Every finding on record at Helia Healthcare of Benton

Based on observation, interview, and record review, the facility failed to provide a comfortable temperature for 9 of 9 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9) reviewed for environment in a sample of 9. This has the potential to affect all 50 residents living in the facility. Findings include:1. R1's Face Sheet documents an admission date of 2/15/25 with included diagnoses of acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, shortness of breath, cough, and hypertension. R1's MDS (Minimum Data Set) dated 5/12/26 documents a BIMS (Brief Interview of Mental Status) of 15, indicating intact cognition. R1's Care Plan documents R1 has chronic obstructive pulmonary disease (COPD) and respiratory failure started 2/19/25 with included intervention of observe for signs and symptoms such as cough, exertional dyspnea, wheezing and crackles, weight loss, use of accessory muscles, cyanosis, orthopnea, and congestion created 3/4/25. On 8/18/26 at 3:38 PM, R1 stated it has been hot in the facility all summer and especially hot when it is hotter outside. R1 stated over the weekend it got extremely hot in the facility and R1 stated she had a bit more of a hard time breathing because it got so hot. R1 stated a couple of the workers went and found a portable air conditioner for her room and turned it on for her and she's never been so happy in her life as she was when they got that portable air unit going in her room. R1 stated she has COPD and it is more difficult for her to breath when it is so hot. R1 stated she didn't eat much of her meals over the weekend because it was too hot. R1 stated she made herself take 10 bites of each meal because she knows she needs it but that was all she could eat due to the heat. 2. R2's Face Sheet documents an admission date of 7/25/23 with included diagnoses of atrial fibrillation, acute cough, muscle weakness, end stage renal disease, hypertension, asthma, and shortness of breath. R2's MDS dated [DATE] documents a BIMS of 11, indicating moderately impaired cognition. R2's Care Plan documents R2 has a diagnosis of asthma started 7/28/23 with included intervention of keep room cool and free of irritants started 7/28/26. On 8/19/26 at 3:27 PM, R2 stated it is always hot in the facility when it is hot outside but over the past weekend it was so hot in the entire facility, even her room. 3. R3's Face Sheet documents an admission date of 4/6/26 with included diagnoses of type 2 diabetes, primary hypertension, and cerebral infarction. R3's MDS dated [DATE] documents a BIMS of 15, indicating intact cognition. On 8/18/26 at 7:56 AM, R3 stated over the weekend it got very hot in the facility. R3 stated his room wasn't too bad because he has a portable air conditioner in his room, but the hallways and dining room was very hot. R3 stated he had a glass wall thermometer he took out to the dining room over the past weekend, and it showed it got up to 86 degrees Fahrenheit (F) one day in the dining room and 88 degrees F on the other. A facility document titled Grievance/Concern/Complaint Form dated 8/14/26 documents it is 84 degrees at 8:58 (pm, verified by R3) in the dinning area and is signed by R3. Under Summary/Findings: Temps taken by maintenance daily and no temperature beyond 71 degrees to 81 degrees. Documents was signed by V1 on 8/17/26. 4. R4's Face Sheet documents an admission date of 3/11/25 with included diagnoses of chronic obstructive pulmonary disease, metabolic encephalopathy, cellulitis of left lower limb, chronic kidney disease, edema, cough, bronchitis, rash and other nonspecific skin eruption, cognitive communication deficit, hypertension, and atrial fibrillation. R4's MDS dated [DATE] documents a BMIS of 10, indicating moderately impaired cognition. R4's Care Plan documents R4 prefers a room temperature above 81 degrees F (Fahrenheit) and reports feeling cold/uncomfortable at temperatures within the facility's normal range with a start date of 7/1/26 and edited on 8/18/26, the corresponding goal documents R4 will remain comfortable while the facility maintains a safe environment and complies with applicable CMS/state requirements edited on 8/18/26 with included interventions of offer alternatives to increasing room temperature, such as appropriate clothing, additional blankets, socks, or other comfort measures, as clinically appropriate created 8/18/26 with a start date of 7/1/26. On 8/18/26 at 8:15 AM, R4's room temperature was measured using a laser infrared thermometer and measured 83.5 degrees F in the middle part of R4's room. On 8/18/26 at 10:54 AM, R4 stated he is very cold natured and usually wears a hoodie all the time to stay warm but today he doesn't need one. R1's room temperature was measured using a laser infrared thermometer and measured at 83.1 degrees F in the middle part of R4's room. 5. R5's Face Sheet documents an admission date of 6/22/26 with included diagnoses of dementia and primary hypertension. R5's MDS dated [DATE] documents a BIMS of 06, indicating severe impairment. On 8/18/26 at 8:37 AM, R5's room temperature was measured at 83.3 degrees F in the middle of R5's room and was 84.2 degrees F near R5's bed, the temperature was measured with a laser infrared thermometer. R5 was sitting in her bed watching television with no covers on and stated it's warm in her room. On 8/18/26 at 12:25 PM, R5 was sitting up in her bed, and her room temperature was measured at 84.7 degrees F in the center of her room using a laser infrared thermometer. R5 stated it was warm in her room and stated it gets even hotter in the evening. R5 was sitting in her bed with no covers on. On 8/18/26 at 3:30 PM, V4 (Maintenance Director) measured the temperature in the center of R5's room with this surveyor present, using a laser infrared thermometer. R5's room temperature was measured at 82.2 degrees F. R5 stated it was warm in her room. R5 was sitting in her bed with no covers on. 6. R6's admission Record documents an admission record of 11/24/23 with included diagnoses of chronic kidney disease stage 5, end stage renal failure, and primary hypertension. R6's MDS dated [DATE] documents a BIMS of 15, indicating intact cognition. On 8/18/16 at 8:18 AM, R6 stated it got so hot over the weekend in the facility that everyone was miserable. R6 stated it is better today since it isn't as hot outside, but it is still too hot in the facility today. 7. R7's admission Record documents an admission date of 1/22/26 with included diagnoses of cellulitis of left lower limb, edema, type 2 diabetes, obstructive sleep apnea, hypertension, and atrial fibrillation. R7's MDS dated [DATE] documents a BIMS of 15, indicating intact cognition. On 8/18/26 at 10:38 AM, R7's room temperature was measured at 81.7 degrees F in the middle of R7's room, the temperature was measured using a laser infrared thermometer. R7 stated she is normally a cold-natural person and over the weekend one night she was in bed and it was hot and the next morning when she woke up, and someone had put an extra fan in her room. 8. R8's Face Sheet documents an admission date of 9/2/25 with included diagnoses of dizziness and giddiness, cough, fatigue, obesity, type 2 diabetes, hypertension, atrial fibrillation, systolic heart failure, and end stage renal disease. R8's MDS dated [DATE] documents a BIMS of 15, indicating intact cognition. On 8/18/26 at 2:31 PM, R8 stated she doesn't go out of her room much because it's too hot outside of her room. R8 stated she is glad she has a portable air conditioner in her room. R8 stated it gets too hot in the facility when it is hot outside. R8 stated it doesn't seem like the air conditioner is working properly. On 8/18/26 at 12:09 PM, R8 was sitting at a table in the dining room and stated it was hot in the facility today, as it normally is. R8 stated at least it is cooler outside today, so it isn't as bad today as it has been. The temperature of the table R8 was sitting at was measured using a laser infrared thermometer and it measured at 82.2 degrees F. 9. R9's Face Sheet documents an admission date of 4/23/26 with included diagnoses of dementia, primary hypertension, weakness, fatigue, and sleep apnea. R9's MDS dated [DATE] documents a BIMS of 09, indicating moderately impaired cognition. On 8/18/26 at 8:55 AM, R9 was sitting in his wheelchair at a table in the dining room. The temperature of R9's wheelchair was measured by V4 (Maintenance Director) using a laser infrared thermometer and the temperature of R9's wheelchair was measured at 87 degrees F and the table R9 was sitting at measured at 84 degrees F. R9 was asked if he was warm and he stated, it feels a little warm in here. On 8/15/26 at 8:52 AM, V4 measured the temperature of a table in the dining room in 2 different places on the table using a laser infrared thermometer with this surveyor present. The table was half in the shade and half in the sun. The table measured at 85 degrees F in the shade and 102 degrees F in the sun. On 8/15/26 at 1:12 PM, V4 measured the temperature of in the middle of the dining room using a laser infrared thermometer with this surveyor present and the temperature was measured at 81.5 degrees F. On 8/18/26 at 8:24 AM, V5 (Certified Nurse's Aide/CNA) stated the air is still not working properly and it's been hot in the facility. V5 stated it gets so hot in the facility when it is hot outside that it is miserable. On 8/18/26 at 8:30 AM, V6 (CNA) stated he normally works midnights, so it isn't as hot in the facility when he is working but it does get pretty hot at night still. On 8/18/26 at 11:42 AM, V7 (Housekeeping) stated its been too hot in the facility for a while now. V7 stated last week it was hotter outside, so the facility was extremely hot. On 8/18/26 at 3:08 PM, V8 (CNA Supervisor) stated she received text messages from staff on 8/15/26 in the evening saying residents were complaining it was too hot in the facility. On 8/18/26 at 2:44 PM, V9 (Dietary Aide) stated the facility is always hot when it is hot outside but over the last week, with extreme heat outside, it has been extremely hot in the facility. V9 stated there was a couple of resident rooms that were cooler since they had portable air units in them, but the entire building was burning up. V9 stated over the last week she has had several residents ask her if anything could be done to cool the facility down. On 8/18/26 at 2:49 PM, V10 (CNA) stated it is always hot in the facility if it is hot outside. V10 stated it's been like that all summer. On 8/18/26 at 2:50 PM, V11 (License Practical Nurse) stated she worked over the weekend when the heat index was so high outside, and it was miserable in the facility. V11 stated she saw a thermometer that was located in the dining room that measured 86 one day and 88 on the other day over the weekend. V11 stated she has had several residents complain to her about the heat in the facility over the last week or so. On 8/18/26 at 8:52 AM, V4 (Maintenance Director) stated he was called in on 8/16/26 due to the air conditioner not working, because of the breakers going out and the facility being hot. V4 stated the facility doesn't actually have air conditioner condenser units, the hospital they are connected to sends 42 degrees F water through pipes in the ceiling to their facility and there are fans that blow over those pipes sending air into the facility. V4 stated he did not take temps in the facility when he first got there because he was concerned with getting the facility cooled down first. V4 stated he worked on the air conditioner then helped the staff get extra portable air conditioner units they had put out in resident rooms and other areas of the facility. V4 stated about 4 hours after the extra portable air units had been running and the air conditioner had been fixed; he checked temperatures in resident rooms and on the south hall the higher temperature he measured was 82 degrees F and that was in the dining room. V4 stated he tries to check temperatures once a day when he is working unless the air conditioner isn't working then he will do it more often. V4 stated they do not have a hygrometer at the facility. V4 stated that when he takes temperatures, he uses the laser infrared thermometer he has used with this surveyor on this survey. On 8/19/26 at 1:52 PM, V1 (Administrator) stated the expected temperatures in the facility are 71 degrees F to 81 degrees F. According to https://www.timeanddate.com/weather/@4233586/historic, on 8/15/26 the highest temperature measured that day was a high of 93 degrees Fahrenheit from 1:52-5:52pm. Humidty reached a high of 84% that day. On 8/16/26 the highest temperature measured for the day was at 95 degrees Fahrenheit at 3:52 pm and 5:52pm. Humidity reached 84% that day. Both days were considered sunny days without overcast. Facility Census sheet printed 18/18/26 documents there are 50 residents living in the facility. A facility policy titled Ambient Temperature Monitoring Policy and Procedure dated August 2026 documents Under Purpose: 2. To promote resident comfort, health, and safety and to ensure timely response when environmental temperatures may place residents at risk. Under Procedure: 10. The facility's target ambient temperature for resident-occupied areas is generally 75 degrees F to 80 degrees F. Readings outside the federal safe-temperature range of 71 degrees F to 81 degrees F will be promptly evaluated and addressed. Resident-specific comfort needs will also be considered.

