Every finding on record at Accura Healthcare of Cascade LLC

Based on observation, record review, staff interviews, and facility policy review the facility failed to protect the resident's right to be free from physical abuse by a staff member for one out of one resident reviewed (Resident #14), when staff physically forced a resident to transfer. This deficient practice resulted in a bruised arm for Resident #14. The facility identified a census of 42 residents. Findings include: Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severely impaired cognitive skills for daily decision making. Per the MDS, the resident had a short and long term memory problem. The MDS did not have any behaviors indicated. The resident's diagnoses included heart failure, high blood pressure, Non-Alzheimer's Dementia, arthritis, and osteoporosis . The MDS indicated Resident #14 was independent with sit to stand transfer, chair to chair or bed transfer, and independent to walk 50 feet with two turns. Review of Resident #14's Care Plan revealed a focus area of self care deficit revised on 7/7/25. The intervention dated 9/18/24 revealed the resident was independent for bed mobility. The intervention revised 4/12/25 revealed for transfer/ambulation, Resident #14 was independent in room with cane. Independent in hallway with front wheeled walker. The care plan intervention dated 7/7/25 directed staff to continue to encourage compliance with cares. Send different staff, try at a later time, etc. Review of the resident's Care Plan revealed a focus area revised 10/6/25 that the resident had exhibited delusional thought processes. The intervention dated 12/10/24 directed staff to encourage Resident #14 to come to meals. If she refuses, encourage to sit up at the table in her room instead of sitting on the bed. Review of Resident #14's progress dated 4/23/26 at 5:41 PM revealed Power of Attorney (POA) notified via telephone of allegations of abuse. A staff member reported witnessed another certified nursing assistant (CNA) grab resident by both arms and yanked her out of her chair after Resident #14 said no when asked if she wanted to go to supper .Informed POA Resident #14 is complaining her arm hurts but will no longer allow staff to visualize her arm .Resident was sitting at the supper table feeding herself when this author observed her. Review of documentation from a Facility Self Report Investigation revealed, in part, the following per the timeline of incident: .On 4/23/26 at approximately 4:31 PM, Registered Nurse (RN), [Staff B], notified Director of Nursing, [Name Redacted] that a Certified Medication Aide/Certified Nursing Assistant (CMA/CNA) [Staff D] reported she witnessed CNA [Staff E] grab resident [Resident #14] by both arms and yank her out of her chair after resident stated no she didn't want to go to supper. On 4/23/26 at approximately 4:32 PM, DON, [Name Redacted], called nurses station 2 and informed Licensed Practical Nurse (LPN), [Staff F] to go visualize resident and check residents arms. The Facility Self Report Investigation further revealed, On 4/24/26 at approximately 4:45 PM, Executive Director, [Name Redacted] and Director of Nursing, [Name Redacted], called CNA [Staff D] in for questioning. During that conversation [Staff D] reported [Staff D] heard a commotion and when [Staff D] looked over [Staff E] was grabbing resident by both arms, yanking her up out of the chair. [Staff D] had heard [Resident #14] tell her she didn't want to get up for supper. [Staff D] told her to stop and she could eat her supper where she was. [Resident #14] started hitting her and [Staff D] don't blame her after seeing that incident DON, [Name Redacted], asked [Staff D] to demonstrate what [Staff D] observed so staff had an accurate description of hand placement. [Staff D] demonstrated by placing her hands on [DON]'s arms. [Staff D] stated it was excessive and over the top. The Facility Self Report Investigation further revealed, On 4/24/26 at approximately 4:51 PM, Executive Director, [Name Redacted] and Director of Nursing, [Name Redacted], called CNA [Staff E] in for questioning. During that conversation [Staff E] stated that she was unaware of any incidents that occurred that she would need to be questioned about. When Executive Director, [Name Redacted], asked [Staff E] if resident [Resident #14] wanted to go to supper, [Staff E] responded no. Executive Director, [Name Redacted] then asked CNA [Staff E] if resident went. CNA [Staff E] responded yes. Executive Director, [Name Redacted], asked CNA [Staff E] how did that interaction go, how did you get her to supper? [Staff E] responded I did a pivot transfer, she put her arms around my neck, I stood her up and turned her so she could sit in her wheelchair.Review of a Reporting Officer Narrative dated 4/23/26 at 6:15 PM revealed, in part, [Staff E] was reported to have begun aggressively pulling on [Resident #14's] arms in an attempt to get her to stand up which caused [Resident #14] pain .[Resident #14] was spoken to about the incident where she was unable to recall much of the incident. [Resident #14] was however was able to recall that when [Staff E] was pulling on her arms it caused her pain. [Resident #14] stated, It hurt like h*ll. As mentioned above, upon speaking to [Resident #14] further, she was unable to recall any of the incident outside pain being caused to her arms. Review of Resident #14's progress note dated 4/23/26 at 7:36 PM revealed, .Resident did state to the sheriff that it hurt at the time but it doesn't hurt now. Review of Resident #14's progress note dated 4/23/26 at 7:54 PM revealed a full head to toe assessment completed at 6:00 PM. The skin section noted skin was warm, dry and intact, with 2 new bruises noted on left forearm. Review of the wound sheet for Resident #14 dated 4/23/26 revealed a new wound, in-house acquired, to the left (L) outer forearm. The wound was described as bruising which measured 0.84 centimeters (cm) by 0.99 cm length. Another wound sheet dated 4/23/26 revealed a second bruise, in house acquired, on the L outer forearm which measured 1.28 cm length by 1.29 cm width. On 5/26/26 at 11:45 AM, Resident #14 sat on a couch in main area, got up per self with cane, and ambulated independently to the table for the meal in the main area. Observation revealed the resident's gait steady, and no difficulty noted with transfer. On 5/27/26 at 12:12 PM, Staff D stated she worked on 4/23/26 with Staff E and she was in the common area of the dementia unit. She heard Staff E tell Resident #14 to get up off the couch for supper. Staff D observed Staff E pulling on Resident #14's forearms. Resident #14 twisted and turned and attempted to get away from Staff E. Staff E did not have a gait belt on Resident #14 and she pulled on her arms. Staff D attempted to tell Staff E could make accommodation and to leave Resident #14 alone. She repeated this three times and Staff E told her Resident #14 had to go to supper. Staff D revealed she observed Staff E physically try to pick up Resident #14 with one arm between residents leg and one on her side and physically force her into a wheelchair. Resident #14 got ahold of her cane, swung it, and tried to hit Staff E. Prior to this incident Resident #14 did not have behaviors. On 5/27/26 at 1:23 PM, Staff E stated she transferred Resident #14 and she refused at first so Staff E left and then Staff E came back to Resident #14. Staff E talked to her and she agreed to transfer to a wheelchair. Staff E gently put her arms around Staff E's neck and then Staff E put her arms under her arms and gently lifted her up and turned her to a wheelchair. Resident #14 was in the main area in the dementia unit and she was sitting on the couch. Staff E explained Resident #14 did hit Staff E, but Staff E really don't why [Resident #14] hit her and then after it she was fine. Staff E explained might have startled her but that was not Staff E's intention. Staff E explained did not reach for her arms. Staff E explained the resident hit her with just her hand. The cane was put to the side and Staff E did give her cane back when Staff E got her in the wheelchair. Staff E explained she did not use a gait belt because she (resident) was independent with transfers. Normally she was independent. Staff E asked her if she wanted help and she said yes is why Staff E assisted her with the transfer. She stated she had no history of problems with Resident #14. On 5/27/26 at 1:37 PM, Staff G, Registered Nurse (RN) stated Resident #14 transferred independently. Staff G explained didn't know if Resident #14 would vocally come out and ask for assist. Staff G explained if the resident looked like she was having hard time getting off the couch Staff G would assist. Staff G revealed Resident #14 didn't frequently need assistance, and Staff G explained didn't even know if in the past 4 months Staff G had even provided assistance with her. Per Staff G, the resident used a cane and was pretty mobile. On 5/27/26 at 2:24 PM Staff H, LPN stated about Staff E sometimes it would be more her tone how she would talk to residents and you addressed that with her and she would improve around me. Staff H did talk to her multiple times regarding her tone with residents. Staff H had one CNA report to Staff H that she didn't like the way Staff E was talking to someone, and Staff H explained reported it to the Administrator and they investigated it. On 5/27/26 at 2:35 PM, Staff J, Licensed Practical Nurse (LPN) revealed they did work with Staff E, and there were complaints about her from the residents and staff. The residents would complain that she was very quick and she would not slow down to listen. Sometimes residents would say she was little bit rougher with transfers and we did educate her on transfers and techniques and repositioning and Staff J felt that got better. Per Staff J, didn't think told Administration about it because it would happen, Staff J would talk to Staff E about it, and it would get better. Staff J explained did remember asking for her not to be in the Alzheimer's unit because she had a very excitable energy and the residents would feed off of that. It was quite a while ago and it was when she became a certified medication aide. Staff J further explained she thought it was a prior Director of Nursing that Staff J discussed it with at the time. They didn't put her back there for a while and then they did schedule her for it again. On 05/27/26 at 2:42 PM Staff I, CNA reported worked with Staff E and she did her work but she would try to get things done quick. Staff E was always in a hurry. Staff I stated she would rush the residents and would try to hurry them along. Everyone noticed it and the nurses would see it, Staff I knew she was talked to about taking a breath and to slow down with cares. On 5/27/26 at 2:51 PM Staff F, LPN reported she worked on 4/23/26 and Staff D reported to her Staff E picked up Resident #14 by the arms aggressively. Staff F explained she reported it to the Director of Nursing (DON) and went to do an assessment. Resident #14 complained of right arm pain and on the left arm she had a bruise. Staff F was not sure of the time but the minute Staff F was told about it, Staff F reported it to the DON and the Administrator. The DON and the Administrator started the investigation. Staff F revealed had worked with Staff E in the past and she was very rough with the residents. We had to tell her multiple times not to yell at the residents and not be so rough. We had told her multiple times not to be doing that. Per Staff F, had told the DON about it and Staff F was not sure what came of it. Staff F explained heard her yell at residents but did not see her be aggressive, but others had reported it to Staff F. Staff F did hear her yell at them and Staff F would have to tell her not to do that. On 5/27/26 at 3:30 PM, Staff K, LPN stated she had worked with Staff E, and Staff K did not like her working in the dementia unit as she did not understand the dementia residents. Staff K explained thought Staff E felt if she gave a simple direction they should be able to follow it. Staff K didn't think she (Staff E) had the patience to be working with dementia residents. Staff K had expressed it to a prior DON a few times. Staff K confirmed told the prior DON 3 -4 other times about Staff E not appropriate to work with dementia residents. Staff K was not aware of any time they had not let Staff E work in the Alzheimer's unit. Staff K just felt she did not have the understanding or the patience to work with residents on the dementia unit. On 5/28/26 at 9:05 AM, Staff L, CNA revealed Resident #14 transferred independent and supervision. Staff L had not had to provide assist to Resident #14 for her to transfer. Staff L did work with Staff E and it appeared to Staff L she was always in a hurry, she was demanding of the residents, and not giving them a chance to do things on their own. For example, she would not wait for a resident to move herself and Staff E would be in a hurry and would want to help her stand up. On 05/28/2026 at 9:46 AM, Staff M, CMA, Business Office Manager stated she also worked in a Human Resource role. She revealed she did not do the disciplinary actions, the supervisors were responsible for them. There was incident when Staff M was working in the Alzheimer's unit as medication aide where a resident did not want Staff E in his room he would not elaborate on it. Staff M informed the nurse and the Administrator. Staff M did Staff E's termination paperwork but no disciplinary actions. On 5/28/2026 at 10:31 AM, the DON revealed worked on 4/23/26. She got a phone call from the nurse that night and was told a CNA reported Staff E grabbed Resident #14 and pulled her up. Staff D reported it was rough and Resident #14 did not want to get up. The DON directed the nurse to do an assessment. We initiated an abuse investigation. Prior to this incident Staff E would need some direction she would get flustered and you would have to guide her to settle down but the DON had never seen her be rough with resident. There were no reports from staff about her behavior until this one reported to her by the nurse (Staff F). The DON denied Staff E ever had any disciplinary actions. The DON stated she was not aware of how Staff E treated or talked to residents prior to this incident. After the incident staff were talking about Staff E's behaviors. The DON stated she would expect staff to treat residents with respect and when you enter their room it is like entering their house. Per the DON, provided education recently for the entire staff 3/11/26 about gentle care and dignity. The prior DON said she did 1:1 education about not talking over residents and the DON went through past DON paperwork and found she had only one signed. The DON wanted staff to know her expectations going forward as the DON. On 5/28/26 at 10:52 AM, the Administrator revealed on 4/23/26 she was informed by the DON that a CNA had made a comment with concerns about an incident in the unit. We immediately started an investigation, separated Staff E from the residents, and subsequently she was terminated. The outcome of our investigation was decided to terminate her position within corporation due to the lack of professionalism and the allegation of abuse. On 5/28/26 at 11:28 AM, Staff M, RN reported she worked with Staff E and she was very incompetent. She was inappropriate with family and residents. Staff M stated with providing cares Staff E was very rough and the residents would complain she was rough with cares. For example, she just would just push and pull residents instead of asking them to grab the bed rail she would just shove the residents over on their side. She didn't do her cares, residents would be wet after she said she would have completed them. Per Staff M, did tell administration about these concerns multiple times. The two prior DON were both told of concerns. Review of employee file for Staff M revealed a hand written note from Staff M dated 6/24/25 addressed to management which stated as licensed RN, Staff M would not train or supervise Staff E as a CMA. Per the letter, Staff M had witnessed too many red flags with her as a CNA. The letter expressed, in part, Many staff and residents have complained about her incompetence, then nothing is done. She is rude and rough with residents. Review of employee file for Staff E revealed no disciplinary actions regarding care provided to residents or any incidents mentioned by coworkers during interviews. The employee file did have a employee termination worksheet dated 5/1/26 for termination date 5/1/26. The termination reason was abuse. The facility provided a policy titled Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy updated 10/19/22 directed Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. It also includes corporal punishment when used to correct or control behavior, including but not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object.The policy further revealed, Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on observation, staff interviews, and facility policy review the facility failed to ensure a nurse remained with a resident after medications were provided to the resident for one of three residents reviewed (Resident #7). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) Resident #7 dated 3/4/26 listed diagnoses of atrial fibrillation, heart failure, diabetes mellitus (DM), Schizophrenia, and Post Traumatic Stress Disorder (PTSD). The Brief Interview for Mental Status (BIMS) showed a score of 15 out of 15, which indicated intact cognition. The Care Plan for Resident #7 revealed a current intervention to give medications as ordered.On 5/27/26 at 8:10 AM, Staff B Registered Nurse prepared the oral medications scheduled for Resident #7. At 8:24 AM, Staff B walked over to Resident #7 as Resident #7 sat at the dining room table with two other residents.Staff B set the pill cup that held 17 different medications down on the table next to Resident #7. Staff B reported she could leave her medication here, Resident #7 liked to take her pills on her own. Staff B walked back to the medication cart and continued to administer medication to other residents in the dining room. The nurse's back was turned away from the resident several times.On 5/27/26 at 8:58 AM, Resident #7 called out she took all her pills.On 5/27/26 at 3:50 PM, Staff C, Licensed Practical Nurse reported none of the resident in the front were able to self-administer medications. She said she would give Resident #7 her medications and as long as she was out in the dining room. Staff C reported she would keep an eye on her, but kept working as Resident #7 took her medication.On 5/28/26 at 8:46 AM, Staff A, Certified Medication Aide reported she knew not to leave meds with the resident to take independently. She reported they needed to watch the resident take all the medication when administered. On 5/28/26 at 10:08 AM, the Director of Nursing reported the nurses were expected to stay with and watch them to ensure all medication was taken. Walking away from a resident with a cup of medication was unacceptable.The facility provided a policy titled Medication Administration dated 12/3/25, which directed to observe resident consumption of medication.

