Every finding on record at Quality Center for Rehabilitation and Healing LLC

Based on review of the National Library of Medicine article review, Black Box Warning review, the facility's Licensed Practical Nurse Job Description review, policy review, facility documentation review, medical record review, observation, and interview, the facility failed to ensure all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely for 2 of 4 (Resident #11 and #12) sampled residents. The findings include: 1. Review of the article from the National Library of Medicine titled, Midazolam, dated 7/6/2025, revealed, .Midazolam [Versed] is a short-acting benzodiazepine [central nervous system depressant drugs that slow brain activity, used for short relief of anxiety and sedation prior to medical procedures] frequently used for.sedation.Midazolam also provides anxiolysis [relieving anxiety].Adverse event risk, including respiratory depression, hypotension [decrease blood pressure].Monitoring vital signs, including blood pressure, heart rate, and respiratory rate, is necessary.Monitoring is essential for older patients. 2. Review of the undated Black Box Warning revealed, .Black Box Warning Details Order: Midazolam HCL [Hydrochloric acid] Injection Solution 5 MG [milligram] /5ML [milliliter].Warning .Midazolam has been associated with profound sedation, respiratory depression, and respiratory arrest .In some cases, where this was not recognized promptly and treated effectively, hypoxic encephalopathy [brain injury from lack of oxygen or blood flow], coma, and death have resulted .provide continuous monitoring of respiratory and cardiac function.Lower doses are necessary for older (over 60 years) or debilitated patients. 3. Review of facility's Licensed Practical Nurse (LPN) Job Description revealed, .Administers treatments and other direct care .Observes and evaluates residents' responses to medications .Communicates educational needs .maintain competency and improve knowledge and skills .Incorporate evidenced-based gerontological knowledge into practice .Have critical thinking skills .make role-appropriate decisions .Apply best practices in the care of persons with cognitive loss . 4. Review of the undated facility policy titled, Nursing Services, revealed, .The medical care of each resident is under the supervision of a Licensed Physician and carried out through the nursing department .The nursing department.participates in the resident's assessment.monitoring changes in resident's medical status.The nursing department.along with the provider will perform pertinent medical assessments, for example taking vital signs as ordered as needed. 5. Review of a typed memo (completed by the DON and sent via a team's chat) dated 7/15/2024, revealed, Ativan [antianxiety medication] IM [intramuscular] is on national back order .there maybe times that the pharmacy is able to fill this request for resident specific orders but it will NOT be in the medbank [emergency stat box] anytime soon That said.Versed.will be used in its place. It is in the [NAME] [benzodiazepine-class of depressant drugs that slow down the central nervous system] drug class and FDA [Federal Drug Administration] approved for anxiety/agitation in low doses. Respiratory status will be [need] to be monitored when this is given. Please make yourself familiar with this medication . 6. Review of the medical record revealed Resident #11 admitted to the facility on [DATE], with diagnoses which included Dementia, Alzheimer's Disease, Major Depressive Disorder, and Psychosis. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Resident #11 had no noted behavior during the assessment period. Review of the Order Summary dated 5/14/2025, revealed .Midazolam HCL . Injection Solution 5 MG/ML [Milligrams per Milliliter] .Inject 2.5 mg [milligrams] intramuscularly one time only for Agitation for 1 Day . Review of the Progress Notes dated 5/14/2025, revealed, .13:12 [1:12 PM].Increased aggression/agitation towards staff and residents. This resident stating I'm going to kick your.I have money, I'm going to pay for an attorney Attempted to redirect resident from crowded area, unsuccessful. Resident refusing p.o. [by mouth] med [medication].Np [Nurse Practitioner].notified, new order received Midazolam 2.5mg [milligrams] IM one time only for increased behaviors. Review of the Medication Administration Record (MAR) dated 5/2025, revealed Versed 2.5 mg IM injection was administered at 12:54 PM on 5/14/2025, by LPN T. Review of the Weights and Vitals Summary for 5/2025, revealed no blood pressure, heart rate, or respirations were obtained prior to or after the administration of Versed on 5/14/2025. 7. Review of the medical record revealed Resident #12 admitted to the facility on [DATE], with diagnoses which included Dementia, Mood Disorder, and anxiety disorder. Review of the admission MDS dated [DATE], revealed Resident #12 had a BIMS score of 6, which indicated severe cognitive impairment. Resident #12 had no noted behavior during the review period. Review of the Progress Notes dated 9/19/2025, revealed, .16:28 [4:28 PM].Resident has increased anxiety this shift. PRN [as needed] ativan not effective, combative with staff, non-complaint with care. Very difficult, sometime not at all redirectable. Unable to sit still. Refusing hydration, snacks, environmental changes, conversation.Will continue to try other avenues. Reported to in house NP, new order provided. Review of the Order Summary dated 9/19/2025, revealed .Midazolam HCL .Injection Solution 5 MG/ML .Inject 0.25 milliliter intramuscularly one time only for anxiety for 1 Day . Review of the MAR dated 9/2025 revealed Versed 2.5 mg IM injection was administered at 5:49 PM on 9/19/2025, by LPN V. Review of the Progress Notes dated 9/19/2025, revealed, .17:53 [5:53 PM].New order for versed.1x [one time] dose r/t [related to] increased anxiety. Review of the Weights and Vitals Summary dated 9/2025 revealed no vitals were obtained prior to or after the administration of Versed on 9/19/2025. During an interview on 10/1/2025 at 5:55 PM, the DON was asked what she would expect the nursing staff to monitor for after a resident was given Versed. The DON stated, .No decline in their respiratory status, going up or down [referring to breathing].do they appear in distress. The DON was asked if she would expect vital signs to be completed with monitoring prior to and after the Versed was given. The DON stated, .if the resident needed that. The DON verified that a memo dated 7/15/2024, related to the use of Versed was sent out to all nurses working at the time by a secure application advising that Resident's respiratory status would need to be monitored when the medication was used, but did not specify a time frame for the monitoring. The DON stated, .I did not set a time frame, if they look at them and they appear to need an assessment, it is a case-by-case basis. The DON acknowledged no further training was provided to the nursing staff related to the administration of Versed besides the memo dated 7/15/2024. During an interview on 10/2/2025 at 12:20 PM, the Medical Director was asked what he would expect the nursing staff to monitor for with the administration of Versed. The Medical Director stated, .monitor, use your nursing judgement.Versed usually out of system in hour and half, 2.5 mg was least effective dose .a 3-hour window of monitoring. During an interview on 12/2/2025 at 12:50 PM, LPN T acknowledged she was aware of the black box warning for the administration of Versed and verified a full set of vitals should be completed when giving Versed. During an interview on 12/2/2025 at 1:33 PM, LPN V confirmed no vital signs were obtained for Resident #12 when she administered the Versed on 9/19/2025. During an interview on 1/6/2026 at 11:10 AM, NP #4 acknowledged Residents should have vital signs before and after the administration of Versed and should be watched closely and monitored for changes in their breathing.

Based on facility policy review, Job Description review, medical record review, and interview the facility failed to provide pharmaceutical services that assured a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate account of medication destruction for 4 of 4 (Resident #8, #10, #11, and #12) sampled residents reviewed for drug destruction. The findings include: 1. Review of a facility policy titled, Emergency Medications, dated 4/2007, revealed .The facility shall maintain a supply of medications typically used in emergencies.The emergency medication supply will include medications that are needed in providing treatment in the immediate need per physician's order.Accessing the emergency medications supply requires 2 nurses to be present to witness the dispensing/wasting of the medication when required. Review of undated facility policy titled, Controlled Substances, revealed, .The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II [controlled substances under the United Stated Controlled Substances Act that have a high potential for abuse] and other controlled substances.When controlled substances are received, an individual resident controlled substance record must be made for each resident who will be receiving a controlled substance.This record must contain: Name of the resident.Name and strength of the medication.Quantity received.Number on hand.Name of provider.Date received.Time of administration.Signature of nurse administering medication. Review of the facility policy titled, Pharmacy Services Overview, dated 2001 revealed, .Policy Interpretation and Implementation .The facility shall contract with a licensed Pharmacist to help obtain and maintain timely and appropriate pharmacy services .This includes .disposal, documentation, and reconciliation of all medications .in the facility . 2. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Psychosis, and Wandering. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Resident #8 had no noted behaviors over the assessment period. Review of the Order Summary dated 12/10/2024, revealed .Midazolam HCL [a central nervous system depressant drug that slows brain activity, used for short relief of anxiety and sedation prior to medical procedures] . Injection Solution 5 MG [milligram] / [per] ML[milliliter] .Inject 2.5 mg intramuscularly one time only for agitation for 1 Day . Review of the emergency stat box (med bank) pull list dated 12/10/2024, revealed a 1 ml vial of Midazolam 5 mg/ml was pulled for Resident #8. Review of the Medication Administration Record (MAR) dated 12/2024, revealed Midazolam 2.5 mg (0.5ml) IM injection was administered on 12/10/2024 at 2:45 AM, by LPN O. The facility was unable to provide documentation of the receipt of the medication and the disposal of the unused Midazolam for Resident #8. 3. Review of the medical record revealed Resident #10 admitted to the facility on [DATE], with diagnoses which included Cerebral Infarction, Vascular Dementia, and Depression. Review of the Order Summary dated 12/6/2024, revealed .Midazolam HCL Injection Solution 5 MG/ML .Inject 2 mg intramuscularly one time only for Anxiety for 1 Day . Review of the med bank pull list dated 12/6/2024, revealed a 1 ml vial of Midazolam 5 mg/ml was pulled for Resident #10. Review of the Medication Administration Record (MAR) for Resident #10 dated 12/2024, revealed Midazolam 2 mg IM (0.4 ml) injection was administered on 12/6/2024 at 9:45 PM, by LPN U. Review of the Order Summary dated 12/7/2024 revealed, .Midazolam HCL . Injection Solution 5 MG/ML .Inject 0.4 ml intramuscularly one time only for agitation/anxiety for 1 Day . Review of the med bank pull list dated 12/7/2024, revealed a 1 ml vial of Midazolam 5 mg/ml was pulled for Resident #10. Review of the MAR dated 12/2024, revealed Midazolam 2 mg (0.4 ml) IM injection was administered on 12/7/2024 at 9:19 PM by LPN U. Review of the admission MDS dated [DATE], revealed Resident #10 had a BIMS score of 9 which indicated moderate impaired cognition. Resident #10 had physical and verbal behaviors directed toward others which significantly interfered with the residents care over the last 7 days. The facility was unable to provide documentation of the receipt of the medication and the disposal of the unused Midazolam for Resident #10. 4. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses which included Dementia, Alzheimer's Disease, Major Depressive Disorder, and Psychosis. Review of the quarterly MDS dated [DATE], revealed Resident #11 had a BIMS score of 5 which indicated severe cognitive impairment. Resident #11 had no noted behavior during the assessment period. Review of the Order Summary dated 5/14/2025, revealed .Midazolam HCL . Injection Solution 5 MG/ML .Inject 2.5 mg intramuscularly one time only for Agitation for 1 Day . Review of the med bank pull list dated 5/14/2025, revealed a 1 ml vial of Midazolam 5 mg/1 ml was pulled for Resident #11. Review of the MAR dated 5/2025, revealed Midazolam 2.5 mg (0.5 ml) IM injection was administered on 5/14/2025 at 12:54 PM by LPN T. The facility was unable to provide documentation of the receipt of the medication and the disposal of the unused Midazolam for Resident #11. 5. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses which included Dementia, Mood Disorder, and Anxiety Disorder. Review of the admission MDS dated [DATE], revealed Resident #12 had a BIMS score of 6 which indicated severe cognitive impairment. Resident #12 had no noted behavior over the assessment period. Review of the Order Summary dated 9/19/2025, revealed .Midazolam HCL .Injection Solution 5 MG/ML .Inject 0.25 milliliter intramuscularly one time only for anxiety for 1 Day . Review of the med bank pull list dated 9/19/2025, revealed a 1 ml vial of Midazolam 5 mg/1 ml was pulled for Resident #12. Review of the MAR dated 9/2025, revealed Midazolam 2.5 mg (0.5ml) IM injection was administered on 9/19/2025 at 5:49 PM by LPN V. Review of the Order Summary dated 9/29/2025 revealed, .Midazolam HCL Injection Solution 5 MG/ML .Inject 2.5 mg intramuscularly one time only for anxiety for 1 Day . Review of the MAR dated 9/2025, revealed Midazolam 2.5 mg IM injection was administered on 9/29/2025 at 1:15 PM by LPN V. Review of the med bank pull list dated 9/29/2025 revealed no Midazolam was pulled for Resident #12. The facility was unable to provide documentation of the receipt and reconciliation of the Midazolam for Resident #12. During a telephone interview on 10/1/2025 at 11:11 AM, the Pharmacist was asked about the process of pulling Versed from the emergency med bank. The Pharmacist stated, .The nurse would have to have an order, it can't be a verbal, the NP would have to write the script and ask dispensing pharmacy. During a telephone interview on 10/1/2025 at 1:50 PM, the (Named Pharmacy) representative stated, .the Med bank was on a different hall than [Named Resident #8] it is not uncommon for one nurse to pull the medication to bring to another hall if it's an emergency situation.a 2nd nurse to watch the nurse waste it. During an interview on 10/1/2025 at 4:05 PM, LPN O was asked about obtaining the Versed from the emergency med bank for Resident #8.an LPN did pull the versed for me [referring to pulling the medication from the emergency med bank].the box was on her hall and if we are having a difficult time with a patient they will bring the meds down to us. LPN O was asked if a narcotic sheet was completed when the Versed was pulled from the emergency med bank. LPN O stated, .I don't remember a narcotic sheet. During an interview on 12/2/2025 at 12:50 PM, LPN T was unable to recall if a narcotic sheet was completed for the Versed administered to Resident #11 on 5/14/2025 at 12:54 PM. During an interview on 12/2/2025 at 1:33 PM, LPN V verified a narcotic sheet was not completed for the Versed administered to Resident #12 on 9/19/2025 and 9/29/2025. During an interview on 12/3/2025 at 4:09 PM, the DON was asked if she had any narcotic sheets for the Versed being pulled from the emergency med bank showing the Versed was pulled by 2 nurses and extra medication was wasted for Resident #8, Resident #10, Resident #11, and Resident #12. The DON stated, .we don't keep them.we shred the narcotic sheet. During an interview on 12/11/2025 at 7:11 PM, the DON was asked where LPN V obtained the Versed to administer to Resident #12 on 9/29/2025, since no medication was pulled from the emergency med bank. The DON stated, .[Named Resident #12] was having a lot of behaviors. That nurse [LPN V] saved the versed in the med cart and 10 days later she gave the medication to her. The DON was asked if Resident #12 had a PRN (as needed) order for the versed prior to 9/29/2025. The DON stated, .No, it was just a one-time order. The DON acknowledged the nurse should have wasted the medication instead of storing the Versed on the medication cart.