Based on interview and record review the facility failed to treat residents with respect and dignity for 10 (R1, R2, R4, R9, R16, R17, R18, R19, R20, R21) of 11 residents reviewed for dignity in a sample of 21. Findings include:1.R1's face sheet documents an admission date of 04/06/2026 with diagnoses including: osteoarthritis, pain, Parkinson's disease, type 2 diabetes, anxiety disorder, major depressive disorder, and cerebral infarction. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 14 indicating R1 is cognitively intact.On 07/01/26 at 10:20 AM, R1 stated there are staff at the facility, mostly on nights, that do give the residents attitude. R1 stated they will roll their eyes at them if they ask for anything. R1 stated depending on the resident they will make them wait longer, and they are just not real nice. R1 stated, they do not treat them with respect and dignity. R1 stated, he has asked them before why they can't just be nice. R1 stated, V6 (Certified Nursing Assistant/CNA) will turn the radio off that the residents are listening to in the dining room and will play the music she wants to play that the residents do not enjoy. R1 stated V6 just is not nice to the residents and she rolls her eyes at you all the time. R1 stated, he has seen V6 stand over R15 and point at him and aggressively talk to him. R1 stated R15's dementia is bad so he doesn't understand but he will have behaviors, but he can't say they are related. R1 stated, he has talked to V1 (Adminstrator) about the staff but nothing changed.2.R2's face sheet documents an admission date of 10/18/22 with diagnoses including: spondylosis, polyosteoarthritis, osteoporosis, chronic kidney disease, major depressive disorder, and anxiety disorder. R2's MDS dated [DATE] documents a BIMS score of 15 indicating R2 is cognitively intact.On 07/01/26 at 9:15 AM, R2 stated V6 talks bad to the residents and gripes at the residents. R2 stated she is very vengeful, she will bring you a coffee cup with no coffee, toast with no butter or jelly. R2 stated, there are CNAs that will walk by a room that has their call light on and they will act like they don't even see it and just look at their phone. R2 stated, there are staff at night that will just give you attitude, roll their eyes at you, and just be snipy with you. R2 stated, V6 and V8 (CNA) definitely do not always treat you with respect and dignity. R2 stated, they have talked to V1 about the staff but nothing changed in fact some staff might have gotten worse.3.R16's face sheet documents an admission date of 09/06/25 with diagnoses including: acute myocardial infarction, acute sinusitis, dysphagia, heart failure, and muscle wasting and atrophy. R16's MDS dated [DATE] documents a BIMS score of 15 indicating R16 is cognitively intact.On 07/01/26 at 2:10 PM, R16 stated they have discussed the staff and CNAs attitudes in resident council meetings before including the one on 06/30/26. R16 stated, when the staff give him attitude he just looks over it and tries not to let it bother him too much.4.R17's face sheet documents an admission date of 12/26/25 with diagnoses including: Parkinsonism, dementia, spondylosis, and chronic kidney disease. R17's MDS dated [DATE] documents a BIMS of 15 indicating R17 is cognitively intact.On 07/01/26 at 12:32 PM, R17 stated she doesn't know if she would say they are treated with respect or dignity, you have to take V8 (CNA) with a grain of salt.5.R9's face sheet documents an admission date of 05/05/26 with diagnoses including: Parkinsonism, diabetes mellitus type II, seizures, and overactive bladder. R9's MDS dated [DATE] documents a BIMS score of 14 indicating R9 is cognitively intact.On 07/01/26 at 12:35 PM, R9 stated V6 and V8 will holler and yell, they are not nice to her.6.R18's face sheet documents an admission date of 05/19/26 with diagnoses including: chronic obstructive pulmonary disease with acute exacerbation, chronic pain, encephalopathy, and anxiety disorder. R18's MDS dated [DATE] documents a BIMS score of 15 indicating R18 is cognitively intact.On 07/01/26 at 12:42 PM, R18 stated V6 hasn't given her too much attitude because she will not take it from her but she has seen her give R19 attitude because R19 used her call light because she was in pain. R18 stated, the staff aren't always the nicest.7.R19's face sheet documents an admission date of 04/28/26 with diagnoses including: displaced fracture of first cervical vertebra, acute and chronic respiratory failure, epilepsy, and Parkinsonism.On 07/01/26 at 12:45 PM, R19 who was alert and oriented, stated the staff are not always nice, they do not talk to you nice sometimes.8.R4's face sheet documents an admission date of 02/15/25 with diagnoses including: acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, fibromyalgia, restlessness and agitation, seizures, and difficulty in walking. R4's MDS dated [DATE] documents a BIMS score of 15 indicating R19 is cognitively intact.On 07/01/26 at 1:45 PM, R4 stated the staff, mostly night staff, including V6 and V8 can be disrespectful to residents. R4 stated V6 and V8 will yell at residents, they say they are not yelling, but where she grew up, if your voice was that loud you were yelling, for pooping or peeing. R4 stated she has seen them yell at other residents that can't talk back as easily. R4 stated they have discussed the staff attitudes including V6 and V8 in resident council. R4 stated, V1 is aware of the staff attitudes but nothing has changed.9.R20's face sheet documents an admission date of 11/24/23 with diagnoses including: hydronephrosis, chronic kidney disease, end stage renal disease, acute cystitis, and anxiety disorder. R20's MDS dated [DATE] documents a BIMS score of 15 indicating R20 is cognitively intact.On 07/01/26 at 3:50 PM, R20 stated they have talked about staff attitudes having bad attitudes in resident council.10.R21's face sheet documents an admission date of 07/15/24 with diagnoses including: type 2 diabetes mellitus with ketoacidosis, chronic obstructive pulmonary disease, chronic respiratory failure, chronic atrial fibrillation, anxiety disorder, and acute embolism and thrombosis of deep veins of lower extremity. R21's MDS dated [DATE] with a BIMS score of 13 indicating R21 is cognitively intact.On 07/01/26 at 3:40 PM R21, stated there are staff that are not always nice. R21 stated, she knows her feelings get hurt easily but one CNA makes her cry often. R21 stated, this CNA was off for a few days and she didn't cry once and she was relaxed. R21 stated, some of the CNAs will tell lies and there are CNAs that will tell her she can't go to the bathroom because it is too close to dinner and then she will have a stomachache trying to hold it or she will have an accident.On 07/01/26 at 12:44 PM V16 (Family) stated she has seen V6 treat a resident not very nice.The resident council minutes dated 06/30/26 do not document any concerns related to staff attitudes.On 07/02/26 at 10:58 AM, V4 (Activities Director) stated they have talked about the staff attitudes after the resident council meeting but she does not remember it being talked about during the meeting. V4 stated, if the residents did talk about staff attitudes during resident council she did not hear them. V4 stated, residents have told her about staff attitudes but she has never submitted a grievance about it.On 07/02/26 at 12:19 PM, V12 (CNA) stated she has been told by the residents about CNA attitudes. V12 stated, she has seen CNAs roll their eyes at residents, made the residents feel like an inconvenience, and give them attitude.On 07/02/26 at 11:32 AM, V9 (CNA) stated she has noticed other CNAs make it seem like the residents are a burden or an inconvenience. V9 stated, there are CNAs that will roll their eyes at the residents. V9 stated, she has not been present when any CNA has turned off the resident's music and played their own, but she has heard about it.On 07/03/26 at 8:06 AM, V1 (Administrator) stated any staff including V6 should not be rude or have attitude with the residents. V1 stated, no staff should be rolling their eyes at any resident, especially if they ask for something. V1 stated, she was unaware V6 would turn off the residents' music and change it to something she would prefer. V1 stated, she would expect the staff to be friendly, professional, caring, attentive, and empathic. The undated policy titled, Resident Rights documents: the resident has a right to a dignified existence, self determination, and communication with, and access to, persons and services inside and outside the facility, including: a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on observation, interview, and record review, the facility failed to provide a comfortable temperature for 8 of 8 residents (R1, R2, R4, R13, R14, R16, R18, R20) reviewed for environment in a sample of 21. Findings include:On 07/01/26 at 12:28 PM the main dining room was 81.3 degrees Fahrenheit (F), at 1:29 PM the temperature was 84.2 degrees F on the left side of the dining room and 83.5 degrees F on the right side of the dining room and the center was 84.0 degrees F. At 2:15 PM the center of the dining room was 85.3 degrees F, at 3:30 PM the dining room was 85.8 degrees F on the right side and 86.7 degrees F on the left side of the dining room and the center was 86.2 degrees F. The north hallway was 81.1 degrees F at 1:30 PM and 82.9 degrees F at 3:06 PM.1. R1's face sheet documents an admission date of 04/06/2026 with diagnoses including: osteoarthritis, pain, Parkinson's disease, type 2 diabetes, anxiety disorder, major depressive disorder, and cerebral infarction. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 14 indicating R1 is cognitively intact.On 07/01/26 at 10:20 AM, R1 stated the facility just keeps getting hotter. R1 stated the dining room gets really hot about after lunch through dinner time, when evening comes it starts to cool off a little.2. R2's face sheet documents an admission date of 10/18/22 with diagnoses including: spondylosis, polyosteoarthritis, osteoporosis, chronic kidney disease, major depressive disorder, and anxiety disorder. R2's MDS dated [DATE] documents a BIMS score of 15 indicating R2 is cognitively intact.On 07/01/26 at 9:15 AM R2, stated, V5 (Maintenance Director) said he would get me a portable air conditioning unit but he finally just got me one a couple days ago, so that has been helpful. R2 stated, the dining room was hot so the facility put big fans in the dining room that just blow stuff everywhere and the dining room is still hot. R2 stated, the dining room gets very warm after lunch until evening.3.R13's face sheet documents an admission date of 06/05/26 with diagnoses including: type 2 diabetes mellitus with diabetic chronic kidney disease, chronic pain, open angle glaucoma, and nontraumatic subdural hemorrhage. R13's MDS dated [DATE] documents a BIMS score of 14 indicating R13 is cognitively intact.On 07/01/26 at 10:17 AM, R13 stated the dining room is too hot, so he does not go there.4. R4's face sheet documents an admission date of 02/15/25 with diagnoses including: acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, fibromyalgia, restlessness and agitation, seizures, and difficulty in walking. R4's MDS dated [DATE] documents a BIMS score of 15 indicating R4 is cognitively intact.On 07/01/26 at 1:45 PM, R4 stated the dining room is too hot.5. R16's face sheet documents an admission date of 09/06/25 with diagnoses including: acute myocardial infarction, acute sinusitis, dysphagia, heart failure, and muscle wasting and atrophy. R16's MDS dated [DATE] documents a BIMS score of 15 indicating R16 is cognitively intact.On 07/01/26 at 2:10 PM, R16 stated the dining room is hot, so he just does not go down there very often.6. R18's face sheet documents an admission date of 05/19/26 with diagnoses including: chronic obstructive pulmonary disease with acute exacerbation, chronic pain, encephalopathy, and anxiety disorder. R18's MDS dated [DATE] documents a BIMS score of 15 indicating R18 is cognitively intact.On 07/01/26 at 12:42 PM R18 stated, the dining room is too hot.7. R20's face sheet documents an admission date of 11/24/23 with diagnoses including: hydronephrosis, chronic kidney disease, end stage renal disease, acute cystitis, and anxiety disorder. R20's MDS dated [DATE] documents a BIMS score of 15 indicating R20 is cognitively intact.On 07/01/26 at 3:40 PM R20 stated, the dining room is too hot.8. On 07/01/26 at 9:50 AM, R14 stated he stays in the small dining room most of the time because it is one of the only cool places. R14 stated, he changed rooms because his room was too hot for him. R14 was alert and oriented at time of interview.On 07/01/26 at 12:44 PM, V16 (Family) stated the dining room is hot.The Resident Council Minutes for 6/30/26 did not include any concerns related to the facility being to hot or any weather related concerns.On 07/02/26 at 10:58 AM, V4 (Activities Director) stated they have talked about the heat at the facility, especially in the dining room during resident council meetings, including the last one on 06/30/26. V4 stated, she does not know how she did not get it in the minutes.On 07/02/26 at 11:08 AM, V9 (CNA) stated several residents have complained about the heat in the facility, especially in the dining room.On 07/02/26 at 12:19 PM, V12 (CNA) stated several residents have complained about the facility being hot to her.The undated facility policy titled, Facility Temperatures documents: 1. Maintenance will monitor the temperatures throughout the building and adjust thermostats/make repairs as necessary to maintain the temperature of 71-81 degrees (Fahrenheit), ensure and maintain a comfortable environment for the residents, staff and guest.

Based on observation, interview, and record review the facility failed to provide a safe, clean, sanitary environment and shower room for 27 (R1, R2, R3, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18. R19. R20, R21, R22, R23, R24, R25, R26, R27, and R28) of 28 residents reviewed for a clean environment. Findings include:On 06/15/26 at 10:30 AM, R4 stated they have been short housekeepers so things have not been as clean. The housekeepers barely have time to take out the trash and sweep the floor. R4 stated the floors have not been as clean and the shower room is gross. R4 was alert and oriented at the time of the interview.On 06/15/26 at 11:15 AM, R2 stated they have not been keeping the facility very clean, especially the shower room. R2 stated they have told the staff about the shower room, but it still has that black stuff in it. R2 stated one time she went into the shower room and there was fecal matter on the shower wand. The sink in her room wasn't cleaned for a week, so she cleaned it, and the toilet is not always clean. R2 was alert and oriented at the time of the interview.On 06/15/26 at 10:25 AM, R3 stated her room is clean enough but the shower room could be cleaner. R3 was alert and oriented at the time of the interview.On 06/15/26 at 10:39 AM, R6's room had crumpled tissues, pieces of string, and food crumbs on the floor.On 06/16/26 at 4:10 PM, R1 stated the facility could be cleaner and the shower room is dirty. R1 was alert and oriented at the time of the interview.On 06/15/25 at 10:42 AM, R5's room had a strong odor and the floor was sticky.On 06/15/26 at 11:43 AM, the shower room on the north hall had a black substance where the floor and wall meet on all three sides of the shower stall.On 06/17/26 at 10:01 AM, V6 (Admissions/Social Services) stated the resident rooms should be clean including the floors and they should not be sticky. V6 stated the shower rooms should be cleaned after every resident and there should not be any black substances growing in the shower rooms. V6 stated she believes the residents on the north hall shower in the shower room on the north hall.The daily Census Report, dated 06/17/26, documents R1, R2, R3, R4, R5, R6, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18. R19. R20, R21, R22, R23, R24, R25, R26, R27, and R28 reside on the north hall.The resident council minutes, dated 05/26/26, document: Residents stated shower rooms are still dirty. The resident council meeting minutes, dated 04/28/26, document: Shower room being very dirty.The undated facility policy titled, Cleaning Guidelines Environmental Services, documents: It is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with a written schedule of cleaning and decontamination based on the area of the facility, type of surface to be cleaned, type of soil present and tasks being performed in the area.

