Every finding on record at Arma Operator, LLC

Based on observation, interview, and record review, the facility failed to develop an individualized activity plan for Resident (R) 25. Findings included:- R25's Electronic Medical Record (EMR) documented a diagnosis of severe intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life). R25's Annual Minimum Data Set (MDS), dated [DATE], documented the staff interviewed R25 and documented she had severe cognitive impairment. The MDS documented it was very important for her to listen to the music she liked, go outside when the weather was nice, and somewhat important to participate in religious activities. The MDS documented R25 was dependent on staff for all activities of daily living (ADL). R25's Activity Care Area Assessment (CAA), dated 08/10/2025, was not triggered. R25's Quarterly MDS, dated [DATE], documented that she had severe cognitive impairment. The MDS documented that she was dependent on staff for all ADLs. R25's Care Plan, revised 06/10/2025, documented that she was dependent on staff for activities, cognitive stimulation, and social interaction due to her cognitive deficits. R25's Recreation Assessment, dated 08/01/2025, documented she preferred to participate in activities once weekly in her room. R25's EMR, from 06/28/26 through 07/26/2026 (30 days), lacked documentation of any activities offered or participated in. Observed on 07/27/2026 at 09:20 AM, R25 sat in her wheelchair in the TV commons area with her eyes open. The TV was turned off, and there was no visual or audible stimulation provided for R25. Observed on 07/27/2026 at 01:44 PM, R25 sat in her wheelchair in the TV commons area with her eyes open. The TV was turned on, and R25 sat with her back towards it. On 07/27/2026 at 02:05 PM, Certified Nurse Aide (CNA) M stated she had not seen anyone do activities with R25 in her room. CNA M stated R25 would go to Bingo at times but was unable to participate in the activity and would usually fall asleep. On 07/28/2026 at 09:08 AM, Activity Staff Z stated she had not done any in-room activities with R25. Activity Staff Z stated R25 should have had one-to-one (1:1) activities due to her cognitive impairment, but those had not taken place. On 07/28/2026 at 09:29 AM, Licensed Nurse (LN) H stated R25 had not received any 1:1 activity in her room. On 07/28/2026 at 03:00 PM, Administrative Staff A stated it was the expectation for dependent residents to have 1:1 activity when they were unable to participate in other activities. The facility policy for Activities and Social Events, approved 10/2025, included: activities, social events, and schedules are developed in conjunction with the residents' interests, assessment, and plan of care.

Based on interview and record review, the facility failed to ensure Resident (R)1 remained free from unnecessary medications when staff failed to monitor R1's consumption and accurately record the total amount of potassium received by R1. Findings included:- R1's Electronic Medical Record (EMR) documented a diagnosis of hypokalemia (low level of potassium in the blood). R1's EMR included the following physician's order: Potassium liquid 20 milliequivalents/15 milliliters, by mouth, three times a day, for a diagnosis of hypokalemia, ordered 07/15/2026. R1's Medication Administration Record (MAR) for July 2026 documented the medication was held eight times and refused one time by R1, since the facility received the order on 07/15/26. R1's EMR lacked documentation that he did not receive the full dose of the potassium liquid for the times when staff provided him the diluted medication. On 07/27/2026 at 01:51 PM, Certified Medication Aide (CMA) R stated the liquid potassium was to be diluted before staff could administer the medication. CMA R stated she diluted the medication in R1's house shake every morning. However, R1 did not always consume all of the house shake, so she was unable to document that R1 had received the medication. CMA R stated she would document the medication was either held or refused. CMA R stated she notified the nurse on duty when R1 did not consume the full dose of potassium. On 07/27/2026 at 02:01 PM, Licensed Nurse (LN) G stated she was unaware of R1 not receiving the full dose of the potassium medication. On 07/28/2026 at 09:31 AM, LN H stated she was unaware of R1 not receiving the full dose of the potassium medication. On 07/28/2026 at 03:00 PM, Administrative Nurse E stated it was the expectation for staff to administer residents' medications, as ordered. When a resident did not receive the ordered dose of a medication, the resident's physician should be notified. The facility policy for Refusal of Treatment, approved 10/2025, included: Documentation pertaining to a resident's refusal of a medication must include the date and time of refusal, the medication refused, and the date and time the physician was notified by the facility staff of the resident's refusal.

Based on interview and record review, the facility failed to electronically submit complete and accurate staffing information to the federal regulatory agency through Payroll-Based Journaling (PBJ) when the facility failed to accurately submit hourly staffing data for all nursing personnel. Findings included:- Review of the PBJ Staffing Data Report for the following time frames revealed Excessively Low Weekend Staffing.Fiscal Year (FY) for:Quarter (Q) 4 of FY 2025 for the timeframe of July 01, 2025, through September 31, 2025.Q1 of FY 2026 for the time frame of October 1, 2025, through December 31, 2026.Q2 of FY 2026 for the time frame of January 1, 2026, through March 31, 2026. Review of the Nursing Schedule and Payroll Data Sheets for the above dates lacked indicators of discernibly excessively low weekend staff as compared to the weekday (Monday through Friday) direct care staffing. On 07/28/2026 at 10:47 AM, Administrative Staff A reported the corporate office made changes to the PBJ report for coding the administrative nurses' hours for providing direct care to the residents when working the weekends. The facility staff at the weekends at the same levels on the weekends as during the weekday. The PBJ reports are submitted by the corporate accounting department. Administrative Staff A stated the facility ran the same staff level on the weekends as throughout the week. The facility's Payroll Based Journal Policy policy, dated 2026, documented that the community will submit payroll data in a uniform format to Centers for Medicare and Medicaid (CMS), including staffing information for community, agency, and contract staff. Direct Care staff are defined as those individuals who have direct interpersonal contact with residents or residents. facility submits the data electronically based upon specifications determined by CMS, which indicate the category of work for each person on direct care staff (including but not limited to whether the individual is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS.

Based on observation, record review, and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility laundry. Findings included: - On 07/28/2026 at 08:19 AM, laundry tour with Housekeeping/Laundry staff U revealed the following items in need of repair in the laundry:The ceiling had an approximate 18-inch by 18-inch unsealed/unfinished sheetrock patch with an approximate one foot by two-inch linear brown section surrounded with approximate four inch unfinished spackling compound. The laundry exit door had a missing door facing/jam surrounding the three sides of the door, exposing irregular, unfinished bare sheetrock through which laundry staff passed to transport laundry. On 07/28/2026 at 08:19 AM, Housekeeping/Laundry Staff U confirmed the above findings and stated the facility maintenance man should be responsible for the repairs in the laundry to ensure a safe, sanitary environment. She indicated the unfinished laundry ceiling repair was initiated to repair damage due to a leak in the roof. The roof was replaced to correct the leak a while ago, but the overhead repair was not completed. On 07/28/2026 at 10:37 AM, Maintenance Staff V verified the above findings and reported he was replacing door frames throughout the facility. Additionally, he was not aware of the need for repair of the ceiling in the laundry area. The facility policy titled Handling of Clean Linen and Linen Distribution, dated 2026, lacked documentation of the repair and maintenance in the laundry area.

Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards for Resident (R) 1, who required staff assistance and a Hoyer (total body mechanical lift) lift for safe transfers. On 01/20/26, R1 slid through the opening in the toileting lift sheet while one staff member manned the lift, and when the other staff member took their hands off the resident and the lift sheet, R1 fell to the floor. R1 sustained an abrasion to her head, pain, and a negative psychosocial outcome as she was afraid and anxious during lift transfers after the incident. Findings included:- The Electronic Medical Record (EMR) for R1 documented diagnoses of polyosteoarthritis (a chronic, degenerative disease affecting five or more joints simultaneously, characterized by cartilage breakdown, joint pain, stiffness, and potential deformity), generalized anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder that causes persistent feelings of sadness), muscle weakness (a reduced ability to exert force, often felt as difficulty lifting, walking, or rising from a chair), unsteadiness on feet (a lack of balance, stability, or coordination while standing or walking, leading to a high risk of falls), and need for assistance with personal care. R1's Quarterly Minimum Data Set (MDS), dated 01/05/26, documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment documented that she had no impairment to her upper or lower extremities and used a wheelchair for mobility. The MDS did not indicate R1 used a mechanical lift for transfers. The MDS documented she required supervision or touching assistance for eating, partial to moderate assistance for oral and personal hygiene, substantial to maximum assistance for upper body dressing, and she was dependent on staff for all other activities of daily living (ADL). The MDS recorded that the resident had no falls since the previous assessment. R1's Significant Change MDS, dated 02/08/26, documented a BIMS score of 12, indicating moderate cognitive impairment. The assessment documented that she had no impairment to her upper or lower extremities, used a wheelchair for mobility, and did not indicate the use of a mechanical lift. The MDS also documented she required supervision or touching assistance for eating, partial to moderate assistance for oral and personal hygiene, substantial to maximum assistance for upper body dressing, and she was dependent on staff for all other ADL. The MDS recorded the resident had one fall with injury since the last assessment. R1's Functional Abilities Care Area Assessment (CAA), dated 02/08/26, documented she was dependent on staff for chair/bed-to-chair transfers and tub/shower transfers. R1's Psychosocial CAA, dated 02/08/26, documented the resident had little interest or pleasure in activities. R1's Fall CAA, dated 02/08/26, documented she had a fall since the previous assessment, and she received antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medication during the look-back period. The Nursing: Lift and Transfer Evaluation, signed and dated 01/05/26, was not completed. R1's Care Plan, with a revision date of 03/30/25, documented she had an ADL self-care performance deficit related to activity intolerance, dementia, and impaired balance. The staff intervention for R1 to use a commode with Hoyer lift transfer by two staff was resolved with a date of 01/20/26. The intervention, with a date of 01/20/26, instructed staff that R1 was to use a bedpan and that she was a Hoyer lift, with two staff, for transfers. The intervention, initiated on 01/20/26 and revised 03/16/26, documented R1 was a Hoyer lift for all transfers and for staff to use a medium sling. The Nursing Progress Note on 01/20/26 at 07:30 PM, documented the certified nurse assistant (CNA) called the nurse to R1's room and told her that R1 slid out of the Hoyer lift sling during a transfer. When the nurse entered the room, the nurse found R1 lying on her back, her legs laid over the top of the lift's legs, and the lift sling was attached to the Hoyer lift. The nurse moved R1's legs off the Hoyer lift leg and assessed a large bump on the back of R1's head. R1 informed the nurse that she had back pain. The note also documented the nurse notified Administrative Nurse D and was instructed to notify Emergency Medical Transport (EMS) to transfer R1 to the Emergency Department (ED) for evaluation. R1 left the facility by EMS to the ED at approximately 07:30 PM. The note documented that staff training for Hoyer lift transfers was provided. The Nursing Progress Note, on 01/20/26 at 11:45 PM, documented R1 returned to the facility. She had a two-centimeter (cm) by one cm abrasion to the back of her head. The nurse and CNA used a Hoyer lift and assisted R1 from her wheelchair to her bed. The Nursing Progress Note, on 01/21/26 at 11:05 AM, documented R1 told the nurse that the abrasion on her head was sore. The Nursing Progress Note, on 01/21/26 at 07:05 PM, documented R1 continued to have complaints of feeling sore and told the nurse that the abrasion on her head was sore. The Nursing Progress Note, on 01/22/26 at 01:24 AM, documented R1 had complaints of pain and being sore all over. The Nursing Progress Note, on 01/23/26 at 12:16 AM, documented R1 had complaints of back and shoulder pain and had a red/purple bruise on the back of her head. The EMR revealed no Nursing: Lift and Transfer Evaluation was completed on R1 until 04/05/26. The untitled facilities' incident report 2722723, dated 01/26/26, documented that on 01/20/26 around 07:00 PM, CNA M and CNA N Hoyer lift transferred R1 from her bedside commode back to her chair. During the transfer, R1 slipped out of the Hoyer lift and landed on the ground. The nurse immediately notified Administrative Nurse D and R1 went to the ED due to R1 bumping her head and had a large bump on her head. Administrative Nurse D arrived at the facility and had the staff re-enact the transfer. The staff said they had to put R1 down and reposition her during that transfer because R1 was moving her arm. When the staff lifted R1 a second time, she started to wiggle, and before they could react, R1 fell through the lift sheet. Administrative Nurse D further documented the lift sheet was the appropriate size and staff utilized the lift sheet and Hoyer appropriately during the re-enactment. Administrative Nurse D documented corrective actions taken included: R1 was changed back to bedpan use for toileting, and nursing staff were re-checked and re-educated on Hoyer lift transfers, and Hoyer transfers monitored monthly at Quality Assurance and Performance Improvement (QAPI). The facility sign-off for Hoyer lift training and education showed a completion date of 01/25/26. CNA M's Witness Statement, dated 01/27/26, documented she and CNA N adjusted the Hoyer sheet under R1 so they could clean her up. CNA N then cleaned R1 up, and when CNA N turned to throw the dirty wipes away and move the commode, R1 complained that her back was hurting and was moving. R1 then slipped through the butt part of the lift sheet, hit her head on the ground first, and then her back hit. CNA N's Witness Statement, dated 01/27/26, documented she and CNA M went into R1's room to move her off the commode, and when they hooked R1 to the Hoyer lift, she made sure the back was down far enough. The other CNA ran the Hoyer and lifted R1 up, and CNA N wiped and cleaned R1 and then turned around and threw the dirty wipes away. When CNA N turned back around, she saw R1's head hit the ground. CNA O's Witness Statement, dated 01/27/26, documented she assisted with taking R1's vitals after she fell out of the Hoyer sling and R1 complained of her head hurting. An observation on 04/07/26 at 09:50 AM revealed CNA P and CNA Q performed a Hoyer transfer on R1 and moved her from her chair to her bed and performed care. Both CNAs maintained good communication with each other and with R1 throughout the transfer. Both CNAs provided instructions to R1 during the transfer, verified the lift sheet was the proper sheet for R1, and instructed R1 to cross her arms on her chest and not move during the transfer. CNA P maintained positive contact with R1 during the transfer and made sure she was not swaying while CNA Q operated the lift. During an interview on 04/07/26 at 10:11 AM, R1 stated after she fell from the Hoyer lift, she was nervous and anxious about using it but had recently become more comfortable with it. R1 also said no staff asked her if she was afraid of using the Hoyer lift, before or after falling from it. She said that ever since falling, she felt like she was sore and her back hurt more. During an interview on 04/07/26 at 09:50 AM, CNA P stated when performing a Hoyer transfer there would always be a minimum of two staff. CNA P said she would verify the lift sheet size, communicate with the resident, one staff would control the lift, the other would stabilize the resident during the transfer, the lift legs would be open for stability when lifting and lowering the resident, and the wheels would be locked. CNA P also said the sling would be attached to the lift by the same loops on all sides. During an interview on 04/07/26 at 10:43 AM, CNA N stated there should be a minimum of two staff when transferring with a Hoyer lift. She said one staff member would operate the Hoyer and the other would have stabilized the resident during the transfer, and the lift sheet would have been verified for the correct size, the legs of the lift would have been opened for stability, and the wheels would be locked when the resident was raised or lowered. During an interview on 04/07/26 at 12:15 PM, Administrative Nurse D stated two was the minimum number of staff required for any Hoyer lift transfer. She said one staff member would position the resident by maintaining constant contact with the resident when in the sling and guided to ensure there was no unnecessary movement during the transfer, and the other staff would operate the lift. Administrative Nurse D stated the lift legs and wheel locks would be positioned and maintained per the manufacturer's recommendation for safety purposes. On 04/07/26 at 01:50 PM, Administrative Nurse D said after R1 fell from the Hoyer lift on 01/20/26, she continued to be transferred with the Hoyer. Administrative Nurse D also said that after the fall, R1 was not re-assessed for increased anxiety, and she did not display any increase in fear or anxiety and did not express any increased anxiety to staff. She further said there was no evaluation of transfer assessment performed after the fall on 01/20/26 until the Significant Change MDS was done on 02/08/26, as it was not necessary because R1 was assessed on admission on [DATE], and it was determined that she required a medium-sized lift sling. Administrative Nurse D also said it was not necessary for therapy to re-evaluate her, as she had already attempted therapy and had not improved with strength or physical ability. Administrative Nurse E said that she performed the MDS assessments and performed the lift assessment and psychosocial assessment for R1 on 02/08/26 when she did the Significant Change MDS. The facility policy Safe Lifting and Movement of Residents, dated 03/2026, documented that nursing staff, in conjunction with the rehabilitation staff, would assess individual residents' needs for transfer assistance on an ongoing basis. Staff would document the resident's transferring and lifting needs in the care plan, and the assessment would include the resident's preferences for assistance, the resident's mobility (degree of dependency), the resident's size, weight-bearing ability, cognitive status, and whether the resident was usually cooperative with staff. The policy also documented that staff responsible for direct resident care would be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. It further documented that enough slings, in sizes required by residents in need, would always be available. The facility completed corrective actions on 01/25/26, prior to the survey. The surveyor verified completion of the actions via observation, review of training records, and staff interviews; therefore, the deficient practice was deemed past noncompliance at a G (isolated, actual harm).

