Every finding on record at Accura Healthcare of Carroll

Based on observation, staff interviews, and policy review the facility failed to provide appropriate incontinence care for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 52 residents. Findings include:The Minimum Data Set (MDS) assessment for Resident #3, dated 4/29/26, included diagnoses of diabetes and morbid obesity. The MDS identified the resident was dependent on staff for toilet hygiene and was frequently incontinent of urine and occasionally of bowel. The MDS indicated the resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment for decision making.Observation on 6/4/26 at 9:10 AM, with the Director of Nursing (DON) in attendance, Staff A, Certified Nurse Aide (CNA) and Staff B, CNA applied gloves and gowns. With Resident #3 lying in bed, Staff A cleansed the front peri area wiping more than once with the same wipe. Staff A and Staff B turned the resident to her left side and removed a visibly wet attends. Staff A, with 3 wipes together, repeatedly wiped up and down on both inner buttocks using the same side of the gathered wipes and then got a new wipe and wiped between the resident's buttocks 3 times with the same wipe, failing to cleanse the resident's outer buttocks and hips. Staff A, with the same gloves on, placed the lift sling under the resident. Staff A and Staff B removed gloves and applied new gloves, failing to complete hand hygiene when changing gloves. Staff A and Staff B placed leg wraps on the resident and Staff A proceeded to remove her gown and gloves, no hand hygiene, exited the resident's room and went down the hall and returned with a full body mechanical lift. Staff A applied a new gown and gloves and with Staff B, transferred the resident from the bed to a commode. Facility Competency for Peri Care form, updated 5/11/21, revealed when cleansing the peri area to use a new wipe for each area and one swipe technique, remove gloves before turning resident to their side, wash anal area, buttocks and both hips, and remove gloves, wash hands, and roll resident to side. Facility Hand Hygiene Policy, updated 11/13/24, revealed staff should always complete hand hygiene before donning gloves and after removing gloves, and between resident care sites. Interview on 6/4/26 at 9:35AM, the DON acknowledged staff did not complete any hand hygiene during care and would expect to complete hand hygiene every time the gloves are changed and before exiting the room. The DON further stated the facility policy is 1 swipe with each wipe and acknowledged she observed the staff wipe multiple times with the same wipe and the stated staff failed to do complete peri care by failing to cleanse all of the peri area, buttocks and hips.

Based on clinical record review, facility document review, facility state self- report intake review, staff interviews, and policy review the facility failed to report to the state agency within the required time frame of 2 hours for an allegation of abuse for 1 of 2 residents reviewed. (Resident #2) The facility reported a census of 52 residents. Findings include:The Minimum Data Set (MDS) for Resident #2 dated 5/4/26 documented diagnoses of intellectual disability, stroke and hemiplegia (paralysis of one side of the body) and was dependent on staff for all activities of daily living. The MDS documented a Brief Interview of Mental Status was unable to be performed due to resident rarely/never understood. State agency Intake Information form, tracking ID 3002328-I/Intake #143823, receipt date and time of 5/4/26 at 8:43 AM, revealed the following information: reporting type of allegation of abuse, occurred on 5/2/26 at 5 AM, reported to the Assistant Director of Nursing (ADON) on 5/4/26 at 6:30 AM that Staff C, Certified Nurse Aide (CNA) walked into Resident #2's room due to hearing her cry from the hallway and when Staff C entered the room, Staff D, CNA had Resident #2 naked on the bed facing the wall rolled over almost on her stomach. Staff D left the room to take the trash out. Staff D left Resident #2 in bed on stomach while she left the room. Resident #2 is not able to roll herself back over. When staff have resident up in the chair Staff D started to brush resident's hair, resident had braids in her hair still. Staff C stated to Staff D that there are braids in but Staff D kept brushing resident's hair and it was causing the hair to be pulled out and resident to vocalize pain. Staff C stopped Staff D from brushing resident's hair and took braid out and then Staff D started to brush resident's hair again and it started to pull the resident's hair out again. Staff C brought the resident out to the common area and helped her to calm down during this time. Staff C observed Staff D mocking the resident while she was crying.Facility Incident Report for Alleged Abuse for Resident #2, dated 5/2/26 at 5 AM, prepared by the ADON, documented the following: Notified 5/4/26 at 6:30 AM of incident that occurred on AM of Saturday 5/2/26 at approximately 5 AM, while getting resident up following last rounds. CNA reported that 200 floor CNA had been in resident's room to check/change and get ready for the day. CNA reports that she answered another resident's light and that resident was stating she was awoken from sleep due to Resident #2 screaming and crying at this time. CNA also reported floor CNA was in Resident #2's room with her rolled to the side, almost on abdomen naked. The resident is unable to turn herself, left her like this to go to the dresser and out in hallway to dispose of trash, put laundry in hall, and see what call lights are on. Upon transferring Resident #2 to wheelchair, floor CNA was aggressively brushing resident's hair with braid in hair from previous day. CNA reports she can hear Resident #2's hair snapping from brushing and resident was verbalizing pain, stating ouch, that hurts. No injuries observed at time of incident. Interview on 6/3/26 at 2:55 PM, Staff C stated on 5/2/26 about 5:15 - 5:30 AM, she reported to Staff E, Licensed Practical Nurse (LPN) that she didn't like what she just saw as Staff D was mean to Resident #2. Staff C stated she reported to Staff E at about 5 AM she could hear Resident #2 crying, she entered the resident's room, and Staff D was over by the dresser with the resident on her side in bed, naked head to toe. Staff C stated Staff D stood at the door and told Staff C she could get the resident done. Staff C stated she then proceeded to answer call lights, and then observed Staff D standing in the hallway and asked Staff D if she was ready to get Resident #2 up. Staff C stated after she and Staff D transferred the resident to her wheelchair, Staff D started brushing the resident's hair, Staff C told Staff D to stop as the resident still had a braid in her hair and Staff D stopped while Staff C took the braid out. Staff C stated Staff D then started brushing the resident's hair again from the top of the resident's head and Staff C told Staff D needed to brush from the bottom because that is the way Staff C always does it. Staff C stated she could hear the resident's hair snapping and breaking, the resident was saying ow and God damn it girl that hurts. Staff C stated the resident was crying and said that girl was mean to me. Staff C stated Staff D said the resident couldn't have candy that morning because she was crying. Staff C stated she told Staff E that she knew they only had 2 hours to report the abuse and asked Staff E if Staff C needed to write up her statement now. Staff C stated Staff E directed her to write up the statement that evening, when she came back to work at 6 PM. Staff C stated she did not write her statement regarding the incident until 5/4/26 after she got off at 6 AM. Staff C stated on 5/4/26 around 6 AM she sent a text message to the ADON asking if Staff E had reported anything to her about the incident on 5/2/26 with Resident #2 and the ADON returned a text that stated she hadn't been notified of the incident by Staff E. Staff C stated the ADON then called her and Staff F, Interim Director of Nursing (DON) and Staff C reported the incident to both of them.Facility document provided of Staff E 's interview on 5/4/26 revealed the following: Staff E states Staff C voiced concerns Saturday morning (5/2/26) that Staff D was antagonizing Resident #2, that she was picking on her to get a response, brushing the resident's hair without taking the braids out. Staff E stated she did nothing with the information. Staff E stated it did not click in her head that it was abuse. Staff E stated that Staff C told her that when Staff D was brushing the resident's hair out she was pulling it. Staff E stated that after the conversation, she checked the resident's head for marks and ensured it was ok. When asked why Staff E was worried enough to check her hair but not report the situation, she didn't know. Staff E stated she knows that it should have been reported.Interview on 6/8/26 at 10:48 AM, the ADON stated on 5/4/26 at 5:42 AM she received a text message from Staff C asking what time she was coming in to work. The ADON stated Staff C continued to text her reporting that Staff D was being verbally, emotionally and physically abusive to Resident #2. The ADON further stated Staff C told her she reported the incident to Staff E right away on 5/2/26 after the incident happened. The ADON stated she then notified Staff F, doing a 3-way phone call including Staff C. Interview on 6/8/26 at 11:51 AM, the Executive Director (ED) stated she was notified on 5/4/26 at approximately 8 AM of the alleged incident on 5/2/26 with Resident #2 and Staff D. The ED stated she reported the incident to the facility's regional office and completed the self-reported incident to the state office on 5/4/26 at 8:43 AM. Facility Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy, updated 10/19/22, revealed all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative and all allegations of resident abuse shall be reported to the state department not later than 2 hours after the allegation is made.Interview on 6/2/26 at 11:56 AM, the ED stated her expectation for allegations of abuse to be reported to management right away and then to be reported to the state office within 2 hours. The ED acknowledged the reported allegation of abuse for Resident #2 was not reported timely.

Based on document review, staff interviews, and facility policy review the facility failed to demonstrate good faith attempts to correct quality deficiencies based on issues that were identified with repeat deficiencies during the current survey process in 1 area and corrections that remained incomplete in a reasonable time frame. The facility reported a census of 48 residents.Findings include:Review of Federal Centers for Medicaid and Medicare Services (CMS) form 2567 for the survey results with correction dates of 10/16/25, and 1/31/26 indicated that the facility had received deficiency F725 related to insufficient nursing staff.Interview on 4/02/26 at 11:13 AM with the Administrator and Staff B Registered Nurse (RN) revealed the facility is currently working on call light audits. The Administrator further revealed that the facility has been providing education to staff on answering call lights in a timely manner while management is completing the call light audits. The Administrator further revealed call lights have gotten a little better, but they are still a concern. Review of a facility provided policy titled, Quality Assurance and Performance Improvement Plan (QAPI) with an updated date of 5/23/23 revealed:a. The QAPI committee analyzes the performance to identify, and follow up on areas of opportunity.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October1 - December 31) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 48 residents.Findings include:Review of the PBJ Staffing Data Report with a run date of 3/25/26 revealed the facility triggered for excessively low weekend staffing. Further review of the document revealed that the submitted weekend staffing data was excessively low. Review of facility provided daily staffing assignment sheets for the months of October 2026 through December 2026 revealed there was sufficient staffing throughout the morning shift through the nights shift with several nurses and certified nursing assistants working these shifts.Interview on 3/31/26 at 11:58 AM with Staff B Registered Nurse (RN) revealed that the excessively low weekend staffing was due to a failed audit for the quarter 4 2025 period while we were using an outside company PBJ module. Staff B then revealed that this outside company had double-counted hours for a number of employees, resulting in over-reporting that quarter. Staff B then revealed that this was corrected now, and would expect this to be correct going forward. Interview on 3/31/26 at 12:37 PM with the Director of Nursing (DON) revealed the facility has no policy on correctly submitting the PBJ, and the facility just follows the regulations.

Based on clinical record review, facility investigative file review, observation, staff interviews, and facility policy review the facility failed to document on the Controlled Drug Use Record and the electronic Medication Administration Record (MAR) when lorazepam (Ativan) medication were administered for 3 of 3 resident reviewed for controlled substance use (Resident #22, #23 and #47). The facility also failed to consistently and accurately reconcile controlled medications and remove expired medications/treatments from the medication room. The facility reported a census of 48 residents. Findings include: The facility self reported to the State Agency on 3/3/26 at 8:54 AM they revealed a total of 33 ml (milliliters) of liquid Ativan (antianxiety medication/controlled substance) was missing between three residents (Resident #22, #23 and #47). On 2/28/26 at approximately 6:00 AM, Staff G, Registered Nurse (RN) and Staff H, Licensed Practical Nurse (LPN) noted an Ativan discrepancy with Resident #22, #23, and #47. Staff H noticed that the bottles were sticky to touch and Staff G said it looked like the bottles had been leaking. On 2/28/26 at approximately 10:19 AM, Staff I, Certified Medication Aide (CMA) notified the Assistant Director of Nursing (ADON) of the Ativan discrepancy. The Director of Nursing (DON) requested Staff I and Staff E, LPN complete a narcotic count. On 2/28/26 at approximately 1:00 PM, it was determined Resident #22 Ativan count was off by 20.75 ml, Resident #23 Ativan count was off by 8 ml and Resident #47 count was off by 5 ml. Staff I, CMA said that the boxes the Ativan bottle were stored in looked like they were wet at one point as if the bottles possibly leaked. It was determined that Resident #23's Ativan box was wet and had leaked through. On 3/2/26 Staff J, LPN had confirmed Resident #22 and Resident #47 Ativan bottles had been previously leaking. Staff J stated that he had noted on 2/23/26 that Resident #22 Ativan bottle had been leaking and Resident #47's Ativan bottle was sticky, but had failed to notify management of this. After receiving witness statements from all nurses and CMAs, all staff indicated they had not been routinely counting refrigerated narcotics. 1. The Minimum Data Set (MDS) for Resident #22 dated 02/11/26 assessment identified a Brief Interview for Mental Status (BIMS) score was a 10, indicating moderately impaired cognition. Resident #22's MDS included diagnoses of non-Alzheimer's dementia, anxiety disorder, bipolar disorder and schizophrenia. The MDS documented Resident #22 received antianxiety medication during the last 7 days. The Care Plan with a target date of 5/17/26 revealed Resident #22 used antianxiety medication related to anxiety. The care plan directed staff to give medications as ordered. The February 2026 Medication Administration Record (MAR) directed to give Lorazepam (Ativan) intensol Oral Concentrate 2mg (milligrams)/ml, 0.25 ml every two hours as needed (PRN) for anxiety, restlessness, and short of breath. The Controlled Drug Use Record January 2026 to March 2026 revealed:a. One- 30 ml bottle of Ativan was received on 12/27/25.b. Ativan was signed out on the Controlled Medication Record but not recorded on the MAR on the following dates: 1/2, 1/9, 1/16, 1/20, 1/23, 1/26, 2/3 , 2/6, 2/7, 2/10, 2/13 (13 times)c. Ativan was documented on MAR as given but not signed out on the Controlled Drug Use Record on the following dates: 1/1, 1/2, 1/9, 1/20, 1/23, 2/7, 2/10 (9 times)2. The MDS for Resident #23 dated 01/22/26 assessment identified a BIMS score was a 04, indicating severe cognitive impairment. Resident #23's MDS included chronic respiratory failure with hypoxia and shortness of breath. The MDS documented Resident #23 did not receive antianxiety medication during the last 7 days.The Care Plan with a target date of 5/12/26 revealed Resident #23 used antianxiety medication related to restlessness and comfort. The care plan directed staff to give medications as ordered. The February 2026 MAR directed to give Lorazepam (Ativan) intensol Oral Concentrate 2mg/ml, 0.25 ml every two hours PRN for restlessness and comfort. The Controlled Drug Use Record January 2026 to March 2026 revealed:a. One- 30 ml bottle of Ativan was received on 1/23/26.b. Ativan was signed out on the Controlled Medication Record but not recorded on the MAR on the following dates: 2/1, 2/12, 2/16, 2/18, 2/20 (5 times)c. Ativan was documented on MAR as given but not signed out on the Controlled Drug Use Record on the following dates: 2/1, 2/3, 2/17, 2/18, 2/24 (5 times)3. The MDS for Resident #47 dated 01/14/26 assessment identified a BIMS score as 13, indicating intact cognition. Resident #47's MDS included non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia. The MDS documented Resident #47 received antianxiety medication during the last 7 days.The Care Plan with a target date of 4/19/26 revealed Resident #47 used antianxiety medication related to diagnosis of paranoid schizophrenia. The care plan directed staff to give medications as ordered. The February 2026 MAR directed to give Lorazepam (Ativan) intensol Oral Concentrate 2mg/ml, 0.25 ml every two hours PRN for increased anxiety and restlessness. The Controlled Drug Use Record December 2025 to March 2026 revealed:a. One- 30 ml bottle of Ativan was received on 12/10/25.b. Ativan was signed out on the Controlled Medication Record but not recorded on the MAR on the following dates: 12/28, 12/29, 12/31, 1/5, 1/6, 1/7, 1/9, 1/10, 1/15, 1/20, 1/26, 2/8, 2/11, 2/12, 2/16, 2/18, 2/22, 2/25 (19 times)c. Ativan was documented on MAR as given but not signed out on the Controlled Drug Use Record on the following dates: 12/11, 12/12, 12/21, 12/23, 12/31, 1/5, 2/4, 2/7, 2/18 (13 times)A facility form titled Monthly Narcotic Count Record labeled Hall 100 documented staff who signed the form, acknowledge transfer of responsibility for the narcotic count and have found that the quantity of each medication counted to be in agreement with the quantity stated on the Individual Narcotic Count Record. The record required documentation of the Nurse on signature and the Nurse off signature for each shift. Review of the count record for Hall 100 revealed the lack of staff signatures, indicating reconciliation of controlled medications for Hall 100 did not occur on the following months, dates and shifts:December 2025:12/3- 2-10 shift on and off12/5- 2-10 shift on and off12/6- 6-2 shift on and off12/7-- 6-2 shift on and off, 2/10 shift on and off12/10- 2-10 shift on and off12/12- 6-2 shift off12/13- 2-10 shift on and off12/15- 2-10 on and off12/16- 6-2 on and off, 2-10 shift on and off12/17- 2-10 shift on and off12/20- 6-2 shift off, 2-10 on and off12/21- 6-2 shift off, 2-10 shift on and off12/26- 2-10 shift on12/27- 6-2 shift off, 2-10 shift on and off12/31- 2-10 shift on and offJanuary 2026:1/15- 2-10 shift on and off1/16- 2-10 shift off1/31- 6-2 shift off, 2-10 shift onReview of the February 2026 Monthly Narcotic Count Record for 100/400 Hall revealed staff signed off each shift that the narcotic count had been completed. A facility form titled Monthly Narcotic Count Record labeled Hall 200 documented staff who signed the form, acknowledge transfer of responsibility for the narcotic count and have found that the quantity of each medication counted to be in agreement with the quantity stated on the Individual Narcotic Count Record. The record required documentation of the Nurse on signature and the Nurse off signature for each shift. Review of the count record for Hall 200 revealed the lack of staff signatures, indicating reconciliation of controlled medications for Hall 200 did not occur on the following months, dates and shifts:December 2025:12/1- 6-2 shift on and off12/8- 6-2 shift on and off12/11- 2-10 shift on and off12/13- 6-2 shift on and off12/14- 6-2 shift on and off12/15- 6-2 shift on and off12/17- 2-10 shift off12/18- 2-10 shift off12/24- 6-2 shift off and 2-10 shift on12/27- 6-2 shift on and off12/28- 6-2 shift on and off12/29- 6-2 shift on and offJanuary 2026:1/10- 6-2 shift off, 2-10 shift on and off1/11- 6-2 shift on and off, 2-10 shift on and off1/26- 6-2 shift off1/28- 2-10 shift on and offFebruary 2026:2/19- 2-10 shift on and off2/28- 2-10 shift on and off, 10-6 shift [NAME] facility form titled Monthly Narcotic Count Record labeled Hall 300 documented staff who signed the form, acknowledge transfer of responsibility for the narcotic count and have found that the quantity of each medication counted to be in agreement with the quantity stated on the Individual Narcotic Count Record. The record required documentation of the Nurse on signature and the Nurse off signature for each shift. Review of the count record for Hall 300 revealed the lack of staff signatures, indicating reconciliation of controlled medications for Hall 300 did not occur on the following months, dates and shifts:December 2025:12/19- 6-2 shift off12/30- 6-2 shift on and offJanuary 2026:1/31/26- 10-6 shift onFebruary 2026:2/9- 6-2 shift on and off2/28- 6-2 shift on and offThe Written Statement dated 3/2/26 from Staff L, LPN documented last week Resident #23's box of Ativan was wet and the bottle had less than what it should have in it. Then when taking out Resident #47's Ativan the label on the bottle was sticky like the bottle had leaked. Staff L documented Staff D was present in the medication room with her. Staff L reported she got busy and forgot to say something. Staff L documented the last time she had counted the Ativan was last week. The Written Statement dated 3/2/26 from Staff M, CMA reported the last time Staff M counted the Ativan was on 2/22/26. She said the Ativan was left in the medication cart and was not in the refrigerator. She said she was unaware that the Ativan was supposed to be refrigerated. An undated Witness Statement from Staff A, CMA documented she could not remember that last she had counted the liquid narcotics. An undated Witness Statement from Staff N, CMA documented she could not remember the last time she had counted the Ativan in the refrigerator in the medication room. On 4/1/26 at 8:32 AM, the DON reported on 2/28/26 she received a call from Staff H, LPN, Staff E, LPN and Staff I, CMA reporting they had found missing liquid Ativan. The DON reported she suggested to the staff to recount all narcotics. She said the first narcotic discrepancy was noticed was on Resident #22. She said there was only 1 ml in Resident #22's Ativan bottle and the Narcotic Record showed 21 ml. She said the count was significantly off. She said the staff counted all the liquid Ativan medications and noted Resident #23's narcotic record to be off 8 ml and Resident #47's narcotic record to be off 5 ml. She said she thought the total of liquid Ativan missing was 33 ml. She said she did compare the Narcotic Administration Records to the Medication Administration records for all three residents and was not able to account for all the missing Ativan. She said she did notice that some of the nurses were giving the liquid Ativan but missing documentation either on the Narcotic Administration Record or the MAR. She said there were three different nurses that wrote in their statements about Ativan spillage. The DON reported she had provided education to the nurses and CMAs regarding narcotic count and reporting spillage to management. When asked about education for medication administration/documentation, she reported she probably should have provided education on that and she did not. The DON said she had made a mistake. She reported she was focused on the concern that multiple nurses' statements voiced they had not been counting the refrigerated narcotics but documenting on the form the narcotic count had been completed. The DON said she felt that everyone was too comfortable and did not document properly. The DON reported she expected staff to count narcotic medication each shift or when handing off the keys including the medication in the refrigerator, staff to document on the Narcotic Medication Administration Records and the MAR when controlled medications are given and staff to report any medication discrepancy or spillage to the management immediately. The DON said the liquid Ativan was kept in a lock box that looked like a brief case. She said the lock box does not stand up and the liquid Ativan lays on its side. She said the liquid Ativan comes in a dark glass bottle. She said she was not sure on the manufacturer's direction related to storage. She said she knows the liquid Ativan has to be kept in the refrigerator. She reported she had pictures of one of the Ativan bottle that showed the box had been wet. On 4/1/26 at 10:57 AM, Staff E, LPN reported the morning of 2/28/26 around 9-10 AM she was informed by Staff I, CMA that the liquid Ativan counts were off. She said she confronted Staff H, LPN who was on the 300 medication cart to see what had been done. Staff E reported she was on the 200 medication cart and did not have any residents on refrigerated controlled medications. Staff E said after lunch she talked to the DON and was instructed to count all the narcotic medications. She said Staff I and herself counted the narcotics and found the same discrepancies as that morning. She said she wrote down the resident names, discrepancies and provided the information to the DON. She said the facility was no longer doing liquid Ativan or morphine. She reported it was an expectation to complete narcotic count with the off-going nurse and sign the form. She said it was an expectation when a narcotic medication was given to document on the MAR and Narcotic Administration Record.On 4/1/26 at 11:16 AM, the ADON reported Staff I, CMA called her on 2/28/26 to report the liquid Ativan counts were off. She said Staff H, LPN had counted that morning with Staff G, RN but had not notified her the counts were off. She said she called the DON. She said the DON and the previous Administrator started an internal investigation and called the Police. She said when Staff I called her she also told her to call the DON and write statements. On 4/1/26 at 1:56 PM, Staff G, RN reported on the morning of 2/28/26 she counted narcotics with Staff H, LPN and then changed her mind and said she counted narcotics with Staff I, CMA. She said they identified missing liquid Ativan during the narcotic count. She said she did not recall who the residents were or how much liquid Ativan was missing. She said Staff I said she would report the missing medications to the DON so she went home. She said there have been so many times things have been wrong. She said the narcotics in the refrigerator were not counted routinely. She said she would ask the staff about counting liquid Ativan and they would say they have not given any so they weren't going to count it. She said when she came back to work she was told the problem had been corrected by removing all the liquid Ativan and morphine. She said when Staff I and herself did the narcotic count, she said she asked Staff I to check the bottles for wetness and Staff I said they looked dry. On 4/1/26 at 2:09 PM, Staff H, LPN reported Staff G, RN/overnight nurse pointed out when counting the narcotics that the liquid Ativan was off. She said one of the bottles of Ativan looked like it had leaked in the box. She said the bottle belonged to Resident #23. She said she did not recall any other liquid damage on the other boxes. She said she could not recall who the other residents were that were short on the Ativan. She said she thought there were a couple of residents down the 100/400 hall. She said the liquid Ativan was kept in a locked box in the refrigerator and the boxes were kept on their sides. She said the Ativan shortage was reported to the DON. She said the DON had her print off the administration record and compare it to the narcotic records. She said there wasn't much difference and did not account for all the Ativan that was missing. She said liquid narcotics are either more or less. She said there was not a solid method of measuring liquid narcotics. She said when administering narcotics it was an expectation to document in the Narcotic book and on the MAR. On 4/1/26 at 2:44 PM, Staff I, CMA reported she came in at 8 AM on 2/28/26 and did a narcotic count with Staff H, LPN. She said Staff H made the comment the Ativan counts were off and did not know what to do. She said Staff E, LPN and Staff H, LPN had not notified management so she reached out to the ADON. She said she was asked by the DON to do a recount of the narcotics. She said Staff E and herself counted the narcotics with the DON on the phone. She said Resident #22, #23 and #47 Ativan counts were off. She said she did not recall the amounts that were off but Resident #22's count was off quite a bit. She said they did look at the narcotic records and it appeared the medication was being signed off but the narcotic records were not compared to the MAR at that time. She said the last time she recalled counting the narcotic including the liquids Ativan was on 2/15 and the counts were correct. She said when she counted the narcotics on 2/28, Resident #22's Ativan box did not look like it had been wet. She said Resident #23 and #47 Ativan boxes had what looked like grease stains, like something had spilled on it. She said the bottles were not sticky and there was no wetness. She said the caps were on tight and the stopper was in place with the hole for the syringe. On 4/1/16 at 3:00 PM, Staff K, RN reported nobody counted the liquid Ativan. He said the last time he counted a bottle of liquid Ativan was for a dying patient at the beginning of February.On 4/1/26 at 9:21 PM, Staff J, LPN reported the liquid Ativan was stored in the refrigerator in the medication room in a locked box. He said the Ativan could not stand upright in the lock box and laid on its side. He said if the lids did not get put back on the bottles they would leak. He said there have been times the boxes have been saturated and he would have to put on gloves and wash the bottles off. He said the facility needed to get something so the bottles/boxes could stand up properly. He said he has told the DON, new ADON and asked the dayshift nurses to pass it on. He reported there had been several Ativan boxes wet and he would not know what bottle had been leaking. He said the boxes were soaked so much the card board would change color to a dark grey. He reported one time Resident #22's bottle of Ativan had the lid off and you could actually see the liquid on the box. He reported he works 6 PM to 6 AM and when he comes in at 6 PM he completes a narcotic count depending on what hall he is assigned. He said in the morning he would count with the day shift nurses coming on. He said sometimes the day shift nurses come in late so only pills are counted on the medication carts and that is it. He reported the liquid Ativan's do not get counted as much. He reported he thought the Ativan shortage was related to the spillage as the boxes have been soaked. He said it was an expectation when administering a control substance to document on the Narcotic Administration Record and on the MAR. On 4/2/26 at 8:45 AM, Staff D, LPN said she had not been counting the narcotic in the refrigerator since January. She said she did not think about the liquid medications since it was in the refrigerator. She said she could not recall which resident's box of Ativan appeared wet or who's count was off. She said she did not report that the count was off to anyone. She said Staff L, LPN was the nurse who was dealing with it. On 4/2/26 at 9:07 AM, an outside Pharmacist said having the liquid Ativan stored upright was most important. He said having the Ativan laying on its side would risk medication leaking out if the lid was not on tight. He said he recommended the Ativan to be upright in the box.On 4/1/26 at 11:45 AM, observation in the medication room revealed the following:1. 53 Tylenol Suppositories- all expired with a variety of dates with the oldest date October 2024 2. 24 boxes of Adhesive remover wipes expired on July 20253. Bottle of [NAME] Aspirin expired February 2026A facility policy titled Controlled Substance updated on 10/19/22 documented the purpose of the policy was the following:To complete a physical inventory of narcotics at each change of shift by two nurses to identify discrepancies and need for reconciliation and accountability.To assure controlled drugs are handled, stored, and disposed of properly.To assure proper record keeping for controlled drugs.The policy directed authorized staff going off duty and coming on duty must count and validate accuracy of narcotic supply for every resident at the change of shift. After the supply was counted and justified, each nurse must record the date and his/her signature verifying that the count was correct.The facility policy titled Medication Administration updated 12/3/25 directed staff to sign the MAR after medications are administered and if the medication was a controlled substance to sign the narcotic book.

