/>Observation during med pass on 08/21/2024 at 08:30 AM, revealed LVN B checked the vital signs for Resident #6 and placed the BP cuff back on the medication cart without cleaning it. She then used the BP cuff to take vital signs for Resident #4 without cleaning the cuff first. <BR/>In an interview on 08/21/2024 at 08:36 AM, LVN B stated she should have cleaned the BP machine in between resident use but didn't. She stated it is policy to clean it before and after use because of the germs and risk for infection. <BR/>2. Review of Resident #17's face sheet reflected an [AGE] year old male admitted to the facility on [DATE] and again on 09/02/2022 with diagnoses of incomplete quadriplegia ( paralysis that affects a person's limbs and body from the neck down), chronic obstructive pulmonary disease (a group of lung disease that blocks airflow and makes it difficult to breathe), and overactive bladder (a problem with bladder function that causes the sudden need to urinate).<BR/>Review of Resident #17's care plan, dated 07/16/2024, reflected resident has a suprapubic catheter and foley care should be provided every shift and as needed. <BR/>Review of Resident #17's orders, date 07/17/2024, reflected an order to flush the catheter with 120-180 milliliters of sterile water every other day. <BR/>Observation on 08/21/2024 at 09:56 AM, during suprapubic catheter irrigation procedure for Resident #17 revealed LVN A sanitize her hands and don gloves and gown. She placed the irrigation tray and supplies on the bedside table, opened the kit and then disconnected the draining bag from Resident #17's catheter and handed it to the resident to hold. She then poured the sterile water into the container and drew up some in the syringe. She connected the syringe to the catheter without cleaning the catheter tip first. She then began attempting to flush the catheter. She was not able to flush the catheter and called for assistance. She then reconnected the old drainage bag to the catheter while waiting for assistance. <BR/>In an interview on 08/21/2024 at 11:10 AM, LVN A stated she forgot to clean the catheter before and after she attempted irrigation and reconnected the old bag. She stated not cleaning her hands and the catheter before irrigation placed the resident at risk for bladder infection. <BR/>In an interview on 08/22/2024 at 5:30 PM, the interim DON stated reusable medical equipment should be sanitized before every use to prevent the spread of infection. She stated she would expect staff to follow procedure for aseptic technique during catheter irrigation to prevent the spread of infection. <BR/>In an interview on 08/22/2024 at 5:50 PM, the Administrator stated the BP cuff should be cleaned in between residents for infection control. She stated she is not a nurse but would expect staff to follow procedure for catheter flushing to prevent the resident from getting an infection. <BR/>Review of facility policy for reusable medical equipment, dated 03/2023, reflected items that come in contact with intact skin but not mucous membranes, such as BP cuffs, should be cleaned and disinfected between residents. <BR/>Review of facility policy for catheter care, dated March 2024, reflected staff should use aseptic technique when there is a break in the closed system and clean technique when handling the catheter, tubing, or drainage bag. The policy does not specifically address the procedure for catheter irrigation. <BR/>3. Observation on 09/20/2024 at 12:13 PM to 12:35 PM, reflected LVN I entered the dining room from the hall. She touched her clothes and moved her hair away from her face. LVN I began to speak to residents and touched the residents' clothes and wheelchair handles. She began to look at the meal trays on the meal tray cart. LVN I picked up one lid of a meal tray and touched the tines ( the pointed prongs that allow you to spear and pick up the food) of the fork of Resident #28's meal tray. LVN I delivered Resident #28's meal tray to him in the dining room and did not change his fork. LVN I returned to the meal tray cart and did not sanitize her hands. She had the meal tray and touched the dirty dishwasher doorknob to enter the dishwasher room and placed meal tray on top of dirty plates and the middle finger, forefinger and ring finger touched dirty dishes in the dishwasher room. She exited the dishwasher room and proceeded to the meal cart without sanitizing or washing her hands. She picked up a meal tray off the meal cart and delivered the meal tray to Resident #1. When LVN I sat the meal tray on the table in front of Resident #1 she opened the thickened liquid water and the top part of her middle finger and fore finger on her right hand touched inside the container and touched the thickened water. LVN J asked LVN I to go into the hall and sanitize her hands. LVN I did not go into the hall to sanitize her hands or attempt to wash her hands. LVN I continued to pass out meal trays. LVN I delivered Resident #11's meal tray to her. She touched resident's hand and her specialty chair. LVN I opened Resident #11's thickened liquid and her forefinger and middle finger touched the thickened liquid and when she removed the lid off of Resident #11's plate of food she touched the green beans. After setting up the meal tray LVN I sat in a chair to begin to feed Resident #11. LVN I was given hand sanitizer and did sanitize her hands prior to feeding Resident #11. During feeding Resident #11, LVN I touched with her fore finger, ring finger and middle finger on her right hand the following: the arms of the chair she was sitting in, touched her own clothes and touched Resident #11's Hoyer lift sling to reposition the sling in Resident #11's chair. She also touched Resident #11's right hand. LVN I did not re-sanitize or wash her hands. LVN I picked up Resident #11's napkin to wipe off Resident #11's mouth. When LVN I wiped Resident #11's mouth she touched the side of Resident #11's upper lip with her fore finger and middle finger on her right hand. LVN J was sanitizing her hands every time she touched the table, chair or any object may be considered contaminated. She was feeding Resident #3.<BR/>In an interview on 08/20/2024 at 1:33 PM, LVN I stated she never sanitized her hands during the time she was passing out meal trays and setting up meal trays for the residents. LVN I stated she was expected to sanitize or wash her hands when passing out meal trays and when she was setting up meal trays for the residents. She stated she did not recall if she touched the tips of the fork, napkins, inside the thickened liquids container for Resident #1 and Resident #11. LVN I stated she did touch the door knob leading into the dishwashing room and she may have touched dirty dishes. She stated she did not recall touching her clothes, her hair, resident's wheelchair, or sling in Resident #11's specialty chair. She stated it was possible she did touch all of this but she was focused on delivering meal trays and feeding Resident #11 instead of what she was touching. LVN I stated it is impossible for staff to sanitize their hands if they touch anything may be contaminated. She stated the only time she sanitized her hands was when she sat on a chair to feed Resident #11. She stated she did touch arm of her chair; the sling Resident was sitting on in her specialty chair and possibly her own clothes. LVN I stated it is crazy to expect staff to sanitize their hands every time they touch an object that may be contaminated. She stated this was impossible. LVN I stated she did wipe Resident #11's mouth and she may have touched the side of her lip with her fingers. She stated if she had touched anything contaminated it was a possibility bacteria could cross contaminate onto the fluids, food, napkin, and Resident #11's mouth. LVN I stated she did not believe it was necessary to sanitize her hands every time she touched any type of object that may be contaminated. She stated staff would be sanitizing their hands every few seconds. LVN I stated she had been in-serviced on passing out meal trays and feeding the residents. She stated during in-service it was explained to wash or sanitize hands in between delivering meal trays to the residents and when feeding the residents. LVN I did not answer the question if a resident may become ill if they did ingest some type of bacteria that potentially transferred from her fingers or hands onto the resident's food or drink. <BR/>In an interview on 08/20/2024 at 00:00, LVN J stated she did ask LVN I to sanitize her hands. She stated LVN I did not sanitize her hands when she was passing out meal trays and setting up meal trays for residents. LVN J stated all staff was expected to sanitize or wash hands during each meal tray delivered to a resident. LVN J stated all staff was to sanitize their hands when they touch their hair, clothes or any object that was considered contaminated. She stated they had been in-serviced on hand hygiene during dining room service. LVN J stated she did not recall the date of the in-service. She stated if a resident did swallow some type of bacteria the resident had a potential of becoming physically ill such as vomiting or diarrhea. <BR/>In an interview on 08/22/2024 at 1:30 PM, ADON G stated all staff was expected to sanitize their hands prior to delivering meal trays and in between each meal tray delivered to a resident. She stated if staff touched any type of object such as doorknob, wheelchair, resident or staff clothes, hair, Hoyer sling, arms of a chair and/ or table, the staff was expected to sanitize or wash their hands after each contact with anything may be considered contaminated. ADON G stated if staff were not washing or sanitizing their hands during meal service and was touching residents' drinks, food or even plates it was a possibility bacteria may cross contaminate food, utensils such as fork and or the resident's plates. She stated if a resident ingested bacteria there was a possibility a resident may become sick with some type of food borne illness. She stated she had only been working at the facility about three weeks and she only knows about the in-services she had completed since she had been employed at this particular facility.<BR/>In an interview with the Administrator on 8/22/2024 at 2:05 PM, she stated all staff was expected to wash or sanitize hands prior and in between each meal tray delivered to the residents. She stated the staff was expected to sanitize or wash hands whenever they became in contact with anything considered contaminated such as: hair, clothes, dirty dishes, wheelchair, arms of a chair, etc. The Administrator stated there was a potential a resident may develop a food borne illness if a resident's food or drink was cross contaminated by bacteria on a staff fingers or hands. She stated she began working at this facility approximately two weeks ago and she was trying to look at a lot of things and the in-services been given in the past she had not looked at the in-services at this time and could not answer if an in-service had been given on dining room hand hygiene.<BR/>Review of facility policy for reusable medical equipment, dated 03/2023, reflected items that come in contact with intact skin but not mucous membranes, such as BP cuffs, should be cleaned and disinfected between residents. <BR/>Review of facility policy for catheter care, dated March 2024, reflected staff should use aseptic technique when there is a break in the closed system and clean technique when handling the catheter, tubing, or drainage bag. The policy does not specifically address the procedure for catheter irrigation. <BR/>Review of the Facility Policy of Hand Hygiene, revised on 10-2020 reflected This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained on the importance of hand hygiene in preventing the transmission of healthcare- associated infections. Use and alcohol-based hand rub containing at least 62 % alcohol; or , alternatively, soap and water for the following situations:<BR/>1. Before and after direct contact with residents.<BR/>2. After direct contact with a resident's intact skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview, and record review the facility failed to ensure residents were free from abuse for 1of 8 residents (Resident #1) reviewed for Abuse.<BR/>The facility failed to ensure Resident # 1 was free from Abuse, as a result Resident #1 was assaulted by Resident #2 on two different occasions and was injured. <BR/>This failure placed all residents at risk for being assaulted by Resident # 2. <BR/>Findings included: <BR/>Review of Resident #1's face sheet reflected that he was a 62- year- old man, admitted to the facility on [DATE]. The face sheet reflected Resident # 1 had a diagnosis of Chronic Congestive heart failure (A chronic condition in which the heart doesn't pump blood as well as it should), Type 2 Diabetes with kidney complication ( a chronic condition that affects the way the body processes blood sugar), Chronic Kidney disease (A loss of kidney function) , Obesity (A disorder involving excessive body fat that increases the risk of health problems), age related cataract (when the lens you're the eyes start to break down and clump together), partial traumatic amputation ( when some of the soft tissue still remains) at knee level, left lower leg. <BR/>Review of Resident # 1's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15 which indicated Resident # 1 had the cognitive ability to make his wants and needs known. Section G functional status of the MDS reflected Resident # 1 required extensive assistance with toileting, bathing, dressing and transfers. <BR/>Review of Resident # 1's care plan dated 4/21/2023 reflected the following goal: Resident # 1 was at risk of loss of ROM (range of motion). Resident # 1 had the following goal: Resident # 1 will improve current level of function in ADL's. The plan had the following interventions<BR/>1. <BR/>Bed mobility: Supervision x1<BR/>2. <BR/>Transfer limited: Limited x1<BR/>3. <BR/>Toileting: Extensive x1<BR/>4. <BR/>Eating: Supervision with set up help<BR/>5. <BR/>Staff assist with ROM (range of motion) daily when direct care is provided to help prevent loss<BR/>Review of Resident # 2's face sheet reflected, a [AGE] year-old man, admitted to the facility on [DATE]. Resident # 2 had a diagnosis of Unspecified Dementia (A mental disorder in which a person loses the ability to think, remember, learn, make decisions, and sole problems) and Cognitive Communication deficit (difficulty with thinking and how someone uses language).<BR/>Review of Resident # 2's quarterly MDS, dated [DATE] reflected a BIMS score of 99 which indicated the interview was not able to be completed. Section G functional status of the MDS reflected Resident #2 required extensive assistance with dressing, total dependence with bathing, eating and some assistance with walking at least 50 feet with turns. <BR/>Review of Resident # 2's care plan dated 4/14/2023, focus Resident # 2 was evaluated as a wandering risk, decreased safety awareness, confusion, and wandering behavior. The care plan reflected the following goal. Resident # 2 will remain free of injuries associated with wandering behaviors. The plan had the following interventions: <BR/>1. <BR/>Encourage to participate in activities of preference <BR/>2. <BR/>Utilize a wander bracelet <BR/>3. <BR/>Observe fore signs/symptoms of agitation, pacing, repetitive verbalizations of wanting to leave, restlessness <BR/>4. <BR/>Provide re-orientation as needed<BR/>5. <BR/>Check wander guard by nurse for placement and function if wander guard is removed replace or place on increased <BR/>monitoring of resident's whereabouts <BR/> Resident # 2care plan reflected the following focus: Resident #2 has potential to be physically aggressive/Dementia. Goal: Resident # 2 will demonstrate effective coping skills. The care plan had the following interventions: <BR/>1. <BR/>Resident's triggers for physical aggression are loud noises.<BR/>2. <BR/>Administer medication as ordered<BR/>3. <BR/>Analyze times of day, places, circumstances, triggers<BR/>4. <BR/>Provide physical and verbal cues to alleviate anxiety, give positive feedback <BR/>5. <BR/>Family to provide sitters in the evenings to monitor resident 1:1<BR/>6. <BR/>Monitor resident every 15 min. continuously <BR/>7. <BR/>When resident becomes agitated: Intervene before agitation escalates<BR/>8. <BR/>Guide from source of distress <BR/>Resident # 2 care plan reflected the following focus: Resident # 2 has impaired cognitive function/dementia or impaired thought processes. Goal: To improve current level of cognitive function. The care plan has the following interventions: <BR/>1. <BR/>Cue, orient, supervise as needed<BR/>Record review of progress note dated 4/2/6/2023 by LVN reflected Resident # 1 was heard yelling help. The note reflected when the LVN got to Resident # 's room she found Resident # 1 hanging halfway off the right side of his bed and Resident # 2 standing at the foot of Resident # 1's bed. The LVN stated she assisted Resident # 1 back into his bed, and Resident # 1 was observed to have redness to the left side of his face. Resident # 1 stated Resident # 2 came into his room and when he asked him to leave, he started hitting him with both hands and with a closed fist. <BR/>Record review of progress note dated 4/30/2023 by LPN reflected there was screaming heard coming from Resident #1's room. LPN stated someone yelled that two Resident's hitting each other. LPN stated when she arrived at Resident # 1's room she observed another staff already in the room that had Resident # 2 from behind and directed him out of Resident # 1's room. The LPN stated Resident # 1 was assessed to have a scratch to the right side of his chest next to an old surgery wound, redness to the back of the neck, his gown was torn from where Resident # 2 had pulled and grabbed Resident # 1, and he complained of pain however, did not want to go to the hospital. The note reflected Resident # 1 reported that Resident # 2 came into his room and punched him multiple times. The note reflected Resident # 1 wanted to call the police and file charges against Resident # 2. <BR/>Record review of progress note dated 4/20/23 by LPN reflected Resident # 2 got behind another resident unknown in a wheelchair and gripped the back of the resident's chair. Resident # 2 was asked to let go of the resident's chair; Resident #2 became upset and gripped the chair tighter and started cursing and shaking his hand in the nurse's face. The note reflected Resident # 2 tried to hit the resident in the wheelchair. <BR/>Observation on 5/15/2023 at 3:30pm, revealed Resident # 2 observed wandering the halls by the nurse's station. Resident was observed going into the nurse's station where they were working. Resident was redirected by staff at the time. Resident was not on 1:1 supervision. Resident # 2 was not able to be formally interviewed by surveyor as he did not have the cognitive ability to understand. <BR/>Observation and interview conducted on 5/16/2023 at 11:00am, revealed Resident # 1's injuries. Resident # 1 had two scratches approximately 3inches long to his right leg, the skin was raised they appeared to be in the healing stage. Resident # 1 had a scratch to the center of his chest approximately 3 inches that was also in the healing stage. This scratch was on top of a previous surgery area on the chest. Resident # 1 stated the scratch to his chest hurt the most because the skin on his chest is thin from a previous surgery he had. Resident # 1 was observed with his left leg amputated. Resident # 1 reported he stayed in his room most of the time. <BR/>During an interview on 5/16/2023 at 11:00am with Resident #1, revealed there was more than one incident. Resident # 1 stated 4/26/2023 was the first incident when Resident # 2 wandered into his room. He stated he told Resident # 2 to get out of his room and stated Resident # 2 started hitting him; he stated he yelled for help. Resident # 1 stated Resident # 2 almost pulled him to the ground when he was hitting him. Resident # 1 stated he spoke with the ADM and stated the ADM assured him that he would take care of the problem and would not allow the resident to come back into his room. Resident # 1 stated the next incident happened on 4/30/2023. He stated Resident # 2 wandered back into his room, and again he stated he told Resident #2 to get out of his room and Resident # 2 started hitting him again. Resident # 1 stated again he yelled for help and staff came to assist. Resident # 1 stated he has welts on his legs from where Resident # 2 was hitting him and Resident # 2 had scratched him on his arm and on his chest. Resident # 1 stated he asked that they call the police, he wanted to file charges against Resident # 2 for his injuries. Resident # 1 stated when he made his report to the police; the police spoke with the facility. Resident # 1 stated the police advised him that the facility advised of Resident # 2's diagnosis and that they would monitor him more closely. Resident # 1 stated Resident # 2 was supposed to be supervised however, he is not because he had been down his hall several times the next day with no supervision, and he doesn't want Resident # 2 hitting on him anymore. <BR/>During a phone interview on 5/15/2023 at 8:42am a Facility visitor, revealed she had visited the facility on 4/30/2023 when the incident between Resident # 1 and Resident # 2 occurred. She stated she heard a resident yelling, and when she went to see what was going on she saw Resident # 2 shaking Resident #1 very aggressively. She stated she asked Resident # 2 if he would come out the room; She stated Resident # 2 grabbed Resident # 1 again and shook him she stated she called for help. The Facility visitor stated Resident # 2 would move all over the building and had caused problems with other residents, she stated she doesn't think he had the appropriate supervision. The Facility visitor stated Resident # 2 is strong and had grabbed her arm before in the past; So she knew how strong he was. Facility visitor stated Resident # 2 had gotten into with other residents and stated staff just sit behind the desk at the nurse's station.