Based on clinical record review, employee file review, staff interview, and facility document review the facility failed to complete hand hygiene and change their gloves during wound care for one out of two residents reviewed (Resident #5). The facility reported a census of 43 residents.Findings include:Resident #5's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of diabetes mellitus (DM), anemia (low iron levels in the blood), chronic kidney disease (CKD), and arthritis. The MDS reflected Resident #5 entered the facility with an unhealed unstageable pressure ulcer.The Care Plan dated 1/21/26, identified Resident #5 had an unstageable ulcer on her left heel present on their admission.Resident #5's March 2026 Treatment Administration Record (TAR) directed to apply a dry gauze dressing to the left heel and change daily. May apply saline to the bandage before removal to help loosen if sticking to wound, one time a day for heel protection.On 3/3/26 at 9:50 AM Staff A, Registered Nurse (RN) completed hand hygiene(HH) with alcohol-based hand sanitizer (ABHS), applied a gown, and gloved. Staff A cleaned the tray table off and placed a barrier on the tray table. Staff A sat the roll of cling wrap, a stack of gauze 4 by 4's, and placed a nonstick pad on the table. Staff A used her scissors and cut cling wrap dressing off Resident #5's left foot with scissors. Staff A placed the scissors on the tray table. Without completing HH, Staff A used her gloved hands to open the normal saline (NS), dampened a 4 by 4, and wiped the wet 4 by 4 around the non-stick pad to peel the stuck dressing off the wound. Staff A threw the 4x4 in the trash. Staff A picked up another 4 by 4 gauze, folded it, moistened it with the NS, and washed the left heel wound with the 4 by 4. Staff A picked up another 4 by 4 and patted the wound dry. Staff A replaced the NS lid and dropped it into the trash can. Without completing HH, Staff A opened a new nonstick pad with the same gloved hands, placed it on the left heel wound, and wrapped the left heel with cling. On 3/3/26 at 9:59 AM without cleaning the scissors after Staff A cut off the old dressing, Staff A cut 2 pieces of tape from the roll and applied them to cling wrap dressing. Staff A cleaned the scissors with a wipe. Staff A removed the EBP completed HH and left the room. On 3/3/26 at 10:04 AM Staff A reported being a new nurse and started at the facility in the fall. On 3/4/26 at 11:11 AM the MDS Coordinator reported the nurses needed to wash their hands, put gloves on before they remove the dressing, take their gloves off complete HH, and put on a new pair of gloves to clean the wound. After they clean the wound, they need to remove their gloves, complete HH, and put new gloves on to apply the new dressing. Once the new dressing is applied staff are expected to remove their gloves and complete HH. On 3/4/26 at 11:30 AM the Interim Director of Nursing (DON)/ Infection Preventionist(IP) reported she expected the nurses to clean their hands as the protocol and procedure directed. On 3/4/26 at 12:10 PM the RN/Interim Executive Director stated they expected the nurses to complete HH and apply gloves before they removed any dressing over a wound. She said if the staff used scissors to cut off a dressing, they needed to clean the scissors before using them again. She stated after the staff removed the dressing they needed to remove their gloves, complete HH, and apply new gloves to clean the wound according to the physician's order. The Interim Executive Director said staff are expected to remove their gloves after they cleaned the wound, complete HH, and apply new gloves to apply the dressing according to the physician's order. She reported when they complete wound care the staff are expected to remove their gloves, complete HH, and clean their scissors. Staff A's Competency for Dressing Change dated 11/9/25 revealed they met the requirements.The facility provided the Competency for Dressing Change dated 5/11/21 directed the following:Gather necessary equipment.Inform the resident of procedure and provide privacy.Wash hands. Position resident and place bed protector as needed.Wash hands; put gloves on.Set up clean field (barrier); prepare supplies.Prepare plastic bag, remove soiled dressing and place in bag.Remove gloves and place in the plastic bag.Wash hands-put on gloves. Perform treatment. Clean from inner edge of wound out. Perform treatment according to orders-apply dressing and date.Discard all waste in plastic bag.Remove gloves and wash hands.Discard waste in biohazard waste and return supplies (clean scissors).

