Every finding on record at Accura Healthcare of Ottumwa

Based on clinical record review, observation, facility policy review and staff interview, the facility failed to ensure staff respected the dignity of residents while transporting residents to and from the shower room for 3 of 4 observations of residents (Residents #5, #53 and #54) transported to the shower room by staff. The facility reported a census of 53. Findings include:1. The Minimum Data Set (MDS) assessment for Resident #53, dated 7/9/25, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated a severe cognitive impairment. The resident assessed dependent on staff for bathing, and required maximum/substantial assistance for transferring. The MDS listed a diagnosis of diagnosis of dementia. Review of the Care Plan, last revised 7/10/25, identified Resident #53 dependent on staff for meeting emotional, intellectual, physical, and social needs. The resident required substantial/maximum assistance of one staff for bathing/showering, dependent on assistance of two staff with a gait belt and walker for ambulation, and dependent on one staff for wheelchair use. During an observation on 9/23/2025 at 7:36 AM, Resident #53 sat in a shower chair in the middle of the hallway approximately 8 feet from the shower room. The resident faced the south end of the hall, in the opposite direction of the bathing/shower room. The resident wore a gown, and had been covered with a blanket. Staff A, Certified Nursing Assistant (CNA), approached Resident #53 and pulled the resident backwards in the shower chair approximately 8 feet into the shower room. While pulling the resident backwards, Staff A told the resident she could not push him forward, because the resident's chair did not have foot pedals on it. 2. The MDS assessment for Resident #5, dated 8/6/25, indicated the resident had a BIMS score of 4 out of 15, which indicated a severe cognitive impairment. The resident dependent on staff for showering/bathing, transferring and lower body dressing. The MDS listed a diagnosis of dementia and anxiety. Review the Care Plan, last revised 8/12/25, identified Resident #5 dependent on staff for meeting emotional, intellectual, physical, and social needs. The resident required total assist of one staff for bathing/showering, did not ambulate, required assist of one for wheelchair use, and required total assist with a non-mechanical lift or assist of two staff using a gait belt. During an observation on 9/23/25 at 3:53 PM, Resident #5 sat in a shower chair at the entrance to her room. Staff B, CNA, pulled the resident backwards down the hallway from the resident's room to the shower room approximately 30 feet. During an observation on 9/23/25 at 4:12 PM, Staff B, CNA, pulled Resident #5 down the hallway in a shower chair with the resident facing the opposite direction of the direction pulled. Staff B pulled the resident backwards approximately 30 feet and stopped approximately 5 feet into the resident's room. The resident faced the open doorway, unclothed and covered with a sheet. When the resident shifted in the chair, she exposed herself from her abdomen to her feet. 3. Review of the MDS assessment, dated 8/20/25, revealed Resident #54 had a BIMS score of 10 out of 15, which indicated moderate cognitive impairment. The list of diagnoses included left femur fracture, adult failure to thrive, and adjustment disorder with depressed mood and anxiety. The MDS indicated Resident #54 required substantial to maximal staff assistance for bathing and transfers. Review of the Care Plan, last revised on 6/24/25, revealed Resident #54 required 1 staff, partial to moderate amount of assistance, for showering twice weekly and as necessary. During an observation on 9/23/25 at 1:06 PM, Staff A, CNA, transported Resident #54 in a shower chair through the hallway with a bath sheet placed over resident's lap. Staff A turned the shower chair to enter the shower room and Resident #54's unclothed left side, from her hip to foot was exposed During an interview on 9/24/2025 at 1:39 PM, Staff A, CNA, reported that when she placed the residents in shower chairs to transport to and from the shower, she would pull the resident down the hall backwards with the resident facing the opposite direction she was pulling. Staff A explained if she pushed a resident forward in the shower chair, the residents would be at risk of putting their feet down and breaking their feet. During an interview on 9/24/25 at 2:55 PM, Staff C, CNA, explained she thought staff treated residents with dignity and respect. Staff C reported that when she assisted residents with showers, she pushed them in their wheelchair to the shower and transferred them to the shower chair while the resident was in the shower room. During an interview on 9/25/25 at 8:50 AM, when asked how staff should transport residents to the shower room, the Director of Nursing (DON) stated that she knew the question was in regards to a resident being drug down the hall backwards in the shower chair. The DON explained that the Assistant Director of Nursing (ADON) had told her about seeing a staff pull a resident backwards in a shower chair on Tuesday (9/23/25). The DON reported that the staff had not received any official direction and the DON had no expectation for how the staff transport the residents to the shower room. The DON explained her only expectation was that the resident's got their shower. The DON reported the shower room in the 100 hall was not big enough for a mechanical lift, wheelchair and shower chair, and staff would have to use the shower room in the 200 or 300 hallways. The DON explained this could create a problem with staff being able to get all of the residents' showers done. During an interview on 9/25/2025 at 9:07 AM, the ADON reported she saw Staff A, CNA, pull a resident in a shower chair backwards down the hall. The ADON reported staff should not pull people down the hallway backwards, and explained this was a dignity concern. The ADON reported she provided education to Staff A, CNA. The ADON reported she reminded Staff A to take the residents in a wheelchair to the shower room and transfer them to the shower chair in the shower room. Remind to take in a w/c to the shower and transfer them there. Review of an undated facility policy, titled Shower Policy, directed the staff to take the residents to the shower room, remove the residents' clothing and transfer them to the shower chair in the shower room.

Based on clinical record review, observation, staff interview, and facility policy review, the facility failed to follow infection control techniques to prevent the potential spread of infection for 1 of 1 residents on transmission-based precautions (Resident #19). The facility reported a census of 58 residents. Findings include: The Diagnosis Report revealed Resident #19 had an onset of COVID-19 on 09/02/24 that was acquired during his stay at the facility. The Care Plan initiated 09/30/21 and revised on 09/03/24 revealed Resident #19 had tested positive for COVID-19 and placed in isolation on 09/02/24. The paper Nurse's Notes revealed on 9/2/24 at 1:20 PM, resident not feeling good. A Covid test done and it was positive. The DON (Director of Nursing), physician, and son notified of positive Covid test. Resident placed in isolation precautions. Observations revealed the following: a. On 09/09/24 at 2:20 PM, a plastic bin with drawers sat outside Resident #19's room. The drawers had personal protective equipment (PPE) (gowns, N95 masks) inside. A box of surgical masks sat on top of the cart, and a container of sanitizing wipes and a box of gloves sat on the handrail in the hallway by the resident's room. The door and area by the resident's room and plastic bin had no signage posted to indicate a resident on isolation or transmission-based precautions (TBP), or the need to don PPE prior to entry into the room. b. On 09/09/24 at 2:23 PM, the surveyor asked Staff B, certified nursing assistant (CNA), about the PPE stored in the hallway area near Resident #19's room. Staff B reported Resident #19 in isolation because he had COVID. c. On 09/09/24 at 2:26 PM, Resident #19 coughed while he sat in a chair in his room. d. On 09/09/24 at 2:26 PM, Staff B, CNA, posted a sign on the wall by Resident #19's room labeled Contact / Droplet Precautions and another sign about the PPE required. Staff B reported Resident #19 was the last resident that tested positive for COVID. Staff B stated the resident would come out of isolation on 9/13/24. During an interview on 09/11/24 at 3:30 PM, the Director of Nursing (DON) reported no order written whenever a resident placed in isolation, they just followed the standard CDC's (Center for Disease Control) recommendations. During exit conference on 09/12/24 11:15 AM, the DON reported the isolation signage didn't get put up by the resident's room because the resident got placed in isolation over the weekend. An Isolation - Initiating Transmission-Based Precautions policy revised 8/2019 revealed TBP initiated whenever a resident developed signs and symptoms of a transmissible infection or had a laboratory confirmed infection and at risk of transmitting the infection to other residents. TBP included contact, droplet, or airborne precautions. The policy revealed when TBP's are implemented, the Infection Preventionist (or designee): a. Clearly identified the type of precautions, the anticipated duration, and the PPE that must be used. b. Determined the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors were aware of the need for and the type of precautions: (1) The signage informed the staff of the type of CDC precautions, the instructions for use of PPE, and/or instructions for visitors / staff to see a nurse before entered the room. (2) TBP's remained in effect until the attending physician or Infection Preventionist discontinued the precautions, which occurred after the criteria for discontinuation met.

