Luther Manor

Inspectors wroteBased on interviews and record review, the facility did not ensure an allegation of abuse was thoroughly investigated for 1 (R3) resident reviewed for allegations of abuse.*The facility did not thoroughly investigate an allegation of abuse from R3 on 4/21/2026.

Inspectors wroteBased on interviews and record review the facility did not ensure residents received needed care and services in accordance with professional standards of practice and the comprehensive care plan to meet each resident's physical, mental, and psychosocial needs for 1 of 1 (R4) residents reviewed for blood sugar testing. R4 had physician's orders for blood sugar testing/monitoring that was not completed as ordered.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 2 (R1 and R2) of 3 residents reviewed with pressure injuries. *R2 is at risk for developing pressure injuries. Facility staff did not document multiple weekly skin checks in the weeks prior to 8/31/25 when R2 developed a facility-acquired stage 3 pressure injury of R2's Sacrum. On 10/22/25, R2 developed two additional facility-acquired stage 2 pressure injuries to R2's right and left hip. On 11/23/25, R2's two hip pressure injuries were resolved but a week later, R2's left hip pressure injury re-opened. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and include the expiration date when applicable for 1 of 2 medication rooms and 1 of 3 medication carts observed, affecting more than 3 residents but less than widespread.

Inspectors wroteBased on interview and record review, the facility did not address and resolve grievances conveyed on behalf of 1 (R9) of 6 grievances reviewed.*R9 expressed care concerns. There was no documentation this was thoroughly investigated, along with an appropriate resolution.

Inspectors wroteBased on interview and record review, the facility did not ensure a resident who uses a psychotropic PRN (as needed) drug had an order limited to 14 days for 1 (R9) of 6 residents reviewed for medications. R9 had an order for PRN Lorazepam with a start date of 11/14/2025 and no end date.

Inspectors wroteBased on interview and record review, the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for 2 (R6 and R5) of 5 residents reviewed for falls. *R6 has a history of falls and is at high risk for falls. R6 experienced falls while at the facility. R6's fall care plan was not updated timely after a fall. R6 has an active intervention for a seat belt while in the wheelchair. On 10/24/25, R6 slid out of R6's wheelchair at the dining room table. After the fall, facility staff entered a new intervention on R6's care plan that documented, Locate [wheelchair] with seat belt, ensure positioning of [wheelchair] on [dining room] table appropriate and close to the table. R6's seat belt was not on the wheelchair at the time of the fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services, and ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments was received for 1 (R51) of 1 residents reviewed.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure staff members timely reported an allegation of suspected abuse to the Administrator for 4 (Residents #1, #2, #3, and #4) of 4 sampled residents related to 2 incidents (01/12/2025 and 07/01/2025) of 3 sampled for abuse. The facility also failed to ensure the facility timely reported an allegation of suspected abuse to the state agency for 2 (Resident #1 and Resident #2) of 4 sampled residents related to 2 incidents (05/20/2025 and 07/01/2025) of 3 sampled for abuse.

Inspectors wroteBased on observation, interviews, and record review the facility did not address and resolve grievances conveyed on behalf of 1 (R1) of 5 residents reviewed for grievances. * On 12/11/2024, a grievance was initiated for R1 regarding R1 requesting to be transferred to bed from R1's wheelchair. R1's grievance stated that a Certified Nursing Assistant (CNA), refused to transfer R1due to the request being too close to the shift change. The refusal resulted in R1 having to wait one hour to be transferred into bed. The grievance packet involving the above grievance was missing information and did not have a clear resolution.

Inspectors wroteBased on record review, review of hospital discharge summary, interview, and facility document review, the facility failed to ensure orders were transcribed correctly for one of three residents (Resident (R) 4) reviewed for medication orders out of 13 sample residents to ensure medications were administered as ordered. This had the potential for the residents to have unmet health care needs.

Inspectors wroteBased on interview and record review, the facility did not ensure that a written consent explaining the risks and benefits of psychotropic medications was obtained for 1 of 1 Residents reviewed (R58). * R58 was prescribed Seroquel, 12.5 mg (milligrams) 2 times daily, an antipsychotic medication for agitation related to Delusional Disorder diagnosis on 9/27/24. On 10/8/24, Seroquel was increased to 12.5 mg 3 times daily. The facility did not have a written, signed consent explaining the risks and benefits of Seroquel by R58's activated power of attorney (POA). Findings Include: 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. R58 currently has an activated Health Care Power of Attorney(HCPOA). [...]

