Every finding on record at Accura Healthcare of Pomeroy, LLC

Based on observations, staff interviews, Electronic Health Record (EHR) review, and policy review, the facility failed to complete appropriate hand hygiene for 3 of 4 residents observed (Resident #16, #19 and #20). The facility further failed to apply a gown when completing catheter care on a resident (Resident #2) with Enhanced Barrier Precautions (EBP). The facility reported a census of 24 residents. Findings include:1.The Minimum Data Set (MDS) dated [DATE] documented Resident #2 had a Brief Interview for Mental Status (BIMS) of 15 that indicated no cognitive impairment. The MDS also documented Resident #2 utilized an indwelling catheter. The MDS documented Resident #2 had a diagnosis of chronic kidney disease, stage 3A and 3B. Review of Resident #2's Care Plan documented a focus that Resident #2 was at risk for colonization with Multidrug-Resistant Organism (MDRO) related to catheter placement, goal was Resident #2 would remain free from MDRO through the review period and an intervention that Resident #2 was on EBP. On 5/12/26 at 11:26 AM an observation revealed Staff A, Certified Nurse Assistant (CNA) performed hand hygiene, applied gloves, failed to apply a gown for Personal Protective Equipment (PPE), and entered Resident #2's room. Staff A grabbed a cylinder and placed it inside a trash bag onto the floor. Staff A used an alcohol swab and cleansed the catheter drainage valve, opened the catheter drainage valve and emptied 750 ml urine output into the cylinder located in the trash bag. Staff A cleansed the catheter drainage valve with an alcohol swab, closed the catheter drainage valve and placed the catheter bag into the dignity bag attached to the wheelchair. Staff A walked into the bathroom, emptied the cylinder into Resident #2's toilet, rinsed out the cylinder, placed the cylinder on the back of the toilet and performed hand hygiene. On 5/12/26 at 2:13 PM the Director Of Nursing (DON) acknowledged facility staff needed to wear the appropriate PPE when emptying the catheter drainage bag and explained Staff A reported to her that she had forgotten to wear a gown during catheter care Resident #2 with the surveyor in the room. 2. The MDS dated [DATE] documented Resident #16 had a BIMS of 0 that indicated she was rarely / never understood. The MDS also indicated Resident #16 had a Percutaneous Endoscopic Gastrostomy (PEG) tube / feeding tube for nutritional supplement. On 5/12/26 at 11:54 AM an observation of medication administration by Staff C, Licensed Practical Nurse (LPN) to Resident #16's PEG tube with Assistant Director of Nursing (ADON) present during observation. Staff C pushed Resident #16 down the hall to her room, returned to the nurses station, obtained a computer from nurses station, obtained keys and returned to the medication cart medication. Staff C obtained medications, walked down the hall to Resident #16's bedroom, barrier placed on tray table, applied a gown, applied gloves, completed no hand hygiene, obtained 200 mL of water from sink, completed residual check, 0 cc gastric content, small amount of pressure applied with 30 mL of water, 60 mL formula added with small amount of pressure to piston syringe and medications given individually with 10 mL of water in-between each medication. Staff C poured the supplemental formula into the syringe with water flushes in-between, the rest of the 200 mL of water poured into the syringe. Staff C pushed the last 40cc of water with piston syringe, extension removed, syringe rinsed in sink with extension, graduate rinsed in the sink, paper towel placed in graduate with syringe, gloves removed, gown removed no hand hygiene completed. Staff C pulled the garbage liner, walked out into the hall to the shower room, pushed code into the door, opened the door, placed the garbage liner in a large garbage can, left the room and completed hand hygiene right before the next room on the right at the sanitizer station on the wall. On 5/12/26 at 12:13 PM the ADON. RN stated she had no concerns with observation of medication administration with Resident #16 by Staff C. 3. The MDS dated [DATE] documented Resident #19 had a BIMS of 14 that indicated no cognitive impairment. The MDS further documented Resident #19 had skin tears and Moisture associated Skin Damage (MASD) with a nonsurgical dressing. On 5/12/26 at 10:37 AM an observation of Staff C change a dressing on Resident #19 with ADON present during wound care. Staff C applied decon wound wash to gauze cut with no gloves on. Staff C entered the room, donned gown, donned gloves, completed no hand hygiene, closed the curtain, pulled the sheet up across the body, removed previous dressing, cleansed area, removed gloves, applied gloves, completed no hand hygiene, dressing pressed into wound under scrotum and 4x4 applied over the area. Staff C removed gloves, doffed gown, removed trash can liner, obtained garbage liner and placed the liner into the garbage can. Staff C left the room with bedside table and garbage liner, entered shower room on right of hall, placed garbage in the shower room, moved up the hall to medication cart past the nurses station, opened medication cart applied gloves, cleansed the top of the bedside table, cleansed scissors, removed gloves, locked medication cart, returned to the nurses station and completed hand hygiene at the sink behind the nurses station. 5/12/26 at 11:02 AM the ADON, RN stated she did not have any concerns with any of the wound care. 4. The MDS dated [DATE] documented Resident #20 had a BIMS of 15 that indicated no cognitive impairment. The MDS further documented Resident #20 had a nephrostomy tube (a thin, flexible catheter inserted through the skin and directly into the kidney to drain urine) placed for urine to drain. On 5/12/26 at 11:17 AM observation of nephrostomy tube emptied by Staff E, Certified Nurse Assistant (CNA) with the ADON present in the room. Observation revealed Staff E applied gown, applied gloves, did not complete hand hygiene, obtained graduated cylinder, placed barrier on the ground, utilized alcohol wipe to cleanse the tip of the catheter, emptied urine from catheter bag, utilized alcohol wipe to cleanse the tip, placed the urostomy bag clip back on shirt, emptied 300cc urine from graduate, cleansed graduate with toilet sprayer, removed gloves, removed gown and completed hand hygiene. On 5/12/26 at 11:23 AM ADON, RN stated no concerns with empty of urostomy On review of a facility provided policy updated 4/20/26 titled, Enhanced Barrier Precautions (EBP) documented EBP referred to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. An order for EBP would be obtained for residents with any of the following: wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (central lines, urinary catheters, feeding tubes) even if the resident is not known to be infected or colonized with a Multidrug-Resistant Organism (MDRO). On review of a facility provided policy titled, Hand Hygiene dated 11/13/24 documented when to perform hand hygiene included: Immediately before touching a resident, before performing aseptic techniques (indwelling device) or handling an invasive medical device, immediately before putting on gloves and after glove removal, after touching a resident or resident's immediate environment, after contact with blood, body fluids or contaminated surfaces, when hands are visibly soiled, before moving from a spoiled body site to a clean body site on the same resident.

Based on clinical record review, staff interviews, and policy review the facility failed to ensure resident's current code status was available for 1 out of 14 residents reviewed (Resident #10). The facility reported a census of 24 residents. Findings include: Resident #10's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 05, indicating severely impaired cognition. Resident #10 MDS's documented diagnoses of hypertension, thyroid disorder, arthritis, Alzheimer's disease and non-Alzheimer's disease. The Clinical Census revealed Resident #10 was admitted to the facility on [DATE]. The Baseline Resident Care Plan lacked documentation regarding Resident #10's code status. The Electronic Medical Record and the paper chart lacked documentation regarding Resident #10's code status. On [DATE] at 9:35 AM, Staff B, Registered Nurse (RN) reported she would first look at the electronic medical record to locate resident advance directives/code status. She said the advance directives are documented on the resident header under code status. She said the code status auto populates to the resident header from the Physician orders. She said if the code status was not listed on the resident header then she would go to the documents tab to look for the IPOST (Iowa Physician Orders for Scope of Treatment). She said if the IPOST was not in the electronic medical record then she would go to the paper chart. Staff B verified Resident #10's code status was not documented in the electronic medical record or in the paper chart. Staff B acknowledged and agreed having to look for the code status would slow down the response time if cardiopulmonary resuscitation (CPR) was needed. Staff B said Resident #10 was admitted from Assisted Living and all the residents who lived in the Assisted Living have a do not resuscitate (DNR) for a code status.On [DATE] at 9:47 AM, Staff B, RN reported she found Resident #10's IPOST on the Assistant Director of Nursing's (ADON) desk. Review of the IPOST revealed Resident #10's code status was CPR with limited additional interventions and the IPOST was completed/signed by the ADON on [DATE]. The IPOST was not signed or dated by the resident, legal representative or a Physician. An email provided by Staff B dated [DATE] revealed the ADON requested Resident #10's daughter to sign the IPOST and return it to the facility so the code status could be signed by the Physician and put into the system correctly. Staff B reported the daughter had not replied yet. Staff B seemed surprised Resident #10 was a full code and acknowledged there was a concern as she thought Resident #10 was a DNR. On [DATE] at 10:53 AM, the ADON reported she resent Resident #10's IPOST to her daughter today. She said she had been working on the floor as a charge nurse and thought she had received Resident #10's IPOST back. She said it was hard to track her emails while working on the floor. She said if a Resident's BIMs score was below a 12 then the Power of Attorney (POA) had to sign the IPOST. She reported Resident #10's daughter lived out of state and was not present during the admission process. The ADON said she tried to get the IPOST completed as soon as possible. The ADON said if the code status wasn't listed, the resident was considered a full code. She said all residents are a full code unless the IPOST directs otherwise. She said she had spoken to Resident #10's daughter on the phone on [DATE] and the daughter wanted a full code, changing from the Assisted Living's standard DNR. The facility policy titled Cardiopulmonary Resuscitation (CPR) updated [DATE] documented the facility would adhere to residents rights to formulate advance directives. The policy documented advance directives to define the scope of medical care would be discussed with the potential resident and/or resident representative at the time of admission. If a resident experienced a cardiac arrest, the facility staff would provide basic life support, including CPR, prior to the arrival of emergency medical services, and:a. In accordance with the resident's advance directives, orb. In the absence of advance directive or a Do Not Resuscitate order, and c. Unless in the professional opinion of a physician, the resident shows obvious signs of clinical death (pupils fixed, absence of respirations or pulse, skin cold to touch, rigor mortis, dependent lividity, decapitation or decomposition).

Based on clinical record review, Center for Medicare and Medicaid (CMS) Long Term Care (LTC) Facility Resident Assessment Instrument (RAI) User Manual and staff interview the facility failed to complete a Minimum Data Set (MDS) Significant Change in Condition Assessment (SCSA) for 2 of 14 residents reviewed (Resident #3 and #5). The facility reported a census of 24 residents. Findings include: 1. The MDS dated [DATE] documented Resident #5 had a BIMS of 1 that indicated severe cognitive impairment. The MDS documented no significant change assessment. Review of Care Plan with review history date of 1/26/26 documented Resident #5 required an assist of 1 staff with walker for transfers initiated on 3/3/25 and ambulation required an assist of 1 with a walker initiated on 3/3/25. Review of current Care Plan documented Resident #5 required an assist of 2 staff with mechanical sit to stand lift for transfers with revision on 5/3/26 and ambulation required an assist of 2 with a mechanical sit to stand initiated on 5/3/26. Review of MDS dated [DATE] documented Resident #5 required partial / moderate assistance where the helper did less than half the effort for walking 10 feet, walking 50 feet with 2 turns, and walking 150 feet. The MDS documented Resident #5 utilized a walker and a wheelchair. Review of MDS dated [DATE] documented Resident #5 did not attempt walking 10 feet, walking 50 feet with 2 turns, and walking 150 feet. The MDS documented Resident #5 no longer utilized the walker but only a wheelchair. Review of EHR titled Functional Abilities and Goals dated 5/20/25 at 6:56 AM documented Resident #5 required partial / moderate assistance where the helper did less than half the effort for sit to stand, chair to bed transfer, toilet transfer and walking 150 feet. The document also documented Resident #5 required supervision or touching assistance for walking 10 feet and walking 50 feet with 2 turns. Review of EHR titled Functional Abilities and Goals dated 4/22/26 at 1:37 PM documented Resident #5 was dependent on staff for sit to stand and bed to chair transfer. The document also documented walking was not attempted due to medical condition or safety concerns for Resident #5. Review of Resident #5's document dated 10/30/25 titled, PT Discharge Summary documented Resident #5 was non-ambulatory with maximal assistance for sit to stand, bed to chair transfers and toilet transfers with a front wheeled walker utilized for transfers. Documented Resident #15 currently utilized a sit to stand mechanical lift for transfers because Resident #15 was unable to straighten the knees. On 5/12/26 at 3:58 PM Staff F, Certified Nurse Assistant (CNA) stated does not get a chance to work with Resident #5 much because he prefers Staff G, CNA. Staff F stated Resident #5 does not walk at all. Staff F stated when she documented not applicable for Resident #5's restorative task it meant that the resident did not walk and stated had not walked in the 6 months. Staff F stated she had not said anything about Resident #5's inability to walk but she knew Staff G had said something about removing the task because he did not walk. On 5/14/26 at 9:18 AM Staff H, CNA stated had worked at the facility for about a week. Staff H stated she had completed training and had been on the floor a couple of days by herself. Staff H explained she was not familiar with restorative care yet she had not had to do it. 2. Resident #3's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS identified Resident #3 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with bed mobility, all transfers and ambulation. Resident #3's MDS included diagnoses of viral hepatitis, diabetes mellitus, chronic pain syndrome and cerebral infarction. The Progress Note titled Fall dated 3/30/26 at 7:47 AM revealed Resident #3 was lowered to the floor due to her right knee giving out. Resident #3 complained of right knee/leg pain and received as needed (PRN) tramadol (opioid pain medication). The Progress Notes dated 4/2/26 revealed Resident #3 returned from a Physician's appointment. Resident #3 had an x-ray of her right knee. The x-ray revealed an acute non-displaced fracture of the fibular neck, no dislocation and mild tricompartmental osteoarthritis of the right knee. Resident #3 was scheduled for an orthopedic appointment on 4/6/26 at 9:45 AM. Resident to be nonweight bearing until appointment. The Progress Note dated 4/6/26 revealed Resident #3 returned to the facility from orthopedic appointment with order to be weight bearing as tolerated to the right lower extremity. The Progress Note dated 4/7/26 documented Resident #3 had significant pain to the right knee and remained non-weight bearing throughout the shift. The Progress Note dated 4/9/26 documented the staff continued to use the mechanical lift for transfers due Resident #3 did not want to put weight on the right lower extremity. The Progress Note dated 4/14/26 documented Resident #3 continued to require the use of a mechanical lift for transfers as weight bearing remains painful. The Progress Note dated 4/16/26 documented Resident #3 continued to require the use of a mechanical lift for transfers due to discomfort. The Progress Note dated 4/17/26 documented Resident #3 continued to use the mechanical lift for transfers with the assistance of two staff members. The Care Plan with a target date of 5/12/26 revealed the following: a. Resident #3's ambulation was put on hold on 3/30/26 until her knee healed. Staff to use a wheelchair- revised 4/7/26 b. Staff to use a mechanical lift with assistance of two staff members for transfers- Initiated 4/2/26 c. Staff may use mechanical sit to stand lift for transfers per therapy recommendations- revised 5/12/26 d. Resident #3 to use a bed pan and staff to provide peri care due to incontinence - revised 4/3/26 Review of Resident #3 MDS Tracking page revealed Resident #3 had not been set up for a Significant Change in Status MDS assessment within 14 days after determination that significant change in resident's status had occurred. On 5/12/26 at 1:07 PM, the Director of Nursing (DON) reported Resident #3 continued to use the mechanical lift for transfers. The DON said therapy would like Resident #3 to use the mechanical sit to stand lift for transfers but she refuses. On 5/12/26 at 4:45 PM, the Assistant Director of Nursing (ADON) reported the Regional Reimbursement Specialist told her that she could either change the quarterly MDS with ARD (assessment reference date) of 5/1/26 to a Significant Change in Status MDS since it had not been exported or open up a new MDS. The ADON reported she opened up a new Significant Change in Status MDS assessment with an ARD date of 5/15/26. On 5/13/26 at 8:27 AM, the DON acknowledged a Significant Change in Status MDS should have been done. She said they were going to complete one now. The DON said she thought Resident #3 would have recovered quicker than she did as she was weight bearing as tolerated. On 5/13/26 at 1:41 PM, the DON reported the facility did not have a policy for Significant Change in Status MDS. She said they follow the RAI manual. The CMS LTC RAI 3.0 User's Manual, Version 1.20.1 October 2025, Chapter 2 under Significant Change in Status Assessment (SCSA) directs the SCSA is a comprehensive assessment that must be completed when the interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either a major improvement or decline. A Significant Change is defined as a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting. 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. The RAI manual directed the ARD to be set no later than the 14th calendar day after determination that significant change in resident's status occurred (determination + 14 calendar days).

Based on clinical record review and staff interviews, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 1 resident reviewed (Residents #15) for insulin administration. The facility reported a census of 24 residents.Findings include: The Minimum Data Set (MDS) assessment for Resident #15 dated 4/1/26 identified a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS included diagnoses of diabetes mellitus and long term use of insulin. The MDS documented Resident #15 received insulin injections and hypoglycemic medications during the last 7 days. The Care Plan with a target date of 6/30/26 revealed Resident #15 was at risk for alteration in blood glucose levels related to diagnosis of diabetes mellitus. The Care Plan directed to administer blood sugars per order, observe for side effects and effectiveness of medications. The Physician Order dated 6/22/25 directed staff to administer Novolog FlexPen (rapid-acting insulin) 100 units/ml (milliliter), inject 28 units subcutaneously (layer of fatty tissue beneath the dermis) two times a day. The order directed to hold the insulin if the blood sugar was less than 120 mg/dl (milligrams per deciliter). Review of March 2026 to May 2026 Treatment Administration Records (TAR) revealed the Novolog Insulin 28 units was administered when the blood sugar was below 120 mg/dl on the following dates/times:March TAR- 3/7 AM- BS-98- insulin given3/19 AM- BS-103- insulin givenApril TAR-4/7 AM- BS 77- insulin given4/7 PM- BS 113- insulin given4/8 AM- BS 114- insulin given4/26 AM- BS 111- insulin givenMay TAR-5/4 AM- BS-87- insulin given On 5/13/26 at 10:45 AM, the Assistant Director of Nursing (ADON) acknowledged the Novolog insulin was documented as given when the blood sugar was below 120 mg/dl. The ADON reported she would expect the physician order to be followed. On 5/13/26 at 1:41 PM, the DON reported the facility did not have a policy regarding following physician orders. She said they follow standards of care.

Based on staff interview, resident interview and Electronic Health Record (EHR) review the facility failed to provide treatment and services to residents that had decreased range of motion to prevent further decrease in range of motion to 2 of 4 residents (Resident #5 and #16). The Facility reported a census of 24 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #5 had a Brief interview for Mental Status (BIMS) of 1 that indicated severe cognitive impairment. Review of Resident #5's Care Plan with review history date of 1/26/26 documented Resident #5 required an assist of 1 staff with walker for transfers initiated on 3/3/25 and ambulation required an assist of 1 with a walker initiated on 3/3/25. The Care Plan documented an intervention of a walker and wheelchair for adaptive equipment with revision date of 6/8/25. Review of Resident #5's current Care Plan documented Resident #5 required an assist of 2 staff with mechanical sit to stand lift for transfers with revision on 5/3/26 and ambulation required an assist of 2 with a mechanical sit to stand initiated on 5/3/26. Review of Resident #5's EHR titled, Task documented an ambulation program to walk with assistance of one staff to and from meals with front wheeled walker, gait belt and wheelchair to follow. Frequency: 3 times daily as tolerated, 5-7 days per week as tolerated with resident refusal on 4/14, 4/15, 4/16, 4/18, 4/19, 4/21, 4/22, 4/23, 4/28, 4/30, 5/7 and 5/11 all on the 2:00 PM - 10:00 PM shift. All other documentation for 3 times a day 5-7 days a week was documented as not applicable. Review of Resident #5's document dated 3/3/26 titled, OT Discharge Summary documented Resident #5 was dependent on toilet transfers.Review of Resident #5's document dated 10/30/25 titled, PT Discharge Summary documented Resident #5 a restorative program was established/trained with leg exercises for bilateral lower extremity strengthening and Resident #5 was to participate in leg exercises. On 5/12/26 at 3:58 PM Staff F, Certified Nurse Assistant (CNA) stated does not get a chance to work with Resident #5 much because he prefers Staff G, CNA. Staff F stated Resident #5 does not walk at all. Staff F stated when she documented not applicable for Resident #5's restorative task it meant that the resident did not walk and stated he had not walked in the 6 months. Staff F stated she had not said anything about Resident #5's inability to walk but she knew Staff G had said something about removing the task because he did not walk. On 5/14/26 at 9:18 AM Staff H, CNA stated had worked at the facility for about a week. Staff H stated she had completed training and had been on the floor a couple of days by herself. Staff H explained she was not familiar with restorative care yet she had not had to do it. 2. The MDS dated [DATE] documented Resident #16 had a BIMS of 0 that indicated she was rarely / never understood. The MDS also indicated Resident #16 had diagnoses of scoliosis, cramp and spasm, Developmental disorder of scholastic skills, and rett's syndrome.On 5/11/26 at 12:44 PM Resident #16's Mother stated she would like some therapy to prevent or decrease the possibility of contractures. Review of Resident #16's EHR documented no restorative therapy, range of motion, or screening by therapy since admission.On 5/12/26 at 4:32 PM Staff G, CNA stated had worked at the facility for 20 years. Staff G stated Resident #5 has been unable to walk for about 6 or 8 months. Staff G stated he had brought it up to the Assistant Director of Nursing (ADON) about 3 weeks ago. Staff G stated he charted not applicable because he required a sit to stand mechanical lift for transfers. Staff G acknowledged he did work with Resident #16 and does not complete any restorative therapy or range of motion with her. Staff G stated he was unaware of any expectation by management for him to complete any restorative therapy that wasn't on the resident's task. Staff G stated there used to be a restorative aide position but that was eliminated. Staff G stated he had no training for restorative therapy. On 5/14/26 at 9:43 AM Staff I, Certified Medication Assistant (CMA) stated she had used a sit to stand mechanical lift for transfers on Resident #5. Staff I explained Resident #5 used to walk with a walker. Staff I said Resident #5 walked about 5 or 6 months ago. Staff I stated she put not applicable because Resident #5 did not walk anymore and used a sit to stand mechanical lift for transfers. Staff I explained until therapy saw Resident #5 staff could not walk him. Staff I stated she could not remember if she had ever told any management or Director of Nursing (DON) or ADON about Resident #5 not walking. Staff I explained she completed restorative with anyone that has a restorative task. Staff I explained when she got Resident #16 dressed she would stretch her arms and stuff because she really doesn't move her extremities by herself. Staff I stated she did not know if she was supposed to or not. Staff I stated she was trained years ago not sure how long ago. On 5/13/26 at 2:31 PM Staff J, Regional Director of Operations / Occupational Therapy (OT) treated Resident #16 recently 2-9-26 thru 3-3-26. Staff J stated Physical Therapy (PT) did an eval only on October 22 2025. Staff J stated there was an evaluation, a daily treatment, and a discharge for Resident #16. Staff J stated had not had Resident #16 on caseload for PT, OT, or speech herself. Staff J explained a lot of time when working with the facilities evaluations are determined during Medicare meetings, review screens or any declines with residents and then they request orders. Staff J explained the facility would also request orders outside of that meeting if they feel the resident needs therapy. Staff I stated if there was any decline then she would be able to see the resident. Staff I said if they would have turned the restorative plans into the facility the facility would have those notes. Staff I stated had worked with the facility since 2019. Staff I stated she was not sure why there was no screening completed with Resident #16 when she entered the facility. Staff I stated Resident #16 was in their system but there was no documentation for her because she was not evaluated. On 5/13/26 at 5:06 PM Staff K, Certified Occupational Assistant, started working at the facility for about a month. Staff K stated she had not discussed any restorative program with the facility. Staff K stated she was not sure how this facility did therapy screening. Staff K stated at other facilities they screen all the residents once a quarter. Staff K stated all residents are supposed to be screened quarterly. Staff K stated they usually develop the restorative plan where they give suggestions on what the residents can work on, they write that up and give it to the DON usually. On 5/14/26 at 10:01 AM Staff L, Speech Therapy stated she worked part time and was not at the facility unless there is a need for speech therapy. Staff L stated she had been at the facility through a contract for about a year. Staff L stated any staff can notify if there was a decline and can reach out to the physician to obtain orders. Staff L explained there are quarterly screens she does not do but there was a list of patients to screen quarterly. Staff L stated everyone at the facility was screened quarterly. Staff L stated the facility did not have a restorative department. Staff L acknowledged she was not as familiar with this building as she was with others. Staff L stated she had not developed a restorative plan for the facility since working at the facility. Staff L stated she was not sure if there was CNA that did restorative at the facility. On 5/14/26 at 11:45 AM the Director of Nursing (DON) stated the facility got restorative plan from therapy. The DON stated the facility had identified that the restorative review was not being completed appropriately. The DON stated the ADON was the Registered Nurse (RN) that overseen the restorative programs. The DON stated the MDS Reimbursement Specialist was going to come to the facility to retraining the ADON on restorative reviews. The DON explained therapy screened off of the quarterly MDS calendar but that was the only process they currently had. The DON stated there were residents at the facility that are not on therapy that would benefit from a restorative plan. The Administrator stated the facility did not have a policy for range of motion or restorative therapy.