Based on observations, cleaning schedule review, and staff and resident interviews, the facility failed to ensure residents had housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 4 residents reviewed (Resident #21, #11, #25 and #24). The facility reported a census of 48 residents.Findings include:The Resident Council notes dated 3/19/26 had none circled, indicating the rooms were not clean, and 1 resident citing a need to sweep under the bed.1.An Assessment Scoring report documented Resident #21 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment.On 3/30/26 at 11:11 a.m. Resident #21 stated sometimes they didn't make her bed. In subsequent interview on 3/31/26 at 2:49 p.m. Resident #21 stated the trash gets so full it won't hold anymore, and some ends up on the floor.2. An Assessment Scoring report documented Resident #11 scored 13 on the BIMS indicating no cognitive impairment.On 3/30/26 at 10:57 a.m. Resident #11 stated she is having trouble getting them to make the bed. She had to wipe things down it got so dusty. Observed dust on the window sill, and a pile of tissue under the bed on the floor. The floor under the resident's recliner black. On 3/31/26 at 2:50 p.m. continued dust on window sill and tissues on floor under the bed. On 4/2/26 at 10:43 a.m. no change with window sill or under bed. The resident's garbage can was over full and garbage on the floor around it.3. An Assessment Scoring report documented Resident #25 scored 9 on the BIMS indicating moderate cognitive impairment.On 3/30/26 at 11:15 a.m. Resident #25's headboard damaged and 1 side torn 1/2 way up from the bottom, and hanging free. The window sill in the room with a thick layer of dust. 4. An Assessment Scoring report documented Resident #24 scored 11 on the BIMS indicating moderate cognitive impairment. On 3/31/26 at 1:13 p.m. Resident #24's window sill had a thick layer of dust. Resident #24 stated he tried to keep the room clean, but he could not get to the window sill because the bed was up against it.On 4/2/26 at 8:25 a.m. Staff O Housekeeping worked in a Resident #25's room. She stated the beds were up against the wall with the window sills so they had to find a time when resident's were not in bed to do them. She acknowledged the broken headboard and unsure how long it had been that way. She didn't realize it was that bad. She said they cleaned the rooms every other day.The March Housekeeping Cleaning Schedule for 3/16/26-3/31/26 showed no checks for cleaning rooms 201 to 213. The schedule documented spot cleaning 3/20, 3/22, 3/25, 3/27, and 3/29/26. The schedule lacked documentation of deep cleaning. The schedule lacked documentation of cleaning rooms [ROOM NUMBERS] from 3/28-3/31/26. The schedule directed rooms would be deep cleaned weekly and as needed. Rooms would be spot cleaned daily.

Based on clinical record review, document review, resident interviews, and staff interviews, the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 6 residents reviewed (Resident #2, #45, #6, and #36). The facility reported a census of 48 residents.Findings include:1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. The MDS further indicated that Resident #2 was dependent on staff for toileting hygiene, personal hygiene, and transferring from chair/bed-to-chair transfers. Interview on 3/30/26 at 11:34 AM with Resident #2 revealed that call lights can take fifteen minutes or longer at times. Resident #2 revealed that she watches the clock, and can tell how long it takes. Review of a facility provided document titled, Location Event Report dated 3/16/26 to 3/31/26 revealed call light response times for Resident #2's room. This document reflected times of 25 minutes, 17 minutes, 26 minutes, and 18 minutes. 2. Review of Resident #45's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. The MDS further indicated that Resident #45 was dependent on staff for toileting hygiene, personal hygiene, and transferring from chair/bed-to-chair transfers. Interview on 3/30/26 at 10:31 AM with Resident #45 revealed that call lights can take a long time to answer at times. Resident #45 further revealed that he watches the clock on his phone. Resident #45 then revealed that he just feels as though there is not enough staff with all the demands of the residents. Review of a facility provided document titled, Location Event Report dated 3/16/26 to 3/31/26 revealed call light response times for Resident #45's room. This document reflected times of 23 minutes, 39 minutes, 18 minutes, 31 minutes, 20 minutes, 28 minutes, 26 minutes, 33 minutes, 22 minutes, 17 minutes, and 22 minutes. Review of facility provided documents titled, Resident Council with dates of 1/22/26, 2/19/26, and 3/19/26 indicated each month that residents had concerns of call lights not being answered in a timely fashion of 15 minutes or less. Interview on 3/31/26 at 10:52 AM with Staff A Certified Nursing Assistant (CNA) revealed that staffing has gotten way better, but it was never really low. Staff A then revealed that she thinks the 2-10pm staff struggle with call lights lasting longer than 15 minutes at times. Staff further revealed that she had heard some call lights taking 15 minutes or longer. Interview on 3/31/26 at 2:40 PM with the Director of Nursing (DON) revealed that she would expect call lights to be answered in 15 minutes or less. 3. The MDS for Resident #6 dated 2/10/26 assessment identified a BIMS score of 14, indicating intact cognition. The Clinical Census revealed Resident #6 resided in room [ROOM NUMBER]-A. On 3/30/26 at 11:08 AM, Resident #6 reported she has waited two hours for her call light to be answered. She said she turned the light on a little before 11:00 AM and the light was not answered until after 1:00 PM. She said she could not remember which day or what she wanted. She said it was over dinner time so that might explain the long call light. She said the call light response time depends on staffing and call ins. She said she watched the clock on the wall to time the call lights. A facility form titled Location Event Report for room [ROOM NUMBER]-A dated 3/16/26 to 3/31/26 revealed the following call light times: 3/16/26- 5:55 PM to 6:15 PM= 19 minutes 3/17/26-10:25 AM to 10:43 AM= 17 minutes 3/17/26- 11:54 AM to 12:13 PM= 19 minutes 3/17/26- 1:55 PM to 2:15 PM= 20 minutes 3/19/26- 3:58 PM to 4:21 PM= 23 minutes 3/20/26- 6:29 PM to 6:52 PM= 22 minutes 3/20/26- 6:53 PM to 7:13 PM=19 minutes 3/21/26- 5:39 PM to 6:02 PM= 23 minutes 3/23/26- 11:50 AM to 12:27 PM= 36 minutes 3/29/26- 7:17 AM to 7:56 AM= 39 minutes 3/31/26- 8:59 AM to 9:16 AM= 17 minutes 4. The MDS for Resident #36 dated 3/9/26 assessment identified a BIMS score of 12, indicating moderately impaired cognition. The Clinical Census revealed Resident #36 resided in room [ROOM NUMBER]-A Private. On 3/30/26 at 12:10 PM, Resident #36 reported call lights are usually 15 minutes or more. He said that he has had a call light on for over an hour. He said he times the call light with the clock on the wall. He said the long call light was in the afternoon after dinner time. He said he did not recall what he needed at the time. A facility form titled Location Event Report for room [ROOM NUMBER] A and B dated 3/16/26 to 3/31/26 revealed the following call light times: 3/18/26- 7:59 PM to 8:20 PM= 21 minutes 3/25/26- 7:45 PM to 8:13 PM= 27 minutes 3/25/26- 9:09 PM to 9:48 PM= 39 minutes Interview on 3/31/26 at 2:50 PM with Staff B Registered Nurse (RN) revealed that the facility does not have a policy regarding call light response times, but the facility does refer to the standards of care.

Based on record review, staff and resident interview, the facility failed to administer medications in a timely manner for 11 of 20 residents reviewed (Resident # 21, #29, #27, #6, #25, #10, #2, #12, #16, #18 and #9). The facility reported a census of 48 residents.Findings include:Resident Council notes dated 3/19/26 indicated pills and treatments were not given timely.1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #21 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included stroke, emphysema, and insomnia.On 3/30/26 at 11:09 a.m. Resident #21 stated a nurse didn't get her her meds until after 10 pm and she usually got them around 8 pm. That disrupted the schedule. She wants them earlier so she can get ready for bed. She said she was supposed to get them earlier, and this was not the 1st time this happened. A Medication Administration Audit dated 4/2/26 documented Resident #21 had the following medications scheduled at 8 p.m. on 3/27/26: Flonase Allergy Relief Nasal Suspension 50 mcg, 2 sprays both nostrils at bedtime, Magnesium Glycinate 100 mg, 4 capsules, Omeprazole delayed release 20 mg, and Melatonin 3 mg. The audit documented the medications were administered at 10:01 p.m. 2. A Medication Administration Audit dated 4/2/26 documented Resident #29 had Tylenol Extra Strength 500 mg 2 tablets scheduled on 3/27/26 at 8 p.m. and administered at 9:24 p.m.The Audit documented the resident had Ropinirole 0.5 mg scheduled for 2 p.m. The medication was administered on 3/29/26 at 5:02 p.m.3. A Medication Administration Audit dated 4/2/26 documented Resident #27 had the following medication scheduled at 8 p.m.: On 3/27/26 Lantus injection 6 units administered at 11:13 p.m. On 3/28/26 Omeprazole 20 mg and Zyprexa 2.5 mg scheduled for 5 a.m. administered at 8:17 a.m. On 3:29/26 Omeprazole 20 mg and Zyprexa scheduled at 5 a.m. administered at 8:16 a.m.4. A Medication Administration Audit dated 4/2/26 documented Resident #6 had Insulin Glargine 50 units scheduled at 8 p.m. and administered at 10:12 p.m.5. A Medication Administration Audit dated 4/2/26 documented Resident #25 had Novolog 8 units scheduled at 7 p.m. The audit showed the insulin administered at 11:13 p.m. On 3/29/26 Resident #25 had Insulin Glargine 36 units scheduled at 8 p.m. and administered at 11:13 p.m.6. A Medication Administration Audit dated 4/2/26 documented Resident #10 had Fluticasone 50 mcg 1 spray in each nostril scheduled for 5 a.m. administered at 8:30 a.m. on 3/27/26 and at 8:08 a.m. on 3/29/26.7. A Medication Administration Audit dated 4/2/26 documented Resident #2 had Pantoprazole 40 mg scheduled for 5 a.m. and administered at 9:01 a.m. on 3/27/26.8. A Medication Administration Audit dated 4/2/26 documented Resident #12 had Levothyroxine 100 mcg scheduled for 5 a.m. and administered at 9:08 a.m.9. A Medication Administration Audit dated 4/2/26 documented Resident #16 had Levothyroxine 25 mcg scheduled for 5 a.m. and administered at 8:06 a.m. on 3/27/26.10. A Medication Administration Audit dated 4/2/26 documented Resident #18 had Levothyroxine 75 mcg scheduled for 5 a.m. and administered at 8:16 a.m. on 3/27/26.11. A Medication Administration Audit dated 4/2/26 documented Resident #9 had Omeprazole 40 mg, Tylenol 650 mg, Levothyroxine 50 mcg, and topical Voltaren Gel 1% to right hip and low back, all scheduled for 5 a.m. and administered at 8:28 a.m. and 8:31 a.m. on 3/27/26.On 4/1/26 at 10:26 a.m. the Interim Director of Nursing stated medications could be given 1 hour before to 1 hour after their scheduled time. She stated she printed off the medications for this hall that were administered late. The facility Medication Administration Policy updated 12/3/25 documented medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the The policy included ensuring the six rights of medication administration were followed included the right time. Medications could be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered by physician.

Based on document review, staff interview, and policy review the facility failed to implement the abuse and neglect policy by not completing background checks prior to staff employment. The facility reported a census of 48 residents.Findings include:Review of Staff C Certified Nursing Assistant (CNA) personnel file revealed no single contact repository (SING) background check. Review of a facility provided document titled, Employee Roster with a date of 3/30/26 indicated that Staff C had a hire date of 2/3/25.Interview 3/31/26 at 12:52 PM with the Director of Nursing (DON) revealed that SING was most likely completed as a third party background check was completed prior to Staff C's hire date. The DON further revealed that the facility could not log into the SING system to obtain the background check as results could not be obtained after 30 days in the system. Follow up interview 4/1/26 at 9:13 AM with the DON confirmed that Staff C did not have a SING background check completed in her file. The DON then confirmed that another background check had been completed prior to Staff C's start date. The DON then revealed that her expectation would be for a SING background check to be completed prior to start dates of new employees. Review of a facility provided policy titled, Nursing Facility Abuse Prevention, Identification, Investigation and Reporting with an updated date of 10/19/22 indicated the facility will conduct an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees and other individuals engaged to provide services to residents, prior to hire.

Based on clinical record review, observation, resident interview, staff interviews, and policy review the facility failed to use universal infection control measures (hand hygiene) during care of two separate wounds for 1 of 5 residents reviewed for infection control (Residents #2). The facility reported a census of 48 residents. Findings include:Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. Further review of the MDS revealed Resident #2 had diagnoses of hypertension (high blood pressure), diabetes mellitus, stroke, and a stage 3 (full-thickness skin loss injury) pressure ulcer to the right buttocks. Interview on 3/30/26 at 11:37 AM with Resident #2 revealed that there were open areas to her buttocks. Resident #2 further revealed the areas to her buttocks are getting dressing changes. Review of Resident #2's Electronic Healthcare Record (EHR) page titled, Clinical Physician Orders revealed an order dated 3/7/26 indicating all wounds were to be cleansed with foaming cleanser, then to cleanse wounds with wound cleanser soaked gauze and let sit for 3-5 minutes. Further review of the physician orders revealed an order dated 3/24/26 indicating to apply a wound paste daily. Another order was entered 3/27/26 for vaseline impregnated gauze to wound following application of the wound paste. Observation on 4/1/26 at 10:19 AM Staff F Licensed Practical Nurse (LPN) completed hand hygiene, and then donned gowns and gloves. Staff F was then observed removing old dressings from Resident #2's left and right buttocks while wearing the same gloves. Staff F then doffed her gloves, and completed hand hygiene. Staff F then donned new gloves and placed wound cleanser soaked gauze onto the left and right buttocks wounds while wearing the same gloves. Staff F then doffed her gloves, and completed hand hygiene. Staff F donned new gloves, and after 4 minutes removed the soaked gauze while wearing the same gloves. Staff F doffed and donned new gloves with proper hand hygiene and completed the wound paste treatment and vaseline treatment to the open areas while donning and doffing gloves between the areas at the appropriate times. Interview on 4/1/26 at 10:46 AM with Staff F LPN revealed that she should have changed gloves between the areas when taking the old dressings off, and when completing new treatments to the separate areas. Interview on 4/1/26 at 10:49 AM with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) revealed that she would have expected the staff to change gloves in between wounds, and when completing care/treatments to different wounds. Interview on 4/1/26 at 10:53 AM with the Director of Nursing (DON) revealed that she would expect gloves to be changed when switching to different open areas on different parts of the body, as this would be a cross contamination concern. Review of a facility provided policy titled, Hand Hygiene with an updated date of 11/13/24 indicated staff should always complete proper hand hygiene between resident care sites.

