Every finding on record at Life Care Center of Rhea County

Based on facility policy review, observations, and interviews, the facility failed to maintain 1 of 1 kitchen and equipment in a clean and sanitary condition, failed to dispose of expired food items, failed to label and date open food items, and failed to maintain nourishment room refrigerator in a clean and sanitary condition in 1 of 2 nourishment rooms which had the potential to affect 71 of 73 residents.The findings include:Review of the facility policy titled, Cleaning Schedule, dated 4/30/2025, revealed .The Director of Food and Nutrition Services shall develop a routine cleaning schedule to ensure that the Food and Service Nutrition Department in maintained in a clean and sanitary manner in accordance with regulatory requirements .Store, prepare, distribute and serve food in accordance with professional standards for food safety .The Director of Food and Nutrition Services monitors the cleaning schedule for timely and appropriate completion of tasks to maintain the department in a clean and sanitary manner .Cleaning Fixed Equipment .the removable parts must be washed and sanitized .non-removable parts cleaned with detergent and hot water, rinsed, air dried, and sprayed with sanitizing solution .Review of the facility policy titled, Ware Washing, dated 4/30/2025, revealed .Procedures for cleaning are readily available to all associates .all items are scraped before being brought to wash .sinks are filled as wash .for washing, rinse with clean water to remove all soap residue, sanitize .Review of the facility policy titled, Food Safety, dated 5/1/2025, revealed .Food is stored and maintained in a clean, safe, and sanitary manner .to minimize contamination and bacterial growth .Pre-packaged food is placed in a leak proof container .the container is labeled .use by date is noted on the label .Food is labeled with the date received .Food not safe for consumption .or the food is in question will be removed .During a kitchen tour observation and interview on 4/6/2026 at 9:50 AM, with the Food Service Director (FSD) and [NAME] A revealed the following:1 single door reach in freezer with a white substance and drip stains on the front of the freezer door and a black substance on and in the folds of the freezer door seal. 1 double oven had black splatter marks and grease covering the surface of the back splash. The right-side oven door had grease build up and food particles in the upper track and a black/brown thick substance streaked down the front of the oven door. The left outer side of the double ovens had grease and residue build up from the adjacent fryer. Grease, grime, food items and dish ware were observed beneath the double ovens on the floor and around the casters. 1 commercial fryer with large amounts of grease build up and food residue. The grease and food particles residue extended down the sides and base of the fryer and onto the floor. The kitchen equipment on either side of the fryer also contained surface grease and food particle buildup. Underneath the fryer were dishes, food items, grease, and grime build up around the casters and bases of the equipment extending to the back wall behind the ovens and fryers. The FSD confirmed the kitchen equipment and floors were not clean or sanitary and stated the cooking equipment was just used to prepare breakfast.1 stationary can opener with a red and black sticky substance on the sides, blade, and base. There was a black substance in the grooves and on the blue square washer of the can opener. The FSD confirmed there was a thick red and black sticky build-up on the components of the can opener, blade, and grooves surrounding the blue square washer and it was not clean. The FSD stated the can opener had just been used to make desert.1 walk in cooler with a large green top container of turkey salad dated 4/1/2026. One medium red top container of turkey salad with a use by date of 3/31/2026 and a shelf-life date of 4/1/2026 available for use. Further tour of the walk-in cooler revealed a dried brown puddle of liquid on a tray holding a milk crate and food debris in the left back corner of the walk-in cooler. The FSD confirmed the turkey salad was expired and available for use. The FSD confirmed the food debris had not been removed and the walk-in cooler needed to be cleaned.1 bag of 10 hardboiled eggs unlabeled, undated and available for use.4 loaves of white bread with a prep (prepare) date of 3/17/2026 and use by date of 3/24/2026 available for use.6 packs of hot dog buns with a prep date of 2/25/2026 and use by date of 3/4/2026 available for use. 7 loaves of Raisin bread with a prep date of 2/25/2026 and a use by date of 3/4/2026 available for use. The FSD stated the labels most likely had not been changed but could not determine when the loaves of bread and buns had been placed for use. 1 open spice container of Cayenne Pepper1 open spice container of Light Chili Powder1 open spice container of Onion Powder1 open spice container of Dill Weed1 open spice container of Ground Mustard1 open spice container of Granulated Garlic1 white plastic cutting board with a black substance on the surface and in the grooves in the center of the cutting board. The FSD confirmed the cutting board was not cleaned properly and stated, .this is not clean . 1 stock pot with a tan flaky caked on residue on the inside wall of the pot. The FSD scraped the residue with her fingers and stated .this must be oatmeal . The FSD confirmed the pot was not clean.1 ice machine with a black/brown unknown substance on the plastic mechanisms inside of the ice machine. The FSD confirmed there was a black substance on the plastic mechanisms inside of the ice machine and conformed the ice machine needed to be cleaned. During a tour on 4/6/2026 at 10:46 AM, of the 200-hall nourishment room with the FSD revealed 1 sandwich unlabeled and undated. The FSD inspected the sandwich and determined it was a turkey salad sandwich. The FSD stated she had no knowledge of how long the sandwich had been in the refrigerator as it was not dated. During an interview on 4/8/2026 at 8:02 AM, the Administrator stated she toured the kitchen on 4/6/2026 after this surveyor toured and confirmed the kitchen was not maintained in a clean or sanitary condition. During a phone interview on 4/8/2026 at 3:08 PM, The Registered Dietician (RD) stated .the sanitary condition of the facility kitchen [NAME] and flows [regular and repeated patterns of change where something declines and improves] .

Based on facility policy review, medical record review, observations, and interviews, the facility failed to provide hand hygiene prior to dining for 3 residents (Resident #72, #30, and #39) of 15 residents observed for dining. Review of the facility's policy titled, Resident Dining Services, revised 4/9/2025, revealed .Resident's receive the necessary services to maintain .personal hygiene .Associates involved in food services will perform hand hygiene prior to distributing trays to residents . Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including Diabetes, Dementia, and Muscle Weakness.Review of the comprehensive care plan for Resident #72 dated 2/12/2026, revealed .Eating: Requires setup .Personal Hygiene: Requires setup .Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #72 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and required set up/clean up assistance with eating and personal hygiene.During an observation on 4/6/2026 at 12:32 PM, Certified Nurse Assistant (CNA) A delivered and set up the lunch meal tray to Resident #72 without offering the resident hand hygiene. CNA A failed to sanitize her hands prior to or after meal set up. Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Parkinson Disease, Muscle Weakness, and Dementia.Review of a quarterly MDS assessment dated [DATE], revealed Resident #30 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact and was independent for eating and required substantial/maximal assistance for personal hygiene. Review of the comprehensive care plan for Resident #30 dated 3/11/2026, revealed .ADL .Self Care Performance Deficit r/t [related to] impaired mobility, Dementia .During an observation on 4/6/2026 at 12:40 PM, Certified Nurse Assistant (CNA) A delivered and set up the lunch meal tray to Resident #30 without offering the resident hand hygiene. CNA A failed to sanitize her hands prior to or after meal set up.Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Diabetes, Muscle Weakness, and Visual Loss.Review of a quarterly MDS assessment dated [DATE], revealed Resident #39 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Resident #39 required setup/clean up assistance for eating and partial/moderate assistance for personal hygiene. Review of the comprehensive care plan for Resident #39 revealed delivered the lunch meal tray to Resident #39. CNA B set up the tray for Resident #39 and failed to offer hand hygiene and failed to sanitize hands after delivering the meal to the resident. , revealed .ADL Assistance .Eating: Requires setup Personal Hygiene: Requires partial/moderate assistance .During an observation on 3/6/2026 at 12:42 PM, CNA B delivered and set up the lunch meal tray to Resident #39 without offering the resident hand hygiene. CNA B failed to sanitize her hands prior to or after meal set up. During an interview on 3/6/2026 at 12:45 PM, CNA A confirmed she had not offered hand hygiene to the residents while passing the lunch trays to Residents #72 and #30 and did not sanitize her hands prior to or after meal setup. During an interview on 3/6/2026 at 12:52 PM, CNA B confirmed she had not offered hand hygiene to the resident while passing the lunch tray to Resident #39 and did not sanitize her hands prior to or after meal set up. During an interview on 3/7/2026 at 12:56 PM, the Infection Preventionist (IP) confirmed hand hygiene was to be offered to residents prior to meals and staff were to perform hand hygiene between residents.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medications were stored properly for 2 residents, (Resident's #39 and #49), and failed to properly store 1 medicated patch.The findings include: Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Visual Loss, and Diabetes. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #39 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation and interview on 4/6/2026 at 2:00 PM, in Resident #39's room revealed 1 nasal spray decongestant [Oxymetazoline HCL 0.05%] in a white container on the bedside table and several cough drops. Further observation revealed 1 opened ear wax removal kit with solution, 1 small medicine cup of barrier cream, and one open box of Med clear canal wax removal in a bath basin on the dresser. The resident stated he kept his nasal spray in his gown pocket for his allergies. During an observation and interview on 4/7/2026 at 11:15 AM, in Resident #39's room revealed 1 nasal spray decongestant [Oxymetazoline HCL 0.05%] in a white container on the bedside table and several cough drops. Further observation revealed 1 opened ear wax removal kit with solution, 1 small medicine cup of barrier cream, and one open box of Med clear canal wax removal in a bath basin on the dresser. The resident showed this surveyor his nasal spray located in the gown pocket and stated, .if they know I have this, they'll throw me out . During an interview on 4/7/2026 at 11:24 AM, the Infection Preventionist (IP) confirmed Resident #39 had nasal spray [Oxymetazoline HCL 0.05%], cough drops, barrier cream, and 2 opened ear wax removal kits in his room. The IP stated, .we administer the medication and remove it from the room. We are not allowed to leave it in the room. He is not supposed to have them . Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Sigmoid colon, Chronic Obstructive Pulmonary Disease, and Vascular Disease. Review of a quarterly MDS assessment dated [DATE] revealed Resident #49 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation and interview on 4/7/2026 at 8:32 AM, in Resident 49's room revealed a medicine cup with 4 orange tablets. The resident stated she gets them from her daughter and keeps them at bedside. During an observation and interview on 4/7/2026 at 11:28 AM, in Resident 49's room revealed a medicine cup with 4 orange tablets. Resident #49 stated she needs them for her stomach. During an interview on 4/7/2026 at 11:30 AM, the IP Nurse stated the observed tablets were antacids and the resident was not permitted to keep them at the bedside. The IP Nurse stated, .we are to watch the resident take the medications, not leave them at bedside . During an observation on 4/6/2026 at 11:00 AM, in the bathroom of room [ROOM NUMBER] revealed a lidocaine patch with the date 1/22 written on the patch, sitting on top of the soap dispenser. During an observation and interview on 4/6/2026 at 11:04 AM, the Unit Manager (UM) confirmed there was a lidocaine patch in the bathroom of room [ROOM NUMBER] and it should not be there. During an interview on 4/7/2026 at 9:21 AM, Infection Preventionist (IP) stated the lidocaine patch in the bathroom of 205 was there from the prior resident .who passed away a couple months ago .

