Every finding on record at Choctaw Residential Center

Based on observation, interview, record review, and facility policy review the facility failed to protect residents from abuse for two (2) of (2) residents reviewed for abuse (Resident # 1 and Resident # 3). Specifically, the facility failed to prevent resident-to-resident inappropriate sexual contact, when (2) incidents occurred when one resident touched another resident inappropriately.Findings include:Record review of the facility policy Resident Rights revised 3/24, revealed, .shall insure each resident of the following.J. THE RIGHT to be free from mental and physical abuses. Each resident has the right to a safe, secure, and homelike environment .The facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. Resident #2 and Resident #3On 03/18/2026 at 10:15 AM, during an interview with Resident #3, the resident reported that she was involved in an incident with Resident #2 on 03/06/2026 in the front lobby area. Resident #3 stated that Resident #2 approached her and touched her leg without her consent. She reported that she informed staff of the incident shortly after it occurred. Resident #3 stated that a nurse spoke with her one time regarding the incident. She indicated that the nurse asked what happened, but there was no further follow up discussion or additional inquiries from other staff members after that initial conversation. Resident #3 reported that she did not receive any updates regarding the outcome of the investigation. Resident #3 stated that she has not seen Resident #2 recently and was informed that he is no longer in the building at the time of the survey. However, she reported that she observed Resident #2's name still listed on the room across from hers, which caused her concern. Resident #3 stated that due to the incident, she plans to avoid Resident #2 if he returns. She reported that she intends to stay in her room or avoid common areas when he is present to prevent further confrontation. On 3/19/26 at 10:36 AM, the Director of Nursing (DON) revealed that, upon review of the incident involving Resident #2 and Resident #3 on 03/06/2026, he was informed that Resident #2 approached Resident #3 in the front lobby and touched her leg without consent. The DON stated the investigation confirmed the allegation through staff interviews and resident statements, and actions taken included assessment of the resident with no noted injuries, implementation of one-to-one observation, and referral to geriatric psychiatric services for further evaluation and management of behaviors.Record review of the facility investigation report dated 03/06/2026, Resident #2 approached Resident #3 while both were seated in the front lobby and touched her leg without consent. Resident #3 reported the incident to staff and stated, I told him to quit and he did leave me alone. Staff assessed Resident #3 and noted no physical injuries.Resident #2 Record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included borderline intellectual functioning. Record review of Resident # 2's Brief Interview for Mental Status (BIMS) Summary Score dated 2/27/26 revealed a BIMS score of 07 indicating the resident had severe cognitive impairment.Record review of Resident #2's nurse's note dated 04/03/2026, late entry at 2250 (10: 50 PM), revealed a female resident reported to the nurse that Resident #2 inappropriately touched her twice on her leg and between her thighs. The nurse documented that the residents were separated, and Resident #2 was escorted to his room and placed on one-to-one supervision. The DON and responsible parties were notified.Resident # 3Record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included cognitive communication deficit. Record review of Resident # 3's Health Status Note dated 3/6/26 revealed no documentation of the inappropriate touching.Resident #1 and Resident #4On 3/19/26 at approximately 10:30 AM, during an interview with Resident #1, the resident reported that an incident occurred in the hallway in front of the nurse's station in which Resident # 4 touched her breasts without her consent. Resident #1 stated that the contact was inappropriate and unwanted. Resident #1 reported that immediately following the incident, she notified a Certified Nurse Aide (CNA) and informed the CNA that the resident had touched her inappropriately on her breast. She stated that she clearly described what occurred at the time of her report. Resident #1 was able to identify Resident #4 by name who had touched her breast.On 03/19/2026 at 10:36 AM, in an interview the DON, revealed that he was notified of the incident involving Resident #4 and Resident #1 on 01/13/2026 at approximately 7:50 PM. The DON stated that initial reports indicated inappropriate touching in the hallway and that immediate actions included separating the residents and assessing the alleged victim for injury. The DON reported that upon review of facility camera footage, it was confirmed that Resident #4 touched Resident #1's breast while passing her in the hallway. The DON revealed that the facility's investigation determined staff responded promptly to the allegation by separating the residents, assessing Resident #1 with no injuries noted, and placing Resident #4 on one-to-one observation. The DON stated that a referral was made for geriatric psychiatric evaluation and that the resident was transferred for further treatment related to inappropriate behaviors. The DON further reported that notifications were made to the physician, responsible party, and state agency per facility protocol. Record review of a second facility investigation dated 01/13/2026, Resident #4 was reported to have touched Resident #1 on the breast in the hallway. Resident #1 confirmed the contact and stated she told him to go away. Review of facility camera footage confirmed that Resident #4 touched Resident #1's breast while passing her in the hallway.Resident # 1 Record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included vascular dementia. Record review of Resident #1's BIMS Evaluation dated 01/19/2026 revealed a score 8 indicating the resident had moderate cognitive impairment.Record review of Resident #1's Health Status Note dated 1/13/2026 at 10:05 PM, revealed Resident #1 reported to the CNA that Resident # 4 was inappropriate with her touching her boobs in the hallway in front of the nurses station.Resident # 4 Record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included cognitive communication deficit. Record review of a BIMS Evaluation dated 7/9/25 revealed Resident #4's BIMS Summary Score was 13 indicating the resident was cognitively intact.Record review of Resident # 4's Health Status Note dated 12/23/2025 at 1:50 PM, revealed Resident was noted to be touching another resident inappropriately at nurses desk. When redirected he just looked at the nurse and kept rolling in w/c (wheelchair). DON and Assistant Director of Nursing (ADON) notified.Record review of Resident #4's Health Status Note dated 1/14/2026 at 4 PM, revealed Resident#4 left the facility to a local psychiatric facility for treatment for behavioral issues.On 03/19/2026 at 10:20 AM, during an interview the Licensed Nursing Home Administrator (LNHA) stated that, as part of the facility's investigation, statements were obtained from staff and residents, and available video footage was reviewed when applicable. She stated the investigation determined that inappropriate contact had occurred between residents and confirmed that staff did respond once the incident was reported. She further stated that the alleged residents were placed on increased supervision, including one-to-one monitoring, and referred for further evaluation to address behavioral concerns. She stated that notifications were made in accordance with facility protocol, including notifying the physician, responsible parties, and appropriate agencies. She noted that from an administrative standpoint, the facility attempted to follow its abuse and investigation procedures and took steps to prevent immediate recurrence. However, the LNHA acknowledged that while the facility responded to the incident, there were areas where the response could have been improved for the affected resident(s). She stated that the facility should have implemented more consistent and ongoing follow-up with the affected residents(s), including routine check-ins to assess fear, anxiety, or other psychosocial effects following the incident. She further stated that the investigation identified a need for stronger communication with the affected residents regarding the protective measures that were put in place, to ensure they felt safe and reassured after the incident. She acknowledged that clearer and more consistent documentation and communication with the interdisciplinary team regarding follow-ups would have supported better monitoring of the resident's well-being. The LNHA stated that services to the affected resident(s) could have been improved by providing more consistent emotional support, more structured and timelier follow-up, and ongoing evaluation of the resident's sense of safety. She stated that while the facility acted, additional measures would have better ensured the residents' rights were fully upheld and that they were protected from potential psychosocial harm.On 03/19/2026 at 10:58 AM, in an interview with the Social Worker, she stated that she was aware of the incident involving the resident(s) #1, #2, #3 and #4 and acknowledged that the affected residents should have received more focused follow-up and supportive services after the allegation was made. She stated that, in accordance with the facility's Resident Rights Policy, residents have the right to feel safe, to be free from abuse, and to have their concerns acknowledged and addressed. She stated that once the allegation was reported, the facility should have ensured the immediate emotional and psychological needs of the resident(s) were assessed, including speaking with them privately, validating their concerns, and ensuring they felt heard.Record review revealed that in both incidents, the residents were in common areas without effective supervision at the time of the events. Although staff responded after the incidents occurred, the facility failed to implement sufficient interventions to prevent inappropriate resident-to-resident contact prior to the incidents.

