Every finding on record at River Falls Post Acute

Based on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services to maintain a safe, clean, comfortable and home-like environment for residents. Specifically, (1) Resident rooms on 100 Hall were found with damaged furniture, floors, walls, and/or trim affecting Resident (R)17, R29, R1, R28, R32, R36, R144, and R148; (2) Two restrooms and a shower room, which were available for use by residents on 100 Hall, was not maintained in good repair and/or in a sanitary manner; (3) The door and pathway to the outdoor designated smoking area were not maintained in a safe, clean, and homelike manner; the door and pathway were routinely used by five residents who smoked (R31, R5, R29, R11, and R23); and (4) Not maintaining vinyl composite tile flooring, wooden handrails, wooden corridor doors, and wood baseboards and trim, found in various locations throughout the facility, in good repair and in a manner that would allow these features to be effectively cleaned and/or sanitized. Findings include: During a tour of the 100 Hall on 03/05/25 at 8:08 AM, conducted in the company of Licensed Practical Nurse (LPN)4. The following observation were made and verified by LPN4 at the time of discovery: 8:11 AM - The floor under the steam table, located in the common area shared by the Nurses' Station and the Small Dining Room, had a section of vinyl composite tile flooring, measuring 15-feet x 3-feet. The edges of the 1-foot square tiles in this section were unsealed and popped up at the corners, making the flooring unable to be effectively cleaned or sanitized. 8:13 AM - The walls and wood trim around the doors and baseboards in the vending machine cubbyhole were damaged. 8:15 AM - A restroom located next to room [ROOM NUMBER], which was identified by LPN4 as being frequently used by residents on 100 Hall, was unclean and in disrepair. The vinyl composite floor tiles in this bathroom were cracked in multiple places, discolored, and appeared to be unclean, especially along the edges of the wall, in front of and around the toilet, and under the sink. There was wall marring along the wall to the left of the toilet below the wall - mounted safety bar, both at a level above the vinyl cove base and halfway up the wall between the top of the cove base and the safety bar. The vinyl cove base itself was unclean, and there was a gap between two adjacent lengths of the cove base. Also at 8:15 AM - The vinyl composite floor tiles in the room occupied by R17 had damage that was visible from the corridor; the damage was in the shape of linear grove the length of approximately 5-feet, and in placed, the groove extended through the tile exposing the underlayment. During an observation and interview on 03/05/25 at 8:20 AM, in the presence of LPN4, R17 stated s/he was aware of the groove in flooring, as it was directly next to her/his bed. S/he reported that, sometimes, the wheels on her/his overbed table got stuck in the big cracks in the tile when s/he moved it. S/he also reported the footboard on her/his bed was broken. R17 demonstrated this by pushing against the footboard with her/his feet and stating the footboard wiggled like a wiggle-worm. S/he stated the footboard had been broken since s/he came to this room. During this interview, an observation found the privacy curtain at the foot of R17's bed to be damaged. While R17's roommate was out of the room, R17 permitted an observation of the physical environment on both sides of the room. Both residents' beds were pushed up against the walls on opposite ends of the room. An examination of the roommate's side of the room found wall marring consistent with scraping of the wall by the upper half rail on the roommate's bed. Further observation found additional wall marring, damage (including deep scratches revealing raw wood) to the wooden window frame, and a baseboard heater across the length of the wall under the window that was damaged and not clean. The rounded corner of the roommate's bedside stand was also damaged, exposing unsealed particle board along the corner and edges of the top of the stand where the veneer had been chipped away. Review of R17's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/23/24, revealed s/he was admitted on [DATE]. Further review of the MDS revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating R17 was cognitively intact. 8:28 AM - R36's room was found to have wall marring along the side of her/his bed consistent with scraping of the wall by the upper half rail of R36's bed. At the head of R36's bed were three wires protruding from a length of metal conduit that ran vertically near the window frame; the ends of the wires were capped with twist-on wire caps. Directly below the end of the metal conduit was a metal backplate with sharp edges. Damaged vinyl composite tiles were noted on the floor. Wall marring was found at the head of the bed and along the side of the roommate's bed, and the wooden frame around the window was also marred. 8:30 AM - Next to R36's room was a door labeled with a sign that announced: Resident's Bathroom Only - No visitors please. On the wall beside this door was a sign indicating the bathroom was accessible to wheelchairs. When opened, the bathroom was found to be unclean and in disrepair. A section of vinyl composite floor tile located immediately inside the doorway to this room, measuring approximately 16-inches by 3-inches, was missing. There was also a gap between the vinyl plank flooring in the corridor to the vinyl composite tile squares inside the bathroom where there was no transitional threshold. The bathroom had a lavatory just inside to the right of the entrance, as well as at least two toilet stalls. Stored inside this bathroom was a 3-bag hamper on wheels made of polyvinyl chloride (PVC) piping. There was a large area of dried brownish colored liquid on the floor between the hamper and the shower stalls. Examination of the sink and the toilet stalls found the walls, floors, and vinyl cove base to be unclean and in disrepair. Upon exiting this bathroom at 8:33 AM on 03/05/25, R36 was observed to enter it and close the door behind her/him. 8:35 AM - The Shower Room, across the hall from room [ROOM NUMBER] and room [ROOM NUMBER], found multiple spots of dark brown material on the floor of the shower stall under and around the shower chair. This material was examined by LPN4, who identified it as feces. The floor of the shower was dry, and there was no evidence that the shower stall had been recently used. The floor tile under the sink cabinet was not sealed and unclean. The vinyl cove base between the sink cabinet and the door frame was pulled away from the wall. 8:51 AM - R29's room had damage to the floor tiles as well as a drawer missing from one of the two wardrobes. R29's wardrobe was noted to be missing a drawer when observed earlier in the week on 03/03/25. When interviewed at 10:35 AM on 03/03/25, in the presence of LPN5, R29 stated the drawer had been missing the entire time s/he had been at the facility. R29 reported s/he was admitted to this facility about two years ago. Review of R29's MDS with an ARD of 02/04/25, revealed s/he was admitted on [DATE]. The resident scored 14 out of 15 on the BIMS, which indicated intact cognition. Additional observations found wall marring and/or damaged floor tiles visible in rooms occupied by R1, R28, R32, R144, and R148. Multiple corridor doors were found with damage through the veneer. Multiple sections of wooden handrails that lacked any coating to seal the exposed raw wood; the unsealed exposed wood presented a surface that was porous and could not be effectively cleaned or sanitized. 8:57 AM - The panic bar on the door leading to the outside designated resident smoking area was missing an end cap; the uncapped end of the panic bar was exposed to residents when the door was open. A broken windowpane in the door was repaired with cardboard and black duct tape. Multiple squares of vinyl composite floor tile in front of the door and in the same general vicinity were broken. The pathway to the outside smoking area was cluttered with various items, including but not limited to: a housekeeping cart, three shopping carts, an empty cardboard box stacked on top of a bedside commode, multiple bedside commodes and/or three in one (3-in-1) commode chairs, a mop bucket, milk crates, reclining cardiac chairs, PVC pipe shower chairs, wheelchairs, and a trapeze bar with stand. On 03/05/25 at approximately 3:15 PM, LPN4 provided a copy of Work Order #7125, which was created on 10/11/24 at 9:02 AM, it documented, window in breezeway door broken need to cover and order new. 8:59 AM - An observation was made of three windows that opened onto the area leading to the designated resident smoking area. LPN4 identified these windows as belonging to room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. All three windows housed air conditioning (A/C) units. The gaps between the A/C unit and the window frame in each window were filled with various porous materials that were non-resistant to inclement weather and/or pests, including loose insulation and cardboard. The cardboard used to fill a gap between the A/C unit and the window frame for room [ROOM NUMBER] was noted to be wet. The above findings were shared with the Administrator and Regional Director of Clinical Services (RDCS)3 at approximately 9:30 AM on 03/05/25, at which time the surveyor requested a copy of the facility's policy on Physical Environment. As of the time of the exit conference at approximately 4:00 PM on 03/05/25, no policy was provided.

Based on observation, interview, and facility policy review, the facility failed to ensure smoking materials were properly disposed of in the designated resident smoking area. The facility also failed to maintain good condition of the fire blanket mounted in the smoking area used by 5 of 5 residents who smoke, Resident (R)5, R11, R23, R29, and R31. Findings include: Review of the facility's policy titled Smoking Policy - Residents, revised on August 2022, documented, Policy Statement: This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation: . 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 4. Ashtrays are emptied only into designated receptacles. 10. Any resident who are [sic] able to smoke will do so under direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. During an observation on 03/05/25 at 8:57 AM, of the designated outdoor resident smoking area and in the company of Licensed Practical Nurse (LPN)4, revealed the designated smoking area was comprised of a table and several outdoor metal benches on a concrete pad, next to a small cinderblock building. Also, on the concrete pad was a large red metal Justrite Oily Waste Can, with a foot pedal and a self-closing device. Mounted on the exterior wall of the cinderblock building was a grey metal box labeled Fire Blanket, a fire extinguisher, and a black metal box labeled Smoker's Apron. On the table was an ashtray. During an observation on 03/05/25 at 9:02 AM, revealed the ashtray located on the table was found to be completely full with about two dozen cigarette butts. The contents of the ashtray had not been emptied into the receptacle. An examination of the Fire Blanket box found the lower half of the box brown with rust; the bottom of the box was badly rusted with metal flaking away from the bottom edge. Upon opening the box, the middle of the fire blanket stored inside the box was found to be damp. The bottom edge of the fire blanket was saturated and covered with mold. The above observations were verified by LPN4 at the time of discovery. A subsequent review of the posted smoking schedule revealed the first smoking time for the residents was not until 11:00 AM, and the last smoking time of the day was at 9:00 PM. The ashtray full of cigarette butts was made almost two hours before the first resident smoking time was due to occur on 03/05/25.

