Every finding on record at Accura Healthcare of Aurelia, LLC

Based on a review of the clinical record, facility policy, and staff interviews, the facility failed to notify the physician when a resident with a history of cardiac and pulmonary conditions and oxygen dependence stopped using a Bilevel Positive Airway Pressure (BiPAP) machine at night for 1 of 12 residents reviewed. The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of congestive heart failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and centrilobular emphysema. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Clinical Physician Orders dated 9/3/25 for Resident #2 showed the following:BiPAP on at bed time and off in the morningOxygen 3 liter per nasal cannula COPD and centrilobular emphysemaDuo Neb breathing treatments twice a day for COPDFluticase-Salmeterol inhaler twice a day for COPDPrednisone tablet daily for COPDTorsmide tablet daily for CHFEmpagliflozin tablet daily for CHFAlbuterol Sulfate inhaler every 6 hours as needed for shortness of breath and wheezing The Care Plan for Resident #2 revised on 8/15/25 showed the resident had a history of CHF, COPD, high blood pressure and arterial fibrillation (irregular heart rhythm). The goal for Resident #2 included the resident will not require hospitalization for her condition. The Care Plan lacked BiPAP usage and information.During an interview on 1/27/26 at 2:25 PM, Resident #2 reported the pulmonologist ordered her to wear a BiPAP at night related to CHF, COPD, and emphysema. When asked about the BiPAP location, the resident reported placing the device on a shelf due to personal preference not to use the machine because the mask fit poorly, despite trying several different masks. When asked about the duration it had been on the shelf, the resident stated at least three months. Upon clarification regarding nonuse during that period, the resident stated, No, I haven't worn it at all for about three months.During an interview on 1/28/26 at 1:27 PM, Staff A, Certified Nursing Assistant (CNA), reported working the night shift in October when the resident began inconsistent BiPAP use. Staff A reported the resident stated, I don't like it. Staff A further reported that in November the resident stopped using it altogether.Review of the December 2025 and January 2026 Treatment Administration Record (TAR) failed to accurately reflect BiPAP usage.During an interview on 1/27/26 at 2:47 PM, the Director of Nursing (DON) reported learning of Resident #2's nonuse of the BiPAP today. When asked if she knew the resident reported not using the BiPAP for the past three months, the DON stated, No. When asked whether staff inaccurately documented BiPAP use, the DON stated, I haven't looked at it. When asked if she felt physician notification was necessary, the DON reported yes. When asked why physician notification was necessary, the DON stated the resident could have breathing issues.During an interview on 1/28/25 at 9:45 AM, the DON stated, They need to document that the resident refused the treatment and notify the physician. The DON also indicated notification was necessary because, if needed, the resident wanted to be resuscitated, and staff recently had a code.During an interview on 1/28/26 at 12:15 AM, the DON reported the facility failed to have a policy regarding physician notification and that the facility followed the standards of care.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #27) reviewed for PASRR requirements. The facility reported a census of 35 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #27 documented diagnoses of dementia, Anxiety Disorder, adjustment disorder with depressed mood, depression and suicidal ideations. The MDS included a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The Medical Diagnosis list for Resident #27 revealed the following diagnoses:General Anxiety Disorder, dated 5/27/25Major depressive disorder, dated 6/12/2Suicidal ideation, dated 7/24/25Adjustment disorder with depressed mood, dated 8/6/25 The Clinical Orders for Resident #27 revealed the following medications:Memantine 2.5 mg tablet for dementia, dated 3/27/25Prozac 40 mg tablet daily for dementia, dated 6/25/25Zyprexa 5 milligram (mg) tablet daily for adjustment disorder with depressed mood, dated 9/7/25 The Telehealth Psych Progress Note dated 1/27/25 for Resident #27 showed the resident received psych services and is scheduled for a future appointment. During an interview on 1/27/25 at 2:47 PM with the Administrator, Director of Nursing (DON), and Social Worker (SW), the SW reported submission of a new PASRR earlier that morning for Resident #27. When asked whether a PASRR should be submitted when a new mental health disorder, mental health medications, and mental health services are present, the SW stated yes. During an interview on 1/28/25 at 9:45 AM, the DON reported asking whether responsibility for resubmission of the PASRR applied to her role. The Administrator instructed that responsibility rested with the Social Worker (SW). The DON further explained that future morning meetings will include team review of medications, new diagnoses, and services to identify the need for PASRR resubmission. During an interview on 1/28/26 at 12:15 AM, the DON reported the facility failed to have a policy regarding PASRRs and that the facility followed the standards of care.

Based on record review, staff interviews and facility policy review the facility failed to accurately document Bilevel Positive Airway Pressure (BiPAP) machine usage for 1 of 12 residents (Residents #2). The facility reported a census of 34 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of congestive heart failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and centrilobular emphysema. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Clinical Physician Orders dated 9/3/25 for Resident #2 showed an order for a BiPAP on at bedtime and off in the morning. During an interview on 1/27/26 at 2:25 PM, Resident #2 reported the pulmonologist ordered her to wear a BiPAP at night related to CHF, COPD, and emphysema. When asked about the BiPAP location, the resident reported placing the device on a shelf due to personal preference not to use the machine because the mask fit poorly, despite trying several different masks. When asked about the duration it had been on the shelf, the resident stated at least three months. Upon clarification regarding nonuse during that period, the resident stated, No, I haven't worn it at all for about three months.During an interview on 1/28/26 at 1:27 PM, Staff A, Certified Nursing Assistant (CNA), reported working the night shift in October when the resident began inconsistent BiPAP use. Staff A reported the resident stated, I don't like it. Staff A further reported that in November the resident stopped using it altogether.Review of the December 2025 Treatment Administration Record (TAR) for Resident #2 showed staff inaccurately documented the resident applied and/or removed the BiPAP every day of the month of December. Review of the January 2025 Treatment Administration Record (TAR) for Resident #2 showed staff inaccurately documented the resident either applied, and/or removed the BiPAP, or failed to document every day of the month of January.During an interview on 1/27/26 at 2:47 PM, the Director of Nursing (DON) reported learning of Resident #2's nonuse of the BiPAP today. When asked if she knew the resident reported not using the BiPAP for the past three months, the DON stated, No. When asked whether staff inaccurately documented BiPAP use, the DON stated, I haven't looked at it. During an interview on 1/28/25 at 9:45 AM, the DON reported reviewing BiPAP usage documentation for Resident #2 and identified inaccurate staff documentation indicating BiPAP use despite resident nonuse. The DON stated, We are going to have education to remind staff not to get in the habit of documenting things were done. They need to document the resident refused the treatment and notify the physician. During an interview on 1/28/26 at 12:15 AM, the DON reported the facility failed to have a policy regarding documentation and that the facility followed the standards of care.

Based on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene before and after catheter care for 1 of 2 residents reviewed (Resident #31). The facility reported a census of 34 residents.Findings include:During an observation on 1/28/26 at 1:08 PM, Staff A, Certified Nursing Assistant (CNA), failed to perform hand hygiene prior to donning personal protective equipment (PPE) and emptying urine from the catheter bag, per policy. Staff A then doffed PPE, failed to perform hand hygiene, and proceeded to arrange the catheter bag, privacy bag, and the resident's blanket before exiting the room.The Hand Hygiene Policy last updated on 11/13/24 identified hand hygiene is required immediately before donning and doffing gloves. During an interview on 1/27/26 at 2:47 PM, the Director of Nursing (DON), reported she expected staff to perform hand hygiene immediately before applying gloves and when staff removed gloves. During an interview on 1/27/26 at 3:31 PM, the Infection Preventionist indicated staff are expected to perform hand hygiene prior to putting on gloves, immediately after removing gloves, and when the staff leave the resident's room.

Based on observation, interview and record review the facility failed to ensure that all residents were free from verbal abuse for 1 of 5 residents reviewed (Resident #2.) Staff reported that on several occasions, a Certified Nurse Aide (CNA) addressed Resident #2 in a disrespectful and derogatory manner. The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) The resident was totally dependent on staff for toileting, dressing, rolling and transfers. She was always incontinent of urine and bowel, and was impaired on both sides of her upper and lower extremities. Diagnoses for Resident #2 included: heart failure, renal insufficiency and quadriplegia.The Care Plan for Resident #2, dated 4/15/25, showed that she was dependent on staff for activities of daily living related to unspecified intellectual disabilities. Staff were to converse while providing care. Resident #2 previously lived in a home for people with intellectual disabilities, and she was unable to care of herself. She required the assistance of two staff with the Hoyer (mechanical lift) for all transfers. Resident #2 could be verbally aggressive, staff were to monitor behaviors when resident became agitated, intervene before agitation escalated. A facility self-report to the Department of Inspections and Appeals and Licensing (DIAL) showed that on 5/1/25, the Executive Director (ED) had been notified that Resident #2 was being verbally abused by Certified Nurse Aide (CNA) Staff F. Staff A, CNA reported that while she and Staff F were transferring Resident #2 with the Hoyer mechanical lift, Staff F said: I hope this hits you in the head and we're not friends, don't call me Buddy. The self report lacked potential dates that the alleged incident occurred. On 10/20/25, Resident #2 was lying in bed as two CNA's prepared to change her brief and transfer her to the wheel chair. When addressed, the resident looked afraid and shook her head no. On 10/20/25 at 12:36 PM, Staff D, CNA said that she heard Staff F say to Resident #2 you need to be put on Hospice and this is why no one comes to visit you. She said that when Staff F would roll the resident over in bed, she would tug the bed pad quick and rough and the resident was afraid of falling. Staff F seemed annoyed by the resident and would just tell the resident to be quiet.On 10/20/25 at 2:04 PM, Staff B CNA, said that Resident #2 would always yell out when they provided incontinence care and transfers, but the resident was not able to swing her arms or hit them. Staff B said that when she and Staff F were transferring the resident with the Hoyer, Staff F threatened to put you down. Staff B interpreted that to mean that she was threatening to drop the resident out of the lift. Staff B said that Staff F said to the resident: You need to be put on hospice and you need to just go already, Staff B did not remember the date of these incidents and said she understood that she should have come forward sooner but she was afraid of retaliation. On 10/20/25 at 12:20 PM, Staff A, CNA, said that Staff F would tell Resident #2 that they weren't friends and she would pull hard on the resident when rolling her in bed. Staff A said that Resident #2 was afraid of falling out of bed and would say; please don't drop me. Staff F seemed annoyed by the resident. When transferring the resident with the mechanical lift into the wheel chair, the bars of the lift often came close to hitting the resident on the head. Staff A said that Staff F would pull back on the sling abruptly when the resident was being lowered down into the wheel chair said; I hope you hit your head on the bar of the lift. A written statement, dated 5/1/25 at 7:34 PM, from Staff H, CNA showed that Staff F was more mean to Resident #2 compared to other residents, more verbally aggressive. Staff H couldn't remember the date it had happened. On 10/21/25 at 12:24 PM, Staff F denied having ever told a resident to shut up and she only suggested that maybe the resident should be on Hospice because it would be a good thing to help her with her anxiety. Staff F said that she had known Resident #2 for over 19 years, worked with her when she was in a group home for intellectual disabilities so she was familiar with how to interact with her. Staff F acknowledged that Resident #2 was afraid of falling when they rolled her in bed, mostly when her head would be down and looking at the floor. Staff F said she just tried to reassure her that we're not going to let you fall. Staff F said that after the allegations in May, she thought it would be best not to care for Resident #2 so there wouldn't be any more false allegations An Employee Corrective Action Form, Written Warning, dated 5/6/25, showed that there were allegations of abuse against Staff F. The expectations were that staff would speak to residents with dignity, respect and to provide great customer services. Staff F was re-educated on the facility abuse policy and she was assigned education on abuse prevention to be completed before returning to work. The written report showed that Staff F had been confronted about her treatment of Resident #2. Staff F responded that she had known the resident for a long time and I just know how she is. Management counseled her to consider her tone and how it may be perceived by other staff and visitors. Staff F and Management agreed that she would not to work with Resident #2 for the time being. On 10/21/25 at 8:30 AM, the ED and the Director of Nursing (DON) stated that they were first informed of the concerns with Staff F on 5/1/25 but did not have dates that the incidents had occurred. The ED said that a family member for Resident #2 reported that when the resident was in the group home, they had to treat her as if she was a 4-year-old. The ED responded that this was not acceptable in the nursing home environment. A facility policy titled: Freedom From Abuse Notice to Employees Resident/Patient Abuse, Neglect and Mistreatment of Belongings. Among the rights specified in the federal and state laws, each resident and patients had the right to a dignified existence and to be free form verbal, sexual, physical or mental abuse; Abuse included but not limited to: verbal abuse, oral, written, gestures language, including sarcastic remarks and derogatory statements, directed to residents' family members or significant others.

Based on interview and policy review the facility failed to report allegations of abuse in a timely manner for 1 of 1 residents reviewed. On 5/1/25, several staff members reported that Staff F was rude and verbally abusive to Resident #2. They did not have dates and times as to when these incidences occurred. The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) The resident was totally dependent on staff for toileting, dressing, rolling and transfers. She was always incontinent of urine and bowel, and was impaired on both sides of her upper and lower extremities. Diagnoses for Resident #2 included: heart failure, renal insufficiency and quadriplegia.The Care Plan for Resident #2 dated 4/15/25, showed that she was dependent on staff for activities of daily living related to unspecified intellectual disabilities. Staff were to converse while providing care. Resident #2 previously lived in a home for people with intellectual disabilities, unable to care of herself. She required the assistance of two staff with the Hoyer (mechanical lift) for all transfers. Resident #2 could be verbally aggressive, staff were to monitor behaviors when resident became agitated, intervene before agitation escalated. A facility self-report to the Department of Inspections and Appeals and Licensing (DIAL) showed that on 5/1/25, the Executive Director (ED) had been notified that Resident #2 was being verbally abused by Certified Nurse Aide (CNA) Staff F. Staff A, CNA reported that while she and Staff F were transferring Resident #2 with the Hoyer mechanical lift, Staff F said: I hope this hits you in the head and we're not friends, don't call me Buddy. The self-report lacked potential dates that the alleged incident occurred. On 10/20/25 at 2:04 PM Staff B said that Staff F was disrespectful and rough with Resident #2. She did not know the dates that this had occurred and said she knew she should have come forward sooner but she was afraid of retaliation. A written statement dated 5/1/25 at 7:34 PM from Staff H, CNA showed that Staff F was more mean to Resident #2 compared to other residents, more aggressive verbally. Staff H couldn't remember when it happened. On 10/21/25 at 11:00 AM, the Director of Nursing (DON) said that they were made aware of the concerns with Staff F, on 5/1/25 but they did not know the date or dates when the incidents occurred. She said the staff that had concerns were educated about the importance of reporting allegations of abuse immediately. 10/21/25 1:10 PM the administrator said that the staff had all been educated on the facility abuse prevention policy and the importance of reporting concerns immediately. A facility policy titled: Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy; Mental abuse was defined as use of verbal or nonverbal conduct which caused or potential to cause the resident to experience humiliation, intimidation fear shame agitation or degradation. All allegations of resident abuse, neglect exploitation mistreatment injuries of unknown origin and misappropriations would be reported immediately to the charge nurse. The charge nurse would be responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. All allegation of resident abuse would be reported to Iowa Department of Inspections and Appeals no later than two hours after the allegations was made.

Based on observation, interviews and record review the facility failed to monitor and treat skin breakdown to prevent worsening of ulcers for 2 of 3 resident reviewed, (Resident #3 and #21). Resident #3 had an ulcer on his toe, staff failed to contact the doctor when treatment was ineffective. The toe was eventually amputated. Resident #21 had chronic pressure areas on her bottom and found to not have treatment in place. The facility reported a census of 32 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficit.) The resident had 1, unhealed, Stage 2 pressure ulcer. The MDS dated [DATE], showed that the resident had a diabetic foot ulcer. He was totally dependent on staff for transfers, toileting and hygiene, Diagnosis included type II diabetes mellitus, dysphagia following cerebrovascular disease, hemiplegia or hemiparesis, cerebrovascular accident. The Care Plan for Resident #3, revised on 1/27/25, showed that he was non-ambulatory and non-weight bearing status and required the assist of 2 for mobility. The resident was at risk for skin impairment with a history of pressure to buttock, right toe, plantar aspect of the 5th toe. Staff were directed to follow the skin treatments as ordered by provider, check all of the body for breaks in skin and treat promptly as ordered by doctor. In an observation on 3/4/25 at 6:44 AM, Staff A Certified Nurse Aide (CNA) and Staff B, CNA prepared to transfer Resident #3 from the wheel chair to the shower chair for a shower. The resident was wearing a shirt and brief. They transferred him to the bed with the use of the Hoyer Mechanical Lift. Once he was in bed, they removed the protective boots that covered his feet up to his knees. The resident had a callous on his right foot where the great toe had been. His right shin had three scabbed areas along the top of the bone. When asked about the scrapes, the CNA's said they didn't know if that was being documented or how long he had the skin breakdown. The chart lacked documentation of the scrapes on his shin. On 3/5/25 at 10:43 AM, Staff D, Registered Nurse (RN) acknowledged that she was responsible for documenting weekly skin issues. She said that she was not aware of any skin breakdown on the right shin for Resident #3. She went into the room and looked at the area and asked the resident what happened. He said that it was from crossing his feet in bed. Staff D said that she would start a skin sheet for him and a risk management because it is scabbed. She said she hadn't been told about it, the girls hadn't told her about those spots and that should have been documented. A review of the chart revealed that on 5/6/24 at 11:50 AM, resident had been readmitted to the facility after a hospitalization with three new areas of skin breakdown. The Readmission Assessment included: Right foot big toe pressure area 0.3 centimeters (cm) x 0.3 cm open area. Right foot little toe pressure area 0.8 cm x 0.5 cm. Right foot second toe scattered scabs. The following documentation was found in the Nursing Notes (NN) and on the paper documentation titled: Non-Ulcer Skin Assessment (SA) leading up to the amputation of the right great toe: a. (NN) 5/8/24, Encounter note by NP; resident post hospitalization for pneumonia and returned to facility with antibiotic therapy. had scabs on left toes and dressing on right great toe, continue orders paint scabs on toes with betadine daily and right great toe remove old dressing, cleanse with saline, apply povidone-iodine to area, skin prep to surround kin and cover with polymen and meplex tape every 2 days, monitor for worsening signs/symptoms. b. (SA) 6/4/24, 0.3 cm x 0.6 cm, wound bed is scabbed, surrounding skin color pink, surrounding tissue wound edges intact. Progress improved continue treatment plan. c. (NN) 6/5/24 Encounter note by NP; skin on toes improved. d. (SA) 6/11/24 size 0.3 cm x 0.6 cm scabbed, red and pink surrounding. improved e. (SA) 6/18/24 size 0.5 cm x 1 cm. improved treatment continued. f. (SA) 6/25/24 size 0.5 cm x 1 cm. improved treatment continued. g. (SA) 7/2/24 0.8 cm x 1 cm. wound bed scab, pink surrounding skin intact wound edges. deteriorated. (chart lacked documentation of physician contact with change). h. (SA) 7/9/24 0.6 cm x 1 cm scab, pink intact and improved i. (SA) 7/16/24 0.5 cm x 1 cm wound bed yellow, surrounding skin pink surrounding tissue fragile progress is improved j. (SA) 7/23/24 0.5 cm x 0.5 cm. surrounding tissue blanchable progress improved slough (dead tissue) yellow or white. k. (NN) Encounter note from the NP, signed on 7/25/24 at 5:02 PM, did not address foot ulcers. l. (SA) 7/30/24, 0.5 cm x 0.5 cm. yellow wound bed surrounding tissue fragile not changed m. (SA) 8/6/24 0.5 cm x 0.5 cm slough 10%, improved n. (NN) 8/13/24 at 10:59, the doctor was in the facility and antibiotic started related to cellulitis (bacterial skin infection) to right great toe. o. (SA) 8/13/24 0.5 cm x 0.5 cm. yellow wound bed, pink surrounding skin, deteriorated, started on antibiotic. A Physician Progress Note dated 8/13/24, showed that the visit diagnosis included; cellulitis and abscess (collection of pus surrounded by inflamed tissue) of toe of right foot. A breakdown to right big toe, area was wet, purulent (containing pus) with redness spreading up the foot. The patient was placed on antibiotic for 10 days. If no improvement, given his severe debility this likely could result in amputation. He had undergone amputation of previous toes due to similar circumstances. Next visit on 9/10/24 will follow closely p. (NN) 8/18/24 at 10:09 AM, Encounter note by NP, follow up to cellulitis of right toe, erythema top of right foot. q. (NN) 8/19/24 at 2:24 PM, less redness and swelling noted to right toe r. (SA) 8/20/24 not changed granulation 90%, 80% red tissue. s. (NN) 8/21/24 at 2:59 PM, no redness swelling odor or signs of infection. (According to the Medication Administration Record, the last day of antibiotic was given on 8/22/24) t. (NN) 8/23/24 at 5:49 PM, foot is slightly pink and warm, resident stated pain in ankle not foot. u. (SA) 8/24/24 0.5 cm x 0.5 cm condition not changed continue with treatment v. (SA) 9/3/24 size unchanged, wound bed white surrounding tissue pink 80% granulation, and white Progress improved w. (SA) 9/10/24, size unchanged, progress was left blank, continue treatment. x. (SA) 9/17/24, size same, progress not changed treatment continue y. (NN) 9/19/24 Encounter by the NP indicated no acute concerns expressed from nursing the documentation lacked any reference to the foot ulcers. z. (NN) 9/24/24 at 9:32 AM, call out to the Nurse Practitioner (NP) with update regards to right foot. Increased redness and drainage. May we have referral to wound nurse. aa. (SA) 9/24/24 measured 0.5 cm x 0.5 cm yellow discharge, 100% slough. Progress deteriorated. Hand written note to be seen by wound care. bb. (NN) 9/24/24 at 9:54 AM, orders for x-ray and referral to bone and joint surgeon. cc. (NN) 9/26/24 at 2:45 PM, out of facility for appointment dd. (NN) 9/26/24 at 4:17 PM resident admitted to hospital to amputate toe. A note from the NP signed on 9/24/24, showed that she spoke with the nurse about concerns that the wound on the right great toe knuckle, had drainage and redness. The resident was unable to feel his toe when it was touched. Initiated orders for a wound culture, antibiotic, x-ray and referral to wound clinic and bone specialist. According to the notes from the Bone, Joint and Sports Surgeons dated 9/26/24 at 4:32 PM, the X-rays of the right foot of Resident #3 showed erosive changes of the distal aspect of the medial proximal phalanx and proximal aspect (bone located on the bottom row) of the distal phalanx (bone at the end of toe) concerning for osteomyelitis. Sensation is diminished to the great toe, open ulceration noted to the dorsal medial aspect of right great toe at interphalangeal joint (joint between the phalanges of toe) It is covered in fibrotic slough, (yellow, tan or white, dead tissue) serous drainage (clear to yellow) present, full-thickness down to the bone measured 1.5 cm x 1.5 cm and there was visible and palpable bone (able to touch) within the wound bed. The toe was erythematous and edematous (red and swollen). Soupy, serous drainage present coming form the wound. Recommended admit to hospital tonight for Intravenous antibiotics, vascular workup and toe amputation within the next few days as long as vascular status was okay. Discussed risks with the patient, biggest risk included delayed wound healing, continued infections, possible need for further surgery and further loss of foot or limb. According to the hospital History and Physical, dated 9/26/24 at 5:33 PM, the principal presenting problem included acute hematogenous osteomyelitis (inflammation of the bone due to infection) of right foot. Presented as an open ulceration to dorsal medial aspect of the right great toe at the interphalangeal joint of the hallux, covered with fibrotic slough, as well as healthy granular tissue. Some serous drainage present. It was full-thickness down to palpable and visible bone. Measured 1.5 cm x 1.5 cm the surrounding erythema to the right great toe. Soupy, serous drainage present. On 3/5/25 at 10:26 AM, Staff D, Registered Nurse (RN) said that she was conducting skin assessments in May of 2024 and when Resident #3 came back from a hospitalization with pneumonia, he had scabs and other pressure injuries to his feet and legs. She said that they suspected that it had been caused by the foot devices that they were using at the hospital. She said that the doctors didn't ever change the treatments and the scabs kept getting moist. Staff D said that Resident #3 was always having some skin breakdown related to his diagnosis of diabetes. Staff D said that they would try a different treatment if the color, pain or discharge changed. The doctors and NP would visit monthly and they were always looking at the resident's feet but they didn't ever see a need to change the treatments. On 3/5/25 at 11:30 AM, Staff D said that Resident #3 didn't get to the wound clinic on 9/24/24 because he was sent right to the bone specialist and then onto the hospital. Staff D reviewed the skin sheets and said that there hadn't been any changes in the toe that would have alerted them to call the doctor. Even if someone had seen a change, the doctor came in once a month and he or she would have looked at the resident's skin. On 3/5/25 at 2:36 PM, Staff E, Licensed Practical Nurse (LPN) remembered when she called the NP on 9/24/24 with her concerns about Resident #3. She said that she thought it was getting worse and they hadn't changed treatment orders. It was about a week prior to the amputation that she noticed changes. She had been directed to report to the Director of Nursing, which she said she did. She said that as an LPN, she was told she was to report to an RN with skin issues. There were times when she would provide treatment and the residents dressing was not in place, or it was soiled and looked as if it hadn't been changed for a while. On 3/5/25 at 12:10 PM, the NP said she remembered the ulcer on the toe of Resident #3 and that she contacted the primary care physician for culture and a wound care referral. She acknowledged that she saw the resident on 8/15/24 for a follow up after the primary care doctor had seen the resident on 8/13 and started an antibiotic for cellulitis on the right foot. The next visit she had with him was on 9/19 but did not make reference to the foot. When asked if she had looked at the foot on the 9/19 visit, she said that whatever she had in her notes was what she provided. The NP said that when she made monthly visits, she would consult with nursing before and after the visit about concerns and stated I can only address what I'm notified of. She stated that everything that she addressed was in her notes and could not say for sure if nursing should have contacted her sooner with changes in condition or what they may have seen leading up to the amputation that could have helped catch the deterioration sooner. On 3/6/25 at 12:35 PM, the DON said that she was not working at the facility in August of 2024 but she did look at the record on the progression of the toe wound for Resident #3 and acknowledged that it was concerning the nurses hadn't noticed the deterioration sooner. The DON read the report from the bone specialist and said that there would have been some warning signs before the wound was down to the bone. She would have directed the nurses to address and reassess the treatments if there wasn't improvement in healing after two weeks of a treatment. The DON said that they have two different skin sheets, one for non-ulcer and one for when an ulcer had developed. The form to be used after ulcer development, had more detailed documentation to include odor, coloring, size etc. 2) The MDS dated [DATE], showed that Resident #21 had a BIMS score of 14 (intact cognitive ability). She required partial assistance with toileting hygiene, dressing and toilet transfers. Resident #21 was at risk for pressure ulcer, and treatments included application of nonsurgical dressing. Her diagnoses included malnutrition, depression, weakness and pressure ulcer of sacral region, Stage 2. On 3/4/25 at 10:04 AM, Staff L, CNA assisted Resident #21 in the bathroom. When asked if she had any skin breakdown, Staff L said that she didn't know of any. The resident said she did, and when she got up from the toilet the CNA acknowledged that she had some protective cream on her buttocks. Staff L wiped her bottom with a cloth and noted some redness and a small slit near the coccyx. The resident said that it did hurt and she asked the CNA for a patch. Staff L said that she could not do that, that would have to be done by the nurse, so the resident asked for a lot of cream. A review of the Orders tab in the electronic chart revealed an order dated 2/5/25 at 2:58 PM, for Mepilex (foam dressing for acute and chronic wounds) to coccyx to be changed every 3 days and as needed (PRN) until healed. A Nursing Note dated 2/3/25 at 1:33 PM, showed that the resident had an area on the inner buttocks below coccyx measured 2 cm x 0.5 cm. Review of the skin sheets found a new sheet titled: Non-ulcer Skin Assessment, started on 2/3/25, that documented an open area to inner buttock, left. The document lacked any follow up measurements or descriptions of the ulcer. On 3/5/25 at 2:48 PM, Staff E said that she applied the dressing for Resident #21 and at times, the dressing has not been on as ordered. On 3/6/25 at 12:33 PM, the DON said that at times, the wound nurse would get pulled to the floor and it may be difficult for her to get all of the assessments completed. She did not know why there wouldn't have been a follow up to measurements or documentation and staff are directed to complete treatments as ordered. On 3/6/25 at 11:11 AM, the Administrator said that they did not have a specific policy for skin assessments, but staff were directed to refer to the DIMES protocol for skin issues. Debridement Infection, Moisture Balance, Edge and Supportive Products. (DIMES) The Wound Care Guidelines included description of wounds and supportive products, but lacked information on when nursing should contact the doctor and recognize the current treatment regimen consider changing.

Based on observation, interview and record review the facility failed to ensure safe transfer techniques with the use of a Gait Belt (GB) for 1 of 3 residents reviewed, (Resident #17). The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intake cognitive ability). He required partial assistance with toileting hygiene, showering, dressing and transfers. Resident #17 had diagnoses that included: atrial fibrillation, heart failure, anxiety and depression. The Care Plan updated on 2/23/25 showed that Resident #17 was at risk for falls and staff were to have the Gait Belt in place for all transfers and to ensure the resident was wearing the appropriate footwear. Limited physical mobility related to morbid obesity. On 3/3/25 at 1:01 PM, Resident #17 was sitting in a wheel chair that did not fit well and he seemed to be sliding down. The resident said that he could stand and pivot with transfers, but he needed assistance with walking. He said that he had a fall in the shower room when he slipped to the floor. Resident #17 said that he didn't want to get the staff in trouble, but the Certified Nurse Aide (CNA) that was transferring him from the shower chair to the wheel chair hadn't used a GB. A Nursing Note dated 2/21/2025 at 11:23 PM, showed that at approximately 6:55 PM that evening, the nurse was alerted to the shower room by a CNA after Resident #17 fell after his shower. The CNA reported to the nurse that Resident #17 had been sitting on the shower chair when he went to stand up onto a dry towel in front of him, he slid out of the chair onto the floor. Upon entering shower room, the nurse noted that the resident was naked, on the floor with his legs extended in front of him. He did not have a GB around him. The intervention initiated at the time of the fall was for the CNA staff to use gait belt with all transfers. On 3/5/25 at 11:03 AM, Staff G, Registered Nurse (RN) said that she remembered when Resident #17 had the fall in the shower and that he did not have a GB applied. She said it was the expectation that staff would always use gait belt with assisted transfers. On 3/6/25 at 12:31 PM, the Director of Nursing (DON) said that the CNA should have dried the upper part of body of the resident after his shower, then put on his shirt before applying the GB. She thought that agency staff were required to complete a competency checklist before working on the floor independently. A checklist form titled: Competency for Ambulation with a Gait Belt updated on 5/11/21, showed that staff were expected to apply GB over clothing and not on bare skin and tighten so it was snug. Stand facing resident, grasp belt on each side brace knees against the resident knees, block resident feet with your feet, assist to standing position. Stand at resident's side while they gain balance and do not let go of the GB. If the learning did not meet the requirements for the competency, training must be given and competency repeated within 14 days.

Based on observation, interview and record review the facility failed to ensure staff followed physicians' orders for 2 of 13 residents reviewed, (Resident #17 and #9). Resident #17 had an order for International Normalized Ratio (INR) blood test to be conducted on 2/13/25, staff failed to complete the blood draw. Staff were directed to report to the doctor if/when the Blood Glucose (BG) levels were out of parameters for Resident #9. The facility failed to follow through according to physician's orders. The facility reported a census of 32 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) He required partial assistance with toileting hygiene, showering, dressing and transfers. Resident #17 was using anticoagulant medications and his diagnoses included: atrial fibrillation, heart failure, anxiety and depression. The Care Plan updated on 2/23/25, showed that Resident #17 was at risk for falls and staff were to have gait belt in place for all transfers and ensure the resident was wearing the appropriate footwear. He had limited physical mobility related to morbid obesity and was at risk for abnormal bleeding related to routine use of anticoagulants. On 3/3/25 at 1:01 PM, Resident #17 was sitting in a wheel chair in his room, he did not have any visible bruising on his arms or legs. The resident said that in February, he had a high INR (measures the clotting time of blood.) The resident said that he had been getting regular labs but they missed one and by the time they checked it, the INR was very high. He did not have any bleeding concerns. A review of the file revealed a Nursing Note dated 2/6/25 at 3:15 PM, for a verbal order to hold warfarin and restart 3 milligrams (mg) on Saturday, recheck INR on Thursday, 2/13/25. The chart lacked documentation that the order for a recheck of the INR had been entered into the electronic chart, or that the blood test had been taken on 2/13/25. According to the Lab Administration report dated 2/24/25 at 8:56 PM high value INR of 8.5 with reference range of 0.86 - 1.18. A document titled: PT/INR Tracking spreadsheet showed the last date that the testing had been documented was on 2/5/25 with no follow up dated for the next INR. On 3/5/25 at 7:30 AM Staff F, Licensed Practical Nurse (LPN) acknowledged that she was the nurse that entered the nursing note and had taken the verbal order on 2/13/25. She remembered the resident and his unstable INRs and they were drawing labs about once a week and were making many medication changes. Staff F had only worked at the facility a few times and did not remember the process for lab draws and if they were entering them directly to the Medication Administration Record (MAR) or if they were just passing on in report to the next shift. Staff F said that she works in many different facilities and they had different processes. On 3/6/25 at 12:30 PM, the Director of Nursing (DON) said that she did a chart audit and found that the INR lab for Resident #17 had been missed on 2/13/25. She said that the nurses didn't always use the INR tracking sheet and there maybe another way to keep closer tabs on the testing and next blood draw using the Electronic Health Record. 2) According to the MDS dated [DATE], Resident #9 had a BIMS score of 14 (intact cognitive ability.) She was dependent on staff for toileting, showering and lower body dressing and required substantial assistance with toilet and sit to stand transferring. Diagnoses for Resident #9 included; anemia, hypertension, peripheral vascular disease, diabetes mellitus, osteoporosis, bipolar disorder, and fracture of the right pubis. A Care Plan revised on 2/12/25, showed that Resident #9 had diabetes and staff were directed to follow doctors' parameters for low/high blood sugars and report as directed. The resident was occasionally dependent on staff and others for meeting her emotional, intellectual, physical and social needs, and staff were to converse with the resident while providing care. Provide resident with cues, reorientation, reassurance and supervision as needed. An Order Audit Report from the electronic chart showed an order on 2/5/25 at 12:24 PM, for Accu-Chek (measures blood glucose levels) to report to the physician if/when the BG levels were greater than 350 mg/dl (milligrams per deciliters) or lower than 70 mg/dl. A review of the electronic record showed that from 2/5/25 - 3/2/25, the BG levels were outside parameters and the chart lacked documentation that the doctor had been contacted on the following dates: a. 2/6/25 at 6:40 AM BG; 367 b. 2/6/25 at 11:23 AM BG: 366 c. 2/6/25 at 7:29 PM BG; 374 d. 2/7/25 at 8:37 AM BG; 386 e. 2/7/25 at 3:14 PM BG; 370 f. 2/8/25 at 7:34 PM BG; 436 g. 2/9/25 at 6:37 AM BG; 371 h. 2/12/25 at 7:26 PM BG; 353 i. 2/13/25 at 12:46 PM BG; 365 j. 2/14/25 at 6:20 AM BG; 358 k. 2/15/25 at 7:30 PM BG; 458 l. 2/16/25 at 4:37 PM BG; 352 m. 3/1/25 at 11:35 AM BG; 351 n. 3/2/25 at 7:35 PM BG; 359 On 3/6/25 at 12:39 PM, the Director of Nursing (DON) said that she was looking through the file for Resident #9 and did see that the high blood glucose levels were not being reported to the physician. She would expect the nurses to follow the doctors' orders on the parameters. The DON said that they did not have a specific policy on reporting blood glucose to the physician.

Based on observation, interview and record review the facility failed to ensure that staff interacted with residents with dignity and respect for 1 of 13 residents reviewed, (Resident#9). The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability.) She was dependent on staff for toileting, showering and lower body dressing and required substantial assistance with toilet and sit to stand transferring. Diagnoses for Resident #9 included; anemia, hypertension, peripheral vascular disease, diabetes mellitus, osteoporosis, bipolar disorder, and fracture of the right pubis A Care Plan revised on 2/12/25, showed that Resident #9 was occasionally dependent on staff and others for meeting her emotional, intellectual, physical and social needs, and staff were to converse with the resident while providing care. Staff were to provide resident with cues, reorientation, reassurance and supervision as needed. The resident required assistance of one staff with a Wheeled [NAME] (FWW) and gait belt. On 3/4/25 at 1:35 PM, Resident #9 was sitting in her recliner. When asked about an interaction with Staff I, Certified Nurse Aide (CNA) that morning, she became fidgety and teary eyed, and said I don't want to get anyone in trouble. Resident #9 said that it was about 4:00 AM that morning when she woke up with abdominal pressure and needed to use the bathroom. The resident turned on her call light and Staff I came into the room, and with a rough tone she snapped what do you want? The resident told the CNA that she needed to use the toilet and the CNA told her that the morning staff could do it later. Resident #9 told Staff I that she was having pressure and really needed to go, so the CNA helped her out of bed into the wheel chair. Resident #9 asked her if she was going to use the gait belt and she said that's not necessary. The resident told her that the other CNA always used it, and that therapy told her they needed to use it every time, but Staff I just responded but that ain't me and proceeded to transfer her to the wheel chair then onto the toilet. She said that she prayed she wouldn't fall. Resident #9 said that once she was on the toilet Staff I yelled at her push! you need to push harder! The resident told her she was trying but she was afraid that her catheter would come out. The CNA stayed in the room for about 10 minutes while the resident was on the toilet then checked on her and said you didn't do anything, I knew you wouldn't. Resident #9 said she felt that the CNA didn't want to help her at all and the resident apologized to the CNA several times. Resident #9 said that she felt afraid when this CNA came into her room because she felt that Staff I really didn't want to take care of her and she didn't feel safe with her. On 3/5/25 at 9:50 AM, Staff I, said that around 4:00 AM Resident #9 had her call light on so she went to check on her. The resident said she needed to go to bathroom so she transferred her to the bathroom with the use of the gait belt. She continued to complain of stomach pressure and Staff I said why don't you try pushing? The resident responded nothing comes out so she waited in the room for about 10 minutes. The resident did not have a bowel movement so she told her to make sure to tell the morning girls so they could try again. She said that she put the resident back to bed with no incident and reminded her to pull her call light if she needed anything else. Staff I said that the resident thanked her several times and they had gotten along great. Staff I maintained that she did everything the resident wanted, when she was on the toilet and said she was having trouble going, she suggested that she push harder. The resident had responded; I am, I'm trying. so Staff I said she didn't think she going to go so she wiped her and assisted her back to bed. Staff I said that she suggested that the resident make sure that the morning girls knew she hadn't had a bowel movement. Staff I maintained that she always used a gait belt with transfers, she suggested that told the resident try to push harder but did not yell at her. Staff I maintained that she treated the resident with respect On 3/5/25 at 2:31 PM, Staff E, Licensed Practical Nurse (LPN) said she administered medication to Resident #9 that morning and asked the resident how she was doing. The resident told her she was still upset about an interaction that happened with Staff I earlier that morning. The resident reported that she needed to use the bathroom and the CNA didn't use the belt when she transferred her and was rude and snapped you said you gotta go, now go! On 3/5/25 at 3:05 PM, Staff K, Activities Director, said that Resident #9 told her that she put on her call light that morning because her stomach was hurting she needed to use the bathroom. When the CNA came in, she told her that it could wait till morning but the resident told her again, that she needed to go to the bathroom so she assisted her to the toilet. The aide said to her Now go! and push! She had small results, and the aide told her she didn't go much, and brought her back into bed. Staff K said that the resident was visibly upset. On 3/6/25 at 12:39 PM, The Director of Nursing (DON) said that Staff I tended to have a loud voice and she could soften her tone around residents because some were more sensitive than others. Facility policy titled: Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, mental abuse was the use of verbal or nonverbal conduct which causes or had the potential to cause the resident to experience humiliation, intimidation, fear, shame agitation or degradation.

Based on observations, facility policy, 2022 Food Code, and staff interview, the facility failed to store kitchenware and utensils in a manner to prevent contamination; failed to store a measuring scoop in a clean manner; bulk foods did not have an open date labeled; provide covered trash cans; cover food stored in a freezer. The facility reported a census of 36 residents. Findings include: Observation on 2/05/24 at 9:13 AM of dry storage room revealed: 1. Two muffin baking pans turned right side up. 2. A powdered drink mix canister with scoop inside. Observation on 2/05/24 at 9:13 AM of main area of kitchen revealed: 1. Two boxes of disposable silverware not closed. 2. Two containers of silverware without eating end of the utensil covered. 3. Shelf storing cutting boards not laying vertically. 4. Reusable and disposable dishware stored right side up and not covered. 5. Two uncovered trash cans. 6. No open date on bulk storage of sugar, flour, and breadcrumbs. 7. Utensils for food preparation and serving stored uncovered on hooks on the wall. Observation on 2/05/24 at 9:16 AM of 2 door freezer revealed a tray of individual dishes of ice cream with no cover. The 2022 Food Code directed, in pertinent part, that receptacles and waste handling units for refuse shall be kept covered inside the food establishment if the receptacle contained food resident and was not in continuous use. The Food Storage Policy dated 2021 directed in pertinent part: 1. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. 2. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products, sugar, dried vegetables, and broken lots of bulk foods or opened packages. All containers or storage bags must be legible and accurately labeled and dated. 3. Scoops must be provided for bulk foods (such as sugar, flour, and spices). Scoops should be kept covered in a protected area near the containers rather than in the containers. Scoops should be washed and sanitized on a regular basis. 4. All (frozen) foods should be covered, labeled, and dated. In an interview on 2/05/24 at 9:26 AM, the Dietary Manager (DM) reported she hadn't thought to date opened bulk sugar, flour, or breadcrumbs. In an interview on 2/07/24 at 1:09 PM, the Dietary Manager reported that a new dietary employee left the scoop in the container of drink mix, that she had lids to the trash cans but the lids did not have pieces to cover the trash cans, that she was the staff member that did not cover the individual portions of ice cream found in the freezer, and that she was aware that utensils and kitchenware needed to be covered.

Based on observation, staff interview and record review, the facility failed to update the resident's care plan to accurately reflect interventions ordered by the physician and accurately list residents current assistance level for 2 of 12 residents reviewed (Residents #23 and #32). The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 documented diagnoses of myositis (a group of rare conditions that can cause muscles to become weak, tired and painful), generalized muscle weakness and radiculopathy (pinched nerve or injury or damage to nerve roots in the area where they leave the spine). The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS revealed Resident #32 has a pressure ulcer or injury and has one or more unhealed pressure ulcers or injuries. The MDS revealed resident was dependent on staff for bed mobility and transfers to and from bed to chair, and chair to bed. Review of the Care Plan with a revision date of 1/25/24 revealed the following information: Resident #32 required assistance of 2 staff to turn and reposition in bed, required assistance of 2 staff with dressing, required assistance of 2 staff with mechanical lift for transfers, required assistance of 1 staff with all personal hygiene and was independently able to move/ wheel self in wheelchair. Review of Treatment Plan signed 2/1/24 revealed the following information: a. Continue to use ROHO cushion. b. Sit upright in wheelchair or other chair with the cushion, do not recline. c. Sit no more than 1.5 hours at a time for meals, then reposition. Other times should be in bed, on his side. d. Protein supplement per dietician. e. Heel protectors. Review of the Order Summary Report signed by the physician dated 2/2/24 revealed the following orders: a. Cleanse and dress right heel three times a week and as needed with an order date of 1/15/24. b. Head of Bed no higher than 30 degrees for skin impairment with an order date of 11/16/23. c. Magic cup for wound healing with an order date of 12/4/23. d. [NAME] hose on during the day and off at night for skin impairment with an order date of 11/16/23. e. Use of better pressure redistribution cushion, sit for no more than one two hours for meals, and reposition on side in bed, turning frequently with an order date of 1/15/24. f. Use Prevalon boots 24 hours a day, remove each shift to check for skin impairment with an order date of 1/15/24. h. When up in wheelchair pressure relief every 15 minutes for skin impairment. i. Arginaid packet daily with an order date of 12/29/23. Review of the February Treatment Administration Record (TAR) revealed the following orders: a. Cleanse and dress right heel three times a week and as needed with a start date of 1/16/24. b. Head of Bed no higher than 30 degrees for skin impairment with a start date of 11/16/23. c. Magic cup for wound healing with a start date of 12/5/23. d. [NAME] hose on during the day and off at night for skin impairment with a start date of 11/16/23. e. Use of better pressure redistribution cushion, sit for no more than one two hours for meals, and reposition on side in bed, turning frequently with a start date of 1/15/24. f. Use Prevalon boots 24 hours a day, remove each shift to check for skin impairment with an start date of 1/15/24. h. When up in wheelchair pressure relief every 15 minutes for skin impairment with a start date of 11/17/23. i. Arginaid packet daily with a start date of 12/29/23. Review of the Care Plan with a revision date of 1/25/24 revealed a focus area the resident has potential or actual impairment to skin integrity. The focus area lacked current interventions ordered by the physician. Interview on 2/06/24 at 1:55 p.m., with the DON revealed she would expect all current interventions to be listed on the care plan and would expect the interventions to be updated as they are changed. 44475 2. The MDS dated [DATE] for Resident #23 revealed a BIMS of 14 which indicated intact cognition. The MDS revealed the resident had diagnoses of diabetes mellitus, insomnia, and generalized muscle weakness. The resident had 2 falls since the last comprehensive MDS assessment. The Care Plan revealed in pertinent part: a. ADL (Activities of Daily Living) Focus Area intervention initiated 2/27/23 and revised on 2/5/24 revealed that for transfers, the resident was independent with 4WW (4 wheeled walker), assist of one as needed. b. Fall Focus Area intervention initiated 1/19/24 revealed that the therapy department changed the resident to assist of 1 with transfers. In an interview on 2/07/24 at 8:45 AM, Staff A, Certified Nurse Assistant (CNA) reported the resident was an assist of 1 with personal cares, but that the resident reported that she performs cares independently instead of putting her call light on for assistance. When Staff A assisted the resident, she charted the task performed as provided with assistance, when the resident reported she performed a task independently, Staff A charts this as independently performed. Staff A reported she was not sure what level of assistance the resident required with care as she has observed the resident walking independently in the hall with only the assistance of her walker since she has required the assistance of 1 with personal cares. In an interview on 2/7/24 at 1:50 PM, the Director of Nursing (DON), reported that the resident was independent, she had required assistance of 1 for ADLs when she received physical therapy (PT) services. The DON reported that we need to update the resident's care plan now because it's not relevant any more. In an interview on 2/6/24 at 3:10 PM, the Director of Nursing (DON) reported that the facility does not have a policy for Care Plans.

Based on clinical record, facility policy, and staff interview, the facility failed to provide a restorative exercise program for 1 of 1 resident reviewed (Resident #20). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of osteoarthritis to his left knee, osteoporosis (loss of bone strength), and muscle weakness. In an interview on 2/05/24 at 10:40 AM, the resident reported that his physical therapy (PT) ended last week and that he was waiting for someone to come to his room this week to show him the exercises he is supposed to do on his own. The resident reported that he goes to a group exercise held in the facility, but that he would like individual assistance with an exercise program to maintain the progress he made in PT. The PT Discharge Summary signed by a PT on 2/1/24 directed, in pertinent part, that the resident: 1. Will continue with ambulation 5-7 times per week with 4 wheeled walker with assist of 1. 2. Will continue to do seated and standing exercises on a modified independent basis. The Care Plan intervention initiated 8/18/22 and revised 12/7/22 directed the following with ambulation: please assist to breakfast with my 4 wheeled walker, with bilateral AFO's (Ankle Foot Orthosis, medical device) on lower extremity. The Task List revealed, in pertinent part, walk to one meal a day with 4 wheeled walker, with bilateral AFO's on lower extremity. In a concurrent record review and interview on 2/07/24 at 9:42 AM, Staff A, Certified Nurse Assistant (CNA), demonstrated where she charts the tasks the resident receives. The task to walk to one meal a day was not present on Staff 's electronic charting device. Staff A reported no other place existed to chart against the task to walk the resident to one meal per day. The Clinical Record lacked documentation that the resident had assistance with seated and standing exercises on a modified independent basis after his PT discharge on 2/1/24. In an interview on 2/07/24 at 1:50 PM, the Director of Nursing (DON) reported that when a resident discharged from therapy services with a restorative exercise program, she adds those to the task list for the CNAs to chart against. The DON reported that the resident was discharged from PT with only a walk to dine program. The DON reported that the electronic health record (EHR) has had some recent glitches, that may be the reason the charting for the resident's walk to dine program was not visible. When the DON was made aware that the walk to dine task started in December 2022, she responded by saying she would make sure to find the documentation and that the only location documentation existed was in the EHR. In an interview on 2/7/24 at 2:20 PM, the DON reported that the walk to dine task was entered into the EHR incorrectly and she could not produce documentation that the task occurred. The facility did not have a policy for restorative therapy.

Based on clinical record, facility policy, and staff interview, the facility failed to develop care plans to reflect side effects of high risk medications insulin and melatonin or an Urinary Tract Infection (UTI) for 2 of 12 residents reviewed (Residents #23 and #32). The facility reported a census of 36 residents. Findings include: 1. The MDS dated [DATE] for Resident #23 revealed a BIMS of 14 which indicated intact cognition. The MDS revealed the resident had diagnoses of diabetes mellitus, insomnia, and generalized muscle weakness. The Order Summary Report signed by a physician on 1/16/24 revealed an order for melatonin, 3 milligrams (mg) given one time per day. In a Nurses Note on 1/11/24 at 8:00 PM, Staff E, Licensed Practical Nurse (LPN) reported, in pertinent part, new order for ATB (antibiotic) for UTI. The Doctor's Orders and Progress Notes signed by an Advanced Practice Registered Nurse (ARNP on 1/11/24 revealed an order for nitrofurantoin (antibiotic) 100 mg BID (twice per day) for 5 days. The Care Plan with an initiated date of 2/7/23 did not contain information related to: a. Melatonin, including side effects. b. UTI diagnosis. The document, What's a care plan in a nursing home?, accessed on 2/07/24 at 10:48 AM from medicare.gov directed, in pertinent part, that the basic care plan include ongoing, regular assessments of a condition to see if health status has changed, with changes to the care plan as needed. In an interview on 2/07/24 at 1:50 PM, the DON reported that she will look into why the resident's infection wasn't on her care plan. When asked why melatonin was not on the resident's care plan, the DON responded by asking what should be on the resident's care plan since she had orders for melatonin. 44474 2. The MDS assessment dated [DATE] for Resident #32 documented diagnoses of diabetes mellitus, hypertension and anemia. The MDS showed the BIMS score of 15, indicating no cognitive impairment. The MDS revealed Resident #32 had taken insulin injections the last 7 out of 7 days in the review period. Review of the Order Summary Report signed by the physician dated 2/2/24 revealed the following orders: a. Humalog injection solution sliding scale three times a day for diabetes with a start date of 11/16/23 b. Humalog kwikpen solution one time a day for diabetes with a start date of 12/5/23 c. Humalog kwikpen solution 2 times a day for diabetes with a start date of 12/4/23 d. Lantus solostar solution one time a day for diabetes with a start date of 11/16/23 Review of the February Medication Administration Record (MAR) revealed the following orders: a. Humalog injection solution sliding scale three times a day with a start date of 11/16/23 b. Humalog kwikpen solution one time a day with a start date of 12/5/23 c. Humalog kwikpen solution 2 times a day with a start date of 12/4/23 d. Lantus solostar solution one time a day with a start date of 11/16/23 Review of the Care Plan with a revision date of 1/25/24 lacked information regarding usage of insulin and signs and symptoms to watch for. Interview on 2/06/24 at 1:56 p.m., with the DON revealed she would expect the care plan to have insulin usage listed and side effects of the medication on the care plan. Interview on 2/06/24 at 3:11 p.m., with the Director of Nursing (DON) revealed the facility does not have a policy on care plans.

Based on record review, interviews and observation the facility failed to use safe transfer techniques for 2 out of 4 residents reviewed (Resident #9 and #21). The facility also failed to ensure the care plan fall intervention of a personal alarm was in place for 1 resident out of 4 residents reviewed for accidents/nursing supervision (Resident #11). The facility reported a census of 28. Findings Include: 1. The Minimum Data Set (MDS) assessment for Resident #9 dated 6/20/22 showed a Brief Interview of Mental Status score (BIMS) of 12 which indicated intact cognition. The MDS indicated Resident #9 required an extensive assistance of 1 person for transfers. The MDS diagnoses included weakness, heart [CONDITION(S)] and hypertension. The Care Plan last revised on 7/1/22 documented Resident #9 required the assistance of 1 person, a gait belt and forward wheeled walker for transfers. The Progress Note dated 8/4/2022 at 10:30 PM for Resident #9 documented nurse summoned by the aide to the residents room. Upon entering the resident was observed face down on the floor with extremities stretched outward. Scant amount of blood noted on the floor upon assessment this nurse finds bone to right arm exposed. The facility called 911 for an ambulance transfer to the emergency room (ER). The Facility Investigation documented on 8/4/22 at approximately 10:40 PM, the Director of Nursing (DON), received a phone call from Staff A, Licensed Practical Nurse (LPN), stating Resident #9 had sustained a witnessed fall resulting in a fracture to her right arm. On 8/4/22 at approximately 10:30 PM, Staff B, Certified Nurses Assistant (CNA), was assisting Resident #9 to bed. Resident had her walker and was turning left to ambulate towards her bed when she lost her balance and fell forward. Staff A, LPN, asked Resident #9 what happened she stated, I fell to the floor. Staff B, CNA, was not using a gait belt at the time of the fall. The facility investigation further documented Resident #9 sustained a comminuted, obliquely oriented fracture of the distal right humeral meta-diaphysis. The distal fracture component is displaced anterolaterally by greater than a shaft width (a severely displaced fracture located at the lower end of the arm bone). The emergency room documentation dated 8/5/22 revealed the ER physician determined via X-ray Resident #9's right arm sustained a severely displaced fracture located at the lower end of the arm bone caused by the fall. The Major Injury Determination Form dated 8/6/22 revealed the ER physician classified Resident #9's right arm fracture to be a Major Injury. The Investigation Questionnaire dated 8/4/22 Staff B, CNA, asked what occurred at the time of the incident. Staff B replied, the resident walked to her bed. Gait belt not in use due to lack of judgment. In an interview on 10/19/22 at 2:53 PM, Staff B, CNA, reported on 8/4/22 she assisted Resident #9 transfer from the recliner using a walker. As Resident #9 stood, she started to fall forward. Staff B attempted to catch the resident but instead kicked the resident's walker causing the resident to fall to the ground. Staff B stated she normally used a gait belt when transferring Resident #9 but for some reason just didn't use a gait belt on this occasion. Staff B confirmed the facility followed up with her regarding gait belt education after the incident. In an interview on 10/20/22 at 7:30 AM, Staff A, LPN, stated she arrived to Resident #9's room immediately after the fall where she observed Resident #9 on the ground not wearing a gait belt. Staff A reported that she would have expected staff to use a gait belt when transferring Resident #9. The facility reported they lacked a policy regarding gait belts or transfers. In an interview on 10/20/22 at 2:36 PM, the DON stated that she would have expected staff to use a gait belt and walker when transferring Resident #9. 2. The MDS assessment for Resident #11 dated 6/6/22 for showed a BIMS of 4 which indicated severe cognitive impairment. The MDS indicated Resident #11 required an extensive assistance of 2 persons for transfers, dressing and personal hygiene. The MDS diagnoses included dementia, anxiety disorder and psychotic disorder. The Care Plan dated 6/6/22 instructed staff to use a TAB alarm on Resident #11 to alert staff when the resident attempted self-transfer. The Progress Note dated 7/18/2022 at 1:30 PM documented Resident #11 found by staff on the floor next to her wheelchair. The resident reported to staff that she fell forward when vomiting from the wheelchair. As a result Resident #11 sustained a hematoma to the left forehead. The Progress Note further documented the CNA stated she forgot to place the TAB alarm back on the resident and CNA educated about the importance of having the TAB alarm on the resident at all times. In an interview on 10/20/22 at 10:11 AM, Staff C, Registered Nurse (RN), reported she responded to Resident #11 's room when Staff D, CNA, reported the resident fell out of her wheelchair. Staff C stated she found Resident #11 on the ground next to the wheelchair with vomit beside her on the floor. Staff C noted a hematoma to the resident's forehead, however did not call for an ambulance at the request of the family. Staff C, RN, reported Staff D, CNA, failed to place the TAB alarm on the resident before the fall. Staff C said the CNAs used the TAB alarm on a consistent basis but this time Staff D forgot to place the alarm after moving the resident back to her room. In an interview on 10/24/22 at 7:25 AM, Staff D, CNA, stated she forgot to place the alarm on Resident #11 because while in the room the resident's neighbor called out for help. Staff D stated she got sidetracked and felt horrible for not placing the alarm on the resident. The facility reported they lacked a policy regarding personal or TAB alarms. In an interview on 10/19/22 at 9:37 AM, the DON explained the TAB alarm works by a pull-string that attached magnetically to the alarm with a garment attachment that clipped to the resident. When a resident leaned too far forward or attempted to stand, the string would be pulled, engage the alarm and alert staff to the resident's movement. When asked if Resident #11 should have a TAB alarm placed when she is not in bed, the DON responded, yes. The DON acknowledged the alarm could have prevented the fall. 3. The MDS assessment for Resident #21 dated 9/26/22 showed a BIMS of 3 which indicated severe cognitive impairment. The MDS indicated Resident #21 was totally dependent on staff for transfers, dressing, toilet use and personal hygiene. The MDS diagnoses included [CONDITION(S)], Alzheimer's Disease, [CONDITION(S)] and cancer. The Care Plan dated 10/10/22 showed transfers are to be done with assistance of 2 persons using a Hoyer (mechanical) lift. Observation on 10/19/22 at 11:14 AM showed Staff E, CNA and Staff F, CNA, prepared to move Resident #21 from the bed to the wheelchair using a EZ Way Smart Lift. The CNAs connected the sling to the machinal lifted and raised Resident #21 from the bed. As Staff F lowered the resident into the wheelchair, Staff E then readjusted the wheelchair without engaging the wheelchair breaks. As the lift shifted and moved forward Staff E struggled to hold the wheelchair in place while pulling and guiding the resident down into the wheelchair. EZ Way Smart Lift Manufacturers Instructions last updated on 8/10/18 instructed when moving the resident from the bed to the wheelchair or toilet on Step 6, #1 Position the wheelchair under the patient and lock the wheels of the wheelchair. In an interview with the DON on 10/20/22 at 3:01 PM, the DON reported that she wasn't sure if the wheelchair locks needed to be engaged when transferring a resident from the bed to a wheelchair using the EZ Way Lift. The DON stated, I don't know. I know I don't lock the breaks.

Based on observation and staff interview, the facility staff failed to practiced appropriate infection control measures and provide proper hand hygiene and glove usage during perineal cares and during resident meals for 2 out of 2 residents reviewed (Resident #21 and Resident #127). The facility reported a census of 28. Finding included: Observation on 10/19/22 at 11:01 AM revealed Staff E, Certified Nursing Assistant (CNA) and Staff G, CNA, provided perineal cares to Resident #21. Staff E cleansed the front perineal area, removed gloves, wiped hands on scrubs then entered the bathroom and rinsed her hands for less than 5 seconds. Staff E then applied gloves, assisted to roll the resident onto her side to clean and remove bowel movement then with soiled gloves Staff E assisted the resident to roll to the other side, changed the bed pad, changed the brief and opened the drawer of the bedside table to obtain another package of wipes. Staff E still with soiled gloves finished wiping the resident, assisted the resident to get comfortable, put away supplies then removed the soiled gloves, wiped hands on scrubs then entered the bathroom to wash her hands. Observations on 10/19/22 at 11:14 AM during Resident #21's perineal care Staff E's waist length hair brushed against several surfaces touching a dirty bed pad, the resident's leg, a garbage bag and garbage receptacle. Staff E's hair also rested against Resident #21's perineal area after Staff E assisted the resident to roll on to her side. Observation on 10/19/22 at 12:07 PM showed Staff E, CNA's, waist length hair brushed against the table top, wheelchair and Resident #127's leg as Staff E reached under the table to adjust the resident's left wheelchair pedal during lunch. Staff E failed to perform hand hygiene then returned to the kitchen door to assist with passing lunch trays. Observations on 10/19/22 at 12:08 PM showed Staff E, CNA, did not perform hand hygiene at any time while passing trays or while assisting residents at lunch. Staff E, CNA, observed to grasp cups by the top rim as she sat the cups on the tables. The Hand Hygiene policy dated 6/16/22 instructed hand hygiene should be performed after contact with blood, body fluids or contaminated surfaces and before moving from a soiled body site to a clean body site on the same resident. In an interview on 10/20/22 at 3:10 PM, the Director of Nursing (DON), stated that she expected staff to perform proper hand hygiene between glove changes and after coming in contact with soiled surfaces. The DON also expected staff to hold cups by the handles and that hair be tied back in a manner that prevented cross contamination issues.

Based on observations, record review, staff interviews, the facility failed to utilize gait belt for safely transferring 1 out of 1 residents reviewed (Resident #27). The facility reported a census of 26 residents. Findings Include: The Minimum Data Set (MDS) with an Assessment Reference Date of 4/9/21 for Resident #27 showed the resident had a Brief Interview for Mental Status score of 3 which indicated severely impaired cognitive status. The MDS showed the resident had diagnoses of Alzheimer's disease, dementia with behaviors, and [CONDITION(S)]. Resident #27 needed extensive assistance with two staff member for transfers, toileting, and bed mobility. Review of the Progress Note dated 4/15/21 at 1:31 PM showed the resident had a fall in the Bay Area (great room). Two staff members went to wake up the resident to take him to the restroom, they stood the resident up and his knees buckled and was lowered to the floor by the two staff members. The resident was wearing gripper socks but the staff had no gait belt in place. Review of the Fall assessment dated [DATE] showed Resident #27 had a history of falls, unable to independently come to a standing position, required hands on assistance to move from place to place, used assistive devices, and had a decrease in muscle coordination which put the resident at high risk for falls. Review of the Care Plan showed Resident #27 required the assistance of two staff members for transfers with an initiation date of 11/19/20. The Care Plan showed the resident to be a risk for falls due to Alzheimer's and directed staff to have a tab alarm in place at all times with an initiated date of 10/8/20. Review of the Quality Assurance Monitoring Tool dated 4/15/21 showed two staff were assisting the resident from the recliner to the wheelchair to use the restroom and his knees buckled and was lowered to the floor by the staff. The form noted that a gait belt was not in place and to educate staff to use with transfers. Interventions initiated at time of fall were: wait until resident is fully awake to transfer, have a gait belt in place, and to discuss medications causing sedation with the physician. During interview on 5/5/21 at 10:08 AM Staff B Certified Nurses Aid (CNA), stated that on 4/15/21 around 10:30 AM she went to transfer the resident with another CNA to toilet him and when they stood the resident up and his knees buckled and was lowered to the floor. Staff B CNA stated they did not use a gait belt as there was no gait belt in the area to use and she did not have one with her. Staff B CNA stated that she thought the resident was strong enough to stand to transfer from the recliner to the wheelchair. Staff B CNA stated that she knows that she should have use a gait belt when assisting to transfer a resident and now carries one with her. During interview on 5/5/21 at 1:25 PM the Director of Nursing (DON) stated they do not have a policy regarding the use of gait belts and use the standard of practice. The DON expects staff to be using a gait belt any time a resident is being assisted with a transfer.

Based on interviews and record review the facility failed to have Licensed Practical Nursing (LPN) staff work within their scope of practice allowed by the Iowa Board of Nursing by allowing an untrained LPN to complete a central line dressing change on 1 out 1 residents reviewed (Resident #7). The facility reports a census of 26. Findings Include: The Minimum Data Set (MDS) with an Assessment Reference Date of 2/1/21 for Resident #7 showed the resident had a Brief Interview for Mental Status score of 14 which indicated intact cognition status. The MDS showed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 required total dependence with assist of two people for transfers and extensive assistance with two people for dressing and hygiene. Review of the Order tab showed the resident had an order to change the peripherally inserted central catheter (PICC) Line dressing every Thursday starting 1/25/21. Review of the Administration Report for February 2021 showed PICC Line dressing every Thursday with a start date of 1/28/21 was completed by a staff member with the initials of CSP on 2/11/21, 2/25/21, 3/25/21, 4/8/21, and 4/22/21. On 5/4/21 at 12:35 pm, the DON confirmed and verified the initials CSP on the Administration Report for 2/11/21, 2/25/21, 3/25/21, 4/8/21, and 4/22/21 for the change of the central line dressing of Resident #7 was those of Staff A. On 5/4/21 at 1:12 PM Staff A LPN stated she has changed the PICC Line dressing for resident #7 several times and that it is done on Thursdays. When Staff A LPN was asked if she had ever taken the Intravenous (IV) course she stated no. Staff A LPN was asked if it was in her scope of practice to change a PICC line dressing without taking the IV class and she stated that she would get back to me. On 5/4/21 at 1:18 PM the Director of Nursing (DON) confirmed that Staff A LPN has not had an IV medication class and was unaware that an LPN had to take the IV class in-order to change the PICC line dressing. Review of the Iowa Administrative Code Chapter 6 states: 6.5(6) the board-approved course shall incorporate the responsibilities of the licensed practical nurse when providing intravenous therapy via a peripheral intravenous catheter, a midline catheter, and a peripherally inserted central catheter (PICC) to children, adults, and elderly adults. When providing intravenous therapy, the LPN shall be under the supervision of a registered nurse. Procedures that may be performed if delegated by the registered nurse are as follows: Changing the dressing of a midline catheter and a PICC line per sterile technique. Review of an email received from the Director of Education with the Iowa Board of Nursing states an LPN may change a peripherally inserted central catheter (PICC) line dressings after taking the IBON approved IV therapy course per Iowa Administrative Code Chapter 6. During interview on 5/5/21 at 1:25 PM, the DON stated they do not have a policy regarding PICC line care and use the standard of practice.

Based on record review, observation and staff interview, the facility failed to replace oxygen tubing on a weekly basis for 1 of 1 resident reviewed for respiratory care (Resident #4). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 identified a Brief Interview for Mental Status (BIMS) score of 6. A score of 6 indicated severe cognitive impairment. The resident required 2+ person assistance for bed mobility, dressing and personal hygiene. The resident had total dependence on staff. The MDS documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified the resident received oxygen therapy while a resident at the facility. The Care Plan dated 4/28/21 identified a self-care performance deficit related to limited mobility, [CONDITION(S)], impaired balance, and weakness. It instructed staff to assist daily in maintaining O2 (oxygen) saturation (blood oxygen level) above 90% by administering O2 at 2 liters (L) per nasal cannula (NC) PRN (as needed). The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 5/03/21 at 11:21 AM revealed Resident #4 rested in bed. Tubing coiled on the O2 concentrator, not in use, and dated with tape marked 4/11/21. The April 2021 Treatment Administration Record (TAR) indicated Staff C changed tubing on 4/17/21 and 04/24/21. The May 2021 TAR showed no initials documented for the tubing change designated for 5/1/21. Observation on 5/3/21 at 2:25 PM revealed the old tubing removed from the concentrator and a plastic bag of unused tubing attached to the concentrator. Observation on 5/4/21 at 12:09 PM revealed tubing in place dated 5/3/21. Tubing change noted on the TAR for 5/1/21, signed by Staff D, Registered Nurse (RN). On 5/4/21 at 3:03 PM the Director of Nursing (DON) stated the initials documented on the TAR represented Staff C, RN. On 5/5/21 at 11:30 AM the DON stated she would attempt to access the date and time of the 5/3/21 TAR entry from Staff D. On 5/5/21 at 12:15 PM the DON stated she was unable to audit and produce the time and date stamp for the 5/1/21 TAR entry from Staff D. On 5/5/21 at 3:00 PM the DON acknowledged orders for weekly O2 tubing change should occur weekly. On 5/5/21 at 3:20 PM the Nurse Consultant produced a PointClickCare-EMAR-Resident Details document dated 5/5/21, which showed the 5/1/21 TAR oxygen tubing change entered on 5/4/21 at 6:47 AM by Staff D. The document showed the next entry made for an oxygen tubing change made on 4/24/20 and 4/17/20 by Staff C.

Based on record review and staff interview, the facility failed to assure a resident did not receive duplication of a medication and the facility failed to meet professional standards for 2 out of 2 resident reviewed (Resident #28 and #25). The facility reported a census of 26 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #28 scored 11 on the Brief Interview for Mental Status (BIMS) indicating cognitive impairment. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician Transfer Order Report dated 2/17/21 included orders to admit to the nursing facility. The medication orders included [MEDICATION(S)] 500 mg by mouth daily. The Progress Notes dated 2/17/21 at 3:40 PM documented due to the pressure ulcer on the resident's left great toe, the dietician recommended Vitamin C 500 mg daily, and questioned if they may start the recommendation. The Progress Notes dated 2/17/21 at 5:52 PM documented receipt of a signed fax from the physician with new orders for Vitamin C 500 mg daily. Family were notified and the electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] The February 2021 eMAR showed the resident received both an [MEDICATION(S)] 500 mg tablet and an [MEDICATION(S)] 500 mg chewable at breakfast time daily from 2/18/21 through 2/28/21. The March 2021 eMAR showed the resident received both an [MEDICATION(S)] 500 mg tablet and an [MEDICATION(S)] 500 mg chewable at breakfast time daily from 3/1/21 to 3/5/21. The Progress Notes dated 3/5/21 at 1:23 PM documented receipt of signed order from the physician to discontinue Vitamin C tablet due resident having a Vitamin C chewable tablet. The Care Plan initiated 2/17/21 and revised 3/1/21 identified the resident had a Stage 1 pressure ulcer to the left great toe due to his shoe rubbing on the toe revised 3/1/21. The interventions included to administer Vitamin C per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 5/5/21 at 11:43 AM the MDS Coordinator stated she figured out when giving medications, they had 2 orders for [MEDICATION(S)]. On 5/6/21 at 7:19 AM the DON confirmed giving 2 doses of the [MEDICATION(S)] a duplicate order and an error. 2. The Minimum Data (MDS) with an Assessment Reference Date of (ARD) of 4/9/21 for Resident #25 showed a Brief Interview Status Score (BIMS) of 15, indicating intact cognitive response. The MDS showed the resident to have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required total dependence of 2 staff for bed transfers, locomotion and dressing. Review of the electronic health record showed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the vitals tab in the electronic health record showed a blood sugar reading of 178 taken on 5/4/21 at 11:36 AM. During observation on 5/4/21 at 11:36 AM Staff A Licensed Practical Nurse (LPN) obtained a [MEDICATION(S)] injection KwickPen from the medication cart and sanitized her hands, the cap was removed, the top of the pen was cleaned with an alcohol prep pad and the needle was applied to the pen. Staff A LPN dialed the pen to 5 units. Staff A LPN failed to prime the insulin pen with 2 units. Staff A LPN applied gloves and prepped area on Resident #25's right upper arm with request from the resident and injected the insulin. The needle cap was removed and disposed in the sharps container, gloves removed and hands sanitized, and cap placed on insulin pen and placed in medication cart. Review of the instruction sheet for [MEDICATION(S)] KwickPen showed to prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures the pen is working properly. If you do not prime before each injection, you may get to much or too little insulin. Step 6: To prime your pen, turn the dose dial to select 2 units. Step 7: Hold your pen with needle pointing up. Tap cartridge holder gently to collect air bubbles at the top. Step 8: Continue holding your pen with needle pointing up. Push the dose knob in until it stops and 0 is seen in the dose window. Hold the dose knob in and count to 5 slowly. You should see insulin at the tip of the needle, if you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. Staff A LPN stated on 4/5/21 at 11:46 PM that she had never primed Insulin pens before and was unaware that priming needed to be done with each injection. Staff A LPN stated that she thought the pen only needed to be primed once when it was first used opened. During interview on 5/5/21 at 1:25 PM the DON stated they do not have a policy regarding insulin pens or medication administration and use the standard of practice. The DON stated she is aware that the insulin pens need to be primed with 2 units before each use and expects the nurses to know that they need to prime the pens before use.

Based on observation, resident interview, record review, and interviews with a wound nurse and staff, the facility failed to provide necessary treatment and services to prevent the development of pressure sores and then promote healing for 1 of 1 resident identified with a pressure ulcer (Resident #1). The facility reported a census of 25 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 09/06/15. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 6. A score of 6 indicated the resident had a severely cognitive impairment. Resident #1 depended on staff assistance for activities of daily living (ADL's) including bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. The MDS reflected the resident had [DIAGNOSES REDACTED]. The MDS identified the resident at risk for the development of pressure ulcers but had no ulcers during the assessment period. The MDS defined a Stage II pressure ulcer as a partial thickness loss of dermis presenting as a shallow open ulcer with a pink or red wound bed, without slough. It may also present as an intact or opened/ruptured blister. The MDS defined a Stage III pressure ulcer as full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. The MDS defined a Stage IV pressure ulcer as full thickness loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. A Braden Scale for Prediction of Pressure Sore Risk scored Resident #1 at 14. A score of 14 identified the resident at a moderate risk for the development of pressure ulcers. The assessment indicated the resident had very limited sensory perception, was chair fast, and had very limited mobility. Resident #1 had occasionally moist skin and a potential problem with friction and shear. The Care Plan dated 06/09/14 and revised on 11/18/15 identified Resident #1 had a pressure area located on the right buttock. The interventions directed the staff to perform the following: a. Resident #1 had an air redistribution mattress, to check every shift for proper inflation (11/18/15). b. Please use only wipes and Provon to cleanse after incontinence. c. Please put bunny boots on at all times. d. Conduct a systematic skin inspection with daily cares, paying particular attention to the bony prominences. e. Sees wound nurse and follow recommendations (11/18/15). f. Turn and reposition frequently, use body pillow as needed in bed. g. Keep off back. h. Roho (cushion) in wheelchair. i. Only up for meals for 30 minutes. A Skin Sheet dated 10/18/15 documented Resident #1 had 2 blisters to the right buttock measuring 1 by 1 cm and 0.5 by 0.5 cm. The skin sheet indicated staff applied [MEDICATION NAME] dressing and offloaded after meals as Resident #1 allowed. The Treatment Administration History showed an order for [REDACTED].>The Progress Notes dated 10/27/15 at 9:10 p.m. documented Resident #1's right buttock area measured 3 by 3 cm with approximately 1 cm depth. The wound bed was covered with dull dark gray wrinkled skin with no drainage or bleeding. Gentle cleansing of the area with soap and water sloughed off dark gray wrinkled skin, leaving a dark, dull red wound bed with a scant amount of light red bleeding. Staff applied triple antibiotic ointment. Staff positioned Resident #1 on the left side to keep pressure from the area. Staff informed Resident #1 he/she would be required to remain in bed, and turn regularly to keep pressure from the area. Staff completed a skin sheet and sent the sheet to the physician. A facsimile (fax) dated 10/19/15 (fax date indicated 10/29/15) at 10:20 a.m. notified the physician Resident #1 had an open area of the right buttock and it did not seem to heal. Staff requested an order for [REDACTED]. A Progress Record by the wound nurse dated 11/04/15 documented she consulted to evaluate and treat Resident #1's buttock ulcer. The note documented the facility discovered a dark purple colored area of skin at the right ischium a week earlier then noted Resident #1's Roho cushion as flat. The note indicated the facility kept Resident #1 off his/her bottom as much as possible. Resident #1 bed ' s had a thin air mattress with coils of air. Resident #1 had an ulcer on his/her right ischial tuberosity measuring 6.5 by 2.2 by at least 0.5 cm deep. The base of the ulcer was covered with a thin layer of yellow slough. The rim appeared pink in areas. The surrounding skin had diffuse pink color that blanched and without increased warmth and 2 cm out from the rim. Resident #1 had an unstageable pressure ulcer of the right ischial tuberosity. The new orders included: a. Cleanse with normal saline, pat dry, apply silver alginate and cover with [MEDICATION NAME] foam 2 times a week and as needed (PRN). b. Use air cushion until Roho cushion repaired or replaced. c. Sit for meals no longer than 1 hour at a time with air cushion/Roho when replaced. d. Discontinue current air mattress on bed and replace with one at least 4 inches thick to redistribute pressure. e. Reposition off affected site in bed. f. Dietician consult for wound healing. A Turning Schedule identified Resident #1 turned every 2 hours starting 11/05/15. A Progress Record by the wound nurse dated 11/11/15 documented Resident #1's ulcer of the right ischial tuberosity measured 3.7 by 2.1 cm with 0.3 cm depth. The base of the wound covered with a thin yellow slough in the center and a pink/red tissue on the perimeter. The surrounding skin light pink with diffuse coloration. Likely an error in measurement the previous week at 6.5 cm, believed it should have been 3.5 cm. The staff reported an odor with yesterday ' s dressing change. Noted a slight odor and the dressing saturated with drainage. Resident #1 had an unstageable pressure ulcer of the ischial tuberosity, likely a Stage III, but slough obscures the central base. The plan included: a. Increase frequency of dressing changes to 3 times a week, cleansing very thoroughly at each dressing change. b. Continue current activity restrictions and repositioning schedules. c. Air overlay at least 4 inches thick or low air loss mattress. d. Report [DIAGNOSES REDACTED] and worsening wound to physician and wound nurse. A Progress Record by the wound nurse dated 11/18/15 documented Resident #1 rested in bed on his/her back. Resident #1 still had the green air mattress on his/her bed which was flat. The wound nurse noted odor with removing the dressing, and the dressing saturated with foul tan drainage, and the wound base nearly completely covered with tan nonviable tissue. The wound nurse trimmed a small amount, with nonviable tissue covering the rest of the base. The ulcer measured 3.6 by 2.4 cm with 1 cm depth, although may be deeper with debridement. Resident #1's catheter appeared to leak as the chux (pad) was saturated with urine. The assessment identified a worsening pressure ulcer of the right ischial tuberosity, odor and increased depth. The ulcer remained unstageable, but likely a Stage IV once debrided, and may require surgical debridement and possibly a wound vac (device to suction debrie from the wound). The plan included: a. Culture and sensitivity of wound done. b. Dakin ' s solution 0.125% dressings. Moisten gauze with solution and insert into ulcer but don't pack. Change dressing every 8 hours and cover with absorbent dressing and tape. Use skin prep under tape. * c. Obtain a pressure redistribution mattress ASAP! Today. d. Limit sitting to eating times only. Half an hour at a time. e. Resident must not lie on back in bed. A Transfer/Discharge Report dated 11/18/15 documented Resident #1 had a catheter change and the catheter would not irrigate for 2 days. An emergency room report dated 11/18/15 documented Resident #1 had lab work including a urinalysis with a urine culture pending. The discharge instructions included to increase fluid consumption and take Bactrim DS (antibiotic) 2 times a day for 5 days. A Progress Record by the wound nurse dated 11/24/15 documented she would discuss the culture results with the physician. Initially Resident #1 had a 5 day course of Bactrim, but finished. A facsimile dated 11/24/15 at 3:45 p.m. notified the physician that Resident #1 finished a 5 day course of Bactrim and requested an extension of the Bactrim. The physician ordered Bactrim DS 2 times a day for 7 days. A Progress Record by the wound nurse dated 11/30/15 documented the culture reviewed and [MEDICATION NAME] (large amount) not covered by Bactrim, sensitive to [MEDICATION NAME] and [MEDICATION NAME]. She would contact the physician's office regarding the same. She would contact a physician with a request for wound debridement. The Progress Notes dated 12/01/15 at 1:36 p.m. documented an infection note. The physician's office phoned and stated Resident #1 had 3 types of bacteria and the most effective treatment would be intravenous [MEDICATION NAME]. They could also treat with intramuscular (IM) [MEDICATION NAME] (antibiotic) and 2 oral antibiotics. Staff visited with Resident #1 regarding his/her wishes and the options explained. Resident #1 did not want IV, and opted for IM and oral antibiotic. Staff notified the physician's nurse. (Resident is severely cognitively impaired) A Hospital Wound Note dated 12/02/15 documented Resident #1 presented to the emergency room (ER) for assessment and debridement of an unstageable pressure ulcer on his/her right ischial tuberosity by a physician. The resident went to the physician's office the previous week, but had no Hoyer lift available so rescheduled at the ER. The pressure ulcer was present for a month. A culture done a couple weeks previous grew multiple organisms,[MEDICAL CONDITION], proteus, [MEDICATION NAME] and an anaerobe which were being treated with oral antibiotics which improved the odor and the [DIAGNOSES REDACTED]. The treatment included Dakin's solution dressings every 8 hours and pressure redistribution. The physician saw Resident #1 at 7:50 a.m. and noted a small amount of yellow and bloody drainage on the old dressing, with minimal odor. The physician debrided the base of the ulcer using sterile forceps and a #15 blade, with a moderate amount of yellow/tan nonviable tissue, and bleeding controlled with pressure. The base appeared clean down to muscle and bone palpable, diagnosed as a Stage IV pressure ulcer by the physician. The wound had undermining present. The staff cleansed the wound with normal saline and redressed. The physician ordered a wound vac to expedite healing. Assessment of the ulcer included it measured 4 by 3 cm with 3 cm depth and moderate sanguineous (bloody) drainage. The Progress Notes dated 12/03/15 at 1:00 p.m. documented an infection note. Staff sent a fax to the physician questioning starting oral antibiotic. The office was notified of Resident #1's wishes 12/01/15 with no new orders received. A fax dated 12/03/15 at 4:00 p.m. notified the physician, per conversation with resident on Tuesday, he/she did not want IV antibiotics. The fax indicated they notified the physician's office of Resident #1's wishes on 12/01/15, and the facility did not have orders. The physician's office replied they had records they faxed orders for [MEDICATION NAME] 500 mg 2 times a day for 10 days. They were to start that and [MEDICATION NAME] 500 mg IM for 3 days, dated 12/04/15. The facility noted the order 12/07/15. The clinical record lacked any other attempts to reach the physician's office to obtain the order. The Progress Notes dated 12/07/15 at 3:07 p.m. documented orders received for [MEDICATION NAME] 500 mg 2 times a day for 10 days and [MEDICATION NAME] 500 mg IM for 3 days (6 days after the physician indicated the need for additional antibiotics). A Medication Administration History for 12/01/15 to 12/31/15 documented Resident #1 received [MEDICATION NAME] ([MEDICATION NAME]) 500 mg injection on 12/07, 12/08, and 12/09/15, and [MEDICATION NAME] V potassium 500 mg 2 times a day for 10 days, starting 12/07/15. A Progress Record by the wound nurse dated 12/16/15 documented to continue current treatment plan with the following notes: position off the affected area. A Progress Record by the wound nurse dated 12/28/15 documented please position off the affected area. During an observation on 01/04/16 at10:56 a.m. the wound nurse changed the dressing to Resident #1's right buttock. The area measured 1.5 by 1 cm with 2.1 cm depth and 2.8 cm tunneling. Just prior to an interview on 01/06/16 at 1:30 p.m. Resident #1 wanted to use the call light for staff to turn him/her. Staff B informed Resident #1 they would turn him/her in half an hour. During the interview Resident #1 stated he/she could only be up for short periods. The resident stated he/she lay in bed most of the time. Resident #1 stated he/she was lying on the sore. During an interview on 01/06/16 at 3:15 p.m. the wound nurse stated Resident #1's right buttock wound was initially unstageable. The wound nurse stated she did not know what dressing they used when she initially saw Resident #1. Skin prep would not be appropriate because the wound was open and drained. She stated the delay in getting a (pressure reducing) mattress did not help the pressure ulcer. The wound nurse stated the previous mattress was not adequate. During an interview on 01/07/16 at 9:30 a.m. the Director of Nursing (DON) stated she could not find an order for [REDACTED]. The DON stated when the nurse practitioner saw Resident #1 on 10/20/15, she did not know he/she had a skin issue on his/her buttock. She agreed the delay in getting the (pressure reducing) mattress was a concern. The DON stated on 12/01/15, they received a call about Resident #1 needing antibiotics for the wound. She talked to Resident #1 about the options for intravenous antibiotics or oral. The DON notified the physician's office 12/01/15 that Resident #1 did not want IV. She stated on 12/03/15 she sent a fax to the physician regarding the antibiotics. She agreed the follow-up was not timely and delayed initiating antibiotics.

Based on observation, record review, interviews, and policy review, the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment for one (1) of four (4) residents reviewed. On 9/17/15, Resident #8 exited the facility without staff knowing the resident ' s whereabouts for approximately 30-45 minutes. A staff reported hearing the door alarm sounding for a long time and did not respond or alert additional staff of the door alarm sounding. The resident eloped again on 9/19/15, and interviews determined the door alarm had been turned off at the time. Observation on 9/21/15, showed the door alarm turned off. Record review identified Resident #8 at risk for elopement. The findings constitute an immediate jeopardy to resident ' s health and safety. The facility identified a census of thirty (30) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 9/17/15 identified Resident #8 with a brief interview for mental status score of 6(severe cognitive impairment). An initial care plan, initiated on the date of admission, identified the resident with wandering and elopement. Nursing progress notes dated 9/17/15 at 12:35 p.m. identified the resident as an elopement risk. The Elopement Policy (undated) revealed the staff are to respond immediately to all activated exit alarms. a). A facility timeline regarding the elopement incident identified the resident admitted to the facility on [DATE] at 2:09 p.m. The resident admitted to the West Wing of the facility. On the same date at 6:50 p.m., the resident went out door #6 (west exit door). A facility investigation regarding the 9/17/15 incident identified the facility admitted the resident on 9/17/15 from the hospital. The resident had [DIAGNOSES REDACTED]. The resident's spouse could not care for the resident at home due to advancing dementia. The investigation revealed that the dietary manager saw the resident attempt to leave the facility via the front door around 5:30 p.m. on 9/17/15. The dietary manager informed a nurse aide to watch the resident because he/she attempted to leave. The dietary manager punched out at 5:35 p.m. At 6:50 p.m. on 9/17/15 the resident left the facility via door #6 with the alarm sounding. Staff assisted a resident in another room when the alarm activated. When staff exited the room, they began to search for the resident. Video surveillance at a convenience store identified the resident made a purchase at 7:02 p.m. At 7:22 p.m. staff observed the resident walking up the street coming back to the facility. The resident wore jeans, shirt, socks and shoes. The weather was 72 degrees. Staff assessed the resident and found no injuries. Following the incident, the facility implemented 15 minute checks and placed a Wanderguard on the resident and a motion alarm on the resident's door. Google maps identified the convenience store was 0.6 miles from the facility. A fax to the physician dated 9/17/15 to report the elopement revealed staff informed the physician that the resident left the facility and was gone for approximately 30 to 45 minutes. Hospital records identified the resident admitted to the hospital on [DATE] and discharged on [DATE]. The discharge plan identified that the resident had an increase in dementia and wandering. The resident's spouse could no longer monitor the resident because the spouse worked full time. A history hospital form, dated 9/15/15 revealed the resident started wandering away from home more often in search of cigarettes or cash to buy them. The resident went into a neighbor's home uninvited looking for cigarettes and wandered to a local gas station. The form identified the resident with dementia with behavior disturbance. The anticipated discharge care was that the resident required nursing home placement to keep the resident from harming self. The physician documented that the resident was at extreme risk of frostbite if the resident wandered off. The physician also documented that there was not much question that the resident would wander off even if he/she did not have shoes on. Staff Working 9/17/15 when elopement occurred: On 9/23/15 at 2:18 p.m. Staff A (registered nurse) stated the resident ate in the dining room and then around 6 p.m. someone assisted the resident to his/her room. She stated no one reported to her that the resident attempted to leave at 5:30 p.m. Staff A stated at 5:45 p.m. she asked the Director of Nursing (DON) whether the resident needed a Wanderguard on and the DON said no, she had assessed him/her. Staff A said the DON left at 6:15 p.m. and Staff A went to supper at 6:30 p.m. Staff A sat there for 5 minutes when she got a call that Resident # 16 was unresponsive and on the EZ stand. Staff A stated she and a nurse aide were in Resident #16's room for 20 to 30 minutes. When they stepped out of the room, they heard the alarm. Staff A thought it was the front door alarm but then she glanced at the alarm board and saw it was door #6. When they approached door #6 the stop sign remained in place across the door. They then began to search and discovered Resident #8 was gone. One staff went outdoors to look and another staff stayed inside looking. Staff A called the Administrator and the Director of Nursing. Staff A stated they found the resident at 7:30 p.m. when they observed the resident walking back to the facility. Staff A stated she thought the resident was gone 45 minutes. On 9/21/15 at 4:38 p.m. Staff B (nurse aide) stated she didn't see anything. She sat at the nurses station and heard an alarm going for a long time. She asked another nurse aide what it was and was told Resident #8 got out. The other nurse aide told Staff B to answer call lights while she and Staff A looked for the resident. Staff B stated an alarm sounded from door 6 and went on for a long time. Staff B stated she didn't know what it was. Review of Staff B's orientation papers identified the alarm board area and Tab alarm area was blank indicating Staff B did not receive orientation on the door alarms. On 9/24/15 at 12:11 p.m. the Administrator identified Staff B's date of hire as 8/12/15. The surveyor attempted to contact the other nurse aide that worked. She no longer worked at the facility and she did not return phone calls. On 9/21/15 at 3:25 p.m. the Director of Nursing stated staff completed the elopement assessment after the 9/17/15 elopement and identified the resident at risk for elopement. If identified at risk, then staff places a Wanderguard bracelet on the resident at risk. Nursing progress notes dated 9/19/15 at 11:09 a.m. revealed the resident turned off the door alarm on his/her room door. b. ) A facility investigation dated 9/19/15 identified Staff C (registered nurse) saw the resident in the Bay area (front lounge) of the facility at 6:05 p.m. on 9/19/15. Staff D (licensed practical nurse) was at the nurses desk and observed Resident #8 (wearing) jeans, shirt and shoes on in the north parking lot at 6:10 p.m. The door alarm panel showed no alarms on. She observed the door alarm switches to door #2 (breakroom) and #7 (front door) in the off position. The Administrator arrived at 7:35 p.m. and confirmed the resident's Wanderguard worked. All doors and Wanderguard functioned when checked. The facility implemented diversional activities and continued 15 minute checks. The facility investigation identified door #2 as the south main entrance into the building and door #7 as the employee breakroom door. This was INCORRECT. According to observation while at the facility and a sheet titled Door alarm locations, Door #2 was the breakroom door exit that exited to the north parking lot (where staff found the resident on 9/19/15) and Door #7 was the front inside door to the facility. On 9/21/15 at 10:30 a.m. the Administrator stated the resident followed Staff H (nurse aide) out the breakroom door (Door #2) on 9/19/15. On 9/28/15 at 12:01 p.m. Staff H (nurse aide) stated she didn't know the resident left until a day or two after the incident. She stated she always watches her surroundings and Resident #8 did not follow her out. She always makes sure the doors shut quickly and stated no one was behind her when she left. On 9/21/15 at 1:12 p.m. the maintenance supervisor stated the Wanderguard to door #9 (door to north parking lot) did not activate when he checked it that morning. He stated he checked the Wanderguard by placing the bracelet piece in his sock and walking through the hall to the #9 exit. He stated he lowered the Wanderguard box and following that, it activated. At 1:40 p.m. the Wanderguard in the north hallway did not activate when the surveyor walked on the far side of the hall with the Wanderguard bracelet piece in a sock. It did not sound until the surveyor walked in the center of the hall closer to the Wanderguard box. The maintenance man then adjusted the Wanderguard box and when rechecked it did activate when the surveyor walked on the far side of the hall. He stated he checked door alarms once a month. A paper of door alarm checks identified the door alarms as last checked on 8/24/15 prior to the elopements. The initial care plan contained an addendum dated 9/19/15 that directed staff to offer diversional activities. An addendum dated 9/22/15 identified that the resident turns his/her room door alarm off. The care plan did not identify 15 minute checks. On 9/22/15 at 6:50 p.m. Staff C (registered nurse) stated she observed the resident in the Bay area at 6:05 p.m. (on 9/19/15). After that, she gave report to Staff D (licensed practical nurse) and during that time, Staff D looked outside and asked if the resident should be outside in the parking area. Staff went out and got the resident. Staff C stated she did not hear any alarms when the resident went out. She stated she has no idea how the resident got outside. She checked the Wanderguard earlier in the shift and it worked fine. On 9/24/15 at 2:55 p.m. Staff C stated she stated she never knew of door switches in the off position. Staff would flip the door #9 switch to take trash out. Door #9 went directly to the south parking lot. On 9/24/15 at 8:15 a.m. Staff D (licensed practical nurse) stated she punched in at 5:40 p.m. on 9/19/15 and assisted in the dining room and at that time Resident #8 got up from the dining table and Staff D asked where the resident planned to go. The resident stated he/she planned to sit in the lounge area. Staff D continued to assist residents and glanced out the window and observed Resident #8 in the back parking lot at 6:11 p.m. Staff D denied hearing any door alarms sound and stated she didn't know how the resident left. When Staff D went out and got the resident, he/she stated they told the resident to go out and look around. The resident came back in and sat in the Bay area. Assessment showed no injury. On 9/24/15 at 2:50 p.m. Staff D stated she observed the door alarm switch to Door #2 (breakroom) in the off position when she checked the board after the resident got out. She didn't know how the alarm switch got in the off position. On 9/21/15 at 2:33 p.m. Staff F (nurse aide) stated she worked on 9/19/15 and did not hear a door alarm sound. On 9/23/15 at 1:46 p.m. Staff G (nurse aide) stated she came to work at 6 p.m. on 9/19/15 and didn't hear any door alarms. She stated she keeps track of the resident by listening for his/her room door alarm. The surveyor informed Staff G that the resident turns the room door alarm off per self. Staff G stated she did not know that. Audibility of door alarms: On 9/24/15 at 12:20 p.m. the surveyor tested door alarm audibility by going in Resident #16's room (room staff were in during 9/17/15 elopement) and shutting the door after Resident #16 agreed. The resident used oxygen and had a television on. The surveyor could not hear the door alarm in the room. On 9/21/15 at 11:46 a.m. Resident #8 led the surveyor to his/her room. The resident walked with a quick steady gait. The resident stated the doctor and spouse wanted the resident to come to the facility. The resident knew what town he/she lived in prior to facility admission. The resident knew the month and year but did not know the town he/she was in or the President's name. The resident did not recall leaving the facility and going to a convenience store. The Department requested information on 9/24/15 of the training that had been provided to staff. The facility provided the Timeline Information Regarding 9/17/15 and 9/19/15 elopements: a. On 9/21/15 the maintenance person placed a TABs alarm on the Door #6 and Door #10 exits to enhance audibility. b. On 9/24/15 the maintenance person began individual training staff on the alarm board. c. On 9/25/15 the facility placed a bar under the alarm door switches so none of the alarms could be turned off other than Door #7 (inside front entrance) and Door #8 (outside front entrance).When an alarm sounds 2 staff view the alarm board. The only way to turn an alarm off is with a key kept at the nurses station. The alarm activation incident is then recorded in a book. d. On 9/26/15 the facility removed the resident's room door alarm. On 9/24/15 at 2:50 p.m. the surveyor walked down the hall and noticed the Door #2 switch in the off position. The surveyor spoke with the maintenance person on 9/24/15 at 3 p.m. who had been at the nurses station and asked him if he knew why the switch was off. He stated he flipped Door #2 and Door #9 off earlier when he went outside. He came back in and flipped Door #9 back on but forgot to flip Door #2 back on. He estimated the switch to Door #2 was flipped off for about 10 minutes. c. On 9/27/15 at 12:30 p.m. Door #6 alarm sounded and Resident #8 went out the door. Staff immediately responded to the alarm and stayed with the resident one to one until the family arrived. Staff placed a motion sensor above the resident's door and stayed one to one with the resident. They applied a pressure pad to the resident's bed. The facility timeline also identified the facility moved the resident to a different hall closer to offices and the nurses station on 9/28/15. Facility documentation forms identified the night nurse checks the alarm bracelets for function every night. The resident had 3 residents that used a Wanderguard (which included Resident #8). The Department received the training information on 9/28/15. The training information titled All Staff Will Know/Demonstrate the Following : a. Whereabouts of the alarm board. b. Green indicator light means system is active. Red button indicates corresponding doors, which are numbered. c. Only toggles 2, 4, 7 and 8 may be in the down position during the day. Toggles 4 needs to be flipped up by the afternoon (dietary personnel during 2nd shift). Only certain toggles may be down during the day hours and are signified by neon yellow circles. These are the main exit doors used frequently. d. Staff would observe the board when passing to ensure all required toggles are in the up/on position. e. All toggles need to be up/on during the night shift. f. If/when a door is open- alarm is activated and red light is on, alarm will sound. If all residents are accounted for and staff has communicated to each other the reason for opening .the alarm toggle may be turned off and the board may be reset. The surveyor identified the training information sent to the Department (previously mention above) now had multiple items crossed. For example, the training now stated Only toggles 7 and 8 may be in the down position during the day (off). On 9/29/15 at 1:47 p.m., the Administrator documented #2 toggle should be in the up (on) position. When the surveyor observed toggle #2 down, it should have been up. On 9/29/15, the facility identified staff were taken to the alarm board which has a permanent bar in place. The facility identified the training document had not been revised yet but staff had current and accurate training. The training now identified the following: All Staff Will Know/Demonstrate the Following : a. Where the alarm board is located. b. Green indicator light means system is active. Red button indicates corresponding doors, which are numbered. c. Only toggles 7 and 8 may be in the down position during the day. d. All toggles need to be up/on during the night shift. e. If/when a door is open- alarm is activated and red light is on, alarm will sound. Staff needs to determine why the door alarm is sounding and report to the charge nurse. The charge nurse must be notified of the door alarm. The reset the board, see the charge nurse. They are the only staff who has the key to disengage the alarm. On 9/29/15, the surveyor verified the education provided to staff had been accurate. The facility abated the immediate jeopardy (IJ) on 9/29/15 and these actions lowered the IJ from a J severity to D severity with the need for ongoing monitoring of door alarms to ensure residents safety.

Based on clinical record review and interviews, the facility failed to provide adequate supervision to protect Resident #1 from hazards; failed to maintain the resident's safety after a fall when staff moved the resident; and failed to update the resident's pocket care plan. Record review established Resident #1's care plan & pocket care directed staff to use a motion detector alarm to the resident's bed. Resident #1 fell on [DATE], and staff interview revealed this safety intervention had not been implemented & the only alarm used had been a pressure pad Tabs clip alarm which had been attached but did not sound when the resident got up unassisted from his/her bed. Staff interview & record review revealed the resident had neck pain, right hip pain and shoulder pain after the fall on [DATE]; however the nurse reported they slid the resident away from the toilet after the fall. Resident #1 sustained a right hip fracture and died on [DATE]. Interview with the physician revealed all the care plan intervention should have been implemented; and the resident should not have been moved from the bathroom floor and 911 should have been called. The resident's pocket care plan lacked information on the Tabs pressure pad clip alarm. The facility identified a census of 28 residents with 1 of 1 closed record reviewed. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #1 dated [DATE] documented his/her [DIAGNOSES REDACTED]. The MDS documented a Brief Interview of Mental Status score of 3 which indicates sever cognitive impairment. The resident required assistance of two persons for completion of bed mobility, transfer, dressing and toileting; and one staff person to assist with hygiene. The resident had limitation in functional range of motion in both upper and lower extremities, and utilized a walker and a wheelchair for mobility. The test for balance identified Resident #1 as unable to stabilize him/her(self) without staff assistance while moving from a seated to standing position, walking, turning around, moving on and off a toilet and surface-to surface transfers. The MDS revealed Resident #1 had been frequently incontinent of bladder and continent of bowel. The resident had been receiving an antidepressant medication 7 of 7 days of the assessment period. The comprehensive care plan updated at the last care conference on [DATE] identified the resident at risk for falls due to an increase in confusion. The care plan goal instructed staff to protect the resident from injury and listed interventions for staff to follow. The care plan interventions directed staff use a motion detector to the resident's bed. The care plan directed staff to apply pressure pad to the resident's chair/recliner/Tabs clipped alarm. The care plan also listed interventions for staff to reminder the resident not to ambulate or transfer without assistance ; use a body pillow for positioning and boundaries and completed later on last rounds (had been attempting to get up to BR (bathroom); and an motion alarm on the door when out of room. The pocket care plan dated [DATE] identified the resident required a motion detector alarm while in bed and gripper socks at HS (bedtime). The pocket care plan noted staff would position pillows when in bed, and the resident required assistance of ,[DATE] persons. The Observation Report form dated [DATE] at 7:25 documented Resident #1 had an unwitnessed fall in his/her bathroom. The resident had been in bed prior to the fall and had his/her gripper socks on his/her feet and his/her call light nearby. The reported noted potential hazards for urine on the floor, and an EZ-stand sitting in corner (of the room). The report noted the resident did take antidepressant medications had a history of [REDACTED]. The report documented the resident tabs alarm in place on bed & the tabs alarm would be attached to the resident ' s top (clothing) differently. The facility sent the resident to the ER for evaluation. The Resident Progress Notes entry completed by Staff E, registered nurse (RN) on [DATE] at 7:37 a.m., documented a certified nursing assistant (CNA) hear the resident calling out for help at 1:00 a.m.. The report documented the tabs alarm was present and in working order. (The report did not say the alarm sounded). When Staff E entered the resident's room she observed the resident lying on his/her right side on the bathroom floor with the resident's head located between the wall and the toilet and the resident's legs in a knee-bent position with the right knee closer to the body than the left one. The resident held the right side of his/her head with the right hand; the resident had a baseball-sized tender lump on the head and complained of neck pain on the right side and stated, " It hurts when I move it" . The resident had external rotation and shortening of the right leg and swelling had been noted on the outer aspect of right hip. The resident could not fully extend the right leg without calling out in pain. Staff E (nurse) and CNA positioned the resident on a bed pad to slide the resident out of the bathroom area to where the Hoyer lift could be used to extract the resident from the floor. The resident received a Hoyer lift to his/her bed for the nurse to complete her assessment. Staff E then called 911 at 1:30 a.m. and the ambulance and emergency personnel arrived at 1:50 a.m., secured the resident's neck with a C-collar, transferred the resident by 4-person left using the bed linen under the resident and left the facility at 2:30 a.m. The Emergency Provider Notes completed by the resident's physician and filed on [DATE] at 7:15 a.m., documented the resident had a fall from the toilet (stool) from a height of ,[DATE] feet and handed on a hard floor/and wall. The point of impact had been his/her head, right hip and right shoulder. The resident had pain in the right hip & right shoulder/(neck). The resident moaned constantly about his/her neck pain. Treatment on scene included a c-collar. X-rays would be completed. The x-ray revealed The resident had an acute right intertrochanteric (hip) fracture. The hospital report of the resident's Brief hospitalization dated [DATE] identified the resident had been transferred to the emergency room via ambulance after a fall at the nursing home. An imagining study of his/her neck had initially identified a fracture however two more readings identified arthritic changes. The resident had a hip fracture and due to the pain of the hip fracture, the resident received IV (intravenous) morphine. The resident died the following day ([DATE]). A review of past medical history listed dementia, hypertension, diabetes, [DIAGNOSES REDACTED] and GERD (gastro esophageal reflux disease). During interview on [DATE] at 10:30 AM, Staff C CNA stated she put Resident #1 to bed around 11:00 p.m., Staff C stated the resident often like to stay up late; she assisted the resident to the toilet prior to going to bed but the resident did not void. Staff C stated she placed a Tabs clip alarm to the resident's right shoulder. Staff C stated the Tabs clip was the only alarm used for the resident. Staff C stated the resident had on a pajama top made of slick material. Staff C stated she checked on the resident between 12:15 a.m.-12:30 a.m., the resident had not been incontinent and had been asleep. Staff C stated she did not check to see if the alarm remained clipped to the resident's nightclothes. Staff C stated that around 1:00 a.m., she went to answer another resident's call light and heard Resident #1 yelling for help. She found the resident lying on the floor of the bathroom with his/her head between the wall and the toilet and his/her body curved around the front of the toilet. There were urine dribbles on the floor and fecal material in the toilet. She left the room and got Staff E. She and Staff E placed a bed pad under the resident's buttocks and pulled him/her away from the toilet and out into the room. Staff C stated the resident had a big bump on the back right side of the head and the resident complained of right leg pain. She and Staff E placed the resident on a mechanical lift sling and transferred the resident from the floor to the bed. Staff C stated that when the resident laid in bed he/she complained of head and neck pain. Staff C stated the alarm clip remained fastened to the alarm box so it had not sounded at the time the resident got out of bed. During interview on [DATE] at 2:45 p.m., Staff E (registered nurse) stated Staff C summoned her to the resident's room around 1:00 a.m.. She saw the resident on his/her right side on the floor in front of the toilet with the resident's head between to toilet and the wall. Staff C stated an EZ stand lift was stored in the bathroom opposite of the toilet. The resident's body curved around the toilet and held both knees in a flexed position. The toilet contained fecal material and saw urine dribbled on the floor. The resident had a raised area on the right side of the head approximately 5 centimeters (cm) in diameter and the resident complained of head and neck pain. She and Staff C placed a bed pad under the resident's hips/buttocks and slid the resident away from the toilet and into the resident's room. The resident's right leg appeared shortened and externally rotated and the resident complained of right hip pain. She and Staff C positioned the resident on a mechanical lift sling and transferred the resident from the floor to bed. Staff E stated staff had to get the resident off the floor and into bed so she could assess the resident. Staff E stated the resident's clip alarm had remained intact on the bed. She pulled it apart to test it and the alarm sounded. Staff E stated she attached the alarm to the resident's pajamas and tugged on it but the clip slid off the slick material of the pajamas. Staff E reported the she now updates the pocket care plans and started doing this a week ago. Prior to that she thought the care plan coordinator updated pocket care plans. Staff E reported the purpose of the pocket care plan is to educate CNAs to the resident's needs and the facility also uses pool staff so they can be aware of the resident's needs. During interview on [DATE] at 4:21 p.m. the resident's physician stated she would have expected the facility to assure all safety devices be in place as directed by the resident's care plan. The resident's physician stated staff should have immediately called 911 and not moved the resident from the bathroom floor. The physician reported the cause of the resident's death had been cardiopulmonary arrest due to hip fracture and there were no other underlying causes. During an interview with Staff F, Licensed Practical Nurse (LPN) on [DATE] at 3:40 p.m., she reported she worked the ,[DATE] shift and Resident #1 had a pressure alarm in his/her wheelchair and also in his/her bed. Staff F reported staff could find what alarm a resident used by looking on the pocket care plans. Resident #1's comprehensive care plan updated on [DATE] identified the resident at risk for falls due to an increase in confusion. The care plan goal instructed staff to protect the resident from injury and listed interventions for staff to follow. The care plan interventions directed staff to apply pressure pad to the resident's chair/recliner/Tabs clipped alarm. The pocket care dated [DATE] lacked the intervention of applying a pressure pad to the resident's chair/recliner/Tabs clipped alarm. On [DATE] at 2:20 p.m., the Director of Nursing stated the prior DON left the nursing home on [DATE] and she took over this week. The resident's pocket care plan did not match the full/comprehensive care plan. The DON stated management discovered on [DATE] that the pocket care plans were not being updated and the MDS nurse is now updating the pocket care plans. Resident #1's pocket care plan (interventions) dated [DATE] had been in effect at the time of Resident #1's fall.

Based on observation, record review, and family and staff interviews, the facility failed to accurately assess and provide interventions in order to prevent a resident at risk for pressure ulcers from developing pressure ulcers and then failed to promote healing for the pressure ulcer (Resident #2). The sample consisted of 2 residents and the facility reported a census of 36 residents. Findings include: 1. A Resident Admission Record document identified Resident #2 had a return admission to the facility from the hospital on [DATE]. The hospital Behavioral Health Discharge Summary dated 7/24/14 reflected the resident had been admitted on [DATE] and discharged on [DATE]. The discharge [DIAGNOSES REDACTED]. The resident weighed 150 pounds upon discharge. The facility scale identified the resident at 146 pounds. Prior to admission into the hospital, the resident weighed 166 pounds on 7/09/14. A Behavioral Health Discharge Summary dated 07/24/14 documented Resident #2 discharged back to the facility. Hospital personnel had conversations with Resident #2's family about the resident ' s physical decline related to the resident ' s refusal to take anything by mouth. A facility Skin Integrity Events form dated 7/24/14 identified the resident had skin redness due to incontinence. The interventions for the redness was identified as cleanse area with soap and water and apply a topical ointment. The form titled Braden Scale for Prediction of Pressure Sore Risk dated 7/24/14 identified the resident had a moderate risk for the development of a pressure ulcer. The interventions included only a turning and repositioning program. The Care Plan dated 7/19/14 identified a problem for pressure ulcer development although the resident ' s skin was intact. The interventions included and directed staff to conduct a systematic skin inspection and to pay particular attention to the bony prominences (any part of the skin where bone is directly under the skin). The Resident Progress Notes dated 07/26/14 at 3:02 p.m. documented Resident #2 had a weight change and would continue to monitor. Resident #2 had a MDS assessment with a reference date of 07/30/14. Resident #2 showed inattention (difficulty focusing attention), altered level of consciousness, and psychomotor [MEDICAL CONDITION] (unusually decreased level of activity). Resident #2 required extensive assistance with activities of daily living which included bed mobility, transfer, eating and personal hygiene. Resident #2 had occasional bowel and frequent bladder incontinence. The MDS documented Resident #2 weighed 146# and did not show a weight loss of 5% in one month or 10% in 6 months (Resident #2 did show 20# loss or 12% loss in less than 1 month). The MDS documented Resident #2 as not at risk for developing pressure ulcers (contradictory to assessment), and other skin problems present with noted moisture associated skin damage. The skin and ulcer treatments were application of ointments/medications only. The facility skin and ulcer treatments had not included pressure reducing devices, turning and repositioning, and nutrition or hydration interventions in order to prevent the development of pressure ulcers. The CAA (Care Area Assessments) dated 7/30/14 identified the resident ' s skin intact. Resident #2 had a MDS assessment with a reference date of 08/11/14. Resident #2 continued to require extensive assistance with activities of daily living, including bed mobility, transfer, eating and personal hygiene. Resident #2 had frequent bowel and bladder incontinence episodes. The MDS documented Resident #2 weighed 149#, which did not reflect a weight loss. The MDS identified Resident #2 as not at risk for developing pressure ulcers, and no other skin problems were present. None of the skin and ulcer treatments were provided which included pressure reducing devices, turning and repositioning, and nutrition or hydration interventions. A CAA dated 08/11/14 documented Resident #2 triggered for pressure ulcers due to a bed mobility self- performance problem, frequent urinary incontinence, and frequent bowel incontinence. Resident #2 had no extrinsic factors including moisture associated skin damage, and the [MEDICATION NAME] factors included immobility, cognitive loss and incontinence. The analysis of findings documented the skin currently intact and the facility would continue with the care plan. A Skin Issue report reflected on 08/07/14, Resident #2 continued with slight redness to the gluteal creases, and the facility continued the use of Calvida cream during cares to areas. The staff would continue to monitor. On 08/18/14, the areas continued with slight redness to the gluteal creases, and continued use of Calvida cream during cares to areas. The staff would continue to monitor. On 08/22/14 the gluteal creases had no redness noted and no open area, they would close the event. A Braden Scale for Prediction of Pressure Sore Risk dated 08/04/14 scored Resident #2 at 23. A score of 23 identified the resident at no risk of developing pressure ulcers. The assessment reflected Resident #2 ' s skin was rarely moist, walked frequently, had no limitations in mobility, had excellent food intake, and moved in the bed or chair independently (contradictory to the clinical record). The assessment documented Resident #2 received no skin interventions including pressure reduction devices, turning/repositioning, and nutrition/hydration. The staff would continue the current Care Plan. An Occupational Therapy Plan of Care dated 08/05/14 documented Resident #2 needed maximum assistance with positioning. A nutritional Progress Note dated 08/15/14 at 11:33 a.m. documented Resident #2 returned from hospital (07/24/14) and weighed 149#. They would go ahead and try a supplement 2.0, 2 ounces, 2 times a day. A facsimile (fax) dated 08/15/14 reflected the staff notified the physician that the dietician recommended Med Pass 2.0 shake daily (instead of 2 times a day), and questioned if they could have an order. The fax documented Resident #2 had a weight decrease from the 1st of the month of 17#. The physician documented and replied yes on the fax. A Skin Issue report dated 09/09/14 documented Resident #2 had openings of a sore. Resident #2 had pain at a 3 on a scale of 1-10. The measures and interventions were decreasing pressure on the buttocks and applying peri- cream around the site. Outcome of interventions used reflected no interventions used. Resident #2 had an open sore to his/her backside in between the buttocks. The surrounding area appeared red and dry. The area measured 1 cm by 1 cm. and the documentation reflected the staff needed to try and take the pressure off the bottom as much as possible. The Care Plan for a problem identified as Pressure Ulcer identified on 9/9/14, the facility planned an approach to apply an alternating air pressure pump mattress to the bed and off load as the resident will allow. A Wound Progress note dated 09/16/14 documented the Wound Nurse was consulted for evaluation and treatment of [REDACTED]. The current treatment was Calvida cream which was a barrier cream. Resident #2 was on an air mattress and had a gel cushion in the wheelchair. Resident got up for meals. Resident #2 lay in bed on his/her side, and incontinent of stool. The ulcer on the coccyx had central yellow necrotic tissue and pink edges. The ulcer was connected to 2 ulcers that were superficial, 1 on the left and 1 on the right, each measuring 1.5 by 1 cm. The total size of the 3 ulcers was 4 by 2 cm. Resident #2 had an unstageable ulcer on the coccyx and 2 superficial ulcers inferiorly close to the rectum, and felt they were more related to moisture from incontinence. They were to discontinue the current ointment and apply Criticaid Clear to the ulcers 4 times a day and as needed (prn) with pericare. The staff were to continue to reposition Resident #2 off his/her back in bed, and maximum time up (in chair) for meals 1-1/2 hours with a cushion (in seat). The dietician consult for wound healing and decreased appetite. A Wound Progress Note dated 09/23/14 documented the overall size of the ulcer to be 4.5 by 1.5 cm. The depth in the center measured 0.1 cm but expect that would be deeper once finished [MEDICATION NAME]. The plan directed staff to continue with the treatment and limit sitting to 1 hour for meals, and turn to sides in bed. A nutritional Progress Note dated 09/26/14 at 11:33 a.m. documented Resident #2 weighed 134#, continuing to decline since return. Supplement was ordered and despite this, weights and ability to return to a more normal range not occurring. The would await family decisions on how aggressive to be with nutrition. Skin integrity a concern as well. A wound Progress Note dated 09/29/14 documented the overall size of the ulcer 4.5 by 1.5 cm. The plan was to discontinue the Criticaid Clear and use [MEDICATION NAME] foam dressing to the ulcer, changing 2 times a week and prn. Continue to limit sitting to 1 hour for meals, turn to sides in bed, and continue all nutritional efforts. A Doctors Orders and Progress Notes dated 10/01/14 reflected Resident #2 had a 60 day follow up. Resident #2 had an open area to the buttocks/coccyx. Resident #2 had wound treatments in place and decreased efforts in nutrition. Resident #2 weighed 130#, The physician documented Resident #2 had a moderate size decubitus of the coccyx, and weight down from 148# on 08/14. Resident #2 needed nutritional supplement 2 times a day (as initially recommended by the dietician). A Wound Progress Note dated 10/07/14 documented an unstageable pressure ulcer on the coccyx decreased in size. The ulcer measured 3.2 by 1.4 cm with a depth of 0.2 cm in the center (decrease in size). The plan directed staff to continue the treatment plan. The Wound Nurse was informed Resident #2 went on hospice and would follow up as needed per request of hospice. A nutritional Progress Note dated 10/10/14 at 11:33 a.m. documented Resident #2 had supplement ordered daily and now increased to 2 times a day. The MDS assessment with a reference date of 10/9/14 identified the resident had not experienced a weight loss of 5 percent in 1 month or 10% in 6 months. Resident #2 had a Stage 3 pressure ulcer. A Stage 3 pressure ulcer is described as full thickness tissue loss, where subcutaneous fat may be visible but bone, tendon or muscle not exposed. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) may be present without obscuring the depth of tissue loss. The MDS identified the wound as measuring 3.0 by 1.5 cm (centimeters) with slough present. The facility used skin and ulcer pressure reducing devices for the chair and bed. A hospice note dated 10/10/14 documented may admit Resident #2 to hospice under routine level of care. Hospice to continue with wound care. On 11/03/14 at 1:14 p.m. the coccyx open area had a yellow base, tissue white in color around the edge of the ulcer, and surrounding skin red. Noted a small amount of tan drainage on the dressing. The area measured 2.6 by 1.5 by 0.2 cm. (increase in size). During an observation on 11/10/14 at 1:04 p.m. Resident #2 sat in bed with the head of the bed elevated greater than 45 degrees. At 4:05 p.m. Resident #2 remained in bed with the head of the bed elevated. At 4:45 p.m. staff got Resident #2 out of the bed. Elevation of the head of the bed at 45 degrees places pressure on to the coccyx region of the body. On 11/12/14 at 8:44 a.m. Staff E and Staff H Certified Nursing Assistants (CNA's) provided morning cares. Resident #2 did not have a dressing to the open area to the crease of his/her buttocks. The area appeared with depth and surrounding redness. Staff wiped the buttock area and placed an incontinent pad. Resident #2 stated he/she had blisters on his/her butt. Staff dressed Resident #2, transferred to the w/c with an air cushion (without a dressing to the open sore). Staff H stated Resident #2 was incontinent of urine and there was no dressing in the pad or the bed. At 9:10 a.m. staff wheeled Resident #2 in the wheelchair to the dining room. During an observation on 11/12/14 at 9:16 a.m. staff assisted Resident #2 with breakfast. At 9:23 a.m. Resident #2 stated his/her butt hurt so bad. Staff continued to feed Resident #2. At 9:48 a.m. Resident #2 finished his/her meal and staff removed him/her from the dining room. At 9:51 a.m. Staff C CNA and the MDS Coordinator assisted Resident #2 to bed and positioned the resident on his/her right side with a pillow to the resident ' s back. On 11/12/14 at 10:12 a.m. Staff I Registered Nurse (RN) and Staff D Licensed Practical Nurse (LPN) stated they were not aware Resident #2 did not have a dressing (to his/her pressure sore). During an observation on 11/12/14 at 10:36 a.m. Staff I and Staff D went to do the dressing. The area to Resident #2's coccyx measured 3 by 1.5 cm with 0.5 cm depth. The redness around the pressure sore extended to 8 by 4 cm. Staff D stated she used a soft wipe (to clean) and did not get in the wound. She applied a [MEDICATION NAME] dressing to the ulcer. During an interview on 11/12/14 at 11:37 a.m. the hospice nurse stated the dressing should be changed 2 times a week and prn (as needed). She stated she left dressings, 4 by 4 (gauze sponges) and wound cleanser on 11/10/14. She stated the wound needed cleansing with the wound cleanser. During an interview on 11/12/14 at 2:00 p.m. Staff D stated they did not have an order for [REDACTED]. She said hospice would come over and rewrite the order. During an interview on 11/13/14 at 6:55 a.m. Staff D stated normally the CNA's would report if a dressing came off, but they were all overwhelmed with the survey process the previous day. During an observation on 11/13/14 at 7:38 a.m. Resident #2 in bed with the head of the bed elevated 45 degrees, slid down in the bed with his/her feet up against the foot board. Resident #2 stated his/her bottom was sore. Resident #2 had a pillow under his/her left shoulder, but not (positioned) off of his/her buttocks. The surveyor reported to Staff D. Staff D called over the Walkie Talkie and using Resident #2's room number that he/she needed a position change and the head of the bed lowered. During a findings meeting with facility staff on 11/13/14 at 10:15 a.m. the Director of Nursing (DON) stated Resident #2 returned from the hospital chair bound and did not eat while at the hospital. She stated the weight loss should come up on the computer. Staff could not explain why the dietician did not assess for 3 weeks after Resident #2 returned from the hospital. Staff did not explain why the weight loss and risk of pressure ulcers were not identified on the MDS's after the resident returned from the hospital. The DON agreed it would be difficult to keep the resident off his/her bottom with the head of the bed elevated. During an interview on 11/12/14 at 1:35 p.m. Resident #2's family member stated Resident #2 was walking prior to going to the hospital. Resident #2 was chair bound when he/she went back to the facility and had a red butt. Now Resident #2 spends most of his/her time in bed because of pressure sores, and did complain of it being sore when visited. Based on observation, record review, and family and staff interviews, the facility failed to accurately assess and provide interventions in order to prevent a resident at risk for pressure ulcers from developing pressure ulcers and then failed to promote healing for the pressure ulcer (Resident #2). The sample consisted of 2 residents and the facility reported a census of 36 residents. Findings include: 1. A Resident Admission Record document identified Resident #2 had a return admission to the facility from the hospital on [DATE]. The hospital Behavioral Health Discharge Summary dated 7/24/14 reflected the resident had been admitted on [DATE] and discharged on [DATE]. The discharge [DIAGNOSES REDACTED]. The resident weighed 150 pounds upon discharge. The facility scale identified the resident at 146 pounds. Prior to admission into the hospital, the resident weighed 166 pounds on 7/09/14. A Behavioral Health Discharge Summary dated 07/24/14 documented Resident #2 discharged back to the facility. Hospital personnel had conversations with Resident #2's family about the resident ' s physical decline related to the resident ' s refusal to take anything by mouth. A facility Skin Integrity Events form dated 7/24/14 identified the resident had skin redness due to incontinence. The interventions for the redness was identified as cleanse area with soap and water and apply a topical ointment. The form titled Braden Scale for Prediction of Pressure Sore Risk dated 7/24/14 identified the resident had a moderate risk for the development of a pressure ulcer. The interventions included only a turning and repositioning program. The Care Plan dated 7/19/14 identified a problem for pressure ulcer development although the resident ' s skin was intact. The interventions included and directed staff to conduct a systematic skin inspection and to pay particular attention to the bony prominences (any part of the skin where bone is directly under the skin). The Resident Progress Notes dated 07/26/14 at 3:02 p.m. documented Resident #2 had a weight change and would continue to monitor. Resident #2 had a MDS assessment with a reference date of 07/30/14. Resident #2 showed inattention (difficulty focusing attention), altered level of consciousness, and psychomotor [MEDICAL CONDITION] (unusually decreased level of activity). Resident #2 required extensive assistance with activities of daily living which included bed mobility, transfer, eating and personal hygiene. Resident #2 had occasional bowel and frequent bladder incontinence. The MDS documented Resident #2 weighed 146# and did not show a weight loss of 5% in one month or 10% in 6 months (Resident #2 did show 20# loss or 12% loss in less than 1 month). The MDS documented Resident #2 as not at risk for developing pressure ulcers (contradictory to assessment), and other skin problems present with noted moisture associated skin damage. The skin and ulcer treatments were application of ointments/medications only. The facility skin and ulcer treatments had not included pressure reducing devices, turning and repositioning, and nutrition or hydration interventions in order to prevent the development of pressure ulcers. The CAA (Care Area Assessments) dated 7/30/14 identified the resident ' s skin intact. Resident #2 had a MDS assessment with a reference date of 08/11/14. Resident #2 continued to require extensive assistance with activities of daily living, including bed mobility, transfer, eating and personal hygiene. Resident #2 had frequent bowel and bladder incontinence episodes. The MDS documented Resident #2 weighed 149#, which did not reflect a weight loss. The MDS identified Resident #2 as not at risk for developing pressure ulcers, and no other skin problems were present. None of the skin and ulcer treatments were provided which included pressure reducing devices, turning and repositioning, and nutrition or hydration interventions. A CAA dated 08/11/14 documented Resident #2 triggered for pressure ulcers due to a bed mobility self- performance problem, frequent urinary incontinence, and frequent bowel incontinence. Resident #2 had no extrinsic factors including moisture associated skin damage, and the [MEDICATION NAME] factors included immobility, cognitive loss and incontinence. The analysis of findings documented the skin currently intact and the facility would continue with the care plan. A Skin Issue report reflected on 08/07/14, Resident #2 continued with slight redness to the gluteal creases, and the facility continued the use of Calvida cream during cares to areas. The staff would continue to monitor. On 08/18/14, the areas continued with slight redness to the gluteal creases, and continued use of Calvida cream during cares to areas. The staff would continue to monitor. On 08/22/14 the gluteal creases had no redness noted and no open area, they would close the event. A Braden Scale for Prediction of Pressure Sore Risk dated 08/04/14 scored Resident #2 at 23. A score of 23 identified the resident at no risk of developing pressure ulcers. The assessment reflected Resident #2 ' s skin was rarely moist, walked frequently, had no limitations in mobility, had excellent food intake, and moved in the bed or chair independently (contradictory to the clinical record). The assessment documented Resident #2 received no skin interventions including pressure reduction devices, turning/repositioning, and nutrition/hydration. The staff would continue the current Care Plan. An Occupational Therapy Plan of Care dated 08/05/14 documented Resident #2 needed maximum assistance with positioning. A nutritional Progress Note dated 08/15/14 at 11:33 a.m. documented Resident #2 returned from hospital (07/24/14) and weighed 149#. They would go ahead and try a supplement 2.0, 2 ounces, 2 times a day. A facsimile (fax) dated 08/15/14 reflected the staff notified the physician that the dietician recommended Med Pass 2.0 shake daily (instead of 2 times a day), and questioned if they could have an order. The fax documented Resident #2 had a weight decrease from the 1st of the month of 17#. The physician documented and replied yes on the fax. A Skin Issue report dated 09/09/14 documented Resident #2 had openings of a sore. Resident #2 had pain at a 3 on a scale of 1-10. The measures and interventions were decreasing pressure on the buttocks and applying peri- cream around the site. Outcome of interventions used reflected no interventions used. Resident #2 had an open sore to his/her backside in between the buttocks. The surrounding area appeared red and dry. The area measured 1 cm by 1 cm. and the documentation reflected the staff needed to try and take the pressure off the bottom as much as possible. The Care Plan for a problem identified as Pressure Ulcer identified on 9/9/14, the facility planned an approach to apply an alternating air pressure pump mattress to the bed and off load as the resident will allow. A Wound Progress note dated 09/16/14 documented the Wound Nurse was consulted for evaluation and treatment of [REDACTED]. The current treatment was Calvida cream which was a barrier cream. Resident #2 was on an air mattress and had a gel cushion in the wheelchair. Resident got up for meals. Resident #2 lay in bed on his/her side, and incontinent of stool. The ulcer on the coccyx had central yellow necrotic tissue and pink edges. The ulcer was connected to 2 ulcers that were superficial, 1 on the left and 1 on the right, each measuring 1.5 by 1 cm. The total size of the 3 ulcers was 4 by 2 cm. Resident #2 had an unstageable ulcer on the coccyx and 2 superficial ulcers inferiorly close to the rectum, and felt they were more related to moisture from incontinence. They were to discontinue the current ointment and apply Criticaid Clear to the ulcers 4 times a day and as needed (prn) with pericare. The staff were to continue to reposition Resident #2 off his/her back in bed, and maximum time up (in chair) for meals 1-1/2 hours with a cushion (in seat). The dietician consult for wound healing and decreased appetite. A Wound Progress Note dated 09/23/14 documented the overall size of the ulcer to be 4.5 by 1.5 cm. The depth in the center measured 0.1 cm but expect that would be deeper once finished [MEDICATION NAME]. The plan directed staff to continue with the treatment and limit sitting to 1 hour for meals, and turn to sides in bed. A nutritional Progress Note dated 09/26/14 at 11:33 a.m. documented Resident #2 weighed 134#, continuing to decline since return. Supplement was ordered and despite this, weights and ability to return to a more normal range not occurring. The would await family decisions on how aggressive to be with nutrition. Skin integrity a concern as well. A Wound Progress Note dated 09/29/14 documented the overall size of the ulcer measured 4.5 by 1.5 cm. The plan was to discontinue the Criticaid Clear and use [MEDICATION NAME] foam dressing to the ulcer, changing 2 times a week and prn (as needed). Continue to limit sitting to 1 hour for meals, turn to sides in bed, and continue all nutritional efforts. A Doctors Orders and Progress Notes dated 10/01/14 reflected Resident #2 had a 60 day follow up. Resident #2 had an open area to the buttocks/coccyx. Resident #2 had wound treatments in place and decreased efforts in nutrition. Resident #2 weighed 130#, The physician documented Resident #2 had a moderate size decubitus of the coccyx, and weight down from 148# on 08/14. Resident #2 needed nutritional supplement 2 times a day (as initially recommended by the dietician). A Wound Progress Note dated 10/07/14 documented an unstageable pressure ulcer on the coccyx decreased in size. The ulcer measured 3.2 by 1.4 cm with a depth of 0.2 cm in the center (decrease in size). The plan directed staff to continue the treatment plan. The Wound Nurse was informed Resident #2 went on hospice and would follow up as needed per request of hospice. A nutritional Progress Note dated 10/10/14 at 11:33 a.m. documented Resident #2 had supplement ordered daily and now increased to 2 times a day. The MDS assessment with a reference date of 10/9/14 identified the resident had not experienced a weight loss of 5 percent in 1 month or 10% in 6 months. Resident #2 had a Stage 3 pressure ulcer. A Stage 3 pressure ulcer is described as full thickness tissue loss, where subcutaneous fat may be visible but bone, tendon or muscle not exposed. Slough (yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous) may be present without obscuring the depth of tissue loss. The MDS identified the wound as measuring 3.0 by 1.5 cm (centimeters) with slough present. The facility used skin and ulcer pressure reducing devices for the chair and bed. A hospice note dated 10/10/14 documented may admit Resident #2 to hospice under routine level of care. Hospice to continue with wound care. On 11/03/14 at 1:14 p.m. the coccyx open area had a yellow base, tissue white in color around the edge of the ulcer, and surrounding skin red. Noted a small amount of tan drainage on the dressing. The area measured 2.6 by 1.5 by 0.2 cm. (increase in size). During an observation on 11/10/14 at 1:04 p.m. Resident #2 sat in bed with the head of the bed elevated greater than 45 degrees. At 4:05 p.m. Resident #2 remained in bed with the head of the bed elevated. At 4:45 p.m. staff got Resident #2 out of the bed. Elevation of the head of the bed at 45 degrees places pressure on to the coccyx region of the body. On 11/12/14 at 8:44 a.m. Staff E and Staff H Certified Nursing Assistants (CNA's) provided morning cares. Resident #2 did not have a dressing to the open area to the crease of his/her buttocks. The area appeared with depth and surrounding redness. Staff wiped the buttock area and placed an incontinent pad. Resident #2 stated he/she had blisters on his/her butt. Staff dressed Resident #2, transferred to the w/c with an air cushion (without a dressing to the open sore). Staff H stated Resident #2 was incontinent of urine and there was no dressing in the pad or the bed. At 9:10 a.m. staff wheeled Resident #2 in the wheelchair to the dining room. During an observation on 11/12/14 at 9:16 a.m. staff assisted Resident #2 with breakfast. At 9:23 a.m. Resident #2 stated his/her butt hurt so bad. Staff continued to feed Resident #2. At 9:48 a.m. Resident #2 finished his/her meal and staff removed him/her from the dining room. At 9:51 a.m. Staff C CNA and the MDS Coordinator assisted Resident #2 to bed and positioned the resident on his/her right side with a pillow to the resident ' s back. On 11/12/14 at 10:12 a.m. Staff I Registered Nurse (RN) and Staff D Licensed Practical Nurse (LPN) stated they were not aware Resident #2 did not have a dressing (to his/her pressure sore). During an observation on 11/12/14 at 10:36 a.m. Staff I and Staff D went to do the dressing. The area to Resident #2's coccyx measured 3 by 1.5 cm with 0.5 cm depth. The redness around the pressure sore extended to 8 by 4 cm. Staff D stated she used a soft wipe (to clean) and did not get in the wound. She applied a [MEDICATION NAME] dressing to the ulcer. During an interview on 11/12/14 at 11:37 a.m. the hospice nurse stated the dressing should be changed 2 times a week and prn (as needed). She stated she left dressings, 4 by 4 (gauze sponges) and wound cleanser on 11/10/14. She stated the wound needed cleansing with the wound cleanser. During an interview on 11/12/14 at 2:00 p.m. Staff D stated they did not have an order for [REDACTED]. She said hospice would come over and rewrite the order. During an interview on 11/13/14 at 6:55 a.m. Staff D stated normally the CNA's would report if a dressing came off, but they were all overwhelmed with the survey process the previous day. During an observation on 11/13/14 at 7:38 a.m. Resident #2 in bed with the head of the bed elevated 45 degrees, slid down in the bed with his/her feet up against the foot board. Resident #2 stated his/her bottom was sore. Resident #2 had a pillow under his/her left shoulder, but not (positioned) off of his/her buttocks. The surveyor reported to Staff D. Staff D called over the Walkie Talkie and using Resident #2's room number that he/she needed a position change and the head of the bed lowered. During a findings meeting with facility staff on 11/13/14 at 10:15 a.m. the Director of Nursing (DON) stated Resident #2 returned from the hospital chair bound and did not eat while at the hospital. She stated the weight loss should come up on the computer. Staff could not explain why the dietician did not assess for 3 weeks after Resident #2 returned from the hospital. Staff did not explain why the weight loss and risk of pressure ulcers were not identified on the MDS's after the resident returned from the hospital. The DON agreed it would be difficult to keep the resident off his/her bottom with the head of the bed elevated. During an interview on 11/12/14 at 1:35 p.m. Resident #2's family member stated Resident #2 was walking prior to going to the hospital. Resident #2 was chair bound when he/she returned to the facility and had a red butt. Now Resident #2 spends most of his/her time in bed because of pressure sores, and did complain of it being sore when visited.