Inspection Reports for
Arma Operator LLC

Complaint reference numbers KS002722723, KS002744366, and KS002646859 were investigated. The deficient practice involved a fall from a mechanical lift resulting in injury and psychosocial impact. Corrective actions included staff re-education and monitoring.

The facility failed to ensure an environment free from accident hazards for a resident requiring mechanical lift assistance, resulting in a fall with injury. Staff training and corrective actions were completed prior to the survey, and the deficient practice was deemed past noncompliance at a 'G' level.

The complaint investigation substantiated neglect when staff transferred Resident 1 without the mechanical lift, causing fractures. Staff failed to report the incident timely. CNA M was terminated, CNA N and CNA O were suspended and received warnings. The facility implemented corrective measures including staff education and audits.

The facility failed to ensure R1 remained free from neglect when Certified Nurse Aides transferred her without using the full-body mechanical lift, resulting in fractures to her left femur and right fibula. Staff failed to report the incident accurately and timely, placing R1 in immediate jeopardy. Corrective actions were implemented prior to the survey.

The complaint investigation revealed that on 05/18/25, CNAs M and N lowered Resident 1 to the floor without using the mechanical lift and did not report the incident to nursing or administration. Resident 1 sustained a distal left femur fracture and a distal right fibula fracture. Staff were suspended or terminated and corrective actions including education and audits were implemented.

The facility failed to ensure R1 remained free from neglect when staff transferred R1 without using the required full-body mechanical lift, resulting in R1 being lowered to the floor and sustaining fractures. Staff failed to report the incident timely and accurately, placing R1 in immediate jeopardy. Corrective actions were completed prior to the survey.

The facility failed to prepare, store, and serve food in a sanitary manner, with multiple instances of expired or undated food items and unsanitary kitchen and food storage conditions observed.

The inspection was triggered by complaint #192384 and included a health resurvey.

The facility failed to prepare, store, and serve food in a sanitary manner, with multiple expired and undated food items and unsanitary kitchen conditions observed. Additionally, the facility failed to electronically submit complete and accurate direct care staffing information, resulting in inaccurate Payroll Based Journal (PBJ) reports for the 3rd and 4th quarters of 2024.

The plan addresses issues including unlabeled and undated food items, cleaning deficiencies in the kitchen and storage areas, and inaccuracies in reporting administrative nurse direct care hours in PBJ.

The plan addresses multiple deficiencies including call light accessibility, resident grievances, resident-to-resident investigations, notification to Ombudsman, nail care, bruising assessments, catheter securement, sanitation issues, and staff skills check-offs. Corrective actions include audits, education sessions, care plan updates, and ongoing monitoring.

The facility had multiple deficiencies including failure to ensure residents had call lights within reach, failure to file and follow up on grievances, inadequate investigation of resident-to-resident altercations, failure to notify the Ombudsman of hospital transfers, inadequate hygiene care for residents, failure to identify causes and prevent repeated skin injuries, improper catheter tubing securing, improper garbage disposal, and lapses in infection control practices.

The inspection included complaint investigations related to call light accessibility, grievance handling, resident-to-resident abuse and sexual abuse, failure to notify Ombudsman of hospital transfers, hygiene care, skin injuries, catheter care, garbage disposal, and infection control breaches.

The facility was found deficient in multiple areas including failure to accommodate resident needs for call light access, failure to file and follow up on grievances, inadequate investigation of resident-to-resident abuse, failure to notify the Ombudsman of hospital transfers, inadequate hygiene care for a resident, failure to prevent repeated skin injuries, improper catheter care, improper garbage disposal, and infection control breaches.

The plan addresses deficiencies related to fall interventions, catheter care, accident interventions, and medication management. Corrective actions include care plan updates, audits, staff education, and ongoing monitoring.

The facility failed to review and revise care plans following resident falls, failed to implement planned fall prevention interventions, failed to update catheter care instructions, and failed to properly label and store medications.

The inspection was triggered by complaint investigation #153890.

The facility failed to review and revise care plans for residents following falls, failed to follow care plan interventions to prevent falls, and failed to appropriately manage a resident's urinary catheter to prevent infections and trauma. Additionally, the facility failed to properly label and store medications, including expired drugs and undated opened medications.

The facility was found to be deficiency free during the COVID-19 survey conducted on June 16, 2020.

The plan addresses medication administration issues, including notification of physician, director of nursing, and resident after occurrences, audits of medication administration, education for licensed nurses and medication aides, and ongoing monitoring through random audits and QAPI committee reviews.

The complaint investigation #142931 was substantiated by findings that staff administered the wrong medications to resident #01 due to confusion between residents with the same first name. The resident was notified and monitored with no adverse effects noted.

The facility failed to follow physician's orders and ensure that one resident received the correct medications, resulting in medication errors where medications intended for another resident were administered. No negative outcomes were noted from the medication errors after monitoring.

The plan details corrective actions including cleaning and repairing facility equipment, updating wound care orders, labeling insulin pens, and improving dietary equipment maintenance. It also describes ongoing audits and staff education to prevent recurrence.

The visit was complaint-related as it included a Health Resurvey and Complaint Investigation with multiple complaint numbers (#135358, #135312, #131980, #131908, #131920, #131888, #136422).

The facility failed to maintain a safe, clean, and homelike environment, including housekeeping and maintenance deficiencies in hallways and resident rooms. The facility also failed to provide timely treatment for a resident's pressure ulcer, ensure proper labeling and storage of insulin pens, and maintain sanitary food procurement, storage, preparation, and service conditions.

The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective 2019-01-31.

The plan outlines corrective actions taken for multiple deficiencies including maintenance repairs, wheelchair modifications, kitchen caulking, and infection control practices related to fecal matter disposal.

The survey found a most serious deficiency at level "F", widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective 2017-12-15.

The inspection included complaint investigations #107740, #101610, and #111274. The complaints involved sanitation, care planning, accident prevention, food safety, and infection control issues.

The facility failed to maintain sanitary housekeeping and maintenance services, failed to properly review and revise a resident's care plan regarding wheelchair foot rest, failed to provide adequate supervision and assistive devices to prevent accidents, failed to prepare food under sanitary conditions, and failed to maintain an effective infection control program related to disposal of contaminated bowel movement material.

The plan addresses deficiencies involving individualized toileting care plans, skin assessments with pressure relieving interventions, and urinary assessments to maintain bladder function. The facility outlines corrective actions including audits, re-education of staff, and ongoing monitoring by the interdisciplinary team and Quality Assurance committee.

The survey found deficiencies at the level of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The inspection was triggered by complaint investigations #106530, 106524, and 107026.

The facility failed to review and revise individualized care plans for residents related to toileting and bladder management, failed to provide timely repositioning and pressure relief to prevent pressure ulcers, and failed to provide appropriate treatment and monitoring for pressure ulcers. The facility also failed to develop individualized toileting plans to maintain normal bladder function for residents.

The report confirms that the previously identified deficiency under regulation 483.25(h) was corrected as of the revisit date. No other deficiencies or uncorrected issues are noted.

The deficiency citation represents investigation findings of complaints #101581 and #101635. The resident fell during transport due to failure to secure the wheelchair and resident properly by a substitute van driver who lacked formal training. The resident sustained multiple injuries and required medical evaluation and treatment.

The facility failed to provide proper wheelchair securement and resident safety during transport in the facility van, resulting in a resident falling from the wheelchair and sustaining injuries including abrasions, bruises, skin tears, and loss of a toenail.

The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance.

The plan addresses staff training and transportation issues, including suspension of a staff member, completion of van training, and ongoing training for transportation aides. Resident and family interviews noted no issues during transportation.

The plan addresses issues related to a resident's elopement, including assessment completion, auditing of elopement status, placement of one-on-one supervision, care plan meetings, and ongoing review of elopement assessments and trends.

The report confirms that the previously reported deficiencies have been corrected as of the revisit date.

The complaint investigation #99420 substantiated that the facility did not prevent a confused resident from leaving the facility without staff knowledge, resulting in an elopement incident.

The facility failed to ensure adequate supervision and assistive devices to prevent one resident with dementia and wandering behavior from eloping without staff knowledge. The resident left the facility unnoticed and was later found and returned by family and police.

The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The plan details corrective actions including resident monitoring, staff re-education, maintenance repairs, audits, and ongoing quality assurance reviews to address deficiencies related to resident care, facility maintenance, infection control, and documentation.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection included a complaint investigation identified by complaint #97676.

The facility was found deficient in multiple areas including failure to notify physicians of resident condition changes, inadequate housekeeping and maintenance, failure to provide necessary care and monitoring, unsafe environment hazards, failure to provide dental services, inadequate drug regimen monitoring, lack of physician supervision for some residents, and failure to maintain an effective infection control program.

The report confirms that deficiencies previously cited under regulations 483.15(a) and 483.25 have been corrected as of the revisit date.

The plan addresses two deficiencies: one related to resident dignity and disrobing risks, and another concerning lab order transcription and processing. Corrective actions include audits, staff education, and implementation of new procedures.

The investigation was based on complaint investigations #93623 and #94158. The findings substantiated issues related to dignity and respect and failure to provide necessary care.

The facility failed to maintain the dignity of a resident by placing them on a mattress on the floor in a common area, frequently dressed in a hospital gown and undressing themselves. The facility also failed to obtain ordered laboratory tests for another resident, resulting in delayed treatment.

The survey found the most serious deficiencies to be D level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The survey found the most serious deficiencies to be at 'F' level, indicating no harm with potential for more than minimal harm and no immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

The plan addresses termination of an administrative staff member, verification of nursing licenses, staff education on licensing policies, maintenance of a nursing license register, and ongoing review of identified trends by the Quality Assurance/Assessment Committee.

The report confirms that the previously cited deficiency with regulation 483.75(g) was corrected as of the revisit date.

The complaint investigation (#91706) substantiated that an unlicensed person performed licensed nurse duties including IV antibiotic administration and TB skin test reading.

The facility failed to provide licensed professional staff to carry out nursing care, including administering IV antibiotics and TB skin tests, by allowing an unlicensed staff member with a lapsed RN license to perform these duties. This deficient practice potentially affected all residents.

The survey found the most serious deficiency to be an 'F' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

This plan of correction is related to a complaint investigation as indicated by the linked complaint report (2567).

The plan addresses deficiencies related to the inventory and availability of OTC/floor stock medications, including audits of physician orders and education of staff on medication reorder policies.

The revisit confirmed that the deficiency related to regulation 483.60(a),(b) was corrected as of the revisit date.

The visit was triggered by complaint investigation #89915. The complaint was substantiated as the facility failed to ensure medication availability for residents.

The facility failed to ensure the availability of medications for administration to three residents. Specifically, medications such as a ProAir inhaler and Calcium supplements were not available or not administered as ordered, leading to delayed treatment and documentation issues.

The survey found the most serious deficiency to be a "D" level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The plan addresses risk of elopement for residents, including assessment procedures, use of wanderguard bracelets, staff education, and monitoring through audits and Quality Assurance Committee reviews.

The report documents that the previously cited deficiency under regulation 483.25(h) was corrected as of the revisit date. No other deficiencies are listed.

The complaint investigation #87235 found the facility failed to prevent elopement of a resident with vascular dementia and behavioral problems. The resident eloped on 5/16/15 by following a visitor out the front door and was found a block away. Staff had discontinued the wanderguard bracelet due to the resident removing it and believed the resident was no longer at risk. Visitors were not informed to watch for residents exiting.

The facility failed to provide adequate supervision for one resident who eloped from the facility without staff knowledge. The resident was found outside the facility after following a visitor out the door, despite previous use of a wanderguard bracelet which was discontinued.

The survey found the most serious deficiency to be a 'D' level deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The report confirms that the deficiencies previously reported on the CMS-2567 have been corrected as of the revisit date.

The facility had deficiencies related to resident supervision when exiting community grounds unsupervised. The plan outlines corrective actions including resident transfer, staff education, audits, and monitoring procedures to ensure resident safety and compliance.

The complaint investigation #86867 was substantiated. The resident eloped from the facility, fell approximately 1.5 blocks away, and sustained bruising and abrasions. The facility did not report the incident to the state agency and lacked proper monitoring procedures.

The facility failed to ensure adequate supervision and safety measures for a resident who left the facility without staff knowledge, resulting in a fall and injury. The facility lacked a sign-in/out system and did not complete safety assessments to determine the resident's ability to leave safely.

The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The facility dietary manager was not certified as required by state regulation. The plan outlines corrective actions including completion of a Certified Dietary Manager course and subsequent certification.

The facility failed to retain the services of a certified dietary manager to oversee dietary staff and maintain a clean and sanitary dietary department for food storage, preparation, and service to residents.

The revisit confirmed that all previously reported deficiencies identified by regulation or LSC provision numbers were corrected by 12/21/2014.

The report confirms that all deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by 12/21/2014.

The report confirms that deficiencies identified in prior inspections with regulation numbers 28-39-153(e) and 28-39-153(f) were corrected by 2014-12-21.

The plan details multiple corrective actions including opening an indoor smoke room, updating resident activity assessments and care plans, ensuring maintenance and cleanliness of the facility, providing education to staff, and monitoring compliance through audits and Quality Assurance/Assessment Committee reviews.

The facility was found deficient in multiple areas including resident rights, activities, housekeeping and maintenance, linen provision, temperature control, comprehensive assessments, care planning, ADL care, accident hazards, immunizations, dietary services, infection control, and environmental safety.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required to address these deficiencies.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance was not achieved.

The revisit confirmed that all previously identified deficiencies were corrected by the facility as of 09/20/2013.

The plan addresses multiple deficiencies including proper completion and distribution of liability/appeal notices, resident trust account management, reporting of resident falls, facility maintenance and sanitation, care plan updates for residents with infections, accidents, and medication monitoring, staffing adequacy, dietary sanitation, infection control, and environmental safety issues such as ventilation and facility repairs.

The facility was found deficient in multiple areas including failure to provide complete liability and appeal notices, inadequate management of resident personal funds, failure to investigate and report resident falls, insufficient housekeeping and maintenance, incomplete resident assessments and care plans, inadequate monitoring of dialysis patients, poor personal hygiene care, improper wound care, failure to prevent accidents and falls, lack of monitoring for adverse drug effects, insufficient nursing staff, unsanitary food storage and preparation, inadequate infection control practices, and unsafe and unsanitary kitchen and facility environment.

The report documents that the deficiency identified under regulation 28-39-162(a) with ID prefix S1000 was corrected on 2012-06-02.

The report documents that previously cited deficiencies have been corrected as of the indicated correction date.

The plan details corrective actions for multiple deficiencies including financial account handling after resident death, grievance procedures, facility maintenance and cleanliness, care plan revisions, medication monitoring, and equipment storage. All corrective actions were accomplished by June 2, 2012.

The facility failed to maintain a fully functioning call light system in 2 of 2 soiled utility rooms, as the call light indicators did not sound or light to alert staff when residents required assistance.