Based on observation, interview, and facility policy review, the facility failed to ensure drugs were properly labeled and stored in locked compartments and under proper temperature controls, as evidenced by: (1) not monitoring medication refrigerator temperatures twice daily when storing vaccines; (2) storing an unidentifiable clear liquid into a syringe in the medication refrigerator, recapping the needle, and storing it in the medication refrigerator; (3) failure to date multi-dose vials of Tuberculin Purified Protein Derivative (PPD) after opening and accessing them; and (4) not securing a medicated cream prescribed for Resident (R)23, which was left unattended in an unlocked shower room. These practices had the potential to affect more than an isolated number of residents with a facility census of 41. Findings include: Review of the undated facility policy titled Medication Labeling and Storage, documented, Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation: Medication Storage: . 4. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. Medication Labeling: 1. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. 5. Multi-dose vials that have been opened or access (e.g., needle puncture) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. 11. Medications may not be transferred between containers. During an observation on 03/05/25 at 7:54 AM, of the medication refrigerator, located in the medication room, in the company of Licensed Practical Nurse (LPN)4, revealed on the outside of the refrigerator's door was a form titled, Refrigerator & Freezer Temperature Log and dated March (with no year). Review of the temperature log found the following instruction: Record the Time, Temperatures & Initials two times (2) each business day, upon arrival (morning) and when closing the office at the end of the day (evening). Twice daily refrigerator and freezer temperatures were recorded at 8:00 AM and 7:00 PM on the first (1st) and second (2nd) day of March, and temperatures were recorded for 8:00 AM on the third (3rd) day of March. There were no temperatures recorded after 8:00AM on the third day of the month. This was verified at the time of the observation by LPN4. During an interview on 03/05/25 at 7:54 AM, LPN4 confirmed that vaccines were being stored in this refrigerator and that the facility's policy required twice daily temperature monitoring. During an observation on 03/05/25 at 7:55 AM, revealed the refrigerator was opened, and its drawer was removed for examination. A loose red-capped syringe (not in a package) was found sticking cap-end up in the back of the drawer. Observation of the syringe found it contained a clear liquid, and the syringe was not labeled. During an interview on 03/05/25 at 7:55 AM, LPN4 confirmed the syringe contained an unidentified liquid and was not labeled. LPN4 was not certain of the syringe's contents but stated, I would assume it is a drawn-up PPD. LPN4 discarded the syringe in a sharps container. Further observation of the drawer revealed two multidose vials of Tubersol (R) Tuberculin PPD with safety caps removed and evidence that the vials had been accessed by needles. Neither of these bottles nor their original packaging had been dated to indicate when the vials had first been opened. Review of the Manufacturer's Instructions on the Tubersol (R) Tuberculin PPD vials stated, Discard opened product after 30 days. The drawer also contained 27 prefilled single-dose syringes of 2024-2025 Influenza Vaccine Flublok (R), which required the twice daily temperature monitoring. LPN4 confirmed these findings. During an observation on 03/05/25 at 8:39 AM, of the shower room, located between rooms [ROOM NUMBERS], while accompanied by LPN4, revealed the shower room was unoccupied at the time of the observation. On the edge of the sink was a box containing a tube of Betamethasone Dipropionate 0.05% cream (used to help relieve discomfort caused by certain skin condition) with a prescription label for R23. During an interview on 03/05/25 at 8:45 AM, LPN4 confirmed the medicated cream should not have been left unsecured in the shower room, and s/he removed it.

Based on observation, interviews, and facility policy review, the facility failed to treat one (1) resident with respect and dignity related to colostomy care for one of two sampled residents, Resident (R)11. Findings include: Review of the Resident's [NAME] of Rights displayed in the Administrative Hall revealed, As a resident of this facility, YOU or your legal guardian has the right to . Be treated with respect and dignity. Review of R11's Face Sheet revealed an admitted [DATE], with diagnoses including but not limited to: Schizophrenia, chronic kidney disease, colostomy, and homicidal/suicidal ideations. Review of R11's Brief Interview for Mental Status (BIMS) dated 12/18/24, revealed R11 scored 13 out of 15, which indicated R11's cognition was intact. Review of R11's Physician Orders, revealed the following orders dated 07/10/24, Change colostomy bag Q [every] shift and PRN [as needed] and Empty colostomy bag Q [every] shift and PRN [as needed]. Review of R11's Care Plan Report, revealed the focus area, Ostomy - Bowel: Resident has a colostomy and is at risk for complications related to concerns with self-image, odor control, skin integrity. The interventions and tasks included the following, Encourage the resident to express feelings/concerns. Keep ostomy site covered. Keep pouch emptied routinely. Maintain privacy while providing care. Observe for signs and symptoms of complications related to colostomy and notify physician of abnormal findings. During an observation of R11, on 03/03/25 at 10:40 AM, revealed the resident sitting in the hallway between Halls one (1) and two (2). R11's colostomy bag was exposed and hanging from the right anterior area. The colostomy bag was half full and contained fecal matter. During an interview on 03/03/25 at 10:45 AM, R11 stated he did not like his colostomy bag, but he had to wear it at all times. R11 stated he had no choice but to wear it like that because he had no privacy bag to cover it and it was never covered. During an interview on 03/04/25 at 9:50 AM, R5 complained of R11 wheeling around the facility all day with his colostomy bag uncovered. R5 stated it was gross to look at the colostomy bag, especially when he/she was in the dining area looking at the food where people were eating, and food was being served. R5 also stated that he/she did not understand why staff did not place a cover over the colostomy bag to prevent residents from looking at it and losing their appetites. During an interview, on 03/05/25 at 11:21 AM, the Assistant Director of Nursing (ADON)2 stated he/she did not know the colostomy bag needed to be covered and now the expectations were for the Social Worker (SW) to have a nice conversation with him/her to have it covered.

Based on record review, interview, and facility policy review, the facility failed to develop a Comprehensive Care Plan addressing the use of an antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications, Resident (R)32. Findings include: Review of the facility's undated policy titled Care Plans, Comprehensive Person-Centered, documented, Policy Statement: A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implements for each resident. Policy Interpretation and Implementation: . 7. The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframes; b. describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of R32's Electronic Medication Record (EMR) revealed s/he was admitted to the facility on [DATE], with diagnosis including but not limited to, unspecified Dementia. Review of R32's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/13/25, revealed a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating R32 had severe cognitive impairment. Further review of the MDS revealed R32 was assessed as requiring moderate to maximal assistance from staff with performing many activities of daily living, such as dressing, bathing, personal hygiene, and toilet use. Review of R32's Order Summary Report for March 2025, found the following Physician Orders: Quetiapine Fumarate (an atypical antipsychotic) oral tablet 50 milligrams (mg) - Give one tablet by mouth one time a day for Dementia with Behaviors (ordered on 01/07/25); and Quetiapine Fumarate oral tablet 50 mg - Give two (2) tablets by mouth at bedtime for Dementia (ordered on 01/07/25). The risks and benefits for the use of this atypical antipsychotic medication were reviewed with R32's responsible party on 01/07/25, and the responsible party gave consent for its use. Review of R32's Progress Notes found an Encounter Note dated 02/21/25, which documented the following, Date of Service: 02/21/2025 Visit Type: Psychiatry Evaluation H&P [History and Physical] . History Of Present Illness: . [R32] is currently at River Falls Post Acute for STR [short-term rehabilitation] after recent hospitalization for not able to care [her/himself]. Per provider records patient has a noted psychiatric diagnosis of dementia. 2/21/25 Patient seen today for initial psychiatric evaluation. Upon assessment patient is resting in bed with [her/his] head covered up. After review of hospital notes patient has had multiple falls at home and [her/his spouse] appears no longer to be able to take [her/him]. Per staff patient stays in [her/his] bed the majority of the time with [her/his] head covered up however at times the patient becomes combative and as needed in the hospital records was very agitated during [her/his] hospital stay. I asked the patient multiple times to uncover [her/his] head speak with me and [she/he] refused to do so. [S/He] did not speak during the assessment [s/he] grunted when I asked [her/him] to uncover [her/his] head so we could talk but never actually spokeduring the assessment. Patient continues to benefit withiout adverse effect(s) identified from current psychotropic medication regimen. Continue medication(s) as prescribed, the patient is stable at curent dose and/or needs more time to see benefiticial effects. Dose reduction attempted and/or reduction at this time will risk decompensation of patient. Monitor for changes in mood or behaviors. [sic] Review of R32's Care Plan Report, which was last reviewed on 02/18/25, found no mention of the use of an antipsychotic medication or the need for staff to monitor for adverse side effects associated with the use of an antipsychotic. During an interview on 03/05/25 at 2:20 PM, the Regional Director of Clinical Services (RDCS)3 confirmed his/her expectation was that if a resident were to receive an antipsychotic medication, this should be addressed in the resident's Care Plan.

