Every finding on record at Accura Healthcare of Toledo

Based on clinical record review, observation, staff and resident interviews, the facility failed to monitor and provide adequate supervision for a resident who wandered into other resident rooms for 1 of 14 residents reviewed (Resident #1). The facility reported a census of 54 residents.Findings include:The Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #1 had a diagnosis of Non-Alzheimer's dementia. It indicated wandering occurred 1-3 days during the 7 day look back period and a wander alarm was used daily. His Brief Interview for Mental Status (BIMS) score was 3 out of 15, which indicated severe cognitive impairment. Per the MDS assessment, the resident walked independently and did not use a mobility device. The Care Plan initiated on 11/10/25 revealed the resident was an elopement risk related to Dementia and able to ambulate independently. The Care Plan intervention dated 11/10/25 indicated that a wander alert bracelet was utilized. The Care Plan focus area dated 12/8/25, revised on 4/15/26, revealed Resident #1 had a behavior problem as evidenced by (AEB) urinating in inappropriate places and running up and down hallways, wandering into others' rooms, kissing another female resident related to dementia. The intervention dated 12/8/25 revealed to intervene as necessary to protect the rights and safety of others, and indicated that staff should approach and speak in a calm manner and divert attention. Remove from situation and take to alternate location as needed. Another intervention dated 12/8/25 directed staff to monitor behavior episodes and attempt to determine the underlying cause by considering location, time of day, persons involved, and situations then document the behavior and potential causes. The Intervention dated 4/14/26 revealed, 1:1 (one to one) supervision when out of room until he is determined to be safe with others. The Electronic Health Record (EHR) documented behaviors related to wandering for Resident #1 as noted below: a. 11/11/25 at 9:44 PM: Observed wandering through the hallway appearing confused and disoriented. He was difficult to verbally redirect.b. 11/12/25 at 5:53 AM: Wandering and having difficulty finding his room.c. 12/25/25 at 12:11 AM: [Wander alert device] was in place but not functioning. No replacement in the facility so on-call staff monitored throughout the shift. The bracelet was also documented as not functioning again at 3:26 PM the same day.d. 1/4/26 at 11:08 PM: Wandering more than usual and trying to go to the casino.e. 1/9/26 at 3:57 AM: Wandering in halls around the facility with no attempts to enter other residents' rooms.f. 3/4/26 at 4:04 AM: Wandering around the facility all night and had not gone to bed.g. 3/5/26 at 4:41 AM: Resident was up all night wandering the facility. h. 3/13/26 at 5:44 AM: Walking around the facility and going into different rooms.i. 3/17/26 at 5:07 AM: Wandering around the hallways for the majority of the shift.j. 3/25/26 at 1:01 AM: Following staff into other resident rooms while they were answering call lights. Redirection caused increased agitation.Resident #1 and Resident #10:The Orders-Administration Note dated 3/28/26 at 7:26 PM present in Resident #1's clinical record revealed, Residents reported [to writer] this resident had become Sexually inappropriate with Resident [Resident #10] and was in her personal space trying to touch her. [Writer] went to and talked with resident and he stated that he didn't mean to make her feel uncomfortable, and that he just wanted to talk to her as friends. [Writer] told him that we need to give everyone their personal space and that to be mindful of the other residents feelings.The Orders-Administration Note dated 3/30/26 at 1:00 PM present in Resident #1's clinical record revealed Interview conducted with other resident that this resident was allegedly was inappropriate with on 3/28. Other resident (Resident #10) is alert and oriented and stated that this resident (Resident #1) was not inappropriate at all with her. He did get close to her, but when she told him he was in her bubble he moved away without issues. Other resident said he did not touch her nor say anything inappropriate to her.In an interview on 4/27/26 at 8:52 AM Resident #10 stated that she had her stop sign put up on her door as wanderers were coming in and she did not like it. It was 8 months ago and they were all gone now. Resident #10 explained Resident # 1 had not come into her room and has only once got into her personal bubble once. She told him to get back and he did. Had not come into her room and she felt the stop sign worked well. Review of a list of Brief Interview for Mental Status (BIMS) scores provided by the facility revealed Resident #10 scored 15 out of 15, which indicated intact cognition. Resident #1 and Resident #2: The Communication with Physician Note dated 4/14/26 at 7:30 PM present in Resident #1's clinical record revealed Change in Condition: Increased confusion and wandering. He was found in another resident's room. He had kissed resident (Resident #2) on the lips while she was in the recliner and was trying to lie down in her bed.During an observation on 4/23/26 at 10:44 AM Resident #1 was not actually across the hall but was across the hall from Resident #2 diagonally. He had a staff member across from his door and an alarm attached to the outside of his door that activated with his wander alert bracelet. One on one staff outside of the room across the hall. On 4/28/26 at 10:30 AM Resident #1 still had a 1 on 1 in place.In an interview on 4/23/26 at 9:32 AM Resident #2 stated that she could not remember if she saw Resident #1 come in the door or if she awakened but he came into her room and kissed her on the lips and then went to her bed and laid down. She put on her call light or she had it on, she could not remember for sure. Stated she was not scared of him as he usually acts normal. She felt safe at the facility and gets good care. She felt bad that he had to have a 1 on 1. Review of a list of BIMS scores provided by the facility revealed Resident #2 scored 11 out of 15, which indicated moderate cognitive impairment. Resident #1 and Resident #7, #8, #13, and #14:In an interview on 4/23/26 at 9:36 AM Resident #8 with BIMS score 15 out of 15 stated that Resident #1 entered her room on 4/14/26. He looked out the window and left. He never said anything to her or touched her in any way. She reported got great care at the facility and felt safe.In an interview on 4/23/26 at 2:40 PM Resident #8 stated that Resident #1 only came into her room that one time on 4/14/26.In an interview on 4/23/26 at 9:40 AM Resident #7 with BIMS score 13 out of 15 stated that Resident #1 sat in her chair and watched TV. She was startled when she saw him but he got up and left. He didn't said anything to her or touch her in any way. She felt safe at the facility but hoped someone was watching him.In an interview on 4/23/26 at 2:40 PM Resident #7 stated that Resident #1 had been in her room watching TV about one month prior to 4/14/26. Only two times.In an interview on 4/23/26 at 2:50 PM Resident #13 with BIMS score 15 out of 15 stated that Resident #1 came into her room only one time on 4/14/26. He came in and took off his shoes and dropped his pants and asked to get in bed with her. Her and the staff told him to get out. It took a while to get him out. Nothing physical or sexual happened. She stated that she is not scared and felt safe. She heard he kissed another resident later that evening.In an interview on 4/27/26 at 9:57 AM Resident #14 explained, in part, that that Resident #1 couldn't remember where his room was anymore.Review of Plan of Care (POC) documentation indicated between 3/30/26 and 4/28/26, 15 shifts documented wandering. Grabbing was indicated on one shift, pushing was indicated on one shift, repeated movement was indicated on two shifts and sexually inappropriate was indicated on one shift. Six shifts were marked not applicable.In an interview on 4/23/26 at 9:47 Staff A, Registered Nurse (RN) stated Resident #1 remained across the hall with a 1 on 1 still in place. He also had an alarm that triggers if he left the room. She stated there were medication changes but not sure which ones. She knew his seroquel (antipsychotic medication) was increased a couple weeks prior to the incident.In an interview on 4/23/26 at 10:44 AM Staff B, Certified Nursing Assistant (CNA) stated she was the 1 on 1 for Resident #1. He comes out every 5-10 minutes usually. She walked with him if he came out and redirected him if he tried entering other resident's rooms.In an interview on 4/23/26 at 12:38 PM the Administrator said that the 1 on 1 with Resident #1 would remain in place until they saw progress with the medication changes. The Administrator explained they changed some medications but he was really declining with his dementia. Hospice declined him since he was still physically in good health. They called [Redacted] for a locked unit and they were concerned with the kiss. They would look at him. In an interview on 4/23/26 at 2:35 PM Staff E, CNA stated that she knew Resident #1 had been wandering for a couple weeks but maybe longer as her days ran together. Maybe since November 2025. He was especially likely to go into another room if the TV was on. Stated that the incidents for rooms [six room numbers redacted] happened the same day. Resident #1 had been going into rooms prior to 4/14/26 but she never heard anything sexual prior to that. Resident #7 told her that he had been in her room before 4/14/26 but only watched TV. In an interview on 4/27/26 at 9:45 AM Staff C, CNA stated that Resident #1 wandered the halls for some time before the incident with Resident #2 on 4/14/26. He would occasionally go into others rooms and they would redirect him. He had not touched or interacted with other residents prior to this incident and now has a 1:1 with him.In an interview on 4/27/26 at 10:04 AM Staff D, CNA stated that Resident #1 has always wandered but mostly halls and around the nurse's station. If he went into a resident room, he would have been redirected. That was the only intervention prior to the incident with Resident #2 and the current 1 on 1.In an interview on 4/27/26 at 10:20 AM, the Administrator stated that Resident #1 had been wandering around the facility since admit and they placed a wander bracelet. He fairly recently started wandering into rooms but was easily redirected and never interacted with residents. For the last couple weeks he had been wandering and following staff and into other resident rooms. They tried Hospice but were unable to get that and they changed medications with psych involvement.In an interview on 4/27/26 at 2:40 PM the Administrator stated that after Resident #1's increase in behaviors they tried to get him into Hospice, changed his medications and had staff redirect when he would enter other residents' rooms. When reviewed Care Plan changes on December 8, 2025, she stated that there were no new interventions put in place until the incident on 4/14/26. She was aware that there was an incident on 3/28/26 with Resident #10 on 3/28/26 but it was not sexual in nature. He was only in her personal space. When questioned if that could be indicative of an escalation of his behaviors, she nodded.

Based on observations, clinical record review, staff interview and resident interview the facility failed to follow physician orders for oxygen use for 1 of 2 residents reviewed for respiratory care (Resident #37). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #37 dated 11/13/25 documented a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. The MDS further documented the resident had diagnoses of paraplegia, heart failure and respiratory failure. The MDS documented oxygen therapy usage. The Care Plan focus dated 3/22/23, revised 6/12/25, revealed Resident #37 had altered respiratory status, difficulty breathing related to history of pulmonary embolism (blood clot in lung) and acute and chronic respiratory failure with hypoxia (referring to lack of oxygen) and heart failure. The Physician Order dated 5/30/25 for R#37 documented oxygen (O2) 2 liters/minute per nasal cannula, every shift related to acute and chronic respiratory failure. On 1/5/26 at 11:51 AM Resident #37 relayed had wanted to wean off oxygen (02), was using 02 via nasal cannula, and said the setting should be set at 2 liters.An observation on 1/5/26 at 11:51 AM revealed Resident #37 lying in bed used 02 per nasal cannula. The 02 cannister setting was set at 3.5 liters. An observation on 1/6/26 at 2:45 PM revealed Resident #37 lying in bed used 02 per nasal cannula. The setting was set at 3 liters.An observation on 1/7/26 at 2:00 PM revealed Resident #37's oxygen cannister setting at 3.5 liters. An interview on 1/7/26 at 3:50 PM, Staff C, Certified Medication Aide (CMA) relayed the nurses monitor residents oxygen and also check their oxygen saturation levels (referred to use of pulse oximetry device to monitor blood oxygen levels). On 1/7/26 at 3:52 PM Staff D, Licensed Practical Nurse (LPN), Staff D queried about R#37 oxygen. Staff D relayed 02 would be checked during the shift, had an eight-hour shift to check resident's oxygen.On 1/7/26 at 3:55 PM the Director of Nurses (DON) relayed believed Resident #37's oxygen should be set at 2 liters, followed the DON, and observed the 02 cannister was set at 3.5 liters. The DON turned down to 2 liters and voiced the CMAs and nurses should monitor for correct setting. On 1/8/25, the Administrator relayed the facility did not have a policy for following physician orders.

Based on clinical record review, policy review and staff interviews, the facility failed to complete smoking assessments for 1 of 1 resident reviewed for smoking (Resident #50). The facility reported a census of 53 residents. Findings include: Resident #50's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) of 7 out of 15, indicating severe cognitive impairment. The MDS further indicated that the resident admitted to the facility on [DATE], had a diagnosis of non-Alzheimer's dementia and was independent with mobility. The Care Plan initiated 8/12/25 revealed Resident #50 was a smoker with goals the resident will not smoke without supervision and will not suffer injury from unsafe smoking practices. During the survey process, the facility provided a list of residents that smoked and Resident #50's name was documented. Review of Progress Notes for Resident #50 revealed she had smoked on the following dates:a.8/24/25b.8/28/25c.9/2/25Further review of Progress Notes revealed on 10/8/25 Social Services spoke to Resident #50 about complaints that the resident had been smoking in her room. The resident agreed to allow the Administrator and Social Services to search the room for smoking materials. Clinical record review revealed a smoking assessment had been completed on Resident #50 on 11/21/25, and revealed the resident required a smoking apron and supervision. The clinical record lacked additional smoking assessments for the resident. Review of facility policy titled, Resident Smoking Process, updated 4/21/22 revealed a Smoking Evaluation with Care Plan interventions addressing safety issues must be completed upon admission, quarterly, annually and for change in condition assessments. On 1/7/26 at 2:35 PM, the Director of Nursing (DON) revealed smoking assessments should have been for completed for Resident #50 with her MDS assessments. On 1/7/27 at 2:50 PM, the Administrator revealed it is an expectation residents have a smoking assessment completed prior to smoking at the facility.