Based on observations, staff interview, and policy review the facility staff failed to serve food under sanitary conditions to prevent food borne illness during 1 of 2 meals observed. The facility identified a census 58 residents. Findings include: During observations on 09/10/24 at 8:40 AM, the Social Services designee peeled a banana for residents in the main dining room, then used her bare hand to remove the banana from the banana peeling and gave the banana to the resident or placed the banana onto the resident's plate. At 08:44 AM, Staff A, certified nursing assistant (CNA), peeled a banana for a resident, then used her bare hand to place the banana onto the resident's plate. Staff A then picked up a slice of toast, placed the bread in the palm of her bare hand and took a knife to apply jelly onto the toast. Staff A then placed the toast onto the resident's plate. During an interview 09/11/24 at 12:50 PM, the Food Service Supervisor reported staff should use a fork or something to hold ready to eat foods such as when they removed a banana peeling, or put jelly or butter on bread. The Food Service Supervisor stated staff could also wear a glove or use a paper towel to hold the food, but staff should not directly touch the resident's food. The facility's General Food Preparation and Handling policy dated 2013 revealed food items prepared to keep free of injurious organisms and substances. Bare hands should never touch raw food directly. Food such as bread or other items served with tongs, fork, or other suitable implements to avoid manual contact of prepared foods.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to process physician orders, and failed to provide and document physician ordered treatments such as wound care and dressing changes for 1 of 5 residents reviewed for skin conditions. The facility also failed to document a change in skin condition and the treatment interventions initiated for 1 of 5 residents reviewed for skin conditions (Resident # 32). The facility reported a census of 58 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #32 had diagnoses of heart failure, anemia, and Alzheimer's disease. The MDS indicated the resident had no skin issues. The Care Plan initiated 6/3/24 and revised on 9/3/24 revealed Resident #32 had abrasions to the left and right knee, top of her right foot, and right pinky toe/nail. The Care Plan directed staff to administer treatments as ordered, monitor for effectiveness, and document skin breakdown measurements. The electronic health record Progress Notes revealed the following: a. On 8/24/24 at 7:00 AM, skin tear on left shin 1.0 centimeter (cm) x 1.5 cm. Cleanse wound with wound cleanser, pat dry, cover with xeroform and a medipore dressing every AM (morning) and PRN (as needed) until healed. b. On 9/1/24 at 4:30 AM, cleanse all abrasions with wound wash and pat dry. Cover the right foot areas #1 and #2, right knee, left knee, right shoulder, and right pinky toe with xeroform, non-adherent pad, and gauze every day until OTA (open to air). An intervention note included to administer treatments as ordered and monitor for effectiveness. c. On 9/3/24 at 1:08 PM, the Assistant Director of Nursing (ADON) documented to discontinue current treatment to the foot and legs. New order obtained to cleanse the knees and right foot, cover with TAO (triple antibiotic ointment), and leave the areas OTA daily until the area healed. d. On 9/10/24 at 12:59 PM, the ADON documented to cleanse the left knee with wound wash, cover with hydrofera blue and a gauze wrap daily. Cleanse the right knee, cover with xeroform, telfa, and a gauze wrap daily. An Incident Report revealed on 9/1/24 at 4:05 AM, a CNA (certified nursing assistant) passed by the resident's room and observed her empty bed. The CNA entered the room and found the resident in a prone position alongside the bed on the floor, and a body pillow on top of her. The resident's bilateral knees had abrasions and the right shoulder had a small abrasion and ecchymosis (bruise). Abrasions cleansed with wound wash, and covered with xeroform, a non-adherent pad, gauze and tape. A Memo to the Physician (Dr) dated 9/1/24 revealed the resident found on the floor in a prone position next to the bed. The resident had superficial abrasions on her knees, the top of her right foot, and her right upper arm. No mass or lacerations noted. The resident surely must have hit her head due to the back of her head found against the bed. The resident moved all extremities, and able to bear weight without complaints. The right pinky toe toenail hung loosely. All areas cleansed with wound wash, and a xeroform and a non-adherent dressing applied. Dressing changes (to be completed) on the PM (evening shift). The Physician's Telephone Orders revealed the following: a. On 8/30/24: a skin tear on the left shin had scabbed over. Order to apply skin prep to the left shin area every AM for 7 days. b. On 9/1/24: cleanse all abrasions with wound wash and pat dry. Cover the right foot, right knee, and left knee with xeroform, non-adherent pad, and a gauze roll. Change the dressing daily until OTA. c. On 9/3/24: discontinue current treatment to the foot, legs, and shoulder. A new order to cleanse the knees and right foot areas, then apply TAO daily, and leave areas OTA until healed. The Order Summary Report revealed the following orders: a. Cleanse areas to bilateral knees and right foot with wound cleanser and pat dry. Cover areas with a thin layer of TAO, and leave OTA daily for wound healing had a start date 9/3/24. b. An order to cleanse bilateral knee abrasions with wound cleanser, pat area dry, then apply xeroform, telfa (a non-adherent dressing), and rolled gauze daily had a start date 9/9/24. c. Cleanse left knee with wound wash, cover with hydrofera blue, and wrap with gauze daily had a start date 9/11/24. d. Cleanse abrasions to right knee with wound cleanser and pat dry. Apply Xeroform, telfa (a non-adherent dressing), gauze, and tape daily started on 9/11/24. The Non-pressure Skin Condition Report dated 9/1/24 revealed the following: a. Left knee abrasion 5.5 cm x 4.5 cm b. Right knee abrasion 1.5 cm x 1.7 cm c. Top of right foot abrasion wound #1 measured 0.5 cm x 2 cm and wound #2 measured 1.5 cm x 1 cm. The section for nurse signature was left blank. d. Right foot pinky toe/toenail had incomplete documentation. e. Right shoulder/ lateral upper arm abrasion measured 9.5 cm x 5 cm. A Routine Medications form dated 9/1/24 revealed the following handwritten order: a. Cleanse left and right knee abrasion with wound wash, pat dry, apply xeroform, non-adherent pad, and a gauze roll every PM started 9/1/24. b. Cleanse top of right foot area #1 and #2 with wound wash, pat dry, apply xeroform, non-adherent pad, and gauze roll every PM started on 9/1/24. Wound #1 measured 0.5 cm x 2 cm and Wound #2 measured 6.0 cm x 1 cm. c. Cleanse right pinky toe/ toenail with wound wash, pat dry, gently weave xeroform around toenail and secure with a small kerlix and tape daily on the PM shift. The Treatment Record (TAR) dated 9/1 - 9/13/24 revealed: a. Apply skin prep to the left shin every AM for 7 days started on 8/30/24. The record lacked staff initials or documentation of the treatment performed 9/1/24 - 9/5/24. b. Cleanse left knee with wound wash, cover with hydrofera blue and gauze daily started on 9/10/24. c. Cleanse right knee with wound wash, cover with xeroform, telfa and gauze daily started on 9/10/24 d. Cleanse top of right foot, apply hydrofera blue and cover with bordered gauze daily until healed started on 9/10/24. e. Cleanse right pinky (little) toe, apply TAO and a Band-Aid daily until healed started on 9/10/24. The treatment record lacked a treatment for TAO and OTA (order started on 9/3/24), and nursing observations and comments about the wound areas. During observation on 9/10/24 at 11:18 AM, Staff C, Registered Nurse (RN), obtained supplies, washed hands, donned gloves, and removed dressings on Resident #32's right and left knee. Staff C cleansed the right and left knee wounds with wound wash and gauze. Staff C reported the left knee wound looked worse from when she previously had looked at the wounds and performed the treatment the prior week. Staff C stated she was going to go get the DON and ask her to look at the area. Staff C left the resident's room. At 11:24 AM, Staff C and the DON entered the resident's room. The DON looked at the resident's left knee wound and reported she planned to call the Dr to get a different treatment order. At the time, the DON asked the resident if her right knee hurt. Resident #32 responded Oh yea, the pain is all the way down there. Staff C measured the wounds and wrote the numbers on a piece of paper: Right knee: 2 cm x 1 cm Left knee: 3 cm x 6.5 cm The DON left the room. At 11:28 AM, Staff C donned a pair of gloves then applied xeroform, telfa, and gauze to the right knee wound. Staff C dated and initialed the dressing. At 11:39 AM, the DON returned to the room and provided supplies to Staff C. The DON told Staff C she would write the order received from the Dr. Staff C applied gloves and proceeded to apply sterile water to a piece of hydrofera blue foam dressing, then applied the hydrofera blue and a rolled gauze dressing to the left knee wound. During observation on 9/10/24 at 1:50 PM, Staff D, CNA, provided cares and assisted the resident into bed. Staff D removed the gripper sock on the resident's feet. The top of the resident's right foot had a border foam dressing and a large dark area of drainage that bled through the dressing. The dressing and tape had no date and no initials. At the time, Resident #32 reported her toe hurt when she walked and her foot caught on the floor. During an interview on 9/10/24 at 12:29 PM, Staff C reported she wrote the Dr's order on a Telephone order form whenever a new order was received. She also entered the order into the computer, faxed the order to pharmacy, wrote the order on the MAR (medication administration record) or TAR, and wrote a note in nurse's Progress Notes about the order and what was done. On 9/10/24 at 2:00 PM, the surveyor approached Staff C and asked about the treatment to Resident #32's foot. Staff C reported she didn't know anything about a treatment for Resident #32's foot. She last saw the resident on Tuesday, 9/3. The resident had a fall on 9/1/24. Staff C reported she normally did resident skin treatments on Mondays but she was not at the facility the past Monday due to the holiday, so she completed the residents' skin assessments and treatments on Tuesday, 9/3/24. On that day, Resident #32's foot had a scab over it, and she applied TAO and left it OTA. At the time, Staff C obtained some supplies and entered the resident's room with the surveyor. Staff C washed her hands, donned gloves, and removed the gripper sock on the resident's right foot. Staff C confirmed the dressing had no date or initials. Staff C stated she was uncertain when the dressing had been applied or last changed. Staff C reported the wound to the top of the foot had a lot of slough in it. The wound had redness around it. Staff C reported the wound was superficial and had a scab and almost healed the prior week. Staff were supposed to put TAO and OTA. She didn't know why or who covered the area. Staff C stated she planned to call the Dr to see about a treatment to the area. She thought the Dr would want therafera blue to help remove the slough. Staff C then removed the broken toenail from the resident's right little toe. Staff C reported to the surveyor the non-pressure skin condition reports for Resident #32's wounds were in Staff E's top desk drawer. She didn't know why the skin condition reports weren't in the treatment book. Normally the TAR and skin assessments were kept in the treatment book. Staff C recalled when she entered the order in the computer for TAO to the area, she printed it off and put it in the treatment book on 9/3/24. Staff C stated she didn't know why the TAR was not in the book today, but facility staff were sorting through papers and looking for it. On 9/10/24 at 2:15 PM, Staff C reported she spoke with the Dr and obtained an order for therafera blue and kerlix to the top of Resident #32's foot starting 9/10/24. Staff C reported she would enter the order. During an interview 9/10/24 at 2:18 PM, Staff E, RN, reported whenever she received a Dr's order, she wrote the order on a Telephone Order form, documented the order in the hard chart (paper) nurse's notes, wrote the order on the MAR or TAR, and sent the order to the pharmacy if it's a medication or treatment order. Staff E explained the Telephone order form was a triplicate form. The original form placed in the resident's chart, the yellow copy was sent to the DON, and the pink copy sent to the ADON/Care Plan Coordinator. Staff E reported the nurses helped enter orders whenever they had a stack of orders to process. Staff E reported skin assessments documented on a non-pressure skin record or pressure wound record. Staff C, Staff E, and the DON completed follow up skin assessments with measurements weekly. They determined if the wound or skin concern improved or deteriorated. Staff E reported she had covered a lot of night shifts so she hadn't been doing the skin assessments unless she found a new skin concern during her shift. Staff E stated she did treatments as ordered and called the Dr if a wound had not showed improvement. Staff E reported when staff found Resident #32 on the floor (9/1/24), she assessed the resident. The resident had abrasions to her knees and right foot. She wrote an order to apply xeroform and kerlix because the wounds looked wet. She suspected the treatment would change to TAO and OTA in a couple of days. She filled out the treatment record form and placed the form in the treatment book, but she had a couple things to write on the skin report so she put the skin report papers in her desk drawer to finish later. Resident #32 just had the abrasions. She planned to come in on Monday to finish filling out the skin record and sign the document but she got distracted and didn't get it done. That's why the forms were still in her desk drawer. She figured the nurse would just measure the areas each week. On 9/10/24 at 2:40 PM, Staff E provided the surveyor the orders she wrote on the TAR on 9/1/24 and reported her initials as the only entries signed off on the treatment on that day only. The TAR had no other staff initials listed 9/1/24 to 9/10/24. During an interview on 9/11/24 at 8:09 AM, the physician reported when he wrote an order, he expected or hoped staff carried out the order, such as a treatment. He reported the facility staff let him know if a medication or treatment was not available or a reason why a treatment should not be carried out. He expected staff to notify him if a wound got worse. The physician reported wounds could be tricky. He gave staff [NAME]-way especially if they were familiar with wound care. The facility had standing orders for nurses to initiate a wound treatment based on an assessment. He gave the nurse discretion about what to do until he could visualize the wound himself. The physician reported he had not seen Resident #32 since she had the fall but he was aware of it and the wound treatment implemented. During an interview 9/11/24 at 10:39 AM, the DON reported Staff C obtained wound measurements weekly. The facility had standing orders for nurses to implement a treatment until the Dr came to the facility and assessed the resident. During an interview 9/11/24 at 2:21 PM, the ADON stated she was also the MDS/ Care Plan Coordinator. The ADON reported she wasn't working on the day Resident #32 had a fall. She entered a nursing Progress Note in the EHR, then went into the resident's Care Plan and entered a comment to administer the treatment as ordered. She entered a comment whenever she updated or revised the Care Plan so she could track the changes and when they occurred. The ADON demonstrated on the computer the steps she took when she entered information into the Care Plan. She confirmed a revision on 9/3/24 on Resident #32 because the resident had a change in wound treatment. The ADON reported she only entered the information on the resident's Care Plan. The DON and Staff C entered the Dr's order into the computer and do what they needed to do to process the order. The ADON explained the process for when an order received. Order written on a telephone order form. The order form is a triplicate form. The white (original) was placed in the Dr's box to review and sign, the pink form went to the ADON to enter the information into the resident's Care Plan or MDS, and the green form given to the DON or Staff C to process the order. The white copy of the form got placed into the paper chart after the Dr signed off on the order. The ADON reported Staff C performed the skin assessments on residents with wounds each week but Staff F performed the skin assessments before Staff C took it over. During an interview 9/11/24 at 2:29 PM, Staff F, RN, reported she was the person designated to do skin assessments a while back but had not done the skin assessments since 5/2024. Staff C, RN, responsible for performing skin assessments since 5/2024. The skin assessment performed weekly on residents with wounds or a skin concern. During an interview 9/12/24 at 9:44 AM, the DON reported she came into the facility on the evening of 9/2/24 to report a COVID positive case at the facility. Staff H, RN, requested her to look at Resident #32's knees and foot. The DON stated she observed the areas. The areas looked dry and scabbed over. She told Staff H to start TAO and Staff C would look at the area the next day. The DON reported she couldn't find Resident #32's skin sheet or TAR. She found the TAR for September in the resident's paper chart, not in the treatment book. She was not able to find Resident #32's skin records but then found them in Staff E's desk this week after the surveyor asked for them. The DON reported Dr's order faxed to pharmacy, but the order not faxed to pharmacy whenever treatment supplies used from their stock. The DON reported Staff G, RN, changed Resident #32's treatment and implemented a standing order for xeroform because the resident's left knee area was too dry and had cracked open. The standing orders gave the nurses discretion to implement treatments for skin tears and abrasions. The DON reported Staff G didn't chart the change in treatment or write the order for the xeroform treatment when she initiated this treatment. The DON reported she expected staff to follow orders and document when treatments performed. The DON reported there were paper records everywhere. Staff had trouble deciphering some documentation and she had to call a nurse to have her relay the notes she wrote. The DON reported Staff E wrote the Incident report and the memo to the Dr about Resident #32's fall and abrasions. During an interview 9/12/24 at 9:54 AM, Staff G, RN, reported Resident #32 had a treatment order that Staff E wrote but Staff E's handwriting was awful. Staff G stated she couldn't read the order. Staff G reported when she came into work over the weekend on 9/8, no TAR found for Resident #32. She had just arrived to work when a CNA came and told her Resident #32's leg was bleeding and she wanted her to look at it. She looked at the area and then cleaned it. Staff G reported the resident's knees were scabbed over, but one knee had cracked open. Staff C oversaw the wounds but since Staff C not working and it was over the weekend, Staff G applied Vaseline and a kerlix over the area. She planned to write the order but it was a crazy day and she didn't get the order written before she left for the day. She wasn't 100 % sure what Staff C would want on the wound but she felt she needed to do something. Staff G explained they had standing orders and it was at the nurse's discretion on what treatment to use. She did what she thought would be the best treatment. Staff G confirmed she did not document a Nurse's Note when the resident's knee had bleeding, the steps she took, or the treatment performed. Staff G reported she couldn't find the TAR so she didn't document the treatment on the TAR either. An undated non-pressure skin condition assessment policy revealed weekly skin assessment of skin conditions documented on non-pressure skin assessment sheet to help prevent infections or other complications for all non-decubitus skin lesions and assure documentation of the healing. All skin conditions such as open areas or abrasions assessed and documented on a non-pressure skin sheet. Subsequent weekly documentation should show the response to treatment as well as a description of the size and appearance of the affected areas. Signs of infection or poor response to treatment reported to the physician. A Physician Order Transcription policy effective 7/2023 revealed orders received and orders transcribed by a nurse onto an order sheet in the patient's chart. Orders signed, dated, timed, and noted at the time it is written on the order sheet or entered into the computer system.

