Every finding on record at Accura Healthcare of Onawa

Based on observations, resident, and staff interviews, the facility failed to display contact information for state and federal agencies in an accessible and prominent location in the facility for 4 out of 4 residents interviewed (Residents #14, #19, #29, #31, and #33). The facility reported a census of 40 residents.Findings include: Observation on 7/8/26 at 2:37 PM revealed a failure to post required contact information in a prominent and accessible location. The facility lacked an accessible displayed directory of pertinent state agencies and advocacy groups, including the state survey agency, licensure office, adult protective services, the State Long Term Care Ombudsman (SLTCO), and the Medicaid Fraud Control Unit, in a format understandable to residents and their representatives.During an interview on 7/8/26 at 3:10 PM, Resident #14 reported an understanding of the Ombudsman. The resident was unable to identify the location of information related to outside agencies.During an interview on 7/8/26 at 3:12 PM, Resident #29 reported she was unfamiliar with the definition of an Ombudsman. The resident reported she was unaware of where any information could be posted.During an interview on 7/8/26 at 3:15 PM, Resident #31 reported no understanding of the definition of the Ombudsman or where information could be posted.During an interview on 7/8/26 at 3:19 PM, Resident #33 stated that she was unfamiliar with the definition of an Ombudsman or where information could be posted.During an interview on 7/8/26 at 3:23 PM, Staff A, Certified Nursing Assistant (CNA), stated they thought Ombudsman information was posted in the copy machine room. Staff A noted that while residents generally do not access the copy room, staff are available to retrieve information upon request.During an interview on 7/8/26 at 3:19 PM, Resident #19 reported that she didn't know the definition of an Ombudsman. Resident #19 she was not aware of where information could be posted.During an interview on 7/8/26 at 3:29 AM, Staff B, Registered Nurse (RN), was asked to identify the location of information related to the Ombudsman. Staff B replied, I don't know what that is.During an interview on 7/8/26 at 3:49 PM, the Director of Nursing (DON) stated that Ombudsman forms were located at the front entrance vestibule. The Interim Administrator acknowledged that because the information was located behind a locked door, it was not accessible and not in a prominent location for residents to access.

Based on observation, review of facility records, resident and staff interviews, and facility policy, the facility failed to ensure that residents and staff were adequately educated regarding the definition of a grievance, the grievance process, and the specific procedures for obtaining forms and filing grievances anonymously for 5 out of 5 residents interviewed (Residents #14, #19, #29, #31, and #33). The facility reported a census of 40 residents.Finding include:Observation on 7/8/26 at 2:37 PM, revealed that the facility failed to provide readily accessible grievance forms in a public area for residents.During an interview on 7/8/26 at 3:10 PM, Resident #14 reported an understanding of the definition of a grievance. The resident was unable to identify the location of grievance forms or the established procedure for their submission.During an interview on 7/8/26 at 3:12 PM, Resident #29 reported she was unfamiliar with the definition of a grievance, the grievance process, and the location of grievance forms.During an interview on 7/8/26 at 3:15 PM, Resident #31 reported an understanding of the definition and process of a grievance; however, the resident stated, I don't know where they keep the forms. I would have to ask.During an interview conducted on 7/8/26 at 3:19 PM, Resident #33 stated that she was unfamiliar with the definition of a grievance, the grievance process, and the location of grievance forms, specifically noting, I have no idea what that is.During an interview on 7/8/26 at 3:23 PM, Staff A, Certified Nursing Assistant (CNA), stated they thought the grievance forms were located in the copy machine room. Staff A noted that while residents generally do not access the copy room, staff are available to retrieve a form upon request.During an interview on 7/8/26 at 3:19 PM, Resident #19 reported that she didn't know the definition of a grievance or where a form could be found.During an interview on 7/8/26 at 3:29 AM, Staff B, Registered Nurse (RN), was asked to identify the location of grievance forms. Staff B replied, I don't know whereThe Grievance Process last updated January 2023 identified the facility will notify residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official is available on the posted grievance process with whom a grievance can be filed, that includes, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality improvement Organization, State Survey Agency and State Long- Term Care ombudsman program or protection and advocacy system.During an interview on 7/8/26 at 3:49 PM with the Director of Nursing (DON) and the Interim Administrator, the DON stated that grievance forms were located at the front entrance. Upon being informed that forms were not accessible in that location and that no information regarding the grievance process was posted, the DON acknowledged that grievance forms must be readily available to residents. The Interim Administrator reported they would search for a facility policy.

Based on observation, clinical record review, and staff interview, the facility failed to ensure comprehensive care plans were updated to reflect current resident needs including restorative care, CPAP therapy, dietary orders, and fall interventions for 4 out of 12 residents reviewed (Residents #7, #8, #36, and #39). The facility reported a census of 40 residents. Findings include: 1. Resident #7's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interrview of Mental Status (BIMS) score of 13/15 indicating normal cognition. The document revealed the resident had a limitation in movement of one leg. The facility's document, Restorative Nursing Program, revealed a start date of 6/25/26 with transfers 3-5 times/day for 5 days/week, ambulation greater than 50' 3 times/day, arm and leg exercises for 20 repetitions daily for 3 times/week with a 2# weight, and Nu-Step for 10-15 minutes. The clinical record's Point of Care documentation revealed data collection availability for arm and leg exercises, transfer practice and ambulation. Resident #7's Care Plan revised 5/9/26 did not include a focus area related to the resident's limitation in movement and the need for a Restorative Nursing Program to prevent regression of skills/strength. 2. The MDS assessment dated [DATE] for Resident #8 documented a BIMS score of 15, indicating no cognitive impairment. The MDS showed diagnoses of obstructive sleep apnea, congestive heart failure, and obesity. On 7/6/26 at 9:49 AM, observation of Resident #8's room confirmed the presence of a CPAP machine. In an interview on 7/9/36 at 8:32 AM, Resident #8 reported he uses the CPAP every night. The resident reported he is not sure if staff clean the CPAP tubing and mask. Review of clinical physician orders for Resident #8 dated 1/8/26 showed an order for nightly CPAP use. Review of Resident #8's care plan revealed that the facility failed to revise the comprehensive care plan to include the use, settings, and cleaning schedule for the CPAP machine. In an interview on 7/9/26 at 10:22 AM, Staff I, Registered Nurse (RN), reported that she added the CPAP information to the care plan on the second day of the survey. When asked if the CPAP information should be added to the care plan upon initiation of the device, Staff I confirmed that it should be. 3. Resident #36's Significant Change MDS Assessment, related to initiation of hospice services, dated 5/13/26 revealed the resident was unable to complete a BIMS and required staff to answer questions regarding the resident's cognitive status. The document included the resident required a mechanically altered diet and had sustained 1 fall during the reporting period. Resident #36's Care Plan, revised 6/1/26, identified a nutritional focus area (revised 11/22/24) with a staff intervention for providing diet as ordered - general pureed diet with honey thick liquids (revised 11/6/24). The document disclosed the resident was a high risk for falls (revised 5/19/26) with staff interventions of the resident would crawl into and out of bed, and wheelchair (w/c) independently as she wishes (revised 11/6/24), the resident needed a safe environment with floor mat next to the bed at night (revised 11/6/24), and the resident needed a safe environment with the bed in the low position at night (revised 11/6/24). The clinical record's Clinical Physician Orders disclosed an order dated 5/15/26 for regular diet, mechanical soft texture and honey consistency. Observed on 7/6/26 at 11:00 AM Resident #36 seated on floor mats with bed in the lowest position with a family member present. Observed on 7/7/26 at 1:30 PM the resident seated on the floor mat with the bed in lowest position engaged in a card activity. Observed on 7/8/26 at 11:30 AM resident seated on the floor mat engaged in a card activity with the bed in the lowest position prior to Staff C, Certified Nurse Assistant (CNA) and Staff E, CNA, completing a transfer from the floor to the w/c. On 7/8/26 at 7:50 AM Staff E stated Resident #36's bed was always low and the mats were on the floor. On 7/8/26 at 11:35 AM Staff C stated the resident's bed was always in a low position and mats were on the floor as the resident will self transfer from her w/c to the floor to play with her cards. The facility failed to update the Care Plan to reflect a change in diet and fall interventions. 4. Resident #39's MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The document provided the resident had not had any falls during the reporting period. The document revealed the resident had a limitation in movement in both legs, The resident's Care Plan, revised 6/3/26, contained a focus area potential for falls initiated on 4/10/25 with staff interventions of an actual fall on 5/23/26 with low air loss mattress removed (initiated 6/3/26), bed to be in lowest position when resident is in it pressure reducing mattress in place (6/15/26), and lab urinary analysis with low bed position (5/23/26). The facility's document, Restorative Nursing Program, revealed a start date of 7/3/26 with arm and leg exercises 10-20 repetitions 1 time/day for 5 days/week and arm exercise with the use of the Omnicycle x15 minutes 2 times/week. The clinical record's Point of Care documentation revealed data collection availability for arm and leg exercises, and use of the Omnicycle. Observed on 7/6/26 at 11:14 AM the resident lying in bed with the bed at a normal height (not low to the floor) with the bedside table next to the bed and a fall mat on the other side of the bedside table - further into the room. Observed on 7/7/26 at 2:30 PM the resident in bed that was not lowered with the bedside table next to the bed, and the fall mat on the other side of the bedside table. On 7/8/26 at 11:30 AM Resident #39 stated the fall mat was put on the floor at the time of his fall. On 7/8/26 at 11:40 AM Staff C stated fall interventions for the resident included the use of a fall mat and a lowered bed. The facility failed to revise a Care Plan to include the resident's limitation in movement, the need for a Restorative Nursing Program to prevent regression of skills/strength and the use of fall mat as an intervention for the risk for falls. On 7/8/26 at 3:45 PM the Director of Nursing (DON) with the Regional Corporate Nurse and Interim Administrator present stated the Care Plans should reflect the resident's current needs, and could be updated by any member of the interdisciplinary team. The staff acknowledged the Care Plans should include all current fall interventions, diets, and the Restorative Nursing Program(s). The facility's Comprehensive Care Plans Policy, updated 12/3/25, revealed the care plan would be reviewed and revised by the interdisciplinary team, and updated in a timely manner to ensure that services provided assist the resident to attain or maintain the highest practicable level of physical, mental, and psychosocial well-being.

Based on clinical record review, resident and staff interviews, and policy review the facility failed to develop and implement programs maintaining residents strength, range of motion (ROM), mobility needs based on the comprehensive assessment and under the direct guidance of a Registered Nurse (RN) for 4 of 4 residents (Resident #3, #7, #17, #39) reviewed. The facility reported a census of 40.Findings include:1. Resident #3's Quarterly Minimum Data Set (MDS) assessment dated [DATE] provided a Brief Interview for Mental Status (BIMS) score of 7/15 indicating moderate cognitive impairment. The document revealed the resident had an impairment in ROM on one side for the upper and lower extremities. The document coded 0 days of at least 15 minutes in the past 7 days of the assessment period for Restorative Nursing Programs (RNP).The Physical Therapy (PT) Discharge summary dated [DATE]-[DATE] revealed recommendations for Restorative Program Established/Trained for lower extremity (LE) exercise, Nu-Step, Ambulation Program for walking to meals with staff/ambulation program. The facility's document, Restorative Nursing Program, revealed a start date of 1/15/26 with interventions of transfers 7 days/week, walking distance of greater than 100' 3-5 times/daily, toileting, and Nu-Step level 3 for 10 minutes. The clinical record's Point of Care documentation for the ambulation program revealed documentation for each of the past 30 days. The clinical record's Plan of Care History for the ambulation program revealed a revision date of 3/24/26. The Clinical record's Point of Care documentation for ROM for the lower body for exercises and use of the Nu-Step revealed no documentation for the past 30 days. The clinical record's Plan of Care History for the lower body exercise revealed a revision date of 3/2/25. 2. Resident #7's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 13/15 indicating normal cognition. The document revealed the resident had a limitation in ROM of one LE and did not receive any RNP services during the reporting period. The PT Discharge summary dated [DATE]-[DATE] revealed recommendations for walk to dine with staff, Nu-Step for 10-15 minutes and LE seated exercises. The facility's document, Restorative Nursing Program, revealed a start date of 6/25/26 with transfers 3-5 times/day for 5 days/week, ambulation greater than 50' 3 times/day, upper extremity (UE) and LE exercises for 20 repetitions daily for 3 times/week with a 2# weight, and Nu-Step for 10-15 minutes. The clinical record's Point of Care documentation for the ambulation program revealed documentation for each day for the past 30 days. The clinical record's Plan of Care History for the ambulation program revealed a revision date of 6/25/26.The clinical record's Point of Care documentation for the upper and lower extremities exercise program with the use of a 2# weight revealed 5 entries for the past 30 days. The clinical record's Plan of Care History for the exercise program revealed a revision date of 6/25/26.The clinical record's Point of Care documentation for the transfer practice 3-5 times/day for 5 days/week revealed 0 documentation for the past 30 days. The clinical record's Plan of Care History for the transfer practice program revealed a revision date of 6/25/26.The clinical record's Point of Care documentation for the Nu-Step revealed 0 documentation for the past 30 days. The clinical record's Plan of Care History for the Nu-Step revealed a revision date of 6/25/26.3. Resident #17's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12/15 indicating moderate cognitive deficit. The document revealed the resident had a limitation in ROM of one UE and one LE, and did not receive any RNP services during the reporting period. The PT Discharge summary dated [DATE]-[DATE] revealed recommendations for walk to dine 2-3 meals/daily, Nu-Step and LE exercises. The clinical record's Point of Care documentation for the ambulation program revealed documentation for each day for the past 30 days. The clinical record's Plan of Care History for the ambulation program revealed a revision date of 1/10/26.The clinical record's Point of Care documentation did not reflect a program for the recommendation of LE exercises or the use of the Nu-Step.4. Resident #39's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The document revealed the resident had a limitation in ROM in bilateral lower extremities (BLE), and did not receive any RNP services during the reporting period. The PT Discharge summary dated [DATE] - 7/2/26 revealed recommendations for forward bends throughout the day at the waist and LE exercises.The facility's document, Restorative Nursing Program, revealed a start date of 7/3/26 with UE and LE exercises 10-20 repetitions 1 time/day for 5 days/week and bilateral upper extremity (BUE) Omnicycle x15 minutes 2 times/week.The clinical record's Point of Care documentation printed on 7/9/26 for the BUE and BLE exercises 1time/day for 5 days/week revealed 0 documentation for the past 30 days. The clinical record's Plan of Care History for the ambulation program revealed a revision date of 7/8/26.The clinical record's Point of Care documentation printed on 7/9/26 for the Omnicycle for 15 minutes twice weekly revealed 0 documentation for the past 30 days. The clinical record's Plan of Care History for the Omnicycle program revealed a revision date of 7/8/26.On 7/6/26 at 1:46 PM Resident #39 stated he was recently discharged from PT and had been working on strengthening his BUE's for propelling his new custom wheelchair (w/c). The resident stated since discharge from therapy he has not had any other exercise programs. On 7/9/26 at 9:00 AM Staff H, Physical Therapist Assistant (PTA)/Rehab Director stated therapy had not been consistently writing RNP as the facility had not been consistently providing the service. The staff stated PT was now writing programs more consistently but the facility was still not consistently completing the recommended programs by the therapy department. Staff H stated when therapy was discontinued, a RNP form was completed and provided to the MDS Coordinator and/or the Director of Nursing (DON) for review and implementation. The staff stated she was not aware of any staff assigned specifically to carry out the RNP, but rather it was Certified Nurse Assistants (CNAs) who worked both as a bath aide and then completed the RNPs. On 7/8/26 at 12:25 PM the MDS Coordinator stated the restorative nursing staff were the bath aides or any CNA. The staff stated the RNP was a work in progress and she was trying to get programs into the electronic record for staff to complete. The staff stated anyone could walk the residents but when questioned about specific exercise programs the staff was unable to speak to that. On 7/8/26 at 12:30 PM Staff G, CNA/bath aide, stated she completed walk to dines, assisted residents with dressing/self care and incorporated the resident's exercise programs into their dressing tasks. The staff stated she did not use any equipment or weights for completion of RNPs. The staff stated she knew to complete programs as they were on the task assignments in the electronic medical record. The staff stated she did not have any additional training.On 7/8/26 at 1:50 PM Staff G, CNA/bath aide stated she did assist some with restorative nursing; however, she primarily completes showers throughout the day and completes them first before assisting with the walking programs. On 7/8/26 at 1:05 PM the DON with the Regional Nurse Consultant present stated the restorative program was a work in progress and she was still learning it. The DON stated any CNA could complete the restorative program if it was in the electronic record to complete. When asked about specific training for staff to complete the programs, the DON stated the CNAs received training in their CNA course to complete restorative nursing. The Regional Nurse Consultant acknowledged for staff to complete specific RNPs they would be required to have specialized training with examples being use of weights and machines. The DON acknowledged she did not know anything about the use of the machines in the therapy room, and that residents would have to be monitored for their use. The DON stated the facility was working to have a designated staff for restorative nursing rather than a shared bath aide/restorative aide position. The DON acknowledged the restorative nursing program needed to be addressed and work needed to be done with the therapy department. The facility's Restorative Program Process document, updated 10/26/21, revealed a resident's level of function would be assessed upon admission, quarterly or with a significant change by the licensed nurse or with collaboration of therapy. The document included the licensed nurse would develop a RNP with recommendations from therapy for strategy and adaptive equipment needs. The document disclosed the licensed nurse would educate the staff on the program, monitor the staff and resident(s) to ensure compliance daily, and write a monthly restorative nursing summary to track the resident(s) progress.