Based on clinical record review, resident interview, staff interview and policy review the facility failed to ensure follow up dental care for one of one resident reviewed for dental services (Resident #37). The facility reported a census of 53 residents. Findings include: The Minimum Data Set (MDS) Assessment for Resident #37 dated 11/13/25 documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS further documented the resident had diagnoses of paraplegia, heart failure and respiratory failure. Per the MDS assessment, the resident required setup or clean-up assistance for oral hygiene. The Care Plan initiated 3/22/23, revised on 3/29/23, relayed Resident #37 had paraplegia. The Care Plan initiated 3/22/23, revised on 6/12/25, revealed the resident had chronic pain. The intervention dated 4/14/23, revised 6/12/25, revealed to administer analgesia as per orders, and the intervention dated 4/14/23, revised on 11/6/24, revealed to evaluate effectiveness of pain interventions. Resident #37's Progress Notes revealed the following:On 4/6/25, acetaminophen 650 milligrams (mg) administered for teeth pain.On 4/10/25, acetaminophen 650 mg administered for teeth pain.On 4/24/25, acetaminophen 650 mg administered for teeth pain.On 5/29/25, acetaminophen 650 mg administered for teeth pain.On 6/20/25, acetaminophen 650 mg administered for teeth pain.A document dated 9/12/25 from the visiting Medicaid dental provider relayed Resident #37's chief complaint, had pain with root tips, recommended root tip extraction on six teeth. A Progress Note dated 9/20/25 reflected visiting dental provider recommendation relayed there are six teeth, recommended extraction, referral to outside office will be made, after extractions and insurance authorization, upper and lower partial plates are recommended.A document dated 11/4/25 from the visiting Medicaid dental provider relayed Resident #37 refused teeth cleaning but, would like his teeth extracted. A referral was sent to facility for extraction of six teeth, and directed the facility to please coordinate a visit with an outside facility for resident to get these extractions taken care of.An interview on 1/7/2025 at 2:05 PM, Resident #37 relayed lost several teeth since came to the facility and needed dental services but, had just waited. Resident #37 relayed at times still had teeth pain, ate potatoes, rice and other soft foods as a result of not being able to chew in the back. Resident #37 relayed had dental services for cleaning, the dentist said, Resident #37 needed to go to town for additional services to get partial/dentures, was ready and willing, difficulty chewing with only front teeth and had intermittent pain. Resident #37 relayed would go anywhere to get the dental work and continued to wait. An interview on 1/8/26 at 12:32 PM with Social Services, Staff B revealed recently took on the role of setting up appointments and had set up an appointment today with the dentist in town due to past dental provider recommendations and alerted Resident #37. An interview 1/8/26 at 1:00 PM with the Administrator, relayed had new processes to ensure dental appointments. The facility policy titled Denture Services updated 10/19/22 documented the facility will assist residents in obtaining routine and 24-hour emergency dental care.

Based on observation, policy review and staff interviews the facility failed to ensure the dish machine reached manufacture guideline temperature to clean dishes and touched ready to eat food with bare hands causing potential cross contamination of food for 1 out of 1 meal observed. The facility reported a census of 43 residents. Findings include: In the course of the initial brief tour of the kitchen on 11/18/24 at 9:51 AM, observed an American Dish Service (ADS) National Sanitation Foundation Machine Model Series AF-3D(S)/AFC-3D(S) low temperature dish machine. There was a placard in the upper left above the rinse aid prime switch that revealed the wash/rinse minimum temperature to be 120 degrees fahrenheit. The Dishwashing Record High Temperature log for the month of November 2024 posted on the wall approximately 4.5 feet from the dish machine revealed the following temperatures recorded three times per day: Wash Rinse Wash Rinse Wash Rinse 11/1/24 -100 110 106 120 100 115 11/2/24 -110 120 100 110 105 120 11/3/24 -Blank Blank Blank Blank 108 120 11/4/24 -124 118 120 122 Blank Blank 11/5/24 -120 100 120 Blank 106 115 11/6/24 -120 100 120 Blank Blank Blank 11/7/24 -130 100 130 Blank 110 120 11/8/24 -Blank Blank Blank Blank Blank Blank 11/9/24 -Blank Blank Blank Blank 120 120 11/10/24-Blank Blank Blank Blank Blank Blank 11/11/24-112 122 Blank Blank Blank Blank 11/12/24-120 100 120 Blank 122 122 11/13/24-120 100 120 Blank 115 Blank 11/14/24-120 80 120 Blank 104 110 11/15/24-Blank Blank Blank 122 104 110 11/16/24-Blank Blank 114 120 Blank Blank 11/17/24-Blank Blank Blank Blank 120 130 11/18/24-112 Blank During an observation on 11/18/24 at 9:53 AM, observed Staff A, Dietary Aide operating the dish machine. Staff A, Dietary Aide revealed she was unaware of the type of dish machine the facility had. Staff A, Dietary Aide revealed the wash temperature is to reach 80? and the rinse temperature is 120 degrees fahrenheit. She acknowledged she was unsure what temperature the dish machine was to be at and just wrote down whatever the gauge read. The dish machine gauge revealed a temperature of 128 degrees fahrenheit. During an interview on 11/18/24 at 9:57 AM, Staff B, Dietary Manager revealed the dish machine is a low temperature chemical sanitation machine requiring a minimum temperature of 120 degrees fahrenheit for the wash/rinse cycles. Staff B, Dietary Manager tested the dish machine with an Ecolab Chlorine test strip and revealed a 100 part per million (PPM) hypochlorite concentration. Staff B, Dietary Manager acknowledged there were many areas left blank on the November 2024 Dishwashing Record High Temperature log. She further acknowledged many recorded temperatures were below the manufacture guidelines of 120 degrees fahrenheit. The facility failed to operate the dish machine at the manufacture guidelines to properly clean/sanitize the dishes. In an interview on 11/19/24 at 11:32 AM, the Consultant Dietitian revealed that she comes monthly to audit the kitchen for food service safety. The Dining Registered Dietitian Kitchen Inspection on 10/31/24 at 2:00 PM documented the log for the dish machine was partially filled out but does have holes. The Consultant Dietitian revealed the facility had been using the wrong log to record wash and rinse temperatures and provided the proper form to the Dietary Manager and Administrator. Observed operation of the dish machine on 11/19/24 at 12:19 PM with Staff B, Dietary Manager. The temperature gauge on the dish machine revealed wash cycle temperature of 124 degrees fahrenheit, rinse cycle temperature of 128 degrees fahrenheit and chemical strip revealed 50 PPM. The ADS Install Manual, AF-3D-S/AFB Series, Revision 4.5, April 28, 2021 on page 2 #3 documented water heaters must provide the minimum temperature of 120 degrees fahrenheit required by the machine. The recommended temperature range for optimal performance is 130-140 degrees fahrenheit. Review of the facility Cleaning Dishes/Dish Machine Policy dated 2021 revealed prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. For low temperature dishwasher spray type dish machines using chemicals to sanitize the wash temperature is 120 degrees fahrenheit. Sanitization is 50 PPM. The policy failed to list the temperature for the rinse cycle. Review of the Dish Machine Temperature Log policy dated 2021 revealed staff will record dish machine temperatures for the wash and rinse cycles at each meal. The facility missed 47 opportunities to record wash/rinse temperatures and on 27 opportunities recorded temperatures below the manufacture guidelines. 2. During continuous observation on 11/19/24 at 11:39 AM, observed Staff C, [NAME] facing the steam table holding a bun in her bare hands. Staff C, [NAME] opened the bun and placed it on a plate sitting on the steam table. Observed an additional 3 plates with open buns on the steam table. Observed Staff C, [NAME] grab cheese slices from a plate to the right of the steam table with her bare hands, placing 1 slice of cheese on each open bun. Staff C, [NAME] proceeded to grab tongs and place a hamburger on each of the 4 open buns. Staff C, [NAME] placed the tongs in the steam table pan on the stove. Staff C, [NAME] placed the top of the bun on each hamburger with her bare hand. Staff C, [NAME] grabbed the handle of a scoop and placed a serving of peas on each of the four plates. Staff C, [NAME] held the top of the bun with her left hand, using a knife with her right hand to quarter each of the hamburger sandwiches. After sectioning one burger she would place the plate on cart that was to her left and then proceeded to do the same until all four plates were on the cart. The cart was taken to the dining room and served to the 4 residents. Observed Staff D, [NAME] with gloved hands place bread on the griddle. Staff D, [NAME] with right gloved hand place a hamburger on the griddle using tongs. Staff D, [NAME] turned and using the same gloved hands took two slices of cheese, placed one on the hamburger and the other on one of the bread slices on the griddle. Staff C, [NAME] looked at the cheese slice on the bread and using her left bare hand picked up the cheese and replaced it on the bread slice on the griddle. Staff D, [NAME] using the same gloved hands picked up a spatula and placed the bread slice from the griddle on top of the bread slice with the cheese. Staff D, [NAME] with his left gloved hand held the top of the grilled cheese sandwich while using a spatula with his gloved right hand to place the grilled cheese sandwich on a plate. Staff C, [NAME] placed her left bare hand on top of the grilled cheese sandwich holding the edges then used her right hand cut the sandwich in half diagonally with a knife. The plate was placed on a cart and taken to the dining room to be served. During an interview on 11/19/24 at 11:49 Staff C, [NAME] acknowledged touching the hamburger buns, cheese, and grilled cheese sandwich with her bare hands. Staff D, [NAME] acknowledged touching the cheese and the grilled cheese sandwich with the gloved hands that came in contact with other potentially contaminated surfaces. Staff C, [NAME] revealed that she normally wears gloves but had been instructed not to wear gloves that day. On 11/19/24 at 11:50 AM Staff B, Dietary Manger acknowledged she observed Staff C, [NAME] touching the hamburger buns and cheese with her bare hands. Review of the facility General Food Preparation and Handling policy dated 2021 revealed bare hands should never touch ready to eat raw food directly. Disposable gloves are a single use item and should be discarded after each use. The policy further stated that food should be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. Staff C, [NAME] and Staff D, [NAME] failed to use proper food handling procedures for the meal service observed.

Based on clinical record review, resident interview, staff interviews, and community members interviews, the facility failed to treat a resident with dignity and respect for 1 of 2 residents reviewed for dignity (Resident #33). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #33 revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15 indicating intact cognition. The MDS further documented diagnoses including acute and chronic respiratory failure. Review of Physician Orders for Resident #33 revealed an order for full code/cardiopulmonary resuscitation (CPR) dated [DATE]. The Care Plan for Resident #33 revised [DATE] revealed the resident had an Iowa Physician Order for Scope of Treatment (IPOST) in place and requested a CPR/full code order. The Care Plan further revealed a goal that the resident will have the requested code status honored during the facility stay. Review of Progress Notes dated [DATE] at 2:05 PM documented by the Director of Nursing (DON) revealed she had been called to Resident #33's room and she told the resident you need to go to the hospital and as she was finishing her sentence both the police officer and the Emergency Medical Technician (EMT) told her it was not her decision to make. The DON further documented the resident was a full code and he needed to go to the hospital because his oxygen level was low and with him being a full code, he needed to go to the hospital or change his code status. During an interview [DATE] at 10:48 AM the DON revealed on [DATE] Resident #33 had contacted 911 himself and that he had a habit of doing that. Revealed 911 then contacted the facility and facility staff requested the ambulance come here as the resident wasn't doing well. The DON further revealed she wanted Resident #33 to go to the hospital to get treatment and stated that is how you have to speak to these guys. The DON denied telling the resident he had to change his code status if he stayed at the facility. During an interview [DATE] at 2:06 PM, Resident #33 stated on [DATE] prior being transferred to the hospital he asked the DON why she was again asking him about his code status as they had already talked about it. Resident #33 stated it made him feel small when she brought up his code status again that day prior to being transferred. During an interview [DATE] at 9:23 AM, Staff E, Certified Nursing Assistant (CNA) revealed she had been in Resident #33's room on [DATE] when the EMTs and a police officer were present. Staff E stated one of the EMTs wanted report so Staff F, CNA went to get the DON. Staff E stated the DON reported the resident was being sent out because he wouldn't change his code status and the EMT said we cannot take him if he does not want to go. Staff E stated after the DON had told Resident #33 you have to change your code status or leave, the EMT told the DON to leave the room and when she did not want to leave, the police officer said the resident was now under the care of the EMTs and the DON left the room. During an interview [DATE] at 9:55 AM, Staff F, CNA revealed she was in Resident #33's room on [DATE] with the 2 EMTs and the police officer. Staff F stated when the DON came into the room she stated the resident was getting shipped out because he wouldn't change his code status and told the resident we can't have you here if you don't change your code status. Staff F further stated she felt like the DON was giving Resident #33 an ultimatum in regards to changing his code status or going to the hospital. During an interview [DATE] at 12:13 PM, Staff G, CNA revealed she had been in Resident #33's room when the EMTs and the police officer were present on [DATE]. Staff G stated the resident made it clear that he didn't want to go to the hospital and the DON didn't give him an option, she gave him an ultimatum that she didn't want him there if he didn't change his code status from full code to DNR. Staff G further stated the DON left the room after an EMT asked her to leave and she felt the DON could have been more professional during the situation. On [DATE] at 1:37 PM, the Administrator revealed the facility did not have a specific policy related for Resident Rights however the information was located in the facility admission packet. Review of the facility's undated admission packet revealed the resident has a right to a dignified existence and the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. During an interview [DATE] at 11:16 AM the Administrator revealed it is an expectation residents are treated with dignity and respect.