Based on clinical record review, policy review, and staff interviews, the facility failed to ensure staff transferred a resident in a safe manner for 1 of 4 residents reviewed for transfer technique (Resident #14). When a staff member assisted Resident #14 to stand from a seated position, she didn't use a gait belt. Resident #14 fell and sustained a wrist fracture and femur (leg bone) fracture. The facility reported a census of 57 residents. Findings include: Resident #14's Minimum Data Set (MDS) assessment dated [DATE], reflected she had a short and long-term memory problem. The cognitive skills for daily decision making indicated Resident #14 had severely impaired decision-making ability. The MDS stated Resident #14 required extensive assistance of 1 staff for transfers, walking, and bathing. The MDS included diagnoses of repeated falls, heart failure, and Alzheimer's disease. The facility Gait Belt Policy, revised 1/4/12, listed purposes of gait belts which included to provide safe transfers for residents and to allow staff to gradually lower a resident to the floor if necessary, reducing the risk of injury. A 4/22/21 Care Plan entry stated Resident #14 required extensive assistance of 1-2 staff to move between surfaces. The Incident/Accident Report dated 9/29/23 reflected Resident #14 left knee gave out, causing her to fall backwards to the floor. The report described her with her leg adducted (in a position toward the center of the body), with a swollen and painful wrist. An undated written statement by Staff B, Certified Nursing Assistant (CNA), stated she assisted Resident #14 with a shower and had her stand at the bar in order to pull up her pants. Resident #14 went down out of the blue and Staff B held her by her underarms hoping she would go down to the floor easier but she still hit the floor pretty hard. Staff B summoned assistance and other staff arrived. A 9/29/23 at 3:50 PM the Nurse's Notes stated Resident #14 sat in front of her wheelchair in a sitting position and complained of right wrist pain and observation revealed swelling and redness in the right wrist and her left leg appeared adducted. The facility transferred Resident #14 out by ambulance. A 9/29/23 at 4:40 PM the Nurse's Notes stated Resident #14 had a right wrist fracture. A 9/29/23 at 7:30 PM the Nurse's Notes stated Resident #14 had a fracture of the left knee and would transfer to a different hospital. A 9/30/23 Emergency Department (ED) Progress Note stated Resident #14 fell , sustaining a femur fracture and wrist fracture. She required a higher level of care. A Major Injury Determination Form, dated 10/2/23, stated as the CNA put on a brief on Resident #14 as she stood after her shower, her left leg gave out causing her to fall backwards to the floor. Resident #14 previously required the assistance of 1-2 staff members for physical activities of daily living (ADL). A 10/5/23 at 11:13 AM Nurse's Note stated Resident #14 readmitted from the hospital following a fracture of the left femur and fright ulna (wrist bone). Resident #14 had an open reduction and internal fixation (ORIF a type of surgical repair of a broken bone) of the left femur on 10/2/23. A 10/5/23 Care Plan entry stated Resident #14 required total assistance by 2 staff and a mechanical lift to move between surfaces. A 10/17/23 Social Progress Notes entry stated Resident #14 had a significant change due to her decline since her fall. Resident #14 appeared down at times and unsure of why she could not do things she did previously. A Care Plan entry, revised 1/8/24 stated Resident #14 required total assistance of 2 staff with a gait belt On 4/24/24 at 3:18 PM, Staff B CNA stated she assisted Resident #14 with her shower. After the shower she had Resident #14 stand up from the shower chair at a bar on the wall and Resident #14 slipped. Staff B stated she did not have a gait belt on Resident #14 and Resident #14 almost fell on top of her. She stated when Resident #14 fell , she only had a shirt on and that was the only thing she could hold on to. She stated after Resident #14 fell , she began to utilize gait belts in that situation. On 4/24/24 at 3:55 PM, the Director of Nursing (DON) stated Resident #14 required the assistance of 1 2 staff members at the time of the fall and staff should have used a gait belt. On 4/24/24 at 4:05 PM, via phone, Staff C, Licensed Practical Nurse (LPN), stated she did not witness Resident #14's fall but arrived after. She stated just looking at her, she knew she broke something, with her left foot sideways and her other foot vertical. She stated she had staff call 911 and they sent her to the hospital. On 4/24/24 at 3:55 p.m., the Director of Nursing (DON) stated Resident #14 required the assistance of 1 2 staff members at the time of the fall and staff should have used a gait belt. On 4/25/24 at 8:12 AM, Staff D, CNA, stated prior to the fall Resident #14 was an easy assist of 1 staff member and she could easily stand at the bar. Staff D stated after the fall she was more difficult and now required the assistance of 2 staff. Staff D stated if she assisted Resident #14 to stand at the bar, she would absolutely utilize a gait belt. On 4/25/24 at 8:36 AM, Staff E, CNA, stated if she stood a resident up at the bar in the shower she would always use a gait belt. She stated after the shower, Resident #14's pants were off so there was nothing else to grab on to. In a 4/25/24 at 11:14 AM email, the Administrator stated with regard to the reporting policy for a major injury, the facility referred to the Major Injury Determination Form.

Based on observation, interview, record review, and the manufacturer insulin packaging insert, the facility failed to prime the insulin pen prior to administration for 1 of 2 residents reviewed for insulin administration (Resident #6). The facility reported a census of 59 residents. Findings include: Resident #6's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 13, indicating intact cognition. The MDS included a diagnosis of diabetes mellitus (DM). The MDS reflected Resident #6 received insulin injections for 7 out of 7 days. The Care Plan revealed a focus area revised on 1/6/24 for Type II DM. The interventions dated 8/16/22 revealed diabetes medication as ordered by doctor. The Electronic Medical Record (EMR) revealed the following diagnoses: a. Type II DM with moderate nonproliferative diabetic retinopathy (the walls of the blood vessels in the retina weaken) with macular edema (swelling inside the retina), right eye. The EMR revealed the following physician orders: a. ordered 3/1/24 - Insulin Detemir subcutaneous solution - inject 18 unit subcutaneously one time a day During an observation on 4/23/24 at 7:58 AM, Staff A, LPN (Licensed Practical Nurse), prepped Resident #6 Detemir insulin pen for administration. She wiped the hub with alcohol, applied the needle, and turned the insulin pen knob to 18 units. She did not prime the insulin pen prior to turning the knob to 18 units. She then injected the insulin into Resident #6 abdomen. During an interview on 4/23/24 at 12:10 PM, Staff A queried if the insulin pen needed primed prior to administration and she stated sometimes, but sometimes they didn't need to because of the needles they used. Staff A stated she would read the box of the needles and make sure they didn't need to prime the needle. Staff A then stated she messed up and should of primed the needle. During an interview on 4/25/24 at 11:05 AM, the DON (Director of Nursing) queried on the prep prior to administering an insulin pen to a resident and she stated that all insulin pens needed primed to at least 2 units. The Facility Medication Administration Policy (no date identified) did not address the process of insulin pen administration. The Insulin Detemir Package Insert dated 1/17/19 revealed the following information: a. Prepare your pen 1. Check your insulin type 2. Attach a new needle 3. Prime your Pen - Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears.

Based on observations, interviews, and policy review, the facility failed to provide food storage and maintain proper food temperatures in a safe and consistent manner. This practice had the potential to affect 56 out of 56 residents who consumed food from the kitchen. Findings include: Review of the facility's undated policy titled, Storage, indicated, food will be stored at the proper temperature and for the appropriate length of time to protect the quality of food, all refrigerated foods and freezer foods will be labeled (if unidentifiable) and dated at time of delivery. Review of the facility's undated policy titled Food Temperatures, indicated, to ensure that food is served at the appropriate temperature to prevent the growth of harmful bacteria and other food borne illnesses, hot food temperatures must read no less than 140F [Fahrenheit] when residents are served; cold, food temperatures should be below 41F at the times during meal service. Review of the facility's undated policy titled Maintenance, indicated, clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a water care professional to test the water quality and recommend appropriate water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing. Cleaner and Sanitizer are the only products approved for use in Manitowoc ice machines. During an initial kitchen walk-through with the Dietary Manager (DM) on [DATE] beginning at 9:38 AM, the following were observed: 1. Located in the reach in refrigerator, the parmesan cheese dressing, one gallon (gal) tub, 90 percent (%) consumed was not labeled or dated. DM stated, this should have been thrown out. 2. Located in the reach in refrigerator, the shredded lettuce dated ,d+[DATE] was brown, wilted, and slimy. 3. Located in the reach in cook's freezer, 25 pieces of cubed steak in plastic bag with freezer burn was opened and not dated. 4. Located in the reach in refrigerator, Hershey Carmel Ice Cream topping was not dated and opened. 5. Located in the reach in refrigerator, HyVee yellow mustard ,d+[DATE] consumed was not dated and expired on [DATE]. 6. Located in the reach in refrigerator, Hyvee ketchup opened over 90 % consumed and was not dated. 7. Located in the reach in refrigerator, Smucker's strawberry jelly 25 % consumed was opened and not dated. 8. Located in the reach in refrigerator, heavy whipping cream was opened and expired on [DATE]. 9. Located in the reach in refrigerator, lime juice over 90 % consumed had expired on [DATE]. 10. Located in the walk-in pantry, opened bag of dry cereal 46 ounces (oz) expired on [DATE]. 11. Located in the walk-in pantry, taco seasoning opened and dated ,d+[DATE] but no use by date. 12. Dry Lemonade drink mix 18 ounces (oz) opened not sealed, with no date received or use by date. 13. Located in the walk-in pantry, egg noodles, five-pound (lb) bag was opened and not dated. 14. Located in the cook's reach in freezer, four loaves of raisin bread, 28 slices per loaf was not dated, with visible ice crystals and freezer burned. 15. Located in the cook's reach in freezer, fajita mix 2.5 lb., five bags not labeled or dated with freezer burn. Observation of facility's main dining room area on [DATE] at 10:40 AM with the DM: 1. Facility ice machine in main dining room had a black and green slime like substance and build up inside the ice machine on the plastic bin that produces ice. 2. Within the Snack cart Rubber Maid ice cooler 48 quart were ten half pint milk assorted flavors, holding at 49 degrees. DM stated, the cold items should be lower than 41 degrees 3. Located in the snack cooler, apple juice and cranberry juice holding at 46 degrees. DM stated, the juice should be holding at 41 degrees or below. During an interview with the DM on [DATE] at 10:45 AM revealed, everyone should know that they are to label all food items received and any opened or expired food items should be thrown out. The DM further stated, the snack cooler should be filled with ice after placing the cold items in it. All cold items should be held at 41 degrees or below. Snacks are passed at 10:00 AM, 2:30 PM and HS [evening]. During this same interview the DM stated, the ice machine is cleaned and sanitized every three to six months or as needed per the manufacturers recommendation. I normally, check it more regularly but have not recently. During an interview on [DATE] at 11:42 AM, Dietary Aide (DA) 1 stated, normally, I would fill the cooler with ice before placing perishables items in it but today a resident was talking to me and telling me her coffee was not good. So, I went to get her another cup of coffee and forgot to fill the cooler with ice.

Based on interview, record review, and policy review, the facility failed to ensure residents who were dependent on staff for shaving assistance received services for one resident (R) R48 reviewed for Activities of Daily Living (ADL) assistance. The sample size was 26 residents. Findings include: Review of the ''Vista Woods Care Center Activities of Daily Living'' policy dated 01/27/12 revealed ''A resident's ability to perform the activities of daily living will remain stable unless circumstances of the resident's clinical condition demonstrate that diminution was unavoidable. This includes the resident's ability to bathe, dress, and groom self.'' ''Residents will be provided appropriate treatment and services to maintain or improve their abilities.'' The facility provided policy did not address ADL assistance for dependent residents. Observation on 11/14/22 at 9:52 AM of resident with chin and upper lip hairs. R48 indicated she would like to have the hairs trimmed and she has not gotten the hairs trimmed in weeks. Observation on 11/16/22 at 8:57 AM of resident with chin and upper lip hairs with the Director of Nursing (DON). The DON confirmed R48 had long chin hairs and the hairs needed to be trimmed. Review of the electronic diagnosis list located under the ''Diagnoses'' tab for R48 included age related physical debility, abnormalities of gait and mobility, hypertension, and type 2 diabetes mellitus with hyperglycemia. Review of the electronic annual ''Minimum Data Set (MDS)'' located under the ''MDS'' tab for R48 with an Assessment Reference Date of 10/03/22 revealed a ''Brief Interview for Mental Status (BIMS)'' score of 15 indicating R48 was cognitively intact. Further review of the ''MDS'' revealed R48 required extensive one person assistance for personal hygiene. Review of the electronic care plan located under the ''Care Plan'' tab dated 10/10/22 revealed ''ADL FUNCTIONAL: [R48] has an ADL self-care performance deficit r/t [related to] constipation, Diabetes Mellitus 2, insomnia, hyperlipidemia, hypertension, depression, pain in right leg, presences or right artificial knee joint, hypokalemia, glaucoma, debility, difficulty walking, pain, other abnormalities of gait and mobility, repeated falls, right femur fracture with Non weight bearing status right leg. COVID precautions.'' During an interview on 11/16/22 at 8:57 AM, the DON confirmed R48 had visible chin hairs. The DON stated the resident should be receiving shaving assistance when she received showers. The DON also confirmed the resident was scheduled for two showers a week.

Based on interviews, record review, and facility policy review, the facility failed to ensure one (Resident (R) 13) of five residents reviewed for unnecessary medications had ongoing clinical indications for the use of an antipsychotic (Haldol). The facility failed to monitor for the target behavior related to the rationale for the antipsychotic. Findings include: Review of a document provided by the facility titled Psychoactive Drug Monitoring, undated indicated . Residents who receive . antipsychotic medications are monitored to evaluate the effectiveness of the medication. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of untoward effects . Behavioral monitoring charts or a similar mechanism are used to document the resident's need for and response to drug therapy . Review of R13's electronic medical record (EMR) titled Admission Record, undated located under Profile tab, indicated the resident was admitted to the facility on [DATE]. Review of R13's Physician Orders located under the Orders tab indicated the resident was to receive Haldol 1 milligram (mg) at bedtime for dementia with behaviors. Review of R13's EMR titled Care Plan located under the Care Plan tab dated 11/18/21 indicated the resident had a diagnosis of Alzheimer's disease, was considered unsafe and attempted to walk without assistance. The care plan indicated the resident was non-compliant with using her call light. The care plan indicated the resident was physically combative with staff during cares and picked at her cheek even though there was nothing on her face. The care plan revealed the resident would be delusional by crying out for her mother. The intervention was to monitor the resident's behaviors in an attempt to determine the underlying cause. The intervention directed staff to document her behavior and potential causes as needed. Review of R13's EMR significant change Minimum Data Set (MDS) with an Assessment Reference Date of 08/17/22 located under the MDS tab indicated the staff could not determine the resident's Brief Interview for Mental Status (BIMS) score. The staff determined the resident had short- and long-term memory problems. This assessment indicated the resident had delusions during the assessment period. During an interview on 11/16/22 at 8:38 AM, Licensed Practical Nurse (LPN) 1 stated R13 can become distressed and combative at times. LPN1 did not provide a response when asked about where the resident's behavior was documented. During an interview on 11/16/22 8:42 AM, Certified Nursing Assistant (CNA) 2 stated R13 cried a great deal and the resident missed her mother. CNA2 stated she just alerted the nurse if the resident had a behavior and confirmed the behavior was not documented by the CNA staff. During an interview on 11/16/22 at 9:36 AM, the Social Services Director (SSD) stated she observed R13 with behaviors such as crying each day but did not document. During an interview on 11/16/22 at 12:26 PM, the Director of Nursing (DON) stated R13 had many episodes of crying and tearfulness. The DON stated the resident will be resistive to showers. The DON stated the staff should be documenting the resident's behavior. During a subsequent interview on 11/16/22 at 12:46 PM, the DON confirmed there were no documented behaviors in R13's clinical records. During an interview on 11/16/22 at 3:25 PM, the Consultant Pharmacist stated R13 should have targeted behaviors documented to ensure the psychotropic medications were effective or not.

