Every finding on record at Accura Healthcare of Sioux City, LLC

Based on observations, staff interviews, and facility policy review the facility failed to ensure proper sanitary conditions in the kitchen area, where staff prepared food. The facility identified a census of 41 residents.Findings included:During the initial kitchen walkthrough on 12/1/25 at 10:35 AM, the following observations were made:a. The double-door refrigerator contained various scattered food debris.b. A cart holding clean dishes also had scattered food debris present.c. The dishwasher showed white, flaky, crusted lime buildup along the top and sides. Additional lime buildup was observed on the coffee machine tray.d. Black spots were seen on the wall and in the corner above the dishwashing area.The Cleaning Instructions: Refrigerators policy dated 2021 policy identified the refrigerators will be cleaned thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be cleaned as they occur. Procedure:1. Remove all food from the refrigerator. Store food in another refrigerator or cooler until the refrigerator is cleaned.2. Remove shelves, drawers, and other removable parts. Wash the parts in the sink using the hand dishwashing method.3. Clean the walls and base of the refrigerator with warm detergent water.4. Rinse and sanitize. Allow to air dry.5. Wipe the exterior of the refrigerator with an approved cleaner or clean cloth, moistened with sanitizing solution.6. Replace the removable parts and food into the refrigerator.7. For walk-in refrigerators, also mop the floors, clean the drains, and wash the walls and ceilings monthly. Store all foods at least 6 inches from the floor and 18 inches from the ceiling.8. Spills should be cleaned at the time they occur.Note: The facility maintenance department should clean the condenser coils and the condensation pans on a regular basis.Note: Follow manufacturer's cleaning and sanitizing instructions if available.The Food and Nutrition Services in Healthcare Facilities dated 2021 identified that the exterior of dishwashers and other appliances should be cleaned daily.In an interview on 12/1/25 at 11:14 PM, the Dietary Manager (DM) stated that she expected the refrigerator and dish cart to be free of any food debris. She also reported that the dishwashing area should not have black spots on the walls, and the exterior of the dishwasher should be free of crusted lime buildup.In an interview on 12/1/25 at 2:42 PM, the Administrator stated that the Dietary Manager (DM) had cleaned and sanitized the refrigerator, dishwasher, and the dishwashing area walls. The Administrator also reported that she expects the kitchen to remain clean and sanitary at all times.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #7) reviewed for PASRR requirements. The facility reported a census of 41 residents.Findings include:1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented diagnoses of anxiety disorder, depression, bipolar disease and schizophrenia. The MDS included a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Medical Diagnosis list for Resident #7 revealed the following diagnoses:other schizophrenia 4/6/2023mild neurocognitive disorder 4/22/25The Clinical Orders for Resident #7 revealed the following medications:divalproex sodium tablet delayed release 500 milligram (mg) 2 tablet by mouth at bedtime for mood stability related to bipolar disorder.quetiapine fumarate tablet 100 mg 2 tablet by mouth at bedtime for bipolar related insomnia related to bipolar disorder.mirtazapine oral tablet 15 mg or depressive disorderThe clinical record for Resident #7 lacked an updated PASRR to include diagnosis of anxiety disorder, schizophrenia and mild neurocognitive disorder. The PASRR also failed to update medications per current orders. In an interview on 12/3/25 at 2:54 PM, the Administrator stated that the facility failed to update Resident #7's PASRR. The Administrator reported that she would be implementing process improvements, as the facility did not follow its standard practice. The Administrator also acknowledged that the facility lacked a formal policy and should have been adhering to standard procedures. She affirmed that the expectation is for PASRRs to be completed promptly and updated as needed when triggers or changes occur.

Based on a review of the clinical record, facility policy, and staff interviews, the facility failed to notify the physician when the resident's blood pressure exceeded the established notification parameters for 1 of 13 residents reviewed (Resident #2). The facility reported a census of 41 residents. Findings include:The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses hypertension, end-stage renal disease and dependence on renal dialysis. The MDS included a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Care Plan for Resident #2 documented a diagnosis of hypertension and included an intervention directing staff to monitor vital signs and report any abnormal findings to the provider.The Clinical Orders dated 8/17/25 for Resident #2 showed an order to check blood pressures daily and call the provider if for systolic below 90 or above 160. The Weights and Vital Signs report for Resident #2 showed that staff failed to notify the physician when the resident's blood pressure exceeded the ordered parameters on the following days during a 30-day look-back period from 11/3/25 through 12/3/25:11/10/2511/11/2511/13/2511/14/2511/16/2511/19/2511/21/2511/22/2511/27/25In an interview on 12/3/25 at 11:24 AM, the Administrator stated that she expected staff to notify the physician when blood pressure readings exceeded established parameters. She also reported that the facility did not have a formal policy regarding physician notification, explaining, We follow standard practice.

Based on a review of clinical records, staff interviews, and facility policy, the facility failed to complete assessments and interventions for necessary care and services related to dialysis. Clinical record review revealed that nursing staff did not complete all required dialysis evaluations for 1 of 1 residents reviewed (Resident #2). The facility reported a census of 41 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses hypertension, end-stage renal disease and dependence on renal dialysis. The MDS included a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Physician Order dated 6/11/25 instructed staff to obtain a full set of vital signs and the resident's weight both before and after dialysis on Monday, Wednesday, and Friday.The Dialysis Assessments for Resident #37 indicated the facility failed to complete the pre-dialysis, post-dialysis, or both evaluations on the following dates during the look-back period from September 2025 through December 1, 2025:1. 9/5/252. 9/12/253. 9/29/254. 11/3/255. 11/23/256. 11/28/257. 12/1/25The Dialysis Care & Monitoring of Resident policy dated 1/30/24 identified the following:STANDARD:To provide adequate long-term access for dialysis and to ensure patency, absence of infection, and absence of bleeding.PROCESS:1. Check the fistula at least daily or whenever the resident or staff expresses concern.2. Assess for thrill, a rippling sensation palpable on the venous side of the fistula.3. Assess for bruit, a rushing or roaring sound heard through a stethoscope, timed with a heartbeat.4. Assess capillary refill of the extremity. Check for edema and ecchymosis in the area around the fistula.5. Assess for redness, increased temperature, and pain in the area surrounding the fistula.6. Instruct the resident to avoid wearing constricting clothing or jewelry on the affected extremity.7. Do not perform venipuncture, injections, or blood pressures on the extremity with the fistula.8. Report any abnormal findings to the dialysis department or physician immediately.Pre- and Post-Dialysis - Assessment and Documentation of the Dialysis ResidentSTANDARD:To assess and evaluate any changes in the resident's physical condition upon return to the facility after receiving dialysis treatment.PROCESS:1. Obtain a full set of vital signs upon return to the facility and report any abnormalities from the resident's normal range to the physician.2. Assess the resident's physical condition upon return, including:o Skin temperatureo Complaints of feeling coldo Complaints of [NAME] Alertness or level of lethargyo Complaints of nausea3. Assess the resident's vascular access site, reporting any bleeding or swelling. Document the condition of the site and/or dressing as dry and intact.4. Administer any medications as ordered.5. Reassess the resident's physical condition and vital signs as warranted with any changes, and report to the resident's physician or physician on-call.6. Document VS and assessment in Progress Notes- report to physician any abnormalities and report to on-coming Nurse to ensure f/u. Document any contact with physician and/or family members. 7. If dialysis report sheets are not received upon return to facility, notify Dialysis unit to send to facility or notify DON to f/u. Notify Physician If: Shunt problems: No bruit, if bleeding noted; Port problems: symptoms of infection, abnormal lab; persistent symptoms of fluid retention. Signs of fluid retention: peripheral edema, weight gain, neck vein distention, orthopnea, elevated BP, tachycardia and tachypnea. During an interview on 12/3/25 at 12:14 PM, the Administrator stated that she was not aware the dialysis assessments were not being completed. She added that she expected staff to perform all pre- and post-dialysis assessments and to adjust the assessment schedule as needed to accommodate holidays. The Administrator also reported that she planned to include dialysis assessments in an improvement plan that will be monitored.

Based on record review and staff interviews the facility failed to provide professional standards of care by not following physician orders to include the updated order and the correct medication end date in the electronic record for 1 out of 13 residents reviewed (Resident #8). The facility reported a census of 41 residents.The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented diagnoses of anemia, obstructive sleep apnea, insomnia. The MDS showed the Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. The Clinical Orders for Resident #8 showed:Check Oxygen Levels Daily and as needed dated 12/1/25Oxygen 2 - 5 liters per nasal cannula to keep levels greater than 92% dated 2/10/25The Weights and Vital records showed the facility failed to check oxygen levels on:12/1/2512/2/2512/3/2512/4/25The Care Plan for Resident #8 failed to indicate the resident's oxygen levels required monitoring or that oxygen supplementation might be needed to maintain oxygen levels greater than 92%. In an interview on 12/3/25 at 9:32 PM, Resident #8 stated she had previously experienced shortness of breath and required oxygen. When asked whether she had ever had an oxygen concentrator in her room, she responded yes, but could not recall when the concentrator was present.During an interview on 12/3/25 at 12:14 PM, the Administrator reported the facility had received a verbal physician's order to change the oxygen monitoring to PRN but failed to implement the change. The Administrator stated the orders were currently being processed. When asked to provide a policy for following physician orders, the Administrator stated, We don't have a policy; we follow standard practices.

Based on clinical record review, family interview, staff interview, and policy review the facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for 2 of 3 residents (Resident #31, and #43) reviewed. The facility reported a census of 41 residents. Findings include: 1. Review of Resident #31's Minimum Data Set (MDS) dated [DATE] revealed Resident #31 entered the facility from a short-term general hospital stay on 6/11/25. The MDS further revealed a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. Interview on 12/01/2025 at 5:25 PM with Resident #31's family member revealed that Resident #31 was in the hospital awhile ago related to having to have a couple of toes amputated related to Resident #31's terrible neuropathy, and poor circulation. Review of a facility provided document titled, Notice of Transfer Form to Long Term Care Ombudsman dated June 2025 revealed that Resident #31 was not on the form. 2. Review of Resident #43's MDS dated [DATE] revealed Resident #43 entered the facility from a short-term general hospital stay on 9/9/25. Review of a facility provided document titled, Notice of Transfer Form to Long Term Care Ombudsman dated September 2025 revealed that Resident #43 was not on the form.Interview on 12/03/2025 of 8:53 AM with the Business Office Manager revealed that she was unaware that residents who went to the hospital should be on the Ombudsman notification. The Business Office Manager then revealed that she ran the report on the computer, and was unaware of the hospitalizations and that they should be on the Ombudsman notification. The Business Office Manager then verified Resident #31 and Resident #43 were not on the appropriate notification to the ombudsman sheet. Interview on 12/03/2025 at 9:08 AM with the Administrator revealed her expectation would be for the appropriate notification to the Ombudsman for hospital visits and discharges. Review of a facility provided policy titled, Notice of Transfer or Discharge Process, with a date of 4/21/25 revealed:a. Copy of the notice must be sent monthly for this type of discharge or transfer to the Office of the State Long-Term Care Ombudsman only by mail, fax or email.

Based on observation, document review and staff interview the facility failed to follow the menu and prepare food to meet the nutritional needs of the residents. The facility reported a census of 43 residents. Findings include: Review untitled document titled Week 3 menu for Wednesday provided by Staff J revealed a. regular diet: 3 oz smoked pork loin, 1 baked sweet potato, and 4 oz buttered peas b. pureed diet: #8 scoop pureed smoked pork loin, #8 scoop mashed sweet potatoes, and pureed buttered peas. c. Mechanical soft diet: 3 oz ground smoked pork loin, 1 baked sweet potato with no skin, and creamed corn. Observation of scoops used by Staff G for lunch meal for 7/19/23 revealed: pureed wax beans size # 16 scoop, pureed meat 3 oz scoop, pureed sweet potato 3 oz scoop, regular sweet potato 3 oz slotted scoop, mechanical soft meat size #16 scoop, Pea 3 oz slotted scoop, wax beans 3 oz slotted scoop. An observation on 7/19/23 at 11:55 AM revealed a pureed diet portion chart behind the food processor in the kitchen. On 7/19/23 at 11:42 AM Staff G stated she just eyeballs the amount of meat for serving size prior to using the food processor for puree. Watched Staff G use a scoop spoon to empty the food processor. After Staff G, finished observed a large amount of food left in the food processor. The scoop spoon could not reach the large amount of food in the corner of the food processor. A continuous observation of the lunch meal revealed the scoop used to serve mechanical soft meat only partially filled when serving residents' portions and the scoop used to serve pureed food only partially filled when serving residents who received pureed diets. On 7/19/23 at 1:36 PM Staff J reported that the meat portion on the pork loin is determined where the net on the uncooked meat lines up, that is where the portion is cut from. Staff J added that while she worked at the facility, they never had a working scale. Staff J stated she sliced meat to make the plate look full. Staff J stated the facility's expectation is to follow the pureed portion chart posted on the wall and added that they did not have #8 sized scoops. On 7/20/23 at 12:34 PM the Dietitian stated The Dietitian stated she expected the staff to use a scale to determine the serving size of pork loin. She expected the staff to use correct size utensils to serve the items on the menu. On 7/22/23 at 10:25 AM the Administrator reported the expectation of the facility is to use the correct size to serve the food. The serving size should be determined by the size that is suggested by the pureed food chart, size suggested by the dietitian, and serving size specified on the menu.

Based on document review, observations, policy, and staff interview the facility failed to employ sufficient staff with the appropriate competencies and skills sets to effectively carry out the functions of the food and nutrition service department. The facility reported a census of 43. residents. Findings include: The Diet Spreadsheets labeled Week 3 Wednesday signed by the Dietitian on 4/13/23 provided by Staff J, Dietary Manager, listed the following information: a. Regular diet: 3 ounces (oz) smoked pork loin, one baked sweet potato, and 4 oz buttered peas. b. Pureed diet: #8 scoop pureed smoked pork loin, #8 scoop mashed sweet potatoes, and #12 scoop pureed buttered peas. c. Mechanical soft diet: 3 oz ground smoked pork loin, one baked sweet potato with no skin, and 4 oz scoop creamed corn. On 7/19/23 observed Staff G's, Cook, scoops used for the lunch meal revealed: a. Pureed wax beans size # 16 scoop, pureed meat 3 oz scoop, and pureed sweet potato 3 oz scoop. b. Regular sweet potato 3 oz slotted scoop, peas 3 oz slotted scoop, and wax beans 3 oz slotted scoop. c. Mechanical soft meat size #16 scoop. On 7/19/23 at 11:55 AM observed a pureed diet portion chart behind the food processor in the kitchen. The Menu Substitution Log provided by Staff J revealed a blank document. On 7/19/23 at 11:42 AM Staff G stated she just eyeballs the amount of meat for serving size prior to using the food processor for puree. Watched Staff G use a scoop spoon to empty the food processor. After Staff G, finished observed a large amount of food left in the food processor. The scoop spoon could not reach the large amount of food in the corner of the food processor. On 7/19/23 at 12:21 PM during the continuous observation of the lunch service witnessed Staff G fill the scoops used to serve the mechanical soft diet and the pureed diets only partially full. Witnessed Staff G picked up a peanut butter and jelly sandwich with gloved hands, placed the sandwich on a plate then picked up tongs for pork, placed pork on plate, picked up strainer spoon for sweet potatoes, and then picked up the lids for room trays. Then with the same gloves and without hand hygiene, Staff G picked up bread, picked up a plate, placed the bread on the plate, picked up the room tray lid, applied the lid to the plate, picked up the strawberry cobblers, and put the cobblers on the tray. Staff G used both hands for each task and repeated these tasks through the entire lunch service without changing her gloves or performing hand hygiene. The Hand Hygiene procedure document updated 10/19/22 provided by the Administrator directed that staff should always complete hand hygiene before and after work, before donning (applying) gloves and after removing gloves, after handling contaminated items and equipment, and whenever their hands become physically soiled. On 7/19/23 at 1:36 PM Staff J reported that the kitchen had a substitution sheet that they submit to the Dietitian. Staff J explained that she substitutes whatever the facility has in the kitchen that is of equal nutritional value. The meat portion on the pork loin is determined where the net on the uncooked meat lines up, that is where the portion is cut from. Staff J added that while she worked at the facility, they never had a working scale. Staff J stated she sliced meat to make the plate look full. Staff J explained that they make substitutions about two to three times a week. Substitutions are made because she forgets to order the food, there is a change in census, and/or the facility did not have enough of that food for all the residents. Staff J stated the facility's expectation is to follow the pureed portion chart posted on the wall and added that they did not have #8 sized scoops. Staff J reported that the facility expected gloves are changed when hands are soiled or when they moved from any contaminated surface and food. Staff J stated that the substitution sheet was for a couple months and she expected that it would be filled out properly. Staff J stated the substitution document should not be blank. On 7/20/23 at 12:34 PM the Dietitian stated new gloves should be applied whenever gloves are dirty. The Dietitian stated she would like no glove use during meal service and that tongs would have been ideal. The Dietitian stated she expected the staff to use a scale to determine the serving size of pork loin. On 7/22/23 at 10:25 AM the Administrator reported the expectation of the facility is to use the correct size to serve the food. The serving size should be determined by the size that is suggested by the pureed food chart, size suggested by the dietitian, and serving size specified on the menu. The Administrator stated she did not mind if the cook substituted foods off the menu. The Administrator explained that they expected that the food would be substituted appropriately. The Administrator stated the facility's expectation for glove use in the kitchen is clean touches clean and soiled touches soiled. The Administrator stated the facility's expectation is that if any of these are not correct, the staff washes their hands and applies new gloves.