Based on observation, clinical record review, and staff interview, the facility failed to notify the physician of a hospital transfer for 1 of 1 residents reviewed for hospitalization (Resident #33) and failed to follow physician orders related to oxygen for 1 of 12 residents reviewed (Resident #20). The facility reported a census of 43 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #33 revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15 indicating intact cognition. The MDS further documented diagnoses including acute and chronic respiratory failure. The Care Plan for Resident #33 revised 3/29/23 documented the resident had altered respiratory status and difficulty breathing and directed staff to monitor for respiratory distress and report to the medical director as needed including decreased pulse oximetry (blood oxygen saturation) and confusion. Review of Progress Notes for Resident #33 revealed on 9/1/24 at 1:47 PM, the Director of Nursing (DON) documented the resident was only oriented to self at the time and his pulse oximetry was 78% on 2 liters of oxygen. The DON further documented the resident was being transferred to the emergency room (ER) on an emergency basis due to vital signs and drastic change in mental cognition. Clinical record review revealed Resident #33 transferred to the hospital on 9/1/24. The clinical record lacked documentation related to physician notification of the transfer. During an interview 11/21/24 at 8:10 AM the Administrator revealed there was not a policy in regards to physician notification as the expectation is to follow regulations. During an interview 11/21/24 at 10:48 AM the Administrator revealed it is an expectation the provider would be notified if a resident was being transferred to the hospital and if it was an emergent situation, the physician would be notified immediately following the transfer. The Administrator acknowledged the physician had not been notified when Resident #33 was transferred to the hospital on 9/1/24. 48886 2. The MDS, dated [DATE], documented Resident #20 had a BIMS score of 14 out of 15, indicating intact cognition. The MDS further documented the resident had diagnoses to include progressive neurological conditions, multiple sclerosis, anxiety disorder, depression, and post traumatic stress disorder. Review of the electronic health record (EHR) for Resident #20 revealed an order for 2 liters (L) of oxygen PRN (as needed) for saturations below 90% and anxiety, with a start date of 3/15/24. During an observation 11/18/24 at 2:45 PM, Resident #20 had her oxygen set at 4 liters, resident was in bed with her oxygen on and in use. During an interview 11/18/24 at 2:45 PM, Resident #20 stated she has not observed staff to change the tubing or the water in the canister/humidifier. During an observation 11/19/24 at 2:45 PM, Resident #20 had her oxygen set at 4 liters, the resident was in bed with her oxygen on and in use. During an observation 11/20/24 at 3:03 PM, Resident #20 had her oxygen set at 4 liters, the resident was in bed with her oxygen on and in use. The tubing had a date of 11/17 and a gallon of distilled water was next to the oxygen machine was a date of 11/15/24. During an interview 11/20/24 at 3:05 PM, Resident #20 stated she had her oxygen on most of the time, she said it is rare that she does not have her oxygen on. She said sometimes it might fall off while she is sleeping. Review of the treatment administration record (TAR) from March of 2024 to November of 2024 for Resident #20 lacked documentation of the administration of oxygen. The TAR did not reflect any dates the resident received oxygen, including the dates the resident was observed to have her oxygen on: 11/18/24, 11/19/24 and 11/20/24. The TAR further lacked documentation the tubing was changed. During an interview 11/20/24 at 3:25 PM, the Administrator and Director of Nursing (DON) stated the oxygen for Resident #20 is a PRN order for anxiety, not for respiratory concerns. The Administrator stated the facility started on the 6th of November using hard charting for the oxygen/nebulizer tubing changed every Saturday during the 3rd shift, this used to be documented on the TAR. The Administrator acknowledged this was not documented on the TAR for Resident #20 prior to November 6th. The Administrator also acknowledged the TAR does not reflect when the resident was using the oxygen. The Administrator and DON acknowledged the order for the resident's oxygen was for 2 L PRN for anxiety, and were unaware the resident was receiving oxygen at 4 L. The Administrator stated an expectation the order is followed and the resident should not receive oxygen at 4 L, or above the ordered 2 L. The Administrator stated an expectation the physician's orders be followed, the TAR should reflect when the resident receives the oxygen, and there should be documentation as to when the tubing is changed. During an interview 11/20/24 at 3:30 PM, the DON stated she went to Resident #20's room and her oxygen was set at 4 L, she moved this down to 2 L. During an interview 11/21/24 at 8:30 AM, the Administrator stated a conversation took place yesterday with the hospice nurse who stated they thought an order had been written for resident to be on 2-4 L oxygen PRN for anxiety, comfort, and oxygen saturation under 90. The Hospice team had been setting resident's oxygen at 4 L when they were here for visits. During an interview 11/21/24 at 10:46 AM, the Administrator stated the facility does not have a policy on following physician orders, they follow professional standards.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (April 1st to June 30th) review, facility staffing assignments review, and staff interviews, the facility failed to submit accurate staffing data for the PBJ Staffing Data Report. The facility reported a census of 43 residents. Findings include: The PBJ Staffing Data Report run date of 11/13/24 triggered for excessively low weekend staffing for the fiscal year 3rd quarter, April 1st to June 30th of 2024. Review of Facility Daily Assignment Sheets and daily posting for the infraction dates reflected the facility had adequate weekend staffing according to their census and facility assessment equation for staff required. During an interview 11/21/24 at 12:32 PM, the Administrator stated an uncertainty as to why the facility triggered for low weekend staffing, stating a corporate human resources (HR) employee submits the PBJ data. Starting in October of this year, the HR employee has sent her an email prior to submitting to PBJ if he notices low RN coverage, and it is usually because they forgot to add in agency staff or the Director of Nursing (DON) or Assistant Director of Nursing (ADON), who also fill in for hours given their lower census if someone does not come in for work. The administrator sent an email to corporate HR to see if they might have an idea why they triggered for low staffing. During an interview 11/21/24 at 1:24 PM, the Administrator stated she received an email from corporate HR. During the fiscal year 3rd quarter, only 3 days of agency staffing were submitted: 5/26 (Sunday), 5/27 (Monday) and 6/9 (Sunday). The Administrator stated this would not accurately reflect the amount of agency staff and believes this is why it would have triggered for low weekend staffing. The Administrator stated they are accurately reporting to PBJ currently. The facility does not have a policy on submitting to PBJ.

Based on clinical record review, staff interview, and facility policy and procedure review at the time of the investigation, the facility failed to document on a resident with a change in condition for 1 of 6 residents reviewed (Resident #6). The facility identified a census of 41 residents. Findings include: 1. A Minimum Data Set (MDS) completed for Resident #6 with an assessment reference date of 7/23/24, documented diagnoses which included heart failure, hypertension, diabetes mellitus, and Non-Alzheimer's dementia. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 7 which indicated moderate impaired cognitive decisions and sometimes is understood and usually understands others. The resident required dependent to substantial assistance from staff for dressing, toilet use, and personal hygiene and dependent with transfers. The MDS also documented a wheelchair as primary mode of transportation. The Care Plan with a focus area initiated 7/23/24, the resident requires tube feeding related to dysphagia, swallowing problems, and also has an oral diet of pureed with nectar thickened liquids. Interventions include: *Listen to lung sounds per protocol. *Monitor/document/report to Medical Doctor, Aspiration- fever, shortness of breath, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration. The Progress Notes dated 8/3/2024 at 6:37 a.m., Health Status Note Text: At approximately 5:55 a.m., Certified Nursing Assistant (CNA) reported resident feeling warm. During assessment, temp. 97.1, Respirations 22, Heart Rate 82, oxygen saturation at 90% on room air, resident complained of sore throat, wet cough observed, crackles audible in bilateral. upper lobes. HOB elevated at this time, writer reported to oncoming nurse who will monitor and report if symptoms worsen. The Progress Notes dated 8/3/2024 at 8:10 a.m., Health Status Note Text: New order from on call provider to start Mucinex x 5 days and for 2-3 view chest x-ray. BioTech closed in this area today and has her scheduled for 8/4-8/5. The clinical record lacked documentation of any further assessment on the resident with a change in condition. Interview on 8/21/24 at 1:30 p.m., the facility Quality Assurance Nurse confirmed and verified that the clinical record lacked any documentation of on-going assessment with Resident #6 with the change in condition and it is the expectation of the nurses to follow the federal rules and guidelines with documentation and the facility policy and procedure. The Clinical Change in Condition Management dated 6/2015, documented The Interdisciplinary team strives to identify and manage all resident/patients that are experiencing a change in condition. Daily observation and communication is important in identifying changes in a resident/patient that requires further investigations. Daily observation includes but is not limited to changes in: *Physical assessment (cardiovascular, respiratory, mental status, neurological) *Behavior *Mobility *Comfort level *Response to medications Clinical care management includes routine assessment, evaluation, response to changes in clinical condition and communication with residents/patients and/or families/responsible parties. Procedure: 1 Assess resident/patient clinical status when a change in condition is identified. 2. Review the resident/patient medical record

Based on clinical record review, staff interview, and speech therapy recommendations the facility failed to provide direction for adequate supervision to implement speech therapy recommendations for 1 of 6 resident reviewed (Resident #1). The facility identified a census of 41 residents. Findings include: The Minimum Data Set (MDS) with an assessment reference dated 7/21/24, documented Resident #1 with diagnoses which included Non-Alzheimer's Dementia, anxiety, depression, bi-polar, and weakness. The MDS documented the resident with the ability to be understood and ability to understand others, with short and long term memory problems and moderately impaired for decision making abilities, and disorganized thinking with delusions. The resident required set up assistance with eating and is edentulous (no natural teeth). The Care Plan with an initiated date of 7/16/24, identified a problem of the resident had nutritional problem or potential nutritional problem related to dementia which could impact intake as disease progresses. Interventions include: *Monitor/document/report to Medical Doctor for signs/symptoms of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals. *Provide, serve diet as ordered. Monitor intake and record q (each) meal. *Registered Dietician to evaluate and make diet change recommendations. *The resident needs a calm, quiet setting at meal times with adequate eating time. The resident prefers to sit (Specify location). Encourage The resident's socialization and interaction with table mates during meals. The Speech Therapy Evaluation and Plan of Treatment dated 7/23/24-8/20/24, documented patient referred due to cognitive concerns and swallowing evaluation completed on this date. Patient was referred due to coughing during meals. Patient is currently on regular solids/thin liquid diet. Patient reports she coughs on everything and has been for a while. Oral exam revealed patient is edentulous. Patient has dentures but does not wear them because she says it is too much work to get them cleaned up, get the glue on and get them in. Cough prior to oral intake. Patient demonstrated coughing episode with thin liquids. Speech therapist would recommend a mechanical soft diet but patient refused. Speech therapist spoke with patients Power of Attorney who was educated on risk of aspiration and recommendations. Patient POA agreed with patients decision to remain on a regular solid diet at this time. Speech therapist recommends swallow study in order to determine safest and least restrictive diet. Distant supervision during oral intake, cues from staff for strategies: small bites, slow rate, alternate solids and liquids. The Clinical Record lacked documentation that these recommendations were followed or implemented. Interview on 8/20/24 at 12:00 p.m., the facility Registered Dietician confirmed and verified that the facility staff needed to follow the Speech Therapist recommendations as written and had no knowledge of the Speech Therapist recommendations for the small bites, alternate solids/liquids. Interview on 8/20/24 at 12:15 p.m., the facility physician confirmed and verified that they were not aware of the Speech Therapist recommendations and that the facility failed to notify that the Speech Therapist recommended a video swallow study and to have Resident #1 alternate solids/liquids and small bites. Interview on 8/20/24 at 1:00 p.m., Staff A, Register Nurse (RN), confirmed and verified that the Speech Therapist recommendations were not followed and that the facility follows the federal regulations and guidelines.

Based on observation, staff interviews and facility policy review, the facility failed to prepare food in a safe/sanitary manner that prevents foodborne illness, when Dietary Staff observed to have left frozen meat to thaw at room temperature. The facility reports a census of 50 residents. Findings Include: During an observation 12/04/23 at 9:00 AM, in the main kitchen with the Dietary Manager (DM) present, two 32 ounce packages of frozen turkey were sitting on the stainless steel counter next to the sink in the kitchen, thawing at room temperature. During an interview 12/04/23 at 9:00 AM, the DM advised the meat is thawing for dinner tonight. The packages of turkey were taken out of the freezer at approximately 8:30 AM on this same date and placed on the counter to thaw at room temperature. The DM indicated an intent to leave the turkey on the counter to thaw for approximately 4-5 hours today and use the turkey for the evening meal. The DM advised this is the method used to thaw meat, and has used this practice more than once during the past few months. During an interview 12/05/23 at 9:30 AM, the Administrator advised the expectation is for Dietary Staff to follow the policy for thawing meat and to thaw meat in a safe manner. The Administrator advised frozen meat was observed on the counter in the kitchen this morning and the Administer threw this meat away. The administrator has been in the kitchen daily since starting employment at the facility and has thrown meat out if it has been observed thawing at room temperature. The Dietary Staff are contracted through a service company and might have a separate policy from the facility policy on safe and appropriate thawing of meat. During an interview 12/05/23 at 9:40 AM, the Administrator discussed a conversation that was just held with the DM and the Director of Dietary Services for contracted service company. The service company found to have a similar policy on safe thawing of meat as the facility. The DM acknowledged to the Administrator thawing meat on the counter in the kitchen for 4-5 hours and acknowledged the policy on thawing meat was not followed. The Administrator educated the DM and the Director of Dietary Services on proper thawing of meat as directed in the policy and had both sign the policy. Review of facility policy titled Sanitation & Food Production, Thawing, dated June of 2015, directed staff to thaw foods according to one of two choices as indicated; either in the refrigerator or as part of the cooking process.

Based on clinical record review, observations, facility policy review, resident and staff interviews, the facility failed to accurately document and submit an accurate resident Minimum Data Set (MDS) assessment for 1 of 1 residents reviewed with a hearing impairment (Resident #49). The facility reported a census of 50 residents. Findings Include: The MDS Assessment for Resident #49 dated 9/26/23 lacked documentation related to a hearing impairment. The MDS documented the resident had not used a hearing aid in the last 7 of 7 days, her ability to hear was adequate and she had no difficulty in normal conversations, social interactions or listening to the television. The current Care Plan for Resident #49 initiated 9/30/23 lacked a focus area or interventions related to the resident having a hearing impairment including use of hearing aids or communication interventions. On 12/4/23 at 10:25 AM, observed Resident #49 wearing hearing aids. The resident indicated in order for her to understand what someone was saying; the information would need to be written down on a pad of paper she had available. The resident stated her hearing aids weren't working and she didn't know when she would be having an appointment to have them fixed. The facility policy titled, Resident Assessment Instrument (RAI)/Minimum Data Set (MDS) dated [DATE], documented the RAI/MDS is an Assessment Tool that assists skilled nursing facility staff to accurately and routinely compile information regarding resident needs and strengths. The policy further documented each individual who completes a section of the MDS must certify the accuracy of that section of the assessment and the MDS coordinator is responsible for ensuring all appropriate edits are made prior to transmission of the data. During an interview 12/11/23 at 10:24 AM, the Interim Director of Nursing acknowledged the use of hearing aids should have been documented in Resident #49's most recent MDS Assessment.