Based on observation, interview and record review the facility failed to provide complete assessments and interventions for 1 of 5 residents reviewed. Staff reported that Resident #2 had on-going agitation that lead to hitting of staff, and regular bruising on his arms from various causes. The chart lacked documentation of these concerns until 7/5/25, when he reported allegations of rough treatment with dark bruising on his arms. The facility reported a census of 26 residents.Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive deficits) The resident did not have behavioral symptoms, directed toward others such as hitting, kicking and pushing, and no rejection of care. He had verbal behavioral symptoms directed toward others 1-3 days during the look-back period. Resident #2 used a manual wheel chair and was able to wheel at least 150 feet and make 2 turns. He was frequently incontinent of urine and always incontinent of bowel. The resident had impaired movement of upper and lower extremities, and was totally dependent on staff for dressing, hygiene and transfers. The Care Plan updated on 3/17/25, showed that Resident #2 had coping deficits related to bipolar disorder, borderline personality disorder, with irritability and anger. He had a long standing history of behaviors with foul language, yelling, spitting, attempting to self-transfer, aggression and hitting.From 5/22/25 - 7/4/25, the Nursing Progress Notes lacked any reference to aggressive behavior, refusal of cares or new bruising.A Nursing Progress Note dated 7/5/25 at 8:22 PM, showed that staff discovered new, dark bruising on both forearms that were not there the previous evening. The resident stated that one of the girls last night did it when she yanked me.A Non-Ulcer Skin Assessment document, showed that his right arm had scattered dark bruising. Total area of 16 centimeters (cm) x 5cm. His left arm had scattered dark bruising; total area of 12cm x 7cm.The following entries were added to the Care Plan after 7/5/25;a. On 7/7/25; padded side rails to prevent skin injuries that might be caused due to intentionally hitting arms and or legs into stationary objects. He often refuses or removes interventions. Allow time to cool down and re-approach.b. On 7/8/25; Use 2 staff for all care due to history of allegations against staff. Intervention included observe for contribute factors for behavior, provide one on one activities as needed.c. On 7/20/25; the resident was combative in the Hoyer lift.d. On 7/25/25; resident refuses Geri sleeves.e. On 8/5/25; the resident runs his wheel chair into the walls, med carts, furniture and railings.f. On 8/7/25; staff to try to help resident identify his boundaries when propelling wheelchair.On 8/11/25 at 9:20 AM, Resident #2 was in the hallway near his room. He was propelling himself by pushing the wheels, and his feet were extended out over the top of the foot pedal. The resident was having some difficulty navigating the corner into his room. At 9:33 AM, he was still trying to turn into his room and his arm was squeezed up against the handrail.On 8/11/25 at 2:51 PM, Staff K, Licensed Practical Nurse (LPN) said that the resident could not bear weight but he thinks he can and it upset him when staff would tell him he can't get up on his own. When asked if he'd had any falls, Resident #2 pointed to the matt on the floor and said that they put it next to his bed. He then said I do it on purpose. He explained that he would roll out of bed on purpose and put himself on the floor so the alarm would go off and it would get their attention. When asked if there were any staff that have treated him rough, he said that there was one who grabbed his arm, mostly the right arm and said it's almost healed now. she was trying to prevent him from getting into the bathroom. He said that sometimes he would bump his arms on the side rails when they rolled him over in bed. On 8/12/25 at 8:21 AM, Staff G, CNA said that since 7/5 when Resident #2 made allegations of abuse, they started taking pictures of all new bruises. She said that there were many times that he would get combative with the staff when they provided cares and when they would report it, they were told that he just didn't like them and to step away from him. She said that there was an incident when they were transferring him with the mechanical lift, he raised his fist and hit the arm of the lift which bruised on his hand. On 8/12/25 at 9:02 AM, Staff C, CMA said that many times Resident #2 was combative and it wasn't documented. She displayed a bruise on her leg where he slammed his wheel chair into her. On 8/12/25 at 9:13 AM Staff I, CNA said that there were many incidences in past, that Resident #2 was combative and he hit her. She reported to Nursing and the Administrator and she was told to just get away from him. She did not see any new interventions or documentation completed.On 8/12/25 at 11:12 AM, Staff B, CNA said that Resident #2 often had bruising on his arms, he would get agitated when the staff tried to clean him. He would report to the nurses whenever it happened.On 8/12/25 at 1:11 PM the Director of Nursing said that Resident #2 often had bruises on his arms because he would bump them on the walls and side rails of the bed. She said that they hadn't been keeping track of the bruising before the incident on 7/5/25.On 8/12/25 at 2:30 PM, the Administrator said that Resident #2 often got caught up on the hall arm rests and in doorways which caused bruising. She said that if there were incidents between residents and staff such as hitting them or running his wheel chair into them, staff should step back and there should be a behavior note in the nursing documentation. They would do an incident report if/when the resident sustained new injury.According to a facility policy dated 5/6/23 titled: Skin Management Protocol to notify the DON and wound nurse of new skin alteration and complete incident report and a skin sheet.

Based on observation, interviews and record review the facility failed to administer medications as ordered for 2 of 5 residents reviewed (Resident #1 and #3.) Within a 5-week timeframe staff reported 3 medication errors for Resident #1. Staff left medications for Resident #3 unattended, and the cup of pills was later discovered on the food tray in the kitchen. The facility reported a census of 26 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #1 was absence of spoken words, she was rarely/never understood. She was unable to participate with a Brief Interview for Mental Status (BIMS) assessment and her cognitive skills were severely limited. Resident #1 was totally dependent on staff for toileting, dressing, hygiene, and transfers and used a wheel chair. He diagnoses included diabetes mellitus, aphasia, seizure disorder, malnutrition and Rett's Syndrome (neurological disorder that causes severe muscle movement) The Care Plan last updated on 4/8/25, showed that Resident #1 had artificial nutrition per gastrostomy tube. She was completely dependant with care, and used a mechanical lift for transfers. The resident had a history of seizures and used psychotropic medications related to Rett's Syndrome, Aphasia, Epilepsy, Scoliosis and spasticity. On 8/11/25 at 9:30 AM, Resident #1 was sitting in front of the television in the dayroom. Her wheel chair was in the upright position, arms crossed at her chest. She had contractures of the hands and her eyes were closed. At 12:00 PM, Staff K, Licensed Practical Nurse (LPN) pushed her back to her room and at 1:10 PM she was in bed with the head of the bed elevated.On 8/11/25 at 2:14 PM, a Family Member (FM) for Resident #1 said she had been up to visit the resident and talked to the nurse that forgot to give the resident her evening medications in May. FM said that there were a couple of temporary staff that didn't give the seizure medication as ordered and the mistakes seemed to always happen on a holiday weekend. According to the Orders tab, Resident #1 had an order for clobazam 2.5 milligrams per milliliter (mg/ml) give 2 ml one time a day in the morning, give 4ml at bedtime.Incident Reports for Resident #1 showed the following:a. On 5/23/25 at 8:30 PM the overnight nurse realized that she had forgotten to give Resident #1 her night medications or feeding.b. On 5/27/25 at 3:10 PM during the morning medication pass the nurse gave the nighttime dose of Clobazam 4 milliliters (ml) instead of the 2 ml. morning dose.c. On 7/5/25 at 7:00 AM during shift change it was discovered that the previous nurse had given 2ml instead of the ordered 4ml night dose.On 8/12/25 at 2:15 PM, Staff J, Registered Nurse (RN) said that she got busy on the evening of 5/23/25 and had forgotten the evening medication and feeding. She said that it was still sitting on the nightstand the following morning.On 8/12/25 at 11:55 AM, The Assistant Director of Nursing (ADON) acknowledged that they'd had a problem with the clozabam and ensuring that the medication was being given as ordered because they've gone back and forth from a bottle and pre-filled syringes.2) According to the MDS dated [DATE], Resident #3 had a BIMS score of 15 (cognitive intact) She was totally dependent on staff for toileting, dressing, rolling and sit to stand. Her diagnoses included: heart failure, renal insufficiency, diabetes mellitus, hip fracture, anxiety and depression. The resident rejected evaluation or care 1-3 days during the look-back period. High-risk drugs included antianxiety, antidepressant, opioid, antiplatelet and hypoglycemic medications.The Care Plan for Resident #3 last updated on 7/10/25, showed that Resident #3 had altered cardiovascular status related to history of acute and chronic diastolic congestive heart failure, bradycardia, obesity, staff were to administer medications as ordered. She had the potential for constipation related to decreased physical mobility and obesity, diverticulosis and diabetes mellitus.On 8/12/25 at 9:38 AM, Resident #3 was in her recliner with a bedside tray pulled up to where she could reach items. She said that she preferred to stay in her room and she took her meal trays in the room as well. She said there was an agency nurse that put her cup of pills in front of her one evening and then left the room. The tray was taken back to the kitchen with the pills and another nurse found them and brought them back to her to take.On 8/12/25 at 2:15 PM, Staff J said that it was a Sunday night when agency staff set a cup of medications for Resident #3 and it was left on the food tray without the resident's knowledge. The kitchen staff picked up the tray and found the medications, and gave them to Staff J, she then took the medications to the resident to take.On 8/13/25 at 10:30 AM the Administrator said that they do not have any residents that have been assessed to be able to administer their own medications unsupervised. She said we don't do that here She said that the nurses should know the 5 rights of medication administration and double check during medication pass.

Based on observation, interview and record review the facility failed to ensure that staff were orientated and trained to care for residents. Temporary nurses and Certified Nurse Aides (CNA) were expected to perform the job duties without proper training. The facility reported a census of 36 residents.Findings include: On 8/12/25 at 1:00 PM, the Administrator and the Assistant Director of Nursing (ADON) stated they had orientation checklists for agency staff. In the absence of the Director of Nursing (DON) they would look for documentation that the following temporary staff had been oriented: Staff C, CNA, Staff E, CNA, and Staff D, Registered Nurse (RN). In an observation on 8/12/25 at 1:10 PM, Staff L, CNA was assisting residents with transfers too and from their rooms. Staff L said that she was with a staffing agency it was her second day at this facility. The last time she worked at this facility was 6 months previous. She said that she did not get an orientation, and she didn't remember any education checklists offered to her before she worked independently with the residents.On 8/12/25 at 10:05 AM, Staff E, CNA said that she worked the overnight shift on the previous Sunday, and it was a difficult night because she was the only aide on floor. She had worked several other shifts at this facility and she tried to transfer Resident #2 without the use of the mechanical lift because he told her that he could stand. When she found that he wasn't standing, she lowered him back down onto the bed. Staff E said that she did not get an orientation or education before she worked independently with the residents. On 8/12/25 at 10:14 AM, Staff M, CNA said that she worked the overnight shifts and she did not get any orientation or education. She said that she knew how to transfer residents and provide cares because she was a CNA for a long time.On 8/12/25 at 10:23 AM, Staff D, RN said that she usually worked the weekends at this facility. She said when she first started she was expected to come in an hour early and another nurse showed her around the building. She did not remember getting a complete orientation or a signed checklist.On 8/12 at 9:45 AM, Resident #5 was in her wheel chair in the dayroom. She had bruising on her left arm and said it was from a recent hospitalization. She said that she was on dialysis and was feeling much better. The resident said that she was concerned about good staff that were leaving and the temporary aides don't know what they are doing. She said that on that morning, she had to explain to the CNA how to help her with her catheter and toileting needs.On 8/13/25 at 11:00 AM, the Administration said that many orientation checklists were on the DON's desk except for the 3 staff that were requested.A form titled: Agency Staff Checklist indicated that the following items would be included in orientation:a. Facility layout with tourb. Shift routine/general duties. Resident care, mechanical lifts, documentation, narcotic count, medication deliveries, change in condition guidelines, 24 hour report, Pocket Care Plans, Medication administrationc. Communication; Door alarms, telephone use, walkie use,d. Abuse Policy; what to report and whene. Resident Incident Reports; falls, skin protocol, medication errors, deathf. Emergencies; physician contacts, hospital contactsg. Emergency Procedures: fire, weather, elopement, leave of absence, emergency carth. DON notificationi. Concern [NAME] signing, staff acknowledged that they had received training for all of the above guidelines and information to perform the job. The orientation was not intended to cover every situation which may arise while on assignment but was a general guideline.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for Quarter 1, 2025 review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 26 residents. Findings include: The PBJ Staffing Data Report with a run date of 4/23/25, for the 1st quarter of the fiscal year 2025; (October 1 - December 31), triggered for a failure to have licensed nursing coverage 24 Hours/Day. Infraction dates included: 10/19, 10/20, 11/28, 12/2, 12/3, 12/4, 12/5, 12/6, 12/8, 12/9, 12/10, 12/11, 12/13, 12/16, 12/17, 12/18, 12/19, 12/20, 12/22, 12/23, 12/24, 12/25, 12/26, 12/27, 12/30 and 12/31. A review of the nursing schedules and timesheets revealed that nurses were on duty on the above dates. On 4/29/25 at 3:30 PM, the Administrator said that the PBJ report was being submitted by a third-party entity. She said that the process had been unorganized and confusing and the facility had identified and arranged for a different company to provide the service in the future. The Administrator said that the report had been showing an overstaffing of nurses on one day, then the following day, showed no nurses at all. She acknowledged that it was not submitted correctly. According to the facility policy dated 2/23/25 titled: Nursing Services and Sufficient Staff, the facility was responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal system.

Based on record, policy, and chart review, the facility failed to follow through with physician's orders for 1 of 13 residents reviewed. Staff were monitoring the blood glucose levels for Resident #23 four times a day and the physician directed them to contact him/her according to the established parameters. In a 3-month timeframe, the blood glucose levels were outside those parameters 8 times, and staff failed to contact the doctor. The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #23 was admitted to the facility on [DATE], and had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) The resident was independent with hygiene, dressing, transfers and walking. Her diagnoses included: hypertension, diabetes mellitus, arthritis, obesity, developmental disorder, edema and long-term use of insulin. The Care Plan for Resident #23, updated on 4/9/25, showed the resident had altered cognition related to a diagnosis of developmental disorder. She was at risk for alteration in blood glucose levels, staff were to report abnormal blood glucose levels to the physician. An order entered on 1/31/25 at 10:12 AM, showed that staff were to monitor the blood sugar levels for Resident #23 four times a day, and notify the provider if blood sugar was more than 400 Milligrams per deciliter (mg/dL) or less than 60 mg/dL. The Blood Sugar Summary (BSS) document in the electronic chart showed the following documentation. On each occasion, the chart lacked information regarding a doctor notification. a. 4/27/25 at 11:22 AM, 56 mg/dL b. 4/10/25 at 3:00 PM, 471 mg/dL c. 3/26/25 at 6:08 PM, 400 mg/dL d. 3/8/25 at 10:25 AM, 429 mg/dL e. 2/15/25 at 3:31 PM, 481 mg/dL f. 2/14/25 at 10:55 AM, 43 mg/dL g. 2/4/25 at 3:52 PM, 406 mg/dL h. 2/1/25 at 7:50 PM, 53 mg/dL The BSS showed that 4 times, Staff C, Licensed Practical Nurse (LPN) administered the glucose test and failed to follow through with a call to the doctor. On 4/30/25 at 2:42 PM, Staff C, said that she was aware of times that Resident #23 had high blood glucose readings but she hadn't ever had to contact the doctor. She didn't remember what the parameters were, but the resident would often eat her roommates cookies and that would cause the high glucose levels. On 4/30/25 at 2:29 PM, Staff D, Regional Clinical Specialist said that if/when there were doctor-ordered parameters, staff were expected to follow through with a call to the doctor. A facility policy dated 2/8/23, titled: Notification of Change in Resident Health Status, the resident's physician would be notified of a change in resident status when there was a significant change in the resident physical, mental or psychosocial status; for example a deterioration in health or clinical complications, or a need to alter treatment significantly such as discontinue an existing form of treatment due to adverse consequences or to begin a new form of treatment.

Based on clinical record review, staff interviews, and facility policy, the facility failed to notify the physician and family regarding a skin condition after a fall (Resident #1). The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 documented diagnosis of schizophrenia, depression, and orthostatic hypotension. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14, indicating no cognitive impairment. Review of facility Progress Notes on 4/30/25 at 10:25 a.m. revealed a nurse documented on 4/28/25 at 7:05 p.m. a fall follow up and revealed a skin condition, a bruise, was found on the back of Resident #1's right leg behind the knee, the bruise measured 2 centimeters (cm) x 4 cm, the bruise was described as yellow, green, purple in color. The Progress Note lacked information that the family and physician was notified. Review of facility skin sheets on 4/30/25 at 10:25 a.m. revealed the facility failed to fill out the skin sheet to monitor the bruise weekly. Review of the facility policy named Weekly Skin Assessment and Documentation Process dated 1/20/23 revealed skin ulcers and non-ulcer will be assessed and documented weekly by the facility wound nurse. Identifying a Skin Ulcer or Non-Ulcer Assessment: 1) The nurse who initially identifies the Skin Ulcer or Non-Ulcer Ulcer will complete the appropriate Skin Assessment (Non-Ulcer or Ulcer Assessment). 2) A separate Skin Assessment (Non-Ulcer or Ulcer Assessment) will be completed for each identified skin/wound alteration. (i.e., if two bruises are identified on one resident, two separate assessments will need to be completed, one for each area.) 3) The treatment orders for all Skin Ulcer or Non-Ulcer will be implemented per the Skin Management Protocol. 4) The Nurse Leader will fax the appropriate wound treatment order per the Skin/Wound Protocol for approval by the physician. 5) The care plan will be updated and reviewed to ensure that the skin/wound alteration and appropriate interventions have been identified on the Care Plan. 6) Notification to Physician 7) When the nurse on the floor observes a new skin/wound alteration they should utilize the fax forms to notify the physician/nurse practitioner or call and put the new order in the electronic health record. Interview on 5/1/25 at 9:30 a.m. with the Administrator stated the expectation would be to follow the facility policy and procedures.

Based on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 1 of 1 residents reviewed who transferred to the hospital (Resident #9). The facility reported a census of 26 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #9 documented diagnoses of quadriplegia, anxiety, depression and chronic pain. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of Resident #9's Progress Notes revealed the following information: 8/13/24 at 4:45 p.m., Resident transferred to the emergency department and admitted to hospital. 8/22/24 at 12:55 p.m., Resident readmitted to facility from the hospital. 12/9/24 at 9:34 a.m., Resident transferred to the emergency department and admitted to hospital. 12/12/24 at 4:57 p.m., Resident readmitted to the facility from the hospital. 1/7/25 at 4:09 a.m., Resident admitted to hospital for surgical procedure. 1/10/25 at 4:00 p.m., Resident readmitted to the facility from the hospital. Review of Resident #9's Census tab revealed the following: 8/13/24- hospital unpaid leave 8/22/24- active 12/9/24 - hospital unpaid leave 12/12/24 - active 1/7/25 - hospital unpaid leave 1/10/25 - active Review of MDS listing revealed the following: 8/13/24 - discharge return anticipated 8/22/24 - Entry 12/9/24 - discharge return anticipated 12/12/25 - Entry 1/7/25 - discharge return anticipated 1/10/25 - Entry Review of the facility document titled Notice of Transfer Form to Long Term Care Ombudsman dated August 2024, December 2024 and January 2025 lacked Resident #9's name. Interview on 4/30/25 at 11:56 a.m., with the Nurse Consultant revealed the facility follows regulation with ombudsman notification. Interview on 4/30/25 at 12:35 p.m. with Administrator revealed she had pulled the same report from the electronic health record for the last couple of years and when she pulled it Resident #9's name is not showing up on the report. The Administrator stated she will have to get a hold of her supervisor to see what she needs to do to correct this report.

