Every finding on record at Accura Healthcare of Ogden, LLC

Based on clinical record review, staff interviews, and policy review, the facility failed to draw a dilantin (medication to treat seizures) blood level as ordered by the medical provider for 1 of 3 residents reviewed for assessment and intervention (Resident #1). The facility reported a census of 44. Findings include:The Minimum Data Set (MDS) Assessment completed on 2/16/26 noted Resident #1 could not complete a Brief Interview for Mental Status. Resident #1 was assessed as severely cognitively impaired to make daily decisions. Diagnoses include dementia and seizure disorder.The April 2026 Medication Administration Record (MAR) showed an order for Dilantin 100 milligrams to be administered twice daily. The start date noted as 5/15/24. Lab results from 11/12/25 showed Resident #1's Dilantin blood levels low at 4.7 micrograms per milliliters ( g/mL). The therapeutic reference range for dilantin is 10-20 g/mL. The Primary Care Provider (PCP) reviewed the results and ordered for a repeat level to be drawn in one month. The EHR lacked documentation that a repeat Dilantin blood draw was completed one month later. No lab order was identified in the EHR to direct staff to complete. No results were identified that indicated the lab was completed. During an interview on 5/4/26 at 1:30 PM, Staff A, Registered Nurse (RN) explained once lab orders are identified and signed off, staff will write the lab in the resident lab calendar to track. Staff A acknowledged the PCP written Dilantin lab order for Resident #1 from 11/12/25. Staff A also acknowledged that a member of the nursing staff signed off on the order. The current resident lab calendar did not go back far enough to verify if the lab was written down. During an interview on 5/5/26 at 10:45 AM, the Director of Nursing (DON) found the previous resident lab calendar. Upon review, the repeat Dilantin lab was not found in the calendar for the month of December 2025. At this point, the DON acknowledged the lab draw was missed and not drawn. The policy New Orders Triple Note Process, updated 3/29/21, outlined the following: A. Double Noting: Oncoming nurse of the next shift will review the order to ensure the order has been inputted into the EHR and all notifications have been completed B. Triple Noting: MDS nurse will review the order to ensure the order has been completed and Care Plan updated as necessary C. Once orders are signed by the physician, they will be placed in the resident's medical record

Based on clinical record review, staff interviews, and policy review, the facilty failed to continue with neurological assessments (neuros) after an unwitnessed fall for 1 of 3 residents reviewed for assessment and intervention (Resident #3). The facilty reported a census of 44. Findings include:The Minimum Data Set (MDS) Assessment completed on 2/10/26 noted Resident #3 could not complete a Brief Interview for Mental Status. Resident #3 was assessed as severely cognitively impaired to make daily decisions. Diagnoses include schizophrenia and seizure disorder.The facility Incident Report #1262 detailed Resident #3 experienced an unwitness fall on 4/15/26 at 2:30 PM. The nurse completing the report documented they were unable to complete neurochecks, pupillary response only (eye assessment). Resident noted with an intellectual disability and was combative. Nursing Progress Notes in the EHR revealed the following: On 4/16/26 at 2:07 AM staff detailed the first documented unwitnessed fall follow-up assessment. Neuro assessment noted as within normal limits (WNL) for resident. Unable to obtain a blood pressure or oxygen saturation level. On 4/16/26 at 1:43 PM no latent injuries noted from the previous fall. No indications of pain or discomfort. Activities per usual for resident. On 4/17/26 at 12:43 AM neuro assessment WNL for resident. Unable to obtain blood pressure but able to obtain temperature, pulse, respiration rate, and oxygen saturation level. On 4/17/26 at 2:24 PM no latent injury noted from the previous fall. No indications of pain or discomfort. Activities per usual for residentThe electronic health record lacked documentation of completed or attempts to complete neuro checks at the specific timed intervals after unwitnessed falls. During an interview on 5/5/26 at 12:30 PM, the Director of Nursing (DON) explained neuro checks are documented on paper and then scanned into the EHR. The DON was unable to identify that neuro checks were initiated or completed on Resident #3 after the unwitnessed fall on 4/15/26. The DON acknowledged staff does struggle with getting vitals on Resident 3. However, they would expect staff to complete neuro checks as scheduled and assess as much as resident will allow. At the very least, the DON would want staff to document resident status (with or without vitals) at the scheduled neuro check intervals. During an interview on 5/5/26 at 1:00 PM, Staff B, Registered Nurse, acknowledged they were the nurse who assessed Resident #3 after the unwitnessed fall on 4/15/26. Staff B explained they attempted to get vitals and initiate neurochecks as per procedure. Due to the resident's intellectual disability, they were unable to complete and noted this in the EHR. Staff B acknowledged they did not attempt any further neurochecks for the remainder of their shift. Staff B believed they checked on Resident #3 one time after the unwitnessed fall. Staff B explained they placed the resident and the fall on Hot Charting. Meaning nursing staff will document resident status related to an event, per shift, for the next 72 hours. The Risk Management policy, updated 9/27/24, outlined the following regarding neurological assessments: 1. Must be completed with every unwitnessed fall or fall with possible head injury 2. Neuro Checks must be completed in the following time frames a. Every 15 minutes x 4 b .Every 30 minutes x2 c. Every hour x 2 d. Every 4 hours x 3 e. Every shift x 3

Based on record review, staff and resident interviews and facility policy review the facility failed to treat 2 of 3 residents (Resident #1 and #3) with dignity and respect. The facility reported a census of 40 residents.Findings include:1. According to the quarterly Minimum Data Set (MDS) assessment with a reference date of 8/31/2025, Resident #1 had a Brief Interview of Mental Status (BIMS) score of 14. A BIMS score of 14 suggested no cognitive impairment. The MDS listed the following diagnoses for Resident #1: major depressive disorder, cancer, heart failure, diabetes mellitus, anxiety, depression, psychotic disorder, paranoid personality disorder, and obesity.A Care Plan Focus Area with an initiation date of 7/9/2024 documented Resident #1 has the potential for alteration in behavior and mood related to diagnoses depression, anxiety, and paranoid personality disorder. She is delusional and believes that nursing staff is changing her medications. She is paranoid and think others are stealing and spying on her. She refuses to stand up for in-house staff when she needs help at times. She is limiting her food and fluid intake on a routine basis. She declines for housekeeping staff to be in her room. I refuse counseling in house or out of facility.The following Progress Note documented by the MDS Coordinator on 10/24/2025 at 9:05 AM: Late entry for 10/23/2025 at 3:45 PM: resident was wheeling herself up the hallway in her wheelchair with a soaker pad in her lap. She reached the top of the hallway, where the threshold is and couldn't make it over the lip. This Registered Nurse (RN) went over to ask resident if she needed assistance and resident stated yes, I can't get over this. This RN attempted to push resident's wheelchair over the threshold with no success and then backed resident up and tried it again with no success. This RN stated to resident that she was going to take resident backwards over the threshold for her safety and resident said no, there's Staff A Certified Nursing Assistant (CNA). She can do it. So, per resident's request this RN asked Staff A to come assist with pushing resident over the threshold. Staff A did and then resident mumbled something about soaker pads and threw the dirty urine-soaked soaker pad at Staff A and called her a dumb b****. This RN stated to resident that was not called for and that she needed to go back to her room and calm down. Resident stated no. This RN then started to turn her wheelchair around and resident then grabbed for the wall and then started pinching Staff A. This RN stated to resident that she needed to stop immediately and then resident swung her arm to the back and hit/scratched this RN x 2 in the face. The RN stated it's time for quiet time in her own personal space.On 11/12/2025 at 11:38 AM Resident #1 denied staff members cursing in front of her or at her. When asked if staff have ever been rough or mean to her, she stated no but was told she had hit two staff members. Resident #1 could not recall this happening but stated if it happened then they probably deserved it. When asked how Staff A treated her, she could not recall who that was.2. According to the significant change MDS assessment tool with a reference date of 8/19/2025, Resident #3 had a BIMS of 13. A BIMS of 13 suggested no cognitive impairment. The MDS listed the following diagnoses: anemia, heart failure, renal failure, hip fracture, seizures, malnutrition, anxiety, depression, bipolar, and schizophrenia.The Care Plan Focus Area with an initiation date of 5/10/2019 documented he had the potential for behaviors and altered coping related to: major depressive disorder, schizoaffective disorder, and anxiety, history of a traumatic brain injury and history of being sexually inappropriate.On 11/12/2025 at 7:25 PM Staff B Licensed Practical Nurse (LPN) stated she overheard Staff A talking with Resident #3 through his roommate's baby monitor. She heard Staff A f*** you too, to Resident #3. Staff B stated Staff A swears like a sailor all the time and has been talked to about it. She swears a lot in front of the residents and has been talked to about this.On 11/13/2025 at 1:36 PM Staff A stated Resident #1 assaulted her and the MDS Coordinator about 3 weeks ago. Resident #1 pinched her and clawed the MDS Coordinator in the face twice. Resident #1 had come down her hall and got stuck on the lip of the flooring. The MDS Coordinator was trying to help her when Resident #1 called for me to help. Once she was able to get her over the lip on the floor the resident threw a urine-soaked bed pad at her and called her a dumb b****. The MDS Coordinator stated we are not going to talk like that, we need to go to your room to calm down. Resident #1 reached around and pinched me. I moved her hands and said get your f***ing hands off me. Then she scratched the MDS Coordinator in the face twice. They called the Director of Nursing (DON) and the cops. When asked what Resident #1 said after she told her to get her hand off of her, Staff A stated she was just mumbling. Staff A acknowledged she said get your f***ing hands off me in the heat of the moment. When asked she assists Resident #3, she stated she has known him since she was [AGE] years old, was a buddy of her dad's. She does not cuss at him but has a sternness with her voice and says things like I will not put up with your BS but does not say bulls***.On 11/14/2025 at 9:34 AM the DON was informed of what Staff A had stated during the incident with Resident #1 on 10/23/2025. The DON stated that is not acceptable and would not like to hear that coming from a staff member. She added unfortunately their staff deal with a lot of abusive residents and staff may be getting worn out by the abuse and she was sure Staff A was at her breaking point. At that same time this occurred they had a resident that was on hospice used her call light 280 times in 7 days. Stuff like that wears on them. The DON stated she could see Staff A saying that because she knew she had a short fuse and they have been dealing with that. Staff A has done much better over the course of the last year as they have been working on it with her. They have told her that when she has moments, she needs to take 5 minutes, go outside, go to the DON's office, get out of resident areas. She acknowledged Staff A does get stern with Resident #3 because his sister tells her to get stern with him. He is manipulative and the sister feels if staff are stern with him they will not get manipulated by him. When the DON was informed of what Staff A has said to Resident #3, she stated that's right on the edge of not sure if it's appropriate. She indicated had Staff A said bulls*** that would not be acceptable.The facility provided a policy titled Promoting/Maintaining Dignity with a revised date of 1/30/2024. It is the practice of this 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.Compliance Guidelines: 1 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. 10. Speak respectfully to residents.

Based on observation, resident interview, staff interviews, clinical record review and facility record review, the facility failed to ensure a homelike environment for 1 of 13 residents reviewed. Resident #22 resided in a room that smelled of urine and needed painting and repairs. Staff failed to remove dirty dishes from the evening meal that remained in the dining room until after the breakfast service began. The facility reported a census of 42 residents.Findings include: 1) In an observation of the dining room and kitchen area on 9/3/25 at 6:30 AM, it was discovered that a multi-level cart contained dirty dishes from the previous day in the dining room area. The cart was not moved back into the kitchen area until 8:00 AM, after the breakfast service had began and the residents were eating. 2) According to the Minimum Data Set (MDS) dated [DATE], Resident #22 had a Brief Interview for Mental Status (BIMS) score of 15 (cognitive intact). She used a walker and a wheel chair due to lower extremity impairment. The resident required toileting hygiene with set up and clean up assistance.According to the Care Plan revised on 10/16/24, Resident #22 had the potential for activity deficit related to major depressive disorder and generalized anxiety disorder. The resident required assistance with toileting and peri care, and frequently declined assistance. Resident #22 would throw her soiled briefs on the floor. Her diagnoses included: heart failure, anxiety disorder, history of falling, paranoid personality disorder, insomnia, unspecified psychosis and morbid obesity,On 9/2/2025 at 11:41 AM, Resident #22 was in a wheel chair in her room. There was a very heavy smell of urine in the environment and there were soiled absorbent pads on the floor next to the bed. The resident said that she was able to get herself to the bathroom and she preferred to sleep in her recliner. The resident said that she was often soaked in urine by morning. The doors to the bathroom and to the hallways were dirty and stained. Many of the wood baseboards and trim areas had chipped paint all around the room.On 9/4/2025 at 7:12 AM, Staff H, Housekeeping, said that the resident told her she would allow anyone to come in and clean her room but she questioned whether the other staff would attempt. Staff H said that when she had a couple of days off for a weekend, by Monday, there would be a pile of urine-soaked briefs in the garbage and the room would smell terrible.On 9/4/25 at 7:30 AM, the Administrator said that Resident #22 would only allow one particular staff person in the room to clean it, and they felt they had done all they could to accommodate her needs as she would allow. She said that the resident was paranoid about staff stealing items in her room. The Administrator indicated that they did not have a policy related to maintaining a homelike environment.According to the Facility assessment dated [DATE], the purpose of the assessment was to determine what resources needed to care for residents during the day to day operations. The services and care offered would be based on the resident needs included behavioral and mental health to manage, identify and implement interventions to help support individuals with issue such as dealing with anxiety, and psychiatric diagnosis.Preventative maintenance and/or cleaning schedules would be in place according to manufacturers recommendations.As part of the facility assessment, staff, resident's family and vendors were interviewed to determine what the facility was lacking or needed in the future: Maintenance - the facility needed some updating and repair, staff was doing some painting, replacing tiles, and beds and mattresses. Resident rooms were being updated and painted, the facility had some issues with maintenance completing work timely.

Based on clinical record review, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 12 residents reviewed (Resident #41). The facility reported a census of 42. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #41 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident had diagnoses to include medically complex conditions, heart failure, hypertension and hyperlipidemia. The MDS revealed the resident was on high risk drug classes to include a diuretic in the look back period. Review of the Electronic Heath Record (EHR) for Resident #41 revealed a physician order of the medication Bumetanide (a diuretic medication) Oral Tablet 2 MG, give one tablet by mouth one time a day for edema with a start date of 5/17/25 and an order for Bumetanide Oral Tablet 1 MG, give 1 tablet by mouth two times a day related to heart failure, with a start date of 3/25/25 and a discontinue date of 5/16/25. Review of the EHR for Resident #41 showed a diagnosis list to include the diagnosis of Edema, unspecified, dated 4/1/25. Review of the EHR under Clinical Physician Orders for Resident #41 revealed an order for daily weights, call the Primary Care Physician (PCP) if weight gain of 3 pounds overnight or 5 pounds in one week, and an order to report to PCP any increase in edema, dyspnea, weight or decrease pulse oximeter, as well as an order for ted hose to apply in the AM and remove at HS (hour of sleep), two times a day for edema. The Care Plan for Resident #41, with an initiation date of 4/1/25, lacked a focus area, goals and interventions for edema and the use of a diuretic. During an interview 9/3/25 at 3:57 PM, the MDS coordinator stated an expectation the diuretic medication and edema be in the care plan, with a focus area, goals and interventions. She acknowledged this was not in the care plan. Review of the facility policy Comprehensive Care Plans, updated April 2025, documented it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality.

Based on observation, interviews and record review the facility failed to complete the required documentation, staff education and nursing assessments for the Restorative Program (RP) for 2 of 2 residents reviewed (Residents #30 and #2.) The facility reported a census of 42 residents.Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #30 did not complete a Brief Interview for Mental Status (BIMS) due to severe cognitive impairment. The resident was totally dependent on staff for toileting hygiene, and lower body dressing and required partial assistance with sit to stand, and transfers. The Restorative Program (RP) was performed for the 6 of the 7 days during the look back period. The Care Plan for Resident #30, dated 2/9/25, showed a focus area for the RP to include: active Range of Motion (ROM) to upper and lower extremities. Nu-step 1-7 times a week, active ROM to upper body exercises with a 1-pound dowel bar for bilateral upper extremities, 1-7 times a week and ambulation program to meals 1-7 times a week. On 9/3/25 at 12:44 PM, Resident #30 was sitting in her wheel chair at the dining room table. She was having some difficulty sitting up straight and leaned over the right arm of the chair. At 12:47 PM, she slowly pushed the wheels towards her room and said that she could use some help. The following was found on the Point of Care (POC) Response History for Ambulation Programs from 8/6/25 – 9/3/25 for Resident #30: a. Ambulate to meal approximately 150 feet, documented 15 times NA (Not Applicable) b. The active range of motion to upper body from 8/13 – 8/27 was not completed in that timeframe and documented 11 times NA. c. The active ROM to upper and lower extremities documented NA 10 times. A review of the Nursing Progress Notes showed that the most recent restorative summary was dated 4/29/25 at 1:48 PM, and included a notation that nursing would continue to monitor participation in the program and adjust according to residents needs and requests. On 9/3/25 at 1:14 PM, Staff A, Certified Nurse Aide (CNA) and Staff B, CNA said that they would document NA on the POC for the Restorative Program exercises when the resident was independent and the Staff didn't need to help them with the exercises. On 9/3/25 at 2:00 PM, Staff B CNA said that she was the primary staff member scheduled to the Restorative Program. Her regular schedule was from 7:30 AM – 4:00 PM, but from 7:30-11:30, she was expected to provide showers and baths, and many times she would be pulled to help with other CNA duties. She said that many times she had just a two-hour timeframe to work with the residents in the therapy room. Staff B said that the CNA's can do the ROM in the rooms with the residents when they are getting them dressed. She was not aware of any specific training for the CNA's on how they should safely provide the services specific to the residents. On 9/4/25 at 11:15 AM, Staff G, CNA said she did the restorative exercises with residents when she's able. She said she hadn't had any specific education at the facility, but learned some in the CNA classes. The facility Orientation Education Schedule showed a list of 39 scheduled on-line classes. The list lacked education on restorative exercises. According to the facility policy titled: Restorative Program Process dated 2021, the purpose was to ensure residents achieved and maintained their highest level of functioning. Upon admission, quarterly and with significant change the resident's level of function would be assessed by the licensed nurse or in collaboration with therapy. The licensed nurse would monitor the daily restorative nursing program documentation in point of care and follow up with staff as needed. The licensed nurse would write a monthly restorative nursing summary to track the residents progress. According to the American Association of Post-Acute Care Nursing (AANAC) Guide to Successful Restorative Programs (found in the Restorative binder), nursing assistants and aides must be trained in the techniques that promote resident involvement. The Facility Assessment showed that they would provide specialized rehabilitation services, and would employ 1 restorative aide full time. The program would be supported with exercise programs lead by the activities director and the floor CNA, and incorporated into restorative tasks. 2. The MDS dated [DATE] for Resident #2, documented the resident had a BIMS score of 13 indicating intact cognition. The MDS identified diagnoses as anxiety disorder, depression, bipolar and schizophrenia. The MDS also documented that Resident #2 was coded dependent with toileting, lower body dressing, personal hygiene and required maximum assistance with sit to stand and partial assistance with sit to lie and [NAME] to sitting on the side of the bed. The care plan for Resident #2 showed a focus area for the RP to include an ambulation program: may walk 50 to 75 feet with assist of 1 and walker with wheelchair to follow 1-7 times weekly. Dressing/grooming program: encourage the resident to participate in am and pm care 1-7 times weekly and transfer practice: supervision with walker for transfers in room [ROOM NUMBER]-7 times weekly. The following was found on POC response history for ambulation programs from 8/6/25-9/4/25 for Resident #2: Ambulation program: may walk 50 to 75 feet with assist of 1 and walker with wheelchair to follow 1-7 times weekly, documented 59 times NA. Dressing/grooming program: encourage resident to participate in AM and PM care 1-7- times weekly, documented 24 times NA Transfer practice: supervision with walker for transfers in room [ROOM NUMBER]-7 times weekly, documented 55 times NA. A review of the nursing progress notes showed that the most recent restorative summary was dated on 4/29/25 and stated the facility will continue to monitor participation in the program and will adjust program according to resident needs/requests. Interview on 9/3/25 with staff F, Director of Therapy, stated that the process when the residents are discharged from a therapy, therapy puts together a restorative program. This restorative program goes to the MDS Coordinator, then the MDS Coordinator puts it together for the restorative aid (RNA). Staff F stated the Restorative Programs can vary from walking, to 1:1's, ROM and group exercises. Staff F stated depending on the program, the floor staff are able to do the ambulation with the resident. Staff F stated the RNA is supposed to do the ROM exercises. She stated the activity person just started so they have started group exercises with the residents. Staff F stated that occasionally she will do some screens to make sure the program is working with the residents, but usually the therapy department would be notified from the staff if there is a change in condition or if the resident is not participating in restorative. Interview on 09/04/2025 at 10:25 AM with Staff F stated that when they make the restorative programs and specify 1 to 7 days, this gives flexibility to the restorative aid/staff time to get the program completed. She stated that sometimes the RNA gets pulled to the floor or if the resident refuses, this gives staff time to complete the program. She stated the goal of the program is to keep the resident at their baseline and maintain their strength. She stated for the resident to maintain their baseline, they would ideally need to be seen more than once. She acknowledged that one day a week was not sufficient enough to maintain the resident's baseline and strength.

Based on observations, staff interview, clinical record review and policy review the facility failed to adequately assess and intervene to prevent skin wounds for 1 of 2 residents reviewed. Resident #6 was on hospice, developed an abrasion on his coccyx and the treatment did not start for two days after it was discovered. The resident was observed to be in his wheel chair for over 2 hours, and when his brief was changed, staff failed to apply barrier cream. The facility reported a census of 42 residents. Findings include:According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He required total dependence for toileting hygiene and lower body dressing, and substantial assistance with rolling, sitting and toileting. The resident had an indwelling urinary catheter.The Care Plan showed that Resident #6 had the potential for changes in skin integrity related to a decline in nutritional status, limited mobility, incontinence, and suprapubic catheter use. On 8/18/25 it was discovered that he had an abrasion on the upper buttock. Staff were to monitor skin with care and notify nursing and the doctor of any changes in skin integrity, and provide treatment as ordered. His diagnoses included benign prostatic hyperplasia, repeated falls, dysphagia following cerebral infarction, protein calorie malnutrition and retention of urine.According to the Skin Sheet-non-ulcer Assessment (SSNUA) dated 8/18/25 at 3:18 PM, a new area, described as an abrasion, was discovered. The skin was pink, the document lacked measurements. A follow up SSNUA dated 8/25/25 at 3:43 PM, indicated that the first layer of skin was off, and measurements included: length 2.5 centimeters (cm) x 1.5 cm width. The resident had pain with touching and the doctor was notified. The chart lacked a weekly follow up assessment due to be completed on 9/01/25.The Quarterly Braden Scale for Prediction Pressure Sore Risk was dated 8/04/25 at 3:45 PM, but completed on 8/20/25 at 3:46 PM, and showed that he was at high risk for pressure sores.A faxed order written on 8/18/25, showed that staff were to apply calmoseptine cream on the skin, topical to upper left buttock/coccyx three times a day and as needed (PRN). According to the Medication Administration Record/Treatment Administration Record (MAR/TAR) The treatment did not begin until 8/20/25. On 9/03/2025 at 6:35 AM, Resident #6 was sitting in the wheel chair at the breakfast table. At 8:42 AM, he had wheeled himself near the nurse station and said bed time several times. At 8:48 AM, his voice got much louder and he said bed! bed! bed! At 8:50 AM, Staff B, Certified Nurse Aide (CNA) took him back to his bedroom.On 9/03/2025 at 10:50 AM, Staff A CNA, Staff B, and Staff C (LPN) prepared to provide personal cares to the resident. He moaned many times as they moved and wiped him with disposable wipes. As they turned him on his side, it was revealed that his left buttocks had a very red spot with a small open area. The staff cleaned the area and applied a clean brief without having applied a barrier cream. On 9/03/2025 at 11:10 AM, Staff D Registered Nurse (RN) said that she saw the spot on the resident's buttocks and agreed that it looked to be open. She said she had contacted Hospice and told them it wasn't getting better and maybe needed new order. The SSNUA dated 9/3/25 at 3:15 PM, showed a measurement of 2.5 cm x 1.5 cm. The document included a note that the nurse had attempted to assess the resident on 9/2/25, but he was in the wheel chair, and on 9/3 he was sleeping when she went to assess him. A facility policy titled: Weekly Skin Assessment and Documentation Process updated on 1/20/23, showed that staff would provide weekly skin assessments. The facility would choose a specific day of the week for the assessment and documentation. When the nurse on the floor observed a new skin alteration they should utilize the fax forms to notify the physician. If a skin wound alteration exhibited any decline or non-healing the nurse would notify the physician. The facility policy, updated on 1/20/23, titled: Weekly Skin Assessment and Documentation Process, showed that skin ulcer and non-ulcers will be assessed and documented weekly by the facility wound nurse.