Based on record review, interview, and facility policy review, the facility failed to ensure resident records were accurately documented and complete, for 2 of 19 residents whose medical records were reviewed, Resident (R)17 and R148. Findings include: Review of the undated facility policy titled Policy on Accuracy of Medical Records documented, Purpose: To ensure that all medical records maintained by River Falls Post Acute are accurate, complete, legible, and timely to support high-quality resident care, legal compliance, and effective communication among healthcare providers. A medical records [sic] accuracy policy for long term care should prioritize detailed, timely, and objective documentation of all patient health information. Scope: This policy applies to all staff, including but not limited to nurses, physicians, therapists, certified nursing assistants (CNAs), and administrative personnel, who document or access resident medical records within the skilled nursing facility. Policy Statement: . All entries in medical records must reflect the true and current condition, care, and treatment of residents. Procedures: 1. Documentation Standards - All entries in medical records must be factual, precise, and based on direct observation, assessment, or resident-reported information. Review of R17's electronic medical record (EMR) found s/he was admitted to the facility on [DATE], with diagnoses including but not limited to: encounter for other orthopedic aftercare, which was secondary to multiple fractures sustained during a motor vehicle accident. Review of R17's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. S/he was also assessed as being dependent or requiring maximal assistance from staff with performing many activities of daily living, such as dressing, bathing, personal hygiene, and toilet use. Review of R17's Order Summary for [DATE] found that cardiopulmonary resuscitation (CPR) was to be performed on the resident in the event of cardiac arrest; this order was dated [DATE]. Further review of the resident's EMR, found an Encounter Note, dated [DATE], which documented the following: Date of Service: [DATE] Visit Type: Follow Up . Code Status: Do Not Attempt Resuscitation (DNR/no CPR). This note was electronically signed by Physician Assistant (PA)6. During an interview on [DATE] at 10:20 AM, the Regional Director of Clinical Services (RDCS)3 confirmed that the resident's Code Status per the [DATE] Order Summary was to perform CPR, and the Encounter Note dated [DATE] documented the resident's Code Status as DNR/No CPR. RDCS3 searched through a binder of documentation maintained by the Director of Nursing (DON) and found documentation where the resident had signed a form titled Resident / Family Consent For Cardiopulmonary Resuscitation on [DATE], and that Attending Physician (AP)9 wrote in his/her own handwriting an order for Full Code on [DATE]. Review of an Encounter Note in the resident's EMR, dated [DATE], found the following: Date of Service: [DATE] Visit Type: MD Admission H&P . Code Status: Discussed Advanced Care Plan with Patient . Patient wishes to be a: DNR . This document was electronically signed by AP9 at 11:03 AM on [DATE]. At 11:22 AM on [DATE], the following addendum was added to the Encounter Note by AP9: Addendum Details: Patient has signed resuscitation orders on ,d+[DATE] desired a full code. [sic] Review of additional Encounter Notes recorded between [DATE] through [DATE] by the resident's AP9, Alternate Physician #10, and PA6, found 11 entries documenting the resident's Code Status as either DNR or No Not Attempt Resuscitate (DNR/no CPR). During a followup interview on [DATE] at 10:25 AM, RDCS3 confirmed that R17's Code Status was incorrectly stated in multiple Encounter Notes. RDCS3 also confirmed that nursing staff would consult the resident's Physician Orders and not the Encounter Notes when determining whether to perform CPR on a given resident. Review of R148's EMR found s/he was recently admitted to the facility on [DATE], with diagnoses including but not limited to: Methicillin Resistant Staphylococcus Aureus Infection (Site Unspecified), Cellulitis of Unspecified Part of Limb, and Local Infection of the Skin and Subcutaneous Tissue (Unspecified). Review of R148's Admission MDS with an ARD of [DATE], revealed a BIMS score of 15 out of 15, which indicated intact cognition. This MDS was still In Progress, and multiple sections of the MDS were not yet completed at the time of the survey. A review of evaluations completed upon the resident's admission to the facility found a Skin & Wound Evaluation V7.0, with an effective date of [DATE] at 6:23 PM. This evaluation documented the presence of a Pressure Injury described as Stage 3: Full-thickness skin loss that was present on admission. The wound measurements were noted as 2.1 centimeters (cm) x 1.0 cm with no depth. The wound bed was described as filled with 100% granulation tissue. However, the location of this wound was not recorded anywhere on the evaluation. The above Skin & Wound Evaluation was shown to Licensed Practical Nurse (LPN)4 at 9:57 AM on [DATE], at which time LPN4 confirmed the location of the wound was not recorded anywhere on the evaluation. During an interview on [DATE] at 2:30 PM, RDCS3 confirmed that it was his/her expectation that each resident's medical record should be accurate and complete, including accurately documenting a resident's Code Status and documenting the location of a resident's pressure injury.

Based on observation and interview, the facility failed to maintain firmly secured handrails on each side of the corridors for resident use. Two sections of handrails were missing from two of four corridors in the resident areas, with holes in the wall and/or wooden attachment sites protruding from the walls where the handrails had been. Findings include: Observations of the facility were made in the company of Licensed Practical Nurse (LPN)4 beginning at 8:08 AM on 03/05/25, with the following findings noted: At 8:08 AM - Observation of the wall between the Linen Room and the Employee Breakroom (across the hall from room [ROOM NUMBER] and room [ROOM NUMBER]), found a 3-foot section of wall where handrailing was missing. At one end of the 3-foot section was a 4-inch x 4-inch piece of wood protruding from the wall; at the other end was a 4-inch x 4-inch square of wall painted blue with a 1-inch-wide hole in the center. This 4 x 4-inch area was painted a different color from the rest of the wall and gave the appearance that another 4 x 4-inch piece of wood was missing. LPN4 verified that a section of handrail was missing from this location. At 8:15 AM - Observation of the wall between a Resident Restroom and room [ROOM NUMBER], found a 16-inch section of wall where handrail was missing. At one end of the 16-inch section was a 4-inch x 4-inch piece of wood protruding from the wall; at the other end was a 4-inch x 4-inch square of wall painted maroon with a large irregular hole in the center. This 4 x 4-inch area was painted a different color from the rest of the wall and gave the appearance that another 4 x 4-inch piece of wood was missing. LPN4 verified that a section of handrail was missing from this location. During an interview with the Administrator and the Regional Director of Clinical Services (RDCS)3, at approximately 9:30 AM on 03/05/25, the surveyor requested a copy of the facility's policy on Physical Environment. As of the time of the exit conference, at approximately 4:00 PM on 03/05/25, no such policy was provided.

Based on review of facility policy, record review, observations, and interviews, the facility failed to ensure that Resident (R)1 was free from accidents, for 1 of 1 residents reviewed for accidents. Specifically, R1 suffered a fracture due to improper transfer by Certified Nursing Assistant (CNA)1. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a last revision date of March 2022, documented, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: . (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. Review of a facility document titled, Patient Care Transfer Techniques: Ensuring Safe and Effective Transfers, which was undated, revealed: Patient Assessment: Prior to a transfer, it is important to assess the patients physical condition, mobility level, weight bearing status, and any specific considerations or precautions. Review of R1's Face Sheet revealed R1 was admitted to the facility with diagnoses including but not limited to: spinal stenosis, lack of coordination, muscle weakness, difficulty walking, and osteoarthritis. Review of R1's Minimum Data Set with an Assessment Reference Date (ARD) of 09/17/24, revealed, Chair/bed-to-chair transfer: The ability to transfer to and from a bed to a chair (or wheelchair). The MDS indicated that R1 was, Dependent - Helper does ALL the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. Review of R1's Care Plan revealed, I have limited physical mobility r/t Cerebral Palsy, spinal stenosis AEB Fatigue, Impaired balance, fluctuation in ADL's, easily agitated during care, left upper extremity and left lower extremities. Further review of the Care plan revealed interventions which directed staff to, TRANSFER: I Require a mechanical sling lift with 2 staff to assist with transfers. Review of the facility 5-Day reportable dated, 09/24/24 revealed the following: Date and time of incident 9/20/24. Type of incident: Bone or joint fracture. Details: CNA was transferring resident from Broda chair to the bed: When his left leg got caught between the Broda chair and bed frame. Summary of incident: Resident Closed fracture of proximal end of left tibia occurred when his left leg accidentally got caught between the broda chair and the bed frame. Intervention to prevent future incident/injury: Education of all CNA ' s for appropriate transfers, reviewing Kardex, transfer audit of all care plans with transfer process. All CNA's will have competency on proper use of mechanical lifts. Care plan reviewed and revised to indicate resident requires sling lift with 2 staff to assist with transfers. Review of R1's Emergency Department Provider Note dated 09/20/24, revealed an xray result, which documented, Closed Fracture of Proximal End of left tibia, unspecified fracture morphology. During an interview on 01/02/25 at 3:00 PM, R1 revealed he remembers being helped by one lady, from the chair to his bed. R1 stated he felt like his leg hit the bed frame when he was being transferred causing the injury. During an interview on 01/02/25 at 3:12 PM, Certified Nursing Assistant (CNA)1 revealed that R1 was being transferred from the broda chair to the bed. During the transfer the resident hit his leg against the rail and CNA1 heard a pop. CNA1 stated R1 was laid in bed and the nurse was called. CNA1 stated that at the time prior to transfer, she did not have access to the system and could not access the patient's Care Plan due to issues with her access. CNA1 further stated multiple attempts have been made to the staff responsible for Electronic Health Records (EHR) access, with no success. CNA1 revealed that she typically works in the rehab unit and that this was her first time caring for R1. CNA1 concluded she thought the resident was a one person transfer based on what everyone else did. CNA1 stated she did not realize that the resident was a two person transfer, with a hoyer lift until after incident occurred. During an interview on 01/02/25 at 6:30 PM, the Director of Nursing revealed when it comes to transfers her expectations is to follow Care Plans. Care plans are accessed in PCC (Point Click Care - computer software program for Electronic Health Records) under the Care Plan tab. The DON states her expectation is for staff to follow the Care Plan and staff are not allowed to deviate from the plan. The DON further states that the CNA did not follow the facility policy and did not meet the facilities expectations when it comes to safe transfer of residents and following care plans. The DON concluded that if R1 was transferred using the mechanical lift the injury may have been avoided.