<BR/>During an interview on 5/15/2023 at 11:55am with the ADON, revealed when the incident initially happened between Resident # 1 and Resident # 2, they tried to monitor Resident # 2 they did not start the 1:1 monitoring of Resident # 2 until the 2nd incident between them happened that's when Resident # 2 was placed on 1:1 supervision. ADON stated they had a care plan meeting the next day on 5/1/2023 and Resident # 2 was taken off the 1:1 monitoring the staff and family would monitor Resident # 2 movements throughout the day. <BR/>Interview on 5/15/2023 at 1:30pm with LVN A, revealed Resident # 2 had a wander guard and they took turns monitoring the resident throughout the day. LVN A stated Resident # 2 was a wanderer and does wander into other resident's rooms. She stated Resident # 2 had shown aggressive behaviors when provoked by loud noises or if someone was physical with him first. <BR/>Interview on 5/16/2023 at 11:30am with the other State agency worker, who revealed she had spoken with Resident # 1 earlier today and stated that he was afraid that Resident # 2 would come back in his room and start hitting him again. She stated that she advised Resident #1 that Resident # 2 was on 1:1 supervision. <BR/>In an interview on 5/16/2023 at 1:15pm with CNA A, revealed she worked the day of the incident on 4/30/3034 between Resident #1 and Resident # 2. CNA A stated she worked on another hall that day and heard Resident # 1 yelling for Resident # 2 to get out of his room. She stated Resident # 2 got upset and started to swing at Resident # 1. CNA A stated Resident # 2 would often go into resident's rooms. She stated when Resident # 2 would get upset he would hit other residents and had hit staff before. CNA A stated they all tried to keep an eye on him and intervene before something happened. She stated Resident # 2 was on 15minute checks and everyone pitched in and monitored. <BR/>An interview on 5/16/2023 at 1:30pm with the House- keeping staff, revealed he worked the day on the 1st incident on 4/26/2023 between Resident # 1 and Resident # 2. He stated the heard Resident # 1 screaming. He stated he proceeded to Resident # 1's along with another staff member and stated Resident # 2 was standing at the end of Resident # 1's bed, Resident #1 stated Resident # 2 was hitting and beating on him. House- keeping staff stated he walked Resident # 2 out of Resident # 1 's room and Resident # 2 was very agitated. House- keeping staff stated Resident # 2 had wandered into other resident's rooms and stated they will just tell him to get out and he will leave.<BR/> An interview on 5/16/2023 at 3:30pm with the Activity Director, revealed she worked the day of the incident on 4/30/203. She stated she heard Resident #1 yelling for help and stated when she stood up she could see another staff had already approached Resident # 1's room. Activity Director stated when she made it down to Resident # 1's room she observed Resident # 1 hanging halfway off his bed almost to the floor. She stated she assisted Resident # 1 back up into his bed and stated he said, [Resident # 2] was hitting him. Activity director stated she also observed Resident # 1 left side of his face was red and Resident # 1 stated Resident # 2 had hit him in his face. <BR/>A phone interview on 5/16/2023 at 4:00pm with Resident # 2's Family member revealed, that there were two incidents of physical aggression that recently took place with Resident # 2. He stated the facility provided 1:1 supervision, moved his room and adjusted his medication. Family member stated the facility asked if he could assist with the supervision but stated he was not able to assist due to his work schedule, so the facility was providing the 1:1 supervision. <BR/>An interview on 5/16/2023 at 4:30pm with the DON, stated she started at facility about a week ago, she stated she expected staff would monitor all residents who are wanders to ensure their safety. She stated that she worked on a new training for staff to know what behaviors to look for and would intervene when residents get agitated before aggression occurred. The DON stated the 1:1 monitoring was the only intervention in place for Resident # 2, staff would monitor and redirect when needed.<BR/>An interview on 5/16/2023 at 4:45pm with ADM, revealed it was his expectation that staff intervene during any resident-to-resident altercations. He stated staff should separate the residents and keep them safe. The ADM stated when their numbers increased, they would increase staff. He stated all staff had been trained on abuse/neglect and understand the expectation if they see or suspect abuse/ neglect. The ADM stated it is his expectation that staff would monitor any residents who wander throughout the day and try to keep them within line of sight. <BR/>Record Review of policy report dated 4/30/2023, reflected the police responded to a simple assault at the facility. The report reflected that the facility would increase supervision of Resident # 2 by getting a sitter to provided 1:1 supervision throughout the day, and the facility would check to see if the wander guard alarm could be placed on the halls to alarm when he goes on certain halls of the facility. The report reflected Resident # 1 stated he just did not want Resident # 2 back him his room hitting on him. The report reflected the report was closed out due to Resident # 2's diagnosis and the facility put interventions in place. <BR/>Record Review of 1:1 monitoring reflected monitoring was started on 4/26/2023 and ended on 5/1/2023. <BR/>Record Review of the following in-services had been completed with staff: <BR/>5/8/2023- Interventions for Residents with agitation/behaviors<BR/>5/2/2023- 1:1 monitoring <BR/>4/27/2013- Resident # 2 behavior/agitation how to handle <BR/>4/27/2023- Resident to Resident altercation <BR/>Review of QAPI - (Quality Assurance and Performance Improvement) dated Feb. 2023 - April 2023 focusing on Resident Centered culture. <BR/>Record review of facility Abuse/Neglect policy dated 10/2022 stated the following:<BR/>Each resident has the right to be free from abuse. Mistreatment, neglect, and corporal punishment, involuntary seclusion and financial abuse. <BR/>The facility will prohibit neglect, mental or physical abuse including involuntary seclusion and the misappropriation of property or finances or residents. <BR/>The facility Quality Assurance /Improvement committee will review the abuse policy to assure effectiveness

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to implement their written policies and procedures that prohibit and prevent the abuse/neglect of residents for one Resident #1) of three residents reviewed for abuse and neglect. <BR/>The facility failed to implement their abuse/neglect policy when LVN A was notified of Resident #1's pain and the administrator was notified of the incident by the COTAand the administrator failed to investigate the injury per policy. <BR/>This failure could place residents at risk of abuse, neglect, physical harm, pain, mental anguish, emotional distress, and serious harm.<BR/>Findings include: <BR/>Record review of Facility Policy on Prohibition of Abuse, Neglect and Misappropriation of Property dated 05/01/01 reflected each resident had the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. The facility will investigate of alleged or suspected abuse, neglect, or misappropriation of property, and will provide notification of information to the proper authorities according to state and federal regulations. <BR/>1. Abuse means: the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.<BR/>2. Verbal abuse is defined as the use of , oral, written, or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Staff responsibility to immediately report any violations or alleged violations.<BR/>3. Neglect: was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility will track all occurrences, trends or patterns that could potentially constitute abuse or neglect. All incidences of unknown origin will be investigated. <BR/>Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). <BR/>Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. <BR/>Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give &frac12; hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and record preferences. <BR/>Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have another nurse in the facility to report of Resident #1's pain. <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident's complaint of pain to the left knee and left knee was slightly swollen. Awaiting return call. <BR/>Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and ordered an x-ray to the left knee. <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to her knee. (Did not specify which knee). <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero<BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected pain medication was given to the resident. Resident #1 was complaining of pain to her left knee and requested pain medication. <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report was received from LVN A concerning Resident #1 had an order for a left knee x-ray. LVN B notified the x-ray company and was informed the x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain?<BR/>0-no pain, 1-3 - mild pain , 4-6- moderate pain , 7-10- severe pain. Every shift follows MD orders. Resident #1 complained of pain to left knee.<BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication was administered. Give one tablet by mouth every four hours as needed for pain. <BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:26 AM, reflected the x-Ray company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. <BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. <BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM, reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. <BR/>Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. <BR/>Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. <BR/>Record review of Resident #1's hospital records from the emergency room hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. <BR/>Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur <BR/>(where the bone flares out like an upside-down funnel). <BR/>Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. <BR/>Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1 room she lifted Resident #1 left leg up and Resident # 1 began to scream, and CNA let the left leg fall onto the bed and began to exit Resident #1 room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time she lifted her leg and when she lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. She stated as she was walking out Resident #1's room , you have that camera in your room, and you are acting all crazy. <BR/>In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he witnessed from the camera in Resident #1's room on 09/18/23 at 5:51 PM staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you're not hurt. You've complained about your back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 9/19/2023 at 10:44 AM and an ambulance was called to take Resident #1 to the hospital on 9/19/2023 at 10:44 AM. He stated there was also video of a CNA checking Resident #1's leg, picking the broken leg up and dropping it back on the bed and telling Resident #1 she was not hurt. Resident #1's family member also stated in the video after CNA dropped Resident #1 leg and began toward the door the CNA stated to Resident #1 you are crazy. He also stated the facility did not do anything for Resident #1 except give her pain medication she was already receiving. He stated he did not believe this medication helped Resident #1 due to Resident #1 continued to be in pain. He also stated Resident #1 was neglected and she needed to be in the hospital for x-rays immediately when Resident #1 began to yell she was in pain and her leg was broken. He stated she would rub on her left leg and by her expression from the video footage he noticed she was in pain. He stated he did not view the videos until 09/19/2023 after family received a phone call Resident #1 was going to be transferred to the hospital. He stated if he had seen the videos from Resident #1's room on 09/18/2023 he would have drove two hours to ensure she was getting the treatment she needed and was sent to the hospital immediately. He stated that was a new pain for Resident #1 and she had not been complaining about her knee. He also stated it was a new symptom for her knee to swell. <BR/>In an interview on 09/20/2023 at 2:41 PM the COTA/ Marketing Coordinator stated she reported to LVN A on 09/18/2023 from 6:00 PM, until approximately 09/18/2023 at 8:25 PM of Resident #1 complaining of pain in knee and left leg. She stated she also reported to LVN A that Resident #1 was making statements her knee was broken. She stated she explained to LVN A Resident #1 was in severe pain. She stated LVN A made the remark that that is normal for Resident #1, she was always complaining about being in pain and that was nothing new. The COTA/ Marketing Coordinator stated LVN A was informed of the information at approximately 6:10 PM and LVN A did not go to Resident #1's room until approximately 8:30 PM. She stated either she or the PTA was always in Resident #1's room from around 6:00 PM until 8:45 PM. She stated LVN A would not go to Resident #1's room to administer pain medication and the resident was in pain for at almost 2 hours. She stated she asked LVN A to give her the pain medication and she would administer it to Resident #1. She stated LVN A gave her the pain medication (narco) and she gave it to Resident #1. She stated she could not sit by and watch Resident #1 be in pain for an hour or more and the nurse refused to go to Resident #1's room due to believing Resident #1 was complaining for no reason. She stated it was difficult to even talk to LVN A due to her expressing no compassion towards Resident #1 and not wanting to assess her to determine if anything was wrong with Resident #1. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator of Resident #1's pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing to go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment or make any type of observation of why Resident #1 was in extreme pain. She stated Resident #1's left knee continued to become larger, and she was going to report Resident #1's condition approximately every 10 minutes and the nurse stated to the COTA/Marketing Coordinator that Resident #1 was ok, that is the way Resident #1 always was and there was not anything wrong with Resident #1. She stated around 8:30 PM LVN A entered Resident #1's room and stated Resident #1's left knee does not look any different than it has in the past. The COTA/Marketing Coordinator stated that LVN A informed her and PTA C to go home, she had this and promised to take care of Resident # 1. She stated LVN A did not assess Resident #1. The COTA/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. The COTA/Marketing Coordinator stated she did believe LVN A was neglecting Resident #1. She stated LVN A refused to go to Resident #1's room and complete an assessment approximately 2 hours after being informed of Resident #1's left knee/ leg pain and Resident #1 stating she thought her leg was broken. She stated she was upset, and the nurse ignored her whenever she reported anything about Resident #1. She stated LVN A neglected Resident #1 on 09/18/2023. <BR/>In an interview on 09/20/2023 at 3:41 PM LVN D stated Resident #1 yelled out frequently. She stated when she was yelling, she was in pain. LVN D stated resident complains about her back hurting. She stated everyone knew Resident #1 yelled frequently when she was in pain. She stated there were times when she was speaking to Resident #1, and she was complaining/ yelling with pain, and she would administer her ordered pain medication without asking Resident #1 where she was hurting or her pain level. She stated she has not ever completed a pain assessment on Resident #1 but now she realized she was required to complete pain assessment and document in nurses notes about Resident #1's pain. She also stated the nurses was expected to ask where the pain was located and the pain level on a scale of zero-ten. She stated zero - no pain and ten- extreme pain. She stated due to Resident #1 complaining about pain all the time the nurses would give her the pain medication if it was scheduled and not ask her any questions. She stated if she had been working on the night of 09/18/2023 and Resident #1 was complaining about pain in her knee she would have given her pain medication and probably would not have asked any questions or completed any type of incident reports or pain assessments due to this was how Resident #1 she was always complained about pain. She stated this was her normal behavior. LVN D stated resident did not have any behavior problems. She stated she would yell but only when she was in pain. She stated Resident #1 was cooperative with staff and did not have any behavior issues. LVN D stated she has given care to Resident #1 numerous times. She stated it varied from week to week, but she was very familiar with Resident #1 physical condition, moods, and behaviors. She also stated when Resident #1 was in pain she did not assess the resident to determine if it was a new pain or pain from her back. She stated everyone in the facility was aware if Resident #1 was in pain she will yell, and we don't assess the pain very closely when giving pain medication. She stated we give her anti -anxiety medication to prevent her from yelling. She also stated she did not believe any assessment was required when she was yelling about pain in her knee. She stated she was not working on 09/18/2023 but she would not have completed a pain assessment on resident. She also stated if a nurse was informed by staff over an hour that Resident #1's knee had increased in size due to swelling, Resident #1 was yelling in pain and Resident #1 stated she thought she broke her leg/knee, a nurse was expected to go to that room immediately due to that was a new pain for Resident #1; and anytime a resident stated they thought their leg/knee was broken that was serious. She stated if a nurse did not visit Resident #1 immediately after allegedly being informed every 10 minutes of her change in physical condition, that would be considered neglect. She stated unless there was an emergency with another resident. She stated a nurse could not ignore when staff was concerned about a resident's physical condition, and they felt there was a major concern for resident's physical health. She stated if a nurse continued to refuse to go to Resident #1's room for almost 2 hours, they did neglect Resident #1. She stated if the staff did not know why Resident # 1's knee was swelling, very painful to touch and Resident #1 allegedly stating her leg was broken, that would be considered an injury of unknown origin and would need to be investigated. <BR/>In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident was in pain and complaining of her left knee hurting<BR/>In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her to transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated this occurred approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of resident and placed the gait belt around the resident waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell my knee hurts. PTA C stated she assumed it was similar of her complaining about her pain in her back. She stated Resident #1 at some point stated her left leg was broken. PTA C also stated she realized this was a different type of pain than what she has complained in the past. She stated COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to come assess Resident #1 due to her knee continued to swell and was becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not come to Resident #1 room to give her pain medication or assess her. She stated the nurse gave COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I didn't know anyone was in the room. PTA C stated no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency. LVN A could have stopped what she was doing and came to Resident #1's room to complete an assessment. She stated if an assessment had been completed and LVN A would have went to Resident #1's room at approximately 6:10 PM she believed Resident #1 would have been sent to the hospital for evaluation that night. She stated she did believe LVN A was neglecting Resident #1. She stated the statements from LVN A was that Resident #1 was always like that and she was always complaining about something, and there was not anything wrong with her. She stated that was deliberate neglect from LVN A . <BR/>In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated she was informed of Resident #1 had pain and some swelling in her left knee. She stated she asked COTA/Marketing Coordinator to inform the nurse to contact the physician and have an x-ray ordered. The Administrator stated anytime a Resident complains of pain whether it is an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1,completing a pain assessment, and asked questions reason Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the Emergency Room. She stated anytime a Resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all this information in the nurses notes and complete a pain assessment. She stated if Resident #1 had a new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician and call 911 to transfer Resident #1 to emergency room. The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated based on the information she learned today (09/21/2023) of Resident #1's new physical concerns she endured on 09/18/2023 Resident #1 required to be assessed by a physician in the emergency room and have x-rays on her left leg and left knee as soon as possible on 09/18/2023. She stated the facility had protocols in place to ensure the residents was receiving the best care for their physical condition whether it was a new physical issue or an old physical issue. She stated the nursing staff on 09/18/2023 did not follow the facility's protocol and there was a system failure. She stated it was the DON's responsibility to monitor the nurses to ensure they were following protocol. She stated it was discussed in the morning meeting on 09/19/2023 about Resident #1's knee and leg. She stated it was discussed Resident #1 needed an X-Ray. She stated the staff was not interviewed