Every finding on record at Colonial Manor of Amana

Based on observation, staff interview, facility record review, and manufacturer instructions, the facility failed to properly maintain the commercial laundry equipment and ensure staff performed the required maintenance to prevent lint accumulation and fire hazards for 1 of 2 laundry dryers (Dryer 1) used for all the resident's laundry in the facility. The facility reported a census of 43 residents.Findings include:On 7/21/26 at 10:45 AM Staff A, Laundry Supervisor, showed dark grey insulation material mixed with lint on the side of Dryer 1 in the laundry room. Staff A removed a basketball-sized pile of lint and insulation material from Dryer 1 and stated Dryer 1 had 12 years of use and represented the worst unit. Staff A demonstrated particles falling off the insulation into the compartment below Dryer 1 where the lint trap sits. Staff A stated all laundry staff and maintenance knew about the issue and staff contacted a laundry machine servicing company several years prior, but Staff A couldn't provide proof of the conversation. Staff A further stated staff clean the lint trap every two loads, clean better at the end of the night, clean the side once a day, and vacuum underneath the lint trap once a month. Staff A stated the facility didn't have a cleaning log or a formal cleaning policy. On 7/21/26 at 11:22 AM Staff B, Maintenance Director, stated during an interview being unaware of current equipment issues and laundry staff hadn't informed Staff B of dryer issues. Upon learning about Dryer 1's condition, Staff B stated being unaware of the issue and requested to inspect Dryer 1. On 7/21/26 at 11:25 AM Staff B inspected the laundry room with Staff A and observed dangling insulation on the right-hand side of Dryer 1 measuring approximately one foot long and over one inch thick. Staff A reiterated calling the laundry machine servicing company several years ago and stated the insulation pulls off in large chunks. Staff B confirmed this represented the first-time staff made Staff B aware of the issue. Staff B instructed Staff A to clean out Dryer 1 and remove Dryer 1 from service due to lint trapped in the insulation creating a fire safety issue. On 7/22/26 at 9:44 AM an email sent to Staff C, Administrator, requested the laundry operator's manual and the laundry cleaning schedule. A record review of an email received from Staff C on 7/22/26 at 10:27 AM showed a statement staff cleans out the dryer lint area daily per recommendations on the front of the lint compartment. The facility failed to provide cleaning logs or a formal policy demonstrating staff performed cleaning. The Operator's Manual for DTCH55 Series Dryers received from Staff C on 7/22/26 at 10:14 AM instructed under Preventive Maintenance to clean the lint screen daily and remove lint accumulation from the lint screen compartment, front control compartment, exhaust system (venting mechanism), and areas above, below, and around the burners (heating components) to prevent a buildup of lint creating a fire hazard.

Based on observation, interviews, facility documentation, and policy review the facility failed to store, prepare, and distribute food under sanitary conditions during 3 of 3 observations. The facility failed to ensure expired foods were discarded, maintain clean work spaces, and manage pest control. The facility reported a census of 43 residents.Findings include:On 7/20/26 at 8:59 AM an observation of the kitchen showed the following:1 reduced calorie cream cheese icing and 1 reduced calorie butter vanilla icing expired 5/5/26.6 containers of bread crumbs expired 6/2/26.Onion skins and white food debris lay on the floor of the walk-in cooler, under the pie filling storage shelf, and on the floor of the dry storage area. A dead cricket and two dead flies lay behind a bug trap next to the storage shelf.Flies landed on the surface of a silver and black cart, on a spatula used to make an omelet, on the hood above the cooking omelet, on the coffee machine, and on food preparation surfaces.The floor felt sticky with food debris noted throughout the kitchen. A two foot by 6 inch section of the floor near the coffee machine contained a yellow powdery substance, with a small area matted into the grout (mortar between tiles) and some tracked towards the cooktop about 5 feet away. Additional white and brown food debris scattered from the same area through the kitchen to the service window about 10-15 feet away. A tater tot and additional food debris lay under the counter drawers near the dishwashing area, which didn't match the food served for breakfast.Water tracked from the dish machine area to the kitchen, making some food debris on the floor pasty.The convection (hot air circulating) oven contained food debris inside where the bottom met the side, and a yellow/brown substance on the door and base of the oven felt sticky to the touch and contained additional food particles. On 7/21/26 at 10:50 AM an observation of the kitchen showed the expired items remained, dry storage and walk-in cooler floors contained food debris and onion skins, dead bugs remained on the floor, and food debris sat pushed against baseboards (molding along bottom of walls) under countertops and sinks. The debris felt dried and hard to the touch. The floor continued feeling sticky in areas, and the section of yellow powdery substance turned pasty and stuck into grout. The tater tot and food debris remained under counter drawers, and a cube of cheese sat under the counter with the toaster. The July 2026 cleaning schedule documented the following missed weekly cleaning tasks:sweep walk in fridge and freezer, weeks 1 and 2dessert cart, week 2cart, weeks 1 and 2grill and stove top, weeks 1 and 2toaster, weeks 1 and 2floor behind the dish room, weeks 1 and 2walls behind the dish room garbage, week 2metal table under the toaster, weeks 1 and 2 On 7/22/26 at 1:23 PM Staff E, Cook, stated staff needed to follow the cleaning schedule. Staff E stated assigned weekly and monthly tasks included the cooler and dry storage areas. Staff E stated staff needed to mop the floor after lunch shift and evening shift. Staff E acknowledged a lot of fly activity in the kitchen and dining room and stated staff tried to close doors better. Staff E indicated residents used the dining room door handicapped button to hold the door open, which had an impact. Staff E expected staff to throw out expired food upon seeing it. On 7/22/26 at 1:31 PM Staff F, Certified Dietary Manager (CDM), reported sometimes having to cover items on the cleaning schedule if Staff F saw tasks didn't get completed. Staff F stated staff needed many reminders, and staff recently discussed mopping. Staff F expected dietary aides and cooks to sweep and mop before leaving for the day, noting staff needed to complete mopping every shift no matter what. Staff F acknowledged the tater tot remained there since at least Sunday. Staff F felt fly activity grew much worse over the past two weeks and didn't know why bug lights in the dining room didn't help. Staff F didn't know expired items existed in dry storage. On 7/22/26 at 1:44 PM during an observation of the kitchen with Staff F, the expired items remained in the storage area. Bugs remained on the floor, and webs and food debris sat under the bins of the pie filling shelf in dry storage. Staff F confirmed this formed part of the cleaning schedule. Staff F stated having just cleaned the convection oven and noted the sticky substance still present felt like tape. Staff E completed mopping during the observation. Further observation of the area with the yellow substance showed some pasty yellow substance remained matted to grout, and food particles continued lining baseboards between counters and under sinks. The tater tot from Monday and cheese cube from Tuesday remained. A record review of an email from Staff G, Administrator, dated 7/22/26 at 1:34 PM showed the facility didn't have a kitchen cleaning policy.

