Every finding on record at Altoona Nursing and Rehabilitation Center

Based on observation, clinical record review, hospital record review, staff and resident interview, mechanical lift user manual, and facility policy review, the facility failed to ensure the safety of residents during a full body mechanical lift transfer for 1 of 3 residents reviewed for safe transfers (Res #2). This resulted in harm to Resident #2 when he fell from the mechanical lift sling during a transfer, resulting in a hip fracture and leg wound. The facility reported a census of 98 residents. Following this event, the facility implemented the following corrective actions:Conducted an immediate internal investigation and Root Cause Analysis (RCA) of the fall, including a simulated transfer to identify contributing factors.Inspected the mechanical lift and sling involved in the incident, as well as all other lifts and slings within the facility, to ensure equipment integrity.Provided mandatory, hands-on re-education to the involved staff, including a successful return demonstration and competency check-off regarding safe mechanical lift operation.The therapy department assessed all residents requiring full-body mechanical lift transfers to verify that current transfer orders were safe and appropriate.Convened an ad-hoc safety meeting on 5/4/26, outside of regular Quality Assurance and Performance Improvement (QAPI) protocols, to review the incident and corrective measures.Updated Resident #2's care plan to mandate three-person transfers.Upon discharge from the hospital, initiation of physical therapy services was done for the resident.Based on the actions taken by the facility prior to the start of the survey on 7/13/26, the event is considered past non-compliance. Findings include: The Minimum Data Set (MDS) of Resident #2 dated 4/30/26 recorded the resident sustained a major injury related to a fall since the prior MDS assessment. The MDS of Resident #2 dated 7/2/26 identified a Brief Interview for Mental Status score of 15 which indicated cognition intact. The MDS identified a diagnosis of hip fracture.The Care Plan of Resident #2 documented a Problem category of Self Care Deficit requiring assistance with Activities of Daily Living, dated 3/28/25. The Care Plan directed staff the Resident transferred with assistance of three staff with the mechanical lift, revision date 4/30/26. The Risk Management Report (Incident Report) dated 4/30/26 documented Res #2 had slid out of the sling of a full body mechanical lift (a mechanical device used to transfer individuals with limited mobility between bed, chair, wheelchair, etc, using a hammock style sling and a mechanical arm to lift and transfer a resident from one surface to another). The resident was observed on the floor while still in the sling with his left foot underneath his right leg (below the knee amputation to that leg). The Report further documented the resident was complaining of left hip pain while remaining on the floor. The nurse called the facility Nurse Practitioner (NP) to report the fall and the resident's pain and received orders to transfer the resident off the floor and put him in bed. After administering pain medication, the NP was called again regarding the resident's pain and orders were received to send to the hospital. The Report documented the non-emergency ambulance was called and the resident was transported to the hospital approximately 30 minutes later, documented as leaving the facility at 11:30 am. The report documented the resident had no observed injuries at the time of the incident. Hospital emergency department records recorded the resident arrived following a 4-foot fall during a transfer; the resident reported a pain level of 9 out of 10 upon evaluation. The resident underwent a computed tomography (CT) scan (a diagnostic scan to see detailed images of bones, organs and soft tissues) and was diagnosed with an acute comminuted impacted and displaced left intertrochanteric hip fracture. (A recent fracture, which the bone was shattered or splintered [comminuted], the broken ends of the bone driven into each other [impacted], the broken pieces shifting out of their normal place [displaced], the fracture being on the left side of the body, at the very top of the femur [thigh bone], just below the ball part of the hip joint. The resident underwent surgical repair of intramedullary nail fixation (IMN fixation, a rod is inserted into the hollow canal of the long bone to stabilize and align the fracture) the following day. The resident was also seen by the hospital wound nurse during his stay, with documentation two wounds on his lower left leg, one an abrasion to the lower shin, measured at 5 cm in length with scant drainage and an additional wound measuring 6.9 cm in length also with scant drainage. A review of the manufacturer's user manual for the mechanical lift involved in the fall outlines the following operational requirements: **Operational Warnings (Page 7):** Always place the lift legs in the open position to lift or lower a patient; close the legs when maneuvering the lift. **Lifting a Patient from the Floor (Page 10):** Verify the patient is uninjured; do not move the patient if injury is suspected; and contact a clinician to determine the necessary next steps.Wound notes from the facility wound Doctor of Nursing Practice (DNP) were reviewed. Notes revealed left lateral calf hematoma status post fall with measurements of 8.2 x 4.6 x 0.1 cm on the visit note dated 5/15/26. The note also described the left hip surgical wound closed with staples. New orders for the calf wound were placed on this date. The DNP continued weekly visits of wound assessment and care. A review of the resident's reported pain scale revealed on the day of the fall, the resident rated his pain as 10/10 four times. While his report of pain varied greatly between 0 and 10, it was documented the resident continued at times to report his pain to be a 10 out of 10 through mid July, two and a half months after the fall.The Medication Administration Record of Resident #2 documented his as needed oxycodone had not been used at all the entire month of April of 2026 until April 30th, the day of the fall. He did have oxycodone scheduled for 5 mg, twice a day. In May he used the medication 17 times, in addition to changes in his scheduled pain medications. On 5/30/26, his as needed order was changed to Norco, a combination medication of hydrocodone and tylenol. He received 45 doses of this in June. Through July 14, 2026, the resident had received 14 doses of the medication in July. On 7/14/26, observations were made of full body mechanical lift transfers for Res #2, Res #3 and Res #6. Resident #2 and Resident #3 both required bariatric accommodations and three staff members (Staff A, Staff D, Staff E, all CNAs) assisted in the safe transfer of these residents. During all observations, staff observed safety precautions and transferred all residents safely. On 7/13/26 at 1:35 pm, the Administrator stated that Staff A and Staff B (both Certified Nurse Aides [CNA]) were the two staff members who cared for Res #2 at the time of the fall. She stated Staff B was running the lift and staff A was guiding the resident. She stated Staff A was present at the facility at that time, but that Staff B had changed her work status to as needed and was not scheduled during the survey week. On 7/13/26 at 1:40 pm, Staff A, CNA described the fall of Res #2. She stated after completing incontinence care they then hooked up the sling to the lift. She stated it was the correct bariatric sling appropriate for the resident's weight (The resident weighs 308 pounds. The lift was safe for use up to 700 pounds and the sling was safe for up to 450 pounds). She stated he had been raised from the bed, was up in the air, moving from the bed to the chair. She stated none of the loops of the sling came loose. She stated all four loops were still on the lift, but the resident shifted his weight and just slid out of the sling. She stated the loops on the leg portion of the sling were around him outside of his body, not criss crossed. She stated the resident has a leg amputation below the knee on his right side. She described the bed had remained at the height they had raised it to when getting the resident dressed. She stated when he slid out, he had not yet been lowered to the recliner. She stated Staff B had pulled the lift from the bed and turned to place him in the recliner but had not gotten him over the recliner yet. Staff A stated she had moved behind the recliner, so she could guide him into the chair, but she had not yet reached for the sling when he fell. She stated he hit the leg of the lift (a long horizontal metal bar) when he fell. She stated the legs of the mechanical lift were in the open position. On 7/13/26 at 2:45 pm, the Administrator stated during the facility internal investigation of the incident, they did a recreation with the Maintenance Director being raised in the sling to represent the resident. She stated when the Maintenance Director shifted his weight around during the recreation, he was able to slide out of the sling also. On 7/13/26 at 3:40 pm, Staff C, Maintenance Director verified the correct placement of the sling underneath him during the recreation of the incident. He stated they did it a few times trying to figure out how it happened. He said while he was eventually able to slide out of it, it took a lot of effort and he had had to lift his hands up on the top bar of the lift and basically swing himself out in order to push his body out.On 7/13/26 at 3:55 pm a call was placed to the manufacturer of the mechanical lift and the sling. Verification was received that the loops of this type of sling are to be placed outside of the resident's legs and not crisscrossed. (The facility had correctly placed the sling). On 7/14/26 at 8:20 am, the Administrator stated after the incident happened, the facility audited all residents who were care planned for the full body mechanical lift. Any of those residents who weighed 250 pounds or greater were assessed by therapy to ensure the full body mechanical lift was the appropriate intervention for the resident and was being used correctly. She stated when the resident returned from the hospital, he was treated by physical therapy and his Care Plan was updated to use three staff members for transfers. She stated the facility also reviewed the manufacturer guidelines of the type of sling to be used for an amputee such as Res #2. The guidelines suggested using a specialty amputee sling but stated that was up to professional discretion. They felt the amputee sling was too small for Res #2's body for a safe transfer. On 7/15/26 at 10:57 am, Staff B, CNA described the day of Res #2's fall. She stated that she and Staff A got Res #2 changed and dressed for the day. She stated they placed the lift sling underneath him and hooked the sling up to the lift. She stated they verified all 4 loops were the same color (for positional safety). She stated she was running the lift, and she raised him up with no issues. She stated she raised him a few inches off the bed to clear him over the bed during the transfer, then she was going to transfer him to the recliner. She stated Staff A was guiding to make sure his leg was off the bed and she then moved behind the recliner. She stated she moved him towards the recliner as Staff A went behind it so Staff A could guide him into the chair. She stated she was on the far side of the lift and the resident was a few inches above the recliner when one of the straps came off of the lift. She stated the strap on the resident's left leg came off of the bar on which the loops attach on the cradle of the mechanical lift. She described that the bar that holds the straps, which is normally horizontal, with the loops holding the resident into the sling, went up vertically, she stated it was facing straight up. She stated the legs of the mechanical lift were opened, but the lift did not tilt and the legs stayed on the floor. She stated it happened so fast, and his body was kind of half on his recliner and half on the floor. She stated his head was on the recliner, his legs were on top of the legs of the lift and the sling was all under his upper body. She stated when he was fully on the floor, the sling was still connected to the lift, with three of the loops on the hooks of the carriage bar. She stated the fourth loop was not on the hooks and when he fell, the sling stayed the way it was. She stated they placed a pillow underneath his head and his legs for comfort prior to the nurse coming in the room. She stated after other employees came to assist, they repositioned the sling back underneath him correctly and put him back in bed before the ambulance arrived. Staff B stated she had only been employed at the facility a few months at the time of the fall but had been a CNA for six years. She stated she had double checked the loops prior to the transfer and that the sling was spread correctly underneath him and centered on the sling. On 7/15/26 at 11:15 am, Staff F, Licensed Practical Nurse (LPN) stated she was the nurse assigned to the resident on the day of the fall, but she was in another room at the time the fall occurred. She stated someone came and got her and informed her of the fall. She stated when she entered the room, Resident #2 was lying on the floor, with his head sort of on the recliner. She stated she did an assessment and called the NP and told her what had happened and what she saw and that he was reporting pain, he was moaning, and he appeared very uncomfortable. She stated the NP asked her if anything was broken and gave her orders to complete another assessment after they transferred him back into the bed, to monitor him and to call her back if needed. She reported the first time she called the NP back to report the resident's pain, she received orders to administer an as needed opioid pain medication and to continue to monitor the resident. She stated after administering the medication, she then returned to the resident room where she had been completing a tube feeding prior to the fall. She stated the next time she went to assess the resident, he was crying out in pain and she called the NP back again but did not get an answer. The resident told me he was unable to feel his left leg and was still reporting his pain at a 10/10 which is very unusual for him. She stated the NP then returned her call and told her to send him to the hospital. She stated she thought it was approximately one hour after the fall when she received orders to send him to the hospital. When Staff F was asked what she recalled she was told by the CNAs in the room, she recalled they told her they were transferring him from the bed to the chair, they heard a noise and he fell to the floor. She stated she was not exactly sure if he fell from the lift or from the chair as she was not in the room at the time of the fall. But she didn't feel how he was positioned appeared to be a fall from the chair. She stated he was still in the sling when she entered the room, and she was the first nurse to come in. She sent one of the CNAs to get more help and to ask Staff I, Registered Nurse to also come help. (Staff I was working another hall). She stated the lift was in the low position, and the sling was hooked on three of the hooks. She stated the fourth loop was not hooked to the lift. She stated his back was on the leg of the lift, with his head on the recliner. She stated the leg rest of the recliner was out, the recliner was tilted forward, and his head was against the foot rest. She said he was on his back, and the legs of the lift were open. The resident's Medication Administration Report documented the oxycodone medication was administered at 10:53 am. A review of the Care Timeline from the local hospital revealed a documented arrival time of 1:25 pm on 4/30/26. On 7/15/26 at 12:15 pm, the facility NP described her phone triage regarding Resident #2's fall. She stated that during the initial call, Staff F, LPN reported the resident had fallen but appeared fine and was lying on the floor. The NP instructed Staff F to return the resident to bed and perform a full assessment. She then stated that when Staff F called back to report the resident was experiencing significant pain, the NP ordered a hospital transfer. The NP stated she believed that 911 services were utilized instead of non-emergency transport to ensure prompt pain relief.The Director of Nursing (DON) explained that the city has a non-emergency transport ambulance but that generally takes an hour or so for them to arrive and the facility uses this service when the situation is not an urgent need for a resident to be transported to the Emergency Department. On 7/15/26 at 1:40 pm, Resident #2 stated he did remember the fall. He stated he was in the lift being transferred and he fell over. He stated prior to the fall, all seemed fine, and he didn't feel the staff had done anything differently than on prior transfers. He stated he landed on his back on the floor and kind of slid down the recliner. He stated he didn't think it was very long until the ambulance came and stated he feels safe in the facility. He did not recall shifting his weight or moving around in the sling prior to the fall. He was unable to state how or why the fall happened. On 7/15/26 at 4:00 pm, Staff I, RN stated he was notified of the fall and asked to come assist. He stated when he entered the room, the resident was on the floor, near the recliner. He did not recall the lift sling being attached to the lift at that time. He stated the resident was complaining of pain while he was on the floor and that Staff F told him the NP had said to get him back into bed for a further assessment. He stated they used the mechanical lift and transferred him into the bed. He stated during the transfer, the resident continued to complain of pain in the left hip. He stated he was reporting pain when on the floor and during the transfer. He stated he thought Staff F called the NP again and got x-ray orders but he returned to his nursing station after assisting with the transfer. On 7/16/26 at 8:04 am, Staff B, CNA came into the facility per the request of the Administrator. The Administrator, the DON, the Maintenance Director, and Staff B entered the room occupied by the State Surveyor, bringing the full body mechanical lift into the room. A sling was on the unoccupied bed and the Administrator stated they wanted to again recreate how the incident happened. A recliner was near the bed in approximately the same position as how Res #2's room was set up. Staff B, CNA described that during the fall, the carriage bar that has the hooks went straight vertical during the fall. She stated that when she had spoken to the State Surveyor on the prior afternoon, she had at that time thought one of the loops of the sling had come off the lift. She stated she now realized it had not. She recalled they lowered the mechanical lift after the fall to make the resident more comfortable, and that is when she released the loop. She said on the prior day, she thought it had come off during the fall but she now did not think that had happened. She stated there was no way the loop was off during the fall. She stated prior to the fall, she had hooked the loops on the resident's left side and Staff A had hooked the loops on the resident's right side. Staff C, the Maintenance Director then laid on the sling on the bed and Staff B was asked to hook the sling up to the lift. She hooked the loops, raised Staff C off the bed and began to guide him towards the recliner. She stated on the day of the fall, it was when she got close to the recliner that the carriage bar flipped upward. She again stated that is when they lowered the lift. She then stated she removed all four of the loops so the resident could be more comfortable and they lifted his upper body and placed a pillow behind him. She stated they then got assistance from the nurse after they removed the sling and placed the pillow. The Administrator verified with Staff B that she had reported to the State Surveyor that a loop came off the carriage bar during the interview the prior day and Staff B verified she had said that. She corrected herself and stated that she then remembered it had not come off. On 7/16/26 at 8:26 am, the Administrator reported following the fall, the full nursing staff were provided education and all did return demonstration/competency checks on all nurses and CNAs as well as verbal education. The management team had multiple team meetings and the ad hoc QAPI meeting was held. She stated while all of the lifts and slings were checked monthly, they completed a full check off all mechanical lifts and slings after the fall. The validation checklist for use of a mechanical lift were provided for Staff A and B. Staff A's checklists were dated 2/10/26 and 4/30/26 (the day of the fall). Staff B's checklists were dated 4/30/26 (the day of the fall) and 5/4/26. The facility policy Safe Lifting and Movement of Residents, revision date July 2017 documented the following:Point 6: Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Point 7: Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques.

Based on observation, clinical record review, resident and staff interviews, the facility failed to follow medical provider orders for 2 of 3 residents (Res #1, Res #4) reviewed for wound management. The facility reported a census of 98 residents. Findings include: 1. The Minimum Data Set (MDS) Assessment of Resident #1 dated 6/11/26 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS identified diagnoses which included coronary artery disease, diabetes (both which increase risk of development of skin wounds), chronic venous hypertension with ulcer and inflammation of the left lower extremity, depression and anxiety. The Wound Treatment Plan Note detailed the DNP (Doctor of Nursing Practice) Wound Specialist visited the resident on 6/19/26 for a scheduled wound assessment. The DNP wrote in her note that the current wound care treatment order was for an unna boot (a specialized, zinc-oxide-impregnated gauze bandage wrapped around the leg to create a semi-rigid compression dressing), however, the leg was open to air (no dressing) upon her arrival. She placed orders on this day to continue current treatment until new supplies arrive, then begin to cleanse with cleaner of choice, apply 1% silver gel, cover with a dressing and secure with a tubigrib (an elasticated tubular support bandage used to provide firm, even compression), change daily and as needed. A review of the June 2026 Treatment Administration Record (TAR) indicated that the Unna boot application, ordered for Tuesdays and Fridays starting 6/16/26, was never signed off as completed. Furthermore, the order was discontinued on 6/19/26, contradicting the DNP's directive to maintain existing treatment until new supplies became available. The prescribed treatment silver gel was not documented as completed until 6/30/26, with supplies being unavailable. The Wound Treatment Plan Note detailed the DNP next visited the resident on 6/24/26 for the next scheduled wound assessment. She again noted the wounds were open to air upon her arrival, noting the wound gel and tubigrips were not yet available. The Wound Treatment Plan Note dated 7/8/26 noted new orders were given on 7/6/26 which the facility had not yet processed. (changing silver gel to silvadene) She again wrote new orders with a note of ok to continue current treatment until new supplies arrive. The TAR reflected the order to stop the silver cell was not discontinued until 7/9/26 and to begin silvadene on 7/10/26. The order was for cleansing the wound, applying silvadene, and then covering with a non-adherent pad, secure with a gauze wrap and then a tubigrip, ordered for 8:00 am each morning. On 7/15/26 at 1:55 pm, Res #1 was sitting at the edge of her bed. She reported to the State Surveyor that her leg was supposed to be wrapped. The leg was open to air with no dressings or tubigrip on the leg. She stated when she is incontinent, urine runs down her leg and burns the wound due to it not being covered as ordered. Her leg was noted to be red and edematous. Review of the TAR revealed the treatment of cleaning, cream and dressings scheduled for 8:00 am that day had been signed off as being complete by Staff H, Certified Medication Aide (CMA). On 7/15/26 at 2:10 pm, Staff H, CMA stated she had given the resident a shower and applied the cream to her leg. She stated as a Medication Aide and not a nurse, it is not within her scope of practice to apply the dressings so the nurse was supposed to do that. She stated she had signed the TAR because she had completed the cleansing and the cream. She voiced she thought the nurse was on a break but she was aware the dressings still needed to be completed. On 7/15/26 at 2:18 pm, Staff G, Licensed Practical Nurse (LPN) stated she had the treatment for Resident #1 and it had been a busy day and she had not had time to complete it yet. She stated there was another resident who was not doing well and she had been busy with him. She gathered the supplies and went to Res #1's room.At 2:27 pm, Staff G, LPN returned to the desk. She stated the DNP was in the building completing rounds so she was going to wait to place the dressing until after she was seen by the wound specialist. The Wound Treatment Plan Note for the 7/15/26 visit detailed that Res #1 had also voiced to the DNP her concern regarding urinary incontinence and her leg becoming grossly contaminated with urine. Her note also stated the resident would benefit from compression on her leg to manage lymphedema and heal wounds. (The tubigrip, a form of compression, was ordered on 6/19/26). 2. The MDS Assessment of Resident #4 dated 4/21/26 documented the resident had a surgical wound. The MDS noted diagnoses including a hip fracture and orthopedic aftercare. The TAR of Resident #4 for April of 2026 reflected an order to change the left hip dressing daily and report signs of redness or warmth, with a start date of 4/23/26. The order was discontinued on 4/29/26. There was no documentation of the dressing change being completed, or refused by the resident to be completed on 4/22/26, 4/23/26 or 4/29/26. On 7/16/26 at 12:52 pm, the Director of Nursing stated the wound care may have been completed and staff failed to sign the TAR. She also stated Res #1 refuses a lot of things and it is difficult knowing what she will and will not allow staff to use on her wounds.

Based on clinical record review, staff and family interviews, and facility policy review, the facility failed to provide routine scheduled baths for 3 of 3 residents reviewed (Resident #1, #5, #10). The facility reported a census of 98 residents. Findings include:1. The Minimum Data Set (MDS) Assessment of Res #1 dated 6/11/26 documented the resident to be dependent on staff assistance for bathing. The Care Plan of Res #1 identified a Problem area of self-care deficit, requiring assistance with Activities of Daily Living (ADLs), dated 6/13/25. The Care Plan directed staff that Res #1 required the assistance of 2 staff members and to encourage bathing twice weekly. The Care Plan identified the resident leaves the facility on therapeutic leave with her family frequently. On 7/14/26 at 9:05 am, the Administrator stated ideally, bathing/showers would be documented in the resident's electronic health record (EHR) but at this time, staff uses physical shower sheets which are filled out by the floor staff. She stated Medical Records then gathers the shower sheets and uploads them into the individual resident EHR. Review of Showers/Bathing for Resident #1 revealed the following:2/14/26 - documented as refused2/25/26 - completed 3/4/26 - completed 3/6/26 - completed 3/11/26 - completed 3/28/26 - completed 4/11/26 - completed 4/15/26 - documented as refused4/22/26 - completed 5/2/26 - completed 5/6/26 - documented as refused, shower sheet states she requested morning of 5/7/265/8/26 - completed 5/27/26 - completed 6/3/26 - completed 6/17/26 - completed 6/30/26 - completed 7/1/26 - completed Resident #1's shower schedule was not met on the following dates, excluding Saturdays when the resident was typically off-site. (Wednesday/Saturday schedule)2/4/26 2/11/26 2/18/26 3/18/26 3/25/26 4/1/26 4/8/26 4/29/26 5/13/26 5/20/266/3/26 6/10/26 6/24/262. The MDS of Res #5 dated 4/16/26 documented the resident to require supervision or touching assistance assistance for bathing. The MDS documented that the resident had intact cognitive skills, with a Brief Interview for Mental Status score of 15 out of 15.The Care Plan of Res #1 identified a Problem area of self-care deficit, requiring assistance with Activities of Daily Living (ADLs), dated 10/24/24. The Care Plan directed staff that Res #5 required the assistance of 1 staff member and to encourage bathing twice weekly. Review of Showers/Bathing for Resident #5 revealed the following:2/4/26 - completed2/7/16 - documented as refused x 32/11/26 - completed2/14/26 - completed2/18/26 - completed2/21/26 - completed2/28/26 - completed3/4/26 - documented as refused3/7/26 - completed3/11/26 - completed3/18/26 - documented as refused3/25/26 - completed4/1/26 - completed4/4/26 - documented as refused4/8/26 - completed4/15/26 - documented as refused - in nursing notes, this is the only refusal documented in notes 4/22/26 - completed4/25/26 - completed4/29/26 - completed5/6/26 - completed5/13/26 - completed5/16/26 - completed5/27/26 - completed5/28/26 - completedResident #5's shower schedule was not met on the following dates (Wednesday/Saturday schedule):2/25/26 3/14/263/21/263/28/264/11/264/18/265/2/265/6/265/9/265/20/265/23/265/30/266/6/266/10/266/13/266/20/266/24/266/27/26On 7/16/26 at 1:10 pm, a family member of Resident #5 stated the resident had expressed to her that it was bothering her to not get her showers. The family member stated the resident had reported to her she was using wet wipes to give herself bed baths because staff was not offering her showers on weekends. The family member was unaware if the resident had reported this concern to staff. 3. The MDS of Res #10 dated 7/2/26 documented the resident to require substantial/maximal assistance for bathing. The Care Plan of Res #10 identified a Problem area of self-care deficit, requiring assistance with Activities of Daily Living (ADLs), dated 4/1/26. The Care Plan directed staff to encourage bathing twice weekly. Review of Showers/Bathing for Resident #10 revealed the following:4/1/26 - completed4/4/26 - completed4/8/26 - completed4/14/26 - completed4/18/26 - documented as refused4/19/26 - completed4/22/26 - completed4/25/26 - completed4/29/26 - documented as refused 5/6/26 - completed5/9/26 - completed5/13/26 - completed5/20/26 - completed5/27/26 - completed6/6/26 - completed6/10/26 - completed6/13/26 - completed6/17/26 - completed6/20/26 - completed6/24/26 - completed6/27/26 - completed7/1/26 - completed7/8/26 - completedResident #10's shower schedule was not met on the following dates (Wednesday/Saturday schedule):4/11/265/2/265/16/265/23/265/30/266/3/26On 7/16/26 at 12:52 pm, the Director of Nursing stated there is a printed shower sheet for the resident's scheduled bathing. She stated each resident is scheduled at least twice a week, and some more often if the resident or family request it. She stated her expectation is for staff to offer a shower. If the resident refuses, staff are to reapproach later and if the refusal continues, then they are to notify the nurse. The nurse is then to speak to the resident and if refusal continues, the nurse is to chart a progress note of the refusal. The undated facility policy Resident Showers documented the following:Policy: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.Point 1: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.