Based on observation, interviews and record review the facility failed to develop a comprehensive care plan for 1 of 13 residents reviewed. Staff utilized a seat buckle in the wheel chair for Resident #15 and the care plan lacked a focus area or interventions for monitoring. Staff failed to include the details related to seat buckle use and did not define interventions to be used during the use of seat buckle. The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #15 was absence of spoken words, rarely/never understood and did not understand others. She was unable to participate with a Brief Interview for Mental Status cognitive skills severely limited. She had upper extremity (shoulder, elbow, wrist and hand) and lower extremity impairment on both sides and was totally dependent on staff for toileting, dressing, hygiene, and transfers and used a wheel chair. Her diagnoses included: diabetes mellitus, aphasia, seizure disorder, malnutrition, Rett's Syndrome (neurological disorder that causes severe muscle movement disability condition leads to loss of motor skills, language abilities loss of purposeful hand skills.) The MDS showed that she did not use a physical trunk restraint. The Care Plan last updated on 4/8/25, showed that the resident had artificial nutrition per gastrostomy tube. If the resident was in the wheelchair, she was to remain upright for one hour following the administration of feeding and fluids. Resident #15 was completely dependent with care, and required a Hoyer mechanical lift for transfers. She had the potential for injury from falls/seizures related to Rett's Syndrome, Aphasia, Epilepsy, Scoliosis, and spasticity, The resident used a small tilt-in-space wheelchair for locomotion, and bilateral 1/2 side rails in bed to allow for boundary identification. On 4/28/25 at 11:18 AM, Resident #15 was sitting in a wheel chair in the dayroom in front of the television sleeping. The wheelchair was slightly tipped back, and she had a waist buckle around her lower abdomen. Her arms were on her chest and her hands were contractures. At 11:43 AM, the resident was still in the dayroom, there were no other residents or staff nearby. On 4/30/25 at 2:23 PM, Staff D, [NAME] Clinical Specialist agreed that the resident did not attempt to access her body, because she did not move her arms or hands on her own. Staff D agreed that the lap strap should be added to the care plan. According to a facility policy titled: Comprehensive Care Plans dated April 2/25, the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objective and timeframe to meet a resident medical nursing and mental and psychosocial needs and all services that were identified int eh resident comprehensive assessment and meet professional standards of quality. The comprehensive care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observation, interview and record review the facility failed to follow through with an intervention for edema management for 1 of 1 resident reviewed. Resident #23 had chronic edema and staff were directed to apply edema wear to her lower extremities in the morning and to remove it at night. The resident was observed to be without the compression stockings all day and staff documented that the task had been completed. The facility reported a census of 26 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #23 was admitted to the facility on [DATE], and had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) The resident was independent with hygiene, dressing, transfers and walking. Her diagnoses included: hypertension, diabetes mellitus, arthritis, obesity, developmental disorder, edema and long-term use of insulin. The resident was taking a diuretic medication. The Care Plan for Resident #23, updated on 4/9/25, showed that she had altered cardiovascular status related to edema and hyperlipidemia, staff were to monitor edema and report changes. The resident had altered cognition related to a diagnosis of developmental disorder. The Orders tab in the electronic chart showed an order dated 2/14/25 at 6:00 AM, to apply edema wear in the morning and remove at night. On 4/28/25 at 12:52 PM, Resident #23 was sitting in her chair in room with feet on the floor. She was wearing gripper socks and her feet were swollen. When asked if she had some compression hose, she pointed to the bathroom where a pair of hose were hanging on the towel rack. She said she needed help to put them on, and they were still wet because they had been washed. The Medication Administration Record/Treatment Administration Record (MAR/TAR) for April, printed on 4/28/25 at 1:43 PM, showed that the nurse had documented that the resident was wearing the edema wear. On 4/28/25 at 4:04 PM, Resident #23 was sitting in a chair near the nurses' station. She was wearing the gripper socks, and did not have her compression hose on. She said that they were still hanging in the bathroom and said they are still wet, I'll get them on tomorrow. The MAR TAR for April, printed on 4/29/25 at 6:47 AM, showed that staff documented that the edema wear had been removed on the night of 4/28/25. On 4/30/25 at 11:56 AM, Staff D, Regional Clinical Specialist, indicated that the facility did not have policies on edema management but that staff were expected to follow the physicians orders.

Based on observation, record review and interviews the facility failed to ensure care plan was updated in a timely manner for 1 of 14 residents reviewed, (Resident #1). Resident #1 had specific orders for her bilevel positive airway pressure (BiPAP) machine. On 3/8/24, the order changed from 2liters (L) of oxygen to 6L and the care plan did not reflect this change. The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #1 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident was independent with toileting hygiene and eating, walking and transfers. The diagnoses included; chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) and Chronic Pain. The Care Plan revised on 2/6/24, showed Resident #1 had actual respiratory abnormalities related to restrictive lung disease and obstructive sleep apneas. She used continuous oxygen and BiPAP at night. The resident had a history of chronic respiratory failure with hypoxia and hypercapnia. Staff were instructed to set the BiPAP at 17V12 centimeters H2O (water) pressure with O2 (oxygen) at 2 Liters (L) per minutes bled with warm humidification. On at night and off in the morning. The Orders tab showed an order dated 3/8/24 at 3:19 PM, for BIPAP at 17V12 centimeters H2O pressure with O2 at 6 liters per minute. On 5/19/24 at 11:22 AM, Resident #1 said that a couple of days prior, an agency nurse forgot to put her BiPAP on overnight and by morning, her oxygen level had dropped into the 70's. A Nursing Note dated 5/10/2024 at 9:03 AM showed Resident #1 complained of being short of breath with oxygen saturations at 78% on 4L O2. She had shallow breathing, her face was red and she was diaphoretic (sweating). On 5/21/24 at 12:12 PM Staff B, RN stated there had been a couple of incidents when the oxygen level was down in the mornings for Resident #1. Her face would turn blue and she really struggled to breath. The provider had asked them to put her back on the BiPAP and bleed in 6liters of oxygen. She said that one day, she worked for over 4 hours to get the oxygen back up. Staff B said that she had gone into the residents room early in the mornings and saw that the BiPAP oxygen level would be set on 3 liters rather than 6 and that was problematic for this resident. In an observation on 5/22/24 at 7:07 AM, the resident was in bed sleeping. The oxygen bled into the BiPAP was set on 7 liters. On 5/22/24 at 10:15 AM, the DON said Resident #1 always had her oxygen or the BiPAP on at all times. When asked about the oxygen bled into the BIPAP order she thought it was 6 liters. When alerted to the fact that the oxygen was set on 7L, the DON said that she would address it with the nurse. The DON was not aware the care plan had not been updated when the oxygen order changed from 2L to 6 liters. On 5/22/24 at 9:54 AM the DON indicated that they did not have a policy on following physicians orders or on care plan updates but they follow the standards of care.

Based on observation, interview and record review the facility failed to follow physician's orders for 2 of 14 residents reviewed, ( Residents #25 and #1). Resident #25 had an order for pantoprazole 20 milligram (mg), when the pharmacy sent 40mg tablets, staff failed to check the right dose and administered the wrong dose daily, from 2/16/24 through 3/12/24. Resident #1 had specific orders for her bilevel positive airway pressure (BiPAP) machine, staff failed to set the oxygen on the correct level. The facility reported a census of 37 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #25 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficit). She was dependent on staff for toileting hygiene, dressings and transfers. Her diagnoses included osteomyelitis of vertebra, insomnia, muscle weakness and low back pain. The Care Plan revised on 4/10/24 showed that Resident #25 had deficits in Activities of Daily Living (ADL) skills due to muscle weakness, obesity repeated falls and heart failure. She had chronic pain related to osteoarthritis, osteomyelitis and wounds. According to a New Prescription Summary sent to the pharmacy, dated 2/16/24, Resident #25 had an order for; pantoprazole sodium oral tablet delayed release 20 milligrams, give 1 tablet one time a day for upset stomach. In a review of personal files, it was discovered that three, Certified Medication Aides (CMAs) were issued Employee Coaching and Consult disciplinary actions for medication errors. The forms were dated 3/13/24 and signed by the Director of Nursing DON. Staff E, CMA administered the wrong dose on 4 separate days. Staff F, CMA administrated the wrong dose on 1 occasion. Staff G, CMA administered the wrong dose on 16 occasions. A Nursing Note dated 3/13/24 at 7:32 AM indicated the pharmacy sent pantoprazole 40mg tabs to the facility instead of 20 mg taps as ordered on 2/16/24. On 5/21/24 at 1:44 PM, when asked about an incident report for Resident #25 related to a medication error, the Director of Nursing (DON) replied that she did not have any incident reports or documentation of a medication error for that resident. At 3:15 PM the DON then said she remembered when Resident #25 was admitted on [DATE], the pharmacy sent 40 mg tablets of pantoprazole instead of 20 mg. She said the error had been discovered on 3/13 and staff were administering the wrong dose from 2/16/24 through 3/12/24. The DON said Staff A, Registered Nurse (RN) discovered the error and the RN was asked to fill out a risk management form. The DON said Staff A must not have completed the form because they did not have one in the file. The DON said that as far as she knew, the family and doctor had not been contacted regarding the error. On 5/21/24 at 3:32 PM Staff A, said she did remember the medication error and she told the DON and she called the pharmacy to get it changed. Staff A said she worked on an as needed (PRN) basis, and she had discovered the error days prior to 3/13. She said she told the charge nurse at that time but when she came back to work on 3/13 it hadn't been corrected. She said she did not fill out an incident report and didn't remember the DON asking her to do that. She did not call the family or doctor and thought that DON had handled those responsibilities. On 5/22/24 at 10:15 AM the DON said she didn't know if the resident had been informed of the medication error and if a risk assessment had been filled out when it happened, that would have triggered them to call the family and the doctor but it didn't happen. A facility policy titled Medication Administration Policy lacked direction to staff to ensure they have double checked that the right dose was administered. 2) According to the MDS dated 4/10/24, Resident #1 was admitted on [DATE] with a BIMS score of 15 (intact cognitive ability). The resident was independent with toileting hygiene and eating, walking and transfers. The diagnoses included; chronic respiratory failure, Chronic Obstructive Pulmonary Disease (COPD) and Chronic Pain. The Care Plan revised on 2/6/24, showed Resident #1 had actual respiratory abnormalities related to restrictive lung disease and obstructive sleep apneas. She used continuous oxygen and BiPAP at night. The resident had a history of chronic respiratory failure with hypoxia and hypercapnia. Staff were instructed to set the BiPAP at 17V12 centimeters H2O (water) pressure with O2 (oxygen) at 2 Liters (L) per minutes bled with warm humidification. On at night and off in the morning. The Orders tab showed an order dated 3/8/24 at 3:19 PM, for BIPAP at 17V12 centimeters H2O pressure with O2 at 6 liters per minute. On 5/19/24 at 11:22 AM, Resident #1 said that a couple of days prior, an agency nurse forgot to put her BiPAP on overnight and by morning, her oxygen level had dropped into the 70's. A Nursing Note dated 5/10/2024 at 9:03 AM showed Resident #1 complained of being short of breath with oxygen saturations at 78% on 4L O2. She had shallow breathing, her face was red and she was diaphoretic (sweating). On 5/21/24 at 12:12 PM Staff B, RN said there had been a couple of incidents when the oxygen level was down in the mornings for Resident #1. Her face would turn blue and she really struggled to breath. The provider had asked them to put her back on the BiPAP and bleed in 6liters of oxygen. She said that one day, she worked for over 4 hours to get the oxygen back up. Staff B said she had gone into the residents room early in the mornings and saw that the BiPAP oxygen level would be set on 3 liters rather than 6 and that was problematic for this resident. In an observation on 5/22/24 at 7:07 AM, the resident was in bed sleeping. The oxygen bled into the BiPAP was set on 7 liters. On 5/22/24 at 10:15 AM, the DON said Resident #1 always had her oxygen or the BiPAP on at all times. When asked about the oxygen bled into the BIPAP order she thought it was 6 liters. When alerted to the fact that the oxygen was set on 7L, the DON said she would address it with the nurse. On 5/22/24 at 9:54 AM the DON indicated they did not have a policy on following physicians orders.

Based on interview and record review the facility failed to notify family and physician after a medication error for 1 of 1 Resident reviewed, (Resident #25). From 2/16/24 - 3/12/24, Resident #25 was given 40 milligrams (mg) of pantoprazole instead of the prescribed 20mg daily dose. The facility reported a census of 37 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #25 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficit). She was dependent on staff for toileting hygiene, dressings and transfers. Her diagnoses included osteomyelitis of vertebra, insomnia, muscle weakness and low back pain. The Care Plan revised on 4/10/24 showed Resident #25 had deficits in Activities of Daily Living (ADL) skills due to muscle weakness, obesity repeated falls and heart failure. She had chronic pain related to osteoarthritis, osteomyelitis and wounds. According to a New Prescription Summary sent to the pharmacy, dated 2/16/24, Resident #25 had an order for; pantoprazole sodium oral tablet delayed release 20 milligrams, give 1 tablet one time a day for upset stomach. In a review of personal files, it was discovered that three, Certified Medication Aides (CMAs) were issued Employee Coaching and Consult disciplinary actions for medication errors. The forms were dated 3/13/24 and signed by the Director of Nursing DON. Staff E, CMA administered the wrong dose on 4 separate days. Staff F, CMA administrated the wrong dose on 1 occasion. Staff G, CMA administered the wrong dose on 16 occasions. A Nursing Note dated 3/13/24 at 7:32 AM indicated the pharmacy sent pantoprazole 40mg tabs to the facility instead of 20 mg taps as ordered on 2/16/24. On 5/21/24 at 1:44 PM, when asked about an incident report for Resident #25 related to a medication error, the Director of Nursing (DON) replied that she did not have any incident reports or documentation of a medication error for that resident. At 3:15 PM the DON then said she remembered that when Resident #25 was admitted on [DATE], the pharmacy sent 40 mg tablets of pantoprazole instead of 20 mg. She said that the error had been discovered on 3/13 and staff were administering the wrong dose from 2/16 through 3/12. The DON said Staff A, Registered Nurse (RN) discovered the error and the RN was asked to fill out a risk management form. The DON said Staff A must not have completed the form because they did not have one in the file. The DON said that as far as she knew, the family and doctor had not been contacted regarding the error. On 5/21/24 at 3:32 PM Staff A, said she did remember the medication error and she told the DON and she called the pharmacy to get it changed. Staff A said she worked on an as needed (PRN) basis, and she had discovered the error days prior to 3/13. She said she told the charge nurse at that time but when she came back to work on 3/13 it hadn't been corrected. She said she did not fill out an incident report and didn't remember the DON asking her to do that. She did not call the family or doctor and thought that DON had handled those responsibilities. On 5/22/24 10:15 AM the DON said she didn't know if the resident had been informed of the medication error and if a risk assessment had been filled out when it happened, that would have triggered them to call the family and the doctor but it didn't happen. A facility policy titled Medication Administration Policy lacked direction to staff to ensure they have double checked that the right dose was administered. On 5/22/24 at 9:54 AM the DON said that they did not have a policy on notification to family and physicians.

Based on observation, interview and record review the facility failed to assess and intervene in a timely manner for 1 of 14 resident reviewed, (Resident #6). Resident #6 fell out of his wheel chair when it rolled off of the van lift. He sustained an injury to his right foot and staff failed to contact the doctor when the resident had reported increase in pain and decrease in movement. The facility reported a census of 37 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). He used a walker and a wheel chair for mobility and he was totally dependent on staff for showers, independent with sit to stand, toilet transfers and walking 10 feet. His diagnoses included Atrial Fibrillation, morbid severe obesity, arthropathy, edema, weakness, venous thrombosis and embolism. He had occasional pain that rarely caused him to lose sleep. He rated his pain intensity at a 2 out of 10, with 10 being the worst. The MDS dated [DATE], showed that during the assessment time, sit to stand transfers and walking was not attempted due to medical condition or safety concerns. He was totally dependent for toilet transfers and sit to lying. On 5/19/24 at 1:20 PM, Resident #6 was in bed lying on his back. He was a large man, and when asked, about his transfer status, the resident said that since his fall, he needed the mechanical full-body lift. Before that he had been mostly independent and was walking with a walker. The resident said that he fell out of his wheel chair when the gait opened on the lift in the transportation van. An Incident Report dated 2/5/24 at 1:48 PM, showed that on that date, Resident #6 was transferred to the hospital for a lymphedema wrapping appointment. While in his wheel chair, he was lowered with a lift platform when the gate opened. The resident had disengaged the breaks on the wheel chair and it rolled off the platform. The resident then fell out of the wheel chair. He was taken to the emergency room for examination and he did not have any apparent injuries at that time. A note was faxed from the facility, to the primary doctor on 2/5/24 at 6:04 PM, regarding the fall and that the emergency room doctor reported to continue with wrapping his leg. The resident complained to overall discomfort upon return to the facility. According to the Medication Administration Record (MAR) for January 2024, Resident #6 had not used the as-needed (PRN) Acetaminophen in the entire month. From February 6th to the 13th the PRN Tylenol was used 10 times. From February 14th -21st the PRN Tylenol was used 4 times. The following documentation was found in the Nursing Progress Notes: a. On 2/5/24 at 3:05 PM resident complained of discomfort in right foot. No injury noted to area. b. On 2/6/24 at 3:02 PM Fall follow up assessment. Resident complained of pain right toe. c. On 2/7/24 at 10:44 AM Fall follow up resident complained of pain all over. d. On 2/7/24 at 1:11 PM, doctor aware of fall with no new orders. (On 5/22/24 at 12:00 PM Staff B said the communication with the doctor was through fax and she did not actually talk to the doctor) e. On 2/7/24 at 10:20 PM discomfort in right foot. f. On 2/8/24 at 9:34 AM discomfort in right foot. g. On 2/10/24 at 12:27 AM right leg and toe pain. h. On 2/11/24 at 1:12 AM right toe pain. i. On 2/12/24 at 1:29 AM right foot discomfort. j. On 2/12/24 at 4:35 AM right toe discomfort. k. On 2/13/24 encounter with Nurse Practitioner (NP), Report right foot pain is worse from last week. He reported he caught his right foot under the wheelchair and unable to bear weight to right foot increased pain across top of foot and toe. Will order an X-ray continue Tylenol PRN. l. On 2/13/24 at 1:31 PM Portable X-ray at the facility. According to the Patient Report from X-ray no acute fracture visualized. m. On 2/16/24 at 12:03 PM Hoyer lift utilized for transfers resident is not bearing weight on right foot. n. On 2/19/24 at 7:40 PM pain and vitals assessment. Right ankle pain, worse with movement, non-medication intervention did not provide relief. Scheduled medication provided. o. On 2/21/24 at 11:00 AM NP in facility and requested a computerized tomography (CT) of right foot due to resident now having pain to posterior right ankle. p. On 2/22/24 at 11:15 NP stated CT scheduled for 2/23/24 at 11:15 AM. q. On 2/24/24 at 7:08 AM impression: fracture about the base of medial malleolus posterior aspect tibial plafond and distal fibular shaft. Nondisplaced third metatarsal neck fracture. r. On 2/26/24 at 11:50 NP made a referral to orthopedics. From 2/7/24 - 2/13/24, staff failed to contact the physician regarding the resident's ongoing pain. From 2/14/24 - 2/21/24 staff failed to contact the physician regarding the continued pain and that his status had changed to non-weight bearing. On 5/21/24 at 9:57 AM Staff C, Registered Nurse (RN), said that on 2/10 and 2/11 she was the nurse for Resident #6 and he had complained of a lot of pain in his foot and toes. She said she didn't look at his foot but his skin tended to be very red and had always had a lot of edema. She said she had not called the doctor about the increased pain because everyone was aware of it and she didn't think it was that alarming to warrant a call to the doctor. On 5/21/24 at 12:00 PM Staff B, RN, said she took care of Resident #6 on 2/7/24 and he complained that he had quite a bit of pain in his foot and toes. When asked about a Nursing Note dated 2/7/24 at 1:11 PM that she entered regarding the fax communication, she said she did not actually talk to the the doctor regarding the increased pain. On 5/22/24 at 10:15 AM the Director of Nursing (DON) said that they hadn't been very concerned about the increased pain until the resident was no longer bearing weight on that foot. Before that time, he had mostly a general discomfort. She said she did not see any bruising after the fall because his legs were always discolored and he had extensive lymphedema. At 10:35 AM on 5/22/24 the DON indicated the facility did not have any policies on change in condition and when to call the doctor. She communicated that they follow standards of care and regulations.

Based on interviews, record and policy review the facility failed to provide post-dialysis assessments for 1 of 1 resident reviewed, (Resident #12). The facility reported a census of 37 residents. Finding include: According to the Minimum Data Set (MDS) dated [DATE], Resident #12 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). She required dialysis treatments and was independent with toilet transfers, walking and dressing. Her diagnoses include; chronic kidney disease, stage 5, acidosis, obsessive compulsive disorder and malnutrition. The Care Plan revised on 3/19/24, showed Resident #12 had a fistula in right arm due to disorder of kidney and ureter. Staff were directed to listen for the bruit or feel for the thrill in fistula daily. She was at risk for dehydration and fluid volume imbalance related to routine use of diuretic medication and current dialysis regimen. Staff were to observe for signs and symptoms of dehydration and to notify the doctor with increase edema, shortness of breath, increased respirations and decreased oxygen saturations. In a review of the record, it was discovered the chart lacked post-dialysis vital signs and assessments on 4/12/24, 4/20/24, 4/29/24, 5/6/24 and 5/13/24. On 5/22/24 at 1:30 PM, Staff B, Registered Nurse (RN) acknowledged that several of the post dialysis assessments had not been edited. She said that if/when the afternoon nurse completed those assessments the document would be closed, and the current assessment information would have been included. On 5/22/24 at 9:54 AM, Staff D, Licensed Practical Nurse (LPN) said that when she was the early morning nurse on dialysis days, she would initiate the assessment document and the second nurse in the afternoon would be responsible to complete and enter the post dialysis vitals on the same form. On 5/22/24 at 10:15 AM, the Director of Nursing (DON) said that staff would meet the resident at the door when she arrived back from dialysis, and they immediately completed an assessment with vital signs. Policy titled Dialysis, Care and Monitor of Resident undated; Post-Dialysis-Assessment and Documentation of the Dialysis Resident standard: To assess for and evaluate any changes of condition related to the residents physical condition upon return to the facility after receiving dialysis treatment. 1. Obtain a set of vital sings upon return to the facility. 2. Assess residents physical condition upon return to the facility. 3. Assess residents vascular access site-report any bleeding or swelling.