Based on observations, interview, record review, and facility policy review, the facility failed to ensure a resident was free from physical restraints. Specifically, the facility failed to assess, monitor, and implement interventions according to standards of practice during the use of a physical restraint that is used for treatment of a medical symptom, and provide ongoing monitoring and evaluation for the continued use for one of one (Resident (R) 47) sampled for physical restraints in a total sample of 27 residents. This failure placed the resident at risk for a diminished quality of life. Findings include: Review of the facility policy titled, Physical Restraints, revised 10/10/10 revealed, The resident has the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's physical medical symptoms. DEFINITION: Physical restraints are any manual method, or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. During an observation on 11/14/22 at 11:58 AM, R47 was seated in a Merry [NAME] (a combination wheelchair and walker used for ambulation that utilizes a front gate and strap to enclose the resident) in the dining room, ambulating while in the Merry Walker. During an observation on 11/14/22 at 1:57 PM, R47 was seated in her Merry [NAME] in the main dining room. During an observation on 11/14/22 at 3:36 PM, R47 was seated in her Merry Walker, pulling at the strap. During an observation on 11/15/22 at 9:43 AM, R47 was in the main dining area seated in her Merry Walker. R47 appeared drowsy. During this same observation, this surveyor asked R47 if she could get out of her chair. R47 did not respond but attempted to engage the latch to unlock the Merry Walker. R47 attempted three times with one hand and then two times with both hands. The resident was unsuccessful in unlocking the lap belt clamp. During an observation on 11/15/22 at 11:23 AM, R47 was observed in dining room seated in Merry Walker. During an observation on 11/16/22 at 10:08 AM, with Certified Nursing Assistant (CNA) 3, R47 was observed in her room seated in her Merry Walker. R47 was prompted four times by CNA3 to unlatch the Merry [NAME] strap. R47 was unsuccessful in unlatching the strap. CNA3 revealed, I have never seen the resident unlatch the belt to get out. During an observation on 11/16/22 at 10:15 AM, with Registered Nurse (RN) 1, R47 was seated in hallway in her Merry Walker. RN1 prompted R47 to unlatch seatbelt and Merry [NAME] bar. R47 was unable to unlatch the seatbelt and unlock the bar. This observation revealed R47's Merry [NAME] had a two-part unlocking process to get out and the resident was unable to perform the process. RN1 stated, the two-part process included unlatching the seatbelt and pulling a small, round pin to release the bar. RN1 revealed, I've never seen her get out and that would mean it's a restraint. Review of R47 Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed R47 was admitted to the facility on [DATE] with the following diagnoses, Parkinson's, depression, and dementia. Review of R47's Minimum Data Set (MDS) located in the EMR under the (MDS) tab with an Assessment Reference Date (ARD) of 09/29/22 revealed, R47 had a Brief Interview for Mental Status (BIMS) score of eleven out of fifteen, indicating R47's cognition was moderately impaired. Review of a Social Services note located in the Social Services tab of the paper chart dated 10/06/22 revealed, R47 was able to complete the BIMS assessment her cognitive interview score was an 11 out of 15 indicating, moderately impaired cognitive ability. She has a diagnosis of dementia and neurocognitive disorder with lewy [sic] bodies. This score is higher than expected and not indicative of her daily cognition . Review of the Social Services note revealed, R47 has delusions, some safety concerns. She is very 'figety' [sic] & [and] wanders aimlessly about the facility in a Merry Walker. Review of Physician Orders located in the EMR under the Orders tab dated 09/29/22 revealed, may use Merry [NAME] as needed. Review of R47's History and Physical located in the paper chart written by the facility's physician, dated 09/29/22 indicated, We are going to try a Merry [NAME] to see if that helps maintain mobility with reduce chance of falls . She is extremely high risk for ongoing falls, which will not be able to be prevented due to her significant impulsivity, poor cognition, and desire to continuously walk. Review of R47's Care Plan located in the EMR under the Care Plan tab dated 10/06/22 revealed an Ambulation care plan which documented the following intervention, May use Merry walker [sic] as needed. An additional Falls care plan documented the following intervention receives comfort in the fact that she is able to move around. Due to her unsafe walking stance, she is currently using a Merry walker [sic] so that she may be more independent in the facility. Review of R47's Hospice Assessment provided by facility dated 09/29/22 revealed, Patient was being fitted into Merry walker for her safety and ability to walk safely in hallways. DON [Director of Nursing] assisted with it. Patient stood up and walked backwards, was instructed to walk forward. Was able to ambulate down three different hallways with standby assist for safely. Did sit down and used her feet to pedal also returned to nurses station and she was winded. Charge nurse gave her a drink of water. Tolerated new device well. Review of R47 EMR and paper chart revealed no other least restrictive interventions were implemented prior to the implementation of the Merry Walker. During an interview on 11/15/22 at 12:07 PM, CNA3 revealed, R47 uses a Merry [NAME] due to confusion and balance. CNA3 further stated that they try to take R47 out of the Merry [NAME] at least every hour. CNA3 was asked, Have you ever seen the resident unclip her belt? CNA3 stated, No I have not, I do not believe the resident can unclip herself. During an interview on 11/15/22 at 2:34 PM, the Minimum Data Set Coordinator (MDSC) stated the Merry [NAME] was not considered a restraint because she can stand up and move around in it. Surveyor asked the MDSC, Can the resident release the belt? The MDSC stated I do not know. I was not there. Surveyor asked were there any other least restrictive interventions implemented prior to the implementation of the Merry Walker. The MDSC stated, no other interventions were attempted. During an interview on 11/15/22 at 2:44 PM, the Physical Therapist (PT) reported, Restraints are something a person cannot be undone by themselves. If a resident required a seatbelt or lab buddy, I believe it is first addressed by nursing and physician and then referred to therapy. Surveyor asked the PT, Would you consider a Merry [NAME] a form of restraint if a resident could not release the belt to exit the chair? The PT stated Yes. During an interview on 11/15/22 at 2:56 PM, the Director of Rehabilitation (DOR) revealed, restraints are considered bed alarms, using a gait belt to tie around a resident in their wheelchair, and anything that would keep someone from moving or getting out of a chair or bed. During an interview on 11/15/22 at 3:02 PM, the Certified Occupational Therapist Assistant (COTA) revealed referring to the Merry Walker, If a resident cannot release the latch or belt, it is considered a restraint. During an interview on 11/15/22 at 3:20 PM, the DON stated, a restraint restricts the freedom of movement, all alarms are considered a restraint, and if a resident is seated in a wheelchair with a lap belt it is a restraint if they cannot remove it. When asked if at the time R47 was assessed for the Merry [NAME] if R47 asked to remove the lab belt, the DON stated, We did not ask the resident to release the belt when we were assessing her for the Merry Walker. The DON furthered shared that the facility Medical Director made the decision to place R47 in the Merry [NAME] and hospice came out to do the assessment. Surveyor asked the DON if during this assessment with hospice was R47 asked to release the seatbelt. The DON stated, No. Surveyor further enquired on how R47 was monitored to ensure that the Merry [NAME] continued to be appropriate. The DON stated, hospice keeps all of the assessments. Surveyor asked were any other least restrictive interventions implemented prior to the implementation of the Merry Walker. The DON stated, no other interventions were attempted. Review of R47 hospice documents provided by the facility revealed no ongoing assessments for the Merry Walker. During an interview on 11/15/22 at 3:46 PM, the Hospice Administrator (HA) revealed, R47 was assessed for the Merry [NAME] on 09/29/22. The HA stated, the facility staff spoke with the Medical Director about safety concerns due to falls. When the resident was placed in the Merry [NAME] the resident could stand, ambulate forward and down the hall by propelling with her feet. Surveyor asked the HA was R47 assessed to ensure she could release the seatbelt latch? The HA stated, the notes do not state if the resident was asked to release the latch. During an interview on 11/15/22 at 4:16 PM, the Medical Director stated there was a combination of things we were concerned about for safety issues she had a lot of falls at her previous. Therapy had failed at a previous facility and the resident was admitted to here and placed on hospice. Through brainstorming it was decided to use the Merry [NAME] to prevent the resident from falling. The Medical Director was asked what would be considered a restraint? The Medical Director stated, any restriction of movement or they cannot get out. Surveyor asked were there any other least restrictive interventions implemented prior to the implementation of the Merry Walker. The Medical Director stated, no other interventions were attempted.

Based on observation, policy review, staff and resident council interviews, the facility failed to maintain hot foods at a safe temperatures. The facility reported a census of 37. Findings include: During the Resident Council meeting on 4/27/21 at 1:40 p.m., 3 of 3 residents stated the food was not hot when they received their room trays. One resident described the food on the room trays as ice cold. The residents reported they observed the room tray cart in the hallway with full food trays for long periods of time while residents were assisted with cares. On 4/28/21 at 8:30 a.m., the last test tray was filled with eggs frittata and two sausage links, covered, and placed on the metal serving rack with the resident trays. The cart immediately left the kitchen to serve the residents in Hall 100. On 4/28/21 at 8:41 a.m., the resident trays and the test tray sat by the nurses station undelivered until 8:41 a.m. before serving down the 100 hall to residents. On 4/28/21 at 8:47 a.m., the Dietary Manager used one of the facility's thermometers to record the temperature of the food on the test tray immediately after all the trays had been served to the residents. The egg frittata had a temperature of 104.5 degrees Fahrenheit (F) and the sausage had a temperature of 102.3 degrees F. During an interview on 4/28/21 at 8:48 a.m., the Dining Manager stated an expectation of staff to serve foods at 140 to 145 degrees F or above. The Food Temperatures policy dated 1995 stated hot food temperatures must read no less than 140 degrees F when served.

Based on observation, policy review, and interview, the facility failed to ask seven of seven residents (Resident (R) 9, R12, R15, R16, R18, R34, R38) that ate their meals in the assisted dining room if they would like to use a clothing protector during the lunch meal before placing a clothing protector on each resident. This affected seven residents who ate in one of two dining rooms. The facility reported a census of 44. Findings include: On 8/19/19, the Surveyor noted that the facility had two dining areas, a main dining area for residents who either ate independently or required very little assistance, and an assisted dining area for residents who were dependent or required extensive assistance by a staff member to complete their meals. Observation on 8/19/19 at 12:00 p.m. revealed the staff assisted Resident #9, #12, #15 #16, #18, #34 and #38 to the assisted dining area. The staff placed each resident at their table. Staff 27 (Nurse Aide) placed a large, striped clothing protector (which snapped at the back of the neck), on each of the seven residents. Staff #27 failed to ask each of the seven residents if they would like to use a clothing protector. During an interview on 8/19/19 at 1:20 p.m., Staff 27 (Nurse Aide) reported the staff assist the residents to the tables in the assisted dining area. Staff 27 asks the residents if they want a clothing protector to keep their clothing clean. If they want a clothing protector, Staff 27 places the protector on them. The Surveyor then reviewed her observation of Staff 27's actions of placing clothing protectors on the seven residents at the beginning of the lunch meal on 8/19/19 without asking residents if they wanted a clothing protector. The Surveyor asked Staff 27 if she agreed that she had not asked the residents if they wanted a clothing protector on before placing a clothing protector on each of the seven resident's. Staff 27 agreed she had not asked each resident if they wanted a clothing protector before placing it on the residents. During an interview on 8/22/19 at 2:35 p.m., the Director of Nursing (DON) reported an expectation of staff to ask each resident if they would like a clothing protector, before placing one on the resident, and then ask the resident if they need assistance to put the clothing protector on. The Dignity policy dated 11/12/10 indicated The facility will promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individually.

