Every finding on record at Colonial Manor of Elma

Based on clinical record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure one of six residents reviewed remained free from a resident to resident physical altercation when a resident with severe cognitive impairment and a known history of aggressive behaviors (Resident #6) hit another resident (Resident #2). Three of six residents reviewed experienced fear from the Resident #6's aggressive behavior (Resident #2, Resident #4, and Resident #5). Resident #2 experienced increased anxiety, social isolation, a decline in nutritional intake, and fear following the incident. Resident #4 and Resident #5 expressed fear of Resident #6 and reported decreased activity participation due to Resident #6's behaviors. The facility reported a census of 32 residents.Findings include:1.Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated severe cognitive impairment. Per the MDS, the resident made herself understood and understood others. The MDS addressed the resident was independent for toileting, hygiene, dressing, ambulation and transfers. Per the MDS, the Resident #6 had no behaviors, did not wander, or reject care. The MDS included diagnoses of hypertension (when the pressure in your blood vessels is too high) Non-Alzheimer's Dementia, and osteoarthritis of the right knee, and the resident received antidepressant medication in the last 7 days.Resident #6's Significant Change MDS assessment dated [DATE] documented the resident had a BIMS score of 1 out of 15, which indicated severe cognitive impairment. Per the MDS, Resident #6 made herself understood and usually understood others. The MDS further revealed the resident had inattention which fluctuated (difficulty focusing attention, being easily distracted or keeping track of what was being said), disorganized thinking which fluctuated (rambling or irrelevant conversation, unclear or illogical flow of ideas or switching from subject to subject), hallucinations (experiences in the absence of real external sensory stimuli), and delusions (misconceptions or beliefs that are firmly held, contrary to reality). Per the MDS, Resident #6 had physical behavioral symptoms directed toward others (hitting, kicking, pushing, scratching, grabbing), verbal behaviors directed towards others (threatening others, screaming at others, and cursing at others,) and other behavioral symptoms not directed towards others (physical symptoms such as hitting, scratching self, pacing, rummaging, screaming, disruptive sounds). Per the MDS, Resident #6's behaviors significantly intruded on the privacy or activity of others, the resident rejected care 1 to 3 days, and the resident wandered 1 to 3 days. The MDS documented that the resident required partial to moderate assistance with dressing, transfers and ambulation. The MDS further revealed the resident required set up assistance with eating and personal hygiene. The MDS included diagnoses of hypertension, Non-Alzheimer's Dementia, and arthritis, and revealed Resident #6 received antidepressant medication in the last 7 days.Resident #6's Plan of Care with target dated 6/22/26 had a focus area for impaired cognitive function related to moderate dementia. An additional focus area with target date 6/22/26 revealed the resident was at risk for elopement/wandering related to memory/disorientation/decision making. Resident #6's Care Plan also included a focus area for psychotropic medication use for dementia diagnosis.The Plan of Care lacked interventions pertaining to the behaviors that were documented on the 3/17/26 MDS.The March 2026 Point of Care (POC) Response History documented behaviors on these dates and times:a. 3/13/26 at 9:59 PM: behavior observed, grabbing others, hitting others, physically aggressive towards others, accusing and cursing at others, frustration, and threatening to others.b. 3/15/26 at 1:09 PM: behavior observed included, in part, expressed frustration/anger at others.c. 3/20/26 at 9:59 PM: behavior observed included, in part, expressed frustration/anger at others.d. 3/23/26 at 9:57 PM: behaviors observed included grabbing others, hitting others, pushing others, grabbing others, scratching others, physically aggressive towards others, accusing of others, cursing at others, and expressed frustration/anger at others, and threatening others.e. 3/24/26 at 1:02 PM: behaviors observed included physical aggression, verbal behaviors, socially inappropriate behavior.The March 2026 Documentation Survey Report documented on 3/20, 3/23, 3/24, 3/25, 3/26, and 3/30, specific instances of behaviors including accusing others, cursing at others, expressing frustration/anger, screaming at others, threatening others, grabbing others, hitting others, physically aggressive, scratching others, pushing others, entering other residents rooms/space, agitation, anxious, restlessness, experiencing hallucinations/delusions, wandering, and verbalizing persistent false beliefs.The Health Status Note dated 3/23/26 at 2:15 PM revealed the resident was being disruptive to other residents while out in the living room and lobby, bossing them around. Other residents do not want her near them due to her confusion and her non-stop talking and her physical closeness to them. Resident has been redirected several times throughout the day by several staff without much success.Non-stop talking continues about changes needed to be made with this place, farm, [redacted], people and what is wrong with them, setting up committees, etc.The Health Status Note dated 3/23/26 at 4:40 PM revealed, .Non-stop talking and worrying about random things in the community: nursing home, staffing, police station, committees, etc.She was not able to stay on topic very long and would get lost in thought.The Incident Report Note dated 3/26/26 at 6:47 PM described, resident was in the hallway and misunderstood what 2 other residents were talking about and confronted them. Staff attempted to keep them apart. Res (Resident #6) slapped the other resident (Resident #2) in the arm and was yelling at her and combative with staff and very difficult to redirect. Res (Resident #6) was becoming more and more violent with staff and residents and verbally abusive towards both. The staff will attempt to keep these 2 residents (Resident #6 and Resident #2) apart.The Alert Note dated 3/27/26 at 4:21 AM stated that Resident #6 attempted to enter another resident's room, and was redirected to her own room.The Behavior Follow-up note dated 3/28/26 at 3:39 PM documented the resident was very difficult to redirect. Has been getting in staff and resident faces, and talking about getting a 2 by 4 and woopping <sic> people who don't shape up. She feels she owns this place. Very violent verbally and threatening .Attempted to elope (leave the facility) X3 (three times) before 2:00 PM.The Behavior Notes for Resident #6 documented the following:a. 3/29/26 at 12:16 AM: Resident out in lobby accusing staff of taking her belongings. CNA (Certified Nursing Assistant) had assisted her previously with finding her shoes. Staff attempted to redirect the resident back to her room. The resident refused and entered nurse's station. Writer attempted to reassure resident that all her belongings are in her room. Resident then started grabbing items and papers off of desk. Writer tried to redirect, but resident grabbed writers wrists and started to squeeze. CNAs got resident attention and she returned to lobby and sat quietly. Now resident again started grabbing items off of CNA's cart. Allowed until resident struck staff on buttocks by whipping chair pad. Resident then ambulated to front door. Writer approached and stood at door way. Resident walked away. Stopped and took out the residents sign out book which is a heavier book. Resident then turned an walker directly to writer, striking writer. When tried to remove book, resident then struck writer's face with closed fist. Staff then walked resident back to her room and assisted into bed.b. 3/30/26 at 2:30 AM: Resident was in the dining room trying to get into the kitchen. Doors were locked but she was aggressively pushing and trying to turn handle. This staff tried to redirect her and she picked up a fork and aggressively waved it at me saying that she was going to get a ball bat and hit me in the head. In addition to this she was also trying to go out the fire door and pull the fire alarm. Eventually she was redirected to the living room and had ice cream, coffee and a cookie. This nurse sat 1:1 with her because she was trying to go back into the dining room and other residents are getting upset with her. She continued to talk about hurting others and that we need to watch out because we are next and she is going to hurt us.c. 3/30/26 at 3:10 PM: Swiping at staff unable to redirect. Picking up objects and hitting staff garbage can and cups. Unable to redirect. Active hallucinations of bank robbery, [NAME] and mayhem. Delusions that she owns everything, that she is the only one that can make choices and that everyone is her [NAME].The Alert Noted dated 3/31/26 at 4:38 AM documented the resident had a few moments of wandering into other rooms and was redirected by staff.The General Progress Note dated 4/1/26 at 2:58 PM documented, Resident currently in the office sitting at her desk with this writer for the last 30 minutes. Prior to this resident was in lobby verbalizing to staff walking by, visitors walking by and residents that we are all in danger, we all need to have guns to take care of those that are a danger to us because they are here to kill us, we should have the power to change things and make better. She thinks that we have law enforcement here and that we also need to include the FBI and that this is not a joke, and in the same breath thinking we are in the school and the kids have taken over because nothing was done. Been reminiscing with resident about previous career and family.The New Order Follow Up Note dated 4/1/26 at 6:13 PM revealed, Resident very difficult to redirect this afternoon. going in other resident rooms, verbally aggressive towards staff. in a very bad mood.During an interview on 4/3/26 at 12:50 PM with Staff A, Housekeeper, Staff A acknowledged that Resident #6 was able to ambulate independently throughout the facility and showed behaviors such as hitting, kicking, and throwing things at staff. Staff A explained the resident had verbal outbursts during meals and activities.Observation on 4/3/26 at 1:05 PM revealed Resident #6 ambulated in front of the nurses' station, and attempted to go into the activity that was going on in the main dining area. A staff member offered a cup of coffee and the resident sat down in a chair in front of the nurses' station. An interview was attempted with Resident #6. Resident #6 was upset that the cows were not being milked, and was not able to recall an incident on 3/26/26.Observation on 4/3/26 at 3:05 PM revealed Resident #6 sat at a desk in the Director of Nursing office, voiced the facility was hers, and that she would make sure that all staff and residents did what she said.On 4/7/26 at 2:00 PM, Staff B, Licensed Practical Nurse (LPN), stated that she worked on the night of the 3/26/26 incident between Resident #6 and Resident #2. Staff B explained that she heard some commotion in the west hallway and came out of the nurses station to investigate. By the time she got to the incident, other staff removed Resident #6 away from Resident #2. Staff B proceeded to do an assessment on Resident #2 and found a red mark on the left shoulder/upper arm area, and after a few minutes the red mark disappeared. On 4/7/26 at 2:42 PM, Staff D, CNA stated that Resident #6's behaviors had gotten a lot worse in the past couple of months and that other residents were fearful and scared of Resident #6.On 4/8/26 at 1:30 PM, Staff G, Registered Nurse (RN) acknowledged that the facility failed to put interventions in place after the 3/26/26 incident, and that the plan of care lacked interventions of behaviors that were identified on the 3/17/26 MDS.2. Resident #2's MDS assessment dated [DATE] documented the resident had a BIMS score of 15 out of 15, which indicated intact cognition. Per the MDS, the resident was able to be understood and understood others. The MDS addressed the resident was independent for personal hygiene, upper extremity dressing, and eating, and once in a motorized wheelchair was independent for mobility. The MDS assessment further revealed the resident had no behaviors, did not wander, and did not exhibit rejection of care. The MDS included diagnosis of Cerebral Palsy, anxiety, depression, and adjustment disorder.Resident #2's Plan of Care, target date 5/13/26, had a focus area that the resident enjoyed activities such as watching movies, listening to music, playing on tablet and going outside when weather permitted. Also enjoys some group activities such as BINGO, paddle wheel, arts and craft/coloring, and social hours and games. The resident's care plan also included a focus area for a history of trauma that may impact psychosocial functioning. The goal target date 5/13/26 revealed, Will seek assistance if feeling symptoms of traumatization and/or anxiety related to trauma.The Progress Note dated 3/26/26 at 10:10 AM documented that the patient shared discomfort with individuals who exhibit loud and aggressive behaviors, which has prompted her preference to spend most of her time alone in her room or outdoors. The patient's mental status during the session included a tearful affect and a depressed mood, with irritable interview behavior. The patient demonstrated openness and engagement in sharing her emotional experiences during the session, including discomfort around loud and aggressive individuals.Continued therapy sessions remain necessary to support her emotional processing to promote growth and autonomy.Encouraging participation in group activities and physical therapy will persist as integral to her holistic treatment.The Incident Report Note dated 3/26/26 at 6:34 PM present in Resident #2's Progress Notes revealed, Resident had an altercation with another resident and the other resident slapped her with an open hand on the left upper arm. Staff witnessed and had been attempting to separate them when it happened. Pain at the time of the incident. Possible injury/bruising in the future. Will attempt to keep the two residents separated.The Long Term Care (LTC) Progress Note dated 3/27/26 at 7:44 AM documented the resident had quite a bit of anxiety and lower mood. She stated she had situational/social anxiety and got stressed out and had to take her meals in her room. She didn't like crowds or large groups of people, which made her nervous. Feels mood has been better in the past. New orders were received to reduce her Wellbutrin (a prescribed antidepressant) and increase Vraylar (a medication to treat bipolar depression or as an add on for major depressive disorder) and add Klonopin (a medication used for panic attacks) 0.5 mg (milligram) every day as needed for anxiety.The Physician Visit Note dated 3/27/26 at 2:52 PM, resident seen by Dr. [Name Redacted] on rounds.assessed resident, reviewed progress notes and recent vitals. New orders to reduce bupropion (Wellbutrin), increase vraylar and Klonopin prn (as needed).The Social Service Note dated 4/7/26 at 1:31 PM, for follow up from incident on 3/26/26, revealed the following: [Resident #2] is voicing increased anxiety being around [Resident #6]. She is stating worry about going to activities during the day. [Resident #2] is still attending but stated [Resident #6] is disruptive during activities. [Resident #2] states she just doesn't want to get hit again. This writer will bring this back to the team and further discuss safety intervention options.The Progress Note dated 4/7/26 at 10:05 AM documented Resident #2 described ongoing anxiety about a resident at the home who exhibited unpredictable outbursts.The patient openly expressed thoughts and emotions about these issues.Observed that the patient's affect was tearful, with an anxious mood noted during the session.Her expressions as well as anxiety related to a certain resident behavior, signal the need for ongoing focus on emotional regulation and interpersonal strategies. On-going sessions are medically necessary to continue addressing the patient's anxiety and depression.Review of Resident #2's Point of Care Response History for activity participation record for March 2026 documented the resident attended group activities on 3/17, 3/19, 3/23, 3/24, 3/27, 3/30, and 3/31. Review of the Documentation Survey Report for March 2026 revealed from 3/1/26-3/25/26, Resident #2 participated in BINGO, arts/crafts, snacks, social hour, trivia, and games. From 3/26-3/31/26, Resident #2 participated in BINGO, games, music, and physical activity.Review of the Point of Care Response History for Nutrition for 3/1/26-3/31/26 revealed the following:a. 3/1/26-3/25/26: Documentation revealed Resident #2 ate 75 %-100% of meals for breakfast, lunch and dinner on 3/1/26, 3/3/26, 3/4/26, 3/6/26, 3/7/26, 3/12/26, 3/14/26, and 3/23/26.b. 3/26/26-3/31/26: Documentation revealed Resident #2 did not eat 75% of meals for breakfast, lunch, and dinner on 3/26/26, 3/27/26, lacked documentation of amount eaten for breakfast and lunch on 3/28/26 and 3/29/26. The resident also did not eat 75% of meals for breakfast, lunch, and dinner on both 3/30/26 and 3/31/26.Observation on 4/3/26 at 10:00 AM revealed Resident #2 in her room. The resident watched television, and sat in a motorized wheelchair.On 4/3/26 at 10:00 AM, Resident #2 explained the following about an incident that happened involving Resident #6 hitting Resident #2 on the left upper shoulder/arm leaving a red mark and it hurt. Resident #2 explained that she was afraid of Resident #6, and stayed in her room due to not wanting to get hit again. Resident #2 stated that if she did come out for meals, she wore headphones and listened to music to drown out Resident #6's verbal outbursts during meals. Resident #2 stated that the facility Administrator indicated that the facility would attempt to keep Resident #6 away but couldn't promise anything. The resident felt like she was isolated to her room due to Resident #6's ability to independently ambulate around the facility. Resident #2 stated that she kept her door to the room closed all the time.Observation on 4/3/26 at 11:30 AM revealed Resident #2 came out of the dining room, wore a pair of white headphones with cellphone on her lap, and went straight to her room making no eye contact with anyone.On 4/3/26 at 12:50 PM, Staff A stated that when she cleaned Resident #2 room, she (resident) would start to cry because she felt she was not able to leave her room because she was afraid of Resident #6. Staff A explained that Resident #2 was very interactive with all staff and other residents and would socialize with them, but since the 3/26/26 incident Resident #2 stayed in her room more.Observation on these dates and times, revealed Resident #2 with her room door closed/shut: 4/3/26 at 1:15 PM, 2:20 PM, and 3:00 PM.On 4/7/26 at 11:15 AM, Resident #2 stated she was still scared of Resident #6, was afraid of getting hit again, and stayed in her room. Resident #2 stated that the primary care physician started a PRN (as needed) medication to help with the panic attacks and anxiety due to being hit by Resident #6.On 4/7/26 at 2:00 PM, Staff B, LPN acknowledged that Resident #2 only came out of her room for meals and wore a white pair of headphones with a cellphone in her lap. Staff B confirmed that Resident #2 would cry due to being scared of Resident #6 and would not make eye contact due to being afraid.On 4/7/26 at 2:30 PM, Staff C, CNA stated that Resident #2 was afraid of Resident #6 and would only come out for meals. Per Staff C, the resident would cry in the mornings not knowing what was going to happen and did not want to get hit again by Resident #6.On 4/7/26 at 2:42 PM, Staff D, CNA stated that Resident #2 was scared of Resident #6 and would cry in her room due to being afraid of getting hit by Resident #6 again. Staff D confirmed and verified that Resident #2 would only come out of her room now for meals. Staff D explained Resident #2 had panic attacks when saw Resident #6.On 4/7/26 at 3:03 PM, Staff E, CNA stated that Resident #2 would cry in her room due to being scared and fearful of getting hit again by Resident #6. Resident #2 would come out of her room wearing a white pair of headphones and a cellphone in her lap and will not make eye contact with anyone.On 4/7/26 at 3:38 PM, Staff F, CNA stated that Resident #2 was fearful and scared of Resident #6 and would come out for some small group activities and meals. Staff F explained the resident wore a white pair of headphones and a cell phone in her lap and would not make eye contact with anyone. Per Staff F, Resident #2 had declined a lot of activities which was a decline, and would sit in her room and cry due to not wanting to get hit again by Resident #6.On 4/7/26 at 4:50 PM, the facility Administrator confirmed that Resident #2 got hit by Resident #6 on 3/26/26 and that Resident #2 still came out for meals and some activities, but participation in activities had declined due to being hit by Resident #6. The Administrator stated that the primary care physician reviewed Resident #2 medications and a new medication was started as a PRN for panic attacks and anxiety.On 4/8/26 at 2:20 PM, Resident #2 Primary Care Physician (PCP) confirmed Resident #6 was seen on 3/27/26 after the incident that occurred on 3/26/26. Resident #2 stated that they were having some anxiety with going out to the dining room for meals and being around large groups. The PCP explained the following: Not until after doing round table discussions did they become aware of the incident between Resident #6 and Resident #2 on 3/26/26, and by adding a PRN medication for Resident #2 would assist in getting through this incident.Observation on 4/8/26 at 5:10 PM revealed Resident #2 sat in the dining room facing east with a white pair of headphones on.3. Resident #4's MDS assessment dated [DATE] documented the resident had a BIMS score of 15 out of 15, which indicated intact cognition. The resident was able to be understood and understood others. The MDS revealed the resident used a walker/wheelchair for mobility, had no behaviors, did not wander, and did not reject care. The MDS included diagnosis of Cerebral Palsy, depression, hypertension, and diabetes mellitus.The Plan of Care for Resident #4, target date 6/10/26, revealed the resident enjoyed independent activities such as word searches, coloring in adult coloring books, and watching movies/listening to music in [Resident #4's] room or friends room. Resident also enjoys group activities such as BINGO, arts and crafts, listening to live on site music, playing card games, and facility outings when offered.On 4/7/26 at 1:00 PM, Resident #4 stated that she was scared and afraid of Resident #6. Resident #4 explained the incident on 3/26/26 happened right outside of her room door. Resident #2 was visiting with another resident across the hall. Resident #6 came up beside Resident #2 and hit Resident #2 on the left shoulder/upper arm area and said I will hit you harder if needed because you are not working hard enough. Resident #4 stated that Resident #2 started to cry, yell, and scream. Staff came running out of rooms, assisted Resident #6 away from Resident #2, and took Resident #2 to her room. Resident #4 said that she would only come out for meals and does not attend activities like she used to due to Resident #6's verbal outburst and behaviors. Resident #4 kept her room door open to see if Resident #6 would come into her room, and would chase out if needed.On 4/7/26 at 2:00 PM, Staff B, LPN, explained Resident #4 was scared of Resident #6. On 4/7/26 at 2:30 PM, Staff C, CNA explained Resident #4 was scared of Resident #6 and would only come out of her room for meals. Staff C explained Resident #4 would leave the door to her room open to make sure if Resident #6 attempts to come in then Resident #4 could chase her out.4. Resident #5's MDS assessment dated [DATE] revealed the resident scored 13 out of 15 on a BIMS exam, which indicated intact cognition. The MDS revealed the resident was able to be understood and understood others. The MDS revealed Resident #5 was independent with a walker for mobility, the resident had no behaviors, did not wander, and did not reject care. The MDS included diagnosis of anemia, heart failure, hypertension, anxiety, and depression.The Plan of Care for Resident #5, target dated 6/7/26, stated that resident enjoyed most group activities such as BINGO, social hours, some games, and independent activities such as word puzzles, reading, watching television, and some arts/crafts.On 4/7/26 at 12:00 PM, Resident #5 stated she was scared of Resident #6 and did not want to come out of her room due to Resident #6 becoming irate and upset. The resident explained Resident #6 would yell and scream during activities and the meal service and would hit anyone. Resident #5 explained that due to this behavior from Resident #6, Resident #5 did not come out for activities.The Abuse, Prevention, Reporting and Investigation Policy with a revision dated 9/25 revealed the following purpose: To provide professional care and services in an environment that is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including, but not limited to.other residents.or other individuals. The policy included the following definition of physical abuse: Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.

