Every finding on record at NHC Healthcare, Sparta

Based on facility policy review, manufacturer's guidelines review, medical record review, facility investigation review, and interviews, the facility failed to provide adequate assistance and supervision to prevent falls for 1 of 3 (Resident #87) residents reviewed for accident hazards. Resident #87, who was dependent on staff for bed mobility, fell from her bed on 5/24/2026 when her bed malfunctioned and was in the highest position. Resident #87 sustained a right wrist fracture and 3 sutures to her right forehead which resulted in actual HARM to the resident. The findings include: Review of the facility policy titled, Patient Care Policies, revised 3/2026, .Safety precautions are taken to prevent .patient accidents . Review of the facility policy titled, Incident and Accident Process, undated, .An incident or accident is defined as any occurrence that is outside the norms [normal] or any happening that is not consistent with the routine operation of the center or care .examples of incidents/accidents are .falls .Significant injury including: Fracture .Closed head injury .Subdural hematoma .Any condition requiring medical treatment outside the center . Review of the undated manufacturer's guidelines titled, [Name of Bed] Series Beds, revealed .Warning Possible Injury .Keep bed in lowest position .Bed should be at lowest convenient height for entry or exit. Failure to do so could result in injury . Review of the medical record revealed Resident #87 was admitted to the facility on [DATE] with diagnoses including Dementia, Diabetes Mellitus, and Hypertension. Review of a comprehensive care plan for Resident #87 dated 11/26/2024, revealed .at risk for falls .Assist w [with] keeping call light within easy reach .safe appropriate footwear . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #87 was nonverbal and unable to complete the Brief Interview for Mental Status (BIMS) assessment. Resident #87 was totally dependent on staff for mobility. Review of a Nurse Progress Note for Resident #87 dated 5/24/2026, revealed .CNA [Certified Nursing Assistant] E was conducting morning round and heard patient's alarm sounding at approximately 0545 [5:45 AM] and upon entering room, patient [Resident #87] sitting on floor next to bed that was raised to highest level .Patient [Resident #87] .laceration noted to right forehead with bright red blood running down right side of face to floor and right periorbital [around eye] hematoma [bruising] forming .patient unable to explain what happened .Laceration cleansed with wound cleanser and pressure dressing applied .ROM [Range of Motion] performed with c/o [complaints of] pain noted upon movement of left arm/wrist .CNA [E] reported to this nurse [Licensed Practical Nurse] C .while receiving shift report from 2nd shift CNA [G] .[CNA E] was told that patient's bed was malfunctioning by raising to highest level without remote or being touched .2nd shift CNA [G] did not report malfunctioning bed to this nurse [LPN C]. This nurse [LPN C] and night shift CNA [E] lowered bed and witnessed bed raising to highest level without remote. [LPN C] then notified .on-call [Nurse Practitioner H] at 0635 [6:35 AM] via phone with orders to send patient to ED [Emergency Department] for further eval [evaluation] . Review of a comprehensive care plan for Resident #87 dated 5/24/2026, revealed .at risk for falls .Patient had recent fall with significant injury [5/24/2026] . A new intervention added on 5/25/2026 revealed .Fall roll mat to both sides of bed with bed in low position . Review of the ED Record for Resident #87 dated 5/24/2026, revealed .presented after a fall with significant right periorbital [around the eye] swelling and ecchymosis [bruising] and complaints of left arm and wrist pain .Laceration is approximately 3 cm [centimeters] long .The wound was reapproximated [closed] in 1 layers using three .sutures . Review of a Radiology Report for Resident #87 dated 5/24/2026, revealed .mildly impacted fracture of the distal left radius [thumb side of wrist] .avulsion [forceful] fracture of the ulnar styloid [pinky side of wrist] . Review of a Nurse Progress Note for Resident #87 dated 5/24/2026 at 12:09 PM, revealed .[Resident #87] returned to facility .via [by way of] EMS [Emergency Medical Service] .large hematoma to right side of face with significant swelling and small laceration to right side of head with 3 sutures .Moderate amount of bleeding noted. Cleansed with wound cleanser .wrapped head .brace to left arm .Neuro [neurological checks] continued .Fall precautions in place. Bed in lowest position, bilateral roll mats in place. Bed/chair alarm in place and functioning. Call light and personal items are within reach . Review of the Incident Report for Resident #87 dated 5/24/2026, revealed .assessed and treated .orders were given by NP [Nurse Practitioner] to send [Resident #87] to ED for further eval [evaluation] and treatment .Nurse manager [LPN B] removed the malfunctioning bed and replaced it on 5/24/2026 .Bed audit was completed by [LPN B] on 5/24/2026 to verify that all other beds in patient rooms were functioning properly . Review of the Post Falls Investigation report for Resident #87 dated 5/24/2026, revealed .laceration to [Right] side of head and left wrist fx [fracture] .sent to ER [Emergency Room] for tx [treatment] and eval .malfunctioning bed was replaced and all beds in facility was assessed .Care Plan Changes .bilateral fall roll mats . Review of a Teachable Moment for CNA G dated 5/24/2026, revealed .Related to .Faulty equipment .Content of Instruction .Instructed CNA [G] to report any faulty equipment to charge nurse immediately in order to prevent any accident/incidents by patients or staff . Review of the typed statement signed by LPN B dated 5/24/2026, revealed .[LPN B] removed the bed from the patient's room .replaced it with a functioning bed from an empty room .The malfunctioning bed was moved to the service hall with a DO NOT USE sign attached to it .completed a bed audit of all beds in the facility . Review of the typed statement signed by the Maintenance Assistant (MA) and Maintenance Director dated 5/24/2026, revealed .learned that [Resident #87's] bed .was malfunctioning .Maintenance Assistant was on call and came in to assess bed. When [MA] arrived, the bed had been removed and was in the back hall with a sign that read DO NOT USE. After learning the bed was rising up gradually on its own [MA] began working on the bed to see if he could recreate the issue that was described .The next day the Maintenance Director and Maintenance Assistant began troubleshooting the bed again and were able to witness the bed gradually rising. Bed was removed from building and will not be used any further . During an interview on 6/23/2026 at 2:50 PM, the Administrator stated he had not been notified of the malfunctioning bed when Resident #87 had a fall. During a telephone interview on 6/23/2026 at 3:14 PM, Family Member I stated she was notified by the facility Resident #87 had a fall after her bed malfunctioned and had been sent to the ER for evaluation and treatment. During an interview on 6/23/2026 at 3:37 PM, LPN [F] stated .[CNA E] did not report that the bed was malfunctioning . The night nurse, LPN C reported to LPN F on 5/24/2026 that the resident had fallen and bed was raising and lowering on its own and CNA E knew about the malfunctioning bed but had not reported it. CNA E forgot to report to LPN C about the malfunctioning bed. LPN F notified the Director of Nursing (DON) about the situation and unit manager LPN B about the incident. LPN B switched the bed out while the patient was out to the hospital for evaluation. . During a telephone interview on 6/23/2026 at 4:09 PM, CNA E stated she was notified on 5/23/2026 by the 2nd shift CNA that Resident #87's bed was malfunctioning. CNA E stated she forgot to report Resident #87's bed was not working properly and it kept going to the highest position on its own. CNA E stated on 5/24/2026 at approximately 5:00 AM, she entered Resident #87s room, observed Resident #87 sitting on the floor, facing the bed, with the bed up in the highest position. CNA E further stated she noticed blood on the resident's head and the dresser in her room. CNA E immediately notified LPN C the resident had fallen and advised the bed was malfunctioning. During an interview on 6/24/2026 at 8:12 AM, the Maintenance Director stated he had no reports of Resident #87s bed malfunctioning until after the bed had already been removed from Resident #87's room. During a telephone interview on 6/24/2026 at 8:15 AM, LPN B stated she removed Resident #87's bed after the resident fell while the resident was at the hospital. During a telephone interview on 6/24/2026 at 9:51 AM, the Medical Director stated he had been made aware of Resident #87's fall due to the malfunctioning bed, and transfer to the hospital. The Medical Director stated he was aware Resident #87 received a significant injury with a fracture and confirmed Resident #87 had been harmed from the fall with fracture. During an interview on 6/24/2026 at 10:28 AM, the Administrator and DON were asked if Resident #87 was harmed when her bed malfunctioned and she fell out of bed. The Administrator confirmed Resident #87 .received an injury from the fall . The DON shook her head in an affirmative manner.