Based on interview, record review, and facility policy review the facility failed to ensure residents received the necessary behavioral health care and services, specifically, the facility failed to proactively assess and implement effective behavioral interventions to address inappropriate sexual behaviors for two (2) of five (5) sampled residents reviewed for behavioral concerns. Resident #1 and Resident #3.Findings include:Record review of the facility policy Resident Rights revised 3/24, revealed, .shall insure each resident of the following.J. THE RIGHT to be free from mental and physical abuses. Each resident has the right to a safe, secure, and homelike environment .The facility is responsible for implementing interventions to prevent resident-to-resident altercations and to ensure supervision sufficient to protect residents from harm. Record review of the facility's Behavioral Health Services policy revealed, It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being Resident #2 and Resident #3During an interview on 03/18/2026 at 10:15 AM, with Resident #3, the resident reported that she was involved in an incident with Resident #2 on 03/06/2026 in the front lobby area. Resident #3 stated that Resident #2 approached her and touched her leg without her consent. She reported that she informed staff of the incident shortly after it occurred. Resident #3 stated that a nurse spoke with her one time regarding the incident. She indicated that the nurse asked what happened, but there was no further follow up discussion or additional inquiries from other staff members after that initial conversation. Resident #3 reported that she did not receive any updates regarding the outcome of the investigation. Resident #3 stated that she has not seen Resident #2 recently and was informed that he is no longer in the building at the time of the survey. However, she reported that she observed Resident #2's name still listed on the room across from hers, which caused her concern. Resident #3 stated that due to the incident, she plans to avoid Resident #2 if he returns. She reported that she intends to stay in her room or avoid common areas when he is present to prevent further confrontation. In an interview on 3/19/26 at 10:36 AM, the Director of Nursing (DON) revealed that, upon review of the incident involving Resident #2 and Resident #3 on 03/06/2026, he was informed that Resident #2 approached Resident #3 in the front lobby and touched her leg without consent. The DON stated the investigation confirmed the allegation through staff interviews and resident statements, and actions taken included assessment of the resident with no noted injuries, implementation of one-to-one observation, and referral to geriatric psychiatric services for further evaluation and management of behaviors.Record review of the facility investigation report dated 03/06/2026, Resident #2 approached Resident #3 while both were seated in the front lobby and touched her leg without consent. Resident #3 reported the incident to staff and stated, I told him to quit and he did leave me alone. Staff assessed Resident #3 and noted no physical injuries.Resident #2 Record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included borderline intellectual functioning. Record review of Resident # 2's Brief Interview for Mental Status (BIMS) Summary Score dated2/27/26 revealed a BIMS score of 07 indicating the resident had severe cognitive impairment.Record review of Resident #2's nurse's note dated 04/03/2026, late entry at 2250 (10:50 PM), revealed a female resident reported to the nurse that Resident #2 inappropriately touched her twice on her leg and between her thighs. The nurse documented that the residents were separated, and Resident #2 was escorted to his room and placed on one-to-one supervision. The DON and responsible parties were notified.Resident # 3Record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included cognitive communication deficit. Record review of Resident # 3's Health Status Note dated 3/6/26 revealed no documentation of the inappropriate touching.Resident #1 and Resident #4During an interview on 3/19/26 at 10:30 AM, with Resident #1, the resident reported that an incident occurred in the hallway in front of the nurse's station in which Resident # 4 touched her breasts without her consent. Resident #1 stated that the contact was inappropriate and unwanted. Resident #1 reported that immediately following the incident, she notified a Certified Nurse Aide (CNA) and informed the CNA that the resident had touched her inappropriately on her breast. She stated that she clearly described what occurred at the time of her report. Resident #1 was able to identify Resident #4 by name who had touched her breast. In an interview on 03/19/2026 at 10:36 AM, the DON, revealed that he was notified of the incident involving Resident #4 and Resident #1 on 01/13/2026 at approximately 7:50 PM. The DON stated that initial reports indicated inappropriate touching in the hallway and that immediate actions included separating the residents and assessing the alleged victim for injury. The DON reported that upon review of facility camera footage, it was confirmed that Resident #4 touched Resident #1's breast while passing her in the hallway. The DON revealed that the facility's investigation determined staff responded promptly to the allegation by separating the residents, assessing Resident #1 with no injuries noted, and placing Resident #4 on one-to-one observation. The DON stated that a referral was made for geriatric psychiatric evaluation and that the resident was transferred for further treatment related to inappropriate behaviors. The DON further reported that notifications were made to the physician, responsible party, and state agency per facility protocol. Record review of a second facility investigation dated 01/13/2026, Resident #4 was reported to have touched Resident #1 on the breast in the hallway. Resident #1 confirmed the contact and stated she told him to go away. Review of facility camera footage confirmed that Resident #4 touched Resident #1's breast while passing her in the hallway.Resident # 1 Record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included vascular dementia. Record review of Resident #1's BIMS Evaluation dated 01/19/2026 revealed a score 8 indicating the resident had moderate cognitive impairment.Record review of Resident #1's Health Status Note dated 1/13/2026 at 10:05 PM, revealed Resident #1 reported to the CNA that Resident # 4 was inappropriate with her touching her boobs in the hallway in front of the nurses station.Resident # 4 Record review of the admission Record revealed the resident was admitted on [DATE] with diagnoses that included cognitive communication deficit. Record review of a BIMS Evaluation dated 7/9/25 revealed Resident #4's BIMS Summary Score was 13 indicating the resident was cognitively intact.Record review of Resident # 4's Health Status Note dated 12/23/2025 at 1:50 PM, revealed Resident was noted to be touching another resident inappropriately at nurses desk. When redirected he just looked at the nurse and kept rolling in w/c (wheelchair). DON and Assistant Director of Nursing (ADON) notified.Record review of Resident #4's Health Status Note dated 1/14/2026 at 4 PM, revealed Resident#4 left the facility to a local psychiatric facility for treatment for behavioral issues.During an interview on 03/19/2026 at 10:20 AM, the Licensed Nursing Home Administrator (LNHA) stated that, as part of the facility's investigation, statements were obtained from staff and residents, and available video footage was reviewed when applicable. She stated the investigation determined that inappropriate contact had occurred between residents and confirmed that staff did respond once the incident was reported. She further stated that the alleged residents were placed on increased supervision, including one-to-one monitoring, and referred for further evaluation to address behavioral concerns. She stated that notifications were made in accordance with facility protocol, including notifying the physician, responsible parties, and appropriate agencies. She noted that from an administrative standpoint, the facility attempted to follow its abuse and investigation procedures and took steps to prevent immediate recurrence. However, the LNHA acknowledged that while the facility responded to the incident, there were areas where the response could have been improved for the affected resident(s). She stated that the facility should have implemented more consistent and ongoing follow-up with the affected residents(s), including routine check-ins to assess fear, anxiety, or other psychosocial effects following the incident. She further stated that the investigation identified a need for stronger communication with the affected residents regarding the protective measures that were put in place, to ensure they felt safe and reassured after the incident. She acknowledged that clearer and more consistent documentation and communication with the interdisciplinary team regarding follow-ups would have supported better monitoring of the resident's well-being. The LNHA stated that services to the affected resident(s) could have been improved by providing more consistent emotional support, more structured and timelier follow-up, and ongoing evaluation of the resident's sense of safety. She stated that while the facility acted, additional measures would have better ensured the residents' rights were fully upheld and that they were protected from potential psychosocial harm.In an interview with the Social Worker, on 3/19/2026 at 10:58 AM, she stated that she was aware of the incident involving the resident(s) #1, #2, #3 and #4 and acknowledged that the affected residents should have received more focused follow-up and supportive services after the allegation was made. She stated that, in accordance with the facility's Resident Rights Policy, residents have the right to feel safe, to be free from abuse, and to have their concerns acknowledged and addressed. She stated that once the allegation was reported, the facility should have ensured the immediate emotional and psychological needs of the resident(s) were assessed, including speaking with them privately, validating their concerns, and ensuring they felt heard.Record review revealed that in both incidents, the residents were in common areas without effective supervision at the time of the events. Although staff responded after the incidents occurred, the facility failed to implement sufficient interventions to prevent inappropriate resident-to-resident contact prior to the incidents.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for nail care, oral hygiene, and hand rolls for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Comprehensive Care Plans unrevised, revealed under, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Review of Resident #74's Care Plan Report revealed under, Focus: I require total assistance with my ADL's (activities of daily living) r/t (related to) CVA (cerebrovascular accident) with left hemiplegia and bilateral hand contractures. Also revealed under, Interventions: Caregiver to don (apply) bilateral hand rolls to bilateral hands to decrease risk of skin breakdown and decrease risk of further contracture formation with skin checks/cleanse at the end of each shift to ensure no adverse effects x(times) 7 days a week . Mouth care: Brush teeth twice daily in the morning and night. X (times) 1 staff to assist with oral care . Nail care: clean and file PRN (as needed), trim my nails weekly. On 3/03/25 at 12:00 PM, an observation of Resident #74, revealed he was lying in bed with long brown discolored nails on the left hand measuring approximately 1 inch (in.) in length. One of his nails was broken off and hanging inside his palm. The residents' upper and lower teeth and lower gum line were covered in a thick white substance. Contractures observed to both hands/fingers with no device in place for contracture management. An observation of Resident #74 on 3/04/25 at 10:15 AM revealed he was lying in bed without hand rolls in place. On 3/05/25 at 7:50 AM, an observation with interview revealed Resident #74 lying in bed with long brown, discolored nails on the left hand and a thick white substance on the upper and lower teeth and the lower gum line. He revealed he asked the staff to brush his teeth. Contractures observed to both hands/fingers with no device in place for contracture management. The resident voiced that sometimes the staff applied a hand towel inside his hands, and stated they were not in his hands now. On 3/05/25 at 8:00 AM an observation and interview with Registered Nurse (RN) #1 confirmed Resident #74 did not have his hand rolls in place, had long nails, and described the residents' teeth as, They need brushing. An interview with the Minimum Data Set (MDS) Nurse on 3/06/25 at 8:20 AM revealed staff should follow Resident #74's care plan. She revealed the purpose of having a care plan was to make staff aware of how to care for the resident. The MDS Nurse confirmed staff did not follow his care plan. Record review of the Admission Record revealed the facility admitted Resident #74 on 2/02/22 with medical diagnoses that included Cerebral Infarction and Hemiplegia Unspecified Affecting the Left Nondominant Side. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated the Resident #74 was cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to resolve a resident grievance in a timely manner related to missing clothing, activities, and noisy environment for four (4) of seven (7) residents that attended resident council. Residents #27, #76, #100, and #309 Findings Include: Review of the facility policy titled Grievance/Complaint Policy unrevised, revealed, It is a policy of this facility that a resident/responsible party/legal representative has the right to voice grievances as follows: . All grievances should be directed/reported to the departmental supervisor and departmental director. Review of the facility policy titled Resident Personal Belongings unrevised, revealed under, Policy: It is the policy of this facility to protect the resident's right to possess personal belongings, such as clothing and furnishings, for their use while in the facility. Also revealed under, Policy Explanation and Compliance Guideline: . 7. The facility will exercise reasonable care for the protection of the resident's property from loss or theft. Resident #27 On 3/03/25 at 12:13 PM, an interview with Resident #27 (Resident Council President) revealed he had 3 shirts, 2 pairs of pants, and 6 pairs of socks missing. He revealed he had reported the missing items to the staff on several occasions. On 3/05/25 at 9:20 AM, an interview with the Case Manager revealed the Ombudsman had come to her office and reported that Resident #27 had missing clothing. She revealed this happened a while back, but she could not recall the date. She revealed she got with the laundry person, and they were going to look for the items. The Case Manager explained that she did not know the status of the clothing, whether it was found or not. An interview with Laundry Staff #1 on 3/05/25 at 9:24 AM revealed she was made aware of Resident #27's missing clothing items about 2 weeks ago. She revealed she had been looking for them but, so far, had not found them. She explained that she would continue to look for the items for a couple more weeks and after that, if she had not located them, she would let the administrator know. An interview with the Long-Term Care Ombudsman on 3/05/25 at 10:10 AM revealed she visited the facility on 2/18/25. She confirmed she had notified the Case Manager that day Resident #27 was missing a black and a white pair of pants, a white shirt with a corvette design on it, a shirt with the saying, If I didn't remember it, it didn't happen, a white shirt with the tribal inauguration on it, 6 pairs of socks (2 white, 2 gray, and 2 black). She revealed the resident voiced to her that day the clothing had been missing for 3 weeks. Record review of the Grievance Forms revealed a grievance was not completed for Resident #27's missing clothing. An interview with Social Services (SS) on 3/05/25 at 1:45 PM revealed she was responsible for completing the grievances for the facility. She explained that when staff come to her with a complaint or concern, she completes the grievance form and then gives it to the necessary department to follow through. She revealed that she followed up to ensure the grievance was resolved later. SS confirmed a grievance was not completed related to Resident #27's missing clothing and revealed it probably should have been done. An interview with the Administrator (ADM) on 3/05/25 at 2:00 PM revealed she was not aware that Resident #27 had missing clothing and voiced that she was not made aware of it until this morning. She revealed the laundry department thinks the resident may have thrown away some of his socks because they were too tight. The ADM confirmed the clothing should have been written up as a grievance for tracking purposes so that staff knew and could quickly find a resolution. Record review of the Admission Record revealed the facility admitted Resident #27 on 10/11/24. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/25 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #27 was cognitively intact. Resident Council During a Resident Council meeting held on 3/05/25 at 1:00 PM, the residents voiced they had discussed in the past meetings wanting more activities. Resident #76 explained there were not enough activities. He revealed they play Bingo on Tuesday, which he voiced that he would like to play more often (at least twice weekly). He revealed playing Bingo was the only thing the facility did that met his interest. Resident #100 revealed they (the residents) do not have activities on the weekends. She explained they sometimes have a church group that comes on Sunday. Resident #100 revealed during the week they do nails, arts and crafts, bingo, and stated, That's about all we do. She explained they may have some preacher or singing on the weekend and stated, We need activities on the weekends. Resident #76 expressed that not everybody likes arts and crafts, I don't. He explained that he told them (the staff) that there were not enough activities on the weekend, and they gave out coloring books. He stated, I'm not a child and I don't like to color. Resident # 309 revealed he was here for therapy. He revealed that during the week, when the office staff were present, the facility had structure but, on the weekends, It's an entirely different atmosphere. He explained on the weekends it was a new group that came in and revealed it sounded like a cow bawling at times. Furthermore, he revealed that he had never heard such noise. He explained that his room was close to the nurse's station and the noise was so bad that he could not sleep. He revealed he would rather not move to another room because he liked his roommate. The residents agreed this was a big concern to them. Resident #309 revealed he had reported the noise to the staff and even to his aide. Resident #76 revealed he had complained several times about the noise on the weekends. He explained that the staff carry on loudly, play music, gather around the desk, and keep up too much noise. Resident #76 explained that he had been woken up many times at night due to the noise level. Record review of the Resident Council Meeting Minutes dated 12/2/24 revealed under, Material Discussed: Resident #76 stated weekends nights to loud and staff on the phone in hallway. An interview with the Administrator (ADM) on 3/05/25 at 2:00 PM revealed she was not aware that the residents had voiced complaints related to the noise level on the weekends. She revealed she did have staff that came in to check on things and revealed most of the staff that worked on the weekends were facility employees with a few agency staff. She acknowledged this concern should have been written up as a grievance. An interview with the Activity Director on 3/05/25 at 2:30 PM revealed they (the facility) did many activities during the week to meet the residents' interest. She revealed picking activities to meet all their preferences was getting harder and harder due to the age group that the facility was getting now. She explained that their youngest resident was in his 20's and revealed it was difficult to plan activities for all age groups. The Activity Director confirmed they had discussed in Resident Council doing more activities. She revealed she had explained to them, if they could come up with something they wanted to do, she was willing to try it. She confirmed they did not have an activity person for the weekend and revealed they sometimes have a church to come. The AD revealed if a concern was discussed during resident council, she would tell the Director of Nursing, or the Assistant Director of Nursing, and they would write up a grievance to investigate. She revealed she told the Assistant Director of Nursing about the Resident #76's complaint about the noisy weekend environment. An interview with the Assistant Director of Nursing (ADON) on 3/06/25 at 8:10 AM revealed he did not recall being made aware of Resident #76's complaint regarding the noise level on the weekends. Review of the Admission Record revealed the facility admitted Resident #76 on 7/30/21 with a medical diagnosis that included type 2 diabetes mellitus with unspecified complications. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/28/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #76 was cognitively intact. Review of the Admission Record revealed the facility admitted Resident #100 on 10/14/24 with a medical diagnosis that included chronic kidney disease, stage 3. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/31/24 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicated Resident #100 was cognitively intact. Review of the Admission Record revealed the facility admitted Resident #309 on 2/18/25 with a medical diagnosis that included type 2 diabetes mellitus with foot ulcer. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/25/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident # 309 was cognitively intact.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a medication cart was locked and secured for one (1) of four (4) survey days. Findings Include: Review of the facility policy titled Medication Storage unrevised, revealed, Policy Explanation and Compliance Guidelines . c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. An observation on 3/03/25 at 12:45 PM revealed the medication cart located on C hall was unlocked and unattended without a nurse in view. An observation and interview with Licensed Practical Nurse (LPN) #1 on 3/03/25 at 12:49 PM confirmed she walked away from the medication cart and left it unlocked. She explained that she got called away and forgot to lock it. LPN #1 revealed leaving the medication cart unlocked gave the residents access to the cart and stated, Any of the residents can get in it and take something. An interview with the Administrator (ADM) on 3/04/25 at 10:11 AM confirmed the nurses should never leave the medication cart unlocked when out of view. She revealed that any resident could walk by and take some medication and have an allergic reaction.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure licensed nursing staff followed professional standards of practice for medication administration. This resulted in the administration of discontinued and incorrectly scheduled medications, and failure to administer prescribed medications. This deficient practice was identified for four (4) of 37 medication administration observation opportunities (Resident #39, Resident #90) CROSS REFERENCE F759 Findings include: A review of the policy titled Medication Administration revealed the following: Policy: Medications are administered by licensed nurses who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.Policy Explanation and Compliance Guidelines: Section 10 states that staff must ensure the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, and f. Right documentation. Resident #39 On 3/05/25 at 8:15 AM, an observation of Licensed Practical Nurse (LPN) #1 administering medications revealed that LPN #1 administered Glipizide 10 mg (milligrams) one tablet orally and Albuterol Sulfate HFA Inhaler 108 (90 Base) (2 puffs) to Resident #39. LPN #1 was not observed verifying the six rights of medication administration by checking the medication label against the medication record. Record review of the Medication Administration Record for 3/05/25 for Resident #39 revealed Glipizide 10 mg (milligrams) was discontinued on 3/03/25.Albuterol Sulfate inhaler was scheduled every six hours at 6:00 AM, 1200 PM, 6:00 PM (1800), and 12:00 AM (0000). The medication was last signed off at 6:00 AM. Mometasone Furoate inhaler signed off as administered at 8:00 AM on 3/05/25. During an interview on 3/5/25 at 1:10 PM, LPN #1 confirmed that she administered Glipizide 10 mg, which had been discontinued on 3/3/25. She also confirmed that she administered Albuterol Sulfate HFA inhaler at an incorrect time, as it had already been given at 6:00 AM. LPN #1 lastly confirmed that she documented administration of Mometasone Furoate inhaler at 8:00 AM, despite not administering it. She acknowledged that failure to verify the six rights of medication administration could lead to adverse resident outcomes. Record revew of the Admission Record of Resident #39 revealed was admitted on [DATE], with diagnoses including Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure. Resident #90 On 3/05/25 at 8:46 AM, an observation of LPN #4 administering medications revealed that LPN #4 administered Aspirin Enteric Coated (EC) 81 mg to Resident #90. LPN #4 did not verify the six rights of medication administration by checking the medication label against the medication record. Record review of the Medication Administration Record for 3/05/25 for Resident #90 revealed Aspirin 81 mg chewable tablet signed off as administered. During an interview on 3/5/25 at 1:20 PM, LPN #4 confirmed that she administered Aspirin EC 81 mg, but later realized it was not the correct medication. She confirmed after reviewing the medication record that she gave the incorrect form of aspirin. She also confirmed she did not thoroughly check the six rights of medication administration and stated that if she had done so, she likely would not have made the error. Record review of the Admission Record revealed Resident #90 was admitted on [DATE], with a diagnosis of End-Stage Renal Disease.