Based on clinical record review, observation, resident interview, staff interview, and facility policy review, the facility failed to keep call lights within reach for 2 of 3 residents reviewed for accommodation of needs (Residents #27, #20, and #7). The facility reported a census of 43 residents.Findings include:1. Resident #27's Minimum Data Set (MDS) quarterly review assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderately impaired cognition. Resident #27 required limited physical assistance of 1 person for toileting, dressing, and personal hygiene. Resident #27's Care Plan revised 7/9/26 identified a self-care deficit. The Care Plan instructed staff to assist Resident #27 with toileting and activities of daily living (ADLs), noting Resident #27 calls for assistance to use the bathroom. On 7/20/26 at 9:54 AM observed Resident #27 sitting in her room with the call light placed under her pillow, away from Resident #27 and out of reach. On 7/20/26 at 9:54 AM Resident #27 stated she had to holler for help or ask her roommate to signal staff when unable to reach her call light because she couldn't get up on her own. Resident #27 stated the call light being out of reach occurs at least once a week, causing stress and leaving her stuck waiting over an hour for help when her roommate isn't around. 2. Resident #20's MDS annual assessment dated [DATE] documented a BIMS score of 14, indicating intact cognition. On 7/20/26 at 10:02 AM Resident #20 stated she helped her roommate (Resident #27) get ahold of staff when Resident #27's call light isn't in reach. Resident #20 stated this occurs at least once a week. 3. Resident #7's MDS comprehensive assessment dated [DATE] documented a BIMS score of 6, indicating severely impaired cognition. Resident #7's MDS documented diagnoses including dementia (memory loss) and recorded Resident #7 experienced a fall since the prior assessment. Resident #7's Care Plan revised 6/22/26 identified a potential for trauma and falls related to orthostatic hypotension (low blood pressure upon standing), vertigo (dizziness), and a history of falling. The Care Plan instructed staff to keep personal items and frequently used items within reach. On 7/21/26 at 10:22 AM witnessed Resident #7 sitting in her recliner. The call light laid in the middle of the bed, out of reach for Resident #7. When asked if she could reach the call light, Resident #7 attempted to stretch her arm over to the bed, but couldn't reach it. On 7/21/26 at 12:20 PM Staff C, Certified Nurse Aide (CNA), stated everyone should have their call light next to them when in their room. On 7/21/26 at 12:35 PM Staff D, Director of Nursing (DON), stated no resident should go without a call light. Staff D stated they expected the staff to make sure the call light was in reach whenever in a resident's room or when a resident laid in bed, they should move the call light near the resident before leaving the room. On 7/22/26 at 2:20 PM Staff E, Administrator, stated the facility didn't have a call light policy.

Based on record review and interview, the facility failed to ensure staff submitted an updated Preadmission Screening and Resident Review (PASRR) when 1 of 1 resident reviewed experienced a change in mental health diagnosis and medication (Resident #8). The facility reported a census of 43 residents.Findings include:A Preadmission Screening and Resident Review (PASRR) dated 11/18/24 indicated Resident #8 had diagnoses of anxiety (excessive worry) and depression (mood disorder). Resident #8 took fluoxetine (antidepressant medication) for depression and trazodone (sleep aid medication) for depression at time of assessment. A Care Plan problem dated 4/17/26 documented Resident #8 had potential for alteration in thought processes related to psychotropic (mind-altering) medication use. Another Care Plan problem dated 4/17/26 indicated potential for ineffective individual coping related to delusions (false beliefs). Resident #8's Medication Administration Record (MAR) dated July 2026 documented the following medications:Fluoxetine HCL 40 mg for depressionMirtazapine 15 mg for depressionQuetiapine fumarate 25 mg for psychosis (loss of contact with reality) Resident #8's Minimum Data Set (MDS) dated [DATE] documented current diagnoses of anxiety disorder, depression, and psychotic disorder. Section N showed Resident #8 took antipsychotic and antidepressant medications on a routine basis. On 7/22/26 at 2:06 PM Staff A, Administrator, stated the social worker maintained responsibility for completing the PASRR when a resident's mental health diagnoses changed. On 7/22/26 at 2:26 PM Staff D, Social Worker, stated receiving session notes from the psychiatric nurse practitioner and informing the MDS coordinator if a change in diagnosis or medication occurred. Staff D stated evaluating new mental health diagnoses or medications to decide if a new PASRR requirement existed, needing to review Resident #8's records to check when psychotic disorder appeared. During a follow-up interview on 7/22/26 at 2:46 PM Staff D stated Resident #8 received the diagnosis of psychosis March 2025 and started quetiapine March 2025. Staff D confirmed Resident #8 didn't have a diagnosis of dementia (memory loss) at the time and didn't complete a PASRR with the psychosis diagnosis and medication change. Staff D stated submitting a PASRR probably represented a good idea, didn't know if the update would've triggered a Level II PASRR, but couldn't know for sure and should've submitted the form. The PASRR Provider Manual dated 2/19/25 instructed nursing the facility staff to contact PASRR to report changes whenever a nursing facility resident with mental illness experienced changes that could affect their placement or service decisions.

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to ensure staff utilized a gait belt in accordance with the care plan for 1 of 3 residents reviewed for transfers(Resident #1). The facility reported a census of 42 residents. Findings include: 1. The Annual Minimum Data Set(MDS) assessment tool, dated 4/4/24, listed diagnoses for Resident #1 which included heart failure, arthritis, and Alzheimer's disease. The MDS stated the resident required supervision or touching assistance with toileting hygiene and toileting transfers. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 13 out of 14, which indicated intact cognition. The facility Gait Belt Policy, reviewed 1/5/24, directed staff to utilize a gait belt with all residents who required any physical assistance to stand, transfer, or ambulate, unless contraindicated as identified on the care plan. Each staff member will have a gait belt readily available for use when on duty. A gait belt will be provided to staff upon hire. A 2/20/24 at 1:21 a.m. Progress Note documented the resident was on her back on the floor and fell trying to reach her tissues. A 3/2/24 11:23 p.m. Progress Note stated the resident was on the floor and tried to pick up tissue paper from the floor and lost her balance. A 3/11/24 Progress Note stated the resident sat on the floor next to her bed and stated she reached for a mint when she slid out of bed. A 4/6/24 untitled nursing progress note stated the resident was seated on the toilet and staff attempted to assist her to a standing position when the resident sat back down after only raising up approximately an inch. The resident stated she would need more help than that and staff used more effort in the next assist. The resident was unable to straighten her knees and moved in a forward motion. The staff member was able to slow the resident's motion but was unable to prevent the resident from kneeling on the floor in front of the toilet. On 4/16/24 at 2:23 p.m., staff walked the resident from her room to the shower room utilizing a gait belt. On 4/16/23 at 3:00 p.m., Resident #1 stated on the night of the fall, she had to go to the bathroom and a staff member kept pulling on her arm to get her off the toilet. She stated she ended up falling on the floor in her own urine. She didn't know the staff member's name but stated she was never rough or unkind but she was in a hurry. She stated she did not feel the staff member was intentionally being mean but stated she was supposed to utilize a gait belt and did not. The current undated Care Plan as of 4/17/24 stated the resident required the assistance of 1 staff with ambulation and transfers. On 4/17/24 at 10:47 a.m., via phone, Staff A Certified Nursing Assistant (CNA) stated Resident #1 required the assistance of 1 staff and could be a difficult transfer. On 4/18/24 at 10:54 a.m., via phone, Staff B Registered Nurse (RN) stated on the night of the fall, the resident was in bed and needed to go to the bathroom. She reported the resident started walking to the bathroom with her walker. Staff B assisted the resident to pull down her pants and sit on the toilet. She stated when she was finished she (Staff B) took the resident under her arm in order to attempt to help her stand up and the resident could not. Staff B stated the resident then looked at her and stated she needed more help than that. Staff B stated (on the second attempt) the resident's knees did not unbend and instead of standing, the resident went forward almost head first and she could not prevent her from going to the floor. Staff B reported she assessed her for possible injuries and then other staff members assisted her off the floor. Staff B stated that the resident required the assistance of 1 staff with a walker and stated she would normally use a gait belt with her. She stated she did not use a gait belt with the resident on the night of the fall because she did not have one with her. On 4/18/24 at 1:05 p.m., the Director of Nursing (DON) stated if a resident required the assistance of staff for transfers, staff should utilize a gait belt. She stated if staff did not have a gait belt, they should locate one to use in the transfer.

