Every finding on record at Restoracy of Carmel

Based on observation, interview and record review, the facility failed to ensure new residents were correctly screened for tuberculosis and staff wore protective gowns for enhanced barrier precautions for 5 of 7 residents reviewed for infection control. (Resident 18, 40, 43, 66 and 54)Findings include:1. The clinical record for Resident 18 was reviewed on 2/19/26 at 2:35 p.m. The diagnoses included, but were not limited to, hypertensive encephalopathy, hypertensive heart disease with heart failure, and hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side. a. The Medication Administration Record (MAR), dated January 2026, indicated Resident 18 was given a tuberculin test on 1/6/26 at 11:27 p.m. The test was not read on 1/8/26 or 1/9/26 (48 to 72 hours after administration) due to the resident being out of the facility on leave of absence with his son. A nursing progress note, dated 1/9/26 at 5:29 p.m., indicated the tuberculin test was not read due to the resident being out of the facility. b. The MAR, dated January 2026, indicated the 2nd step test was administered on 1/20/26 at 10:52 p.m., and was read on 1/22/26 at 6:19 p.m. This was not 48 to 72 hours after administration. During an interview, on 2/20/26 at 10:30 a.m., the ADON (Assistant Director of Nursing) indicated a two (2) step tuberculosis test was needed at the time of admission and should be read within the 48-to-72-hour window, not too early or too late. 2. The clinical record for Resident 40 was reviewed on 2/19/26 at 10:01 a.m. The diagnoses included, but were not limited to, traumatic hemorrhage of the left cerebrum with unknown loss of consciousness, traumatic subdural hemorrhage, and paroxysmal atrial fibrillation. The MAR, dated February 2026, indicated a tuberculin test was administered on 2/8/26 at 6:10 p.m., and was read on 2/10/26 at 9:44 a.m. This was not 48 to 72 hours after administration. 3. The clinical record for Resident 43 was reviewed on 2/18/26 at 2:49 p.m. The diagnoses included, but were not limited to, Parkinson's disease, congestive heart failure, retention of urine, dysphagia, type 2 diabetes mellitus, and obstructive and reflux uropathy. The MAR, dated February 2026, indicated a tuberculin test was administered on 2/2/26 at 10:02 p.m., and was read on 2/4/26 at 5:30 p.m. This was not 48 to 72 hours after administration. The MAR, dated February 2026, indicated the second step tuberculin test was administered on 2/16/26 at 9:02 p.m., and was read on 2/18/26 at 5:02 p.m. This was not 48 to 72 hours after administration. 4. During a wound care observation, on 2/19/26 at 11:02 a.m., Licensed Practical Nurse (LPN) 2 was not wearing a gown when completing the wound care for Resident 66's pressure ulcer. The clinical record for Resident 66 was reviewed on 2/19/26 at 2:48 p.m. The diagnoses included, but were not limited to, type 2 diabetes, chronic diastolic heart failure, and long- term use of insulin. The nursing progress notes indicated Resident 66 was diagnosed with a stage 3 pressure ulcer of the heel on 1/19/26. A physician's order, dated 1/19/26, indicated the resident required Enhanced Barrier Precautions due to a foley catheter. During an interview, on 2/20/26 at 10:38 a.m., the Assistant Director of Nursing (ADON) indicated staff were supposed to wear gowns during wound care for pressure ulcers. 5. During a catheter care observation for Resident 54, on 2/19/26 at 11:19 a.m., Qualified Medication Aide (QMA) 7 wore a cloth hospital gown for Personal Protective Equipment (PPE). The clinical record for Resident 54 was reviewed on 2/19/26 at 11:01 a.m. The diagnoses included, but were not limited to, obstructive and reflux uropathy, benign prostatic hyperplasia, and other disorders of the kidney and ureter. A physician's order, dated 9/10/25, indicated Resident 54 required enhanced barrier precautions due to a suprapubic catheter. A current care plan, dated 9/10/25, indicated Resident 54 was on enhanced barrier precautions and the direct care staff were to utilize gowns and gloves for all personal care. During an interview, on 2/20/26 at 10:38 a.m., the Assistant Director of Nursing (ADON) indicated the facility was getting rid of all their reusable gowns and using disposable. The staff were supposed to be wearing disposable gowns when doing catheter care. A current facility policy, titled Screening Residents for Tuberculosis, dated 5/20/20 and provided by the Executive Director on 2/19/26 at 4:10 p.m., indicated . Admitting and readmitting residents will be tested for .TB disease within 3 days of admission, utilizing the tuberculin skin tests .adhere to the state regulations for screening of new admissions or readmissions related to the screening for tuberculosis infection and disease A current CDC healthcare education document, titled Tuberculin Skin Testing Information for Health Care Providers, downloaded from https://www.cdc.gov/tb/publications/factsheets/testing/Tuberculin_Skin_Testing_Information_for_Health_Care_Providers.pdf on 2/20/26 at 9:36 a.m., indicated .The skin test should be read between 48 and 72 hours after administration.The reasons for .false-negative reactions may include .incorrect method of giving the TST. A current facility policy, titled Enhanced Barrier Precautions, dated as approved 4/1/24 and received from the Executive Director on 2/19/26 at 9:10 a.m., indicated .Enhanced Barrier Precautions indications.Residents with chronic wounds and/or indwelling medical devices, even without a known MDRO infection or colonization. A. Chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, non-healing surgical wounds, and venous ulcers. B. Indwelling medical devices include central lines (including PICC), urinary catheter, feeding tubes.Enhanced Barrier Precautions will be utilized only during prolonged high-contact resident care activities. Examples include but not limited to.Device care or use: Central line (including PICC), urinary catheter.Wound care of chronic wounds. 3.1-18(b)(1) 3.1-18(b)(2) 3.1-18(e)

Based on interview and record review, the facility failed to ensure the physician was notified of a three (3) pound weight gain according to the physician's order for 1 of 3 residents reviewed for notification of change. (Resident 4)Findings include:The clinical record for Resident 4 was reviewed on 2/17/26 at 3:10 p.m. The diagnoses included, but were not limited to, heart failure, stage 3 chronic kidney disease, and type 2 diabetes.A care plan indicated Resident 4 was at risk for potential alteration of nutrition and weight status. Interventions included, but were not limited to, obtain and evaluate weights as ordered and notify the physician and family of any significant changes.A physician's order, with a start date of 10/3/24 and an end date of 1/7/26, indicated to weigh Resident 4 every Monday and Thursday and to notify the Nurse Practitioner (NP) for a weight increase of three (3) pounds.The following weights were documented in the clinical record:a. On 9/22/25, the weight was 239 pounds. On 9/25/25, the weight was 242.2 pounds. This was a gain of three (3) pounds or more.b. On 10/16/25, the weight was 241 pounds. On 10/20/25, the weight was 248.3 pounds. This was a gain of three (3) pounds or more.c. On 12/1/25, the weight was 227 pounds. On 12/3/25, the weight was 230.2 pounds. This was a gain of three (3) pounds or more.During an interview, on 2/19/26 at 9:51 a.m., Licensed Practical Nurse (LPN) 2 indicated the weight gain notification to the provider would be documented in the progress notes and she could not find the documentation in the clinical record.During an interview, on 2/19/26 at 3:38 p.m., the Director of Nursing (DON) indicated the facility could not find the notifications for Resident 4's weight gain and it should have been documented in a progress note. The facility could not find the documentation. A current facility policy, titled Weight and Height of Resident, dated as approved 5/20/20 and received from the Executive Director on 2/20/26 at 9:42 a.m., indicated .Report significant weight loss/weight gain to the nurse supervisor.Report other information in accordance with facility policy and professional standards of practice.3.1-5(a)(2)3.1-5(a)(3)

Based on interview and record review, the facility failed to ensure proper discharge information was documented in the electronic health record for 3 of 6 residents reviewed for discharge. (Resident 5, 6 and 77)Findings include:1. The clinical record for Resident 5 was reviewed on 2/18/26 at 2:28 p.m. The diagnoses included, but were not limited to, repeated falls, traumatic subdural hemorrhage without loss of consciousness, and dementia.A nursing progress note, dated 1/6/26 at 8:00 p.m., indicated an order was received to send Resident 5 to the emergency room for an evaluation and treatment.A nursing progress note, dated 1/6/26 at 8:10 p.m., indicated an EMT (emergency medical technician) arrived at the facility to transport Resident 5 to the hospital.Resident 5 was discharged from the facility and admitted to the hospital from [DATE] to 1/9/26.The electronic health record did not contain documentation a report was called to the receiving facility, special instructions or precautions for ongoing care were provided, a copy of Resident 5's discharge summary, and a copy of the bed hold policy was provided to the resident at the time of discharge.2. The clinical record for Resident 6 was reviewed on 2/18/26 at 12:53 p.m. The diagnoses included, but were not limited to, unsteadiness on feet, multiple fractures of ribs on the right side, and laceration without foreign body of other part of head.A nursing progress note, dated 12/23/25, indicated Resident 6 was sent to the hospital for treatment.Resident 6 was discharged from the facility and admitted to the hospital from [DATE] to 1/5/26.The electronic health record did not contain documentation a report was called to the receiving facility, special instructions or precautions for ongoing care were provided, a copy of Resident 6's discharge summary, and a copy of the bed hold policy was provided to the resident at the time of discharge.3. The clinical record for Resident 77 was reviewed on 2/17/26 at 3:29 p.m. The diagnoses included, but were not limited to, heart failure, chronic obstructive pulmonary disease, and amyotrophic lateral sclerosis (ALS).A nursing progress note, dated 1/19/26, indicated EMT arrived at the facility to transport Resident 77 to the hospital.Resident 77 was discharged from the facility to the hospital on 1/19/26.The electronic health record did not contain documentation a report was called to the receiving facility, special instructions or precautions for ongoing care were provided, a copy of Resident 77's discharge summary, and a copy of the bed hold policy was provided to the resident at the time of discharge.During an interview, on 2/18/26 at 1:44 p.m., the Executive Director (ED) indicated the facility did not utilize the electronic health records transfer/discharge assessment. The nurse would gather all information needed, call report to the receiving facility, document all required information in a progress note, and all appropriate paperwork would be sent with EMS (emergency medical service).During an interview, on 2/19/26 at 11:56 a.m., LPN (Licensed Practical Nurse) 2 indicated when a resident was transferred or discharged to the hospital the nurse would send a transfer sheet which would include: the resident's face sheet, medication list and when the medication was last administered, the resident's demographics, and the bed hold policy with EMS. LPN 2 indicated the facility did not have a specific assessment or document for what occurred with the resident, who report was given to, or where the resident was being transferred and the nurse should document the information in a progress note.During an interview, on 2/20/26 at 10:45 a.m., the Assistant Director of Nursing (ADON) indicated the protocol for discharging a resident would be to obtain an order from the physician for the resident to be sent to the hospital, call and inform the resident's family of the need and to get family approval for the transfer, contact EMS for transport and inquire where the resident would be transferred to, call report to the appropriate facility, print the resident's face sheet, medication list, POST form, bed hold and send all documents in the discharge packet to the hospital, then document all of this in a progress note.A current facility policy, titled Transfer or Discharge Documentation, dated 5/20/20 and received from the ED on 2/19/26 at 1:42 p.m., indicated .When a resident is transferred or discharged , details of this transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider.When a resident is transferred or discharged from the facility, the following information will be documented in the medical record.The basis for the transfer or discharge.That an appropriate notice was provided to the resident and/or legal representative.The date and time of the transfer or discharge.The new location of the resident.The mode of transportation.A summary of the resident's overall medical, physical, and mental condition.Disposition of personal effects.Disposition of medications.Others as appropriate or as necessary and.The signature of the person recording the data in the medical record.Should the resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider.The basis for the transfer or discharge.All special instructions or precautions for ongoing care.comprehensive care plan goals.All other necessary information, including a copy of the residents discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care.3.1-12(a)(6)(A)(i)3.1-12(a)(6)(B)

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASSAR) level I screen contained current mental health diagnoses and mental health medications for 1 of 2 residents reviewed for PASSAR. (Resident 75) The deficient practice was corrected on 2/12/26, prior to the start of the survey, and was therefore past noncompliance.Findings include:The clinical record for Resident 75 was reviewed on 2/19/26 at 8:48 a.m. The diagnoses included, but were not limited to, depression, anxiety, insomnia, and dementia.A PASSAR level I screen, dated 7/9/25, indicated no current or past mental health diagnoses were known or suspected. The current or past mental health medications were buspirone (an anxiety medication) and trazodone (used to treat insomnia and sometimes used to treat depression). The diagnosis for both medications was listed as unknown. The level I screen indicated there was no evidence of an intellectual/developmental disability or a serious behavioral health condition and if changes occurred or new information refutes the findings, a new screen must be completed.The PASSAR level I did not include accurate diagnoses of depression, anxiety or dementia and did not include accurate medication dosage or accurate prescribed mental health medications.A physician's order, dated 7/11/25 and discontinued 1/15/26, indicated Resident 75 received buspirone 5 milligrams (mg) twice a day related to anxiety. A physician's order, dated 7/21/25, indicated Resident 75 received duloxetine (an antidepressant medication) 60 mg related to depression.The care plans, dated 7/14/25, indicated Resident 75 received an antianxiety medication related to anxiety and an antidepressant medication related to depression.During an interview, on 2/19/26 at 12:19 p.m., the Executive Director (ED) indicated the facility had conducted an audit on PASSAR's earlier in the month (February) and found several level I screenings had not been updated.During an interview, on 2/19/26 at 3:27 p.m., the Social Service Director (SSD) indicated she had conducted an audit for level I PASSAR's to ensure all the information on the PASSAR's was correct and had found several which needed to be resubmitted.A current facility policy, titled Preadmission Screening and Resident Review (PASSR)/(LOC), dated 4/25/24 and received from the ED on 2/19/26 at 12:28 p.m., indicated .ensure all residents have the required screenings. This includes Level 1 PASSR, Level 2 PASSR, and Level of Care. It is the responsibility of the Business Office Manager, Social Service Director, MDS nurse, and/or designee to complete and/or track.ensuring new admission Level 1 PASSR are accurate.initiate a new Level 1, when a resident meets the qualifications.Level 1 completion procedure must be completed within 72 hours by the assigned or designated team member.Diagnosis-Assigned to Social Service Director.Mental Health Medications-Assigned to Social Service Director.This deficient practice was corrected by 2/12/26 after the facility implemented a systemic plan that included the following actions: an audit of all PASSARs were completed to ensure all information was correct, updated PASSARs were submitted if incorrect information was found, all new admission PASSARs are audited by the next business day to ensure the hospital or previous facility completed the PASSAR appropriately and are resubmitted if the previous facility information was incorrect, in-service education was conducted for all staff members responsible for ensuring PASSAR accuracy and completion.3.1-16(d)(1)(A)3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to ensure a medication cart was free of expired medications for 1 of 3 medication carts reviewed for medication storage and labeling. (Cottage 3)Findings include:The Cottage 3 medication cart was reviewed on 2/19/26 at 11:33 a.m. The following was observed:a. In the narcotic lock box, lorazepam (an antianxiety medication) with an unknown prescription filled date and a quantity of 30 out of 30 was past the expiration date of 1/15/26.b. In the narcotic lock box, lorazepam with an unknown prescription filled date and a quantity of 4 out of 30 was past the expiration date of 12/18/25.During an interview, on 2/19/26 at 11:33 a.m., QMA (Qualified Medication Aide) 7 indicated pharmacy audited the medication carts monthly and the nurses would also monitor for expired medications.During an interview, on 2/19/26 at 2:05 p.m., the Executive Director (ED) indicated the facility did not have a policy regarding medication cart audits.A current facility policy, titled Storage of Medications, dated 5/20/20 and received from the ED on 2/19/26 at 1:42 p.m., indicated .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.A current facility policy, titled Pharmacy services, dated 5/20/20 and received from the ED on 2/19/26 at 1:42 p.m., indicated .Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice.3.1-25(o)