Based on observation, policy review and staff interview, the facility failed to ensure infection control prevention and practices to prevent touching of medication with bare hands or dirty gloves during medication administration for 3 of 5 residents observed (Residents #27, #1, and #11). The facility identified a census of 36 residents.Findings include:Observation completed during the Medication Administration Task revealed the following:A. On 2/19/26 at 7:07 AM Staff B, Certified Medication Aide (CMA), voiced she planned to give Resident #27 his medications. Staff B without performing hand hygiene applied gloves, obtained her keys, opened the double lock narcotic drawer, touched the computer mouse with her right gloved hand to check the physician order. Staff B touched multiple resident medication cards in the narcotic drawer, retrieved Resident #27's Methadone (narcotic medication) card, punched the pill into her right gloved hand, and placed it into the medication cup. Staff B administered the medication to Resident #27.B. On 2/19/26 at 7:14 AM Staff B, opened the drawers on the medication cart, she flipped through the medication cards, and touched the computer mouse with her right hand, Staff B individually popped Resident #1's Eliquis (blood thinner), metoprolol (blood pressure medicine), omeprazole (stomach acid reducing medicine), spironolactone (pill used to lower the excess fluid from the body while keeping electrolytes in the blood) from the medication card directly into her right hand and placed each pill into a medication cup. Staff B removed the stock acetaminophen (Tylenol) bottle from the medication cart, removed the lid, shook one pill into the palm of her left hand, and placed the pill into the cup with her left hand. Staff B administered the medications to Resident #1 after she got into her wheelchair. C. On 2/19/26 at 7:26 AM Staff B failed to perform hand hygiene, then placed her fingers of her right hand inside a plastic cup and placed the cup on top of the medication cart. She voiced she would get Resident #11's medication ready. Staff B opened the bottom drawer of the medication cart multiple times and pulled up several bottles of Miralax (powder put into liquids daily to help with bowel movements) looking for Resident #11's medication. Staff B opened the second drawer of the medication cart, removed a stock bottle of 81 Milligram (MG) aspirin, opened the lid, shook one aspirin from the bottle directly into her left hand, and placed the pill in a medication cup. Staff B obtained a stock bottle of multivitamins from the medication cart, removed the lid, shook one tablet from the bottle into her left hand and placed it in the medication cart. Staff B removed a generic bottle of Senokot S (medicine to help with bowel movements) from the medication cart, shook two tabs from the open bottle into her left hand and placed it in the medication cup. Staff B placed 17 grams of Miralax into the plastic cup on top of the cart, filled it with water and stirred. Staff B administered the medications to Resident #11. A review of Resident #27, #11 and #1's February 2026 Electronic Medication Administration Records on 2/19/26 revealed Staff B signed the medications listed above as administered. On 2/19/26 at 7:56 AM Staff C, CMA, reported they are to perform hand hygiene between each medication pass and pills should only be touched with a clean glove if a medication needed touched. Pills shouldn't be touched with bare hands that have touched other items or surfaces. On 2/19/26 at 9:39 AM Staff D, Licensed Practical Nurse (LPN), explained hand hygiene should be completed between each resident's medication pass. Hands should be sanitized or use gloves to handle any oral medications. If gloves are used, the gloves cannot touch anything else other than the pill. On 2/19/26 at 9:59 AM the Director of Nursing (DON) reported she expected the nursing staff to wash their hands prior to the medication pass and between each resident's medication pass. Staff should pop the medication from the medication card directly into the medication cup. If the nursing staff wear gloves, they should only touch the medication and nothing anything else. The staff really shouldn't wear gloves when they prepare the medication. The Medication Administration-Medication Pass Policy, revised May 2023, provided by the facility, documented a Purpose to safely and accurately prepare and administer medication according to the physician orders and patient needs. The Policy, under General Instructions directed not to touch medication or inside of the medication cup. Tablets and capsules if obtained from a bottle, transfer to the bottle cap, then into the medication cup. If the medication/pill is obtained from a medication card, transfer it directly into the medication cup. The Policy directed to perform hand hygiene before and after each resident's medication pass. The policy lacked direction on the use of gloves in handling medication/pills.