Based on clinical record review, policy review, and staff interview, the facility failed to further assess and intervene after a change in mental status after a fall for 1 of 4 residents reviewed for assessment and intervention (Resident #2). The facility reported a census of 42 residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment tool, dated [DATE], listed diagnoses for Resident #2 which included high blood pressure, stroke, respiratory failure, insomnia, and cognitive communication deficit. The MDS stated the resident was independent with walking and listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. A [DATE] Care Plan entry stated the resident was independent with walking in his room. A [DATE] Family Practice clinic note stated the resident had no cognitive impairment and no disorientation to person, place, or time. A [DATE] at 12:30 a.m. untitled nursing note stated staff found the resident on the floor. The resident stated he was trying to get up and sustained a hematoma (bruise) to the right eyebrow and skin tears to the right eyebrow, right elbow, and right hand and an abrasion to the right knee. Nurse charting revealed the facility conducted neurological assessments at the following times with normal results: [DATE] 1:30 a.m. [DATE] 2:30 a.m. [DATE] 3:30 a.m. [DATE] 9:09 a.m. [DATE] 11:28 a.m. [DATE] 11:13 p.m. [DATE] 3:26 a.m. A [DATE] 9:27 a.m. untitled nursing note stated the resident was alert and oriented x 2 and stated the town was Channel 9. A [DATE] 3:14 p.m. untitled nursing note stated the resident was alert and oriented to self and month. A [DATE] 7:30 p.m. untitled nursing note stated staff went into the room to administer medications and the resident responded but did not open his eyes. A [DATE] 8:10 p.m. untitled nursing note stated the resident sat in the recliner and frothed at the mouth with apneic spells (periods of not breathing). The resident had blue hands and was sluggish with fixed pupils. Staff was unable to obtain a blood pressure and obtained an order to send the resident to the hospital. The resident had a pulse when the ambulance arrived but when they listened to the apical pulse(a pulse point on the chest at the bottom tip of the heart), it was absent and the resident had no respirations. The paramedics initiated Cardiopulmonary Resuscitation(CPR). The resident's pulse and blood pressure were restored at the hospital. A [DATE] 11:22 p.m. untitled nursing note stated the facility was notified at 10:52 p.m., that the resident passed away. The facility lacked documentation of provider notification or further assessment and intervention after the resident had a mental status change during the [DATE] 9:27 a.m. and [DATE] 3:14 p.m. assessments. The undated facility policy Charting Protocol directed staff to notify the physician when a behavior change occurred. On [DATE] at 1:05 p.m., the Director of Nursing (DON) was queried with regard to her expectations if a resident had a change from alert and oriented x 4 (person, place, time, and situation) to not being able to state the town. She stated that if there was a change, she would expect staff to notify the physician. On [DATE] at 10:11 a.m., via phone, Staff C Doctor of Medicine (MD) stated he would have wanted staff to inform him and the resident's family of the resident's mental status changes.

Based on clinical record review, observations, staff interviews and policy review the facility failed to provide complete perineal (groin and bottom) cares in a way to prevent contamination following an incontinent episode for 1 of 3 residents observed for incontinent cares (Resident #12). The facility reported a census of 37 residents. Finding Include: The Minimum Data Set (MDS) Assessment for Resident #12 completed on 9/07/23, included diagnoses of non-Alzheimer's Dementia, Diabetes Mellitus, and renal insufficiency/renal failure/end-stage renal disease. The Brief Interview for Mental Status (BIMS), revealed score of 2 out of 15 indicating severe cognitive impairment. The MDS identified the resident required total dependence with two or more staff assistance for toileting and extensive assistance of one staff for dressing and personal hygiene tasks. The MDS documented the resident always incontinent of urine and frequently incontinent of bowel. Resident #12's Care Plan, revised 9/18/23, revealed focus areas for alterations in elimination: bowel incontinence and bladder incontinence and focus area for self-care deficit. On 10/03/23 at 10:06 AM, Staff A, Certified Nursing Assistant (CNA) and Staff B, CNA transferred Resident #12 to the toilet. Staff B removed Resident #12's brief soiled from urinary incontinence. Staff A and B removed gloves, performed hand hygiene, and applied new gloves. Staff A helped stand Resident #12, Staff B wiped bottom and continued to use the same wipe multiple times after wipe become soiled with bowel movement (BM). Staff B failed to complete incontinent cares on Resident #12's front (groin) area following urinary incontinence. Staff B continued to wear same gloves after cleaning BM to apply a clean brief, manage resident clothing, and move the stand lift towards wheelchair. On 10/03/23 at 10:15 AM, Staff B, CNA, reported hand hygiene and glove change are expected when entering and exiting a resident room and after removing a soiled brief. Staff B confirmed urinary incontinence to be the reason she removed the original brief. On 10/05/23 at 10:45 AM, the Director of Nursing (DON) stated she expected the staff to change gloves and perform hand hygiene after touching soiled surfaces or when gloves become contaminated, before a clean brief and clothing is touched. The DON stated that she expected wipes to be thrown away after one use, not used multiple times following contamination. Facility provided a document titled, Nurse Aide Skills Checklist: Provide Incontinent Care, dated 7/2007, which instructed to remove gloves and reapply if soiled with BM or vaginal discharge and to change cloth or cloth surface with each wipe.

