Newport Tn Opco Llc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) manual review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #53) of 24 residents reviewed. The findings include:Review of the MDS 3.0 RAI Manual version 19.1 dated 10/2024, revealed . J1800 .Any Falls Since Admission/Entry or Reentry or Prior Assessment .Code 1, yes: if the resident has fallen since the last assessment .Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, and Hypothyroidism.Review of the Nurse Note for Resident #53 dated 4/14/2025, revealed .Resident found on floor .doorway .Resident sitting on her bottom .Review of a quarterly MDS assessment dated [DATE], revealed Resident #53 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further record review revealed Resident #53 had not fell since the previous assessment.Review of the comprehensive care plan for Resident #53 revised 7/6/2025, revealed .Fall 4/14/25 .During an interview on 8/20/2025 at 2:58 PM, the MDS Coordinator confirmed Resident #53's quarterly MDS assessment dated [DATE] was inaccurate.

Based on facility policy review, observation, and interviews, the facility failed to follow infection control practices during 1 of 2 medication administration observations.The findings include: Review of the facility's undated policy titled, Medication Administration Policy and Procedure, revealed .Perform hand hygiene . During an observation of medication administration on 8/19/2025 at 8:00 AM, revealed Licensed Practical Nurse (LPN) A prepared medications for Resident #42, entered the resident's room, administered the medication, and exited the room without washing or sanitizing the hands. LPN A returned to the medication cart, prepared medications for Resident #63 entered the resident's room, handed the resident a plastic cup of medications, and the resident dropped an over the counter (otc) pain medication on the floor. LPN A picked up the medication, placed the medication in a plastic cup, ensured all the resident's other medications were administered, exited the room, and discarded the medication without washing or sanitizing the hands. Further observation revealed LPN A prepared another otc pain medication for Resident #63, entered the resident's room, administered the medication, and exited the room without washing or sanitizing the hands. During an interview on 8/18/2025 at 8:09 AM, LPN A confirmed she failed to wash or sanitize her hands during medication administration and after she retrieved the medication off the floor. During an interview on 8/18/2025 at 8:20 AM, the Director of Nursing (DON) confirmed LPN A failed to follow proper infection control practices when she failed to wash or sanitize the hands during medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to meet safety and sanitation requirements for 2 residents (Resident #60 and #74) personal refrigerators of 5 resident personal refrigerators observed.The findings include: Review of the facility's undated policy titled, Refrigerators in the Residents' Rooms, revealed .The Administrator will designate the staff who will be responsible for cleaning the refrigerator weekly and discard any foods that are out of compliance .Foods with use-by dates shall be discarded accordingly . Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Malnutrition, Major Depressive Disorder, Chronic Obstructive Pulmonary Disease (COPD) and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #60 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. During an observation on 8/18/2025 at 11:55 AM, in Resident #60's room, revealed the residents room contained a personal refrigerator. The refrigerator contained tangerines in a plastic container with an expiration date of 4/5/2025. During an observation on 8/19/2025 at 1:30 PM, in Resident #60's room, revealed the residents room contained a personal refrigerator. The refrigerator contained tangerines in a plastic container with an expiration date of 4/5/2025. During an interview and observation on 8/19/2025 at 2:30 PM, in Resident #60's room, the Director of Nursing (DON) stated it was the responsibility of the housekeeping staff to maintain personal refrigerators in resident rooms. The DON confirmed Resident #60 had a container of tangerines with an expiration date of 4/5/2025 and was available for resident consumption. Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including Diabetes, Stroke, Major Depressive Disorder, Osteoarthritis and Diverticulitis. Review of an annual MDS assessment dated [DATE], revealed Resident #74 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. During observations on 8/18/2025 at 12:02 PM and on 8/19/2025 at 1:35 PM, in Resident #74's room, revealed the residents room contained a personal refrigerator. The refrigerator contained a 6 ounce (oz) bottle of mustard half full with an expiration date of 10/31/2024. Further observation revealed a 4 oz unopened container of jello with an expiration date of 5/19/2024 and a 4 oz unopened container of chocolate pudding with an expiration date of 4/25/2024. During an interview and observation on 8/19/2025 at 2:35 PM, in Resident #74's room, the DON stated it was the responsibility of the housekeeping staff to maintain personal refrigerators in resident rooms. The DON confirmed Resident #74 had a container of jello and chocolate pudding which had expired and was available for resident consumption.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to revise the care plan for 2 residents (Resident #53 and #11) of 24 residents reviewed for care plans. The findings include:
Review of the facility's undated policy titled, Care Plan Revision guidelines, revealed .The purpose .provide consistent process .for reviewing and revising the care plan .residents experiencing a .change .A resident's .care plan will be reviewed and revised as necessary .
Review of the facility's undated policy titled, Fall Prevention & Management Program guideline, undated, revealed .high fall risk identified .facility will develop plan of care .plan of care will be revised as needed .
Review of the medical record revealed Resident #53 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes, and Hypothyroidism.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #53 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment.
Review of the comprehensive care plan for Resident #53 revised 7/6/2025, revealed .Night light to be place .
During an observation on 8/19/2025 at 10:30 AM, revealed Resident #53 sitting up in chair in room and a night light was not observed in the room.
During an observation on 8/20/2025 at 7:50 AM, revealed Resident #53 was sitting up on side of bed and a night light was not observed in the room.
During an observation and interview on 8/20/2025 at 9:42 AM, the Director of Nursing (DON) confirmed a night light was not in Resident #53's room, the night light had been discontinued on 7/6/2025, and the care plan had not been revised to reflect discontinuation of the night light.
Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia, and Abnormal Weight loss.
Review of the comprehensive care plan for Resident #11 dated 5/27/2025, revealed .the resident is able to eat independently after set up, cues, and oversight .
Review of an Occupational Weight Loss Screen dated 8/5/2025, revealed .patient needs assistance/supervision with all self-feeding .
Review of a quarterly MDS assessment dated [DATE], revealed the assessment was in progress. Further review revealed Resident #11 scored a 1 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #11 was dependent on staff for eating assistance.
During an interview on 8/18/2025 at 1:05 PM, Certified Nursing Assistant (CNA) G stated Resident #11 required total assistance with eating.
During an observation on 8/18/2025 at 1:15 PM, revealed staff were assisting Resident #11 with eating the lunch meal.