Based on clinical record review, hospital record review, medical provider, staff, and family interviews and facility policy review, the facility failed to notify the medical provider of orders requiring follow-up upon a resident's admission to the facility following a hospital stay for one of three residents reviewed (Res #10) for medications. The facility reported a census of 98 residents. Findings include: The Minimum Data Set (MDS) Assessment of Resident #10 dated 7/2/26 identified an admission date to the facility of 3/31/26 and that she admitted to the facility from an acute care hospital. The MDS documented diagnoses which included hypertension (high blood pressure) and atrial fibrillation (an irregular and often very fast heartbeat. It happens when the heart's upper chambers receive chaotic electrical signals, causing them to quiver or shake instead of pumping blood smoothly into the lower chambers). The MDS identified a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairement. The medication list from the hospital dated 3/31/26 directed that the following medications be held upon the resident's admission to the facility, pending further orders from the resident's physician or care provider:a. Bumetanide, 1 mg tablet taken daily (a diuretic).b. Spironolactone, 25 mg tablet taken daily (also a diuretic). These hold orders required waiting for the resident's doctor or other care provider to authorize resumption. The resident's Electronic Health Record (EHR) failed to document that the medical director or other provider was at any time notified of these medications needing to be assessed. The General Progress Note dated 5/26/26, nearly two months after facility admission, documented the resident's daughter came to a staff nurse expressing concerns about the resident's legs swelling. The nurse then assessed the resident and documented 2+ pitting edema in both legs (a moderate level of swelling where pressing your finger into the affected area leaves a dent about 3 to 4 mm deep. This indentation typically lasts up to 15 seconds before the skin rebounds to its normal shape). The Medication Administration Record (MAR) for Resident #10 for May of 2026 documented an order for Spironolactone, 25 mg tablet taken daily was ordered to begin on 5/31/26 but was not administered on that day due to the medication not being available. The June of 2026 MAR, documented the medication remained unavailable and was not administered for the first time until 6/3/26. An order for TED hose (specialty compression stockings for edema) was placed on 5/28/26 as well and started on 5/29/26 to be worn during the day and removed at bedtime. On 7/14/26 at 4:44 pm, the Director of Nursing (DON) confirmed her name was on the Electronic Health Record (EHR) of Resident #10 as transcribing the medication orders upon the resident's admission to the facility. She explained that one person places the orders in the EHR and a second nurse confirms the order. She stated she was unable to tell if she did the original transcription or the confirmation but stated she likely was the person who did the second check and confirmed the orders. She described the procedure is that one nurse would place the orders in the system first, and then a second nurse verifies these against the received orders and completes a double check to make sure all are correct before confirming the orders. She stated if a resident has orders such as Resident #10, for medications to be paused, she makes a note of that of notifying the provider. She stated they also email the provider a copy of the admission orders. Upon reviewing the chart of Resident #10, the DON stated she was unable to locate any notes with documentation of the paused medications for Res #10. She stated at that time, the Advanced Registered Nurse Practitioner (ARNP) was in the building five days a week, full time, Monday through Friday. She stated she would have physically given her the note if she had written one and verified the ARNP saw Resident #10 the next day on 4/1/26. On 7/15/26 at 10:50 am the DON stated after the conversation the prior evening of the paused medications for Resident #10, she notified the ARNP of the error. She stated she also notified the facility's corporate office and the Director of Clinical Services completed a chart review on the error. She stated that the ARNP gave no new orders and the Director of Clinical Services did not feel there was any clinical need for the resident to have restarted both diuretics. The resident's weight remained stable and the resident was on the diuretics for edema and did not have a diagnosis such as Congestive Heart Failure, but does have some basic cardiac issues. She stated she realized how significant this could have been and the facility will address the error. On 7/15/26 at 12:00 pm, the ARNP stated she recalled her admission visit with Resident #10. She stated the resident's daughter was aware the hospital had placed the medications on hold and they had a discussion about the resident's medications and her frequent urination. She stated the daughter expressed concerns of the resident's dementia, her cognitive state worsening. She stated she recalled discussing the risks vs the benefits of restarting the diuretic medications and that this conversation took place on the initial admission visit on 4/1/26. She stated she always reviews hospital notes. She stated she, at that time of the interview, was unable to review her notes from that visit due to her having a poor internet connection where she was at during the conversation. She stated she documents everything in her visit notes and does not document anywhere else. The 4/1/26 visit note authored by the ARNP was reviewed and failed to reveal any documentation of the resident's daughter being present at the visit or any conversation regarding the use of diuretics. The note identified the person(s) present during the vist as the patient only. On 7/16/26 at 8:26 am, the Administrator stated the ARNP had placed a note in Res #10's chart regarding the conversation she stated she had with Res #10's daughter on 4/1/26. The note was created on 7/16/26 at 8:08 am and dated 7/15/26 at 7:59 am. The note documented the provider had spoken with the resident and her daughter in April at admission with regards to hospital records with bumex (bumetanide) and spirolactone w/reference to hospital orders and family concerns of bathroom frequency due to risk of falls was discussed. On 7/16/26 at 10:20 am, the daughter of Resident #10 stated she had not been aware the hospital had stopped her mother's orders for diuretics. She stated a few weeks after admission, she noted that her feet were very swollen and mentioned it to the nurse on duty. She recalled telling the nurse she didn't understand why they would be so swollen because she took water pills (diuretics). She said the nurse seemed very confused and told her that there were no orders for any diuretics. The resident's daughter stated that because her mother has atrial fibrillation, without taking the diuretic, fluid can start building up around her heart. She stated she then went to a second nurse and requested that ARNP contact her regarding this. She stated it was a few days later when the ARNP contacted her and they discussed all of her medications. The undated facility policy titled Medication Reconciliation documented the following: Policy: This facility reconciles medication frequently throughout a resident's stay to ensure that the resident is free of any significant medication errors, and that the facility's medication error rate is less than 5 percent.Point 4. admission Processes: Verify resident identifiers on the information received.Compare orders to hospital records, etc. Obtain clarification orders as needed.Transcribe orders in accordance with procedures for admission orders.Have a second nurse review transcribed orders for accuracy and cosign the orders, indicating the review.Order medications from pharmacy in accordance with facility procedures for ordering medications.Verify medications received match the medication orders.Obtain home list of medications from resident/representative. Place on chart for physician review and revision of medication regimen, if warranted.

Based on record review, staff interview, the Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1, and policy/guidance review the facility failed to ensure accuracy on residents' Comprehensive Minimum Data Set (MDS) assessments. Residents reviewed were coded incorrectly indicating their diagnoses were not determined to be a Preadmission Screening and Resident Review (PASRR) condition for 5 of 9 residents reviewed for MDS discrepancies (Residents #4, #7, #8, #53, and #54). The facility reported a census of 93 residents.Findings include:1. The MDS completed on 5/6/25, documented Resident #4's Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS included diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, and schizophrenia. Section A1500 of Resident #4's MDS indicated resident is not currently considered by the state a level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Review of PASRR dated 6/29/23 indicated Resident #4 as level I positive with conditions of mental health disability and intellectual disability. Further review of the PASRR document stated Since this evaluation has determined that you have a PASRR condition, the facility will need to document your PASRR condition in important Medicaid nursing facility paperwork. The facility should mark yes for question A1500 on the Minimum Data Set, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?. Also, your specific PASRR condition(s) should be checked in question A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.2. The MDS completed on 5/6/25, documented Resident #7's BIMS score of 9, indicating moderate cognitive impairment. Diagnoses include anxiety disorder, depression, bipolar disorder, and post traumatic stress disorder. (PTSD). Section A1500 of Resident #7's MDS indicated resident is not currently considered by the state a level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.Review of PASRR dated 6/5/23 indicated Resident #7 had a level I positive with conditions of mental health disability. Further review of the PASRR document stated Since this evaluation has determined that you have a PASRR condition, the facility will need to document your PASRR condition in important Medicaid nursing facility paperwork. The facility should mark yes for question A1500 on the Minimum Data Set, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?. Also, your specific PASRR condition(s) should be checked in question A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.3. The MDS completed on 5/6/25, documented Resident #8's BIMS score of 15, indicating cognitively intact. Diagnoses include cerebral palsy, anxiety disorder, depression, schizophrenia, and PTSD. Section A1500 of Resident #8's MDS indicated resident is not currently considered by the state a level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.Review of PASRR dated 5/12/25 indicated Resident #8 as level I positive with conditions of mental health disability, intellectual disability (ID), and developmental disability/related condition (DD/RC). Further review of the PASRR document stated Since this evaluation has determined that you have a PASRR condition, the facility will need to document your PASRR condition in important Medicaid nursing facility paperwork. The facility should mark yes for question A1500 on the Minimum Data Set, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? Also, your specific PASRR condition(s) should be checked in question A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.4. The MDS completed on 3/2/26, documented Resident #53's BIMS score of 99, indicating the resident was unable to complete the interview. Diagnoses include Non-Alzheimer's Dementia and bipolar disorder. Section A1500 of Resident #53's MDS indicated resident is not currently considered by the state a level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.Review of PASRR dated 9/14/23 indicated Resident #53 as level I positive with conditions of mental health disability. Further review of the PASRR document stated Since this evaluation has determined that you have a PASRR condition, the facility will need to document your PASRR condition in important Medicaid nursing facility paperwork. The facility should mark yes for question A1500 on the Minimum Data Set, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?. Also, your specific PASRR condition(s) should be checked in question A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.5. The MDS completed on 5/30/25, documented Resident #54's BIMS score of 15, indicating cognitively intact. Diagnoses include anxiety disorder, depression, and bipolar disorder. Section A1500 of Resident #54's MDS indicated resident is not currently considered by the state a level II PASRR process to have serious mental illness and/or intellectual disability or a related condition.Review of PASRR dated 4/18/25 indicated Resident #54 as level II with approved special services for serious mental illness and diagnosis of bipolar disorder. Further review of the PASRR document stated Since this evaluation has determined that you have a PASRR condition, the facility will need to document your PASRR condition in important Medicaid nursing facility paperwork. The facility should mark yes for question A1500 on the Minimum Data Set, Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition?. Also, your specific PASRR condition(s) should be checked in question A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.During an interview on 3/19/26 at 12:18 PM Staff G, Corporate Offsite MDS Coordinator, stated the finalized MDS are submitted remotely. The facility's corporation had a Travel MDS Nurse go onsite to the facilities and complete the resident's in person assessments. The Travel MDS Nurse enters their assessments into the resident's electronic health record. Staff G, completes the other MDS areas with document review, like PASRRs, builds the MDS and finalizes the assessment. Staff G, reviewed noted documents, identified the PASSR documentation instructions for A1500, acknowledged the information didn't get completed correctly. Staff G verbalized they didn't have a complete understanding of the PASRRs and their documentation. Review of facility provided MDS 3.0 Completion Policy dated 2025 stated the following:Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan.1. Interdisciplinary Responsibility for Completion of MDS Sections:a. The responsibility of all sections of the MDS will be clearly assigned. b. Persons completing part of the assessment must attest to the accuracy of the section they completed by signature and indication of the relevant sections.c. The R.N. Coordinator signs, dates, and attests to timely completion of the RAI, once all other disciplines have completed their sections.The LTC Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 directed to code 1, yes if PASRR level II screening determined the resident had a serious mental illness.

Based on observation, staff interviews, resident interview, record review and policy, the facility failed to follow professional standards of medication administration for 1 of 4 resident's observed for medication administration (Resident #69). During an observation the staff left medication at bedside. The facility reported a census of 93.Findings include:Resident #69's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating a cognition intact. The MDS included diagnoses of diabetes, heart, lung, and kidney disease. Resident #69's March 2026 Medication Administration Record (MAR) included the following orders:a. Albuterol inhaler, inhale two puffs orally three times a dayb. Ipratropium bromide nasal solution, two sprays in both nostrils three times a day c. Fluticasone propionate nasal suspension two sprays in both nostrils two times a day On 3/18/26 at 12:24 PM, observed Resident #69 sitting at her bedside with her tray table in front of her. Observed a clear plastic bag with medications of two inhalers and a medicated nasal spray. Resident #69 reported the medication belonged to her and the staff left it for her.On 3/18/26 at 12:35 PM, Staff C, Certified Medication Aide (CMA), explained Resident #69 wanted her medications left with her. They usually try to sit with her until she takes all of her medications. She knew Resident #69 had the nose spray and inhalers at her bedside. Staff C confirmed Resident #69 didn't have orders to leave the medications at her bedside. Staff C explained they left them there because Resident #69 would scream if she didn't get her way. On 3/18/26 at 12:40 PM, Staff B, Licensed Practical Nurse (LPN), confirmed Resident #69 didn't have orders to keep medications at her bedside. She knew of confused residents in the hall including Resident #69's roommate. Staff B would ensure to remove the medications from the bedside and put in the locked medication cart.On 3/18/26 at 12:45 PM, the Assistant Director of Nursing (ADON) acknowledged Resident #69 didn't have an order to keep medications at her bedside. The ADON reported they would check on getting a physician's order so Resident #69 could administer their own meds if locked for safety. The facility policy titled, Resident Self-Administration of Medication dated 2025 documented consideration to appropriateness, safety, cognitive stats and ability, would include an assessment form and permitted only when it does not present a risk to confused residents. When determined bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the medication cart or medication room.

Based on observations, clinical record review, staff interview, representative interview and facility policy review the facility failed to provide hand/nail hygiene for 3 of 3 days observed for one of 24 residents reviewed (Resident # 77). The facility reported a census of 93.Findings include: Resident #77's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 2, indicating severe cognitive impairments. The MDS included diagnoses of multiple sclerosis (an autoimmune disease where the immune system attacks the protective nerve covering, disrupting brain-body communication) and dementia.The Care Plan Focus initiated 7/12/24 documented Resident #77 had a self-care deficit and required assistance with activities of daily living (ADLs). The Interventions directed to provide nail care by checking, trimming, and cleaning nails during bath days and whenever needed.On 3/16/26 at 5:14 PM, Resident #77's Representative noted the cleanliness of Resident #77 could improve, specifically they requested better hand hygiene. An observation revealed brownish dark substance under Resident #77's nails.On 3/17/26 at 3:09 PM, observed Resident #77 sitting in a room looking outside, with a brownish, dark substance noted under fingernails.On 3/18/26 at 1:05 PM, witnessed Staff F, Certified Nurse Aide (CNA) take Resident #77 from the dining room in a wheel chair and placed in the common room in front of the television. Staff F failed to perform hand hygiene for Resident #77 after the meal. Resident #77 had dark, brownish material observed under their fingernails. On 3/18/26 at 1:24 PM, Staff E, CNA, and Staff F assisted Resident #77 to bed. They acknowledged Resident #77 depended on staff to help with their care. They acknowledged Resident #77's nails had a brownish dark substance underneath on both hands. When questioned about Resident #77's hygiene, including oral and hand hygiene, the CNAs responded that nail care is typically handled by the activities staff once a week or is performed during showers.On 3/18/26 1:31 PM, the Assistant Director of Nurses (ADON) reported the staff have access to a small tool to clean under nails. They thought what Resident #77 had under their nails was likely food since Resident #77 ate with their hands. The ADON added they would ensure someone trimmed and cleaned Resident #77's nails right away. A sign observed in Resident #77's room revealed, they liked to eat with their hands. The sign directed to please help them clean the wheel chair and themselves after each meal.A policy titled Nail Care dated 2025 instructed to provide routine cleaning and inspection of nails during care on an ongoing basis.

Based on electronic health record (EHR) review, staff interviews, and policy review, the facility failed to complete neurological checks for a resident with an unwitnessed fall for 1 of 2 residents reviewed for falls (Resident #98). The facility reported a census of 93. Findings include: The Minimum Data Set (MDS) Assessment completed 1/19/26 revealed Resident #98 had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS noted Resident #98 required substantial to maximum staff assistance for transfers and bed mobility. Resident #98 utilized a wheelchair for mobility. Diagnoses include anemia (low red cell blood count), diabetes, insomnia, and osteomyelitis (infection of the bone) to the amputation site of the right lower leg/foot. The Care Plan, initiated 1/15/26, indicated Resident #98 had a risk for falls due to impaired balance, recent AMputation, poor safety awareness, and impaired neuromuscular function (connection breakdown between nerves and muscles causing weakness, fatigue). The Care Plan indicated a fall on 1/17/26. The Progress Note dated 1/17/26 at 3:09 PM completed by the Advanced Practice Registered Nurse (ARNP), described Resident #98 as a poor historian due to cognitive/psychiatric impairment. They saw Resident #98 due to hallucinations, a fall, and a lack of intravenous (IV) access. During the visit, Resident #98 commented the ceiling was coming down and the lights slid down the wall. The ARNP decreased their pain medications. The Progress Note dated 1/17/26 at 7:06 PM documented nursing was notified at 12:30 PM as Resident #98 was on the floor. After assessing, the staff returned Resident #98 to bed using a mechanical lift. Resident #98 explained they tried to sit on the edge of the bed when they slid out and voiced they did not hit their head. The facility Incident Report noted no one witnessed Resident #98's fall. Resident #98 didn't go to the hospital. The EHR lacked documentation of neurological checks after the unwitnessed fall. During an interview on 3/19/26 at 8:45 AM, Staff H, Licensed Practical Nurse (LPN), confirmed they worked as the nurse on duty at the time of Resident #98's fall. Staff H stated Resident #98 appeared intact cogitatively but noted some acute confusion possibly related to an on-going infection. Staff H explained neurological checks were initiated and documented on paper, as per facility procedures. After their shift was over, Staff H informed the on-coming nurse of Resident #98's fall and passed on the neurological checks sheet for further assessments. During an interview on 3/19/26 at 12:24 PM, the Director of Nursing (DON) voiced they were under the impression that neurological checks were not indicated at this time. Since Resident #98 had a higher BIMS and voiced they did not hit their head, neurological checks did not need to be completed. The American Association of Post-Acute Care Nursing Post Fall Assessments released August 2021 defined a neurological check as an assessment of neurological status, often called a neuro check. A neuro check should be done when a resident hits their head or if it is unknown if they hit their head (unwitnessed fall). The section related to Follow-up Assessment and Monitoring indicated it is not always immediately obvious that a resident sustained a life threatening injury. Therefore, nurses must take great care to complete thorough follow-up assessments. The policy Assessing Falls and Their Causes, version 1.3, noted the following:If a resident fell or is found on the floor without a witness, evaluate for possible injuries to the head, neck, spine, and extremities;Observe for delayed complications of a fall for approximately 48-hours after an observed or suspected fall;Document observed signs or symptoms of pain, swelling, and any changes in level or responsiveness/consciousness. The undated policy Head Injury noted an assessment is completed following a known, suspected, or verbalized head injury. Neuro checks performed as indicated or as specified by the physician. Continue to monitor for 72-hours following the incident or until Resident #98 is asymptomatic for a period of time specified by the physician.

Based on electronic health record (EHR) review, staff interviews, and policy review, the facility failed to complete smoking assessments for 1 of 1 residents reviewed for smoking (Resident #4). The facility reported a census of 93. Findings include: The Minimum Data Set (MDS) Assessment completed 3/12/26 revealed Resident #4 with a Brief Interview for Mental Status score of 10, indicating impaired cognition. Diagnoses include non-Alzheimer's dementia, seizure disorder, and stroke. The Care Plan with a Target Date of 6/14/26 indicated Resident #4 smoked. Interventions included the completion of quarterly smoking assessments.The facilty acknowledged it is a smoking facility and provided a list of current residents who smoke. Resident #4's name was noted. Review of the EHR verified a smoking assessment was completed on 3/12/26. No further smoking assessments were identified that correlated with the resident's quarterly MDS (4/30/25, 7/28/25, 10/23/25, and 1/21/26). During an interview on 3/18/26, Staff I, Activities Assistant, confirmed Resident #4 went out to smoke during the designated smoke times. Staff I explained any smoking safety devices, like a smoking apron, are identified through smoking assessments completed by the nursing staff. When asked how often the assessments are completed, Staff I thought quarterly. During an interview on 3/19/26 at 12:20 PM, Staff G, corporate offsite MDS Coordinator, explained the finalized MDS is submitted remotely. The facility didn't have a specific staff member onsite to complete. Staff G added a corporate Travel MDS Nurse went to facilities and completed any required in-person assessments, like a smoking assessment. During an interview on 3/19/26 at 12:45 PM, the Director of Nursing (DON) explained smoking assessments are now completed by the corporate MDS Coordinator, which is a new process prior to this, smoking assessments were completed by the facility's unit managers quarterly. The DON reviewed Resident #4's EHR and acknowledged the lack of smoking assessments. The policy Tobacco Policy, updated 9/21/23, noted residents who wish to use tobacco/smoke will be evaluated for safe smoking upon admission and quarterly.