Based on facility policy review, medical record review, Emergency Medical Services (EMS) record review, Hospital record review, Facility investigation review, and interview, the facility failed to ensure an injury of unknown origin was reported to the appropriate agencies immediately, but not later than 2 hours after the injury was noted, for 1 of 11 (Resident #2) sampled residents reviewed for abuse. The findings include: 1. Review of the undated facility policy titled, Abuse Reporting, revealed, .All personnel.are required to immediately report any incident or suspected incident of resident abuse, neglect.including injuries of an unknown source.The incident will be reported to the Abuse Coordinator.FEDERAL REGULATION (42 CFR 483.13) requires the reporting of alleged violations of abuse.including injuries of unknown origin, immediately to the Abuse Coordinator.and to appropriate state agencies in accordance with state law.The facility must report abuse.within 24 hours after the reasonable cause threshold (suspicion) is concluded. If serious bodily injury has been sustained by a resident, the incident will be reported immediately but not later than 2 hours after forming suspicion.State public health law requires the reporting of abuse.immediately to state agencies having 'reasonable cause' to believe that abuse.has occurred. 'Reasonable cause' is defined as when, upon review of the circumstances there is sufficient evidence for a prudent person to believe that abuse, neglect.has occurred.The presence of a physical condition.bruise.which is inconsistent with the history of course of treatment of the resident.The facility must report to the state agencies.injuries of unknown origin.This might occur without or before the facility investigation into the incident, or it may occur at any time during the investigation.An immediate investigation will commenceand [commence and] a stated and signed statement from the person reporting the incident will be obtained.the Abuse Coordinator.will request social services to follow up with the resident/resident representative and document findings in the medical record.Once the incident has been identified and the investigation initiated, the administrator.will provide the appropriate agencies.with a report of the findings of the investigation within 5 working days.Should the findings reveal that abuse did occur, the report will include the corrective actions taken by the facility to prevent abuse from recurring. 2. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status score (BIMS) of 2, which indicated severe cognitive impairment. Resident #2 was dependent for toileting, shower/bathing, dressing, personal hygiene, bed mobility, and sit to stand and walking were not attempted over the assessment period. Resident #2 had no pain present during the assessment period. Review of the Kardex (key information on how to care for a resident) Report as of 5/2/2025, revealed .Chair/bed to chair transfer.Dependent x [times] 2 Staff with Mechanical.Lift. Review of the Progress Note dated 5/2/2025 at 1:06 PM, revealed .Resident noted with increased pain and spasms to BLE [both lower extremities]. NP [Nurse Practitioner #2] notified. Review of NP #2's Progress Note dated 5/2/2025 and signed at 3:09 PM, revealed .requesting visit for RLE [right lower extremity] Pain.Patient's [Family Member (FM) F] requested a [I] see her at bedside today. [FM F] reports that patient has been experiencing significant pain over the last hour. Patient's nurse states she received gabapentin [medication given for nerve pain].Generalized weakness.palpation [touch] was identified to the right lower extremity.She feels pain to touch.report no new injuries or falls.New Order: Robaxin [muscle relaxant medication] 500 mg [milligram] via [by way of] PEG [Percutaneous Endoscopic Gastrostomy] tube x [times] 1 dose Staff to notify provider for.concerns, pain unrelieved by pain medication regimen or new/worsening pain Continue Tylenol 1000 mg via PEG tube 3 times daily Continue gabapentin 100 mg via PEG tube twice daily Continue gabapentin 3 [300] mg via PEG tube daily at bedtime. Review of the Order Summary Report for Resident #2 revealed, .Methocarbamol [Robaxin] Oral Tablet 500 mg.Give 1 tablet.one time only for muscle spasm/pain for 1 Day.Order Date.5/2/2025. Review of the Medication Administration Record (MAR) dated 5/2025, revealed Resident #2 had a pain level of 9 (pain scale of 1-10 with 10 being the highest level of pain) on 5/2/2024 at 4:00 PM, with routine administration of Gabapentin 100 mg capsule. Review of the photographs of Resident #2 provided by FM A with a time stamp 5/3/2025 at 12:31 PM, revealed the following wounds a. Right axillary area (armpit) purple bruise approximately 2 centimeters (cm) w (width) by 4 cm l (length); b. 2nd toe on the end of left foot - an approximately 1 cm w by 1 cm l open abrasion; c. left calf - red excoriated (damage to the surface of the skin) area approximately 2.5 cm w by 6.5 cm l; d. Outer side of the left leg adjacent to area c- a bruise, green/purple in color approximately 2 cm w by 2 cm l; e. Upper left leg near the left groin - a bruise, green/purple in color approximately 4 cm w by 1.5 cm l; f. 2nd elongated area under area e - a bruise, red/faint purple in color approximately 2 cm w by 0.5 cm l; g. 3rd elongated area under area f to the inside of upper left leg - red/faint purple approximately 1 cm w by 1 cm l; h. 4th elongated area adjacent to area g - red/faint purple approximately 3 cm w by 0.5 cm l; i. Left and Right knee area - red petechiae (small red spots found with trauma or clotting disorders) areas. Review of Facility #1's investigation revealed an undated signed written statement completed by Certified Nursing Assistant (CNA) M which revealed, .Friday night/Sat [Saturday] [5/2/2025-5/3/2025] morn [morning] approx [approximately] midnight while attempting to change resident [Resident #2], I noticed resident acting as if rolling side to side was more painful then [than] normally [normal]. When rolling back over I noticed marks on left side and notified the charge nurse. Review of the MAR dated 5/2025, revealed Resident #2 had a pain level of 8 on 5/3/2025 at 9:00 PM, with routine administration of Tylenol extra strength 500 mg tablet. Review of the Progress Note dated 5/3/2025 at 10:45 PM, revealed .Resident observed with severe pain when moving lower extremities during incont [incontinence] care. Pain rated 8 using PAINAID [PAINAD] scale [PAINAD scale used to assess pain in patients with dementia].On call NP [NP #1] notified. New orders for ketorolac [anti-inflammatory medication given for moderate to severe acute pain] inj [injection] 30 mg/ml [milliliter] one time only and to obtain x-rays of bilateral hips and lower extremities.Resident received IM [Intramuscular] inj [injection] to left hip.Supervisor notified. Review of NP #1's Progress Note dated 5/3/2025, revealed .On Call Telemedicine Visit.Nurse called in stating that yesterday [5/2/2025], patient was complaining of her legs hurting really bad. Every times [time] when nurses move her, she screams in pain and states that it is in her legs. She was given muscle spasm medication yesterday. It helped a little bit. She is on Tylenol routine. Chart was reviewed.Bilateral lower extremity pain.X-rays of bilateral hips and lower extremities. IM Toradol [Ketorolac] 30 mg x 1 dose for pain 7-10/10 [7 to 10 on a scale of 1 to 10]. Review of the Order Summary Report for Resident #2 revealed, .x-ray to bilateral hips and lower extremities one time only for pain for 1 day.Order Date.5/3/2025.Ketorolac Tromethamine Injection Solution 30MG/ML.inject 30 mg intramuscular one time only for pain assessed higher than 7 for 1 day.Order Date.5/3/2025. Review of the MAR dated 5/3/2025 at 10:49 PM, revealed LPN B administered a Ketorolac injection to Resident #2 for pain. LPN B contacted NP #1 to report Resident #2 experienced severe pain with movement. Review of the Progress Note dated 5/4/2025 at 8:13 PM, revealed .Upon medication administration, resident observed with weakness and pallor [pale appearance].BP [blood pressure] 134/82 [normal BP reading is less than 120/80], RR [respiratory rate] 16 [normal range 12-18], and o2 [oxygen] sat [saturation] 94% [percent] [normal range between 95% to 100%] on room air. Bruising to left upper thigh with scratches on bruising and rash noted to left outer lower extremity. On callprovider [call provider] [NP #1] notified followed with new orders to receive Rocephin [antibiotic] 1 G [gram] IM once daily x2 days. STAT CXR [chest x-ray], and to obtain CBC w diff [Complete Blood Count with differential - common blood test that provides detailed information about the different cells in the blood] and BMP [Basic Metabolic Panel - blood test to check for electrolytes, kidney function, glucose, and calcium].Supervisor notified.To follow up with in house tomorrow. Review of the Order Summary Report for Resident #2 revealed, .STAT CXR one time only for 1 day.Order Date.5/4/2025.cefTRIAXone Sodium [Rocephin] Injection Solution .1 GM intramuscularly one time a day for sepsis [infection] protocol for 2 Days. Review of the Progress Note dated 5/4/2025 at 8:49 PM, revealed .[Named Mobile x-ray] unable to obtain STAT [immediately] CXR. Rep [Representative] states CXR to be completed tomorrow morning. Review of the Radiology report dated 5/5/2025 at 3:09 PM, revealed acute left and right displaced femur (thigh bone) fractures with Osteopenia (lower than normal bone mineral density) present. Review of the Progress Note dated 5/5/2025 at 4:16 AM, revealed .Received x-ray results from bilateral hip and lower extremity x-rays. Results show right and left femur fractures-both noted with displacement. Resident [Resident #2] currently showing sx/s [signs and symptoms] of pain. On call [NP #1] notified with order to send resident to ER [Emergency Room] for eval [evaluation]. [Named FM F] notified.Supervisor notified. Review of the Order Summary Report for Resident #2 revealed, .Send to ER d/t [due to] left and right femoral fracture.Order Date.5/5/2025. Review of Facility #1's Progress Notes completed by LPN D for Resident #2 dated 5/6/2025 at 5:43 PM, revealed .this nurse spoke with [FM F] this date to follow up on resident condition. [FM F] states that resident has cast placed to left leg and ortho [orthopedic] wanting to complete right total knee however [FM F] unsure that is the best thing at this time. [FM F] questioned this nurse about injury and states he does not understand how this can happen. this nurse educated on osteopenia, osteoarthritis and possible causes of pathological fractures.[FM F] requested meeting with this nurse and DON [Director of Nursing] later this week. 3. Review of Facility #1's investigation revealed a typed statement dated 5/5/2025, signed by LPN D revealed, .I called and spoke with [Medical Doctor #2] about an update on [Named Resident #2] concerning recent admission to hospital regarding fractures to bilateral femurs. [MD #2] stated the fractures were likely due to osteoporosis because her bones were so bad and there is no known trauma. Continued review of Facility #1's investigation revealed a typed form with question asked Any issues or incident with [Named Resident #2], with staff names typed with staff answer No. No staff members who were interviewed or staff members performing the interviews signed the form. 4. Review of the EMS #1's Patient Care Record dated 5/5/2025 at 4:23 AM for Resident #2 revealed, .Extremity Pain.Signs & Symptoms Leg Pain (Primary).04:39 [4:39 AM].BP 93/55.04:41 [4:41 AM].BP 89/55.Pulse 102.04:44 [4:44 AM].BP 81/52.04:51 [4:51 AM] 79/64.Left Leg.Pain.Right Leg.Pain.dispatched emergent to [Named Facility #1].for pain, arrival on scene, staff states that the pt [Patient] was complaining of pain sat [Saturday] morning when they moved them [Resident #2].an x-ray.came back with both femurs displaced.states that the pt had recently gotten a Toradol [Ketorolac] shot along with a shot for Rocephin unable to determine why. staff states that the pt has been more pale then [than] normal unable to determine how long it has been for. staff denied any recent trauma, pt does not normally ambulate, bed bound and has left sided deficits from previous stroke. staff also states the pt has a PEG tube and has been NPO [nothing by mouth]. during initial assessment the pt is repeating what sounds like please help me over and over. pt speech is normally difficult to understand and is normal for her baseline. pt was moved to stretcher with a 5 person sheet drag and secured with all available seatbelts and guard rails up.secondary assessment, and transport the pt is repeating please help me. unable to determine pain scale of specifically where the pt is hurting due to baseline AMS [Altered Mental Status].pt was hypotensive [low blood pressure] during care.while reading printed Hx [History] of pt from NH [Nursing Home] the x-ray states that bilateral femurs are fractured distally.arrival at er, pt was moved to ER bed with a 3 person sheet drag and secured with bed rails up. gave short report to rn [Registered Nurse] and doctor, told staff the story as told above.Emergency Response.Emergent.Lights and Sirens. 5. Review of Hospital #1's photographs of Resident #2 upon admission on [DATE], revealed the same area of injuries as the complainant's photographs and additional areas noted. An area of green bruising noted to the left of pubic area approximately 1 cm wide x 0.5 cm long and an excoriated open area with dried blood under the fold of the right breast approximately 3 cm wide x 1 cm long. Review of Hospital #1's History and Physical for Resident #2 dated 5/5/2025 at 5:26 AM, revealed, .TRAUMA SERVICE HISTORY AND PHYSICAL .Chief complaint/Reason for admission: Mechanism of Injury Details: unknown mechanism.Per EMS report, x-rays at the facility revealed bilateral femur fractures. Staff reports that patient complained of leg pain after using a lift to transfer the patient from bed to chair. Patient is bedbound previous stroke with residual left-sided deficit.Patient was a level 1 trauma activation [generally includes Mechanism of Injury: High-speed motor vehicle collision.Fall from significant height.crush injury.Extremity trauma.multiple fractures] secondary to hypotension and [en] route .She was noted on radiographs [x-rays] to have evidence of bilateral distal femur fractures. The patient has had.report from the hospital that I [Medical Doctor #2] have received directly .no falls and no history of any trauma.The patient does have some occupational therapy that was being tried and apparently the patient had made some progress. The patient did however on Friday according to the report I received from the family [have] pain in her knee area.It is notable that the patient [referring to FM F] does have concerns about the causation of which I [Medical Director #2] have no other information as to any cause. The patient does have a displaced right distal femur fracture.supracondylar fracture [break in the thighbone that occurs just above the knee joint] of course is comminuted [breaks into multiple pieces]. There is a left supracondylar femur fracture which is also identified and is comminuted but is not as far displaced.Current Facility [Hospital #1] - Administered Medications.fentanyl [medication used for severe pain] 50 mcg [micrograms] intraVENOUS Q20 [every 20] Min [Minutes] PRN [as needed].HYDROmorphine [medication used for moderate to severe pain] 0.5 mg intraVENOUS Q4H [every 4 hours] PRN.oxyCODONE [medication given for moderate to severe pain] 5 mg.Q6H [every 6 hours] PRN.Lower extremities are noted to have bilateral splints applied. Swelling is present over both the right and left distal thigh.x-ray femur right.Acute fracture of the distal femur with approximately one half bone width posterior [back] and lateral [side to side] displacement of the distal segment [a bone fracture in which the part of the bone farthest from the body has been shifted backward and to the side, by an amount equal to half the bone's width].X-ray femur left.Acute comminuted, impacted fracture [where the bone breaks into multiple pieces (three or more) and one bone fragment is driven into another bone fragment] of the distal femur.MUSCULOSKELETAL.Intramuscular hematoma [a collection of blood that clots within a muscle] in the medial left thigh.PROCEDURE: Indications:Closed fracture left distal femur.Procedure Description May 5,2025 Patient is brought to the operating room.The leg is then elevated.There is some bruising posteriorly to the distal thigh.A long-leg cast is applied.The patient did have radiographs taken showing improved position of the distal femur relative to the shaft on both AP [Anterior Posterior] lateral views.Patient's condition remains critical, requires frequent assessment and interventions, and/or is unstable with conditions that pose a significant threat to life or risk of prolonged impairment.S/p [status post] OR [operating room] yest [yesterday] for LLE [Left Lower Extremity] cast. S/p 2u [2 units] PRBC [packed red blood cell] transfused yest [yesterday] for Hgb [hemoglobin] 6.9 [Normal range 12.0 to 15.5 g/dL [grams/deciliter].and hypotension. admitted to ICU [Intensive Care Unit] postop [postoperatively] for monitoring. Review of Hospital #1's Procedure Description dated 5/7/2025, revealed .Application of long-leg cast right lower extremity.The patient was brought to the operating room.The patient has the area of the fracture identified and I [MD #2] have been able to manipulate it and reduce it back into better alignment.The patient has the long-leg cast applied.The patient is awakened from the anesthetic and taken to the recovery room. Resident #2 readmitted to Facility #1 on 5/9/2025. 6. During a telephone interview on 9/23/2025 at 7:09 PM, Registered Nurse (RN) C was asked if she knew how Resident #2 sustained femur fractures to the left and right leg. RN C stated, .I don't know how that happened. I was actually just stepping in for a floor nurse [referring to 5/2/2025]. I don't know the information about that case. During a telephone interview on 9/23/2025 at 7:15 PM, LPN D was asked if she knew how Resident #2 sustained femur fractures to the left and right leg. LPN D stated, .I am not 100% sure, I think bone mass, Osteoporosis [bones become weak and brittle] . During a telephone interview on 9/23/2025 at 7:25 PM, LPN B was asked if she knew how Resident #2 sustained femur fractures to the left and right leg. LPN B stated, .I don't know how the fractures occurred. During an interview on 9/24/2025 at 1:25 PM, FM F was asked about Resident #2's femur fractures to left and right leg. FM F stated, .we [referring to FM A] had a talk with the head nurse.she said Osteoporosis, I disagreed.[MD #2] called me and said the only time he seen this type of injury was with a head on car crash.I got a call about 3:00 [AM] in the morning on Monday [5/5/2025] and the nurse said she has to go to the hospital.2 broken legs, I was here on Wednesday [4/30/2025], off on Thursday [5/1/2025].back on Friday [5/2/2025] they were broken.I got the NP to see her on Friday.she was in pain when I touched her legs it hurt, her legs were swollen.my wife couldn't tell me what happened.before the pain she could move her legs some.the head nurse asked around nobody [referring to staff] said anything. During a telephone interview on 9/24/2025 at 1:30 PM, Radiologist #1 was asked if Resident #2's fractures were caused by trauma. Radiologist #1 stated, .I can tell you this Osteoporosis does not cause fractures, there has to be a cause for the injury.having Osteoporosis or Osteopenia doesn't have anything to do with how it happened.something has to cause the fracture.Yes she did have Osteopenia and Demineralization [loss of mineral content from a bone] but something has to cause the injury. During an interview on 9/24/2025 at 2:52 PM, NP #2 was asked about his visit with Resident #2 on 5/2/2025 and if Resident #2 had a diagnosis of Osteoporosis. NP #2 stated, .No, I believe it [diagnosis] was identified on the x-ray over the weekend [5/4/2025].Osteopenia on the x-ray.I performed a physical assessment on her [5/2/2025].pain was reported, I can't relate the pain had to do with the fracture.I can only speak on the note.I have seen her various times, she could not walk.occurred over the weekend not present per my note [NP #2 was referring to the injury]. NP #2 was asked if Osteopenia can cause a fracture. NP #2 stated, .it can contribute to it.It was noted on the x-ray for Osteopenia, to my knowledge that is the 1st time it was diagnosed. During an interview on 9/25/2025 at 8:30 AM, the Administrator (Abuse Coordinator) was asked if the facility determined how Resident #2 sustained femur fractures to left and right leg. The Administrator stated, .It's spontaneous, pathological, she was sent to the hospital, I called [Named MD #2], he confirmed my thoughts, we investigated and there was no incident.I did not feel it was an injury of unknown source, immobility, how long she had been immobile, therapy had started sitting her on the edge of the bed.bones, larger woman contributing factors, lying in bed for excessive amount of time.she was getting up in the Broda chair [chair designed for individuals who require long-term seating and complex positioning for comfort and safety].she got up for a shower with the use of the lift on Thursday [5/1/2025]. The Administrator was asked about the hospital admission paperwork that noted Resident #2 had experienced pain after being transferred with the use of the lift. The Administrator stated, .I checked with staff no one reported any issues with the lift. During a telephone interview on 9/25/2025 at 9:50 AM, FM A stated, .went to visit her on Saturday [5/3/2025] usually when I go, I like to look at her skin and lotion her feet down.when I sat on the side of her bed she just started screaming, She was anxious. I checked for marks on her body, anything abnormal, I noticed little red spots on both her legs.I took pictures of all her injuries .toe next to big toe with dried blood on the blanket, back of her leg at top of her thigh, and all the way down the calf it looked like her skin had been rubbed against something.looked like a carpet burn, under her right arm was a bruised area.the color was purple and red like she had been pulled in that area.I called the staff down there.I am not sure who it was because I was so upset.I asked them to explain to me how those injuries happened and why she was screaming in pain.this was on Saturday.he [FM F] finds out on Monday [5/5/2025] she [Resident #2] has 2 broken femurs.when we got to the hospital the nurse took pictures of her injuries.the doctor comes in and says he doesn't see those injuries accept with a motor vehicle accident.the [Named MD #2] gave us options and we decided the cast to both legs would be the best.I know the staff took her for a shower on Thursday [5/1/2025] it had to have happened between Wednesday and Friday [4/30/2025-5/2/2025].she [Resident #2] was yelling and grabbing at her legs.the person I reported the injuries to on Saturday [5/3/2025] just blew me off and said we will have to do blood work. During a telephone interview on 9/25/2025 at 11:47 AM, CNA M [CNA who cared for Resident #2 on Saturday 5/3/2025] stated, .I work night shift I will call you back. CNA M never returned this Surveyor's call. During a telephone interview on 9/25/2025 at 12:26 PM, NP #1 was asked when she was notified about Resident #2 experiencing pain on 5/3/2025, 5/4/2025, and 5/5/2025, did the nurse allow her to visualize the resident or if any bruising was reported. NP #1 stated, .if it is in my note. NP #1 was asked if an accident was reported to her related to Resident #2. NP #1 stated, .yeah.same thing if an accident it would be in my note.if I had seen a picture of the resident, it would be in my note. During an interview on 9/25/2025 at 2:16 PM, LPN H stated, .She [Resident #2] complained of pain and the NP ordered an x-ray.She was anxious and crying that is why we called the NP on Sunday [5/4/2025] to see if we should increase her pain medications. During an interview on 9/25/2025 at 3:09 PM, the Administrator and DON were asked when they were notified of the injury with Resident #2. The DON stated, .I think [Named LPN B] notified us on Monday [5/5/2025] morning. The DON was asked when Resident #2 started experiencing pain, did she physically assess the resident. The DON stated, No. The DON was asked if she was notified of any bruises on Resident #2. The DON stated, .talked about bruise around the injection site [referring to the IM medications given for pain].no nurses reported any concerns with Resident #2 over the weekend. The DON was asked what she would expect nursing to do if a bruise of unknown origin was found on a resident. The DON stated, .bruises would be reported to a charge nurse, put on a shower sheet if CNA finds one.the nurse would report it to Administrator and myself, call on call staff, and notify family, complete a skin assessment. The Administrator was asked if a timeline was completed with Resident #2's injury, if staff members were called or questioned in person, and why staff did not sign the typed statement. The Administrator stated, .they [staff] don't sign it.it doesn't say whether it is in person or by phone.it doesn't include a timeline.no way to know what happened.it was pathological, no way to pinpoint. The Administrator was asked if any education was given to the staff related to the injury with Resident #2. The Administrator stated, .nothing in particular.nothing reported to the state agency.I did not believe it was an injury of unknown origin. The Administrator was asked if an injury of unknown origin should be reported to the state agency. The Administrator stated, .report within 2 hours. On 9/25/2025 at 3:33 PM, a voice message was left with Hospital #1's Accreditation and Regulatory Specialist to set up a call with MD #3. During an interview on 9/26/2025 at 10:27 AM, MD #2 was asked if he was aware of the origin of Resident #2's injury when he evaluated her during her hospital stay. MD #2 stated, .I don't really know, 2 broken legs.Nobody [referring to staff at Facility #1] gave me evidence of really what happened.terrible thing that this happened.sure her bones were not in alignment.there was a fair amount of swelling.I don't recall saying this was a spontaneous fracture.it is clear that I can't say what caused the injury. This surveyor stated to MD #2 it is my understanding that Osteoporosis does not cause a fracture but may be a contributing factor. MD #2 stated, .Yes, that is correct on your understanding of Osteoporosis.[FM F] loves her.I seen him at the hospital and I saw him Tuesday in my office when she [Resident #2] came back for follow up.the fractures are healing.[FM F] did question the injury.I would have been angry [Resident #2's injuries]. A (Named videoconference call) meeting was conducted on 10/8/2025 at 10:30 AM, with MD #3 and Accreditation and Regulator Specialist for Hospital #1. MD #3 was asked if he was the admitting physician for Resident #2 on 5/5/2024. MD #3 stated, Yes. MD #3 was asked why Resident #2 was admitted as a Trauma Level Activation Level 1. MD #3 stated, .we have 3 tiers the hospital goes by so we can make sure appropriate resources are there for the injuries.in her case [Resident #2] was hypotensive status with systolic pressure of the 80's so that is highest level of activation. MD #3 was asked if he was notified by Facility #1 on how Resident #2's injuries occurred. MD #3 stated, .I was not notified by the facility which is not uncommon.EMS told me patient complained of pain after using the lift to get her up to a chair.she was confused and she couldn't tell me what happened.I did not see family with her when she arrived at the hospital which was around 5:05 AM when I saw her. MD #3 was asked what was his physical assessment of Resident #2. MD #3 stated, .pain and tenderness in her lower extremities.I spent maybe 20-30 minutes with her and the trauma service assumed care for her. MD #3 was asked when he normally sees this type of injury. MD #3 stated, .Motor Vehicle injuries or with a fall which can cause a force or stress to the bone. MD #3 was asked if Osteoporosis can cause this type of fracture or some type of injury must occur. MD #3 stated, .Osteoporosis is a weakening of the bone but there has to be some type of external pressure or force that would lead to the fracture.