and there was not any questioning of what happened to Resident #1's left knee or left leg. The Administrator stated after today ( 09/21/2023) she realized either she or the DON needed to complete an investigation of what happened with Resident #1. She stated if a nurse continued to refuse to assess a resident after being asked several times by the staff, she would consider that neglect. She also stated if a staff knew Resident #1 was in extreme pain in her left leg and they lifted the left leg in the air and did not gently place the left leg on the bed she would consider that abuse. She also stated if staff made a statement to Resident #1 as she was leaving the room that Resident #1 was crazy, she stated that was verbal abuse. She stated in the abuse and neglect policy and protocol it was clear what to do if anything was suspected and she stated they did not follow protocol to investigate what occurred with Resident #1 on 09/18/2023. The Administrator also stated if Resident #1 complained that her leg was broken, her knee continued to swell and she was in extreme pain within a few seconds after she was transferred from a wheelchair to the bed, there was a potential of an injury of unknown origin. She stated no one reported that to her. The Administrator did not see the electronic video given from family; however, she heard the video and the Administrator stated Resident #1 stated her leg was broken. <BR/>In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated if it was reported to the nurse of Resident #1 having pain and swelling in her left knee and Resident #1 believed her left knee or left leg was broken, LVN A did not follow proper protocol to ensure Resident #1 was receiving the medical care she needed the night of 09/18/2023. She stated Resident #1 needed to be transferred to the hospital on [DATE]. LVN B stated if staff continued to report to LVN A over an hour that Resident #1 was in pain, the swelling in left knee had increased in size and Resident #1 stated her leg/knee was broken, LVN A was expected to go to Resident #1's room immediately. She stated if LVN A continued to refuse to assess Resident #1 that would be considered neglect, unless there was an emergency with another resident. She stated if it was verified there was not an emergency every time staff was reporting the new physical condition Resident #1 was in , LVN A did neglect Resident #1. She also stated on Tuesday 09/19/2023 at approximately 9:00 AM in the staff meeting she reported Resident #1's knee was swollen, and she had been in pain. She stated she also informed the administrative staff in the morning meeting that the x-ray department may not be available to come to the facility until the afternoon. She stated the Administrator stated to call the physician and send Resident #1 to hospital[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #1) of five residents reviewed for quality of care. <BR/>The facility failed to assess and obtain x-ray when Resident #1 began complaining acute pain and her knee/leg was broken in her left leg. The facility failed to order x-ray on 09/18/2023. <BR/>An Immediate Jeopardy (IJ) situation was identified and on 09/21/2023 and Immediate Jeopardy template was presented to the facility on [DATE] at 3:37 PM. While the IJ was removed on 09/23/2023 the facility remained out of compliance at a severity level of actual harm at a scope of isolation due to staff needing more time to monitor the plan of removal for effectiveness. <BR/>This failure placed residents at risk for potential delay in medical intervention, uncontrolled pain, decline in health and a decreased quality of life. <BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). <BR/>Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. <BR/>Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give &frac12; hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and resident preferences . <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident complain of pain to the left knee and left knee slightly swollen, awaiting return call. <BR/>Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and received an order for an x-ray to left knee. <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to knee. ( Did not specify which knee). <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero<BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected the pain medication was given to the resident. Resident #1 complaining of pain in left knee and requested pain medication. <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report received from LVN A concerning Resident #1 had an order for left knee x-ray. LVN B notified the X-ray company and was informed x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain?<BR/>0-no pain, 1-3 - mild, 4-6- moderate, 7-10- severe. Every shift follows MD orders. Resident #1 complained of pain to left knee. <BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication administered. Give one tablet by mouth every four hours as needed for pain. <BR/>Record review of Resident #1's nurses notes dated 09/ 19/2023 at 10:26 AM, reflected the X-Ray company was unable to do the x-ray at the facility for resident #1 left knee. Resident #1 will be transferred via EMS to a hospital for x-ray to left knee. Resident #1 aware and notified family. <BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS at the facility to transport resident to hospital. <BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM , reflected the pain medication was ineffective and follow-up pain was a five. Resident #1 transferred to emergency room for evaluation and treatment. <BR/>Record review of Resident #1's hospital records from the emergency room hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. <BR/>Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur ( where the bone flares out like an upside-down funnel). <BR/>Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. <BR/>Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. <BR/>Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. <BR/>Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by MDS Coordinator. <BR/>Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. The staff did not have another nurse in the facility to report of Resident #1's pain and knee swelling. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:52 PM COTA/ Marketing Coordinator and PTA began to transfer Resident #1 from her wheelchair to her bed. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell my knee is hurting my knee is broken. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 05:53 PM Resident #1 was yelling my knee is hurting and my leg broken. Resident #1 began to rub her left leg as she continued to yell. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident would scream she was hurting. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 6:00 PM, Resident #1 stated you ( PTA) turned me around and Resident #1 was looking at PTA as she made this statement. The PTA stated, we did not mean to hurt you. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by family revealed on 09/18/2023 at 7:58 PM, CNA H was in Resident #1 room she lifted Resident #1 left leg up and Resident # 1 began to scream, and CNA let the left leg fall onto the bed and began to exit Resident #1 room. CNA H was not providing care to Resident #1. Resident #1 was screaming the entire time she lifted her leg and when she lowered the left leg on the bed. Resident #1 was not yelling prior to CNA H picking up her leg. She stated as she was walking out Resident #1's room , you have that camera in your room, and you are acting all crazy. <BR/>In an interview on 09/20/2023 at 2:41 PM the COTA/ Marketing Coordinator stated she heard Resident #1 yelling for help around 6:00 PM on 09/18/2023. She stated when she entered Resident #1 room approximately 6:05 PM Resident #1 was needing assistance to be transferred to bed from her recliner. She stated she explained to resident she needed to find a gait belt and get someone to help her with the transfer. The COTA/ Marketing Coordinator stated she asked the PTA C to assist her transferring Resident #1. She stated PTA assisted her with Resident #1's transfer from the recliner to wheelchair. She stated Resident #1 complained about back pain. COTA/Marketing Coordinator also stated Resident #1 wheelchair was positioned beside the bed to transfer onto her bed. She stated she was in front of the resident, and they placed the gait belt on resident and assisted her from the wheelchair and pivoted resident for her to sit on the bed. She stated resident was not yelling during the transfer, however, within a few seconds of resident sitting on the bed the resident began to yell my knee hurts. She stated Resident #1 repeated stating her knee hurts. COTA/ Marketing Coordinator stated she and the PTA C assisted resident to lie in bed in supine position and this is when she noticed Resident #1's knee begins to swell. She stated Resident #1 complained of her pain being at 10 on a pain scale of 0 being in no pain to 10 being in extreme pain. She stated the PTA stayed in the room and she left the room to report this to the LVN A approximately 6:30 PM She stated LVN A did not go to Resident #1's room to assess resident. She stated LVN A was at her nurses' cart preparing to administer medications. She stated she explained to LVN A Resident #1 was in extreme pain in her left knee and the knee was swelling. She stated she stayed at the facility until she knew Resident #1 was going to be seen by the nurse. She stated it was approximately 8:30 PM when the nurse entered Resident #1's room for the first time after reported to LVN A of Resident being in pain. She stated she did become frustrated with LVN A ignoring Resident #1 pain and knee swelling that she told her just give me the medicine and she will give it to her. She stated she could not stand to see Resident #1 in pain any longer and the nurse would not come to the Resident #1's room. The COTA/ Marketing coordinator stated she got the pain medication from the nurse and took it to Resident and gave the pain medication to Resident #1. She stated she reported to LVN A Resident #1 was complaining her leg/knee was broken and LVN A stated resident is always complaining about something hurting this was not anything new. The COTA/ Marketing Coordinator stated she was so upset because she stated she kept reporting to LVN A about Resident #1's condition with her left knee and she continued to ignore her. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator of Resident #1 had pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing and come to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not coming to Resident #1's room to complete an assessment on her or giving her pain medication when Resident #1 was in pain more than an hour before LVN D gave me the pain medication to give to Resident #1. She stated she had to do something because Resident #1's left knee swelling was increasing, and the pain was getting a lot worse. She also stated LVN A stated Resident #1's left knee doesn't look any different than it has in the past. LVN A told COTA/Marketing Coordinator and PTA C to go home she had this and promised to take care of Resident # 1. The PT/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital for x-rays. She stated she saw Resident #1 being transferred to the ambulance. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. She stated after she got home, she was afraid Resident #1 might have known she had a broken bone, and she may lie in the bed all night without any treatment. <BR/>In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he reviewed the video in Resident #1's room from his house. He stated on 09/18/2023 when the COTA and PTA transferred Resident #1 from the wheelchair to the bed Resident #1 began yelling as soon as she sat on the bed that her knee was hurting, and her leg was broken . He stated she was rubbing her left leg. He stated the COTA and PTA C assisted the resident in her bed and she continued to yell. He stated his concern was the staff allowed Resident #1 to lay in the bed until the next day in pain and complaining her leg was broken and they did not do anything but put an ice pack on her knee and put a small pillow under her left knee. He also stated everything was on the video of what occurred, and the facility failed to provide Resident #1 care when she was in extreme pain and complaining her leg was broken. <BR/>In an interview on 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident #1 was in pain. <BR/>In an interview on 09/21/2023 at 11:05 AM, attempted to contact CNA H and left voice message of name, agency, and phone number. CNA H was in Resident #1 room for a short time when Resident #1 was in pain on 09/18/2023<BR/>In an interview on 09/21/2023 at 11:10 AM, attempted to contact CNA I and left voice message of name, agency and phone number . CNA I was in the facility and was in Resident #1's room when she was in pain. <BR/>In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her to transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated this occurred approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of resident and placed the gait belt around the resident waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell my knee hurts. PTA C stated she assumed it was similar of her complaining about her pain in her back. She stated Resident #1 at some point stated her left leg was broken. PTA C also stated she realized this was a different type of pain than what she has complained in the past. She stated COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to come assess Resident #1 due to her knee continued to swell and was becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not come to Resident #1 room to give her pain medication or assess her. She stated the nurse gave COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I didn't know anyone was in the room. PTA C stated no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency. LVN A could have stopped what she was doing and came to Resident #1's room. She also stated LVN A stated Resident #1's left knee does not look any different than it has in the past. LVN A told the COTA/Marketing Coordinator and the PTA C to go home she had this and promised to take care of Resident # 1. <BR/>In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated was informed Resident #1 had pain and some swelling in her left knee. She stated she asked COTA/Marketing Coordinator to inform the nurse to contact the physician and have an x-ray ordered. The Administrator stated anytime a Resident complains of pain whether it is an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1,completing a pain assessment, and asked questions reason Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the Emergency Room. She stated anytime a Resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all this information in the nurses notes and complete a pain assessment. She stated if Resident #1 had a new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician and call 911 to transfer Resident #1 to emergency room. The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated based on the information she learned today (09/21/2023) of Resident #1's new physical concerns she endured on 09/18/2023 Resident #1 was required to be assessed by a physician in the emergency room and have x-rays on her left leg and left knee as soon as possible on 09/18/2023. She stated the facility had protocols in place to ensure the residents were receiving the best care for their physical condition whether it was a new physical issue or an old physical issue. She stated the nursing staff on 09/18/2023 did not follow the facility's protocol and there was a system failure. She stated it was the DON's responsibility to monitor the nurses to ensure they were following protocol. <BR/>In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated if it was reported to the nurse that Resident #1 was in pain, she would have immediately assessed Resident #1. She stated LVN A did not follow proper protocol to ensure Resident #1 was receiving the medical care she needed the night of 09/18/2023. She stated Resident #1 needed to be transferred to the hospital on [DATE] . LVN B stated she was the oncoming nurse after LVN A. <BR/>In an interview on 09/22/2023 at 9:55 AM, LVN F stated if any staff reported a resident was having a new pain and their knee was swelling, she stated she would immediately go to that resident's room and assess the resident. She stated she would complete a pain assessment and if resident were in severe pain and has stated her leg was broken, she would contact the MD immediately and if the MD did not return call within 5 minutes, she would immediately call 911. She stated if a nurse did not complete an assessment on the resident or ask the other staff questions of what might have caused the knee to swell, she did not follow proper protocol. LVN F stated nurse was expected to assess residents whenever there is a change of condition and a new pain in the knee with it swelling and the resident yelling her leg was broken that is a change of condition. She stated she did not give care very often to Resident #1, but she did know Resident #1 would yell when she was only in pain. She stated Resident #1 should not have stayed in the facility all night if she said her left leg was broken if her left knee was swelling, and she was in extreme pain . She stated Resident #1 needed to be transferred to the emergency room the night of 09/18/2023. She stated anytime a resident voices pain to a nurse, or another staff reports a resident was in pain the nurses was to complete pain assessment. She stated the nurse was required to ask resident where the pain is located and the pain level using the pain scale of zero - not having any pain and ten- having extreme pain. She stated a nurse was expected to document this in nurses notes when they administer pain medication and if a resident is in pain an assessment was required to be completed. She stated LVN A was expected to go immediately to Resident #1's room to complete an assessment and if Resident #1 was complaining about extreme pain and stated her leg/ knee was broken, Resident #1 needed to be sent to the emergency room immediately. <BR/>In an interview on 09/22/2023 at 10:30 AM, the ADON stated anytime a Resident had pain whether a new pain or an ongoing pain the nurse was expected to assess the resident and complete a pain scale with the resident. ADON stated pain scale was when zero - no pain and ten- extreme pain. She stated any time a resident reported pain the nurse was to complete a pain assessment and document in the nurses notes where the pain is located and the pain scale. She stated Resident #1 only had one pain assessment completed and it was completed at the time of the MDS Assessment. She stated Resident #1 did complain about pain frequently, however, she expected the nurses to complete pain assessments each time the resident had a pain higher than a zero. She stated the nurses will document pain once a shift on the MAR, however, that does not indicate the resident did not have any pain that shift. The ADON stated there was a pain assessment in the electronic medical record and it was expected for the nurses to complete pain assessment each time a resident complained of being in pain. She stated there was a possibility something else may be occurring with the residents' physical condition and completing an assessment it will ensure the nurse will not be missing any other acute physical issues with the resident. She stated if LVN A had completed a pain assessment on Resident #1 she would have known the extent of the pain and Resident #1 needed to be transferred to the hospital immediately. She also stated if it was reported to LVN A Resident #1 was complaining of her leg being broken the nurse was expected to call 911 immediately, contact the physician and the family. She stated there was a failure in the facility's protocol regarding Resident #1's care on 09/18/2023. <BR/>In an interview on 09/22/2023 at 1:36 PM, attempted to contact LVN A and was unable to leave message. LVN A was in the facility when Resident #1 was complaining of pain and her left knee hurting <BR/>Review of Resident #1's Facility Policy on Pain Management Program dated 01/2023 reflected the facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management. The facility will assess everyone for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The facility will identify the characteristics of pain such as location, intensity, frequency, pattern , and severity. The facility will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The facility will evaluate how pain is affecting mood, activities of daily living, sleep, and the resident's quality of life, as well as how pain may be contributing to complications such as gait disturbances, social isolation, and falls. The interdisciplinary team will make attempts to determine root cause of the pain and collaborate with physician to conduct necessary diagnostics and evaluation to identify potential source of pain and determine plan of care. <BR/>The Administrator and Director of Nurses was notified on 09/21/2023 at 3:37 PM than an Immediate Jeopardy had been identified due to the above failure and an IJ template was provided and POR was requested at this time.<BR/>The following POR was accepted on 09/23/2023 at 7:38 AM:<BR/>On 09/21/2023 an abbreviated survey was initiated at (facility). On 09/21/2023 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety.<BR/>The notification of Immediate Threat states as follows: <BR/>On 09/21/2023 an abbreviated survey was initiated at facility. On 09/21/2023 the surveyor provided an Immediate Threat (IT) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety.<BR/>The notification of Immediate Threat states as follows:<BR/>F684: Quality of Care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.<BR/>DON/Designee conducted pain assessment for all residents on September 21, 2023, to ensure that no other resident effected. Documents are in POR binder and uploaded to resident's chart. The facility will follow policy and procedure regarding assessment injuries and pain to protect individuals in similar circumstances. No other residents noted to have injuries.