Based on observations, facility document review, staff interviews, and policy review the facility failed to store and distribute food in accordance with professional standards. The facility failed to complete refrigerator and freezer temperature logs, dish machine log and store/label food items in a refrigerator. The facility reported a census of 40 residents.Findings include: Observed on 7/6/26 at 10:00 AM during the initial kitchen walk through thermometers present in the walk-in freezer, walk-in cooler and 4 door refrigerator. The 4 door refrigerator contained 2 dessert dishes with uncovered fruit, an unlabeled/undated beverage pitcher with a white liquid, and a premade container of opened salad without an opened date. Review of the June 2026 temperature log for the walk-in cooler, walk-in freezer and 4 door refrigerator revealed data collection should occur on the AM and PM shifts. The document disclosed that for 30 days of documentation there were 6 days of complete missing documentation, 11 days of partial documentation, and 13 days of completed documentation. The July temperature log provided on 7/6/26 revealed no documentation for temperature checks for the walk-in cooler, walk-in freezer and 4 door refrigerator. Review of the June 2026 dishwashing low temperature/chemical machine revealed data collection should occur at each meal. The June document disclosed that for 90 opportunities for data collection there were 24 entries (27% completion). The July log reviewed on 7/6/26 at 10:15 AM revealed of 16 possible entries there were 8 completed (50%). On 7/6/26 at 10:15 AM the Dietary Supervisor acknowledged the 2 uncovered dishes of fruit should have been covered and dated, the pitcher of white liquid should be labeled and dated, and the opened container of pre-made salad should have been labeled with an opened date. The staff removed each item and discarded them during the observation.On 7/7/26 at 12:30 PM the Dietary Supervisor stated her expectation was for staff to complete all logs at the time of checking as that was part of their job expectations and training. The Dietary Supervisor stated training and education would be provided in the upcoming week with all staff regarding the completion of logs. The Dietary Supervisor stated the expectation that all items opened be covered and labeled before placing in the refrigerator. On 7/8/26 at 3:50 PM the Interim Administrator acknowledged recent awareness of the incomplete kitchen logs and unlabeled items in the refrigerator. The facility's Food Storage Policy, dated 2021, revealed leftover food should be stored in covered containers or wrapped securely, labeled and dated prior to refrigeration. The document included refrigerator and freezer temperatures need to be monitored twice daily by internal thermometers and recorded.The facility's Dish Machine Temperature Log Policy, dated 2021, revealed a log should be posted near the dish machine for documentation of the temperatures throughout the dishwashing process. The document included staff should record dish machine temperatures for the wash and rinse cycles at each meal with the director monitoring the logs to assure temperatures were appropriate and staff were correctly monitoring the temperatures.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the physician was notified in a timely manner regarding the malfunction of the resident's (Resident #31) CPAP machine. While the equipment failure was documented in progress notes from 6/24/26 through 7/3/26, the facility failed to communicate this change in status to the physician, resulting in an avoidable delay in respiratory care. The facility reported a census of 40 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #31 documented a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), obesity, and sleep-related hypoventilation. The MDS indicated Resident #31 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Clinical Physician Order dated 7/30/24 for Resident #31 showed an order for CPAP with oxygen to be used at bedtime. The Care Plan for Resident #31 dated 8/5/24 showed oxygen and CPAP use related to shortness of breath secondary to chronic obstructive pulmonary disease and congestive heart failure. The Care Plan also showed the resident refused to wear the CPAP at times. During an interview on 07/6/26 at 1:45 PM, Resident #31 reported that her CPAP machine had not worked for approximately one week. The resident stated that she believes staff broke the machine when they moved the refrigerator that the CPAP rested on. When asked if she notified anyone, the resident reported that she told the night nurse, who knew it was not working. When asked about the impact on her sleep without the CPAP, the resident stated, I didn't sleep as well. The resident also reported that she continued to use oxygen at night. The Progress Note for 6/24/26 at 2:11 AM documented the CPAP device as broken. The Progress Note for 6/24/26 at 10:27 PM documented CPAP device malfunction with a cord problem already reported. The Progress Note for 6/25/26 at 10:32 PM documented CPAP device malfunction. The Progress Note for 6/29/26 at 1:25 AM documented awaiting a replacement CPAP machine. The Progress Note for 6/30/26 at 5:04 AM documented the CPAP machine is not functioning right now. The Progress Note for 6/30/26 at 11:15 PM documented the CPAP device not functioning properly. The Progress Note for 7/3/26 at 1:28 AM documented the CPAP machine is out of order. During an interview on 7/6/26 at 2:55 PM, the Director of Nursing (DON) stated she was unaware Resident #31's CPAP machine was broken. The DON examined the CPAP and identified a broken power cord at the plug-in base. She stated staff who discovered the malfunction should have immediately notified the physician. During an interview on 07/08/26, Staff J (RN) confirmed discovering the CPAP malfunction on 06/24/26. Although the resident reported the issue to him, Staff J did not notify the physician. Instead, he informed the oncoming day shift nurse, assuming they would handle the notification. During a subsequent shift, Staff J observed that the device remained broken but failed to verify if the physician had been alerted. The Notification of Change in Resident Health Status policy last updated 5/11/25 revealed the policy failed to provide specific guidance regarding the management and physician notification process for CPAP or other respiratory equipment failures. During an interview on 7/8/26 at 3:36 PM, the Director of Nursing (DON), Interim Administrator, and Nurse Consultant participated in a discussion where the DON reported that she provided 1:1 education to the nurse who initially discovered the malfunctioning CPAP. The DON confirmed that staff who discover equipment malfunctions must notify the physician immediately.

Based on clinical record review, staff interviews, and policy review the facility failed to provide a bed hold for a resident transferred to the hospital for 1 of 1 residents (Residents #7) reviewed. The facility reported a census of 40 residents. Findings include:Resident #7's Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed the discharge was unplanned and occurred on 5/14/26 to a short term general hospital. The clinical record's census revealed the resident had a hospital leave unpaid from 5/14 - 5/20/26. Entries in the clinical record's Progress Notes revealed on 5/14/26 at 10:51 AM the resident was at a wound clinic appointment and was sent to the emergency room from the clinic and on 5/14/26 at 1:17 PM the resident was admitted to the hospital.On 7/7/26 at 3:30 PM the MDS Coordinator stated she did not see the bed hold document in the electronic record, but would continue to look for it. On 7/8/26 at 1:00 PM the Director of Nursing (DON) with the Regional Clinical Nurse Present confirmed a bed hold was not completed. The DON stated there had previously been a staff in social services who completed the bed holds, but at this time the charge nurse was supposed to complete or notify another staff for completion of the bed hold. The DON stated at the time of the notification of the resident being transferred from the clinic to the hospital a bed hold should have been initiated. The facility provided document, Emergency Notice of Transfer/Discharge, updated 4/4/25 - Iowa, revealed an opportunity for documentation for a resident or resident's representative to indicate whether to hold or not to hold the bed during a period when the resident was expected to return to the facility. The document included the ability to indicate when contact was made by phone if necessary.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to protect residents from accidents and injuries for 2 of 3 residents (Residents #36, #39). The facility failed to follow fall interventions identified on the Care Plan. The facility reported a census of 40 residents. Findings include: 1. Resident #36's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4/15 indicating severe cognitive impairment. The document coded the resident required dependent assistance for dressing, toilet hygiene, and partial/moderate assistance for transfers. The document disclosed the resident had 0 falls during the reporting period.Resident #36's Quarterly MDS assessment dated [DATE] revealed the resident was unable to complete the BIMS but staff interview provided the resident was able to recall the current season, location of her room, staff names/faces and that she was in a nursing facility. The document coded the resident required dependent assistance for dressing, toilet hygiene, and substantial/maximal assistance for transfers. The document disclosed the resident had 1 fall during the reporting period.The Care Plan revised 6/1/26 identified a focus area for self care performance deficit revised on 5/19/26 with staff interventions of pairs for cares for toileting (revised 8/11/25), pairs for cares for transfers (revised 8/27/25) and pairs for cares/staff participation for bathing (revised 8/11/25). The facility's documentation for a fall on 3/11/26 revealed the resident fell while in the shower room. The document indicated the resident did not sustain an injury.The facility's documentation for a fall on 5/9/26 revealed the resident had a loss of balance and fell while in the bathroom, and sustained a laceration. The clinical record's Progress Notes revealed the following entries:On 3/11/26 at 2:00 PM the resident sustained a fall, steri strips were applied to the superficial area by the nurse practitioner who was in the facility. The resident requested to be seen in the emergency room. Per the nurse practitioner a scan was completed and was negative.On 3/12/26 at 11:55 AM new order for Bacitracin daily to the area on the left part of the resident's head. On 5/9/26 at 8:02 PM Certified Nursing Assistant (CNA) in bathroom with resident when the resident leaned forward and fell sustaining a 2 cm gash, .5 wide that stopped bleeding with a cool compress. On 7/8/26 at 7:50 AM Staff E, CNA, stated the resident required 2 staff assistance for self care tasks and transfers. Staff E stated staff should not leave her while completing toileting. The staff stated the resident required assistance for standing but could not walk.On 7/8/26 at 11:35 AM Staff C, CNA, stated the resident was always a 2 staff assistance for transfers, toileting, and dressing. On 7/8/26 at 1:50 PM Staff F, CNA/Bath Aide, stated the resident required 2 staff assistance for transfers to and from the modified shower chair, and 1 staff for bathing.On 7/9/26 at 7:00 AM reviewed the Care Plan, revised 6/1/26, with the Director of Nursing (DON) for the self care deficit with staff interventions for the resident requiring 2 staff assistance for transfers, toileting and bathing. The DON acknowledged pairs for cares indicated 2 staff and the resident had required 2 staff for transfers, toileting, and bathing since 8/25. The DON concurred the resident should have had 2 staff present during each of the falls that occurred in 3/25 and 5/25 based on the interventions stated in the self care deficit. The DON indicated she thought changing to 2 staff was a new intervention since 5/25 (most recent fall) due to the resident's decreased stability rather than the resident's size. Reviewed the 3/11/26 fall report and documentation of no injury and no hospitalization with the DON, and the DON stated that was incorrect as the resident did sustain a head injury, did go to the hospital and had a CT scan completed which was negative. The DON stated the staff should be referring to the Care Plan and following the interventions for residents. The facility failed to follow Care Plan interventions for the prevention of 2 falls. 2. The MDS assessment dated [DATE] revealed a BIMS score of 15/15 indicating normal cognition. The document provided the resident had not had any falls during the reporting period. Resident #39's Care Plan revised 6/3/26 contained a focus area for potential for falls initiated on 4/10/25 with staff interventions of an actual fall on 5/23/26 with low air loss mattress removed (initiated 6/3/26), bed to be in lowest position when resident is in it pressure reducing mattress in place (6/15/26), and lab urinary analysis with low bed position (5/23/26).Observed on 7/6/26 at 11:14 AM the resident lying in bed with the bed at a normal height (not low to the floor) with the bedside table next to the bed and a fall mat on the other side of the bedside table - further into the room. Observed on 7/7/26 at 2:30 PM the resident in bed that was not lowered with the bedside table next to the bed, and the fall mat on the other side of the bedside table.Observed on 7/8/26 at 11:30 AM the resident lying in bed with the bed not in a low position and the fall mat folded, leaning against the wall at the foot of the bed. Observed on 7/8/26 at 1:20 PM the resident lying in a bed, not lowered, with the fall mat folded and leaning against the wall. On 7/6/26 at 1:44 PM Resident #39 stated he had fallen from bed while dreaming. On 7/8/26 at 11:30 AM the resident stated the fall mat was put down at the time of his fall. The resident stated he did not like the fall mat as it prohibited the bedside table from being near him. Resident #39 stated the staff put the fall mat down on the floor at night. On 7/8/26 at 11:40 AM Staff C stated fall interventions for the resident included the use of a fall mat and a lowered bed. The staff stated the resident's fall occurred when the resident was confused. On 7/9/26 at 8:15 AM Staff G, CNA, stated staff referred to the Care Plan for information on resident assistance needs. On 7/8/26 at 3:50 PM the Director of Nursing (DON) with the Regional Nurse Consultant and Interim Administrator present expected staff to follow the fall interventions that were put into place and on the Care Plan. The facility's Comprehensive Care Plans Policy, updated 12/3/25, revealed staff would be notified of their roles and responsibilities for carrying out the interventions in the Care Plans initially and when changes occurred.

Based on observations, clinical record review, resident and staff interviews, the facility failed to ensure a resident received required respiratory care when the Continuous Positive Airway Pressure (CPAP) malfunctioned. The facility documented the device as broken or malfunctioning in progress notes from 6/24/26 through 7/3/26. The Director of Nursing remained unaware of the equipment failure until 7/6/26. The facility reported a census of 40 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #31 documented a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), obesity, and sleep-related hypoventilation. The MDS indicated Resident #31 used a non-invasive mechanical ventilator. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment.The Clinical Physician Order dated 7/30/24 for Resident #31 showed an order for CPAP with oxygen to be used at bedtime.The Care Plan for Resident #31 dated 8/5/24 showed oxygen and CPAP use related to shortness of breath secondary to chronic obstructive pulmonary disease and congestive heart failure. The Care Plan also showed the resident refused to wear the CPAP at times. During an interview on 7/6/26 at 1:45 PM, Resident #31 reported that her CPAP machine had not worked for approximately one week. The resident stated that she believes staff broke the machine when they moved the refrigerator that the CPAP rested on. When asked if she notified anyone, the resident reported that she told the night nurse, who knew it was not working. When asked about the impact on her sleep without the CPAP, the resident stated, I didn't sleep as well. The resident also reported that she continued to use oxygen at night.The Progress Note for 6/24/26 at 2:11 AM documented the CPAP device as broken.The Progress Note for 6/24/26 at 10:27 PM documented CPAP device malfunction with a cord problem already reported.The Progress Note for 6/25/26 at 10:32 PM documented CPAP device malfunction.The Progress Note for 6/29/26 at 1:25 AM documented awaiting a replacement CPAP machine.The Progress Note for 6/30/26 at 5:04 AM documented the CPAP machine is not functioning right now.The Progress Note for 6/30/26 at 11:15 PM documented the CPAP device not functioning properly.The Progress Note for 7/3/26 at 1:28 AM documented the CPAP machine is out of order. During an interview on 7/6/26 at 2:55 PM, the Director of Nursing (DON) stated she was unaware Resident #31's CPAP machine was broken. The DON examined the CPAP and identified a broken power cord at the plug-in base. She stated staff who discovered the malfunction should have immediately notified the DON. She further stated she would check with maintenance for a replacement cord.During an interview on 7/6/26 at 4:40 PM, the DON stated she would provide education to the floor staff who initially charted the malfunction.During an interview on 7/6/26 at 6:10 PM, the DON reported that she found a replacement CPAP machine within the facility and connected it for the resident's use.During an interview on 7/8/26 at 10:21 AM, Staff J, Registered Nurse (RN), confirmed that the resident reported the broken CPAP machine to him. When asked if this occurred on 6/24/26, when staff initially charted the device as broken, the nurse confirmed he first discovered the malfunction. Staff J reported the broken CPAP to the oncoming day shift nurse, assuming that the nurse would procure a replacement. During his next shift, he observed that the machine remained broken and discussed it with his coworker, yet he failed to follow up with the DON, or the Administrator, assuming the facility was replacing the machine.During an interview on 7/8/26 at 3:36 PM, the DON, Interim Administrator, and Nurse Consultant participated in a discussion where the DON reported that she provided 1:1 education to the nurse who initially discovered the malfunctioning CPAP. The DON also agreed to provide a copy of the facility's CPAP policy.During a follow-up interview on 7/9/26 at 8:57 AM, the DON stated that she would provide the CPAP policy if the facility maintained one; however, the facility never provided the policy.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to provide infection prevention measures with hand hygiene during wound care and dependent activities of daily living (ADLs) for 2 of 12 residents (Residents #19, #36) reviewed. The facility reported a census of 40 residents.Findings include: 1. Resident #19's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of 15/15 indicating normal cognition. The document included the resident had an open lesion and received a turning/repositioning program, application of nonsurgical dressings, and applications of ointments/medications. The Care Plan for Resident #19 revised 6/1/26 revealed an impaired skin integrity focus area (revised 6/5/26) with interventions of administering treatments as ordered (11/6/24), monitoring/documenting changes in skin status (11/6/24), and treatment as ordered until follow up at wound clinic (7/7/26).The clinical record's Physician Orders revealed an order dated 6/24/26 for wound treatment to buttock: 1. Cleanse with wound cleanser, apply sure prep rapid dry to periwound and under adhesive contact area. 2. Fill depth with silvasorb gel on moistened gauze 3. Apply therahoney gel to the surrounding wound bed. 4. Apply Optilock dressing every 3 days and PRN. Observed on 7/6/25 at 5:36 PM Staff D, Licensed Practical Nurse (LPN), provide wound care for Resident #19 that included the following: Staff D entered Resident #19's room with the wound care supplies covered on a bedside table with a barrier placed. Staff D donned a gown, completed hand hygiene and donned gloves.The staff removed a soiled bandage, placed a towel between the resident and the bed.Staff D removed gloves, placed empty trash bags on the bed, and donned new gloves without hand hygiene.The staff cleansed the wound with wound cleaner, removed gloves, and applied new gloves without hand hygiene.Staff D touched packaging, obtained gauze pads, patted the inside of the wound and then the outside of the wound using the same gauze pads.The staff was unable to locate the skin prep, removed gloves and gown, adjusted the resident's medication pump, completed hand hygiene and left the room.Staff D reentered the room, donned a gown and gloves without hand hygiene and applied the skin prep.The staff changed gloves without hand hygiene, applied Silvasorb to soaked gauze pads and packed into the wound. The staff changed gloves without hand hygiene, soaked a gauze pad, placed on the wound, applied Therahoney around the wound bed, and placed the Optilock dressing on the wound, changed gloves without hand hygiene and dated the dressing. Staff D changed gloves without hand hygiene, obtained a disposable bed pad from the closet, and discovered the resident's sheet needed to be changed. After removal of gloves, gown with hand hygiene completed, the staff left the room to obtain a clean sheet. Upon return to the room, staff completed hand hygiene, donned gown and gloves, completed peri care, rolled the soiled bed pad and sheet, initiated the new sheet with part of it falling onto the floor with the new bed pad. Staff D completed the bed making process, removed gloves, gown, tied trash and soiled linen bags, removed from the room to the receptacles outside of the room and completed hand hygiene. 2. Resident #36's Significant Change MDS dated [DATE] revealed the resident was unable to complete the BIMS but staff interview provided the resident was able to recall the current season, location of her room, staff names/faces and that she was a nursing facility. The document coded the resident required dependent assistance for dressing, toilet hygiene, and substantial/maximal assistance for transfers. The document disclosed the resident was always incontinent of bladder and always continent of bowel. The Care Plan revised 6/1/26 identified a focus area for self care performance deficit revised on 5/19/26 with staff interventions of pairs for toileting revised 8/11/25 and pairs for transfers (revised 8/27/25).Observed on 7/8/26 at 11:30 AM Staff C, Certified Nursing Assistant (CNA), and Staff E, CNA, provide transfers and toileting care for Resident #36 with the following noted: Staff C and Staff E entered the resident's room, completed hand hygiene, and donned gloves.Staff C donned a gait belt to Resident #36, and both staff assisted the resident with a transfer from floor to wheelchair (w/c). Staff E assisted the resident to the bathroom in the w/c. Staff C changed gloves without hand hygiene. Staff C and E assisted the resident into a standing position at the grab bar. Staff E assisted the resident with maintaining a standing position while Staff C lowered the resident's garments. Both staff assisted the resident to move to a seated position on the toilet.Staff E removed the resident's pants and wet brief, and initiated the clean brief and replaced the resident's pants.Both staff assisted the resident into a standing position at the grab bar. Staff C completed peri care while Staff E assisted the resident maintain a standing position. Upon completion of peri care Staff C pulled up the resident's brief and pants.Both staff assisted the resident from a standing position to the w/c. Both staff removed their gloves and completed hand hygiene.On 7/8/26 at 3:45 PM the Director of Nursing (DON) expected gloves to be changed between dirty and clean tasks. The DON stated hand hygiene should be completed with each glove change. The Interim Administrator and Regional Clinical Nurse, who were present, concurred with the DON's statements. The facility's Competency for Dressing Change (Non-Sterile), updated 5/11/21, revealed opportunities for hand hygiene with each glove change and glove changes to occur following removal and discarding of soiled dressing and performing of treatment. The facility's Hand Washing Policy and Procedure revealed hand washing was the single most important component for preventing the spread of infection. The facility's Using Gloves Policy, updated 11/13/24, revealed hand hygiene must be performed after removing gloves and did not replace hand hygiene. The document included gloves must be replaced as soon as practical when contaminated.

Based on schedule review, staff interviews and document review the facility failed to ensure that a Registered Nurse (RN) was at the facility for 8 consecutive hours every day. In a review of the 30-day nursing schedule, on 2 days the facility failed to have RN coverage. The facility reported a census of 32 residents. Findings include: In a review of the April, 2025 Nursing Schedule it was discovered that on the 13th and the 17th, the schedule lacked a Registered Nurse. On 5/07/25 at 10:04 AM, the Director of Nursing (DON) acknowledged that on the 13th (a Sunday) and the 17th (a Thursday) of April there was no RN coverage. On 5/07/25 at 3:29 PM, Staff D, Nurse Consultant said that she wasn't sure if they had a policy on RN coverage but they follow the standard of care to have 8 consecutive hours of RN coverage per day. The Facility Assessment updated on 8/8/24, showed that the general approach to staffing would ensure that the facility had sufficient staff to meet the needs of the residents at any time given. The staffing plan depended on census, acuity and availability to hire.

