Every finding on record at Serenity Spring Senior Living at Arlington

Review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, interview, and policy review, the facility failed to ensure the medical director attended the meetings quarterly. This had the potential to affect all residents. The facility census was 44.Findings include:Review of QAPI sign-in sheets revealed the medical director did not attend QAPI on 11/25, 12/25, 01/26, 02/26, and 03/26. The facility was unable to locate the sign-in sheets for 01/26 and 03/26.Interview on 07/09/26 at 11:46 A.M. with the Administrator revealed he provided all the QAPI sign-in sheets that he was able to locate. Interview on 07/09/26 at 1:14 P.M. with Interim Director of Nursing (IDON #158) revealed the medical director should have attended the meeting on 01/26 however, they were unable to locate the sign-in sheet. IDON #158 verified the dates listed above were not attended by the medical director.Review of policy titled, Quality Assurance and Performance Improvement (QAPI) Program, revised February 2020 revealed the Administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements. The committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments to the plan.

Based on medical record review, review of the infection control documentation, observation, staff interview, and policy review, the facility failed to ensure infection control standards were implemented in the facility for medication administration. This affected seven residents (#43, #19, #34, #16, #25, #2, and #47) of seven residents observed for medication administration. Furthermore, the facility failed to ensure infection surveillance in the facility. This had the potential to affect all residents. The facility failed to ensure Enhanced Barrier Precautions (EBP) and Contact Precautions (CP) signs were posted per the physician orders. This affected two residents (#3 and #15). Additionally, the facility failed to wear the appropriate Personal Protective Equipment (PPE) for residents in EBP and CP. This affected two (#28 and #46). The facility census was 44. Findings include: 1. Observation on 07/07/26 beginning at 7:36 A.M. through 8:34 A.M. of medication administration completed by Licensed Practical Nurse (LPN) #145 revealed LPN #145 took vital signs on five residents, gave oral medications to five residents (#19, #34, #16, #35, and #2), administered a lidocaine patch using gloves to one resident (#16), administered eye drops using gloves to one resident (#43), administered insulin (#16 and #2), and took residents blood sugar (#16 and #47) while utilizing gloves without performing hand hygiene between each task. Furthermore, while administering medication on 07/07/26 at 8:28 A.M. to Resident #25, LPN #145 set the cup of water mixed with MiraLAX on the floor, gave Resident #25 a bite of pills in pudding, and then gave Resident #25 a drink of the MiraLAX that was placed on the floor. Interview on 07/07/26 at 8:50 A.M. with LPN #145 verified hand hygiene was not completed during medication administration for all residents including when she took a blood sugar, took vitals on five residents, applied a lidocaine patch, and while administering oral and subcutaneous medications. Furthermore, LPN #145 verified she placed the cup of water and MiraLAX on the floor before giving Resident #25 a drink. LPN #145 stated the hand sanitizer was taken off of the medication cart the day prior and was placed at the nurse's station. 2. Review of the infection control documentation for 2026 revealed no infection surveillance was completed. Interview on 07/08/26 at 4:19 P.M. with Nursing Manager (NM) #121 who was the facility's Infection Preventionist (IP) revealed she was hired into the position of IP in May of 2026. Prior to her being hired in May 2026, no one had been in the role of the IP and no one was completing the infection surveillance in the facility. Interview on 07/09/26 at 8:51 A.M. with NM #121 verified all documentation completed before May 2026 and back to January of 2026 was completed in July of 2026 because she had to go back through and complete it. NM #121 verified she was back dating all of the infection control documentation. Review of policy titled, Surveillance for Infections, revised June 2023 revealed the infection preventionist will conduct ongoing surveillance for healthcare associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. 3. Review of Resident #3's medical record revealed an admission date of 01/22/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, acute and chronic respiratory failure with hypoxia, hyperlipidemia, systolic heart failure, gastro-esophageal reflux disease without esophagitis, and dementia. Review of Resident #3's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of ten. Review of Resident #3's physician orders revealed an order with a start date of 06/11/26 for Contact Precautions (CP) due to Extended-Spectrum Beta-Lactamases (ESBL) in his urine. Observation on 07/06/26 at 8:39 A.M. of Resident #3's door and room revealed no sign was posted regarding contact precautions. Interview on 07/06/26 at 8:44 A.M. with Licensed Practical Nurse (LPN) #227 verified no contact precautions sign was posted on or around Resident #3's door or inside of his room. Observation on 07/06/26 at 11:07 A.M. of Resident #3's door revealed an Enhanced Barrier Precautions (EBP) sign posted on Resident #3's door. Interview on 07/08/26 at 3:16 P.M. with the Director of Nursing (DON) verified Resident #3 had a EBP sign on his door and his physician order was for CP. 4. Review of the medical record for Resident #15 revealed an admission date of 07/01/24 with diagnoses including but not limited to acute kidney failure, cerebral infarction, hemiplegia/hemiparesis following cerebral infarction, enterocolitis due to clostridium difficile, cognitive communication disorder, and adult failure to thrive. Review of physician orders revealed EBP due to extended-spectrum beta-lactamase (ESBL) in urine. Observation on 07/07/26 at 7:46 A.M. revealed no signage for EBP located on the resident's door. Interview on 07/07/26 at 8:01 A.M. with Interim Director of Nursing (IDON #158) revealed Resident #15 had an order for EBP. IDON #158 verified the resident did not have any signage to indicate that he was in EBP. IDON #158 verified the resident would continue to be in EBP until the physician order was discontinued. Follow-up observation on 07/08/26 at 8:42 A.M. revealed no signage for EBP was located on the resident's door. 5. Review of Resident #28's medical record revealed an admission date of 12/02/21. Diagnoses included hemiplegia and hemiparesis, anxiety disorder, major depressive disorder, acute kidney failure, dysphagia, and muscle weakness. Review of Resident #28's quarterly MDS assessment dated [DATE] revealed Resident #28 had moderately impaired cognition with a Brief BIMS score of 12. Furthermore, Resident #28 was at risk for pressure ulcers. Review of Resident #28's care plan dated 04/14/26 revealed Resident #28 had the potential for skin impairment related to debility and limited use of the left side with interventions that included to keep skin clean and dry applying lotion on dry skin. Do not apply lotion to the site of injury. Furthermore, Resident #28 required EBP related to wounds. Review of Resident #28's physician orders revealed an order to cleanse the sacrum with wound cleanser, pat dry, and apply triad on the area every day for Moisture Associated Skin Damage (MASD). Observation on 07/08/26 at 3:06 P.M. of wound care for Resident #28 completed by Registered Nurse (RN) #122 and assisted by Certified Nurse Aide (CNA) #164 revealed RN #122 and CNA #164 wore gloves but did not wear gowns as required. Interview on 07/08/26 at 3:12 P.M. with RN #122 and CNA #164 verified they did not wear gowns during the wound care dressing change. 6. Review of medical record for Resident #46 revealed an admission date of 09/10/21 with diagnoses including but not limited to neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, spinal stenosis lumbar region, constipation, major depressive disorder, chronic pain, and retention of urine. Review of physician orders revealed foley catheter care every shift and EBP due to chronic catheter usage. Review of care plan dated 09/10/21 revealed EBP catheter. Interventions included EBP for all resident with wounds, lines, drains, and infections. Observation on 07/09/26 at 1:36 P.M. of foley catheter care for Resident #46 with CNA #164 revealed the aide entered room, washed hands, provided privacy, filled a basin with warm water, gathered basin, washcloths, towel, and placed them on the over the bed table. CNA #164 then donned gloves, unhooked the residents brief, placed soap onto the washcloth and wet it in the basin. CNA #164 cleansed the catheter from the urethra down using different parts of the washcloth. CNA #164 then wet another washcloth with plain water and rinsed the area using the same technique. CNA #164 then dried the area in the same manner. CNA #164 then refastened the brief, positioned the resident for comfort, cleaned up the area, and washed hands. CNA #164 did not don a gown for the procedure as indicated on the EBP signage posted on the door of the resident's room. Interview on 07/09/26 at 1:45 P.M. with CNA #164 revealed that they verified they should have donned a gown prior to providing catheter care for Resident #46. Review of policy titled, Enhanced Barrier Precautions, dated December 2024 revealed EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of multi-drug resistant organisms (MDRO) colonization. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, rehab services in the therapy gym when the therapist is anticipating prolonged close physical contact while assisting with any of the above, device care or use of the following are some examples: central line, urinary catheter, feeding tube, tracheostomy, PICC/Midline, dialysis catheter, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, venous/arterial ulcers, and chronic wounds which is a wound greater than 30 days.