Based on interview, record review, and facility document review, the facility failed to ensure that one (Resident(R) 137) of one residents reviewed for medication errors, was assessed for self-administration of medications. Nursing staff left medication with R137, who was not assessed to self-administer them. Findings include: Review of the facility's policy titled Self-Administration of Medications dated 02/2021, revealed Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so .As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Review of R137's undated Admission Record located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, major depressive disorder, and spinal stenosis of the lumbar region. Review of R137's five-day entry Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/23/23, located in the EMR under the MDS tab, revealed the resident had moderate cognitive impairment, based on a Brief Interview for Mental Status (BIMS) score of 10 out of 15. The resident required limited assistance of one person for bed mobility and extensive assistance of one person for personal hygiene. Due to admitting diagnoses, an attempt to transfer, locomotion on unit, dressing, and toilet use, were not assessed during the look back period. Review of R137's entire EMR revealed no evidence that the IDT had assessed the resident to determine if it was safe for the resident to self-administer medications. Review of R137's Care Plan dated 06/19/23, located in the EMR under the Care Plan tab, revealed the resident had not been care planned for self-administration of medications. Review of R137's Physician Orders for the month of June 2023, located in the EMR under the Orders tab, indicated R137's orders included acetaminophen 325 milligram (mg), give two tablets every six hours as needed for mild pain or fever greater than or equal to 100.4 The resident also had an order for Carvediol 6.25 mg, one table two times daily. The resident did not have an order for Benadryl. Further review of the physician orders revealed R137 did not have an order for self-administration of medications. Review of R137's Nurse's Note dated 06/30/23, located in the EMR under the Progress Notes tab, revealed that a nurse left medication with R137, although the resident was not assessed as safe for self-administration. Per this note, I [nurse] included prn [as needed] acetaminophen with the night meds because resident complaint [sic] of pain in legs around knees. however [sic], resident did not take because resident waited for daughter to come before taking. resident [sic] only took the carvediol[sic] [treats the blood pressure]. I had conversation with resident's daughter later in night concerning resident's medication. She brought the acetaminophens back to show me, along with a benadryl [an antihistamine] which she said that she found in the resident's bed. resident [sic] does not have an order for this medication. During an interview conducted with the Director of Nursing (DON) on 07/04/23 at 12:45PM, the DON stated Licensed Practical Nurse (LPN) 3 notified her immediately after the incident. The family was already at the bedside when the event happened, and the Medical Director was made aware of the incident and ordered the facility to monitor the resident. A urinalysis was also ordered to rule out any other medications in the resident's system and was negative. A Facility Reportable Incident (FRI) was submitted to the State Survey Agency (SSA) on 06/30/23, and an investigation was initiated by the Director of Clinical Services (DCS). Per the DON, the nurse was suspended until the investigation was completed. During the interview, the DON confirmed that R137 had not been assessed to self-administer medication and the resident was not cognitively intact enough to be able to do so. During a telephone interview with LPN3 on 07/04/23 at 1:10 PM, LPN3 stated that while giving R137 her nighttime medications, he took the medication cup with two Tylenol and carvedilol into room and handed it to the resident then walked out of the room. When questioned if he had witnessed the resident take the medication, LPN3 stated No, I did not, LPN3 stated he did not know why he left the medication with the resident, but I know I should have stayed. LPN3 stated, The daughter came out carrying the medication cup and told me that she had told her mother not to take medications until she got there. The daughter asked me what medications were in the medication cup. I saw the two Tylenol and a Benadryl capsule. LPN3 stated he had not administered Benadryl, explaining, No, she doesn't have an order for Benadryl, I don't know where that came from. An interview with the DCS on 07/05/23 at 4:19 PM, revealed that the facility had not determined where the Benadryl (that was found in the resident's bed) came from. The DCS confirmed that R137 did not have orders for Benadryl, adding that there was only one resident who currently had as needed orders for Benadryl, and that resident was on a different medication cart. When questioned concerning the process for resident's self-administration of medications, the DCS replied residents are assessed on admission and periodically to evaluate if they are cognitively intact enough to self-administer medications. The DCS confirmed R137 was not assessed for self-administration of medications, and the medication should not have been left with the resident.

Based on record review, interview, and review of the facility's policy titled Abuse and Neglect-Clinical Protocol, the facility failed to ensure that Resident (R)1 was free from abuse, for 1 of 3 residents reviewed for abuse. Findings include: Review of the facility's policy titled, Abuse and Neglect - Clinical Protocol with a revised date of March 2018, revealed, 1. Abuse . the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse . 2. Willful . the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. R1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1's Skin assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 0, indicating R1 had severe cognitive impairment. Review of the facility's incident report dated 5/13/22 revealed, that staff was outside R1's room when they heard loud voices coming from the room. Staff heard R1 say, come get this b**** off me. When staff arrived in the room, Certified Nursing Assistant (CNA)1 was observed on top of R1, holding him down by his wrists, yelling Call 911, I'm going to kill him. Review of the facility's Medical Director (MD) witness statement dated 05/18/22, revealed, Nothing in the past medical history to give any indication that this was a possiblity. Nothing in the pre employment assessment/questionnaire that would indicate risk of this behavior. 11+ years of employment here with no indication that would be indicative of this behavior. ER drug screen and complete work up showed nothing contributory. Per discussion with peers and staff members, no conversation or observed behaviors that would indicate pending incident. No indication of willful intent by the CNA based on her comments immediately after and since the occurrence. Based on every report or statement, we're dealing with a classic nondrug induced psychotic break. Review of the facility's In-Service Employee Tracking revealed CNA1 received in-service for Abuse, Neglect, Elder Justice Act, and Resident Rights on 01/25/22. Review of CNA1's SC Certified Nursing Assistant Package requested through Hire Right, dated 12/25/20 revealed the following: Adjudication Status: Meets Company Standards Court Records - completed - meets company standards Prohibited Parties - completed - meets company standards National Sex Offender Registry - completed - meets company standards Widescreen Plus National Criminal Search - completed - meets company standards Nurse Aide Registry - completed - meets company standards Healthcare Statewide Criminal Search - completed - meets company standards Health Care Sanctions - completed - meets company standards Review of CNA1's SLED (S.C. Law Enforcement Division) Catch (Citizens Access to Criminal Histories) dated 12/18/20 revealed No Arrest Data In an interview with CNA2 on 5/25/22 at 10:40 AM. CNA2 stated she heard a lot of cursing and screaming while she was next door providing care to another resident. CNA2 went to the room and CNA1 was on top of R1 holding him down by his wrists. CNA2 stayed with R1 until the nurses arrived. In an interview with CNA3 on 5/25/22 at 10:45 AM, CNA3 stated she heard a loud noise and cursing and screaming coming from R1's room. She went to the room and saw CNA1 over R1, holding him by his wrist screaming, Call 911, I am going to kill him. CNA3 also stated that CNA1 kept referring to the R1 as her husband. CNA3 then went to get the nurses while CNA2 stayed with R1. In an interview with Licensed Practical Nurse (LPN)1 on 5/25/22 at 10:55 AM, LPN1 revealed she was outside with LPN2 when CNA3 came and said they needed help. LPN 1 and LPN 2 went inside the room and asked what was going on. CNA1 got off R1 and CNA1 began referencing R1 as her husband. LPN1 got CNA1 to leave the room and go outside with her. LPN1 and CNA1 went outside. In an interview with LPN2 on 5/25/22 at 11:00 AM, LPN2 stated that she saw LPN1 and CNA1 in the courtyard and LPN1 waived for her to come over. CNA1 was talking about children being molested and her husband having a [CONDITION(S)]. LPN2 states she has known CNA1 for [AGE] years and she is one of the best CNAs she has ever worked with. LPN2 states she just could not believe that CNA1 was acting the way she was. In an interview with the Administrator on 5/25/22 at 11:15 AM, the Administrator stated she spoke with CNA1 and CNA1 told her she had been up all night and couldn't sleep, so she sat on her porch. CNA1 revealed to the Administrator she began to hear voices and the wind was telling her to go to work and check on her residents. CNA1 then asked the Administrator were they going to go shoot her husband or will he just die of a silent [CONDITION(S)]. When CNA1 was asked what happened, she told the Administrator she was checking on her residents, but they were all asleep. But when she went into R1's room, he was pleasuring himself and she wanted him to stop. CNA1 was transported to the emergency room of the local hospital, accompanied by LPN1. CNA1 was admitted to the lockdown unit at the local hospital later that evening.