Based on observation, staff interview, resident interviews and record view the facility failed to post the correct lunch menu and failed to ensure residents were offered meal options. The facility reported a census of 32 residents. Findings include: On 5/6/25 at 11:00 AM, the bulletin board outside of the kitchen door contained a copy of the meal schedule for the month of May. For Week 1, Tuesday 5/6, the lunch meal for the day was listed as; spaghetti with meat sauce, seasonal vegetable, garlic toast and pumpkin dessert. On 5/6/25 at 11:10 AM Staff C prepared the lunch meal of goulash, garlic toast, mixed vegetables and poppy seed cake. When asked about the menu changes, she said that they were transitioning to the new company that would be managing the facility, and they were trying to use up the food they had on hand. When asked if the residents had a menu that they would fill out daily, Staff C said they had a checklist with the resident's names. When the staff had time, the dietary aides would go around to the residents in the morning and ask them if they would like an alternate. She said that the task did not get completed that morning and the residents were not aware of the changes. According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) On 5/07/25 at 12:44 PM, Resident #3 was in her room eating the lunch meal and an aide was with her for supervision. The resident had some coughing as she fed herself. Resident #3 said that the kitchen staff would post the menus for the month, and she would look at it occasionally but the staff didn't always come around and ask her before the meal. The MDS dated [DATE], showed that Resident #24 had a BIMS score of 12 (moderate cognitive deficit) On 5/7/25 at 12:48 PM, Resident #24 was pushing herself in her wheel chair back to her room. She pointed to the documents taped on her door that had the menu and alternatives for those days. She said they have some different choices, but on one day, the only other choice was a hot dog and she could not eat hot dogs. On 5/7 the mixed vegetables included peas and she could not tolerate peas. She said that she did not have anyone come and ask her that morning if she wanted any substitutes for the lunch meal. The MDS dated [DATE], showed that Resident #15 had a BIMS score of 15 (intact cognitive ability.) She had a low salt, diabetic diet. On 5/7/25 at 12:52 PM, Resident #15 was in her room eating lunch. She said that she would look at the monthly menu that was hanging on her door for what was being served that day and if they would like alternatives. She said it would be nice if someone were to come around and ask if they would like an alternative. That morning, she had a waffle and it was a lot to eat so she wasn't very hungry for lunch. She would have taken the option of a half a sandwich if staff had come around and asked. The Meal Alternatives document hanging on the door of resident's rooms stated that dietary staff must be informed of alternatives by 9:30 am for lunch or 1:30 PM for dinner. On 5/07/25 at 6:52 AM, the Dietary Manager said the dietary aides would go around to the residents and ask if they wanted the alternative, but she generally knew their preferences. She was not aware of any facility policy on food choices.

Based on observation, staff interview and policy review the facility failed to ensure that outdated foods had been discarded in a timely manner. The facility reported a census of 32 residents. Findings include. In an observation of the kitchen and coolers, on 5/05/25 at 9:40 AM, it was discovered that the walk-in refrigerator contained a bag of shredded carrots on the lower shelf. The bag was taped shut and the tape was dated 4/11/25. Staff C, [NAME] looked at that package and found that the expiration date was 4/18/25. Staff C then threw the carrots in the trash. The dry storage area contained 2 bags of gram cracker crumbs. The package was marked with an open date of 2/26/25. The Dietary Manager (DM) was not sure about an expiration date but agreed that the crumbs should be discarded. On 5/07/25 at 6:52 AM, the DM said that she would go through the coolers and dry storage looking for outdates on the day of deliveries. Other times, the staff may catch the outdates. She was not aware of a policy on checking for outdated food. According to policy titled: Food Brought in by Family/Visitors, dated January of 2023, food and beverage in their original container that were past the manufacturers expiration date would be discarded.

Based on resident interview, staff interview, and policy review the facility failed to ensure 1 of 1 resident's (Resident #24) personal property was protected from loss or theft. The facility reported a census of 32 residents. Findings include: Review of Resident #24's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Interview 5/05/25 at 12:18 PM Resident #24 revealed she was missing a blouse with hearts, and two pairs of jeans. Resident #24 revealed that she had told staff and that the items were never replaced. Interview 5/06/25 at 8:00 AM with Staff A revealed laundry will complete inventory sheets for residents. Staff A further revealed that she was unaware she was supposed to complete inventory sheets. Staff A further revealed once the facility was switched to another company inventory sheets started to be completed, and she realized she was to be doing the inventory sheets. Staff A then revealed she was unable to locate Resident #24's inventory sheet. Interview 5/06/25 at 8:21 AM with the Administrator revealed that her expectation would be for inventory sheets to be filled out correctly and followed up on to update. The Administrator further revealed her expectation would be for inventory lists to be updated and items to be replaced if lost or stolen. Review of a facility provided policy titled, Grievance Policy with a revision date of January 2023 documented: a. The facility will take appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction confirms a violation of any of these residents' rights within its area of responsibility.

Based on clinical record review, resident interview, staff interviews and policy review the facility failed to accurately document and monitor the use of controlled substances for1 of 1 residenst reviewed. Resident #84 had prescriptions for oxycodone pain medication, scheduled three times a day and as needed (PRN.) The documentation of number of tablets administered on the Controlled Drug Count Record, was not in accordance with the Medication Administration Record (MAR.) The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #84 was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) The resident was dependent on staff for toileting, and transfers, and had a scheduled and as needed (PRN) pain medication. The residents' diagnoses included; anemia, renal insufficiency, pneumonia, cellulitis and pressure ulcers. The Care Plan for Resident #84, dated 4/10/25, showed that he had pain related to cellulitis of the perineum, wounds to bilateral buttock and the penis. Staff were to monitor for efficacy of pain medication and notify physician of adjustments needed. On 5/5/25 at 10:55 AM, Resident #84 was lying in bed on his back. He said he had some large wounds on his bottom that were causing him some pain. The resident said that sometimes, it took staff a long time to answer the call light and he had to wait for his medications. A review of the Orders tab in the electronic chart revealed the following: a. An order dated 4/22/25 at 2:50 PM for oxycodone 5milligrams (mg) give 1 tablet three times a day. b. An order dated 4/10/25 at 12:49 PM for oxycodone 5mg one tab every 4 hours as needed for acute pain for 14 days. c. An order 4/25/25 at 10:54 AM, oxycodone 5mg one tab every 4 hours as needed for pain. The Controlled Drug Administration Record (CDAR) for Resident #84, showed the pharmacy delivered 18 tablets (tabs) on 4/10/25, 28 tabs on 4/12/25, and 60 tabs on 4/22/25. A total of 106 tabs delivered. On 5/7/25 at 2:20 PM, a Pharmacy Representative verified the number delivered. On 5/7/25 at 3:20 PM, Staff E, Registered Nurse (RN) said Resident #84 had just one bubble package of oxycodone in the locked drawer and it had 11 tabs remaining. A review of the Medication Administration Record (MAR) for April and May showed that oxycodone had been administered 85 times to Resident #84. According to the CDAR documents from 4/10/25-5/7/25, 105 tabs had been administered since admission on 4/10/25. On 5/06/25 at 6:12 AM, Staff F, RN, said that the nurses would count together at every shift change and then initial the Controlled Drug Count Record (CDCR) sheet, kept at the front of the binder on the medication cart. The CDCR for May, 2025 stated: signing below acknowledges that you have counted the controlled drugs on hand and have found that the quantity of each medication counted is in agreement with the quantity stated on individual narcotic form. The documentation was missing one signature on each of the following dates: 5/3, 5/4 and 5/5. On 5/07/25 at 3:26 PM, Staff D, Nurse Consultant, said that the leadership would be looking at the controlled substances forms and doing education with the staff. She said that going forward, she would like to see them use a separate sheet for each order, rather than use the same one for PRN and scheduled doses. She agreed that it was confusing and more challenging to manage when several orders were on one sheet. A facility policy titled: Controlled Substances dated 4/25/24, showed that no more than one prescription for a controlled substance would be entered on one individual narcotic sheet.

Based on staff interviews and clinical record review the facility failed to follow medication orders for 1 of 3 residents. Resident #1 had a medication order for treatment of low blood pressure (BP) and staff were directed to hold the medication when the systolic BP (top number) was higher than 130. In the month of June, staff administered the medication many times outside of the parameters. The facility reported a census of 35 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficits). The resident was totally dependent on staff for transfers and dressing and required hemodialysis services. Her diagnosis included anemia, hypertension, gastroesophageal reflux disease (GERD), end stage renal disease (ESRD) and diabetes mellitus. The Care Plan for Resident #1, dated 7/26/24, showed that the resident received hemodialysis related to ESRD. Staff were directed to communicate with the dialysis unit and to monitor for signs and symptoms of renal insufficiency such as change in heart and lung sounds, obtain vital signs and weight per protocol and report significant change in pulse, respirations and blood pressure immediately. Resident #1 was at risk for alteration in nutritional status related to diabetes with potential for abnormal blood sugar. Staff were to obtain blood sugar per physician order and monitor for hyperglycemia and hypoglycemia. The Clinical Physician's Order revealed an order dated 2/28/24 at 2:34 PM, for Midodrine 10 milligrams (mg) one tab three times a day. Hold if systolic BP was greater than 130. The Medication Administration Record for June 2024 showed that the medication was given on the following date and blood pressures: a. June 1; 135/95 b. June 2; 148/75 c. June 3; 138/74 and 132/70 d. June 16; 135/74 and 140/68 e. June 18; 141/68 f. June 20; 144/65 g. June 24; 134/70 h. June 25; 138/64 On 7/27/24 at 2:45 PM, the Director of Nursing (DON) said they did not have a policy on following physician orders. Nurse Consultant said we follow the orders. On 7/27/24 at 4:00 PM, the DON said that she needed to do some education with the staff that documented that they gave the medication when the blood pressures had been outside the recommended parameters.

Based on staff interviews, clinical record review and hospital record review, the facility failed to provide complete and timely assessments and interventions for 1 of 3 residents reviewed. Resident #1 was readmitted to the facility after a long hospitalization . Staff failed to document current vital signs and failed to obtain a blood glucose level upon admission. The facility reported a census of 35 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficits). The resident was totally dependent on staff for transfers and dressing and required hemodialysis services. Her diagnosis included anemia, hypertension, gastroesophageal reflux disease (GERD), end stage renal disease (ESRD) and diabetes mellitus. The Care Plan for Resident #1, dated 7/26/24, showed that the resident received hemodialysis related to ESRD. Staff were directed to communicate with the dialysis unit and to monitor for signs and symptoms of renal insufficiency such as change in heart and lung sounds, obtain vital signs and weight per protocol and report significant change in pulse, respirations and blood pressure immediately. Resident #1 was at risk for alteration in nutritional status related to diabetes with potential for abnormal blood sugar. Staff were to obtain blood sugar per physician order and monitor for hyperglycemia and hypoglycemia. The Medication Administration Record (MAR) for the month of July 2024 showed an order dated 2/28/24 at 2:29 PM for Insulin Lispro Solution 100 units per milliliters to be injected as per sliding scale (units determined per glucose level). According to a Nursing Data Collection document for reentry, dated 7/16/24 at 2:59 PM Resident #1 was readmitted to the facility after a hospitalization . The vital signs entered upon admission were from 6/26/24 at 7:39 PM and the chart lacked a blood glucose check. On 7/27/24 at 12:34 PM, the Director of Nursing (DON) said that the admitting nurse had documented the vital signs (VS) on paper but failed to enter them into the electronic chart but the VS were stable. She did not find documentation of a blood glucose level upon admission. The DON said that the insulin had not been delivered from the pharmacy on 7/16, the resident was not having symptoms of hypo or hyperglycemia, and the nurse did not have an order for blood glucose checks, so not having checked the blood glucose upon admission was not a failure. On Page 15 from the Hospital Discharge Instructions dated 7/16/24 at 12:14 PM, showed that staff were to check blood glucose before meals and at bedtime unless otherwise directed by the physician. Staff were to notify the physician if the blood glucose was above 240 milligrams per deciliter (mg/dl) for 48 hours if it was above 400 mg/dl, and did not respond to attempts to correct it. If the blood glucose was less than 70 was symptomatic and did not respond to attempts to correct it. On 7/27/24 at 1:45 PM the DON said that they do not have a policy on admission assessments.

Based on staff interviews, clinical record review and policy review the facility failed to conduct pre-dialysis assessments for 2 of 2 residents (Resident #1, and #3) reviewed. The facility reported a census of 35 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive deficits). The resident was totally dependent on staff for transfers and dressing and required hemodialysis services. Her diagnosis included anemia, hypertension, gastroesophageal reflux disease (GERD), end stage renal disease (ESRD) and diabetes mellitus. The Care Plan for Resident #1, dated 7/26/24, showed that the resident received hemodialysis related to ESRD. Staff were directed to communicate with the dialysis unit and to monitor for signs and symptoms of renal insufficiency such as change in heart and lung sounds, obtain vital signs and weight per protocol and report significant change in pulse, respirations and blood pressure immediately. Resident #1 was at risk for alteration in nutritional status related to diabetes with potential for abnormal blood sugar. Staff were to obtain blood sugar per physician order and monitor for hyperglycemia and hypoglycemia. A review of the Dialysis Communication documents for the month of June revealed that on 6/10, 6/12, 6/14 and 6/21/24 staff failed to include pre-dialysis assessments to include vital signs or weights. A Nursing Note dated 6/28/24 at 11:00 AM documented the dialysis unit called the nursing home that morning to inform them the resident was sent to the Emergency Department (ED) with a high pulse and low blood pressure. The chart lacked documentation of vital signs on 6/28/24 before the resident was sent to dialysis. 2. According to the MDS assessment dated [DATE] Resident #3 had a BIMS score of 0 (severe cognitive deficits). The resident was totally dependent on staff for eating, dressing, showering and transfers. Diagnosis included dependence on renal dialysis, Parkinsons, seizure disorder and obstructive uropathy. The Care Plan for Resident #3, updated on 5/21/24 showed that the resident required hemodialysis related to renal failure. Staff were to obtain vital signs and weight per protocol and report significant changes in pulse, respirations and blood pressure immediately. A review of the Dialysis Communication documents for the month of July revealed that on 7/10, 7/15 7/17, 7/19 and 7/24/24, staff failed to include pre-dialysis assessments to include vital signs or weights for Resident #3. On 7/27/24 at 10:11 AM, the Director of Nursing (DON) said that the nursing staff at the facility did not do pre-dialysis assessments because the dialysis department completed those. The nursing home staff had been instructed to keep that part of the form blank for the dialysis nurses to fill out. When asked how the staff would know if the resident was well enough to tolerate going to dialysis before sending her, the DON again responded dialysis does their own assessment. According to the facility policy titled: Dialysis Communication dated 8/2015, the purpose of the policy was to communicate resident information between the nursing facility and dialysis center. Prior to the resident departure to the dialysis center, and upon return to the nursing facility, the nurse would record vital signs, blood sugar and any changes since the last dialysis appointment.

Based on observations, staff interviews, and facility policy review the facility failed to ensure sanitary conditions where staff prepared and stored food. The facility identified a census of 34 residents. Findings included: The initial kitchen walkthrough on 06/10/24 at 11:34 AM revealed the following: a. The stove top showed a thick layer of grease with food splatter and a variety of food debris. b. Open shelving contained food debris and dried liquid. c. Two carts contained a variety of scattered food debris. d. The floor contained an accumulation of food debris and a variety of dried liquid. During the kitchen walkthrough the Dietary Manager (DM) reported that she expected the stove, shelfs, carts and floor to be clean and free of food, dried liquid, and debris. When reviewing the cleaning logs, the DM stated, We complete the routine cleaning and sign our logs. There is a problem with someone that worked this past weekend. I'll follow up. The Cleaning and Sanitizing policy last revised June 2015 identified the facility promotes a clean and sanitary environment for its employees, resident/patients, and visitors. The entire Nutrition Services team maintains clean and sanitary kitchen facilities and equipment. Walls, floors, ceiling, equipment, and utensils are clean, sanitized, and in good working order. All local, State, and Federal regulations are followed in order to assure a safe and sanitary Nutrition Services Department. In an interview on 06/12/24 at 1:32 PM, the Administrator relayed that the DM talked with her about the findings in the kitchen. When asked if she expected the DM to keep the stove, open shelving, carts and floor clean and sanitary, the Administrator replied, yes.