Based on review of the facility policy, review of the United Stated Department of Agricultures' website, observation and interview the facility failed to maintain a sanitary kitchen, failed to ensure kitchen equipment was maintained in a sanitary condition, and failed to ensure food was served at the appropriate temperature during the pre-plating temperature check. Review of the facility policy titled, Cleaning Equipment, revised 11/2017, revealed .Equipment must be cleaned and/or sanitized after every use and according to manufacturers' recommendations .The physical facilities shall be cleaned as often as necessary to keep them clean. Review of the United Stated Department of Agricultures' website, an article titled, Danger Zone (40 degrees Fahrenheit - 140 degrees Fahrenheit) undated, revealed .Leaving food out too long at room temperature and cause bacteria .to grow to dangerous levels that can cause illness. Bacteria grow more rapidly in the range of temperatures between 40 degrees and 140 degrees Fahrenheit, doubling in number in as little as 20 minutes. This range of temperatures is often called the danger zone .Keep cold food cold-at or below 40 degrees Fahrenheit .Place food in containers on ice . The findings include: During an observation of the dietary department with the Dietary Manager (DM) and Registered Dietitian (RD) on 6/9/2025 at 11:05 AM, revealed the floor in the dish washing room was observed to have a large amount of foodstuff remains present on various parts of the dish washing room, the garbage disposal had the same foodstuff in and around it's opening as it had been turned on with a large amount of food present in the [NAME] on the disposal. The wall beside the dishwasher appeared to have a large area of discoloration with multiple tiles broken on the wall. Continued observation revealed the dry goods storage area was observed, the door of the dry storage was noted to be held open by a large industrial fan; a partially used commercial sized bag of brown sugar was noted which was packaged in a plastic lined paper bag material. The brown sugar bag on the storage shelf was not resealed after the last use. The end of the bag appeared to be folded over on itself which created an air gap, allowing the potential contamination of the product from insects. The bag of brown sugar was not labeled with the date the product was opened for use; a housefly was also observed crawling on the outside of the bag near the opening. The DM stated the bag of brown sugar should have been labeled with the date it was opened, and the bag should be sealed before being put back on the shelf. Neither the DM nor the RD voiced when the last time the pest control technician visited the kitchen. Continued observation revealed the 4-burner gas stove, steamer, deep fryer, and convection oven were observed to be in unsanitary condition. The stove had dark brown food debris on the handle to the oven compartment. The steamer had light brown food debris on the bottom front of the door and the operational control panel of the unit. The deep fryer had copious amount of granular food debris present on the top drip tray of the unit. The sides of the deep fryer was observed to have the same food debris granules present with dried tan fluid streaked on both sides of the unit. The DM stated the kitchen equipment was cleaned daily, and a deep cleaning of the kitchen and equipment was completed weekly. The nutrition rooms was toured with the DM, 1 container of employee food stuff was observed in the 200-hall nourishment room refrigerator, the outside of the container was not labeled with the correct contents, resident name, or date it was opened. The contents were pasta salad stored in a plastic container. During an observation/interview on 6/9/2025 at 11:50 AM, with the DM to observe the food temperatures for Lunch service. The following food temperatures were observed as out of safe range: 1.No bake cheesecake scoop - 55 degrees farenheit. The no bake cheesecake scoop temperature was checked on 2 separate containers, and both were 55 degrees. The trays of the no bake cheesecake scoops were arranged on metal trays of an uncovered cart while distributed on the residents' lunch trays. The RD stated she thought the no bake cheesecake could be served at room temperature. The label on the back of the product advised to refrigerate after mixing.

Based on facility policy review, medical record review, and interview, the facility failed to document if residents had an advanced directive and residents advance directive decisions in the medical record for 5 residents (Residents #5, #33, #57, #67, and #76) of 24 residents reviewed for advanced directives. The findings include: Review of the facility policy titled, Social Work Services Manual revised 11/2017, revealed .Included in the Patient Rights booklet is the Patient's Right to Form Advanced Directives .All information regarding advance directives is to be included directly in the Patient Rights booklet . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses which included Displaced Fracture of Surgical Neck of Left Humerus, Type 2 Diabetes Mellitus with Neuropathy, Chronic Obstructive Pulmonary Disease, and Chronic Kidney Disease. Review of a Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of the medical record revealed no documentation for Resident #5's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Dementia, Hypothyroidism, and Anxiety. Review of a quarterly MDS assessment dated [DATE], revealed Resident #33 was severely impaired for daily decision making. Review of the medical record revealed no documentation for Resident #33's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses which included Discitis, Sepsis, Osteomyelitis, Dysphagia, Chronic Respiratory Failure, and Metabolic Encephalopathy. Review of an admission MDS assessment dated [DATE], revealed Resident #57 scored a 13 on the BIMS assessment which indicated the resident had intact cognition. Review of the medical record revealed no documentation for Resident #57's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed that Resident #67 was admitted to the facility on [DATE], with diagnoses which included Dementia, Atrial Fibrillation, and Adult Failure to Thrive. Review of a significant change MDS assessment dated [DATE], revealed Resident #67 scored a 3 on the BIMS assessment which indicated the resident was severely cognitively impaired. Review of the medical record revealed no documentation for Resident #67's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. Review of the medical record revealed that Resident #76 was admitted to the facility on [DATE], with diagnoses which included Heart Failure, Chronic Obstructive Pulmonary Disease, and Adult Failure to Thrive. Review of a quarterly MDS assessment dated [DATE], revealed Resident #76 scored a 4 on the BIMS assessment which indicated the resident was severely cognitively impaired. Review of the medical record revealed no documentation for Resident #76's decisions regarding advanced directives to include advanced care planning, living will, and power of attorney. During an interview on 6/11/2025 at 12:04 PM, the Director of Nursing (DON) stated there were no documentation in the medical records to indicate if Resident's #5, #33, #57, #67, and #76 had an advance directive or information regarding the residents advance directive decisions. During further interview the DON confirmed the facility failed to document if the residents had an advance directive and resident advance directive decisions in the medical record for Residents #5, #33, #57, #67, and #76.

