Every finding on record at Maquoketa Care Center

Based on observation, clinical record review, document review, policy review, resident and staff interviews, the facility failed to protect and provide a safe environment for 1 of 3 residents reviewed from resident-to-resident abuse (Resident #32). On 6/14/26 at 7:44 AM Resident #42 walked from his dining room chair over to Resident #32 who sat in a Broda wheelchair (specialty wheelchair) and struck Resident #32 on the left side of the head with his cane. This deficient practice resulted in a 5 Centimeter (CM) bump with a 1 CM lesion to Resident #32's head and facial bruising. The facility reported a census of 33 residents. The concern was identified and corrected June 16, 2026 with an all staff huddle to provide resident safety education, prior to surveyor entrance on June 29, 2026. The deficiency F600 is considered past non-compliance. Findings include:A Progress Note review of Resident #32 and Resident #42's charts revealed a prior resident-to-resident altercation in which Resident #42 struck Resident #32 in face with his cane several times which resulted in bruising to the eye and cheek on 4/19/26. 1. Resident #32's 6/3/26 Minimum Data Set (MDS) Assessment showed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating a moderate cognitive loss. Resident #32 was dependent upon staff for bed to chair transfers and did not walk. The MDS listed diagnoses of Non-Alzheimer's Dementia and depression. Resident #32's ADL Care Plan, target date 8/25/26, documented he was non-ambulatory, utilized a Broda chair for locomotion and was totally dependent upon staff to propel his wheelchair. The Care Plan Focus noted Resident #32 had potential verbally aggressive behaviors toward other residents related to dementia. The Care Plan specified to keep proper separation of the residents during an internal investigation of an incident from 4/19/26. If the resident had agitation and/or showed signs of agitation by becoming verbally aggressive, staff were to provide safety and allow time to de-escalate.An Incident Report dated 6/14/26 at 7:45 AM detailed Resident #32 was involved in a resident-to-resident altercation. Resident #32 was interviewed at 8:45 AM while sitting in his reclined Broda chair with ice on the left side of his head. Resident #32 had a 5 Centimeter (CM) by 2 CM bump with a 1 CM laceration in the center to his left forehead. Resident #32 stated he was sitting, minding his own business when Resident #42 walked by and struck him in the face. He didn't know what triggered (it) and felt unsafe around Resident #42. A 6/15/26 Provider signed Condition Report/Communication Form notified the Provider that Resident #32 was involved in a resident-to-resident altercation and new skin areas were noted. The Weekly Skin assessment dated [DATE] documented Resident #32 with bruising starting to the left hand, a skin tear bump inside above the left eye and a bump above the left eye.2.Resident #42's MDS assessment dated [DATE] documented a BIMS score of 13 out of 15 indicating intact memory. Resident #42 also had intact cognitive abilities for daily decision making, walked with a cane, and transferred from one surface to another surface without staff assistance. The MDS listed diagnoses of stroke and depression.Resident #42's 6/23/26 Care Plan Focus detailed he had the potential to be physically aggressive related to a history of resident-to-resident incident. The Care Plan directed the staff to note if becoming agitated or increased anxiety in the common area. Staff to assist to a quiet area and allow time to de-escalate; separate resident from another resident via room change while looking for placement at another facility; Resident #42 with a history of physical altercation with Resident #32. Staff to monitor and maintain separation between both residents. A 6/14/2026 8:45 AM Nurses Note written by the Director of Nursing (DON) documented she was contacted by the facility at 7:44 AM regarding a resident-to-resident altercation. She advised staff to assist Resident #42 to his room. She arrived at facility at 8:27 AM to interview residents and staff. Resident #42 was interviewed at 8:30 AM, while sitting in bed, in his room eating his cereal. Resident #42 was asked what happened. The resident stated, He got some more. The resident was asked, Why he hit the other resident with his cane? The resident stated, Because he deserved it. Inquired if the other resident had said or done anything to him that resulted in the incident. The resident stated, No, he was smiling about something. If he thinks he is going to get away with calling me a worthless son of a bitch, he has another thing coming. Asked again if the other resident said that to him this morning. The resident stated, No, from before. Then asked resident how many times he thought he hit the other resident. The resident stated, 4-5 times. Based on the conversation, it was determined the resident was still upset about the previous incident from April (4/19/26) and the incident (6/14/26) was unprovoked. The resident was asked if he were to see the other resident again, would he hit him for no reason? The resident stated, Yes. The staff reported the resident was sitting at his table (closest to wall of flowers, facing the wall with flowers) waiting for breakfast. The other resident was brought out and placed, in his Broda chair, next to the back medication cart approximately 15 feet from resident. The Resident had his back toward the other resident involved in the incident. There was one Registered Nurse (RN) and two Certified Medication Aides (CMAs) present in the main dining room when Resident #32 was brought out to the main dining room (MDR). The RN went to assist another resident in Hallway 2. One CMA went to assist a different resident in Hallway 2; two Certified Nursing Assistants (CNAs) were assisting a resident in Hallway 3, and one CNA was assisting a resident in Hallway 2. One CMA was standing at the front medication cart at the time of the incident. She stated she thought Resident (#42) was walking back to his room when he walked by her. The Resident (#42) is independent and comes and goes from the MDR at his leisure. The CMA glanced down at her computer screen when Resident #42 started striking Resident #32. Review of the Facility's Final Investigation revealed the following Direct Witness Statements:Staff H, CNA brought Resident #32 out to the dining room area and placed him next to the back medication cart. She thought placing him next to a staff member would be the safest in case anything happened while Resident #42 was eating breakfast in the dining room. She was in another resident's room when the incident occurred. She hadn't seen Resident #32 since she assisted him to the dining room and Resident #42 was at the dining room table waiting for breakfast. Staff F, CNA/CMA statement documented at approximately 7:44 AM, she was passing medications on the front medication cart when Resident #42 walked past her. She thought the resident was going back to his room. She glanced back down at the Medication Administration Record (MAR) on the computer and heard Resident #42 strike Resident #32. She looked up when Resident #42 struck Resident #32 with his cane. She immediately ran over and separated both residents and had Resident #42 go back and sit at his table. Staff I, Housekeeper statement documented she was behind the nurses' station cleaning the bathroom. She walked out of the bathroom to get rid of garbage when she saw Resident #42 get up from his table. She thought Resident #42 was going back to his room as he is independent. When she looked back up, she witnessed Resident #42 strike Resident #32 with his cane. She did not hear Resident #32 say anything to Resident #42 before the incident. Staff C, RN statement documented Resident #32 was sitting near the nurses' station on the [NAME] side close to the medication cart for Hallway 3/4. She informed the staff to keep an eye on Resident #42 and #32 before she left to go down hallway 2 to help another resident. Staff G, CNA/CMA statement documented at approximately 7:45 AM, she was at the back medication cart located on the [NAME] side of the nurses' station when Staff J, CNA called for help to walk a resident from their room to the main dining room. When she sat the resident down in dining room chair, she heard Staff F, say, No. No. No. When she turned around, she saw Staff F stopping Resident #42. She immediately paged Staff C over the walkie talkie to come to the dining room. A review of the Facility Final Investigation included the following Resident Statements:Interview completed by the DON on 6/14/2026 at approximately 8:30 AM, Resident #32 was asked what happened this morning. Resident stated that he was sitting and minding his own business when Resident #42 walked by and struck him in the face. He didn't know what triggered that and felt unsafe around Resident #42. On 06/14/2026 at approximately 8:45 AM the DON conducted a resident interview with Resident #42. When asked why he hit the other resident, Resident #42 stated he believed Resident #32 deserved it. When asked if the other resident had said or done anything to him that resulted in the incident, Resident #42 stated there was nothing that triggered him in that moment. When asked again if the other resident said anything to him that morning, Resident #42 stated, No, from before. Based on conversation, it was determined Resident #42 was still upset about the previous incident and the incident (6/14/26) was unprovoked. The Administrator conducted another interview on 6/15/2026 with Resident #32. Resident #32 stated his head was sore but he didn't know what happened. When asked if Resident #32 felt safe in the building, Resident #32 stated he would if Resident #42 was not in the building. The Facility Final Investigation Root Cause Analysis determined the primary contributing factor was a failure to consistently maintain previously identified supervision and separation interventions between Resident #42 and Resident #32. Resident #42 remained fixated on the previous altercation and independently approached Resident #32, resulting in the resident-to-resident assault.A 6/29/26 review of Resident #32 and Resident #42's Electronic Healthcare Record Clinical Census revealed Resident #32 and #42 were roommates from 1/12/26 to 3/15/26. Further review revealed a Progress Note written by Staff J, RN which documented on 3/14/26 at 9:00 PM Resident #42 voiced he wished for a new room stating he was sick of his roommate's shit. He hadn't slept in three days and hadn't slept at all. His roommate would not be quiet or let him be. A 6/29/26 review of Resident #42's Clinical Record Progress Notes documented Resident #42 was discharged from the facility to another nursing facility on 6/15/25 at 1:15 PM. Observation on 6/29/26 at 12:40 PM Staff K, CNA assisted Resident #32 as he a sat in the Broda chair from the dining room to his room. Resident #32 did not show any fear of staff or other residents. In an interview completed on 6/29/2026 at 12:54 PM Staff K, CNA reported Resident #32 had been scared of Resident #42. Resident #42 hit him with his cane. There had been more than one episode of him hitting the resident with his cane. They kept Resident #32 in his room for meals and Resident #42 would eat out in the dining room to keep them separated. Staff K didn't feel Resident #32 was afraid of any residents now that Resident #42 was discharged from the facility.In an interview completed on 6/29/2026 at12:56 PM Resident #32 verbalized a while back another resident had hit him in the left side of the forehead with his cane. They had to move him once because of that. Then after he hit him again, they moved him out of the building. He felt safe now. Observation on 6/30/26 at 8:25 AM revealed Resident #32 sitting in a reclined Broda wheelchair in his room with a bedside table across his body. Resident #32 had his call light and his television was on. He showed no signs of distress. During interview on 6/30/2026 at 5:06 PM Staff F reported she was the only staff member in the (main) dining room at the time of the incident. She had positioned her medication cart facing toward the nurses' station so that her back was facing the residents in the dining room. Resident #42 got up from the dining room table, walked approximately 30 feet behind her heading down the 3 Hallway. Resident #32 was seated in the wheelchair across from the other side of the nurses' station (leading down to the 3 Hallway). She thought Resident #42 was going back to his room so she was looking back down at the Electronic Medication Administration Record (EMAR) and pulling medications out of the medication cart when she heard a hitting sound. She looked up and Resident #42 was hitting Resident #32 with his cane in the head. She told Resident #42 to lower his cane and had him go back to sit at the dining room table. Resident #32 had blood from a wound on his head and stated repeatedly, Ouch, ouch, ouch, why did he hit me? Resident #32 had not made any comments prior to the incident. She was shocked that it happened. Someone had told her to watch Resident #32 and #42 as they get into arguments. She thought that meant screaming/yelling. Staff F voiced she didn't know Resident #42 was violent. They were instructed the Hallway 1-2 medication cart was to be positioned toward the residents in the dining room to provide supervision. Observation on 7/1/26 at 7:05 AM Staff F had the medication cart positioned in front of the nurses' station facing toward the residents to be able to provide supervision in the dining room. Observation on 7/1/26 at 7:06 AM Staff G had the 3 and 4 hallway medication cart positioned across from the nurses station on the [NAME] side facing the dining room to be able to supervise residents in the dining room. Interview on 7/1/26 at 8:35 AM Staff C voiced she had to remain in the dining room to provide supervision during the breakfast meal. In an interview completed on 7/1/26 at 9:31 AM Staff G recalled on that day (6/14/26), the CNA's assisted Resident #32 up and placed him by her hallway 3/4 medication cart which was by the activities board across from the nurses' station. There were only 3 CNA staff on duty that day. She got called away from the dining room to go walk a resident. She walked past Resident #42 who was sitting in his dining room chair by the entrance to Hallway 2. She walked another resident past where Resident #42 sat in the dining room and continued to walk the other resident to the back of the dining room by the assistive dining tables. Resident #42 must have gotten up the second she walked by. That was when Resident #42 started hitting Resident #32. She heard Resident #32 screaming. Staff F stopped Resident #42. Resident #32 was bleeding from the left side of his forehead. She and another aide assisted Resident #42 away from the situation. They were told to take him to the back dining room on Hallway 4. Staff G further reported Resident #32 kept repeatedly yelling, Ouch! Ouch! Ouch! Why did he hit me? She thought Resident #42 got in a few hits before Staff F was able to get them separated. After the incident, Resident #42 verbalized Resident #32 had more coming to him and he was a son of a bitch or something like that but definitely said he had more coming to him. She felt Resident #42 recognized Resident #32. Resident #32 did remember after the fact that he was hit by a man with a cane. Resident #32 had bruises to his chin and his hand the next day. Resident #42 did display aggressive behaviors hitting the dining room table when dietary staff did not bring his food out timely. She had reported that to the nurse. She would give Resident #42 a snack and he would be okay with that. She heard other staff state they had been roommates and she felt that was where the hate built up. She didn't recall either resident having any behaviors or interaction prior to the incident. Staff G voiced Staff F hadn't been fully informed of the full aspects of the situation between the two residents. She thought it was just verbal behavior, not physical altercations. When queried if Resident #42 hitting Resident #32 in the head with his cane was abuse, Staff G replied, Yes. The incident could have probably been prevented if Staff H would not have placed Resident #32 in Resident #42's walkway. It was preventable. During interview on 7/1/26 at 9:53 AM Staff C reported the incident occurred on 6/14/26 at 7:44 AM. Staff H assisted Resident #32 from his room out by the wall across from the nurses' station. Staff C said Resident #32's location was okay as long they could keep an eye on him. There were three staff in the dining room at that time. She left the dining room to go check on another resident, then she got a call that an incident happened. She assisted Resident #32 back to his room. She cleaned a small gash that was bleeding on his left forehead around his eye. It had started to bump and bruise. She stopped the bleeding with pressure, steri-stripped the wound, and placed ice on it. Resident #32 kept stating, Why would someone hit me? Resident #32 had been sitting there, not saying anything. Resident #42 walked from his dining room table approximately 10-20 feet to Resident #32. She had told Staff F to keep eyes on the two residents, but did not indicate specific behaviors. Resident #42 meant to hit Resident #32. When queried if Resident #42 hitting Resident #32 was abuse, Staff C stated, Yes. In hindsight, she should have had the staff leave Resident #32 in his room or in a different location in the dining room. Resident #32 emotional trauma was getting less and less. The day after he kept asking why anyone would want to hit him. Observation on 7/01/26 at 10:17 AM Resident #32 lay in bed with call light in rest with eyes closed resting. Interview on 7/1/26 at 10:21 AM Staff F thought Resident #42 got 2-3 more hits in before she was able to stop him. Resident #42 purposely hit Resident #32. Resident #42 said that mother F_cker deserved it or something like that. She felt that Resident #42 abused Resident #32 because he hit him. Staff F voiced she felt the incident could have been avoided if Resident #32 was not been brought out to the dining room until after Resident #42 had eaten and gone back to his room. Resident #42 would get aggressive, worked up and start banging his fists on the table if he didn't get food right away. Staff F specifically voiced the incident could have been prevented, if they told new staff there are violent residents that would hit and not try to sugar coat it. During interview on 7/1/26 at 10:50 AM Resident #32's family member reported Resident #42 had hit Resident #32 in the head with a cane during two separate incidents. They were trying to keep the residents separated. The last time Resident #32 was just sitting next to the nurses' station when Resident #42 came along and decided to hit him with his cane. She had expressed to the nursing home staff that they should be very, very careful, as Resident #42 could hit anybody, even defenseless little ladies. The last thing they tried was to move Resident #42 to a different wing to keep a better eye on him. She wasn't sure that was enough. She was concerned for Resident #32 and all the residents. The first time Resident #32 forgot about the incident. The second time, Resident #32 said something about being concerned that the guy might come in and hit him again. Resident #32 had a bruise around his chin, side of his face, and to his hand. She thought for a while Resident #32 was scared to come out of his room and thought he would get hit again. During an interview on 7/1/26 at 11:38 AM the DON reported there was a prior incident in April 2026 where Resident #42 hit Resident #32 in the head with his cane. After that, they updated Resident #32 and #42's care plans to monitor for agitation and take to a quiet area. Resident#42 never really gave any precursor of being agitated. He has a switch and it just went off. The only person that had set that switch off is Resident #32. She was notified of the incident at 7:45 AM at home by Staff G. When she arrived Resident#32 was in his room with ice on his head. Resident #42 was in his room sitting, eating cereal. The DON reviewed the 6/14/26 Nurses Note that she had written and verbalized the note was what had happened. Based on the conversation she had with Resident #42 that day, Resident #42 intended to hit Resident #32. He knew exactly what he was doing. He recognized Resident #32. Staff F was the only CMA in the main dining room. In talking with Staff F, she didn't feel she was aware of the true prior incident. She expected Staff F to keep eyes on Resident #32 and #42 but with her not having the back ground knowledge and not knowing that Resident #42 had been physical with Resident #32, that may have affected things. The incident may have been prevented if staff had kept Resident #32 in his room until they were ready in the dining room. When queried if Resident #42 had abused Resident #32, the DON stated, Yes. Resident #32 had a bump on the left side of his head with a small laceration and some bruising on his jaw. Through the investigation, after the first encounter, they should have moved Resident #42 to a different room sooner where he wouldn't cross paths with Resident #32. During an interview on 7/1/26 at 12:14 PM the Administrator reported she was out of town on vacation when she got the call from Staff G. She got the details, resident locations, staff locations so that she could initiate a self-report to the State. She verified with Staff C that the residents were separated. She educated staff to keep the residents separated. The following Monday (6/15/26) she did an all-staff huddle running through the 4/19/26 situation and the interventions of medication reviews, identifying behaviors and continued separation since that time obviously didn't work and that was on them. The incident happened again and truly the incident was on them. She re-educated on continued separation. They had been looking at solutions on how to properly educate staff and make it effective. They potentially should have moved Resident #42 so that separation could have been maintained more effectively. The Administrator voiced per the SOM (States Operational Manual) Resident #42 hitting Resident #32 in the head with his cane was abuse. The Abuse Prevention, Identification, Investigation and Reporting Policy revised 4/5/17 included a Policy Statement all resident have the right to be free from abuse. Residents must not be subjected to abuse by anyone, including other residents. The Policy documented Resident Abuse under Federal Certification Guidelines (42 Code of Federal Regulations (CFR) 483.12 and 42 CFR 483.5 defined the following:Abuse means the willful infliction of injury resulting in physical harm, pain or mental anguish. Physical Abuse included hitting. Mental abuse included threats of punishment. Resident-to-Resident physical contact that occurs, which includes where residents are hit and results in physical harm, pain and mental anguish is considered to be resident-to-resident abuse.