Based on observations, Resident Council Minutes, resident and staff interviews, the facility failed to answer resident call lights within the allotted professional standard of 15 minutes for 3 of 5 residents reviewed (Resident #3, #4 and #11) . The facility reported a census of 97 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12 indicating moderately impaired cognition. The MDS documented Resident #4 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. or , The assistance of 2 or more helpers is required for the resident to complete the activity) for toileting and transfers. The MDS included diagnoses of hemiplegia (paralysis affecting left nondominant side of body), anxiety and respiratory failure. During a continuous observation on 10/28/25 from 9:20 AM to 10:00 AM the following was revealed; note at 9:20 AM Resident #4's call light on. At 9:40 AM the Assistant Director of Nursing yelled out and asked the resident from the doorway what his light was on for. Resident #4 reported he wanted to get to his recliner. At 9:50 AM two Certified Nurses Aides (CNA) went in to assist the resident. On 10/19/25 at 9:33 AM Resident#4 reported he had waited up to an hour and a half at times for his call light to be answered. Resident #4 reported he watched his clock to see how long it takes at times. Resident #4 verbalized it is different this week due to the state surveyors in the building and reported there is not normally office staff answering the call lights like they have been today. Resident #4 reported management knows about the call lights but nothing changes. Review of the Resident Council Meeting minutes for August, September and October of 2025 documented residents voiced the following; long waits for call lights, staff telling residents they will be back and not returning and being left on the toilet 30+ minutes. The minutes lacked follow up documentation with the concerns of call lights, staffing and being left on the toilet. On 10/30/25 at 11:15 AM Staff C, CNA reported there is not enough staff at times to get call lights answered timely. Staff C verbalized she tries to get them in time but it doesn't always happen.On 10/30/25 at 11:20 AM Staff D, CNA reported not enough staff, and sometimes they are short staffed with call ins.On 10/30/25 at 11:50 AM the Director of Nursing (DON) and Administrator reported they expect staff to answer the call light within 15 minutes. 2. Resident #3's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition. The MDS documented Resident #3 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. or , The assistance of 2 or more helpers is required for the resident to complete the activity) for toileting and transfers. The MDS included diagnoses of diabetes, hip fracture and depression. Continuous observation on 10/28/25 from 6:50 PM to 7:17 PM noted Resident #3 call light on when turning down the hallway toward Resident #3's room. At 7:17 PM staff went in to answer the call light and assisted the resident while she was on the commode. On 10/28/25 at 7:10 PM Resident #3 reported it can be hours for her call light to be answered. Resident #3 reported that sometimes she had to call the facility to get someone to her room. Resident #3 reported she had voiced it to management but nothing changes. 3. Resident #11's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognition. The MDS documented Resident #11 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. The assistance of 2 or more helpers is required for the resident to complete the activity for toileting and transfers. The MDS included anxiety and cancer for a diagnoses. During a continuous observation on 10/30/25 at 11:15 AM to 11:40 AM. At 11:18 AM noted Resident #11 call light on. At 11:25 AM the DON walks past the room of Resident #11 and sees the call light on but does not stop. At 11:35 AM a CNA went in with the EZ stand machine and left the machine. CNA reported he would be back when he got another staff member. At 11:39 AM staff came back in to assist the resident. On 10/30/25 at 11:37 AM Resident #11 reported to this surveyor it is sometimes two to three hours for her call light. She then pointed to the clock under her tv and said she times it. This was while in the Ez stand waiting for the staff to return.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure staff protected and prevented resident to resident abuse for 1 of 3 reviewed (Resident #7), when Resident #6 hit Resident #7 a couple of times in the back while in the main lobby area. Resident #7 had a known history of resident-to-resident altercations and the facility failed to evaluate the effectiveness of the interventions to prevent harm to other residents. The facility reported a census of 97 residents. Findings include: 1. Resident #6's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. The MDS included diagnoses of dementia and diabetes. Resident #6's Care Plan documented a problem with the revision date of 11/21/24 as follows; the Resident had episodes of behaviors as evidenced by negative verbalizations, name calling, cursing at others, aggressive behaviors toward other residents, tearfulness, rude statements, and refusing care. The following Care Plan entries documented interventions completed, and Interventions for staff related to the residents behaviors;a. 10/13/24: verbal aggression initiated by Resident #6 towards another residents and physical aggression returned to Resident #6 then Resident #6 returned physical aggression to other the resident. Residents separated and will be living in separate areas of the building.b. 11/4/24: aggression initiated by Resident #6 at another resident. Residents separated and seated at different tables. c. Intervene as necessary to protect the rights and safety of the other residents. Approach/ speak in a clam manner, divert attention if needed. Remove from thesituation and take to alternate location as needed. Initiated 8/4/23d. Observe and chart behaviors as necessary and report to the physician. Initiated 8/4/23e. Observe for early warning signs of oncoming behaviors. Approach in a calm manner, call by name and remove from unwanted stimuli. Initiated 8/4/23f. Refer to psychological/psychiatric consults as indicated. Initiated 8/4/23. On 10/29/25 continuous observation of the dining room from 12:00 PM to 12:40 PM revealed staff in and out of the area. Most of the time when the nurses were in the dining area, they were faced away from the residents at the medication carts in the area. At 12:25 PM Resident #6 yelled at another resident in the dining room pull up your pants you fat ass. No staff were present at the time of the incident. The Facility Investigation dated 10/27/25 documented that on 10/24/25 at approximately 3:15PM Staff A, Registered Nurse (RN) observed Resident #6 strike Resident #7 on the back a couple of times in the main lobby area. The residents were separated immediately and the Administrator notified. Further investigation determined Resident #6 was coming out to the main lobby to sit at her table when she noticed Resident #7 sitting there. Resident #6 reported she used cuss words toward Resident #7 and told him to move out of her spot. When Resident #7 began moving he backed his wheelchair into Resident #6 because he didn't like how Resident #6 was speaking to him, which resulted in Resident #6 striking Resident #7 in the back. The residents were separated by staff and were redirected safely to their respective areas. On 10/29/25 the surveyor requested all Resident #6's incident reports from resident-to-resident altercations from the Director of Nursing (DON). Resident #6's Progress Notes documented the following;a. 10/6/24 at 12:08 PM Resident #6 noted the last two days, picking on another female resident. If she is in her way of getting thru to her table, she shoves her wheelchair to move her so she can get through. Today Resident #6 shoved her again and stated You dumb bitch, get out of my way. Staff spoke with Resident #6 about the way she was treating the other resident and reminded her that she cannot put her hands on anyone or anyone's wheelchair and not shove her or anyone else. Resident #6 stated well you think she can get out of the way, what do you want me to do, go all the way around? Staff reported to Resident #6 that she could do that or even ask the individual to move so she could get thru. b. 10/14/25 at 12:45 PM Resident #6 yelled Fuck you to a resident who didn't hear what she stated to her, so Resident #6 was upset with her. The other resident was asked to move to another table for lunch so that Resident #6 wasn't tempted to yell at her again.c. 10/29/25 at 10:14 AM Resident #6 verbal towards tablemate, stating Why don't you fucking shut your mouth. Resident #6 was asked to move to another table at breakfast, and did so willingly. Resident #6 also stated to this nurse Shut the fucking ice container, the ice will melt.d. 11/2/25 at 12:53 PM Resident #6 telling another resident to Shut up. Reminded Resident #6 that it isn't appropriate to say that to other residents. Resident #6 states Then she needs to just go to her room.e. 3/18/25 at 4:58 PM: Resident #6 upset that a resident was sitting by her table and she wanted her moved as She's looking at me. Reminded Resident #6 that every resident has the right to sit where they want in the lobby and that she can look at her. Resident #6 states No she can't move the old dinosaur. Reminded Resident #6 again not appropriate to call other resident's names. States I don't give a shit.f. 3/22/25 at 2:39 PM Resident #6 was verbal toward another resident. Telling the other resident to shut up, you don't belong here. Resident #6 then proceeded to push the other resident (in her wheelchair) into the table the other resident was sitting at. Resident #6 was reminded by staff it was inappropriate and not to touch another resident or tell them to shut up. g. 4/20/25 4:56 PM Resident #6 kicked another resident's walker because it was next to the spot where Resident #6 sits for meals. The other resident went to another table and Resident #6 yelled at him telling him to pull his pants up.h. 4/21/25 at 3:08 PM Resident #6 was cursing and yelling at a resident trying to get on the dining table where she was sitting during breakfast. The other resident was asked to move to a different table.i. 5/15/25 at 10:37 PM Resident #6 being rude to another resident in the dining hall. Resident #6 did not like another resident in the dining hall and shoved his concentrator. Resident #6 moved away and no further issues.j. 9/27/25 at 11:35 AM Resident #6 was witnessed showing her middle finger to another resident and calling him a foul name. Redirection given and education with teach back.The residents clinical record lacked a root cause analysis, and resident center approach to assist the facility staff members from decreasing or preventing reoccurring resident-to-resident incidents that involved Resident#6. On 10/29/25 at 10:40 AM the DON reported they did not have incident report for the 10/6/24 and 3/22/25 resident to resident altercations due to no one being hurt. On 10/29/25 at 1:25 PM the DON reported the 10/24/25 incident where Resident #6 hit another resident, the intervention was separation. She reported there was no other inventions put in place because they could not remove Resident #6 from the dining room because of her rights. She reported the facility did not look at any other inventions. On 10/29/25 at 2:10 PM Staff E, Certified Nurses Aide (CNA) reported that Resident#6 yelled at other residents, but she had never seen her hit anyone. She stated that the other residents just know not to sit at her table.On 10/29/25 at 2:15 PM Staff F, Certified Medication Aide (CMA) reported that Resident#6 yelled a lot and it is due to residents sitting at her table, Resident#6 doesn't like anyone in her area in the dinning area. Staff F, reported that just know to stay away. On 10/29/25 at 2:40 PM Staff B, Licensed Practical Nurse (LPN) reported she could not recall who the other resident was for the 10/06/24 or the 3/22/25 incidents. Staff B reported she could not recall if the resident on 3/22/25 hit the table or not. Staff B reported she did not fill out an incident report but if the resident would have been hurt, she would have. Staff B verbalized Resident #6 is possessive of her spot in the dining room/main lobby area. Staff B reported Resident #6 doesn't want anyone to sit at her spot ever. The Nursing Abuse Prevention, Identification, Investigation and Reporting Policy dated 7/8/24 directed staff as follows: Rational: All Residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This includes prohibiting nursing facility staff from taking acts that result in person degradation, including the taking or using photographs or recording in any manner that would demean or humiliate a resident, and prohibits using of equipment (e.g., cameras, smart phones, and other electronic devices) to take, keep or distribute photographs and/or recording on social media or through multimedia messages. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. -Physical abuse includes, but not limited to hitting, slapping, pinching, and kicking. It also includes corporal punishment when used to correct or control behavior, including but not limited to, pinching, spanking, slapping hands, flicking, or hitting with an object. - Resident-to-resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish is considered resident-to-resident abuse. Resident-to-resident sexual harassment, sexual coercion, or sexual assault is also considered abuse. The facility will presume that instances of abuse caused physical harm, or pain or mental anguish in residents with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the absence of evidence to the contrary. An example would be a resident slapping another resident who is physically or cognitively impaired, even though the resident who was slapped showed no reaction (e.g., yelp or grimace), it is presumed the resident experienced pain. 2. Resident #7's MDS assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. The MDS included diagnoses of dementia and hypertension (high blood pressure). On 10/30/25 at 11:00 AM Resident #7 reported he had an altercation in the dining room on the other end recently with Resident #6 due to Resident #6 being mean toward him. Resident #7 reported Resident #6 is crazy. Resident #7 reported he was not doing anything but sitting at a table enjoying his afternoon. Resident #7 reported he never wants to go back to that area because Resident #7 is crazy to deal with.

Based on record review, policy review and staff interview, the facility failed to complete incident reports or document for 2 of 3 resident-to-resident altercations reviewed (Resident #6). The facility reported a census of 97 residents. Findings include: Resident #6's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 10 indicating moderately impaired cognition. The MDS included diagnoses of dementia and diabetes. Resident #6's Progress Notes documented the following:a. 10/6/24 at 12:08 PM Resident #6 has been noted the last two days, picking on another female resident. If she is in her way of getting thru to her table, she shoves her wheelchair to move her so she can get through. Today Resident #6 shoved her again and stated You dumb bitch, get out of my way. Staff spoke with Resident #6 about the way she was treating the other resident and reminded her that she cannot put her hands on anyone or anyone's wheelchair and not shove her or anyone else. Resident #6 stated well you think she can get out of the way, what do you want me to do, go all the way around? Staff reported to Resident #6 that she could do that or even ask the individual to move so she could get thru. b. 3/22/25 at 2:39 PM Resident #6 was verbal toward another resident. Telling the other resident to shut up, and you don't belong here. Resident #6 then proceeded to push the other resident (in her wheelchair) into the table the other resident was sitting at. Resident #6 was reminded by staff it was inappropriate and not to touch another resident or tell them to shut up. On 10/29/25 at 10:40 AM the Director of Nursing (DON) reported they did not have incident reports for the 10/6/24 and 3/22/25 resident-to-resident altercations due to no one being hurt. On 10/29/25 at 1:25 PM the DON reported the 10/24/25 incident where Resident #6 hit another resident, the intervention was separation. She reported there was no other inventions put in place because they could not remove Resident #6 from the dining room because of her rights. She reported the facility did not look at any other inventions. On 10/29/25 at 2:40 PM Staff B, Licensed Practical Nurse (LPN) reported the 10/6/24 and the 3/22/25 incidents she cannot recall who the other resident was. Staff B reported she did not chart or follow up with other residents involved in either of incidents. Staff B reported she could not recall if the resident on 3/22/25 hit the table or not. Staff B reported she did not fill out an incident report but if the resident would have been hurt she would have. Staff B verbalized Resident #6 is possessive of her spot in the dining room/main lobby area. Staff B reported Resident #6 doesn't want anyone to sit at her spot ever. Staff B reported looking back she should have charted on both residents. The Accident and Incidents-Investigating and Reporting Policy dated July 2017 directed staff as follows: Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: a. The Nurse Supervisor/ Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. b. The following data, as applicable shall be included on the Report of Incident/Accident form: date and time of accident or incident , circumstances surrounding the accident or incident, where the accident or incident took place, who was involved, condition of who was affected, corrective action taken, and follow-up information.c. The Incident/Accident report will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.

Based on observation, resident interviews, staff interviews and policy review, the facility failed to provide comfortable and safe temperature levels in the building for one of two dinning rooms. The facility reported a census of 90 residents. Findings include: During an observation on 6/23/25 at 1:10 PM the back dining room area thermostat read 83 degrees. The dining room was uncomfortably warm, staff in the dining room and residents in the dining room waiting to go outside to smoke had flushed faces and staff had sweat on their faces. There were two fans in the dining area. During an interview 6/23/15 at 1:15 PM Staff A, Licensed Practical Nurse (LPN), stated the air conditioning unit in the dining room kept freezing up and quitting this weekend and it was even hotter in the dining room this weekend, on Sunday. She called the Director of Nursing (DON) on Sunday, they were unable to get someone out to fix it on Sunday, the unit was out all day on Sunday and the temperature in the dining room was in the high 80's. Staff A stated it was very uncomfortable on Sunday in the dining room and continues to be uncomfortable. Staff A stated each resident has their own air conditioning unit in their bedroom, and they can control their room temperature. Staff A stated the residents had the option of eating in their room or staying in the dining room to eat, they had residents eating in the dining room for all three meals yesterday and for breakfast and lunch today. During an interview 6/23/25 at 1:50 PM the DON and Administrator stated the building is [AGE] years old and has boiler heat. The building does not have central air conditioning, each resident room has a window air conditioning unit. The hallways are cooled by the air conditioning units in the resident's rooms. The two dining rooms have a dual unit on the wall which provides heat and air conditioning. The DON stated she received a call this weekend, on Sunday, that the unit in the back dining room was not working. They could not get a company in to look at it until this morning, the unit was frozen. They said the worker had to wait for it to thaw which would take a few hours and they hope to have it working by the end of the day. The DON and Administrator acknowledged the back dining room has not had a working air conditioning unit since Sunday morning. There are fans in the dining room and residents have eaten in the dining room, they also have the option to eat in their rooms. The DON and Administrator acknowledged it was hot in the back dining room. Both stated there had not been another plan in place to cool the dining room while the unit is being repaired and the dining room is still being used. During an interview 6/23/25 at 2:30 PM Staff C, maintenance, stated he received a call on Sunday that the back dining room was hot and the unit did not seem to be working. Staff C came to the facility on Sunday and the air conditioning unit in the back dining room was not working, the unit was frozen. Staff C called a company to come out yesterday but the soonest anyone could come out was today (Monday), they said they would be here first thing in the morning. The company went to the wrong building so Staff C called another company who came out late this morning. The unit was frozen, they have to wait for it to thaw and then they will determine if they need to replace any parts. They will have it working again today. The unit was repaired and working at 4:30 PM on 6/23/25. During an interview 6/24/25 at 8:10 AM Staff B, dietary staff, stated she worked on Sunday, the 22nd of June, and the air conditioning unit was not working in the back dining room. Staff B works in the back dining room. They called maintenance on Sunday, however the air conditioning unit was not fixed until yesterday late afternoon. Staff B felt the temperature in the dining room on Sunday was in the high 80's or low 90's by the end of the day. She said most residents chose to eat dinner in their rooms as the dining room was so hot, however they had residents who ate all three meals in the dining room. They had fans, but it did not cool off the dining room. Staff B stated it had never been this hot in the dining room. During an interview 6/24/25 at 7:39 AM Staff D, LPN, stated the back dining room is so hot, this morning the temperature in the dining room was 81 degrees. Staff D stated my skin was tingly hot yesterday. Staff D stated the back dining room the past few days has been between 81 - 83 degrees and said everyone is hot. Staff D stated they use the airconditioners in resident rooms to cool the facility since the air unit is broken in the dining room. During an interview 6/24/25 at 8:48 AM, the Administrator acknowledged the temperature was too warm in the back dining room on Sunday and during the morning and afternoon yesterday. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. During an interview/observation 6/24/25 at 9:10 AM Resident #8 stated thank you for getting us air in here, it was hot over this weekend. Resident #8 just had a sheet covering him, no clothes and a small fan blowing onto him. The MDS assessment dated [DATE] for Resident #12 documented a BIMS score of 15, indicating intact cognition. During an interview 6/24/25 at 11:20 AM, Resident #12 stated this past weekend the air conditioning unit in the back dining room where she eats quit working. She said on Sunday it was so hot in the dining room, it felt like it was 500 degrees there. She said she had sweat on her face and her body when she was in the dining room eating on Sunday and for breakfast and lunch on Monday. She ate breakfast, lunch and dinner in the dining room on Sunday and she was so hot she lost her appetite and did not eat all of her food. She had plenty of fluids. She did not stay in the dining room long as she wanted to go back to her room to cool off. The air conditioning unit in her room always works. During an interview 6/24/25 at 2:21 PM, Staff E, Certified Medical Assistant (CMA), stated she worked on Sunday (the 22nd of June) and the air conditioning unit was not working in the back dining room. During lunch on Sunday she took a resident back to their room as it was so hot the resident said they could not eat in the heat and finished her lunch in her room. The resident has Chronic Obstructive Pulmonary Disease (COPD) and was uncomfortable in the dining room. Staff E stated it was so hot on Sunday in the dining room. Review of the facility Quality of Life-Homelike Environment policy, with a revision date of May 2027, documented residents are provided with a safe, clean, comfortable and homelike environment with comfortable and safe temperatures (71°F - 81°F).

Based on clinical record review, medication administration log, staff interview, and facility policy review, the facility failed to prepare or administer medication as prescribed and ordered by the physician for 2 of 3 residents reviewed (Resident #2, #7). The facility reported a census of 90. Findings include: 1. The Annual Minimum data set (MDS) for Resident #2, dated 05/14/2025, documented her brief interview for mental status (BIMS) score as 15, indicating fully intact cognition. It documented the following relevant diagnoses: anemia (low blood iron), renal insufficiency (kidney failure), and Diabetes Mellitus (Diabetes). Review of the Care Plan for Resident #2, last revised on 05/21/2025, recorded the resident's diabetic status and instructed staff members to give medications as ordered by doctor. It also instructed staff members to monitor the resident for signs of hyperglycemia and hypoglycemia (high and low blood sugar). It instructed staff members to document side effects and effectiveness. Review of the medication and treatment administration records (MAR and TAR), from 01/01/2025 to 06/23/2025 revealed the following: Resident #2 had an order for Insulin Lispro Subcutaneous Solution Cartridge 100 UNIT/ML to be administered three times a day via a sliding scale. Morning, Noon, and Evening. Resident #2 had an order for Lantus Subcutaneous Solution 100 UNIT/ML to be administered twice a day. Morning and Evening. On 05/08/2025 the MAR lacked documentation for Insulin Lispro subcutaneous injection (Insulin Lispro) on the evening administration. On 05/11/2025 the MAR lacked documentation for Insulin Lispro on the evening administration. On 05/15/2025 the MAR lacked documentation for Insulin Lispro on the evening administration. On 05/23/2025 the MAR lacked documentation for Insulin Lispro during the morning and noon administration. On 05/31/2025 the MAR lacked documentation for Insulin Lispro during the evening administration. On 06/10/2025 the MAR lacked documentation for Insulin Lispro during the evening administration. On 05/08/2025 the MAR lacked documentation for Lantus Subcutaneous Solution (Insulin Glargine) during the evening administration. On 05/23/2025 the MAR lacked documentation for Insulin Glargine on the morning administration. On 05/31/2025 the MAR lacked documentation for Insulin Glargine on the evening administration. The missing documentation corresponded to higher blood sugar readings following the missing administration on 05/08/2025, 05/11/2025, 05/15/2025 where the next blood sugar was recorded as 400, and 05/23/2025 where the next recorded blood sugar was 320. In an interview on 06/25/2025 at 08:28 AM with Resident #2, she stated she had missed at least three doses in the last month of her evening insulin. She stated that on numerous other occasions she has had to track down a nurse and remind them she required her insulin. She stated even when she gets her insulin she feels it is given late. She stated when she misses her insulin she feels sick, and mentioned she had been hospitalized for high blood sugar in the distant past. She was unable to identify which nurse failed to give her the insulin, but was able to state it almost always occurs during the evening administration of her medication. 2. The Quarterly MDS for Resident #7, dated 04/24/2025, documented his BIMS as 15, indicating fully intact cognition. It failed to document the resident's diagnoses of glaucoma. Review of Resident #7's Care Plan, last revised on 05/07/2025, warned staff members he had impaired vision due to a diagnosis of glaucoma and macular degeneration. It instructed staff members to administer medication and eye drops as ordered and document decreased visual function. Review of the MAR and TAR for Resident #7 documented the following: Resident #7 was prescribed Latanoprost PF Ophthalmic Solution 0.005 % (Latanoprost) once daily before bed. The Latanoprost was marked as unavailable and not administered on the following dates. 04/26/2025 04/27/2025 04/29/2025 04/30/2025 05/01/2025 05/02/2025 05/03/2025 05/04/2025 05/05/2025 06/06/2025 In an interview on 06/24/2025 at 10:57 AM with Resident #7, he stated the staff had told him his eye drops were unavailable for at least a week in May or April, and during that time his eyes hurt and bothered him. He was unsure why one nurse would find the medication only for the nurse the next day to be unable to find it. In an interview on 06/26/2025 at 11:11 AM with Staff D, Licensed Practical Nurse (LPN), she was able to accurately state the process for providing medications to a resident. She stated she would never assume a medication was given it was not documented as given in the MAR. She stated if she noticed a medication was unavailable or was not documented on she would contact the nurse who marked it or failed to mark it and then speak with management. She was unfamiliar with residents missing eye drops or insulin injections. In an interview on 06/26/2025 at 11:22 AM with Staff F, Registered Nurse (RN), she stated all medication is required to be documented in the MAR, and if the medication was not given or otherwise missed she would contact the physician or provider for further instructions. She stated if a medication is unavailable it is their job to contact the pharmacy and get a medication as soon as possible. In an interview on 06/25/2025 at 12:15 PM with the Director of Nursing (DON) she stated she had been aware of a resident reporting several missing doses of medication. She confirmed the only place staff members document medications is in the MAR. She stated her expectation is for staff members to give medications as ordered. A policy covering the accuracy of medication administration was asked for but unavailable.