The facility reported a census of 39 residents with five residents sampled for abuse and neglect. Based on interview and record review, the facility failed to ensure Resident (R)1 remained free from neglect. On [DATE] Certified Nurse Aide (CNA) M and CNA N attempted to transfer R1 from a shower chair to R1's wheelchair without using the full-body mechanical lift as required in R1's Care Plan. R1 could not bear weight so CNA M and CNA N lowered R1 to the floor. The staff attempted to lift R1 off the floor without using the mechanical lift but were unsuccessful, so they obtained the full-body mechanical lift, and both CNA staff lifted R1 into her wheelchair. CNA M and CNA N did not report the incident to Licensed Nurse (LN) G and only reported R1 bent her leg during a transfer and complained of pain. In the early morning hours of [DATE], CNA O and CNA M reported to LN H that R1 complained of leg pain. LN H assessed R1's left knee, which was slightly larger than the right. X-ray results showed R1 had a distal (further away) left femur (thigh bone) fracture and a distal right fibula (one of the bones in the lower leg) fracture. On [DATE] at approximately 02:00 PM, CNA M told CNA O she dropped R1 on the previous shift and asked CNA O what to do. CNA O advised CNA M to report the incident to the nursing staff. Administrative staff were not informed of the incident leading to the fractures until [DATE] at approximately 08:50 PM when CNA O asked Administrative Nurse E if CNA M had reported that R1 was dropped. The facility failed to use the lift per R1's Care Plan and accurately report the occurrence for follow-up care. This neglect placed R1 in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) revealed a diagnosis of age-related osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased risk for broken bones). R1's Annual Minimum Data Set (MDS), dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The assessment documented R1 utilized a wheelchair for locomotion and was dependent on staff for most activities of daily living (ADL) including transfers. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated [DATE] documented R1 had impaired cognitive function with disorganized thinking and lacked a sense of reality. The Falls CAA dated [DATE] documented R1 was at risk for falls related to poor safety awareness and a history of falls. R1's Quarterly MDS dated [DATE] documented the BIMS assessment was not completed. Per staff interview, the assessment revealed R1 had memory problems with severely impaired cognition. The assessment documented R1 utilized a wheelchair for locomotion and was dependent on staff for all ADLs except and eating. The MDS documented R1 was dependent on staff for transfers. R1's Care Plan noted on [DATE], staff identified R1 had an ADL self-care deficit related to impaired balance. The plan recorded an intervention, dated [DATE], which directed staff R1 required the use of a full body mechanical lift for transfers with the assistance of two staff. A Nursing: Progress Note documented on [DATE] at 01:48 PM by Licensed Nurse (LN) G with an effective date of [DATE] at 02:00 PM noted R1 received a shower before lunch and reported pain in the left knee after the shower, though the assessment revealed no injuries. LN G documented staff reported R1 raised her leg a little but staff did not hear a pop or anything. LN G documented staff reported R1 was agitated, screaming, and yelling when staff bathed her earlier in the shift. A Nursing: Progress Note dated [DATE] at 11:12 PM by LN H documented R1 complained of left knee pain when staff attempted to reposition her. The note documented R1 required a full body mechanical lift for transfers and staff assisted R1 into bed. The note documented R1's left knee had inward positioning with swelling, but no discoloration. LN H documented an (unnamed) CNA reported that on [DATE] the CNA bent the resident's leg during a transfer and heard a pop. LN H called R1's physician but was unable to reach a nurse so LN H faxed the report to R1's physician. A Nursing: Progress Note dated [DATE] at 11:51 AM by Administrative Nurse D documented R1's physician called and ordered a left hip and left knee X-ray. A Nursing: Progress Note dated [DATE] at 02:35 PM by Administrative Nurse D documented R1's X-ray examination could not be completed until the following day due to weather issues. A Nursing: Progress Note dated [DATE] at 02:38 PM by Administrative Nurse D documented staff notified R1's responsible party the resident's X-ray could not be completed until the following morning due to weather concerns. Administrative Nurse D documented R1's daughter did not want R1 to go to the emergency department (ED) if the resident was comfortable in the facility and noted she was fine with the X-ray examination scheduled for the following morning. A Nursing: Progress Note dated [DATE] at 08:27 AM by Administrative Nurse D with an effective date of [DATE] at 11:24 PM documented an (unnamed) CNA reported she and another (unnamed) staff member transferred R1 on [DATE] without the use of a full body mechanical lift. Administrative Nurse D documented the CNA staff lowered R1 to the ground, but did not notify the nurse of R1's fall. The note documented CNA staff reported to the (unnamed) LN that R1 complained of pain when positioning the mechanical lift sling. A Nursing: Progress Note dated [DATE] at 05:34 AM by LN I documented R1 yelled out during repositioning, but not after repositioning. The note documented R1 had no bruising on her left leg, but she did have some swelling to the left knee with inward positioning. A Nursing: Progress Note dated [DATE] at 08:28 AM by Administrative Nurse D documented staff attempted to call R1's responsible party but were unable to reach her. A Nursing: Progress Note dated [DATE] at 08:30 AM by Administrative Nurse D documented staff notified R1's physician that R1 was lowered to the floor on [DATE]. A Nursing: Progress Note dated [DATE] at 08:56 AM by Administrative Nurse D documented staff notified R1's representative that staff transferred R1 without a mechanical lift and lowered R1 to the floor. A Nursing: Progress Note dated [DATE] at 04:29 PM with an effective time of 12:00 PM by Administrative Nurse D documented R1's physician called the facility and ordered staff to send R1 to the ED for evaluation. Staff notified R1's representative. A Nursing: Progress Note dated [DATE] at 12:21 PM by LN J documented staff received a call with R1's X-ray results. The note documented R1 had a distal femur fracture and staff notified Administrative Nurse D and the charge nurse. A Nursing: Progress Note dated [DATE] at 01:36 PM by LN G documented R1 went to the ED via Emergency Medical Services (EMS). A Nursing: Progress Note dated [DATE] at 05:56 PM by Administrative Nurse D documented R1 was admitted to the hospital for a possible surgical consult. A Nursing: Progress Note dated [DATE] at 06:12 PM by LN G documented staff notified R1's representative. A Nursing: Progress Note dated [DATE] at 01:35 PM by LN K documented the facility received a call from the hospital with report of a diagnosis of a non-surgical left femur fractur; R1 had an immobilizer on the left leg. A Nursing: Progress Note dated [DATE] at 01:00 PM by LN L documented staff repositioned R1 with the assistance of three staff and when R1's right foot was touched, R1 yelled out. LN L contacted R1's physician and requested X-ray orders but was unsuccessful. A Nursing: Progress Note dated [DATE] at 01:15 PM by LN L documented staff contacted R1's representative related to R1's right lower leg and foot pain and that attempts to contact R1's physician was unsuccessful. LN L documented R1's representative agreed to wait and contact R1's physician the following morning and said not to send R1 to the ED. Staff faxed R1's physician with an update and request for X-rays. A Nursing: Progress Note dated [DATE] at 10:09 PM by LN H documented R1 had pain in her right foot and leg with movement. LN H contacted R1's physician's office to report the pain and request an X-ray. A Nursing: Progress Note dated [DATE] at 01:32 PM by LN H documented R1's physician ordered an X-ray of R1's right ankle, knee, hip, and pelvis. LN H documented staff notified R1's representative. A Nursing: Progress Note dated [DATE] at 03:08 PM, LN H documented the facility received the resident's radiology reports and faxed them to R1's physician. LN H documented the radiology results included a non-displaced (bone edges were together) transverse (across the bone) fracture of the distal right fibula (one of the bones in the lower leg) with associated soft tissue swelling. LN H documented R1's daughter was unable to be contacted via telephone. A Nursing: Progress Note dated [DATE] at 03:55 PM by Administrative Nurse D documented staff called R1's orthopedic (bone specialist) physician for an earlier follow-up appointment related to the discovery of an additional fracture. Administrative Nurse D documented R1's right lower extremity was immobilized until her appointment with the orthopedic physician. Administrative Nurse D documented staff would notify R1's representative when the follow-up appointment was confirmed. A Nursing: Progress Note dated [DATE] at 09:58 AM, Administrative Nurse D documented R1's orthopedic physician called and informed staff R1 did not need to be seen sooner related to the additional fracture. A Nursing: Progress Note dated [DATE] at 10:14 AM by Administrative Nurse D documented staff updated R1's representative on R1's condition and notified them of the resident's orthopedic appointment. A Nursing: Progress Note dated [DATE] at 02:31 AM by LN I documented R1 expired at 01:35 AM. Staff notified Administrative Nurse D at 01:38 AM and R1's daughter at 01:48 AM. The facility's investigation noted on [DATE] at approximately 10:30 AM, CNA M notified LN G that during a transfer, CNA M tucked the mechanical lift sheet (sling) under R1; her knee bent, and the resident complained of pain during the transfer. LN G assessed the area and found no injuries. On [DATE] after breakfast, CNA O and CNA M reported to the nurse (LN H) that R1 complained of left leg pain. LN H observed the inward rotation of R1's left leg and attempted to notify R1's physician and Administrative Nurse D. Administrative Nurse D also assessed R1's leg, notified R1's physician, and received X-ray orders. On [DATE] at 09:17 PM, Administrative Nurse D documented she was contacted by Administrative Nurse E who was told by CNA O that CNA M said she and CNA N dropped R1 during a transfer from the shower chair to R1's wheelchair without the use of a mechanical lift on [DATE]. On the night of [DATE], Administrative Nurse D met with CNA M and CNA O. CNA M stated she did not tell the complete truth about what happened with R1 and verified she did not tell the nurse that they lowered R1 to the ground. CNA M, CNA N, and CNA O were suspended on [DATE] pending the facility's investigation. CNA N's Witness Statement notarized on [DATE] documented that she and CNA M brought R1 to the shower and CMA M told her R1 could stand so they stood the resident and transferred her into the shower chair. CNA N noted she left to assist other residents and when she returned, they again stood R1 to finish dressing and transfer. The statement noted during the transfer, CNA M and CNA N lowered R1 to the ground. CNA N noted she advised CNA M they needed to notify the nurse of R1's fall but CNA M was worried because they did not use the lift per R1's plan of care. CNA M felt both staff would be disciplined and potentially terminated. CNA N documented CNA M persuaded her to try to stand R1 to get her off the floor, but they were unable to do so. The statement recorded CNA N again advised CNA M they needed to get the nurse, but CNA M said they would not report it to the nurse but would use the mechanical lift instead. CNA N noted they retrieved the mechanical lift and assisted R1 to her wheelchair. CNA N documented during this incident CNA M told CNA N to take this to the grave repeatedly until CNA N agreed. CNA N reported CNA M said R1 was fine, just a little sore. CNA M's Witness Statement notarized on [DATE] documented on [DATE] CNA M and CNA N transferred R1 from her wheelchair to the shower chair with a [NAME] and pivot method. The statement recorded the first transfer happened without incident but after the shower, they attempted to stand and transfer the resident to her wheelchair, but the resident's knees buckled, and the CNA staff lowered the resident to the floor. The statement noted that staff placed a sling under the resident and used the mechanical lift to get R1 off the floor and into her chair. CNA M documented when she put R1's feet on the foot pedals R1 complained of pain in her left knee. CNA M documented CNA N then stated, Take this to the grave and CNA M agreed. CNA M documented the charge nurse was unaware that they lowered R1 to the floor, but the nurse was notified that R1 complained of left leg and knee pain. CNA M documented there was no obvious swelling or deformity of R1's left leg at the time of the incident. LN H's Witness Statement notarized on [DATE] documented on [DATE] CNA M requested her to assess R1's knee. LN H noted R1's left knee was bigger than the right with no redness or bruising. LN H documented CNA M told her that the previous day ([DATE]), CNA M bent R1's knee, heard a pop, and reported it to the LN on duty at that time. LN H documented she told CNA M to lay R1 down after breakfast for a full assessment. The statement documented LN H assessed R1 after breakfast and noted an inward position of R1's left knee without discoloration. LN H documented she contacted R1's physician and instructed CNA M to notify Administrative Nurse D who also assessed R1. LN H documented she interviewed CNA M who stated she had raised R1's whole leg and bent R1's knee. Administrative Nurse E's Witness Statement notarized on [DATE] documented on [DATE] at approximately 09:15 PM, CNA O told her two other CNAs who worked on [DATE] had dropped R1 on the floor, when they transferred R1 without the mechanical lift. Administrative Nurse E noted CNA O reported CNA M and CNA N transferred R1 from the floor to the wheelchair themselves but failed to report the fall. Administrative Nurse E documented on [DATE] at approximately 09:20 PM, she notified Administrative Nurse D and Administrative Staff A of the incident. LN G's Witness Statement notarized on [DATE] documented on [DATE] before lunch, CNA M reported to her that R1 complained of pain in the left knee. LN G documented she assessed R1's left knee and there was no swelling or discoloration. LN G documented staff reported they raised R1's leg a little bit but did not hear a pop. LN G documented on [DATE] at approximately 08:15 AM, Administrative Nurse D notified her that CNA M and CNA N transferred R1 without using the mechanical lift and R1 had been lowered to the floor. LN G documented she was not aware that R1 was lowered to the floor and the situation was not reported to her by the CNA staff. CNA O's Witness Statement notarized on [DATE] documented on [DATE] at approximately 06:10 AM, she noticed R1 was guarding her leg. She noted CNA M told her that CNA M moved R1's leg on [DATE], hear a pop, and reported it to the nurse. CNA O documented on [DATE] at 02:00 PM, CNA M stated she dropped R1 the previous day and asked CNA O what she would do. CNA O documented she told CNA M to report it, and CNA M said OK. CNA O documented that at approximately 07:30 PM, she contacted Administrative Nurse E and reported the incident to Administrative Nurse E. During an interview on [DATE] at 10:55 AM, CNA Q revealed she did not know about the incident that happened with R1 but had received ANE training since the incident. CNA Q revealed that if a resident fell, or was discovered to have fallen, staff should ensure the resident was safe and call for help which included notifying the nurse. CNA Q said the nurse would then assess the resident, and staff would follow the instructions of the nurse. CNA Q stated that under no circumstances were staff to move a resident who fell without permission from the nurse. During an interview on [DATE] at 11:20 AM, CNA N stated CNA M wanted help to move R1 from the wheelchair to the shower chair using a stand and pivot transfer. CNA N stated she knew that R1 was care planned for a full-body mechanical lift but complied said she with CNA M's desire to do the standing transfer. CNA N said staff transferred R1 from the wheelchair to the shower chair without incident and then she left the room to tend to other duties. CNA N said after CNA M called for her to assist with a pivot transfer back to the wheelchair and using a gait belt, they stood R1 up to fix her clothing and perform a pivot transfer. CNA N said R1 could not remain standing, and they lowered R1 to the ground. CNA N revealed she wanted to go notify the nurse, but CNA M said to not notify the nurse. CNA N revealed that she and CNA M attempted to lift R1 from the ground without a mechanical lift but were unable to complete the task. CNA N said she left the shower area and returned with the full body lift, and they lifted R1 from the floor and into her wheelchair. CNA N said CNA M repeatedly told her that what just happened would be something that they would take to the grave and CNA N agreed. CNA N stated she did not tell anybody until she was questioned by management staff. CNA N said she knew now that if a resident had a fall staff should tell the nurse immediately. During an interview on [DATE] at 11:25 AM, LN G said on [DATE], CNA M reported she lifted R1's leg to get the mechanical lift sling around her leg when she heard or felt a pop. LN G said she assessed R1 and did not find any injury and was not able to elicit a pain response during the assessment. LN G stated staff were expected to not move a resident after a fall until the nurse assessed the resident for injuries and said the nurse would assist in getting the resident off the floor. During an interview on [DATE] at 11:47 AM, Administrative Nurse E reported she was off duty when CNA O contacted her and asked if CNA M was in trouble and said that she knew what happened to R1. Administrative Nurse E said CNA O revealed that CNA M told her they dropped R1 the previous day ([DATE]). Administrative Nurse E said she then contacted Administrative Nurse D and Administrative Staff A and responded to the facility to assist in the investigation. Administrative Nurse E then provided a timeline of the text conversation on [DATE] between herself and CNA O. On [DATE] at 11:55 AM, Administrative Nurse D said when LN H learned of the occurrence, she asked Administrative Nurse D to assess R1 for injury. Administrative Nurse D said when she assessed R1, her left leg was shortened and had internal rotation but no bruising or other signs of injury and noted R1 did have pain. Administrative Nurse D stated after the shift was over, Administrative Nurse E notified her of an allegation that involved CNA M, CNA N, and CNA O. Administrative Nurse D stated CNA O should have immediately notified the nurse on duty or a member of administration when the CNA learned from CNA M what happened on [DATE]. Administrative Nurse D verified R1 sustained a right distal fibula fracture and a left distal femur fracture. Administrative Nurse D said CNA M was terminated, CNA N and CNA O were suspended, and received final written warnings for violating policies. Administrative Nurse D stated all staff received education related to abuse, neglect, and exploitation (ANE) and on immediately reporting suspected ANE events, proper use of the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), following the resident care plans, as well as safe lift usage. On [DATE] at 12:05 PM, Administrative Staff A reported that she was notified by Administrative Nurse D and Administrative Nurse E of an allegation that CNA M and CNA N dropped R1 during a transfer and the incident was not correctly reported to nursing staff or administration. Administrative Staff A stated her, Administrative Nurse D, and Administrative Nurse E came to the facility to obtain witness statements from CNA M and CNA O and to initiate the investigation. Administrative Staff A stated she expected staff who witnessed or discovered a fall not to move the resident until the resident was assessed by a nurse. Administrative Staff A said any staff who learned of an ANE event or had the suspicion of an ANE event should report it immediately to their supervisor or a member of management. During an interview on [DATE] at 12:41 PM, CNA O said on [DATE] at the end of the shift, CNA M told her that on [DATE], CNA M and CNA N dropped R1 onto the floor in the shower area and CNA M heard a crunch but did not report the incident to the nurse. CNA O said she identified the incident as a fall and informed CNA M that she should tell the nurse immediately about what happened. CNA O said later that evening, she contacted Administrative Nurse E to inquire what kind of trouble CNA M and CNA N were in, and Administrative Nurse E denied knowledge of anything that would cause trouble for the CNA, so she told Administrative Nurse E what CNA M had told her at the end of the shift on [DATE]. The facility's Abuse Prevention Program F 600 policy, dated 08/2024, documented residents have the right to be free from abuse and neglect. The policy defined neglect as the failure to provide goods or services to the resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy defined abuse as the deprivation by an individual of goods and services necessary to attain or maintain physical, mental, or psychological well-being. On [DATE] at 03:00 PM, Administrative Staff A and Administrative Nurse D received the Immediate Jeopardy [IJ] Template and were informed of the IJ for R1. The facility's corrective measures, fully completed by [DATE] included the following, which were verified by the surveyor on-site during the investigation:/ 1. CNA M was suspended from [DATE] to [DATE] and terminated on [DATE]. 2. CNA N and CNA O were suspended from [DATE] to [DATE] and received final written warnings for violating policies on [DATE]. 3. All staff received education related to ANE and immediately reporting suspected ANE events, proper use of the Kardex, following the resident's care planned interventions as well as safe lift usage, completed [DATE] at 08:00 PM. 4. The facility completed pain assessments on all residents for 72 hours to ensure no additional residents were affected. 5. The facility performed random mechanical lift performance audits. 6. The facility held an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting related to the occurrence. All corrections were completed prior to the onsite survey therefore the deficient practice was cited as past noncompliance and remained at a scope and severity of J.