Based on observation, clinical record review, policy review and staff interviews, the facility failed to maintain a safe, sanitary, and infection-controlled environment to prevent the potential development and transmission of disease and pathogenic organisms. Specifically, the facility failed to ensure proper hand hygiene protocols were executed during wound care dressing changes for 2 of 2 residents observed (#6 and #24); failed to utilize a gown as part of Enhanced Barrier Precautions (EBP) for 1 of 2 residents observed with indwelling medical devices (Resident #5); and failed to ensure medications were administered free from significant contamination and errors for 2 of 7 residents observed during oral medication administration passes (Resident #18 and Resident #43). Staff dropped oral medications onto the top of a medication cart, retrieved the pills with bare hands, and administered them to the residents. These deficient practices placed the residents at risk for cross-contamination, and created a potential for the introduction of infectious pathogens.Findings include: 1.A Brief Interview for Mental Status, BIMS, evaluation conducted on 6/30/2026 for Resident #5 revealed a score of 15 out of 15 which indicated cognition intact. The Care Plan initiated on 4/13/26 identified a focus area for Enhanced Barrier Precautions related to the resident's feeding tube per Centers for Disease Control and Prevention (CDC) guidelines. The Care Plan established a goal for the resident to remain free from signs and symptoms of infection related to the feeding tube throughout the review period. The Care Plan directed staff to implement the following interventions: a.Ensure a storage bin containing PPE per CDC guidelines is maintained in the resident's room. b. Ensure an EBP alert sign is posted on the resident's door. c. Follow CDC guidelines for Enhanced Barrier Precautions during care. Observation on 6/30/26 at 10:18 AM revealed Staff B, Registered Nurse (RN), entered Resident #5's room to perform a feeding tube site treatment and gauze dressing change. Staff B performed hand hygiene and applied clean gloves, but failed to don a protective gown. A review of the resident's room entry revealed an Enhanced Barrier Precautions (EBP) sign posted on the door, signaling the requirement for full Personal Protective Equipment (PPE) during high-contact cares. In an interview on 6/30/26 at 10:25 AM, Staff B, RN, acknowledged she failed to follow EBP protocols during the feeding tube care. Staff B stated she should have donned a gown for the treatment and confirmed she performed the procedure incorrectly. 2. The MDS dated [DATE] for Resident # 24 identified a BIMS score of 13 out of 15 which indicated cognition intact. The Care Plan initiated on 5/31/26 identified a focus area for multiple venous stasis ulcers of the bilateral lower extremities related to congestive heart failure (CHF) and peripheral vascular disease (PVD). The Care Plan established a goal for the resident to remain free from signs and symptoms of infection. A secondary focus area initiated on 5/31/26 identified the requirement for Enhanced Barrier Precautions (EBP) related to the bilateral lower extremity venous stasis ulcers per Centers for Disease Control and Prevention (CDC) guidelines. The Care Plan established an ongoing goal for the resident to exhibit no signs or symptoms of infection. The Care Plan directed nursing staff to implement the following interventions: a.Ensure a storage bin containing personal protective equipment (PPE) is maintained in the resident's room per CDC guidelines. b. Ensure an EBP alert sign is posted on the resident's door. c. Follow CDC guidelines for Enhanced Barrier Precautions during care Observation on 7/1/26 at 7:19 AM revealed Staff C, Registered Nurse (RN), entered Resident #24's room to perform a left leg dressing change. Staff C performed hand hygiene, donned a protective gown and clean gloves, and gathered treatment supplies. Staff C removed the soiled dressing, cleaned the wound bed, and removed her contaminated gloves. Staff C failed to perform hand hygiene prior to donning a new pair of clean gloves, applying medication to the wound, and covering the site with gauze. Staff C realized she lacked an abdominal (ABD) pad to complete the dressing. Staff C removed her personal protective equipment (PPE), performed hand hygiene, and exited the room to retrieve the supply. Upon returning to the room, Staff C donned a new protective gown and clean gloves, but failed to perform hand hygiene prior to contact. Staff C placed the ABD pad over the wound bed and removed her gloves, failing to perform hand hygiene. Staff C then wrapped the resident's leg with gauze and secured it with tape. Staff C removed the disposable gown and applied compression stockings to the resident. Staff C exited the room to locate clean socks. Upon her return to the room, Staff C performed hand hygiene. In an interview on 7/1/26 at 3:00 PM, The Director of Nursing (DON), stated the facility expected employees to perform hand hygiene prior to entering a resident's room, before and after touching a resident, upon leaving a room, after using the bathroom, after eating, and between glove uses and glove changes. When asked regarding expectations for Enhanced Barrier Precautions, The DON stated staff must implement EBP and wear proper personal protective equipment during any care involving a resident's feeding tube, including dressing changes, application of split gauze, or cleaning the site. She further stated EBP applied to wound care, catheter care, or any direct contact with a resident on contact isolation. When asked to clarify the facility's policy regarding glove changes during a single dressing change and whether hand hygiene is required between removing contaminated gloves and applying clean gloves to administer medication, The DON stated employees must utilize hand hygiene anytime they change their gloves. 3. Resident #6's MDS assessment dated [DATE] showed a BIMS score of 15 out of 15 indicating intact cognition. Resident #6 had diagnoses of coronary artery disease (CAD), high blood pressure, peripheral vascular disease (PDV), diabetes mellitus, and stroke. The MDS documented Resident #6 with an unhealed stage 3 pressure injury, not present upon admission and a diabetic foot ulcer. The Resident received pressure injury care, application of nonsurgical dressings, and application of dressing to the feet. Resident #6's July 2026 Electronic Treatment Administration Record (ETAR) listed the following Physician Orders:a.Left Heel: Cleanse with Vashe (skin cleanser used to clean/irrigate chronic wounds). Apply collagen (advanced wound dressing used to treat complex or stalled wounds) to any areas of undermining, cover with Poly Mem AG (scored) (an advanced wound care dressing infused with silver to fight germs and infections), then cover with ABD pad and secure in place with roll gauze and tape, one time a day every Wednesday and Saturday for wound treatment. Start date 6/27/2026.b.Right Lateral Foot: Cleanse with Vashe. Apply collagen to any areas of undermining, cover with Poly Mem AG (scored), then cover with ABD pad and secure in place with roll gauze and tape. Change one time a day on Wednesday and Saturdays for wound treatment. Start date 6/27/2026. Observation on 7/01/26 at 1:42 PM Staff C, donned a mask, isolation gown, washed her hands and donned gloves. Staff C set up two clean barriers on the floor with the dressing supplies sitting on a clean barrier to Staff C's left side. Resident #6 sat in his wheelchair. Staff C sat directly on the floor. During the provision of the treatment, Staff C measured the left heel pressure wound, then laid the measuring tape and her pen directly on the floor to her right side. Staff C placed the collagen, PolyMem Ag dressing, ABD pad and Kling gauze. Staff C picked the dirty pen from the floor with her right gloved hand, dated a piece of tape with the pen then used her gloved hands to secure the tape over the left foot pressure injury wound dressing. Staff C changed her gloves without performing hand hygiene, removed Resident #6's padded boot and gripper sock from his right foot. Staff C changed her gloves and performed hand hygiene, applied new gloves and proceeded to cleanse Resident #6's diabetic wound as ordered. Staff C measure the diabetic wound to the right outer foot. Picked up the dirty pen from the floor, wrote down the measurements, then laid the measuring tape and pen back down directly on the floor. Staff C picked up the scissors cut the collagen dressing and AG dressing to fit the wound. Staff C placed the collagen dressing on the wound, tapping her contaminated glove on top of the collagen dressing on the wound. Staff C proceeded to open a package of rolled gauze on the clean barrier. She placed the black AG dressing, ABD pad and covered the wound dressing with the Kling gauze. Staff C measured a 0.6 Centimeters (CM) by 0.6 CM area to the top of the right foot. Staff C then applied betadine to the area. Staff C removed her gloves, performed hand hygiene, gloved and finished applying the Kling wrap to the right foot. Staff C then picked up the dirty pen from the floor, wrote the date on a piece of tape and secured the Kling gauze with the piece of tape. Staff C used the same dirty gloves to apply Lamictal lotion to the left and right lower legs and toes. Staff C then picked up the measuring tape from the floor and placed along the left toes to measure what she called scabby areas then placed the measuring tape back directly onto the floor. Observation on 7/1/26 at 2:59 PM of the July 2026 Electronic Treatment Administration Record (ETAR) revealed Staff C signed off the physician ordered treatments as completed. During an interview on 7/1/26 at 3:13 PM the DON explained it should be second nature as Staff C had done Resident #6's treatments before. She would expect all supplies, anything the nurse needed to touch to be on a clean barrier. A plastic bag or dirty barrier should have been set up to contain any dirty items. After she handled the dirty pen from the floor, she should have removed her gloves, performed hand hygiene and put on clean gloves. Ideally, she would have the nurse set a pen on a barrier and remove her gloves before using the pen to write down measurements. The Clean Dressing Change Policy revised 1/2026 documented it was the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. The Policy directed to set up a clean field on the overbed table with needed supplies for wound cleansing and dressing application. Place a disposable cloth or linen saver on the overbed table. Place only the supplies to be used per wound on the clean field at one time (wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings and tape. Establish area for soiled products to be placed (chux or plastic bag). 4. Observation of the afternoon medication administration on 6/29/26 at 4:17 PM revealed Staff D, Certified Medication Aide, (CMA) performed hand hygiene. She then opened the medication administration drawer with her right hand, pulled out the medication bin, and placed it on top of the medication cart with her right hand. Staff D pulled the tab from a single unit dose of Metformin 50 Milligrams (MG) and placed the medication into a dispensing cup. Staff D pulled the tab from a single dose unit of Tramadol 50 MG (one tablet). The pill missed the dispensing cup and landed directly on the top of the surface of the medication cart. Staff D picked up the fallen Tramadol tablet directly from the cart surface using her bare right hand. Staff D placed the contaminated Tramadol pill back into the medication dispensing cup and proceeded to administer the medications to Resident #43. Review of Resident #43's June 2026 Electronic Medication Administration Record (EMAR) showed Staff D signed that Resident #43's medications (including Metformin and Tramadol) were administered during the afternoon medication pass on 6/29/26. 5. Observation of the morning medication administration on 6/30/26 at 6:59 AM revealed Staff E, RN began setting up morning medications to administer to Resident #18. During the medication set up, Staff E opened and closed the medication cart drawers four times. Staff E touched the Tylenol bottle, multiple vitamin bottle, Zyrtec bottle, Ferrocite medication pack, and the medication bin containing single-dose medication cassettes. Staff E also touched the physical tabs on each medication cassette. Staff E knocked over the medication cup during the setup process. Two pills fell out of the dispensing cup and onto the top surface of the medication cart. Staff E picked up the two fallen pills directly from the cart surface using her bare right hand. Staff E placed the contaminated pills back into the resident's medication cup and proceeded to administer the pills to Resident #18. The June 2026 Electronic Medication Administration Record (EMAR) showed Staff E signed the EMAR documenting Resident #18 received the medications. During interview completed on 6/30/26 at 2:01 PM Staff E reported when a medication falls out of the medication cup, staff should discard the medication or pick up the pill using a glove or a spoon. Staff E further explained she realized she should not have picked up Resident #18's pill when it fell out of the cup earlier during the medication pass. In an interview conducted on 7/1/26 at 7:08 AM Staff F, CMA explained if a pill falls out of the dispensing cup onto the top of the medication cart, she destroys the medication due to possible contamination and administers a new pill to the resident. During an interview on 7/1/26 at 9:29 AM the Director of Nursing (DON) explained if a pill falls out of the medication cup onto the medication cart, she would expect the nursing staff to utilize a glove or a spoon to pick up the medication. If the medication fell on the floor, the nurses should destroy the medication and administer a new pill. Interview on 7/1/26 at 9:40 AM Staff G, CMA reported if she drops a pill, she will destroy the medication and take the extra pill that is in the single dose cassette to administer to the resident. The Administering Medications Policy, revised December 2012 directed the DON would supervise and direct all nursing personnel who administer medications and/or related functions. Staff should follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, precautions) for the administration of medications, as applicable.