Based on observation, interview, and record review the facility failed to ensure that one of two sampled residents with pressure ulcers, Resident #10 received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The findings include: Observation of Licensed Practical Nurse (LPN) #4 on [DATE] at 1:53 p.m. during preparation for Resident #10's pressure ulcer dressing change revealed the nurse dropped the scissors onto the floor of the Nurse's station when gathering the supplies for the procedure. LPN #4 picked the scissors up from the floor and used them to cut a 4x4 gauze sponge which s/he opened while at the wound cart in the hallway near the Nurse's station. LPN #4 carried the dressing change supplies to Resident #10's room and placed them directly onto the resident's bed without a barrier. LPN #4 then proceeded with the pressure ulcer care [DATE] at 2:00 p.m. Observed Resident #10's right great toe pressure ulcer when assessed by the Medical Director on [DATE] at 3:15 p.m. The Physician stated that the ulcer was an improved Stage three (3) ulcer. The Physician stated that the facility did not downstage pressure ulcers and that if the wound was staged at a three (3) then even if it improved it would be a three (3). Observed Resident #10's pressure ulcer re-dressed by LPN #3 with good technique. Review of the facility policy/procedure for Non-sterile Dressing Change dated [DATE] indicated in the Overview that the purpose of this procedure was to provide guidelines for non-sterile dressing changes to protect wounds from injury and to prevent the introduction of bacteria. The procedure indicated the step-by-step process for dressing changes that included the placement of equipment on the bedside stand or over bed table. Arrange the supplies so that they can easily be reached. If using scissors, clean with bleach wipe prior to procedure. Review of the Progress Notes by the Medical Director dated [DATE] revealed that Resident #10's pressure ulcer would be considered unavoidable due to her malnutrition, generalized immobility and generalized [CONDITION(S)]. All efforts have been in place to prove this wound and avoid new or worsening wounds. Review of the Admission Record for Resident #10 revealed initial admission into the facility on [DATE] and readmission into the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) for Resident #10 dated [DATE] revealed readmission into the facility [DATE] from an acute hospital. The staff assessed Resident #10's cognitive ability as severely impaired. Resident #10 exhibited no behaviors. The resident was totally dependent on one staff member for bed mobility, dressing, eating, toilet use, personal hygiene, and bathing. Resident #10 had impaired range of motion of both upper and lower extremities. The resident was always incontinent of urine and bowel. Staff assessment of Resident #10's pain indicated that s/he made non-verbal sounds and had facial expressions which indicated pain on one (1) to two (2) days of the lookback period. Resident #10 had no falls. The resident was 63 inches tall and weighed 89 pounds. Resident #10 was at risk for pressure ulcers but had no pressure ulcers. Resident #10 received no special treatments. Review of the Care Area Assessment Summary for Resident #10 revealed care plan decisions for [CONDITION(S)], cognitive loss/dementia, visual function, communication, urinary incontinence, psychosocial well-being, mood state, activities, falls, nutritional status, pressure ulcer, [CONDITION(S)] drug use and pain. Review of the quarterly MDS for Resident #10 revealed reentry into the facility on [DATE] from another nursing home or swing bed. Staff assessment of the resident's cognitive skills indicated s/he was severely cognitively impaired. The resident had no behaviors. Resident #10 was totally dependent on two (2) staff for bed mobility, transfers, and toilet use. The resident was totally dependent on one (1) staff for locomotion on and off the unit, dressing, eating, personal hygiene and bathing. The resident had impaired range of motion of both upper and lower extremities. Resident #10 was always incontinent of urine and bowel. Staff assessed the resident with indicator of pain which included non-verbal sounds and facial expressions on one (1) to two (2) days of the lookback period. Resident #10 was 60 inches tall and weighed 92 pounds. No weight loss. Resident #10 had one Stage four (4) pressure ulcer. Resident #10 received five (5) days of passive range of motion. The Resident was examined by the Physician or Nurse Practitioner #2 times over the 14-day period and the resident's orders were changed twice in the 14 days. Review of the Care Plan for Resident #10 revealed plans that included: -Activities of daily living (ADL) self-care performance deficit including oral hygiene related to impaired mobility and weakness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Initiated [DATE] and revised on [DATE]. Goals included: -will have needs met on daily basis through the next review date. -Will be appropriately dressed in assistance by the next review date. Interventions: - Required assist of one (1) to two (2) staff for dressing. -Quarter side rails two (2) for position and to define parameters of bed. -Required assist of one (1) to two (2) staff for bathing and showers as needed. -Required assist of one (1) staff for meals. -Required assist of one (1) to two (2) staff for personal hygiene and oral care. -Require using Lift with two (2) staff assistance for transfers. Has Impaired functional mobility related to limited range of motion upper and lower extremities some days it is better than others at times tenses up her muscles. Initiated [DATE] and revised on [DATE]. Goals included: -will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date. Initiated [DATE], Revised on [DATE] and target date [DATE]. -will have no decease in ROM through next review date. Initiated [DATE] target date [DATE]. Interventions included: -May be out of bed up in Geri Chair for positioning and mobility as tolerated. Initiated [DATE] -Restorative program for ROM to bilateral hands as tolerated 15 minutes per day, five (5) days a week. [DATE] revised on [DATE]. -Observe/document/report as needed any signs/symptoms of immobility: contractures forming or worsening, thrombus formation, skin breakdown, fall related injury. Initiated [DATE] and revised [DATE]. Potential for skin breakdown related to fragile skin, incontinent, impaired mobility, impaired circulation, impaired range of motion, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Goals: Will have no further skin issues through the next review date. Initiated [DATE] revised on [DATE] target date [DATE] -Will have a decrease in skin tears through the next review date. Initiated [DATE]. Target date [DATE]. -Will have no further pressure ulcer through next review date. Initiated [DATE]. Revised [DATE]. Target date [DATE]. Interventions: [DATE]- Lotion skin all over her body daily during care as tolerated due to dry scaly skin. Revised on [DATE]. -[DATE] Place house shoes or socks on before transferring her with mechanical lift. Revision [DATE]. -[DATE] Heel protectors as ordered. Revised [DATE] -Administer treatments as ordered and observe for effectiveness. Initiated [DATE] and revised [DATE]. -Apply Prevalon boots to bilateral heels as tolerated initiated [DATE] -Float heels as tolerated. [DATE]. -Need a moisturized applied as needed to skin. Do not massage over bony prominences and use mild cleansers for peri-care/washing. [DATE] and revised on [DATE]. -Required air mattress to bed. Check for position and placement as ordered. [DATE] revised [DATE]. - Required skin inspection during peri care. Observe or redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Initiated [DATE] and revised on [DATE]. -Medications as ordered. -Monitor skin integrity to bilateral hands. Apply kerlix gauze to bilateral hands as ordered. Initiated [DATE] and revised [DATE] - Notify Family, Medical Doctor, and Registered Dietitian as needed. [DATE]. -Obtain and observe lab/diagnostic work if ordered. Report results to MD and follow up as indicated. [DATE] revised on [DATE]. -Podiatrist may treat as indicated. [DATE] -Supplements as ordered. [DATE]. Revised [DATE]. -Treatments as ordered. [DATE] and revision [DATE]. Alteration in skin integrity related to pressure area right great toe dated [DATE] revised on [DATE]. Goal: -Will have minimal risk of infection of pressure ulcer during 90-day review period. Initiated [DATE], revised [DATE]. Target date [DATE]. -Will exhibit healing of pressure ulcers through the next 90 days. Initiated [DATE], revised [DATE]. Target date [DATE]. Interventions: -Air mattress as ordered -Apply Prevalon Boots to bilateral heels as tolerated -Licensed nurse weekly skin check -Observe for numbness, pain, pallor, decreased or absent pulses, changes in color/temperature in extremity or [CONDITION(S)], report all changes to the MD/ ARNP -Provide with a podiatrist consult as needed -Provide with a wound care consult with physician as needed -Provide medications as ordered -Render treatment as ordered. Monitor response to treatment. If poor response or condition worsens, notify MD/ARNP -Supplements as ordered. Review of the Braden Scale for Predicting Pressure Sore Risk version 3 dated [DATE] revealed Resident #10 had a score of 10 which indicated high risk for pressure ulcer development. Review of the Braden Scale for Predicting Pressure Sore Risk version 3 dated [DATE] revealed a score of nine (9) which indicated the resident had a very high risk for the development of pressure sores. Review of the Braden Scale for Predicting Pressure Sore Risk version 3 for Resident #10 revealed a score of 12 which indicated high risk for development of pressure ulcers. Review of the Weekly Wound Information Sheet for Resident #10 effective [DATE] revealed the location of the wound was the right foot first metatarsal phalangeal joint (right first toe). The wound was facility acquired. Stage two (2) pressure ulcer. 1.5 centimeters by 1.0 centimeters by 0.1 cm with no drainage. The Medical Doctor (MD) was notified on [DATE]. The Responsible party was notified on [DATE]. Review of the Weekly wound Information Sheet dated [DATE] revealed the pressure ulcer on Resident #10's right great toe was a Stage three (3) ulcer that measured 0.3 cm by 0.2 cm by 0.1 cm. Review of the Progress of the wound indicated the area to the right first toe at joint was slightly open without exudate. Review of the [NAME] Wound Physician's Wound Evaluation Management Summary dated [DATE] revealed the chief complaint of wound on her right first toe. At the request of the referring provider a thorough wound care assessment and evaluation was performed today. Resident has a Stage three (3) pressure wound of the right first (1st) toe for at least seven (7) days duration. Wound size 0.3 by 0.2 by 0.1 cm. Review of the Weekly Wound Log dated [DATE] through [DATE] indicated that Resident #10's right great toe pressure ulcer was a Stage four (4) ulcer that measured 0.5 cm by 1.4 cm by 0.2 cm. Interview with LPN #4 on [DATE] at 2:42 p.m. in the Nurse's station revealed that s/he didn't realize that s/he picked the scissors up from the floor and used them to cut the gauze. The nurse stated that s/he was nervous. When questioned about his/her failure to use a barrier under the dressing change supplies LPN#4 stated that s/he knew that there was supposed to be a barrier, that was why s/he put a 4x4 gauze under the resident's foot. Interview with the Administrator on [DATE] at 9:00 a.m. in the Conference Room revealed that LPN#4 was a new nurse and was nervous during the care provided to Resident #10. The facility had created a Quality Assurance Performance Improvement (QAPI)/ Action Plan to address the use of improper technique for pressure ulcer care.