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure resident health information remained private and confidential for 1 resident (Resident #67) of 3 residents observed during medication administration, which had the potential to allow unauthorized individuals access to the residents's private health information.The findings include:Review of the facility's undated policy titled, Safeguarding Electronic Health Information, revealed .Laptop computers .containing PHI [Protected Health Information] should not be left unattended .Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses including Diabetes, Muscle Weakness, and Anxiety.During an observation and interview on 4/7/2026 at 8:05 AM, revealed the 100 hall medication cart computer screen was open with Resident #67's PHI displayed on the screen and visible to the public. Further observation revealed Licensed Practical Nurse (LPN) C walked out of Resident #67's room at 8:07 AM. LPN C stated she .forgot . to ensure the computer screen was locked and covered before leaving the medication cart. LPN C confirmed Resident #67's PHI was not protected and was available for the public to view.During an interview on 4/7/2026 at 2:11 PM, the Infection Preventionist (IP) stated staff were expected to ensure the computer screen was locked and covered to maintain the resident's privacy.

Based on facility policy review, observations, and interviews the facility failed to ensure respiratory equipment was stored appropriately for 4 residents (Residents #1, #5, #27, and #72) of 11 residents observed for oxygen therapy.The findings include: Review of the facility's policy titled, Oxygen Administration (Infection Control, Safety, & [and] Storage), dated 3/3/2026, revealed .To ensure that oxygen is administered and stored safely .Store oxygen and respiratory supplies in bag .when not in use . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Dementia, and Dependence on Supplemental Oxygen. Review of the comprehensive care plan for Resident #1 dated 3/13/2026, revealed .resident has COPD .Give aerosol (breathing treatment) .as ordered . Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The resident had COPD. Review of the medication administration record (MAR) for 4/2026 revealed Resident #1 received .Ipratropium-Albuterol Solution (medication delivered by aerosol treatment) 0.5-2.5 (3) MG [milligrams]/3ML [milliliters] 3 ml inhale orally via nebulizer [device to deliver breathing treatments] four times a day . Continued review revealed the resident received breathing treatments 4 times a day as ordered. During an observation on 4/7/2026 at 9:37 AM, in Resident #1's room, revealed a nebulizer mask was uncovered, open to air, and laying on top of the nebulizer. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of Dementia, Heart Disease, and Heart Failure. Review of a quarterly MDS assessment dated [DATE], revealed Resident #27 scored 0 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan for Resident #27 dated 3/11/2026, revealed .resident has oxygen therapy .administer oxygen as ordered by physician . During an observation on 4/6/2026 at 3:00 PM, in Resident #27's room revealed a oxygen tubing was wrapped around the flow meter uncovered and open to air. Review of the MAR for 4/2026 revealed Resident #27 received .O2 [oxygen] 2 liters PRN [as needed] . on 4/6/2026, 4/7/2026 and 4/8/2026. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Respiratory Failure, and Asthma. Review of the comprehensive care plan for Resident #5 revised 1/14/2026, revealed .resident has oxygen therapy r/t [related to] acute respiratory therapy with hypoxia [lack of oxygen] .give medications as ordered .administer oxygen as ordered by physician . Review of a quarterly MDS assessment dated [DATE], revealed Resident #5 scored 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the MAR for 4/2026 revealed Resident #5 received .Ipratropium-Albuterol Solution 3 ml inhale orally via nebulizer every 6 hours as needed for shortness of breath . Continued review revealed the resident received breathing treatment on 4/6/2026. During an observation on 4/6/2026 at 3:00 PM, in Resident #5's room revealed a nebulizer mask was uncovered and laying on top of her dresser. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses of COPD, Dementia, and Diabetes. Review of the comprehensive care plan for Resident #72 dated 2/13/2026, revealed .resident has COPD .give medications as ordered . Review of a quarterly MDS assessment dated [DATE], revealed Resident #72 scored 12 on the BIMS assessment which indicated the resident was cognitively intact. The resident had COPD. Review of the MAR for 4/2026 revealed Resident #72 received .Ipratropium-Albuterol Solution 3 ml inhale orally via nebulizer four times a day . Continued review revealed the resident received breathing treatments 4 times a day as ordered. During an observation on 4/6/2026 at 3:15 PM, in Resident #72's room revealed a nebulizer mask was uncovered, open to air and laying on top of his dresser next to a urinal containing urine. During an interview on 4/7/2026 at 4:00 PM the Infection Preventionist reviewed photographs obtained by the State Surveyor of the uncovered nebulizer masks and nasal cannula prongs and confirmed the oxygen equipment for Resident's #1, #5, #27, and #72 was not stored appropriately.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with the potential to affect 72 of 73 residents in the facility. The findings include: Review of the facility policy titled, Cleaning Schedule, dated 4/27/2022, showed .The Director of Food and Nutrition Services develops a cleaning schedule, with assistance from the Registered Dietitian, to ensure that the Food and Nutrition Services department remains clean and sanitary at all times .Equipment and Utensil Cleaning and Sanitation - A potential cause of foodborne outbreaks is improper cleaning (washing and sanitizing) of equipment and protecting equipment from contamination .Cleaning Fixed Equipment - when cleaning fixed equipment .the removable parts must be washed and sanitized and non-removable parts cleaned with detergent and hot water .air dried and sprayed with a sanitizing solution .equipment is reassembled .The Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed . During an observation on 9/19/2022 at 10:28 AM, a tour of the kitchen was conducted with the Director of Dietary (DD) and the following was observed: 1.The convection oven had brown dried food debris on the front of both doors, the front of the bottom face plate, and on the bottom shelf of the metal cart where the convection oven was sitting. 2.The top of the steamer cart was found with dried brown food debris. 3.The outside of the deep fryer had dried brown food debris covering both sides. 4.The stove doors had copious amounts of brown/red gum-like buildup. 5. A scoop was observed in the salt storage bin. 6. The can opener had brown/black gum-like food debris above the blade. During an interview on 9/19/2022 at 11:35 AM, the DD confirmed the kitchen equipment was not in sanitary condition, he was responsible for maintaining the cleaniless and oversight of the kitchen, and stated .the equipment cleaning needed to be done . During an interview on 9/21/22 10:43 AM, the Administrator confirmed it was her expectation for the facility's kitchen to be maintained in a sanitary manner.