Based on observations, resident and staff interviews, record review and facility policy review, the facility failed to maintain a medication error rate less than 5% as evidence by the administration of discontinued and incorrectly scheduled medications and failure to administer prescribed medications. This deficient practice was identified in four (4) of 37 medication administration observation opportunities. The medication error rate was 10.81%. This affected Resident #39 and Resident #90. CROSS REFERENCE F658 Findings include: A review of the policy titled Medication Administration revealed the following, Policy: Medications are administered by licensed nurses who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Policy Explanation and Compliance Guidelines: Section 10 states that staff must ensure the six rights of medication administration are followed: a. Right resident, b. Right drug, c. Right dosage, d. Right route, e. Right time, and f. Right documentation . Resident #39 An observation of Licensed Practical Nurse (LPN) #1 on 3/05/25 at 8:15 AM, administering medications revealed that LPN #1 administered Glipizide 10 mg (milligrams) (one tablet orally) and Albuterol Sulfate HFA Inhaler 108 (90 Base) (2 puffs) to Resident #39. LPN #1 did not verify the six rights of medication administration by comparing the medication label with the electronic/paper medication administration record before administration. Record review of the Medication Administration Record for 3/05/25 for Resident #39 revealed Glipizide 10 mg was discontinued on 3/03/25. Albuterol Sulfate inhaler was scheduled every six hours at 6:00 AM, 1200 PM, 6:00 PM (1800), and 12:00 AM (0000). The medication was last signed off at 6:00 AM. Mometasone Furoate inhaler signed off as administered at 8:00 AM on 3/05/25. On 3/5/25 at 1:10 PM, during an interview LPN #1 confirmed that she made medication errors when administering Resident #39's medications. She admitted that she administered Glipizide 10 mg, which had been discontinued on 3/3/25 and also Albuterol Sulfate HFA inhaler at an incorrect time, as it had already been given at 6:00 AM. She then confirmed that she also documented administration of Mometasone Furoate inhaler at 8:00 AM, despite not administering it. She acknowledged that failure to verify the six rights of medication administration could lead to adverse resident outcomes. Resident Admission Record: Resident #39 was admitted on [DATE], with diagnoses including Type 2 Diabetes Mellitus and Chronic Systolic Congestive Heart Failure. Resident #90 An observation of LPN #4 administering medications on 3/05/25 at 8:46 AM, revealed that LPN #4 administered Aspirin Enteric Coated (EC) 81 mg to Resident #90. LPN #4 did not verify the six rights of medication administration by checking the medication label against the medication record. Record review of the Medication Administration Record for 3/05/25 for Resident #90 revealed Aspirin 81 mg chewable tablet signed off as administered. On 3/5/25 at 1:20 PM, during an interview LPN #4 confirmed after reviewing the medication record that she gave the incorrect form of aspirin when she administered Aspirin EC 81 mg, but later realized it was not the correct medication. She also confirmed she did not thoroughly check the six rights of medication administration and stated that if she had done so, she likely would not have made the error. Record review of Resident #90's Admission Record revealed the facility admitted the resident on 1/04/25, with diagnoses that included End-Stage Renal Disease.

Based on staff interviews, record reviews, and facility policy review, the facility failed to obtain a stop date for as-needed (PRN) psychotropic medications for two (2) of six (6) residents reviewed who were receiving psychotropic medications (Resident #43 and Resident #259). Findings Include: Review of the facility policy titled, Use of Psychotropic Medications, last revised in March 2025, revealed the following under Policy Explanation and Compliance Guidelines: Section 16: Psychotropic medications used on a PRN basis must be limited to no more than 14 days unless the provider determines it is appropriate to extend the order. The medical record must indicate a specific duration. Resident #43 Record review of the Order Summary Report for Resident #43 revealed an order dated 12/06/24 for Ativan (Lorazepam) 1 mg (milligram), to be administered one tablet by mouth every 12 hours as needed for anxiety with no stop date provided. Record review of the admission Record revealed Resident #43 was admitted to the facility on [DATE], with a diagnosis of Anxiety. Record review of Resident #43's Quarterly Minimum Data Set (MDS), Section C, dated 1/28/25, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. During an interview with the Director of Nursing (DON) on 3/04/25 at 12:24 PM, he confirmed that Resident #43 had a PRN order for Ativan without a stop date. Resident #259 Record review of the Order Summary Report for Resident #259 revealed an order dated 2/20/25 for Clorazepate Dipotassium 3.75 mg, to be administered one tablet by mouth every 12 hours as needed for anxiety with no stop date provided. Review of the admission Record revealed Resident #259 was admitted to the facility on [DATE], with a diagnosis of Anxiety. Record review of Resident #259's admission MDS, Section C, dated 2/20/25, revealed a BIMS score of 15, indicating the resident was cognitively intact. During an interview with the DON on 3/04/25 at 12:28 PM, he confirmed that Resident #259 had a PRN order for Clorazepate Dipotassium without a stop date. The DON further stated that all PRN psychotropic medications should have a stop date to ensure residents are reevaluated for continued need. He acknowledged that failure to include a stop date could result in residents continuing to receive medications they no longer need.

