Every finding on record at Landmark Nursing & Rehabilitation CTR of West Mon

Based on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. The facility failed to 1) Identify Resident #14 had a MDRO infection and implement contact precautions, and 2) implement EBP for Resident #23 and #94.Findings:Resident #14 Review of the facility's undated Infection Control Precautions (Isolation) Policy revealed the following in part: Policy: Prevent the spread of infection Equipment: Provided by infection control coordinator Procedure: 5. All residents placed in isolation, for suspected or confirmed infections, shall have isolation precautions implemented in accordance with procedures established in the CDC Guidelines for Isolation Precautions in Hospitals. Review of the record for Resident #14 revealed an admission date of 04/02/2025 with diagnoses that included cerebral infarction, dementia, hypertension, and stage 3 pressure ulcer. Review of the quarterly MDS assessment dated [DATE] revealed Resident #14 had an unhealed stage 3 pressure ulcer. On 03/09/2026 at 9:13 a.m., interview with S9LPN revealed Resident #14 was on EBP due to the presence of a PEG tube and a pressure ulcer. On 03/09/2026 at 12:40 p.m., interview with S2DON and S10LPN revealed Resident #14 received IV antibiotics for a wound infection. Review of the physician orders revealed an order dated 02/26/2026 for Meropenem 1 gram IV reconstituted solution was ordered every 8 hours for 8 days due to sacral wound infection. Review of Resident #14's sacral wound culture results revealed detection of antibiotic resistant organisms present. On 03/09/2026 at 5:07 p.m., interview with S11RN/Infection Preventionist confirmed contact precautions had not been implemented for Resident #14. On 03/10/2026 at 9:12 a.m., interview with S2DON and S11RN/Infection Preventionist revealed the culture report was received on 02/25/2026. S2DON and S11RN/Infection Preventionist further confirmed contact precautions should have been implemented for Resident #14. On 03/10/2026 at 9:30 a.m., S2DON was informed of findings related to failure to implement contact precautions for Resident #14. Review of the provider's Enhanced Barrier Precautions policy and procedure dated 08/12/2024 revealed the following in part: It is the policy of this facility to implement Enhanced Barrier Precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). Definitions: Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and gloves use during high-contact resident care activities for residents known to be colonized or infected with MDRO, as well as, those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices.) Wound in relation to this guidance, generally includes resident with chronic wounds, and not those with only shorter-lasting wounds, such as skin tears covered with Band-aid or similar dressing. Examples of chronic wounds include, but not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers. Resident #23 Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses of proximal atrial fibrillation, malignant neoplasm of upper lobe unspecified bronchus or lung, carcinoma in stitu of left bronchus and lung, essential hypertension, pleural effusion, pneumonia, chronic obstructive pulmonary disease, peripheral vascular disease, anemia, weakness, chronic respiratory failure with hypoxia, dependence on oxygen, and urinary retention. Review of Resident #23's current March 2026 physician orders revealed the following:1) 03/07/2026: change 16 french foley catheter routinely (every 30 days); 2) 16 french catheter care with soap and water every shift; 3) monitor urine color every shift; and 4) 16 french catheter monitor condition of urine every shift. On 03/08/2026 at 9:50 a.m., an observation of Resident #23 revealed an indwelling urinary catheter with drainage bag was secured to the bed frame on left side of bed. Further observation revealed no EBP signage on the door or outside Resident #23's room. On 03/09/2026 at 1:10 p.m., S2DON was informed of observation on 03/08/2026 which revealed Resident #23 had a urinary catheter in place and there was no signage indicating EBP in place. S2DON confirmed Resident #23 should be on EBP related to the indwelling catheter, and there should have been a sign posted outside Resident #23's door indicating he was on EBP. Resident #94 Record review revealed Resident #94 was readmitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complications, restless leg syndrome, encounters for orthopedic aftercare following surgical amputation, generalized anxiety disorder, paroxysmal atrial fibrillation, muscle wasting and atrophy multiple sites, ventricular tachycardia, pain unspecified, resistance to multiple antibiotics, essential hypertension, obstructive sleep apnea, primary generalized osteoarthritis, constipation, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris. Review of current March 2026 Physician orders revealed the following orders: 1) 01/13/2025 for Enhanced Barrier Precautions utilized when performing high contact resident care activities; 2) 03/08/2026 for left shin arterial ulcer: Cleanse with wound cleanser, and pat dry with gauze. Cover with bag balm ointment, secure with border gauze dressing. Change every other day or until resolved; 3) 03/08/2026 for left ankle arterial ulcer: cleanse with wound cleanser and pat dry with gauze. Cover with bag balm ointment. Cover with gauze. Secure with kerlix and tape. Chance every other day or until resolved; 4) 03/08/2026 for left plantar foot arterial ulcer: cleanse with wound cleanser and pat dry with gauze, Cover with bag balm ointment. Cover with gauze. Secure with kerlix and tape. Change every other day or until resolved; and 5) 03/08/2026 left dorsum 2nd digit arterial ulcer: cleanse with wound cleanser and pat dry with gauze. Cover with bag balm ointment. Cover with gauze. Secure with kerlix and tape. Change every other day or until resolved. On 03/08/2026 at 9:45 a.m., an observation of Resident #94 revealed a dressing that was dry and intact to the left ankle and foot. Resident #94 reported being moved to this room about a week ago. Further observation revealed no EBP signage noted on the door or outside Resident #94's room indicating EBP were in place. On 03/09/2026 at 1:10 p.m., S2DON confirmed EBP precautions should be in place for Resident #94 due to chronic arterial wounds. S2DON was informed EBP signage was not observed on 03/09/2026 for Resident #94

Based on observations, interviews, and record reviews, the facility failed to assess residents for self-administration of medications for 1 (#51) of 1 sampled residents observed for medications available at the bedside. Findings: Review of the facility's undated Medication Storage in the Facility policy revealed the following, in part: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing or medical personnel and pharmacy personnel. Review of the medical record for Resident #51 revealed an admission date of 01/28/2026. Resident #51 had diagnoses that included depression, schizophrenia, cognitive communication deficit, hemiplegia, and presbyopia. Review of the admission MDS assessment dated [DATE] revealed Resident #51 had a BIMS score of 13 which indicated intact cognition for daily decision making. On 03/08/2026 at 9:00 a.m., and 12:10 p.m., observations of Resident #51's room revealed a bottle of Zaditor eye drops was on the bedside table. Review of Resident #51's March 2026 physician orders revealed no documented evidence of an order for Zaditor eye drops. Interview with Resident #51 on 03/08/2026 at 12:45 p.m. revealed she uses the eye drops in her eyes when they feel dry, and she administers the eye drops by herself. On 03/08/2026 at 3:30 p.m., observation of Resident #51's room with S2DON revealed a bottle of Zaditor eye drops was on the bedside table. S2DON confirmed Resident #51 should not have medications for use at the bedside.

Based on observations and interviews, the facility failed to ensure residents have the right to a clean, comfortable and homelike environment for 3 (#16, #29 and #51) of 3 residents reviewed for environment by 1) having unsanitary overbed tables for resident use (#16 and #29) and having an air conditioner unit in need of repair for resident #51. Findings: Resident 16 On 03/08/2026 at 11:15 a.m., 4:03 p.m. and on 03/09/2026 at 1:45 p.m. observations of Resident #16's overbed table revealed spills and splatters on top of the table. On 03/09/2026 at 2:05 p.m. observation of Resident #16's overbed table with S4Housekeeping Supervisor revealed spills and splatters on top of the table. Interview with S4Housekeeping Supervisor on 03/09/2026 at 2:10 p.m. confirmed Resident #16's overbed table was dirty and needed to be cleaned. Resident 29 On 03/08/2026 at 11:15 a.m., 4:03 p.m. and on 03/09/2026 at 1:45 p.m. observations of Resident #29's overbed table revealed spills and splatters on top of the table. On 03/09/2026 at 2:05 p.m. observation of Resident #29's overbed table with S4Housekeeping Supervisor revealed spills and splatters on top of the table. Interview with S4Housekeeping Supervisor on 03/09/2026 at 2:10 p.m. confirmed Resident #29's overbed table was dirty and needed to be cleaned. Resident #51 On 03/08/2026 at 3:53 p.m., and on 03/09/2026 at 1:55 p.m. observations of Resident #51's air conditioner unit revealed the unit was not secured to the wall and a gap was noted on each side of the unit. On 03/09/2026 at 2:00 p.m. observation of Resident #51's air conditioning unit with S5Maintenance Supervisor revealed the unit was not secured to the wall and a gap was noted on each side of the unit. On 03/09/2026 at 2:05 p.m. interview with S5Maintenance Supervisor confirmed the air conditioner unit should have been secured to the wall and a gap was noted on each side of the unit.

Based on record review, observations, and interview, the facility failed to develop a comprehensive person-centered care plan for 1 (#99) of 2 sampled resident reviewed for ADLs. The provider failed to develop an ADLs care plan for Resident #99.Findings:Record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complication, stage 2 pressure ulcer sacral region, chronic obstructive pulmonary disease, need for assistance with personal care, lack of coordination, muscle wasting and atrophy not elsewhere specified right shoulder, major depressive disorder, generalized anxiety disorder, peripheral vascular disease, hypertensive heart disease with heart failure, personal history of venous thrombosis and embolism, obstructive sleep apnea, and obesity. Review of the current March 2026 Physician orders revealed an order dated 12/24/2025: requires x1 person assist with ADLs. Review of the comprehensive care plan revealed no evidence to support Resident #99's need for assistance with ADLs was addressed. Observations of Resident #99 on 03/08/2026 at 8:20 a.m. and 03/09/2026 at 9:35 a.m. revealed, the fingernails were long with a dark brown colored grimy substance under the fingernails on both hands. On 03/09/2026 at 10:00 a.m., observation of Resident #99 with S2DON revealed Resident #99's fingernails were long with a dark brown grimy substance under the fingernails on both hands. S2DON confirmed Resident #99's fingernails needed to be cleaned and trimmed. On 03/09/2026 at 12:15 p.m., interview with S2DON confirmed a care plan had not been developed related to ADLs for Resident #99. S2DON further confirmed there was no care plan that specified who would trim and clean Resident #99's finger nails or how often nail care would be done.

Based on observations, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. The facility failed to ensure residents' fingernails were clean and trimmed in a timely manner for 1 (#99) of 2 residents reviewed for activities of daily living. Findings:Record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus without complication, stage 2 pressure ulcer sacral region, chronic obstructive pulmonary disease, need for assistance with personal care, lack of coordination, muscle wasting and atrophy not elsewhere specified right shoulder, major depressive disorder, generalized anxiety disorder, peripheral vascular disease, hypertensive heart disease with heart failure, personal history of venous thrombosis and embolism, obstructive sleep apnea, and obesity. Review of the current March 2026 Physician orders revealed an order dated 12/24/2025: requires x1 person assist with ADLs. Observations of Resident #99 on 03/08/2026 at 8:20 a.m. and 03/09/2026 at 9:35 a.m. revealed, the fingernails were long with a dark brown colored grimy substance under the fingernails on both hands. On 03/09/2026 at 10:00 a.m., observation of Resident #99 with S2DON revealed Resident #99's fingernails were long with a dark brown grimy substance under the fingernails on both hands. S2DON confirmed Resident #99's fingernails needed to be cleaned and trimmed.

Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for edema while a resident was receiving a diuretic for 1 (#92) of 5 residents reviewed for unnecessary medications. Findings: Review of the medical record for Resident #92 revealed an admission date of 10/22/2024. Resident #92 had diagnoses that included edema, Parkinson's disease, and dementia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #92 had a BIMS score of 5 which indicated severe cognitive impairment for daily decision making and required assistance with ADLs. Review of Resident #92's March 2026 physician orders revealed an order dated 03/04/2026 for Lasix (diuretic) 20 mg, give one tablet by mouth one time a day related to edema. Review of the March 2026 MAR and nurses notes revealed no documented evidence the nurses monitored Resident #92 for edema. Interview on 03/10/2026 at 10:10 a.m. with S3LPN confirmed there was no documented evidence that Resident #92 was monitored for edema. Interview on 03/10/2026 at 10:20 a.m. with S2DON confirmed there was no documented evidence of monitoring for edema while taking Lasix (diuretic) for Resident #92.

Based on record reviews and interviews, the facility failed to ensure that the nursing staff are able to demonstrate competency in skills necessary to care for the resident needs for 1 (#6) of 5 residents sampled for the unnecessary medication review. This was evidenced by the nurses failing to administer as needed blood pressure medication as ordered for Resident #6.Findings:Review of Resident #6's record revealed an admission date of 07/18/2020 with readmission of 11/23/2024. Resident #6 had the following diagnoses chronic systolic congestive heart failure, shortness of breath, chest pain, angina pectoris, atrial fibrillation, and essential hypertension. Review of Resident #6's quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 which indicated moderate cognitive impairment. Review of Resident #6's March 2026 Physician's Orders revealed an order dated 02/10/2026 for Clonidine HCL oral tablet 0.1 mg give 1 tablet by mouth every 12 hours as needed for hypertension, and parameters for blood pressure included to give 1 tablet if systolic was greater than 160 or if diastolic was greater than 90. Review of Resident #6's February 2026 MAR revealed 9 times that the resident's diastolic blood pressure was greater than 90 and the nurses failed to document administration of Clonidine HCL as ordered. Review of Resident #6's March 2026 MAR revealed 3 times that the resident's diastolic blood pressure was greater than 90 and the nurses failed to document administration of Clonidine HCL as ordered. An interview on 03/10/2026 at 2:24 p.m. with S6LPN, during the review of Resident #6's current physician's orders and her February 2026 MAR, confirmed that she worked with the resident on 02/11/2026. S6LPN confirmed the resident's diastolic blood pressure was greater than 90, and she failed to administer Clonidine HCL as per the resident's orders. An interview on 03/10/2026 at 2:45 p.m. with S2DON confirmed the nurses failed to administer Clonidine HCL (as needed blood pressure medication) 9 times during February 2026 and 3 times in March 2026, when Resident #6's diastolic blood pressure was greater than 90.

Based on record reviews and interviews, the provider failed to ensure MDS assessments were completed and submitted timely for 3 (#3, #96, and #107) of 3 sampled residents reviewed for assessments.Findings: Resident #3Review of Resident #3's record revealed an admission date of [DATE] and resident expired in the facility on [DATE]. Review of Resident #3's MDS assessments revealed a discharge (death in facility) MDS assessment dated [DATE] was not completed and transmitted to CMS until [DATE]. An interview on [DATE] at 1:10 p.m. with S7MDS/LPN confirmed Resident #3 expired in the facility on [DATE]. S7MDS/LPN revealed she failed to complete and transmit Resident #3's discharge (death in facility) MDS assessment dated [DATE] to CMS within 7 days ([DATE]). Resident #96 Review of Resident #96's record revealed an admission date of [DATE] and a discharge date of [DATE]. Review of Resident #96's MDS assessments revealed no documented evidence a discharge MDS assessment was completed or transmitted to CMS for the resident. An interview on [DATE] at 1:10 p.m. with S7MDS/LPN revealed Resident #96 was discharged from the facility on [DATE]. S7MDS/LPN confirmed she failed to complete and transmit a discharge MDS assessment to CMS within 14 days ([DATE]). Resident #107Review of Resident #107's record revealed an admission date of [DATE]. Review of Resident #107's MDS assessments revealed an annual MDS assessment dated [DATE] was not completed and transmitted to CMS until [DATE]. An interview on [DATE] at 1:10 p.m. with S7MDS/LPN confirmed Resident #107's annual MDS assessment dated [DATE] was not completed and transmitted to CMS until [DATE]. S7MDS/LPN confirmed this assessment should have been transmitted to CMS by [DATE]. An interview on [DATE] at 2:45 p.m. with S2DON confirmed the MDS assessments were not completed and transmitted to CMS in a timely manner for Resident #3, Resident #96, and Resident #107.

Based on interview and record reviews, the facility failed to ensure it assessed residents using the quarterly review instrument approved by Centers for Medicare & Medicaid Service (CMS) not less frequently than once every 3 months by failing to complete the Minimum Data Set (MDS) assessment at least every 3 months for 4 (#8, #15, #55, #63) of 4 sampled residents reviewed for timeliness of MDS assessments. Findings: Review of the MDS for resident #8 revealed the last completed MDS assessment was dated 09/10/2024. Review of the MDS for resident #15 revealed the last completed MDS assessment was dated 08/02/2024. Review of the MDS for resident #55 revealed the last completed MDS assessment was dated 08/30/2024. Review of the MDS for resident #63 revealed the last completed MDS assessment was dated 09/11/2024. On 01/25/2025 at 10:30 a.m., interview with #S3Clinical Care Coordinator confirmed the MDS assessments were not completed at least every 3 months for residents #8, #15, #55 and #63.

Based on observations, interviews, and record reviews, the facility failed to implement a comprehensive person centered care plan for 1 (#24) of 1 resident reviewed for constipation and 2 (#26, #60) of 2 residents reviewed for smoking. Findings: Resident #24 0n 01/13/2025 at 9:06 a.m., interview with resident #24 revealed she had recurrent problems with constipation. Review of the medical record for resident #24 revealed she had a diagnosis of constipation. Review of the care plan revealed it addressed the constipation with an intervention to assess bowel patterns. Review of the January 2025 documentation for the resident's bowel status revealed it was not recorded for 13 of 13 day shifts, for 4 of 13 evening shifts, and for 7 of 13 night shifts. On 01/15/2025 at 8:30 a.m., an interview with S2Director of Nursing (DON) confirmed the facility had not been consistently assessing the resident's bowel movements. 22575 Resident #26 Review of the medical record for resident #26 revealed he was admitted to the facility on [DATE] with diagnoses of epilepsy, insomnia, acute bronchitis, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed resident #26 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident was moderately cognitively impaired and he needed limited assistance with activities of daily living. An interview with resident #26 on 01/13/2025 at 10:37 a.m. revealed he was a smoker and stated he kept his cigarettes and lighter in his room. Also, the resident had oxygen at 2 liters per nasal cannula. Review of the medical record revealed the last Safe Smoking assessment dated [DATE] revealed he was a safe smoker. Review of the current care plan revealed an intervention to assess the resident quarterly for safe smoking. On 01/15/2025 at 5:00 p.m., S1Administrator was informed there was no current quarterly Safe Smoking Assessment for resident #26. On 01/15/2025 at 2:00 p.m., a phone interview with S2Director of Nursing (DON) confirmed they had not conducted a quarterly Safe Smoking Assessment for resident #26 since 08/24/2024. Resident #60 Review of the medical record for resident #60 revealed the resident was admitted to the facility on [DATE] with diagnosis of personal history of nicotine dependence, hyperlipidemia, chronic pain, and muscle wasting and atrophy. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed resident #60 had a BIMS score of 12 which indicated the resident was moderately cognitively impaired and needed limited assistance with activities of daily living. An interview with resident #60 on 01/13/2025 at 10:37 a.m. revealed he was a smoker and stated he kept his cigarettes and lighter in his room. Review of resident 60's medical record revealed the last safe smoking assessment dated [DATE] revealed he was a safe smoker. Review of the current care plan revealed an intervention to assess the resident quarterly for safe smoking. On 01/15/2025 at 5:00 p.m., S1Administrator was informed there was no current quarterly Safe Smoking Assessment for resident #60. On 01/15/2025 at 2:00 p.m., a phone interview with S2DON confirmed they had not conducted a quarterly Safe Smoking Assessment for resident #60 since 08/22/2024.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to ensure labs were collected as ordered for 1 (#84) of 5 (#9, #18, #42, #84, #94) residents reviewed for unneccessary medications. Findings: Review of the medical record for resident #84 revealed she was admitted on [DATE] with a diagnosis of hyperlipidemia. Review of the January 2024 physician orders revealed the physician ordered Rosuvastatin 20 milligrams (mg) at bedtime for the treatment of hyperlipidemia. On 03/01/2024, the physician ordered Lipid levels to be obtained every 6 months. Review of the medical record for resident #84 revealed there were no lipid levels done. On 01/14/2025 at 2:00 p.m., interview with S2Director of Nursing (DON) confirmed the facility had not obtained lipid levels for resident #84.