Based on medical record review and interview, the facility failed to refer 1 resident (Resident #31) of 4 residents reviewed for Pre-Admission Screening and Resident Review (PASARR), to the state-designated authority for a Level II PASARR after the resident was identified with a new mental health diagnosis. The findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Notice of PASARR Level I for Resident #31 dated 9/3/2021, showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record showed a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/21/2022 at 9:55 AM, the Director of Admissions and the Social Services Director stated a new mental health diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .The Director of Admissions confirmed a new PASARR had not been resubmitted after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on the Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, facility policy review, medical record review, and interviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 2 residents (Resident #48 and Resident #50) of 18 residents reviewed for MDS assessments. The findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated October 2019 showed .Weight Loss .Weight should be monitored on a continuing basis .From the medical record, compare the resident's weight in the current observation period to his or her weight in the observation period 180 days ago .If the current weight is less than the weight in the observation period 180 days ago, calculate the percentage of weight loss .Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by the physician .Medications Received .Steps for Assessment . Review the resident's medical record for documentation that any of these medications were received by the resident during the 7-day look-back period .Record the number of days an anticoagulant [medication that decreases the ability of the blood to clot] medication was received by the resident at any time during the 7-day look-back period .Do not code antiplatelet medications such as aspirin/extended release, [MEDICATION(S)], or [MEDICATION(S)] here . Review of the facility's policy titled, Resident Assessment Instrument & Care Plan Development, revised 8/16/2022, shows .The facility will follow the procedures set forth in the Resident Assessment Instrument (RAI) User's Manual 3.0 when completing MDS, Care Area Assessment, and Comprehensive Care Plan . Resident #48 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #48's Order Summary Report showed an order dated 12/20/2021 for Aspirin-[MEDICATION(S)] ([MEDICATION(S)]) (an antiplatelet medication) 25-200 milligrams by mouth two times a day. Review of Resident #48's annual MDS assessment dated [DATE], showed Resident #48 received an anticoagulant daily. During an interview on 9/21/2022 at 9:44 AM, the MDS Coordinator confirmed the annual MDS assessment dated [DATE] was inaccurate as [MEDICATION(S)] had been coded as an anticoagulant. Resident #50 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #50's Weights and Vitals Summary showed Resident #50 weighed 215 pounds (lbs) on 2/15/2022 and 191 lbs on 8/2/2022, indicating Resident #50 had a weight loss of 11.16%. Review of Resident #50's quarterly MDS assessment dated [DATE], showed the resident had no weight loss of 5% or more in the last month or 10% or more in the last 6 months. During an interview on 9/21/2022 at 9:58 AM, the MDS Coordinator stated Resident #50 weighed 215 lbs on 2/15/2022 and 191 lbs on 8/2/2022. The MDS Coordinator confirmed the weights on 2/15/2022 and 8/2/2022 were used for the quarterly MDS assessment dated [DATE]. Continued interview confirmed Resident #50 had a weight loss of greater than 10% and the MDS assessment dated [DATE] was coded inaccurately.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure medical information was not visible for 2 residents (#39 and #66) of 18 residents reviewed for dignity. The findings include: Review of the facility's policy titled, Dignity, dated 8/3/2021, showed .Each resident has the right to be treated with dignity and respect. Interactions and activities with residents .must focus on maintaining and enhancing the resident's self-esteem, self-worth .The facility must protect and promote the rights of the resident .All residents will be treated with dignity and respect .Examples of treating residents with dignity and respect include, but are not limited to .Residents should not be excluded from conservations during activities or when care is being provided, nor should staff discuss residents in settings where others can overhear private or protected information or document in charts/electronic health records where others can see a resident's information .Refraining from practices demeaning to residents . Resident #39 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #39 had severely impaired cognitive skills for daily decision making. During an observation on 9/19/2022 at 11:18 AM, a sign was posted on Resident #39's closet door that read, .[Resident #39's first name] Feeding Tips .Sit upright at/near 90 degrees .Ensure [Resident #39's first name] swallowed the last bite/drink by checking his mouth .Alternate bites/drinks to clear any leftovers in his mouth .Help [Resident #39's first name] take small drinks from the blue cups; don't let him tilt his head back .No pillows during mealseating .Take your time, fast feeding = increased risk of aspiration .Thank you!!! Let me know if you have questions .[Speech Language Pathologist's first and last name] .SLP [Speech Language Pathologist] . The sign was visible to anyone who entered the room. During an observation on 9/19/2022 at 4:05 PM, Resident #39 was lying in bed watching television. A sign was posted Resident #39's closet door that read, .[Resident #39's first name] Feeding Tips .Sit upright at/near 90 degrees .Ensure [Resident #39's first name] swallowed the last bite/drink by checking his mouth .Alternate bites/drinks to clear any leftovers in his mouth .Help [Resident #39's first name] take small drinks from the blue cups; don't let him tilt his head back .No pillows during mealseating .Take your time, fast feeding = increased risk of aspiration .Thank you!!! Let me know if you have questions .[Speech Language Pathologist's first and last name] .SLP [Speech Language Pathologist] . The sign was visible to anyone who entered the room. During a telephone interview on 9/19/2022 at 6:33 PM, Resident #39's responsible party stated she had not requested any signage be placed in the resident's room and the facility staff had not discussed the placement of the signage with her. During an observation on 9/20/2022 at 7:56 AM, Resident #39 was lying in the bed being fed by a facility staff member. There was a sign posted on Resident #39's door that read, .[Resident #39's first name] Feeding Tips .Sit upright at/near 90 degrees .Ensure [Resident #39's first name] swallowed the last bite/drink by checking his mouth .Alternate bites/drinks to clear any leftovers in his mouth .Help [Resident #39's first name] take small drinks from the blue cups; don't let him tilt his head back .No pillows during mealseating .Take your time, fast feeding = increased risk of aspiration .Thank you!!! Let me know if you have questions .[Speech Language Pathologist's first and last name] .SLP [Speech Language Pathologist] . The sign was visible to anyone who entered the room. During an observation and interview on 9/20/2022 at 3:04 PM, in Resident #39's room, the Director of Nursing (DON) confirmed the sign on the closet door was visible to anyone who entered the room. The DON stated the sign was posted by speech therapy. The DON confirmed resident care needs were to be communicated to staff by verbal report or the care plan. During a telephone interview on 9/21/2022 at 10:34 AM, the SLP confirmed she posted the sign in Resident #39's room to notify Resident #39's caregivers of tips to prevent aspiration for the resident. The SLP confirmed the sign had not been requested by or discussed with Resident #39 or Resident #39's responsible party prior to being posted. Resident #66 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual MDS assessment dated [DATE], showed Resident #66 had moderate cognitive impairment and was at risk for developing pressure ulcers. During an observation on 9/19/2022 at 10:50 AM, there was a sign posted on Resident #66's closet door that read, Please, float my heels. The sign was visible to anyone who entered the room. During an observation on 9/19/2022 at 4:01 PM, there was a sign on Resident #66's closet door that read, Please, float my heels. The sign was visible to anyone who entered the room. During a telephone interview on 9/19/2022 at 6:26 PM, Resident #66's emergency contact stated he had not requested for the signage to be posted and the facility had not discussed posting the signage with him. During a telephone interview on 9/19/2022 at 6:45 PM, Resident #66's conservator stated she had not requested for the signage to be posted and the facility staff had not discussed posting the signage with her. During an observation on 9/20/2022 at 7:31 AM, there was a sign posted on Resident #66's closet door that read, Please, float my heels. The sign was visible to anyone who entered the room. During an interview with the DON on 9/20/2022 at 10:03 AM, the DON stated the sign in the resident's room was posted by an unknown staff member as a reminder for staff to float the resident's heels to prevent skin breakdown. During an observation and interview on 9/20/2022 at 2:54 PM, in Resident #66's room, the DON confirmed the sign was visible to anyone who entered the room. The DON confirmed resident care information was to be communicated to staff by the care plan and if signs were posted they should be placed in areas not visible to others, for example behind the closet door. During an interview on 9/20/2022 at 3:39 PM, the DON confirmed the signage in the resident's room had not been requested by the resident or family.

Based on review of the facility policy and procedures, record review, observation and interview, the facility failed to maintain appropriate infection control practices during a dressing change for 1 resident (Resident #31) of 2 residents observed for a dressing change observed and during medication administration for 2 residents (Residents #35 and #32) of 6 residents observed for medication administration. The findings include: Review of the facility's policy titled, Hand Hygiene, revised 7/15/2022, showed .Handwashing/hand hygiene is generally considered the most important single procedure for preventing . infections .Purpose .decrease the risk of transmission of infection by appropriate hand hygiene .When to perform proper hand hygiene with (ABHR) [alcohol-based hand rub] and with soap and water .Before and after all resident contact .After contact with potentially infectious material .After contact with blood, body fluids .Before applying gloves .After removal of gloves . Review of the facility's policy titled, Documentation & Assessment of Wounds, revised 8/23/2021, showed .This facility will utilize .Lippincott procedure .Wound Management, Long Term Care . Review of the facility's undated Lippincott procedure titled, Wound Management, Long Term Care, showed .Implementation .Perform hand hygiene .Put on gloves .Remove the old dressing .Remove .gloves, perform hand hygiene .put on new gloves .Clean the periwound skin .Remove .gloves, perform hand hygiene .put on new gloves . Resident #31 was admitted to facility on 7/19/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set (MDS) assessment dated [DATE], showed Resident #31 had an unhealed pressure ulcer present. During an observation on 9/21/2022 at 7:36 AM, in Resident #31's room, the Wound Nurse removed Resident #31's dressing which was soiled with reddish-brown drainage. The Wound Nurse discarded the soiled dressing, removed the dirty gloves, and donned new gloves without sanitizing the hands. The Wound Nurse cleaned the wound, removed the dirty gloves, and donned new gloves without sanitizing the hands. During an interview on 9/21/2022 at 7:55 AM, the Wound Nurse confirmed the hands were not sanitized after removing dirty gloves and donning new gloves during the dressing change for Resident #31. During an interview on 9/21/2022 at 8:34 AM, the Infection Preventionist stated it was the facility's expectation for the Wound Nurse to sanitize the hands between glove changes when wound care was provided. Resident #35 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 9/19/2022 at 11:15 AM, in Resident #35's room, Licensed Practical Nurse (LPN) #1, with gloved hands, took a blood sample from the resident's finger for a blood glucose test. LPN #1 returned to the medication cart, disinfected the blood glucose testing device, removed the gloves, documented on the computer, and retrieved insulin from the medication cart drawer without disinfecting the hands.The LPN disinfected the hands, donned new gloves and administered insulin to Resident #35. LPN #1 removed the gloves and returned the insulin to the medication cart drawer without disinfecting the hands. The LPN escorted Resident #32 to his room by wheelchair from the dining room. LPN #1 donned new gloves without disinfecting the hands, completed a blood glucose test on Resident #32, discarded the gloves, and documented on the computer without disinfecting the hands. The LPN retrieved the insulin from the medication cart drawer, donned new gloves without disinfecting the hands and administered insulin to Resident #32. LPN #1 removed the gloves and returned the insulin to the medication cart drawer without disinfecting the hands and escorted Resident #32 back to the dining room. During an interview on 9/20/2022 at 8:17 AM, LPN #1 confirmed she had not washed her hands after glove changes and between patient care .it was my mistake . During an interview on 9/21/2022 at 8:40 AM, the Infection Preventionist confirmed staff were expected to disinfect their hands after glove removal and between patient contact.