Based on observation, resident and staff interviews, record review and facility policy review, the facility failed to provide a safe, clean homelike environment for Residents #6, #11, and #60. This was for one (1) of four (4) hallways. Findings include: A record review of facility policy titled Safe and Homelike Environment, dated 2024, revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . A record review of the facility policy titled, Deep Cleaning Rooms undated revealed, (6) Check all room curtains if it needs taking to laundry for washing. Resident #6 During an observation and interview on 03/03/25 at 3:10 PM, Resident #6's room was noted to have a large section of the wall (approximately 3 feet by 3 feet) with scratches and paint missing. Behind the resident's headboard of her bed, a piece of plywood measuring approximately 4 feet by 3 feet was noted to be attached to wall. The plywood had large chunks of wood missing which left uneven and splintered edges on the broken part as well as on the edges of the plywood. Resident #6 stated she would like for it to be repaired. On 3/5/25 at 1:30 PM, during an observation and interview, the Administrator confirmed the paint on the wall was in disrepair and the broken and splintered plywood on the wall behind the resident's bed could cause an injury. She confirmed each resident should have a safe, clean, and homelike environment and the facility failed to provide this for Resident #6. Record review of Admission Record revealed the facility admitted Resident #6 on 12/16/2020. Diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus, and Dementia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/24 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #60 During an observation on 03/03/25 at 1:06 PM, an overwhelmingly strong and foul-smelling urine odor was noted in the hallway near Resident #60's room with the smell covering approximately 15 - 20 feet of the hallway from the resident's doorway. Upon opening the door to the resident's room, the foul smell was overpowering. Neither of the residents living in that room were in the room at the time. During an interview on 3/4/25 at 12:20 PM, Certified Nursing Assistant (CNA) #1 revealed Resident #60 frequently urinated on the floor while he attempted to use the toilet. She stated they have tried to mop the floor every hour or two and replaced the flooring in his bathroom, but the smell is still overwhelming. An observation during the interview confirmed that the urine smell in the hallway of Resident #60's room was still foul and overpowering. An interview on 3/4/25 at 12:25 PM, with CNA #3 confirmed that Resident #60's room and hallway near the resident's room had a strong smell of urine present. She stated she felt that the resident attempted to urinate in the toilet but would frequently miss and urinate on the floor. Her interview revealed that housekeeping mopped the floor every hour or two, but there was still a strong and very unpleasant smell, and she had several residents complain about the bad smell. During an interview on 3/4/25 at 12:30 PM, Licensed Practical Nurse (LPN) #3 confirmed that the urine smell in and near Resident #60's room had been an ongoing problem. She acknowledged that the resident pees on the floor, and even though unintentional, it still smelled terrible and it is not fair to other residents. This is their home, and they should not have to live in a stinky home. She stated she did not know what else could be done to improve the situation, but they have had residents and family members complain about the awful smell. During an interview with the Director of Nursing (DON) on 3/5/25 at 10:30 AM, he revealed he and the staff had worked with Resident #60 to try to improve this concern. They had assisted him with voiding in the toilet and even tried to encourage him to sit down while toileting. The resident was unwilling to try that and was unwilling to be prompted by staff to toilet more often. The DON stated the resident would go into the bathroom but before he was positioned properly, he would urinate on the floor. The DON confirmed that he was aware of the terrible smell in the resident's room as well as in the hallway surrounding the resident's room and had tried multiple things to help improve the smell. The floor was replaced which helped for a while, but he confirmed there was a foul odor in that area of the facility which had not been successfully resolved. During an interview on 3/5/25 at 10:35 AM, the Administrator stated she was aware of the foul urine odor in and near Resident #60's room. She stated multiple options had been tried such as replacement of the floor and wall in bathroom, resealing the toilet, mopping frequently, education and encouragement of resident with different techniques of voiding, but none of these led to a permanent solution to the problem. She confirmed this concern had continued to occur and an acceptable and permanent solution had not been established. She also confirmed it was not fair for the other residents to have to accept this strong, foul urine smell in their home. She confirmed that each resident had the right to a clean, comfortable, homelike environment and the facility failed to provide this for the residents in that area. Record review of Resident #60's Admission Record revealed the facility admitted him on 3/25/2019. Diagnoses included Chronic Obstructive Pulmonary Disease and Borderline Intellectual Functioning. Record review of the MDS with an ARD of 1/10/25 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated that Resident #60 had a moderate cognitive impairment. 46013 Resident #11 An observation and interview on 3/03/25 at 12:05 PM, revealed multiple large splotched discolored areas to the privacy curtain visible upon entering Resident #11's room. Resident #11 revealed that This curtain needs cleaning; they don't ever clean it. An observation on 3/04/25 at 10:10 AM and again on 3/5/25 at 8:20 AM revealed the privacy curtain remained dirty with multiple large, discolored splotches throughout the fabric on the curtain. During an observation and interview on 3/05/25 at 8:30 AM, LPN #2 confirmed the privacy curtain in Resident #11's room was dirty and stained and needed to be pulled down and cleaned. She revealed it is not a home-like environment and wasn't sure when it was last cleaned. During an observation and interview on 3/05/25 at 9:45 AM, the Administrator confirmed the privacy curtain in Resident #11's room was extremely dirty and stated, I was just in this room yesterday and didn't even notice it. Resident #11 revealed It's been dirty like this for a long time. A record review of Resident #11's Admission Record revealed the facility admitted the resident on 02/24/2012 with diagnoses that included Major Depressive Disorder, Unspecified Kidney Failure, and Anxiety Disorder. A record review of Resident #11's MDS Section C with an ARD of 1/23/2025 revealed a BIMS score of 15, indicating that the resident is cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure hand rolls were applied for a resident with finger contractures for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Prevention of Decline in Range of Motion unrevised, revealed under, Policy: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Record review of the Treatment Administration Record (TAR) revealed an order dated 7/08/24, Caregiver to don (put on) B (bilateral) hand rolls to B (bilateral) hands to decrease risk of skin breakdown and decrease risk of further contracture formation with skin checks/cleanse at the end of each shift to ensure no adverse effects x (times) 7 days a week every shift. The hand rolls were signed as applied/administered on each shift (day, evening, and night) for the dates of 3/3/25 and 3/4/25. An observation on 3/03/25 at 12:00 PM revealed Resident #74 lying in bed. Contractures observed to both hands/fingers with no device in place for contracture management. An observation of Resident #74 on 3/04/25 at 10:15 AM revealed he was lying in bed without hand rolls in place. An observation and interview on 3/05/25 at 7:50 AM with Resident #74 revealed the resident was lying in bed with no hand rolls in place. The resident voiced that sometimes the staff applied a hand towel inside his hands but confirmed that he did not have any now. An observation and interview with Registered Nurse (RN) #1 on 3/05/25 at 8:00 AM confirmed Resident #74 were supposed to have hand rolls that the nurses applied, but did not have the hand rolls in place. She revealed the resident could develop worsening contractures and skin breakdown by not wearing them as ordered. Record review of the Therapist Progress & (and) Discharge Summary dated 1/04/24 revealed under, Discharge Plans & (and) Instructions: Patient discharged to nursing care for placement of B (bilateral) hands rolls to decrease risk of skin breakdown as well as decreased risk of further contracture formation. An interview with the Occupational Therapist (OT) on 3/05/25 at 8:34 AM revealed she recommended Resident #74 to wear hand rolls due to his severe hand/finger contractures. She revealed the purpose of him wearing them was to prevent skin breakdown and further worsening of his contractures, and confirmed without staff applying them, his contractures could become worse. An interview with the Administrator (ADM) on 3/5/25 at 2:00 PM confirmed that the staff should be applying Resident #74's hand rolls or have documentation to reflect why it was not. Record review of the Admission Record revealed the facility admitted Resident #74 on 2/02/22 with medical diagnoses that included Cerebral Infarction and Hemiplegia Unspecified Affecting the Left Nondominant Side. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated that Resident #74 was cognitively intact. Also revealed under section GG, functional limitation in range of motion (shoulder, elbow, wrist, hand), impairment on both sides was marked.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to provide activities that met the interest of the residents for three (3) of 25 sampled residents. Resident #6, #9, and #41 Findings Include: Review of the facility policy titled Activities revealed under, Policy: It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Resident #6 During an interview on 3/4/25 at 9:00 AM, Resident #6 stated the facility does not offer activities on the weekends and she would like to have activities on these days as well as during the week. She revealed she had been sick and had preferred to do activities in her room, but lately she felt better and wanted to participate in group activities. An interview with the Activity Director (AD) on 3/5/25 at 8:00 AM, revealed she worked Monday through Friday and on the weekends the charge nurse would assist the residents with independent activities. She stated she left puzzles and coloring sheets for the residents that wanted to do those activities. She stated that church groups would occasionally have services in the facility on the weekend, but otherwise, she confirmed there were no organized group activities planned for the residents on the weekend. An interview with the Administrator (ADM) on 3/6/25 at 8:45 AM, revealed the facility did not have a weekend activity staff member, but she was attempting to hire one. She stated the Activity Director would leave puzzles and coloring sheets for the residents. She confirmed the facility failed to provide structured and scheduled activities on the weekends for the residents that preferred to participate on those days. Review of the February and March 2025 activity schedules confirmed on Saturdays and Sundays Independent activities of choice was listed. Record review of the February 2025 Activity Attendance Record for Resident #6 revealed there was no activity documentation for the weekend days. Record review of Resident #6's Admission Record revealed the facility admitted her on 12/16/2020. Her diagnoses included Hemiplegia and Hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus, and Dementia. Record review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/19/24 Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated this resident was cognitively intact. Review of section F revealed for the question how important is it to you to do your favorite activities and the resident's response was very important. Resident #9 During an interview on 3/04/25 at 8:46 AM, Resident #9 stated she participated in the bingo and singing activities during the week, but there were not any activities on the weekends. She stated she would like for the facility to offer activities on the weekend for her and other residents to participate in. Record review of the February 2025 Activity Attendance Record for Resident #9 revealed there was no activity documentation for the weekend days of the month. Record review of Resident #9's Admission Record revealed the facility admitted the resident on 7/6/2018 originally with the most recent admitted [DATE]. Diagnoses included Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Hemiplegia and Hemiparesis following Cerebral Infarction. Record review of Resident #9's MDS with an ARD of 10/24/24 Section C revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of Section F revealed for the question how important is it to you to do your favorite activities and the resident's response was very important. For the question how important is it to you to do things with groups of people the resident's response was very important. 47874 Resident #41 An interview with Resident #41 on 3/05/25 at 8:10 AM revealed she liked to play cards such as Spades and Monopoly. She revealed there were no activities on the weekends and all they did was sit around. The resident explained that during the weekend they (the facility) sometimes had church singing, but she did not like music. She revealed she would like more things to do that she liked. She voiced they (the residents) do have puzzles that were always available, but she was tired of that. Record review of Resident #41's February 2025 Activity Attendance Record revealed there was no activity participation for the weekend days of the month. Also revealed the resident was marked as participating in outside time (smoking), hall social, watching TV, and being up in her wheelchair. An interview with Certified Nurse Aide (CNA) #1 on 3/05/25 at 7:55 AM revealed she worked some weekends. She confirmed the facility did not have weekend activities and stated, We sometimes have church members that come sing, but it's not often. She revealed there were no other activities conducted on the weekends. An interview with Housekeeping #1 on 3/05/25 at 9:18 AM revealed she worked four (4) days on and two (2) days off, which included her working some weekends. She confirmed the facility had no weekend activities and stated, No, they don't do anything. Record review of the January, February 2025 activity calendars revealed on the weekends, Independent activities of choice were listed. An interview with the AD on 3/05/25 at 2:30 PM revealed she had been in the activity position for about five (5) years and acknowledged the residents should have activities, including the weekends, which included their likes. The AD revealed Resident #41 liked to play Bingo. She revealed that she included smoking as part of the resident's activity record and hall social, which included social conversation while she was waiting in the hall to go smoke. She revealed, in her opinion, she had done all she could do to meet the interest of Resident #41. Record review revealed the Activity Director completed the 40 Hour Basic Activity Director Course dated 11/8/21. Record review of the Admission Record revealed the facility admitted Resident #41 on 9/6/24 with a medical diagnosis that included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side. Record review of the MDS with an ARD of 9/16/24 revealed under, Section C, a BIMS summary score of 13, which indicated Resident #41 was cognitively intact. Also revealed, under section F0500 . F. How important is it to you to do your favorite activities? Very important was marked.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident dependent on staff for Activities of Daily Living (ADLs) received oral care and nail care for one (1) of 25 sampled residents. Resident #74 Findings Include: Review of the facility policy titled Activities of Daily Living Policy with a revision date of 7/2014, revealed under, Policy Statement: Based on previous evaluations and current date, the nursing staff, in conjunction with Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify the level of care a resident requires for ADLs. An observation of Resident #74, on 3/03/25 at 12:00 PM, revealed he was lying in bed with fingernails that were approximately 1 inch (in.) in length on the left hand with a brown substance on each nail and one nail that was broken off and hanging inside his palm. The residents' upper and lower teeth and lower gum line were covered in a thick white substance. An observation with interview on 3/05/25 at 7:50 AM with Resident #74 revealed no change in the resident's appearance and he stated that he had asked the staff in the past to brush his teeth. An observation and interview with Registered Nurse (RN) #1 on 3/05/25 at 8:00 AM confirmed Resident #74 had long nails on the left fingers that could cause skin breakdown due to his contracted fingers, which were turned inward toward the palm. She revealed the nurses, or the aides, could trim his nails. RN #1 described the residents' teeth as, They need brushing. She confirmed that staff failing to do this could cause gingivitis and tooth decay. She revealed the aides were responsible for brushing his teeth daily. An interview with the Administrator (ADM) on 3/05/25 at 2:00 PM revealed her expectations were for staff to perform the care tasks listed and document accordingly. Record review of the March 2025 Documentation Survey Report for Resident #74 revealed the resident requires total dependence for personal hygiene with the assist of 1- two (2) staff. Record review of the Admission Record revealed the facility admitted Resident #74 on 2/02/22 with medical diagnoses that included Cerebral Infarction and Hemiplegia Unspecified Affecting the Left Nondominant Side. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/11/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated that Resident #74 was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy the facility failed to follow a physician order for a resident who was prescribed fluid restriction for one (1) of nine (9) residents on fluid restriction. Resident #25 Findings include: A review of the policy titled, Fluid Restriction, revealed Fluids will be restricted, originated 9/04, revealed Policy: Fluids will be restricted for residents as directed by physician's orders. The following conditions may require intervention of restricting fluids: .end stage renal disease. Limiting fluids places the residents at high risk for dehydration. Procedure: 1.)Fluids will be distributed to residents placed on fluid restriction in the manner indicated below (Fluid Restriction)1200 cc (cubic centimeter) (Total nursing)360 cc (By Shift 120 cc day 120 cc eve (evening) 120 cc noc (night) Total Dietary) 840 cc (Breakfast) 360 cc (Dinner) 240 cc (Supper) 240 cc.3.)Nursing service will document intake and output. An interview with Resident #25 on 8/21/23 at 2:00 PM, she revealed she was on dialysis and stated she did not know if she was on fluid restrictions and stated, I may be since I am on dialysis, but I am unsure. An observation of the breakfast tray on 8/22/23 at 8:00 AM, revealed 360 cc of fluids on the tray. An interview with the Director of Nursing (DON) on 8/22/23 at 12:45 PM, he revealed after review of the physician's orders and medication record he confirmed Resident #25 had an order for a 1200 milliliter (ml) fluid restriction. The DON revealed the physician's order did not have the fluid amounts broken down for staff to know exactly how much fluids to provide the resident and confirmed that they did not have any monitoring of Intake and Output (I & O) documented. The DON confirmed the fluid restriction should have been broken down for staff to know the number of fluids to provide the resident and the I &O should be documented on the medication record. The DON indicated a potential concern from not monitoring the I & O is the resident could take in too much fluid and cause fluid overload. An interview with the Dietary Manager on 8/22/23 at 1:00 PM, she revealed the resident was on a 1200 cc fluid restriction and revealed she uses the breakdown of fluids on the fluid restriction policy to know how much fluid to provide a resident on fluid restriction each meal. The Dietary Manager revealed she was unaware of how the nursing staff communicates the amount fluids to provide to the resident. An interview with the Registered Dietician (RD) on 8/22/23 at 1:05 PM, she revealed Resident #25 is on a 1200 cc fluid restriction and her I & O should be monitored and totaled daily to ensure the resident is adhering to the fluid restriction and not consuming too much or not enough fluids. The RD revealed possible concerns from not monitoring I &O is dehydration or possible fluid overload. A interview with the Minimum Data Set (MDS) Coordinator on 8/22/23 at 1:15 PM revealed after review of the physician's orders that the physician's orders reflects the resident is on 1200 cc fluid restriction but no monitoring for I &O or break down of the fluid intake on the physicians orders and confirmed the nursing staff would not know how much fluids to provide to the resident. An interview with Certified Nurse Assistant (CNA) #1 with the MDS Coordinator in presence on 8/22/23 at 1:25 PM, she revealed Resident #25 was not on any fluid restrictions to her knowledge. An interview with the MDS Coordinator on 8/22/23 at 1:30 PM, revealed the facility has looked into the I & O issues in the past but could not get it added as a special requirement for nurses to document the amount of I & O and the 24-hour totals. An interview with Licensed Practical Nurse (LPN)#1 on 08/22/23 at 2:33 PM, revealed she believed Resident # 25 was on fluid restriction, but she was unaware of the specific amount of fluid restriction. LPN #1 revealed I just give her about a 1/2 of cup of water with each medication pass and she drinks what she wants. LPN #1 confirmed they were not monitoring I & O on the resident but confirmed they should be monitoring I & O since she is on fluid restriction. Record review of the Physician Orders for August 2023 revealed an order dated 3/10/23 NAS (No Added Salt) Regular with 1200 cc fluids restriction. A review of the Medication Administration Record for August 2023, revealed Resident #25 had medications scheduled for 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, and 8:00 PM daily. Record review of the Face Sheet revealed that the facility admitted the resident on 3/10/23 with diagnoses that included Hypertensive heart and chronic kidney disease with heart failure with stage (5) five chronic kidney/ESRD (end-stage renal disease). Record review of the MDS with an Assessment Reference Date (ARD) on 6/09/23, Section C revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated that he was cognitively intact. Section O revealed that it was coded as receiving dialysis.