Based on review of the facility infection control binder, staff interview, and policy review, the facility failed to ensure McGeer's criteria/antibiotic stewardship were followed prior to administration of antibiotics. This had the potential to affect all residents. The facility census was 44. Findings include:Review of the facility's infection control binder revealed from January 2026 through June 2026 the facility did not conduct ongoing review for antibiotic stewardship. Interview on 07/08/26 at 4:19 P.M. with Nursing Manager (NM) #121 who was the facility's Infection Preventionist (IP) revealed she was hired into the position of IP in May of 2026. Prior to her being hired in May 2026, no one had been completing McGeer's for infections and antibiotics were given per the physician orders. NM #121 stated she was trying to go back to January 2026 and fill in the infection control documentation for all of 2026 but was finding this difficult as there was no monitoring of infections or antibiotics in place. Furthermore, NM #121 stated she was asking nurses why residents were placed on antibiotics and what their symptoms were dating back to January 2026. Interview on 07/09/26 at 8:51 A.M. with NM #121 verified all documentation completed before May 2026 and back to January of 2026 was completed in July of 2026 because she had to go back through and complete it. NM #121 verified she was back dating all of the infection control documentation. Review of the facility policy titled Antibiotic Stewardship - Orders for Antibiotics with a revision date of December 2016 revealed antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program and in conjunction with the facility's general policy for medication utilization and prescribing.

Based on review of personnel files and interview, the facility failed to ensure Certified Nursing Assistants (CNAs) had 12 hours of annual in-services as required. This affected three CNAs (#109, #110, and #162) of three CNA personnel files reviewed and had the potential to affect all 44 residents in the facility. The facility census was 44. Review of CNA #109's personnel file revealed a date of hire of 04/30/26. Further review of her personnel file revealed no evidence of any training hours since the last recertification survey on 04/18/24.Review of CNA #110's personnel file revealed a date of hire of 05/28/26. Further review of her personnel file revealed no evidence of any training hours since the last recertification survey on 04/18/24.Review of CNA #162's personnel file revealed a date of hire of 06/18/25. Further review of her personnel file revealed no evidence of any training hours since the last recertification survey on 04/18/24.Interview on 04/12/25 at 2:01P.M. with Human Resource Manager (HRM) #100 verified CNAs #109, #110, and #162 did not have 12 hours of annual in-servicing as required.

Based on review of Resident Council minutes, interviews, and policy review, the facility failed to respond to concerns in a timely manner and report to the council the steps taken to rectify any concerns. This affected six residents (#1, #3, #6, #18, #20, and #34) of six residents who regularly attended Resident Council meetings. The facility census was 44.Findings include:Review of Resident Council minutes for January 28, 2026, revealed a concern regarding residents still being left in the bathroom on the toilet for too long.Review of Resident Council minutes for February 19, 2026, revealed a concern regarding residents still being left on the toilet for too long.Review of Resident Council minutes for March 18, 2026, revealed a concern regarding some residents still being left on the toilet here and there.Interview on 07/08/26 at 11:10 A.M. with Resident #20 revealed that the residents had concerns regarding being left on the toilet too long and call light times on night shift go on longer than they like. Resident #20 stated they had not had any department head or staff come and let them know what has been done to try and rectify the concerns. Resident #20 stated that the staff member that takes the minute notes would go to each department and let them know what the concerns were.Interview on 07/08/26 at 1:45 P.M. with Activity Director (AD #169) revealed that they made copies of the council minutes and gave them to each manager regarding the concerns. AD #169 stated that the managers then came up with an action plan. AD #169 verified there were repeated concerns that were being brought to the meetings. Interview on 07/09/26 at 8:14 A.M. with AD #169 verified the facility was unable to provide or locate documentation regarding the follow up to the nursing concerns that were identified in three consecutive resident council meetings.Review of policy titled Resident Council revised February 2021 revealed a Resident Council Response Form will be utilized to track issues and their resolution. The facility department related to any issues will be responsible for addressing the items of concern.