Based on facility policy review, medical record review, review of facility documents, and interview, the facility failed to protect the resident's right to be free from physical abuse by a resident for 1 resident (Resident #200) of 24 residents reviewed for abuse. Findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 2/1/2023 revealed, .Abuse .will not be tolerated by anyone, including staff, patients, consultants, volunteers, family members or legal guardians, friends, visitor or any other individual in this center. The patient has the right to be free from abuse .Definitions. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical Abuse: includes hitting, slapping, pinching, and kicking .Procedure. All alleged violations and all substantiated incidents will be reported immediately to the Administrator or her/his designated representative and to other officials in accordance with State and Federal law (including to the State survey and certification agency). A. Internal Investigation Policy. 1. Policy. All events reported as possible abuse .will be investigated to determine whether the alleged abuse .did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident .Procedure. a. The investigation is conducted immediately under the following circumstances .When it is identified that an alleged incident may have occurred .7. Protection Policy .Patients will be protected from harm during an investigation. Procedure. 1. Staff will respond immediately to protect the alleged victim and integrity of the investigation .4. Examining the alleged victim for any sign of injury .Increased supervision of the alleged victim and patients . Resident #38 was admitted to the facility on [DATE] with diagnoses including Chronic obstructive pulmonary disease, Encounter for palliative care, Peripheral vascular disease, Unspecified dementia, moderate, with other behavioral disturbance, and Delusional disorders. Medical record review of Resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 00 on the Brief Interview of Mental Status (BIMS) which indicated the resident was severely cognitively impaired. Resident #200 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Dementia with Agitation, and Delusional disorders. Medical record review of Resident #200's significant change MDS assessment dated [DATE] revealed the resident scored a 5 on the Brief Interview of Mental Status (BIMS) which indicated the resident was severely cognitively impaired. Review of the facility's investigation revealed on 7/3/2024, Resident #38 and Resident #200 were observed at the Nurses Station. Resident #38 was observed slapping another resident (Resident #200) as he propelled in front of him. Resident #200 exchanged a slap back with his fist per facility documentation. Both residents were separated and assessed. No apparent injuries were noted to either resident. Law Enforcement arrived and no report was filed. Both residents were followed up with from social services, no lingering psychosocial effects were noted from either resident. Review of Resident #38's nurses progress note dated 7/3/2024 at 11:09 PM, Resident #38 was 1:1 and sent to the local hospital for evaluation and treatment. Resident #200 was escorted to his room. Resident #38 had a stay at the local hospital from [DATE]-[DATE]. Interviews were attempted with staff during the complaint investigation, due to the length of time since the allegation was reported, staff were unfamiliar with Resident# 200. During an interview on 6/11/2025 at 1:50 PM, the Director of Nursing (DON) stated she was involved with the reporting of the altercation to the State Agency, she recalled the altercation was witnessed. Resident #200 had rolled in front of Resident #38; Resident #38 then swung at Resident #200 making contact. Resident #200 returned a swing at Resident #38 with his fist and made contact. The DON stated the altercation did happen.

Based on facility policy review, medical record review, observation, and interview, the facility failed to date and properly store a nebulizer with mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for 1 resident (Resident #63) of 8 sampled residents reviewed. The findings include: Review of the facility policy titled, Infection Control Manual Volume 1, updated and reviewed February 2025, revealed, .306 .Respiratory Therapy Equipment .1. Equipment associated with machines such as oxygen, nebulizers, IPPB (Intermittent Positive Pressure Breathing) machines and suction machines are not shared among patients .2. Respiratory equipment is dated when placed at bedside and replaced on schedule .3. Respiratory equipment (i.e. [that is], nasal cannula, aerosols, etc. (et cetera [and so on]) at bedside will be covered with a plastic bag when not in use . Medical record review revealed Resident #63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dementia, Anxiety, Major Depressive Disorder, Psychotic Disorder with Delusions, Hypertension, and Type 2 Diabetes Mellitus. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #63 was unable to complete the Brief Interview of Mental Status (BIMS) assessment due to severe cognitive impairment. Review of a Care Plan, initiated 12/7/2023 and last reviewed/revised 5/22/2025, revealed Resident #63 was care planned for, .Problem: Respiratory Function-at risk for compromise related to: Dysphagia, oropharyngeal phase, times of nasal stuffiness, Chronic sinusitis, unspecified .Approach: Administer medications as ordered . Review of the Physician Order Report for Resident #63, dated 2/1/2025-3/31/2025, revealed an order with a start date of 2/5/2025, for .ipratropium-albuterol solution for nebulization; 0.5 mg (milligrams)-3 mg (2.5 mg base)/3 mL (milliliters); amt (amount):1 vial; inhalation .Special Instructions: prn shortness of breath/congestion Twice A Day-PRN (as needed) . Continued review revealed the order was discontinued on 3/18/2025. During an observation in Resident #63's room on 6/9/2025 at 12:14 PM, a nebulizer with mask and tubing was observed, undated and uncovered, not stored in a bag, hanging on the wall near the resident's bed. During an observation and interview in Resident #63's room on 6/11/2025 at 10:05 AM, a nebulizer with mask and tubing was observed, undated and uncovered, not stored in a bag, hanging on the wall near the resident's bed. The Director of Nursing (DON) confirmed the nebulizer with mask and tubing was undated and uncovered, not stored in a bag, hanging on the wall near the resident's bed. The DON stated that nebulizers should be stored in plastics bags. The DON then removed and discarded the nebulizer that was observed in Resident #63's room.

Based on observations, interviews, facility documentation review, and review of the facility's policy, the facility failed to maintain an effective pest control system to ensure the kitchen's environment was free of pests. This failure had the potential to affect all residents of the facility. Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines, revised 11/2017 revealed, .The Center will implement preventive measures which focus on denying pests access to the building, eliminating sources of food and shelter, and by working with a pest control operator .1. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by routinely inspecting incoming shipments of food and supplies. 2. Premises should be routinely inspected for evidence of pests and finding reported to appropriate personnel .5. Center should work with a pest control operator (PCO) in using preventive and control measures to eliminate pests and keep them from infesting the building . During an observation on 6/9/2025 between 11:05 AM - 11:50 AM, with the Dietary Manager (DM) and Registered Dietitian (RD) , revealed the dry goods storage area was observed, the door of the dry storage was noted to be held open by a large industrial fan; a partially used commercial sized bag of brown sugar was noted which was packaged in a plastic lined paper bag material. The brown sugar bag on the storage shelf was not resealed after the last use. The end of the bag appeared to be folded over on itself which created an air gap , thus allowing the potential contamination of the product from insects. A housefly was also observed crawling on the outside of the bag near the opening. During an observation/interview on 6/11/2025 at 3:00 PM, the dry goods room was observed without the partially used bag of brown sugar. When the RD was asked the disposition of the brown sugar bag, she stated it was discarded. Neither the Dietary Manager nor the Registered Dietitian (RD) voiced when the last time the pest control technician visited the kitchen.