Based on observation, resident and staff interview, record review, and facility policy review the facility failed to implement a care plan for fluid restriction for Resident #25, Activity of Daily Living (ADL) care for Resident # 86 and splint application for Resident #91, for three (3) of 27 care plans reviewed. Findings include: Review of the facility policy titled, Comprehensive Care Plan Policy, revealed Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Resident #25 Record review of the Care Plan, with a problem onset date of 8/2/2022 revealed , At risk for nutritional decline/dehydration r/t . ESRD (end stage renal disease) .fluid restriction .Approaches: NAS (no added salt) LCS (low concentrated sweet) diet with 1200 ml fluid restriction During an interview with Resident #25 on 8/21/23 at 2:00 PM, revealed she was on dialysis. The State Agency (SA) asked Resident #25 if she was on a fluid restriction and she stated, I may be since I am on dialysis, but I am unsure. An interview with the Minimum Data Set (MDS) Coordinator on 8/22/23 at 1:15 PM, she revealed after review of the nutrition care plan for Resident # 25 with the SA, that the care plan reflected that the resident was on 1200 cc (cubic centimeter) fluid restriction. The MDS Coordinator confirmed the care plan related to the 1200 cc fluid restriction was not being followed, and the purpose of the care plan is to develop and implement a holistic view of the resident's specific needs and provide interventions to best meet the resident's needs. Record review of the Face Sheet revealed that the resident was admitted to the facility on [DATE] with diagnosis of Hypertensive heart and chronic kidney disease with heart failure with stage (5) five chronic kidney/ESRD (end-stage renal disease). Record review of the MDS, Section C, with an Assessment Reference Date (ARD) of 6/09/23, revealed that Resident # 25 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated that he was cognitively intact. Section O revealed Resident # 25 was coded as receiving dialysis. Resident #86 Record review of Resident #86's Care Plan with a problem onset date of 4/6/2022 revealed 7. I require extensive to max (maximum) assist with ADLs except with eating r/t (related to) CVA (Cerebral Vascular Accident) with hemiplegia and muscle weakness .I am incontinent of bowel and bladders with the use of adult briefs .Approaches .Toilet use: Incontinent of bowel and bladder with use of adult briefs .14.I am at risk for skin impairments r/t to incontinence, brief use, decreased mobility, diabetes, use of anticoagulant .Approaches .Provide me prompt incontinent care . During an interview on 08/21/23 08:26 AM, with Resident #86 revealed that he stays in the bed most of the time and sleeps a lot because that is what he prefers. He stated that the staff does not come to change him every two hours and he wished they would come check on him more often than they do. On 8/22/23 at 9:00 AM, during an interview with Resident #86 revealed that his brief was changed around 7:15 AM. An observation on 8/22/23 at 10:30 AM revealed Certified Nurse Assistant (CNA) #3 and CNA #5 performed incontinent care on Resident #86. Resident #86 confirmed in interview on 8/22/23 at 10:45 AM, that he had incontinent care around 7:30 AM and again around 10:15 AM. During an interview on 8/23/23 at 8:00 AM, with Registered Nurse (RN) #2 confirmed that Resident #86 had a care plan that indicated that he needed prompt incontinent care. She stated that means that anytime he calls for help the staff need to get to him as quick as possible to prevent skin breakdown and he also needs to just be checked on every 2 hours to see if he needs incontinent care because he sleeps a good bit. She stated that the care plan guides the care of the residents. Record review of Resident #86's Face Sheet revealed he was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, unspecified and Need for assistance with personal care. Record review of Resident # 86's MDS with an ARD of 6/13/23 revealed in Section C, a BIMS score of 15, which indicated the resident is cognitively intact and in Section G that the resident needed extensive assistance with toilet use and personal hygiene. Resident #91 Record review of the Care Plan with a problem onset date of 6/9/22 revealed, .8. I require extensive assistance with ADLs, .Approaches: Caregiver to DON (apply) Resting Hand Splint to RUE (right upper extremity) to maintain proper alignment of RUE and to prevent contracture formation. Check Skin every two hours to ensure no adverse effects . An observation on 8/21/23 at 11:00 AM of Resident #91 right wrist revealed the appearance of a contracture to right wrist area with no device in place. An interview with the MDS Coordinator on 8/22/23 at 3:00 PM, she revealed after review of the care plan related to contracture for Resident #91, it was care planned to wear a splint and confirmed if staff are not applying it the staff were not following the residents individualized care plan. Record review of the Face Sheet revealed that the facility admitted Resident #91 to the facility on [DATE] with diagnoses of Cerebral Infarction due to unspecified occlusions or stenosis of unspecified cerebral artery and Hemiplegia following cerebral infarction affecting non-dominate right side. Record review of the MDS with an ARD of 8/22/23, Section C , revealed that Resident # 91 had a BIMS score of 3 which indicated that he was severely cognitively impaired. Section G0400 revealed Resident # 91 was coded 1) Impairment on one side for both upper and lower extremities. 47157

Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide incontinent care every two hours and as needed for a resident dependent on staff for Activities of Daily Living (ADL) for one (1) of 98 residents reviewed. Resident #86 Findings include: Review of the facility policy titled, Activity of Daily Living Policy with a revision date of 01/2013 revealed Policy Statement: Based on previous evaluations and current data, the nursing staff, in conjunction with Attending Physician, Consultant Pharmacist, therapy staff, and others, will seek to identify the level of care a resident requires for ADL's . An interview on 08/21/23 08:26 AM, with Resident #86 revealed the staff does not always come and change him when he needs it. He stated that he stays in the bed most of the time and sleeps a lot because that is what he prefers. He stated that the staff does not come to change him every two hours and he wished they would come check on him more often than they do. An interview on 8/22//23 at 9:00 AM, with Resident #86 revealed that his brief was changed around 7:15 AM this morning. An observation on 8/22/23 at 10:30 AM, revealed Certified Nurse Assistant (CNA) #3 and CNA #5 performed incontinent care on Resident #86. An interview on 8/22/23 at 10:45 AM, with Resident #86 confirmed he had incontinent care around 7:15 AM and again around 10:30 AM. An interview on 8/22/23 at 1:45 PM, with CNA #3 revealed that it is hard to get incontinent care completed especially on day shift. She stated they try to make as many rounds and do as much incontinent care that needs to be done before the breakfast trays come out, but once the trays come out, they must pass trays and then help feed those residents that need fed. She stated that if a resident uses their call lights and need changing then we go ahead and do the care then, otherwise after we pick up breakfast trays then we start the daily baths and perform incontinent care as much as we can. She revealed there are two CNAs on Resident #86's hall and that one of them takes lunch from 10:45 AM-11:15 AM and then the other takes lunch from 11:15 AM-11:45 AM. She stated by the time they both get back from lunch, then the lunch trays are coming out and we have to pass the trays, help feed and then pick up the trays. She revealed that they try to do incontinent care at least one time before lunch, then after lunch and check with them again before we leave at 3:00 PM. An observation on 8/22/23 at 2:00 PM, revealed that CNA #3 and CNA #5 performed incontinent care on Resident #86. An interview on 8/22/23 at 3:00 PM, with Resident #86 revealed the staff had come and changed him once since lunch. An interview on 8/22/23 at 4:15 PM, with the Administrator and the Director of Nurses (DON) confirmed that Resident #86 needed to be checked and provided incontinent care every 2 hours if needed. The Administrator stated that they must do better at that. An interview on 8/23/23 at 8:00 AM, with Registered Nurse (RN) #2 confirmed that Resident #86 needed prompt incontinent care. She revealed that means that anytime he calls for help the staff need to get to him as quick as possible to prevent skin breakdown and he also needs to just be checked on every 2 hours to see if he needs incontinent care because he sleeps a good bit. Record review of Resident #86s Face Sheet revealed he was admitted to the facility on [DATE] with medical diagnoses that included Cerebral Infarction, unspecified and Need for assistance with personal care. Record review of Resident # 86's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/13/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact and in Section G that the resident needed extensive assistance with toilet use and personal hygiene.

Based on observation, staff interview, record review, and facility policy the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion as evidenced by staff not applying a hand splint as ordered for one (1) of 41 residents with limited range of motion. Resident #91 Findings include: Review of the facility policy titled, Use of Assistive Devices, dated October 2022, revealed Policy: The purpose of this policy is to provide a reliable process for proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: A nurse with responsibility for the resident will monitor for the consistent use of the device and safety in the use of the device. An observation on 8/21/23 at 11:00 AM, of Resident #91's right wrist revealed the appearance of a contracture to right wrist area with no device in place. An observation of Resident #91's right arm/wrist area on 8/22/23 at 8:30 AM, revealed no splinting device to right wrist/hand. Record review of the August 2023 Treatment Record revealed the following treatment, Caregiver to don (apply) Resting Hand Splint to RUE (right upper extremity) to maintain proper alignment of RUE and to prevent contracture formation. Check Skin every two hours to ensure no adverse effects. A review of the August 2023 Physician Orders for Resident #91 revealed an order dated 9/14/22, Caregiver to don (apply) Resting Hand Splint to RUE (right upper extremity) to maintain proper alignment of RUE and to prevent contracture formation. Check Skin every two hours to ensure no adverse effects. An observation and interview with Licensed Practical Nurse (LPN) #1 on 08/22/23 at 2:33 PM, revealed during the interview LPN #1 stated that Resident #91 did not have a splint ordered for his contracted hand. Upon review of the physician's orders for Resident #91 with LPN #1 she confirmed Resident #91 did have an order for a right-hand splint and confirmed the splint should have been applied this morning. LPN #1 confirmed through observation that the resident did not have a splint on and confirmed she had not applied or checked the splint because she thought therapy discontinued it a while ago. An interview with the Director of Nursing (DON) on 08/22/23 at 2:50 PM, revealed Resident #91 should have a right-hand splint and confirmed if staff were not applying the splint as ordered they were not following the physician's orders, and this could potentially cause worsening of contracture to right hand. An interview with the Occupational Therapist (OT) on 8/22/23 at 3:10 PM, she revealed Resident #91 should have been wearing a right-hand splint. The OT revealed possible concerns from not wearing splint as ordered could lead to worsening contractures, changes in joint integrity. and skin concern issues. Record review of the Face Sheet revealed that the facility admitted the resident to the facility on [DATE] with diagnoses of Cerebral Infarction due to unspecified occlusions or stenosis of unspecified cerebral artery and Hemiplegia following cerebral infarction affecting non-dominate right side. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 8/22/23, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated that she was severely cognitively impaired. Section G0400 revealed Resident # 91 was coded 1-Impairment on one side for both upper and lower extremities.