Based on record review, observation, interview, and policy review, the facility failed to ensure a dignity bag was placed on a foley catheter bag. This affected one (#46) of one resident reviewed for foley catheters. The facility census was 44.Findings include:Review of the medical record for Resident #46 revealed an admission date of 09/10/21 with diagnoses including but not limited to neuromuscular dysfunction of bladder and retention of urine.Review of the care plan dated 09/10/21 revealed Resident #46 had an indwelling catheter related to neurogenic bladder. Interventions included enhanced barrier precautions per protocol and put in privacy bag and keep bag off the floor.Observation on 07/07/26 at 12:39 P.M. of Resident #46 in the dining room revealed the catheter bag hanging from the wheelchair uncovered and urine visible in the bag.Interview on 07/07/26 at 12:41 P.M. with Certified Nursing Assistant (CNA #164) revealed the facility did have privacy bags for the foley catheters. CNA #164 verified the privacy bag was not on the resident's foley and that urine was visible while the resident was in the dining room.Follow up observation on 07/08/26 at 8:28 A.M. revealed Resident #46 was in the dining room in the wheelchair with foley bag hanging on bottom of wheelchair without a privacy cover and urine visible in the bag.Review of policy titled, Dignity, revised February 2021 revealed demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: helping the resident to keep urinary catheter bags covered.

Based on record review, interview, and policy review the facility failed to ensure comprehensive care plan reflected the residents' current status. This affected three (#15, #4, and #3) of 15 residents reviewed for care plans. The facility census was 44. 1.Review of medical record for Resident #15 revealed an admission date of 07/01/24 with diagnoses including but not limited to cognitive communication deficit, cerebral infarction, acute kidney failure, and adult failure to thrive. Review of physician orders revealed enhanced barrier precautions (EBP) for Extended-Spectrum Beta-Lactamase (ESBL) and cleanse left lower extremity (LLE) wound with wound cleanser, pat dry, cover with bordered gauze every day shift and as needed. Review of care plan dated 07/01/26 revealed no care plan regarding EBP or wound to LLE. Interview on 07/09/26 at 8:29 A.M. with Minimum Data Set Nurse (MDS #106) revealed they verified there was no care plan for EBP or wound to LLE. 2. Record review for Resident #4 revealed this resident was admitted to the facility on [DATE] with the following diagnoses: extended spectrum beta lactamase (ESBL), chronic kidney disease, and malignant neoplasm of peritoneum. Review of the MDS quarterly assessment dated [DATE] revealed this resident had intact cognition evidenced by a Brief Interview for Mental Status (BIMS) score of 15. This resident was assessed to need moderate assistance with toileting, dressing and bathing. Supervision with walking. Resident #4 received antibiotic medication. Medical record review for Resident #4 revealed the resident had a diagnosis of extended spectrum beta lactamase (ESBL) and an active physician order for Enhanced Barrier Precautions (EBP) isolation. However, the Care Plan dated 06/23/26 did not contain any care plan addressing ESBL or the required EBP isolation interventions. Interview on 07/07/26 at 2:21 P.M. with the MDS #106 confirmed Resident #4 did not have a care plan for ESBL diagnosis or EBP. 3. Review of Resident #3's medical record revealed an admission date of 01/22/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, acute and chronic respiratory failure with hypoxia, hyperlipidemia, systolic heart failure, gastro-esophageal reflux disease without esophagitis, and dementia. Review of Resident #3's significant change MDS assessment dated [DATE] revealed Resident #3 had moderately impaired cognition with a BIMS score of ten. Review of Resident #3's physician orders revealed an order with a start date of 06/27/26 for Ertapenem Sodium injection solution one gram with instructions to give one dose intravenously one time a day for osteomyelitis. Further review of Resident #3's physician orders revealed no active orders for a Peripherally Inserted Central Catheter (PICC) line, dressing changes for the PICC line, or flushes for the PICC line. Review of Resident #3's care plan dated 06/01/26 revealed the PICC line was not included in the care plan. Observation on 07/06/26 at 8:38 A.M. of Resident #3's PICC line revealed it was dated 06/27/26. Interview on 07/08/26 at 3:16 P.M. with the Director of Nursing (DON) verified Resident #3's PICC line was not included in the care plan. Facility policy, Care Plans, Comprehensive Person-Centered, dated 03/22, revealed the interdisciplinary team reviews and updates the care plan when there has been a significant change, desired outcome is not met, readmission from hospital, and at least quarterly.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure the care plan was updated to include fall interventions. This affected one (Resident #10) of 14 residents reviewed for care plans. The facility census was 44. Findings include: Review of the medical record for Resident #10 revealed an admission date of 04/26/24 with diagnoses including but not limited to displaced fracture of medial condyle of left humerus and unspecified fracture of left femur. Review of physician orders revealed Dycem to recliner for fall prevention every shift for safety/prevention of falls. Review of the care plan dated 04/26/24 revealed the resident was at risk for falls related to confusion, deconditioning as evidenced by altered gait and balance. Interventions included ensure the resident is wearing appropriate footwear fully enclosed slip resistant shoes or gripper socks when transferring or mobilizing in wheelchair (06/18/25), avoid clothing that is fall risk (08/07/25), evaluated for and supplied wheelchair with anti-rollback device (08/12/25), and door to room and curtain pulled back when unattended by staff for visual monitoring and bed in lowest position and floor mat placed at bedside (08/13/25). Further review of care plan revealed no intervention regarding Dycem to recliner for fall prevention every shift for safety/prevention of falls. Interview on 07/07/26 at 1:19 P.M. with Interim Director of Nursing (IDON #158) revealed they verified no intervention for Dycem in the recliner per physician order was located. Review of policy titled, Falls and Fall Risk, Managing, revised March 2018 revealed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