Based on facility policy review, medical record review, facility documentation review, observation and interview the facility failed to prevent abuse for 1 resident (#2) of 5 residents reviewed for abuse. The findings include: Review of the facility policy, Protection of Residents: Reducing the Threat of Abuse & Neglect, undated revealed .resident has the right to be free from abuse .Resident's must not be subjected to abuse by anyone .includes but is not limited to .other residents .residents will be protected from all types of abuse .Identify, correct and intervene in situations in which abuse .is more likely to occur .Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict .such as: Verbally aggressive behavior; Physically aggressive behavior .Following identification of alleged abuse, the resident(s) .are protected .to prevent recurrence .Interventions must be implemented to assure the safety of all residents . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #1's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. Further review revealed Resident #1 had verbal behaviors directed towards, and of rejection of care. Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #2's significant change in status MDS dated [DATE] revealed the resident scored a 6 on the BIMS indicating the resident had severe impairment. Further review revealed the resident had no verbal or physical behaviors exhibited, no rejection of care and no wandering exhibited. Medical record review of the Comprehensive Care Plan for Resident #1 revealed .has potential to throw items .r/t (related to) Anger, Poor impulse control, [MEDICAL CONDITION] disorder .has potential to be verbally aggressive . AT RISK FOR INEFFECTUAL COPING DUE TO DX (diagnosis): ANXIETY AND DEPRESSION .has a psychosocial well-being problem R/T (related to) DECREASED SENSE OF INITIVATIVE, UNSETTLED RELATIONSHIPS, DEPRESSION . Medical record review of Resident #1's behavior note dated 11/9/19 revealed .cussing, screaming, swinging .not easily redirected . Medical record review of Resident #1's behavioral note dated 11/10/19 revealed .cussing, verbally aggressive . hollering .not easily redirected . Review of the facility documentation review dated 11/14/19 revealed .On 11/9/19, while leaving the dining room, Resident #1 .initiated an attempted physical altercation with Resident #2 resulting in Resident #2 obtaining a skin tear to their left hand . Interview with Resident #1 was attempted on 11/25/19 at 2:15 PM, in the resident's room, revealed the resident stated to the surveyor .Get the (explicit) out of here. I'm not talking to you or any (explicit) body from the state . Interview with CNA#1 on 11/25/19 at 3:32 PM, at the 200 hallway nurses station, revealed (Resident #1) .knows what she is doing .knows right from wrong .she is easily set off and at times combative with staff . Continued interview confirmed Resident #1 was verbally abusive towards other residents and was not easily redirected by staff. Observation and Interview with Resident #2 on 11/25/19 at 3:50 PM, in the breezeway of the main entrance, revealed she had an altercation with another resident about a week ago. The resident states .that one lady (Resident #1) fusses with everyone all the time and wants to fight them . Continued interview revealed that during the altercation with the other resident she got a sore on her hand. (resident showed surveyor her left hand with an area on the top of the hand with scab on top of it). Observation of the Resident #2's left hand revealed a scabbed area to the top of the hand. Interview with LPN #1 on 11/26/19 at 8:27 AM, in the conference room, revealed Resident #1 does exhibit behaviors. She gets mad .cusses .swings .this is typical behavior for her . Interview with CNA #3 on 11/26/19 at 10:21 AM, in the conference room, confirmed on 11/9/19 Resident #2 entered the dining room and Resident #1 yelled .Shut up . and then witnessed Resident #1 hit Resident #2. Continued interview revealed Resident #1 .yells and cusses all the time on a daily basis and was verbally agressive toward others. Interview with the Administrator on 11/26/19 at 1:24 PM, in the conference room, confirmed she was aware of the altercation between the two residents that resulted in a skin tear to Resident #2.

Based on facility policy review, observation, and interview, the facility failed to maintain food at correct temperatures in 1 of 1 walk in cooler; failed to ensure food was sealed and dated in 1 of 1 freezer; failed to ensure pans were completely air dried before storing; failed to clean kitchen equipment; failed to ensure food was sealed and not stored past the expiration date in 1 of 1 dry storage room; failed to maintain resident foods in a sanitary manner in 3 of 3 nourishment rooms, potentially affecting 54 of 55 residents. The findings include: Review of the facility policy, Food and Nutrition Services, dated [DATE], revealed .To prevent contamination of food products and therefore prevent foodborne illness .Provide safe food services .Keep adequate records of temperature: refrigeration .Maintain storage of perishable foods at 41 degrees Fahrenheit or below .Refrigerated foods must be stored at temperatures of 41 degrees Fahrenheit or below .All pots and pans must be air dried .Ranges and grills should be cleaned .equipment should be cleaned and sanitized . Review of the facility policy, Food in Storage Areas, undated, revealed .monitor how effectively the units (refrigerators/coolers) are working .Report any issues with the unit immediately to the Director of Food and Nutrition Services and/or Maintenance .Date food .When items such as cereal .are opened but .entire contents .not used .place in .container with a securely fitting lid. Be sure to label and date the container . Review of the facility policy, Food Brought into Facility, revised [DATE], revealed .Food is stored .in accordance with professional standards for food safety . Observation on [DATE] at 10:45 AM, with the Certified Dietary Manager (CDM), in the kitchen in front of the main walk in cooler, revealed a Refrigerator/Freezer Temperature Log dated (MONTH) 2019, with the following documentation: a) [DATE] a documented PM temperature of 44 degrees. b) [DATE] a documented PM temperature of 42 degrees. c) [DATE] a documented PM temperature of 42 degrees. d) [DATE] a documented PM temperature of 43 degrees. e) [DATE] a documented PM temperature of 43 degrees. f) [DATE] no documentation of PM temperatures. g) [DATE] a documented PM temperature of 42 degrees. h) [DATE] a documented PM temperature of 43 degrees. i) [DATE] a documented PM temperature of 42 degrees. j) [DATE] a documented PM temperature of 42 degrees. k) [DATE] a documented PM temperature of 42 degrees. l) [DATE] a documented PM temperature of 42 degrees. m) [DATE] a documented PM temperature of 42 degrees. n) [DATE] a documented PM temperature of 42 degrees. o) [DATE] a documented PM temperature of 42 degrees. p) [DATE] a documented PM temperature of 42 degrees. q) [DATE] a documented PM temperature of 42 degrees. r) [DATE] a documented PM temperature of 42 degrees. s) [DATE] a documented PM temperature of 42 degrees. t) [DATE] a documented PM temperature of 42 degrees. u) [DATE] a documented PM temperature of 42 degrees. v) [DATE] a documented PM temperature of 42 degrees. w) [DATE] no documentation of PM temperatures. x) [DATE] no documentation of PM temperatures. Interview with the CDM on [DATE] at 10:45 AM, in the kitchen, in front of the walk in cooler, confirmed the CDM was aware the main walk in cooler temperatures were out of range for several days and the CDM did not notify the Maintenance Director. Continued interview confirmed the food items were not maintained at appropriate food temperatures. Observation and interview with the CDM on [DATE] at 10:42 AM, in the kitchen, in the main walk in freezer revealed 10 catfish fillets in a box undated, open to air, and available for resident consumption. Interview with the CDM confirmed the catfish fillets were undated, open to air, and available for resident consumption. Observation and interview with the CDM, on [DATE] at 10:50 AM, in the kitchen, in front of the pan storage rack, revealed 3 stacked 8 quart sized pans, 2 stacked 4 quart sized pans, and 4 stacked long short pans, all covered in a clear liquid substance. Interview with the CDM confirmed the pans were not thoroughly air dried after sanitization before storing. Review of the Weekly Cleaning Schedule for Cooks and Aides dated ,[DATE] revealed the drip pans had not been cleaned for 3 consecutive weeks from [DATE] - [DATE]. Observation and interview with the CDM on [DATE] at 10:55 AM, in the kitchen in front of the gas stove top drip pan area revealed 3 drip pans covered in dry dark brown crusty debris. Interview with the CDM confirmed the staff had not cleaned and maintained the stove top and grill drip pans in a sanitary manner. Continued interview confirmed the facility had not cleaned the stove top and grill drip pans weekly on [DATE], [DATE], and [DATE]. Further interview confirmed the facility failed to follow their policy. Review of the Weekly Cleaning Schedule for Cooks and Aides dated ,[DATE] revealed the deep fryer had not been cleaned weekly on [DATE], [DATE] and [DATE]. Observation and interview with the CDM on [DATE] at 10:58 AM, in the kitchen, in front of the deep fryer, revealed a thick dark brown/black liquid substance with floating dark brown debris scattered throughout the liquid substance. Interview with the CDM confirmed the facility was scheduled to change the grease every 2 days after use. Continued interview confirmed the facility failed to clean the deep fryer weekly as scheduled on [DATE], [DATE], and [DATE]. Observation and interview with the CDM on [DATE] at 11:08 AM, in the dry storage area revealed: a) 1 box of 42 ounces of quick oats, with a use by date of [DATE]. b) 1 plastic storage container of approximately 6 ounces of corn flakes cereal with an open date of [DATE] and a use by date of [DATE]. Further observation revealed the cereal did not have secure lid and was open to air. c) 1 plastic container of approximately 20 ounces of crisp rice cereal did not have secure lid and open to air. d) 1 plastic container of approximately 8 ounces of bran cereal with raisins with an opened date of [DATE] and a use by date of [DATE]. Further observation revealed the cereal did not have a secured lid and was open to air. e) 1 plastic container of approximately 24 ounces of wheat frosted cereal open to air, unlabeled, and undated. f) 1 plastic container of approximately 1 ounce of toasted oats cereal did not have a secure lid and was open to air. Interview with the CDM confirmed the food items did not have a secure tight fitting lid and outdated food items had not been discarded. Continued interview confirmed the facility failed to follow their policy. Observation and interview with the CDM on [DATE] at 11:00 AM, in the 300 hallway nourishment room revealed: a) Two blue hard plastic ice packs stored in the freezer. Continued observation revealed signage on the outside of the freezer door labeled NO ICE PACKS IN FREEZER, ICE PACK TO BE STORED IN THE FREEZER IN THE MED ROOM. b) Dry, yellow, crusty debris scattered throughout the microwave located on the countertop. Interview with the CDM confirmed the ice packs were inappropriately stored in the residents' nourishment refrigerator and the microwave needed cleaning. Observation and interview with the CDM on [DATE] on 11:10 AM, in the 200 hallway nourishment room revealed: a) Nine 11 ounce vanilla flavored liquid bottles of nutritional supplement, in the refrigerator unlabeled with resident's name. b) Five 8 ounce chocolate flavored liquid bottles of nutritional supplements, in the refrigerator with an expiration date of [DATE]. Interview with the CDM confirmed the nutritional supplements were brought in by resident's family or visitors and stored in the nutritional room for individualized personal use. Continued interview confirmed the facility failed to label food brought in by family/visitors with resident's name and discard expired foods brought in by family. Observation and interview with the CDM on [DATE] at 11:18 AM, in the 100 hallway nourishment room revealed: a) Three 4 ounce plastic cups of cottage cheese labeled prepared [DATE] an one 4 ounce plastic cup of peaches labeled prepared [DATE]. Interview with the CDM revealed foods prepared by the kitchen and stored in the nourishment refrigerator should be used by the date prepared or be discarded the next day ([DATE]). b) One 12 ounce plastic squeeze bottle of applesauce approximately ½ full with an expiration date of [DATE]. d) One 20 ounce bottle of dark colored soda approximately ¾ full, undated, and unlabeled with a resident's name. Interview with the CDM confirmed the did not discard expired food items, date food items, or label resident personal food items brought in by family/visitors.

