Arc at Normal

Inspectors wroteBased on observations, interview and record review, the facility failed to implement proper infection control practices to prevent cross contamination, for three of four (R1, R4 and R5) residents, reviewed for infection control, in a sample of 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable and appetizing for two of three (R2 and R5) residents, reviewed for Dietary Services, in a sample list of 12.

Inspectors wroteBased on interview and record review, the facility failed to prevent a pressure ulcer from developing by failing to implement pressure relieving interventions for one (R2) resident and failed to complete pressure ulcer treatments as ordered for two (R2, R3) residents reviewed for pressure ulcers in the sample list of 14. This failure resulted in R2 developing a Deep Tissue Injury to the Right Heel.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a focus care plan for one (R2) of three residents reviewed for care plans in a total sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable and safe ambient temperature for one (R1) of eight residents reviewed for physical environment.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from physical abuse for two (R3 and R4) of three residents reviewed for abuse in a total sample of 17 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to transfer residents according to the care plan and facility policy for four of six residents (R2, R4, R7 and R8), reviewed for accidents, in a sample of 15.

Inspectors wroteBased upon observation, interview, and record review, the facility failed to protect residents from abuse for seven (R3, R4, R5, R6, R9, R12, and R14) of eleven residents reviewed on a sample list of 17 residents. R3's undated Care Plan documents R3's diagnosis of Hyperlipidemia, Major Depressive Disorder, Alzheimer's Disease with Early Onset, Unspecified Glaucoma, Essential (Primary) Hypertension, Unspecified Protein-Calorie Malnutrition, Anxiety Disorder, and Dementia in Other Diseases Classified Elsewhere, Mild, With Other Behavioral Disturbance. Care Plan also documents R3 at high risk for abuse. [...]

Inspectors wroteBased upon observation, interview, and record review the facility failed to care for a resident in a manner that promotes maintenance or enhancement of his or her quality of life for one (R5) of three residents reviewed for quality of care out of a sample list of 17 residents.

Inspectors wroteBased upon interview and record review, the facility failed to prevent a resident from misappropriation by staff for one (R13) of three residents reviewed on a sample list of 17 residents. Facility file dated 12/11/25 documents V6 Certified Nursing Assistant (CNA), transported R13 to R13's home which was 30 miles away from the facility to get clothing for R13. R13 gave $50.00 to V6 for compensation. V6 informed the nurse after returning to the facility. V6 was terminated for exploitation of a resident. V6 placed R13 in V6's personal car. V6 had no training from the facility related to transportation of a resident. R13 did not have permission to leave the facility. R13's Progress Notes do not document R13 out of facility at any time. R13's Minimum Data Set (MDS) section C dated 12/3/25 documents R13 has no cognitive impairments. [...]

Inspectors wroteBased upon interview and record review the facility failed to develop and implement a baseline care plan for one (R1) of three residents reviewed for quality of care out of a sample list of 17 residents. R1's care plan documents an admission date to the facility as 12/24/2025 with the following diagnosis: Wedge Compression Fracture of Fourth Thoracic Vertebra, Subsequent Encounter for Fracture with Routine Healing (S22.040d), and Unspecified Fracture of Fourth Thoracic Vertebra. R1's care plan documents a focus assessment was initiated on 12/24/2025 regarding R1 having an Activity of Daily Living (ADL) deficit with no goals nor interventions documented. On 02/03/2025 at 10:30 AM, V10 Minimal Data Set (MDS)/Care Plan Coordinator stated R1's care plan did not document goals nor interventions for the multiple focus areas withing R1's care plan. [...]

Inspectors wroteBased upon interview and record review, the facility failed to assess and control a resident's pain for one (R2) of three residents reviewed on a sample list of 17 residents. R2's face sheet dated 1/15/26 documents R2 was admitted to the facility on [DATE] and expired 12/29/25. [...]