Based on record review, observation, interview, and policy review, the facility failed to ensure palm protectors were applied as ordered. This affected one (#28) resident of one resident reviewed for splints/braces. The facility census was 44.Findings include:Review of medical record for Resident #28 revealed an admission date of 12/02/21 with diagnoses including but not limited to contracture of muscle left hand, contracture left elbow, and contracture of left wrist.Review of physician orders revealed check left hand contracture daily for skin breakdown, left heel protector while in bed, and mobility per care plan.Review of Kardex for Certified Nursing Assistants (CNAs) revealed provide left palm protector to left hand. Apply in the morning and remove at bedtime. Review of care plan dated 05/08/24 revealed the resident has potential for skin impairment related to debility and limited use of left side. Interventions included heel protector on left foot while in bed and provide left palm protector to left hand. Apply in the morning and remove at bedtime.Observation and Interview on 07/06/26 at 10:45 A.M. with Resident #28 revealed that there were photos above the resident's bed indicating how to apply palm protector to the left hand. Resident #28 stated that she did not have the palm protector on currently. Resident #28 stated the aides were to put it on in the morning and remove it when she goes to bed at night. Resident #28 stated that they don't always put it on. Resident #28 denied refusing to allow the staff to put the palm protector on and was unsure if it made her hand feel better or worse.Observation on 07/08/26 at 1:20 P.M. revealed the resident was resting in bed. Left hand palm protector is noted to be on the resident's dresser. Interview on 07/08/26 at 4:13 P.M. with CNA #160 revealed that the resident's palm protector was on the dresser located across the room. CNA #160 verified the palm protector was not on the resident and asked the resident if she wanted it on and the resident stated yes. CNA #160 placed the palm protector on at this time.Further observation on 07/09/26 at 9:30 A.M. revealed the resident was resting in bed with no palm protector on the left hand.Follow-up observation on 07/09/26 at 10:51 A.M. revealed the resident was resting in bed with her left arm resting on her chest with no palm protector on.Review of policy titled, Assistive Devices and Equipment, revised January 2023 revealed certain devices and equipment that assist with resident mobility, safety and independence are provided for residents. These may include (but are not limited to) specialized eating utensils and equipment, safety devices for the bathroom, and mobility/positioning devices such as wheelchairs, walkers, cans, and splints/brace.

Based on medical record review, observation, staff interview, and policy review, the facility failed to ensure a Peripherally Inserted Central Catheter (PICC) line dressing was changed per professional standards of practice. Furthermore, the facility failed to ensure a PICC line was flushed per professional standards of practice. This affected one resident (#3) of one resident reviewed for PICC lines. The facility census was 44. Findings include:Review of Resident #3's medical record revealed an admission date of 01/22/25. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, acute and chronic respiratory failure with hypoxia, hyperlipidemia, systolic heart failure, gastro-esophageal reflux disease without esophagitis, and dementia. Review of Resident #3's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of ten. Review of Resident #3's care plan dated 06/01/26 revealed the PICC line was not included in the care plan. Review of Resident #3's physician orders revealed an order with a start date of 06/27/26 for Ertapenem Sodium injection solution one gram with instructions to give one dose intravenously one time a day for osteomyelitis. Further review of Resident #3's physician orders revealed no active orders for a Peripherally Inserted Central Catheter (PICC) line, dressing changes for the PICC line, or flushes for the PICC line. Review of Resident #3's Medication and Treatment Administration Record (MAR, TAR) for the month of July 2026 revealed no documentation regarding changing the dressing for the PICC line or flushes for the PICC line. Observation on 07/06/26 at 8:38 A.M. of Resident #3's PICC line revealed it was dated 06/27/26. Interview on 07/06/26 at 8:44 A.M. with Licensed Practical Nurse (LPN) #227 verified Resident #3's PICC line dressing was dated 06/27/26. Interview on 07/08/26 at 3:16 P.M. with the Director of Nursing (DON) verified Resident #3's physician orders did not include dressing changes for the PICC line and did not include flushes for the PICC line. Furthermore, the DON verified PICC line dressings should be changed weekly and flushes should be administered before and after all medications given through the PICC line. Review of the facility policy titled, Central Venous Catheter Flushing and Locking, with a last revised date of March 2022 revealed to flush the catheter and aspirate for blood prior to each infusion to assess catheter function and to flush after each infusion to clear the medication from the catheter lumen.

Based on observation, staff interview, and policy review, the facility failed to ensure insulin was labeled with an open date and failed to ensure expired insulin pens were properly disposed of. This affected three residents (#9, #14, and #27) of three residents reviewed for medication storage. The facility census was 44. Findings include:Observation and concurrent interview with Registered Nurse (RN) #107 on [DATE] at 9:00 A.M. of the 200-hall medication cart verified three insulin pens that were opened, had been used, and were undated. Furthermore, Resident #9's opened and used Insulin lispro was dated [DATE], Resident #14's opened and used Lantus was dated [DATE], and Resident #27's opened and used Novolog was dated [DATE]. Review of the manufacturer's instructions for insulin lispro revealed to throw away the insulin lispro pen you are using after 28 days, even if it still has insulin left in it. Review of the manufacturer's instructions for insulin glargine or Lantus revealed to only use the pen for up to 28 days after it's first use. Throw away the Lantus pen you are using after 28 days even if it still has insulin left in it. Review of the manufacturer's instructions for insulin aspart or Novolog revealed if stored outside of refrigeration prior to it's first use, it should be used within 28 days or thrown away. Review of the facility policy titled Insulin Administration, with a last revision date of [DATE] revealed prior to administering insulin, to check the expiration date. If opening a new vial, record the expiration date and time on the vial and follow manufacturers' recommendations for expiration after opening.