Based on observations, clinical chart review and staff interview the facility failed to implement policies and procedures regarding the technical aspect of checking placement for gastrostomy tubes by failing to check placement for 2 of 2 residents (Resident #2 and Resident #33). The facility reported a census of 42 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #33, documented the resident did not have Brief Interview for Mental Status (BIMS) completed due to Resident #33 is rarely/never understood. The MDS identified diagnosis as anxiety, psychotic disorder, severe intellectual disability and encephalopathy. The MDS also documented that the resident received nutrition through a gastric feeding tube.Observation completed on 9/3/25 at 11:40 a.m. with Staff H, Registered Nurse (RN) and Staff I, Certified Nursing Assistant, (CNA) completed hand hygiene in Resident #33's room. Staff H applied gloves to both hands and hooked up the tube feeding to Resident #33. Staff H did not check placement of the gastrostomy tube. After Staff H hooked up the feeding, she removed her gloves and completed hand hygiene.Interview with Staff H on 9/3/25 at 11:50 a.m. acknowledged that they are supposed to be checking placement of the g-tube, she stated that she does not check the placement due to it would be traumatic to Resident #33. Review of the resident record lacks information regarding checking placement of the g-tube.Review of the Progress Notes dated 9/4/25 for Resident #33 revealed a fax was received from the primary physician to check placement on the gastrotomy tube. 2. The Minimum Data Set (MDS) dated [DATE] for Resident #2, documented the resident had a BIMS score of 13 indicating intact cognition. The MDS identified diagnosis as anxiety disorder, depression, bipolar and schizophrenia. The MDS also documented that the resident has a gastric feeding tube.Review of the resident record lacks information regarding checking placement of the g-tube.Interview with the Director of Nursing (DON) on 9/3/25 at 1:30 p.m. stated the expectation is to check placement for G-tubes, she stated that they are checking placement for Resident #10, but not for Resident #2 and Resident #33. She stated both of them have specialized gastrotomy tubes. Interview with the DON on 9/3/25 at 1:48 p.m. she stated that they do not have a policy regarding feeding tubes, she stated they have a competency checklist for them. The DON revealed she found out they have to check placement on those specialized tubes so she will be placing a call to their primary physician to get orders.

Based on observations, staff interview, record review and policy review the facility failed to implement adequate infection control practices for 2 of 5 residents reviewed (Residents #33 and #6). Staff failed to use Enhanced Barrier Precautions (EBP) while providing care to Resident #33 who had a tube feeding, and during a transfer for Resident #6, who had a urinary catheter. The facility reported a census of 42 residents. Findings include:1) According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability). He required total dependence for toileting hygiene and lower body dressing, and substantial assistance with rolling, sitting and toileting. The resident had an indwelling urinary catheter. The Care Plan initiated 10/30/24 showed that Resident #6 had the potential for changes in skin integrity related to a decline in nutritional status, limited mobility, incontinence, and suprapubic catheter use. On 8/18/25 it was discovered that he had an abrasion on the upper buttock. Staff were to monitor skin with care and notify nursing and the doctor of any changes in skin integrity, and provide treatment as ordered. His diagnoses included benign prostatic hyperplasia, repeated falls, dysphagia following cerebral infarction, protein calorie malnutrition and retention of urine. The Care Plan lacked specific information and instructions for the use of EBP. On 9/3/25 at 8:50 AM, Staff B, Certified Nurse Aide (CNA) took Resident #6 back to his bedroom to transfer him into bed. The resident was in a Wheel Chair (WC,) and there was a urinary catheter hooked under his WC. With ungloved hands, Staff B held onto the catheter tubing, reached down under the WC, unhooked the catheter and hooked it to a pocket on the side of her scrub pants and assisted the resident into bed. Staff B then put the catheter bag in a tub on the floor. The staff member failed to wash her hands before leaving the room, then used a hand sanitizer as she walked down the hallway. On 9/4/25 at 12:07 PM, the Infection Preventionist said that Staff B should have used EBP while transferring Resident #6 into bed. She said that the catheter should not be hooked onto her person, and she would provide education on hand hygiene and catheter care. According to the facility policy titled: Enhanced Barrier Precautions updated on 11/13/24, an order for EBP would be obtained for residents with: indwelling medical devices including urinary catheters and feeding tubes. EBP barrier precautions would be found outside the resident's room when performing transfers and assisting during when anticipating close physical contact while assisting with transfers and mobility. 2) The MDS dated [DATE] for Resident #33, documented the resident did not have BIMS completed due to Resident #33 is rarely/never understood. The MDS identified diagnoses as anxiety, psychotic disorder, severe intellectual disability and encephalopathy. The MDS also documented that the resident received nutrition through a gastric feeding tube. Review of the Care Plan dated 5/22/25 documented enhanced barrier precautions (EBP) is in place. On 9/3/25 at 11:40 a.m. observed Staff H, Registered Nurse (RN) and Staff I, Certified Nursing Assistant, (CNA) hook up the feeding to Resident #33. After Staff H hooked up the feeding, she removed her gloves and completed hand hygiene. Both staff members failed to apply EBP. Interview with Staff H on 9/3/25 at 11:50 a.m. stated they do not wear the EBP due to the resident will pull and grab at the gowns and the gloves. Interview on 9/3/25 at 2:39 p.m. with the Corporate Nurse stated she would expect the staff to apply EBP while providing care on a resident with a gastrostomy tube.

Based on observation, policy review, and staff interview, staff failed to serve food under sanitary conditions, in order to reduce the risk of contamination and foodborne illness. The facility reported a census of 36 residents. Findings include: On 10/23/24 from 11:40 AM - 12:50 PM, during continuous observation of the lunch service, Staff B, [NAME] was preparing food items for the residents' plates and Staff C, [NAME] was preparing drinks. Throughout the meal service, Staff C spilled milk on the floor, put on a glove and cleaned up the milk with a paper towel, removed the glove, did not complete hand hygiene and proceeded to fill the glasses and place the glasses on the residents' trays. Staff C applied a glove and with the same gloved hand opened the refrigerator door, picked up a slice of cheese and placed the slice of cheese on a hamburger that was served to a resident. Staff B washed her hands, applied gloves, and with the gloved hand touched the outside of the butter container, removed the lid and with the same gloved hand touched a slice of bread. Facility policy, Bare Hand Contact with Food and Use of Plastic Gloves dated 2021, documented gloves are just like hands, anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. If used, single use gloves shall be used for only one task and discarded when interruptions occur in the operation, and hands are to be washed after removing single use gloves. Interview on 10/23/24 at 2:00 PM, the Dietary Manager stated expectation when using gloves to touch any food items, to not touch other items prior to touching the food item. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: 1) Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation, 2) prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) and requires food employees to wash their hands immediately before engaging in food preparation, including before donning gloves for working with food, in order to prevent cross contamination when changing tasks.

Based on observations, staff interview, and policy review the facility failed to maintain the kitchen, food preparation and service area free of insects. The facility reported a census of 36 residents. Findings include: Observation on 10/21/24 at 10:18 AM, the door to the kitchen from the hallway has a sign posted on the door, for the door to remain closed, and the door was open: several flies observed throughout the kitchen area. The Dietary Manager (DM) acknowledged the flies and stated the door across from the open kitchen door goes to the outside and is used frequently. Continuous observation on 10/23/24 from 11:40 AM - 12:50 PM, the door to the outside of the building, across from the kitchen door, propped open, with staff coming in and out thru the kitchen door, as unloading truck. Meal service conducted and several flies observed throughout the kitchen, landing on plates, bread/butter, food on the plates for residents, utensils being used for service, and also flying around and landing on both dietary aides. Facility policy Pest Control dated 2021, documented appropriate action will be taken to eliminate any reported pest situation in the department. Interview on 10/23/23 at 2:00 PM, the DM stated the kitchen had not been treated for the flies and expectation for flies to not be in the kitchen and not on food and service items.

Based on observations, clinical record review, and staff interviews, the facility failed to notify the Physician for a resident with a 10-pound weight loss in 10 days for 1 (Resident #86) of 1 resident reviewed for weight loss. The facility reported a census of 36 residents. Findings include: The Minimum Data Set summary for Resident #86, dated 10/23/24, documented the resident was admitted [DATE]. Observation on 10/21/24 at 12:10 PM, Resident #86 did not eat any of her lunch and propelled herself out of the dining room. The weights and vitals form for Resident #86, documented the following dates and weights: a. 10/10/24 - 132.4 pounds b. 10/20/24- 121.4 pounds, with a weight loss of 10 pounds in 10 days. A 10 pound weight loss triggers for greater than 7.5 percent loss which is significant. Interview on 10/24/24 at 12:31 PM, the Director of Nursing confirmed the Physician was not notified of the resident's weight loss and expectation the Physician should have been notified.

Based on clinical record review and staff interview, the facility failed to complete a comprehensive assessment no less than once every three months for 1 of 13 residents reviewed (Residents #18). The facility reported a census of 36 residents. Findings include: Review of the Resident #18's clinical record revealed the last Minimal Data Set (MDS) assessment was completed on 6/14/24. The next scheduled quarterly comprehensive assessment was due 9/14/24 and as of 10/23/24, the assessment had not been completed and is greater than 25 days overdue. During an interview on 10/24/24 at 10:30 AM, Staff A, MDS coordinator, acknowledged the overdue comprehensive assessment for Resident #18. Staff A unable to provide rationale for the missed assessment.

Based on observations, clinical record review, and staff interviews, the facility failed to revise and update the resident's care plan for 2 residents (Resident #14 and #22) on a diuretic (medication to help the body get rid of excess fluid) and a resident (Resident #26) placed on hospice of 12 residents reviewed. The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #14, dated 9/21/24, included diagnoses of diabetes and renal (kidney) failure. The MDS further documented the resident was receiving a diuretic medication. Resident #14's Care Plan, revised 10/1/24, lacked an update with a focus and interventions for the diuretic medication and monitoring. 2. The MDS for Resident #22, dated 8/2/24, included diagnoses of heart failure and diabetes. The MDS further documented the resident was receiving a diuretic medication. Resident #22's Care Plan, revised 8/9/24, lacked an update with a focus and interventions for the diuretic medication and monitoring. 3. The MDS for Resident #26, dated 8/14/24, included diagnoses of diabetes and stroke. The MDS further documented the resident was receiving a diuretic medication. The Clinical Census for Resident #26 documented the resident was placed on hospice services 10/15/24. Resident #26's Care Plan, revised 10/19/24, lacked an update with a focus and interventions for hospice care. Interview on 10/24/24 at 1:26 PM, the MDS Coordinator stated expectation for diuretic medication and hospice services to be included on care plan and expectation for care plans to updated. Interview on 10/24/24 at 2:15 PM, the Administrator stated the facility did not have a policy for updating care plans, they follow the standard of practice.

Based on clinical record review and staff interview the facility failed to obtain follow-up laboratory (lab) blood work in the time frame as ordered by the Primary Care Provider (PCP) for use of Coumadin, an anticoagulant, for Resident #7. The facility reported a census of 36 residents. Findings include: The Minimal Data Set (MDS) assessment dated [DATE] revealed Resident #7 with a Brief Interview for Status score of 13 indicating intact cognition. Diagnoses on the MDS include atrial fibrillation/other dysrhythmias, heart failure, hypertension, and renal insufficiency/renal failure/or end stage renal disease. Anticoagulant use indicated on the MDS. Admission lab blood work for Resident #7 obtained on 8/30/24 revealed a Prothrombin Time (PT) level of 16.5 seconds (reference range 9.9-13.1 seconds) and International Normalized Ratio (INR) result of 1.4 (reference range 0.9-1.2). The PCP ordered follow-up PT and INR to be completed in one week, with a date of 9/6/24. Lab results on 9/6/24 revealed a PT level of 38.0 seconds and an INR of 3.3 both indicated as high levels. The PCP ordered follow-up PT and INR to be completed on Monday, 9/9/24. Lab work was not completed on the date as specified by the PCP, which was 9/9/24. There is no indication in the clinical record that staff notified the PCP of the delayed lab work. Lab results on 9/10/24 revealed a PT level of 60.6 seconds and an INR of 8.3 both indicated as high levels. PCP ordered follow-up PT and INR to be completed on Thursday, 9/12/24. Lab results on 9/12/24 revealed a PT level of 32.4 seconds and an INR of 2.8. PCP ordered follow-up PT and INR to be completed in 7-10 days, with dates of 9/19/24 - 9/22/24. Lab results on 9/18/24 revealed a PT level of 35.3 seconds and an INR of 3.0. PCP ordered follow-up PT and INR to be completed in 2 weeks, with a date of 10/2/24. Lab work was not completed on the date as specified by the PCP, which was 10/2/24. There is no indication in the clinical record that staff notified the PCP of the delayed lab work. Lab results on 10/4/24 revealed a PT level of 53.7 seconds and an INR of 4.7. PCP ordered follow-up PT and INR to be completed on Thursday, 10/10/24 or Friday 10/11/24. Lab work was not completed on the dates as specific by the PCP, which was 10/10/24- 10/11/24. There is no indication in the clinical record that staff notified the PCP of the delayed lab work. Lab results on 10/15/24 revealed at PT level of 30.3 seconds and an INR of 3.6. PCP ordered follow-up PT and INR to be completed in one week, with a date of 10/23/24. During an interview on 10/23/24 at 4:15 PM, the Director of Nursing (DON) reported routine labs obtained on Wednesdays. Given the urgency of PT and INR monitoring, these labs are typically obtained as outlined by the PCP. The DON voiced an expectation for staff to document in the clinical record if a lab draw missed or unsuccessful. The DON stated staff should also notify the PCP. During a follow-up interview on 10/24/24 at 9:00 AM, the DON explained ordered lab draws are hand-written in the lab calendar, which all staff have access to. The night shift staff reviews the calendar daily and will prepare a lab face sheet for the upcoming labs for the next day. Night shift staff will also note the upcoming lab draw on the 24-hour nursing report sheet. In addition, PT/INR results and next lab draw dates are tracked on a separate form titled PT/INR Tracking. Review of the lab calendar with the DON showed staff wrote for a PT and INR on Resident #7 to be obtained on 10/2/24 as well as 10/11/24. The PT/INR Tracking form also noted follow-up labs to be obtained on 10/2/24 and 10/11/24. The DON acknowledged the delay in lab work and unable to provide a rationale for the oversight. The lab draw ordered for 9/9/24 was obtained on 9/10/24. Both the lab calendar and PT/INR Tracking form noted a draw date of 9/10/24.

Based on observation, policy review, and staff interview, the facility failed to prepare and serve food under sanitary conditions to reduce the risk of contamination and foodborne illness. The facility reported a census of 37 residents. Findings include: On 7/26/23 at 11:35 AM observed the Dietary Manager (DM), while wearing the same gloves, touch a cutting board, the outside of a bread package, then remove two slices of bread, and place the bread on the cutting board. While wearing the same gloves removed a container of peanut butter from the cupboard, remove the lid, and then remove a bottle of jelly from the refrigerator. The DM removed the gloves, washed their hands, and applied new gloves. Then proceeded to touch the outside of the jelly bottle to squeezed jelly onto the bread and apply peanut butter to the bread while touching the bread with the same gloves. On 7/26/23 during a continuous observation starting at 11:45 AM, Staff A, Dietary Aide (DA), washed her hands, applied gloves, and started serving meal plates. The DA proceeded to wipe sweat from her forehead with her gloved hand, two different times. Without changing her gloves or completing hand hygiene, Staff A proceeded to continue serving the meal plates. As Staff A worked she touched the plates, utensils, paper meal slips, and then with the same gloved hands touched a hot dog bun while placing a hot dog in the bun. Staff A touched a hot dog bun at two different occurrences. Then with the same gloved hands, Staff A cut a hamburger sandwich and touched the top of the bun. The Bare Hand Contact with Food and Use of Plastic Gloves policy dated 2021, directed to use single use gloves for only one task (such as working with ready-to-eat food) and for no other purpose. Discard the gloves when damaged or soiled, or when interruptions occur in the operation. On 7/27/23 at 3:17 PM, the DM stated they expected when handling food with gloves, to not touch other items prior to touching food. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry, includes the following requirements: a. Single-use gloves are to be used for only one task, such as working with ready-to-eat food and for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. b. Prohibits food employees from bare hand contact with ready-to-eat food (unless washing fruits and vegetables) c. Requires food employees to wash their hands immediately before engaging in food preparation, including before donning (applying) gloves for working with food, to prevent cross contamination when changing tasks.

Based on clinical record review and staff interviews, the facility failed to notify the Physician when a medication was not available for 1 of 1 resident reviewed (Resident #137). Findings include: Resident #137's Minimum Data Set (MDS) assessment dated [DATE] identified a completed Staff Assessment for Mental Status, indicating severely impaired cognition. The MDS indicated that Resident #137 required extensive assistance of two persons with transfers and required total dependence of two persons with bed mobility and toilet use. The MDS indicated Resident #137 walking did not occur. Resident #137's MDS included diagnoses of pneumonia, renal insufficiency (poor functioning kidneys), stroke, metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), and alcohol dependence with withdrawal delirium (confusion caused by a withdrawal of alcohol). A Physician Order dated 4/18/23 directed staff to administer olanzapine (antipsychotic medication) 10 mg (milligrams) IM (intramuscular injection/shot in the muscle) one time and then start olanzapine 5 mg po (by mouth orally) every HS (hour of sleep) starting on 4/19/23. The April 2023 Medication Administration Record (MAR) included the following orders dated a. Start date 4/18/23; discontinued date 4/19/23: directed the staff to inject olanzapine 10 mg IM one time only for agitation related to alcohol dependence with withdrawal delirium for 2 days. i. On 4/18/23 the olanzapine order on the MAR revealed a blank space without initials representing Resident #137 did not receive the medication. ii. On 4/19/23 the olanzapine IM injection included documentation that indicated Resident #137 received the medication. b. Start date 4/19/23; discontinued date 4/20/23 directed the staff to inject olanzapine 10 mg IM one time only for agitation related to alcohol dependence with withdrawal delirium for 2 days. i. The MAR include documentation of a 9, indicating hold see progress notes. c. Start date: 4/20/23 directed the staff to inject olanzapine 10 mg IM one time only for agitation related to alcohol dependence with withdrawal delirium until 4/20/23 at 11:59 PM. i. The MAR indicated that Resident #137 received their second dose on 4/20/23 at 6:55 PM. d. Start dated 4/19/23; discontinued date 4/21/23: Instructed to give olanzapine oral tablet 5 mg by mouth one time a day for agitation related to alcohol dependence with withdrawal delirium. i. The MAR reflected that Resident #137 received oral olanzapine 5mg on 4/19/23 and 4/20/23. On 7/26/23 at 4:23 PM, the DON verified she could not locate a Physician order to administer olanzapine IM for two days. She explained that the only order she could locate instructed to give the medication one time on 4/18/23. On 7/26/23 at 4:24 PM, the Assistant Director of Nursing (ADON) reported the pharmacy did not have the olanzapine IM available on 4/18/23. The ADON reported they received the medication on 4/19/23. The clinical record lacked documentation that the facility notified the provider of the facility's inability to obtain the olanzapine IM medication on 4/18/23. On 7/27/23 at 10:25 AM the Director of Nursing (DON) reported that she would expect the staff to notify the physician if the facility could not provide a one-time order to receive further direction. On 7/27/23 at 11:26 AM, the DON reported the facility did not have a policy related to Physician notification, as the facility followed the standard of care.

Based on clinical record review, staff interviews and review of Medicare guidelines, the facility failed to provide a notice of Medicare Non-coverage 48 hours in advance of services ending for 1 of 3 residents reviewed (Resident #28). In addition, the facility failed to provide the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) form for 1 of 1 resident (Resident #28) whose skilled stay ended and continued to reside in the facility. Findings include: 1. Resident #28's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 9, indicating moderately impaired cognition. The MDS indicated that Resident #28 required extensive assistance of two persons with bed mobility, transfers, and toilet use. The MDS indicated that Resident #28 did not walk in the lookback period. Resident #28's MDS included diagnoses of pneumonia, heart failure, hypertension (high blood pressure greater than 130/89), renal (kidney) disease, diabetes mellitus, hemiplegia (paralysis of one side of the body) affecting left side, adult failure to thrive (decline in status due to loss of appetite, loss of weight, and less activity) and tracheostomy (an artificial opening in the throat that allows someone to breath) status. Resident #28's Clinical Census listed an admitted [DATE] for a Medicare Part A Skilled stay. A facility form titled Therapy Discharge Notification dated 4/12/23 indicated Resident #28 was not appropriated for skilled care and would be discharged from therapy services (Physical and Occupational therapy) on 4/14/23. A therapy and facility representative signed the form on 4/12/23. A CMS (Center of Medicare and Medicaid Services) form (10123-NOMNC)(Approved 12/31/11) titled Notice of Medicare Non-Coverage documented that Resident #28 therapy services would end on 4/14/23. Resident #28's wife signed the form on 4/14/23. Resident #28's wife signed the CMS form (CMS-R-131) (Exp. 6/30/23) titled Advance Beneficiary Notice of Non-coverage (ABN) on 4/14/23. On 7/27/23 at 8:16 AM, Staff B, MDS Coordinator, reported being the person responsible for completing the Medicare Notices and SNFABNs. Staff B acknowledged and verified that Resident #28 or Resident #28's wife did not receive the Medicare notice 48 hours prior to services ending. They received the notice when Resident #28's wife signed the form on 4/14/23. Staff B reported she only had the SNFABN #CMS-R131 (exp. 6/30/23) form available to give. On 7/27/23 at 11:26 AM, the Director of Nursing (DON) stated she did not have a facility policy regarding Medicare Notices, as they followed the Medicare guidelines.