Based on observation, record review, family and staff interviews, the facility failed to safely transfer 1 of 4 residents reviewed for supervision, which resulted in an injury that included facial bone fractures around the left eye, right index finger and left 4th rib fractures of the resident (Resident #1). The facility reported a census of 36 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 with diagnoses of diabetes, dementia, and depression. The resident required total assistance for transfers with 2 person assistance and total assistance for toilet use and personal hygiene with 1 person to assist. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 0 out of 15, indicating the resident with severely impaired cognition. The Care Plan dated 6/9/22 revealed Resident #1 to be transferred with a Sara Stand Lift (a mechanical lift) and 2 person assist and eat with verbal cues and supervision of staff. The resident was eating a soft diet and on 7/13/22, there was an intervention added to change the diet to puree. The Care Plan dated 8/1/22 documented Resident #1 to be transferred by a Hoyer mechanical lift (total lift) with 2 person assist, and identified with a self-care deficit and needed assistance with meals for 3 months on a pureed diet. A directive was added to not leave resident unattended in the Bath House, utilize seat belt while in bath chair, and it is to remain buckled until appropriate lift is in front of resident, sling in place and attached for transfer. During an interview on 8/16/22 at 11:35 PM, a family member revealed Resident #1 had fallen from a shower chair and was in the hospital for 3 days. The family member stated Resident #1 broke her facial bone and right hand. The Resident needed a pureed diet and someone to feed it to her after the return from the 3 day hospital stay. This family member stated the same thing happened in 2019, Resident #1 fell from the bath chair onto her face and received a laceration above her eye that needed stitches. An Incident Report dated 7/11/22 at 10:45 AM revealed that Resident #1 fell from a bath chair, face down onto the floor after a Certified Nursing Assistant (CNA) unbuckled the seat belt and turned away to reach for a lift. The Resident had injuries and was taken to a hospital by an ambulance. The Hospital Medical Record dated 7/11/22 documented Resident #1 presented to the emergency room (ER) with a laceration above her left eye and had bruising to her face, left hand, left knee and a skin tear to her left arm. The resident was admitted for 3 days for observation with a diagnosis of facial bone fractures around her left eye, right index finger and left 4th rib fractures. During an interview on 8/16/22 at 2:40 PM, Staff C, Licensed Practical Nurse (LPN) stated she was called into the Bath House on the morning of 7/11/22 and seen Resident #1 face down on the floor, the resident was bleeding from her head, and she evaluated her, called for an ambulance and notified the physician and family. Staff C stated she remembered a fall from 3 years ago that involved Resident #1 and the seat belt not being fastened after the bath. Staff C stated they received training on transfer safety in the Bath House. During an interview on 8/17/22 at 9:57 AM, Staff A, CNA stated he gave a bath to Resident #1, dried her off, dressed her and called for assistance for the transfer to the wheel chair. Staff A stated he removed the safety belt that held Resident #1 in the seat to the bath chair, turned and took 1 step to see around the wall, to look for the lift that Staff B, CNA was bring from around the corner. Then Resident #1 fell forward to the floor onto her face. Staff A stated he was trained by Staff F, CNA on the safety precautions with the bath chair. During an interview on 8/17/22 at 11:45 AM Staff B, CNA stated she was called to the Bath House to assist with the transfer and as she was bringing the Sara Stand Lift to the room with Staff A and Resident #1, she heard a boom. Staff B stated she entered the room and seen Resident #1 on the floor face down. Staff B stated she was not trained in the Bath House but was trained for lift safety. During an interview on 8/17/22 at 11:29 AM, Staff D, CNA stated she was employed at this facility in 2008 and was trained in the Bath House to get the resident dried, dressed and get the equipment in front of the resident and the sling on before removing the belt. Staff D stated she was instructed to remove the belt last. Staff D reported the Physical Therapist gave training after this fall with Resident #1 and there was instruction added to Resident #1's Care Plan for transfers in the Bath House. A document titled Cascade Premier and Elite Premier Bathing Systems Safe Operation & Daily Maintenance Instructions dated 6/25/09 revealed on page 9, only personnel thoroughly trained in the operation of the [NAME] Swivel Lift System should operate this equipment, operation by untrained personnel could result in injury to the operator or patient. The [NAME] Patient Care distributor is available at your request to provide complete in-service training on the operation on the equipment's proper operation. The warning on page 10 revealed failure to secure the resident properly with the seat belt could result in injury to the resident or operator. Step 7 & 8 on page 11 are instruction for seat belt use. On page 15, transferring out of swivel bathing system, step 8 instruct to carefully remove the belt from the resident to ensure they do not slip out of the swivel lift chair. During an interview on 8/17/22 at 4:45 PM Staff F, CNA stated she mentored staff in the Bath House. Staff stated, you don't take the seat belt off until the resident is hooked up to the lift or the Hoyer, safety comes first. During an interview on 8/17/22 at 2:22 AM Staff E, CNA, Restorative Director stated she trained Staff A when employed as a Temporary Nurse Aide (TNA) in 2020. Staff E stated she gave instruction to staff in the Bath House to keep the seat belt on and latched until the resident is hooked up to the transfer device. Staff E stated she is currently developing a spreadsheet for training in response to the recent Quality Assurance and Performance Improvement (QAPI) identification for a lack of documentation for the training received by staff. Staff E stated this documentation tool will be completed by the end of August 2022. During an interview on 8/17/22 at 10:29 AM, the Director of Nursing (DON) stated the CNA involved with this incident was very sorry when presented with the corrective action. The DON stated she changed the Care Plan after the fall to include that in the Bath House staff are not to remove the seat belt until the lift is in front of Resident #1 and sling is around her. The DON stated she was not here when the fall happened to Resident #1 in 2019 and stated the intervention then was to have paper towels near the bath. The DON stated after this fall, the Physical Therapist trained the CNA's on safe transfers for the Bath House. We treat these residents like family and that is my philosophy and my expectations are that people provide safe care and keep our residents safe. The DON stated she is currently completing daily audits on transfers in the Bath House and the QAPI team is developing a document to track training for all departments. During an interview on 8/17/22 at 10:29 AM, the Administrator stated there was grab bars installed in the Bath House to assist with transfers and to increase safety with transfers. The Administrator stated the Physical Therapist provided training to the staff to include the use of the grab bars. An undated document provided titled Safe Transfers in the Bath House revealed a training provided by the facility's Physical Therapist. A document titled Rehab Communication dated 7/12/22 documented a recommendation from the Physical Therapist for maintenance to place horizontal grab bars to the walls next to the whirlpools to provide safe and stable transfers for all residents. An observation of the Bath House revealed that the grab bars have been installed.

Based on observation, staff interview, record review and Policy review, the facility failed to attempt to use alternatives to bed rails and assess the residents for the risk of entrapment prior to the installation of bed rails for three of 31 residents reviewed for bed rails (Resident #1, #31 and #36). The facility reported a census of 38 residents. Findings Include: 1. Review of Resident #1's Face Sheet located in the Electronic Medical Record (EMR) under the Topic tab revealed Resident #1 was admitted to the facility on [DATE]. Review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 02/17/22 and located in the EMR under the Topic tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of four out of 15, indicating the resident cognitively impaired and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Side Rail assessment, dated 05/06/22, revealed only five components that included: a. Able to make decisions: No. b. Preference of assist rails: Resident and or family agree to the use of assist rails, consent signed. c. Bed mobility: Uses assist rail to increase bed mobility. d. Safety issues: History of attempts to get out of bed unsafely (climbs over and around side rails or attempts to exit at foot of bed). e. Assist rail decision: ½ assist rails up x 2 for positioning assistance and bed mobility. Review of Resident #1's Side Rail Assessment revealed the assessment did not address alternatives tried prior to the use of side rails and failed to address Resident #1's risk for entrapment. On the following observations Resident #1's bed was observed in the low position and with half-length size siderails up on both sides of the head of the bed: a. On 05/23/22 at 10:10 AM. b. On 05/24/22 at 3:08 PM. c. On 05/25/21 at 9:40 AM. d. On 05/26/22 at 10:28 AM. 2. Review of Resident #31's Face Sheet located in the EMR under the Topic tab revealed Resident #31 was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #31's Quarterly MDS with an ARD date of 04/20/22 and located in the EMR under the Topic tab revealed the resident had a BIMS score of six out of 15, indicating the resident cognitively impaired and had falls prior to admission. Review of Resident #31's Fall Risk Assessment, dated 04/20/22, located in the EMR under the Topic tab revealed Resident #31 was high risk for falls. Review of Resident #31's Side Rail Assessment, dated 04/20/22, revealed only five components that included: a. Able to make decisions: No. b. Preference of assist rails: Resident and or family agree to the use of assist rails two half assist rails. c. Bed mobility: Uses assist rail to increase bed mobility. d. Safety issues: None. e. Assist rail decision: ½ assist rails up x 2 for positioning assistance and bed mobility, body pillow as border reminder, low bed, bedside mat. Review of Resident #31's Side Rail Assessment revealed the assessment did not address what alternative were tried prior to the use of side rails as well as failed to assess Resident #31's risk of entrapment. On the following observations Resident #31's bed was observed in the low position and with half-length size siderails up on both sides of the head of the bed: a. On 05/23/22 at about 10:15 AM. b. On 05/24/22 at 1:00 PM. c. On 05/25/21 at 9:50 AM. d. On 05/26/22 at 10:25 AM. On 05/25/22 at 9:50 AM, Resident #31 observed to be small framed and frail and in bed with side rails up. Resident #31 was asked why she had side rails on her bed, and she stated the siderails help to keep her in bed, so she didn't fall out and to help her to position herself in bed. 3. Review of Resident #36's Face Sheet located in the EMR under the Topic tab revealed Resident #36 was admitted on [DATE] for long term care. Resident #36's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #36's Quarterly MDS with an ARD date of 05/05/22 and located in the EMR under the Topic tab revealed the resident had a BIMS score of seven out of 15, indicating the resident cognitively impaired and had falls since admission. Review of Resident #36's Side Rail Assessment, dated 05/04/22, revealed only five components: a. Preference of assist rails: Resident and or family agree to the use of assist rails consent signed two half assist rails. b. Bed mobility: Uses assist rail to increase bed mobility. c. Safety issues: None. d. Assist rail decision: ½ assist rails up x 2 for positioning assistance and bed mobility, body pillow as border reminder, low bed, bedside mat e. Able to make decisions: No. Resident #36's Side Rail Assessment did not address alternative tried prior to the use of side rails and failed to assess the resident's risk of entrapment. On the following observations Resident #36's bed was observed in the low position and with half-length size siderails up on both sides of the head of the bed: a. On 05/23/22 at 1:45 PM. b. On 05/24/22 at 2:00 PM. c. On 05/25/21 at 8:22 AM. d. On 05/26/22 at 10:27 AM Interview on 05/24/22 at 1:17 PM, Infection Preventionist (IP) stated she was the charge nurse for Resident #1, Resident #31, and Resident #36's hall and the residents had side rails because they were a fall risk. The side rails helped to keep them from rolling out of bed as this was the first intervention for fall prevention and the side rails were always put in place at admission. She went on to say if the residents kept falling out of bed, other ideas were used. On 05/24/22 at 2:30 PM, Assistant Director of Nursing (ADON) stated Resident #1, Resident #31, and Resident #36's had side rails on their bed for repositioning and because he falls out of bed. On 05/25/22 at 9:54 AM, Certified Nurse Aide (CNA)2 and CNA1 stated Resident #1, Resident #31, and Resident #36's all used side rails for mobility and to keep them in bed as they were a fall risk. They went on to say a body pillow was placed against the rail to keep Resident #36 in bed. On 05/25/22 at 10:56 AM, CNA1 was asked if she thought the side rails were a restraint for the residents and she stated no because the residents could still move in bed. However, none of the three residents discussed, Resident #1, Resident #31, nor Resident #36, could lower the side rail themselves due to the lever not accessible to them. On 05/25/22 at 1:00 PM, the Assistant Director of Nursing (ADON) stated she was unaware of the regulation requiring certain components to be in the side rail assessments. The ADON confirmed the residents with dementia, Resident #1,#31, and #36, could not lower the side rails on their own but did not consider the side rails to be restraints. On 05/25/22 at 3:35 PM, Social Service Director (SSD) stated she had residents/families sign consents for side rails upon admission. When she was asked How did she know if the resident needed side rails, she stated she had them sign the consent and then they could decide if they wanted to use them or not later. On 05/26/22 at 10:20 AM, the Administrator was asked if safety checks were conducted on the residents' side rails and their risk of entrapment. She stated no Safety Assessments had been conducted. When asked about the manufacturer's requirements for the side rails, she stated she thought the beds came with the side rails but wasn't sure. She went on to say she didn't have the manufacturer's requirements as the last time they ordered a new bed was about a year ago. Review of the facility's policy titled, Side Rail, dated 03/02/22, revealed, Side Rail Assessments are reviewed on a quarterly basis using an individualized Patient Assessment. The assessment is done in conjunction with members of the interdisciplinary team. Review of the undated Consent for Use of Side Rails, revealed The facility will use side rails after evaluation and Care Planning deem it is appropriate to treat the resident's medical symptoms and assist the resident in attaining or maintaining his or her highest practicable physical and psychosocial well-being. The facility will monitor the resident's status and adjust care, as necessary.