Based on staff interviews, record review and facility policy review, the facility failed to notify the Physician or the Nurse Practitioner (NP) of changes in condition for medication administration for a resident for one (1) of nine (9) residents reviewed. Resident #63. Findings include: Record review of facility policy titled, Administering Medications, dated April 2006, revealed, Medications will be administered in a timely manner and as prescribed by the resident's Attending Physician or the facility's Medical Director. The policy also revealed, The Director of Nursing Services and Attending Physician must be notified when two (2) consecutive doses of a medication are refused or withheld. During the record review of Electronic Medical Record (EMAR) for the month of August 2023, it was revealed that Resident #63 did not receive his ordered 8 AM medications for 14 of the 22 days recorded from 8/1/23 - 8/22/23. The reason documented for 13 of the held doses was that the resident was asleep or refused by resident. There was no documentation that the Charge Nurse, Medical Doctor (MD), or the Nurse Practitioner (NP) were notified. There was no documentation of any new orders related to these medications. For one of those 14 days of morning medications not given, the administration documentation area on the EMAR was blank and there was no documentation that the medications were given or not given. An interview with Registered Nurse (RN) #2 on 8/23/23 at 11:00 AM, revealed if he or any resident was too sleepy to take their medications, she would check back with the resident during the medication administration time frame. She stated if the resident was still too sleepy to take the medication during the time frame for medication to be administered, she would notify the NP/MD for guidance on what to do or to obtain new orders. She stated if a resident does not take medications ordered, the provider needs to be notified and documented in the computer and paper chart. An interview with the Assistant Director of Nursing (ADON) on 8/23/23 at 11:35 AM, revealed the facility strives to offer a home-like environment for each resident and if they are sleeping, the nurse should return later to try again. He stated if the resident was still asleep and unable to take the medications during the allotted time frame, the NP/MD should be notified, and the facility failed to do this. An interview with the Director of Nursing (DON) on 8/23/23 at 2:10 PM, revealed that neither the MD nor the NP were notified of the medications missed by the resident and confirmed the resident missed multiple doses of his August 2023 morning medications. He confirmed the facility failed to notify the NP/MD for the resident's medication doses not given. An interview with the NP on 8/23/23 at 2:20 PM, revealed she was not informed that the resident was often sleepy in the morning and for the month of August, he missed 14 out of 22 days of his AM doses of medications due to refusals or sleepiness. She stated had she known, she would have adjusted in his medication regimen, such as changing the administration time to a time he was more awake. She stated she was aware the resident was sleepy at times, but not that medication was being held due to his sleepiness. She confirmed the facility failed to notify her of medication doses being missed. During an interview on 8/23/23 at 2:50 PM, the Administrator confirmed that the facility failed to notify the NP or the MD that the medications were not administered as ordered when the resident was asleep or didn't take his medications and they should have been notified. A phone interview with Licensed Practical Nurse (LPN) #4 on 8/23/23 at 5:05 PM, revealed she had taken care of Resident #63 and was assigned to him on some of the days the medications were held. She stated that occasionally the resident would refuse his medications, but for most of those held doses he was too sleepy to take his meds safely. She stated she went back to see if he was more awake, but if he was not, she would waste the meds and document the reason on the EMAR. She confirmed she failed to notify the MD or the NP when the medications were held. Record review of the Physician Order List revealed orders for Metoprolol Tartrate 50 milligrams (mg) by mouth two times daily related to Hypertension, Colace 100 mg by mouth two times daily related to constipation, Calcium-Vitamin D 500 mg-5 micrograms (mcg) one tablet by mouth two times daily related to supplement, Memantine 10 mg by mouth two times daily related to dementia, Vitamin B12 1000 mcg by mouth daily related to supplement, Glycolax 17 grams by mouth daily related to constipation, Aspirin 81 mg by mouth daily related to prophylactic for deep vein thrombosis, Vitamin D3 50,000 units by mouth once weekly on Tuesdays related to supplement, and Escitalopram 10 mg by mouth daily related to depression. Record review of EMAR revealed from 8/1/23 - 8/22/23 revealed the resident's 8 AM medications were held due to being asleep on 8/1/23, 8/2/23, 8/3/23, 8/14/23, 8/16/23, and 8/18/23. The record revealed the 8 AM medications were refused by the resident on 8/4/23, 8/6/23, 8/7/23, 8/11/23, 8/17/23, 8/19/23, and 8/21/23. Record review of Face Sheet revealed Resident #63 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, Dementia, Hypertensive Heart Disease with Heart Failure, Vitamin D Deficiency, Chronic Systolic (Congestive) Heart Failure, Anxiety Disorder, Depression, Psychotic Disorder with Delusions, Cardiomegaly, Vitamin B12 Deficiency Anemia, Constipation, Atherosclerotic Heart Disease of Native Coronary Artery, and Ischemic Cardiomyopathy. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 5/26/23, revealed a Brief Interview for Mental Status (BIMS) of two (2) indicating the resident was severely cognitively impaired.

Based on record review, staff interviews and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessments for a Preadmission Screening Resident Review (PASRR) for Resident #23 and restraint use for Resident #63 for two (2) of 24 sampled residents. Findings include: Record review of facility policy titled, Policy for Completing MDS, dated ,d+[DATE] revealed, . The RN (Registered Nurse) Coordinator will check for completeness of assessment by the end date and signed and date. Each person completing sections of the MDS must sign and certify its accuracy . Resident # 23 A record review of Resident # 23's Summary Findings Report, dated 9/21/2020, revealed . Mental Health: .The resident meets criteria for having a diagnosis of mental illness as defined by Preadmission Screening Resident Review (PASRR) . A record review of Resident # 23's annual MDS with Assessment Reference Date (ARD) of 7/28/23 indicated a No to question A1500, which asked if Resident #23 had been evaluated by a Level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition. During an interview on 8/22/23 at 12:00 PM, Social Service #1, who coded section A of the MDS, reviewed the annual MDS and confirmed it was inaccurate. She verified it was coded in error as Resident #23 had been approved for a Level II PASRR and determined to have a serious mental illness. During the interview on 8/22/23 at 12:15 PM, Registered Nurse (RN) # 1 reviewed the Annual MDS and confirmed it was inaccurate. The MDS Nurse verified it was coded in error as Resident #23 had been approved for a Level II PASRR and determined to have a serious mental illness. During an interview on 8/22/23 at 1:30 PM with the Director of Nursing (DON) he acknowledged Resident # 23's Annual MDS was inaccurately coded. He verified that it is his expectation that the MDS should be coded accurately. A record review of Resident #23's Face Sheet reveals Resident #23 was admitted to the facility on [DATE] with a diagnoses that included Schizoaffective disorder, depressive type. Resident #63 An observation on 8/22/23 at 2:00 PM, revealed Resident #63 was sitting in his wheelchair with a lap belt in place. Resident #63 was observed unfastening the Velcro and opening the belt independently. An observation and interview on 8/23/23 at 8:30 AM, revealed the Administrator with Resident #63. She asked the resident to remove his strap and he easily opened the Velcro and the buckle and opened the belt. The Administrator confirmed that since the resident could remove the belt, it was not considered a restraint but was used for safety. An interview with the MDS Licensed Practical Nurse (LPN) on 8/23/23 at 9:05 AM, revealed she was the MDS staff person that entered the information in the assessment for Resident #63. She confirmed the resident could remove the belt on his own and she mistakenly entered a restraint for this resident when she did his assessment. During an interview on 8/23/23 at 2:50 PM, the Administrator confirmed the MDS was not coded correctly and was inaccurate on the resident's MDS. She confirmed the resident's lap belt is not considered a restraint and it should not have been coded as one and that this was an MDS discrepancy. Record review of Resident #63's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Dementia, and Psychotic Disorder with Delusions. Record review of the MDS with an ARD of 5/26/23 revealed in Section P, the resident was coded with a trunk restraint for chair. Section C revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. 47158

Based on observation, staff and resident interview, record review and facility policy review, the facility failed to provide a follow up to grievances voiced by residents related to laundry services for two (2) of seven (7) residents reviewed during investigations (Resident #37 and Resident #150) and for grievance reported during resident council for one (1) of six (6) residents in attendance, (Resident #93). Findings included: Review of facility policy titled, Resident's Rights, undated, revealed, All nursing home facilities shall adopt and make public a statement of the rights and the responsibilities of the residents residing in such facilities and shall treat such residents in accordance with the provisions of said statement. The statement shall insure each resident of the following: . C. The right to present grievances on behalf of himself, herself, or others to the facility's staff or Administrator, to governmental officials, or to any other person without fear of reprisal and to join with other residents or individuals within or outside of the facility to work for improvements in resident care. H. The right to have privacy in treatment and in caring for personal needs, confidentiality in the treatment of personal and medical records, and security in storing and using personal possessions. Resident #37 An interview with Resident #37 on 08/21/23 at 3:25 PM, revealed the resident had clothing items that were missing. She stated she discussed her laundry concerns with the staff and was told the laundry was backed up because the person working in laundry was off work. She stated she sent pants, shirts, and 10-12 pairs of panties and since these items were not returned she was down to her last pair of panties. She stated she needed her clothes returned within a reasonable amount of time so she would have clean clothes to wear and could choose what she wanted to wear. An observation during a tour of the laundry with the Administrator on 8/22/23 at 11:45 AM, revealed eight large barrels of soiled clothes on the dirty side of the laundry. Six of these were completely full and the other two were each half full. On the clean laundry side, a large clothes rack (approximately 12 feet long) was noted to be full of residents' clean clothes hanging on the rack. Dividers with residents' room numbers were on the hanging clothes rack with each resident's clothes next to that divider. This rack was completely full. On another wall, there were cubicles labeled with residents' room numbers containing socks and other clothing items. An interview with Laundry/Housekeeper #2 on 8/22/23 at 11:55 AM, revealed she had been working in the laundry two (2) days each week to help get the laundry caught up. She stated the laundry was backed up since there had not been a full-time person working. She stated she was training a new full-time worker that started on 8/14/23 and confirmed that several residents had asked about their clothing and when they would receive them back. An interview with the Activity Director on 8/23/23 at 8:45 AM, revealed the laundry concerns were not mentioned in the Resident Council meeting, but she was told by several residents that their clothing items were missing. She stated she went to the laundry room and located those items for the residents. She stated she did not put this in the Resident Council minutes since she immediately resolved that resident's concern. She stated any concern mentioned in Resident Council was given to the department head so concern could be addressed. She stated that she needed to put any concerns in the minutes and follow up at the next meeting to ensure the concerns were addressed and resolved. She confirmed that the staff were aware of the laundry concerns and residents not receiving there clothing back in a timely manner. During an interview on 8/23/23 at 3:25 PM, the Administrator confirmed that due to a staffing issue, the facility failed to return clean laundry to residents timely. She stated she was aware of the residents' concerns and grievances and a solution was not made timely. She stated that she and the Ombudsman had also discussed the residents' concerns with not having their laundry available. An interview with Certified Nursing Assistant (CNA) #5 on 8/24/23 at 8:08 AM, revealed she and the other staff were aware the laundry had been backed up and the residents would occasionally ask about having their items returned. She stated if a resident needed clothing, the staff would look in the laundry to find some of the resident's clothing. Record review of Face Sheet revealed Resident #37 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Fibromyalgia, Anxiety Disorder, and Depression. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 6/21/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #150 An interview with Resident #150 on 8/21/23 at 3:25 PM, revealed her Laundry had been missing for days, and she only had one clean outfit left. She stated she had asked staff members several times to return her clothing items. During an interview on 8/22/23 at 11:45 AM, the Administrator confirmed the laundry had been backed up and the residents' clothes were not returned timely. She stated a housekeeping employee was working in the laundry two days each week, but the facility had been without a full-time laundry worker during the month of July and until August 14th, when a full-time worker was hired and started. She confirmed the residents did not get their clothes quickly and some had not gotten all their clothes back and this was a concern from the residents, and they had not provided follow up timely in a response to the resident's grievance. An interview with the resident on 8/22/23 at 3:10 PM, revealed her concern with the laundry was that she was in the facility for therapy and did not have a lot of clothes with her and wanted to be certain she had something to wear each day. Record review of the Face Sheet revealed that Resident #150 was admitted to the facility on [DATE] with diagnoses that included Chronic Kidney Disease and Type 2 Diabetes Mellitus. Record review of the MDS with an ARD of 8/15/23, revealed a BIMS score of 14, which indicated Resident #150 was cognitively intact. 44804 Resident #93 During this resident council meeting on 8/22/23 at 2:00 PM, Resident #93 revealed that he had complained about the water pressure in the showers on his hall, It just barely spits water out. He stated that it takes forever to take a shower because you can barely get wet and there is no stripping on the floor of the shower. He revealed he had complained about this before, but nothing had been done and no one had come and talked to him about it. An observation on 8/22/23 at 2:30 PM, revealed the shower on the Blue Unit had low water pressure and no safety stripping on the floors of the shower. An interview and observation on 8/22/23 at 2:40 PM, with Certified Nurse Assistant (CNA) #4 confirmed there was no safety stripping on the floor of the shower on the Blue Unit and the water pressure was very low. She stated the safety stripping needs to be in place to keep the residents from slipping and falling and the water pressure being low means it would take a long time to give a shower to a resident or for them to take and finish a shower. She revealed that things like this should be reported to maintenance and the CNAs should tell the nurse about the residents' complaints. She stated she thinks that maintenance has worked on the shower heads already to help with the water pressure, but she is not sure about the stripping and admitted that she has not reported it to anyone. An interview on 8/23/23 at 8:20 AM, with the Administrator confirmed that Resident #93 had mentioned it in resident council meeting last month about the showers not having a safety strip and that he had voiced a grievance about the low water pressure. The Administrator confirmed that she had not been told and a maintenance order had not been put in, but it should have been. An interview on 8/23/23 at 8:45 AM, with the Activity Director confirmed that once she gets the grievance from the resident that she goes to the department head and lets them know the concern. She confirmed that she just realized that Resident #93 had mentioned it in the resident council meeting in the beginning of August. An interview on 8/23/23 at 9:00 AM, with the Assistant Director of Nursing (ADON) confirmed that the Activities Director had told him about the showers on the blue hall but never told him a specific resident. He revealed that he told the Maintenance man and that he said Ok. He confirmed that there was no documentation of the maintenance request or follow up but there should have been. Record review of the Resident Council meeting minutes from 8/7/23 revealed that Resident #93 complained about needing safety stripping on the floor of the showers on his hallway and the water pressure was bad. An interview on 8/23/23 at 3:45 PM, with the Administrator confirmed that she feels like grievances need to be written up for accountability and follow up and need to be resolved timely. Record review of the Face Sheet revealed that Resident #93 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder and Weakness. Record review of the MDS with ARD of 6/30/23, revealed a BIMS score of 15, which indicated the resident was cognitively intact.