Based on clinical record review, staff interviews and facility policy review the facility failed to provide a notice of bed hold for 2 of 2 residents reviewed (Resident #28 and #137) for discharge to the hospital. Findings include: 1. Resident #28's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 9, indicating moderately impaired cognition. The MDS indicated that Resident #28 required extensive assistance of two persons with bed mobility, transfers, and toilet use. The MDS indicated that Resident #28 did not walk in the lookback period. Resident #28's MDS included diagnoses of pneumonia, heart failure, hypertension (high blood pressure greater than 130/89), renal (kidney) disease, diabetes mellitus, hemiplegia (paralysis of one side of the body) affecting left side, adult failure to thrive (decline in status due to loss of appetite, loss of weight, and less activity) and tracheostomy (an artificial opening in the throat that allows someone to breath) status. Resident #28's Clinical Census listed an admitted [DATE] for a Medicare Part A Skilled stay. The Health Status Note dated 3/17/23 at 6:10 PM reflected that after Resident #28 transferred to the hospital, the hospital admitted him for weakness and an elevated white blood cell count for intravenous (IV) antibiotics. The clinical record lacked documentation that the facility provided a bed hold notice to Resident #28 and/or Resident #28's Representative upon discharge to the hospital. On 7/27/23 at 12:30 PM, the Director of Nursing (DON) acknowledged and verified the facility did not complete a bed hold for Resident #28. The DON stated she expected the staff to complete a bed hold form upon the resident's discharge to the hospital. 2. Resident #137's Minimum Data Set (MDS) assessment dated [DATE] identified a completed Staff Assessment for Mental Status, indicating severely impaired cognition. The MDS indicated that Resident #137 required extensive assistance of two persons with transfers and required total dependence of two persons with bed mobility and toilet use. The MDS indicated Resident #137 walking did not occur. Resident #137's MDS included diagnoses of pneumonia, renal insufficiency (poor functioning kidneys), stroke, metabolic encephalopathy (problem in the brain caused by chemical imbalance in the blood), and alcohol dependence with withdrawal delirium (confusion caused by a withdrawal of alcohol). Resident #137's Clinical Census listed an admitted [DATE] for a Medicare Part A Skilled stay. A Progress Note dated 4/22/23 at 9:52 AM revealed Resident #137 was transferred to the hospital by ambulance. The note documented Resident #137's oxygen saturation level (oxygen in the blood) was 79% on Oxygen at 3 liters per nasal cannula. The Health Status Note dated 4/22/23 at 1:33 PM reflected that Resident #137 had a large brain bleed and the local hospital planned to transfer him to another hospital due to not having a neurosurgeon available. The clinical record lacked documentation the facility provided a bed hold notice to Resident #137 and/or Resident #137's Representative upon discharge to the hospital. The Notice of Bed Hold Policy and Return policy revised 5/15/23 directed the following: a. A Medicaid resident's bed is held upon transfer for 10 days per month for a hospital stay and 18 days annually for a leave of absence. b. A Medicare skilled resident who is admitted to the hospital may pay to hold the bed at the agreed upon rate pending return to the facility. If the resident or their representative does not wish to hold the bed, the facility should be notified in writing. c. A private pay resident bed will be held upon transfer with the following considerations, the resident or their representative must pay the facility at the private pay bed hold rate or notify the facility in writing if chose not to hold the bed; and if at any time the resident or representative wish to discontinue the bed hold the facility would be notified in writing. d. The facility would readmit a resident whose hospitalization or therapeutic leave exceeds the bed hold period upon the first availability of a bed if the resident required serviced provided by the facility and eligible for nursing facility service. The form included two areas that required initials: i. DO NOT request bed hold ii. Do request bed hold and agree to the terms of payment. Agree to pay bed hold in the amount of [specified amount] per day for [specific name], resident. g. Signature and date of the facility representative, witness, and the resident and/or responsible party. On 7/27/23 at 10:25 AM, the DON verified that the facility did not complete a bed hold for Resident #137. The DON stated she expected the staff to complete a bed hold form upon the resident's discharge to the hospital.

Based on clinical record review and staff interviews, the facility failed to have an order to suction a resident with a tracheostomy 1 of 1 resident reviewed (Resident #28). Findings includes: Resident #28's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMs) score of 9, indicating moderately impaired cognition. The MDS indicated that Resident #28 required extensive assistance of two persons with bed mobility, transfers, and toilet use. The MDS indicated that Resident #28 did not walk in the lookback period. Resident #28's MDS included diagnoses of pneumonia, heart failure, hypertension (high blood pressure greater than 130/89), renal (kidney) disease, diabetes mellitus, hemiplegia (paralysis of one side of the body) affecting left side, adult failure to thrive (decline in status due to loss of appetite, loss of weight, and less activity) and tracheostomy (an artificial opening in the throat that allows someone to breath) status. The Care Plan Focus revised 3/31/23 identified that Resident #28 had the potential for respiratory abnormalities related to his tracheostomy site, chronic obstructive pulmonary disease (COPD, long term lung disease that affects breathing), the use of oxygen, and pneumonia. The Intervention dated 3/31/23 listed that Resident #28 had a suction machine from home and directed to suction as needed and per his request. The clinical record lacked a Physician order to suction Resident #28 via the tracheostomy site prior to 7/26/23. Review of the facility competency for tracheostomy training revised on 5/11/21 lacked direction to check the physician order prior to suctioning. On 7/24/23 at 11:30 AM Staff C, Registered Nurse (RN), stated she used the suction machine to suction Resident #28 via the tracheostomy two times in the past. On 7/27/23 at 3:15 PM, the Director of Nursing (DON) verified the facility did not have a physician order to suctioning Resident #28 prior to 7/26/23. The DON said she expected a physician order for suctioning before suctioning the resident. The DON reported that the facility did not have a policy related to suctioning or obtaining physician orders, as it is a standard of practice to obtain a physician order before doing something like that. On 7/27/23 at 3:35 PM, Staff D, Licensed Practical Nurse (LPN), reported that she suctioned Resident #28 multiple times in the past. She usually suctioned Resident #28 about once a shift.

Based on record review, observations, and staff interviews, the facility failed to ensure residents were not at risk for bed rail entrapment as identified for 5 of 35 residents. Specifically, the facility failed to ensure the space between the bed rail and mattress did not create a risk of entrapment for Resident #33; and failed to implement a system to ensure side rails gaps did not create the risk of entrapment for Residents #1, #25, #90, & Resident #190. Observations of side rail gaps showed the space large enough for head entrapment; and the space between the mattress and side rail was large enough for head entrapment to occur. In addition, the facility failed to ensure they monitored bed rails to prevent entrapment for residents and identified which residents used side rails; and failed to obtained resident consent forms for side rails until [DATE]. Interview with the DON revealed she was unaware of the allowable space/dimensions for side rails used by residents or the allowable space between the side rail and mattress to prevent entrapment; and unable to provide an updated list of residents that used side rails. Interviews with the Administrator confirmed the facility failed to train staff on the correct dimension when using side rails; and acknowledged there was not a process followed or used by the facility to determine if bed rails were safe after applied to a resident's bed. The failure to ensure residents would not become entrapped within the bed rail and or the failure to ensure residents could not be entrapped between the inside surface of the rail and mattress put residents at risk of serious injury, impairment, or death which placed residents in immediate jeopardy situation. The facility reported a census of 35 residents. Findings include: 1. Review of the Food and Drug Administration's (FDA) Hospital Bed Safety Workgroup article, Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, dated [DATE], indicated, in pertinent part, .Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team .Bed rail use for patient's mobility and/or transferring, for example, turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan .Inspect, evaluate, maintain, and upgrade equipment(beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment of patient needs, considering all relevant risk factors .If it is determined that bed rails are required .The mattress to bed rail interface should prevent an individual from falling between the mattress and bed. Maintenance and monitoring of the bed, mattress, and accessories such as patient/caregiver assist items .should be ongoing . According to the FDA's Guidance for Industry and FDA Staff article, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued [DATE], For [AGE] years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. FDA received approximately 691 entrapment reports over a period of [AGE] years from [DATE] to [DATE]. In these reports, 413 people died , 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or footboards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Entrapments have occurred in a variety of patient care settings . A. The FDA recommended dimensional limit for zones 1 through 4, and suggested if any alternative approach be least as stringent as the ones describe below: a. Zone 1 - within the rail. Zone 1 is any open space within the perimeter of the rail. Opening in the rail should be small enough to prevent the head from entering. The recommend space is less than 4 and ¾ inches, representing head breadth. b. Zone 3- between the rail and the mattress. Zone 3 is the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment when taking into account the mattress compressibility, and shift of the mattress or rail, and the degree of play from loosened rails. The FDA recommended a dimensional limit of less than 4 and ¾ inches for the area between the inside surface of that rail. The facility provided an email dated as received on [DATE] from the Director of Clinical Services Accura Healthcare which directed the facility to implement a new screen on all residents to check all beds rails for proper use. The email directed specifically that there cannot be any opening wider than 4 and ¾. A document titled Side Rail Rationale directed, if side rails are indicated, asses measurement of rails to ensure gaps are no greater than 4 ¾ inches. The Facility failed to provide a facility policy or procedure that addressed side rail use when requested by surveyor. 1.) The Minimum Data Set (MDS) assessment tool dated [DATE] for Resident #33 identified his [DIAGNOSES REDACTED]. The assessment revealed Resident #33 required one staff assistance for personal hygiene, bathing, and eating. The MDS revealed Resident #33 required assistance of 2 staff for bed mobility, transfers, dressing, and for toilet use. The MDS showed the resident's BIMS (Brief Interview for Mental Status) cognitive test was not completed because the resident was severely cognitively impaired. The MDS identified the resident had 2 or more falls without injury since the previous assessment. A care plan dated as revised on [DATE], did not indicate bed rails were used. The care plan identified the resident had falls on [DATE], [DATE], [DATE], [DATE], and [DATE]. The care plan revealed the resident had poor safety awareness due to advanced dementia and [MEDICAL CONDITION] medications. Resident #33 would be re-evaluated for hospice services. A facility fall investigation showed Resident #33 had 2 falls on [DATE] when found on the floor next to the bed between the wall and bed. The 2 falls were back to back falls on the ,[DATE] shift. According to the Side Rail Rationale Screen dated [DATE], Resident #33 had an assessment which revealed the following information: a. the resident was non-ambulatory. b. the resident had an alteration in safety awareness related to cognitive decline. c. had a history of [REDACTED]. d. had difficulty with balance or poor trunk control. e. took medications which required extra safety precautions. The resident demonstrated poor bed mobility, difficulty moving to a sitting position on the side of the bed, and the resident would benefit from using side rail for positioning or support. The conclusion revealed side rails would provide for safety. The assessment revealed, if side rails are used, assess measurement of the rails to ensure gaps are no greater than 4 & ¾ inches. An observation on [DATE] at 8:00 a.m., revealed the resident lying on his/her right side in bed resting. One side of the bed was against the wall and one side of the bed had top ½ side rail up. An observation on [DATE] at 8:30 a.m., revealed the space between the mattress and ½ bed rail measured 6 inches by the maintenance supervisor with the mattress pushed against the wall. (This area is the space between the inside surface of the rail and the mattress.)The maintenance supervisor confirmed this measurement. The resident was not in the bed at this time. (The space should be small enough to prevent head entrapment.) An observation on [DATE] at 1:20 p.m., revealed Resident #33 in bed lying on his/her right side. The space between the (inside surface) of the mattress and side rail remained. An observation on [DATE] at 4:45 p.m. revealed the bed had been replaced with a different bed from the hospice agency. 2. The MDS assessment tool dated [DATE] listed [DIAGNOSES REDACTED]. The MDS indicated the resident received anticoagulant medication, diuretic medication, and opioid medication. The MDS revealed the resident required one staff assistance for bed mobility, dressing, toilet use, and personal hygiene; and two staff assistance for transfers. The MDS listed the resident's BIMS as 14 out of 15, indicating intact cognition. The MDS identified the resident had no falls since the previous assessment. A care plan initiated on [DATE] and revised on [DATE], did not indicate bed rails were used. According to the Side Rail Rationale Screen dated [DATE], Resident #1 had an assessment which revealed the following information: a. the resident was non-ambulatory. b. had difficulty with balance or poor trunk control. c. took medications which required extra safety precautions. The resident demonstrated poor bed mobility, difficulty moving to a sitting position on the side of the bed, and the resident expressed a desire to have a side rail. The conclusion revealed the resident would benefit from using the side rail for positioning or support. The assessment revealed, if side rails are used, assess measurement of the rails to ensure gaps are no greater than 4 & ¾ inches. Observation on [DATE] 10:30 a.m., revealed the Maintenance Supervisor measured a gap within the bed rail that measured 7.5 inches. The bed rail was observed to have a two mesh panels attached to the outer side of the rail. A triangle shaped gap in the mesh was observed where the two mesh panels met in the middle of the bed rail opening. The Maintenance Supervisor confirmed the measurement. Observation on [DATE] at 1:00 p.m., the Director of Nursing, (DON) was able to pass an object of 4 ¾ inches circumference through the gap within the bed rail. The object was provided and measured by the facility. (The opening in the rail should be small enough to prevent a head from entering.) 3. The MDS assessment tool dated [DATE] listed [DIAGNOSES REDACTED]. The MDS revealed the resident required set up for eating and supervision for bathing. The MDS listed the resident's BIMS (Brief Interview for Mental Status) as 15 out of 15, indicating intact cognition. The MDS stated the resident had no falls since the previous assessment. A care plan initiated on [DATE] and revised on [DATE] did not indicate bed rails were used. Resident # 25 care plan revealed she required services to address mental health and had [DIAGNOSES REDACTED]. According to the Side Rail Rationale Screen dated [DATE], Resident #25 had an assessment which revealed the following information: a. took medications which required extra safety precautions. The resident demonstrated poor bed mobility and the conclusion was the resident would benefit from using side rail for positioning or support however, the resident expressed a desire to not use side rails. The assessment revealed if side rails are used, assess measurement of the rails to ensure gaps are no greater than 4 & ¾ inches. Observation on [DATE] 10:30 a.m. revealed the Maintenance Supervisor measured the gap within the bed rail for Resident #25, which measured 8 inches. The Maintenance Supervisor confirmed the measurement. Observation on [DATE] 1:00 pm revealed the DON was able to pass an object that measured 4 ¾ inches circumference through the gap within the bed rail. The object was provided and measured by the facility. 4. The MDS assessment tool dated [DATE] listed [DIAGNOSES REDACTED]. The MDS indicates the resident received anticoagulant medications and diuretic. The MDS revealed the resident required extensive assist of 2 staff for bed mobility, transfers and toilet use and dressing. The MDS listed the resident's BIMS (Brief Interview for Mental Status) as 15 out of 15, indicating intact cognition. The resident had a fall with fracture on [DATE]. A care plan dated as last revised on [DATE], indicated side rails were not used. The care plan initiated on [DATE] and revised on [DATE] revealed the resident required extensive assistance from two staff with bed mobility. Resident #90's Side Rail Rationale Screen dated [DATE], revealed the resident: a. took medication that would require increased safety precautions. b. had poor bed mobility. c. expressed a desire to have side rails while in bed. d. had a history of [REDACTED]. e. the resident was non-ambulatory. The resident demonstrated poor bed mobility, difficulty moving to a sitting position on the side of the bed, thus the resident would benefit from using side rail for positioning or support. The conclusion revealed side rails would provide for safety and to promote independence with bed mobility. The assessment revealed, if side rails are used, assess measurement of the rails to ensure gaps are no greater than 4 & ¾ inches. Observation on [DATE] 10:30 a.m., revealed the Maintenance Supervisor measured the gap within bed rail which measured 7.5 inches. The Maintenance Supervisor confirmed the measurement. Observation on [DATE] 1:00 pm the DON was able to pass object of 4 ¾ inches circumference through the gap within the bed rail. The object was provided and measured by the facility. (The opening in the rail should be small enough to prevent a head from entering.) 5. The MDS (Minimum Data Set) assessment tool had not been completed as resident 190 was admitted [DATE]. According to the Physician order [REDACTED].#190's listed [DIAGNOSES REDACTED]. A care plan dated [DATE] identified ½ side rails are used for safety and independence. The resident's Side Rail Rationale Screen, dated [DATE], revealed the resident: a. took medication that would require increased safety precautions. b. would benefit from using the side rail for positioning or support. c. expressed a desire to have side rails while in bed. d. had a history of [REDACTED]. e. had an alteration in safety awareness due to cognitive decline. f. had poor bed mobility. Observation on [DATE] 10:30 a.m. the Maintenance Supervisor measured a gap within the bed rail which measured 9 inches. The Maintenance Supervisor confirmed the measurement. Observation on [DATE] 1:00 p.m. the DON was able to pass an object of 4 ¾ inches circumference through the gap within the bed rail. The object was provided and measured by the facility. (The opening in the rail should be small enough to prevent a head from entering.) B. The CNA Pocket care plan listed current residents' names and included information specific to each residents care needs. Residents # 1, #25, and #90 were not listed for side rails. C. Record review for Residents #33, #1, #25, #90 and #190 showed no side rail consent forms. Interviews: During an interview on [DATE] at 8:30 Am., the DON stated The Maintenance Supervisor is responsible for checking and maintaining side rail compliance. The maintenance Supervisor stated is unaware of any formal checklist for this task. The Maintenance Supervisor further stated he checks the beds and rails the first and third weeks of the month to make sure they are tight. The Maintenance Supervisor confirmed he does not document this check. He stated the nursing department is going to provide him with a list of beds to check. During an interview, conducted with the Director of Nursing (DON) on [DATE] at 10:20 a.m., the DON stated she was aware of the regulation to monitor that bed rails meet the guidelines established for zones (,[DATE] dimensional limits) to prevent entrapment. The DON first reported side rails monitoring occurred during rounds; yet when asked to explain how the monitoring occurred, she responded the pocket care plans listed the type of side rail and monitoring occurred during rounds. The DON then updated her previous statement and said she did not know the side rail dimensions to prevent entrapment or how much gap (space) was allowed between a side rail and mattress. The DON was unable to provide an updated list of residents that used side rails. The DON stated the facility used older beds that failed to meet the bed rail requirements. The DON stated Corporate had directed bed rails be inspected and that a mesh bag be placed over any side rails that failed to meet the requirements. The DON was unable to identify a process for monitoring beds in the facility. She stated the nurse assesses the need for them (side rails) and then Maintenance placed them on. The DON indicated the Side Rail Rationale Screen was used to determine if a bed rail would be useful for a resident. In an interview on [DATE] at 2:15 pm with the Administrator and the Corporate Nurse Consultant, the corporate nurse provided an email from the Director of Clinical Services received by the facility which directed side rails should not have an opening or gap greater than 4 and ¾ inches. The Corporate nurse further stated, Side Rail Rationale Screen implemented on Saturday [DATE]. They reported confirmed the facility failed to train staff to correctly measure opening to assure side rail in compliance. The Administrator shared documentation of an in-service completed today ([DATE]) that directed staff to report holes or deviations in protective mesh immediately and fill out a work order. The Administrator confirmed there was not a process followed by the facility to determine if bed rails were safe after they were applied to a bed. In an interview on [DATE] at 12:40 pm, the MDS/Care planning nurse stated consents for side rails are obtained upon admission and updated with changes to type of side rail, addition or deletion of side rails. The MDS nurse then provided consents for Residents #1, #25, #33, #90, and Resident #190 dated as signed today ([DATE]). The MDS/Care planning nurse confirmed consents were obtained after requested by surveyor. Stated may have been signed upon admission, but was unable to locate these. She confirmed Resident #190 had been admitted on [DATE] and a consent form was not obtained upon admission or when side rails had been placed. In an interview on [DATE] at 11:45, the DON stated upon admission, signed consent form for side rails were expected; and when there was a change in side rails screening. She confirmed she could not locate consent from admission for Residents #33, #1, #25, #90 and #190; and obtained signed consent forms today ([DATE]). Further confirmed consent should have been signed for Resident #190 upon admission ([DATE]). The DON further stated the facility does not obtain physician's orders [REDACTED]. The facility abated the IJ on [DATE] when they completed the following: 1.All bed rails were accessed for openings of 4 & ¾ or greater. Bed rails exceeding the allowable measurement were corrected using a mesh netting on both side of the bed rail. An in-service was held on [DATE] with Staff, CNA, Nurses with directives to notify the charge nurse & complete a work order if the protective mesh becomes torn, or developed holes or deviations. The facility planned to modify or replace permanently any side rail that had an opening of 4 & ¾ or larger and on [DATE] reported the removed the 5 beds and replace them with beds with appropriate side rail (dimensions). The facility will monitor side rails that could pose a risk of entrapment during morning rounds. Additionally the maintenance director was educated on the regulations gaps and will conduct bed rail safety audits and document results and corrective actions taken. The facility removed Resident #33's bed on [DATE]. These actions lowered the scope and severity of the IJ to an E severity level.

Based on observation, record review, and staff interview, the facility failed to ensure staff provided safe transfers with a mechanical lift for 1 of 14 active residents reviewed (Resident #90). The facility reported a census of 35 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 9/1/17, listed Resident #90's [DIAGNOSES REDACTED]. The MDS revealed the resident required extensive assist of 2 staff for bed mobility, transfers and toilet use and dressing. Resident #90 scored 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The care plan initiated on 7/14/17 revealed the resident required extensive assistance from two staff for Hoyer lift transfers to and from bed, wheelchair, bed, and from commode to bed. A Fall Scene Investigation Report dated 12/14/17 at 8:38 p.m., documented the left leg part of the Hoyer (mechanical lift) sling came off the Hoyer during a transfer assisted by staff from the commode. A re-enactment of the fall documented after using the commode, staff placed Resident #90 on a Hoyer shower sling. Staff A Registered Nurse (RN) secured the 2 straps by Resident #90's head with the middle and longest straps both secured inside the metal bars. Staff B Certified Nursing Assistant (CNA) secured the bottom leg straps on the longest strap around the metal bars. They lifted the resident with Staff A at his/her head and Staff B controlling the switch. The left leg strap became unfastened. Staff A saw this and tried to get in between the resident and the floor. She could not get under the resident or between the resident and the night stand due to the (transfer) pole in the resident's room. Resident #90 went down on his/her left side. The root cause of the fall included the commode needed to face the window in the resident's room, not the nightstand, so she didn't have to turn 180 degrees in the lift to get to the head of the bed. Due to the (transfer) pole in the room, it could not be done. In a written statement Staff B wrote on 12/14/17 she and Staff A had Resident #90 on the commode. They stood her to wipe her and put the Hoyer sling beneath her, and laid a soaker pad between her butt and thighs and the sling because the resident stated the sling cut into her. They hooked the bottom to the purple loops and top to green. They lifted her as normal, turned her slinged body to face the right way, and as they moved to lay her on the bed, somehow one of the bottom loops slipped off. Staff B wrote the resident landed on her left side and was yelling that her hip hurt and she needed up. Staff B sat with Resident #90 until the paramedics took her out (to the emergency room ). In a Fall Investigation Witness Statement dated 12/14/17 Staff A documented she had a theory as to what may have caused the incident. She documented the space was too cluttered to adequately transfer the resident in the safest possible way. The way they had the room arranged, Resident #90 had to make a 180 degree turn to get off the commode and into bed. A History and Physical dated 12/15/17 documented Resident #90 had a history of [REDACTED]. The resident suffered a displaced left femoral neck fracture after a Hoyer (mechanical lift) related incident on 12/14/17. Resident #90 cleared for left hip hemiarthroplasty (surgical repair). A Quality Assurance Monitoring Tool dated 12/14/17 documented Resident #90 fell from the Hoyer to the floor in his/her room during a transfer from the commode to the bed. Environmental reasons for the fall included clutter in the room, too many objects. The report documented they needed to remove the (transfer) pole from the room. The new interventions included rearrangement of the room and removal of the pole. During an observation on 1/2/18 at 11:40 a.m. Staff C Certified Medication Aide (CMA) and Staff D Certified Nursing Assistant (CNA) transferred Resident # 90 to bed with the Hoyer lift with hip abductor pillow in place (between legs). Staff used green loops of full body sling on all 4 hooks. Resident #90 transferred to the bed. During an interview on 1/3/17 at 2:45 p.m. Staff A Registered Nurse (RN) stated the incident where Resident #90 fell out of the sling was the 2nd time she had assisted to transfer him/her with the lift, but she had assisted with other residents and her dad was a quadriplegic so she had used a lift since she was young. Resident #90 used a transfer pole during the day to transfer from the wheelchair to the commode. She grabbed onto it to assist with the transfer. It was bolted to the floor and stationary. She went to assist Staff B Certified Nursing Assistant (CNA) with the transfer off the commode. Resident #90 stood using the pole and Staff A washed her buttocks. They placed a blue mesh sling with a cutout for the commode under the resident and hooked the straps to the metal hooks. She applied the straps at the residents head and Staff B at the lower body. Staff B was at the resident's feet and ran the lift and raised the resident off the commode. Staff A removed the commode from under the resident. Staff B started turning the lift and Staff A guided Resident #90's body. They had to turn the resident 180 degrees to get her head toward the head of the bed due to the pole in front of the nightstand and having to get around everything. When they turned Resident #90 she seemed to tilt lower to the left and the strap came off the left lower hook. She had never seen this happen before and felt the arrangement of the room was a factor. During an interview on 1/4/17 at 3 pm Staff B CNA stated Resident # 90 used the pole to transfer to the commode. She used the lift to transfer to bed. They used a blue mesh sling with a hole cutout. She didn't know what size. She said she had used all different lifts with the resident, whatever was available. They also used a soaker pad between the resident and the sling. She said the resident had never previously complained of slipping with the pad in place. Staff B put the straps on the lower end and Staff A by the head. She said it was just habit to double check the straps. She ran the lift at the resident's feet and Staff A at her head. They turned her around and something happened. The strap came off and the resident fell . She said they had done it the same way many times. During an interview on 1/3/17 at 3:15 pm the Director of Nursing (DON) stated she did not contact the company after the incident. They took the lift sling out of circulation after they did a reenactment with the nurse consultant. Observation of the sling showed the loops were intact. The tags were worn and unreadable. During a call on 1/4/17 at 8:47 a.m. a customer service representative at Invacare regarding the incident with the lift, stated they had not had reports of this type of incident when the lift was used properly and functioned properly. She said if the loop of the sling was properly in the lift hook it should not come out. She said if you watch the videos on you tube they use only the lift sling, nothing between the resident and the sling. During an interview on 1/4/18 at 10:03 a.m. the DON stated they used the incontinent pad between the resident and the sling per the resident's request. She said she questioned it's use also, at the time. She did not know if they counseled the resident on the safety of it's use prior to. She said the sling with the hole in it caused discomfort and that is why they used the pad between. She did not know why they used the sling with the hole since Resident #90 had finished on the commode and was cleaned up prior to placing the sling. The Manual/Electric Portable Patient Lift page 9 directed a warning when using the sling do not use any kind of plastic back incontinence pad or seating cushion between the patient and sling material that may cause the patient to slide out of the sling during transfer. Page 10 of the manual documented a warning when transferring a patient and directed staff to: when elevated a few inches off the surface of the stationary object (wheelchair/commode/bed) and before moving the patient, check again to make sure that the sling is properly connected to the hooks of the hanger bar. If any attachments are not properly in place, lower the patient back onto the stationary object and correct this problem.