Based on observations, interviews and record review the facility failed to maintain cleanliness in 1 out of 1 Kitchens reviewed in the facility. The facility reported census of 31 residents. Findings included: 1. During an observation of the kitchen 01/13/21 at 12:02 p.m., a cobweb on the underside of the right front hood over the stove. 2. During an observation on 01/13/21 12:08 p.m., the top of stove hood on all 3 sides noted 100% covered with fuzz and residue, the top left corner held dark brown cob webs approximately 5 by 5 inches. A dead fly hung from the front left side of the stove hood. 3. During an observation on 01/13/21 at 12:20 p.m., a dead moth hung from the gas line pipe where it met the ceiling tile. 4. During an observation on 1/13/21 12:25 p.m., the top section on the back wall in Kitchen, over the snack cart contained 2 heating/cooling vents approximately 18 inches by 12 inches with 4 grates in each. The vents held 15- 25% black fuzz. The 2 ceiling tiles above the vents contained 25-50 % black fuzz. During an interview on 1/13/21 at 12:02 p.m., Staff A, Cook reported under the hood is cleaned every 6 months. During an interview 1/13/21 at 12:04 p.m., the Dietitian stated the scheduled cleaning company failed to complete the cleaning on the stove hood on January 23, 2021. The Dietitian revealed not knowing if the top of the stove hood is on a cleaning schedule, but would think the Maintenance Department would be in charge of that. During an interview on 1/13/21 at 2:43 p.m., the Administrator reported the vents and the top of the hood of the stove are expected to be cleaned each month. Review of the Weekly Cleaning Schedule on the wall in the Kitchen dated 1/2021, lacked any direction for staff to clean the vents and the top of the hood of the stove.

Based on observation, staff interview, and record review the facility failed to follow the appropriate measures for the prevention of infection with the application of eye drops for 1 of 1 resident (Resident #26) observed. The facility identified a census of 48 residents. Findings include: 1. Review of Resident #26's Physician order [REDACTED]. During an observation on 6/13/19 at 4:03 p.m. revealed Staff A, Registered Nurse (RN) wheeled the resident in a wheelchair to the medication room to apply the eye drops. Staff A washed hands, gloved, and took the eye drop container from the medication cart. Staff A then placed the inside cap from the eye drop bottle down onto the counter top in the med room without a barrier. When done administering the eye drops, Staff A placed the cap back onto the eye drop bottle without any cleansing. During an interview on 6/14/19 01:45 p.m., Staff C, Licensed Practical Nurse, reported when giving eye drops you should put the cap of the bottle on a Kleenex or some kind of a barrier. During an interview on 6/14/19 at 2:00 p.m., the Director of Nursing (RN), reported when applying eye drops you can hold the bottle's lid in your hand or if you put it down, you should have a barrier such as a Kleenex or paper towel.

Based on observation, clinical record review, and interviews, the facility failed to ensure residents received adequate supervision to protect against accidents for 1 of 14 residents (Resident #13). Observation and staff interview revealed the facility failed to provide a call light in reach for Resident #13 to utilize to obtain assistance when needed for a safe method of transfer. The facility reported a census of 48 residents. Findings include: The Minimum Data Set (MDS) assessment with a reference date of 3/28/19 for Resident #13 identified a Brief Interview for Mental Status (BIMS) score of 13 indicative of intact cognition. According to the MDS, the resident required the assistance of one staff for transfers, personal hygiene, toilet use and dressing. A balance during transition and walking test identified the resident as not steady and only able to stabilize with staff assistance. The resident identified with [DIAGNOSES REDACTED]. The care plan revealed the resident had the history of a [MEDICAL CONDITION]. During an observation on 6/14/19 at 7:45 a.m., noted Resident # 13 was resting in a recliner with her eyes closed and the call light not within reach and the resident's phone not within reach either. During an observation on 6/14/19 8:30 a.m., the resident resting in a recliner with no call light in reach. The call light was attached to the bedframe which is not within the resident's reach. Staff B, Certified Nurse Aide (CNA), entered the resident's room and offered for her to get up for the today. Resident stated she was too tired at this time. Interviewed Staff B at this time and asked if resident had her call light. Staff B stated that no, she did not have her call light within reach. The call light was still attached to the bed frame out of the resident's reach. During this observation a sign in the resident's room revealed that PLEASE CALL, DON'T FALL and included a picture of a call light. During an observation on 6/15/19 at 7:35 a.m., the resident's call light noted on. During an interview with the resident at that time when asked if she turned call light on, she stated yes. A document titled Fall Fax Report revealed Resident #13 sustained five falls since (MONTH) 2019 on the following days: a. On 3/26/2019, she fell three times at 12:15 a.m., 7:24 a.m., and 8:37 p.m b. On 4/6/2019 fell at 12:05 a.m c. On 4/25/2019 fell at 8:30 a.m The Care Plan for the resident dated 3/28/19 identified the resident to have a history of falls and directed staff the resident required assist one staff with ambulation and transfers A Fall Risk assessment dated [DATE] documented the resident scored 9, a score of 7-9 indicated the resident with a moderate risk for falls. During an interview on 6/14/19 at 9:55 a.m., the Director of Nursing (DON) confirmed the resident should have a call light within her reach