Inspectors wroteUNCORRECTED ON VERIFICATION VISIT Based on record review and staff interviews, the facility did not ensure that 3 allegations of abuse involving 2 residents (R2 and R58) and 1 Resident to Resident (R3 and R4) altercation were reported to the State Survey Agency within the required reporting timeframe . * R2's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting a bruise of unknown origin was submitted to the State Survey Agency on 9/3/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/16/24. * R58's Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report documenting an allegation of rape was submitted to the State Survey Agency on 9/26/24. The Misconduct Incident Report was not submitted to the State Survey Agency until 10/16/24. [...]

Inspectors wroteUNCORRECTED ON VERIFICATION VISIT Based on record review and staff interview, the facility did not ensure all allegations involving potential abuse (R58) and Resident to Resident altercation (R3 and R4) were thoroughly investigated for 3 of 3 reviewed self reports. * R58's Facility Reported Incident (FRI) dated 9/12/24 documents an allegation of R58 being raped along with R58 sustaining blunt force trauma to the chest. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. The FRI does not contain an investigation of the blunt force trauma. Facility Reported Incident (FRI) dated 10/16/24 documents an allegation of R58 being raped by a male caregiver. The FRI does not contain other resident statements, all staff statements, or a root cause analysis of the circumstances of the allegation. [...]

Inspectors wroteBased on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R58) of 1 Resident reviewed with PASARR level 2 recommendations. *R58's PASARR dated 10//21/24 determination states R58 requires specialized psychiatric rehabilitation services to address R58's mental illness. Findings Include: The facility's policy Resident Assessment-Coordination with PASARR Program dated 10/22/21 documents: Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder for 1 (R58) of 1 residents reviewed for PASARR screening. * R58 was admitted on [DATE] and the Level I PASARR was completed indicating R58 would be in the skilled nursing facility for less than 30 days. R58 is currently a Resident in the facility. A Level I PASARR was not resubmitted/updated indicating R58 was going to be at the facility longer than the 30 exemption period triggering a Level II PASARR to be completed until 10/16/24. On 10/21/24, it was determined that R58 requires services called 'specialized psychiatric rehabilitation services' for R58's mental illness.

Inspectors wroteUNCORRECTED ON VERIFICATION VISIT Based on interview and record review, the facility did not update the person-centered care plan and ensure the comprehensive care plan was implemented to meet a resident's psychosocial needs for 1 (R58) of 1 resident. * R58's comprehensive care plan has not been updated with person-centered interventions including incorporating Level II PASARR recommendations of requiring 'specialized psychiatric rehabilitation services'. Findings Include: The facility policy titled Comprehensive Care Plans revised 9/23, documents: .Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not develop and implement an effective discharge planning process focusing on resident discharge goals, and preparation for transition for 1 (R58) of 1 residents reviewed for discharge planning. * R58 was admitted to the facility on [DATE] with a Left Femur Fracture with the goal to discharge home and/or a lesser restrictive environment. R58 has not had consistent and active discharge planning since admission. Findings Include: The facility's policy Transfer and discharge date d 10/21 documents: .The comprehensive, person-centered care plan shall contain the Resident's goals for admission and desired outcomes and shall be in alignment with the discharge. 1.) R58 was admitted to the facility on [DATE] with diagnoses of Depression, Fracture of Left Femur, Unspecified Severe Protein-Calorie Malnutrition, Polyneuropathy, and Anemia. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 1 (R150) of 8 residents reviewed for ADL's (Activity of Daily Living). On 10/29/24, R150 was not provided with incontinence care every two hours and was observed with a saturated incontinence product.