Based on clinical record review, staff interviews, and Pharmacy interview, the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents reviewed (Resident #51). The facility reported a census of 48 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #51 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included fractures and other multiple trauma, a seizure disorder, a mood disorder, and mild cognitive impairment.The Care Plan initiated 12/11/25 identified Resident #51 at risk for adverse effects from the routine/as needed (PRN) use of anticonvulsants. The resident had a diagnosis of epilepsy. Interventions included observing for the effectiveness of medications, report significant side effects to the physician, and review medications as necessary. 1. The Medication Administration Record (MAR) for December showed the resident to receive Cenobamate 100 mg daily at breakfast related to seizures. The MAR documented the resident did not receive the medication 12/10-14/25, or 12/16-24/26. The MAR documented by check the resident had received the medication, however the medication was not available.The Progress Notes dated 12/10/25 at 9:43 a.m. documented Cenobamate Oral Tablet 100 mg not available, pending approval.The Progress Notes dated 12/11/25 at 7:25 a.m. documented Cenobamate not available, pending delivery. The Primary Care Provider (PCP) notified.The Progress Notes dated 12/12/25 at 7:33 a.m. documented Cenobamate not available, pending delivery. PCP notified.The Progress Notes dated 12/15/25 at 10:39 a.m. documented the Advanced Registered Nurse Practitioner (ARNP) in house reviewed admission paper work. No new orders obtained. The record lacked documentation they discussed not receiving the Cenobamate.The Progress Notes dated 12/16/25 at 7:31 a.m. documented Cenobamate med not available, pending delivery. PCP notified.The Progress Notes dated 12/18/25 at 7:56 a.m. documented Cenobamate not available.The Progress Notes dated 12/19/25 at 7:57 a.m. documented Cenobamate not available.The Progress Notes dated 12/21/25 at 07:12 a.m. documented Cenobamate not available, pending delivery. PCP notified.The clinical record lacked documentation the facility called the pharmacy to find out why the medication had not arrived.A hospital Progress Note dated 12/22/25 documented the resident seen at the nursing home for an acute concern. The resident had continued pain. Staff reported she continued to have behaviors and yell out. Staff reported the resident had not received an antiseizure medication since she had been at facility. Staff called pharmacy and reported they did not receive prescription from the hospital at time of discharge.A Psych Consult report dated 12/23/25 documented it was noted from the review of her medication that she did not receive one of her antiseizure medications from the previous 2 weeks. The pharmacist made a note in her medical record the information around her not receiving the medication and potential withdrawal symptoms which included increased anxiety, depressed mood, insomnia, increased seizure risk, and with case reports showing panic attacks and aggressive behaviors. The resident not receiving the cenobamate for 2 weeks may contribute to behavioral concerns as withdrawal symptoms may correlate with this or at least exacerbate symptoms. Would recommend getting back on the anticonvulsant medication that she had not recently been getting, pending the recommendations from the medical provider/neurologist that prescribed the medication.On 4/1/26 at 1:05 p.m. a representative of the Resident's pharmacy stated Xcopri (cenobamate) is a controlled drug and they have to have a script to dispense. She said they sent a script request to the hospital on [DATE]. They did not receive one. On 12/10/25 they sent a script request to the Nurse Practitioner and was returned denied. A second request sent to the Nurse Practitioner was also denied. They received information from the hospital on [DATE], and a script, so they could obtain and send the medication out.On 4/1/26 at 3:10 p.m. the Assistant Director of Nursing (ADON) looked through Resident #51's records and confirmed there was no documentation facility staff had called the pharmacy about the Cenobamate to find out why they had not received it. She confirmed the resident would have received the medication sooner if they had.On 4/2/26 at 10:22 a.m. a Pharmacist at the resident's pharmacy stated if Cenobamate was stopped abruptly, it could cause nervous system excitability, emotional instability, agitation, and an increased risk of seizures.2. The Medication List from the hospital dated 12/9/25 included Resident #51 should start taking Clobazam (for seizures)10 mg, 1.5 mg tablets (15 mg total) in the morning.The December 2025 MAR for Resident #51 documented the medication Clobazam 10 mg daily at breakfast with a start date of 10/10/25 at 7 a.m. The MAR documented Resident #51 received Clobazam 10 mg at breakfast on 12/10/25.A Pharmacist's Report to Nursing dated 12/10/25 informed them Resident #51 admitted on Clobazam 10 mg a.m. and 20 mg p.m. Hospital records indicated the resident should be on Clobazam 15 mg a.m. and 20 mg p.m.The December 2025 MAR documented Clobazam 10 mg, give 1.5 tablet by mouth one time a day with a start date of 12/11/25 at 7 a.m. 3. The Medication List from the hospital dated 12/9/25 included Resident #51 should start taking Lacosamide (for sezures) 50 mg 5 tabs at bedtime.The December 2025 MAR documented Lacosamide 50 mg 1 tablet by mouth at bedtime with a start date of 12/09/25 at 8 p.m. A Pharmacist's Report to Nursing dated 12/10/25 documented Resident #51 had an order for Lacosamide 200 mg a.m. and 50 mg HS, but hospital records indicated the dose should be Lacosamide 200 mg a.m. and 250 mg p.m.The December 2025 MAR documented Lacosamide Oral Tablet 50 mg, give 5 tablet by mouth one time a day with a start date of 12/10/25 at 8 p.m.On 4/1/26 at 3:10 p.m. the ADON confirmed medication errors occurred due to transcription errors the day the resident admitted to the facility. The Pharmacy Consultant caught the errors on 12/10/25. Resident #51 had received the wrong dose of 2 medications.

Based on observation, clinical record review, resident interviews, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 3 of 15 residents (Residents #2, #5, and #45) reviewed. The facility reported a census of 48 residents.Findings include:1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. Interview on 3/30/26 at 11:35 AM with Resident #2 revealed the food that comes on lunch trays is often cold, and not warm when it is delivered. 2. Review of Resident #5's MDS dated [DATE] revealed a BIMS score of 13 indicating intact cognitive functioning. Interview on 3/30/26 at 11:14 AM with Resident #5 revealed the food is often cold when it is delivered on room trays when it should be hot. 3. Review of Resident #45's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. Interview on 3/30/26 at 10:32 AM with Resident #45 revealed the food does not taste good, and sometimes the food is not up to temperature. During continuous observation on 4/1/26 from 11:30 AM until 11:44 AM room trays observed to be delivered to the East hallway on an open air cart with plates covered with lids. At 11:33 AM room trays were delivered to the North hallway and left in the same manner as the East hallway and both were left in the hallways. At 11:35 AM the staff were then observed passing the trays in the East hallway, with trays being passed in the North hallway at 11:38 AM. On 4/1/26 at 11:44 AM a test tray obtained and temperatures were obtained revealing the mashed potatoes having a temperature of 129.7 degrees and the mixed vegetables being 121 degrees. Interview on 4/1/26 at 11:51 AM with the Certified Dietary Manager (CDM) revealed that she would like to have food served at 135 degrees or warmer. The CDM then revealed that this would be her expectation. Review of a facility provided policy titled, Food Temperatures with a date of 2021 indicated that all hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 degrees.

Based on clinical record review, resident interview, staff interview, and facility policy review the facility failed to ensure a resident's preference for med time for 1 of 2 resident's reviewed (Resident #21). The facility reported a census of 48 residents.Findings include:According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #21 scored 14 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident's diagnoses included stroke, emphysema, and insomnia.On 3/30/26 at 11:09 a.m. Resident #21 stated a nurse didn't get her meds until after 10 pm Saturday night, and she usually gets them around 8, that disrupts the schedule. She wants them earlier so she can get ready for bed. She said she was supposed to get them earlier, and this was not the 1st time this happened.A Medication Administration Audit dated 4/2/26 documented Resident #21 had the following medications scheduled at 8 p.m.: Flonase Allergy Relief Nasal Suspension 50 mcg, 2 sprays both nostrils, Magnesium Glycinate 100 mg, 4 capsules, Omeprazole delayed release 20 mg, and Melatonin 3 mg. The medications were administered at 10:01 p.m. Resident Council notes dated 3/19/26 indicated pills and treatments were not given timely.On 4/1/26 at 10:26 a.m. the Interim Director of Nursing stated medications could be given 1 hour before to 1 hour after their scheduled time. She confirmed Resident #21's medications were not administered timely.The facility Medication Administration Policy updated 12/3/25 documented medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. The policy included ensuring the six rights of medication administration were followed including the right time. Medications could be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered by physician.

Based on clinical record review, staff interview and guidance from the 2025 Resident Assessment Instrument (RAI) manual, the facility failed to complete and transmit a Minimum Data Set (MDS) assessment within federal guideline for 2 of 2 resident reviewed for MDS assessments (Resident #4 and #17). The facility reported a census of 48 residents. Findings include: 1. Review of the census tab in the electronic health record (EHR) revealed Resident #4 was discharged on 1/7/26. The Progress Note on 1/7/26 indicated Resident #4 had been discharged to Assisted Living. The MDS section of the EHR revealed a discharge MDS had not been set up or completed. 2. Review of the census tab in the EHR revealed Resident #17 was discharged on 2/10/26. The Progress Note on 2/10/26 indicated Resident #17 had returned home. The MDS section of the EHR revealed a discharge MDS had not been set up or completed. On 3/30/26 at 3:48 PM, the Interim Director of Nursing (DON) acknowledged Resident #4 and Resident #17 discharge MDS was not completed. She said a discharge MDS was expected to be completed when a resident discharges from the facility according to the RAI manual. On 3/30/26 at 4:20 PM, the MDS Coordinator reported she had missed completing the discharge MDS for R#4 and R#17 as she was learning new job tasks. According to the 2025 RAI, a discharge assessment must be dated for the date of the resident's discharge from the facility and must be completed no later than 14 days following the discharge date .

Based on clinical record review, staff interviews, and pharmacist interview, the facility failed to intervene and call the pharmacy and follow up with a physician when medication was unavailable for 1 of 6 residents reviewed (Resident #51). The facility reported a census of 48 residents.Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #51 scored 10 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident's diagnoses included fractures and other multiple trauma, a seizure disorder, a mood disorder, and mild cognitive impairment. The Care Plan initiated 12/11/25 identified Resident #51 at risk for adverse effects from the routine/as needed (PRN) use of anticonvulsants. The resident had a diagnosis of epilepsy. Interventions included observing for the effectiveness of medications, reporting significant side effects to the physician, and reviewing medications as necessary. The Medication Administration Record (MAR) for December showed the Resident #51 to receive Cenobamate 100 mg daily at breakfast related to seizures. The MAR documented the resident did not receive the medication 12/10-12/14/25, or 12/16-12/24/25. The MAR documented by check the resident had received the medication on 12/15/25, however the medication was not available. The Progress Notes dated 12/10/25 at 9:43 a.m. documented Cenobamate Oral Tablet 100 mg not available, pending approval. The Progress Notes dated 12/11/25 at 7:25 a.m. documented Cenobamate not available, pending delivery. The Primary Care Provider (PCP) notified. The Progress Notes dated 12/12/25 at 7:33 a.m. documented Cenobamate not available, pending delivery. PCP notified. The Progress Notes dated 12/15/25 at 10:39 a.m. documented the Advanced Registered Nurse Practitioner (ARNP) in house reviewed admission paper work. No new orders obtained. The record lacked documentation they discussed not receiving the Cenobamate. The Progress Notes dated 12/16/25 at 7:31 a.m. documented Cenobamate not available, pending delivery. PCP notified. The Progress Notes dated 12/18/25 at 7:56 a.m. documented Cenobamate not available. The Progress Notes dated 12/19/25 at 7:57 a.m. documented Cenobamate not available. The Progress Notes dated 12/21/25 at 07:12 a.m. documented Cenobamate not available, pending delivery. PCP notified. The clinical record lacked documentation the facility called the pharmacy to find out why the medication had not arrived, identified the risks of not receiving the medication, or monitored the resident for possible negative effects of the resident not receiving the medication. A hospital Progress Note dated 12/22/25 documented the resident seen at the nursing home for an acute concern. The resident had continued pain. Staff reported she continued to have behaviors and yell out. Staff reported the resident had not received an antiseizure medication since she had been at the facility. Hospital staff called the pharmacy and they reported they did not receive a prescription from the hospital at the time of discharge. A Psych Consult report dated 12/23/25 documented it was noted from the review of Resident #51's medication, that she did not receive one of her antiseizure medications from the previous 2 weeks. The pharmacist made a note in her medical record the information around her not receiving the medication and potential withdrawal symptoms which included increased anxiety, depressed mood, insomnia, increased seizure risk, and with case reports showing panic attacks and aggressive behaviors. The resident not receiving the Cenobamate for 2 weeks may contribute to behavioral concerns as withdrawal symptoms may correlate with this or at least exacerbate symptoms. Would recommend getting back on the anticonvulsant medication that she had not recently been getting, pending the recommendations from the medical provider/neurologist that prescribed the medication. On 4/1/26 at 3:10 p.m. the Assistant Director of Nursing (ADON) looked through Resident #51's records and confirmed there was no documentation facility staff had called the pharmacy about the Cenobamate to find out why they had not received it. She confirmed the resident would have received the medication sooner if they had. On 4/2/26 at 10:22 a.m. a Pharmacist at the resident's pharmacy stated if Cenobamate was stopped abruptly, it could cause nervous system excitability, emotional instability, agitation, and an increased risk of seizures.

Based on observations, clinical record review and policy review the facility failed to give medications according to manufacturer's instructions for 2 out of 5 residents observed during medication pass (Resident #24 and #14). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #24 dated 2/11/26 identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS identified Resident #24 was independent with bed mobility and transfers. The MDS included diagnoses of non-alzheimer's dementia, seizure disorder and anxiety disorder. The April 2026 Medication Administration Record (MAR) directed staff to administer Fosamax (used to treat or prevent osteoporosis) 70 MG (milligrams) one tablet by mouth one time a week in the Early AM on Wednesday related to osteoporosis. The order lacked specific directions on how the medication should be administered. During observation with the morning medication pass on 4/1/26 with Resident #24 and review of April 2026 MAR revealed the following medications were given at the same time as the Fosamax:-Lisinopril 10 mg 1 tablet -Memantine Hydrochloride 5 mg 1 tablet -Multivitamin with minerals 1 tablet-Potassium Chloride ER 10 mEq 1 tablet-Thiamine 100 mg 1 tablet-Carbamazepine 200 mg 2 tablets-Clonazepam 0.5 mg 1/2 tablet-Levetriacetam 750 mg 1 tablet-Risperdone 0.25 mg 1 tablet -Buspirone HCL 10mg 1 tablet-Gabapentin 300 mg 1 capsuleOn 4/1/26 at 7:19 AM, observed Staff D, Licensed Practical Nurse (LPN) administer the Fosamax medication to Resident #24 with other medications during breakfast with a glass of apple juice. Resident #24 was sitting at the table eating breakfast. On 4/1/26 at 9:21 AM, Staff D, LPN reported Early on the MAR indicated to administer the medication prior to 7 AM. She said the night nurses do not administer any medications except for as needed (PRN) medications. She said when she worked at a previous facility and the Fosamax medications were delivered 30-60 minutes prior to breakfast with no other medications. The Fosamax medication manufacturer's instructions instructed patients to swallow the medication whole with 6 to 8 ounces plain water at least 30 minutes before the first food, drink or medication of the day and not to lie down for at least 30 minutes after taking the medication and until after food. The manufacturer's instructions documented calcium supplement, antacids, vitamins or other oral medications can interfere with the absorption of the Fosamax. 2. The MDS assessment for Resident #14 dated 3/18/26 identified a BIMS score of 06, indicating severe impaired cognition.The MDS identified Resident #14 required substantial/maximal assistance with bed mobility and sit to stand transfers. The MDS included diagnoses of hypothyroidism. The April 2026 MAR directed staff to administer Levothyroxine Sodium 125 mcg (micrograms) one tablet by mouth every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday at breakfast related to hypothyroidism. The order lacked specific directions on how the medication should be administered. During observation with the morning medication pass on 4/1/26 with Resident #14 and review of April 2026 MAR revealed the following medications were given at the same time as the Levothyroxine:-Tylenol 325 mg 2 tablets-Loratadine 10 mg 1 tablet-Multivitamin with mineral 1 tablet-Osyter Calcium 500 mg 1 tablet-Cholecalciferol 125 mcg 1 tabletOn 4/1/26 at 7:25 AM, observed Staff E, LPN administered Levothyroxine medication to Resident #14 with other medications during breakfast. Resident #14 was sitting at the table eating breakfast. On 4/1/26 at 8:20 AM, Staff E acknowledged she administered the Levothyroxine with other medications and with breakfast.On 4/1/26 at 9:05 AM, the Interim Director of Nursing (DON) reported it was an expectation for nursing to administrator Fosamax and the Levothyroxine medications on an empty stomach prior to breakfast. The Levothyroxine medication manufacturer's instructions instructed patients to take the medication at the same time before breakfast on an empty stomach with water. The facility policy titled Medication Administration updated 12/3/25 instructed staff to administer medications as ordered in accordance with manufacturer specifications.

Based on clinical record review, facility document review, staff interviews and resident interviews, the facility failed to answer call lights in a timely manner for 4 of 4 residents reviewed (Resident #3, #4, #5 and #6). The facility reported a census of 52 residents.Findings include:1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #3 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The MDS documented the resident was dependent on staff for toileting hygiene, showering, dressing, rolling left and right, transfers and mobility in the wheelchair. The resident's diagnoses included diabetes, a fracture (ankle), and chronic obstructive lung disease.On 12/22/25 at 3:11 p.m. Resident #3 stated she didn't keep time for call lights, but had to wait a long time on weekends to get the light answered. A review of Resident #3's call light logs for the previous 2 weekends revealed:On 12/14/25 at 8:31 a.m. a call light of 31 minutes.On 12/14/25 at 10:32 a.m. a call light of 22 minutes.On 12/14/25 at 11:27 a.m. a call light of 24 minutes.On 12/14/25 at 12:42 p.m. a call light of 23 minutes.On 12/20/25 at 9:24 a.m. a call light of 24 minutes.On 12/20/25 at 10:11 a.m. a call light of 30 minutes.On 12/20/25 at 12:31 p.m. a call light of 30 minutes.On 12/20/25 at 3:24 p.m. a call light of 24 minutes.On 12/21/25 at 9:44 a.m. a call light of 38 minutes.On 12/21/25 at 11:29 a.m. a call light of 29 minutes.On 12/21/25 at 1:24 p.m. a call light of 39 minutes.On 12/21/25 at 4:18 p.m. a call light of 27 minutes.On 12/21/25 at 5:44 p.m. a call light of 39 minutes.2) According to the MDS assessment dated 12/10//25, Resident #4 scored 15 on the BIMS indicating no cognitive impairment. The MDS documented the resident was dependent on staff for toileting hygiene. The resident's diagnoses included diabetes, a stroke, emphysema, anxiety and depression.On 12/23/25 at 8:43 a.m. Resident #4 stated call lights were bad on the weekends. It could take a long time to get help. She said she could do some things herself, but she needed help with others.A review of Resident #4's call light logs for the previous 2 weekends revealed: On 12/13/25 at 6:48 a.m. a call light time of 39 minutes.On 12/20/25 at 6:38 a.m. a call light time of 32 minutes.On 12/21/25 at 12:35 a.m. a call light time of 17 minutes.On 12/21/25 at 6:56 a.m. a call light time of 20 minutes.3) According to the MDS assessment dated [DATE], Resident #5 scored 9 on the BIMS indicating moderate cognitive impairment. The MDS documented the resident was dependent on staff for toileting hygiene, lower body dressing, personal hygiene, and bed to chair and chair to bed transfers. The resident's diagnoses included heart failure, diabetes, non-Alzheimer's dementia, and presence of an automatic cardiac defibrillator.On 12/23/25 at 8:55 a.m. Resident #5 stated it took too long to get help on weekends. They didn't answer the call light right away, then say they had to get help and it took longer.A review of Resident #5's call light logs for the previous 2 weekends revealed:On 12/20/25 at 8:53 a.m. a call light time of 37 minutes.On 12/20/25 at 12:28 p.m. a call light time of 39 minutes.On 12/20/25 at 7:32 p.m. a call light time of 26 minutes.4) According to the MDS assessment dated [DATE], Resident #6 scored 15 on the BIMS indicating no cognitive impairment. The MDS documented the resident was dependent on staff for toileting hygiene, and lower body dressing, and required substantial/maximal assist with rolling left to right, and bed to chair and chair to bed transfers. The resident's diagnoses included heart failure, diabetes, non-Alzheimer's dementia, and presence of an automatic cardiac defibrillator.On 12/23/25 at 9:10 a.m. Resident #6 stated call light response is slower on weekends. She said she waited 40 minutes this past weekend.A review of Resident #6's call light logs for the previous 2 weekends revealed:On 12/13/25 at 1:24 p.m. a call light time of 20 minutes.On 12/14/25 at 4:53 a.m. a call light time of 19 minutes.On 12/14/25 at 6:43 p.m. a call light time of 19 minutes.On 12/20/25 at 12 p.m. a call light time of 39 minutes.On 12/20/25 at 12:37 p.m. a call light time of 36 minutes.On 12/23/25 at 11:33 a.m. the Administrator indicated staff knew who/what call light was on when she pointed out monitors that showed the call lights on, as well as how long the light had been on.On 12/23/25 at 1:15 p.m. the Administrator stated they did not have a call light policy. They followed the state standard, and call lights were expected to be answered within 15 minutes.