Based on medical record review, hospital record review, facility document review, observation, and interview, the facility failed to adequately monitor and implement appropriate interventions for 1 of 1 (Resident #21) resident who was exhibiting self-mutilating behaviors. Between 6/23/2023 and 7/17/2023, Resident #1 began chewing on his fingers which resulted in infection and subsequent partial amputations on 7/18/2023. The facility's failure to adequately monitor and implement interventions resulted in harm. The findings include: Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Acquired Absence of Right Leg Below Knee (right below the knee amputation), Dementia, Anxiety Disorder, Diabetes Mellitus, and Partial Traumatic Transphalangeal (usually involves the four fingers in similar or slightly varying degrees) Amputation of Unspecified Fingers (Resident #21 had amputations to varying degrees to all fingers of both hands on 7/18/2023 except the fifth finger on the right hand which had been previously amputated). Review of the current Care Plan for Resident #21 revealed, .04/11/2023 .Observe for changes in status, notify interdisciplinary team as needed .Observe skin during care and report any abnormal findings ro nurse . Review of the Quarterly Minimum Data Set (MDS) for Resident #21 dated 5/24/2023, revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Resident #21 required total assistance with Activities of Daily Living (ADLs). Review of the Psychiatric Evaluation dated 6/23/2023, revealed, .has been observed 'chewing on his fingers' and there is concern that he is experiencing anxiety .[Resident #21] reports 'I've done that my whole life' when asked about chewing on his fingers . Review of the current Care Plan for Resident #21 revealed, .6/23/2023 left index finger abrasion .Obsessively chewing on finger/nails resulting in open areas. Resident has history of nail biting and picking at skin according to family . Interventions included, .6/23/2023 Refer to Psych [Psychiatric] NP [Nurse Practitioner] for eval [evaluation] . Review of the Psychotherapy Progress Note dated 6/26/2023, revealed, .Patient [Resident #21] was depressed because he has a hard time being here and wants to go home .DIAGNOSIS .Adjustment disorder with depressed mood . Review of the current Care Plan for Resident #21 revealed, .6/29/2023 offer oral motor tool [chewable tool used as a safe alternative to chewing on fingers] as tolerated .6/30/2023 Consult with psych and social services as needed . Review of the Psychotherapy Progress Note dated 7/5/2023, revealed, .Patient was depressed because he was having a hard time being here and was biting fingers to cope . Review of the Psychiatric Periodic Evaluation dated 7/5/2023, for Resident #21 revealed, .[Resident #21] continues to experience anxiety and chewing on his fingers. Currently receiving a second round of antibiotics for cellulitis in his fingers. Wound care nurse and medical provider have both recommended that he wear a glove to protect his fingers and promote healing. Dressings have been applied to his hands after wound care, but he has chewed on them and removed them .experiencing anxiety throughout the day and at night. Does not remember when he chews on his fingers. Staff has tried utilizing a chewy tube [oral motor devices designed to provide a chewable surface for biting and chewing], but he does not remember to use or understand to use it due to cognitive impairment. Nurse reports today that Buspar [anti-anxiety medication] and Hydroxyzine [antihistamine which can be used to treat anxiety] have not been helpful .Agree with recommendation by medical provider and wound care for patient to wear gloves for protection . (According to the documented timeline provided by the facility, the Administrator and Director of Nursing (DON) searched for gloves on 7/3/2023, 10 days after Resident #21 began chewing on his fingers, but they were unable to find appropriate gloves. There was no documentation provided that the facility addressed the recommendation of the gloves after 7/3/2023 until the gloves were ordered on 8/2/2023 (34 days after Resident #21 began chewing on her fingers). There was no documentation provided when the intervention of gloves was first recommended). There was no documentation facility staff put anything over Resident #21's hands to keep him from chewing on his fingers prior to his hospitalization on [DATE]. Review of the NP Progress notes dated 7/11/2023, revealed, .[Resident #21] being seen today for evaluation of cellulitis to hands. Patient completed Keflex [antibiotic], and on July 3rd patient was started on Bactrim DS [combination of two antibiotics] 1 tablet every 12 hours for ten days. Patient has areas of scabbing .Fingers open to air .Per facility staff, patient continues to chew on his fingers intermittently .PHYSICAL EXAMINATION .Extremities .multiple fingers noted to have scabbing as well as open areas secondary to patient's chewing on his fingers . Review of the NP Progress notes dated 7/12/2023, revealed, .patient being seen today for evaluation of bilateral hands for increased inflammation and drainage .facility staff reports that patient has continued to chew on his fingers and as a result, patient has several open areas as well as redness and continued infection .Patient also has complaints that his bilateral hands are hurting .PHYSICAL EXAMINATION .Extremities . Patient noted to have slough [dead tissue, usually cream or yellow in color], scabbing, inflammation, and redness to seven of his fingers. Appearance of fingers is consistent with cellulitis/infection .ASSESSMENT AND PLAN .Anxiety. Medications evaluated, currently have not been effective .Facility staff instructed to redirect patient should he be noted to be chewing on his fingers and utilize previous intervention if noted to be effective . Review of a Nursing Progress note dated 7/17/2023, revealed, .During morning medication administration, this nurse found resident chewing on his fingers. Nurse tried redirecting resident but was unsuccessful . Review of a Nursing Progress note dated 7/17/2023, revealed, .family request gloves to be placed to residents bilat [bilateral] hands to protect skin/bandages to allow for healing .the gloves family requesting wear will not limit function or ability to complete ADLS . Resident #21 was admitted to the hospital on 7/17/2023, and the gloves were not provided. Review of the NP Progress notes dated 7/17/2023, revealed, .Patient has known history of chewing on his fingers. Patient has been treated with Keflex and Bactrim [antibiotics] .also previously evaluated by psych for increased anxiety and medications were adjusted .Despite medication changes and above interventions (psych evaluation), facility staff reports that patient has continued to chew on his fingers and as a result, patient has several open areas as well as redness and continued infection .Bilateral hands assessed today. Patient noted to have scabbing, slough, drainage, as well as redness and swelling to seven fingers . Review of Hospital #1 Progress Notes for Resident #21 dated 7/17/2023, revealed, .Facility staff report pt [patient] has been 'chewing his fingers' to the point that he now requires surgery .Fingers were wrapped with gauze and Coban [a type of elastic dressing] in the ED [Emergency Department] .Per nursing report, the patient will take the bandages off and start picking at his hands so a sitter [sitter was ordered for Resident #21 while in Hospital #1] was ordered . Review of the Hospital #1 Operative Report for Resident #21 dated 7/18/2023, revealed, .The patient then has the digits amputated taking the nail and excised the entirety of the nailbed including the germinal matrix [area of soft tissue underneath the nail bed]. The patient had this procedure done on all the digits on both the right and left hands. It is notable the only digit which was not involved was the little finger on the right side . Review of the facility current care plan following Resident #21's hospital stay from 7/17/2023-7/21/2023 and the amputations of his fingers on 7/18/2023, revealed, .7/21/23 [2023] Noted on readmission. Amputation surgical sites to the left had 2nd-4th digits and right hand 3rd-5th digits . The interventions for Resident #21 to address the continued chewing of his fingers included, .7/21/2023 .Enhanced barrier precautions due to wounds . Review of a Facility Nursing Progress note dated 7/22/2023, revealed, Pt [patient] was found to be chewing on the hard plastic mitts that are protecting his hands. The CNA [Certified Nursing Assistant] found him coughing small pieces of them up . Review of a Facility Nursing Progress note dated 7/22/2023, revealed, Walked into pt room and found pt chewing on his hand splints. Tried redirecting pt with no positive results. Pt stated he didnt [sic] realize what he was doing when nurse asked why he was chewing on his hands . Review of a Facility Nursing Progress note dated 7/22/2023, revealed, Received call from [Hospital #1] at 1000 [10:00 AM] regarding pt wound cultures. Pt was positive for MRSA in wounds . Review of the facility current care plan revealed, .7/24/2023 .Contact Transmission Based Precautions related to MRSA [methicillin-resistant Staphylococcus aureus] .7/26/2023 Q [every] 30 minute checks due to removing bandages .7/28/2023 1:1 [resident safety measure requiring continuous observation by staff] for behaviors . Continued review revealed undated assessment for, .exhibits behavioral problems including .chews on his hands and fingers until they bleed .Resident chews on his splints at times, compulsive chewing disorder, skin picking disorder, removing dressings . There were no additional interventions documented in the care plan from Resident #21's readmission on 7/21/2023 to 7/26/2023 (5 days) when the facility implemented every 30 minute checks from 6:00 AM to 6:00 PM and one to one observation from 6:00 PM to 6:00 AM. There was no documentation provided the facility included the hand splits in Resident #21's care plan which were placed by the hospital following the amputation of Resident #21's fingers. Review of a documented timeline for Resident #21 provided by the facility revealed the following: 6/23/2023 Wound care staff observed Resident #21 chewing on the tip of the left index finger, and wound care staff applied a dressing. 6/26/2023 Resident #21's family reported that resident had a history of anxiety and noted to chew on his tongue as well. 6/30/2023 Staff provided an oral motor tool, but the tool was non-effective. Resident removing bandages. (There were no further interventions documented on the timeline from 6/30/2023 to 7/5/2023 (5 days) when the Psych NP added Seroquel (antispychotic medication) at bedtime). 7/3/2023 The Administrator and Director of Nursing (DON) searched for various types of gloves that would fit resident hands, but they were unable to find appropriate gloves at this time. (There was no documentation provided the facility notified the provider that they were unable to implement the recommended intervention (gloves) or attempted to implement an alternative intervention). 7/3/2023 and 7/24/2023 Resident #21 continued to removed bandages. 7/17/2023 Facility spoke with resident's family about the use of gloves, and family indicated they would provide gloves. Resident sent to the hospital before gloves provided. 7/21/2023 Resident returned from hospital with hard plastic mitts with protective covering. (There was no documentation provided that the plastic mitts were added to the care plan). 7/22/2023 Resident chewing on foam padding from the edges of the splints. (LPN #8 documented she unsuccessfully attempted to redirect Resident #21 from chewing on the splints. There were no further interventions documented to prevent Resident #21 from chewing on the splints until 7/26/2023, 4 days later). 7/26/2023 Splints removed, and resident placed on every 30 minute checks during the day time and one to one observation at night for behavoring monitoring. 7/28/2023 Observation changed from every 30 minute checks to one to one observation due to resident attempting to remove and bite bandages. 8/2/2023 Gloves ordered. The facility ordered a larger size on 8/4/2023 and a different brand on 8/8/2023 due to gloves not fitting. The facility was unable to find gloves that would fit the resident. There was no documentation the facility implemented any new interventions for Resident #21 to prevent him from biting on the splint and fingers from readmission on 7/21/2023 to 7/24/2023 when Resident #21 was started on Prozac (antidepression medication) and Buspar (anti-anxiety medication). During an interview on 8/8/2023 at 10:32 AM, the DON stated she was notified on 6/23/2023 when Resident #21 started chewing on his fingers. The DON stated she was told Resident #21 had a wound on his finger from chewing. She stated she and the Administrator investigated the incident and developed a timeline with interventions and actions (timeline listed above). During an interview on 8/8/2023 at 12:21 PM, Family Member #2 stated he visited with Resident #21, on 7/6/2023. He stated Resident #21 had been chewing on his fingers, and the facility told him they were working on it. He stated he brought in medical supplies to bandage and treat the resident's fingers because he believed the facility wasn't treating them. He stated he started cleaning Resident #21's hands, and they looked horrible. He stated there were no dressings on Resident #21's fingers. He stated the nurse came into the room and told him he could not apply dressings to his hands because the bandages would be a choking hazard. He stated he explained to the nurse that he would sit with him and stop him if he chewed the bandages. He stated the nurse then told him wrappping his hands or putting gloves on him would be considered a restraint, and restraints were not allowed in the facility. He stated the nurse told him as soon as he left, the bandages would be have to be removed. Family Member #2 stated he visited again on 7/17/2023, and on this visit he was able to see the bones in Resident #21's wounds. He stated he demanded the Administrator come to the room. He stated he asked the Administrator again why they could not put something over Resident #21's fingers. He stated the Administrator told him she had ordered gloves, but at that point the gloves would not fit over the fingers. He stated the orthopedic doctor (Doctor #2) came and evaluated the resident and gave orders for him to be sent to the hospital. He stated Doctor #2 told him the fingers with wounds would have to be amputated. Family Member #2 stated that on 7/22/2023 and 7/24/2023, he had Doctor #1 look at Resident #21's finger wounds. He stated he asked the doctor about applying restraints to keep Resident #21 from biting at his fingers, and why Doctor #1 could not write an order for a soft restraint. He stated Doctor #1 told him he tried to order restraints, but upper management in the corporation would not allow him to. During an interview on 8/8/2023 at 2:39 PM, NP #1 stated she assessed Resident #21 initially on 6/23/2023 for an infected finger. She stated she ordered an antibiotic to be given, wound care consult, and requested a psych consult. She stated at that time, he was only biting 1 finger. She stated when she saw him again on 7/3/2023, multiple fingers were involved. She stated the antibiotic she had ordered was completed, but he continued to have infection, so she ordered another antibiotic. She stated she recommended something be put over his fingers to keep him from chewing them. There was no documentation facility staff put anything over Resident #21's hands to keep him from chewing on his fingers prior to his hospitalization on [DATE]. During an interview on 8/8/2023 at 4:22 PM, Licensed Practical Nurse (LPN) #6 stated Resident #21 started chewing on his nails to begin with. She stated she reported it to psych and the NP. LPN #6 stated she then went on vacation for a week, and when she returned Resident #21 had chewed on his fingers until there were wounds. LPN #6 stated nursing staff started bandaging his hands for the wounds, and he would chew the bandages off within minutes. She stated she had tried to put socks on his hands at night. LPN #6 stated Resident #21's sister would come often and bring candy and chew toys for him. LPN #6 stated when she returned from vacation, she was told the staff was not allowed to cover his hands with socks because it would be a restraint. LPN #6 stated she placed some latex gloves on him one time, but he chewed on his fingers regardless. There was no documentation provided that the socks or latex gloves were documented on the care plan as an intervention. During an interview on 8/8/2023 at 4:35 PM, when this surveyor asked the DON when it would be appropriate to use a restraint, the DON replied, If they [residents] are on a vent [ventilator, machine that acts ]. She stated she did not think there would be any other time the use of a restraint would be appropriate. She stated the nursing staff had suggested putting a glove over Resident #21's hand, but she was afraid Resident #21 would chew through it. During a phone interview on 8/9/2023 at 10:05 AM, Family Member #3 stated she used to come every day to visit and sit with Resident #21. She stated he started chewing on his fingers, and she asked the staff to cover his hands with something to prevent him from chewing them. She stated she bought a pair of carpenter gloves and brought them in, and the nurses told her they could not put them on him because it would be a restraint. She stated when she was sitting with him and he would start to chew on his fingers, she would tell him to stop, and he would stop. She stated he needed someone to sit with him all the time to remind him, but the family could not afford to pay someone to do that. She stated when she would visit, there would be no bandages on Resident #21's fingers. During an interview on 8/9/2023 at 11:00 AM, Registered Nurse (RN) #2 stated she had witnessed Resident #21 chew on his fingers twice. She stated he would be sleeping and then wake up and put his fingers in his mouth and chew on them. During an interview on 8/9/2023 at 11:05 AM, LPN #9 stated after Resident #21's sister would leave, he would start chewing on his fingers. LPN #9 stated she would re-direct him. She stated she suggested mitten restraints and was told by the Administrator and DON they could not be used. She stated, In the meanwhile, he kept chewing. The wounds became worse. LPN #6 stated when she re-directed him, Resident #21 would stop chewing on his fingers. During an interview on 8/9/2023 at 11:57 AM, Doctor #1 stated he had seen Resident #21 four times. He stated he suggested putting some sort of glove over Resident #21's hands. He stated he spoke with Resident #21's family upon readmission from the hospital (7/21/2023) following the amputations. He stated the family was upset the resident had been allowed to chew his fingers off. Doctor #1 stated in his opinion, wrist restraints would have been appropriate. During an interview on 8/9/2023 at 12:13 PM, Wound Nurse #2 stated when she saw Resident #21 on 6/23/2023, he was bleeding from his left hand. She stated she went to her cart to get some supplies, and when she returned, he was chewing on his fingers. She stated she cleaned and dressed the finger. She stated the next time she saw him that week, he had started chewing on another finger. She stated the first finger looked worse than it did when she first saw it. She stated she would see him chewing on his bandages. She stated when she came into his room in the mornings, she would see him chewing his fingers and the bandages would be gone. She stated she tried to wrap his hand like a mitten, but he would chew through it. She stated he was never put on 1:1 observation until he was readmitted from the hospital following the amputations (Resident #21 was placed on 1:1 observation on 7/28/2023, seven days after the readmission from the hospital on 7/21/2023 for the amputation of his fingers). During an interview on 8/9/2023 at 12:46 PM, the Administrator stated an inpatient psych stay was never discussed as an option for Resident #21's chewing behavior. The Administrator stated 1:1 observation to keep him from chewing on his fingers was not considered, until he was readmitted following the finger amputations. (Resident #21 was placed on 1:1 observation at night (6:00 PM to 6:00 AM) on 7/26/2023 (5 days after readmission from the hospital) and continuous 1:1 observation (day and night shift) on 7/28/2023 (7 days after readmission from the hosptial)). During an interview on 8/9/2023 at 1:06 PM, Doctor #2 stated Resident #21's chewing behavior was the direct cause for Resident #21's fingers to be partially amputated. During an interview on 8/9/2023 at 1:29 PM, Certified Nurse Assistant (CNA) #6 stated she had been sitting 1:1 observation with Resident #21 several times since he returned from the hospital following the amputations. She stated he pulls his covers over his head when he is sleeping. She stated he has tried to chew on his fingers, but they are wrapped with bandages. She stated he does not chew his fingers in his sleep. She stated she verbally re-directs him when he begins to chew his fingers, and he immediately stops.

