Every finding on record at Colonial Manor Nursing & Rehabilitation Home

Based on observation, record review, and interviews, the facility failed to ensure CNAs have the specific competencies, and skill sets necessary to care for resident needs by not wearing appropriate PPE when providing care to a resident on EBP for 1 (#5) of 5 residents reviewed for competent nursing staff.Findings: Review of the facility's Enhanced Barrier Precautions policy dated 01/08/2026 revealed the following in part:Policy:It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms.Definitions: Enhanced barrier precautions refers to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices).2. Initiation of Enhanced Barrier Precautions-b. An order for enhanced barrier precautions will be obtained for the residents with any of the following:i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO.Review of the medical record for Resident #5 revealed an initial admission date of 08/15/2022 and a readmit date of 04/06/2026. Resident #5 had diagnoses that included gastrostomy tube, muscle wasting and atrophy, vascular dementia, hemiplegia and hemiparesis.Review of the current MDS assessment dated [DATE] revealed Resident #5 had severe cognitive impairment, a feeding tube, and pressure ulcers.Review of the current careplan revealed Resident #5 was on EBP related to PEG placement and wounds to the left heel and right lateral buttock. The direct care staff were to utilize gowns and gloves for all personal care.Review of the April 2026 physician orders revealed an order dated 01/06/2026 for EBP every shift.On 05/05/2026 at 10:35 a.m. observation of S3CNA revealed she was giving Resident #5 a bed bath. Further observation revealed S3CNA wore gloves but did not wear a gown when performing care. On 05/05/2026 at 3:30 p.m. interview with S3CNA confirmed Resident #5 was on EBP and she did not wear a gown when providing care. On 05/05/2026 at 3:50 p.m. interview with S4CNA Supervisor confirmed Resident #5 was on EBP and S3CNA should have worn a gown when providing care. On 05/05/2026 at 4:00 p.m. S1Administrator and S2DON were notified of S3CNA not wearing the appropriate PPE when providing care to Resident #5 on EBP.

Based on observations and interviews, the facility failed to: 1.) ensure proper hair restraint for kitchen staff and 2.) store food and discard expired items in accordance with professional standards for food service safety. This deficient practice had the potential to effect 57 residents that received meals prepared in the facility's kitchen. Findings:Review of the undated facility's date marking for food safety policy revealed in part, the following:-The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded.-The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared.-The marking system shall consist of a label and the day/date of opening.-The discard day or date may not exceed the manufacturer's use by date, or 48 hours, whichever is earliest.Review of the undated facility's dietary employee personal hygiene policy revealed in part, the following:-All dietary staff must wear hair restraints (e.g. hairnet, hat and/or beard restraint) to prevent hair from contacting foodOn 01/06/2026 at 7:55 a.m. during an initial kitchen tour of the revealed the following:The dry storage area contained the following items that had been opened and not labeled with an open date: a (22 quart) storage container was open and not covered with a hard white substance on the bottom (identified as sugar by the S5Dietary Manager), within this storage container - an opened five pound bag of cake mix with no open date, an open five pound bag of gingerbread mix not labeled with an open date, an opened five pound bag of cornmeal with no open date, two open bags identified by the S5Dietary Manager as brownie mix not labeled with an open date, one package of peach drink mix opened and not labeled with an open date, one (32) ounce package of cheese sauce powder mix opened and not labeled and one (17) ounce package of mouse mix, opened and not labeled.The walk- in refrigerator contained three individual containers of whole milk dated December 23, three individual containers of whole milk dated December 28 and two milk crates containing individual containers of reduced fat milk dated January 4.The walk- in freezer contained: four loaves of bread that were identified by S5Dietary Manger with no identifying information or dates, one bag of what was identified as pieces of sausage by the S5Dietary Manager with no open date, one unlabeled bag of white circular objects approximately 2 inches in diameter identified by S5Dietary Manger as cookies with no identifying information or dates.Observation of S6Cook on 01/05/2026 at 8:01 a.m. revealed S6Cook was not wearing a hairnet or any type of hair covering while working in the kitchen. During an interview at this time, S6Cook confirmed he/she forgot his/her hair covering.Observation and interview with S6Cook on 01/05/2026 at 11:25 a.m. revealed S6Cook was not wearing a beard covering and explained the facility did not have any beard coverings.During an interview on 01/06/2026 at 8:15 a.m., S5Dietary Manager confirmed the above items should have been labeled with open dates according to the facility policy after being opened and the individual milk containers from December 23 and December 28 should have not been in the walk- in cooler.During an interview on 01/05/2026 at 11:27 a.m., S5Dietary Manager confirmed S6Cook should be wearing a beard net and the facility did not have any available. During an interview on 01/07/2026 at 2:37 p.m., S1Administrator confirmed staff should wear hair nets and beard coverings according to the facility policy.During an interview on 01/07/2026 at 2:39 p.m., S1Administrator confirmed items in the kitchen should be labeled and dated with open dates and kitchen staff should be following facility policies.

Based on observations and interviews, the facility failed to ensure garbage had been disposed of properly. The facility census was 58 residents and the deficient practice had the potential to affect all residents.Findings:Review of the facility's Disposal of Garbage and Refuse policy undated revealed in part,:-Garbage and refuse containers shall be durable, cleanable, and free from crack or leaks and covered when not in use.-Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.Observation during the initial tour of the kitchen on 01/05/2026 at 7:55 a.m. revealed only 1 trash can in the kitchen, that trash can was covered and did not have a foot pedal. Further observation revealed the dining area attached to the kitchen and separated from the dishwashing area by an open window contained an uncovered trash can.Observation of the outside dumpsters on 01/06/2026 at 8:37 a.m. revealed one dumpster with three large and long rusted horizontal cracks on the bottom front of the dumpster that made items inside the dumpster visible. The same dumpster also had a corner with a large separation of the metal that made a white trash bag and items in the dumpster visible through the separation. During an interview on 01/05/2026 at 7:55 a.m., S5Dietary Manger confirmed the only trash can in the kitchen did not have a foot pedal and the trash can in the kitchen/dining area separated by the dishwashing area open window was uncovered.During an interview with S1Administrator on 01/07/2026 at 2:49 p.m., S1Administrator confirmed all trash should be discarded and contained appropriately.

Based on observation and interviews the facility failed to maintain all kitchen equipment in safe operating condition as evidenced by the three torn door seals on three individual refrigerator doors of one refrigerator, one broken toaster, one toaster missing a crumb catcher, two of the three toasters were stored and full of bread crumbs, four full size pans covered in a black hardened substance, four half pans covered in a black hardened substance, two ovens covered with hardened black substance, one oven with four silver pieces of material approximately the size of a golf ball and a microwave with dark splattered substance on top and sides.Findings:Observation of the kitchen during the initial tour on 01/05/2026 at 7:55 a.m. revealed three torn door seals on three individual refrigerator doors of one refrigerator, one broken toaster, one toaster missing a crumb catcher, two of the three toasters were stored and full of bread crumbs, four full size pans covered in a black hardened substance, four half pans covered in a black hardened substance, two ovens covered with hardened black substance, one oven with four silver pieces of material approximately the size of a golf ball and a microwave with dark splattered substance on top and sides. During an interview on 01/05/2026 at 8:35 a.m. S5Dietary Manger confirmed the kitchen equipment should be working and clean. During an interview on 01/07/2026 at 3:00 p.m. S1Administrator confirmed the equipment in the kitchen should be in good repair and clean.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable and homelike environment for 2 (#39 and #46) of 2 sampled residents reviewed for environmental concerns.The facility failed to ensure:1. Resident #39's air conditioning/heating unit was kept clean;2. Resident #46's sink faucet remained in good repair. Findings:Resident #39On 01/05/2026 at 9:40 a.m. and 01/06/2026 at 8:40 a.m., a black substance was observed on the vent of Resident #39's air conditioner/heating unit.On 01/06/2026 at 9:20 a.m., an observation conducted with S1Administrator of Resident #39's air conditioning/heating unit confirmed that the vent had a black substance present and the vent needed to be cleaned. Resident #46On 01/05/2026 at 10:15 a.m. and 01/06/2026 at 8:45 a.m., observations made of Resident #46's bathroom sink revealed the faucet to be corroded and cracked creating a gap in the faucet underneath the cold water tap.On 01/06/2026 at 9:22 a.m., an observation conducted with S1Administrator confirmed Resident #46's sink faucet was damaged and cracked from corrosion and needed to be replaced.