Based on observation, clinical record review, facility skills checklist review, staff and family interviews, the facility failed to provide appropriate wheel chair positioning for one of eight residents reviewed (Resident #1) and failed to provide proper pericare for one of six residents observed during personal cares. (Resident #2) The facility census was 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required staff assistance for bed mobility, transfers and toilet use. The Care Plan dated 1/29/15, identified the manual wheel chair as the resident's primary means for locomotion. The care plan directed staff to reposition with personal cares and as needed. Observation on 2/3/15 at 10:30 a.m., revealed Staff A, certified nurse aide, CNA and Staff B, CNA entered the resident's room to provided personal cares. The resident agreed to get out of bed and sit in his/her wheelchair. Observation revealed staff transferred the resident by hoyer and positioned the resident in his/her wheelchair. Observation revealed the resident leaned to the right without support provided. Staff B propped a pillow under the resident's right under arm area and tucked the other end of the pillow along the edge of the wheelchair arm rest. Observation revealed the residents lower right arm, right wrist and right hand dangled in a downward motion without support. Observation revealed the resident's left upper and lower arm was squeezed against the left side of the wheelchair with no support provided. Staff assisted the resident in the wheelchair to the dinning room area at 11:45 a.m. During interview on 2/3/15 at 1:30 p.m., the resident's spouse revealed concern for the resident's position and expressed the resident looked so uncomfortable and revealed their desire for the resident to be comfortable. During interview on 2/3/15 at 2:30 p.m., the Director of Nursing revealed a night staff person had stayed late and repositioned the resident prior to going off shift. 1, The MDS assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment identified the resident required limited assistance for bed mobility, dressing, personal hygiene and toileting. Observation on 2/3/15 at 8:25 a.m., revealed the resident laying on his/her back in bed with a large area of urine soaked into the "soaker pad" placed under the resident. Observation revealed on the outer edge was dried, yellow in color and encircled the saturated urine soaked area. The area extended under and outside of the resident's body from his/her shoulders down to the resident's knees. Observation revealed Staff A, CNA cleansed the resident's left hip and buttocks in a back to front direction and in a back and forth motion. Review of the facility Nurse Aide Skills checklist for Incontinent Care dated 7/07 revealed directions for the staff to cleanse front to back and to wash buttocks and upper thighs.

Based on facility policy review, resident and staff interview, the facility failed to ensure resident call lights were answered promptly in order to meet residents needs for four of eight residents interviewed. The facility census was 55 residents. Findings include: 1. During group interview conducted on 2/2/15 at 1:40 p.m., four eight residents present stated concerns about staff response to call lights. One resident stated their call light was not answered for up to 1/2 hour. The resident indicated they had a watch to time staff response to his/her call light. One resident stated it took a long time for their call light to be answered with more than a 1/2 hour wait. The resident admitted to wetting themselves which made them feel impatient and neglected. The resident indicated they had a clock on a stand to monitor the time it took for the call light to be answered. Another resident indicated being in the bathroom with the emergency light on and it was not answered for 1/2 hour to 45 minutes. The resident indicated staff will say they are short handed and no one showed up. The resident showed the surveyor a watch that he/she used to time the length of time his/her call light was on. Another resident indicated he/she used a cellular telephone for a clock and it took 20 minutes to get a call light answered. 2. During interview on 2/4/15 at 11:20 a.m., the Director of Nursing stated they expected resident call lights to be answered in less than 15 minutes. Review of an undated facility policy titled Call Light Procedure documented call lights will be answered within 15 minutes of the initial page.

Based on record review, staff interview, facility investigation and policy, the facility failed to timely report an allegation of abuse/mistreatment for 1 of 15 residents (Resident #15). The facility identified a census of 55 residents. Findings include: Resident #15 had [DIAGNOSES REDACTED]. The MDS documented the resident with a Brief Interview for Mental Status (BIMS) score of 11 indicating the resident moderately cognitively impaired. The assessment revealed the resident had behaviors that fluctuated related to inattention and disorganized thinking. The MDS documented the resident as needing assistance of 1 staff for walking in their room and corridor. The assessment identified the resident unsteady and only able to stabilize with staff ' s assistance when walking, when moving from seated to standing positon and when turning around. A care plan of the resident ' s current needs with a goal date of 1/26/15, revealed the resident used a walker and required staff assistance with ambulation. The care plan indicated to monitor the resident for gait assistance and allow the resident to lie down after meals. During the review of a facility investigation of an alleged violation involving mistreatment of [REDACTED]. Staff D, Registered Nurse (RN) allegedly yelled at Resident #15 in the dining room to sit down and then pulled on the gait belt of the resident to assist in walking. A review revealed no report made to the abuse unit at the Department of Inspections and Appeals. Interview with the facility Administrator on 2/3/15 at 9:20 a.m. revealed Staff D, RN as worried the resident was going to fall and they were trying to get the resident's attention and the resident as not listening. The facility Administrator indicated the facility felt Staff D, RN was trying to protect the resident and if they were trying to abuse the resident Staff D, RN would not have been so attentive to the resident. A statement by Staff D, RN for the facility investigation documented his actions as unprofessional and he had been afraid and anxious for Resident #15's safety. Staff D documented the resident thrashed about and Staff D as not wanting the resident to fall. Staff D documented he did not recall if he used profanity. A note in the facility investigative file revealed a resignation note from Staff D, RN dated 7/25/2014 at 8:02 p.m. Staff G ' s statement (unsigned or not dated) documented Staff D had been called into the dining room to help calm Resident #15 down. After Staff D got the resident calm down, the resident got up and walked by him/her(self). Staff D walked with Resident #15 to the lobby but the resident kept trying to go back to his/her room. Staff D called for assistance from a CNA and Staff G came over and tried to calm Resident #15 down. Staff G documented Staff D then yelled Resident #15 ' s name and asked him/her to go to the lobby. Staff D then said F(expletive) Christ. Staff E came out from a nearby room when Staff D yelled. Staff D then said he was just going to carry Resident #15 to the lobby; and Staff G told Staff D to " Stop " he could not do carry the resident. Staff G asked Staff E to take Resident #15. Staff G documented Resident #15 asked Staff D to stop pulling so hard on the gait belt. Staff E ' s statement documented she heard a loud scream coming from the hallway. Staff E observed Staff D holding onto Resident #15 ' s gait belt. Staff E ran down the hallway to help Staff D and she heard Staff D say he was just going to lift Resident #15 up and carry the resident. Staff D had been holding on to the Resident extremely tight and this made Staff E upset. Staff E told Staff D to she would take Resident #15 from here. Staff D was yanking and pulling Resident #15 to the point (that) his/her walker was only down on the resident ' s left side. Staff E took ahold of Resident #15 ' s gait belt and the resident started to sit on Staff E ' s left leg (and Staff E braced herself on the wall). Staff E assisted the resident to his/her room after the incident. Staff F ' s statement documented Staff G came to her and reported she needed her assistance. Staff G reported Staff D screamed at Resident #15 and upon entering the room Staff E said she really needed to talk with her. Staff E was physically shaking and tearful. Staff E and Staff D went to the nurses station with Staff F. Staff E reported Staff D was pulling and yanking on Resident #15 ' s gait belt so hard she could not stand so she leaned on the wall. Staff F documented she asked Staff D to completed his statement since three (3) CNAs told Staff F the same story. Staff F documented she notified the DON and ADON of the situation at that time. On the advisement of the surveyor in the facility during the annual survey and complaint investigations the facility Administrator faxed the 7/25/14 facility investigation of alleged mistreatment of [REDACTED]. The Administrator sent the Department a written narrative which included the following regarding the incident. The Administrator documented no staff member was present to see what had happened, and several staff made assumptions. The Administrator documented at the time this occurred and still today he felt this was inappropriate/isolate incident and he chose to not call this in as a self-reported incident. Review of a revised Abuse policy dated 10/10/14 included the following: The resident has the right to be free from verbal, sexual, physical, psychological abuse, corporal punishment and involuntary seclusion. The policy documented the facility prohibits mistreatment and neglect. The Reporting/Responses section of the policy documented in part the following: All employees must immediately report any incident of suspected abuse to the person in charge. No employee shall knowingly attempt, with or without threats or promise of benefit to induce another to fail to report an incident of suspected abuse, alter, change, or render unavailable a report made by another; or without information to reporting agencies. The Administrator will examine all sources of information, evaluate the resident, and will make an oral and written to DIA and Colonial Manor Board of Directors within one working day. The Administrator will send a written report to the same parties within 5 working days of the oral report.