Based on record review, staff interviews, and policy review the facility failed to protect 1 of 2 resident's rights to be free from misappropriation of their opioid pain medication patches (fentanyl) (an extremely potent, synthetic (lab-made) opioid used for pain) (Resident #42). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #42 documented a Brief Interview for Mental Status (BIMS) of 9, indicating moderate cognitive impairment. The MDS included diagnoses of low back pain, age related osteoporosis, and limitation of activities due to disability. The MDS reflected she took an opioid medication during the lookback period.Resident #42's Order Summary Report signed by her doctor on 10/24/25 included an order for a fentanyl patch 25 milligrams (mg) with a start date of 10/1/25. Resident #42's Orders in her Electronic Health Record (EHR) included an order for a fentanyl patch 25 mg with a start date of 10/1/25 and an end date of 12/2/25. Review of the facility's undated Investigation: Criminal Act - Medication Diversion, Final Report revealed a concern was identified for Resident #42's fentanyl pain medication. Staff N, Registered Nurse (RN), identified on 11/9/25 she found two (2) fentanyl patch packages empty. The packages looked like they were cut, the patch removed, and placed back into the box with tape on them. The facility started an investigation into the misappropriation of Resident #42 missing fentanyl pain medication. The facility notified local law enforcement on 11/9/25 and started an investigation. The facility implemented the following action plan:a. Thorough narcotic medication and record audit completed.b. Nursing staff re-education completed. Education included updated narcotic count process to ensure patch pouches are intact, patch placement location documented in the medication record, and narcotic policy review.c. Resident #42 pain assessment conductedd. A six-week narcotic count audit will be conducted bi-weeklyOn 2/19/26 at 9:52 AM the Director of Nursing (DON) reported the facility identified Resident #42 had 2 missing fentanyl patches back in November 2025. She added the facility never had anything like that happen. She explained since then, they changed how they count the fentanyl patches. Instead of just looking at the patches, they pull them out and actually look at them to see if someone tampered with them.In an interview on 2/19/26 at 1:52 AM the Administrator reported their system worked, they always counted the fentanyl patches; however, they identified Resident #42 had 2 fentanyl patches missing from their packaging and taped shut. They now verify they are sealed, not cut open and taped shut. The facility's Patient Protection Guidelines Abuse Prevention, Reporting, and Investigation policy reviewed September 2025 defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a patient's belongings or money without the patient's consent. The facility will upon receiving a report of an allegation of resident abuse, neglect, exploitation, injuries of unknown origin or misappropriation, immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process.

Based on record review and staff interviews the facility failed to accurately code 2 of 2 Minimum Data Set (MDS) assessments for residents with a Pre-admission Screening and Resident Review (PASRR) Level II outcome (a formal determination that confirms if an individual with suspected serious mental illness or intellectual disability requires Medicaid-certified nursing facility care and defines their need for specialized services) (Resident #4 and #32). The facility reported a census of 36 residents. Findings include:1. Resident #4's MDS assessment dated [DATE] identified she didn't have a state level II PASRR serious mental illness and/or intellectual disability or related condition. The MDS documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS included diagnoses of anxiety, depression, bipolar, and schizophrenia. Resident #4's PASRR notice of nursing facility approval dated 12/2/15 reflected she met the criteria for mental illness as defined by PASRR. In an interview on 2/19/26 at 1:52 PM the Administrator revealed when they completed the MDS back in March 2025 they had concerns with the MDS' accuracy by the MDS Coordinator at the time. The Administrator added she no longer worked at the facility, and they haven't had problems since. In an e-mail correspondence with the Administrator on 2/19/26 at 1:32 PM she explained the facility followed the Resident Assessment Instrument (RAI) MDS guidelines (Federal requirements governing the standardized assessment of nursing home residents). 2. Resident #32's MDS assessment dated [DATE] identified he didn't have a state level II PASRR serious mental illness and/or intellectual disability or related condition. The MDS documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. Resident #32's PASRR dated 8/10/17 reflected he met the criteria for mental illness as defined by PASRR. Resident #32's Addendum to PASRR Summary of Findings dated 12/20/17 documented a Level II approved with specialized services. On 2/19/26 at 11:02 AM Staff G, MDS Coordinator, confirmed the facility coded the Annual MDS wrong as Resident #32 is a level II PASRR.

Based on record review, staff interviews, and policy review the facility failed to provided 1 of 2 residents with specialized services as the resident's Pre-admission Screening and Resident Review (PASRR) directs (Resident #4). The facility reported a census of 36 residents. Findings include: Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 15, indicating no cognitive impairment. The MDS included diagnoses of anxiety, depression, bipolar, and schizophrenia. Resident #4's PASRR dated 12/2/15 directed she required specialized services of a behavior management plan for addressing behaviors of anxiety/worry, verbal aggression, abrasiveness/irritable behaviors and inappropriate communication of anger. Review of Resident #4 Care Plan on 2/17/16 lacked a behavior management plan. In an interview on 2/19/26 at 2:06 PM the Director of Nursing (DON) reported she didn't have a behavior management plan for Resident #4.In an e-mail correspondence with the Administrator on 2/19/26 at 1:32 PM she explained the facility followed the PASRR provider's guidelines (a two-level, federally mandated screening process for all nursing home residents to identify serious mental Illness, intellectual disability, or related conditions) for completing PASRR's.

Based on observation, record review, policy review, resident, and staff interview, the facility failed to ensure appropriate infection control prevention and practices to prevent cross contamination when providing incontinent cares. The observation revealed the staff failed to remove soiled gloves, perform hand hygiene, and not touch a clean brief with soiled gloves for 1 of 2 residents observed (Resident #7). The facility identified a census of 36 residents.Findings include:Resident #7's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. Resident #7 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort.) with lower body dressing and toileting hygiene. The MDS documented she is not on a toileting program and is frequently incontinent for bowel and bladder. The MDS included diagnoses of renal (kidney) failure, diabetes mellitus, and hypertension (high blood pressure).The Care Plan Focus with a Target date of 4/15/26 identified Resident #7 had bowel and bladder incontinence related to cognitive impairment and mobility. The Interventions directed the following:a. Resident #7 wore incontinent briefs. b. Gets frequent urinary tract infections (UTI), ensure peri cares are focused on twice per day. The Care Plan Report lacked direction on use of enhanced barrier precautions ( EBP infection control measures in nursing homes and skilled nursing facilities that require staff to wear gowns and gloves during high-contact resident care to reduce the spread of multidrug-resistant organisms) when providing care. A Communication with Physician note on 2/10/26 at 1:13 PM documented a new lab draw order for a complete blood count ( CBC measures the cells circulating in the blood), a comprehensive metabolic panel ( CMP used to evaluate, diagnose, and monitor health conditions by measuring chemical balance, metabolism, liver/kidney function and electrolytes) and urinalysis ( UA examines a urine sample's physical, chemical and microscopic properties to check for urinary tract infections UTI). with micro/culture related to right side flank pain. A Progress Note dated 2/11/26 at 10:34 AM documented Resident #7 complained of lower quadrant pain, elevated blood pressure, and requested to transfer to the emergency room. A Communication with Physician note dated 2/11/26 at 11:12 AM documented Resident #7 transferred to the emergency room prior to facility completing the labs and UA. A New Order Note on 2/12/26 at 00:52 AM documented Resident #7 returned to the facility with orders for ondansetron 4 milligrams (mg) disintegrating tablet (Zofran ODT) and cefdinir 300 mg capsule (Omnicef) for a UTI. The final Urine Culture and Sensitivity verified 2/13/26 showed >100,000 CFU/ml (colony forming units per milliliter) Escherichia coli (E-Coli) mixed growth. On 2/17/26 at 1:11 PM, Resident #7 laid on her left side on top of the bed covers. Staff E, Certified Nursing Assistant (CNA), and Staff F, CNA, applied (donned) EBP. Staff F explained incontinent cares would be provided. The unfastened brief revealed Resident #7 incontinent of urine and bowel. After Staff F completed Resident #7's incontinence care, they used the dirty gloves to open a clean brief and place it under Resident #7. Without completing hand hygiene, Staff F removed her dirty gloves and fastened the brief. On 2/17/26 at 1:14 PM Staff F verbalized she should have removed her gloves and performed handy hygiene prior to placing the clean brief on Resident #7. On 2/17/25 at 1:19 PM, the Director of Nursing (DON) acknowledged she observed Staff F provided improper incontinent care. The DON acknowledged Resident #7 recently received a diagnosis of a UTI. On 2/18/26 at 3:45 PM, Resident #7 reported when she went to the emergency room on 2/11/26 she had pain in her side. She verbalized her back hurt and didn't feel better. Review of the facility provided Incontinence Care policy revised August 2003 directed staff to:a. Cleanse the peri-area with a cleansing agent or disposable wipe wiping from front of perineum toward the rectum. Turn patient from side to side to cleanse affected area, as needed. Rinse with water if needed per cleansing agent manufacturer's instructions.b. If feces present, remove with toilet paper or disposable wipe by wiping from front of perineum to rectum. Discard soiled materials and discard glovesc. Wash hands if visibly soiled and apply new gloves.d. Apply clean brief/incontinent pad/undergarment.