Inspectors wroteBased upon interview and record review, the facility failed to protect one resident (R3) of four residents reviewed for physical abuse in a sample list of six residents. R2's Progress Note dated 9/6/25 documents a Psychosocial assessment was reviewed for R2. The assessment completed related to Physical Altercation - Resident to Resident. Behavioral diagnosis include: Unspecified Dementia, Moderate, Without Behavioral Disturbance; Psychotic Disturbance, Mood Disturbance, And Anxiety; Dysphagia, Oral Phase; Alzheimer's Disease With Early Onset, Dementia In Other Diseases Classified Elsewhere, Moderate, With Agitation; Unspecified Fracture Of Left Femur, Subsequent Encounter For Closed Fracture With Routine Healing; Fracture Of Unspecified Part Of Neck Of Left Femur, Subsequent Encounter For Closed Fracture With Routine Healing; [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement and revise a comprehensive care plan to address falls for two (R1, R3) of three residents reviewed for falls in a sample list of four. Findings Include:Fall Policy dated 10/2024 documents the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The same policy documents the care plan addresses each fall, Interventions are changed with each fall, as appropriate.1. [...]

Inspectors wroteBased on interview and record review the facility failed to initiate resident centered interventions to prevent falls for one resident (R1) of three residents reviewed for falls in a sample list of four residents. This failure resulted in R1 falling from the wheelchair. Findings Include:Fall Policy dated 10/2024 documents that the program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The same policy documents the Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. [...]

Inspectors wroteBased on interview and record review the facility repeatedly failed to ensure residents' right to be free from physical abuse of R8 by R9, R5 by R4, R12 by R11, and R13 by R9. R5, R8, R12 and R13, are four of 20 residents reviewed for abuse on the sample list of 25.

Inspectors wroteBased on interview and record review, the facility failed to accurately encode minimum data sets for antipsychotic medications and falls, and failed to complete the correct minimum data set for a discharged resident. These failures affect two residents (R6 and R1) out of thirteen reviewed for minimum data sets on a sample list of 25.

Inspectors wroteBased on interview and record review the facility failed repeatedly to maintain complete and accurate medical records for two of 14 residents (R2 and R14) reviewed for accuracy of medical records on the sample list of 25.

Inspectors wroteBased on interview and record review, the facility failed to protect two residents' (R1, R10) from physical abuse for two of eight residents reviewed for physical abuse in a sample list if 15. Findings Include: Facility Abuse Prevention and Reporting policy effective 09/2024, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain medical evaluation and treatment following a resident's fall. This failure resulted in R2 experiencing aches, sharp pains, and a significant decline in cognitive, continence, and ambulatory status. R2 was one of three residents reviewed for accidents on a sample list of three.

Inspectors wroteBased on interview and record review, the facility failed to manage new onset pain for a resident after a fall. This failure resulted in R2 experiencing aches, sharp pains, low oxygen levels, and a significant change in cognitive status. R2 was one of three residents reviewed for accidents on a sample list of three.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse by a staff member for one (R1) of three residents reviewed for physical abuse from a total sample list of nine residents.

Inspectors wroteBased on observation, interview and record review the facility failed to report an allegation of abuse to the State Agency in a timely manner for one (R1) of three residents reviewed for abuse from a total sample list of nine residents reviewed.

Inspectors wroteBased on interview and record review the facility failed to follow physician orders for one (R1) of three residents reviewed for physician orders from a total sample list of 103 residents. This failure resulted in R1 being hospitalized with high ammonia levels that could have resulted in permanent harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary linen supplies for 97(R2, R3, R8-R103) of 103 residents reviewed for linen supplies from a total sample list of 103 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of three residents (R1) reviewed for abuse in the sample of three. Findings Include: The Facility Abuse Prevention and Reporting policy effective 09/2024, documents this facility affirms the right of their residents to be free from abuse, neglect, exploitation, misappropriation of property, and deprivation of goods and services. This policy documents abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The same policy documents physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. [...]