Based on record review and resident and staff interviews, the facility failed to ensure 3 residents (Residents #2, #3 & #6) were safe from physical abuse from another resident (Resident #1). The facility reported a census of 43 residents and the sample consisted of 7 residents. Findings: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 1/7/16. The MDS identified Resident #1 with [DIAGNOSES REDACTED]. The MDS indicated the resident as severely cognitively impaired. The resident required extensive assistance of one staff person with transfers but independent with mobility with the use of a wheelchair. The resident's Care Plan dated 9/30/14 indicated the resident becomes frustrated about communicating with others and directed staff to be patient when trying to communicate. No other focus areas or interventions related to the resident's history of aggressive behavior had been noted. Social service progress notes dated 11/20/15 documented the resident's behavior appropriate with occasional outbursts when he/she gets frustrated. A social services evaluation dated 11/20/15 documented the resident will swing his/her hand at staff and peers (residents). When the resident is upset he/she will wave hands, will refuse to move and will swing at anyone. Interdisciplinary progress notes of 2/24/16-3/28/16 revealed the resident will agitate other residents, slams residents doors, pounds on tables where residents are sitting, teases residents on purpose, very combative with staff, yelling and bumping into other residents and repeatedly runs into staff and residents with h/her wheelchair and then laughs about it. 2. An MDS with an ARD date of 3/1/16 documented Resident #2 with [DIAGNOSES REDACTED]. A brief interview mental status (BIMS) indicated normal cognition. During an interview dated 5/11/16 at 2:30 p.m. the resident reported Resident #1, on multiple occasions purposely bump his/her wheelchair into him/her and would hit his/her on the arms, shoulder and back. Resident #2 had asked the resident to stop bumping into and hitting h/her but the resident continued to do this. 3. An MDS with an ARD date of 2/18/16 documented Resident #3 with [DIAGNOSES REDACTED]. A BIMS indicated normal cognition. During an interview dated 5/10/16 at 3:30 p.m. the resident reported Resident #1 would purposely bump into him/her with his/her wheelchair and then hit him/her left arm, usually twice and it would hurt. The resident reported he/she had told the nurse that Resident #1 was hitting him/her arm but Resident #1 continued to hit him/her. Resident #1 would bump into him/her and hit him/her at least twice daily and it never stopped until Resident #1 left the facility. 4. An MDS with an ARD date of 3/1/16 documented Resident #6 with [DIAGNOSES REDACTED]. A BIMS indicated moderate cognitive impairment. During an interview dated 5/11/16 at 3:50 p.m. the resident reported Resident #1 has purposely bumped and hit h/her several times when h/she was in the dining room. The resident reported h/she has been upset, cries and is depressed because of what Resident #1 has done to h/her. The resident reported h/she has told staff and they do nothing about it. During an interview dated 4/28/16 at 9:59 a.m. Staff A, a certified nursing assistant (CNA) stated Resident #1 is combative with other residents. The resident pedals himself/herself backwards and bumps into other residents, slams doors and there has been two incidents where the resident has hit Resident #6 on two separate occasions and a similar incident where Resident #1 hit Resident #2. Resident #1's behavior has been ongoing for about a month. Staff A reported she had reported these events to the Director of Nursing. During an interview dated 4/8/16 at 10:40 a.m. Staff D, a registered nurse (RN) reported she works part-time twice weekly and hasn't seen any physical altercations between residents. She has seen Resident # purposely bumped h/her wheelchair into other residents but she is not aware of Resident #1 hitting residents. During an interview dated 5/10/16 at 11:30 a.m. Staff E, CNA stated Resident #1 bumped into other residents possibly on purpose. The resident would pedal backwards, was deaf and unable to speak and would make audible sounds and would beat on tables. During an interview dated 5/10/16 at 1:19 p.m. Staff F, RN reported Resident #1 was deaf and unable to speak and knew sign language. The resident had a five year old mentality and had been diagnosed with [REDACTED]. The resident purposely bumped into other residents and with an open hand, hit resident's arms, legs or shoulders. The resident was non-discriminatory with his/her hitting. Resident #1 had 3 to 4 residents he/she targeted and would bump into and hit them (Residents #2, #3 and #6.) Staff would see Resident #1 coming toward other residents and staff and redirect him/her when the resident was close. Resident #1 would hit Resident #3 and he/she would complain it hurt when Resident #1 hit he/her. During an interview dated 5/10/16 at 3:16 p.m., Staff G, CNA reported Resident #1 has hit a lot of residents with a closed fist. The resident would hit Resident #3 anytime he/she was around Resident #3. Resident #1 would also hit Resident #6. Staff G stated she reported her concerns to the Administrator, but the Administrator stated Resident #1 was flirting with all the female residents. Resident #3 complained all the time of Resident #1 hitting h/her. During an interview dated 5/10/16 at 3:44 p.m. Staff H, RN reported Resident #1 self -mobile and had a history of [REDACTED]. Staff H reported she had not seen Resident #1 hit anyone. She had heard from other staff that Resident #3 complained of Resident #1 hitting him/her. Staff H reported she made observations over multiple days and witnessed the resident pat Resident #3 on the shoulder and didn't see anything wrong with the resident's actions. Resident #3 was upset over this but nothing was done about Resident #1's behavior. During an interview dated 5/11/16 at 11:38 a.m. Staff I, CNA, activity director and social services designee reported Resident #1 had difficulty communicating when he/she first arrived at the facility. The resident would hit residents with an open hand and also with a closed hand to get a resident's attention. At times other residents would be upset and hit back. The residents would pedal himself/herself backwards and didn't pay attention to where h/she was going and bumped into residents. Staff attempted to get the resident to turn around and pedal forwards instead of backwards but the resident wasn't compliant. The resident would hit Resident #3 and Resident #3 would report the hit to staff. Staff I stated when Resident #3 attended an activity she would place the resident in an area where h/she would not be accessible to Resident #1. She stated what she had done to protect Resident #3 from Resident #1 may not have been done by other staff. Staff were directed to keep an eye on all residents. Staff I reported it was hard for her to do her job when she always worried what Resident #1 would do next. The facility policy/procedures titled Abuse Policy and Procedures, dated 4/02, documented that residents have the right to be free from verbal, mental, sexual, physical, involuntary seclusion, neglect and misappropriation of property. The policy defines abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Physical abuse includes slapping, hitting, pinching, kicking and includes controlling behavior through corporal punishment. The policy further indicated if resident-to-resident abuse is suspected, the residents must be protected from each other to prevent reoccurrence. During an interview dated 5/11/16 at 3:16 p.m. the Administrator and the Director of Nursing reported Resident #1's Care Plan did not reflect the resident ' s needs. There were no interventions identified in the care plan related to the resident's behavior. The Administrator reported the tapping on other residents by Resident #1 was the resident's way of communicating his/her presence and she never felt it was done with meanness or harm. Resident #1 would pedal backwards on purpose despite staff trying to get the resident to use his/her wheelchair to pedal forward and not backwards. The Administrator reported if she thought Resident #1 was abusive to other residents she would have taken corrective action and report the events to the department.

Based on record review and resident and staff interviews, the facility failed to provide adequate supervision to ensure Resident #1 did not hit or bump a wheelchair into other residents (Residents #2, #3, #6). The facility reported a census of 43 residents and the sample consisted of 7 residents. Findings: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 1/7/16. The MDS identified Resident #1 with [DIAGNOSES REDACTED]. The MDS indicated the resident as severely cognitively impaired. The resident required extensive assistance of one staff person with transfers but independent with mobility with the use of a wheelchair. The resident's Care Plan dated 9/30/14 indicated the resident becomes frustrated about communicating with others and directed staff to be patient when trying to communicate. No other focus areas or interventions related to the resident's history of aggressive behavior had been noted. Social service progress notes dated 11/20/15 documented the resident's behavior appropriate with occasional outbursts when he/she gets frustrated. A social services evaluation dated 11/20/15 documented the resident will swing his/her hand at staff and peers (residents). When the resident is upset he/she will wave hands, will refuse to move and will swing at anyone. Interdisciplinary Progress Notes indicated the following: On 2/24/16 at 3:14 a.m. resident slamming doors and trying to run into people with he/her wheelchair. On 2/25/16 at 3:30 a.m. the resident propelling self around facility in a wheelchair, runs into staff, slams resident doors, pounds on a table and yells at staff when staff attempt to communicate. On 2/26/16 at 1:57 a.m. the resident continues to agitate other residents. On 2/27/16 at 1:33 a.m. the resident continues to have behaviors, yells out and combative with staff. On 2/27/16 at 8:00 p.m. the resident continues to have behaviors this shift of teasing residents on purpose, running into residents and spitting out his/her supper and evening medications. On 2/28/16 at 9:59 p.m. the resident has behaviors throughout the shift; running into residents and teasing residents. On 2/29/16 at 2:42 p.m. the resident had some behaviors with other residents but easily redirected. On 3/8/16 at 2:43 p.m. the resident up all night, yelling and trying to bump into other residents, wandering up and down the hall slamming doors and becomes upset when staff attempts to stop the behavior. On 3/9/16 at 3:07 a.m. the resident becomes combative with staff when attempting to encourage to rest in bed. On 3/10/16 at 3:15 a.m. the resident awake and propelling self in wheelchair and becomes upset and combative toward staff when staff attempt to encourage the resident to rest in bed. On 3/12/16 at 3:34 p.m. the resident continues to have behavior, running into other residents with wheelchair. On 3/19/16 at 9:46 p.m. the resident continues to have behaviors of teasing other residents and running wheelchair into other residents. On 3/20/16 at 2:55 a.m. the resident remains the same and tried to run wheelchair into other residents and not sleeping at night. On 3/23/16 at 3:03 a.m. the resident was non-compliant with taking medications and insists on running into people with wheelchair and then laughing about it. On 3/24/16 at 3:06 a.m. the staff tried to put the resident in bed and the resident hits staff. On 3/28/16 at 3:24 a.m. the resident tools around unit running into other resident ' s doors and trying to run into residents very combative by hitting staff as they try to help the resident. On 3/31/16 at 11:00 p.m. the facility discharged the resident. 2. Resident #2 had a MDS with a reference date of 3/1/16. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview of Mental Status) score of15. A score of 15 represented a normal cognitive status. On 5/11/16 at 2:30 p.m. Resident #2 was interviewed and stated on multiple occasions, Resident #1 would purposely bump his/her wheelchair into him/her and would hit him/her arms, shoulder and back. Resident #2 asked the resident to stop bumping into him/her but the resident continued. 3. Resident #3 had a MDS with a reference date of 2/18/16. The MDS identified the resident had [DIAGNOSES REDACTED]. (stroke). The MDS identified the resident had a BIMS score of 15. The score of 15 represented a normal cognitive status. During an interview dated 5/10/16 at 3:30 p.m. the resident reported Resident #1 would purposely bump into his/her wheelchair and then hit him/her left arm, usually twice and it would hurt. The resident reported he/she had told the nurse that Resident #1 was hitting him/her arm but Resident #1 continued to hit his/her. Resident #1 would bump into his/her and hit him/her at least twice daily and it never stopped until Resident #1 left the facility. 4. Resident #6 had a MDS with a reference date of 3/1/16. The MDS identified the resident had [DIAGNOSES REDACTED]. On 5/11/16 at 3:50 p.m. Resident #6 was interviewed. The resident reported Resident #1 has purposely bumped and hit his/her several times when he/she was in the dining room. The resident reported as been upset, cries and is depressed because of what Resident #1 has done to him/her. The resident reported he/she has told staff and they do nothing about it. An interview with a group of 5 residents on 5/11/16 at 11:00 a.m. reported they were aware of instances in which a resident was abused by another resident. The residents reported Resident #1 purposely runs into other residents with his/her wheelchair and then hits residents with an open hand. Two residents reported Resident #1 has used a closed fist when hitting residents. Residents reported they heard from residents who have been hit by Resident #1 that it hurts and are in pain when Resident #1 has hit them. Residents reported Resident #1 has hit Resident #2, #3 and #6 and then laughs about it. Residents report they were fearful and tried to stay away from the resident. Residents reported staff rarely intervened and there were no repercussions of his/her actions. Residents reported they themselves have not been hit by Resident #1. During an interview dated 4/28/16 at 9:59 a.m. Staff A, a certified nursing assistant (CNA) stated Resident #1 is combative with other residents. The resident pedals self -backwards and bumps into other residents, slams doors and there have been two incidents where the resident has hit Resident #6 on two separate occasions and a similar incident when Resident #1 hit Resident #2. Resident #1's behavior has been ongoing for about a month. Staff A reported she had reported these events to the Director of Nursing (DON). During an interview dated 4/8/16 at 10:40 a.m. Staff D, a registered nurse (RN) reported she works part-time twice weekly and hasn't seen any physical altercations between residents. Staff D stated she saw Resident #1 purposely bump the wheelchair into other residents but unaware of Resident #1 hitting other residents. During an interview dated 5/10/16 at 11:30 a.m. Staff E, CNA stated Resident #1 bumped into other residents possibly on purpose. The resident would pedal backwards was deaf and could not speak and would make audible sounds. Staff E stated the resident would beat on tables. During an interview dated 5/10/16 at 1:19 p.m. Staff F, RN reported Resident #1 was deaf and could not speak but knew sign language. The resident had a five year old mentality and had been diagnosed with [REDACTED]. The resident purposely bumped into other residents and with an open hand, hit resident's arms, legs or shoulders. The resident was non-discriminatory with hitting. Resident #1 had 3 to 4 residents targeted and would bump into and hit them (Residents #2, #3 and #6). Staff would see Resident #1 coming toward other residents and staff redirected the resident when close. Resident #1 would hit Resident #3 and Resident #3 would complain it hurt. During an interview dated 5/10/16 at 3:16 p.m., Staff G, CNA reported Resident #1 had hit a lot of residents with a closed fist. The resident would hit Resident #3 anytime he/she was around Resident #3. Resident #1 would also hit Resident #6. Staff G stated she reported her concerns to the Administrator, but the Administrator stated Resident #1 was flirting with all the female residents. Resident #3 complained all the time of Resident #1 hitting him/her. During an interview dated 5/10/16 at 3:44 p.m. Staff H, RN reported Resident #1 as self- mobile and had a history of [REDACTED]. Staff H reported she had not seen Resident #1 hit any anyone. She had heard from other staff that Resident #3 complained of Resident #1 hitting him/her. Staff H reported she made observations over multiple days and witnessed the resident pat Resident #3 on the shoulder and didn't see anything wrong with the resident's actions. Resident #3 was upset over this but nothing was done about Resident #1's behavior. During an interview dated 5/11/16 at 11:38 a.m. Staff I, CNA, activity director and social services designee, reported Resident #1 had difficulty communicating when arrived at the facility. The resident would hit residents with an open hand and also with a closed hand to get a resident's attention. At times other residents would be upset and hit back. The resident would pedal self-backwards and didn't pay attention to where he/she was going and bumped into residents. Staff attempted to get the resident to turn around and pedal forwards instead of backwards but the resident wasn't compliant. The resident would hit Resident #3 and Resident #3 would report the hit to staff. Staff I stated when Resident #3 attended an activity she would place the resident in an area where he/she would not be accessible to Resident #1. She stated what she had done to protect Resident #3 from Resident #1 may not have been done by other staff. Staff were directed to keep an eye on all residents. Staff I reported it was hard for her to do her job when she always worried what Resident #1 would do next.

Based on record review, observation and staff interview the facility failed to provide adequate supervision to ensure against hazards to self for 2 of 5 residents reviewed (Resident #1 & #2). The facility reported a census of 43 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 12/29/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMS (Brief Interview for Mental Status) score of 8. A score of 8 determined the resident had a moderate impairment of cognitive status. According to the MDS the resident required extensive assistance with bed mobility, transfers and toilet use. The MDS identified the resident had 2 falls with no injury since the prior assessment. Review of the Fall Risk assessment dated [DATE] reflected the resident with a total score of 16. A total score above 10 represented a high risk. The Care Plan dated 12/15/15, identified the resident as a potential risk for injury due to falls. The Care Plan identified the resident had falls on 12/24/15, 12/28/15 and 1/19/16. On 12/24/15, the Care Plan was updated to include staff were educated to ensure placement of an alarm at all times. On 12/28/15, the Care Plan was updated to encourage the resident to remain in the lounge area or high traffic area when up in the wheelchair and to prevent being alone in the room. Review of the Quality Assurance Monitoring Tool dated 12/24/15 at 4:00 PM reflected the staff heard the resident yell for help and found the resident laying on the floor with his/her legs caught in the wheelchair pedals. The personal alarm on but not hooked (ineffective). The new intervention directed the staff to not leave the resident in the room in the wheelchair and place him/her in bed. Review of the Quality Assurance Monitoring Tool dated 12/28/15 at 2:40 PM reflected the resident was found sitting on the wheelchair foot pedals by his/her bed. The safety devices were not in place and working properly. The interventions implemented included pressure alarm at all times (post occurrence). Review of the Quality Assurance Monitoring Tool dated 1/19/16 at 3:45 PM identified the staff responded to the call light. The door to the room was closed. Staff noted the alarm sounded behind the door. Staff felt resistance when opening the door and found the resident leaning on the door with his/her head. The resident moved his/her head and staff entered the room and found the resident on the floor. The resident attempted to reposition self and immediately yelled out in pain and grasped the right hip. The staff nurse notified the physician. Review of the Radiology Report dated 1/19/06 revealed the resident had a nondisplaced intertrochanteric (hip) fracture. Review of the TAR (Treatment Administration Record) dated 2/1/16 to 2/29/16 identified the treatment for [REDACTED]. The TAR signed as completed on 2/4/16 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 5:50 AM. The TAR also signed as completed on 2/5/16 6:00 AM to 2:00 PM. Review of the Interdisciplinary Progress Notes (IPN) dated 12/25/15 at 1:45 AM (late entry for 12/24/15 at 4:00 PM) reflected the staff heard the resident yelling for help and found lying on the floor with his/her legs caught in the wheelchair pedals and foot rest. The resident stated that he/she tried to get into bed and fell . The alarm did not sound and not hooked up (to activate). The staff placed the alarm on the wheelchair and then placed at the nurse ' s station. Review of the IPN dated 1/19/16 at 3:45 PM identified the staff attempted to enter the room to answer the call light and felt resistance when she attempted to open the door. The resident laid on the floor and positioned on back and leaned to the left side. Upon movement the resident yelled out in pain, stated it hurt and grasped at his/her right hip. The nurse notified the physician and received new orders to send the resident to the emergency room for evaluation and treatment. The resident's alarm had sounded behind a closed door. The resident stated he/she got up to open the window because it was warm in the room. The resident often noncompliant with call light use. Observation on 2/4/16 at 1:50 PM reflected the resident sat in a wheelchair in the resident's room. The call light observed on the wall behind the resident's bed. The resident could not reach the call light. The resident did not have an alarm. Observation on 2/5/16 at 8:00 AM reflected the resident in a wheelchair at the nurse ' s station. The resident did not have an alarm. At 8:30 AM the resident wheeled to the assisted dining table. The resident remained at the dining room table in the wheelchair with no alarm. At 10:10 AM observation identified the resident in bed with an alarm in place. The resident's roommate closed the resident ' s room door. At 10:50 AM Staff E, RN entered the resident's room and the door remained open when she left. Observation on 2/5/26 at 11:10 AM identified the resident's roommate returned to the room and closed the door. The door remained closed through 12:10 AM. On 2/4/16 at 1:55 p.m. Staff A, RN (Registered Nurse) was interviewed and stated at approximately 3:30 PM, Staff B, CNA (Certified Nursing Assistant) answered a call light. The resident's roommate had turned on the alarm due to the resident's fall. She attempted to get in the door due to it had been shut. The resident moved enough to let staff in and attempted to roll him/herself and screamed in pain and pointed to his/her right hip. Staff A stated she immediately called the doctor and sent the resident to the emergency room . The alarm had been sounding but could not hear it due to call lights going off, a dull sounding alarm and the door had been shut. Some of the resident's alarms are louder. She stated the resident's roommate shuts the door to the room. She further stated there had been 3 staff on duty that afternoon (CNA, CMA (certified medication assistant) and RN). Staff A stated the facility normally had 4 staff members scheduled to work. On 2/4/16 at 3:45 PM Staff B (Certified Nursing Assistant) was interviewed and stated Staff A, RN and Staff C, CMA (Certified Medical Assistant) passed (administered) medications and it was a busy afternoon due to call lights (activated). Staff B stated she had been working on the 100 hall and heard an alarm on the 200 hall and went to take care of that resident. She finished, came down the 200 hall and saw the call light on in the resident's room. When she got to the beginning of the hall she could hear the alarm. She stated that she had been able to slip through the door after the resident moved. She yelled to Staff C to get the nurses. Staff A and the DON (Director of Nursing) came to the room. She further stated at 2:00 PM, the resident appeared to be asleep in bed. The roommate had not been in the room due to a smoke break. Staff B stated she had seen the resident's roommate close the door before and staff tell him/her to leave the door open. On 2/4/16 at 4:05 PM, Staff C (Certified Medical Assistant) was interviewed and stated she had been working at the medication cart and trying to help answer alarms and call lights. Staff C stated she was following Staff B when she answered the call light in the resident's room. The roommate had put the call light on and that had been unusual. She went to get the nurses and Staff A and the DON came to the room. On 2/5/16 at 2:15 PM, Staff B (Certified Nursing Assistant) was interviewed and stated the resident should have an alarm on when in the wheelchair. Staff B searched the resident's room and unable to find the alarm. Staff B stated she did not know what happened to it (alarm). Staff B replaced the alarm. On 2/5/16 at 11:00 AM, the Administrator was interviewed and she stated the CNAs and all nursing staff are responsible for alarm placement. During an interview with the DON on 2/11/16 at 11:04 PM, she stated they try to have 2 CNAs, 1 nurse and 1 CMA on the 2:00 to 10:00 PM shift. The facility uses agency staff too and sometimes they (the facility) can't fulfill the (resident ' s) needs, which had been the reason on that day. She also stated she had some high school students who can't come in (to work) until 4:00 PM on some days. 2. According to the MDS dated [DATE], Resident #2 had [DIAGNOSES REDACTED]. The MDS identified the resident with a BIMS score of 2. A score of 2 represented the resident had a severe cognitive impairment. According to the MDS, the resident required extensive assistance with bed mobility, dressing and toilet use. The Care Plan identified the resident had 1 fall without injury since the prior assessment. Review of the Fall Risk assessment dated [DATE], identified a score of 14. A total score above 10 represented a high risk. The Care Plan dated 4/22/15 directed staff to ensure a pressure alarm on at all times. On 1/4/16 the Care Plan was updated to include staff education. On 1/5/16 the Care Plan was updated to remove the pressure alarm and replace with clip personal alarm at all times. On 1/21/16 the Care Plan was updated to keep all resident snacks and beverages on the dining room tables rather than putting on the ledge. Review of the Quality Assurance Monitoring Tool dated 1/4/16 at 1:15 PM identified the resident was found on the floor by staff. The staff found the resident sitting on buttocks next to the bed. The safety devices not in place or working properly. The new intervention indicated the staff were educated. Review of the Quality Assurance Monitoring Tool dated 1/20/16 at 4:45 PM revealed the resident attempted to stand up by grabbing the ledge of the divider wall and fell . The staff found the resident lying on his/her right side. The alarm sounded. The new intervention included to keep all snacks and beverages on the dining room tables rather than putting on the ledge. Review of the Interdisciplinary Progress Notes (IPN) dated 1/4/16 at 1:15 PM revealed the resident found sitting on the floor next to the bed by staff. On 1/20/16 at 4:45 PM the resident found on the floor, laying on his/her right side. During an interview with Staff D, CNA on 2/5/16 at 11:50 AM she stated that she had been at the end of the hall and the resident's roommate yelled at her out the door that she/he on the floor. She did not remember hearing an alarm and went to get the nurse. The nurse went to the resident's room. During an interview with Staff E, RN on 2/5/16 at 2:25 PM she stated an agency staff member had toileted the resident and put him/her in bed in his/her room. The resident did not usually lie down in his/her room. The alarm did not sound and it had not been placed correctly under the resident. Review of the Quality Assurance Tool dated 9/2005 directed the staff to include suggested preventative measures. The form also directed the Director of Nursing to initiate any further investigation on any episode that resulted in injury to the resident.