Based on clinical record review, staff interview, and facility policy, the facility failed to ensure bed hold notice was sent to the resident and or the resident's responsible person after giving a verbal consent when residents transferred out of the facility for 1 of 3 residents reviewed (Residents #19). The facility reported a census of 34 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #19 documented diagnosis of heart failure, hyperlipidemia and asthma. The MDS showed the Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of Resident #19's progress notes revealed the following information: a. on 8/26/23 at 9:27 p.m.,the ambulance was at the facility to take Resident #19 to the emergency room . b. On 8/29/23 at 11:39 a.m., the resident returned to the facility. Review of Resident #19's census tab revealed the following information: a. 8/26/23 hospital unpaid leave b. 8/29/23 active Review of the clinical record revealed a bed hold dated 8/26/23 lacked information regarding bed hold notice that was sent to resident and or the resident's responsible person after giving a verbal consent. Review of an undated facility provided policy titled, Bed Hold Requirement and Notification revealed: a. Complete the Bed Hold Form prior to transferring the resident/patient to the hospital. In cases of an emergency transfer, written notification must be provided within twenty- four hours of transfer.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to assess skin conditions after discovery to prevent a decline in the pressure wound for 1 of 3 residents reviewed (Resident #3). Resident #3 admitted to the facility with skin conditions of surgical incisions, some skin tears, and bruising on 11/29/23. During his time at the facility, he developed additional skin conditions that lead to a hospitalization due to an infection in his wounds. The hospital records revealed that Resident #3 had a pressure ulcer to his back, coccyx, and left heel. The record included those in addition to his fractures that happened prior to his admission to the nursing home of his left hip and shoulder. Resident #3's clinical record at the nursing home lacked documentation related to the pressure ulcers. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only, it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, with no tendon or muscle exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue) may be present on some parts of the wound bed, often including undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Other staging considerations include: Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. Tissue in this area may have started as painful, firm, mushy, boggy, warmer or cooler tissue than adjacent areas. These changes often precede skin color changes and discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS indicated he had an impairment to one side of his upper and lower extremities. The MDS included diagnoses of pathological hip fracture, atrial fibrillation, anxiety, depression, and left shoulder fracture. Resident #3 had a risk for developing pressure ulcers, had no unhealed pressure ulcers/injuries, but did have surgical wounds. Resident #3 had a pressure reducing device for his chair and bed. The Baseline Care Plan dated 11/29/23 indicated Resident #3 had wounds other than pressure injury identified and the wound would heal without signs/symptoms of infection. The Interventions included: assess, document, and notify the physician of wound healing progress, administer medications, and supplements per physician's orders. The section labeled describe additional skin interventions, remained blank. The Baseline Care Plan reflected that he required assistance from one staff for bed mobility, transfers, walking, toileting and used a walker for locomotion. The Care Plan Focus dated 12/12/23 documented Resident #3 had the potential for the development of pressure ulcers related to immobility. The Interventions directed to follow facility policies/protocols for the prevention of skin breakdown, inform the resident and family of any new area of skin breakdown, and to treat pain as ordered prior to turning to ensure the resident is comfortable. Braden Scale Review Scores a. 11/29/23 - 18, indicating a low risk for the development of pressure ulcers. b. 12/4/23 - 10, indicating a high risk for the development of pressure ulcers. c. 12/11/23 - 15, indicating a low risk for the development of pressure ulcers. The Medication Review Report signed by the physician on 12/1/23 included the following orders: - 11/28/23: Complete Braden assessment every week on Mondays for 4 weeks upon admission, for skin integrity. - 11/29/23: Monitor left hip incision and keep clean, dry, and intact, every shift for health maintenance. Notify the physician of any signs/symptoms of infection. The Medication Review Report signed by the physician on 12/13/23 included the following orders: - 11/29/23: Monitor left hip incision and keep clean, dry and intact, notify physician of any signs and symptoms of infection, every shift for health maintenance. - 12/5/23: Mighty shake one time a day for wound healing. - 12/6/23: Cover all skin tear areas (left front shin, left lateral knee, right upper arm) with Mepilex every day until healed and then discontinue. - 12/7/23: Dressing (4x4 gauze and paper tape) to left hip every 1 hour as needed (PRN) for surgical incision healing. - 12/12/23: Left lower extremity wound: cleanse with wound cleanser, cover with calcium alginate with silver, then cover with super absorbent dressing every day shift for wound treatment. The Nursing Data Collection assessment dated [DATE] at 11:04 AM listed Resident #3 had skin integrity issues to his left hip of a surgical incision and to the left shoulder of bruising. The Health Status Note dated 11/29/23 at 12:23 PM indicated Resident #3 admitted to the facility following surgical repairs of a left hip and left shoulder fracture. He had sutures to his left thigh, with an abrasion. The wound wept through the dressing and required daily changes. The Fax dated 12/4/23 from the facility to the physician Resident #3 continued to want to stay in bed and sleep. He continued to get weak, with a poor appetite, an intake of approximately 25%, and a fair fluid intake. The note reflected the facility had concerns with Resident #3 may have depression. They planned to continue to encourage Resident #3 to get up to eat. The physician responded on 12/4/23 with an order for mirtazapine (antidepressant, appetite suppressant) 75 milligrams (mg). The Health Status Note dated 12/4/23 at 10:28 AM recorded the nurse faxed the doctor about Resident #3 staying in bed all the time, having a poor appetite, and acting depressed. The Health Status Note dated 12/4/23 at 5:22 PM reflected the completed skin check revealed areas present upon admission. The Fax dated 12/4/23 from the facility to the physician included a copy of Resident #3's skin sheet. The communication inquired for an order to cover skin tear areas with Mepilex every day until healed then discontinue. On 12/5/23, the provider responded, yes. The Health Status Note dated 12/5/23 at 2:39 PM listed the Dietitian faxed the provider recommendations to start Resident #3 with a mighty shake (nutritional supplement) every day for wound healing. Review of the hot charting binder revealed on 12/1/23-12/5/23 Resident #3 remained on skilled therapy status post (after) a left hip and shoulder fracture due to a fall. The Health Status Note dated 12/7/23 at 12:07 PM reflected Resident #3 returned from his physician appointment with his staples removed from his left hip with a dressing in place with instructions to change PRN. The Fax dated 12/11/23 from the facility to the physician indicated Resident #3's open areas on his left lower extremities didn't show improvement. The facility requested orders for: 1. Cleanse area with house wound cleanser. 2. Cover with Calcium Alginate with Silver; 3. Cover with super absorbent dressing; 4. Change every day until healed. On 12/12/23 - The provider responded yes. The Binder review for the dates on 12/5/23-12/11/23 resident remained on skilled therapy status post left hip and shoulder fracture due to a fall. New order for mirtazapine at bedtime for depression, multiple skin issues. The Order Note dated 12/12/23 at 12:48 AM indicated the facility received a fax with a new order to cleanse Resident #3's left lower extremity wound with wound cleanse, cover with calcium alginate with silver (dressing), cover with a super absorbent dressing, and change daily until healed. The Nursing Daily Skilled Assessment v.8 - v 4s from 11/29/23 until 12/13/23 lacked information related to Resident #3's skin condition, appearance, measurements, or an assessment. The Health Status Note dated 12/14/23 at 11:20 AM reflected Resident #3 continued to have a poor appetite, with a decrease in his fluid intake, increased lethargy, and didn't want to do anything. Resident #3 continued to have edema to his bilateral lower extremities, but denied pain. The nurse sent a fax to the clinic. The Health Status Note dated 12/14/23 at 2:30 PM described Resident #3 as shaky, similar to shivering and hard to arouse from sleep. The staff reported a decrease in urine output and called the clinic. The Health Status Note dated 12/14/23 at 3:00 PM reflected Resident #3's physician gave orders to send him to the emergency room . The Health Status Note dated 12/14/23 at 6:45 PM indicated the hospital reported they admitted Resident #3 for dehydration and right leg cellulitis (skin infection). The Hospital Physical assessment dated [DATE] at 9:32 PM listed Resident #3 reported his pain as a 5 (moderate pain) out of 10 (severe pain) due to his left hip fracture, left shoulder fracture, pressure sores to his coccyx, spine, and left heel. The section labeled Nursing Notes: listed the staff floated his heels, as he had a stage 3/unstageable pressure sore on his left heel. The staff used pillows to position Resident #3 with the plan to turn him every 2 hours to prevent further sores. The note amended on 12/14/23 at 11:32 PM indicated Resident #3 had the following wounds: a. Wound 1 location/type: decubitus ulcer, stage 3 and unstageable-eschar left heel. - Assessment/Interventions: surrounding tissue: red left open to air, heels floated. b. Wound 2 location/type: decubitus ulcer, stage 3 to his coccyx. - Assessment/Interventions: sacral mepilex dressing clean, dry and intact. c. Wound 3 location/type: decubitus ulcer, stage 3 to his spine, mepilex applied. Staff to turn Resident #3 sided to side every 2 hours. - Assessment/Intervention: mepilex dressing clean, dry and intact. The eInteract Transfer V3 form dated 12/14/23 at 3:00 PM listed Resident #3's admitted as 11/29/23 at 8:48 AM. The facility transferred him to a local hospital for increased lethargy (tiredness) and shakiness. The transfer form lacked information related to Resident #3's skin conditions. The Binder Review revealed on 12/11/23-12/15/23 Resident #1 remained on skilled therapy status post left hip and shoulder fracture due to a fall. He received a new order for mirtazapine at bedtime for depression, multiple skin issues. Decreased Lexapro (anti-depressant) due to interactions. The Hospital Physical Therapy note dated 12/16/23 at 1:20 PM described Resident #3's pressure ulcer on his spine as healing with improved epithelialization with bridge (strands or patches of tissue which form 'bridges' across the wound bed secondary to infection) through the inferior (lower part of wound) part of the wound. The staff redressed the pressure ulcer on thoracic spine (mid back) with Mepilex. The sacral wound looked improved, they redressed the wound with Mepilex and paper tape on the most inferior aspect to reduce chance of fecal (bowel) contamination. A new mepilex pad placed on his left heel as the wound still had black eschar (dead tissue). The Hospital Physical Therapy note dated 12/18/23 at 10:13 AM indicated the staff recommended a surgical consult to possibly perform surgical debridement (remove dead tissue to increase healing) of left heel ulcer. Two pillows placed under the resident to help prevent pressure sores while seated in the recliner. The Hospital Physical Therapy note dated 12/27/23 at 9:53 AM the dressing change to Resident #3's thoracic spine wound revealed a lot of good red granulation tissue (new tissue) with minimal white (possible sign of healing) showing. On 12/27/23 at 10:34 AM the Hospital Nurse that admitted Resident #3 stated she didn't see anything about pressure ulcers on his transfer form, and the nursing home staff didn't report any to her. She explained he had pressure sores on his spine and coccyx (tailbone). She reported he had a wound to his left heel. The wound appeared half open, while the other half looked necrotic. The wound looked black, but not leathery. Resident #3 had multiple skin tears on his arms and legs. His legs appeared banged up too. On 12/27/23 at 11:05 AM Staff F, Licensed Practical Nurse (LPN), explained Resident #3 admitted towards the end of her shift. She remembered during the nursing report he had skin issues to his left arm, on his foot, but couldn't remember if it was at the top of his foot and a scratch on one of his legs. She looked up his admission skin assessment and read it. The skin assessment indicated he had bruises on right back leg, left abdominal side and back of left leg. He had skin tears on his left front shin, left outside knee, right upper arm, another on his left outside knee, and left upper arm. He also had surgical sites to the outside of his left knee and 3 different ones on his left hip. On 12/27/23 at 11:13 AM Staff L, Certified Medication Aide (CMA), stated Resident #3 transferred with two persons with an EZ-stand (standing mechanical lift) but he didn't like to get up often and he didn't like to eat. He had edema in his legs that wept all the time. Staff L believed he had failed to thrive. When asked if he had any other skin concerns she responded he had a sore on his back from the use of a gait belt or EZ-stand, and they covered his wound due to that reason. Staff L reported she didn't believe he had anything on his bottom or heel and that she didn't know anything else. On 12/27/23 at 11:20 AM Staff E, Physical Therapist Assistant (PTA), explained Resident #3 didn't transfer well, had cognitive issues, and was hard of hearing. She indicated his lower extremities wept all the time. They tried to pad his spine because it seemed like anytime they tried to use the gait belt it would put pressure on his spine. The nursing staff applied a pad dressing to the area for protection. He was compliant with therapy and would always try but it was hard for him. On 12/27/23 at 1:45 PM Staff G, LPN, reported Resident #3 needed assistance from two persons and/or EZ-stand but he didn't want to do a lot. He had a poor appetite and wanted to stay in bed. Resident #3 allowed staff to help reposition him but they had to be careful because of his hip fracture repair. When asked if he had any skin issues or wounds, he replied he had a lot of bruising before his admission, with skin tears, and surgical wounds on his left leg. When asked if Resident #3 had wounds on his bottom or heels, Staff G denied wounds. He added he had edema to both lower extremities, with weeping on his right lower leg. On 12/28/23 at 9:04 AM Staff K, Certified Nursing Assistant (CNA), stated Resident #3 always wanted to be in bed but when he got up they transferred him by stand-pivot, then he changed to assistance of two persons with the EZ-stand. She stated his legs leaked and she thought he had cellulitis, but the nurses knew that. The nurse told them to lay him down but that didn't solve his issue. When asked if he had other skin concerns, she responded Resident #3 had 2-3 discolored but couldn't remember if open spots on his buttocks with a surgical site to his hip. Staff K knew he got those from his fall before his admission to the facility. She denied any skin concerns to his back or heels other than bruises. They started to use the EZ-stand because the gait belt hurt his back. She added he repositioned well from side to side. She reported the discoloration on his buttocks to Staff H, LPN. On 12/28/23 at 12:00 PM Staff A, CMA, reported Resident #3 wanted to lay in bed all the time. He had cellulitis on his legs and didn't know if he had it on both legs or not. She informed Staff H that the wound wept and it needed to be wrapped. When asked if he had a sore on his bottom, she replied she didn't see it due to a Band-Aid on it. He had a big bruise on his back, which prevented them from using a gait belt with him, so they started to use an EZ-stand to transfer him. Staff H told her the nurses knew about that, but she couldn't recall anything on his heels. He was compliant with repositioning. On 12/28/23 at 1:00 PM Staff H reported she vaguely remembered Resident #3 and couldn't remember if he had skin issues. When asked what she would do if a resident had a new skin issue, she responded she typically did a skin assessment, notify the family, and the physician. On 12/28/23 at 1:33 PM Staff J, CNA, reported Resident #3 liked to stay in bed, and didn't have a repositioning program but he would allow them to reposition him. He had a broken hip so he had pain but repositioned. When asked if he had any skin issues she stated the last few days before going to the hospital his legs wept, but she didn't notice any open areas. She couldn't remember if he had bruising or redness to his bottom or heels. She added he wouldn't eat a lot. When asked what she would do if she noticed new skin issues on a resident, she explained she would tell the nurse, and if they didn't do anything, she would tell the next nurse. On 12/28/23 at 2:37 PM Staff I, Registered Nurse (RN), described herself as usually being the charge nurse on duty and didn't work Resident #3's hall. If the other staff had concerns they came to her about them. She remembered Resident #3 had incision sites to his hip and arm from his surgery prior to coming to the facility. She believed he had issues with his legs and maybe bottom but could not recall the specifics. On 1/2/24 at 12:49 PM during an attempted call to Resident #3's physician, the nurse reported he would be out of the office for the week. On 1/10/24 at 11:21 AM attempted another call to Resident #3's physician. The Hospital Director reported the doctor was out of the office and added he would message him to tell him to return the surveyor's call. At the end of the survey the physician didn't return the call. On 1/10/24 at 1:01 PM the Assistant Director of Nursing (ADON)/MDS Coordinator stated the previous Director of Nursing (DON) did Resident #3's Baseline Care Plan. When she completed his MDS it guided her to update his Care Plan to reflect his risk for pressure ulcers. Resident #3 admitted to the facility for Physical and Occupational Therapy due to a broken hip and shoulder. The ADON/MDS Coordinator described him as a tiny, small man that didn't have a lot of meat on his bones. When asked if he had any skin issues, she indicated she only remembered a spot on his back because he had no meat on his bones. When PT used a gait belt it rubbed on his back. In addition, he had a surgical wound but didn't remember having any pressure ulcers or anything of that nature. The ADON/MDS Coordinator reviewed the skin assessments and when asked why no one completed a skin assessment for the area on Resident #3's back, she replied PT would have reported that to the nurse. When asked about the band aid and discoloration to his bottom, she responded she needed to look through the progress notes but if he had issues, the weekly skin assessment would include them. When notified the hospital found stage III pressure ulcers to his spine, coccyx, and heel she exclaimed oh someone should have documented about that, but she would need to review his chart. After informing her, his clinical record lacked documentation in his progress notes, weekly skin assessments, skilled assessments, and documents tab she replied that is where she would look, too. She indicated she would look to see what she could find. On 1/10/24 at 1:15 PM the ADON/MDS Coordinator returned with a fax to the doctor about Resident #3's open areas to his lower extremities not improving. She reported that it was all she could find at that time. On 1/10/24 at 1:50 PM Staff M, previous DON, reported Resident #3 came to the facility on skilled therapy due to a hip fracture and dislocated shoulder. At his admission, he looked extremely bruised on his left side to his face and shoulder, however, his hip incision looked good. They completed a head-to-toe assessment and remembered documenting a stage 1 or redness on his buttocks. At that time, they applied a barrier cream. He could reposition himself independently with an assist bar while in bed. She believed he moved side-to-side by himself. After informing Staff M about the skin issues the hospital documented on his coccyx, spine, and heel, she responded she didn't remember the issue with his spine. He was in therapy early in his stay when therapy staff showed her his spine. He was malnourished so they put sheepskin on the back of his wheelchair for protection. He had no open areas at that time and they only did it as a preventative measure. He had a bony back that made it easy to see his spine but the skin didn't have breaks. She added the area didn't happen overnight. She could not recall any concerns with his heels, but Resident #3 had redness on his coccyx, and they used a barrier cream. On 1/11/24 at 9:03 AM Staff E provided the Physical Therapy Treatment Encounter note dated 12/13/23. The note indicated following Resident #3's walk, she noticed an area on his thoracic spine with skin tears/shearing from use of the gait belt. The area happened with a barrier between his skin and the belt. Noted redness on right lateral rib area. Nursing notified/addressed/treated. Staff E electronically signed the note on 12/13/23 at 3:52 PM. On 1/11/24 at 9:47 AM the Administrator stated she could only find a fax from 12/4/23 about getting orders to cover Resident #3's skin tears with a Mepilex every day until healed then discontinues. When informed the fax didn't address his spine, coccyx, and heel wounds, she replied that was all she could find for his orders. On 1/12/24 at 12:17 PM the Regional Nurse Consultant reported the abrasion on Resident #3's back happened when they used the gait belt. She indicated she would need to look in his chart to see about the documentation for that abrasion. She explained on 12/11/23 included his last weekly skin assessment and the note lacked documentation of his spine, coccyx, or heel injuries. When informed the hospital documented he had stage III decubitus ulcers to those areas, she responded they reached out to the hospital for his history and physical. When she spoke to the staff no one reported skin concerns. She indicated she spoke with the PTA that worked with him as well. After notifying the Regional Nurse Consultant that Resident #3's clinical record lacked documentation that Staff E found a skin tear/shearing to his thoracic spine, she replied she would need to look at his chart. The facility's Skin Care and Wound Management policy dated June 2015 indicated the facility staff strived to prevent resident skin impairment and to promote the healing of existing wounds. The interdisciplinary team worked with the resident and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. Components of the skin care and wound management program include at least the following: - Weekly monitoring of resident skin status - Daily monitoring of existing wounds - Application of treatment protocols based on clinical best practice standards for promotion of wound healing. - Monitoring for consistent implementation of interventions and effectiveness of interventions. - Review and modification of treatment plans, as applicable. Treatment: - Obtain a physician's order for the identified protocol or treatment order - Document treatment protocols on the TAR - Monitor and document progress towards goals - Communicate changes to the caregiving team, resident/patient and/or family/responsible party. The form defines a pressure ulcer as a localized injury to skin and/or underlying tissue usually over a bony prominence, because of pressure or pressure in combination with shear and/or friction.