Based on observation, interview and record review, the facility failed to ensure refrigerated food was not expired and refrigerators were maintained at proper temperatures for food safety for 2 of 6 refrigerators reviewed (Cottage 6) which supplied food to 2 of 6 cottages. (Cottage 1 and Cottage 6)Findings include:The kitchen in Cottage 6 was reviewed on 2/16/26 at 10:05 a.m. The following was observed:1. Refrigerator 2 which contained, but were not limited to, dairy products and mayonnaise.a. A tub of ricotta cheese with an expiration date of 2/13/26 was opened and less than half of the ricotta cheese remained in the container. Next to the opened and expired container was an unopened tub of Ricotta cheese with an expiration date not yet surpassed.b. An internal thermometer sat on the back of the top shelf and read fifty (50) degrees Fahrenheit.2. Refrigerator 3 which contained, but were not limited to, milk and condiments.a. An internal thermometer sat on the back of the top shelf and read forty-eight (48) degrees Fahrenheit.During an interview, on 2/16/26 at 10:09 a.m., the Dietary Manager (DM) indicated the meals prepared in Cottage 6 were served to both Cottage 6 and Cottage 1. The Dietary Manager observed the expiration date and internal temperatures and indicated the tub of ricotta cheese was past the expiration date and should be discarded. The elevated internal temperature was most likely due to the refrigerator doors being opened during breakfast clean up.After breakfast clean up and allowing the doors for Refrigerator 2 and Refrigerator 3 to remain closed, on 2/16/26 at 10:55 a.m., a second observation of the internal temperature was forty-six (46) degrees Fahrenheit in Refrigerator 2 and fifty-six (56) degrees Fahrenheit in Refrigerator 3.During an interview, on 2/16/26 at 10:58 a.m., [NAME] 6 indicated the internal temperature of the refrigerators should be thirty-five (35) to forty (40) degrees Fahrenheit.The refrigerator temperature log for Cottage 6, for February 2026, was missing a documented p.m. (evening/night) temperature on 2/15/26. A documented a.m. (morning) temperature on 2/16/25 for refrigerators 2 and 3 indicated the internal temperature of both refrigerators was thirty-six (36) degrees Fahrenheit.A current facility policy, titled Refrigerators and Freezers, undated and received from the Director of Nursing on 2/17/26 at 11:01 a.m., indicated .This community will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.Acceptable temperature ranges are 35 degrees Fahrenheit to 41 degrees Fahrenheit.employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.Supervisors will be responsible for ensuring food items in.refrigerators.are not expired.3.1-21(i)(1)3.1-21(i)(3)

Based on observation, interview and record review, the facility failed to ensure urinary catheter bags had dignity covers in place for 2 of 3 residents reviewed for dignity. (Resident 40 and 52) Findings include: 1. During an observation, on 2/24/25 at 10:28 a.m., Resident 40 was in the TV area and his catheter bag did not have a dignity cover (a cover which blocked the appearance of urine in the catheter bag). The clinical record for Resident 40 was reviewed on 2/21/25 at 11:06 a.m. The diagnoses included, but were not limited to, benign prostatic hyperplasia, other obstructive and reflux uropathy, and hypertension. A physician's order, with a start date of 1/22/23, indicated the resident had a urinary catheter. A current urinary catheter care plan indicated to encourage/assist the resident to obscure visibility of the drainage bag with a dignity cover as appropriate. During an interview, on 2/24/25 at 10:57 a.m., Licensed Practical Nurse (LPN) 4 indicated the catheter bag did not have a dignity cover. 2. During an observation, on 2/20/25 at 10:23 a.m., Resident 52 was out in the TV area and had a catheter bag under his chair and did not have a dignity cover for his urinary catheter. During an observation, on 2/24/25 at 10:54 a.m., Resident 52 was out in the TV area and did not have a dignity cover for his urinary catheter. The clinical record for Resident 52 was reviewed on 2/21/25 at 10:55 a.m. The diagnoses included, but were not limited to chronic kidney disease, neuromuscular dysfunction of the bladder, and muscle weakness. A physician's order, with a start date of 1/21/25, indicated the resident had a Foley catheter for urinary retention. During an interview, on 2/24/25 at 10:57 a.m., LPN 4 indicated the catheter did not have a cover which needed to be fixed. A current facility policy, titled Quality of Life - Dignity, dated as approved in May 2020, and received from the Director of Nursing on 2/25/25 at 3:00 p.m., indicated .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered 3.1-3(t)

Based on interview and record review, the facility failed to ensure staff followed the physician's orders regarding medication administration for 2 of 2 residents reviewed for quality of care. (Resident 19 and 7) Findings include: 1. The clinical record for Resident 19 was reviewed on 2/21/25 at 11:42 a.m. The diagnoses included, but were not limited to, type 2 diabetes, heart failure, and hypertension. A physician's order, with a start date of 5/14/24, indicated to give hydralazine (a medication to lower blood pressure) 10 milligrams (mg) every 4 hours as needed for a systolic blood pressure (SBP) above 170. The medication administration record (MAR) indicated the following: On 9/28/24, the systolic blood pressure was 195. hydralazine was not given. On 10/4/24, the systolic blood pressure was 175. hydralazine was not given. On 10/25/24, the systolic blood pressure was 171. hydralazine was not given. On 11/25/24, the systolic blood pressure was 179. hydralazine was not given. During an interview, on 2/24/25 at 11:41 a.m., the Director of Nursing (DON) indicated the medication should have been given and documented in the MAR. During an interview, on 2/25/25 at 11:37 a.m., the DON indicated she could not find any information the medication was given. It should have been documented in the MAR. 50901 2. The clinical record for Resident 7 was reviewed on 2/21/25 at 1:14 p.m. The diagnoses included, but were not limited to, hypertension, neuromuscular dysfunction of the bladder, and benign prostatic hyperplasia. a. A physician's order, with a start date of 1/31/25, indicated to give sacubitril-valsartan (a medication used to treat heart failure) every 12 hours for hypertension with instructions to hold the medication if the systolic blood pressure was below 110. The Medication Administration Record (MAR) indicated sacubitril-valsartan was administered with the systolic blood pressure below the ordered hold parameter on 1/31/25. The MAR indicated sacubitril-valsartan was administered 3 times with the systolic blood pressure below the ordered hold parameter in February 2025. b. A physician's order, with a start date of 9/4/24, indicated to give metoprolol succinate (a medication used to lower blood pressure) once a day for hypertension with instructions to hold the medication if the systolic blood pressure was below 110 or if the heart rate was below 55. The MAR indicated metoprolol succinate was administered eight (8) times with the systolic blood pressure below the ordered hold parameter and one (1) time with the heart rate below the ordered hold parameter in January 2025. The MAR indicated metoprolol succinate was administered four (4) times with the systolic blood pressure below the ordered hold parameter and one (1) time with the heart rate below the ordered hold parameter in February 2025. During an interview, on 2/25/25 at 1:46 p.m., the Director of Nursing (DON) indicated a check mark on the MAR indicated the medication was administered. While reviewing the MAR with the DON, she indicated the medications were administered with the systolic blood pressure and/or the heart rate below the ordered hold parameter. A current facility policy, titled Medication Administration General Guidelines Policy, with an approval date of 5/27/20 and received from the DON on 2/26/25 at 12:00 p.m., indicated .The licensed nurse and/or the QMA shall administer each resident's medications in accordance with the physician's order .Medications are administered in accordance with written orders of the attending physician 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure catheter bags were not touching a dirty surface and catheters were disposed of properly for 3 of 5 residents reviewed for infection control. (Resident 52, 7 and 44) Findings include: 1. During an observation, on 2/19/25 at 10:10 a.m., Resident 52's catheter bag was resting on his Broda chair's footrest (a specialty wheelchair). The residents' feet were resting on top of the catheter bag. During an observation, on 2/19/25 at 10:12 a.m., a staff member transported the resident to the TV area from the dining table. During an observation, on 2/19/25 at 12:30 p.m., Resident 52's feet were still resting on his catheter in the same position. No staff had noticed the placement of the catheter bag. The clinical record for Resident 52 was reviewed on 2/21/25 at 10:55 a.m. The diagnoses included, but were not limited to, chronic kidney disease, neuromuscular dysfunction of the bladder, and muscle weakness. A physician's order, with a start date of 1/21/25, indicated the resident had a Foley catheter for urinary retention. During an interview, on 2/24/25 at 10:57 a.m., LPN 4 indicated education would need to be provided for staff about the placement of catheter bags. 50901 2. The clinical record for Resident 7 was reviewed on 2/21/25 at 1:14 p.m. The diagnoses included, but were not limited to, neuromuscular dysfunction of the bladder and benign prostatic hyperplasia with lower urinary tract symptoms. During an observation and interview, on 2/19/25 at 10:38 a.m., a used catheter drainage bag was in a trash can next to Resident 7's bed. Resident 7 indicated his catheter bag was leaking a few days ago and the nurse changed the catheter bag. The Medication Administration Record (MAR) indicated Resident 7's catheter had last been changed on 2/3/25. There was no documentation in the electronic medical record to indicate Resident 7's catheter had been changed after 2/3/25. 3. The clinical record for Resident 44 was reviewed on 2/21/25 at 1:42 p.m. The diagnoses included, but were not limited to, paraplegia, neuromuscular dysfunction of the bladder, and retention of urine. During an observation and interview, on 2/24/25 at 10:43 a.m., a catheter drainage bag with dried brown sediment inside the bag, and a used leg drainage bag (a smaller catheter drainage bag) were hanging on a grab bar located in Resident 44's bathroom. Resident 44 indicated the larger catheter drainage bag hanging in her bathroom had been there for a month and the leg bag had been hanging in the bathroom since she returned from her doctor appointment a week ago. A physician's order indicated Resident 44 left the facility for a Urology appointment on 2/11/25. During an interview, on 2/24/25 at 10:55 a.m., Registered Nurse 3 observed the used catheter bags. RN 3 indicated the catheter drainage bags appeared to have been used and all catheter drainage bags should be disposed of properly after being changed. A current facility policy, titled Resident Rights, and received from the Executive Director on 2/25/25 at 3:00 p.m., indicated .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to .a dignified existence .equal access to quality care A current facility policy, titled Infection Prevention and Control, with an approval date of 5/27/20 and received upon entrance, indicated .Our community has an Infection Prevention and Control Program .The objectives of the IPCC are to .Provide community guidelines for a safe and sanitary environment .Review and help monitor the medical waste management plan .Surveillance of the workplace to ensure that required work practices are observed 3.1-18(b)(4)

Based on interview and record review, the facility failed to ensure residents' credit cards were kept safe and secure during their admission for 2 of 3 residents being reviewed for misappropriation of property. (Residents B and C) The deficient practice was corrected on 8/5/24, prior to the start of the survey, and was therefore past noncompliance. Findings include: 1. A facility reported incident, dated 7/31/24, indicated Resident B's son reported to the Executive Director (ED) two of her credit cards were fraudulently used by a person identified as CNA 1. The credit cards were canceled. The city police department was notified. CNA 1 was immediately suspended. A facility document, titled Allegation Investigation Form, dated 8/5/24, indicated CNA 1 was terminated on 8/5/24. Resident B's son reported to the ED there were suspicious charges on his mother's credit cards. The ED and the son called the credit card company to confirm the spelling of a person who had used the resident's credit card to order Door Dash. The son was prompted to look deeper into Resident B's credit card statements and found roughly 18 charges he was not able to account for Resident B making. An investigation was started, which showed CNA 1 worked in the home Resident B was admitted to. Her credit cards were fraudulently used without her knowledge. CNA 1 was terminated, on 8/5/24, due to probable cause she was involved in the fraudulent credit cards activity. A facility document, titled Employee Status Change Form, dated 8/5/24, indicated CNA 1 was terminated, on 8/5/24, without being eligible for rehire due to the theft of a resident's credit cards and fraud. The explanation for dismissal was CNA 1 was proven by the credit card company and the police department to have used Resident B's credit cards fraudulently. During an interview, on 8/6/24 at 12:38 p.m., the ED indicated Resident B's son discovered CNA 1 had stolen Resident B's credit card numbers after a Door Dash charge was on the resident's credit card account. He knew his mother would not have ordered Door Dash. He looked through the credit card statements and discovered other charges which he knew Resident B did not make. The ED indicated he terminated the employee, since the police officer felt there was enough evidence to charge CNA 1 with the Door Dash charge. The resident's son and the police officer were continuing to investigate if CNA 1 was responsible for the other charges on both credit cards. During an interview, on 8/6/24 at 2:18 p.m., the ED and Officer 3 were in attendance. Officer 3 indicated he had spoken to Resident B, and she had not given permission for anyone to use her credit cards. The charge as of now for CNA 1 was fraud due to utilization of credit cards without authorization and since the amount she spent was over $750.00, it would most likely be a level six felony charge. The resident's son noticed multiple transactions on his mother's credit cards which he had disputed all the charges. 2. During a phone interview, on 8/7/24 at 3:57 p.m., Resident C indicated after she was discharged from the facility, she discovered her credit cards were missing from her wallet. Two credit card companies were investigating fraudulent charges. She indicated the person who stole her credit cards was CNA 1. The person charged $705.09, from 7/6/24 to 7/13/24, on one card and charged $93.00 on another credit card. Her money was reimbursed by the credit card companies. She had not contacted the police, only the credit card companies. A current facility policy, titled Abuse Policy, dated as revised 8/2/23 and provided by the Director of Nursing on 8/6/24 at 1:45 p.m., indicated .It is the policy .to ensure that all residents .are free from .misappropriation of resident property and exploitation. This includes but is not limited to .ensure that all employees, residents, family members, consultants, physicians and visitors are aware that .exploitation of residents and misappropriation of resident property .is strictly forbidden by this provider .Misappropriation of Resident property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. 10. Exploitation: Taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats or coercion. 11. Mistreatment: Inappropriate treatment or exploitation of a resident The deficient practice was corrected by 8/5/24, after the facility implemented a systemic plan which included CNA 1 was terminated for credit card fraud on 8/5/24, abuse in-servicing was initiated for all staff, staff members were interviewed, residents were interviewed, and misappropriation of property was included in the QAPI (Quality Assurance Performance Improvement) program. 3.1-28(a)