Based on record review, staff interview, and document review the facility failed to notify the physician with a change in condition for 2 of 2 residents reviewed (Residents #7 and #22). Finding include: 1. Resident #7's Minimum Data Set (MDS) dated [DATE] for documented a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS included a diagnosis of edema. Resident #7 had a weight loss of 5% or more in the previous month or a loss of 10% or more in the previous six months while not on a physician-prescribed weight-loss regimen. The MDS listed that Resident #7 received a diuretic (medication to remove excess fluids) for seven out of seven days in the lookback period. Resident #7 June 2023 Medication Administration Record (MAR) included the following orders dated 7/22/22: a. Daily weight and notify the physician if weight gain of 2-3 pounds overnight or 4-5 pounds in five days. Notify the physician with any change in condition, chest pain, intolerable pain, unable to tolerate diet, and shortness of breath. The MAR listed the following weights that had a weight gain that required notification to the physician: i. 6/9/23 at 11:37 AM - 150.0 lbs.; 6/10/23 at 1:49 PM - 154.2 lbs. Weight gain of 4.2 lbs. ii. 6/19/23 at 11:55 AM - 150.8 lbs.; 6/20/23 at 7:24 AM - 153.2 lbs. Weight gain 2.4 lbs. iii. 6/21/23 at 11:06 AM - 151.4 lbs.; 6/22/23 at 10:47 AM - 154.0 lbs. Weight gain 2.6 lbs. iv. 6/7/23 at 11:41 AM - 149.4 lbs.; 6/10/23 at 1:49 PM - 154.2 lbs. Weight gain 4.8 lbs. v. 6/19/23 at 11:55 AM - 150.8 lbs.; 6/24/23 at 10:04 AM - 155.0 lbs. Weight gain 4.2 lbs. b. Furosemide Tablet 20 milligrams (MG). Give 1 tablet by mouth one time a day related to unspecified edema. Resident #7 July 2023 Medication Administration Record (MAR) included the following orders dated 7/22/22: a. Daily weight and notify the physician if weight gain of 2-3 pounds overnight or 4-5 pounds in five days. Notify the physician with any change in condition, chest pain, intolerable pain, unable to tolerate diet, and shortness of breath. The MAR listed the following weights that had a weight gain that required notification to the physician: - 7/1/23 at 7:56 AM - 156.2 lbs.; 7/2/23 at 7:46 AM - 159.4 lbs. Weight gain 3.2 lbs. b. Furosemide Tablet 20 milligrams (MG). Give 1 tablet by mouth one time a day related to unspecified edema. Resident #7's clinical record lacked documentation that the facility notified the physician with weight gain for the months of April, May, June or July. On 7/19/23 at 4:07 PM the Director of Nursing (DON) said she expected the staff notify the physician with fluctuations in weight as ordered by the physician. 2. Resident #22's MDS assessment dated [DATE] identified a BIMS score of 13, indicating no cognitive impairment. The MDS included a diagnosis of type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by elevated blood sugars that cause pain). Resident #22's June 2023 MAR listed an order dated 1/9/23 to notify the physician for blood sugars above 240 for 48 hours or above 350 and does not respond to attempts at correction four times a day for monitoring related to type 2 diabetes mellitus without complications. Call the doctor for blood sugars greater than 350 or less than 60. a. Blood sugars over 350 on 1, 4, 5, 6, 7, 9, 14, 16, 17, 19, 20, 24, 25, 26, 27, 28, and 29. b. Blood sugars above 240 for 48 hours or longer: i. 6/4/23 at noon through noon on 6/9/23. ii. 6/12/23 at breakfast through breakfast 6/15/23. iii. 6/17/23 at bedtime through the evening meal on 6/21. Resident #22's July 2023 MAR listed an order dated 1/9/23 to notify the physician for blood sugars above 240 for 48 hours or above 350 and does not respond to attempts at correction four times a day for monitoring related to type 2 diabetes mellitus without complications. Call the doctor for blood sugars greater than 350 or less than 60. a. Blood sugars over 350 on 1, 2, 4, 5, 8, 9, 12, 16, 17, and 19. b. Blood sugars above 240 for 48 hours or longer: i. 7/8/23 at bedtime through noon on 7/11/23. ii. 7/13/23 at breakfast through noon on 7/17/23. Resident #22 clinical record lacked documentation that the facility notified the physician of their blood sugar for months of July and June. One time on 6/29/23, Resident #22 had a blood sugar of 424.

Based on observations, record review, staff interviews, and policy reviews, the facility failed to provide proper hand hygiene after catheter care for 1 of 1 residents reviewed (Resident #13). In addition, the facility failed to complete hand hygiene during a medication administration for 1 out of 3 residents reviewed (Resident #17). Findings include: 1. Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Resident #13 required total assistance from two persons for toilet use and extensive assistance from two persons for personal hygiene. The MDS included diagnoses of neurogenic bladder (difficulty with urinating) and renal insufficiency (poor functioning kidneys). On 7/18/23 at 1:04 PM watched Staff Q, Certified Nursing Assistant (CNA), empty Resident #13's urine collection bag into a container, wiped the tip of the drain with an alcohol wipe, replaced the drain into the holder. Without removing her gloves after touching the urine collection bag, Staff Q touched the privacy bag, bed controls, and a package of wipes. Staff O, CNA, then emptied the urine from the container, removed her gloves then failed to perform hand hygiene before touching the wheelchair handles and repositioning Resident #13's arms and blankets. The Hand Hygiene policy updated 10/19/23 instructed to perform hand hygiene immediately after glove removal, after contact with blood, body fluids, or contaminated surfaces. On 7/18/23 at 1:32 PM, the Director of Nursing (DON), acknowledged that she expected staff to remove their gloves, and perform hand hygiene after emptying the urine collection bag, emptying urine from a container, or any time after providing resident care. The DON expressed there is some room for improvement. 47673 2. Resident #36's MDS assessment dated [DATE] identified a BIMS score of 11, indicating moderate cognitive impairment. The MDS included a diagnosis of hypotension (low blood pressure). On 7/19/23 at 7:37 AM during a continuous observation of Staff E, Certified Medication Aide, doing a medication pass, Staff E failed to complete hand hygiene at the cart prior to removal of medications from the medication card. Staff E cut the pain relief patches open with scissors, then locked the medication cart, walked to the room, and knocked on the door. Before and after entering Resident #36's room, Staff E failed to complete hand hygiene. Resident #36 requested lukewarm water from the tap to take their medication with. Staff E obtained water from the sink and gave Resident #36 their medication without any hand hygiene. Without hand hygiene, Staff E applied gloves, then applied Resident #36's lidocaine patches. Staff E applied initials and date to both patches. Staff E removed gloves and then did hand hygiene. Staff E handed Resident #36 a medicated inhaler, who inhaled two puffs. Staff E walked out of Resident #36's room returned to the medication cart and then walked down to the dining room. The Hand Hygiene policy updated 10/19/22 provided by the Administrator instructed that staff should always complete hand hygiene before and after work, before performing any invasive procedures, before donning gloves and after removing gloves, after handling contaminated items and equipment, between resident care sites, and whenever your hands become physically soiled. On 7/19/23 at 4:17 PM the DON reported she expected the staff to perform hand hygiene prior to and after medication administration.

Based on observations and staff interviews the facility failed to label food with dates after opening, failed to maintain a clean kitchen, perform hand hygiene, and change gloves after touching dirty items. The facility identified a census of 43 residents. Findings included: 1. An initial kitchen tour conducted on 7/17/23 at 10:54 AM, revealed the following previously open items stored in the refrigerator without an open date: a. Ranch dressing b. French dressing c. Italian dressing d. An unlabeled bottle of Mayonnaise e. Barbeque sauce f. Minced garlic In addition, observed eggs stored directly on top of juice bottles. 2. Observed the following concerns with cleanliness: a. The kitchen floor felt sticky with the appearance of dried food and food debris on it. b. Open shelves covered with dust and found with scattered food debris. c. Bottom of double door fridge found with scattered food debris and dried on food. d. Dishware stored on a portable cart. Cart located within the tape on the floor marking the dirty side of the kitchen. Dishware not covered or inverted. e. Stove top, griddle, and oven revealed brown baked on grease buildup and a variety of food debris. The Food Safety and Sanitation policy dated 2021 identified that the environment health service of the local public health department would routinely inspect the department following their accepted standards and regulations. The Director of food and nutrition services will have a copy of the applicable regulations on file to meet the regulations. The food and nutrition services department will follow regulations as outlined by other official health and organizations with jurisdiction over the facility. The section labeled Food Storage instructed that when a food package is opened the food item should be marked to indicate the opened date. The date is used to determine when to discard the food. The Food Safety - Director of Food and Nutrition Services' Responsibilities policy dated 2021 instructed that the Director of food and nutrition services should assure sanitary conditions will be maintained in the food storage, preparation, and serving areas. On 7/17/23 at 11:31 AM, the Dietary Manager (DM), reported that the staff who worked the last weekend failed to complete their assigned cleaning duties. The DM reported that she expected all areas of the kitchen to be clean and sanitary. The DM reported that she expected staff to complete all assigned cleaning duties. The DM also stated that she expected staff to label food packages and containers with an opened date. 47673 2. On 7/19/23 at 12:21 PM during the continuous observation of the lunch service witnessed Staff G fill the scoops used to serve the mechanical soft diet and the pureed diets only partially full. Witnessed Staff G picked up a peanut butter and jelly sandwich with gloved hands, placed the sandwich on a plate then picked up tongs for pork, placed pork on plate, picked up strainer spoon for sweet potatoes, and then picked up the lids for room trays. Then with the same gloves and without hand hygiene, Staff G picked up bread, picked up a plate, placed the bread on the plate, picked up the room tray lid, applied the lid to the plate, picked up the strawberry cobblers, and put the cobblers on the tray. Staff G used both hands for each task and repeated these tasks through the entire lunch service without changing her gloves or performing hand hygiene. On 7/19/23 at 1:36 PM Staff J, Dietary Manager, stated the facility's expectation is that gloves are changed when hands are soiled or when moving from any contaminated surface and food. On 7/20/23 at 12:34 PM the Dietitian stated new gloves should be applied whenever gloves are dirty. The Dietitian stated she would like no glove use during meal service and that tongs would have been ideal. On 7/22/23 at 10:25 AM Administrator stated the facility's expectation for glove use in the kitchen is clean touches clean and soiled touches soiled. The Administrator stated the facility's expectation is that if any of these are not correct, the staff washes their hands and applies new gloves. The Hand Hygiene procedure document updated 10/19/22 provided by the Administrator directed that staff should always complete hand hygiene before and after work, before donning (applying) gloves and after removing gloves, after handling contaminated items and equipment, and whenever their hands become physically soiled.

Based on clincial record review and staff interviews, the facility failed to ensure that staff who took a resident's blood pressure knew when to notify the nurse of a low result for one of one residents reviewed (Resident #36). Findings include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS included a diagnosis of hypotension (low blood pressure). Resident #36's July 2023 MAR listed an order dated 6/3/23 for Midodrine HCl (medication used to raise blood pressure) oral tablet 5 MG. Give two tablets by mouth three times a day before meals for hypotension. The last pill must be given before 6 PM, hold if blood pressure is 130/85 or above. - 7/19/23 - Staff E, Certified Medication Aide (CMA), documented a blood pressure of 79/49 (average blood pressure for a typical person is 120/80). On 7/19/23 at 9:35 AM Staff E reported that Resident #36 had a blood pressure within range. The blood pressure was less than 130/85 so the blood pressure was good enough to give the medication this morning. She would only notify the nurse if it was a low blood pressure. She did not know at what blood pressure she would notify the nurse, as she did not know the parameters of when to tell them nurse of a low blood pressure. She took their blood pressure earlier that morning with their blood sugar. On 7/19/23 at 9:30 AM Staff F, Licensed Practical Nurse (LPN), denied notification of any excessively low blood pressure that morning shift. Electronic record review of blood pressure expectations revealed blood pressure Systolic abnormal high rate is greater than 139. Abnormally low rate is less than 90. Diastolic abnormal high rate is greater than 89. Abnormal low rate is less than 60. On 7/19/23 at 9:46 AM Staff F stated any blood pressure with a systolic blood pressure less than 80 and diastolic blood pressure less than 60 should be notified to the nurse and would require an assessment. Staff F stated she educated Staff E on parameters for notification of low blood pressures. Staff F stated a blood pressure of 79/49 is a blood pressure that should be told to a nurse. Staff F stated she reassessed Resident #36 that morning shift after educating Staff E on low blood pressures. On 7/19/23 at 9:50 AM the Director of Nursing (DON) explained that the staff should have notified the nurse for blood pressure of 79/49. The DON reported that if a person had a low blood pressure with another symptom then they would automatically notify the nurse. The staff should notify of anything under 100/60. On 7/19/23 at 10:30 AM Staff D, Registered Nurse (RN) / Nurse consultant, reported that they expected the staff to follow standards of practice. Staff D added that the facility did not have a policy related to notification and follow-up for altered vitals.

Based on clinical record review, staff interview, and facility policy review, the facility failed to manage oxygen usage for 1 out of 1 residents reviewed (Resident #13) for oxygen use. Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Resident #13 required total assistance from two persons for toilet use and extensive assistance from two persons for personal hygiene. The MDS included diagnoses of heart failure, chronic obstructive pulmonary disease (COPD, long-term lung disease that affects breathing), and anemia (low iron levels in the blood). Resident #13 received oxygen therapy in the lookback period. The Care Plan Focus revised 8/9/22 indicated that Resident #13 had a potential for or actual respiratory abnormalities related to COPD. The Intervention revised 1/8/23 directed oxygen at 3 liters per nasal cannula (3L/NC) while in bed to keep oxygen saturations above 90%. On 7/17/23 at 1:50 PM witnessed Resident #13's oxygen concentrator set at 3.5 L/NC while she rested in bed. On 7/18/23 at 1:32 PM observed Resident #13's oxygen concentrator set at 3.5 L/NC while she rested in bed. Resident #13's Clinical Physician Orders included an order dated 11/16/22 instructing that while she laid in bed, she could have oxygen at 3 L/NC or mask to keep oxygen saturation above 90%. Resident #13's July 2023 Medication Administration Record listed an order dated 11/16/22 instructing that while she laid in bed, she could have oxygen at 3 L/NC or mask to keep oxygen saturation above 90%. On 7/19/23 at 2:01 PM, Staff S, Licensed Practical Nurse (LPN), verified that Resident #13's oxygen setting should be at 3 L/NC. After Staff S entered Resident #13's room, she reported Resident #13's oxygen concentrator showed she received 3.5 L/NC of oxygen. Staff S reduced the oxygen flow to 3 L/NC. On 7/19/22 at 2:41 PM, the Administrator, reported that she expected residents to receive oxygen as ordered by the provider. The Administrator reported that the facility lacked an oxygen policy.