Based on interview and record review, the facility failed to ensure a resident who enters the facility with an indwelling catheter is assessed for removal of the catheter as soon as possible, and to provide appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 (R1) residents reviewed for catheters in the sample of 8. This failure resulted in R1 being hospitalized for a Urinary Tract Infection and altered mental status.Findings include:R1's Face sheet documents an admission date of 9/29/2025 from a local hospital and documents a discharge date of 12/4/25 with the following diagnoses in part; Displaced supracondylar fracture without intercondylar extension of lower end of left femur, subsequent encounter for closed fracture with routine healing, rash and other nonspecific skin eruption, periprosthetic fracture around internal prosthetic left knee joint, and urinary retention.R1's Minimum Data Set (MDS) dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 3, indicating R1 was severely cognitively impaired.R1's Care Plan documents in the section titled, Problem that R1 requires an indwelling urinary catheter R/T (related to) urinary retention with a start date of 9/30/25. R1's Care Plan further documents the following in this section under approach. Urology consult as indicated and report symptoms of UTI (Urinary Tract Infection) with an approach start date of 9/30/25.R1's Physician's Order Sheet documents an order with a start date of 9/30/25 and a discontinue date of 11/22/25 for Indwelling Catheter - Change Catheter and Drainage Bag PRN (as needed).R1's Patient Referral from the local hospital with a print date of 9/26/25 documents under Patient Lines/Drains/Airway Status that R1 had a catheter that was placed on 9/24/25. There is no documentation that R1 had a history of urinary retention prior to his admission on [DATE] in this document.R1's Hospital Discharge Summary from the local hospital with a creation date of 9/29/25 and print date of 2/20/2026, documents R1 had an ambulatory referral to Urology. Under Assessment and Plan it documents Urinary Retention: Patient had urinary retention after removing Foley catheter. Place Foley catheter. Urology service is not on-call, will we are [sic] Foley catheter upon discharge and visit urology clinic at outpatient. There is no documentation that R1 had a history of urinary retention prior to this hospitalization.R1's Physician Progress Note authored by V12 (Physician) dated 10/17/25 does not document R1 had an indwelling catheter or documentation regarding urinary retention.R1's Progress Note dated 10/15/2025 at 10:59AM documents spoke with wife about urologist, she reported that he had put in for sx (surgery) and has no urinary retention dx (Diagnosis), sent md (medical doctor) request to d/c (discontinue) fc (foley catheter).R1's Progress Note dated 10/15/2025 at 2:34PM documents per md, referral sent to urology, awaiting their call to schedule an appt.R1's Progress Note dated 10/20/2025 at 2:44PM documents sent md message through (name of messaging service) about who was his referral sent to for urology wife was wanting to know when his appt. was. we have still yet to receive a call about an appt.R1's Progress Note dated 10/21/2025 at 1:55PM documents reached out to (local hospital) urology et (and) was referred to (local hospital), was reported that they will call back in approx. 2 wks (weeks) for f/u (follow up).R1's Progress Note dated 10/30/25 at 1:35PM documents This nurse called and spoke with (V14-Family Member) about concerns he has.This nurse explained that Urology appointment is on 11/17/25 at 10:30AM at (name of clinic), he asked about the resident catheter, that he says it hurts, explained that it was placed when resident was in hospital and we cannot remove it without a doctor order and he needs to be seen for follow up with urologist on that regard.R1's Progress Note dated 10/30/25 at 3:34pm documents T/C (telephone call) to Urologist to determine if resident appointment could be moved up per family request. They state they do not have anything sooner than what is scheduled. This nurse asked if they had a wait list he could be put on in case of a cancellation, and she states they do and she put his information in the computer and would contact facility if change.R1's Progress Note dated 10/30/25 at 8:40pm, documents Message sent to NP (V11 Nurse Practitioner) updating on family concerns about urinary pain, catheter is patent and intact, draining amber urine without difficulty. Resident does pull on the catheter tubing at times so may have gotten germs from hand onto the catheter. Has urology appointment set up. Informed him of family concerns and requested to do a UA (urinalysis).R1's Progress Note dated 10/31/2025 at 2:40pm documents T/C (telephone call) received from NP (V11 Nurse Practitioner) he was asking about resident catheter and was place in hospital and has follow up with urology. NP states that is fine, just wanted to make sure if he didn't need it to try and remove. NP states if family continues to question, explain hospital said to see urology and it cannot be removed until that time. Explained that family had been educated on this.There is no documentation in R1's Progress Notes or R1's Physician Order History that an order to obtain a urinalysis was received.R1's Progress Note dated 11/2/2025 at 3:11pm documents Res (Resident) c/o (complaint of) not being able to urinate. Did assess abd (abdomen) and distention felt. Urine has much sedimentation in it. Did replace f/c (foley catheter) with # 16 French and a 10cc bulb. Good urine return noted. Upon later evaluation -Res states he feels better and abd distention is gone.R1's Progress Note dated 11/20/25 at 4:22pm documents Called Urology office .spoke with (staff member), informed her that we have not yet received office notes or orders from res (resident) visit earlier this week, and provider agreed to remove foley and allow res (resident) to void on his own. She is going to re fax office notes and orders at this time. Res has been up for meals and is currently in room visiting with family .R1's Progress Note dated 11/21/25 at 5:33pm documents Per urology's request, catheter was removed today without complication. explained procedure to patient, ensured privacy, and performed hand hygiene. catheter balloon fully deflated and catheter withdrawn smoothly. Tip intact. patient tolerated procedure well with no signs of discomfort or bleeding. Perineal area cleansed and patient instructed to increase oral fluids and staff notified to encourage him as well. will continue to monitor urinary output and signs of urinary retention.R1's Progress Note dated 11/23/25 at 1:27pm documents 11/23/2025 [Recorded as Late Entry on 11/24/2025 10:30 PM] Res up in wc (wheelchair) with mech assist for transfers. Res alert, and able to make needs known. Res is tolerating Foley cath removal and has been able to urinate this shift on his own and without cath in place. Fluids encouraged and taken well, res will take fluids despite having thickened liquids. Res appears calmer and less agitated since catheter removal and cont (continue) to void yellow urine without distress. Will cont to monitor.R1's Progress Note dated 12/4/25 at 12:22 AM recorded as a late entry on 12/5/25 at 12:23am documents This nurse was called to residents room as resident had change in behavior. Per wife resident did not speak or feed self at dinner but allowed wife to feed them. Resident prompted to say name and resident slurred response. Able to make eye contact for a short period and then resident eyes would roll back. Spastic movements (short jerky motions) of body. Wife present. Sent to ER (name of hospital) for eval via EMS (Emergency Medical Services).R1's History and Physical Report from the local hospital dated 12/5/25 under History of Present Illness documents He presented to ER 9Emergency Room) with complaints of altered mental status from a local rehab facility. Family notes he has been in the facility for the last 2 months after a hip fracture. He went to facility for rehab. Family notes that he has been slowly deteriorating over the last 2 weeks. Speech declining, unable to feed self. ER workup significant for urine positive for UTI (Urinary Tract Infection), WBC (White Blood Cell) normal at 9.6, sodium elevated 157, lactic acid 2.8. He was given IV (intravenous) hydration and IV Rocephin. admitted to the floor for continued monitoring and management. Under Assessment and Plan diagnoses of altered mental status, UTI, and hypernatremia are documented.On 2/18/26 at 10:22am, V14 (family member) stated R1's catheter was not changed for over 4 weeks. V14 stated he was told they had to have urologist order to take it out, R1 only had the catheter for surgery and had no prior urinary issues. V14 stated he questioned administration several times about whether R1 could be dehydrated or have a UTI (Urinary Tract Infection). V14 stated he reported R1 was having urinary pain, and he was told they would request a Urinalysis but one was never done. V14 stated he requested to speak to the physician on more than one occasion but was never given the opportunity.On 2/18/26 at 2:11pm, V3 (Licensed Practical Nurse/LPN) stated R1's family was really concerned about him and his condition. V3 stated R1's family really tried to stay on top of his care. V3 stated she believes somewhere along the way the ball was dropped on scheduling R1's follow-up appointments. V3 stated R1 was admitted with a catheter and there was some confusion as to why it was still in place. V3 stated they called to get clarification, and it was left in place because R1 had some retention at the hospital, and they were waiting for R1 to follow up with urology for removal. V3 stated R1's catheter was really irritating for him; he would mess with it often. V3 stated R1's family did complain of it hurting him, but not to her. V3 stated if someone has a urinary retention and sediment with a catheter which resulted in it having to be changed, she would report symptoms to the physician. V3 stated even if symptoms were alleviated with catheter change. On 2/19/26 at 12:04pm, V4 (Licensed Practical Nurse/LPN) stated R1 did have a catheter that was put in at the hospital for surgery, but it was left in because he had urinary retention after surgery. V4 stated R1 had a referral for urology, and they were awaiting on that appointment to remove it. V4 stated R1 messed with it constantly, she was not sure if it was bothering him or if it was his anxiety. V4 stated she did change R1's catheter on or around November 2nd due to having retention and sediment in his drainage bag. V4 stated the new catheter was draining properly. V4 stated R1 had a standing order to change the catheter, so she did not have to contact the physician to let him know the symptoms that led to it being changed or that she changed it.On 2/23/26 at 1:35pm, V2 (Assistant Administrator) stated she covers the duties of Social Services Director when the facility does not have one. V2 stated if she was not provided with discharge instructions and follow-up appointments, she would reach out to the facility or hospital the resident came from and find out and make the appointments immediately. V2 stated she may not do it that day depending on when they admitted , but the next business day that she could. V2 confirmed that R1's urology appointment was not addressed until 10/15/25 and should have been addressed sooner.On 2/23/26 at 3:20pm, V1(Administrator) stated that she would expect a physician to be notified if a resident had urinary retention and abdominal distention, even if they had a standing order and symptoms were alleviated with catheterization.On 2/24/26 at 10:32am, V12 (Physician) stated he did R1's initial comprehensive evaluation in the facility. V12 stated R1's care was transferred to another provider shortly after. V12 stated there could be a few reasons why R1's catheter was not included in his initial assessment, he stated it could have been that he was not informed of it, or that he had more pertinent issues to address. V12 stated he does not recall knowing that R1 had a catheter, but he had a brief interaction and that was months ago. V12 stated it is very common for residents to come from the hospital with no previous history of urinary issues with a catheter. V12 stated sometimes he doubts if the hospital even tries to trial removal or just passes it off to the facility with a referral to urology. V12 stated getting a resident with a fracture like R1's to a urology appointment can be challenging. V12 stated he is pretty aggressive at safely removing a catheter and returning back to normal function with his own patients, even if they have a urology consultation. V12 stated he could not stress enough doing it safely, but with someone with no previous issues, it can typically be done successfully in house. V12 stated if he received a report of pain with a urinary catheter, he would order a urinalysis.On 2/24/26 at 11:33pm, V1 (Administrator) stated she did not see any lab results scanned into R1's file, but she requested R1's lab records from the hospital.On 2/24/26 at 11:48am, V1 forwarded R1's hospital lab results, there were no labs obtained at the facility prior to R1's hospitalization on 12/4/26.The facility Policy titled, Catheter Care, Urinary with a revision date of July 2017 documents under the section, Complications it states in section b. If the resident indicates that his or her bladder is full or that he or she needs to void (Urinate), notify the physician or supervisor. Under section e. Observe for other signs and symptoms of urinary tract infection or urinary retention.

Based on interview, observation, and record review the facility failed to remove expired medications from current medication supply for 2 (R17, R45) of 2 residents reviewed for pharmacy services in the sample of 35. Findings include: 1. R17's Face Sheet documents an admission date of 5/1/23 with diagnoses including in part fibromyalgia, lower abdominal pain, other chronic pain, pain in right hand, pain in left wrist, and pain in throat. R17's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition. R17's Continuity of Care Document dated May 22, 2025, documents an order for Tramadol (schedule IV narcotic) tablet 25 milligrams (mg) 1 tablet oral twice a day for pain ordered on 3/7/24 and discontinued on 5/20/25. On 5/20/25 at 11:24 AM, there was an expired card of tramadol HCL 50 mg half tablets for R17 in the medication cart with an expiration date of 2/14/25. R17's Medication Administration Record (MAR) dated 2/1/2025-2/28/2025 documents that R17 received tramadol 25 mg on 2/15/25 at 7:12 PM and 2/16/25 at 6:50 PM. R17's MAR dated 5/1/2025-5/20/2025 documents that R17 received tramadol 25 mg on 5/3/25 at 7:45 PM. On 5/20/25 at 12:20 PM, V4 (Registered Nurse/RN) confirmed the tramadol for R17 was expired. V4 removed the card from the medication cart and stated it should have been removed from the cart when it expired. V4 stated the director of nursing checks the medication carts for expired medication and a pharmacy representative was just in the facility and should have found it. 2. R45's Face Sheet documents an admission date of 2/8/24 with diagnoses including in part arthritis and pain. R45's MDS dated [DATE] documents a BIMS of 9 indicating moderately impaired cognition. R45's most recent Care Plan documents a problem of R45 is at risk for pain related to diagnosis of arthritis with a start date of 9/19/24, goal of R45 will have pain under control with medication or resolved as seen by verbalization or free of signs or symptoms of pain, and approach of observe effectiveness of medication and provide analgesics as ordered and as needed. R45's Continuity of Care Document dated May 22, 2025, documents a current order for albuterol sulfate solution for nebulization 0.63 mg/2 milliliters (ml) inhalation every 6 hours as needed ordered on 2/26/24. On 5/20/25 at 11:50 AM, there was expired albuterol nebulizer solution 0.63 mg/3 ml for R45 in the medication room cabinet with other resident's medications with an expiration date of April 2025. On 5/20/25 at 12:27 PM, V6 (RN) confirmed R45's albuterol nebulizer solution was expired as of April 2025. V6 removed the medication from the medication room and stated it should have been taken out of the room when it expired. An undated facility policy titled Storage of Medication documents under Procedures, it documents H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed form inventory, disposed of according to procedures for medication dispose and reordered from the pharmacy, if a current order exists. On the same document under Expiration Dating, it documents F. The nurse will check the expiration date of each medication before administering, G. No expired medication will be administered to a resident, H. All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining.