Based on facility policy review, observations, and interviews, the facility failed to provide effective maintenance services to maintain a safe and homelike environment for 1 of 4 (Smoking Area #1) outside smoking areas where residents had independent access to smoke throughout out the day. Failure to provide effective maintenance services resulted in peeling paint to 7 outside benches and 1 bench with broken board to the seated area. The findings include: Review of the facility's undated policy titled, Quality of Life - Homelike Environment revealed, .Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .the characteristics of the facility that reflect a personalized, homelike setting . Observations and interview in Smoking Area #1 on 8/7/2023 at 12:55 PM, revealed 5 residents smoking independently. Physical Therapy Assistant (PTA) #1 stated independent smokers come out to smoke whenever they want to smoke. Observations in Smoking Area #1 on 8/7/2023 at 1:00 PM, revealed 7 wood benches with missing red paint. Observations in Smoking Area #1 on 8/8/2023 at 9:10 AM, revealed 1 wood bench with a broken board to the seated area with all 7 benches missing paint. During an interview on 8/8/2023 at 9:20 AM, the Administrator confirmed all 7 benches were missing paint, and 1 bench had a broken board to seated area in Smoking Area #1. The Administrator confirmed residents were able to freely come to this area to smoke independently, the benches needed to be painted, and broken board on the bench needed to be fixed.