Based on observations, staff interviews, and policy review, the facility failed to provide a comfortable and homelike environment. The facility identified a census of 94 residents. Findings include: 1. Observations revealed the following: a. On 2/24/25 at 1:45 PM, a loud beeping sound audible in the hallway and in a resident's room with the door closed. b. On 2/24/25 at 1:47 PM, Hall A and B had an odor that smelled like urine. A large gray barrel had the lid partially off and garbage inside. Hall C had four wheelchairs, a linen cart, a weight chair, a Broda chair, a mechanical lift and carts with lids lined along the hallway. c. On 2/24/25 at 1:55 PM, a loud beeping sound continued in the ABC hall. d. On 2/24/25 at 2:09 PM, the loud beeping sound continued. e. On 2/24/25 at 2:32 PM, the loud beeping sound subsided. f. On 2/24/25 at 3:02 PM, Hall C had three wheelchairs, a broda chair, a weight chair, a linen cart, a mechanical lift, and a soiled linen cart parked along the handrail in the hallway. g. On 2/24/25 at 3:19 PM, a male resident in a wheelchair sat in Hall A and another male resident in a motorized wheelchair came down the same hall going in the opposite direction in the same hall. Hall A had five wheelchairs, a mechanical lift, two 3-drawer bins with PPE (personal protective equipment) inside, a linen cart, a soiled linen and trash cart with lids were parked along the hall and blocking the handrail so the resident in the wheelchair was unable to use the handrail and maneuver himself down the hall. Staff M, Licensed Practical Nurse (LPN), came and assisted the male resident in the wheelchair in order for the resident in the motorized wheelchair to get by. Resident #12 kept pointing at a wheelchair that was in her way in the hallway because she was not able to propel herself in the wheelchair due to the equipment in the hall. h. On 2/24/25 at 3:30 PM, the [NAME] hall had a high pitched beeping sound. i. On 2/25/25 at 8:00 AM, the ABC hall had a constant high-pitched beeping sound. A light panel at the nurse's station had an A lit up in red and a C lit up in white. Hall A had five wheelchairs, one 4-wheeled walker, two 3-drawer bins with PPE inside, a linen cart, a weight chair, a mechanical lift, and a treatment cart parked along the even numbered side of Hall A. Hall C had a mechanical lift, a wheelchair, a weight chair, a black chair, a soiled linen and trash cart with lids, and a clean linen cart parked along the odd numbered side of the hall. j. On 2/25/25 at 8:15 AM, the panel at the nurse's station continued to have a constant high-pitched beeping sound. The red and white lights labeled C were lit up on the panel. The beeping sound was audible in Halls A, B, and C. At 8:25 AM, the constant high-pitched beeping sound continued at the nurse's station panel. The red and white lights labeled C were lit up on the panel. At 8:40 AM, the constant high-pitched beeping sound continued at the nurse's station panel. At 8:53 AM, the high-pitched beeping sound continued at the nurse's station panel. At 8:57 AM, the beeping sound stopped and no call lights were on in Halls A, B or C. h. On 2/25/25 at 10:52 AM, the [NAME] Hall's soiled linen cart was full and had two bags of soiled linen propping the lid open on the cart. i. On 2/25/25 at 12:53 PM, Hall A had a linen cart, a trash and soiled linen cart, a mechanical lift, four wheelchairs, one 4-wheeled walked, two 3-drawer bins with PPE inside parked in the hallway on the side with even numbered rooms. At the time, a large air mattress was lying on the floor in the hallway. j. On 2/26/25 at 10:54 AM, a gray barrel with lid was parked in the hallway outside room A33. Resident #39 sat in a motorized wheelchair and drove himself down Hall A toward the dining room. The resident stopped the motorized wheelchair and moved the barrel to the handrail then pushed the barrel with the footrests on the wheelchair until he could get past the objects in the hallway. In an interview 2/26/25 at 7:36 AM, Staff K, Housekeeper, reported she cleaned Halls B and C, and sometimes cleaned Hall A when another housekeeper not working the area. Staff K reported the equipment was always parked in the hallway. Staff K confirmed she had observed residents having a hard time getting through the halls due to the amount of equipment kept in it. On 2/26/25 at 3:25 PM in an interview with Staff L, Assistant Director of Nursing (ADON), a continuous beeping sound was heard. The surveyor asked Staff L what the sound was. Staff L reported the beeping sound was a call light. At that time, another alarm sounded. Staff L identified the alarm as a door alarm and then went to check it. Staff L came back and said she could tell the various sounds based on the sound and how loud the sound or the alarm was. Staff L reported the facility used to have call lights that just lit up in the hall by the resident rooms but one day maintenance did something so the call lights would sound/beep. Staff L reported a resident also wandered and set off the exit door alarm. The loud sounds and alarms constantly went off during the day. Staff L thought the alarms and beeping sounds made residents more antsy and the residents had increased behaviors. Staff L reported the loud sounds /alarms were constant all day long. She agreed the lack of sleep could make people more on edge and have less tolerance. Staff L acknowledged they stored lots of equipment in the hallways because they had no storage room for the equipment. She asked staff to fold up the wheelchairs kept in the hallway to give people more room to get through the area. Staff had to move over and stop in the hallway in order to let a resident or others pass by. In an interview 2/27/25 at 10:20 AM, Resident #35 reported the door alarms went off at least eight times during the day. Resident #35 reported the alarm sounded whenever another resident or someone went out the exit door. The alarm also went off at night. Resident #35 reported she just had to get used to the alarms going off but acknowledged it was hard to get much sleep. A Quality of Life-Homelike Environment policy revised 5/2017 revealed a safe, clean, comfortable and homelike environment provided to the residents. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including comfortable noise levels, an orderly environment, and clean bed linens in good condition. 46513 2. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] Resident #54 included primary diagnoses debility cardiorespiratory condition, additional diagnoses, stroke, anxiety, depression and documented need for assistance with personal care. Resident coded independent with dressing and personal hygiene, is frequently incontinent. Resident #54 had not attempted to walk ten feet due to medical condition or safety concerns, independently transferred wheel chair to bed and toilet. The Brief Interview for Mental Status (BIMS) exam scored 15 out of 15 indicated intact cognition. The Care Plan intervention initiated 4/5/23 relayed Resident #54 had a self-care deficit as evidenced by requiring assistance with activities of daily living (ADLs) impaired balance during transitions, required assistance, incontinence. During an observation on 02/24/25 at 1:33 PM Resident #54 lying on her bed, mattress was dark blue plastic like covering, no sheets or linens of any kind. The bed had strong odor of urine. During an observation on 2/25/25 at 3:00 PM Resident #54 lying on her bed no sheets on the plastic like material that covered mattress. During an observation on 2/26/25 at 3:05 PM Resident #54 lying on bed no covering on the mattress. On 2/26/25 at 3:05 PM Resident #54 relayed housekeeping came in today, had no concerns with that and Certified Nursing Assistant (CNA) staff are supposed to provide linens and they still have not done so or offered help. During an observation on 02/27/25 01:36 PM observed Resident #54 lying on the bed, no covering on the mattress. On 2/27/25 at 1:40 PM met with the Director of Nurses (DON) and the Administrator. The DON relayed Resident #54 has history of incontinence in bed, changed the mattress as a result, relayed linen changes are expected to be done on shower days and as needed, was not aware of concerns regarding resident bedding. The Administrator and DON did not know why resident #54 would not have sheets on the mattress. The DON relayed would visit with Resident #54. On 02/27/25 at 1:46 PM Resident #54 in room, DON visited with Resident #54 who voiced is a little weak. DON queried about the bedding. Resident #54 relayed staff would take care of bedding, did not know when. 3. During an interview on 2/26/24 at 8:40, Registered Nurse (RN) Staff D queried regarding the strong odor of urine odor in the [NAME] hall. RN, Staff D relayed containers of dirty linen and trash is usual and would be taken to another room when the containers were full. Observation on 2/26/25 at 8:40 AM revealed two covered containers of trash and soiled linens about half full. A strong pungent odor throughout the entire west hall. 49990 3. A direct observation on 02/25/2025 at 08:28 AM revealed a loud repetitive alarm sounding in Halls A, B, and C. It sounded from at least the time of initial observation until 08:41 AM when the alarm finally ended. Facility staff identified the alarm as the call light alarm. A direct observation on 02/25/2025 at 09:04 PM revealed The [NAME] Hall room light alarm currently sounding. The alarm could be heard in all six hallways of the building clearly. In an interview on 02/25/2025 at 09:15 PM with Staff W, Registered Nurse (RN), she noted the facility is always this loud. She reported it is sometimes so noisy she has trouble thinking. In an interview on 02/25/2025 at 09:19 PM with Resident #84 he demanded to know what the commotion was outside. He did not notice it was the surveyor stated he just saw someone walking by and wanted to know what was going on. He stated the facility has been extremely loud, with an alarm sounding continuously for some time and what sounded like a party in the hallway. The sounds of the party were identified as the television in the ABC hall dining room, which was currently airing a television show at max volume. The surveyor confirmed the television could be heard clearly down halls A, B, and C. A direct observation of the ABC halls on 02/25/2025 at 09:19 PM revealed an alarm sounding in the C hallway that could be heard clearly in all three hallways. It sounded from 09:19 PM until 09:32 PM when it ended. A direct observation on 02/25/2025 at 09:36 PM revealed an alarm in the North/South/West portion of the building beginning to sound. It could be heard clearing in the A hallway. It sounded until 09:48 PM. A direct observation on 02/25/2025 at 10:23 PM revealed an alarm sounding in the North/South/West portion of the building. It can be clearly heard in all halls. It sounded until 10:37 PM. A direct observation on 02/25/2025 at 10:42 PM revealed the television in the A/B/C portion of the building had finally been turned off and was no longer making sound. In an interview on 02/27/2025 at 09:30 AM with Resident #74, he reported the building is always too loud. It makes it hard to sleep. Alarms go off all day and night. In an interview on 02/27/2025 at 12:06 PM with Staff E, Certified Nurses Aide (CNA) , she noted the facility is always loud. She stated residents have complained to her about trouble sleeping because of the constant loud alarms sounding in the building. She stated it drives her crazy listening to the constant drone of the alarms and loud TVs. She stated she does not feel the residents get any peace and quiet, even at night. In an interview on 02/27/2024 at 12:37 PM with the Director of Nursing (DON), she agreed the building was too loud, and noted the A/B/C halls were the loudest. She stated the volume of the alarm system increased after a recent change to the A/B/C hall alarm system.

Based on direct observation, clinical record review, and Resident and staff interview, the facility failed to provide the residents the assistance needed in order to complete their individual activities of daily living for 4 of 4 residents reviewed (Residents #3, #12, #58, and #84). The facility reported a census of 94. Findings include: 1. The Quarterly MDS for Resident #84, dated 01/28/2025, documented his brief interview for mental status (BIMS) score as 15, indicating intact cognition. It documented the following diagnoses: Heart failure, Hypertension, renal insufficiency, Cerebrovascular Event (Stroke), Seizure disorder, Malnutrition, Acute respiratory failure, muscle weakness, and difficulty in walking. It further documented the resident was dependent upon staff for transferring, ambulation, and personal cares. The Care Plan for Resident #84, last revised 02/03/2025, documented the resident required an assist of one person for personal cares and encouragement for oral hygiene. It instructed staff members to check nail length and trim/clean on bath days and as needed. The Care Plan also documented the resident had impaired vision due to glaucoma and macular degeneration. In a direct observation on 02/24/2025 at 12:41 PM, Resident #84's fingernails were noted to be over an inch longer and visibly soiled with dark colored material. In the ensuring interview with Resident #84, he stated he had been requesting staff assisting him in cutting his fingernails for approximately a week. He stated he has trouble seeing his fingernails and can't see well enough to cut them due to his declining vision, but he knew his nails were too long because he had been cutting himself when he scratched. A review of shower/bath sheets documented Resident #84 had his nails last cut during a shower on 01/27/2025, however, this documentation is discrepant from the state of Resident #84's fingernails. Resident #84 stated his nails had not been cut since he admitted to the facility that he could remember; his admitted was noted as 11/28/2024. In an interview on 02/27/2025 at 12:06 PM with Staff E and Staff J (CNAs), they confirmed CNAs and Shower Aides are responsible for trimming nails during showers and as requested by the residents, they noted the only place to document nail care is the shower sheets. They stated they could not remember having cut Resident #84's fingernails recently. In an interview on 02/27/2025 at 12:30 PM with Staff A, Registered Nurse (RN), she confirmed CNAs and bathe aides document nail care on bath/shower sheets. She stated that CNAs are responsible for nail care unless a resident is diabetic, and she confirmed Resident #84 was not diabetic. In an interview on 02/27/2025 at 12:37 PM with the Director of Nursing (DON), she stated CNAs are responsible for trimming a resident's nails as needed and when requested. She confirmed the bathing/shower sheets are the only place to document the cares. She agreed the residents nails had not been trimmed in a considerable amount of time. Review of a facility provided document titled Activities of Daily Living (ADL), Supporting, with a last revised date in March of 2018, documented appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with hygiene. 34817 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had diagnoses of non-Alzheimer's dementia, diabetes and bipolar disorder. The MDS indicated the resident had impaired short-term and long-term memory and severely impaired daily decision making skills. The MDS indicated the resident required substantial to maximum assistance for bathing and had dependence on staff for personal hygiene. The Care Plan revised 12/5/24 revealed the resident required assistance with activities of daily living (ADL's). The Care Plan directed staff to provide assistance of one for bathing/showering, encourage bathing twice a week, trim and clean nails on bath days and as necessary and report any changes to the charge nurse. The Care Plan also revealed the resident needed set-up assistance for grooming and hygiene cares. The Care Plan directed staff to encourage cares in the morning, afternoon, and at bedtime, and reapproach and attempt ADL's at a later time if the resident became agitated or combative when staff tried to provide a shower or shaved her. The Pocket Care Plan revealed the resident required assistance of one staff for bathing. The Skin Monitoring: Comprehensive CNA (certified nursing assistant) Shower Review form reviewed 1/1/25 to 2/21/25 revealed the resident last had her face shaved on 1/29/25, last had her nails clipped on 1/29/25, and last had her hair washed on 2/5/25. Only 3 of 9 shower review forms documented 1/2025 and 3 of 6 shower review forms documented for 2/2025. The Task Care Record reviewed 2/1 - 2/25/25 revealed a shower/bath documented on 2/12/25. The Task Care Record lacked documentation about shaving, hair washed or nails clipped. The Progress Notes revealed staff documented the resident would not allow staff to clean and cut her nails on 12/29/24 at 3:23 PM and 2/25/25 at 3:35 PM. The progress notes lacked the resident refused a bath, hair washed, nails cut, or face shaved 2/1/25 - 2/24/25. The Shower Schedule for ABC on Hall C revealed Resident #12 scheduled for a shower on Wednesdays and Saturdays on the 6 AM - 2 PM shift. Observations revealed the following: a. On 2/24/25 at 3:20 PM, Resident #12 sat in a wheelchair in the hallway holding an empty glass in her hand. The resident had at least a 1/4 inch growth of facial hair to her chin and around her mouth. Her fingernails were long and a nail was broken. The resident had brown debris under her right thumb and her hair appeared greasy. b. On 2/25/25 at 2:40 PM, Resident #12 sat in a wheelchair in the hallway. The resident's had dried spillage on her striped pants and shirt from lunch. The resident continued to have white hair growth around her chin and mouth. At 4:45 PM, the resident continued to wear the striped pants and shirt with dried brownish-red spillage. The resident still had white hair growth around her chin and mouth. In an interview on 2/26/25 at 7:45 AM, Staff L, Assistant Director of Nursing (ADON), reported the resident's showers were documented in POC (Point of Care) as well as on paper. On 2/26/25 at 10:20 AM, the Director of Nursing (DON) reported she found some more shower sheets in Staff L's office. The DON provided the additional paper shower sheets to the surveyor to review. In an interview on 2/27/25 at 10:10 AM, Staff L, ADON, reported she expected staff provided the residents a shower as scheduled. The staff filled out a paper shower sheet whenever the resident had a shower. Staff L reported staff marked off if the resident's hair was washed and if the nails were clipped. She expected staff to document if the resident refused a bath and tell the nurse. Staff L stated she expected all residents, including female residents, got shaved twice a week, typically when they had their shower. In an interview 2/27/25 at 10:21 AM, Staff G, CNA, reported the shower schedule listed the resident rooms for each hall and the shift assigned to give the resident a shower. Staff G stated they also had to fill out a (paper) CNA shower sheet whenever a shower completed. The shower sheet had the resident's name on it. A shower also included washing the resident's hair and cutting the resident's nails. The category for nails trimmed was listed on that resident's shower sheet if a resident was supposed to get their nails cut by the CNA. If a resident refused a shower, she asked the resident again, and if the resident still refused a shower, she talked to the nurse. In an interview 2/27/25 at 12:00 PM, the Administrator reported no policy found for grooming or showers. A Supporting Activities of Daily Living policy revised 3/2018 revealed residents will be provided with the care and services to maintain their ability to carry out ADL's, including hygiene, bathing, and grooming. If cognitively impaired resident resisted care, staff will not assume the resident refused or declined care. Staff shall approach the resident in a different way or at a different time, or have another staff member speak with the resident as appropriate. 46513 3. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #58 revealed diagnoses included heart failure, seizure disorder, respiratory failure and bipolar disorder. Resident #58 required partial/moderate assistance with shower/bathing, transfers and sit to stand indicated a helper lifts holds or supports trunk or limbs, provides less than half of efforts. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The Care Plan dated 2/14/25 for Resident #58 relayed has self-care deficit as evidenced by requiring assistance with activities of daily living (ADLs) impaired balance during transitions required assistance walking. Interventions for bathing included one assist, encourage bathing twice a week, inspect skin during showers and alert the charge nurse of any skin issues. Noted history of refusing, prefers sponge bath, continue to reproach, educate, and encourage shower. The Electronic Record, look back to admit on 2/13/25 dated 2/25/25 revealed no showers given. One check mark to indicate on 2/15/25 Resident #58 refused The Progress Notes beginning at admit 2/13/25 did not document Resident #58 had refused bathing and did not document resident was approached, reproached, educated or encouraged to shower. On 2/24/25 at 10:00 AM Resident relayed not sure he had a shower and stated, they don't do much for you here. On 2/25/25 at 5:30 PM the Director of Nurses (DON) relayed showers should be documented in the electronic record and also on a paper record. Explained had a new staff that was supposed to audit this process who had been missing work. 4. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed diagnoses included Spina Bifida, heart and respiratory failure, neurogenic bladder and seizure disorder. Resident #3 coded for dependent on assistance of two or more with toileting, dressing, personal hygiene and bathing. The MDS revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Care Plan initiated 11/16/22 documented Resident #3 has self-care deficits evidenced by requiring assistance with activities of daily living. Interventions for bathing included two people assist, encourage bathing twice weekly, inspect skin and alert changes to the charge nurse. The Electronic Record, bathing/shower task beginning 10/28/24 to 2/25/25 displayed check marks indicated bathing activity. Documentation included: not applicable - (11) eleven times, Refused -(1) one time. Revealed (8)eight showers given in a (4) four-month period. Last shower prior to survey was 2/3/25 per the electronic record. On 2/24/25 at 1:08 PM Resident #3 relayed is supposed to have showers twice a week and there are many excuses from staff, relayed needs several staff to assist out of bed and this is very difficult. Resident #3 relayed it was a few weeks back since had a shower.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to ensure staff appropriately and safely transferred three of five residents observed during transfers (Resident #12, #19 and #84). The facility also failed to ensure cigarettes kept in a secure location for one of two residents reviewed for smoking (Resident#79). The facility also failed to reduce clutter in six of six hallways to create a homelike environment, and to ensure clear hallways for the residents to easily move throughout the facility without obstacles. The facility identified a census of 94 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had diagnoses of osteoporosis, dementia and bipolar disorder. The MDS documented the resident had 2 or more falls without injury. The MDS indicated the resident had impaired range of motion to bilateral lower extremities, and required substantial to maximum assistance for transfers. The Care Plan revised 12/5/24 revealed the resident had a risk for falls related poor safety awareness and impaired balance. The resident required a safe environment, utilized a wheelchair for mobility, and required the assistance of one for transfers. During observation on 2/25/25 at 9:01 AM, Staff H, certified nursing assistant (CNA) pushed Resident #12 in a wheelchair down Hall B to the small common area across from the ABC nurse's station without foot pedals. The resident's feet moved back and forth on the floor as the resident sat in the wheelchair and Staff H pushed the wheelchair. In an interview 2/26/25 at 3:25 PM, Staff L, Assistant Director of Nursing (ADON) reported she expected wheelchair pedals in place whenever staff pushed residents in a wheelchair. 2. The MDS assessment dated [DATE] revealed Resident #19 had diagnoses of arthritis, osteoporosis, and dementia. The MDS documented the resident required substantial to maximum assistance for transfers. The resident had two or more falls with injury and one fall with injury during the look-back period. The Care Plan revised 2/13/25 revealed Resident #19 had falls related to impaired balance and poor safety awareness. The Care Plan directed staff to cue, orient and supervise the resident, provide assistance of one staff for transfers, park the wheelchair next to the bed when resident in bed, apply brakes on the wheelchair, and ensure the resident wore the appropriate footwear whenever he utilized the wheelchair or ambulated. The Pocket Care Plan for Hall C updated 1/30/25 revealed Resident #19 required assistance of one for transfers. The Pocket Care Plan revealed in capital letters and black bold print: ALWAYS USE YOUR GAIT BELT. Observations revealed the following: a. On 2/24/25 at 2:43 PM, Resident #19 lying in bed with his left leg hanging over the edge of the bed. The resident had a bruise on his left eye and a large purple hematoma and abrasion on the top left side of his head. No wheelchair was parked next to the bed. b. On 2/25/25 at 8:05 AM, the resident lying in bed on his back. The wheelchair was parked across the room. c. On 2/25/25 at 12:57 PM, Staff H, CNA, entered Resident #19's room and assisted the resident to the edge of the bed, then placed her arm under the resident's right arm and assisted the resident from the bed to a wheelchair. The resident held the arms on the wheelchair and was bent over the wheelchair. The resident was shaky and appeared unsteady during the transfer. The resident had socks on his feet but no shoes or gripper socks on. Staff H had a gait belt draped over her left shoulder and across her body but did not apply and use the gait belt when she transferred the resident. Staff H did not lock the brakes on the wheelchair before she transferred the resident. The wheelchair moved backward after the resident sat down in the wheelchair. At 1:01 PM, Staff H left the room. The call light string hung by the wall out of the resident's reach. In an interview on 2/25/25 at 4:51 PM, Staff L, ADON, reported she updated the Pocket Care Plans on the share drive. Pocket Care Plans kept in a folder at the nurse's station for each hall. Staff L confirmed the Pocket Care Plans updated on 2/20/25. She knows she updated the Pocket Care Plan for Hall C on the same date but she didn't change the date on the document. The date on the Pocket Care Plan for Hall C was 1/30/25 but it had current information and should be dated 2/20/25, because she updated Hall C's Pocket Care Plan when the Pocket Care Plans were updated for Hall A and Hall B. In an interview 2/26/25 at 3:25 PM, Staff L, ADON, reported she expected staff to use a gait belt whenever they transferred a resident who required assistance of one or two for transfers. She also expected staff lock the brakes on the wheelchair before a resident transferred. In an interview 2/27/25 at 10:21 AM, Staff G, CNA, reported she looked at the Point of Care (POC) and the paper pocket care plan to know how a resident transferred. Staff G stated a gait belt always used for residents that required the assistance of one or two staff for transfers. A Fall Prevention Program updated 12/23/01 revealed a gait belt should be used for all non-Hoyer staff assisted transfers. 3. The Quarterly MDS assessment dated [DATE] revealed Resident #79 had diagnoses of non-Alzheimer's dementia, lack of coordination, and muscle weakness. The resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severely impaired cognition. The Care Plan revised 3/27/24 revealed the resident had impaired thought processes as evidenced by short-term and long-term memory deficit and impaired decisions related to diagnoses of encephalopathy and dementia. The Care Plan revealed the resident preferred to smoke while at the facility. The goal included the resident will smoke with appropriate safety precautions in place. The Care Plan directed staff to observe the resident to make sure the smoking policy is being followed and to insure the safety of self/others, ensure the resident gave cigarettes to the nurse or family after smoking, and do not allow the resident to keep cigarettes or smoking materials in his room. Observations revealed: a. On 2/25/25 at 2:19 PM, two cigarettes sat on top of a dresser in room [ROOM NUMBER]. One of the cigarettes had a burnt off end and over half of the cigarette was gone, and one cigarette had not been smoked. At the time, the resident sat on the bed in the room. Staff I, LPN, stood in the room and provided a treatment to the resident's roommate. At 2:22 PM, Staff I, LPN, bagged up the trash and left the room. At 2:30 PM, the cigarettes remained on top of the dresser in the resident's room. b. On 2/26/25 at 7:23 AM, Resident #79 sat in a wheelchair in the room. Two cigarettes sat on the nightstand by the resident's bed. During an interview on 2/27/25 at 10:21 AM, Staff G, CNA, reported the residents' cigarettes were kept in a locked area. She would let the nurse know if she found cigarettes in a resident's room. In an interview 2/27/25 at 8:45 AM, Staff L, ADON, reported resident cigarettes kept in a locked storage room by the nurse's station. The cigarette packs had the resident's name on it. Staff L reported different staff took the smokers outside at designated smoke times. Staff gave residents a cigarette and used a lighter to light the cigarettes. Resident #79's cigarette pack had a note on it to let staff know they needed to monitor the resident because he sometimes pocketed cigarettes. The Facility's Tobacco Policy revised 9/21/23 revealed the facility shall maintain safe resident cigarette use practices. All employees share in the responsibility of enforcing the policy. Any tobacco use or smoking related privileges and concerns shall be noted on the care plan. Cigarette materials for residents will be secured by the facility when not in use. 4. The Quarterly MDS assessment dated [DATE] revealed Resident #84 had diagnoses of anemia, atrial fibrillation (irregular heartbeat), cerebrovascular accident (CVA (stroke), muscle weakness, and seizure disorder. The MDS indicated the resident had dependence on staff for transfers. The Care Plan revised 12/19/24 revealed Resident #84 had impaired balance during transitions and required assistance with Activities of Daily Living (ADL's). The Care Plan directed staff to use an EZ stand and assistance of two for transfers. During observations on 2/26/25 at 11:38 AM, Staff F, CNA, and Staff G, CNA, placed a sling behind Resident #84 and attached the sling to a stand mechanical lift. Staff F raised the resident up in the stand mechanical lift. Resident #84 stated he felt kind of dizzy after the staff stood him up. Staff G took disposable wipes and cleansed the resident's buttocks area, then Staff F placed a clean brief on the resident. At 11:43 AM, Staff F and Staff G transferred the resident from the bathroom over to the bed. The strap on the stand mechanical lift moved on the left side and the resident yelled out, what was that? Staff lowered the resident onto the bed. Resident #84 said sarcastically I'm ok. I'll live, I think. Staff removed the sling from the lift, then moved the residents legs onto the bed. Staff L, ADON stood in the room and observed staff during the transfer. A Sit to Stand Lift Competency Checklist revealed the following procedural steps: a. Gather equipment. b. Check to ensure harness and loops are in good condition. c. Place the harness wings beneath the underarms of the resident and fasten the buckle securely around the waist. d. Attach the harness to the sit to stand lift. Secure one loop of each wing to the metal hooks at the end of the boom. Use the shortest straps whenever possible and make sure to use the same loop position on both sides. e. Place the resident's feet on the foot support place with the shins against the shin support. f. Position the resident's arms on the outside of the harness and place their hands on the padded handles. g. Raise the resident to the standing position. h. Unlock the stand wheels and move the resident to the desired location. Do not lock the wheels on the lift. Lower the resident onto the bed, chair or toilet. i. Remove the lifting strap. j. Wash hands. Observations revealed the following: a. On 2/24/25 at 1:47 PM, Hall C had four wheelchairs, a linen cart, a weight chair, a Broda chair, a mechanical lift and carts with lids lined along the hallway. b. On 2/24/25 at 3:02 PM, Hall C had three wheelchairs, a Broda chair, a weight chair, a linen cart, a mechanical lift, and a soiled linen cart parked along the handrail in the hallway. c. On 2/24/25 at 3:19 PM, a male resident in a wheelchair sat in Hall A and another male resident in a motorized wheelchair came down the same hall going in the opposite direction in the same hall. Hall A had five wheelchairs, a mechanical lift, two 3-drawer bins with PPE (personal protective equipment) inside, a linen cart, a soiled linen and trash cart with lids were parked along the hall and blocking the handrail so the resident in the wheelchair was unable to use the handrail and maneuver himself down the hall. Staff M, Licensed Practical Nurse, came and assisted the male resident in the wheelchair in order for the resident in the motorized wheelchair to get by. Resident #12 kept pointing at a wheelchair that was in her way in the hallway because she was not able to propel herself in the wheelchair due to the equipment in the hall. d. On 2/25/25 at 8:00 AM, Hall A had five wheelchairs, one 4-wheeled walker, two 3-drawer bins with PPE inside, a linen cart, a weight chair, a mechanical lift, and a treatment cart parked along the even numbered side of Hall A. Hall C had a mechanical lift, a wheelchair, a weight chair, a black chair, a soiled linen and trash cart with lids, and a clean linen cart parked along the odd numbered side of the hall. e. On 2/25/25 at 12:53 PM, Hall A had a linen cart, a trash and soiled linen cart, a mechanical lift, four wheelchairs, one 4-wheeled walked, two 3-drawer bins with PPE inside parked in the hallway on the side with even numbered rooms. At the time, a large air mattress was lying on the floor in the hallway. f. On 2/26/25 at 10:54 AM, a gray barrel with lid was parked in the hallway outside room A33. Resident #39 sat in a motorized wheelchair and drove himself down Hall A toward the dining room. The resident stopped the motorized wheelchair and moved the barrel to the handrail then pushed the barrel with the footrests on the wheelchair until he could get past the objects in the hallway. In an interview 2/26/25 at 7:36 AM, Staff K, Housekeeper, reported she cleaned Halls B and C, and sometimes cleaned Hall A when another housekeeper not working the area. Staff K reported the equipment was always parked in the hallway. Staff K confirmed she had observed residents having a hard time getting through the halls due to the amount of equipment kept in it. On 2/26/25 at 3:25 PM in an interview with Staff L, ADON, acknowledged they stored lots of equipment in the hallways because they had no storage room for the equipment. She asked staff to fold up the wheelchairs kept in the hallway to give people more room to get through the area. Staff had to move over and stop in the hallway in order to let a resident or others pass by. A Quality of Life-Homelike Environment policy revised 5/2017 revealed a safe, clean, comfortable and homelike environment provided to the residents. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting, including an orderly environment. 46513 5. The Minimum Data Set (MDS) for Resident #36 dated 2/11/25 revealed resident scored 09 on a Brief Interview for Mental Status (BIMS) exam, indicated moderate cognitive impairment. The MDS revealed the resident had not attempted to walk at least ten feet due to medical condition, safety concerns and used a manual wheelchair. The medical diagnoses included heart disease, kidney disease, hepatitis, dementia, seizure disorder, intellectual disabilities and psychotic disorders. The Care plan completed 7/20/23 for Resident #36 revealed a focus of self-care deficit as evidenced by requiring assistance with activities of daily living, impaired balance during transitions requiring assistance. interventions under mobility documented Resident #36 utilizes wheelchair that he can self propel, staff assist as needed. On 02/24/25 at 12:21 PM observation of resident #36 leaving the dining room with Registered Nurse (RN) Staff A behind the wheel chair, Staff RN pushed the chair several feet to Resident room. Staff A stopped and when resident did move self in the wheel chair Staff A pushed Resident #36 to the room approximated 25 feet to the door way. On 2/24/25 at 12:39 PM RN Staff A relayed Resident #36 will often scream, help and will not stop screaming until is helped, Relayed did push Resident and did not know why he does not have foot pedals on the wheel chair, would check on this. On 2/24/25 at 12:56 PM The Director of Nurses (DON) relayed staff should encourage resident mobility in the wheel chair and would look into having pedals assessable. The administrator present acknowledged the risks when a resident is pushed in a wheelchair without foot pedals. 49990 A direct observation on 02/24/2025 at 03:51 PM revealed clutter throughout the facility halls, including mechanical lifts, medication carts, wheelchairs, shower chairs, and other supportive devices. During the observation the A hall became blocked by a medication cart while in use by a nurse, forcing residents to wait before passing through the hall. A direct observation on 02/25/2025 at 09:21 AM revealed Staff Z, Activities Director, pushing Resident #60 in her wheelchair without foot pedals, Resident #60's legs were kicking quickly in an attempt to avoid contact with the pavement while being pushed. A direct observation on 02/25/2025 at 09:36 AM Revealed the North hallway currently impassable as multiple residents attempted to pass through the hallway at the same time. A certified nurses aide intervened at 09:38 AM to provide passage through the hall. A direct observation on 02/26/2025 at 02:00 PM revealed two residents blocking the A hall. One was asleep in her wheelchair and one was positioned in such a way that it made passing through by foot difficult and with the use of a mobility aide impossible. From 02:00 PM until 02:32 PM the hallway remained impassable with three different CNAs seen squeezing through on foot without attempting to clear the blockage. At 02:23 PM a CNA finally intervened, ending the blockage by providing transportation for the sleeping resident into her bedroom. During an observation on 02/25/2025 at 10:56 PM Staff V (CNA), and Staff W (RN), approached the surveyor to report the state of the halls. Staff V noted the halls are extremely cluttered and he has reported this to facility leadership several times without resolution. He noted the halls are often impassable and make his job more difficult. Staff W noted that she agrees with Staff V and that she believes the halls are a hazard to residents. In an interview on 02/27/2025 at 12:06 PM with Staff E (CNA), and Staff F (CNA), they stated there were too many objects in the hallways. Staff E noted that it prevents her from doing her job. She noted she has seen residents, especially those with cognitive impairments, becoming agitated and upset with each other when they can't get through the hallways. Staff F noted the procedure for when a resident is sleeping in the hallway is to gently wake them up and ask them if they would like to take a nap in their bed or a chair, and to assist them out of the hallway. In an interview on 02/27/2025 at 12:37 PM with the Director of Nursing (DON), she noted the halls have been an issue in the past. She mentioned she believed there had been a performance improvement plan (PIP) for the halls. She acknowledged a resident should not have been allowed to sleep in the hallway and block the path. The residents should have been assisted to their destinations and the sleeping resident should have been provided with assistance to her bed or a chair to rest. In an interview on 02/27/2025 at 11:01 AM with the Facility Administrator, she acknowledged the objects blocking the hall was an issue during the last survey, where it was the target of a citation. She noted there had been a PIP to address the issue after the last annual survey but it was closed without resolution.