Based on observations, record review, and interviews the facility failed to properly use a mechanical lift to avoid hazards and prevent accidents for 1 of 1 residents reviewed (Resident #13). Findings include: Resident #13's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Resident #13 required total assistance from two persons for toilet use and extensive assistance from two persons for personal hygiene. The MDS included diagnoses of neurogenic bladder (difficulty with urinating) and renal insufficiency (poor functioning kidneys). The Care Plan Focus revised 8/9/22 indicated that Resident #13 had an activities of daily living (ADL) deficit due to weakness and a history of cerebral (brain) events. The Intervention dated 8/9/22 instructed that Resident #13 required the assistance of two person for transfers with the full body mechanical lift. On 7/18/23 at 12:52 PM observed Staff O, Certified Nurse Aide (CNA), and Staff Q, CNA, transfer Resident #13 with a full-body mechanical lift from her wheelchair to the bed. Staff O and Staff Q failed to lock the brakes of Resident #13's wheelchair before lifting her with the full-body mechanical left. The Competency for Hoyer Lift updated 5/11/21 instructed staff to place the chair that the resident will be transferred into in position and make sure the brakes are secured. On 7/18/23 at 1:32 PM, the Administrator and the Director of Nursing reported that they both would have to refer to the lift guide for instructions. The Administrator reported the staff are trained on all mechanical lifts and mechanical stands. They expect the staff to follow the education.

Based on record review, resident, and staff interviews the facility failed to assess a resident's blood sugar after a drop in level with a low rise rate for over an hour and half (Resident #92). Following this assessment, no staff assessed Resident #92 for over three hours. Resident #92 developed a change in condition that required an admission to the hospital due to her hypoglycemic (low blood sugar) status. Findings Included: Resident #92's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included a diagnosis of diabetes mellitus. The Care Plan dated 6/19/23 identified Resident #92 as a diabetic with a goal not to have any ill effects from hypoglycemia or hyperglycemia. On 7/17/23 at 2:05 PM Resident #92 reported that she went to the hospital a few weeks ago for low blood sugars. The Health Status Note dated 7/5/23 at 2:59 AM indicated that 1:00 AM the nurse observed Resident #92 with her C-Pap (machine to help treat sleep apnea while sleeping) and her leg hanging over the bed. She had slurred speech and did not make sense. Resident #92 had a blood sugar (BS) of 32. The nurse contacted the provider who gave an order for a glucagon injection. The nurse gave Resident #92 the glucagon injection in her right upper arm. The nurse rechecked Resident #92's blood sugar as followed: a. 1:15 AM - BS of 44 mg/dL. b. 1:30 AM - BS of 55 mg/dL. c. 3:00 AM - BS of 74 mg/dL. - Resident #92 drank 200 milliliters (ML) of juice, had a bite of graham cracker, and three tablespoons of honey. d. 5:30 AM - BS of 60 mg/dL. - Resident #92 vomited after receiving honey, the nurse gave the resident as needed Zofran (anti-nausea medicine). The Health Status Note dated 7/5/23 at 8:55 AM labeled Late Entry reflected that the charge nurse requested an order to send Resident #92 to the emergency room (ER) from the provider. The provider declined to give an order to send her to the ER, but gave an order to administer glucagon. Resident #92's nurse called the provider's office and spoke with the provider's nurse who directed to give the glucagon at that time and if they did not see an improvement in 30 minutes in her alertness, they could Resident #92 to the ER. At 9:30 AM the provider's nurse called back for an update on Resident #92. The nurse reported her blood sugar as 94 mg/dL, the nurse received an order to send Resident #92 to the ER. The Health Status Note dated 7/5/23 at 10:07 AM listed that Resident #92 had a blood sugar of 40, she appeared alert but very disoriented. She did not know where she was. Her face looked pale and dusty (gray type coloring). Resident #92 reported to the nurse that she did not feel right. The nurse called the provider who said to give glucagon and if not better within a half hour, they could send to the ER. A half hour later, the nurse checked Resident #92 blood sugar and got a result of 94. Resident #92 reported that she did not feel any better, so the facility sent her to the ER via ambulance. On 7/20/23 at 10:02 AM, Staff R, Licensed Practical Nurse (LPN), reported that the facility did not have a policy or guidelines for the treatment of hypoglycemia. When asked how often blood sugars should be checked, what diet interventions should be used, and when should the provider be notified of hypoglycemia, Staff R responded, that she used her own judgment. On 7/20/23 at 10:02 AM, Staff R, Licensed Practical Nurse (LPN), reported that the facility lacked a policy or guidelines for the treatment of hypoglycemia. When asked how often blood sugars should be checked, what diet interventions should be used, and when should the provider be notified of hypoglycemia, Staff R responded, that she used her own judgment. On 7/20/23 at 11:11 AM, the Director of Nursing (DON), reported the facility lacked a hypoglycemic protocol or policy. The DON reported that she would have done more after 5:30 AM. The DON could not determine, by the nurse's documentation, if the resident was properly assessed or treated. On 7/20/23 at 1:59 PM, the DON reported that if after the first dose of glucagon (medication injected to raise a person blood sugar) Resident #92's blood sugar failed to rise, and stayed at a stable level, she expected the staff to notify the doctor to obtain parameters and request an order to send them to ER if needed.

Based on record review, staff interviews, and policy review the facility failed to complete a discharge summary after a resident discharged on 1 of 1 resident reviewed (Resident #141). Finding include: Resident #141's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) of 14 indicating no cognitive impairment. Resident #141's Electronic Health Record (EHR) and paper chart lacked a discharge summary and personal belongings list for their discharge on 5/2/23. On 7/20/23 at 1:54 PM Staff D, Registered Nurse (RN) / Nurse Consultant, stated a discharge summary was not completed for Resident #141. On 7/20/23 at 2:10 PM Staff D, stated the facility had no policy for completion of a discharge summary, as the facility followed the state regulations for completion of a discharge summary upon a resident's discharge.

Based on record review, resident interviews, resident family interview, and staff interviews the facility failed to provide an opportunity for a resident and/or a Resident's Representative to participate in a Care Conference to discuss the residents care 1 of 12 residents reviewed (Resident #33). Finding include: Resident #33's Minimum Data Set (MDS) assessment dated [DATE] listed an admitted [DATE]. The MDS identified a Brief Interview of Mental Status (BIMS) of 9 indicating moderate cognitive impairment. On 7/17/23 at 10:37 AM Resident #33 stated that she did not remember ever attending a Care Conference. On 7/20/23 at 11:07 AM Resident #33's Representative (RR #33) stated the previous Social Worker used to notify her but she never got notified now. RR #33 only got invited to attend two of the reviews since Resident #33 lived at the facility. RR #33 explained that the facility did not send her any letters related Care Conferences. RR #33's explained the facility only notified her the day of or the day before the Care Conference for the two times they invited her. RR #33 added that she could attend the Care Conference with that little of a notice. The Care Conference Review reflected the following: a. 11/3/22 listed that Resident #33 declined to come and that RR #33 could not attend due to [scribbled out information]. b. The Care Plan Summary Review dated 3/23/23 indicated that Resident #33 declined to participate but lacked documentation of RR #33's response. c. 3/23/23 indicated that the facility attempted to call RR #33 on 3/20/23 but she had a full voicemail box, no documentation of additional attempts to contact her. d. 6/15/23 lacked documentation of an invitation sent to Resident #33 or RR #33. On 7/20/23 at 9:05 AM Staff C, MDS Coordinator / Registered Nurse (RN), stated she attended and entered the note for the Care Conference. On 7/20/23 at 9:18 AM Staff B, Social Worker, stated she had a checklist for the Resident's Representative notification. She sent all letters to the Resident's Representative one month before the Care Conference. Staff B explained that she invited Resident #33 to her Care Conferences but she always refused. Staff B added that she did not document that she sent letters or that she notified the family representatives anywhere. On 7/18/23 at 2:10 PM Staff D, Registered Nurse (RN) / Nurse Consultant, stated the facility did not have a policy for a Comprehensive Care Plan review. Staff D stated the facility followed the state regulations for Comprehensive Care Plan Reviews.

Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for a Level II PASRR evaluation and determination for 1 out of 1 residents (Resident #22) reviewed for PASRR requirements. Finding include: 1. Resident #22's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) of 1, indicating no cognitive impairment. The Mood section of the MDS listed a score of 9, indicating mild depression. Resident #22 exhibited a rejection of care for one to three days in the lookback period. The MDS included diagnoses of paranoid schizophrenia and bipolar disorder. Resident #22 received an antipsychotic and an antidepressant for five out of the seven day lookback period. The Notice of PASRR Level I Screen Outcome Explanation, dated 3/18/21 reflected a notice of no PASRR Level II Required. The PASRR Level I Identification Screen listed nursing facility placement as appropriate for Resident #22. The PASRR Level I screen remains valid for her stay at the nursing facility and should be transferred with her if she relocated. No further Level I screening is required unless you are known to have or are suspected of having a serious mental illness, an intellectual, or developmental disability and exhibit a significant change in treatment needs. The PASRR listed no mental health diagnoses known or suspected. The Level I screen indicated that a PASRR disability is not present because of the following reason: Resident #22 had no evidence of a PASRR condition of an intellectual or developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings, a new screen must be submitted. Resident #22's Medical Diagnosis list included diagnoses of paranoid schizophrenia and bipolar disorder diagnosed on [DATE]. Resident #22's July 2023 Medication Administration Records (MAR) included an order for Aripiprazole (Antipsychotic medication) tablet 15 milligrams (MG). Give 1 tablet by mouth one time a day related to paranoid schizophrenia. Resident #22's chart lacked a follow-up and/or a resubmission of a PASRR with the diagnosis of paranoid schizophrenia and bipolar disorder. On 7/18/23 at 1:58 PM Staff C, MDS Coordinator, reported that if a resident had a change in diagnosis or medication, the facility would fill out a significant change assessment and submit it to PASRR. Staff C stated someone should have submitted a significant change PASRR for Resident #22. Staff C stated PASRR assessments are completed on everyone that enters the facility. On 7/18/23 at 2:10 PM Staff D, Registered Nurse (RN) / Nurse Consultant, stated the facility had no policy related to PASRRs. Staff D added that the facility followed the state regulations for PASRR submissions.

Based on observations, resident interviews, and staff interviews the facility failed to provide residents with ready access to their personal funds managed by the facility for 5 of 43 residents reviewed (Resident #5, #7, #14, #16, and #18). The facility set a limit of $20 for all residents for their resident trust account for less than 24-hour notice. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #7 documented a Brief Interview of Mental Status (BIMS) of 15, indicating no cognitive impairment. On 7/17/23 at 12:06 PM Resident #7 stated residents at the facility are only allowed to get $20.00 cash a day from their personal funds. Resident #7 stated she wished she could get more than $20.00 at a time. 2. The MDS dated [DATE] for Resident #14 documented a BIMS of 14, indicating no cognitive impairment. On 7/17/23 at 1:33 PM Resident #14 stated there is not staff present on the weekend to give money out from personal funds. Resident #14 stated she cannot get money on the weekend. 3. The MDS dated [DATE] for Resident #16 documented a BIMS of 13, indicating no cognitive impairment. On 7/17/23 at 1:33 PM Resident #16 stated there is not a staff member at the facility on the weekend to give money out from their personal funds. Resident #14 stated she cannot get money on the weekend. Observation of a document posted on the business office door dated 10/5/22 revealed, Residents trust the business office only keeps a small amount of money in the office. The Business Office will only be able to give $20.00 at one time. Any resident requesting more than $20.00 will need to give a 24 hour notice/request so the business office can go to process the request through the bank. On 7/18/23 at 2:53 PM Staff A, Business Office Manager, stated she is only allowed $220.00 a month in the cash box at the facility. Staff A stated that was the amount given to her as a total when she started at the facility. Staff A stated all the residents had to do was ask for money 24 hours in advance to get more than $20.00. Staff A stated Residents #5, #7, #14, #16, and #18 had trust funds with the facility. Staff A stated the facility had a lock box on the medication cart with $20.00. Staff A added that if the nurses ran out of money in medication cart on the weekend they could call her Staff A, but she lived one and a half hours away. On 7/18/23 at 3:29 PM the Administer stated Staff B, the Social Worker, lives in the town and has access to the resident funds and can come into the facility if needed to give the residents money from their trust fund. The Administrator stated expectation is residents have access to their money when they need it. On 7/19/23 at 4:41 PM Staff B stated she never got personal funds out for any resident and she never gave cash to the residents. She had a card with all the residents' funds on it. Staff B said she never bought anything on the weekend. She must talk to Staff A before she can buy anything for the residents at the facility and denied ever receiving a call on the weekend to get a resident money. She added that she did not have access to the money at the facility. She must fill out a form to get permission for her to get cash out and denied that she ever got cash out of the account, but added that she did have the pin number. No one ever asked for cash but she did not work on the weekends.

Based on observation, clinical record review, resident, and staff interviews, the facility failed to respect each resident's dignity by speaking a foreign language in the presence of residents for 2 out of 13 residents reviewed (Residents #3 and Resident #25). Findings included: 1. Resident #25's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS listed that Resident #25 could understand others. On 7/18/23 at 10:01 PM, Resident #25 reported that some staff often spoke Spanish in her presence and during cares. When asked how that made her feel, Resident #25 replied that it made her think they are saying something they don't like about her. She did not know if they thought she could understand them, or if they are trying to tell her to do something. Resident #25 reported that she does not understand Spanish. 2. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented the Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS reflected that Resident #3 could understand others. On 7/19/23 at 9:35 AM, Resident #3 reported that the staff spoke Spanish in her presence regularly. Resident #3 stated, it made her uncomfortable because she thought that they did not want her to know what they are saying, so she felt they must be talking about her. Resident #3 reported more than a couple of Certified Nurse Aides (CNAs) spoke Spanish in her presence and during cares. Resident #3 explained that she did tell her concerns to the Administration. The Grievance Form dated 5/16/23 indicated that Resident #23 reported that Staff N, CNA, and Staff O, CNA, talked a lot and talked in Spanish that they could not understand. Resident #3 explained that they did not appreciate anyone talking in a foreign language while getting them up. They were joking around and laughing for quite a while. The Employee Corrective Action Form dated 5/16/23 identified Staff N, CNA, received an infraction due to a resident's complaint for speaking a language the resident did not understand while providing cares. The form instructed the facility expectations moving forward that staff would speak the preferred language of the resident while in the presence of residents as the facility is their home. On 7/19/23 at 10:45 AM, Staff B, Activities Director, reported that she received resident complaints, during a Resident Council meeting, that staff spoke Spanish in the presence of residents. Staff B reported the following CNAs to the Administrator: Staff K, Staff L, Staff M, Staff P. On 7/19/23 at 10:54 AM, Staff I, CNA, reported in the past week she witnessed Staff N and Staff O speak Spanish in the presence of residents. On 7/19/23 at 1:11 PM the Administrator reported providing past corrective action to staff that spoke Spanish in the presence of residents. The Administrator stated that the staff shouldn't speak Spanish in the resident care areas, including the nurses' station, due to the facility being the residents' home. The Administrator explained that the only time staff can use Spanish is with primarily Spanish speaking residents. The facility had one resident who spoke primarily Spanish. On 7/19/23 at 5:15 PM, Staff O, CNA, stated she received discipline for speaking Spanish in the presence of residents. Staff O reported that she did not understand why speaking Spanish is not acceptable. Staff O reported that at times staff want to talk about things that are personal and should be able to speak Spanish. The Resident Rights policy dated November 2016 identified that residents have the right to be fully informed in language that he or she can understand about his or her total health status including but not limited to, his or her medical condition.