Based on observation, record review and staff interview, the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment for two (2) of 5 (five) residents reviewed. Resident #1 eloped from the facility without staff knowledge. Staff H (nurse aide) turned off the panel alarm without fully investigating what caused the alarm to activate. A maintenance personnel observed the resident unattended wandering outside in the grass outside. No staff working that day remembered hearing the second alarm (a local Radio Shack alarm at the door exit) or said they turned it off. Resident #5 did not have routine Wanderguard checks from 1/7/15 to 2/2/15. The findings constitute an immediate jeopardy to the resident's health and safety. The facility census was thirty-eight (38) residents. Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 12/8/14, assessed Resident #1 with a brief interview for mental status (BIMS) score of "10" (moderate cognitive impairment). The resident admitted to the facility on [DATE] from psychiatric hospital. The resident had difficulty understanding others and responded adequately to simple direct communication only. The resident had the following indicators of delirium: inattention and disorganized thinking. The resident had hallucinations, delusions and wandering behavior. The resident was independent with ambulation and but required supervision ambulating on and off the unit. A balance during transitions and walking test identified the resident as steady at all times. The resident had been diagnosed with [REDACTED]. The resident did not have falls since the previous assessment. An elopement risk assessment dated [DATE], identified the resident with a score of "7". A score of 7 identified the resident at risk for elopement. The form identified that the resident used a Wanderguard bracelet. A care plan, dated 10/14/14, identified the resident with wandering behavior. The care plan revealed the resident had a potential for elopement and used a Wanderguard bracelet. A social progress notes dated 12/31/14 documented the resident had behaviors of wandering, disorientated and had a strong history of delusions/paranoia and aggravation/aggressiveness with others. (A nursing notes dated 9/9/14 at 10:15 (p.m.) documented a behavior incident were the resident started spinning in circles and saying he/she can't catch up. The nurse's notes identified the resident took off out the front door, and the Wanderguard alarm sounded. The resident started spinning in circles on the lawn then sat down and log rolled through the grass. The DON and Administrator assisted the nurse and finally got the resident (back) inside.) A late entry for 1/26/15 at 12:04 p.m., dated 1/27/15 documented the maintenance employee observed the resident wandering in the grassy area outside of the 300 hallway door. The staff redirected the resident into the building. The nursing staff checked the resident's Wanderguard on his/her right after the incident and it functioned accordingly. The alarms to all facility doorways were checked and functioned appropriately. A staff member heard alarm to doorway sound but turned off the alarm before visualizing which door had been alarming. The staff approached the nursing staff and asked why there was that noise in which the nurse responded she did not hear the noise. The nursing staff asked another staff if they recognize the noise and that staff said they were unaware of what the sound was. The DON educated all staff present at the in-service this day. A Quality Assessment (QA) Monitoring Tool dated 1/26/15 at 12:04 p.m. revealed a maintenance employee observed Resident #1 wandering in the grass area outside the 300 hall exit door area. The resident appeared confused as usual and wore a shirt with sweater over it, dress type pants, shoes and socks. The resident's Wanderguard safety device had been on the resident's right ankle at the time of the elopement. The resident did not sustain injury. The QA tool revealed a new employee shut the door alarm off before investigating why the alarm activated. An elopement investigative report dated 1/26/15 identified that prior to the elopement, the resident did not exhibit increased agitation or behaviors. An elopement details report revealed Staff H (nurse aide) last saw the resident at 12 p.m. standing in the 300 hallway. The resident exited through the door at the end of the 300 hallway between 12 p.m. and 12:04 p.m. The report identified the temperature was 38 degrees and sunny with no snow present on the ground. The report indicated staff followed the care plan but a staff did not follow policy and procedure in responding to the door alarm which had bearing on the incident. An untitled documented of information the facility provided to the Department revealed all doors that lead outside accessed by residents are alarmed. In addition, the main front door has a Wanderguard alarm. The reports did not address the local Radio Shack alarm located at the 300 hall exit and whether it activated when the 300 hall door opened or if anyone admitted to turning it off. On 2/3/15 at 9:05 a.m. the Administrator stated he was not aware of any issues with the local radio shack alarm. He stated he had no reason to believe the alarm did not sound. It may have gone off and turned off on its own after 80 seconds. Door checks: On 1/29/15 at 11:35 a.m. the maintenance person stated he checks the panel alarms weekly and the Wanderguard door once a month. He stated there were no problems at any check. He did not document any of the door or Wanderguard door checks. He stated Resident #1 wanders a lot. He never saw the resident try to get out or talk of leaving. At that time the surveyor and maintenance person checked all the door alarms. Observation showed each wing had an exit door. Each exit door contained an alarm that alarmed at a panel at the nurses station and a local Radio Shack alarm that alarmed at the hall exit. The panel at the nurses station contained a light for each exit door which would light up if the alarm activated after the door opened. The front door contained an alarm that alarmed at the nurses station panel and a Wanderguard alarm which also activated when checked with a Wanderguard. The maintenance person also showed the surveyor where he observed the resident on the day of the incident. He identified the resident as approximately 30 feet away from the 300 door exit ambulating on the grass. On 2/3/15 at 10 a.m. the maintenance person stated all alarms functioned following the elopement. He did not change batteries in the local Radio Shack alarms because there was no need to. On 2/2/15 at 10:26 a.m. the Director of Nursing stated the night nurse checks the door alarms every night and documents the checks on the 24 hour sheets. The 24 hour nursing report sheets identified Staff E, licensed practical nurse (LPN) performed door alarm checks on 1/25/15 at 11:45 p.m. and 1/26/15 at 12:50 a.m. On 2/2/15 at 1:34 p.m. Staff E, LPN stated every once in a while she checks the door alarms for function. She doesn't like to check them after everyone is asleep. She said the alarms are loud on the 300 halls. She stated either that night or a couple nights before the incident, Resident #5 got up and opened the 300 hall door and looked out. The alarms worked then. She stated if it's after 10 p.m. or 11 p.m. she might not check the alarms because she doesn't want to wake residents up. She stated she was pretty sure she tested them the night before the incident. On 2/2/15 at 12:50 p.m. the 300 hall local alarm activated and turned off on its own after 1 minute and 20 seconds. When asked if the local Radio Shack alarm failed to activate at the time of the elopement, the maintenance person stated that "like anything it may not have sounded" but he had no knowledge that it didn't activate. Observation showed, on 1/29/15 at 12:20 p.m., Resident #1 seated in an easy chair in the activity room. The resident denied going outdoors. The resident did not know the month, year or town he/she was in. The resident then stated, "I wish I could get back to Boone". Observation showed a Wanderguard bracelet on his/her right ankle. Observation showed, on 2/2/14 at 10:55 a.m. the resident wandering down 400 hall. Staff asked the resident if he/she was looking for his/her room. The resident said yes. At that time, staff assisted the resident to his/her room. The resident entered the room and shut the door. Staff Working when the incident occurred: On 1/29/15 at 12:27 p.m. Staff H (nurse aide) stated around 11:30 a.m. on the day of the incident, Resident #1 requested help donning a sweater. Staff H assisted with the sweater and Resident #1 then asked if he/she could go to his/her room and Staff H told the resident yes. Staff H went back to the dining room and assisted residents and then heard a door alarm. She was not sure which alarm it was. She stated she did not look at the board to see which light came on. She went to the top of the halls and looked down each hall and didn't see anything so she turned the alarm off and went back to assisting residents. When asked why she didn't check the panel and identify which exit door alarmed and then go down the hall and look out the exit, she stated she just forgot. She was aware that is what she should do. She also thought for sure she would have seen someone because the alarm just activated. On 2/3/15 at 9:55 a.m. she stated she didn't remember if the 300 hall exit local Radio Shack alarm activated. On 2/3/15 at 9:05 a.m. the Director of Nursing and MDS/care plan nurse stated they heard a panel alarm but did not hear the local Radio Shack alarm. On 2/3/15 at 9:05 a.m. the Administrator stated he was on the phone and hears alarms all day so he was not sure if he heard the alarm at that time or not. On 2/3/15 at 10:04 a.m. Staff A (housekeeping) stated he did not hear any alarms. On 2/3/15 at 10:05 a.m. Staff B (nurse aide) stated she was giving showers and didn't hear anything until she came out of the shower after the incident. On 2/2/15 at 2:30 p.m. Staff C (dietary) stated she did not hear an alarm and did not turn off any alarms. On 2/2/15 at 3 p.m. Staff D (dietary) stated he heard an alarm for about 15 seconds. He thought it was the alarm at the smoker's door which is by the kitchen. He was not sure which alarm it was. On 2/2/15 at 11:15 a.m.,Staff F (nurse aide) stated she did not hear an alarm. On 1/29/15 at 12:40 p.m. Staff G (registered nurse) stated she was at the nurse's station when the incident occurred. She did not hear any alarms. She stated she heard an unfamiliar noise. Staff H came to her while Staff G passed medications and asked Staff G if she saw anything. Staff G had no clue what Staff H talked about or that Staff H referred to an alarm going off. If Staff G would have known, she would have had Staff H check outside the exit door and check the perimeter (outside area). She stated she assessed the resident when he/she returned into the facility and there was no injury. On 1/29/15 at 2:30 p.m. Staff K (licensed practical nurse) stated she was at lunch when the incident occurred and when she came back, the incident already occurred. On 1/29/15 at 1:50 p.m. Staff L (nurse aide) stated she did not remember if she heard an alarm. She was talking to residents. On 2/2/15 at 1:18 p.m. Staff L stated she did not hear a local Radio Shack alarm. On 2/3/15 at 10:45 a.m. the Activity Director stated she probably heard an alarm but she hears alarms throughout the day. She checks the alarm if she is at a stopping point during an activity or if it continues alarming. On the day of the incident, she heard an alarm and went to the nurse's station and saw 3 or 4 staff standing in front of the alarm panel and was told the resident left the facility. On 2/3/15 at 9:52 a.m. Staff P (nurse aide) stated she did not hear a local Radio Shack alarm sounding. She stated if it would have activated, she would have heard it, she was feeding residents. She did hear the panel alarm activate and saw Staff H turn it off. Staff P stated she didn't know what happened with that alarm as she was feeding residents. On 2/2/15 at 4:38 p.m. the office manager stated she didn't hear an alarm because she was on a conference call. On 2/3/15 at 9 a.m. Staff Q (housekeeping/laundry) stated she didn't hear any alarms. On 2/3/15 at 3:50 p.m. Staff R (dietary) stated she was in the kitchen and didn't hear anything. Additional interview: On 2/2/15 at 5:01 p.m., the facility owner stated he wanted to make known that the local Radio Shack alarm was just a back-up alarm. Weather: On 2/2/15 at 11 a.m. the State Climatologist stated the temperature in Boone at 11:55 a.m. on the day of the incident was 45 degrees with wind at 17 miles per hour (mph) with gusts at 23 mph making the wind chill 37 degrees. The skies were clear. Walk Away/Missing Resident Policy (undated): The policy directed staff to identify the door that caused the alarm to activate. Staff should proceed to that door an attempt to verify the cause of the alarm activation. Should a resident be found exiting the door or outside the door, return the resident into the facility and follow up appropriately. Should staff be unable to determine the cause of the alarm activation, all known potential elopement risk residents should be immediately accounted for. If all are accounted for, a further accountability of all residents is warranted. 2. The facility identified via a form that Resident #5 use a Wanderguard bracelets. On 1/29/15 at 11 a.m. the Director of Nursing identified that Wanderguard bracelets are checked every shift by the charge nurse and staff documented the checks on the treatment administration record (TAR). Review of Resident #5's January 7-31/2015 TAR revealed no Wanderguard checks. The January 1-6/2015 TAR revealed the Wanderguard was checked every shift during that time frame. The February 2015 TAR did not contain Wanderguard checks. On 2/3/15 at 11:25 a.m. the Director of Nursing stated the facility must have missed the Wanderguard checks when they switched computer systems in January and began using new TARS. Observation showed, on 1/29/15 at 1:45 p.m., Resident #5's Wanderguard bracelet checked as functional when checked with the Wanderguard bracelet checker. The facility abated the IJ on 1/26/15, when they completed the following: a). Placed a cover and lock over the door alarm panel. b). Educated staff at an in-service on the policy and procedure for preventing residents from exiting undetected. At the in-service the facility re-iterates what to do when the alarm sounds to all staff. c). The facility tested all alarm devices including Wanderguard equipment. These actions lowered the deficiency from a scope and severity of J to D, with the need for ongoing monitoring of residents ' Wanderguard bracelets to maintain residents safety.

Based on record review, physician and staff interviews, the facility failed to assess a resident after an onset of adverse symptoms which represented a change in condition, notify the physician of the resident ' s condition and failed to obtain signed physician telephone orders for 1 of 5 residents reviewed. Resident #6 experienced a change in breathing, responsiveness and functioning which resulted in an extreme condition change. The facility failed to assess the resident and failed to notify the physician of the change. The resident expired and staff did not provide CPR (cardio [MEDICAL CONDITION] resuscitation) per wishes of the resident. The physician stated she should have been notified and would have sent the resident to the emergency room for care. The facility reported a census of forty (40) residents. Findings include: 1. Resident #6 had a Minimum Data Set (MDS) assessment with a reference date of [DATE] which identified an admission date of [DATE]. The MDS identified the resident with clear speech and usually understood. Resident #6 had difficulty communicating some words or finishing thoughts but able if prompted or given time. The resident usually understood others but may miss some part/intent of message but comprehends most conversation. The resident had a brief interview for mental status (BIMS) score of "9" (moderate cognitive impairment). The resident did not have mood or behavior symptoms. The resident was independent with all cares other than supervised bathing. The resident had [DIAGNOSES REDACTED]. A Balance during transitions and Walking test identified the resident as steady at all times with all aspects of the test. The resident had no functional limitations of range of motion in the upper or lower extremities. The resident measured 70 inches and weighed 231 pounds. The resident was [AGE] years old and a full code (wanted cardiopulmonary resuscitation CPR) A [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].) daily, Vitamin B-1 daily, [MEDICATION NAME] (for stomach) 20 mg. daily and [MEDICATION NAME] (antipsychotic) 25 mg three times daily. A care plan dated [DATE] contained a problem/need of "advanced directives". The care plan indicated the resident/responsible party requested CPR. The care plan also revealed the resident was court ordered to the facility due to a serious mental illness. The care plan identified a potential for change of condition and cognitive changes. The care plan directed staff to assess for change in condition/function and notify the physician as needed. The care plan identified the resident as independently ambulatory without assistance devices. Nurse ' s Notes: On [DATE] at 9:30 p.m., the resident told staff he/she felt "full of anxiety". On [DATE] at 6:35 p.m. the facility telephoned the resident's physician due to the resident's requests for [MEDICATION NAME] (antianxiety) and [MEDICATION NAME] (antianxiety). The physician wanted to see the resident first before changing orders since the physician had not seen the resident for a year. Staff scheduled an appointment for [DATE]. On [DATE] at 9 p.m., the resident asked about nerve medicine. Staff explained the physician requested to see the resident before changing orders. Staff told the resident they arranged for an appointment with the physician. On [DATE] at 3:45 p.m. the resident complained of nerves. Staff reminded the resident of the appointment coming up soon to help with anxiety. On [DATE] at 3:45 p.m. staff observed the resident with increased anxiety. On ,[DATE]/ at 2:15 p.m. staff observed increased agitation. Staff faxed the physician of the concerns. At 9 p.m. staff attempted to check the resident's vital signs and he refused. Staff called the physician and moved up the appointment to get the resident on medications. At that time, the physician stated the resident should take [MEDICATION NAME] among others but won ' t prescribe them until the physician sees the resident. The surveyor requested a copy of the facsimile (fax) and the Director of Nursing stated she could not locate it. On [DATE] at 3:40 p.m. staff measured the resident's temperature at 100 degrees. The resident was able to make needs known. Staff administered Tylenol (antipyretic) and the temperature measured 99.5 degrees at recheck (no time given). Staff changed linens on the resident's bed due to diaphoresis. The resident appeared shaky which staff observed since admission. On [DATE] at 10:15 a.m. staff identified the resident as alert and oriented times two to three and able to make needs known. Vital signs at that time: Blood pressure ,[DATE], Pulse 98, Respirations 17 Temperature 98.9 degrees. As Staff B documented the above entry, the resident came running from the room. Sitting up and down, pushing, hitting and breathing heavily. The resident could not sit still and kept screaming "no". At one point, the resident broke into the Administrator's office. The resident appeared very anxious and confused. Staff B telephoned the Director of Nursing while dealing with the resident to inform her that Staff B thought the facility needed to send the resident to the emergency room for evaluation or get an order for [REDACTED]. Staff B phoned the resident's psychiatric physician's nurse who informed Staff B that the resident is no longer a patient of that physician so they could not do anything. Staff B administered the [MEDICATION NAME] 5 mg. intramuscularly (IM). At 11:30 a.m., Staff B documented that the resident rested peacefully at this time. The Director of Nursing (DON) documented on [DATE] at 10:15 a.m., late entry revealed the DON arrived at the facility at 10:15 a.m. finding the resident aggressive and restless. The DON asked the resident to sit with her at the table and the resident could only sit for a few seconds before getting up and attempting to get up again. Staff walked with the resident a few feet before the resident bent over to sit on the floor. The resident lay down on the floor in the front lobby and appeared extremely restless. The nurse sat on the floor with the resident approximately 45 minutes while the charge nurse (Staff B) obtained an order for [REDACTED]. Observation revealed deep breathing at that time. On [DATE] at 1 p.m. the DON documented she checked on the resident. The resident rested peacefully with some agonal (difficult breathing prior to [MEDICAL CONDITION]) breathing noted. On [DATE] at 1:40 p.m. Staff B went in the resident's room with the DON to check the resident. They found the resident not breathing and without a pulse. They checked for a full 5 minutes and pronounced the resident dead at 1:31 p.m. The closed resident record did not contain evidence the facility completed a body assessment or vital sign assessment after 10:15 a.m. The DON provided a death certificate signed by the resident's physician that identified cause of death as "[MEDICAL CONDITION]" and "ischemic [MEDICAL CONDITION]". Staff Interviews: On [DATE] at 11:52 a.m. the DON documented the resident was breathing quieter when laid down. The resident was sweaty because she felt it when transferring the resident to bed. The DON stated she checked the resident multiple times to ensure the resident was calm. The [MEDICATION NAME] appeared to work well for the resident. When she and Staff B checked the resident at 1:40 p.m. they found him/her absent of vital signs. The resident appeared yellow/ashen in color with his/her mouth open with no signs of life. The resident felt cool to the touch with mouth open and eyes partly closed. The mucus membranes appeared moist and the resident was difficult to move and undress due to rigor. The DON identified normal effects of [MEDICATION NAME] to include: shallow respirations, calm/quiet affect, sleepiness and possible fatigue. The DON identified agonal breathing as breathing with some difficulty similar to snoring but quieter. The DON stated she would not perform CPR because she found the resident dead. If the resident would show signs of life such as pulse, respirations, movement, warmth, then staff would start CPR immediately. When asked what attempts the facility made to notify the physician of the resident's requests for more medication for anxiety, the DON stated they tried to get something for the resident but the physician would not change orders until the physician saw the resident. The resident had an appointment scheduled for [DATE] but there was a transportation mix-up so the resident could not go. The facility rescheduled the appointment for the following week. During the interview, the DON stated after the resident lay on the floor, she rubbed the resident's back and asked if the resident had pain. The resident did not answer. The resident's color appeared normal but the resident had very heavy accessory breathing. The DON sat with the resident for 20 minutes. The resident looked uncomfortable but did not voice any complaints. Three to four minutes after Staff B administered the [MEDICATION NAME] injection, they got a male housekeeper to assist with the transfer of the resident into the wheelchair. She stated the resident "semi bore weight " . The DON stated she did not know what caused the resident's condition change. The [MEDICATION NAME] would not have taken effect yet. The DON stated she thought something physically went on with the resident. The resident was sweaty because the DON's arm got wet when she removed it from behind the resident's head after the transfer. Staff C (nurse aide) lifted the resident's legs into the bed. After staff lifted the resident into bed the resident breathed heavy but not too coarse. Staff covered the resident with a sheet and cracked the window. The DON checked the resident 2 to 3 times before they found he/she expired. The resident's breaths appeared shallow at approximately 22 to 23 per minute. The resident appeared pale but the resident always was kind of pale. When the DON viewed the resident at 1 p.m., the resident did not look like he/she was in pain but appeared like he/she was trying to catch his/her breath. The resident kind of moaned when she asked how he/she felt. The DON stated she did not think it abnormal for anyone that got [MEDICATION NAME] to respond in that manner. The resident was not uncomfortable and the [MEDICATION NAME] worked well for the resident so the DON would not have expected staff to notify the physician of a condition change. On [DATE] at 1:52 p.m. the DON confirmed she did not check the resident's vital signs after the condition change. On [DATE] at 4:05 p.m. Staff B (Licensed Practical Nurse) documented that on the day of the incident, the resident came out of his/her room very anxious and walking very fast back and forth saying things like "I want a cigarette" "No I don't" and going in and out the front door. The resident would stand up and sit down repeatedly. Staff B thought it was odd so she placed a call to the on call physician try and send the resident for a psychiatric evaluation or see what else they could do. Staff B called the DON who told Staff B not to send the resident out for an evaluation because she was almost at the facility. The DON arrived and from that point on, Staff B let her take over the resident's care. The DON sat with the resident and told Staff B to call the physician and get an order for [REDACTED]. At that time, Staff B stated the resident breathing and coloring seemed appropriate. Around 1:30 p.m. the DON came to Staff B and said they should go check the resident. As they walked down the hall, Staff B could see from the hall that the resident expired. The resident appeared pale blue with his/her mouth open and cool to the touch with firm upper extremities. Staff B documented in hindsight she should have notified the physician of the resident's behavior after the injection but the DON monitored the resident while Staff B tried to get caught up passing medications. On [DATE] at 3:38 p.m., prior to writing the above statement, Staff B stated she assessed the resident that morning prior to the condition change. Staff B stated after the injection, the resident wasn't able to walk and was zonked-"out of it" The resident did not get lunch the day due to being "zonked". On [DATE] at 2:15 p.m. of the same day when questioned further about the resident's level of responsiveness and functional ability, Staff B stated she helped get the resident into the wheelchair for transport to the resident's room. She stated she did not think the resident could have sat up by him/herself in the wheelchair due to the resident being so "out of it" She stated she didn't think the resident's eyes were open and the resident couldn't talk. They lifted the resident into the bed. Staff B stated after the incident she wondered if the resident had pain even though the resident did not report any pain. On [DATE] at 11:45 a.m. Staff B stated no one had to hold the resident so Staff B could administer the injection. The resident laid still. On [DATE] at 9:35 a.m. Staff C (nurse aide) stated after breakfast the resident came out of his/her room acting different, walking poorly with his/her coat on, and trying to get out. They got the resident to sit in a chair and the coat off then the resident got up again and tried to get out. The resident would not answer questions. Staff B didn't know what was wrong so she called the DON to see if the resident could go to the hospital. The resident was between the front doors when the DON arrived. The resident lowered to the ground and couldn't get up. The resident identified self as "falling". They got the resident in a chair again and the resident got up. Staff C left the area and when she came back through, she observed the resident laying on the ground with the DON talking to the resident. Staff C stated she observed the resident sweating and breathing fast like the resident was anxious. She stated staff got the resident into a wheelchair for transport to the resident's room. Around 12:45 p.m. and 1 p.m. she took Resident #8 to their room and saw the resident from the hallway. From what Staff C could see, the resident appeared asleep. After that, the DON got her and said the resident expired. The resident had blood in his/her mouth. It was pooled in the back of the mouth, on the lips, under the tongue and in the right cheek area. It was dried on the resident's lips and took a while for Staff C to remove it. She described the color of the blood as a darker red. Staff C stated when she and the DON rolled the resident, the resident's back still felt warm. Staff C stated the resident was not stiff because the resident's arm bent during the cleaning process. On [DATE] at 8:03 a.m. Staff E (Activity Director) stated she worked on [DATE] doing laundry. She stated she arrived at the facility at 6 a.m., and saw the resident laying on the couch. The resident suddenly bolted up from the couch saying "I got to go". The resident got ,[DATE]th of the way down the hall and turned around and came back. Staff E thought that seemed odd. She then went into the laundry room. Around 10:30 a.m. or 11 a.m., she came out of the laundry room and saw the resident going from table to table and not sitting down. The resident was sweating profusely. Staff E observed the resident's shirt was wet from sweat. Staff E stated she and another staff walked with the resident who was unsteady. Staff E held the resident's hand and it felt cool and clammy. The resident went forward and back when he/she ambulated. The resident kept saying "I got to go". The resident also breathed fast. Staff E stated Staff B thought the resident needed the hospital but the DON thought the resident needed a shot. Staff B then went back to doing laundry. The next day, Staff E found out the resident expired. On [DATE] at 11:45 a.m., Staff F (nurse aide) stated she came into work around 11:45 a.m. and saw the resident in bed moaning and groaning. She tried to tell the resident a joke but the resident did not respond. The resident appeared sedated and did not open his/her eyes. The resident looked sweaty. After 12:30 p.m. Staff F checked the resident's room for a meal tray but the resident did not get a tray because the resident was not awake enough to eat. The resident appeared uncomfortable and still moaned and groaned. Staff F stated she informed Staff B of the resident's continued moaning. She also stated she saw blood on the resident's mouth that was not present when she saw the resident earlier at 11:45 a.m.. She stated she worked the night shift the prior night and the resident was very anxious but did not complain of anything. On [DATE] at 8:45 a.m. Staff H (housekeeper) stated around 9:30 a.m. to 10 a.m., the resident wouldn't sit still in the dining room. He and Staff B took the resident out to smoke. The resident still wouldn't sit still. The resident slammed doors and rammed the door of the Administrators office causing it to open. Staff B called the DON and said the resident needed to go to the hospital and a few minutes later the DON pulled up. Later he observed the resident laying on the floor. After the injection the resident appeared limp and did not respond. The only thing Staff H heard from the resident was snoring. The resident didn't bear weight when they transferred him/her into the wheelchair and into bed. The resident was a full lift. Staff H stated the resident's condition was a big change from his/her usual. On [DATE] at 10:42 a.m., Staff I (nurse aide) stated she gave the resident a shower the morning of [DATE]. The resident had trouble standing in the shower. The resident usually performed the shower by him/herself. The resident was anxious so staff took the resident out for a cigarette. Staff I went back to work when she saw the resident again, he/she was on the floor lying down. The resident stayed on the floor until Staff I and other staff picked the resident up from the floor and took the resident to his/her room. The resident didn't bear weight for the transfer. Staff lifted the resident. Staff I stated the resident had audible somewhat rapid breathing with an occasional deep breath. The resident appeared very sweaty. When staff transferred the resident into the bed. Staff I stated she heard the resident reply "ok" when she explained they were placing the resident in bed. Staff I stated there was a condition change because the resident couldn't walk. She stated she saw the resident around 12:30 p.m. before she left work for the day. The resident still breathed rapidly when she left. Physician Interviews: On [DATE] at 10:16 a.m. the resident's physician stated she made a mistake on the resident's death certificate when she wrote cause of death was [MEDICAL CONDITION] and ischemic [MEDICAL CONDITION]. She stated she had two deaths that day and got them mixed up. She does not know the resident's cause of death. She plans on changing it to "unknown cause". She stated the facility should have assessed the resident and called with the resident's condition change. The physician could have and would have sent the resident to the emergency room (ER). The physician stated the resident should have gotten more care. She stated the [MEDICATION NAME] (antipsychotic) would take 15 to 20 minutes to show any effects and thought something physical may have occurred to cause the change. On the same date at 11:12 a.m., the physician stated the [MEDICATION NAME] would not cause the changes in condition the resident experienced. The changes in the resident condition were concerning. On [DATE] at 8:56 a.m., the surveyor telephoned the physician that released the resident's body. He stated the [MEDICATION NAME] would make the resident more calm and manageable. It should not cause the change of condition the resident experienced. Note: At the time of the complaint investigation ,the complaint was coded at a "J" immediate and serious jeopardy. By [DATE], the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. As of [DATE], the facility had educated their staff for assessment and intervention regarding change in condition and needs to be reported to the physician and family, sudden onset, marked change and unrelieved by measures already prescribed. The staff were educated that from this moment forward all residents that are a code status would receive CPR regardless of clinical judgement. As of [DATE] the facility continued to need to: . Continue ongoing staff inservices regarding assessment/intervention, change of condition, reporting to the physician and family notifcation. . Continue to provide inservices to staff regarding facility position when a resident requests CPR per the advanced directives.