Based on observation, document review, facility assessment, resident and staff interviews, the facility failed to provide sufficient nursing staff to meet the residents' needs safely, in a timely manner and that promotes each resident's rights, physical, mental, and psychosocial well-being. The facility reported a census of 94 residents. Findings include: Observation of breakfast dining on 2/25/25 revealed the following: 8:30 AM, twenty-four residents were sitting in one of the facility's two dining rooms, dietary staff noted to be plating resident's food from a steam table. 8:39 AM, twenty-one of twenty-four residents had been served, three residents sat at an assisted feeding table had not been served their breakfast. 8:42 AM, a Certified Nursing Assistant (CNA) entered the dining room and assisted one male resident with feeding. Staff A, Registered Nurse (RN) assisted the second male resident with feeding. 8:46 AM, the third male resident, sat with his eyes closed, had his food sitting in front of him and not eating. 8:47 AM, Staff L, Assistant Director of Nursing (ADON) entered the dining room, Staff A, RN, pointed at the third male resident, indicating to the ADON the third resident needing assistance. 8:48 AM, Staff A, RN, spoke with the third male resident, asking him about eating. He had an untouched plate of pancakes, scrambled eggs, and a bowl of hot cereal. 8:50 AM, another CNA entered the dining room, offered the third resident beverages to drink, then sat with the resident to assist with feeding. During a confidential resident interview on 2/24/25 at 12:41 PM, Resident stated when he pushes his call light it can take 45 minutes to 2 hours for nursing staff to respond. The Resident had been told by nursing staff that they ' re going to do something or that they're going to get an order for something, but then don't. The Resident feels there is very little follow through from nursing staff and that nurses hold grudges. Nursing staff will come into his room and turn the call light off without addressing his concerns or needs. Resident stated he required transfers with a mechanical lift and this is often done with one person instead of the required two. The Resident verbalized concern of retaliation from nursing staff. Upon entrance of facility on 2/25/25 at 9:15 PM, Staff V, RN, informed surveyor they had come at an excellent time and was planning on quitting because the staffing ratios are insane, by 10:00 PM the only people in the facility's front unit will be her and two CNAs. That is only three people for approximately 46 residents and indicated the ratio will be similar in the facility's second unit, with one nurse and two CNAs for 48 residents. On 2/25/25 at 10:19 PM, a CNA was overheard telling the nurse she wanted out of this place and wants to be done here. The CNA went on to say she feels there are a lot of corners being cut causing the residents to suffer, residents reported they had not been offered showers this week and another resident hadn't been offered a shower in three weeks. The CNA continued by saying the residents don't feel heard and feels that residents are often overlooked because they don't have enough staff most of the time. During an interview on 2/25/25 at 10:56 PM, Staff V, CNA reported at night there are only four CNAs in the building, making it hard to respond to call lights. During an interview on 2/27/25 at 12:06 PM, Staff E, CNA, stated she feels they do not have enough people to do their job, it's hard some days. When DIAL (Department of Inspections, Appeals, and Licensing) is here there are more people but usually there are less. During an interview on 2/27/25 at 12:06 PM, Staff N, CNA, stated that usually they're short staffed and it makes it so hard to do the job. On 2/27/25 at 12:26 PM, Staff X, CNA, stated she felt they did not have enough staff to consistently do their jobs, that the lights and alarms go off for a long time, 30-40 minutes, and CNAs are struggling and just can't keep up. Review of Centers for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Data Report (a staffing data report that identifies triggered staffing areas of concern) revealed, the facility was triggered for excessively low weekend staffing for July 1, 2024 - September 30, 2024. Review of Facility Assessment, updated on 7/22/24 indicated, on page 29, the staffing plan based on resident population and their needs for care and support the facility's approach to ensure sufficient staff to meet the needs of the residents includes six to eight CNAs scheduled to the unit during the day shift, bath aides work 4, ten hour days to accommodate the resident's bathing, meals, toileting, etc. Additionally one to two Restorative Aides overlaps from the first to the second shift to assist with meals, toileting and other cares. During the evening shift six to eight CNAs are scheduled on the units. The night shift has four CNAs scheduled on the units. Page 35 indicated staffing patterns per unit for a census of 95 residents, two CNAs per hall, total of 8 CNAs for 6:00 AM to 2:00 PM, 8 CNAs for 2:00 PM to 10:00 PM, and 4 CNAs 10:00 PM to 6:00 AM. Review of facility provided daily staffing schedules for the weekends of July 1, 2024 through September 30, 2024 revealed of the two units in the facility, 13 shifts from 6:00 AM to 2:00 PM had 3 or less CNAs available on each unit (less than 1-1.5 CNAs on each hall), 9 shifts from 2:00 PM to 10:00 PM had 3 or less CNAs available on each unit (less than 1-1.5 CNAs on each hall), and on one occurrence, from 10:00 PM to 6:00 AM a unit had 1 CNA (1 CNA for two halls). Review of facility provided daily staffing schedule for the weekends of February 2025 (three weekends) revealed of the two units in the facility, 2 shifts from 6:00 AM to 2:00 PM had 3 or less CNAs available on each unit (less than 1-1.5 CNAs on each hall), 4 shifts from 2:00 PM to 10:00 PM had 3 or less CNAs available on each unit (less than 1-1.5 CNAs on each hall), and on one occurrence, from 10:00 PM to 6:00 AM a unit had 1 CNA (1 CNA for two halls). During an interview on 2/27/25 at 2:10 PM, Staff Y, Scheduling Coordinator, revealed when making the schedules for each unit it is expected to schedule 4-5 CNAs on each unit for the 6:00 AM to 2:00 PM and 2:00 PM to 10:00 PM shifts and 2 CNAs on each unit for the 10:00 PM to 6:00 AM shift. The schedules are made out this way but there are often call-ins and there have been CNAs who have no call no show for their shift. Staff Y, Scheduling Coordinator acknowledged there have been shifts where only 3 CNAs have been on each unit, which happened frequently and he did his best to find coverage for the CNAs that did not make their shift and had covered these shifts many times himself, as he is also a CNA.

Based on staff interview, review of CMS-2567 reports, and facility policy review, the facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies identified on the facility's current recertification survey. The facility reported a census of 94 residents. Findings include: Review of facility's CMS 2567 from a recertification and complaint surveys on 4/11/24, 2/13/24, 12/29/22, and 3/23/22 revealed the facility received non-harm level citations for infection prevention and control. The facility's Plan Of Correction (POC) for Recertification and Complaint Survey dated 4/11/24, revealed correction date of 5/2/24 for infection prevention and control revealed documentation present at the end of the CMS-2567 form included the following: The Facility reasonably ensures that infection control procedures are followed. This includes the proper usage of gloves for patients during perineal cares to prevent cross contamination. 1. Residents have been receiving proper cares 2. All residents who require assistance with personal cares and all residents who require isolation precautions could be affected. 3. All staff education was completed on 4/30/24 where proper glove usage and infection control practices were discussed. A CNA skills fair slot had been scheduled for May 9th, 14th and 16th 2024 where all CNAs are to have competency sign offs completed for ADL care, glove usage and infection control practices. The QAA committee reviewed this deficiency during its monthly meeting on 4/30/24. 4. The Director of Nursing or designee will complete weekly audits for 8 weeks to ensure that staff are using gloves appropriately and preventing cross contamination. The facility's POC for Complaint survey dated 2/13/24, revealed correction date of 3/11/24 for infection prevention and control revealed documentation present at the end of the CMS-2567 form included the following: The Facility reasonably ensures that infection control procedures are followed. This includes the proper usage of gloves for patients in isolation as well as during perineal cares. 1. Residents have been receiving proper perineal care and are no longer on isolation precautions. 2. All residents who require assistance with personal cares and all residents who require isolation precautions could be affected. 3. An education was conducted with direct care staff on 3/5/24 regarding proper glove usage during perineal cares as well as when a patient is on isolation precautions. Facility peri care audits were initiated on 3/6/24. Gloves, hand hygiene, and cleansing are all specifically addressed in the audit. Educational posters regarding hand hygiene and infection control were placed in common areas around the facility on 3/8/24. 4. The Director of Nursing or designee will complete weekly audits for 8 weeks to ensure that staff are using gloves appropriately and completing hand hygiene as required. The facility's POC for Recertification and Complaint Survey dated 12/29/22, revealed correction date of 2/8/23 for infection prevention and control revealed documentation present at the end of the CMS-2567 form included the following: 1. All facility staff members were re-educated on appropriate Personal Protective Equipment (PPE) usage and compliance. 2. All staff will have completed the 4 educational videos per directed plan of correction by 2/8/23. PPE Lessons, Sparkling Surfaces, Clean Hands, Keep COVID OUT. 3. QA team participated in watching the Telligen Root Cause Analysis Training per directed plan of correction on 2/9/23. 4. QA team will monitor weekly for 4 weeks and then monthly for 3 months and ongoing for compliance. 5. PPE compliance audits will be completed 5 days a week x2 weeks. Weekly x4 weeks. Monthly x3 months and ongoing for compliance thereafter. Results will be forwarded to the QA/QAPI committee for review. The facility's POC for Recertification and Complaint Survey dated 3/23/22, revealed correction date of 4/14/22 for infection prevention and control revealed documentation present at the end of the CMS-2567 form included the following: The Facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 1. Staff will receive education regarding proper hand hygiene and glove use per facility policy and procedures. 2. Staff education regarding proper hand hygiene and glove use. 3. Audits will be completed weekly x2, twice weekly x2, monthly x2 and then randomly as needed. Results will be forwarded to the QA/QAPI Committee for review. 4. Responsible party: Infection Preventionist/DON/ADON The facility's current Recertification Survey, entrance date 2/24/25, resulted in multiple repeated non-harm level deficient practices for the following areas: Safe/Clean/Comfortable/Homelike Environment, Activities of Daily Living (ADL), ADL Care Provided for Dependent Residents, Free of Accidents Hazards/Supervision/Devices, Sufficient Nursing Staff. On 02/27/25 at 4:24 PM, Facility Administrator revealed the Quality Assurance Committee meets monthly and continues to review concerns. Facility Administrator acknowledged repeat deficiencies and stated the facility created a RN Education position, this RN is responsible for continuing education to staff, providing audits and monitoring, providing orientation for new employees along with other responsibilities to assist and educate staff to maintain resident's safety and satisfaction as well as meeting regulations and compliance. Facility Administrator stated a RN had been hired for this position but is not currently able to meet the criteria of the position and will be looking for a replacement. The facility has also hired a new Environmental Manager and Laundry Manager and they have implemented new procedures. Review of facility provided Quality Assurance Performance Improvement (QAPI), updated 1/2/25 stated the following: The purpose of QAPI in our organization is to develop a culture of proactive leadership that solicits the input from employees in various departments, including contracted professionals, if indicated, as well as those we serve Residents, Resident Representatives, and family members. Further, our purpose includes ongoing development of plans for improvement leading to systematic changes that support exceptional health care to seniors and operating excellence in every aspect of our business. A. The facility Administrator will be responsible for leadership and coordination of QAPI plan. B. Corporate will provide leadership development opportunities regarding the QAPI process and facility wide education will be made available. C. The facility Administrator will monitor and ensure necessary resources (time, equipment, training, etc .) are available and will consult with the regional management team as needed to procure these resources. D. The Director of Nursing, or designee will be responsible for the development and ongoing monitoring of care giver proficiency. 1. Proficiency shall be determined during the orientation process using orientation checklists. 2. Ongoing proficiency shall be determined through the evaluation process and all other processes deemed necessary through the QAPI process.