Based on record review and interviews, the facility failed to ensure 1 (#1) of 3 (#1, #2, #3) residents reviewed for accidents received the necessary supervision to prevent avoidable accidents including a fall. The deficient practice resulted in an actual harm for Resident #1 on 08/22/2024 at 12:25 p.m. when Resident #1 suffered major injuries from falling out of the bed to the floor while left unattended during a bed bath. S4 CNA (Certified Nursing Assistant) was providing a bed bath to Resident #1. S4 CNA left the room to get more supplies for the bath and Resident #1 rolled off the bed and to the floor. Resident #1 was sent to a local hospital ER (emergency room ) on 08/22/2024. Review of the hospital records revealed Resident #1 suffered bilateral supracondylar fractures of the right and left femurs requiring ORIF (open reduction internal fixation) of the right femur and a closed reduction and Ex-Fix application of the left distal femur on 08/22/2024. Resident #1 remained in the hospital at the time of the investigation. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. The Completion date was 08/26/2024. Findings: On 09/03/2024, review of the record for Resident #1 revealed an admitted [DATE]. Further review of the record for Resident #1 revealed diagnoses in part of atresia and stenosis of urethra and bladder neck, schizoaffective disorder, seizures, multiple sclerosis, muscle wasting and atrophy, lack of coordination, cognitive communication deficit, aphasia and a past history on 01/09/2020 of non-displaced extra-articular fracture of the left calcaneus, and displaced fracture of medial malleolus of left tibia. Review of the August 2024 Physician orders revealed to use the Vander-Lift with 2 people for transfers and 2 person total assist with bed mobility. Further review of the record revealed on 08/04/2024 Resident #1 weighed 256 pounds. Review of the quarterly MDS (Minimum Data Set) dated 05/10/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 9 indicating Resident #1 had moderate cognitive impairment. Further review of the MDS revealed Resident #1 had the following functional abilities: limited range of motion to bilateral upper extremities and lower extremities. Review of Resident #1's MDS revealed Resident #1 required total dependence for bed mobility with two person assist. Resident #1 was always incontinent of bowel and bladder. Review of the current plan of care revealed Resident #1 was at risk for falls. Review of the approaches in part revealed transfer using 2 person assist with Vander-Lift. Review of the facility incident report dated 08/22/2024 at approximately 12:25 p.m. revealed Resident #1 was receiving personal care by S4 CNA. During the care, Resident #1's bowels had moved and S4 CNA realized she did not have enough supplies to complete the care, so she left the room to gather more. While she was gathering supplies, she heard Resident #1 yell out and she immediately returned to the room. S4 CNA found Resident #1 beside the bed, on the floor, on her knees, between the bed and the wall. S4 CNA immediately called for assistance. S5 LPN (Licensed Practical Nurse) arrived to find Resident #1 on her knees, on the floor, with her hands on top of the mattress, complaining of pain to both of her legs. Resident #1 reported that she fell out of the bed. S5 LPN assessed the resident for injuries and noted a skin tear to her right knee. S5 LPN contacted the physician and orders were received to send to hospital for further evaluation. On 08/22/2024 at 9:35 p.m., S9 LPN received a call from the emergency room informing her that Resident #1 had fractures in bilateral legs and would be having surgery to repair them. S9 LPN immediately notified the DON (Director of Nurses) who then informed the Administrator. Review of the hospital record regarding the injuries sustained from this incident revealed Resident #1 received supracondylar fractures of the right and left femurs. Treatment received was an ORIF to the right and closed reduction and Ex-Fix application of the left distal femur fracture on 08/22/2024. On 09/04/2024 at 11:30 a.m., an interview with S4 CNA revealed on 08/22/2024 about 12:25 p.m. she was assisting the CNAs on the hall. The CNA that normally cares for Resident #1 was on lunch break and had already put supplies in the room for Resident #1 to get a bath. S4 CNA said this was only the second time she had provided care to Resident #1 and said she was giving Resident #1 a bath by herself and was not aware Resident #1 required a 2 person assist with bathing and transferring and failed to review the wall care plan in the resident's room that noted Resident #1 was a 2 person assist. S4 CNA said during the bath, Resident #1 had a bowel movement and she did not have enough supplies in the room. S4 CNA said she turned Resident #1 to face the wall and the resident's hands were touching the wall. S4 CNA lowered the bed and stepped out of the room. S4 CNA said she was not sure if the bed was locked and she did not check the break on the bed before she started the bath or before leaving the room. S4 CNA said she did not even have enough time to get the towel off the cart in the hall when she heard Resident #1 hollering for help. S4 CNA said when she came back in the room, Resident #1 was on her knees between the wall and the bed and Resident #1 was complaining of her right knee hurting. S4 CNA said the bed had moved away from the wall. On 09/04/2024 at 1:30 p.m., an interview with S5 LPN revealed she was at the main desk and S4 CNA came and told her that Resident #1 was on the floor. S5 LPN said she went to the room and Resident 1 was on her knees between the bed and the wall with her hands on the mattress. S5 LPN reported Resident #1 only complained of her right knee hurting and she noticed a skin tear to her right knee. S5 LPN said they got multiple staff, lowered Resident #1 to the floor and then used the lift to get her up off the floor. Resident #1 was sent to the hospital. S5 LPN said she was not sure if the bed was in the lock position when the accident occurred. On 09/03/2024 at 2:30 p.m., an interview with S8 CNA Assistant Supervisor confirmed there should have been 2 staff present when providing care for resident #1 and S4 CNA should not have left the bed unlocked when she left the room. On 09/04/2024 at 2:00 p.m., an interview with S3 DON confirmed S4 CNA should not have been providing care to Resident #1 without another staff member present and S4 CNA should have ensured the bed was locked before leaving the room. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice with the completion date of 08/26/2024: 1. Resident #1 was sent to the hospital for evaluation. 2. S4 CNA was suspended pending investigation. 3. S4 CNA was in-serviced on 08/22/2024 on care of residents in bed, to read the wall care plan. The wall care plan is a piece of paper that is placed on each resident's wall by the bed that has the specific care needs for the resident. To make sure all supplies are obtained prior to beginning care, ensure bed wheels are locked, ensure resident in safe position in bed before leaving room (not close to edge of bed but in middle of bed). 4. All nurses and CNAs were in-serviced from 08/23/2024 to 08/26/2024 on the resident wall care plan, 2 person assist with mobility in the bed, toileting, incontinent care, turning and reposition, bathing, a CNA should be on each side of bed. Check with nurse if any questions. Never leave a room with the resident not in safe position, ensure the wheels are locked on the bed. 5. Baseline assessments of all residents functional capabilities performed, care plans updated for all residents with changes to baseline functional status, all in room resident care plans were updated and monitors were put in place to ensure compliance of corrective action. 6. QAPI (Quality Assurance/Performance Improvement) monitors were conducted to ensure that care received while in bed reflects what the baseline review of functional status and needs assessment are followed. 7. QAPI Monitor - Locks on bed monitored 3 times per week.

Based on record review and interview, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 (#1) of 3 (#1, #2, #3) residents reviewed. S4 CNA (Certified Nursing Assistant) failed to provide 2 person assistance during bed mobility for Resident #1 and failed to ensure the bed was in the locked position prior to exiting Resident #1's room. The facility implemented corrective actions prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. The Completion date was 08/26/2024. Findings: On 09/03/2024 review of the record for Resident #1 revealed an admitted [DATE]. Further review of the record for Resident #1 revealed diagnoses in part of atresia and stenosis of urethra and bladder neck, schizoaffective disorder, seizures, multiple sclerosis, muscle wasting and atrophy, lack of coordination, cognitive communication deficit, aphasia and a past history on 01/09/2020 of non-displaced extra-articular fracture of the left calcaneus, and displaced fracture of medial malleolus of left tibia. Review of the August 2024 Physician orders revealed to use the Vander-Lift with 2 people for transfers and 2 person total assist with bed mobility. Further review of the record revealed on 08/04/2024 Resident #1 weighed 256 pounds. Review of the quarterly MDS (Minimum Data Set) dated 05/10/2024 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 9 indicating Resident #1 had moderate cognitive impairment. Further review of the MDS revealed Resident #1 had the following functional abilities: limited range of motion to bilateral upper extremities and lower extremities. Review of Resident #1's MDS revealed Resident #1 required total dependence for bed mobility with two person assist. Resident #1 was always incontinent of bowel and bladder. Review of the current plan of care revealed Resident #1 was at risk for falls. Review of the approaches in part revealed transfer using 2 person assist with Vander-Lift. Review of the facility incident report dated 08/22/2024 at approximately 12:25 p.m. revealed Resident #1 was receiving personal care by S4 CNA. During the care, Resident #1's bowels had moved and S4 CNA realized she did not have enough supplies to complete the care, so she left the room to gather more. While she was gathering supplies, she heard Resident #1 yell out and she immediately returned to the room. S4 CNA found Resident #1 beside the bed, on the floor, on her knees, between the bed and the wall. S4 CNA immediately called for assistance. S5 LPN (Licensed Practical Nurse) arrived to find Resident #1 on her knees, on the floor, with her hands on top of the mattress, complaining of pain to both of her legs. Resident #1 reported that she fell out of the bed. S5 LPN assessed the resident for injuries and noted a skin tear to her right knee. S5 LPN contacted the physician and orders were received to send to hospital for further evaluation. On 08/22/2024 at 9:35 p.m., S9 LPN received a call from the emergency room informing her that Resident #1 had fractures in bilateral legs and would be having surgery to repair them. S9 LPN immediately notified the Director of Nurses (DON) who then informed the Administrator. Review of the hospital record regarding the injuries sustained from this incident revealed Resident #1 received supracondylar fractures of the right and left femurs. Treatment received was an ORIF (open reduction internal fixation) to the right femur and closed reduction and Ex-Fix application of the left distal femur fracture on 08/22/2024. On 09/04/2024 at 11:30 a.m., an interview with S4 CNA revealed on 08/22/2024 about 12:25 p.m. she was assisting the CNAs on the hall. The CNA that normally cares for Resident #1 was on lunch break and had already put supplies in the room for Resident #1 to get a bath. S4 CNA said this was only the second time she had provided care to Resident #1. S4 CNA said she was giving Resident #1 a bath by herself and was not aware Resident #1 required a 2 person assist with bathing and transferring and failed to review the wall care plan in the resident's room that noted Resident #1 was a 2 person assist. During the bath Resident #1 had a bowel movement and she did not have enough supplies in the room. S4 CNA said she turned Resident #1 to face the wall and the resident's hands were touching the wall lowered the bed and stepped out of the room. S4 CNA said she was not sure if the bed was locked and she did not check the break on the bed before she started the bath or before leaving the room. S4 CNA said she did not even have enough time to get the towel off the cart in the hall when she heard Resident #1 hollering for help. S4 CNA said when she came back in the room Resident #1 was on her knees between the wall and the bed and Resident #1 was complaining of her right knee hurting. S4 CNA said the bed had moved away from the wall. On 09/04/2024 at 1:30 p.m., an interview with S5 LPN revealed she was at the main desk and S4 CNA came and told her that Resident #1 was on the floor. S5 LPN said she went to the room and Resident #1 was on her knees between the bed and the wall with her hands on the mattress and only complained of her right knee hurting and she noticed a skin tear to her right knee. S5 LPN said they got multiple staff, lowered Resident #1 to the floor and then used the lift to get her up off the floor. Resident #1 was sent to the hospital. S5 LPN said she was not sure if the bed was in the lock position when the accident occurred. On 09/03/2024 at 2:30 p.m., an interview with S8 CNA Assistant Supervisor confirmed there should have been 2 staff present when providing care for resident #1 and S4 CNA should not have been providing care by herself and should have checked the locks on the bed prior to exiting the room. On 09/04/2024 at 2:00 p.m., an interview with S3 DON confirmed S4 CNA should not have been providing care to Resident #1 without another staff member present and S4 CNA should have ensured the bed was locked before leaving the room. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following corrective actions to correct the deficient practice prior to entering the facility. The facility implemented the following actions to correct the deficient practice with the completion date of 08/26/2024: 1. Resident #1 was sent to the hospital for evaluation. 2. S4 CNA was suspended pending investigation. 3. S4 CNA was in-serviced on 08/22/2024 on care of residents in bed, to read the wall care plan. The wall care plan is a piece of paper that is placed on each resident's wall by the bed that has the specific care needs for the resident. To make sure all supplies are obtained prior to beginning care, ensure bed wheels are locked, ensure resident in safe position in bed before leaving room (not close to edge of bed but in middle of bed). 4. All nurses and CNAs were in-serviced from 08/23/2024 to 08/26/2024 on the resident wall care plan, 2 person assist with mobility in the bed, toileting, incontinent care, turning and reposition, bathing, a CNA should be on each side of bed. Check with nurse if any questions. Never leave a room with the resident not in safe position, ensure the wheels are locked on the bed. 5. Baseline assessments of all residents functional capabilities performed, care plans updated for all residents with changes to baseline functional status, all in room resident care plans were updated and monitors were put in place to ensure compliance of corrective action. 6. QAPI (Quality Assurance/Performance Improvement) monitors were conducted to ensure that care received while in bed reflects what the baseline review of functional status and needs assessment are followed. 7. QAPI Monitor - Locks on bed monitored 3 times per week.