Based on clinical record review, resident interview, staff interviews, and policy review the facility failed to respect a resident's right to choose when to go to bed in the evening (Resident #28). The facility reported a census of 33 residents.Findings include:The Minimum Data Set (MDS) for Resident #28 dated 06/03/2026 documented diagnoses of limitation of activities due to disability, anxiety and depression, and acute pain due to trauma. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition.Section F of the Annual MDS dated [DATE] indicated it was very important to the resident to choose her own bedtime.The resident's Care Plan with an admission date of 05/03/2024 indicated the resident required assistance with ADLs (activities of daily living) related to weakness and balance deficits which placed her at risk for falls, injury, and skin breakdown. She needed the assistance of 1 staff for evening cares, toilet transfers, and getting in and out of bed. The resident's Care Plan and Kardex (point of care tracking) did not include the resident's bedtime preference.On 06/29/2026 at 11:23 AM Resident # 28 stated she was not able to choose when to go to bed at night. When asked why, she reported sometimes her medications were late which delayed her bedtime or she was waiting for staff. Resident #28 revealed she had been to bed as late as 12:30 AM because she had to go around their schedule. She stated some residents required a lot of staff time so others had to wait.On 07/01/2026 at 2:06 PM the Director of Nursing (DON) confirmed the resident verbalized to the nurse and to the DON that she had received her medications later than she would like. The DON stated she educated staff that 11:30 PM or 12:00 AM was too late. She expected staff to manage time better and pass medications on time.On 07/01/2026 at 2:30 PM Staff L, Registered Nurse (RN) acknowledged she had a window of time to administer medications, and stated Resident #28 needed to have her medications early to get to bed on time. She reported staff tried to help each other with resident care, and she assisted with transfers which usually meant she got behind. Staff L confirmed she knew Resident #28 had been given medications and assisted to bed later than she wanted.A Resident's Rights Policy dated 01/2026 documented that all residents have the right to a dignified existence and self-determination.

Based on clinical record review, staff interviews, and the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual the facility failed to submit a quarterly assessment within the required time frame for 1 of 2 residents reviewed (Residents #38). The facility reported a census of 33 residents. Findings include: During the annual recertification survey a review of the clinical records for Resident #38 revealed the Minimum Data Set (MDS) quarterly assessment dated [DATE] was completed on 05/22/2026. It was not marked as submitted. The MDS summary screen revealed the assessment had been marked as not required.On 07/01/2026 the Director of Nursing (DON) stated she would have to ask the MDS Coordinator, Staff M, about the submission timelines for quarterly assessment. Staff M responded by text that the timeline would depend on the type of assessment and indicated their system reported when it had to be submitted.On 07/02/2026 at 9:36 AM the Administrator stated she would prefer the MDS Coordinator address the timeline for submission and contacted her at another facility during the interview. Staff M returned the call and stated this was the same thing that happened with another resident. She reported she caught the first one but must have missed this one. Staff M stated this one was 40 days overdue and she would need to correct it.Page 2-18 of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2025 indicated the quarterly assessment should be submitted 14 days after the MDS completion date.

Based on clinical record review, observation, resident interview, staff interview, facility policy, and facility record review, the facility failed to ensure sufficient nursing staff were available to answer call lights in a timely manner to meet the needs of residents. This affected 3 of 3 residents reviewed for sufficient staffing (Residents #5, #24, and #28). The facility reported a census of 33 residents.Findings include: 1.A Brief Interview for Mental Status, BIMS, evaluation conducted on 06/30/2026 for Resident #5 revealed a score of 15 out of 15 which indicated cognition intact. On 6/29/26 at 2:28 PM, Resident #5 stated he experienced prolonged call light response times throughout his residency. He stated staff often took 45 minutes to one hour to answer his call light. He noted the response times worsened in the morning before breakfast when multiple residents required concurrent assistance to get out of bed. He stated the facility required additional staff to cover that period. In an interview on 6/30/26 at 10:10 AM, Resident #5 stated his call light remained active and unanswered from 7:00 AM to 7:30 AM that morning. While in the resident's room on 6/30/26 at 10:13 AM, Staff A, CNA, entered the room and confirmed the resident's call light remained unanswered for an extended duration that morning. Staff A acknowledged she failed to answer the call light sooner due to completing cares for other residents with higher acuity needs. 2. The MDS for Resident #24 dated 5/24/2026 identified a BIMS score of 13 out of 15 which indicated cognition intact. In an interview on 6/29/26 at 11:55 AM, Resident #24 stated he waited 30 minutes for staff to answer his call light that morning. He stated call light response times varied by shift, and noted the third shift experienced increased delays before the morning shift arrived. He stated staff left him on the commode and promised to return, but failed to do so. He stated he reactivated his call light and waited an additional 30 minutes for staff to return. He further noted staff frequently deactivated his call light without completing cares and forgot to return. He stated he routinely reactivated his call light to ensure staff returned. An observation on 7/1/26 at 6:23 AM revealed Resident #24's call light was active. In an interview on 7/1/26 at 6:36 AM, Resident #24 stated no staff members entered his room since he activated the call light. Observation on 7/1/26 at 6:39 AM revealed facility staff entered the room and answered the call light, resulting in a 16-minute response time. In an interview on 7/1/26 at 3:00 PM, The Director of Nursing (DON), stated the facility expected call lights to be answered within 15 minutes of activation. The DON stated if a delay occurs, staff must speak with the resident to inform them that assistance is coming. DON acknowledged that leadership educated staff to not deactivate a call light prematurely because they may forget to return to the resident, noting this is an ongoing issue within the facility. When asked how the facility ensures resident safety during 30-minute response gaps when staff claim they are too busy with other residents, DON stated administration attempted to reinforce that all facility employees, including dietary staff, are authorized to answer call lights. She stated if an employee cannot directly assist with a resident's physical needs, they must page for assistance on the radio and leave the call light illuminated until the resident's need is fully met. When asked how daily sufficient staffing is determined and whether adjustments are made for resident acuity, DON stated the facility census was currently on the lower side. She stated the facility attempts to staff with four to five Certified Nurse Aides (CNAs) daily. The DON acknowledged that some resident care areas are more time-consuming than others, and stated she reaches out to alternative personnel if staff members call in absent. The DON explicitly acknowledged she was aware of an ongoing facility issue regarding long call light wait times. She stated she wanted staff nurses and medication aides to assist with call lights rather than staying confined strictly to their primary job duties, and noted leadership is trying to teach those staff to answer call lights. 3. The Minimum Data Set (MDS) for Resident #28 dated 06/03/2026 documented diagnoses of limitation of activities due to disability, acute pain due to trauma, and generalized muscle weakness. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. The resident's Care Plan indicated the resident required assistance with ADLs (activities of daily living) related to weakness and balance deficits which placed her at risk for falls, injury, and skin breakdown. During an interview on 06/29/2026 at 11:23 AM Resident #28 stated she had been to bed as late as 12:30 AM partially because of waiting for staff. She reported that on Saturday (06/27/2026) or Sunday (06/28/2026) her light was on in her bathroom for 45 minutes while she waited for help. She stated she knew it was 45 minutes because she took her phone into the bathroom with her, and had to call the front desk for help when no one came. A document titled Resident Council Meeting dated 06/03/2026, start time 10:29 AM, indicated residents reported call lights took a while to get answered, at times 20 minutes or more. A document titled Resident Council Follow-Up Meeting Department Concerns and Corrections, dated 06/24/2026 at 10:35 AM documented the Administrator told the residents she would have an education meeting for nursing staff about answering call lights. At 11:14 AM on 07/02/2026 the Administrator reported she had a copy of the phone calls made to the facility on [DATE] and 06/28/2026. The report documented Resident #28 placed calls to the facility from her cell phone both days. A policy titled Call Lights: Accessibility and Timely Response reviewed/revised 01/2026 documented all staff members who saw or heard an activated call light were responsible for responding. Guideline 11.a. documented the first step in responding to call lights was to turn off the signal light in the resident's room. The policy did not include the length of time in which staff should respond.