Based on clinical record review, Bath Sheet review, facility policy review, resident and staff interviews, the facility failed to provide at least two showers, baths or whirlpool baths per week for 1 of 3 residents reviewed for bathing(Resident #5). The facility reported a census of 50 residents. Findings Include: The Significant Change Minimum Data Set (MDS) assessment dated [DATE] for Resident #5 documented she had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicating moderately impaired cognition. The MDS identified the resident required limited assistance of 1 staff for bed mobility and toileting, supervision with transfers and physical help in part of bathing activity. The MDS indicated the resident had diagnosis of peripheral vascular disease, atrial fibrillation, arthritis, non-Alzheimer's dementia, and anxiety disorder. The Care Plan Focus Area revised 10/16/23 identified a need for assistance with activities of daily living including staff participation with bathing. Per documentation in Section GG of the - Shower/Bathe Task, the resident was to receive a shower/bath on Mondays and Thursdays on the evening shift. The documentation indicated the resident did not receive a shower/bath on 11/2/23, 11/6/23, 11/9/23, 11/13/23, and 11/23/23. The facility provided copy of shower sheet for 11/22/23 indicating resident received a shower on that date. The Plan of Care (POC) Response History (electronic documentation for care) with a look back of 30 days and printed on 12/5/23 at 2:25 PM, the prompt Shower/Bathe Self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair) documented the following: a. On 11/13/23 at 9:59 PM not applicable. b. On 11/16/23 at 2:25 PM substantial/maximal assistance - helper does more than half the effort. c. On 11/20/23 at 2:25 PM resident refused. d. On 11/23/23 at 9:05 PM not applicable. e. On 11/27/23 at 3:11 PM independent - resident completed the activity by themselves. f. On 11/30/23 at 9:59 PM supervision or touching assistance - helper provided verbal cues and/or contact guard assistance. g. On 12/4/23 at 5:25 PM independent - resident completed the activity by themselves. In an interview on 12/4/23 at 5:10 PM, the resident stated she did not believe she had set up shower days and she sometimes did not receive showers. She stated her family heard staff say they were short staffed and no showers/baths would be given. In an interview on 12/11/23 at 11:45 AM, the Interim Director of Nursing (DON) stated it was the expectation bathing be completed twice a week and as needed. The Interim DON further revealed if a resident refused bathing, the refusal was to be documented. The facility provided policy titled Bathing dated 1/2013 stated staff were to provide the resident with the opportunity to bathe according to preference and facility procedure. They were to document refusal of all or part of the shower and notify the physician of any changes or concerns in the resident response to bathing, ability to participate or changes in clinical condition. Staff were to review and revise resident bathing plan, as indicated.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to provide the opportunity for the resident and/or resident representative to participate in the development, review and revision of a Care Plan on a quarterly basis for 1 of 1 residents reviewed (Resident #48). The facility reported a census of 50 residents. Findings Include: The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #48 with an admitted [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS indicated the resident had diagnoses that included cerebral palsy, seizure disorder, adult failure to thrive, obesity and borderline intellectual functioning. Resident required extensive assistance of 2 staff for bed mobility, transfers, toileting, and personal hygiene and required supervision with eating. Record review revealed a copy of a Care Review form dated 6/21/23 which indicated the resident was present and the resident's family was present via phone for the Care Conference. No documentation of the Care Plan meeting being held or resident/family notification of the Care Plan meeting in September 2023 found in the resident's record In an interview on 12/5/23 at 9:18 AM, Resident #48 stated he was unaware of what a Care Plan meeting was and did not believe he had ever participated in one or been told of any upcoming Care Plan meetings. In an interview on 12/6/23 at 2:21 PM, the Interim Director of Nursing (DON) stated Resident #48 was invited to the initial Care Plan meeting but he was unable to find documentation that the resident or his family were notified of the September Care Plan Meeting. In an interview on 12/6/23 at 2:22 PM, the Administrator provided documentation of times the facility had attempted to call family and/or spoken with family related to the Resident #48's care but there was no documentation the Care Plan Meeting information was discussed. The Administrator stated the resident did have a Care Plan Meeting coming up on 12/13/23 and reported they had attempted to contact family about attending on this date. In an interview on 12/11/23 at 1:35 PM, the interim DON stated it was the expectation both the resident and the resident's family/representative be given the opportunity to be present for the Care Plan Meeting unless the competent resident chose not to have family/representative present. The resident and family/representative were to be notified verbally, via phone or via letter and there was to be follow up documentation in the progress notes in the Electronic Health Record. In a facility provided policy titled Care Plan Development dated 8/2015, and documented the resident/family/legal guardian's are encouraged to attend Care Plan Meetings and will be notified in writing via postal service of date and time of meeting. The Social Worker/MDS Coordinator will send invitations to the meeting and schedule times for the Care Plan Meeting which will be held on a specific date and start time as designated by the facility. Accommodations for scheduling will be made according to residents/family/legal guardian's availability or needs as necessary. Attendance may be defined as in person or telephonically.

Based on clinical record review, staff and resident interviews, and policy review, the facility failed to follow a Comprehensive Care Plan for 1 of 1 residents reviewed for a hearing impairment (Resident #49). The facility reported a census of 50 residents. Findings Include: The Admission Minimum Data Set (MDS) Assessment for Resident #49 dated 9/26/23 lacked documentation related to a hearing impairment. The MDS documented the resident had not used a hearing aid in the last 7 of 7 days, her ability to hear was adequate and she had no difficulty in normal conversations, social interactions or listening to the television. The current Care Plan for Resident #49 initiated 9/30/23 lacked a focus area or interventions related to the resident having a hearing impairment, use of hearing aids or interventions for communication. On 12/4/23 at 10:25 AM, observed Resident #49 wearing hearing aids. The resident stated her hearing aids weren't working and she didn't know when she would be having an appointment to have them fixed. The resident further indicated in order for her to understand what someone was saying; the information would need to be written down on a pad of paper she had available. Review of facility policy titled, Care Plan Development, dated August 2015, documented an individualized, Comprehensive Care Plan will be developed for each resident after the completion date of a comprehensive MDS Assessment, and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Review of facility policy titled, Resident Assessment Instrument (RAI)/Minimum Data Set (MDS), dated [DATE], documented the RAI/MDS is an Assessment Tool that assists skilled nursing facility staff to accurately and routinely compile information regarding resident needs and strengths to facilitate the development of an individualized plan of care for the resident. During an interview 12/11/23 at 10:24 AM, the Interim Director of Nursing revealed the use of hearing aids including interventions should have been documented in Resident #49's Care Plan.

Based on clinical record review and staff interview, the facility failed to document an accurate code status for 1 of 24 residents reviewed for Advanced Directives (a legal document that tells your doctor your wishes about your health care if you can't make the decisions yourself (Resident #9). The facility reported a census of 50 residents. Findings Include: The Admission Minimum Data Set (MDS) Assessment tool dated [DATE], documented Resident #9 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating moderately impaired cognition. The resident had diagnoses of spinal stenosis, bilateral artificial knee joints, coronary atherosclerosis, tachycardia and tobacco use. The MDS documented [DATE] as the resident's admitted . The Care Plan dated on [DATE] did not address Resident #9's Advanced Directives. The Iowa Physician Orders for Scope of Treatment (IPOST) signed by the resident on [DATE] and the physician on [DATE] indicated the resident desired to be a Do Not Resuscitate (DNR) status in the event her heart stopped beating. The Electronic Health Record (EHR) indicated the resident desired to be a full code under the code status listed in the resident profile area and she was her own decision maker. The Physician Orders Summary in the EHR dated [DATE] indicated the resident was to be a Full Code and desired Cardiopulmonary Resuscitation (CPR). In an interview on [DATE] at 12:10 PM, the Director of Nursing (DON) stated it was the expectation IPOST Audits be completed monthly to ensure the Physician Order matches the IPOST The facility provided policy for Emergency Care/CPR dated ,d+[DATE] and last reviewed on ,d+[DATE] indicated the Physician's Order for full code or DNR was written based on the wishes of the resident/resident representative or legally authorized party. Code status orders were to be renewed on admission, quarterly and as needed basis and with any significant change of condition by the Interdisciplinary Team. Code states was to be renewed by the physician's review and signature on monthly orders. Each resident/or representative or legally authorized party was to have their code status documented in the medical record.

Based on clinical record review, staff interviews, facility investigation review, facility policy review, and facility door alarm check review, the facility failed to promptly repair a broken door alarm, failed to put effective interventions in place while awaiting door repair, failed to follow the door check policies to check the door alarms daily, and failed to identify a resident's moderate elopement risk and put in effective interventions to mitigate the risk of elopement for 1 of 3 residents reviewed (Resident #2). The resident eloped on 1/23/23 at approximately 6:20 PM and a neighbor notified the facility the resident was outside alone by the curb at 6:30 PM. The weather was 30 degrees outside, with winds at 10 mile per hour(mph) with a wind chill temp of 21 degrees, and snow on the ground. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The staff reported a census of 40 residents. On 6/28/23 at 2:15 PM, the Department of Inspections and Appeals staff contacted the facility staff to notify them of the Immediate Jeopardy situation at the facility beginning on January 23, 2023. The facility removed the immediacy on 6/29/23 by completing the following: 1. On 1/30/23 the front door mag lock was repaired and was functioning properly. A new elopement assessment was completed on 1/23/23 by the licensed nurse and wander guard bracelet applied. Care plan updated on 1/23/23 to reflect current elopement risk and interventions. 2. Interim Director of Nursing (DON) or Designee completed new Elopement Risk Assessment and reviewed the Care Plan on 1/23/23 and 1/24/23 to ensure elopement risk behaviors are identified and interventions are in place. 3. Beginning 1/23/23-1/24/23 the Interim Administrator or Designee educated on Elopement Policy and Procedure. Education began on 1/23/23 provided by facility staff by the Administrator/Designee regarding checking exit door alarm system. DON educated the MDS nurse and licensed nurses beginning /29/23 regarding requirements of completing elopement risk assessments accurately and updating the care plan to include interventions for residents at moderate to severe risk of elopement. The scope lowered from a J to a D at the time of the survey after ensuring the facility implemented education and their policy and procedures. Findings include: The Minimum Data Set (MDS) assessment, dated 12/3/22, for Resident #2, included diagnoses of Non-Alzheimer's Dementia, depression, and chronic obstructive pulmonary disease (lung disease causes difficulty breathing). The MDS identified the resident needed limited assistance of 1 staff for walking and dressing; and limited assistance of 2 staff for bed mobility, transfer, and toilet use. A Brief Interview for Mental Status score of 4 out of 15, indicated severe cognitive impairment for decision-making. The MDS documented the resident did not use any alarm to monitor resident movement. The Elopement Risk Assessment for Resident #2, dated 7/26/22, documented a score of 5, moderate risk for wandering due to forgetfulness, independent with walker, early dementia, and taking antidepressants, with summary of resident is not a elopement risk, no intervention needed at this time. The Elopement Risk Assessment for the resident, dated 1/23/23, documented a score of 5, moderate risk for wandering due to disoriented, medication change, independent with walker, Alzheimer's Disease, taking antidepressants, with summary of wander guard to be applied due to exited facility unattended. The Elopement Risk Assessment for the resident, dated 1/25/23, documented a score of 22, high risk for wandering due to disoriented, exhibits/expresses fear and anxiety, medication change, independent with walker, taking antidepressants and narcotics, early dementia, known wandering/history (hx) of wandering, known exit seeking/hx of exit seeking, with summary of wander guard applied and care plan updated. The clinical record lacked quarterly Elopement Risk Assessment after 7/26/22. The Care Plan with resolved date 12/21/20 documented the resident was an elopement risk/wanderer as evidenced by a history of attempts to leave the facility unattended and an impaired safety awareness. The Care Plan lacked any revision with the change in the Elopement Risk Assessment on 7/26/22. The Progress Notes for Resident #2 documented the following: On 1/13/23 at 8:46 AM received signed order to discontinue Donepezil (medication to treat dementia) but dementia may increase. On 1/15/23 at 8:38 PM resident up and down, wanting to go outside and following staff around. Resident has baseline confusion. Resident redirected several times. On 1/18/23 at 4:37 AM resident up all night this shift. Pleasant, has both wandered and sat. Numerous attempts to guide her to her room without success. On 1/23/23 at 4:06 PM resident anxious, restless, and wandering. Became agitated with staff when not understanding questions. Called resident's niece to come visit. Niece on her way to take resident outside for a cigarette at resident's request. The facility Incident Report titled, Elopement for Resident #2 dated 1/23/23 at 6:30 PM, documented: Facility staff received phone call from outside source stating there was possibly one of our residents outside with a walker slightly down the road. When staff arrived, they stated it was Resident #2 and redirected her back inside. Resident stated she just wanted to go home. The facility form titled, 5 Day Investigation Summary for Resident #2, documentation included: Elopement on 1/23/23 with resident found 96 steps away from the front door of the facility and standing next to the curb along the facility property. Facility Investigative Findings: no staff member witnessed resident go out a door and staff report they did not hear the front door alarm sound. Nurse completed an audit of all exit doors on 1/23/23 and all sounded appropriately when opened. The front entrance door of facility mag lock was awaiting repairs prior to the event therefore a temporary double alarm device had been placed on both sides of the door. Due to staff not hearing this alarm device sound at the time of the incident, a staff member was assigned to watch the door until door is repaired. Door schedule for repair on 1/30/23. Interview on 6/27/23 at 9:16 AM, Staff A, current Business Office Manager (BOM) and Provisional Administrator at time of elopement stated procedure for response to door alarms is daily door alarm checks by nursing on day shift, the procedure is to go to each door and check with wander guard and check all exterior door alarms and all staff are trained upon hire. Staff A stated the procedure for responding to door alarms is any staff hears door alarm, go see why the alarm went off, determine why alarm went off, and once determine why the alarm went off can put in a code to clear the alarm. Staff A stated when Resident #2 elopement occurred on 1/23/23, the mag lock on the front door was not working, the facility was waiting on a part, the door had not been working for a week or less prior to the elopement, and the facility had put 2 other door alarms on the front door that would go off automatic anytime the front door opened. Staff A stated the alarm would stop when the door shut and all staff were aware they needed to check the door as the alarm would not keep alarming. Staff A stated the Maintenance Supervisor (MS) applied the alarm. Staff A stated the alarm was loud but not as loud as the regular door alarm, that you could hear it. Staff A stated Resident #2 was placed on wander guard after the elopement and had staff manning the front door 24 hours until could get the door repaired. Staff A stated the door is repaired and thinks was fixed in a week to 10 days. Interview on 6/27/23 at 12:05 PM, the Climatologist stated on 1/23/23 at 6:30 PM at the facility location, the temperature was 30 degrees Fahrenheit, humidity 88%, winds out of the west at 10 mph with wind chill temperature of 21 degrees, and visibility of 6 miles with no precipitation. Facility Visit Report, (repair bill) dated 1/30/23, for current facility documented: replaced the power supply with the power supply that was shipped out with the lock and front entrance is working properly and according to specs. Interview on 6/27/23 at 12:22PM, Staff B, Director of Nursing (DON) at time of elopement, stated she received a call on 1/23/23 and informed of Resident #2's elopement. Staff B stated the front door alarm did not sound or lock prior to the elopement but she had no knowledge of this until after Resident #2 got out. Staff B stated she was made aware of the front door problems after the incident. Staff B stated she thinks some alarm was put on the front door after the elopement. Staff B stated she had no knowledge the mag lock was broken prior to elopement and that through the investigation is when she found out the mag lock was broke and alarm had been applied prior to the elopement. Staff B thought the MS applied a 2nd alarm on 1/24/23 and staff placed at the front door until fixed. Staff B stated she thought Resident #2 had recently had a medication change prior to the elopement, had more confusion, and had the primary care physician review Resident #2's medications after the elopement. Staff B stated her expectation for all residents is to have elopement risk assessment completed quarterly and as needed. Interview on 6/27/23 at 12:43 PM, Staff G, Registered Nurse (RN) stated she was working on 1/23/23 at the time of Resident #2's elopement. Staff G stated the facility received an outside call that Resident #2 was outside by the road and the Activity Director (AD) brought the resident back in the facility. Staff G stated she was not aware the door alarm was broken but apparently the alarm system on the front door was not working and she was not aware. Staff G stated could go out the front door with no alarm sounding. Staff G stated she was told by staff (can't remember who) that Staff A or the AD were aware that the front door was broken and needed a magnet. Interview on 6/27/23 at 1:25 PM, Staff C, Certified Medication Aide (CMA) stated the policy for door alarms was to check wander guards, door alarms, and squawk boxes daily, complete the form, and turn into the DON. Interview on 6/27/23 at 1:39 PM Staff D, Licensed Practical Nurse, LPN stated the procedure for door alarms was for the nurse or CMA to check alarms daily. Staff D stated there have been multiple issues with the front door for the past year, mainly with the wander guard and magnet. Staff D stated when the magnet wasn't working the door wouldn't lock and could go in or out the door without an alarm sounding. Staff D stated probably around January 2023 the facility had to put another alarm on the front door as the regular alarm wasn't working but unsure when; she was unsure if it was before or after the elopement. Staff D stated if alarms are not working during the checks, staff are to document it on a sheet, and notify the MS. Interview on 6/28/23 at 9:19 AM, Staff E, CMA stated policy for door alarm checks completed sometime throughout shift and just day shift completes. Interview on 6/28/23 at 5:30 PM, Staff F, LPN stated door alarm checks to be completed daily, if not working, notify ADM and stay at the door until someone comes to fix it. Review of facility documents titled Door Alarm Checks for 1/1/23 - 1/23/23, revealed completed forms for 1/1, 1/2, 1/3, 1/4, 1/5, 1/10, 1/14, 1/15, and 1/18/23, lacking sheets for 14 days of the 23 days. Interview on 6/27/23 at 10:30 AM, Staff H, current DON, stated unable to find any other daily door alarm check sheets for the time period of 1/1/23 - 1/23/23. Staff H stated expectation for door alarm checks to be completed daily. Facility policy titled, Electronic Monitoring/Alarm System, revised 12/2019 documented the facility may utilize an electronic monitoring/alarm system to protect appropriate residents, an ongoing monitoring process of the exit alarms is present, the system is operational at all times: with procedure to maintain alarmed perimeter exits 24 hours, 7 days a week and check exit alarm systems daily to assure functionality. Facility policy titled, Elopement issued 6/18/19, documented the following: 1. An evaluation will be completed upon admission, quarterly, and with significant change. 2. Any resident displaying significant wandering behavior will be evaluated for elopement risk and care planned appropriately. 3. Care plans will address wandering as a specific problem.