Inspectors wroteBased upon observation, interview and record review, the facility did not ensure 1 (R58) of 4 residents reviewed received medically related social services to address individual Resident needs in order to maintain the highest practicable physical, mental, and psychosocial well-being. * R58 has a history of trauma as identified in a trauma assessment completed on [DATE]. The facility social worker (SW)-C did not establish an individualized plan of care to address R58's trauma. On [DATE], a Level II PASARR screen determined that R58 requires specialized psychiatric rehabilitation services to promote the highest practicable psychosocial well-being for R58. The facility did not update R58's comprehensive care plan with person-centered interventions. SW-D has not actively assisted R58 to identify and prepare for alternate placement.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, record review and interviews, the facility did not ensure that 1 (R62) of 5 residents reviewed received care, consistent with professional standards of practice to prevent the development of pressure injures and or to promote healing, prevent infection and prevent additional pressure injuries from developing. * R62 developed a pressure injury on the right buttock on 6/30/24 that was not comprehensively assessed and did not have physician notification for a treatment until 7/10/24. R62's pressure injury declined during this time, and on 7/10/24, the wound physician assessed the pressure injury as unstageable. The wound physician ordered a debriding treatment. On 7/17/24, the pressure injury was mechanically debrided to a stage 4 pressure injury. R62 was not assessed for weight loss prior to this pressure injury development. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that 1 of 3 residents (R62) reviewed, based on a comprehensive assessment, maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range. * R62 was admitted with severe protein malnutrition. R62's nutritional assessments did not include actual weights that were obtained by facility staff and/or individualized interventions to provide adequate nutrition. R62 developed two periods of severe weight loss (130 lbs to 69.2 lbs, a 46.7% weight loss) that factored into the development of a stage 4 pressure injury and R62 being placed on hospice services. The facility's failure to conduct comprehensive assessments, to develop an individualized plan of care, and to provide adequate nutrition created a finding of immediate jeopardy that began on 3/20/24. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure the Covid 19 outbreak reflected accurate data, the surveillance of infections were not identified on the infection line list and the monthly infections rates did not accurately identify infections. Visual alerts such as signs at the entrance to notify everyone of the current outbreak and instructions about current recommendations was not done. * CNAs (Certified Nursing Assistants) were observed not using hand hygiene appropriately during meal service. These deficient practices have the ability to affect all 90 residents residing at the facility at the time of the survey.

Inspectors wrote4.) R59 was admitted to the facility on [DATE] with a diagnoses that includes chronic kidney disease, anemia, osteoarthritis, and constipation. R59's Quarterly MDS (Minimum Data Set) dated 8/19/24, documents that R59 has short and long-term memory problems, impairments to both upper extremities, and is dependent with toileting, dressing, and transferring. R59 was documented as not having a BIMS (Brief Interview for Mental Status) evaluation due to R59 is rarely/never understood. R59's care plan, dated 12/15/23, documents: ~ R59 has an Activities of Daily Living (ADL) self-care performance deficit related to impaired mobility and osteoarthritis (date initiated 12/15/23, revised on 8/23/24). Interventions include: 1. Provide appropriate level of assistance for ADL care needs to R59 (date initiated 12/15/23). 2. R59 requires a set up for eating (date initiated 5/22/24). 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure 2 of 2 medication storage rooms did not have expired stock medication and expired & not dated insulin for R11. * Expired 0.9 sodium chloride irrigation 500 ml (milliliter) bottle, stock Systane lubricant eye drops and tear eye drop advanced were observed in the 2900 unit medication storage room. * Expired stock tear eye drop advance and a bottle of Lantus insulin was expired for R11. A second bottle of Lantus, which was open & used, was not dated when opened. This has the potential to affect 9 residents residing on the 2700 unit and 14 residents residing on the 2900 unit who may have eye drops ordered.

Inspectors wroteBased on record review and interview, the facility did not ensure residents on psychotropic medications received monitoring, and dose reductions, to minimize use of these medications. This was observed with 4 (R50, R62, R38 and R49) of 6 resident medication reviews. - R50 receives an antipsychotic medication, and did not have a AIMS (abnormal involuntary movement scale) assessment, to monitor for side effects. - R62 receives an antipsychotic medication, and did not have a AIMS assessment, to monitor side effects. - R38 receives Cymbalta and Sertraline once daily for depression. The facility has no evidence of AIMS (abnormal involuntary monitory scale) monitoring and no evidence of an attempted dose reduction. - R49 receives an psychotropic medication that was not reviewed for a gradual dose reduction.

Inspectors wroteBased on interview and record review the Facility did not report 2 (R5 and R77) of 3 allegations of abuse or neglect to the State Survey Agency during the required timeframe. A report of abuse or neglect was not reported to the Nursing Home Administrator (NHA)-A for 1 (R77) of 3 allegations during the required timeframe. * An accusation of abuse was made involving R77 which was not reported to the NHA-A during the required timeframe. * The Facility did not report a resident-to-resident altercation involving R77 to the State Survey Agency. * On 7/9/24, R5 returned to the facility from a hospitalization on 7/3/24 - 7/9/24. R5 was discovered to have a femur fracture and the facility did not conduct an investigation or report the injury of unknown origin to the State Agency.

Inspectors wroteBased on interview and record review, the facility did not ensure 2 (R5 and R77) of 3 residents reviewed had thorough investigations into allegations of abuse or injuries of unknown origin. * On 7/9/24, R5 returned to the facility from a hospitalization. R5 was discovered to have a femur fracture and the facility did not conduct an investigation into R5's femur fracture. * An accusation of abuse was made involving R77 which was not investigated thoroughly * A resident-to-resident altercation took place involving R77 which was not investigated thoroughly

Inspectors wroteBased on interview and record review, the facility did not ensure 3 (R5, R34, and R32) of 3 residents reviewed that required hospitalizations were given written reason for transfer to the hospital and the facility did not send this notification to the Ombudsman. R5 was transferred to the hospital on 8/23/24, 8/12/24, 7/3/24, 5/24/24, and 5/15/24 for changes in condition. R5 or their representative did not receive written notification of transfer to the hospital and the State Ombudsman was not sent a copy of this notice. R34 was transferred to the hospital on 4/6/24 while residing in the facility and evidence was not provided R34 or their representative were given the required transfer notice information including appeal rights. On 8/12/24, R32 had a change in condition and was sent to the hospital. R32 was admitted to the hospital and a bed hold notice was given. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the Minimum Data Set (MDS) accurately reflected the resident's status at the time of the assessment for 1 (R77) of 24 residents reviewed. R77's Quarterly Minimum Data Set (MDS) with an assessment reference date of 6/19/24, did not accurately reflect R77's occurrence of behaviors.

Inspectors wroteBased on observation, interview, and record review the Facility did not update the comprehensive person-centered care plan for 3 (R29, R49, and R64) of 24 residents to meet a resident's medical, nursing and psychosocial needs that are identified in the comprehensive assessment. * R64's care plan was not updated when foley catheter was removed. * R49's care plan was not updated to address condom catheter use. * R29's care plan was not updated for compression sleeve use.

Inspectors wroteBased on record review and interview, the facility did not follow up on pharmacist recommendations reports, with the monthly medication reviews for 2 (R62 and R77) of 5 residents reviewed. - R62 and R77's pharmacy irregularities reports documented by the pharmacist for the physician were not acted upon.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 (R64) of 1 residents reviewed were free from significant medication errors. *R64 had a physician order to receive Plavix Oral Tablet 75mg (anticoagulant) one time a day. R64 did not receive 6 administrations of Plavix between 7/28/2024 and 8/11/2024.

Inspectors wroteBased on interview and record review the facility did not ensure 1 of 5 Certified Nursing Assistants (CNAs) reviewed received the required 12 hours of continuing competence training. This deficient practice has the ability to affect 90 residents whom could receive care from the CNA. CNA-M was hired on 10/31/22 and received only 4.5 hours of continuing competence training.

Inspectors wrote2.) R2 was admitted to the facility on [DATE]. R2's diagnoses included Chronic Kidney Disease, Heart Failure and Diabetes Mellitus. R2's Quarterly MDS dated [DATE] documents R2 is at risk for pressure injuries. On 3/5/24 a Braden assessment was conducted for Resident with a score of 16 indicating R2 is at risk for pressure injuries. On 3/9/24, R2 was discharged to the hospital. R2 returned from the hospital to the facility on 3/20/24. On 6/3/24 at 11:15 AM, Surveyor observed R2 in their room lying in bed. R2 had a pressure relieving air mattress in place at this time. R2's left heel was floated on a pillow to provide pressure relief. Surveyor attempted to conduct interview with R2 at this time. R2 declined interview with surveyor at this time responding, I am in no mood to talk with anyone any time soon. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure care plans were implemented for residents determined to be at risk for falls and did not ensure residents were comprehensively assessed after a fall to implement preventive measures based on the assessment for 2 (R1 and R3) of 4 residents reviewed for falls. *R1 was admitted to the facility after sustaining a fractured left hip from a fall in the community. R1 was assessed to be a high risk for falls and no care plan was developed to address the fall risk. On 4/22/2024, R1 fell from bed and sustained a fracture to the right hip. *R3 fell on [DATE] and sustained a fractured to the right hip. The fall was not thoroughly investigated as to the root cause and no care plan interventions were implemented to prevent future falls. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that an allegation of abuse involving 1 (R3) of 2 residents reviewed for allegations of abuse were reported immediately to the State Survey Agency. *On 4/17/24 an allegation of R3 being choked by a certified nursing assistant(CNA) was not reported to the state survey agency within 2 hours and local law enforcement was not notified of the allegation immediately. Findings Include: Surveyor reviewed the facility's Alleged Incidents of Abuse, Neglect, Exploitation and Mistreatment-Reporting and Investigation policy and procedure last revised 2/2020 and notes the following in regards to reporting: [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure all allegations involving potential abuse, neglect and misappropriation of Resident property were thoroughly investigated for 2 (R3 and R4) of 2 sampled residents. *R3's Facility Reported Incident(FRI) dated 4/17/24 documents an allegation of R3 being choked. The FRI does not contain other Resident statements, all staff statements, the reasoning for why the local law enforcement was not notified and a root cause analysis of the circumstances of the allegation. *R4's Facility Reported Incident(FRI) dated 4/1/24 documents an allegation of R3 being choked. The FRI does not contain other Resident statements, all staff statements, and a root cause analysis of the circumstances of the allegation. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 1 (R3) of 1 residents reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. *R3's hospital discharge paperwork dated 12/20/23 has instructions for R3 to follow-up for an orthopaedic consult to be scheduled within 6 weeks after discharge. R3 did not have a consult until 3/11/24. The consult documented that R3 was to return in 1 month for repeat x-rays. R3 did not have that appointment. R3 was scheduled for an orthopaedic appointment on 5/7/24 which R3 did not attend. Findings Include: 1.) On 6/5/24 at 11:54 AM, Administrator(NHA-A) informed Surveyor the facility does not have a policy and procedure for Resident appointments. [...]

Inspectors wroteBased on observation, record review, and staff and resident interview, the facility did not ensure that all treatments and care was provided to 1 (Resident 8) of 1 sampled residents in accordance with professional standards of practice. * R8 presented with an open area to the right, superior buttocks. The open area was not assessed by a Registered Nurse (RN), nor was the treatment consistently completed as ordered. R8 was to be repositioned every 2 hours to relieve pressure on the open area and repositioning was not consistently completed. R8 was also incontinent of bladder. R8 had a toileting problem which was not consistently followed. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure residents at risk for pressure injuries or those admitted with pressure injuries received care consistent with professional standards of practice to prevent pressure ulcers from developing for 3 (R11, R1, and R7) of 4 residents reviewed for pressure injuries. * R11 was admitted with excoriation to the coccyx extending to the bilateral buttock which developed into an unstagable pressure injury to the sacrum that was never comprehensively assessed. R11 was admitted on [DATE] with excoriation to the coccyx extending to the bilateral buttocks, with treatment obtained. On [DATE] the Skin Only Evaluation documented open wounds to the coccy with no comprehensive assessment conducted. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure a system of records of receipt and disposition of all controlled drugs in sufficient detail enabled an accurate reconciliation affecting 1 unit of 2 units. * Licensed Practical Nurse Unit Manager (LPN UM)-K diverted narcotic medications from discharged and expired residents. LPN UM-K did not follow the procedure to have two nurses sign the narcotic record form when narcotics were destroyed and shredded narcotic record forms so narcotic medications could not be reconciled.

Inspectors wroteBased on record review and staff interview, the facility did not report the results of abuse/neglect investigations to the state agency within 5 working days for 1 (Resident 2) of 5 sampled investigations. The facility reported an initial allegation of abuse/neglect to the state agency but did not report the full investigation within five working days as required by state law.

Inspectors wroteBased on record review and staff interview, the facility did not have evidence that alleged violations were thoroughly investigated for 3 (Residents 3, 4 and 6 ) of 5 sampled allegations of abuse/neglect. The facility submitted allegations of abuse/neglect for Residents (R) 3, 4 and 6, but there was not evidence that the allegations were thoroughly investigated nor did the facility complete training to staff to ensure they should not take money for any residents in attempt to prevent exploitation.

Inspectors wroteBased on observation, staff and resident interview, the facility did not ensure that 1 (Resident 8) of 1 sampled residents received appropriate treatment and services to restore continence to the extent possible. * R8 was incontinent of bladder. The facility did not complete a comprehensive assessment for bladder incontinence. The facility did not complete a voiding study in attempt to determine a voiding pattern and develop a toileting schedule based on the voiding study. The facility developed a toileting schedule but was not based on a voiding study. The plan of care directed staff that R8 was to be checked and change every 3 hours during the AM and PM shift. This was not consistently followed.