Based on observation, clinical record review, interviews, and policy review the facility failed to ensure timely medication administration was conducted in accordance with manufacturer instructions and professional standards to prevent a significant medication error for 1 of 1 residents observed during medication administration (Resident #33). Specifically, a Registered Nurse (RN) prepared to inject 5 units of Novolog insulin instead of the prescribed 3 units by combining the safety prime and the therapeutic dose into a single mechanical step. The facility further failed to administer medications at the scheduled time for 1 of 1 residents reviewed (Resident #28). The facility reported a census of 33 residents.Findings include: 1. The Minimum Data Set (MDS) for Resident #28 dated 06/03/2026 documented diagnoses of restless leg syndrome, anxiety disorder, and acute pain due to trauma. The Brief Interview for Mental Status (BIMS) score of 15/15 indicated intact cognition. The resident's Care Plan indicated the resident used buspirone and lorazepam for anxiety disorder. The associated task directed nurses to administer the medications as ordered by the physician. A document titled Resident Council Follow-Up meeting dated 05/27/2026 documented a resident was concerned they did not receive their medication until 10:00 PM on 05/05/2026. An investigation confirmed the incident and noted the Director of Nursing (DON) would continue to monitor. On 06/29/2026 at 11:23 AM Resident #28 stated she often didn't get to bed on time because of late medications in the evening. She reported being up as late as 12:30 AM by the time all of her medications were given and cares were done. A document titled Medication Administration Audit Report downloaded from the resident's Electronic Health Record on 07/01/2026 at 9:15 AM documented the following medications scheduled for 19:00 (7:00 PM): a. Tylenol PM extra strength oral tablet 500-25 MG (diphenhydramine-acetaminophen) Give 1 tablet by mouth one time a day for sleep aid related to acute pain due to trauma.b. lorazepam oral tablet 1 MG Give 1 tablet by mouth 3 times a day related to anxiety disorder.c. primidone oral tablet 50 MG Give 2 tablets by mouth two times a day for restless leg syndrome. These medications were administered to the resident on 06/22/2026 at 8:23 PM, 06/23/2026 at 9:20 PM, 06/24/2026 at 9:29 PM, 06/25/2026 at 9:24 PM, 06/26/2026 at 9:39 PM, 06/29/2026 at 9:05 PM, and 06/30/2026 at 9:33 PM. On 07/01/2026 at 2:06 PM the Director of Nursing (DON) confirmed the resident verbalized to both the nurse and the DON that she had often received her medications later than she would like. The DON stated she educated in house and agency staff that 11:30 PM or 12:00 AM (which included medications and treatments) was too late. She expected staff to manage time better and pass medications on time. The DON stated it was on her to do list to have another conversation with a staff member who was often late with this resident's medication. She stated when she was informed about late medications, which are technically a medication error, she communicated with the doctor pretty regularly. She stated the medication error process was to talk with the nursing staff, send the information to the pharmacy, speak with the medical director and/or the primary care provider, and to discuss it at Quality Assurance Process Improvement (QAPI). She did not think all of these steps were done for all of the dates listed here. During an interview with Staff L, Registered Nurse (RN) on 07/01/2026 at 2:30 PM she stated the nurses usually had a window of an hour to administer medication. The Staff L reported that if she didn't give Resident #28 her medication first, then it was usually late because she helped with transfers. Staff L acknowledged she was late with Resident #28's medication a lot, and stated she never reported late medication to the doctors because she knew 2 of them would say it wouldn't make a difference, but she guessed that if the medication could have an immediate impact she would probably call. 2. Review of Resident #33's Minimum Data Set (MDS) Assessment, dated 5/13/26, revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 10, indicating severe cognitive loss. The MDS documented active diagnoses of diabetes mellitus and Non-Alzheimer's Dementia. The assessment further verified the resident received insulin injections on all 7 days of the assessment look-back period. Review of Resident 33's June 2026 Electronic Medication Administration Record (EMAR) revealed a current physician's order to administer Novolog (insulin) injection, 3 units under the skin (subcutaneously) with meals. On 6/30/26 at 12:47 PM, during the Medication Administration Task observation, Staff B, Registered Nurse, (RN) reviewed Resident #33's June 2026 EMAR. Staff B obtained Resident #33's Novolog insulin pen and set the dosage dial to 5 units. Staff B verbalized 2 units were for the air shot to prime the pen, and 3 units were for the ordered dose. Staff B began to approach Resident #33 to administer the injection. Staff B was stopped from administering the 5 units of Novolog to Resident #33. Immediately following the intervention on 6/30/26 at 12:48 PM Staff B stated a pharmacist had previously taught them to administer insulin pens in that manner. Staff B further verbalized she would administer the insulin the old-fashion way. She dialed the insulin pen to 2 units and compressed the injection button into the air. No insulin was observed coming from the tip of the needle. Staff B then set the dial on the pen to 3 units and administered the insulin to Resident #33. Staff B failed to perform the air shot to prime the needle according to the manufacturer's instructions for insulin administration. During an interview on 6/30/26 at 1:02 PM the Pharmacist explained she provided a power point education on adherence to insulin administration to maintain blood sugars within the acceptable ranges. She did not discuss insulin administration or anything about an air shot at that time. She further explained the nurses should set the insulin pen to 2 units to ensure the needle is patent, then set the pen to the ordered amount of insulin for administration. Nurses should follow the manufacturer's directions for insulin administration. A 6/30/26 review of the 1/30/26 Insulin Power Point Education provided by the Pharmacist confirmed the education did not cover insulin administration. During an interview on 6/30/26 at 3:05 PM, the Director of Nursing (DON) explained she expected the nurses to: 1. Set the insulin pen dial to 2 units.2. Depress the injection button and ensure insulin cleared the needle.3. Set the pen to the prescribed insulin dosage to be administered. The DON verified she expected the nursing staff to perform two separate steps, priming the pen, then administering the insulin and follow the manufacturer instructions for administration. The Insulin Pen Policy revised 5/2026 directed insulin pens would be primed prior to each use to avoid collection of air in the insulin reservoir. The Policy Procedure further directed to prime the pen, dial 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. Turn the dose selector to the ordered dose. A click will be heard for each unit dialed. Check the dose a second time and administer the insulin. The Novolog Instructions for Use directed the following:a. Turn the dose selector to 2 units.b. Hold the insulin pen with the needle pointing up. Tap the cartridge gently with a finger a few times to make any air bubbles collect at the top of the cartridge.c. Keep the needle pointing upward, press the push-button all the way in until the dose selector returns to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times.d. Check and ensure the dose selector is set at zero. e. Turn the dose selector to the number of units needed for injection.