During an interview on 8/20/2025 at 3:10 PM, the MDS coordinator confirmed the facility failed to revise Resident #11's comprehensive care plan to reflect the resident's dependence on staff with eating assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 1 resident (Resident #25) of 5 residents reviewed for PASARR. The findings include:Review of the facility's policy titled, Coordination with PASARR Program, undated, revealed .This facility coordinates assessments with the .(PASARR) program .to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services .appropriate to their needs .any level II resident who experiences a significant change in status will be referred promptly to the mental health or intellectual disability authority for additional resident review .Review of a PASARR Level 1 screen for Resident #25 dated 8/31/2023, revealed the resident had a mental health diagnosis of Depression (mild or situational).Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnosis including Hypertension and Muscle Weakness. Continued review revealed the resident received a new mental health condition of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder on 6/1/2024.Review of the Comprehensive Care Plan dated 4/24/2025, revealed Resident #25 had a care plan for Major Depressive Disorder and PTSD.Review of a quarterly Minimum Data Set (MDS) assessment for Resident #25 dated 6/12/2025, revealed Resident #25 had an active diagnosis which included Depression and Post Traumatic Stress Disorder (PTSD).Review of the medical record revealed a new PASARR for Resident #25 was not submitted after a new mental health diagnosis of Post Traumatic Stress Disorder and Major Depressive Disorder was added.During a record review and interview on 8/19/2025 at 3:21 PM, the Medical Records Licensed Practical Nurse (LPN) stated she was responsible for referring to the state designated agency for PASARRS after new mental health conditions were identified or diagnosed. During further interview the Medical Records LPN confirmed she failed to refer Resident #25 to the state designated agency for PASARRS after the new mental health conditions were added.During an interview on 8/20/2025 at 8:19 AM, the Director of Nursing (DON) confirmed the facility policy for referring to the state agency for PASARRS after identifying new mental health conditions was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observations, and interviews, the facility failed to maintain a safe, clean, homelike environment for 15 resident rooms (#213, #217, #223, #211, #103, #124, #127, #219, #119, #310, #312, #115, #125, #224, and #210) of 68 resident rooms observed, 3 of 5 hallways observed, and 1 of 1 activity rooms observed. The findings include: Review of the facility's policy titled, Resident Environmental Quality, undated, revealed .It is the policy of this facility to be .maintained to provide a safe .sanitary and comfortable environment for residents .and the public . During an observation on 8/18/2025 at 10:00 AM, revealed the floor of the 200 hallway was unclean and had a dirty residue. During an observation on 8/18/2025 at 10:13 AM, revealed the floor of the 300 hallway was unclean and had a dirty residue. During an observation on 8/18/2025 at 10:21 AM, revealed the floor of the 100 hallway was unclean and had a dirty residue. During an observation on 8/18/2025 at 11:50 AM, revealed 3 lights over the sink in resident room [ROOM NUMBER] were not working. During an observation on 8/18/2025 at 11:55 AM, revealed 3 lights over the sink in resident room [ROOM NUMBER] were not working. During an observation on 8/19/2025 at 8:25 AM, on the 100 hallway revealed the floor in front of the entry door to personal care room [ROOM NUMBER] had a dark dirty residue. Further observation revealed the door and door frame had missing/chipped paint and there was brown paint (the color the doors used to be) showing where the paint had been chipped. During an observation on 8/19/2025 at 8:27 AM, revealed the floor in front of the entry door to personal care room [ROOM NUMBER] on the 100 hallway had a dark dirty residue. The door frame had missing/chipped paint and there was brown paint (the color the doors used to be) showing where the paint was missing. Further observation revealed the baseboard next to the door had an unknown brown substance. During an observation on 8/19/2025 at 8:30 AM, revealed the baseboard in the 100 hallway between resident room's 106 and 108 had an unknown brown substance. During an observation on 8/19/2025 at 8:32 AM, revealed the entry door and doorframe to resident room [ROOM NUMBER] had missing/chipped paint and there was brown paint (the color the doors used to be) showing where the paint was missing. During an observation on 8/19/2025 at 8:36 AM, revealed the entry door, doorframe, and bathroom door to resident room [ROOM NUMBER] had missing/chipped paint and there was brown paint (the color the doors used to be) showing where the paint was missing. During an observation on 8/19/2025 at 8:40 AM, revealed the floor in resident room [ROOM NUMBER] had a dark dirty residue. During an observation on 8/19/2025 at 8:45 AM, revealed the unit 1 nurse's station floor had a dark dirty residue. During an observation on 8/19/2025 at 9:30 AM, revealed the ceiling in resident room [ROOM NUMBER] had 2 large brown rings. During an observation on 8/19/2025 at 1:50 PM, revealed the floor in resident room [ROOM NUMBER] had a dark dirty residue. The bathroom floor around the toilet had missing linoleum, and some of the popcorn sprayed texture at the light fixture was missing. Further observation revealed loose and missing pieces of the cove base (a vinyl trim installed at the bottom of a wall where it meets the floor) to the left of the bathroom door. During an observation on 8/19/2025 at 1:56 PM, revealed the floor and bathroom floor in resident room [ROOM NUMBER] had a dark dirty residue. Further observation revealed excessive damage exposing the corner bead behind the sheet rock mud to the right of the bathroom door and the cove base was loose from the wall. During an observation on 8/19/2025 at 2:00 PM, revealed the floor in resident room [ROOM NUMBER] had a dark dirty residue. During an observation on 8/19/2025 at 2:12 PM, revealed the floor at the entrance door to resident room [ROOM NUMBER] had a dark dirty residue. Further observation revealed the entrance door was scuffed and had missing wood pieces. During an interview on 8/19/2025 at 2:50 PM, Housekeeping Aide B stated the floors to the facility .look terrible .they have been like this for the past year or two .the facility would look so much cleaner if the floors were stripped and cleaned . During an interview on 8/19/2025 at 3:20 PM, Certified Nursing Assistant (CNA) C stated the floors had looked dirty in the facility for .at least 2 years . During an observation on 8/19/2025 at 3:30 PM, revealed the entrance door to resident room [ROOM NUMBER] had multiple layers of clear tape affixed to the right upper corner of the door. During an interview on 8/19/2025 at 3:35 PM, Housekeeping Aide D stated the facility had an employee several years ago (unsure of the exact date) who .used wax to clean the floors and ruined them .that is why the floors look nasty . During a telephone interview on 8/19/2025 at 3:38 PM, Licensed Practical Nurse (LPN) F stated the facility floors had looked dirty for the past couple of years and were getting worse. The facility had been in negotiations with her spouse's company for approximately 3-4 weeks to strip and wax the hallways (not the resident rooms) at the facility .they [the facility and the spouse's company] had finally come to an agreement .and they will start on Monday [8/25/2025] [to clean the floors] . During an interview on 8/19/2025 at 3:46 PM, LPN E stated .the floors need to be stripped and waxed . LPN E also stated the facility had been .working with a company for a while [unsure of the dates] to come and wax the floors . During an observation on 8/20/2025 at 8:40 AM, revealed the cabinets in the activity room had chipped missing paint and the floors had a dark dirty residue. During an observation on 8/20/2025 at 8:44 AM, revealed across the wall, resident room [ROOM NUMBER] had loose wall paper. During an observation on 8/20/2025 at 8:47 AM, revealed the entry door frame and bathroom doorframe to resident room [ROOM NUMBER] had missing/chipped paint and had brown paint showing (the color the doors used to be) where the paint was missing. Further observation revealed the floors in the room had a dark dirty residue and the cove base was loose at the bottom right of the bathroom door. During an observation on 8/20/2025 at 8:53 AM, revealed the bathroom door frame in resident room [ROOM NUMBER] had missing/chipped paint. Further observation revealed the floor in the bathroom had loose/torn linoleum. During an observation on 8/20/2025 at 8:57 AM, revealed the floors and the wall to the left of the entrance door in resident room [ROOM NUMBER] had a dark dirty residue. During observations and interviews on 8/20/2025 starting at 2:37 PM and ending at 3:05 PM, with the Maintenance Director, Administrator, and [NAME] President of Life Safety, confirmed the facility was not maintained in a clean, sanitary, and homelike environment on 3 of 5 hallways, 15 resident rooms, and the activity room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview, the facility failed to store the Continuous Positive Airway Pressure (CPAP - equipment used for individuals with sleep apnea) mask appropriately for 1 resident (Resident #31) of 5 residents reviewed for CPAP.
The findings include:
Review of the facility's undated policy titled, CPAP/BiPAP [Bilevel Positive Airway Pressure] Cleaning Guidelines, revealed .Cover with plastic bag .
Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Type 2 Diabetes Mellitus, and Obstructive Sleep Apnea.
Review of a comprehensive care plan dated 4/25/2023, revealed .Respiratory Status Care Plan .At risk for impaired respiratory status .
Review of the Physician's Orders for Resident #31 dated 3/24/2024, revealed .CPAP Mode of Therapy .on at hs [bed time] and off upon waking and prn [as needed] .
Review of an annual Minimum Data Set assessment dated [DATE], revealed Resident #31 scored a 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact.
During an observation and interview on 6/24/2024 at 12:10 PM, in Resident #31's room, the resident's CPAP mask was lying uncovered on the bedside table. The resident stated the staff never offered to put the mask in a bag.
During an observation on 6/25/2024 at 10:15 AM, in Resident #31's room, the resident's CPAP mask was lying uncovered on the bedside table exposed to room air.
During an observation and interview on 6/25/2024 at 10:17 AM, in Resident #31's room, Licensed Practical Nurse M observed Resident #31's CPAP mask lying uncovered and exposed to room air on the resident's bedside table. The LPN confirmed the mask should be stored in a bag while it was not in use. The LPN confirmed there was no storage bag in the room and had to leave the room to obtain a storage bag.
During an interview on 6/26/2024 at 9:43 AM, the Physician's Assistant stated the resident had not had any respiratory infections recently.
During an interview on 6/26/2024 at 10:35 AM, the DON stated it was her expectation when CPAP masks were not in use, they would be stored in a plastic bag. The DON confirmed the CPAP mask uncovered and exposed to room air on Resident #31's bedside table was not stored appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility investigation review, medical record review, and interview, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 resident (Resident #76) of 15 residents reviewed for abuse.
The findings include:
Review of the facility policy titled, Abuse, Neglect, Misappropriation of Property, Exploitation, and Injuries of Unknown Source, dated 9/26/2023, revealed .It is the organization's intention to attempt to prevent the occurrence of abuse .Abuse includes .verbal abuse .Verbal abuse is use of oral .gestured language that includes any threat, or any frightening disparaging or derogatory language to residents .regardless of their .ability to comprehend or disability .
Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Depression.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #76 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Resident #76 required a wheelchair for mobility and was dependent on staff for transfers.
Review of the medical record revealed Resident #56 (witness) was admitted to the facility on [DATE] with diagnoses including Hemiplegia (one sided paralysis or weakness) Affecting Left Nondominant Side, Absence of Right Leg Below Knee, Abnormalities of Gait and Mobility.
Review of a quarterly MDS assessment dated [DATE], revealed Resident #56 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Resident #56 required a wheelchair for mobility and required substantial/maximal assistance from staff for transfers.
Review of the facility's investigation documentation revealed there was an altercation on 6/12/2024 at approximately 7:00 PM, at the west wing nurses' station. Licensed Practical Nurse (LPN) G asked Certified Nursing Assistant (CNA) L (agency employee) to complete her charting prior to leaving her shift. CNA L began yelling loudly explicit language towards staff. CNA L stated she did not need this [explicit language] place and needed to be in Chattanooga. Residents #56 and #76 were seated in wheelchairs outside the nurse's station and witnessed the confrontation between CNA L and LPN G. Resident #56 told CNA L to leave LPN G alone. CNA L then leaned over nurse station and told Resident #76 It's none of your business and you can meet me out in the parking lot. LPN K was at the east wing nurses' station and heard the commotion and responded to the west wing to see what was going on. LPN K arrived at the west wing nurse's station and observed CNA L cursing at facility staff with residents close by. LPN K told CNA L she needed to leave the facility and escorted CNA L out of the building. CNA L continued to speak poorly about the facility and staff while walking out. LPN G immediately assessed Residents #56 and #76 with no injuries noted. Resident #76 stated she was scared initially during the confrontation and stated she was fine and no longer afraid after CNA L was escorted out of the facility. The facility staff immediately notified the Director of Nursing (DON) and Administrator, and an investigation was started. CNA L was placed on Blocked from working list. The Administrator notified CNA L's staffing agency, Adult Protective Services, police, and the Ombudsman of the altercation.
Review of CNA H's witness statement dated 6/13/2024, revealed .I was walking up [NAME] 2 Hall going to the Nurses Station .[LPN G] was trying to help [CNA L] Log in to .[computer program] and [CNA L] started screaming and cussing saying she didn't have time to chart .she had to leave and was told [CNA L] she needed to finish her charting before she left .it was part of the CNA Job .[CNA L then jumped up swinging her arms .up in [LPN G's] face .the residents was .screaming get out of our nurse's face .[CNA L] then turned .Cussing .[Resident #76] .Nurse came from East Hall and walked [CNA L] out the door .[CNA L] was Screaming down the hallway, she didn't need this place and we were all [NAME] Crackers .
Review of RN I's emailed witness statement dated 6/14/2024, revealed .Incident took place on the evening of June 12, 2024 .As I [RN I] came up the hallway .could hear shouting coming from the nursing station .witnessed .[CNA L] and [LPN G] involved in an altercation .[CNA L] was verbally attacking .[LPN G] .proceeded to step between them in an effort to deescalate the situation .two female residents in wheelchairs .were sitting across from the nursing station .asked .[CNA L] repeatedly to leave the facility .advised [CNA L] if she did not leave that I was going to call the Law at which time [CNA L] stated she was not going to leave .another nurse came .and was able to get .[CNA L] .to exit the building .[CNA L] continued with profane, insulting, and abusive language towards .[LPN G] and other staff .until [CNA L] .was out of my area of observation .
Review of Resident #76's undated witness statement, revealed .at the end of shift I was sitting at the nurses desk and I looked over at [CNA L] and [CNA L] stated .I am going to get you [Resident #76] too, if you want to run your mouth you can meet me out in the parking lot .Then she [CNA L] started cussing LPN G out .
Review of Resident #56's undated witness statement, revealed .[CNA L] stated she needed to leave to go home. [LPN G] was trying to help [CNA L] log in to .the computer to do her charting. Then [CNA L] started yelling at [LPN G]. [CNA L] called [LPN G] a Gay Cracker. [Resident #56] stated to leave [LPN G] alone and that [CNA L] needed to leave. [CNA L] got in [Resident #76's] face threatening [Resident #76] .
Review of LPN G's undated witness statement, revealed .[CNA L] was upset she had to chart .[LPN G] asked [CNA L] to use the Desktop computer so [LPN G] could use the Laptop [computer] for .med pass [medication administration] [CNA L] proceeded to tell [LPN G] she didn't have a log in .[LPN G] explained .would text supervisor and get [CNA L] a log in .[CNA L] said everyone was being rude. [LPN G] told [CNA L] no one was being rude that she just needed to .finish charting .[CNA L] got upset and got up in [LPN G's] face .[CNA L] became angry and started screaming at staff and residents [no named residents] .nurse on East came down and was able to escort [CNA L] .out of the building .
Review of CNA J's undated witness statement, revealed .On 6/12/2024 [CNA J] witnessed [CNA L] stand up and get in [LPN G's] Face screaming .Calling [LPN G] derogatory names .[CNA L] turned .to .[Resident #76] .screaming .Shut the [Explicit language] up .It's none of your business .[LPN K] .walked [CNA L] out of the builidng .
Review of the Psychiatric Follow-Up Note for Resident #76 dated 6/12/2024, revealed .Patient was involved in an incident with the CNA who has since been dismissed from the facility. No signs of psychosocial harm at this time. She continues at her baseline resting in room .Patient stable .
Review of the Nurse's Notes for Resident #76 dated 6/13/2024, revealed .f/u [follow up] with psychosocial wellbeing check; pt [patient] has been up in w/c [wheelchair], pleasant, laughing, interacting well with staff, has been attending activities; ate lunch in dining room; good appetite; no voiced needs or wants .
Review of the Nurse's Notes for Resident #76 dated 6/14/2024, revealed .Psychosocial well check visit .Resident in great spirits this am out and about visiting residents, states to this worker she is feeling and doing well .
Review of the Nurse's Notes for Resident #76 dated 6/17/2024, revealed . follow up with [Resident #76] to last week's incident states she is doing great and no lasting effects from the event .
During an observation and interview on 6/24/2024 at 10:30 AM, Resident #76 was sitting up in a wheelchair at the nurses' station. Resident #76 rolled herself back into her room. Resident #76 stated there had been an incident a couple of weeks ago where a CNA was yelling at a nurse. Another resident (Resident #56) told the CNA to stop, and the CNA stated to the resident the CNA would meet Resident #76 out in the parking lot. Resident #76 stated she felt the CNA meant she wanted to fight the resident when she stated she would meet the resident in the parking lot. Facility staff escorted the CNA out of the building and the resident felt the facility staff acted promptly and had protected her. Resident #76 stated she felt safe during the incident and had not experienced any ill effects from it.
During an interview on 6/24/2024 at 11:19 AM, Resident #56 stated she had not been abused or witnessed a resident be abused by anyone at the facility.
During a telephone interview on 6/25/2024 at 10:09 AM, CNA J stated on 6/12/2024 at approximately 7:00 PM she was walking towards west wing's Nurse's station. Resident #56 and Resident #76 were sitting at the nurses' station. LPN G asked CNA L to complete her charting before she left. CNA L stood up in LPN G's face, screaming at him and called LPN G derogatory names. LPN G told CNA L to complete charting before leaving the facility. CNA L screamed, .I don't need this [Explicit language] place . CNA L stated to LPN G, .You need to fix your hair you [Explicit Language] fag . CNA J stated LPN K came over from the other unit and told CNA L she needed to leave. CNA J stated that in the middle of this, Resident #56 leaned over the desk and tried to get CNA L away from LPN G. CNA J stated Resident #76 said something, and CNA L told Resident #76, .Well you can meet me out in the parking lot . LPN K escorted CNA L out of the building. CNA J stated she checked on Resident #76 and the resident reported feeling safe.
During an interview on 6/25/2024 at 10:46 AM, CNA H stated on 6/12/2024 at approximately 7:00 PM, she was walking up to west wing nurse's desk and heard loud voices. LPG G was telling CNA L she needed to finish her charting before leaving. CNA L was screaming saying that she had to leave and go to [Explicit Language] Chattanooga and did not need this place. LPN G told CNA L that it was her job and CNA L got up in LPN G's face, started slinging her arms and cursing at LPN G. CNA H stated Residents #56 and #76 were seated outside the nurse's station during the confrontation. LPN G told CNA L nicely to please get out of his face and the residents were screaming .get out of our nurse's face . CNA L said to Resident #76, .it's not your problem and we can meet out in the parking lot . LPN K then came and walked CNA L to the door. CNA L continued to scream that she did not need this place and that we were all .white crackers . CNA H stated she checked on Resident #76 and initially she was scared but felt safe after CNA L was escorted out of the facility.
During an interview on 6/25/2024 at 8:23 PM, LPN K (worked 7:00 PM-7:00 AM on 6/12/2024) stated she heard yelling from the west wing nurse's station and was concerned that it could be a resident and proceeded down hallway towards the west nurse's station. When LPN K got to the west wing nurse's station she observed Resident #56 and Resident #76 seated outside the nurse's station. LPN K stated CNA L was yelling and cursing at staff. LPN G told CNA L she needed to leave and if she didn't leave, they would call 911. LPN K perceived CNA L's behavior as hostile. LPN K escorted CNA L out of the facility. LPN K stated CNA L continued speaking with slanderous words about the facility and staff while escorting her out of the building.
During an interview on 6/25/2024 at 3:15 PM, Resident #56 stated she had not been abused or cursed by anyone at the facility. The resident also stated she had not witnessed a resident be abused or cursed by anyone at the facility.
During a telephone interview on 6/26/2024 at 8:12 AM, LPN G stated he worked 7:00PM-7:00 AM on 6/12/2024. LPN G stated CNA L was sitting at the nursing station using a laptop computer. LPN G explained to CNA L he needed to use the laptop to complete a medication administration pass to the residents. LPN G asked CNA L if she could use the desktop computer and the CNA stated she did have a log in for the computer. LPN G explained he would contact a supervisor to obtain a log in for the CNA. CNA L stated everyone was being rude, did not have time to complete her documentation, and she needed to be in Chattanooga. LPN G explained to CNA L that no one was being rude, and her charting needed to be finished. CNA L was upset and got in LPN G's face. Residents #56 and #76 were seated outside the nurse's station and told CNA L .You better leave (LPN G) alone . CNA H arrived and told (LPN G) to walk away. The nurse on east wing, LPN K, arrived to escort CNA L out of the building. The supervisor notified the DON and Administrator of the altercation and the adminstrator came to the facility to start an immediate investigation.
During an interview on 6/26/2024 at 1:20 PM, Resident #56 (when directly asked about an alleged incident from 6/12/2024) stated she remembered an incident which involved CNA L. Resident #56 and Resident #76 were seated at the nurse'ss station on the west wing around 7:00 PM. LPN G asked CNA L to complete her charting. CNA L got up in LPN G's face and stated she needed to go home. Resident #56 stated she told CNA L to be quiet and not talk to LPN G that way. CNA L turned to Resident #76 and said, .It's not your problem and you and can meet me out in the parking lot . Resident #56 stated staff immediately protected her and Resident #76. CNA L was escorted out of the building. Resident #56 stated she was not affected from the incident.
During an interview on 6/26/2024 at 4:15 PM, the Administrator confirmed CNA L verbally abused Resident #76 when CNA L used profantity and threatened the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews the facility failed to assess 1 resident (Resident #71) for smoking of 3 residents reviewed for smoking.
The findings include:
Review of the facility's undated policy titled Smoking Procedures for Residents, revealed .Residents who desire to smoke will be assessed for safety with smoking materials upon admission or initially request to smoke as well as on a quarterly basis .
Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Infection of the Left Lower Leg, Kidney Failure, and Heart Attack.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #71 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact.
Record review of Resident #71's assessments revealed the resident was not assessed for smoking.
During an observation at the east hall smoking area on 6/25/2024 at 9:44 AM, revealed Resident #71 was smoking a cigarette while wearing a smoking apron during the supervised scheduled smoke break for residents.
During an observation at the east hall smoking area on 6/25/2024 at 4:30 PM, revealed Resident #71 was smoking a cigarette while wearing a smoking apron during the supervised scheduled smoke break for residents.
During an interview in the conference room on 6/25/2024 at 10:52 AM, the Administrator stated Resident #71 started smoking in 5/2024.
During an interview on 6/25/2024 at 11:11 AM, the Director of Nursing stated Resident #71 smoked at the facility and confirmed the resident was not assessed for smoking.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews the facility failed to develop a person-centered care plan related to smoking for 1 resident (Resident #71) of 3 residents reviewed for smoking.
The findings include:
Review of the facility's undated policy titled, Comprehensive Care Plans, revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with .needs that are identified .The care planning process will include .Services provided or arranged by the facility .the comprehensive care plan will describe at minimum .The services that are to be furnished .Resident specific interventions that reflect the resident's needs and preferences .
Review of the medical record revealed Resident #71 was admitted to the facility on [DATE] with diagnoses including Infection of the Left Lower Leg, Kidney Failure, and Heart Attack.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #71 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact.
Record review of a comprehensive care plan for Resident #71 revised 5/30/2024, revealed the resident did not have a smoking care plan.
During an observation at the east hall smoking area on 6/25/2024 at 9:44 AM, revealed Resident #71 was smoking a cigarette while wearing a smoking apron during the supervised scheduled smoke break for residents.
During an observation at the east hall smoking area on 6/25/2024 at 4:30 PM, revealed Resident #71 was smoking a cigarette while wearing a smoking apron during the supervised scheduled smoke break for residents.
During an interview in the conference room on 6/25/2024 at 10:52 AM, the Administrator stated Resident #71 started smoking in 5/2024.
During an interview on 6/25/2024 at 11:11 AM, the Director of Nursing stated Resident #71 smoked at the facility and confirmed a smoking care plan was not developed for Resident #71.

Based on facility policy review, facility document review, and interview, the facility failed to provide the services of a Registered Nurse (RN) for the minimum requirement of 8 hours a day for 1 day (6/23/2024) of 32 days reviewed between the period of 5/23/2024 and 6/23/2024.
The findings include:
Review of the facility's undated policy titled, Nursing Services and Sufficient Staff, revealed .The facility will provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident .the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week .
Review of the facility document titled, Daily Staffing Form, dated 6/23/2024, revealed no RN was on duty working in the facility.
During an interview on 6/26/2024 at 9:15 AM, The Administrator confirmed the facility failed to provide the minimum requirement of 8 hours RN coverage on 6/23/2024.

Based on facility policy review, observations, and interviews the facility failed to ensure expired supplies were not available for resident use in 2 of 2 medication rooms observed.
The findings include:
Review of the facility's undated policy titled, Medical Products & Supplies Use and Storage, revealed .The facility will follow manufacturers' guidelines when using medical devices .which includes syringes, tubes .expired item will not be used .
During an observation and interview in the east medication room on 6/26/2024 at 3:49 PM, with Licensed Practical Nurse (LPN) A and LPN B revealed 25- 3 mL (milliliter) blue top blood collection tubes with an expiration date of 3/31/2024. LPN A and LPN B stated the facility occasionally collected blood specimens. LPN A and LPN B confirmed the 25- 3 mL blue top blood collection tubes were expired and available for resident use.
During an observation and interview in the west medication room on 6/26/2024 at 4:02 PM, with LPN C, revealed 10- 28 gauge (ga) x (by) ½ inch (in) syringes with an expiration date of 11/30/2023, and 77- 28 ga x ½ in syringes with an expiration date of 4/20/2023 (a total of 87 syringes). LPN C confirmed the 87- 28 ga x ½ in syringes were expired and available for resident use.
During an observation and interview with the Director of Nursing (DON) in the west medication room on 6/26/2024 at 4:08 PM, the DON stated CNA D/Central Supply was responsible to check medication rooms weekly and discard expired supplies. The DON confirmed the expired 25- mL blue top blood collection tubes in the east medication room and the 87- 28 ga x ½ in syringes in the west medication room should have been removed from the medication room and not available for resident use.
During an observation and interview on 6/26/2024 at 4:10 PM, with CNA D/Central Supply in the west medication room, on 6/26/2024 at 4:10 PM, CNA D/Central Supply stated she was responsible to check the medication rooms for expired medications and supplies. CNA D/Central Supply stated, .I try to check them twice a month . CNA D/Central Supply stated the expired syringes should have been discarded.

Based on facility policy review, observation, and interview, the facility failed to maintain a sanitary environment in 1 of 1 kitchen, in 1 of 1 walk-in refrigerator, in 1 of 1 walk-in freezer, in 1 of 1 stand-alone refrigerator, and in 1 of 1 food and paper storage room observed, potentially affecting 61 of 65 residents in the facility.
The findings include:
Review of the facility policy Food Storage: Dry Goods, dated 9/2017, showed .Dining Services Director or designee regularly inspects [food service areas] [for] contamination .
Review of the facility policy Foods Storage, dated 4/2018, showed .foods will be stored wrapped or in covered containers, labeled and dated .
Review of the facility policy Food Safe Handling for Foods from Visitors, dated 7/2019 showed .discard .any food items that have been stored for [equal to or greater than] 7 days .
Observation and interview with the Lead [NAME] (LC) #1 on 6/6/2021 at 9:36 AM, in the kitchen, showed 30 uncovered small bowls of stewed apple dessert on an uncovered rack and 2 cups of loose cornmeal in a pitcher, covered with plastic wrap dated 2/2021, inside a confectioner sugar bin. Interview confirmed the facility failed to ensure the 30 uncovered small bowls of stewed apple dessert was labeled, and dated. Continued interview confirmed the facility failed to discard expired food items available for resident use.
Observation and interview with LC #1 on 6/6/2021 at 9:45 AM, in the walk-in refrigerator showed the following:
2 boiled eggs, unshelled, in yellow liquid in a sealed plastic bag, dated 5/21/2021
1 opened 45-ounce jar of spaghetti sauce containing 1 cup, undated
15 opened unwrapped blueberry muffins, loose in box, undated
Interview with LC #1 confirmed the facility failed to ensure resident food was labeled and dated and failed to discard expired food items available for resident use.
Observation and interview with LC #1 on 6/6/2021 at 9:50 AM, in the walk-in fridge showed the following staff food items:
One 16-ounce yogurt
One 9-ounce frozen orange chicken dinner
One 16-ounce salad dressing, ¾ full
One 8-ounce frozen dinner, undated
Interview with LC #1 confirmed the facility failed to store staff food items in a separate refrigerator from resident use.
Observation and interview with LC #1 on 6/6/2021 at 9:55 AM, in the walk-in freezer, showed 10 uncovered, undated frozen breadsticks. Interview confirmed the facility failed to ensure resident food was covered, labeled and dated.
Observation and interview with LC #1 on 6/6/2021 at 10:00 AM, in the kitchen at the stand-alone refrigerator showed the following:
One opened employee 20-ounce bottle sports drink, undated
One 46 fluid ounce thickened orange juice, approximately ¾ remaining, undated
One 32 fluid ounce thickened dairy drink, approximately 1 cup remaining, undated
One 32 fluid ounce thickened dairy drink, approximately ¾ cup remaining, undated
One 32 fluid ounce thickened dairy drink, approximately ½ cup remaining, undated
One 32 fluid ounce chicken broth, opened and undated
4 cups of tea remaining in covered pitcher, dated 5/21/21(expired 9 days)
4-ounce cup pineapple snack, undated
3 pre-made cheese sandwiches, undated
Individually poured liquids uncovered:
Three 8-ounce nectar thick milk
Three 8-ounce nectar thick water
Two 8-ounce nectar thick tea
Two 8-ounce fruit punch
Two 8-ounce cranberry juice
Two 4-ounce cranberry juice
Two 8-ounce apple juice
One 8-ounce orange juice
Interview with LC #1 confirmed the facility failed to ensure resident food was labeled, covered, dated, and failed to discard expired food items available for resident use. Continued interview confirmed the facility failed to store an employee sports drink in a separate refrigerator.
Observation and interview with LC #1 on 6/6/2021 at 10:10 AM, in the food and paper storage room showed the following:
One 128 fluid ounce pancake syrup, approximately 1/4 cup remaining, undated
One 5-pound bag cornbread mix, 2.5 pounds remaining, undated
6 cups corn cereal opened in large zipped bag, undated
42 ounces oats, ¾ cup remaining, undated
One 5-pound bag cornbread mix, 3/4 mix remaining, undated
1.5 cups cake mix in box opened, undated
Interview with LC #1 confirmed the facility failed to ensure resident food was labeled and dated.
Observation with LC #1 on 6/6/2021 at 10:21 AM, in the food and paper storage room showed, upon entry, two damaged areas in the left far corner ceiling of the room. Proximal damaged area, approximately eight inches in diameter, with actual break in ceiling tile. The distal damaged area was approximately four inches in diameter. Both areas were light brown in color, with a darker brown ring surrounding each perimeter. Continued observation showed two boxes situated directly underneath the discolorations on a food storage rack. Both boxes and contents were stained and misshapen. Continued observation showed black debris on 2 of 2 ceiling vent covers.
Interview with LC #1 on 6/6/2021 at 10:25 AM, in the food and paper storage room, confirmed she had not noticed or reported the damaged boxes in the corner on the food storage rack, or the damaged ceiling above the food storage rack. Continued interview confirmed the facility did not maintain a sanitary environment.
Observation with LC #1 on 6/6/2021 at 12:05 PM, in the kitchen, showed black debris on 6 of 6 ceiling vent covers.
Interview with LC #1 on 6/6/2021 at 12:15 PM, in the kitchen, confirmed black debris on 6 of 6 ceiling vent covers. Continued interview confirmed the facility had not maintain a sanitary environment in the kitchen.
Observation with the District Manager (DM) and Director of Maintenance on 6/6/2021 at 12:35 PM, in the food and paper storage room, confirmed the presence of two discolored and damaged areas in the left far corner ceiling of the room and black debris in 8 out of 8 ceiling vent covers in the storage room and kitchen area.
Interview with the DM and Director of Maintenance on 6/6/2021 at 12:45 PM, confirmed the facility failed to maintain a sanitary environment. Continued interview showed he was responsible for all vent cover cleaning and he was not aware of the leaks in the ceiling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to prevent accidents for 1 resident (Resident #259) of 4 residents reviewed for accidents. The facility failed to transfer Resident #259 with the care planned intervention for transfer. The facility's failure resulted in a fracture of the resident's proximal left tibia (upper part of the shin bone) and Harm for Resident #259.
The findings include:
Review of the facility policy titled LIFT, TRANSFER, AND REPOSITIONING POLICY dated 2010, showed .The IDT [Interdisciplinary Team] will use the Company Lift and Transfer Guide .to develop care plan interventions that will continue to focus on ensuring the residents attain and maintain their highest level of physical functioning .Residents identified as partial weight-bearing or non-weight bearing and needing assistance with lifts and transfers shall be lifted using an appropriate mechanical lift .Direct care staff will be responsible for the following .Lifting and transferring residents in accordance with the residents' plans of care .
Medical record review showed Resident #259 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Anxiety Disorder, Edema, Epilepsy, Chronic Pain, Major Depressive Disorder, Chronic Kidney Disease.
Medical record review of Resident #259's comprehensive care plan, dated 6/15/2017, showed the resident had a self-care deficit related to impaired mobility. Further review showed the resident was at risk for falls related to impaired mobility, required a mechanical lift with 2 staff members assistance for transfers. A lift pad was to be left underneath him, while in the wheelchair.
Medical record review of the quarterly Minimum Data Set (MDS) assessment, dated 8/10/2020, showed Resident #259 was cognitively intact, totally dependent with 2 persons assist for transfers, did not walk, and had range of motion impairments to both legs.
Medical record review of an SBAR (Situation, Background, Assessment, and Recommendation) Communication Form, dated 10/10/2020, showed Resident #259 had complained of pain to the left lower leg. The area below the left knee was red, swollen, and painful. A Physician's Assistant (PA) was notified with a new order for an x-ray to be obtained.
Review of a radiology report, dated 10/11/2020, showed .KNEE EXAM .LEFT .non-displaced fracture of the proximal tibia .
Review of a Nursing Progress Note, dated 10/12/2020, showed .PA evaluated resident post [after] xray results, current history and med [medication] regimen, stated x-ray showed non-displaced fracture and demineralization on bone which could have predisposed condition for fracture .Pain regimen in place .
Review of Resident #259's pain level flowsheet, included in the Medication Administration Record (MAR), showed a pain level of 2 on the morning of 10/10/2020. Review showed the pain medication was administered on 10/11/2021- 10/15/2020 with a pain level of 1-5 and the resident's pain was relieved.
Medical record review of a PA Progress Note, dated 10/12/2020, showed the follow-up after Resident #259's x-ray, .The patient was complaining of left leg pain .after the patient was transported from his bed to his wheelchair. X-rays were performed, and I am reviewing those results today .He has flaccid paralysis [loose and floppy] of bilateral [both] lower extremities [legs] .
Interview with Certified Nursing Assistant (CNA) #1, on 6/7/2021 at 3:20 PM, showed she had worked the day shift on 10/9/2020. Interview showed she had gone into Resident #259's room and he was insisting she get him up into the wheelchair. She stated he did not like using the mechanical lift because he said it squeezed him. CNA #1 stated staff often transferred the resident with 2 assist, not using the lift. CNA #1 stated she had not transferred him by herself before 10/9/2020. She stated she assisted him to a seated position on the side of the bed and he put his arms around her neck. CNA #1 stated the resident was unable to put weight on his legs, so she positioned the bed higher than the wheelchair, and slid him into the wheelchair. She stated once he was seated in the wheelchair, he said his leg was hurting and his right leg was behind the left leg. CNA #1 stated he complained of hurting for about 20 minutes. She placed his feet on the footrests of the wheelchair, and he did not complain anymore of pain during the shift. CNA #1 stated she had not reported the transfer and the resident's subsequent complaint of pain to the nurse, because he had stopped complaining of pain. She stated she did not transfer the resident back to bed on her shift. CNA #1 confirmed the resident was care planned for the use of a mechanical lift for transfers and stated she was unsure if she had ever reported his refusals to use the lift to a nurse.
Interview with the PA on 6/7/2021 at 3:30 PM, confirmed CNA #1 had transferred Resident #259 from the bed to the wheelchair without use of the mechanical lift and without assist from another staff member. The PA stated when the resident complained of pain, the morning of 10/10/2021, an x-ray had been obtained which showed a tibial plateau fracture (a break in the larger lower leg bone below the knee). The PA confirmed the resident was unable to bear weight on his legs, before and after the leg fracture. The PA further stated she believed CNA #1's failure to follow the care planned intervention for a lift transfer on 10/9/2020 had caused Resident #259's leg fracture.
Interview with Licensed Practical Nurse (LPN) #4 on 6/8/2021 at 8:25 AM, confirmed she had worked the day shift on 10/10/2020 and assessed Resident #259 for a complaint of pain. She stated the resident told her he had gotten hurt the previous day, during a transfer to the wheelchair on 10/9/2020. She stated she notified the PA and obtained an x-ray. LPN #4 stated the resident required a mechanical lift for transfers.
Interview with CNA #2 on 6/8/2021 at 8:40 AM, confirmed she worked the evening shift on 10/9/2020. She stated she assisted CNA #3 to transfer Resident #259 from the wheelchair back to the bed. She stated there wasn't a lift pad under the resident, so they were unable to use the mechanical lift to transfer. She stated they transferred the resident with a 2-person assist and a gait belt. CNA #2 confirmed the resident was care planned for the use of a mechanical lift for transfers.
Interview with CNA #4 on 6/8/2021 at 8:54 AM, confirmed she had worked the night shift on 10/9/2020. She stated Resident #259 did not complain of pain during the night. CNA #4 confirmed the resident required the use of a mechanical lift for transfers.
Interview with CNA #5 on 6/8/2021 at 9:01 AM, confirmed she had worked the day shift on 10/10/2020. She stated Resident #259 complained of pain in his lower left leg, in the shin area, while she was getting him ready to get up in the wheelchair. She stated she had rolled him in the bed to get him dressed, his left leg was swollen and red and she reported it to the nurse. She stated the resident had told her his leg got caught in the wheelchair the previous day (10/9/2020) when a staff member transferred him without assistance. CNA #5 confirmed the care plan stated the resident required a mechanical lift for transfers.
Interview with the LPN MDS Coordinator on 6/8/2021 at 9:24 AM, confirmed Resident #259's risk for falls care plan showed an intervention for the use of a mechanical lift, initiated on 6/15/2017. She stated therapy had evaluated and recommended a mechanical lift as the safest method of transfer. She confirmed the CNAs had access to the care plans in the computerized charting system.
During interview by telephone with Resident #259's Attending Physician on 6/8/2021 at 9:58 AM, the physician stated CNA #1 .should have followed the protocol . for the resident's transfers. He stated the injury did sound consistent with the reported incident.
Interview with the Director of Nursing (DON) on 6/8/2021 at 12:56 PM, confirmed CNA #1 transferred Resident #259 on 10/9/2020 by herself, without the use of a mechanical lift. She further confirmed on 10/10/2020 the resident had began to complain of pain in his left lower leg, an x-ray had been obtained, and the resident had sustained a fracture of his left proximal tibia. The DON stated physical therapy had completed an evaluation and determined the mechanical lift was the safest method of transfer for the resident. The DON stated she did not believe the resident was able to bear weight on his legs during a transfer. The DON confirmed the improper transfer of Resident #259 on 10/9/2020 could have caused the fracture of the resident's proximal tibia. The DON confirmed the care plan had not been followed during the transfer on 10/9/2020 and confirmed the resident was at increased risk for fracture due to bone demineralization.
Interview with the District Director of Clinical Services on 6/8/2021 at 1:18 PM, confirmed the facility had identified the Harm to Resident #259 and had taken actions to correct the non-compliance.
A plan of correction was developed from 10/10/2020-10/14/2020 to address the deficient practice that resulted in Harm on 10/9/2020. The corrective actions were validated on-site by the surveyors on 6/7/2021-6/8/2021 through interviews and review of documents. The facility's Allegation of Compliance for the Prevention of Accidents, dated 10/14/2020, was presented to the survey team and documented the following corrective actions were implemented.
On 10/12/2020, counseling by use of the Teachable Moment was given to the 3 CNA's identified as transferring the affected resident out of the bed and later back to bed without use of the lift.
On 10/12/2020, interviews were conducted by the Activities Director and the DON with all interviewable residents related to their care received by the CNA involved in the incident and with their care in general to rule out neglect or care plans not being followed.
On 10/13/2020-10/14/2020 the DON completed an audit of 100% of all residents' [NAME] and care plans.
On 10/13/2020-10/14/2020 the Therapy Director completed an audit of 100% of all residents' care plans and [NAME] for the appropriateness of each resident's requirement needs for transfer. Care plans were updated as needed.
On 10/14/2020, the facility's Quality Assurance/Performance Improvement committee met and determined the root causes of the incident, reviewed the corrective actions taken, and planned for ongoing assessment tasks to confirm continued compliance.
On 10/14/2020, orientation for newly hired nursing staff included education to follow care planned transfer status for residents.
On 10/13/2020, the 64 nursing department employees received education to address use of the Care Plan and [NAME] instructions related to transfers.
On 10/14/2020, the 64 nursing department employees received re-education to address abuse, resident rights verses resident and staff safety.
Audits of the residents' [NAME] and care plans were completed by the DON and ADON on 10/12/2020, 10/21/2020, 10/30/2020, 11/2/2020, and 12/3/2020, and confirmed there were no issues noted with inappropriate transfers.
1. Surveyors interviewed the DON on 6/8/2021 at 2:00 PM, in the conference room. Interview confirmed there had not been any further incidents involving resident transfers.
2. Interview and review of audits for evaluation of transfers with lifts, with the DON, showed the observational audits were completed for 4 consecutive weeks as planned from 10/14/2020-11/14/2020 and then monthly x 2 as planned through 1/4/2021.
3. Surveyors interviewed 9 CNA's and 4 LPN's for knowledge of the inservices provided in the corrective action plan, safe use of mechanical lifts and no knowledge deficits were identified.
The harm was cited past noncompliance and the facility is not required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to follow the Comprehensive Care Plan for 1 resident (Resident #259) of 4 residents to ensure a safe transfer with a mechanical lift. The facility's failure resulted in a fracture of the resident's proximal left tibia (upper part of the shin bone) and Harm for Resident #259.
The findings include:
Review of the facility policy titled Comprehensive Care Plan revised May 2021, showed .The plan must address the resident's individual needs, strengths, and preferences .The Comprehensive Care Plan planning process includes: .Incorporation of the resident's personal .preferences .The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs .At a minimum, the care plan is updated with each comprehensive and quarterly assessment .
Medical record review showed Resident #259 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Anxiety Disorder, Edema, Epilepsy, Chronic Pain, Major Depressive Disorder, and Chronic Kidney Disease.
Medical record review of Resident #259's Comprehensive Care Plan, dated 6/15/2017, showed the resident had a self-care deficit related to impaired mobility with a linked intervention TRANSFER: The resident requires total assistance by (2) staff to move between surfaces. Continued review showed there was a second Focus [problem] revised on 12/04/2019, .assistance with transfers r/t [related to] impaired mobility . with the linked intervention .Mechanical lift with 2 staff members assistance with transfers with red sling .
Medical record review of the quarterly Minimum Data Set (MDS) assessment, dated 8/10/2020, showed Resident #259 was cognitively intact, totally dependent with 2 persons assist for transfers, did not walk, and had range of motion impairments to both legs.
Medical record review of an SBAR (Situation, Background, Assessment, and Recommendation) Communication Form, dated 10/10/2020, showed Resident #259 had complained of pain to the left lower leg. The area below the left knee was red, swollen, and painful. A Physician's Assistant (PA) was notified with a new order for an x-ray obtained.
Review of a radiology report, dated 10/11/2020, showed .KNEE EXAM .LEFT .non-displaced fracture of the proximal tibia .
Interview with Certified Nursing Assistant (CNA) #1, on 6/7/2021 at 3:20 PM, showed she had worked the day shift on 10/9/2020. Interview showed she had gone into Resident #259's room and he was insisting she get him up into the wheelchair. CNA #1 stated the staff often transferred the resident with 2 assist, not using the lift. CNA #1 stated she had not transferred him by herself before 10/9/2020. She stated she assisted him to a seated position on the side of the bed and he put his arms around her neck. She stated the resident was unable to put weight on his legs, so she positioned the bed higher than the wheelchair, and slid him into the wheelchair. She stated once he was seated in the wheelchair, he said his leg was hurting and his right leg was behind the left leg. CNA #1 confirmed the resident was care planned for the use of a mechanical lift for transfers.
Interview with the PA on 6/7/2021 at 3:30 PM, confirmed the CNA had transferred Resident #259 from the bed to the wheelchair without use of the mechanical lift and without assist from another staff member. The PA further stated she believed CNA #1's failure to follow the care planned intervention for a lift transfer on 10/9/2020 had caused Resident #259's leg fracture.
Interview with CNA #2 on 6/8/2021 at 8:40 AM, confirmed she worked the evening shift on 10/9/2020. She stated she assisted CNA #3 to transfer Resident #259 from the wheelchair back to the bed. She stated they transferred the resident with a 2-person assist and a gait belt. CNA #2 confirmed the resident was care planned for the use of a mechanical lift for transfers.
Interview with the LPN (Licensed Practical Nurse) MDS Coordinator on 6/8/2021 at 9:24 AM, confirmed Resident #259's risk for falls care plan showed an intervention for the use of a mechanical lift, initiated on 6/15/2017. She stated therapy had evaluated and recommended a mechanical lift as the safest method of transfer. She confirmed the CNA's had access to the care plans in the computerized charting.
Interview with the Director of Nursing (DON) on 6/8/2021 at 12:56 PM, confirmed the care plan had not been followed during the transfer on 10/9/2021.
Interview with the District Director of Clinical Services on 6/8/2021 at 1:18 PM, confirmed the facility had identified the Harm to Resident #259 and had taken actions to correct the non-compliance.
A plan of correction was developed from 10/10/2020-10/14/2020 to address the deficient practice that resulted in Harm on 10/9/2020. The corrective actions were validated on-site by the surveyors on 6/7/2021-6/8/2021 through interviews and review of documents. The facility's Allegation of Compliance for the Prevention of Accidents, dated 10/14/2020, was presented to the survey team and documented the following corrective actions were implemented.
On 10/12/2020, counseling by use of the Teachable Moment was given to the 3 CNA's identified as transferring the affected resident out of the bed and later back to bed without use of the lift.
On 10/12/2020, interviews were conducted by the Activities Director and the DON with all interviewable residents related to their care received by the CNA involved in the incident and with their care in general to rule out neglect or care plans not being followed.
On 10/13/2020-10/14/2020 the DON completed an audit of 100% of all residents' [NAME] and care plans.
On 10/13/2020-10/14/2020 the Therapy Director completed an audit of 100% of all residents' care plans and [NAME] for the appropriateness of each resident's requirement needs for transfer. Care plans were updated as needed.
On 10/14/2020, the facility's Quality Assurance/Performance Improvement committee met and determined the root causes of the incident, reviewed the corrective actions taken, and planned for ongoing assessment tasks to confirm continued compliance.
On 10/14/2020, orientation for newly hired nursing staff included education to follow care planned transfer status for residents.
On 10/13/2020, the 64 nursing department employees received education to address use of the Care Plan and [NAME] instructions related to transfers.
On 10/14/2020, the 64 nursing department employees received re-education to address abuse, resident rights verses resident and staff safety.
Audits of the residents' [NAME] and care plans were completed by the DON and ADON on 10/12/2020, 10/21/2020, 10/30/2020, 11/2/2020, and 12/3/2020, and confirmed there were no issues noted with inappropriate transfers.
1. Surveyors interviewed the DON on 6/8/2021 at 2:00 PM, in the conference room. Interview confirmed there had not been any further incidents involving resident transfers.
2. Interview and review of audits for evaluation of transfers with lifts, with the DON, showed the observational audits were completed for 4 consecutive weeks as planned from 10/14/2020-11/14/2020 and then monthly x 2 as planned through 1/4/2021.
3. Surveyors interviewed 9 CNA's and 4 LPN's for knowledge of the inservices provided in the corrective action plan, safe use of mechanical lifts and no knowledge deficits were identified.
The harm was cited past noncompliance and the facility is not required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure 1 resident (Resident #1) of 4 residents reviewed were referred to the appropriate designated authority for Level 2 PASARR (Pre-admission Screening and Annual Resident Review) evaluation and determination after a newly evident medical diagnosis.
The findings include:
Resident #1 was admitted to the facility on [DATE], with diagnoses including Acute Hematuria, Dysphagia, Major Depressive Disorder and Dementia. Medical record review showed the resident had the diagnosis of Psychosis added on 11/19/2019.
Interview with the Health Information Manager on 6/7/2021 at 1:29 PM, showed she was responsible for submission request of PASARR Level II to the appropriate designated authority when needed. Continued interview confirmed the Health Information Manager failed to notify the designated authority of the newly diagnosed Psychosis for resident #1.

Based on facility policy review, observation, pest control documentation review, and interview, the facility failed to maintain an effective pest control program in 1 of 1 paper storage rooms, potentially affecting 61 of 65 residents.
The findings include:
Review of facility policy, Pest Control [Infection Prevention] revised 4/2021, showed .emphasis on the pest control program in kitchens .monitoring environment will be done by the center's staff. Pest control problems will be reported promptly .
Review of facility policy, Pest Control, revised 9/2017, showed .Dining Services Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis or as needed .all food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin .
Review of (named) pest control company invoice, dated 5/15/2021, showed rodent services consisting of bait-trap (mouse and insect glue board, pre-baited to attract mice and insects) were placed at the facility in May 2021.
Observation with the Lead [NAME] (LC) #1 on 6/6/2021 at 10:21 AM, in the food and paper storage room showed two boxes, with contents stained and misshapen, situated on the top of a food storage rack. Continued observation showed one box contained discolored labels and the second box contained a glue board rat tray with three dead mice affixed to the surface of the board and six boxes of toothpicks.
Interview with LC #1 on 6/6/2021 at 10:25 AM, in the kitchen, confirmed .there was three mice on that board .
Interview with the District Manager on 6/6/2021 at 12:40 PM, confirmed LC#1 had communicated the discovery of three mice on a glue board on a top food rack in the food and paper storage room on 6/6/2021. Continued interview confirmed food storage areas were to be checked regularly for any signs of pests by all staff and problems reported to the pest control company. Continued interview confirmed the facility failed to monitor for rodents and pests.
Interview with the Director of Maintenance on 6/6/2021 at 12:45 PM, confirmed he was made aware of the three dead mice stuck on the glue board on 6/6/2021. Continued interview showed he was unaware of a rodent issue.
Interview with the Director of Maintenance on 6/7/2021 at 10:45 AM, confirmed he was responsible for reporting issues promptly to the extermination company. Continued interview confirmed the facility failed to monitor for rodents and pests.