Based on staff and resident interview, record review and facility policy review the facility failed to assist a resident with his right to vote for one (1) of five (5) residents reviewed for voting rights. Resident #31 Findings Include: Review of the facility policy titled, Resident Rights with no revision date revealed that each resident had, . A. The right to civil and religious liberties . Review of the facility policy titled, Voting Policy revealed It is a policy of this facility that all residents reserve the right to vote in local, State and Federal elections .If a resident desires to go to the local precinct to vote, transportation arrangements will be made if .and Social Services will be responsible for arranging voting by absentee ballot for any resident who so desires. During the Resident Council meeting on 8/22/23 at 2:00 PM, Resident #31 revealed he has lived at the facility for two years and no one has ever spoke to him about voting, but he would like to. An interview on 8/22/23 at 3:15 PM with Social Services revealed that all residents are asked about voting on admission and if they need assistance. A record review with Social Services revealed that Resident #31 did not have a social history assessment completed when he was admitted and the question about needing or wanting assistance with voting was not addressed with the resident. She stated voting assistance should have been addressed with the resident so he could go vote or vote absentee if he wanted to. An interview on 8/23/23 at 3:45 PM, with the Administrator confirmed that residents should be offered transportation to go vote or assisted with absentee voting. This should be addressed with them around election times. Record review of Resident #31's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Peripheral Vascular Disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident is cognitively intact.

Based on observation, record review, policy/procedure review, and interview; the facility failed to maintain a quality assessment and assurance committee that would develop and implement appropriate plans of action to correct hazardous chemicals accessible to residents with risk of wandering for one (1) of four (4) chemical storage rooms and one (1) of one (1) beauty shops. The facility's failure to provide quality assessment facility doors to ensure the safety of the facility residents had the likelihood of placing cognitively impaired, wandering residents at risk for serious injury, harm, impairment, or death as evidenced by housekeeping and maintenance staff failed to secure hazardous chemicals behind locked doors and away from cognitively impaired, wandering residents. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 11/16/15, and was determined to exist on 11/16/15 when observation during initial tour of the facility revealed cleaning chemicals and insecticides stored unsecured in an unlocked office/storage room and hair products stored in an unlocked beauty shop. The SA notified the facility on 11/16/15 of the Immediate Jeopardy and Substandard Quality of Care. The facility submitted a credible Allegation of Compliance (AOC) on 11/18/15, the State Agency Surveyor validated the facility's Allegation of Compliance (AOC) and the Immediate Jeopardy was determined to be removed 11/18/15 prior to exit from the facility on 11/19/15. Therefore, 42 CFR 483.75 (o), F520 was lowered from a J level deficiency to a D level or isolated deficiency while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility's policy/procedure of Quality Assessment and Assurance Committee with a revision date of August 2006 revealed Policy Statement: This facility shall establish and maintain a Quality Assessment and Assurance Committee that oversees the identification and handling of quality issues. The Goals of the Committee are: The primary goals of the Quality Assessment and Assurance Committee are: 1. To monitor and evaluate the appropriateness and quality of care provided within the framework of the Quality Assessment and Assurance Plan; 2. To oversee facility systems and processes related to improving quality of care and services; 3. To promote consistent facility systems and processes and appropriate practices in resident care; 4. To help identify negative outcomes relative to resident care and resolve them appropriately; 5. To help departments, consultants and ancillary services implement plans to correct identified issues in quality of care; 6. To coordinate the development, implementation, monitoring, and evaluation of action plans to achieve specified quality goals; 7. To help departments, consultants and ancillary services establish effective accountability for care quality; and 8. To coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members. Record review of the facility's policy/procedure of Quality Assessment and Assurance Plan (revised August 2006) revealed, Purpose: The primary purposes of the Quality Assessment and Assurance Plan are: 1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and safety; 2. To reinforce and build upon effective systems of services and positive care measures; 3. To provide a structure and process to correct identified quality deficiencies; 4. To establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome . 7. To establish a system and process to maintain documentation relative to the Quality Assessment and Assurance Program, as a basis for demonstrating that there is an effective ongoing program. Observation on 11/16/15 at 10:15 AM revealed the Beauty Shop door unlocked. There was no staff present in this room. There were two (2) cabinets found unlocked with one (1) 5 ounce (oz) bottle of dry shampoo, 1 aerosol 10.5 oz can of mousse, and nine (9) cans of 11 oz aerosol hairspray. Observation on 11/16/15 at 10:25 AM revealed the Maintenance/Housekeeping/Laundry office door unlocked with no staff present. There were shelves and unlocked cabinets with multiple containers of wax stripper, floor finish stripper, antiseptic soaps, lotions and sanitizers, carpet cleaner, glass cleaner, furniture polish, steel polish and insecticides. Record review of the facility 2567 from the Annual Survey of 8/20/15 revealed, During tour of the facility on 8/18/15 at 10:00 AM, observation and interview revealed the 100 hall storage closet door was unlocked. A key code entry lock was on the door, but had been left unlocked. Inside was an electrical outlet box which was unlocked and opened, along with an ice machine and staff personal items . Observation and interview again of the 200 hall storage closet on 8/18/15 at 5:00 PM, revealed the storage closet door remained unlocked. Inside the storage closet was the electrical box, unlocked and open, personal staff items, and the ice machine. Review of the facility's Plan of Correction for the unlocked closet/storage room revealed the facility stated, Door will be observed during 7- 10 by the Administrator and will be documented on door monitoring form that has been implemented. The Director of Nursing, Assistant Director of Nursing, the QA (Quality Assurance) Nurse and the Maintenance Director will all be doing checks between 7 to midnight to ensure the doors are locked and closed. The monitoring is done on the form implemented . QA committee members will do checks on the ice room doors a minimum of 4 X weekly for the next 3 months. Review of sign in sheets revealed on 8/21/15 a weekly meeting was held after the Annual Survey of 8/20/15 had completed. A Plan of Correction was discussed at this time. The minutes of the meeting revealed 4. Ice Room Doors: The ice room doors must be locked at all times. All team members are to be monitoring this. If a door is found unlocked by a staff member, (name of administrator), is to be notified immediately. She will review the camera to see who should be held responsible. Attendees were: Administrator, Director of Nursing, Social Worker, Staff Coordinator, Maintenance Director and Housekeeping Director. A Quarterly Quality Assurance Committee meeting was conducted 10/29/15. Minutes were not provided. The sign in sheet had the following signatures of those that attended: Administrator, Maintenance Director, Housekeeping Director, Licensed Social Worker, Director of Nurses, Staffing Coordinator, and the Medical Director. Interview with the Maintenance Director on 11/16/15 at 2:10 PM revealed, We had a form on our closet ice door and a closet where a med cart is kept and lift batteries are kept. Right after State came; (name of Administrator) did a check list for routine lock checks on those two doors. If you went past it, you would sign your name, time of day and date you checked those doors. It did not involve all the facility doors, just those two doors. Review of the Locked Door Audit form listed in the facility's Plan of Correction with a completion date of 10/12/15 revealed Location listed either Pink Side or Blue Side. The form was not specific to which door, or doors were being monitored. Pink Side was designated as resident rooms 101-132 and Blue Side was identified as resident rooms 201-232. Employee initials were documented and open or closed and locked were circled. Review of these visual monitoring forms revealed staff signature of who did the monitoring, times and dates of the monitoring and which side was observed. Interview with the Administrator on 11/16/15 at 2:25 PM revealed the facility only documented the visual monitoring of the 2 ice room doors and the in-service was on the ice room doors staying locked. The facility submitted a credible Allegation of Compliance on 11/18/15 for the Immediate Jeopardy. Review of the facility's credible Allegation of Compliance revealed the facility took the following measures to remove the Immediate Jeopardy. 1. On November 16, 2015, at approximately 10:30 AM, the Housekeeping/Maintenance/Laundry door was locked by the Maintenance Director to prevent anyone walking into the area before the doorknob could be changed to a self locking knob. The door knob was changed by the Maintenance Director to a self locking doorknob on November 16, 2015, at approximately 3:00 p.m. A person must have the key to enter into the room. Keys will be kept by the Administrator, Maintenance Director, Maintenance Assistant, weekend charge nurse, and the Housekeeping Supervisor. On November 16, 2015 at 4:20 p.m., the Maintenance Director was in-serviced and disciplined by the Administrator about the importance of the housekeeping/maintenance office door being locked, chemicals being stored appropriately and his responsibility to ensure policies and regulations regarding the secured storage of chemicals are being met. At 6:30 p.m. on November 16, 2015, all chemicals were locked into cabinets in the housekeeping office. 2. The Administrator began visual audits of the housekeeping/maintenance office door on November 16, 2015 at 11:30 AM. The housekeeping/maintenance door was also visually audited on November 16, 2015 at 12:15 PM and 4:30 PM by the Administrator. During the audits of the office door, it was found to be closed and locked each time. The Administrator also followed up verbally, on November 16, 2015, with each housekeeper on duty, the Maintenance Director, Maintenance Assistant and the Housekeeping Department to ensure they understood the importance of keeping all chemicals locked away at all times, expect when they had them in their hands. They also understood that disciplinary actions, up to termination, will be taken if the door is found unlocked again or if any chemicals are found unattended and easily accessible to residents and public. 3. An emergency quality assurance committee meeting was held at 4:45 p.m. on November 16, 2015, due to an immediate jeopardy being identified, with the Social Worker, Maintenance Director, interim Director of Nursing, Staff Development Director, Administrator, and Medical Director. During the quality assurance committee meeting, the policies were reviewed on the storage of chemicals and the systematic changes that need to take place to ensure there is not a reoccurrence. The team decided that the policies do not need to be revised; but that visual auditing for unsecured chemicals should take place to ensure that chemicals are properly locked away in a secure area, pad locks are to be used on chemical cabinets in housekeeping/maintenance office and door knob was changed to a self locking door knob with key required for entry. 4. The Maintenance Director and the Housekeeping Director have been disciplined accordingly by the Administrator, with the Housekeeping Director being disciplined and in-serviced, by the Administrator, on November 17, 2015 at 10:15 a.m. One on one in-service was completed with each housekeeping/laundry and maintenance employee by 2 employees from laundry and 1 employee from maintenance was in-serviced on the guidelines of chemical storage. In-servicing is vital to ensure each employee understands their part for continuous quality improvement. At 3:30 p.m. on November 17, 2015 in-services for all employees was initiated on chemical storage guidelines by Administrator and Staff Development Director. No employee will work until they have been in-serviced on the regulations and guidelines of chemical storage. 5. Visual auditing and monitoring for unsecured chemicals began November 16, 2015 at 11:30 A.M. by the Administrator, by walking around facility and visually looking in areas for unsecured chemicals. No other unsecured chemicals were found. 6. We feel the immediate jeopardy was removed as of November 18, 2015. On 11/18/15 and 11/19/15, the State Agency Surveyor validated the facility had implemented the following measures to remove the Immediate Jeopardy as of 11/18/15. The acceptable, credible Allegation of Compliance was verified by interviews and record review of inservices across all disciplines. These interviews included one (1) Social Worker, 1 Licensed Practical Nurse, three (3) Registered Nurses, 3 Certified Nurse Aides, 1 Restorative Aide, 1 Laundry worker, 1 Maintenance Assistant, 3 Housekeepers, 1 Housekeeping Supervisor/Director, 1 Medical Records Worker, 1 Occupational Therapist, 3 Business Office Workers, 3 Kitchen/Cook Aides, 1 Activity/Transport Certified Nurse Assistant. The staff interviews revealed knowledge of the facility's policy/procedure for Chemical Storage and attendance of the in-service on Chemical Storage that began on November 17, 2015. Observation on 11/18/15 revealed the Maintenance/Housekeeping/Laundry office door knob had been replaced and locked. Observation on 11/18/15 revealed all cabinets with chemicals were secured with locks and shelves were emptied of all chemicals. Record review on 11/18/15 of personal files revealed the Maintenance Director and Housekeeping Director were disciplined and both were in serviced on secured storage of chemicals. Record review on 11/18/15 of log sheets confirmed that visual audits of locked chemical doors were being completed. On 11/18/15 record review revealed Quality Assurance Committee meeting on 11/16/15 and the sign-in sheet. Those attending were the Administrator, interim Director of Nursing, Medical Director, Staff Development Registered Nurse, and Licensed Social Worker. Record review of sign in sheets revealed an inservice began staff wide on 11/17/15 at 3:30 PM on securing chemicals, and that no staff are allowed to work until inserviced.