Based on observations, staff interviews, and facility document review the facility failed to train staff regarding the full body lift sizing guidelines for 2 out of 2 resident reviewed. The facility reported a census of 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #6 dated 6/11/25, listed diagnoses of stroke, and Alzheimer's Disease. The MDS revealed the Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment). The MDS reflected Resident #6 dependent with chair to bed and bed to chair transfers. The Care Plan for Resident #6 dated 4/23/24, identified her as dependent upon 2 staff for all transfers utilizing the full body lift. The Care Plan directed no beige sling (slippery). The Care Plan failed to identify what size of lift sling to use. On 7/2/25 at 9:37 AM, A Certified Nurses Aid (CNA) took Resident #6 to her room. Staff C, reported she's a new CNA to this facility. Her partner CNA went to get the Director Of Nursing (DON). The CNA explained to Resident #6 she's going to bed. The Business Office Manager (BOM)/CNA entered the room to assist Resident #6 into the bed with the full body lift. The staff directed Resident #6 to hug herself as they lifted her. Staff used a cloth blue full body sling to lift Resident #6. Raised the resident, legs of the lift wide bed lowered lifted feet lower the other CNA unhook sling after lowered to the bed. On 7/2/26 at 4:40 PM, Staff D, Licensed Practical Nurse (LPN) reported the staff all have a personal preference on the full body slings they pick to use for the residents. On 7/3/25 at 11:20 AM, the Assistant Director of Nursing (ADON) confirmed several of the full body lift sling tags appeared illegible. The ADON confirmed the tags needed to show the size of the full body lift sling. The ADON reported the facility failed to know the tags were illegible and they failed to know the staff were using the slings according to their own personal preference. On 7/3/25 at 1:57 PM, the DON reported it's unacceptable for the staff to use any sling they like with the lifts. They are expected to know the size for each of the residents. On 7/3/25 at 2:16 the DON revealed the facility lacked a system in place for distinguishing sling sizes. On 7/3/25 at 2:20 PM, the Administrator confirmed the facility lacked a system for the lift sizing for residents. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 scored a 0 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment the resident is completely dependent on staff requiring a 2 person assist and a Hoyer lift. Review of Resident #4's Care Plan dated 10/2/2024 revealed, the resident is dependent on staff due to impaired mobility. The resident is dependent on staff for meeting all needs including emotional, intellectual, physical, and social needs due to cognitive deficits and physical limitations. On 6/27/25 at approximately 7:35 pm Resident #4 had a fall from a Hoyer lift as he was being transferred into bed by two seasoned staff Certified Nursing Assistants (CNA's). Facility nursing staff immediately commenced assessment of the resident's injuries and provided first aid. Facility staff notified the on-call physician and the on-call hospice worker. Hospice advised they would notify the family to allow facility staff to care for the resident. Hospice advised that unless bleeding can not be stopped the resident does not need to be transported to the hospital at this time. On 7/2/25 at 12:20 pm Staff B, Certified Nursing Assistant, (CNA) was queried regarding the incident. Staff B advised she and another staff CNA were transferring the resident back to bed when the incident occurred. She shared that both she and the other CNA were right there with the resident but the fall happened so fast they were unable to prevent the fall. Staff B advised she had her hand on the resident's upper leg but was unable to stop him when he lunged forward. The resident had stiffened up and straightened his legs and then reached up and grabbed the Hoyer straps which caused the front sling to shift downward causing the resident to propel forward sliding out of the sling. The resident fell forward and his face and mouth landed on the leg of the Hoyer. It is believed when the resident fell forward he hit his forehead on the guide bar near the top front of the lift. The resident was talking the entire time and did not lose consciousness. Towels were used to apply pressure to his forehead to stop the bleeding. A blanket was placed over the resident to keep him warm. Nursing staff including the Director of Nursing, (DON) assessed the resident and initiated the facility fall protocol. The resident's physician was contacted as well as Hospice. Staff B who worked as a CNA for 17 years and has been employed at this facility for five years has no knowledge of this resident or any other resident having a fall from a Hoyer. CNA's have Hoyer training in their certification process. Upon hire all CNA's have to demonstrate they are competent using the mechanical Hoyers. Staff in-service trainings conducted yearly provide refresher training. Random staff audits are conducted to assess staff competency. Prior to use, Hoyer slings are checked for integrity. Staff B advised they have various Hoyer slings that are used interchangeably with the Hoyers. The particular sling used during the transfer was the nylon dark blue with bright pink trim. These particular slings are not staff favorites as they tend to be somewhat slick if the resident is moving around. Staff B advised, staff typically use the sling that is already in use with the resident for that day. On 7/2/2025 at approximately 1:40 pm Staff A was interviewed regarding this incident. Staff A advised she was assisting staff B with Resident #4 when the incident occurred. Resident #4 has a habit of grabbing onto the Hoyer straps when being transferred. On this day, he had a hold of the top straps on the Hoyer sling. He was asked to hug his body as this is often done to keep the resident's arms and hands away from any Hoyer movement. We have always told the residents they should cross their arms and hug themselves and hold on. As we went to pull the wheelchair back and turn him towards the bed he grabbed a hold of the top of the straps again and this tilted the sling downward. As he did this he also stiffened up at the same time and this propelled him forward. Although we had a hand on his leg this did not prevent him from propelling forward, falling out and hitting his face on the leg of the Hoyer. Staff A advised they do not always use the same sling or Hoyer it just depends on what is available. Staff A advised it is a hit or miss as to what sling they use with the white Hoyer which is typically kept in this resident's hallway. Staff A advised the particular sling they were using during that transfer is not a favorite as it tends to be a little slippery depending on what type of material the resident's clothes are made of. Staff A advised nursing has been made aware of staff 's concern with the material of those particular slings. Staff A described this sling as dark blue with bright trim on the outside. Staff A was not sure what size these slings would be. Staff A advised she has been a CNA for many years and has never had a resident fall out of a Hoyer. Hoyer audits and yearly training are required at the facility. On 7/3/25 at 10:30 am Staff E Licensed Practical Nurse, (LPN) was queried regarding the Hoyer lift process and slings. Staff E advised as a nurse she frequently assists with Hoyer transfers. Staff E was asked how staff determine what sling they use with the residents. Staff E shared sizing is determined based on resident size as there are different size slings. Previously the slings were not marked for size but they are now. The slings are stored in a closet and they were not sorted or kept in any particular order. Staff E advised she does not care for the dark blue sling with the magenta border as it is too slippery. When asked, Staff E advised she had been told by CNA's they had expressed this concern to management but she herself had not. When asked for clarification Staff E advised she has never seen a staff member use the Hoyer inappropriately or not follow procedures and protocol when conducting a Hoyer transfer. Although she was not present at the time of the incident she advised both CNA's involved are very experienced with transfers and she feels this was an unfortunate accident and not an error on the part of the staff members. The mechanical full body lift owners guide undated, directed always ensure the sling is the correct size and capacity for the patient being transferred.