Based on facility policy review, medical record review, observation, and interview, the facility failed to implement interventions on care plans for 2 of 60 (Resident #9 and #106) residents reviewed. The findings include: Review of the undated facility policy titled, Comprehensive Care Planning, revealed, .The facility will develop a comprehensive, person-centered care plan for each resident that included measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs .The care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .When making decisions about the care plan .Determine whether the problem needs an intervention .establish which items need further assessment or review . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Cerebral Infarction, Essential Hypertension, and Repeated Falls. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #9 had Brief Interview for Mental Status (BIMS) score of 13 which indicated no cognitive impairment. Review of section G for transfer (how resident gets up from seated position) revealed total dependence (resident was unable to assist in any way) of two plus person physical assistance. Review of the comprehensive fall care plan revealed, .The resident is at risk for falls r/t [related to] impaired balance and weakness .Interventions/tasks .date initiated 1/23/2023 colored tape to call light . Observations in Resident #9's room on 8/7/2023 at 10:00 AM and 8/8/2023 at 9:00 AM, revealed Resident #9 seated in a reclined wheel chair with call light in reach. There was no colored tape observed attached to the call light. During an interview on 8/9/2023 at 9:40 AM, the Director of Nursing (DON) confirmed Resident #9's fall care plan intervention was for the call light to have colored tape. While in Resident #9's room, the DON confirmed there was no colored tape attached to the call light. Review of the medical record revealed Resident #106 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Hemiplegia and Hemiparesis following Cerebral Infarction, and Essential Tremor. Review of the Quarterly MDS dated [DATE] revealed Resident #106 had BIMS score of 7 which indicated severe impaired cognition and was assessed for transfer with total dependence of two plus person physical assist (requires more than minor physical assistance). Review of the comprehensive fall care plan revealed, .The resident is at risk for falls r/t limited mobility, Parkinson's, tremors .Hemiplegia and Hemiparesis, Muscle weakness .Poor safety awareness .does not always use call light or ask for assistance .Interventions/tasks .Assist with transfers as needed .Safety mat to right side of bed . Observations in Resident 106's room on 8/8/2023 at 9:52 AM and 8/9/2023 at 9:00 AM, Resident #106 was lying in the bed with a fall mat to left side of the bed. During an interview on 8/9/2023 at 9:05 AM, Certified Nursing Assistant (CNA) #10 confirmed Resident #106 was unable to walk and had to be transferred with a total mechanical lift. During an interview on 8/9/2023 at 9:06 AM, Licensed Practical Nurse #8 confirmed Resident #106's fall mat was on the left side of bed while observing the mat on the floor in the resident's room. During an interview on 8/9/2023 at 9:10 AM, the DON confirmed the facility failed to ensure the fall mat was on the right side of Resident #106's bed and failed to ensure the fall care plan was updated to reflect use of a total mechanical lift for transfer.

Based on facility policy review, medical record review, and interviews, the facility failed to ensure nursing staff was competent when one (1) nurse failed to administer medications ordered by the physician to 1 of 3 (Resident #365) residents reviewed. The findings include: Review of the facility's undated policy titled, Medication Administration, revealed, .Orders for medications and treatments will be consistent with principles of safe and effective order writing .Orders that cannot be administered due to pharmacy delay or between delivery times and that cannot be retrieved from any in-house medication dispenser will be communicated to the physician/provider for further instruction . Review of the medical record revealed Resident #365 was admitted to the facility on [DATE] with diagnoses which included Non-ST Elevation Myocardial Infarction (type of heart attack that happens when the heart is not getting enough oxygen), and Atherosclerotic Heart Disease of Native Coronary Artery (build up of plaque in the inner lining of an artery). Review of the Admission Orders for Resident #365 revealed an order for Ticagrelor (a medication used for persons with a history of heart attack or stroke) 90 mg (milligram) one tablet by mouth every 12 hours. Review of the Medication Administration Record (MAR) revealed Licensed Practical Nurse (LPN) #9 documented she held Resident #365's Ticagrelor medication (scheduled on 6/10/2023 at 9:00 PM) and referred to the Progress Notes. Review of the Progress Notes on 6/10/2023 revealed no documentation related to the nurse holding the Ticagrelor medication. During an interview on 8/9/2023 at 4:00 PM, Licensed Practical Nurse (LPN) #9 stated she was the nurse on duty during the night shift on 6/10/2023 when Resident #365 was admitted . She confirmed she did not administer the medication but did not state why the medication was held.

Based on facility policy review, medical record review, observation and interview, the facility failed to store a resident's personal food in a safe manner for 1 of 25 (Resident #9) residents reviewed with personal refrigerators. The findings include: Review of the undated facility policy titled, Foods Brought in by Family/Visitors, revealed .The facility will permit liberalized diets as much as possible and clinically advised. Nursing staff and/ or the Dietician must be aware of and approve all foods/drinks that are brought to a resident by all visitors . Review of the undated facility policy titled, Personal Refrigerators, Use of, revealed .It is the goal of the facility to provide optimal care .comfort of its residents. The facility will also respect residents' dignity, freedom of choice and individuality to the extent possible. If a resident/representative requests the use of a personal refrigerator for their room in the facility, this request will be reviewed by the Interdisciplinary Care Plan Team in an effort to balance resident needs and resident choice. The resident/representative will be notified of the decision, and a plan will be made .All appliances brought into the facility by a resident/ representative must be reviewed and approved for use by the Director of maintenance/designee .When a family/representative requests to bring in a personal refrigerator, the Interdisciplinary Care Plan Team will determine the appropriateness of the request .If it is determined that the resident/representative is not a viable candidate for the use of a personal refrigerator, the resident/representative will be notified . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Cerebral Infarction, Essential Hypertension, and Repeated Falls. Review of the Annual Minimum Data Set, dated dated dated [DATE] revealed Resident #9 had Brief Interview for Mental Status score of 13 which indicated no cognitive impairment. Observations in Resident #9's room on 8/7/2023 at 10:00 AM and 8/8/2023 at 9:00 AM, revealed Resident #9 seated in a reclined wheel chair. A small personal refrigerator was observed on the night stand. During observations and interview in Resident #9's room on 8/9/2023 at 9:20 AM, a clear bag with 4 pieces of bread was observed on top of her personal refrigerator. Resident #9 stated she requested some of her individual bottles of orange juice in her personal refrigerator. The Physical Therapist Assistant (PTA) #1 came into Resident #9's room to retrieve the orange juice for the resident. The Surveyor observed a clear bag filled with some slices of what appeared to be sandwich meat in the refrigerator. The PTA confirmed the bag of sandwich meat and bag of sliced bread had no label or expiration date. During an interview on 8/9/2023 at 9:30 AM, the Director of Nursing observed and confirmed the bag of sandwich meat and sliced bread in Resident #9's room had no label or expiration date. During an interview on 8/10/2023 at 10:35 AM, the Administrator confirmed the Interdisciplinary Care Plan Team had not reviewed, notified, or made decisions or a plan in regards to Resident #9's use of her personal refrigerator according to the facility policy.