Based on facility policy review, observation, and interview, the facility failed to ensure medications, biologicals, and medical supplies were not expired in 2 of 3 medication rooms observed. The findings include: Review of the facility policy Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles revised 7/23/19, revealed .Facility should ensure that medications and biologicals .have expired date on the label .are stored separate from other medications until destroyed or returned to the pharmacy or supplier . Observation and interview on 8/26/19 at 2:40 PM, with Licensed Practical Nurse (LPN) #1, in the 100 medication room, revealed (1) - 250 milliliters (ml) injectable insulin (medication used to control blood sugar) pen with an expiration date of 11/19/18; (1) - [MEDICATION NAME] Lock (medication used to thin the blood) 5 ml syringe with an expiration date of 8/31/18; (9) - [MEDICATION NAME] Santyl (ointment of wound healing) ointment 30 gram tubes with an expiration date of 10/2018; and (3) - sterile transport swabs (medical supplies used for laboratory testing) with an expiration date of 6/2019. Interview with LPN #1 confirmed the medications, biologicals and supplies were expired and available for patient use. Continued interview confirmed the expired medications and supplies were to be discarded by the nurses. Observation and interview with LPN # 2 on 8/26/19 at 3:36 PM, in the 200 medication room, revealed (100) - [MEDICATION NAME] suppositories (laxative) 10 milligrams (mg) with an expiration date of 6/2019; (1) - Glucose Control Solution (for testing blood glucose) 4 ml bottle with an expiration date of 7/31/19; and (1) - [MEDICATION NAME] Control Solution (solution for testing blood glucose monitors) 4 ml bottle with an expiration date of 7/31/2019. Continued interview confirmed the medications and medical supplies were expired and available for patient use. Further interview confirmed the expired medications and expired medical supplies were to be discarded by the nurses.

Based on review of facility policies, medical record review, review of facility investigation, observations, and interviews, the facility failed to prevent abuse for 1 resident (#30) of 55 residents reviewed for abuse. The findings include: Review of the facility policy Protection of Residents: Reducing the Threat of Abuse & (and) Neglect, revised 11/19/16, revealed, .Charges of abuse and/or neglect are among the most serious allegations that can occur in a nursing home. It becomes paramount for nursing home providers to champion the safety and protection of each resident. To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hard-line, zero tolerance approach to resident abuse .All residents have the right to be free from abuse .Residents must not be subjected to abuse by anyone. This includes but is not limited to: staff .Definitions .Verbal Abuse The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance .Mental Abuse Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. (MONTH) occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Review of the facility policy Protecting Patient Privacy and Prohibiting Mental Abuse: Photography and Social Media, dated 8/30/16, revealed, .This facility will ensure that an environment as home-like as possible will be provided to all patients which will include a culture and environment that treats each resident with respect and dignity. All forms of abuse are prohibited, including mental abuse. Mental abuse may include conduct which causes or has the potential to cause the resident to experience humiliation, intimidations, fear, shame, agitation, or degradation . Review of the facility policy, Protection of Residents: Reducing the Threat of Abuse & Neglect, revised 1/21/19, revealed .To minimize the threat of abuse and/or neglect, nursing homes must incorporate clear-cut policies and practices that demonstrate a hardline, zero-tolerance approach to resident abuse .Each resident has the right to be free from abuse .This includes but is not limited to: staff .Definitions .Verbal Abuse - The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance .Mental Abuse - Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. (MONTH) occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum (MDS) data set [DATE] revealed Resident #30's Brief Interview for Mental Status score was 15, indicating the resident was cognitively intact. Continued review revealed the resident required extensive assistance of one staff member for bed mobility and transfer. Review of a facility investigation witness statement by Resident #30 on 10/10/18 revealed At approximately 9:15 PM I turned on my call light for a diaper and linen change. In the process a CNA (Certified Nursing Assistant) by the name of (CNA #2) turned me by digging her fingers into my hip, thigh & knee. I told her it hurt. She wouldn't let go. I pried her fingers loose. She started screaming at me. She said 'If you didn't piss the bed & soak it we wouldn't have to do this.' I told her to get out! She said 'great' and threw a package of wipes at the mirror. She started waving her arms and as she went out she called me a bastard . Review of a facility investigation witness statement by CNA #2 on 10/10/18 revealed, Went into (Resident #30's room) to help (CNA #3) with (Resident #30), when we were changing his brief and pad he rolled to the right with no problem when he rolled to the left (CNA #3) couldn't get the end of the pad or brief so I gently rolled him so she could reach them. When I did (Resident #30) smacked me on the right hand and said it was hurting his hip I told him I was sorry and he said yes I was sorry and that he didn't want me in his room anymore, so I took off my gloves and left the room. Review of a facility investigation interview conducted by the Administrator with CNA #3 on 10/11/18 revealed, Resident call light on - CNA stated she doesn't go in his room alone because resident 'went off' on her and another CNA .CNA & other CNA was turning resident - resident said that hurts to other CNA and other CNA and resident were 'back and forth' - unclear on words. Other CNA started leaving room and tossed wipes toward mirror. As other CNA was leaving room she stated 'you bastard' while at the door .CNA stated that resident said other CNA was digging fingers into hip. CNA stated she has never seen other CNA like that. Stated she don't think other CNA was intentionally hurt him. Other CNA doesn't normally work with this resident and know how to hold him over. CNA stated it got heated and in the moment . Review of a facility investigation interview by the Administrator and Social Services Director (SSD) with Resident #30 on 10/11/18 revealed, After 9 pm turned on call light - 2 CNAs came into room. Turned resident to one side then another and resident stated when he is turned sometimes his hip hurts. He was on his side and the one CNA had his thigh and he stated that it hurts so resident took his hand and moved her hand. CNA and resident said a few things not clear on words. CNA had stepped back from bed. CNA stated you're not going to talk to us like a dog. Resident told CNA to get out. CNA tossed the wet wipes to counter that hit the mirror. CNA started out the room and said you're a bastard .Resident stated that CNA had commented during change when assisting with changing that they won't have to do this if he didn't piss and drown the bed . Observation and interview with Resident #30 on 8/26/19 at 11:09 AM, in the resident's room, revealed on 10/10/18 CNA #2 was assisting CNA #3 with incontinence care. Continued interview revealed Resident #30 and CNA #2 both got upset during the care and CNA #2 made the comment, .if you didn't piss and soak the bed we wouldn't have to do this . Further interview revealed as CNA #2 left the room .she tossed a package of wipes at the shelf hitting the mirror and called me a bastard. Interview with CNA #2 on 8/28/19 at 8:18 AM, in the conference room, revealed she had provided care for Resident #30 on 10/10/18. Continued interview confirmed while she provided care, the resident became belligerent; she removed her gloves, tossed them in a chair, and left the room. Further interview revealed she denied making any derogatory statement toward Resident #30. Interview with the Director of Nursing (DON) on 8/28/19 at 8:28 AM, in conference room, revealed the DON had reviewed CNA #3's statement with her at the time of the incident. Continued interview with the DON confirmed CNA #3 stated CNA #2 was leaving Resident #30's room, she tossed the wipes toward the mirror and stated, .You bastard . Telephone interview with Licensed Practical Nurse (LPN) #3 on 8/28/19 at 10:35 AM, revealed CNA #2 reported to LPN #3 that she (CNA #2) and Resident #30 got upset with one another during his care and she left the room. Continued interview revealed when LPN #3 interviewed Resident #30, he was upset with CNA #2 because she had called him something to do with his mother, she believes it was bastard. Further interview revealed he did not want her back in his room. Continued interview confirmed during LPN #3's interview with CNA #3, CNA #3 reported Resident #30 and CNA #2 got upset with each other during resident care, and as CNA #2 was leaving the room she tossed a pack of wipes toward the mirror and called the resident a bastard. Interview with the SSD on 8/28/19 at 11:24 AM, in the conference room, revealed she and the Administrator spoke with Resident #30 about the interaction that occurred on 10/10/18. Continued interview revealed Resident #30 told the SSD CNA #2 tossed wet wipes on a table hitting the mirror, and the CNA called him a bastard. Interview with the Administrator on 8/28/19 at 11:35 AM, in the Administrator's office, revealed Resident #30 reported CNA #2 had called him a bastard and had tossed wet wipes onto a table hitting the mirror. During the interview, the facility's policies on abuse and definitions of abuse were reviewed. Further interview revealed the Administrator denied the incident was abuse.