<BR/>Action Taken: <BR/>Immediately, on September 21, 2023, Corporate clinical specialist in serviced DON and ADM to include Quality of ca[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to ensure each residents' environment remained free of accident hazards for one (Resident #1) of four residents reviewed for accidents and hazards. <BR/>The facility failed to ensure CNA A did not unlock the wheels and move Resident #1's bed during peri care, causing Resident #1 to fall. This resulted in Resident #1 being sent to the hospital with fractures and lacerations.<BR/>An Immediate Jeopardy (IJ) existed from 05/31/2025 - 06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the deficient practice prior to the beginning of the investigation.<BR/>This failure could result in residents experiencing accidents, injuries, and diminished quality of life. <BR/>Findings included:<BR/>Review of Resident #1's face sheet, dated 06/10/2025, reflected Resident #1 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: history of falling ( person experienced past falls), muscle wasting and atrophy, not elsewhere classified (decrease in size and strength of muscle tissue), lack of coordination (the inability to smoothly and accurately control body movements), hypertensive heart disease without heart failure (the heart conditions caused by long-term high blood pressure- a condition where the force of blood against the artery walls is consistently too high, making the heart work harder to pump blood- that do not involve heart failure).<BR/>Review of Resident #1's MDS Assessment, dated 05/28/2025, reflected Resident #1 was unable to complete brief interview for mental status. Resident #1 had poor short- and long-term memory recall. Her decision-making ability was severely impaired. She was dependent on staff for the following: eating, oral hygiene, toileting hygiene, showers, upper and lower dressing, personal hygiene, and transfers. She was incontinent of bowel and bladder. <BR/>Review of Resident #1's Comprehensive Care Plan, revision date of 05/31/2025, reflected Resident #1 had an actual fall. Interventions: Bed mobility and toileting use two person assist. Inservice staff on amount of assist needed and update Kardex. Continue interventions on the at-risk plan. Monitor/document/report as needed to MD for signs and symptoms of pain, bruises, and change of mental status. New Onset of the following: confusion, sleepiness, inability to maintain posture, and agitation. Resident #1 had an ADL self-care performance deficit. She was dependent on staff for bed mobility, eating, toileting, oral hygiene, showers, dressing (upper and lower body), personal hygiene, and transfers. <BR/>Review of Resident #1's hospital records, dated 05/31/2025, reflected Resident #1 was transferred to the emergency room at local hospital on [DATE]. She had x-rays and was assessed by medical doctors. Resident #1 was discharged back to the facility on [DATE] with diagnosis of right anterior superior iliac spine fracture (a break in the bony projection on the front and upper part of the right hip bone), forehead laceration (a jagged or irregular tear or cut in the skin or other soft body tissue), right elbow soft tissue foreign body (refers to the presence of an object, like a splinter, thorn or, metal, that has entered the skin and become embedded in the soft tissues) and right pulmonary nodule (a small, discrete spot or growth in the right lung that appears denser than the surrounding lung tissue). <BR/>Review of written statement by CNA A reflected on 05/31/2025 at 9:50 AM, Resident #1 was lying in bed receiving peri care from CNA A. There was a lot of loose BM everywhere on the bed. CNA A began to provide peri-care to Resident #1. CNA A had cleaned Resident #1 on one side and needed to be on the side of the bed located against the wall. CNA A moved the bed away from the wall to have easy access to Resident #1. When CNA A was moving the bed, Resident #1 fell off the bed. CNA A confirmed there was loose stool on the alternating air mattress causing the air mattress to be slick. <BR/>An Immediate Jeopardy (IJ) existed from 05/31/2025-06/02/2025. The IJ was determined to be at past noncompliance as the facility had implemented the following actions prior to investigation start: <BR/>Review of facility's Inservice records, dated 05/31/2025, reflected all nursing staff received in-services on abuse/neglect policies and fall with injury protocol. <BR/>Review of the facility's accident hazards/supervision devices quiz, completed on 05/31/2025 and was ongoing, reflected all nursing staff completed this quiz and passed. <BR/>Review of the facility's safe peri care and bed mobility for high-risk resident's quiz, completed on 05/31/2025, reflected all nursing staff had completed the quiz and passed. <BR/>Review of the facility's interviews with interviewable residents, dated 06/01/2025, reflected 9 residents had received care from CNA A and they all knew CNA A. The following was asked of the residents:<BR/>1. <BR/>Do you know CNA A- Yes<BR/>2. <BR/>Do you know who to report to if you had problems with any staff? - Yes.<BR/>3. <BR/>Has CNA A provided you with care- Yes.<BR/>4. <BR/>Do you feel safe when CNA A provided care for you? Yes<BR/>5. <BR/>Do you feel safe at this facility? Yes<BR/>Review of the facility's skin assessments, on 06/10/2025, of all Residents after the incident on 05/31/2025. There were no new skin concerns. <BR/>Review of the facility's maintenance records, on 06/10/2025, reflected all beds were checked for any issues such as locking the bed or any malfunction of the beds. There were no concerns of all Residents beds. <BR/>Review of Resident #1's medical records, on 06/10/2025, reflected Resident #1 was being monitored for signs of pain post-incident. There was no concerns of pain. <BR/>Review of Resident #1's Kardex, on 06/10/2025, reflected peri care assistance was added to her Kardex on 05/30/2025.<BR/>Review of the facility's investigation, on 06/10/2025, reflected all residents Kardex was updated on 05/30/2025 to reflect peri-care assistance. <BR/>Review of CNA A's personnel record, on 06/10/2025, reflected she was suspended on 05/31/2025 until investigation was completed. CNA A returned to work on 06/06/2025. CNA A's misconduct was up to date and no concerns noted. <BR/>Observation on 06/10/2025 at 9:05 AM, Resident #1 was lying in bed. She was not interviewable. Resident #1 was lying in bed. She was in a fetal position facing the wall. She made eye contact and did mumble. Resident did not exhibit signs of being in pain such as: grimacing, tense body posture, restlessness, moaning, etc. Resident #1's bed was in lowest position. <BR/>Interview on 06/10/2025 at 9:18 AM, CNA B stated she did receive in-service on abuse and neglect within the past 2 weeks. She stated she did not recall the exact date. She stated examples of abuse was yelling at a resident, hitting a resident, or can be sexual abuse. CNA B stated neglect was when staff refused to give resident food, water and/or assist resident to the bathroom. CNA B stated she had been in-service on fall protocol. She stated never move a resident when they fall. She stated a nurse was required to assess the resident and give instructions to the CNA after she completed her assessment. CNA B stated she did take a quiz on falls and peri care. She stated she was reminded if a resident was a one person assist, to always ask for assistance if there was a safety issue. CNA B stated staff was never to move a bed during peri-care. She stated if a bed needed to be move this was expected to be completed prior to beginning peri-care and to ask another staff for assistance. CNA B stated peri care assistance was not on the Kardex until after the incident with Resident #1. <BR/>Interview on 06/10/2205 at 9:40 AM, CNA C stated she had received in-service on abuse and neglect, fall protocol, and peri care end of May. She stated she did not recall the exact date; however, it was the last weekend of May 2025. She stated the following was types of neglect: refusing to give resident a shower, feeding a resident, give resident water, etc. CNA C stated abuse was when someone hit, cussed, or yelled at a resident. She stated she did take quizzes on falls and peri care. She stated she was a new CNA and she learned to always ask for assistance with a resident required one person assist, if there was any safety concerns. She stated she would never move a bed during peri-care. She stated if a bed needs to be moved to reach one side of the resident, the bed was expected to be moved prior to peri-care and it was always in good practice to have two staff in the room when moving a bed. CNA C stated assistance with peri-care was not on the Kardex until after the incident with Resident #1. <BR/>Interview on 06/10/2025 at 10:58 AM, CNA D stated she was walking by Resident #1's room and opened the door to check on Resident #1. She stated CNA A was giving peri-care to Resident #1. CNA D stated Resident #1 was on her right side while lying in bed. She stated she exited the room and did not witness Resident #1 fall. She stated she was given quizzes on pericare and falls. CNA D stated she had been in-service on fall protocol and abuse/neglect. She stated abuse was when a staff kicked or yelled at a resident. She stated touching resident in private areas was also considered abuse. CNA D stated neglect was not changing a resident brief, not giving resident food, or not assisting a resident to the bathroom. She stated if a resident fell or was found on the floor only the nurse was trained to assess the resident. She stated the CNA was not to move the resident until the nurse completed all her assessments and gave directions to the CNA of what to do after the assessments. She stated when giving peri care the bed was to remain locked. She stated during the in-service the DON explained if a staff needed assistance for the staff to use call light and walkie talkies would be provided to the staff to use whenever they may need assistance with a resident. CNA D stated if a resident is a one person assist and a staff felt the resident may need more than one person the staff was expected to call for assistance. She stated peri care assistance was not on the Kardex prior to the incident with Resident #1. She stated after the incident with Resident #1 peri care assistance was on all residents Kardex. <BR/>Interview on 06/10/2025 at 10:35 AM, CNA A stated she began peri-care and cleaning Resident #1 on 05/30/2025 around 9:30 AM. She stated there was a lot of feces and some of it was loose stools. She stated feces were all over the bed. CNA A stated Resident #1 was lying on her back. She stated she needed to be on the right side of Resident #1 to finish cleaning the feces off Resident #1. She stated she rolled Resident #1 to the right side of the bed facing the wall. CNA A stated after she rolled Resident #1 to the right side she walked to the end of the bed and unlocked the bed. CNA A stated she began to move the bed away from the wall and this is when Resident #1 fell off the bed. She stated Resident #1 fell between the bed and the wall. CNA A stated she was at the end of the bed and attempted to catch Resident #1 prior to her falling. CNA A stated she was trained not to move the bed during peri-care. She stated the training was prior to the incident, however, she did not recall the date. CNA A stated she was required to unlock the bed prior to peri care and ask for assistance if there was any issues with giving peri-care. CNA A stated Resident #1 peri care was not on the Kardex. She stated she had given care to Resident #1 several times and she was a one person assist with peri-care. She stated she did ask a nurse a few months ago and this was the nurse's instructions of peri care on Resident #1 being 1 person assist. CNA A did not recall the name of the nurse or the date she questioned Resident #1's peri care. She stated she was in-service on peri-care, fall protocol, abuse, and neglect, prior to her returning from her suspension. CNA A stated neglect was when a staff refused to change a resident dirty brief, refused to feed a resident, refused to give resident water, etc. She stated slapping, yelling, or cussing a resident was abuse. CNA A stated she learned to always ask for assistance when needing to move a bed and never to move a bed during peri-care. She stated only move a bed prior to peri-care and ensure another staff was in the room for any assistance. CNA A stated she was the only witness to the fall of Resident #1. <BR/>Interview on 06/10/2025 at 2:17 PM, the Director of Nurses stated her expectations for peri care was for each CNA to gather their supplies before they enter a resident's room. She stated the CNAs were expected to position the resident in bed according to what type of peri-care is needed. The Director of Nurses stated the staff may raise the bed to the height level of the staff to provide peri-care. She sated the CNAs were expected to follow PPE guidance during peri-care. The Director of Nurses stated if the staff needed to unlock the bed, the CNA was expected to ensure the resident was stable in the bed. She stated the bed was to be moved prior to giving peri care and it was safe practice to have two staff in the room when moving a bed as a precaution. The Director of Nurses stated one staff would be on the left side of the bed and the other staff would be on the right side of the bed. She stated moving a bed when staff was at the foot of the bed was not best practice. She stated CNA A did not follow the correct protocol when moving the bed. The Director of Nurses stated CNA A was not to move the bed when standing at the foot of the bed and during peri-care. She stated the facility had purchased walkie-talkies for all staff to use when they may need assistance. The Director or Nurses stated she expected the walkie-talkies to be always with the staff and to use them when they are needing assistance with anything related to a resident care. She stated random checks was being completed with CNA A and the other CNAs during peri-care. The Director of Nurses stated the training and in servicing was ongoing. She stated they were beginning unannounced abuse drills, and this would be follow-up in QAPI. <BR/>Interview on 06/10/2025 at 3:02 PM, the Administrator stated her expectations for peri-care was for staff to ask for assistance, if there was any question about safety concerns. She stated the bed was required to be locked during peri-care. The Administrator stated CNA A was not to move Resident #1's bed during peri-care. She stated if Resident #1's bed needed to be moved, CNA A was expected to move it prior to beginning peri-care. She stated moving Resident #1's bed when CNA A was standing at the end of the bed may have contributed to Resident #1's fall. The Administrator stated the facility's investigation was inconclusive. <BR/>Facility Policy on Perineal Care, revised 04/16/2024, reflected The Purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. <BR/>Preparation:<BR/>1. <BR/>Review the resident's care plan to assess for any special needs of the resident.<BR/>2. <BR/>Assemble the equipment and supplies as needed.<BR/>(note: Enhanced Barrier Precautions would be used during peri care if resident has any qualifying condition).<BR/>Equipment and Supplies<BR/>The following equipment and supplies will be necessary when performing this procedure:<BR/>1. <BR/>Wash basin.<BR/>2. <BR/>Towels<BR/>3. <BR/>Washcloth<BR/>4. <BR/>Soap (or other authorized cleansing agent) or cleaning wipes and <BR/>5. <BR/>Trash bag and personal protective equipment (gowns, gloves, mask, etc., as needed)<BR/>Steps in the Procedure<BR/>1. <BR/>Place the equipment on the beside stand. Arrange the supplies so they can be easily reached.<BR/>2. <BR/>Explain the procedure to resident.<BR/>3. <BR/>Provide privacy.<BR/>4. <BR/>Wash hands and apply gloves. Toilet resident if on the toileting program and or remove brief.<BR/>5. <BR/>Place bed protector under resident's buttocks. <BR/>6. <BR/>Position resident with legs apart (if possible) avoid unnecessary exposure. Use wet washcloth/ cleaning wipes and apply soap/peri wash.<BR/>For a Female resident:<BR/>a. <BR/>Wet washcloth and apply soap or skin cleansing agent.<BR/>b. <BR/>Wash perineal area (between the anus and the vagina), wiping from front to back.<BR/>(1) <BR/>Separate labia (the fleshy folds of skin that make up the external female genitalia) and wash area downward from front to back (Note: if the resident has an indwelling catheter, gently wash the juncture tubing from the urethra (the tube that lets urine leave your bladder) down the catheter about three inches. Gently rinse and dry the area.)<BR/>(2) <BR/>Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in the same directions, using fresh water and a clean washcloth. <BR/>(3) <BR/>Gently Dry perineum.<BR/>c. <BR/>Ask the resident to turn on her side with her top leg slightly bent, if able. <BR/>d. <BR/>Rinse wash cloth and apply soap or skin cleansing agent.<BR/>e. <BR/>Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. <BR/>f. <BR/>Rinse and dry thoroughly.<BR/>Facility Policy on Fall Prevention Program, reviewed on 06/10/2024, reflected a fall can be defined as: when a resident is found on the floor; a resident slides to the floor unassisted; a resident rolls off the bed/chair onto the floor, including bedside mat; and a resident fall off any apparatus/equipment used for transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one (Resident #1) of four residents reviewed for pain in that:<BR/>The facility failed to properly assess or provide effective pain management to Resident #1 after a new onset of pain following the accidental fracture of her left tibia during a transfer from wheelchair to her bed. <BR/>This failure could place residents at risk of not receiving the highest practicable care through resident assessments by recognizing and addressing the physical dysfunctions in an effective and timely manner to prevent residents from further harm, injury, or death<BR/>Findings included: <BR/>Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain (pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements), left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). <BR/>Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the resident's cognition was intact. Resident #1 did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed to require staff to stabilize her when moving from a seated to standing position, moving on and off the toilet, and surface-to-surface transfers. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. <BR/>Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions included that the resident required extensive assistance by two staff members. Resident #1 required extensive assistance by one staff member with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions included to anticipate the resident's need for pain relief and respond immediately to any complaint of pain; identify and record previous pain history and management of that pain and impact of function; identify previous response to analgesia (treatment that prevents you from feeling pain while you are awake) including pain relief, side effects and impact on function; monitor/document for probable cause of each pian episode; and remove/limit causes where possible. Resident #1's further interventions were: monitor/document for side effects of pain medication; administer analgesia as per orders; give &frac12; hour before treatments or care; notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain; provide the resident and family with information about pain and options available for pain management; and discuss and residents' preferences . <BR/>Record review of Resident #1's Physician Orders last reviewed on 07/31/2023 reflected Resident #1 had a physician order for Norco Oral Tablet 7.5-325 milligram give tablet by mouth every four hours as needed for pain. <BR/>Record review of Resident #1's Physician Orders last reviewed on 07/31/2023 reflected Resident #1 had a physician order for Acetaminophen Extra Strength oral Tablet 500 mg by mouth every six hours as needed for pain. <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 6:50 PM, reflected pain medication was given by mouth every four hours for pain. Resident #1 complained of left knee pain and requested pain medication. <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 8:10 PM, reflected the MD was notified of resident's complaint of pain to the left knee and left knee was slightly swollen. Awaiting return call. <BR/>Record review of Resident #1's nurses notes dates 09/18/2023 at 9:14 PM, reflected the MD returned call and ordered an x-ray to the left knee. <BR/>Record review of Resident #1's nurses notes dated 09/18/2023 at 11:41 PM, reflected pain medication was given by mouth every four hours as needed for pain. Resident #1 reported pain to her knee. (Did not specify which knee). <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 1:05 AM, reflected the pain medication was effective and follow-up pain scale was zero<BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 4:15 AM, reflected pain medication was given to the resident. Resident #1 was complaining of pain to her left knee and requested pain medication. <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 8:09 AM, reflected report was received from LVN A concerning Resident #1 had an order for a left knee x-ray. LVN B notified the x-ray company and was informed the x-ray company would be at the facility as soon as possible. Resident aware. Signed by LVN B <BR/>Record review of Resident #1's nurses note dated 09/19/2023 at 10:05 AM, reflected Was the resident in pain?<BR/>0-no pain, 1-3 - mild pain , 4-6- moderate pain , 7-10- severe pain. Every shift follows MD orders. Resident #1 complained of pain to left knee.<BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:06 AM, reflected pain medication was administered. Give one tablet by mouth every four hours as needed for pain. <BR/>Record review of Resident #1's nurses notes dated 09/ 19/2023 at 10:26 AM, reflected the x-Ray company was unable to do the x-ray at the facility for Resident #1's left knee. Resident #1 would be transferred via EMS to the hospital for an x-ray to her left knee. Resident #1 aware and the family was notified. <BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:44 AM, reflected EMS was at the facility to transport the resident to hospital. <BR/>Record review of Resident #1's nurses notes dated 09/19/2023 at 10:47 AM , reflected the pain medication was ineffective and follow-up pain was a five (moderately strong pain). Resident #1 was transferred to emergency room for evaluation and treatment. <BR/>Record review of Resident #1's pain assessments reflected there was only one pain assessment completed from 07/21/2023 through 09/19/2023. <BR/>Record review of Resident #1's pain assessment dated [DATE] reflected Resident #1 had been in pain for the past five days. She frequently had pain. Resident #1 was assessed she had difficulty completing her day-to-day activities as related to her pain. Her pain was moderate. Resident #1 was on scheduled pain medication. Signed by the MDS Coordinator. <BR/>Record review of Resident #1's hospital records from the emergency room Hospital A dated 09/19/2023 reflected Resident #1 was transferred by EMS with a complaint of knee pain. She was being transferred between the bed and wheelchair yesterday (09/18/2023) in the facility where she resided when her knee twisted and then became painful and swollen. EMS reported she was given 7.5 milligram of pain medication this AM (09/19/2023) for pain. The EMS did not know the time the pain medication was administered. admission: Urgent, admission Source: Nursing Home. Nursing Assessment: extremity lower. There was obvious swelling to the knee and there appeared to be slight angulation (two ends of the broken bone are at an angle to each other) of the leg. No bruising or open wounds noted to the knee. <BR/>Record review of Resident #1's doctors notes from the emergency room Hospital A dated 09/19/2023 reflected Resident #1was transferred to the hospital on [DATE] from the nursing home where she resided. On 09/18/2023 Resident #1 was being rotated out of her wheelchair when the staff heard a popping noise from her left knee, and she had called out in pain. The staff noticed on 09/19/2023 the knee continued to be swollen and very painful for the patient when she was moving her knee. Resident #1 was transferred to emergency room for evaluation for possible knee dislocation or knee fracture or any injury. Resident #1was able to express that she felt a significant amount of pain when her left knee was mobilized. The x-ray result reflected Resident #1 had traumatic fracture of the distal femur ( where the bone flares out like an upside-down funnel) <BR/>Record review of Resident #1's emergency room clinical course and plan reflected, Resident #1 had a distal femur fracture. The fracture was acutely comminuted fracture (a type of fracture where broken bones fracture into more than three separate pieces). Resident #1's pain was under control if the leg was immobile. Two rigid boards were placed on the side of the knee and an ace bandage was used to wrap around the knee for compression and stability. Resident #1 would be transferred to a hospital with orthopedics. Resident #1 required a higher level of care. <BR/>Record review of Resident #1's emergency room history and physical from a hospital B dated 09/20/2023 reflected chief complaint of Resident #1: Left knee pain after hearing a pop, being lifted from wheelchair to bed. Resident #1 was transferred from the nursing home following left knee pain during the time when the staff were trying to transition her from her wheelchair to her bed. There was a popping noise and Resident #1 had immediate pain. Resident #1 was seen today (09/20/2023) in the hospital bed with her left leg splinted. Imaging studies reflected: X-ray of the left knee, two views reflected impression, acute mildly comminuted fracture of the distal femur medtadiaphysis (a type of fracture where broken bones fracture more than three separated places - medtadiaphysis is a term used to describe the combined region of a long bone and the shaft of the bone. Lesions that span both regions). Plan: to admit to surgical unit. <BR/>Record review of the Daily Nurses Schedule for 09/18/2023 for the 6:00 PM - 6:00 AM shift reflected LVN A was the only nurse in the facility. There was not another nurse the staff could report Resident #1 was in pain. LVN A was the only nurse on duty. <BR/>Observation on 09/20/2023 of Resident #1's electronic monitoring video supplied by the family revealed on 09/18/2023 revealed the following:<BR/>- At 05:44 PM, the COTA/Marketing Coordinator stated to Resident #1 she had not transferred Resident #1 before, and asked Resident #1 if she was able to help during transfers or did, she need a gait belt. The COTA/Marketing Coordinator stated she was going to find a gait belt. <BR/>-At 05:49 PM, the COTA/ Marketing Coordinator and PTA began transferring Resident #1 from the recliner to the wheelchair ( on 09/18/2023 PM) Resident #1 complained about her back hurting but was not yelling. <BR/>- At 05:52 PM, the COTA/Marketing Coordinator and PTA began to transfer Resident #1 ( by 2 person assist with gait belt) from her wheelchair to her bed in PM. Resident #1 was not yelling or complaining about pain. Resident #1 was transferred to her bed and as soon as she sat on the bed, she began to yell that her knee was hurting, and her knee was broken. <BR/>- At 05:53 PM, Resident #1 began to rub her left leg as she continued to yell. Resident #1 continued to yell when staff would touch her left leg or move her left leg. Resident #1 would scream she was hurting. <BR/>- At 6:00 PM. Resident #1 stated to PTA that they turned her around and Resident #1 was looking at PTA as she made the statement. The PTA stated to Resident #1 they did not mean to hurt her. <BR/>In an interview on 09/20/2023 at 12:58 PM the Director of Nurses stated anytime a resident was requesting a pain medication or makes a statement they are in pain; prior to giving the pain medication the nurse was expected to ask the resident where the pain was located and to ask the resident on a scale of 0-10 with zero meaning no pain and ten being the highest pain level what was the resident's pain level was. She stated the nurse was expected to document that information in the nurses notes of where the pain was located and the pain scale. The Director of Nurses stated a pain assessment was required to be completed when a resident reported they were in pain. She also stated the nurse administering the pain medication was the nurse expected to complete the pain assessment. She stated there was only one pain assessment in Resident #1's electronic medical record. The Director of Nurses stated pain assessment was required whenever a resident complained about being in pain. She stated Resident #1 did yell al lot when she was in pain and was in pain al lot. She stated if Resident #1 complained about her left knee and leg hurting that was a new pain for Resident #1. She stated if Resident #1's left knee was swollen the nurse was expected to do a complete pain assessment and possibly incident report to determine if anything happened during the resident's transfer from the wheelchair to the bed. The Director of Nurses stated it was reported to her by the PT/ Marketing Coordinator on 09/19/2023 Resident #1 was yelling her left knee and left leg were hurting after she was transferred from the wheelchair to the bed. She stated the nurse was expected to gather information from the COTA/Marketing Coordinator and PTA who transferred Resident #1 and possibly needed an incident report completed and the nurse was required to completed a pain assessment or do some type of assessment of the resident. The Director of Nurses stated Resident #1 only yelled out when she was in pain. She stated she was not aware of any behavior problems Resident #1 had with staff or with anyone. She stated Resident #1 should have been transferred to the emergency room on [DATE] after the nurse received orders for the x-ray. She stated the x-ray company does not come to the facility if there is an x-ray needed any time after 5:00 PM and before 8:00 AM. She also stated the nurse was expected to complete a pain assessment or document in the nurses notes of Resident #1 complaining about her knee and the knee swelling. She stated the nurse on duty that night was responsible for documenting on Resident #1 on 09/18/2023. <BR/>In an interview on 09/20/2023 at 2:41 PM the COTA/Marketing Coordinator stated she heard Resident #1 yelling for help around 6:00 PM on 09/18/2023. She stated when she entered Resident #1's room at approximately 6:05 PM Resident #1 was needing assistance to be transferred to her bed from her recliner. She stated she explained to the resident she needed to find a gait belt and get someone to help her with the transfer. The COTA / Marketing Coordinator stated she asked PTA C to assist her transferring Resident #1. She stated the PTA assisted her with Resident #1's transfer from the recliner to wheelchair. She stated Resident #1 complained about back pain. The COTA/Marketing Coordinator also stated Resident #1's wheelchair was positioned beside the bed to transfer onto her bed. She stated she was in front of the resident, and they placed the gait belt on the resident and assisted her from the wheelchair. They pivoted the resident for her to sit on the bed. She stated resident was not yelling during the transfer, however, within few seconds of the resident sitting on the bed the resident began to yell my knee hurts. She stated Resident #1 repeated stating her knee hurt. The COTA/ Marketing Coordinator stated she and PTA C assisted the resident to lie in bed in a supine position (resident is face up with their head resting on a pad positioner or pillow),and that was when she noticed Resident #1's knee began to swell. She stated Resident #1 complained of her pain being at 10 on a pain scale of zero being in no pain to ten being in extreme pain. She stated the PTA stayed in the room and she left the room to report that to the LVN A at approximately 6:30 PM. She stated LVN A did not go to Resident #1's room to assess the resident. She stated LVN A was at her nurses' cart preparing to administer medications. She stated she explained to LVN A Resident #1 was in extreme pain in her left knee and the knee was swelling. She stated she stayed at the facility until she knew Resident #1 was going to be seen by the nurse. She stated it was approximately 8:30 PM when the nurse entered Resident #1's room for the first time after she reported Resident #1's pain and swelling to LVN A. She stated she did become frustrated with LVN A ignoring Resident #1's pain and knee swelling that she told her just give Me the medicine and she will give it to her. She stated she could not stand to see Resident #1 in pain any longer and the nurse would not come to the Resident #1's room. The COTA/ Marketing Coordinator stated she got the pain medication from the nurse and took it to Resident #1 and gave the pain medication narco to Resident #1. She stated after numerous times of reporting to LVN A to go assess Resident #1, the LVN A stated the resident is always in pain that is not anything new. The COTA/ Marketing Coordinator stated she was so upset because she stated she kept reporting to LVN A about Resident #1's condition with her left knee and she continued to ignore her. She also stated she called the Administrator on 09/18/2023 ( did not recall the time). She stated she informed the Administrator Resident #1 had pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing and go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment on her or giving her pain medication when Resident #1 was in pain more than an hour before LVN A gave me the pain medication to give to Resident #1. She stated she had to do something because Resident #1's left knee swelling was increasing, and the pain was getting a lot worse. <BR/>In an interview on 09/20/2023 at 3:41 PM LVN D stated Resident #1 yells out frequently. She stated when she is yelling, she is in pain. LVN D stated the resident complains about her back hurting. She stated everyone knew Resident #1 yelled frequently when she was in pain. She stated there were times when she was speaking to Resident #1, and she was complaining/ yelling with pain, and she would administer her ordered pain medication without asking Resident #1 where she was hurting or her pain level. She stated she has not ever completed a pain assessment on Resident #1 but now she realized she was required to complete a pain assessment and document in the nurses notes about Resident #1's pain. She also stated the nurses were expected to ask where the pain was located and the pain level on a scale of zero-ten. She stated zero was- no pain and ten was extreme pain. She stated due to Resident #1 complaining about pain all the time the nurses would give her the pain medication if it was scheduled and not ask her any questions. She stated if she had been working on the night of 09/18/2023 and Resident #1 was complaining about pain in her knee she would have given her pain medication and probably would not have asked any questions or completed any type of incident report or pain assessment due to Resident #1always complained about pain. She stated that was her normal behavior. LVN D stated the resident did not have any behavior problems. She stated she would yell but only when she was in pain. She stated Resident #1 was cooperative with staff and did not have any behavior issues. LVN D stated she has given care to Resident #1 numerous times. She stated it varied from week to week, but she was very familiar with Resident #1's physical condition, moods, and behaviors. LVN D stated Resident #1 will yell out when she is in pain. She stated she had severe back pain and had an MRI. She also stated when Resident #1 was in pain she did not assess the resident to determine if it was a new pain or pain from her back. She stated everyone knows if Resident #1 is in pain she will yell, and they do not assess the pain very closely when giving pain medication. She stated the nurses gives her anti -anxiety medication to prevent her from yelling. She also stated she did not believe any assessment was required when she was yelling about pain in her knee. She stated she was not working on 09/18/2023 but she would not have completed a pain assessment on resident. <BR/>In an interview on 09/20/2023 at 8:11 PM Resident #1's family member stated he witnessed from the camera in Resident #1's room on 09/18/2023 at 5:51 PM, staff breaking Resident #1's leg, Resident #1 complaining of pain and staff saying back to Resident #1 you know you're not hurt. He stated the staff said to Resident #1 she complained about her back hurting before too and it was nothing. He stated staff did not call the family to notify them of the incident until 09/19/2023 and an ambulance was called to transfer Resident #1 to the hospital on [DATE]. He also stated when the staff began to realize Resident #1 was in pain one of the staff turned the volume up on the television where it was difficult at times after those statements to hear what staff was saying. <BR/>On 09/21/2023 at 11:00 AM, attempted to contact LVN A and was unable to leave a message.<BR/>On 09/21/2023 at 11:05 AM, attempted to contact CNA H and left a voice message . CNA H was in Resident #1's room for few minutes on 09/18/2023. <BR/>In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated that occurred 09/18/2023 approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of the resident and placed the gait belt around the resident's waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell her knee hurt. PTA C stated she assumed it was similar of her complaining about her back pain. She stated at some point Resident #1 stated her left leg was broken. PTA C also stated she realized that was a different type of pain than what she has complained in the past. She stated the COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to assess Resident #1 due to her knee continuing to swell and becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not go to Resident #1's room to give her pain medication or assess her. She stated the nurse gave the PT/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 the pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room at approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee for approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she was hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated oh are you a family member I did not know anyone was in the room. PTA C stated, no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee. PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and the COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in her left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine; she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency and LVN A could have stopped what she was doing and came to Resident #1's room. <BR/>In an interview on 09/21/2023 at 2:45 PM the Administrator stated the COTA/ Marketing Coordinator contacted her on 09/18/2023 in the evening. She stated she did not recall the exact time. She stated she was informed Resident #1 had pain and some swelling in her left knee. She stated she asked the COTA/Marketing Coordinator to inform the nurse to contact the physician and request an x-ray to be ordered. The Administrator stated anytime a resident complained of pain whether it was an old or new pain she expected a pain assessment to be completed. She stated LVN A was expected to assess Resident #1 and ask the staff who was in Resident #1's room questions and contact the DON with the information. She stated LVN A did not follow protocol of assessing Resident #1, completing a pain assessment, and asked staff questions of how Resident #1 knee began to swell and why Resident # 1 believed her leg was broken. The Administrator stated Resident #1 needed an x-ray on 09/18/2023 and if the x-ray company could not come to the facility, the nurse was expected to call the MD and request for Resident #1 to be sent to the emergency room that night. She stated if Resident #1 was in pain and complaining of her left knee being broken on 09/18/2023, 911 needed to be called and EMS transfer her to the hospital. She stated anytime a resident complains of pain the nurse was expected to ask the resident where the pain was located , the level of the pain, and to document all that information in the nurses notes and complete a pain assessment. She stated if Resident #1 had new pain after a transfer, the nurse was expected to ask the staff questions about the transfer, immediately do an assessment, and begin an incident report (reviewed incident reports and did not observe any incident reports of this incident of Resident #1 on 09/18/2023) if needed. She stated the nurse was expected to contact the DON with the information and after she contacted the physician, then call 911 to transfer Resident #1 to emergency room. The Administrator stated it was not best practice to have a resident in the facility from the night of 09/18/2023 until the morning of 09/19/2023 in pain with a possible left leg or knee fracture. She stated it was the DON's responsibility to monitor the nurses to ensure they are following protocol. <BR/>In an interview on 09/22/2023 at 8:40 AM Med Aide E stated she had given medications to Resident #1 except pain medications and her anxiety medications. She stated whenever Resident #1 has reported to her she was in pain she would inform the nurse. She stated Resident #1 did not exhibit any behavior problems; however, she would yell only when in pain. She stated other than yelling she was not aware of any behavior problems with Resident #1. She also stated if a resident had new pain and was complaining for hours of being in pain and had stated her leg or knee was broken, the resident needed to be transferred to emergency room immediately. Med Aide E stated Resident #1 was alert and oriented and was able to verbalize her pain, and the nurse needed to listen to Resident #1 and should know it could be serious and needed immediate medical attention in the hospital. She stated she would continue to ask the nurse to send a resident to hospital if the resident was complaining of knee pain, if the knee was swollen, and if resident stated her leg was broken. <BR/>In an interview on 09/22/2023 at 9:05 AM, LVN B stated Resident #1 did complain about pain frequently. LVN B stated the resident did not have any behavior problems except for yelling when she was in pain. She stated whenever a resident complained about pain, the nurse was expected to ask where the pain was located and complete a pain scale assessment with zero indicated no pain and ten indicated extreme pain. She stated that was to be documented in the nurses notes at the time of administer the pain medication. LVN B also stated the nurse was expected to speak to the resident within 2 hours and determine if the pain medication was effective. She stated a pain assessment was required whenever a resident was in pain. She stated she had given medications to Resident #1 when she had been in pain. She also stated there should be more than one pain assessment completed on Resident #1 due to her having pain a lot. She stated a nurse giving the resident pain medication since she had been admitted should have completed a pain assessment on Resident #1. She stated the nurse would document the pain level on the MAR when they interact with a resident. LVN B stated, however, the resident may have pain during the shift and there was not a place on the MAR to document that pain. She stated when a resident had pain during the shift where the pain is located, and the pain level was required to be documented in the nurses notes prior to administering pain medication. She also stated if the pain was not a zero, a pain assessment was required to be completed. She stated she was surprised that only MDS Nurse completed a pain assessment. <BR/>In an interview on 09/22/2023 at 9:55 AM, LVN F stated if any staff reported a resident was having a new pain and their knee was swelling, she would immediately go to that resident's room and assess the resident. She stated she would complete a pain assessment and if resident were in severe pain and has stated her leg was broken, she would contact the MD immediately and if the MD did not return call within 5 minutes, she would immediately call 911. She stated if a nurse did not complete an assessment on the resident or ask the other staff questions of what might have caused the knee to swell, she did not follow proper protocol. LVN F stated the nurse was expected to assess residents whenever there is a change of condition and a new pain in the knee with swelling and the resident yelling her leg was broken, that is a change of condition. She stated she did not give care very often to Resident #1, but she did know Resident #1 would yell when she was only in pain. She stated Resident #1 should not have stayed in the facility all night if she said her left leg was broken, if her left knee was swelling, and she was in extreme pain . She stated Resident #1 needed to be transferred to the emergency room the night of 09/18/2023. She stated anytime a resident voices pain to a nurse, or another staff reports a resident was in pain the nurse was to complete pain assessment. She stated the nurse was required to ask the resident where the pain is located and the pain level using the pain scale of zero which indicated no pain and a ten which indicated extreme pain. She s[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents' needs as identified through resident assessments and described in the plan of care for one of one resident (Resident #1) one of one nurses and one of one COTA reviewed for competent nursing staff. <BR/>The facility failed to ensure nursing staff were properly trained and nursing staff failed to report to management when the nurse gave the COTA a pain pill to administer to Resident #1. <BR/>This failure could place residents at risk for serious injury, serious harm, serious impairment, or death.