Based on clinical record reviews and staff interviews, the facility failed to thoroughly assess a resident for fall risk and/or implement interventions to prevent falls for 2 of 3 residents reviewed (Resident #93 and #15). 1. Resident #93 admitted to the facility from another facility and within the first 48 hours she fell sustaining a head injury. Staff denied know that Resident #93 had a risk for falls, and the fall risk assessment did not get completed. The Care Plan from the previous facility indicated Resident #93 as a risk for falls with an intervention to assure appropriate footwear, shoes, or gripper socks. At the time of the fall, Resident #93 did not utilize appropriate footwear. 2. Resident #15 identified interventions indicated that she needed two staff with a sit to stand lift for transfers. At the time of her fall, only one staff member assisted her with the use of the sit to stand lift. The facility reported a census of 45 residents. Findings include: 1. Resident #93's Minimum Data Set (MDS) assessment dated [DATE] (completed at the previous facility and in this facility's electronic health record, EHR) identified a Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impairment. Resident #93 required extensive assistance with bed mobility, transfers, toilet use, dressing and personal hygiene. The MDS indicated that Resident #93 did not walk. The MDS included a diagnosis of non-Alzheimer's dementia. The Care Plan sent from the facility Resident #93 transferred from identified that she needed assistance with transfers, bed mobility, and ambulation. The interventions included that Resident #93 often did not wait for assistance and transferred on her own. The Care Plan identified Resident #93 needed assistance with using the toilet. The interventions included that Resident #93 did not think she needed assistance from the staff despite her history of falling. Resident #93 received education on the risks of not waiting for staff assistance. The Care Plan identified Resident #93's risk for falls with interventions that she should wear gripper socks when not wearing shoes. The Progress Notes dated [DATE] at 12:42 p.m. documented that Resident #93 admitted from another nursing facility. The resident appeared alert, oriented to person, disoriented to place, disoriented to time, and oriented to situation. She responded to questions appropriately. Resident #93 used a wheelchair for mobility. The Progress Note dated [DATE] at 2:44 p.m. indicated that the system identified a possible drug interaction with the use of [MEDICATION(S)] (anticoagulant) Tablet 5 mg with [MEDICATION(S)] Patch 1.3% (pain patch) due to the increased risk of bleeding. The Admission Fall Risk assessment dated [DATE] lacked documentation. The Progress Notes dated [DATE] at 10:44 a.m. documented that the nurse responded to a call to Resident #93's room. Upon arriving, she observed Resident #93 laying on the floor on her left side facing the window. Resident #93 had a large amount of blood underneath her face. When assessed the nurse noted a large laceration to her left eye and to the top of her forehead in the center. Neither injury could be approximated due to size. The staff applied pressure and called 911 to assist them. They placed a pillow under Resident #93's head but did not move her due to complaints of hip pain. Paramedics arrived and Resident #93 went to the hospital. The facility notified the family who reported that they would meet her there. The Progress Note dated [DATE] At 3:00 p.m. recorded that a nurse from the hospital called to say that Resident #93 would be admitted . A History and Physical dated [DATE] documented Resident #93's diagnoses included bilateral small subdural hematomas secondary to a mechanical fall. The Neurosurgeon evaluated the patient, they would observe overnight and recheck a computed tomography (CT) scan the next morning. The emergency room (ER) provider indicated that he would defer further management to the neurosurgeon. Resident #93 also had facial lacerations secondary to the fall. The ER provider repaired the mid forehead laceration. The ER provider contacted plastic surgery to evaluate the left lower eyelid. The ER provider indicated that he would defer further management to the plastic surgeon's judgment. A hospital Progress Note dated [DATE] at 8:09 a.m. documented that Resident #93 admitted to the hospital following a fall at the nursing home. She used an anticoagulant, [MEDICATION(S)]. She had small bilateral subdural hematomas. The nursing staff reported that she had a general physical decline with decreased appetite, weight loss, and memory problems over the last 3 years. The emergency department reported Resident #93 was awake, oriented, and speaking the day before, but she noted to be much less active today. She slept in bed with her mouth open. She initially awakened and responded to verbal stimulus with mostly incomprehensible speech. She did not follow commands. She did spontaneously move all 4 extremities. She had significant bruising with abrasions on the left side of her head and face which were covered with dressings. A CT scan without contrast of the head today showed significant increase in the subdural hematoma on the right with mild mass-effect, including slight midline shift (an important indicator of increased intracranial pressure), and effacement of the ventricle (an indicator of a lack of blood flow). The left subdural hematoma showed no significant change. Given Resident #93's general decline over the last few years and progression of the subdural hematoma, the physician believed the resident had a high chance of continuing to have neurologic decline from the subdural hematoma. I do not recommend craniotomy for evacuation of the hematoma, as the patient's chance of survival without operation would be quite poor. The Progress Note dated [DATE] at 12:31 p.m. indicated that Resident #93 returned to the facility unresponsive. The Progress Note dated [DATE] at 1:14 p.m. documented the involvement of hospice regarding the care of Resident #93. The Progress Note dated [DATE] at 6:15 p.m. indicated that family called the nurse to Resident #93's room. Upon assessment of Resident #93, the nurse determined that she died at 6:55 p.m. On [DATE] at 11:35 a.m. Staff D, Certified Nursing Assistant (CNA), explained that she worked the day Resident #93 fell . Resident #93 went out to breakfast, and laid down after. She did not lay her down and didn't know who did. She added at the time she learned of Resident #93's fall, she sat at the nurses' station. Staff D saw Resident #93 on the floor, but she mostly looked at her head where the blood came from. She said Resident #93 did not have on shoes, she only wore socks, and she didn't think they were gripper socks. On [DATE] at 11:43 a.m. Staff E, CNA, stated that she worked the day Resident #93 fell . She reported that she did not lay Resident #93 down after breakfast. She didn't know a lot about her, but Resident #93's family member told her that she would transfer herself and wasn't safe in doing so. On [DATE] at 11:47 a.m. Staff F, CNA, reported that she did baths. She did not see Resident #93 on the day that she fell . Staff F explained that she did not know Resident #93's risk for falls. On [DATE] at 11:50 a.m. Staff G, CNA, worked the day Resident #93 fell . She indicated that she did not know of Resident #93 risk for falls. She did not lay Resident #93 down after breakfast. She said that Resident #93 fell at the foot of her bed, like she got up, and walked a short distance. She did not have shoes on, and she did not think the socks she wore were gripper socks. She thought they didn't know Resident #93 had a risk of falls because they rushed to bring so many new residents at once. On [DATE] at 11:57 a.m. Staff H, Certified Medication Aide (CMA), stated she passed meds on the opposite hall and that she did not know that Resident #93 had a risk for falls. On [DATE] at 12:03 p.m. Staff I, CNA, stated that she thought she got Resident #93 up for breakfast that day, but didn't think that she laid her down after breakfast. She said if they laid residents down they would take their shoes off. Staff I reported that she did not know the resident was a fall risk. On [DATE] at 12:10 p.m. Staff J, Licensed Practical Nurse (LPN), reported that she was the only charge nurse on duty at the time and she didn't have support. She said prior to the fall she didn't know about Resident #93's risk for falls. She said the information was there but not really available. She said that after Resident #93 fell , she found information of her risk for falls and interventions to prevent her falls. She said Resident #93 had plain socks on, not gripper socks, and no shoes. She said they admitted too many residents at once, resulting in them not knowing important information. 2. Resident #15's MDS dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS documented Resident #15 required the assistance of two staff for bed mobility, transfers, toilet use, and personal care. The MDS documented a functional limitation in range of motion on one side of the upper and lower extremities. Resident #15 normally used a wheelchair for mobility. The MDS included diagnoses of a nontraumatic intracerebral intracranial hemorrhage (historical brain bleed not due to external force), [CONDITION(S)] (widespread muscle pain), [CONDITION(S)] (brain disease and damage), and disorders of the peripheral nervous system. The Care Plan Focus dated [DATE], indicated that he had an activities of daily living (ADL) deficit due to a history of [CONDITION(S)] (stroke) with left sided weakness. The Focus included a section related to restorative indicating that Resident #15 would maintain the ability to transfer with the standing mechanical lift (EZ Stand). The intervention revised [DATE] directed that Resident #15 required the assistance of two staff with transfers and toilet use with an EZ Stand. The HAWK-Fall Risk Assessment - V 2 dated [DATE] documented Resident #15 had a score of 9, indicating moderate risk for falls. The Fall Progress Note dated [DATE] at 12:44 PM documented that a Certified Nurse Aide (CNA) called the nurse reporting that Resident #15 and the CNA fell in her room while attempting to transfer her. Upon entering the room the nurse notes Resident #15 laying on the floor, on the left side of the bed. Resident #15 laid on her left side with her left arm under her body with her legs straight out. Resident #15 requested to get up from the floor. The CNA reported that Resident #15 didn't hit her head. Resident #15 denied hitting her head when asked. The staff assisted Resident #15 off the floor with an assist of three and the full body mechanical lift. Resident #15 went to the hospital by ambulance per her family's request. The Progress Note dated [DATE] at 5:18 PM recorded that Resident #15 returned to the facility with no new orders. On [DATE] at 10:15 AM, Resident #15's family member, explained that she fell recently while in the EZ Stand with only one staff member assisting her. The family wanted her examined in the Emergency Department for any injuries. Resident #15's explained that they were informed at the time by the DON that the facility would investigate the fall, though the family did not get informed of the outcome of their investigation. The Incident Report dated [DATE] at 9:29 AM, identified as #582 Witnessed Fall documented one staff member present for the fall during Resident #15's transfer. The [Facility's Name] Competency for the EZ Stand policy, updated [DATE], directed that two caregivers be present for all EZ Stand transfers and to assist each other in the proper placement of both upper and lower straps. The directions instructed the staff to designate one as the lead and the other as the helper. The lead will operate the equipment and instruct the resident while the helper assists in the safe transfer and movement of the equipment. On [DATE] at 4:51 PM the Nurse Consultant, acknowledged that the CNA transferred Resident #15 with an EZ Stand with only one staff present. The Nurse Consultant explained that Resident #15 slid out of the harness used to secure her to the stand, resulting in her falling to the floor. The Nurse Consultant reported the facility re-educated the staff on the proper use of an EZ Stand. She added that she expected the staff to follow the Care Plan and the facility provided competency training on the EZ Stand.

Based on record review, resident and staff interviews, the facility failed to provide restorative exercises as planned for 4 of 13 residents sampled (Resident #15, Resident #20, Resident #31, and Resident #38). The facility reported a census of 35 residents. Findings included: 1. Resident #31's 7/8/19 Minimum Data Set documented to the resident with severely impaired cognitive function. The resident required extensive assistance of 2 staff for bed mobility and transfers. The resident did not ambulate. The resident's care plan included a problem which stated the resident had a deficit in activities of daily living due to a [DIAGNOSES REDACTED]. The goal stated a plan for the resident to return to previous level. A 1/15/19 Therapy to Restorative Nursing Communication directed staff to place 1.5 pound weights and complete balloon tap, stand/walk (3 attempts with a front wheeled walker and assistance of 2 staff). No frequency identified. From 1/19-1/30/19 the record lacked documentation indicating staff assisted the resident with any exercises. Staff documented assistance provided with active range of motion to upper and lower extremities on 2/19/19. The record lacked documentation indicating staff assisted the resident with any exercises from 3/1/19 to 3/30/19. Staff documented assistance provided with active range of motion to the upper and lower extremities on 4/4/19, 5/1/19, 6/11/19, 6/17/19, and twice on 6/25/19. The record lacked documentation indicating staff assisted the resident with exercises in (MONTH) 2019. Staff documented assistance provided with the range of motion exercises on 8/7/19. The record lacked any documentation indicating staff offered or the resident declined participation any other time from 1/15/19 to 8/21/19. During interview on 8/21/19 at 3:16 PM the DON stated the restorative plan dated 1/15/19 was not added to the electronic documentation system until (MONTH) of 2019. She confirmed the restorative program not completed at all in (MONTH) 2019, staff had assisted the resident with the program only once in (MONTH) 2019, none in (MONTH) 2019, staff had assisted with the program once in (MONTH) and once in (MONTH) 2019, four times in (MONTH) 2019, not done at all in (MONTH) 2019 and once in (MONTH) of 2019. On 08/21/19 03:39 PM the current therapy contract physical therapist (PT) reviewed the Therapy to Restorative Nursing Communication for the resident dated 1/15/19 which did not specify frequency of the treatment. She stated daily treatment would be ideal, but 3 times weekly would be the minimum to have any effect. She stated she evaluated the resident and stated the resident's legs were very stiff. On 8/15/19 facility staff sent a facsimile to the resident's physician requesting a physical therapy and occupational therapy evaluation treatment due to a functional decline. During interview on 08/21/19 at 2:52 PM the Director of Nursing identified the resident with a decline in ability to stand and bear weight for transfers. An 8/19/19 PT Plan of Care identified the reason for referral as a decline in functional activities resulting in decreased strength , transfer, stand balance and ambulation. 2. Resident #15's 6/5/19 MDS documented the resident with severely impaired cognitive function. A 6/18/18 Therapy to Restorative Nursing Communication form directed staff to assist the resident with exercises including Motomed (exercise bicycle) for 15 minutes or walk outside around the facility or standing and tap balloon back and forth as long as tolerated 3-5 times weekly. From 6/1/19 to 8/21/19 staff documented the resident declined participation once in (MONTH) and once in (MONTH) 2019. Staff assisted the resident with exercises twice in (MONTH) 2019. The record lacked any documentation indicating staff offered to assist or the resident declined participation any other time during June, (MONTH) or (MONTH) 2019. 3. Resident #20's 6/13/19 MDS documented the resident with severely impaired cognitive function and the resident required extensive assistance of 2 staff for transfers and did not ambulate. A 5/2/18 Therapy to Restorative Nursing Communication form directed staff to assist the resident with exercises including Motor Med (exercise bicycle) 15 minutes 3-5 times weekly. The document noted the resident may have bad days with increased pain, shortness of breath, high anxiety when the resident occasionally refused exercises. The document stated on those days don't do restorative. The resident's care plan directed staff to assist the resident with a Restorative program 3-5 times a week with a goal to return or maintain the resident's highest practicable physical, mental and psychological functional level and well being. From (MONTH) 1, 2019 to (MONTH) 21/2019 staff documented they assisted the resident with the program one time in June, two times in (MONTH) and one time in August. The record lacked any documentation indicating staff offered the resident exercises or that the resident declined assistance with the exercises. 4. Resident #38's 7/30/19 MDS documented the resident with intact cognitive function. The resident required extensive assistance of staff for transfers and ambulation. The resident's care plan included a plan for Restorative program 3-7 times weekly with a goal to return or maintain my highest practicable physical, mental and psychological functional level and well being. A 1/25/18 Therapy to Restorative Nursing Communication directed staff to assist the resident with bilateral lower extremity exercises with a 4 pound weight and blue theraband or Motomed for 15 minutes and a walking program for 15 minutes daily, bilateral upper exercises with a 4 pound weight. The communication form directed staff to offer assistance with the exercises 6 times weekly. On 8/21/19 facility staff provided documentation they assisted the resident with ambulation program for 15 minutes on 6/13/19 and for 10 minutes on 6/26/19. Staff assisted the resident with active range of motion exercises to the upper and lower extremities for 15 minutes on 6/26/19. The record lacked any documentation indicating staff offered or the resident declined participation any other time from 6/1/19 to 8/21/19. During interview on 8/22/19 at 7:29 AM when asked if staff assisted him with exercises, the resident stated, not very often. When told documentation showed no exercises completed since (MONTH) he confirmed that was probably correct.