Based on facility policy review, facility documentation review, medical record reviews, observations, and interviews, the facility failed to ensure each resident received adequate assistance devices for 3 out of 9 residents (Residents #9, #41, and #49) reviewed, which resulted in actual harm, (Resident #9 fractured femur and lacerations) and (Resident #41 increase physical pain and anguish) for 2 of the 9 residents. The findings include: Review of the facility's undated policy, Accidents and Incidents-Investigating and Reporting, revealed, .Accidents or incidents involving residents, employees, visitors, vendors, etc. (further, similar items included), occurring on our premises are to be investigated and reported to the Administrator or designee .The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall document the information regarding the incident or accident .review the information for the purposes of ensuring care plan was updated .appropriate interventions were initiated and implemented if necessary . Review of the facility's undated policy, Activities of Daily Living, revealed, .It is the policy of the facility to make every effort to respond to the residents' requests and needs. The facility's goal is to assist the resident with maintaining as much independence as possible with their Activities of Daily Living but providing assistance where needed . Review of the facility's undated policy, Safe Lifting and Movement of Residents, revealed, .In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents .Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis as a resident's level of assistance can fluctuate up or down frequently .Staff will document resident transferring and lifting needs on the Kardex [an electronic charting system used to inform nursing staff regarding the resident's needs] and in the care plan .Mechanical lifts shall be made readily available 24 hours a day .Safe lifting and movement of residents is part of an overall facility employee health and safety program . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Morbid Severe Obesity, History of Falls, and Disorders of Bone Density. Review of the Quarterly Minimum Data Set (MDS) for Resident #9 dated 9/19/2022 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognitive impairment. Continued review revealed Resident #9 was classified as total dependent upon 2 or more persons for transfers. Review of the care plan for Resident #9 revealed, .Transfers .Extensive Assist x [times] 1 staff Date Initiated 3/21/2019 created on 11/29/2018 .Transfers: Totally Dependent x 2 Staff (Mechanical Lift) Date Initiated: 12/13/2022 Created on: 6/14/2021 Revision on: 12/13/2022 .Uso del [NAME] .Personal totalmente dependiente [use fully dependent staff] x 1 Date Initiated: 12/14/2022 Created on 8/18/2022 . Review of the Physical Therapy notes for Resident #9 revealed, .Start of Care: 7/14/2022 Comments: Chronic BL [bilateral] knee pain limiting and performed with TD+ [Total Dependence Plus] at this date. Pt [patient] to be utilizing a hoyer lift [total body mechanical lift] by nursing staff for pt. and staff safety. STS [Sit to Stand] lift attempted multiple times throughout this POC [plan of care], however pt. does not help assist or come into standing with the lift, and therefore the STS lift is not appropriate or safe for pt. at this time . Continued review revealed, .Instruction: educated staff on need/importance of using a hoyer lift for EOB [edge of bed] w/c [wheelchair] transfers as it is not safe for the staff or pt. to transfer her without it d/t [due to] her size, obesity, and chronic pain that limits these transfers and her risk for buckling . Continued review of the Therapy notes revealed, .Discharge Summary 8/23/2022 .Staff educated on all sequences of bed mobility and transfers with slow processing and extra time to complete. Staff educated on use of lift for transfers due to patient obesity and increased risk of falls . Review of the Kardex Report (brief overview of individual resident care needs) for Resident #9 dated 9/25/2022 (prior to the accident) revealed, Transfers .Totally Dependent x 1 staff member. Review of the ADL (Activities of Daily Living) flow sheet for Resident #9 dated 1/1/2022 - until day she fell on [DATE], revealed the resident was transferred with a mechanical lift with assistance of 2 persons 29 times out of 96 times the staff transferred Resident #9. Review of the Incident Report for Resident #9 dated 9/26/2022 revealed, .Resident fell to knees after tech attempted to assist resident to stand and pivot from bed to w/c [wheelchair] this shift. Resident fell to knees d/t [due to] lower extremity weakness with feet underneath her buttock. Fall was witnessed and resident did not hit her head. Resident transferred back into bed and neuro checks began immediately .bleeding noted from deep lacerations to bottoms of 2nd, 3rd, 4th, and 5th toes of L [left] foot after foot was suspected to have been bent back upon landing from fall. Large clots passed from toes, bleeding stopped and dressing applied after resident was assessed by NP [Nurse Practitioner] .Resident c/o [complained of] Bilat [Bilateral] knee, bilat lower leg and bilat foot pain, some swelling noted to both knees and lower extremities. Received order to [send] resident nonemergent to ER [emergency room ] for further evaluation. Stated, My legs just gave out and I fell . Immediate Action Taken: dressings applied to wounds on toes of L foot. Resident to be transferred via Hoyer Lift (mechanical lift). Review of the Kardex Report for Resident #9 dated 9/26/2022 at 16:25 (4:25 PM) after the accident at 13:54 (1:54 PM) the Kardex Report was updated to Transfers .Totally Dependent x 2 staff (mechanical lift) . Review of the Hospital Record for Resident #9 dated 9/27/2022 revealed, .presents due to a fall at [named nursing home] with right leg pain. Patient states she was being transferred today .when they dropped her reportedly. Patient is nonambulatory at baseline and uses a wheelchair due to chronic debility from previous hip fractures. Appears she has a facial droop which son states is chronic. She only reports right leg pain .imaging suggestive of right spiral femur fracture . Observation and interview in Resident #9's room on 2/23/2023 at 9:31 AM revealed Resident #9 in her bed surrounded by her personal belongings. Resident #9 stated they dropped her once when they were transferring her and now they use a lift to put her in her chair. During an interview on 2/23/2023 at 9:36 AM, the Director Of Nursing (DON) stated Resident #9 had a fall in September 2022 which resulted in lacerations and a fracture. DON stated CNA #17 was trying to get Resident #9 up without a lift. DON stated Resident #9 required assistance of 2 staff, at least. She stated there was only 1 CNA in the room for the transfer. During an interview on 2/28/2023 at 9:46 AM, Licensed Practical Nurse (LPN) #3 (also known as the Unit Manager) stated Resident #9 fell during a transfer from bed to chair. LPN #3 stated now, Resident #9 was to use a mechanical lift for transfers. During the interview, LPN #3 looked on the EMR (Electronic Medical Record) and stated Resident #9 was ordered to be an extensive assist transfer with 2 person assist as of 2/5/2019. LPN #3 stated extensive assist means it takes 2 humans and the resident does not help in any capacity in transferring. LPN #3 stated there was only 1 person assisting with the transfer for Resident #9 the day she fell on [DATE]. During an interview on 2/28/2023 at 10:21 AM, CNA #23 stated she had taken care of Resident #9 many times. CNA #23 stated back in June or July of 2022 she went PRN (as needed) and at that time she was a total body lift. She stated normally the mode of transfer was in their charting system Kardex (electronic Kardex report). When reviewing the documentation for Resident #9 on the CNA's charting ADL sheet, it was documented Resident #9 was transferred 4/2 a few times, which meant total dependence of 1 person transfer. CNA #23 stated she didn't know how that kind of transfer could be possible. During an interview on 2/28/2023 at 10:36 AM, CNA #24 stated before Resident #9 fractured her leg, she was a sit-to-stand lift for transfers. CNA #24 stated Resident #9 always used that type of lift and never fell when she transferred her. When CNA #24 was shown she had charted her transfer status in the electronic charting system as 4/2 (meaning total dependence of 1 person assist), CNA #24 stated she had been charting wrong and thought 4/2 meant total dependence of 2 staff. CNA #24 stated she should have been charting 4/3 [total dependent of 2 person assist]. During an interview on 2/28/2023 at 11:18 AM, Physical Therapist (PT) #1 stated she knew Resident #9 very well. PT #1 stated she did Resident #9's discharge/recertification and discharged her on 8/23/2022. PT #1 stated Resident #9 was total dependence without attempts to initiate and had been transferred using a full body mechanical lift. During an interview on 2/28/2023 at 11:30 AM, the MDS Coordinator stated Resident #9's transfer status, according to the MDS, was a 4/3, meaning she was to be transferred using a full body mechanical lift with 2 person assist. MDS Coordinator stated the care plan should read the same, unless after the MDS was completed something changed or a therapist changed the recommendation. During an interview on 2/28/2023 at 11:42 AM, the Care Plan Coordinator stated the care plan for Resident #9 stated her transfer status was a 4/2 meaning total dependence of 1 person assist. The Care Plan Coordinator confirmed one of the entries regarding transfer status was in Spanish, and it stated Resident #9 was totally dependent for transfer with 1 person assist and it was created on 8/18/2022. The Care Plan Coordinator also stated there was another entry on the care plan for Resident #9 that stated she was totally dependent for transfer with assistance of 2 persons created on 6/14/2021. The Care Plan Coordinator confirmed the task documented on the care plan for Resident #9 regarding her transfer status is incorrect. During an interview on 2/28/2023 at 12:02 PM, the Nurse Practitioner (NP) #1 stated she assessed Resident #9 after she fell on [DATE]. NP #1 stated she was concerned about her right leg and her toes, which were bleeding and X-ray post the fall revealed right leg was fractured. During an interview on 2/28/2023 at 12:09 PM, PT #2 stated before Resident #9 had the fall on 9/26/2022, nursing staff had to use a full body mechanical lift. PT #2 stated she was on therapy caseload from 7/14/2022-8/22/2022. PT #2 stated Resident #9 discontinued therapy on 8/23/2022 required a full body mechanical lift with 2 person assist for transfers. PT #2 stated the therapist communicated with the nursing staff through the electronic medical record program then the rehab tech was responsible for entering the information into the system. During an interview on 2/28/2023 at 12:30 PM, the Rehab Tech stated the care plan dated 8/18/2022 for Resident #9 was total dependence x 1 person assist. The Rehab Tech was not sure how that could be possible. Rehab Tech stated the therapists put the information on a sheet of paper and she would enter it into the electronic charting system. Rehab Tech stated after she enters the information the document was destroyed. Rehab Tech stated Resident #9 shouldn't have gone from total assist of 2 with a lift, to total dependence with assist of 1. Rehab Tech stated to her knowledge, Resident #9 has always been total dependence with the full body mechanical lift for transfers. During an interview on 2/28/2023 at 12:49 PM, the Administrator stated after Resident #9's fall on 9/26/2022, the immediate intervention implemented was to ensure the resident was transferred via full body mechanical lift using 2 persons. The Administrator stated it was entered as 4/3 which meant Total Dependence and Not helping and not bearing any weight during the transfer. The Administrator stated some residents can be classified as total dependent x 1 person for transfers. The Administrator stated CNA #17 doing the transfer was following the care plan, which had Resident #9 as total dependent x 1 assist before the fall. The Administrator stated the CNA could have picked up and transferred Resident #9. (Resident #9's weight at time of fall was 233 pounds) During an interview on 2/28/2023 at 2:00 PM, CNA #1 stated total dependent residents always require 2 staff for transfers. During an interview on 3/1/2023 at 8:20 AM, CNA #17 stated he transferred Resident #9 on 9/26/2022, the day she fell . CNA #17 stated he did not check Resident #9's care plan beforehand. CNA #17 stated Resident #9 would stand and pivot. CNA #17 stated her legs started to give out and he lowered her gently to the floor. CNA #17 stated after Resident #9 fell , he went and got the nurse to assess her. CNA #17 stated, they placed her in a lift and put her back in the bed. After she was transferred to the hospital, I was given a teachable moment regarding transfers. I was shown how to look at the Kardex Report and see their transfer status. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses which included Diaphragmatic Hernia, Hypothyroidism, and Fracture of Unspecified Part of Neck of Right Femur. Review of the Quarterly MDS assessment for Resident #41 dated 1/5/2023 revealed Resident #41 had a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed Resident #41 required total dependence of two or more persons for transfers. Review of the comprehensive care plan revealed Resident #41 had a focus/assessment for, .Resident requires assist with activities of daily living related to hip Fracture, Dementia, Osteoarthritis, and Impaired Mobility .Intervention initiated on 6/28/2021 for transfers (4/3): totally dependent x 2 staff (mechanical lift) . Review of the High Risk/Abuse Investigation Checklist dated 10/4/2022 revealed, .[Resident #41] alleged to NP [Nurse Practitioner #3] that 2 days ago a tech [technician] was putting her in wt [weight] chair and resident told tech she needs lift and tech said no she can hold onto her .resident right leg got tangled with tech leg .knee was bothering her and she didn't tell anyone at the time as she didn't want to get anyone in trouble but when still hurting she thought she better say something tech task - total dependent .DON [reviewed video surveillance] .saw [CNA #26] take weight chair in on 10/4/2022 not 10/3/2022 therapy referral made . Review of the 10/2022 Medication Administration Record (MAR) revealed Resident #41 received Ibuprofen tablet 600 milligram (mg) on 10/4/2022 and 10/5/2022 with a pain scale of 5 and 8 on a pain scale of 1-10. Review of Resident #41's NP #3's Progress Notes revealed, .10/5/2022 10:26 [AM] .currently being evaluated today for complaints of right knee and right femur pain .reports negative interacts [negative encounter while staff providing care] previous day and request evaluation of leg with pain .reports decrease in range of motion .family at bedside and reports pain with movement .extremities right leg pain noted with range of motion movements right kneecap edematous .assessment and plan .right knee, right femur pain .we will order right knee and right femur x-ray to be obtained stat [immediate, without delay]. Patient receiving Ibuprofen 600 mg every 8 hours as needed for pain . Continued review of Resident #41's NP #3's Progress Notes revealed 10/5/2022 13:59 [1:59 PM] .complained to nurse that her right knee and right leg were hurting her more today .nurse assessed resident and attempted range of motion to right leg, resident was unable to bend knee or do range of motion d/t [due to] being in pain. Further review of Resident #41's NP #3's Progress Notes revealed, .10/6/2022 .currently being evaluated today for evaluation of x-ray results pending previous condition of right knee and right leg pain .current x-ray results show no new injuries .Patient still reports decline in range of motion .Assessment and Plan: Osteoarthritis/proximal femur with minimum displacement. We will refer patient to orthopedic for evaluation. No new fractures noted. Patient had displaced right proximal femur fracture on 6/24 [6/24/2022] . Review of the Physical Therapy (PT) evaluation and plan of treatment dated 10/11/2022 for Resident #41 revealed, .referred to skilled PT services d/t [due to] pain on right knee. Upon PT evaluation, pt [patient] exhibits tenderness on right thigh, knee, leg and ankle area with decreased ROM [range of motion] .d/t complaint of severe pain . During an interview on 2/23/2023 at 1:09 PM, the DON stated, I reviewed our surveillance cameras and [CNA #26] did go into [Resident #41]'s room with the weight chair. The [CNA #26] did not bring a lift into the room. After the incident, we did educate the staff on proper use of the lift because the policy requires two people to transfer with a lift. During an interview on 2/23/2023 at 1:30 PM, Resident #41 was alert and oriented. Resident #41 stated, A CNA came in my room with the weight chair and told me she was going to weigh me. I told the CNA I couldn't stand and she would have to get a lift. That was when the lady just grabbed me up. I told her again I couldn't stand, then she got me up and when she did my knee popped. I yelled when it happened and the CNA threw me back on the bed [Resident #41 denied any abuse]. I don't remember what she looked like but I made it clear I did not want her back in my room again. The nurse looked at my leg but she couldn't find anything wrong then. My right knee started hurting, swelled up, and they ordered an x-ray. I called my niece and told her about it. I haven't seen that CNA anymore. The staff have always got me up with a lift. I am just not able to bear my weight anymore due to Arthritis. During an interview on 3/1/2023 at 9:40 AM, DON confirmed CNA #26 didn't use lift when she weighed Resident #41. The DON confirmed care plan intervention for transfers was totally dependent x 2 staff, mechanical lift. During an interview on 3/22/2023 at 6:00 PM, NP #3 stated, After the incident happened [Resident #41 transferred without the use of the lift], she had increase in pain, hurting worse after the incident. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Interstitial Pulmonary Disease (progressive scarring of lung tissue), Cirrhosis of Liver (chronic liver damage), and Spondylosis (a painful condition of the spine), Thoracic (center of your upper and middle back). Review of the Quarterly MDS assessment for Resident #49 revealed a BIMS score of 3, which indicated severe cognitive impairment. Continued review revealed Resident #49 was totally dependent upon 2 staff members for transfers. Review of the comprehensive care plan for Resident #49 revealed focus/assessments for, .resident requires assist with activities of daily living related to weakness, limited mobility, and dementia, osteoarthritis, convulsions, contractures, pain, depression .Interventions: .Transfers (4/3) Totally Dependent x 2 Staff (Mechanical Lift) . Review of the ADL flow sheet for Resident #49 dated 12/31/2022-3/2/2023 revealed the resident was not transferred using a lift and 2 persons 74 times out of 127 times the staff transferred Resident #49. During an interview on 3/1/2023 at 11:28 AM, CNA #28 stated they transfer Resident #49 with 2 people. CNA #28 stated, We got him up this morning without the lift. During an interview on 3/1/2023 at 11:32 AM, CNA #27 stated she got Resident #49 out of bed this morning by herself. She stated sometimes he cooperates, and she is able to do it by herself. When asked how the staff is to know how to transfer a resident, she stated the information is on the Kardex. Review of the Kardex with this surveyor present, CNA #27 stated, Oh. It says he is supposed to be a mechanical lift with 2 people to assist. During an interview on 3/1/2023 at 11:43 AM, LPN #13 reviewed Resident #49's Kardex Report with this surveyor, Resident #49 was totally dependent with assist of 2 staff members and required a mechanical lift for transfers. During an interview in Resident #49's room on 3/1/2023 at 12:16 PM, the DON confirmed Resident #49 was care planned to be totally dependent with assistance of 2 and a mechanical lift for transfers.

Based on facility policy review, medical record review and interviews, the facility failed to develop and implement a person centered care plan for 2 of 9 sampled residents (Resident #9 and Resident #29) reviewed for care plans. The findings include: Review of the facility's undated policy titled, Comprehensive Care Planning, revealed, .The facility will develop a comprehensive, person-centered care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs which are identified in the comprehensive assessment . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Morbid Severe Obesity, History of Falls, and Disorders of Bone Density. Review of the Quarterly MDS for Resident #9 dated 9/19/2022 revealed a BIMS score of 14, which indicated no cognitive impairment. Continued review revealed Resident #9 was classified as total dependent upon 2 or more persons for transfers. Review of the care plan for Resident #9 revealed, .Transfers .Extensive Assist x [times] 1 staff Date Initiated 3/21/2019 created on : 11/29/2018 .Transfers: Totally Dependent x 2 Staff (Mechanical Lift) Date Initiated: 12/13/2022 Created on: 6/14/2021 Revision on: 12/13/2022 . Review of the ADL (Activities of Daily Living) Certified Nursing Assistant (CNA) documentation sheets revealed Resident #9 was transferred with a mechanical lift with assistance of 2 persons only 29 times out of 96 total times transferred from June 2022 through the day she fell on [DATE]. During an interview on 2/28/2023 at 11:18 AM, Physical Therapist (PT) #1 stated she knew Resident #9 very well. PT #1 stated she did Resident #9's discharge/recertification and discharged her on 8/23/2022. PT #1 stated Resident #9 was total dependence without attempts to initiate and had been transferred using a full body mechanical lift. During an interview on 2/28/2023 at 11:42 AM, the Care Plan Coordinator stated the care plan for Resident #9 stated her transfer status on 1/28/2019 was a 4/2, meaning total dependence of 1 person assist. She also stated there was another entry on the care plan for Resident #9 that stated she was totally dependent for transfer with assistance of 2 persons created on 6/14/2021 and revised on 12/13/2022. She confirmed the task documented on the care plan for Resident #9 dated 1/28/2019 regarding her transfer status is incorrect. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included Displaced Fracture of Base of Neck of Right Femur, Difficulty in Walking, and Muscle Weakness. Review of the Admission MDS assessment data 9/11/2022 revealed Resident #29 had a BIMS score of 14, which indicated no cognitive impairment. Review of the facility investigation dated 9/20/2022, revealed Resident #29 alleged a staff member was verbally abusive to her. The staff member she described was a close match of a description of an agency CNA. Resident #29 alleged CNA #6. Resident #29 reported the allegation to a Physical Therapy Assistant (PTA)#3 the following morning (9/20/2022). Resident #29 told PTA #3 a nurse had been mean, yelling at her and being mad at her. Resident #42 (Resident #29's roommate) stated the yelling was so loud it woke her up. Resident #42 stated she heard the nurse say, you'll get your ass in bed or I'll call the cops. Other residents and staff were interviewed and stated they did not hear any yelling in the hallway. Resident #29 and Resident #42 were interviewed multiple times and the results were not consistent with the original allegation statement. In-services on Abuse policy were provided and Social Services followed up with Resident #29 for 72 hours. The investigation states that Resident #29's care plan was reviewed and revised. During an interview on 2/27/2023 at 1:35 PM, the Social Services Director (SSD) reviewed the care plan for Resident #29 and confirmed the care plan was not implemented for the actual allegation of abuse. She stated, At that time, we were not adding the allegations of abuse to the care plans, but we are now. She stated she expected the allegations to be a focus of concern on the care plan with interventions. She stated the Social Service department would be the one to implement the care plan focus.