Based on observation, interview and record review, the facility failed to ensure a resident had documentation for the use of a positioning device, to ensure residents had splints placed as ordered by the physician, to notify the physician of a blood sugar which was out of parameter and to ensure a resident's skin impairment was accurately assessed and documented for 5 of 5 residents reviewed for quality of care. (Resident 6, 44, 64, 5 and 23) Findings include: 1. During an observation, on 2/19/24 at 2:25 p.m., Resident 6 had a device on the seat of her wheelchair with a black raised area sticking up between the resident's legs. During an observation, on 2/22/24 at 10:47 a.m., the resident was sitting up in her wheelchair in the common area. The device was still on the resident's wheelchair with the black raised area sticking up between her legs. The clinical record for Resident 6 was reviewed on 2/21/24 at 11:38 a.m. The diagnoses included, but were not limited to, hemiplegia (paralysis of one side of the body) and hemiparesis (weakness) following cerebral infarction affecting the left non dominant side, dementia, anxiety disorder, and depressive episodes. A care plan, dated 10/12/22, indicated the resident had an activity of daily living (ADL) self-care performance deficit related to limited mobility, pain issues, weakness, and left sided paralysis. The interventions included, but were not limited to, anti-roll backs (device to lock a wheelchair when a resident stands up), anti-tippers (a device to keep the wheelchair from tipping back), and left foot/leg rest on the wheelchair. The care plan did not include the Pommel cushion to be in the wheelchair. A physician's order, dated 2/20/24, indicated to have anti-roll backs, anti-tippers, and a left leg rest and foot support for the resident's wheelchair. The physician's orders did not include the use of the Pommel cushion in the wheelchair. During an interview, on 2/22/24 at 10:48 a.m., QMA 10 did not know what type of cushion/device was in the resident's wheelchair. During an interview, on 2/22/24 at 10:49 a.m., QMA 4 did not know what type of cushion/device was in the resident's wheelchair. At that time, QMA 11, who was also present, searched the electronic health record and could not find information about the device in the resident's electronic health record. During an interview, on 2/22/24 at 11:04 a.m., the Lead Physical Therapist (PT) indicated the resident had a Pommel cushion in her wheelchair which was used to help with positioning, to maintain alignment, and to reduce the risk for falls. It reduced the risk of falls by preventing the resident from sliding down in her wheelchair and helped the resident maintain an upright position. Occupational therapy would do a lot of wheelchair positioning devices. During an interview, on 2/22/24 at 11:11 a.m., the Lead PT indicated the current therapy department took over for another therapy company. On 12/2/22, the resident's daughter had requested occupational therapy for seating and positioning since the resident had been sliding out of her wheelchair. The Pommel cushion was secured to the wheelchair. The Lead PT was not sure if they needed a physician's order for the use of the Pommel cushion or if the Pommel cushion should be included in the plan of care. During an interview, on 2/22/24 at 3:55 p.m., the Minimum Data Set (MDS) Coordinator indicated the resident had a cushion in her wheelchair and the facility would not enter anything in the electronic record for just a cushion. The cushion in the wheelchair was not a Pommel cushion used for positioning. During an interview, on 2/22/24 at 3:56 p.m., the Director of Nursing (DON) indicated the cushion should be listed on the care plan if it was used as a fall prevention. During an interview, on 2/23/24 at 10:53 a.m., the [NAME] President who was also a PT indicated the resident had been at the facility since 2022 and had the Pommel cushion for 5 years. A therapist was going to do an evaluation for a replacement of the current Pommel cushion since it was 5 years old. The resident would lean to one side if the Pommel cushion was not used for positioning. The cushion helped with positioning for meals and participation in activities. The [NAME] President indicated the cushion was not utilized to keep the resident from sliding out of the wheelchair. The Pommel cushion was not included in the care plan and there was no physician's order for the Pommel cushion. The brand of the Pommel cushion was not known although it did look like the Secure convex Pommel cushion. 2. During an observation, on 2/19/24 at 2: 5 p.m., Resident 44 was leaned back in his Broda chair (a chair used for positioning) in the common area and there was no splint on his right hand. During an observation, on 2/21/24 at 11:10 a/m., the resident was sitting up in his Broda chair in the common area. There was no splint on the resident's right hand. During an observation, on 2/22/24 at 9:46 a.m., the resident was in the common area in his Broda chair and staff were feeding the resident bites of food. The resident did not have a splint on his right hand. The clinical record for Resident 44 was reviewed on 2/21/24 at 10:20 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, heart failure, dementia without behavioral disturbance, and chronic kidney disease stage 3. A physician's order, dated 11/18/23, indicated to place a right-hand splint on the resident in the a.m., and to remove it before dinner. A Treatment Administration Record (TAR), dated 2/1/24 through 2/21/24, indicated the resident had the splint to the right hand in place on 2/19, 2/21 and 2/22. The splint was marked as applied and the resident did not have the splint in place. During an interview, on 2/22/24 at 11:36 a.m., CNA 6 indicated therapy staff just brought in a splint for the resident's right hand. The staff could not put the splint on the right hand because there was not a splint in the facility. CNA 6 thought the splint had been discontinued. During an interview, on 2/22/24 at 1:25 p.m., the Lead PT indicated he did just provide a splint for Resident 44's right hand, on 2/22/24. He did not know how long the resident had been without a splint to the right hand. 3. The clinical record for Resident 64 was reviewed on 2/21/24 at 3:12 p.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus, rheumatoid arthritis, congestive heart failure, atrial fibrillation, long term use of insulin, repeated falls, and a cognitive communication deficit. A physician's order, dated 11/18/23, indicated to complete accu-checks (blood glucose testing) as needed and to notify the physician for a blood sugar reading less than 70 or greater than 300. On 11/23/24 at 9:45 a.m., the resident's blood sugar was 465. There was no progress note to show the physician was notified of the blood sugar reading and no documentation of a repeat blood sugar. 4. The clinical record for Resident 5 was reviewed on 2/21/24 at 4:42 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia without behavioral disturbance, atrial fibrillation, rheumatoid arthritis, and osteoporosis. A weekly skin assessment, dated 1/31/24, indicated a new skin area was noted. There was open skin on the resident's sacrum which measured 1 centimeter (cm) by 1 cm. The area was identified as a non-pressure area, and a treatment was ordered. The treatment order was not located in the electronic health record (EHR). A care plan, dated 2/9/24, indicated the resident had a potential for impaired skin integrity related to impaired mobility and impaired cognition. The goal was for the skin to remain intact through the review date. The interventions included, but were not limited to, apply house barrier cream as needed, encourage good nutrition and hydration, and a weekly skin assessment by a licensed nurse. During an interview, the Assistant Director of Nursing (ADON) indicated the nurse had incorrectly identified the skin condition on 1/31/24. The resident had old scar tissue which was pink in color. The resident did not have open skin, so no treatment was prescribed. The ADON had forgotten to document the updated information in the electronic health record. 44598 5. During an observation, on 2/21/24 at 10:59 a.m., Resident 23 was sitting in the lounge. The resident was not wearing a right ankle brace, foam boots, or a left palm protector. During an observation, on 2/22/24 at 11:51 a.m., the resident was sitting in the lounge and was not wearing a right ankle brace, foam boots, or a left palm protector. During an observation, on 2/23/24 at 10:15 a.m., the resident did not have her heels off loaded, was not wearing a left-hand palm protector, and did not have a brace to the right ankle. During an observation, on 2/23/24 at 10:20 a.m., CNA 3 went to the resident's room and could not locate the residents left hand palm protector, a right ankle brace, or foam boots. The clinical record for Resident 23 was reviewed on 2/22/24 at 11:53 a.m. The diagnoses included, but were not limited to, contracture of the left hand, quadriplegia, Alzheimer's disorder, dementia, diabetes mellitus, congestive heart failure, and anxiety disorder. A care plan, revised on 10/21/22, indicated the resident was required to wear a left-hand splint and right ankle brace. The interventions included, but were not limited to, applying the splint per order, and observing the skin underneath the splint for redness and irritation. A quarterly Minimum Data Set assessment, dated 11/22/22, indicated Resident 23 was dependent on staff for oral hygiene, toileting, showers, bathing, dressing, and personal hygiene. The resident made no effort to complete the activity. A physician's order, dated 1/9/23, indicated to always wear a left-hand palm protector. The palm protector could be off for hand hygiene. A physician's order, dated 5/26/23, indicated to apply a brace to the right ankle during the day. A physician's order, dated 12/11/23, indicated to offload the resident's heels while in bed and in the chair. The resident was to use a foam boot or equivalent every shift. During an interview, on 2/23/24 at 10:30 a.m., CNA 3 indicated physical therapy had stopped the resident's order for the palm protector. CNA 3 indicated she had never seen the brace or splint. During an interview, on 2/22/24 at 11:59 a.m., QMA 4 indicated the CNAs normally put on braces and splints. During an interview, on 2/23/24 at 2:22 p.m., Physical Therapist 5 indicated the multiple splints were discontinued by Occupational Therapy. The order was not removed from the orders and should have been. During an interview, 2/23/24 at 2:25 p.m., DON 2 indicated they should have questioned the order for the devices when the resident was not wearing them. 46961 A current policy, titled Pressure Injury Risk Assessment, not dated, indicated .the purpose of this procedure is to provide guidelines for the assessment and identification of resident at risk of developing pressure injuries .skin will be assessed for the presence of developing pressure injuries on a weekly basis or more frequently if indicated .nurses will conduct skin assessments at least weekly to identify changes .the following information should be recorded in the resident's medical record utilizing facility forms: type of assessment conducted (for example, admission assessment, weekly skin integrity tool) .the date and time and type of skin care provided, if appropriate .the name title (or initials) of the individual who conducted the assessment .any change in the resident's condition, if identified .the condition of the resident's skin (i.e. the size and location of any red or tender areas, (if identified) .initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted .documentation in medical record addressing MD (medical doctor) notification if new skin alteration noted with change of plan of care if indicated .documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change of plan of care if indicated A current policy, titled Change in a Resident's Condition or Status, dated 5/20/20 and received from DON 1, on 2/23/24 at 4:03 p.m., indicated .our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) A current policy, titled Assistive Devices and Equipment, dated 5/20/20 and received from the Director of Nursing on 2/23/24 at 11:25 a.m., indicated .provides, maintains, trains, and supervises the use of assistive devices and equipment for residents .Devices and equipment that assist with resident mobility, positioning, safety and independence are provided for residents. These include but are not limited to: Positioning Aides (e.g., braces, wedges, splints, joint stabilizer) .Recommendations for the use of devices and equipment are based on the comprehensive assessment by therapy services .Staff will be trained and will demonstrate competency in the use of devices and equipment prior to assisting or supervising residents 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure the provider documented the rationale for not agreeing with a pharmacist recommendation for gradual dose reductions and pharmacy reviews and failed to give a rational for not discontinuing the use of a prophylactic antibiotic for 4 of 5 residents reviewed for unnecessary medications. (Residents 3, 36, 38 and 42) Findings include: 1. The clinical record for Resident 3 was reviewed on 2/21/24 at 9:36 a.m. The diagnoses included, but were not limited to, major depressive disorder, bipolar disorder, vascular dementia, and anxiety. A gradual dose reduction (GDR), dated 1/2/24, indicated the resident was due for a trial reduction of olanzapine (an antipsychotic medication). Discontinue the morning dose of 2.5 mg (milligram) and continue the evening dose of 10 mg. The provider disagreed with the recommendation and the note indicated verbal from MD and was dated 1/5/24. There was no clinical rationale as to why the provider disagreed with the pharmacist recommendations. A note to the attending physician/provider, dated 2/7/24, indicated the current dose of olanzapine 30 mg at night was considered high dose therapy. The labeled max dose was 20 mg at night. The recommended action was to evaluate the continued need of the current dose. The note indicated the doctor was aware and refused the GDR. The document was signed on 2/8/24. There was no clinical rationale as to why the provider disagreed with the pharmacist recommendations. A GDR, dated 3/9/24, indicated the resident was due for a trial reduction of lorazepam (an antianxiety medication) 0.5 mg in the evening for anxiety. If therapy was to continue at the current dose, please provide a statement of rationale. The provider marked disagree and did not provide any notes or rationales. 2. The clinical record for Resident 36 was reviewed on 2/21/24 at 11:18 a.m. The diagnoses included, but were not limited to, dementia with psychotic disturbance, major depressive disorder, Alzheimer's disease, and anxiety disorder. A note to the attending physician/provider, dated 1/2/24, indicated the resident was on mirtazapine (an antidepressant medication) 7.5 mg in the evening for appetite stimulation. The resident's weight had remained stable. The recommendation was to avoid the use of the medication and work with dietary to utilize non-pharmacologic methods to achieve sustainable weight goals. The provider disagreed with the recommendation and indicated failed prior GDR. The prior GDR was in November of 2023, almost 2 months prior. During an interview, on 2/22/24 at 3:13 p.m., the Director of Nursing (DON) 2 indicated they would need to do education on documentation on the pharmacy reviews. 49891 3. During an observation, on 2/19/24 at 3:17 p.m., Resident 38 appeared calm and smiled frequently. During an observation, on 2/20/24 at 10:30 a.m., Resident 38 was calm and appeared comfortable while lying in bed after breakfast with his wife at his bedside. During an observation, on 2/22/24 at 9:42 a.m., Resident 38 was trying to eat breakfast with his eyes closed. Despite frequent cuing from staff, the resident kept closing his eyes again and was having difficulty eating his breakfast. The clinical record for Resident 38 was reviewed on 2/22/24 at 11:07 a.m. The diagnoses included, but were not limited to, Parkinson's disease with dyskinesia, dementia in other diseases with psychotic disturbance, hallucinations, and insomnia. A care plan, initiated 11/18/22, indicated the physician was to consider dosage reductions when clinically appropriate for the psychotropic medications of Resident 38. In a pharmacist's note to the attending physician/prescriber, dated 5/19/23, the prescriber disagreed to a gradual dose reduction for quetiapine for depression to 25 mg at bedtime with no rationale given. In a pharmacist's note to the attending physician/prescriber, dated 11/10/23, the prescriber disagreed to a gradual dose reduction for quetiapine to 25 mg in the evening and 50 mg at bedtime for dementia with no rationale given. The prescriber noted neurology was aware of the recommendation. In a pharmacist's note to the attending physician/prescriber, dated 12/4/23, the prescriber disagreed to a gradual dose reduction for sertraline to 50 mg each day for depression and indicated the resident was stable on the current dose. During an interview, on 2/22/24 at 3:15 p.m., DON 2 indicated the physician may have documented the reasons for refusing the pharmacist's recommendation for the gradual dose reductions somewhere else in the clinical record. She did not know the prescriber needed to document a clinical reason for disagreeing with the pharmacy recommendation. 4. During an interview, on 2/21/24 at 10:58 a.m., Resident 42 indicated her urologist had put her on cephalexin (an antibiotic) prophylactically after she had a severe urinary tract infection with sepsis and was in the intensive care unit at the hospital. The clinical record for Resident 42 was reviewed on 2/21/24 at 11:06 a.m. The diagnoses included, but were not limited to, multiple sclerosis, recurrent major depressive disorder, anxiety disorder, and insomnia. A physician's order, dated 11/17/22, indicated to give Fluoxetine 20 mg every morning for depression. A physician's order, dated 11/17/22, indicated to give Cephalexin 500 mg every morning and had no stop date recorded. In a pharmacist's note to the attending physician/prescriber, dated 5/19/23, the prescriber disagreed to a gradual dose reduction for fluoxetine for depression to 10 mg with no rationale given. In a pharmacist's note to the attending physician/prescriber, dated 11/14/23, the prescriber disagreed to a gradual dose reduction for fluoxetine for depression to 10 mg with no rationale given. In a pharmacist's note to the attending physician/prescriber, dated 4/24/23, the prescriber disagreed to discontinuing the cephalexin with no rationale given. In a pharmacist's note to the attending physician/prescriber, dated 10/23/23, the prescriber checked agree to discontinuing cephalexin and then marked disagree indicating the resident refused. In a pharmacist's note to the attending physician/prescriber, dated 12/11/23, the prescriber disagreed to discontinuing cephalexin and indicated the resident refused. During an interview, on 2/22/24 at 3:15 p.m., DON 2 indicated the physician might have documented the reasons for refusing the pharmacist's recommendation for gradual dose reductions and discontinuing the antibiotic for Resident 42 somewhere else in the clinical record. She did not know the prescriber needed to document a clinical reason for disagreeing with the pharmacy recommendation. A current policy, titled Tapering Medications and Gradual Dose Reduction, dated as approved on 5/20/20 and received from DON 1 on 2/2324 at 11:35 a.m., indicated .the GDR may be considered contraindicated if .the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder .Attempted tapering of psychopharmacologic medications .The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident's function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder 3.1-25(i)

Based on observation, record review and interview, the facility failed to ensure the refrigerators and freezers were clean, food was sealed, labeled, and dated, and expired foods were discarded for 4 of 6 kitchens reviewed. (Kitchen 3, 4, 5 and 6) Findings include: 1. During an observation, on [DATE] at 1:10 p.m., the kitchen in Cottage 3 had the following: a. cooked cream of wheat brought in by a family which was dated [DATE]. b. The freezer drawers were very dirty and had brown dried liquid spilled inside. c. The refrigerator in the kitchen had lime built up near the ice machine. During an interview, on [DATE] at 1:13 p.m., the Dietary Manager (DM) indicated the cooked cream of wheat should have been discarded after 3 days and the freezer looked like a soda exploded. During an interview, on [DATE] at 1:15 p.m., Cook 8 indicated the cream of wheat was frozen and was taken out when needed. 2. During an observation, on [DATE] at 10:37 a.m., the kitchen in Cottage 4 had the following: a. The refrigerator in the kitchen was dirty on the outside. The left side of the refrigerator where the ice came out had lime buildup. b. Three spices in the cabinet above the right side of the counter had one bottle of black pepper, seasoned salt, and cinnamon without an opened date and the bottles were sticky. c. The refrigerator in the storage room had a brown sticky substance on the door and inside on the bottom shelf. During an interview, on [DATE] at 10:39 a.m., the DM indicated the spices should have a date when opened on the label. The refrigerators were to be wiped off every shift. 3. During an observation, on [DATE] at 1:05 p.m., the kitchen in Cottage 5 had the following: a. The refrigerator in the dry storage area had meat defrosting with no thermometer in the refrigerator. 4. During an observation, on [DATE] at 1:10 p.m., the kitchen in Cottage 6 had the following: a. The cans in the dry storage did not have received dates. b. The bags of cereal were open and undated. c. Two bags of rice were undated. During an interview, on [DATE] at 1:49 p.m., Cook 7 indicated she did not know when the facility received the cans, and the cans should have received dates on them. A current policy, titled Food Receiving and Storage, dated [DATE] and received from DON 1 on [DATE] at 3:53 p.m., indicated .Foods shall be received and stored in a manner that complies with safe food handling practices .Food Services, or other designated staff, will maintain clean food storage area at all times .Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by' date). Such foods will be rotated using a first in-first out system .All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) .Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods A current policy, titled Food Brought by Family/Visitors, dated [DATE] and received from DON 1 upon entrance, indicated .Food brought to the facility be visitors and family is permitted. Facility staff will strive to balance residents' choice and a homelike environment with the nutritional and safety needs of residents .The nursing staff will discard perishable foods on or before the use by date .The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger 3XXX,d+[DATE](i)(1) 3XXX,d+[DATE](i)(3)