Based on facility policy review, medical record review, review of facility investigation, observation, and interviews, the facility failed to ensure allegations of abuse were reported timely to the State Survey Agency for 1 resident (#30) of 55 residents reviewed for abuse. The findings include: Review of the facility policy Reporting Alleged Abuse, revised 2/7/17, revealed, .Federal requirements mandate that facilities must ensure all allegations of abuse . are reported immediately to their state survey agency. Facilities must ensure that all alleged violations involving abuse .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency .) . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation witness statement by Resident #30 on 10/10/18 revealed At approximately 9:15 PM I turned on my call light for a diaper and linen change. In the process a CNA (Certified Nursing Assistant) by the name of (CNA #2) turned me by digging her fingers into my hip, thigh & knee. I told her it hurt. She wouldn't let go. I pried her fingers loose. She started screaming at me. She said 'If you didn't piss the bed & soak it we wouldn't have to do this.' I told her to get out! She said 'great' and threw a package of wipes at the mirror. She started waving her arms and as she went out she called me a bastard . Review of a facility investigation interview conducted by the Administrator with CNA #3 on 10/11/18 revealed, Resident call light on - CNA stated she doesn't go in his room alone because resident 'went off' on her and another CNA .CNA & other CNA was turning resident - resident said that hurts to other CNA and other CNA and resident were 'back and forth' - unclear on words. Other CNA started leaving room and tossed wipes toward mirror. As other CNA was leaving room she stated 'you bastard' while at the door .CNA stated that resident said other CNA was digging fingers into hip. CNA stated she has never seen other CNA like that. Stated she don't think other CNA was intentionally hurt him. Other CNA doesn't normally work with this resident and know how to hold him over. CNA stated it got heated and in the moment . Observation and interview with Resident #30 on 8/26/19 at 11:09 AM, in the resident's room, revealed on 10/10/18 CNA #2 was assisting CNA #3 with incontinence care. Continued interview revealed CNA #2 made the comment, .if you didn't piss and soak the bed we wouldn't have to do this . Further interview revealed as CNA #2 left the room .she tossed a package of wipes at the shelf hitting the mirror and called me a bastard. Further interview revealed Resident #30 reported the incident to someone at the facility that night, but could not remember who. Continued interview revealed Resident #30 also reported the incident to the Administrator on 10/11/18. Interview with the Administrator on 8/28/19 at 11:35 AM, in the Administrator's office, revealed she was made aware of the allegation of verbal abuse on 10/10/18 between 9:00 PM and 10:00 PM. Continued interview revealed Resident #30 told the Administrator on 10/11/19 that CNA #2 had called him a bastard and had tossed wet wipes onto the table hitting the mirror. Further interview confirmed the facility did not report the alleged allegation to the State Survey Agency. Refer to F-600

Based on facility policy review, medical record review, and interview, the facility failed to ensure residents and/or resident's representative participation in care planning for 2 residents (#23, #52) of 9 residents reviewed for care planning. The findings include: Review of the facility policy Resident Assessment & (and) Care Plan, revised 11/28/16, revealed .an Interdisciplinary Team including but not limited to: The Patient, Social Services, Activities, Dietary, Nursing, Nurse Aide, Therapist, Physician, Pharmacist, and the Patient's family as the patient desires .an individualized person-centered care plan for each patient that is reviewed by the interdisciplinary team with each assessment including the patient and other participants as the patient desires .a written explanation must be included in the patient's medical record if participation of the patient and their representative is determined not to be practicable for the development of the resident's care plan . Medical record review revealed Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #23's Minimum Data Set (MDS) assessments revealed a Quarterly assessment had been completed on 2/28/19, a Quarterly assessment had been completed on 5/31/19, a Quarterly assessment had been completed on 6/11/19, and an Annual assessment had been completed on 7/2/19. Medical record review of Resident #23's Annual MDS assessment dated [DATE] revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had severe cognitive impairment. Medical record review revealed no documentation Resident #23's representative was invited or participated in review of the care plan after each assessment. Interview with Resident #23's family member on 8/26/19 at 12:08 PM, in the resident's room, revealed the family had attended care plan reviews in the past. Continued interview revealed the family had not been invited recently, but was interested in attending. Interview with MDS Nurse #2 on 8/28/19 at 10:22 AM, in the MDS office, confirmed the MDS nurses were responsible for inviting residents or resident's representatives to the care plan reviews. Interview with MDS Nurse #1 on 8/28/19 at 10:23 AM, in the MDS office, confirmed Resident #23's family member visited most days. Interview with MDS Nurse #1 on 8/28/19 at 12:15 PM, in the conference room, confirmed there was no documentation Resident #23's representative had been invited or attended the care plan reviews completed with the Quarterly assessment on 2/28/19, the Quarterly assessment on 5/31/19, the Quarterly assessment on 6/11/19, or the Annual assessment on 7/2/19. Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #52's MDS assessments revealed a Quarterly assessment had been completed on 6/15/19, and a Significant Change in Status assessment had been completed on 8/15/19. Medical record review of the Significant Change in Status MDS assessment dated [DATE], revealed Resident #52 had a BIMS score of 13, indicating the resident was cognitively intact. Medical record review revealed no documentation Resident #52 had been invited or attended the care plan review after the Quarterly assessment completed on 6/15/19 or the Significant Change in Status assessment completed on 8/15/19. Interview with Resident #52 on 8/27/19 at 8:15 AM, in the resident's room, revealed the resident had been invited to care plan reviews in the past and had enjoyed attending. Continued interview revealed the resident had not been invited recently, but would like to attend. Interview with MDS Nurse #1 on 8/28/19 at 12:13 PM, in the conference room, confirmed there was no documentation Resident #52 had been invited or attended the care plan reviews completed after the Quarterly assessment on 6/15/19 or the Significant Change in Status assessment on 8/15/19.

Based on facility policy review, medical record review, review of falls investigations, and interview, the facility failed to implement a fall intervention to prevent accidents for 1 resident (#52) of 3 residents reviewed. The findings include: Review of the facility policy Fall Management, effective 12/13/18, revealed .The facility must ensure .each resident receives adequate supervision and assistance devices to prevent accidents .Implement interventions, including adequate supervision and assistive devices, consistent with .care plan .in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident . Medical record review revealed Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Continued review revealed the resident required total assist of 2 staff members for transfers and total assist of 1 staff member for bathing. Medical record review of the current Comprehensive Care Plan dated 1/14/19 revealed .BATHING/SHOWERING: The resident is able to minimally participate in the shower, staff member x (times)1 with assistance with bathing .resident is at risk for falls r/t (related to) impaired mobility, weakness, diabetes, [MEDICAL CONDITIONS] . Medical record review of a nursing progress note dated 7/17/19 revealed .Resident was getting shower by CNA .the shower chair was slippery while trying to get dressed and she started sliding into floor .assisted .to floor . Review of a facility fall investigation dated 7/17/19 revealed Resident #52 had a fall in the shower room. Continued review revealed .Resident stated the shower chair was slippery while she was getting dressed and she started to slide out. CNA (certified nurse's assistant) .assisted resident to floor .INTERVENTION: DYCEN (dycem) TO SHOWER CHAIR . Medical record review of the care plan revealed an update, .7/18/19 .dycem (non-slip mat) to shower chair . Medical record review of the shower schedule dated 7/17/19-8/28/19 revealed Resident #52 had received a shower on 7/19/19, 7/22/19, 7/24/19, 7/29/19, 7/31/19, 8/2/19, 8/5/19, 8/7/19, 8/9/19, 8/12/9, 8/14/19, 8/16/19, 8/19/19, 8/21/19, 8/23/19, and 8/26/19 (a total of 16 showers) since the fall on 7/17/19. Interview with Resident #52 on 8/27/19 at 8:18 AM, in the resident's room, revealed the resident had a fall .in the shower and slipped out of the shower chair. The girl had finished my shower and had put lotion on me and my gown and I started slipping out of the chair . Interview with Resident #52 on 8/28/19 at 9:35 AM, on the 100 hallway at the nurse's station, revealed the dycem had not been placed in the shower chair since her fall on 7/17/19. Interview with CNA #1 on 8/27/19 at 2:14 PM, in the conference room, revealed .I was .giving her a shower .she was finished with shower .put her gown on and had her briefs pulled up to her knees .when she started to slip out of the wet shower chair. I assisted her to the floor and called for help . Continued interview confirmed she had assisted the resident with showering on days since the fall on 7/17/19 and had not used dycem in the shower chair. Further interview revealed the CNA was not aware a new intervention of dycem in the shower chair had been implemented after the fall on 7/17/19. Interview with the Director of Nursing (DON) on 8/28/19 at 11:54 AM, in the Administrator's office, confirmed the facility failed to implement an intervention to prevent further accidents for Resident #52.

Based on facility policy review, observation and interview the facility failed to follow appropriate infection control practices for 1 Resident (#16) of 3 residents reviewed for pressure ulcers of 28 sampled residents. The findings include: Review of the facility policy, Wound Care/Treatment Clean Dressing Change, revised 2/25/15, revealed .Prepare a clean field with the necessary equipment .Remove your gloves and discard them .Put on new gloves .Follow hand hygiene protocol . Medical record review revealed Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of Resident #16's Care Plan dated 6/21/18 revealed .Resident has pressure ulcer .Stage 4 RIGHT ISCHIUM . Continued review revealed intervention in place included wound care as ordered by physician. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #16 had a Brief Interview of Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. Continued review revealed the Resident had unhealed pressure ulcers stage 1 or higher. Further review revealed Resident #16 received pressure ulcer and surgical wound care. Medical record review of the Physician Orders dated 9/2018 revealed .Right ischium: Stage 4 PU (pressure ulcer): Irrigate with gateway rinse (antifungal), [MEDICATION NAME] (antibiotic), [MEDICATION NAME] (antibiotic) and 400 ml (milliliters) normal saline, apply zinc oxide (skin care and preventive medicine) to periwound (tissue surrounding a wound), apply santyl (medicine to aid with healing of skin ulcers) to necrotic tissue, lightly pack with ¼ strength Dankin's Solution (used as an antiseptic to cleanse wounds in order to prevent infections) and gauze . Cover with ABD pad (highly absorbent dressing that provides padding and protection for large wounds) and tape .Change daily and prn (as needed) . Observation with the Wound Care Nurse, Director of Nursing (DON), Certified Nursing Assistant (CNA) #1 and Physical Therapist (PT) #1 on 9/26/18 at 8:40 AM, of Resident #16's Pressure ulcer wound care and dressing change of the right ischium (hip), in the resident's room, revealed a clean field containing supplies were located on a bedside table next to the resident on the left side of the bed. Continued observation revealed Resident #16 was placed on her right side in the bed for wound care by CNA #1 and the Wound Care Nurse. Further observation revealed the resident's right ischium dressing was removed by the Wound Care Nurse. Continued observation revealed a [DEVICE] was in place on the resident's left ischium and sacral area. Further observation revealed the Wound Care Nurse irrigated the resident's right ischium with the gateway rinse and dried the area. Further observation revealed the Wound Care Nurse then removed her gloves and washed her hands. Continued observation revealed Santyl was then applied to the resident's necrotic tissue on the right ischium. Further observation revealed the Wound Care Nurse began packing the right ischium pressure ulcer with ¼ strength Dankin solution and gauze. Continued observation revealed the Wound Care Nurse was standing on the left side of the resident's bed. The Wound Care Nurse then stated I don't have any scissors while she continued to pack the gauze in Resident #16's right ischium pressure ulcer. Continued observation revealed a pair of scissors laying partially out of a pocket of a nurse jacket laying in a chair, in the corner, on the left side, of the resident's room. Continued observation revealed PT #1 stated I see scissors in your jacket pocket. Further observation revealed the Wound Care Nurse then requested PT #1 retrieve the scissors from the pocket of her jacket lying in chair. Further observation revealed PT#1 handed the Wound Care Nurse the non-sanitized and unclean scissors hanging partially out of her unclean jacket pocket. Continued observation revealed the Wound Care Nurse's gloves were then contaminated by the dirty scissors. Further observation revealed the wound care nurse failed to remove the contaminated gloves. Further observation revealed while wearing the same gloves and holding the contaminated scissors the Wound Care Nurse cut the gauze she had partially packed in Resident #16's right ischium pressure ulcer. Continued observation revealed the Wound Care Nurse then packed the unclean gauze she had contaminated with the scissors into the resident's right ischium pressure ulcer. Further observation revealed the Wound Care Nurse, while wearing the same gloves, applied Zinc oxide to the resident's periwound. Continued observation revealed the Wound Care Nurse then placed the ABD pad on the wound, and the dressing was labeled and dated. Interview with the Director of Nursing on 09/26/18 at 9:57 AM, in the conference room, confirmed the facility failed to adhere to appropriate infection control practices and maintain a sanitary wound care dressing change for Resident #16. Interview with the Wound Care Nurse on 9/26/18 at 11:00 AM, in the conference room, confirmed the scissors were located in her jacket pocket and were not sanitized prior to cutting the gauze used to pack Resident #16's pressure ulcer. Continued interview confirmed the facility failed to adhere to appropriate infection control practices during a pressure ulcer dressing change.