Based on facility policy review, medical record review, observation, and interview the facility failed to perform Interdisciplinary Team (IDT) meetings for 1 of 5 sampled residents (Resident #3) reviewed for IDT meetings, the facility failed to revise a care plan for 2 of 9 sampled residents (Resident #49 and #51) reviewed for falls, and facility failed to revise a care plan for 1 of 9 sampled residents (Resident #16) reviewed for allegations of abuse. The findings include: Review of the facility's undated policy titled, Comprehensive Care Planning, revealed, .The facility will develop a comprehensive, person-centered care plan for each resident that includes measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs which are identified in the comprehensive assessment. The Care Planning/Interdisciplinary Team is responsible for the development of the comprehensive care plan. An initial Care Plan will be developed within 48 hours of admission to the facility .The resident/representative may request meetings, request revisions and give input into the type of care provided . Review of the medical record revealed Resident #3 was originally admitted on [DATE], readmitted on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia, Systemic Inflammatory Response Syndrome of Non-infectious Origin without Acute Organ Dysfunction, and Pressure Ulcer of Left Buttock and Right Buttock. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the medical record for Resident #3 revealed one care plan meeting on 12/9/2021. No further care plan meetings were noted nor any family participation in the care planning process. During an interview on 3/8/2023 at 8:42 AM, Regional Administrator stated, Care plan meetings don't have to be traditional. During an interview on 3/8/2023 at 11:55 AM, MDS Coordinator stated, We have done walking rounds on residents that we were concerned about, I don't see any walking round notes for [Resident #3]. Weekly rounds are group meetings and some of the IDT team members are involved. During an interview on 3/8/2023 at 12:29 PM, Social Service Director stated, I only have documentation of one care plan meeting for [Resident #3] and it is for 12/9/2021. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Interstitial Pulmonary Disease, Cirrhosis of Liver, and Spondylosis Without Myelopathy or Radiculopathy, Thoracic. Review of the Quarterly MDS assessment for Resident #49 revealed a BIMS score of 3, which indicated severe cognitive impairment. Continued review revealed he required extensive assistance of 1 caregiver for bed mobility, Locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. Continued review revealed he was totally dependent upon 2 staff members for transfers. Review of the comprehensive care plan for Resident #49 revealed focus/assessments for, .the resident is at risk for falls related to impaired mobility, dementia, poor safety awareness, impulsiveness, convulsion diagnosis, and does not always ask for assistance .Interventions: Colored tape to soft touch call light .Transfers Totally Dependent x 2 Staff (Mechanical Lift) . Review of the ADL flow sheet for Resident #49 dated 12/31/2022-3/2/2023 revealed the resident was not transferred using a lift and 2 persons 74 times out of 127 times the facility failed to transfer the resident in accordance with the care plan. During an interview on 3/1/2023 at 11:28 AM, CNA #28 stated they transfer Resident #49 with 2 people. She stated, We don't use a lift. Observation in Resident #49's room on 3/1/2023 at 11:30 AM, revealed there was no colored tape on the soft call light and bilateral padded mats on the floor beside the bed. Interventions observed in Resident #49's room were not on the comprehensive care plan. During an interview on 3/1/2023 at 11:32 AM, CNA #27 stated she got Resident #49 out of bed this morning by herself. When asked how the staff is to know how to transfer a resident, she stated the information is on the Kardex Report (quick reference to the particular needs of a resident). Review of the Kardex and the care plan with this surveyor present, CNA #27 stated, Oh. It says [Resident #49] was supposed to be a mechanical lift with 2 people to assist. During an interview in Resident #49's room on 3/1/2023 at 11:43 AM, Licensed Practical Nurse (LPN) #13 confirmed there was no colored tape on the soft call light, and there were bilateral padded mats to the floor beside his bed. Upon reviewing the care plan with her, she stated there should be colored tape on the call light and there was no care plan intervention for the padded fall mats beside the resident's bed. Continued review of Resident #49's Kardex and care plan revealed he was totally dependent with assist of 2 staff members and required a mechanical lift for transfers. During an interview in Resident #49's room on 3/1/2023 at 12:16 PM, the Director of Nursing (DON) confirmed there were bilateral padded mats on the floor beside his bed, colored tape on the call light, and they were not on the care plan as an intervention. Continued review and interview, the DON confirmed Resident #49 was care planned to be totally dependent with assistance of 2 and a mechanical lift for transfers and the CNAs should not be transferring him without a full body mechanical lift. Review of the medical record revealed Resident #51 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Parkinson's Disease and Hemiplegia and Hemiparesis. Review of the Quarterly MDS assessment for Resident #51 dated 2/15/2023 revealed a BIMS score of 10, which indicated moderate cognitive impairment. Continued review revealed he was totally dependent upon 2 or more staff for transfers. Review of the undated care plan for Resident #51 revealed a focus/assessment for, .Resident requires assist with activities of daily living r/t [related to] dx [diagnosis] of Parkinson, Arthritis, Weakness, Tremors, CVA [Cerebrovascular Accident] with hemiplegia, Dementia, and diabetes .Interventions: Transfers: (4/3) Totally Dependent x 2 Staff (Mechanical Lift) .The resident is at risk for falls r/t limited mobility, Parkinson's, tremors, Psychotic Disorder with hallucination, Hemiplegia and Hemiparesis, Muscle Weakness, Osteoarthritis .Interventions: Scoop mattress to define borders .Sign in room to remind resident to use call light .Non-skid material to w/c [wheelchair] seat .Safety mat to left side of bed . Observation and interview on 3/1/2023 at 11:14 AM in Resident #51's room revealed he was out of his room at the time. Observation of the room revealed a padded mat on the floor to the right side of the bed. Interview with CNA #29, she stated, The mat is on the right side of the bed on the floor because that is the side he crawls out of most of the time. During an interview in Resident #51's room on 3/1/2023 at 12:16 PM, the DON confirmed the padded floor mat was on the floor on the right side of the bed. The DON confirmed according to the care plan, the padded mat was supposed to be on the left side of the bed. Review of the medial record revealed Resident #16 was readmitted to the facility on [DATE] with diagnoses which included Schizophrenia, Anxiety Disorder, and Bipolar Disorder. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #16 had a BIMS score of 14 indicating no cognitive impairment. Review of Resident #16's care plan interventions dated 12/23/2022 revealed, .Consult with psych and social services as needed. Provide comfort and reassurance . Review of the Facility Report dated 12/23/2022 revealed Resident #16 had been involved in a resident to resident altercation, . [Resident #16] reached out and made physical contact with [Resident #15] with the back of hand. Resident #15 reported that contact was made to right side of face however when camera footage was reviewed contact was made to left side of face . Review of the progress note dated 12/25/2022 revealed .Spoke with resident [Resident #50] regarding complaints of roommate [Resident #16]. Resident states roommate is rude but denies feeling unsafe at this time . Review of the progress noted dated 12/26/2022 revealed, .Resident [Resident #16] is moving to room .today due to roommate incompatibility . During an interview on 2/27/2023 at 12:01 PM, LPN #8 stated, Resident #16 was moved to another room with Resident #50. On 12/23/2022 LPN #8 remembered seeing Resident #50 in the lobby and she told LPN #8 that Resident #16 was making statements and made her feel uncomfortable. LPN #8 notified the supervisor and they moved Resident #50 on 12/26/2022. Resident #16 was not on 1 to 1 observation in room with Resident #50. During an interview on 2/27/2023 at 2:02 PM, the DON stated on 12/23/2022 it appeared Resident #15 and Resident #16 had a verbal spat before it turned to a physical altercation. The facility did not think Resident #16 was incompatible with other residents and they thought it was an isolated incident. It was to her understanding Resident #16 had made some comments and Resident #50 did not like the comments but initially did not want to move to another room. Resident #50 did move to another room after speaking with her. Resident #16 had not exhibited this type of behavior before. Continued interview confirmed Resident #16 had made Resident #50 uncomfortable while sharing a room thus causing her to move to another room. The DON did not remember what care plan intervention was in prior to Resident #16 moving to another room with Resident #50 after the 12/23/2022 altercation. The DON reviewed Resident #16's current care plan and confirmed the care plan did not have interventions in place after the 12/23/2022 verbal/physical contact with Resident #15. 44447

Based on facility policy review, observation, and interview the facility failed to maintain proper infection control during wound care to prevent the development and transmission of infections for 1 of 5 sampled residents (Resident #38 ) reviewed for wounds. The findings include: Review of the undated facility policy titled, Pressure Ulcer Treatment, revealed, .The pressure ulcer treatment program should focus on the following strategies .Pressure ulcer care .Managing bacterial colonization and infection .Steps in the Procedure .Prepare supplies for treatment .Prepare bedside stand. Establish a clean field .Place the clean equipment on the clean field. Arrange supplies so they can be easily reached .Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field .Wash and dry your hands thoroughly. Put on clean gloves. Loosen tape and remove soiled dressing. Pull glove over dressing and discard into plastic or biohazard bag .Wash and dry your hands thoroughly .Open dry, clean dressing[s] by pulling corners of the exterior wrapping outward, touching only the exterior surface. Label and tape or dressing with date and initials. Place on clean field. Using clean technique, open other products [ .prescribed dressing; dry, clean gauze] .Cleanse the wound with ordered cleanser .If using gauze, use a clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area [usually, from the center outward]. Apply the ordered dressing and secure with tape or bordered dressing per order .Apply label with date and initials on top of dressing .Discard disposable items into the designated container .Wash and dry your hands thoroughly . Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus with Foot Ulcer, Non-Pressure Chronic Ulcer of other part of Left Foot with Fat layer exposed, and Acquired Absence of Other Left Toes. Review of the active Order Summary Report revealed, .Order Summary .Cleanse left plantar aspect of foot with wound cleanser, apply Hydrogel, collagen and cover with dry dressing every day shift .Start Date 1/14/2023 . During an observation of wound care for Resident #38 on 3/2/2023 at 8:50 AM, the Wound Nurse proceeded to wound cart after sanitizing hands, he pulled Hydrogel and collagen from cart and mixed the two together while standing in the hall. He continued to pull out 4 x 4 gauze which he opened, tore a strip of tape, stuck it to the top of wound cart, dated and initialed the tape, then picked up the tape and stuck the tape onto his uniform. Prior to going into Resident #38's room, he grabbed a clean hand towel off linen cart, proceeded to place it on a dirty overbed table, and laid wound care supplies on the towel. The Wound Care Nurse performed hand washing and applied clean gloves. He removed Resident #38's dressing to his left foot which revealed a soiled dressing and an open wound. The Wound Nurse disposed of soiled dressing in the garbage in the resident's bathroom, performed hand washing and applied another pair of clean gloves. The Wound Nurse then applied wound cleanser to the opened 4 x 4 gauze and cleansed the wound in circular motion crossing over the same areas and then folding the 4 x 4 gauze, and wiped over the wound again. The Wound Nurse then grabbed gauze to wrap the wound and proceeded to secure dressing with the tape that was previously stuck to wound cart and his personal uniform. This Surveyor asked the Wound Nurse to step outside the room to discuss his wound care. Interview with the Wound Care Nurse revealed the nurse did not maintain infection control practices during the wound dressing change. The Wound Nurse stated, It's not a sterile dressing just a clean dressing change. During an interview on 3/1/2023 at 12:16 PM, the Director of Nursing confirmed she expected the Wound Care Nurse to follow the Pressure Ulcer Treatment policy when performing wound care.

Based on facility policy review, medical record review, observation and interview, the facility failed to label and date oxygen tubing and humidified containers for 2 of 4 sampled residents (Residents #2 and #6) reviewed receiving oxygen therapy, and the facility failed to properly date and store nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) masks for 3 of 4 sampled residents (Residents #2, #4 and #6) reviewed receiving nebulizer treatments. The facility also failed to date and properly store [CONDITION(S)] (bilevel positive air pressure device) tubing and mask for 1 of 1 sampled residents (Resident #3) reviewed receiving [CONDITION(S)] therapy. The findings include: Review of the facility's undated policy titled Oxygen Administration revealed, .It is the policy of this facility is to provide guidelines for safe oxygen administration .Oxygen tubing will be changed as ordered and PRN [as needed]. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 used oxygen therapy while a resident in facility. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #2 revealed, .Change oxygen tubing .every night shift, every 2 weeks on Wednesday . Observation in Resident #2's room on [DATE] at 12:10 PM, revealed resident sitting on the side of bed with and oxygen cannula in her nares. Oxygen via concentrator in use with humidifier container attached, and not dated. The nebulizer machine was at bedside with attached tubing and mask. The nebulizer mask or tubing were not labeled and dated or properly stored. During an interview on [DATE] at 12:10 PM with Resident #2, he stated, I use it (oxygen) all the time. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ IPAP [inspired positive air pressure] max [maximum] 18, EPAP [expired positive air pressure] min [minimum] 8, PS [pressure setting] 4. Clean mask with warm soapy water daily. Change mask, tubing and filter quarterly. Observation in Resident #3's room on [DATE] at 4:00 PM, revealed resident awake and sitting in wheelchair. He had a [CONDITION(S)] machine, face mask and tubing on his nightstand. The tubing and mask were not labeled or properly stored. During an interview on [DATE] at 4:00 PM, Resident #3 stated, I use it ([CONDITION(S)]) sometimes. Review of the medical record for Resident #4 revealed he was admitted to facility [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #4 revealed, .Change O2 [oxygen] and neb [nebulizer] tubing/setup .every dayshift, every 2 weeks on Saturday and as needed . Observation on [DATE] at 4:00 PM, revealed Resident #4 in his room. Nebulizer equipment (mask, tubing and machine) was on his nightstand and was not labeled and dated or properly stored. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Airvo [compact nasal high flow system with inbuilt flow generator]: 31 degrees; 15LPM [liters per minute] of air; FIO2 [flow of inspiration of oxygen], 60% [percent] (10 liters of oxygen); Replace sterile water bag when it is empty . Observation in Resident #6's room on [DATE] at 3:53 PM revealed Airvo in place with oxygen concentrator at bedside and Airvo/oxygen tubing and humidifier container was not labeled or dated. The nebulizer equipment was on the shelf beside bed with tubing and mask attached and not labeled or dated. The nebulizer mask was hanging on the closet doorknob and not properly stored. During and interview on [DATE] at 3:55 PM, Resident #6 stated, I use my oxygen all the time and it is hooked to the concentrator and that machine [Airvo]. When asked if she received nebulizer treatments, she stated Yes. During an interview on [DATE] at 3:55 PM in Resident #2 and #6's shared room, the Director of Nursing (DON) confirmed the oxygen tubings and humidifier containers were not labeled or dated, and the nebulizer tubings were not dated and masks were not properly stored. She stated she expected all oxygen equipment to be labeled, dated and properly stored. During an interview on [DATE] at 4:00 PM in Resident #3 and #4's shared room, the DON confirmed the nebulizer tubing and mask for Resident #4 was not labeled or dated and his mask not properly stored. She also confirmed the [CONDITION(S)] tubing was not labeled or dated, and the mask not properly stored for Resident #3. She stated she expected all oxygen equipment to be labeled, dated and properly stored.