Based on observations, interviews and record review the facility failed to monitor and treat pressure wounds to prevent worsening for 2 of 3 residents reviewed (Resident #5 and #6). 1. Resident #5 had sores on her feet, legs, and heels. An observation determined that Resident #5's did not have protective boots on her heels, instead they rested on her bed. Resident #5 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to implement the order for approximately one month. 2. Resident #6 admitted to the facility without skin issues and developed a sore on her bottom. The Care Plan lacked information related to pressure ulcers and/or interventions to prevent them. The facility reported a census of 40 residents. Findings Include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). May be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. Resident #5's Minimum Data Set (MDS) indicated an admitted [DATE] from another nursing home or swing bed. The MDS identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS coded Resident #5 required total dependence of two persons for transfers and toilet use. Resident #5 required extensive assistance from one person for bed mobility. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/18/22 at 7:15 AM observed Resident #5 laying on her back in bed with both of her feet wrapped in Ace bandages. An observation revealed that her recliner had two heel protective boots in it. Witnessed Resident #5's right foot propped up with a pillow under it and the left heel rested on the bed with a pillow next to her foot. Observed the Ace bandage and pillow soiled with what looked to be drainage coming from the heel and side of her left foot. Resident #5 said that she had sores on both feet and on her bottom. Resident #5 did not know for sure how often someone changed her bandages or time of the treatment schedule. Resident #5 added that the staff didn't always put cream on her bottom after brief changes. On 8/22/22 at 8:54 AM there was a blanket brace at the bottom of the resident's bed, the blankets were not on top of the structure. The resident said that the staff had just put that on her bed and didn't tell her why. She was wearing the heel protective boots. As the staff removed the boots to get her dressed, the l left heel was exposed and revealed a large dark pressure. Certified Medication Aide (CMA) Staff D said that the driver from Pace was waiting to take the resident to her appointment in Sioux City that was at 11:00 AM. She said that the resident would probably be out of the facility most of the day. The Care Plan Focus dated 8/3/22 indicated Resident #5 had five pressure ulcers related to immobility, poor nutrition, diabetes, and [CONDITION(S)]. The Care Plan included the following interventions dated 8/3/22 directed the staff to give medications as ordered. a. Assess, record, and monitor wound healing (weekly). Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the medical doctor (MD). b. Monitor, document, and report to MD as needed changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length X width X depth), stage. c. Monitor nutritional status. Serve diet as ordered, monitor and record intake. d. Foot cradle to end of bed. Date initiated: 8/19/22 The Care Plan Focus revised 7/25/22 indicated that Resident #5 had a potential nutritional problem related to obesity, type II diabetes mellitus, stage III chronic kidney disease, congestive heart failure, [CONDITION(S)] of chronic disease, depression, gastrointestinal reflux disease, and [CONDITION(S)]. Resident #5 had increased nutritional needs due to altered skin integrity. The Focus included an intervention initiated on 7/25/22 and revised on 8/22/22 to provide and serve supplements as ordered: Glucerna 240 cubic centimeters (cc) if she ate less than 50 percent (%) of her meal three times a day and liquacel 30 cc every day. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . - The July 2022 Medication Administration Records (MAR) lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] - The August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5's August 2022 Treatment Administration Record (TAR) included an order dated 7/19/22 to apply heel protectors to be worn at all times unless taken off and heels are floated with pillows every shift for skin protection three times a day. The TAR indicated that Resident #5 wore her heel boots every day except 8/21/22, due to a lack of documentation on the evening shift. On 8/23/22, the documentation indicated Resident #5 went to the hospital. The TAR lacked documentation of Resident #5 refusing to wear her heel protectors. The Clinic Progress Notes dated 8/22/22 at 4:42 PM indicated that Resident #5's left foot had gangrene to her toes. The Provider noted that the area continued to decline and referred her back to the Vascular Surgeon for amputation. The lab results identified an increase in Resident #5's potassium levels, her medication got increased and added a supplementation of some [MEDICATION(S)]. The Pressure Injury Weekly Assessment documentation in the electronic record was as follows: a. admitted d 7/19/22 at 9:32 AM identified two skin areas to Resident #5 one a stage II to her left toe and a stage II to her left lower leg. Neither wound had measurements documented. The Diabetic ulcers appear black and at a stage II with no pain, drainage, or odor noted. b. On 7/22/22 at 11:37 AM - (One Skin Sheet) i. Left buttock (Stage II Pressure) measured 2 centimeters (cm) by (x) 2 cm x 0.1 cm. ii. Rear left lower leg (Unstageable Pressure) measured 6 cm x 2 cm x 0 cm iii. Rear left lower leg (Unstageable Pressure) measured 1 cm x 1 cm x 0 cm iv. Rear left lower leg (Unstageable Pressure) measured 1.5 cm x 1 cm x 0 cm - (Second Skin Sheet) v. Left heel (Unstageable pressure) measured 3 cm x 3.5 cm x 0 cm vi. Left toes (Unstageable pressure) measured 1.4 cm x 2 cm x 0 cm vii. Left toes (Unstageable pressure) measured 0.7 cm x 0.5 cm x 0 cm viii. Side of left foot (Unstageable pressure) measured 4.7 cm x 4 cm x 0 1. Wound bed appearance: Eschar (a collection of dry, dead tissue within a wound) 2. Drainage: None 3. Odor: None 4. Surround skin color: dry 5. Surrounding tissue/wound edges: dry 6. Physician notified: 7/21/22 7. Additional comments indicated the last two toes on the left foot appeared completely necrotic (dead tissue) c. On 7/29/22 at 10:58 AM i. Left lower leg rear (Unstageable Pressure) measured 6 cm x 2 cm ii. Left lower leg rear (Unstageable Pressure) measured 1 cm x 1 cm x 0 cm iii. Left lower leg rear (Unstageable Pressure) measured 1.5 cm x 1.0 cm x 0 cm iv. Left buttock (Stage II Pressure) measured 2 cm x 2 cm x 0.1 cm v. Lacked documentation on left heel and inside of her left foot. 1. Wound bed appearance: pink/red 2. Drainage: Small amount of bloody drainage 3. Odor: No 4. Surrounding skin color: intact 5. Surrounding tissue/wound edges: intact 6. Physician Notified: 7/21/22 d. On 8/5/22 at 10:36 AM; Left inside foot 11 cm x 2 cm Unstageable. Left heel 7 cm x 5 cm stage III. Left outside foot 2 cm x 2 cm. Left rear lower leg 4.5 cm x 1.5 cm x 0.4 depth stage III. Right heel 1 cm x 1 cm. On 8/23/22 at 9:24 AM the Nurse Practitioner (NP) reported that she cared for Resident #5 for a while. She explained that she was very familiar of Resident #5's complicated state. The NP said that her previous nursing home did not notify them soon enough about Resident #5's wounds. The NP explained that when the doctor saw Resident #5 on 8/22/22, he became concerned about the big decline in the condition of her wounds. She reported that the doctor suspected Resident #5's feet did not get off-loaded because he saw a new pressure area on her foot about the size of a palm. The NP said that they noticed Resident #5 going downward for a while and would probably need a leg amputation. The History and Physical dated 8/23/22 at 7:54 PM recorded that Resident #5 had a chronic wound to her left and right feet who presented to the emergency department (ED) per request of vascular surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 reported that she had her dressing changed once daily. Resident #5 added that she also had a bedsore. Resident #5 denied foot pain but complained of pain to her lateral leg (side of her leg) in the ED. Due to her worsening leukocytosis (elevated white blood cell count), they had concerns about an infected wound. The ED consulted the doctor who planned a left BKA the next day. Her potassium was elevated 5.5. She is constipated, has not had BM for quite some time, and did receive [MEDICATION(S)] (medication is used to treat a high level of potassium in your blood) the day before. Sodium 130, creatinine 1.48, EGFR 36, blood sugar 219, elevated alkaline phosphatase 2833, Procalcitonin 0.28, hemoglobin 7.3. An x-ray of her left foot showed severe soft tissue swelling, subcutaneous air surrounding the medial aspect of the first digit with associated underlying lytic/erosive changes concerning acute [CONDITION(S)]. Also progressive lytic/sclerotic changes to the midfoot in tars metatarsal articulation, neuropathic joint versus chronic [CONDITION(S)]. In the ED, she did receive intravenous (IV) [MEDICATION(S)] as well as [MEDICATION(S)] (antibiotics). Resident #5's extremity is observed to have one plus (1+) [CONDITION(S)] to her left leg, warm. Significant necrotic (dying tissue) gangrene (a serious condition where a loss of blood supply causes body tissue to die) of her left great toe with surrounding [CONDITION(S)] (redness), swelling, and foul-smelling. Her right foot revealed a small deep wound without signs of infection. A grade two decubitus ulcer to her sacral area. Necrotic gangrene of left foot mainly left great toe and midfoot, concerning for severe soft tissue infection and acute versus chronic [CONDITION(S)] [CONDITION(S)] (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) with leukocytosis, [CONDITION(S)] (elevated heart rate), and underlying [CONDITION(S)] (PVD). The Consultation Report dated 8/24/22 at 6:31 AM indicated that Resident #5's left foot had extensive wet and dry gangrene to the dorsum (upper part) of her left foot and heel with a foul odor present. The Assessment and Plan documented that Resident #5 had a left diabetic foot infection with wet and dry gangrene with a concern for [CONDITION(S)] (an infection in the bone). The ED consulted the Vascular Team for an evaluation of a left below-knee amputation. With no current indication of [CONDITION(S)], the Hospital NP recommended medical optimization prior to surgery with respiratory and cardiac evaluation. The Hospital's NP discussed with Resident #5 about an option for two-stage amputation (with guillotine amputation and delayed primary closure) versus one stage amputation. The Hospital NP recommended medical optimization prior to surgery with plans to proceed with left below the knee amputation (BKA) in one to two days. Resident #5 verbalized understanding and would like to proceed with the left BKA The Health Status Note dated 8/24/22 at 11:47 PM indicated that the facility received a fax from the NP regarding Resident #5's blood pressure while at the clinic due to an elevated white blood cell count, and a low hemoglobin due to gangrene of her left toes with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Resident #6's MDS assessment dated [DATE] indicated that she admitted to the facility on [DATE]. The MDS identified a BIMS score of 15, indicating intact cognition. The MDS recorded Resident #6 had frequent incontinence of bowel and utilized an intermittent catheter due to a [CONDITION(S)]. Resident #6 required extensive assistance with bed mobility, transfers, and toilet use. Resident #6's Care Plan initiated on 12/29/21 lacked a Focus area related to pressure sore risk or interventions to prevent the development of pressure injuries. The Braden Scale 7.13.2016(2) documented the following assessments: a. 12/10/21: Score of 20. - The assessment documented that Resident #6 had no sensory impairment, rarely had moist skin, limited or non-existent ability to walk, slightly limited mobility, excellent nutrition, and no apparent problem with friction and shearing. b. 12/17/21: Score of 15, indicating low risk - The assessment documented that Resident #6 had very limited sensory impairment, rarely had moist skin, limited or non-existent ability to walk, slightly limited mobility, adequate nutrition, and a problem with friction and shearing. c. 12/24/21: Score of 13, moderate risk - The documented that Resident #6 had slightly limited sensory impairment, occasionally had moist skin, limited or non-existent ability to walk, very limited mobility, probably inadequate nutrition, and a problem with friction and shearing. The Nursing Admission Data Collection ( 016) - V 4 dated 12/3/21 indicated that Resident #6 could move independently in bed and required extensive assistance of two persons with toilet use. Resident #6 did not require a specialty bed or mattress. Resident #6's skin sweep determined no identified skin impairments. The Braden Scale Completed identified a 15-18 score indicating mild risk and that she had signs/symptoms of infection that could impact her skin breakdown risk. The Weekly Skin Assessment - V 1 identified the following assessments a. 12/10/21: Intact, warm, dry skin, and normal for her ethnic group. b. 12/14/21: recorded the discovery of a facility acquired stage II pressure during routine perineal cares. The area measured 5 cm x 2 cm x 0.2 cm depth in the right gluteal fold. i. The facility notified the doctor by fax on 12/14/22 at 4:29 PM with no new orders. 1. Treatment - [MEDICATION(S)] cream and a four by four gauze pending the MD's return fax. 2. Care Plan interventions indicated Resident #5 received education to get off of her right side and start getting out of bed as she frequently refuses. ii. The description of the wound recorded the following 1. Drainage: none 2. Odor: none 3. Wound bed appearance: red and white 4. Surrounding skin color: normal 5. Surrounding tissue/wound edges: rolled c. 12/17/21: Skin not intact, had open areas, skin felt warm, and dry with normal skin color for her ethnic group. i. Right buttock (facility acquired stage II pressure) measured 5 cm x 2 cm x 0.2 d. 12/24/21: Skin not intact, had open areas, skin felt warm, and dry with normal skin color for her ethnic group. i. Coccyx wound (Stage III pressure) measured 6 cm x 6 cm The Pressure Injury Weekly Assessment - Version 4 identified the following a. 12/14/21: Right gluteal fold (Stage II Pressure) measured 5 cm x 2 cm x 0.2 cm depth. i. The description of the wound recorded the following 1. Drainage: none 2. Odor: none 3. Wound bed appearance: red and white 4. Surrounding skin color: normal 5. Surrounding tissue/wound edges: rolled b. 12/17/21: Right gluteal fold (Stage II Pressure) measured 5 cm x 2 cm x 0.2 cm depth. i. The description of the wound recorded the following: 1. Drainage: none 2. Odor: none 3. Wound bed appearance: red 4. Surrounding skin color: normal 5. Surrounding tissue/wound edges: rolled c. 12/24/21: Coccyx wound (Stage III pressure) measured 6 cm x 6 cm i. The description of the wound recorded the following 1. Drainage: none 2. Odor: none 3. Wound bed appearance: red 4. Surrounding skin color: normal 5. Surrounding tissue/wound edges: rolled The Clinical Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The chart lacked documentation of notification to the MD about Resident #6's worsening pressure on the coccyx. On 8/23/22 at 1:33 PM Resident #6's family member said that she spent 10 days in the hospital with a urinary tract infection and then she went to the nursing home for skilled care. Initially, she seemed to be making progress and would be able to go home. Resident #6's family member said that the facility had a challenge that they couldn't keep her bottom changed. Due to this, she developed a pressure sore on her bottom and they couldn't get it to heal. When the sore got progressively worse, he decided to take her to another nursing home. He said they didn't have trouble with the staff, it seemed they just didn't have enough help. On 8/24/22 at 11:15 AM Resident #6 said that the staff encouraged her to move from side to side and they would put a wedge behind her to support her. However, she had a problem with diarrhea and she had no feeling from the waist down so she did not know when she became soiled. Therefore she couldn't feel the sore developing. She said that she got showers regularly but did not remember any staff saying anything about a spot on her bottom. She acknowledged that she would refuse position changes if she didn't have a good mood. On 8/23/22 at 12:25 The Director of Nursing (DON) said that they did not have a Baseline Care Plan for Resident #6 just the Admission Summary. She said that Resident #6 went home from the facility and they did not have a visit summary or any recapitulation of stay. 8/29/22 at 1:57 PM the Attending Physician's Nurse reported that he did not see any communication information from the facility about Resident #6's decline in her pressure ulcers. He added that they only kept faxes from facilities for about 60 days. On 8/30/22 at 12:13 PM the Administrator said that the DON had noticed on 12/22/22 that Resident #6 did not have any treatment orders for the pressure on her bottom so she got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Skin Care and Wound Management policy dated 6/15 included the following guidance: The facility staff strives to prevent resident/patient skin impairment and to promote the healing of existing wounds. The interdisciplinary team works with the resident/patient and/or family/responsible party to identify and implement interventions to prevent and treat potential skin integrity issues. The interdisciplinary team evaluates and documents identified skin impairments and pre-existing signs to determine the type of impairment, underlying condition contributing to it, and description of impairment to determine appropriate treatment. Components of the skin care and wound management program include, but are not limited to, the following: a. Identification of resident/patients at risk for developing pressure ulcers. b. Implementation of prevention strategies to minimize the potential for developing c. Interdisciplinary review of identified skin impairments. d. Monitoring for consistent implementation of interventions and effectiveness of interventions. e. Review and modification of treatment plans, as applicable. f. Analysis of facility pressure ulcer data for quality improvement opportunities. The facility will develop a care plan with input from the interdisciplinary team and the resident/patient and family/responsible party. Document individualized goals and interventions to manage risk factors. - Note: If a resident/patient refuses care, document the following, including, but not limited to: a. Evaluation to determine basis of refusal b. Notification of physician and family c. Identification and evaluation of potential alternate interventions

Based on observation, record review and interviews the facility failed to assure planned restorative programs for 1 of 16 residents (Resident #19). The facility reported a census of 45 residents. Findings included: The Minimum Data Set ((MDS) dated [DATE] for Resident #19 indicated a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive deficit. The MDS documented the resident required limited assistance of one staff for bed mobility, dressing, and personal hygiene, and extensive assistance of two staff transfers and toilet. The resident walked with one staff in room once or twice . The MDS dated [DATE] indicated the residents' functional status declined and the resident now required total dependence with transfers, toileting and personal hygiene. The resident did not ambulate in room. A physical therapy (PT) evaluation dated 2/22/19 to 3/24/19 identified the resident with good rehab potential. The functional mobility assessment area of the evaluation identified the resident could ambulate 25 feet on level surfaces with minimum assistance and a two wheeled walker. The resident required maximum assistance with transfers, bed mobility and sit to stand. At the conclusion of therapy on 3/22/19, PT recommended a restorative nursing program (RNP). The RNP program directed staff to ensure the resident performed Nu Step 3 to 4 times a week for 10 to 15 minutes, Stand frame, seated therapy exercise with 3 pound ankle weights and sit to stands 5 reps. The care plan updated on 6/1/18 identified the resident with potential for pain and directed staff to monitor changes in self-care deficit and report changes to the medical director. The care plan also indicated communication difficulties and impaired cognitive functioning. The clinical record contained no documentation of RNP services provided to the resident. Another referral had been made to PT and OT services which was approved from 7/25/19 through 8/23/19. OT initial assessment from 7/25/19 identified the resident with weakness and decline in ADLs (activities of daily living) from last evaluation completed 4/19. At the conclusion of OT therapy on 8/23/19, OT did not recommend an RNP program. During interview on 11/20/19 at 9:57 AM, LPN staff D stated that the facility hasn't had restorative services for a couple years. She stated she understood it was one of the deficiencies from last year's survey but there were no changes made. Observation: During an observation on 11/18/19 at 11:28 AM in the dining room, the resident sat in her wheel chair in a slouched position with her head hanging close to her lap. On 11/18/19 at 12:11 PM she was at the lunch table attempting to drink from a cup but had difficulty due to her slouched position with her chin at the level of the table. On 11/19/19 at 10:30 AM observation showed the resident sleeping in her wheel chair with her head in her chest, almost in her lap. Director of Nursing (DON) Interview: On 11/21/19 at 7:50 AM the DON stated that there had not been a restorative program at the facility for over 4 years. When asked what happens when there is a recommendation from PT for a resident after they've been discharged , she said the referral comes to her but because the corporation doesn't support a restorative program so they are unable to follow through. She stated she had a couple of Certified Nursing Assistants (CNA's) trained to do restorative and they would like to but are forced to work on the floor. The DON stated she recently referred the resident back to PT and is looking into getting her a better wheel chair so she can reach the table better. She understands that there has been a decline in the residents Activities of Daily Living (ADL) due to the gaps in services.

Based on record review, staff interviews and review of the facility policy/procedures, the facility failed to provide adequate supervision to Resident #1 when door alarms sounded and the staff failed to respond to ensure a resident did not elope from the facility. The sample consisted of 8 residents and the facility reported a census of 49 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 4/7/2016. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMs (brief interview for mental status) score of 3. A score of 3 identified the resident with severe cognitive impairments. According to the MDS the resident required total dependence with bed mobility, transfers, dressing and toilet use. The resident was identified as independent with locomotion on and off the unit and utilized a wheel chair for a device. The MDS indicated the resident had wandering behaviors. The Care Plan dated 1/15/16 identified the resident at risk for elopement due to impaired cognitive function from a traumatic subdural hemorrhage. The interventions directed the staff that the resident wore a Wander guard (device to monitor resident from leaving and doors alarm when opened. The resident had a Wander guard located on the right wrist and staff were directed to monitor for placement every shift and function each day. The Care Plan also identified the resident scored a 6 on the elopement scale. A score of 6 indicated the resident a high risk for an elopement. The Care Plan indicated the doors are alarmed for safety and the resident has a Wander guard on the wheelchair. The Elopement Risk Tool dated 4/8/16, identified the resident had a total score of 6. A score of 5 or above indicated a high risk of elopement. Review of the Elopement Incident Report dated 5/22/16 at 4:55 PM, indicated the resident was found outside by Staff A, CNA (Certified Nursing Assistant). Staff A was leaving the parking lot for a break. Staff A noticed the resident by Wing 3C, on the grass. Staff A returned the resident into the facility by wheelchair. The Progress Notes dated 5/22/16 at 4:55 PM revealed the resident found outside by Staff A, CNA. Staff had been leaving the parking lot for break and noticed the resident by Wing 3C on the grass. The CNA assisted the resident back into the facility, propelled in the wheel chair by staff. The resident confused at the time. The resident placed on 15 minute tracker checks. On 5/31/16 at 2:20 PM, Staff A (Certified Nursing Assistant) was interviewed and stated she last saw the resident in the facility at approximately 2:30 PM to 2:45 PM. Staff A stated the resident had tried to open the front door before but had not tried the door on Hall 3. The resident did exit seek more after he/she first came to the facility. She further stated that she had been at the front nurses ' station. At approximately 4:25 PM to 4:30 PM the door alarm sounded. She saw it identified as Wing 3 but could not remember a specific door identified. She told Staff B, LPN (Licensed Practical Nurse) the door alarm went off. He stated it probably had been another resident just going out to the garden. Staff B left the area and the alarm sounded again and Staff A shut the alarm off. Staff B returned and she asked him why the alarms kept sounding. Staff B stated if the door did not shut all of the way it will do that. She then went to break at 4:55 PM. She saw the resident in the wheel chair in the grass. She then assisted the resident back into the facility. On 5/31/16 at 2:45 PM, Staff B (Licensed Practical Nurse) was interviewed and stated he had been with Staff A at the front nurses ' station. Staff B stated he heard the door alarm and Staff A had been at the computer and looked at the monitor. Staff B stated he told her (Staff A) the alarm had probably been Resident #5. Staff A did not state what door had been sounding. Staff A also told him the alarm sounded again. Staff B stated the door probably did not get shut. Staff B stated Resident #5 did tell him that he/she goes to the garden that day and had been normal for Resident #5 to shut the alarm off on Hall 3. During an interview with Staff C, RN (Registered Nurse) on 5/31/16 at 4:10 PM she stated she last saw the resident around 4:00 to 4:15 PM in Wing 5. She stated Staff B had told her that the resident had been outside. She did an assessment and the resident had no injury. She further stated the resident had always set off door alarms. The resident normally got stuck in the doorway threshold and never went outside. Staff C stated the alarm at the end of Wing 3 had been turned off. Staff immediately checked all of the door alarms and the alarms did function. During an interview with the Administrator on 6/1/16 at 3:45 PM, she stated she expected staff to physically check all door alarms to ensure the residents are safe. During an interview with the State Climatologist on 6/1/16 at 12:36 PM, he stated on 5/22/16 at 5:00 PM the temperature registered at 84 degrees Fahrenheit with 23 mph (mile per hour) winds and gusts to 33 mph with clear skies. Review of the facility policy/procedure titled. Elopement Prevention & Management, dated 3/2013, directed staff to do the following: a. Evaluate all residents/patients on admission for risk of elopement. b. Obtain a current photograph of residents identified for risk of elopement. c. Complete the Elopement Risk Alert. d. Place the Elopement Risk Alert form in the elopement risk identification notebook. e. Develop the care plan with input from the interdisciplinary team and the resident and family/responsible party. f. Initiate individualized interventions to address risk of elopement. Interventions may include environmental modifications to prevent undetected exit (door alarms, wander alerts) g. Communicate individualized interventions to the caregiving staff, resident and or family/responsible party. h. Evaluate and document effectiveness of interventions during the Care Management meeting. Modify goals and interventions as indicated. Communicate modifications to the caregiving staff, resident and or family/responsible party. Note: Prior to the investigation, the facility provided in-service education to all staff and abated the immediate jeopardy on 5/23/16 (prior to investigation). The in-service education consisted of the following: · Review of the facility Elopement policy/procedure and the requirement to investigate all alarms when they sound. The investigation must be immediate and thorough. · Alarms are not to be silenced until it is determed the residents are safe. · Staff are to respond to all alarms. All concerns are to be communicated to the Administrator or DON (Director of Nursing) immediately. · Resident safety addressed as being paramount in the facility.