Based on interviews with 7 of 8 residents interviewed in the group interview, clinical record review and observations of 3 meals served revealed residents did not receive their meals in a timely manner. The facility reported a census of 48 residents. Findings include: 1. Observations of the breakfast meal on 6/5/18 revealed Residents #30, #34, #24, #27, and #10 at the breakfast table at 8:15 a.m. Staff served Resident #34 at 8:17 a.m. Staff served Residents #10 and #27 at 8:23 a.m. Staff served Residents #24 and #30 at 8:30 a.m. Observations of the lunch meal on 6/5/18 revealed Residents #20, #24, #30, and #34 at the lunch table at 12:09 p.m. Staff served Residents #24, #20, and #30 at 12:32 p.m. Staff served Resident #34 at 12:36 p.m. 2. During the group interview on 6/4/18 at 1:15 p.m., 7 of 8 interviewable residents present stated meals were often served late. They stated this could be any meal but the evening meal was especially late. They stated the evening meal was supposed to start at 6:00 p.m. but they often did not eat until 6:30-6:45 p.m. 3. Resident Council Minutes, dated 3/20/18, recorded residents stated the evening meals ran late. Resident Council Minutes, dated 4/24/18, documented the Dietary Manager would address the late supper issue. During an interview on 6/6/18 at 1:57 p.m., the DON (Director of Nursing) acknowledged late meals were a problem. A review of the undated facility policy titled: mealtimes revealed documentation that meal service begins at: Breakfast 8:00 a.m. Lunch 12:00 p.m. Supper 6:00 p.m. 3. Resident #39's Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED]. It also identified the resident to be cognitively impaired with a BIMS (brief interview for mental status) score of 10 out of 15. The resident required supervision with eating. A review of the care plan with the target date of 8/8/18 identified the resident with the focus area of potential fluid deficit related to diuretic use and staff instruction to invite the resident to activities that promote additional fluid intake; offer drinks during one to one visits and ensure that all beverages offered comply with diet/fluid restrictions and consistency requirements. It also identified the resident with a focus of diabetes mellitus type 2 and directed staff to monitor/document/report compliance with diet and document any problems as needed. Observation on 6/4/18 at 12:05 p.m. seated in the main dining room with one cup of coffee, one glass of water and condiments on table. At 12:25 p.m. she remained in main dining room, waiting to be served lunch and worked on crossword puzzle. Neither Resident #39 or her tablemate had received lunch. At 12:37 p.m. staff served a tuna sandwich with macaroni salad and brownie, one glass of water and one cup of coffee. The resident's lunch arrived 37 minutes after the planned start of the meal. Observation on 6/5/18 at 8:00 a.m. and 8:30 a.m. revealed Resident #39 seated in the main dining room waiting to be served breakfast. At 8:34 a.m. the staff served the resident breakfast, 34 minutes after the planned start of the meal. 4. Resident #42's MDS assessment dated [DATE] documented [DIAGNOSES REDACTED]. It also identified the resident to be cognitively impaired with a BIMS score of 8 out of 15. The resident required supervision with eating. The resident's care plan, updated on 10/20/17, identified she had the potential of nutritional problems and directed staff to provide a mechanical soft diet as ordered, to monitor her intake and record the intake at each meal. Observations on 6/4/18 at 12:08 p.m. and 12:36 p.m. revealed Resident #42 sat in the main dining room with one glass of water and condiments on the table. At 12:33 p.m., staff served the resident lunch and she fed herself independently. The resident received her food 33 minutes after the planned start of the meal. An observation of the noon meal service on 6/5/18 revealed the first meal to be served at 12:06 p.m. and the last meal to be served at 12:42 p.m. with 9 resident meals served after 12:30 p.m. During an interview on 6/6/18 at 11:56 a.m. Staff A, CNA (certified nursing assistant) reported the following mealtimes: breakfast is 8:00 a.m., lunch is at noon and supper at 6:00 p.m. She also reported there were times where meals are late, that usually nursing staff usually pass the trays and the Social worker and Activity coordinator also help to pass trays. In an interview on 6/6/18 at 12:05 p.m. Staff B, CNA reported the following mealtimes: breakfast is 8:00 a.m., lunch is at noon and supper at 6:00 p.m. She also reported that nursing staff had the responsibility to pass trays to the residents. During an interview on 6/5/18 at 12:20 p.m. , Staff C, CNA reported the following mealtimes: breakfast is 8:00 a.m., lunch is at noon and supper at 6:00 p.m. and that the nurse aides usually pass the trays to the residents with the help of the social worker and activity coordinator during the week. In an interview on 6/6/18 at 1:04 p.m. Staff D, LPN (Licensed Practical Nurse) reported the following mealtimes: breakfast is 8:00 a.m., lunch is at noon and supper at 6:00 p.m. and that the nurse aides usually pass the trays to the residents with the help of the social worker and activity coordinator during the week. During an interview on 6/6/18 at 1:18 p.m., Staff H, cook reported the following mealtimes: breakfast is 8:00 a.m., lunch is at noon and supper at 6:00 p.m. and felt meals had usually been served on time In an interview on 6/6/18 at 1:23 p.m., Staff I, cook reported the following mealtimes: breakfast is 8:00 a.m., lunch is at noon and supper at 6:00 p.m. The nursing staff usually serve the meals which are sometimes late and she has to stop serving the meals when a special order comes in for an item that had not already been prepared. Sometimes co-workers are not always helpful with those special orders, which the 9 a.m. to 2 p.m. person should do. During an interview on 6/6/18 at 1:43 p.m., Staff J, dietary aide/cook reported the following mealtimes breakfast is 8:00 a.m., lunch is at noon and supper at 6:00 p.m., that at times meals can be late if the nurse aides take an extra break or are late from break In an interview on 6/6/18 at 1:47 p.m., the Dietary Director reported the following mealtimes breakfast is 8:00 a.m., lunch is at noon and supper at 6:00 p.m., that at times meals can be late if the staff in the dining room aren't ready. Usually nursing staff serves the meals and will rotate between serving meals in the assisted dining room, then the main dining room, etc. The residents have complained it takes too long, usually at supper time. Dietary staff try to serve within 30 minutes. One of the residents had expressed that ½ hour was too long to wait. Nursing staff with the help of the Social worker, the rehab aide and Activities director will pass trays. Sometimes a resident will refuse what is served and request something different. Sometimes the dietary aides will not help out with the above and Staff I, cook will stop serving and prepare the special request. Other times she reported a problem that staff think they need more breaks.

Based on record review and resident and staff interviews, the facility failed to answer call lights in a timely manner for 4 of 8 interviewable residents present in the group interview including 1 resident(Resident #20)of 5 also interviewed individually during the survey. The facility reported a census of 48 residents. Findings: 1. During the group interview on 6/4/18 at 1:15 p.m., 4 out of 8 interviewable residents stated they had to wait longer than 15 minutes for staff to respond to their call lights. All 4 stated they wore incontinence pads because they had had accidents waiting so long for staff to respond. Three residents stated they had to wait longer than 30 minutes for staff to respond. All utilized clocks or watches to time the lights. 2. Resident Council Minutes, dated 3/20/18, revealed residents had a concern of third shift call lights taking longer to answer. During an interview on 6/6/18 at 1:57 p.m., the DON(Director of Nursing) stated she expected staff to answer call lights within 15 minutes. She stated she did not believe the facility had a policy related to call lights. 3. Resident #20's Minimum Data Set (MDS) annual assessment completed 4/4/18 documented she had [DIAGNOSES REDACTED]. It also identified the resident with a BIMS (brief interview for mental status) score of 10 out of 15 indicating moderate cognitive impairment. The resident required the assistance of one staff with most activities of daily living and she had occasional incontinence of bladder. The resident's care plan, revised on 4/10/18, documented the following focus areas: self-care deficit, behavior, cardiovascular, impaired cognitive ability, potential oral problems due to dentures, potential fluid deficit related to diuretic use, fall risk, [MEDICAL CONDITION], pain, potential nutritional problem, potential for pressure ulcer and impaired visual function During group interview, Resident #20 complained about staff taking too long to answer her call lights which can take as long as 2 hours to answer on the night shift. During interview on 6/6/18 9:50 a.m. the DON stated the facility did not have the capability to print out reports from the call light system. On 6/6/18 9:50 a.m., Resident #20 sat in wheelchair in her room, appeared comfortable, had a clock on wall visible from her bed. She reported she did has waited an average of 45 minutes to up to 2 hours to get her call light answered on the night shift and that she had lost control of her bladder, which made her feel like an idiot and made her feel like a 2 year old. It was absolutely embarrassing and should not happen. The resident stated she talked about the concern during care conferences and was told it would be taken care of, but it still happens. During an interview on 6/6/18 at 11:56 a.m., Staff A, CNA (certified nursing assistant) reported staff should answer call lights within 5 minutes, typically there are 2 nurses and 6 aides that work on first shift and they are short staffed at least once a week. In an interview on 6/6/18 at 12:05 p.m., Staff B, CNA reported staff should answer call lights within 5 minutes, typically there are 2 nurses and 6 aides that work on first shift and they are short staffed at least once every other week. However, there are staff to pick up the extra shifts. During an interview on 6/5/18 at 12:20 p.m., Staff C, CNA reported staff should answer call lights as quickly as possible. Typically there are 2 nurses and 6 aides working on the first shift. In an interview at 6/6/18 at 2:02 p.m., the DON reported she expected her staff to answer call lights within 15 minutes. That Resident #20 had complained that she had to wait for a while to get her call light answered during the night shift and she spoke to the staff about it. The DON also stated she completed an audit on the resident's call lights on night shift and found lights were answered within 15 minutes. At 3:02 p.m., the DON reported Resident #20 had dementia, which she hides her very well. The DON did not 'buy into the fact' the resident's call light had not been answered for up to 2 hours. During an interview on 6/7/18 7:04 a.m., the Maintenance supervisor reported that he has worked at the facility for [AGE] years and has always started his day at 3:00 a.m. He stated never seeing a call light stay on for more than 15 minutes, however, he had no documentation to verify this.

Based on clinical record review, observation, and staff interview, the facility failed to ensure a catheter anchor in place for one sampled resident who required an indwelling urinary catheter (Resident #33). The facility reported a census of 48 residents. Findings include: 1. Resident #33's Minimum Data Set (MDS) assessment date 4/11/18 documented [DIAGNOSES REDACTED]. It also identified the resident to be cognitively impaired with a BIMS (brief interview for mental status) score of 6 out of 15. The assessment identified the resident required assistance of one staff with toilet use, supervision with personal hygiene and an indwelling catheter. Resident #33 walked independently. The resident's care plan revised on 9/14/17 identified a focus of an indwelling catheter due to [MEDICAL CONDITION] bladder. The care plan instructed, in part, to monitor and document intake and output as per facility policy and to monitor and document pain/discomfort due to the catheter. Review of urine culture dated 4/9/18 revealed an infection of 100,000 CFU/ml of Proteus mirabilis The resident's physician ordered [MEDICATION NAME] 500 milligrams three times daily for 7 days for Proteus urinary tract infection on 4/12/18. A review of the nurse's notes revealed the following entries: -- On 1/7/18 at 1:00 a.m. the resident appeared to have a small spot on his penis less than 1/2 centimeter, possibly rubbed area. -- On 1/7/18 at 7:40 a.m. staff noted leaking around the catheter. Staff discontinued the catheter and inserted a new catheter without difficulty. -- On 2/25/18 at 11:30 p.m. staff documented finding him sitting on a stool, holding onto his penis due to thinking the catheter was going to fall out. Once in bathroom, staff noted his penis as very swollen with a small amount of blood. Staff cleansed the area and replaced the catheter. During an observation on 6/5/18 beginning at 7:12 a.m. Staff F and Staff G, CNAs (certified nursing assistants) used the correct technique to cleanse the resident after he had a bowel movement and then pulled up his incontinent briefs and pants. The resident's urinary (Foley) catheter was connected to large drainage bag without a catheter anchor in place. At 7:14 a.m. Staff G provided standby assistance while the resident walked using a cane and the resident sat in recliner. Staff G removed her gloves, washed hands and remained with Resident #33 as Staff F left the room to find a leg bag. At 7:17 a.m. Staff F placed plastic bags on floor underneath large drainage bag and performed used correct techniques to cleanse the spigot, drain the large bag. Staff F then pulled the catheter tubing from underneath the resident's scrotum; the tubing appeared taught and had no anchor to secure the catheter in place. Staff F disconnected the tubing from Foley catheter, wiped the end with alcohol then connected a leg bag to urinary catheter. At 7:26 a.m. Staff G left room to find straps for leg bag and she returned to room with straps for leg bag. Staff F removed her gloves and used alcohol hand sanitizer and attached straps to leg bag and secured to the resident's leg. Staff completed the care at 7:31 a.m. Neither aide applied a catheter anchor to the resident's thigh prior to leaving the resident's room. During an interview on 6/6/18 at 11:56 a.m., Staff A, CNA reported Foley catheters should be held in place with a sticker placed on the resident's thigh. In an interview on 6/6/18 at 12:05 p.m., Staff B, CNA reported Foley catheters should be held in place with a butterfly sticker on the resident's thigh to keep the tubing from getting kinked. During an interview on 6/5/18 at 12:20 p.m., Staff C, CNA reported Foley catheters should be held in place with a butterfly strapholder that should be placed on the resident's thigh to keep the tubing from being pulled. In an interview on 6/6/18 at 1:04 p.m., Staff D, LPN (Licensed Practical Nurse) reported Foley catheters should be held in place with an adhesive that is placed by the port on the resident's thigh. On 6/6/18 at 2:02 p.m., the Director of Nursing (DON) reported Foley catheter should be secured by an anchor placed on the thigh. Observation at 2:10 p.m. with the DON revealed the resident did not have a catheter anchor in place and the DON verified this.