Based on clinical record review, resident interview, staff interview, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner. The facility reported a census of 47 residents.Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia, and morbid obesity. Interview 10/14/25 at 10:30 AM with Resident #1 revealed that call lights take longer than 15 minutes often, especially on the evenings and weekends. 2. Review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. The MDS further revealed diagnoses of diabetes mellitus, hyperlipidemia, anxiety disorder, respiratory failure, post polio syndrome, and morbid obesity. Interview 10/14/25 at 2:05 PM with Resident #5 revealed call lights take over 15 minutes in the mornings, and the weekends often. 3. Review of Resident #4's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognition. The MDS further revealed diagnoses of hyperlipidemia, arthritis, hip fracture, osteoporosis, and need for assistance with personal care. Interview 10/14/25 at 1:49 PM with Resident #4 revealed call lights often take over 15 minutes, and it always feels like the facility is short staffed. 4. Review of Resident #5's MDS dated [DATE] revealed a BIMS score of 12 indicating moderate cognitive impairment. The MDS further revealed diagnosis of cirrhosis, diabetes mellitus, anxiety disorder, and bipolar disorder. Interview 10/14/25 at 1:55 PM with Resident #5 revealed that he feels that there is not enough staff on the pm shift or on the weekends, and call lights can take longer than 15 minutes at a time.Interview 10/15/25 at 8:20 AM with the Director of Nursing (DON) revealed that call lights are an issue, and the facility is working on getting them better. The DON provided the call light log with response times up to 39 minutes. The DON then revealed that her expectation is for call lights to be answered in 15 minutes or less.Review of a facility provided document titled, Building Escalation Hourly Summary Report, dated 10/9/25 through 10/15/25 revealed call light response times ranging from 16 minutes in length to 39 minutes on multiple occasions. Follow up interview 10/15/25 at 9:40 AM with the DON revealed that the facility does not have a call light policy, and that the facility just follows the standards of care.

Based on clinical record review, staff interview, and policy review the facility failed to revise and implement care plans for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 47 residents. Findings include: Review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS further revealed diagnoses of heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia, and morbid obesity.Review of Resident #1's Care Plan revealed that Resident #1 was at risk for falls related to weakness with an intervention for Resident #1 to have on the proper footwear prior to transfers initiated 1/29/23. The Care Plan further revealed Resident #1 had activities of daily living deficit related to weakness with an intervention for transfers with assistance with two staff with a walker and gait belt dated 1/11/23. Review of a facility provided document titled, Physical Therapy Discharge summary dated [DATE] revealed Resident #1 was discharged from physical therapy for meeting the goals of transferring from chair/bed-to-chair with supervision or touching assistance with contact guard assistance and four wheeled walker. Interview 10/14/25 at 10:30 AM with Resident #1 revealed that she has muscle jerks from time to time. Resident #1 revealed that she was sitting on the side of the bed, and her walker was in front of her and her wheelchair was to the side to be transferred too. Resident #1 revealed she stood up and became dizzy and the Certified Nursing Assistant (CNA) had her sit back down. Resident #1 revealed that she did have a gait belt on for the transfer, but asked the CNA to remove the gait belt as she was nauseous. Resident #1 then revealed that she had a jerking moment and fell onto the floor. Interview 10/15/25 with the Director of Nursing (DON) revealed that Resident #1's care plan was not correct with the transferring assistance as it was saying assist with two staff with a walker and gait belt when it should have been assisted with one staff with a gait belt and walker. The DON further revealed that her expectation would be for care plans to be updated appropriately. Interview 10/15/25 at 9:06 AM with Staff A CNA was the bath aide on the day of the incident with Resident #1. Staff A revealed that she was the bath aide that day and that Staff B CNA had put Resident #1's shoes on. Staff A revealed that Resident #1 was a transfer assist of one with a gait belt and walker. Staff A further revealed that Resident #1 preferred the gait belt to be worn high under her armpits as she was a larger resident. Staff A revealed that Resident #1 was sitting on the side of the bed with the gait belt on and a walker in front of her. Staff A then revealed when Resident #1 stood up she began to become shaky so Staff A then had Resident #1 sit back down. Staff A then revealed that she took the gait belt off to readjust the belt as Resident #1 stated she was nauseous and wanted the belt off for a moment. Staff A revealed that Resident #1 became anxious, and stood up and started to fall diagonally and forward. Staff A revealed that she reacted as fast as she could, and then grabbed Resident #1's gown, but could not hold Resident #1 up. Staff A revealed that Resident #1 fell to the floor on her stomach. Staff A then revealed that she radioed for help. Staff A revealed that a nurse came to the room and four staff members utilized a full body mechanical lift with a sling to transfer Resident #1 to a motorized wheelchair. Staff A revealed that Resident #1 was not complaining of any pain except for a little pain to a toe. Staff A revealed that Resident #1 did not complain of any pain in the ankle until later in the day. Interview 10/15/25 at 9:17 AM with Staff C CNA revealed that she was called to Resident #1's room for assistance after the incident. Staff C revealed that when she entered the room Resident #1 was laying on the floor on her stomach. Staff C revealed that there were a couple of nurses and CNAs already present in the room when she arrived. Staff C revealed that she obtained the full body mechanical lift and sling and helped reposition Resident #1 onto her back after the nurse completed an assessment. Staff C revealed that Resident #1 was complaining of toe pain at the time. Staff C revealed that Resident #1 was moving her feet around, and did have shoes on at that time. Staff C then revealed that Resident #1 was an assist of one with a gait belt and four wheeled walker for transfers. Interview 10/15/25 at 9:27 AM with Staff D Licensed Practical Nurse (LPN) revealed that she was called to Resident #1's room after the incident by Staff A on the walkie system. Staff D revealed that Resident #1 was laying on the floor on her stomach when she entered the room. Staff D then revealed that she assessed Resident #1 while she was on the floor. Staff D then revealed that Resident #1 was complaining of ankle and toe pain, but was not complaining of hip or leg pain. Staff D revealed that Resident #1 stated she slipped out of bed first, and then stated that she had a jerky moment and fell. Staff D revealed that staff helped assist Resident #1 to her back, and then Staff D assessed more. Staff D revealed that Resident #1 did not complain of pain once staff rolled her to her back. Staff D then revealed that the staff in the room then utilized a full body mechanical lift with a sling to transfer Resident #1 to her mechanical wheelchair per Resident #1 not wanting to go back to bed. Staff D then revealed that Resident #1 was complaining about pain to the right ankle. Staff D then revealed that Resident #1 did have a normal range of motion with no facial grimacing or pain noted. Staff D revealed that Resident #1 is obese and has lymphedema so there was no swelling or bruising that Staff D could tell. Staff D revealed that Resident #1 stated she was okay until later in the afternoon, and this is when Resident #1 was complaining of pain more. Staff D then revealed that she had Resident #1 sent to the hospital at this time for an x-ray. Interview 10/15/25 at 9:47 AM with Staff B revealed that she was called into the room after Resident #1 fell. Staff B revealed that when she arrived Resident #1 was laying face down on the floor. Staff B then revealed that Resident #1 always has her shoes on before a transfer. Staff B then revealed that all staff in the room assisted Resident #1 with a full body mechanical lift and sling to Resident #1's wheelchair after the nurse assessed Resident #1. Staff B revealed that Resident #1 did not complain of any pain until after she was transferred to the wheelchair. Staff B then revealed that Resident #1 was a transfer assist with one staff with a gait belt and four wheeled walker. Staff B further revealed that Resident #1 was to have two staff in the room at all times for cares related to false allegations. Review of a facility provided document titled, Comprehensive Care Plans dated April 2025 documented:a. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on staff interview, resident interviews, facility documentation and policy review, the facility failed to provide care for 6 out of 15 residents reviewed (Resident #1,#6, #9, #11, #12, #2) in a manner to promote dignity and respect. The facility reported a census of 47 residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified a Staff Assessment for Mental Status indicating severely impaired cognition. The MDS identified Resident #1 was dependent on staff for eating. Resident #1's MDS included diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder. On 6/18/25 at 9:37 AM, Staff B, Registered Nurse (RN) reported on 6/5/25 during breakfast she observed Resident #1 reached for his plate of food and saw Staff A, Certified Nursing Assistant (CNA) push his hands away. She said Resident #1 reached for the plate of food 3-4 more times and Staff A would swat his hands away. She said each time Staff A would get more and more aggressive with pushing his hands away. She said she was getting ready to intervene when she observed Staff A shove Resident #1's wheelchair away from the table and take him out to the common area. 2. Resident #6's MDS assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. On 6/18/25 at 12:53 PM, Resident #6 reported Staff A, CNA did not have the best bedside manners. She said Staff A would come off like you were bothering her. She said she did not like to ask for help if she thought she was being bothersome. She said the other aides do not make her feel that way. She said you have to have a certain personality when working with people. 3. Resident #9's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. A facility form titled Resident Investigation Questionnaire dated 6/6/25 documented Resident #9 reported Staff A, CNA rushed through cares, left the room when she was trying to tell her something and has a bad attitude all the time. The form further documented Resident #9 had to wait long after lunch when Staff A worked to go to the bathroom. On 6/19/25 at 9:00 AM, Resident #9 reported she had a long call light over the weekend and it took forever for the staff to come. She said she thought her call light was on for an hour. She said she can not wait that long to go to the bathroom. She said she had an accident (urinated herself) and it made her feel terrible. 4. Resident #11's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. A facility form titled Resident Investigation Questionnaire dated 6/6/25 documented Resident #11 reported Staff A, CNA had a bad attitude and was a little rough. On 6/18/25 at 12:40 PM, Resident #11 said Staff A, CNA was rude/harsh related to the tone of her voice and short tempered. Resident #11 reported Staff A had thrown her pillows and blankets on her, did not give her water when she asked for it, and didn't help her get off the toilet. Resident #11 stated she was left on the toilet for 20 minutes. Resident #11 said she felt her dignity was being ruined because of how Staff A treated her. 5. Resident #12's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. A facility form titled Resident Investigation Questionnaire dated 6/6/25 documented Resident #12 reported Staff A, CNA had a negative attitude, was quick with cares, needed to slow down and not rush people. 6. Resident #2's MDS assessment dated [DATE] identified a BIMS score of 9, indicating moderately impaired cognition. On 6/23/25 at 3:22 PM, Hospice RN reported Resident #2 had mentioned concerns with one staff member in the past (Staff C,CNA) but had not mentioned anything in the last month. She said last week somebody had brought Resident #2's lunch tray to his room, did not set the tray up and he spilled some of the food while trying to eat. The Hospice RN reported Resident #2 told her that he was called an asshole because he spilled the food. The Hospice RN said she was not 100% sure which staff member was involved. She said when she left the facility she talked to one of the nurses and asked them to make sure his tray table was over him and set up so he could reach his food. On 6/23/25 at 3:57 PM, the Hospice Social Worker reported she did not feel the staff were willing to go to Resident #2's room to help him quickly. She said the general tone of CNAs when answering Resident #2 was short and rude. She said hospice had made a suggestion of getting Resident #2 up for all meals so he had a change in scenery to help with his mood and depression. She said Staff C, CNA stated the 2 PM-10 PM shift did not have enough staff to get Resident #2 up so he would have to stay in bed unless he requested to get up. The Hospice Social Worker reported she felt Resident #2 and Staff C did not click and she thought it had to do with Staff C's demeanor and attitude. On 6/24/25 at 9:34 AM, Resident #2 reported Staff C and him go back and forth. He reported answering a question regarding Staff C put him in a tough place and that he did not want to have any retaliation from the staff. Resident #2 reported he just wanted to get along with Staff C. He reported a few days ago Staff C had raised her voice to him and he told her to get out of his room. He reported Staff C can get snippy and have an attitude at times. When asked what he meant by snippy, Resident #2 said Staff C had told him that he had pushed his call button too many times and that he did not appreciate that she had to take care of other people. On 6/19/25 at 1:30 PM, [NAME], DON reported she expected the staff to treat residents with dignity and respect. A facility policy titled Promoting/Maintaining Resident Dignity dated 1/30/24 documented it was the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.

Based on clinical record review, staff interviews and policy review the facility failed to conduct appropriate weight monitoring, nutritional assessments, interventions and timely Physician/family notifications for 1 of 2 residents reviewed (Resident #13) for weight loss resulting in severe unplanned weight loss. The facility reported a census of 48 residents. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #13 was independent with eating and was on a therapeutic diet. The MDS documented Resident #13 did not have a 5% weight loss in the last month or 10 % weight loss in the last 6 months. Resident #13's MDS included diagnoses of anemia, diabetes mellitus, paraplegia (loss or impairment of motor and sensory functions in the lower half of the body), depression, cirrhosis and chronic kidney disease. The MDS identified Resident #13 had a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle). The Care Plan with target date of 5/13/25 documented Resident #13 had a potential for altered nutrition related to diagnosis of diabetes, depression, Barrett's esophagus, cirrhosis of the liver, paraplegia, chronic kidney disease, body mass index greater than 24.9, pressure area and colostomy. The Care Plan directed staff to obtain weights per facility protocol, record and report any significant changes and encourage good oral intake at meals, especially protein. The Medication Administration Record March 2025 directed staff to administer the following physician orders: -Beneprotein oral powder (protein) 1 scoop one time a day mixed in food or beverage of choice for stage 4 pressure ulcer to left buttocks. -Boost Glucose Control Oral Liquid (nutritional supplement) 8 ounces one time a day for stage 4 pressure ulcer to left buttocks. -Juven oral packet (nutritional supplement) one packet two times a day for wound healing. -Multivitamin one tablet one time a day. -Vitamin C 500 mg (milligrams) one tablet one time a day. The Weight Summary documented the following weights over the past three months and the scale used to obtain the weight: 3/12/2025- 233.9 lbs (pounds)- mechanical lift 3/10/2025- 230.6 lbs- mechanical lift 2/21/2025- 239.0 lbs- mechanical lift 1/7/2025- 274.0 lbs- wheelchair scale 12/27/2024- 272.8 lbs- wheelchair scale 12/26/2024- 270.6 lbs- wheelchair scale 12/25/2024- 270.4 lbs- wheelchair scale 12/24/2024- 268.2 lbs- wheelchair scale 12/22/2024- 271.0 lbs- wheelchair scale 12/9/2024- 273.8 lbs- wheelchair scale Review of the Weight Summary revealed on 1/7/25, Resident #13 weighed 274 lbs and on 2/21/25, weighed 239 pounds which was a -12.77 % weight loss. Review of the Weight Summary revealed on 1/7/25, Resident #13 weighed 274 lbs and on 3/10/25, weighed 230.6 pounds which was a -15.84 % weight loss. Review of the Weight Summary revealed on 1/7/25, Resident #13 weighed 274 lbs and on 3/12/25, weighed 233.9 pounds which was a -14.64 % weight loss. A Progress Note dated 1/13/25 documented Resident #13 had complaints of sores in his mouth and was seen by the facility ARNP (Advance Registered Nurse Practitioner). The note documented that a new order was received for magic mouth wash four times a day for 10 days. A Progress Note dated 1/14/25 documented Resident #13 was lethargic, pasty, vomiting and had excessive loose stools in his colostomy bag. The note documented the following vital signs: blood pressure 88/56, pulse 95, pulse oximetry (oxygen in the blood) 94 % on room air and blood sugar 123. The on call Physician was notified and new orders received to send Resident #13 to the emergency room for fluids and evaluation. A Progress Note dated 1/15/25 documented Resident #13 was admitted to the hospital for dehydration. A Hospital Note dated 1/15/25 documented Resident #13 was admitted to the hospital for nausea, vomiting and norovirus (a highly contagious virus that causes acute gastroenteritis, or inflammation of the stomach and intestines). A Hospital Note dated 1/16/25 documented Resident #13 reported that he can't eat well due to oral thrush (fungal infection) and to continue the nystatin (medication to treat fungal infections) swish and swallow. A Progress Note dated 1/17/25 documented Resident #13 returned to the facility from the hospital. A facility form titled Return Admission Assessment on 1/17/25 documented Resident #13 returning diagnosis was recovered from Norovirus. The vital section of the form documented the most recent weight of 274 lbs on 1/7/25. The assessment lacked documentation of a new weight being obtained following the hospitalization . A Progress Note dated 1/18/25 documented Resident #13 complained of weakness, left abdominal pain and decreased appetite. A Progress Note dated 1/22/25 at 11:31 AM documented Resident #13 had 4+ (severe) edema to lower legs. A Progress Note dated 1/22/25 at 11:52 AM documented Resident #13 PCP (Primary Care Physician) was notified of the edema and ordered edema wear on in the morning and off at bed time. A Progress Note dated 1/29/25 documented Resident #13 complained of his mouth bothering him. The note indicated there were no visual areas of concern. The facility ARNP was notified and new orders received for Nystatin Mouth Throat Suspension Swish and Spit, may give 30 ml (milliliters) every 6 hours as needed until bottle is gone or expires on 2/3/25. A Progress Note titled Nutrition/Dietary Note dated 1/31/25 documented RD (Registered Dietician) annual assessment completed. The assessment indicated Resident #13 was on a regular diet with small servings and intakes averaging 50% for most meals with 240-480 ml of fluid per meal. The assessment documented Resident #13 weighed 274 lbs on 1/7/25 and the weight was used to calculate Resident #13 weight trends in the past 30 days, 90 days and 180 days. The note documented Resident #13 weights were not clinically significant. The note indicated that there was some edema noted and that there were no new nutrition recommendations at this time. The Progress Note lacked documentation that the RD requested or recommended a weight be done post hospitalization to ensure the nutrition assessment was accurate. A Progress Note dated 2/24/25 documented a new order was received for lidocaine mouth/throat solution 15 ml every 6 hours as needed for complaints of mouth pain. A Progress Note titled 2/26/25 titled Nutrition/Dietary Note documented Resident #13 showed a weight of 239 lbs on 2/21/25 which was a 35 lb weight loss in 6 weeks. The note documented the RD questioned if the weight was accurate and requested nursing to obtain a reweigh. The note documented Resident #13 continued to have a stage 4 pressure area to the left buttocks which was deteriorating per latest skin assessment and the treatment was ongoing. The note documented Resident #13 received multiple supplements for wound healing: Juven 1 packet twice a day, Boost Glucose Control 8 ounces every day, and beneprotein 1 scoop everyday. The note documented the RD would wait for the reweigh and then would reassess. The note documented staff was to notify the RD of any significant changes or concerns. Review of the clinical record revealed Resident #13 was weighed on 3/10/25, 12 days after the request for a reweigh, and weighed 230.6 lbs which was an additional weight loss of 8.4 lbs. The clinical record lacked documentation that the RD was notified of the reweigh. The clinical record lacked any further dietary assessments, interventions, and Physician/family notifications. The Weight Summary on 3/12/25 documented Resident #13 weighed 233.9 lbs. The weight on 3/12/25 was obtained after the surveyor voiced concerns regarding Resident #13's weight loss. Review of the February meal intakes documented for Resident #13 revealed the intake varied daily and averaged above 50%. On 3/12/25 at 9:38 AM, Resident #13 reported he felt the weight loss was due to his kidney stones and hospitalization s. He said he could not keep anything down when he would try to eat. He said he started not to feel good after Christmas time. He said his appetite and intakes have improved. He reported the staff either weigh him with the mechanical lift or the wheelchair scale. When asked about the weight of 230 lbs, Resident #13 said that was a low weight for him and questioned the accuracy of the weight. He reported he did not feel like he had lost that much weight. On 3/12/25 at 11:30 AM, the Corporate Nurse reported Resident #13 was reweighed with both the mechanical lift and the wheelchair scale and the weight was still in the 230's. The Corporate Nurse acknowledged the concern with the significant weight loss. She reported she would expect staff to obtain a reweigh in a timely manner and for the management staff to be reviewing and auditing the medical record and updating the dietician. She reported she would expect assessment and interventions to be put in place for the weight loss. When asked how often Resident #13 should be weighed, the Corporate Nurse reported she would have to check but would expect the weight to be obtained according to the Physician's order. Review of the clinical record lacked a Physician order regarding how often staff was to obtain a weight for Resident #13. On 3/12/25 at 4:30 PM, the Corporate Nurse reported the facility would follow standards of care and expect monthly weights to be obtained if there was not a physician order. On 3/13/25 at 9:00 AM, the facility RD (Registered Dietician) reported that each week she would run a weight/vital report and any residents triggered with significant changes were assessed. She reported she would discuss any concerns with dietary and nursing as needed and make recommendations. She reported she would fill out a Physician Fax Form with any new recommendations and attach the Physician Fax Form to the weight loss report. She reported she gives the information to nursing to send to the Physician. She reported nursing was responsible for ensuring the fax was returned and recommendations addressed. When asked what the expectations were for weighing residents at the facility, she reported the facility was currently taking a look at the process as weights are all over the board. She reported she would like the weights to be individualized based on the situation, needs and what the provider wants. She reported residents with wounds she would usually recommend weekly weights. She reported Resident #13 was hospitalized in January and when he returned weekly weights were not started/obtained. She verified a weight for Resident #13 was not obtained upon return from the hospital on 1/17/25 and he was not weighed until 2/21/25. She reported on 2/26/25 she had requested a reweigh and she was not sure why the weight was not obtained until 3/10/25. She reported she did not have any notes written down for Resident #13 from the week of 3/3/25. She reported she worked on an assessment for Resident #13 last night and had emailed nursing asking for additional information regarding his fluid retention and what scales were used to obtain the weights. She reported once she got the information she requested from nursing, she would make additional recommendations for supplements. When asked if she felt the weight loss was avoidable or unavoidable, she reported that the question was hard to answer without having all the information and without having the weights to look at after his hospitalization . The RD verified Resident #13 had a very significant weight loss and she was not sure if the weight loss was fluid related or if his intake documented might not be accurate. She reported the facility was trying to figure out what was going on and determining what Resident #13 needs are. On 3/13/25 at 10:10 AM, the Corporate Nurse reported the facility does not have a policy that addressed significant weight loss. She reported the facility would follow standards of practice and follow the regulations which include physician notifications and implementing interventions for weight loss. A facility policy titled Weight and Height Measurement dated 10/25/21 documented Residents are weighed on admission daily for three days, then weekly for three weeks, then monthly unless otherwise ordered by nursing order or the attending physician to monitor the resident's condition. Residents' height is measured on admission. The purpose of the policy was the following: a. To obtain accurate baseline weight and height of each resident. b. To maintain constant control of weight changes. c. To assess the nutrition and hydration status of the resident. d. To identify significant changes in condition. The policy directed staff that if a resident had gained or lost three or more pounds the resident needs to be reweighed with nurse supervision. If the nurse has verified weight change, the nurse must notify the physician and nursing leadership.

Based on observation, clinical record review, staff interview and facility policy review, the facility failed to have interventions in place to prevent the development of a pressure ulcer for 1 of 4 residents reviewed (Resident #14). This resulted in harm to Resident #14 when she developed a Stage III pressure ulcer. The facility reported a census of 48 residents. Findings include: Determining the Stage of Pressure Injury: Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes of intact skin may also indicate a deep tissue PI (see below). Stage 2 Pressure Ulcer: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable PU/PI. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident ' s physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The Admission Minimum Data Set (MDS) of Resident #14 dated 11/15/24 recorded the resident had no pressure ulcers, but was at risk of the development of pressure ulcers. The MDS coded the resident had a pressure reducing device for the chair, no pressure reducing device for bed. The MDS coded the resident was not on a turning/repositioning program. The MDS coded no nutrition or hydration interventions in place to manage skin problems. The MDS documented diagnoses that included Type 2 diabetes with foot ulcer; peripheral vascular disease, cerebrovascular accident (CVA/Stroke), hemiplegia (paralysis of one side of the body) bipolar disorder. The MDS coded the resident required substantial assistance to roll left to right in bed. The Quarterly MDS of Resident #14 dated 12/15/24 coded the resident dependent on staff for rolling left to right in bed. The MDS coded the resident had no pressure ulcers. The MDS coded the resident to be at risk of pressure ulcer development. The Care Plan of Resident #14 identified a focus area of risk of falls due to hemiplegia (paralysis or weakness on one side of the body) of the resident's left non-dominant side. The Care Plan identified a focus area of being at risk for skin integrity impairment related to Type 2 diabetes. The Care Plan identified a focus area of ADL (Activities of Daily Living), deficit due to hemiplegia of the left side, dated 11/4/24 . The Care Plan failed to document any need for turning/repositioning for the prevention of pressure ulcers. The Care Plan failed to identify what assistance the resident needed for bed mobility. The Skin/Wound note dated 3/2/25 at 12:54 pm identified treatments were completed to wounds on resident's heels (diabetic ulcers). The noted documented education was provided about changing positions frequently and the resident got upset. The note documented a recommendation to get a pressure relieving mattress on the bed. The Skin/Wound note dated 3/2/25 at 4:08 pm documented an open area was identified on the resident's right buttock with purulent drainage. The Ulcer Skin Assessment sheet documented a Stage III pressure ulcer was first observed on 3/2/25 on the right buttock of the resident. Assessments were completed on 3/4/25 and 3/11/25. 3/4/25: 3 x 2 x 0.3 mm. Moderate amount of purulent exudate (thick, opaque fluid). Wound bed red, surrounding skin within normal limits, wound edges macerated, jagged edges. 3/11/25: 3 x 2 0.3 mm. Moderate amount of serosanguinous exudate (fluid containing both serum [clear, watery liquid] and blood). Wound bed red, surrounding skin within normal limits, wound edges macerated, jagged edges. The Kardex, revision date 3/7/25, used by the facility Certified Nurse Aides as a snapshot of resident care, noted Resident #14 to be at risk of pressure ulcers and required frequent repositioning. On 3/12/25 at 9:11 am, the Assistant Director of Nursing (ADON) stated the wound on the resident's buttocks was a pressure ulcer. She stated it developed during a time the resident was primarily in her recliner and not using her bed. She stated the recliner became saturated with urine from her catheter clogging and was removed from the room by the resident's family. Observation of wound care began on 3/12/25 at 9:15 am with Staff G, Licensed Practical Nurse (LPN) and the ADON. Wound care was completed on diabetic ulcers of the resident's heels. After this was completed, Staff G, LPN and the ADON told Resident #14 they needed to reposition her to complete wound care on her buttocks. It was observed it took both staff members to turn Resident #14 onto her right side in the bed which the resident appeared to be resistive to. The ADON assisted the resident to stay on her right side while Staff G opened the resident's incontinent brief. It was noted there was no current dressing in place covering the resident's pressure ulcer. Staff G stated there was a dressing in place on the prior day. The ADON stated the Certified Nurse Aides (CNA) sometimes remove the dressing if the resident was incontinent of bowel. Staff G, after having performed hand hygiene and donning gloves, cleansed the pressure ulcer. She removed her gloves, performed hand hygiene, donned new gloves, and applied triad paste (a paste which helps maintain a moisture wound healing environment) and applied a mepilex (absorbent foam) dressing over the wound. On 3/12/25 at 12:11 pm, Staff H, Certified Nurse Aide (CNA) stated the normal routine for the resident was to provide cares for her in the morning, and clean her if she was incontinent of bowel. She stated the resident ate in her room and received room trays. She stated near the end of the shift, staff emptied her catheter. She stated that was about it and the resident rang her call light if she wanted or needed anything additional. Staff H did not state anything regarding the resident requiring or receiving any repositioning in bed. On 3/12/25 at 2:16 pm, the MDS Coordinator stated Resident #14 has an overlay mattress on her bed for prevention of pressure ulcers. She stated she had asked the CNAs to put this on her bed sometime in the last two weeks or so. On 3/12/25 at 2:19 pm, the MDS Coordinator verified placement of the overlay mattress on the bed. She offered repositioning to Resident #14. The resident declined and remained on her back in bed with the head of bed elevated. Continuous observation of cares revealed the following: On 3/12/25 at 2:20 pm Staff I, CNA provided the resident with fresh ice water. She asked the resident if she needed anything else. No repositioning was completed. On 3/12/25 at 3:09 pm, Staff H and Staff I were observed rounding on residents on the hall Resident #14 resided on. On 3/12/25 at 3:17 pm, Staff H and Staff I knocked on the door of Resident #14 and entered her room, they exited approximately 15-20 seconds later. The State Surveyor entered the room immediately after Staff H and Staff I left the room and observed Resident #14 to still be on her back, in the same position she was in one hour earlier. On 3/12/25 at 5:00 pm, Staff H, CNA was observed to start passing room trays on the hallway. On 3/12/25 at 5:02 pm, the Nurse Consultant was informed of the continuous observation and lack of repositioning provided. She stated residents unable to turn themselves should be repositioned a minimum of every two hours or following any specific physician orders. On 3/12/25 at 5:09 pm, Staff H arrived at the door of Resident #14's room with her evening meal. Staff J, CNA was also nearby. The Nurse Consultant told Staff H and Staff J she was able to assist them in repositioning Resident #14. Upon entering the room, Staff J told Resident #14 it was time to reposition in bed and Resident #14 agreed. Per observation, Resident #14 was dependent on both Staff H and Staff J to be repositioned towards her left side. Staff J provided the resident with her meal and told her she would need to be repositioned again in another 2 hours. Resident #14 was repositioned 2 hours and 50 minutes after continuous observation began. On 3/13/25 at 8:36 am, the ADON stated the resident did have a pressure reducing cushion in her recliner during the time she was spending most of her time in the recliner rather than the bed. She stated the CNA staff should be repositioning every two hours for any resident unable to reposition themselves. The facility policy Skin Management Protocol, updated 5/16/23, failed to document any interventions such as repositioning.

Based on record review, observation, and staff interviews, the facility failed to protect residents from environment hazards when residents' beds were placed with the side of the beds against the baseboard heater. Resident #4 attempted to get out of bed unassisted and fell on the baseboard heater sustaining burns. Observation identified sixteen remaining beds were located near heaters and unsafe. The facility failed to ensure a bed side rail functioned properly and a bed lowered to a safe height (Resident #1). The sample consisted of 7 residents. The facility reported a census of 74 residents. Findings include: Resident #4 had an admission MDS (Minimum Data Set) assessment, with a reference date of 4/12/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had impaired long and short term memory loss, displayed no behavioral symptoms, required extensive assistance of 2 staff members for bed mobility, transfers and did not walk. The Care Plan identified the resident at risk for falls due to a CVA (Cerebral Vascular Accident- stroke), weakness, and immobility. The Care Plan listed the following interventions: On 4/6/17- Assess quarterly and as needed for risk of falls; On 4/6/17-Assure appropriate footwear on when up; On 5/8/17- High low bed; On 5/4/17- Use a recline back wheelchair; On 5/2/17-Personal alarm at all times The Care Plan identified the resident had an activities of daily living deficit and listed the following interventions: On 4/26/17-t transfer with 2 staff members and a Hoyer (mechanical) lift. The Skin Integrity Investigation dated 4/27/17 at 7:15 a.m. documented a burn/blister to the left lower leg, left foot 2nd, 3rd, and 4th toes. The prevention intervention listed to move the bed from the radiator. The Care Plan documented the resident as at risk for skin breakdown and had blisters on the lower leg as well as toes due to attempting to transfer unassisted out of bed. The resident sustained [REDACTED]. The Care Plan listed the following interventions: On 4/26/17-Air mattress overlay on the bed On 4/26/17- Heel protectors in bed On 4/6/17-Monitor skin with cares, alert the nurse of any open/red areas so the physician can be contacted. On 4/27/17-Keep bed away from radiant heater On 5/8/17- Treatment to blisters, as ordered. The Hospice Physician Certification/Recertification of Terminal Illness dated 4/18/17, identified the resident had a wound to the right lateral left leg that measured 3.5 (centimeters) x (by) 1.7 cm. The note lacked physician notification and or treatment orders. The Progress Notes dated 4/20/17 at 2:30 a.m. indicated Staff B, Registered Nurse from a staffing agency, documented the resident had a 4 cm x 2 cm old blistered site. Staff documented the area as not open, no drainage, no warmth, no discomfort, and surrounding skin slightly pink. During an interview on 5/10/17 at 12:56 p.m. Staff B stated she worked the night shift on 4/20/17 and documented in the Progress Notes there was documentation about an area on the resident's right calf. Staff H, certified nurse aide, alerted her to the area. Staff B stated the area appeared to be an abrasion. Staff B stated she looked through the resident's chart and found no documentation of the area. Staff B stated she did not notify the physician or family due to the hour (during the night). Staff B reported the information to the next shift. During an interview on 5/10/17 at 1:55 p.m. Staff H told Staff B he observed a red area to the resident's right calf that looked like an opened blister. Staff H stated the resident had restless legs and kicked legs out of bed. During an interview on 5/10/17 at 3:34 p.m. Staff F, Hospice nurse, stated she observed the area on the 4/21/17 and obtained treatment orders. Staff F stated the area originally looked like an abrasion from the Hoyer lift sling and now the area looked like a burn. The Progress Notes dated 4/21/17 at 10:39 a.m. documented the Hospice social worker visited the resident and stated the Hospice nurse will be called regarding the open area on the resident's right calf. The Progress Notes documented the skin as an open area. The Skin Condition Report dated 4/21/17 documented a scabbed area with drainage to the resident's right lateral calf that measured 3.5 cm x 1.7 cm. On 4/24/17 the area measured 3.5 cm x 1.7 cm. On 5/2/17 the area measured 5.7 cm x 4 cm. On 5/8/17 the area measured 12 cm x 5 cm. The record lacked notification of the right leg wound's increase in size to the physician. The Medication Administration Record documented an order for [REDACTED]. The Progress Note dated 4/27/17 at 9:21 p.m. documented the resident attempted to get out of bed and the resident laid the left leg on the radiator causing a burn to the left lower extremity causing a blister that measured 7.8 cm x 6.2 cm with superficial open areas to the 2nd, 3rd, and 4th left foot toes. The Progress Notes documented the staff sent a facsimile to the physician and notified the family. The new skin area dated 4/27/17 documented the resident had a burn on the left lower leg and left toes sustained during an attempt to transfer from bed landing on the radiator by the bed. A facsimile dated 4/27/17 sent to the physician at 7:43 a.m. asked for triple antibiotic ointment to the resident's burns to the left leg and 2nd, 3rd, 4th on the left foot. The facsimile did not include the measurements or description of the wounds. The Skin Condition Report dated 4/27/17 documented a skin area on the left lower leg that measured 7.6 cm x 6.2 cm, left foot 2nd toe that measured 1.9 cm x .7 cm, left foot 3rd toe circular area that measured .9, and left foot 4th toe circular area that measured .8 cm. The Skin Condition Report dated 5/2/17 documented the left leg area measured 5.7 cm x 4 cm, left foot 2nd toe circular area that measured .6 cm, left foot 3rd toe circular area that measured 1 cm x .1 cm, and left foot 4th toe area that measured 1.2 cm x .7 cm. The Skin Condition Report dated 5/8/17 lacked documentation of the left leg area. The measurements for the toe areas remained unchanged. The Quality Assurance Performance Improvement (undated) documented a plan to move all beds away from heating registers. During an interview on 5/10/17 at 7:45 a.m. the Assisted Director of Nursing (ADON) stated after the incident, the facility moved all beds away from the baseboard heaters and moved all beds away from the head of the bed against the baseboard heaters. The ADON stated a certified nurse aide (could not recall the name) informed him the resident had fallen onto the baseboard heater. The ADON stated the resident had one leg in bed and the other leg lying on the baseboard heater. The ADON touched the heater and found it hot. The ADON stated he did not know about the light switch by the bed that controlled the activation of the baseboard heater. The ADON stated he measured the areas and sent a facsimile to the physician requesting triple antibiotic ointment. The ADON stated he performed the weekly examinations of the residents with skin impairment. The ADON could not definitely say the cause of the right leg area but stated it could have been a burn. The ADON stated a physician had not yet examined the wounds. During an interview on 5/16/17 at 11:37 a.m. Staff V, certified nurse aide, stated the other aide on duty discovered the resident half in the bed and leg on top of the heater. Staff V stated the resident kicked his/her legs out of bed frequently and would not wear socks in bed. The resident had foam boots but would kick the boots off. On 5/10/17 at 8:05 a.m. a tour of the resident rooms identified an additional 16 beds were located against the heater and the head of the bed against the heater. In the resident's room, observation identified a switch; located on the wall to activate the heater (the switch resembled a light switch). The switch was activated. Two minutes after activation, the heater temperature tested at 174 degrees Fahrenheit. During an observation on 5/9/17 at 8:00 a.m. Staff G, certified nurse aide, and Staff E, certified nurse aide, assisted the resident with personal cares. The resident moved the lower extremities with ease and kicked legs out of bed multiple times during the assistance with personal cares. Staff used the Hoyer mechanical lift to transfer. The Hoyer lift straps went around the upper thigh area and did not have contact with the calf area. During an observation on 5/10/17 at 1:09 p.m. Staff C, licensed practical nurse, performed the dressing changes. Photographs identified multiple wounds on the toes and leg. Note: At the time of the complaint investigation, the complaint was coded at a K, immediate and serious jeopardy. By 5/10/17, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the E level. The facility audited each room for placement of the beds and followed the manufacturer recommendation for clearance around each heating unit. All staff received an in-service about heat registers, burns, heater panel switches to activate the heaters and about other electrical items plugged in that required supervision. The facility plan to install a guard system around each heater and anticipate a date of completion to be 5/30/17. All heater switches were labeled and the dial adjusted and regulated to 2-2.5 on the dial. As of the 5/17/17 exit conference, the facility continued to need to: Monitor resident rooms to ensure the beds are away from the base heaters per the manufactures recommendation. Monitor heater switch dials to ensure the switches are identified and labeled. Monitor the heater guard system to ensure the devices provide safety for residents. 2. Resident #1 had a MDS assessment with a reference date of 2/15/17. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had severely impaired cognition and decision making skills. The MDS documented the resident required extensive assistance of two staff for transfers and bed mobility. The Care Plan dated 11/16/15, and revised on 2/28/17, identified the resident had a fall risk. The Care Plan directed staff to place ½ side rails up on the bed to aide with transfers and bed mobility, remind the resident to use the call light, use a hi-lo bed and mat at the bedside, and place items within reach. An incident report dated 2/27/17, at 10:30 p.m., identified staff found the resident lying on the floor by the bed and complained of left shoulder pain. The resident reported he/she fell out of bed when tried to get up to go to the bathroom. The progress notes dated 2/18/17, at 1:30 p.m., revealed a hi-lo bed used and mat placed at the bedside whenever the resident in bed. An x-ray report dated 2/28/17 identified no left shoulder fractures. During observation on 5/9/17, at 6:47 a.m., Staff J, Certified Nursing Assistant (CNA), provided pericare (perineal cleansing) for Resident #1, then left the resident's bedside to assist a co-worker and the resident's roommate in the bathroom. Staff J left Resident #1's bed in the high position, and left the side rail on the bed in a vertical position, but did not engage or lock the side rail in place. The resident laid on his/her right side and held onto the side rail attached to the right side of the bed. At that time, observation identified no mat on the floor by the resident's bed, and the call light cord wrapped around a bar on the side rail but the call light button rested on the floor and away from the resident. At 6:51 a.m., Staff J opened the bathroom door and walked by the resident's bed. Staff J reported the resident's side rail looked funny, and then asked Resident #1 what he/she had done with his/her side rail. Staff J lowered the resident's bed toward the floor. In an interview on 5/11/17, at 10:35 a.m., Staff K, CNA, reported the facility required staff to lower beds toward the floor on all residents for safety reasons. Staff K reported Resident #1's side rail should be in the up position and a mat placed on the floor by the resident's bed whenever the resident in bed. On 5/10/17, at 8:05 a.m., the bed side rails at the facility were observed. Observation revealed the side rail on Resident #1's bed in a vertical position attached to the bed frame. The metal side rail could be turned 360 degrees in a clockwise and then a counterclockwise direction without the side rail engaged and the side rail attached loosely on the bed. On 5/10/17 at 11:55 a.m., Staff I, Maintenance Assistant, was interviewed and reported the facility performed preventative measures on the bed equipment annually, but Resident #1 rented the bed from an outside vendor and the vendor had the responsibility to check and repair the beds. Staff I confirmed he had received no work order for a malfunctioning or broken side rail in the 300 Hall. Staff I confirmed Resident #1's side rail as loose and it should not rotate 360 degrees clockwise or counterclockwise on the bed. Staff I planned to follow up to have the side rail repaired. On 5/10/17, at 5:00 p.m., the Corporate Compliance Officer, was interviewed and stated she expected the vendor who supplied equipment or beds to inspect the equipment before bringing it to the facility. On 5/11/17, at 10:40 a.m., observation revealed both side rails in an up position on Resident #1's bed. The observation identified the side rails secured to the bed frame and engaged appropriately when raised to an up position, and no longer turned clockwise or counterclockwise.