Based on observation, interviews, record review, and facility policy review, the facility failed to document, report, and monitor a newly identified skin alteration for 1 (Resident #70) of 2 residents reviewed for pressure ulcers. Findings included: Review of a facility policy titled, 100 Assessment Guidelines, last reviewed in January 2024, revealed, .iv. Daily Skin Inspection 1. Performed by caregivers during bath and/or assistance with ADLs [activities of daily living]. Changes in skin integrity and/or signs/symptoms of complications are reported to a licensed nurse . Review of a facility document titled, Patient Care Policies, last reviewed in February 2023, revealed, .The charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the physician or physician extender and the patient's representative . Review of a Resident Face Sheet revealed the facility admitted Resident #70 on 10/02/2022 and readmitted the resident on 09/28/2023 with diagnoses that included dysphasia (inability to use or understand words), dysphagia (difficulty swallowing), and hemiplegia (one-sided paralysis) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting right dominant side. Review of a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/14/2024, revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. According to the MDS, Resident #70 required partial/moderate assistance from staff with rolling from their back to their left and right side in bed and had an upper extremity functional limitation in range of motion on one side. The MDS further indicated Resident #70 was at risk for developing pressure ulcers/injuries but had no unhealed pressure ulcers/injuries at the time of the assessment. The MDS did not reflect the presence of any other skin conditions, including infection of the foot, diabetic foot ulcers, or other open lesions on the foot. Review of Resident #70's Care Plan, revealed a Problem area with a start date of 10/02/2022 that indicated the resident was at for risk skin breakdown and development of pressure ulcers or injuries related to gastrostomy status, bowel incontinence, decreased mobility, and generalized weakness. Review of an untitled document with a front and back body template used to notate observed skin alterations, dated 02/23/2024, revealed a circled area to the back of Resident #70's right lower leg close to the resident's heel with the word sore handwritten on the document. Certified Nurse Aide (CNA) #7 and Licensed Practical Nurse (LPN) #2 signed and dated the document on 02/23/2024. Review of Resident #70's Progress Notes, for the timeframe from 02/21/2024 through 02/27/2024, revealed the notes lacked documentation regarding the right lower leg skin alteration that was identified on 02/23/2024. Review of Resident #70's Active Orders, revealed no orders to monitor or treat the skin alteration to the resident's right lower leg that was identified on 02/23/2024. During an interview on 02/26/2024 at 10:38 AM, Resident #70 stated they had a wound on their right heel. Resident #70 stated they told the nurse, but no one had looked at the wound and said there were no treatments being provided for the wound. During an interview on 02/27/2024 at 6:07 PM, CNA #7 stated she saw the area on Resident #70's right lower leg when completing a skin check. CNA #7 stated the area looked like a scab or abrasion with pink skin on the edges and no blood present. CNA #7 stated she mentioned it to the resident, and the resident did not know how it happened. CNA #7 stated she completed the skin check sheet and gave the sheet to LPN #2. CNA #7 said she did not recall seeing the wound prior to 02/23/2024. During a telephone interview on 02/27/2024 at 6:28 PM, LPN #2 stated he was notified by CNA #7 about the wound to Resident #70's right leg and indicated he assessed the area. LPN #2 stated the area was located on the back of Resident #70's right lower leg above the ankle bone, was the size of a dime or penny, and was scabbed over with reddened borders. LPN #2 stated there was no drainage and no signs of infection. LPN #2 stated the resident reported they were not sure how it happened. LPN #2 stated he did not notify the physician or Nurse Manager (NM) #31 (responsible for wound care) of Resident #70's skin alteration because he thought the area had been previously identified since the area was scabbed over. LPN #2 stated the normal process for a newly identified area would be to notify NM #31, if the area needed to be assessed and to notify the physician if the area appeared to require treatment. LPN #2 stated he should have documented his assessment and a description of the wound in the resident's medical record as a progress note and should have notified the physician and NM #31. During an interview on 02/27/2024 at 4:20 PM, Registered Nurse (RN) #4 confirmed there were no physician's orders in Resident #70's medical record regarding the skin alteration on the resident's right lower leg. RN #4 said when the skin alteration was identified, the nurse should have assessed the area, determined what treatment was needed, and notified NM #31, who was currently responsible for wound care. On 02/27/2024 at 4:25 PM, an observation of Resident #70's right lower leg was completed in the resident's room, with RN #4. Resident #70's right lower extremity was noted to have a dime sized circular area with slightly irregular and dried edges. The tissue was red in color, with no drainage, no odor, and no scab present. At this time, Resident #70 denied pain to the area. During an interview on 02/27/2024 at 4:30 PM, NM #31 confirmed there was no documentation, including physician orders or treatment, in Resident #70's medical record regarding their right lower leg skin alteration. NM #31 stated she was not notified of Resident #70's wound. NM #31 further stated that when a new skin concern was identified, the nurse was responsible for assessing the skin alteration and documenting their findings, notifying NM #31 for follow-up, and notifying the physician for a treatment order if necessary. NM #31 stated she had looked at the skin alteration on 02/27/2024 and described the wound as an abrasion with no drainage, and stated it was in the healing stage. NM #31 stated Resident #70's skin alteration not being documented in the medical record or being monitored could have led to the area worsening or becoming infected. During an interview on 02/28/2024 at 1:08 PM, the Nurse Practitioner (NP) said she expected staff to notify her and NM #31 as soon as new skin concerns were identified. The NP stated when nothing was done for a wound there was a risk for further deterioration and a potential for the wound to progress to a skin ulcer or infection . During a follow-up interview on 02/28/24 at 02:01 PM, the NP stated she had evaluated Resident #70's skin and said the area was scabbed over and did not require any treatment. Review of Resident #70's Progress Note, documented by the NP and dated 02/28/2024 at 2:00 PM, revealed, Assessed abrasion to right lower extremity. Small scabbed area noted, no treatment indicated. During an interview on 02/28/2024 at 3:45 PM, the Medical Doctor (MD) stated he expected a nurse to notify the nurse responsible for treatments when a new wound was identified, so the wound could be assessed. The MD further stated he would want to be notified immediately if the wound was open. During an interview on 02/29/2024 at 10:57 AM, the Director of Nursing (DON) stated the nurse that initially confirmed the skin alteration to Resident #70's right lower leg was responsible for assessing and determining treatment needs, the cause of the wound, and any interventions needed for the prevention of skin alterations. The DON stated that when the nurse aide notified the nurse of Resident #70's skin alteration there should have been documentation entered in the medical record. The DON further stated Resident #70's skin alteration could have declined further had the facility not assessed and addressed the area. During an interview on 02/29/2024 at 11:06 AM, the Administrator stated the nurse was expected to assess, document, and notify the DON and the physician when Resident #70's skin alteration was identified. The Administrator stated skin alterations could worsen or become infected if not addressed.