Based on clinical record review, observations and interviews, the facility failed to carry out interventions and/or timely assessments to prevent and/or treat pressure ulcers for three of six residents reviewed with pressure ulcers or at a high risk for pressure ulcers (Residents #8, #40, and #41). The facility reported a census of 48 residents. Findings: 1. The MDS (Minimum Data Set) assessment tool, dated 3/14/18, for Resident #8 listed [DIAGNOSES REDACTED]. The MDS recorded she required the assistance of one staff with personal hygiene, walking, bed mobility, transfers, dressing, toilet use and bathing. The resident had the risk for developing pressure ulcers but had no unhealed ulcers at the time of the assessment. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as nine out of 15, indicating moderately impaired cognition. The Braden Scale for Predicting Pressure Sore Risk, dated 3/18/18, listed the resident's score as 14, indicating a moderate risk for pressure sore development. An observation on 6/6/18 at 9:44 a.m. revealed the resident had a dark red/brownish area on the bottom of her left heel. The DON (Director of Nursing) measured the area as 0.6 cm (centimeters) x 1.4 cm(length x width). The resident's feet were floated on pillows and the DON removed her soft boots prior to measuring the area and re-applied the boots when finished. The care plan, revised 2/24/17, instructed Resident #8 had the potential for pressure ulcer development related to impaired bed mobility and toilet use and a history of Stage 2 pressure ulcers (ulcers with partial thickness loss of skin) on the right buttocks. The care plan directed staff to turn and reposition the resident and utilize a pressure reducing mattress but did not include direction for staff to float the resident's heels or apply boots. The resident's Wound/Skin Healing Records documented an unstageable pressure ulcer of the left heel and defined the stage of unstageable as known but not stageable due to non-removable dressing/device, due to coverage of wound bed by slough and/or eschar or as suspected deep tissue injury in evolution. The record listed the onset date as 5/29/18 with the measurement of 2 cm x 2.5 cm. The resident's Wound/Skin Healing Records documented a Stage 1 pressure ulcer of the right heel and defined Stage 1 as 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. The record listed the onset date as 5/29/18 with the measurement of 3 cm x 3 cm and the ulcer as healed on 6/4/18. A Progress Note entry, dated 5/29/18 at 12:10 p.m., recorded Resident #8 had unstageable pressure ulcers and directed staff to utilize moon boots (soft boots) on both feet at all times except when walking or showering. The facility lacked any documentation of flotation of the resident's heels or application of soft boots prior to the date of the pressure ulcer developing on 5/29/18. During an interview on 6/6/18 at 10:50 a.m., Staff E CNA (Certified Nursing Assistant) stated she discovered the resident's heel ulcer last Monday. She stated at this point the facility began floating the resident's heels and applying soft boots. During an interview on 6/6/18 at 12:11 p.m., Staff B CNA stated after Resident #8 acquired heel ulcers, the facility initiated the interventions of floating the resident's heels and applying boots. During an interview on 6/6/18 at 1:21 p.m., the DON stated prior to Resident #8's development of heel ulcers, the staff did not assist Resident #8 to float her heels. She stated floating her heels was one factor which helped the ulcer improve since the date of development. 2. The MDS assessment tool, dated 5/9/18, listed [DIAGNOSES REDACTED]., [MEDICAL CONDITION], atril fibrillation (an irregular heart rhythm), chronic [MEDICAL CONDITION] and hallucinations. The MDS recorded she required the assistance of one staff for bed mobility, transfers, walking, dressing, toilet use, personal hygiene, and bathing. The assessment recorded the resident as at risk for the development of pressure ulcers and she had one unhealed Stage 2 pressure ulcer. The MDS listed the resident's BIMS score as 6 out of 15, indicating severely impaired cognition. The Braden Scale for Predicting Pressure Sore Risk, dated 5/14/18, listed the resident's score as 16, indicating a mild risk for pressure ulcer development. A care plan entry, revised 5/16/18, documented she had a history of [REDACTED]. The care plan lacked information related to a pressure reducing device for the recliner. Observations at the following times revealed the resident sitting in the recliner in her room with an incontinent pad under her and no cushion present in the recliner: a. 6/4/18 at 10:03 a.m., 11:29 a.m. and 12:05 p.m. b. 6/5/18 at 6:18 a.m., 7:30 a.m., 8:00 a.m., 9:15 a.m., 9:52 a.m., 10:51 a.m. and 11:20 a.m. c. 6/6/18 at 7:32 a.m. During an observation on 6/5/18 at 8:00 a.m., Staff B CNA cleansed both the resident's buttocks. The area was red and when Staff B cleansed the area the resident stated ouch. An observation on 6/6/18 at 9:43 a.m. revealed both of the resident's buttocks as red. The DON palpated the areas to check for blanching and the resident stated ouch. The Wound/Skin Healing Records recorded the resident had a Stage 2 pressure ulcer on the right buttock with an onset date of 5/7/18 and a measurement of 0.2 cm x 0.5 cm. A Progress Notes entry dated 5/16/18 listed the right buttock pressure area as resolved. A Social Services Note, dated 5/23/18, documented the resident refused a recliner cushion. The record lacked any further documentation of resident refusals of a cushion or any documentation of staff attempts to encourage a different type of cushion to relieve pressure while Resident #8 sat in her recliner. The facility's Pressure Sore Skin Assessments policy, reviewed 1/27/12, instructed staff would ensure residents entering the facility without pressure sores would not develop pressure sores unless the individual's clinical condition demonstrated it was unavoidable. During an interview on 6/6/18 at 10:50 a.m., Staff E CNA stated the resident never slept in bed, always in the recliner. She stated she had never seen a cushion in the recliner and thought the resident had an open area on the buttocks previously. During an interview on 6/6/18 at 12:11 p.m., Staff B CNA stated the resident always slept in the recliner and she had never seen a cushion in the recliner. During an interview on 6/6/18 at 1:29 p.m., the DON stated the resident was at risk for the redevelopment of pressure ulcers in the buttock area. 3. Resident #40's MDS assessment dated [DATE] documented he had [DIAGNOSES REDACTED]. The assessment documented a BIMS score of 12 out of 15, indicating moderate cognitive impairment. Resident #40 required the assistance of one staff with bed mobility, transfers, dressing, toilet use and personal hygiene and experienced frequent incontinence of bladder and bowel. The assessment documented he had one Stage 2 pressure ulcer with the onset date of 5/9/18 and the risk of developing further pressure ulcers. The resident's Care Plan, updated 2/27/18, identified the resident with the problem of a history of unstageable pressure ulcer on his sacrum and potential for pressure ulcer development Interventions included: Administer medications and treatments as ordered and evaluate for effectiveness Requires extensive assistance of one to reposition in bed Non-compliant with requests to reposition at times, re-direct, re-attempt and educate on benefits of repositioning Requires Liquid Cell 2 ounces twice daily to promote wound healing Pressure reducing devices on bed, chair and recliner. Ortho boots on in bed Follow facility protocols to prevent skin breakdown Monitor/record/report any changes in skin status to hospice Provide thorough peri cares after each incontinent episode Utilize incontinent products and barrier creams Weekly skin documentation measurement of each skin breakdown to include length, width, depth, type of tissue and exudate. Review of physician orders [REDACTED]. A review of nurse's notes revealed the following entries: a. 5/3/18 at 6:43 a.m. - Discontinue collagen powder & wound gel. Clean the coccyx wound, cover it with calcium aliginate & a bordered foam dressing daily b. 5/8/18 at 1:25 p.m. - Give 4 ounces of supplement twice daily and continue Liquid cell 2 oz BID to promote wound healing. The notes and the electronic medical record contained no documentation on 5/9/18 of measurements of the pressure ulcer identified on 5/9/18. Review of wound/skin healing record identified resident with a Stage 2 pressure ulcer with an onset date 5/9/18 on the left buttock: a. 5/16/18 - First measurement documented with a length (L) of 0.7 cm, a width (W) of 0.6 cm and a depth (D) of 0.1 cm. The wound showed no exudate or odor, the wound bed had [MEDICATION NAME] tissue the surrounding skin appeared normal. The clinical record had no documentation to show staff notified the dietary department, family or physician. b. 5/23/18 - Measurements of a L of 0.7 cm, a W of 0.5 cm and D of 0.1 cm with no change in the appearance of the wound. c. 5/30/18 - Measurements of a L of 3.5 cm, a W of 2.5 cm and D of 0.1 cm with no change in surrounding skin and tissue During an observation of wound care on 6/5/18 at 9:54 a.m., Staff D, LPN provided the resident's ordered treatment. The wound appeared to have healthy tissue and had no odor or redness to the surrounding skin. During an interview on 6/5/18 8:24 a.m. the DON reported there should have been documentation of measurements and the assessment of the wound on 5/9/18. In an interview on 6/6/18 at 1:04 p.m. Staff D, LPN reported the resident's pressure ulcer may have been caused by shearing which lead to the ulcer healing, opening, healing and opening again. The resident's nutritional status had also been altered; sometimes he refuses to eat and he drinks the supplements about 80% of the time. He also reported assessments of the wound should include the appearance and measurements. During an interview on 6/7/18 at 9:37 a.m., the DON reported she could not locate documentation of an assessment or measurements of the wound when first identified on 5/9/18. The facility's Pressure Sore Skin Assessments policy, reviewed 1/27/12, instructed staff to assess any new pressure sore as soon as discovered. Include all pertinent information on pressure sore form, as well as in nurse's notes, location of open area, stage, measurement in centimeters of width and depth surrounding skin conditions and any drainage should be described.

The following deficiency relates to facility self reports -I and -I: Based on observation, record review and staff interviews, the facility failed to provide adequate supervision Resident #1 eloped from the facility without staff knowledge and Resident #2 sustained a subdural hematoma after a fall. The sample included 4 residents and concern identified for 2 of 4 residents. (Resident #1 and #2) The facility reported census was 52. Findings include: 1. According to Resident #1's Minimum Data Set (MDS) assessment with assessment reference date of 1/3/18, Resident #1 had impaired short and long term memory deficits and severely impaired cognitive skills for daily decision making. Resident #1 was independently mobile in wheelchair and required extensive assistance with dressing, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. Resident #1's plan of care identified a behavioral problem which included episodes of agitation, combativeness, and attempts to get up unassisted and past episodes of attempting to elope related to dementia. Interventions included: a. Alarms to alert staff when attempting to get up unassisted. b. When anxious and upset investigate the reason. Resident sometimes likes to be walked or needs to go to the bathroom. c. Wanderguard (alarm to alert staff resident is by external door) in place to alert staff of attempts to elope. (discontinued 12/14/17) Initial Wandering assessment dated [DATE] indicated Resident #1 met criteria for use of a Wanderguard. Wanderguard was initiated at that time. Daily Nursing Notes dated 12/14/17 at 10:00 a.m. documented new order to discontinue Wanderguard. In an interview on 2/20/18 at 3:00 p.m. the Director of Nursing (DON), stated on 12/4/17 the quality assurance team met and discussed various issues including the use of the Wanderguard on Resident #1. Resident #1 had been on a Wanderguard since his admission in April 2016 and had never demonstrated exit seeking behavior or verbalized wanting to leave. The team decided the Wanderguard could be discontinued, but not before a planned medication adjustment was completed. On 12/14/17 the Wanderguard was discontinued without incident. On the evening of 1/25/18 the DON was notified of Resident #1 exiting the building undetected and tipping his wheelchair over. Resident #1 sustained a small hematoma to his/her forehead and abrasions to his/her left shoulder and knee. The DON stated the front door alarm had sounded and Staff A responded. Staff A reportedly looked outside and didn't see anything and returned to work. A few minutes later a visitor arrived and reported a resident was outside and had tipped his wheelchair over. In an interview on 2/20/18 at 4:40 p.m. Staff A, certified nurse aide, stated on the evening of 1/25/18 he was working down the 200 hall and when exiting a resident's room heard a door alarm sounding. Staff A responded and looked at the alarm panel which identified the alarming door. Light #7 indicating the front door was activated. Staff A went to the door and then stepped outside, walked to the corner of the building and looked around. Staff A stated he did not see anyone and returned into the building, shut off the alarm and returned to work. Staff A stated a few minutes later he was summoned back up front and informed Resident #1 had tipped his wheelchair over outside. Staff A stated he was surprised to hear it was Resident #1 because Resident #1 was not known to exit seek. Staff A stated Resident #1 was found lying next to the front wheel of a parked car in the parking space next to the south sidewalk. Resident #1 was wearing a black sweat shirt and bottoms and was difficult to see. In an interview on 2/20/18 at 4:45 p.m. Staff B, registered nurse, stated on the evening of 1/25/18 she was down hall 300 when an aide asked for her assistance on the 100 hall. Staff B went to room [ROOM NUMBER] and was assessing the resident and discussing care issues. As they walked out of the room, there was a visitor standing at the nurse's station. The visitor reported there was a man tipped over in his wheelchair outside. Staff B went out with others and found Resident #1 tipped over in his wheelchair next to a parked car. Staff B assisted Resident #1 back into his wheelchair and propelled him back inside. Staff B stated she was surprised to see that it was Resident #1 because he/she was not known to exit seek. Staff B stated she never heard an alarm sound. In an interview on 2/26/18 at 2:00 p.m. Staff C, registered nurse, stated on the evening of 1/25/18 she was down hall 100 assessing a resident. When she came out of the room, a visitor at the front desk reported there was a man that had fallen outside. Staff C went out and found Resident #1 laying on the ground next to his tipped over wheelchair. Staff C and others got Resident #1 back into his wheelchair and into the facility. Staff C stated she never heard an alarm sound and was surprised Resident #1 had went outside, because he hadn't attempted to do so since first being admitted over 1 1/2 years ago. Staff C stated she had last seen Resident #1 in the dining room at around 7:45 p.m. and he was found outside at around 8:00 p.m. When asked about how door alarms are responded to, Staff C stated if a door alarm sounds staff are to respond and if not certain who set the alarm off they are to look outside and if they do not see anyone they can come in an shut the alarm off. Staff C stated there was no expectation to do a resident head count. Review of the facilities Door Alarms and Wanderguard (old) policy found there is no instruction or expectation of staff response to door alarms, no instruction or expectation to investigate the cause of the alarm and when the cause was unknown no instruction or expectation of staff to expand a search and to ensure all residents are accounted for. 2. According to Resident #2's Minimum Data Set (MDS) assessment with assessment reference date of 11/29/17, Resident #2 had a Brief Interview for Mental Status score of 11 indicating moderately impaired cognitive skills for daily decision making. Resident #2 required limited assistance with transfers, ambulation and personal hygiene needs and extensive assistance with dressing and toilet use. Resident #2's [DIAGNOSES REDACTED]. Resident #2's plan of care identified a high risk for falls. Interventions included: a. Resident #1 requires extensive assistance of one staff, gait belt and walker to ambulate/transfer. b. Non-skid footwear. c. Call light within reach and encourage Resident #1 to use it for assistance. d. Sensor alarm in chair and wheelchair. (discontinued 11/20/17) There was no reevaluation of the removal of the personal alarm. Radiology report dated 2/15/18 noted impression: Moderate to large size acute left subdural hematoma measuring up to 2 centimeters in thickness with 1.8 centimeters of midline shift. In an interview on 2/27/18 at 10:30 a.m. Staff D, certified nurse aide, stated on the afternoon (1:55 p.m.) of 2/15/18 she was down 200 hall attending to other residents and in proximity of Resident #2's room, when she heard someone say Oh followed by a crash. Staff D entered Resident #2's room and found her lying on the floor in front of her roommate's recliner with the roommates walker tipped over. Resident #2 immediately complained of a headache and was assisted up and moved to the nurse's station to be monitored. Resident #2 did not comment as to why she had gotten up. Staff D stated Resident #2 had been taken to the bathroom by Staff E just 15-20 minutes earlier. Staff D stated she frequently looks in on Resident #2 because she gets up unassisted so often throughout the day. Staff D stated Resident #2's floor alarm was discontinued a while back and she doesn't believe it should have been. Staff D stated the alarm was effective for Resident #2. Staff D stated when the alarm sounded, Resident #2 would usually stop and wait for staff to arrive. In an interview on 2/27/18 at 10:50 p.m. Staff E, certified nurse aide, stated on 2/15/18 around 1:30 p.m. to 1:45 p.m. she had assisted Resident #2 up to the bathroom and back into his/her recliner. Staff E stated she went to break and upon returning discovered Resident #2 had fallen. Staff E stated Resident #2 used his/her call light, but was known to get up unassisted throughout the day. Staff E stated Resident #2 used to have an alarm and she would use the alarm to get staff's attention. At that time, Resident #2 was not getting up unassisted so the alarm was discontinued. In an interview on 2/27/18 at 2:45 p.m. Staff F, certified nurse aide, stated Resident #2 was pleasant and alert. When Resident #2 was admitted (11/9/16) she got up unassisted a lot. They used an alarm and that helped a lot. Resident #2 would use the alarm to get staff's attention and wait instead of getting up without help. The alarm was discontinued and although Resident #2 would use her call light, he/she often got up unassisted. Staff E stated recently Resident #2 was getting up unassisted very frequently. Staff E stated the floor alarm was effective and she had mentioned to nursing a couple of times that they should reinstate the alarm. In an interview on 2/27/18 at 3:04 p.m. Staff A, certified nurse aide, stated Resident #2 was a nice lady, but a little impatient. Staff A stated when Resident #2 had an alarm she would use it instead of the call light to get staff's attention. Resident #2 would activate the alarm and wait for staff to take her to the bathroom. When the alarm was discontinued, Resident #2 began getting up unassisted to use the bathroom without using the call light. In an interview on 2/26/18 at 4:40 p.m. the Director of Nursing (DON), stated Resident #2 was admitted in November 2016 and had a fall in December 2016, but had since been fall free. Resident #2 was placed on alarms and seemed to use the alarms as a way of getting staff attention. Resident #2 would also use her call light. Over several months her fall risk remained high, but was decreasing. They were trying to toilet her more frequently, which was decreasing her tendencies of getting up unassisted. They made an alarm change in October 2017 and following a push to become alarm free, they discontinued Resident #2's alarm on 11/20/17. Resident #2 continued to get up unassisted periodically, but hadn't fallen until the 2/15/18 incident. On 2/27/18, the facility abated the IJ when they updated the door alarm & Wanderguad policy on if an alarm was triggered and the cause was unknown, staff should go outside the door and do a visual sweep of the area and account for all residents by doing a head count. The facility educated staff of these changes. These findings lowered the IJ from a J severity level to an G with ongoing monitoring to ensure residents safety/supervision (including falls).