An investigation of complaint TN 140 conducted on 2/02/2022 at 10:00 AM . Health deficiencies were cited in relation to the complaint investigation TN 140 under 42 CFR Part 483, Requirements for Long Term Care Facilities. Based on facility policy, medical record review, observations and interviews, the facility failed to develop and implement a care plan to address the use of an anticoagulant for 1 (Resident #1) of 3 residents reviewed. Review of the facility's undated policy titled MDS (Minimum Data Set)/Care Plans revealed .The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs .lead to the resident's highest obtainable level of independence .including the right to refuse treatment .initiated upon admission and maintained by the Nurse Manager/Designee within the resident's medical record . Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment dated [DATE] for Resident #1 revealed a BIMS score of 15, which indicated no cognitive impairment. Continued review revealed she required extensive assistance of 1 caregiver for toilet use and personal hygiene. Continued review revealed she was always incontinent of bowel. Continued review revealed Resident #1 received an anticoagulant 3 of the 7-day look back period. Review of the Order Summary Report dated 2/2/2022 for Resident #1 revealed .6/7/2021 Regular Diet, 1/14/2022 Monitor for s/s of active bleeding, 6/7/2021 Aspirin Tablet Chewable 81 mg, 1/11/2022 [MEDICATION(S)] Tablet (a blood thinner) 0.25 mg . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan for Resident #1 revealed no assessment, goals or interventions related to the use of an anticoagulant.

Based on facility policy, record review, observation and interviews, the facility failed to notify the family regarding an incident of alleged abuse for 1 (#1) of 3 sampled residents. Review of the facility's undated policy titled, Abuse Reporting, revealed, .The facility will not condone resident abuse by anyone, including staff members, other residents, consultants, volunteers and staff of other agencies serving the resident, resident representative, family members, legal guardians, sponsors, friends, or other individuals. The facility adheres to the reporting stipulations put forth in the Elder Justice Act .All personnel including volunteers are required to immediately report any incident or suspected incident of resident abuse, neglect, exploitation .and misappropriation of resident property, and suspected incidents of resident to resident abuse .Should an alleged/suspected violation or substantial incident of mistreatment, neglect, exploitation, injuries of an unknown source or abuse .be reported, the facility administrator/designee will promptly notify the following persons or agencies .of such incident as required by state regulation. The state licensing/certification agency responsible for surveying/licensing the facility, Resident's representative .Resident's attending physician . Review of the medical record revealed Resident # 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed, Resident #1 had a Brief Interview for Mental Status score of 3. She required extensive assist for bed mobility, dressing and eating. She was totally dependent on staff for transfer, locomotion on and off unit, toileting, personal hygiene and bathing. She was noted that ambulation did not occur. She was always incontinent of both bowel and bladder. Observation and interview of Resident #1 on 12/07/2021 at 12:30 PM, revealed resident in bed with clean neat appearance and no signs of wetness or odors noted. Resident reported that she feels pretty good. She stated that her family is gone all the time since they married and left. She reported that she got cleaned up this morning. She also stated that if her medicine tastes good, she takes it. She stated sometimes she spits it out because it doesn't taste good. She stated that she doesn't have any pain and that she is just tired. During a phone interview on 12/07/2021 at 3:57 PM, family member of Resident #1 stated that she was not notified of the incident that was investigated by the facility and reported in the complaint. During an interview on 12/7/2021 at 4:20 PM, the administrator confirmed that the family of Resident #1 was not made aware of the incident as reported in the Facility Reported Investigation.

Based on facility policy, observations, and interviews the facility failed to properly store appropriate foods and beverages in 1 of 3 refrigerators in the kitchen area and appropriate beverages in 1 of 3 milk coolers in the dry stock area to prevent cross-contamination. The findings included Review of undated facility policy Food and Nutrition Services revealed .nutrition services staff will evaluate .food and beverages for resident consumption are appropriately stored . Observation of the tray-line fridge (refrigerator) in the kitchen area on 6/24/2021 at 8:55 AM revealed 3 plastic bottles approximately 16 to 20 ounces (oz) sitting in the lower right corner of the tray-line fridge. 2 of the 3 bottles were clear green in color with labels on each bottle reading Mountain Dew and 1 clear uncolored bottle with a label on the bottle reading Diet Coke. Each of the 3 bottle were approximately half to a quarter full. Continued observation of milk cooler #2 in the dry stock area revealed a clear, uncolored plastic bottle 16 oz in size approximately half full of clear liquid. The Certified Dietary Manager (CDM) immediately removed the 2 bottles from the tray-line fridge and the 1 bottle from milk cooler #1 and disposed of the 4 bottles. Interview with the CDM on 6/24/2021 at 8:55 AM confirmed the 3 bottles in the tray-line fridge and 1 bottle in milk cooler #2 were not suppose to be stored in the Dietary Department refrigerators and coolers. She also confirmed the Dietary staff had received staff education on not using the Dietary Department refrigerators and coolers to store personal drinks.

Based on facility policy review, medical record review, observation and interview the facility failed to cover a urinary drainage bag for 1 of 2 (Resident #2) residents observed. The findings include: Review of the undated facility policy Dignity revealed .Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 was severely impaired for daily decision making. Medical record review of the care plan dated 1/16/2021 revealed Resident #2 was care planned for .foley catheter inplace due to [MEDICAL CONDITION] and wounds . Observation on 2/10/2021 at 10:31 AM in Resident #2's room revealed Resident #2 in bed with his eyes closed lying in a supine position at a 45-degree angle. Continued observation revealed a urinary drainage bag hanging below the resident on the side of the bed and the bag was not covered. During an interview on 2/10/2021 at 10:37 AM with Registered Nurse (RN) #1 confirmed the urinary drainage bag should have placed in a dignity bag. During an interview on 2/10/2021 at 2:32 PM with RN #3 confirmed staff were to place the urinary drainage bags in the dignity bag to maintain the dignity of the resident. During an interview on 2/11/2021 at 3:55 PM with the Director of Nursing (DON) and Administrator confirmed they expected staff to maintain a dignity bag cover over a urinary drainage bag.

Based on facility policy review, medical record review and interview, the facility failed to allow 1 of 3 residents (Resident #2) to exercise his right to decline hygiene care. The findings include: Review of the facility policy Resident Rights revised 12/2016 revealed .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be supported by the facility in exercising his or her rights . Review of the medical record revealed Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed Resident #2 had a BIMS score of 8 which indicated severe cognitive impairment. Continued review revealed Resident #1 required physical help in part of bathing activity with one staff member. Review of the care plan dated 11/30/2019 revealed .Resident has a behavioral problem related to inappropriate behaviors that are sexual in nature, resident has history of making lewd comments (offensive) and history of exposing his genitals. Can be combative at times, refusing care and direction .Resident has the potential for a psychosocial wellbeing problem related to adjusting to another environment, impaired cognition, past history of inappropriate and combative behaviors and anxiety . Review of the progress note dated 10/29/2020 revealed .Called to shower room to apply first aid to skin tear x 2 to top of left hand. Resident had one skin tear 3 x 3 cm (centimeters) in size, one 2 x 2 cm in size. Moderate amount of bright red bleeding noted to tears. Washed with water steri strips applied. A few minutes later CNA informed me resident had been very combative while in the shower now has a tear on top of right hand and some bruising to bilateral forearms. Skin tear 3 x 3 cm in size noted to top of right hand. Skin tears to bilateral hands bleeding lightly. Cleansed areas patted dry steri strips applied, covered with [MEDICATION NAME] wrapped with roll gauze until bleeding stops . Resident also has bruising to right forearm one to anterior forearm near elbow, 4x4 cm in size. Another bruise to mid anterior forearm 5 x 5 cm in size. Another bruise to right outer forearm near wrist 2 cm in width by 3 cm in length. Left hand anterior with a bruise purple in color 5 x 5 cm in size. (named physician notified of skin tears and bruises. Referred to unit manager to notify family . During a telephone interview on 12/4/2020 at 2:49 PM with CNA #1 revealed it had been 2 weeks since Resident #2 had a shower and CNA #1 had noticed an odor. Continued interview confirmed, first of all he needed to be bathed and I was confident once I got him in there he would calm down. Unfortunately, that was not the case. Once he began being combative, I should have stopped right then and there and taken him right out. During an interview on 12/4/2020 at 5:11 PM with the Director of Nursing (DON) revealed the CNAs were to let the nurses know if a resident refused care so it could be determined another way to perform some type of hygiene. Continued interview confirmed they (residents) have a right to refuse. During an interview on 12/4/2020 at 5:20 PM with the Administrator confirmed, staff was to step away and give space to the resident after refusal of care. Then try and come back again.

Based on medical record review and interview the facility failed to update a code status on a comprehensive care plan for 1 of 3 residents (Resident #1) reviewed. The findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 scored 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Review of the care plan dated [DATE] revealed Resident #1 was care planned as a full code status. During a telephone interview on [DATE] at 4:21 PM with the Director of Nursing (DON) confirmed the care plan had not been updated at the time the code status changed. Continued interview confirmed Resident #1 had died before the MDS Nurse could update the care plan in the system.

Based on facility policy review, manufacturer guidelines, observation, facility maintenance reports and interview, the facility failed to ensure clean and sanitary conditions of the main kitchen ice machine, food contact surfaces (dishes), failed to maintain the dish machine in proper working order to prevent cross contamination and failed to date, label and monitor refrigerated and dry foods. The findings include: Review of facility policy, Ice Machines and Ice Storage, undated revealed .Ice machines will be used and maintained to assure a safe and sanitary supply of ice . Review of manufacturer guidelines titled, Scotsman Ice systems, revealed .Clean or replace air filter and clean the air condenser .It is the users responsibility to keep the ice machine and storage bin in a sanitary condition .Without human intervention, sanitation will not be maintained . Observation of the ice machine on [DATE] at 8:52 AM, in the kitchen revealed green debris on the ice. Interview with the Dietary Manager on [DATE] at 8:53 AM in the kitchen revealed . I don't know what that is, it should not be there . Interview with Nurse Consultant #1 on [DATE] at 9:04 AM in the Administrators office revealed .that looks like trash . Interview with the Assistant Dietary Manager on [DATE] at 11:08 AM revealed .we use this ice machine for all the resident drinks as we plate the food for the dining room and all the hall carts .but it is shut down now to be cleaned . Review of the maintenance results for the main kitchen ice machine dated [DATE] at 6:26 AM revealed .I found calcium and lime build up .We have decided to start a new preventative maintenance schedule for these machines . Review of the Ice Machine Work Report from named Appliance Service dated [DATE] revealed .Cleaned units and replaced bin sensor in Dietary area . Review of facility policy, Cleaning Dishes/Dishwasher, undated revealed .Dish machines will be checked prior to meals to assure proper functioning .During the unloading process, visually inspect all items for cleanliness . Review of manufacture guidelines titled named Dish service revealed .Normal Checks to include; Screens and trays are all in good order .drains are clear .Spray patterns are consistent and typical .Lime build up on any conveyor can be a problem . Observation on [DATE] at 8:55 PM in the kitchen, in the presence of the Dietary Manager revealed 6 plate covers on the clean plate cover drying rack splattered with obvious dried debris. Observation of the dishroom on [DATE] at 9:00 PM in the kitchen, in the presence of the Dietary Manager revealed a full rack of plates, cups and bowls that just came through the dish machine splattered with green and yellow debris. Interview with the Dietary Manager on [DATE] at 9:05 PM in the kitchen revealed .I don't know what that is, but it shouldn't be on there .it needs to be scrubbed . Observation of the dishroom on [DATE] at 11:00 AM in the presence of the Dietary Manager revealed green and yellow splattered debris on 6 of 23 plates that just emerged from the dish machine. Observation of the clean plate cover rack on [DATE] at 11:02 AM, in the presence of the Dietary Manager revealed 2 plate covers located on the clean rack with large areas of splattered dried debris. Observation of the clean plate Low-Rater on [DATE] at 11:04 AM beside the tray line, ready for plating the food, and in the presence of the Assistant Dietary Manager revealed 12 of 15 randomly selected plates were covered with splattered dried green and yellow debris. Interview with the Dietary Manager on [DATE] at 11:03 AM in the kitchen revealed, when asked by the surveyor if these looked clean, the Dietary Manager stated, .no they are not . Interview with the Assistant Dietary Manager on [DATE] at 11:06 AM in the kitchen confirmed .these plates are all dirty and must be rewashed before the food can be plated . Further interview revealed . something is definitely wrong today with the dish washer, the washing process, or both . Interview with the Administrator on [DATE] at 2:10 PM outside the conference room confirmed We have taken the dish machine apart . Continued interview revealed .We will find out what the problem is before the day is over . Review of the maintenance report for the kitchen dish machine dated [DATE] at 6:54 AM revealed .I proceeded to shut the dishwasher down and start deep cleaning and sanitation .The drain line was noticed to be slow draining .The dietary Manager is in charge of de-liming and de-scaling the machine .We will be doing a deep clean on this machine once a month to prevent large amounts of scale and lime from occurring in the future . Continued review of the facility investigative note dated [DATE] regarding the dish machine revealed .Team noticed lime build up within the machine as well as a few pieces of flatware within the machine preventing it from draining adequately . Review of facility policy, Food Receiving and Storage, dated 2001 and revised (MONTH) (YEAR) revealed .Foods shall be received and stored in a manner that complies with safe food handling practices .All foods stored in the refrigerator or freezer will be covered, labeled and dated . Observation of the walk in refrigerator on [DATE] at 8:29 PM in the presence of the Dietary Manager revealed half a block of margarine uncovered lying on the shelf, opened and not dated or labeled. Further observation revealed red grapes stored loose in the bottom of a box. Observation of the walk in freezer on [DATE] at 8:35 PM in the presence of the Dietary Manager revealed 3 bags of chicken tenders opened, not dated and not labeled, 1 bag of french fries opened, not dated, not labeled and 1 bag of frozen hamburger patties opened, not labeled and not dated. Observation of the dry storage area on [DATE] at 8:40 PM in the presence of the Dietary Manager revealed 1 bag of hamburger buns opened and not dated,1 bag of rolls opened and not dated, 1 bag of penne noodles (5 pound bag) opened and not dated,1 bag of pasta noodles (5 pound bag) opened and not dated, ,[DATE] ounce containers of thickened lemon water expired on [DATE] and ,[DATE] ounce containers of honey light consistency thickened cranberry cocktail expired on [DATE], [DATE], and [DATE]. Interview with the Dietary Manager on [DATE] at 8:46 PM in the dry storage area revealed .I would rather have not found any foods opened and not dated .but I would rather have found them in the refrigerator than in the dry storage . Interview with the Registered Dietician on [DATE] at 7:00 PM outside the conference room confirmed .There should never be any type of debris in the ice at any time . Continued interview confirmed .The dish machine was stopped up and was not functioning properly .The food, especially green beans and other food which had been collecting in the bottom of the dish machine was splattering back up onto the dishes as they were going through the dish machine .The dishes were coming out more soiled than when they were going in .So we shut it down and sent out styrofoam plates and cups until we can get it repaired . Continued interview confirmed .opened, undated, unlabeled or expired foods should never be found in the refrigerators, the walk in freezer, or in the dry storage areas at any time . Interview with the Administrator on [DATE] at 8:10 PM in her office confirmed .The dish machine was not working correctly .but it is fixed now and working fine . Continued interview confirmed .We also had someone to come in and clean and fix the ice machine in the kitchen .