Based on observation, interview and record review, the facility failed to ensure a resident was asked or instructed prior to repositioning for 1 of 1 resident reviewed for respect and dignity. (Resident 28) Finding includes: During an observation, on 2/20/24 at 10:30 a.m., Resident 28 was laying, in a recliner, with her head on the right armrest. The resident's chin was touching her chest. The resident was moving around in the recliner. During an observation, on 2/21/24 at 11:06 a.m., the resident was sleeping in a recliner in the lounge. There was no staff interaction with the resident. During an observation, on 2/22/24 at 9:48 a.m., the resident was laying, in her recliner, with her head on the right armrest. CNA 6 approached the resident and stood behind her. CNA 6 took both hands and placed them under the resident's arms. Without saying anything to the resident, CNA 6 lifted the resident up in the recliner. CNA 6 let go of the resident, she slid back down, and her head landed on the right armrest of the chair. CNA 6 walked away from the resident and left the resident with her head on the armrest. Another staff member positioned the resident in an upright position. The clinical record for Resident 28 was reviewed on 2/22/24 at 1:25 p.m. The diagnoses included, but were not limited to, Alzheimer's disease, dementia, psychotic disorder with delusions, hypertension, depression, anxiety disorder, and reduced mobility. A care plan, dated as revised on 3/11/23, indicated the resident preferred to sleep in her personal bed from home. The interventions included, but were not limited to, assisting the resident as needed with bed mobility. A care plan, dated as revised on 3/11/23, indicated the resident preferred to sit or lay on the floor at times. The interventions included, but were not limited to, maintaining safety and frequent rounding by staff. During an interview, on 2/22/24 at 9:35 a.m., QMA 4 indicated the resident's daughter requested for the resident to sit in her own personal recliner. QMA 4 indicated providing care without letting the resident know what you were doing was unacceptable. During an interview, on 2/22/24 at 10:16 a.m., the Administrator indicated it was not acceptable for CNA 6 to reposition the resident without telling the resident what he was doing. A current policy, titled Resident Rights, not dated and received from the Director of Nursing on 2/22/24 at 11:11 a.m., indicated .Employees shall treat all residents with kindness, respect and dignity .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a dignified existence .be treated with respect, kindness, and dignity 3.1-3(t)

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) were completed when new mental health diagnoses were added for 2 of 4 residents reviewed for PASARR. (Resident 5 and 36) Findings include: 1. The clinical record for Resident 5 was reviewed on 2/19/24 at 2:16 p.m. The diagnoses included, but were not limited to, Parkinson's disease, dementia without behavioral disturbance, atrial fibrillation, delusional disorder, and hallucinations. A PASARR level I, dated 5/25/17, indicated the resident had no mental health diagnosis and had no mental health medications. There were no known mental health behaviors which affected interpersonal interactions and no known mental health symptoms which affected the resident's ability to think through or complete tasks which the resident would be physically capable of completing. If changes occurred or new information refuted the findings, then a new screen must be submitted. The diagnoses of delusional disorder and hallucinations were added on 7/3/18. A care plan, dated 7/3/18, indicated the resident had psychosis and could exhibit delusions and hallucinations at times. The resident reported seeing people in her room and staff reported no people were present. The resident had diagnoses of delusional disorder, dementia, and hallucinations. The approaches included, but were not limited to, administering medications as ordered. During an interview, on 2/23/24 at 9:37 a.m., the Administrator indicated the PASARR was not completed and should have been done again when the new diagnoses of delusional disorder and hallucinations were added. 48525 2. The clinical record for Resident 36 was reviewed on 2/21/24 at 11:18 a.m. The diagnoses included, but were not limited to, dementia with psychotic disturbance, major depressive disorder, Alzheimer's disease, and anxiety disorder. A PASARR level I, dated 7/16/20, indicated no level 2 PASARR was required. No serious mental illness, intellectual disabilities, or related conditions. No mental health diagnoses were known, no dementia diagnoses were known, and no mental health medications were known. A medical diagnoses sheet indicated the resident was diagnosed with major depressive disorder on 12/4/20. A medical diagnoses sheet indicated the resident was diagnosed with psychotic disorder with delusions on 1/18/21. A medical diagnoses sheet indicated the resident was diagnosed with dementia with anxiety on 10/30/23. A medical diagnoses sheet indicated the resident was diagnosed with anxiety disorder on 4/24/23. A physician's order, with a start date of 1/8/24, indicated the resident was started on Olanzapine (an antipsychotic medication) 5 milligrams. A physician's order, with a start date of 10/16/23, indicated the resident was started on Mirtazapine (an antidepressant medication) 7.5 milligrams. During an interview, on 2/23/24 at 9:37 a.m., the Administrator indicated another PASARR should have been done. The resident did have some diagnoses which would lead to another PASARR needing to be completed. A current policy, titled Admission Criteria, dated 5/20/20 and received from the Director of Nursing on 2/23/24 at 11:15 a.m., indicated .The Restoracy admits only residents whose medical and nursing care needs can be met .All new admissions and readmissions are screened for mental disorders [MD], intellectual disabilities [ID] or related disorders [RD] per the Medicaid Pre-Admission Screening and Resident Review [PASARR] process .The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD< ID or RD .If the level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II [evaluation and determination] screening process 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on interview and record review, the facility failed to complete a Level 1 Preadmission Screening and Resident Review (PASARR) prior to admission for 1 of 4 residents reviewed for PASARR. (Resident 3) Finding includes: The clinical record for Resident 3 was reviewed on 2/21/24 at 9:36 a.m. The diagnoses included, but were not limited to, vascular dementia, major depressive disorder, bipolar disorder, and anxiety. The resident was admitted on [DATE]. A medical diagnoses sheet indicated the resident had the following diagnoses: a. major depressive disorder on 1/3/22. b. anxiety disorder on 1/5/22. c. bipolar disorder on 1/5/22. There was no evidence a PASARR level 1 was completed on or prior to admission. During an interview, on 2/23/24 at 9:37 a.m., the Administrator indicated the PASARR was not completed, and it should have been. A current policy, titled Admission Criteria, dated 5/20/20 and received from the Director of Nursing on 2/23/24 at 11:15 a.m., indicated .The Restoracy admits only residents whose medical and nursing care needs can be met .All new admissions and readmissions are screened for mental disorders [MD], intellectual disabilities [ID] or related disorders [RD] per the Medicaid Pre-Admission Screening and Resident Review [PASARR] process .The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD< ID or RD .If the level I screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II [evaluation and determination] screening process 3.1-16(d)(1)(A) 3.1-16(d)(1)(B)

Based on observation, interview and record review, the facility failed to provide quarterly care plan conferences and failed to include the use of a positioning cushion in the comprehensive care plan of 2 of 5 residents reviewed for care planning. (Resident 53 and 6) Findings include: 1. During an interview, on 2/20/24 at 10:25 a.m., Resident 53 indicated she did not remember attending any meetings about her care in a long time. During an interview, on 2/22/24 at 9:50 a.m., Resident 53 indicated she had not been invited or attended a care plan meeting in the past year. The clinical record for Resident 53 was reviewed on 2/22/24 at 10:48 A.M. The diagnoses included, but were not limited to, stage 4 pressure ulcer of left buttock, stage 4 pressure ulcer of right buttock, multiple sclerosis, type 2 diabetes mellitus, other chronic osteomyelitis, incomplete paraplegia, and benign neoplasm (mass) of spinal meninges. A Brief Interview of Mental Status (BIMS), dated 1/23/24, indicated Resident 53's cognition was intact. A social service note, dated 10/4/22 at 12:32 p.m., indicated a care conference for Resident 53 was completed. The resident, resident's daughter, and the social worker attended. This was the last recorded care conference for Resident 53 located in the medical record. A social service progress note, dated 11/27/23 at 7:58 p.m., indicated the Social Service Designee invited the resident's representative to schedule a quarterly care plan. During an interview, on 2/22/24 at 3:15 p.m., the Director of Nursing (DON) indicated she did not find any further documentation for care conferences except for the social services note, on 11/27/23, which she provided. 46961 2. During an observation, on 2/21/24 at 11:58 a.m., Resident 6 was sitting up in her wheelchair in front of the television, music was playing, and she had a cushion on her wheelchair with a black part protruding up between her legs. She was moving her right leg and not moving her left. The left foot was not on the footrest. During an observation, on 2/22/24 at 10:47 a.m., the resident was sitting up in her wheelchair in the common area with the pommel cushion (a cushion to provide positioning) in her chair and with th pommel protruding between her legs. The clinical record for Resident 6 was reviewed on 2/21/24 at 11:38 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, dementia, and sequalae unspecified cerebrovascular disease. There were no orders for a pommel cushion. A care plan, dated 10/12/22, indicated the resident had an ADL (activities of daily living) selfcare deficit. Interventions included, but were not limited to, anti-rollbacks, anti-tippers, left foot/leg rest, the resident had a splint for staff to place and remove per order, her daughter often took the splint home to wash and did not return it promptly, stand-up lift as ordered, required assistance from staff to turn and reposition, required assistance to eat, required assistance to toilet, and required assistance to move between surfaces. There was no intervention for a pommel cushion. During an interview, on 2/22/24 at 11:04 a.m., the lead Physical Therapist (PT) indicated the resident had a pommel cushion. The pommel cushion was used to help with positioning, maintaining alignment, and reducing the risk for falls. It prevented falls by preventing the resident from sliding down in the chair and helped maintain the upright position. During an interview, on 2/22/24 at 11:11 a.m., the lead PT indicated they just took over therapy from another company. He pulled the evaluation, dated 12/2/22, and it indicated the resident was referred to occupational therapy due to the daughter had requested a seating and positioning evaluation, because the resident was sliding out of her chair. The resident already had the cushion when his company took over, on November 1, 2022. He did not know the policy and was not sure the resident needed an order or a care plan or both. A current policy, titled Care Plans, Comprehensive Person-Centered, dated as approved on 5/20/20 and received from the DON on 2/23/24 at 3:32 p.m., indicated The Interdisciplinary Team includes .The resident and the resident's legal representative .The comprehensive, person-centered care plan will: Incorporate identified problem areas .Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and reflect currently recognized standards of practice for problem areas and conditions .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change .The Interdisciplinary Team must review and update the care plan .At least quarterly, in conjunction with the required MDS assessment. 3.1-35(a) 3.1-35(b)(1) 3.1-35(d)(2)(B)

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) care received the oral care recommendations from the dentist for 1 of 2 residents reviewed for ADL care. (Resident 5) Finding includes: During an observation, on 2/19/24 at 2:16 p.m., the resident had her mouth open, and no teeth were observed. The clinical record for Resident 5 was reviewed on 2/21/24 at 4:42 p.m. The diagnoses included, but were not limited to, dementia without behavioral disturbance, atrial fibrillation, rheumatoid arthritis, osteoporosis, and delusional disorder. A care plan, dated 7/25/17, indicated the resident had a potential risk for an activities of daily living (ADL) self-care performance deficit related to dementia and Parkinson's disease. The resident required assistance due to impaired coordination and balance. The goal was to maintain the current level of function with dressing and hygiene. The interventions included, but were not limited to, assist to the bathroom upon rising and before and after meals and assist with the right knee brace in the morning. The care plan did not include oral care. A care plan, dated 8/8/17, indicated the resident had a potential risk for oral/dental health problems related to needing assistance with oral care. The resident had her own teeth. The goal was to be free of infection, pain, or bleeding in the oral cavity by the review date. The approaches included, but were not limited to, administering medications as ordered, coordinate arrangements for dental care, and diet as ordered. A dental note, dated 9/12/23, indicated the resident had poor periodontal health. The resident had moderate plaque (a sticky film which hardens if not removed and could damage teeth and lead to tooth decay or loss) and calculus (calcified dental plaque). The resident was partially edentulous, her oral hygiene was poor, there was moderate calculus and there were root tips where 10 teeth had been. A dental note, dated 10/10/23, indicated the resident needed to have her teeth brushed twice daily specifically at the gum line, daily mouthwash rinse was recommended for gingiva (gums of mouth) health. The resident needed daily assistance with oral hygiene. During an interview, on 2/23/24 at 2:09 p.m., the Director of Nursing (DON) 1 indicated the recommendations from the dentist to assist the resident with the twice daily brushing of her teeth and the recommendation for daily mouthwash did not get entered as an order and did not get added to the resident's plan of care. During an interview, on 2/23/24 at 2:39 p.m., DON 2 indicated the facility would complete regular brushing of the resident's teeth. The care plan did not include the recommendations from the dentist about her oral health being poor, the buildup of tartar and calculus, the need to brush twice daily specifically at the gumline or the recommendation for the daily mouthwash. A current policy, titled Activities of Daily Living (ADL), Supporting, dated 5/20/20, indicated .residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .appropriate care and services with be provided for residents who are unable to carry out ADLs independently with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming and oral care) .if residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care .approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate .interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preference, stated goals and recognized standards of practice .the resident's response to interventions will be monitored, evaluated and revised as appropriate 3.1-38(a)(3)(C)