Based on record review, observation and interviews with resident, family member and staff interviews, the facility failed to provide planned nutritional interventions, document consumption of supplements and communicate effectively regarding nutritional interventions to maintain acceptable parameters of nutritional for 4 of 17 residents reviewed (Residents #1, #3, #4, and #21). The facility reported a census of 74 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE]; documented Resident #1 had [DIAGNOSES REDACTED]. The resident scored 5 out of 15 on the Brief interview for Mental Status (BIMS) interview indicating severe cognitive and memory impairment. The MDS documented the resident needed supervision and set up for eating. The assessment documented the resident had an unplanned weight loss and to receive a mechanically altered diet. The Care Plan dated 3/29/15, and revised on 2/23/17, documented the resident had a nutritional risk due to [DIAGNOSES REDACTED]. The Care Plan directed staff to follow recommended dietary interventions to ensure adequate nutrient intake, serve a regular diet with ground meat, and provide a sippy cup during meals as needed. The Care Plan identified the resident had broken dentures. The resident's diet change order for 2/13/17 identified chocolate milk with meals to increase caloric intake. The diet change order dated 3/29/17, gave direction to serve Ensure pudding at lunch. The facility provided a list of the resident's weight, which included the following: 11/10/16 -209 pounds (lbs.) 12/9/16 - 207 lbs. 1/9/17 - 201 lbs. 2/20/17 - 199 lbs. 3/20/17 - 190.5 lbs. 4/24/17 - 184.5 lbs. The weights reflect a 3 % weight loss in 1 month (March-April 2017). The weights reflect a 7.3 % weight loss in 3 months (February -April 2017). The weights reflected a significant weight loss of 11.7 % in 6 months (November -April 2017). The Dietary Progress Notes recorded the following: On 1/9/17, resident on a regular, ground meat diet and had a continued slow weight loss. The dietician recommended offering high calorie snacks to the resident. On 2/13/17, chocolate milk started with meals to increase caloric intake. On 3/2/17, a family member expressed concerns the resident had lost weight and did not eat well. On 3/20/17, the resident refused chocolate milk; chocolate milk discontinued. On 3/29/17, the resident weighed 188 lbs. and had significant weight loss in 6 months. The dietician recommended Ensure pudding at lunch to increase nutrient intake. On 5/8/17, the resident weighed 183.5 lbs. and the dietician wrote the resident received Ensure pudding at lunch. A fax to the physician on 2/2/17 requested a Hospice evaluation due to a decline in the resident's weight. A fax to the physician on 3/1/17 requested supplements twice a day for weight maintenance because the resident had broken their dentures 3 months ago. Dining observations identified the following: On 5/9/17 at 7:40 a.m. Resident #1 sat in the dining room and fed self potato chips. Observation identified the resident had a sippy cup which contained juice, bowl of corn flakes with milk, sausage and toast on the table in front of the resident. At 12:20 p.m. the resident sat in a wheelchair in the dining room and a family member sat next to the resident. The resident had a plate sitting in front of in/her. On the plate contained the following: pulled pork, scalloped potatoes and broccoli/cauliflower. A bread plate and a glass of water sat on the table in front of the resident. The resident drank tomato juice from a sippy cup. On 5/10/17 at 8:05 a.m. Resident #1 sat in a wheelchair in the dining room and fed self corn flakes with milk. The resident drank tomato juice in a sippy cup. At 12:50 p.m., the resident sat in the dining room and fed self spaghetti. A sippy cup with tomato juice sat on the table by the resident. In an interview 5/10/17 at 2:20 p.m. the resident's family member reported s/he had lost weight and was supposed to have a supplement. The family member routinely visited during the meal time and reported the resident had not received a supplement at that time and reported he/she felt concerned if the resident received their recommended supplements. The family member stated it was their decision to not fix the broken dentures, but the diet should reflect food the resident could eat. 2. The MDS assessment dated [DATE] documented Resident #3 had [DIAGNOSES REDACTED]. The MDS documented the resident needed supervision and set up for eating. The assessment documented the resident had no or unknown weight loss in 1 or 6 month period. The Care Plan dated 5/16/16 and revised on 4/24/17 documented the resident had a nutritional risk due to [DIAGNOSES REDACTED]. The Care Plan directed staff to serve recommended dietary interventions to increase nutrients and fluid intake, serve a regular diet and obtain weights per facility protocol. The resident's diet change order for 2/20/17 directed to serve whole chocolate milk during meals to increase caloric intake. The diet change order 4/24/17 indicated Ensure Clear served during meals to increase caloric intake and fluids. The facility provided a list of the resident's weight, which included the following: 11/2/16 -143 lbs. 12/6/16 - 139 lbs. 1/6/17 - 136 lbs. 2/7/17 - 133.5 lbs. 3/7/17 - 136.5 lbs. 4/4/17 - 130.5 lbs. The weights reflected a 4.19 % weight loss in 1 month (March-April 2017). The weights reflected a 2.09 % weight loss in 3 months (February -April 2017). The weights reflected an 8.74 % weight loss in 6 months (November -April 2017). The Dietary Progress Notes recorded the following: On 1/23/17 - Resident #3 received a regular diet and had their meat cut up. The resident had a slight weight loss from 140's to 130's. On 2/20/17 - The Dietician recommended chocolate milk or whole milk at meals to increase caloric intake due to a significant weight loss in 30 days. On 3/3/17 - Chocolate milk discontinued because the resident refused the chocolate milk at meals. The dietician recommended continued monitoring of the resident's weight. On 4/24/17 - The resident had a continued slow weight loss. The dietician recommended Ensure Clear with meals for increased nutrient intake and weight loss prevention. Dining observations revealed the following: On 5/9/17 at 9:15 a.m. the resident sat in the dining room and fed self his/her breakfast. The resident dunked toast in a cup of coffee and the observation revealed no other beverages on the table by the resident. At 12:10 p.m., the resident sat in a wheelchair in the dining room and fed self. The resident had a cup of coffee next to his/her plate on the table. An empty glass sat upside down on the table and no other beverages were on the table by the resident. On 5/10/17, at 8:15 a.m. the resident sat in the dining room and drank tea from a cup. Observation revealed no other beverages on the table by the resident. On 5/11/17 at 10:20 a.m. Staff M, Dietary Cook, was interviewed and reported they had a list of residents who received dietary supplements recommended by the dietician. Staff M reported the dietary aides are assigned to pass out any dietary nutritional supplements such as chocolate milk, Ensure pudding or other nutritional products. Staff M confirmed Resident #1 and Resident #3 on the list and supposed to receive Ensure pudding during the lunch meal. On 5/11/17 at 11:05 a.m. Staff M and Staff N, Dietary Aides, were interviewed and reported the staff documented the resident intakes on an IPAD, but they had no way to chart the individual dietary product consumed, such as chocolate milk, ensure pudding, or ensure clear liquid. The staff could only record the total fluid amount consumed by each resident. 3. Resident #4 had a MDS with a reference date of 4/12/17. The MDS identified [DIAGNOSES REDACTED]. The resident had impaired long and short term memory problems. The MDS documented the resident weighed 157 pounds. The Nutrition assessment dated [DATE] documented the resident lost 21 pounds since admission on 4/5/17. The dietician recommended chocolate milk at meals. During observation on 5/9/17 at 12:30 p.m., staff fed the resident lunch. Staff did not provide chocolate milk. During observation on 5/10/17 at 8:17 a.m., staff fed the resident breakfast. Staff did not provide chocolate milk. During an interview on 5/9/17 at 3:08 p.m., the resident's spouse stated the resident loved chocolate milk. 4. The MDS assessment dated [DATE] documented Resident #21 had a [DIAGNOSES REDACTED]. The assessment documented she/he entered the facility on 4/7/17, had no memory or cognitive impairment and required supervision with eating. The assessment documented Resident #21 received nutritional approaches while at the facility. The Weekly Weight Summary report documented Resident #21 weighed 182.5 pounds on 4/17/17, 183 pounds on 4/24/17, 164.5 pounds on 5/1/17 and 160.5 pounds on 5/8/17. The Dietary Nutritional Intervention sheet dated 4/24/17 documented Resident #21 was to receive the dietary intervention of chocolate milk with meals. Observation of the meal service on 5/8/17 at 12:00 p.m. identified Resident #21 did not receive chocolate milk on the tray delivered to his/her room. The resident stated she/he received two large glasses of white milk and drank only one. Resident #21 stated she/he would have drank the chocolate milk but didn't want two glasses of white milk. On 5/8/17 at 12:55 p.m. the dietician was interviewed and stated Resident #21 needed increased calories due to [MEDICAL CONDITION] and weight loss. The dietitian provided a copy of a diet order dated 5/1/17 for Resident #21 to have chocolate milk with all meals and Ensure Clear twice a day for snacks. The Dietary Manager provided the meal card on 5/8/17 at noon for Resident #21 which had no documentation of the direction for chocolate milk with meals. They subsequently added the notation when the Dietitian directed to do so.

Based on record review, staff and family interviews, observation and an interview with a group of residents, the facility failed to ensure the facility had sufficient staff assigned to meet the needs of the residents and prevent a major injury for 1 of 7 residents reviewed (Resident #14). The facility reported a census of 74 residents. Findings include: 1. Resident #14 had a MDS (Minimum Data Set) assessment with a reference date of 4/29/17. The MDS identified an admission date of [DATE]. The MDS identified the resident able to make self understood and could understand others. The MDS revealed the resident required the limited physical assistance of 1 person for transfers, walking in room and corridor, and for locomotion on and off the unit. The MDS coded the resident's balance during transitions and walking as not steady, only able to stabilize with staff assistance for the following: moving from seated to standing position; walking; turning around and facing the opposite direction while walking; moving on and off toilet; and surface-to-surface transfer. The MDS marked the use of a walker and wheelchair for mobility devices. The MDS documented [DIAGNOSES REDACTED]. The Brief Interview for Mental Status dated 4/26/17 at 11:10 a.m. documented a score of 12. A score of 12 indicated moderate cognitive impairment. The Care Plan identified a focus area revised 4/27/17 for an ADL (activities of daily living) deficit due to weakness. The Care Plan directed staff to provide assistance of 1 (person), walker, and gait belt for transfers. The Care Plan contained no entries pertaining to removal of a wheelchair from the resident's room. The Task List Report printed 5/3/17 documented a Nursing Rehab program initiated on 4/27/17. The task directed staff to ambulate the resident to and from all meals and activities with walker and the assistance x1 (one person). The task scheduled the ambulation to be done at 9:00 a.m., 1:00 p.m., 6:00 p.m., and PRN (as needed). The Rehab Communication 2 form dated 4/27/17 documented recommendation/instructions from the therapist. The form recorded the resident needed: assist x1 with FWW (front wheeled walker) for all gait and transfers; to ambulate to/from all meals and activities with FWW and assist x1; and the wheelchair to be removed from the resident's room. The Progress Notes dated 4/27/17 at 10:25 a.m. documented the resident skilled for PT (physical therapy)/OT (occupational therapy) for observation and assessment. The entry recorded the resident ambulated with assist of 1 with walker. The entry documented the resident non-compliant with using call light, up walking with walker in the room, gait steady, balance good, and education on the use of the call light and awaiting assistance. The Progress Notes dated 4/27/17 at 10:46 a.m. documented the care plan changed. The resident to receive assist x1 with walker for all gait and transfers; ambulate to and from meals and activities with walker, assist x1; therapy removing wheelchair from the room; and the Care Plan updated. The Progress Notes dated 4/27/17 at 8:21 p.m. documented the resident used a FWW in the room independently and ambulated with a steady gait. The Progress Notes dated 4/29/17 at 6:23 p.m. documented the nurse called to the resident's room due to the resident experiencing an unwitnessed fall with the resident on the floor in front of the chair. The entry recorded the resident alert and oriented. The untitled incident report dated 4/29/17 at 6:30 p.m. and revised on 5/8/17 at 1:11 p.m., documented the resident experienced an unwitnessed fall. The report recorded the resident stated he/she tried to get up from the wheelchair after supper, missed, and fell on the floor bumping head on the wall but not hard. The Progress Notes dated 4/29/17 at 6:30 p.m. documented a change in condition form completed and faxed to the MD (medical doctor). The Progress Notes dated 4/29/17 at 8:15 p.m. documented the on-call doctor called and a verbal order received to send the resident to the ER (emergency room ) for evaluation. The Progress Notes dated 4/29/17 at 8:27 p.m. documented a late entry by Staff P, LPN (Licensed Practical Nurse). The entry recorded Staff P responded and assessed the resident on the floor. The entry documented the resident's speech clear, the resident able to answer questions, and the resident stated he/she hit his/her head on the wall but it didn't hurt. The Progress Notes dated 4/29/17 at 8:30 p.m. documented the ambulance arrived to pick up the resident. The entry recorded the ambulance personnel attempted to ask the resident questions regarding the fall, but the resident gave no rx (response) and speech slurred/garbled. The Progress Notes dated 4/29/17 at 8:45 p.m., documented by Staff Q, LPN, recorded the resident stated he/she bumped his/her head on the wall but not hard. The entry documented the resident made the statement at the time of the fall when alert/oriented x4. Staff Q wrote the residents VS (vital signs) WNL (within normal limits) for the first 4 checks but the B/P (blood pressure increased and the resident started to slur speech, and the began to vomit. The Imaging Report dated 4/29/17 recorded the results of a CT (computer tomography) scan of the resident's head. The subtitled section Impression, documented an acute left subdural hematoma with local mass effect and left-to-right herniation (a traumatic collection of blood around the brain). The Progress Notes dated 4/30/17 at 1:10 p.m. documented a report call received from the hospital ER RN. The entry recorded ER RN reported the resident unresponsive most of the time in the ER and admitted for comfort cares as remained unresponsive. The Major Injury Determination Form signed on 5/5/17 by the resident's physician, documented the physician reviewed the circumstances, injury, and prognosis of the patient and believed the injury sustained was a major injury. Staff statements, staff interviews, family interviews: In a written statement dated 4/30/17, Staff R, CNA (Certified Nurse Aide), documented she saw the resident on the floor in a sitting position in the resident's room on 4/29/17 at 6:00 p.m. Staff R recorded she asked the resident what happened and the resident stated he/she tired of waiting in the dining room so he/she pushed him/herself back in wheelchair with walker in front of him/her. Staff R documented the resident said when he/she got back to his/her room, he/she thought he/she could stand up and walk over to the couch. Staff R stated the resident reported he/she fell hitting head on wall. On 5/3/17, Staff O, MDS/RN (Registered Nurse) Coordinator, typed a statement regarding the resident's therapy recommendation. Staff O documented therapy gave her a communication/recommendation paper on 4/27/17 at 10:45 a.m. Staff O wrote the paper recommended the resident: receive assist x1 with walker for all gait and transfers; be ambulated to and from all meals and activities with walker and assist x1; and remove the wheelchair from the room. Staff O explained the recommendation was so the resident would ambulate to and from all meals and not ride in the wheelchair from the room. Staff O documented since the Care Plan already directed the assistance of 1 staff person, walker, and gait belt for transfers, she did not include removing the wheelchair from the resident's room in the Care Plan; that way if the resident needed the wheelchair for long rides, appointments, or if tired, the resident could still use the wheelchair. Staff O wrote she entered an ambulation program, based on the therapy recommendations, into the Tasks in PCC (the section of the computer program called point click care where the CNA's documented and received information). Staff O documented she then removed the wheelchair from the resident's room. In an interview on 5/8/17 at 3:10 p.m., Staff P (Agency nurse) stated he recalled the resident's fall on 4/29/17 around 6:15 p.m. Staff P said he went to assess the resident when he/she on the floor. Staff P reported the resident said something about going to the loveseat. Staff P commented the resident at that time very alert and oriented with no signs/symptoms of dementia. Staff P stated he did not feel there was enough staff that night to meet the resident's needs. Staff P recalled no CNA for the 100 hall because staff split the hall (CNA's assigned to other hallways take a few rooms each to oversee). Staff P commented honestly felt not safe for aides to split the assignment of the 100 hall. In an interview on 5/9/17 at 6:10 p.m., Staff R (certified nursing assistant) stated she clocked in at 6:00 p.m. on 4/29/17. Staff R said she walked down 100 hall and saw the resident sitting on the floor. Staff R reported the resident stated he/she got tired of waiting in the dining room so got wheelchair and walker and took self to room. Staff R commented the resident said he/she thought he/she could stand and walk to couch but fell hitting head on the wall. Staff R reported she completed vitals on the resident every 15 minutes 4 times and then on the 1st 30 minute check she noticed the resident changed. Staff R said the resident laid over on the couch, non-coherent. Staff R responded when asked about enough staff she did not feel there was enough staff. Staff R commented they had enough that night but Staff U, CNA, had to leave and Staff G, CNA, from the 100 hall had to take his place on another hall. Staff R stated she thought the 100 hall had 6 or 7 residents living there that night. Staff R reported if staff called in on overnights, the facility pulled the 100 hall aide and the other 3 CNA's must split the 100 hall. Staff R stated that 1 resident on the 100 hall required assist of 2 staff members. Staff R stated the facility staffed short a lot and she shared her concern with management. Staff R commented management responded they should be able to handle it. On 5/9/17 at 6:30 p.m., Staff T, CMA (Certified Medication Aide) was interviewed and stated she does not like when the 100 hall aide is pulled because there is a resident on 100 hall with an alarm. Staff T said the 200 hall has approximately 20 residents as does the 300 hall. Staff T reported the residents on the 200 and 300 halls want to get to bed but call lights going on the 100 hall. Staff T stated the 300 hall aide responsible to cover rooms [ROOM NUMBER]. Staff T said the facility often short staffed with no 100 hall aide. Staff T reported the residents on the 100 hall have the following needs: 1 resident has a personal alarm and constantly self transfers; 1 resident needed 2 staff members to assist with cares; 1 resident on the call light a lot because needs assist to use the bathroom a lot; and another resident that received medical treatments required frequent trips to the bathroom. Staff T stated the 400 hall aide covers the resident with the alarm but the alarms can't be heard on the 400 hall and Staff T felt that was a danger. On 5/9/17 at 6:50 p.m., Staff S, CNA, stated she worked from 2:30 p.m. to 11:00 p.m. on 4/29/17. Staff S reported the 100 hall to be for those residents needing therapy and mostly independent. Staff S responded yes and no when asked if she felt the facility had enough staff to meet resident needs. Staff S commented she did not think splitting the 100 hall doable because when on the 300 hall she can't see the 100 hall and when assigned to the 200 hall she can't hear anything from the 100 hall. Observation on 5/9/17 at 7:00 p.m. identified when standing on the 300 or 400 hall, as unable to see the 100 hall. Observation revealed an extra-large activity room at the end of the 100 hall and must walk thru the room, turn 90 degrees right to get to the 400 hall. Observations further revealed when standing on the 400 hall or at the end of the 200 or 300 halls, could not hear residents living in the 100 hall. On 5/9/17 at 7:45 p.m., a family member was interviewed and stated he/she visited the resident on 4/28/17. The family member stated the resident reported he/she would put light on and not get help. The family member stated the resident said he/she was supposed to get help. The family member reported he/she unable to talk to the resident at the hospital due to the resident in a coma until he/she passed away on 5/7/17. In an interview on 5/10/17 at 12:40 p.m., Staff G, CNA, stated she was scheduled to the 100 hall on 4/29/17. Staff G reported Staff U left from 5:00 p.m. to 8:00 p.m. so she had been pulled to cover his hall. Staff G stated she assisted the resident to walk to supper but not back. Staff G said she walked the resident with the walker while pulling the wheelchair behind them and the resident sat in the wheelchair in the dining room. Staff G reported the wheelchair obtained from the resident's room. Staff G commented when Staff R came at 6:00 p.m., she called for help because the resident laid on the floor. Staff G reported after she was pulled from the 100 hall assignment, the 400 hall aide would have been in charge of the resident because the hall was split assignment. Staff R said she did not see anyone assist the resident out of the dining room. Staff G stated she had not taken care of the resident before that night. Staff G said her 1st interaction with the resident occurred at 2:30 p.m. when she introduced herself to the resident and the 2nd interaction occurred when she walked the resident to the dining room. Staff G reported she did not assist the resident with any cares before or after walking. Staff G stated it was very often typical for the 100 hall to be split and she did not feel the facility could safely meet the residents' needs because so far away from the other hallways can't hear the alarms. On 5/10/17 at 1:16 p.m., the Administrator stated the 100 hall was dedicated to skilled short term residents except for 2 residents that are long term with behaviors. The Administrator stated depending on time and complexity, the facility tried to staff a dedicated CNA if 4 or 5 skilled residents are on the hall. The Administrator stated with the census under 77, she did not feel case load there. The Administrator stated 1 resident on the 100 hall required assist of 2 staff members. The Administrator stated she thought therapy removed the wheelchair due to the resident's sciatica (nerve pain) and wanted the resident to move. The Administrator acknowledged she did not see any documentation of the resident refusing to walk. The Administrator stated the facility did have some pendent call lights (necklace) but the resident did not have one. On 5/10/17 at 2:40 p.m., Staff Q stated she worked 2:00 p.m. to 10:00 p.m. 4/29/17. Staff Q said she conversed with the resident after the fall and they had a good conversation. Staff Q stated she questioned the resident about what he/she was doing and the resident responded he/she tried to get up but did not have the wheelchair backed up to the wall. Staff Q said the resident reported he/she hit his/her head on the wall but not hard. Staff Q stated at the 7:30 p.m. check, the resident couldn't get any clear speech out. Staff Q reported that day to be the 1st time she met the resident. Staff Q stated the 1st time she saw the resident, she saw him/her in the dining room in a wheelchair but did not know who he/she was yet. Staff Q said the resident did not have a pendent call light and the residents that walk have pendent call lights. Staff Q recalled the resident self-propelled from the dining room in a wheelchair towards the hallways. Staff Q stated she did not know the resident was supposed to be ambulated because she did not recognize who he/she was the 1st time she seen him/her. Staff Q recalled Staff G pulled at 5:00 p.m. from the 100 hall because Staff U left. Staff Q stated the aides on the other 3 halls are responsible for covering the 100 hall. Staff Q said if on the 400 hall, she could not hear the 100 hall because of the big activity room between the halls. Staff Q said she could not hear the 100 hall from the 200 or 300 halls either. Staff Q commented with people with alarms, needed to have someone assigned to the 100 hall. Staff Q stated she understood 100 hall for the skilled short term residents and those residents needed more focus and attention. Staff Q said it seemed the 100 hall got pushed to the back burner when split rather than focusing on it due to greater acuity. In a family interview on 5/10/17 at 4:25 p.m., a family member stated he/she visited the resident on the morning of 4/29/17. The family member stated the resident reported when he/she put the call light on it took a long time for someone to respond. In an interview on 5/10/17 at 4:45 p.m., Staff A, RN/Corporate Compliance Nurse, stated the expectations is the plan of care tasks (Task List Report) to be completed by the CNA's. Staff A confirmed the resident should have been ambulated to and from the dining room. 100 Hall Census Information: The Daily Census report printed 5/10/17 documented the following number of residents residing on the 100 hall from 4/19/17 thru 5/10/17: a. 6 on 4/19 b. 5 on 4/20, 4/21 c. 4 on 4/22, 4/23, 4/24, 4/25 d. 5 on 4/26, 4/27 e. 6 on 4/28, 4/29 (1 discharged and 1 admitted this day), 4/30, 5/1 f. 5 on 5/2, 5/3, 5/4, 5/5, 5/6, 5/7, 5/10 Staffing assignments: From 4/1/17 thru 5/11/17, the daily hall assignment sheets titled Today's Care Givers, assigned no CNA's to the 100 Hall directly for the Day Shift (6:00 a.m. to 2:00 p.m.) on these dates: a. April - 4/15, 4/18 from 6:00 a.m. to 11:00 a.m., 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, 4/30 b. May - 5/1, 5/2, 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10 From 4/1/17 thru 5/11/17, the Today's Care Givers, assigned no CNA's to the 100 Hall directly for the Eve Shift (2:00 p.m. to 10:00 p.m.) on these dates: a. April - 4/10, 4/15 from 2:00 p.m. to 6:00 p.m., 4/17, 4/18 from 6:00 p.m. to 10:00 p.m., 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29 from 5:00 p.m. to 8:00 p.m., 4/30 b. May - 5/1, 5/2 from 2:00 p.m. to 7:00 p.m., 5/3, 5/4, 5/5, 5/6, 5/7, 5/8, 5/9, 5/10 from 6:00 p.m. to 10:00 p.m., 5/11 From 4/1/17 thru 5/11/17, the Today's Care Givers, assigned no CNA's to the 100 Hall directly for the Overnight Shift (10:00 p.m. to 6:00 a.m.) on these dates: a. April - 4/7 from 10:00 p.m. to 4:00 a.m., 4/20, 4/21, 4/22, 4/30 from 10:00 p.m. to 2:00 a.m. b. May - 5/3, 5/5, 5/6, 5/7 On 5/8/17 at 3:00 p.m. a group of 5 residents were interviewed. Five of the 5 residents in attendance voiced the facility is short staffed on Saturdays.