Inspectors wrote2. R10's Minimum Data Set (MDS) dated [DATE] documents the following: R10's Brief Interview of Mental Status score of two (2) out of a possible 15, indicating severe cognitive impairment. The same MDS documents R10 had two or more, falls since the last quarterly assessment. R10's Care Plan dated 12/30/24 documents the following: Focus: (R10) is at risk for falls r/t (related /to) dementia, morbid obesity, muscle wasting and difficulty walking. HX (history) of hip FX's (fracture). Interventions include: Apply (name brand non-skid material) on top and under w/chair (wheelchair) cushion. Date Initiated: 07/05/2024. On 2/20/25 at 2:10 PM R10 was seated in his wheelchair bedside. V33, Certified Occupational Therapy Assistant (COTA) and an unidentified Certified Nursing Assistant assisted R10 to a standing position from R10's wheelchair. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ the services of a qualified director of food and nutrition services. This failure has the potential to affect all 105 residents residing in the facility. Findings Include: On 02/18/25 at 08:35 am V7, Dietary Manager (DM) was actively supervising dietary staff during breakfast meal service. V7 stated he has worked at the facility, as the dietary manager, since November 2024. V7 DM stated he has not taken the required classes to qualify as the dietary manager. On 2/19/25 at 2:45 pm V14, Regional Dietary Manager confirmed V7 DM has not had the training to qualify as the dietary manager. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 2/18/25 documents 105 residents reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for cross-contamination and food-borne illness, by failing to maintain clean food contact areas, free of grease-like substances, rust, dangling strands of accumulated dust-like substance, loose caulking and chipped paint. These failures have the potential to affect all 105 residents residing in the facility. Findings Include: On 2/19/25 at 12:30 pm during the follow- up kitchen tour with V7, Dietary Manager (DM)there was an approximate eight-foot long metal shelf, above the three well sink. The metal shelf above the three well sink had copious amounts of rust and brown and black grease-like debris adhering to the underside surface. Directly below the underside, soiled metal shelf are approximately twenty hanging brackets. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain comfortable room temperatures for seven of seven residents (R37, R48, R55, R71, R80, R104, R105) reviewed for comfortable homelike environment on the sample list of 36. Findings Include: Resident Council Meeting Minutes dated 12/2/24 document resident complaints concerning it being too cold in the building. Resident Council Meeting Minutes dated 1/6/25 document resident complaints concerning resident rooms were really cold. Resident Council Meeting Minutes dated 2/3/25 document requests for plastic to be put on windows due to cold temperatures. On 2/18/25 at 11:00 AM the 100 Hallway was much colder than the common areas or other main hallways and dining rooms. On 2/18/25 at 10:35 AM the 101-115 Hallway registered a temperature of 66.2 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, inteview, and record review the facility failed to implement side rails only after completing a side rail assessment and obtaining informed consent for three of three residents (R10, R79, R88) reviewed for side rails on the sample list of 36. Findings Include: The facility's Side Rail/Bed Rail policy dated October 2024 documents the purpose of the policy is to ensure the appropriate, safe and correct installation, use, and maintenance of bed rails. The facility shall ensure that prior to the installation of bed rails, the facility has attempted to use alternatives. After alternatives to bed rails have been attempted and determined that these alternatives do not meet the resident's needs, the facility shall assess the resident for the risks of entrapment and possible benefits of bed rails. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly secure R96's indwelling catheter tubing to R96's wheelchair. R96 is one of two residents reviewed for urinary catheters on the sample list of 36. Findings Include: On 2/18/25 at 12:15 PM, R96 indwelling catheter tubing was dragging on the floor underneath R96 high back wheelchair. On 2/19/25 at 10:32 AM, R96 indwelling catheter tubing was dragging on the floor underneath R96 high back wheelchair. On 02/19/25 at 10:38 AM, V25 (Certified Nursing Aide) confirmed R96's indwelling catheter tubing was hanging underneath R96's highback wheelchair and stated that it should not be dragging on the floor. The facility Catheter Care Policy dated 10/2024 documents the following: to establish guidelines to reduce the risk of or prevent infections in residents with an indwelling catheter. [...]

Inspectors wroteBased on interview, and record review, the facility failed to administer intravenous medications as ordered by the physician. This failure affects two residents (R1, R2) out of three reviewed for intravenous medication administration on a sample of six.

Inspectors wroteBased on interview, and record review the facility failed to protect a resident's (R2) right to be free from sexual abuse by another resident (R1), resulting in psychosocial harm of R2. R1 and R2 are two of seven residents reviewed for abuse in the sample list of seven.