Based on record review, staff interviews and review of the facility policy/procedures, the facility staff members (Staff E and Staff B) failed to report to the person in charge or the person ' s designated agent of suspected dependent adult abuse who shall notify the Iowa Department of Inspections and Appeals within 24 hours of such notification or the next business day (Resident #1). The facility identified a census of 43 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 2/13/14. The MDS assessed Resident #1 with a brief interview for mental status score of 2. A score of 2 identified the resident had a severe cognitive impairment. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident had behavior symptoms that included: verbal behaviors directed towards others. The resident rejected care daily. The MDS identified the resident as independent with bed mobility, transfers, eating and ambulation in room. The resident required extensive assistance with toileting, personal hygiene and bathing. The resident was frequently incontinent of urine. A Care Plan dated 9/20/13 identified the resident was resistive to bathing at times. The intervention directed staff to re-approach the resident PRN (as needed). FIRST INCIDENT: On 7/2/14 at 1:50 p.m. Staff E (nurse aide) stated she worked when an incident occurred involving Staff K (registered nurse). Staff K told her they needed to get Resident #1 up for a shower. Staff E stated Staff K removed her glasses and left them at the nurses ' station and Staff E followed Staff K to the resident's room. Staff K filled up an emesis basin with water and poured it on the resident's ankles and shins. Resident #1 popped up from the bed and hit Staff K. Staff K got the resident in the shower chair and Staff E pushed the resident to the shower. The resident still wore a silk night gown and cotton underwear. The resident refused to remove the gown and underwear so Staff K showered the resident with his/her clothes on. Staff K soaped the resident with clothes on and sprayed the resident with his/her clothes on. During the procedure, the resident grabbed Staff K's shirt and pulled on it. After the shower, they went to the nurses ' station and Staff K said she called the Director of Nursing (DON) and the DON knew about Staff K using the water to get the resident up so Staff E didn't report it. She believed Staff K did tell the DON because when she said it, she had the phone in her hand. Staff E stated the resident's bed appeared completely drenched. Staff K would tell the resident it was an accident and she tripped causing the water to spill. When Staff E saw the incident, Staff K did not pretend like it was an accident. Staff E just saw it happen once. On 7/3/14 at 10:10 a.m. Staff E reviewed bath records and determined the incident occurred on 12/28/13. Other Incidents including Final Incident: On 6/25/14 at 1:36 p.m. Staff B (nurse aide) was interviewed and stated she saw Staff K pour cold water along the side of the resident so the water would touch the resident. She saw this more than once. She did not report it because Staff K told her the DON knew about it. Staff B saw it around the first of February and then 2 or 3 times after that. Pouring the water so the resident got wet, made the resident angry and then the resident would yell. The resident did not like the cold water at all. The last time Staff B witnessed it, the resident knew what was about to happen because the resident saw the water basin on the couch. The resident said, Then you're going to get the water and Staff K then got the water and poured it by the resident so the resident got wet. The last incident Staff B saw was the incident that got reported. The facility had to throw the resident's bed out because the mattress was so wet. Staff B stated Staff K filled a large square basin with some cold water and poured it on the bed. The bed dripped as staff took it out because it was full from all the basin water dumped on it. On 6/25/14 at 3:45 p.m. Staff H (nurse aide) was interviewed and stated on 2/26/14 she overheard nurse aides talking about Staff K pouring water on Resident #1 to get the resident to take a shower. She went to Resident #1's room to put a pad on the bed and the bed looked wet. She put her hand on the bed and it felt damp. She pushed on it and it was squishy wet. She looked under the bed and there was a puddle of water under it. Staff H stated she considered going to the Director of Nursing (DON) but the DON and Staff K were friends so she went to the Administrator and reported the incident on 2/26/14. On 7/2/14 at 2:50 p.m. the DON denied knowledge of Staff K deliberately pouring water on Resident #1. She stated she knew of one incident in which Staff K stated she accidentally spilled water on the resident but that is all she knew. On 7/3/14 at 1:53 p.m., the DON stated the State Agency phone number and corporate complaint numbers are posted if staff wants to report a supervisor or someone in management. The Interim Administrator documented in a summary of the alleged abuse dated 3/1/14, that two staff knew of incidents of potential abuse and they reported this to the Director of Nursing (DON) who did nothing and they didn't know what else to do. The Interim Administrator spoke with the DON who denied that anyone reported possible abuse to her. The two staff also reported they did not tell the Interim Administrator because they feared Staff K. The two staff received counseling and the facility conducted staff in-services regarding the immediate reporting of abuse. Review of the facility policy for reporting abuse directed staff to notify the shift supervisor immediately. Staff should report the incident immediately to the Administrator and DON. The staff then notifies the State Agency.

Based on record review and interviews with the physician and staff members, the facility failed to prevent the development of pressure ulcers, provide interventions to promote healing and prevent infection of the pressure ulcers (Resident #2). The sample consisted of 5 residents and the facility reported a census of 43 residents. Resident #2 was admitted with a 40 centimeter abrasion from TED hose (compression stockings to enhance blood flow to the legs) and two surgical incisions. After admission the resident developed additional open areas. The facility assessed a black area with redness on the left inner thigh on 5/9/13 with no physician notification or follow up until the physician diagnosed the resident with left extremity [MEDICAL CONDITION] on 5/13/14. On 5/16/14 the resident saw a physician who assessed four bedsores to the right lower leg and the area to the right groin. The facility did not assess the areas prior to the visit. Findings include: 1. Resident #2 had a Minimum Data Set (MDS) assessment with a reference date of 4/28/14 which identified the resident with a BIMS (brief interview for mental status) score of 11. A score of 11 reflected the resident had a moderate cognitive impairment. The resident was admitted to the facility on [DATE] following repair of a right [MEDICAL CONDITION]. The resident had the following indicators of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident required total staff assistance with bed mobility, transfers and toileting. The resident required extensive staff assistance with ambulation in the corridor, dressing, personal hygiene and bathing. A balance during transitions and walking identified the resident as not steady and only able to stabilize with staff assistance in all areas of testing. The resident used a walker and wheelchair for mobility. The resident had [DIAGNOSES REDACTED]. The MDS identified the resident as at risk for developing pressure areas. The MDS identified that the resident did not have unhealed pressure sores. The facility identified the resident with surgical wounds and moisture associated skin damage. A Resident-Data Collection form dated 4/13/14 identified the resident with the following areas on admission: 40 centimeter (cm.) by 0.5 cm abrasion around left calf, 4 cm. incision right knee and 20 cm. incision right hip. An admission orders [REDACTED]. Use paper tape and no ointments or tub bath and PRAFO boot to right leg/foot when in bed. A transfer instruction sheet from the surgery center dated 4/13/14 identified the resident with a wound to bilateral buttocks. The instruction form identified the resident with fragile skin. The resident used an EZ (mechanical lift) stand for transfers. A Braden scale for predicting pressure sore risk dated 3/8/14 identified the resident with a score of 16. A score of 12 or less represented high risk. The nurses notes dated 4/27/14 at 9 p.m. identified the right knee incision as healed, the right thigh incision intact with a small amount of drainage, the left upper calf blistered area without fluid with a small 2.5 cm. by .75 area with 0.2 cm. depth on the upper inner calf with inner aspect black in color. A nursing home appointment communication sheet dated 5/13/14 identified the physician assessed the right hip incision and areas on the left lower thigh. The physician progress notes [REDACTED]. The physician ordered TAO to the left thigh four times a day and [MEDICATION NAME] (antibiotic) 400 milligrams 9 mg.) daily for 14 days. The physician also directed staff to elevate the left extremity three times a day during the day and return in one week. Left thigh: A nonpressure skin condition record dated 4/13/14 identified a 40 cm. by 0.5 c.m. fluid filled abrasion to the left thigh area. Originally the non-pressure skin condition record identified the area as the left calf. Someone crossed through "calf" and wrote "thigh" on the skin condition record. The next measurement dated 4/20/14 identified the area measured 40 cm. by 1 cm. The fluid drained and the area contained a 2.5 cm. by 0.75 cm. with a depth of 0.2 cm. area filled with necrotic tissue. The record lacked evidence the facility notified the physician of the necrotic area until one week later. On 4/28/14 the physician saw the resident. The physician identified the resident with bilateral one plus [MEDICAL CONDITION]. The left thigh had full thickness skin breakdown with eschar just above the knee where TED hose appeared to have rolled and caused skin breakdown. The lesion measured 3 to 4 millimeters (mm) by 4 cm. without [DIAGNOSES REDACTED]. The assessment was: skin breakdown pressure type sore from TED hose, left anterior thigh. Will discontinue TED hose and continue to monitor. The nonpressure skin condition record did not contain further documentation of the area until 5/4/14. Staff did not measure the area. Staff wrote the necrotic area appeared granulated and intact with no bleeding and slight reddening. The resident denied discomfort. A nonpressure skin condition record dated 5/6/14 identified a fluid reabsorbed area around the left medial thigh measuring 9 cm. by 1 cm. with 0.75 depth and lateral area measured 15.5 c.m. by 0.5 cm. On 5/6/14 the facility began assessing two areas on the left thigh on the non-pressure skin condition form. One on the medial aspect measured 9 cm. by 1 cm. by 0.75 cm. One on the lateral aspect measured 15 cm. by 0.5 cm. Nurses notes dated 5/13/14 at 9 p.m. identified the an area to the left lateral area on the thigh as "dry", the left medial thigh measured 8.75 cm. by 1 cm. and appeared scabbed. Staff applied Triple Antibiotic Ointment to the area. Left inner thigh: Nurses notes dated 4/20/14 at 8 p.m. identified the skin area on the left medial thigh healing without bleeding. The entry did not contain a measurement. A fax, dated 5/7/14 informed the physician of a scabbed area on the left inner thigh (no measurement). Staff asked the physician if they could apply Triple Antibiotic Ointment (TAO) at bedtime until healed. The physician responded "OK". The Skilled Daily Nurses Notes dated 5/9/14 at 1:30 a.m. identified the area continued to appear black with slight redness. The area measured 9 cm. by 1 cm. The resident had a low grade fever 99.1 degrees. No further documentation of the area or physician notification of the area until 5/13/14 when the physician diagnosed the resident with left extremity [MEDICAL CONDITION]. Left upper inside calf: The Nurses Notes dated 4/14/14 at 6 p.m. revealed staff received a facsimile from the physician regarding the area around the left calf where TED hose rubbed causing a fluid filled abrasion (no size listed). The fax informed the physician they would monitor the areas until healed. The physician responded "noted". The Nurses Notes dated 4/27/14 at 9 p.m. identified the left upper calf blistered area without fluid with a small 2.5 cm. by .75 area with 0.2 cm. depth on the upper inner calf with inner aspect black in color. On 4/27/14 the facility notified the physician per fax of an area to the left upper inside calf measuring 2.5 cm. by 0.75 cm. with depth of 0.2 c.m. with black tissue bed. The physician wrote "noted". No further documentation of area. Right hip incision: A non-pressure skin condition record, dated 4/13/14 regarding the right thigh incision revealed it measured 20 centimeters (cm.). Surrounding skin and wound bed normal. A non-pressure skin condition record, dated 4/20/14 regarding the right thigh incision identified no change in size. Surroundings skin and wound bed normal. The resident saw the physician on 4/25/14. The physician directed staff to continue with current orders of daily dressing changes. Staff should remove sutures on 5/2/14 and apply steri strips. Nurses notes dated 4/27/14 at 9 p.m. identified the right thigh incision intact with a small amount of drainage (no measurement) On 4/28/14 the physician saw the resident. The physician did not examine the surgical incision because the resident sat up in a wheelchair at the time of examination. Skilled daily notes dated 5/3/14 at 1 a.m. identified staff removed the sutures from the right hip and applied steri strips. A nonpressure skin condition record, dated 5/4/14 identified the right thigh measured 19 cm. The incision had continued redness with no drainage or complaints of pain. A Skilled Daily Nurses Notes dated 5/9/14 at 1:30 a.m. identified a 4 cm. by 1.5 cm. dark thick scab present mid incision without inflammation. A small amount of serosanguinous drainage was present. The staff did not inform the physician of the change in the area until 5/13/14. A nursing home appointment communication sheet dated 5/13/14 identified the physician assessed the right hip incision and the areas on the left lower thigh. The physician progress notes [REDACTED]. The physician ordered TAO to the left thigh four times a day and [MEDICATION NAME] (antibiotic) 400 milligrams 9 mg.) daily for 14 days. The physician also directed staff to elevate the left extremity three times a day during the day and return in one week. The nurses notes dated 5/13/14 at 9 p.m. identified the right hip incision measured 20 cm. by 0.5 cm. with a scabbed area in the middle that measured 8 cm. by 2 cm. with small amount of light green drainage on the dressing. The resident started antibiotics that shift. The Skilled Daily Nurses Notes dated 5/14/14 (no time listed) identified the incision with redness, a black midline scab with foul smelling serous drainage. The facility called the surgeon's nurse . The Nurses Notes dated 5/14/14 at 1:15 p.m. revealed the facility spoke with the surgeon's nurse about the resident's right hip incision appearing moist and red with foul smelling serous drainage. The area contained a black scab midline in the incision. The entry identified the resident went to a physician on 5/13/14 and began an antibiotic for [MEDICAL CONDITION]. The surgeon's nurse moved the resident's appointment up from June 6, 2014 to May 16, 2014. The Nurses Notes dated 5/15/14 at 9 p.m. identified the resident with [MEDICAL CONDITION] to both lower extremities. The right lower extremity was tender to the touch with redness noted around the right hip incision and a moderate amount of serous bloody colored drainage. The area to the right lower thigh continued with a scabbed area. The Skilled Daily Nurses Notes dated 5/16/14 (no time listed) identified the right hip area dressing as saturated with serosanguineous drainage with foul odor. The incision edges appeared moist with gaping noted. Right heel: The Skilled Daily Notes dated 4/17/14 at 9:45 a.m. identified the right heel as slightly red. The heel area blanched easily and staff applied a foam block. No further documentation of area. A fax, dated 5/5/14 identified the facility sent a request to discontinue the PRAFO boot to the right leg/foot except when working with therapy or bathing. The physician responded "OK". Right thigh abrasion: Skilled Daily Nurses Notes dated 4/22/14 (no time identified) revealed a right thigh abrasion contained a scab. (no measurement) No further documentation of the area. Right buttock: A transfer instruction sheet from the surgery center dated 4/13/14 identified the resident with a wound to bilateral buttocks. The Nurses Notes dated 4/14/14 at 6 p.m. revealed staff received a facsimile from the physician regarding a 0.5 centimeter (cm.) by 0.25 cm. abrasion to the right buttock. The physician wrote "noted" No further documentation until 5/4/14 (20 days since initial assessment) when a non-pressure skin condition record identified the area measured 0.25 cm. by 0.25 cm. No further documentation until 5/13/14 (9 days since previous assessment) when a non-pressure skin condition record identified the area measured 0.25 cm. by 0.25 cm. Right thigh blister: The Skilled Daily Nurses Notes dated 4/29/14 (no time listed) identified the resident with a dry scabbed right thigh blister. No further documentation of the area. Right outer lower leg: A fax dated 5/8/14 informed the physician of a fluid filled blister on the right outer lower leg measuring 0.5 cm. by 2 cm. long slightly warm to the touch and slightly reddened. The resident stated the area felt tender to the touch. Staff wrote they would monitor the area weekly and document until healed. The physician wrote "OK". The Skilled Daily Nurses Notes dated 5/9/14 at 10:30 a.m. identified the blister to the right outer lower leg unchanged. The Skilled Daily Notes dated 5/11/14 at 9:30 a.m. identified the right calf beginning to dry and heal. No measurements or appearance documented. On 5/13/14 the physician diagnosed the resident with right lower extremity [MEDICAL CONDITION]. A nursing home appointment communication sheet dated 5/13/14 reflected the physician identified the resident with right lower extremity [MEDICAL CONDITION] and left thigh [MEDICAL CONDITION]. The physician ordered TAO (triple antibiotic ointment) to the left thigh four times a day and [MEDICATION NAME] (antibiotic) 400 milligrams (mg.) daily for 14 days. The physician also directed staff to elevate the left extremity three times a day during the day and return in one week. The Nurses Notes dated 5/13/14 at 9 p.m. identified the area to the right outer lower leg measured 2.75 cm. by 1 cm. The blister popped and pale pink loose skin lay over the wound bed. The Skilled Daily Notes dated 5/15/13 identified the right lower extremity slightly red from ankle to shin and tender to the touch. Right outer ankle: The Skilled Daily Nurses Notes dated 5/10/14 (no time listed) identified a small amount of serous drainage from the ankle. No size or appearance listed. On 5/13/14 the physician diagnosed the resident with right lower extremity [MEDICAL CONDITION]. The Skilled Daily Nurses notes dated 5/15/14 (no time listed) identified the right ankle as scabbed. No size or appearance documented. The Skilled Daily Nurses Notes dated 5/16/14 (no time listed) identified a few scabbed areas to the right outer ankle. No size or appearance documented. On 5/16/14 at 8:30 a.m. the Skilled Daily Nurses Notes identified the resident was transported to the surgical center for an evaluation. The surgical center documentation, dated 5/16/14 identified the resident with an open infected right hip incision. The right hip area was an open surgical site with a surrounding red and inflamed area tender to the touch. The physician documented he could not fully appreciate the true length and depth of the opening. The resident also had [MEDICAL CONDITION] to the right ankle with four bedsores present on the Achilles tendon area. To the right lower leg posteriorly to the ankle were four skin pressure wounds with eschar present and corresponding circumferential [MEDICAL CONDITION] to the area with some [MEDICAL CONDITION] noted. The resident also had an open area to the left thigh that measured 4 cm. in length and 1.0 by 1.5 cm. in width where Ted hose eroded the skin. The resident had a closed but red and painful area to the right groin. The resident underwent [REDACTED]. The physician documented the resident initially did well following hip surgery but ultimately developed superficial ulcers and skin breakdown. The resident developed skin breakdown over the incision and "it was not monitored". The resident had wound dehiscence (wound opens along incision line) and had drainage from the hip which intraoperatively proved to most likely developed from superficial to deep. A large full thickness decubitus ulcer was debrided of eschar tissue as well as skin edges. The post-operative [DIAGNOSES REDACTED]. The facility failed to assess four bedsores to the right lower leg and the area to the right groin. On 7/15/14 at 10:52 a.m. the physician stated the facility should have assessed the four bedsores (pressure ulcers) and area to the groin. On 7/2/14 at 12:55 p.m.,. the Director of Nursing stated staff did not measure/assess the areas on the resident's right outer ankle documented on 5/16/14 because the nurse knew the physician would see the resident on 5/16/14. A Care Plan dated 11/7/13 identified the resident with impaired skin integrity related to impaired mobility and diabetes. The care plan directed staff to assess/record/monitor wound healing. Measure length, width and depth when possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. Assist with frequent repositioning. On 7/2/14 at 11:08 a.m. the Director of Nursing stated the resident thought the PRAFO boot felt to hard so in place of the PRAFO, she tried the SkilCare heel float cushion and the resident said that was hot. The resident then tried the Zero-G floated heel cushion in place of the PRAFO. The facility policy directed staff to complete a skin sheet for any new open area. All skin issues/wounds need to have a treatment immediately. Facility policy regarding "location" identified that even though the location of the wound should seem obvious, it is imperative that the location be properly communicated. Regarding size, the policy stated that length, width and depth were important descriptors when documenting one aspect of the healing process. Staff will enhance the care provided to the resident if they can determine the parameter of the wound with correct measurements using a consistent approach. The policy also directed staff to notify the physician if staff notes problems with lack of progress, infection or worsening condition. If a skin condition does not improve in 2 weeks, then notify the physician. The facility failed to identify correct locations and did not always include weekly measurements for existing open areas.