Based on observation, record review and interview, the facility failed to protect the resident's right to be free from physical and verbal abuse and psychosocial harm by staff for 1 (#1) of 3 (#1,#2, #3) sampled residents. The deficient practice resulted in actual harm for resident #1 (who was cognitively impaired with communication deficits) on 05/19/2024 at 6:10 p.m. when S3CNA (Certified Nursing Assistant) physically and verbally abused resident #1 by forcefully grabbing resident #1's lower extremities, hands and arms in an attempt to reposition resident #1 and the resident sustained two red bruises that were identified on the left upper arm, and a reddened bruise was noted to the left hand, between thumb and index finger, red bruise was noted on top of right hand and a red bruise noted to the upper right arm. S3CNA cursed resident #1 and expressed anger at resident #1. Even though there was no significant decline in mental or physical functioning, it can be determined that the reasonable person would have experienced severe psychosocial harm as a result of the physical and verbal abuse, since a reasonable person would not expect to be treated in this manner in her own home or a health care facility. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Policy dated October 2023 revealed the following: The facility will not condone any form of resident abuse or neglect. Each resident residing in this facility has the right to be free from verbal, sexual, mental and physical abuse including corporal punishment. Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, facility members or legal guardians, friends or other individuals. Physical abuse includes hitting, slapping, pinching, and kicking. Additionally, it included acts of corporal punishment to control behavior. Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend or disability. Additionally threats of corporal punishment to control behavior are considered verbal abuse. Review of resident #1's electronic health record revealed an admitted [DATE] with diagnosis that included encephalopathy, aphasia following cerebral infarction, abnormal weight loss, lack of coordination, muscle wasting, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a BIMS (Brief Mental Status Interview) score of 3, which indicated the resident is cognitively impaired and unable to make daily decisions. Further review revealed the resident needs assistance with all activities of daily living including incontinence care. Review of the facility's investigation documentation revealed the following: On 05/20/2024 it was reported to the facility that S3CNA was physically rough and spoke rudely to resident #1 during incontinence care on 05/19/2024. Resident #1's responsible party brought a video of the incontinence care performed by S3CNA on 05/19/2024 at 6:10 p.m. After watching the video that was time and date stamped for 05/19/2024 at 06:10 p.m., the Administration contacted S3CNA and notified her of being suspended pending completion of the investigation. Law enforcement was notified and a report was made to the state in reference to the allegation of abuse. Review of the protective actions taken at this time was resident #1 was immediately examined by medical staff for injuries and supervision increased. Results of the exam revealed two red bruises were identified on the left upper arm, and a reddened bruise was noted to the left hand, between thumb and index finger, red bruise was noted on top of right hand and a red bruise noted to the upper right arm. Interview on 06/04/2024 at 10:10 a.m. with S1Administrator confirmed that during the video of incontinence care for resident #1 it showed S7CNA was also in the room with S3CNA and several other CNA's were standing in the doorway. During this video recording S3CNA was seen in the room, with the door open to the hallway, curtain opened in view of the roommate, and window blinds opened. S1Administator stated all staff involved were suspended and later terminated due to staff not reporting the incident of abuse. During an interview on 06/04/2024 at 11:10 a.m. S2DON (Director of Nurses) stated S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN (Licensed Practical Nurse) were all suspended on 05/20/2024 while the allegation of abuse was being investigated and they were all terminated on 05/23/2024. S2DON stated S7CNA was on one side of resident #1's bed on her phone, while S3CNA was pulling and trying to move the resident in bed very roughly, S7CNA assisted S3CNA pulling the resident up in the bed and then left the resident's room. S2DON confirmed S4CNA, S5CNA, and S6CNA were standing in resident 1's doorway when the care was provided. S2DON stated the physical exam of resident #1 on 05/20/2024 revealed two red bruises on the left upper arm, a reddened bruise to the left hand, between the thumb and index finger, a red bruise was noted on top of the right hand and a red bruise noted to the upper right arm. On 06/04/2024 at 1:45 p.m. observation of the video with audio, date and time stamped as 05/19/2024 at 06:07 p.m., revealed a one minute and 59 seconds footage of resident #1 undressed lying in a fetal position on her right side in the bed. S3CNA was observed handling the resident roughly, grabbing onto her lower extremities which were bent at the knees and rapidly, with force attempting to turn her over to the opposite side of the bed. Resident #1 was observed to nearly fall off the edge of the bed, but was caught by S3CNA. S3CNA could be heard on the video cursing using the word s___ and expressing anger at times during the care. S3CNA was also observed to be grabbing at the resident's hands and arms forcefully in order to turn the resident over. Phone interviews were attempted with S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN during the survey with no success on 06/04/2024 at 2:30pm, 6/05/2024 at 9:10 a.m. and 06/05/2024 at 1:10 p.m. On 06/04/2024 at 8:30 a.m. observation of resident #1 revealed she was sitting in her wheelchair in the dining room eating breakfast. Resident #1 was unable to answer questions asked by the surveyor due to cognitive impairment. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice. 1. On 05/20/2024 at 02:50 p.m. responsible party of resident #1 produced video footage of the previous evening (05/19/2024) beginning at approximately 06:07 p.m. through 06:23 p.m. that revealed physical and verbal abuse against resident #1 by S3CNA and S7CNA. 2. On 05/20/2024 all CNA's and LPN involved were suspended pending the results of the investigation. Statements were obtained from staff members present during the care on 05/19/2024 were S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN. 3. On 05/20/2024 body audits were performed on all residents who were cared for by S3CNA and S7CNA. Body audits were then conducted on all resident in the facility and were completed by 05/23/2024. 4. On 05/20/2024 through 05/23/2024- the following In-services were done. 1. Dignity for residents with cameras 2. Dignity and maintaining dignity 3. Abuse and Neglect 4. Definitions and policies for abuse and neglect 5. Reporting abuse and neglect 5. On 05/21/2024 interviews were conducted with residents who were cared for by S3CNA and S7CNA. 6. On 05/23/2024 all CNA's and LPN involved were terminated. The QA (quality assurance) implemented changes and will be monitored by QAPI Quality Assurance Performance Improvement plan) began on 05/20/2024. 1. A QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This will be completed by interviewing a random sample of residents by the DON (director of Nurses) three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 2. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of Incident and Accident reports by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 3. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of nurse's notes by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 4. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of skin inspection monitors by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. The effectiveness of the corrective actions will be discussed weekly for four weeks at the Quality Assurance and Performance Improvement meeting with findings added to the minutes. Additional in-services and or corrective actions will be implemented as needed. The facility was determined to be in compliance as of May 23, 2024 after completing their action plan that included termination of the employees involved in the incident, assessment of residents, completion of the in-services to all facility staff, and continued review of the QAPI monitoring that was put into place by the facility.

Based on observation, record review, and interview the facility failed to provide personal privacy during incontient care for 1 (#1) of 3 (#1,#2,#3) residents reviewed for incontinent care. Findings: Review of resident #1's electronic health record revealed an admitted [DATE] with diagnoses that included encephalopathy, aphasia following cerebral infarction, abnormal weight loss, lack of coordination, muscle wasting, and Alzheimer's disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a BIMS (Brief Mental Status Interview) score of 3 which indicated the resident is cognitively impaired and unable to make daily decisions. Further review revealed the resident needs assistance with all activities of daily living including incontinence care. Review of the facility's investigation documentation revealed the following: On 05/20/2024 it was reported to the facility that S3CNA was physically rough and spoke rudely to resident #1 during incontinence care. Resident #1's responsible party brought a video of the incontinence care performed by S3CNA on 05/19/2024 at 6:10 p.m. to the facility on [DATE]. After watching the video which was time and date stamped for 05/19/2024 at 06:10 p.m., the Administration contacted S3CNA and notified her of being suspended pending completion of the investigation. On 06/04/2024 at 1:45 p.m. an observation of the video with audio, date and time stamped as 05/19/2024 at 06:07 p.m., revealed a one minute and 59 seconds footage of resident #1 undressed lying in a fetal position on her right side in the bed. The video also showed the window blind to be open, the privacy curtain was against the wall and not pulled to obstruct the view of the roommate, and the door to the hall was open during the care being provided. An interview on 06/04/2024 at 10:10 a.m. with S1Administrator confirmed that during the video of incontinence care for resident #1 it showed S7CNA was also in the room with S3CNA and several other CNAs were standing in the doorway. During this video S3CNA was seen in the room, with the door open to the hallway, the privacy curtain opened with the resident in full view of the roommate, and the window blinds opened. S1Administrator stated that privacy should have been provided during the incontient care by the staff, but wasn't. An interview on 06/04/2024 at 11:10 a.m. with S2DON (Director of Nurses) stated S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN (Licensed Practical Nurse) were all suspended on 05/20/2024 while the allegation of abuse was being investigated and they were all terminated on 05/23/2024. S2DON stated after viewing the video provided by resident #1's family that the staff left the blinds open on the window, privacy curtain was not pulled and the resident's door was left open to the hallway when they were providing care to the resident; and privacy was not maintained for resident #1.