The facility reported a census of 40 residents. Based on observation, interview and record review, the facility failed to prepare, store, and serve food in a sanitary manner for the residents of the facility. Findings included: - On 12/17/24 at 12:55 PM, during the initial tour of the facility with Dietary Staff BB the following areas of concern were identified: 1. A squeeze type bottle of ranch salad dressing had an open date of 10/11/24. 2. A squeeze type bottle of Italian salad dressing had an open date of 10/04/24. 3. A one-gallon container of pickle relish had an open date of 06/04/24. 4. An open package of turkey lunch meat had an open date of 12/03/24. Dietary Staff BB stated all the above items were beyond their safe use date, which varied from seven days for the lunch meat and would consult with consulting staff GG to determine the safe use period for the salad dressings and pickle relish. The following opened items lacked open dates: 1. A one-gallon container of pickle slices. 2. A one-gallon container of mayonnaise. 3. A one-gallon container of thousand island salad dressing. 4. A one-gallon container of barbeque sauce. 5. A container of [NAME] Lynch salad dressing. 6. A 16-ounce (oz) container of ranch dressing. 7. A 46 oz container of apple sauce. 8. One large bag of shredded red cabbage. 9. A 35 oz packages of frosted flakes, rice crisps, and fruit whirls. 10. A box of corn starch. 11. A one-gallon container of pancake syrup. Dietary Staff BB confirmed the above items should have open dates to determine expiration of safe use. Observation of the kitchen environment, on 12/18/24 at 01:55 PM, with Consulting Staff GG, revealed the following areas of concern: 1. The large, covered trash can next to the stove contained food debris, grime, and spillage on the lid and outer surfaces. 2. The rolling door window through which the cook passed plates of food from the steam table to serve to residents contained dust and grime over the entire surface. 3. The steam table had an accumulation of orange rust like discolorations in the water bins and grime over the outer surfaces of the table. The back splash of the steam table contained smudges of unknown substance. 4. The plastic six drawer storage unit for condiments contained particles of sugar and grime on the interior surfaces and grime discolorations over the exterior surfaces 5. The outside of the two-door refrigerator contained sticky substances on the handles and smudges on the doors. 6. The stand alone six shelf oven contained an accumulation of grime and food substances over the entire interior, which included the doors and the six metal racks. The outer top surface contained dust. 7. The stove back splash contained an area approximately ten by eight inches of brown substance. 8. The stove's two ovens, used for storage, exterior handles contained a sticky substance. 9. Four air vents above the stove contained an accumulation of a sticky substance. 10. A metal shelf which stored food storage bags, contained an accumulation of grime across the surface. 11. A three-drawer storage unit which stored kitchen utensils, interior contained food debris, and the exterior contained grime. 12. The drying rack contained seven wet steam table food pans stacked on top of one another and another six medium sized wet food pans stacked on top of each other. 13. The ice machine drainpipe was placed directly in the drainpipe leading to the sewer and lacked a two-inch air gap to prevent back flow of sewage bacteria. 14. A dry goods storage shelf contained spillage of a sticky substance across an area of approximately two feet by six inches. Dietary Consultant GG confirmed the above issues. Observation on 12/18/24 at 03:08 PM, revealed the [NAME] Hall resident snack refrigerator contained the following areas of concern: 1. An undated a squeeze bottle of orange salad dressing, 2. An opened 46 oz container of apple sauce undated. 3. An opened jar of cheese dip undated. 4. An opened loaf of bread undated. 5.A Tupperware container of unknown substance. The freezer contained three ice packs, a smashed ice cream sandwich and an accumulation of ice on all interior surfaces. Interview, on 12/18/24 at 03:08 PM, with Licensed Nurse (LN) G, revealed housekeeping or dietary were responsible for maintenance of the refrigerator and resident snacks. Observation, on 12/19/24 at 07:30 AM, revealed the East Hall resident snack refrigerator contained the following undated opened food items: 1. A 14 oz container of ketchup. 2. A 16 oz container of ranch dressing. 3. A 16 oz container of dill pickles. 4. Two 12 oz bottles of mustard. 5. A 7.5 oz container of taco sauce. 6. A plastic fast food coffee cup 3/4 full. 7. A partially eaten sheet cake. 8. A package of cream cheese in a plastic bag. The refrigerator also contained a container with a pie slice labeled with a resident's name and the dated 11/14/24, and a Tupperware container with a resident's name with no date. The freezer contained the following areas of concern: 1. A 16 oz container of cool whip partially used with frost accumulation. 2. A fast food frosty with no date and evidence of frost accumulation. 3. A house shake dated 12/06/24. 4. 12 ice packs. The fruit bowl on the east hall snack area contained an apple with a rotten spot and seven oranges with wrinkled skins. This area also contained an open 12 oz bottle of sugar free syrup, undated. The three-drawer plastic snack unit contained salt and food debris in the interior of the drawers. Interview, on 12/19/24 at 08:00 AM, with Certified Nurse Aide (CNA) M, revealed dietary manages the resident snack area and the ice packs were used for residents with injuries. Interview, on 12/19/24 at 08:10 AM, with Licensed Nurse (LN) H, revealed housekeeping/dietary manage the resident snack areas. Interview, on 12/19/24 at 01:30 PM, with Dietary Staff BB, revealed she would expect dietary staff to manage the resident's snack areas which included the refrigerators. The facility policy Refrigerators and Freezers reviewed 10/2024, instructed staff to label and clearly mark food to indicate the date or day by which the food shall be consumed or discarded. Staff to keep refrigerators clean and free of debris on a scheduled basis and as necessary. The Facility policy Sanitation reviewed 10/2024, instructed staff to keep all kitchens and kitchen areas clean, free from litter and rubbish. Equipment, food contact surfaces and utensils shall be washed to remove of completely loosen soils using the manual or mechanical means as necessary. Food service staff will be trained to maintain cleanliness throughout their work areas. The facility failed to prepare, store, and serve food in a sanitary manner to the residents of the facility to prevent food borne illness.

The facility reported a census of 41 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests. Findings included: - On 03/14/23 at 08:45 AM, during a tour of the kitchen areas with Dietary Staff (DS) BB, revealed six dumpster containers from the backside of the kitchen. The observation included two dumpster lids open with trash bags exposed out the top and with one missing lid. Trash and debris surrounded the outside ground level of the dumpster units. On 03/14/23 at 8:45 AM, DS BB verified the above findings. She reported the entire facility used the dumpsters and should close the lids to contain the trash and refuse. Dietary Staff BB stated the missing lid had been missing for a while and a new one on order. She agreed the open lids should have been closed. The facility lacked a policy for containment of the garbage and refuse. The facility failed to maintain and/or dispose of facility garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests, for the residents of the facility.

The facility reported a census of 41 residents. Based on interview and record review the facility failed to file grievance reports and follow up with resident concerns voiced during the resident council meetings. Findings included: - Review of the resident council notes revealed the following concerns: 1. On 08/15/22, the residents had concerns that the call lights were not getting answered in a timely fashion, wished the food was warmer and the veggies were not burnt. 2. On 09/19/22, the residents had concerns that 90 percent of the meals were cold, the Certified Medication Aides (CMA) would forget pills and the Certified Nurse's Aides (CNAs) on the east hall were not being courteous to each other. 3. On 10/17/22, the residents had concerns that they went twice down to play BINGO, and nobody showed up. 4. On 11/21/22, the residents had concerns of a chair that needed repaired and that the staff needed to make sure the dishes were clean and none of them chipped. 5. On 12/20/22, the residents had concerns that the staff were taking too long to answer call lights. 6. On 01/23/23, the residents had concerns documented that the CNAs on east needs little work, the west CNAs needs some work, dietary needs some work. and activities needs work. Review of the facility Monthly Grievance Log dated January 2022 through January 2023, revealed one grievance logged, filed by the resident council, on 12/20/22 for call light wait times. The log lacked a date entered for when the facility notified the complainant of resolution. On 03/16/23 at 09:25 AM, Social Services Staff X stated when the residents said activities needed work, they wanted longer activities and did not think there was enough. They thought a couple of the CNAs were being loud. The residents wanted those requiring assistance with meals to be served after they received their meals so it would not leave one CNA to pass out the meals, so they did switch that around. On 03/16/23 at 09:47 AM, CNA MM and CMA R stated they would ask the resident if they could help them with a problem and if not they would find administration and tell Social Service X. The paperwork goes to the administrator, and they were not sure how to file a grievance anonymously. When there was a concern the social worker writes it down and talks to the administrator of the director of nursing and they try to rectify it. It goes through a chain of command. They should get back immediately and go right then to see what the issue or concern is within the same day. On 03/16/23 at 11:54 AM, Social Services Staff X stated there were grievance forms located outside of the door and one was given to them in the admission packet. The company was going online, and family members that want to file a grievance online would be able to. Forms were used currently, and they were not tracked to see if concern were fixed, and there was not a method to monitor for patterns. Social Services X stated there was not a system to follow up for effective resolution per action plan, and if the resident did not complain they would consider the issue resolved. Old business was not always addressed in the resident council meetings or the effectiveness of a corrective action in the next meeting. On 03/16/23 at 02:53 PM, Administrative Staff A stated the grievance forms were outside of Social Service Staff X's office and at each nurse's station. Anyone could fill out a grievance form and turn them into the administrator, director of nursing, or social services and depending on what department it affected would be who was responsible for investigating, following up with the resident, and then turning that information in to the social service staff. A lot of things can be resolved right then, and we do not fill out a grievance form for that. The facility policy for, Filing Grievances/Complaints effective May 2022, revealed the resident has a right to voice grievances or complaints to the facility or other agencies or entities that hears grievance without discrimination or reprisal and without fear of discrimination or reprisal. Upon receipts of a grievance and/or complaint, the grievance official will investigate the allegation and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint. The grievance official will also give a written grievance decision to the resident. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems. The facility failed to file grievances with several resident concerns, investigate the concern, and follow up with them regarding resolution.

The facility reported a census of 41 residents, with 17 sampled for review. Based on interview and record review the facility failed to thoroughly investigate allegations when they failed to conduct resident interviews specifically related to the allegations of the self-investigations for two residents R6 and R23 on three occurrences of resident to resident altercation/abuse, and for two residents, R31 and R28 when the facility investigated resident to resident altercation/sexual abuse. Findings included: - The Medical Diagnosis tab for R6 included diagnoses of Alzheimer's Disease (a progressive mental deterioration characterized by confusion and memory failure), metabolic encephalopathy (a chemical imbalance of the blood that affects the brain that can lead to personality changes), and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). The Annual Minimum Data Set (MDS), dated [DATE] assessed R6 with a Brief Interview of Mental Status (BIMS) score of 11, indicating moderate cognitive impairment, disorganized thinking, no behaviors however, rejected care one to three days of the assessment period. She required supervision and setup for transfers and locomotion on and off the unit. R6 had no impairment to her range of motion and used a wheelchair for mobility. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 07/06/22 for R6 revealed she could make her basic wants/needs known and had disorganized thinking at times. The ADL [activities of daily living] Functional/Rehabilitation Potential CAA dated 07/06/22 for R6 revealed she required supervision for most ADL's and at times would need more assistance. The Behavioral Symptoms CAA dated 07/06/22 revealed R6 occasionally rejected care and was adamant about doing cares herself and not allowing staff assistance. The Quarterly MDS dated [DATE] assessed R6 with a BIMS score of nine indicating moderate cognitive impairment, continued to have disorganized thinking, and did not reject care. R6 had physical and verbal behaviors directed towards others which occurred one to three days of the seven-day assessment period. R6 required supervision for transfers, locomotion on/off unit, has no range of motion impairments, and continued to use a wheelchair for mobility. The Care Plan dated 04/08/21, included R6 makes impulsive decisions and had increased memory loss at times in the evenings. R6 had a mood problem displayed as agitation, anxiety, or restlessness. R6 was more restless and agitated during evening hours and would have delusions at times not always redirectable. R6 used a wheelchair for mobility and had a tendency to wander around the facility. The other resident R23, who was the other resident, involved in three resident/resident altercations/abuse not thoroughly investigated included the following. The Physician Orders dated 03/01/23 for R23 included diagnoses of Alzheimer's Disease, anxiety disorder, and vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain). The Annual MDS dated [DATE] assessed R23 with a short and long-term memory problem and severely impaired decision making and disorganized thinking. R23 wandered daily and had other behavior symptoms not directed towards others one to three days of the seven-day assessment period. She required supervision of staff for transfers, ambulation, and locomotion on/off the unit. R23 had no impairments to her range of motion and did not require the use of a mobility device. The Cognitive Loss/Dementia CAA dated 04/12/22 revealed R23 had impaired cognitive function related to dementia. she realizes she was not home but did not understand where she was or why she was there. The Behavioral Symptoms CAA dated 04/12/22 revealed R23 wandered, did not like to be in a room alone, and the staff were to distract her from wandering. The Quarterly MDS dated [DATE] assessed R23 with a short and long-term memory problem, severely impaired decision making, and disorganized thinking. She continued to require supervision for transfers, ambulation, and locomotion on/off the unit. R23 did not have a range of motion impairment and did not require a mobility device. The Care Plan revised on 02/17/22 revealed R23 wandered and liked to stay busy. The staff were to distract her from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. A. The first incident of resident-to-resident altercation/abuse between these two residents reviewed included: The Progress Note dated 11/24/22 at 04:00 PM, for R6 revealed R6 was sitting in her wheelchair near the dining room while another resident (R23) was standing nearby. Certified Nurse Aide (CNA) was walking toward lobby to inform R6 she had a phone call. R23 began to push R6 in her wheelchair by the handles when R6 turned slightly around in her wheelchair and hit R6's hand with an open hand. R23 hit R6 in the back and left shoulder area. R6 then hit R23 in the left side of the chest. CNA immediately separated residents. The Progress Note dated 11/24/22 at 04:00 PM, for R23 revealed R23 was standing up near the dining room while another resident (R6) was sitting in her wheelchair nearby. CNA was walking toward the lobby area to tell R6 she had a phone call. R23 began to push R6 in her wheelchair by the handles when R6 turned slightly around in her wheelchair and hit R23's hand with an open hand. R23 hit R6 in the back of the left shoulder area then R6 hit her on the left side of the chest. CNA immediately separated the residents. Review of the facility self-investigation of this revealed the Resident Interview forms, dated 12/05/22, included questions: 1. Has staff been respectful when providing care? 2. Have you ever witnessed staff being rough or rude to another resident? 3. If you witness a staff member being rough or rude to another resident do you feel comfortable reporting it to other staff? B. The second occasion of resident-to-resident altercation/abuse with these two residents reviewed included: The Progress Note dated 11/29/22 at 02:30 PM, for R23 revealed staff had reported they witnessed another resident (R6) hit R23 on the right shoulder and when told to stop R6 hit R23 on the arm three more times, and the staff separated the residents. The Progress Note dated 11/29/22 at 02:30 PM for R6 revealed another resident (R23) was leaving the dining room and R6 hit R23 on the right shoulder and when R23 told R6 to stop R23 hit R6 three more times on the arm, and the staff separated the residents. Review of the facility self-investigation included the Resident Interview forms, dated 12/05/22, included questions: 1. Has staff been respectful when providing care? 2. Have you ever witnessed staff being rough or rude to another resident? 3. If you witness a staff member being rough or rude to another resident do you feel comfortable reporting it to other staff? The facility failed to interview residents with questions related to the scenario of the resident to resident, was questioning about staff treatment to residents rather than if there were concerns with other residents. C. The third occasion of resident-to-resident altercation/abuse reviewed included: The Progress Note dated 01/12/23 at 07:00 PM for R23 revealed the nurse heard R23 yell and observed R6 slap R23 on the arm with an open hand and R23 turned around and slapped R6 on the arm with an open hand. A CNA separated the residents. The Progress Note dated 01/12/23 at 07:00 PM for R6 revealed the nurse heard R6 yell and observed R6 swatting an open hand at R23 with not contact made after R23 attempted to push R6's wheelchair. R23 slapped R6 on the arm with an open hand and R6 turned around and slapped R23 on the arm with an open hand. A CNA intervened and separated the residents. Review of the facility self-investigation revealed the Resident Interview forms, dated 01/18/23, included questions: 1. Has staff been respectful when providing care? 2. Have you ever witnessed staff being rough or rude to another resident? 3. If you witness a staff member being rough or rude to another resident do you feel comfortable reporting it to other staff? The facility failed to interview residents with questions related to the scenario of the resident to resident, was questioning about staff treatment to residents rather than if there were concerns with other residents. On 03/20/23 at 01:28 PM, Administrative Nurse D questioned where do the questions from the Resident Interview form come from and she stated the facility used a standard form, and if there was missing money there was a different form for that. Administrative Nurse D stated the resident questions were not related to the scenario except the last one on the form that asked if the resident felt safe there. The facility policy Abuse Prevention Program, Investigation effective August 2022 revealed the individual conducting the investigation will as a minimum interview the resident roommate, family members, and visitors, as able or as appropriate to the situation. The facility failed to conduct three thorough investigations when interviewing residents about staff behaviors versus resident behaviors, when altercations/abuse occurred between these two residents. - The electronic medical record EMR of R28 included diagnoses of bipolar disorder, alcohol abuse, and dementia with mood disturbance. Nurses' notes dated 03/03/23 at 06:10 PM, documented a certified nurse aide (CNA) saw male resident (R31) in R28 room while she was in her recliner. Male resident stood over her and kissing her on lips. CNA immediately intervened and separated the residents. Police notified and questioned R28 about a male being in her room. R28 stated, He was in here, and I told him to leave and not come back. But this was a few days ago. The resident was unable to give accurate details. The 01/04/23, Minimum Data Set MDS, documented R28 had severe impaired cognition and unable to complete a score for cognitive patterns. The 12/21/22, MDS, documented R31 had a Brief Interview for Mental Status BIMS score of 10 indicating he had moderately impaired cognition. R31 had disorganized thinking and no behaviors. R31's current plan of care included addition dated 02/05/22, Reminisce using photos of his family and friends. Enjoys talking about his family, grandchildren, and girlfriend. Another addition on 08/18/22, Erratic behavior at times. History of making inappropriate comments towards staff. Staff to redirect behavior. Review of the facility self-investigation related to resident-to-resident altercation/sexual abuse, documented an incident between Resident (R)31 and R28, on 03/03/23 at 06:10 PM. Staff found R31 in the room of R28, standing over her in her recliner with his mouth on her mouth. Both were fully clothed and were immediately separated by staff. Further review revealed the resident interviews questions: 1. Has staff been respectful when providing care? 2. Have you ever witnessed staff being rough or rude to another resident? 3. If you witness a staff member being rough or rude to another resident do you feel comfortable reporting it to other staff? 4. Do you feel that your needs are addressed timely? 5. Do you feel like this is a safe place to live? The facility failed to interview residents with questions related to the scenario of the resident to resident. The staff questioned residents staff treatment to residents rather than if there were concerns with other residents. On 03/20/23 at 01:28 PM, Administrative Nurse D questioned where do the questions from the Resident Interview form come from and she stated the facility used a standard form, and if there was missing money there was a different form for that. Administrative Nurse D stated the resident questions were not related to the scenario except the last one on the form that asked if the resident felt safe there. The facility policy Abuse Prevention Program, Investigation effective August 2022 revealed the individual conducting the investigation will as a minimum interview the resident roommate, family members, and visitors, as able or as appropriate to the situation. The facility failed to conduct a thorough investigation when interviewing residents about staff behaviors versus resident behaviors, when the altercations/sexual abuse occurred between these two residents.