Based on clinical record review, policy review and staff interview, the facility failed to document non-pharmacological interventions prior to administering anti-anxiety medication for anxiety and/or restlessness for 1 of 1 resident sampled (Resident #35). The facility identified a census of 36.Findings include:Resident #35's Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00, indicating a severe cognitive loss. The MDS listed diagnoses of non-Alzheimer's dementia and anxiety. The MDS reflected Resident #35 used an anti-anxiety medication during the lookback period. An Order Summary Report signed by the Provider on 12/11/25 documented an order dated 11/7/25 for lorazepam (anti-anxiety, psychotropic medication) oral tablet 0.5 milligrams (MG), give 0.5 tablet by mouth every 2 hours as needed (PRN) for anxiety/restlessness.The Care Plan Focus dated 2/11/25 indicated Resident #35 utilized psychotropic medication in the category of anti-anxiety medication related to agitation and anxiety. The Targeted Goal of 4/15/26 aimed for Resident #45 to remain free of complications related to the use of psychotropic medication. The Care Plan Intervention revised 10/13/25 directed the nursing and certified nursing assistant (CNA) staff to attempt to provide the following non-pharmacological interventions prior to the use of psychotropic medications: one to one, hydration, snacks, television, music, toileting, going outside, hand massage, gentle touch/hug holding hands, shoulder rub, deep breathing exercises, family visits, and phone calls.The Psychotropic Medication Monthly Review dated 1/29/26 completed by the Director Of Nursing (DON) documented Resident #35 didn't exhibit any behaviors. The As Needed Psychotropic Medication included an order for lorazepam oral tablet 0.5 MG for anxiety and restlessness. The Review lacked documentation of the non-pharmacological interventions provided. The review of the Progress Notes identified the following PRN administrations of lorazepam given without documentation of non-pharmacological interventions prior to the administration:a. 1/9/26 at 8:48 PM administered by Staff H, Registered Nurse (RN).b. 1/10/26 at 8:30 AM administered by Staff I, Certified Medication Aide (CMA)c. 1/10/26 at 8:44 PM by Staff J, Licensed Practical Nurse (LPN)d. 1/11/26 at 11:40 PM administered by Staff Je. 1/13/26 at 2:15 AM administered by Staff K, LPNf. 1/27/26 at 11:29 PM administered by Staff L, RNg. 1/29/26 at 5:13 AM administered by Staff M, LPNh. 2/5/26 at 12:48 AM administered by Staff JInterview on 2/18/26 at 3:35 PM Staff A, RN, reported they are required to do non-pharmacological interventions prior to giving an as needed medication and document the interventions in the progress notes. She reviewed several of Resident #35's January 2026 lorazepam documented administrations in the Progress Notes and confirmed the progress notes didn't have interventions documented. During an interview on 2/18/26 at 3:40 PM the DON explained she completed a monthly psychotropic medication review and looked at non-pharmacological interventions as part of that review. The nurses are to do non-pharmacological interventions prior to administering Resident #35's as needed lorazepam and document the interventions in the progress notes. She reviewed the January 2026 Progress Notes and confirmed most of the entries didn't have non-pharmacological interventions documented prior to administration.A follow-up interview completed on 2/19/26 at 9:43 AM the DON reported they added a new field on 2/18/26 into the as needed documentation field that require the nursing staff to document non-pharmacological interventions and the behaviors for which they gave the medication. The Usage of Psychotropic Medication Guidance, revised March 2025, provided by the facility, documented each resident's drug regime will be free from unnecessary psychotropic drugs. The Guidance defined Psychotropic Drug/Medication as any drug that affected the brain activities associated with mental processes and behavior. Psychotropic drugs included anti-anxiety medications. The Guidance under PRN use failed to address/direct nursing staff on the implementation and documentation of non-pharmacological interventions prior to the administration of as needed anti-anxiety medications.

Based on record review, staff interviews, and policy review the facility failed to obtain daily weights and notify the Doctor of a 3-pound (lb.) weight gain is identified in a day as the Doctor ordered for 1 of 1 resident reviewed for nutrition (Resident #6). The facility reported a census of 36 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #6 documented a Brief Interview for Mental Status (BIMS) of 6, indicating severe cognitive impairment. The MDS documented diagnoses of aphasia (difficulty swallowing), metabolic encephalopathy (brain dysfunction caused by underlying systemic diseases, toxic exposure, or electrolyte imbalances), and acute respiratory failure. Review of Resident #6 Order Summary Report signed by his doctor on 11/25/25 documented an order to obtain daily weights and notify the doctor of weight greater than 3 lb. in a day and 5 lb. in a week starting 9/12/25Review of Resident #6 Weights in his Electronic Health Record (EHR) from 11/20/25 to 2/18/25 (past 90 days) identified he had a 3 lb. weight gain from the day before on: 11/24/25, 12/11/25, and 12/25/25. The Weights section lacked a daily weight on: 11/21/25, 11/29/25, 11/26/25, 1/3/26, 1/8/26, 1/12/26, 1/19/26, 1/27/26, 1/29/26, 2/4/26, 2/7/26, and 2/14/26. Review of Resident #6 Progress Notes from 11/24/25 to 12/30/25 lacked notification to his doctor regarding the 3 lb. weight gains on 11/24/25, 12/11/25, and 12/25/25Resident #6's Care Plan on 2/17/26 instructed to monitor weights and notify his doctor of significant weight changes.In an interview on 2/19/26 at 9:52 AM with the Director of Nursing (DON) revealed Resident #6 had a lot of issues with edema without a cause a few months ago and the reason they started the daily weights. She added she couldn't find a notification to the doctor for the weight gains on 11/24/25, 12/11/25, and 12/25/25, or the missing weights on 11/21/25, 11/29/25, 11/26/25, 1/3/26, 1/8/26, 1/12/26, 1/19/26,1/27/26, 1/29/26, 2/4/26, 2/7/26, and 2/14/26. She explained they should follow his daily weight order. In an interview on 2/19/26 at 1:52 PM the Administrator reported they expected the staff to obtain the weight daily and put them into the system so they can be reviewed.The facility's Weight Management Guidelines policy revised June 2023 instructed the medical practitioner may order daily weights based upon a resident's nutrition or fluid status; daily weight changes are usually related to fluid status rather than nutrition status.

Based on record review, staff interviews, and policy review the facility failed to implement a Care Plan chair alarm intervention for 1 of 3 residents reviewed for falls (Resident #3). The facility reported a census of 31 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) of 2 out of 15, which indicated severe cognitive impairment. The MDS documented the need for substantial/maximal assistance (staff did more than half the effort) for transfers and walking up to 50 feet. The MDS also documented diagnoses of non-Alzheimer's dementia, anxiety, respiratory failure, and adult failure to thrive.The Care Plan created 2/18/25 revealed, Resident is at risk for falls. The Intervention initiated 2/24/25 and created on 3/6/25 revealed, Chair alarm placed to alert staff when I am self transferring. Review of the Witness Statement for Staff A License Practical Nurse (LPN) dated 4/30/25 at 11:45 AM documented on 4/25/25 she watched Resident #3 stand up impulsively from the wheelchair and immediately fall over. The statement lacked if the chair alarm was in place. During an interview on 8/26/25 at 3:12 PM with Staff C, Staffing Coordinator and Activities Director revealed she helped with Resident #3 fall on 4/25/25 and did not recall seeing the chair alarm in his wheelchair. During an interview on 8/26/25 and 4:14 PM with Staff D, Social Services Designee revealed she did not recall a wheelchair in alarm in place during Resident #3 fall on 4/25/25. During an interview on 8/28/25 at 12:59 PM with the Director of Nursing (DON) revealed if he had a chair alarm on his Care Plan that should of been in place at the time of the fall. She revealed she was not the Director of Nursing at the facility when the fall occurred. During an interview on 8/28/25 at 2:44 PM the Administrator revealed she would of expected the chair alarm to be used when Resident #3 fell, however it would of not of changed the outcome because it was an observed fall. Review of the facilities policy and procedure for Alarms, Voice Activated Devices, Monitoring Devices, last revised 4/25/25 instructed: The use of any type of alarming device, including audio devices (such as personal alarms, monitors and voice activated chair commands), used to alert staff of a change in position, will be assessed for appropriateness and continued effectiveness. (Alarming devices do not generally prevent a resident from falling but may alter staff of position changes with residents who have diminished cognition related to self-safety.)

Based on clinical record review, policy review, resident and staff interviews, the facility failed to treat a resident with dignity and respect for 1 of 3 residents sampled (Resident #4). The facility identified a census of 30 residents. Findings include: Resident #4 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. During an interview on 2/11/25 at 4:01 PM Resident #4 reported Staff B, Certified Nursing Assistant (CNA) came into her room during the night and started mouthing off yelling Staff A, Licensed Practical Nurse (LPN), that fucking fat ass he doesn't do anything, repeatedly. He sits on his butt all night and then goes outside to smoke every two hours. Then Staff B left the room. Resident #4 voiced Staff B is rude at times and she doesn't feel that Staff B should be talking to her about other employees or residents. She is always complaining how she can't take care of Resident #27 because she doesn't want her taking care of her and Resident #19 and one other resident always have their call lights on all night long and she is tired of that. Resident #4 voiced she was really disappointed when Staff A cut down hours and then quit. Staff A was a good nurse to her. He was always on time with her medications and took good care of her. At 4:04 PM Resident #4 verbalized she was offended when Staff B used offensive language and started to yell about a nurse that she liked in her own room. Staff B had provided care to her twice in the past week without using profanity, but Resident #4 added if it happens again, she would be uncomfortable with Staff B taking care of her. During an interview on 2/11/25 at 4:28 AM Staff B reported on 1/26/25 shortly after the start of shift she went in to Resident #4 room to check on her roommate to be sure she wasn't crawling out of bed. While in Resident #4 room, Staff B verbalized, that fat ass upset me. Resident #4 asked her who and Staff B responded Staff A had upset her. Staff B reported she knows she should not have said that to Resident #4 but she was really upset. Staff B voiced they are not to use profanity at work. On 2/11/25 at 4:50 PM the Director of Nursing (DON) reported Staff A had reported that Staff B would not follow instructions on the night shift. She had gotten a report from Staff A that Staff B had called him a fat ass. She had talked with Resident #4 just last week and Resident #4 was okay with Staff B taking care of her. During an interview on 2/12/25 at 11:20 AM Staff A reported he had multiple altercations with Staff B. The last incident was 1/26/25. He had been working with another resident that was having difficulty breathing and Staff B was in the room freaking, making the resident more anxious, so he told her to leave the room. He then went up to the nurses' station to chart. Staff B was at the nurses' station telling Staff C, CNA that Staff A was lazy and wouldn't do anything to help the residents. Staff A reported he came out of the nurses' station and told Staff B that was not true and to stop saying those things or she could go home. He verbalized Staff B told him he was not a regular nurse there and couldn't tell her what to do, she didn't have to listen to him. On 1/27/25 on his next night shift, Resident #4 told him that Staff B was in her room yelling the night before (1/26/25) that he was a lazy fat fuck repeatedly. Resident #4 apologized to Staff A that staff would call him names and voiced she felt bad for him. It felt awful that a resident had to apologize for her. A 2/12/25 review of employee time cards showed the following: a. Staff A worked 1/26/25 time in 5:54 PM; time out 6:33 AM. b. Staff B worked 1/26/25 time in 10:08 PM; time out 6:03 AM. On 2/13/25 at 9:29 AM Staff F, Registered Nurse (RN) voiced the use of profanity in front of a resident is not acceptable. She would correct the employee right away, write the employee up, and report the incident to the DON. On 2/13/25 at 9:45 AM the DON reported regarding dignity, profanity is not to be used in front of residents. Interview 2/13/25 at 9:58 AM the Administrator reported staff are to follow resident rights with privacy and respect. They are to promote a homelike environment. It is inappropriate and unprofessional for staff to use profanity in front of residents. The 4/2024 Resident Rights - Dignity and Respect Policy documented a purpose to lay the foundation for treating all residents with dignity and respect and maintaining and enhancing his or her self-esteem and self-worth. The procedure directed: Each Resident has the right to considerate and respectful care and to be treated with honesty, dignity, respect and with reasonable accommodation of individual.