Based on record review and interview the facility failed to ensure an allegation of abuse by staff was reported immediately to the facility administrator no later than 2 hours after the allegation was made for 1 (#1) of 3 (#1, #2, #3) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Abuse Policy dated October 2023 revealed the following: Reporting of Accidents and Incidents: Regardless of how minor an injury may be, all accidents or incidents involving a resident, employee or visitor must be reported. Report all accidents or incidents to your immediate supervisor as soon as you can. All accidents/incidents must be reported to the staff/charge nurse as soon as practical, (on that shift). If the accident/incident involves suspected patient abuse/neglect, or injury is of unknown origin, the staff/charge nurse must immediately report it to the Director of Nurses and Administrator so that the facility abuse/neglect reporting and investigation procedures can be implemented. Review of resident #1's electronic health record revealed an admitted [DATE] with diagnoses that included encephalopathy, aphasia following cerebral infarction, abnormal weight loss, lack of coordination, muscle wasting, and Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has a BIMS (Brief Mental Status Interview) score of 3 which indicated the resident is cognitively impaired and unable to make daily decisions. Further review revealed the resident needs assistance with all activities of daily living including incontinence care. Review of the facility's investigation documentation revealed the following: On 05/20/2024 it was reported to the facility that S3CNA was physically rough and spoke rudely to resident #1 during incontinence care on 05/19/2024. Resident #1's responsible party brought a video of the incontinence care performed by S3CNA on 05/19/2024 at 6:10 p.m. After watching the video time and date stamped 05/19/2024 at 06:10 p.m., the Administration contacted S3CNA and notified her of being suspended pending completion of the investigation. Law enforcement was notified and a report was made to the state in reference to the allegation of abuse. Review of the protective actions taken at this time was resident #1 was resident #1 was immediately examined by medical staff for injuries and supervision increased. Results of the exam revealed two red bruises were identified on the left upper arm, and a reddened bruise was noted to the left hand, between thumb and index finger, red bruise was noted on top of right hand and a red bruise noted to the upper right arm. Interview on 06/04/2024 at 10:10 a.m. with S1Administrator confirmed that during the video of incontinence care for resident #1 it showed S7CNA was also in the room with S3CNA and several other CNA's standing in the doorway. During this video recording S3CNA was seen in the room, with the door open to the hallway, curtain opened in view of the roommate, and window blinds opened. S1Administator stated all staff involved were suspended and later terminated. S1Administrator confirmed the staff involved did not report the abuse to anyone and she was not aware of the abuse allegation until after watching the video resident#1's family provided of the care on 05/19/2024. An interview on 06/04/2024 at 11:10 a.m. with S2DON (Director of Nurses) stated S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN were all suspended on 05/20/2024 while the allegation of abuse was being investigated and they were all terminated on 05/23/2024. S2DON stated S7CNA was on one side of resident #1's bed on her phone, while S3CNA was pulling and trying to move the resident in bed very roughly, S7CNA assisted S3CNA pulling the resident up in the bed and then left the resident's room. S2DON confirm S4CNA, S5CNA, S6CNA and S7CNA were standing in resident #1's doorway when the care was provided. S2DON stated the physical exam of resident #1 on 05/20/2024 revealed two red bruises on the left upper arm, a reddened bruise to the left hand, between the thumb and index finger, a red bruise was noted on top of the right hand and a red bruise noted to the upper right arm. S2DON confirmed the staff involved did not report the abuse to anyone and she was not aware of the incident till resident #1's family provided the video evidence on the following day, 05/20/2024. On 06/04/2024 at 1:45 p.m. an observation of the video with audio, date and time stamped as 05/19/2024 at 06:07 p.m., revealed a one minute and 59 seconds footage of resident #1 undressed lying in a fetal position on her right side in the bed. S3CNA was observed handling the resident roughly, grabbing onto her lower extremities which were bent at the knees and rapidly, with force attempting to turn her over to the opposite side of the bed. Resident #1 was observed to nearly fall off the edge of the bed, but was caught by S3CNA. S3CNA could be heard on the video cursing using the word sh__ and expressing anger at times during the care. S3CNA was also observed to be grabbing at the resident's hands and arms forcefully in order to turn the resident over. Phone interviews were attempted with S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN during the survey with no success on 06/04/2024 at 2:30pm, 6/05/2024 at 9:10 a.m. and 06/05/2024 at 1:10 p.m. On 06/04/2024 at 8:30 a.m. observation of resident #1 revealed she was sitting in her wheelchair in the dining room eating breakfast. Resident #1 was unable to answer questions asked by the surveyor due to cognitive impairment. During the survey, in-service records and QA (Quality Assurance) monitoring records were reviewed, and it was determined that the facility had implemented the following actions to correct the deficient practice of reporting abuse incidents according to the facility's policies. 1. On 05/20/2024 all CNA's and LPN involved were suspended pending the results of the investigation. Statements were obtained from staff members present during the care of resident #1on 05/19/2024 were S3CNA, S4CNA, S5CNA, S6CNA, S7CNA and S8LPN. 2. In-services completed: 1. Reporting abuse and neglect-05/21/2024 2. Definitions and policies for abuse and neglect-05/22/2024 3. On 05/21/2024 interviews were conducted with residents who were cared for by S3CNA and S7CNA. 4. On 05/23/2024 all CNA's and LPN involved were terminated. The QA (quality assurance) implemented changes and will be monitored by QAPI (Quality Assurance Performance Improvement plan) began on 05/20/2024. 1. QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This will be completed by interviewing a random sample of residents by the DON (director of Nurses) three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 2. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of Incident and Accident reports by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 3. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of nurse's notes by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. 4. An additional QAPI monitor has been developed to ensure staff is reporting any signs of abuse/neglect/dignity. This monitor will be conducted by reviewing a random sample of skin inspection monitors by the DON three times a week for four weeks then monthly until compliance is reached. Any non-compliance will be addressed. The effectiveness of the corrective actions will be discussed weekly for four weeks at the Quality Assurance and Performance Improvement meeting with findings added to the minutes. Additional in-services and or corrective actions will be implemented as needed. The facility was determined to be in compliance as of May 23, 2024 after completing their action plan noted above.

Based on record reviews and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered careplan for 2 (#4, #32) of 6 (#4, #32, #51, #57, #111, #177) residents reviewed for medication administration.The facility failed to ensure: 1) nurses administered Insulin according to the residents sliding scale parameters, and report high blood surgars to the resident's physician as ordered (#32) 2) nursing staff reported abnormal blood sugars to the attending physician or nurse practioner and failed to update the plan of care to adress the abnormal blood sugars (#4) Findings: Resident #32 Review of resident #32's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Type 2 diabetes mellitus and long term use of Insulin. Review of resident #32's 10/25/2023 Quarterly Minimum Data Set assessment revealed her Brief Interview for Mental Status Score was 11, indicating she was moderately cognitively impaired. Further review revealed resident #32 required substantial to maximal assistance for most Activities of Daily Living. Review of resident #32's January 2024 Physician Orders revealed an order dated 08/06/2022 for blood sugar checks Before Meals and At Bedtime (AC and HS) per Sliding Scale (SS) per Novolog Flexpen as follows: 0-70=give 8 oz juice with 1 pack of sugar 71-250=0 Units (U) 251-300=3U 301-350=4U 351-400=5U 401-450=9U 451-999=10U and call Nurse Practitioner (NP) or Physician (MD) Review of resident #32's January 2023 Medication Administration Record (MAR) revealed on the following dates, the nurses failed to follow the above Novolog Flexpen SS as ordered: On 1/02/2024 at 4:30 p.m., resident #32's Blood Sugar (BS) was 303, and S6 Licensed Practical Nurse (LPN) gave 3U instead of 4U. On 1/07/2024 at 9:00 p.m., resident #32's BS was 496, and S7LPN failed to notify resident #32's MD of the 496 BS and she failed to recheck resident #32's BS after the 496 reading. On 1/08/2024 at 9:00 p.m., resident #32's BS was 323, and S8LPN administered 3U instead of 4U. On 01/10/2024 at 1:30 p.m., an interview with the S2DON confirmed S7LPN failed to notify resident #32's physician of the 496 BS on 1/07/2023 and she also failed to recheck the resident's BS after the high reading. S2DON also confirmed that S6LPN and S8LPN failed to follow resident #32's Novolog Flexpen SS per physician's orders. 40238 Resident #4 Record review revealed resident # 4 was admitted to the facility on [DATE] with diagnoses that included diabetes, Alzheimer`s disease, hypertension and Bipolar disease. Further record review of the most recent completed minimum data set assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 14 which indicated resident #4 was cognitively intact. On 01/08/24 at 11:20 a.m., an interview with resident #4 was conducted in the dining room. Resident #4 reported her blood glucose was not regulated and she thought it might be making her feel bad. Review of resident #4's active orders for January 2024 revealed the following: Humulin R U-100 Insulin give 5 units Subcutaneous before each meal and at bedtime Review of finger stick blood sugars for January 01-07, 2024 for resident #4 revealed the following readings: 01/01/2024 06:30a.m. 63 11:30 a.m. 222 04:30 p.m. 267 09:00 p.m. 354 01/02/2024 06:30a.m. 96 11:30 a.m. 259 04:30 p.m. 201 09:00 p.m. 329 01/03/2024 06:30a.m. 83 11:30 a.m. 197 04:30 p.m. 229 09:00 p.m. 367 01/04/2024 6:30a.m. 213 11:30 a.m. 135 04:30 p.m. 228 09:00 p.m. 354 01/05/2024 06:30a.m. 66 11:30 a.m. 225 04:30 p.m. 292 09:00 p.m. 292 01/06/2024 06:30a.m. 86 11:30 a.m. 484 04:30 p.m. 367 9:00 p.m. 279 01/07/2024 06:30a.m. 75 11:30 a.m. 364 Record review revealed no record of nursing staff notifying the physician or nurse practitioner of the fluctuating blood sugars from 01/01/2024-01/07/2024. Record review revealed no record in progress notes that addressed the fluctuating finger stick blood sugars from 01/01/2024-01/07/2024. Record review revealed the last registered dietician assessment was completed on 02/22/2023. On 01/09/2024 at 2:30 p.m. record review revealed an active care plan initiated on 03/14/2017 related to the potential for alterations in blood sugars related to diabetes. The care plan was last updated on 07/31/2019. On 01/09/2024 at 03:05 p.m. an interview with S3 LPN revealed she had provided care for resident # 4. S3 LPN confirmed resident # 4`s finger stick blood glucose levels had been fluctuating from the 60`s to the 400`s for the past week. S3 LPN reported she did not have record of the physician or nurse practitioner being notified of the abnormal blood sugars from 01/01/2024-01/07/2024. On 01/09/24 at 03:15 p.m. an interview with S4 clinical care coordinator (CCC) confirmed resident # 4 did not have an updated care plan for alterations in blood sugars related to diabetes recorded in the past six months. On 01/09/24 at 03:27 p.m. an interview with S2 DON revealed she was aware of resident # 4 having a history of abnormal blood sugars. S2 DON agreed nursing staff should have reported the abnormal finger stick blood glucose findings from 01/01/2024-01/07/2024 to the attending physician or nurse practitioner.

Based on observation and interview, the facility failed to ensure all drugs and biologicals were accessible only to authorized personnel by failing to ensure the medication room remained locked. Findings: On 01/09/2024 at 6:30a.m., observation of the medication room revealed the door was open and no staff were within the room. There were 3 medication carts within the room that were locked. The carts and the medications within the room were accessible to residents. Medication blister packs were located on open shelves within the room and accessible to anyone that was able to enter the room. Interview at that time with S5LPN confirmed the door to the medication room was open and medications were accessible.