Based on observation, clinical record review, resident and staff interviews, and facility policy, the facility failed to provide a safe environment and protect one of seven residents reviewed from resident to resident abuse (Resident #2). On 4/19/26, Resident #1 stood over Resident #2 while Resident #2 was in a reclined wheelchair, and Resident #1 hit Resident #2 in the face with the handle of his cane 3 to 4 times. This deficient practice resulted in a slightly swollen eye for Resident #2 with bruising to the left cheek under Resident #2's eye. The facility reported a census of 37 residents.The facility corrected the deficient practice per past noncompliance through the following actions: -Medication Review for Resident #1 and Resident #2-Staff education on separation of residents-Physical Therapy (PT) evaluation for Resident #1-Psychiatric evaluation per Physician recommendationsFindings include:The MDS (Minimum Data Set) dated 4/1/2026 revealed Resident #1 had intact cognitive abilities for daily decision making, ambulated with a cane, and transferred from one surface to another without staff assistance. The resident had diagnoses including stroke, difficulty in walking and depression.Resident #1's Care Plan with a target date of 6/23/2026 included the resident had impaired cognitive function or impaired thought processes related to encephalopathy, history of TIA's (Transient Ischemic Attacks), and recent CVA (Cerebrovascular Accident), with the goal to be able to communicate basic needs on a daily basis. Initiated on 12/5/2025 the Care Plan directed staff to administer medication as ordered and monitor for side effects and effectiveness, use the resident's preferred name, identify yourself at each interaction, face the resident when speaking and make eye contact. Reduce any distractions and provide the resident with necessary cues - stop and return if agitated. On 4/20/2026, the Care Plan added: if staff notice that I am becoming agitated or having increased anxiety in common area, staff to assist me to quiet area and allow me time to de-escalate.An Incident Report dated 4/19/2026 at 7:45 a.m. revealed a resident to resident incident occurred in the dining room. A nurse heard commotion from the dining area while charting at the nurse's station. The nurse observed Resident #1 standing over Resident #2. Resident #2 sat against the east wall in a Broda (reclined wheel chair). Resident #1 hit Resident #2 in the face with the handle of the cane. Staff observed 3-4 hits before she could reach Resident #1 and obtain the cane. Resident #1 hit Resident #2 in the face with the handle of the cane. Resident #1 went back to the area where he normally eats breakfast. When asked why he got up and hit Resident #2, he replied because he ruins my life. Resident #1 then sat quietly at the table, and never asked for his cane back. Resident #2 had a slightly swollen eye, with slight discoloration. The resident (Resident #2) asked why Resident #1 did that to him. Staff immediately separated the residents, and initiated neurological checks on Resident #2. Staff notified the physician, administrator and on call nurse manager. Resident #2 injuries observed at the time of the incident: Bruise - face. Bruise started on the left cheek, under the eye, slightly swollen and measured 3 cm (centimeters) by 2.5 cm.Review of resident statements included as part of the facility's investigation revealed the following:a. Resident #1: On 4/19/2026, at approximately 0750 (7:50 AM), facility nurse asked [Resident #1] what happened, [Resident #1] stated, he [Resident #2] ruins my life and he called me a son of a b**ch. Facility ADON (Assistant Director of Nursing) interviewed [Resident #1] again at approximately 0900am on 04/19/2026. Facility ADON noted that resident stated that [Resident #2] said to him you dirty rotten son of a b**ch. Facility Administrator interviewed [Resident #1] again on 04/20/2026 noting that [Resident #1] stated that they were conversing as normal when [Resident #2] changed conversation tone. Facility administrator educated resident on asking for help from facility staff. Facility administrator and facility ADON educated [Resident #1] on behavior toward other residents and not resulting to violence.b. Resident #2: On 4/19/2026 at approximately 0750 (7:50 a.m.), [Resident #2] stated to facility nurse why did he do that? Review of the Reasonable Explanation section of the Facility Investigation revealed, in part, It is reasonable to believe that [Resident #2] misheard what [Resident #1] had said that aggravated him. It is reasonable to believe that [Resident #1] misinterpreted what [Resident #2] had said causing [Resident #1] to become defensive and strike [Resident #2] with his cane. A progress note dated 4/19/2026 at 9:54 a.m. documented Resident #1 involved in incident this morning with another resident. Upon identification of incident, resident was immediately separated from the other resident. Administrator, physician and family notified. Resident continued to be separated from other resident and behaviors will be monitored. Statement obtained from resident.A progress note dated 4/19/2026 at 10:22 a.m. included the facility sent a fax to the physician to look through Resident #1's medications, with provider recommendation for no change at this time. Review of Condition Report/Communication Forms for Resident #1 revealed the facility requested an order from the physician for PT (Physical Therapy) to evaluate and treat. The physician ordered PT as well as a Psych evaluation on 4/23/2026. Observation on 5/12/2026 at 12:15 p.m. revealed Resident #1 seated at the dining room table near the nurse's station, the west end of the dining room, with his cane nearby. The resident ate his noon meal independently with his right hand and adaptive silverware. The resident appeared alert, engaged, and calm.Observation on 5/12/2026 at 1:50 p.m. revealed Resident #1 lying in bed on his right side facing the door, awake and alert. The resident reported no residents ever wandered into his room. He denied having friends at the facility. Observation on 5/13/2026 at 11:30 a.m. revealed the resident in bed, alert and verbal. When asked if he had an incident with Resident #2, he replied yes. When asked what happened, he replied he called me a worthless son of a b**ch, and that is why I hit him.2. Resident #2's MDS dated [DATE] revealed he had moderately impaired cognitive skills, dependent on staff for transfers using a mechanical lift, used a wheelchair for mobility, required supervision with eating, and had a diagnosis of dementia.Resident #2's Care Plan revealed he required assistance with ADL's (Activities of Daily Living). On 8/23/2021 the care plan added: per family, he may become short tempered. It directed staff to allow him to voice his frustrations, and he may ask staff to leave his room. On 4/1/2026, the Care Plan indicated comfort was to be the primary focus of care.The Care Plan addressed the resident's cognitive function/impaired thought processes related to dementia diagnosis that results in his frustration exhibited with verbal behaviors. It instructed staff to provide safety and allow him time to self-deescalate if he became agitated and/or showed signs of agitation by becoming verbally aggressive. Have a different staff reproach him at a later time when able. Initiated on 12/12/2023.Resident #2's progress notes 4/19/2026 at 10:11 a.m. included: Resident was involved in an incident at approximately 7:45 a.m. After completion of head to toe assessment, resident obtained a small bump/bruise measuring 3.0 by 2.5 cm. Administrator, physician notified and message left with family to call back.The progress note on 4/19/2026 at 10:41 a.m. revealed staff provided neurological and vitals assessments. The resident denied pain in the area and refused ice. Observation on 5/12/2026 at 12:20 p.m. revealed Resident #2 in a Broda chair with his noon meal on a tray table positioned in front of him. He wore sun glasses and a baseball cap. He ate independently with a spoon. His beverages were served in cups with straws. He sat at the east side of the dining room near the window with staff present.Observation on 5/13/2026 at 7:30 a.m. revealed Resident #2 in the Broda chair near the east side of the dining room eating breakfast with set up assistance of staff.On 5/13/2026 at 8:50 a.m. Resident #2 sat upright in bed after staff provided a shower. He wore a gown and a baseball cap. The resident had a light yellow bruise under his left eye. When asked what happened to cause the bruise, the resident answered I do not know. When asked if someone had hit him, he answered must have. When asked what could do to make life better for him while living at the facility, he answered I can't think of anything.On 5/13/2026 at 10:30 a.m., Staff A, Administrator reported Resident #1 and Resident #2 were prior roommates, however Resident #2 preferred to stay up late and have his television loud which affected Resident #1's sleep. Resident #1 moved to another room in the same hall. Resident #1 never showed aggressive behavior prior to this incident. Resident #2 states things but is easily redirected. Staff A felt Resident #1 got tired of Resident #2 saying things to others. Staff separated the two residents in the dining room, staff were educated to continue the separation and they have had no further incidents. Staff D, RN (Registered Nurse) worked at the time of the incident. Staff C, ADON (Assistant Director of Nursing) came to the facility in response to the incident. Staff A educated staff to maintain the separation during the investigation. The facility uses a group chat where all staff are notified at the same time. The incident occurred on a Sunday. On Monday, Staff A verbally spoke to staff, nursing and dietary about the separation. They found the separation successful and continued with it. Resident #2 had some incidents in the past which prompted medication changes and they have seen improvement. No other resident has ever struck Resident #2. The facility followed up appropriately, immediately separated the residents, initiated the investigation and notified state.On 5/13/2026 at 10:42 a.m., Staff C, ADON reported working at the facility for two years. She got a call from Staff D, RN stating Resident #1 hit Resident #2 in the face with his cane. Staff C reported to the facility and assessed Resident #2. He had a bruise under his left eye. Resident #1's current roommate said he felt safe. When she asked Resident #2 if he felt safe, he replied I was in a fight. Resident #1 is not an aggressive man, and there have been no further behaviors. Resident #1 said Resident #2 had been talking crap about some of the female residents and he could not take it any longer.On 5/14/2026 at 12:01 p.m. Staff D, RN via phone, reported working the day of the incident between Resident #1 and Resident #2. She had worked the night shift but was still at the facility. She had just completed doing a narcotic count in the medication room, walked out and planned to sit at the nurse's station to complete her charting. She heard a commotion, observed Resident #1 with his cane in the air, hitting Resident #2. Resident #2 normally did not sit near Resident #1's table. She saw the cane, ran over and grabbed it from Resident #1. Resident #2 wore a baseball cap which prevented the cane from directly hitting his face. She assessed the residents, assisted Resident #2 to his room and bed, and called the Administrator. Resident #1, normally a sweet man, never showed any aggressive behaviors prior or since. Resident #2 makes comments under his breath. Resident #1 said something about Resident #2 making his life miserable.On 5/13/2026 at 9:00 a.m., Staff B, DON (Director of Nursing) reported Resident #1 had a physician's referral for a psych evaluation at [Hospital Name Redacted]. They are waiting on insurance verification prior to setting up an appointment. Her understanding of the incident involving Resident #1 and Resident #2 is that Resident #2 threatened Resident #1, and he got up from the table, took his cane and hit him. They separated the residents, did urinalysis on both residents, and requested medication reviews with no changes made. Resident #1 had a physical therapy evaluation related to his ambulation. Therapy continues to work with him, is doing well, however the only option is to give him a walker instead of a cane at this time. He continues to use a cane. The facility Resident to Resident Incident Policy and Procedure, undated, included, It is the policy of this facility to ensure the safety, dignity, and well-being of all residents. Any resident-to-resident incident resulting in actual or potential physical, emotional, psychological, or sexual harm will be addressed immediately, thoroughly investigated, appropriately documented, and reported in accordance with applicable federal regulations .and facility abuse prevention policies.Resident-to-resident incidents may constitute abuse and will be evaluated under the facility Abuse Prevention, Identification, Investigation, and Reporting Policy.The policy defined as resident to resident incident was any interaction between residents that results in or has the potential to result in: Physical harm, pain, mental anguish, emotional distress, intimidation, sexual coercion or inappropriate sexual contact, psychological harm, or threats or aggressive behaviors. Examples included, but were not limited to, hitting, slapping, pinching, kicking, biting, pushing, throwing objects, verbal threats or intimidation, sexual behaviors or unwanted sexual contact, and harassment or coercion. The policy noted, Resident-to-resident incidents may be considered abuse under federal and state regulations.

Based on observation, record review, and staff interviews the facility failed to properly assess a residents oxygen saturation level to determine the need for oxygen per physician order for 1 of 1 residents reviewed with oxygen (Resident #2). The facility identified a census of 35 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 indicated a Brief Interview for Mental Status (BIMS) score of 10/15 which indicates cognitive impairment. The MDS documented diagnoses of chronic obstructive pulmonary disease (progressive lung disease making it difficult to breathe) and respiratory failure. The physician order report summary for Resident #2 revealed an order dated 1/28/25 for Supplemental oxygen at 0.5-1 liter per minute via nasal cannula to maintain oxygen saturation greater than 88 percent as needed for respiratory treatment. Review of the medication administration record for April and May revealed the order for oxygen but directed staff it was as needed. The oxygen saturation was not checked on the medication administration record for April or May. The Care Plan has a focus area for Residents #2 which revealed chronic obstructive pulmonary disease with an intervention dated 4/16/25 which directed staff to provide oxygen at 0.5 to 1 liter per nasal cannula to maintain oxygen saturation greater than 88 percent. On 5/28/25 at 1:05 PM observed Resident #2 sitting in her room in her recliner. No signs and symptoms of respiratory distress noted. She does have an oxygen concentrator in her room. On 05/29/25 at 11:54 AM Staff A, Registered Nurse (RN) stated if there is an order for oxygen on a resident oxygen saturation should be checked daily otherwise check if they are short of breath. If the order says to maintain oxygen saturation above a certain percent the residents oxygen saturation should be checked every shift. The order would be on the medication administration record of when to check it. She verified on Resident #2 medication administration record the oxygen was listed as needed but to maintain above 88 percent. I would say for her with the order she should be scheduled to check the oxygen at least every shift to know if she needs it or not. On 05/29/25 at 11:56 AM the Director of Nursing (DON) stated with an order to maintain oxygen above a certain percent staff should be checking the oxygen saturation every shift. Regarding Resident #2, I don't if she has one on the MAR because she refuses to wear it and they were bleeding it into her BiPap at night. With the order she has from the physician I would expect them to check it at least every shift.