Based on record review, interview, and policy review the facility failed to ensure the medical records were accurate and complete. This affected two (#15 and #46) of two residents reviewed for medical record documentation. The facility census was 44. Findings include:1.Review of the medical record for Resident #15 revealed an admission date of 07/01/24 with diagnoses including but not limited to cognitive communication deficit, cerebral infarction, acute kidney failure, and adult failure to thrive.Review of physician orders revealed cleanse left lower extremity with wound cleanser pat dry apply xeroform cover with bordered gauze every day shift, behavior monitoring: document all non-pharmacological interventions attempted for all behaviors, moisture barrier ointment twice daily as indicated to keep irritants or moisture from skin surface, monitor contracture to right hand for skin breakdown: cleanse with soap and water and dry thoroughly twice daily notify provider if issues arise, monitor for signs and symptoms (s/s) of urinary tract infection (UTI) and send urinalysis (UA) culture and sensitivity (c/s) if indicated.Review of TAR for June 2026 revealed the following documentation missing on night shift on 06/05/26, 06/19/26, 06/20/26, 06/23/26, 06/25/26, 06/26/26, and 06/28/26 for behavior monitoring: document all non-pharmacological interventions attempted for all behaviors, moisture barrier ointment twice daily as indicated to keep irritants or moisture from skin surface, monitor contracture to right hand for skin breakdown: cleanse with soap and water and dry thoroughly twice daily notify provider if issues arise, monitor for s/s of UTI and send UA c/s if indicated.Review of TAR for July 2026 revealed no documentation for cleanse LLE with wound cleanser pat dry apply xeroform cover with bordered gauze every day shift on 07/01/26 and 07/06/26. The following documentation missing on night shift on 07/01/26, 07/02/26, 07/03/26, 07/04/26, and 07/06/26 for the following: behavior monitoring: document all non-pharmacological interventions attempted for all behaviors, moisture barrier ointment twice daily as indicated to keep irritants or moisture from skin surface, monitor contracture to right hand for skin breakdown: cleanse with soap and water and dry thoroughly twice daily notify provider if issues arise, monitor for s/s of UTI and send UA c/s if indicated.2. Review of medical record for Resident #46 revealed an admission date of 09/10/21 with diagnoses including but not limited to neuromuscular dysfunction of bladder, chronic obstructive pulmonary disease, spinal stenosis lumbar region, constipation, major depressive disorder, chronic pain, and retention of urine.Review of physician orders revealed change catheter drainage bag weekly and as needed, change foley basin weekly on Sunday night sift, dry skin: house barrier ointment twice daily to keep irritants or moisture from skin surface, encourage to elevate legs when up in chair, enhanced barrier precautions due to chronic catheter use, foley catheter care every shift, ROHO cushion to wheelchair when up, skin sleeves to bilateral arms every shift for skin protection keep on 24 hours seven days a week due to scratching, wash bilateral lower extremities (BLE) with soap and water every shift apply lotion to BLE twice daily and cover with tubi-grips to remain on at all times except for bathing, foley catheter output every shift, cleanse nebulizer tubing and appliances daily with warm soapy water, and oxygen saturation.Review of TAR dated June 2026 revealed the following treatments not signed off as completed: change catheter drainage bag weekly and as needed as well as change out foley basin weekly on Sunday night shift not marked as completed on 06/21/26 and 06/28/26. The following treatments were not marked as completed on 06/05/26, 06/19/26, 06/21/26, 06/26/26, and 06/28/26 on night shift: dry skin: house barrier ointment twice daily to keep irritants or moisture from skin surface, encourage to elevate legs when up in chair, enhanced barrier precautions d/t chronic catheter use, foley catheter care every shift, ROHO cushion to w/c when up do not place large ROHO cushion in recliner due to fall risk, skin sleeves bilateral arms every shift for skin protection keep on 24/7 due to scratching, wash BLE with soap and water every shift apply lotion to bilateral lower extremities twice daily cover with tubi-grips to remain on at all times except for bathing, may be changed when soiled notify MD with any changes. Foley catheter output every shift was not documented on day shift on 06/03/26, 06/04/26, 06/06/26, 06/12/26, 06/13/26, 06/17/26, 06/21/26, 06/27/26, 06/28/26, and 06/30/26. On night shift not documented on 06/05/26, 06/19/26, 06/21/26, 06/24/26, 06/26/26, and 06/28/26. Oxygen saturation was not documented on night shift on 06/24/26, 06/26/26, and 06/28/26. Review of TAR dated July 2026 revealed the following treatments were not documented as completed on 07/01/26, 07/02/26, 07/03/26, 07/04/26, and 07/05/26: dry skin: house barrier ointment twice daily to keep irritants or moisture from skin surface, encourage to elevate legs when up in chair, enhanced barrier precautions d/t chronic catheter use, foley catheter care every shift, ROHO cushion to w/c when up do not place large ROHO cushion in recliner due to fall risk, skin sleeves bilateral arms every shift for skin protection keep on 24/7 due to scratching, wash BLE with soap and water every shift apply lotion to bilateral lower extremities twice daily cover with tubi-grips to remain on at all times except for bathing, may be changed when soiled notify MD with any changes, foley catheter output every shift, oxygen saturation every shift, and cleanse nebulizer tubing and appliances daily with warm soapy water.Interview on 07/09/26 at approximately 10:45 A.M. with Interim Director of Nursing (IDON #158) verified the missing TAR documentation listed above for Resident #15 and Resident #46. IDON #158 verified it was a pattern on night shift for both residents.Review of policy titled, Charting and Documentation, revised July 2017 revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Based on observation, staff interview, and policy review, the facility failed to ensure open food products were dated and covered in the kitchen. This had the potential to affect all 33 residents who the facility identified to all receive food from the kitchen. The facility census was 33. Findings include: Observation on 04/15/24 at 8:20 A.M. of the kitchen revealed in the dry storage area, five bags of open pasta were not dated. In the walk-in refrigerator, two trays of mandarin oranges were not covered or dated and two bags of mozzarella cheese open with no date. In the walk-in freezer, one bag of Salisbury steak open with no date. In the reach-in refrigerator, there was one container of ham, one container of strawberries, and one container of dill pickles not dated. Interview on 04/15/24 at 8:30 A.M. with Dietary Manager (DM) #500 verified the five bag of pasta, two trays of mandarin oranges, two bags of mozzarella cheese, one bag of Salisbury steak, one container of each ham, strawberries, and pickles were all not dated. DM #500 verified the mandarin oranges were also not covered. DM #500 stated that they typically date the food as it comes into the facility on delivery date. Review of the facility's policy titled Food Receiving and Storage revised October 2017 revealed dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using the first in- first out system. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date). Open containers must be dated and sealed or covered during storage.