Based on record review, staff and physician interviews, the facility failed to provide each resident with sufficient fluid intake to maintain proper hydration and health for one of 5 residents reviewed for assessment intervention. Resident #1 was at a high risk for dehydration related to meal and fluid refusals, elevated BUN (Blood Urea Nitrogen) readings and decreased intake from 6/14/14 to 6/24/14. The record lacked evidence the facility assessed the resident for dehydration, responded to the changes and failed to provided additional intervention to help prevent dehydration and increase intake . On 6/24/14 the resident entered the hospital with marked dehydration. The facility identified the facility had a census of 43 residents. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 2/13/14 which assessed the resident with a brief interview for mental status score of 2 (severe cognitive impairment). The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident had behavior symptoms that included: verbal behaviors directed towards others. The resident rejected care daily. The MDS identified the resident as independent with bed mobility, transfers, eating and ambulation in room. The resident required extensive assistance with toileting, personal hygiene and bathing. The resident was frequently incontinent of urine. The resident had [DIAGNOSES REDACTED]. The MDS did not identify significant weight loss or gain. An annual evaluation dated 2/21/14 identified the resident needed1400 to 1500 cc fluid needed (daily) for adequate hydration. On 2/21/14 the dietician documented the resident's fluid intake as adequate at 400 to 900 cc per day with meals. The dietician identified a potential for inadequate oral intakes related to disordered eating pattern evidenced by skipping breakfast and history if skipping breakfast and lunch. Staff should encourage the resident to get up for meals and continue to monitor weight trends and intakes. A dietary progress note, dated 6/6/14 identified the resident had a 10.4 pound weight loss or 7% since 4/28/14. The facility notified the physician who ordered blood laboratory work and a urinalysis. The resident refused breakfast June 1 to June 6; refused noon meals June 1,2,3 and ate 100% on the 4th noon meal and 50% on the 5th noon meal, refused one supper meal; ate 100% of 3 and 50% of one. The dietician identified the resident did not meet intake needs with current intakes and documented the facility may wish to discuss son's wishes for nutritional support versus comfort care if the resident continued meal refusals. On 7/2/14 at 4:17 p.m. the Director of Nursing stated she did not speak with the resident's responsible party about nutritional support versus comfort care. Blood laboratory testing completed on 6/4/14 identified the resident with a blood urea nitrogen (BUN) reading of 50 (high) and creatinine (1.7) high. On 6/12/14 the BUN was 28 (high) and Creatinine 1.2 (normal). The resident's [MEDICATION NAME] was 3.2 (low) measures protein in the blood. A Medication Administration Record [REDACTED]. Review of June 2014 intake records revealed the resident took only four meals between 6/14/14 to 6/24/14. The resident ate 50% of 3 of the meals and all of one meal. The record fluid intake for the same time frame identified the resident had 1180 cc in those 10 days. This deviated from prior intakes. The prior half of the June 2014 intake record showed that the resident ate at least one meal a day and drank fluids on a daily basis. A CNA (certified nurse aide) ADL (activity of daily living) tracking form for June 2014 contained a section titled Fluids Offered. The form identified the night shift offered fluids every night that month and the day shift and evening shift offered fluids two times between both shifts that month. Regarding snacks during the 6/14/14 to 6/24/14 time frame, the resident refused 16 times, staff offered a snack 5 times, not offered 6 times and no documentation 9 times. On 7/2/14 at 4:17 p.m. the Director of Nursing stated she told staff they only needed to fill out the fluids offered section of the CNA/ ADL tracking form if the resident was on intake and output monitoring. Resident #1 was not on intake and output monitoring so staff did not need to complete the fluid section. Interviews: When asked about the resident's intakes in the week prior to hospitalization Staff D (nurse aide) stated on 7/3/14 at 2:33 p.m., the resident would hardly take ( food or drinks) anything. Staff D would take the supper tray in and the resident would lie in bed and open his/her eyes and say he/she would get up and try it. Staff D would check on the resident later and the resident still laid in bed. Staff D stated the resident's food and fluid intake declined "very much". She noticed the resident stayed in bed continually and didn't want staff to bother him/her for anything. Staff D would come on duty at 2 p.m. and the resident's lunch tray would still sit in the resident's room. Staff D would take it to the kitchen around 2 to 2:30 p.m. and then later bring the supper tray. . Staff D stated the resident sometimes took snacks offered but she would come back and the snacks would still sit in the resident's ottoman. The resident's family brought in snacks but the resident just picked at them. Staff D stated the resident also had a bout of diarrhea prior to going to the hospital. On 7/2/14 at 1:50 p.m. Staff E (nurse aide) stated the resident's family brought snacks for the resident and the resident would sometimes eat breakfast. Staff would bring the resident a tray and sometimes the resident ate and drank and sometimes he/she didn't. On 7/2/14 at 11:25 a.m. Staff G (nurse aide) stated the resident did not have good intakes before the hospital. The resident wouldn't get out of bed. The day the resident went to the hospital (6/24/14) Staff G found the resident unresponsive in the bathroom. On 7/3/14 at 9:40 a.m. Staff C (nurse aide) stated the resident ate and drank when he/she wanted to. Staff woke the resident up and told the resident they delivered a food tray. They would leave the tray and they would go back and wake the resident up again. The resident would say "OK". Staff offered the resident snacks but the resident didn't really eat them. The snacks sat there. On 7/2/14 at 12:22 p.m. Staff I (licensed practical nurse) stated the resident refused to eat. The resident refused breakfast and rarely ate lunch. Review of the Nurses Notes did not identify any documentation regarding the resident's lack of intake or an assessment for dehydration even though the resident was at high risk related to lack of intake and previous elevated BUN readings on 6/4/14 and 6/12/14. The Nurses Notes contained no entries from 6/18/14 to 6/24/14. On 6/24/14 at 10:10 a.m. a nurse aide found the resident unresponsive, diaphoretic, lethargic and nauseated. Staff assisted the resident back to bed and started oxygen at 2 liters per cannula due to the resident's blood oxygen level at 70%. The resident's blood pressure was 70/56, pulse 57. The facility notified the physician who directed staff to send the resident to the emergency room (ER) for examination. The Nurses Notes identified the resident was admitted to the hospital. A hospital history and physical dated 6/24/14 identified the resident with a low blood pressure and appeared, for all intensive purposes to exhibit dehydration. The physician documented the resident did not eat well the past few months. The resident has severe Alzheimer's and has self-neglect syndrome where the resident did not eat or drink which resulted in marked dehydration with low blood pressure. The resident responded well to hydration. The hospital gave the resident a liter of fluid in the ER (emergency room ) which brought the blood pressure up, the [MEDICAL CONDITION] and the dehydration mildly improved. The physician wrote that the resident didn't eat food unless encouraged. The physician documented "Marked Dehydration" was present on admission. The resident was admitted to the hospital for rehydration and to monitor the cardiac situation and get (obtain) cardiac enzymes (blood test). Upon arrival to the ER, the BUN measured 51 (high) and creatinine 2.2 (high). The resident's eGFR was 21 (severely decreased renal function) A hospital discharge summary dated 7/1/14 revealed the primary [DIAGNOSES REDACTED]. The discharge stated the resident was dry and they rehydrated the resident. The resident transferred from the hospital to another facility with an Alzheimer's unit. The BUN and creatinine on the day of discharge (7/1/14) was: BUN 12 (normal) and creatinine 0.7 (normal) The resident's eGFR on discharge was 80 (normal renal function). On 7/3/14 at 9:22 a.m. the physician stated the resident's decreased intakes contributed to dehydration. The facility could have done a better job but it wasn't total negligence. He stated if he is aware of decreased intakes like the resident had, he usually responds to those reports. When asked if the facility should have conducted assessments for dehydration, the physician stated he didn't know what the nursing home does. On 6/25/14 at 5:27 p.m. a family member was interviewed and stated the resident's (loved one's) eating and drinking went downhill. The family member did not know of the facility providing the resident with snacks or supplements. The family member stated the resident loved chocolate and they would take that to the resident but they were careful as to how much they gave the resident. The facility policy for hydration identified the facility should identify and assess resident's at risk for dehydration and implement individualized interventions based on resident needs and goals which promote fluid intake to maintain sufficient hydration. The Care Plan dated 5/15/14 identified the resident with a potential for alteration in nutrition-weight loss related to fluctuating oral intakes and history of weight loss prior to admission. The care plan did not identify a potential problem with dehydration. Regarding fluid, the Care Plan directed staff to: encourage fluid intake, an intervention in place since 12/18/13 (no alteration). On 7/17/14 at 2:15 p.m. the surveyor discussed all the above information at the exit conference. Following the conference, the DON sent an email dated 7/17/14 at 3:50 p.m. The DON documented in the e-mail that the resident was up independently in his/her room and also had snacks in his/her room brought in by family. The Care Plan intervention of "encourage fluid and obtain lab values per physician orders" present as accurate of monitoring of a resident who is up independently is unrealistic. The DON also wrote that she was confused as to how realistically the facility could force fluids/food or other dietary measures on a resident who has the right to refuse bathing-does that resident also have the right to refuse meals? Regarding the elevated BUN/creatinine, the DON wrote that a recheck of lab values is performed with a physician order [REDACTED]. A recheck was not indicated. On 7/17/14 at 5:27 p.m. the DON clarified the sentence The Care Plan intervention of "encourage fluid and obtain lab values per physician orders" present as accurate of monitoring of a resident who is up independently is unrealistic. The DON stated it should read : The Care Plan intervention of "encourage fluid and obtain lab values per physician orders [REDACTED].