Based on record review and staff interviews, the facility failed to implement the written health care plan and transfer Resident #1 with the assistance of a mechanical lift and adequately supervise the resident to prevent accidents. The sample consisted of 3 residents and the facility reported a census of 55 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment dated [DATE], which identified the resident had a BIMS ( Brief Interview for Mental Status) score of 0. A score of 0 reflected the resident a severely impaired for cognitive status. The assessment reflected the resident required total staff assistance with transferring and bed mobility and extensive staff assistance with dressing, toilet use, personal hygiene and bathing. Resident #1 did not ambulate. In reference to balance during transition and walking, Resident #1 required staff assistance to stabilize with moving from seated to standing position; moving on and off the toilet; and surface to surface transfers. The Care Plan identified a problem with self- care deficit; needed total assistance. The approach directed staff to transfer the resident with a Hoyer (mechanical lift) and the assistance of 2 people. The approach reflected the resident as dependent for wheelchair mobility. The form titled North Daily List, available to all certified nursing assistants, reflected Resident #1 required a Hoyer lift transfer with 2 staff assistance and the resident could not ambulate. A hospital summary report dated 11/1/13 revealed Resident #1 presented (to the hospital) with right knee pain following a fall. This A.M., the resident was showering with the help of aids, and she/he lost her/his balance and was gradually lowered to her/his knees. Later in the days, the resident had complaints of pain and he/she was brought to the emergency room for an evaluation. The resident has difficulty with ambulation from lower extremity contractures and she/she spends a good portion of the time in bed or chair. The right leg x-ray film revealed an oblique (slanted or tilted) femur (thigh bone) fracture with posterior displacement, diffuse osteopenia (bone mineral density is lower than normal) and osteoarthritis (structural and functional failure of joint). The hospital summary reflected the physician admitted the resident into the hospital for pain management of the acute right distal femur fracture (above knee). The resident ' s not a surgical candidate and the leg was casted for stability. The physician ordered Oxycodone (narcotic analgesic) elixir 2.5 milligram every 4 hours and IV (intravenous) Dilaudid (narcotic analgesic) .05 milligram every hour as needed for pain. The plan directed hospital staff that the resident would be discharged to the facility when the pain was well controlled and treatment plan is in place. The note identified the resident in pain at the right lower extremity area. The record identified the resident returned to the facility on [DATE] with Physician order [REDACTED]. On 11/18/13 at 9:49 a.m. Staff A (certified nursing assistant) was interviewed and stated on the morning of the incident (11/01/13), she transferred Resident #1 from the wheel chair to the bath chair by the Hoyer lift and the assistance of Staff B. Staff A stated following the transfer, the Hoyer sling was soiled with feces and staff A placed the sling in the wash barrel in the bath house. Upon completion of Resident #1's bath, Staff A stated she asked Staff B to locate another (clean) Hoyer sling. Staff B could not find a sling, so Staff A stated she put a gait belt on Resident #1 and called for the assistance of a third helper (Staff C). Staff A stated as they started to lift Resident #1 with the gait belt, Staff C was to adjust Resident #1's outer clothing, but Resident #1 started to defecate, so they lowered Resident #1 to the floor. Staff A stated she heard a "pop" but thought the noise was the resident ' s shoe. Staff A stated she has never transferred Resident #1 with a pivot transfer (with gait belt) before, and acknowledged that it was her idea to proceed with a pivot transfer. Later, the nurse found a lift sling. On 11/19/2013 at 10:49 a.m. Staff B (certified nursing assistant) was interviewed and stated three nursing assistants transferred Resident #1 from the wheel chair to the shower chair on the morning of 11/01/13. Staff B stated she looked for a second Hoyer sling to use (due to feces on the one just used). Staff B stated she checked in the laundry room, Resident #1's room and the closet across the hall from Resident #1's room and could not locate a sling. Staff B stated she then asked a nurse, Staff D who directed her to check the laundry room. Staff B stated she rechecked all the areas she had originally checked. Staff B stated she returned to assist another resident in the bath house when Staff A requested assistance with Resident #1. Staff B reported that Resident #1 was seated "cockeyed" in the shower chair and he/she thought the nursing assistants were going to reposition Resident #1 in the shower chair. Staff B stated all of a sudden Resident #1 was coming toward her as in a pivot transfer. Staff B stated she "messed up" and did not question Staff A about what they were going to do. Staff B stated if had known they were going to attempt a pivot transfer, and then she would have alerted a nurse or used the soiled Hoyer sling. Staff B also stated that during the attempted transfer, the shower chair kept sliding back, because the brakes were not on (locked). Staff B stated had the brakes been on, staff likely could have easily assisted Resident #1 back to the shower chair. On 11/19/2013 at 12:31 p.m. Staff C (certified nursing assistant) was interviewed and stated she had gone to the bath house (on 11/01/13) because she heard another resident yelling and other staff talking about Hoyer slings, a sling being soiled, and staff looking for slings in the laundry room, the resident's room and the bath house. Staff C stated she was also aware that a nursing assistant had asked a nurse about where to find a sling, and received an answer on additional places to look. Staff C stated one of the other nursing assistants asked her to assist with doing a transfer for Resident #1. Staff C stated she just didn't feel right about doing it, but staff had the gait belt on Resident #1. The shower chair brakes were not locked and Resident #1 became involuntary of bowel. The shower chair was too high to assist the resident to be seated. The gait belt was loose and slid up under the resident ' s arms. Staff C stated she was at a loss and couldn't do anything. On 11/19/13 at 7:46 a.m., Staff D (licensed practical nurse) was interviewed and stated on 11/01/13, shortly after reading the change of shift report sheet, she recalled staff asking the whereabouts of a Hoyer sling. Staff D stated she expressed to the nursing assistant that she knew there were at least 2 more Hoyer slings available and when Staff B left the dining room, Staff D stated she assumed Staff B went back to search for the sling. Staff D stated she went to her office and within minutes, Staff C asked about another sling, via the walkie talkie system. Staff D stated (via walkie talkie) that Staff B was in the process of looking for one. Staff D stated another minute or so passed and then a nursing assistant again, via the walkie talkie system, requested a nurse to the bath house for Resident #1. Staff D stated she responded and observed Resident #1 sitting on the floor in front of the shower chair. Staff D stated she asked the nursing assistants if they had asked a nurse if this type of transfer (pivot transfer) had been approved, and there was no response from the three nursing assistants. Staff D stated she found 2 slings in the north hall supply closet (took 1-2 minutes to find sling after leaving the bath house). Staff D stated she went back to the bath house and 3 nurses and Staff C transferred the resident with the Hoyer lift. On 11/20/12 at 10:43 a.m. Staff H (certified nursing assistant) was interviewed and stated she had the nurse's instruct her about the proper use of the new Hoyer lift. Staff H stated nursing staff took the actual Hoyer lift manual and went over the proper use. Staff H stated she then reviewed the information with Staff A and Staff B just prior to Staff A and Staff B transferring Resident #1 from the wheel chair to the shower chair. Staff H stated during an interview on 11/19/13 at 2:08 p.m. that she would not transfer Resident #1 without a Hoyer lift, as it was specifically documented Resident #1 required a Hoyer lift and staff assistance. Staff H added that if she did not have the proper equipment or could not locate a sling, she would take her concerns to the nurse. During additional random staff interviews, Staff I, Staff J and Staff K stated they would not transfer Resident #1 without a Hoyer and sling, and if in doubt they would take their concerns to the charge nurse. The Director of Nursing (DON) was interviewed on 11/19/13 at 12:11 p.m. and stated the facility purchased a new Hoyer lift on 10/15/13. The DON stated at the time, they put the new Hoyer out for use; he/she removed the old Hoyer lift and slings, and replaced them with the new Hoyer lift and appropriate slings. Staff F stated she did more 1 on 1 training verses a formal in-service about the new lift as the lift was the same brand as the old lift, just a newer model. The Director of Nursing stated on the morning of 11/01/13, Staff H asked a nurse to review the use of the new lift with her. The DON showed Staff A and Staff B and then Staff A and Staff B transferred Resident #1 from the wheel chair to the shower chair. The DON stated she did not understand why Staff A and Staff B did what they did, as they have been educated on the use of the lift as well as going to the nurse should they have questions. The DON acknowledged Staff A and Staff B failed to follow the plan of care for Resident #1 with transferring Resident #1 in a safe manner according to Resident #1's needs which resulted in the resident obtaining a fractured femur.