Based on facility record review, facility policy review, resident, and staff interviews, the facility failed to revise and update the Care Plan to address fall interventions for 1 of 1 residents reviewed (Resident #7). Findings include: Resident #7s Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS indicated that Resident #7 required extensive assistance of one staff with dressing, personal hygiene, and toilet use. Resident #7 was independent with all other activities of daily living. The MDS included diagnoses of high blood pressure, depression, atrial fibrillation (irregular and often faster heartbeat), severe morbid obesity (a serious health condition that can interfere with basic physical functions such as breathing or walking), attention deficit hyperactivity disorder (a mental health condition with a short attention span), arthropathy (joint disease), long term anticoagulant (blood thinner) medication use, edema (swelling), and weakness. Resident #7's Care Plan, revised 4/16/23 indicated that he had a risk for fall with injury related to his diagnoses of atrial fibrillation, morbid obesity, edema, weakness, anticoagulant use, depression, and arthropathy. On 6/12/23 at 12:49 PM Resident #7 reported that he recently fell three times. He explained that two of the falls happened as he got off the scale after checking his weight. The third time occurred when he backed up to sit in his reclining chair and missed it. Resident #7 stated that he thought he fainted getting off the scale one time, and his knee gave out the second time. The Health Status Note dated 2/25/23 at 1:32 PM reflected that Resident #7's knee gave out as he got off the scale, causing him to fall to his hands and knees, eventually ending up on his abdomen (stomach) on the floor. The facility staff unable to get Resident #7 up. The facility called the emergency medical services (EMS) to assist with getting him off the floor. The staff remain with Resident #7 offering support until EMS arrived. EMS arrived at 11:45 AM and assisted Resident #7 off the floor into a wheelchair at 12:25 PM. Resident #7 stayed on the floor for about one hour before for getting up. The assessment revealed a bruised and swollen kneecap. The nurse offered Tylenol and an ice pack, but Resident #7 declined. The Fall Note dated 3/30/23 at 2:15 PM the Certified Nurse Aide / Certified Medication Aide (CNA/CMA) reported Resident #7 was on the floor in front of his recliner. The floor nurse could not assess him due to doing treatments with another resident. Resident #7 reported that as he walked backwards without his walker, he lost his balance, and sat on his buttocks. Resident #7 denied any complaints of pain or discomfort. Four staff with the use of the full-body mechanical lift assisted Resident #7 off the floor. The assessment revealed that Resident #7 denied pain at the time of the fall but then complained of a slight ache in his buttocks approximately 30 minutes later. He denied the need for pain medications. In addition, the assessment revealed no injuries noted at time of his fall. Resident #7 refused to have vital signs checked at the time of the fall. Resident #7 just wanted off the floor. Resident #7 is independent with ambulation with the use of his walker. Intervention initiated at time of fall: The staff educated Resident #7 to use his walker at all times and to not walk backwards. Also encouraged to use his call light for staff to assist him in carrying bags next time he has the Activity Director go shopping. The Fall Note dated 4/30/23 at 11:38 AM reflected that Resident #7 had a witnessed fall while stepping of the scale. He lost his balance on the incline and fell on to his buttocks. Resident #7 reported that he lost his balance and fell directly on his tailbone. The staff used an assist of five and the full-body mechanical lift to get him into his wheelchair. The Intervention initiated at the time of the fall directed the staff to not use the scale until the Director of Nursing determines it is safe as the scale incline needed reassessed. The Fall Follow-up Note dated 5/1/23 at 11:24 AM indicated that Resident #7 denied feeling dizzy when the fall happened the other day and explained that he must have just blacked out. The Resident's Care Plan lacked documentation of Interventions for the falls that occurred in February, March, or April 2023 to prevent further falls from happening. The facility reported that they did not have a no policy related to revising or updating Care Plans. On 6/15/23 at 9:50 AM, the Director of Nursing (DON) stated she expected the timely completion of updates to the Care Plans. In addition, if a fall occurred on a weekend, she expected the staff to update the Care Plan by the following Tuesday.

Based on observation, record review, resident and staff interviews the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 6 residents (Resident #1). Resident #1, a resident with cognitive impairment, exited the facility without staff knowledge. Staff did not know the resident was gone until they received a phone call alerting them the resident was at a local bar and grill establishment. The facility reported a census of twenty-three (23) residents. Findings include: 1. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED]. The MDS assessed the resident with a BIMS (brief interview for mental status) score of 3 (severe cognitive impairment). The MDS documented no wandering and the resident required supervision with locomotion off the unit. A Preadmission Screening and Resident Review (PASRR) dated 6/18/18, documented Resident #1 with moderate intellectual disability, and cognitive decline secondary to moderate intellectual disability and age-relate physical decline and currently requires 24-hour supervision for safety and well being. A Mini-Mental Exam completed on 1/4/21, documented a score of 9. A score of 9 or less revealed severe cognitive impairment. A Risk Assessment: Elopement form dated 1/4/21 at 9:24 a.m., documented: a score of 4 for which indicated high level of risk for elopement and precautions initiated and care planned: *resident independent in mobility with/without assistive device-yes *previous history of wandering-yes *mental illness-yes *Episodes of disorientation/confusion-yes *is resident considered to be at risk for elopement-yes *is careplan current in relationship to the residents elopement risk-yes A care plan dated as initiated 3/01/19 identified a focus area titled resident potential for injury to risk of falls, elopement risk/wanderer related to placement in facility, impaired safety awareness with resident will remain safe over the next review date, interventions include to: *STOP signs on exit doors (initiated 2/6/21) *1-1 supervision at all times (initiated 2/5/21)(resolved 2/11/21) *15 minute checks for close observation (initiated 2/11/21) *Assess for change in condition/function *Resident evaluated and treated by therapy and cleared as independent in facility with walker (10/24/18) The facility notified the physician of the incident via facsimile (fax) dated 2/5/21 at 10:00 p.m., The fax revealed the resident left the building, unattended tonight. Staff returned the resident without incident. Assessment and vital signs as follows: Head to toe assessment: Resident agitated and yelling. When asked what happened resident just started yelling about how this is all messed up and not where resident needed to be. Head to toe assessment done: purple intact bruise to right hand, 5 centimeters(cm.) by 3 centimeters. No drainage, denied pain. No other skin injury noted. Hands and toes slightly cold. No skin injury noted due to cold. Capillary refill brisk. Lungs clear to auscultation, respirations even and unlabored. Resident wore a t-shirt and bib overalls like normal. Socks, shoes and clothing all dry. Vital signs: Temperature- 96.1 degrees Fahrenheit Pulse-80 Respirations-16 Blood Pressure-116/70 Oxygen Saturation-93% room air Staff placed the resident on one to one supervision until further notice. Staff also placed the resident in isolation due to the resident in public place without proper COVID-19 precautions in place. A progress note date 2/5/2021 at 6:10 p.m., documented: HEAD TO TOE ASSESSMENT: Resident agitated and yelling. When asked what happened resident the resident started yelling about how this is all messed up and not where he needed to be. Head to toe skin assessment done: purple intact bruise to right hand, 5 cm X 3 cm. No drainage, denied pain. No other skin injury noted. Hands and toes slightly cold. No skin injury noted due to the cold. Capillary refill brisk. Lungs clear to auscultation, respirations even and unlabored. Resident wore a t-shirt and bib overalls like normal. Socks, shoes, and clothing appear dry. Vital signs: Temperature 96.1 degrees Fahrenheit Pulse-80 Respirations-16 Blood Pressure-116/70 Oxygen saturation-93% Room Air A progress note dated 2/5/2021 at 6:16 p.m., documented a Non-pressure ulcer located on right hand: Type of skin issue: bruise - purple Size: 5 centimeters by 3 centimeters Description of skin integrity (edges/surrounding tissue): intact A Progress note dated 2/5/2021 at 7:16 p.m., documented call placed to family. The facility informed them the resident eloped from the facility. Staff last saw the resident leave the dining room at 5:45 p.m. and received a call from the bar & grill at 6:00 p.m. The family states Oh for pity sake and laughed and reported no surprise as the resident frequently walked the town in the past. The bar used to be a cafe that resident frequently went to. A summary written by the facility: 2/5/21 Staff notified management at 6:11 p.m., on 02/05/21 of receiving a call from a bar and grill establishment on Highway 4 reporting they believed they had a care center resident in the bar/restaurant. Staff reported that a Certified Nursing Assistant (CNA) left for the bar and grill to pick up the resident. Immediately staff observed the alarm panel. All of the door alarms were in the on position. Staff checked all doors for function and all alarms functioned. Staff completed a head count and accounted for all other residents. Staff questioned every staff member who was in the building. Every staff member denied hearing the alarm activate and reported they did not turn off an activated door alarm. Observation of the resident's window showed it as locked and closed. The charge nurse reported they looked outside for tracks in the snow. The nurse followed tracks outside the front door and east down the sidewalk in front of the building and then did not see any further tracks. Staff determined the resident exited thru the front door. Staff placed an alarm on the inner door to alert staff if a resident would exit the front interior door to the front entry way. The resident appeared agitated upon return to the facility on [DATE]. Staff immediately placed the resident on 1-1 supervision and placed the resident in isolation due to having gone out of the building and in a public place without proper precautions related to COVID-19. Staff did not interview the resident at that time due to the resident's agitation. Nurse completed a head to toe assessment. Resident appeared clean and dry upon return to the facility. The Charge nurse followed the residents walker tracks as follows: from the front door down the front side walk, headed east, no further tracks observed in the intersection. The charge nurse took a right on South(NAME)street and headed south. Walker tracks observed again. Walker tracks stopped at the alley that heads south towards the bar and grill. Staff changed code to the front door and the assisted living door code. The facility spoke with the manager at the bar and grill. The manager reported the resident came to the building, went to the back room and sat down. They attempted to wait on the resident, who became angry and banged on the table. The grill worker asked manager to assist with the customer (resident). The manager identified the resident at the bar and grill for approximately 10 minutes before the manager came over to assist the co-worker. When the manager walked over to the resident, the manager noticed the resident had a walker with a sign on it. The manager instructed the co-worker to call the care center because people usually don't have walkers with signs on them unless they live at a nursing facility. The manager reported when resident came into the bar and grill, he did not appear cold and observed the resident's feet appeared dry. The resident seemed confused. The manager wondered how the resident got to the bar and grill as the roads to the bar and grill contained snow. The charge nurse requested the manager review the security camera footage at the bar and grill to see if they could see where the resident came from. The manager returned the call and reported after review of security cameral footage, the resident came from the side of the building by the alley. The facility determined staff last saw the resident around 5:45 p.m., when he left the facility dining room after eating supper. Staff then observed the resident sitting in a chair at the nurses station. The call received from the bar and grill at approximately 6:10 p.m., after the sat inside the bar for approximately 10 minutes. Walking to the Coop Bar and Grill took a facility staff 3 minutes 48 seconds. The resident ambulates at a fast pace with his walker at times. The facility interviewed the resident on 2/6/21. His BIMS score a 9. Staff asked the resident what season it was and the resident replied Its summer with a snowstorm and laughed. The facility asked the resident what he did last night. The resident stated he went out for a drink. When asked where he went, the resident stated he didn't know and stated it was a crazy world out there. Staff did not ask any further questions and completed a BIMS and mini mental assessments. An Elopement Investigative Report dated 2/5/21 documented: 1. Is the resident cognitively impaired with poor decision making skills-yes 2. What is the residents BIMS score on the last MDS-3 3. Is the resident physically impaired-yes 4. What is the residents diagnosis-intellectual disability, diabetes, anxiety, elevated PSA, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], and [DIAGNOSES REDACTED]. 5. What is the residents ambulatory status/Does the resident use devices for mobility- Independent with ambulation, uses walker 6. Does the resident have an elopement assessment completed at least quarterly-yes, if yes, what is the score-4, what was the date completed 1/4/21 7. Does the resident have a history of leaving the building without informing the staff-yes 8. Does the resident wear safety wanderguard device-no wanderguard system 10. What was the residents status prior to the elopement-including description of mental, physical, and emotional status- just ate supper, left dining room, sat in chair at nurses station. no behaviors reported. 11. Does the resident have a care plan that addresses wandering and risk for elopement-yes 12. Were the door alarms working properly-yes 13. Check the door alarms now and document if working properly and the time- working at 6:15 p.m. 14. Check door alarm audit tool to ensure documentation has been completed per policy. If not provide those staff with counseling. 15. How did the resident exit the facility-out the front door 16. What time of day did the elopement occur- between 5:45 p.m.-6:10 p.m. 17. When was the resident last seen and by whom?- time-5:45 p.m. CNA observed resident leave dining room and then sit in a chair at nurses station. 18. What was the resident doing when last seen-sitting in chair at nurses station 19. Where was the resident at when last seen-nurse station 20. What time did you realize the resident was missing-6:10 p.m. 21. What time did the facility take action-6:10 p.m. 22. When was the resident found-6:10 p.m. 23. Who found the resident-staff member at bar and grill 24. Where was the resident found- bar and grill. 25. Was the resident injured during the elopement-yes, bruise to right hand 26. What was the weather like outside-cold 27. What was the temperature outside at the time of the elopement- 10 degrees, if cold what was the wind chill factor- minus 2 degrees feels like 28. What was the resident wearing for clothing- overalls, t-shirt, socks, shoes A Risk Assessment: Elopement form dated 2/6/21 at 2:42 p.m., documented: a score of 3 for which indicated high level of risk and precautions initiated, proceed to care plan; *resident independent in mobility with/without assistive device-yes *previous history of wandering-yes *Episodes of disorientation/confusion-yes *is resident considered to be at risk for elopement-yes *is careplan current in relationship to the residents elopement risk-yes Review of the Resident Risk/Elopement (Missing Resident) Process with no date, documented: to provide a safe environment for all residents, properly assess resident and plan their care plan to prevent accidents related to wandering behavior or elopement. Elopement- Slipping away secretly, running away, or leaving without accompaniment or knowledge of the staff. Implementation: Residents identified at risk for elopement: *residents whose assessment identifies them at risk for elopement, the following steps will be taken: *An alarm bracelet may be placed on the resident to audibly alert staff of attempts by the resident to exit the facility. *The residents careplan shall address behaviors using resident specific goals and/or approaches as assessed by the interdisciplinary team *A current picture of the resident will be maintained in the facility *Facility staff will ensure that all exit alarms are responded to immediately *Staff will encourage activities which the resident enjoys in order to occupy/distract the resident. Review of the Door Alarm Checks for the month of February 2021, instructions: Document PASS or FAIL by each door and your initials at the bottom of the column. FAIL, you must notify Maintenance/Administrator IMMEDIATELY. Review of the form revealed: *February 5th, with no pass or fail in the boxes for the door alarms and no initials at the bottom of the column. (indicating no check done) On 2/15/21 at 1:41 p.m., Staff A (housekeeper/laundry) confirmed and verified that it is the expectation of the housekeeping/laundry staff to complete door alarm checks as required every day. Staff A recalled on 2/5/21 the door alarms were checked but could not recall if the alarms sounded or not. Staff A thought they sounded but since the form didn't get completed as expected, Staff A could not verify if the door alarms did sound. Staff A continued to state that the expectation is to fill out the door alarm checks form as required and to write pass or fail next to each door and then initial at the bottom of the date that the door alarms were completed. During an interview on 2/16/21 at 9:45 a.m., Staff B (registered nurse) stated it is the expectation that housekeeping/laundry staff check door alarms every day and document on the form that the door alarms either passed or failed. Staff B stated that on 2/5/21, Staff A was assigned door alarm checks and Staff B was behind the nurses station. Staff B could not recall if the door alarms sounded or not when Staff A checked the alarms on that day. Staff B went on to say that around 6:05 p.m., prior to giving report to the next nurse coming on duty, the telephone rang and it was the manager from the bar and grill reporting a male resident with a walker at the bar and grill becoming upset and if the facility had a resident missing and unaccounted for. Staff B stated that the Elopement (Missing Resident) policy went immediately into affect. Staff B explained that another staff member went to the bar and grill and brought the resident back. Staff B then completed a head to toe assessment on the resident and placed the resident in the isolation part of the facility per direction of the director of nursing (DON). Staff B identified Resident #1 seen at 5:10 p.m., going into the dining room for the supper meal. Staff B went on to say they attempted to walk the same path Resident #1 would of taken. Staff B went out the front door of the facility, found walker tracks in the snow, proceeded to follow the walker tracks to the intersection of 7th street and(NAME)Ave, then lost the tracks, Staff B kept walking south on(NAME)Ave and picked up the walker tracks again but lost them so Staff B came back to the facility. On 2/10/21 at 4:10 p.m., Staff C (certified nursing assistant) stated that on 2/5/21 Staff C observed the dining room for the supper meal. Staff C stated she didn't recall hearing the front door alarm sounding. Staff C stated she last saw Resident #1 leave the dining room with the walker around 5:45 p.m. On 2/10/21 at 3:45 p.m., Staff D (certified nursing assistant) stated he last saw the resident at 5:10 p.m. sitting in the dining room with supper meal in front of him. Staff D stated he went to the bar and grill to return Resident #1 to the facility and Resident #1 appeared very agitated and did not want to leave the bar and grill. On 2/15/21 at 3:15 p.m., Staff E (certified medication aide/Certified nursing assistant) stated she last saw Resident #1 in the dining room with a supper meal at 5:10 p.m.-5:15 p.m. On 2/16/21 at 10:30 a.m., Staff F (certified nursing assistant) revealed last seeing the resident around 5 p.m. when he ambulated to the dining room. Staff F assisted another resident with a room tray and upon leaving that resident's room about 6:10 p.m., received notice that Resident #1 left the facility unattended. Staff F proceeded to check all door alarms, check the residents window, did head count on resident at the facility. Staff F could not recall if the door alarm sounded or not due to being in another residents room. On 2/10/21 at 4:00 p.m., Staff G (certified nursing assistant) stated that Resident #1 was last seen by them about 5:30 p.m. Staff G stated that they were in a resident room assisting the resident due to the call light being on. Staff G stated that they don't recall hearing a door alarm sounding on 2/5/21. Staff G came out of the residents room about 6:15 p.m., and was told that the Coop Bar and Grill had just called and that a male resident was there and to start the Missing person policy. Staff G stated that they assisted Staff F in doing head count on all the residents, checking door alarms, checking the resident window to verify that it was closed and doing room checks. On 2/15/21 at 1:05 p.m., the DON confirmed and identified housekeeping/laundry department as responsible to check all the door alarms and to document on the door check alarm form if the door alarms passed or failed and to initial the box of door alarm checks completed. The DON confirmed and verified that on 2/5/21, the door alarm checks failed to have a pass or fail and staff initials in the box and to their understanding if the form is not completed then the alarm checks were not done. The DON confirmed and verified that the boxes on the door alarm checks for the month of February were left blank and that the expectation is for the form to be completed and if the door alarms do not pass to notify the DON, Administrator or the maintenance director right away to get them fixed. During an environmental tour on 2/10/21 at 1:20 a.m., the facility assistant director of nursing went around to all the door alarms and they all sounded and staff responded quickly to the alarms. The distance from the facility front door to the bar and grill was approximately 0.2 miles (per Google maps), for which the resident ambulated in snow covered streets and crossed an intersection covered with snow. The bar and grill was located on Highway 4 where heavy traffic travels and moderate speed. The facility documented per a stop watch that it took 3:48:67 to walk to the bar and grill. The state climatologist identified the weather on 2/5/21 at 6 pm. in Pomeroy as 10 degrees Fahrenheit, with the wind chill making the temperature -4 degrees. Observation on 2/17/20 at 8:15 a.m., revealed the speed limit sign on Highway 4 going south stated 45 miles per hour. The facility removed the immediate jeopardy on 2/5/21 prior to the surveyor's entrance, by educating all staff working and prior to working on Elopement Risk/Elopement (Missing Resident) Process. The facility implemented 1 to 1 supervision of the resident. The facility directed nurses to complete door alarm checks twice a day and revised the template. The facility placed a stop sign and an additional alarm on the interior door of the front lobby on 2/5/21 and changed door codes of the front door and assisted living door. The removal of the immediate jeopardy resulted in the removal of the deficient practice and the surveyor observed interventions in place. The State Agency notified the facility of the immediate jeopardy on 2/17/21.

Based on observation, record review, and staff interview, the facility failed to provide restorative services to improve or maintain Resident #7's range of motion. The sample consisted of 5 residents and the facility reported a census of 27 residents. Findings include: Resident #7 had a MDS (Minimum Data Set) assessment with a reference date of 10/31/17. The MDS identified the resident had long and short term memory problems and severely impaired skills for daily decision making. The MDS indicated the resident depended on staff for activities of daily living and had functional limitation with range of motion in both lower and both upper extremities. Resident #7's [DIAGNOSES REDACTED].#7 received no range of motion the previous 7 days. A Physical Therapy Discharge Summary dated 3/3/17 documented caregiver education given on the need to follow through with ROM (range of motion) restorative program and wearing of contracture braces as per schedule. The resident made limited progress with left knee extension PROM (passive range of motion), and demonstrated increasing tone. Staff must continue to be consistent with ROM and wearing contracture braces in order to prevent worsening of contractures, The Care Plan, revised on 11/11/17, identified Resident #7 with ADL self performance deficit. The goal revealed Resident #7 would maintain the highest practicable level of mobility. The interventions included restorative as indicated. The Care Plan was revised on 10/22/16 and identified Resident #7 had a potential for pain with [DIAGNOSES REDACTED]. The interventions included therapy as indicated. A fax dated 6/19/17 notified the physician that Resident #7 had a moist open area to the right antecubital area, measuring 6.5 by 4 by 0.5 centimeters (cm). The area appeared macerated with the surrounding/outer edges with bloody drainage. The fax requested a daily dressing change. The physician replied, okay with above. A physician visit form dated 6/21/17 documented Resident #7 had skin breakdown in the right antecubital area. Resident #7 had severe contractures especially in hands and upper extremities. The physician directed to check with hospice about possibility of occupational therapy (OT) looking at upper extremity contractures to lessen antecubital skin breakdown. The clinical record lacked any evaluation by O.T. A fax dated 7/13/17, notified the physician that Resident #7's right antecubital had a foul odor and [DIAGNOSES REDACTED] (redness) around wound. The fax requested an order for [REDACTED]. The physician responded to do a culture 1st, then start Bactrim DS 2 times a day for 10 days, and increase the [MEDICATION NAME] to 3 times a day. A fax dated 7/24/17 notified the physician Resident #7 completed 10 days of Bactrim due to a positive wound culture showing proteus and [MEDICAL CONDITION] (MRSA). The resident received hospice care with no need for a 2nd round of antibiotic. The fax requested an order for [REDACTED]. A fax dated 7/31/17 notified the physician the resident continued with a non-healing wound to the right antecubital. Resident #7 had a poor prognosis and continued hospice care. The fax requested a [DIAGNOSES REDACTED]. The fax indicated family aware and wanted the resident comfortable. The physician responded the resident had an intertriginous (area where areas of skin touch or rub together) skin ulcer. A Physician visit form dated 8/16/17 documented Resident #7 had an open wound to the right upper arm due to a contracture, Stage 4, down to the muscle. A fax dated 9/2/17 at 11 p.m. notified the physician Resident #7 had an order for [REDACTED]. A Skin Condition Record documented the ulcer first observed 6/19/17. On 11/20/17, the ulcer measured 1.2 by 0.5 by 0.1 cm. During an observation on 11/21/17 at 9 a.m. Resident #7 sat in a gerichair in the dining room. Resident #7 had his/her upper extremities up tight against his/her chest with his/her hands contracted in a downward position. During an observation on 11/22/17 at 10:30 a.m. Staff U Certified Nursing Assistant (CNA) and Staff AA CNA transferred Resident #7 to bed with a total mechanical lift, and provided incontinence care. Resident #7's extremities remained rigid throughout care and repositioning. During an observation on 11/22/17 at 11:15 a.m. Staff O Registered Nurse (RN) and Staff G Licensed Practical Nurse (LPN) applied a dressing to Resident #7's right antecubital ulcer. The open area appeared light pink to a smaller dark pink area. Resident #7 tensed with attempts to move the arm (to see/dress the area), with facial grimacing and furrowed brow. Staff G stated you could previously see the tendon. A PRN (as needed) Medication Administration Record [REDACTED]. On 11/27/17 at 8:20 a.m. the Director of Nursing (DON) stated she found no written documentation of a ROM restorative program for the resident. The DON stated they had no documentation of the application of the braces and stated they (staff) did them after meals. The DON stated she discontinued (the braces) the end of April or early May because the resident refused them.

