Colonial Manor of Elma

Inspectors wroteBased on clinical record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure one of six residents reviewed remained free from a resident to resident physical altercation when a resident with severe cognitive impairment and a known history of aggressive behaviors (Resident #6) hit another resident (Resident #2). Three of six residents reviewed experienced fear from the Resident #6's aggressive behavior (Resident #2, Resident #4, and Resident #5). Resident #2 experienced increased anxiety, social isolation, a decline in nutritional intake, and fear following the incident. Resident #4 and Resident #5 expressed fear of Resident #6 and reported decreased activity participation due to Resident #6's behaviors. The facility reported a census of 32 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to protect 1 of 2 resident's rights to be free from misappropriation of their opioid pain medication patches (fentanyl) (an extremely potent, synthetic (lab-made) opioid used for pain) (Resident #42). The facility reported a census of 36 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to document non-pharmacological interventions prior to administering anti-anxiety medication for anxiety and/or restlessness for 1 of 1 resident sampled (Resident #35). The facility identified a census of 36.

Inspectors wroteBased on record review and staff interviews the facility failed to accurately code 2 of 2 Minimum Data Set (MDS) assessments for residents with a Pre-admission Screening and Resident Review (PASRR) Level II outcome (a formal determination that confirms if an individual with suspected serious mental illness or intellectual disability requires Medicaid-certified nursing facility care and defines their need for specialized services) (Resident #4 and #32). The facility reported a census of 36 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to provided 1 of 2 residents with specialized services as the resident's Pre-admission Screening and Resident Review (PASRR) directs (Resident #4). The facility reported a census of 36 residents.

Inspectors wroteBased on observation, record review, policy review, resident, and staff interview, the facility failed to ensure appropriate infection control prevention and practices to prevent cross contamination when providing incontinent cares. The observation revealed the staff failed to remove soiled gloves, perform hand hygiene, and not touch a clean brief with soiled gloves for 1 of 2 residents observed (Resident #7). The facility identified a census of 36 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to obtain daily weights and notify the Doctor of a 3-pound (lb.) weight gain is identified in a day as the Doctor ordered for 1 of 1 resident reviewed for nutrition (Resident #6). The facility reported a census of 36 residents.

Inspectors wroteBased on observation, policy review and staff interview, the facility failed to ensure infection control prevention and practices to prevent touching of medication with bare hands or dirty gloves during medication administration for 3 of 5 residents observed (Residents #27, #1, and #11). The facility identified a census of 36 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to implement a Care Plan chair alarm intervention for 1 of 3 residents reviewed for falls (Resident #3). The facility reported a census of 31 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented a Brief Interview for Mental Status (BIMS) of 2 out of 15, which indicated severe cognitive impairment. The MDS documented the need for substantial/maximal assistance (staff did more than half the effort) for transfers and walking up to 50 feet. The MDS also documented diagnoses of non-Alzheimer's dementia, anxiety, respiratory failure, and adult failure to thrive. The Care Plan created 2/18/25 revealed, Resident is at risk for falls. The Intervention initiated 2/24/25 and created on 3/6/25 revealed, Chair alarm placed to alert staff when I am self transferring. [...]

Inspectors wroteBased on clinical record review, policy review, resident and staff interviews, the facility failed to treat a resident with dignity and respect for 1 of 3 residents sampled (Resident #4). The facility identified a census of 30 residents.

Inspectors wroteBased on observation, policy review, clinical record review, and staff interview, the facility failed to utilize appropriate EBP per the CDC during the provision of catheter care to minimize the risk of cross contamination that may lead to the spread of multi-drug resistant organisms for 3 of 3 residents sampled (Residents #5, #4, and #10). The facility reported a census of 30 residents.

Inspectors wroteBased on clinical record review, Centers for Medicare and Medicaid Services (CMS) Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual review, and staff interview, the facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) within 14 days of hospice election for 1 of 1 residents reviewed for hospice care (Resident #23). The facility reported a census of 30 residents.

Inspectors wroteBased on observation, clinical record review, document review, policy review, resident and staff interviews, the facility failed to provide a full assessment for 1 of 4 residents sampled for falls (Resident #2). Resident #2 fell on [DATE] at 9:50 PM. Resident #2 exhibited left hip pain and an externally rotated left leg. Staff A, Assistant Director of Nursing (ADON) failed to assess the resident and assisted Resident #2 from the floor to standing position where Resident #2 could not bear weight on his left leg. Staff A called for help and Staff B, Certified Nursing Assistant (CNA) assisted her to transfer Resident #2 into a wheelchair and then they transferred him to lay in bed. Resident #2 was transferred to the emergency room department on 10/13/24. Resident #2 was diagnosed with a left hip fracture on 10/14/24. [...]

Inspectors wroteBased on facility record review and staff interviews, the facility failed to ensure the facility's Dietary Service Manager had the required qualifications in the absence of a full-time dietician. The facility reported a census of 35 residents.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to follow physician orders for 1 of 2 residents reviewed (Resident #17). The facility reported a census of 35 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure assessments were done for 1 of 2 residents reviewed to determine if she remained at baseline or had a decline (Resident #15). The facility reported a census of 35 residents.