Based on observation, interview and record review, the facility failed to ensure cognitively stimulating activities were offered daily for 3 of 5 residents reviewed for activities. (Resident 23, 51 and 61) Findings include: 1. During an observation, on 2/20/24 at 10:46 a.m., the Activity Director entered Cottage 4's lounge carrying two children's books. The Activity Director informed the residents she was going to read a book about the month. The Activity Director read the book and left the cottage. During an observation, on 2/20/24 at 10:50 a.m., Resident 23 was sitting in a high back wheelchair in Cottage 4's lounge. The television was playing a musical and the volume was loud. The resident's head was tilted down. During an observation, on 2/21/24 at 10:59 a.m., the resident was sitting in Cottage 4's lounge with the television on. The head of the wheelchair was leaning back, and the resident was looking around. There were no activity staff in the cottage. During an observation, on 2/23/24 at 10:15 a.m., the resident was sitting in a high back wheelchair. The television was on, and the resident's wheelchair was pointing in the opposite direction and the resident was unable to watch the television. The clinical record for Resident 23 was reviewed on 2/22/24 at 11:53 a.m. The diagnoses included, but were not limited to, contracture of left hand, quadriplegia, Alzheimer's disorder, dementia, diabetes mellitus, congestive heart failure, and anxiety disorder. The resident did not have a care plan for activities. A facility activity log, for 1/1/24 to 1/31/24, indicated the resident missed 3 activities marked for the day shift and 6 activities marked for the evening shift. A facility activity log, for 2/1/24 to 2/23/24, indicated the resident missed 4 activities marked for the day shift and 7 activities marked for the evening shift. During an interview, on 2/22/24 at 11:59 a.m., the Director of Nursing (DON) 2 indicated the activity log for January and February were missing several holes and if there was no documentation then the activity was not done. 2. During an observation, on 2/20/24 at 10:50 a.m., Resident 51 was sitting in a wheelchair in Cottage 4's lounge. The television was playing a musical and the volume was loud. The resident's head was tilted down. During an observation, on 2/22/24 at 10:40 a.m., the resident was sitting in a wheelchair with his eyes closed. The television was playing very loud music. During an observation, on 2/22/24 at 4:00 p.m., the resident was sitting in a wheelchair with his eyes closed. The television was playing a basketball game, and the volume was turned up. During an observation, on 2/23/24 at 10:49 a.m., the resident was sitting in his wheelchair in the lounge. The staff brought other residents into the lounge and lined all the residents up in front of the television. The clinical record for Resident 51 was reviewed on 2/22/24 at 9:18 a.m. The diagnoses included, but were not limited to, diabetes mellitus, congestive heart failure, hypertension, Alzheimer's disease, and dementia. A care plan, dated as revised on 4/4/23, indicated the resident's preference was to keep to self and participate in self-directed activities of interest and choice. The interventions included, but were not limited to, having reading materials available, listening to favorite types of music, and participating in activities with groups of people of similar and common interest. A facility activity log, for 1/1/24 to 1/31/24, indicated the resident missed 4 activities marked for the day shift and 6 activities marked for the evening shift. A facility activity log, for 2/1/24 to 2/23/24, indicated the resident missed 3 activities marked for the day shift and 7 activities marked for the evening shift. During an interview, on 2/23/24 at 10:13 a.m., QMA 4 indicated the facility had a new Activity Director. The Activity Director went between several cottages and did the activities. QMA 4 would only see the Activity Director a few times a day. 3. During an observation, on 2/20/24 at 10:33 a.m., Resident 61 was sitting in the lounge with the television on. There were no activity staff present. During an observation, on 2/20/24 at 10:56 a.m., the resident was sitting in a wheelchair in the lounge with the television on. The resident's eyes were open, and she was staring at the floor. During an observation, on 2/21/24 at 10:57 a.m., the resident was sitting in her wheelchair in the lounge with no activity staff present. The resident was opening and closing her eyes. During an observation, on 2/22/24 at 9:20 a.m., the resident was sitting in her wheelchair with the television on and no activity staff was present. During an observation, on 2/23/24 at 10:46 a.m., the resident was asleep in her wheelchair. The resident's head leaning forward. The clinical record for Resident 61 was reviewed on 2/22/24 at 11:27 a.m. The diagnoses included, but were not limited to, senile degeneration of brain, depression, hypertension, and anxiety. The resident did not have a care plan for activities. A facility activity log, for 1/1/24 to 1/31/24, indicated the resident missed 3 activities marked for the day shift and 5 activities marked for the evening shift. A facility activity log, for 2/1/24 to 2/23/24, indicated the resident missed 3 activities marked for the day shift and 7 activities marked for the evening shift. During an interview, on 2/20/24 at 11:42 a.m., a family member indicated there were not a lot of activities to interact with the residents. The resident's family member did not know what the staff did for activities for Resident 61. They did not see any staff doing activities with the residents. They would like to see the residents doing more things besides sitting in front of the television all the time. During an interview, on 2/22/24 at 3:00 p.m., DON 2 indicated if the residents did not have something charted it was probably because they had agency staff or they just did not chart the activities. When there was no documentation, it probably was not done. During an interview, on 2/22/24 at 4:50 p.m., DON 2 indicated the resident did not have an activity care plan and should have had one. A current policy, titled Activities Program Policy, dated 5/27/20 and received from the Director of Nursing on 2/23/24 at 11:15 a.m., indicated .To support our vision of enjoying each day, connecting with other and balancing with others and individual fulfillment through meaningful activities and stimulation .The Activities program at The Restoracy focuses on balancing engagement with others and individual fulfillment through meaningful activities and stimulation .The resident's activity goal will match his/her functional ability with attainable challenges and personal preferences .All residents, including those who wish to remain in their rooms, will be offered a variety or alternative activities based on their interests, hobbies, and preferences .The activity calendar is posted monthly and includes activities 7 days per week. Unplanned changes to the activity calendar will be posted as soon as possible .Activities are designed to meet the interests, physical and psychosocial wellbeing of each resident, in keeping with the individual comprehensive care plan .The activity program is directed by a qualified Activity Coordinator 3.1-33(a) 3.1-33(b)(8) 3.1-33(d)(2)

Based on interview and record review, the facility failed to ensure a resident who had a colostomy had specific direction for colostomy care for 1 of 1 resident reviewed for bowel and bladder. (Resident 25) Finding includes: The clinical record for Resident 25 was reviewed on 2/20/24 at 3:03 p.m. The diagnoses included, but were not limited to, colostomy. A care plan, dated 10/26/23, indicated the resident had an alteration in gastrointestinal status, and an ostomy related to colon cancer. Interventions included to assist the resident with ostomy care as needed, to give medications as ordered, to monitor and document side effects and the effectiveness of the medications, to obtain and monitor lab or diagnostic work as ordered, and to report the lab and diagnostic results to the physician and follow up as indicated. A physician's order, dated 12/23/23, indicated to change the colostomy bag every 3 days and as needed due to dislodgement. A physician's order, dated 12/25/23, indicated to check the colostomy bag for patency. There were no resident specific directions for the colostomy. During an interview, on 2/22/24 at 2:28 p.m., LPN 2 indicated she did not know what brand or size of bag the resident wore. The colostomy bags came in a red and white box. The supplies were ordered from a pharmacy and were delivered. When changing the bag, she cleaned the area around the stoma with soap and water, cut the hole in the bag, applied skin prep, and gave it time to dry. She was not sure if there were other products to be used. She indicated the resident had excoriation around the stoma because the bag was not fitted correctly. A current policy, titled Colostomy /Ileostomy Care - Clinical Protocol, not dated and received from the Director of Nursing, on 2/22/24 at 1:30 p.m., indicated .the purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter .review the resident's care plan to assess for any special needs of the resident, assemble the equipment and supplies as needed .the following equipment and supplies will be necessary when performing this procedure .skin cleansing prep, clean drainage bag, soap and water, barrier creams and lotions and personal protective equipment 3.1-47(3)

Based on interview and record review, the facility failed to identity injuries of unknown origin as possible abuse for 3 of 11 residents in Cottage 3 reviewed for injuries of unknown origin. (Resident 27, 5 and 46) The immediate jeopardy began on November 2, 2022, when Resident 27 was found to have a bruising on the right side of the forehead. On 11/8/22, Resident 5 was noted to have discoloration and a skin tear. On 12/2/22, Resident 46 was noted to have several bruises on her left arm. The Director of Nursing was notified of the immediate jeopardy on 12/5/22 at 4:02 p.m. The immediate jeopardy was removed on 12/07/22, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1. The record for Resident 27 was reviewed on 12/5/22 at 11:00 p.m. Diagnoses included, but was not limited to, Alzheimer's disease, depression, anxiety, and dementia. A care plan, dated 3/24/20, indicated Resident 27 had an activity of daily living (ADL) self-care performance deficit related to her Alzheimer's disease, dementia, and decline in mobility. Interventions included, but were not limited to, provide skin inspection weekly and observe for redness, open areas, scratches, cuts, bruises, and report changes to the nurse. The Quarterly Minimum Data Set (MDS) assessment, dated 11/18/22, indicated Resident 27 had a severe cognitive impairment and demonstrated no behaviors. She required supervision with walking, transfers, and eating. She required limited assistance for personal hygiene, bed mobility, toilet use, dressing, and locomotion on the unit. The Treatment Administration Record (TAR), dated 10/31/22, indicated Resident 27 was scheduled to have a shower on Monday and Thursday with a head-to-toe assessment in the evening on Monday and Thursday. A shower and a head-to-toe assessment was completed on 10/31/22. Resident 27's skin observation task, dated 11/1/22 to 11/27/22, lacked indication bruising was noted. A Nurse Progress note, dated 11/2/22 at 5:47 p.m., indicated the nurse was notified a bruising on the right side of Resident 27's forehead. The area was assessed by the nurse and described as dark purple-blackish area in color and measured 4 cm (centimeter) by 3 cm. The nursing team was made aware. The progress note lacked indication family, or the provider was notified, an investigation was completed, or the care plan was updated. A Skin Observation assessment, dated 11/3/22 at 10:58 p.m., indicated Resident 27 had no new skin issues. A physician's progress note, dated 11/3/22 at 2:28 p.m., indicated Resident 27 was seen for an acute visit for a bruise on her forehead. She had a bruise on the right side of the forehead and was an unwitnessed injury. The contusion measured 4 cm by 3 cm and Resident 27 had not been taking blood thinners. During an interview, on 12/5/22 at 10:18 a.m., the Assistant Director of Nursing (ADON) indicated staff needed to have education on documentation, communication, and assessment of an injury of unknown source. They resident was at risk for a potential delay in treatment by not reporting concerns as soon as the injury happened or was observed. A Nursing Assistant was terminated in Nonmember related to concerns about rough care and an increase in bruising was found. 2. The record for Resident 5 was reviewed on 12/5/22 at 12:00 p.m. Diagnoses included, but were not limited to, dementia, depressive disorder, chronic obstructive pulmonary disease, and chronic kidney disease. A care plan, dated 12/3/22, indicated Resident 5 had a history of developing bruising, skin tears, and abrasions easily and sometimes from unknown causes. She was at risk for future falls, bruising, and skin tears due to fragile skin and unsteadiness at time. Interventions included, but were not limited to, remove wander guard, complete a new elopement assessment, and put the wander guard around the walker if it was still appropriate in attempt to prevent further skin breakdown, and staff were to encourage the resident to reposition if sitting with legs cross for too long in attempt to prevent further bruising. A Quarterly Minimum Data Set (MDS) assessment, date 9/26/22, indicated the resident had demonstrated no behaviors, and had a severe cognitive impairment. She required supervision for walking, transfers, and eating. She required limited assistance for personal hygiene, bed mobility, toilet use, dressing, and locomotion on the unit. The Treatment Administration Record (TAR), dated 11/22, indicated for the staff to complete a skin assessment weekly on Tuesday in the morning, and complete a skin observation assessment on Thursday. Staff were to document any abnormal findings. A skin observation task, dated 11/8/22 at 11:59 p.m., indicated Resident 5 had discoloration and a skin tear. A skin observation, dated 11/9/22 at 10:00 a.m., indicated she had the following bruising: a. On the back of right hand was a bruise which measured 2 centimeters (cm) x 2 cm. b. On the right elbow was a bruise which measured 2.5 cm by 1 cm. c. On the left iliac crest was a bruise which measured 7 cm by 3 cm. d. On the front left knee was a bruise which measured 5 cm x 2 cm. A nurse progress note, dated 11/9/22 at 10:15 a.m., indicated Resident 5 had bruising on her right inner wrist and bicep, the left side of her abdomen, and her left inner thigh which was light reddish-purple in color. Her skin was intact. Resident 5 was unable to explain what occurred due to her cognition. The nurse progress note lacked indication the physician was notified, or the bruise of unknown origin was investigated. A physician's progress note, dated 11/9/22 at 4:09 p.m., indicated Resident 5 was seen for a pain management visit. The progress note indicated she had no rash. The record lacked indication the resident had falls around the time the bruising was found. During an interview, on 12/2/22 at 3:29 p.m., the Director of Nursing (DON) indicated a family member had reported concerns regarding rough care from staff to the residents. On 11/22, a Nursing Assistant was terminated because of concerns related to rough care. During an interview, on 12/2/22 at 3:32 p.m., the Administrator indicated he would report immediately if he was notified of an injury of unknown source. Staff should be reporting immediately to the nurse, DON, or Administrator any concerns related to an injury of unknown source. During an interview, on 12/2/22 at 4:00 p.m., the Assistant Director of Nursing (ADON) indicated no education was provided to staff on investigating or reporting injuries of unknown source after the concerns were found on 11/9/22. No investigation was completed and an update to Resident 5's care plan had not been completed for the 11/9/22, injury of unknown source. During an interview, on 12/5/22 at 9:44 a.m., with the DON and ADON, they indicated staff were educated on 12/2/22 related to reporting of incidents of abuse, neglect, and injuries of unknown sources. The DON indicated she had a concern staff was not reporting the incident immediately when it was found, the lack of documentation, and not completing an assessment. Staff should have followed up the chain of command to the ADON, DON, or Administrator when concerns were found. The DON indicated her expectation for staff when an injury was identified was to complete a skin assessment, notify the family and provider, and communicate to the management staff. 3. The record for Resident 46 was reviewed on 11/29/22 on 11:00 a.m. Diagnoses included but were not limited to, dementia, delusional disorders, major depressive disorder, anxiety, macular degeneration, Parkinson's disease, and psychotic disorder. A care plan, dated 10/23/22, indicated Resident 46 had a behavior problem with physical aggression during brief changes by hitting, spiting, and biting related to dementia, depression, and psychosis due to Parkinson. Interventions, included but were not limited to, administer medications as ordered, monitor and document for side effects and effectiveness, anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting, encourage the elder to express feelings appropriately, explain all procedures to the elder before starting and allow the elder to acknowledge an understanding or accept, intervene as necessary to protect the rights and safety of others, approach the resident calmly and speak in a respectful tone of voice, divert attention and remove from a situation and take to an alternate location as needed. A quarterly MDS assessment, dated 12/1/22, indicated she had severe cognitive impairment and demonstrated no physical behaviors. The MDS further indicated she was an extensive assistance of one staff of all activities of daily living. A skin observation task, dated from 11/24/22 to 12/2/22, indicated no issues were found on Resident 46 skin. Physician's orders included, but were not limited to, on 7/16/22, staff were to provide a weekly skin assessment from head to toe every Thursday. On 12/3/22, staff were to clean the skin tear with normal saline, apply bacitracin (antibiotic ointment) and leave open to air. A Skin Observation, dated 12/1/22 on 12:11 a.m., indicated Resident 26 had bruising on left forearm. A progress note, dated 12/2/22 at 7:50 a.m., and created on 12/2/22 at 11:27 a.m., indicated the nurse received a phone call to notify her Resident 46 had several bruises on her left arm. The wound was cleansed, and a bandage applied. The second bruise, close to the left elbow measured 7 cm by 5 cm and was described as dark purple in color. During the dressing change, Resident 46 was described as uncomfortable, and she grimaced during the wound cleaning. The bruise closest to her wrist measured 7.5 cm x 3 cm and had a skin tear which measured 2 cm by 1 cm and was described as dark purple and lighter purplish pink areas. A small area above the left elbow measured 1 cm by 1 cm was described as red in color. A progress note, dated 12/2/22 at 3:35 p.m., indicated the nurse was notified by the Nursing Assistant Resident 46 was combative with care overnight when she was checked and changed to see if she was incontinent. Resident 46 was startled by the Nursing Assistant and had grabbed her chest area. The Nursing Assistant released the grip of Resident 46 to change her brief. The nurse notified the Nurse Practitioner. A progress note, dated 12/2/22 at 4:21 p.m., indicated the nurse obtained an order for both skin tears to be cleaned with normal saline, apply bacitracin, and to leave the skin tears open to air. The Power of Attorney and DON were notified. A progress note, dated 12/2/22 at 6:12 p.m., indicated the staff, the DON, and the Executive Director were notified of the bruising and skin tear to the resident's left arm. The nurse assessed the area and investigated what transpired when bruise and skin tear occurred. The Nurse Practitioner was notified of what occurred and orders were put in place for the skin tear. The resident had a history of being combative during care at times. Resident 46 was startled when the CNA went in to give care around 2:00/2:30 a.m., and she grabbed the CNA's chest area. The CNA then removed the grip the resident had on her breast. This was reported to the staff nurse and the management followed up on all concerns at this time. A Social Service progress note, dated 12/2/22 at 7:10 p.m., and created on 12/2/22 at 7:14 p.m., indicated the Social Service Director (SSD) was sitting with the resident when the Nursing Assistant attempted to put a sleeve on the resident's arm with the bruising and wound, but the resident refused. On 12/3/22, the Nursing Assistant indicated at 2:17 p.m., the resident had a red, bruised, scratched, discolored, and open area. During an interview, on 12/01/22 at 8:59 a.m., the Executive Director indicated the facility had identified a concern regarding increased bruising which were unexplained. During an interview, on 12/1/22 at 10:30 a.m., Nursing Assistant (NA) indicated she had observed bruising on residents which was not on the resident the day before when she worked. She had not received any recent education on abuse or reporting injuries of an unknown source, since before 11/22. During an interview, on 12/2/22 at 12:20 p.m., the Memory Care Coordinator indicated she had reported many times to the ED and the DON concerns about rough care, bruising, and injuries of unknown sources which had occurred in Cottage 3 and Cottage 4. During an interview, on 12/02/22 at 3:03 p.m., the DON indicated she had concerns regarding the unexplained bruising on residents. Her expectation was for staff to report concerns regarding bruising or injuries to the nurse, nurse manager, DON, or ED immediately. When she started her employment, skin assessments were completed to monitor or check for bruising. The facility had not completed any audits, observations, or investigations regarding the unexplained bruising. She was aware of three or four other incidents of bruising or injuries of unknown source. During an interview, on 12/2/22 on 4:25 p.m., the DON indicated education was not provided and she was going to start training now. A copy of education on abuse, care planning, investigation was requested. The DON indicated the staff had no education except when hired on abuse, or dementia. Education was not provided on abuse or reporting after the incidents. She was unsure if the cooks were educated on dementia. The week she was hired, around 11/9/22, a staff member was let go due to rough care. A current facility policy, titled Prevention of Elder Abuse, Neglect, and Misappropriation of Elder Property Policy, dated 2016, indicated each elder living in this community had the right to be free from abuse, neglect, and misappropriation of their property. All reported incidents will be immediately investigated. The Immediate Jeopardy that began on 11/2/22 was removed on 12/7/22 when the facility completed a head-to-toe skin assessment on all residents and interviewed all cognitively intact residents for any concerns of mistreatment. The facility in-serviced all staff on the Abuse Policy, body areas which were considered vulnerable or areas of concern, and the Elder Justice Law. 3.1-27(a)(1) 3.1-27(a)(3)