Based on observation, record review, staff, resident and physician interviews, the facility failed to ensure that 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 4 of 4 residents reviewed with accidents/injury. Resident #1 sustained a fracture due to a hurried transfer. Resident #2 sustained falls when staff failed to follow care plan interventions for transfers. Resident #3 sustained falls and exacerabtion of pain when the alarm failed to sound. The facility knew Resident #4 would not use the call light and/or wait for assistance and that the resident would attempt to get up on own plus attempt to toilet self. The facility continued to rely on the resident reqrequestthe toilet and did not implement toileting interventions. Facility census was forty (40) residents Findings include: 1. A Minimum Data Set (MDS) with assessment reference date of 10/23/12 assessed Resident # 1 with a brief interview for mental status score of "15" (no cognitive impairment). The resident was independent with bed mobility, transfers, dressing, toileting and personal hygiene. The resident was nonambulatory. The resident had functional limitations in range of motion of both lower extremities. The resident had [DIAGNOSES REDACTED]. The resident rated pain as a "7" over the previous 5 days on a scale of 0 to 10 with zero being no pain and 10 as the worst imaginable pain. The resident measured 67 inches and weighed 170 pounds. The resident had no history of falls. History: A report of consultation dated 11/8/12 identified the resident with a [DIAGNOSES REDACTED]. The consultation determined the resident needed surgery for [REDACTED]. An operative report dated 2/15/13 identified the resident underwent [REDACTED]. Nurses notes: Nurses notes identified the resident returned to the facility on [DATE] at 4:30 p.m. The entry identified the resident transferred with the assistance of one staff. Nurses notes dated 2/24/13 at 3:45 a.m. identified the resident as alert and oriented times three and able to make needs known. Staff got the resident up with assistance of one staff using walker. The resident's gait was slow and steady. The resident did use the wheelchair for mobility to bathroom with assistance of one during the night due to right hip discomfort. Nurses notes dated 2/24/13 at 1 p.m. indicated the resident had increased pain in the right hip/leg. At 9:10 p.m. the resident experienced pain but tolerated the pain well with the use of pain medications. The resident stated when the pain became less he/she would attempt to do more ambulating. Nurses notes dated 2/25/13 at 2:05 a.m. staff medicated the resident for hip pain. At 8 a.m. staff documented the resident complained of pain with a rating of "6" on a scale of zero to 10 with some relief from pain medications. At 5 p.m. staff received an order for [REDACTED]. Portable x-ray arrived at 5:30 p.m. at 8:30 p.m. the resident complained of severe pain and was in tears. The facility educated the staff on proper transfer of residents with hip surgery. Physical therapy (PT) notes dated 2/25/13 at 5:13 p.m. revealed the resident told PT staff that he/she heard a pop in the hip when nursing staff performed a toilet transfer during the night and had pain since. The resident wanted to participate in therapy but pain limited the resident's ability to participate. . Nurses notes dated 2/26/13 at 8 a.m. identified the resident complained of pain that rated an "8" with little relief from pain medication. At 1 p.m. the facility sent a facsimile with the x-ray results to the physician. The physician responded by stating if the pain did not improve in 24 to 48 hours then call the orthopedic physician for an appointment. At 10 p.m. the resident rated the pain as"6". Nurses notes dated 2/27/13 at 3 a.m. indicated the resident took Tylenol at 1 a.m. and 5 a.m. for pain. Nurses notes dated 2/28/13 at 3:30 a.m. identified the pain as better not as sharp. At 9:30 p.m. the resident identified self with pain but stated its tolerable with pain medications and Fentanyl (narcotic patch). Subsequent nurses notes identified the resident stated the pain was "doing better". Nurses notes dated 3/7/13 at 8 p.m. revealed the resident had an appointment with the orthopedic surgeon and informed him an incident occurred a week prior when staff dropped the leg during a transfer causing increased swelling and pain. The orthopedic physician identified a fracture in the right greater trochanter. The physician stated the fracture would heal on its own. The physician ordered the resident should continue physical/occupational therapy but don't push it if the resident has a lot of pain. The physician identified a firm area present at the top of the incision and stated it was a hemorrhage which would heal on its own. Orthopedic Physician Visit Information (2 visits): On a consultation report, dated 3/7/13, the physician documented the resident had an episode of legs dropped while getting in/out of bed one week ago with increased swelling and pain since. Hip range of motion resulted in minimal pain. The incision healed with a small scabbed area at the proximal incision site that contained large fluid collection subcutaneously. The x-ray showed a small greater trochanteric fracture with one centimeter displacement. The hematoma should resolve. An encounter form, dated 3/7/13 and written by the orthopedic physician stated he informed the resident of the greater trochanter fracture and that it accounts for the pain onset the resident suffered after the incident and the feeling of a pop. The fracture is displaced at least one centimeter (cm.) proximally. It is a small piece about one cm. in diameter and there is nothing to do about it at this time. The resident developed some bleeding and a large hematoma developed subcutaneously. The physician stated staff needed to monitor the hematoma closely as it is a prime area for an infection to develop. The injury sustained would slow the resident's recovery but eventually the resident would get relief from pain and be happy with the outcome of the surgery. physician progress notes [REDACTED]. On that date x-ray showed a well aligned total hip with displaced greater trochanteric fracture. Orthopedic Physician Interview: On 4/11/13 at 8:16 a.m. the surveyor informed the physician of the nurse aide's account of the transfer. The nurse aide identified the transfer as a slow and unhurried easy transfer the night the injury occurred. The physician stated the injury could not have occurred with a slow unhurried transfer. He stated it was due to an incident. The resident presented to him with pain, hematoma and a fracture which seems to be due to an incident. The injury did not correlate with an comorbities of the resident. It was due to an incident. On 3/25/13 at 10 a.m. the physician signed a major injury determination form. On the form, the physician indicated the resident sustained [REDACTED]. Staff Interviews: On 4/10/13 at 6:20 a.m., Staff G (nurse aide) stated the resident's call light activated and she answered it. The resident requested to use the bathroom. The resident laid on his/her back and Staff G helped the resident to a sitting position at the bedside. As Staff G turned the resident, there was a small popping sound, like a finger popping. The resident stated he/she heard the popping sound and said he/she felt fine. Staff G stated she got the resident up on the resident's cue when the resident stated he/she was ready. Staff G stated the resident would move the upper body and Staff G moved the lower body by grabbing the resident's outer thighs and slowly bring them around. Staff G transferred the resident to the bathroom and back via wheelchair. Staff G stated no one else was in the room when the transfer occurred. Staff G denied performing the transfer in a hurry. Staff G stated she reported the popping sound to the nurse. On 4/18/13 at 8 p.m. Staff K (registered nurse) stated she worked the night of the incident but did not witness it. She stated the nurse aide took the resident to the bathroom and said she heard popping. She stated neither staff nor resident informed her of a problem with the transfer. She stated she did not know for sure if the resident got in or out of bed when the popping occurred. She stated the resident did not complain of anything that night. Resident Observation and Interview: Observation showed, on 4/9/13 at 12:42 p.m. the resident seated in a lounge chair in his/her room. The resident stated she underwent hip surgery to replace a worn out hip joint. She denied having any falls at the facility. She stated the night of the incident, she had been back from surgery that replaced the hip joint for 3 or 4 days. The resident had a cold and needed to urinate. Staff had just been in the room when the resident turned the call light on. The resident heard staff say he/she had her "God damn light on again". The resident stated staff had to assist her legs when they performed a transfer. The resident told the staff to wait but staff went ahead and the leg dropped and then it popped. The resident stated she went through 2 to 3 weeks of pain after the incident due to a piece of the hip breaking off that should be in a straight line. The resident stated this incident made him/her afraid to call for help. The resident identified Staff G as the staff involved in the incident. Now that staff avoids the resident. The resident thinks staff hurried and didn't wait when he/she said he/she wasn't ready. 2. A Minimum Data Set (MDS) with assessment reference date of 4/5/13 assessed Resident #3 with a brief interview for mental status score of 12 (moderate cognitive impairment). The resident required limited staff assistance with bed mobility, transfers, ambulation in room, dressing, toileting, personal hygiene and bathing. A balance during transitions and walking test identified the resident as not steady but able to stabilize without staff assistance. The resident utilized a walker and wheelchair. The resident was continent of bowel and bladder and not on a toileting program. The resident took a hypnotic medication temazepam every night for insomnia. The resident had [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE] identified the resident with a fall risk score of "16". A score of 10 or above identified high risk. admission orders [REDACTED]. Nurses notes dated 4/1/13 at 7 p.m. documented the resident would use a pad alarm in the wheelchair and bed due to confusion and history of several falls. A Care Area Assessment (CAA) summary, dated 4/17/13, revealed the resident admitted to the facility on [DATE] following surgical repair of a left closed hip fracture. The resident's current activity orders were for partial toe-touch weight bearing and assistance of one for cares. The CAA identified the resident as noncompliant and ambulated with family and often attempted to exit the bed or wheelchair without regard for safety. The resident utilized a bed/chair pressure alarm. Staff applied nonskid strips to floor in room. The resident received temazepam (benzodiazepine hypnotic) 15 milligrams every night for insomnia. admission orders [REDACTED]. The resident continued to receive the drug through present (4/21/13). According to www.drugs.com regarding the medication temazepam, the sedative effects of the drug may last longer in older adults. Accidental falls are common in elderly patients taking benzodiazepines. Use caution to avoid falls or accidental injury while taking the drug. Temazepam should be used only a short time to treat insomnia. After 7 to 10 nights of use, talk to the physician about whether temazepam should still be administered. The drug may cause confusion. The record lacked evidence the facility spoke with the physician regarding the drug. An intial care plan dated 4/1/13 identified the resident required assistance with toileting. The care plan identified the resident as up ad lib with a walker. The care plan did not address alarms or the need for partial weight bearing assistance. The care plan did not identify the use of a sleeping pill. Nurses notes dated 4/6/13 at 8:30 p.m. revealed the resident continued to need assistance of one with activities of daily living but resident forgets and transfers self . Nurses notes dated 4/10/13 at 1:10 a.m. revealed a nurse aide summoned Staff L (registered nurse) to the room. Observation showed the resident on the floor in front of the bed in a sitting position with bilateral lower extremities outstretched in front of resident. The resident stated he/she tried to get slippers on but couldn't do it. The bed alarm was in place but did not sound. Staff did not observe injury and identified the resident as full weight bearing on both lower extremities. Staff noted the resident incontinent of urine. According to a quality assurance monitoring tool, dated 4/10/13, the facility implemented nonskid strips following the fall. On 4/20/13 at 10:31 p.m. Staff L stated the alarm worked earlier in the shift. She stated they did notice the alarm did not alarm very loudly. She stated since the fall she found out about a high/low switch on the alarms. She found it on low another night after the fall. She did not know the setting on the night of the fall. Nurses notes dated 4/16/13 at 5 a.m. stated staff responded to the alarm sounding and saw the resident stand while sitting at the foot of the bed. The resident's feet slipped on the floor and the resident sat on the floor. Staff transferred the resident into a wheelchair and transported the resident to the lounge area. Following the 4/16/13 fall, the facility moved the resident closer to the nurses station. A care plan dated 4/17/13 identified the staff relied on the resident to request the toilet and check and change. The resident had a history of [REDACTED]. The care plan identified the psychotropic drug used for insomnia but did not contain nonpharmacologic interventions to promote sleep. It also stated to report side effects to the physician. Nurses notes dated 4/19/13 at 1 p.m. identified the resident as very confused and in need of constant reminders to use call light and wait for help. Nurses notes dated 4/20/13 at 3 a.m., revealed the resident continued with confusion and not using the call light for assistance. Nurses notes dated 4/20/13 at 5:30 a.m., staff passed by the resident's room and found the resident out of bed but could not reach the resident in time. The resident fell to the floor. The resident's bed alarm did not sound. Staff checked the resident 15 minutes before the fall. The entry did not identify injury. Nurses notes dated 4/21/13 at 1:30 p.m. the resident complained of back and hip pain. Staff administered Tylenol (analgesic) for the pain. On the same date at 6:30 p.m. staff phoned the resident's physician to ask for an x-ray due to the resident complaining of severe pain. At 8:20 p.m. portable x-ray arrived. The resident continued to complain of pain on the left lower side/back. The resident remained very confused and needs constant reminders to use the call light. At 10:20 p.m. the facility received the x-ray results and sent them to the physician. The lumbar spine x-ray showed a mild wedged-shaped compression fracture at the T12 level of the spine with indeterminate age. The physician ordered Mobic (nonsteroidal anti-inflammatory) 7.5 milligrams (mg.) daily. A QA monitoring tool, dated 4/22/13 at 8:30 a.m. revealed staff initiated 15 minute checks after the fall and assess toilet needs hourly. The facility also plans to obtain an alarming mat for the resident. On 4/22/13 at 2:59 p.m., the DON emailed the surveyor to report the resident had a history of [REDACTED]. On 4/23/13 at 1:11 p.m. the physican stated the resident had a previous T12 wedge compression fracture so the fall probably exacerbated the resident's osteoporosis and prior injury. He stated he would need to re-evaluate the resident and the pain at a later date to know more about the extent of the injury. He stated the facility did not consult with him about the resident's temazepam and he planned to discontinue it due to the side effect of falls. Observation: Observation showed, on 4/11/13 at 10 a.m. the resident seated in a wheelchair in his/her room with pressure pad alarm on wheelchair. The resident stated he/she fell in the bedroom and the resident didn't think he/she had an alarm at that time. At 10:05 a.m. Staff J (nurse aide) assisted the resident to a standing position and the alarm sounded. The resident bore full weight on both legs and walked without any cues from staff to only apply partial weight on the left extremity. On the same date at 3:12 p.m. Staff N (nurse aide) stood the resident up from bed with a gait belt. The resident bore full weight on both legs with no cue from staff to only apply partial weight bearing on the left leg. On 4/11/13 at 4:15 p.m. Staff N stated she didn't know if the resident was full or partial weight bearing because Staff N is still in training. On 4/15/13 at 12:57 p.m. Staff J stated the resident's status is full weight bearing and over the weekend the resident's son took the resident out. The resident ambulated all the way from the facility door entrance to the end of the sidewalk. On 4/15/13 at 10:45 a.m. staff weighed the resident on the stand up scale. The resident stood on the scale unsupported bearing full weight on both legs. 3. A Minimum Data Set (MDS) with assessment reference date of 1/28/13 assessed Resident #2 with a brief interview for mental status score of "8" (moderate cognitive impairment) . The resident required extensive staff assistance with bed mobility, transfers, dressing and bathing. The resident required limited staff assistance with toileting and personal hygiene needs. A balance during transitions and walking test identified the resident as not steady and only able to stabilize with staff assistance. The resident had [DIAGNOSES REDACTED]. The resident had 2 falls since the previous assessment without injury. The resident measured 71 inches tall and weighed 237 pounds. Nurses notes dated 8/11/12 at 4:05 p.m. identified one nurse aide assisted the resident to the bathroom with a gait belt. When staff lifted the resident , the resident lost balance and slid down out of the wheelchair. A Quality Assurance (QA) monitoring tool dated 8/11/13 identified the intervention following the fall as: Gait belt and assistance of two staff . A quality assurance (QA) monitoring tool dated 10/29/12 at 7:45 a.m. revealed the resident and one nurse aide walked to the wheelchair without a gait belt. The resident became unsteady and staff lowered the resident to the floor. The resident told the charge nurse he/she fell because he/she didn't wear a gait belt. The resident did not sustain injury. The intervention implemented following the fall was: Educated staff. A quality assurance (QA) monitoring tool dated 12/9/12 at 2:05 p.m. revealed the resident stood holding the bar in the shower room with one nurse aide behind the resident. The resident became weak and started leaning to the left and nurse aide could not hold the resident up so staff lowered the resident to the floor. The resident did not sustain injury. A quality assurance (QA) monitoring tool dated 2/9/13 at 5:25 p.m. revealed the resident removed the alarm seat belt and staff found the resident sitting on the bathroom floor with leg under the resident. The alarm did not sound due to it was shut off. The resident did not sustain injury. The intervention implemented following the fall was: Educated nurse aides to turn alarm belt back on after shutting it off. A quality assurance (QA) monitoring tool dated 2/17/13 at 7 p.m. revealed one staff lowered the resident to the floor during a transfer from wheelchair to couch. Staff did not use a gait belt. The resident did not sustain injury. The intervention implemented following the fall was: Educated the aide on safety and properly transferring a resident and the need to always use and properly use a gait belt. A care plan dated 2/4/13 identified the resident with a potential ADL (activity of daily living) decline due to weakness and gait/balance disturbance and directed 2 staff to assist the resident. The potential for loss of balance component to the care plan dated 2/4/13 directed staff to use a gait belt. Observation showed, on 4/10/13 at 6:10 a.m. the resident in bed with the alarm on. At 8:35 a.m. of the same date, two staff transferred the resident from bed to wheelchair and the same two staff transferred the resident onto the toilet. Staff used a gait belt. At that time, Staff C (nurse aide) and Staff O (nurse aide) stated they usually transfer the resident with two staff. 4. A Minimum Data Set (MDS) with assessment reference date of 11/5/12 assessed Resident #4 with a brief interview for mental status (BIMS) score of 5 (severe cognitive impairment). The MDS identified the resident as independent with ambulation in room and toileting. A "balance during transitions and walking" test identified the resident as not steady but able to stabilize without staff assistance when moving from seated to standing position, moving on and off toilet and surface to surface transfer (between bed and chair). The resident was not steady and only able to stabilize with staff assistance while turning around and facing the opposite direction while walking and walking itself. The resident used a wheelchair and walker. The resident was continent of bladder and incontinent of bowel occasionally. The resident was not on a toileting plan. The resident had [DIAGNOSES REDACTED]. The MDS did not identify falls. The resident measured 54 inches tall and weighed 99 pounds. The resident did not use side rails. A fall risk assessment dated [DATE] identified the resident with a fall risk of "9". A score of 10 or above identified high risk. A quality assurance (QA) monitoring tool dated 10/6/12 identified the resident got dizzy and fell while ambulating to the dining room chair from the wheelchair for lunch. The resident complained of hip, ankle and arm hurting. Observation showed a 1 centimeter (cm.) by 1.2 cm. bruise to the right outer ankle and the resident had difficulty bearing weight on the foot. The resident transported to the emergency room (ER) for examination and an ER discharge instruction sheet revealed the physician diagnosed the resident with a contusion. The intervention following the 10/6/12 fall was: educated when feeling dizzy to wait for help. A QA monitoring tool dated 12/20/12 at 5:30 a.m. identified the resident slid out of bed. The resident stated he/she hit his/her head. The intervention was: Daughter would like siderails on bed. On 12/22/12 the resident transported to the hospital for evaluation for increased confusion. The physician diagnosed the resident with a CVA and GI (gastrointestinal) bleed. The resident returned to the facility from the hospital on [DATE]. A QA monitoring tool dated 1/14/13 at 9:15 p.m. identified staff took the resident to the toilet and left the resident by self. The resident slid off the toilet while ambulating back to bed. gripper socks folded over the toes and the resident fell . The resident hit his/her head on the floor. The intervention was: smaller gripper socks and do not leave in bathroom by self and due to resident is up with assistance of one. An entry dated 1/15/13 identified the facility educated staff regarding the importance of safety while toileting. Staff will not leave the resident unattended. Physical therapy (PT) information dated 1/25/13 indicated the resident required standby assistance with toilet transfers and hand held assistance while ambulating. PT ended for the resident on 2/2/13 but no end of therapy recommendations were available. A QA monitoring tool dated 3/21/13 at 11:10 a.m. revealed staff found the resident on the floor after hearing yelling. The resident was in the bathroom and ambulating to a chair and fell . The resident hit his/her head and sustained a 3 cm. by 3 cm. bruise and bump tonight side of forehead. The intervention was: Assist of one with transfers. A QA monitoring tool dated 4/6/13 at 10:50 p.m. stated staff heard the resident yelling and found the resident on the floor by the bed. The fall investigation identified no alarms in use when the fall occurred The QA tool identified the resident used the call light but did not wait for the staff. The intervention follow the incident was: pressure alarm. A QA monitoring tool dated 4/8/13 at 4 p.m. identified the resident attempted to transfer self to toilet and hit head. The form identified the resident's alarm sounded when the fall occurred. The intervention following the fall was: Resident reeducated on use of call all light. Resident is resistant to the use of more alarms. A care plan dated 3/4/13 identified the resident with weakness and gait/balance disturbance. The care plan directed staff to assist the resident with one staff for transfer with toileting and identified the resident is noncompliant with asking for help. However the 4/6/13 fall investigation identified the resident did pull the call light. The investigation identified the resident as noncompliant with waiting for staff assistance. The facility added a pressure alarm to the care plan on 4/8/13. The care plan did not identify scheduled toileting. It identified the resident would toilet when requested, even though staff previously documented on the care plan the resident was noncompliant with asking for help. Observations: Observation showed, on 4/9/13 at 4:42 p.m. the resident in bed on the left side. The bed did not contain siderails. The resident ambulated to the bathroom with one staff. The resident complained of being dizzy. Staff assisted the resident back to bed. The bed alarm functioned. Observation showed, on 4/10/13 at 5:30 a.m. the resident hollering out. The resident did not have the call light activated. At that time, Staff G stated they try to get the resident to use the call light and wait for help but the resident is noncompliant. On 4/10/13 at 8:35 a.m. the surveyor entered the resident room to observe Staff O ambulate the resident to the bathroom without a gait belt. When asked about not using the gait belt, Staff O stated the resident was already up and ambulating when she arrived at the room and so Staff O just assisted the resident the rest of the way. The resident's alarm activated. Observation showed staff stayed with the resident in the bathroom and used a gait belt to assist the resident back to bed.