The facility reported a census of 41 residents with 17 residents sampled which included four residents reviewed for infection control technique during provided care procedures. Based on observation, interview and record review, the facility failed to provide appropriate care and services to prevent cross contamination and prevent the spread of infection for four of the four residents sampled as followed: 1. Direct care staff failed to sanitize their hands before and after glove application, removal, and maintain separation of clean and dirty procedure during peri care for three residents (R)16 and R 12, and 14. 2. Facility staff failed to sanitize a blood pressure cuff used for multiple residents between resident use. 3. Facility staff failed to administer eye drops in a sanitary manner for R16, by placing the eye drop cap on an unclean surface and then replacing the cap on the bottle without sanitizing the cap. Findings included: - On 03/15/23 at 03:23 PM, Certified Nurse Aide (CNA) Q and Certified Medication Aide (CMA) S sanitized hands and entered resident (R)16's room. They transferred the resident from her wheelchair to her bed, applied gloves (without washing or sanitizing their hands) and proceeded to remove R 16's soiled incontinent brief and provided peri care. Certified Nurse Aide (CNA) Q and Certified Medication Aide (CMA) S did not sanitize their hands prior to applying gloves and changed the resident's wet brief, provided peri care, and applied a new brief without sanitizing their hands or changing gloves between the soiled removal and clean brief application. On 03/15/23 at 03:26 PM, CNA Q picked up a soiled disposable wipe from the floor with an ungloved hand and threw the soiled wipe into the trash can, pulled the trash bag from the trash can and placed the trash bag directly on the floor before leaving the room. She turned the doorknob and proceeded to exit the room without washing her hands. On 03/21/23 at 01:32 PM, Administrative Nurse D stated she expected staff to follow the facility protocol for providing peri-care for the resident to prevent the spread of infections and promote a safe sanitary environment. She reported staff should always sanitize their hands before entering a resident's room. Staff should wash their hands before applying gloves, after removing gloves prior to reapplying gloves, and should remove gloves and wash hands between the removal of a soiled incontinent brief and in between application of a new brief. Trash bag with linen nor trash should never be placed directly on the floor. The facility checklist for Perineal Care, dated 2019, documentation included .infection Control-Perform hand hygiene and apply clean gloves. Use infection Control measures and standard precautions throughout the entire procedure to prevent the transmission of microorganisms. Clean and disinfect any contaminated surfaces. The facility failed to provide appropriate care and services to prevent cross contamination and prevent the spread of infection related to hand hygiene, use of gloves, providing peri care and sanitizing contaminated surfaces for the resident. 41121 - On 03/16/23 at 08:14 AM, observation of medication pass by Certified Medication Aide (CMA) LL revealed she removed the cap off of a bottle of eye drops and placed it on an unsanitary towel on top of the medication cart. The towel contained brown colored spots on it. CMA LL administered the eye drops to R16 then replaced the cap on the bottle of eye drops without sanitizing it first. On 03/16/23 at 08:24 AM, during observation of medication pass, CMA LL used a digital wrist blood pressure cuff on R23 without sanitizing it first and prior observation revealed she used it on another resident prior to that. CMA LL failed to sanitize the blood pressure cuff after use on R23. On 03/16/23 at 08:29 AM, CMA LL stated she does not sanitize the blood pressure cuff between resident uses, had done that when there was an outbreak of COVID-19 (highly contagious respiratory disease) but she did not do that now. On 03/20/23 at 01:37 PM, Administrative Nurse D stated the cap of the eye drop container should not be placed on top of the soiled towel on the med cart and it further explained it was not in the facility policy to clean the blood pressure cuff between uses, however, it should be sanitized between uses. The facility policy for Instillation of Eye Drops effective May 2022, lacked instruction for cleansing of the eye drop container cap if placed on an unsanitary surface. The facility policy for Blood Pressure Measuring effective May 2022, provided instructions for cleaning of the stethoscope following blood pressure measurement with an inflatable blood pressure cuff and lacked instructions for cleaning before and/or after use of a digital wrist cuff. The facility failed to ensure sanitary practices used for shared resident equipment and eye drop administration increasing the risk of the residents for developing infections. - On 03/15/23 at 09:07 AM, observed Certified Nurse Aide (CNA) O provide incontinence peri-care to R12. CNA O used multiple swipes from front to back with the same wipe, picked up a bottle of nourishing cream and wipes, then removed the gloves and applied a new pair to continue without performing hand hygiene between. Another resident observation, on 03/15/23 at 10:59 AM, revealed CNA O provided incontinent peri-care to R14. CNA O used a disposable wipe to cleanse the left crease between leg and peri-area, then the right crease, then cleansed the center of her peri-area front to back multiple times with the same wipe. CNA O then removed the gloves and applied a new pair without performing hand hygiene. On 03/20/23 at 01:37 PM Administrative Nurse D stated staff should remove gloves after peri-care and perform hand hygiene before applying a new pair of gloves. Administrative D stated the staff should use a different wipe per swipe while performing peri-care. The facility policy for Perineal Care effective May 2022, lacked instructions for peri-care using disposable wipes. The facility policy for Handwashing/Hand Hygiene effective October 2022, revealed employees must wash their hands for at least 20 seconds using soap and water following removal of gloves. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60 to 90 percent ethanol or isopropanol after removing gloves. The facility failed to ensure appropriate hand hygiene and peri-care procedures performed to ensure they met infection control standards to reduce the risk of causing or spreading infections.

The facility reported a census of 41 residents with seventeen selected for review. Based on observation, interview, and record review, the facility failed to ensure accommodation of needs were met for two or the residents, Resident (R)17 and R13 by failure to have their call light in reach so they could alert staff of any needs. Findings included: - The Quarterly Minimum Data Set, dated dated dated [DATE] for R17 assessed her having absence of spoken words, required assistance with Activities of Daily Livings, and had limitation to her range of motion to one side of her upper extremities. On 03/14/23 at 04:19 PM, observed R17 sitting in the recliner in her room and the call light cord was across the bed with the call light button out of the resident's reach. A sign that read Call don't fall was posted on the door of her room. R17 pointed to her bed and when asked if she wanted to lay down, she shook her head up and down indicating yes. The surveyor alerted the staff to R17's request. R17 was using a facial tissue to wipe her mouth with her left hand. On 03/14/23 at 04:50 PM, Licensed Nurse (LN) G stated R17 could activate the call light when she needed assistance. On 03/15/23 at 09:38 AM, Licensed Nurse (LN) G stated R17 activated her call light this morning when in bed for her tracheostomy (opening though the neck into the trachea through which an indwelling tube may be inserted) care to be done. On 03/16/23 at 02:20 PM, observed R17 sitting in her recliner in her room. The call light cord lay across the bed with the call light button out of the resident's reach. R17 made a hand gesture indicating to come into her room. On 03/16/23 at 02:25 PM, Certified Medication Aide (CMA) T stated R17 probably wanted to go to bed and could use her call light. CMA T confirmed the call light was not within the resident's reach. CMA T explained remembering the call light box being on the other wall, rather than by the doorway of the room, where there was a square of white paint on the wall. On 03/16/23 at 02:27 PM, LN J stated R17's call light cord was long enough to reach to her when she was in the recliner, however when she checked it, the cord was not long enough. LN J stated she would alert Maintenance Staff U that R17 needed a longer call light cord. On 03/16/23 at 02:46 PM, Maintenance Staff U stated he was not aware R17's call light cord was not long enough until LN J just reported to him and did know why the call light box was moved by the doorway rather than on the wall behind the bed. On 03/16/23 at 02:48 PM, LN J stated R17 moved in that room on 11/03/22 and was not sure if the furniture had been rearranged since she moved in there but could recall her being able to reach the call light before from the recliner. On 03/16/23 at 02:51 PM, Administrative Staff A stated she would expect R17 to have her call light in reach and would think staff would have said something about it not being long enough before now. The facility policy Answering the Call Light dated October 2010, revealed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. The facility failed to ensure accommodation of the resident's need to be able to reach the call light so she could alert the staff when she needed assistance. - The Annual Minimum Data Set, dated dated dated [DATE] for R13 assessed her with a Brief Interview of Mental Status Score (BIMS) of 15, indicating intact cognition. R13 required extensive assistance of two staff for toilet use and had no range of motion limitations to her upper extremities. On 03/16/23 at 01:30 PM, during resident council meeting, R13 stated that three weeks ago on a Friday the staff assisted her to the commode before shift change and failed to ensure she had her call light to use when they left the room. R13 stated she sat on the commode for one and a half hours before staff assisted her. The first prior shift assisted her to the commode, and then they went home. On 03/16/23 at 01:56 PM, Administrative Nurse D stated she spoke with Certified Medication Aide (CMA) R about communicating to the oncoming shift, who assisted R13 onto the commode and provided education about ensuring the call light was in reach. Administrative Nurse D stated she had come into the facility around 03:15 PM that day and R13 was not on the commode at that time. The facility policy Answering the Call Light dated October 2010, revealed when the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. The facility failed to ensure accommodation of needs for R13 to have access to her call light, when on the commode to alert staff when she required further assistance.

The facility reported a census of 41 with 17 selected for review including three reviewed for hospitalization . Based on record review and interview, the facility failed to provide notification to the Ombudsman office for Resident (R)12 and R6 following transfers to the hospital. Findings included: - The Progress Note dated 12/30/22 at 10:45 AM, revealed the facility transferred R12 to the emergency room for evaluation. The Progress Note dated 12/30/22 at 03:30 PM, revealed R12 admitted to the hospital. The electronic medical record lacked documentation of notification to the Ombudsman office. On 03/21/23 at 12:08 PM, Social Service Staff X stated she emails the Ombudsman at the end of every month and forgot to send an email. Social Service Staff X stated an email was to be sent monthly and it had not been sent since August or September that she sent the notification to the Ombudsman office. On 03/21/23 at 12:12 PM, Administrative Staff A stated she expected the Ombudsman office to receive notification monthly of the resident transfers and discharges. The facility policy Transfer and/or Discharge, Including Against Medical Advice dated October 2022, lacked instructions for notification to the Ombudsman office for transfers to the hospital when expected to return. The facility failed to provide notification to the Ombudsman office when R12 transferred to the hospital on 12/30/22. - The Progress Note dated 02/07/23 at 04:15 PM, revealed the facility transferred R6 to the hospital for admission. The electronic medical record lacked documentation of notification to the Ombudsman office. On 03/21/23 at 12:08 PM, Social Service Staff X stated she emails the Ombudsman at the end of every month and forgot to send an email. Social Service Staff X stated an email was to be sent monthly and it had not been sent since August or September that she sent notification to the Ombudsman office. On 03/21/23 at 12:12 PM, Administrative Staff A stated she expected the Ombudsman office to receive notification monthly of transfers and discharges. The facility policy Transfer and/or Discharge, Including Against Medical Advice dated October 2022, lacked instructions for notification to the Ombudsman office for transfers to the hospital when expected to return. The facility failed to provide notification to the Ombudsman office when R6 transferred to the hospital on 02/07/23.

The facility reported a census of 41 residents with 17 selected for review including three residents reviewed for activities of daily living (ADL's). Based on observation, record review, and interview, the facility failed to provide appropriate hygiene and grooming cares to Resident (R)33. Findings included: - The Medical Diagnosis tab for R33 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) and diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R33 with loss of short- and long-term memory and with severely impaired decision-making ability. He required extensive assistance of two or more with personal hygiene and bathing. The Annual MDS dated [DATE] for R33 revealed no changes to his memory, decision making skills, personal hygiene, or bathing assistance. The Activities of Daily Living Care Area Assessment was not triggered for the Annual MDS dated [DATE]. The Care Plan dated 01/05/23 for R33 revealed he required one staff participation with personal hygiene needs. The Orders tab for R33 lacked instructions for fingernail care. The Treatment Administration Record for 03/01-03/16/23 for R33 lacked instructions for fingernail care. The Task tab for bathing revealed R33 received some type of bath on 03/09/23 and 03/12/23. The Progress Notes lacked any resident refusal of fingernail care for 03/09/23 and 03/12/23. On 03/14/23 at 10:05 AM, observed R33 sitting in a recliner in the living room area near the nurse's station on the east side. R33's fingernails noted to be long with a brown substance under them, and the left thumb nail had a red colored substance under it. On 03/15/23 at 10:28 AM, R33 was sitting in the hallway in a wheelchair, his fingernails remained long with a brown substance under them. On 03/15/23 at 02:43 PM, Certified Nurse Aide (CNA) M stated fingernail care, trimming and cleaning, was done when the resident had a shower or more often if needed. CNA M stated if a resident was diabetic, the staff would let the nurse know, and the nurse would do the nail care. On 03/16/23 at 09:56 AM, observed R33 sitting in the recliner in the living room area, his fingernails continued to be long with the dark substance under them. On 03/16/23 at 10:37 AM, CNA N stated R33 had showers scheduled on Sunday and Thursday mornings and she helped with his shower this morning. CNA N stated she tries to do fingernail care when the resident is in the shower. CNA N stated she did not provide fingernail care to R33 this morning because she forgot and stated she doesn't trim them the nurse does that. CNA N observed his fingernails and stated they needed to be cleaned. On 03/20/23 at 10:33 AM, Administrative Nurse D stated fingernail trimming, and cleaning, should be done during the shower unless diabetic, then the nurse's do the fingernail care and it was on the Treatment Administration Record for them to do. The facility policy Care of Fingernails/Toenails dated effective May 2022, revealed the purpose of the procedure was to keep nails trimmed, to clean the nail bed, and to prevent infections. Nail care included daily cleaning and regular trimming. The facility failed to ensure R33's nails were adequately cleaned and that he received regular trimming of the jagged nails.