Based on record review and interviews, the facility failed to ensure that all alleged violations involving injuries of unknown source are reported immediately to the state agency, but not later than 2 hours after the allegation is made, if the events that caused the allegation results in serious bodily injury for 1 (#5) of 2 (#3 and #5) resident investigations reviewed. Findings: Review of the facility's current abuse policy revealed, in part: IV. Reporting Requirements: Nursing facility must report to the state agency any incidents and allegations of abuse, neglect, exploitation, misappropriation of resident property and/or injuries of unknown origin immediately, but no later than 2 hours after the allegation is made, if the event that caused the allegation involves abuse or results in bodily harm or injury. Review of the medical record for resident #5 revealed an admitted [DATE], with diagnoses of hypertension, vascular dementia, repeated falls, traumatic subarachnoid hemorrhage with loss of consciousness, multiple fractures of right side ribs, aphasia, hyperlipidemia, vascular dementia, unspecified fracture of facial bones, and fracture of upper end of left tibia. Review of resident #5's Admit Minimum Data Set assessment dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score was assessed to be 5, which indicated she had severely impaired cognitive skills for daily decision making. The resident required one person extensive assistance with bed mobility and toilet use. The resident required two person extensive assistance with transfers and one person limited assistance with dressing, eating, and personal hygiene. The resident had impaired range of motion on one lower extremity. An interview with S3Certified Nursing Assistant (CNA) on 11/01/2023 at 8:22 a.m. revealed she had worked with resident #5 previously and when she noticed the bruise on her right shoulder on 09/18/2023, she notified the nurse. Review of the nurses notes dated 09/18/2023 at 12:00 p.m. by S2Licensed Practical Nurse (LPN) revealed S3CNA notified this nurse of bruise to resident #5's right shoulder and head. When assessed noted large bruise to right shoulder, large bruise to right posterior head and hematoma to right posterior head. Resident #5 denies having a fall or any other type of trauma, resident is unable to recall how she obtained the bruises and hematoma, active range of motion/passive range of motion exercises performed with some pain, resident complained of pain to right upper extremity when moved but denies pain when resting, pain rated 5 on a 10 point scale, right shoulder x-ray ordered. Review of the x-ray report dated 9/18/23 for resident #5 revealed fracture of the distal clavicle of indeterminate age. Findings may be acute and should be correlated clinically. Review of the investigation report turned into the state revealed the incident involving resident #5 was discovered on 09/18/2023 at 5:30 p.m. and entered on 09/19/2023 at 5:17 p.m. Further review revealed the following description: staff observed bruising to right shoulder. X-ray was obtained which showed fracture on the distal clavicle of indeterminate age. Resident #5 denies fall. Last Brief Interview for Mental Status was 5. No falls had been reported by staff. Investigation ongoing at this time. An interview with S1Administrator on 10/31/2023 at 2:30 p.m. confirmed that she was responsible for entering the investigation report that is turned into the state agency. S1Administrator further confirmed the incident was not entered within 2 hours following the discovery of resident #5's fractured clavicle.

Based on observations and interviews, the facility failed to maintain an infection prevention and control program to provide a sanitary environment to help prevent the development and transmission of communicable disease and infections. This deficient practice has the potential to affect all 117 residents who currently received care and services from the provider. 1) The provider failed to ensure all staff wore KN95 face masks during an outbreak status in accordance with facility's policies and procedures; 2) The provider failed to ensure staff's personal items, including cat food was not stored in the clean laundry room; and, 3) The provider failed to ensure staff's personal items were not stored in the hallway and near an area that was designated for resident restorative therapy. Findings: Review of the policy and procedure regarding the use of face mask during an outbreak (Referring to COVID-19) read as follows: Staff were instructed to wear N95 respirators in COVID rooms only, KN95 within the facility during outbreak status, and when out of outbreak status, a surgical mask is appropriated if a mask is desired. On 09/11/2023 at 8:10 a.m., an observation revealed a signage on the doors located at the front entrance of the facility indicating that the facility was in an outbreak status and masks were required. On 09/11/2023 at 8:15 a.m., S2Assistant Administrator confirmed the facility was in a COVID-19 outbreak testing status and all visitors and staff were required to wear a KN95 face mask. On 09/11/2023 at 3:16 p.m., S5ADON (Assistant Director of Nursing) reported that she was currently the facility infection control preventionist. S5ADON (Assistant Director of Nursing) further reported that the facility currently had one employee, S7LPN (Licensed Practical Nurse) who had tested positive for the COVID-19 virus on 09/09/2023 and was on leave at that time. On 09/11/2023 at 4:50 p.m., upon arrival to the laundry department, S8Laundry Worker was observed standing inside of the laundry department without a face mask on. She reported that she was alone in the department when she was not wearing her face mask. Observation of the designated clean laundry room with S8Laundry Worker revealed large fan that was turned and blowing air towards the clean clothing, blankets, and linen items that were located on the shelves. The fan had a large buildup of dust on the fan blades and facing. Observation further revealed a large bag located on a bottom shelf. Inside the bag was a smaller bag containing cat food. S8Laundry Worker reported there was a cat that stayed outside and the workers would use the cat food to feed the animal. Further observation revealed a large black backpack type bag, a cell phone, and a Styrofoam box sitting on top of and in direct contact with a small table top. There were two hand towels on the table. S8Laundry Worker reported the bag, cell phone, and Styrofoam container belonged her (S8Laundry Worker). S8Laundry Worker retrieved the reported that she did have a locker to place her personal belongings in. She further reported that the table was used to fold clothing items for resident use. S8Laundry Worker confirmed that the items should not have been stored in the clean laundry room due to cross contamination. On 09/11/2023 at 5:10 p.m., observation revealed S9CNA and S10CNA ambulating throughout Hall A. Both employees were wearing their KN95 face masks incorrectly as the masks did not completely cover the nose area. On 09/11/2023 at 5:23 p.m., observation revealed S9CNA was observed at the nurses' station with her face mask no applied correctly as it did not completely cover the nose area. On 09/12/2023 at 8:43 a.m., observation revealed S11Housekeeper and S12Transportation Driver standing in the hallway near the laundry department visiting. S11Housekeeper had her face mask down and was drinking. Further observation revealed S12Transportation Driver was wearing a KN95 face mask, but the masks was observed below his nose. S11Housekeeper and S12Transporation Driver reported they knew the masks were supposed to completely cover the bridge of the nose. They confirmed the face masks were incorrectly applied. Further observation of the hallway revealed a small desk that had a hand propelled bicycle type exercise equipment sitting on it. There was a large purse sitting on the window seal to the right of the table. S11Housekeeper reported she thought the purse belonged to S13Restorative CNA. On 09/12/2023 at approximately 9:55 a.m., S3Assistant Administrator was notified of the findings regarding the incorrect use of the face masks and the purse sitting in the window seal. During the observation, S13Restorative CNA was present and confirmed the purse belonged to her and the area next to the purse was designated as the restorative area for residents to participate in restorative exercises. S3Assistant Administrator confirmed the observations of S11Housekeeper and S12Transportation Driver should have on and applied correctly when in the hallway. He further confirmed that S13Restorative CNA should not have stored her purse in the window seal. On 09/13/2023 at 2:13 p.m., observation revealed S14CNA opening the door to exit the room of resident #7 and #8. Further observation revealed S14CNA had a KN95 face mask positioned below her face and in the front of her neck. S14CNA reported she had been assisting resident #7 and the reason she was not wearing the face mask was, because she could not breathe. S14CNA confirmed that she was aware that she was required to wear the face mask during a time of COVID-19 outbreak testing and when providing care for resident #7. After the observation and interview with S14CNA, S2Assistant Administrator was notified of the findings. S2Assistant Administrator confirmed that S14CNA did not wear the face mask as required. On 09/14/2023 at 4:00 p.m., S1Administrator was notified of the above findings that were observed during the Focused Infection Control Survey. S1Administrator confirmed that is was the policy of the facility that all staff were required to have a KN95 face mask and to correctly have the masks placed on their faces during the facility's outbreak testing of COVID-19.