Based on facility document review, staff interview, and facility policy review the facility failed to ensure staff certified in Cardiopulmonary Resuscitation (CPR) were scheduled 24 hours per day/7 days a week. The facility reported a census of 40 residents. Findings: During review of the facility nursing schedule dated [DATE] (schedule for [DATE] - [DATE]), the document failed to show scheduled CPR certified staff on ,d+[DATE], ,d+[DATE], and [DATE] for the 2 PM - 10 PM shift. Review of facility form titled, Birthday List, dated [DATE], documented 20 residents with a Full Code status (in the event that a resident's heart stops beating, CPR is initiated). Facility policy titled, Emergency Care/CPR reviewed ,d+[DATE], documented the facility provides Basic Life Support CPR only and the physician's order for full code is written based on the wishes of the resident. During an interview on [DATE] at 4:16 PM, the Director of Nursing (DON) acknowledged the facility failed to have certified CPR staff on duty on ,d+[DATE], ,d+[DATE], and [DATE] for the 2 PM - 10 PM shift, when the facility has residents with a Full Code status. The DON stated expectation for CPR certified staff on duty 24 hours/7 days a week.

Based on clinical record reviews, observations, resident and staff interviews, and facility policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 4 of 4 residents reviewed (Residents #49, #30, #34, #32) for administration of medications and supplements. The facility reported a census of 48 residents. Findings include: 1. Resident #49 admitted to the facility on [DATE], according to the clinical census form dated 10/13/22. Resident #49 did not have a Minimum Data Set (MDS) completed at the time of the survey. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #49's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/22 at 8:10 a.m. observation revealed Staff A, Certified Medication Aide (CMA) prepare the resident's [MEDICATION(S)] powder with water in a plastic cup. Staff A observed Resident #49 drink half of the medication and then left the room. Staff A failed to observe and ensure Resident #49 received all of the medication before leaving. The facility policy titled Medication Administration revised January 2013 directed staff to remain with residents until all medication is taken. During an interview on 10/12/22 at 10:20 a.m. the Director of Nursing (DON) reported she would expect the CMA to observe the resident take all of the fiber drink prior to leaving the room to ensure the resident received all the medication. 2. Resident #30's MDS assessment dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 4, indicating severely impaired cognition. The assessment documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised 8/31/20 identified Resident #30 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan also documented Resident #30 had impaired cognitive function and thought processes related to dementia. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #30's EMAR for October 2022 documented administration of the [MEDICATION(S)] inhaler twice a day. On 10/12/22 at 9:02 a.m. observation revealed Staff B, CMA provided the [MEDICATION(S)] inhaler to Resident #30. Resident #30 self-administered the inhaler. Resident #30 took two quick puffs from the inhaler, one after another. Resident #30 did not inhale or hold her breath during medication administration. Staff B did provide Resident #30 with instructions or directions on how to use the inhaler for maximum benefit. The facility's policy titled Medication Administration Metered Dose Inhaler revised January 2013 instructed staff to complete the following steps when administering a inhaler: Point #9 - Staff instruct the resident to exhale to their lungs, place the tip of the spacer in the mouth and maintain a tight seal. Point #10 - Staff to instruct the resident to activate the inhaler during the first third of a slow maximal inhalation and continue to inhale until lungs are filled with air. Point #11 - Staff to instruct the resident to hold their breath for 3-5 seconds, as able. Point #12 - Staff are to wait at least one minute for multiple inhalations of the same drug. During an interview on 10/12/2022 at 10:20 a.m. the DON reported she would expect the CMA to supervise the administration of the inhaler to ensure the inhaler is given appropriately according to standards of practice. 3. Resident #34's MDS assessment dated [DATE] identified a BIMS score of 15, indicating intact cognition. The MDS identified Resident #34 as having moisture associated skin damage in the seven-day lookback period. The MDS also identified the facility had placed a pressure reducing device in the resident's chair/bed and provided a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan with revision date of 8/22/22 identified Resident #34 as at risk for impaired skin integrity. The Care Plan directed staff to encourage good nutrition and hydration in order to promote healthier skin. The Dietitian's progress note dated 7/19/22 recorded that Resident #34 received Prostat twice a day to aid with meeting her protein needs for wound healing. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the resident's EMAR, staff failed to administer the resident's Prostat on the following dates: a. 8/24/22 b. 8/25/22 c. 8/26/22 d. 8/27/22 e. 8/28/22 f. 8/29/22 g. 8/30/22 h. 8/31/22 i. 9/01/22 j. 9/02/22 Review of Progress Notes from 8/24/22 - 9/01/22 and 9/05/22 indicated the facility did not have Prostat available due to the medication not being available and out of stock. 4. Resident #32's MDS assessment dated [DATE] assessment identified a BIMS score of 15, indicating intact cognition. The MDS indicated Resident #32 had an unhealed stage three pressure ulcer during the seven day lookback period. The MDS also identified the facility had placed a pressure reducing device in the resident's chair and bed, provided pressure ulcer care, a turning program, in addition the facility added nutrition and hydration interventions. Resident #32's MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised on 8/30/22 identified Resident #32 had a nutritional risk related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan directed staff to provide Prostat 30 milliliter four times a day to aid in wound healing. The dietitian progress note dated 8/30/22 stated Resident #32 received Prostat twice a day to support protein needs for skin health. The progress note also stated the dietician recommended increasing the Prostat to four times a day. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the EMAR, staff failed to administer the resident's Prostat on the following dates: a. 8/24/22 b. 8/25/22 c. 8/26/22 d. 8/27/22 e. 8/28/22 f. 8/29/22 g. 8/30/22 h. 8/31/22 i. 9/01/22 j. 9/02/22 k. 9/03/22 l. 9/04/22 m. 9/05/22 Review of Progress Notes from 8/24/22-9/05/22 indicated the facility did not have Prostat available due to medication not being available and out of stock. During an interview 10/18/22 at 10:45 a.m. the DON reported her expectations are for supplies like Prostat to be available. The DON stated if the supply is not available, she would expect staff to call different supply chains to locate it. The DON stated if staff could not locate the needed supply then she would expect staff to call the doctor for direction or different orders.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to update care plans with changes for 4 out of 16 residents reviewed (Residents #25, #44, #8 and #32). The facility reported a census of 48 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #25's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment documented she had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated moderately impaired cognition. The resident required a limited assist of 1 for transfers and ambulation. During interview on 10/10/22 at 2:14 P.M., Resident #25 stated that she had went to rehabilitation (rehab) and then they stopped and haven't done anything since. She stated she had gotten pretty weak with walking. The resident stated that she would use her walker and staff would walk beside her with a belt on. She stated they did have her walking outside with assistance but they quit doing that. A progress note dated 10/5/22 at 9:48 A.M., documented a care conference was held with Resident #25, the Licensed Home Administrator, the Director of Rehab, and the Social Services designee. Resident #25 continued to have unrealistic goals to return home independently. Since last Friday she had refused to participate in walk-to-dine program therapy had setup for her to continue to maintain strength. When asked why she was not walking to the dining room, she stated, I'm mad I wanted to go home last week. The resident was again educated on the goals she needs to be able to do in order to return to the community. Resident #25 reported her sister is out of the country for 1 year, so she had no support system in place at this time. Staff planned to obtain orders for therapy PT/OT (Physical Therapy/Occupational Therapy) and reviewed her I-POST (an advance health care directive) with no changes. On 10/14/22, Resident #25 stated she did not want to walk to the dining room. She stated she has a cold right now and does not want to be in front of people. On 10/18/22 at 11:11 A.M., the Director of Rehab, COTA (Certified Occupational Therapy Aide), stated Resident #25 was released from therapy on a walk-to-dine program. Resident #25 had been participating in the walk-to-dine program, but she hadn't been feeling well as of late so had been refusing. Review of Resident #25's Care Plan after conversation with the Director of Rehab revealed no restorative interventions care planned for the resident. 2. The MDS assessment dated [DATE] documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident scored 15 out of 15 on the BIMS test, indicating intact memory and cognition. Resident #44 required the extensive assistance of 2 for toilet use, transfers, and bed mobility. Resident #44's Care Plan instructed the following: a. Resident #44 required intermittent assistance with using the restroom, initiated 4/12/21 and revised on 4/25/21. b. Ensure the resident had an unobstructed path to the bathroom, initiated 4/12/21 and revised on 4/25/21. c. Resident #44 generally utilized a commode independently and staff assist upon her request, initiated 4/12/21. An email response from the Director of Nursing (DON) on 10/20/22 at 1:43 P.M., when asked about the above Care Plan interventions, the DON documented the resident used the bedpan. 3. The MDS assessment dated [DATE] documented Resident #8 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented the resident had severely impaired cognition and received antipsychotic and antidepressant medications for 7 of 7 days during the look-back period. Resident #8's Care Plan, revised on 8/24/22, lacked a focus area or intervention for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview 10/18/22 at 11:56 AM, the DON stated the expectation that [CONDITION(S)] would be addressed on Resident # 8's Care Plan. During an interview 10/20/22 at 11:00 AM the DON stated a Care Plan is a working document and should be accurate and updated on an almost daily basis as it reflects what is going on with the resident at the time. 4. Resident #32's MDS assessment of 7/15/22 identified a BIMS score of 15. The MDS indicated Resident #32 had highly impaired vision with object identification in question but his eyes appeared to follow objects. The MDS recorded Resident #32 did not wear corrective lenses. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 had been diagnosed ,d+[DATE] with Proliferative/Neurovascular Diabetic Retinopathy with macular [CONDITION(S)] and [MEDICATION(S)] hemorrhage of the right eye. Resident #32 had a past eye surgery on 4/5/22 to his right eye. A Health Status Note dated 10/5/22 at 7:11 p.m. recorded the resident reported to staff that his vision had gotten worse. Resident #32 reported he could not see his clock except for the black coloring around the outer edges. The clinical record recorded Resident #32 had eye surgery scheduled on 10/13/22. The surgery had been planned prior to Resident #32 reporting the decline in his vision. The Resident #32's Care Plan, revised 8/22/22. did not address Resident #32's past or present medical conditions and complications related to his vision. The Care Plan lacked any updates or changes since his decline in vision on 10/5/22. The Care Plan lacked any focus areas, goals or interventions related to Resident #32's vision problems. The facility's policy titled Clinical Change in Condition Policy, revised June 2015, directed staff to review Care Plan goals and interventions, modify as indicated and update staff of changes. During an interview 10/17/22 at 12:00 p.m. Staff G, Assistant Director of Nursing (ADON) reported she was not aware Resident #32's vision had declined. The ADON stated she would expect the resident's Care Plan to address his impaired vision and stated that is what the care plan is for. During an interview on 10/18/2022 at 10:45 a.m. the DON stated the expectation that Care Plans be revised when changes occur. The DON reported the Care Plan is a working document.