The facility reported a census of 41 residents, with six residents sampled for accidents. Based on observation, interview and record review, the facility failed to identify contributing causes of one Resident (R24) of the six sampled residents, with multiple injuries of unknown origin (skin tears and bruise) and failed to implement appropriate immediate interventions to prevent further repeated skin injuries for this resident. Finding included: - Review of Resident (R)24's, Physician Orders, dated 03/01/23, revealed diagnoses which included, non-displaced inter-trochanteric fracture of left femur (broken upper left leg), dementia (progressive mental disorder characterized by failing memory, confusion), iron deficiency anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), and hypothyroidism(condition characterized by decreased activity of the thyroid gland). The Admission Minimum Data Set (MDS) dated [DATE], documented, the Brief Interview for Mental Status (BIMS) score of 99 had, severe cognitive impairment and was rarely/never understood. She required extensive assistance of staff for bed mobility, transfers, toilet use, and for personal hygiene needs. Her balance during transition was not steady and she was only able to stabilize with staff assistance. The resident's formal clinical skin assessment revealed the resident was at risk for pressure ulcer/injury and had four deep tissue pressure ulcer injuries on admission. The resident received treatment for skin tears. The Pressure ulcers/Injury Care Area Assessment (CAA), dated 12/01/22, documentation included the resident was at risk for pressure injury, incontinent, and had multiple pressure injury from a hospital stay. The wound care nurse was to assess the areas weekly, and the licensed nurse to assess every shift. The Certified Nurse Aide (CNA) was to inspect the resident's skin with cares. R24 had a Low Air Loss (LAL) mattress with other interventions in place. Staff were to reposition her often. The facility staff will follow-up with wound care and the physician as needed. The Care Plan, (CP) for skin conditions, dated 02/21/23, was initiated 11/23/22, documentation included directions to the staff to observe for open areas, scratches, bruises, and report them to the nurse. Staff to administer treatments as ordered and monitor for effectiveness. Staff were to educate the resident/family/caregivers as to causes of skin issues and the importance of taking care during ambulation/mobility, and frequent repositioning. Staff to follow the facility policies/protocols for the prevention/treatment of skin. The staff should monitor/document/report to the physician any changes in skin status. The resident with bleeding precautions due to her taking hematological medications (medications that affect blood clotting). The Comprehensive Care Plan lacked revisions for skin conditions after 1/26/23. On 03/14/23 at 02:16 PM, the back of the resident's bilateral hands with blue black discoloration over the surface of the back of her hands. She stated she had problems with bruising and discoloration for many years. The immediate surface areas surrounding the resident such as grab bars or the bed which could cause trauma, lacked any signs of blood. Her bedside table was in reach to her right side. On 03/15/23 at 12:19 PM, two CNAs MM and AA entered the resident's room. They turned and repositioned the resident and provided peri care. Staff used extensive assistance to reposition the resident from a lying to a sitting position. Staff applied the gait belt and assisted the resident to a standing position. She pivoted to the wheelchair and sat down. The w/c foot pedals were applied, and her feet positioned on the pedals. On 03/20/23 at 02:49 PM, the resident stated her hands have always had concerns with discoloration on top of her hands. She reported she bumped her hands sometimes. On 03/15/23 at 02:34 PM, Certified Medication Aide (CMA) S reported the resident's individual interventions are located on the Kardex [the Electronic Medical Record (EMT)]. When staff identify a change in condition, skin condition or injury such as a discolored area or skin tear, they report it to the nurse, who then assesses the injury. The nurses should determine the cause of the injury and implement an immediate intervention to prevent further skin injury. The nursing administrative staff reviews the intervention for appropriateness, makes any recommendations, and then completes the investigation. The Certified Medication Aide (CMA)s have access to the notes in the EMR. The Certified Nurse Aides (CNA) have a communication book at the desk for guidance related to implementing new interventions. CMA S stated she was not aware of the cause for the discoloration on the resident's hands. She reported the nurses would be a better person to ask about the discolored areas and the protocol for skin tears. Staff should notify the nurse of changes in the resident's skin condition. She will assess the area and instruct staff what to do to prevent further injury. CNA M reported she was not aware of the cause of the discoloration on the resident's hands nor what was done to prevent them from reoccurring. On 03/20/23 at 02:33 PM, Licensed Nurse (LN) I stated the resident always has discoloration on her hands. The resident always wears long sleeves, and the staff should us a gait belt when transferring the resident to prevent injury to her hands. The staff notified the nurse when R24 gets a new skin area. The nurse should assess the resident and initiate an investigation to determine the reason for the injury, and then put an intervention in place to prevent further skin injury. On 03/21/23 at 01:32 PM, Administrative Nurse D, verified the above findings. She agreed the skin conditions noted above lacked a thorough investigation to determine the root cause and/or contributing factors to the injury. She verified the resident's medical record and the facility's investigation failed to reflect immediate interventions to prevent further skin injuries, as they should. The facility policy Investigating Unexplained Injuries, dated 03/2023, documentation included injury of unknown source is defined as an injury (including bruises, abrasions, and injuries of unknown source), which definition includes the incidence of injuries overtime. Documentation should include information relevant to risk factors and conditions that could cause or predispose someone to similar symptoms/injury. The facility failed to identify the contributing causes of the resident's multiple skin injuries of unknown origin (skin tears and bruise) and failed to implement appropriate immediate interventions to prevent further repeated skin injuries for this resident.

The facility reported a census of 41 residents with 17 selected for review including two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) or urinary tract infection (UTI). Based on observation, interview, and record review, the facility failed to ensure Resident (R)18's urinary catheter tubing was appropriately secured to prevent urethral trauma in case of tugging on the catheter tubing. Findings included: - The Medial Diagnosis tab for R18 included a diagnoses of neuromuscular dysfunction of the bladder, benign prostate hypertrophy (BPH - non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), and the need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE] assessed R18 with a Brief Interview of Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. R18 required extensive assistance of one staff for toilet use and had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE] revealed R18 required extensive assistance for toilet use and had a suprapubic catheter (urinary catheter inserted into the bladder through the skin). R18 had a history of UTI's and was at risk for recurrent UTI's. The Quarterly MDS dated [DATE] assessed R18 with a BIMS score of 12 indicating moderate cognitive impairment, required extensive assist of two or more for toilet use, had an indwelling catheter in place, and had a diagnosis of a UTI in the past 30 days. The Care Plan dated 01/05/23 revealed R18 had a suprapubic catheter and the staff were instructed to position the catheter bag and tubing below the level of the bladder. The care plan lacked instructions for an anchoring device to secure the catheter tubing. The facility revised the care plan on 03/17/23 to include R18 did not wish to have a catheter anchor, and an additional revision on 03/17/23 revealed staff reported he will not leave the catheter anchor in place and will trial a catheter leg strap for effectiveness. On 03/14/23 at 09:29 AM, observed resident in his room with shorts on and the urinary catheter tubing had a plastic clip which was clipped to the bottom of the leg of his shorts, no catheter anchor was visible at this time. The catheter's tubing swung freely with the movement of the short's leg. On 03/15/23 at 01:47 PM, observed R18's catheter tubing secured by a plastic clip to the leg of his shorts. The catheter tubing swung freely with the movement of the short's leg. On 03/15/23 at 01:50 PM, Certified Nurse Aide (CNA) O stated clipping the tubing to his shorts was the method staff used to secure the tubing and R18 removed the ones that stick to his skin. On 03/20/23 at 11:31 AM, Administrative Nurse D when questioned if R18's catheter tubing should be anchored to secure it, stated it had an anchor in place today and he had picked it off before, but what he has on today was different then what was tried before. Administrative Nurse D stated if R18 leaves an anchor on, the catheter tubing should not be clipped to his shorts. The facility policy Indwelling Urinary Catheters effective June 2022, instructed to ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site, the catheter tubing should be strapped to the resident's inner thigh. The facility failed to ensure R18's catheter tubing was appropriately secured to prevent urethral trauma in case of tugging on the catheter tubing.

The facility reported a census of 41 residents. Based on interview and observation, the facility failed to appropriately label and store drugs for five residents; when two insulin medications lacked open dates for Resident (R ) 31 and 147; two eye drops lacked opened dates for R30 and R19; and two expired medications remained in the medication carts for R15 and R21. Findings included: - On 08/24/21 at 02:24 PM, inspection of the Certified Medication Aide (CMA) medication cart with CMA R revealed the following: One opened bottle of [MEDICATION(S)] nasal spray, with pharmacy labeled for Resident (R)15, with an expiration date of 05/15/20. One open bottle of [MEDICATION(S)] eye drops, with pharmacy labeled for R19, which lacked an opened date. One opened bottle of [MEDICATION(S)] eye drops, with pharmacy labeled for R30, which lacked an open date. Furthermore, on 08/24/21 at 04:58 PM, inspection of the west nurses' medication cart, with Licensed Nurse (LN) H, revealed the following: One open aspartamine insulin pen, ready for use, with pharmacy labeled for R147, which lacked an open date. LN H stated she opened it today and forgot to date it. One open [MEDICATION(S)] insulin pen, ready for use, with pharmacy labeled for R31, which lacked an open date. LN H verified the pen was undated and almost empty. One open bottle of ondanstron oral drops, ready for use, with pharmacy labeled for R21, expired on 05/25/21. On 08/24/21 at 02:30 PM, CMA R stated eye drops should be dated when they are opened. There should not be expired medications in the medication cart. On 08/24/21 at 05:05 PM, LN H stated she would expect to see open dates on the insulin pens and other medications like eye drops. She would not expect to find expired medications in the medication carts. On 08/26/21 02:05 PM, Administrative Nurse D stated she expects expired medications would be removed from the medication carts, and would expect eye drops, and insulin pens to be labeled with the date they are opened. A facility policy titled Storage of Medications F761, dated 05/2021, instructed the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. The policy lacked instruction regarding dating medications with open date. The facility failed to appropriately label and store drugs for these five residents.

The facility reported a census of 41 residents. The sample contained 12 residents. Based on interview and record review, the facility failed to review and revise the care plan for two sampled residents including, Resident (R)6, related to interventions following falls to prevent further accidents and R31, related to care and services for a urinary catheter to prevent urinary tract infections and/or urethral trauma. Findings included: - The signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change Minimum Data Set (MDS), dated [DATE], documented the resident as unable to complete the Brief Interview for Mental Status (BIMS). Staff assessed R6 with short and long-term memory problems. R6 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. A Falls Care Area Assessment, dated 06/09/21, documented R6 was at risk for falls. She was non-compliant with asking for assistance for standing and often attempted to stand without staff assistance. The staff reviewed and revised the plan of care to ensure proper interventions were in place to prevent falls. The fall care plan contained interventions including but not limited to the following: Dycem (thin non-slip material) in the recliner seat, dated 03/06/21. Moved bedside table closer so the resident could reach her drink, dated 03/14/21. Staff education on current care plan including the use of dycem in the resident's recliner, dated 03/15/21. This intervention planned on 03/06/21 was to be implemented 9 days prior to this fall. Provide 2 glasses of water for the resident while sitting in the day area, dated 04/17/21. The resident was to sit in the recliner next to the nurse's station, dated 05/05/21. When the resident sits in the recliner at the nurses' station, have distractions available for her. Magazines, snacks, pen, paper, dated 05/12/21. Staff to toilet the resident at 06:00 AM, dated 05/18/21. Staff to assisted the resident to the recliner, dated 07/14/21. Nurses notes revealed the resident experienced several falls, including the following, in which the staff failed to provide/ensure planned interventions remained in place to prevent further falls, or failed to plan and implement new interventions following falls to prevent further falls. 1.) A Nursing Note, dated 05/02/21, documented R6 had an unwitnessed fall. The staff found the resident seated on the floor near the toilet in a peer's room. R6 stated she needed to use the bathroom. A Fall Investigation, dated 05/02/21 at 02:00 PM, documented the resident needed to use the toilet, and the staff assisted the resident to the toilet. However, the staff failed to plan and implement an intervention to reduce her risk for additional falls when she need to go to the bathroom. 2.) A Nurses Note, dated 07/14/21, documented R6 had an unwitnessed fall from her wheelchair while attempting to transfer to a recliner. Staff assisted R6 to the recliner and her sock was adjusted. A Fall Investigation, dated 07/14/21 at 06:11 PM, documented the resident wanted to sit in a recliner. The wheelchair was uncomfortable and she tried to take the cushion out. Staff transferred R6 to the recliner. However, the staff failed to plan and implement an intervention to reduce her risk for additional falls when she wanted in the recliner. Observation, on 08/25/21 at 04:09 PM, revealed Certified Nursing Aide (CNA) Q assisted R6 to a recliner close to the nurses' station. However, the staff failed to ensure the recliner seat contained the planned intervention of the dycem and the staff also failed to provide any drinks to the resident as planned to prevent falls. Continued various observations over the next hour revealed the staff failed to provide the resident with any available drinks to prevent falls. On 08/25/21 at 02:02 PM, CNA P stated something new was supposed to be in the care plan after a resident fell . On 08/25/21 at 05:03 PM, Licensed Nurse I stated when a resident falls, nurses are expected to update the care plan with a new intervention to prevent further falls. On 08/26/21 at 04:26 PM, Administrative Nurse D stated she would expect after a resident fell that some different intervention to try to keep residents from falling again would be put in place after each fall. Having dycem in the seat of the recliner and having two drinks beside the resident when in the recliner were care planned interventions for this resident to prevent further falls. It was expected that the staff followed the care planned interventions to prevent falls. The facility failed to review and revise this resident's care plan to include interventions following falls to prevent further falls. - The signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS), dated [DATE], documented R31's Brief Interview for Mental Status (BIMS) score was 15, which indicated he was cognitively intact. He did not have a urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment documented the resident was always incontinent, and often declined to use a urinal or alert staff to need to use the toilet. The current care plan, dated 06/23/21, lacked instruction for caring for his catheter. A signed physician order, dated 07/12/21, instructed staff to change the resident's urinary catheter monthly and to change the bag weekly. On 08/26/21 at 02:05 PM, Administrative Nurse D stated R31's catheter was identified in the plan of care, but instructions to the staff related to how to care for the urinary catheter were not. A facility policy for updating the resident care plans was unavailable. The facility failed to update this resident's plan of care with care instructions to the staff for his urinary catheter.