Based on medical record review and interview the facility failed to provide an evaluation and rationale for continued use of a PRN (as needed) antianxiety drug beyond 14 days for 1 resident (#56) of 5 residents reviewed for unnecessary medications of 28 sampled residents. The findings include: Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a readmission Physician's Recapitulation Order dated 8/30/18 for the month of (MONTH) (YEAR), revealed the medication .[MEDICATION NAME] . (an anti-anxiety drug) was prescribed PO (by mouth) every 8 hours PRN. Medical record review of Physician's Progress Notes dated 8/30/18 through 9/16/18 revealed the physician failed to provide an evaluation and rationale for the continued use of the [MEDICATION NAME] beyond 14 days. Medical record review of a PRN Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 9/26/18 at 10:46 AM, in the conference room, confirmed the PRN [MEDICATION NAME] was prescribed for over 14 days, and confirmed the facility failed to document a rationale for the continued use of the PRN antianxiety medication beyond the 14 days.

Based on facility policy review, medical record review, observation, and interview the facility failed to maintain dignity of 1 Resident (#136) of 3 residents reviewed for dignity of 33 sampled residents. The findings included: Review of the facility policy Resident's Rights, undated and signed by the Administrator 9/7/17 revealed, .A resident is treated with consideration, respect and full recognition of his/her dignity and individuality, including privacy in treatment and in care for his/her personal needs . Medical record review revealed Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #136 had a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident was severely cognitively impaired. Continued review revealed the resident required extensive assistance with activities of daily living. Medical record review of Resident #136's care plan dated 5/5/17 revealed .Resident has impaired functional mobility to Bilateral Upper Extremities, Bilateral Lower Extremities . Continued review revealed .Res (resident) has ADL (activities of daily living) Self-Care Deficit .Related to [MEDICAL CONDITION], Dementia . Review of a facility document by the Assistant Director of Nursing (ADON) dated 9/6/17 at 10:45 AM, revealed . (CNA #1) was coming down the hall and (Resident #136) said 'Can somebody take me to my room?' (Certified Nursing Assistant #1) walked by (Resident #136) and (Resident #136) repeated herself again and (CNA #1) said 'I can't right now I'm busy,'I made a stern face to (CNA #1) and she said 'I'll get you in a minute (Resident #136).' I (ADON) went around toward (CNA #1) and told her to move now! . Observation on 9/6/17 at 10:10 AM, in the 100 hall, near the nursing station and lounge area, revealed Resident #136 in a wheel chair. Continued observation revealed CNA #1 walked towards the 100 hall nursing station. Further observation revealed Resident #136 stated to CNA #1 .Can I go to my room . Continued observation revealed CNA #1 continued to walk down the hall toward the nursing station and did not acknowledge Resident #136's request to go to her room. Further observation revealed Resident #136 repeated the request to go to her room a second time. Continued observation revealed CNA #1 turned around and stated in a loud firm tone .No . Further observation revealed the CNA then looked around the nursing station and hall and then stated .In just a minute . in a lower tone. Continued observation revealed CNA #1 walked down the 100 hall away from Resident #136. Interview with the Director of Nursing (DON) on 9/7/17 at 10:42 AM, in the DON's office, confirmed the facility failed to maintain Resident #136's dignity. Continued interview confirmed the facility failed to address the resident's needs immediately. Further interiew confirmed .The way the staff (CNA #1) spoke to the resident. We do not talk to people that way in a harsh tone . Interview with the Administrator on 9/7/17 at 11:03 AM, in the Administrator's office, confirmed the facility failed to maintain Resident #136's dignity.

Based on medical record review, observation, review of a facility investigation, and interview, the facility failed to ensure a safe seating device was provided resulting in Actual Harm and a right ankle fracture when the foot was caught under the wheelchair during transport to one resident (#30) of five residents reviewed. The findings included: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (with 15 being the highest score indicating intact cognition). Continued review revealed the resident was non-ambulatory and used a wheelchair for mobility; and required extensive assistance from one staff person to and from the dining room and activities when using a wheelchair. Medical record review of an Updated Occupational Therapy (OT) Treatment Plan for discharge date d September 4, 2013, revealed resident #30 received OT for wheelchair mobility (custom low-seated wheelchair) from July 16, 2013, and was discharged from therapy on September 4, 2013. Continued review revealed, "...efficiently propels wheelchair 10 (ten) feet to increase functional mobility using B (bilateral) UE (upper extremities)...Further expectation for improvement limited due to pt's (patient's) progressive Parkinson's Disease and decreased insight to deficits. Pt has significant contracture in trunk, hips, and pelvis which causes a leg length discrepancy that R (right) (leg) is longer than L (left) (leg)...wheelchair assists (resident) to be able to sit in a position that (resident) can drive (resident's) chair with (resident's) arms..." Continued review revealed no documentation the resident's feet were used to propel the wheelchair. The resident was discharged from OT services secondary to having reached the maximum potential. Medical record review of an OT evaluation dated March 11, 2014, revealed the reason for referral included wheelchair positioning. Continued review revealed the resident "often scoots (resident's self) down into the wheelchair and "not able to reposition (resident's self) without verbal and tactile cues." Continued review revealed no documentation the resident's feet were used to propel the wheelchair. Further review revealed the resident did not receive OT services after the evaluation. Continued review of OT services provided to resident #30 revealed no documentation the resident's wheelchair was screened or evaluated for safety after March 11, 2014. Review of a facility investigation dated July 20, 2014, revealed, "...7/19 (July 19, 2014) during a transfer (transport) of resident #30 from dining room (resident's) foot got caught under wheelchair. No bruising or swelling. No c/o (complaint of) pain at time. C/O pain the next day..." Continued review revealed the resident had bruising and complaints of pain during assistance with dressing on the morning of July 20 at 7:10 a.m., and was administered Acetaminophen 500 milligrams, by mouth (for pain). Medical record review of a Nurse's Note dated July 20, 2014, at 7:10 a.m., revealed, "While getting (resident #30) up for the day, (resident's) CNA (Certified Nursing Assistant) noticed a large bruise on the right shin with swelling down into the foot. (Physician)...notified. an order for [REDACTED]. (Radiology provider) contacted. Family notified..." Medical record review of a Physician's Telephone Order dated July 20 (no time) revealed, "X-ray of (R) shin & (and) ankle D/T (due to) Lg (large) amt (amount) of bruising and swelling..." Medical record review of an Imaging Services Report of the right ankle dated July 20, 2014, revealed a Bimalleolar (inner and outer side of ankle) versus Trimalleolar (back of ankle) Distal (lower) Tibia (shin bone) and Fibula (smaller bone beside the shin bone) and soft tissue swelling. Medical record review of a Nurse's Note dated July 20, 2014, at 2:02 p.m., revealed resident #30 was transferred to the hospital emergency room (ER). Medical record review of a Nurse's Note dated July 20, 2014, at 5:07 p.m., revealed the resident returned from the ER with the "right ankle wrapped with a bandage (splinted) and an ice pack on top of it." Medical record review of a Physician's Telephone Order dated July 20, 2014, (no time) revealed the resident returned to the facility from the ER with orders for Hydrocodone 7.5 milligrams with Acetaminophen 325 milligrams every four hours as needed for pain; and to contact an Orthopedic office on Monday for follow-up of the fracture ankle. Medical record review of an Orthopedic Consult dated July 25, 2014, at 10:45 a.m., revealed, "Chief Complaint: Right ankle injury, onset 7/20/14...Problems: Bimalleolar fracture of ankle, right...Physical Exam:...patient was seated in a wheelchair. The ankle was ecchymotic and swollen...the skin...was intact...There was no breakdown of skin...from (resident's) prior splint...Assessment and Plan:...Bimalleolar fracture, closed. To wear tall Pneumatic walking boot at all times especially during transfers...This is a non-ambulatory patient with dementia...do not think a cast would be safe as if the ankle shifts in the cast, a pressure sore could develop...a fracture brace may be the lesser of the evils...no indication for surgical management..." Observation of resident #30 on September 8, 2014, at 5:30 p.m., in the dining room, confirmed the resident was seated in a tilt-in-space wheelchair (designed to tilt backward while maintaining the hip, knee, and ankle angles in the same position), which was different from the resident's customized, low-seated wheelchair. Continued observation confirmed the left foot was contracted medially (turned toward the middle of the resident's body) and the right lower extremity was in a fracture stabilization device. Interview with CNA #2 on September 8, 2014, at 5:00 p.m., in the conference room confirmed resident #30 sustained a right ankle fracture on July 19, 2014, between 6:30 p.m., and 7:00 p.m., when being transported out of the dining room after supper. Continued interview confirmed CNA #2 stated, "(Resident's) feet went up under the wheelchair between the wheels and got caught up under there. The wheelchair stopped because the (right) foot was turned and caught on the floor under the wheelchair...I gently pulled (resident's) foot out by pulling on the leg just below the knee...(Resident) pulls feet back under the wheelchair...(resident) has gotten...feet caught before...legs and feet aren't exactly straight (left foot is contracted and right leg is longer than the left)...this is the first time it broke. (Resident) could wheel (resident's self) using (resident's) hands, but not (resident's) feet...did not have any foot pedals (footrests) on...never has had foot pedals (footrests) on her wheelchair that I know of and I've worked here a year...Once I got (resident's) foot out, (resident) was taken (transported) to (resident's) room... in the same wheelchair..." Continued interview with CNA #2 confirmed once the resident was transported, the resident would take the left foot and pull the right foot under the wheelchair; and positioned both feet under the wheelchair once the wheelchair was stopped. Further interview confirmed CNA #2 had not reported the resident's feet getting caught under the wheelchair during transportation and was unable to recall the dates or the number of times the feet were caught under the wheelchair. Interview with the Occupational Therapist on September 8, 2014, at 5:45 p.m., in the conference room confirmed resident #30 had received OT services from July 15 through September 4, 2013 for wheelchair positioning and trunk strengthening due to "lateral trunk lean (the upper body leaned while seated in the wheelchair)." Continued interview confirmed the resident used the arms and hands to self-propel the wheelchair; and no footrests were on the wheelchair. The OT stated, "When the resident's foot was first caught under the wheelchair a referral should have been submitted (to OT) to screen the resident for an appropriate and safe wheelchair (seating device). Continued interview with the Occupational Therapist confirmed, if a referral to screen had been received, the Occupational Therapist would have proceeded with an evaluation; and to prevent injury or the feet from getting caught under the wheelchair, a calf-board and footrests would have been placed on the wheelchair. Further interview with the Occupational Therapist confirmed the facility had failed to ensure a safe seating device was provided for resident #30 resulting in a fracture (Harm) of the ankle. C/O