Based on observation, interview, and record review the facility failed to double lock controlled medications 1 of 1 (R27) residents reviewed for medication storage in the sample of 35. Findings include: R27's admission Record documents an admission date of 10/18/2022 with diagnoses including in part spondylosis, polyosteoarthritis, age-related osteoporosis, and chronic pain. R27's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 13 indicating that R27 is cognitively intact. R27's most recent Care Plan documents a problem area of R27 has pain at times due to degenerative joint disease, goal of resident will have no episodes of uncontrolled pain, and approach of medications as ordered. R27's Continuity of Care Document dated May 22, 2025, documents an order for hydrocodone-acetaminophen-(schedule II narcotic) tablet 3-325 milligram (mg), 1 tablet oral every 6 hours as needed, ordered 9/7/23. On 5/20/25 at 11:08 AM, a medication card belonging to R27 with hydrocodone/acetaminophen 5-325 Milligram (mg) was in an unlocked cabinet, in the locked medication room. At this time, V3 (Registered Nurse/RN) stated the medication was in that cabinet because it needed to be destroyed. On 5/20/25 at 12:24 PM, V3 and V4 (RN) stated they don't know if the door on the cabinet locked where the narcotic was located. V4 tried her keys on the cabinet lock and the key turns but the lock does not lock the door and it still opens. On 5/22/25 at 8:32 AM, V4 stated hydrocodone/acetaminophen should be double locked. An undated facility policy titled Controlled Substance Storage documents under Procedures B. Schedule II-V medications and other medications subject to abuse or diversion are stored in a permanently affixed, double-locked compartment separate from all other medications or per state regulation.

Based on interview and record review the facility failed to follow the Pneumococcal Immunization Policy to ensure accurate documentation and administration of the Pneumococcal Immunization for 1 of 5 (R3) reviewed for Pneumococcal Immunizations in the sample of 35. Findings Include: R3's Resident Face Sheet documents an admission date of 12/09/2024, with a date of birth indicating that R3 is [AGE] years of age. The same Face Sheet documents the following diagnoses in part; type 2 diabetes mellitus without complications and cough. R3's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 11, indicating R3 is moderately cognitively impaired. R3's Continuity of Care Document dated 5/22/25 documents under Immunizations documents the date 12/21/20 next to Pneumococcal Vaccine with a status of completed. There is no documentation in R3's medical record documenting the type of Pneumococcal Vaccine that R3 received. On 05/21/2025 at 11:37am, V1 (Administrator) stated vaccinations should be in the electronic medical record. V1 stated when a resident admits they ask the resident or the family about vaccination history. V1 stated if they don't know they may call the doctor to see what he recommends. A document titled Vaccine Consent and Release in R3's medical record dated 12/26/2024 and signed by R3's Power of Attorney (POA) indicates that R3's POA agrees to the Pneumococcal vaccination schedule. It also indicated they did not recall R3's vaccination history or if she had received the pneumococcal vaccine before. On 05/21/2025 at 11:38am, V2 (Business Office Manager/BOM) stated she would try to see if she could print off vaccinations from R3's local hospital records. V2 stated she was pretty sure there were vaccinations on there. On 5/21/25, V2 provided R3's local hospital's electronic medical records with a print date of 05/21/2025, documenting that R3 received the following Pneumococcal vaccinations, PCV13 (pneumococcal 13-valent conjugate vaccine) on 11/18/2019 and 12/16/2020. The facility was unable to provide reproduceable evidence that R3 received vaccinations at this facility. According to the Center for Disease Control (CDC) located at (https://www.cdc.gov/vaccfines/vpd/pneumo/hcp/pneumoapp.html) a patient who is over the age of 50, who has only received the PCV13, and none of the others; is recommended to be given one dose of PCV20 (20-valent pneumococcal conjugate vaccine) or PCV21 (21-valent conjugate pneumococcal vaccine) at least one year after PCV13. Regardless of which vaccine is used, (PCV20 or PCV21) their pneumococcal vaccinations are complete. The facility policy titled Pneumococcal Vaccine with a revision date of February 11, 2022, under Policy, documents It is the policy of (name of facility) that all residents are protected from incident of pneumonia by obtaining pneumococcal vaccines, if desired, per the CDC guidelines. In the section titled Schedule for Administering Pneumococcal Vaccines it states Follow CDC guidelines with use of Pneumo Recs VaxAdvisor mobile app. On 05/22/2025 at 1:00pm, V5 (Licensed Practical Nurse/Infection Prevention) stated if a resident is admitted and their Power of Attorney signed a consent for a pneumonia vaccination, they might contact the doctor to see if he had any recommendations if previous vaccinations are unknown. V5 stated if the doctor was contacted it would be in the Progress Notes. V5 stated she was not aware of the specifics of the Center for Disease Control (CDC) guidelines of completing the series for pneumococcal vaccinations or the app associated with it. V5 could not confirm whether R3 had any pneumococcal vaccinations. There is no documentation of communication with R3's doctor about the pneumococcal vaccination documented in R3's medical record.

Based on observation, interview, and record review the facility failed to follow proper infection control techniques during wound care for 1 of 5 residents (R30) reviewed for infection control in the sample of 30. The findings include: R30's face sheet documents an admitted [DATE] with diagnoses including: Sepsis, unspecified, Unspecified open wound, left foot, Laceration without foreign body of left lesser toe(s) without damage to nail, Other iron deficiency anemias, Type 2 diabetes mellitus with unspecified complications, Venous insufficiency (chronic) (peripheral), Muscle wasting and atrophy, not elsewhere classified, multiple sites, Unspecified open wound of unspecified toe(s) without damage to nail, sequela, Pain, unspecified, Other hypoglycemia, Unspecified atrial fibrillation, Muscle weakness (generalized), Other abnormalities of gait and mobility, and Other lack of coordination. R30's Minimum Data Set (MDS) dated [DATE] documents under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates that R30 is cognitively intact. Section GG documents R30 is dependent with toileting, showering, and dressing. R30's Current Care Plan documents under problems: R30 has a diabetic ulcer to left heel with intervention of: enhanced barrier precautions per facility protocol and treat ulcer as ordered. R30's Care Plan documents that R30 is at risk for skin breakdown or pressure ulcers related to decreased mobility with interventions of: keep skin clean and dry as possible and observe skin condition with daily care. R30's Care Plan documents that R30 is at risk for complications due to diabetes diagnosis with intervention of: notify V13 (Medical Doctor) as needed. R30's Physician orders documents an order dated 03/06/24 for Betadine 10% solution to open wound, to left foot, cleanse wound with normal saline (NS) apply betadine and calcium alginate and gauze wrap every day. On 04/24/24 at 1:38 PM, V4 (Registered Nurse) was observed donning a gown and gloves and entering R30's room, which had a sign on the door that stated enhanced barrier precautions. V4 placed a clean towel on a bedside table and placed treatment supplies with several pairs of gloves on the towel. V4 removed a pair of scissors from her pocket. V4 cut the soiled dressing off R30's foot with the scissors, the contaminated scissors were placed on the clean towel next to the clean dressing supplies without cleansing the scissors. V4 doffed her soiled gloves and donned clean gloves without performing hand hygiene between. V4 used the soiled scissors and cut a clean piece of gauze from a roll. V4 took the piece of gauze and some normal saline and cleansed R30's foot. V4 doffed her gloves and donned a new pair of gloves without performing hand hygiene. V4 applied betadine to R30's left heel along with calcium alginate. V4 then wrapped R30's left foot with the gauze she had cut with the soiled scissors. V4 doffed her gloves, placed the dirty scissors in her pants pocket and then performed hand hygiene. On 04/24/24 at 2:00 PM, V4 stated she did not clean the scissors after she removed the old dressing from R30's left foot. V4 stated, she did have an alcohol wipe she was going to use to wipe off the scissors after she removed the old dressing, however she lost or misplaced the alcohol wipe when she entered R30's room. V4 stated, she did cleanse the scissors before entering the room and placed them in her pocket. V4 said, she did place the dirty scissor in her pocket when she was exiting the room. V4 stated, she did not perform hand hygiene in between gloves changes when she removed the old dressing and applied the new dressing. On 04/24/2024 at 03:00 pm, V3 (Infection Preventionist/IP) stated that after you remove a dirty dressing with scissors you should clean the scissor and then wash your hands. V3 stated that you should always wash your hands or sanitize them in between glove changes. V3 stated that should be common practice. V3 stated that all dressing changes are expected to be done according to Professional Standards of Practice. V3 stated that a resident who is on enhanced barrier precautions is at a higher risk of infection. V3 stated that it is very important to maintain proper infection control practices for all residents. The facility policy titled Isolation Precautions/ Enhanced Barrier Precautions (EBP) dated 4/1/24 documents the following under Guidance: EBP is used in conjunction with standard precautions and expand the use of PPE (Personal Protective Equipment) to donning of gown and gloves during high-contact resident care activities that provide the opportunities for transfer of MDRO's (multi drug resistant organisms) to staff hand and clothing . EBP ae indicated for residents with any of the following: .Wounds and/ or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO .Facilities should ensure PPE and alcohol based hand rub are readily accessible to staff. The facility policy titled Dressing, Dry/Clean dated January 2018, documents in part under procedures 2. Place the clean equipment on the bedside stand. Arrange the supplies so they can be easily reached. 8. Put on clean gloves, loosen tape and remove soiled dressing 9. Pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry your hands thoroughly. 11. Open dry, clean dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 14. Put on clean gloves.

Based on observation, interview and record review the facility failed to ensure that the dishes and food contact surfaces were being effectively sanitized. This has the potential to effect all 44 residents residing in the facility. The Findings Include: On 6/7/22 at 9:30 AM during the initial tour of the kitchen when asked to check the sanitizer level in the dish machine the sanitizer test strip indicated less that 25 parts per million (PPM) of chlorine was registering on the test strip. At that time, V4 (Dietary Supervisor) stated that the manufacturer guidelines recommended between 50-100PPM. V4 attempted to prime the sanitizer line of the machine, but was having no success at getting the sanitizer level to reach desired range. V4 instructed kitchen staff to use the 3 compartment manual sink until the dish washer could be repaired. The daily log hung near the dish machine for the month of June showed that they checked the sanitizer level once daily and had been registering at the minimum level of 50. V4 stated at this time that they just had regular routine maintenance last week and have not had any issues with the machine, other that it may need a new pump. At this time of observation the dish machine is very loud and when V4 was asked if that was common, he stated 'sometimes.' On 6/7/22 at 9:45 AM, V4 checked the sanitizer level in the bucket water used to wipe down and sanitize surfaces in the food prep are. This chlorine sanitizer test strip was not registering any sanitizer in the water. V4 went to make a new solution and after several attempts of having to dilute the solution to get it within acceptable range due to adding too much sanitizer the level came to be 100 PPM, which is acceptable range. On 6/7/22 at 10:00 AM, V4 stated that they do not have a policy on when to check the levels, but he tells the staff to check it in the morning before the starting dishes. The Resident Census and Conditions of Residents signed and dated on 6/7/22 documents 44 residents living in the facility.

Based on observation, interview, and record review the facility failed to provide reproducible evidence if a pressure ulcer was assessed. The physician was notified and treatment orders were obtained for 1 of 3 (R2) residents reviewed for pressure ulcers in the sample of 27. Findings Include: R2's Resident Face Sheet dated 6/10/22 documents R2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's MDS (Minimum Data Set) dated 6/2/22 documents R2 has a severe cognitive impairment. R2's Braden Scale assessment dated [DATE] documents a score of 12, which indicates R2 is at high risk for developing pressure ulcers. On 06/09/22 at 2:14 PM, R2 was observed with V6 (Licensed Practical Nurse) and V7 (Certified Nursing Assistant) present. R2's lower extremities were observed and bilateral feet were in heel protector boots that had straps that crossed over the top of R2's feet and attached to the opposite side of the boot. Under the strap of the heel protector boot on the right foot there was a bandage with a date of 6/7/22. When asked about the bandage V6 (LPN) stated she was not aware of the area and she wished she had known about it yesterday when V8 (Wound Specialist) was in the facility because he could have looked at it. V7 (CNA) stated it looks like it came from the strap of the heel protector. V6 removed the dressing and cleaned the area with normal saline, measured the area, and applied a border gauze. The area was an open area that was superficial in depth with no signs/symptoms of infection. V6 stated the area measured 2 x 0.8 cm. V6 confirmed the dressing she removed from the area was dated 6/7/22. Reviewed R2's electronic medical record including; Events, wound assessments, Observations, Progress Notes, Physician Orders, and treatment records with no assessment, physician notification, physician order, or treatments of the pressure area to the top of R2's right foot documented. V8 (Wound Specialist) progress note dated 6/8/22 does not document an area to the top of R2's right foot. On 06/09/22 at 2:49 PM, V2 (Director of Nurses) stated there were no orders and no documentation for the area noted to the top of R2's right foot. V2 stated they would be getting orders and it would be documented as an event. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .cleanse wound to top of right foot with wound cleanser or saline. Pat dry. Apply border foam dressing. Change daily and prn (as needed) if missing or soiled . There was no order for treatment to this area prior to 6/9/22. R2's Care Plan documents a problem area with a start date of 7/1/2020 that documents, Resident (R2) is at risk for pressure injury R/T (related to) decreased mobility, incontinence, oxygen use/tubing, PVD (peripheral vascular disease). Pt (patient-R2) has hx (history) of chronic [CONDITION(S)] and [CONDITION(S)] to bil (bilateral) lower ext (extremities), lupus hx (history) noted .6/9/22 Area to top of Rt (right) foot noted. Under Approach R2's care plan documents interventions that include report any signs of skin breakdown (sore, tender, red, or broken areas) dated 7/1/2020 .monitor for signs of non-healing/infection and report to MD (physician) PRN (as needed)- start date 6/9/2022 and Tx (treatment) to area as ordered -start date 6/9/2022 . On 6/10/22 at 8:50 AM, V8 (Wound Specialist) stated R2 refuses care at times and the pressure ulcers were unavoidable due to her decline in condition.