Based on observations, staff interviews, and facility cleaning lists the facility failed to maintain clean dry goods storage containers for 2 out of 2 containers, failed to clean 4 out of 4 vents, and failed to maintain a clean floor in the kitchen. The facility reported a census of 42 residents. Findings include: On 5/12/25 at 10:08 AM, Staff B, [NAME] stood in the kitchen at the prep table as he seasoned chicken while his hair net failed to contain the back part of his hair that left about 4 inches that hung onto his neck and shoulders. On 5/12/25 10:10 AM, the sugar and the flour plastic covers held light gray film and white powder over the handles and the top 50% of the lids. The wall to the right of the stove was 75% covered in splattered brown residue. The floor had food debris scattered about. On 5/12/25 10:13 AM, the vents over the spice table contained gray fuzz on 80% of the vents above the hand washing sink and the refrigerator held gray fuzz on 80% of the vent. On 5/12/25 at 12:04 PM, Staff C, Dining Services Assistant wore her hair net with about 3 inches of her hair hanging outside the hairnet in front of her ears as she poured drinks to the residents in the dining room. On 5/12/25 at 12:14 PM, Staff B, served all the residents in the main dining room while about 4 inches of hair hung out from the back side of the hairnet throughout meal service. On 5/14/25 11:48 AM Staff A, [NAME] reported every night cleaning is expected to be done and if they see or make a mess they are expected to clean it up. On 05/14/25 at 12:05 PM the Dietary Manager (DM) reported the floor needed a buffing clean to get the black grime cleaned off. As she looked at the black grime substance under the prep counters, under the steam oven, and in the corners of the kitchen on the floor. On 5/14/25 at 12:40 PM Staff A, [NAME] reported no one can pass the office line on the floor without a hairnet on. She reported all hair needs to be up and restrained with the hairnet. On 5/14/25 at 12:42 PM, the kitchen floor under the steamer and under the oven looked like a black residue and the back corner wall looked like thick fuzz about 6 by 8 inches then 10 inches by 1 inch of black grime residue on the floor. On 5/14/25 at 12:52 PM the Dietary Manager (DM), reported hair nets are expected to be worn to contain all the staff's hair in the kitchen and while serving food. She reported the staff sweep and mop the floor in the kitchen daily. She reported the black marks won't go away with that cleaning. The DM stated the staff are expected to clean per the schedule and after a mess is made. The DM stated they used a cleaning schedule for most of the cleaning. She said the staff clean the sugar and flour containers when they are empty before refilling them. The DM stated the Maintenance man cleaned the vent in January she thought. She verified the fuzz on the four vents over the refrigerator and spice table. The Dietary Cleaning sheet undated directed the staff to sweep and mop the floors daily, failed to direct the staff to wipe down messes on the walls or cleaning of the vents on the wall. The Dietary Cleaning List undated directed: a. Sweep underneath all tables, stove, oven, counters. b. Sweep and clean floor and baseboard under dish machine c. Scrub walls and baseboards, especially by dish line, behind the trash can, stoves, and working areas.

Based on observations and staff interviews the facility failed to maintain a clean and sanitary environment for the residents. The facility identified a census of 38 residents. Findings include: On 5/30/23 at 10:15 a.m. in the Chronic Confusion Dementing Illness (CCDI) unit, observed the carpet with dirty areas of dried spills and dried food matted in the carpet of the main dining area. On 5/31/23 at 10:00 a.m. observed staff in the CCDI unit vacuuming the carpet in the main dining area after breakfast. Dried spills and matted food still present in the carpet. On 5/31/23 at 12:28 p.m. observed the general population dining room with carpet dirty and dried up spills in the main dining area. An interview on 5/31/23 at 1:55 p.m. with Staff A, Housekeeping Staff, reported that the floors are deep cleaned weekly and carpet is vacuumed daily. On 5/31/23 at 2:29 p.m. observed carpet in the CCDI unit with dried spills and matted food still present in the carpet in the main dining area. An interview on 6/1/23 at 8:56 a.m with Housekeeping Supervisor, reported every Tuesday morning the floors in the main dining room and CCDI unit get deep cleaned. Housekeeping does not take care of the carpet it is contracted out or Maintenance spot cleans it. It is up to the Administrator when it gets cleaned. Housekeeping during the week has 3 to 4 staff and on the weekend 2 staff. An interview on 6/1/23 at 9:09 a.m. with the administrator, stated that she is unsure when Maintenance last cleaned the carpet but the carpet is going to be replaced in a few weeks away. When asked what they were doing in the meantime to keep the carpet clean, she reported that Maintenance is to spot clean the carpet. An interview on 6/1/23 at 9:30 a.m. with the maintenance man, reported that he only cleans the carpets when it gets really bad and it has been awhile. There is no policy or schedule for the clean of carpet. An interview on 6/1/23 at 9:50 a.m. with the Administrator, reported that flooring has no been ordered. It was added to the budget to work on getting flooring decided.

Based on observation, dietary menu review and staff interview, the facility failed to ensure staff utilized proper food handling during observation of one meal service. The facility census was 43 residents. Findings include: 1. The facility's Diet Spreadsheet for Week 2 on Monday showed the noon meal included spaghetti and meatballs and garlic bread. Observation on 1/27/20 at 11:40 a.m., revealed the steam tray delivered to the Dementia Unit. Staff A, certified nurse aide (CNA) and Staff B, CNA were in and out of the kitchen area as they plated and served food to residents. Staff A wore plastic gloves while dishing out the food from the steam table. The garlic bread came in a separate, heated crock pot. Staff A touched the plates, steam pan covers, handles of spatulas and spoodles. Staff A lifted the lid off the crock pot and directly touched the garlic bread and placed the bread on the residents plates. Staff A did change gloves one time during the entire meal. Staff A continued to set up the resident plates while touching the garlic bread and touching all the handles, covers, plates, and with no glove change. Staff served 10 residents in the Dementia Unit. During interview on 1/27/20 at 12:19 p.m., Staff A and Staff B reported they just started serving the food in the Dementia Unit a few months ago and were still getting use to it. An interview on 1/28/20 at 12:41 p.m. the Dietician remarked staff are not expected to keep the same gloves on when directly handling food, they should be changed. She noted once food is directly touched the same hands or gloves should not touch anything else. The facility's policy for Proper Use of Single-Use Gloves, from Health and Hygiene, undated, stated the policy as for dietary services wearing single-use gloves when necessary to protect both patrons and employees from contagious and foodborne illnesses when handling ready to eat foods. The Procedure included included: - change disposable gloves between tasks and not wear them continuously. A glove must be limited to one task only-thus the term Single Use. Once a person dons the glove(s) and leaves the task to open a refrigerator, oven, box, bag, etc., the glove(s) are contaminated and are to be removed/replaced before returning to handling the ready to eat food items(s). - it is preferred to use a utensil ( such as a tong) instead of gloves when handling 'ready to eat' foods, if at all possible.