Based on policy review, medical record review and interview, the facility failed to prevent physical abuse for 1 resident (#1) of 3 residents reviewed for abuse. The findings included: Review of Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation policy, revised 12/11/2017 showed, .Abuse .will not be tolerated by anyone, including staff .The patient has the right to be free from abuse . Further review showed the definition of abuse was .the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS (Minimum Data Set) dated 11/8/2020 showed the resident was not oriented and was severely cognitively impaired. Review of documentation provided by the facility (not dated) showed .Pt (patient) (Resident #1) has a primary [DIAGNOSES REDACTED]. Pt requires extensive assistance or total dependence with activities of daily living and decision making. Caregivers for the patient entered the patient's room to provide care and assist patient to bed. Upon entering the room and beginning to provide care, patient became agitated and struck out at one of the CNAs (certified nurse assistant) (CNA #1) hitting her face shield. CNA (CNA #1) reacted and struck patient on forehead. CNA (CNA #2) ensured the patient's safety and exited the room with the CNA (CNA #1). Then reported the event to her LPN (Licensed Practical Nurse) supervisor. Supervisor immediately questioned the CNA (CNA #1), notified the DON (Director of Nurses) and CNA (CNA #1) was escorted out of the building. DON and Administrator came to the center. DON examined the patient. No signs of pain but the patient did have a dime size blue bruise on her forehead. LPN supervisor, ADON (Assistant Director of Nurses) and DON then performed skin assessments and interviewed each patient on the unit with no issues or concerns from the patients noted . Medical record review of a Psychiatric Evaluation dated 11/12/2020 showed Resident #1 became agitated with activities of daily living only and tried to grab staff facemask/clothes. Medical record review of a nurse's note dated 11/11/2020 at 12:48 AM showed, .Per staff report, patient (Resident #1) showing combativeness during care, that resulted in staff reaction. Patient (Resident #1) noted to have a bruise to mid forehead at hairline. (Resident's physician) notified via phone. Attempted to notify (family) without success. Message left to return call . Review of CNA #1's statement provided by facility (not dated) showed, .We were putting (Resident #1) to bed using the stand-up lift. I was putting the belt of the lift around her and she was punching me in the side of the face. She mostly hit my face shield. She was trying to bite (CNA #2's) hand too. I tapped her on the side of the forehead with 2 fingers after she hit my face and face shield while I put her gown on. She didn't have any reaction after I tapped her. I would never hurt that woman or another of my patients intentionally . Review of CNA #2's statement provided by the facility dated 11/10/2020 showed, .Myself and (CNA #1) were putting (Resident #1) to bed with a stand up lift. As we started to assist her, she started getting agitated and then started hitting us. As (CNA #1) was trying to put her night gown on, she swung at (CNA #1) and hit her face and face shield. After she hit (CNA #1's) face, (CNA #1) smacked (Resident #1) on the forehead with an open hand. I was shocked and didn't know what to say right after (CNA #1) smacked her forehead. (Resident #1) grabbed her forehead and said 'oh oh'. (CNA #1) said, 'when you get aggressive with her, it changes her temperament'. After she smacked her, she said to me 'you didn't see that'. (CNA #1) started raising the lift and we put her in the bed and we both left the room. We then went to another room and she could tell I was upset. She was trying to explain how she smacked (Resident #1) and how hard. She then smacked me on the forehead and said 'All I did was smack her with my fingers' and she kept making excuses trying to get me to be ok with what she did. She then said 'I know I was wrong, and I shouldn't have done that .' Interview with CNA #1 on 12/3/2020 at 3:15 PM by telephone showed she and CNA #2 were trying to change Resident #1's gown and place her into bed. She put the belt around her and Resident #1 hit her face shield. She stated she never struck the resident. CNA#1 stated the resident was combative a lot, however she never struck the resident. When asked why she was terminated CNA #1 stated, .I was let go because the resident got a bruise. I never struck her . Interview with CNA #2 on 12/3/2020 at 6:00 PM by telephone showed she witnessed CNA #1 strike the resident with a open hand on the forehead. CNA #2 stated at the time this happened she was so shocked that she wrote down everything that happened. She offered to send this information to the surveyor. CNA #2 said she notified the LPN supervisor and CNA #1 was escorted off the premises. Review of information sent by CNA #2 dated 11/10/2020 around 8:30 PM showed, .(CNA #1) and myself were putting (Resident #1) to bed, began to take off (Resident #1's) sweater she crossed her arms but she wasn't aggravated yet we then told her 'lets put your gown on' we both grabbed her hands to put her gown on, she became combative and started hitting my stomach and she tried to bite my arm. I continued to put the gown on and then I let go of her right arm but (CNA #1) was not done putting the gown on her left side. (Resident #1) swung at (CNA #1's) face but never made contact, she hit the face shield instead of (CNA #1's) face. (CNA #1) then raised her right hand (open handed) and hit (Resident #1) on the forehead (Resident #1) said 'oh' and right after (CNA #1) said 'You didn't see that' I didn't respond I was in shock. (CNA #1) then continued to raise the stand up and we put (Resident #1) in bed then (CNA #1) said 'If you get aggressive with her it changes her temperament' I still didn't respond. We both walked out of the room together and we walked up the hall (I was looking for the nurse) but 2 different pts (patients) were crawling out of the bed, we changed them and put them back in bed (I never left her alone with pts) after we walked out together and I looked for the nurse but she was off the floor so we put another pt to bed because she was sliding out of bed, while putting the 3rd pt to bed she could tell I was upset and while in the bathroom she smacked my head and said 'I only hit her with my fingers .I know I shouldn't have done that, I was wrong'. She said that 2 times. We then walked out of the room I went to 'lunch' (CNA #1) went and sat at the nurse's station, while the nurse was at the other end of the hall. I drove around the building and notified the nurse . Interview with the DON on 12/2/2020 at 1:00 PM confirmed Resident #1 was physically abused by CNA #1 and the CNA was terminated.

Based on medical record review, fall investigation review, observation and interview, the facility failed to provide interventions to prevent accidents for 1 resident (#15) of 5 residents reviewed for falls. The findings include: Medical record review revealed Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Comprehensive Care Plan, dated 2/6/19, and edited on 7/29/19 and 10/29/19, revealed Resident #15 had a history of [REDACTED].Reposition/Re-adjust patient in chair when she becomes restless and agitated .alarm to bed and layback (facility's name for the resident's type of chair) . Medical record review of Resident #15's Significant Change Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The resident required extensive assistance of 2 persons for transfers, extensive assistance with 1 person physical assist for locomotion, and the resident was not steady when moving from a seated to a standing position. Review of an undated Manager Investigation of Incident and an Event Report dated 6/1/19 revealed Resident #15 had a witnessed fall, without injury, on 6/1/19 at 6:07 PM, while seated in a gerichair (type of reclining chair) at the nurse's station. The resident slid to the edge of the foot rest, and then slid from the foot rest to the floor. Continued review revealed .Alarm was not sounding when patient fell , alarm was replaced . Further review revealed .OLD ALARM WAS SOUNDING BUT SEEMS TO HAVE A SHORT FROM PATIENT FREQUENTLY PLAYING WITH DEVICE . Review of a Manager Investigation of Incident and an Event Report dated 6/25/19, revealed Resident #15 fell on [DATE] at 6:33 PM. The resident was seated in front of the dining room listening to her music when she got out of her layback chair and walked independently. The resident's alarm was not sounding and she had been seen playing with the alarm prior to standing up from the chair. Staff witnessed the resident walking, she became unstable, and was lowered to the floor. Medical record review of Resident #15's Significant Change MDS dated [DATE], revealed a BIMS score of 3, indicating severe cognitive impairment. The resident required extensive assistance of 2 persons for transfers, was total dependence with 1 person physical assist for locomotion, and was not steady when moving from a seated to a standing position. Medical record review of Resident #15's Physical Therapy (PT) Plan of Care dated 8/23/19 revealed PT treated the resident from 7/15/19-8/23/19. Continued review revealed .Patient requires frequent verbal cues to stay on task due to poor attention span .Daily Life .condition of confusion . Medical record review of Resident #15s Fall Risk Assessment Tool dated 9/4/19 revealed the resident was a high fall risk. Review of a Manager Investigation of Incident and an Event Report dated 10/9/19 revealed Resident #15 fell on [DATE] at 2:30 PM in the dining room. The resident was participating in a singing activity when she attempted to stand up and fell from her gerichair. The resident's alarm did not sound. Observation and interview on 10/29/19 at 12:30 PM, in Resident #15's room, revealed she was seated in a Geri-chair with her daughter present. Interview with the resident's daughter confirmed .fell recently (10/9/19) .cannot stand or walk independently but will try to . Observation on 10/30/19 at 3:44 PM, at the Unit 3 nurses station, revealed Resident #15 seated in her Geri-chair with the chair with alarm in place. Interview and review of fall investigations with the Unit 3 Manager on 10/30/19 at 1:53 PM, in the conference room, confirmed the chair alarm was not sounding during the resident's fall on 6/1/19. Continued interview confirmed the Unit Manager changes the alarm batteries once a week. Further review revealed .Nurse checks alarm placement and other fall interventions q (every) shift and functionality of alarms . Continued interview confirmed a Geri-chair and a layback chair are the same chair. Further interview confirmed the chair alarm did not sound when Resident #15 exited her chair at the singing activity on 10/9/19. Interview with the Director of Nursing (DON) on 10/30/19 at 4:38 PM, in the conference room, confirmed Resident 15's alarm was not sounding at the time of the 6/1/19 and the 10/9/19 falls.