Based on observation, interview and record review the facility failed to ensure that the Administration used its resources effectively to maintain the highest practical well-being for 1 (#1) of 7 residents in a total sample of 7 investigated for dehydration. The facility failed to: 1. Follow their hydration policy regarding the need for monitoring the residents intake and output. 2. Have a system in place to ensure the care plan was reviewed and revised for specific interventions to prevent further dehydration. 3. supervise staff to ensure the resident's plan of care was being implemented to prevent dehydration. The above failures resulted in resident #1 being hospitalized for [REDACTED]. 1. the facility did not follow the resident's written physician orders [REDACTED]. 2. did not ensure a resident's fluid intake was monitored and evaluated to assure the recommended fluids were received (#1, ) 3. did not follow the facility hydration policy and procedure (#1,) 4. did not implement new interventions to prevent further episodes of dehydration after resident was hospitalized for [REDACTED]. 5. did not report resident problems of poor skin turgor and problems with swallowing and chewing to medical doctor (#1). Resident #1 was in immediate jeopardy on 4/9/12 when resident #1 returned from the hospital with a [DIAGNOSES REDACTED]. The facility continued to have no fluid intake monitoring after resident #1 returned from the hospital on [DATE]. The facility failed to implement interventions to prevent the reoccurrence of dehydration after resident # 1 returned from the hospital. On 05/08/12 at 4:10PM, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal which included: 1.) the ADON being responsible for ensuring the daily fluid intake and output report is completed each shift; 2.) the ADON and CNA Supervisor conducted immediate training of staff on proper and accurate intake and output measuring, documenting, and reporting; 3.) staff monitoring of resident #1 for signs and symptoms of dehydration; 4.) the facility notifying the medical doctor and family if resident #1 does not meet fluid requirements; and 5.) the facility ensuring labs are drawn if ordered by the medical doctor. The deficient practice continued at a level G for resident #1, after the removal of the immediate jeopardy on 05/08/12. Findings: 1. Review of the record for sampled resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Nutrition/Hydration policy and procedure revealed: Measuring of actual cc's for intake and output (I and O) purposes will only be monitored for residents meeting the following criteria; residents who are admitted or readmitted to the facility with a [DIAGNOSES REDACTED]. (These residents will have an I and O completed until the Registered Dietitian has reviewed their medical status and verified fluid status is stable, recommending to discontinue I and O monitoring). Review of the readmit orders to the facility from the hospital dated 04/09/12 revealed [DIAGNOSES REDACTED]. Further review of the orders revealed the facility was to monitor the resident's intake and output every shift. Review of the current physician orders [REDACTED]. Review of the dehydration risk assessment dated [DATE] the resident scored 16 which indicated the resident was at risk for dehydration. Review of the plan of care revealed: one glass of water with meals in addition to other fluids, offer fluids every 2 hours while awake, report signs and symptoms of dehydration to MD, monitor % of fluid intake with meals and offer alternate fluid if consumption is less than 50%. Review of the physician orders [REDACTED]. Further review of the May 2012 physician orders [REDACTED].#1 required a minimum of 2036cc/day to prevent dehydration. Fluid needs were recalculated again on 4/12/12 for the resident and the resident now required 2073cc/day. On 5/8/12 at 3:00PM, an interview with S10LPN,MDS Coordinator revealed that she is supposed to review the resident's intake and output monitoring prior to calculating the resident's fluid needs. S10LPN,MDS Coordinator confirmed she did not review the resident's intake and output monitoring when doing the fluid calculations on 4/17/12 and 4/23/12. Review of the February 2012 intake and output monitoring revealed there were no totals for any of the days in February and a total of 15 days were missing documentation of fluids. Review of the March 2012 intake and output monitoring revealed it was not in the record and an interview with S3DON on 5/4/12 at 2PM confirmed she was not able to locate the intake and output monitoring for the month of March. Review of the March 2012 MAR (medication administration record) revealed documentation for fluid intake with meals was on the MAR indicated [REDACTED]. Further review revealed the documentation on each page did not match: On 3/20/12 - page 1 revealed no documentation of fluids (blank) with meals but on page 2 breakfast was a 2, lunch was a 2, and supper a 3. On 3/21/12 - page 1 revealed all meals were a 4 for fluid intake, but page 2 revealed breakfast was a 1, lunch was a 4 and supper was a 3 for fluid intake. On 3/22/12 - page 1 revealed all meals a 4 for fluid intake, but page 2 revealed breakfast 1, lunch 4, and supper a 3 for fluid intake. On 3/23/12 - page 1 revealed all meals a 4 for fluid intake, but page 2 revealed breakfast 1, lunch 4, and supper 3 for fluid intake. On 3/24/12 - page 1 revealed breakfast a 1, lunch 1 and supper 3 for fluid intake, but page 2 revealed all meals were a 3 for fluid intake. A breakdown of the fluids with meals per the MAR indicated [REDACTED]= 1-25%, 2= 26-50%, 3= 51-75%, 4= 76-100%, 5= refused. On 5/4/12 at 10:30AM, interview with S3DON confirmed the two different pages on the March 2012 MAR for fluid intake documentation were different and there was no way to tell which form was accurate. S3DON further confirmed that the facility was unsure how much fluid the resident consumed with each meal. Review of the nurses notes dated 4/6/12 revealed documentation of a week 4 summary for March 27,2012. The notes revealed that the resident had poor skin turgor and some problems with chewing and swallowing. Further review of the nurses' notes revealed there was no documentation the resident's MD was notified of the poor skin turgor of problems with chewing and swallowing. Review of the April 2012 intake and output monitoring revealed it was started on 4/1/12 and 4/2/12 but both days were not totaled. On 4/2/12, the resident was sent to the emergency room and admitted to the hospital. Review of the History and Physical from the hospital admit on 4/2/12 revealed [DIAGNOSES REDACTED]. Review of the hospital admit lab dated 4/2/12 revealed the following results for resident #1: Result: Normal Result: NA 150H (132-146) mmol/L - High sodium indicates dehydration K 4.7H (3.4-4.4) mmol/L - Potassium indicates dehydration CL- 113H (99-109)mmol/L - Chloride indicates dehydration CO2- 33 H (20-31)mmol/L - Carbon [MEDICATION NAME]- dehydration GLU- 116 H (74-106)md/dl - Glucose- diabetes BUN- 29 H (9-23) mg/dl - Blood Urea Nitrogen- dehydration Creat- 1.0 (0.5-1.1) mg/dl - Creatinine Ca 9.5 (8.7-10.4) mg/dl- Calcium TP 7.4 (5.7-8.2) gm/dl - Total Protein Alb 3.6 (3.2-4.8) gm/dl - [MEDICATION NAME] Tbil 0.4 (0.3-1.0) mg/dl - Total Bilirubin Alk Phos 64 (45-129) u/l- Alkaline [MEDICATION NAME] AST 34 (0-34) IU/L- [MEDICATION NAME] Aminotransferase ALT 26 (10-49) U/L- [MEDICATION NAME] Transaminase Mg 2.2 (1.3-2.7) mg/dl- Magnesium Review of the urinalysis dated 4/3/12 (while in the hospital) revealed: Yellow, Yellow,Straw cloudy, Clear SpGr 1.02 1.003-1.035 (Specific Gravity) PH 6.0, 5.0-9.0 Leuk- Lg Negative [MEDICATION NAME]- Neg Negative Protein- Neg Negative Glu- Neg Negative (Glucose) [MEDICATION NAME]- Trace Negative Urobilinogen- 0.2 0.2-1.0 Bilirubin- Neg Negative Occ Blood- Trace Negative Micros- Indicated WBC- TNTC - White Blood Cell-(too numerous to count) RBC- 0-1 - Red Blood Cell Epi- 2+ squamous - [MEDICATION NAME] cells Review of the emergency room report dated 4/2/12 revealed the resident received 2000 cc of normal saline in the emergency room for dehydration. Review of the hospital admit orders dated 4/2/12 revealed the resident was to be given another 500cc [MEDICATION NAME] of normal saline and then continue the intravenous fluids of normal saline at 100cc/hour. Review of the documentation of intake and output monitoring after the resident returned from the hospital on [DATE] revealed they were not totaled and had missing days On 4/9/12-4/12/12 there were no totals for the day and there was no documentation of fluid intake for the 11PM-7AM shift, on 4/16/12-4/17/12 there was no totals of fluid intake calculated, 4/19/12-4/22/12 there was no documentation of intake or output on any of the shifts and there was no total of fluids consumed, on 4/25/12-4/30/12 there was only documentation of fluid intake on 4/25/12 from 3PM-11PM and on 4/26/12 on the 11PM-7AM shift. There was no other documentation of fluid intake or totals for any of the other shifts after 4/27/12. On 5/3/12 at 10:30AM, an interview with S3DON confirmed the documentation of the intake and output monitoring was incomplete and not totaled daily. S3DON further confirmed that the facility was not accurately monitoring the resident's fluid intake in order to prevent further episodes of dehydration. On 5/3/12, review of the May 2012 intake and output documentation revealed no documentation on the 7-3 shift, and no totals. On 5/3/12 at 10:30AM, an interview with the S3DON confirmed the intake and output form for May 2012 was incomplete, not totaled and there was no way to accurately monitor the resident's fluid intake to prevent future dehydration. Review of the resident's plan of care dated 3/1/12 on 5/8/12 revealed there were no new approaches implemented after the resident returned from the hospital with a [DIAGNOSES REDACTED]. On 5/8/12 at 3:00PM, interview with S10LPN,MDS Coordinator confirmed there were no updates to the resident's care plan regarding new interventions to prevent further dehydration. On 5/8/12 at 1:30PM, interview with S11CNA revealed that she gives the resident fluids about 6 times per shift, but the resident takes in very little at a time. S11CNA stated that she was not sure exactly how much the resident consumes because she does not measure the exact amount/cc's. S11CNA revealed she gave the resident a little bit of grape juice between breakfast and lunch but did not measure the exact amount. On 5/8/12 at 1:45PM, interview with S12LPN revealed she had already documented the fluids for the day. At the time of the interview, S12LPN revealed she was not aware of the grape juice S11CNA had given the resident between breakfast and lunch. She confirmed the fluid intake documented would not be correct since she was not aware of the amount of grape juice consumed by the resident.