Based on observation, record review, and staff interviews, the facility failed to assess for the development of pressure ulcers as a result of contracture of the arm and geri sleeves (Resident #7,) and failed to provide intervetnions and assessment to prevent and heal a pressure ulcer (Resident #4) The sample consisted of 9 residents and the facility reported a census of 27 residents. Findings include: 1. Resident #7 had a MDS (Minimum Data Set) assessment with a reference date of 10/31/17. The MDS identified the resident had long and short term memory problems and severely impaired skills for daily decision making. The MDS indicated the resident depended on staff for activities of daily living and had functional limitation with range of motion in both lower and both upper extremities. Resident #7's [DIAGNOSES REDACTED].#7 received no range of motion the previous 7 days and at risk for pressure ulcers. A fax dated 6/19/17 notified the physician that Resident #7 had a moist open area to the right antecubital area, measuring 6.5 by 4 by 0.5 centimeters (cm). The area appeared macerated with the surrounding/outer edges with bloody drainage. The fax requested a daily dressing change. The physician replied, okay with above. A Physician visit form dated 6/21/17 documented Resident #7 had skin breakdown in the right antecubital area. Resident #7 had severe contractures especially in hands and upper extremities. The physician directed to check with hospice about possibility of occupational therapy (OT) looking at upper extremity contractures to lessen antecubital skin breakdown. The clinical record lacked any evaluation by O.T. A fax dated 7/13/17, notified the physician that Resident #7's right antecubital had a foul odor and [DIAGNOSES REDACTED] (redness) around wound. The fax requested an order for [REDACTED]. The physician responded to do a culture 1st, then start Bactrim DS 2 times a day for 10 days, and increase the [MEDICATION NAME] to 3 times a day. A fax dated 7/24/17 notified the physician Resident #7 completed 10 days of Bactrim due to a positive wound culture showing proteus and [MEDICAL CONDITION] (MRSA). The resident received hospice care with no need for a 2nd round of antibiotic. The fax requested an order for [REDACTED]. A fax dated 7/31/17 notified the physician the resident continued with a non-healing wound to the right antecubital. The fax indicated family aware and wanted the resident comfortable. The physician responded the resident had an intertriginous (area where areas of skin touch or rub together) skin ulcer. A Physician visit form dated 8/16/17 documented Resident #7 had an open wound to the right upper arm due to a contracture, Stage IV, down to the muscle. A fax dated 9/2/17 at 11 p.m. notified the physician that Resident #7 had an order for [REDACTED]. A Skin Condition Record documented the ulcer was first observed on 6/19/17. On 11/20/17, the ulcer measured 1.2 by 0.5 by 0.1 cm. During an observation on 11/21/17 at 9 a.m. Resident #7 sat in a gerichair in the dining room. Resident #7 had her upper extremities up tight against his/her chest with his/her hands contracted in a downward position. During an observation on 11/22/17 at 11:15 a.m. Staff O Registered Nurse (RN) and Staff G Licensed Practical Nurse (LPN) applied a dressing to Resident #7's right antecubital ulcer. The open area appeared light pink to a smaller dark pink area. Resident #7 tensed with attempts to move the arm (to see/dress the area), with facial grimacing and furrowed brow. Staff G stated you could previously see the tendon. A PRN (as needed) Medication Administration Record [REDACTED]. 2.Resident #4's 12/27/16 Minimum Data Set documented the resident required extensive assistance of 2 staff for bed mobility, total assistance of 2 staff for transfers and did not ambulate. The resident had functional limitations in range of motion of 1 upper extremity and 1 lower extremity. The resident had [DIAGNOSES REDACTED]. The MDS documented the resident at risk for pressure ulcers. The resident's physician's orders [REDACTED]. The resident's care plan did not include an intervention to place a pressure reduction cushion in the wheelchair or recliner until 11/11/17. On 1/29/17 staff documented in the nursing Progress Notes the resident had an open area to the coccyx which measured 0.2 by 0.2 centimeters. Staff informed the physician via facsimile report and received an order to cover the area with [MEDICATION NAME] changing every 3 days and as needed to discontinue when the area healed. Staff documented on a Skin Pressure Record the area healed on 2/27/17. On the Treatment Administration Record (TAR) and Nursing Progress Notes staff continued to document application of the [MEDICATION NAME] until it was discontinued on 4/17/17. During interview on 11/21/17 at 1:44 p.m. the Director of Nursing (DON) stated she had started a skin sheet on 4/27/17. The 4/27/17 Skin Condition Record for non-pressure skin conditions documented scattered red areas 15 by 15 cm. over both the resident's buttocks. She stated on 4/27/17 the coccyx had not been open. The resident's 10/21/17 MDS documented the resident required extensive assistance of 2 staff for transfers and extensive assistance of 1 staff for bed mobility and ambulation. The resident still had functional limitations in range of motion to one upper and one lower extremity and remained at risk for pressure ulcers. During observation on 11/21/17 at 9:57 a.m. the resident sat in a recliner in his/her room. The resident had no pressure relieving cushion in the chair. The resident remained seated in the recliner until 1:51 p.m. During interview on 11/21/17 at 1:39 p.m. Staff DD, Licensed Practical Nurse (LPN) stated she had asked the resident to toilet or move from the chair and the resident refused. She stated Staff G, Certified Nursing Assistant (CNA) had also asked the resident before the noon meal and the resident had declined at that time as well. At 1:51 p.m. the DON asked the resident about toileting. The resident declined but did agree to stand so staff could check the skin on his/her bottom. The resident had a large reddened area over both buttocks and a small open area on the coccyx. The resident stated his/her bottom hurt. Staff later provided a copy of the 11/21/17 Wound/Skin Healing Record which documented a Stage 2 pressure area on the coccyx which measured 0.2 by 0.1 by 0.1 cm. The reddened area over the buttocks measured 5 cm. by 8 cm. On 11/22/17 at at 7:59 a.m. the resident laid in bed asleep. The bed had no dynamic pressure relief. At 10:02 the resident remained asleep in bed as before. On 11/22/17 at 11:31 a.m. the resident sat in the recliner in his/her room with no pressure relieving device in place. When asked how his/her bottom felt the resident stated it felt about the same and said, it still hurts.

Based on observation, record review and staff interviews, the facility failed to ensure one (1) of three (3) residents were free from resident to resident abuse. Resident #1 inappropriately touched Resident #2 and record review established Resident #2 lacked the ability to comprehend Resident #1's inappropriate touching. A reasonable person would find Resident #1's actions towards Resident #2 as abusive. Facility census was eighteen (18) residents. Findings include: 1. An Minimum Data Set (MDS) with assessment reference date of 11/20/16, assessed Resident #2 with a BIMS score of 0 (severe cognitive impairment) The resident had the following indicators of [MEDICAL CONDITION] continuously present: inattention and disorganized thinking. The resident had physical behaviors directed at others daily and hallucinations and delusions. The resident did not ambulate and required extensive staff assistance for locomotion on unit in wheelchair. The resident had [DIAGNOSES REDACTED]. A care plan revealed a problem dated 8/9/16 with the resident as an elopement risk due to wandering related to dementia. The care plan directed staff to distract the resident from wandering by offering diversions, structured activities, food conversation, TV or a book. Under a problem discharge planning dated 8/9/16, the care plan directed staff not to leave the resident unattended when sitting up in wheelchair. Regarding the care plan intervention not to leave the resident unattended in the wheelchair: On 1/26/17 at 2:10 p.m. Staff D CNA stated staff cant be with the resident all the time. On 1/26/17 at 2:27 p.m. Staff E CNA stated he didn't know about the directive. On 1/26/17 at 3 p.m. Staff F CNA stated they didn't follow the directive. The only resident they do that for is Resident #1. On 1/19/17 at 4:18 p.m. Resident #2 sat in a wheelchair in his/her room. The resident wore slacks with an elastic waist band. The resident did not respond to questions. The resident made a random comment let's go up here after awhile that did not pertain to any conversation the surveyor attempted to elicit from the resident. Nursing progress notes dated 1/3/17 at 11:45 a.m. revealed a nurse aide reported seeing Resident #1 with his/her hands down Resident #2's pants. Staff separated the residents. 2. A Minimum Data Set (MDS) with assessment reference date of 10/24/16, assessed Resident #1 with a brief interview for mental status (BIMS) score of 6 (severe cognitive impairment). The resident had highly impaired hearing and had hearing aides. The MDS identified verbal behaviors 1 to 3 days out of 7 and rejection of care. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, ambulation in room, dressing, toileting, personal hygiene and bathing. The MDS identified the resident's locomotion in corridor occurred once or twice with staff assistance. The resident used a wheelchair for mobility and walker when ambulating. The resident was always incontinent of bladder and bowel. The resident had [DIAGNOSES REDACTED]. Review of Resident #1's nursing progress notes revealed the following information regarding the resident's behaviors: On 6/17/16 at 4:30 p.m. the resident slapped staff in the face twice. On 8/3/16 at 5:46 p.m. the resident hit a nurse aide in the face with a fist. On 8/30/16 at 9:20 a.m. the resident shoved a nurse aide to the floor and identified it as funny. On 9/5/16 at 3:17 p.m. the resident attempted to kick staff yesterday. On 9/13/16 at 12:27 p.m. the resident punched staff in the face. On 9/26/16 at 9:49 p.m. the resident asked staff to touch and play with the resident's penis. On 9/27/16 at 11:28 a.m. the resident asked staff if she wanted to play with the resident's penis. On 11/8/16 at 1:53 p.m. the resident smacked staff in the face. On 12/21/16 at 12:27 p.m. staff observed the resident playing with him/her(self) and being sexually inappropriate. The resident stated to staff come on I have something for you. The resident then asked staff if they wanted to play with it (the resident's penis). The resident had been out at the dinning room table at this time and no further behaviors observed. On 1/3/17 2:20 p.m. the resident to resident incident involving Resident #2. On 1/4/17 at 9:46 a.m. the resident grabbed staff's vaginal area in the dining room and another resident witnessed the incident. On 1/8/17 at 12:36 a.m. the resident attempted to shove and hit staff. Behavior sheet documentation of sexually inappropriate behavior identified the resident with sexual behaviors on the following dates: 6/22/16 at 9:06 a.m., 7/14/16 at 8:43 p.m., 7/21/16 at 9:25 a.m., 9/24/16 at 1:58 p.m. The behavior sheet did not identify what exactly the behavior was or who the resident directed the behavior to. The record lacked evidence that the facility informed the physician of the incidents that occurred prior to 1/3/17 other than a facsimile (fax) dated 8/30/16 which reported the 8/30/16 incident. The physician responded to the fax by directing staff to monitor the resident and if behaviors continued, the resident may have to be medicated and/or go to counseling. On 1/24/17 at 12:25 p.m. the Director of Nursing (DON) confirmed she could find no evidence of any other physician notification of behaviors other than 8/30/16 prior to the 1/3/17 incident. An encounter note dated 1/10/17 at 9 a.m. revealed Resident #1 saw a psychiatric- mental health nurse practitioner (PMHNP). The PMHNP documented the resident had an isolated incident with Resident #2 (on 1/3/17) and no past behavioral issues. On 1/26/17 at 12:25 p.m. the DON stated she did not remember if she reported any other behaviors to the PMHNP. She identified herself and Staff I LPN (licensed practical nurse) as the only staff involved with the telehealth visit. At that time, Staff I stated she did not report any other behaviors to the PMHNP. Staff Interviews: On 1/23/17 at 11:44 a.m. Staff A CNA stated she observed Resident #1 parked by the nurses station with his/her hand on Resident #2's leg rubbing Resident #2's knee. Staff A backed Resident #2 up out of Resident #1's reach and went to tell the nurse about it. Staff A turned around to tell Staff B CNA and Resident #2 was by Resident #1 again. Staff B went to the residents and that is when Staff B saw Resident #1's hand under Resident #2's pants. They backed Resident #2 up again and moved Resident #1 away. On 1/24/17 at 8:42 a.m. Staff B stated she talked to a staff and looked over at Resident #1 and Resident #2 seated by the nurses station. Resident #1's hand moved and his/her hand was down in Resident #2's pants all the way to the elbow. Resident #1 refused to remove it when asked so Staff B removed it. Staff B stated she observed Resident #2 attempt to remove Resident #1's hand and push him/her away. After that, Resident #1 went over to Resident #3 and tried to touch Resident #3 and rubbed Resident #3's arm from top to bottom. After that, staff determined someone needed to stay with Resident #1 at all times. Staff B stated she never saw Resident #1 touch other residents before. The resident did make remarks to staff about wanting staff to touch him/her. Staff B stated this happened numerous times and she reported it to the nurses. Staff B did not think the behaviors were addressed. Staff B also stated she heard the resident hit and kicked staff. On 1/24/17 at 10:38 a.m. the Administrator stated staff initially just backed up Resident #2 to separate the residents. She stated Resident #2 mostly sat where parked but once every 2 weeks or so the resident will move around in the wheelchair. Resident #2 reaches out and takes others hands and holds their hand to his/her cheek. The resident touches everything not just people. On 1/24/17 at 11:40 a.m. Staff C LPN (licensed practical nurse) stated Staff A told her Resident #1 was getting friendly with Resident #2. The next minute Staff B said Resident #1 had his/her hand down the pants of Resident #2. Staff C stated that Resident #2 does grab at people and occasionally wanders. She never saw Resident #1 touch other residents before. Observation and interview with Resident #1: On 1/23/17 at 10:05 a.m. observation showed Resident #1 in bed with a bed alarm in place and motion sensor on the doorway. A 15 minute checksheet hanging in the resident room revealed up- to- date 15 minute checks in place. The resident complained of a tummy ache. At that time the resident stated 6 to 8 weeks ago a resident took Resident #1's hand and put it on their pants. The resident stated it just happened one time. The other resident put Resident #1's hand on his/her leg. It didn't hurt anyone. The other resident still waves at Resident #1 everytime Resident #1 goes by. The other resident puts his/her hand out for Resident #1 to hold. Resident #1 stated this better be dropped soon because it's no federal offense. Resident #1's care plan: The care plan identified a potential for behavior and altered coping problem related to loss of spouse, [DIAGNOSES REDACTED]. resident had a history of [REDACTED]. The care plan initiation date was 11/23/16 (even though the resident had multiple behaviors documented prior to 11/23/16). The care plan directed staff to redirect the resident and provide 1 to 1 activities as needed. An addendum to the care plan dated 1/3/17 identified the resident inappropriately touched another resident. After the incident, the care plan identified the resident was one to one when out of room, 15 minute checks, motion sensor on door and bed/chair alarms. On 1/24/17 at 9:33 a.m. the DON stated there was nothing on the care plan about or for behaviors until 11/23/16. Resident #3: On 1/19/17 at 10 a.m. Resident #3 laid in bed. Resident #3 reported Resident #1 touched him/her. Resident #3 stated she saw Resident #1 put his/her hand inside Resident #2's pants. Resident #3 stated he/she only observed the action once. Facility policy dated 12/18/16 included the statements all residents had the right to be fee from abuse, neglect, misappropriation of resident property, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility policy identified resident to resident sexual harassment, sexual coercion or sexual assault is also considered abuse. The facility will presume that instances of abuse caused physical harm or pain or mental anguish in resident with cognitive impairments in the absence of evidence to the contrary.

Based on record review and staff interviews, the facility failed to provide adequate nursing supervision to ensure against hazards from self and the health service supervisor failed to supervise the implementation of the written health care plan for 2 of 5 residents reviewed (Resident #1 & #5). The facility identified a census of 20 current residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of 3/23/15. The MDS identified Resident #1 had [DIAGNOSES REDACTED]. According to the Brief Interview for Mental Status, the resident scored a 3. A score of 3 identifies severe cognitive impairment. The MDS reflected the resident required extensive assistance with bed mobility, transfers, ambulation and toilet use. According to the MDS the resident could not steady self- independently and only able to stabilize self with staff assistance when moving from seated to standing position and surface to surface transfer. The resident used a walker and a wheelchair. The Care Plan, revised on 3/26/15, identified a focus area with self-care deficit due to a [DIAGNOSES REDACTED]. The interventions directed staff to use the alarm device at all times. The Care Plan directed staff to use the walker and 1 to 2 staff assistance for ambulation. The Morse Fall Scale dated 5/4/15 identified the resident with a score of 70. A score of 45 and higher determines the resident at high risk for falls. Review of the Incident and Accident Report dated 5/5/14 at 1:15 PM reflected the resident's personal alarm sounded and staff responded promptly. The resident slid down to the chair foot rest. The chair tipped forward and the resident slid on to the floor on buttocks from the chair. The report identified the resident did not have any injuries and range of motion determined no pain. The new intervention included to not put the foot rest in an up position when the resident sat in the recliner. Review of the Incident and Accident Report dated 8/20/14 at 4:00 PM reflected the resident's alarm activated in the resident ' s room. When the nursing assistant entered the room, the resident appeared half out of the recliner on both hands and knees. The recliner still in the position and the feet were out. The resident stated that someone pushed him/her out of the chair. The report reflected the resident had no apparent injuries and the resident denied any pain. The report did not address any new interventions. An Incident Report dated 4/30/15 at 2:20 PM reflected the resident yelled for help. The staff found the resident lying on the right side on the floor of his/her room. The bed alarm had not been connected. The resident could not move and reported hip pain. The Hospice nurse obtained an order from the physician to transfer the resident to the hospital. The Progress Note dated 4/30/15 at 5:57 p.m. reflected the nurse at the nurse ' s station hear the resident yell for assistance at 2:20 p.m. The nurse found the resident lying on the floor on left side. The resident held her/his hand on the left hip when asked where the area hurt. The hospital emergency room record identified the resident had fallen and landed on the carpet with the point of impact being the left hip. The resident expressed pain in left hip. The physical exam determined decreased range of motion of the left hip and tenderness. The resident became more comfortable after a second dose of Morphine (given before x-ray) (narcotic analgesic). The Hospital Imaging Report dated 4/30/15 identified the resident had an impacted intertrochanteric fracture of the left femur which appeared to be a four-part fracture. The facility fall investigation dated 5/1/15 identified the pad alarm on the bed was noted to be unplugged so the staff could not be aware of the resident ' s movement. The investigation determined the resident ' s Care Plan had not been followed. On 5/20/15 at 10:30 A.M., Staff A, RN (Registered Nurse) was interviewed and stated the resident had been in bed after the noon meal. The resident hollered and she ran to the room. The resident laid on the right side on the floor. The resident stated his/her hip hurt. The pad alarm had been in the bed. The cord hung on the side of the bed and not engaged. The CNA who put the resident to bed had been sure she heard the alarm sound. Staff A stated the alarm could not have sounded if not plugged in and the need for the alarm had been on the Care Plan. On 5/21/15 at 9:10 A.M. Staff F, CNA (Certified Nursing Assistant) was interviewed and stated she had assisted the resident to the recliner at 1:00 PM and the alarm had been on. Staff F stated at 1:45 PM she asked Staff G, CNA to toilet the resident and put the resident to bed. Staff F came to the nurse ' s station and asked if the resident had been in bed and she said yes. Staff F stated around 2:20 PM the resident's light was on in the room. Staff F went to the room and saw Staff A assisting the resident on the floor. The alarm did not sound and she saw the alarm not plugged in. She further stated she would always double check the resident's alarms. The alarm will sound when the resident sits down and she always checks the alarm box light before leaving the room. On 5/21/15 at 2:00 PM, Staff G, CNA was interviewed and stated she assisted the resident to the toilet and then directed him/her to bed. Staff G stated she thought she heard the pad alarm beep (sound) when she laid the resident down in bed. Staff G stated she had the resident's door open and may have heard another resident's alarm. Staff G stated she did not look at the box for a light. Staff G further stated someone had unplugged the alarm when they got the resident up out of bed and knew some people do that. Staff G stated she did not feel the alarms should ever be unplugged. 2. Resident #5 had a MDS assessment with a reference date of 5/13/15. The MDS identified the resident had [DIAGNOSES REDACTED]. According to the MDS the resident had impairment on 1 side of the lower extremity that interfered with daily functions or placed the resident at risk of injury. The resident required mobility devices of a walker and wheelchair. Resident #5 had a BIMS score of 7 which identified the resident with a severe cognitive impairment. The Care Plan revised on 5/14/15 identified a focus area of activity of daily living self- care performance deficit related to a history of a right hip fracture. The interventions directed the staff the resident used a walker and wheelchair for mobility. Observation on 5/21/15 at 10:40 AM revealed Staff E, CNA, pushing the resident in the wheelchair without foot pedals. Staff E pushed the resident in the wheelchair from the East hall through the South hall, to the activity room and the resident held his/her feet above the floor. The distance measured approximately 50 foot.