<BR/>The findings include:<BR/>Record review of Resident #1's face sheet, dated 09/22/2023, revealed Resident #1 was an [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses which included low back pain ( pain between the lower edge of the ribs), signs symptoms of musculoskeletal system ( mild to severe aches, low back pain, numbness, tingling, atrophy, and weakness), muscle weakness ( a lack of strength in the muscles), osteoporosis without current pathological fracture (generally caused by a fall from a standing height or lower and usually involves the spine, hip or wrist), lack of coordination (uncoordinated movement due to a muscle control problem that causes an inability to coordinate movements) left foot drop ( caused by weakness of the muscles involved in lifting the front part of the foot) and, abnormalities of gait and mobility (when a person is unable to walk in the usually way). <BR/>Record review of Resident #1's Annual MDS assessment, dated 07/28/2023, reflected Resident #1 had a BIMS score of fifteen, which indicated the residents' cognition was intact. Resident did not reject care. Resident #1 was assessed to require extensive assistance by two staff members for transfers. She required extensive assistance by one staff for bed mobility and toileting. Resident #1 was also assessed to require limited assistance by one staff for personal hygiene. She was assessed require staff to stabilize her when moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer. Resident #1 was on scheduled pain medication and PRN pain medication. She had frequent pain. Resident #1 did not exhibit any behaviors. <BR/>Record review of Resident #1's Comprehensive Care Plan completed on 08/17/2023 reflected Resident #1 had an ADL self-care performance deficit. Interventions: resident required extensive assistance by two staff members with transfers. Resident #1 required extensive assistance by one staff members with bed mobility. Resident #1 was at risk for falls related to gait/balance problems. She had limited physical mobility. Resident had chronic pain related to osteoporosis (a condition when bone strength weakens) Interventions: anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Identify and record previous pain history and management of that pain and impact of function. Identify previous response to analgesia including pain relief, side effects and impact on function. Monitor/ document for probable cause of each pian episode. Remove/limit causes where possible. Resident #1's further interventions were: Monitor/document for side effects of pain medication. Administer analgesia as per orders. Give &frac12; hour before treatments or care. Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's experience of pain. Provide the resident and family with information about pain and options available for pain management. Discuss and resident preferences . <BR/>Record Review of the video provided by the family member on 9/18/2023 reflected COTA/ Marketing Coordinator and PTA was in Resident #1's room. The COTA/ Marketing Coordinator exited Resident #1 room at 6:09 PM. PTA stayed in Resident #1 room and was talking to Resident #1. Resident #1 stated several times I think it is broken as she was rubbing her left leg. COTA/ Marketing Coordinator entered Resident #1's room and at 6:12 PM she began to open the small clear plastic pouch with medication been crushed and poured it into a medication cup. COTA/ Marketing Coordinator opened a small container of apple sauce and put apple sauce in the medication cup with the medication. COTA / Marketing Coordinator began to stir the medication in the cup and at 6:13 PM the PTA poured some more crushed medication into the cup. COTA /Marketing Coordinator asked Resident #1 if she wanted her medicine. She also asked Resident #1 if she wanted to take one big bite and at 6:13 PM COTA/ Marketing Coordinator gave Resident #1 her medication. COTA/Marketing Coordinator asked Resident #1 how long it took for her medicine to help her. <BR/>Record review of Resident #1's medication administration record for the month of 09/2023 reflected on 09/18/2023 there was not any medication signed out by anyone around the time of 6:09 PM. The PRN medication was signed out be LVN A at 6:50 PM and at 11:41 PM. <BR/>In an interview on 09/20/2023 at 2:41 PM, the COTA /Marketing Coordinator stated she reported to LVN A on 09/18/2023 from 6:00 PM, until approximately 09/18/2023 at 8:25 PM of Resident #1 complaining of pain in knee and left leg. She stated she also reported to LVN A that Resident #1 was making statements her knee was broken. She stated she explained to LVN A Resident #1 was in severe pain. She stated LVN A made the remark that that is normal for Resident #1, she was always complaining about being in pain and that was nothing new. The COTA/Marketing Coordinator stated LVN A was informed of the information at approximately 6:10 PM and LVN A did not go to Resident #1's room until approximately 8:30 PM. She stated either she or the PTA was always in Resident #1's room from around 6:00 PM until 8:45 PM. She stated LVN A would not go to Resident #1's room to administer pain medication and the resident was in pain for at almost 2 hours. She stated she asked LVN A to give her the pain medication and she would administer it to Resident #1. She stated LVN A gave her the pain medication (Norco) and she gave it to Resident #1. She stated she could not sit by and watch Resident #1 be in pain for an hour or more and the nurse refused to go to Resident #1's room due to believing Resident #1 was complaining for no reason. She stated it was difficult to even talk to LVN A due to her expressing no compassion towards Resident #1 and not wanting to assess her to determine if anything was wrong with Resident #1. She also stated she called the Administrator on 09/18/2023 (did not recall the time). She stated she informed the Administrator of Resident #1's pain and swelling in the left knee. She stated the Administrator advised her to speak with the nurse and explain to the nurse to call the MD and have x-rays ordered. She stated she spoke with LVN A and explained the Administrator stated to call the MD and have x-rays ordered. She stated LVN A was organizing to pass out medications and began to pass medications and there was not an emergency occurring where she could not stop what she was doing to go to Resident #1's room. She stated she did not feel comfortable leaving Resident #1 on 09/18/2023 due to LVN A not going to Resident #1's room to complete an assessment or make any type of observation of why Resident #1 was in extreme pain. She stated Resident #1's left knee continued to become larger, and she was going to report Resident #1's condition approximately every 10 minutes and the nurse stated to the COTA/Marketing Coordinator that Resident #1 was ok, that is the way Resident #1 always was and there was not anything wrong with Resident #1. She stated around 8:30 PM LVN A entered Resident #1's room and stated Resident #1's left knee does not look any different than it has in the past. The COTA/Marketing Coordinator stated that LVN A informed her and PTA C to go home, she had this and promised to take care of Resident # 1. She stated LVN A did not assess Resident #1. The COTA/Marketing Coordinator stated when she came on duty on 09/19/2023 the ambulance was in front of the facility transferring Resident #1 to the hospital. She stated she was shocked and could not believe LVN A allowed Resident #1 to remain in the facility that night without getting an x-ray or doing anything to ensure Resident #1 did not have any broken bones. The COTA/Marketing Coordinator stated she did believe LVN A was neglecting Resident #1. She stated LVN A refused to go to Resident #1's room and complete an assessment approximately 2 hours after being informed of Resident #1's left knee/leg pain and Resident #1 stating she thought her leg was broken. She stated she was upset, and the nurse ignored her whenever she reported anything about Resident #1. She stated LVN A neglected Resident #1 on 09/18/2023. <BR/> In an interview on 09/21/2023 at 12:00 PM, PTA C stated the COTA/ Marketing Coordinator asked her to help her transfer Resident #1 from her recliner to the wheelchair and then to the bed. She stated that occurred 09/18/2023 approximately 6:00 PM. She stated Resident #1 was transferred from the recliner to the wheelchair and Resident #1 complained about her back hurting after the transfer. She stated Resident #1 was assisted by the bed in her wheelchair to prepare for the transfer from the wheelchair to the bed. She stated once Resident #1 was in her wheelchair by the bed she was calm and quit complaining about her back hurting. PTA C stated the COTA/ Marketing Coordinator was in front of the resident and placed the gait belt around the resident's waist. She stated they began to transfer Resident #1 to the bed and as soon as they pivoted Resident #1 onto the bed, she began to yell her knee hurt. PTA C stated she assumed it was similar of her complaining about her back pain. She stated at some point Resident #1 stated her left leg was broken. PTA C also stated she realized that was a different type of pain than what she has complained in the past. She stated the COTA/ Marketing Coordinator left the room to report to LVN A. She stated they kept waiting on pain medication or the nurse to assess Resident #1 due to her knee continuing to swell and becoming larger. She stated Resident #1 would yell in pain when her leg was barely touched or moved. Resident #1 would rub her knee and below the knee onto her left leg and stated it was broken. PTA C stated LVN A would not go to Resident #1's room to give her pain medication or assess her. She stated the nurse gave the COTA/ Marketing Coordinator the pain medication and the COTA/ Marketing Coordinator gave Resident #1 the pain medication. PTA C stated she did not recall the time, but she thought it was around 7:00 PM. She stated LVN A entered Resident #1's room at approximately 8:30 PM. She stated she was in the room while LVN A talked to Resident #1. PTA C stated LVN A looked at Resident #1's knee for approximately 5 seconds and stated her knee is fine. PTA C stated LVN A did not assess Resident #1 or ask her if she was hurting in other areas. She stated LVN A did not ask Resident #1 what her pain level was or if the pain medication was effective. She also stated LVN A did not realize PTA C was in the room. PTA C stated when LVN A saw her in the room she stated, oh are you a family member I did not know anyone was in the room. PTA C stated, no I am not a family member I am a Physical Therapist Assistant at this facility, and I helped assist Resident #1 to be when she began complaining about her knee PTA C stated LVN A did not ask her any questions about the transfer or anything about Resident #1. PTA C stated she informed LVN A that she and the COTA/ Marketing Coordinator had been in the room with Resident #1 since around 6:00 PM after she began complaining about pain in her left knee and stating her left leg was broken. She stated LVN A walked out of the room and stated she is fine; she always complains about pain. She also stated LVN A was preparing to pass out medications and began to pass out meds to residents and there was not an emergency and LVN A could have stopped what she was doing and came to Resident #1's room. <BR/>1. In an interview on 10/18/2023 at 11:35 AM, the Director of Nurses stated only a licensed nurse or a medication aide was the only staff to administer any type of medication to a resident. She stated a non-nurse staff would not know if she was administering the correct medication. She stated it was not the facilities protocol for a non-nurse to administer any medication. She stated a resident could choke and there were protocols to follow when administering medications such as: ensuring it is the correct person by viewing the resident picture on the medication administration record, the nurse required to check to ensure it was the correct medication, ensure it was given at the right time and it was the right dose. She stated if a non-nurse was giving the medication how did that person know the nurse completed all of these precautions prior to placing medicine in the cup and give the medication to the non-nurse. She stated this is not the facility protocol. <BR/>In an interview on 10/19/2023 at 10:40 AM, Med Aide E stated she had been a Med Aide approximately 10 or 15 years and she stated she was taught in med-aide class it was not protocol for a med-aide or a nurse to give medication to a non -nurse staff to administer to a resident. She stated if a nurse or med-aide signs the medication administration form that the nurse or med-aide gave the medication and then give the medication to a non-nurse, a nurse or med-aide could lose their license. She stated anything could go wrong with a non -nurse administering any type of medication. Med Aide E stated how does the nurse knows the non -nursing staff will give it to the resident. She also stated there were certain residents required their medication be administered a certain way such as in pudding or may need extra water to ensure the resident swallowed the pill. She stated this was against nursing protocol and she would never allow anyone give medication she had put her initial on the medication administration record. She stated whoever signs the record they are responsible for the medication. Med-Aide E also stated if a nurse gave medication to a non-nurse staff the nurse was 100 percent wrong. She stated a resident could choke on the medication, may pocket the medication, and not swallow the medicine. She stated there was a cluster of mistakes possibly could occur with the resident. She also stated when administering medications, the nurse or med-aide was expected to look at the picture on the MAR prior to administering the medication. <BR/>She stated she had been in serviced on medications on 10/19/2023 from the ADON. She stated the ADON discussed all medications was only to be administered by nurses and med-aides and if you are not a licensed nurse or medication- aide do not take any medications from the nurse or medication aide and administer the medication to a resident. <BR/>In an interview on 10/19/2023 at 10:50 AM CNA P stated she received an in-service on medications from the ADON on 10/19/2023. She stated anyone who was not a nurse or medication -aide was not to give medicines to a resident or take medications from the nurse or med-aide. <BR/>In an interview on 10/19/2023 at 11:15 AM, LVN D stated the ADON gave an in-service on 10/19/2023 about not giving medications to a non-nurse staff for them to administer medication to a resident. She stated it could be dangerous for the resident if a non-nurse gave a resident medication. She stated a resident could choke and how did the nurse know the staff would not take the medication themselves and not give it to the resident. She stated when she gives medications, she views the medical medication record and compares it to the medicine located in the package. She stated when she determined it was the correct medication, she would place the pills in a medicine cup. She stated after she completed this process with all the medicines a resident takes, she would compare the resident to the picture on the mar and then administer the medication. She stated if a resident required medications to be crushed, she would crush the medicines. She stated a resident receiving medication from a non-nurse may choke or have difficulty with swallowing med or may prefer to take the medication a certain way such as place the pill in a certain area in the resident's mouth. <BR/>In an interview on 10/19/2023 at 1:00 PM the Administrator stated she as in serviced on medications by the Corporate Nurse she stated a non-nurse was not qualified to administer medications. She stated only nurses and med-aides were qualified to administer medications. When asked her the potential of what may happen to a resident or with the medication if a non-nurse administer medication to a resident, the Administrator stated she was no clinical and was not answering any questions about medications or the potential result of non-nurse giving medications. That would be a nursing question not an Administrator question. She stated again she was not clinical and don't know what a nurse was supposed to do when administering medications. I will have to refer to the facility policy and protocol I am not familiar with it at this time. When the Administrator was asked if she was not in serviced by the corporate nurse today, she stated I will not answer any questions. The administrator left the conference room and did not return for further interview. <BR/>2. In an interview on 10/19/2023 at 1:20 PM the ADON stated she stated gave in-service on 10/19/2023 to all staff about medications. She stated she in serviced all staff related to only licensed nurses and medication-aides were the only staff to administer any type of medication to a resident. She stated there was a possibility a resident could choke when given a medication and if a non-nurse was giving the medication there were several negative possibilities could happen to the resident. The ADON stated she could keep naming them, but she believed point was made of negative outcome with possible choking. She stated there were 5 rights on giving medications. She stated all nurses and med-aides was expected to follow the 5 rights: Right Person, Right Medication, Right Route, Right Time, Right Dosage<BR/>The ADON stated when a nurse was administering medication it was expected for the nurse to view the resident picture in the medication administration record and to ensure when administering the medication, it was to the right person and had the right dose and medication. She stated as a nurse she would not expect a non-nurse to administer medications. She stated she did not have any idea how the non -nurse would know if she was giving the right medication. The ADON also stated she did not know why the nurse gave the medication to the non-nurse. She stated she was not aware of the knowledge the non-nurse had about medications. <BR/>Record Review of the in-service on Medication Administration given by the ADON ( the in-service was not dated but was verified by the Administrator this was the in-service given to all the staff by the ADON. The in-service consists of the following:<BR/>1. All medications should only be administered by a licensed nurse or medication aide.<BR/>2. If you are not a licensed nurse or medication aide. Do not take medication from a licensed nurse or medication aide and administer the medication to a resident. <BR/>Record Review of in-service on Medication Administration given by the Administrator and Corporate Clinical Specialist on 10/19/2023. A video was shown to all staff on medication administration training from the corporate you tube video. The video explained how to administer medication correctly. There were not any details about the video shared prior to exit. <BR/>Record Review of in-service on medications not dated, however, it came from a binder dated January 2023 to June 2023. The in-service was on medications need to be given in a timely manner. Medication times are part of the five medication rights such as:<BR/>1. Right person<BR/>2. Right medication<BR/>3. Right time<BR/>4. Right route<BR/>5. Right dosage<BR/>LVN A attended this in-service. <BR/>Record Review of the facility policy on Administering Medications dated 04/2019 reflected the following:<BR/>1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. <BR/>2. The individual administering medications verifies the resident's identity before giving the resident his/her medications. <BR/>3. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method of administration before giving the medication. The individual administering the medication initials the resident's medication administration records in the resident's medical record: the date and time the medication was administered, the dosage, the route of the administration, any complaints or symptoms for which the drug was administered, any results achieved and when those results were observed and the signature and title of the person administering the drug.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview, and record review the facility failed to ensure residents were free from abuse for 1of 8 residents (Resident #1) reviewed for Abuse.