Based on observation, record review and interviews, the facility failed to report an injury of unknown origin to the State Agency no later than 24 hours in accordance with State law for 1 (#55) of 1 resident reviewed for abuse.Findings: Review of the incident and accident policy and procedure with review/revised date of 07/01/2025 revealed in part:It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Policy explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Alert risk management and/or administration of occurrence's that could result in claims or further reporting requirements. Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: 2. Licensed staff will report incidents/accidents and assist with completion of any investigative information to identify root causes. 4. Incidents that rise to the level of abuse, misappropriation, or neglect will be managed and reported according to the facility abuse prevention policy. 5. The following incidents/accidents require an incident/accident report but are not limited to: alleged abuse, elopement, entrapment, equipment malfunction, falls, observed accidents/incidents, resident to resident altercations, resident injuries due to staff handling, self-inflicted injuries and unobserved injuries. 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. 15. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the DON and/or Administrator. Review of the policy and procedure for Abuse, Neglect, and Exploitation with a revised date of 07/01/2025 revealed in part: Policy:It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Policy Explanation and Compliance guidelines:1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention.2. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written.The components of the facility abuse prohibition plan are discussed herein:II Employee Training C. Training topics will include:3. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown origin. 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown origin. IV. Identification of Abuse, Neglect, and ExploitationA. The facility will have a written procedure to assist staff in identifying the different types of abuse- mental, verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.B. Possible indicators of abuse include, but are not limited to:3. Physical injury of resident of unknown sourceVII. Reporting/ResponseA. The facility will have written procedure that include:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within the specified timeframes.a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury,B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident as required by state agencies. Record review revealed Resident #55 had diagnoses of chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and history of malignant neoplasm of the right breast.Review of the quarterly MDS dated [DATE] revealed Resident #55 had a BIMS of 8 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #55 was dependent on staff for all ADLs and required substantial/maximum assistance with rolling in bed and was dependent for transfers. On 01/05/2026 at 9:15 a.m., an observation of Resident #55 revealed she was sitting up in bed. Further observation revealed a large bruise to the right shoulder/armpit area. Interview with Resident #55 at that time revealed she was unable to state how the bruise to the right shoulder/armpit area occurred.On 01/06/2026 at 1:27 p.m., an interview with S7CNA during an observation of changing resident #55's brief revealed she stated the bruise to the right shoulder/armpit had been there for several weeks. S7CNA further stated she was not aware of a specific reason for the bruising.Review of Resident #55's current medications in part revealed an order for Eliquis 2.5 mg twice a day by mouth.Review of the nurses' note dated 12/04/2025 by S4Treatment Nurse revealed she was notified by the hospice CNA that a new large bruise was identified under the right armpit. S4Treatment Nurse performed a skin assessment of the area. The bruise was 7 cm by 3 cm with a light purple tint. Resident was asked if she had any pain and resident responded, Well, I didn't even know it was there. But it doesn't hurt. When asked if resident remembers how it was acquired, resident stated, No, but you know how fragile my skin is. S4Treatment nurse noted that the sling lift was used Monday to transfer the resident to the Geri chair. S4Treatment nurse educated primary CNAs of proper placement of lift and lift techniques.On 01/07/2026 at 8:30 a.m., an interview with S8LPN regarding the bruise to Resident #55 right shoulder/armpit area revealed the resident was gotten up a while back with the lift and they believe the lift pad caused the bruise. S8LPN further said it was reported to S2DON and S1Administrator. On 01/07/2026 at 8:40 a.m., an interview with S2DON revealed she was aware of the bruise on Resident #55's right shoulder/armpit but did not remember how it happened and was not sure if an incident report with an investigation was completed when the bruise was identified on 12/04/2025. S2DON further stated the only information they had regarding the bruise to the right shoulder/armpit area were the notes in the computer and then S2DON produced a written statement she had completed. Review of the written statement by S2DON dated 12/04/2025 revealed:I was notified by the wound care nurse that a bruise was noted to resident right shoulder/armpit area. Upon exam, active range of motion/passive range of motion were within normal limits and resident denies pain. When I asked her what happened, the resident states I didn't even know it was there. Resident has a history of easy bruising and skin tears. The lift used to maneuver resident is the sling lift which does not go under the arms to cause the bruising. Sometimes resident is assisted by placing her hand under her arm to assist her sitting up or repositioning. CNAs were verbally spoken to by wound care nurse on using draw sheets and proper body mechanics for positioning patient and that she is a very easy bruiser. During an interview on 01/07/2026 at 10:39 a.m., S2DON confirmed the facility did not report the injury of unknown origin to the State Agency as required regarding the large bruise to Resident #55's right shoulder/armpit area when it was identified on 12/04/2025. During an interview on 01/07/2026 at 1:15 p.m., S1Administrator confirmed they did not report the bruise to the right shoulder/armpit area on Resident #55 when it was discovered to the State Agency as an injury of unknown origin when it was discovered.

Based on observation, record review and interviews, the facility failed to investigate an injury of unknown origin for 1 (#55) of 1 resident reviewed for abuse. Findings:Review of the incident and accident policy and procedure with review/revised date of 07/01/2025 revealed in part:It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Policy explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Alert risk management and/or administration of occurrence's that could result in claims or further reporting requirements. Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines: 2. Licensed staff will report incidents/accidents and assist with completion of any investigative information to identify root causes. 4. Incidents that rise to the level of abuse, misappropriation, or neglect will be managed and reported according to the facility abuse prevention policy. 5. The following incidents/accidents require an incident/accident report but are not limited to: alleged abuse, elopement, entrapment, equipment malfunction, falls, observed accidents/incidents, resident to resident altercations, resident injuries due to staff handling, self-inflicted injuries and unobserved injuries. 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-up interventions. 15. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the DON and/or Administrator. Review of the policy and procedure for Abuse, Neglect, and Exploitation with a revised date of 07/01/2025 revealed in part: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Policy Explanation and Compliance guidelines:1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property.b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention.2. The facility will provide ongoing oversight and supervision of staff in order to ensure that its policies are implemented as written.The components of the facility abuse prohibition plan are discussed herein: II Employee Training C. Training topics will include: 3. Recognizing signs of abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown origin. 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown origin. IV. Identification of Abuse, Neglect, and ExploitationA. The facility will have a written procedure to assist staff in identifying the different types of abuse- mental, verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.B. Possible indicators of abuse include, but are not limited to:3. Physical injury of resident of unknown sourceV. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigating include:1. Identifying staff responsible for the investigation.3. Investigating different types of alleged violations.4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred, the extent, and cause, and6. Providing complete and thorough documentation of the investigation. Record review revealed Resident #55 had diagnoses of chronic diastolic congestive heart failure, atrial fibrillation, dementia, cognitive communication deficit, rheumatoid arthritis, and history of malignant neoplasm of the right breast.Review of the quarterly MDS dated [DATE] revealed Resident #55 had a BIMS of 8 indicating moderate cognitive impairment. Further review of the MDS revealed Resident #55 was dependent on staff for all ADLs and required substantial/maximum assistance with rolling in bed and was dependent for transfers. Review of Resident #55's current medications in part revealed an order for Eliquis 2.5 mg twice a day by mouth.On 01/05/2026 at 9:15 a.m., an observation of Resident #55 revealed she was sitting up in bed. Further observation revealed a large bruise to the right shoulder/armpit area. Interview with Resident #55 at that time revealed she was unable to state how the bruise to the right shoulder/armpit area occurred.On 01/06/2026 at 1:27 p.m., an interview with S7CNA during an observation of changing resident #55's brief revealed she stated the bruise to the right shoulder/armpit had been there for several weeks. S7CNA further stated she was not aware of a specific reason for the bruising.On 01/07/2026 at 8:30 a.m., an interview with S8LPN regarding the bruise to Resident #55 right shoulder/armpit area revealed the resident was gotten up a while back with the lift and they believe the lift pad caused the bruise. S8LPN further said it was reported to S2DON and S1Administrator. On 01/07/2026 at 8:40 a.m., an interview with S2DON revealed she was aware of the bruise on Resident #55's right shoulder/armpit but did not remember how it happened and was not sure if an incident report with an investigation was completed when the bruise was identified on 12/04/2025. S2DON further stated the only information they had regarding the bruise to the right shoulder/armpit area were the notes in the computer and then S2DON produced a written statement she had completed.Review of the nurses' note dated 12/04/2025 by S4Treatment Nurse revealed she was notified by the hospice CNA that a new large bruise was identified under the right armpit. S4Treatment Nurse performed a skin assessment of the area. The bruise was 7 cm by 3 cm with a light purple tint. Resident was asked if she had any pain and resident responded, Well, I didn't even know it was there. But it doesn't hurt. When asked if resident remembers how it was acquired, resident stated, No, but you know how fragile my skin is. S4Treatment nurse noted that the sling lift was used Monday to transfer the resident to the Geri chair. S4Treatment nurse educated primary CNAs of proper placement of lift and lift techniques. Review of the written statement by S2DON dated 12/04/2025 revealed:I was notified by the wound care nurse that a bruise was noted to resident right shoulder/armpit area. Upon exam, active range of motion/passive range of motion were within normal limits and resident denies pain. When I asked her what happened, the resident states I didn't even know it was there. Resident has a history of easy bruising and skin tears. The lift used to maneuver resident is the sling lift which does not go under the arms to cause the bruising. Sometimes resident is assisted by placing her hand under her arm to assist her sitting up or repositioning. CNAs were verbally spoken to by wound care nurse on using draw sheets and proper body mechanics for positioning patient and that she is a very easy bruiser. During an interview on 01/07/2026 at 10:39 a.m., S2DON confirmed the facility did not complete a full investigation regarding the large bruise to Resident #55's right shoulder/armpit area which was an injury of unknown origin when it was identified on 12/04/2025. During an interview on 01/07/2026 at 1:15 p.m., S1Administrator confirmed they did not investigate the cause of the bruise to the right shoulder/armpit area which was an injury of unknown origin on Resident #55 when it was discovered on 12/04/2025.