Based on clinical record review and staff interviews, the facility failed to ensure Resident #1 received an appropriate food texture. Resident #1 had a history of [REDACTED]. Resident #1 received the peanut butter sandwich on [DATE], choked and went into [MEDICAL CONDITION], which resulted in an immediate jeopardy to resident health and safety. The sample consisted of four total residents. The facility identified a census of 34 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] documented [DIAGNOSES REDACTED]. The MDS also documented a Brief Interview of Mental Status (BIMS) score of 7 which indicated moderate cognitive impairment. Resident #1 required extensive assistance with transfer, ambulation, dressing and toilet use and oversight, encouragement, cueing and set-up for eating. The assessment documented he experienced coughing or choking during meals or when swallowing medications and received a mechanically altered diet. The care plan problem revised [DATE] identified the resident with a nutritional problem or potential nutritional problem related to a history of choking. The care plan instructed staff that Resident #1 could not have peanut butter sandwiches due to history of choking on one on [DATE]. The Visual/Bedside Kardex Report, which is accessible to certified nursing assistants (CNA's), also contained the directive to not give the resident peanut butter sandwiches due to history of choking under the Safety and Eating/Nutrition sections. A Progress Notes entry dated [DATE] at 11:53 PM documented the resident was given a peanut butter sandwich while in bed with the head of the bed up. The CNA across the hall heard him choking, transferred him to the wheelchair and performed the [MEDICATION NAME] maneuver which resulted in a piece of sandwich being cleared from his airway. A Progress Notes entry dated [DATE] at 9:54 PM documented the resident appeared to be choking at 7:15 PM. Staff assisted the resident and he coughed up a piece of chicken, measuring approximately 1 x 1 (inch). Staff requested an order for [REDACTED]. The SLP (Speech/Language Pathologist) Evaluation & Plan of Treatment dated [DATE] documented a Clinical Bedside Assessment of Swallowing: Neuromuscular/Anatomic Disorders which assessed the resident to be within functional limits for oral prep phase and oral phase and mild impairment in the pharyngeal phase and no signs or symptoms of [MEDICAL CONDITION] dysphagia present. The Objective Tests/Measured & Additional Analysis of SLP assessment documented the resident exhibited reduced attention to task and inattention to bolus ( the rounded mass of chewed food right before swallowing). The SLP discharged the resident from care on [DATE] and directed resident continue on a mechanical soft diet with regular liquids as previously ordered with occasional supervision and to cue the resident to complete his meals. A Progress Notes entry dated [DATE] at 9:34 PM completed by Staff A, licensed practical nurse (LPN) documented she was at the nursing desk at 7:30 PM at which time Resident #1 was propelling himself in his wheelchair and stating I'm choking, I'm choking. Staff A yelled for help and performed the [MEDICATION NAME] maneuver without success. Staff C, LPN responded and also performed the [MEDICATION NAME] without success. Staff called 911 and transferred the resident to the floor to start CPR (cardiopulmonary resuscitation). The fire department responded, took over CPR performance as Resident #1 remained non-responsive and then transferred him to the hospital. The hospital History and Physical dated [DATE] documented the resident brought to the emergency room because it was reported the resident was given a peanut butter sandwich, which he was not supposed to have, and it appeared he choked and aspirated. EMS services reported the resident had no heart rhythm enroute to the hospital and advanced cardiac life support (ACLS) protocol was initiated and the patient regained spontaneous circulation. Resident #1 admitted to the intensive care unit (ICU) due to his [MEDICAL CONDITION]. A computerized axial tomography (CT) report dated [DATE] documented the following: 1. Complete collapse to the left lung with significant right-to-left shift of the mediastinal structures. Suspect food impacted within the proximal left mainstem bronchus based on provided clinical history. 2. Malpositioned [MEDICATION NAME] tube terminating within the upper esophagus 3. Displaced fractures of the right 3rd through 6th and left 3rd through 7th ribs. 4. Scattered ground-glass and dense consolidation throughout the right lung, aspiration pneumonitis versus possible developing infection. A [MEDICATION NAME] was performed and pieces of sandwich were removed from the resident's bronchus. The resident expired in the hospital on [DATE]. During interview on [DATE] at 3:29 PM Staff A stated she is usually assigned to the hall where the resident resided and was aware he could not have peanut butter sandwiches because it was on his care plan as he had experienced choking spells on them in the past. Resident #1's wife had told her in the past she did not think he should have peanut butter. After supper on [DATE] Resident #1 and two other residents sat in the lounge next to the nursing desk watching TV . Staff B, CNA, passed snacks to all residents and she knew she was in the lounge area. Staff B left the area and started down the 200 hallway when Resident #1 wheeled himself around the fireplace in the lounge and said I'm choking, I'm choking. She said the resident's lips were blue in color and she yelled for help. The resident went nonresponsive. She attempted the [MEDICATION NAME] maneuver without success. Staff C responded to her call for help, called 911 also attempted the [MEDICATION NAME] maneuver without success. Staff D, CNA, also attempted the [MEDICATION NAME] maneuver without success so he and Staff E, CNA, lifted Resident #1 from the wheelchair to the floor and began chest compressions and she used the Ambu bag to support respirations. The emergency management system (EMS) personnel arrived and cleared the resident's airway when they intubated him and took over CPR. Staff B, CNA, also responded to her call for help and told her she had given the resident ,[DATE] peanut butter and jelly sandwich. Staff A stated the resident had a tendency to put too much food in his mouth and sometimes staff had to remind him not to take big bites. During interview on [DATE] at 2:20 PM Staff B stated she passed snacks to the residents after supper on [DATE]. The snack cart contained a bowl of Jello for Resident #1. She offered it to him two different times and encouraged him to eat it, but he wanted a peanut butter and jelly sandwich. There are peanut butter and jelly sandwiches on the snack cart and she gave him ½ of one. She sat in the lounge area and assisted another resident to eat a snack and Resident #1 was eating his sandwich just fine. After the other residents in the lounge were done with their snacks, she left the area to go down a hallway. She had just gone around the nursing desk and she heard the nurse yell for help and she responded. Staff tried to do the [MEDICATION NAME] maneuver but it did not work. She told the nurse she gave him a peanut butter and jelly sandwich. Staff B stated she had given the resident peanut butter sandwiches two times before and he never had any problems with them. She was not sure, but she thought she did not know the resident was not to have them. During interview on [DATE] at 3:07 PM Staff C stated she was not aware the resident could not have peanut butter sandwiches and the resident's recent SLP evaluation did not address if he could or could not have peanut butter. During interview on [DATE] at 11:45 AM, Staff F, CNA, stated she had not been aware of the fact the resident could not have peanut butter sandwiches. She stated the resident had never asked her for one but if he had she would check with the charge nurse first to get approval. During interview on [DATE] at 1:36 PM the Director of Nursing (DON) stated Staff B routinely cared for the resident and all CNA's have access to the Point of Care (Kardex) plan on the tablets accessible to staff at any time. She stated the resident's care plan stated that he could not have a peanut butter sandwich due to his history of choking. She expects CNA's to know the information contained on the point of care plan for each resident but the facility has no policy that directs staff to routinely review the resident care pan directives because any changes to them are addressed in the daily huddle meetings. The facility abated the immediate jeopardy situation on [DATE] through the following actions: a. Staff education on all resident diet orders, allergies and food restrictions. b. Staff response when residents request food items they are restricted from eating. c. Nursing education for residents who wish to receive restricted foods. d. Posting residents' current diet orders, restrictions and allergies on the snack cart.

Based on clinical record review, staff and physician interviews and facility policy review, facility staff failed to implement CPR (cardiopulmonary resuscitation) for one resident who desired CPR (Resident #4) of 24 residents sampled, which resulted in an immediate jeopardy to residents health and safety. The facility identified a census of 37 current residents. Findings include: 1. According to the MDS (minimum data set) dated [DATE] Resident #4 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 15 which indicated intact cognitive status. According to the MDS the resident required extensive assistance with bed mobility, dressing and toilet use and total dependence with transfers. The MDS identified the resident required oxygen therapy. The care plan dated [DATE] directed staff to provide CPR (cardiopulmonary resuscitation). Review of the Iowa Physician order [REDACTED]. The resident also requested Full treatment including intubation, advanced airway interventions, mechanical ventilation and cardioversion as indicated. Transfer to hospital if indicated and included critical care. Review of the Order Summary Report dated [DATE] through [DATE] revealed the order the resident a full code. Review of the Progress Notes dated [DATE] at 1:30 AM revealed the resident alert and responsive knows staff name. The resident had been restless and short of breath. He requested [MEDICATION NAME] for general pain. Keeps taking [MEDICAL CONDITION] (bilevel positive Airway Pressure) off, reapplied several times and eventually agreed to wear O2 via mask as mouth breathing. Gave him as needed updraft which helped very little. O2 SAT 78 % when came in room and he had [MEDICAL CONDITION] off, after applied O2 at 3 L per mask and his O2 sat went up to 87 %. Nail beds cyanotic, head of bed elevated. Will continue to monitor. Blood pressure ,[DATE], heart tones rapid and irregular. Resident asks for pop and drank without problems. At 3:30 PM revealed staff had been monitoring the resident and he remained dyspneic and at the time, sleeping, oxygen on via mask at 3 liters. Respirations deep and more even at 30 per minute, cyanosis to nail beds and O2 sat at 85 %. Review of the Progress Notes dated [DATE] at 3:45 AM revealed the CNA reported the resident not breathing. Upon assessment, no heart tones, respirations and no blood. Resident mottled to hands and feet. No response. Did call 911 and the operator asked nurse if resident beyond help and staff reported that he had been. Will send paramedics to facility. Family planned to come to the facility later today to sign DNR (do not resuscitate) but currently a full code. The resident beyond any help. No response to any compressions. At 4:10 AM Paramedics arrive and asses and say to call funeral home if family had one arranged. Still not able to reach son, called and spoke with brother-in-law again and he to continue to try to reach son. Body cleaned, called Physician on call and received OK to send the body to funeral home. At 4:30 AM waiting for family to OK to call funeral home. Administrator notified. The facility identified a total of 17 residents with request for full code (CPR). During an interview with Staff A, CNA on [DATE] at 12:11 PM she stated she worked 10:00 PM to 6:00 AM. She stated at approximately 3:40 AM she and Staff G, CNA went into the resident's room. Staff G put the pulse oximeter on his finger and Staff A had noticed he was not breathing. Staff A went to get Staff I, LPN and she checked his pulse. Staff I said yep he's gone and left the room and called the nurse on call. Staff I called the fire department and they came to the facility and went to the residents room. She further stated Staff I did not do chest compressions. She stated the resident's hands and lips had been purple in color and she noted a small bruise on his left shoulder. He had no discoloring anywhere else and had not been still when they cleaned him after he passed. During an interview with Staff G, CNA on [DATE] at 2:00 PM she stated she worked the 2:00 PM to 10:00 PM shift and the 10:00 PM to 6:00 AM shift. She stated after her lunch break she and Staff A went to the resident's room. When they went to the resident's room, she checked his O2 sat and there had been nothing. Staff A went to get the nurse and she stayed in the room. Staff I came in and said he was gone and left the room to make phone calls. She stated she and Staff A cleaned the resident up the best they could. She stated his skin was cool and had a look about him. His color was gray and not normal.(NAME)stated Staff I checked(NAME)with a stethoscope and said he was gone. Staff G did not recall any purple discoloration. She stated it took approximately 20 minutes to finish cleaning him and then they went up to the desk. She stated she did not see Staff I do chest compressions did not come back into the room and she was gone quite a while. Review of the Time sheet for Staff G, CNA (Certified nursing assistant) revealed she ended lunch break at 3:35 AM. During an interview with Staff I, LPN on ,[DATE]/at 2:30 PM she stated she had been in the residents room approximately 20 to 30 minutes before he passed and he was asleep. 20 minutes later the CNAs called her in and he had been turning purple and mottled, had no heart rate and no respirations. She stated she knew his son was coming to sign DNR papers. She called the nurse on call and said it was pointless to call the ambulance. She said the resident had been mottled and started to stiffen. Staff I stated she started 1 or 2 chest compressions and realized she would have to get on the bed or put the bed way down because the resident had been too large. She further stated she realized he was a full code. During an interview with the resident's physician on [DATE] at 8:30 AM he stated the resident had been able to make own decisions and chose to be a full code. He further stated within 7 minutes or so and staff visualized the resident he did expect them to provide CPR. If it had been 70 minutes or 7 hour he would not expect CPR to be provided. Review of the Policy and Procedure titled Cardiopulmonary Resuscitation (not dated) directed the staff to do the following: a. In the event of a medical emergency during which cardiopulmonary resuscitation may be required, the nurse or other staff member certified in CPR will initiate CPR. Another staff member will dial 911 and access emergency licensed personnel to the facility to continue resuscitation and transport the resident to the hospital. b. CPR will be initiated an emergency personnel summoned by calling 911 in the event that a resident has a cardiopulmonary arrest, unless (1) there is the presence of obviously clinical signs of irreversible death (dependent lividity or rigor mortis); or the resident or surrogate has indicated that resuscitation is not desired and the physician has issued a do not resuscitate (DNR) order which is located in the resident's clinical record. c. All licensed nursing staff will be required to be certified in CPR and be re-certified in a timely manner. Other staff that is currently certified may initiate or assist with CPR on residents designated as full code. d. All residents and their families and/or significant others will be informed of this policy upon admission to facility. Review of the Resident's Bill of Rights dated ,[DATE] directed staff to do the following: a. The facility must provide equal access to quality care regardless of diagnoses, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. The immediate jeopardy to resident health and safety was abated on [DATE] after the facility educated staff on the American Heart Association guidelines for CPR. The facility also reeducated staff on their CPR policy on [DATE].

Based on clinical record review, staff interview and facility policy review, the facility failed to ensure residents remained free from abuse for 1 of 4 residents reviewed (Resident #1). The facility identified a census of 42 current residents. Findings include: 1. According to the MDS (minimum data set) assessment dated [DATE], Resident #1 had [DIAGNOSES REDACTED]. The MDS identified the resident had a BIMs (brief interview for mental status) score of 6 which indicated severe memory and cognitive impairment. The assessment documented that Resident #1 required the assistance of two with transfers. The resident's Plan of Care updated on 6/29/16 documented that Resident #1 had the potential for altered behavior and/or altered coping related to dementia, anxiety, depression and other mental disorders due to known physiological conditions. The Plan of Care instructed to provide diversional activities, redirection, or to re-approach the resident if s/he resisted care. During an interview with Staff B, CNA (certified nursing assistant) on 8/5/16 at 11:20 AM she stated that she assisted Staff E, CNA to transfer the resident after supper on 7/18/16 at 7 to 7:30 p.m. Resident #1 became anxious and repeatedly called out for help which was normal for the resident. Staff B witnessed Staff E hit Resident #1 on the back of the head and heard a thud. Staff E told the resident they were the ones taking care of him/her and that's why family doesn't come and see the resident. Resident #1 said don't hit me. Staff B thought the act was abusive; she tried to tell Staff E not to do it, but did not as Staff B felt timid. During an interview with Staff E, CNA on 8/26/16 at 1 p.m. she stated she helped to transfer the resident The resident had tried to hit her. She then joked with the resident and tapped him/her on the back of the head and said to the resident 'I'm going to tell your spouse'. Review of the Abuse Policy and Procedures dated 4/02 identified residents have the right to be free from verbal, mental, sexual, physical, involuntary seclusion, neglect and misappropriation of property.