<BR/>The facility failed to ensure Resident # 1 was free from Abuse, as a result Resident #1 was assaulted by Resident #2 on two different occasions and was injured. <BR/>This failure placed all residents at risk for being assaulted by Resident # 2. <BR/>Findings included: <BR/>Review of Resident #1's face sheet reflected that he was a 62- year- old man, admitted to the facility on [DATE]. The face sheet reflected Resident # 1 had a diagnosis of Chronic Congestive heart failure (A chronic condition in which the heart doesn't pump blood as well as it should), Type 2 Diabetes with kidney complication ( a chronic condition that affects the way the body processes blood sugar), Chronic Kidney disease (A loss of kidney function) , Obesity (A disorder involving excessive body fat that increases the risk of health problems), age related cataract (when the lens you're the eyes start to break down and clump together), partial traumatic amputation ( when some of the soft tissue still remains) at knee level, left lower leg. <BR/>Review of Resident # 1's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 15 which indicated Resident # 1 had the cognitive ability to make his wants and needs known. Section G functional status of the MDS reflected Resident # 1 required extensive assistance with toileting, bathing, dressing and transfers. <BR/>Review of Resident # 1's care plan dated 4/21/2023 reflected the following goal: Resident # 1 was at risk of loss of ROM (range of motion). Resident # 1 had the following goal: Resident # 1 will improve current level of function in ADL's. The plan had the following interventions<BR/>1. <BR/>Bed mobility: Supervision x1<BR/>2. <BR/>Transfer limited: Limited x1<BR/>3. <BR/>Toileting: Extensive x1<BR/>4. <BR/>Eating: Supervision with set up help<BR/>5. <BR/>Staff assist with ROM (range of motion) daily when direct care is provided to help prevent loss<BR/>Review of Resident # 2's face sheet reflected, a [AGE] year-old man, admitted to the facility on [DATE]. Resident # 2 had a diagnosis of Unspecified Dementia (A mental disorder in which a person loses the ability to think, remember, learn, make decisions, and sole problems) and Cognitive Communication deficit (difficulty with thinking and how someone uses language).<BR/>Review of Resident # 2's quarterly MDS, dated [DATE] reflected a BIMS score of 99 which indicated the interview was not able to be completed. Section G functional status of the MDS reflected Resident #2 required extensive assistance with dressing, total dependence with bathing, eating and some assistance with walking at least 50 feet with turns. <BR/>Review of Resident # 2's care plan dated 4/14/2023, focus Resident # 2 was evaluated as a wandering risk, decreased safety awareness, confusion, and wandering behavior. The care plan reflected the following goal. Resident # 2 will remain free of injuries associated with wandering behaviors. The plan had the following interventions: <BR/>1. <BR/>Encourage to participate in activities of preference <BR/>2. <BR/>Utilize a wander bracelet <BR/>3. <BR/>Observe fore signs/symptoms of agitation, pacing, repetitive verbalizations of wanting to leave, restlessness <BR/>4. <BR/>Provide re-orientation as needed<BR/>5. <BR/>Check wander guard by nurse for placement and function if wander guard is removed replace or place on increased <BR/>monitoring of resident's whereabouts <BR/> Resident # 2care plan reflected the following focus: Resident #2 has potential to be physically aggressive/Dementia. Goal: Resident # 2 will demonstrate effective coping skills. The care plan had the following interventions: <BR/>1. <BR/>Resident's triggers for physical aggression are loud noises.<BR/>2. <BR/>Administer medication as ordered<BR/>3. <BR/>Analyze times of day, places, circumstances, triggers<BR/>4. <BR/>Provide physical and verbal cues to alleviate anxiety, give positive feedback <BR/>5. <BR/>Family to provide sitters in the evenings to monitor resident 1:1<BR/>6. <BR/>Monitor resident every 15 min. continuously <BR/>7. <BR/>When resident becomes agitated: Intervene before agitation escalates<BR/>8. <BR/>Guide from source of distress <BR/>Resident # 2 care plan reflected the following focus: Resident # 2 has impaired cognitive function/dementia or impaired thought processes. Goal: To improve current level of cognitive function. The care plan has the following interventions: <BR/>1. <BR/>Cue, orient, supervise as needed<BR/>Record review of progress note dated 4/2/6/2023 by LVN reflected Resident # 1 was heard yelling help. The note reflected when the LVN got to Resident # 's room she found Resident # 1 hanging halfway off the right side of his bed and Resident # 2 standing at the foot of Resident # 1's bed. The LVN stated she assisted Resident # 1 back into his bed, and Resident # 1 was observed to have redness to the left side of his face. Resident # 1 stated Resident # 2 came into his room and when he asked him to leave, he started hitting him with both hands and with a closed fist. <BR/>Record review of progress note dated 4/30/2023 by LPN reflected there was screaming heard coming from Resident #1's room. LPN stated someone yelled that two Resident's hitting each other. LPN stated when she arrived at Resident # 1's room she observed another staff already in the room that had Resident # 2 from behind and directed him out of Resident # 1's room. The LPN stated Resident # 1 was assessed to have a scratch to the right side of his chest next to an old surgery wound, redness to the back of the neck, his gown was torn from where Resident # 2 had pulled and grabbed Resident # 1, and he complained of pain however, did not want to go to the hospital. The note reflected Resident # 1 reported that Resident # 2 came into his room and punched him multiple times. The note reflected Resident # 1 wanted to call the police and file charges against Resident # 2. <BR/>Record review of progress note dated 4/20/23 by LPN reflected Resident # 2 got behind another resident unknown in a wheelchair and gripped the back of the resident's chair. Resident # 2 was asked to let go of the resident's chair; Resident #2 became upset and gripped the chair tighter and started cursing and shaking his hand in the nurse's face. The note reflected Resident # 2 tried to hit the resident in the wheelchair. <BR/>Observation on 5/15/2023 at 3:30pm, revealed Resident # 2 observed wandering the halls by the nurse's station. Resident was observed going into the nurse's station where they were working. Resident was redirected by staff at the time. Resident was not on 1:1 supervision. Resident # 2 was not able to be formally interviewed by surveyor as he did not have the cognitive ability to understand. <BR/>Observation and interview conducted on 5/16/2023 at 11:00am, revealed Resident # 1's injuries. Resident # 1 had two scratches approximately 3inches long to his right leg, the skin was raised they appeared to be in the healing stage. Resident # 1 had a scratch to the center of his chest approximately 3 inches that was also in the healing stage. This scratch was on top of a previous surgery area on the chest. Resident # 1 stated the scratch to his chest hurt the most because the skin on his chest is thin from a previous surgery he had. Resident # 1 was observed with his left leg amputated. Resident # 1 reported he stayed in his room most of the time. <BR/>During an interview on 5/16/2023 at 11:00am with Resident #1, revealed there was more than one incident. Resident # 1 stated 4/26/2023 was the first incident when Resident # 2 wandered into his room. He stated he told Resident # 2 to get out of his room and stated Resident # 2 started hitting him; he stated he yelled for help. Resident # 1 stated Resident # 2 almost pulled him to the ground when he was hitting him. Resident # 1 stated he spoke with the ADM and stated the ADM assured him that he would take care of the problem and would not allow the resident to come back into his room. Resident # 1 stated the next incident happened on 4/30/2023. He stated Resident # 2 wandered back into his room, and again he stated he told Resident #2 to get out of his room and Resident # 2 started hitting him again. Resident # 1 stated again he yelled for help and staff came to assist. Resident # 1 stated he has welts on his legs from where Resident # 2 was hitting him and Resident # 2 had scratched him on his arm and on his chest. Resident # 1 stated he asked that they call the police, he wanted to file charges against Resident # 2 for his injuries. Resident # 1 stated when he made his report to the police; the police spoke with the facility. Resident # 1 stated the police advised him that the facility advised of Resident # 2's diagnosis and that they would monitor him more closely. Resident # 1 stated Resident # 2 was supposed to be supervised however, he is not because he had been down his hall several times the next day with no supervision, and he doesn't want Resident # 2 hitting on him anymore. <BR/>During a phone interview on 5/15/2023 at 8:42am a Facility visitor, revealed she had visited the facility on 4/30/2023 when the incident between Resident # 1 and Resident # 2 occurred. She stated she heard a resident yelling, and when she went to see what was going on she saw Resident # 2 shaking Resident #1 very aggressively. She stated she asked Resident # 2 if he would come out the room; She stated Resident # 2 grabbed Resident # 1 again and shook him she stated she called for help. The Facility visitor stated Resident # 2 would move all over the building and had caused problems with other residents, she stated she doesn't think he had the appropriate supervision. The Facility visitor stated Resident # 2 is strong and had grabbed her arm before in the past; So she knew how strong he was. Facility visitor stated Resident # 2 had gotten into with other residents and stated staff just sit behind the desk at the nurse's station.<BR/>During an interview on 5/15/2023 at 11:55am with the ADON, revealed when the incident initially happened between Resident # 1 and Resident # 2, they tried to monitor Resident # 2 they did not start the 1:1 monitoring of Resident # 2 until the 2nd incident between them happened that's when Resident # 2 was placed on 1:1 supervision. ADON stated they had a care plan meeting the next day on 5/1/2023 and Resident # 2 was taken off the 1:1 monitoring the staff and family would monitor Resident # 2 movements throughout the day. <BR/>Interview on 5/15/2023 at 1:30pm with LVN A, revealed Resident # 2 had a wander guard and they took turns monitoring the resident throughout the day. LVN A stated Resident # 2 was a wanderer and does wander into other resident's rooms. She stated Resident # 2 had shown aggressive behaviors when provoked by loud noises or if someone was physical with him first. <BR/>Interview on 5/16/2023 at 11:30am with the other State agency worker, who revealed she had spoken with Resident # 1 earlier today and stated that he was afraid that Resident # 2 would come back in his room and start hitting him again. She stated that she advised Resident #1 that Resident # 2 was on 1:1 supervision. <BR/>In an interview on 5/16/2023 at 1:15pm with CNA A, revealed she worked the day of the incident on 4/30/3034 between Resident #1 and Resident # 2. CNA A stated she worked on another hall that day and heard Resident # 1 yelling for Resident # 2 to get out of his room. She stated Resident # 2 got upset and started to swing at Resident # 1. CNA A stated Resident # 2 would often go into resident's rooms. She stated when Resident # 2 would get upset he would hit other residents and had hit staff before. CNA A stated they all tried to keep an eye on him and intervene before something happened. She stated Resident # 2 was on 15minute checks and everyone pitched in and monitored. <BR/>An interview on 5/16/2023 at 1:30pm with the House- keeping staff, revealed he worked the day on the 1st incident on 4/26/2023 between Resident # 1 and Resident # 2. He stated the heard Resident # 1 screaming. He stated he proceeded to Resident # 1's along with another staff member and stated Resident # 2 was standing at the end of Resident # 1's bed, Resident #1 stated Resident # 2 was hitting and beating on him. House- keeping staff stated he walked Resident # 2 out of Resident # 1 's room and Resident # 2 was very agitated. House- keeping staff stated Resident # 2 had wandered into other resident's rooms and stated they will just tell him to get out and he will leave.<BR/> An interview on 5/16/2023 at 3:30pm with the Activity Director, revealed she worked the day of the incident on 4/30/203. She stated she heard Resident #1 yelling for help and stated when she stood up she could see another staff had already approached Resident # 1's room. Activity Director stated when she made it down to Resident # 1's room she observed Resident # 1 hanging halfway off his bed almost to the floor. She stated she assisted Resident # 1 back up into his bed and stated he said, [Resident # 2] was hitting him. Activity director stated she also observed Resident # 1 left side of his face was red and Resident # 1 stated Resident # 2 had hit him in his face. <BR/>A phone interview on 5/16/2023 at 4:00pm with Resident # 2's Family member revealed, that there were two incidents of physical aggression that recently took place with Resident # 2. He stated the facility provided 1:1 supervision, moved his room and adjusted his medication. Family member stated the facility asked if he could assist with the supervision but stated he was not able to assist due to his work schedule, so the facility was providing the 1:1 supervision. <BR/>An interview on 5/16/2023 at 4:30pm with the DON, stated she started at facility about a week ago, she stated she expected staff would monitor all residents who are wanders to ensure their safety. She stated that she worked on a new training for staff to know what behaviors to look for and would intervene when residents get agitated before aggression occurred. The DON stated the 1:1 monitoring was the only intervention in place for Resident # 2, staff would monitor and redirect when needed.<BR/>An interview on 5/16/2023 at 4:45pm with ADM, revealed it was his expectation that staff intervene during any resident-to-resident altercations. He stated staff should separate the residents and keep them safe. The ADM stated when their numbers increased, they would increase staff. He stated all staff had been trained on abuse/neglect and understand the expectation if they see or suspect abuse/ neglect. The ADM stated it is his expectation that staff would monitor any residents who wander throughout the day and try to keep them within line of sight. <BR/>Record Review of policy report dated 4/30/2023, reflected the police responded to a simple assault at the facility. The report reflected that the facility would increase supervision of Resident # 2 by getting a sitter to provided 1:1 supervision throughout the day, and the facility would check to see if the wander guard alarm could be placed on the halls to alarm when he goes on certain halls of the facility. The report reflected Resident # 1 stated he just did not want Resident # 2 back him his room hitting on him. The report reflected the report was closed out due to Resident # 2's diagnosis and the facility put interventions in place. <BR/>Record Review of 1:1 monitoring reflected monitoring was started on 4/26/2023 and ended on 5/1/2023. <BR/>Record Review of the following in-services had been completed with staff: <BR/>5/8/2023- Interventions for Residents with agitation/behaviors<BR/>5/2/2023- 1:1 monitoring <BR/>4/27/2013- Resident # 2 behavior/agitation how to handle <BR/>4/27/2023- Resident to Resident altercation <BR/>Review of QAPI - (Quality Assurance and Performance Improvement) dated Feb. 2023 - April 2023 focusing on Resident Centered culture. <BR/>Record review of facility Abuse/Neglect policy dated 10/2022 stated the following:<BR/>Each resident has the right to be free from abuse. Mistreatment, neglect, and corporal punishment, involuntary seclusion and financial abuse. <BR/>The facility will prohibit neglect, mental or physical abuse including involuntary seclusion and the misappropriation of property or finances or residents. <BR/>The facility Quality Assurance /Improvement committee will review the abuse policy to assure effectiveness

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interviews and record review the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the category of work for each person on direct care staff for 1 (facility) of 1 facility reviewed for PBJ Data submissions. <BR/>The facility failed to ensure the PBJ staffing Data submitted to CMS was accurate on 05/15/23, which showed the facility had low levels of RN and DON staff hours for the 2nd quarter of the 2023 fiscal year. <BR/>This failure could place residents at risk of not having adequate staffing coverage based on the facility's census which could result in inadequate care, decreased physical, mental and psycho-social well-being. <BR/>The findings included:<BR/>Record review of the facility's staff roster, undated indicated the facility had two RN Nurse Supervisors and one DON. <BR/>Record review of the facility's 672 CMS form (Resident Census and Conditions of Residents) dated 07/13/23 revealed a census of 29 residents. <BR/>Record review of the CMS PBJ Staffing Data Report ([DATE] - March 31 2023) run date 07/06/2023 revealed this facility triggered for A One star rating, No RN hours and failed to have licensing nursing coverage 24 hours/day revealed Infraction Dates: No RN hours 01/01 (SU); 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/09 (MO); 01/10 (TU); 01/11 (WE); 01/12; (TH); 01/13 (FR); 01/14 (SA); 01/15 (SU); 01/16 (MO); 01/17 (TU); 01/18 (WE); 01/19 (TH); 01/20 (FR); 01/21 (SA); 01/23 (MO); 01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/30 (MO); 02/01 (WE); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/13 (MO); 02/14 (TU); 02/15 (WE); 02/16; (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/20 (MO); 02/21 (TU); 02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); 02/26 (SU); 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11; (SA); 03/12 (SU); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) .Failed to have Licensed Nursing Coverage 24 Hours/Day 01/01 (SU); 01/03 (TU); 01/06 (FR); 01/07 (SA); 01/11 (WE); 01/14 (SA); 01/15 (SU); 01/20 (FR); 01/21; (SA); 01/25 (WE); 01/30 (MO); 02/09 (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/22 (WE);03/18 (SA) .<BR/>Record review of the PBJ Staffing Summary Report for 2023 2nd Quarter (01/01/23 - 03/31/23) run date 07/11/23 provided by the Administrator revealed staffing hours: One Registered Nurse Director of nursing - 45.00 hours, two Registered Nurses - 153.11 hours . <BR/>Interview on 07/11/23 at 3:15 pm, the Administrator stated he was not sure who sent the PBJ reports to CMS but would find out. <BR/>Interview on 07/13/23 at 2:50 pm, the Clinical RN Specialist stated this facility had a CHOW on April 1, 2023, and was not sure who did the PBJ submission reports to CMS but would find out. <BR/>Interview on 07/13/23 at 4:09 pm, the [NAME] President of Clinical Services stated she was not aware of any current RN shortages and the facility had RN coverage 8 hours or more that she knew of. She stated she and the Corporate Representative were responsible for ensuring the PBJ data was submitted and accurate. She stated her and the Corporate Representative reviewed and uploaded the PBJ employee data and reviewed the daily RN coverages to ensure the facility had 8 RN hours or more of coverage then submitted the data to CMS. She stated not being aware of any issues with the accuracy of the PBJ Data submitted to CMS for the previous quarters and this facility's PBJ data was not due again until August 2023. She stated the previous owner should have submitted the PBJ reports accurately for the previous months and would have to check to see if they did. She stated she thought their Corporate Representative checked to see if the previous owner submitted the PBJ data and accurately and could not confirm because the corporate representative was currently on leave and would reach out to the previous facility owner and follow-up with the HHSC Surveyor. <BR/>Interview on 07/13/23 at 5:33 pm, the Administrator stated not being aware of any issues with inaccurate PBJ data submissions which were completed at their corporate level. He stated he was not aware and not sure why this facility had a one star rating and did not have enough RN hours based on the previous PBJ reports. He provided the HHSC Surveyor the contact information for the previous owner's corporate person who did the PBJ transmissions. After review of the PBJ summary report for the 2nd quarter 2023, the Administrator stated he was not sure why the number of RN and DON hours worked were so low. <BR/>Interview on 07/13/23 at 6:17 pm, Previous owner's PBJ Representative I stated she had not submitted PBJ Data submissions to CMS for this facility. <BR/>Interview on 07/17/23 at 8:43 am, The [NAME] President of Clinical Services stated she had not looked at the (01/01/23 - 03/31/23) PBJ quarter and was not aware the facility currently had one star, no RN coverage and low nurse staffing ratings with CMS and was not surprised. She stated she did not have to review or validate those previous PBJ reports because of the CHOW effective 04/01/23. She stated she had no access to the previous PBJ reports until just recently. She stated when the staff hours for a quarter was 150 hours or less it triggered for one star and low staff ratings. <BR/>Record review of the PBJ policy revised 3/2023 revealed, Policy: Staffing and census information will be reported electronically to CMS through the Payroll-Based Journal system in compliance with 6106 of the Affordable Care Act .9. Staffing information is collected daily and reported for each fiscal quarter .