Based on the facility's water management program information, staff interview, review of the Centers for Disease Control (CDC) guidance, and review of the facility policy, the facility failed to have an appropriate Legionella water management program in place. This had the potential to affect all 33 residents in the facility. Findings include: Review of the most recent Legionella documentation information revealed the facility's Legionella information contained both cold and hot water chlorine testing and eye wash station testing. The cold and hot water chlorine residual testing verified the facility had not conducted a chlorine residual testing since 11/29/23. The 2024 log for the eye wash station revealed the station was inspected (included running water for three minutes) on 02/01/24, 03/11/24, and 04/09/24. Interview on 04/18/24 at 9:00 A.M. and 9:45 A.M. with the Administrator verified the facility has not completed chlorine residual testing since November 2023. There was no evidence of flushing of stagnant water except for monthly inspections of the eyewash stations. The Administrator revealed the former maintenance director had left in December 2023. The position was filled in February or March 2024 through early April 2024. The maintenance director position had been filled effective 04/18/24. Interview on 04/18/24 at 12:25 P.M. with the Administrator and Regional Director of Operations #701 verified the facility did not have Legionella prevention, detection, and control measures in place including a risk assessment, facility mapping of water sources, flushes, or testing. The facility has identified five current unoccupied resident rooms including rooms 112, 115, 206, 214, and 215. Review of the undated CDC guidance titled, Overview of Water Management Programs, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: o Establish a water management program team o Describe the building water systems using text and flow diagrams o Burden of Waterborne Disease o Read about various illnesses, including Legionnaires' disease, in CDC's first estimates of the impact of waterborne disease in the United States. o Identify areas where Legionella could grow and spread o Decide where control measures should be applied and how to monitor them o Establish ways to intervene when control limits are not met o Make sure the program is running as designed (verification) and is effective (validation) o Document and communicate all the activities Review of the facility's policy titled Legionella Water Management Program, revised October 2023, revealed the water management program includes but not limited to the following a detailed description and diagram of the water system in the facility including receiving, cold water distribution, heating, hot water distribution, and waste. Also, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne pathogens including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers, humidifiers, hot tubs, fountains, and medication devices.

Based on review of the medical record, staff interview, and facility policy review, the facility failed to complete for advanced directives for six (#2, #15, #22, #24, #28, and #30) of six residents reviewed for advanced directives and one (#22) resident reviewed hospice. The facility census was 33. Findings include: 1. Review of the medical record for Resident #22 revealed the resident was admitted on [DATE]. Diagnoses included Alzheimer's disease, dementia, cerebral atherosclerosis, occlusion and stenosis of unspecified carotid artery disease, personal history of malignant neoplasm of bladder, benign prostatic hyperplasia (BPH) without lower urinary tract symptoms, and encounter for palliative care. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was severely cognitively impaired. Review of the facility's provided care plans for Resident #22 revealed the facility failed to develop and implement a comprehensive person-centered care plan for advanced directives and hospice services. Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #22 did not have advanced directives included in the comprehensive care plan. In addition, Resident #22 did not have a comprehensive care plan for hospice services to include information for coordination of care. 41528 2. Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included end stage renal disease, generalized anxiety disorder, kidney transplant status, and dementia. Review of the physician orders revealed Resident #2's advanced directive was do not resuscitate comfort care arrest (DNRCCA). Review of the most recent care plan revealed Resident #2 did not have a care plan for advanced directive. Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #2 did not have advanced directives included in the comprehensive care plan. 3. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, spinal stenosis, type two diabetes mellitus with diabetic chronic kidney disease, hypertensive chronic kidney disease, chronic kidney disease stage three, dementia, chronic respiratory failure, and hypoxia. Review of the Minimum Data Set (MDS) assessment, dated 02/16/24, revealed the resident was moderately cognitively impaired. Review of the physician order revealed Resident #15's advanced directive was do not resuscitate comfort care (DNRCC). Review of the most recent care plan revealed Resident #15 did not have a care plan for advanced directive. Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #15 did not have advanced directives included in the comprehensive care plan. 4. Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnoses included Alzheimer's disease, dementia in other diseases with behavioral disturbance, and personal history of transient ischemic attack and cerebral infarction without residual deficits. Review of the Minimum Data Set (MDS) assessment, dated 01/30/24, revealed the resident was rarely/never understood. Review of the physician order revealed Resident #24's advanced directive was do not resuscitate comfort care (DNRCC). Review of the most recent care plan revealed Resident #24 did not have a care plan for advanced directive. Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #24 did not have advanced directives included in the comprehensive care plan. 5. Review of medical record for Resident #28 revealed an admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia, dementia, malignant neoplasm of bronchus or lung, major depressive disorder, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had severe cognitive impairment. Review of the physician orders revealed Resident #28 was a do not resuscitate comfort care (DNRCC), Review of the care plan dated 01/15/24 for Resident #28 revealed no care plan for advance directives. Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #28 did not have advanced directives included in the comprehensive care plan. 6. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including displaced intertrochanteric fracture of right femur, chronic pain syndrome, chronic kidney disease stage three, and pain in right hip. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #30 was cognitively intact. Review of the physician orders revealed Resident #30 was a do not resuscitate comfort care arrest (DNRCCA). Review of the care plan dated 02/15/24 for Resident #30 revealed no care plan for advance directives. Interview on 04/16/24 at 1:03 P.M. with the Director of Nursing (DON) verified Resident #30 did not have advanced directives included in the comprehensive care plan. Review of the facility's policy titled Comprehensive Person-Centered Care Plan, revised March 2022, revealed the comprehensive person-centered care plan describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment.

Based on record review, interview, and policy review, the facility failed to ensure communication was maintained between the facility and dialysis center. This affected one (Resident #2) of one reviewed for dialysis. The facility census was 33. Findings include: Review of the medical record for Resident #2 revealed an admitted [DATE]. Diagnoses included end stage renal disease and kidney transplant status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 was independent for activities of daily living. Review of the physician orders revealed Resident #2 received dialysis services on Monday, Wednesday, and Friday and check for thrill/bruit to fistula in right upper arm. There was no mention of where dialysis was performed with address and phone number in the physician orders for dialysis. Review of the care plan dated 02/22/24 revealed Resident #2 required hemodialysis related to end stage renal disease. The care plan did not include which dialysis center or contact information for the dialysis center. Review of the dialysis communication/referral forms to be sent with Resident #2 on dialysis days revealed the facility did not fill out their portion on 03/22/24, 04/07/24, 04/10/24, 04/12/24, and 04/15/24. Further review of the dialysis communication/referral forms sent with Resident #2 revealed the only forms sent with the resident on dialysis days were on 02/28/24, 03/13/24, 03/22/24, 04/07/24, 04/10/24, 04/12/24, and 04/15/24. Resident #2's dialysis days were Monday, Wednesday, and Friday. Since admission to the facility on [DATE], the resident would have been to dialysis 25 times at a minimum. The communication form was missed 19 dialysis days. Interview on 04/16/24 at 1:16 P.M. with the Director of Nursing (DON) verified the communication form was hit or miss on whether the dialysis center sends them back to the facility. The DON verified that several of the returned communication sheets were not filled out by the facility nurse and the dialysis center information was completed. The DON stated the dialysis center information would be listed on the face sheet. The DON verified the face sheet for Resident #2 did not include the dialysis center information. Interview on 04/16/24 at 2:15 P.M. with Dialysis Registered Nurse (RN #700) verified the communication forms have been missed due to staffing. RN #700 stated that they have a plan in place to improve the communication form being filled out for each dialysis treatment. RN #700 stated they do have communication on the phone with the facility. Review of the facility policy titled End-Stage Renal Disease, Care of a Resident with, revised September 2023, revealed agreements between the facility and the contracted end stage renal disease facility include all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented, and how information will be exchanged between the facilities.