Based on observation, clinical record review and staff interview, the facility failed to complete personal cares for three of four residents reviewed. (Resident #35, #11 & #24) The facility census was 43 residents. Findings include: 1. Resident 35's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had a good memory, required extensive assistance with daily cares, and had a Foley catheter in place for bladder functions. The MDS assessment revealed the resident had a [DIAGNOSES REDACTED]. The Care Plan revised on 1/13/20, showed the resident had a self care deficit related to impaired mobility, weakness, [MEDICAL CONDITION], and dependence on a wheelchair. Interventions included to have a partial bed/sponge bath twice per day and a shower twice per week. The Kardex utilized by the certified nurse aides (CNA) dated 1/29/20 showed the resident was to have a partial bed/sponge bath twice per day and shower twice per week. Observation on 1/28/20 at 7:44 a.m., revealed Staff A, CNA, performed catheter care put failed to complete a partial bath as planned. Staff A dressed the resident and transferred the resident to the wheelchair. During interview on 1/29/20 at 12:30 p.m., Staff C, CNA, reported a partial bath was when staff washed the resident's under the arms, breasts, and performed perineal cares. Staff C reported perineal cares included washing front to back, new wipe with every swipe, and cleanse the buttocks cheeks and hips when incontinent. Staff C noted when doing catheter care, staff should do full perineal cares, even if the resident was not incontinent. The facility's Skills Checklist-for Partial bath, undated, included to wash the resident's chest, axilla (armpits), body folds, and perineal area. 2. Resident #11's MDS dated [DATE] assessment showed the resident had severe memory loss, required extensive staff assistance for daily cares, and frequently incontinent of bladder and bowel functions. The MDS assessment showed the resident had [DIAGNOSES REDACTED]. The Care Plan revised on 6/7/19 showed the resident had a potential for altered skin integrity related to incontinence, dementia, hypertension, [MEDICAL CONDITIONS], history of falls, decreased mobility, and [MEDICAL CONDITION] with previous [MEDICAL CONDITION] infarction. An intervention included to assist with incontinent care after each incontinent episode. The Kardex for the nursing aides showed to assist with incontinent care after each episode. Observation on 1/27/20 at 1:21 p.m. revealed Staff D, CNA and Staff C, CNA performed incontinence care for the resident. Staff D cleansed the front peri area and buttocks from front to back but failed cleanse the resident's buttock cheeks and hips. 3. The MDS (Minimum Data Set) dated 1/06/20, indicated Resident #24 had [DIAGNOSES REDACTED]. The activities of daily living section indicated the resident required extensive assistance of one to two staff with personal hygiene and toileting and had an indwelling catheter. During observation on 1/29/20 at 7:14 a.m., Staff A, CNA and Staff H, CNA provided catheter care to the resident. Staff H, CNA wiped the residents abdominal folds and pulled the foreskin back and cleansed the penis. Staff A assisted Staff H to turn resident on right side but failed to wash the residents scrotum or the catheter tubing. Staff H wiped the buttocks and the gluteal fold wiping from back to front. Staff H did not remove gloves or wash hands and applied a barrier cream. During interview on 1/29/20 at 1:47 p.m., Staff B, CNA, reported to make sure you cleanse the tube at least four inches down and cleanse the scrotum. She noted to always wipe front to back when providing perineal cares. During interview on 1/29/20 at 1:51 p.m. Staff A, CNA, reported staff should change gloves between cleansing a resident and putting barrier cream on buttocks. Staff A noted one should wipe from the front to the back and cleanse the tip of penis and the catheter tubing down to the y-connection.

Based on clinical record review, physician, staff and family interviews and facility policy review, the facility failed to notify one of three families reviewed when the resident (Resident #3) had a change in condition. The facility reported a census of 44. Findings include: 1. According to the MDS (Minimum Data Set) dated 2/15/2019, Resident #3 had memory impairment, required extensive assistance of staff transfer from one surface to another and with dining. The MDS revealed the resident had [DIAGNOSES REDACTED]. The resident's Care Plan directed staff to administer antianxiety and antidepressant medications and monitor the resident for side effects and safety every shift, doll therapy or stuffed animals as needed and accepted by resident, provide with activities such as large piece puzzles and or clothing to sort and fold, assist with meals as needed, likes to use clothing protector and offer fluids in small plastic med cups. The resident's face sheet revealed the resident had four emergency contacts listed with the spouse listed as the first emergency contact. Progress Notes dated 3/1/2019 included: At 11:04 a.m., Staff A, RN (Registered Nurse) called to resident's room, CNA's (Certified Nurse's Aides) noted a foreign object in resident's mouth. After much coaxing, a small plastic object was retrieved. Staff noted a small metal spring in resident's mouth and he/she chewed on it. Staff unable to get resident to spit it out or allow staff to remove it. Resident swallowed multiple times, stopped chewing and object no longer visible. Staff notified the physician and left a message for the resident's spouse to return call to facility. At 3:15 p.m. Bio-Tech, portable x-ray to facility to complete x-rays. Spring visible, waiting on reply from physician. At 3:20 p.m. the resident appeared comfortable and in no acute distress. At 6:21 p.m. the physician ordered a repeat of the abdominal x-ray. Bio-Tech called. At 7:35 p.m. Bio-Tech arrived, resident had a small amount of brown/yellow emesis on shirt. Patient cleaned up and had a medium loose stool in brief. No metallic object found in stool. Resident diaphoretic at this time. Vitals taken. During x-ray patient had dry heaves with a small amount of brown/yellow mucous emesis. Patient verbalized I don't feel well. Staff assisted Bio-tech to finish x-ray. At 8:35 p.m. Staff B, RN called Bio-Tech to see if x-rays had been returned. At 8:45 p.m. Staff B called the physician to report the resident had diaphoresis, emesis and vitals. Physician approved of sending the resident to the ER with family approval. CNA approached Staff B and reported the resident had passed. At 9:03 p.m. Staff B notified the Director of Nursing (DON) that the resident passed away. At 9:45 p.m. The physician met the family at the facility to speak to them. The Medical Examiner arrived at the facility at 11:54 p.m. and spoke to the family about autopsy. At 1:06 a.m. the resident discharged to the care of Cedar Memorial funeral home. Bio-Tech X-ray dated 3/1/2019 revealed two metallic foreign objects in the region of the [MEDICAL CONDITION] junction or proximal body of the stomach. The larger metallic density measures 10 by 8 mm (millimeters). The second x-ray dated 3/1/2019 revealed no foreign body seen in abdomen or pelvis. During a phone interview on 4/10/2019 at 8:30 a.m., the physician reported the resident's condition did not appear urgent until moments before he/she passed away. The physician said the facility should have gotten consent from the family prior to the resident's receiving the tests and they understand that now. When he/she arrived at the facility to speak with the family after the resident passed away, he/she did not know the family had not been made aware of the resident's incident earlier in the day. During an interview with the Administer on 4/10/2019 at 10:15 a.m., he/she reported all nurses were educated regarding family notification and they implemented audit sheets for daily review to ensure appropriate procedures were followed. During an interview on 4/10/2019 at 9:30 a.m., the DON (Director of Nursing) reported he/she called the resident's spouse and left a message to return the call so the facility could make him/her aware of the resident's incident and the physician's orders [REDACTED]. The DON left that day at 2:45 p.m. The DON indicated the facility should have made further attempts to notify family and should have received family consent. Since this incident, the facility implemented an audit system and educated all nurses regarding family notification. During interview on 4/9/2019 at 2:40 p.m., Staff A, RN revealed he/she failed to inform the resident's family of a change in condition. During an interview on 4/16/2019 at 11 o'clock a.m., Staff B, RN reported not calling the family regarding the resident's condition until the time of the resident's passing.