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 9 (RN coverage days) of 101 days reviewed for RN coverage. <BR/>The ADON/Staffing Coordinator failed to have an effective documentation and tracking system and was unaware of which RN's worked when she reviewed the schedule sheets and based on the timesheets, there was not 8 hours of RN Coverage on: 05/13/23, 05/14/23, 05/29/23, 06/11/23, 06/22/23, 07/06/23, 07/07/23, 07/09/23 and 07/10/23. <BR/>These failures could place all residents at risk of not having an adequate amount of higher level nursing services which could result in a decline in the residents mental, physical and psycho-social well-being. <BR/>Findings included: <BR/>Record review of the facility's staff roster, undated indicated the facility had two RN Nurse Supervisors and one DON. <BR/>Record review of the facility's 672 CMS form (Resident Census and Conditions of Residents) dated 07/13/23 revealed a census of 29 residents.<BR/>Record review of the Facility's May Staff Schedule Sheet from 05/01/23 to 05/31/23 revealed no RN Coverage for 24 days: 05/01/23, 05/02/23, 05/03/23, 05/04/23, 05/05/23, 05/07/23, 05/08/23, 05/09/23, 05/10/23, 05/11/23, 05/12/23, 05/15/23, 05/16/23, 05/17/23, 05/18/23, 05/19/23, 05/22/23, 05/23/23, 05/24/23, 05/25/23, 05/26/23, 05/29/23, 05/30/23 and 05/31/23.<BR/>Record review of the Facility's June Staff Schedule Sheet from 06/01/23 to 06/30/23 revealed no RN Coverage for 19 days: 06/01/23, 06/02/23, 06/05/23, 06/06/23, 06/07/23, 06/08/23, 06/12/23, 06/13/23, 06/14/23, 06/15/23, 06/18/23, 06/20/23, 06/21/23, 06/22/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23 and 06/30/23. <BR/>Record review of the Facility's July Staff Schedule Sheet from 07/01/23 to 07/13/23 revealed no RN Coverage for 9 days: 07/03/23, 07/04/23, 07/05/23, 07/06/23, 07/07/23, 07/10/23, 07/11/23, 07/12/23 and 07/13/23.<BR/>A) Record review of RN A's time sheets 05/01/23 to 07/04/23, provided by the ADON/Staffing/ Coordinator revealed she worked 8 hours or more per day on 05/06/23, 05/07/23, 05/20/23, 05/21/23, 05/27/23, 05/28/23, 06/03/23, 06/04/23, 06/09/23, 06/10/23, 06/19/23, 06/23/23, 07/01/23, 07/02/23 and 07/04/23. <BR/>Record review of the Facility's Staff Schedule Sheets for May 2023, June 2023 and July 2023 revealed RN A worked 05/06/23, 05/13/23, 05/14/23, 05/20/23, 05/21/23, 05/27/23, 05/28/23. 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/19/23, 07/01/23 and 07/02/23.<BR/>B) Record review of RN B's time sheet dated 06/01/23 to 06/30/23, provided by ADON/Staffing Coordinator revealed she worked 8 hours or more on 06/17/23, 06/24/23 and 06/25/23. <BR/>Record review of the Facility's Staff Schedule sheets for May 2023, June 2023 and July 2023 undated revealed RN B worked 05/06/23, 06/24/23 and 06/25/23. <BR/>C) Record review of the DON's time sheets dated from 06/20/23 to 07/13/23, provided by the ADON/Staffing Coordinator revealed she worked 8 hours or more on 06/20/23, 06/21/23, 06/26/23, 06/27/23, 06/28/23, 06/29/23, 06/30/23, 07/03/23, 07/05/23, 07/11/23. <BR/>Review of the Facility's Staff Schedule sheets for June 2023 and July 2023 undated revealed the DON did not work any days in June 2023 or July 2023.<BR/>Record review of the facility's Direct Care Staff Daily Assignment Sheet/Sign in Sheets from 06/22/23 to 07/11/23, provided by ADON/Staffing Coordinator revealed the DON worked 06/22/23, 07/05/23, 07/06/23, 07/07/23, 07/10/23, 07/11/23. <BR/>D)Record review of the facility's May 2023, June 2023 and July 2023 Schedule Sheets revealed the Clinical RN Clinical Specialist worked on 06/09/23, 06/16/23, and 06/23/23. <BR/>E) Record review of the Staffing Agency time sheets dated 05/03/23, 05/04/23, 05/05/23, 06/18/23 and 07/08/23 revealed Shift details .RN nurse's name . shift resolution: Resolved .Provider Worked Shift. In the top right hand corner. <BR/>F) Record review of the Staffing Agency time sheet dated 07/09/23 revealed, Shift opening, Shift details .Specialty: Registered Nurse did not have a RN nurse's name on it and no shift resolution and it did not indicate a provider worked shift, in the top right hand corner.<BR/>Record review of the CMS PBJ Staffing Data Report ([DATE] - March 31 2023) run date 07/06/2023 revealed this facility triggered for A One star rating, No RN hours and failed to have licensing nursing coverage 24 hours/day revealed Infraction Dates: No RN hours 01/01 (SU); 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/06 (FR); 01/09 (MO); 01/10 (TU); 01/11 (WE); 01/12; (TH); 01/13 (FR); 01/14 (SA); 01/15 (SU); 01/16 (MO); 01/17 (TU); 01/18 (WE); 01/19 (TH); 01/20 (FR); 01/21 (SA); 01/23 (MO); 01/24 (TU); 01/25 (WE); 01/26 (TH); 01/27 (FR); 01/30 (MO); 02/01 (WE); 02/07 (TU); 02/08 (WE); 02/09 (TH); 02/10 (FR); 02/13 (MO); 02/14 (TU); 02/15 (WE); 02/16; (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/20 (MO); 02/21 (TU); 02/22 (WE); 02/23 (TH); 02/24 (FR); 02/25 (SA); 02/26 (SU); 03/01 (WE); 03/02 (TH); 03/03 (FR); 03/06 (MO); 03/07 (TU); 03/08 (WE); 03/09 (TH); 03/10 (FR); 03/11; (SA); 03/12 (SU); 03/14 (TU); 03/15 (WE); 03/16 (TH); 03/17 (FR); 03/20 (MO); 03/21 (TU); 03/22 (WE); 03/23 (TH); 03/24 (FR); 03/27 (MO); 03/28 (TU); 03/29 (WE); 03/30 (TH); 03/31 (FR) .Failed to have Licensed Nursing Coverage 24 Hours/Day 01/01 (SU); 01/03 (TU); 01/06 (FR); 01/07 (SA); 01/11 (WE); 01/14 (SA); 01/15 (SU); 01/20 (FR); 01/21; (SA); 01/25 (WE); 01/30 (MO); 02/09 (TH); 02/17 (FR); 02/18 (SA); 02/19 (SU); 02/22 (WE);03/18 (SA) .<BR/>Record review of the PBJ Staffing Summary Report for 2023 2nd Quarter (01/01/23 - 03/31/23) run date 07/11/23 provided by the Administrator revealed staffing hours: One Registered Nurse Director of nursing - 45.00 hours, two Registered Nurses - 153.11 hours . <BR/>Interview on 07/11/23 at 4:00 pm, the ADON/Staffing Coordinator stated they used Agency staffing for RN coverage at times and said since being at this facility for the past three months, they always had RN coverage. She stated they had a DON and two RN weekend supervisors. She stated she was responsible for ensuring they had enough RN's for the weekends and the DON worked Monday - Friday. She stated RN A worked every weekend and if she could not work she asked RN B about working and if she could not, she contacted the Staffing Agency for RN coverage. She stated the staff had to contact her four hours before their shift to call off. She stated they did not have enough staff and needed three LVN's and one PRN RN Supervisor to work the weekends. She stated she could only go back to 04/01/23 for the timesheets because they had a CHOW on 04/01/23. She stated RN coverage was needed because the LVN's practice only went so far like they could not pronounce a death, sign off on care plans, do picc line dressings and if staff ever had a question they had an RN to go to. She stated for 05/13/23 and 5/14/23 she was not sure if RN A worked those days and thought maybe a Corporate RN came in and RN A was sent home. She stated she was not told by the Administrator or anyone else if an RN agency nurse worked those days. <BR/>Interview on 07/13/23 at 10:75 am, RN A stated she had retired and was an RN nurse who worked at this facility PRN and usually worked two weekends/four days out of the month and the other RN B covered working the other two weekends. She stated she did not work too often. She stated on 05/13/23 she worked for 4 hours and did not work 05/14/23 and thought RN filled in for her. She stated she was not sure if she worked 6/11/23 - 06/18/23 but she worked on 06/19/23, 06/23/23, 07/01/23, 07/02/23 and 07/04/23. She stated RN's were needed to make critical decisions and supervise the staff to ensure the residents had quality of care and was within the state regulations. <BR/>Interview on 07/13/23 at 3:55 pm, RN B worked here at times as a PRN RN nurse and last worked here a few weekends back and passed out meds in June 2023 and was not sure if she worked 6/11/23 but did not work May 2023. She stated she had not worked July 2023 and added she was a PRN RN and RN A worked more than she did at this facility. <BR/>Interview on 07/13/23 at 12:33 pm, the ADON/Staffing Coordinator stated RN A worked 06/11/23 and 06/12/23 and said she was not sure why RN A missed punch sheet was not filled out all the way showing she worked 06/11/23. She stated on 5/13/23 RN A worked four hours and was not sure why and would have to get on the phone and talked to her. She stated the Corporate RN's sat in her office but did keep up with when they worked and had no documentation to prove they worked. She stated on 07/09/23 she was not able to confirm an agency nurse worked because there was no RN listed on the time sheet form. She stated RN A covered pretty much every weekend. <BR/>Interview on 07/13/23 at 2:29 pm, the DON stated she started work at this facility on 06/20/23 and had to call off work on 6/22/23 and 6/23/23 because she got sick and week after that on 07/06/23 and 07/07/23 she took off from work because she had a family emergency. She stated she was pretty sure the facility had RN coverage as far as she knew. She stated they had two RN Supervisors and herself working at this facility and the designated RN supervisor for the weekends was RN A and RN B was the other RN who worked the other weekends. She stated they also used agency nurses for RN coverage at times and stated she was not aware of any inconsistencies with the RN timesheets and schedule sheets. She stated the ADON/staffing coordinator was responsible for ensuring they had sufficient RN coverage. She stated the facility needed 8 hours of RN coverage for supervision of the clinical staff, the LVN's and CNA's and was a state regulation. She stated they did not have a nurse waiver in place and stated if there was no RN at the facility no one would be able to pronounce a death, pull picc line, have a delegation of duties and supervision of the staff. She stated her expectations for RN coverage was to meet the standard for RN coverage. <BR/>Interview on 07/13/23 at 2:50 pm, the Clinical RN Specialist stated they did not have any nursing waivers and this facility had a CHOW on April 1, 2023, and added they had proof of RN coverage at all times and if the facility did not have RN coverage in the building she or other Corporate RN's worked. She stated her and the other corporate RN hours did not sign the sign in sheets. She stated she was not sure why the Agency RN's name was not on the timesheet for 07/09/23 and thought the RN who worked had not logged in her time yet. She stated the ADON/Staffing Coordinator was good about letting her know when they needed to get an Agency RN and believed RN A worked the weekends but was not sure if she worked every weekend. She stated RN B worked but was not sure how often she worked here and the last time she worked here was last month. She stated they were trying to hire more RN's by posting on the job board Indeed. She stated the facility needed 8 hours RN coverage daily for overseeing the LVN's and making sure they were not doing anything out of their scope, communication with the Doctors and family members and took the DON duties on the weekends and to ensure everyone was being taken care of. She stated the RN's assisted with the resident's plan of care, removing picc lines, pronouncing death, changing out central lines and hub needles. She stated ADON/Staffing Coordinator tried to get the nursing schedule created a week in advance and if someone called off and she could not find a replacement she would let her know. She stated they had a policy that the staff must call the ADON/Staffing coordinator no later than two hours prior to starting their shift. She stated she was not aware of any inconsistencies between the time sheets and assignment sheets and added they had a good system with tracking the RN coverage hours. She stated the training was pending with new DON who just started working here 06/20/23 to assist with tracking the RN hours. She stated the DON called off one day Friday 6/23/23 she worked in the DON's place and thought that RN A worked 6/22/23 but was not sure, then the DON was off for a family emergency in July 2023 and think agency RN's worked in her place but was not sure. She stated the DON was responsible for ensuring they had RN coverage in the building and the administrator should follow-up to ensure it. She stated on 5/13/23 and 5/14/23 she was on vacation she did not work. She stated she had not done the orientation with the new DON so that they would have a better way of tracking and documenting to ensure they had RN coverages and was not sure why RN A timesheet on 06/11/23 was different from what was on the schedule sheet, then stated RN A had a mis-punch on 06/11/23 but was not able to provide a completed form with signatures from RN A and supervisor to confirm it. She stated when the RN's worked they needed to sign the schedule sheets also which was making it hard for them to determine who worked when. She stated RN A and DON had some issues with missed punches and could not provide proof they worked on certain days. She stated everyone had staffing challenges, but they figured it out and said she was getting ready to do an orientation training next week with the new DON who was going to do great here. <BR/>Interview on 07/13/23 at 4:09 pm, the [NAME] President of Clinical Services stated she and the Corporate Representative reviewed the daily RN coverages to ensure there was 8 hours of RN coverage or more daily then submitted them with the other staffing data to CMS quarterly and said she was not aware of any RN coverage issues at this facility.<BR/>Interview on 07/13/23 at 5:33 pm, the Administrator stated working at this facility since 12/01/22 and the facility did not have a nurse waiver. He stated he was not aware CMS had the facility listed with a one star rating because of not having enough RN hours since 10/01/22. He stated they had DON H in December 2022 until March 2023 and from March 2023 to April 2023 the facility had Acting DON D . He stated they did not have a fulltime DON from May 2023 to June 20, 2023, but the Clinical RN Specialist worked here at various times but was not sure of the actual days she worked and no documentation to confirm. He stated the facility was currently looking for a designated RN weekend supervisor to work the weekends because RN A and RN B work PRN weekends. He stated not being aware of any issues with the ADON/Staffing Coordinator not updating the schedule sheets if they changed and was not aware of any issues with her being able to keep track of the RN hours. He stated after review of RN A's timesheet dated 06/11/23 and schedule sheet 06/11/23 and was not really sure why there was inconsistencies with RN A's timesheets and schedule sheets. He stated the DON was responsible for ensuring the facility had RN coverage, the Administrator said they needed to find a better way to document on the assignment sheets for RN coverage. He stated the facility was not using RN Agency in December 2022 because the facility had RN coverage daily since he worked here and with the help of the Corporate RN's and agency staffing. He stated he had no proof the Corporate RN's worked at the facility because they were salaried and would talk to Corporate about getting the Corporate RN to sign their names on the assignment sheets. He stated the facility needed to create a better schedule sheet for better record keeping. He stated the staff were supposed to notify the ADON/Staffing Coordinator if they called off 4 hours prior to starting their shift so the ADON/Staffing Coordinator had to find the nursing coverage by first contacting the PRN RN's and if they could not work then get an agency staff and if that failed to find coverage she was supposed to call him so he could help. <BR/>Interview on 07/13/23 at 6:11 pm, the Business Office Manager stated she worked here 12 years and said they have had a few DON's within the past year. She stated she was not really sure, but DON D was the acting DON from April 2023, and she stopped working here May 2023. She stated they had two RN Supervisors RN A and RN B and was not aware of any RN coverage issues and RN A worked as far as she knew was the main RN supervisor on the weekends. She stated RN B did not work too much and that they were currently looking for more RN's using the job posting board Indeed and used agency nursing staff. She stated she was not aware of any RN coverages issues from October 2022 to current.<BR/>Record review of the facility's RN Position Description updated 04_2017 revealed, Job Summary: Registered nurses oversee the activities of the nursing staff. The RN is responsible for overseeing each patient's overall health and medical histories .RN's are also responsible for advanced activities such as starting intravenous infusions, administering oxygen, monitoring blood sugar levels and consulting with the supervising physicians . <BR/>Record review of the facility's Staffing, Sufficient and competent Nursing policy revised 03-2023 revealed, Policy statement: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with the resident care plan and the facility assessment .Sufficient Staff .A registered nurse provides services as least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement comprehensive care plans that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for one (Resident #27) of three residents reviewed for care plans. <BR/>The facility failed to implement a comprehensive care plan for Resident #27. <BR/>This failure could place residents at risk of not meeting their immediate needs, long term and or short-term goals, and and interventions.<BR/>Findings included:<BR/>Record review of Resident #27's admission MDS dated [DATE] revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Hemiplegia (paralysis) affecting the left side, Diabetes Mellitus (high blood sugar), and Hyperlipidemia (high cholesterol). With a BIMs of 15 (cognitively intact). Resident #27 is visually impaired, with verbal behavioral symptoms towards others, she requires limited to extensive assistance with ADLs, she requires set up and supervision during meals, and has occasional incontinence. <BR/>Record review of Resident #27's Care Plans revealed there was a total of three care plans initiated on 6/20/23. The care plans available were the use of antidepressant (Sertraline), the use of antipsychotic (Keppra), and the use of anti-anxiety (Hydroxyzine). Further investigation revealed there were no person-centered comprehensive care plans available. <BR/>Record review of Resident #27's Fall Scale Evaluation dated 6/11/23 revealed she was a high fall risk. <BR/>Record review of Residents #27's care plans dated 6/20/23 revealed there was no short-term or long-term fall care plan was available.<BR/>Interview with LVN E on 07/13/23 at 11:46 AM revealed the MDS nurse was the one responsible for doing the person-centered comprehensive care plans. MDS nurse does care plans for new admissions and updates them for short-term and long-term issues. She stated the charge nurses do not do any care plans; they only do the baseline care plan assessment upon admission. She stated that the risk of not having up to date care plans could be that the nurses would not know the right interventions for the residents, and they would not get adequate care. <BR/>Interview with MDS F on 07/13/23 at 12:52 PM revealed MDS was responsible for completing all care plans with the help of the DON. She stated the DON opened the care plans on admission, and she completed them within 7 days of completing the MDS assessment. She stated she was responsible for both short term and long-term care plans. She stated the short-term care plans were updated during morning meetings and long-term care plans were updated with MDS assessments. She cannot recall any breakdown or issues with care plans being missed. <BR/>Interview and record review with MDS F on 07/13/23 at 2:09 PM revealed Resident #27 did not have comprehensive care plans and there were only three medication care plans available. She stated there should be more care plans to include other areas for the residents such as medical care, behavioral care, activities, dietary, fall prevention, and they should be person centered, she was not sure how they were missed. She stated the risk of not having up to date care plans could lead to complications and further decline of the resident. To avoid missing care plans she stated she will bring her laptop to their morning meetings to assess any short-term and long-term changes of the residents and discuss with IDT. <BR/>Record review of Resident #27's Care Plan dated 06/20/2023, revealed person-centered comprehensive care plans were initiated and created on 07/13/23. Comprehensive care plans were provided at the conclusion of the survey. <BR/>Interview with ADON/Staffing Coordinator on 07/13/23 at 2:13 PM revealed MDS F and DON were responsible for care plans, which also included the comprehensive person-centered care plans. MDS F also was responsible to complete the short-term and long-term care plans. She stated the CNAs could see the interventions for the residents based on the [NAME]. She stated her expectation was that the care plans would be completed according to the facility policy. She also stated the risk for the care plans not being up to date would be the CNAs and nurses would not know how to properly care for the resident. <BR/>Interview with CNA G on 07/13/23 at 2:18 PM revealed she would be able to see how to care for the residents by looking in the [NAME]. This is where she would be able to see if the resident had specific interventions like if they are a fall risk. <BR/>Interview with DON on 07/13/23 at 2:22 PM revealed MDS nurse was responsible to complete short-term and long-term person-centered comprehensive care plans. She stated that she opened them on admission and MDS F completed them within 7 days of completing the MDS assessment. She stated her expectation was that the care plans should be documented within the patient chart that includes goals and interventions. Her expectation was that MDS F would update care plans quarterly and as needed. Missing care plans for Resident #27 would be reviewed along with all residents moving forward to ensure completion. Risks to residents of gaps in care plans would be they would not be cared for properly. <BR/>Record review of policy titled Care Plans, Comprehensive Person-Centered with a revision date of [DATE] revealed comprehensive, person-centered care plans will be developed within 7 days of the completion of the required comprehensive assessment (MDS). It also revealed that comprehensive, person-centered care plans that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident.