**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff, and resident, caregiver, and responsible party interviews, record review, and facility policy review the facility failed to accurately complete an elopement assessment and identify risks to prevent an unsupervised resident from exiting the facility door for one (1) of three (3) residents reviewed for elopement and wandering. Resident #1. Findings Include: Review of the facility policy, Accidents and Interventions dated 05/05/19 revealed, The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s) . An interview on 05/05/25 at 8:45 AM with Administrator (ADM), revealed that on 04/26/25, they had a resident to propel himself in his wheelchair outside the facility through an automated sliding door. She revealed that Resident #1 had been at the facility less than a week, he had limited mobility, and there had been no indications that he was an elopement risk. ADM revealed that on 04/26/25 at 7:20 PM, two resident assistants brought Resident #1 from the Assisted Living side, over to the 700 hall of the rehabilitation unit where he resided. She revealed that the resident assistants informed staff that Resident #1 was outside the automatic doors in his wheelchair. ADM revealed that they thought he belonged in the assisted living department and assisted him back into the building. ADM revealed that she arrived at the facility, reviewed the video surveillance, and determined that Resident #1 exited the front of the building through the automatic sliding glass doors and he was assisted back into the assisted living area of the building. An interview on 05/05/25 at 9:20 AM with ADM, revealed that Resident #1 had an elopement risk evaluation completed on admission and had a risk of zero for wandering and elopement documented. She revealed that when a resident's cognition was not good, they had to go by what the family said and the family had not told them that he had elopement risks. An observation and interview with the resident sitter on 05/05/25 at 9:40 AM, revealed Resident #1 sitting in his room in his manual wheelchair with his private caregiver sitting beside him. Resident #1 had a wander guard bracelet intact to his right arm. The caregiver revealed that was now sitting with Resident #1 during the day. She revealed that this behavior wasn't new for him, that at home, he would go outside during the night. A phone interview on 05/05/25 at 10:25 AM with Resident #1's Responsible Party (RP), revealed that he had dementia, he was confused a lot, and he lived with her prior to coming to the facility. She revealed that Resident #1 fell on [DATE] at her house, broke his hip, had surgery and from the hospital, he admitted to the facility for therapy. She revealed that he had been there for four or five days when he got out of the facility. Resident #1's RP confirmed that he had wandered at home, he got out of the house at night, and they had to put alarms on all of the outside doors and they put cameras up. Resident #1's RP revealed that she signed his admission paperwork when he was admitted to the facility and she said the staff never asked her if he wandered or if he had ever gotten out of the house. Resident #1's RP confirmed that she didn't think he would go anywhere because he had a broken hip and was in a wheelchair and she never said anything to the facility. An interview on 05/05/25 at 11:10 AM with Registered Nurse (RN) #1, revealed that she completed all the admission assessments and evaluations during the admission process including the Elopement Evaluation. She revealed that if the resident was not able to give a good history or answer questions appropriately, she asked the family. RN #1 revealed that Resident #1 was confused, and she spoke with the RP about his history of wandering. RN #1 revealed that the RP didn't verbalize any issues or concerns with Resident #1 at that time, and that she usually asked in a more casual way about their behaviors at home and confirmed that she did not directly ask the question that was on the Elopement Assessment Form, Does the Resident have a history of elopement or an attempted elopement while at home? She revealed that she tried to make the admission process more personable with the family and she asked general questions. RN #1 revealed that during Resident #1's Elopement Risk Assessment, there was nothing said that would indicate that the resident had a history of wandering or elopement. RN #1 revealed that she would make sure and clarify from now on, so the question would be answered properly to ensure the safety of the residents. A phone interview on 05/05/25 at 4:12 PM, a phone with Registered Nurse Clinical Coordinator (RNCC), revealed that she received a phone call from the hall nurse on 04/26/25 that Resident #1 had gotten out of the facility unsupervised. She revealed that she came to the facility and checked him out. She revealed that he was very confused but was not hurt. She revealed that she called Resident #1's daughter, and she told her that he had been obsessed with locked doors at home prior to coming there and RNCC revealed that she did not verbalize that he had these wandering behaviors before. Record review of Resident #1's admission Elopement Evaluation dated 04/21/25 revealed the question, Does the Resident have a history of elopement or an attempted elopement while at home and the answer No was marked. Record review of Resident #1's admission Record revealed an admission date of 04/21/25 and that he had diagnoses that included Displaced Intertrochanteric Fracture of Right Femur and Dementia. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/28/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 06 which indicated that he had severe cognitive deficits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review and facility policy review, the facility failed to ensure a resident's wheelchair was in good repair for one (1) of 26 residents reviewed during survey. Resident #236 Findings Include: Review of facility policy titled, Safe and Homelike Environment date implemented 1/2024, revealed under the Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belonging to the extent possible. This includes ensuring the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk . An interview and observation on 08/05/24 at 2:20 PM, with Resident #236 revealed she was complaining of her wheelchair arm on the right side being messed up and bothering her. She stated that she had told the nurse twice, but no one has done anything. This observation revealed that the leather covering for the resident's right wheelchair arm rest was missing about three (3) to four (4) inches back from the front, exposing foam and metal that was rough to the touch in places. An observation and interview on 08/05/24 at 2:32 PM, with Certified Nurse Assistant (CNA) #1 confirmed that Resident #236's right wheelchair arm was torn. She stated she had not heard the resident complain. She stated that they could notify maintenance. The State Agency (SA) observed CNA #1 place a call to maintenance and reported Resident #236 needed a new wheelchair immediately. An interview on 08/06/24 at 10:09 AM with the Director of Therapy confirmed that Resident #236's right wheelchair arm torn, exposing foam and the metal was rough to the touch in places. She stated that the therapist had told her that the resident refused to have her wheelchair replaced, but wanted the arm fixed, but had failed to document any of that information. She admitted that the therapist should have documented something about the condition of the wheelchair. She stated that the therapist needed to make sure they are documenting issues like this because we want to be sure and provide the elders with all that they need. An interview with Occupational Therapy (OT) on 08/06/24 at 11:41 AM, confirmed that she noticed when she picked the resident up for therapy on 6/6/24 that her personal wheelchairs overall condition was not good but does not recall specifically noticing the condition of the right arm rest. She revealed she talked with the resident about getting a new wheelchair, but the resident declined. She admits that she never documented anything and confirmed that today the resident complained of her right wheelchair arm and noticed the armrest was in bad condition. An interview on 8/7/24 at 9:45 AM with the Administrator confirmed that the Resident #236's wheelchair arm should have been repaired. She revealed that her expectation was that staff would document that the resident and family had been spoken with about getting a new chair, plus we have plenty of wheelchairs here, it could have been replaced. Record review of Resident #236's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Muscle Weakness.

Based on staff interview, record review, and facility policy review, the facility failed to accurately submit information into the Minimum Data Set (MDS) assessment system for one (1) of 26 residents sampled. Resident #34 Findings include: Record review of facility policy titled, Conducting an Accurate Resident Assessment, dated October 2023, revealed, .The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) . Record review of Center for Medicare and Medicaid Services (CMS)'s Resident Assessment Instrument (RAI) dated October 2023 revealed, Insulin is a medication used to treat diabetes mellitus (DM). Steps for Assessment: 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician . changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed Record review of Resident #34's Order Review History Report for May 2024 revealed no order for Insulin. Review revealed an order for Ozempic dated 9/29/23 to be given every seven (7) days. Record review of Resident #34's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/31/24, Section N - Medications, revealed one (1) insulin injection was received during the last seven (7) days or since admission/entry or reentry if less than 7 days. During an interview on 8/7/24 at 9:55 AM, the Registered Nurse MDS Coordinator revealed that due to her misunderstanding, she entered Ozempic as an insulin and since it is not an insulin, it should not have been coded as one. She stated this was an error on her part and this led to inaccurate information being submitted into the MDS system. She confirmed she entered that Resident #34 was receiving insulin when she was not, therefore, the MDS was submitted inaccurately. During an interview on 8/7/24 at 10:05 AM, the Administrator confirmed that Ozempic was not an insulin and it should not have been coded as an insulin on the MDS assessment. She confirmed the MDS assessment represents each resident's status at the time of the assessment and the facility failed to accurately complete the MDS assessment for this resident. Record review of Resident #34's admission Record revealed the facility admitted the resident initially on 10/16/17. Resident #34 has current diagnoses that included Type 2 diabetes mellitus and Dementia. Record review of MDS with Assessment Reference Date (ARD) of 5/31/24 revealed a Brief Interview for Mental Status (BIMS) of 5 indicating the resident has severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident that required the use of Enhanced Barrier Precautions (EBP) (Resident #85) and assistance with Activities of Daily Living (ADL's) (Resident #106) for two (2) of twenty-six care plans reviewed. Resident #85 and #106 Findings Include: Record review of the facility policy titled Comprehensive Care Plans dated 10/2022 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #85 Record review of Resident #85's Care Plan revealed Focus: The resident requires tube feeding r/t (related to) Dysphagia .Interventions .Elder to remain on enhanced barrier precautions with care at all times d/t (due to) presence of PEG (Percutaneous Endoscopic Gastrostomy) tube and Foley catheter . During an observation on 08/06/24 at 11:00 AM, of Resident #85's PEG tube care revealed an Enhanced Barrier Precaution sign on the inside of his door. Licensed Practical Nurse (LPN) #1 entered Resident #85's room, washed her hands, applied gloves and failed to apply a protective gown. During an interview on 08/06/24 at 11:20 AM, Licensed Practical Nurse (LPN) #1 revealed that she should have put on a gown before she provided Resident #85's PEG tube care to help prevent the spread of germs. She revealed that Enhanced Barrier Precautions were put in place to protect the nurse and to protect the resident from the spread of infection and she stated, I knew to do it, I was just nervous. LPN #1 revealed that residents with foley catheters, PEG tubes or open wounds were placed on enhanced barrier precautions. During an interview on 08/07/24 at 9:45 AM, Registered Nurse (RN) Infection Preventionist, revealed that LPN #1 should have worn gloves and a gown while providing PEG tube care as part of the enhanced barrier precautions. She revealed that residents with open wounds and those with indwelling devices such as PEG tubes were placed on Enhanced Barrier Precautions to protect the resident and the staff member to help prevent the spread of germs and possible infection. During an interview on 08/07/24 at 1:30 PM, RN Minimum Data Set (MDS) Coordinator, revealed that the purpose of the comprehensive care plan was to outline each resident's plan of care and what individualized care was needed and provided. She agreed that LPN #1 failed to follow the care plan when she did not wear a gown while she provided Resident #85's PEG Tube care. Record review of Resident #85's Order Summary Report revealed an order dated 04/01/24, Elder to remain on enhanced barrier precautions with care at all times d/t (due to) presence of PEG tube and Foley catheter. Record review of Resident #85's admission Record revealed an admission date of 12/15/2023 and had diagnoses that included Dysphagia and Encounter for Attention to Gastrostomy. Resident #106 Record review of the Care Plan with a date initiated of 12/23/22, for Resident #106 revealed Focus: Resident needs assist with ADL's (activities of daily living) . Interventions: Assist with adl's as needed . During an observation of Resident #106 on 8/5/2024 at 12:09 PM revealed, he was lying in bed, alert with confusion. The resident was unkempt, with his hair unbrushed and greasy on the edges. Gray facial hair observed on his face and above his lip, measuring approximately one fourth (1/4) inch in length. Long fingernails observed on both hands measuring approximately three-eights (3/8) inch in length. During an observation and interview with Licensed Practical Nurse (LPN) # 2 on 8/6/2024 at 10:35 AM, confirmed Resident #106 was unkempt, had long nails and needed to be shaved. During an interview with the Minimum Data Set (MDS) Coordinator on 8/7/2024 at 1:40 PM, revealed the purpose of the care plan was to provide an outline for resident care. She confirmed the activity of daily living (ADL) care plan was not followed for Resident #106. Review of the admission Record revealed the facility admitted Resident #106 on 12/23/2022 with medical diagnoses that included Unspecified dementia.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide the necessary assistance with activities of daily living (ADLs) for a resident dependent on staff for bathing, shaving, and nail care for one (1) of 26 residents sampled. Resident #106 Findings Include: Record review of the facility policy titled Activities of Daily Living dated 10/2023 revealed Policy . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care . An observation of Resident #106 on 8/5/2024 at 12:09 PM revealed, he was lying in bed, alert with confusion. The resident was unkept, with his hair unbrushed and greasy on the edges. Gray facial hair was observed on his face and above his lip, measuring approximately one fourth (1/4) inch in length. Long fingernails were observed on both hands measuring approximately three-eights (3/8) inch in length. An observation and interview with Certified Nurse Aide (CNA) # 2 on 8/6/2024 at 10:25 AM revealed, Resident # 106 was scheduled to get his shower on Monday, Wednesday, and Friday on the 3-11 shift. She explained that the resident should have gotten a shower last night and stated, He does not look like he was showered. CNA #2 revealed the aides were responsible for shaving the male residents with showers and cutting their nails if the resident was not a diabetic. She confirmed Resident #106 needed shaving, and his nails needed to be cut. CNA #2 revealed the resident could scratch himself and cause injury. An observation and interview with Licensed Practical Nurse (LPN) # 2 on 8/6/2024 at 10:35 AM, confirmed Resident #106 was unkempt, had long nails and needed to be shaved. She revealed the resident was not a diabetic, so the aides were responsible for cutting his nails when needed. Record review of the Kardex for Resident #106 revealed .Bathing: ADL -Bathing as ordered . An interview with the Director of Nursing (DON) on 8/7/2024 at 1:35 PM, revealed with Resident #106's ADL care, her expectations were for the aides to include nail care (cleaning, cutting, and filing) and shaving on designated shower day. Review of the admission Record revealed the facility admitted Resident #106 on 12/23/2022 with medical diagnoses that included Unspecified dementia

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than five (5) % (percent) for two (2) of 28 medication opportunities involving Resident #84. Medication error rate was 7.14%. Findings Include: Review of the facility policy titled Medication Administration dated 1/2024 revealed Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: 10. Ensure that the six rights of medication administration are followed .c. Right dosage . An observation of medication pass, with Licensed Practical Nurse (LPN) #3 on 8/7/2024 at 8:09 AM, revealed she prepared and administered MiraLax 17 grams one capful mixed in water to Resident #84. She then handed the resident a bottle of Flonase (Fluticasone Propionate) nasal spray, in which he administered one spray to each nostril. Record review of Resident #84's August 2024 Medication Administration Record (MAR) revealed an order dated 11/1/2022, Fluticasone Propionate Suspension (Allergies) 50 MCG (micrograms)/ACT (actuation) 2 (two) spray in each nostril one time a day related to Allergic Rhinitis. Also revealed an order dated 4/29/2024, MiraLax Oral Powder (stool softener) 17 GM (grams)/scoop give 34 gram orally two times a day for constipation in 240 ml (milliliters) of liquid. An interview on 8/7/2024 at 8:16 AM with LPN #3, confirmed she did not administer Resident #84's MiraLax and Flonase according to the physician order. She stated the resident liked to give his own nasal spray, but she should have instructed him to give the two sprays instead of one. She explained that she overlooked that the resident was supposed to have 34 grams of MiraLax, and she should have given two capfuls. LPN #3 stated, I just missed it. She revealed not getting the entire dosage of MiraLax could cause constipation. An interview on 8/7/2024 at 10:10 AM, with the Director of Nursing (DON), confirmed Resident #84's physician orders were not followed. She revealed her expectations were for the nurses to view the Medication Administration Record (MAR) and ensure they were giving the correct ordered dose before administration. Record review of the admission Record revealed the facility admitted Resident #84 on 12/20/2023 with medical diagnoses that included Allergic Rhinitis and Constipation.

Based on observation, staff interviews, record review, and facility policy review the facility failed to prevent the possibility of the spread of infection as evidenced by failing to ensure Enhanced Barrier Precautions were followed during a resident care treatment for one (1) of four (4) resident care treatments observed. Resident #85. Findings Included: Record review of the facility policy Gastrostomy Site Care dated 05/2023 revealed Policy: It is the policy of the facility to perform gastrostomy site care as ordered and per current standard of practice. Policy Explanation and Compliance Guidelines .10. Apply any other PPE (Personal Protective Equipment) as needed to protect self from any exposure to infectious material and to comply with any isolation precautions ordered . Record review of the undated facility policy titled, Enhanced Barrier Precautions revealed .Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities 4. High-contact resident care activities include .g. Device care or use: . urinary catheters, feeding tubes An observation on 08/06/24 at 11:00 AM, of Resident #85's Percutaneous Endoscopic Gastrostomy (PEG) tube care revealed an Enhanced Barrier Precaution sign on the inside of the door. Licensed Practical Nurse (LPN) #1 entered Resident #85's room, washed her hands, applied gloves and failed to apply a protective gown prior to beginning care. An interview on 08/06/24 at 11:20 AM with LPN #1 revealed that she should have put on a gown before providing Resident #85's PEG tube care to help prevent the spread of germs. She revealed that enhanced barrier precautions were put in place to protect the nurse and to protect the resident from the spread of infection and she stated, I knew to do it, I was just nervous. LPN #1 revealed that they followed enhanced barrier precautions when providing care to anyone with a foley catheter, PEG tube, or open wounds. An interview on 08/07/24 at 9:45 AM with Registered Nurse, Infection Preventionist revealed that LPN #1 should have worn gloves and a gown while providing PEG tube care as part of the enhanced barrier precautions. She revealed residents with open wounds and those with indwelling devices such as PEG tubes were placed on enhanced barrier precautions to protect the resident and the staff member and to help prevent the possible spread of infection. RN Infection Preventionist revealed that bacteria could be passed from the resident to staff on their uniforms and infection could be transmitted to other residents without protective gowns in use. An interview on 08/07/24 at 9:55 AM, with the Director of Nursing (DON), revealed residents with open wounds, foley catheters and PEG tubes were placed on enhanced barrier precautions to prevent the spread of infection. She agreed that LPN #1 should have worn a gown and gloves when providing PEG tube care for Resident #85 to prevent the spread of potential infection. Record review of Resident #85's Order Summary Report revealed an order dated 04/01/24, Elder to remain on enhanced barrier precautions with care at all times d/t (due to) presence of PEG tube and Foley catheter. Record review of Resident #85's admission Record revealed an admission date of 12/15/2023 and had diagnoses that included Dysphagia and Encounter for Attention to Gastrostomy.

Based on staff interviews, Resident Representative (RR) interview, record review and facility policy review, the facility failed to ensure that one (1) of five (5) sampled residents were protected from physical abuse. Resident #1. Findings included: Record review of the Abuse, Neglect, and Exploitation facility policy dated 03/15/2024, revealed under Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. On 07/01/24 at 10:00 AM, a brief interview with the Administrator revealed that she reported an incident involving a Certified Nursing Assistant (CNA) who aggressively transferred a resident from the bed to her wheelchair and it was recorded on the ring camera that had been placed in the resident's room by her family. On 07/01/24 at 10:15 AM, an interview with the Administrator (ADM) revealed that on the morning of 05/26/24, Resident #1's Resident Representative (RR) sent a snippet of a video that was recorded on the ring camera to the CNA Supervisor. The ADM revealed that Resident #1's RR felt like the employee was rough with her. ADM said that she viewed the video which showed that CNA #1 was transferring Resident #1 from the bed to the wheelchair, and Resident #1 leaned back resisting care and let go of the rail. The ADM revealed that Resident #1 then stated Ain't nobody worth a damn and CNA #1 roughly grabbed Resident #1 under her arm pits and did a quick transfer into the wheelchair. The ADM stated, It made me cringe. ADM revealed that they suspended CNA #1 pending investigation and because of the aggressive handling, she terminated her. ADM revealed that they did a full body audit on Resident #1 and found some bruising under her left armpit and some scattered bruising on both arms that were now healed. She revealed that Resident #1 had Dementia, required more assistance, and needed the staff to be patient with her, allow her more time and not get in a hurry. ADM confirmed that this transfer was too aggressive and stated, I'm just sick over it. ADM revealed that she called CNA #1 in to watch the video and write a statement and CNA #1 reported that Resident #1 had been more resistant to getting up and said she should have left her in bed. ADM revealed that CNA #1 also told her that when Resident #1 let go of the transfer bar, she made the instant decision to transfer her quickly to the wheelchair. The ADM stated that CNA #1 was remorseful and revealed that she had no idea until after watching the video as to how quickly she transferred Resident #1. ADM revealed that CNA #1 did not intentionally harm Resident #1, but a bruise was found under her left armpit and scattered bruising on bilateral arms. ADM revealed that she terminated CNA #1 on 05/29/24 because of the incident. On 07/01/24 at 11:55 AM, an interview with Director of Nursing (DON), revealed that she watched the video a couple times and was shocked and saddened that this incident happened with one of their residents. She revealed that it broke her heart to think that they had someone working with these residents who had no compassion. DON revealed that the staff knew that the family was not able to be there often to see Resident #1 and they had a video camera in her room so they could see her. She stated that Resident #1's family trusted them to take care of her and they let them down. She stated, I hate this happened. On 07/01/24 at 12:15 PM, an interview with CNA Supervisor, revealed that on Saturday morning, May 26, 2024, Resident #1's RR sent her a video that showed that CNA #1 entered the room of Resident #1, dressed her, and was aggressive with her during transfer from the bed to her wheelchair. CNA Supervisor revealed that she saw and heard on video that Resident #1 said that no one was worth a damn around there and then CNA #1 moved quickly and did a swift transfer. CNA Supervisor revealed that CNA #1 should have managed her time better to avoid being in a hurry, should have allowed Resident #1 more time to transfer or she should have waited on someone to help with the transfer. On 07/01/24 at 12:50 PM, a phone interview with Resident #1's RR revealed that she had a ring camera placed in her sister's room and she watched how the staff treated her. She revealed that on the camera footage on 05/26/24, she observed CNA #1 enter the room to get her up and dressed at 5:30 AM, and stated, She practically grabbed her up and throwed her into the wheelchair. RR revealed CNA #1 did not have any patience with her and seemed to be in a hurry and stated, I hope she hasn't treated anyone else like this. Resident #1's RR revealed that she reported this to CNA Supervisor and that CNA #1 had been fired. The State Agency (SA) had attempted to contact CNA #1 several times throughout the investigation and on 07/03/24 at 8:27 AM, CNA #1 returned the phone call. The interview with CNA #1, revealed that she worked at the facility on an As Needed basis and had another full-time job. She revealed that she hadn't worked in two weeks prior to the incident with Resident #1. CNA #1 revealed that on the morning of 05/26/24, she entered Resident #1's room, cleaned her up and dressed her, and when she was ready to transfer her, Resident #1 would not budge. She revealed that prior to this day, Resident #1 would follow commands and help during the transfers. CNA #1 revealed that she was already pressed for time and decided to swiftly transfer her to her wheelchair. CNA #1 revealed the Administrator called her back in to watch the video and she confirmed that it looked like a rough transfer but that was never her intention. She revealed that she normally asked for help with residents, but the nurse wasn't there, and she stated, So I hurried and picked her up, put her in the chair before either of us got hurt. CNA #1 revealed this was a mistake on her end and that she should have left Resident #1 in the bed until she could get help with the transfer because safety should always come first. Record review of CNA #1's Timesheet revealed that she clocked in on 05/25/24 at 10:57 PM and clocked out on 05/26/24 at 7:16 AM and this was the last date that she worked. Record review of CNA #1's written Statement revealed that she had bacon in the oven and had gone into Resident #1's room to get her up and noticed that she was a little more irritable than normal. CNA #1 revealed that when she went to put her shirt on, she leaned back with hesitation. CNA #1 revealed that she pulled resident towards her preparing to pivot, realized Resident #1 had let go of the rail and then took the opportunity to move very quickly to prevent from hurting the resident and herself during the transfer. CNA #1 included in her statement an apology and stated that this was not the appropriate way to transfer a resident. Record review of the Offense/Incident Report completed by the Police Department on 05/28/24 revealed that an officer was dispatched to the facility in regards to a patient being mistreated by an employee. ADM reported to the officer that the ring camera from Resident #1's room was able to record the whole incident. In the video you see CNA #1 aggressively grabbing under Resident #1's arms to the extent that it left noticeable bruising under Resident #1's arms. Officer was able to watch the video of CNA #1 aggressively picking up Resident #1 and in a throwing motion placed her from the bed to the wheelchair. Record review of Resident #1's Progress Note dated 05/26/24, revealed that Resident #1's RR observed on camera in her sister's room in the early morning that she was transferred in an aggressive manner from CNA #1 and she did not want this CNA to take care of her sister anymore. Record review of Resident #1's Progress Note dated 05/27/24 revealed that she had noted a bruise to her left armpit and scattered bruising to her bilateral arms. Record review of Resident #1's admission Record revealed an admission date of 11/08/2021 and she had diagnoses that included Alzheimer's Disease and Vascular Dementia. Record review of Resident #1's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/10/2024 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated that she had severe cognitive deficits. Record review of Resident #1's Weekly Nursing Note and Skin Audit form dated 05/27/24 revealed that a bruise was noted to left armpit and scattered bruising to bilateral arms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review the facility failed to promote and maintain the dignity of a resident as evidenced by a urinary catheter bag with no privacy bag for one (1) of four (4) residents reviewed with a urinary catheter. Resident #115 Findings Include: Record review of the facility policy titled, Promoting/Maintaining Resident Dignity with a revision date of 10/2022 revealed Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality 12. Maintain resident privacy . Record review of a typed statement dated April 12, 2023 and signed by the Administrator revealed We do not have a specific policy on covering catheter bags. An observation on 04/11/23 at 3:48 PM, revealed Resident #115 sitting in the day room of the (Proper name) building on the sofa with his urinary catheter bag hanging off the front of the sofa with no cover over the urine bag that was full of urine. An interview on 4/12/23 at 12:05 PM, with the Director of Nurses (DON) confirmed that residents with urine catheter bags should have a privacy bag covering their urine catheter bag for the resident's dignity. She revealed that the facility has blue privacy bags, and the staff are aware they should always put a privacy bag over the urine catheter bag based on an understood policy. An interview on 4/12/23 at 3:15 PM, with the Administrator confirmed that it is an understood policy that urine catheter bags should be covered with a privacy bag regarding dignity for the resident. Record review of Resident #115's Order Summary Report revealed an order dated 3/15/23, Indwelling Foley catheter in place due to neurogenic bladder . Record review of Resident #115's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Retention of urine and Vascular dementia, unspecified severity. Record review of Resident #115's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/21/23 revealed in Section H that the resident has an indwelling catheter and in Section C a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident is severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, and record review the facility failed to provide a resident with an appropriately sized wheelchair for one (1) of 32 residents reviewed. Resident #107 Findings include: Record review of a typed statement dated April 12, 2023 and signed by the Administrator revealed We do not have a policy on Wheelchair Sizing. There is a protocol that therapy follows but not a written policy. An observation on 04/11/23 at 4:45 PM, revealed Resident #107 sitting in her wheelchair in the dayroom, complaining that her wheelchair was too big for her, and she has told people, but they think it is fine. This observation revealed there was 2-4 inches of space on the seat on either side of the resident between her hips and the wheelchair arms. Her arms were stretched over the arms of the wheelchair with only her fingers reaching the self-propel wheels and she was using her tiptoes to push her wheelchair. This observation revealed she was not able to put her feet flat on the floor unless she scooted to the front edge of the wheelchair seat. An interview on 4/12/23 at 2:30 PM, with the Rehabilitation (Rehab) Director revealed that new admissions are provided a wheelchair and that the resident is evaluated on the same day of admission or the next day to make sure the wheelchair size is correct. She stated that the resident's wheelchair should allow the resident's feet to sit flat on the floor while sitting in the wheelchair and should have 1-2 inches of space between the resident's side of hip and the arm of the chair. An interview on 4/12/23 at 3:40 PM, with the Rehab Director confirmed that Resident #107's wheelchair was too big for her body size. She confirmed that she went and evaluated the chair size and determined that the chair was an 18 inch and the resident needed a 16-inch chair and needs some of the height taken off, so that the resident's feet can be flat to the floor. She stated that with the resident's wheelchair being too big could cause the self-propelling of the wheelchair not to be easy and she then stated that we want it to be easy for them. An interview on 4/12/23 at 4:30 PM, with the Administrator confirmed that Resident #107 should not have had a wheelchair that was too big for her. She revealed that she does not understand why one of the Registered Nurses RN's or Shabazz's (Certified Nursing Assistants) had not already mentioned it to someone. Record review of Resident #107's admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Muscle Weakness. Record review of Resident #107's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/13/23 revealed in Section C a Brief Interview for Mental Status of 05, which indicates the resident is severely cognitively impaired and in Section G that the resident uses a wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review the facility failed to ensure that a Certified Nurse Assistant (CNA) maintained an up-to-date certification for one (1) of 115 certifications reviewed. Finding include: Review of the facility policy titled, License Verification, dated 10/2022 revealed all personnel that require a license or certification shall be verified through the appropriate issuing agency. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure. Any licensed /certified employee is responsible for submitting verification of licensure/certification renewal to Human Resources prior to expiration. Record review of the Certified Nursing Assistant (CNA) certifications revealed CNA #1 did not have an up-to-date certification on file. A copy of the certification revealed it expired on [DATE]. An interview on [DATE] at 11:15 AM, with the Administrator (ADM) confirmed the CNA #1's certification was not up to date in the employee folder and the CNA had been working at the facility since her certification had expired. She stated she works full time 11/7 shift in one of the Greenhouses. She stated there had been no issues reported regarding the care given by CNA #1. The ADM stated a double check of licenses and certifications should be done with a spread sheet of up-to-date employees from their payroll system. The ADM confirmed that CNA #1 would not be working as a certified nursing assistant until her certification was renewed. An interview on [DATE] at 11:20 AM with the Human Resources Manager revealed she was responsible for keeping track of the CNA certifications. She stated that she goes by her binder, but CNA #1's certification was not in the binder and that she does not do a double check using a list of employees. Record review of CNA #1's certification from the Mississippi Nurse Aide Registry revealed Status-Inactive and an Expiration Date 01-31-2023. Record review of CNA #1's payroll information revealed she had worked five days from [DATE], through [DATE].

Based on observation, staff interview and facility policy review the facility failed to change gloves during wound care while going from a dirty site to a clean site and failed to perform hand hygiene between glove changes for one (1) of four (4) residents observed during wound care. Resident #3 Findings include: Review of Facility Policy dated 10/2022 on Clean Dressing Change revealed, Policy: It is the policy of this facility to provide wound care in a manner to decrease the potential for infection and/or cross-contamination . Policy Explanation and Compliance Guidelines: . 9. Loosen the tape and remove the existing dressing. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wounds as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound Pat dry with gauze .14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered . On 04/13/23 at 9:05 AM, observation of wound care to Resident # 3's abdomen performed by Registered Nurse (RN) #2 revealed this RN donned clean gloves, cleaned wound with wound cleanser, patted dry with 4x4s, applied Opticell AG, and covered with bordered dressing. RN#2 failed to perform hand hygiene and change gloves after cleaning the wound bed. RN #2 used the same gloves to clean the wound bed and to apply the Opticell AG and wound dressing. On 04/13/23 at 9:15 AM, an interview with RN#2 revealed that she realized that she had forgotten to wash her hands and change gloves after cleaning the wound. She confirmed that she knew she was supposed to wash her hands and change her gloves after cleaning the wound bed and before applying the wound treatment and dressing. RN#2 stated, I paused a minute during the wound care when I remembered; but it was too late. RN#2 revealed that not changing gloves after cleaning the wound bed and before applying the wound treatment and dressing could cause germs to spread and it could contaminate the wound and cause an infection. On 04/13/23 at 10:00 AM, an interview with the Director of Nursing (DON) revealed it was in their policy to wash hands and change gloves between cleaning a wound and applying treatment and dressing to the wound bed. The DON revealed that not washing hands nor changing gloves could cause contamination and infection. On 04/13/23 at 10:10 AM, an interview with the Administrator revealed it was their policy to wash hands and change gloves during wound care. She confirmed that not washing hands and changing gloves after cleaning the wound bed and prior to applying the treatment and dressing to the wound could cause contamination. Record review of Resident #3's admission Record documented admit date of 06/20/2019 with the following diagnoses to include: Essential Hypertension, unspecified, Morbid Obesity due to excess calories, Cerebral Palsy, unspecified, and Ventral Hernia without obstruction or gangrene. Record Review of Resident #3's Minimum Data Set Section C with Assessment Reference Date of 02/13/2023, documented his Brief Interview for Mental Status (BIMS) Score of 15 which indicated that Resident #3 was cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to accurately screen a resident on a Pre-admission Screening (PAS) application for one (1) of 33 sampled residents, Resident #124. Findings include: Review of the facility's Resident Assessment - Coordination with PASARR Program policy, dated 11/2019, revealed: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. A review of Resident #124's Pre-admission Screening (PAS) Application for Long Term Care, dated 01/15/2020, revealed under Section IX - Level II Determination, was marked no for criteria statement person has diagnosis of Alzheimer's Disease or other Dementia. The PAS application also revealed, no was marked to the Level II Referral criteria statement person has a diagnosis of a major mental illness and person takes or has a history of taking psychotropic medication(s). Review of Resident #124's medical record, revealed he was admitted by the facility on 01/14/2020, with diagnoses which included Dementia with Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder, and Psychosis Not Due to a Substance or Known Physiological Condition. Review of the February 2020 physician orders for Resident #124, revealed orders for the following psychotropic medications: Olanzapine 5 milligram (mg) tablet one tablet by mouth (PO) every night for Dementia with behavioral disturbances, with an order date of 01/14/2020, Ativan 0.5 mg tablet one tablet by mouth every 4 hours as needed (PRN) for 14 days due to Anxiety, with an order date of 01/29/2020 and stop date of 02/12/2020; and Sertraline HCL 25 mg tablet give one and a half tablet (to total 37.5 mg) by mouth daily due to Depression, with an order date of 01/14/2020. A review of Resident #124's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 01/22/2020, revealed Section N (Medications) was coded to reflect the resident received an antipsychotic and antidepressant medication for seven (7) days, and received an antianxiety medication for 6 days; during the 7 day look back period. During an interview, on 02/13/2020 at 11:43 AM, the facility's admission Coordinator stated she was responsible for completing the Pre-admission Screening (PAS) Application for Long Term Care. She stated Resident #124 had a diagnosis of Dementia and Major Mental Illness and was receiving psychotropic medications upon admission to the facility. The admission Coordinator confirmed the PAS application was inaccurately filled out and submitted. During an interview on 02/13/20 at 02:25 PM, Director of Nursing (DON), confirmed the facility failed to submit the PAS accurately. The DON stated accuracy is important for proper placement and care for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to develop a care plan for Activities, for two (2) of 29 care plans reviewed, Resident #85 and #91. Findings include: Review of the facility's Comprehensive Care Plans policy, dated 2017, revealed, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Resident #85 Review of the comprehensive care plan for Resident #85, revealed there was not a care developed for Activities. A review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/25/2019, revealed Section F (Preferences for Customary Routine and Activities) was completed by staff. The staff assessment indicated the resident preferred listening to music and participating in religious activities or practices. Review of the Brief Interview of Mental Status (BIMS), revealed Resident #85 had a score of 15, which indicated intact cognitive status. On 02/11/2020 at 9:49 AM, during an interview with Resident #85, she stated I just stay to myself. Resident #85 revealed that the facility will sometimes have something fun to do like Bingo, but not all the time. During an interview, on 02/12/2020 at 3:30 PM, the Director of Nursing (DON) confirmed there was not an Activities care plan for Resident #85. The DON revealed, the Activity Assistant was off on medical leave, and Resident #85 was one of their newer residents. The DON stated the Activity Director was working by herself and must not have gotten it done yet. A review of the facility's Face Sheet revealed, Resident #85 was admitted by the facility on 12/18/2019, with diagnoses which included Diabetes Type 2, Major Depression, Anxiety Disorder, Pain, and Hypertension. Resident #91 A review of Resident #91's comprehensive care plan, revealed there was no Activities care plan present. Review of the admission MDS Assessment, with an ARD of 01/15/2020, revealed Section F (Preferences for Customary Routine and Activities) indicated Resident #91 activities that were very important to her included: having books, newspapers and magazines to read, listening to music, being around animals, keeping up with the news, doing favorite activities, going outside to get fresh air when the weather was good and participating in religious activities or practices. Review of the Brief Interview of Mental Status (BIMS), revealed Resident #91 had a score of 11, which indicated moderate cognitive impairment. On 02/11/2020 at 10:14 AM, during an interview with Resident # 91, she stated, I kind of stay in my room, because a lot of noise bothers me. I just watch TV, I guess. An interview with the DON, on 02/12/2020 at 3:30 PM, confirmed there was no Activities care plan for Resident #91. A review of facility's Face Sheet, revealed Resident # 91 was admitted on [DATE], with diagnoses which included Major Depression, Anxiety, Hypothyroidism, and Age-related Osteoporosis.

Based on observation, staff interview, and manufacturer's recommendation the facility failed to instruct the resident to rinse her mouth after use of a steroid inhaler, for one (1) of two (2) residents observed receiving an inhaled medication during medication pass, Resident #127. Findings include: Review of the facility's Administration of Metered Dose Inhalers policy, dated 01/08/2018, revealed: Rinse mouth when required per manufacturer recommendations or according to standards of practice. A review of the manufacturer's recommendations for Symbicort 160-4.5 mcg, revealed: After inhalation, the patient should rinse the mouth with water without swallowing. During an observation, on 02/11/2020 at 9:00 AM, Licensed Practical Nurse (LPN) #1 administered Symbicort 160-4.5 micrograms (mcg) to Resident #127, giving two puffs/inhalations by mouth. LPN #1 did not provide a cup of water for the resident to rinse her mouth and spit after the inhaler use as per manufacturer's recommendations. LPN #1 exited the resident's room and returned to the medication cart. An interview with LPN #1, on 02/11/2020 at 9:05 AM, revealed, she knew the routine. LPN #1 asked, Should I have to remind her to rinse her mouth every day when she uses the inhaler? LPN #1 confirmed she did not provide a cup of water to the resident for her to rinse her mouth and spit, and stated she would take the resident some water back to her room if she needed to. A review of LPN #1's Licensed/Registered Nurse Competency, dated 10/07/2019, revealed she received training in Medication Management , which included Respiratory medications. Review of the facility's Face Sheet, revealed, Resident #127 was admitted by the facility on 08/14/2018, with diagnoses which included, Acute and Chronic Respiratory Failure and Unspecified Dementia with Behavioral Disturbances. A review of the most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/03/2020, revealed Resident #127 had a score of 14 on the Brief Interview for Mental Status (BIMS), which indicated intact cognitive ability.

On 02/10/2020 at 11:45 AM, during an initial tour of House #3 and interview with Certified Nurse Aide (CNA) #1, the following items were observed opened and undated: - 1 bag of Cheerios - 1 box of Yellow Cake Mix - 1 box of Devil Food Cake - 1 bag of vanilla wafers - 1 bag of white flour - 1 bag of orange jello - A large bin of potatoes 2-3 inches off the floor CNA #1 stated they are suppose to be putting those orange labels on stuff that is opened and doesn't get used up. CNA #1 revealed items are supposed to be dated so they would know when it goes bad. On 02-10-2020 at 12:30 PM, during initial tour in House #4, and interview with CNA #5, the following items were observed opened and undated: - 1 bag of Cheerios - 2 bags of coffee - 1 bag of pecans CNA #5 stated that sometimes the girls get in a rush to get things prepped and cooked, and they forget to put the labels on stuff right. CNA #5 revealed that she tries to watch for those things, but must have missed a few. During an interview with the Director of Nursing (DON) on 02/12/2020 at 3:00 PM, she stated, they (Shabazz) are supposed to label everything they open, unless it is all used up. The DON stated, someone could really get sick, if certain food items are past their edible date. Based on observation, staff interview and facility policy review, the facility failed to maintain a safe and sanitary dietary environment, as evidenced by, unclean ovens, dirty food bins, scoops left in the food bins, and expired foods, for three (3) of 11 kitchens observed. Review of the facility's policy, Sanitizing Ingredient Bins - #4054 undated, revealed: Ingredient bins will be sanitized on a regular basis. Review of the facility's Cleaning Ovens - #4079 policy, undated, revealed: Ovens will be cleaned and sanitized on a regular basis. A review of the facility's Food Storage and Handling policy, undated, revealed, it is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, appropriate manner for the purpose of preventing food borne illnesses. All dry, refrigerated, and frozen items are stored six (6) inches above the floor and not more than 18 inches from the ceiling, in a temperature controlled room. Dry bulk items, such as rice, sugar, and flour are stored in seamless containers with tight fitting lids and are clearly labeled. Scoops should not be left in food bins. On 02/10/2020 at 10:32 AM, an observation, during initial tour of the kitchen, revealed three (3) large plastic bins containing flour, meal and sugar. There were scoops observed in the meal and flour bins, and a small metal bowl turned upside down in the sugar. The tops and inner edges of the bins had yellowish, brown dry material and crumbs on them. The Dietary Director (DD) removed the scoops from the bins, and the Dietary Manager (DM) removed the small metal bowl from the sugar bin. During an interview, on 02/10/2020 at 10:35 AM, with the Dietary Manager (DM), she stated all of the items were contaminated, and would have to be discarded because the scoops should not be left in the bins. The DM confirmed the bins were dirty and needed to be cleaned. On 02/10/2020 at 10:45 AM, an observation of the convection oven, revealed inside of the oven door, walls, and racks were coated with brown, sticky material and drips of black material hanging from the rack. The bottom of the oven and door opening, contained brownish dry spills, food crumbs and debris. On 02/10/2020 at 10:47 AM, an observation of the two (2) ovens under the range, revealed the walls, inside of the doors, and racks were coated with brown and black build-up. The bottom of both ovens had brownish-black build-up, crumbs and black debris on the floor, shelf ledges, and door crevices. An observation and interview on 02/10/20 at 10:50 AM, with the Dietary Director (DD), confirmed the condition of the convection oven and range ovens. The DD stated they were horribly dirty and embarrassing. He stated the build-up on the ovens could be the cause of a fire, and the black stuff hanging off the racks could cause contamination of foods. An interview, on 02/12/2020 at 9:45 AM, with the Registered Dietician (RD) revealed the facility started with a new company the first of the year, and they had not gotten the new schedules in place for cleaning, but that was no excuse for the dirty ovens and bins.