Based on observation, record review, and interview the facility failed to ensure an infection prevention and control program was maintained to help prevent the development and transmission of communicable diseases and infections for 4 (#5, #7, #17, #20) of 4 residents reviewed for infection control. The facility failed to ensure:1. EBP precautions were followed during catheter care (#5);2. Infections control procedures followed during wound care (#7);3. A syringe was stored properly after staff provided PEG care (#20); and4. An EBP sign was placed on a resident's door (#17)Findings: Review of the facility's Infection Prevention and Control Program policy revised on 05/01/2025 revealed in part: Policy Explanation and Compliance Guidelines: 4. Standard Precautions: e. Environmental cleaning and disinfection shall be performed according to facility policy. All staff have responsibilities related to the cleanliness of the facility, and are to report problems outside of their scope to the appropriate department. 10. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. Review of the Flushing a Feeding Tube policy dated 05/01/2025 revealed the plunger should have been removed from the barrel of the syringe and staff were to wash the equipment in warm water and place into the labeled bag. Review of the policy and procedure titled Transmission Based Precautions with a reviewed/revised date of 06/01/2025 revealed in part: Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens modes of transmission. Initiation of Transmission-Based Precautions (Isolation Precautions). e. Signage that includes instructions for use of specific PPE will be placed in a conspicuous location outside the resident's room, wing, or facility wide. Additionally, either the CDC category of transmission-based precautions or instructions to see the nurse before entering will be included in the signage. f. The facility will have PPE readily available near the entrance of the resident's room and will don appropriate PPE before or upon entry into the environment of a resident on transmission-based precautions. Resident #17 Review of the medical record revealed Resident #17 had an admission date of 12/30/2025 with diagnoses which included venous insufficiency and type 2 diabetes. Review of the January 2026 physician orders revealed Resident #17 had 3 pressure ulcers and 3 venous ulcers. On 01/06/2026 at 9:05a.m., an interview with S4Treatment Nurse confirmed Resident #17 had 3 pressure ulcers and 3 venous ulcers. On 01/06/2026 at 8:30 a.m., an observation Resident #17's door revealed there was no signage indicating transmission based precautions were to be implemented. On 01/02/2026 at 10:45 a.m., an interview with S2DON confirmed the proper signage should have been placed on Resident #17's door. Resident #20 Review of the medical record revealed Resident #20 was admitted on [DATE] with diagnoses which included dysphagia. On 01/06/2026 at 9:50 a.m., a bolus feeding by S3LPN was observed. After completion of the bolus feeding, S3LPN left the piston syringes assembled and did not rinse them with warm water. There was water in the tip of one syringe and tube feeding liquid remained in the tip of the second syringe. On 01/06/2026 at 10:45 a.m., an interview with S2DON confirmed the syringes should have been disassembled, rinsed, and allowed to dry. Resident #7 Review of Resident #7's medical record revealed an admission date of 01/23/2019 with diagnoses that included Stage 3 pressure ulcer to left dorsum 1st digit, chronic peripheral venous insufficiency, diabetes mellitus, and generalized muscle wasting and atrophy. Review of Resident #7's medical record revealed a physician order dated 11/21/2025: cleanse stage 3 PU to left medial distal 1st digit with wound cleanser, pat dry, apply Hydrogel AG, cover with bordered foam, and secure with tape as needed for soilage or dislodgement until healed. Review of Resident #7's medical record revealed a care plan for Resident #7's Stage 3 pressure ulcer to left medial distal 1st digit. Further review revealed an intervention to provide wound care treatment as ordered. On 01/06/2026 at 8:10 a.m., an observation of Resident #7's wound care revealed S4Treatment Nurse failed to perform the following: -sanitize the resident's over bed table prior to placing the wound care supplies on the table. -place a protective barrier between the small red biohazard bag and the resident's over bed table. -sanitize the small pen light after the pen light made contact with Resident #7's wound. -sanitize the resident's over bed table after removal of the small red biohazard bag. On 01/06/2026 at 8:30 a.m., an interview with S4Treatment Nurse reported she had completed wound care. S4Treatment confirmed she had failed to properly sanitize her pen light, the resident's over bed table prior to and after wound care, and to place a protective barrier under the small red biohazard bag that was placed on the resident's over bed table. On 01/07/2026 at 3:20 a.m., S2DON was informed of the above infection control concerns identified during wound care for Resident #7. S2DON acknowledged S4Treatment Nurse failed to follow proper infection control procedures. Resident #5 Review of the record for resident #5 revealed diagnoses in part of: resistant to multiple antibiotics, urinary tract infection, and urinary retention with foley catheter placement. Review of the current physician orders in part revealed to cleanse the foley catheter with soap and water every shift, Enhanced Barrier Precautions every shift. Review of the care plan revealed: The resident is on enhanced barrier precautions (EBP) related to foley catheter. Approaches - direct care staff to utilize gowns and gloves for all personal care. On 01/07/2026 at 9:59 a.m., observation of the outside of resident #5's door revealed signage indicating enhanced barrier precautions. Further observation revealed there was PPE located on the wall next to the resident's door. Observation of catheter care performed by S7CNA revealed she did not utilize a gown to provide catheter care. On 01/07/2026 at 10:15 a.m., an interview with S7CNA confirmed there was signage on Resident #5's door indicating the resident was on enhanced barrier precautions and further confirmed that she should have worn a gown while providing catheter care.

Based on record review and interview, the facility failed to ensure residents have the right to be free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. The facility failed to ensure a PRN order for a psychotropic medication was limited to 14 days for 1 (#2) of 5 residents reviewed for unnecessary medications.Findings:Review of the medical record for Resident #2 revealed a re-admission date of 08/31/2020 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, hypertension, diabetes, late syphilis, and unspecified dementia (unspecified severity) with other behavioral.Review of the most recent physician's orders dated 10/03/2024 revealed an order for Oxazepam oral capsule 15 milligrams PRN every 24 hours as needed for insomnia to be given at night with no discontinue date. Review of the Pharmaceutical Consultant Report dated 10/13/2025 revealed the following recommendation for Oxazepam 15 milligrams every night PRN: a PRN psychotropic is limited to 14 days and required the prescriber to evaluate the resident prior to extending the order. If extending the order, document the rationale for the extended time period in the medical record and indicate a specific duration. Further review of the report revealed the physician did not indicate a specific duration for the PRN order. During an interview on 01/07/2026 at 2:09 p.m., S2DON confirmed the physician did not indicate a specific duration for the PRN order of a psychotropic medication.

Based on observation, record review and interview the facility failed to update the plan of care for 1 (#55) of 1 resident reviewed for an injury of unknown origin.Findings: On 01/05/2026 at 9:15 a.m., an observation of resident #55 revealed she was sitting up in bed. Further observation revealed a large bruise to the right shoulder/armpit area. Interview with resident #55 at that time revealed she was unable to state how the bruise to the right shoulder/armpit area occurred.On 01/06/2026 at 1:27 p.m., an interview with S7CNA during an observation of changing resident #55's brief revealed she stated the bruise to the right shoulder/armpit had been there for several weeks.On 01/07/2026 record review revealed resident #55 had diagnoses of chronic diastolic congestive heart failure, atrial fibrillation, Dementia, Cognitive Communication Deficit, Rheumatoid Arthritis, and history of malignant neoplasm of the right breast.Review of the quarterly MDS dated [DATE] revealed resident #55 had a BIMS of 8 indicating moderate cognitive impairment.Further review of the MDS revealed resident #55 was dependent on staff for all ADLs and required substantial/maximum assistance with rolling in bed.Review of resident #55's current medications revealed an order for Eliquis 2.5mg twice a day by mouth.Review of the nurses' note dated 12/04/2025 by S4Treatment Nurse revealed she was notified by the hospice CNA that a new large bruise was identified under the right armpit. S4Treatment Nurse performed a skin assessment of the area. The bruise was 7cm by 3cm with a light purple tint.Review of the plan of care revealed the resident was on anticoagulant therapy.Approaches to the plan of care revealed- daily skin inspections and report abnormalities to the nurse. Further review of the approaches revealed to monitor/document/report as needed adverse reactions of anticoagulant therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in v/s.On 01/07/2026 at 1:19 p.m., a review of the current plan of care revealed it was not updated when the bruise to the right shoulder/armpit was identified. On 01/07/2025 at 1:30 p.m., an interview with S2DON agreed the plan of care was not updated when the bruise appeared to resident #55's right shoulder/armpit area.