Based on medical record review, observation, review of a facility investigation, and interview, the facility failed to ensure wheelchair footrests were available for use and failed to ensure a timely evaluation for an appropriate seating device resulting in Actual Harm and a right ankle fracture when the resident's foot was caught under the wheelchair during transport for one resident (#30) of five residents reviewed. The findings included: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (with 15 being the highest score indicating intact cognition). Continued review revealed the resident was non-ambulatory, used a wheelchair for mobility, and required extensive assistance from one staff person to and from the dining room and activities when using a wheelchair. Continued review revealed the resident was not able to stand with stability from a seated position without staff assistance. Further review revealed the resident's range of motion was functionally impaired on both sides of the lower extremities. Medical record review of an Updated Occupational Therapy (OT) Treatment Plan for discharge date d September 4, 2013, revealed resident #30 received OT for wheelchair mobility (custom low-seated wheelchair) from July 16, 2013, and was discharged from therapy on September 4, 2013, once the maximum potential was reached. Continued review revealed the resident propelled the wheelchair using both arms and hands. Continued review revealed the resident had contractures and length discrepancies in the legs (right longer than left) and review revealed no documentation the feet were used for wheelchair mobility. Medical record review of an OT evaluation dated March 11, 2014, revealed the reason for referral included wheelchair positioning. Continued review revealed the resident scooted down into the wheelchair and was not able to reposition (resident's self) without staff assistance. Continued review revealed no documentation the resident's feet were used to propel the wheelchair and the resident did not receive OT services after the evaluation. Continued review revealed no documentation resident #30's wheelchair was screened or evaluated for safety after March 11, 2014. Review of a facility investigation dated July 20, 2014, revealed, "...7/19 (July 19, 2014) during a transfer (transport) of resident #30 from dining room (resident's) foot got caught under wheelchair. Medical record review of a Nurse's Note dated July 20, 2014, at 7:10 a.m., revealed, "While getting resident #30 up for the day, (resident's) CNA (Certified Nursing Assistant) noticed a large bruise on the right shin with swelling down into the foot..." Medical record review of a Physician's Telephone Order dated July 20, 2014, (no time) revealed and x-ray of the right shin and ankle was ordered. Medical record review of an Imaging Services Report of the right ankle dated July 20, 2014, revealed a right ankle fracture with soft tissue swelling. Medical record review of the Nurses' Notes dated July 20, 2014, revealed resident #30 was transferred to the hospital emergency room (ER) at 2:02 p.m., and returned to the facility on the same day at 5:07 p.m., with the right ankle wrapped and splinted. Medical record review of a Physician's Telephone Order dated September 8, 2014, (no time), revealed, "OT (Occupational Therapy) evaluate and treat as indicated for wheelchair positioning." Observation of resident #30 on September 8, 2014, at 5:30 p.m., in the dining room, confirmed the resident was seated in a tilt-in-space wheelchair (designed to tilt backward while maintaining the hip, knee, and ankle angles in the same position). Continued observation on September 8, 2014, at 6:27 p.m., near the 100-Hall Nurse's Station, confirmed the resident remained in the tilt-in-space wheelchair, which did not fit the resident's size. The headrest on the top of the wheelchair was above the resident's head and was too high for the resident's head; and the resident's legs were too short to reach the footrests on the wheelchair. The resident's upper body was unsupported and leaned toward the right; and the bilateral ankles were crossed. Interview with CNA #2 on September 8, 2014, at 5:00 p.m., in the conference room confirmed resident #30 sustained a right ankle fracture on July 19, 2014, between 6:30 p.m., and 7:00 p.m., when being transported out of the dining room after supper. Continued interview confirmed CNA #2 stated, "(Resident's) feet went up under the wheelchair between the wheels and got caught up under there. The wheelchair stopped because the (right) foot was turned and caught on the floor under the wheelchair...I gently pulled (resident's) foot out by pulling on the leg just below the knee...(Resident) pulls feet back under the wheelchair...(resident) has gotten...feet caught before...legs and feet aren't exactly straight (left foot is contracted and right leg is longer than the left)...this is the first time it broke. (Resident) could wheel (resident's self) using (resident's) hands, but not (resident's) feet...did not have any foot pedals (footrests) on...never has had foot pedals (footrests) on her wheelchair that I know of and I've worked here a year..." Further interview confirmed CNA #2 had not reported the resident's feet getting caught under the wheelchair during transportation. Interview with the Occupational Therapist on September 8, 2014, at 5:45 p.m., in the presence of the Therapy Program Manager, in the conference room confirmed footrests were not available in the resident's room for staff to use with resident #30's customized wheelchair (wheelchair used prior to the tilt-in-space wheelchair). Continued interview with the Occupational Therapist confirmed the resident received Occupational Therapy services for wheelchair mobility (custom low-seated wheelchair) from July 16, 2013, and was discharged from therapy on September 4, 2013, and footrests were not used to reduce the risk of falling had the resident attempted to stand. Continued interview confirmed the Occupational Therapist stated, "The custom chair (wheelchair) had footrests, but I didn't leave them in (resident's) room to be used...I was afraid they would get lost." Continued interview confirmed a referral for a screen or evaluation was not received after March 11, 2014, until September 8, 2014. Further interview with the Occupational Therapist confirmed the resident required the use of the footrests during transportation to prevent the feet from getting caught under the wheelchair and the facility had failed to provide the footrests. Interview with the Occupational Therapist, Therapy Program Manager, who is a Physical Therapist, and Director of Nursing (DON), on September 8, 2014, at 6:38 p.m., in the conference room confirmed the resident was identified on September 5, 2014, to be seated in an inappropriate wheelchair, a tilt-in-space wheelchair (implemented on August 28, 2014) without an evaluation. Continued interview with the DON confirmed resident #30 was placed in the tilt-in-space wheelchair on August 28, 2014, and stated, "...I noticed (resident) with (resident's) fractured ankle (right ankle) up under the (customized) wheelchair...I pulled the leg and foot out from under the wheelchair...placed in tilt-in-space wheelchair..." Continued interview confirmed the current wheelchair (tilt-in-space) the resident was seated in was not the correct wheelchair for the resident, and the Therapy Program Manager stated, and the Occupational Therapist agreed, "...It does not provide the trunk support needed or the appropriate leg support due to leg scissoring (crossing of the legs)..." Continued interview confirmed the Occupational Therapist stated, "...The old custom-fitted wheelchair was found in the resident's bathroom on September 5, 2014...I took it to (Therapy Program Manager) and (Therapy Program Manager) asked me to start the process to get a wheelchair evaluation (call the Physician and get an order to evaluate). Continued interview confirmed the Therapy Program Manager stated, and the Occupational Therapist agreed, "It was late on September 5, around 5:00 p.m., when it was discovered the resident was in a different wheelchair (tilt-in-space)..." Continued interview confirmed the Occupational Therapist stated, "I work Monday through Friday...I don't work on Saturday or Sunday...(Therapy Program Manager) waited until today (September 8, 2014) to get the order and I will do the evaluation tomorrow (September 9, 2014-four days later)..." Continued interview with the Occupational Therapist, Therapy Program Manager, and DON confirmed the facility had failed to ensure a timely evaluation for an appropriate seating device for resident #30. C/O