Based on facility policy review, observation, and interview, the facility failed to maintain cleanliness for 10 of 28 privacy curtains observed on 1 of 3 hallways. The findings include: Review of the facility policy un-named (housekeeping), undated, revealed .2. AS REQUIRED .e. Launder cubicle curtains . Observation on 9/30/18 from 9:15 AM to 12:50 PM, on the 200 Hall, revealed soiled or stained privacy curtains in rooms 217-A, 219-B, 221-B, 222-A, 225-A, 226-A, 226-B, 227-A, 229-A and 229-B. Observation and interview on 10/1/18 at 8:30 AM, with the Assistant Director of Nursing (ADON), in room [ROOM NUMBER]-A, confirmed the privacy curtain had 2 brown smudges and was soiled. Observation and interview on 10/2/18 at 10:20 AM, with the Director of Nursing (DON), confirmed the privacy curtains in resident rooms 217-A, 219-B, 221-B, 222-A, and 225-A, were either stained or soiled. Observation and interview on 10/2/18 at 10:30 AM, with the ADON, confirmed the privacy curtains in resident rooms 226-A, 226-B, 227-A, 229-A, 229-B were either stained or soiled. Interview with the Housekeeping Manager on 10/2/18 at 11:15 AM, in the conference room, revealed .if a curtain is stained it would be pitched and a new one would be replaced. Further interview revealed the privacy curtains had not been laundered on the 200 hall.

Based on review of facility policy, medical record review, review of Incident/Accident reports, observation and interview, the facility failed to develop and implement an intervention to prevent future falls from a wheelchair for 1 resident (#36) of 4 residents reviewed for falls of 36 sampled residents. The findings include: Review of the facility policy QM (quality management) REVIEW AND REPORTING: DATA SOURCES, revised 8/13/13, revealed .examples of incidents/accidents are: Falls .Potential Hazards: .Equipment .Wheels not locked on wheelchairs .Defective or broken equipment .1. Investigation .Obtain information on what happened .get patient's statement about what happened .Review the Care plan for any possible updates that might be required related to a change/update . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) was 15, indicating the resident was cognitively intact. Continued review revealed the resident was assessed as requiring the assistance of 1 staff member for transfers and used a wheelchair for mobility and locomotion. Further review revealed the resident had 1 fall since previous MDS assessment completed 11/13/17. Review of Incident/Accident reports for Resident #36 revealed the following: 1. A fall on 4/8/18 at 3:10 PM, with no apparent injury .sitting on floor on bottom in front of w/c (wheelchair) .Pt (patient) stated he was trying to reach for his coke when fell .lost his balance .Post incident interventions .Reacher .pt to be provided with a reacher to assist with getting objects .history of falling . 2. A fall on 7/30/18 at 7:10 PM, with no apparent injury .lying on the floor .left side with left arm tucked underneath him .Patient's statement regarding the incident .stated he had dropped his jello onto the floor and was reaching to get it when the wheelchair slipped out from him .Summary .Pt stated the wheelchair slipped out from under him . 3. A fall on 7/31/18 at 10:00 AM, with Type of Injury - Bruise/discoloration, - Abrasion Location of Injury - Upper back, - Lower back, - Left hip .assess patient's w/c noted antiroll back was not working properly and also brakes not working properly .Location of incident - Patient's Bathroom .Patient's statement regarding the incident pt states he was transferring to the toilet when his wheelchair rolled away from him .Post incident interventions .Maintence (maintenance) to Check brakes and antiroll back to w/c . Medical record review of the current Care Plan, last updated 9/27/18 revealed, .Patient is at risk for falls . Continued review revealed 19 interventions were included to address repeated falls over the previous 17 months and none of the interventions included locking the wheelchair brakes when resident was using. Observation and interview with Resident #36 on 9/30/18 at 10:30 AM, in the resident's room revealed the resident seated in his wheelchair in his room. Continued observation revealed no other wheel chairs in the room. Interview with the resident, at the same time, revealed when the resident was asked if he had fallen in the facility, the resident responded, .A few months ago . Observation and interview with Resident #36 on 10/2/18 at 10:35 AM, revealed the resident sitting in his wheelchair with the brakes unlocked. Interview revealed the resident got up before breakfast, spent the majority of the day in his wheelchair, and did not routinely apply the brakes on the wheelchair. Interview with the Director of Nursing (DON) on 10/2/18 at 9:00 AM, in the 200 hall nursing station, confirmed Resident #36 had 2 falls on consecutive days 7/30/18 and 7/31/18. Continued interview revealed the resident's statement on 7/30/18 the wheelchair slipped out from under him was not addressed. Further interview confirmed the wheelchair brakes and antiroll back mechanism were not assessed until after the 2nd fall from the wheelchair on 7/31/18. Continued interview confirmed the wheelchair brakes and antiroll back mechanisms were .not working properly . Interview with the maintenance supervisor on 10/2/18 at 12:20 PM, in the conference room, confirmed the work order to fix Resident #36's wheelchair was received and completed on 7/31/18 (after the 2nd fall from the wheelchair). Continued interview confirmed the wheelchair brak and antiroll back mechanism were not funtioning correctly. wheelchair brake was broken and the antiroll back mechanism had malfunctioned. Further interview revealed .one of the brake handles was completely broken off . Interview with the DON on 10/2/18 at 12:30 PM, in the conference room, confirmed the broken wheelchair brakes, and the antiroll back mechanism malfunction was not addressed until after the second fall on 7/31/18.

Based on observation and interview, the facility failed to ensure expired medications were properly disposed of in 1 of 3 medication rooms. The findings include: Observation with Licensed Practical Nurse (LPN) #1 on 10/2/18, at 10:22 AM, of the 300 hall medication room, revealed the following expired medication stored in the locked cabinet: 1 bottle of 60 stool softener tablets expired 7/18. Interview with LPN #1, on 10/2/18, at 10:22 AM, in the 300 hall medication room, confirmed the medication was expired, available for resident use, and had not been properly disposed of.