The facility reported a census of 41 residents with 12 selected for review including two reviewed for falls. Based on observation, interview, and record review, the facility failed to follow interventions on the care plan for Resident (R)35 to prevent further falls and failed to follow interventions on the care plan for R6 and implement new interventions following falls to prevent further falls. Findings included: - The Order Summary Report, dated 07/16/21, for Resident (R)35 included diagnoses of muscle weakness, abnormalities of gait and mobility, unsteadiness on feet, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Annual Minimum Data Set (MDS), dated [DATE], assessed R35 with short and long term memory impairment and severely impaired decision making. She required extensive assistance of one staff for bed mobility, walking in and out of the room, locomotion on and off the unit, and toilet use. R35 required extensive assistance of two or more staff for transfers and her balance during transitions and walking was not steady and required staff assistance to stabilize. She used a wheelchair for mobility and had one non-injury fall since the last assessment. The Falls Care Area Assessment (CAA), dated 05/03/21, indicated R35 was at risk for falls and would not ask for assistance prior to ambulating, and would sometimes ambulate without proper footwear. The Quarterly MDS, dated [DATE], revealed no changes to the prior assessment except she did not walk in the corridor, she had two non-injury falls, and she had two falls with injury that were not major. The Care Plan, dated 08/24/21, included R35 was at risk for falls, was unaware of her safety needs, had confusion, comprehension was poor, she wandered, and had gait and balance problems. The interventions on the care plan included, but were not limited to, the following interventions: 1. A revised intervention, on 12/28/17, for gripper strips in the bathroom. 2. On 02/03/20, remove bedside table on wheels from my room, only take it into the room for short periods of time such as for meals in the room so R35 did not use it to regain balance. 3. On 06/30/21, Dycem (a thin nonslip material) in the wheelchair at all times. The Progress Notes, located in the EMR, revealed that R35 fell on these dates: 05/04/21, 05/15/21, 06/30/21, 07/13/21, 07/14/21, and 08/04/21. On 08/23/21 at 09:22 AM, R35 was laying on her bed with eyes closed and a table with wheels sat parked several feet from the foot of the bed with a foam cup and a hairbrush on top. On 08/23/21 at 03:10 PM, R35 exited her room walking while pushing her wheelchair and started down the hallway, Licensed Nurse (LN) G responded and provided assistance to walk with her for a short distance and then to sit in the wheelchair. On 08/24/21 at 02:23 PM, R35 was resting in bed with her eyes closed. The wheelchair sat parked next to the bed which lacked the planned Dycem in place. The bathroom lacked the planned gripper strips, and there was a table with wheels parked in front of the recliner in her room. On 08/25/21 at 08:35 AM, R35 was in her room in the wheelchair that was next to her bed. A table with wheels was in her room parked next to the wall just to the right of the doorway. On 08/25/21 at 10:23 AM, Certified Nurse Aide (CNA) M and CNA N transferred R35 from the wheelchair to her bed. The wheelchair lacked the planned Dycem in place in the seat. On 08/25/21 at 10:33 AM, CNA M stated that R35 was a fall risk and any new interventions would be communicated by the charge nurse, during other staff at shift change, and the electronic charting system. CNA M confirmed that at one point Dycem was to be in R35's wheelchair, the table with wheels should not be in her room as she will get up and use it as a way to walk and potentially fall because she will get up at times and walk around the room by herself. CNA M also believed that the gripper strips should be in the bathroom. On 08/25/21 at 01:20 PM, LN G stated that R35 was a fall risk and interventions included Dycem to her wheelchair, gripper strips in front of the toilet in the bathroom, and she should not have a wheeled table in her room as she has used as a walker before. Initially with a new intervention, staff monitored it to make sure the intervention was in place and collectively as a team the aides know, for example, who has Dycem in their chair, and if the interventions are not in place they should be fixed. The CNA's should be told in report who has had a fall and the interventions, and it is also made available on the communication board in the electronic charting that we print off for the nurse for that shift report. On 08/26/21 at 03:03 PM, Administrative Nurse D stated that interventions following a fall are placed on the care plan and would expect the staff to follow the care plan. The intervention regarding the table with wheels was one the family had built, and it was by the window with plants on it, we had it removed. Administrative Nurse D stated she did not feel the overbed table with wheels in her room was a safety issue because it would be more like a walker for her to use. The facility policy Falls and Fall Risk, Managing, dated 05/2021, instructed the staff will identify interventions related to a resident's specific risks and causes to try and prevent the resident from falling, and trying to minimize complications from falling. The interdisciplinary team will attempt to identify appropriate interventions to reduce the risk of falls. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (dizziness, weakness) has resolved. The facility failed to follow interventions on the care plan for R35 to reduce her risk of repeated falling. - The signed Physician Order Sheet (POS), dated 07/16/21, documented R6's diagnoses included anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and unspecified dementia (progressive mental disorder characterized by failing memory, confusion). A significant change Minimum Data Set (MDS), dated [DATE], documented the resident unable to complete Brief Interview for Mental Status (BIMS). Staff assessed R6 had short and long-term memory problems. R6 required extensive assistance with bed mobility, transfer, dressing, toileting, and personal hygiene. A Falls Care Area Assessment, dated 06/09/21, documented R6 was at risk for falls. She was non-compliant with asking for assistance with standing and often attempted to stand without staff assistance. The staff reviewed and revised the plan of care to ensure proper interventions were in place to prevent falls. The fall care plan contained interventions as follows: Resident likes to sit on the floor and at times gets out of bed to sit on the fall mat, dated 03/02/21. New call light in the room and toileted, dated 03/05/21. Dycem (thin non-slip material) in the recliner, dated 03/06/21. Assisted to wheelchair to propel self, dated 03/14/21. Moved bedside table closer so the resident could reach her drink, dated 03/14/21. Staff education on current care plan including the use of dycem in the resident's recliner, dated 03/15/21. Ensure restrooms near the front lobby are locked at all times, dated 03/20/21. Ensure that resident wears appropriate footwear tennis shoes or non-skid socks when ambulating or mobilizing in w/c, dated 04/08/21. Keep frequently used items next to resident, dated 04/14/21. Provide 2 glasses of water for resident while sitting in day area, dated 04/17/21. Resident to sit in recliner next to nurse's station, dated 05/05/21. Check orthostatic blood pressures for 72 hours, dated 05/12/21. When resident is sitting in recliner at nurses' station have distractions available for her. Magazines, snacks, pen, paper, dated 05/12/21. Toilet resident at 06:00 AM, dated 05/18/21. Assisted resident to recliner, dated 07/14/21. Offer snack in bed if agitated, dated 07/20/21. Do not leave resident unattended in bathroom. Resident has a tendency to attempt self-transfers and not alert staff for need to toilet or wait for staff assistance, dated 08/05/21. Resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide fails as ordered, handrails on walls, personal items within reach, dated 08/05/21. A Nursing Note, dated 03/15/21 at 06:49 PM, documented R6 scooted her bottom to the foot of the recliner, then onto the floor. Intervention identified to place dycum in the recliner per care plan. Staff educated on the current plan of care. A Fall Investigation, dated 03/15/21, documented R6 sat on the footrest of the recliner and slid down. On 08/26/21 at 04:30 PM, Administrative Nurse D verified staff were not following the care plan, failing to put dycem in the recliner, and she reeducated staff regarding the plan of care. A Nursing Note, dated 05/02/21 documented R6 had an unwitnessed fall. Resident sat near the toilet in a peer's room. R6 stated she needed to use the bathroom. A Fall Investigation, dated 05/02/21 at 02:00 PM, documented the resident needed to use the toilet, and the staff assisted the resident to the toilet. However, the staff failed to plan and implement an intervention to reduce her risk for additional falls. A Nurses Note, dated 07/14/21, documented R6 had an unwitnessed fall from her wheelchair while attempting to transfer to a recliner. Staff assisted R6 to the recliner and her sock was adjusted. A Fall Investigation, dated 07/14/21 at 06:11 PM, documented the resident wanted to sit in a recliner. The wheelchair was uncomfortable and she tried to take the cushion out. Staff transferred R6 to the recliner. Staff failed to plan and implement an intervention to reduce her risk for additional falls. On 08/24/21 at 02:20 PM, R6 perused a magazine while seated in a recliner close to the nurses' station. No dycem was in the recliner, and she had no drinks available. On 08/25/21 at 04:09 PM, Certified Nursing Assistant (CNA) Q assisted R6 to a recliner close to the nurses' station. No dycem was in the recliner seat, and staff failed to provide any drinks to the resident. Continued various observations over the next hour revealed the resident lacked any available drinks. On 08/25/21 at 11:12 AM, CNA P stated when R6 was in the recliner, someone was there to keep an eye on her. In the afternoon she was awake and so we give her magazines to keep her occupied. We generally just give her magazines unless she asks for something else. On 08/25/21 at 03:53 PM, CNA Q stated we have to keep her so we supervise her as we walk by. We have to check on her. At night, she gets more active, so then she is in the recliner. She gets magazines to keep her occupied. On 08/25/21 at 05:16 PM, Licensed Nurse I stated R6 is very impulsive and sundowns (condition where a person tends to become confused or disoriented toward the end of the day) badly in the evening, and voices delusions. Sometimes she thinks that her son is coming to get her, or that her car is outside. She becomes angry and threatens things such as her intent to throw her wheelchair out the window. She is happy and pleasant during the day, but very angry in the evenings. We keep an eye on her when she is in her wheelchair and give her snacks and whatever she asks for. On 08/26/21 at 04:26 PM, Administrative Nurse D stated she would expect some different intervention to try to keep residents from falling again be put in place after each fall. Having dycem in the seat of the recliner and having two drinks beside the resident when in the recliner are care planned interventions in place for this resident to prevent falls. It is expected that care planned interventions to prevent falls are followed by the staff. A facility policy titled Falls and Fall Risk, Managing F689, dated 05/21, instructed the Interdisciplinary Team (IDT) will attempt to identify appropriate interventions to reduce risk of falls . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. The IDT will identify and implement relevant interventions. The facility failed to reduce risk for falling by failing to implement care planned interventions of providing dycem and drinks when in the recliner and failed to identify and implement new interventions for two falls in this resident.

The facility reported a census of 41 residents. The sample contained 12 residents, with one selected for review of urinary catheters. Based on observation, interview and record review, the facility failed to appropriately manage the catheter of one of one resident, to prevent urinary tract infections and or urethral trauma to Resident (R) 31. Findings included: - The signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS), dated [DATE], documented R31's Brief Interview for Mental Status (BIMS) score was 15, which indicated he was cognitively intact. He did not have a urinary catheter. The Urinary Incontinence and Indwelling Catheter Care Area Assessment documented resident was always incontinent, and often declined to use a urinal or alert staff to need to use the toilet. The current care plan, dated 06/23/21 lacked instruction for caring for his catheter. A signed physician order, dated 07/12/21, instructed staff to change the catheter monthly and change the bag weekly. On 08/23/21 at 09:37 AM, R31's tubing touched directly on the ground, approximately 5 inches, as he sat in his wheelchair in the dining room. On 08/23/21 at12:04 PM, R31 sat in his room in his wheelchair. He did not have an anchor to secure his catheter and approximately five inches of the catheter tubing touched directly on the floor. On 08/23/21 at 01:51 PM, approximately five inches of R31's catheter tubing dragged along the floor as he propelled himself in his wheelchair. On 08/23/21 at 02:27 PM, R31 used a pedal exerciser in his room. Approximately five inches of the catheter tubing raised and lowered and scraped directly across on the floor with each pedal rotation. On 08/25/21 at 07:33 AM, R31's Licensed Nurse (LN) I verified R31's catheter was unanchored and unsecured. On 08/25/21 at 08:10 AM, Certified Nursing Assistant (CNA) O and CNA P used a full lift to transfer R31 from his bed to his wheelchair. During transport, the foley bag remained suspended from a loop on the sling, causing the foley bag to hang at the level of the resident's neck and above the bladder, throughout the transfer. On 08/25/21 at 08:15 AM, CNA O stated the catheter urine collection bag should remain lower than R31's bladder and verified that they failed to do so during the transfer. His catheter should be anchored and the tubing should remain off the floor. 08/25/21 at 09:10 AM, LN I stated catheter tubing should be off of the floor at all times, and the urine collection bag should remain below the level of his bladder. The catheter should remain anchored to prevent any urethral trauma. On 08/26/21 at 02:05 PM, Administrative Nurse D stated she expected R31's catheter tubing to remain off of the floor, and the urine collection bag kept below the level of the resident's bladder. Catheter tubing should be anchored to secure it from causing urethral trauma. A facility policy titled Indwelling Urinary Catheters F690, dated 05/2021, instructed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bad from flowing back into the urinary bladder .be sure the catheter tubing and drainage bag are kept off the floor. Ensure that the catheter remains secured with a leg strap to reduce friction and movement. The facility failed to appropriately manage the urinary catheter to prevent urinary tract infections and or urethral trauma to this resident.