Based on interview and record review, the facility failed to provide an environment free of accidents and hazards for 1 of 4 residents reviewed for abuse. Certified Nursing Aide (CNA) #1 transferred Resident #1 by themselves, using the sling lift. Facility policy states that residents are to be transferred by two staff members when the lift is being used. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of 5-day reportable for Resident #1's injury of unknown origin on 12/21/20 at approximately 11 AM revealed the injury was discovered 10/15/20 at approximately 10:25 AM. The resident indicated pain on their right shoulder and discoloration was observed (13 cm x 11 cm) during assessment of the area. X-ray showed no fracture, but findings were consistent with chronic rotator cuff tear. Facility investigation revealed an improper transfer on 10/13/20. Review of Resident #1's care plan on 12/21/20 at approximately 12:15 PM revealed that The resident requires assistance by (2) staff via sling lift to move between surfaces. This intervention was initiated on 8/9/2019. Review of CNA #1's employee action form on 12/21/20 at approximately 11:20 AM revealed that CNA #1 was terminated because they Failed to follow policy and procedure. Review of staff witness statements on 12/21/20 at approximately 11:25 AM revealed that CNA #1 got the resident up by themselves using the sling lift, as no other staff were available. Review of facility policy on 12/21/20 at approximately 12:10 PM revealed that The use of a mechanical lift requires the assistance of two staff members at all times.

Based on record review, interviews and facility policy review, the facility failed to notify the physician and family of a fall for 1 (Resident 2) of 3 residents reviewed for accidents. Findings are: The facility's policy titled, Fall Procedure, revised on 08/2019, indicated the following, Procedure 3. If a fall occurs the following actions will be taken: i. Notify MD and responsible representative. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed severe cognitive impairment and extensive assistance from staff for activities of daily living (ADL). The Care Area Assessment indicated Resident 2 was at risk for falls related to muscle weakness, need for assistance with ADLs, difficulty walking and history of falls. Resident 2's care plan, initiated on 08/19/20, included a risk for fall related injuries. Review of Resident 2's Emergency Department (ED) record dated 09/03/20 revealed Resident 2 sustained a right impacted femoral neck [MEDICAL CONDITION]. The physician recommended nonoperative care related to the fracture. A fall incident report dated 09/04/20 by Nurse 1, revealed that on 09/01/20, Certified Nursing Assistant (CNA) 1 was in the room with Resident 2 when she went down on one knee with assistance and sat on the floor. Resident 2 was assessed, vital signs were stable, was able to move lower extremities without complaints of pain or discomfort. No documentation for notifications of the physician or resident representative was found in Resident 2's electronic medical record (EMR). On 09/17/20 at 2:35 PM, an interview was conducted with CNA 1 who stated he entered Resident 2's room to see her holding onto her bedside commode with both hands, facing the commode. The CNA stated Resident 2 looked wobbly and looked like her leg would give out. As he assisted her, the resident went down to the floor with her right knee hitting the floor first and then sitting on the floor with both knees up and her feet flat on the floor. The CNA stated he left to get the nurse and the nurse looked at Resident 2. After the nurse left, Resident 2 pointed to the commode and he helped her stand up and she used the commode. The CNA stated Resident 2 leaned on the commode to get cleaned up after and then he assisted her to walk to her bed. She did not act like either of her legs were weak. The CNA reported Resident 2 was positioned in bed and went to sleep. On 09/17/20 at 3:55 PM, an interview was conducted with Nurse 1, who stated she was notified by CNA 1 on the evening of 09/01/20, that he had lowered Resident 2 to the floor. The nurse stated Resident 2 did not fall, did not have any pain, and was assessed by the nurse to the best of her ability. The nurse stated she did not write the incident report until 09/04/20. The nurse stated she did not notify anyone of the fall and was unable to explain her failure to do so. On 09/17/20 at 3:46 PM, an interview was conducted with the Nurse Practitioner (NP) who stated she had not known Resident 2 had a fall 2 days prior when she examined her on the morning of 09/03/20. The NP stated she thought it was obvious Resident 2 had a fracture because she exhibited pain and limited range of motion to the right side. The NP stated she ordered x-rays to be done that day. The NP stated she asked the Director of Nursing (DON) if Resident 2 had a fall, but the DON stated she did not know of one. On 09/18/20 at 10:26 AM, an interview was conducted with the DON who stated Resident 2 had a witnessed fall on 09/01/20 and Nurse 1 had not notified her or the physician of the fall. The DON stated she had not known of the possibility of the fall until after the NP examined Resident 2. The DON stated Nurse 1 wrote the incident report for the fall on 09/04/20 and the care plan was updated on that date. The DON stated staff were educated on the fall policy on 09/07/2020, but Nurse 1 did not attend the education and resigned shortly after. The DON stated she expected to be notified along with the physician and resident representative anytime a resident had a fall.

Based on record review, staff interviews and facility policy review, the facility failed to report a fall and follow the facility's policy for monitoring a resident after a fall for one (Resident 2) of three residents reviewed for accidents. This deficient practice delayed timely intervention for a resident who sustained a [MEDICAL CONDITION]. Findings are: The facility's policy titled, Fall Procedure, revised on 08/2019, indicated the following, Procedure 3. If a fall occurs the following actions will be taken: b. Monitor the resident each shift for 72 hours. d. Pain will be evaluated every shift for 72 hours for all residents that experience a fall. E. Document evaluation, pertinent facts. i. Notify MD and Responsible representative. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 2's admission Minimum Data Set (MDS) assessment dated [DATE] revealed severe cognitive impairment and extensive assistance from staff for activities of daily living (ADL). The Care Area Assessment indicated Resident 2 was at risk for falls related to muscle weakness, need for assistance with ADLs, difficulty walking and history of falls. Resident 2's care plan, initiated on 08/19/20, included a risk for fall related injuries. Resident 2 was discharged on [DATE] and was no longer residing at the facility. Review of Resident 2's Emergency Department (ED) record dated 09/03/20 revealed Resident 2 sustained a right impacted femoral neck [MEDICAL CONDITION]. The physician recommended nonoperative care related to the fracture. A fall incident report dated 09/04/20 by Nurse 1, revealed on 09/01/20, Certified Nursing Assistant (CNA) 1 was in the room with Resident 2 when she went down on one knee with assistance and sat on the floor. Resident 2 was assessed, vital signs were stable, and was able to move lower extremities without complaints of pain or discomfort. No other documentation of the fall was included in the resident's electronic medical record (EMR). On 09/17/20 at 2:35 PM, an interview was conducted with CNA 1 who stated he entered Resident 2's room to see her holding onto her bedside commode with both hands facing the commode. The CNA stated Resident 2 looked wobbly and looked like her leg would give out. As he assisted her, she went down to the floor with her right knee hitting the floor first and then sitting on the floor with both knees up and her feet flat on the floor. The CNA stated he left to get the nurse and the nurse looked at Resident 2. When the nurse left, Resident 2 pointed to the commode and he helped her stand up and she used the commode. The CNA stated Resident 2 leaned on the commode to get cleaned up after and then he assisted her to walk to her bed. She did not act like either of her legs were weak. The CNA reported Resident 2 was positioned in bed and went to sleep. On 09/17/20 at 3:55 PM, an interview was conducted with Nurse 1, who stated she was notified by CNA 1 on the evening of 09/01/20, that he had lowered Resident 2 to the floor. The nurse stated Resident 2 did not fall, did not have any pain, and was assessed by the nurse to the best of her ability. The nurse stated she did not write the incident report until 09/04/20. The nurse stated she did not notify anyone of the fall and was unable to explain her failure to do so. On 09/17/20 at 4:26 PM, an interview was conducted with CNA 2 who stated she cared for Resident 2 on 09/02/20. CNA 2 stated Resident 2 was tired that day and did not get up, but the CNA did not think that was unusual because there had been days in the past that she had not wanted to get up. The CNA stated she assisted Resident 2 into a wheelchair and took her to the bathroom, where Resident 2 transferred herself to the toilet and then back to bed. During the transfer, Resident 2 stated she thought her foot must be hurting, and CNA 2 reminded Resident 2 that her foot had been injured in a fall prior to her admission. On 09/17/20 at 9:21 PM, an interview was conducted with Nurse 2 who cared for Resident 2 on the night of 09/02/20. The nurse stated Resident 2 was sleepy on the night of 09/02/20 when she and another nurse went into the room to try and get a urine sample via catheterization. The nurse stated she thought Resident 2 was not her normal self. She thought Resident 2 must have had COVID-19 as she had recently had a test conducted for [MEDICAL CONDITION]. The nurse stated Resident 2 had both hands on her hips when they positioned her for the catheterization. The nurse indicated Resident 2 did not complain of pain during the positioning for the catheterization but did make facial grimacing when they were conducting the catheterization. The nurse stated Resident 2 went back to sleep after the procedure. The nurse put Resident 2 in the book to be seen by the nurse practitioner (NP) the next day since she was sleepy and not herself. The nurse made no notations in the residents record of the catheterization, hip guarding, or facial grimacing witnessed of the resident The nurse stated she did not know Resident 2 had experienced a fall at that time and did not see any bruising or swelling of the hips. On 09/17/20 at 3:46 PM, an interview was conducted with the Nurse Practitioner (NP) who stated she did not know Resident 2 had experienced a fall 2 days prior when she examined her on the morning of 09/03/20. The NP stated she thought it was obvious Resident 2 had a fracture because she exhibited pain and limited range of motion to the right side. The NP stated she ordered x-rays to be done that day. The NP stated she asked the Director of Nursing (DON) if Resident 2 had a fall, but the DON stated she did not know of one. On 09/18/20 at 10:26 AM, an interview was conducted with the DON who stated the physician saw Resident 2 on 08/31/20 for reports of nausea and vomiting. A COVID-19 test was ordered and conducted that day. The physician again saw Resident 2 on 09/02/20 for lethargy and ordered blood and urine tests. The DON stated the NP saw Resident 2 on 09/03/20 and ordered hip and knee x-rays. The DON stated she expected staff to notify her, the physician, and the resident's representative (RR) anytime a resident had a fall. The DON stated Resident 2 was not monitored after the fall as the facility had not known of the witnessed fall. The DON stated Nurse 1 came to the facility on [DATE] and filled out the incident report on that day, and the care plan was updated on that date. Staff education on falls was conducted on 09/07/20, but Nurse 1 did not attend and resigned shortly after that date.