Based on record review and interview, the facility failed to plan dietary services and nutritional needs for 1 of 10 residents with severe weight loss (Resident #1). The facility staff advised the resident's physician of the resident's weight loss, however the clinical record lacked any intervention to meet the nutrition needs or a maintain and/or prevent further weight loss (such as an increase in snacks, ice cream with meals or a request for a nutritional supplement). The dietitian revealed she had not been informed of the resident's weight loss. The facility reported a census of 42 residents. Findings included: According to a Minimum Data Set (MDS) with an assessment reference date of 10/23/13, Resident #3's [DIAGNOSES REDACTED]. The same MDS identified the resident's mental status as moderately intact. The MDS revealed the resident required supervision only with eating and had no difficulty with swallowing. The MDS documented the resident had no known weight loss of 5% or more in the previous month and had no known weight loss of 10% or more in the previous 6 months.The MDS documented the resident's admitted as 10/17/13. The resident's weight had been identified as 144 pounds. Prior to the resident's admission to the nursing home, an emergency room report identified on 10/15/13 the resident had complaints of generalized weakness. The resident had been seen a couple months ago with some focal neurological symptoms and received skilled services. The report documented a week ago the resident had been discharged from skilled services to home. For the last week the resident had unable to ambulate and unable to go to the bathroom. The report identified the resident had decreased intake in the last week and had been eating only once (1) a day. The initial admission form at the nursing home dated 10/17/13 identified the resident's weight on admission at 144 pounds. Review of physician's orders [REDACTED]. A Dietary Care Plan dated 10/17/13, revealed the resident's admission weight of 144 pounds (lbs). The same care plan included a goal for no significant weight change in the quarter (3 month period). The care plan included approaches for staff as follows: Monitor the resident's acceptance of diet/meals. Offer substitutes as necessary. Monitor the resident's weight weekly for 3 weeks after admission, then monthly. Monitor the resident's hydration and nutrition. Keep the resident's doctor informed of problems as necessary. Review of Resident #3's dietary record lacked an evaluation for Nutritional History form. The evaluation form considers the physical characteristic of the individual (height, weight, any recent weight changes), completes a clinical observations not limited to ( nausea, mouth pain, swollen lips or gums, swollen dry tongue, poor appetite, vomiting, ) and ask the resident for food preferences/tolerances, likes and dislikes, etc. Review of a Dietary Progress note dated 10/21/13 revealed a facility Dietitian documented the resident as being followed by the Dietitian as the resident's stay progressed. The note identified the resident's weight at 144 pounds. Review of a Weekly Weight Monitoring Log documented Resident #3's weights in pounds (lbs) as follows: 10/26/13 - 145.96 11/2/13 - 139.08 11/9/13 - 138.0 11/16/13 - 138.0 11/23/13 - 134.08 11/30/13 - 130.08 12/7/13 - 127.0 12/14/13 - 127.12 12/26/13 - 128.12 12/28/13 - 130.08 1/7/14 - 129.0 Based upon the facility's weight records, on 10/21/13 Resident #3 ' s weight was at 144 pounds and on 11/23/13 his/her weight was at 134.08 pounds. Resident # 3 experienced weight loss of 6.9 % (severe loss) in one month. From 10/21/13 to 12/26/13, Resident #3's weight showed 11.02 % weight loss (144 pounds - 128.1 pounds). Review of Resident #3's meal intake records dated revealed the following approximate food intake averages: (note- percentages include the resident took bites only at some meals and refusals of some meals, as documented by staff). 10/18/13 - 10/31/13: Breakfast - 95% Lunch - 70% Supper - 78% 11/1/13 - 11/31/13: Breakfast - 84% Lunch - 60% Supper - 64% 12/1/13 - 12/31/13: Breakfast - 74% Lunch - 54% Supper - 44% 1/1/14 - 1/6/14: Breakfast - 71% Lunch - 67% Supper - 71% Review of a Physician consultation form dated 11/13/13, revealed staff documented the resident's October weight of 148 lbs and his/her November weight of 139.08 lbs. Staff documented a bout of nausea and vomiting for approximately 3 days and documented the resident with a poor appetite. Further review of the same form revealed a Physician increased the resident's anti-depressant medication and recommended a follow up visit for 3 weeks. The physician's clinical note dated 11/13/13 documented the resident had been seen for weight loss. The resident had problems of weight loss for 3 weeks. The resident's appetite had decreased and along with his/her dietary intake. The note identified the resident had lost 5 pounds and the symptoms had been associated with nausea and vomiting. The note identified the plan to increase [MEDICATION NAME] (antidepressant medication) to 20 milligrams. The physician wanted to recheck the resident's mood in three weeks. The resident's weight was noted at 139 pounds. A 11/26/13 physician's clinical note identified the resident had been seen for a cold. The note revealed the resident continued to lose weight and had a follow up in one week to address his/her depression. The physician's note listed the resident's weight at 122 pounds on 11/26/13. The resident started on an [MEDICATION NAME] (antibiotic) medication. Review of Nurse's Notes dated 11/29/13 at 8:00 P.M., staff documented the resident's family member visited, brought the resident a malt and the resident drank 100% of the malt. A 12/4/13 physician's clinical note identified the resident had complaints of abdominal pain for the past few weeks. The resident had a decreased appetite, diarrhea and vomiting at times. The clinical note documented, " according to Hallmark Facility records his/her weight has dropped from 148 to 130.8 (pounds) " . The note identified the resident was also being seen for mouth pain. The mouth pain had been and a sore mouth for "quite awhile." The resident's weight was listed at 130 pounds. Review of a Physician consultation form dated 12/4/13 revealed staff documented the resident as not having felt well and had a poor appetite. Staff documented the resident's weight loss between October and November 30, 2013 and documented the resident experienced a moist, non-productive cough. Further review of the same form revealed a Physician ordered the resident to rinse his/her mouth after the use of his/her inhaler and ordered staff to increase the resident's hydration. Review of Nurse's Notes dated 12/12/13 at 11:00 P.M., staff documented the resident's family member brought the resident a malt and the resident drank 50% of the malt with his/her family member's assistance. The resident's care plans lacked any interventions except for the 12/4/13 to rinse the resident's mouth with [MEDICATION NAME] and offer sugar free hard candy to help salvation and encourage fluids. The resident's dietary progress note showed no other information except for the one dated 10/21/13. Record review showed the only Nutritional Evaluation/Re-evaluation had been completed on 10/21/13. During interview on 1/7/14 at 11:30 A.M., the facility Director of Nursing (DON) reported the facility had no documentation in regards to discussion of Resident #3's weight trends or losses during weekly weight meetings with the Dietitian. During telephone interview on 1/7/14 at 1:40 P.M., Resident #3's Physician's nurse reported an oral nutritional supplement (Boost), as being initiated on 1/7/14 after the Surveyor called the Physician's office in regards to the resident's weight loss. Review of the facility Dietary Supervisor job description, included the following duties: Interview resident's or family members, as necessary, to obtain diet history Participate in maintaining records of the residents likes and dislikes Review and revise care plans and assessments as necessary Provide substitute foods of similar nutritive value to residents who refuse foods. During interview on 1/7/14 at 3:05 P.M., the facility Dietitian stated she reviews residents weights during her weekly visits to the facility. The Dietitian stated she gets together with the facility DON and MDS Coordinator and reviews weights. The Dietitian reported at times the facility had no weights for the Dietitian to review for some unknown reason. The Dietitian reported not being aware of Resident #3's weight loss and reported the resident's weight loss as not addressed by the facility DON or MDS coordinator during her weekly visits. The Dietitian stated she expected staff to notify her of any resident's weight loss of 6% within a 1 month period. The Dietitian reported nursing staff could implement nutritional interventions without a Dietitian's recommendations such as extra snacks, ice cream or obtain an order from a Physician for a supplement. During interview on 1/8/14 at 8:00 A.M., the DON stated if the facility nurses let a Physician know of a resident's weight loss and no nutritional intervention had been implemented, she would expect the Dietitian to make a recommended nutritional intervention. During interview on 1/7/14 at 9:30 A.M., Resident #3 stated no staff at the facility had asked his/her preferences for food. The resident stated he/she enjoyed ice cream, but only received ice cream on occasion as a dessert. The resident stated he/she received whole milk with his/her meals after he/she requested the whole milk. The resident stated he/she requested the whole milk due to not eating sufficiently and not having an appetite. The resident stated he/she received a supplemental drink in the past and would drink a supplement again if offered. A facility weight monitoring policy and procedure, with a revision date of 7/10, included a purpose to monitor weight changes and to assess the nutritional status of a resident. The same policy included suggested parameters for the evaluation of significant unplanned and undesired weight loss as follows: 1 month interval - 5% significant loss. Greater than 5% - severe loss 3 month interval - 7.5% significant loss. Greater than 7.5% - severe loss 6 month interval - 10% significant loss. Greater than 10% - severe loss. The same policy and procedure included documentation for nursing staff to notify a Physician and document in a resident's clinical record, a resident's severity of weight loss, based upon the suggested parameters described above. The policy and procedure included documentation for a staff to initiate an intervention as indicated.