Inspectors wroteBased on interview, and record review the facility failed to care plan and develop/implement behavior tracking and interventions to address and prevent behaviors of inappropriate touching/sexual abuse for R1. R1 and R2 are two of seven residents reviewed for abuse in the sample list of seven.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from sexual abuse for two of five residents (R1, R2) reviewed for abuse on the sample list of five. Findings Include: On 4/29/24 at 8:25 am, V3 (R1's family) stated R2 was roaming the halls and entered R1's room, placed R2's hand on R1's chest and R1's hand on R2's groin, without saying anything. V3 stated R1 started screaming no, no. get out and R2 left the room. V3 explained that R1 was so horrified, R1 didn't say anything about it to anyone until the next day, then R1 reported it to V4 Medical Director. V4 reported it to the facility and at that time, they got the police involved. R1 didn't want to press charges or anything, R1 just wants to forget that it happened. R2's ongoing Diagnosis Listing documents R2 has Metabolic Encephalopathy, Parkinson's, Dementia, and Cognitive Communication Deficit. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent cross contamination of a wound, turn and reposition every two hours, document the receipt of wound treatments, and measure and assess wounds upon identification of the wound for three of three residents (R1, R9, and R10) reviewed for pressure ulcers on the sample list of ten.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain comfortable temperatures in a dining room and resident bedroom. These failures affected six residents (R39, R74, R76, R88, R91, R26) of six reviewed for comfortable temperatures on the sample list of 48. 1. On 1/21/24 at 9:30AM, R39's room had a space heater in use. The space heater was sitting on the counter, oscillating and blowing toward R39. On 1/21/24 at 9:00AM, V5, R39's Family Member stated that R39's room was cold and he visits daily. On 1/21/24 at 9:31AM, V19, R39's Family Member stated that they brought in a space heater for R39 approximately a week ago because her room was so cold. On 1/24/24 at 2:00PM, V1 Administrator said that the temperatures in R39's room on both 1/10/2024 and 1/16/2024 were below the acceptable range of 71 to 81 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide showers and personal cares for residents dependent on staff for hygiene for eight (R13, R29, R30, R42, R46, R47, R68 and R207) of eight residents reviewed for hygiene on the sample list of 48 residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete R93's comprehensive assessment. This failure affects one (R93) of three residents reviewed for accuracy of assessments on the sample list of 48.

Inspectors wroteBased on observation, interview, and record review the facility failed to initiate a resident Care Plan for Oral Care for one resident for (R42) of 28 residents reviewed for Care Plans in a sample list of 48. Findings Include: R42's Functional Abilities and Goals admission assessment dated [DATE] documents Oral Hygiene Not Assessed. R42's Minimum Data Set (MDS) dated [DATE] documents R42 is moderately cognitively impaired and requires supervision to assist of one staff to complete ADLs (Activities of Daily Living). On 1/21/24 at 11:00AM R42 was seated in a wheelchair in R42's room. R42 had several front teeth missing and the remaining teeth were visibly crusted with debris. R42 stated I forget to brush my teeth sometimes, but I can eat ok. R42's Care Plan reviewed date 12/18/23 does not include a Care Plan addressing R42's missing teeth or his need for oral care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to remain free of a fire hazard for one (R39) of 28 residents reviewed for fire hazards from a total sample list of 48 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain urinary catheter tubing and collection bag off the floor for one of two residents (R256) reviewed for urinary catheters on the sample list of 48.

Inspectors wroteBased on observation, interview and record review the facility failed to provide humidification as ordered for oxygen administration for one (R60) of one residents reviewed for oxygenation from a total sample list of 48 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's PICC (Peripherally Inserted Central Catheter) infusion line and IV (Intravenous) pump were patent (open and not blocked) and infusing a physician ordered IV antibiotic 24/7 (24 hours a day/seven days a week) for one of two residents (R1) reviewed for PICC lines in the sample of three. These failures resulted in the facility failing to administer R1's physician ordered continuous IV (Intravenous) antibiotic as ordered for the treatment of R1's Sepsis and Epidural Abscess (infection of the spine or skull), R1 experiencing numerous occasions of mental anguish, and R1 experiencing an unwanted visit to the emergency room (ER) room to gain vascular access.