Based on interviews and record review, the facility failed to ensure the physician and family were notified after a resident's fall for 1 (#1) of 1 resident reviewed for falls. Findings: Review of the facility's fall prevention program dated 01/01/2025 revealed when any resident experienced a fall the facility will assess the resident, complete an incident report, notify the physician and family and document all assessments and actions. Review of resident #1's medical record revealed diagnoses which included depression, anxiety, dementia, repeated falls and a non-displaced fracture of the shaft of the right clavicle. On 03/11/2025 at 3:10 p.m., interview with S4Certified Nursing Assistant (CNA) revealed shortly before 10:00 p.m., on 02/16/2025 she heard a housekeeper yell out that resident #1 was on the floor. S4CNA and another CNA ran to the resident's room and found the resident sitting on the floor. S3Licensed Practical Nurse (LPN) entered the room immediately after them. The nurse assessed the resident found no injuries and then the 2 CNAs assisted resident #1 to bed. The resident did not complain of pain at that time. On 03/12/2025 at 11:05 a.m., interview with S5CNA revealed on 02/16/25 near 10:00 p.m., she heard a housekeeper say that resident #1 was on the floor. S5CNA and S4CNA ran to the resident's room and found the resident sitting on the floor with her legs extended. S5CNA reported S3LPN entered the room right behind them and assessed the resident. After the S3LPN assessed the resident, S4CNA and S5CNA assisted resident #1 with getting dressed for bed and then helped her to bed. S5CNA reported resident #1 never voiced any pain. On 03/12/2025 at 12:20 p.m., interview with S3LPN revealed on the evening of 02/16/2025 a housekeeper called down the hall that resident #1 was on the floor. Two CNAs ran to the resident #1's room and she entered behind them. The resident was on the floor. She assessed the resident and found no injuries. The resident voiced no pain or injury and displayed no non-verbal indication of pain or injury. S3LPN confirmed she did not contact the physician and family regarding the fall. Review of resident #1's record revealed there was no documented evidence of the family or the physician notifications on 02/16/2025 following resident #1's fall. On 03/11/2025 at 1:30 p.m., interview with S1Administrator and S2Director of Nursing (DON) confirmed S3LPN should have contacted the physician and family regarding resident #1's fall.

Based on interviews and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice when the nursing staff failed to document a post fall assessment and complete an incident report as stated in the facility's fall prevention program policy for 1 (#1) of 1 residents reviewed for accidents that experienced a fall. Findings: Review of the facility's fall prevention program dated 01/01/2025 revealed when any resident experienced a fall the facility will assess the resident, complete an incident report, notify the physician and family and document all assessments and actions. Review of resident #1's medical record revealed diagnoses which included depression, anxiety, dementia, repeated falls and a non-displaced fracture of the shaft of the right clavicle. Review of the 03/05/2025 quarterly Minimum Data Set assessment revealed the resident was independent with indoor mobility. Resident #1 scored a 3 on her Brief Interview for Mental Status assessment indicating severe cognitive impairment. Review of the Fall Risk assessment dated [DATE] revealed the resident scored a 13 indicating she was at risk for falls. Review of the progress notes of resident #1 revealed on 02/17/2025 at 9:38 a.m. resident #1 was found to have fresh bruising over the right collar bone. The resident voiced only soreness. The progress notes also stated there had been no reports of falls and that the nurse practitioner was in the facility. The nurse practitioner examined the resident and orders were given to send resident #1 to the emergency room for evaluation. Review of the hospital's computed tomography (CT) scan revealed the resident had a subtle non-displaced fracture of the left clavicular neck. Review of resident #1's record failed to reveal a progress note documenting a post fall assessment on 02/16/2025 or an incident report regarding a fall on 02/16/2025. Review of the facility's investigation dated 02/17/2025 regarding the fresh bruising over the right collar bone of resident #1 revealed on 02/16/2025 two Certified Nurse Aides (CNA) were called to the room of resident #1 when another staff saw resident #1 on the floor. Written statements from S4CNA and S5CNA indicated they entered the room and found resident #1 sitting upright on the floor. On 03/11/2025 at 3:10 p.m., interview with S4CNA revealed shortly before 10:00 p.m., on 02/16/2025 she heard a housekeeper yell out that resident #1 was on the floor. S4CNA and another CNA ran to the resident's room and found the resident sitting on the floor. S3Licensed Practical Nurse (LPN) entered the room immediately after them. The nurse assessed the resident found no injuries and then the 2 CNAs assisted resident #1 to bed. The resident did not complain of pain at that time. On 03/12/2025 at 11:05 a.m., interview with S5CNA revealed on 02/16/2025 near 10:00 p.m. she heard a housekeeper say that resident #1 was on the floor. S5CNA and S4CNA ran to the resident's room and found the resident sitting on the floor with her legs extended. S5CNA reported S3LPN entered the room right behind them and assessed the resident. After the S3LPN assessed the resident, S4CNA and S5CNA assisted resident #1 with getting dressed for bed then helped her to bed. She reported resident #1 never voiced any pain. On 03/12/2025 at 12:20 p.m., interview with S3LPN revealed on the evening of 02/16/2025 a housekeeper called down the hall that resident #1 was on the floor. Two CNAs ran to resident #1's room and she entered behind them. The resident was on the floor. She assessed the resident and found no injuries. The resident voiced no pain or injury and displayed no non-verbal indication of pain or injury. S3LPN confirmed she did not complete an incident report or document a post fall assessment regarding the fall. On 03/11/2025 at 1:30 p.m., interview with S1Administrator and S2Director of Nursing (DON) revealed S3LPN failed to complete an incident report on the fall and failed to document a post fall assessment.

Based on observations, record review, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 1 (#20) of 1 (#20) resident reviewed for restraints. Findings: Review of the facility Restraint Free Environment policy revised 12/02/2024 revealed the following, in part: Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definitions: Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints may include, but are not limited to applying leg or arm restraints that the resident cannot remove. Review of resident #20's medical record revealed she was admitted to the facility on [DATE] with diagnoses of cognitive communication deficit, Alzheimer's disease, generalized anxiety disorder, major depressive disorder, unspecified pruritus, and polyneuropathy. Review of resident #20's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 99, which indicated the interview was not successful. Resident #20 required extensive assistance for most activities of daily living. Further review revealed there was no documentation the resident had a restraint. Review of resident #20's medical record revealed her current care plan revealed she was at a high risk for skin tears due to the resident scratching herself. Further review revealed an approach for resident #20 to wear socks or gloves on her hands to keep her from scratching herself. Further review of resident #20's medical record revealed no documented evidence of a pre-restraint assessment, restraint consent, nor monitoring for the limb restraint use (socks on her hands). On 12/16/2024 at 9:40 a.m., an observation revealed resident # 20 was in her wheelchair in her room and she had socks on her hands. The resident was nonverbal and could not inform surveyor why she had socks on her hands. On 12/16/2024 at 11:10 a.m., an interview with S9Certified Nursing Assistant (CNA) revealed they put socks on the resident's hands because she scratches herself. S9CNA reported resident #20 cannot take the socks off her hands by herself. On 12/18/2024 at 8:28 a.m., an observation revealed resident # 20 was in her wheelchair in her room and she had socks on her hands. On 12/18/2024 at 1:13 p.m., an interview with S7Licensed Practical Nurse (LPN) revealed they have been using socks on the resident's hands due to she scratches herself. S7LPN confirmed the resident cannot take the socks off her hands without help. On 12/18/2024 at 1:40 p.m., an interview with S3Assistant Director of Nursing and S8LPN/MDS Nurse confirmed the facility failed to obtain a pre-restraint assessment and restraint consent; and there was no monitoring for the socks being used on the resident's hands.

Based on observation, interviews and record review, the facility failed to implement a comprehensive person-centered care plan for each resident for 1 (#41) of 1 residents reviewed for anticoagulants. Findings: On 12/16/2024 at 10:00 a.m., observation of the resident #41's hands revealed she had bruising to the back of both hands. Resident #41 reported she took a blood thinner. Review of the medical record revealed resident received the blood thinning medication Eliquis 2.5 milligrams (mg) twice daily. Review of the care plan revealed it addressed anti-coagulant use with an intervention to monitor for bruising. Review of the Medication Administration Record (MAR) revealed the nursing staff were to monitor for bruising each shift. Review of the December 2024 MAR revealed every entry indicated resident #41 had no bruising. On 12/17/2024 at 1:05 p.m., interview with S3Assistant Director of Nursing confirmed resident #41 had bruising to her hands and the nursing staff failed to document the bruising on the MAR.

Based on observations and interviews, the facility failed to ensure the resident enviornment remained as free of accident hazards as possible by failing to ensure resident rooms maintained a water temperature of less than 120 degrees for 4 (#19, 37, 41, 66) of 4 residents whose rooms were assessed for water temperatures. Findings: On 12/16/2024 at 9:00 a.m., a check of the water temperatures in the residents' rooms was done with the S2Maintenance Supervisor. The water temperature for resident #41's room was 127.0 degrees. The water temperature for resident #66's room was 127.2 degrees. The water temperature for resident #19's room was 127.8 degrees. The water temperature for resident #37's room was 127.2 degrees. S1Maintenance Supervisor confirmed the water temperatures were in excess of 120 degrees. On 12/16/2024 at 9:30 a.m., S1Assistant Administrator confirmed the water temperatures in the residents' rooms should not be in excess of 120 degrees.

Based on observations, record review and interviews, the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (#4) of 3 (#1, #4, #43) residents reviewed for pressure ulcers. The facility failed to provide a pressure relieving device as ordered for the resident. Findings: Review of the medical record for resident #4 revealed an admitted [DATE] with diagnosis of atrial fibrillation, cerebrovascular accident, edema, muscle wasting, dysphagia, hypertension, vascular dementia, history of urinary tract infection, history of stage 3 pressure ulcer to the left heel, depressive disorder, and contracture to the left elbow. Review of the Annual Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for mental Status score of 6 which indicated severe cognitive impairment. Further review revealed the resident needed maximum assistance with all activities of daily living. Review of resident #4's December 2024 physician's orders revealed an order for heel protectors to be worn at all times with a start date of 06/06/2024. Review of resident #4's current care plan dated 05/15/2024 revealed he had an un-stageable pressure ulcer to the left heel. Further review revealed an intervention to provide heel protectors to bilateral feet. Review of the Braden Scale for predicting pressure ulcer risk evaluation dated 11/27/2024 revealed the resident was at moderate risk due to a history of a pressure ulcer to the left heel. Review of the skin and wound evaluation dated 9/24/2024 revealed the resident had a stage III (full-thickness skin loss) to the left heel acquired in the facility. The surrounding skin was fragile skin that was at risk for breakdown. Additional care was heel suspension/protection device. Progress: pressure ulcer resolved will continue with preventative measures. An observation on 12/16/2024 at 11:00 a.m., revealed sample resident #4 was sitting in his Geri chair in the lobby the resident did not have any heel protectors on. An observation on 12/17/2024 at 8:30 a.m., revealed the resident was sitting in the Geri chair in his room. The resident was dressed and had socks on his feet and the heel protectors were lying in the chair not on the resident. An observation on 12/17/2024 at 2:50 p.m., revealed resident #4 was sitting in his Geri chair in the lobby. The resident was dressed and had socks on but did not have heel protectors on as ordered. On 12/18/2024 at 8:00 a.m., the resident had been placed on isolation in his room due to a positive COVID test dated 12/18/2024. An observation revealed the resident was lying in bed eating breakfast and he did not have his heel protectors on. An interview on 12/18/2024 at 10:15 a.m., with S4Licensed Practical Nurse confirmed sample resident #4 was at high risk for pressure ulcers and had a physician's order to wear heel protectors at all times. She was not sure if the resident had them on or not. She stated the Certified Nurse Assistants (CNAs) that get them up every morning are responsible for making sure the resident had them on. An interview on 12/18/2024 at 10:30 a.m., with S5CNA revealed she had been taking care of resident #4 the last few days and she had not placed the heel protectors on the resident. An interview on 12/18/2024 at 1:40 p.m., with S3Assistant Director of Nursing confirmed resident #4 should have had the heel protectors on as ordered due to him being at risk for pressure ulcers.

Based on observation, record review and interview, the facility failed to maintain an infection control program to help prevent the development and transmission of communicable diseases and infections by failing to implement its policy for enhanced barrier precautions for 1 (#37) of 1 residents reviewed for transmission based precautions. Findings: On 12/16/2024 at 8:45 a.m., observation of resident #37 revealed she had a Foley catheter. Observation of resident #37's door revealed there was no signage regarding Enhanced Barrier Precaution and there were no personal protective equipment supplies located nearby resident #37's room. Review of the facility's Enhanced Barrier Precautions policy dated 11/01/2024 revealed catheters were a qualifying condition for the implementation of enhanced barrier precautions. The policy also read Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves. The policy also indicated gowns and gloves should be available immediately outside the resident's room. On 12/17/2024 at 9:10 a.m., interview with S3Assistant Director of Nursing confirmed the facility did not implement their enhanced barrier precautions policy by failing to place signage and PPE near the door of resident #37's room.