Based on interview and record review the facility failed to administer a diuretic medication as ordered by the physician for 3 days for 1 of 3 residents (R2) reviewed for significant medication errors in the the sample of 13. The Finding Include: R2's Electronic Medical Record documents R2 was admitted to the facility on [DATE] with a weight of 379 pounds. R2 has [DIAGNOSES REDACTED]. The July, 2019 physician's orders [REDACTED]. The 07/05/19 Minimum Data Set (MDS) documents R2 has a Brief Interview for Mental Status of 15 which indicates R2 is cognitively intact. The MDS documents R2 requires extensive assistance of one person for bed mobility. The 07/12/19 Progress Note per V5 (Physician) documents R2 was seen in the facility for increased weight gain of approximately 20-30 pounds over the past few months, eating a lot of junk food and will not do anything for herself or keep her legs elevated. Weight on 07/12/19 was 435 pounds. (The Facility Weight Log documents 437 pounds on 07/12/19.) R2 has 3-4+ [MEDICAL CONDITION] of both lower extremities with [DIAGNOSES REDACTED] of skin and few areas of weeping and water blister formation. Chronic Venous Stasis changes of both legs. Assessment: 1. [MEDICAL CONDITION] 2. Bilateral Lower Extremity [MEDICAL CONDITION] 3. Weight Gain. Currently on [MEDICATION NAME] 20 milligrams (mg) 1.5 tablets orally (po) daily for total dosing of 30mg/day. V5's Treatment Plan included an increase in R2's [MEDICATION NAME] to 30mg two times (bid) po for 5 days (total dosing of 60mg/day), then back down to 40mg po daily (on 7/17/19). The 07/12/19 Electronic Medication Administration Record (MAR) History documents R2 was given the increased dose of [MEDICATION NAME] 30mg bid from 07/12/19 - 07/16/19, and was given the decreased [MEDICATION NAME] does of 40mg daily on 7/17/19 as per V5's order, however the [MEDICATION NAME] 40mg daily dose was not given on 07/18/19, 07/19/19 and 07/20/19. The MAR documents a start date on 7/21/19 for [MEDICATION NAME] 20mg, 2 tablets, po daily (40mg total) and was given that morning. The Facility's (July 2014) Obtaining and Following Physician order [REDACTED]. When it is discovered that a physician's orders [REDACTED]. On 08/01/19 at 11:45am, V2 (Director of Nurses) stated V15 (Licensed Practical Nurse/LPN) edited the 07/17/19 [MEDICATION NAME] order incorrectly on the MAR. V2 stated this resulted in R2 not receiving the ordered [MEDICATION NAME] for 3 days, 07/18/19 - 07/20/19. V2 stated, on 07/21/19, V15 realized the [MEDICATION NAME] was not on R2's MAR, and that is when V15 placed the order back on the MAR and resumed the correct daily dose. V2 stated if a medication error has been made, the nurse is to fill out a Medication Error Report and notify the physician and V2. V2 stated V15 did not fill out this Report or notify V15 or V2. On 08/01/19 at 3:45pm, V5 (Physician) stated the facility should have given R2 the [MEDICATION NAME] per his orders.

Based on interview and record review, the facility failed to follow physician orders for 1 of 3 residents (R2) reviewed for physician's orders in the sample of 13. Findings include: R2's Electronic Medical Record documents R2 was admitted to the facility on [DATE] with a weight of 379 pounds. R2 has [DIAGNOSES REDACTED]. The July, 2019 Physician's Orders state R2 is on continuous oxygen per nasal cannual at 2-4 liters/minute to maintain oxygen saturation at 92%. The 07/05/19 Minimum Data Set (MDS) documents R2 has a Brief Interview for Mental Status of 15, which indicates R2 is cognitively intact. The MDS documents R2 requires extensive assistance of one person for bed mobility and transfers. The 07/12/19 Progress Note per V5 (Physician) documents R2 was seen in the facility for increased weight gain of approximately 20-30 pounds over the past few months in addition to dietary and medical non-compliance. R2 has 3-4+ [MEDICAL CONDITION] of both lower extremities with [DIAGNOSES REDACTED] of skin and a few areas of weeping and water blister formation. V5's Treatment Plan on 07/12/19 included an increase in R2's [MEDICATION NAME] to 30mg two times (bid) po (orally) daily for 5 days, then to back down to 40mg po daily (on 7/17/19) with a Complete Metabolic Panel (CMP) to be drawn in 7 days. The 07/12/19 Electronic Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On 08/01/19 at 11:45am, V2 (Director of Nurses) stated V15 (Licensed Practical Nurse/LPN) edited the 07/17/19 [MEDICATION NAME] order incorrectly on the MAR. V2 stated this resulted in the [MEDICATION NAME] not being given to R2 for 3 days, 07/18/19 - 07/20/19. V2 stated, on 07/21/19, V15 realized the [MEDICATION NAME] was not on R2's MAR. V2 stated V15 then placed the order back on the MAR for the ordered [MEDICATION NAME] 20mg, 2 tabs, po daily. V2 stated if a medication error has been made, the nurse is to fill out a Medication Error Report and notify the physician and V2. V2 stated V15 did not fill out this Report or notify V15 or V2. In addition, V2 stated an order was sent to the laboratory on 07/12/19 requesting the CMP to be drawn on R2 on 07/17/19. V2 stated the CMP was not drawn, and she is speaking with the laboratory to find out what caused this error. V2 stated the nurses keep a paper record that details what labs need to be done and on what day. V2 stated the nurses are to verify each day that these labs are drawn, but R2's CMP was missed. The Facility's (July 2014) Obtaining and Following Physician Orders policy states, Procedure: .10. When it is discovered that a physician's order was not implemented, the nurse shall immediately notify the physician of this failure and document the omission on an accident and incident form. On 08/01/19 at 3:45pm, V5 (Physician) stated the facility should have given R2 the [MEDICATION NAME] per his orders and should have drawn the CMP.

Based on observation, record review, and interview, the facility failed to accurately assess residents for the appropriateness of side rails and to obtain consents for side rail use for three of three residents (R57, R26, and R16) reviewed for side rails in the sample of 41. Findings include: 1. On 05/10/18 at 10:00am, V8, Certified Nursing Assistant (CNA), and V7, Registered Nurse, were observed providing incontinence care for R57. After the perineal cleansing was completed, V8 raised R57's half side rails on both sides of the bed. V8 stated staff usually put R57's rails up so that she can use them to reposition herself. R57 used the side rails to roll to the side of the bed so that V8 could change her incontinence pad. After care was completed, V8 left the side rails up and exited the room. R57's electronic Physicians Orders did not document a physicians order for side rail use. 05/02/18 Minimum Data Set documented a Brief Interview for Mental Status Score of 7, indicating R57 is moderately cognitively impaired. R57's Side Rail assessment dated [DATE] completed by V3, Minimum Data Set Coordinator, documented, This screening tool assists to identify the need for side rail use. Specify reason for use: N/A (Not applicable). Specify interventions to minimize the risk of injury when side rails ARE indicated: N/A. Resident/family in agreement with side rail decisions and understands the benefits and risks: No-No side rails. On 05/10/18 at 11:00am, V3, stated she did not realize R57 was using side rails for positioning and stated she would need to update R57's assessment to reflect side rail use. V3 stated that a consent for side rail use had not been obtained from R57's POA (Power of Attorney) but she would obtain one as soon as possible. On 05/10/18 at 2:00pm, V3 presented a Side Rail Consent dated 05/10/18 at 11:18am documenting that V12, R57's POA had given verbal consent for side rail use. On 05/11/18 R57's Physicians Orders had been updated with an order for [REDACTED].>2. On 05/10/18 at 1:45pm, V5 and V6, Both CNA's, were observed providing catheter care for R26. After the care was provided, V5 raised R26's half side rails on both sides of the bed and left the room. R26's electronic current Physicians Orders did not document an order for [REDACTED]. Specify reason for use: N/A(Not applicable). Specify interventions to minimize the risk of injury when side rails ARE indicated: N/A. Resident/family in agreement with side rail decisions and understands the benefits and risks: No-No side rails. On 05/10/18 at 3:15pm, V3 stated she did not realize staff were using side rails for R26, and stated she would need to update R26's assessment to reflect side rail use and to get consent from R26's POA. On 05/11/18 at 9:00am, V3 presented a Side Rail Consent dated 05/11/18 at 8:45am documenting that V13, R26's POA had given verbal consent for side rail use. On 05/11/18 R26's Physicians Orders had been updated with an order for [REDACTED].> 3. On 5/08/2018 at 10:13 am, R16 was resting in bed with quarter-length side rails up on each side of the bed. These side rails were in the up position on 5/10/18, at 3:10 pm, and 5/11/18 at 8:00 am. On 5/11/18, at 9:00 am, when asked about the use of side rails for R16, V11, CNA stated that, once in awhile R16 might reach over and grab the side rail, when staff is assisting her with care, such as helping her to dress. R16's Minimum Data Set of 3/6/2018 indicates that R16 requires extensive assistance of 2 staff for bed mobility and transfers. A document titled Assessment-Side Rail and dated 3/7/2018, indicates that side rails are not indicated and the reason for this decision is checked as Minimize injury caused by attempts to get out of bed unassisted, and that there is no potential risk involved with the non-use of side rails. R16's physician's orders [REDACTED].>On 5/11/18 at 9:44 am, V3, Care Plan and Minimum Data Set Coordinator, stated that R16 should not have side rails up.

Based on interview and record review the facility failed to follow their abuse policy and procedure and investigate an allegation of abuse for one (R4) of 3 residents reviewed for abuse in the sample of 15, and three residents in the supplemental sample. Findings Include: R4's Daily Skilled Nurse's Note dated 3/26/17 and done by E3, LPN (Licensed Practical Nurse), documents the following: Late Entry, 2-10 PM, Resident up in wheelchair, complains of being treated bad at [MEDICAL TREATMENT] yesterday. and She (R4) also states they were yelling at her to hold her arm still, very rudely. R4 states she would like to have [MEDICAL TREATMENT] at another facility. Director of Nursing notified. On 4/20/17, E2 DON (Director of Nursing) stated the only thing she was made aware of was that R4 would like to go to a different [MEDICAL TREATMENT] center, and was not made aware of any allegations of mistreatment. On 4/20/17, E1 (Administrator) stated she had not been made aware of R4's allegation of being treated badly at [MEDICAL TREATMENT] or that [MEDICAL TREATMENT] staff had been yelling at her. E1 stated this would be considered an allegation of abuse and E3 LPN should have made her aware of it immediately. E1 stated she is the abuse coordinator and she should have been made aware of R4's allegation and an investigation should have been started at that time. The facility policy titled Abuse Prevention Program) dated December 16, 2016 shows under 5. Internal Reporting Requirements and Identification of Allegation: Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. Supervisors shall immediately inform administrator of all reports of incidents, allegations, or suspicions of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate an incident investigation. Under 8. External Reporting of Potential Abuse: Initial reporting of allegations-In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a.) ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of property are reported immediately or not later than 24 hours to the State Survey Agency, and under d.) Five day final abuse investigation report will be sent to the Department of Public Health.

Based on interview and record review the facility failed to implement their abuse policy and procedure for one (R4) of three residents reviewed for abuse in the sample of 15, and three residents in the supplemental sample. Findings Include: R4's Daily Skilled Nurse's Note dated 3/26/17 and done by E3 LPN (Licensed Practical Nurse) documents the following: Late Entry, 2-10 PM, Resident up in wheelchair, complains of being treated bad at [MEDICAL TREATMENT] yesterday. and She (R4) also states they were yelling at her to hold her arm still, very rudely. R4 states she would like to have [MEDICAL TREATMENT] at another facility. Director of Nursing notified. On 4/20/17, E2 DON (Director of Nursing) stated the only thing she was made aware of was that R4 would like to go to a different [MEDICAL TREATMENT] and was not made aware of any allegations of mistreatment. On 4/20/17, E1 (Administrator) stated she had not been made aware of R4's allegation of being treated badly at [MEDICAL TREATMENT], or that [MEDICAL TREATMENT] staff had been yelling at her. E1 stated this would be considered an allegation of abuse and E3 LPN should have made her aware of it immediately. E1 stated she is the abuse coordinator and she should have been made aware of R4's allegation, and an investigation should have been started at that time. The facility policy titled Abuse Prevention Program dated December 16, 2016 shows under #5. Internal Reporting Requirements and Identification of Allegation: Employees are required to report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect immediately to the administrator. Supervisors shall immediately inform administrator of all reports of incidents, allegations, or suspicions of potential abuse, neglect, or misappropriation of property. Upon learning of the report, the administrator shall initiate and incident investigation. Under 8. External Reporting of Potential Abuse: Initial reporting of allegations-In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: a.) ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin and misappropriation of property are reported immediately or not later than 24 hours to the State Survey Agency, and under d.) Five day final abuse investigation report will be sent to the Department of Public Health.

Based on interview and record review, the facility failed to monitor behavioral symptoms of depression and ensure social services were provided for one (R4) of seven residents reviewed for depressive symptoms in the sample of 15. Findings Include: R4's POS (Physicians Order Sheet) for period of April 1, 2017 to April 30, 2017 shows R4 has a [DIAGNOSES REDACTED]. R4 also has orders on the same POS for anti-depression medication Duloxetine 60 mg - take one capsule by mouth every morning every morning that is also used for depression. Review of R4's chart shows no documentation of behavior monitoring sheets. However, R4's Daily skilled Nurse's Note dated 4-15-17 documents R4 very depressed this evening. One to one and she seemed to be more cheerful after the visit. R4 says she just gets to thinking about things and gets self all upset. On 4/20/17 at 10:40 AM, E4 (Social Service Director) stated she had not been made aware of R4 voicing issues with depression. E4 stated if she had been made aware, she would have talked to R4 one to one and tried to find out if there was any specific reason for the voiced depression in order to proceed with interventions and treatments for her, as well as follow up and track her behaviors. R4's Care Conference documents an admitted [DATE], and under approaches shows - Anti-depressant: monitor R4 at the start and throughout therapy for any signs of clinical worsening, suicidal ideation, or unusual changes in behavior. R4 also is to have behavior tracking per policy. On 4/19/17 at 10:00 AM, E2 (Director of Nursing) stated she could not find any behavior tracking sheets for R4, and that she had looked last night and again this morning and there were none. On 4/20/17 at 4:20 PM E4 SSD (Social Service Director) stated behavior tracking is done on any resident that is on any psychotropic medication. E4 confirmed this would include anti-depressants. E4 stated she usually started the behavior tracking sheets. When E4 was asked why no behavior sheets were done for R4, E4 stated she had not realized R4 was taking anti-depressant medications.