Based on observations, staff interviews, and review of the facility policy, the facility failed to ensure proper hand hygiene was used during food preparation and dishwashing. This affected one resident (#11) and had the potential to affect all 36 residents residing in the facility. The facility census was 36. Findings include: 1. Observation of meal service on 07/05/23 beginning at 11:52 A.M. revealed Cook #520 wearing plastic gloves and touching serving utensils, drawers, and the lid of the plate-warming machine. Cook #520 did not change her gloves and continued to plate Resident #11's meal. Cook #520 picked up a knife with her right hand, and held the ham in place with her left gloved hand and cut the ham into bite-sized pieces. Cook #520 then placed the plate on the meal cart and the meal cart left the kitchen to be passed out to residents. Cook #520 did not change her gloves during the observation. Interview on 07/05/23 at 12:00 P.M. with Cook #520 confirmed she touched Resident #11's ham with her left gloved hand which had touched several non-food items in the kitchen. Cook #520 confirmed she was aware she should not have touched ready-to-eat food without washing her hands and putting on clean gloves. 2. Observation on 07/05/23 at approximately 12:45 P.M. revealed Dietary Aide #521 rinsing dirty dishes and stacking them into the dish rack, then opening the dish machine and removing clean dishes, without washing her hands in between touching the dirty dishes and clean dishes. Further observation revealed Dietary Aide #521 pushed the dirty dishes into the machine, then began unloading clean dishes and putting them away. Interview with Dietary Aide #521 confirmed she touched the clean dishes after handling dirty dishes without washing her hands. Dietary Aide #521 stated she was unaware of the need to wash her hands between touching dirty and clean dishes. Dietary Aide #521 did not re-wash the clean dishes she had already unloaded. Review of the facility's policy titled Hand Washing and Glove Use, reviewed 06/14/23, revealed employees must wash hands before handling food, when switching tasks, and after performing any activity that could contaminate hands.

Based on record review, observation, and staff interview, the facility failed to provide adequate portions of protein to residents on texture modified diets. This affected seven residents (#6, #12, #19, #23, #27, #29, and #91) identified by the facility to be on texture modified diets. The facility census was 36. Findings include: Observation during meal service on 07/05/23 beginning at 11:52 A.M. revealed Cook #520 served pureed ham using a two-ounce scoop and minced and moist (chopped small) ham using a 1.625 ounce scoop. Interview on 07/05/23 at 12:25 P.M. with Cook #520 revealed she did not have a spreadsheet with serving sizes. Cook #520 further verified the appropriate serving sizes were listed on each resident's meal tickets. Cook #520 confirmed the portion size listed on the meal tickets for pureed ham was five ounces and confirmed she only provided a two ounce portion. Cook #520 confirmed the portion listed on the meal ticket for minced and moist ham was four ounces and confirmed she only provided a 1.625 ounce portion. Cook #520 confirmed the residents who received texture modified meat did not receive the correct portion. Review of the facility's list of diets revealed Residents #6, #12, #19, #23, #27, #29, and #91 were on texture modified diets.

Based on medical record review, observations, resident and staff interview and policy review, the facility failed to ensure the call lights were within reach of residents. This affected one (Resident #12) of five residents reviewed for call lights. The facility census was 36. Findings include: Record review for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #12 included acute kidney failure, chronic kidney disease, auditory hallucination, depression, and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition, was incontinent of bowel and bladder, and was a one-person assist with activities of daily living. Review of Resident #12's care plans dated 02/09/20 revealed a focus for risk for falls. Interventions included to educate the resident to ask for assistance. Observation and interview on 07/03/23 at 9:20 A.M. revealed Resident #12 sitting in his wheelchair with his back to his bed. Resident #12's call light was on his bed and not within reach. Resident #12 stated he did not have his call light and Resident #12 stated he would holler if he needed assistance from staff. Observation and interview on 07/05/23 at 4:33 P.M. revealed Resident #12 was sitting up in his recliner. When asked where his call light was, Resident #12 stated he did not know. Resident #12 answered he did not know what to do if he would need help from a staff member. Resident #12's call light was not visible during the observation. Interview on 07/05/23 at 4:40 P.M. with State tested Nurse Aide (STNA ) #477 verified Resident #12's call light was behind his back under him in his recliner. STNA #477 verified the call light was to be placed within reach for the resident's use. Review of the facility's policy titled Call-Light, dated 10/21/22, revealed when staff leave a resident room, they are to place the call light within easy reach of the resident.

Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident with a history of falling. This affected one (Resident #17) of four residents reviewed for falls. The facility census was 36. Findings include: Review of the medical record for Resident #17 revealed an admitted [DATE] with diagnoses including chronic pain, insomnia, and a history of falling. Review of a progress note dated 06/02/23 revealed Resident #17 fell at approximately 3:00 A.M. while standing and attempting to remove her nightgown while a state tested nurse aide (STNA) was changing the chair pad. Resident #17 stumbled backwards due to her slip-on slippers. Review of an additional progress note dated 06/02/23 revealed a plan to remove the slip-on slippers and replace them with the new enclosed slippers. Review of the current care plan for Resident #17 revealed she was at risk for falls. Interventions included ensuring Resident #17 was wearing appropriate footwear, including fully enclosed slip resistant shoes, skid resistant slippers, or gripper socks when ambulating or mobilizing in her wheelchair. Review of the facility's Fall Scene Huddle Worksheet revealed Resident #17 fell on [DATE] due to wearing slip-on slippers and the intervention was to use gripper socks instead of slippers. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 had intact cognition and required extensive assistance of one person for bed mobility, transfers, toileting and hygiene. Resident #17 had one fall without injury since the previous assessment completed 05/30/23. Observation on 07/05/23 at 9:17 A.M. revealed Resident #17 sitting in her recliner in her room wearing slip-on slippers. Observation on 07/05/23 at 12:18 P.M. revealed Resident #17 sitting in her wheelchair in the dining room wearing slip-on slippers. Interview at that time with Licensed Practical Nurse (LPN) #400 confirmed Resident #17 was wearing slip-on slippers. LPN #400 confirmed Resident #17 was supposed to be wearing fully enclosed slippers. Interview on 07/06/23 at 11:49 A.M. with the Director of Nursing (DON) confirmed Resident #17 should be wearing gripper socks, not backless slippers. The DON stated she spoke with Resident #17 who was agreeable to wearing gripper socks. Observation and interview on 07/06/23 at 11:53 A.M. with Registered Nurse (RN) #433 revealed Resident #17 sitting in her wheelchair in the dining room. RN #433 confirmed Resident #17 was wearing slip-on slippers. Interview on 07/06/23 at 2:53 P.M. with STNA #499 revealed she was assigned to provide care for Resident #17 during the morning shift on 07/06/23 and was aware Resident #17 should be wearing gripper socks because the slip on slippers were causing her to fall. STNA #499 stated she did not notice Resident #17's footwear throughout the day. Review of the facility's fall policy, last reviewed on March 2023, revealed fall interventions should be implemented and updated in the care plan, as needed.

Based on medical record review, staff interview, resident interview, and review of the facility investigation, the facility failed to ensure provide supervision when hazards presented in the environment. This caused actual harm for one resident (#31) who was not removed from her room before laying glue in the floor outside of her door in preparation for new carpet. As a result Resident #31 stepped onto the glue which caused her feet to stick to the floor, which caused her to fall and suffer a [MEDICAL CONDITION] humeral neck. This affected one (#31) of one resident investigated for accidents. The facility census was 46. Finding include: Review of the medical record for Resident #31 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. Review of the care plan revealed an activity of daily living with self-care performance deficit related to impaired balance and left knee giving out at times. Review of progress notes dated 11/8/2017 at 1:51 P.M. revealed Resident #31 was lying on the floor outside the door to her room. The resident was complaining of right shoulder pain. The resident stated her feet stuck to the floor when she came out of the room. The resident stated she fell on to her right knee and right shoulder and had pain in the shoulder. The physician was notified and an x-ray was ordered. Review of the radiology report dated 11/08/17 revealed Resident #31 had an acute [MEDICAL CONDITION] neck. Review of the physician orders [REDACTED]. Review of the facility investigation dated 11/08/17 at 11:48 A.M. revealed Resident #31's feet stuck to the floor due to glue placement during the laying of new carpet. The plan of care was updated at this time. Interview on 12/19/17 at 8:50 A.M., the Director of Nursing (DON) verified the carpet was being replaced on Resident #31's hall. The DON stated the facility had extra staff working on this hall to ensure all residents left their rooms before the glue was placed, but they had missed Resident #31. The resident was still in her room when the glue was laid, therefore the resident fell when her feet stuck to the floor, causing the shoulder fracture. Interview with Resident #31 on 12/20/17 at 2:40 P.M. confirmed she came out of her room to go to the dining room and her feet stuck to the glue on the floor. She stated she fell on to her right side. Resident #31 sated the only person who was around was a man who was putting down the carpet.

Based on medical record review, staff interview,and facility policy review, the facility failed to implement fall interventions for one resident (#42), resulting in actual harm when the resident sustained [REDACTED]. This affected one (Resident #42) of three residents reviewed for falls. The facility census was 48. Findings include: Review of Resident #42's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/01/14, the resident was admitted to the hospital with [REDACTED]. Review of Resident #42's minimum data set (MDS) annual assessment dated [DATE] revealed the residents brief interview for mental status (BIMS) was scored as a three indicating a severe decline in cognition. She required extensive assistance of one staff member for all activities of daily living including transfers. Review of the Resident #42's plan of care dated 03/20/14 revealed that the resident was at risk for falls due to injury from falls, decreased mobility, and medication regimen. The interventions included sensor and mobility alarms to be on at all times for safety except during hands on care. Review of Resident #42's risk assessments dated 04/13/13 and 04/19/14 revealed the resident was assessed as being a high risk for falls. Review of the nurses notes dated 04/13/14 at 4:00 P.M. revealed that the resident was found on the floor. The incident resulted in a bruise to her left arm measuring 14 centimeters (cm) by 7.0 cm Review of the incident details report dated 04/13/14 at 4:00 P.M. revealed staff found the resident on the floor in her room lying beside her dresser. There were no alarms sounding at the time of the incident Review of Resident #42's hospital history and physical examination [REDACTED]. Interview on 05/13/14 at 1:30 P.M. with the Director of Nursing (DON) revealed that on 04/13/14, a State tested Nursing Assistant (STNA), took the resident to the bathroom at approximately 1:45 P.M. and stated that she turned on both alarms before leaving the room. At 4:00 P.M. on 04/13/14, the second shift STNA went to check on the resident to take her to the bathroom, and found her on the floor in her room by her dresser. The DON verified that direct care staff make rounds every two hours. She verified the investigation report did not determine why the alarms did not sound. She stated that it was her determination that the STNA who took her to the bathroom at 1:45 P.M. on 04/13/14 forgot to turn the alarms back on however, the STNA denied this. The DON stated that there was no disciplinary action, no staff in-services, or new interventions put into place following the incident. Continued interview with the DON verified that on 05/01/14, while in the hospital, a chest x-ray revealed Resident #42 had a left posterior fourth rib fracture which the DON verified was determined to be due to the fall on 04/13/14. Review of the facility policy titled, "Prevention and Management of Falls" revealed that an avoidable accident means than an accident occurred without individualized fall prevention and a management program in place.