Based on record review and interview, the facility failed to ensure each resident was provided with sufficient fluid intake to maintain proper hydration and health for 2 (#1, #2) of 2 sampled residents diagnosed with [REDACTED].(#1, #2, #3, #4, #5, #6, #7). The facility failed to: 1. follow the resident's written physician orders to monitor intake and output (#1) 2. ensure a resident's fluid intake was monitored and evaluated to assure the recommended fluids were received (#1, #2 ) 3. follow the facility hydration policy and procedure (#1, #2) 4. implement new interventions to prevent further episodes of dehydration after resident was hospitalized for [REDACTED]. 5. implement interventions to prevent dehydration after resident was assessed as being at risk for dehydration on 03/23/12 (#1) 6. report resident problems of poor skin turgor and problems with swallowing and chewing to medical doctor (#1). Resident #1 was in immediate jeopardy on 4/9/12 when resident #1 returned from the hospital with a [DIAGNOSES REDACTED]. The facility continued to have no fluid intake monitoring after resident #1 returned from the hospital on [DATE]. The facility failed to implement interventions to prevent the reoccurrence of dehydration after resident # 1 returned from the hospital. On 05/08/12 at 4:10PM, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal which included: 1.) the ADON being responsible for ensuring the daily fluid intake and output report is completed each shift; 2.) the ADON and CNA Supervisor conducted immediate training of staff on proper and accurate intake and output measuring, documenting, and reporting; 3.) staff monitoring of resident #1 for signs and symptoms of dehydration; 4.) the facility notifying the medical doctor and family if resident #1 does not meet fluid requirements; and 5.) the facility ensuring labs are drawn if ordered by the medical doctor. The deficient practice continued at a level G for resident #1, after the removal of the immediate jeopardy on 05/08/12. Findings: 1. Review of the record for sampled resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Nutrition/Hydration policy and procedure revealed: Measuring of actual cc's for intake and output (I and O) purposes will only be monitored for residents meeting the following criteria; residents who are admitted or readmitted to the facility with a [DIAGNOSES REDACTED]. (These residents will have an I and O completed until the Registered Dietitian has reviewed their medical status and verified fluid status is stable, recommending to discontinue I and O monitoring). Review of the readmit orders to the facility from the hospital dated 04/09/12 revealed [DIAGNOSES REDACTED]. Further review of the orders revealed the facility was to monitor the resident's intake and output every shift. Review of the current physician orders for May 2012 revealed a diet order for nectar thickened liquids / pureed with no straws; supervise all intake; Ensure one can three times a day with meals; offer fluids every two hours while awake to prevent intravascular volume depletion and to aid in nutritional status. Review of the dehydration risk assessment dated [DATE] the resident scored 16 which indicated the resident was at risk for dehydration. Review of the plan of care revealed: one glass of water with meals in addition to other fluids, offer fluids every 2 hours while awake, report signs and symptoms of dehydration to MD, monitor % of fluid intake with meals and offer alternate fluid if consumption is less than 50%. Review of the physician orders for February through May 2012 revealed the resident was to have intake and output monitored every shift. Further review of the May 2012 physician orders revealed an order to document intake and output every shift: Fluid calculations were performed on 3/23/12 and resident #1 required a minimum of 2036cc/day to prevent dehydration. Fluid needs were recalculated again on 4/12/12 for the resident and the resident now required 2073cc/day. On 5/8/12 at 3:00PM, an interview with S10LPN,MDS Coordinator revealed that she is supposed to review the resident's intake and output monitoring prior to calculating the resident's fluid needs. S10LPN,MDS Coordinator confirmed she did not review the resident's intake and output monitoring when doing the fluid calculations on 4/17/12 and 4/23/12. Review of the February 2012 intake and output monitoring revealed there were no totals for any of the days in February and a total of 15 days were missing documentation of fluids. Review of the March 2012 intake and output monitoring revealed it was not in the record and an interview with S3DON on 5/4/12 at 2PM confirmed she was not able to locate the intake and output monitoring for the month of March. Review of the March 2012 MAR (medication administration record) revealed documentation for fluid intake with meals was on the MAR indicated [REDACTED]. Further review revealed the documentation on each page did not match: On 3/20/12 - page 1 revealed no documentation of fluids (blank) with meals but on page 2 breakfast was a 2, lunch was a 2, and supper a 3. On 3/21/12 - page 1 revealed all meals were a 4 for fluid intake, but page 2 revealed breakfast was a 1, lunch was a 4 and supper was a 3 for fluid intake. On 3/22/12 - page 1 revealed all meals a 4 for fluid intake, but page 2 revealed breakfast 1, lunch 4, and supper a 3 for fluid intake. On 3/23/12 - page 1 revealed all meals a 4 for fluid intake, but page 2 revealed breakfast 1, lunch 4, and supper 3 for fluid intake. On 3/24/12 - page 1 revealed breakfast a 1, lunch 1 and supper 3 for fluid intake, but page 2 revealed all meals were a 3 for fluid intake. A breakdown of the fluids with meals per the MAR indicated [REDACTED]= 1-25%, 2= 26-50%, 3= 51-75%, 4= 76-100%, 5= refused. On 5/4/12 at 10:30AM, interview with S3DON confirmed the two different pages on the March 2012 MAR for fluid intake documentation were different and there was no way to tell which form was accurate. S3DON further confirmed that the facility was unsure how much fluid the resident consumed with each meal. Review of the nurses notes dated 4/6/12 revealed documentation of a week 4 summary for March 27,2012. The notes revealed that the resident had poor skin turgor and some problems with chewing and swallowing. Further review of the nurses' notes revealed there was no documentation the resident's MD was notified of the poor skin turgor of problems with chewing and swallowing. Review of the April 2012 intake and output monitoring revealed it was started on 4/1/12 and 4/2/12 but both days were not totaled. On 4/2/12, the resident was sent to the emergency room and admitted to the hospital. Review of the History and Physical from the hospital admit on 4/2/12 revealed [DIAGNOSES REDACTED]. Review of the hospital admit lab dated 4/2/12 revealed the following results for resident #1: Result: Normal Result: NA 150H (132-146) mmol/L - High sodium indicates dehydration K 4.7H (3.4-4.4) mmol/L - Potassium indicates dehydration CL- 113H (99-109)mmol/L - Chloride indicates dehydration CO2- 33 H (20-31)mmol/L - Carbon [MEDICATION NAME]- dehydration GLU- 116 H (74-106)md/dl - Glucose- diabetes BUN- 29 H (9-23) mg/dl - Blood Urea Nitrogen- dehydration Creat- 1.0 (0.5-1.1) mg/dl - Creatinine Ca 9.5 (8.7-10.4) mg/dl- Calcium TP 7.4 (5.7-8.2) gm/dl - Total Protein Alb 3.6 (3.2-4.8) gm/dl - [MEDICATION NAME] Tbil 0.4 (0.3-1.0) mg/dl - Total Bilirubin Alk Phos 64 (45-129) u/l- Alkaline [MEDICATION NAME] AST 34 (0-34) IU/L- [MEDICATION NAME] Aminotransferase ALT 26 (10-49) U/L- [MEDICATION NAME] Transaminase Mg 2.2 (1.3-2.7) mg/dl- Magnesium Review of the urinalysis dated 4/3/12 (while in the hospital) revealed: Yellow, Yellow,Straw cloudy, Clear SpGr 1.02 1.003-1.035 (Specific Gravity) PH 6.0, 5.0-9.0 Leuk- Lg Negative [MEDICATION NAME]- Neg Negative Protein- Neg Negative Glu- Neg Negative (Glucose) [MEDICATION NAME]- Trace Negative Urobilinogen- 0.2 0.2-1.0 Bilirubin- Neg Negative Occ Blood- Trace Negative Micros- Indicated WBC- TNTC - White Blood Cell-(too numerous to count) RBC- 0-1 - Red Blood Cell Epi- 2+ squamous - [MEDICATION NAME] cells Review of the emergency room report dated 4/2/12 revealed the resident received 2000 cc of normal saline in the emergency room for dehydration. Review of the hospital admit orders dated 4/2/12 revealed the resident was to be given another 500cc [MEDICATION NAME] of normal saline and then continue the intravenous fluids of normal saline at 100cc/hour. Review of the documentation of intake and output monitoring after the resident returned from the hospital on [DATE] revealed they were not totaled and had missing days On 4/9/12-4/12/12 there were no totals for the day and there was no documentation of fluid intake for the 11PM-7AM shift, on 4/16/12-4/17/12 there was no totals of fluid intake calculated, 4/19/12-4/22/12 there was no documentation of intake or output on any of the shifts and there was no total of fluids consumed, on 4/25/12-4/30/12 there was only documentation of fluid intake on 4/25/12 from 3PM-11PM and on 4/26/12 on the 11PM-7AM shift. There was no other documentation of fluid intake or totals for any of the other shifts after 4/27/12. On 5/3/12 at 10:30AM, an interview with S3DON confirmed the documentation of the intake and output monitoring was incomplete and not totaled daily. S3DON further confirmed that the facility was not accurately monitoring the resident's fluid intake in order to prevent further episodes of dehydration. On 5/3/12, review of the May 2012 intake and output documentation revealed no documentation on the 7-3 shift, and no totals. On 5/3/12 at 10:30AM, an interview with the S3DON confirmed the intake and output form for May 2012 was incomplete, not totaled and there was no way to accurately monitor the resident's fluid intake to prevent future dehydration. Review of the resident's plan of care dated 3/1/12 on 5/8/12 revealed there were no new approaches implemented after the resident returned from the hospital with a [DIAGNOSES REDACTED]. On 5/8/12 at 3:00PM, interview with S10LPN,MDS Coordinator confirmed there were no updates to the resident's care plan regarding new interventions to prevent further dehydration. On 5/8/12 at 1:30PM, interview with S11CNA revealed that she gives the resident fluids about 6 times per shift, but the resident takes in very little at a time. S11CNA stated that she was not sure exactly how much the resident consumes because she does not measure the exact amount/cc's. S11CNA revealed she gave the resident a little bit of grape juice between breakfast and lunch but did not measure the exact amount. On 5/8/12 at 1:45PM, interview with S12LPN revealed she had already documented the fluids for the day. At the time of the interview, S12LPN revealed she was not aware of the grape juice S11CNA had given the resident between breakfast and lunch. She confirmed the fluid intake documented would not be correct since she was not aware of the amount of grape juice consumed by the resident. 2. Review of the record for sampled resident #2 revealed the resident had [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was cognitively impaired, dependent on staff for all ADLs and was receiving hospice services. Review of the physician orders dated 1/24/12 revealed an order for [REDACTED]. Review of the medical record revealed that the facility obtained a urine culture from the resident on 4/3/12, with results indicating a UTI with culture results to follow. Review of the record revealed that the facility assessed the resident to be at high risk for dehydration. Review of the resident's most recent fluid calculations (dated 1/28/12) performed by the facility revealed that the resident needed at least 1386cc/day to maintain fluid needs. Review of the resident's monthly intake and output monitoring for March, April and May 2012 revealed multiple skips in the daily documentation and the failure to total up each days fluid intake and output by the facility. Review of the facility policy revealed that residents who have a catheter would be on intake and output monitoring. There was no documented evidence that the facility reassessed the resident's fluid needs after being diagnosed with [REDACTED]. On 5/3/12 at 11AM, interview with S3DON confirmed that the resident' fluid needs was not recalculated after being diagnosed with [REDACTED]. Further interview with S3DON confirmed that the facility was not assessing the resident's fluid intake to ensure the minimum fluid needs were being met to maintain the resident's hydration status.

Based on record review and interview, the facility failed to ensure the care plan was reviewed and revised for 2 (#1, 2) of 7 sampled residents (#1, #2, #3, #4, #5, #6, #7). The facility failed to: 1. ensure the care plans were reviewed and revised to include interventions related to hydration needs (#1) 2. Ensure the care plans were reviewd and revised to include interventions related to urinary tract infection, urinary status, and diet. (#2) 3. Review and revise care plan to include monitoring intake and output every shift as spcified by the physician on re-admission orders [REDACTED] 4. include changes to resident #2's care plan by not having new approaches to address urinary status, urinary tract infections, and diet orders. Resident #1 was in immediate jeopardy on 4/9/12 when resident #1 returned from the hospital with a [DIAGNOSES REDACTED]. The facility continued to have no fluid intake monitoring after resident #1 returned from the hospital on [DATE]. The facility failed to implement interventions to prevent the reoccurrence of dehydration after resident # 1 returned from the hospital. On 05/08/12 at 4:10PM, the immediate jeopardy was removed when the facility presented the survey team with a plan of removal which included: 1.) the ADON being responsible for ensuring the daily fluid intake and output report is completed each shift; 2.) the ADON and CNA Supervisor conducted immediate training of staff on proper and accurate intake and output measuring, documenting, and reporting; 3.) staff monitoring of resident #1 for signs and symptoms of dehydration; 4.) the facility notifying the medical doctor and family if resident #1 does not meet fluid requirements; and 5.) the facility ensuring labs are drawn if ordered by the medical doctor. The deficient practice continued at a level G for resident #1, after the removal of the immediate jeopardy on 05/08/12. Findings: 1. Review of the record for sampled resident #1 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed that the resident was hosptalized on [DATE] with [DIAGNOSES REDACTED]. Review of the plan of care dated 3/1/11 revealed there were no new approaches implemented for the resident to prevent the reoccurrence of dehydration. On 5/8/12 at 3:00PM interview with S10LPN,MDS confirmed there were no updates to resident #1 care plan for new approaches to prevent dehydration. Review of the readmit orders to the facility from the hospital dated 04/09/12 revealed [DIAGNOSES REDACTED]. Further review of the orders revealed the facility was to monitor the resident's intake and output every shift. 2. Review of the medical record for sampled resident #2 revealed that on 4/6/12, the resident was diagnosed with [REDACTED]. The physician ordered antibiotics to treat the UTI. Review of the resident's care plan revealed the UTI and ordered treatment was not updated on the careplan. Further review of the record revealed that the resident's diet was changed to pureed on 12/19/11. The resident's care plan revealed the a feeding deficit related to choking, with a regular diet ordered. The care plan was not updated with the new diet ordered on [DATE]. Further review of the resident's care plan revealed that it addressed a problem of toileting deficit, with approaches to toilet every 2 hours and pericare after each incontinent episode. The care plan also addressed that the resident had an indwelling catheter. The resident's care plan was not updated regarding current urinary status. Further review of the the resident's full care plan revealed that it was last updated 1/28/12-4/28/12. There was no documented evidence that the resident's care plan was updated and current. On 5/3/12 at 11AM, S3DON confirmed the above findings.