Based on observation, interview, and record review the facility failed to ensure proper positioning of an indwelling urinary catheter, and failed to follow accepted protocols for urinary catheter care for one (R2) of eight residents reviewed for indwelling urinary catheters and incontinence care in the sample of 15. Findings include: The facility's policy titled Catheter Care, Urinary dated July 2014 shows the purpose of this procedure is to prevent catheter-associated urinary tract infection. This policy goes on to say the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. This same policy shows, be sure the catheter tubing and bag are kept off the floor. This same policy shows, be sure the catheter tubing and bag are kept off the floor. On the following days, 4/18/17, 4/19/17, and 4/20/17 on several occasions it was noted that R2's urinary drainage bag was hooked to the arm of her reclining chair putting the urinary bag above the residents bladder. On 4/18/17 at 8:00 AM, 10:30 AM and 1:00 PM, R2's indwelling catheter tubing was noted on the floor. On 4/19/17 at 11:00 AM R2's indwelling catheter tubing was again noted on the floor. On 4/18/17 at 10:35 AM, and on 4/19/17 at 2:15 PM, R2 had no anchor on her catheter to prevent injuries. On 4/20/17 at 9:50 AM, E2 DON (Director of Nursing) stated anchors are to be used with anyone that has a catheter, and the bag and tubing should be kept below the residents bladder. E2 also stated that residents' bag or tubing should not be on the floor due to infection control issues. The facility policy titled Perineal Care dated December 2016 documents the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. This policy goes on to say when washing perineal area, wipe front to back and wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttock. On 4/18/17 at 10:35 AM, E5 and E10 CNA's(Certified Nursing Assistants) were providing perineal care to R2 after being incontinent of bowel. During this procedure, it was noted that E10 wiped feces off of R2 from rectum to labia instead of labia to rectum. On 4/20/17 at 9:50 AM, E2 stated when providing incontinence care to residents, staff should be wiping front to back or basically clean to dirty, which would be from the vaginal area to the buttock area if they were doing incontinent care on the backside of the resident.

Based on interview and record review, the facility failed to implement behavior tracking to ensure adequate monitoring of depressive symptoms for one (R4) of seven residents reviewed for depressive symptoms in the sample of 15. Findings include: R4's POS (Physicians Order Sheet) for period of April 1, 2017 to April 30, 2017 shows R4 has a [DIAGNOSES REDACTED]. R4 also has orders on the same POS for anti-depression medication Duloxetine 60 mg - take one capsule by mouth every morning every morning. Review of R4's chart shows no documentation of behavior monitoring sheets. However, R4's Daily skilled Nurse's Note dated 4-15-17 shows R4 very depressed this evening. One to one and she seemed to be more cheerful after the visit. R4 says she just gets to thinking about things and gets self all upset. On 4/20/17 at 10:40 AM, E4 (Social Service Director) stated she had not been made aware of R4 voicing issues with depression. E4 stated if she had been made aware she would have talked to R4 one to one and tried to find out if there was any specific reason for the voiced depression in order to proceed with interventions and treatments for her, as well as follow up and track her behaviors. R4's Care Conference documents an admission date of [DATE], and under approaches shows - Anti-depressant: monitor R4 at the start and throughout therapy for any signs of clinical worsening, suicidal ideation, or unusual changes in behavior. R4 also is to have behavior tracking per policy. On 4/19/17 at 10:00 AM, E2 (Director of Nursing) stated she could not find any behavior tracking sheets for R4 and that she had looked last night and again this morning, and there were none. On 4/20/17 at 4:20 PM, E4 SSD (Social Service Director) stated behavior tracking is done on any resident that is on any [MEDICAL CONDITION] medication. E4 confirmed this would include anti-depressants. E4 stated she usually started the behavior tracking sheets. When E4 was asked why no behavior sheets were done for R4, E4 stated she had not realized R4 was taking any anti-depressant medication.

Based on observation, interview and record review the facility failed to follow identified care plan approaches for two (R3, R4) of 15 residents reviewed for Care Plans in the sample of 15. Finding include: 1.) R4's Care Conference documents an admission date of [DATE], and under approaches shows - Anti-depressant: monitor R4 at the start and throughout therapy for any signs of clinical worsening, suicidal ideation, or unusual changes in behavior. R4 also is to have behavior tracking per policy. On 4/19/17 at 10:00 AM, E2 (Director of Nursing) stated she could not find any behavior tracking sheets for R4, and that she had looked last night and again this morning and there were none. On 4/20/17 at 4:20 PM E4 SSD (Social Service Director) stated behavior tracking is done on any resident that is on any [MEDICAL CONDITION] medication. E4 confirmed this would include anti-depressants. E4 stated she usually started the behavior tracking sheets. When E4 was asked why no behavior sheets were done for R4, E4 stated she had not realized R4 was taking anti-depressant medications. 2.) R3's Care Plan dated 3/14/16 shows an intervention to free float heels. On 4/18/17 at 9:31 AM, R3 was observed in bed without her heels free floating.

Based on interview, and record review, the facility failed to prevent an injury from an improper transfer for one of three residents (R2) reviewed for improper technique during a transfer in the sample of three. These failures resulted in R2 being transferred to a local hospital for surgical repair of a right fractured femur. Findings include: 1. On 10-15-14 at 5:35 PM E7 (Certified Nurse Aide) stated in September, 2014, she got between R2 and the car door to assist in transferring R2 from her wheelchair into the family car. E7 stated she did not use a gait belt during the transfer, nor did she get another staff person to assist her with the transfer. E7 stated she put her arms around R2's waist and held onto her pants during the transfer. R2's foot got caught in the wheel chair wheel, and I heard a pop. R2 did not fall. R2's incident and accident report dated 09-05-14 at 6:00 PM indicates: Certified Nurse Aide transferring resident from wheelchair to family car. Resident right foot caught under left wheel of wheelchair during transfer and resident complained of pain to right leg. Investigation results: Noted fracture right femur sent to local hospital for admit, ortho consult, ongoing per ortho results and possible surgical outcome. R2 was readmitted to the facility on [DATE] according to the Nursing Evaluation, which indicates a [DIAGNOSES REDACTED]. R2's skin condition is documented as having surgical area to right thigh with six staples, right knee area posterior -two areas with staples each with four staples, one area to anterior with four staples, incision mid of knee with fourteen staples. R2's Minimum (MDS) data set [DATE] indicates in Section G0110. B. Transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from toilet) to need extensive assistance of two plus persons physical assist. The facility's policy and procedure with a revision date of February, 2012 indicates: Gait Belt Use--Policy--It is the policy of Helia Healthcare that gait belts will be used when staff are transferring weight bearing residents or assisting them with walking for the safety of the resident or the employee.

Based on interviews, observations and record review, the facility failed to immediately start an abuse investigation after administrative staff received a report of staff raising a resident's (R3) leg up high and with enough force to cause the resident who was seated in a wheelchair with a seatbelt on to fall backwards, hit head on the floor, and receive an [MEDICAL CONDITION] with Subarachnoid Hemorrhage which resulted in the resident death. The facility staff failed to immediately report the incident of alleged physical abuse to the Administrator. The facility staff failed to notify law enforcement and the state agency regarding the alleged physical abuse. The facility also failed to thoroughly screen potential employees, train current employees, and failed to protect all residents by allowing the staff involved to continue to work two more midnight shifts. These failures resulted in 70 in-house residents being at risk of potential abuse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 09-26-13, the facility remains out of compliance at a Severity Level 2 as the facility continues to educate staff on the reporting and investigation requirements for allegations of abuse and evaluate the effectiveness of their education regarding these requirements. The findings include: On 09-24-13, the facility indicated an in-house census of 70 residents on the Facility Data Sheet. E4, Certified Nurses Aide, wrote a statement dated 09-23-13 that states on Saturday, September 21, 2013 at approximately 4:30 am, E4 put R3 in her wheel chair and secured her safety belt and locked the wheelchair. E6, Licensed Practical Nurse, tried to look at R3's dressing on her toes and R3 started kicking at him. E6 was observed to grab R3's leg in a rough and abrupt manner, jerk her leg up to her eye level, flipping R3 backwards in her wheel chair and causing R3's head to hit the floor with a sound "like a baseball bat hitting a ball of a grand slam". Also, E4 wrote a seven page letter addressed to E1, Administrator and left it for E1 to read on 09-23-13. This letter states that E6, Licensed Practical Nurse, was in a "very bad mood" during his midnight shift (10 PM to 6 AM) on 09-21-13. E4 describes in this letter that E6's rough and abrupt actions caused R3 to fall backwards onto the floor in her wheel chair. Also, E4 wrote that E4 spoke with E3, Certified Nurse Aide Supervisor,several times and was told to write in her statement everything before and after the incident of 09-21-13. E4 stated she also spoke to E2, Director of Nurses, who told E4 to "only write what happened in the room and I shouldn't (should not) use words in the report like her leg was lifted rough or abruptly" and E4 should report only "that he lifted her leg and the chair tipped over". E4 was interviewed by phone on 09-25-13 at 2:40 PM. During this interview, E4 stated that "E6 reached for R3's foot and jerked her leg up high. R3's leg came up to R3's eye level and the chair tipped over." E4 said "The noise was so loud, it sounded like a bat hitting something." When asked when E2, Director of Nurses, was notified, E4 stated that "E6 called E2 after the incident happened." E4 also stated that "E7 called E4 sometime between 7:30 am and 9:30 am. E4 told E7 during this phone call that E6 grabbed R3's leg and it was pulled above her head causing the wheel chair to tip backwards." E4 stated "around 10am on 09-21-13, E4 talked to E2 and told her what happened." E4 stated during this interview that "E2 told her E2 would investigate the incident and E2 would also contact E1, Administrator. E2 stated she also sent a text message to E3 after the conversation with E2 and told her what happened." E7 was interviewed by phone on 09-27-13 at 12:20pm and stated that later the morning of 09-21-13, E4 did tell her "I need to tell you something, there was more that happened in that room. There is more to it." E7 stated that she told E4, "You have to report and tell the truth." E2 stated on 09-25-13 at 10:15 am that she was notified that R3 had fallen and was sent to the emergency room at approximately 4:40 am on 09-21-13 but she did not start an investigation of the incident until 09-23-13. E2, Director of Nurses, wrote a statement dated 09-21-13 at 4:40 am that she received a call from E6, Licensed Practical Nurse, and stated that he was getting ready to send R3 to the hospital due to a possible head injury. E2 stated that E6 leaned down to secure the bandage to R3's foot and had raised her leg up to observe the dressing. R3 was agitated and was kicking at him. E6 stated that the next thing E6 knew the resident was tipping backwards in the chair. On 09-26-13 at 11:30 am, E2 stated that no one mentioned rough or unusual treatment to her so she did not think she needed to start an abuse investigation. E2 stated that an abuse investigation was started on 09-23-13 when she read a statement by E4 stating that E6 was rough with R3. E2 stated she did not think this incident was suspicious or unusual. E1 was interviewed at 10:10 am on 09-25-13 and stated that he was notified on 09-21-13 sometime in the morning (exact time unknown) that R3 had fallen but did not have any idea that E4 thought it was because of a rough act by E6. E1 verified that they did not start an investigation until 09-23-13 at 8:15 am. Review of the employee file for E6, Licensed Practical Nurse, documents that E6 was hired on 05-11-12 and did not have a background check completed and his facility Telephone Reference Check Form only had his name on it with no other information completed. The Illinois Department of Financial and Professional Regulations (IDFPR) license look up information was not found. E1, Administrator stated during an interview on 09-16-13 at 6:50 PM that the IDFPR license look up information was found. The information for E6 documents that E6 had been disciplined with a suspension from 03-05-1993 to 06-04-1993 for "Alleged mistreatment residents" and Probation from 06-05-1993 to 06-04-1995 for "Alleged mistreatment residents". E1 and E2, Director of Nurses stated they did not know of this disciplinary action on E6's Licensed Practical Nurse license. Review of the facility employee inservice educations information documents that the most recent staff abuse inservice is dated 07-26-13 and documents that the facility reviewed the full abuse policy and procedure . Of the 25 Certified Nurse Aides who were hired before the date of this inservice, 18 (E4,E5, E9 - E26 ) did not attended this inservice. Of the 9 Registered Nurses and Licensed Practical Nurses that were employees before the date of the inservice, 6 nurses (E6, E7, E27-E30) did not attend the inservice. E4, Certified Nurses Aide ,E5, Certified Nurses Aide, E6, Licensed Practical Nurse, and E7, Licensed Practical Nurse (all who had some involvement in this incident) did not receive the abuse policy and procedure training according to the attached inservice. This training material included appropriate interventions to deal with aggressive and or catastrophic reactions of residents. E4 stated during an interview on 09-26-13 at 12:50 pm that she did miss the last abuse inservice about two months ago. E5 stated during an interview on 09-26-13 at 2:55pm that she had training while in school and that at one time at this facility they had abuse inservice every other pay day but it would be good to offer training during midnight shift. E2 stated on 09-25-13 at 10:15 am that E6 worked midnights on 09-21-13 and 09-22-13, the two days following the incident. The facility Nursing Schedule for September 8th - 21st, 2013 and September 22nd - October 5, 2013, documents that E6 worked midnights on 09-21-13 and 09-22-13 after R3's fall and E4's allegations against E6 were made known. Review of the Regional Illinois Department of Public Health incident and accident file for this facility did not indicate that an incident report or a notice of an allegation of abuse by E6 to R3 had been initiated. On 09-25-13 at 1:15 PM, E1 stated that an incident report was completed and faxed on 09-21-13 at 12:16 PM. E1 then stated that the fax did not go through and produced a "Fax Error Report" for this incident dated 09-21-13 at 12:16 PM. Also, E1 stated during a 09-26-13 at 7:15 pm interview that he did not re-send this incident report nor did they send a notification of allegation of abuse involving R3's fall on 09-21-13. E1 was observed sending by fax the notification of the 09-21-13 incident and the notification of the abuse investigation concerning this incident at 7:25pm on 09-26-13 to Public Health. E1 also stated during this interview that law enforcement was not notified. The final facility abuse investigation of this 09-21-13 abuse allegation involving R3 has not been received as of 10-02-13. E1, Administrator and E2, Director of Nurses, were notified of the Immediate Jeopardy on 09-26-13 at 2:50 PM. The Immediate Jeopardy was determined to have begun on 09-21-13 at 4:45 am when staff failed to identify abuse by investigation of unusual and/or suspicious incidents, protect all residents from abuse by immediately barring an alleged perpetrator from residents, immediately notify the Administrator of an allegation of abuse, appropriately screen all potential staff, inservice all staff, and require attendance at inservice training on abuse, and report all allegations of abuse to the state agency and local law enforcement as required regarding abuse allegations. This was after E7 received a report of E6 raising a resident's (R3) leg up high and with enough force to cause the resident who was seated in a wheelchair with a seatbelt on to fall backwards, hit head on the floor, and receive an [MEDICAL CONDITION] with Subarachnoid Hemorrhage according to reports received from the local hospital dated 09-21-13 which resulted in the resident death. The surveyor confirmed by record review and interview that the facility took the following actions to remove the Immediate Jeopardy. A. An investigation was initiated on 09-23-13 at 8:15am after E1 read a statement from E4 concerning the roughness of E6 to R3 on 09-21-13. This investigation will include interviews of interviewable residents and all employees to ensure no other episodes of abuse has occurred that the facility is unaware of. B. The alleged perpetrator, E6 was suspended pending outcome of the investigation on 09-23-13 at 8:15am. C. On 09-26-13 and 09-27-13, the facility has audited all employee files to ensure that all employees are educated and compliant with the facilities abuse policy and the state and federal guidelines. D. On 09-26-13 and 09-27-13 all staff have been in-serviced on the facility's policy and procedure for abuse as well as the 1150B of the Social Security Act, all new hires will be in-serviced by the Abuse Coordinator on or before their hire date. E. On 09-26-13 and 09-27-13 audits of pre-employment requirements for all staff were completed. Any staff with issues concerning background checks, registry checks, or recently hired employee reference checks were rectified. F. On 09-26-13 at 7:25pm, the facility faxed the 09-21-13 incident report to Public Health and changed the fall investigation to an abuse investigation. G. As of 09-27-13 the facility will do quarterly in-servicing on policy and procedure for Abuse as well as the 1150B of the Social Security Act as a quality measure to ensure that staff is refreshed on the importance of the policies for abuse and immediate reporting. H. As of 09-27-13 through the facility's Quality Assurance process, Medical Records/or designee will ensure all new hires are in compliance with the facility's pre-employment policy, the abuse policy, state and federal guidelines, and the 1150B of the Social Security Act and every attempt to obtain reference checks are met with these policies. I. As of 10-01-13, the facility will initiate random audits/questioning of staff on the abuse policy and procedures and 1150B of the Social Security Act. There will be 8 staff members audited during each quarter beginning October, 2013.