Based on observation, interviews and policy review, the facility failed to ensure residents' dignity demonstrated by lack of dressing assistance prior to a meal in the main dining room and disregard to privacy for 2 of 6 residents reviewed for dignity (Residents #84, #89). The facility reported a census of 94 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #89 dated 2/11/254 documented diagnosis included non-traumatic spinal cord dysfunction and paraplegia. The MDS revealed the resident had required substantial or maximal assistance with upper and lower body dressing. The Brief Interview for Mental Status (BIMS) exam scored 15 out of 15 which indicated intact cognition. The Care Plan focus initiated 1/23/25 for Resident #89 documented, self-care deficit as evidenced by requiring assistance with activities of daily living included dressing. Intervention under category of dressing and undressing, directed one-person assistance. The mobility category documented, does not ambulate, utilizes wheelchair that staff propels. An observation on 2/24/25 at 12:44 PM Resident #89 sitting in the main dining room eating lunch. Resident #89 wore a hospital gown with a blanket on his lap. The hospital gown was open revealing residents' skin on his back. In an interview on 2/24/25 at 12:45 Resident #89 relayed to the Administrator and surveyor when asked if wanted to get dressed prior to the meal, and if staff offered to assist with dressing. Resident #89 responded the staff were too busy and acknowledged staff had not offered to assist with dressing today. On 2/24/25 The Administrator acknowledged a dignity concern related to Resident #89 not having assistance with change of clothing and coming to the dining room not dressed appropriately. Facility policy titled, Dignity revised February 2021 documented, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times, #5a directed when assisting with care, encourage to dress in clothing that they prefer. 49990 2. The Quarterly MDS for Resident #84, dated 01/28/2025, documented his brief interview for mental status (BIMS) score as 15, which indicated intact cognition. It documented the following diagnoses: Heart failure, Hypertension, renal insufficiency, and revealed the resident had a urinary tract infection no more than 30 days before the MDS was finished. It further documented the resident was dependent upon staff for toileting transfers, toileting and personal hygiene, as well as lower body dressing. The Care Plan for Resident #84, last revised 02/03/2025, documented the resident required two-person assistance for toileting and toileting hygiene. It also documented the resident had impaired vision due to glaucoma and macular degeneration. The Quarterly MDS for Resident #74, dated 12/12/2024, documented the residents BIMS score as 13, indicating intact cognition. It further documented Resident #74 was dependent on staff for all transfers and ambulation. In a direct observation on 02/26/2025 at 11:20 AM, Staff E (CNA), and Staff F (CNA), were providing toileting assistance for Resident #84 at his request. During the observation Staff E and Staff F used a mechanical lift to assist Resident #84 to the rest room, and due to the constrains on the size of the bathroom and the equipment they were unable to close the bathroom door. They pulled the resident's hospital style gown up, without closing the privacy curtain for his roommate (Resident #74), exposing Resident #84's genital area to his roommate. In an interview on 02/27/2025 at 09:30 AM with Resident #74, he stated staff members never pull the curtain when assisting his roommate with toileting. He stated it bothers him, and that he should not have to see it. He stated it bothers him.

Based on clinic record review, staff interviews, and facility policy review, the facility failed to adequately assess and notify the physician when a resident had a change in condition. The resident's heart stopped and the facility initiated CPR. The facility failed to provide effective Cardiopulmonary Resuscitation (CPR) in accordance with professional standards of care. The facility failed to perform CPR on a hard surface and failed to utilize an Automatic External Defibrillator (AED). Concerns were identified for 1 of 19 sampled (Resident #13). This failure resulted in immediate jeopardy to the health, safety, and security of the residents. 54 of 95 residents had a full code status. The facility reported a census of 95 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) of 15 that indicated intact cognition. The resident required limited assistance of 1 staff for transfers, and supervision of 1 staff for bed mobility. The MDS included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13 received diuretic and opioid 7 out of 7 of the look back day period. The MDS lacked documentation of pacemaker/defibrillator. The Baseline Care Plan dated [DATE] stated Resident #13 had a defibrillator and a full code status. The History and Physical report dated [DATE] documented Resident #13 had a pacemaker inserted on [DATE]. Resident #13's Iowa Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #13 had a desire for CPR and comfort measures only. The Care Plan revised [DATE], revealed Resident #13 had advance directives with a desire to be full code. The staff directives included interventions to follow IPOST and physician order. Resident #13 had CHF, [CONDITION(S)], chronic kidney disease, and used routine cardiac medications. The Care Plan directed staff to monitor/document/report as needed any signs or symptoms of CHF and [CONDITION(S)] (low potassium in the blood), shortness of breath, muscle weakness, and fatigue. The Order Summary Report dated [DATE] revealed Resident #13 had a full code status. Review of the Progress Notes revealed the following: a. The Progress Note late entry dated [DATE] at 8:00 PM for [DATE] at 01:15 AM, Staff Z (Registered Nurse) documented Resident #13 complained of her stomach hurting mid abdomen. Abdomen firm and bowel sounds diminished but present in all four quadrants. Staff gave the resident Milk of Magnesia (laxative) with large results. While the resident sat on the stool, she stated her legs felt numb, she could not feel her toes, and she felt funny. Vitals included Blood Pressure ,d+[DATE], Pulse 91, Respirations 20, Temperature 95.1, and Oxygen Saturation 93%. The staff placed a call to the on call physician answering services. The staff did not receive a return call and asked Resident #13 if she still needed the doctor called. b. The Progress Note dated [DATE] at 08:24 PM revealed Resident #13 received as needed (PRN) [MEDICATION(S)] ,d+[DATE] mg, 1 tablet, for chronic pain all over, and [MEDICATION(S)] 25 mg PRN for itching. At 02:19 AM, Resident #13 rated her pain at a 3. c. The Progress Note late entry dated [DATE] at 12:30 AM for [DATE] at 04:13 AM, Staff AA (Registered Nurse) documented she visited with Resident #13 as the on call physician failed to returned the call. Resident #13 stated she was feeling a bit better and would like to wait until morning as she wanted to go to bed. Staff assisted Resident #13 to bed and Resident #13 reported feeling hot. Staff removed the blankets, placed a fan on Resident #13. Resident #13 reported feeling much better. Staff A documented a plan to pass information on to the day nurse to contact the physician if Resident #13 desired. d. The Progress Note late entry dated [DATE] at 04:15 AM for [DATE] at 04:53 AM, Staff AA (Registered Nurse) heard Resident #13 call out I am having a heart attack. Upon arrival to the room, Resident #13 found pale and unresponsive. Staff unable to detect a heart rate or respirations. Staff initiated CPR and called 911. CPR continued until paramedics arrived and took over CPR at 03:25 AM. e. The Progress Note dated [DATE] at 04:53 AM, documented at 04:45 AM the Medical Examiner notified the facility that Resident #13 expired at the emergency room and requested information on cause of death from the on-call physician. The Emergency Medical Services (EMS) Patient Care Record dated [DATE] revealed EMS received the request for services at 03:10 AM for resident in cardiac arrest. Staff on site unable to provide much information on the patient or her conditions. Nursing staff stated the resident yelled out, they went to check on her and thought she might have been having a [CONDITION(S)]. The resident stopped breathing and staff started CPR on the Resident #13 in her bed. EMS arrived at the scene, resident unresponsive, apneic, and pulseless. Staff performing chest compressions in her bed. Skin conditions pale, cyanotic, cool and dry. Pupils fixed and unresponsive. Resident moved to the floor and chest compressions started. The Crash Cart Inventory Checklist dated 2021 for North, West South (NWS) hall, revealed ,d+[DATE] checks included backboard and an AED. During an interview on [DATE] at 11:23 AM, Staff DD (Certified Nurse Aide) reported Staff AA (Registered Nurse) called her while she was on break. Staff AA told Staff DD to get Staff CC (Licensed Practical Nurse) from the ABC unit. Staff AA informed Staff DD she had CPR in progress and needed assistance. Staff AA had CPR in progress for 6 or 7 minutes and requested someone else take over due to fatigue. Staff DD reported Staff CC arrived and said she was tired, didn't feel well, and didn't want to do CPR. Staff DD thought Staff CC was scared. Staff DD started chest compressions. Staff AA grabbed the ambu bag and they continued CPR until the police arrived. Staff DD acknowledged she had CPR during high school in 2016, but admitted she had never done CPR and had no idea what she was doing. During a second interview on [DATE] at 12:25 PM, Staff DD reported Staff AA, Staff CC, Staff D, and Staff BB were all present in the room during CPR but the staff did not utilize an AED. Staff DD had no knowledge if the facility had an AED. During an interview on [DATE] at 02:15 PM, Staff D (Certified Medication Aide) stated Staff U (Certified Nurse Aide) approached Staff D at 4:00 PM to 5:00 PM (before supper) and reported Resident #13 did not feel good. Staff D checked Resident #13 who reported she did not feel well. Staff D reported to Staff Z (Registered Nurse) that Resident #13 did not feel well. Staff Z assessed Resident #13 and reported she called the on call doctor but the doctor failed to return the call. Later that night Resident #13 complained she was not feeling well to Staff BB (Certified Nurse Aide). Resident #13 complained about both of her legs, and unable to move them. Staff BB requested assistance from Staff D. Staff D asked Resident #13 to kick and she kicked with both legs. Staff D and Staff BB assisted Resident #13 to a standing position for 2 to 3 minutes and provided perineal cares and then assisted Resident #13 to sit in a chair. Staff D and Staff BB exited the room. Just after midnight, Staff D heard Resident #13 having a [CONDITION(S)]. Staff D entered the room to assist Staff AA (Registered Nurse). Staff AA called Staff CC (Licensed Practical Nurse) and 911, and started chest compressions. Staff D reported Resident #13 looked deceased , had no movement, a pale color, and had her eyes open. Staff CC arrived and felt a pulse. However, Staff AA had auscultated with a stethoscope and heard no heartbeat. Staff D was instructed to go to the front door to meet the ambulance. At that time, CPR had not been started. Staff AA left the room to retrieve the emergency cart. Staff D acknowledged he did not see any staff use the AED and unsure if an AED is on the emergency cart. During an interview on [DATE] at 4:38 PM, Staff BB (Certified Nurse Aide) stated she learned during shift report on [DATE] Resident #13 had a large, diarrhea bowel movement on the previous shift. Staff BB checked on Resident #13 after report. Resident #13 sat in her chair and denied any needs. An unknown time later, Resident #13 had her call light on and reported she felt weak. Resident #13 walked to the bathroom using a gait belt and assistance of 2 staff. Thirty minutes later, Resident #13 reported numbness in her feet and knees and unable to walk. Staff D instructed Resident #13 to kick both feet and move her legs. Staff D (Certified Medication Aide) and Staff BB transferred Resident #13 into a wheelchair and then to bed. Normally Resident #13 walked. However, on this night she required a wheelchair with staff assistance to move from the bathroom to her bed. Resident #13 seemed calmer then. Staff BB told staff Z (Registered Nurse) to check on Resident #13. Staff Z obtained vital signs. Resident #13 reported not feeling well. Staff Z reported she would call the doctor. Staff BB reported later on she stood at the Nurses Station and heard Resident #13 holler I think I am having a heart attack. Resident #13 did not normally yell out like that. Staff BB immediately went to the room and found Resident #13 having a [CONDITION(S)]. Resident #13 color looked like death. Staff AA (Registered Nurse) arrived and Resident #13 was not moving. Staff AA instructed Staff BB to get the crash cart. Staff DD (Certified Nurse Aide) responded from the back hall and Staff D was in the room. Staff DD reported when she arrived with the crash cart, Staff AA checked resident and initiated CPR. Staff AA performed compressions. Staff BB unsure which staff called 911 or if AED used. Staff AA requested another staff take over compressions due to fatigue. Staff BB unable to remember if Staff CC was in the room. Staff BB did not hear Staff CC decline to do CPR. Staff BB reported being certified in CPR [AGE] years ago. During an interview on [DATE] at 09:10 PM, Staff CC (Licensed Practical Nurse) reported she worked on the ABC unit the evening Resident #13 coded. Staff DD instructed Staff CC to call 911. Staff CC went to the front desk to gather information to call 911. Someone reported 911already called. Staff CC rushed to Resident #13's room and asked what happened. Everything seemed very chaotic and Staff CC needed to confirm if Resident #13 had a full code status. Staff CC checked for a pulse and Resident #13's body felt warm. Staff CC reported she gave ,d+[DATE] breaths for CPR. Staff CC stated she never declined to do CPR when Staff AA requested a break due to fatigue. Staff AA asked Staff CC to take over, but Staff DD started CPR because she was standing next to Staff AA. Staff CC stated no AED used during this time and she is uncertain what time CPR started. During an interview on [DATE] at 09:20 PM, Staff Z (Registered Nurse) reported Resident #13 did not feel well around 08:00 or 08:30 PM. Staff Z reported Resident #13 had stable vital signs. Resident #13 complained of her stomach hurting earlier. Resident #13 [NAME] faint bowel sounds and no bowel movement for a few days. Her blood sugar was a little high. Staff Z called the on call doctor, but never received a response. Staff Z asked Resident #13 if she wanted the doctor paged again. Resident #13 told her no, and thought she could wait until the morning and did not want to go to the hospital. Staff Z reported she did no further assessment on Resident #13 and left her shift at 10:30 PM. Staff Z realized she took keys from the facility home and needed to return them. Staff Z returned to the facility at 11:00 p.m. and staff informed her Resident #13 coded and they performed CPR. During an interview on [DATE] at 08:45 PM, Staff Z acknowledged she paged the on call physician once on [DATE] for Resident #13 and did not follow up with the answering service when the physician failed to return the call. Staff Z reported leaving the facility around 10:00 to 10:30 PM and returned at approximately 11:,d+[DATE]:15 PM to return keys. Staff Z reported she heard sirens. At the time, Staff D told Staff Z CPR in progress on Resident #13. The Surveyor further questions Staff Z regarding timeline and noted the EMS report documented EMS on site at 03:15 AM. Staff Z said Oh no it wasn't that late. Well, I don't know what time it was. My times are all mixed up. Staff Z started crying uncontrollably, and handed the phone to the Director of Nurses (DON). The DON reported she was notified at 04:41 AM that Resident #13 died . When the time line questioned, the DON reported Staff Z clocked out at 1:00 AM, it took Staff Z about 45 minutes to get home, and 45 minutes to get back to the facility. During a follow up interview on [DATE] at 08:30 AM, Staff Z stated she is uncertain of the exact time she paged the on call physician, but thought it was around 08:00 or 09:00 PM. The surveyor informed Staff Z the answering service recorded the first time they received a page was [DATE] at 12:13 AM regarding Resident #13. Staff Z said she was very busy that night, and she wasn't sure of the time. Staff Z acknowledged it is possible she did not page the doctor until around 12:13 AM. The time punch data report starting [DATE] at 12:00 AM to [DATE] at 10:03 PM showed Staff Z clocked in at 02:00 PM on [DATE] and clocked out at 1:00 AM on [DATE]. During an interview on [DATE] at 11:33 AM, Staff FF (Licensed Practical Nurse) reported the facility had an AED located on the emergency cart in the medication room and she knew how to use the AED. During an interview on [DATE] at 11:36 AM, Staff GG (Licensed Practical Nurse) reported she is not certified in CPR and received no training on how to use the AED. Staff GG had knowledge the AED stored on the emergency cart. During an interview on [DATE] at 11:40 AM, Staff HH (Certified Nurse Aide) reported he is not currently certified in CPR. He knew the facility had an AED, but did not know the location of the emergency cart and had not been trained at this facility to use the AED. During an interview on [DATE] at 11:42 AM, Staff II (Certified Nurse Aide) reported she is CPR certified and knew where the emergency cart was located but did not know if the emergency cart had an AED. During an interview on [DATE] at 11:45 AM, Staff N (Certified Nurse Aide) reported she is CPR certified and did not know where the emergency cart was located. During an interview on [DATE] at 11:53 AM, Staff JJ (Certified Nurse Aide) reported he doesn't t know where the emergency cart is located, he did not know what an AED was, or how to use it. During an interview on [DATE] at 11:54 AM, Staff AA (Registered Nurse) she was signed to Resident #13. Staff AA received report from Staff Z. Staff Z thought Resident #13 might need to go to the hospital. Staff Z informed Staff AA Resident #13 didn't feel right, her feet felt numb, toes tingly, and the symptoms are new for her. Staff Z called the on call doctor, but received no call back. After report, Staff AA checked Resident #13. Resident #13 sat in a wheelchair and reported her feet and legs felt better. The resident requested to lay down. Staff AA did not recheck vital signs and requested staff assist Resident #13 into bed. Staff AA asked Resident #13 if she wanted the on call doctor notified and Resident #13 said she just wanted to get in bed. At 02:00 AM, Resident #13 started crying out, Staff D and Staff AA checked the resident. Resident complained of feeling hot and blankets removed. Around 3:00 AM, Resident #13 cried out she was having a heart attack. When Staff AA arrived in the room, Resident #13 was unresponsive. Staff AA directed Staff BB to grab the chart to check the code status. Staff BB didn't know where to look, so Staff AA ran and checked code status on the computer and the paper chart for the IPOST because sometimes they don't match. Upon return to room, Resident #13 was pale, had her eyes rolled back, and was not responding. Staff AA called for staff assistance, called 911, and started chest compressions. When Staff AA got tired from doing chest compressions, she asked Staff CC to take over. Staff CC whispered she was too scared. Staff DD started chest compressions. Staff CC did not help in any part of the CPR process. Staff BB brought the emergency cart into the room and handed Staff AA the ambu bag. Staff AA gave breaths while Staff DD performed compressions. Upon EMS arrival, EMS staff stated they needed to move the resident to the floor or use a backboard in order for CPR to be performed correctly. Staff AA acknowledged her CPR certification not current and she received no facility training on what to do in an emergency situation. Staff AA was not sure whether the cart contained an AED. During an interview on [DATE] at 12:49 PM, Staff EE (Advanced Registered Nurse Practitioner) reported cardiac arrest, coronary [CONDITION(S)] disease, and complications of diabetes type 1 as the cause of death for Resident #13. Staff EE reported the process notification of an on-call physician included the facility staff called the office and the answering service paged the provider's cell phone. The answering service indicated an urgent message in an emergent situation as directed by facility staff. Staff EE stated not on call evening hours of [DATE] or early morning hours of [DATE]. During an interview on [DATE] at 02:35 PM, Staff M (Certified Nurse Aide) reported she started working at the facility 2 weeks ago and Staff M reported she received no orientation about the location of the AED or emergency cart. During an interview on [DATE] at 02:47 PM, Staff KK (Occupational Therapy Assistant) reported she didn't know the location of the emergency cart or AED. During an interview on [DATE] at 02:49 PM, the Director of Nurses reported no AED used at their facility, and she didn't know why the emergency cart had an AED. During an interview on [DATE] at 07:19 PM Staff LL (Advanced Registered Nurse Practitioner) reported she was on call the evening of [DATE] going into the morning of [DATE]. Staff LL unable to recall if she received a page from the facility on [DATE] around 08:00 or 08:30 PM. Staff LL worked until about 10:45 PM in her office with her phone beside her. Staff LL recalled she stayed up later packing for a vacation and never heard her phone ring. Staff LL said the facility staff should have called the answering service back if they didn't get a response, and make an urgent request if warranted. Furthermore, if no response from the on call provider, the answering service had the option to page the second on call provider. Staff LL expected the staff to call 911 in an emergency. Staff LL reported on [DATE] between 05:00 and 06:00 AM she received a call requesting cause of death for a death certificate. Staff LL referred the caller to contact the primary care provider during office hours. During an interview on [DATE] at 11:16 AM, the Director of Nurses (DON) reported whenever a resident had a change in condition she expected the staff to perform an assessment, check vital signs, and notify the physician, but it depended on the situation. She expected staff to follow the policy and use their nursing judgement. If no response from the physician after being paged, she would call the answering service back. The DON expected staff document physician notification and resident assessments in the progress notes. The DON reported Resident #13 had chronic pain, diabetic [CONDITION(S)], and difficulty walking. The DON stated aches, pains, and weakness common for Resident #13 and didn't feel this was abnormal. The DON stated she expected staff to know the location of the emergency cart, but some staff lacked understanding due to communication barriers. The DON reported she learned during the survey week the AED should not have been on the crash cart, although she performed monthly checks on the AED. The DON acknowledged a written CPR policy that included AED use, however she had been instructed the AED portion should have been crossed out and did not apply to their facility. The DON further acknowledged CPR should be performed on a hard surface such as deflating a bed, a back board, or on the floor. On [DATE] at 01:40 PM, the Administrator reported she arranged a CPR class for staff on [DATE] at 09:00 AM. The Administrator reported she planned to work with the local fire department for CPR training going forward to maintain staff CPR certifications. The Administrator reported she had worked at the facility since ,d+[DATE]. One day as they were rummaging through the cabinet by the nurse's station, they came across an AED. The AED should not have been on the unit. She never bought patches or checked the AED machine batteries, and the AED machine not maintained for use in the facility. The current DON checked the emergency cart routinely and filled out a checklist after the emergency cart checked. The Administrator had no knowledge the AED had been placed on the emergency cart. On [DATE] at 02:07 PM, Staff MM (Physician's Office Manager) reported she checked the answering service log for the dates of [DATE] and [DATE]. Staff MM reported no calls came from the facility on [DATE] regarding Resident #13 but there was a call on [DATE] at 12:13 AM. Staff MM spoke with the Nurse Practitioner on call, who reported she didn't remember receiving that page and did not have a record of any calls on her phone because messages got deleted after about 7 days. Staff MM said the answering service received no calls back from the facility to re-page or call the secondary person on call. The only other call that came in was at 4:40 AM on the [DATE] notifying the provider of Resident #13's cardiac arrest, transfer, and death. During an interview on [DATE] at 02:20 PM, Staff W (Licensed Practical Nurse) reported they had some manuals by the Nurse's Station. Staff W proceeded to show the surveyor the manuals which included fall/incidents, exposure control plan, and the disaster/emergency preparedness plan. Staff W reported not sure where any other policies kept. Staff W reported the change in condition protocol reviewed during an in-service today, and she had to sign off on the procedure. Staff W reported if a resident had a change in condition she notified the physician. If the physician had not called back in a timely manner, she called the physician again, then the DON and 911 if necessary. During an interview [DATE] at 02:30 PM, Staff X (Licensed Practical Nurse) reported she worked at the facility [AGE] years and familiar with the facility ' s policies and what to do if a resident had a change in condition. Staff X reported whenever a resident had a change in condition, she contacted the physician, and initiated CPR if warranted. Staff X reported she used her nursing judgement and common sense. During an interview [DATE] at 02:35 PM, Staff Y (Registered Nurse) reported she worked at the facility for a year. Staff Y reported some policies located on the computer electronic health record (EHR) and had some policies and procedures in binder at the nurse ' s station. Staff Y reported she filled out a SBAR in the EHR when a resident had a change in condition, and notified the physician or called 911, depending on the situation. The Acute Condition Changes -Clinical Protocol (revised [DATE]) stated: a. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident. b. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, call or page the physician and request a prompt response (within approximately one-half hour or less). c. The attending physician (or practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. d. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. e. The staff will monitor and document the resident/patient's progress and responses to treatment. The Emergency Procedure-Cardiopulmonary Resuscitation policy (revised [DATE]) reflected: a. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a [CONDITION(S)]. b. The chances of surviving a sudden cardiac arrest may be increased if CPR is initiated immediately upon collapse. c. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival. d. If an individual is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR, unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual, or there are obvious signs of irreversible death, such as rigor mortis). e. The CPR team in this facility shall include at least one nurse, one LPN/LVN and two CNAs, all of whom have received training and certification in CPR/BLS. f. If an individual is found unresponsive, briefly assess, activate the emergency response system, instruct staff to retrieve AED, and initiate basic life support (BLS) sequence of events. The undated position description for a registered nurse revealed a nurse assists or institutes emergency measures for sudden adverse developments. Responds to emergency situations based upon nursing standards, policies, procedures and protocols. During an interview on [DATE] at 2:25 PM Staff V (Paramedic) stated the facility staff failed to provide the IPOST or that the Resident had a pacemaker/defibrillator. Staff V explained that a Paramedic had gotten shocked from residents defibrillator during the resuscitation attempt. The State Agency notified the facility of the Immediate Jeopardy on [DATE] at 2:00 p.m. The facility removed the Immediate Jeopardy on [DATE] by providing education on acute condition changes, charting and documentation, physician notification, initiated CPR training, assess the AED for proper function, review staff schedules to ensure 2 CPR certified staff on duty at all times, education on performing CPR on hard surface, ensure ongoing CPR training, and implemented a tracking system to ensure staff are current on CPR training. The scope lowered from J to D at the time of the survey after ensuring the facility implemented education and their policy and procedure.