CI # Based on observation, record review, and staff interviews, the facility failed to follow the care plan related to transfer of a resident, resulting in a fracture of Resident #3's right tibia and fibula for one (1) of two (2) allegations of abuse reviewed. Findings Include: A review of Resident #3's care plan revealed a problem onset of 5/29/13, stated that the resident was at risk for falls related to medication use, impaired mobility, diagnose of [MEDICAL CONDITION] and visual decline related to [MEDICAL CONDITION] and hypertension. The goal target date of 10/30/15 said resident would have no falls and reposition every two hours and as needed. 2. Provide total lift for transfers. 3. Provide two-person assist with lift for transfers and weights, non-weight bearing. Resident #3's care plan was not followed as evidenced by her being transferred without the use of a total lift and two person assist on 8/2/15 and again on 8/3/15. An injury of a fractured right tibia and fibula resulted. Review of the facility's investigation conducted by the Administrator revealed that on 8/4/15 at approximately 6:00 AM, a CNA called Licensed Practical Nurse (LPN) #3 to Resident #3's room to look at Resident #3's leg. Upon entering, the nurse observed the resident's right lower leg was swollen, bruised and painful to touch. The DON was notified. The facility transferred Resident #3 to the hospital and was admitted for a fractured tibia and fibula. The facility investigation concluded Resident #3 was injured when LPN #2 transferred the resident without the use of a total lift device, but instead picked the resident up on 8/2/15 and on 8/3/15. LPN #2 was placed on leave until investigation was complete. Review of the facility video tapes failed to identify any abuse incident with Resident #3. Interview on 8/19/15 at 5:45 PM revealed LPN #2 replied she had never looked at the care plan to see about Resident #3's transfer status and stated she was not sure how Resident #3 was supposed to be transferred. LPN #2 stated she assisted with transfers on occasion and stated she did not look at resident care plans to see how they were to be transferred. She stated she usually had seen how the CNAs transferred the resident. She explained she had never seen the CNAs transfer Resident #3 because the resident did not usually get up out of bed. On 8/19/15 at 6:50 PM, an interview with CNA #7 revealed transfer residents were on the cardex or Kiosk. CNA #7 explained Resident #3's care plan read to use a total 2 person mechanical lift. CNA #7 stated they never picked up a resident assessed for 2 person lift manually. Review of the facility's face sheet revealed, the facility admitted the Resident #3 on 11/25/03. Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's the Minimum Data Set (BIMS) score of three (3) indicating the resident had severe impairment.

CI # Based on observation, record review, staff interview and facility policy review, the facility failed to: (a) transfer a resident as assessed, resulting in a fracture of Resident #3's right tibia/fibula for one (1) of two (2) allegations of abuse reviewed (CI # ) , and (b) ensure a closet with electrical outlet box was locked for one (1) of two (2) environmental tours. Findings Include: (a) Review of the facility's undated Lifting Policy revealed the facility, will provide a safe work environment for resident care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personnel and resident injury . All staff are accountable for utilizing proper body mechanics, lifting techniques and resident safety . Staff members will utilize the proper transfer procedure for each resident. This includes the use of the resident transfer devices or other lifting equipment and applying body mechanics. Review of the facility's investigation conducted by the Administrator revealed that on 8/4/15 at approximately 6:00 AM, a Certified Nurses Assistant (CNA) called Licensed Practical Nurse (LPN) #3 to Resident #3's room to look at Resident #3's leg. Upon entering, the nurse observed the resident's right lower leg was swollen, bruised and painful to touch. The Director of Nurses (DON) was notified. The facility transferred Resident #3 to the hospital and was admitted for a fractured tibia and fibula. The facility investigation concluded Resident #3 was injured when LPN #2 transferred the resident without the use of a total lift device, but instead picked the resident up on 8/2/15 and on 8/3/15. The nurse was placed on leave until investigation was complete. Review of the facility video tapes failed to identify any abuse incident with Resident #3. Observation and interview on 8/17/15 at 11:20 AM, during the initial tour of the facility with Registered Nurse (RN) #3 revealed a frail Resident #3, lying in bed with the bed in the low position. An interview with RN #3 revealed Resident #3 had a recent fracture and had a cast present above the right knee. Review of nursing notes revealed on 8/4/15 at 7:26 AM, LPN #3 recorded a 7-3 shift CNA called her to Resident #3's room to look at the resident's right leg with noted swelling, bruising and painful to touch. The Director of Nurses was notified. Review of hospital reports dated 8/4/15 revealed the Radiologist at the local hospital confirmed there were right tibia and fibula fractures with overlapping of the fracture fragments and the local hospital transferred the resident to a hospital with a Consulting Orthopedist for management of right tibia fibular fracture. The resident received splint to the right lower extremity. According to the hospital reports, on 8/5/15 the orthopedist reported placing a long leg cast with good padding. Review of the 7/16/15 Lift/Transfer/Assistance assessment revealed Resident #3 was dependent, requiring more that 50 percent assistance by staff and was a total lift. She cannot bear weight. She does not have upper body strength to support her weight during transfer. Interview with Resident #3 on 8/19/15 at 11:50 AM revealed Resident #3 said LPN #2 was getting her up from the chair to bed. LPN #2 had her under the arms, lifted her by picking her up and put her in the bed. Resident #3 said she yelled out with pain and remarked, you broke my leg. LPN #2 told her no, she hadn't and laughed. Resident #3 said LPN #2 didn't believe that her leg was broken but it hurt something awful. On 8/19/15 at 11:55 AM, an interview with Resident #3's roommate revealed the roommate stated at the time of the incident, the curtain was pulled, and she could not see well. The roommate stated she heard what happened when LPN #2 got Resident #3 up from the gerichair and back to bed. She heard Resident #3 scream out with pain and tell her that she broke her leg. LPN #2 told Resident #3 she didn't break her leg. The roommate stated LPN #2 did not laugh at her, just said it in a playful way. Resident #3's roommate had a Brief Interview of Mental Status (BIMS) score of 15, indicating she was cognitively intact. On 8/19/15 at 2:45 PM, a telephone interview with CNA #1 revealed the CNA was unable to recall the exact date. CNA #1 explained she did recall Resident #3 yelling out and LPN #2 instructing CNA #1 and CNA #4 to get Resident #3 up out of bed. CNA #1 recalled she went to get the lift and she thought during that time CNA # 4 went to assist another resident. When together they entered Resident #3's room, she was already up in the gerichair. LPN #2 told the CNAs to put Resident #3 back into the bed. CNA #1 said she knew Resident #3 required a 2 person lift, but because the resident was so little and frail and already had a draw sheet under her in the chair, together CNA #1 and CNA #4 lifted her with the draw sheet and put her back into bed. CNA #1 stated LPN #2 told them that she had gotten Resident #3 up into the chair. The CNA stated no lift was observed in the room. Review of LPN #2's written statement dated 8/4/2015 and signed by LPN #2 read: On August 3, 2015 between 8:00 AM and 10:00 AM, Resident #3 was observed with her legs hanging over the side of the bed. I asked the CNAs to get a gerichair so I could get her up so she would not fall. I lifted her long enough to transfer her to the gerichair. Once she was in the gerichair I put a pillow under her legs. She stated 'I want a pillow behind my neck', so I put the pillow behind her instead. She sat in the day room until about lunch time, when she was put back to bed. I went back in the room to tend to the resident's roommate. Resident #3 said 'those girls broke my leg'. I asked her what girls? She stated, 'you know whose girls.' I don't know who the girls were, and I was unaware that she had been put back to bed. I asked her where and touched her on the thigh area. I asked if it was right here, and she said yes. I touched down the rest of her leg and pulled her sock down. I saw no areas that looked to be swollen or red. She asked for a pain pill and I gave her one. On 8/3/15 a telephone interview by the DON to CNA #1 related to Resident #3's care on 8/3/15 revealed Resident #3 was hollering out that her leg hurt and her neck was broken. No bruising or other differences were noted. She stated she positioned the resident's legs on pillows as usual. CNA #1 was questioned if resident #3 was hollering when was assisted up to the gerichair the prior day. CNA #1 replied she had not gotten Resident #3 up the prior day but that she and CNA #4 had put her to bed and that they did not see anything wrong at that time. On 8/19/15 at 3:30 PM, an interview with CNA #2 revealed transfers were always 2-person. Some residents can use the stand to lift and others are total lift. They never pivot or pick-up residents. CNA #2 explained she would check the care plans that are always available in the cabinet at the nurses' station or ask a nurse to find out the transfer status of a resident. On 8/19/15 at 3:37 PM, interview with CNA #3 revealed to find out a resident's transfer status, she explained she would get a report from the off-going shift, or ask the nurse. On 8/19/15 at 5:45 PM, a conference call with LPN #2 revealed LPN #2 reported putting Resident #3 into a gerichair on a day shift. LPN #2 reported she had transferred Resident #3 two (2) times herself, by raising the head of her bed, putting her arms under the resident's arms and transferring her from the bed to the gerichair. She reported Resident #3 cannot stand and that she never put weight on her legs, her knees were bent but her feet did not touch the floor and she did not bear any weight. LPN #2 admitted she did not wait for the CNAs to return with the lift and she replied, it was bad judgment on her part. LPN #2 stated there were no indications of pain during the transfer. LPN #2 said Resident #3 told her those girls (implying the CNAs) broke her leg. She said she looked at the resident's leg and couldn't see any injury - when her upper thigh was touched, she said that hurt. Asked LPN #2 how many times she had transferred resident #3 by herself and she replied, two. On 8/19/15 at 6:50 PM, an interview with CNA #7 revealed CNA #7 was asked how she knew how to transfer residents, and she replied on the cardex or Kiosk. CNA #7 explained for example, a four (4) on the Kiosk means a two person total lift. CNA #7 stated that the CNA 's never pick up a resident assessed for '2 person total lift' manually. We are a 'no lift' facility meaning we never manually transfer anymore. On 8/20/15 at 11:25 AM an interview with CNA #4 revealed she denied working with Resident #3 on Sunday, 8/2/15, but did so on Monday 8/3/15 on the 7 AM - 3 PM shift. She denied knowing how Resident #3 got into the gerichair on 8/3/15, but recalled the Assistant Director of Nurses (ADON) adjusting pillows for this resident in the day room, CNA #4 stated she and CNA #1 moved Resident #3 from the gerichair to her bed, picking her up with the draw sheet that was already under her and placing her back into bed. Asked how she knows how to transfer residents, CNA #1 replied they look at the cardex or Kiosk and that Resident #3 is to always be a total lift - 2 person. Asked the facility's policy on lifting and transferring residents, she replied 'a total lift only facility'. CNA #4 stated she had always used the lift until this time on 8/3/15. She said she rarely assisted with Resident #3 and did not notice any bruising on her. On 8/20/15 at 1:50 PM, interview with the DON revealed the facility's policy on transfers of residents was to always to use lifts, 2 person assist. The DON explained therapy evaluates all residents and makes recommendations on transfer status and stated there are not to be any manual lifts, all transfers and lifts are to be done mechanically. The DON explained the incident with Resident #3 occurred due to an inappropriate transfer. The DON reported the facility's investigation told them LPN #2 got Resident #3 up without following the facility's policy. Review of the facility's face sheet revealed, the facility admitted the Resident #3 on 11/25/03. Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's the Minimum Data Set (BIMS) score of three (3) indicating the resident had severe impairment. (b) During tour of the facility on 8/18/15 at 10:00 AM, observation and interview revealed the 100 hall storage closet door was unlocked. A key code entry lock was on the door, but had been left unlocked. Inside was an electrical outlet box which was unlocked and opened, along with an ice machine and staff personal items. LPN #1 confirmed the unlocked door, and confirmed the door was to remain locked for the safety of residents. LPN #1 immediately locked door. Observation and interview again of the 200 hall storage closet on 8/18/15 at 5:00 PM, revealed the storage closet door remained unlocked. Inside the storage closet was the electrical box unlocked and opened, personal staff items, and the ice machine. RN #1 confirmed door was unlocked at this time and stated the door was supposed to remain locked to restrict resident access. Storage closet door had key code lock to door. RN #1 immediately locked door. Interview with the Administrator on 8/18/15 at 4:05 PM, confirmed staff have been in serviced on ensuring doors with key code entry, remain locked.