Based on interview, observations and record review, the facility failed to implement the facility abuse prohibition policy to ensure that all allegations of abuse were immediately reported to the state agency, law enforcement, and administrator and investigated timely. In addition, the facility failed to ensure that all staff, including supervisory staff and the Administration were effectively trained in abuse investigation, reporting requirements, and appropriate interventions to deal with aggressive and/or catastrophic reactions. The facility failed to suspend an alleged perpetrator after an allegation was received and the facility also failed to screen their employees according to the facility policy. These failures resulted in 70 in-house residents being put at risk of potential abuse as a result of the facility staff not following their policy related to reporting potential abuse, investigating potential abuse, protecting residents, and screening potential staff. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 09-26-13, the facility remains out of compliance at a Severity Level 2 while the facility continues to educate all staff, audit current staff files, implement a fail safe mechanism to screen potential employees and evaluate the effectiveness of their interventions regarding the requirements for allegations of abuse . The findings include: 1. The facility policy titled "Abuse, Prevention and Prohibition Of" with a revision date of July 2011, documents in this policy under Screening "The facility will not knowingly employ individuals who have been found guilty of abusing, neglecting or mistreating residents or misappropriating their properties. A person at a supervisory level will interview potential employees. All employees will have criminal background checks, state and federal required checks, employment reference checks (previous and current), and license/certification confirmation.. The facility will make reasonable efforts to uncover information about any past criminal prosecutions." Review of the employee file for E6, Licensed Practical Nurse, documents that E6 was hired on 05-11-12 and did not have a background check completed and his facility Telephone Reference Check Form only had his name on it with no other information completed. The Illinois Department of Financial and Professional Regulations (IDFPR) license look up information was not found. E1, Administrator stated during an interview on 09-16-13 at 6:50 PM that the IDFPR license look up information was found. The information for E6 documents that E6 had been disciplined with a suspension from 03-05-1993 to 06-04-1993 for "Alleged mistreatment residents" and Probation from 06-05-1993 to 06-04-1995 for "Alleged mistreatment residents". E1 and E2, Director of Nurses stated they did not know of this disciplinary action on E6's Licensed Practical Nurse license. 2. The facility policy titled "Abuse, Prevention and Prohibition Of" with a revision date of July 2011, documents in this policy under Training: "Facility staff shall be trained on the abuse prohibition program during orientation, annually, and ongoing during educational sessions......Additional In-services shall include: Appropriate interventions to deal with aggressive and or catastrophic reactions of residents. (Catastrophic reactions are defined as reactions or mood changes of a resident in response to what may seem to be minimal stimuli." Review of the facility employee inservice education information documents that the most recent staff abuse inservice is dated 07-26-13 and documents that the facility reviewed the full abuse policy and procedure. Of the 25 Certified Nurse Aides who were hired before the date of the in-service, 18 (E4, E5, E9-E26) did not attended this inservice. Of the 9 Registered Nurses and Licensed Practical Nurses that were employees before the date of the in-service, 6 nurses (E6, E7, E27-E30) did not attend the inservice. E4, Certified Nurses Aide, E5, Certified Nurses Aide, , E6, Licensed Practical Nurse, and E7, Licensed Practical Nurse (all who had some involvement in this incident) did not receive the abuse policy and procedure training according to the attached inservice. This training material included appropriate interventions to deal with aggressive and or catastrophic reactions of residents. E4 stated during an interview on 09-26-13 at 12:50 pm that she did miss the last abuse inservice about two months ago. E5 stated during an interview on 09-26-13 at 2:55pm that she had training while in school and that at one time at this facility they had abuse inservice every other pay day but it would be good to offer training during midnight shift. 3. The facility policy titled "Abuse, Prevention and Prohibition of" with a revision date of July 2011, documents in this policy under Identification: "Upon report of such abnormalities of suspicious injuries (black eyes, rope marks, cigarette burns) the Director of Nursing is responsible for their evaluation and assessment....An abuse investigation may also be conducted based on the investigation findings." E2, Director of Nurses, wrote a statement dated 09-21-13 at 4:40 am that she received a call from E6, Licensed Practical Nurse, and stated that he was getting ready to send R3 to the hospital due to a possible head injury. E2 stated in this statement that E6 leaned down to secure the bandage to R3's foot and had raised her leg up to observe the dressing. R3 was agitated and was kicking at him. E6 stated that the next thing E6 knew the resident was tipping backwards in the chair. On 09-26-13 at 11:30 am, E2 stated that no one mentioned rough or unusual treatment to her so she did not think she needed to start an abuse investigation. E2 stated that an abuse investigation was started on 09-23-13 when she read a statement by E4 stating E6 was rough with R3. E2 stated she did not think this incident was suspicious or unusual. 4. The facility policy titled "Abuse, Prevention and Prohibition of" with a revision date of July, 2011, documents in this policy under Investigation: "Resident abuse must be reported immediately to the Administrator." E4, Certified Nurses Aide, wrote a statement dated 09-23-13 that states on Saturday, September 21, 2013 at approximately 4:30 am, E4 put R3 in her wheel chair and secured her safety belt and locked the wheelchair. E6, Licensed Practical Nurse, tried to look at R3's dressing on her toes and R3 started kicking at him. E6 was observed to grab R3's leg in a rough and abrupt manner, jerk her leg up to her eye level, flipping R3 backwards in her wheel chair and causing R3's head to hit the floor with a sound "like a baseball bat hitting a ball of a grand slam". Also, E4 wrote a seven page letter addressed to E1, Administrator and left it for E1 to read on 09-23-13. This letter states that E6, Licensed Practical Nurse, was in a "very bad mood" during his midnight shift (10 PM to 6 AM) on 09-21-13. E4 describes in this letter that E6's rough and abrupt actions caused R3 to fall backwards onto the floor in her wheel chair. Also, E4 wrote that E4 spoke with E3, Certified Nurse Aide Supervisor,several times and was told to write in her statement everything before and after the incident of 09-21-13. E4 stated she also spoke to E2, Director of Nurses, who told E4 to "only write what happened in the room and I shouldn't (should not) use words in the report like her leg was lifted rough or abruptly" and E4 should report only "that he lifted her leg and the chair tipped over". E4 was interviewed by phone on 09-25-13 at 2:40 PM. During this interview, E4 stated that "E6 reached for R3's foot and jerked her leg up high. R3's leg came up to R3's eye level and the chair tipped over." E4 said "The noise was so loud, it sounded like a bat hitting something." When asked when E2, Director of Nurses, was notified, E4 stated that "E6 called E2 after the incident happened." E4 also stated that "E7 called E4 sometime between 7:30 am and 9:30 am. E4 told E7 during this phone call that E6 grabbed R3's leg and it was pulled above her head causing the wheel chair to tip backwards." E4 stated "around 10am on 09-21-13, E4 talked to E2 and told her what happened." E4 stated during this interview that "E2 told her E2 would investigate the incident and E2 would also contact E1, Administrator. E2 stated she also sent a text message to E3 after the conversation with E2 and told her what happened." E7 was interviewed by phone on 09-27-13 at 12:20pm and stated that later the morning of 09-21-13, E4 did tell her "I need to tell you something, there was more that happened in that room. There is more to it." E7 stated that she told E4, "You have to report and tell the truth." E2 stated on 09-25-13 at 10:15 am that she was notified that R3 had fallen and was sent to the emergency room at approximately 4:40 am on 09-21-13 but she did not start an investigation of the incident until 09-23-13. E2, Director of Nurses, wrote a statement dated 09-21-13 at 4:40 am that she received a call from E6, Licensed Practical Nurse, and stated that he was getting ready to send R3 to the hospital due to a possible head injury. E2 stated that E6 leaned down to secure the bandage to R3's foot and had raised her leg up to observe the dressing. R3 was agitated and was kicking at him. E6 stated that the next thing E6 knew the resident was tipping backwards in the chair. On 09-26-13 at 11:30 am, E2 stated that no one mentioned rough or unusual treatment to her so she did not think she needed to start an abuse investigation. E2 stated that an abuse investigations was started on 09-23-13 when she read a statement by E4 stating that E6 was rough with R3. E2 stated she did not think this incident was suspicious or unusual. E1 was interviewed at 10:10 am on 09-25-13 and stated that he was notified on 09-21-13 sometime in the morning (exact time unknown)that R3 had fallen but did not have any idea that E4 thought it was because of a rough act by E6. E1 verified that they did not start an investigation until 09-23-13 at 8:15 am. 5. The facility policy titled "Abuse, Prevention and Prohibition of" with a revision date of July, 2011, documents in this policy under Protection: "If a person is identified in the allegation of abuse, that person will not be allowed access to the facility while the investigation is in progress." E2 stated on 09-25-13 at 10:15 am that E6 worked midnights on 09-21-13 and 09-22-13, the two days following the incident. The facility Nursing Schedule for September 8th - 21st, 2013 and September 22nd - October 5, 2013, documents that E6 worked midnights on 09-21-13 and 09-22-13 after R3's 09-21-13 at 4:30 am fall and E4's allegations against E6 were made. 6. The facility policy titled "Abuse, Prevention and Prohibition of" with a revision date of July, 2011, documents in this policy under Reporting/Response: "The facility employee or agent who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility Administrator and /or the Director of Nursing." and "The facility Administrator, employee, or agent who has reasonable cause to believe any resident with whom they have direct contact has been subjected to abuse or neglect, or any allegation of abuse or neglect shall immediately report or cause a report to be made to the mandated state agency per reporting criteria or in person. Such reports may also be made to the local law enforcement agency in the same manner..." Review of the Regional Illinois Department of Public Health incident and accident file for this facility did not indicate that an incident report or a notice of an allegation of abuse by E6 to R3 had been initiated. On 09-25-13 at 1:15 PM, E1 stated that an incident report was completed and faxed on 09-21-13 at 12:16 PM. E1 then stated that the fax did not go through and produced a "Fax Error Report" for this incident dated 09-21-13 at 12:16 PM. Also, E1 stated during a 09-26-13 at 7:15 pm interview that he did not re-send this incident report nor had they sent a notification of allegation of abuse involving R3's fall on 09-21-13. E1 was observed sending by fax the notification of the 09-21-13 incident and the notification of the abuse investigation concerning this incident at 7:25pm on 09-26-13 to Public Health. E1 also stated during this interview that law enforcement was not notified. 7. These failures started after administrative staff received a report of staff raising a resident's (R3) leg up high and with enough force to cause the resident who was seated in a wheelchair with a seatbelt on to fall backwards, hit head on the floor, and receive an [MEDICAL CONDITION] with Subarachnoid Hemorrhage which resulted in the resident death. 8. On 09-24-13, the facility indicated an in-house census of 70 residents on the Facility Data Sheet. 9. E1, Administrator and E2, Director of Nurses, were notified of the Immediate Jeopardy on 09-26-13 at 2:50 PM. The Immediate Jeopardy was determined to have begun on 09-21-13 at 4:45 am when staff failed to follow the facility policies and procedures regarding identifying abuse by investigation of unusual and/or suspicious incidents, protecting all residents from abuse by immediately barring an alleged perpetrator from residents, by immediately notifying the Administrator of an allegation of abuse, appropriately screening all potential staff, inservicing all staff, requiring attendance at inservice training on abuse, and reporting all allegations of abuse to the state agency and local law enforcement as required regarding abuse allegations. This was after E7 received a report of E6 raising a resident's (R3) leg up high and with enough force to cause the resident who was seated in a wheelchair with a seatbelt on to fall backwards, hit head on the floor, and receive an [MEDICAL CONDITION] with Subarachnoid Hemorrhage according to reports received from the local hospital dated 09-21-13 which resulted in the resident death. The surveyor confirmed by record review and interview that the facility took the following actions to remove the Immediate Jeopardy. A. An investigation was initiated on 09-23-13 at 8:15 after E1 read a statement from E4 concerning the roughness of E6 to R3 on 09-21-13. This investigation will include interviews of interviewable residents and all employees to ensure no other episodes of abuse has occurred that the facility is unaware of. B. The alleged perpetrator, E6 was suspended pending outcome of the investigation on 09-23-13 at 8:15. C. On 09-26-13 and 09-27-13, the facility has audited all employee files to ensure that all employees are educated and complaint with the facilities abuse policy and the state and federal guidelines. D. On 09-26-13 and 09-27-13 all staff have been in-serviced on the facility's policy and procedure for abuse as well as the 1150B of the Social Security Act, all new hires will be in-serviced by the Abuse Coordinator on or before their hire date. E. On 09-26-13 and 09-27-13 audits of pre-employment requirements for all staff were completed. Any staff with issues concerning background checks, registry checks, or recently hired employee reference checks were rectified. F. On 09-26-13, the facility faxed the 09-21-13 incident report to Public Health and changed the fall investigation to an abuse investigation. G. As of 09-27-13 the facility will do quarterly in-servicing on policy and procedure for Abuse as well as the 1150B of the Social Security Act as a quality measure to ensure that staff is refreshed on the importance of the policies for abuse and immediate reporting. H. As of 09-27-13 through the facility's Quality Assurance process, Medical Records/or designee will ensure all new hires are in compliance with the facility's pre-employment policy, the abuse policy, state and federal guidelines, and the 1150B of the Social Security Act and every attempt to obtain reference checks are met with these policies. I. As of 10-01-13, the facility will initiate random audits/questioning of staff on the abuse policy and procedures and 1150B of the Social Security Act. There will be 8 staff members audited during each quarter beginning October, 2013.