Based on observation, record review and interviews, the facility failed to protect the residents' right to be free from verbal and physical abuse and psychosocial harm by staff for 1 (#1) of 3 (#1, #2, #3) sampled residents. The actual harm resulted for resident #1, who was cognitively impaired, on 08/26/2024 at 2:28 a.m. when S4 Certified Nursing Assistant (CNA) was observed being verbally and physically abusive to resident #1 while providing care. Resident #1's family member observed S4CNA being verbally and physically abusive to resident #1 while reviewing video surveillance camera footage. Because this type of inappropriate, unwanted verbal and physical abuse would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the resident's position would have experienced severe psychosocial harm-dehumanization, and humiliation - as a result of the verbal and physical abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance citation. Findings: Review of the facility's Abuse, Neglect and Exploitation Policy, dated 07/31/2024, revealed in-part: Policy: It is the policy of this facility to provide for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical Abuse includes, but not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Record review revealed resident #1 was admitted to the facility 12/29/2023 with diagnoses that included dementia unspecified severity with anxiety, encephalopathy unspecified, chronic systolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, seizures, insomnia, generalized muscle weakness, other lack of coordination, other abnormalities of gait and mobility, major depressive disorder recurrent, essential hypertension, atrial fibrillation, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following cerebral infarction, needs for assistance with personal care, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated resident #1 was severely cognitive impaired for daily decision making. Further review revealed resident #1 required limited physical assistance by one staff with bed mobility, transfers, eating, and toilet use. Resident #1 was occasionally incontinent of bowel and bladder. Resident #1 was unable to walk and used manual wheelchair for ambulation. Review of the facility's investigation documentation of the 08/26/2024 incident revealed a summary of events that included: On Tuesday 08/27/2024 around 4:00 p.m. resident #1's family member came to the facility and informed S1Administrator and S2Assistant Administrator about S4CNA mistreating resident #1 while providing care during the early morning hours of 08/26/2024. Resident #1's family member reported she actually saw the incident on the camera footage from resident #1' room on the night of 08/26/2024, but she did not come to us immediately because she needed to take some time to herself. At this point it is Tuesday afternoon when she brought the footage to us. S1Admininstrator and S2Asssistant Administrator viewed the video footage from resident #1's family member's cell phone. The footage showed S4CNA in the room with resident #1. Resident #1was sitting in her wheelchair and S4CNA told her she was going to fall out of the chair if she didn't sit up more. S4CNA help to pull her up in the chair a couple of times. S4CNA then went on to tell resident #1 she was going to put her in the bed. It appeared, based on body language that resident #1 did not want to go to bed. S4CNA proceeded to use the front arm rest to push the wheelchair and resident #1. Resident #1 placed her hands on top of S4CNA's hands (on the arm rest of the wheelchair). S4CNA repeatedly stated, Get your hands off of me. S4CNA said this while pushing the wheelchair towards the bed. Resident #1 then lifts her foot up towards S4CNA's leg and S4CNA tells resident #1 not to kick her and she better not kick her. At this point resident #1 is holding her foot up between them. S4CNA proceeds to state, if you kick me I am going to beat your ass. S4CNA then gets resident #1 to the bedside and is telling her to stand up and get in the bed. Resident #1 doesn't appear to try to get up. S4CNA then lifts her to sit her on the side of bed. At this time resident #1 does not attempt to lay back. S4CNA tries to lay her down herself, but resident #1 still does not move. S4CNA then picks up resident #1's legs and quickly swings them around onto the bed to lay her down causing resident #1 to fall back into the bed/wall area. Resident #1 then speaks up and says a string of curse words that were hard to understand from the footage, but she was clearly upset based on the tone and words she used. S4CNA then told her to stay in the bed. S4CNA continued to cover her up with blankets after checking her brief to be sure it was dry. S4CNA then went back to the chair near the door and sat down. Nothing seems to happen further until closer to the end of S4CNA's shift. Resident #1 appears to want to go to the bathroom and S4CNA tells her to do it since she has a brief on. Resident #1 can be transferred to the toilet, although it is difficult for her, it is possible. During an interview on 09/23/2024 at 12:05 p.m., resident #1's family member revealed there are 2 video cameras in resident #1's room which are motion activated. Resident #1's family member reported last Monday night (08/26/2024) she reviewed the video camera footage that was sent to an app on her cell phone. Resident #1's family member report she did not like how S4CNA treated resident #1 during the early hours of 08/26/2024. Resident #1's family member revealed she did not notify anyone at the facility until, 08/27/2024 at 4:00 p.m., when she met with S1Admininstrator and S2Assistant Administrator and showed them the video recordings of how S4CNA treated resident #1. Resident #1's family member reported they fired S4CNA. Resident #1's family member allowed surveyor to review the video footage recordings on her cell phone. The video footage included audio and were dated and time stamped with the start of each video. Review of the video recordings revealed the following: On 08/26/2024 at 2:28 a.m., resident #1 was sitting in manual wheelchair and S4CNA was in resident #1's room providing1:1 observation. S4CNA tells resident #1, Get your butt over in that bed and stay in it. S4CNA was noted to be pushing resident #1's wheelchair backwards by holding on to the front wheelchair armrest. Resident #1 placed her hands on top of S4CNA's hands that were on the wheelchair armrest. S4CNA was noted to repeatedly tell resident #1 Get your hands off me. Resident #1 raised her left foot up off the foot rest and extended slowly towards S4CNA's legs. S4CNA was noted to repeatedly tell resident #1 don't you kick me as S4CNA was pushing resident #1 backwards in her manual wheelchair to the bed. Resident #1 raised her left leg up to put distance between them. S4CNA was noted to tell resident #1, woman if you kick me I will beat your ass, get up. S4CNA then stated, trying to help you and you trying to act stupid, gonna get you in the bed and you gonna stay there. S4CNA positioned the wheelchair next to the bed and stated, you want to get in the bed or not. Resident #1 did not appear to want to go to bed. S4CNA was noted to reposition resident #1 up in the wheelchair and allowed her to stay in the wheelchair and continued to provide 1:1 monitoring. Resident #1 did not attempt to hit or kick S4CNA. On 08/26/2024 at 4:12 a.m., S4CNA was noted to tell resident #1, sit up you, you gonna fall out of the wheelchair as she physically assisted resident #1 up in the wheelchair by lifting resident #1 under her arms. Resident #1 was noted to say, Leave me alone. On 08/26/2024 at 4:27 a.m., S4CNA positioned resident #1's wheelchair against her bed and assisted resident #1 to a standing position by holding on to her left arm. S4CNA was noted to tell resident #1, Sit down, don't you feel better now you are in bed. Resident #1 had sat upright on the side of the bed with her feet resting on the floor. S4CNA was noted to yell at resident #1, lay down! On 08/26/2024 at 4:28 a.m., S4CNA was noted to yell at resident #1 again, lay down as S4CNA physically pushed back resident #1's left shoulder to get her to lay down in the bed. Resident #1 did not appear to want to lay down and did not lay back. S4CNA was observed to grab resident #1 by the ankles and forcefully lifted them up and put both of her lower extremities in the bed. This caused resident #1 to fall backward on the left side of the bed and resident #1 was noted to hit her left/back side of her head against the cinder block wall located next to the bed. Resident #1 responded by saying, you son of a bitch. S4CNA was noted to tell resident #1, better not get your butt back up as she covered resident #1's lower extremities and torso with a blanket. At 4:30 a.m. S4CNA is noted to check resident #1 brief to see if she was wet. Resident #1 is noted to say, I need to go to the bathroom. S4CNA was noted tell resident #1, you have a pamper on, go ahead and use it or just hold it. During an interview on 09/25/2024 at 1:25 p.m., S1Administrator confirmed S4CNA verbally and physically abused resident #1. S1Administrator further confirmed a reasonable person would have become very upset being treated the way S4CNA treated resident #1. During the survey, in-service records, S4CNA employee file, resident (BIMS >7 and BIMS<7) assessments for abuse and neglect, resident progress notes, resident skin assessments, resident council minutes, Quality Assurance (QA) monitoring records were reviewed along with interviews with staff and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice with the completion date of 09/05/2024: -S4CNA was terminated on 08/27/2024. -All Staff education/in-service on Abuse/Neglect Policy and Procedure was completed on 08/28/2024. -Resident interviews for potential abuse or neglect completed weekly for 2 weeks -BIMS of 8 or above (indicating moderately impaired cognition to cognitively intact) interview for all residents in building completed 08/28/2024 and 09/05/2025. -Residents who are in the hospital on 08/29/2024 completed on return 08/30/2024. -BIMS of 7 or lower (indicating severe cognitive impairment) verbally completed 08/28/2024 with resident/staff. -BIMS of 7 or lower completed and progress note entered completed 09/04/2024. -QA Agenda updated to include Abuse/Neglect Training and Resident Monitoring (Added to 3rd Quarter meeting 08/28/2024) -Resident Council Meeting Agenda updated for Resident Rights/Abuse/Neglect Reporting. -Residents in Council Meeting educated on Abuse/Neglect and how to report to if necessary was completed 09/04/2024. -Resident Body Assessments Completed 08/29/2024 and 09/05/2024 -All of the above monitoring for completion by S1Administrator and S2Assistant Administrator with completion date 09/05/2024, no evidence of abuse found, verified by documentation. -Continued Future Monitoring for Plan of Correction as follows will be verified by S1Administrator, S2Assistant Administrator, or designee: -Resident Interviews/Education for potential abuse or neglect to be completed once quarterly; Residents with BIMS 8 and above written interviews, Residents with BIMS of 7 or below behavior notes/Staff monitoring in progress notes (October 2024 - December 2024, January 2025 - March 2025, April 2025 - June 2025 and July 2025 - September 2025). -Staff/Resident In-Service Education to be provided monthly on the Abuse/Neglect policy and reporting procedures: -Monthly in-services for Staff beginning September 2024 and will continue each month until August 2025 -Monthly Resident council meetings will review and educate residents on abuse, neglect, and resident right policies beginning September 2024 and will continue each month until August 2025 -Resident Interviews, Staff in-services, and Resident Council Minutes will be provided as part of QA quarterly meeting agenda beginning August 2024 (3rd quarter 2024) and continue through September 2025 (3rd quarter 2025). -Resident skin assessments are completed weekly on all residents and will continue to be completed weekly and are verified by treatment nurse, S6Licensed Practical Nurse (LPN), or designee. These will be monitored for any specific changes related to potential abuse or neglect through August 2025.

Based on observation and interviews, the facility failed to treat each resident with respect and dignity in a manor and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. This failed practice occurred when S4Certified Nursing Assistant (CNA) did not assist resident #1 to the restroom after resident #1 requested to go to the restroom. Findings: Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia unspecified severity with anxiety, encephalopathy unspecified, chronic systolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, seizures, insomnia, generalized muscle weakness, other lack of coordination, other abnormalities of gait and mobility, major depressive disorder recurrent, essential hypertension, atrial fibrillation, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following cerebral infarction, needs for assistance with personal care, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated resident #1 was severely cognitive impaired for daily decision making. Further review revealed resident #1 required limited physical assistance by one staff with bed mobility, transfers, eating, and toilet use. Resident #1 was occasionally incontinent of bowel and bladder. Resident #1 was unable to walk and used manual wheelchair for ambulation. Further record review revealed resident #1 had an active care plan care for self-care and mobility deficit and required assistance from staff with bathing, dressing, feeding, hygiene, and toileting. Intervention included to provide resident #1 with assistance with Activities of Daily Living (ADLs) as needed. During an interview on 09/23/2024 at 12:05 p.m., resident #1's family member reported she had reviewed the video camera footage from resident #1's room and observed S4CNA refuse to take resident #1 to the bathroom and told her to go ahead and use it or hold it because she was wearing a brief. Resident #1's family member allowed surveyor to review the video footage recordings on her cell phone. The video footage included audio and were dated and time stamped with the start of each video. Review of the video recordings revealed the following: On 08/26/2024 around 4:30 a.m., resident #1 was lying in the bed and S4CNA was noted to tell resident #1, better not get your butt back up as she covered resident #1's lower extremities and torso with a blanket. Resident #1 was noted to say, I need to go to the bathroom. S4CNA was noted tell resident #1, you have a pamper on, go ahead and use it or just hold it. On 09/24/2024 at 12:40 p.m., an interview with S1Administrator confirmed S4CNA should have assisted resident #1 to the rest room after resident #1 reported she needed to go to the bathroom. S1Administrator further confirmed S4CNA should not have told resident #1 to go ahead and use it because she was wearing a brief or to just hold it.