Based on interview and record review, the facility failed to thoroughly investigate injuries of unknown origin as possible allegations of abuse and report to the state agency potentially preventing further injury to a resident for 3 of 11 residents reviewed for injuries of unknown origin. (Resident 27, 5 and 46) The immediate jeopardy began on November 2, 2022, when Resident 27 was found to have a bruising on the right side of the forehead. On 11/8/22, Resident 5 was noted to have discoloration and a skin tear. On 12/2/22, Resident 46 was noted to have several bruises on her left arm. The Director of Nursing was notified of the immediate jeopardy on 12/5/22 at 4:02 p.m. The immediate jeopardy was removed on 12/07/22, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings Include: 1. The record for Resident 27 was reviewed on 12/5/22 at 11:00 p.m. Diagnoses included, but was not limited to, Alzheimer's disease, depression, anxiety, and dementia. A progress note, dated 11/2/22 at 5:47 p.m., indicated Resident 27 had bruising to the right side of her forehead and the nurse assessed the bruise. The progress note lacked indication the bruising of unknown source was investigated. 2. The record for Resident 5 was reviewed on 12/5/22 at 12:00 p.m. Diagnoses included, but were not limited to, dementia, depressive disorder, chronic obstructive pulmonary disease, and chronic kidney disease. A progress note, dated 11/9/22 at 10:15 a.m., indicated Resident 5 had bruising to her right inner wrist, under her arm, the left side of her abdomen, and her left inner thigh. The progress notes further indicated the bruising was assessed and family was notified. A review of Resident 5's medical record lacked indication the unexplained bruising was investigated. 3. The record for Resident 46 was reviewed on 11/29/22 on 11:00 a.m. Diagnoses included but were not limited to, dementia, delusional disorders, major depressive disorder, anxiety, macular degeneration, Parkinson's disease, and psychotic disorder. A progress note, dated 12/2/22 at 7:50 a.m., and created on 12/2/22 at 11:27 a.m., indicated the nurse received a phone call to notify her Resident 46 had several bruises on her left arm. The wound was cleansed, and a bandage was applied. The second bruise, close to the left elbow measured 7 cm by 5 cm and was described as dark purple in color. During the dressing change, Resident 46 was described as uncomfortable, and she grimaced during the wound cleaning. A progress note, dated 12/2/22 at 3:35 p.m., indicated the nurse was notified by the Nursing Assistant, Resident 46 was combative with care overnight when she was checked and changed to see if she was incontinent. The resident was started by the Nursing Assistant and had grabbed her chest area. The Nursing Assistant released the grip of Resident 46 to change her brief. Resident 46's record lacked indication the injuries were reported or investigated immediately after the injury occurred. During an interview, on 12/01/22 at 8:59 a.m., the Executive Director (ED) indicated the facility had identified an increase in unexplained bruising in Cottage 3. If an injury or bruising of unknown origin was found, the staff should immediately report the concern to the nursing staff and follow the chain of command. The injury of unknown source should be investigated to determine the cause and to ensure the resident safety. During an interview, on 12/1/22 at 10:30 a.m., a Nursing Assistant (NA) indicated she had observed bruising on residents which was not on the resident the day before when she worked. She had not received any recent education on abuse or reporting injuries of an unknown source, since before 11/22. During an interview, on 12/2/22 at 12:20 p.m., the Memory Care Coordinator indicated she had reported many times to the ED and the DON regarding concerns about rough care, bruising, and injuries of unknown origin which had occurred in Cottage 3 and Cottage 4. During an interview, on 12/02/22 at 3:03 p.m., the DON indicated she had concerns regarding the unexplained bruising on residents. Her expectation was for staff to report concerns regarding bruising or injuries to the nurse, nurse manager, DON, or ED immediately. When she started her employment, skin assessments were completed to monitor or check for bruising. The DON indicated the facility had not completed any audits, observations, or investigations regarding the unexplained bruising. She was aware of three or four other incidents of bruising or injuries of an unknown source. During an interview, on 12/2/22 on 4:25 p.m., the DON indicated education was not provided and she was going to start training now. A copy of education on abuse, care planning, investigation was requested. The DON indicated the staff had no education except when hired on abuse, or dementia. Education was not provided on abuse or reporting after the incidents. She was unsure if the cooks were educated on dementia. The week she was hired, around 11/9/22, a staff member was let go due to rough care. During an interview, on 12/5/22 at 3:15 p.m., the ED indicated concerns for bruising of an unknown source should be investigated to rule out concerns for abuse. The concern was with the communication from staff and the reporting of bruising or injuries of an unknown source. A current facility policy, titled Investigating Injuries of Unknown Origin, dated 2016, indicated an injury shall be classified as an injury of unknown source when both conditions are met: a. The resident is unable to explain how the injury occurred or the injury was not observed by a team member or visitor. b. The injury is suspicious because of the extent or the location or the injury is in an area not vulnerable to trauma, or the number of injuries observed at a particular time or incidences of injury that occurred over time cannot be explained. Injuries of unknown causes will be investigated to determine if abuse or neglect could be a contributing factor. The Immediate Jeopardy that began on 11/2/22 was removed on 12/7/22 when the facility completed a head-to-toe skin assessment on all residents and interviewed all cognitively intact residents for any concerns of mistreatment. The Executive Director reviewed the Division of Long-Term Care Reporting Policy and the facility Abuse Investigation and Reporting Policy. Education was provided to the Director of Nursing, Assistant Director of Nursing, Memory Care Facilitator, and Social Service Director. 3.1-28(c) 3.1-28(d) 3.1-28(e)

Based on observation, interview and record review, the facility failed to provide nutritional supplements as ordered by the physician and Registered Dietician and failed to follow-up on recommendations from the Registered Dietician to prevent further weight loss for 1 of 5 residents reviewed for nutrition. (Resident D) This resulted in Resident D having a decrease in weight of 12.9% in 180 days. Finding includes: During a dining observation, on 09/27/2021 at 12:24 p.m., Resident D did not receive yogurt for lunch. During a dining observation, on 09/29/2021 at 9:02 a.m., the resident was not given a straw or a Provale cup (a specialized cup used to deliver small amounts of liquid with every drinking motion used with swallowing disorders). During a dining observation, on 9/29/2021 at 12:45 a.m., the resident was not given a Provale cup or yogurt. On 9/30/2021 at 9:49 a.m., the resident was in her room, sitting in her chair, she had a Styrofoam cup of water sitting on her bedside table. On 9/30/2021 at 3:20 p.m., a Styrofoam cup of water was in the resident's room. The resident indicated she was not given yogurt or ensure for lunch. During a dining observation, on 10/01/2021 at 8:55 a.m., the resident was not given a Provale cup. During an interview, on 10/01/2021 at 2:00 p.m., the resident indicated she was not given yogurt for lunch. During a kitchen tour with CNA 6 at 2:11 p.m., she indicated there was not any yogurt in either refrigerator. During a dining observation, on 10/04/2021 at 8:46 a.m., the resident was given water in a Styrofoam cup. During an interview, on 10/04/2021 at 09:20 a.m., the resident indicated she did not get her ensure with breakfast and in her room she had a large Styrofoam cup of water on her night stand. During a dining observation, on 10/04/2021 at 12:36 p.m. through 1:55 p.m., the resident was given a large Styrofoam cup of water and was not given Ensure or a straw. At 12:45 p.m., LPN 10 brought the resident a large plastic cup filled with lemonade. It was not a Provale cup and did not have a straw. During an interview, at that time, LPN 10 indicated She just don't want it in that cup. She also did not receive yogurt. During an interview, at that time, CNA 7 indicated communication was poor and she was unaware of which residents were supposed to have yogurt with lunch. The nurse would be the one to know but did not communicate the information with her. At 1:13 p.m., LPN 10 indicated she did not know the resident was suppose to get a yogurt, she did not know where to find out if a resident was supposed to have anything special with meals. The record for Resident D was reviewed on 09/29/2021 at 10:10 a.m. Diagnoses, included but were not limited to, [CONDITION(S)], stroke and malnutrition. A care plan, dated 10/20/2020, indicated the resident had an ADL (activities of daily living) performance deficit related to [CONDITION(S)]. Interventions included, but were not limited to, Provale cup for all liquids which was initiated on 11/20/2020. A care plan, dated 07/28/2021, indicated the resident was a nutritional risk related to [CONDITION(S)], triggering for a significant weight loss x 30 day. Interventions included, but were not limited to, provide and serve supplements as ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A dietary report sheet indicated the additional directions for the resident's diet were to provide one can of ensure with breakfast and lunch, give 120 ml of Med Pass, yogurt at lunch and all fluids provided in a Provale cup. A RD (Registered Dietician) note, dated 08/28/2021, indicated the resident had a 8.4% significant weight loss over 30 days and recommended to offer yogurt at lunch and start Med Pass 120 ml four times a day. Also recommend to offer ice cream at dinner and yogurt at lunch related to the enjoyment of softer foods. Will discuss with the Nurse Practitioner (NP) to start an appetite stimulant. A RD note, dated 09/15/2021, indicated the resident had a 7.4% significant weight loss over 30 days, a 7.8% significant loss over 90 days and a 12.9% significant loss over 180 days. The resident was receiving yogurt at lunch and ice cream at dinner to provide extra calories. The resident had increased difficulty feeding self and a decreased appetite. The RD recommended to offer Ensure plus 1 can at meals and to discuss with the NP to start an appetite stimulant related to weight loss and intake of less than 50%. There was no documentation in the resident's record to indicated the NP was notified to discuss starting an appetite stimulant after the RD recommendation on 8/28/21 or 9/15/21. During an interview, on 10/04/21 at 3:29 p.m., the Admissions/Trainer (MAT) indicated it was the dieticians responsibility to follow through with her recommendations. Dietary interventions recommended from the RD would be documented on the resident's dietary sheet and kept in a binder in the kitchen. The CNAs and Nurses should know to refer to the sheet for added dietary recommendations for increased calories/nutritional value. The resident should have received yogurt with each lunch. During an interview, on 10/14/2021 at 3:30 p.m., the ED indicated each residents diet including nutritional supplements, special additions and restrictions were kept in a binder in the kitchen of each cottage. During an interview, on 10/4/21 at 4:30 p.m., the current dietician indicated she just started and had not been in to officially assess the resident yet and she was unable to talk with the previous RD who made the recommendations. She could not attribute as to why there was a delay in getting the order for the appetite stimulant. A nutrition/weight loss policy was not provided when requested, on 10/04/2025 at 4:15 p.m., the ED indicated at that time it was the expectation of nursing to follow physician orders. 3.1-46(1)