Based on record review, including photo evidence, staff, wound nurse and physician interviews, the facility failed to ensure that a resident with pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one of two residents with pressure sores. Resident # 12 entered the facility with a one centimeter (cm.) pressure sore. The facility failed to adequately assess Resident #12's pressure sore. Facility records did not reflect the severity of the resident's pressure sore which required debridement and a wound vac device after admission to the hospital. The wound was also identified [MEDICAL CONDITION] ([MEDICAL CONDITION] Resistant Staphlococcus) and also had a positive blood culture. The resident had 2 additional pressure sores upon admission to the hospital that the facility did not identify, assess or treat. The facility failed to conduct a dietary assessment. Hospital personnel identified the resident with an [MEDICATION NAME] of 1.9 and stated an [MEDICATION NAME] of 1.9 is unable to support tissue. The facility identified a census of 41 residents. Findings include: 1. An AHA nursing admission assessment dated [DATE] at 4 p.m. identified Resident #12 as admitted to the facility. The admission assessment information identified the resident had [DIAGNOSES REDACTED]. The admission assessment identified the following pressure areas: Stage I red area on the outer aspect of the left hip measuring 0.8 centimeters (cm.) by 0.5 cm., Stage I red area left inner buttock measuring 3.5 cm. by 1 cm. and a Stage IV red area with white middle one cm. by one cm. (no location listed). A weekly pressure ulcer progress report identified the Stage IV area as located on the right inner buttock. The pressure ulcer record identified the area as "unstageable". A skin risk assessment contained in the AHA nursing admission assessment, identified the resident with a score of "17" (low risk for pressure ulcers). The assessment revealed the resident did not have a sensory impairment that would contribute to pressure ulcer development, skin occasionally moist which required an extra linen change approximately once a day, the resident walked occasionally but spent the majority of the shift in the bed or chair, mobility slightly limited and makes frequent though slight changes in body or extremity position independently, nutrition adequate, problem with friction and shear due to requiring moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. The resident frequently slides down in bed or chair and requires frequent repositioning with maximum assistance. A facsimile (fax) from the hospital dated 3/5/12 (day of admission to facility) identified an unstageable pressure ulcer to the right ischium which measured 1 cm. by 1 cm. with a depth of 0.2 cm. The physician order [REDACTED]. A skilled flow sheet dated 3/5/12 identified Resident #12 required limited staff assistance with bed mobility, grooming, dressing and extensive staff assistance with transfers, toileting and ambulation. The Facility Weekly Pressure Ulcer Progress Reports: On 3/5/12 (day of admission) the resident had an unstageable 1 cm. by 1 cm. pressure sore on the right ischial area with no depth. On 3/6/12 the report identified an unstageable 6 cm. by 6 cm. area with 3 cm. by 3.5 cm. red black and white middle area within. Follow discovery of the area worsening. The facility sent a fax to the physician on 3/7/12. The fax informed the physician of a stage 4 area on the right inner buttock that increased in size from 1 cm. by 1 cm. to 6 cm. by 6 cm. with 3 cm. by 3.5 cm. open area with serosanguinous drainage. The area had a white middle with some eschar and area around open area is red and hard. The fax asked if the physician had any new orders. The physician faxed back on 3/7/12 at 1 p.m. to consult wound care team. The nurses ' notes dated 3/7/12 at 2 p.m. indicated the wound center was contacted and the Treatment Administration Record (TAR) amended. However, the TAR did not reflect any changes. The Weekly Pressure Ulcer Progress Reported on 3/13/12, the resident refused to have staff remove the dressing due to staff applied a new dressing the night before. The last documented assessment of the right ischial pressure sore was 3/6/12. A fax to the physician dated 3/8/12 identified a 2 cm. by 1 cm. open area to the right buttock. Staff applied a dressing. The dates on the fax indicated the facility did not send the fax until 3/12/12. On 3/13/12 the staffs documented the area as red and not open. The area measured 1.7 cm. by 0.8 cm. Staff Interviews: On 3/15/12 at 12:05 p.m. Staff D (nurse aide) stated the first time staff was told to lay the resident down after meals and turn side to side was yesterday. Before yesterday, staff would lay the resident down if he/she looked tired. A lot of times the resident did not want to lie down. The resident got a special mattress to the bed and wheelchair a couple days ago before that, the resident used a facility dark blue mattress on the bed and another cushion in the wheelchair (gel). On 3/15/12 at 9:55 a.m. Staff B (Director of Nursing) stated on 3/12/12 the facility obtained different orders for the resident's bottom because she had never done a treatment before as ordered on [DATE] (day of admission). The resident had an appointment at the wound center scheduled for 3/22/12. When asked why the facility did not assess or measure the area since 3/6/12, Staff B stated on 3/13/12 the resident refused to allow the nurse to assess the area because staff just changed the dressing the night before. Staff did not assess and document the area the night before because the day shift usually does it. Staff B stated nurse aides know how to care for the resident through verbal instruction and stated there was no care instruction available in writing for the nurse aides. On 3/20/12 at 2:35 p.m. Staff B stated she last saw the right ischial pressure sore on 3/7/12 and it did not look like the photo the surveyor obtained from the hospital (on hospital admission 3/14/12). She stated the outer edge of the sore appeared purple and on the bottom part of the area, yellow slough was present. She stated she called the wound center on 3/9/12 to inform them of the lack of improvement of the sore and did not get a response until 3/12/12 On 3/15/12 at 4:04 p.m., Staff I (nurse aide) stated the resident would sit on the couch or in the wheelchair. When the resident sat on the couch, no pressure reduction device was used. Staff I stated on 3/12/12 the pressure sore had a bad odor and observation revealed the dressing falling off. Staff I told Staff M (charge nurse) and they changed the dressing. Staff I identified the sore as worse and stated she observed other sores on the resident's bottom at that time. On 3/19/12 at 4:05 p.m. Staff G (nurse aide) stated she observed the resident's bottom before he/she left for the hospital. The resident had one or two smaller sores at the "top of buttock (sacral/coccyx area)" and the big sore which had a foul odor. On 3/20/12 at 1:05 p.m., Staff J (nurse aide) stated she gave the resident a shower on 3/14/12 and observed an open area above the coccyx. It was present before that date and that is why Staff J checked off "no new open areas" on the weekly nurse aide skin report form on the day of the shower. On 3/20/12 at 1:33 p.m. Staff L (Licensed Practical Nurse) stated she last saw the resident's right ischial pressure sore on 3/9/12 and it did not look as bad as the 3/14/12 hospital photo the surveyor showed her. It was not as black or deep and there were no pustule areas or drainage. Staff L stated the area on the right coccyx area was present on 3/13/12 and staff put house barrier cream on the wound. Staff L stated she healed off the top coccyx sore on 3/13/12 because it was not red or open. Staff L stated the left pressure sore above the coccyx was not open on 3/13/12. Staff could not locate the initial care plan (and still in place as the current care plan) when the surveyor requested it. Several hours later Staff L brought it to the surveyor stating she found it. Staff L stated she made out Resident #12's care plan but she could not tell the surveyor when or even approximately when she completed the care plan. The initial care plan did not identify pressure reduction to the wheelchair. On 3/20/12 at 2:22 p.m., Staff M (Registered Nurse) stated she saw the resident's right ischial sore on 3/12/12 and it appeared redder. She did not see pustule areas. She stated she applied a [MEDICATION NAME] to the right open sore present by the coccyx. On 3/14/12 at 3:05 p.m. she stated she did not know what was normal regarding pressure sores because she did not usually care for residents with them (pressure sores). Staff M stated she did not smell any odor because she has an impairment that prevents her from smelling anything. On 3/19/12 at 2:30 p.m. Staff N (Licensed Practical Nurse) stated she last saw the resident's right ischial pressure sore on 3/6/12 and it looked horrid. She stated the resident moved from the couch to the wheelchair and back. When seated on the couch the resident did not use pressure reduction. The resident would sometimes refuse repositioning. On 3/14/12 at 1:45 staff observed the resident slumping in the chair. Temperature 99.5 degrees, pulse 180, blood pressure 120/60. The facility had the resident transported to the hospital. Hospital records and photos identified the right ischial area as a stage IV pressure ulcer measuring 8.5 cm. by 3.5 cm. with a depth of 2.5 cm. with copious amounts of foul drainage. Records and photos also identified the resident with the following Stage II pressure ulcers (not identified by the facility): two areas on the upper coccyx measuring 1.5 cm. by 0.6 cm. and 1.2 cm. by 0.9 cm. A hospital admission history and physical dated 3/14/12 identified the resident with an elevated white count and temperature of 102 degrees. The history and physical identified the resident with cellulites According to hospital records on 3/14/12 at 7:30 p.m. the wound nurse (CWOCN-Certified Wound Ostomy Care Nurse) identified the right medial proximal buttock wound as very foul smelling slough and brown eschar covered, leaking at edges. CWOCN deroofed and debrided the wound. As she did this the wound made a sizzling sound with drainage bubbling out from the wound. The drainage was red; foul smelling and purulent with possible gas gangrene in wound. After debridement, the staff applied a wound vac (pump to assist with wound healing). On 3/19/12 at 10:50 a.m., the physician stated the resident entered the nursing home facility with an open erythremic area. The physician stated he would do testing to see of the area was the result of a fistula. The resident had a positive blood culture related to the infection in the pressure sore. On 3/23/12 at 10:29 a.m., the physician stated the resident's pressure sore was healing and scans did not identify a fistula. The resident is on the 8th or 9th day of antibiotics. The physician stated he is not 100% sure what happened to cause this sore to deteriorate so rapidly and he was not sure if the nursing home could have done more. Sometimes mother nature just takes its course. Regarding the assessment of the wound, the physician stated the facility should have a more current assessment than 3/6/12 on record and should have called saying it was not better. He stated his last notification was the 3/7/12 fax. On 3/19/12 at 10:20 a.m., the CWOCN stated the resident has dementia and has a hard time following directions. He may not comply with instructions to turn/reposition. The CWOCN stated when the resident went to the nursing home he/she had a small area of pressure. The CWOCN stated the sore was definitely a pressure sore. The resident also had a lot of co morbidities which may cause rapid increases in the size of the sore. The CWOCN identified the resident's [MEDICATION NAME] as 1.9 (low). She stated when an [MEDICATION NAME] is that low it cannot support tissue. The normal [MEDICATION NAME] values are 3.5-5.0 identified in Wound Care A Collaborative Practice Manual for Health Professionals, Third Edition page 61 and written by Sussman and Bates-Jensen. The physician discharge summary from the hospital dated 2/27/2012 and just before admission into the facility revealed an [MEDICATION NAME] level of 3.0. When the resident was admitted on [DATE] with this history and pressure ulcers present, should have alerted the dietician to assess the resident promptly for proper protein needs essential for healing. In a note written by the CWOCN dated 3/15/12 (after sent to the hospital), she stated the facility treated the resident proactively by obtaining a Roho cushion and off loading overlay. She stated the facility started protein drinks. Due to the resident's failing condition, compliance has been a challenge with offloading. When questioned on 3/26/12 at 10:40 a.m. about the resident receiving protein drinks at the facility, the CWOCN stated she went by what the facility told her. The record lacked evidence of a dietary consult or interventions that increased protein intake. Staff B confirmed on 3/19/12 at 10:15 a.m. no dietary consult was completed. Staff B also provided the surveyor with a fax that identified the staff would give [MEDICATION NAME] 1 packet twice per day, zinc 220 milligrams (mg.) daily for 10 days and Vitamin C 500 mg twice per day for 30 days. The fax returned to the facility on [DATE] and Staff B identified staff not initiating these measures due to the resident in the hospital when the fax returned to the facility. On 3/27/12 at 11:22 a.m., the Director of Nursing confirmed [MEDICATION NAME] was the protein drink intended for the resident but the protein drinks were not started because the resident went to the hospital before the facility could implement the drinks. The Director of Nursing also stated she implemented the Roho cushion for the wheelchair and alternating air mattress for the bed on the night of 3/12/12. On 3/26/12 at 10:40 a.m. in a follow up interview with the CWOCN, she stated she was surprised by the appearance of the resident's pressure sores when he/she was admitted to the hospital on [DATE]. She stated the Director of Nursing informed her the area was worse on 3/13/12 but she did not know how bad it was. That was when they made the resident an appointment for March 22 at the wound center. If known they could have seen the resident on an emergent basis. The surveyor also questioned the CWOCN on the coccyx sores identified on hospital admission. The photo shows an open area on the right coccyx and the CWOCN documented it as the left. The CWOCN stated the sores were around the center of the coccyx. She also stated the pressure sores were improving. The resident was receiving TPN (Total [MEDICATION NAME] Nutrition). The CWOCN stated the organism in the wound [MEDICAL CONDITION] ([MEDICAL CONDITION] (organism).