Based on record review and interviews, the provider failed to ensure an alleged violation involving verbal and physical abuse that was reported to the Administrator by resident #1's family member was reported immediately, but no later than 2 hours after being made aware, to the State Survey Agency in accordance with State Laws for 1 (#1) of 3 (#1, #2, #3) sampled residents. Findings: Review of the facility's Abuse, Neglect and Exploitation Policy, dated 07/31/2024, revealed in-part: Policy: It is the policy of this facility to provide for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychological well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical Abuse includes, but not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the administrator, state agency, adult protection services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframes: a. Immediately, but no later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Record review revealed resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia unspecified severity with anxiety, encephalopathy unspecified, chronic systolic congestive heart failure, chronic obstructive pulmonary disease with acute exacerbation, seizures, insomnia, generalized muscle weakness, other lack of coordination, other abnormalities of gait and mobility, major depressive disorder recurrent, essential hypertension, atrial fibrillation, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, aphasia following cerebral infarction, needs for assistance with personal care, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated resident #1 was severely cognitive impaired for daily decision making. Further review revealed resident #1 required limited physical assistance by one staff with bed mobility, transfers, eating, and toilet use. Resident #1 was occasionally incontinent of bowel and bladder. Resident #1 was unable to walk and used manual wheelchair for ambulation. During an interview on 09/23/2024 at 9:30 a.m., S1Administrator revealed resident #1's family member came to the facility on [DATE] at 4:00 p.m. and informed her and S2Assistant Administrator that she did not like how S4 Certified Nursing Assistant (CNA) treated resident #1 while providing care during the early hours of 08/26/2024. Resident #1's family member reported S4CNA made rude comments and handled resident #1 roughly while she performed her care. S1Admininstrator and S2Asssistant Administrator viewed the video footage dated 08/26/2024 from 2 video cameras placed in resident #1's room by the family on resident #1's family member's cell phone. Review of the dated and time stamped video recordings revealed the following: On 08/26/2024 at 2:28 a.m., resident #1 was sitting in manual wheelchair and S4CNA was in resident #1's room providing1:1 observation. S4CNA tells resident #1, Get your butt over in that bed and stay in it. S4CNA was noted to be pushing resident #1's wheelchair backwards by holding on to the front wheelchair armrest. Resident #1 placed her hands on top of S4CNA's hands that were on the wheelchair armrest. S4CNA was noted to repeatedly tell resident #1 Get your hands off me. Resident #1 raised her left foot up off the foot rest and extended slowly towards S4CNA's legs. S4CNA was noted to repeatedly tell resident #1 don't you kick me as S4CNA was pushing resident #1 backwards in her manual wheelchair to the bed. Resident #1 raised her left leg up to put distance between them. S4CNA was noted to tell resident #1, woman if you kick me I will beat your ass, get up. S4CNA then stated, trying to help you and you trying to act stupid, gonna get you in the bed and you gonna stay there. S4CNA positioned the wheelchair next to the bed and stated, you want to get in the bed or not. Resident #1 did not appear to want to go to bed. S4CNA was noted to reposition resident #1 up in the wheelchair and allowed her to stay in the wheelchair and continued to provide 1:1 monitoring. Resident #1 did not attempt to hit or kick S4CNA. On 08/26/2024 at 4:12 a.m., S4CNA was noted to tell resident #1, sit up you, you gonna fall out of the wheelchair as she physically assisted resident #1 up in the wheelchair by lifting resident #1 under her arms. Resident #1 was noted to say, Leave me alone. On 08/26/2024 at 4:27 a.m., S4CNA positioned resident #1's wheelchair against her bed and assisted resident #1 to a standing position by holding on to her left arm. S4CNA was noted to tell resident #1, Sit down, don't you feel better now you are in bed. Resident #1 had sat upright on the side of the bed with her feet resting on the floor. S4CNA was noted to yell at resident #1, lay down! On 08/26/2024 at 4:28 a.m., S4CNA was noted to yell at resident #1 again, lay down as S4CNA physically pushed back resident #1's left shoulder to get her to lay down in the bed. Resident #1 did not appear to want to lay down and did not lay back. S4CNA was observed to grab resident #1 by the ankles and forcefully lifted them up and put both of her lower extremities in the bed. This caused resident #1 to fall backward on the left side of the bed and resident #1 was noted to hit her left/back side of her head against the cinder block wall located next to the bed. Resident #1 responded by saying, you son of a bitch. S4CNA was noted to tell resident #1, better not get your butt back up as she covered resident #1's lower extremities and torso with a blanket. During an interview on 09/25/2024 at 1:25 p.m., S1Administrator confirmed S4CNA verbally and physically abused resident #1 on 08/26/2024. Review of the incident investigation report to State Survey Agency revealed S1Amininstrator submitted the report on 08/28/2024 at 5:51 p.m. The incident occurred on 08/26/2024 at 3:30 a.m. The incident was discovered on 08/27/2024 at 4:00 p.m. On 09/24/2024 at 12:32 p.m., an interview with S1Administrator confirmed she did not submit the incident investigation report to the State Survey Agency until 08/28/2024 at 5:51 p.m. and not within 2 hours of being informed of the alleged abuse allegation.

Based on record reviews and interviews, the facility failed to protect the resident's right to be free from sexual abuse and psychosocial harm by another resident for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed for abuse. The actual harm resulted for resident #1, who was severely cognitively impaired, being sexually assaulted by resident #2. On 02/19/2024 at 9:15 p.m. S3CNA (Certified Nursing Assistant) witnessed resident #2 standing at the bedside of resident #1. Resident #2 had his penis in the mouth of resident #1. Because this type of unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in the resident's condition would have experienced severe psychosocial harm, dehumanization and humiliation as a result of the non-consensual sexual contact. Findings: Review of the facility current Abuse Prevention and Exploitation policy revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent, abuse, neglect, exploitation and misappropriation of resident property. The policy also defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Review of the medical record for resident #1 revealed he had diagnoses which included unspecified intellectual disabilities, bipolar disorder, dysphagia, muscle wasting and atrophy. Review of the Admission MDS (Minimum Data Set) assessment dated [DATE] revealed the facility was unable to conduct the BIMS (Brief Interview for Mental Status) assessment. Resident #1 was nonverbal. The facility also determined his cognitive skills for daily decision making were severely impaired. The resident's admitted was 01/09/2024. Review of the medical record for resident #2 revealed he had diagnoses which included major depression, anxiety, traumatic brain injury, unspecified neurosyphilis and pseudobulbar affect. Review of the quarterly MDS dated [DATE] revealed his BIMS score was 7 indicating severe cognitive impairment. The resident's admitted was 06/23/2021. Review of the nurse's notes revealed on 02/19/2024 at 9:15 p.m., S3CNA witnessed resident #2 standing at the bedside of resident #1. Resident #2 had his penis in the mouth of resident #1. The staff yelled down the hall for the nurse. The residents were separated and moved into different rooms and placed on one on one monitoring status. The sheriff's department was notified. The nurse's notes also indicated both residents were assessed head to toe and no injuries were discovered. Review of the Sherriff's department report dated 02/19/2024 revealed S3CNA walked in and discovered resident #2 with his penis in the mouth of resident #1. Resident #2 was read his [NAME] rights and stated that he understood them. Resident #2 reported My roommate sucked my d___. He also reported to the deputy that it happened on 3 separate occasions. The nursing home staff had removed resident #1 from the bedroom prior to the Deputy's arrival. It was reported to the deputy that a staff would be seated outside the room of resident #2 to ensure he had no contact with any other resident and to make sure he did not leave his room. On 02/26/2024 at 10:40 a.m., interview with S4LPN (Licensed Practical Nurse) revealed she worked the day shift after the incident and she discharged the resident #2 to the behavioral hospital. The staff reported when she arrived both residents were being monitored by staff on a one on one basis. She reported she had worked at the facility for about a year. S4LPN reported she had never observed either resident act in a sexually inappropriate manner.