Based on observation, clinical record review and staff interview, the facility failed to update the plan of care for one of 14 residents reviewed. (Resident #14) The facility census was 45 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 had [DIAGNOSES REDACTED]. A Physician Transfer Order Report dated 7/30/18, documented the resident transferring back to the facility after hip surgery. The Care Plan dated 8/4/18, showed the resident in the CCDI Unit (Chronically Confused Demented Individual) as ordered by the physician. The Care Plan revealed the resident preferred activities which included walking and had a potential for elopement and seeking exit doors, asking people for rides, and talked of leaving. Observation on 11/18/18 at 10:58 a.m., revealed the resident in a wheelchair sitting by the birds in the main dining room area. The resident no longer resided in the CCDI Unit, but in a room in the North Hall. Observation on 11/18/18 at 1:27 p.m., revealed staff transferred the resident to bed with the Hoyer lift, as the resident did not stand or ambulate to bed. During interview on 11/19/18 at 2:15 p.m., the Director of Nursing (DON), reported the resident had surgery and returned to the facility on [DATE]. She reported the care plan should have been updated at that time.

Based on observation, clinical record review, and staff interview the facility showed 1 of 1 resident reviewed (Resident #15) did not have a clinical condition or medical [DIAGNOSES REDACTED]. The facility identified a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #15 had [DIAGNOSES REDACTED]. The Care Plan dated 8/3/18, showed the potential for altered skin integrity related to dementia, reduced mobility due to a femur fracture with surgical repair. An intervention for this concern included the resident had an indwelling Foley catheter in place and staff were to monitor the area around the catheter for skin breakdown. Observation on 11/18/18 at 10:58 a.m. revealed the resident up in high back wheelchair with the Foley drainage overnight bag covered with a personal cloth under the wheelchair. A Physician Transfer Order Report dated 7/30/18, included an order for [REDACTED]. A Progress Note dated 8/7/18, showed the resident continued to have an indwelling Foley catheter due to pain and mood disturbances caused by personal cares to the resident. During interview on 11/19/18 at 11:35 a.m. the MDS Coordinator, Registered Nurse (RN) and the Director of Nursing (DON), reported the physician noted in a progress note the resident maintain the indwelling Foley catheter. When reviewing the Progress Report dated 8/7/18, both agreed there was no medical [DIAGNOSES REDACTED]. During interview on 11/20/18 at 8:07 a.m., the DON reported it was standard in the RAI manual to have a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to ensure staff utilized hair nets when serving resident food items and failed to ensure all staff serving food was properly trained regarding dietary sanitation. The facility reported a census of 50 residents. Findings include: During an observation on 7/11/16 at 7:48 a.m., the Housekeeping Supervisor dished up and served food to residents in the main dining. The Housekeeping Supervisor's hair is chin length in the front and sides, the staff failed to wear a hair net while serving food. During an observation on 7/11/16 at 9:30 a.m., the Activity Director dished up food from the behind the tables in the main dining room and served residents. The Activity Director's hair is shoulder length and wore no hair net at this time. An observation on 7/12/16 at 8:20 a.m., Office Manager dishes up and serves food to residents in the main dining room. The Office Manager's hair is shoulder length and wore no hair net when dishing up and serving the resident. During an observation on 7/12/16 at 8:28 a.m., the Activity Director assisted in dishing up food and serving residents in the main dining room with out a hair net on. During an observation on 7/12/16 at 9:04 a.m., Staff Q Certified Nursing Assistant (CNA) dished up and served food to residents without a hair net on. An observation on 7/13/16 at 8:00 a.m., the Housekeeping Supervisor plated food from behind the table from the steam table without a hair net on. An observation on 7/13/16 at 8:50 a.m., Staff J CNA stood behind the serving table in the main dining room. Staff J poured cereal, opened a banana and then put gloves on. Staff J removed bread out of the bread sack and put it in the toaster. Staff J took gloves off, walked out from behind the table and over by the nurses station to help a resident move 5 feet. Staff J used hand sanitizer, gloved, took the toast from the toaster with the gloved hands, took the lid off the butter, picked up the butter knife from the table and buttered the toast holding the toast with the gloved hands. Staff J opened a jelly packet with gloved hands, held the toast and applied jelly to the toast. Staff J took tongs with the gloved hand, picked up bacon from the steam table and placed it all on the resident's plate with the gloved hands. Staff J's hair is in a loose bun on top, no hairnet net on during the process of dishing food, preparing and serving the food. During an interview on 7/14/16 at 7:34 a.m., the Housekeeping Supervisor stated they have not received training of how to serve food, wash hands and glove. She reported they don't use hair nets because we are not in the kitchen cooking food. During an interview on 7/14/16 at 8:00 a.m., Staff J CNA stated they haven't received training for meal service just gloves and hands hairnets. Staff J reported not wearing a hairnet when serving in the main dining yesterday, but thinks hairnet should be worn. Staff J stated it isn't any different serving out of the small steam table in the main dining room or the steam table in the unit, we have to wear hairnets in the unit. During an interview on 7/13/16 at 2:38 p.m., the Dietary Supervisor reported the department heads serving food do not need hair nets because they are not preparing food per the direction of the previous Administrator. The Dietary Supervisor reported hand sanitizer is not allowed for the dietary staff and expects the department hands to wash hands before serving. The facility provided a policy and procedure titled Hair Restraints, Jewelry and Fingernails dated June 2015. The policy directed staff to ensure food and beverages, clean equipment, utensils and linens do not come in contact with hair. The policy directed Food employees to wear hair restraints such as hats, hair coverings or hair nets, beard restraints. Hair restraints must be sufficient to contain, cover and restrain hair.

Based on record review and interviews the facility failed to identify all the required components in the abuse policy. The facility reported a census of 50 residents. Findings included: Review of the facility policy titled Shady Rest Care Center Abuse Policy dated 12/4/15, the policy failed to identify if reasonable suspicion of abuse results in serious bodily injury to a resident it shall be reported immediately once forming the suspicion but not longer then 2 hours and failed to include contacting law enforcement immediately with a suspicion of an alleged crime. During interviews on 7/14/16 at 11:10 a.m., the Social Service Director reported teaching the Mandatory 2 hour Dependent Adult Abuse training and assisted in the development of the facility abuse policy. The Social Services Director admitted not knowing the facility abuse policy lacked the section covering reasonable suspicion of abuse resulting in serious bodily injury to a resident it shall be reported immediately once forming the suspicion but not longer then 2 hours. During in interview on 7/14/16 at 12:10 p.m., the Administrator stated the expectation is reporting abuse to the State as soon as possible. The Administrator indicated a requirement of calling the police with crime when believing a crime is committed. The Administrator stated a plan to update the policy to add to report immediately but not to exceed 2 hours. .

Based on observation and staff interviews, the facility failed to provide maintenance services to 7 of 9 output air vents, loose wallpaper, and discolored wall paper in the CCDI unit. The unit identified 11 residents. The facility identified a census of 50 residents. Findings include: 1. Observation on Environmental tour on 7/13/16 at 9:00 a.m. with the Administrator, the Environmental Director, and Staff H, Maintenance Personnel, revealed the following: a. 7 out of 9 output air vents on the high walls of the CCDI Unit contained gray debris/dust all around the 4 corners of the vents. The gray debris/dust spread out approximately 1 to 3 inches from the corners onto the light gray, beige wallpaper. b. 6 inches of loose wallpaper noted to the lower part of the wall between rooms 106 and 107. c. 12 to 14 inches of a dark yellow seam which appeared to have been repaired, stood out against the gray/beige wallpaper. During an interview with Staff H at this time, the staff stated the vents should be cleaned of the debris/dust. An interview on 7/14/16 at 6:50 a.m. the Environmental Director reported not knowing who cleans the vents, but noted they have a company that comes out every 6 months to clean the vents. 2. During an observation on 7/12/16/ at 8:22 a.m., 7 out of 9 vents measuring approximately 4 x 8 inches along the upper walls in the Dementia unit contain gray residue at the corners 1-2 inches outward.