Based on observation, record review, and interview, the facility failed to complete adequate perineal cares for 2 of 8 incontinent residents(Residents #5 and #8). The facility reported a census of 52 residents. Findings: 1. The MDS(Minimum Data Set) assessment tool, dated 1/25/17, listed [DIAGNOSES REDACTED]. The MDS stated the resident required extensive assistance of 1 staff for bed mobility, walking, dressing, eating, and personal hygiene, and extensive assistance of 2 staff for transfers, toilet use, and bathing. The MDS stated the resident was frequently incontinent of bowel and bladder and listed the resident's cognition as severely impaired. During an observation on 3/13/17 at 12:58 p.m., Staff B CNA(Certified Nursing Assistant) removed the resident's incontinent brief as the resident sat on the toilet. The brief appeared wet. After the resident finished on the toilet, Staff B and Staff C CNA assisted the resident to stand up from the toilet and hold onto a bar on the wall. While the resident stood, Staff C cleansed the resident's rectum in a front to back direction with a disposable wipe. Staff C did not cleanse the resident's frontal perineal area including the penis, scrotum, inner thighs, or inguinal folds. After the completion of cares, Staff B stated to the surveyor the brief she removed was medium wet. A 1/6/17 laboratory report revealed a urine culture positive for esherichia coli(a bacteria). A 1/6/17 physician's orders [REDACTED]. The care plan, dated 2/1/17, stated the resident required extensive assistance of 1 staff for personal hygiene and toilet use. 2. The MDS assessment tool, dated 2/8/17, listed [DIAGNOSES REDACTED]. The MDS stated the resident was independent with bed mobility, transfers, walking, and personal hygiene but required limited assistance of 1 staff for dressing and toilet use and extensive assistance of 1 staff for bathing. The MDS stated the resident was occasionally incontinent of urine and listed the resident's BIMS(Brief Interview for Mental Status) score as 7 out of 15, indicating severely impaired cognition. During an observation on 3/14/17 at 7:03 a.m., Staff A CNA removed the resident's incontinent brief as the resident sat on the toilet. After the resident finished on the toilet, Staff A cleansed the resident's rectal area in a front to back direction with a wipe as the resident stood in front of the toilet. Staff A did not cleanse the resident's frontal perineal area, inguinal folds, or inner thighs. After the completion of cares, Staff A stated to the surveyor the brief she removed was wet and a little soiled. The care plan, dated 2/15/17, stated the resident required limited assistance of 1 staff for incontinence cares. The facility policy entitled Procedure for Pericare/Incontinent Care, revised 2/27/14, directed staff to cleanse all areas in contact with urine/feces including the thighs, penis, scrotum, and hips. During an interview on 3/15/17 at 1:51 p.m., the Director of Nursing stated during incontinence cares, staff should cleanse all areas in contact with urine.

Based on record review and staff interviews, the facility failed to provide adequate supervision (assistance of two staff during a transfer and with bed mobility) to mitigate the risk for injury during cares for 2 of 4 residents reviewed. (Residents #1, #2) The facility reported census was 56. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 9/7/16. The MDS identified the resident had short and long term memory deficits and severely impaired cognitive status. Resident #1 required extensive assistance of two staff members for transfers and toilet use and required extensive assistance of 1 staff member for dressing. Resident #1's [DIAGNOSES REDACTED]. The Daily Nurse's Notes dated 11/23/16 at 8:00 a.m. indicated when staff assisted Resident #1 up to be weighed, he/she complained of pain in the right arm when staff lifted the arm. At 2:30 p.m. during a shower, staff observed a large purple area on Resident #1 ' s upper right arm. At 7:45 p.m. staff reported the upper right arm had increased warmth and swelling. Staff applied ice packs to the area. Family was notified and agreed to send resident to emergency room for further evaluation. At 8:00 p.m. staff obtained an order for [REDACTED]. At 10:12 p.m. family called and reported Resident #1 had a fractured right humerus (upper arm). At 10:50 p.m. Resident #1 returned to facility with an immobilizer on his/her right arm. The Diagnostic Imaging report dated 11/23/16 indicated Resident #1 had an acute displaced fracture proximal humerus, neck of the humerus. osteopenic bones, degenerative changes. According to Resident #1's care plan; he/she required extensive assistance by two staff to move between surfaces. According to the care guide (cheat sheet for aides to use as a quick reference of care) dated 11/16/16, Resident #1 was determined an assist x1 (1 staff member) for activities of daily living (ADLs), transfers and ambulation with a gait belt and walker. In an interview on 12/27/16 at 11:49 a.m. Staff A, certified nurse aide, stated she first noticed Resident #1 was having arm pain on the morning of 11/23/16 at around 7:30 a.m. when she and Staff B were preparing to get the resident ' s weight. According to Staff A, she attempted to place her gait belt around Resident #1 and he/she (the resident) pulled his/her right arm into his/her body, not allowing Staff A to get under his/her arm. Resident #1 was grimacing and in obvious pain and discomfort. Staff A informed the nurse, Staff C, who evaluated Resident #1's arm and cautioned the aides to be careful with the right arm. Staff A and Staff B preceded to transfer Resident #1 from his/her wheelchair onto the weight chair and back again. Staff A stated in general; Resident #1 was difficult to transfer and especially since having problems with weight bearing which started about two weeks earlier. Staff A denied lifting Resident #1 up by his/her arms, but noted it would be easy for someone to put additional force on Resident #1's arms if he/she were to suddenly drop. Staff A stated she was not involved with any transfers of Resident #1 that morning until the transfer into the weight chair. In an interview on 12/27/16 at 12:09 p.m. Staff B, certified nurse aide, stated she first noticed concerns with Resident #1 on the morning of 11/23/16 when she and Staff A were assigned to get resident weights. Resident #1 was in his/her wheelchair and was not his/her normal self. Staff B stated there had been on-going issues with him/her not bearing weight well. Staff B stated Staff C was informed and checked on Resident #1. Staff B and Staff A then placed a gait belt around the waist of Resident #1 and lifted him/her onto the weight chair and then back into his/her wheelchair. Staff B denied lifting under Resident #1's arms and denied hearing any pop or crack during the transfer. Staff B stated it was not until the next day that she heard Resident #1 had a fractured right arm. Staff B stated Resident #1 was a 1-2 person assist with transfers prior to having issues with his/her legs. Staff B stated she was unaware when his/her transfer status changed from 1-2 staff to 2 staff assist with transfers. Staff B stated she was not involved with any transfers of Resident #1 that morning until the transfer into and from the weight chair. In an interview on 12/27/16 at 12:53 p.m. Staff C, Registered Nurse, stated on the morning of 11/23/16 around 8:00 a.m. Staff A alerted her to Resident #1 grimacing when his/her right arm was moved. Staff C assessed the arm and noted the grimacing as the arm was moved. Staff C cautioned staff to be careful and provided Resident #1 Tylenol for pain. Staff C stated she did not remove the resident's sweater and look at his/her skin. Staff C stated she was not involved with any transfers of Resident #1 that morning. Staff C stated she has heard other aides report Staff F has transferred residents requiring two assist by herself, but was unable to identify the aides which have said this. In an interview on 12/27/16 at 12:28 p.m. Staff D, certified nurse aide stated on the morning of 11/23/16, she and Staff E were assigned to the 100 hall. Staff F was a float and had gone into Resident #1's room to get him/her up. Staff D stated she told Staff F to let her know when she needed help with the transfer. Staff D stated Resident #1 was not bearing weight well and was a 2 person assist. Staff D stated Staff F never asked her for help and she later learned Staff E didn't help her either. Staff D stated Staff F was a float and not as familiar with Resident #1 and his/her recent weight bearing issues. Staff D stated she and Staff E assisted Resident #1 into his/her recliner later that morning and again that afternoon. Staff D stated she could tell Resident #1 was uncomfortable with transfers. Staff D stated she was not aware Resident #1 had a fractured arm until she was called at home that evening. In an interview on 12/27/16 at 2:19 p.m. Staff E, certified nurse aide, stated on the morning of 11/23/16 he was assigned to Resident #1's hall. Staff E stated he was not involved with getting Resident #1 up and dressed that morning. Staff E stated he thought Staff F had gotten him/her up and maybe Staff D had helped her. Staff E stated he and Staff D assisted Resident #1 to the toilet after breakfast and they could tell he/she was in distress. Staff E stated he used assist of two staff and a gait belt whenever he was involved with Resident #1. Staff E stated Resident #1 was having problems with standing and that is when he/she was changed to a two person assist. Staff E denied lifting Resident #1 from under his/her arms and insisted he always used a gait belt. In an interview on 12/28/16 at 12:30 p.m. Staff F stated on the morning of 11/23/16 she was a float on 100 hall and not familiar with the residents. Staff F stated she was not provided report nor given a care guide sheet for that hall and did not know the transfer status of Resident #1. Staff F stated she does not recall getting Resident #1 up that morning, but stated if other staff were saying she did, she must have. Staff F stated she also might have transferred Resident #1 by herself, but again noted she does not know for certain. In an interview on 12/28/16 at 9:05 a.m. Staff G, restorative aide, stated Resident #1 receives upper and lower extremity range of motion (ROM) for 15 minutes a day, five times a week. Staff G stated on the morning of 11/23/16 at around 5:15 a.m. to 5:30 a.m. she provided Resident #1 ROM exercises while he/she lied in bed. Staff G stated Resident #1 shoulders are generally stiff, so she primarily works on the elbow, wrist and fingers. Staff G stated she did not notice any indication Resident #1 was in pain or discomfort in her right arm that morning. Staff G stated she was not involved in any transfers involving Resident #1 that morning. 2. Resident #2 had a MDS assessment with a reference date of 9/21/16. The MDS identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated the resident had a severely impaired cognitive status. According to the MDS, Resident #2 required extensive assistance of 2 staff members with transfers, dressing, toilet use and personal hygiene needs. Resident #2's [DIAGNOSES REDACTED]. According to Resident #2's care plan, he/she required 2 staff member assistance and gait belt or stand up (mechanical lift) for transfers and extensive assistance by 2 staff to turn and reposition in bed. Resident #2 required total assistance of one staff person for dressing needs. According to the care guide (cheat sheet for aides to use as a quick reference of care) Resident #2 was an upper partial assist x1 and 2 assist and gait belt with transfers . Resident #2 was to also use a personal alarm while in bed and wheel chair. In an interview on 1/4/17 at 9:32 a.m. Staff J, Assistant Director of Nursing, stated she was responsible for developing and up-dating care guides for aides. Staff J was asked what upper partial assist x1 meant regarding Resident #2. Staff J indicated it meant cares involving the upper torso, dressing, etc. Staff J stated she did not intend for that to mean sitting Resident #2 up at his/her bedside, although admitted staff might interpret it that way. Staff J stated following Resident #2's fall it was changed on the care guide and staff educated on its meaning. Staff J stated they added the two person assist with bed mobility and clarified this meant that two staff were required when sitting Resident #2 up at the bedside. In an interview on 12/28/16 at 12:30 p.m. Staff F, certified nurse aide, stated on the morning of 12/13/16 she was preparing Resident #2 for his/her shower and assisted him/her up into a sitting position at his/her bedside. Staff F stated she was waiting for Staff H to transfer Resident #2 onto the shower chair. While standing in front of Resident #2, Staff F stated she started to remove her gait belt from her waist and without notice Resident #2 laid down backwards onto the bed, said oh and then slid off the bed onto the floor. Staff F placed a pillow under Resident #2's head, went to the door and got help. Staff I responded and assessed Resident #2. Resident #2 stated he/she hurt all over but wanted to get up. Staff F placed a gait belt on Resident #2 and Staff I assisted with lifting Resident #2 into the shower chair. Resident #2 was not bearing weight on his/her left side. Staff F stated she was aware Resident #2 was an assist of two staff with transfers and stated he/she is usually fine with sitting up. Staff F stated at the time of the incident they were finishing up on the hall and she anticipated Staff H would be in the room shortly to assist with the transfer. In an interview on 12/27/16 at 4:44 p.m. Staff H certified nurse aide, stated she was in another resident ' s room with a new nurse on the morning of 12/13/16 when Resident #2 fell . Staff H stated she later heard from Staff F that Staff F had Resident #2 sitting up at his/her bedside and Resident #2 slid off and onto the floor. Staff H stated she was unaware that Staff F was getting Resident #2 up. Staff H stated Resident #2 uses a Sara Lift (mechanical lift) to get up and she would never begin the process without having a second staff available. In an interview on 12/28/16 at 1:30 p.m. Staff I, Registered Nurse, indicated she was called to Resident #2's room on 12/13/16. Staff F stated she was getting Resident #2 prepped for a shower and waiting for her partner, Staff H to do the transfer. Staff F stated Resident #2 laid back onto the bed and then slid onto the floor. Staff I stated she assessed Resident #2, who was complaining of leg pain, but adamantly wanted up off the floor. Resident #2 was lifted up with assist of two staff and using the gait belt and then taken to the shower. Resident #2 was reassessed and believed to have a hip fracture. The Daily Nurse ' s Notes dated 12/13/16 at 7:25 a.m. indicated a CNA reported Resident #2 on the floor in front of the bed. Upon assessment, Resident #2 noted lying on the floor parallel to bed and stating he/she hurts all over and head hurts. The nurse performed neurological checks and resident transferred with the assistance of two staff and gait belt onto the shower chair. At 7:40 a.m. the resident had a 1 centimeter laceration on the back of the left ear and an 11 centimeter abrasion on the upper left arm. At 7:50 a.m. the resident transferred from the shower chair into a wheelchair with the assistance of 3 (staff members) and a gait belt. Resident voiced left leg pain. At 8:15 a.m. the nurse notified the physician and received orders to x-ray. At 9:30 a.m. x-rays were completed. At 10:30 a.m. x-ray results known, but waiting for physician to review to determine need for hospitalization . At 1:45 p.m. the facility received orders to have the resident sent to hospital for a further evaluation. At 2:40 p.m. resident left facility in route to hospital. The Radiology Report dated 12/13/16 indicated an acute fracture left femoral neck (hip). The x-ray showed vascular calcifications and osteopenic bones. The facility investigation summary, written by the Administrator, dated 12/13/16, indicated Staff F failed to follow the care plan related to requiring a two person assist with bed mobility. The investigation report identified Staff F indicated she knew Resident #2 was a two person assist with transfers, but thought he/she was a 1-2 person assist with bed mobility.