Based on observation, interview and record review, the facility failed to ensure a resident was adequately supervised during toileting and failed to accurately assess for injuries upon discovering the resident had fallen for 1 of 3 residents reviewed for accidents. (Resident B) Resident B required an emergency room visit and staple placement to a laceration sustained during the fall. During an observation of Cottage 4, on July 06, 2021 at 10:17 a.m., LPN 2 was observed in the nursing office on the phone. Resident B was in a wheelchair parked in the doorway facing into the office. LPN 2 hung up the phone and indicated she was going to do a treatment on the resident. The nurse walked over to the overhead cabinets, moved items around, then closed them. She turned to Resident B, lowered herself to eye level, and asked the resident to look at her. She then asked the resident to hold her hands and squeeze. She then moved down to the resident's left leg, removed her sock and shoe, and looked at her left ankle and foot. The nurse put the sock and shoe back on resident and asked if she wanted a drink. A drink of water was provided, and the nurse indicated she was finished with the resident. The nurse made no indication the resident had recently fallen. Resident B was alert, clean, dry and did not show signs of distress. The nurse removed the resident from the doorway and began a walk through of the cottage. During an observation of Resident B, on July 06, 2021 at 3:23 p.m., with the Director of Nursing in attendance, five staples were noted on the back of Resident B's head. The wound was linear from the 10 o'clock to 5 o'clock position and no bleeding was present. The length of the wound was difficult to assess due to areas of dried blood on the scalp. The resident was alert and did not appear to be distressed. The record for Resident B was reviewed on July 06, 2021 at 3:35 p.m. Diagnoses included, but were not limited to, Alzheimer's disease, [CONDITION(S)] and [CONDITION(S)] and collapse (fainting). A nursing note, dated July 06, 2021 at 12:15 p.m., indicated the resident was found on her back inside the visitor bathroom. She did not remember what happen. The DON (Director of Nursing), NP (Nurse Practitioner) and her daughter were notified. The NP gave the okay to send the resident to the hospital for stitches on the back of her head because she had an opened area which was bleeding. A care plan, initiated on November 14, 2017, indicated the resident was at a risk for self-care related to Alzheimer's disease and required supervision and assist of one staff for toileting. A care plan, initiated on November 14, 2017, indicated the resident had the potential for a fall related to impaired safety awareness and blood pressure fluctuations. The emergency room (ER) report indicated Resident B was admitted to theER on [DATE] at 12:05 p.m. She presented to the Emergency Department after suffering from an unwitnessed fall approximately 2 hours past, bleeding was controlled prior to admission. She came in with a significant 2 cm (centimeter) laceration to her left occipital scalp (back of head). The patient had no recollection and was unable to provide an accurate history. The resident was on [MEDICATION(S)] (a blood thinner) therapy. The resident was discharged from theER on [DATE] at 2:14 p.m. During an interview, on July 06, 2021 at 12:57 a.m., LPN 2 indicated Resident B had fallen prior to the initial observation of the cottage, at 10:17 a.m., that morning but she was unable to give the time of the fall. LPN 2 indicated she did not do a neurological check (an assessment which included pulse, respiration, and blood pressure measurements, assessment of pupil size and reactivity, and equality of hand grip strength). She had checked the resident's vital signs, skin and legs. The resident did sustain a small opening on the back of her head, but she did not measure it and there was no bleeding. The nurse put the time of the fall at 10:48 a.m., and she contacted emergency transportation, via 911, at 11:13 a.m. The family member and physician were contacted but she could not recall the time of contact. After checking the record, the nurse indicated she called 911 at 11:35 a.m., maybe 11:40 a.m. She did not place the call sooner because she did not know the resident needed staples/sutures to the head wound. She did notify the Director of Nursing. LPN 2 then revisited the incident, indicating the resident was found laying in feces, she had the resident cleaned up and contacted the Director of Nursing who responded after the walk through of the cottage. She then left Cottage 4 and went to Cottage 5. The Director of Nursing called her and asked if she was aware a resident had fallen. She informed him she was going to do an assessment. The Director of Nursing told her to return to Cottage 4 and complete the assessment. She did return to the cottage and complete an assessment and this was when she found a small opening at the back of the resident's head. There was no bleeding at the time and she did not measure the wound. She informed the Director of Nursing the resident needed to go to the hospital and she called emergency medical services. During an interview, on July 06, 2021 at 1:11 p.m., CNA 3 indicated Resident B fell sometime between 9:30 a.m. and 9:45 a.m., that morning. She was washing dishes and cleaning up from breakfast when LPN 2 asked her to help with a resident who was in the rest room. The nurse then went to the office. CNA 3 indicated she went to the common area restroom. The door was slightly open, there was diarrhea everywhere, in the commode, on the seat and on the floor. The resident was laying on the floor and was bleeding, but she could not tell where the blood was coming from. Resident B was alert and told CNA 3 she needed help, asked the CNA not to leave her she needed help. CNA 3 went to get the nurse and informed her the resident was on the floor. CNA 3 indicated the nurse told her to clean the resident up first. Another staff member went to get help. CNA 3 noted the resident had an open area on her hand but did not observe any bleeding from the resident's head. She did clean the resident up and even brushed her hair and did not see any bleeding. The nurse was not observed to have checked the resident's vital signs or do any assessment but went to the office and got on the phone and computer. She indicated the State Surveyor entered the cottage while she (CNA 3) was carrying the soiled linens used to clean up the resident after the fall. The surveyor walked around the cottage and went to the nursing office. The nurse completed a walk through with the surveyor and then exited the cottage after the observation was completed and the surveyor had exited the cottage. The Director of Nursing did come and look at the resident. She indicated another staff member did observe bleeding from the resident's head, but it was a couple hours later, about 2 hours later, and she did observe emergency services arrive around 11:30 a.m. During an interview, on July 06, 2021 at 1:31 p.m., Staff Member 4 indicated she witnessed Resident B on the bathroom floor, laying in feces and blood. It was around 9:30 a.m. The nurse did not come and assess the resident. She recalled there were residents eating breakfast and Resident B left the area and went to the bathroom, she believed the nurse was aware the resident was in the bathroom and LPN 2 asked another staff member to go help the resident. The CNA went to assist and found the resident on the floor. The CNA informed the nurse. The nurse did not go assess the resident, but instead went to the nursing office. Staff Member 4 went to get help of another CNA. She then went to assist with dining in place of the second CNA. The nurse was still in the office. She indicated she did observed bleeding about two hours later. The emergency services arrived close to 11:30-11:45 a.m. Emergency services was not contacted until after the resident had been cleaned up. During an interview, on July 06, 2021 at 2:32 p.m., the Director of Nursing indicated he did look at Resident B. She had sustained a skin tear on her hand and an injury on the back of her head approximately 2.5 centimeters long and 0.2 centimeters deep, but he did not measure the wound. There was a little blood. The resident was sent out to the hospital related to a head injury. During an interview, on July 06, 2021 at 3:07 p.m., CNA 5 indicated a resident fell in the restroom. She did not witness the fall, but did observe the resident on the floor in blood and feces. The nurse told CNA 3 to clean up the resident. CNA 5 assisted her. The nurse did not assess the resident. The nurse went into the office. The fall was about 9:30 a.m. During an interview, on July 07, 2021 at 2:25 p.m., the MDS Coordinator indicated neuro-checks were to be completed for an unwitnessed fall, if unwitnessed and the resident indicated they did not hit their head then they did not need to be completed. A Post Fall 72-Hour Monitoring Report for Resident B indicated there was no documented time for the base line (initial assessment) vital signs. The following times were documented with vital signs and neuro checks: 10:45, 11:00, 11:15 and 11:30. There was a notation in the upper right corner which indicated .Back at 2:21 p.m. There was no documentation for the 3:00 p.m. neurological check and the next documented assessment was on 07/07/21 at 6:00 a.m. A facility document, titled Post Fall 72-Hour Monitoring Report, provided the Executive Director on July 07, 2021, indicated .This assessment should be completed at the following intervals for follow up for falls .A fall that is unwitnessed, or in which the head is struck, requires neurological checks .Initial assessment (B-baseline) followed by q (every) 15 min (minutes) x 4 .q30 min x 2 .every hour x 2 .once per shift for 72 hours .Time of fall .10:45 An undated facility policy, titled Fall Prevention and Management Protocol, provided by the MDS Coordinator on July 07, 2021 at 2:25 p.m., indicated .Document a progress note on the fall, include the following information .How you became aware of the fall .Condition/position the elder was found in .Ask the elder what they were doing at the time of the fall .ROM(range of motion) at time of fall .Pain level and location .Injury sustained .Vital signs .Neuro checks if applicable .Interventions that were in place at time of fall .documentation that you notified MD(physician) and family .include measurement in note .Initiate neuro checks: ANY unwitnessed fall This Federal tag relates to Complaint IN 714. 3.1-45(a)(2)

Based on observation, interview and record review, the facility failed to provide effective pain management in accordance with the resident's comprehensive care plan for 1 of 3 cognitively impaired residents reviewed experiencing pain. (Resident D) This resulted in Resident D having impaired mobility, mood, poor quality of life and increased the risk of pressure ulcers. Finding includes: During a telephone interview, on 5/17/21 at 3:45 p.m., Resident D's friend indicated the resident had no family nearby. She was a long-time friend and the only person able to visit the resident on a regular basis. Since before 4/27/21, she observed Resident D had pain in her hips and knees from prior hip surgery. She would not unlock her knees because of her pain. She did not have pillows or other devices to place between her legs for comfort or to protect her skin when she was in bed. She had not seen the sores, but staff told her the resident had sores on her knees because they were locked so tightly together. When she talked to staff about her legs, the only reply she received was we're trying to manage her pain. The resident was so anxious and in pain, she cried all the time. She said things like, I'm dying. I don't want to die. Please help me. When she was in pain, she became agitated and confrontational with staff. She sometimes screamed when the friend just touched the wheelchair. She did not want to be touched or eat due to pain. During an observation and interview, on 5/20/21 at 2:25 p.m., with Nurse Practitioner (NP) 17, Resident D was lying on a low air loss mattress with wedges at the top right, and lower left and right sides of the bed. The foam insert for the wedge on the top left side of the bed was still on the chair across the room. The resident's right knee was bent across her left leg. The resident was holding onto the leg. NP 17 indicated there was a scar on her left leg, probably from lying that way for so long. She observed a red area on the left leg under the right knee. When the NP tried to separate the legs to view under the right leg, the resident yelled out Ow. The NP was not able to separate the leg to view the skin underneath without inducing pain. The NP said they definitely needed to do something proactive to prevent skin breakdown. Resident D's medical record was reviewed on 5/20/21 at 10:00 a.m. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D's quarterly Minimum Data Set (MDS) assessment, dated 4/09/21, indicated she had a severely impaired cognitive status. She had no behavior symptoms and had not resisted care. She required extensive assistance by one person for bed mobility, transfers, dressing, toileting and personal hygiene. She was totally dependent on one person for bathing. She did not walk. The MDS documented she had no pain and no significant weight loss in the last one month or six months. She was at risk for developing pressure ulcers but had no unhealed pressure ulcers. Resident D's comprehensive care plan, initiated on 8/08/18, indicated she had chronic pain. Approaches included, but were not limited to, administer [MEDICATION(S)] as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Notify the physician and hospice if interventions were unsuccessful or if the current complaint was a significant change from the resident's past experience of pain. Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion or withdrawal or resistance to care. Observe and report to the nurse any signs of non-verbal pain: changes in breathing, vocalizations (grunting, moans, yelling out); mood/behavior (changes, more irritable, restless, aggressive, squirmy); face (sad, crying, worried, clenched teeth, grimacing); body (tense, rigid, curled up, thrashing). Observe and report to nurse loss of appetite, refusal to eat or weight loss. Resident D's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A [MEDICATION(S)] patch, 72-hour, 12 micrograms per hour (mcg/hr) and to change every three days, was ordered on 1/05/20 for chronic pain and discontinued on 4/10/21. It was administered on 4/02/21, 4/05/21, 4/08/21 and 04/10/21. An identical order for [MEDICATION(S)] patch, 72-hour, 12 mcg/hr, was ordered on 4/20/21. It was applied/changed on 4/21/21, 4/24/21, 4/27/21, and 4/30/21, 5/03/21, 5/06/21, 5/09/21, 5/12/21, 5/15/21 and 5/18/21. There was no record the facility applied or changed a [MEDICATION(S)] patch between 4/10/21 and 4/20/21. [MEDICATION(S)] (concentrate) solution, 20 milligrams/milliliter (mg/ml), indicated to give .25 ml by mouth at bedtime. It was ordered on 4/10/20, administered from 4/10/21 through 4/14/21, and discontinued on 4/14/21. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] (concentrate solution) 20 mg/ml, indicated to give .25 ml by mouth every two hours as needed for pain. It was ordered on 1/10/19. It was not administered during April 2021. Prior to 5/20/21, it was administered only once in May 2021, on 05/06/21, for pain rated at 6 on a scale of 1 to 10. The April and May 2021 MARs also indicated Resident D had an order to give 650 mg of acetaminophen (Tylenol) every 6 hours as needed for mild pain or fever. It was not administered in April or May 2021. [MEDICATION(S)] cream 1% (Voltaren, nonsteroidal anti-inflammatory) was ordered on 4/24/21 to be applied every morning and at bedtime for pain and was applied 4/24/21 through 5/20/21 to her right front knee. Resident D's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident D's Skin Observation Tool, dated 4/24/21, indicated she had a stage 2 pressure ulcer on the front of her left knee and a skin tear on her right ankle. Resident D's Weights and Vitals record, dated 5/20/21, documented she lost 5.8 pounds between 4/06/21 and 5/06/21, representing a 5.4 percent weight loss over one month. It also documented she lost 16.8 pounds between 11/03/20 to 05/06/21 for a 14.2 percent weight loss over 180 days. [MEDICATION(S)] (AVINza, Duramorph) was reviewed on 5/25/21 from the Davis's Drug Guide website (https://www.drugguide.com/ddo/). The guide indicated the peak effect of [MEDICATION(S)] administered orally was achieved after 60 minutes, the half-life (time of a drug's active substance to reduce by half) was 2 to 4 hours, and the duration was 4 to 5 hours. During an interview, on 5/18/21 at 5:08 p.m., Licensed Practical Nurse (LPN) 14 indicated Resident D had a [MEDICATION(S)] patch (opioid pain medication) which was changed every three days. She also received scheduled [MEDICATION(S)]. She observed the resident had breakthrough pain. Sometimes she woke up with it and she had it at varying times of the day. There was no pattern. Because of her dementia, the resident could not say if she had pain or request pain medication. She got agitated and fidgety and said things like, I'm ready to go home. She responded well to scheduled pain medication when she received it. She was not over sedated, and LPN 14 could tell the difference the medication made because she would not yell out and was calmer and nicer to staff. She did not straighten one knee and she held her knees tightly together. Once positioned with pillows she slept better. She also had behavior symptoms of yelling out, resisting care and negative verbalizations when she got tired, as the sun went down every evening, or around 7:00 p.m. During an interview, on 5/19/21 at 5:01 p.m., Qualified Medication Aide (QMA) 2 indicated Resident D would not let anyone touch her. If they touched her leg the resident yelled Ow! and then stopped. She randomly screamed out. One leg was contracted; she could not straighten it. She had scheduled [MEDICATION(S)] and could also get [MEDICATION(S)] as needed (PRN) every two hours. QMA 2 indicated she thought her yelling out was a behavior symptom of resisting care and not related to pain. She screamed out when the doctor tried to examine her. She did not receive PRN [MEDICATION(S)] prior to receiving care by the CNAs. The resident barely ate. During an observation, on 5/19/21 at 5:10 p.m., the resident was heard yelling from the common area, more than two bedrooms away. Upon entering the room, the resident was in a wheelchair, dressed in clean clothes and had wet hair. CNA 15 was kneeling in front of the resident saying, let me see your foot. CNA 16 was standing behind CNA 15. The resident was yelling out, Ow! It Hurts! I want to go home! No one likes me! She grimaced, clenched her eyes shut, and tightened her hands and shoulders. CNA 15 very lightly touched the top of the resident's knee, and the resident yelled out and indicated, I don't like this. CNA 15 indicated the resident did this (yelled out) if she just touched her. The CNAs escorted the resident to the dining room in her wheelchair. She continued to say she did not like this and mumbled other indiscernible things. During an interview, on 5/19/21 at 5:20 p.m., CNA 16 indicated they had just given the resident a shower. CNA 15 and CNA 16 indicated they did not know whether she was pre-medicated before receiving the shower. The two CNAs indicated the resident yelled out throughout the care they provided. During an interview, on 5/19/21 at 5:10 p.m., LPN 14 indicated she thought Resident D's crying out was more of a behavior symptom because she cried out with any/all care. She did not know if pain or behavior symptoms were discussed with the resident's doctor. When asked if the CNAs coordinated pain medication before providing care, the LPN indicated the CNAs asked her to assess the resident if they thought she was in pain. They did not ask for PRN medication with care because the resident always cried out. During an interview, on 5/19/21 at 5:20 p.m., CNA 15 indicated when they positioned Resident D in bed, she grabbed the CNA so tightly she left marks in the CNAs arms. The CNA demonstrated two red marks on the inside of one arm. CNA 15 indicated the resident verbalized she was in pain. The CNA said: She's in pain. The CNA indicated there were four wedges on the sides of the bed: two on each side at the foot of the bed, and two on each side at the top of the bed. When the CNA positioned the resident in bed, she placed her on her left side, facing the wall. The resident gripped the wedge at the top of the bed on the left so tightly, she pulled the foam out of the cushion. The resident would not lay on her back. She did not straighten out her leg. She crossed her legs so tightly, she had red marks on her legs. CNA 15 put a pillow between her knees, but the resident pulled it out. Observation at this time, confirmed the cushion/wedge at the top left side of the bed was torn and a long piece of foam was on a chair across the room. There was only one pillow in the room, at the top of the bed. During an interview, on 5/20/21 at 11:21 a.m., NP 17 indicated Resident D had some contractures due to [CONDITION(S)] (degenerative joint disease with common symptoms of joint pain and stiffness). The resident could not put her right knee into extension. Usually, hospice managed the pain medicine. The facility's physician saw the resident on 4/10/21. Staff said her pain seemed under treated. She had orders for PRN [MEDICATION(S)], but she could not request it because of severe dementia. The physician added scheduled [MEDICATION(S)] and discontinued the [MEDICATION(S)] patch because she would have scheduled [MEDICATION(S)]. NP 17 saw the resident on 4/10/21 and 4/12/21 to make sure she was tolerating [MEDICATION(S)] okay. The resident wrenched when she tried to do anything with her right knee. There was no reported injury. The NP believed the pain was due to arthritic changes. She did not know if the resident could be seen by therapy because the resident was on hospice services. Perhaps therapy could recommend devices to help with positioning for comfort measures. None of the staff had mentioned reddened skin areas. She had not done an in-depth skin evaluation. No statements about behavior symptoms had been reported to the NP by staff, and she had not observed them. Had it been reported to her, she would normally look for acute causes for [CONDITION(S)] (e.g., a urinary tract infection or medication change). If it was not medical, she would get a psychiatric consult. The resident had not had a recent psychiatric evaluation and was not receiving [CONDITION(S)] medication. During an interview, on 5/20/21 at 12:20 p.m., the Therapy Director indicated no one had contacted him about Resident D's possible pain or contracture. Grabbing onto the side cushion so tightly she removed the foam, would definitely indicate pain. There was a possible mechanism for the facility's therapy department to work with the hospice residents and/or hospice may have their own therapist. With a referral, they could evaluate the resident to recommend positioning devices for comfort. During an interview, on 5/20/21 at 1:03 p.m., Resident D's hospice nurse indicated the resident could still walk a little bit when she was admitted to hospice but could not now. She had new, increased pain. The hospice service's Medical Director typically managed pain. They (the facility) discontinued her [MEDICATION(S)] patch and put her on scheduled [MEDICATION(S)], twice a day but [MEDICATION(S)] was short acting. When the hospice nurse saw the resident a week later, she restarted her [MEDICATION(S)] patch because the resident was in excruciating pain. She kept her on her liquid, scheduled [MEDICATION(S)]. She was doing great on the [MEDICATION(S)] patch and had zero pain, even with care or movement. It had not been reported to her the resident was currently crying out during care. They had PRN [MEDICATION(S)] they could give her. According to the facility records, the last time the facility gave her the PRN [MEDICATION(S)] prior to today was on 5/06/21. Regarding her yelling out, even though the resident had dementia, they could not say her calling out was not related to pain. The hospice nurse wished the facility used the PRN more, because it helped them calculate the scheduled medication needs. When they saw how much PRN medication was administered in a 24-hour period they could assess her breakthrough pain and adjust her scheduled medications. For example, they could increase her [MEDICATION(S)] patch from 12 micrograms (mcg) an hour to 25 mcg an hour. No one had communicated issues with positioning. Therapy could evaluate her for comfort and positioning related to her right knee, even though the resident was receiving hospice services. She saw the resident be nasty to staff and other residents at times, but she was easily redirected. No one had reported sundowning, depression or behavior symptoms. No psychiatric evaluation had been ordered. Had they known, they could order lorazepam (anti-anxiety) or try [MEDICATION(S)] (antidepressant). During an interview, on 5/20/21 at 2:25 p.m., LPN 5 indicated Resident D had some redness on her ankle where she tightly crossed her legs in bed. When she applied cream to her knee, the resident screamed: get away! After she received her morning medications, including her scheduled [MEDICATION(S)], she was nice. A current facility policy, titled Pain - Clinical Protocol, dated June 2013 and provided by the Executive Director on 8/20/21, indicated .2. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The staff and physician will identify the nature (characteristics such as location, intensity, frequency, pattern, etc.) and severity of pain .The staff will observe the resident (during rest and movement) for evidence of pain; for example, grimacing while being repositioned or having a wound dressing changed .The staff will discuss significant changes in levels of comfort with the attending physician who will consider adjusting interventions accordingly. This may include non-pharmacological measures and adjustments of regular and PRN [MEDICATION(S)] doses to find the best combination of effectiveness and tolerable side effects .If the resident's pain is complex or not responding to standard interventions, the attending physician may consider a psychiatric evaluation or referral to a pain clinic or specialist. This Federal Tag relates to complaints IN 036 and IN 758. 3.1-37(a)