Based on record review, Facility Assessment review, resident and staff interviews, and policy review the facility failed to employ sufficient numbers of staff to meet resident needs, and failed to answer call lights in a timely manner for 3 of 4 residents reviewed (Resident #1, Resident #3, and Anonymous). The facility reported a census of 31 residents. Findings include: 1. A review of the facility staff schedules from November 2nd through December 7th, 2024 revealed Certified Nursing Aides (CNAs) were not present in the required ratios during the day shifts as follows: ~ Missing one CNA- 14 days ~ Missing two CNAs- 3 days In an interview on 12/02/24 at 1:12 PM a resident who wished to remain anonymous explained staff were not coming in often enough to toilet them. They were short staffed in the facility. On 12/05/24 at 8:12 AM the same resident noted the previous evening they put the call light on at 7:00 PM and watched the clock on the wall- it was almost exactly two hours before staff came to assist them to bed for the evening. In an interview on 12/05/24 at 9:02 AM the Director of Nursing (DON) explained she would love to have 3-4 aides per day shift but did not think the facility was understaffed with just 3. She acknowledged the fourth person would be helpful. She noted the Administrator decided how many staff were needed based on the census but she did the scheduling and they talked about it with every new admission. In an interview on 12/05/24 at 10:33 AM the Administrator explained the staffing ratios were a group effort- the team looked at the Patient Per Day (PPD) numbers as well as the acuity of the residents. They staffed 3-4 CNA's during each day shift and 2 at night. She noted they had the facility assessment but mostly decide based on the PPD and acuity. She updated the Facility Assessment in the fall when they had a higher census, but acknowledged the required ratio was based on the average and that was 33 residents. On 12/04/24 the census was 34 and they still ran with only 6 CNAs. She acknowledged there was no reason a resident should have to wait almost two hours for assistance. The Facility Assessment Tool, updated 7/2024 expressed the following: Staffing plans are based on resident volume. The average daily census is 33 residents. Special consideration is taken when residents with special needs or care requirements are present on admission or develop during the stay at the facility. The staffing mix is flexible to accommodate increased acuity based on Interdisciplinary Team assessment. It instructed staff ratios to be the following: ~ Days- Certified Nursing Aides (CNA's) 7-9 ~ Evenings- CNA's 1-2 A. The Minimum Data Set (MDS) for a resident who wished to remain anonymous indicated a Brief Interview for Mental Status (BIMS) score of 15/15 indicating no cognitive impairment. In an interview on 12/02/24 at 1:12 PM the resident explained they have had the call light on for an hour or more at times- this happened on all shifts. They felt the facility was short staffed. The resident remarked one time they waited a very long time for the call light to be answered and tried to toilet themselves when they could not wait any longer. This resulted in physical injury. The facility policy titled Call Light, Use Of, undated instructed staff to answer all call lights promptly whether or not the resident was assigned to them. All call lights must be answered within 15 minutes. Five minutes for initial response is preferred, up to 15 minutes is allowed per state and federal regulation. B. The Minimum Data Set (MDS) for Resident #1 dated 9/2/24 documented a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated intact cognition. Diagnoses included spinal stenosis (narrowing of the spinal canal that compresses the spinal cord and nerves), stress incontinence, and other abnormalities of gait and mobility. During an interview on 12/2/24 at 11:52 AM Resident #1 stated she had experienced long call lights with 2 hours the longest she had kept track of. She reported that answering a call light in 15 minutes was fast at this facility. She said sometimes she did not put the light on because she knew they (staff) were not going to come. Resident #1 stated that morning she put the light on at 2:00 AM and nobody came until after 3:00 AM. She pointed to the clock in her room as her measure of time. She also felt some of the nurses could be more helpful answering the lights. During a follow up interview on 12/5/24 at 8:52 AM, Resident #1 stated she recently had an issue with her call light not working and had to use her cell phone to call the facility to get staff to come to her room. She reported that happened in the past week. On 12/4/24 at 2:53 PM Staff D, Certified Nursing Assistant (CNA) stated that a long call light is 15 minutes. She confirmed residents complained to her about call lights over 15 minutes. She indicated dinner time was especially difficult due to residents who remained in the dining room, some who wanted to go to their rooms, others wanted to go to bed, and some still needed bathing. C. The Minimum Data Set (MDS) for Resident #3 dated 9/4/24 documented a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated intact cognition. Diagnoses included Parkinson's disease, a history of falling, and sequelae of cerebral infarction (long term effects of a stroke). During an interview with Resident #3 on 12/2/24 at 11:31 AM he was observed in his room watching his TV and the door. He reported that the facility was definitely short staffed. He further stated that when he sat there all day, watched them work, and waited for them to come help him it was pretty obvious they needed more help. He reported the day before yesterday (Saturday, 11/30/24) he waited an hour on the toilet for someone to come help him. Resident # 3 stated he tried to make allowances for it but it still hurt him when he was left sitting there on the toilet for so long. He stated it got ' old, real old ' . At 1:10 PM on 12/4/24 Staff B, CNA stated that call lights of 15-20 minutes were long. She acknowledged that residents have complained about the call lights and that ' every resident ' complained about 2nd shift. She reported residents who have the ability to do so have turned their call lights on as early as 2:45 PM when they wanted to get to a 3:30 activity. She stated showers and activities impacted how long call lights took as well as the residents who needed help, other things going on, and who the staff were. On 12/5/24 at 8:55 AM the Director of Nursing stated she knew the facility had 15 minutes to answer call lights but they strived for 10-12 minutes. She acknowledged they have had a few complaints and stated the facility did call light audits. On 12/5/24 at 9:33 AM the Administrator stated meal times were the most difficult for call lights. She reported staff had been educated on answering them within 15 minutes and that all staff were responsible for answering them. 48452

Based on observation, staff interviews, and policy review the facility failed to keep all medication locked in the medication cart as required. The facility reported a census of 31 residents. Findings include: In an observation on 12/02/24 at 8:00 AM the bottom drawer of a medication cart in the back hall was found open with medications exposed. This surveyor was able to approach the cart and access medications in the drawer. No nurse or staff were visualized next to the cart or down the hallway. In an interview on 12/03/24 at 1:40 PM Staff A, Registered Nurse (RN) explained the expectation for the medication cart was for it to be kept locked, the laptop screen to be locked out, and any personal health information to be covered when not directly at it. She admitted she thought the cart was locked this morning when she went to help another staff and it wasn't. She did not notice until she returned to the cart. In an interview on 12/04/24 at 10:18 AM the Director of Nursing explained she expected staff to always ensure the cart was locked if they were not there actively getting medications ready. If staff were not using the computer, it must be kept locked. She voiced concern that the cart was open and the access that could have given to other residents. The facility policy titled Storage of Medications, updated 2/2007 instructed compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals to be locked when not in use; and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others.

Based on observation, maintenance record review, resident interviews, and staff interviews the facility failed to maintain a clean and sanitary environment for resident bathing including holes in floor, missing floor tiles, stained wall tiles, and dirty/damaged air vents. The facility reported a census of 31 residents. Findings include: An observation at 10:49 AM on 12/2/24 in the shower room across from room [ROOM NUMBER] revealed a missing section of the gray floor. The top of the hole nearest the wall with the shower head measured 9 inches wide, the bottom of the hole towards the middle of the shower stall measured 4 inches wide, and the length of the hole was 2 feet. The inside of the hole contained a wet, black substance and a puddle of water sat between the hole and the drain. The drain was covered with light colored hair and fuzz. At 11:11 AM on 12/2/24 the stall in the shower room across from room [ROOM NUMBER] contained shower tiles along the floor and the wall marked with light orange and brown stains, with a bumpy substance coming out from the surface of the tile. The corners of the stall contained black and white spots. A musty smell came from the area of the shower and drain. At the entrance to the shower stall there was a 4 inch gap between the metal transition strip and the tile in the shower. One section of the gap to the left of center revealed a missing chunk of flooring approximately 4 inches by 2 inches, stained with a wet black substance. To the left of center another chunk was missing approximately 7 inches by 2.5 inches, stained with a wet black substance. On the outside of the transition strip a section of the gray floor was cut out and measured approximately 3 inches by 3 inches. The exposed floor underneath was wet and contained black and white substances. Inside the shower 5 tiles were missing, which created a hole in the floor about 3 inches x 2 inches, located about 6 inches from the sunken drain. The open areas inside and outside of the shower stall lacked the water repellent surfaces necessary to keep the under-floor dry. This prevented proper sanitizing and allowed these sections to hold standing water that encouraged bacteria growth. The vent around one of the ceiling lights contained fuzzy fibers, 3 of the vent slats were broken, and one of them hung down approximately 2 inches from the vent. Some of the slats were stained an orange/brown color and 4 of the slats were warped as though they melted. During an interview on 12/2/24 at 11:31 AM Resident #3 stated he felt mostly safe in the shower room, but the wheels of the shower chairs got stuck in the floor a lot and it was hard to get them to move where they (staff) want them. He said it was ' kind of dirty. ' During an interview at 11:52 AM on 12/2/24 Resident #1 reported one of her biggest concerns was infection control in the shower room in her hallway. She stated the shower chair wheels often got stuck in the holes and the room was dirty. She did not think there was any good way to disinfect the holes in the floor and it was just getting worse. Resident #1 stated she had spoken to staff about it but nothing had been done. On 12/4/24 at 1:10 PM Staff B, Certified Nursing Assistant (CNA), stated the shower room had gotten worse over time. She reported she had been at the facility over a year and a half and there was already damage when she started. On 12/4/24 at 2:53 PM Staff D, CNA stated the damage in the shower room had been there quite awhile. She stated she reported it to the prior facility maintenance person and he kept saying it would get fixed but was never done. When asked if the current staff knew about the problem, she said yes. She stated it was scary moving the shower chairs because they had to push residents into the shower and they were afraid they would hit the ruts or missing tiles. She stated there was water that seeped out from under the tile no matter what they did to try to get rid of it. On 12/5/24 at 9:33 AM the Administrator confirmed she was aware of the shower damage. She reported that she had been talking to maintenance about the damage and they were looking for matching tiles. A policy titled Work Orders revised in 2004 documented it was the responsibility of the department directors to fill out and forward work orders to the maintenance director. It indicated work orders would be prioritized based on need. A document titled Maintenance Log revealed the shower room across from room [ROOM NUMBER] had chipped tiles on 8/29/24. The entry was crossed off without the floor being repaired.

Based on observation, record review, staff interview, resident interview, and policy review the facility failed to treat residents with dignity and respect throughout cares provided for 1 of 3 residents reviewed (Resident #1). Staff and other residents entered a shower room without the bathing resident's permission and without effective privacy barriers in place. The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 9/2/24 documented a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated intact cognition. Diagnoses included spinal stenosis (narrowing of the spinal canal that compresses the spinal cord and nerves), stress incontinence, and other abnormalities of gait and mobility. The MDS further documented Resident #1 required supervision or touch assistance with tub/shower transfers and partial to moderate assistance with bathing. During an observation of the shower room across from resident room on 12/2/24 at 11:11 AM a shower curtain pushed against the wall hung from a ceiling track that ran the length of the front of the shower. 11 metal bead strips connected the track to the shower curtain. 10 of them were tangled together and could not be separated. The curtain did not cover the shower stall for privacy. The interior side of the stall contained a large opening into the rest of the room. There was no curtain on the track to cover that opening, and the track did not extend to cover the whole opening. The facility's wheelchair scale sat angled in the corner on the same half of the room as the exposed opening. A linen bin against the wall contained used towels, which indicated the room was in use for bathing. During an interview at 11:52 AM on 12/2/24 Resident #1 reported dignity and privacy concerns related to cares and bathing in the facility. She stated some staff did not knock before entering her room. That was part of the reason she posted a sign on the outside of her door to direct visitors. She stated some staff did not shut the doors to her room or bathroom when they assisted her with cares. She reported she heard staff share private information over the walkie talkies. Her biggest concerns were infection control in the shower room and aides who brought residents into the shower room during her shower to weigh them on the wheelchair scale. She stated it was not uncommon and questioned why staff couldn't just wait for her to be done. During a follow up interview on 12/5/24 at 8:52 AM, Resident #1 reported the shower room incidents happened more than once, most recently last week. She stated she told the aides to wrap the shower curtain around the door handle when she was in the room to try to prevent anyone else from coming in during her shower. On 12/4/24 at 1:10 PM Staff B, Certified Nursing Assistant (CNA), stated there was a shower curtain in the bathroom but it wouldn't do anything to cover the stall. A resident who entered would still be able to see inside of the stall. On 12/5/24 at 11:14 AM Staff E, CNA confirmed Resident #1 had asked her to wrap the shower curtain around the shower room door. She reported if a resident was bathing and staff needed a towel or something, staff did go into the room to get them. She wasn't aware of a resident being brought in. During an interview at 8:55 AM on 12/5/24 the Director of Nursing denied knowing aides brought other residents in for weights during showers. At 9:33 AM on 12/5/24 the Administrator stated she was not aware aides brought residents in for weights during showers and that was not acceptable in any way, shape, or form. A policy titled Residents' Rights Policy dated 10/2023 documented residents have the right to a dignified existence as well as personal privacy and confidentiality.