Based on record review and staff interviews, the facility failed to provide services in accordance with the care plan for 2 of 4 residents reviewed. Resident's #1, #2) The facility reported census was 56 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool with assessment reference date of 9/7/16, Resident #1 required extensive assistance with physical assistance of two staff with transfers, dressing, toilet use and personal hygiene needs. Resident #1's [DIAGNOSES REDACTED]. According to Resident #1's care plan; he/she required extensive assistance by two staff to move between surfaces. According to the care guide (cheat sheet for aides to use as a quick reference of care) dated 11/16/16, Resident #1 was determined an assist x 1 (1 staff member) for activities of daily living (ADLs), transfers and ambulation with a gait belt and walker. In an interview on 12/28/16 at 12:30 p.m. Staff F stated on the morning of 11/23/16 she was a float on 100 hall and not familiar with the residents. Staff F stated she was not did not provide report nor given a care guide sheet for that hall and did not know the transfer status of Resident #1. Staff F stated she does not recall getting Resident #1 up that morning, but stated if other staff were saying she did, she must have. Staff F stated she also might have transferred Resident #1 by herself, but again noted she does not know for certain. In an interview on 12/27/16 at 12:28 p.m. Staff D, certified nurse aide stated on the morning of 11/23/16, she and Staff E were assigned to the 100 hall. Staff F was a float and had gone into Resident #1's room to get him/her up. Staff D stated she told Staff F to let her know when she needed help with the transfer. Staff D stated Resident #1 was not bearing weight well and was a 2 person assist. Staff D stated Staff F never asked her for help and she later learned Staff E didn't help her either. Staff D stated Staff F was a float and not as familiar with Resident #1 and his/her recent weight bearing issues. Staff D stated she and Staff E assisted Resident #1 into his/her recliner later that morning and again that afternoon. Staff D stated she could tell Resident #1 was uncomfortable with transfers. Staff D stated she was not aware Resident #1 had a fractured arm until she was called at home that evening. In an interview on 12/27/16 at 2:19 p.m. Staff E, certified nurse aide, stated on the morning of 11/23/16 he was assigned to Resident #1's hall. Staff E stated he was not involved with getting Resident #1 up and dressed that morning. Staff E stated he thought Staff F had gotten him/her up and maybe Staff D had helped her. Staff E stated he and Staff D assisted Resident #1 to the toilet after breakfast and they could tell he/she was in distress. Staff E stated he used assist of two staff and a gait belt whenever he was involved with Resident #1. Staff E stated Resident #1 was having problems with standing and that is when he/she was changed to a two person assist. Staff E denied lifting Resident #1 from under his/her arms and insisted he always used a gait belt. 2. Resident #2 had a MDS assessment with a reference date of 9/21/16. The MDS identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 5. A score of 5 indicated the resident had a severely impaired cognitive status. According to the MDS, Resident #2 required extensive assistance of 2 staff members with transfers, dressing, toilet use and personal hygiene needs. Resident #2's [DIAGNOSES REDACTED]. According to Resident #2's care plan, he/she required two assist and gait belt or stand up (mechanical lift) for transfers and extensive assistance by two staff to turn and reposition in bed. Resident #2 requires total assistance of one staff to dress. According to the care guide (cheat sheet for aides to use as a quick reference of care) Resident #2 was an upper partial assist x 1 and 2 assist and gait belt with transfers . Resident #2 was to also use a personal alarm while in bed and wheel chair. In an interview on 1/4/17 at 9:32 a.m. Staff J, Assistant Director of Nursing, stated she was responsible for developing and up-dating care guides for aides. Staff J was asked what upper partial assist x1 meant regarding Resident #2. Staff J indicated it meant cares involving the upper torso, dressing, etc. Staff J stated she did not intend for that to mean sitting Resident #2 up at his/her bedside, although admitted staff might interpret it that way. Staff J stated following Resident #2's fall it was changed on the care guide and staff educated on its meaning. Staff J stated they added the two person assist with bed mobility and clarified this meant that two staff were required when sitting Resident #2 up at the bedside. In an interview on 12/28/16 at 12:30 p.m. Staff F, certified nurse aide, stated on the morning of 12/13/16 she was preparing Resident #2 for his/her shower and assisted him/her up into a sitting position at his/her bedside. Staff F stated she was waiting for Staff H to transfer Resident #2 onto the shower chair. While standing in front of Resident #2, Staff F stated she started to remove her gait belt from her waist and without notice Resident #2 laid down backwards onto the bed, said oh and then slid off the bed onto the floor. Staff F placed a pillow under Resident #2's head, went to the door and got help. Staff I responded and assessed Resident #2. Resident #2 stated he/she hurt all over but wanted to get up. Staff F placed a gait belt on Resident #2 and Staff I assisted with lifting Resident #2 into the shower chair. Resident #2 was not bearing weight on his/her left side. Staff F stated she was aware Resident #2 was an assist of two staff with transfers and stated he/she is usually fine with sitting up. Staff F stated at the time of the incident they were finishing up on the hall and she anticipated Staff H would be in the room shortly to assist with the transfer. In an interview on 12/27/16 at 4:44 p.m. Staff H certified nurse aide, stated she was in another resident's room with a new nurse on the morning of 12/13/16 when Resident #2 fell . Staff H stated she later heard from Staff F that Staff F had Resident #2 sitting up at his/her bedside and Resident #2 slid off and onto the floor. Staff H stated she was unaware that Staff F was getting Resident #2 up. Staff H stated Resident #2 uses a Sara Lift (mechanical lift) to get up and she would never begin the process without having a second staff available. In an interview on 12/28/16 at 1:30 p.m. Staff I, Registered Nurse, indicated she was called to Resident #2's room on 12/13/16. Staff F stated she was getting Resident #2 prepped for a shower and waiting for her partner, Staff H to do the transfer. Staff F stated Resident #2 laid back onto the bed and then slid onto the floor. Staff I stated she assessed Resident #2, who was complaining of leg pain, but adamantly wanted up off the floor. Resident #2 was lifted up with assist of two staff and using the gait belt and then taken to the shower. Resident #2 was reassessed and believed to have a [MEDICAL CONDITION]. Daily Nurse ' s Notes dated 12/13/16 at 7:25 a.m. stated CNA reports Resident #2 on floor in front of bed. Upon assessment Resident #2 noted lying on floor parallel to bed and stating he/she hurts all over, my head hurts. Neuro checks initiated and resident transferred with assist of two staff and gait belt onto shower chair. At 7:40 a.m. resident has 1 centimeter laceration back of left ear and 11 centimeter abrasion on upper left arm. At 7:50 a.m. resident transferred from shower chair into wheelchair with assist of 3 with gait belt. Resident indicating left leg is pain. At 8:15 a.m. physician notified and orders to x-ray. At 9:30 a.m. x-rays were completed. At 10:30 a.m. x-ray results known, but waiting on physician review to determine need for hospitalization . At 1:45 p.m. facility received orders to have resident sent to hospital for further evaluation. At 2:40 p.m. resident left facility in route to hospital. Facility investigation summary written by the Administrator indicated Staff F failed to follow the care plan related to requiring a two assist with bed mobility. Staff F indicated she knew Resident #2 was a two person assist with transfers, but thought he/she was a 1-2 person assist with bed mobility.

Based on observation, record review, staff and resident interviews, and review of the facility policy, the facility failed to follow the facility policy and failed to place a gait belt on a resident prior to a transfer and did not provide adequate supervision to ensure against hazards from self and elements in the environment (Resident #15). The sample consisted of 15 residents and the facility reported a census of 59 residents. Findings include: 1. The admission MDS (Minimum Data Set) assessment, with a reference date of 10/24/2011, documented Resident #15 with a BIMS (Brief Interview of Mental Status) of 14. A score of 14 indicated the resident's long and short term memory to be intact. The assessment indicated the resident required extensive assistance of at least 2 staff members with bed mobility, transfers, and toilet use. Resident #15 demonstrated lower extremity impairments on one side. The MDS documented the resident had [DIAGNOSES REDACTED]. The MDS did not indicate the resident had a history of [REDACTED]. The Care Plan with a start date of 11/2/2011 identified a problem with activities of daily living and functional impaired with bed mobility, transfers, ambulation, locomotion, dressing, toilet use and bathing related to infection in the right knee from a prosthetic device. The resident wore a brace on the right knee and had partial weight bearing of the right leg. The approach directed staff to provide assistance of 1 to 2 staff persons, gait belt and walker for transfers. The approach directed staff to apply nonskid footwear and remind the resident of partial weight bearing status of the right leg. A Fall Risk Assessment, dated 10/17/2011, identified the resident at high risk for falls with a score of 12. A score of 10 and above represented a high risk for falls. A nursing note dated 10/30/2011 at 5:05 a.m. documented the facility staff found the resident on the floor at the bedside. The resident sustained [REDACTED]. and a 1/2 centimeter by 1/4 centimeter open area over the bridge of the nose. A nursing note dated 11/07/2011 at 12:30 a.m. documented the resident sustained [REDACTED]. In both cases, the resident did not use the call light and the resident transferred self and ambulated without assistance. On 11/04/2011 the physical therapist discharged Resident #15 from physical therapy because the resident could not meet the therapy goals (moderately independent transfers with a wheeled walker) due to continuing problems with the resident's right knee and poor balance. The therapist instructed the staff to assist the resident with transfers and the resident should only bear partial weight on the right lower extremity. On 12/04/2011, Resident #15 started a new physical therapy program. The reasons for continued therapy included difficulty with transfers, decreased activity tolerance, and safety issues. An incident/accident reported dated 12/12/2011 at 12:50 p.m. indicated Staff D reported the resident had fallen. Staff E assessed the resident, who complained of left hip pain, and found no deformities. Staff D reported while assisting the resident from the wheelchair to a standing position, the right wheelchair pedal caught the resident's leg/foot causing the resident to fall to the floor. The resident sustained [REDACTED]. The Staff ambulated the resident to the toilet. On 12/12/2011, an x-ray of the resident's left pelvis and left hip revealed an acute left intertrochanteric femoral fracture. The facility transferred the resident to the local hospital. A therapy progress note dated 12/12/13 (incorrect documented year) written by Staff D (Physical Therapy Assistant) described the 12/12/11 accident with Resident #15. Staff D indicated she placed the resident's wheelchair outside the bathroom door with the resident in the chair. Staff D locked the wheelchair brakes and placed a walker in front of the resident. Resident #15 stood up and Staff D asked the resident to stand there while she pulled the wheelchair back. At that time the resident, who stood on the right foot, lost his/her balance, and fell to the left side onto the floor. The note indicated the resident voiced the right foot would not move. After the assessment, the resident voiced pain with weight bearing. The nurse contacted the physician and requested an x-ray. When questioned by the Administrator on 12/13/2011, Staff D informed the Administrator she was removing the wheelchair pedal and the resident would not wait, lost his/her balance on the right leg where the resident wore an immobilizer due and fell . In a written statement dated 12/20/2011 at 8:35 a.m., Staff D documented that on the date of the fall/fracture incident, Resident #15 needed to use the restroom. After placing the wheel chair (with the resident in it) and a walker outside of the bathroom, the resident stood up. Staff D asked the resident to stand there while she pulled the wheelchair backward. The resident stepped on his/her right foot, lost his/her balance, and fell to the left onto the floor. During an interview on 12/22/2011 at 7:30 a.m., Resident #15 verbalized remembering the fall on 12/12/2011. The resident remembered Staff D being in the bathroom with him/her. Resident #15 used a walker to stand up from the wheelchair, lost his/her balance and fell . Staff D did not have contact with the resident when standing and had not placed a gait belt on the resident. Resident #15 verbalized Staff D used a gait belt when transferring him/her previously. The resident denied getting the right leg caught in the wheelchair or any problems with the right leg at that time and had an immobilizer on that extremity at the time of the fall. In an interview on 12/21/2011 at 9:15 a.m., Staff E revealed at times the resident's right leg immobilizer would slip down and need to be repositioned. At the time of the fall, both the resident and Staff D verbalized the wheelchair pedal had caused the fall. At the time of the incident, Staff E first viewed the resident seated on the floor on the buttocks facing the bathroom doorway. In interviews on 12/20/2011 with Staff Fat 11:20 a.m., Staff G at 1:20 p.m., Staff H at 1:25 p.m. and Staff I at 4:30 p.m., all confirmed they used a gait belt and a walker when transferring Resident # 15. During observations on 12/20/2011 at 11:10 a.m. and 11:40 a.m., Staff D worked with 2 different residents on the parallel bars and along the rail in one hall of the facility for sit to stand and ambulation exercises. Staff D used a gait belt for both residents. During an interview on 12/20/2011 at 11:00 A.M., the physical therapist stated it was customary to use a gait belt on physical therapy patients until the patient was considered moderately independent or independent in gait and transfers. The physical therapist also verbalized he had spoken to Staff D after the resident's accident about always using a gait belt when transferring residents. The facility's undated Gait Belt Policy directed facility staff to use a gait belt to provide safe transfers and ambulation.