The facility reported a census of 32 residents with 14 selected for review, which included 2 residents reviewed for nutrition. Based on observation, record review and interview, the facility failed to implement recommendations from the registered dietician for weight loss of one of 2 (#34) resident's reviewed for nutrition. Findings included; - Resident #34 admitted to the facility on [DATE], with the following [DIAGNOSES REDACTED]. The admission MDS 3.0 (minimum data set) with a date of 12/20/11, revealed the resident had a BIMS (brief interview of mental status) score of 3 indicating severely impaired cognition. The resident without behaviors. Required supervision for eating. Shortness of breath on exertion and a fever. The resident without a swallowing problem, and no oral problems. The resident weighed 158 pounds. No weight loss noted. The 90 day MDS 3.0 (minimum data set) with a date of 3/13/12, revealed the resident had a BIMS score of 2 indicating severely impaired cognition. The resident with no rejection of care, wandering daily, and physical behavior 1-3 days. The resident required extensive staff assistance of 1 for eating. The resident with shortness of breath on exertion, sitting, at rest, and lying flat, along with a fever. Documented with coughing or choking during meals or swallowing medication. The resident weighed 137 pounds and marked weight loss. No nutrition approach noted. The CAAS (care area assessment) summary, dated 12/20/11, documented for nutrition; the resident is at risk for pressure ulcers and impaired skin integrity. The resident cognition CAAS, documented the resident has memory recall problems and a [DIAGNOSES REDACTED]. The resident's care plan, dated 12/26/11, for nutrition included consume meals in assisted dining room, assist me as needed. Offer me hydration cart and snack when available. I like chocolate. Weigh me monthly, and as ordered. Notify me and my family, and PCP ( primary care physician) for significant changes in my weight. On 12/28/11, encourage and assist me to drink 2000 cc (cubic centimeters) of fluids per day. On 12/28/11, obtain dietary and pharmacy consult every 2 months. On 1/10/12, I am on a regular pureed food, nectar thickened liquids. The resident's care plan updated, 1/13/12, has had weight loss, weigh weekly, Med Pass 90 cc TID (three times daily). The resident's weight on admission, 12/14/11, 158 pounds per the facility weight variance report. The report further documented: On 1/2/12, 145 pounds per the facility weight variance report, a loss of 13 pounds/8.23% (percent) in less than 30 days. The clinical record lacked weekly weights documented from 1/14/12 through 2/1/12 as planned. On 2/1/12, 145 pounds per the facility weight variance report. On 2/7/12, 142 pounds per the facility weight variance report. On 2/8/12, 142 pounds per the facility weight variance report. On 2/15/12, 141 pounds per the facility weight variance report. On 2/21/12, 140 pounds per the facility weight variance report. On 2/22/12, 140 pounds per facility weight variance report. On 3/5/12, 137 pounds, per the facility weight variance report, a loss of 21 pounds/13.29% in less than 3 months. On 4/3/12, 132 pounds per the facility weight variance report. On 4/11/12, 134 pounds per the facility weight variance report. On 4/18/12, 134 pounds, per the facility weight variance report, the resident with a 13 pound/8.5% weight loss in less than 30 days. On 4/25/12, 134 pounds, per the April 2012, MAR (medication administration record). The resident's weight on 5/2/12, 135 pounds, per the May 2012 MAR. The resident experienced a total weight loss of 23 pounds/14.5% in less than 5 months. The clinical record documented the physician notified of the initial loss of 13 pounds, ordered lab, dated 1/3/12,which documented the resident with a hemoglobin of 12.2, low, normal range is 14-17; the hematocrit is 39, low, the normal range is 42-52. The residents [MEDICATION NAME] level is 3.0, low, normal range is 3.6 to 5.1, with no new orders received from the physician. A nutritional assessment, dated 1/10/12, documented the resident on a regular diet; height of 67 inches, weight is 145 pounds. The resident's IBW (ideal body weight) is 133-163 pounds, he/she is at goal body weight. The resident has a BMI (body mass index) of 22.7 ( within normal acceptable limits). The resident required daily cleaning of dentures, with a chewing and swallowing or nutritional problems. The resident required 1800-2220 cal (calories), 72-89 grams of protein and 1800-2220 cc (cubic centimeters) fluids in a 24 hour day. The resident with a 3 to 5% weight change in 30 days. The residents' meal intake meets 26-75% of estimated needs, and consumes 1,500-2,00 cc day. Is taking 5 or more medications daily. The resident with [DIAGNOSES REDACTED]. Required assist with eating, [MEDICATION NAME] 3.0-3.4, hemoglobin and hematocrit low on 1/3/12 and the skin is intact. The nutritional risk indicator evaluation the resident scored a 13, (8 or more points-High Risk). No referrals necessary. The plan of care for the resident; admitted on regular diet, [DIAGNOSES REDACTED]. ST (speech therapy) consult today. Will await recommendation for appropriate diet. The resident t assisted with eating and appetite reported good recently. Weight is down 8.5% in 19 days. Recommend a 3 day weight check to ensure accuracy. Currently weighed is 145 pounds, ideal body weight for age and height is 133-163 pounds. The residents [MEDICATION NAME] lab low at 3.0 on 1/3/12. Recommend additional protein by adding an extra egg at breakfast and/or 1 oz extra meat at lunch and dinner. On 3/16/12 dietary progress notes, documented the following; the resident continues on a pureed diet with nectar thickened liquids and MedPass 90 cc by mouth TID. Weight is down 3.8% in 33 days to 137 pounds. Ideal body weight for height and age is 133-163#. Appetite is reported as varied. Recommend 1. Preferred snack list from resident/family and add these foods between meals. 2 Add 4-6 oz (ounces), OJ (orange juice), or Vitamin C fortified juice BID (twice daily). Continue to encourage intake. On 5/1/12 at 8:11 A. M, dietary staff U reported, "The recommendations given to the DON (director of nursing), and he/she will then follow up. Staff stated," the recommendation for the extra protein (egg and extra meat), dated 1/10/14, had not been acted upon nor had the recommendations on 3/16/12, for additional snack between meals and orange juice. The snack cart goes out only in the evenings for the HS (bedtime) snack. I have crackers, fruit, cakes, donuts. We don't send out anything special for a pureed diet. The resident is on the special nutritional program, (super cereal), whole milk and the med pass. Anymore it is just automatic to start a resident on special nutrition program. I believe his/her meal consumption went down. If a see the resident in the dining room between meals, I offer a snack make a slurry out of graham crackers and vanilla wafers or something. Weight meetings are weekly, the MDS coordinator is over them." On 5/1/12 at 1:55 P. M., administrative nursing staff B reported, " If the dietician has recommendations, it needs to go through the dietary manager first. If it is food then she can provide it, if it is medication then I will get it. I don't know why the resident did not receive the recommendations." The clinical record lacked documentation facility staff initiated the dietary recommendations. On 4/30/12 at 9:00 A. M., certified nursing staff M, " Reported the resident feeds himself, we have to encourage him/her to continue feeding self. The resident usually eats good, he/she likes to eat chocolate. The resident offered snacks, and walks all the time." On 4/30/12 at 9:00 A. M., licensed nursing staff 0 reported, "The resident needs encouragement and does feed self, and receives med pass. The family brings chocolate, he/she loves chocolate. On 4/30/12 at 12:04 P. M., the resident's lunch tray of pureed spaghetti, creamed corn, jello cake. The resident also with 120 cc of nectar thickened milk, and 240 cc of thickened water, and a cup of coffee, thickened by the nurse. The resident ate all but the spaghetti, and ate all of the cream corn. The resident requested another bowl of cream corn. The resident ate the 2nd bowl of cream corn. Certified nursing staff , sitting at the table offering encouragement to the resident to complete the meal. On 4/30/12 at 12:19 P. M., the resident given 90 cc of med pass to drink at the dining room table during lunch, by certified nursing staff G. Certified nursing staff G, returned 2 times to encourage the resident to complete the med pass. On 4/30/12 at 12:30 P. M., the resident ate 2 servings of creamed corn and 1 serving of the jello cake and a few bites of the spaghetti, drank all of the med pass. On 4/30/12 at 3:15 P. M., certified nursing staff N reported, " The resident eats in the assisted dining room. He/She needs reminders to eat at times. We give snacks in the evenings likes cookies and sandwiches." On 5/1/12 at 8:00 A. M., the resident feeding self breakfast in the assisted dining room, ate 100% of the pureed diet, certified nursing staff P, encouraging the resident to eat. The resident drank all of his/her fluids including the med pass and milk. On 5/1/12 at 2:00 P.M., administrative nursing staff C reported, "The resident's weight dropped because he/she was sick when first came here with the flu, then he/she fought 2 upper respiratory infections. The resident is doing better now. I don't know why the recommendations did not get started. We offer snacks, like a slurry with graham crackers or cookies, his/her family brings in chocolate." The resident's meal intake for December 2011, documented the resident's meal intake of 25-65%. The January 2012 meal intake, documented the resident ate 20-75% of meals. The resident ate 50-75% from 1/20/12 through 2/19/12. The resident ate 50-75% of meal from 2/19/12 through 3/1/12. The March 2012 meal intake percentage for the resident is 60-100 % of diet. The April 2012 meal intake percentage for the resident is 60-90% of diet. On 5/3/12 at 11:00 A. M., administrative nursing staff B reported, " We do not have a policy relating to a resident who eats less than 75% of a meal. We do not routinely supplement if the resident eats less than 75% of their meal." The facility policy for Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol, revised October 2010, documented the following; " Assessment and Recognition ....3.) The threshold for significant unplanned and undesired weight loss will be based on the following criteria... a. 1 month -5% weight loss is significant; greater than 5% is severe. 3 months-7.5% weight loss is significant; greater than 7.5% is severe. 6 months-10% weight loss is significant; greater than 10% is severe. Cause Identification ....1.) The physician will review possible causes of anorexia or weight loss with the nursing staff and/or Dietitian before ordering interventions. Treatment/Management....2.) The physician will authorize and the staff will implement appropriate general or cause specific interventions, as indicated, with careful consideration of the following;...b.) Nutritional needs: The dietitian will help the physician determine the appropriate diet for the resident based on the resident's degree of nutritional impairment, expressed wishes, and underlying causes and conditions. If the resident's nutritional or caloric needs have changed, but the diet has not, this may help to clarify the appropriate interventions." The facility failed to follow recommendations of the dietician on 1/10/12, to increase protein after the facility identified the resident with an 8.5% significant weight loss from 12/14/11 to 1/2/12, failed to follow recommendations of the dietician on 3/16/12 to supply a preferred snack between meals, and failed to have a system in place to supplement the resident's meal intake when the resident consumed less than 75% of the meal served. The resident experienced a 23 pound/14.5% weight loss in less than 5 months, including significant weight loss of 21 pounds/13.29% in less than 3 months.

The facility reported a census of 39 residents, with 2 residents selected for review of pressure ulcers. Based on observation, interview, and record review, the facility failed to provide and implement interventions, for one of two residents, (#28), at risk for pressure ulcers, and failed to provide staff assistance to reposition the dependent resident timely. Findings included: - The facility readmitted resident #28, on 1/10/11. The medical record contained [DIAGNOSES REDACTED]. The 11/12/10, quarterly MDS (minimum data set), recorded the resident's cognition as impaired, short and long term memory problems. The assessment listed activities of daily living (ADL's) assistance, as extensive assist of two persons, for bed mobility, repositioning, toileting, transfers, and moving from one position to another. The assessment further identified the resident at risk for pressure ulcers, and required a pressure reducing device for bed, and a turning and repositioning program, The 9/24/10, care plan recorded, "Has pressure reducing mattress on bed. May use pillows for positioning when in bed. Assist with turning and repositioning every two hours and as needed. Provide incontinence care after each incontinent episode. Report any signs of skin breakdown sore, tender, red, or broken areas. Skin monitored routinely." The 11/2/10, care plan included, "Minimize skin exposure to moisture. Check and change every 2 to 3 hours at bedtime and as needed. Toilet as resident is able." The 12/2/10, care plan included, "Recurring area on buttocks." The 1/10/11, pressure ulcer risk assessment form documented a score of 17, with a score of 15-18, as at high risk for skin breakdown. On 2/8/11, at 10:45 am, observation revealed two open area's on the resident's buttocks. The resident's left buttocks, revealed an area approximately 0.6 cm, (centimeters), x 0.5 cm. in diameter, and a depth of approximately 0.2 cm. and bright red color. The resident's right buttock revealed an area approximately 3.4 cm. x 3 cm. in diameter, and a depth of approximately 0.2 cm. as well as bright red color. Licensed staff C failed to stage the wound. On 2/9/11, at 1:00, 2:00 pm, 2:30 pm, 3:00 pm, 3:30 pm, 3:45 pm, and 4:00 pm, the resident's position remained unchanged for a period of three hours, while in bed. At 4:01 pm, certified nursing staff H and I, provided incontinence care. Observation revealed fecal matter up under the [MEDICATION NAME] dressing. The direct care staff then removed the [MEDICATION NAME] dressing, which revealed the wound open and bleeding. On 2/10/11, at 7:00, through 9:15 am, observation revealed the resident positioned in the bed on his/her back, without a position change, for a period of two hours and 15 minutes. During incontinence care, at 9:15 am, observation revealed, the [MEDICATION NAME] dressing loose at the bottom edge, white over 85% of the surface,with fecal matter on and under the dressing material. Staff F and J, washed the loosened [MEDICATION NAME] section just like they washed the resident's skin, with disposable washcloths and tapwater. After providing care, staff positioned the resident into the recliner, without offloading devices or pillows. On 2/10/11, from 9:15 am, at 10:15 am, 10:45 am, 11:15 am, 11:30 am, until 11:45 am, observations revealed the resident continued to sit in the recliner, without any position changes, for a period of two hours and 30 minutes. The staff then positioned the resident into a wheelchair, without any offloading devices. On 2/10/11, at 12:15 pm, observation revealed, direct care staff F and L, positioned the resident onto the bed, tilted towards the left side, and used a long body pillow, at the resident's neck, back, and legs, to ensure the resident remained in the tilted position. At 1:40 pm, 2:15 pm, 2:45 pm, and 3:30 pm, observation revealed the resident's position remained unchanged, for a period of 3 hours and 15 minutes. On 2/9/11 at 3:52 pm, certified nursing assistant H stated, "No I haven't moved him yet this afternoon." On 2/10/11, at 11:45 am, and again at 2:05 pm, direct care staff F stated, "I just got him/her up for lunch. I haven't done anything else since we got him/her cleaned up earlier this morning." On 2/10/11, at 3:04 pm, the resident's spouse stated, "They called me the other day to tell me about his/her sore on his/her bottom. He/She didn't have that, and now he/she does, so I wish they could have prevented it, but he/she has had them before, so maybe they can't control it." On 2/10/11, at 3:05 pm, direct care staff N, stated, "No I haven't turned him/her since this morning. I have to get help to do him/her now, since he/she has a sore." On 2/10/11, at 3:40 pm, direct care staff O, stated, "We just now turned him/her to his/her right side. I haven't turned him/her, before now." On 2/10/11, at 3:45 pm, direct care staff P, stated, "I haven't turned him/her." On 2/10/11, at 3:55 pm, licensed staff M, stated, "No the aides didn't tell me about anything new with the dressing or any problems with the dressing." On 2/14/11, at 10:20 am, direct care staff F,stated, "I know for sure the one on his/her left side was there when he/she came back from the hospital. The other one I am not so sure about." Measurements reported on 2/15/11, revealed right buttocks measurement of 3.0 cm. x 3.0 cm. and the left buttock measurement of 1.0 cm x 0.9 cm. Licensed staff E stated, "I changed the dressing today. It is more crusty than it was on Friday. It is hard to tell, on the depth. It was bleeding when we cleaned it and changed the dressing." Staff failed to stage the wound on this date. The facility's 2001 policy for the prevention of pressure ulcers recorded, "Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time, causing increased pressure or a decrease of circulation to that area and subsequent destruction of tissue. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin, ie..perspiration, feces, urine,... decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and or mental condition. Change position at least every two hours or more frequently if needed...Raise the head of the bed as little and for as short a time as possible,...When repositioning, reduce friction and shear by lifting, using appropriate lifting technique and equipment, rather than dragging....Chair fast...change position at least every 1 hour...change position at least every hour and use foam, gel or air cushion as indicated to relieve pressure..." The facility failed to provide care and treatment as planned, including timely dressing changes, timely repositioning, and assessment to prevent the development of a pressure sore, to this dependent resident, identified at risk for pressure ulcers.