Inspectors wroteBased on interview and record review the facility failed to notify the physician of a resident not receiving a physician ordered IV (Intravenous) antibiotic medication for one of three residents (R1) reviewed for notification of changes in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to provide sufficient and competent staff (Registered Nurse/RN) to infuse a physician ordered IV (Intravenous) antibiotic 24/7 (24 hours a day/seven days a week) and to ensure a resident's PICC (Peripherally Inserted Central Catheter) infusion line and IV (Intravenous) pump remained patent (open and not blocked) for one of three residents (R1) reviewed for adequate staffing in the sample of three.

Inspectors wroteBased on interview and record review the facility failed to infuse a physician ordered IV (Intravenous) antibiotic 24/7 (24 hours a day/seven days a week) for one of three residents (R1) reviewed for medication errors in the sample of three.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor for and notify the physician of changes in weight and edema for a resident with chronic kidney disease, and failed to transcribe and complete laboratory testing as ordered for one of one residents (R27) reviewed for edema on the sample list of 46. This failure resulted in R27 having a 13 pound weight gain in one month with increased lower extremity edema which caused pain and a decrease in mobility. This failure also resulted in R27's kidney function deteriorating from a stage 2 to a stage 3B kidney failure. Findings Include: On 12/12/22 at 2:27 PM, R27 was sitting up in the wheelchair with edema to bilateral lower extremities. R27 stated R27's legs are sore due to being more swollen than normal and that R27's socks are cutting into R27's legs. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to prevent a fall by failing to provide supervision, ensure a call light was within reach and failing to ensure a wheelchair cushion was not moveable for one (R59) of seven residents reviewed for falls on the sample list of 46. This failure resulted in R59 falling out of the wheelchair, hitting her head and sustaining a laceration which required emergency medical attention and 25 staples to close the laceration. 1. R59's emergency room report dated 12/12/22 documents R59 presents with complaints of a ground level fall and likely hit her head on the bed frame. This report documents R59 had a large flap laceration to the left mid/frontal scalp region. This report documents the laceration to the head was closed with 25 staples. On 12/12/22 at 2:15 PM, R59 was lying in bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure cooking surfaces and dish storage areas were clean and free of cross contamination prior to continued use. This failure had the potential to affect all 121 residents residing in the facility all or most of whom consume food prepared in the facility kitchen.

Inspectors wroteBased on interview and record review the facility failed to hold QAPI (Quality Assurance and Performance Improvement) meetings at least quarterly. This failure has the potential to affect all 121 residents residing at the facility. Findings Include: The facility's Quality Assurance Sign-In Sheets document the facility held a meeting on 5/22/22 to cover the QAPI meeting requirement for January, February, and March of 2022, and a meeting 7/20/22 to cover the QAPI meeting requirement for April, May, and June of 2022. There is no documentation to support a meeting was held to cover the QAPI meeting requirement for July, August, and September of 2022. On 12/14/22 at 11:00AM V1, Administrator stated We were not able to have a QAPI meeting for the months of July, August, and September of 2022. We are working on scheduling one with our Medical Director of October, November, and December 2022. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop comprehensive care plans for four of 24 residents (R56, R58, R174, R117) reviewed for care plans in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete initial assessments prior to the start of psychotropic medications and quarterly, failed to justify PRN (as needed) psychotropics, failed to identify/track targeted behaviors, failed to document specific diagnosed conditions for psychotropic medications for six residents (R100, R95, R117, R21, R38, R329) of six residents reviewed for Psychotropic medication in a sample list of 46.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications according to Physician's Orders for three of seven residents (R60, R79, R80) reviewed for medication administration on the sample list of 46 residents. The facility had five errors out of 25 opportunities for a medication error rate of 20%. Findings Include: The facility Medication Administration Policy dated 1/11/10 documents medications will accurately be administered following physician orders. Crush only medications that can be crushed or physician has given orders to crush. 1.) On 12/14/22 at 8:23 AM, V21 LPN (Licensed Practical Nurse) prepared R79's morning medications that included Metoprolol {Beta Blocker} ER (extended release) 50 mg (milligrams) tablet and Potassium 20 meq (milliequivalents) tablet. [...]