Based on observation, record review and staff interview, the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one resident with a pressure sore (Resident #1). The facility identified their census at seventy-six (76) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 11/25/15, assessed Resident #1 with long and short term memory impairments and severely impaired decision making skills. The resident required total assistance of 2 staff with bed mobility and transfers. The resident did not ambulate. The resident had functional limitations in range of motion of both upper and lower extremities. The resident used a wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident ' s height at 53 inches tall and his/her weighed at 99 pounds. The resident received nutrition via feeding tube. The MDS identified the resident at risk for pressure sore development and revealed the resident did not have pressure sores at the time of the MDS assessment. On 1/28/16 at 4:18 p.m., observation showed a dressing on the resident's right bunion (on his/her right foot). At that time, the Director of Nursing (DON) stated the bunion area reopened over the weekend. She stated staff should have applied a plaid Spenco boot to the foot for pressure reduction but instead staff applied a tan heel protector that covered half the foot and not the bunion area. The tan heel protector left the bunion area exposed and without protection of a foot protector. The DON stated the tan heel protector is what the resident wore when he/she came up with the open bunion last weekend. The DON stated it really frustrated her because they got the resident all healed and now it's open. At that time, the DON pulled back the dressing to reveal a dime size yellow scabbed area surrounded by redness on the right bunion. The resident wore off loading boots. Following observation of the bunion, at this time, the DON took the surveyor to the supply area and showed her the tan heel protector and plaid Spenco boot. Observation revealed the tan heel protector as a protector that would cover the heel area of the foot. Observation showed the plaid Spenco boot covered the heel and foot area. On 2/11/16 at 4:20 p.m. the DON stated the resident admitted to the facility with open areas including the right bunion area. She stated the bunion area took one year to heal and that the area remained healed for one year until it reopened 1/24/16. An admission nursing assessment dated [DATE] identified the resident admitted to the facility on that date with a 2 centimeter (cm.) by 1.6 cm. open area to the right bunion and multiple other pressure sores. A physician note dated 12/5/15 identified the resident admitted to the facility with multiple deep ulcerations of the sacrum, back and extremities. The resident underwent [REDACTED]. The resident gradually progressed to where the ulcers completely healed. The resident remains bedridden with [DEVICE] feeding but condition stabilized. The resident is on Hospice care. The progress note identified the resident with peripheral artery disease. A care plan with last care plan date of 12/1/15, identified the facility implemented off loading boots on 1/24/16. At the time staff initiated off loading boots, they resolved the intervention of Spenco boots on when in bed. The Spenco boot intervention contained the start date 9/26/13. On 2/15/16 at 11:55 a.m. the DON identified the Spenco boot as a plaid boot that covered the whole foot. Prior to the bunion reopening, the resident used a tan covered heel protector that covered the heel area, not the bunion. A facsimile (fax) to the physician dated 1/24/16 identified an open area on the right bunion with surrounding redness. An addendum dated 1/27/16, identified the area with a yellow center. The physician ordered [MEDICATION NAME] DS (antibiotic) twice a day for 2 weeks and [MEDICATION NAME] (antibiotic) ointment to the bunion twice a day for 2 weeks. On 2/4/16 at 11:50 a.m. Staff G (licensed practical nurse) identified herself as the primary nurse on Resident #1's hall. She stated prior to the bunion area reopening, the resident used the tan heel protector which did not cover the bunion area. On 2/15/16 at 9:45 p.m. the surveyor requested the latest dietary assessment for protein needs since the bunion reopened on 1/24/15. The facility gave the surveyor a dietary note dated 11/25/15 at 1:06 p.m. that did not identify the resident with a pressure sore. A pressure ulcer documentation form dated 1/24/16, identified a Stage 2 pressure sore to the right bunion measuring 1 cm. by 1 cm. with a small amount of serosanguinous exudate. The sore contained a red wound bed and wound edges and surrounding tissues appeared red. The most current assessment of the bunion pressure sore dated 2/15/16 revealed a 1 cm. by 1 cm. stage 2 area to the right bunion with a small amount of serosanguinous exudate. The wound bed, wound edges and surrounding tissue appeared pink and white. Observation revealed on 2/4/16 at 10:30 a.m., the resident in bed with offloading boots on. On the same date at 11:30 a.m. the resident sat in a wheelchair with offloading boots on. On the same date at 4:35 p.m. the resident laid in bed with the offloading boots on.

Based on record review and interviews, the facility failed to provide adequate supervision to protect one of five residents (Resident #6) from hazards; and failed to maintain the resident ' s safety after a fall when staff moved the resident. Resident #6 fell from his/her bed on 12/12/15 and staff interviews revealed they did not know how long the resident ' s alarm had been sounding before they responded. Interviews revealed the resident reported hip pain when staff tried to sit him/her up and staff then rolled the resident to his/her back and the resident yelled out. The nurse reported the resident refused to cooperate and could not straighten his/her legs. The next day, the oncoming aides transferred the resident (not knowing the resident had fallen the night before) and the resident would not bear weight on his/her right leg. Resident #6 sustained a fractured right hip. The facility census was seventy-six (76) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 12/9/15 assessed Resident #6 with a Brief Interview for Mental Status score of 3 which indicated the resident had severe cognitive impairment. The resident required limited staff assistance with bed mobility, transfers and ambulation. The resident required total staff assistance with toileting. A balance during transitions and walking test revealed the resident with a score of 2 in all areas of testing. A score of 2 identified the resident as not steady and only able to stabilize with staff assistance. The resident had [DIAGNOSES REDACTED]. A care plan dated 10/8/15 identified the resident admitted to the facility 6/2/15. The care plan identified a problem of history of falls. The care plan directed staff to transfer and ambulate the resident with a walker, one staff and gait belt. The resident used a high low bed with mat on the floor when in bed and a sentry pad alarm at all times. The care plan identified the resident on Hospice care. Record review documented Resident #6 had 5 recent falls with no injury (on 12/7/15, 12/5/15, 12/2/15, 11/9/15, 11/1/15). An incident report dated 12/12/15 at 9:30 p.m. revealed the resident's alarm sounded and a nurse aide called for the nurse. Staff observed the resident lying on his/her right side beside the recliner. Prior to the fall, the resident was in bed. The resident said he/she fell on the cement. The resident did not have gripper socks on. The resident uncrossed his/her legs independently and complained of soreness all over. Staff completed a body check and did not note any injury. Staff sat the resident up and then stood the resident with 3 staff and a gait belt. Staff placed the resident in a wheelchair and then in bed. At the time of the fall, the resident's mobility status was ambulatory with the assistance of one staff and assistive device. The incident report identified the following predisposing factors prior to the fall: poor lighting, confusion, impaired memory, improper footwear, alarm on and sounding, ambulating without assistance and siderails up. A fall investigation identified the resident with a history of falls and antianxiety drug use. The resident got up and ambulated. The incident report identified that the resident resided on the 200 hall. On 2/4/16 at 4:15 p.m. Staff A CNA stated she was in room 111 with a resident and could not leave when the incident occurred. Staff A identified herself as the only staff on the 100 hall at the time. She identified one CNA (Staff B) on the 200 hall. The other CNA on the 200 hall left at 9 p.m., leaving Staff B by herself. Staff A did not hear the alarm until she came out of a resident ' s room. She went to the resident's room and was the first staff to arrive. She did not know how long the alarm sounded before she got there. She stated she put a pillow under the resident's head and got the nurse. The resident complained of pain. She stated staff got the resident up with a gait belt and the resident did not bear weight on the leg. Staff A stated they got the resident up before staff assessed the resident. After they got the resident in bed, Staff A left the room. On 2/9/16 at 2:15 p.m. Staff B CNA stated she worked with another resident in 208 when the resident fell . She stated she could not hear the alarm until she opened the door. When she opened the door she saw Staff A heading for the room. She stated she could not hear the alarm in 208 because the television was on and at the same time, she and the resident in 208 talked. She stated Resident #6's hip hurt really bad when they tried to sit the resident up. When staff rolled the resident to his/her back the resident yelled out ow. They got the resident in bed and once in bed, the resident went to sleep. On 2/8/16 at 7:41 p.m. Staff C (RN- registered nurse) stated the resident did complain of pain but once he/she got in bed, he/she did not complain. She administered pain medication to the resident. Through the night, the resident appeared awake but did not have pain complaints. When assessed, the resident refused to cooperate and visually the resident would not straighten his/her legs. Staff C stated she did not hear the alarm. She was on another hall counting narcotics. She identified the resident's bed as in low with a mat and the resident used 1/2 siderails. On 2/9/16 at 3:44 p.m., Staff D (CNA) stated she worked the overnight shift after the fall. She stated she repositioned the resident and he/she would moan but the resident would kind of moan anyway, prior to the fall. It was not really any different than before. She did not notice anything abnormal. On 2/10/16 at 8:50 a.m. Staff E (CNA) stated when she first arrived at work the morning after the fall around 7:30 a.m., no one reported any changes or anything about the resident having a fall. She heard the resident hollering, which the resident usually does but the hollering sounded different and the resident looked like he/she was in pain. Staff E got the resident ready and then transferred the resident with another staff. The resident drug the leg which was not like usual, and then the resident started rubbing the leg. Staff E reported to the nurse that she didn't know what was wrong with the resident but when they transferred him/her the resident started grabbing his/her leg. That is when the nurse informed her of a fall the night before. At one point Staff E observed the resident's foot hanging and when Staff E moved it gently, the resident rubbed the leg as if it hurt. Nursing progress notes dated 12/13/15 at 9:51 a.m. revealed the resident fell the night before and during morning care, the resident yelled out with facial grimacing when staff moved the right extremity. When the resident sat in a wheelchair, the resident appeared quiet. The resident tried not to bear weight on the right extremity. At 9:55 a.m. staff administered Morphine (narcotic) for right leg pain between the knee and hip. The resident's pain rated 9 on a scale of 0 to 10 with 10 being the most pain. Staff notified the physician and the resident transported to the emergency room (ER) for evaluation at 10 a.m. On the same date at 11:40 a.m. the hospital called and advised the facility that the resident had a fractured trochanter that required a total hip replacement. An imaging report dated 12/13/15 identified an x-ray of the right hip showed a comminuted nondisplaced intertrochanteric fracture of the proximal femur. An Orthopaedics Inpatient Consultation dated 12/13/15 revealed the physician discussed the risks of surgery with the resident's responsible party. The risks of surgical intervention included bleeding, infection, blood clot, neurovascular damage, nonunion, delayed union, malunion, hardware complications, need for further surgery, anesthesia related complications, postoperative medical complications, even death. An Orthopedics Operative Note dated 12/14/15 revealed the resident underwent [REDACTED]. A provider note dated 12/15/15 identified the repair as a closed reduction, intramedullary hip screw fixation, right. Nursing progress notes identified the resident returned to the facility 12/18/15 at 8:50 a.m. with a right hip fracture incision to the upper right hip 5 centimeters (cm.) with 14 staples, mid incision 3 cm. with 6 staples and lower incision 2.5 cm. with 6 staples.

Based on record review, family interview, staff interview and policy review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 10 residents reviewed (Resident #2 and Resident #1). Facility census was seventy-six (76) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 10/7/14 assessed Resident #2 with a brief interview for mental status (BIMS) score of 14 (no cognitive impairment). Resident #2 required total staff assistance with transfers an extensive assistance with toileting and listed Resident #2 as non-ambulatory. The MDS identified impairment in range of motion of one side of the upper extremities for Resident #2. The MDS [DIAGNOSES REDACTED]. Resident #2 measured 72 inches tall and weighed 301 pounds. The MDS listed Resident #2 lacked bruises or skin tears identified on the MDS. A care plan contained an intervention dated 7/12/14 that directed staff to use a 4 point (Hoyer mechanical) lift with two assist to transfer the resident. An incident/accident report dated 7/17/14 identified Resident #2 received a 2 centimeter (cm) skin tear to the right anterior shin from using the PALs (mechanical) stand lift. Resident #2 stated his/her legs bumped the leg on the pads of the lift. The skin investigation form dated 7/17/14 revealed the injury occurred when nurse aides assisted Resident #2 into the PALs stand lift. After the incident the facility educated staff members on proper positioning of residents legs when staff members utilized the PALs stand lift. A skin tear assessment dated [DATE] at 8 a.m. revealed Resident #2 received a skin tear to the left outer leg measuring 3cm by 2 cm. A written document provided on 4/27/14 at 9:30 a.m., revealed the Administrator documented that Resident #2 came from the hospital on [DATE] with a skin tear in the same area. The area healed on 7/25/14. She wrote that the area obtained 8/4/14 was the same area. On 4/28/15 at 12:30 p.m. the Director of Nursing stated the facility failed to complete an incident report or an investigation regarding the skin tear. An incident/accident report dated 8/9/14 at 12:30 a.m. revealed staff observed a 9 cm by 3 cm very dark blue purple bruise to the right inner sole of the foot. A skin investigation form dated 8/11/14 at 10:00 a.m. revealed Resident #2 received a 4 cm by 3 cm bruise to the right inner foot. The form identified the cause of the injury as Resident #2 up with two staff members and the PALs stand lift. Resident #2 also had [DIAGNOSES REDACTED]. The intervention was to apply Sween (moisturizing) Cream to the lower legs at bedtime. A bruise assessment dated [DATE] at 10:55 a.m. revealed Resident #2 had a 6 cm by 2.5 cm bruise to the inner right foot. In a written document provided to the surveyor by the Administrator on 4/27/14 at 9:30 a.m., the Administrator documented the 8/9/14 and 8/18/14 areas involved the same incident. The 8/18/14 bruise assessment identified staff received education to use care with Resident #2's legs and feet during transfers. A rehab communication form dated 8/18/14 written by the physical therapist enforced that staff needed to transfer Resident #2 via the 4 point Hoyer (mechanical) lift. On 4/28/15 at 12:30 p.m. the DON identified the 8/9/14 and 8/18/14 areas as the same incident. An incident/accident report dated 9/2/14 at 12:20 a.m. and bruise assessment form identified Resident #2 with a flat dark blue light red bruise measuring 2.5 cm by 2 cm to the lower right knee/inner leg that Resident #2 identified as a little tender to the touch. Resident #2 stated he/she probably bumped it. The report also identified a 2 cm by 0.2 cm by 0.3 cm. abrasion area to the left outer hip. Resident #2 stated he/she scratched the area. An accident/incident report dated 10/4/14 at 7:10 p.m. revealed Resident #2 received a 3 inch by 1.5 inch raised hematoma to the left inner shin after staff transferred Resident #2 with the PALs stand lift. In an undated skin tear questionnaire, Resident #2 stated the injury occurred when transferred with the PALs lift and that the area was painful. On 4/22/15 at 2:20 p.m. Staff B Certified Nursing Assistant (CNA) stated she assisted Staff A, CNA with Resident #2's transfer. Prior to the transfer, Staff A stated Resident #2 should use a 4 point lift for the transfer but they would go ahead and use the PALs. Regarding Resident #2 using the PALs lift and not the 4 point Hoyer lift, the Administrator stated a physical therapy treatment note dated 8/7/14 and 9/4/14 indicated Resident #2 was safe using the PALs lift. On 4/27/15 at 3:15 p.m. the physical therapist that wrote the entry stated Resident #2 was just safe for that day with the one transfer she observed. Resident #2 was inconsistent with transfers and that is why she did not change the directive to staff. Staff still needed to use the 4 point lift with all transfers. According to Resident #2 ' s care plan regarding mobility listed interventions for staff to utilize a 4 point mechanical lift and 2 staff members to transfer Resident #2. The care plan identified the PALS transfer intervention was cancelled on 6/20/14 Interview on 4/23/15 at 12:09 p.m., revealed Staff S confirmed Resident #2 began using the 4 point mechanical lift on 7/12/14 and the directive was in place through 10/4/14. 2. A MDS assessment reference date of 3/10/15 assessed Resident #1 with an impaired ability to understand others. The MDS identified Resident #1 responded adequately to simple direct communication only. Resident #1exhibited short and long term memory impairments and moderately impaired decision making skills. Resident#1 experienced moderate difficulty hearing. Others had to increase volume and speak distinctly when talking with him/her. Resident #1 had impaired vision and could see large print but not regular print. Resident #1 wore glasses. Resident #1 exhibited the following symptoms of delirium: inattention, disorganized thinking and delusions. Resident#1 required extensive assistance of two staff with bed mobility, transfers and toileting and required total assistance of one staff with personal hygiene (oral care). Resident #1 was non-ambulatory. Resident #1 was frequently incontinent of bladder. The MDS identified Resident #1 ' s [DIAGNOSES REDACTED]. Resident #1 was 62 inches tall and weighed 215 pounds. The MDS listed Resident #1 exhibited no bruises or skin tears. Resident #1 received antipsychotic, antianxiety and antidepressant medication daily. An incident/accident report dated 7/3/14 at 4:30 a.m. revealed staff observed bruising to the right outer leg. The first area measured 14 cm by 2 cm by 7 cm and the second area measured 7 cm by 2 cm. The skin investigation form identified the cause of the bruising as transfer from wheelchair to toilet. The form identified staff changed the care plan and directed staff to use geri legs for Resident #1. An incident/accident report dated 7/8/14 at 1:20 a.m. revealed staff observed a 5.4 cm by 6 cm dark purple hematoma to the right lower inner leg. The skin investigation form identified that Resident #1 propelled self and may have bumped his/her own leg. In the area care plan changes made, staff wrote wear geri-legs. An incident/accident report dated 7/22/14 at 3 p.m. revealed staff observed two bruises on each buttock. Staff measured a 5 cm by 3 cm bruise to the right buttock and a 2 cm by 1 cm bruise to the left buttock. The skin investigation form identified increased difficulty with transfers and toileting. Resident #1 may have hit the side bar of the toilet with transfer to the toilet. The bruise assessment form dated 7/22/14 identified the immediate nursing intervention was to remind staff to assist Resident #1 with sitting down on the toilet and wheelchair so Resident #1 is seated softly. The care plan directed staff to use the PALs (stand) lift when toileting Resident #1. A rehabilitation screen dated 7/23/14 identified the nursing department stated Resident #1 received bruises on the buttocks from attempting to sit too early when transferred to the toilet. Therapy directed staff to use the PALs (stand lift) when toileting Resident #1. An incident/accident report dated 8/1/14 at 9:50 a.m. identified a 4.5 cm by 0.5 cm purple bruise to the right inner knee cap. The bruise assessment form dated 8/1/14 identified the immediate nursing intervention to prevent further injury as educating the nurse aide to watch leg placement when transferring Resident #1. The skin investigation form dated 8/1/14 revealed Resident #1 with increased difficulty with transfers. Staff gave a rehab screen to physical therapy (PT) to assess transfers. Physical Therapy (PT) identified Resident #1 was screened May, June and July. Staff review 7/23/14 screen for more information. Staff added the following intervention to the care plan: Watch body positioning when using PALs lift and put towel between lift pad and knees. An incident/accident report dated 8/2/14 at 11 a.m. a 2.5 cm by 1.2 cm light purple bruise to the left pinky. The area appeared slightly swollen. The report identified Resident #1 in the bathroom with two CNA ' s. As CNA ' s transferred Resident #1 off the toilet and lifted Resident #1up in the PALs lift, Resident #1 stated ouch so the CNA ' s stopped and noted Resident #1's left pinky stuck between the toilet bar and the PALs lift. Staff gave Resident #1 an ice pack and asked him/her to hold it over the area. The skin investigation form dated 8/4/14 identified staff needed to show more attention to Resident #1 ' s hand placement on PALs lift during transfers. The care plan intervention following the incident was watch hand placement on PALs handle during transfers. A bruise assessment dated [DATE] at 4:30 a.m. revealed a 1 cm hematoma bruise to the right outer elbow. The immediate intervention identified staff applied geri gloves and on 8/15/14 staff padded the side-rails. On 4/28/15 at 10:53 a.m. the Director of Nursing stated the paperwork regarding the incident did not include whether geri sleeves were in place when staff found the bruise so she did not know. An incident/accident report dated 8/28/14 at 12:30 a.m. revealed staff observed a 4 cm by 5 cm bruise to the lower inner thigh. The skin investigation form identified the care plan change after this bruise as staff educated when using PALs lift to remind Resident #1 to keep feet planted on platform and to watch for leg/knee placement. (Already done with 8/1/14 incident) Staff asked Resident #1 if he/she knew what caused the bruise. Resident #1 ' s unable to relay the cause of the bruise. An incident/accident report dated 9/6/14 at 3:45 a.m. identified Resident #1with a 2.5 cm by 2 cm and 3.5 cm by 2 cm firm dark blue bruise to the area below the right knee/inner leg. Staff asked Resident #1 if he/she knew what caused the bruise. Resident #1 ' s not aware of the cause of the bruise. The skin investigation form identified the cause of the incident as knees rubbing together. The intervention was to place a pillow or bath blanket between legs when in bed. An incident/accident report dated 10/8/14 at 2:30 p.m. identified Resident #1 with a dark purple bruise measuring 1.5 cm by 1.5 cm anteriorly and 4.5 cm by 3 cm bruise posterior on the left fifth digit. The area appeared swollen but Resident #1 could move the finger. A skin investigation form dated 10/8/14 identified that when staff raised Resident #1 up with the PALs lift, the left 5th finger jammed between the bar of the Pals lift and the safety bar on the bathroom wall. The intervention was that staff would change the position of the bar in the bathroom. A skin tear assessment dated [DATE] at 5 a.m. identified Resident #1 with a 0.2 cm laceration with dried blood to the right corner of the mouth. The facility faxed the physician about the laceration on 1/24/15. The fax informed the physician that staff did not know when the laceration occurred and Resident #1 grimaced when staff gently touched and cleansed the area. The care plan identified an intervention for Chapstick on 1/26/15. Interview on 4/23/15 at 8:08 a.m. Staff O LPN (licensed practical nurse) stated she could see the cause of the cut by the mouth as from denture placement. Staff O stated staff was directed to put Chapstick on the area. Interview on 4/23/15 at 9:20 a.m., when asked about the cut by Resident#1's mouth, the Director of Nursing (DON) stated Resident #1 had dry skin. Interview on 4/23/15 at 10:05 a.m. Staff A CNA stated she saw the cut by Resident #1's mouth. She stated she didn't think Resident #1's mouth appeared dry or chapped. An incident/accident report dated 1/26/15 at 2:00 p.m. revealed Resident #1 with a deep purple bruise to the left upper posterior arm and identified staff was unsure of the cause. A bruise assessment identified the area measured 4 cm by 3.5 cm with an immediate intervention to educate staff to handle Resident#1's arms gently with dressing and transfers. A skin investigation form dated 1/26/15 identified the factors that caused the incident as resident transferred with PALs lift and bumped on handrail in bathroom. The form listed care plan changes as geri arms at all times (already in place, see 7/3/14 intervention) and remove bathroom handrail. On 4/28/15 at 12:55 p.m. Staff C (maintenance) stated he removed the grab bar on 1/29/15. The surveyor asked him if bathroom handrail and grab bar meant the same thing and he stated yes. An incident/accident report dated 1/30/15 at 9:30 a.m. revealed staff observed a faded bruise to the Resident #1's right posterior hand. The bruise extended from the posterior palm to the nail beds of the Resident#1's 3rd and 4th digits. A skin investigation form dated 1/30/15 at 9:30 a.m. identified the bruise to the right hand to measure 12 cm by 6 cm. The form identified the factors that caused the incident/injury as the grab bar in the bathroom. The form listed the care plan changes as remove grab bar in bathroom. An incident/accident report dated 2/23/15 at 10:30 a.m. revealed staff observed a deep purple flat bruise to Resident #1's right posterior hand with unknown cause measuring 7 cm by 7 cm. A skin investigation form dated 2/24/15 identified factors that caused the injury as Resident #1 propelling self and occasionally cutting corners too closely. The form listed the care plan changes as geri-gloves at all times (already in place). A bruise assessment dated [DATE] at 11:20 a.m. revealed staff observed a 7 cm by 5.5 cm bruise to the left lower cheek/jaw. An incident/accident report dated 4/11/15 at 10:15 a.m. revealed staff observed a 17 cm by 4.5 cm bruise to Resident #1's under arm into the breast line due to an unknown cause. The report identified the nurse educated staff to not dress the resident with a bra to see if that caused the injury. A skin investigation form identified the factor that caused the bruise as bra too tight. The form identified the care plan changes as phones family for larger bras and 4 point (Hoyer mechanical) lift. There was no evidence the facility visited with staff that took care of Resident#1 to determine if anything unusual occurred to cause the bruise. On 4/30/15 at 3:34 p.m. Resident #1's daughter stated she had purchased new bras for Resident #1 6 to 8 months ago and she knew Resident #1 did not increase in size since that time so she did not believe the bras caused the bruising. The daughter thought the PALs lift must have caused it. Regarding the 4/11/15 bruise, Staff B CNA stated she saw the bruise at 6:00 a.m. that morning. The day before Resident #1received a shower and the bruise was not there then. On 4/25/15 at 4:53 p.m. Staff P CNA stated she didn't know how Resident #1 got bruises unless staff didn't watch when using the PALs lift. On 4/22/15 at 11:03 a.m. Staff G (nutritional aide) identified Resident#1's fingers and hands as always black and blue. Resident #1 wore geri-sleeves. On 4/23/15 at 9:20 a.m., when asked if Resident #1 bruised easily, the DON stated Resident #1 had a lot of bruises and resisted care. On 4/22/15 at 12:35 p.m. Staff K LPN stated Resident #1 bruised easily. Resident #1 took Aspirin and Resident #1 also pushed self in the wheelchair and might catch his/her hands on the wall. That is why Resident #1 used geri-sleeves. On 4/22/15 at Staff J RN (registered nurse) stated Resident #1 bruised easily and she thought the physician should order blood work to check for a cause. On 4/27/15 at 12:03 p.m. Staff Q CNA stated Resident #1 kept his/her hands in his/her lap when wheeling in the wheelchair. Resident #1 used his/her feet to propel the wheelchair, not the hands. She stated 9 times out of 10 the hands would get bruised in the bathroom from the rails on the toilet or else the bedrails. On 4/22/15 at 11:30 a.m. Staff I LPN stated Resident #1 got bruises from the PALs lift. On 4/22/15 at 3:27 p.m. Staff E CNA stated other staff would tell her Resident #1 received bruising on the hands from the bar in the bathroom or the PALs lift. On 4/27/15 at 10:22 a.m. Staff E stated Resident #1's hand got pinched in the bar by the toilet. It would pinch between the lift and the bar. The hands got pinched a lot or else Resident #1's hands hit the bathroom door when staff took Resident #1 out of the bathroom. Staff E stated Resident #1 quit wheeling self a long time ago. On 4/27/15 at 11:36 a.m. Staff R RN stated staff kept slamming Resident #1's finger when they took Resident #1 into the bathroom just because staff members didn't watch. Staff just rammed the resident in there. One time, Resident #1's little finger even appeared broken. Another time staff saw bruising to the lower inner thigh above the knee. Staff R stated it appeared from staff grabbing Resident #1's leg. Facility policy identified injury of unknown origin as an injury in which the source of the injury was not observed by anyone or the resident could not explain the source of the injury or if the injury was suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one point in time or the incidence of injuries over time. On 4/27/15 at 2:40 p.m. the Administrator stated if the intervention is staff education that is all verbal and there would be nothing else written about it to record the education.

Based on record review, interviews and undated policy/procedure review the facility failed to ensure proper supervision, procedures and Care Plan interventions are followed to minimize the risk of falls and/or injury for 2 of 5 residents reviewed with a history of falls (Resident #10 and Resident #12). The facility reported a census of 76 residents. Findings included: 1.Resident #10's 12/30/14 Minimum Data Set (MDS) assessment documented Resident #10 Brief Interview for Mental Status score of 10 indicated moderately impaired cognitive function, required extensive assistance of 2 staff for transfers and did not ambulate. The MDS [DIAGNOSES REDACTED]. Resident #10's MDS listed a weight of 291 pounds. Review of Resident #10's Care Plan initiated December 2014 revealed a history of falls and intervention to utilize a four point lift for all transfers. Review of the facility undated procedure for the four point lift revealed the following information: a. Sling color/size guide b. The back of the lift contains a list of residents that utilized the lift to include the color of sling for each resident. (Notify the Director of Nursing (DON) for any updates to the list). c. Safety tip #1 directions include checking the slings for excessive wear and remove from service if found. Notify management to replace slings removed from service. d. Safety tip #2 directions include straps placed onto lift and assure tight as resident lifted. The slip clip needs secured to the lift prior to lifting the resident. Review of the progress note dated 1/21/15 at 4:09 p.m. revealed staff documented Resident #10 required a four point lift to transfer for safety. Resident #10 no longer strong enough to hang on to the PALS mechanical transfer device and keep his/her feet on the platform. Progress notes on 1/21/15 at 11:43 p.m. staff documented an attempt to transfer Resident #10 out of the wheelchair to bed using the 4-point lift. Resident #10 ended up on his/her back on the floor with the lower straps of the lift pad still attached to the lift. Resident #10 complained of pain on the right side of head, toward the posterior aspect. Staff noted a small raised area. Resident #10 indicated tenderness when area touched. During interview on 4/21/15 at 3:12 p.m. the Director of Nursing (DON) stated the resident had fallen because a sling strap came unhooked. She stated they had done staff education in regard to how to properly attach the straps of the sling to the lift. She stated the Certified Nursing Assistant (CNA) involved had been temporary agency staff. During interview on 4/22/15 at 7:58 a.m. the DON demonstrated how staff attached the sling by means of straps to the mechanical 4-point lift. The straps had flat rectangular attachments on the ends with keyhole shaped cutouts. The larger portion of the cutout fit over a knob on the lift then the attachment had to be pulled down to place the smaller end of the attachment over the knob which locked the strap in place. She stated when the resident fell this had not been done, the strap came loose and the resident fell . During interview on 4/22/15 at 8:31 a.m. Staff A, CNA stated the person who hooked up Resident #10 ' s sling straps on 1/21/15 was Staff D, CNA, temporary agency staff. Staff A stated Staff D had not worked in the facility before. Staff A stated as Staff D raised Resident #10 up with the lift one of the top straps came loose. Staff A stated one minute Resident #10 was going up and the next the resident laid on the floor. Staff A stated Resident #10 fell back on the wheelchair and fell over with it. Staff A stated facility staff are trained to lock the straps in place Staff A stated with pool aides you are not sure what they know. Staff A stated earlier that shift staff used the same lift to transfer another resident so Staff D should have known how to hook it up. During interview on 4/22/15 at 10:22 a.m. Staff C, CNA confirmed he worked at the facility in January 2015 as temporary agency staff. Staff C stated when he started working at the facility he received no orientation to the facility or facility equipment. Staff C stated the 4-point lift was different and he had not previously used it. Staff C stated other staff at the facility showed him how to use it and to be sure the straps were locked in place. During interview on 4/22/15 at 12:14 p.m. Staff B, CNA confirmed she had worked at the facility in January 2015 as temporary agency staff. Staff B stated she received no formal orientation to the facility or the equipment used. Staff B stated the aides she worked with oriented her to the 4-point lift. Staff B didn't know about any orientation program in the facility. Staff B stated she last worked in the facility in middle of March 2015. During interview on 4/22/15 at 8:59 a.m. the DON produced a check list currently used to orient temporary agency staff. The DON stated the facility began using the orientation form in February. The DON stated the facility lacked documentation of any orientation provided to Staff D. During interview on 4/22/15 at 11:11 a.m. Resident #10 stated he/she remembered falling from the sling lift. Resident #10 stated not able to recall any injury with fall. Resident #10 claimed he/she felt fearful of being transferred using the lift. When asked how long he/she remained fearful after the fall Resident #10 stated he/she still felt afraid. Resident #10 stated he/she wished the mechanical lift didn ' t need to be utilized. 2. According to Resident #12 ' s MDS dated [DATE] revealed a BIMS score of 15 that indicated intact cognition. The MDS identified Resident #12 required one staff members assistance for transfers and ambulation and mobility devices used included a walker and wheelchair. Resident#12's Care Plan initiated 8/25/14 stated he/she required assistance with bathing dressing, set-up for grooming, mobility and toileting due to unsteadiness secondary to Parkinson's Disease. Beginning on 8/25/14 Resident#12's Care Plan directed one staff to assist for transfers using a gait belt. The Care Plan further directed staff to apply a seat belt alarm in the wheelchair and recliner beginning on 9/6/14. On 1/25/15 at 6:10 p.m. staff documented on an Incident/Accident Report Staff B, CNA assisted Resident#12's roommate in the bathroom. Resident #12 rose from a seated position to retrieve something from a drawer. According to the incident report staff failed to ensure the alarm was turned on. Staff B CNA found Resident #12 on his/her knees attempting to rise after a fall. Resident #12 exhibited had no apparent injuries. A 1/26/15 typed document titled Discussion with (Staff B) stated Staff B confirmed in the bathroom with Resident #12 ' s roommate when she heard Resident #12 fall. When asked why the seatbelt alarm had not been hooked-up Staff B stated he/she forgot.

Based on observation, record review, and staff interviews, the facility failed to assess Resident #2 for pain and provide interventions in order to decrease pain. The sample consisted of 13 residents and the facility reported a census of 78 residents. Findings included: 1. The Minimum Data Set (MDS) assessment tool, with a reference date of December 30, 2013, documented Resident #2 with severe cognitive impairment, inattention, disorganized thinking, altered level of consciousness, psychomotor [MEDICAL CONDITION], and verbal behaviors directed towards others daily. The MDS documented the resident required total staff assistance for personal cares, had not walked, and with occasional moderate pain according to the resident. The MDS documented the resident's [DIAGNOSES REDACTED]. The MDS documented one Stage 3 pressure ulcer and three Stage 4 pressure ulcers and all pressure ulcers present when admitted . In addition, the MDS documented two unstageable pressure ulcers present and present when admitted . The resident's Care Plan identified a Focus area, pain with repositioning, [DIAGNOSES REDACTED]. Interventions directed staff to medicate as ordered, utilize PRN (as needed) medication, assess for effectiveness and notify the physician if ineffective. The plan directed staff to reposition the resident slowly, provide reassurance with cares and repositioning, and the resident stopped yelling at times with a calm approach, eye contact, and reassurance. The same Care Plan identified a focus area for severely impaired cognition. The resident soft spoken and mumble at times and other times screamed and cursed clearly (initiated 7/31/13, revised 1/6/14). An MDS Coordinator Progress Notes entry dated 1/13/14 at 12:51 p.m. documented a resident goal to not disrupt others unmet. The note documented the resident screamed and yelled with cares, staff attempted interventions such as talking quietly to the resident during cares and change the subject for distraction, interventions frequently, but not always, successful, and directed staff to continue the same approaches. An MDS Coordinator Progress Note entry dated 1/13/14 at 1:12 p.m., documented a resident goal to yell out less with repositioning partially met. The note documented diversion and soothing conversation during transfers and repositioning improved this goal and to continue [MEDICATION NAME] (Tylenol) on a scheduled basis. The January 2014 Medication Administration sheets documented the resident received Tylenol 650 mg. (milligrams) three times daily at breakfast, noon, and evening for contractures of multiple joints. Additional medications included [MEDICATION NAME] 50 mg. at breakfast and in the evening for [MEDICAL CONDITION], pressure ulcer to hip and joint contractures and [MEDICATION NAME]/[MEDICATION NAME] 5/325 mg. every four to six hours as needed for moderate pain. The medication sheet indicated the resident received one dose of [MEDICATION NAME]/[MEDICATION NAME] on 1/7/14 at 9:38 p.m. and none since then. A nursing Progress Note documented the resident had knee pain at the time and the resident asleep at 11:03 p.m. During observation on 1/28/14 at 8:08 a.m., Staff AQ and Staff BX CNA's (Certified Nurse's Aide) provided morning cares. Staff AQ informed the resident she planned to wash his/her face and the resident screamed for help. Staff AQ washed the resident's face gently and the resident screamed for help. Staff AQ stated the resident screamed loudly when catheter care given and the resident proceeded to scream and curse during catheter care. The staff turned the resident to the left side and observation revealed the resident had a loose coccyx dressing, open at the bottom, and a moderate amount of soft stool on the resident's body below the coccyx dressing and near the rectal opening. Staff AQ cleaned the stool from the resident's body and the resident screamed "help me" several times and face grimaced. Observation after the stool cleaned revealed open skin at the bottom of the coccyx dressing and near the resident's rectal opening. When staff washed the resident's fee, the resident screamed "help me, my feet". The resident screamed when the staff used a full body lift and transferred the resident to a wheel chair. The resident stated it felt uncomfortable when first sat in the wheel chair. Following oral care, the resident denied pain and stopped screaming. During observation on 1/28/14 at 1:20 p.m., Staff CX CNA assisted the resident with active/passive restorative exercises to the arms and legs, played balloon toss, the resident stacked four cones, and moved rings from the left side to the right side. Staff CX spoke quietly to the resident and the resident completed the program without screaming and hollering. Facility Wound Care Skin Integrity Evaluation sheets dated 12/12/13 documented the resident with the following stage 3 pressure ulcers: a. Coccyx ulcer 5.0 by 0.60 by 0.3 cm (centimeters) present since 7/18/13 (admitted ). b. Left upper sacrum ulcer 0.7 by 0.5 by less than 0.2 cm since 7/18/13. c. Left iliac crest ulcer 1.20 by 0.50 by 0.20 cm since 7/18/13. d. Left trochanter ulcer 3.00 by 1.80 by 0.5 cm with 1.0 cm undermining from seven to nine o'clock. The nursing Progress Notes documented the resident with the following wounds on 1/20/14 at 11:19 a.m. a. Coccyx wound 4.0 by 0.8 by 0.3 cm (centimeter), wound bed with 100% granulation, peri wound pink and fragile, unable to assess drainage as dressing off. b. Left upper sacrum intact. c. Left iliac crest 0.8 by 0.3 cm with 100% granulation, peri wound pink and fragile, scant amount of serosanguinous drainage. d. Left trochanter 2.8 by 1.5 by 0.2 cm with 0.2 cm undermining at 6 to 8 o'clock, wound bed 100% granulation, peri wound pink and fragile, and scant amount of serosanguinous drainage. In addition, a nurse Progress Note entry, dated 1/17/14 at 10:03 p.m., documented a new superficial skin ulcer, measured 1 cm by 0.2 cm, and located distal to the coccyx and above the rectum. During observation on 1/29/14 at 11:03 a.m., Staff AF completed the treatments for the resident's pressure sores on the resident's left hip/buttock and coccyx/rectal area: Staff AF informed the resident of the dressing change steps ahead of each step. Staff AF removed the dressings from the pressure sores and used clean 4 by 4 gauze pads and Sea Clens Wound Cleanser to clean the left upper sacrum, left iliac crest, left trochanter, and coccyx/rectal area wounds. The resident hollered out when staff cleansed each wound. Staff AF used a cotton tipped applicator with Hydrogel, wiped the applicator briefly over the open wounds on the left iliac crest, left trochanter, and coccyx/rectal areas, and the resident hollered out each time the applicator touched the open area. Staff AF covered the wounds with dressings; applied light pressure to secure the dressings in place, and the resident hollered out and grimaced. The resident yelled out "felt it" when staff applied the dressing on the left iliac crest. During an interview on 1/29/14 at 3:20 p.m., a Nurse Consultant stated she checked the resident's medical record and failed to find documentation that staff attempted to administer [MEDICATION NAME] prior to treatments and cares. The Nurse Consultant stated the nurse talked to the resident and explained what she was doing during wound care. During an interview on 1/30/14 at 1:55 p.m., Staff BK LPN (Licensed Practical Nurse) stated she performed the resident's daily wound care most of the time and informed the resident of the process step by step. Staff BK stated she showed the resident each item used during the treatment and the resident yelled out at times when heard a package open. Staff BK stated [MEDICATION NAME] prior to the treatment had not been attempted because the resident's stomach may become upset from the [MEDICATION NAME]/[MEDICATION NAME] because the resident had past stomach issues. Staff BK stated she gave the resident [MEDICATION NAME] PLO (used to treat anxiety) 0.5 mg. [MEDICATION NAME] (through the skin) at least 30 minutes before the resident's treatment today, and saw no change. Staff BK called the physician, and obtained a PRN order to try [MEDICATION NAME] (used to treat anxiety) before the treatment 1/31/14. Staff BK felt the resident's hollering anxiety related and not pain related. Record review revealed the resident received the following PRN medications, used to treat anxiety in January 2014 and not given prior to dressing changes: a. January 7, 2014 at 1:27 a.m., staff administered Klonopin (antipsychotic) 0.25 mg after the resident in bed wide awake and repeated Clifford, Clifford over and over again. b. January 11, 2014 at 8:33 p.m., staff administered [MEDICATION NAME] PLO 0.5 mg. [MEDICATION NAME] after the resident yelled out to a sibling for help. c. January 15, 2014 at 8:04 a.m., staff administered [MEDICATION NAME] PLO 0.5 mg. [MEDICATION NAME] for increased anxiety. During an interview on 1/28/14 at 2:50 p.m., the DON (Director of Nursing) verified the resident's record lacked a behavior sheet for January 2014. The DON confirmed the record should have a behavior sheet. During an interview on 1/30/14 at 12:25 p.m., a Nurse Consultant stated the facility lacked a pain control policy/procedure and nursing assessments and interventions for pain medications when needed. During an interview on 2/4/14 at 2:05 p.m., the DON stated the facility assessed resident's for pain every shift when a skilled resident and with every MDS completed. The DON stated Resident #2 used all 100 days of skilled care after admitted (7/18/13).