Based on interview, record review, and review of the facility's policy, the facility failed to implement their abuse prohibition policy by failing to train two Certified Nursing Assistant ((CNA) #20 and CNA#13) out of a sample of five CNAs. The failure to implement the facility's abuse prohibition policy had the potential to adversely affect all 40 residents residing in the facility. (Cross Reference F[AGE]0 and F947). Findings include: 1. Review of CNA#20's personnel file, provided by the facility, revealed the staff member was hired on 06/13/06. Review of a document titled, Employee Educational Profile, for CNA#20 revealed the staff member attended abuse and neglect prohibition on 09/20/16. 2. Review of CNA#13's personnel file, provided by the facility, revealed the staff member was hired on 10/01/12. Review of a document titled, Employee Educational Profile, for CNA#13, revealed the staff member attended abuse and neglect prohibition on 09/20/16. During an interview on 12/31/19 at 2:41 PM, he/she was asked to provide the telephone numbers for CNA#20 and CNA13. This information was not provided by the conclusion of the investigation. During an interview with the Administrator on 01/01/2020 at 9:22 AM, the Administrator confirmed CNA#20 and CNA#13 did not receive abuse prohibition training since 2016. The Administrator stated he/she was recently employed as of 10/19. Review of the facility's policy entitled, Abuse Prevention, dated as revised 11/19, revealed, . Training/Identification/Prevention.Staff receives orientation and ongoing training, at a minimum yearly, on . Appropriate interventions to deal with aggressive and/or reactions of residents . How to report their knowledge related to allegations and reasonable suspicion of a crime . Notification of their reporting obligations under the Elder Justice Act (EJA) to report a suspicion of a crime to the state survey agency . What constitutes abuse, neglect, and misappropriation . Reporting of abuse and whom to report abuse to within the facility .

Based on observation, interview, and record review, it was determined that the facility failed to provide timely interventions and care in accordance with professional standards of practice to allow for the highest level of practicable well-being for one resident (Resident #6) of three residents reviewed regarding skin care. Failure to provide timely interventions and care may result in the deterioration of the resident's skin integrity. Findings include: The Admission Record, part of the electronic medical record, (EMR) revealed Resident #6 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status (BI[CONDITION]). He/she had short and long term memory problems and disorganized thinking. The functional status in the MDS revealed the resident required extensive assistance to total dependence for activities of daily living to include extensive assistance of one for bed mobility and was incontinent of bowel and bladder. The MDS assessment also indicated the resident was at risk for the development of pressure ulcers. The Licensed Nurse Weekly Skin Observation (Weekly Skin Checks), dated 12/08/19, revealed the resident's skin was fragile and had a history of [REDACTED]. The care plan initiated 11/05/19 revealed the resident was at risk for alterations in skin integrity. The interventions included weekly skin assessments. Preventative measures to prevent skin tears included protective sleeves to bilateral arms as tolerated. Identify potential causative factors and eliminate/resolve when possible. As tolerated heel protectors on while in bed. Assist with toileting. Assist with repositioning in bed and transfers using proper technique when moving to avoid skin damage. CNA to provide skin checks during delivery of care and report skin changes, irritation, or breakdown to the nurse. Float heels while in bed as tolerated. Provide incontinent care after each incontinent episode and cleanse and apply protective barrier. On 12/31/19 at 10:50 AM the Assistant Director of Nursing (ADON) and the surveyor were observing Resident #6's skin integrity. During the observation, a dressing was observed on the upper left hip. There were no markings on the dressing to indicate the date the dressing was applied or an initial of the staff who applied the dressing. The ADON stated she was unaware of the purpose of the dressing. The ADON removed the dressing from the top of the left hip of Resident #6. The dressing was an occlusive Vaseline gauze dressing. The observation revealed a linear abrasion to Resident #6's left upper hip. The Skin/Wound Note Progress Note dated 12/31/19 at 11:41 AM entered into the record completed by the ADON following the discovery of the abrasion documented it was found during a skin audit with the surveyor. There was an occlusive dressing removed. There was a reddened area that measured 4.3 centimeters (cm) by 0.5 cm. The nurse practitioner and the resident's responsible party were notified. An interview with DON on 12/31/19 at 12:30 PM stated she was investigating the left hip abrasion that was identified by the surveyor today. The DON stated Registered Nurse (RN) #4 had taken care of the resident the last two days, working 12 hour shifts. The DON stated he/she spoke with RN #4. The DON stated RN#4 stated he/she saw the dressing, but did not know why it was there, who placed it there or followed up to determine the reason for the dressing. RN#4 stated he/she never checked under the dressing. On 12/31/19 at 2:30 PM the ADON, the clinical nurse consultant, and the DON observed Resident #6's left hip abrasion that was now open to air. The wound was pink in color and presented as an abrasion. ADON #1 and the DON confirmed there was no documentation of the abrasion found in the resident's record. An interview with RN #4 on 12/31/19 at 2:50 PM revealed he/she noticed the left hip dressing when he/she placed a [MEDICATION NAME] on the resident's back today. RN#4 stated he/she did not know why it was there or who placed it there. RN#4 stated he/she did not check what was under the dressing or follow-up with why the dressing was there. RN#4 stated he/she had not ever noticed it before today. An interview on 01/01/2020 at 10:55 AM with the Administrator revealed the expectation of the facility was that the healthcare workers observe any changes in the residents, report these changes and document these changes. The facility expects the CNAs to report to the licensed nurses and the nurses to respond according to professional standards of practice. The Administrator confirmed these expectations were not met in regard to Resident #6. An interview with DON on 01/01/2020 at 11:20 AM verified CNA #39 discovered the left hip abrasion on 12/26/19 and notified RN #4 several times during the 7:00 AM to 7:00 PM shift. The CNA#39 notified the licensed practical nurse (LPN) #9 as she came on for the following 12 hour shift since the RN#4 did not respond to the concern of CNA#39 about Resident #6. LPN #9 placed a dry dressing on the abrasion to the left upper hip area of Resident #6 but did not document or notify anyone. LPN #9 told the DON the abrasion was about three centimeters in length. The DON confirmed the wound was larger than when LPN #9 had observed it on 12/26/19. The DON verified there were no care plans, no nurse's notes, no notification of the physician documented, no skin assessment, and no treatment record regarding the abrasion. The DON verified a second dressing to Resident #6 was provided to the abrasion due to the dressing observed on 12/31/19 was not dated, was not initialed, was not a dry dressing originally placed on the area by LPN#9 on 12/26/19. The DON was unable to determine who the second nurse may have been. There was no documentation in the record of a second dressing change for Resident #6. The DON stated it would be her expectation staff would notify the physician, obtain an order, document the order in the treatment record and update the resident's skin assessment and care plan. The DON had not completed the investigation at the time of the exit but stated the abrasion was caused by the use of incontinence briefs against the skin of the resident. An interview with LPN #9 on 01/01/2020 at 12:00 PM revealed CNA#39 called her into Resident #6's room to observe the area on the resident's upper left hip. The LPN stated the CNA had reported he/she had notified RN #4 several times during his/her shift, but he/she did not respond. The LPN stated he/she cleansed it and applied a dry dressing which she signed and dated. LPN#9 stated he/she did not document anything or notify anyone. LPN#9 stated he/she worked 7:00 PM to 7:00 AM. He/She stated RN #4 followed her at 7:00 AM on [DATE]. The Skin Protocol policy, revised August 2019, included the licensed nurse identified an alteration in skin integrity, the nurse was to notify the physician for a treatment order, and document the communication in the resident's medical record. This citation is the result of a Facility Reported Incident investigation.