Based on record review and staff, physician and community member interviews and review of policy/procedures, the health service supervisor and the facility administrator failed to plan for and direct the nursing care and services in order that Resident #1 ' s needs where met and failed to provide sufficient preparation and orientation to Resident #1 in order to assure a safe and orderly discharge from the facility. The facility reported a census of 36 residents. The sample consisted of 3 residents. Findings include: 1. An admission record resident information document identified Resident #1 had an admission date of [DATE]. The document identified the resident had the following [DIAGNOSES REDACTED]. The initial social service admit note dated 7/23/13 indicated the Department of Human Services took over the case since the resident could no longer take care of himself/herself at home and the resident ' s house was not livable. The resident had requested to go to a veterans home so he/she could visit with other veterans. The discharge plan would be to apply for admission into a veterans home. The Discharge Plan Review dated 7/23/13 identified the resident ' s length of stay uncertain but potential for discharge is good. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 11/1/13. The MDS identified the resident had a BIMS (Brief Interview for Mental Status) score of 13. A score of 13 reflected the resident had no cognitive impairments (short or long term memory). The assessment revealed the resident did demonstrate disorganized thinking; disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). This behavior presented continuously and did not fluctuate. Resident #1 required supervision with activities of daily living (ADL's) including transfer, ambulation, dressing, toilet use and hygiene, and extensive assist with bathing. The MDS documented Resident #1 experienced shortness of breath or trouble breathing with exertion (walking, bathing, transferring), and shortness of breath while lying flat. A Care Plan dated 08/08/13 identified Resident #1 with diabetes and [MEDICAL CONDITION]. The interventions included: a. Administer medications per (physician ' s) order. b. Diabetes medication per (physician ' s) order. The Care Plan identified potential impaired skin integrity and included the interventions: a. Monitor Resident #1's ability to perform own toileting and hygiene, assist as indicated and provide peri (perineal)care after each incontinent episode and as needed (prn). The Care Plan identified Resident #1 at risk for injury due to a fall and included the interventions: a. Resident #1 needed a safe environment with floors free from spills and/or clutter, glare free light, a working and reachable call light, a bed in low position at night, handrails on the walls, and personal items within reach. The Care Plan identified Resident #1 with an ADL (Activities of Daily Living) self-care performance deficit, and the interventions included: a. Assist daily with all AM and PM cares. The Care Plan identified Resident #1 with depression related to [MEDICAL CONDITION], and interventions included: a. Administer medications as ordered. b. Monitor/record/report to physician as needed... refusal of medication or therapies. The care plan lacked identification of any interventions regarding discharge plans for Resident #1. A letter dated 09/23/13 from the facility, informed the resident that he/she would be involuntarily discharged from the facility due to nonpayment for the services provided during the stay at the facility. The letter informed the resident the discharge would be effective 10/23/13, at which time he/she would be released into the custody of his/her own recognizance.. The letter informed the resident that his/her health had improved enough that he/she can be discharged to an apartment with home health (services) and diabetes education. The Nurse ' s Notes dated 9/24/13 at 10:00 a.m. revealed a conference was held with the resident, social worker, administrator and the nurse. The resident received the involuntary discharge and the resident expressed understanding. The Nurse's Note dated 10/07/13 at 3:30 a.m. documented Resident #1 sat in the dining room reading. Resident #1 stated having trouble, and had been up since 3:00 a.m. worried about his/her living situation. Staff provided one to one with little success. The Social Services Progress Notes dated 10/11/13 documented staff assisted Resident #1 with an application for a low income apartment in another town per his/her request. The Social Services Progress Notes dated 10/15/13 documented an apartment would be available 10/18/13. Resident #1 indicated his/her money was gone and would not have money available for the deposit and rent until the beginning of November (2013). On staff suggestion, Resident #1 called and let them know and they agreed to hold the apartment until November when he/she had funds available. The Social Services Progress Notes dated 10/28/13 documented staff spoke to the van driver and the van was available to transfer Resident #1 to the apartment. Staff spoke to Resident #1 about the apartment being unfurnished and told Resident #1 the van driver could stop by his/her old property to pick up some items if needed. Resident #1 declined, indicating he/she had things taken care of. Resident #1 indicated he/she had people bringing items to the apartment so this would be unnecessary. The facility sent a facsimile (fax), dated 10/29/13 to the physician. The facility staff questioned if the facility could have the approval for Resident #1's discharge to a low income apartments and to use the present medications. The physician responded to discharge as noted. The Social Services Progress Notes dated 10/30/13 documented staff spoke to Resident #1 to reconfirm that he/she had things set up for his/her apartment. Resident #1 stated being okay. The Nurse's Notes dated 10/30/13 at 2:00 p.m. documented staff asked Resident #1 if he/she needed medications ordered for when he/she left on 11/01/13. Resident #1 stated the need to make a phone call and all would be taken care of. The Nurse's Notes dated 10/31/13 at 10:30 a.m. documented a review of the medication list for when Resident #1 discharged from the facility. Resident #1 stated having all of his medication, insulin and treatments already. Staff offered to order oxygen for when Resident #1 went home. Resident #1 refused stating he/she would order from the pharmacy the next day. Resident #1 refused home health services. The Nurse's Notes dated 11/01/13 at 11:30 a.m. documented Resident #1 discharged , taking all personal belongings. Staff returned medications to the pharmacy. At 6:00 p.m. staff telephoned the head (person in charge) of the apartments to check on Resident #1's status. Staff gave him/her (apartment charge person) Resident #1's DHS case worker's number. The Nurse's Notes dated 11/02/13 at 6:00 a.m. documented an addendum; Resident #1's 11:00 a.m. medications, [MEDICATION NAME] and Novulin insulin, and nasal spray sent with him/her. When Resident #1 left he/she stated having everything he/she needed at home. The facility Summary of Discharge of Resident's Stay dated 11/04/13 documented Resident #1 had a history of [REDACTED]. Resident #1 had a history of [REDACTED]. Resident #1 refused home health care, and refused to have medications and oxygen set up with the pharmacy for home delivery. Resident #1 had a decreased activity tolerance secondary to [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Resident #1 required supervision/reminders with ADL's/hygiene. A Sheriff's Report dated 11/02/13 at 2:18 p.m. documented an officer met with a tenant at the apartments in reference to another tenant that just arrived and may be in distress. The tenant said a little over 24 hours previously, a facility van dropped off the man/woman and stated it was Resident #1. The officer knew Resident #1 because on at least 2 occasions he had checked on his/her welfare, the latest on 07/13/13 when they removed him/her from his/her home because he/she could not care for him/herself. Resident #1 had diabetes, morbidly obesity and it would appear he/she may have diminished capacity. The officer made an initial observation through the picture window of his/her locked apartment. Resident #1 sat in a chair next to the stove, and he/she held onto the stove with one hand and tried to brace him/herself with the other so he/she would not fall off the chair. Upon seeing the officer, Resident #1 attempted to get up, and the officer motioned him/her to stay there. The officer called a key holder to the apartment. The officer entered the common area and gained entry into Resident #1's apartment. Upon entering the apartment, the officer saw Resident #1 breathing heavily with rapid respirations. The officer noted Resident #1's eyes reacted slowly and the whites of his/her eyes appeared yellow. Resident #1 had difficulty answering questions. The resident didn't know the day or how long he/she had been there. The resident voiced he/she slept in the closet. The officer did look in the closet and it did appear he/she did sleep there. The officer checked the refrigerator and found little food. A local Pastor who assists at a food pantry brought the food. Other than 2 chairs, the apartment had no furniture. Resident #1 did not have medication or any way to check his/her blood sugar. The officer contacted a local health care provider on call with the ambulance service, and they responded. The health care provider told the officer in her opinion, Resident #1 would not have made it through the night. They transported Resident #1 to the local hospital, and later to another hospital for more extensive care. The officer telephoned the facility and asked to talk to someone in charge. A woman who identified herself as the charge nurse spoke to the officer. The officer asked the charge nurse how Resident #1 came to be dropped off at an empty apartment with no food, no medicine, no furniture, no bed, and no personal belongings. The charge nurse said Resident #1 had names and numbers of people to contact to get all of those things. The officer asked how Resident #1 could do that with no phone. The charge nurse became increasingly uncomfortable and referred the officer to the administrator. When he called the number given for the administrator, it went to voicemail. He also telephoned the number for DHS Protective Services. Photographs were obtained. The Nurse's Progress Notes dated 11/02/13 documented staff received a phone call from the local emergency room (ER) from a nurse wanting to know Resident #1's history due to him/her transferring to the ER. The nurse also requested a medication list. A local hospital Outpatient Dictation dated 11/02/13 documented Resident #1 transferred to the ER by ambulance with shortness of breath. Resident #1 had oxygen saturation (amount of oxygen in the blood) of 85% on room air (normal 92-100%). Upon arrival to the ER Resident #1 had tachypnea (rapid respirations), [MEDICAL CONDITION](pulse greater than 100), and severe respiratory distress. The ambulance crew started oxygen by a non rebreather mask and his/her oxygen went to the upper 90's. The physical exam revealed a temperature of 101.9 (normal 98.6), pulse of 126 (normal rate is 60-100), respirations of 60 (norm 16 to 20), blood pressure 151/82, and oxygen saturation of 85%. Resident #1's lower legs had [MEDICAL CONDITION] (swelling) and [DIAGNOSES REDACTED] (redness) with clear drainage from the [DIAGNOSES REDACTED]tous area on the right lower leg. Resident #1 received a nebulizer (breathing) treatment, [MEDICATION NAME] (antianxiety), [MEDICATION NAME] (combination antibiotic) and Tylenol in the ER. Resident #1 transferred to another hospital for further evaluation and advance specialized care. The Emergency Department Physician Notes from the hospital Resident #1 transferred to on 11/02/13 documented Resident #1 had an EKG showing uncontrolled [MEDICAL CONDITION]. Resident #1 received an Aspirin and had an elevated BNP (blood test that indicates heart failure) so he/she received [MEDICATION NAME] (a medication routinely had been while living at the facility). A History and Physical dated 11/02/1 identified an impression and plan of: a. For acute [MEDICAL CONDITION] they would start [MEDICATION NAME] (breathing treatments), aggressively control his/her heart rate and blood pressure, and continue to maintain appropriate oxygenation. b. [MEDICAL CONDITION] they would put him/her on intravenous (IV) antibiotics. c. For obstructive sleep apnea they would start [MEDICAL CONDITION] (breathing machine). d. For anxiety they would have [MEDICATION NAME] (antianxiety medication available as needed. e. For borderline Troponin (elevated levels can indicate heart damage) they suspected related to [MEDICAL CONDITION], and also to the [MEDICAL CONDITION], and thought they would see improvement with better heart rate control. f. For [MEDICAL CONDITION] with rapid ventricular response they would start a [MEDICATION NAME] drip for rate control. g. For bilateral venous stasis [MEDICAL CONDITION] they would start antibiotic, obtain wound cultures if possible, and dress the wound to the right lower extremity. h. For suspected urinary tract infection they would send urine for culture and start IV antibiotics. Resident #1 was a critical high risk for severe decompensation due to his/her multiple issues of [MEDICAL CONDITIONS] with rapid ventricular response (rapid ventricular heart rate), severe anxiety, [MEDICAL CONDITION] (blood infection). Resident #1's clinical condition was extremely guarded. A Consultation report dated 11/02/13 regarding positive blood culture documented Resident #1 had multiple areas of skin breakdown on his/her right lower extremity. They looked very shallow and early Stage 2 ulcers at various stages of healing, covering about a 2 by 4 inch area. A Consultation report dated 11/03/13 regarding the [MEDICAL CONDITION] documented when Resident #1 found to be hypoxic (deprived of oxygen) and tachypneic when he/she came in. They placed him/her on [MEDICAL CONDITION], and he/she desaturated significantly when taken off. The chest x-ray showed what looked like bilateral interstitial infiltrate suggestive of maybe pneumonia involving the right middle and lower lobe (of lung) versus fluid overload. Resident #1 was obviously sick, having multiple comorbidities (2 or more coexisting medical conditions), now on [MEDICAL CONDITION]. In a County Sheriff's Department form dated 11/04/14, a tenant (who met with the officer on 11/02/13 at Resident #1's apartment) documented on 11/01/13 Resident #1 moved in to an apartment. After meeting Resident #1 the tenant found out he/she arrived from the facility. The tenant became concerned when he/she found Resident #1 had no food, medications, or even furniture. The (apartment) manager telephoned the facility and they told him/her the Administrator would call and explain the situation. While waiting, the manager went to the store and purchased some food for Resident #1. The tenant brought a blanket, silverware, and a bowl to warm soup in. Resident #1 acquired 2 chairs from the community room, and the tenant brought the microwave from there also so Resident #1 could warm the soup the manager purchased for him/her. The tenant asked Resident #1 what else he/she needed and he/she stated not getting his/her insulin. The tenant telephoned the physician's office and informed them of the situation. The tenant received a call from the physician's nurse stating the administrator would call him/her. At approximately 5:15 p.m. the Administrator called. The tenant asked why they would leave someone without food or medications in an apartment with no furniture. The Administrator responded that Resident #1 was a manipulative person and capable of walking across the street to the nursing home and getting something to eat. The tenant told the Administrator Resident #1 could not even walk 5 feet. The Administrator answered that they gave Resident #1 a list of resources and they offered to move furniture to the apartment. The Administrator said this after she explained why Resident #1 could not go back to his/her home. She told the Administrator Resident #1 could not call anyone because he/she had no phone. The tenant made sure Resident #1 had a blanket that night to cover up with. The next morning the tenant checked on Resident #1 and noticed he/she had trouble breathing. An officer arrived on 11/02/13 at 2:00 p.m. and after checking on Resident #1, called the ambulance. During an interview on 11/13/13 at 1:10 p.m. the tenant who neighbored Resident #1's apartment (and wrote above statement) stated she got involved with Resident #1 when the apartment manager told her that the facility had dropped him/her off at the apartment and he/she didn't have anything there. The tenant stated when she talked to the (facility) Administrator, she told the tenant about Resident #1 being manipulative and he/she could get up and get what he/she needed. The tenant stated there was a nursing home across the street, but she didn't know if people could just go there and eat, and she said Resident #1 would not be able to walk over there. She said the Administrator told her about Resident #1's house being condemned and said they offered to move his/her furniture over to the apartment. The Administrator told her the house had contamination with feces and the furniture had feces on it. He/she asked the Administrator how they could move furniture contaminated with feces to the apartment. He/she asked the Administrator why Resident #1 did not have medication and the Administrator told him/her it was not her (Administrator's) problem. He/she said Resident #1's legs were oozing before going to the hospital. He/she noticed this when he/she put Resident #1's shoes on. During an interview on 11/13/13 at 1:15 p.m. the Physician Hospitalist stated Resident #1 not having his/her medication for 24 hours would definitely contribute to his/her serious condition. He stated stress also contributes to health problems. He said Resident #1 had [MEDICAL CONDITIONS], pneumonia,[MEDICAL CONDITION], respiratory distress and [MEDICAL CONDITION] as well as other issues. The hospitalist stated Resident #1 initially went to another hospital, but due to the multiple problems, they sent him/her to a hospital with more specialists, and he/she had multiple consults. On 11/08/13 at 11:29 a.m. the Administrator was interviewed and stated initially they (facility) gave Resident #1 a 30 day discharge notice. The Administrator stated they (the facility) went beyond that time waiting for adequate housing. She suggested the local low income housing, but Resident #1 wanted a different town's housing. The facility obtained an application and she helped Resident #1 complete the form. She stated in mid-October they got the apartment, but Resident #1 ran out of money. She told Resident #1 to call and see if they would hold the apartment for the next month and he did. Resident #1 made a lot of phone calls. She stated she told Resident #1 the apartment was unfurnished. Resident #1 said friends from church were going to bring furniture, and she had no reason to doubt him/her. Resident #1 said they would meet him/her at the apartment and bring furniture and food. She believed what Resident #1 told her. The Administrator stated she left that Friday for a funeral. She stated she started receiving calls about Resident #1 having nothing there (at the apartment). The Administrator stated after they knew Resident #1 did not have things; they should have called people from the church to see what was happening. She stated Resident #1 was happy with the facility because he lived there for free. The Administrator stated the DON told her Resident #1 ordered his/her medications from the Veteran's Administration (VA). On 11/08/13 at 10:33 a.m. the Director of Nursing (DON) was interviewed and stated the social services designee left (quit employment). The DON stated discharge should be an interdisciplinary process. The Administrator said she had done social services before administrating, so she took (social work department) over. The DON stated when Resident #1 came to the facility it was sort of an emergency situation. They went to the hospital and they had already started the Medicaid application process and it should not be a problem. Resident #1 was admitted from the hospital and said he/she would only come if it didn't cost anything. Resident #1 rapidly improved. The DON stated the Administrator contacted the apartment manager in another town. They gave Resident #1 a 30 day (discharge) notice due to non-payment. The DON stated it wasn't like Resident #1 didn't have money, because he/she had the van driver take him/her to Walmart and the Dollar Store, and he/she paid some bills. The DON stated she did not notify the physician that Resident #1 refused home health care and other assistance. The DON stated the Administrator told her it was all taken care of. On the day of Resident #1's discharge, the van driver called her and said he obtained Resident #1 a chair. He told her Resident #1 had nothing in the apartment. The DON told the van driver she didn't know anything about the details. The DON attempted to reach the Administrator. The DON received a call from someone from the apartment questioning what they were going to do about it (the situation). She told that person she thought the church people were bringing things. The Administrator telephoned and the DON told her there was nothing in the apartment, and she asked the Administrator to call this person (doesn't know name). The Administrator said it was all taken care of and Resident #1 had $1,400. The DON stated she pondered going to get Resident #1 but they had discharged him/her. The DON stated the Administrator said Resident #1 had church people coming over the next day. The DON stated Resident #1 had to go because he/she would not pay. She stated Resident #1 took showers at the facility. She did not know if the apartment had a tub or shower because she had never been there. They had not performed a home or trial visit. The DON admitted she knew Resident #1 did not have his/her meds, furniture, food, or a phone. The DON stated Resident #1 took most of his/her meds in the a.m. When looking at Resident #1's MAR (Medication Administration Record) she noted several medications scheduled for the p.m. She stated she took no action because the Administrator assured her it was all taken care of. She stated Resident #1 ordered his/her meds from the VA 2 days before he/she discharged . When asked how he/she did this without prescription #'s she didn't know. When asked when the meds were to arrive and where, she didn't know. She did not follow up. The DON stated Resident #1 did not have skin sheets regarding his/her lower legs. She stated they were not open; they would bubble up and drain. On 11/08/13 at 10:10 a.m. Staff A, Registered Nurse (RN), was interviewed and stated the evening of Resident #1's discharge to the apartment, she understood they had received calls about his/her well- being. She was concerned about his/her welfare and wanted to see how he/she was doing. When she called, the apartment manager said Resident #1 slept on a couch in the laundry room and they thought he/she had been incontinence due to an odor. She gave the apartment manager the number of the Department of Human Services caseworker on Resident #1's face sheet. Staff A stated Resident #1 had a lot of psychiatric issues and would ask staff to wipe him after a bowel movement. She didn't know if he/she couldn't do it (wipe self), or wouldn't do it, but she thought he/she couldn't. Staff A stated Resident #1 needed supervision with cares, and staff assisted with his/her baths. Resident #1 could walk but not long distances. Staff A stated Resident #1 needed some of his/her medications that day and his oxygen. Staff A stated she had concerns about the situation and it crossed her mind to go and pick Resident #1 up, but she could not leave her post (the facility). On 11/08/13 at 8:50 a.m. Staff B, Licensed Practical Nurse (LPN), stated she knew Resident #1 outside of the facility, they went to the same church. She worked the day before Resident #1 discharged . She gave Resident #1 a copy of his/her MAR. She stated Resident #1 was familiar with his/her medications. Resident #1 told her he had a glucometer at home, and he/she had most of his/her pills at home still. Resident #1 assured her he/she had everything at home. Resident #1 said someone would bring things over. Staff B did not follow up. She said people brought things to the facility for Resident #1 at times. She stated Resident #1 had her phone number, her husband's phone number, and the pastor's phone number. She stated if she had known Resident #1 did not have someone bringing things to him/her, she would have made calls to make sure he/she got what he/she needed. Staff B stated Resident #1 would need his/her medications and oxygen that day. On 11/07/13 at 2:12 p.m. Staff D LPN was interviewed and stated she worked the day Resident #1 discharged . Resident #1 took his/her clothes, C-PAP, [MEDICATION NAME] and Novulin insulin, [MEDICATION NAME] and 11:00 a.m. meds with him/her. Resident #1 stated having insulin syringes at home. She offered to order his/her medications a couple days earlier and he/she said no. Resident #1 stated having all this at home. She did not follow up. Staff D stated Resident #1 received some help with a shower. She stated she didn't know the distance to the grocery store, but the pharmacy delivered. She thought Resident #1 had access to a phone. She didn't know how Resident #1 would get to the store, but he/she would get angry if they asked him/her questions, and he/she stated having everything lined up. She thought the physician knew Resident #1 refused home health care and okayed (approved) the discharge. Staff D stated she found out the next day Resident #1 did not have furniture and food in the apartment. She stated if she had known, she obviously would have done something different. She stated Resident #1 would need his /her medication that day and oxygen that night. During an interview on 11/07/13 at 4:06 p.m. Staff C, the Van Driver/LPN stated he drove Resident #1 to the apartment. Staff C stated he stopped at City Hall to put a deposit on electricity, and then to the apartment. Staff C turned the heat on, and the apartment had electricity. The apartment had no furniture and the curtains laid on the counter. Resident #1 had 5 boxes of items including clothes and papers. Resident #1 had a hospital pitcher with him/her and Staff C filled the pitcher before he left. Resident #1 had no phone. Staff C grabbed Resident #1 a chair so he had something to sit on. When Staff C asked Resident #1 if someone would bring things, he/she said "No". Staff C called back and talked to the DON and asked if she knew if someone would bring Resident #1 some things and she did not know, and the Administrator was gone. Staff C stated he told the DON he obtained Resident #1 a chair and she really didn't know what to do. Staff C stated he wanted to stop at Resident #1's house to get some things, but was told just to take Resident #1 to the apartment. He said he would have stopped anyway, but they were late leaving and he had to work 2-10 p.m. Staff C said he did not see the people who ran the apartments because they were late, so they were going to meet with Resident #1 at 2:30 p.m. Staff C later the lady from the apartments called him and said Resident #1 had nothing there. Staff C gave her the facility number to call the DON. Staff C stated it was a pretty poor set up. When he called the DON from the apartment he told her Resident #1 did not have anything he/she needed there. Staff C stated Resident #1 did not walk very well. During an interview on 11/07/13 at 4:53 p.m. Staff E LPN stated she did not work the day Resident #1 discharged . She did not know why they discharged Resident #1. She said Resident #1 needed staff assistance with peri care. On 11/02/13 she received a call from a nurse at the local hospital who wanted to speak to a supervisor. Staff E stated she could help. The hospital nurse said Resident #1 was in the ER, septic and didn't look good. The nurse stated Resident #1 did not have a med list and could not tell them what he/she took. The nurse said Resident #1's legs were draining. Staff E stated Resident #1's legs drained earlier in the week. She did not feel Resident #1 could change dressings very well. Staff E stated she heard about the situation when they took Resident #1 to the apartment. She said she would not leave a resident in a situation where they had no food, furniture, meds or a phone. She said Resident 1 would need his/her meds and oxygen that day. On 11/08/13 at 9:42 a.m. Resident #1's Physician was interviewed and stated Resident #1 absolutely should not have been left in an apartment with no food, no furniture, no medications and no phone. It was obviously inappropriate to do so. He said someone from the apartments notified him the afternoon of 11/01/13 that the facility had dropped Resident #1 off in this situation. They called the facility and a nurse stated she would make some calls. The physician stated he was not aware Resident #1 refused home health care. If he had known, he probably would not discharge Resident #1 (from the facility). During an interview on 11/08/13 at 9:21 a.m. the Pastor of Resident #1's church stated he had no idea Resident #1 was even going to an apartment. The Pastor stated Staff B communicated to him a few times about some things Resident #1 needed, and he got some things to Staff B for Resident #1. Staff B did not tell the Pastor Resident #1 would discharge. The Pastor stated he would not have helped with setting Resident #1 up in an apartment because he did not think Resident #1 should live alone. The Pastor stated he had let Resident #1 know that. He stated both he and a member of the church care committee let Resident #1 know this. During an interview on 11/08/13 at 10:28 a.m. a friend and church member stated he had not talked to Resident #1 for a long time. He did not know anything about Resident #1 moving. He said he had no idea why they would have Resident #1 live by him/herself in his/her condition. The Social Services Manual, Resident/Family Care and Services Discharge Planning directed the social services department works with the interdisciplinary team to assist the resident with the discharge process. Discharge planning begins at admission and throughout the continuum of care. The Director of social services or designee is responsible for coordinating the discharge planning process. Note: At the time of the complaint investigation, the complaint was coded at a "J", immediate and serious jeopardy. By 11/12/13, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "D" level. The administrator initiated an audit to determine resident potential discharge plans. The staff received training regarding discharge planning, discharge summary form, discharge information form and notification to the physician. As of the 11/20/13 exit conference, the facility continued to need to . Inservice all employees regarding discharge planning, implementation of discharge forms and notification to the physician. .Monitor nursing and social service staff to ensure compliance with discharge procedures, planning and facility policy/procedures.

Based on record review, interviews with staff and physician, and policy review, the facility failed to plan nursing services to effectively monitor anticoagulant medication according to physician's orders [REDACTED]. Resident #8's physician directed staff to hold the [MEDICATION NAME] medication for two days and then lower the [MEDICATION NAME] amount. The resident continued to receive the [MEDICATION NAME] with elevated [MEDICATION NAME]/INR levels and no facility staff monitored or timely implemented the physician's orders [REDACTED]. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 had [DIAGNOSES REDACTED]. The MDS identified the resident with a brief interview for mental status score of 10, which indicates moderate cognitive impairment. Review of the lab (laboratory) report for [MEDICATION NAME]/INR (blood clotting time) dated 10/11/10 revealed the physician's orders [REDACTED]. At this time the lab listed the resident's INR at 1.8. Review of the lab report [MEDICATION NAME]/INR dated 11/1/10 revealed the lab value for [MEDICATION NAME] 44.3 (normal 8.1 - 12.4 seconds) and INR value of 4.4 (normal 0.9 - 1.0 ratio). (Therapeutic range using INR 2.0 - 3.0 for [MEDICAL CONDITION]). The lab report also documented a physician's orders [REDACTED]. Nursing staff did not note the order until 11/3/10. Review of the MAR (medication administration record) dated November 2010 revealed the order for [MEDICATION NAME] 3 mg administered on 11/1/10 and 11/2/10. Review of the fax (facsimile) to the Physician dated 11/3/10 revealed the notification that staff had not held the [MEDICATION NAME] on Monday and Tuesday per order. The notification also included the lab values of [MEDICATION NAME] 44.3 and INR value of 4.4. The physician ordered to hold the medication 2 days then decrease [MEDICATION NAME] to 1.5 mg every day. Review of the Nursing Notes dated 11/2/10 at 3:00 PM revealed the entry that the CNA (certified nursing assistant) noticed dark purple bruising to the top of both the resident's hands. The resident voiced no complaints of pain of discomfort. An Incident Report dated 11/2/10 documented the resident with bruising to each hand, measuring 8.5 by 9 cm (centimeters) on the left hand and 8.5 by 10 cm on the right hand. The report identified a possible contributing factor as bumping their hand on the grab bar in the bathroom. The interventions put in place involved skin repair cream to bilateral hands and [MEDICATION NAME] changes. Review of the Nursing Notes dated 11/3/10 at 5:35 PM revealed the facility received a fax from 11/1/10 on 11/3/10. The [MEDICATION NAME] had not been held per new order. Review of the Nursing Notes dated 11/3/10 at 3:35 PM revealed the new order for [MEDICATION NAME]/INR, to draw now and call the results immediately. Review of the Physician's Telephone Orders dated 11/3/10 at 3:35 PM revealed the order to check the resident's [MEDICATION NAME]/INR and call results immediately. Review of the lab report dated 11/3/10 at 4:57 PM revealed the lab value for [MEDICATION NAME] at 78.5 high seconds (Low=8.10 high=12.44) and the lab value for INR 8.0 high critical (low=0.93 high=1.06). The fax also included a new order to administer [MEDICATION NAME] 5 mg (vitamin K to help clot blood) stat (immediately), hold the [MEDICATION NAME] and draw [MEDICATION NAME]/INR on 11/4/10. During an interview with the Director of Nursing on 12/29/10 at approximately 2:00 PM she stated that the fax machine had run out of ink and the fax did not print. She also stated the facility had an action plan completed for this situation. During interview on 1/14/11 at 5 PM, the resident's physician stated in part that he would expect a nurse in the nursing home to notify him if they did not receive a response the following day on an abnormal lab. The physician stated he's a squeaky-wheel and kept on things until they are done. The facility's Physicians Medication Orders policy dated 2010 directed the medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. The facility's Lab and Diagnostic Test Results - Clinical Protocol dated 2010 documented in part that a physician will respond within an appropriate time frame, based on the request from nursing staff and the clinical significance of the information. This response should occur 1 hour, if immediate notification is required or by the end of the next office day to a non-emergency message.