Based on observation, record review, and staff, resident and family member interviews, the facility failed to ensure all residents received medications as ordered by a physician, and failed to prevent a serious medication error when staff administered several medications to the wrong resident, for 1 of 4 resident records reviewed (Resident #4), This resulted in an Immediate Jeopardy, which the facility removed as of [DATE]. The facility reported a census of 49 residents. Findings Include: The [DATE] Minimum Data Set (MDS) Assessment Tool revealed Resident #4 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also documented the resident required assistance of at least 1 staff to reposition in bed, transfer to and from bed and chair, ambulation, dressing, toileting, personal hygiene and bathing, and received [MEDICATION(S)] medications on a scheduled and as-needed basis and non-pharmacological interventions for occasional pain rated as 8 on a 0 to 10 pain scale, with 10 rated as the highest pain possible. A nutritional problem related to chronic kidney disease, initiated on the Nursing Care Plan [DATE] directed staff to administer medications as ordered and monitor for medication side effects. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] (an anti-[CONDITION(S)] medication used to treat partial seizures and neuropathic pain) 300 milligrams (mg) oral twice daily, scheduled in the morning and evening, order dated [DATE]. b. Carbodopa/[MEDICATION(S)] (a medication for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . c. [MEDICATION(S)] (a medication used to reduce cholesterol level) 40 mg oral daily at HS, order dated [DATE]. d. Oxycodone (pain medication) 5 mg oral twice daily, scheduled in the morning and evening, order dated [DATE] at 3:59 p.m. e. Oxycodone 5 mg oral daily at HS, order dated [DATE] at 7:11 p.m. The resident's December, 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] a. [MEDICATION(S)] scheduled for evening administered by Staff A, Licensed Practical Nurse (LPN). b. Carbodopa/[MEDICATION(S)] scheduled for evening and HS both documented as administered by Staff A. c. [MEDICATION(S)] administered by Staff A at HS. d. Oxycodone 5 mg administered every 4 hours as needed, administered by Staff A at 5:52 p.m. and 9:58 p.m., and both the scheduled evening, and scheduled HS doses, were not documented as administered. The facility's Medication Administration policy, dated last revised [DATE] directed staff: a. Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] b. Identify resident via wristband or picture ID. c. Explain procedure to the resident, include the type of medication ordered, the reason, frequency and route. d. Read the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . e. Verify the pharmacy prescription label on the drug and the manufacturer's identification system matches the MAR. f. Verify the following again, by comparing medications to the MAR prior to administering: 1. Correct resident 2. Correct medication 3. Expiration date 4. Dose and dosage form 5. Route 6. Time g. Remain with the resident until all medication is taken. Resident #4's Nursing Progress Notes revealed the following entries: a. On [DATE] at 11:00 p.m., Staff B, Registered Nurse (RN), stated resident unresponsive at that time. [CONDITION(S)] was applied, blood sugar 208. Family member at bedside, sternal rub (painful stimulus) woke resident only for a moment. b. On [DATE] at 12:20 a.m., Staff B stated 2nd shift nurse (Staff A) re-entered building, reported she gave wrong medications to resident and placed phone call to physician with orders to monitor resident. Staff B and family member checked vital signs, temperature 97.3 Fahrenheit, pulse 72, respirations 15 (normal range 16 to 20 per minute), blood pressure 86 over 60 (normal range 110 to 140 over 60 to 80 millimeters mercury, mmHg), oxygen saturation 87 percent (normal 97 to 100 percent) with [CONDITION(S)] on, still unresponsive. Another call placed to physician, new orders to administer [MEDICATION(S)] (a medication to reverse effects of narcotic medications) and send to the hospital emergency room (ER) for evaluation, oxygen started. [MEDICATION(S)] given, 911 called, called hospital with verbal report, Director of Nursing (DON) notified. c. On [DATE] at 5:10 a.m., Staff B stated notified by ER Nurse that resident intubated and being life-flighted to the Intensive Care Unit (ICU) at a larger hospital. A late entry recorded by the DON at [DATE] at 12:52 p.m., and labeled [DATE] at 12:33 p.m., stated the resident was inadvertently given another resident's medication that included the following: a. DitropanXL (an [MEDICATION(S)] medication). b. [MEDICATION(S)] 1200 mg. c. [MEDICATION(S)] 100 mg (an antihistamine known to cause sedation, usual dose 25 mg). d. Lorazepam 3 mg (an anti-anxiety medication, usual dose 0.25 to 0.5 mg). e. [MEDICATION(S)] 40 mg (a proton pump inhibitor medication used to treat [CONDITION(S)] reflux). f. [MEDICATION(S)] 4 mg (an Alpha-adrenergic antagonist, muscle relaxant medication, usual dose 2 to 4 mg). g. [MEDICATION(S)] 10 mg (a strong sleeping medication). The noted recorded Resident #4 received Oxycodone 5 mg that was his prescribed medication as well. The Nurse was going to give Resident #4 his medication for bedtime, he was in the bathroom, so the Nurse was going to give another resident their medications and had dispensed them into a med cup. Then Resident #4 finished in the bathroom and asked for a pain pill. The Nurse inadvertently put his pain pill in the med cup with the other resident's medications and accidentally gave all to Resident #4. The resident became very sleepy, then unresponsive. Physician notified, 911 called, resident transported to hospital by ambulance. The Hospital ER Progress Note revealed the resident arrived at 1:27 a.m. on [DATE], treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident less arousable at 2:40 a.m., [MEDICATION(S)] repeated without improvement, the resident intubated (tube inserted into the lungs through the mouth), an ICU physician at the larger hospital consulted and agreed to accept and treat the resident, and life-flighted to the hospital at 5:10 a.m., due to lack of available emergent ground transportation. The [DATE] hospital discharge summary revealed the resident admitted to the ICU for airway protection due to altered mental status that followed a medication error at the nursing home, reacquired mechanical ventilation (a respirator) on [DATE], condition had improved and discharged home on [DATE] with appropriate medical follow-up care. Staff interviews revealed: On [DATE] at 7:10 p.m., Staff B, RN, stated she worked the 10 p.m. to 6 a.m. night shift that started [DATE], at approximately 11:00 p.m. she attempted to assess the resident per her usual routine and was unable to wake him without painful stimulus, normally he was awake and alert. She assessed the resident, called his family member (who also worked at the facility) to the room, neither were able to determine the sudden change of his condition until Staff A returned to the building at approximately 12:00 a.m., and stated she administered Resident #1's HS medications to Resident #4, in addition to his Oxycodone. They called the physician for orders, she administered [MEDICATION(S)], the resident remained unresponsive except to painful stimulus, had low oxygen saturation and the resident was sent to the ER by ambulance for treatment. On [DATE] at 4:58 p.m., Staff A, LPN, stated she worked the 2 p.m. to 10 p.m. evening shift on [DATE], Resident #4 was in the bathroom when she went to administer his scheduled HS meds, denied that she had set his medication up ahead of time, she waited outside his room, he remained in the bathroom for several minutes, so she prepared Resident #1's HS medications (a resident located on a different hall), and before she could administer the medications to Resident #1, Resident #4 came out of the bathroom and said he wanted a pain pill. Staff A stated she got his pain pill ready (removed it from the narcotic compartment of the medication cart and signed the Narcotic Inventory Control Sheet for the administration), put his pain pill in the med cup with the other medications intended for Resident #1 without thinking about it, and administered all to Resident #4. Staff A stated she administered Resident #1's medications afterwards, she had to obtain all the medications again and didn't even think about it. She said after she gave report to the Night Nurse (Staff B), she remained in the facility charting, and heard Staff B call the resident's family member to the room, saw them obtain equipment to assess his vital signs and heard he wasn't waking up. The resident had complained several times that he was tired, was getting woke up and not sleeping well, and she thought he was just tired and asleep. She finished her work, left the facility and as she warmed her car up to leave she realized what she had done, returned to the facility immediately, notified Staff B, the family member, and called the physician for orders. During a second interview on [DATE] at 2:41 p.m., Staff A stated when she got Resident #1's HS medications ready on [DATE], she used the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she administered Resident #1's medications afterwards. When Staff A was shown computer documents that indicated she signed that she administered Resident #1's HS medications at 9:51 p.m. on [DATE], and Resident #4's Oxycodone at 9:58 p.m. on [DATE], and that she failed to record 2 doses of [MEDICATION(S)] and 2 doses of HS Lorazepam on Resident #1's Narcotic Inventory Control Sheets for those medications as required, Staff A stated she must have signed off the medications were administered when she prepared them, and couldn't answer if she had administered Resident #1's HS medications on [DATE]. On [DATE] at 5:22 p.m., the DON stated they were in the process of auditing Medication Pass with all nursing staff since the medication error occurred, Staff A did not work [DATE] and they completed a medication audit of her earlier that day, before she administered medications to any residents, and all Nursing Staff educated on the medication administration Policy/Procedure. The DON stated she had no performance concerns for Staff A prior to the incident, she was normally a very conscientious employee. The DON stated staff should not pre-pour or prepare resident medications, and administer medications to only 1 resident at a time, and complete the process before beginning to administer medications to a different resident. On [DATE] at 8:40 a.m., the DON stated she interviewed Resident #1 on the morning of [DATE], the resident didn't believe she had received her HS medication the night before because she was awake several times through the night which was unusual for her, and the DON completed a Medication Error Report associated to the omission of Resident #1's HS medications on [DATE]. During an interview [DATE] at 9:10 a.m., Resident #4's family member and responsible party stated on the evening of [DATE], she didn't know what had happened to the resident, he was normally awake and alert, but that night was very sedated, unresponsive and neither Staff B or herself would have known what was wrong if Staff A had not admitted the mistake she made and was thankful for that. While in theER on [DATE], the physician told the family the hospital staff repeated the [MEDICATION(S)] without much effect, and if they didn't intubate the resident then, they may not have been able to in the event he had a [CONDITION(S)] and required cardiopulmonary resuscitation (CPR). The physician then reported the care the resident required was beyond the capacity of that hospital and why he was life-flighted to the larger hospital. The family member stated it was quite a frightening experience, the resident continued to have some short-term memory deficits since the medication error that was not present before, but had otherwise recovered from the incident. The State Agency informed the facility of the Immediate Jeopardy on [DATE] at 2:15 p.m. The Facility had removed the Immediate Jeopardy on [DATE] by implementing the following actions:. a. Re-educating Staff A, RN on the Rights of Medication Administration and successfully passed medications on a Medication Pass Observation. b. Licensed Nurses and Oral Medication Technicians were re-educated by the Director of Nursing or Designee on the Rights of Medication Administration and all completed an observed Medication Pass on or before [DATE], or prior to the staff's next shift of work. c. The facility will continue to monitor Staff A, RN to have successful Medication Pass Observations completed monthly for 3 months, an Audit of random Medication Pass Observations will be completed weekly for 4 weeks, then monthly for 2 months. d. The Quality Assurance Performance Improvement (QAPI) Committee will monitor results, review and make recommendations as needed. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and updated their policy and procedure.