Based on record review, and staff and resident interview, the facility failed to provide adequate assessment and timely interventions for 2 of 3 reviewed residents who experienced significant change in conditions (Resident #1 and #2). The facility reported a census of 41 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 12 on the Brief Interview for Mental Status, indicating some cognitive impairment. The MDS indicated Resident #1 demonstrated independence in most activities of daily living. The resident's dietary care plan identified approaches to monitor the resident's acceptance of diet/meals, and hydration and nutrition. Resident #1's care plan included potential for, or actual risk, of abnormal bleeding related to taking anticoagulants. Approaches included: Notify physician as necessary, observe for abnormal signs and symptoms of bleeding to include bruising, drop in blood pressure, increased pulse rate, occult bleeding, or hemorrhage. The resident's July 2011 medication administration records (MARS) indicated he/she received Aspirin 81 milligrams (mg) every day, and [MEDICATION NAME] 75 mg every day. The facility's medication reference, Mosby's Drug Guide for Nurses, Fourth Edition, identified the following information: a. Aspirin's adverse effects included gastrointestinal (GI) bleeding. Patient education included informing the patient to report any symptoms of bleeding. b. [MEDICATION NAME]'s drug interactions included increased bleeding tendencies when taken with aspirin. The resident's Initial Nutritional History/assessment dated [DATE] documented Resident #1's estimated fluid needs at 1,920 cubic centimeters (cc) of fluid per day. The nutritional assessment dated [DATE] indicated Resident #1 consumed 75 to 100% of his/her food. The Daily Diet Monitor Record for July showed the following intakes for Resident #1: a. On 07/15/11: 75% food, 240 cc fluids at breakfast, 25% food and 120 cc fluids at lunch, and no food or fluids at supper (total 360 cc fluid). b. On 07/16/11: 75% food and 60 cc fluids at breakfast, 25% food and 120 cc fluid at lunch, and no food or fluids at supper (total 180 cc fluid). c. On 07/17/11: 25% food and 60 cc fluids at breakfast, 25% food and 120 cc fluids at lunch, and no food or fluids at supper (total 180 cc fluid). d. On 07/18/11: 25% food and 60 cc fluids at breakfast. The intake records revealed Resident #1 consumed an average of 27.5% food and 240 cc fluid per day between 07/15/11 and 07/18/11. The Nurse's Notes dated 07/16/11 at 4:30 p.m. documented Resident #1 had voiced no complaints thus far. The Nurse's Notes lacked any further documentation regarding the resident's condition between 07/16/11 to 07/18/11 (after the resident left for his/her dental appointment). The Nurse's notes dated 07/18/11 at 11:00 a.m. documented after Resident #1 went to the dentist's office, the facility received a call (from the dentist's office) that the resident had experienced some difficulty and needed to use the bathroom. The facility informed the dentist's office they would send staff up ASAP (as soon as possible) to help him/her. Facility staff left minutes later. At 11:15 a.m., the facility faxed recent laboratory work and the resident's MARS to the emergency room department. The hospital reported to the facility that Resident #1 had 2 black loose stools since arriving there and his/her hemoglobin and hematocrit blood levels had been drawn with low results. At 1:15 p.m. the facility received a call from the emergency room nurse informing them that they had admitted Resident #1 to the hospital with a questionable [MEDICAL CONDITION]. A History and Physical report dated 07/18/11 documented Resident #1 had presented to the emergency room with a chief complaint of a syncopal episode (temporary loss of consciousness). EMS (emergency medical services) personnel had reported that Resident #1 had a blood pressure of 80/60 (low) upon their arrival to the dentist's office. Other findings included: Resident #1 had a 2 day history of diarrhea, physical exam revealed a pale, chronically ill appearing person with pale sclera and a somewhat dry oropharynx (mouth and throat). The laboratory results included a hemoglobin of 7.5, hematocrit 23, BUN 68 (normal 7 to 18) and creatinine of 1.87 (0.44 to 1.21), indicative of kidney (renal) function. Stool was positive for occult blood. The assessment: a. GI bleed. b. Severe [MEDICAL CONDITION]. c. Dehydration. d. [MEDICAL CONDITION]. e. Dental infection. The plan included admission to the special care unit, blood [MEDICAL CONDITION], and to hold the medications aspirin and [MEDICATION NAME]. A hospital Discharge Summary dated 07/20/11 identified Resident #1's primary Diagnosis: [REDACTED]. a. GI bleed Secondary Diagnoses: [REDACTED]. b. [MEDICAL CONDITION] secondary to blood loss. c. Dehydration. During the hospital course Resident #1 received intravenous medication and [MEDICATION NAME] for pain. He/she also received 3 units of packed red blood cells. The stools slowed down significantly. The laboratory tests and justification directed Resident #1 to have follow-up blood tests drawn for BMP (includes BUN and creatinine) in one week for acute [MEDICAL CONDITION], and CBC in one week for [MEDICAL CONDITION]. During an interview on 08/10/11 at 9:34 a.m., staff at the dentist's office stated Resident #1 arrived to the office by bus, and the bus driver helped him/her into the office. They got a wheelchair for the resident because they could see something was wrong with him/her. They took Resident #1 back to a chair, looked at his/her tooth, brought him/her back out to the entryway and the resident voiced needing to use the bathroom. They called the facility because the resident seemed in pain and was crying. The facility told them Resident #1 was capable of going to the bathroom on his/her own. Staff at the dentist office assisted Resident #1 to the bathroom. Resident #1 voiced wanting to go to the hospital. The staff at the dentist's office called the facility and informed them they would call 911. The facility told them not to call 911, that Resident #1 had been like this for a couple of days and he/she was fine. Resident #1 ended up passing out. Someone from the facility did come and were upset with the resident for taking his/her shoes off. During an interview on 08/09/11 at 11:02 a.m., Resident #1 stated he/she remembered being hospitalized . Resident #1 stated his/her stomach had been so upset, but they got it all fixed up and he/she felt pretty good right now. During an interview on 08/10/11 at 11:03 a.m., Staff E, Licensed Practical Nurse (LPN), stated Resident #1 went to the dentist around 10:30 a.m. on 7/18/11. Staff E stated she went in to the resident's room prior to that to tell him/her to get ready for the appointment and Resident #1 just sat there like in a daze. Staff E had to assist Resident #1 to get ready which was unusual for him/her. Staff E stated the dentist's office called around 11:00 or 11:30 a.m. and stated Resident #1 needed help. She asked what kind of help. They told Staff E they were going to call 911. Staff E told them not to call 911; she would send someone over there. Staff E sent Staff B, Certified Nursing Assistant (CNA), to the dentist's office because she could usually get Resident #1 turned around. Staff E stated Staff B called from the dentist's office stating the ambulance was on its way. Staff E stated Staff B thought the resident was "putting it on." Staff E stated Resident #1 had attention seeking behaviors and would complain of illness or of needing more assistance. Staff E stated sometimes when he/she got anxious, he/she would do this. Staff E stated anti-anxiety medication usually helped this. When asked how they would know the difference between Resident #1 being really ill or it being "put on," Staff E stated she didn't know. During a subsequent interview at 11:03 a.m., Staff E stated she did not know Resident #1 had had diarrhea. Staff E stated if a resident had diarrhea and was not taking adequate fluids, she would check his/her vital signs. During an interview on 08/10/11 at 1:32 p.m., Staff B, CNA, stated she went to the dentist's office under the impression she would be assisting Resident #1 back on the bus. When she arrived, Resident #1 was in the bathroom. Staff B stated one of the staff at the dentist's office had assisted Resident #1 to the bathroom. Staff B stated Resident #1 looked weak and his/her head drooped. The dentist's office staff had removed the resident's shoes and called the ambulance. Staff B stated Resident #1 had been incontinent of bowel, and she removed the resident's soiled underwear. They put Resident #1's shoes on and transferred him/her to the wheelchair. When the paramedics arrived, they took over. Staff B stated prior to this incident, Resident #1 had not been coming out for all meals and complained of not feeling right. During an interview on 08/11/11 at 2:18 p.m., Staff F, CNA, stated she had just started working at the facility on 07/06/11. Staff F stated she had noticed Resident #1 getting weak, wouldn't come out for meals, and needed more assistance with personal cares. Resident #1 had said he/she didn't feel good; felt hot one minute, cold the next. Staff F stated the resident as always tired and had a decline in his/her health. During an interview on 08/11/11 at 1:46 p.m., Staff G, LPN, stated Resident #1 made no complaints to her the days preceding his/her hospitalization . Staff G stated no one reported the resident had diarrhea to her. Staff G stated if she knew Resident #1 had diarrhea and hadn't drank adequate fluids, she would have performed a head to toe assessment of the resident, and based on the findings, would call the physician. Staff G stated if she had concerns about a resident being dehydrated, she would check his/her skin turgor and mucous membranes. During an interview on 08/11/11 at 2:00 p.m., Staff H, CMA/CNA, stated she knew Resident #1 didn't feel well prior to the hospitalization and she had reported this to the nurse. Resident #1 hadn't been acting his/her normal self, and had complained of some nausea. Staff H stated Resident #1 was hard to gauge sometimes due to his/her attention seeking behaviors. During an interview on 08/10/11 at 2:30 p.m., Staff A, Registered Nurse (RN), stated they had tried getting Resident #1 into see the physician because the resident had been complaining and they didn't know if it was due to his/her attention seeking behavior. Staff A stated they had difficulty getting him/her an appointment, then the appointment was cancelled. Staff A agreed that did not negate the facility's responsibility to assess the resident. Staff A stated she would have assessed the resident. During an interview on 08/10/11 at 11:45 a.m., Staff C, Certified Medication Aide (CMA)/CNA, stated normally Resident #1 was independent. Staff C stated she knew Resident #1 did not feel well. Staff C stated Resident #1 complained a lot, about a lot of things. Staff C thought Resident #1 did not come out for meals the day before (the hospitalization ) and that she had diarrhea. Staff C stated Resident #1's color was terrible and she could tell the resident didn't feel well. During an interview on 08/10/11 at 1:15 p.m., Staff D, Licensed Practical Nurse (LPN), stated Resident #1 complained of not feeling well for a week prior to his/her hospitalization . Staff D stated if a resident didn't drink well, she would check skin turgor and look in his/her mouth to see if they were dry. During an interview on 08/11/11 at 12:05 p.m., Staff I, CNA, stated Resident #1 complained of not feeling well and asked to go to the hospital prior to his/her hospitalization . Staff I stated she reported this to the nurse. Staff I stated she tried to get Resident #1 to eat. Resident #1 had stools but Staff I didn't know how much. Resident #1 was weak and needed more assistance. During an interview on 08/11/11 at 12:00 p.m., Staff J stated Resident #1 didn't feel well prior to his/her hospitalization . Staff J could not be specific as to when, but she may have delivered trays to Resident #1's room because he/she didn't feel like coming out. During an interview on 08/11/11 at 11:31 a.m., Staff K, CNA, stated prior to his/her hospitalization , Resident #1 did not feel good. Staff K stated Resident #1 just wanted to lay in bed, didn't eat very well, and was paler than usual. During an interview on 08/11/11 at 11:16 a.m., Staff L, CNA, stated Resident #1 hadn't felt right for about 3 weeks prior to his/her hospitalization . He/she didn't feel well the morning he/she was hospitalized , and Staff L actually thought he/she had a doctor's appointment. Staff L stated Resident #1 had been having diarrhea and had some that morning. She put a brief on Resident #1 so he/she wouldn't have an accident on the way back to his/her room. Staff L stated Resident #1 had black stools. Staff L stated Resident #1 was weak and needed more assistance with ADLs (activities of daily living) for a couple of weeks. Staff L stated she reported this to the nurse and they were aware Resident #1 didn't feel well and had diarrhea. During a findings discussion with the facility on 08/11/11, Staff A stated Resident #1 had constipation for a few days and received Milk of Magnesia (MOM), a laxative, per request which probably caused the diarrhea, and that the resident took iron pills. Staff A stated they were checking the resident's bowels sounds secondary to the diarrhea. The resident had had liquid stools the day of the dental appointment and staff thought that was as a result of the MOM. Staff A stated you are not going to feel well if you're having loose stools. Staff A stated Resident #1 was probably getting dehydrated and the heat index was very high that day. Staff A stated 2 days of loose stools throws your bowels off. Staff confirmed Resident #1 received MOM on the 12th and 13th, and went to the dental appointment on the 18th, 5 days later. During an interview on 08/11/11 at 10:05 a.m., the Administrator stated she had an occasion to witness Resident #1's stools. Sometime prior to 07/11/11, she was giving a tour of the facility to some people. The resident had put his/her call light on during the tour and said someone should look at his/her stool. The Administrator stated Resident #1 had had a loose, black, tarry stool. The Administrator said she reported it to the Director of Nursing, and she had responded that the resident's stools were always that way because of the iron he/she took. When asked about the Resident #1 receiving 2 doses of MOM after that for constipation, the Administrator stated, "That's just what she told me." The Administrator stated she had asked a CNA about the resident's bowel movements and she said Resident #1 was independent and did most things him/herself, but when did have a bowel movement it was normally loose, black, and tarry. During an interview on 08/11/11 at 10:26 a.m., the physician's nurse stated if Resident #1 hadn't drunk adequate fluids and had loose stools, there would be a concern for dehydration, and the physician would expect the facility to assess the resident for that. The facility used the internet for a reference and provided the following information regarding dehydration from the Mayo Clinic: Dehydration occurs when you lose more fluid than you take in, and the body doesn't have enough water and other fluids to carry out it's normal functions. You can usually reverse mild to moderate dehydration by drinking more fluids. Treat children and older adults with greater caution. Call the physician if they have any symptoms of mild or moderate dehydration. Symptoms of mild to moderate dehydration include a dry, sticky mouth and tiredness. Severe dehydration can cause low blood pressure. A physician can often diagnose dehydration on the basis of physical signs and symptoms such as little or no urination, sunken eyes, and skin that lacks its normal elasticity and resilience when pinched. When dehydrated you're likely to have low blood pressure, especially when moving from a lying to a standing position. Information regarding [MEDICAL CONDITION] documented signs that may indicate the presence of bleeding in the digestive tract and require further investigation include: fatigue, weakness, pale appearance. Red flags: Several findings suggest hypovolemia (low blood volume): [MEDICAL CONDITIONS], pallor, diaphoresis and [MEDICAL CONDITION] 2) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #2 demonstrated short term memory problems and moderately impaired cognitive skills for daily decision making. The assessment indicated Resident #2 required extensive assistance of 2 staff with transfers, ambulation, dressing, toileting and personal hygiene. The resident's active [DIAGNOSES REDACTED]. The Care Plan dated 02/02/11 identified Resident #2 with the potential for pain and the interventions included: a. Assess for signs and symptoms of pain. b. Notify the physician of uncontrolled pain. c. Medications as ordered. d. Review medications. The Nurse's Notes dated 07/02/11 at 9:45 a.m. documented the aides came to get the nurse to look at Resident #2's right lower extremity. The resident's shin, calf and side of the right lower leg was red and warm to the touch. Staff noticed a lump on the back of the resident's calf. Resident #2 yelled out in pain when staff touched the area. At 10:00 a.m. (same day) staff called the doctor on call and received an order to administer Keflex, an antibiotic, to the resident. At 1:55 p.m. staff marked the area on the resident's leg for monitoring purposes. At 9:00 p.m., staff noted the right lower extremity continued to be reddened with increased warmth, and a lump to the back of the calf. Resident #2 yelled out in pain when the nurse assessed the area. The Nurse's notes dated 07/03/11 at 6:00 a.m. documented the resident's right lower extremity appeared reddened with a painful lump on the back of the calf. At 10:25 a.m., staff documented Resident #2 continued to complain of pain to the lump on the right lower extremity. At 8:05 p.m., staff documented the right lower extremity had increased warmth and pain, Redness better, resident complained of pain when the area was touched. At 10:15 p.m., staff documented Resident #2 yelled out in pain. Assessment done and revealed the right lower extremity with increased redness and warmth above the knee to the mid thigh. The lump to the calf was larger with tight skin and redness. Very painful. CNAs noted Resident #2 had more difficulty bearing weight when transferred to bed. Resident #2's routine [MEDICATION NAME] (pain medication) had not been effective with the pain. The Nurse's Notes dated 07/04/11 at 3:15 a.m. documented Resident #2 up to the bedside commode with assist of 2 staff. Resident #2 complained of pain in the calf of the right leg. Noted a large lump to the right calf with redness and warmth from the toes to the mid thigh. Resident #2 had [MEDICAL CONDITION] from the toes to the mid thigh. Continued on antibiotic without adverse side effects. At 9:00 a.m., staff documented the area to the resident's right lower extremity had progressed to the middle of the right thigh. Area was red, warm to touch, and the lump to the back of the calf was larger. Resident #2 complained of severe pain. Resident had a low grade temperature the previous evening and had received routine Tylenol at 6:00 a.m. At 9:15 a.m., staff notified the physician on call of the resident's condition and received orders to send the resident to the hospital by ambulance for evaluation and treatment. At 12:30 p.m., staff documented the hospital admitted Resident #2 for treatment of [REDACTED]. A Patient Transfer Form dated 07/04/11 documented that on 07/02/11, staff found a red, rashy area on Resident #2's right lower extremity with a large lump noted to the back of the calf. Resident #2 complained of pain when touching the leg and the leg felt very warm to touch from the ankle to the mid-calf. The physician on call had placed Resident #2 on Keflex. On 07/04/11 the red area progressed to the mid-thigh and the right lower extremity from the ankle to the mid-thigh warm was to touch. The lump to the back of the calf became larger and Resident #2 complained of severe pain. Resident #2 ran a low grade temperature last night. Resident #2 received routine Tylenol every day at 6:00 a.m. A History and Physical report dated 07/04/11 documented the resident's chief complaint as [MEDICAL CONDITION]. The report indicated the physician had admitted Resident #2 through the emergency room after a report that in the past 2 days he/she had worsening [MEDICAL CONDITION] of his/her lower extremities with [DIAGNOSES REDACTED] and swelling spreading up the right thigh. The assessment and plan included: a. [MEDICAL CONDITION] of the legs, right greater than left, with a complicating history of diabetes. The guide in this situation is coverage with intravenous antibiotics. b. Elevated D-dimer with swelling of the leg. Would obtain a venous doppler to look for [MEDICAL CONDITION]. In the meantime cover with [MEDICATION NAME], and bedrest until see the results of the venous doppler. The hospital Discharge Summary dated 07/11/11 documented Resident #2's principle [DIAGNOSES REDACTED]. a. [MEDICAL CONDITION] right leg. b. [MEDICAL CONDITION] Resistant Staph Aureus (MRSA) [MEDICAL CONDITION] right leg. During an interview on 08/10/11 at 1:46 p.m., Staff G, LPN, stated she had charted on Resident #2 (on 07/03/11 at 10:15 p.m.) at the end of her shift. Staff G stated Resident #2 did not have pain at that time (although she had charted the resident did have pain). Staff G stated during the interview Resident #2 had routine pain medication (which she charted as ineffective) and prn (as needed) Tylenol. If those medications didn't work she would need to call the physician. During an interview on 08/10/11 at 12:05 p.m., Staff I, CNA, stated she told the nurse Resident #2 had something wrong with his/her leg. The nurse gave her a marker so she could outline the area to see if it got bigger. Staff I stated Resident #2 hollered out with any movement of the right leg. During an interview on 08/10/11 at 11:16 a.m., Staff L, CNA, stated Resident #2's leg was red and kept getting bigger and that the resident demonstrated a lot of pain to the point he/she really couldn't stand. During an interview on 08/10/11 at 11:45 a.m., Staff C, CMA/CNA, stated on 07/02/11 the night shift reported Resident #2 had a rash on his/her leg. Later they noticed the leg as swollen and he/she complained of a lot of pain. Resident #2 didn't want to stand on it. Staff C stated it seemed he/she had pain all the time; he/she complained of it all day. Staff C stated on 07/04/11 she could see Resident #2 in pain. Staff C thought Resident #2 got something for it. When Staff C looked at the medication sheets, she could find no evidence the resident had received any pain medication other than what he/she had previously been taking. Staff C stated the nurse was aware of Resident #2's pain. During an interview on 08/10/11 at 9:55 a.m., Staff M, LPN, stated she worked at the facility, but quit a few weeks ago. Staff M stated if pain medications were not effective a physician should be called; they could always call the on call physician. During an interview on 08/10/11 at 2:30 p.m., Staff A stated staff should have implemented and documented measures regarding the resident's leg pain. If pain control measures were not effective, the physician should have been notified. Information provided by the facility regarding [MEDICAL CONDITION] identified the following symptoms of [MEDICAL CONDITION]: a. Swelling. b. Pain. c. Tenderness. d. Redness of the skin. If you have any of these symptoms, you should see your doctor as soon as possible. The resident's July 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] the right lower extremity. At no time did facility staff assess the resident's pain or call the physician to report the resident complained of pain.

Based on clinical record review and interviews, the facility failed to adequately assess and provide interventions intended to prevent the development of pressure sores for 1 of 9 reviewed residents who developed a Stage III pressure sore (Resident #5). The facility identified a census 40 residents. Findings include: 1. The Minimum Data Set (MDS) assessment with an assessment reference date of 6/7/11documented Resident #5 had [DIAGNOSES REDACTED]. The same MDS documented the resident as severely cognitively impaired, required limited assistance of 1 staff for completion of bed mobility and dressing, and extensive assistance of 2 staff for transfers and bathing. The assessment indicated the resident as non-ambulatory outside of his/her room and required extensive assistance of 2 staff to walk in his/her room. The assessment indicated the resident as at risk for pressure sore development and incorrectly coded the resident as having a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed without slough or an intact or open serum-filled blister) pressure ulcer first identified on 5/12/11. Wound clinic documentation beginning 5/19/11 and continuing through 7/25/11 indicated the resident had a Stage III pressure ulcer to his/her right heel. A Stage III ulcer is described as full thickness tissue loss and subcutaneous fat may be visible. The resident scored 17 on the Skin Risk assessment dated [DATE] which indicated the resident a low risk for development of pressure ulcers. The resident's care plan initially dated 4/28/11 identified the resident with a potential for skin integrity concerns related to diabetes and impaired mobility; a [DIAGNOSES REDACTED]. Interventions intended to keep the resident's skin intact included: assess skin condition, specialty mattress to bed and chair, and increase mobility and activity as tolerated. The care plan did not include a turning/repositioning intervention even though the resident's MDS assessment indicated he/she required limited assistance of 1 staff for bed mobility; the care plan also did not direct staff to float the resident's heels when he/she lay in bed. An entry dated 5/12/11 identified an open area to the resident's right heel and on 5/16/11, an open area to the resident's left heel was noted. Both entries directed staff to float the resident's heels. During an interview on 7/27/11 at 3:20 p.m., the facility's nurse consultant stated it was facility policy that certified nursing assistants (CNAs) document on a skin sheet any abnormal areas found on the resident's skin during bathing and to report these areas to the nurse. She also stated the nurses were to complete a weekly head-to-toe skin check of each resident and document completion of those checks on the residents' Medication Administration Records (MAR). Review of Resident #5's bath skin sheets dated 5/3, 6, 10, 13, 17, 20, 24, 27 and 31/11 revealed no abnormal skin areas had been noted. Review of the resident's April and May, 2011 MARs revealed no weekly skin checks documented until 5/22/11. A Report of Consultation dated 4/14/11 indicated the resident as currently not in heart failure and ordered the facility to weigh the resident daily and record weights, to administer [MEDICATION NAME] (diuretic medication) 40 milligrams to the resident if his/her weight increased 3 pounds over a 1-2 day period, and to apply knee-high compression stockings (to the resident's legs) on in the morning and off in the evening. Review of the Medication Administration Records for April and May, 2011 revealed documentation of the application of these compression stocking daily through 5/19/11 on which date the resident's order changed. A nurses' note dated 5/9/11 at 9:25 a.m. documented the resident had bilateral 2+ [MEDICAL CONDITION] to his/her bilateral lower extremities. Staff notified the physician who ordered the resident receive [MEDICATION NAME] 40 mg every other day. A nurses' notes dated 5/11/11 at 10:20 p.m. documented the resident had an open area to the right heel which measured 1 centimeter (cm) x 0.3 cm, purple in color and no drainage noted. The entry further documented a 3 cm x 3 cm white area surrounded the open area. The facility notified the resident's physician of this condition change. A nurses' note dated 5/12/11 at 10:30 a.m. documented the resident's right heel as red with yellowish drainage noted; staff contacted the on-call physician and received an order to culture the wound and obtain a complete blood count (CBC) on the next laboratory day. A nurses' note dated 5/12/11 at 2:20 p.m. documented the physician ordered the resident start taking Bactrim DS (an antibiotic), one tablet two times daily (BID), for 14 days and to set up an appointment for the resident to be evaluated at the wound clinic. The facility's Weekly Pressure Ulcer Progress Report dated 5/14/11 documented the area on the resident's right heel as a Stage II pressure ulcer which measured 3.5 cm x 2.0 cm with yellow drainage. A nurses' note dated 5/16/11 at 1:45 p.m. documented the resident had a fluid filled blister measuring 2.2 cm x 1.4 cm on his/her left heel. A nurses' note dated 5/17/11 at 2:35 p.m. indicated that ambulation boots had been ordered to relieve pressure to the resident's heels. A nurses' note dated 5/18/11 at 10:00 p.m. documented the resident had black areas in the middle of the open areas on both heels. Wound clinic documentation dated 5/19/11 documented the resident had a Stage III (full thickness tissue loss and subcutaneous fat may be visible) pressure ulcer on the right heel which measured 2.6 cm x 3.0 cm with a total involved area of 4.5 cm x 5.0 cm; 40% of the wound base was covered with slough (dying tissue). The resident's left heel ulcer measured 1.5 cm x 1.5 cm. The report further documented the resident had 4+ [MEDICAL CONDITION] to both legs. The clinic documented the resident arrived with no compression stockings on and the resident's daughter stated the she had never seen compression stockings on the resident. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The documentation also indicated the resident's right heel wound was infected with stapholoccus aureas for which the resident received Bactrim. The documentation included treatment orders including: administer Tylenol 325 mg routinely twice a day, apply ace wraps to legs in the a.m., exposing the heels, remove at night, and suspend heels at all times! A nurses' note dated 5/20/11 at 10:40 p.m. documented that ambulation boots had been applied to the resident's feet. The facility's non-pressure sore skin conditions form dated 5/22/11 documented the resident's left heel had a 1.8 cm x 1.0 cm ruptured blister (open are) without drainage and the area was almost healed. An entry dated 5/30/11 documented the area as resolved (healed). The facility's Weekly Pressure Ulcer Progress Report dated 5/22/11 documented the resident's right heel as a Stage II ulcer which measured 3.2 cm x 2.0 cm with yellow drainage and pink in color. The facility's Weekly Pressure Ulcer Progress Report dated 5/30/11 documented the resident's right heel as a Stage II ulcer which measured 3.0 cm x 2.0 cm with yellow drainage and purple in color. The wound clinic documentation dated 6/2/11 documented the resident's right heel as a Stage III ulcer which measured 1.2 cm x 3.0 cm and a pressure ulcer on the left heel with no measurements or stage documented. The facility's Weekly Pressure Ulcer Progress Report dated 6/5/11 documented the resident's right heel ulcer as a Stage II which measured 3.0 cm x 2.0 cm with yellow drainage and purple in the middle and pink/yellow in color around the ulcer. The wound clinic documentation dated 6/16/11 documented the resident right heel as a Stage III ulcer which measured 1/5 cm x 2.8 cm. The facility's Weekly Pressure Ulcer Progress Report dated 6/14/11 documented the resident right heel as a Stage II ulcer which measured 2.8 cm x cm x 1.5 cm with a red wound bed. The wound clinic documentation dated 6/23/11 documented the resident right heel as Stage III ulcer which measured 1.0 cm x 1.8 cm; 1.0 cm of slough tissue removed by curettage (cutting). The facility's Weekly Pressure Ulcer Progress Report dated 6/26/11 documented the resident right heel as a Stage II ulcer which measured 1.8 cm x cm x 1.2 cm with a red wound bed. The facility's Weekly Pressure Ulcer Progress Report dated 7/3/11 documented the resident right heel as a Stage II ulcer which measured 1.4 cm x cm x 1.0 cm with a pink wound bed. The wound clinic documentation dated 7/7/11 documented the resident right heel as Stage III ulcer and measured 0.9 cm x 1.8 cm and 1.2 cm. The facility's Weekly Pressure Ulcer Progress Report dated 7/10/11 documented the resident right heel ulcer as a Stage II which measured 1.2 cm x cm x 0.9 cm with a pink wound bed. The facility's Weekly Pressure Ulcer Progress Report dated 7/19/11 documented the resident right heel ulcer as a Stage II which measured 0.8 cm x cm x 0.6 cm with a pink wound bed. The wound clinic documentation dated 7/25/11 documented the resident right heel ulcer as Stage III and measured 0.7 cm x 1.8 cm and 1.4 cm with a pink wound bed. The facility's Weekly Pressure Ulcer Progress Report dated 7/26/11 documented the resident's right heel as healed. During an interview on 7/28/11 at 3:27 p.m., the facility's Director of Nursing stated she was not sure why the CNA staff or licensed nurses did not notice the areas on the resident's heels sooner as the resident was dependent on staff for application of the compression stockings and bathing. She also stated she could not explain why Resident #5 did not have weekly head-to-toe skin checks by a licensed nurse, as directed by facility policy, until 5/22/11.