Based on observation, record review and staff interview, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed (Resident #2). Facility census was twenty-four (24) residents. Findings include: A Minimum Data Set (MDS) with assessment reference date of 11/12/14, documented Resident #2 with a brief interview for mental status (BIMS) score of "3" (severe cognitive impairment). Resident #2 required extensive assistance of two staff with bed mobility, transfers, ambulation, toileting and personal hygiene. A "balance during transitions and walking" test identified Resident #2 as not steady and only able to stabilize with staff assistance in all areas of testing. Resident #2 used a walker and a wheelchair for mobility. Resident #2 ' s [DIAGNOSES REDACTED]. The MDS for Resident #2 listed no history of falls. The resident was 66 inches tall and weighed 147 pounds. An incident report dated 10/30/14 at 7:30 p.m. documented by Staff B revealed Staff D (nurse aide) assisted Resident #2 to ambulate from the commode to the bed. Resident #2 bumped the right shin (calf) on the bed rail. The resident received a 3 centimeter (cm.) by 1 cm. skin tear. The intervention was: Move side rail out of way and monitor position of leg to prevent injury. On 1/13/15 at 2:05 p.m. Staff D stated unable to recall if the rubber covering was in place when the 10/30/14 incident occurred regarding Resident #2. On 1/14/15 at 10:20 a.m. Staff B (licensed practical nurse) stated the end piece on the side rail that covered the side rail edge was present but loose. Staff B taped it and covered a towel around the entire rail. A care plan change sheet revision dated 11/19/14 directed staff to use two staff to assist the resident with transfers and ambulation. An incident report dated 1/4/15 at 9:00 p.m. documented by Staff C (registered nurse), revealed Staff F (nurse aide) transferred Resident #2 from the wheelchair to the bed and bumped the resident's right leg on the bed rail causing an abrasion and bruise to the leg. The abrasion measured 4.5 cm. by 2.4 cm. with a 12 cm. by 14 cm. bruise. The intervention was: lamb wool padding to bedrail and staff disciplined for not using 2 staff to transfer Resident #2. The bed rail failed to have an end cap in place. On 1/13/14 at 1:11 p.m. Staff C stated she was at the nurses ' station when she heard Staff F tell Resident #2 he/she had pants on so it couldn't have hurt that bad. Staff C stated Staff F transferred the resident by herself and hit the resident's leg on the bedrail. Staff C stated she didn't think Staff F understood Resident #2 required two staff members for transfers. Staff C stated they never transfer Resident #2 with one staff any other time. The care plans are available at the nurses ' station if staff has questions. The Resident#2's leg hit the bare metal portion of the bed rail. The rubber to cover the ragged metal was missing. Following the incident staff covered it with sheepskin. Resident #2 ' s leg area started to bruise that night and more bruising appeared the next day. Staff C stated the chest bruise discovered on 1/8/15 was also likely from the 1/4/15 incident. Nursing progress notes dated 1/4/15 at 11:40 p.m. revealed "weeping" through the dressing on the leg and onto the bedding. Staff C changed the dressing to Adaptic (form of non-stick dressing), ABD (absorbent dressing) pad, wrapped with cling and secured with tape. Staff notified the physician of the findings and area bruise with Resident #2 ' s complaints of pain. Nursing progress notes dated 1/6/15 at 12:14 a.m. identified the abraised area as weeping a pink watery substance. The surrounding area around the skin tear contained a deep purple hematoma approximately 14 cm. by 12 cm. Resident #2 expressed discomfort. Intervention noted of staff elevating Resident #2 ' s leg. Nursing progress notes dated 1/7/14 at 12:53 a.m. identified the lower right calf as red swollen and warm. The nurse faxed the physician. On the same date at 11:50 a.m. Resident #2 cried out with pain from the right leg in the early morning. Since that time, Resident #2 appeared calm and rested in a chair for 3 hours. On the same date at 11:51 a.m., staff informed the physician of the condition of the right leg. The leg from the ankle to slightly above the knee was swollen and hard. Resident #2 complained of pain. The ankle and knee became red and the wound drained serosanguineous drainage. The leg felt warm to the touch. On the same date at 11:53 a.m., the physician responded to the fax and directed staff to apply ice to area if needed for up to 3 days from injury. On the same date at 3:30 p.m., the physician came to the facility and saw the resident and evaluated the leg. Doctors order and progress notes dated 1/7/15, revealed the physician wrote Resident #2 hit the right lower leg on the bedrail resulting in a large hematoma that worsened. The resident complains of pain and cannot walk because of the pain. The assessment showed a purple discoloration from the anterior to posterior aspect of the lower leg and calf. The resident had a minor abrasion of the anterior leg. Adaptic in place. The bruising extended to the foot and was tender to the touch with swelling. The physician identified the injury as a contusion with secondary hematoma. The physician directed staff to observe the area and elevate the leg. Cover the abrasion with Adaptic as needed daily. Monitor for ulceration or localization. Administer Tylenol #3 (narcotic pain reliever) every 6 hours as needed for pain. A skin condition report identified, on 1/7/15 the skin injury measured 3.5 cm. by 3 cm. with a depth of less than 0.1 cm. The bruising measured 30 cm. by 15 cm. Nursing progress notes, dated 1/8/14 at 8:59 a.m. revealed staff observed bruises to the right lateral rib area and under the right arm extending to mid right breast. (No sizes listed) The entry revealed staff would use a Hoyer mechanical lift to transfer Resident #2 due to the resident no longer able to stand on the right leg following the 1/4/15 injury. On 1/13/15 at 2:12 p.m. Staff F (nurse aide) stated she stood Resident #2 up and what happened surprised her. She stated she was a nurse aide for [AGE] years and was strong. She stated she transferred Resident #2 by herself. She knew Resident #2 required 2 staff but she did not think about it at the time. The side rail was up and the bottom piece was sharp. Sometimes staff remembered to cover the edge with a blanket prior to transfer and sometimes they didn't. Staff F stated she knew it looked like she slammed Resident #2 into bed but she didn't. Resident #2's leg bumped the side rail and the resident immediately said "my leg hurts my leg hurts" Staff F stated the resident wore pants and socks so she didn't think the skin would tear. When asked how the chest injury could have occurred, Staff F stated probably from having her arm under the resident's arm. The surveyor asked if she used a gait belt and Staff F didn't remember. She stated she bear hugged Resident #2 with her arms under the resident's arms and got Resident #2 into bed. She denied any fall or lowering of the resident occurred. Observation showed, on 1/13/15 at 1:00 p.m. two staff transfer Resident #2 into bed. When staff merely touched the resident's right leg he/she exclaimed "ouch". Observation showed gauze dressing wrapped around the resident #2's right lower leg. A large area of dark purple red bruising and swelling was present on the entire back of Resident #2's right lower leg to the bottom of the foot and on the foot and ankle to above the back of the right knee with lighter purple bruising from above the right knee up to the lower right buttock. The front of the right lower leg also contained bruising but it was not as dark or extensive as the back of the leg. A large area of dark purple bruising was present under the right breast extending around to the right chest wall. When asked if he/she had leg pain after Resident #2 laid in bed, the resident replied "yes". Review of PRN (as needed) medications administered revealed staff administered Tylenol #3 10 times from 1/8/14 to 1/12/14 for moaning and pain from the leg injury. On 1/13/15 at 12:40 p.m. the MDS/care plan nurse stated Staff F transferred Resident #2 with one staff on 1/4/15 and she was supposed to use 2 staff. She stated she did not have an incident report for the chest bruising but the chest bruises were from the 1/4/15 transfer. MDS Nurse acknowledged Staff failed to complete an incident report for the chest bruises when first noticed. The facility failed to complete an incident report for the chest bruising until 1/13/15, after the surveyor asked for an assessment/measurement of the bruising. The incident report (dated 1/13/15) revealed staff observed bruising on 1/8/15 to the right lateral rib area under the right arm and extending to the mid-right chest area. The area measured 3 cm. by 26 cm. Staff notified the physician of the bruising on 1/13/15. Interview on 1/13/15 at 1:16 p.m. with the Director of Nursing (DON) identified staff failed to complete an incident report or skin assessment sheet when the chest bruising was noted for Resident #2. On 1/14/15 at 10:15 a.m. the DON stated yesterday she questioned Staff C if Staff F used a gait belt for the 1/4/15 transfer of Resident #2. Staff C stated the resident was already in bed when she arrived to the room and she did not know if a gait belt was used. The DON stated she would speak with Staff F again since she told the surveyor did not know if Staff F used a gait belt during the transfer.

Based on observation, staff interview and facility policy review, the facility failed to follow appropriate infection control precautions while performing perineal cares and performing a treatment for 1 of 2 residents observed during personal cares. ( Resident #2) The facility identified a census of 29 residents. Findings include: According to a Minimum Data Set (MDS) assessment form dated 3/18/13, Resident #2 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a Brief Interview For Mental Status (MDS) score of 4 out of 15, required extensive assistance of 2 staff members with bed mobility, transfers and toilet use, as having an indwelling catheter, always incontinent of his/her bowels and with 1 stage IV pressure ulcers. According to a Care Plan dated 3/19/13, the resident had a problem with self care deficit due to a cognitive loss. The approaches included the following: a. High calorie ice cream. (dated 3/18/13) b. Had foley catheter due to urinary retention. c. Monitor skin with routine cares. d. Pressure ulcer risk. (dated 3/25/13) e. Had a stage IV pressure ulcer on his/her sacral area. Follow wound care dressing orders. f. Assess and document on the skin sheet. g. Incontinent of the bowel. h. Toilet after lunch and after supper on the commode. i. Work with Hospice to assist with cares. j. Lay the resident down after meals. k. Pressure reduction air mattress and cushion in the wheelchair. l. Reposition side to side when in bed. m. Taking [MEDICATION NAME] three times a day. (dated 3/25/13) A wound culture report form with gram stain dated 2/22/1, final report dated 2/25/13, indicated the resident had a light growth of Methicillin Resistant Staphylococcus Aureus with a moderate growth of mixed gram positive rods. An observation 4/3/13 at 1:40 p.m., revealed Staff I, Registered Nurse (RN) and the Director of Nursing (DON) had entered the resident's room and set up the equipment and treatment supplies on the resident's bedside stand. The staff members gloved their hands, positioned the resident on his/her right side as Staff I removed the packing from the resident's sacral pressure ulcer. With the same gloved hands the staff member filled a syringe with 20 cubic centimeters (cc's) of acetic acid, flushed the ulcer and refilled the syringe with acetic acid. With the same gloved hands the staff member held a container of flagl powder and poured some of the powder on a surface area of a 4 x 4 and placed the powder into wound bed of the ulcer and proceeded to throw the 4 x 4 gauze into a garbage can postioned at bedside. The staff member then packed the wound with gauze as she applied acetic acid to the gauze utilizing the same syringe and as she packed the ulcer. The staff member then cut the extra gauze that was not utilized in the treatment, threw the gauze in the garbage and placed the scissors on the bedside stand. The staff member utilized the remaining acetic acid in the syringe and further moistened the gauze packing in the wound. At that point the staff member changed her gloves, applied wound gel around the outer aspect of the ulcer, disposed of the excess wound gel and gloves in the garbage can and place an ABD pad over the ulcer. The resident had been positioned for comfort and the staff members washed their hands. At that point, the DON took the scissors and [MEDICATION NAME] powder off of the bedside stand with un-gloved hands and took the items to the nurses station, placed them directly on the work counter and exited the area. Staff I arrived at the nurses station and with un-gloved hands, cleansed the scissors with Lysol wipes, wiped the counter under the scissors, took the scissors to the dirty utility room and placed them in an appropriate disinfectant however Staff I failed to cleanse the container of [MEDICATION NAME] powder which remained positioned on the counter. When the staff member returned to the nurses station she placed the [MEDICATION NAME] powder in a plastic bag and placed the item into the bottom drawer of the medication cart positioned in the nurses station. An observation 4/2/13 at 4:30 p.m., revealed Staff O, CNA and Staff P, CNA had positioned the resident on his/her right side in bed and performed perineal care while cleansing stool from the resident's rectum area up to the edge of the resident's sacral pressure ulcer. A laboratory form dated 2/15/13, indicated there had been a light growth of mixed bowel flora in the resident's coccyx wound. An Exposure Control Plan For Bloodborne Pathogens procedure dated 3/26/08 directed staff to put on clean gloves just before touching mucous membranes and non-intact skin and to remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another resident.