Inspectors wroteBased on interview and record review the facility failed to request a medication refill for one of one resident (R56) reviewed for significant medication errors. R56 did not receive 4 of 4 scheduled once weekly doses of diabetes medication as ordered by the physician.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the call light response cord was within reach for three of 24 residents (R58, R44, R43) reviewed for accommodation of needs in the sample list of 46.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent misappropriation of one hundred and thirty three dollars for one (R49) of three residents reviewed for abuse on the sample list of 46.

Inspectors wroteBased on interview and record review, the facility failed to conduct care plan meetings with resident's and/or resident representative's for two of 46 residents (R44, R100) reviewed for care plans on the sample list of 46. Findings Include: 1.) R44's ongoing census report documents R44 was admitted to the facility on [DATE]. R44's MDS (Minimum Data Set) dated 11/24/22 documents R44 is alert and oriented. On 12/12/22 at 1:11 PM, R44 stated I don't know what you are talking about when asked if R44 was invited to the care plan meetings, and participated in them. At this time, V35 (R44's family) who was in the room with R44 stated V35 gets a letter about the care plan meetings, which were held over the telephone but that R44 was not a part of it. V35 stated she didn't realize R44 could be involved with the care plan meetings. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent cross contamination of a pressure ulcer for one of five residents (R43) reviewed for pressure ulcers on the sample list of 46. Findings Include: R43's December Physician Orders document orders for the following pressure ulcer treatments: Right upper lateral ankle wound - cleanse with Normal Saline or Wound Cleanser, apply a mixture of Gentamicin ointment and Santyl {Chemical Debrider} to wound, then cover with thick absorbent gauze pad and secure with gauze wrap daily. Right lateral calf wound - Cleanse with Normal Saline or Wound Cleanser, apply a mixture of Santyl and Gentamicin ointment, cover with calcium alginate and a thick absorbent gauze pad and secure with gauze wrap daily and as needed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a knee immobilizer was in place as ordered for one of one resident (R56) reviewed for positioning devices in the sample list of 46.

Inspectors wroteBased on observation, interview and record review the facility failed to keep the indwelling urinary catheter collection bag and tubing off of the floor, failed to ensure the indwelling urinary catheter tubing was secure, and failed to prevent backflow of urine for two of two residents (R174, R27) reviewed for catheters in the sample list of 46.

Inspectors wroteBased on conservation, interviews, and record reviews the facility failed to employ sufficient kitchen staff to ensure the facility could clean the flat ware within enough time to serve meals without the use of plastic utensils for staff convenience. This failure impacts R327, one of 46 residents on the sample list.

Inspectors wroteBased on interview and record review, the facility failed to state in the arbitration agreement that the agreement can be rescinded within 30 days of signing it and that it is not required to sign an agreement for binding arbitration as a condition of admission to, or to continue to receive care at, the facility. They also failed to explain the arbitration agreement in a manner that the resident and their representative understands. This failure affects R15 and R60, two of 46 residents on the sample list.

Inspectors wroteBased on interview and record review the facility failed to offer/administer Influenza vaccines for two residents (R17,R38) of five residents reviewed for immunization in a sample list of 46 residents. Findings Include: 1.) R17's Immunization consent signed by R17 on 9/26/22 documents I have been educated on the risks and benefits of receiving the influenza (flu) vaccine and I do want to be vaccinated annually. R17's immunization flow sheet documents R17 has not received the flu shot. R17's Minimum Data Set (MDS) dated [DATE] documents R17 is cognitively intact. On 12/12/22 at 10:00AM R17 stated I signed my consent for a flu shot, but I haven't got one yet. 2.) R38's Immunization consent signed by R38 on 11/7/22 documents I have been educated on the risks and benefits of receiving the influenza vaccine and I do want to be vaccinated annually. [...]