Based on observation, clinical record review and staff interviews, the facility failed to address the use of an anticoagulant medication for one resident (Resident #20), the use of antidepressant and diuretic medications for one resident (Resident #4) and the use of prophylactic antibiotics for two residents (Resident #12 and #15) when resident Care Plans reviewed. The facility reported a census of 25 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment Tool dated 1/20/22 identified Resident #20 as cognitively intact with a Brief Interview for Mental Status (BIMS) of 14, had documentation of the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident required limited staff assistance with most activities of daily living. It also identified the resident had orders for an anticoagulant (blood thinner). The Physician's Orders dated 12/7/21 revealed the following medication: [MEDICATION(S)] 2.5 milligrams (mg's) by mouth two times a day. A review of the Care Plan on 2/23/22 revealed the resident identified on 10/6/21 with the problem of the need for assist with Activities of Daily Living (ADL's) and with use of anticoagulation medication ([MEDICATION(S)]) and the last revision date of 2/3/22 did not include interventions to monitor for side effects of [MEDICATION(S)] ordered. The Care Plan with the initiation date of 2/26/22 (during the survey) identified the resident with the problem of being on an anticoagulant therapy ([MEDICATION(S)]) related to [CONDITION(S)] and had the following interventions: a. Daily skin inspection. Report abnormalities to the nurse. b. Monitor/document/report as needed adverse reactions of anticoagulant therapy: blood tinged or red blood in the urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs c. Review medication list for adverse reactions. Avoid use of aspirin or NSAIDS (non-steroidal anti-[CONDITION(S)] drugs) d. Vitamin K- antidote to anticoagulant for bleeding emergencies is located in the stat box. 2. The MDS dated [DATE] identified Resident #15 as severely cognitively impaired with a BIMS of 99 and documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident required extensive staff assistance with most activities of daily living. It also identified the resident had orders for an antibiotic. The Physician's Orders dated 12/9/19 revealed the following: [MEDICATION(S)] (antimicrobial medication)100 mg's, one tablet one time a day for prophylactic related to urinary tract infection ([CONDITION(S)]). A review of the Care Plan on 2/24/22 revealed the resident identified with the problem of needed assist with cares related to weakness related to recurrent [CONDITION(S)]'s on 12/9/19 and failed to address interventions on monitoring for signs and symptoms of [CONDITION(S)]'s and the potential side effects or interactions with other medications. The Care Plan with the initiation date of 2/28/22 (during the survey) identified the resident with the problem of being admitted on antibiotic therapy related to a history of UTIs and had the following interventions: a. Administer antibiotic as ordered by the physician. b. Monitor/document/report as needed adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia and hypersensitivity/allergic reactions (rashes, welts, hives, swelling to face/throat). c. Monitor/document/report as needed signs and symptoms of secondary infection related to antibiotic therapy: oral thrush (white coating in mouth, tongue), persistent diarrhea and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus. d. Report pertinent lab results to the physician. In an observation on 2/23/22 at 8:35 AM, the resident sat up in her wheelchair, the Dietary Aide that served her encouraged her to drink all her fluids which included one glass each of chocolate supplement and a glass of water. In an observation on 2/23/22 at 11:36 AM, the resident sat up in her wheelchair when the Dietary Manager served her meal of a bowl of tomato soup, one glass each of chocolate supplement and water and encouraged her to take all her fluids. In an interview on 2/24/22 at 11:00 AM, Staff F, Registered Nurse (RN) reported a Care Plan for a resident with orders for [MEDICATION(S)] should include watching for bruising and other kinds of bleeding and that the Director of Nursing (DON), Assistant MDS Coordinator or herself would be responsible for initiating and updating Care Plans In an interview on 2/24/22 at 11:08 AM, Staff C, RN reported a Care Plan for a resident with orders for [MEDICATION(S)] should include watching for any unusual bleeding, checking pulse, blood pressure, making sure they aren't having dizziness, making sure they don't have falls, if they do fall - check what caused the falls, talk to the doctor if any falls or bleeding. She also reported the MDS Director/DON had the responsibility of initiating and updating Care Plans. In an interview on 2/24/22 at 11:13 AM, Staff G, RN reported a Care Plan for a resident with orders for [MEDICATION(S)] should include: looking for bleeding, protect the resident from bruising as they would bruise easily, pad the chair arms, look for dizziness, sit before they stand up suddenly, check vitals make sure blood pressure and pulse are normal. She also reported all nurses are responsible for initiating and updating Care Plans and that the current Care Plan Coordinator that is responsible for MDS data entry is also the Director of Nursing (DON) and Staff F also assists. In an interview on 2/28/22 at 1:25 PM, the DON reported the following when a resident has orders for the following: a. For an Anticoagulant - the Care Plan should include daily monitors such as watching for bruising, redness, abnormal bleeding, monitor labs as ordered by physician, administer medication as ordered by the physician b. For a Diuretic - the Care Plan should include: monitors for lab, address abnormal lab with the doctor and administer the medications as ordered c. For a Prophylactic antibiotic - the Care Plan should include: administer as ordered by the physician, monitor for adverse effects, if there were any lab reports and report abnormal levels to the physician. Review of need for a different antibiotic if a new [CONDITION(S)] (urinary tract infection) had been identified. A review of the facility policy titled: Person-Centered Care Plans with the last revision date of November 2019 revealed the following: a. The Interdisciplinary Team (IDT) will utilize a set of assessments in combination with resident or resident representative interviews and review of resident medical record. The facility will utilize the information obtained through these assessments and interview for the development of such Plan of Care. The Care Planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal preferences in developing the goals of care. b. Will include measurable objectives and timeframes to be able to assess whether objectives have been met. c. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. d. Build on residents' strengths, incorporate identified problem areas, and reflect the resident's expressed wishes regarding care and treatment goals. e. Reflect currently recognized standards of practice for problem areas and conditions. f. The Plan of Care process will be overseen by an RN in good standing with the state the facility resides in. g. The Interdisciplinary Team must review and update the Care Plan if the following occurs: - When there has been a significant change in the resident's condition. - When the desired outcome is not met. - When the resident has been readmitted to the facility from a hospital stay; and - At least quarterly, in conjunction with the required Quarterly MDS Assessment. 3. The MDS Assessment for Resident #4 dated 11/24/21, reflected a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan for Resident #4 dated 2/17/2020, failed to address Resident #4's use of an antidepressant and the side effects the staff are expected to monitor for. The Care Plan also failed to direct the staff to monitor for signs and symptoms (s/s) of dehydration related to the use of a diuretic medications. The Kardex (document Nursing Staff refer to) dated 2/23/22, failed to identify the use of an antidepressant and the side effects the staff are expected to monitor for and failed to direct staff to monitor for the s/s of dehydration related to the use of diuretic medications. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (antidepressant) 40 milligrams (mg's) by mouth at bedtime related to depressive disorder. b. [MEDICATION(S)] (Diuretic) 20 mg's by mouth one time a day for weight loss. c. [MEDICATION(S)] (Diuretic) 25 mg's by mouth one time a day for [CONDITION(S)]. On 2/22/22 at 11:25 AM, Resident #4 sat in her wheel chair at the dining room table with 3 drinks in front of her. 4. The MDS Assessment for Resident #12 dated 12/29/21, reflected a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS listed the BIMS score of 2 (severe cognitive impairments) and reflected the resident required extensive assist of 2 staff for toileting and extensive assist of 1 staff for personal hygiene. The MDS identified Resident #12 always incontinent of bowel and bladder. The Care Plan for Resident # 12 identified a target date of 3/22/22, failed to address the prophylaxis antibiotic for a personal history of [CONDITION(S)]'s. The Kardex dated 2/23/22, lacked documentation related to the prophylaxis antibiotic. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/24/22 at 11:17 AM, Staff G, Registered Nurse (RN) reported when a resident takes a diuretic medication the nurses need to monitor the resident for dehydration, skin, dry mouth, intake & output, dizziness, weakness and laboratory tests. On 2/24/22 at 11:19 AM, Staff C, RN stated she would look for the antidepressant drug side effects and adverse reactions in the Drug Hand Book.

Based on clinical record review, staff and family interviews, the facility failed to provide adequate supervision in the dining room to prevent accidents for one resident reviewed with a history of falls. (Resident #236) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #236 had [DIAGNOSES REDACTED]. The MDS assessment indicated the resident required limited assistance of one with transfers and ambulation. The plan of care dated 9/7/17, directed the resident to be up independently with walker in the dining room and front lounge only. The resident was up with assistance of one staff, gait belt and walker throughout the rest of the facility. An incident/accident report dated 8/23/18, documented the resident was walking around a table in the dining room without her walker when she fell on to her bottom on the floor. The facility added an intervention to place sign on the walker to remind the resident to take the walker with her. An incident/accident investigation report dated 10/5/18, documented the resident was in the main dining room laying floor on her back with the walker in front of her. Staff added toilet with assistance to prevent further falling. A physician order [REDACTED]. A fall screener completed on 10/10/18 and 7/17/18, documented an score of 80 for both assessments. Screen evaluated the history of falling, gait and mental status. The assessment stated the resident had history falls, gait was weak and mental status overestimated limits or forgets limits. Morse fall scoring: High Risk for 45 and higher. A Physical Therapy evaluation and plan of treatment completed 10/11/18, documented the resident was demonstrating both lower extremity/proximal weakness, balance deficits, and decline in functional mobility. The resident required cueing for safety with transfers and proper hand placement. The resident was able to navigate the hallway, room and bathroom using front wheeled walker with stand by assistance but required moderate assistance with toileting and maximum assistance with lower extremity dressing. Nurse progress notes dated 10/20/18 at 5:50 p.m., revealed a visitor came to the front nurse station to inform staff the resident was on the floor down the hallway. The nurse assessed the situation along with other nurse on duty. The floor was dry, hallway was well lit and the resident had the front wheeled walker with her. The resident was last seen in the Main Dining Room. The X-ray report from Finley Hospital dated 10/20/18 at 8:45 p.m., revealed a proximal right femoral fracture. During interview on 11/14/18 at 1:19 p.m., the visitor who found the resident on the floor in the hallway states she walked from the main dining room to her husbands room that evening during the meal time and when she came out she saw the resident on the floor and told the nurse. She did not recall seeing the resident when she went into the room. During interview on 11/14/18 at 2:19 p.m., Staff H, Certified Nurse Aide, CNA stated she did not witness the fall on 10/20/18. Staff H stated she was in the dining room feeding another resident when she heard someone yell the resident had fallen. The resident had been sitting at the first table when she was last saw her in the dining room. Staff H stated there was another CNA in the Dining room with her and two nurses were passing medication. Typically the resident would be up with one assistance but she must have got up and walked away without assistance the night of the fall. During interview on 11/14/18 at 2:25 p.m., Staff I, Licensed Practical Nurse, LPN stated she saw the resident on 10/20/18 sitting at the table in the center first row eating her supper meal. Staff I left the dining room to use the restroom and was alerted to the fall by another staff member knocking on the door. During interview on 11/14/18 at 2:38 p.m., Staff J, CNA stated she was in the dining room and heard someone say the resident had fallen. Staff J had she back to the hallway the resident had gone down. During interview on 11/14/18 at 3:18 p.m., Staff K, CNA stated at the time of the fall she was at the back table feeding residents and heard the nurse calling for help. Typically the resident would ask to go back to her room and she was an assist of one for ambulation. Staff K stated her back was turned to the rest of the dining room. During interview on 11/14/18 at 3:26 p.m., Staff L, LPN stated a family member came and got her in the middle of supper time to notify her of the residents fall. There was a lot of people present and it was busy due to it being the supper hour. Staff L stated she was by the medication cart in the dining room area when she was notified. Staff L could not remember what she was doing and does not recall seeing the resident prior to the fall. During interview on 11/14/18 at 4:04 p.m., Staff M, CNA stated she was out in the dining room feeding residents and went to a resident room to answer a call light and when coming back to the hallway the resident was on the floor. Staff M stated the resident was not in the hall when they left the dining room to go answer the call light. During interview on 11/15/18 at 1:21 p.m., the Director of Nursing (DON) stated her expectation was to have staff in dining room to assist the resident and to place a gait belt on the resident and redirect the resident back to the common area with assistance. She was not sure how staff did not see the resident get up and leave the dining room. During interview on 11/15/18 at 1:42 p.m., the Administrator was able to establish that when the visitor left the dining room the resident was not there and when the visitor came out of her husbands room the resident was on the floor. Based on staff statements no one was able to state they witnessed the resident leave the dining room. The Administrator expected staff to supervise the dining room and assist the residents as needed.