Based on observation, record review, and interview, the facility failed to ensure that resident with a surgical wound (#114) and a resident with multiple unidentified open wounds(#9) received treatment and care in accordance with professional standards of practice. This deficient practice included 2(#114,#9) of 2(#114, #9) residents at high risk of skin impairment out of a total sample of 33 residents reviewed. The facility failed to 1) obtain and provide wound care according to physician orders [REDACTED].#9), and 3)to identify open wounds for (#9). This deficient practice resulted in actual harm for resident #114, a new post op partial left foot [MEDICAL CONDITION]. The resident was admitted to the facility on [DATE] without orders to care for a new surgical wound. The wound was not cleansed and dressed from the admission date of [DATE] until 02-07-2018. The facility failed to follow physician orders [REDACTED]. The resident was sent to a local wound clinic on 02-27-2018 and the wound was found to be infected. Findings: Resident #114 Review of the record for resident #114 revealed an admission date of [DATE] from a wound care hospital. Further review revealed the following Diagnoses: [REDACTED]. Review of the treatment administration record for resident #114 revealed that facility did not obtain an order and or treat the surgical wound to left foot amputation site between the admission date of [DATE] to 02/07/18. A physician order [REDACTED]. This order was discontinued and new order obtained on 02/27/2018. The wound physician orderd the wound care to the left foot on 02-27-2018. The order included to clean with wound cleanser, pat dry, 25% saline moistened gauze, 4x4, kerlix, change daily. Interview with resident #114 on 02/27/2018 at 3:18PM revealed that the facility had not changed his dressing to his left lower leg as ordered by physician for over a week when he was first admitted . He stated that he went to wound care physician today 02/27/18 and the physician was very upset about the healing progress of his surgical wound. The resident stated that he was given a shot of antibiotics and will start oral antibiotics beginning today and he was informed if the wound did not show any improvement that he will have to have more amputated. The resident said that the facility has not changed the surgical dressing an additional three or four days since admission, in addition to the first seven days the wound went without care. The resident was unable to give specific dates in which wound care was not performed. Review of the record revealed that resident #114 went out of facility for followup with wound care physician on 02/27/2018. Review of the physician progress report for resident #114 dated 02/27/2018 at 10:45AM revealed the following: 1) keep glucose less than 200 consistently, 2) wound care to left foot ulcer- change dressing daily, 3) 1 gram [MEDICATION NAME] (antibiotic) administered, 4) Bactrim DS 1 tablet by mouth today and daily for 7 days, 5) return in 1 week, and 6) CBC (complete blood count) and chem 8 drawn today and obtained MRI (Magnetic Resonance Imaging) of left foot- possible osteomyleitis or abscess. Interview with S2DON (Director of Nurse) on 03/01/2018 at 2:00PM confirmed that resident #114 received no wound care treatment for [REDACTED]. Interview with S18 Therapy Program Director on 03/01/2018 at 2:30PM revealed that resident #114 went to therapy to be evaluated on 02/26/18. S18 Therapy Program Director said the resident came to therapy and his heel protector was dirty and had a copious amount of drainage in it. Further interview with S18 Therapy Program Director revealed that a nurse, S9 LPN, was notified and looked at the bandage and the date on the bandage which was dated 02/24/2018. Further interview with S 18 Therapy Program Director revealed that the S9 LPN stated to her that the bandage for resident #114 should be changed daily. Review of the weekly wound assessments for left leg surgical wound revealed the following measurements: 02-09-2018: 4.1cm (centimeters) x 4.6 cm x 0.3; 02-16-2018: 4.1cm x 4.6 cm x 0.3; and 02-23-2018: 5cm x 5.2 cm x 0.6. Interview with S2DON (Director of Nurses) on 03/02/2018 at 11:30AM confirmed that resident #114 was admitted on [DATE] from a wound care facility with a surgical wound to left foot. Further interview with S2DON revealed that on 01/30/2018 she unwrapped the bandage and rewrapped it with Kerlix. S2DON stated she did not assess the wound at this time and she made an assumption that wound care orders were on the chart. Further interview with S2DON revealed that on 02/06/18 or 02/07/18 she went to assess the wound and determined that wound care orders were not obtained upon admission. S2DON confirmed that the surgical wound has become worse in condition and the resident is on antibiotics. Resident #9 Review of the record revealed Resident #9 had [DIAGNOSES REDACTED]. On 02/27/18 at 2:30PM, Resident #9 was observed in a wheelchair ambulating independently in the hall. Resident was wearing black shoes with a strap across the top of her feet. Resident was not wearing heel protectors. Review of current physician's orders [REDACTED]. 09/27/17- apply heel protectors to left foot every day, 10/18/17-wear compression hose daily, 11/08/17- apply heel protectors daily, 01/10/18- cleanse left heel with NS (normal saline), apply [MEDICATION NAME] blue, (moisturize with NS, wring out excess moisture), apply gauze, kerlix, and tape- change daily. On 02/28/18 at 1:50PM, S2Director of Nurses confirmed that no weekly skin assessments/body audits were conducted for the requested months of January and February 2018 for Resident #9. On 03/02/18 at 9:56AM, an observation of Resident #9's skin with S3MDS (Minimum Data Set) Coordinator revealed the following findings: right shoulder- several small open areas of skin, left arm- two open areas of skin to forearm/ one above elbow, left shoulder- 3 scabbed areas, 1 open area of skin, left inner elbow- open area of skin, right hip- several small open areas of skin, left hip- several small open areas of skin, right thigh- open area of skin, left knee- small open area noted with bright red blood coming from the area. On 03/02/18 at 10AM, S3MDS (Minimum Data Set) Coordinator reported that Resident #9 scratches her skin. S3MDS (Minimum Data Set) Coordinator confirmed that there is no record of the open areas of skin due to weekly skin assessments/body audits have not been carried out. S3MDS Coordinator added that she was going to put a dressing on the resident's left knee where bright red blood was noted.

Based on record review and interview, the facility failed to ensure that a resident with a supra pubic catheter received the appropriate care and services to prevent urinary tract infections to the extent possible for 1(#2) of 2 (#1, #2) residents with an indwelling catheter out of a sample of 5 residents reviewed. This failed practice resulted in an actual harm on 11/30/2017 for Resident #2, who has a history of urinary tract infections, was found unresponsive in bed. The LPN (Licensed Practical Nurse) stated that on 11/30/2017 the resident's catheter bag was full of cloudy colored urine with a little sediment in it and described the catheter insertion site as red. The resident was transferred to a local hospital and upon examination in the emergency room had a copious amount, approximately 400cc (cubic centimeters), of bloody purulent urine that was drained from the site of the suprapubic catheter into a urinal once the catheter was removed. Resident #2 was admitted in the hospital with the physician's clinical impression listed as Changed Mental Status with lethargy, [MEDICAL CONDITION] with Acute [MEDICAL CONDITIONS] and Urinary Tract Infection associated with indwelling catheter. Findings: Record review revealed Resident #2 was admitted to the nursing facility on 09/08/2017 with [DIAGNOSES REDACTED]. A review of November 2017 physician's orders [REDACTED]. A review of Resident #2's MDS (Minimum Data Set) dated 10/04/2017 revealed a BIMS (Brief interview for mental status) score of 6. Resident #2's MDS revealed resident was coded as total dependence for toilet use, personal hygiene, and bathing. Resident was coded as having an indwelling catheter and always bowel incontinent. A review of November 2017 Treatment record reveals resident's catheter was not changed in November at this facility. It was documented as last changed at this nursing facility on 10/11/2017 by S1DON (Director of Nursing) A review of nurse's note dated 10/27/2017 revealed Resident #2 was taken by ambulance to a local hospital for treatment and evaluation of a leaking supra pubic catheter and distended abdomen. A review of nurse's note dated 10/28/2017 revealed a note by S1DON stating resident returned to the facility and S1DON was given report that Resident #2's suprapubic catheter was changed in the hospital. A review of nurse's notes dated 11/30/2017 revealed resident was found unresponsive at 2:10PM. Resident #2 was transferred to a local hospital at 2:25PM by ambulance. A review of Resident #2's care plan, who has a history of urinary tract infections, revealed it did not address caring for the suprapubic catheter insertion or assessing for signs of a urinary tract infection, such as documenting the urine's appearance, including color, consistency, odor, or output amount. A review of the November 2017 MAR (Medication Administration Record) revealed nurses initialed every shift in November for completing, Suprapubic catheter care every shift with soap and water. Only initials were placed on the MAR by the nurse and no other documentation. A review of the nurse's notes in the days preceding Resident #2's admission to the hospital on [DATE] revealed no documentation of the appearance of Resident #2's urine or the catheter insertion site. Hospital records from the local hospital were obtained for Resident #2's transfer on 11/30/2017 and were reviewed. The Physician's clinical report stated, Suprapubic cath removed with copious amounts of bloody purulent urine from opening. Urine is so thick lab cannot test it. We will send it for urine culture. A wound culture was also done at suprapubic site. Patient had approximately 400cc (cubic centimeters) of bloody/purulent urine that drained directly from site into a urinal. Physician's clinical impression: Changed mental status with lethargy, [MEDICAL CONDITION] with acute [MEDICAL CONDITIONS], and urinary tract infection associated with indwelling catheter. Urine culture results from the local hospital dated 11/30/2017 revealed culture was positive for Escherichia coli and Proteus mirabilis. Wound culture results revealed culture was positive for Proteus mirabilis, [MEDICATION NAME]-resistant [MEDICATION NAME], and Escherichia coli. Hospital records revealed resident was transferred from the local hospital to another nursing facility later on 11/30/2017 for a higher level of care. Interviewed S3SSD (Social Services Director) at 9:55AM on 12/12/17, who stated that Resident #2 came to this nursing facility a few months ago after having a bad urinary tract infection that required hospitalization for intravenous antibiotics. After Resident #2 was transferred to the hospital on [DATE], his daughter told her she was upset with his care at the facility. She didn't think his catheter had been changed and he was unkempt. She stated his daughter told her he was not coming back to reside at this facility. An interview was conducted with S2LPN (Licensed Practical Nurse) at 2:57PM on 12/12/2017. She confirmed she came in to work on 11/30/2017 at 12:30PM and was caring for Resident #2. She stated that around 2:00PM a CNA (Certified Nursing Assistant) notified her that Resident #2 was unresponsive. She stated she went in the resident's room and found him unresponsive. She said she did a sternal rub, took vital signs, and sent Resident #2 out to the hospital. She stated that his catheter bag was full of cloudy colored urine and it had a little sediment in it. Also, she said the area of catheter insertion was red but she thought it was because he pulled on it a lot. An interview was conducted with S1DON at 3:30PM on 12/12/2017 who stated on 11/30/2017 she was told by a CNA that Resident #2's catheter was leaking. She said she was going to change it but he became unresponsive before she could change it. She confirmed that Resident #2's urine looked bad. When asked to describe it, she said it looked like pus. She confirmed that the nurses should have noticed this when doing catheter care and obtained a urinalysis and called it in to the doctor. She confirmed that this urine change would not have happened suddenly. S1DON confirmed that the nurses should document the appearance of the urine in the nurse's notes and that there was no documentation of the urine's appearance in the record for the days leading up to the resident's hospitalization . She confirmed it is the nurse's job to do catheter care every shift and they should be assessing the urine. She stated she or the weekend RN could have changed Resident #2's catheter and confirmed it had not been changed since Resident #2's hospital stay from 10/27/2017-10/28/2017.