Based on observation, clinical and facility record review and staff interview, the facility failed to provide adequate assessment and timely intervention for 1 of 8 residents reviewed (Resident #8). Resident #8 sustained an injury to his/her toe. Despite the fact the facility documented the status of the wound deteriorated for 3 weeks, and the wound showed signs and symptoms of infection for a week, the facility failed to notify the physician in a timely manner. The facility obtained a wound center consult, but didn't get the resident in for a week. The resident continued to show signs of infection with no orders obtained from the physician. The resident received treatment at the wound center for an infected great toe with partial debridement. The same resident also had a documented red perineum with scratches. The facility failed to obtain an order to treat the wounds and when a culture came back positive, the facility failed to obtain a response from the doctor for a week. The facility failed to document an assessment of the wounds to the perineum and the resident required debridement of a full thickness wound which showed multiple organisms on culture. The facility reported a census of 42. Findings include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #8 scored 3 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Resident #8 required extensive assistance with activities of daily living (ADLs) including transfer, dressing, toilet use and personal hygiene. Resident #8's [DIAGNOSES REDACTED]. The MDS documented Resident #8 at risk for developing pressure ulcers. The MDS documented Resident #8 had a Stage II pressure ulcer. The Care Plan dated 11/6/12 identified Resident #8 with the potential for and/or actual changes in skin integrity. The interventions included: a. Assess skin conditions. b. Specialty cushion to chair. c. Turn and reposition. d. Treat per physician order. e. Keep nails short and smooth. f. Assess footwear. g. Notify the physician as needed (prn). h. Monitor for signs and symptoms of infection. i. Heel protector to right heel (effective 6/30/13). The care plan also identified the resident had the potential for infection. The interventions included: j. Treatments as ordered. k. Notify the physician as needed. a. The Nurse's Notes dated 7/10/13 at 9:40 a.m. documented Resident #8 had a 0.9 by 0.2 centimeter (cm) open area to the right great toe with a scant amount of bleeding. Resident #8 did not have socks on. At 10:15 a.m. staff notified the physician with new orders for triple antibiotic ointment and a Band-Aid to the right great toe, to change daily until healed. A Physician's Telephone Order dated 7/10/13 directed to apply triple antibiotic ointment and a Band-Aid to the right great toe and to change daily until healed. The Nurse's Notes dated 7/16/13 at 3:45 a.m. documented the right great toe appeared bruised with a skin tear and open to air. The Nurse's Notes dated 7/23/13 at 2:00 a.m. documented the right great toe remained swollen and red. The Nurse's Notes dated 7/25/13 at 3:20 p.m. documented a dressing change to Resident #8's right foot with some drainage, odor and redness noted. Staff changed the dressing to the resident's right heel noting no signs/symptoms of infection to the heel. The Nurse's Notes dated 7/26/13 at 3:37 p.m. documented a dressing change to the right foot. The great toe had a small amount of drainage. The tissue appeared white with reddened surrounding tissue. The Nurse's Notes dated 7/27/13 at 3:00 p.m. documented Resident #8's right great toe red and [MEDICAL CONDITION], with a dark scab to the tip. The top of the toe had 2 pinpoint open weeping areas. The Nurse's Notes dated 7/28/13 at 3:30 p.m. documented Resident #8's right great toe had a moderate amount of yellow purulent drainage to the dressing. Staff noted decreased [MEDICAL CONDITION] and [DIAGNOSES REDACTED] and the tip of the toe as dark, with a so softened scab and a yellow edge. The Nurse's Notes dated 7/30/13 at 2:20 a.m. documented Resident #8's right great toe reddened, warm to touch and [MEDICAL CONDITION]. At 6:35 a.m. Resident #8 had Band-Aids on the right great toe. One Band-Aid fell off and the other hung. Staff removed the hanging Band-Aid and left open to air. At 11:10 a.m. the right great toe had increased [DIAGNOSES REDACTED] and [MEDICAL CONDITION], with a black scab to the tip. Staff called the physician's office and received approval to refer Resident #8 to the wound clinic. Staff made an appointment for 8/6/13 (a week later). The Nurse's Notes dated 7/31/13 at 3:00 a.m. documented the right great toe continued to be red and warm to the touch. The Nurse's Notes dated 8/1/13 at 1:30 a.m. documented the right great toe continued to have a black scab. The Nurse's Notes dated 8/5/13 at 12:45 p.m. documented the great toe as macerated around the the wound edges and had a small amount of light brown drainage on the old dressing. The Nurse's Notes dated 8/9/13 at 6:15 p.m. documented staff from the wound center called and Resident #[MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staph aureus) positive and Proteus positive and gave new orders for Bactrim DS (an antibiotic) 2 times a day for 10 days. The Nurse's Notes dated 8/10/13 at 2:30 a.m. documented Resident #8 received an antibiotic due to his/[MEDICAL CONDITION] positive peri area and an infected right foot. A Non-Pressure Skin Condition Record for Resident #8's right great toe documented on 7/10/13 he/she had a 0.9 by 0.2 centimeter skin tear. The record described the wound as a partial thickness wound with a scant amount of serosanguinous drainage. The wound bed appeared dark pink or red and the surrounding skin appeared normal for the skin. On 7/17/13 the toe wound measured 1 by 1 cm with no drainage and documented the wound had deteriorated. On 7/24/13 the toe wound measured 1.1 by 1 cm and had deteriorated. The progress note documented black and red (color). On 7/31/13 the toe wound measured 1.5 by 1.2 cm with reddened surrounding skin and had deteriorated. The progress note documented black and red and Resident #8 had an appointment with the wound clinic. On 8/7/13 (after being seen at the wound clinic) the toe wound measured 3 by 2 cm and had deteriorated. The progress note documented black, saw wound clinic with treatment change. On 8/14/13 the toe wound lacked an assessment. A History and Physical dated 8/6/13 documented Resident #8 referred to the wound clinic and this presented the first opportunity for them to provide care to Resident #8. The physical exam documented the right great toe had an ulcer primarily black centrally and measured 2.5 by 1.8 cm. There was [DIAGNOSES REDACTED] of the right great toe with the right great toe swollen significantly compared to that of the left foot. The assessment documented an infected Stage II right great toe diabetic ulcer, potentially a Stage III. An Operative/Procedure Report dated 8/6/13 documented selective debridement of 35% to the right great distal toe ulcer measuring 2.5 by 1.8 by 0.1 cm. The surgeon debrided the periphery of the wound. The central portion of the ulcer was scored to allow for enzymatic therapy penetration. The procedure was done to facilitate treatment and healing. During an observation on 8/21/13 at 1:32 p.m. Staff B Registered Nurse (RN) prepared to do Resident #8's treatments. Staff B measured Resident #8's right great toe wound at 3.2 by 2 cm and covered with black eschar. Down from the toe (metatarsal area) Resident #8 had a reddened area with a dark discolored area within it. Staff B did not measure this area. During an interview on 8/21/13 at 2:40 p.m. the DON (Director of Nursing) stated she didn't know why Staff B didn't measure the redness and discoloration to the medial foot. She said that's why she asked her if she needed to do anything else. The DON agreed the whole area needed measured. A wound center Progress Note dated 8/23/13 documented Resident #8's great toe ulcer had black eschar measuring 3 by 1.7 cm. The right medial foot, first metatarsal head had a shallow ulcer measuring 3 by 2 cm, covered with greenish eschar and slough. During an interview on 8/22/13 at 2:55 p.m. Staff K RN stated she thought the toe wound got bad, so she got orders for a wound clinic referral. She said when she called she told them that they had been treating the toe and it just kept getting worse. They told her 8/6/13 would be the first appointment they had. She stated she did not notify the physician the wound center could not see Resident #8 for a week. During an interview on 8/29/13 at 11:05 a.m. the wound clinic Advanced Registered Nurse Practitioner (ARNP) stated they had a nurse line for the wound clinic. If someone needed to be seen urgently, they tried to work them in. He said the gangrene (toe ulcer) probably occurred simultaneously from the [MEDICAL CONDITION] and the infection. Antibiotics delay the spread of infection and earlier treatment may have kept it from getting so bad. During an interview on 9/4/13 at 8:32 a.m. the office nurse for Resident #8's physician stated on 7/30/13 the facility called and reported the toe did not respond to treatment and asked if they could have a referral to the would center and they okayed it. The notes did not indicate signs and symptoms of infection and they also did not get notification the wound center could not see Resident #8 for a week. The physician would have wanted to know this; they could have done something. b. The Nurse's Notes dated 7/20/13 at 2:50 a.m. documented Resident #8's genital area as very reddened and tender. The clinical record lacked documentation of notification of the physician. The Nurse's Notes dated 7/21/13 at 3:05 a.m. documented Resident #8's genital area as less reddened. The Nurse's Notes dated 7/24/13 at 5:45 a.m. documented CNAs observed blood on the back of Resident #8's genital area. Two open areas were observed, from Resident #8 scratching the area with his/her fingernails. Resident #8's perineal area and groins were extremely reddened. It looked like it could [MEDICAL CONDITION] positive. Staff sent a facsimile (fax) the physician to report and questioned if he wanted [MEDICAL CONDITION] swab and or to start medication to the area. At 3:00 p.m. staff received the okay to culture the areas [MEDICAL CONDITION] as requested. At 8:00 p.m. the perineal area remained reddened. The Nurse's Notes dated 7/25/13 at 5:40 a.m. documented Resident #8 had an extremely reddened perineum and groins and staff provided gentle perineal care. At 3:20 p.m. the open areas to the genital area remained. The Nurse's Notes dated 7/26/13 at 7:20 a.m. documented the wound culture of Resident #8's genital area obtained. The perineal area, groins and rectal area remained reddened. At 3:37 p.m. Resident #8's groin and perineal area continued to be reddened. The Nurse's Notes dated 7/27/13 at 5:10 a.m. documented Resident #8's perineum and groins continued red and the scratches had no drainage. The Nurse's Notes dated 7/28/13 at 1:10 a.m. documented Resident #8's perineal area and groin remained red. The Nurse's Notes dated 7/29/13 at 1:00 a.m. documented the perineal area and groin remained red. At 3:40 p.m. the facility received a fax regarding [MEDICAL CONDITION] culture of Resident # 8's genital area. The final report showed the wound [MEDICAL CONDITION] positive. Staff faxed the lab results for any new orders. At 2:20 a.m. the perineum and groins remained reddened. The Nurse's Notes dated 7/31/13 at 3:00 a.m. documented the peri area remained reddened. The Nurse's Notes dated 8/3/13 at 1:30 a.m. documented Resident #8's perineum as very reddened. The Nurse's Notes dated 8/6/13 at 3:45 p.m. documented the facility received a signed fax regarding [MEDICAL CONDITION] culture of Resident #8's genital area with new orders for [MEDICATION NAME] (an antibiotic) 500 mg every day for 10 days (one week after the facility received the lab results). The Nurse's Notes dated 8/7/13 at 2:30 a.m. documented the redness to the perineum much improved. Resident #8 continued on an antibiotic due to [MEDICAL CONDITION] positive genital open areas. A Quality Assurance Monitoring Tool dated 7/24/13 at 5:30 a.m. documented Resident #8 scratched his/her posterior genital area and ended up with 2 open areas from his/her fingernails. The tool documented a treatment in place and to monitor weekly (the record identified no treatment to the area until 8/6/13). A Non-Pressure Skin Condition Record for Resident #8's perineum, groins, and genital area documented when a CNA checked Resident #8, he/she had a small amount of blood coming from the genital area. The perineum, groins and buttocks were all reddened and he/she complained of itching and hurting. Staff provided skin care and notified the physician of the issues to the area. The record lacked an assessment of the open skin. On 7/31/13 the record documented the areas as slightly reddened and intact. On 8/7/13 the record documented the areas as slightly red. On 8/14/13 the record documented a 2 by 2 cm partial thickness wound with slough and reddened surrounding skin. The progress note recorded Resident #8 had a red nodule with a foul smelling open area in the middle. An Operative/Procedure Report dated 8/14/13 documented Resident #8 had debridement of 100% skin and subcutaneous to the left genital ulcer where pre-operative measurements were 1.6 by 1 by 0.1 cm with the wound covered with thick yellow eschar and draining yellow discolored fluid. The post-procedure measurements were 1.8 by 1.2 by 1.8 cm with undermining circumferential max of 0.6 cm. The procedures were performed in the wound center. Resident #8's left genital ulcer was debrided of skin and subcutaneous tissue, removing eschar, slough, debris, biofilm and subcutaneous tissue down to and through the point of reaching a healthy viable wound base. On 8/19/13 cultures were reviewed and the genital ulcer was positive for multiple organisms. During an observation on 8/21/13 at 1:32 p.m. Staff B prepared to do Resident #8's treatment. The DON lifted Resident #8's left leg up (to see the genital ulcer). The area measured 1.3 by 0.9 by 0.9 cm. Staff B and the DON both thought the area to be the same area where Resident #8 scratched and it developed into an abscess. Staff B stated they lanced the area at the wound center. During an interview on 8/22/13 at 9:10 a.m. Staff B stated she didn't know Resident #8 had open areas on his/her genital area when she did his/her assessment (prior to the abscess). She said she only did skin assessments on Wednesdays, so if something happened in between the nurses needed to do an assessment and measure the areas and call the physician for some kind of treatment. She said they needed to make sure they were getting a response to faxes they sent in a timely manner. They needed to call if they didn't get a return fax. During an interview on 8/22/13 at 2:55 p.m. Staff K RN stated Resident #8 had superficial open areas on his/her genital region. She didn't know if they treated them. During an interview on 8/22/13 at 1:51 p.m. the wound clinic Advanced Registered Nurse Practitioner (ARNP) stated it would potentially have been beneficial if Resident #8 was seen sooner. He said when they talk to nursing facilities they tell them they can't help them if they don't bring them in. He said they needed a physician referral and as soon as they get the okay from the doctor they can call for an appointment. They try to get them in within a few days and will see them as soon as possible if urgent. The ARNP stated the ulcer to the genital area had eschar covering it by the time they saw it. It was a full thickness wound. He said it started as an infection that got to the point of ulceration. The facility's policy for Non-Pressure Skin Condition Assessments dated 7/2010 identified the purpose to provide weekly assessments of all skin conditions that were not pressure sores, to help prevent infection and other complications for all non-pressure [MEDICAL CONDITION], and to provide documentation of skin assessments. The policy directed to begin a non-pressure skin assessment sheet upon assessment of non intact skin. The description of any skin condition must be completed including size, color, area and date found. The physician must be kept aware of a change of condition. If stable, subsequent weekly documentation on the non-pressure form should show response to treatment as well as description with size and appearance of the affected area. Any signs or symptoms of infection or poor response to treatment should be reported to the DON and physician for new orders. The facility's undated General Wound Guidelines directed to select a treatment that kept the wound bed moist and the periwound skin dry. The guidelines included re-evaluation of the wound's response to the prescribed treatment. If the wound did not progress or worsened, report to the DON and evaluate for the need to inform the physician of the wound status.