Based on observation, clinical record review and staff interview, the facility failed to revise and update resident care plans for four of 14 residents reviewed. (Resident #4, #10, #13 & #14) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #13 required extensive staff assistance with all cares, had impairment for range of motion on both the upper extremities and lower extremities. The Resident's Occupational Therapy (OT) Report dated 9/14/18 showed the reason for referral to OT to evaluate and treat for left hand splint to address decreased PROM, prevent joint deformity, and maintain skin integrity. The report showed the resident would benefit from the use of a hand splint. The OT discharge note dated 11/6/17 showed the long term goal for the resident and Staff completed with demonstration of a good carryover of established wearing schedule (4 hours) for left hand splint to improve joint alignment and maintain good skin integrity. The Task for the Restorative Staff included to place a carrot fully inflated for 4 hours into the resident's left hand after Passive Range of Motion (PROM). After removing the carrot, check the resident's skin. This is to be completed 3 to 7 times a week. The Kardex used for the Nursing Aides, in the computer, failed to identify any carrot (splint) device to be placed into the resident's contracted left hand. There is no instruction under resident care nor any instruction who performs the placement, when they perform the task. The Care Plan updated 10/15/18, failed to identify measures taken for the resident's left hand contracture. Observation on 11/13/18 at 10:47 a.m., revealed Staff F, Certified Nursing Aide, CNA placed an air bottle-like (carrot) covered in a soft cushion into the residents left hand. Staff F reported the resident used it for the contracture in the resident's left hand. Observation on 11/14/18 at 7:20 a.m., showed the resident up in the wheelchair with no carrot in the left hand. During interview on 11/15/18 at 7:05 a.m., Staff B, CNA/Restorative Aide reported the treatment for [REDACTED]. The carrot was to be in place for 4 hours a day and can be placed by restorative or a CNA. During interview on 11/15/18 at 7:30 a.m. Staff C, CNA, reported as far as she knew restorative staff was suppose to place the carrot in the resident's hand. Staff C did not know when, how often or the times for that placement. During interview on 11/15/18 at 7:45 a.m., Staff D, Registered Nurse, acting MDS Coordinator, reported being unaware if the resident needed anything for the left hand contracture, and replied restorative would know that answer. Staff D noted if the resident was using something special, such as a splint, it should be care planned in the resident's record. 2. The MDS assessment dated [DATE], documented Resident #14 required extensive staff assistance for toileting, and had frequent bladder incontinence. A Physician order [REDACTED]. The POS failed to identify the size, the type of catheter, and the method/procedure (clean or sterile) for the catherization. The Medication Administration Record [REDACTED]. The MAR failed to identify the size, the type of catheter, and the method/procedure (clean or sterile) for the catherization. The Care Plan identified the resident required assistance with daily cares and had urine retention. An intervention included staff to provide straight catherizations 3 times a day. The Care Plan failed to identify the type, size of the catheter and the type of procedure to use for the catherization. Observation on 11/14/18 at 1:16 p.m., revealed Staff A, Licensed Practical Nurse, LPN provided catheter care utilizing a special (Coude) sterile, straight catheter. During interview on 11/14/18 at 2:41 p.m. Staff A reported checking with the Director of Nursing, who reported they did change the resident's catheter procedure to a sterile procedure, sometime back in October. The DON informed Staff A the change had been documented in a communication book. Staff A stated she did not usually work that Hall. She had checked with the resident's MAR, which only said to catherize the resident three times a day. 3. The Medication Administration Record [REDACTED]. A Physician order [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During observation on 11/13/18 at 12:00 p.m., the resident's bilateral lower extremities were wrapped with ace wraps. During observation on 11/14/18 at 3:37 p.m., wraps to bilateral lower extremities was in place. The Care Plan with a target date of 2/6/19, lacked direction to staff about the ace wraps ordered by the Physician. During interview on 11/15/18 at 8:40 a.m., Staff A, LPN reported the ace wraps was not on the care plan. 4. The MDS assessment dated [DATE], documented Resident #10 had [DIAGNOSES REDACTED]. The plan of care revised 9/10/18, indicated the resident was on an antidepressant and antianxiety medication related to depression and anxiety. The goals for the resident to be free from discomfort or adverse reactions related to antidepressant/anti-anxiety therapy, and take the lowest therapeutic dose of medication. Nursing Staff was directed to administer the antidepressant and antianxiety medications as ordered, monitor/document side effects and effectiveness and communicate with the pharmacist and the physician regarding dose reduction of [MEDICAL CONDITION] medication, communicate with pharmacist/physician regarding therapeutic dose management, and consult pharmacist for monthly medication review. The care plan includes to educate the resident/family/caregivers about risks, benefits and the side effects of the antidepressant and antianxiety therapy. The care plan failed to show the individual behaviors the resident may display and what interventions the nursing staff should implement to assist the resident to lessen or cease the behavior. Review of the Certified Nurse Aide (CNA) Documentation Survey Report in the P[NAME] for (MONTH) through (MONTH) (YEAR) on behaviors marked for the resident showed frequent crying and yelling/screaming marked as behaviors the resident displayed. During interview on 11/15/18 at 1:11 p.m., Staff D, registered nurse, RN stated there was no particular behavior monitoring sheet for staff to utilize. Staff document in the progress notes or can go into the P[NAME] and document behaviors if seen. During an interview on 11/15/18 at 1:39 p.m., the DON they would expect the care plan to include what particular behaviors to look for on the resident listed and what interventions nursing staff may utilize to help the resident.

Based on clinical record review, facility policy review, resident and staff interview, the facility failed to develop a comprehensive person-centered care plan for one of 14 residents related to a toileting program. (Resident #10) The facility census was 35 residents. Finding include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #10 had [DIAGNOSES REDACTED]. The plan of care dated 9/20/18, indicated the resident required assistance with activities of daily living related to a fall. The care plan did not address the toileting needs of the resident. The Certified Nurse Aide (CNA) Documentation Survey Report for (MONTH) (YEAR), toilet use indicated the assistance level for the resident was to be independent the majority of the time. The assistance level changed to extensive to total assist of 1 to 2 staff as of 8/29/18 when the resident returned from the hospital following a [MEDICAL CONDITION]. The resident remained that level of assistance till approximately 11/5/18 when the resident became assist of 1 staff with a front wheeled walker in the resident's room. The resident was now limited assistance of 1 staff for toileting. During interview on 11/13/18 at 3:28 p.m., the resident stated they had urinary tract infections (UTI's) at times, and had for a few years now. The resident stated staff help them to go to the bathroom when needed or they come and ask I need to go. During interview on 11/15/18 at 10:37 a.m., Staff C, CNA stated they assist the resident to the bathroom to use the toilet and the resident will do her own cares and staff will follow up with the resident. During interview on 11/15/18 at 1:09 p.m., Staff C, CNA reported they try to toilet the resident every 2 hours, which was a usual rule of thumb for staff to follow. Staff C stated the resident does use her call light when she needs to use the toilet. Staff C explained the resident does wear a brief, but was continent more times than not. During interview on 11/15/18 at 3:15 p.m., the Director of Nursing (DON) stated they would expect the care plan to include a toileting program and include offering the restroom to the resident at least every 2 hours. During interview on 11/15/18 at 4:32 p.m., the DON and the Nurse Consultant presented a page from a care plan the resident that showed the resident had a toileting program when returned from the hospital on [DATE]. The care plan presented at the time showed the resident to be an assist x 2 with Bed Side Commode toileting or assist of x 1 with bedpan before and after meals and at bedtime, and as needed when the resident requests. The care plan identified the resident to be incontinent and wear incontinence briefs for dignity. The care plan directed the nursing staff to provide incontinence cares with each incontinent episode. The date for the care plan shown to be date initiated 8/29/18 and resolved date of 11/13/18. When the active care plan was reviewed with the DON and Nurse Consultant it was noted the active care plan did not reflect a toileting program for the resident. Both stated the care plan was lacking the current status of the resident and her toileting needs. Review of the Comprehensive Person-Centered Care Plans Policy revised 12/2016, states a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of the residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, clinical record review and staff interview, the facility failed to clarify a physician order [REDACTED].#14) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 required extensive staff assistance for toileting and had frequent bladder incontinence and had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The POS failed to identify the size, the type, and the method of catherization (clean or sterile). The Medication Administration Record [REDACTED]. The MAR failed to identify the size, the type , and the procedure of catherization (clean or sterile). During interview on 11/14/18 at 2:15 p.m., Staff A, Licensed practical nurse, LPN reported they completed the straight catherization on the resident utilizing a special one (Coude catheter, due to the bent tip) that was sterile. Staff A reported checking with the Director of Nursing (DON), who reported, they did change the resident's catheter procedure to a sterile procedure, sometime back in October. The DON informed Staff A the change was documented in a communication book. Staff A stated she did not usually work that Hall and had checked the resident's MAR, which only said to catherize the resident three times a day. During interview on 11/15/18 at 10:50 a.m., the DON reported reviewing the resident's frequent urinary tract infections and felt using a sterile method would be beneficial. The DON remarked she dropped the ball, and should have asked for a physician order. The physician order [REDACTED]. therefore inform staff what to do and what catheter to use. The DON commented the written order to straight catherize the resident 3 times a day, lacked information of what size, type of catheter and the type of procedure to use for the catheterization.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to ensure professional nursing staff prime the Insulin Pen per the manufactures reconditions for one resident to ensure the correct dose was administered. (Resident # 14) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #14 had [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The Physician order [REDACTED]. During observation on 11/15/18 at 8:08 a.m., Staff D, registered nurse, RN removed the [MEDICATION NAME] Insulin pen from the medication cart and dialed the [MEDICATION NAME]pen to the 10 units. Staff A failed to prime the insulin pen before dialing up the ordered dose. During interview on 11/15/18 at 8:09 a.m., Staff D stated they never primed the insulin pen before administering insulin and expressed the need to review the policy. During interview on 11/15/18 at 8:21 a.m., Staff D called the pharmacy to clarify the need to prime the insulin pen before dialing up the dose of insulin for administration. Staff A confirmed the requirement of priming the insulin pen and further reported never receiving any education to prime insulin pens before now. During interview on 11/15/18 at 9:30 a.m., the Director of Nursing (DON) stated nurses were to prime the insulin pen before admiration. The DON report not providing education to the nurses on priming the insulin pens. The Facility provided a policy titled How to use you [MEDICATION NAME] dated 2009, directing at step # 2 Do an air shot (prime the needle) 1. Dial 2 units. 2. Hold the syringe with the needle pointing up and tap the reservoir gently to move air bubbles to the top of the needle. 3. Press the push button on the top of the syringe as far as it will go until drop of insulin appears. The policy continues at step # 3 Dial up your dose

Based on observation, clinical record review and staff interview, the facility failed to provide proper catheter care for one resident reviewed with a catheter. (Resident #14) The facility census was 35 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], showed Resident #14 had [DIAGNOSES REDACTED]. A Physician order [REDACTED]. The POS failed to identify the size, the type of catheter, and the method/procedure (clean or sterile) for the catherization. Observation on 11/14/18 at 1:16 p.m., revealed Staff A, Licensed Practical Nurse, LPN entered the residents room, failed to cleanse hands but applied gloves and removed the resident's pants, touched the blanket and recovered the resident. Staff A washed hands and put on a pair of non-sterile gloves. Staff A took 2 by 2 inch gauze pads, poured [MEDICATION NAME] solution on them and while gloved, uncovered the resident's peri area. Wearing the same gloves, Staff A cleansed the urethral site (with the [MEDICATION NAME] gauzes) at the opening center using a circular downward motion. When completed Staff A re-covered the resident with the blanket. Staff A changed gloves, opened the plastic bag of the lubricant-KY-jelly, placed a squirt of the jelly on a paper barrier, and opened the [MEDICATION NAME] to drop a squirt unto the KY-jelly. Staff A changed gloves (un-sterile) and opened the sterile catheter and rubbed the tip of the catheter into the mixture lubricating the catheter. Without changing gloves, Staff A moved the blanket off of the resident's peri area and touched the sterile catheter and inserted it into the resident's urethra site. During interview on 11/14/18 at 2:15 p.m., Staff A reported the straight catheter method was not a sterile procedure. The catheter was a special one (Coude catheter, due to the bent tip) that is sterile. During interview on 11/15/18 at 10:50 a.m., the director of nursing, DON acknowledged Staff A did not keep the procedure clean or sterile. The DON remarked the [MEDICATION NAME] solution should have not been mixed in with the KY-jelly, as [MEDICATION NAME] was typically used topically.

Based on staff interview and record review the facility failed to provide Mandatory Abuse Training within 6 months from the date of hire for 1 out of 5 employees. The facility identified a census of 39 residents. Findings include: 1. Record Review of Staff D, Licensed Practical Nurse, employee record showed a hire date of 12/30/16. Staff D's employee record failed to identify or document any Dependent Adult Mandatory Abuse Training completed within 6 months of hire. Interview on 8/9/17 at 9:40 a.m., the Administrator reported the Office Manager notified Staff D on 7/6/17 her Mandatory Abuse Training for Dependent Adults should have been completed on 7/3/17. The Office Manager gave Staff D a booklet. Staff D believed she had received the Mandatory Abuse Training at her last employment and currently dated within the 5 year period. The Administrator reported upon further review on 8/8/17, the Mandatory Abuse Training at Staff D's last employment had been a refresher course and not the required 2 hour training course. The Office Manager had been under the impression Staff D just had the course at the last employment and forgot to follow up on any certification or documentation. The Administration reported the Office Manager kept a running list of staff due for the Mandatory Training but failed to identify Staff D's Mandatory Abuse Training had not been completed. The facility's Abuse Prevention, Intervention, Investigation, & Reporting Policy and Procedure, revised on 4-1-17, Training for Employees included the following: - Each employee shall be required to complete 2 hours of training related to the identification and reporting of dependent adult abuse within 6 months of initial employment. Each employee shall complete at least 2 hours of additional dependent adult abuse identification and reporting training every 5 years.