Based on record review, and staff and provider interview the facility failed to provide treatment and care in accordance with professional standards of care for 1 of 3 sampled (Resident #12) who had an [DEVICE] (stabilizing frame to hold fractured bones in position). The facility failed to follow physician's orders [REDACTED].#12 attended follow up appointments. The lack of treatment and care resulted in Resident #12 developing osteo[DIAGNOSES REDACTED] (bone infection) which required hospitalization . The facility reported a census of 98. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #12 admitted to the facility on [DATE]. Resident #12 had memory problems and modified independence with decision making. Resident #12 required extensive assistance with bed mobility, transfer, locomotion on and off the unit, dressing, hygiene and toilet use. The MDS listed [DIAGNOSES REDACTED]. The Care Plan initiated 11/25/20 identified Resident #12 admitted with pressure ulcers that require treatments. The Care Plan updated on 12/29/20 directed staff to apply treatment, creams and dressing per orders, report any new or worsening skin concerns to my nurse and/or doctor dated, and follow my treatment order as directs, weekly treatment documentation to include measurements, of each skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes. The Care Plan failed to direct staff how to care for Resident #12's [DEVICE] and weight bearing status. The Physician Discharge Summary dated 11/9/20 revealed Resident #12 admitted to the hospital on [DATE] and discharged to the nursing home on 11/9/20. Resident #12 had bilateral ankle fractures in August of 2020 with right ankle external fixation. Resident #12 had a Podiatrist follow her care while hospitalized . Hospital x-rays of the right ankle showed the external fixation hardware in adequate position, and best to keep it on and follow up with x-rays to assess for healing. The Discharge Procedure Orders included the following orders: a. Change the right lower extremity dressings 3 times per week on Monday, Wednesday, and Friday) for right lower extremity. b. Apply Xeroform (non-adhering protective dressing) to pin sites, 4x4 gauze to pin sites, kerlix (gauze bandage) and light Ace (elastic) bandage. c. Weight Bearing as Tolerated on the left lower extremity and Non Weight Bearing on the right lower extremity. d. Follow up after discharge with Specialist for assessment of healing of right ankle and re-evaluation of external fixation hardware. The orders specified the provider who placed the fixation hardware to follow up one week after discharge from the hospital. Review of a Progress Note dated 11/9/20 at 4:46 p.m., revealed Resident #12 admitted to the facility and had 5 pressure areas, and [DEVICE] pin sites-two pin sites on the lateral side (further from the middle) of the right leg/foot, one pin site to the lateral side of the right fibula and one on the medial (closer to the middle of the body) side of the right tibia, one pin site on the lateral side of the right foot and one pin site on the medial side of the right foot. No treatment orders were received, pressure area treatment orders were clarified with hospital nurse. A Progress Note dated 11/27/20 at 3:20 p.m., Staff A (Licensed Practical Nurse) documented Resident #12 had serosanguinous (thin watery) drainage from right ankle near ankle metal fixator. A Progress Note dated 12/2/20 at 10:04 a.m., revealed Resident #12 had a follow up appointment for the right lower extremity fixator scheduled on 12/4/20. A Progress Note dated 12/3/20 at 11:49 a.m., documented Resident #12 tested positive for COVID. A Progress Note dated 12/4/20 at 2:30 p.m., Staff A (Licensed Practical Nurse) documented a call to discharging physician to report drainage, warmth, redness to lateral/medial right ankle. The Provider returned a call at 3:32 p.m. and no new orders received. At 3:41 p.m., Staff A notified the facility Physician Assistant (PA) and received order for Keflex 500mg one capsule three times a day for right ankle infection for 10 days. An Order Note dated 12/11/20 at 3:20, documented Staff A notified the Physician's Assistant and received new order to discontinue previous dressing and start change dressing to right lower extremity every MWF. Apply xeroform to pin sites, 4x4 gauze to pin sites, kerlix and light ace bandage every day shift. Cleanse areas with wound cleanser prior to applying xeroform. A Progress Note initiated on 12/14/20 at 5:18 p.m., Staff B (Licensed Practical Nurse) documented Resident #12 discontinued from skilled level of care and was moved to another room. A Progress Note dated 12/15/20 at 11:54 a.m. documented Resident #12 had an appointment with the Podiatrist on 12/18/20 at 11:15 a.m. for removal of internal rotator and [DEVICE]. Staff scheduled to go with resident and transportation set up. A Progress Note dated 12/18/20 at 4:02 p.m., Staff C (Assistant Director of Nurses) documented Resident #12 returned from an appointment with the Podiatrist with a new order to admit to the hospital for intravenous antibiotics for osteo[DIAGNOSES REDACTED] (infection of the bone). Hardware removed from right leg. X-rays taken, resident to be admitted to the hospital when bed available. Wound care directed to be [MEDICATION NAME] soaked gauze with kling wrapped gauze twice a day until admission for foot wounds. The Podiatry History and Physical dated 12/18/20 documented Resident #12 admitted to the hospital with [REDACTED]. Resident #12 had a 1 week follow up appointment after hospital discharge on 11/9/20. Resident #1 failed to follow up until today (12/18/20). Resident #12's partial fifth metatarsal (foot bone) amputation site was healing well at discharge from hospital. However, wound now dehisced (opened) and had signs and infection present. With the lack of follow up despite having an [DEVICE] in place for an extended amount of time there was a concern for neglect behavior from the nursing home. The Treatment Administration Record (TAR) for December 2020 revealed an order dated 11/11/20 to the change dressing to Resident #12's right lower extremity. The order directed to apply xeroform to pin the sites, apply 4 x 4 gauze to pin sites, apply kerlix and a light ace bandage one time a day every Monday, Wednesday, Friday. The order discontinued on 12/11/20. The TAR for December 2020 revealed a new order dated 12/12/20 directed to change the dressing to the right lower extremity on every Monday, Wednesday, and Friday. Cleanse the wound with wound cleanser, apply Xerofrom to pin sites, apply 4x4 gauze to pin sites, cover with kerlix and a light ace bandage every day shift. The TAR directed the staff to complete the treatment every Monday, Wednesday, and Friday and every day shift. The TAR directed the staff to sign the treatment out as completed every day. The December 2020 TAR lacked documentation to reflect the staff completed the treatment as ordered on [DATE], 12/14/20, and 12/18/20. During an interview on 12/29/20 at 11:40 a.m., Staff A (Licensed Practical Nurse) stated that she had routinely cared for Resident #12. Staff A contacted the Facility Provider on 11/27/20 to report serosanguinous drainage from right ankle near the metal fixator. Stated this was a change. On 12/2/20, she scheduled a follow up appointment for 12/4/20 with the foot and ankle surgeon at the direction of Staff B (Licensed Practical Nurse). Staff A further stated the appointment on 12/4/20 was cancelled by the facility because the resident tested positive for COVID on 12/3/20. On 12/4/20, she called the Hospital Provider to report had assessed increased drainage, warmth, and redness of the right lower extremity. She became aware after talking to the nurse that the Hospital Provider was no longer following the resident, confirmed she had thought she was contacting the foot and ankle surgeon. Stated she then notified the Facility Physician Assistant (PA) who ordered an antibiotic. Further stated the PA had not previously seen the resident. On 12/11/20, due to continued concerns with right lower leg, again contacted PA who ordered the treatment to the right lower leg to now be completed every day. Stated she is now aware that when she transcribed the order she failed to delete the MWF, so still read MWF, then directed every day. The TAR identified boxes for the treatment to now be signed for every day. Staff A stated the order as written was unclear. Staff A further stated she had completed the treatment and dressing on 12/11/20. Confirmed that she had dated and initialed dressings when completed. Stated if the dressing that was removed from Resident #12's right foot and ankle on 12/18/20 was dated 12/11/20 then it hadn't been completed in that time. The resident had moved from the skilled area to the back on 12/14/20 and she had not cared for her since that date. During an interview on 12/29/20 at 4:16 p.m., Facility Physician's Assistant confirmed that she had been contacted on 12/4/20 related to increased drainage, warmth and redness in right ankle area. Stated she had not seen resident prior to this phone contact and was not made aware the resident had an [DEVICE] device in place. Further stated if had been made aware would have expected staff to alert the foot and ankle surgeon for further instruction given the increased risk of osteo[DIAGNOSES REDACTED]. Would additionally have expected routine follow up by the foot and ankle surgeon and was unaware this was not occurring. Further confirmed she had ordered an increase in the frequency of treatment and dressing change to 7 days a week from 3 days of week when contacted due to continued concerns. During an interview on 12/30/20 at 9:45 a.m., the Hospital Provider's Nurse stated she had been contacted on 12/4/20 related to increased drainage, warmth, and redness in the right ankle. She directed facility staff to call Podiatry or have the Facility Provider see the resident. Reviewed the discharge summary and reported directed one week follow up with the Podiatrist. Stated would not be able to verify that the hospital summary was sent to the facility, but would expect the facility to call and enquire if had questions regarding the external hardware device. During an interview on 1/4/20 at 2:27 p.m., the Podiatrist stated that he would have expected to see the resident as a follow up for [DEVICE] one week after discharge from the hospital and weekly thereafter. Further confirmed resident had not attended any appointments after discharge on 11/9/20 until 12/18/20 when required hospitalization . Stated clinic would not have cancelled any appointments and are seeing COVID positive residents in the clinic. Further stated the facility nurse attending resident stated the facility is not letting residents leave because of COVID. Stated when the Resident #12 presented on 12/18/20 the dressing in place on the right foot/ankle was dated as last changed on 12/11/20 and the fixator was loose with increased drainage. Stated the dressing had been ordered by him to be changed three times a week. He was unaware the treatment had been changed to daily or that the resident had presented with signs and symptoms of infection on 12/4/20 and would have expected to have been notified. The Podiatrist stated it was his medical opinion that poor follow-up, not attending appointments, failure to complete treatment as ordered, and not notifying with changes such as: signs and symptoms of infection, and loose hardware are the cause of hospitalization . During an interview on 1/5/20 at 11:04 p.m., the Podiatrist Office Nurse stated she was present for the 12/18/20 appointment. She removed the dressing on the right foot/ankle which was dated as last changed on 12/11/20. Further stated she had removed the ace wrap bandage and noted the gauze was stuck to wounds, and had an obvious odor. Stated she said to the facility nurse attending that the dressing was dated 12/11/20 and is supposed to be changed three times a week. The Podiatrist Office Nurse further stated the resident had missed multiple appointments. Scheduled for regular intervals with external hardware. Further stated would be considered a no call/no show after 30 minutes and their office would not have cancelled any appointments. Clarified needs to be monitored closely when external hardware in place. During an interview on 12/29/20 at 11:15 a.m., Staff C (Assistant Director of Nurses) confirmed she had attended the 12/18/20 appointment with Resident #12. Stated the Podiatrist was concerned with the right foot and wanted Resident #12 to go directly to the hospital for hardware removal. Stated earlier appointment had been canceled due to COVID positive, but wasn't sure if the facility or the clinic had cancelled. Stated dates and initials dressing when completes dressing change. Further stated if dressing was dated 12/11/20 then that would be the date the dressing was last changed. She would expect the dressing and treatment to be completed daily if ordered daily. During an interview on 12/28/20 at 4:00 p.m., the Facility Wound Nurse stated Resident #12 admitted with pressure ulcers and wounds to the right foot for [DEVICE]. Confirmed she completed weekly assessments but floor nurses would be responsible to complete treatments. Stated she dates and initials dressing when completes dressing change, and would expect to be completed as ordered. Further stated she would not be responsible to schedule follow up appointments for [DEVICE], would be the responsibility of the Director of Nursing and the Assistant Director of Nursing. During an interview on 12/28/20 at 4:17 p.m., Staff B (Assistant Director of Nurses) stated could not provide any documentation of appointments made with the Podiatrist prior to the 12/4/20 appointment that was cancelled. She stated the appointment was cancelled by the clinic due to the resident testing positive for COVID the day before. Stated she had not scheduled any appointments prior to 12/4/20 as there had been no direction to do so. Staff B stated an expectation of staff to change the dressing as ordered and to date and initial the dressing with change. Confirmed the date on a dressing would be the last time the dressing was changed. Further interview on 12/29/20 the ADON reviewed the treatment that had been changed on 12/11/20 to be completed daily. Stated the order as written was confusing. The MWF was not deleted and remained in bold print, and was followed in small print to complete every day. Confirmed treatment was not completed as ordered 12/11/20-12/18/20. During an interview on 1/4/20 at 10:50 a.m., the Administrator confirmed that treatment had not been completed daily as ordered on [DATE]-12/18/20. Stated the order was confusing, and could find no documentation of triple check of new orders as expected. On 12/30/20 at 2:00 p.m. the State Agency informed the facility of the Immediate Jeopardy. The facility removed the Immediate Jeopardy on 12/30/20 reviewing all wound orders for accuracy, reviewing all care plans for residents with wounds for accuracy, educating nursing staff on the proper procedure for completion of treatments for physician's orders [REDACTED]. [REDACTED]. At the time of the exit the scope and severity was lowered from a J to D as we need to see if the facily is implementing proper procedure for treatments.

Based on observation, record review, policy review and resident and staff interviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 3 sampled (Resident #3). The facility failed to properly transcribe an order for [REDACTED]. Findings Include: 1. Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had [DIAGNOSES REDACTED]. Resident #3 scored 15 on the Brief Interview for Mental Status (BIMS). A score of 15 identified intact cognition. The MDS further documented the resident received insulin injections. The Care Plan identified Resident #3 had Type 2 Diabetes Mellitus with [MEDICAL CONDITION] and retinopathy and directed the staff to complete accu-checks and administer insulin as ordered by the Physician, and monitor/document/report as needed signs and symptoms of [DIAGNOSES REDACTED] (sweating, tremor, increased heart rate ([MEDICAL CONDITION], pallor, nervousness, confusion, slurred speech, lack of coordination, and staggering gait). Review of the December 2020 Medication Administration Record [REDACTED] a. An order dated 12/7/20 at 4:30 p.m., to administer [MEDICATION NAME] 100 unit/ml inject 10 units subcutaneously before meals every Monday, Wednesday, Friday and Sunday for Type 2 Diabetes Mellitus. b. An order dated 12/8/20 at 4:00 a.m., to administer [MEDICATION NAME] 100 unit/ml Inject 10 units subcutaneously before meals every Tuesday, Thursday, Saturday, and Sunday for Type 2 Diabetes Mellitus. c. On 12/13/20 at 4:14 a.m., Staff D (Registered Nurse) administered 10 units of [MEDICATION NAME]subcutaneously to the right lower quadrant of Resident #3's abdomen. d. On 12/13/20 at 4:51 a.m., Staff D, administered another 10 units of [MEDICATION NAME]administered subcutaneously to the left lower quadrant of Resident #3's abdomen. An Order Entry sheet dated 12/15/20 revealed on 12/7/20 at 3:50 p.m. Staff C (Assistant Director of Nursing) entered the [MEDICATION NAME] order and entered a dose of 10 units before meals at 4:00 a.m., 12:00 p.m. and 4:30 p.m. on Tuesday, Thursday, Saturday and Sunday and 10 units before meals at 5:30 a.m., 12:30 p.m. and 4:30 p.m. on every Monday, Wednesday, Friday and Sunday. The sheet revealed two 10 unit doses on Sunday. During an interview on 12/6/20 at 1:30 p.m., Staff C (Assistant Director of Nurses) reviewed the above order sheet and admitted she transcribed the order wrong when Resident #3 had the insulin order changed due COVID and a change in [MEDICAL TREATMENT] time on 11/30/20. Staff C entered the order to change the time to 4:00 a.m. on [MEDICAL TREATMENT] days (Tuesday, Thursday and Saturday) and 5:30 a.m. on non-[MEDICAL TREATMENT] days (Monday, Wednesday, Friday and Sunday). Staff C realized now that she had entered Sunday incorrectly which directed staff to administer 10 units of insulin at 4:00 a.m. and 5:30 a.m. on Sundays. Staff C further stated the time change order should have been double and triple checked for accuracy, however she could not provide documentation that this had occurred. Staff C explained the process after an order is received is a triple check form is attached and the next nurse should double check the order for accuracy and place in her box for the triple check. Since she had initiated the order, another nurse would need to complete the triple check, however it should have been returned to her box, but it had not. During an interview on 12/16/20 at 9:35 a.m., Staff D (Agency Registered Nurse) confirmed she worked the overnight shift from 6:00 p.m. on 12/12/20 (Saturday) to 6:00 a.m. on 12/13/20 (Sunday) morning. Staff D never worked at the facility prior to this. Staff D confirmed she administered Resident #3's insulin at 4:00 a.m. and again at 5:30 a.m. Resident #3 informed Staff D that he normally hadn't receive insulin at that time, so she double checked the MAR prior to administering. She was aware that he was a [MEDICAL TREATMENT] patient, but not familiar with his care needs. Stated she gave the resident the 4:00 a.m. injection, then returned to room at 5:30 and gave the second ordered injection. Staff D reported Resident #3 alert and she recalled no other interaction with Resident #3. The Progress Notes dated 12/13/20 revealed the following: a. At 8:30 a.m., Staff A (Licensed Practical Nurse) documented Resident #3 had a blood glucose level of 34, lethargic, diaphoretic, and unable to arouse. The staff rubbed sugar on Resident #3's gums. b. At 8:35 a.m., Staff A administered a [MEDICATION NAME] injection. c. At 9:00 a.m., Staff A Resident #3 still lethargic and not responding and had a blood glucose level of 57. d. At 9:45 a.m., Staff E (Registered Nurse asked to assist, blood glucose level 69, lethargic and difficult to arouse. Aroused with vigorous tactile stimuli and loud verbalization of his name, and confused when normally oriented. Resident #3 tachypneic (rapid respirations) at 28 breaths per minute. Oxygen saturation 73% on room air. Placed on 2 liters of oxygen per nasal cannula. Staff called 911, Medics arrived quickly and report given. e. At 3:00 p.m. Staff F (Registered Nurse) talked to the nurse and physician at the hospital and learned Resident #3 admitted for a collapsed left lung with mucus plug, determined an acute event. According to a Medication Error Report sheet dated 12/13/20 revealed Resident #3 received [MEDICATION NAME] 10 units at 4:00 a.m. and 5:30 a.m. Resident #3 had an outcome of dropped blood glucose level. The staff provided an intervention of juice and [MEDICATION NAME] to raise the blood glucose level. The sheet included a summary of the error and documented the type of error as duplicate order and the reason for the error as transcription error. Review of a History and Physical dated 12/13/20 revealed Resident #3 presented to the Emergency Department with altered mental status after receiving a double dose of insulin. Resident #3 had a blood glucose level of 34 and received [MEDICATION NAME]. He had an oxygen saturation in the mid-70s on room air upon arrival. Assessment included hypoglycemic episode due to double insulin dosing. On 12/21/20 at 1:30 p.m. the Administrator provided a blank form titled Triple Check. The Administrator explained the staff complete the form with all new orders. The form directs first check to be completed by the receiving nurse, the second and third check are to be completed by the charge or shift nurse. The Administrator confirmed the facility was unable to find a completed triple check form for the insulin order entered on 12/7/20. The Administrator stated an expectation of staff to complete the triple check from for all new orders. During an interview on 12/15/20 at 12:40 p.m., Staff A (Licensed Practical Nurse) stated she entered Resident #3's room to deliver room tray and take vital signs and was unable to wake Resident #3 up. Resident #3 had a blood glucose level of 34. Staff A placed sugar on a toothette and placed it inside Resident #3's cheek. Staff A sent another staff to obtain the Emergency Kit for [MEDICATION NAME]. She had another emergency so asked Staff E (Registered Nurse) to assist. Staff A confirmed that she had knowledge of the triple check system to assure orders are correct. During an interview on 12/16/20 at 1:00 p.m., Staff E (Registered Nurse) stated at 9:30 a.m., Staff A (Licensed Practical Nurse asked for assistance with Resident #3. Staff A informed Resident #3 had a low blood glucose level that wasn't raising. Staff E obtained a blood glucose level of 69. Resident #3 had an altered mental status, required vigorous tactile stimulation, confused and usually made own decisions, and had audible congestion. Staff E reported Resident #3 critically ill, a full code, and needed to be transferred out. Staff E called 911 and Medics arrived quickly. Staff E had knowledge of the triple check system for new orders. Staff E reported the facility did not require a double check prior to administering insulin. On 12/17/20 at 4:40 p.m. the State Agency informed the facility of the Immediate Jeopardy. The facility removed the Immediate Jeopardy on 12/17/20 by educating staff on the procedure for transcribing physician's orders [REDACTED]. After the corrective actions the scope and severity lowered from J to D.