Inspectors wrote3. R76 was admitted to the facility 6/8/23 with diagnoses that include Fracture of Right Femur, Fracture of Left Femur, Fracture of Shaft of Right Humerus, Fracture of Lower End of Left Humerus, Fracture of Head of Left Radius, Fracture of Lower End of Left Radius, Fracture of Upper End of Left Ulna, Fracture of Right Forearm, Fracture of Olecranon Process, Fracture of Trapezium, Fracture of Right Patella, Fracture of Left Patella, Bimalleolar Fracture of Left Lower Leg, Multiple Fractures of Ribs, Fracture of Sternum, Acute Pain Due to Trauma, and Bipolar Disorder. Surveyor reviewed R76's Minimum Data Set (MDS) admission assessment with an assessment reference date of 6/15/23. Documented under Cognition was a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. Documented under Medications was .Medications Received: [...]

Inspectors wroteBased on record review and interview, the facility did not ensure allegations of abuse involving 2 residents (R138 and R76) of 3 residents reviewed for abuse were reported in accordance with regulatory time frames. The facility did not ensure R138's allegation of abuse was reported immediately, but no later than 2 hours, to the Administrator and to the State Agency. The facility did not ensure the results of their investigation involving R76's allegation of abuse was reported to the State Agency within 5 working days of the incident. *R138 reported to Licensed Practical Nurse (LPN)-D on the evening of 4/12/23, that R138 was physically assaulted during a shower. LPN-D did not report the alleged allegation of abuse to the Administrator. [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure all allegations of abuse was thoroughly investigated for 1 (R138) of 3 self-reports reviewed for abuse, neglect, and mistreatment. The facility did not have evidence of preventing further abuse while the investigation was in progress. * On 4/12/23, R138 reported to Licensed Practical Nurse (LPN)-D that Certified Nursing Assistant (CNA)-H was physically assaulting her during a shower. On 4/12/23, LPN-D reported to Registered Nurse (RN) G that R138 was upset but did not specify the allegation of abuse. The facility did not prevent the potential for further abuse from occurring as the accused CNA-H continued performing resident cares after the allegation was first made on 4/12/23. The facility did not initiate an investigation into this allegation of abuse until the following day on 4/13/23. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 Residents (R20, R29, and R26) of 4 residents reviewed for hospitalization received a transfer notice to include date of transfer, reason for transfer, location of transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. In addition, the facility did not notify the State Long-Term Care Ombudsman of hospital transfers for 3 Residents (R20, R29, and R26) of 4 residents reviewed for hospitalization. R20 was transferred to the hospital on 6/22/23, 6/23/23, 6/29/23, and 7/24/23. The facility did not provide R20, their representative, and the Ombudsman notice of transfer. R29 was transferred to the hospital on 4/18/23 and 5/23/23. The facility did not provide R29, their representative, or the Ombudsman notice of transfer. R26 was transferred to the hospital on 5/7/23. [...]

Inspectors wroteBased on record review and interview, the facility did not provide written notice of the facility bed-hold policy for 3 (R20, R29, R26) of 4 residents reviewed for hospital transfers. R20 was transferred to the hospital on 6/22/23, 6/23/23, 6/29/23, and 7/24/23. A bed hold notice was not provided to R20 and their resident representative. R29 was transferred to the hospital on 4/18/23 and 5/23/23. A bed hold notice was not provided to R29 and their representative. R26 was transferred to the hospital on 5/7/23. A bed hold notice was not provided to resident and their resident representative.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility did not ensure that a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder (PTSD), receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 1 (R76) residents reviewed with a history of trauma. * R76 was admitted to the facility on [DATE] after a prolonged hospital stay from multiple fractures and complications related to a gunshot wound (GSW) and a fall out of a window from a 4th story building and bipolar disorder. R76 had multiple complications and was admitted to the facility with identified trauma and related behaviors. The facility completed a Brief Trauma Questionnaire Assessment with R76. [...]

Inspectors wroteBased on observation, interview and record review the facility did not ensure it maintained a medication error rate below 5 percent during observations of medication administration affecting 1 (R36) of 4 residents observed. Two medication errors were observed out of twenty-eight opportunities, for a total error rate of 7.14%. * R36 was administered 2 medications whole with applesauce that should not be chewed. R36 was observed chewing Januvia and Memantine ER (extended release) and drug manufacturers recommendations are not to chew the medication.