Based on observation, interview and record review, the facility failed to ensure residents requiring assistance with activities of daily living (ADLs) by 2 staff members received adequate supervision and assistive devices to prevent accidents for 2 of 3 residents reviewed for accident hazards (Residents B and F). This resulted in harm when Resident B had a fall which resulted in an orbital eye fracture and was admitted to the hospital. The facility also failed to secure hazardous chemicals in 1 of 5 laundry areas (Cottage 5). Findings include: 1. During a tour of the facility, on 12/16/20 at 11:40 a.m., Resident B was observed to be sitting in her room, in a wheelchair, watching TV. She had specialized shoes on her feet and braces on each leg. The left side of Resident B's face appeared swollen with minimal discoloration under her left eye and the white of her left eye appeared reddened. During an interview, on 12/16/20 at 11:40 a.m., the resident indicated she had sustained a fall from her bed 5 weeks ago when a staff member was assisting her with incontinent care. She rolled over too far and fell over the side rail to the floor. Resident B indicated she landed on her left side and injured the left side of her face during the fall which caused her to be hospitalized . On 12/16/20 at 12:00 p.m. and 12:50 p.m., LPN 1 was interviewed. The LPN indicated she was taking report on the morning of 11/04/20 about 7:30 a.m. to 7:45 a.m., when she heard Resident B yelling from her room. She ran to the room and found Resident B laying on the floor on her left side. At the time she entered the room, she saw one CNA in the resident's room. The LPN indicated when she first found the resident on the floor and assessed her, there did not appear to be serious injury. However, suddenly, the area around Resident B's left eye began to swell and the resident's left eye appeared to be bleeding and bulging from the socket. She immediately called 911 and the resident was transported to the hospital. During an interview, on 12/17/20 at 11:30 a.m., Resident B indicated there was one staff member in the room assisting her at the time of her fall on 11/04/2020. She did not know the staff person's name and added this staff person had not assisted her since her fall and her return from the hospital. The record for Resident B was reviewed on 12/16/20 at 1:00 p.m. Her [DIAGNOSES REDACTED]. The progress notes indicated the following entry on 11/04/2020 at 8:53 a.m. Elder rolled out of bed during patient care. Head to toe assessment performed, On call notified .orders obtained to send Elder to (name of hospital), via ambulance . The resident's care plan regarding ADL (activities of daily living) for bed mobility, initiated on 5/24/2017 and last updated on 5/09/2020, indicated The elder requires extensive assist by (2) staff to turn re-position in bed. During an interview, on 12/17/20 at 11:10 a.m., the Therapy Department Manager indicated Resident B was receiving therapy at the time of the fall on 11/04/2020. The resident was being seen for core strengthening, wheelchair propulsion and maintaining an upright stance during transfers. When questioned, the manager indicated Resident B was able to assist in rolling but can't do it on her own. He felt it was appropriate for two staff members to assist in bed mobility in order for the resident to remain in the side position and to keep the resident from rolling off the bed. He indicated, at the time of the resident's fall on 11/04/20, the resident had an air mattress on her bed. Following the resident's fall, therapy had recommended to change the resident from an air mattress to a bariatric bed with bolsters in an attempt to prevent a recurrence of the fall. During a review of the facility investigation of Resident B's fall, on 12/16/20 at 2:30 p.m., the investigation indicated the following, 11/10/20 During our investigation it found that the CNA (certified nursing assistant) was rolling elder to her right side to perform care, as she was rolling the elder, the elder took hold of the grab bar, rolled to far and started falling when CNA attempted to stop the fall, she was unable to get a firm hold on Elder to stop the fall (sic). As the Elder was falling, she hit her face on the bedside table. CNA rushed to Elder side, yelled for help that when nurse entered to room to room to assist (sic). Staff in-service on proper turning and repositioning. Elder returned from hospital with a follow up visit with (name of physician) Oculofacial Plastic and Orbital Surgery and new orders . The facility investigation included a handwritten statement from CNA 2, the staff member assisting the resident at the time of the event and indicated the following: Walked into resident room to begin getting her up asked resident was she okay she stated that she was fine just ready to get up for breakfast. (sic) Resident proceeded to grab bar to turn to the right as I gave her assistance, once I notice resident was falling I attempted to grab her but was unable to grasp her firmly. I then went to the right side of the bed to be with resident as I proceeded to call for help. During an interview, on 12/17/20 at 9:30 a.m., the Executive Director (ED) indicated CNA 2, assisting Resident B at the time of her fall from bed on 11/40/20, was no longer employed at the facility. Attempts to reach CNA 2 via telephone during the survey were unsuccessful. 2. During an observation, on 12/17/20 at 12:27 p.m., Resident B told CNA 10 she needed to be changed. CNA 10 pushed Resident B's wheelchair from the dining room to the resident's bedroom and brought a standing and raising (SARA, sit-to-stand) mechanical lift into the room. The CNA placed the safety belt around the resident, secured the belt to the lift and advised the resident to hold on to the lift's handrail. Using the lift, she raised the resident to a standing position while the resident held on to the handrails of the lift. The resident was leaning backwards, holding tightly and grunting. The resident's face turned red with the effort of holding on. The CNA pushed the SARA lift from the bedroom to the adjourning restroom and lowered the resident down to sit on the toilet. While the CNA was operating the lift, there was not a second staff member in the room to ensure resident safety. After the resident was finished voiding, the CNA used the lift to return the resident to a standing position. CNA 10 pushed the SARA lift with the resident to the wheelchair next to the bed and lowered the resident into the wheelchair. During an interview, on 12/17/20 at 12:35 p.m., CNA 10 indicated she got help to transfer Resident B to bed, but usually took her to the bathroom by herself. When asked how she knew what kind of help or assistive devices the resident needed, the CNA indicated nothing was written down. She charted on a tablet but had not and was not able to log on that day. She did not think the point-of-care (POC) program on her tablet informed her of the kind of assistance the resident required. The Staff Development Coordinator helped the CNA to sign onto a computer, but CNA 10 was unable to find what kind of assistance the resident needed. During an interview, on 12/17/20 at 1:52 p.m., with the Staff Development Coordinator and CNA 10, the Staff Development Coordinator indicated the CNA's POC program did not provide information on how the resident was assisted with ADLs. It was documented in the resident's care plan, and the CNA's were able to see and review the resident's care plan on their tablets. CNA 10 indicated she only looked at the care plan if the resident was new. During an interview, on 12/17/20 at 11:10 a.m., the Therapy Program Manager indicated Resident B was on their caseload. She required two people for bed mobility and transfers, so she needed two staff members for incontinent care, changing clothes, toileting and personal hygiene. A MDS assessment, dated 11/19/20, indicated the resident was cognitively intact. She required extensive assistance by two people for transfers and toilet use. Resident B's care plan, dated 12/02/20 and reviewed on 12/17/20, indicated she had the potential risk for ADL self-care performance deficit related to impaired coordination/balance with standing and had cauda equina syndrome (damaged nerves below the spinal cord). The elder (resident) requires extensive assist by (2) staff for toileting .The elder is extensive assist of (2) staff for transferring. Elder to utilize Hoyer (mechanical sling) lift for transfers. The facility's Using of Mechanical Lift policy and procedure dated 2016, reflected 1. Observe the elder for capability of the elder to participate in the transfer. 2. Stand up lift used for the Elder to have 1 to 2 staff members. 3. Perform the lift as care plan instructs 3. During an observation, on 12/16/20 at 11:18 a.m., Resident F was lying on an air mattress on her left side with a pillow wedged between her knees. There was no floor mat, side rail or mattress bolsters. CNA 11 raised the bed to the highest position, checked the brief and determined the resident was incontinent of bladder. While the bed was in its highest position, the CNA walked into the adjourning bathroom to get a fresh brief and then left the room to get disposable wipes. The CNA did not return to the bedside until 11:22 a.m., while the bed remained in its highest position. Standing on Resident F's left side, the CNA cleaned the front perineum area. She rolled the resident onto the resident's right side, facing away from the CNA and very close to the edge of the bed. The CNA asked the resident to hold onto the bed, but there was nothing for the resident to hold. The CNA cleaned the back side of the resident, rolled the resident back onto her back and then pulled the brief from under the resident, potentially causing skin sheers. The CNA put new pants on the resident and rolled the resident again to her right side, away from the CNA, to pull the pants up to the resident's waist. The CNA left the resident's room at 11:31 a.m., with the resident's bed in the highest position, to get assistance to transfer the resident. She returned to the bedside at 11:36 a.m. During the continued observation, on 12/16/20 at 11:36 a.m., CNA 12 stood on the left side of Resident F's bed. She rolled Resident F to the right side, facing away from the CNA to put a shirt on the resident. CNA 11 was not at the bedside; she was at the resident's closet across the room. CNA 12 lowered the bed to a flat position. With her hand on the back of the resident's neck and the other hand under her knees, CNA 12 pivoted the resident to the side of the bed, causing strain on the resident's neck. CNA 11, standing to the left of the resident, put her left arm under the resident's left armpit and her right hand on the elastic waist of the pants. CNA 12 placed her right arm under the resident's right armpit and her left hand on the elastic waist of the pants. They lifted and transferred the resident into the wheelchair. The resident's shoulders raised during the transfer, and her the pants rose to the middle of her back, revealing strain on the resident's shoulders and friction across the resident's perineal area. During an interview, on 12/16/20 at 11:40 a.m., CNA 12 indicated each resident had their own gait belt which hung in the room. She did not see a gait belt for Resident F. During an interview, on 12/17/20 at 11:07 a.m., the Therapy Department Manager indicated the Therapy department was educating staff on Resident F's contracture management and positioning. Her medical history included a stroke which left her with one arm she could not use. The Therapy department's assessment of Resident F's functional status indicated she required two people to assist with ADLs and she should be transferred with a gait belt. They did not recommend grabbing underneath the arms because it could potentially dislocate her shoulder. She required two people to move her in bed and for incontinent care and dressing. She required two people because she could not maintain a position on her side and could roll out. She also had an air mattress, which slid easier than a regular mattress. Resident F's medical record was reviewed on 12/16/20 at 3:21 p.m. [DIAGNOSES REDACTED]. Resident F's most recent MDS assessment, dated 10/12/20, documented she had severely impaired cognitive skills. She required extensive assistance by two people for bed mobility, transfers, dressing, personal hygiene and toileting. Resident F's care plan, dated 10/12/20, reflected she had a significant decline in ADL function due to stroke with right sided [MEDICAL CONDITION]. Interventions included, but were not limited to, Bed Mobility: The elder is totally dependent on (1-2) staff for re-positioning and turning in bed every 2 hours and as necessary .Dressing: The elder requires extensive assistance by (1-2) staff to dress. Personal Hygiene: The elder requires extensive assist by (1-2) staff with personal hygiene and oral care. Transfer: The elder is totally dependent on (2) staff for transferring .Do not lay on R (right) side, this position is pushing her R shoulder out of socket and making her hips 'wind swept.' During an interview, on 12/17/20 at 11:30 a.m., the MDS Coordinator indicated she also wrote the residents' care plans. She was asked why Resident F's care plan indicated she could be aided by one to two people with ADLs while the MDS assessment and the Therapy Department recommended the assistance of two people. The MDS Coordinator indicated when CNA's were manually lifting a resident they could transfer the resident independently if the resident was having a good day and/or depending on who was providing the care, e.g., if the resident had confidence with the staff and was used to them. With no exception, they required two people to assist a resident if they were transferring a resident with a mechanical lift. During an interview, on 12/17/20 at 3:00 p.m., the ED and Acting Director of Nurses indicated they did not know how the CNA's determined they could perform ADL care independently when the care plan reflected a resident could be assisted by either one or two people. They would not ask a CNA to assess a resident. They did not have a written policy related to determining the number of staff to assist with ADLs. Staff members performing a manually assisted transfer (without a mechanical lift), were expected to use a gait belt. Each resident should have a gait belt in their room dedicated for their personal use. A current facility policy, titled Using a Transfer Belt in Transferring an Elder between Two Surfaces, undated and provided by the Executive Director on 12/17/20 at 3:38 p.m., reflected: When an elder requires assistance in transferring between two surfaces (bed to wheelchair, wheelchair to toilet) the team member assisting the elder must review the elder preference form. The household licensed nurse will record on the elder preference form the type of assistance to be provided and how many team members will be needed for a safe transfer. 4. During an observation in Cottage 5, on 12/16/20 from 11:20 a.m. to 12:00 noon, the door to a hallway which accessed two laundry rooms and a garage with an exit to the outdoors was wedged open with a paint can. The unsecured hallway was accessible from the common area of the Cottage. The doors to the two laundry rooms in the exposed hallway were open. A bleach bottle and an opened container of Tide PODS Laundry Detergent was laying on top of the clothes driers of both laundry rooms (for a total of two unsecured bleach bottles and two unsecured Tide PODS containers). CNA's 12 and 11 were observed to walk past the door three to four times. During an interview, on 12/16/20 at 12:00 p.m., CNA 12 indicated two residents in Cottage 5 were confused and independently mobile and acknowledged the bleach and Tide PODS were unsecured. The CNA did the laundry, but she did not know who had propped the door open. CNA 12 indicated the door should not be propped open and should only be accessible to staff members who knew the code for the code-key entry lock into the hallway. During an interview, on 12/17/20 at 3:00 p.m., the ED and Acting Director of Nurses indicated the hallway to the garage and laundry areas should always remain locked. Laundry products should not be accessible to residents. A current facility policy, titled Safe Use of Chemical, dated 2016, reflected .7. All chemicals will be stored in a locked cabinet when not in use .Chemicals related to housekeeping duties such as cleaning furniture and floors will be locked in the housekeeping closet. Items are to be removed from these areas when needed, and the cabinet or closet immediately locked. 8. Containers of chemicals will not be left on tables or countertops unsupervised with the exception of the container of sanitizer located next to the sink in the kitchen This Federal Tag relates to Complaint IN 476. 3.1-45(a)(1) 3.1-45(a)(2)