Based on observation, policy review, clinical record review, and staff interview, the facility failed to utilize appropriate EBP per the CDC during the provision of catheter care to minimize the risk of cross contamination that may lead to the spread of multi-drug resistant organisms for 3 of 3 residents sampled (Residents #5, #4, and #10). The facility reported a census of 30 residents. Findings include: 1. Resident #5 Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 09 out of 15 indicating moderate cognitive impairment. It documented Resident #5 had diagnoses of renal insufficiency, neurogenic bladder, and Cerebral Palsy. The MDS further documented Resident #5 utilized an indwelling catheter for a diagnosis of neurogenic bladder. A 8/26/23 review of Resident #5 Electronic Healthcare Record (EHR) listed a Physician Order for a 16 French (size) Foley catheter to be continued. The Care Plan with an undated focus date directed Resident #5 required Enhanced Barrier Precautions (EBP) related to the Foley catheter. The Care Plan directed staff to maintain proper EBP per the facility policy. Observation on 2/11/25 at 12:26 PM Staff G, Certified Nurse Aide (CNA) entered Resident #5 room, washed her hands, put on gloves, and obtained a plastic bag and a graduate container to empty Resident #5 urinary drainage bag. Staff G emptied Resident #5 urinary drainage bag, stored the graduate container, removed gloves, washed her hands and exited Resident #5 room. Staff G failed to apply an isolation gown prior to emptying Resident #5 urinary drainage bag as required for EBP. Throughout observation no EBP sign noted in or out of the room. During an interview on 2/11/25 at 4:00 PM Staff C, CNA said they do not have any current residents that they need to wear gowns when doing care. Staff C reported if there were any residents there would be a sign hanging outside the door and they would have reported it in the shift meeting prior to getting to the floor. During an interview on 2/11/25 4:12 PM Staff H, CNA reported there are no residents currently that staff need to wear gowns for. If they needed any Personal Protective Equipment (PPE) besides gloves there would be a three drawer container with PPE and a sign outside the door to the room. If they have anyone they need to wear gowns and such they will discuss it at the shift meeting. During an interview 2/11/25 04:17 PM Staff B reported currently there are no residents who they use gowns for that she is aware of. The facility will have a posting outside the door of the resident's room if they did and would say it at the shift meeting at the beginning of the shift. In an interview 2/11/25 at 4:46 PM the DON initially reported they did not have any residents that require the use of isolation gowns in the facility. Then she stated all residents that have urinary catheters are to be on EBP. The EBP are communicated to staff through the resident Care Plan and kardex (care guide). Maintenance is supposed to place a PPE cart in the resident's room so the PPE is available for EBP. The residents all should have the Center for Disease Control and Prevention CDC sign up for EBP, but they don't stick to the walls and come down. She expects gloves and isolation gowns to be utilized when emptying urinary drainage bags. The facility policy titled Enhanced Barrier Precautions with revised date of 3/2024 directed staff EBP will be used in conjunction with standard precautions for residents with any of the following (if/when Contact Precautions requirements are not in place): Wounds and/or indwelling medical devices (even if the resident is not known to be infected or colonized with a targeted MDRO). CDC guidelines dated 6/12/2022 documented EBP expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. 42133 2. Resident #4 MDS assessment dated [DATE] showed a BIMS score of 15 out of 15 indicating intact cognition. The MDS documented Resident #4 utilized an indwelling catheter for a diagnosis of neurogenic bladder. A 2/10/25 review of Resident #4 Electronic Healthcare Record (EHR) listed a Physician Order for a 20 French (size) Foley catheter to be changed once a month. The Care Plan with an undated focus date directed Resident #4 required EBP related to the Foley catheter. The Care Plan directed staff to maintain proper EBP per the facility policy. Observation on 2/10/24 at 9:45 AM revealed a CDC sign directing staff how to apply and remove gloves and an isolation gown hanging on the wall to the left of Resident #4 room door. Observation on 2/10/25 at 1:33 PM Staff D, CNA entered Resident #4 room, washed her hands, put on gloves and obtained a plastic bag and a graduate container to empty Resident #4 urinary drainage bag. Staff D emptied Resident #4 urinary drainage bag, stored the graduate container, removed gloves, washed her hands and exited Resident #4 room. Staff D failed to apply an isolation gown prior to emptying Resident #4 urinary drainage bag as required for EBP. During an interview on 2/11/25 at 1:08 PM Staff E, CNA reported they are required to use gloves when performing catheter care and when emptying the urinary drainage bag. The use of an isolation gown is optional and the gowns are not in the resident rooms. If they want an isolation gown, they have to go get one from supply. On 2/11/25 at 4:05 PM Resident #4 reported she has never seen any of the CNA's staff wear isolation gowns when they empty her urinary drainage bag. Interview on 2/11/25 at 4:46 PM the DON initially reported they did not have any residents that require the use of isolation gowns in the facility. Then she stated all residents that have urinary catheters are to be on EBP. The EBP are communicated to staff through the resident care plan and kardex (care guide). Maintenance is supposed to place a PPE cart in the resident's room so the PPE is available for EBP. Resident #4 should have a gown hanging up in her room and a plastic cart with PPE in her bathroom. The residents all had CDC signs up, but they don't stick to the walls and come down. She expects gloves and isolation gowns to be utilized when emptying urinary drainage bags. Observation on 02/11/25 at 5:04 PM of Resident #4 bathroom with the DON revealed a PPE cart with a CDC Contact Precaution Sign laying on top of the cart. The isolation cart contained five disposable isolation gowns. The DON reported the PPE was available for staff to use. 3. Resident #10 MDS assessment dated [DATE] showed a BIMS score of 14 out of 15 indicating intact cognition. The MDS documented Resident #10 utilized an indwelling catheter for a diagnosis of benign prostatic hyperplasia (BPH, enlarged prostate) and obstructive uropathy (flow of urine is blocked within the urinary tract). A 2/11/25 review of Resident #10 EHR revealed a physician order to replace a 20 French Foley catheter every 30 days and as needed. Resident #10 undated Care Plan included a Focus detailing he required EBP related to the use of a urinary catheter. The Care Plan directed the staff to wear a gown and gloves while performing high-contact care activities which included when caring for an indwelling urinary catheter. Observation on 2/11/25 at 12:59 PM Staff E washed her hands, applied gloves, set up a plastic barrier and a graduate and emptied Resident #10 urinary drainage bag without applying a isolation gown per the Care Plan and CDC guidelines for EBP. During an observation on 2/11/25 at 5:06 PM the DON inspected Resident #10 bathroom and reported he did not have a PPE isolation bin in his room for EBP or an EBP sign on his door. Resident #10 voiced he didn't recall any staff wearing isolation gowns when they emptied his urinary drainage bag.

Based on clinical record review, Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview, the facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) within 14 days of hospice election for 1 of 1 residents reviewed for hospice care (Resident #23). The facility reported a census of 30 residents. Findings include: Resident #23 SCSA MDS dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 00 indicating severe cognitive loss. The MDS documented Resident #23 as dependent upon staff to provide for her activities of daily living (ADLs). The MDS listed diagnoses of cancer, end stage renal disease, diabetes mellitus, and Non-Alzheimer's Dementia. The MDS lacked documentation Resident #23 received hospice care services. A Hospice Election Statement and Hospice Admission Consent Form signed by Resident #23 family representative showed the family signed Resident #23 into hospice care on 1/13/25. Resident #23 Electronic Healthcare Record (EHR) Census showed Resident #23 on hospice care 1/13/25. A Hospice Medication Order Sheet signed by the Provider on 1/15/25 documented 1/13/25 admit to (Hospice) services. A 2/11/25 review of Resident #23 Electronic Healthcare Record (EHR) MDS page lacked documentation Resident #23 had a SCSA MDS set up within 14 days from the hospice election date of 1/13/25. On 2/11/25 at 3:25 PM the MDS Coordinator reported she usually becomes aware of who is admitted to hospice at the daily meetings they have Monday through Friday. She then sets up a SCSA MDS that has to be completed within 14 days. She reviewed Resident #23 EHR and reported she was aware that Resident #23 went on hospice care. She further voiced the SCSA MDS just got missed. She follows the RAI to complete the MDS. During an interview on 2/11/25 at 3:30 PM the DON reported hospice provides them with a slip notifying them of admission to hospice, but she does not keep those slips. She reviewed Resident #23 MDS's and reported she expects the MDS Coordinator to complete a SCSA MDS per the RAI. The LTC RAI 3.0 User's Manual Version 1.19.1 October 2024 Chapter 2, Page 2- 17 of the RAI manual specifies the SCSA MDS completion date is 14 days from the determination that a significant change in resident status has occurred (determination date plus 14 calendar days). Page 2-25 specifies a SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident.