Based on observation, interviews, and record review, the facility staff failed to prevent one resident (R3) from receiving serious physical injury due to staff (E6) raising R3's leg to eye level and with enough force to cause the resident who was seated in a wheelchair with a seatbelt on to fall backwards, hit head on the floor, and receive an [MEDICAL CONDITION] with Subarachnoid Hemorrhage which resulted in death for 1 of 3 residents (R3) reviewed for falls in the sample of 3. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at a Severity Level 2 as the facility continues to educate and monitor staff on abuse policies and procedures. Findings include: R3 was an [AGE] year old female that resided in the facility since [DATE] with [DIAGNOSES REDACTED]. According to the most recent quarterly Minimum Data Set (MDS) dated [DATE], R3 has physical behavioral symptoms of hitting, kicking, scratching, grabbing, threatening, screaming, and cursing others. R3's quarterly MDS dated [DATE] documents that she had long and short term memory issues. R3's Care Plan dated [DATE], has a Problem listed as R3 exhibits non-compliant behavior by refusing her medications and treatments with an approach listed as "reapproach when refusing care and treatments; and for residents safety use 2 staff when doing care" and another Problem listed as R3 has difficulty with communicating needs and following simple commands at times due to cognitive decline with an approach listed "observe closely and anticipate needs as needed". R3's wheelchair was observed on [DATE] at 10:15 am to be shorter than a normal sized wheelchair with a self releasing seat belt and a seat belt alarm hanging on the back of the chair. According to E3, Certified Nurse Aide Supervisor, on [DATE] at 2:12 pm, the wheelchair, weighs 40 lbs. Measurements of R3's chair on [DATE] documents the chair was 15 inches from the floor to the seat (Height) and 15 inches from the seat edges (width). Also observed during this time was the wheel chair brakes on the right side of the chair in the locked position allows the right chair wheel to move freely and the brake on the left side of the wheel chair in the locked position does not allow the wheel to move. According to the Vital Sign and Weight Record R3 weighed 156 pounds on [DATE] and according to the Minimum Data Sets (MDS) dated [DATE], R3 is 5 feet 2 inches tall. The Nurses Notes dated [DATE] at 4:45 A.M. documents E6 (Licensed Practical Nurse) lifted R3's foot up. The wheelchair with the resident in it went backwards. R3 did not appear to hit any body parts. E6 undid quick release belt allowing R3 to slide out of the wheelchair with assistance of E4 and E5 (Certified Nurses Aides). An Incident Report dated [DATE] at 4:45 A.M. completed by E6 states "I bend down lifted foot up causing w/c (wheel chair) to tip backwards with resident, a seat with self release belt intact", and lists R3's condition before the incident as aggressive and strikes at staff for all activities of daily living. E6 was interviewed over the phone on [DATE] at 11:05 A.M., and E6 stated that "as I raised R3's leg by the pant leg, R3 slapped me. I stepped back and I lifted her left leg placing my hand on the back of her heel and the next thing I knew she was on the floor, the wheel chair tipping over backwards." An undated statement with the time given as 4:15 A.M. written by E6 includes the following. "I bent over to remove excess tape and R3 struck me on the side of my face knocking my glasses askew. I backed up half a step and raised foot again, the next thing I knew R3's wheelchair was tipped backwards and R3 was lying still in seat position with self release restraint in place." E4, Certified Nurses Aide, wrote a statement dated [DATE] that states on Saturday, [DATE] at approximately 4:30 am, E4 put R3 in her wheel chair and secured her safety belt and locked the wheelchair. E6, Licensed Practical Nurse, tried to look at R3's dressing on her toes and R3 started kicking at him. E6 was observed to grab R3's leg in a rough and abrupt manner, jerk her leg up to her eye level, flipping R3 backwards in her wheel chair and causing R3's head to hit the floor with a sound "like a baseball bat hitting a ball of a grand slam". Also, E4 wrote a seven page letter addressed to E1, Administrator and left it for E1 to read on [DATE]. This letter states that E6, Licensed Practical Nurse, was in a "very bad mood" during his midnight shift (10 PM to 6 AM) on [DATE]. E4 describes in this letter that E6's rough and abrupt actions caused R3 to fall backwards onto the floor in her wheel chair. Also, E4 wrote that E4 spoke with E3, Certified Nurse Aide Supervisor,several times and was told to write in her statement everything before and after the incident of [DATE]. E4 stated she also spoke to E2, Director of Nurses, who told E4 to "only write what happened in the room and I shouldn't (should not) use words in the report like her leg was lifted rough or abruptly" and E4 should report only "that he lifted her leg and the chair tipped over". During a phone interview on [DATE] at 2:40 P.M., E4 stated the following. E4 stated E6 reached for R3's foot and jerked R3's leg so high R3's left leg came up to R3's face, eye level and the wheelchair tipped over, and E6 is "too rough with the residents". E4 also stated she reported to E7 (Licensed Practical Nurse who was working on the other hall) shortly before E4 left the facility at the end of the shift at approximately 6:00 A.M. the way R3's leg was lifted. E4 stated E2 (Director of Nurses) called E4 between 7:30 A.M. and 9:30 A.M. and E4 told E2 at that time how E6 grabbed R3's leg and the leg was above R3's head when the wheelchair tipped backwards. E4 said E2 told E4 the situation would be investigated and that E2 would contact E1 (Administrator). E4 stated she sent a text message to E3 (Certified Nurses Aide Supervisor) after E4 talked with E2 around 10:00 A.M. and explained that E6 grabbed R3's leg and lifted it up to R3's eye level hard causing the chair to flip. During an interview on [DATE] at 1:45 P.M., E3 stated E3 had received a text from E9 saying R3 had an accident. E3 called the facility and talked with E9 and was told E 10 (Certified Nurses Aide) gave E4 a ride home on [DATE] and E4 was upset about what happened in R3's room. E3 called E4 at home on [DATE] at 7:43 A.M. and E4 reported E6 lifted E3's legs up to high and the wheelchair went back and R3 fell backwards. On [DATE] at 2:10 pm E3 was interviewed by phone and stated that E4 told her that E6 "jerked R3's leg up roughly". During an interview on [DATE] at 12:20 P.M., E7 stated that E4 told E7 later the morning of [DATE] that "there was more that happened in R3's room" and E7 said she told E4 "you have to report and tell the truth". E4 called E7 Sunday morning around 8:30 A.M., and said to E7 "E6 was rough and abrupt in E4's opinion but never used the word abuse." E2 stated on [DATE] at 10:15 am that she was notified that R3 had fallen and was sent to the emergency room at approximately 4:40 am on [DATE] but she did not start an investigation of the incident until [DATE]. E1 was interviewed at 10:10 am on [DATE] and stated that he was notified on [DATE] sometime in the morning (exact time unknown) that R3 had fallen but did not have any idea that E4 thought it was because of a rough act by E6. E1 verified that they did not start an investigation until [DATE] at 8:15 am. A [DATE] Radiology Report from a Computer Topography (CT) of R3's head documents the impression as "Significant posterior fossa acute [MEDICAL CONDITION] with Subarachnoid hemorrhage extending into the pons with Intraventricular hemorrhage." This was obtained after R3 went to the emergency room the morning of [DATE] according to Z3 and Z4, emergency room Registered Nurses during an interview on [DATE] at 1:20 pm. Z3 confirmed that R3 expired on [DATE]. The History & Physical for R3's admission to the hospital on [DATE] documents the chief complaint as "Unresponsiveness". The plan given was to provide comfort and no aggressive measures due to R3's condition and poor prognosis. Z1, Physician for R3 stated during a telephone interview on [DATE] at 7:35 am that "R3 has been his patient for many years and R3's cognitive status has declined in the last few years to the point she does not recognize anyone." Z1 described R3 as been non-compliant, hitting and being physically aggressive. When asked about Z1's examinations of R3, Z1 stated that "he would try to exam her but she would hit, because she always hit and "I would leave her alone, just back off as I should have. As staff should have." Z1 stated, "( R3) is the kind of resident that things like this happen to because of her behaviors. When she was having behaviors with care, staff should have backed off. That is what she wanted." Z1 also stated that usually a fall causes the hemorrhage and the hemorrhage causes the death but that cannot be proven until the autopsy report is received. Z2, Coroner, stated in an interview on [DATE] at 11:05am that R3's Death Certificate is "Pending Investigation". Z2 stated that it will be a few weeks until the pathologist report on the brain autopsy is received. E1, Administrator and E2, Director of Nurses, were notified of the Immediate Jeopardy on [DATE] at 2:50 PM. The Immediate Jeopardy was determined to have begun on [DATE] at 4:45 am when E6, Licensed Practical Nurse, raised R3's leg up high and with enough force to cause the resident who was seated in a wheelchair with a seatbelt on to fall backwards, hit head on the floor, and receive an [MEDICAL CONDITION] with Subarachnoid Hemorrhage according to reports received from the local hospital dated [DATE] which resulted in the resident death. The surveyor confirmed by record review and interview that the facility took the following actions to remove the Immediate Jeopardy. A. An investigation was initiated on [DATE] at 8:15 a.m. after E1 read a statement from E4 concerning the roughness of E6 to R3 on [DATE]. This investigation will include interviews of interviewable residents and all employees to ensure no other episodes of abuse has occurred that the facility is unaware of. B. The alleged perpetrator, E6 was suspended pending outcome of the investigation on [DATE] at 8:15. C. On [DATE] and [DATE], the facility has audited all employee files to ensure that all employees are educated and compliant with the facilities abuse policy and the state and federal guidelines. D. On [DATE] and [DATE] all staff have been in-serviced on the facility's policy and procedure for abuse as well as the 1150B of the Social Security Act, all new hires will be in-serviced by the Abuse Coordinator on or before their hire date. E. On [DATE] and [DATE] audits of pre-employment requirements for all staff were completed. Any staff with issues concerning background checks, registry checks, or recently hired employee reference checks were rectified. F. On [DATE], the facility faxed the [DATE] incident report to Public Health and changed the fall investigation to an abuse investigation. G. As of [DATE] the facility will do quarterly in-servicing on policy and procedure for Abuse as well as the 1150B of the Social Security Act as a quality measure to ensure that staff is refreshed on the importance of the policies for abuse and immediate reporting. H. As of [DATE] through the facility's Quality Assurance process, Medical Records/or designee will ensure all new hires are in compliance with the facility's pre-employment policy, the abuse policy, state and federal guidelines, and the 1150B of the Social Security Act and every attempt to obtain reference checks are met with these policies. I. As of [DATE], the facility will initiate random audits/questioning of staff on the abuse policy and procedures and 1150B of the Social Security Act. There will be 8 staff members audited during each quarter beginning October, 2013.