Based on observation, record review, interviews with resident, physician and staff, the facility failed to provide the necessary provisions to ensure residents received adequate supervision with transfers; or supervision from hazards in the environment for 3 of 9 residents (Resident #1, # 6, and # 8) reviewed. The facility reported a census of 37 residents. Findings include: 1. Clinical record review of Resident #1's Minimum Data Set (MDS) assessment reference date of 9/6/10 identified his/her [DIAGNOSES REDACTED]. The assessment revealed Resident #1 had a urinary tract infection (UTI) in last 30 days. The MDS documented the resident had no short or long term memory deficits. The MDS documented the resident ' s cognition as poor for making daily decisions or supervision/cues. The MDS identified due to the resident ' s dependency s(he) required two or more staff for bed mobility and transfers. The resident had functional limitations in range of motion on both his/her arms, legs and feet. The resident also had partial loss of voluntary movement on his/her leg and foot. The assessment documented no complaints of pain. The MDS documented the resident had fallen in the past 31-180 days. Clinical record review of the Care Plan dated 9/14/10 documented a goal for the resident to remain safe due to his/her impaired mobility, obesity, along with the history of falls. The interventions listed a physical and occupational therapy evaluations as ordered, adaptive devices/ equipment as indicated (wheelchair) and a restorative program. The care plan directed 2 staff to provide the assistance during Hoyer lift transfers. Record review of the Resident Information Sheet dated 9/24/10 utilized by the Certified Nursing Assistants (CNAs) revealed the resident used a wheelchair and the resident required to assist for transfers with the Hoyer lift. The sheet also documented the resident a fall risk. Clinical record review of the Fall Risk Evaluation dated 5/13/10 and 9/1/10 revealed the resident had a score of 14. A resident who scored a 10 or higher at risk for falls. a. Clinical record review of the Nurse's Notes dated 9/19/10 at 12:10 PM revealed the nurse had heard the CNA's call out from the resident's room. The nurse had gone to the resident's room and found the resident lying on the floor on his/her back. The Hoyer pad had been connected by 3 straps to the Hoyer lift. The CNA's reported to the nurse that a fourth strap had come over the loop. The resident complained of shoulder and left side pain. The resident also complained of chest pain and had trouble breathing with wheezing apparent. The CNA's reported to the charge nurse the resident did not hit his/her head. The facility transferred the resident to the hospital. At 2:30 PM the nurse called the hospital and received a report the resident having respiratory distress and had episodes of V-tachycardia (fast heart rhythm). Clinical record review of the Accident/ Incident Report date 9/19/10 at 11:50 AM documented the resident had been sent to the hospital by ambulance. The recommendation to prevent recurrence of the fall documented a Hoyer lift training with CNA's had been provided. Clinical record review of the Falls Investigation Worksheet dated 9/19/10 revealed the resident had fallen at 11:45 AM transferring in the Hoyer lift. The record documented the assistive device had been used according to the manufacturer's specifications and fitted the resident's needs. Clinical record review of the Emergency Department Physician Notes dated 9/19/10 documented the resident had fallen out of a Hoyer lift raised approximately 4-5 feet in the air. The chest computed tomography (CT scan) showed the following injuries: a. Acute left sided pneumothorax. (occur after physical trauma to the chest) b. Acute left anterior rib 4 through 7 rib fractures. c. Acute comminuted fracture of 6 and 7. d. Acute posterior rib fracture of 8 and 9. e. Acute compression fracture of T4 and T5. Clinical record review of the Diagnostic Radiology final report dated 9/21/10 at 8:58 AM identified fractures of multiple of the visualized ribs with acute fracture of the posterolateral aspect of the left 3rd rib, displaced fractures of the lateral aspect of the left 4th, 5th, and most likely 6th ribs. Fracture of the posterior aspect of the 7th rib with the remainder of the ribs not visualized due to underexposure and poor inspiration. A hospital consultation report documented the resident had pain when s(he) attempted to flex or extend his/her elbow. The hospital history and physical documented the resident had been given morphine for pain control and the orthopedics would see him/her to address the arm fracture. The hospital Diagnostic Radiology report dated 9/19/10 at 1:01 PM documented evidence of comminuted fracture of the most distal humerus with posterior displacement of the fractured distal fragments and some anterior angulation at the fracture site. Evidence of comminuted fracture of the olecranon process of ulna also. Suggestion of the left elbow joint effusion. Clinical record review of the Operation Final Report dated 9/29/10 revealed postoperative [DIAGNOSES REDACTED]. The resident underwent [REDACTED]. An interview with the Physician Assistant on 10/4/10 at 10:45 AM revealed the resident had a left elbow fracture in 2 different areas. The doctor had performed an ORF on the resident and placed screws and a plate in the left elbow. The resident also had several rib fractures and had been placed in intensive care for respiratory distress. The resident had been intubated for a couple of days due to a small pneumothorax. The fractures were directly related to the fall and the injuries were pretty severe. The resident will have permanent damage to the left elbow with limited movement of the left elbow and stiffness. An interview with the pulmonary Physician on 10/6/10 at 11:30 AM revealed the resident had been placed in intensive care for a couple of days due to a small pneumothorax. The resident had a history of [REDACTED]. The resident spent a few days in intensive care related to the respiratory distress. The fall directly caused the fractured ribs. An interview with Resident # 1 on 10/4/10 at 9:45 AM in hospital revealed s(he) did not know if the straps to the Hoyer lift had broke or just came loose. The resident stated staff present in the room at the time of the fall were Staff K CNA, Staff Y CNA, and Staff QQ CNA. The resident said he/she had been in bed and the staff were going to get him/her up for lunch. The resident said the Hoyer pad had already been under him/her. Staff QQ CNA and Staff Y CNA were lifting the Hoyer lift. The resident said staff had moved the Hoyer away from the bed, off to the right side of the bed. The resident said no staff were holding the Hoyer pad or the resident when transferring from the bed and up in the air. The resident stated his/her arms were placed across his/her chest and did not remember if the legs were crossed. The resident stated both legs were not moving. Staff had used the tan pad with brown edges to transfer the resident. The staff always used the tan pad to transfer the resident. The resident said he/she felt like he/she had flipped out of the pad upside down. The resident stated s(he) had fallen on the Hoyer legs and floor and hit the left arm and ribs. The resident stated the fall took his/her breath away. The resident heard no noise prior to the fall. The resident remembered staff turned the resident over and did not remember any further details. The resident did say s(he) had been previously hit by the Hoyer lift and caused a skin tear (in February 2010). Staff Interviews: An interview with Staff Y CNA on 9/28/10 at 9:35 AM revealed she and Staff QQ CNA had entered the resident's room. They were the only staff in the room. The resident had been lying in bed and they were going to get the resident up for lunch. Staff Y stated they provided cares to the resident and put the Hoyer pad under the resident. The color of the pad had been tan with the brown edges. Staff Y stated they did not use the blue mesh pad on the resident because it squished the resident and had been uncomfortable for the resident. Staff Y stated Staff QQ (CNA) had been on the right side of the bed. Staff Y stated Staff QQ brought the Hoyer legs under the bed. The Hoyer legs were closed. The Hoyer lift had been placed at chest level. Staff Y stated the black straps on the Hoyer lift were used to connect the head portion of the pad to the Hoyer. Two straps were connected to the top hooks and two straps were connected to the lower hooks. The middle hooks were left undone. The Hoyer pad straps had been crossed under the resident and placed between the resident's legs. Staff QQ lifted the Hoyer and Staff Y CNA remained on the left side of the bed. Staff Y stated she came to the right side of the bed and stood at the foot of the bed. Staff Y stated she had not been holding the Hoyer pad or resident as they began to transfer the resident. Staff Y stated Staff QQ had the resident raised up in the Hoyer approximately 3 feet, pulling away from the bed. She said Staff QQ CNA opened the Hoyer legs approximately 1/2 way out from under the bed. Staff Y stated the resident had his/her arms crossed across the chest. The Hoyer had been positioned at approximately a 45 degree angle from the bed. The resident faced the cupboards/ door in the room. She said they heard a noise and the resident had fallen onto the Hoyer legs. Staff Y demonstrated how the resident lay on the floor and on his/her left side. Staff Y stated the lower left strap of the tan pad had come undone. The strap did not break. An interview with Staff QQ CNA on 9/28/10 at 11:45 AM revealed she had worked at the facility for 4 years. Staff QQ stated the day of the fall, she and Staff Y CNA went into the resident's room to get the resident up for lunch. They emptied the resident's catheter and adjusted the Hoyer pad under the resident, which had already been under the resident. Staff QQ stated she stood behind the Hoyer lift, controlling the lift. Staff QQ stated she lowered the lift to the resident and they both connected the straps of the pad to the lift. Staff QQ stated she hooked the pad on the right side and Staff Y attached the pad to the lift of the left side. Staff Y stood on the left side of the bed. Staff QQ stated she started to pull the lift away from the bed, the legs were closed at the time and she began to open the legs as the lift rolled away from the bed. Staff QQ stated staff Y walked away from the bed and stood behind the resident's wheelchair. At the time neither staff member were holding the resident or pad when transferring. Staff QQ stated as she turned the Hoyer lift to the right, she heard a noise and the resident had fallen, hitting the right leg of the lift. The lower left strap of the lift had come off. The strap had not broken. The resident lay on his/her left side and complained of chest pain and appeared short of breath. Staff QQ did not realize the pad used on the resident, a tan pad with brown edges, should not have been used for the Invacare Reliant 600 lift. Staff QQ stated they had always used the tan pad for the resident and had never been told not to use the tan pad. An interview with Staff F, Registered Nurse (RN), on 9/30/10 at 9:37 AM revalued she had been working the day of the fall. The CNA's came to her and told her the resident had fallen. When she entered the room, the room had been laying on the floor. The resident complained of chest pain and left shoulder pain. The resident had trouble breathing, so they placed oxygen on the resident. She said when the ambulance personal arrived, they sat the resident up in a sitting position. The resident complained of pain at the time. The paramedics placed the resident on a tarp and placed the resident on a gurney. Staff F stated they had been doing daily weights on the resident and the resident weighed 315 pounds. She said Staff Y CNA and Staff QQ CNA were the CNA's transferring the resident at the time of the fall. The staff used a tan pad to transfer the resident. The lower left strap of the Hoyer pad had come undone and not broke with the transfer. The straps were still crossed and one strap hanging from the lift. She revealed there were specific pad to be used for the facility Hoyer lift. The pad were the color blue. She said she did not know if the tan pad had been designed to use with the facility lift. She said she called the hospital and the hospital reported the resident had fractured ribs and a fractured elbow. An interview with Staff D CNA held on 9/30/10 at 10:25 AM revealed she had not been in the room when the fall occurred. When she entered the room, the resident had been lying on the floor with the head up against the bed and feet were facing the roommate ' s bed. The tan pad still connected to the lift had one strap hanging from the lift. She said she did not think the tan pad brand name should have been used to transfer the resident on the lift, but had been using the tan pad with the resident since the resident arrived to the facility. She never questioned using the tan pad rather the required blue pads. An interview with Staff II CNA on 9/29/10 at 2:47 am revealed the staff had been using the tan pad to transfer the resident since she started at the facility a year ago. The staff did not become aware of the recommendations by the company of the lift not to use any other pad to transfer residents other than the required blue pads. She said when the Hoyer lift is used, one staff member controls the lift and the second staff member is to hold the pad/ and or resident to guide the resident to the bed or wheelchair. She said when the strap is not placed on the hook correctly, the strap can slip and come off the hook during the transfers. An interview with Staff K CNA on 9/29/10 at 2:10 PM revealed the facility had 4 residents that required the use of the Hoyer lift for transfers. Resident # 1 had been the only resident the staff used the tan pad for transfers. She stated she thought the tan pad had been designed to use with the facility Hoyer lift. Staff used the blue pad with the remainder 3 residents. The blue pad did not cross at the legs as the tan pad did. An interview with the Director of Nursing (DON) on 9/28/10 at 12:30 PM revealed the Invacare Reliant 600 had been the only Hoyer lift used in the facility. She revealed there were only 3 blue pads in the facility and thought they could use both the blue pads and tan pad with the Reliant 600 lift. She said she did not believe the instructions designated specific pad to be used for the lift. She did say the facility did not have the original directions for the lift and did obtain directions for the Invacare Reliant 600 off the Internet. At that time she became aware the blue pads were specific to be used for the Reliant 600 lift. She said the tan lift had come with the resident when she arrived from the hospital to the facility. The pad actually documented 8 SE on the pad and had a label for an EZ Lift. The resident had not fallen from the lift prior to the fall. The only incident prior to this had been the Hoyer lift tipped and hit the resident on the arm. She thought the staff had been using the blue pad but had not really paid attention to the color of the pad used on the residents. Record review of the instructions for Lifting the Patient received from the Internet by the DON revealed Invacare slings are made specifically for use with Invacare Patient lifts. For the safety of the patient, DO NOT use sling and patient lifts of different manufacturers. Also included, at all times there is an aide in front of resident providing safety and security for the resident. b. Clinical record review of the Nurse's Notes dated 2/6/10 at 5:00 PM revealed during a transfer from the bed to the wheelchair, Resident #1 had still been attached in the Hoyer lift. The Hoyer lift had been pulled over and tipped to the side and the resident had been hit on the arm. The resident received a skin tea to the right hand measuring 1 centimeter (cm) x 1.5 cm and a second open area on the right forearm measuring 2 cm x 5.2 cm. Clinical record review of the Accident/ Incident Report dated 2/6/10 revealed the resident had been placed in a wheelchair with the Hoyer lift still attached to the resident. Staff had pulled the resident over and the Hoyer lift tipper over and hit the resident on top of the arm. The recommendation to prevent the fall recurrence (documented by the nurse) revealed to open the Hoyer legs when putting the resident in the wheelchair. Record review of the document, Lifting the Patient, (undated) revealed the legs of the Hoyer lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. Staff interview with Staff F Registered Nurse (RN) on 9/30/10 at 9:37 am revealed the Certified Nursing Assistants (CNA), working the 2-10 shift, had come to her and reported an accident. She said the CNA's had told her the resident had still been in the Hoyer lift pad. The resident had been 1-2 inches above the wheelchair, where the staff were transferring the resident. She said the staff were pulling the resident back into the wheelchair. The resident had been holding onto the Hoyer lift pad straps. The Hoyer lift had tipped and landed on the resident and hit the resident on the arm. The resident received a skin tear and measured approximately 8 cm x 5 cm.. She said the scar from the skin remained visible for a couple of months. She said the Hoyer lift legs were closed when she walked into the room. c. Record review of the MDS assessment dated [DATE] identified Resident #1 with [DIAGNOSES REDACTED]. The MDS documented the resident had no short or long term memory losses and moderately impaired cognitive skills for daily decision-making. The MDS identified the resident required 2 or more staff to assist with transfers, and needed extensive assistance for bed mobility. The assessment documented the resident did not walk, and used a wheelchair as his/her primary mode of locomotion. The updated Care Plan dated 4/19/10 identified the resident had a potential for impaired mobility due to obesity and a history of falls. The care plan identified the resident used a wheelchair. Review of the Accident/ Incident Report dated 5/4/10 at 12:00 PM revealed the nurse arrived at the scene. The resident had been found laying face down in the van and verbally responding to staff. Staff could not move the resident due to neck and head pain. The report documented a recommendation to use a different vehicle with a larger wheelchair when transporting Resident #1. On 10/4/10 at 10:00 am, Staff I (van driver) and the surveyor observed the area outside where the facility van had been parked. The ramp from the van had been lowered down on the ground. The surveyor used a tape measure to determine the width of the ramp to the van. The width of the ramp measured 30 inches across. Staff I verified the measurement of the ramp at 30 inches across. Both the van driver and surveyor re-entered the building and asked the Director or Nursing (DON) and Executive Director to present the wheelchair used by the resident when the fall occurred on 5/4/10. he DON entered a resident's room, (Room # 207), and brought out the resident's wheelchair. The DON verified the wheelchair had been used by Resident# 1 when the fall occurred in the van. The DON stated they used another resident's wheelchair to transport Resident # 1 because the resident's bariatric wheelchair had been too big and would not fit in the van. Staff I verified the wheelchair brought out of room # 207 had been the wheelchair used by Resident # 1 when the fall occurred. The surveyor and the van driver returned outside where the van remained parked in front of the facility and placed the wheelchair on the ramp. The left side of the wheelchair remained on the ramp, while the right side of the wheelchair stuck between the inner, rubber wheel of the wheelchair and the smaller metal wheel on the outside. The surveyor measured the wheelchair width from one wheel to the second wheel, which measured 33 inches across and Staff I verified the measurement. The surveyor measured the opening of the van door which showed it measured 32 inches. Staff I then demonstrated what had occurred on 5/4/10. Staff I stated the resident fell forward in the van and landed on his/her face. The Final Report from the hospital dated 5/4/10 showed Resident #1 sustained an acute left shoulder, left ankle, and left foot strain/contusion as result of the fall. During an interview with Resident #1 on 10/4/10 at 9:45 am s(he) discussed the incident when s/(he) fell in the van. Resident #1 stated staff placed him/her in a different wheelchair since his/her had been too wide to fit on the van. Resident #1 stated the wheelchair got stuck when they were at the top of the ramp and then the wheelchair tipped over and s(he) fell over (into the van). The resident stated s(he) bounced their head 3 times on the floor. Resident #1 stated the van driver kept apologizing and s(he) remained on the floor for approximately 10 minutes before the ambulance arrived. The resident stated s(he) received bruises after the fall. Resident #1 stated his/her eyes remained bruised for about 5 weeks. Interview with Staff I on 9/28/10 at 10:30 AM revealed he transported all the residents to their appointments. Staff I stated when he placed Resident # 1 on the ramp of the van, the wheelchair got stuck on the right side of the van door. The wheelchair had been too wide for the opening and got stuck in the door. Staff I stated he told the resident to sit still so he could adjust the wheelchair back. Staff I stated as he pulled back, the resident leaned forward and fell out of the wheelchair into the van. Staff I stated he told the nurses and the Executive Director what had happened and they tried to get the resident out of the van but could not remove him/her off the floor. Staff I stated the ambulance personnel arrived 30 to 45 minutes after the incident. Staff I stated he had transported the resident to other appointments, but had used a smaller wheelchair. On 10/4/10 at 10:00 AM Staff I stated he continued to transport residents larger in size using the facility van. Staff I stated he had transported other residents and had no other problems. Staff interview with Staff M (RN) on 9/30/10 at 9:10 AM revealed she had not seen the fall occurred in the facility van. She said when she went out to the van, the resident had been inside of the van and lying on his/her stomach with the face up against the corner of the van. Staff M stated she asked the van driver what happened and he stated he did not know and he had been pushing the resident into the van when something got caught. She said the resident complained of pain in the neck and back. She said the resident had trouble breathing so she applied oxygen on the resident. Staff M stated the resident did not have any bruising on the face at that time. Staff M revealed the facility had to borrow a wheelchair from another resident, as Resident #1 ' s wheelchair had been too wide for the ramp. Staff M stated the resident had been using another resident's wheelchair at the time of the fall. An interview held on 10/4/10 at 1:48 PM with the Executive Director revealed she did not know of any other incidents involving Staff I and transporting the residents. She knew of the accident involving Resident # 1 and stated the resident had not been in his/her bariatric wheelchair when the incident occurred. She stated the resident had been using another wheelchair from another resident. She appeared surprised of the wheelchair width compared to the width of the ramp and stated she had not been aware of the discrepancy and would notify the corporate office. 2. Clinical record review of the MDS assessment dated [DATE] for Resident # 6 revealed [DIAGNOSES REDACTED]. The MDS documented the resident had no long or short term memory loss and cognitive skills for decision making were independent-decisions consistent/reasonable. The MDS documented the resident required limited assistance of 1 staff for bed mobility and total dependence of 2 or more staff for transfers. Clinical record review of the Care Plan dated 7/30/10 revealed the resident had a potential for gait/balance disturbance. The care plan intervention directed staff to provide adaptive devices/equipment as indicated. Clinical record review of the Safe Smoking Evaluation dated 2/11/10 for the resident documented the resident had been unable to safely light a cigarette with a lighter. The resident also did not utilize ashtrays safely and properly. The record documented the resident required supervision by staff, volunteers, or family members at all times when smoking. The resident also required assistance with lighting the cigarette. The resident flicked the ashes on the ground during the observation. Observation on 9/28/10 at 2:45 PM revealed the resident transferred from the room to the courtyard assisted by Staff II CNA. A second resident actually carried the cigarettes and light outside for the resident. Staff II CNA left the resident out in the courtyard unsupervised. The second resident actually lighted the cigarette for the resident and sat by the resident as they both smoked. At 2:55 PM, the resident continued to sit in the courtyard with no staff present in the courtyard. 3. Clinical record review of the significant change MDS dated [DATE] for Resident # 8 revealed his/her [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident had long and short term memory loss and cognitive skills for decision making were moderately impaired. The resident required one person limited assistance for bed mobility and two or more staff for extensive assistance for transfers. The MDS documented the resident had functional limitation in range of motion on one side of the leg and foot. Clinical record review of the Care Plan dated 9/14/10 documented Resident #8 had a loss of balance and had falls in the past 30 days. The care plan interventions directed staff to assess for change in condition or function. The care plan also directed a physical and occupational therapy evaluations as ordered, adaptive equipment/devices as indicated (wheelchair with an anti-tip seat.) The care plan directed staff use personal alarms and floor mat to ensure the resident remain safe. The Fall Risk Evaluation dated 6/15/10 and 8/30/10 revealed a score of 20. A resident who scored 10 or higher is at risk for falls. The Fall Risk Evaluation dated 9/9/10 revealed Resident #8 scored 18. Clinical record review of the Accident/ Incident Report documented the following falls: a. On 5/9/10 the resident found sitting upright on floor in room in front of the wheelchair. The resident stated had missed the seat when attempting to sit in the wheelchair. The recommendation to prevent fall recurrence listed informed the resident he/she should not attempt into wheelchair by him/her (self). b. On 5/19/10 at 8:00 am the resident had been found on the floor next to the bed. The resident stated he/she had been sitting on the edge of the bed and slipped down the side and fell on to the floor. The intervention directed staff to place both side rails up. At 10:45 PM the staff entered the room and found the resident laying on the floor on the right side next to the bed. The interventions directed staff to lower the bed, put up the side rails, apply an alarm, and place a fall mat on the floor. c. On 8/30/10 at 3:15 PM the resident had been found lying on the floor on his/her abdomen. The recommendation to prevent fall recurrence documented the clip to the personal alarm (PA) no longer worked and had been replaced. The resident had been transferred to the hospital for exam. d. On 8/31/10 at 2:00 PM the resident had been found lying on the right side on the floor. The resident had been in the wrong wheelchair and placed in the appropriate wheelchair. Observations revealed: a. On 9/29/10 at 7:50 am the resident sat in the wheelchair in the dining room. The Personal alarm string lay on the floor hanging from the wheelchair. The clip not attached to the resident. At 7:54 am Staff Y CNA approached the resident and gave the resident syrup for breakfast. She did not connect the PA clip to the resident. At 8:05 am the resident continued to sit in the wheelchair without the PA attached to the resident. At 8:15 am the resident continued to sit in the wheelchair in the dining room sleeping. At 8:28 am the resident sat in the wheelchair, sleeping without the PA attached to the resident. At 8:39 am the resident removed him/her(self) from the dining room table, propelling the wheelchair. The resident stopped to ask Staff D CNA for directions to the resident's room. She gave the resident directions to the room and did not recognize the PA had not been attached to the resident. At 8:45 am the maintenance supervisor stopped the resident in the west hallway and attached the PA clip to the resident. b. Observation on 10/4/10 at 11:00 am the resident sat in the dining room with no PA attached to the resident or wheelchair. At 11:30 am the resident continued to sit in the wheelchair in the dining room without a PA attached. At 1:00 PM the resident continued to sit in the dining room, in the wheelchair without a PA attached to the wheelchair or resident. At 1:15 PM Staff M Registered Nurse (RN) verified the resident did not have a PA attached to the resident or wheelchair. She went to the resident's room with the surveyor and found the PA attached to the resident's right side of the bed on the side rail.