Based on observation, clinical record review, document review, policy review, resident and staff interviews, the facility failed to provide a full assessment for 1 of 4 residents sampled for falls (Resident #2). Resident #2 fell on [DATE] at 9:50 PM. Resident #2 exhibited left hip pain and an externally rotated left leg. Staff A, Assistant Director of Nursing (ADON) failed to assess the resident and assisted Resident #2 from the floor to standing position where Resident #2 could not bear weight on his left leg. Staff A called for help and Staff B, Certified Nursing Assistant (CNA) assisted her to transfer Resident #2 into a wheelchair and then they transferred him to lay in bed. Resident #2 was transferred to the emergency room department on 10/13/24. Resident #2 was diagnosed with a left hip fracture on 10/14/24. The facility mitigated the situation through staff education on falls from 10/14/24 - 10/17/24 for nursing staff. The facility identified a census of 30 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. The MDS documented Resident #2 had a functional impairment on both lower sides of the body (hip, knee, ankle, foot) and utilized a walker for walking. The MDS showed Resident #2 required substantial to maximum assistance (a helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort) with toileting and supervision/touch assistance (a helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) for chair to bed/bed to chair transfers, toilet transfers, and walking 10, 50, and 150 feet. The MDS further documented Resident #2 was frequently incontinent of bowel and bladder. The MDS listed diagnoses of neurogenic bladder, anemia, hypertension, and anxiety disorder. The MDS identified Resident #2 without pain, no falls since the prior assessment; utilized alarms of the bed, chair, and wander guard on a daily basis. A 9/02/24 Alarm Review Monthly Assessment documented Resident #2 utilized a bed alarm when in bed and a chair alarm when up in the chair to alert staff when Resident #2 changed positions independently. The Alarm Review Monthly Assessment further documented no plan to reduce the use of the alarms as the resident continued to transfer independently and the devices alerted staff for assistance. A 9/27/2024 8:15 AM Communication with Family/Related Party Progress Note written by Staff A (LPN/ADON), documented she received a phone call from Resident #2 family member to discuss the discontinuation of bed/chair alarms. She reported to the family it was a company-wide policy fall alarms would no longer be used and the alarms would be removed some time next week. The family member voiced understanding but had concerns Resident #2 would fall and break a hip if the fall alarms were removed. She reassured the family member Resident #2 would still be assisted as needed and that he does use his call light/doorbell when he needs assistance. A Progress Note titled Incident Report dated 10/13/2024 at 9:50 PM documented by Staff A (LPN/ADON) showed a Late Entry into Resident #2 Medical Record containing the following information: a. Describe the Situation: banging noise heard down the hallway; upon investigation, found resident banging into door of wardrobe; resident leaning forward and holding on to walker with arms stretched out; in order to prevent resident from falling forward, nurse quickly wrapped arms around resident's waist and pulled him to my knee to attempt to hold him steady; propped resident on knee while holding onto waist and applied gait belt as nurse called out for help and CNAs came to hold/stand resident up and walk to bed; noticed resident not putting weight on left leg; encouraged resident to advance left leg but resident was unable to move it; CNAs got wheelchair to assist the resident to sit and then transported the resident into bed; once in bed the left leg noted to be externally rotated and painful; nurse attempted to inspect leg without rolling resident to side and determined leg was injured. b. Assessment of Resident including Range of Motion (ROM) and Pain: left leg externally rotated; pain in the left leg. c. Vital Signs - if a fall, include orthostatic blood pressures: not applicable. d. Describe Any Injury Noted: left leg externally rotated; transfer to emergency department, per family request. e. List Any Treatment Provided: assisted to standing position and transferred into the wheelchair and then into the bed with two staff assist and gait belt. f. List Relevant Interventions That Were In Place at the Time of the Incident: resident call light in reach, not utilized; doorbell on his walker, not utilized. g. Preliminary Recommendations, if any, for Consideration as Further Preventative Measures: night-light/hall-light/over-the-bed-light in room to be turned on while in bed. h. List Responsible Party Notified: family notified. i. The Incident Note detailed the Director of Nursing (DON) and the Administrator had been notified and the Provider was notified via facsimile (fax). The original Incident Report Progress Note was lined through in Resident #2 Medical Record to indicate to omit the entry. A Second 10/13/2024 9:50 PM Incident Report Progress Note documented by Staff A included a corrected late entry entered 10/15/24 at 2:35 AM which included the following information: a. Describe Situation: heard some tapping coming from north hall; upon inspection, resident noted to be on the floor with his back against the outside bathroom wall and right foot tapping on the door to get staff attention; nurse put gait belt on and wrapped arms around resident to stand him up and called for CNAs to help. The nurse propped up resident on her knee to steady him while waiting for CNAs to help get resident into bed. When the CNAs came to help stand him, noted that his leg was externally rotated. The CNAs retrieved a wheelchair and got resident into the wheelchair; he was then assisted into bed. b. Assessment of Resident including range of motion (ROM) and Pain: resident complained of pain in the left leg and noted external rotation of his left leg. c. Vital Signs - If fall, include orthostatic blood pressure: within normal limits (WNL). d. Describe Any Injury Noted: left leg externally rotated. e. List Any Treatment Provided: resident assisted off floor and into bed; family called. f. List Relevant Interventions That Were In Place At The Time of The Incident: call light within reach, not utilized; doorbell attached to walker, not utilized; proper footwear on. g. Preliminary Recommendations, if any, for Consideration as Further Preventative Measures: bed alarm h. List Responsible Party Notified: family notified. The Incident Note also detailed the Director of Nursing and the Administrator had been notified and the Provider was notified via facsimile (fax). The amended 10/13/24 Incident Note failed to document Staff A provided documentation of actual vital signs (temperature, pulse, respirations, blood pressure and oxygen saturation, pain) and assessment of ROM of the upper and lower extremities prior to assisting Resident #2 up off the floor. The original lined through documentation had vital signs documented as not applicable. The amended Incident Report documented vital signs as WNL. A 10/14/24 Emergency/Urgent Care Report documented Resident #2 with a diagnosis of a left hip fracture. The 10/14/24 Hospital History and Physical documented the Chief Complaint as left hip pain. The History of Present Illness further documented the patient had an unwitnessed fall at the facility earlier this morning. He was unable to stand on his own and was transferred to the hospital for definitive management. Radiographs were obtained demonstrating a left hip fracture. The patient reported pain in the left hip. The Assessment/Plan noted a hip fracture on the left; hip injury major. Resident #2 Care Plan revised 10/15/24 noted Resident #2 at a risk for falls and (fall) alarms had been removed due to the resident removing the alarms on his own and shutting the alarms off. The Activities of Daily Living (ADL) Care Plan directed Resident #2 required the assistance of one staff member with a gait belt and a two-wheeled walker for walking and transferring. A 10/15/24 document from Staff A's Employee Record documented by the Director of Nursing (DON) documented Staff A approached her in her office and started crying. Staff A stated she had lied. Resident #2 fell on [DATE]. Staff A stated she was afraid to tell the family he fell and didn't know what to do. The DON informed her they needed to report this to the administrator. Staff A verbalized she messed up and was sorry. The Document was signed by the DON. A 10/15/24 document retrieved from Staff A's Employee File documented by the DON documented after the conversation with Staff A and the Administrator regarding Resident #2 incident, Staff A came back into the DON's office and stated, Am I going to get fired? What is going to happen? The DON informed her she didn't know. Staff A replied, I should not have told you guys and kept my mouth shut, and this wouldn't be happening. The DON stated she did the right thing in telling the truth. Staff A stated, I don't think so. The document was signed by the DON. A Facility Self-Report to the Department of Inspection, Appeals and Licensing (DIAL) showed the Facility submitted a 10/15/24 11:44 AM report to the State Agency regarding an Accident with Major Injury for Resident #2. The Incident Summary documented on 10/13/24 at 10:26 PM, it was reported Resident #2 was sent out to the emergency room . Staff A found the resident standing outside the bathroom and non-weight bearing on the left leg. Following assessment of the left leg, Staff A found the hip to be displaced. The Facility was notified on 10/14/24 at 8:20 AM that Resident #2 had a confirmed hip fracture. Staff A arrived to work 10/15/24 at 8:45 AM and reported to the DON and the Administrator, she incorrectly documented her statement and original incident report in Point Click Care (PCC, electronic medical records system). Staff A reported she came into the facility at 2:00 AM 10/15/24 and generated a second incident report to show Resident #2 was found on the floor at shift change on 10/13/24 at 9:50 PM. She entered Resident #2 resident room to find him on the floor tapping his foot against his closet. Staff A proceeded to assist Resident #2 off the floor and then called for the aides to help her. The Self-Report identified Staff A was placed on suspension immediately as of 10/15/24 at 10:17 AM. Further investigation submitted to the State Agency revealed Staff A, after entering Resident #2 room, asked him what happened and he stated, fall. Staff A put the gait belt on him while looking over the situation. His legs were bent at the knee and his arms were at his sides with his hands on the floor. Staff A panicked as his bed alarm had just been taken away per company policy. Staff A stood Resident #2 part-way up and propped/stabilized him with her knee under his buttocks while yelling for help from the CNAs as Resident #2 could not bear weight on his left leg. Staff B grabbed the gait belt on the left side to help fully stand the resident. Upon fully standing, resident's left leg was turned outward and noted that he could not advance his leg. Staff A and Staff B transferred the resident into a wheelchair and then transferred him into bed in a lying position. Staff A informed Resident #2 she thought his leg was hurt and asked if he wanted to go to the hospital and he state, yeah. The Report further detailed an emailed statement from Staff A on 10/17/24 at 8:45 AM, Resident #2 did complaint of pain in his left leg when assisted to a full standing position. In response to was there deformation seen, heard, cracking, popping, moving before getting up, Staff A responded yes to an extent. His legs were bent and unable to fully straighten them. An undated, unsigned Facility Investigation entailed the above information, including the Facility was notified on 10/21/2024, following radiology tests obtained on 10/19/2024, Resident #2 had fractured 3rd and 4th ribs on his right side. The Investigation further detailed Resident #2 shut his room door at approximately 9:28 PM and was attempting to re-open the door at 9:49 PM. Staff A entered his room at approximately 9:20 PM and exited his room at approximately 9:22 PM. Resident #2 was assisted to bed by a CNA at approximately 7:24 PM. The Facility Investigation concluded there was no staff culpability related to the fall. Staff were following his Care Plan, supervising, and meeting his needs appropriately. It was an unavoidable fall. A Witness Statement dated 10/13/24 at 3:11 PM for Staff B documented when she entered Resident #2 room to see he was at the front door of the room with a gait belt on. They wanted him to go back to bed, but he couldn't move his leg. She could see that his leg was not right and he couldn't move it. The Witness Statement contained documentation Staff B was aware not to try get a resident up off the floor after a fall and wait for a nurse to come. A Witness Statement dated 10/17/24 at 3:30 PM Staff D, CNA documented she worked 2:30 - 10:00 PM on 10/13/24. She had last seen Resident #2 after supper sitting in the recliner in the lounge area. She had walked him out to supper and he didn't seem out of character. The Witness Statement documented Staff D observed Staff A on the right side of Resident #2 holding him up (in the room). It kind of looked like Staff A was holding the resident up with her knee. Staff B was on the other side of Resident #2 holding him with her arm. Staff D brought the wheelchair into the room. Staff D Witness Statement identified she knew to call for a nurse and not get a resident up off the floor if they fall. A Witness Statement dated 10/17/24 at 3:38 PM Staff E, CNA documented she worked 10/13/24 2:30 PM to 10:00 PM. She had last seen Resident #2 sitting his recliner in the lounge area. The Witness Statement identified Staff E was aware to make sure a resident is safe and never move them. Call for the nurse, never leave the room, and wait for the nurse to come in. Observation on 12/03/24 at 12:22 PM Staff G, CMA and Staff H, CNA assisted Resident #2 via the standing lift from his wheelchair to the bathroom for cares, then to transfer into bed. Resident #2 stood upright in the standing lift without complaints of pain. The DON reported Resident #2 was just evaluated by therapy on 11/27/24 and moved from a full mechanical lift to the standing lift. Interview on 12/03/24 at 12:37 PM Resident #2 when asked if he remembered his last fall when he broke his hip stated, yes. When asked if he recalled where he fell , he stated and pointed, front door of room. When asked if he had pain while on the floor he responded, yes. When asked if the nurse moved his legs to see if he was injured before getting him up off the floor he responded, No. On 12/03/24 at 1:23 PM Staff D reported she didn't actually see the 10/13/24 incident happen. Staff A and Staff B were already in the room. They yelled to bring a wheelchair. When she brought the wheelchair to the room she saw Staff A had her knee under Resident #2 thigh area, next to his butt holding him up. She dropped off the wheelchair and she left the room. On 12/03/24 at 1:39 PM Staff E verbalized Resident #2 needed a hand on the gait belt to keep him steady and verbal cues to take big steps, when it came to walking. He used a two wheeled walker with the front wheels and tennis balls on the back. He had a door bell on his walker to call for help. He used the doorbell anytime he needed something, if people were not around. If people were around he would say something or just raise his hand. They were told they couldn't use fall alarms anymore. They were told to do more frequent checks on the residents that had the fall alarms discontinued. They tried to walk up and down the hallways as much as possible. She didn't really see Resident #2 the night of the incident. Interview on 12/03/24 1:51 PM Staff B explained they were almost done in another resident's room. She heard the nurse calling for help from Resident #2 room. Staff A and Resident #2 were standing between the room doorway and the bathroom door with Resident #2 facing the closet. She didn't know what happened, but Resident #2 foot was turned in a weird way. He couldn't get his foot straight and he couldn't move. It was painful for him to stand. They assisted him to sit in the wheelchair. Put the wheelchair by his bed and did a two-person manual transfer from the wheelchair to the bed. The nurse decided they needed to move him to his bed. Interview on 12/04/24 at 7:20 AM, Staff F, Registered Nurse (RN) reported when a resident falls, they keep them on the floor, get a set of vital signs and move their arms and legs (ROM) to assess if they are injured before assisting them up off the floor. She voiced if a resident exhibits a change in ROM, she is to keep the resident immobilized on the floor and call 911 to send the resident out to the hospital. The facility provided fall education to the nursing staff after Resident #2 fall on keeping the resident on the floor if injured and completing an assessment. Staff F explained the fall alarms were discontinued about 4-6 weeks ago. They started by notifying the family of the alarm reduction to see if the family had any concerns with the fall alarms being removed. If the family had concerns with the fall alarms being removed, then DON would follow up with the family on their concerns. During an interview on 12/04/24 at 8:10 AM the DON reported Staff A did not do an assessment before standing Resident #2 up off the floor. The DON voiced she wouldn't lie and Staff A did not do an assessment before she tried to stand Resident #2 from the floor. She further explained she thought Resident #2 leg was bent when he was sitting on the floor and he couldn't stand on the leg when Staff A lifted him up off the floor, but that the Administrator had watched the camera footage and she could talk more about that. She voiced she expects the nursing staff to complete a full assessment including vital signs (temperature, pulse, respirations, blood pressure and pulse oximetry), range of motion (ROM) and a pain assessment. A resident should not be moved if there are signs of injury. She explained documenting vitals signs WNL is not acceptable as part of the facility fall documentation. She explained they provided staff education on falls to the nursing staff after Resident #2 fall. They have a fall care path that they educated on and that they use. Interview on 12/04/24 at 9:20 AM the DON reported Resident #2 does have garbled speech but he is able to communicate his needs. The DON voiced in her professional opinion the actions taken by Staff A to not assess Resident #2 and move him from the floor may have worsened his condition. Interview completed with the Administrator on 12/04/24 at 9:32 AM revealed she confirmed they did have camera footage that she was able to review. By the time they completed the investigation, the camera footage had recorded over the video. She viewed the camera that was positioned at the entrance to Resident #2 hallway by his room. She observed Staff A entered Resident #2 room at 9:20 PM and exited the room at 9:22 PM. At 9:28 PM the room door started to close. The Resident was the only one in the room. She believed Resident #2 walked from the bed to the door and closed the door. At 9:49 PM the door begins to open. She assumed Resident #2 tried to open the door himself. At 9:58 PM Staff A entered the room herself. She couldn't see Resident #2 on the camera. She could see Staff A grab the gait belt with two hands on each side of Resident #2 back as she tried to pull him up off the floor. At 10:00 PM Staff B entered the room. Staff D brought the wheelchair to the room. Only Staff A and Staff B remained in the room. The Administrator verbalized she did not see Staff A take in a stethoscope, blood pressure cuff, or any equipment in the room. She did not see Staff A go in front of the resident to try to move his arms or legs. The Administrator voiced she absolutely would not expect one nurse to lift a resident up off the floor by herself and she couldn't confirm that Staff A did an assessment on the resident. She expects vital signs, ROM, and pain assessments to be completed and documented within the incident report when a resident falls. She acknowledged and stated she did not see any documentation of any range of motion assessment in the documentation on the actual Incident Report. She responded without vital signs and a full assessment, Resident #2 should not have been assisted up off the floor. She reported she could not make assumptions, but that the lack of assessment did not benefit the resident in regard the resident being transferred out of the facility and a diagnosis of a fractured hip. On 12/04/24 at 9:47 AM the DON provided Staff A's Time Card. The Time Card showed Staff A worked 10/15/24 from 7:34 AM to 10:07 AM. The DON further explained that is when Staff A informed her that she had lied about what she charted in Resident #2 chart and that he had fallen. She reported Staff A was working in the office that day and was suspended pending an investigation 10/15/24. She was eventually terminated 10/25/24 due to lying in her documentation. During an interview on 12/04/24 10:20 AM Staff A explained they were told by the Nurse Consultant that the new company no longer wanted to use fall alarms. She talked to Resident #2 family about the alarm reduction and the family was not happy. The alarms were discontinued within 1-2 days of the consultant notifying the facility of the alarm reduction. They were given directions to just walk the halls and peek in on residents frequently. The night of the fall (10/13/24) She hadn't seen the resident up until the time of the fall. When she entered his room, he was sitting in the entrance to the room. His back was against the bathroom wall inside his doorway of the room and his legs were facing toward the closet. After her conversation with the daughter on the fall alarms, she panicked. She was petrified. Staff A verbalized she knew his left leg was broken, but she put the gait belt on him and got up off the floor by herself anyway. She had no idea why she got Resident #2 up off the floor when she knew his leg was broken. She panicked. When she had talked with the family prior on the alarm reduction, the family stated they would be waiting for a phone call that Resident #2 broke his hip and that would be the end of him. Staff A reiterated she was scared and that is what drove the events of that night. She shouldn't have gotten the resident up off the floor by herself. Staff A stated, she did not do vital signs or further assessment (ROM, pain assessment) on the resident. She documented WNL on the amended Incident Report as the ambulance responded to the nursing home call and they took vital signs on the resident when they arrived and his vital signs were WNL. Staff A reported she absolutely should not have transferred him up off the floor when she knew his left leg was broken. During an interview on 12/04/24 at 1:59 PM Resident #2 Provider voiced it probably would be best to keep a resident immobilized if a fall occurs and the resident exhibits external rotation of a leg and leg/hip pain. The Fall Care Path, utilized for staff education between 10/15/24 - 10/16/24 directed the following: a. Take Vital Signs - temperature, blood pressure, pulse, respirations, oxygen saturation and finger stick glucose if diabetic. The Care Path directed a box chart for parameters on vital signs. b. Initial Nursing Evaluation for Injury and/or Mental Status Change - do not move off the floor until a complete exam has been performed. Suspected fracture or new bone deformity, head trauma, altered mental status (decreased level of consciousness, suspicion of seizure, new or worsened cognitive impairment), laceration requiring sutures/samples. If yes, Notify the Medical Doctor, Nurse Practitioner or Physician Assistant. If No, evaluate signs and symptoms for immediate notification - abnormal lung sounds, new/irregular pulse, chest pain, acute decline in ADLs, new or worsening incontinence, sign/symptoms suggestive of a stroke (weakness, numbness or tingling), new or worsening pain unrelated to head trauma or a suspected fracture. The Fall Occurrence revised 2/24, under Purpose documented it is the policy of the facility to ensure that residents are evaluated for fall risks and implement interventions to minimize risk for falls and/or risk of injury from falls. The Procedure directed residents would be assessed by a licensed nurse prior to being moved after a fall. The Guidelines for Charting After a Fall, provided by the facility, directed: a. Chart ROM on all extremities with or without discomfort (if severe discomfort noted or shortening of the extremity or external rotation, do not move the resident until emergency medical technicians arrive for transport to the hospital). b. Chart a full set of vital signs. c. Chart Resident Complaint of pain rated on scale of 1-10 with 10 being the worst pain.