Based on record review and staff interview, the facility failed to ensure that two Certified Nursing Assistants ((CNA) #13, and CNA#25) out of a sample of five, were provided routine annual evaluations. Failure to complete the annual evaluations which addressed measures of performance as a CNA and identified areas of needed improvement could affect provision of training for the staff member and the quality care for residents. Findings include: 1. Review of CNA#13's paper personnel file, revealed the staff member was hired on 10/01/12. Review of a document titled, Performance Evaluation, for CNA#13, revealed the staff member's last annual performance review was on 09/27/16. The staff member went to an as needed (PRN) position on 03/29/17. 2. Review of CNA#25's paper personnel file, revealed the staff member was hired on 04/27/16. Review of a document titled, Performance Evaluation, for CNA#25, revealed the staff member's last annual performance review was on 10/01/17. The staff member went to a PRN position on 09/22/19. During an interview on 12/31/19 at 2:41 PM, the Administrator stated the direct supervisor of the CNAs' would complete the annual performance review. It was during this interview the Administrator was asked for the CNAs' telephone numbers and these telephone numbers were not provided. During an interview on 12/31/19 at 2:50 PM, the Assistant Director of Nursing (ADON) stated he/she did not do the annual reviews for the CNAs and neither did the Director of Nursing (DON). During an interview on 12/31/19 at 2:50 PM, Registered Nurse (RN#4) stated he/she did not perform annual CNA reviews, but did state he/she did supervise the CNAs while on the floor. During an interview on 12/31/19 at 3:00 PM, Licensed Practical Nurse (LPN#9) stated he/she did not conduct the annual CNA reviews. During an interview on 12/31/19 at 3:45 PM, the DON stated he/she did not complete PRN CNA annual reviews. The DON stated she determines competency while she was out on the floor working with staff. At 3:58 PM, the Administrator and the Business Office Manager (BOM) entered the conference room. The BOM stated the two CNAs were considered employees of the facility. The BOM stated he/she was not sure why the PRN CNAs were not passed onto the DON for completion of the annual reviews and went on to state it has always been this way.

Based on interviews and record review, the facility failed to ensure that two Certified Nursing Assistants ((CNA)s #20 and CNA#13), out of five sampled, were in-serviced annually on dementia care, abuse prohibition, and additional training which would ensure CNA staff were competent to perform their duties within a nursing home. This failure placed 40 residents at risk for improper care and services. Findings include: 1. Review of CNA#20's personnel file, provided by the facility, revealed the staff member was hired on 06/13/06. Review of the staff member's personnel file, CNA#20 went to as needed (PRN) status on 03/01/16. CNA#20 had no evidence of participating in annual in-services since 2016. There was no evidence of dementia care, abuse prohibition, or any additional training for CNA#20 since 2016 provided by the facility or any other entity. 2. Review of CNA#13's personnel file, provided by the facility, revealed the staff member was hired on 10/01/13. Review of the staff member's personnel file, CNA13 went to PRN status on 03/29/17. CNA#13 had no evidence of participating in annual in-services since 2016. There was no evidence of dementia care, abuse prohibition, or any additional training for CNA#13 since 2016 provided by the facility or any other entity. Review of facility training packet titled, Employee Education Hours, with a hand written date of 09/25/19 identified the following training was to be provided by the Director of Nursing (DON) to CNAs on an annual basis: . Abuse, Neglect, Exploitation.Injury of unknown source.Reporting Suspected or confirmed abuse.Fall Prevention.Turning/Repositioning.Catheter Care Male/Female.Behaviors. After these training objectives, was a document titled, Written Competency Behavior Assessment and Intervention. There were 10 multiple choice questions which were to be taken by the CNAs to ensure their understanding of the material in-serviced on. Also included in this training packet, were documents for return demonstration for hand washing, a full body lift, perineal care for both male and female residents, and catheter care for both male and female residents. During an interview on 01/01/2020 at 9:22 AM, the Administrator presented documents to show evidence of CNA training. During this interview, the Administrator confirmed both CNA#20 and CNA#13 had no annual in-services since 2016. The Administrator stated it was her belief the PRN CNAs received training from other facilities, in which they worked full-time. A request was made for policies on CNA training. The facility did not provide these documents prior to the end of the investigation. During a subsequent interview on 01/01/2020 at 10:46 AM, with the Administrator, he/she once again stated the CNAs received training from other facilities. Also present during this interview was the Clinical Services Consultant (CSC). CSC stated the PRN CNAs needed to bring in proof of their training on dementia care, abuse prevention, and any other competencies they have received. CSC stated in-service training was provided at their facility every six months, upon hire, and as needed. During an interview on 01/01/2020 at 11:09 AM, with the DON, the DON stated he/she attempted to reach the PRN CNAs by telephone and was unsuccessful. The DON stated the facility needed to put a plan in place to train the PRN CNAs and make this a higher priority for the facility.

Based on record review, review of facility policy titled Abuse Prevention Program and interview, the facility failed to implement its Abuse Prevention Program policy related to investigating and reporting for Residents #17 and #24, 2 of 12 residents sampled for Abuse. An injury of unknown origin for Resident #17 was not investigated or reported to the State Agency. An allegation of abuse made by Resident #24 was not investigated or reported to the State Agency. The findings included: The facility admitted Resident #17 with [DIAGNOSES REDACTED]. Record review of Resident #17's nurse's notes on 7/16/19 at 2:26 PM, revealed on 2/6/19 the nurse was called to the resident's room where a nurse aide was with the resident in the bathroom. The resident was tearful, complained of left upper arm pain and a purple/blue discoloration was observed on the resident's left, inner, upper arm. The note indicated the findings were reported to the Director of Nursing (DON) and nurse practitioner. Record review of Resident #17's progress notes from 2/6/19, on 7/16/19 at 3:10 PM, revealed the nurse practitioner evaluated the resident after receiving the report of the injury of unknown origin. The progress note also revealed the resident had tenderness, pain and limited ROM of the left arm. In addition the resident had an ecchymotic area to the left upper arm, trauma unknown. Pt (patient) is poor historian. Review of the facility's reportable incidents on 7/16/19 at 2:45 PM, revealed no documentation indicating the facility investigated the cause of the discoloration and pain to Resident #17's arm. In addition, there was no documentation to indicate the injury of unknown origin was reported to the State Agency. During an interview with the Director of Nursing (DON) on 7/16/19 at 8:47 AM, the DON stated s/he did not know about the Resident #17's injury of unknown origin on 2/6/19. The DON confirmed the nurse's notes indicated she/he was made aware of the injury on 2/6/19 but stated the nurse did not report the incident to her/him. The DON stated a nurse who identifies an injury of unknown origin is to complete an Incident Report and SBAR (Situation, Background, Assessment and Recommendation) note per facility protocol. The DON stated this was not done. The DON stated had s/he been aware of the incident it would have been investigated and reported to the State Agency per the facility's Abuse Prevention Program policy. The DON stated s/he had not read the nurse's note from 2/6/19 until now. During an interview with Licensed Practical Nurse (LPN) #2 on 7/17/19 at 10:32 AM, LPN #2 stated s/he was the nurse who identified the injury of unknown origin for Resident #17 and wrote the nurse's note on 2/6. LPN #2 stated the DON was not in the building at the time s/he evaluated the resident but did report the injury of unknown origin to the DON when s/he arrived in the building. LPN #2 stated s/he also notified the nurse practitioner who ordered x-rays of Resident #17's arm. LPN #2 stated s/he did not complete an Incident Report or SBAR note per facility protocol. Review of the facility's Abuse Prevention Program policy revealed should an injury of unknown origin be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. In addition, if an injury of unknown origin is reported, the Administrator, or his/her designee, will promptly notify the State licensing/certification agency. Review of Resident #17's nurse's notes and the care plan revealed the resident had a history of [REDACTED]. The x-rays completed on 2/6/19 revealed no fracture. The nurse practitioner followed up with Resident #17 on 2/13/19 and the resident was able to move her/his left arm with no tenderness or pain. During an interview with the Resident Representative (RR), the RR stated the resident had a long history of running into or bumping into things causing bruising or other injuries. The RR stated this hasn't been much of an issue over the last few months due to Resident #17 not trying to get up as much as s/he used to. Resident #24 was admitted to the facility 6/5/19 with [DIAGNOSES REDACTED]. Interview with Resident #24 on 7/15/19 at approximately 10:15 AM revealed an unidentified Certified Nursing Assistant (CNA) was rough with the resident and bruised him/her. This occurred a week ago. S/he informed CNA #1. Interview with CNA #1 on 7/15/19 at approximately 10:27 AM revealed that s/he spoke with Resident #24 and noticed a bruise on his/her arm. The resident said a colored girl had yanked his/her arm around. The CNA was not sure if it had been reported. Interview with Administrator and Director of Nursing on 7/15/19 at approximately 10:33 AM revealed there had been no reports related to Resident #24. Interview with DON on 7/15/19 at approximately 3:43 PM s/he confirmed CNA #1 should have reported suspected abuse to the facility. Review of the facility Abuse Policy on 7/16/19 at approximately 2:05 PM revealed it is the responsibility of employees, facility consults, physicians, family, visitors, vendors or others to report any incident or suspected incident of neglect or resident abuse.

Based on interview and record review the facility failed to report a reasonable suspicion of a crime for 1 of 12 residents reviewed for abuse. Resident #24 made an allegation of abuse that was not reported to the police or state. The findings included: Resident #24 was admitted to the facility 6/5/19 with [DIAGNOSES REDACTED]. Interview with Resident #24 on 7/15/19 at approximately 10:15 AM revealed an unidentified Certified Nursing Assistant (CNA) was rough with the resident and bruised him/her. This occurred a week ago. S/he informed CNA #1. Interview with CNA #1 on 7/15/19 at approximately 10:27 AM revealed that s/he spoke with Resident #24 and noticed a bruise on his/her arm. The resident said a colored girl had yanked his/her arm around. The CNA was not sure if it had been reported. Interview with Administrator and Director of Nursing on 7/15/19 at approximately 10:33 AM revealed there had been no reports related to Resident #24. Interview with DON on 7/15/19 at approximately 3:43 PM s/he confirmed CNA #1 should have reported suspected abuse to the facility. Review of the facility Abuse Policy on 7/16/19 at approximately 2:05 PM revealed it is the responsibility of employees, facility consults, physicians, family, visitors, vendors or others to report any incident or suspected incident of neglect or resident abuse.