Based on observation, clinical record review, and review of the facility Nursing Drug Handbook, the facility failed to administer eye drops to 1 of 2 residents observed for eye drop administration utilizing technique to meet professional standards of quality. (Resident #10) The facility census was 58 residents. Findings include: Resident #10 had a [DIAGNOSES REDACTED]. The January 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Observation on 1/2/13 at 8:04 a.m. revealed Staff I, licensed practical nurse (LPN) instill [MEDICATION NAME] eye drops, 1 drop into each eye for Resident #10. No finger pressure occurred to the lacrimal (tear) sac of the left or right eye by either Staff I, LPN or by the resident after instillation of the eye medication. Review of the facility Nursing 2012 Drug Handbook page 1325 under the heading of Administration documented the following: Apply light finger pressure on lacrimal sac for 1 minute after instilling drug to minimize systemic (heart, blood vessels, and air passage) absorption.

Based on record review, observation and interview, the facility failed to provide appropriate incontinence cares for 3 of 12 residents reviewed. (Resident # 1, Resident #2, and Resident #3) The facility identified a census of 58 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 12/5/12 documented Resident #1 had [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) documented the resident with moderately impaired cognition. According to the MDS, the resident required extensive assistance of 2 or more staff for transfers, toileting, dressing and personal hygiene. Observation revealed 1/2/13, at 7:45 a.m. Staff E, certified nurse aide (CNA) and Staff F, CNA, provided incontinent care to the resident while in the bed. The observation revealed the resident expelled a small amount of bowel movement onto the washcloth. Staff E then cleansed the rectal area and the left and right side of the rectum with disposable wipes. Staff E cleansed the rectal area with the same side of the wipes in a back and forth direction. Staff E and Staff F then positioned the resident on his/her back. Staff E cleansed and rinsed the left and right groin twice with the same side of the wipe. Staff E cleansed and rinsed and dried in a repeated back and forth direction with the same side of the wipe. Staff E failed to cleanse the resident's buttock, the inner legs and both hip areas. Staff E and Staff F transferred the resident from his/her bed onto the bedside commode. Observation revealed the resident urinated into the commode. Staff F cleansed the front perineal (peri) area and the rectal area. Staff F failed to cleanse the buttocks, inner legs or hip areas. 2. The MDS dated [DATE] documented Resident #2 had [DIAGNOSES REDACTED]. The BIMS documented the resident with moderately impaired cognition. The MDS documented the resident required extensive assistance of 2 or more staff for transfers, toileting, dressing, toileting, and personal hygiene. Observation on 1/2/13 at 8:10 a.m. revealed the resident incontinent of urine. Staff E and Staff F assisted the resident to the bathroom and positioned the resident onto the toilet. The resident urinated into the toilet. The observation revealed Staff E cleansed the resident's rectal area and the right and left buttocks with the same side of the washcloth. Staff E wiped in full circles to cleanse, rinse and to dry the buttock areas. The staff failed to cleanse the front groin areas, both hips and inner legs. 3. The MDS dated [DATE] documented Resident #3 had [DIAGNOSES REDACTED]. The BIMS documented the resident with moderately impaired cognition. The MDS documented the resident required limited assistance of 2 or more staff for transfers, toileting, dressing, and toileting. Observation on 1/3/13 at 9:00 a.m. revealed Staff G, CNA, and Staff H, CNA, assisted the resident to the bathroom. Staff H described the brief worn by the resident as containing a small amount of urine. Staff H cleansed the rectal area 3 times appropriately. On the 4th time Staff H used the same side of the peri wipe twice on the rectal area. The staff failed to cleanse the buttocks, inner legs, or front perineal areas. Review of the undated facility Peri-care Audit directed the staff to wash all soiled areas from front to back and to use wipes only three times-each swipe a different area on wipe. When interviewed on 1/3/13 at 3:30 p.m. the Assistant Director of Nursing(ADON) stated his/her awareness of the need for additional perineal care instructions to all the staff.

Based on observation, record review, and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, safe, orderly, and comfortable interior. The facility reported a census of 58 residents. Findings include: Observation on 12/7/11 at 7:15 a.m. revealed the motorized wheelchair of Resident #7 with a left arm rest with foam padding off of the arm rest. Debris under the pressure relieving pad in the wheelchair presented along with a surgical boot and shoe on top of the pressure relieving cushion with the soiled soles of the shoes resting on the pressure relieving cushion. Observation on 12/7/11 at 10:15 a.m. revealed 3 of 9 tables in the dining room just off of the dietary kitchen with table legs with dried liquid spatters. The attached dining room area revealed 4 of 8 tables with table legs with dried liquid spatters. During the environmental tour on 12/08/11 at 10:07 a.m. with the environmental services supervisor, housekeeping supervisor, and the Director of Nursing a tour of the dining room revealed table legs remaining soiled. With interview on 12/8/11 at 10:25 a.m., Staff A, dietary aide, reported cleaning of the table legs on the cleaning schedule. Review of the cleaning schedule record revealed dining room table legs on the weekly cleaning assignments. The last cleaning schedule day revealed a date of 12/5/11. However, the cleaning schedule not checked as cleaning of the table legs completed. Observation on 12/8/11 at 7:02 a.m. revealed facility staff transferring Resident #6 from the bed to a rolling commode/shower chair. The transfer took place with the commode/shower chair rolling. Observation revealed a lock present on the left rear of the commode/shower chair but no locking brake on the right rear. Facility staff made contact with the environmental services supervisor for repair of the resident care equipment. Observation on 12/7/11 at 9:05 a.m. revealed Resident #2's left wheelchair pedal with dried food debris Observation on 12/07/11 at 12/15 p.m. revealed Resident #2's front two wheels of the wheelchair with dried food debris in a splattered pattern, appeared as dried hot chocolate. Observation on 12/09/11 at 9:00 a.m. revealed Resident #2's wheelchair with the same appearance as described on 12/07/11. Observation on 12/07/11 at 10:39 a.m. revealed Resident #4's wheelchair with wheels and spokes with splattered brown and white food debris, and the left handrest contained a crack which revealed white padding. Observation on 12/09/11 at 7:45 a.m. revealed Resident #4's wheelchair wheels and spokes with splatter brown and white food debris, and the left handrest contained a crack which revealed white padding. Observation on 12/09/11 at 8:04 a.m. revealed Resident #11's wheelchair left brake and right leg rest with dried pale yellow food debris, and the inside right panel contained red, orange, and pale yellow sticky food debris, under the seat cushion numerous food crumbs. Observation on 12/09/11 at 9:05 revealed Resident #11 sat in the wheelchair in the main dining with the wheelchair continued soiled. .

Based on staff interviews and observations, the facility failed to keep medications in a locked area. The facility reported a census of 59 residents. Findings include: Observation on 1/4/11 at 4:15 a.m. revealed a white medication cart sitting in the hall by the nurses station unlocked, with 3 prepared medications in medication cups sitting on top of the cart. Upon entering the building at 4:15 a.m. the surveyor found the unlocked cart in the hall and no staff by the medication cart. At 4:17 a.m. a staff nurse exited a resident's room and walked up the hall. During an interview with Staff A, nurse, on 1/4/11 at 4:18 a.m., Staff A stated she forgot to lock the medication cart as she had a resident yelling down the hall and went to assist the resident. The facility identified 4 residents who wandered about the facility.