Based on medical record review, observation and interview, the facility failed to work with 1 resident (#16) in the care plan process to support the resident's choices, and desired outcomes of 36 residents reviewed. The findings include: Medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review revealed the resident was assessed as having no plans for discharge from the facility. Observation of the resident on 9/30/18 at 10:00 AM, revealed the resident in her wheelchair with the left foot resting on top of the right foot. Continued observation revealed the resident propelled herself with her right foot up and down the hallways. Interview with the resident on 10/1/18 at 9:00 AM, in her room, revealed the resident expressed questions about her diet as ordered and complained about information not being forthcoming related to her discharge plan. Further interview revealed she had not been included in a care plan meeting or had a care plan shared with her. Interview with the Social Services Director on 10/2/18 at 7:45 AM, in her office, confirmed the resident was assisted by an outside resource for housing and a tentative discharge was being planned. Continued interview confirmed the facility's interdisciplinary team (IDT) had not met with the resident, and confirmed the resident was responsible for her own decisions. Interview with the MDS Nurse on 10/2/18 at 11:10 AM, in the conference room, confirmed the IDT met to develop Resident #16's plan of care and did not include the resident. Continued interview confirmed the facility failed to include the resident in the developement of the resident's plan of care.

Based on medical record review and interview, the facility failed to ensure laboratory tests were completed for 1 (#109) resident of 5 residents reviewed for unnecessary medications of 29 residents reviewed. The findings included: Medical record review revealed Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED].BMP (Basic Metabolic Panel) every week on Thursday .Ammonia Level every week on Thursday . Medical record review revealed no laboratory results for the BMP or Ammonia Level on 8/31/17 (Thursday). Interview with the Director of Nursing on 9/20/17 at 11:15 AM, in the conference room, confirmed the laboratory tests were not completed on 8/31/17.

Based on medical record review, observation, and interview, the facility failed to promote dignity for 2 residents (#45, #30) who share a room and are incontinent of bowel and bladder, by ensuring the room is free from odors of 31 residents reviewed. The findings included: Medical record review revealed Resident #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set ((MDS) dated [DATE], revealed the resident was incontinent of bowel and bladder with no control noted, and required extensive assistance with Activities of Daily Living (ADL)s. Medical record review revealed Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE] revealed the resident was incontinent of bowel and bladder with no control noted, and required extensive assistance with ADLs. Observation in Resident #45 and #30's room on 9/19/16 at 10:45 AM, revealed a strong urine and feces odor especially near Resident #45's bed. Observation and interview with the Assistant Regional Nurse on 9/19/16 at 11:00 AM, in Resident #45 and #30's room, confirmed the presence of strong urine and feces odor.

Based on facility policy review, medical record review, facility documentation review, and interview, the facility failed to provide documentation of skin assessments for 1 resident (#39) of 31 residents reviewed. The findings included: Review of the Skin Integrity Manual, section: Skin Integrity Prevention and Management .Assessment Guidelines .revealed, .Weekly Skin and Wound Assessments .Skin assessment includes skin integrity .absence or presence of [MEDICAL CONDITION]; color and temperature of skin, tissue tolerance, nutritional and hydration status (Documented on Skin Assessment Record) . Medical record review revealed Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of Resident #39's Skin Assessment Progress Note dated 10/22/15, revealed the resident had .slight redness to buttocks . as the only area of impaired skin integrity noted. Continued review revealed the next documented skin assessment was not completed until 11/21/15, a month later. Interview with the Director of Nursing on 9/20/16 at 3:50 PM, in the conference room, confirmed no documentation of Resident #39's skin assessments had been completed weekly. Continued interview confirmed Resident #39's medical record was incomplete.

Based on facility policy review, review of the Resident Council minutes, interview, and medical record review, the facility failed to ensure residents could voice grievances or concerns without discrimination or reprisal for 1 (Resident #76) of 42 sampled residents. The findings included: Review of the facility policy The Resident's Council with a revision date of 9/1/14, revealed .primary purpose is to create opportunities to execute meaningful decisions.the potential to identify needs and interests, prioritize their top issues and take action.are organized to ensure and strengthen rights, self-worth, independence and values.all concerns voiced by patients are to be written in the minutes, and if action is required it should be reported as well.the subject of concern should appear in each month's minutes until the patient feels satisfied. This would simply require you asking the patient in the meeting if their concern has been taken care of and report their response. Interview with the Activity Assistant on 8/11/15 at 3:25 PM at Nurses Station 2 revealed, when asked about Resident council president, .she has periods of confusion. When asked what topics are discussed during the meeting, stated .events in the community and here.they talk about community projects. When asked if the residents discuss concerns or problems, the Activity Assistant stated, .residents don't voice any concerns during the resident council meetings.they take those to the front office. Medical record review of a Quarterly Minimum (MDS) data set [DATE] for Resident #76 revealed the resident was cognitively intact with a Brief Interview of Mental Status score of 15 out of 15; has clear speech; makes self understood; and has clear comprehension to understand others. Interview with Resident #76 on 8/12/15 at 8:15 AM in the resident's room, when asked about the Resident Council meetings and topics of discussion, stated .we discuss what's happening in the center and around here in the community.read the newspaper and obituaries. When asked if residents discuss concerns or problems, the resident stated .if the food is not warm or the coffee is cold.but that's about it. When asked if a resident had a personal item missing and brought it up during the resident council meeting and if it would be discussed, the resident stated, .if it gets brought up, the resident is told to go to the front office to report it. When asked if any concerns were resolved, the resident stated .nothing is resolved.and there's no confidentiality either.if I say something in confidence to (named employee, who attends the Resident Council meetings) then in no time the nurses or other's will ask me about it. Continued interview revealed .last time during survey a man talked with me and the other residents.afterwards we had a meeting and got 'blessed out' for talking and saying things. When asked if the resident feared retaliation, the resident stated .yes. Review of the Resident Council Meeting minutes from 8/21/14 to 7/16/15 revealed no documentation of concerns voiced by the residents in attendance, and the average number of residents in attendance was 8. Continued review revealed Resident #76 had attended every Resident Council meeting in the past 12 months. Interview with the Administrator on 8/12/15 at 4:05 PM in the conference room, when asked if during the resident council meetings, had residents brought up concerns, stated .they can bring up concerns.they've not brought any to me. After discussion of resident interviews and the concerns related to call lights, cold food,coffee, and not enough food, the administrator stated .I've not heard of any concerns. When asked if the resident council meeting was not a forum for the ones in attendance to offer suggestions or voice concerns that affect their care and quality of life and not be afraid of retaliation, the administrator did not respond.