Based on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility reported a census of 35 residents. Findings include: During an interview on 4/29/24 at 9;50 AM, the Dietary Manager reported the facility is working on getting her enrolled in the dietary manager classes. During an interview on 4/30/24 at 10:42 AM, the Consultant Dietician reported the Dietary Manager is not certified but currently in the course. She reported when she is in the building it varies when she comes but reviews the residents at least once a week. Review of the Dietary Manager's employee file lacked documentation of a certificate of completion of the Dietary Manager courses.

Based on record review, staff interviews, and policy review, the facility failed to follow physician orders for 1 of 2 residents reviewed (Resident #17). The facility reported a census of 35 residents. Finding include: Resident #17 Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS include diagnoses of benign prostatic hyperplasia, anxiety, and hypertension Review of Resident #17's Electronic Health Record (EHR) revealed a Physician Order for referral to Urology on 1/22/24. Review of the Progress Notes lacked documentation of an appointment being made or call out to make the appointment. During an interview on 5/01/24 at 11:12 AM, the Director of Nursing (DON) reported there was no documentation of any call to Urology nor an appointment scheduled to see Urology for Resident #17. She reported she talked with the nurse who noted the order and was not sure why it was not done. The DON reported she expected staff to call and get an appointment set up right away when the referral came on 1/22/24. During an interview on 5/02/24 at 11:54 AM, the DON reported the facility did not have a policy for Physician's Orders. She reported the facility follows professional standards.