Based on observation, record review, wound care nurse, air mattress representative and staff interviews and review of facility policy, the facility failed to ensure staff appropriately assessed and implemented interventions to prevent the development of avoidable pressure ulcers, promote healing and prevent infection for 2 of 3 of three residents reviewed with pressure ulcers and or skin breakdown. (Resident #2 and #4). The facility identified a census of 29 residents. Findings include: 1. Resident #2 had an MDS (Minimum Data Set) assessment, with a reference date of 2/10/2013, which identified the resident required extensive assistance by 2 staff members for the resident ' s activities of daily living including bed mobility and transfers. The MDS indicated the resident did not have pressure ulcers and the facility used pressure reducing devices for the chair, bed, turning and repositioning program. The MDS reflected the resident had moisture associated skin damage and staff applied an ointment. The Care Plan identified a problem with self- care deficit due to cognitive loss and back pain. The goal date of 2/11/2013 identified the resident would be free of red or open areas. The approach directed staff to apply aloe Vista every day to red or open areas and reposition every 2 hours while in bed. The staff were to encourage the resident to lie down for one hour after lunch per the wife ' s request, monitor skin and provide instant breakfast each day (reduced to 4 ounces per day to prevent weight gain). The approach indicated the resident had returned from the hospital with a red area which opened a little after the assessment period. The care plan did not address the use of pressure relieving devices. The resident had [DIAGNOSES REDACTED]. An Incident and Accident Report form dated 1/22/13 indicated the resident had the following superficial open areas (3) on his/her gluteal region/coccyx related to having loose bowel movements (BM) due to the flu in the facility. The areas had been cleansed, aloe vista applied and the resident positioned off his/her back with the use of a body pillow. The assessment did not reveal documentation related to depth of the wound, surrounding skin, drainage or odor. A = 1 centimeter (cm) in diameter. B = 3 cm x 1.3 cm. C = 1 cm in diameter An Incident and Accident Report form entry dated 1/29/13, reflected the resident had the following open areas on his/her gluteal region/coccyx. The areas were left open to air with an application of aloe vista with cares and staff positioned the resident from side to side when in bed but that the resident often refused to lie down in the afternoon. The assessment failed to reveal documentation related depth, surrounding skin, drainage or odor. Site A = 1.3 cm superficial area with a yellow wound bed. Site B = 0.2 cm slit on the coccyx area with a pink wound bed. Site C = 0.7 cm x 0.7 cm superficial area with a red wound bed. An Incident and Accident Report form entry dated 2/6/13, identified all wounds were dark red in color, 0.1 cm deep and appeared to have been getting worse. The facility staff received a new order for [MEDICATION NAME] (nutritional supplement to promote healing) two times a day (BID), with a plan to continue to lay the resident down after lunch but that he/she often refused. The entry indicated the resident had been incontinent of BM (bowel movement) and the staff had planned to continue with the use of Aloe Vista. The assessment did not reflect size of the ulcers (length or width), the surrounding skin, drainage or odor. A fax form dated 2/6/13, indicated the facility received a physician's order [REDACTED]. An Incident and Accident Report form entry dated 2/11/13, identified the size of the open areas on the resident's gluteal region/coccyx were as follows: A = 1.3 cm x 1.8 open area approximately 0.2 cm deep with a black center with green edges. B = 1 cm x 1 cm open area approximately 0.2 cm deep with a black center with green edges. C = 0.2 cm x 0.2 cm superficial area with a pink wound bed. The form indicated the resident received [MEDICATION NAME] BID, had been lying down after meals and the staff continued to position the resident from side to side. New interventions included setting the resident on a commode BID (twice a day) and changing the treatment to [MEDICATION NAME] covered with [MEDICATION NAME] and a fax had been sent to the physician. The assessment did not reflect documentation related to the surrounding skin, drainage or odor. A Braden Scale form dated 2/5/13 and 11/13/12, identified a score of 17. A score of 17 indicated the resident at a mild risk for skin breakdown. A fax form dated 2/12/13, indicated the facility received a physician order [REDACTED]. A physician form dated 2/13/13, indicated the facility received a physician's order [REDACTED]. A fax form dated 2/18/13, identified the resident's ulcerated coccyx area had tunneling present. The Physician ordered [MEDICATION NAME] AG, cover with gauze and Meplix tape. The facility also received an order for [REDACTED]. An Incident and Accident Report form entry dated 2/19/13, indicated the resident had the following open areas on the gluteal region/coccyx. The resident had been experiencing loose bowel movements presumed related to an antibiotic, continued on [MEDICATION NAME] and position the resident on side when in bed. The resident now complained of pain to all of the ulcerated areas, had been seen by a Wound Care Nurse and received the following orders per ulcerated area: Site A = Stage III, 2 cm ulcer described as 1 cm deep with a black wound bed. A culture had been performed along with a new treatment to pack the ulcer with [MEDICATION NAME], cover with gauze and tape with [MEDICATION NAME]. Site B = 2 cm x (by)1 cm ulcer with a red wound bed and yellow slough along the edges. The treatment had been to cover with [MEDICATION NAME] and [MEDICATION NAME]. C =0.2 cm superficial open area with a pink wound bed. The treatment had been to cover with [MEDICATION NAME] and [MEDICATION NAME]. A Physician order [REDACTED]. (Site) A = (coccyx) - 2.7 cm x 1.5 cm and 2.8 cm deep with undermining from 3 to 7 o'clock 8 cm deep and with tunneling at 6 o'clock at 2.9 cm. The staff were directed to pack the coccyx ulcer with [MEDICATION NAME] and cover with [MEDICATION NAME] every day. (Site) B = (right superior inner buttock) - 1.3 cm x 2.2 cm and 0.3 cm deep. The staff were directed to apply Santyl daily and cover with [MEDICATION NAME]. A Progress Report form from the wound clinic dated 2/22/13, indicated the medial coccyx wound measured as follows: 2.7 cm x 1.5 cm and 2.8 cm deep. A Progress Report form from the wound clinic dated 2/22/13, indicated the right superior gluteus pressure ulcer measured as follows: 1.3 cm x 2.2 cm and 0.3 cm deep. A wound culture report form with gram stain dated 2/22/13 with the final report dated 2/25/13, indicated the resident had a light growth of [MEDICAL CONDITION] (MRSA} with a moderate growth of mixed gram positive rods. A Nurse's Notes entry dated 2/26/13 reflected the resident had been attending a wound clinic weekly with pressure ulcers that measured as follows. The facility staff continued to position the resident on a commode BID (twice a day) to facilitate a bowel movement, the staff laid the resident down after meals, positioned him/her from side to side and that the resident continued to complain of pain with touch. (Coccyx Site) A = 2.7 cm x (by)1.5 cm x (by) 2.8 cm with tunneling at 6 o'clock. The wound had been described as black and green with a foul odor. A culture and sensitivity had been completed and the resident had been started on [MEDICATION NAME] (antibiotic) 4 times a day for 10 days and the facility staff were continuing with the treatment from the Wound Clinic. (Right Superior upper buttock Site) B = 1.3 cm x (by) 2.2 cm x (by) 0.3 cm. The wound bed had been red with no drainage. The facility staff were applying Santyl and covered the area with [MEDICATION NAME] with a border. A Progress Report form from the wound clinic dated 3/6/13, indicated the medial coccyx wound measured as follows: 4 cm x (by) 2 cm and 4 cm deep. A Progress Report form from the wound clinic dated 3/6/13, indicated the right superior gluteus pressure ulcer measured as follows: 1.2 cm x (by)2.1 cm and 0.2 cm deep. An Admission History and Physical form dated 3/9/13, indicated the resident had been admitted to the hospital on [DATE] related to a stage IV sacral decubitus ulcer that measured 4 cm deep, 2 cm wide and 4 cm from cranial to caudal in nature. There had been undermining and tunneling with the ulcer filled with necrotic tissue and a light growth of [MEDICATION NAME] Resistant Staphylococcus Aurous. The resident had been mildly hypotensive (low blood pressure) with pressures in the 80's with his/her actual blood pressure at 88/40. A Physician Transfer Order Report form dated 3/11/13, indicated the resident had been discharged from the hospital with a treatment order for 1/8th strength Dakin ' s solution soaked gauze packed into the coccyx wound, wound gel and [MEDICATION NAME] border daily to the buttock wound, a pressure reducing mattress if available and chair cushion when up in the wheelchair and [MEDICATION NAME] BID with meals. A Pomeroy Care Center form dated 3/12/13, indicated the resident had been admitted to Hospice care on 3/11/13. A E-Z Graph Wound Assessment Worksheet dated 3/12/13, indicated the resident had a sacral ulcer that measured 4 cm x (by) 2.5 cm and as 4 cm deep. The area had an odor, slough, undermining and tunneling with a yellow wound base, a moderate amount of serous drainage and [DIAGNOSES REDACTED]tous. There had been a 2nd ulcer that measured 1 cm by (by)1.5 cm by 0.1 cm however no other documentation had been present. The form indicated the ulcerated areas had been related to pressure, had deteriorated and were 100% of slough and that the resident complained of pain when the staff provided the wound care which consisted of a Dakin solution packing. The narrative section indicated the resident had been readmitted to the facility from the hospital on 3-11-13 with the ulcerated area having been worse than the previous assessment prior to hospitalization . A fax form dated 3/14/13, indicated the facility received an order to discontinue the present wound cares with a new treatment that read as follows: a. Cleanse the coccyx ulcer daily and as needed with 0.25% Acetic Acid using a 20 cc syringe and pack the area lightly with an acetic acid moistened conform dressing and cover with ABD pads. The staff were also directed to apply an antifungal ointment to the surrounding rash area and administer Lopermide 4 mg initially with diarrhea then 2 mg after each loose BM not to exceed 16 mg's per day. An E-Z Graph Wound Assessment Worksheet dated 3/19/13, reflected the resident's ulcers measured 4.5 cm x (by) 2.5 cm and as 3.5 cm deep. The area had an odor, slough, undermining and tunneling with a red and yellow wound base, a small amount of serous drainage and [DIAGNOSES REDACTED]tous. There had been a 2nd ulcer that measured 1 cm x 0.5 cm however no other documentation had been present. The form indicated the ulcerated areas had been related to pressure and had deteriorated with 75% of clean nongranulating tissue and 25% of slough present. The form indicated the resident complained of pain when the staff provided wound care which consisted of Acetic Acid, conform and covered with an ABD pad. Resident #2 had a Minimum Data Set (MDS) assessment, with a reference date of 3/18/13, which identified the resident required extensive assistance of 2 staff members with bed mobility, transfers and toilet use, as having an indwelling catheter, always incontinent of bowel function and had a stage IV pressure ulcer. An Assessment Screens form dated 3/11/13 reflected the resident had a score of 14 which placed the resident at a moderate risk for skin breakdown. According to a Care Plan dated 3/19/13, the resident had a problem with self- care deficit due to a cognitive loss. The approaches directed the staff to perform the following: a. High calorie ice cream. (dated 3/18/13) b. Had Foley catheter due to [MEDICAL CONDITION]. c. Monitor skin with routine cares. d. Pressure ulcer risk. (dated 3/25/13) e. Had a stage IV pressure ulcer on his/her sacral area. Follow wound care dressing orders. f. Assess and document on the skin sheet. g. Incontinent of the bowel. h. Toilet after lunch and after supper on the commode. i. Work with Hospice to assist with cares. j. Lay the resident down after meals. k. Pressure reduction air mattress and cushion in the wheelchair. l. Reposition side to side when in bed. m. Taking [MEDICATION NAME] three times a day. (dated 3/25/13) A physician order [REDACTED]. A Pomeroy Care Center fax form dated 3/25/13, indicated the resident received an order to discontinue the Nu gauze and pack the coccyx wound with crushed [MEDICATION NAME] (used for bacterial and parasitic infections) and apply to 0.25% acetic acid soaked gauze and to have loosely packed the [MEDICATION NAME] and gauze into the wound. The staff were also directed to increase the resident's [MEDICATION NAME] to 3 times a day (TID). A E-Z Graph Wound Assessment Worksheet dated 3/29/12, indicated the resident's ulcer measured 4.5 cm x (by) 3 cm and as 5 cm deep. The area had an odor, eschar and slough with undermining, a red, yellow, gray and black wound base and a moderate amount of purulent drainage. There had been no documentation observed related to the 2nd ulcer. The form indicated the ulcerated area had been related to pressure and had deteriorated with 50% of slough and 50 % of eschar and the resident complained of pain with touch when staff performed the treatment and position changes. The form indicated the treatment continued to consist of Acetic Acid soaked gauze. The narrative section of the form described the skin around the wound as pink with no tunneling present however the wound had been deeper at the 6 o'clock area of the wound. On 4/4/13 at 9 a.m. Staff I performed a treatment to the resident's sacral area and identified the measurements as: The ulcerated area had been odorous with a moderate amount of yellow/green drainage. a. 5 cm (head to toe) x (by) 3.4 cm (hip to hip) and 5 cm deep. On 4/3/2013 at 1:40 p.m. Staff I, Registered Nurse, and the Director of Nursing (DON) entered the resident ' s room and set up the equipment and treatment supplies on the resident ' s bedside stand. The staff members gloved their hands, positioned the resident on to the resident ' s right side as Staff I removed the packing from the resident ' s sacral pressure ulcer. With the same gloved hands, the staff member filled a syringe with 20 cc ' s (cubic centimeters) of acetic acid, flushed the ulcer and refilled the syringe with acetic acid. With the same gloved hands, the staff member held a container of [MEDICATION NAME] powder and poured powder on to the surface of a 4 by 4 gauze square and placed the powder into the wound bed of the ulcer and then removed and threw the 4 by 4 gauze into a garbage container. The staff member then packed the wound with gauze as she applied acetic acid to the gauze utilizing the same syringe as she packed the ulcer. The staff member then cut the extra gauze that was not utilized in the treatment, threw the gauze in the garbage and placed the scissors on the bedside stand. The staff member utilized the remaining acetic acid in the syringe and further moistened the gauze packing the wound. At that point the staff member changed her gloves, applied wound gel around the outer aspect of the ulcer, disposed of the excess wound gel and gloves in the garbage container and placed an ABD pad over the ulcer. The resident had been positioned for comfort and the staff members washed their hands. The DON took the scissors and [MEDICATION NAME] powder off of the bedside stand without gloved hands, cleansed the scissors with Lysol wipes, wiped the counter under the scissors, took the scissors to the dirty utility room and placed them in an appropriate disinfectant, however, Staff I did not cleanse the container of [MEDICATION NAME] powder which remained positioned on the counter. When the staff person returned to the nurse ' s station, she placed the [MEDICATION NAME] powder in a plastic bag and placed the item into the bottom drawer of the medication cart positioned at the nurse ' s station. On 4/3/13 at 9:50 a.m., Staff I was interviewed and confirmed she measured skin areas one time a week but did so on different days of the week. On 4/2/13 at 4:30 p.m., observation revealed Staff O, CNA and Staff P, CNA had positioned the resident on his/her right side in bed and performed perineal care while cleansing feces from the resident's rectum area up to the edge of the resident's sacral pressure ulcer. A laboratory form dated 2/15/13, indicated there had been a light growth of mixed bowel flora in the resident's coccyx wound. On 4/2/13 at 2:10 p.m., observation revealed a quarter sized open area on the resident's left hip that had been dark yellow in color with scattered black specs. During an interview on 4/2/13 at approximately 2:45 p.m. the surveyor requested the skin sheets for the open area on the resident's left hip from Staff I (Registered Nurse). During an interview on 4/2/13 at 3:10 p.m., Staff I confirmed she had been aware the resident had the area on his/her left hip approximately 2 weeks prior. When she first observed the area it had pink in color however she forgot to complete a skin sheet and had not been treating the area. On 4/2/13 at 3:40 p.m., Staff I measured the area on the resident's left hip and covered the area with a Meplix border dressing without first cleansing the area. Staff I stated she was unsure if the resident needed repositioned. Staff I kept the resident in a supine position and raised the head of the bed (this places pressure on buttock/coccyx area). Staff I left the room and then reentered. An odor of feces was present in the room. Staff I did not check the resident for incontinence. Staff I stated the resident would need repositioned in approximately 25 minutes. Staff I measured the left hip pressure ulcer as: 2.2 cm x (by) 1.2 cm green/yellow area with black spots present and 0.3 cm of redness surrounding the wound. The staff member described the area as leathery to the touch with no drainage present. An Incident and Accident Report form dated 4/2/13 at 3:45 p.m., indicated the resident had a gray/green colored area with black specks on the left hip and felt leathery to the touch. The area measured 2.2 cm x (by) 1.2 cm with 0.3 cm of redness surrounding the wound. A Meplix border dressing had been applied with a plan to reposition the resident from side to back. On 4/4/13 at 9 a.m., Staff I performed a treatment to the resident's left hip area with the measurements as follows: a. 1 cm (length) by (by) 1.8 cm (width) with no depth but soft to touch. On 4/3/13 at 10:40 a.m. a specialized Wound Care Nurse was interviewed and confirmed she would have expected the facility staff to assess and measure open wounds at least weekly. The wound care nurse also stated she personally did not look at the layering of bedding between the resident and a specialized cushioning device but she would have expected the area to have been off loaded so there would not have been any pressure to the ulcerated area. On 4/2/13 at 2 p.m., observation revealed the resident positioned on his/her left side in bed and resting on an alternating air flow mattress. The staff had covered the mattress with a fitted sheet, 2 washable soaker pads overlapped and 2 disposable incontinent pads overlapped. During an interview at the same time Staff A, Certified Nursing Assistant, confirmed 1 of the washable soaker pads should not have been positioned under the resident. On 4/2/13 at 2:20 p.m., observation revealed the DON and Staff M, Licensed Practical Nurse, had provided cares and positioned the resident on his/her back and then exited the room. On 4/3/13 at 9 a.m., observation revealed the resident position in a supine position (on back) while in bed. On 4/4/13 at 9 a.m., observation revealed the resident positioned in bed and resting on top of the alternating air flow mattress which was covered with a fitted sheet, top sheet, bedspread, a washable soaker pad, a disposable incontinent pad and the resident wore a yellow incontinent brief. On 4/3/13 at 11 a.m., a representative from the alternating pressure air mattress manufacturer was interviewed and confirmed the company ' s recommendations had been to have as few layers between the mattress and the resident. The representative stated the more layers between the pressure reducing mattress and the resident would have decreased the effectiveness of pressure relief. 2. According to a MDS assessment form dated 3/3/13, Resident #4 had [DIAGNOSES REDACTED]. The assessment indicated the resident had a BIMS score of 6 out of 15, required extensive assistance of 2 staff with bed mobility, dressing, toilet use, personal hygiene and as having 2 unstageable pressure ulcers A Care Plan dated 3/14/13, indicated the resident had [DIAGNOSES REDACTED]. The Care Plan indicated the resident had a problem with self-care deficit with approaches that included the following: a. Seeing the Wound Care Nurse for 2 pressure ulcers. (dated 3/4/13) A Skin Assessment: The Braden Scale Risk Predictors for Skin Breakdown form dated 2/26/13, indicated the resident had a score of 14. (A score of 13-14 placed the resident at moderate risk for skin breakdown). An Incident and Accident Report form dated 1/24/13, indicated the resident had an area on the back of his/her right calf that measured 2 cm x (by) 1.2 cm and 0.4 cm deep that appeared to have been an old skin tear that had reopened. The assessment did not reveal documentation related to the surrounding skin, drainage or odor. A fax form signed by a physician on 1/25/13, indicated the facility received an order to cleanse the area, apply triple antibiotic ointment, cover with [MEDICATION NAME] and change every day (QD). A Nurse's Notes entry on the back of the Incident and Accident form dated 2/12/13, indicated the wound measured 2.5 cm x (by) 3.0 cm and 0.4 cm deep. The wound bed had been pale green slough with red wound edges. The assessment failed to reveal documentation related to the surrounding skin, drainage or odor. A fax form signed by a physician on 2/14/13, indicated the resident received an order for [REDACTED]. A Nurse's Notes entry on the back of the Incident and Accident form dated 2/19/13, indicated the wound measured 3 cm x (by) 2.3 cm and 0.4 cm deep. The wound bed had been pale green with a large amount of serosanginous drainage with no complaints of pain. The assessment failed to reveal documentation related to the surrounding skin or odor. A Nurse's Notes entry on the back of the Incident and Accident form dated 2/26/13, indicated the wound measured 4 cm x (by) 2.3 cm and 0.3 cm deep. The wound bed had been 80% green slough with a black center and reddened edges however the resident did not have a temperature. The assessment failed to reveal documentation related to the surrounding skin, drainage, and odor or pain level. A fax form signed by a physician 2/27/13, indicated the facility received an order for [REDACTED]. A Progress Record form dated 2/28/13, indicated the wound measured 3 cm x (by) 2.8 cm and less than 0.1 cm deep with a black center surrounded by yellow and a pink rim. The form indicated there had been no [DIAGNOSES REDACTED] or increased warmth to the area which had been caused from pressure from the residents leg brace. The wound care nurse requested staff continue with cleansing the area with normal saline and applying a foam cushion BID/weekly and PRN. A fax form signed by a physician on 3/5/13, indicated the facility received an order for [REDACTED]. A Progress Record form dated 3/5/13, indicated the wound measured 3 cm x (by) 2.8 cm and 0.2 cm deep with a black center surrounded by yellow tissue and a pink rim. Occasional pink bud had been noted in the base but somewhat dry. The Wound Care Nurse requested staff discontinue the current treatment and start an application of a [MEDICATION NAME] dressing BID/weekly and PRN. A Nurse's Notes entry on the back of the Incident and Accident form dated 3/5/13, indicated the resident had been assessed by a wound care nurse weekly and her measurements had been 3 cm x 2.8 cm with a black center and yellow nonviable tissue with a pink rim. The facility received new orders for a [MEDICATION NAME] dressing to have been applied BID and PRN. The assessment failed to reveal documentation related to the surrounding skin, drainage, and odor or pain level. A Nurse's Notes entry on the back of the Incident and Accident form dated 3/12/13, directed the reader to see the wound care nurse wound assessment. A Progress Record form dated 3/12/13, indicated the wound measured 2.6 cm x (by) 2 cm with a yellow nonviable tissue in the base and no further black tissue. The wound care nurse requested staff continue the same treatment. A E-Z Graph Wound Assessment Worksheet dated 3/19/13, indicated the resident's ulcers measured 3.5 cm x (by)2.5 cm with no depth. The area had slough but no odor, undermining and tunneling with a yellow wound base, a small amount of green drainage and [DIAGNOSES REDACTED]tous. The form indicated the resident had pain only when performing wound care and the status had been unchanged. A E-Z Graph Wound Assessment Worksheet dated 3/26/13, indicated the resident's ulcers measured 5 cm x(by) 2.8 cm with no deep. The area contained slough, had an odor but no undermining and tunneling. The wound base had been described as yellow brown with a moderate amount of purulent drainage and [DIAGNOSES REDACTED]tous. The form indicated the resident had pain only when performing wound care and the status of the wound had deteriorated. A Progress Record form dated 3/26/13, indicated the wound measured 5.5 cm x (by) 2.5 cm with 3 cm of distal black leathery eschar firmly attached. Proximal the wound had been described as yellow nonviable tissue. The front rim contained [DIAGNOSES REDACTED] without increased warmth or induration however the resident complained of pain. The wound care nurse requested staff continue the same treatment. An Incident and Accident Report form dated 1/26/13, indicated the resident had an open area on his/her coccyx that measured 0.5 cm x (by) 0.8 cm. The assessment failed to reveal documentation related to the depth, surrounding skin, drainage or odor. A fax form, signed by a physician on 1/28/13, directed the staff to apply Aloe Vista to the coccyx area until healed. A fax form signed by a physician 2/15/13, indicated the area on the resident's coccyx had increased in size to 1 cm x(by) 1.4 cm with dark edges with a new order an application of [MEDICATION NAME] to the area to have been changed every 3 days and PRN. A Nurses Notes entry on the back of an Incident and Accident Report form dated 2/16/13, indicated the skin sheet had been filed before follow up with the coccyx wound the facility staff had not assessed the area weekly. A Nurse ' s Notes entry on the back of an Incident and Accident Report form dated 2/20/13, indicated the area on the resident's coccyx measured 1 cm x(by) 1.2 cm and as superficially opened. The wound bed had been described as red, with no signs and symptoms of infection or drainage. The assessment did not reveal documentation related to the surrounding skin, odor or pain level. [MEDICATION NAME] had been applied and covered with [MEDICATION NAME]. A Nurse ' s Notes entry on the back of an Incident and Accident Report form dated 2/26/13, indicated the area on the resident's coccyx measured 1 cm x (by)1.5 cm and as superficially opened. The wound bed had been described as red along the edges with yellow/green slough. The resident had been incontinent of BM, staff were to encourage the resident to lay on his/her side and continue the use of [MEDICATION NAME] covered with [MEDICATION NAME]. The assessment failed to reveal documentation related to the surrounding skin, odor pain level. A Progress Record form dated 2/28/13, indicated the coccyx wound measured 2.8 cm x (by) 1.2 cm covered with yellow slough and unstageable. The wound care nurse requested staff continue the same treatment. A Nurse ' s Notes entry on the back of an Incident and Accident Report form dated 3/5/13, indicated the resident had been assessed by a wound care nurse weekly and her measurements had been 3 cm x (by)0.9 cm and 0.2 cm deep with yellow slough in the base of the wound and the treatment had been changed to a foam dressing with border. The assessment did not reveal documentation related to the surrounding skin, drainage, and odor or pain level. A Progress Record form dated 3/5/13, indicated the wound measured as stated above with yellow slough in the base, no [DIAGNOSES REDACTED] or increased warmth. The wound care nurse requested staff discontinue the current treatment and apply a bordered form BID/weekly and PRN. A Nurse ' s Notes entry on the back of the Incident and Accident Report form dated 3/12/13 directed the reader to see the wound care nurse assessment. A Progress Record form dated 3/12/13, indicated the wound measured 2.6 cm x (by)1 cm and as less than 0.1 cm deep with pale yellow slough in the base and occasional pink buds poking through and a moderate amount of serous drainage with no odor. However the area had no [DIAGNOSES REDACTED] or increased warmth. The wound care nurse requested staff continue the same treatment. A Nurse's Notes entry on the back of the Incident and Accident form dated 3/19/13, indicated the area on the resident's coccyx measured 3 cm x 1 cm and 0.2 cm deep. The wound bed had been described as red with spots of yellow slough. The resident had not complained of pain and repositioned the resident from side to side and continued the same treatment. The assessment failed to reveal documentation related to the surrounding skin or odor. A Nurse ' s Notes entry on the back of an Incident and Accident Report form dated 3/26/13, indicated the area on the resident's coccyx measured 2cm x(by) 0.8 cm and 0.2 cm deep. The wound bed had been described with 50 % slough and 50 % healthy pink tissue with a plan to continue the current treatment. The assessment failed to reveal documentation related to the surrounding skin, odor or pain level. A Progress Record form dated 3/26/13, indicated the wound measured 2.7 cm x (by) 0.8 cm and 0.1 cm deep. The wound base contained 80 % of yellow-nonviable tissue with pink granular buds present and a moderate amount of serious drainage without odor. There had been no periwound [DIAGNOSES REDACTED] or increased warmth. The wound care nurse requested staff continue the current treatment. A History and Physical form dated 3/28/13, indicated the resident had been admitted to the hospital with [REDACTED]. A physician order [REDACTED]. A fax form signed by the physician 3/27/13, indicated the facility received an order to culture the wound with a treatment that consisted of santyl