Based on facility policy review, review of Resident Council minutes, medical record review, and interview, the facility failed to ensure the residents were able to express concerns within the meeting. The findings included: Review of the facility policy The Resident's Council with a revision date of 9/1/14, revealed .primary purpose is to create opportunities to execute meaningful decisions.the potential to identify needs and interests, prioritize their top issues and take action.are organized to ensure and strengthen rights, self-worth, independence and values.all concerns voiced by patients are to be written in the minutes, and if action is required it should be reported as well.the subject of concern should appear in each month's minutes until the patient feels satisfied. This would simply require you asking the patient in the meeting if their concern has been taken care of and report their response. Review of the Resident Council Meeting minutes from 8/21/14 to 7/16/15 revealed no documentation of concerns voiced by the residents in attendance and the average number of residents in attendance was 8. Continued review revealed Resident #62 was elected Resident Council president on 4/9/15 and had attended 9 out of 12 meetings. Continued review revealed Resident #44 had attended 6 out of 12 meetings; Resident #31 had attended 8 out of 12 meetings; and Resident #76 had attended every Resident Council meeting in the past 12 months. Medical record review of a Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident #62 revealed the resident was moderately cognitively impaired; was able to express ideas and wants; and was able to understand others. Interview with the Resident Council president (Resident #62) on 8/11/15 at 3:17 PM in Nurses Station 3 dining room revealed .we've not had any meetings.no one's said anything about it. When asked if she was the elected president she stated, .that's what they tell me. Interview with the Activity Assistant on 8/11/15 at 3:25 PM at Nurses Station 2 revealed, when asked about Resident Council president (Resident #62) stated, .she has periods of confusion. When asked what topics are discussed during the meeting, stated .events in the community and here.they talk about community projects. When asked if the residents discuss concerns or problems, the Activity Assistant stated, .residents don't voice any concerns during the resident council meetings.they take those to the front office. Medical record review of a Quarterly MDS dated [DATE] for Resident #44 revealed the resident was moderately cognitively impaired; understood others with clear comprehension and was able to make self understood. Interview with Resident #44 on 8/12/15 at 7:50 AM in the resident's room revealed, when asked about the Resident Council meetings and topics of discussion stated .we meet every month.I go to it. When asked if someone had a concern or complaint would it be discussed in the meeting, she stated .I guess so. Medical record review of a Significant Change MDS dated [DATE] for Resident #31 revealed the resident was moderately cognitively impaired; has unclear speech or mumbled words; and responds to simple, direct communication only. Interview with Resident #31 on 8/12/15 at 8:00 AM in the resident's room, when asked about the Resident Council meetings and topics of discussion, stated, .we read the (named newspaper) and talk about anything going on.talk about the garden.we don't want to talk about anything bad.try to keep it positive. When asked if there had been any concerns lately, the resident stated .at night we have a problem with call lights.not answering them and waiting a long time. When asked if concerns such as the call lights are discussed during resident council meetings, Resident #31 stated, .no.we want to keep things positive. Medical record review of a Quarterly MDS dated [DATE] for Resident #76 revealed the resident was cognitively intact with a Brief Interview of Mental Status score of 15 out of 15; has clear speech; made self understood; and had clear comprehension to understand others. Interview with Resident #76 on 8/12/15 at 8:15 AM in the resident's room, when asked about the Resident Council meetings and topics of discussion, stated .we discuss what's happening in the center and around here in the community.read the newspaper and obituaries. When asked if residents discuss concerns or problems, the resident stated .if the food is not warm or the coffee is cold.but that's about it. When asked if a resident had a personal item missing and brought it up during the resident council meeting if it would be discussed, the resident stated, .if it gets brought up, the resident is told to go to the front office to report it. When asked if any concerns were resolved, the resident stated .nothing is resolved.and there's no confidentiality either.if I say something in confidence to (named employee, who attends the Resident Council meetings) then in no time the nurses or other's will ask me about it. Continued interview revealed .last time during survey a man talked with me and the other residents.afterwards we had a meeting and got 'blessed out' for talking and saying things. When asked if the resident feared retaliation, the resident stated .yes. Interview with the Administrator on 8/12/15 at 9:25 AM in the Administrator's office, when asked what her expectation of the Resident Council meeting stated, .to be able to come talk.it's their meeting.talk about upcoming activities.what they want and don't want on the calendar. Interview with the Administrator on 8/12/15 at 4:05 PM in the conference room, when asked if during the resident council meetings, had residents brought up concerns, stated .they can bring up concerns.they've not brought any to me. After discussion of resident interviews and the concerns related to call lights, cold food, coffee, and not enough food, the administrator stated .I've not heard of any concerns. When asked if the resident council meeting was not a forum for the ones in attendance to offer suggestions or voice concerns that affect their care and quality of life, the administrator did not respond.

Based on facility policy review, medical record review, and interview, the facility failed to recognize an incident as alleged abuse and failed to follow the facility policy for investigating allegations of abuse for one (Resident #108) of 42 residents reviewed. The findings included: Review of the facility policy entitled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, and Misappropriation of Property dated 8/1/2011, revealed .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, or misappropriation of patient property did or did not take place.The investigation is conducted immediately when it is identified that an alleged incident may have occurred.Partners suspected of taking actions that would cause potential harm to a patient or other patients will be immediately placed on administrative leave pending result of investigation. Medical record review revealed Resident #108 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE], revealed Resident #108 had a Brief Interview for Mental Status score of 13/15; required extensive assistance of two people for transfers, dressing, and bathing; required extensive assistance with toileting and grooming; and required supervision with eating. Review of a Service Recovery Summary dated 6/19/15, revealed .he had a concern that a therapist was rough putting him in bed and his wrist fx (fracture) was worse after that. X-rays taken. Nothing found on x-ray but a cast was placed instead of just the brace he came here with. He clashed personalities with a male nurse so that nurse doesn't go into the room anymore. He says staff talking about him outside his room. He would say people were talking about him and no one be in hall. Interview with the Administrator on August 12, 2015, at 9:20 AM, revealed the facility did not feel this was potential abuse so an investigation was not completed. Continued interview confirmed the facility policy was not followed.

Based on facility policy review, medical record review, and interview, the facility failed to recognize an incident as alleged abuse and failed to investigate the incident thoroughly for 1 (Resident #108) of 42 residents reviewed. The findings included: Review of the facility policy entitled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, and Misappropriation of Property dated 8/1/2011, revealed .All events reported as possible abuse, neglect, or misappropriation of patient property will be investigated to determine whether the alleged abuse, neglect, or misappropriation of patient property did or did not take place.The investigation is conducted immediately when it is identified that an alleged incident may have occurred.Partners suspected of taking actions that would cause potential harm to a patient or other patients will be immediately placed on administrative leave pending result of investigation. Medical record review revealed Resident #108 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum (MDS) data set [DATE], revealed Resident #108 had a Brief Interview for Mental Status score of 13/15 (15 indicates fully oriented with no memory problems); required extensive assistance of two people for transfers, dressing, and bathing; required extensive assistance with toileting and grooming; and required supervision with eating. Review of a Service Recovery Summary dated 6/19/15, revealed .he had a concern that a therapist was rough putting him in bed and his wrist fx (fracture) was worse after that. X-rays taken. Nothing found on x-ray but a cast was placed instead of just the brace he came here with. He clashed personalities with a male nurse so that nurse doesn't go into the room anymore. He says staff talking about him outside his room. He would say people were talking about him and no one be in hall. Review of the employee file of the alleged perpetrator revealed no disciplinary actions and no complaints about her behavior or resident treatment. Interview with the Administrator on August 12, 2015, at 9:20 AM, revealed the facility did not feel this was potential abuse and confirmed an investigation was not completed. Interview with the Unit Manager on 8/12/15, at 10:15 AM in the conference room revealed Resident #108 was a difficult resident who had outbursts of cursing staff and throwing things at staff. Continued interview revealed by the time the resident was discharged , only 1 physical therapist could enter his room. Further interview revealed the Crisis Team (psychiatric team available for residents who are decompensating) was called 3 times to assist with controlling the behaviors of Resident #108 but he did not meet their criteria for involuntary commitment. Continued interview revealed the PTA (Physical Therapy Assistant) and 2 CNTs (Certified Nursing Technicians) were trying to get Resident #108 on a sliding board to transfer him to the chair. Further interview revealed Resident #108 was uncooperative and threw the sliding board at one of the CNTs. Continued interview revealed the Unit Manager talked to Resident #108 who stated he did not like the PTA and did not want therapy at that time. Further interview revealed the Unit Manager assessed the resident's wrist and detected no abnormality, but an Orthopedics consult was obtained. Continued interview revealed the Unit Manager confirmed there was no formal investigation of the incident.