Based on observation, clinical record review, resident, and staff interviews the facility failed to notify the Dietician for nutritional interventions or follow Dietary recommendations when given, document skin assessments consistently and accurately to promote healing of facility acquired pressure sores for two of two residents reviewed with pressure sores. Resident #7 and #8. The facility reported a census of 54 Residents. Findings include: 1. According to the Minimum Data Set (MDS) Assessment Tool dated 7/13/2020, Resident #7 documented with moderately impaired cognitive abilities, transferred from one surface to another with extensive assistance of two staff, required supervision and set up assistance with eating, had no risk of developing pressure ulcers/injuries and no unhealed pressure ulcers/injuries. The MDS documented the resident had [DIAGNOSES REDACTED]. The resident record also revealed he/she admitted with Shingles. The Care Plan identified Resident #7 with a nutritional risk initiated 7/15/2020 and directed staff to monitor lab/diagnostic work as ordered, provide and serve diet as ordered, and Registered Dietician (RD) to evaluate and make change recommendations as needed. The Care Plan identified the resident with the potential for impaired skin integrity due to limited mobility, impaired cognition and diabetes. It directed staff to encourage good nutrition and hydration in order to promote healthier skin, monitor/document location, size and treatment of [REDACTED]. Staff were also to encourage resident to wear bilateral pressure reduction boots when not transferring or ambulating and use caution during transfers and bed mobility. The July physician's orders [REDACTED]. a. On 7/9/2020 - weekly skin assessments to be completed on Thursdays. b. On 8/25/2020 - cleanse area to right heel, apply alginate dressing, cover with bordered gauze and secure with kerlix. c. On 8/22/2020 - crusting procedure (zinc and stoma powder) to coccyx two times a day until healed. The July Medication and Treatment Administration Record (MAR/TAR ) included orders related to the resident's wounds: Weekly Skin Assessments on Thursday with documentation of completion on 7/9, 7/16, 7/23, 7/30/2020. The August MAR/TAR included orders related to the resident's wounds: a. Cleanse area to right heel and apply calcium alginate, cover with ABD pad and secure with kerlix daily until healed, ordered 8/22/2020. b. Cleanse area to right heel, apply alginate dressing, cover with bordered gauze and secure with kerlix until healed, ordered 8/25/2020. c. Apply [MEDICATION NAME] to coccyx open areas two times a day (BID) until healed, ordered 7/31/2020 and discontinued on 8/22/2020. d. Apply [MEDICATION NAME] to right heel every three days or sooner if needed every 72 hours, ordered on 8/6 and discontinued on 8/22/2020. c. Crusting Procedure (zinc and stoma powder) BID to coccyx until healed, ordered 8/22/2020. The Progress Notes included: a. On 7/15/2020, Staff A, Dietician reported Resident #7 admitted to skilled due to urinary tract infection, weight stable with intakes on regular diet and thin liquids is adequate with average of 75% intakes. He/she eats independently but does require some supervision and assistance. Per skin report on 7/9/2020, skin intact, no [MEDICAL CONDITION], blood glucose reviewed. No recommendations at this time. Continue weekly weights, and contact dietician with any nutrition concerns. b. On 7/30/2020 staff noted two small areas to coccyx, 0.25 cm (centimeters) and 0.20 cm, surrounding skin brown. Fax sent to physician for treatment. c. On 7/31/2020 the physician ordered [MEDICATION NAME] to areas two times a day until healed. d. On 8/3/2020 the family requested a recliner be placed in the resident's room so he/she could elevate feet during the day. e. On 8/4/2020 the resident moved to a new room. f. On 8/5/2020 Staff A recommended weekly weights and a 2 liter fluid restriction due to weight gain, history of [MEDICAL CONDITION] and currently on [MEDICATION NAME] 20 mg milligrams). g. On 8/5/2020 a CNA noted a blister to the resident's right heel that measured 6.0 cm by 6.5 cm. Staff applied a moon boot and notified the physician via fax. h. On 8/10/2020 staff documented the coccyx wound appeared worse and measured 3.5 cm by 4.5 cm with yellow eschar to wound bed. Resident positioned on side and physician notified. The physician ordered Crusting Procedure to coccyx two times a day until healed. i. On 8/10/2020 the physician ordered right heel treatment: cleanse with normal saline and apply calcium alginate, cover with ABD pad and apply kerlix every day until healed. Staff called the resident's family member and discussed placing a air mattress on the resident's bed and family in agreement. j. On 8/18/2020 the physician ordered Santyl to buttock wound. Physician discontinued order due to insurance non-coverage. The Nursing Admission Assessment effective date 7/8/2020 revealed Resident #7 had no identified pressure areas. Skin Assessments included: a. Weekly skin assessments documenting skin intact: 7/9, 7/16, 7/23, b. On 7/30/2020: Coccyx had two open areas measuring 0.25 cm and 0.2 cm., superficial depth, wound bed pink, scant drainage with no odor. Resident complained of some discomfort. Physician notified. c. On 8/5/2020: Right Heel blister, 6.5 X 6.0 cm. suspected deep tissue injury. Blister intact, top edges pink/red, bottom edge purple. Physician notified. d. On 8/6/2020 - Coccyx: 0.1 X 0.1 pink area noted to coccyx. Area not open. e. On 8/9/2020 - Heel: Pressure area, 3.2 X 4.9 X 0.3, Stage II. Beefy Red, dark purple area to distal part of wound. Distal part of wound boggy. Physician and family notified. f. On 8/10/2020 - Coccyx: 3.5 X 4.5 cm open area to coccyx with yellow eschar, surrounding skin is pink. Physician notified. g. On 8/20/2020 - Sacrum: 3 X 5 cm open area, wound bed with 70% granulation and 30% slough. Pressure injury: 5 X 3 X 0.4 cm, Stage II. h. On 8/23/2020 - Coccyx: 4.5 X 3.5 X 0.3 cm, Stage II. Current treatment, crusting procedure. The facility failed to document assessments of the resident's right heel wound from 8/9/2020 - 8/24/2020. The lab report dated 5/21/2020 revealed the resident had an [MEDICATION NAME] level of 3.3, with normal range of 3.3 - 4.5/dl. The Physician's After Visit Summary dated 8/24/2020 revealed the physician ordered [MEDICATION NAME] (antibiotic) and made referrals to the Healing Center and ordered an Ultrasound of the right leg. The [DIAGNOSES REDACTED]. Observation on 8/25/2020 revealed the resident seated in his/her room, in a wheel chair without foot pedals and with gripper socks on bilaterally. The resident failed to have blue foam boot on the right foot. Observation on 8/25/2020 at 10:45 A.M. revealed Staff B, Licensed Practical Nurse (LPN) provide treatment to Resident #7's right heel and buttock wounds: a. The right heel wound measured 3.3 X 2.6 cm with eschar (dark scab of dead skin). b. The bilateral buttock wound (coccyx and sacral wound combined), butterfly shaped measured 4.2 X 3.7 X 0.9 cm. c. The wound base appeared red with white edges and the surrounding skin had a red scattered rash. Staff B indicated the rash was new. d. Staff B applied the treatments as the physician ordered. The physician progress notes [REDACTED]. The physician determined the resident had [MEDICAL CONDITION] of the right lower extremity and ordered an antibiotic and an ultrasound of the right leg. The physician also ordered the resident be seen at the wound clinic. The resident had an appointment made for Friday, 8/28/2020 at the wound clinic. During an interview on 8/25/2020 at approximately 1:00 P.M., Staff A, Dietician reported he/she had no knowledge of Resident #7's pressure wounds. Due to Covid-19, he/she could not enter the facility since March and relied on nursing to communicate any concerns regarding residents. Staff A stated unaware Resident #7 had wounds, if he/she had, he/she would have recommended a supplement to assist with wound healing. During an interview on 8/25/2020 at 2 p.m., Staff C, LPN indicated the Dietician emails Staff C along with Staff D, Director of Nursing (DON) weekly and asks if they have any concerns. The Dietician last emailed on 8/12/2020, during the power outage. Staff C reported, LPN's are not allowed to stage wounds, that had to be done by a Registered Nurse (RN). Protein supplements such as pro-stat is documented on the MAR for nurses to administer. During an interview on 8/25/2020 at 9:30 a.m., Staff D, DON reported the resident had an appointment with the physician on 8/25/2020 and the resident's family asked if he/she could start going to the wound clinic. During an interview on 8/25/2020 at approximately 9:15 a.m., Resident #7 reported seeing the doctor yesterday. The doctor did not know they weren't sending him/her to the wound center and they scheduled an appointment. The resident also had another test ordered and he/she also received a new medication but could not recall the name of it. 2. The MDS dated [DATE] revealed Resident #8 with no risk of pressure ulcer/injury risk and no unhealed pressure ulcers/injuries. The MDS dated [DATE] revealed the resident with severe cognitive impairment, transferred from one surface to another with extensive assistance of one staff, required supervision and set up assistance for eating, did no ambulate and had [DIAGNOSES REDACTED]. The MDS documented the resident had one Stage 2 pressure ulcer. The Care Plan identified the resident had potential for nutritional problems related to [DIAGNOSES REDACTED]. It directed the Dietician to evaluate and make diet change recommendations as needed quarterly, annually and as needed. The resident had a potential for impaired skin integrity due to limited mobility related to [MEDICAL CONDITION]. The Care Plan directed staff to monitor/document location, size and treatment of [REDACTED]. Staff were to assist resident with utilizing a pressure reduction boot to right foot at all times, remove during transfers and ambulation. The physician's orders [REDACTED].>a. 5/11/2020 - Apply [MEDICATION NAME] to right heel every three days and as needed, and apply moon boots when open. Apply moon boots. Staff A, Dietician notes documented the following: a. On 5/18/2020, Staff A recommended pro-stat 1 ounce every day for 30 days for pressure ulcer. b. On 7/8/2020, recommended a house supplement for weight loss in the past 3 months. The Dietician recommended supplement, 60 ml/day for 30 days. c. On 8/12/2020, recommended pro-stat or an equivalent protein supplement, one ounce a day for 30 days. Weight stable. Labs dated 6/15/2020 revealed [MEDICATION NAME] 3.4 and total protein 7.1 g/dl. Skin Assessments included: a. On 5/8/2020 - Right Heel, 2.5 X 1.2 cm, St I, MD notified. b. On 5/20 and 5/22/20- weekly skin assessment. Skin intact. No areas of concern identified. c. On 5/28/2020 - Right Heel, 2.0 X 13.5, Stage I. Dark red wound bed with intact surrounding tissue. Center boggy. MD notified. d. On 6/19/2020 - Right Heel, 2.5 X 2.4 X 0.2 cm. Wound bed pink. 7/3/2020 - Right Heel, Pressure, 1.2 X 1.0 X 0.2 cm. Stage II. White macerated wound edge with normal skin surround. e. On 7/10/2020 - Right Heel, Pressure, 2.4 X 2.4 X 0.4, Stage I. f. On 7/17/2020 Weekly Skin Assessment: Intact skin. g. On 7/17/2020 - Right Heel, 1.25 X 1.0 X 0.1. Stage II h. On 7/24/2020 - Weekly Skin Assessment, skin intact. i. On 7/24/2020 - Right Heel, Pressure, 1.5 X 1.02 X 0.1 j. On 7/31/2020 - Right Heel, Pressure, 1.25 X 0.5 X 0.1 Stage II k. On 8/7/2020 - Right Heel, Pressure 1 X 0.75 X 0.1 State II l. On 8/7/2020 - Weekly Skin Assessment, Skin intact. m. On 8/14/2020 - Nurse's note: Stage II, pink wound bed, 1 X 0.25 X 0.1. [MEDICATION NAME] applied. Observation on 8/25/2020 at approximately 12:15 p.m., revealed Resident #8 seated in the wheel chair facing the bed with a tray table and lunch items. The wheel chair had no foot pedals and the resident wore gripper sox and no blue moon boot. Observation on 8/25/2020 at 2:30 p.m., revealed Staff F, LPN provide wound treatment and assessment for the resident's right heel. The wound measured 1.5 X 1.0 cm. Staff F cleansed the area with normal saline and applied an ointment, border gauze and kling wrap. Staff F indicated the wound appeared to be healing. The wound base appeared red with white edges. Staff F reported sometimes the resident ate the yogurt served as a bedtime snack, about 50 % of the time. Resident #8 reported he/she did not like the yogurt. During an interview on 8/25/2020 at approximately 1:25 p.m., Staff A, Dietician reported he/she recommended pro-stat due to the resident's stage II right heel ulcer. Staff A reported the facility had not yet responded to the recommendation. Staff A indicated there have been recommendations that the facility has failed to follow up with. He/she reviews resident charts weekly, emails Staff C, LPN, Staff D, DON and Staff E, Dietary Staff in the morning and asks if they have any residents with concerns. Staff A usually fails to get a response. At the end of the day, Staff A informs the same staff residents reviewed and recommendations. During an interview on 8/26/2020 at 9:45 a.m., Staff D, DON reported Resident #8 received yogurt due to an issue with [MEDICAL CONDITION]. ([MEDICAL CONDITION], a bacteria). During an interview on 8/26/2020 at 11:05 a.m., Staff D, reported informing Resident #8's physician on 8/24 of the Dietician's recommendation. The resident received Pro-stat in May for 30 days, and did not receive house supplement in July. Staff D reported being aware of the skin assessment and documentation issue and has a Quality Assurance plan in place. Going forward, Staff D plans to do all pressure sore assessments and has a nurses meeting scheduled to provide education regarding proper documentation and weekly assessments where staff is to look at the entire body.