Based on observation, record review and staff interviews the facility failed to maintain oxygen tanks in a secured area in order to prevent accidents and failed to follow planned fall prevention measures for 1 of 5 residents (Resident #8). The facility identified a census of 50 residents. Findings include: 1. During initial tour on 7/11/16 at 8:08 a.m. the North Hall shower room revealed a sign on the door that said under construction-keep the door closed. A sign next to that showed a red label which stated 'oxygen'. Observations revealed the door unlocked with 12 green oxygen tanks inside. Observation on 7/11/16 from 9:30 a.m.-2:30 p.m. revealed the North Hall shower room door closed and unlocked with 2 oxygen tanks inside. Observation on 7/13/16 at 6:05 a.m. showed the North Hall shower room door closed and unlocked with oxygen tanks inside. On Environmental tour on 7/13/16 at 9:00 a.m. with the Administrator, the Environmental Director, and Staff H, Maintenance Personnel , revealed the door closed and unlocked with 2 oxygen tanks inside. The Management staff reported the O2 tanks were empty and did not have to be behind a locked door. They believed the empty oxygen tanks only needed to be secured. 2. Resident #8's Admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident scored 4 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severe impairment with making daily decisions. The MDS showed the resident required extensive staff assistance with bed mobility, transfers, and toileting. The resident had a fall in the last 2 to 6 months. The MDS also showed the resident had [DIAGNOSES REDACTED]. The Care Plan initiated on 1/15/16 identified a problem for a potential for injury related to dementia. Interventions for this problem included: -ensure the call light is within reach when in room and encourage use. -the resident rarely/never uses the call light. Anticipate the resident's needs. Resident #8's Fall Assessment Sheet's revealed the following falls: a. On 1/10/16 the staff found the resident on the floor. The staff put an intervention in place to keep the resident's feet down while in the recliner and 15 minutes checks. b. On 1/12/16 staff observed the resident on the floor in their room. The staff put interventions in place for therapy and applied hipsters. c. On 1/27/16 the resident attempted to self transfer and slipped. The staff put interventions in place of Dycem in the resident's recliner and wheelchair. d. On 2/6/16 the staff found the resident on the floor in their room. The staff contacted the resident's physician and received an order to treat ear wax build-up. e. On 2/13/16 the staff found the resident on the floor in their room. The assessment form indicated the staff were not aware of the intervention directive of keeping the resident's recliner foot rest down while in recliner. A Notification of Incident dated 2/13/16 to the physician reported the resident sitting on the floor, on the recliner foot rest of the tipped recliner. An intervention included a sign placed in the room for a reminder to unplugged the recliner and re-education to staff regarding keeping the recliner foot rest down while in the recliner. The CNA (Certified Nursing Aide) Kardex for Resident #8, dated 7/2016 directed the staff to place a Dycem in the resident's wheelchair and recliner. The CNA Kardex is a reference check for CNA's on how to take care of residents. Observation on 7/11/16 at 11:20 a.m. revealed the resident transferred by staff from the wheelchair to the toilet and then to bed. The recliner and wheelchair seat did not have a Dycem pad. Observation on 7/12/16 at 7:05 a.m. and 9:35 a.m. revealed the resident sitting in the wheelchair. The wheelchair seat did not have a Dycem pad. Observation on 7/13/16 at 8:30 a.m. and 2:00 p.m. revealed the resident in the wheelchair. The recliner seat did not have a Dycem pad. Observation on 7/14/16 at 6:30 a.m. revealed the resident in bed. The recliner and wheelchair seat did not have a Dycem pad. An interview on 7/14/16 at 6:48 a.m. Staff B, CNA, reported she thought the resident should have a Dycem pad in the recliner and wheelchair. An interview on 7/14/16 at 7:45 a.m. Staff K, CNA, reported not typically working on Resident #8's hall. Staff K reported if the Dycem pad hadn't been in the recliner, then it probably wasn't in the wheelchair. Staff K did not know if the resident had the Dycem pad in the wheelchair that morning and indicated she will check with the restorative aide to see if the Dycem pad should be in place. At 7:50 a.m., Staff K reported the resident should have the Dycem pad in place and would go put it in place. An interview on 7/14/16 at 10:20 a.m. The Assistant Director of Nursing (ADON), Registered Nurse, reported not knowing the Dycem pad hadn't been in place for the resident and reported Resident #8 is a fall risk. The DON reported staff should follow the resident's care plan and CNA Kardex. 3. During an observation in the locked Dementia Unit on 7/12/16 at 8:03 a.m. and 4:40 p.m., Resident # 4's bathroom had within the reach of a standing resident, a full spray can of air freshener, the label reads keep put of the reach of children. During an interview on 7/12/16 at 9:30 a.m., Staff O CNA stated all 11 of the residents in the Locked Unit can wander about the unit.

Based on observation, staff interviews and record review the facility failed to follow a care plan for fall prevention for 1 of 12 residents reviewed (Resident #8). The facility identified a census of 50 residents. Findings include: 1. Review of Resident #8's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had short and long term memory loss and severely impaired cognitive skills. The MDS showed the resident required extensive assistance of 1 staff with bed mobility, transfers, and toileting. Resident #8 had an indwelling catheter, with occasional incontinence with bowel functions, and no range of motion limitations. The MDS showed the resident had [DIAGNOSES REDACTED]. The Care Plan revised on 7/12/16 identified a problem for a potential for injury related to dementia. An intervention, initiated on 1/27/16, for this problem included to have Dycem (non-slip pad) in the resident's wheelchair and recliner. Review of Resident #8's CNA (Certified Nursing Aide) Kardex dated 7/2016 directed the staff to apply a Dycem pad to the resident's wheelchair and recliner. The CNA Kardex is a reference tool for CNA's on how to care for their residents. Resident #8's Fall Assessment Sheets dated 1/10/16, 1/12/16, 1/27/16, 2/6/16, and 2/13/16 revealed the resident experienced falls. Observation on 7/11/16 at 11:20 a.m. revealed the staff transferred the resident from the wheelchair to the toilet and then to bed. The recliner and wheelchair seat did not have a Dycem pad. Observation on 7/12/16 at 7:05 a.m. and 9:35 a.m. revealed the resident sitting in the wheelchair. The wheelchair seat did not have a Dycem pad. Observation on 7/13/16 at 8:30 a.m. and 2:00 p.m. revealed the resident in the wheelchair. The recliner seat did not have a Dycem pad. Observation on 7/14/16 at 6:30 a.m. revealed the resident in bed. The recliner and wheelchair seat did not have a Dycem pad. An interview on 7/14/16 at 6:48 a.m. Staff B, CNA, reported she thought the resident should have a Dycem pad in the recliner and wheelchair. Staff B did not remember if the resident had the Dycem pad in the wheelchair on 7/11/16, when she had transferred the resident into the wheelchair. An interview on 7/14/16 at 7:45 a.m. Staff K, CNA, reported not typically working on Resident #8's hall. Staff K reported if the Dycem pad hadn't been in the recliner, then it probably wasn't in the wheelchair. Staff K did not know if the resident had the Dycem pad in the wheelchair that morning and indicated she will check with the restorative aide to see if the Dycem pad should be in place. At 7:50 a.m., Staff K reported the resident should have the Dycem pad in place and would go put it in place. An interview on 7/14/16 at 10:20 a.m. The Assistant Director of Nursing (ADON), Registered Nurse, reported not knowing the Dycem pad hadn't been in place for the resident and reported Resident #8 is a fall risk. The DON reported staff should follow the resident's care plan and CNA Kardex.