Based on observations, interviews, and record review, the facility failed to ensure assessments were done for 1 of 2 residents reviewed to determine if she remained at baseline or had a decline (Resident #15). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) dated [DATE], documented Resident #15 had impairment on both sides of her upper and lower extremities. Review of Resident #15's Care Plan revealed this resident was not on a restorative care program. On 4/29/24 at 11:30 a.m., Resident #15 was observed laying in her bed. On 4/29/24 at 1:02 p.m., Resident #15 was up and dressed sitting in the room recliner, yelling out to lay down in bed for 8 minutes. No call light on, just periodically yelling for help. Staff went in at this time and placed a gait belt on the resident and reported they would assist her to lay down. On 5/1/24 at 1:34 p.m., Resident #15 was sitting in her recliner, eyes were closed. She didn't respond to the knock at the door. Door was open, she appeared to be sleeping. On 5/1/24 at 3:21 p.m., the Director of Nursing (DON), stated Resident #15 did not have a restorative program. She refused and would not allow it. She pulled up the Restorative Summary dated 5/29/22 and stated that it documented that Resident #15 was not in a program because of her refusals. This DON stated that Resident #15's Care Plan addressed her refusals. A Request for Therapy Screen dated 4/4/23 at 10:55 a.m., documented that the annual MDS requires therapy screen. It documented that this resident was at baseline for ADLs and mobility. No therapy was indicated. On 5/1/24 at 3:40 p.m., the DON brought in the above Therapy Screen and stated that this resident would have another therapy screen done with her annual. When told the annual had already been done, she stated that it's okay they just need to do it annually and there was still time to do that. When asked if the Therapy Screen was normally done with the annual, she stated they just need to ask therapy to do it. On 5/1/24 at 4:00 p.m., the MDS Coordinator stated she did not do range of motion (ROM) assessments. She stated she did not know what therapy or restorative does for assessments. This MDS Coordinator asked if they were supposed to check ROM with annual assessments. She stated that she didn't know anything about it. She stated that the Assistant Director of Nursing (ADON) was the facility's restorative person. On 5/2/24 at 9:15 a.m., the ADON stated that she was learning that she needed to do the facility's annual therapy screens. This ADON stated that she took over restorative duties when she took the ADON position not too long ago. The ADON stated that Resident #15 did not allow much intervention from staff. She stated that this resident refuses many things and has many behaviors. This ADON stated this resident really didn't do much at all. The ADON acknowledged the concern of not doing at least an annual assessment to determine no loss of ROM or no need for therapy or restorative care. On 5/2/24 at 10:39 a.m., the Occupational Therapist (OT), stated that normally they talk about residents at Medicare meetings regarding residents who have fallen, who may be declining, or who may need help in the dining room with swallowing things. A lot of our referrals come from those meetings. Medicare meetings are held every Thursday at 11:30 am. She stated that generally when residents are on therapy and they discharge, therapy will put a restorative program into place. This OT stated that Resident #15 was not one they have had on therapy in a while. This OT stated they used to do assessments by paper and now they do it electronically. This OT stated therapy does not know when a resident's annual comes up. She stated that therapy has their own screening process different from what the facility has. She stated that normally the Social Services staff, the MDS Coordinator, the DON, sometimes the ADON, the Physical Therapy staff, the Administrative Assistant, and herself attend the weekly meetings. This OT stated she has seen the restorative program stronger here when they had a restorative Certified Nurse Aide (CNA) dedicated to just doing restorative. This OT acknowledged the importance of documentation of a residents' refusals and ongoing assessment of a resident to show the resident hasn't changed from baseline status. On 5/2/24 at 11:47 p.m., the DON acknowledged the concern that the annual assessment wasn't done to check baseline status for this resident. She stated that they missed it. This DON stated they had a process in place and are now going to make sure that the therapy evaluations are getting done. She stated they now just put in to have therapy assess 2 other residents who are having their annual/comprehensive assessment done. An undated Therapy Screening Policy and Procedure directed that a representative from at least one therapy discipline will participate in a screening to determine a resident's therapy needs in the following instances: One week prior to the annual MDS observation period.

Based on clinical record review, observation, and resident and staff interviews, the facility failed to provide planned bathes for one of three residents reviewed for activities of daily living (Resident #17). The facility reported a census of 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 identified a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicated intact memory and cognition. The MDS identified Resident #17 did not reject care during the assessment period. The MDS documented Resident #17 required the assistance of two staff for transfers and physical help in part of her bathing activity. The MDS recorded the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Care Plan, revised 8/18/21, identified a need for assistance in dressing, toileting, repositioning, transferring and bathing. The Care Plan informed staff the resident preferred to take a bed bath at least once a week but staff were to encourage a shower one to two times per week. The Activities of Daily Living (ADL) for bathing under the Task tab in the resident's electronic medical record (EMR) documented the resident received a shower or whirlpool bath on the following dates in September 2021: Showers on 9/3/21, 9/7/21, 9/17/21, 9/21/21, 9/24/21, and 9/28/21 and a whirlpool bath on 9/14/21. It was also noted the resident declined her shower on 9/10/21. On 10/1/21 the facility went into COVID-19 outbreak status. Since the time of the outbreak the ADL for bathing under the EMR Task tab for Resident # 17 had documentation of a shower or whirlpool bath being completed on the following dates: shower on 10/10/21 and a whirlpool bath on 10/1/21. It was also documented the resident's showers were rescheduled on the following dates: 10/5/21, 10/8/21, 10/12/21, 10/15/21, and 10/19/21 with no documentation that staff completed the baths. In an interview on 10/19/21 at 8:27 a.m., Resident # 17 stated she had not been receiving her scheduled showers and staff gave her last shower over a week ago. In an interview on 10/19/21 at 10:20 a.m., the Director of Nursing (DON) reported staff had only been giving bed baths to residents in the COVID-19 unit. She reported the other residents in the facility received showers as staffing allowed but were to be offered a bed bath if staff could not provide the resident their scheduled shower. In an interview on 10/20/21 at 01:05 p.m., Resident # 17 reported she had still not had a bath since 10/10/21. She denied being offered a bed bath and stated when she asked staff for a bath she was told staff were too busy. In an interview on 10/20/21 at 01:11 p.m., the DON reported it was her expectation residents be offered a shower or bath at least twice a week. She expected if staff were unable to give the shower or bath, they would offer the resident a bed bath. She stated with the COVID-19 outbreak, the facility had been short staffed and offered bed baths to the residents if staff did not have time to complete the resident's scheduled shower or bath. The DON further stated that if staff documented bathing was to be rescheduled, it would be her expectation the next shift attempt it or it would be completed the next day. Staff were to document showers or bed baths given at a later time or date. In an interview on 10/20/21 at 03:41 p.m., the Nurse Consultant stated the expectation and the facility's standard that every resident had the right to request the number of baths or showers they wanted each week but the facility was to offer baths to residents a minimum of twice a week. She reported staff told her they had been offering/giving the residents bed baths but had not been documenting them. She stated she did not believe there were any policies on bathing or activities of daily living for the facility.

Based on clinical record review, observation, facility policy review and staff interview, facility staff failed to use an assistive device (a gait belt) during transfer assistance of one of three residents (#12) reviewed for Activities of Daily Living (ADLs). The facility identified a census of 35 current residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment of 8/4/21, Resident #12 had diagnoses that included [CONDITION(S)] (a heart arrhythmia), [CONDITION(S)], [CONDITION(S)], generalized muscle weakness and abnormalities of gait and mobility. The assessment documented she walked independently at the time of the assessment. Resident #12 displayed impaired balance during all transitions and while walking, but could stabilize without staff assistance. The MDS documented Resident #12 had impaired range of motion on one lower extremity. Resident #12's Care Plan with a target date of 11/2/21 documented she needed assistance with her Activities of Daily Living related to limited mobility of the right hop and trunk, muscle weakness, and abnormalities of gait and mobility. The Care Plan instructed Resident #12 can be independent in her room with toilet use, dressing and mobility with a walker. The Care Plan instructed staff to assist Resident #12 as needed. During observation on 10/18/21 at 2:27 PM, Staff A, Certified Nursing Assistant attempted to assist Resident #12 to stand by placing her arm under the resident's arm. Resident #12 could not stand. Staff B, Licensed Practical Nurse entered the room to assist. Staff A and Staff B placed their arms under the resident's arms, one on each side, and assisted the resident to stand. Neither staff used a gait belt to assist Resident #12 to stand. The facility policy titled Transfer/Gait Belts/Ambulation and used of Safety Straps/Belts last revised on 11/08, directed that staff use gait belts on residents who require assistance with transfers and/or ambulation when mechanical lifting devices are not used. During an interview on 10/20/21 at 3:23 PM, the Director of Nursing stated Staff A and B should have used a gait belt while helping Resident #12 to stand.

Based on record review and interview, the facility failed to report missing resident funds to the Department of Inspection and Appeals immediately after the allegation was made. The facility reported of a census of 30 residence. Findings include: According to the Minimum Data Set assessment tool, dated 10/1/15, Resident #10 had [DIAGNOSES REDACTED]. Review of the facility's investigation revealed Resident #10 reported to Social Services on 10/6/15, $40.00 was missing from the drawer in his/her night stand. During an interview on 11/12/15 at 12:25 p.m., Social Services (SS) reported they documented the missing money on an action report form and placed the report in the Administrator's mail. SS reported they called Resident #10's and verified the resident had had possession of (2) twenty dollar bills. During an interview on 11/12/15 at 12:34 p.m., the Director of Nursing (DON) reported Resident #10 discharged from the facility on 11/6/15. The DON reported they became aware of the missing money on 11/6/15. The DON also reported they talked with the Administrator the next morning regarding the missing money and stated they completed most of the staff interviews. The DON stated they were directed to report the missing money to Department of Inspection and Appeals, and said the Administrator called the police on 10/8/15. During an interview on 11/12/15 at 1:06 p.m., the Administrator reported they learned of the missing money on 10/7/15 when they read the action report and directed the DON to conduct an investigation at that time. The Administrator reported they thought the resident had no money in their possession, but after the resident's son verified he gave the resident money, the DON called and reported the missing money to the Department of Inspection and Appeals on 10/8/15 at 12:21 p.m. The Administrator reported they called the police. The facility policy titled Mandatory Reporting of Dependant Adult Abuse, Crimes, and Other Notification revised 8/11/11, directed staff regarding Reporting Guidelines: Reasonable suspicion of a crime against any individual who is a resident or receiving care at a long term care facility must be reported to the state survey agency on behalf of the Secretary of the Department of Health and Human Services and to local law enforcement agency: a) within 2 hours of forming a suspicion if there is a serious bodily injury b) within 24 hours of forming a suspicion if there is no serious bodily injury. The policy continued on page 6 of 9 point # 11, the Administrator is required to report allegations of the following whether perpetrated by caregiver, another resident, volunteer, or visitor, to the state survey agency in accordance with the guidelines in # 2. e) Misappropriation of resident property - The deliberate misplacement, exploitation wrongful, temporary or permanent use of resident's belongings of money with out the resident's consent.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure staff properly transferred one of three residents observed in order to prevent accident hazards. (Resident #4 ) The facility census was 31 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. and muscle weakness. The MDS assessment documented the resident had a score of 10 on the Brief Interview for Mental Status (BIMS), indicating some cognitive impairment. The MDS assessment documented the resident required extensive assistance with transfers and ambulation, was not steady and was only able to stabilize with staff assistance when moving from a seated to a standing position, walking and turning around. The MDS assessment documented the resident had range of motion impairments on both side of his/her lower extremities. An Admission/Readmission Fall Risk Assessment and Interventions form dated 5/16/12, indicated the resident with potential fall risk factors. Observation on 3/18/14 at 11:45 a.m., revealed Staff A, Licensed Practical Nurse, LPN was in the residents room as the resident laid in a low bed with his/her bilateral feet positioned on the floor and his/her upper torso at a 30-45 degree angle in bed. Staff A held the resident's right arm/hand and pulled him/her up into a sitting position without any further bodily support. Staff A proceeded to transfer the resident from the low bed to the wheel chair utilizing a pivot technique and holding onto the resident's pants on his/her right side and the resident's left side torso, without the use of a gait belt and with much difficulty. During interview on 3/18/14 at 12:10 p.m., Staff A confirmed she failed to utilize a gait belt when transferring the resident per facilities protocol. During interview on 3/19/14 at 11:10 a.m., Staff B, Certified Nurse Aide, CNA confirmed she entered the room as Staff A transferred the resident on 3/18/14 without the use of a gait belt and was having difficulty with the transfer. Staff B confirmed the facility standard of practice was to utilize a gait belt with residents who required staff assistance. Review of the facilities Transfer/Gait Belts/Ambulation and Use of Safety Straps/Belts policy revised 11/08, directed staff to utilize a gait belt on residents who required staff assistance with transfers and/or ambulation when mechanical lifting devices were not been used.