Based on observation, record review, interviews with staff, resident, and ARNP (advanced registered nurse practitioner), the facility failed to provide adequate supervision for 5 of 5 residents reviewed for supervision concerns (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5). The facility admitted two registered sex offender residents (Resident #1 and Resident #2) and failed to provide adequate supervision to other residents or children visiting the nursing home. In January 2011, Resident #3 alerted the facility staff that Resident #1 had inappropriate touched him/her and the facility failed to provide adequate supervision to Resident #3 to maintain his/her safety from Resident #1. On 8/21/11, a child visitor reported she witnessed Resident #1 touching Resident #3 between his/her legs. Resident #1 also targeted Resident #4, and would frequently attempt to take the resident to the restroom. The management staff and director of nursing failed to plan for and direct services to adequately supervise Resident #1, until directed by the Department. This constituted an immediate jeopardy situation to the health and safety of residents. In addition, the facility failed to provide adequate supervision for Resident #2 from contact with children. The resident ' s care plan identified he/she with an established history of pedophilia however the management staff allowed Resident #2 to engage in contact with children. In addition, the facility also failed to implement safety interventions to reduce hazards and risk for injury to Resident #5. The facility identified a census of 33 residents. The facility identified a census of 33 residents. Findings include: 1. Resident #1's clinical record identified he/she court ordered to reside at Pomeroy Care Center. An admission record identified the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A 9/21/10 civil commitment unit for sexual offenders form identified the resident with [DIAGNOSES REDACTED]. and mental status full time care at Pomeroy Care Center was necessary. The resident will be discharged to the nursing home and will remain there under a 229 commitment until it is determined the resident no longer needs full time care. A Minimum Data Set (MDS) with assessment reference date of 8/16/11 assessed Resident #1 with a brief interview for mental status (BIMS) score of 5 (severe cognitive impairment). The MDS identified the resident as independent with bed mobility, transfers, ambulation, eating, toileting and dressing. The resident required limited staff assistance with personal hygiene and extensive staff assistance with bathing. The MDS did not identify problem behavior in the previous 2 weeks. Resident #1's clinical record at the nursing home contained an annual report dated 7/13/10 which evaluated the resident. The document indicated the following: A patient committed to the sex offender unit (CCUSO) must be evaluated annually from date of commitment to help determine whether probable cause exists to believe the patient no longer represents a high risk for sexual re-offending. The intent of the 7/13/10 evaluation was to provide a summary of the patient ' s progress during the resident's eighth year of treatment and recommendations regarding the resident ' s possible release. The report identified the resident as ready for discharge because the resident did not actively participate in treatment since 2005 and subsequently developed medical conditions. On 8/16/06 CCUSO referred the resident to a neuropsychology laboratory where the resident received a [DIAGNOSES REDACTED]. The report also documented the mental abnormality of committed person had clearly demonstrated a serious difficulty controlling his/her behavior, both in general and, more specifically, in the realm of sexual behavior. These characteristics in turn, predispose him/her to commit sexually violent offenses in a degree constituting such people as menace to the health and safety of other's. The report contained multiple areas of evaluation and concluded the patient had not only lost interest in treatment but progressively less able to participated due to his/her cognitive impairments and other medical conditions and the writer's believed due to all of the factors considered in the evaluation, he/she did not currently meet the definition of sexually violent predator as described in Chapter 229A. The examiner indicated the resident did not currently meet the threshold of "Sexually Violent Predator" as defined in Chapter 229A. The resident also had [DIAGNOSES REDACTED]. The report documented the resident suffering early stages of dementia. According to the "24 hour report" shift communication reports (not a part of the residents' permanent record) identified the following information regarding Resident #1: On 1/2/11 WATCH caught taking Resident #4 to bathroom and helping Resident #3 to stand. Gets angry when redirected. On 1/4/11 Told to stop pushing residents and Resident #1 told staff to (expletive)--- you. Tried to assist Resident #4 to bed. On 1/5/11 Caught-helping Resident #3 out of bed. Redirected and told not to help residents. On 1/10/11 Continues to try and assist Resident #4. On 1/11/11 Resident #3 said Resident #1 tried to stick hand down his/her pants. On 1/12/11 WATCH! Do not allow in Resident #3/ Resident #4's room. On 1/31/11 Unbuckled Resident #4 seat belt and assisted him/her to bed. On 2/7/11 Going into Resident #3's room. Told C.N.A. (certified nursing assistant) to (expletive) off. On 2/17/11 Found in Resident #4's room and removed alarm. On 2/24/11 Hanging outside Resident#3's door about 30 minutes this morning while Resident #3 slept. Easily redirected. On 3/5/11 Found going into Resident #3's room. Redirected easily. On 4/10/11 Found at Resident #3's room multiple times. On 6/8/11 Helped Resident #4 into bed. Watch. On 6/28/11 Undid Resident #4's seatbelt this afternoon. On 7/9/11 A staff's grandchild reported Resident #1 tried to kiss him/her. On 7/11/11 Stalking Resident #3's room. Watch. On 7/30/11 Transferred Resident #4. Swearing when redirected Calling staff "stupid (expletive) you're not my (expletive) boss" On 7/31/11 Cussing and yelling at staff when they redirected resident out of Resident #3's room Asked staff "What do you think I'm going to do rape him/her" Calling staff "mother (expletive)." On 8/6/11 Found outside Resident #4's room with Resident #4's seat belt undone. Told resident to stay out of room and get staff if help is needed. Yelled at staff and said a few profanities. None of the above incident noted in the " 24 hour report " were in the nurses notes with the exception of the following: 1/5/11, 2/7/11, 7/30/11, 7/31/11 and 8/6/11. Additional information in the nurses notes identified on 2/7/11 at 8 p.m., when spoken to about not going into other resident's room that Resident #1 stated he/she could "do what I want". On 7/31/11 at 3:30 p.m., Resident #1 told staff he/she would leave the other resident's room when "I'm ready mother (expletive)". On 8/6/11 at 6 p.m. the resident denied unbuckling Resident #4's seatbelt when confronted. A behavior mood checklist for Resident #1 contained a narrative on the back of the checklist dated 8/1/11 which revealed Resident #1 threatened to hit Resident #11 in the head with a baseball bat. The behavior mood checklist identified an "X" in the box for sexual aggression on 8/21/11. In addition to the 8/21/11 episode of sexual aggression, the August 2011 behavior/mood checklists identified 13 episodes of pacing, 12 incidents of wandering, two episodes of yelling and screaming and one threat of physical harm. A nurses note entry in Resident #1's record dated 8/22/11 at 3 p.m. identified a" report of inappropriate contact with opposite sex resident on 8/21/11. See investigation". Nurses notes in the resident's record did not contain any further information regarding the incident. The investigation contained written statements by staff. The facility reported the incident to Resident #1's psychiatric ARNP. In a report to the Department of Inspections and Appeals dated 8/22/11, the Administrator identified an 8 year old reported an alleged incident occurring between a male and female resident. The female is in the upper 90's with advanced dementia and the male resident is ambulatory with an IQ in the 70 to 80 range. The female received treatment for [REDACTED]. Following the alleged incident the facility installed a motion sensor and a video monitor in the victim's room (Resident #3). Staff will check the perpetrator's (Resident #1) whereabouts every 15 minutes. According to the police report titled Assault with the Intent to Commit Sexual Abuse, the 8 year old child witnessed Resident #1 pull the covers off and was touching Resident #3 between his/her legs; and Resident #3 stated, " No, No, No!. " The police report obtained a written statement from a nurse (Staff B) who reported she had been approached by a staff and their 8 year old child. The child reported to Staff B she witnessed a man (Resident #1) doing something to the person (Resident #3) in bed, doing something between his/her legs in the private area. The psychiatric ARNP saw Resident #1 on 2/1/11 and identified Resident #1 the resident assists peers to stand and goes into opposite sex resident rooms. The resident shows anger when redirected from peers. At that visit the ARNP told the resident to maintain space between him/her(self) and peers. The ARNP saw the resident on 5/6/11 and stated the resident did not go into peer's rooms since last visit based on information provided to her by Staff M. On 7/26/11 the ARNP identified the resident "eyeing" teenage visitors to the facility. Staff are cautious of this and watch the resident related to past sexual acting out history. During interview, on 9/12/11 at 9:35 p.m., the ARNP stated she placed the resident on Lexapro after staff informed her of the 8/21/11 incident. She stated she thought the resident knew right from wrong and could process information. The resident "probably would" lie to cover up an inappropriate incident. The ARNP stated the resident is a risk to others and if he/she stayed at the facility, the resident would require one to one supervision for the safety of others due to other potential victims at the facility. When asked if the resident's preference (a child) was not available to victimize then would the resident seek out a geriatric resident, the ARNP stated a child is vulnerable and a geriatric resident is vulnerable - the similarities are striking. An interview was conducted, on 10/3/11 at 10:01 a.m., with the Administrator of CCUSO in Cherokee. He stated, the facility was informed that Resident #1's primary issue was with children and majority of offenses were against kids. They made recommendations to monitor the resident since those with dementia can be unpredictable. When asked if the resident would seek out a fell ow resident if children were not available, he stated he had not seen the resident for some time and when in CCUSO staff always observed the resident and did not observe the resident to prey on others but the resident resided on a same sex unit. The resident did want to help others at times. When informed a child sat on Resident #1's lap, he stated they do not recommend physical contact of any sort and staff should redirect the child away from the resident. He declined to comment on the resident's ability to know right from wrong since he had not seen the resident in a long time. On 8/31/11 at 9:33 a.m., the Administrator stated the Sheriff's office notified the schools and day cares that child molesters resided at the facility. During an interview on 9/12/11 at 10 a.m. the Sheriff's office stated they do not notify the schools and day cares of a child molester unless the molester plans to attend the school. They also stated Resident #1 came into the facility without the Sheriff's knowledge-they did not know the resident resided at the facility. They stated it did not break the law for Resident #1 to have a child on his/her lap but it ' s not a smart thing to do-common sense must be used. Resident #1 Interview: When interviewed, on 8/25/11 at 11:35 a.m. Resident #1 denied going into other resident rooms. When asked about a room at the end of the hall (Resident #3's room) the resident stated he/she had not been down there for "quite awhile". When re-interviewed on 8/31/11 at 10:20 a.m., the resident stated he/she did not remember being in Resident #3's room. The resident stated he/she knew Resident #3 but he/she did not remember going in the room. When told of the possibility of a camera in Resident #3's room, when he/she entered, the resident stated he/she never saw a camera and never looked for one. The resident stated he/she did not think he/she touched Resident #3. When asked if he/she knew for sure, the resident replied, "No". The surveyor asked the resident if he/she knew the year and the resident stated, "Not for sure". The resident knew the month was August and thought it was Monday. The resident knew the President's name. Resident #1 informed the surveyor three times that he/she did not remember telling anyone he/she touched Resident #3. Interviews: Staff working when the 8/21/11 incident occurred: On 8/25/11 at 1:26 p.m., Staff B (registered nurse) stated on Sunday 8/21/11 around 11:30 a.m. Staff C (nurse aide) informed Staff B that her 8 year old daughter went to get a pop and came back crying that there was a person in Resident #3's room with his/her hands in Resident #3's private area. The 8 year old later identified the resident in Resident #3's room as Resident #1. Staff B then went to Resident #3's room and found the resident crying. When Staff B asked the resident what was wrong, the resident replied the resident (Resident #1) keeps coming in his/her room and would not leave even when told to by Resident #3. Resident #3 then begged Staff B not to leave him/her. Staff B asked the resident what Resident #1 did. The resident demonstrated by covering his/her periarea with the resident ' s own hands to show where Resident #1 touched him/her. Staff B stated observation showed the blankets folded to the foot of the bed and did not appear as if Resident #3 kicked them off. Resident #3's brief appeared tampered with on the left side and the tabs to the brief were stuck inside the brief. Staff B stated Resident #3 never removed or attempted to remove his/her brief in the past. Also at this time, Resident #3 complained his/her "crotch hurt". Assessment showed 2 red marks down each of Resident #3's labia (anatomical structures of the female genitalia). Staff B covered the resident and then went to Resident #1's room with Staff D. Resident #1 denied being in Resident #3's room. Staff B then informed Resident #1 someone witnessed him/her in Resident #3's room and also a camera. Resident #1 immediately replied "Ok I was just in there talking". Resident #1 then became angry and began swearing. As they walked out of Resident #1's room, the resident stated, "I can do whatever I want". Staff B then attempted to call the DON with no answer. Staff B waited 30 minutes and then called the Administrator, who asked if Staff B charted the incident and when told she had not, the Administrator directed Staff B not to chart it and just put the information on notebook paper. Staff B then asked about starting a "skin sheet" to document the red labia areas. The Administrator directed Staff B not to and stated "We will take care of it". The DON then called and directed Staff B to call the State agency, family and police. According to Staff B, the DON confirmed the Administrator's directive to not chart it in the nurses notes and they would "take care of it". Staff B stated she felt like the DON and Administrator did not believe anything because Resident #3 is confused. The DON and Administrator kept saying Resident #3 did not know what he/she was talking about. Staff B stated sometime back Resident #3 told staff that Resident #1 put his/her hands down Resident #3's pants( the incident on 1/11/11). Staff B stated Staff F informed the DON of the allegation and now the DON denies knowing about it. Staff B stated Resident #1 sits by the nurses station at times and will watch staff and when they are busy Resident #1 goes to Resident #3's room. Staff B stated the Administrator and DON came to the facility 8/21/11. The Administrator stated Resident #1 "likes little girls not old ladies". Staff B then asked about the time Resident #3 reported Resident #1 put his/her hands down Resident #3's pants several months ago. The Administrator stated she did not know what Staff B was speaking about. Staff B stated the DON then denied knowledge of Resident #1 previously in Resident #3's room. On 9/1/11 at 1:55 p.m., Staff C (nurse aide) stated and documented in a written statement: her 8 year old came to the facility to get a pop. When she came back from getting a pop, the 8 year old was crying horribly and informed Staff C that Resident #1 pulled Resident #3's covers off and touched Resident #3 between the legs as Resident #3 said "No no no!" Staff C then took the 8 year old to Staff B to report the incident. Following that, the 8 year old was too scared to ride her bike home so Staff C punched out and took the 8 year old to grandma's. Staff C stated it appeared that someone other than the resident removed Resident #3's covers, instead of the resident kicking them off. On 9/1/11 at 3:23 p.m. the surveyor interviewed the 8 year old with permission from her parent. The 8 year old repeated stated she saw someone in Resident #3's room doing something between the resident's legs. (A hand written a statement dated 8/21/11, with Staff G ' s name described the scratch marks as " the red marks looked like fingernail marks. " ) During an interview and written statement with Staff G (certified nurse aide) nurse aide) on 9/6/11 at 12:52 p.m., she reported the following: Staff G stated on 8/21 11 at 11:45 a.m., Staff B asked her to go check Resident #3 and get the resident up because the resident was crying and wanted out of bed. Staff G and Staff D (certified nurse aide) went to the room and observed the resident crying and holding his/her hands over the "private area". Staff informed the resident they would change him/her. When they pulled the covers back, Staff G observed that the resident's brief appeared hardly attached at the sides and was pulled part way down on the front. Staff G noticed that the resident's labia appeared red and looked dry. Staff G stated the red marks looked like scratch marks. They transferred the resident into the wheelchair and she complained (s)he hurt. Staff D left to get the nurse Staff B. When Staff B arrived they had the resident show Staff B where the pain was. The resident pointed to the 2 red marks and said it felt like someone stuck something hard down his/her pants and the resident did want them to do it. Staff G stated she has observed Resident #1 walking down Resident #3's hall and stop and stare into rooms of female residents but just glance in male resident rooms. They reported the situation to the DON who just brushed it off like it was nothing and said, "Oh well this is the resident that said 3 men took her into the woods and raped her". When staff showed the DON, the labia red marks Staff A stated the resident most likely scratched self. Staff G stated she has seen Resident #1 watch staff and see what is going on. When the incident occurred, 2 nurse aides are on break while the other 2 are feeding residents. Staff G stated before the incident, they did nothing and now since it ' s happened, they had a camera and alarm that goes off in Resident #3 ' s room. Staff G stated, " when State is coming we have a 15 minute check sheet that a staff member writes their name on and write what he/she was doing at the time, but any other time, we do not have one. " (A hand written a statement dated 8/21/11, with Staff D ' s name described the scratch marks as " the red marks looked like fingernail marks. " ) During an interview with Staff D (certified nurse aide) on 9/811 she reported and documented in her written statement the following: Staff B asked her and Staff G to provide care to the resident and get the resident up from bed. When Staff D entered the room, she observed the resident crying that the labia hurt. Prior to removing the resident's brief, they noticed it was loose. They continued to provide care and the resident continued to cry the entire time they provided care. Observation showed two red marks where brief rubbed on the inside of the legs and two areas that looked like fingernail scratches on each labia. They then got Staff B to come and assess the area. Staff B asked the resident if the resident would know the person that was in his/her room and the resident said yes it was someone he/she went to school with. While on the toilet, the resident told Staff D it felt like she/he got scratched with a hair brush down there. Staff D accompanied Staff B to Resident #1's room when Staff B asked the resident if he/she went into Resident #3's room. Resident #1 denied going into the room. Then when told they could see what he/she did to Resident #3, the resident stated he/she just talked to Resident #3. Resident #1 then became angry and started swearing. Staff D stated she observed Resident #1 look into Resident #3's room while going up and down halls. Staff D also saw Resident #1 go into Resident #4's room and assisted Resident #4 to bed. Following the incident, staff placed a sensor in Resident #3's room so if Resident #1 entered the room again the alarm would sound. Staff D thought Resident #1 was a risk to other residents because the resident knows what he/she is doing. During an interview with Staff L(certified nurse aide) nurse aide) on 8/31/11 at 12:42 p.m., she reported and documented in her written statement the following: she worked the day of the incident but was on break when it occurred. Following the incident, when Staff L saw Resident #3, the resident cried. Staff L never saw Resident #3 cry like that before and the resident stated someone came in his/her room. Staff L had not known Resident #3 to take his/her blankets or covers off. She stated Resident #3 had never taken his/her brief off and never pulled the gown up because the resident was always cold. Staff L stated Resident #3 could not hit or kick to defend self against Resident #1. Staff L stated Resident #1 was in Resident #4's room in the past and took the resident's seatbelt off. When told to leave the room, Resident #1 swore and used foul language. Staff L stated she observed Resident #1 in Resident #3's room and by the room. Staff L stated Resident #1 knows when staff was busy at mealtime and goes in Resident #3's room when staff was busy at the meal time. When asked what he/she was doing there, Resident #1 would say he/she had been talking with Resident #3. When staff saw Resident #1 heading towards Resident #3's room they would ask where he/she was going. Resident #1 would respond to the activity room and then look into Resident #3's room when he/she walked by. After the incident, the nurse told Staff L to keep an eye on Resident #1 and he/she could not go down by Resident #3's room. After meals make sure Resident #1 is in his/her room. Staff L stated there was never a 15 minute check on Resident #1 after what happened to Resident #3, it was just started on 8/25/11. Staff L stated the 15 minute checks should have been started right away when Resident #1 was going into residents room, so we knew where he/she was at. Staff L stated she did not think Resident #1 should be at the nursing home because Resident #1 knew he/she can do anything to harm another resident like he/she had before. Staff L stated and documented on 9/15/11 at 10:08 a.m., that most of the staff will tell the nurses what ' s going on with Resident #1 and the nurse ' s will tell the DON. On 8/31/11 at 12:07 p.m., Staff U (nurse aide) stated and documented she worked on 8/21/11 but worked another hall and was on break when the incident occurred. Staff U she saw Resident #1 wandering the halls in the past and lately she noticed the resident by Resident #3's room "quite a bit". Resident #1 will stand at the doorway and look in the room then will glance back down the hall. Staff U stated Resident #1 had paid a lot of attention to Resident #4 in the past. Resident #1 unfastened Resident #4's seatbelt and stared at Resident #4's crotch area. In the past the facility instructed staff to "keep an eye" on Resident #1. Staff U stated she considered Resident #1 a risk to other residents because the resident knows when it ' s a good time to wander the hall when people are at lunch or very busy. Staff U had seen Resident #3 throw the blanket to the side. Staff U had not seen Resident #3 unfasten his/her brief or pull gown up. Resident #3 had complained of back pain in the past. Other Staff: On 9/29/11 at 4:29 p.m. Staff EE, L.P.N. (licensed practical nurse) stated she worked 2 p.m. to 6 p.m. on the day the incident occurred (8/21/11). She stated the police officer arrived on her shift. The DON accompanied the police officer when she interviewed Resident #1 and Resident #3. Staff EE stated Resident #3 did not seem any different on her shift and Resident #1 stayed in his/her room but did come out for supper. Staff EE stated a couple weeks before the incident occurred, she worked when the doctor came to examine Resident #3 for a yeast infection. Staff EE explained to the resident they needed to check his/her peri area. Resident #3 stated it was OK as long as they did not " rub it". Staff EE stated it seemed odd that Resident #3 would say such a thing. She stated she never saw Resident #1 in Resident #3's room. She saw Resident #1 target Resident #4 and once took the resident's seat belt off saying he/she tried to help the resident. On 9/8/11 at 10:12 a.m., Staff I (nurse aide) stated and documented the following: he observed Resident #1 walk down hallways and stare in opposite sex resident rooms. When Resident #1 noticed staff watching, the resident then moved on his/her way. Resident #1 took Resident #4 to the bathroom and just about had the resident's pants pulled down before staff walked in and stopped the resident. Resident #1 stopped and stared at an opposite sex resident who inadvertently pulled their covers back and laid with only underwear on. Staff reported all the incidents to the charge nurse. Staff I stated after the 1/11/11 incident the DON told the CNAs not to let Resident #1 go in other resident rooms but staff was not told why. Staff I stated Resident #1 is a risk because the resident wanders and stares into rooms and watches the aides to determine when they are the busiest. Staff I stated Resident #1 is not monitored well enough because the resident can easily slip in and out of a room without anyone knowing it. On 9/1/11 at 3:47 p.m. Staff K (activity director) stated and documented her grandchild accompanied her to the facility on [DATE] and as Staff K spoke with another resident, Resident #1 told the grandchild, "I could just kiss you". Staff K will never again bring her grandchild to the facility. Staff K stated every day around 11:30 a.m. to 12 p.m., Resident #1 would come to the activity room when residents went to lunch. Staff K stated Resident #1 would walk to Resident #3's room and back to the activity area. Staff K thinks Resident #1 knew staff were busy at this time. This is also the time frame the 8/21/11 incident occurred. Staff K stated daycare children came to the facility every week in the summer. One day the children did crafts with the residents. A child got in the lap of Resident #1 and wiggled around hugging Resident #1 and laying his/her head on the shoulder of Resident #1 Staff K stated she could not say anything to the resident because of "Resident #1's rights". The 1st graders came to the facility on ce a month during the school year and some parents knew there was a sex offender at the facility. The school asked if Resident #1 and Resident #2 could stay in their rooms and the Administrator said no because of resident rights. Occasionally when Resident #3 sat in his/her wheelchair, the resident would see Resident #1 and say, "He/she likes me and wants to be with me". On 8/31/11 at 4:27 p.m., Staff F (registered nurse) stated and documented in her written statement: in January 2011, Staff P reported that Resident #3 came out of the lounge after sitting in the lounge with Resident #1. At that time, Resident #3 stated Resident #1 tried to stick his/her hand down Resident #3's pants. Staff F assessed Resident #3 and saw no marks. Staff F called the Administrator and DON. The DON informed her that Resident #3 is confused and asked if anyone saw it. Staff F stated no one saw it, Resident #3 just reported it occurred. The DON stated Resident #1 may need to return to Cherokee. The DON instructed staff not to document the incident and they would handle it tomorrow. Staff F wrote about the incident on the 24 hour communication sheets. Staff F stated Resident #1 went to Resident #3's room multiple times. Staff also caught Resident #1 in Resident #4's room. When redirected out of rooms, Resident #1 becomes angry and swears at staff. Management is aware Resident #1 does this. One night after just coming on duty, a nurse aide informed Staff F that Resident #1 was in Resident #4's room. Staff F told the C.N.A. to get the DON and she directed staff to take the resident out of the room because the DON could not do anything right now. Staff F stated even though management knew of Resident #1 going into other resident rooms, there was no special monitoring of Resident #1. Staff F stated Resident #1 would walk down to Resident #3's room and look in. Staff shut Resident #3's room door part way and the resident continued to look in. Staff F believed Resident #1 is a risk to other residents because he/she goes into Resident #3 and Resident #4's rooms and if it happened once it will happen again. Staff F reported Resident #1 watches until he/she believes staff is too busy to notice. When all staff would go to a resident room at the end of another hallway, the resident would try to go to Resident #3's room. Staff F stated Resident #3 had kicked covers off before but not to the bottom of the bed. Staff F had not known Resident #3 to unhook his/her own brief or pull his/her gown up. Since the 8/21/11 incident, Resident #1 had stayed in his/her room because the resident knows something is going on. On 8/31/11 at 10:50 a.m., Staff J (licensed practical nurse) documented and stated during her interview the following: she had seen Resident #1 at Resident #3's doorway. Staff J could redirect the resident without problem but now the resident yells and cusses at staff when redirected. Staff J stated Resident #1 had unfastened Resident #4's seatbelt. Staff J stated prior to 8/21/11 if the resident is not in his/her room, she will look at the nurses station or the front lounge. Staff J stated she does not think Resident #1 is confused. She thinks the resident is aware of what he/she is doing. Resident #1 will stop and look towards the nurses station before visiting with Resident #4. If staff is at the nurses station, Resident #1 will ignore Resident #4. On 9/6/11 at 5:05 p.m., Staff N (licensed practical nurse) stated and documented the following: prior to the incident, she observed Resident #1 standing at Resident #3's door and look down the hallway. Otherwise Resident #1 seemed fine at the facility. Staff N now questions whether Resident #1 should reside at the facility. Staff N observed Resident #3 pull covers to the side in the past but not unfasten the brief or pull up his/her gown. On 9/8/11 at 8:55 a.m., Staff O (nurse aide) stated and documented in his written statement: prior to the 8/21/11 incident, he observed Resident #1 pacing back and forth in front of Res

Based on observation, clinical record review and staff interview, the facility failed to ensure three of eight residents reviewed had assistive devices/shoes in place while in the wheelchair to prevent injury. (Resident #3, #4 & #9). The facility census was 33 residents. Findings include: Review of the facility's policy and procedure entitled Wheelchairs (undated) directed staff to do the following: a. Explain purpose and procedure to patient and bring wheelchair to bedside. Lock wheels b. Adjust footpiece's. They can be folded and swung to the side for easy access to bed, toilet or tub. Do not remove footpiece's. 1. The minimum data set (MDS) assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with transfers and dressing and total dependence with locomotion on and off the unit. The assessment documented 1 fall without injury since admission or the last assessment. Review of the Skin Assessment/Investigation dated 12/15/11 at 11:45 a.m., revealed a bruise of unknown origin. The bruise measured 7 cm (centimeters) by 6 cm to the right foot. The document identified the resident had been combative with cares and could be due to the wheelchair foot pedals and would put shoes on the residents feet at all times while in the wheelchair. The care plan dated 9/21/09, directed staff to have the resident wear gripper socks in bed. The care plan did not document direction to provide shoes when up in the wheelchair. Observation on 12/20/11 at 9:40 a.m., revealed the resident in the wheelchair at the nurses station. The resident did not wear shoes, but wore non-skid cloth slippers. Observation throughout the day through 2:50 p.m., revealed the resident in the wheelchair without shoes but wearing cloth (crochet) slippers instead. Observation on 12/20/11 at 3:10 p.m., revealed a large bruise purple and yellow in color on the top portion of the right foot. During interview on 12/20/11 at 3:10 p.m., Staff A, CNA stated staff put a shoe on that gave the resident a little more protection from the wheelchair pedals. The CNA communication book dated 12/15/11, directed staff to please make sure the resident had shoes on when up in the wheelchair due to having a large bruise on the right foot. The document was initialed by three aides. 2. The MDS assessment dated [DATE], documented Resident #3 had [DIAGNOSES REDACTED]. The MDS identified the resident with a Brief Interview for Mental Status (BIMS) summary score of 5 which indicated impairment of cognitive skills for daily decision making. The MDS assessment documented the resident required extensive assistance for bed mobility, transfers and locomotion on and off of the unit. The MDS assessment identified the resident with 1 fall with no injury and 1 fall with major injury since the prior assessment. The care plan dated 10/11/10, revealed the resident at high risk for injury from falls and directed staff to keep the floor free of trip hazards. Review of the fall assessment screen (undated) revealed a total score of 8 with 10 or greater a high risk. Observation on 12/10/11 at 9:55 a.m., revealed Staff C, CNA (Certified Nurse Aide) pushed the resident in the wheelchair from the Nurses Station to the Activity room. The wheelchair did not have foot pedals attached. Staff C told the resident to pick up his/her feet. Observation on 12/20/11 at 10:30 a.m., revealed Staff B, CNA pushed the resident from the activity room to the nurse station and to the dining room. The wheelchair did not have foot pedals attached. Observation revealed the residents feet were just above floor level. Observation on 12/20/11 at 4:12 p.m., revealed Staff E, CNA pushed the resident from the resident's room to the lounge area. The resident lifted their feet up as Staff E pushed them. At 4:30 p.m., the resident moved him/herself to the nurses station and stopped and stated they were too weak. Staff F, Dietary Aide pushed the resident from the nurses station to the dining room and requested the resident to put up his/her feet instead of obtaining the foot pedals. 3. The MDS assessment dated [DATE], documented Resident #9 had [DIAGNOSES REDACTED]. The MDS identified the resident required extensive assistance with bed mobility, transfers and locomotion on and off the unit. The assessment documented the resident had no history of falls. Review of the care plan dated 5/4/09, revealed the resident with a self care deficit related to immobility. Observation on 12/20/11 at 10:00 a.m., revealed Staff C, CNA pushed the resident from the nurses station to the activity room in the resident's wheelchair. The wheelchair had no foot pedals attached. Observation revealed it was approximately 152 feet from the nurses station to the activity room. Observation on 12/20/11 at 10:46 a.m., revealed the Activity Director pushed the resident in the wheelchair to the dining room. The chair contained no foot pedals. Observation revealed it was approximately 32 feet from the nursing station to the dining room. Observation on 12/20/11 at 1:29 p.m., revealed Staff B, CNA pushed the resident from the resident's room to the nurses station. The wheel chair had no wheel chair pedals attached. Staff B told the resident they needed to pick up their feet. During interview on 12/21/11 at 9:00 a.m., the Director of Nursing and the MDS Coordinator stated staff were expected to use wheel chair pedals when pushing a resident in the wheelchair and identified the foot pedals as located in the maintenance closet.