Based on observation, record review and staff interviews the facility failed to provide appropriate peri cares for 1 of 2 residents reviewed (Resident #7). The facility identified a census of 50 residents. Findings include: 1. Resident #7's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had short and long term memory loss and moderate impairment with cognitive skills. The MDS showed the resident required extensive staff assistance with bed mobility, transfers, and toileting. The resident had frequent incontinence with bladder functions and continent with bowel functions. The MDS further indicated the resident had [DIAGNOSES REDACTED]. The Care Plan identified a problem for altered skin integrity with a goal revised on 4/20/26 to remain free from skin breakdown. Interventions for this goal included to monitor for signs and symptoms of urinary infection, provide incontinence products, and encourage the resident to follow house toileting policy. Observation on 7/12/16 at 6:45 a.m. showed Staff C, Certified Nursing Aide (CNA) performing morning cares for the resident in bed. Staff C picked up a soiled towel from the floor and placed it on the clean tray table that had a clean towel barrier with supplies. Staff C removed the wet depends and washed the peri area from front to back, using the same surface of the cloth several times with a back and forth movement. Staff C washed each side in this manner and then washed down the middle in one swipe downward. Staff C cleansed in the same manner with the rinsing and drying of the resident. The resident rolled to the right side and Staff C washed the sides of the buttocks in a back and forth movements, using the same surface of the cloth several times. Staff C did not wash, rinse or dry the resident's hips and failed to change the gloves between the front and back side. With the same gloves Staff C used to cleanse the resident, the staff applied barrier cream. An interview on 7/13/16 at 6:05 a.m. Staff E, CNA, reported when doing peri cares, you wash across the top of the groin, with one swipe down each side, down the middle, changing the surface of the cloth each time. She reported to do the same for rinsing and drying the area. Staff E reported to do the same with the buttocks area, swiping from the front, up the back, changing the surface of the cloth, changing gloves from the front to the back. Staff E reported soiled linens should not be placed on the floor, but disposed of in a plastic bag and/or placed in the dirty hamper. An interview on 7/13/16 at 6:45 a.m. Staff F, Licensed Practical Nurse (LPN), reported when doing peri cares, one cleans from the front to the back, one swipe, changing the cloth surface each time, down each side and down the middle. She reported to do the same with the resident's buttocks area. Staff F reported to do the same technique with rinsing and drying the resident. Staff F stated you need to change the gloves between the front and the back. Staff F noted soiled linens should never be placed on the floor. An interview on 7/11/16 at 10:20 a.m. the Assistant Director of Nursing (ADON), Registered Nurse, reported expectation of staff is to follow the facility's policy on incontinence cares. She stated the resident's hips should be also cleansed with peri cares. The ADON noted soiled linens should not be placed on the floor. The facility's Skills Checklist to Provide Incontinent Care dated 7/1/15 included the following: - to wash down each side of the perineal area, front to back. -change cloth or cloth surface with each wipe. -place soiled washcloths in appropriate place. -turn the resident to side and wash the buttocks and upper thighs. -wash the anal area, front to back-rinse and dry thoroughly.

Based on observation, staff interviews and record review, the facility failed to provide complete catheter care for 2 out of 2 residents observed (Residents #1 and #8). The facility reported a census of 50 residents. Findings included: 1. According the Minimum Data Set ((MDS) dated [DATE], Resident # 1 had [DIAGNOSES REDACTED]. During an observation on 7/12/16 at 8:39 a.m., the urinary catheter tube lay on the floor under Resident #1's wheel chair. Staff B Certified Nurses Aid (CNA) took the urinary catheter bag out from the bag from under the w/c and as the bag passed to the front of the w/c the tubing touched the floor. The blue drainage spout from the urinary catheter collection bag hung out of the holder and Staff B put the drainage spout back in the holder without cleaning the spout off. During an observation on 7/13/16 at 6:43 a.m., Staff I CNA removed the under clothes from Resident # 1 lifting the urinary catheter drainage bag up higher then the resident's body in the bed 6 times letting urine drain back towards the resident body. As Staff I put the urinary catheter bag into the holder on the walker the blue drainage spout came out of the holder. Staff I put the blue drainage spout back in the holder without cleaning the spout off. During an observation on 7/13/16 at 6:54 a.m., Staff I dressed the lower extremities of Resident # 1, lifted the urinary catheter collection bag up over 1 foot higher then the resident's body in bed 6 times. During an observation on 7/13/16 at 7:05 a.m., the catheter bag tube lay on the floor. Staff I moved the urinary catheter bag and clipped the tubing onto the pants of Resident # 1. During an interview on 7/13/16 at 2:20 p.m., Staff H stated when moving the urinary catheter bag it is held no higher then the bladder. If the urinary catheter bag drainage spout comes out if the holder it must be cleaned with an alcohol swab before it is put back in the holder area. During an interview on 7/14/16 at 10:20 a.m., the Quality Assurance (QA) Nurse, also the Infection Control Nurse, reported doing skills review, including catheter care, with staff recently. 2. Resident #8's Minimum Data Set (MDS) assessment dated [DATE] showed the resident had short and long term memory loss and moderately impaired with cognitive skills. The MDS showed the resident required extensive staff assistance with bed mobility, transfers, and toileting. The resident had a catheter and occasional incontinence with bowel functions. The MDS indicated the resident had [DIAGNOSES REDACTED]. The Care Plan identified a problem for altered skin integrity with a goal revised on 4/13/26 to remain free from skin breakdown related to incontinence. Interventions for this goal included to monitor for signs and symptoms of urinary infection, provide incontinence products, encourage the resident to follow house toileting policy, and assist with incontinence care after each incontinent episode. Observation on 7/11/16 at 11:43 a.m. revealed Staff A CNA and Staff B CNA provided incontinence cares for Resident #8 after they were incontinent of a large amount of stool. The resident's head of the bed lay flat with the foot of the bed elevated. During cares the staff rolled the resident from side to side, placing the catheter bag and tubing at the resident's feet, higher than the resident's waist. The catheter tubing contained yellow urine. Staff A completed peri cares but failed to cleanse the resident's right hip area and failed to keep the resident's catheter tube below the resident's waist area. During the provision of cares Staff B removed the soiled catheter strap but failed to re-apply another catheter strap after cares were completed. During an interview on 7/13/16 at 6:45 a.m. Staff F, Licensed Practical Nurse (LPN), reported when doing catheter cares, you do the same as peri cares. After cleansing each side, you go down the middle and then cleanse insertion site of the catheter and down the tubing. Staff F reported the catheter bag and tubing should not be placed on the floor. She reported if there is urine in the tubing the catheter bag and tubing should be placed below the resident's bladder level. Staff E also noted the drainage tube of the catheter bag should never touch the floor and if it did, it should be cleansed off with alcohol before placing it back into the holder. During an interview on 7/11/16 at 10:20 a.m. the Assistant Director of Nursing (ADON), Registered Nurse, reported expecting staff to follow the facility's policy on catheter cares. She noted if the resident had stool present the resident's buttocks should be cleansed first before the peri area, to do the dirty area first. The front groin area should be cleansed down each side, then down the middle, then cleaning down the tubing. The ADON reported if there is urine in the catheter tubing, the tubing and bag should not be raised above the resident's waist. She also noted catheter straps should be applied when a resident has a catheter. The facility's Skills Checklist to Provide Catheter Care dated 7/1/15 included the following: - position the resident lying flat on their back. -clean area around the meatus, using a clean area of the cloth for each stroke. -clean at least 4 inches of the catheter nearest the meatus, moving in one direction, using a clean area of cloth for each stroke. Review of the facility's Incontinence Skills Checklist dated 7/1/15 directed the staff to check position of drainage bag and tubing to make sure it is positioned correctly.

Based on observation and staff interviews the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection for 2 of 8 resident rooms. The facility identified a census of 50 residents. Findings include: 1. Observation on 7/12/16 at 6:45 a.m. showed Staff C, Certified Nursing Aide (CNA) performing morning cares for the Resident #7 in bed. Staff C picked up a soiled towel from the floor and placed it on the clean tray table containing supplies. The soiled linen stayed on the clean surface during the cares. An interview on 7/13/16 at 6:05 a.m. Staff E, CNA, reported soiled linens should not be placed on the floor, but disposed of in a plastic bag and/or placed in dirty hamper. An interview on 7/13/16 at 6:45 a.m. Staff F, Licensed Practical Nurse (LPN), reported soiled linens should never be placed on the floor. An interview on 7/11/16 at 10:20 a.m. the Assistant Director of Nursing (ADON), Registered Nurse, reported soiled linens should not be placed on the floor. 2. During an observation of cares in room [ROOM NUMBER] on 7/12/16 at 4:40 p.m., on the floor next to Staff N sat a pile of personal clothing, not in a bag. Staff N picked up the clothes and placed the clothes in the resident's chair. During an interview on 7/14/16 at 10:20 a.m., the Quality Assurance (QA), also the Infection Control Nurse, reported clothing items do not belong on the floor. Staff are expected to put clothing items in a plastic bag and not directly on the floor, The QA Nurse continued to report doing skills with the staff not long ago.

Based on Quality Assurance meeting attendance records and staff interview the facility failed to hold the minimum quarterly meetings of every 3 months. The facility reported a census of 50 residents. Findings include: 1. Review of the Quality Assurance (QA) meeting attendance sign-in sheets revealed the facility postponed a meeting due in October 2015 and held it November 2015, due to medical leave of the QA nurse. The QA meeting for April 2016 postponed to May 2016 due to illness of the Medical Director. During an interview on 7/14/16 at 12:46 p.m., the QA Nurse, confirmed the facility failed to have 2 quarterly Quality Assurance meetings on time in the past year. The QA Nurse reported the medical leave of the QA Nurse and the illness of the Medical Director made it difficult to complete the meetings on time.