Based on observation, clinical record review and staff interview, the facility failed to ensure routine range of motion exercises were completed on two of nine residents to prevent a decline in functional range of motion (Residents #1 & #7). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident required two staff assistance for bed mobility and transfers. The MDS documented the resident had no limitations in range of motion. A range of motion assessment dated [DATE], documented the resident scored a 12. The form documented that a score higher than 7 indicated a high risk for developing contractures. The MDS dated [DATE], documented the resident had functional limitation in range of motion to one side of the upper extremity (shoulder, elbow, wrist, hand). The MDS dated [DATE], documented the resident had limitations in functional range of motion to the bilateral lower extremities (hip, knee, ankle, foot). The assessment revealed Resident #1 had not used occupational therapy (OT) or physical therapy (PT) services during the assessment (within 7 calendar days). The MDS assessment identified the resident did not have active or passive range of motion programs performed by restorative nursing. The assessment identified no restorative nursing programs had been practiced for bed mobility, transfers, dressing or grooming. A range of motion assessment dated [DATE], documented the resident scored a 13. The form included a blank space at the bottom behind the statement "if changes were negative were they avoidable". The space had been left blank. The comment section indicated there had been no changes in the resident's condition. The care plan dated 2/22/15, lacked a goal or plan to address a decline in range of motion or intervention for staff to complete range of motion exercises with the resident. Clinical record review revealed the resident had four Range of Motion Data Collection forms in their chart with a section for each day from January 1, 2015 through January 16, 2015. Each of the 16 days had a line drawn down the entire section indicating the resident requires assistance but had full range of motion for his/her neck, arm, hand, hip/knee, ankle and toes. During observation on 3/10/15 at 10:30 a.m., Staff I (Certified Nurse Aide, CNA) and Staff J (CNA) transferred the resident from bed to commode, then back to bed. During the transfers, the resident's legs remained flexed at the hips and knees with the bilateral feet not touching the floor. The resident laid in a very flexed fetal position when in bed. During the observation staff dressed the resident and completed morning cares. No range of motion exercises were completed during the observation. During interview with Staff E (Certified Nurse Aide, CNA) on 3/11/15 at 10:55 a.m., she verified she had been a facility restorative aide. Staff E stated there had been no restorative plan set up for Resident #1. Staff E stated she did not do any planned routine range of motion exercises. Staff E stated the MDS nurse would set up the restorative plans for the residents when needed. During an interview with Staff A, Licensed Practical Nurse (LPN) on 3/12/15 at 6:30 a.m., she stated the previous facility Director of Nursing had created forms after the previous annual survey because the facility needed a plan of correction due to being cited for range of motion issues. Staff A stated there had been forms the facility had not been able to find after the DON had left from the position. Staff A stated when a new corporation took over the facility they had the facility start the Data Collection forms. During an interview with the facility Restorative Program Director on 3/12/15 at 9:10 a.m., she stated the resident had currently been on the case load for Occupational Therapy. She stated Resident #1 had been referred for wheelchair positioning and that had been the primary reason she had been seeing the resident. During an interview with Staff F (CNA) on 3/12/15 at 9:30 a.m., she stated she does not do separate range of motion exercises with the resident but she dressed the resident in the morning so the resident got assistance with raising both arms when staff put their shirt on. On 3/12/15, at 11:30 a.m., the Restorative Program Director stated she had talked with the Occupational Therapist and they had also planned on re-certifying the resident to work on bed positioning but had started with the wheelchair first. 2. The Range of Motion Collection log dated November 2014, indicated Resident #7 had been independent with full range of motion to neck, arms, hands, legs, and ankles. Resident #7 received a referral for skilled therapy due to a decline in ambulatory status after a fall & hospitalized from [DATE] to 12/17/14. The OT Daily Notes dated 12/18/14, document the resident would benefit from OT services in order to address impairments and return to prior level of function. The OT Daily Notes dated 12/22/14 documented the resident completed therapeutic exercises for Upper Extremities to facility independence in self care tasks. The therapist completed bilateral upper extremity PROM (passive ROM) in all planes to avoid development of contractures. The resident continued therapy, and on 1/1/15, the daily PT notes documented PROM to right lower extremity to maintain and reduce pain. The resident ambulated two times with front wheeled walker with minimal assistance of 1-2. The resident ambulated 8 feet the 20 feet. The next daily therapy notes showed the resident had been seen by OT on 3/12/15 (during the survey). The Minimum Data Set (MDS) assessment dated [DATE] for Resident #7 documented [DIAGNOSES REDACTED]. The MDS documented the resident cognitive level severely impaired. The MDS documented the resident required one staff assistance for eating and two staff assistance for bathing, transfers, dressing, bed mobility, toilet use, and personal hygiene. The MDS documented no impairment in upper extremity (shoulder, elbow, wrist/hand) for range of motion. The assessment revealed Resident #7 had used occupational therapy and physical therapy services starting on 12/18/14. The MDS assessment dated [DATE], documented the resident required one staff assistance for eating, and two staff assistance for bathing, transfers, dressing, bed mobility, toilet use, and personal hygiene. The MDS documented the resident totally dependent for eating, and had impaired range of motion to bilateral upper extremities. The assessment revealed Resident #7 had used occupational therapy and physical therapy services starting on 12/18/14. The MDS assessment identified the resident did not have active or passive range of motion programs performed by restorative nursing. The assessment identified no restorative nursing programs had been practiced for bed mobility, transfers, dressing or grooming. The care plan dated 01/02/15, included a care plan for self care deficit related to impaired balance, limited mobility, and dementia. The care plan goal included resident will maintain current level of function through the review date. The care plan directed staff to: a. Assist the resident with bathing, dressing, and grooming every morning, evening, and as needed. b. Encourage the resident to participate to the fullest extent possible with each interaction. c. Encourage the resident to use call bell for assistance. During an interview 3/10/2015 at 10:00 a.m., Staff D, CNA, reported no restorative activity being done with the resident. During an interview 3/12/2015 at 7:10 a.m., Staff A, LPN, reported the resident used to require 1 assist but the resident has had a progressive decline and currently required 1 to 2 assist during cares and transfers. Staff A reported the resident does not always transfer easily. During an interview 3/12/2015 at 8:33 a.m., Staff E, CNA, reported a decline in resident condition in the past few months since resident fell in December, 2014. During an interview 3/12/2015 at 9:02 a.m., the Director of Rehab reported the resident had some therapy after a hospital stay but discontinued therapy in January, 2015 when resident's progress plateaued.

Based on clinical record review, resident and staff interviews, the facility failed to direct nursing services to ensure Resident #2 received adequate supervision against hazard and failed to supervise the implementation of care plan directives to meet resident(s) safety needs. The facility reported a census of sixty- six (66) residents with four residents reviewed. Findings include: According to the Face Sheet dated 8/4/11, Resident #2 had [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE], Resident #2 had total dependence on 2 staff for bed mobility, dressing, toilet use and personal hygiene. Resident #2 did not walk but utilized a motorized wheelchair and required extensive assistance of 1 staff for locomotion throughout the facility. The assessment identified the resident could understand others and had communication skills whereas others could understood him/her. Review of the Care Plan dated 5/20/12 revealed Resident #2 sustained a fall with minor injuries. The Care Plan directed staff to transfer Resident #2 with 2 staff and the mechanical lift for all transfers. The Care Plan further indicated that on 5/20/12 the staff had education on proper transfers, a C.N.A. received disciplinary action and the resident requested the use of the mesh sling for transfers. Review of the Nurse's Notes dated 5/20/12 revealed a nurse in the room next to Resident #2's heard and "thud" and a scream at 4:30 p.m. Upon entering Resident #2's room, the nurse found Resident #2 on the floor, laying over the legs of the mechanical lift with a pool of blood forming under the resident ' s right (eye) temple. The nurse contacted the physician and received an order to transfer Resident #2 to the hospital per ambulance. While at the hospital Resident #2 received x-rays and a CT of the head. Resident #2 returned to the facility on [DATE] at 00:15 a.m. Review of a CT of Head Brain without Contrast Report dated 5/20/12 indicated Resident #2 sustained a closed head trauma. The report indicated the Resident had a large left frontal scalp hematoma without underlying fracture and no intracranial blood seen. Review of the Resident Incident Report dated 5/20/12 at 4:30 p.m. revealed Resident #2 received a laceration to their right temple and other potential injuries as a result of a fall from an Arjo Hoyer Lift. At the time of the incident, Resident #2 had been in the Hoyer sling when he/she fell the sling had only 3 points attached to the sling instead of all 4 points attached. Review of the Lifting Machine Policy dated 10/10 indicated two nursing assistants are required to perform the mechanical lifting procedure. Review of a facsimile dated 5/21/12 to Resident #2's physician revealed the following skin issues after their fall on 5/20/12: a. Above the left eye an 8 X 10 centimeter purple bruise with the left eye swelling. b. The right elbow with a 6 X 6 blue purple bruise. c. Upper left thigh, purple in color, measured 19 X 9 centimeters. d. Upper right thigh, purple bruise, measured 8 X 6 centimeters. e. Left inner ankle bruise measured 4 X 6 centimeters. f. Upper right arm purple bruise measured 11 X 9 centimeters. g. The top of the right toes had a faint purple/blue area, measured 2 X 2 centimeters. h. The top of the right foot on top of their 2nd toe, faint purple bruise, measured 3 X 1 centimeters. i. Underneath the left foot third toe a purple bruise, measured 1 X 1/2 centimeters. Review of a 1:1 Education Form dated 5/24/12 indicated Staff A could return to work but further incidents involving failure to follow policy for usage of the mechanical lifts will result in termination. The education form directed Staff A to always have 2 staff present when using a mechanical lift, always pull down on tabs of sling to ensure they are fully locked and to always carry their Walkie with them to communicate with their co-workers to request assistance with transfers. During an interview with Resident #2 on 6/5/12 at 9:00 a.m., the resident stated the staff hooked up the sling, lifted him/her off the bed with only 1 staff. The left side of the sling became unhooked and he/she fell on the floor. The resident stated he/she hit their left side of their face on the floor and was bleeding. The resident stated for several days he/she stayed in their room because of the bruises on their face but is now coming out to the dining room. The resident stated it was scary to get up with the lift now. During an interview with Staff A on 6/5/12 at 2:30 p.m., Staff A indicated on Sunday, May 20, 2012 she came back from break and needed to get Resident #2 ready for his/her evening meal. Staff A went into the resident's room put the sling under the resident. Staff A stated a nurse came in to administer eye drops to Resident #2 and asked if someone was coming to help her( with the transfer), Staff A stated yes. Staff A told the nurse that another staff was giving resident ' s baths. The nurse left the room and Staff A did not have the Walkie with her to call for help. Staff A hooked up the sling and lifted Resident #2 up into the air by her(self). Staff A lifted the resident up into the air and moved Resident #2 into the middle of the room while he/she was up in the air. During the transfer, Staff A was going to position Resident #2 to sit up in the sling and the resident fell on to the floor. Resident #2 screamed and fell to the floor on his/her face, landing on top of the lift legs. The hall nurse came into the room and sent Staff A out to get more staff to help with the situation. Staff A stated she did not ask for help with the transfer and admitted she had transferred Resident #2 alone using the mechanical lift. Staff A stated she had transferred Resident #2 alone before in the lift prior to this incident but did not have problems. During an interview with Staff B on 6/11/12 at 11:45 a.m. revealed she had transferred residents using a Hoyer lift without a second person. Staff B stated at times a facility nurse would walk into the room, notice the lift transfer with one staff and walk back out of the room. The facility nurse did not reprimand or tell the staff they need to have 2 staff for mechanical lift transfers. During an interview with the Director of Nurses (D.O.N.) on 6/5/12 at 10:15 a.m., the D.O.N. stated she re-enacted the fall of Resident #2's on May 20, 2012, but could not figure out how the resident fell . The D.O.N. stated the staff transferred Resident #2 using the mechanical lift without a second person present and the resident fell from the mechanical lift. Staff A told the D.O.N. during the investigation she was in a hurry.

Based on observation, record review and family, resident and staff interviews, the facility failed to direct the nursing care services so each resident ' s safety needs are met and the facility failed to supervise the implementation of the plan of care. (Resident #1). Four residents were reviewed. The facility identified a census of 61 residents. The facility failed to ensure 1 resident's call light was within reach. The resident needed to use the restroom and could not alert the staff. The resident exited the bed, fell and sustained facial injuries. The facility reported a census of 61 residents. Findings include: 1. Resident #1 had an MDS (Minimum Data Set) assessment with a reference date of 12/18/2011. The assessment reflected Resident #1 had no cognitive impairment, required extensive assistance of one staff to transfer between surfaces, dress and use the toilet. The assessment indicated the resident did not ambulate, had continence of bowel and bladder, and had a previous fall with no injury. The MDS revealed the resident had [DIAGNOSES REDACTED]. The Care Plan identified the resident had a problem with the potential to fall due to dizziness and the use of [MEDICAL CONDITION] medication usage. One of the intervention approaches directed staff to keep the call light within reach and to respond to call light promptly. The Care Plan identified a problem with the need to use the restroom and required staff assistance. The approach indicated the resident would use the call light to alert staff when needed to use the restroom. In the Nurse's Notes dated 12/30/2011 at 11:57 p.m., Staff A, RN (Registered Nurse) documented a CNA (Certified Nurse's Aide) requested assistance in Resident #1's room. Staff A observed the resident on the floor with blood on the floor. The resident reported attempting to transfer from the bed to the commode and sustained a fall due to not being able to wait any longer for help. Staff assessed the resident and notified the physician and family and transferred the resident to the emergency room . At 6:00 a.m. the resident returned to the facility with physician's orders [REDACTED]. The Diagnostic Imaging Report dated 12/31/2011 revealed no fracture or dislocation of the Resident #1's left knee or skull. The Head CT reported the resident had an indeterminate nasal bone fracture. The Fall Investigation Worksheet dated 12/31/2011 documented Resident #1 transferred self from the bed to commode and sustained a fall. The resident failed to use the call light to request help to transfer due to the device clipped to the recliner and out of the resident ' s reach. No alarms were in place at the time. On 09/26/2011 Resident #1 scored 15 points on a Fall Risk Assessment representing a high risk for falls. A Physical Therapy Discharge Summary dated 10/11/2011 documented the resident discharged from therapy services due to refusing treatment. During an interview with Resident #1 and family member present on 01/24/2012 at 11:30 a.m., the resident reported falling to the floor because the call light "was clear across the room". The resident waited and called for help, but could not wait any longer. The resident had bruising to the face at the time, but barely visible at present. Now the resident has an alarm at night when in bed. During an interview on 01/25/2012 at 8:30 a.m., Staff A reported working as the charge nurse on 12/20/2011 during the night shift. At approximately midnight Staff B, CNA summoned Staff A to Resident #1's room and observed the resident on the floor with blood present. Staff A assessed the resident, called the physician and family and transferred the resident to the emergency room . Staff A revealed the resident reported not able to reach the call light that was attached to the recliner and attempted to self transfer to the commode and back to bed. The resident normally always used the call light when needing assistance. Since that incident, staff check call light placement at the end of every shift. During an interview on 01/24/2012 at 5:30 p.m., Staff C, CNA reported assisting Resident #1 to bed on 12/30/2011 at approximately 8:00 p.m. The resident had the call light nearby while in the recliner, but Staff C failed to recall if he/she transferred the call light to the bed. The resident usually used the call light when needing assistance. At approximately 9:30 p.m. Staff C checked the resident but failed to check call light placement. Now staffs check all call lights and alarms at the end of the shift. Staff C reported receiving a disciplinary action for not placing Resident #1's call light within reach. During an interview on 01/25/2012 at 10:40 a.m. Staff B, CNA reported working the night shift on 12/30/2011. Staff B approached the nurse ' s station around midnight and heard a resident talking. Staff B asked Staff A who had assumed the sound was another resident who frequently called out. Staff B walked down Hall #2 to make sure and found Resident #1 on the floor and asking for "help". Resident #1 reported needing to use the toilet but could not reach the call light, and no staff heard the call for help until the resident fell to the floor. Since that incident staffs check alarms and call lights at the beginning and end of each shift. Staff B indicated the resident always used the call light when needing assistance. During an interview on 01/24/2012 at 12:50 p.m. the DON (Director of Nursing) reported Resident #1 had another fall on 11/30/2011 where staff lowered the resident to the floor when the resident's knees buckled shift. Observation on 01/25/2012 at 7:25 a.m. revealed Resident #1 in the recliner with feet up and the wheel chair in front of the recliner. The call light hung from the side rail of the bed and the resident had no call light within reach. At 7:30 a.m. the surveyor reported the observation to the DON. The DON moved the call light from the side rail to the recliner, within the resident's reach. At 7:28 a.m. Staff E, LPN reported Resident #1 remained in the room due to not feeling well. At 7:35 a.m. Staff D, LPN reported transferring the resident to the recliner and failed to move the call light from the bed to the chair. The DON reported Staff D received a verbal warning for failure to place the resident's call light within reach prior to leaving the resident' room.