The following deficiency relates to complaint # . Based on record review and staff interviews, the facility failed to provide necessary treatment and services consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 1 of 18 sampled (Resident #8). The facility reported a census of 97. Findings include: According to the Minimum Data Set (MDS) assessments dated of 2/14/19 Resident #8 had [DIAGNOSES REDACTED]. Resident #8 had severe cognitive impairments. The MDS dated [DATE] revealed Resident #8 required extensive assistance with mobility, transfers, dressing, toilet use and personal hygiene needs. Resident #8 had frequent incontinence of bowel and had a catheter. The CNA (Nurse Aide) Pocket Care Plan revealed no interventions for Resident #8. The Physical Therapy Treatment Encounter notes dated 2/19/19 revealed the Physical Therapy Assistant observed a blister on Resident #8's right heel and informed the nursing staff. The notes revealed the nursing staff unaware of the blister and stated they would provide heel float/booties for Resident #8. During an interview on 3/13/19 at 2:00 p.m., Staff W (Physical Therapy Assistant) stated in mid-February she discovered a blister on Resident #8's right heel. Staff W stated she reported this to an unknown nurse and documented it in her notes. During an interview on 3/14/19 at 10:30 a.m., Staff X (Certified Nurse Aide) stated she discovered a sore on Resident #8's bottom on 2/24/19 and reported it to the nurse. She noticed on 2/26/19 the sore had worsened and informed the nurse. On 2/26/19, Staff X also discovered a huge blister on Resident #8's right heel and informed the nurse of this as well. During an interview on 3/13/19 at 4:40 p.m., Staff H (Registered Nurse) stated she first heard about Resident #8's blister from Staff T. Staff H reported they implemented measures to float Resident #8's heels. Staff H stated she did not notify the physician. Staff H remembered informing the overnight staff of the blister. Staff H did not remember if interventions were added to the care plan. During an interview on 3/14/19 at 10:19 a.m., Staff Y (Licensed Practical Nurse) stated on 2/26/19 she was informed by Staff X that Resident #8 had a sore on her bottom and a blister on her right heel. Staff Y stated Staff X stated she had reported the sore on Resident #8's bottom a couple days earlier to Staff T and nothing had been done. Staff Y stated she informed the Director of Nurses and filled out wound assessment reports for both areas, contacted the physician and obtained treatment orders. Staff Y stated she asked Staff T about the skin wounds and Staff T denied knowing anything about them. Staff Y stated she had recently resigned because nurses were not properly taking care of issues professionally, ignored wound care and neglected residents. The Departmental Notes lacked a wound assessment report, physician notification, family notification and care plan interventions for the heel wound and left buttock wound. The Wound Assessment Report dated 2/26/19 revealed Resident #8 had pressure ulcer on the right heel measuring 4 centimeters (cm) (length) by 5.5 cm (width) and a Stage II pressure ulcer on her left buttock that measured 6 cm (length) by 4.7 cm (width) and 0.1 cm (depth). The Telephone Orders dated 2/26/19 revealed the following orders: a. Cleanse the left buttock, apply triad wound gel, cover with [MEDICATION NAME], gentle dressing and change every three days. b. Check the placement of the left buttock dressing every day. c. Paint the left heel blister with [MEDICATION NAME] twice a day until healed. Review of the (MONTH) 2019 Treatment Record sheet revealed an order dated 2/26/19 to complete a weekly skin assessment and document in wound manager. The Wound Assessment Report dated 3/4/19 revealed Resident #8 had an irritation and excoriation from moisture on his coccyx measuring 5 cm (length) by 5 cm (width). The staff notified the physician and no new orders received. The Departmental Notes dated 3/4/19 at 5:22 p.m., revealed Resident 8's Family Member had concerns that Resident #8 had been at the facility for 24 days and now had pressure wounds. The Famility Member reported it appeared Resident #8 was not getting treatments, the aides were not floating her heels and the nurses did not know the treatment for [REDACTED]. The Wound Assessment Report dated 3/7/19 revealed Resident #8 had a blister on left lateral shin measuring 11 cm (length) by 12 cm (width). The staff notified the physician. The Departmental Notes dated 3/7/19 lacked documentation of the left shin blister, family notification and care plan interventions related to wound care During an interview on 3/14/19 at 9:50 a.m. Staff Z (MDS Coordinator) stated on Monday 3/11/19 she noticed the blistering progressed to Resident #8's toes. Staff Z stated she filled out wound assessment reports, notified the physician and obtained treatment orders. Staff Z stated she was not certain who within the facility was currently providing weekly skin assessments. The Wound Assessment Report sheet dated 3/11/19 revealed Resident #8's left lateral shin blister expanded onto Resident #8's foot and toes. The sheet revealed the staff notified the physician and received a new treatment to cleanse left lower leg with wound cleanser, apply Vaseline gauze, wrap with kling; apply triple antibiotic to the left foot blister, cover with 4 x 4's and wrap with kling twice daily and apply [MEDICATION NAME] to left 3rd, 4th and 5th toes twice daily. The Departmental Notes dated 3/12/19 at 1:59 p.m., revealed the areas on Resident #8's legs and feet worsening and contacted the Physician. The Physician ordered an arterial Doppler to both lower extremities to rule out arterial insufficiency. Observations on 3/12/19 at 4:35 p.m. and 3/13/19 at 7:50 a.m. found Resident #8 wearing foam boots and staff floating heels while in bed. However the care plan and pocket care plans do not have use of foam boots or floating of heels as a formal intervention.

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent a resident with impaired decision-making skills from leaving the facility without knowledge or authorization of the staff (elopement) for 1 of 6 residents reviewed (Resident #1). On 9/9/18, Resident #1 left the facility through a door equipped with an alarm. The door alarm sounded, but staff failed to assess the cause of the alarm and determine if all residents remained in the facility. As a result, staff were unaware Resident #1 had wandered outside 400 feet away and not visible door window area, until found by Dietary staff that had reported to work. This constituted an Immediate Jeopardy (IJ) to resident health and safety. The facility reported a census of 89 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 9/6/18 revealed the Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS documented the resident scored 9 of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment that showed the resident experienced moderate cognitive impairment and displayed no symptoms of [MEDICAL CONDITION]. The MDS also documented Resident #1 required extensive assist by at least 1 staff for transfers to and from the bed, ambulation (walking), dressing, toilet use, personal hygiene and bathing. The nursing care plan initiated 8/9/18 identified problems and included interventions: 1. Required assistance with activities of daily living (ADLs) due to weakness and some confusion. The care plan directed staff to setup, cue and provide 1 staff assist as needed with dressing, hygiene and bathing. 2. At risk for falls related to confusion, oxygen tubing (trip hazard), history of hallucination, weakness, and decreased mobility. The care plan directed staff to ensure the resident ambulated with walker, keep environment free of clutter, transfer with assist of 1 person, and utilize wheel chair for longer distance mobility. An elopement risk assessment completed on 8/10/18 revealed the resident did not have a history of wandering or attempts to open doors or windows (exit seeking behavior), did not express anger related to nursing home placement, and did not have a history of elopement from home or facility. The facility's undated Missing Resident/Elopement Policy & Procedure directed staff: 1. Prevent a resident's departure from the facility if possible. 2. If a resident exited the building, or staff identified a resident was missing, staff to enlist assistance from nearby staff, inform the charge nurse, and make a thorough search of the building and premises. If unable to locate resident, notify the administrator, Director of Nursing (DON), the resident's guardian, physician, and law enforcement; provide a picture of the resident to law enforcement upon arrival. 3. Upon return of the resident, examine for injuries, notify physician of findings, complete an incident report, and document event in the nursing notes. Include time of the event, persons notified, condition of resident upon return to the facility, physician notification and orders, treatment if indicated, and any other pertinent information. 4. Maintenance personnel responsible to ensure the door alarms remain operational for 24 hour service and checked on a routine basis. Documentation completed by the certified nursing assistants (CNAs) revealed: 9/9/18 at 11:28 a.m., Staff S, CNA, recorded the resident required 1 person assist for transfers and bed mobility, and limited assistance for ambulation in room. 9/9/18 at 2:45 p.m., Staff T, CNA, recorded the resident used the toilet and completed their own personal hygiene independently. The facility reported incident described Resident #1 exited a west door at approximately 3:00 p.m. on 9/9/18. The door alarm sounded and staff looked out the window but did not go outside to check the reason for the alarm. The facility reported a dietary employee found the resident outside at approximately 3:05 p.m. The resident was returned to the building without injury ,and staff applied a Wanderguard transponder device to the resident's person. The facility reported they then re-educated all staff regarding door alarms and elopement procedures. According to https://weather.com/weather/monthly/l/ :4:US, the outside temperature at the time was approximately 76 degrees. The staff assignment sheet for the 2 p.m. to 10 p.m. shift on 9/9/18 revealed Staff T originally assigned to the resident's hall, then changed to the C hall. The sheet further revealed Staff U, CNA, originally assigned to the A hall, then changed to Resident #1's hall. Observation during a walk with the DON on 10/23/18 at 9:55 a.m., from the west exit door to the dumpsters in the parking lot, revealed the resident had been found at least 400 feet away and not visible from the window by the door. According to Google Maps https://www.google.com/maps/place/Altoona+Nursing+%26+Rehabilitation+Center/@41XXX 96,-93XXX 47,861m/data=!3m1!1e3!4m5!3m4!1s0x0:0x9ee4ca3e91ff4967!8m2!3d41XXX 59!4d-93XXX 3, behind the back yard of the facility bordered a wooded area with dry creek beds that abut a 2 acre lake. Review of Mccracken,(NAME)and the Staff at Recreational Guides. Des Moines and Polk County Fishing and Floating Guide Book: A Complete fishing and floating information for Polk County, Iowa. Ed. Recreational Guides, (MONTH) 25, (YEAR). Page 6, ebook., the lake contains 3 types of fish with no depth given. A residential road bordered the front and side yard of the facility with a speed limit of at least 25 miles per hour. Staff interviews revealed: 10/18/18 at 2:32 p.m., Staff U, CNA stated on 9/9/18, Staff V, CNA, announced over the intercom to check and clear the west hall door. Resident #1 was initially assigned to Staff T, then assigned to her sometime after the shift started. Staff U reported she was in the Break Room on a 15 minute break sometime between 3:30 p.m. and 4:00 p.m., and left the break room to check to door. She stated no alarm sounded when she checked it, the alarm was reset at the panel at the nurse's station, she looked out through the window by the door and didn't see anyone. Staff U reported she thought someone had not punched in the code and then opened the door. A kitchen employee came in and said they found the resident outside by the dumpster's, so a Wanderguard was applied to the resident and she monitored the resident closely after that. Staff U also reported the resident continued to go to the west door several times and to the front door that evening, but didn't get anywhere do to the Wanderguard alarm. 10/22/18 at 3:20 p.m., Staff T, CNA, stated he did not recall that Resident #1 was assigned to him on 9/9/18, but he remembered a resident got outside and staff got in trouble because they didn't go outside to check the door alarm. Staff T reported if a door sounded, staff had to go outside to check, and if they couldn't determine the cause for the alarm they went from room to room to account for all residents. Staff T stated he learned this in orientation at this facility and every other facility he worked at. 10/23/18 at 4:16 p.m., Staff V, CNA, stated he worked the 2 to 10 shift on 9/9/18 and was assigned to the B hall. Staff V reported he did not hear a door alarm that day and denied he had paged overhead to clear the alarm. Staff V stated other CNAs had called in that day, so Staff T was assigned to Resident #1's hall and had passed ice water when they determined they had to revise assignments due to the call-ins. At that time he then was assigned to the C hall and Staff U assigned to the resident's hall. Staff V remembered that Staff X, dietary aide, walked in with Resident #1 around 3:15 p.m.; the resident had her walker but didn't have oxygen applied. Staff V assisted the resident to a wheel chair and transported her to the front nurse's station. Staff V stated he learned in orientation at the facility that staff had to check outside when a door alarm sounded. 10/22/18 at 2:36 p.m., Staff X, dietary aide (DA), stated when she pulled into the parking lot to work on 9/9/18 at approximately 2:45 p.m., she saw Resident #1 by the dumpsters as she headed away from the building. Staff X reported the resident was dressed with shoes on, and said she was going home She was able to convince the resident and assisted her to return to the building to tell the nurse, Staff Y, she found the resident outside. 10/22/18 at 4:00 p.m., Staff Y, RN, stated on 9/9/18, she was in a resident's room when Staff X was in the hall with Resident #1, and said she found her outside and directed her to get her nurse, Staff Z. Staff Y reported she instructed Staff Z, an agency nurse, to assess the resident and call the manager on duty to report it. 10/23/18 at 8:42 a.m., Staff Z, staffing agency RN, stated she worked on 9/9/18 was told by 1 of the nurses that 1 of her residents was missing. Staff Z reported the resident was in the hall with Staff V who said the resident was just brought in and the resident said she was going home. Staff Z reported she assessed the resident and there were no injuries, she applied a Wanderguard and called the Director of Nursing and the manager on call. Staff Z stated if a door alarm sounded, they were to check the board to identify what door, check and clear the alarm, and if they can't clear the alarm then staff does a head count. She stated she had she has had to do that a different day that she had worked at the facility. 10/23/18 at 7:44 a.m., the Administrator and DON stated maintenance checked all door alarms weekly, the alarms were checked on 9/7/18 then again on 9/10/18 due to the elopement, and staff check Wanderguard alarms daily. They reported staff required to go outside to check and clear door alarms as they were instructed during orientation. 10/24/18 at 8:10 a.m., The DON stated the resident was weak and required physical therapy when admitted to the facility, got stronger with therapy, and that enabled her independent departure. The DON reported staff last saw Resident #1 at 2:45 p.m. on 9/9/18 when Staff T took her to the bathroom. The facility abated the Immediate Jeopardy on 9/10/18 by implementing the following actions: 1. The facility reassessed all residents for potential elopement risk. 2. The facility updated the Elopement Book to contain the most current Elopement Policy, pictures of each resident identified as at risk for elopement, and demographic information related to said resident. 3. The Director and Assistant Director of Nursing re-educated staff regarding the Elopement Policy prior to working with residents again. 4. The facility contracted with a vendor to retrofit and rewire the exit door with a key pad which required a code rather than a button to push to clear the alarm. 5. The facility audited wanderguards and ensured function tests recorded as completed (to be done daily going forward). 6. The facility completed door alarm checks (to be completed weekly thereafter) 7. The facility increased Elopement Drills to monthly on each shift for the next three months and/or until compliance achieved. 8. The facility reviewed all care plans for all residents deemed to be at risk for elopement based on elopement assessments to ensure interventions documented to protect each resident and ensure interventions in place to protect each resident and ensure resident safety.

Based on record review and staff interviews, the facility failed to provide adequate supervision to prevent accidents for one of five residents reviewed (Resident #1). The facility reported a census of 98 residents. Findings include: According to the (Minimum Data Set) assessment tool dated 11/3/16, Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident had disorganized thinking that fluctuated and displayed moderately impaired cognitive skills. The MDS noted Resident #1 required extensive assistance for all ADLs (activities of daily living), had an impaired lower extremity, and could only balance with the assistance of staff. The Care Plan dated 10/16/16 documented Resident #1 as at risk for falls related to impaired mobility. The Care Plan instructed staff to maintain a safe environment, and indicated that Resident #1 required the assistance of staff to transfer. The Care Plan also noted the resident sustained [REDACTED]. According to the Fall Risk (MDS) data set [DATE], a score between 7 and 18 was considered as at high risk for falls. The form assigned Resident #1 a score of 11 (high risk). The Resident Incident Report dated 6/20/16 at 7:10 p.m. documented staff found Resident #1 on the floor next to a planter in the front lobby. The resident said he/she was cold and trying to go somewhere warmer. A visitor stated the resident pushed a straight chair to the location where he she fell , and staff noticed the resident's walker and wheelchair across the room from where the resident fell . The resident complained of his/her foot hurting and staff did find an area on the foot that was slightly reddened. The Departmental Notes dated 11/7/17 at 2:14 p.m. documented a CNA called staff to the resident's room where the resident sat on the floor next to the bed. The resident told staff he/she was trying to get his/her glasses and slipped off the bed. Staff found the glasses on the nightstand. The resident reported knee pain, which was normal for the resident. The Resident Incident Report dated 11/17/16 at 7:55 p.m. documented Resident #1 sustained a fracture after falling. According to the report, staff heard the resident call for help. When they entered the resident's room, staff found the resident on the floor next to the bed. The resident had transferred themselves from the toilet and fell after the bedside table with which the resident tried to balance him/herself rolled away. The BioTech X-ray report dated 11/17/16 at 9:26 p.m. revealed the physician ordered an X-ray because Resident #1 experienced pain and was unable to bear weight after a fall. The x-ray determined the resident sustained [REDACTED]. An Individual Education Form dated 12/8/16 documented Staff A, CNA (certified nursing assistant), received education related to the 11/17/16 fracture Resident #1 sustained during a fall after Staff A left the resident on the toilet unattended. The education reminded Staff A to remain with residents that are deemed fall risks while taking them to the toilet. During an interview on 12/7/16 at 9:30 a.m., Staff C, CNA revealed she worked 6:00 a.m. to 8:00 p.m. the day Resident #1 sustained the hip fracture. She stated she saw the resident's family member and asked why he/she seemed upset. The family member told Staff C Resident #1 fell and the physician ordered an X-ray. According to the CNA, the resident had been his/her usual self (confused) that day. The CNA stated she always stayed in the room whenever she took Resident #1 to the toilet because she believed the resident would attempt to get up if he/she had the opportunity. An interview on 12/7/16 at noon with Staff B, LPN (licensed practical nurse), revealed she had worked at the facility since March 2015. According to the nurse, Resident #1 had a history of [REDACTED]. Staff B stated when she started her shift at 6:00 p.m., Resident #1 acted as confused as he/she always did. Staff B said she had been in the hall passing medications when she heard a cry for help. Staff B said she followed Staff A into the room and saw the resident lying on the floor next to the bed. According to Staff B, Staff A left Resident #1 alone in the bath room. She stated the resident self-transferred from the toilet, walked to the bedside table and fell as it rolled away from her. Staff B said she would not have left Resident #1 in the bathroom alone. The nurse stated the resident had not been able to bear weight when they he/she was assisted to stand. An interview on 12/7/16 at 1:45 p.m. with Staff A, CNA revealed she had worked at the facility for 6 years and cared for Resident #1 almost every time she worked. According to the CNA, Resident #1 was acting tired and confused per his/her norm. The CNA said she assisted the resident to the toilet around 8:00 p.m. Staff A reported she always stayed with the resident when he/she was on the toilet because he/she sometimes stood up due to being confused. The CNA said she didn't know what she was thinking, but the resident was so tired .she thought Resident #1 was ok for the moment, as she noticed another resident with a history of falls and confusion walking alone in the hallway. Staff A said that Resident #1 had a history of [REDACTED]. The CNA said there had not been anybody else around that could assist one of the two residents and thought the ambulatory resident needed the most immediate attention. The CNA said they frequently work short staffed on the evening shift, and believed that contributed to the fall. An interview on 12/7/16 at 2:45 p.m. with Staff E, CNA, revealed she had worked at the facility since last February. According to the CNA, she could not get all of her work done because the facility did not have enough staff. During an interview on 12/8/16 at 10:35, the DON stated she would always expect staff to follow the care plan and stay with residents while taking them to the toilet.

Based on observations, record review, and staff and physician interviews, the facility failed to follow the physician's order for a diet with thickened liquids for Resident # 31. The sample consisted of 7 residents that required therapeutic diets. The facility identified a census of 90 residents. Findings include: 1. Resident #31 had a 5 day Minimum Data Set assessment with a reference date of 05/24/2016. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 identified the resident had no cognitive impairments. Resident # 31 required the extensive assistance of at least 1 staff person for bed mobility, transfers, dressing, toilet use, and personal hygiene. One staff person assisted with meals even though the resident demonstrated a high involvement with eating. The health conditions for shortness of breath remained unchecked, as did the prognosis for life expectancy of less than 6 months. The MDS documentation identified a mechanically altered soft diet for Resident # 31 but any swallowing disorder or oral/dental problems remained unchecked. [DIAGNOSES REDACTED]. vomit. The Care Plan, with a problem onset date of 04/26/2016 and updated 05/17/2016 upon return to the facility after a hospitalization , identified Resident # 31 as an assist of 1 with a wheel chair as needed and skilled services for Physical Therapy, Occupational Therapy, and Speech Therapy. The resident ' s code status was Do Not Resuscitate (DNR). The Care Plan identified an alteration in nutrition related to hypoxic [MEDICAL CONDITION] with dysphagia (difficulty eating), [MEDICAL CONDITIONS](acid reflux into the esophagus), and Parkinson ' s disease. A swallow study dated 04/28/2016 determined a requirement for thickened liquids long term and a mechanically soft diet. The Care Plan directed staff to ensure Resident # 31 remained in a 90 degree seated position to promote adequate swallowing patterns during meals and to remain upright for at least 30 minutes after meals with any chewing or swallowing difficulty reported promptly. 05/23/2016, the Strict Frasier protocol was added to the plan of care. This required staff to make sure Resident # 31's teeth were brushed after each meal, remained upright, and did not drink any water for at least 30 minutes after meals. When water was ingested, the resident should be seated in a 90 degree position with honey thick liquids. 04/22/2016, a swallow evaluation showed poor clearance and mild pooling after swallowing of thickened liquids which cleared with a second swallow. Trying to advance regular food caused definite difficulties propelling a bolus of food into the esophagus. Several swallows finally cleared the airway. The final conclusion resulted in restricting Resident # 31 to honey thickened liquids and pureed food. On 05/06/2016, nursing staff noted a change in the resident's mentation and dark urine in the indwelling urinary catheter bag. A previously ordered urine laboratory test returned with profuse bacteria. The Physician gave an order for [REDACTED]. Upon readmission to the facility on [DATE], the Physician wrote orders for a skilled level of care, and a mechanically soft diet with honey thickened liquids for Resident # 31. On 05/23/2016 an order for [REDACTED]. On 05/21/2016, after an x-ray, which showed left lower lobe infiltrates and a nodule in the left upper lobe, the physician ordered [MEDICATION NAME] (an antibiotic to treat bacteria/pneumonia) 750 milligrams every day for 1 week, [MEDICATION NAME] (aerosol inhalation treatments to open the airways) 4 times a day for 1 week, [MEDICATION NAME] (a steroid) 40 milligrams for 5 days and the 20 milligrams for 5 days, and have the Speech Therapist continue to follow the resident. On 05/23/2016, the physician's documentation on the form Resident Encounter identified the resident ' s respiratory status included efforts to breathe, wheezes, and rib excursion (rib pain). Orders included continued treatment with a current antibiotic ([MEDICATION NAME]) and skilled services with a notation of the resident's continual decline and future discussion with family concerning treatment for [REDACTED]. 05/25/2016 at 2:57 P.M. a follow up visit (Resident Encounter form) identified a lung mass, left lower lobe 11 millimeter nodule, pneumonia aspiration, and altered mental status. A conference would be scheduled with family for the following week. The current orders remained unchanged. The Physician made a notation of Resident # 31's repeated hospitalization s for aspiration pneumonia and identified the resident's present respiratory condition as normal with a wet cough and decreased profusions and rhonchi (harsh rattling). Resident # 31 also demonstrated mental confusion. Speech Therapy received an order to work with Resident # 31 for 5 times a week for 2 weeks upon return from the hospital on [DATE]. Areas to be evaluated and treated included swallowing, cognitive skills, oral functions, and evaluation of speech sound conduction and understanding. The Speech Therapist's note of 05/19/2016 identified Resident # 31's difficulties with aspiration pneumonia and hospitalization s since January 2016. Documentation included the resident's feeding self while seated at a 90 degree angle, utilizing honey thick liquids, and the chin tuck/head turn technique. At that time, the therapist noted a delayed cough even on honey thickened liquids. The plan included caregivers/staff giving the resident cues and close supervision with meals and hydration. The resident could accomplish 50% of the task with cognitive assistance from staff. 05/25/2016, the assessment summary documented by the Speech Therapist noted the resident had a cycle of good days followed by bad days. Task completion by resident remained at 50% and staff 50%. A review of the Department Notes by nursing dated 5/18/16 to 5/20/16 identified the resident had no breathing or oxygen saturation difficulties, and no coughing/swallowing issues. On 05/20/2016 the Dietician's assessment identified the orders for a mechanically soft diet with honey thick liquids and Speech Therapy to follow Resident # 31. The resident experienced no dental issues. Recommendations included encouraging fluid/oral intake and a thickened (non-milk) supplement for additional calories. The Departmental Notes by Nursing dated 5/23/16 at 10:47 p.m. indicated a new order for Free Water Protocol. Strict Frazier water protocol, and 30 minutes after eating, oral cares prior to consumption and must set up at a 90 degree angle. The Departmental Notes by nursing noted Resident # 31 demonstrated no respiratory distress and air saturation levels remained in the 90% levels, but did experience some decreased lung sounds until 05/26/2016. The overnight shift note of 05/26/2016 at 2:20 A.M. documented Resident #31 experienced cloudy dark urine in the catheter bag, a trace of [MEDICAL CONDITION] in the lower extremities, blood pressure of 98/60, confusion, and nausea. The lung saturations on room air remained in the 90%. Previous notes documented the blood pressure usually averaged from 130's over 70's to 110's over 70's. On 05/25/2015, a nursing note at 11:43 A.M. indicated the resident's blood pressure read 97/50. At 10:02 A.M. on 05/26/2016, Staff Nurse A (Licensed Practical Nurse) documented Resident # 31's lung sounds as diminished with oxygen saturation at 81% and administered oxygen at 2 liters, then initiated a call to the physician. At breakfast, the Speech Therapist informed Staff A the resident drank thin liquids and had lung crackles. The nursing note identified the resident's lungs as sounding very full. Staff A received orders from the physician for [MEDICATION NAME] (a diuretic to flush water build up from the body) 40 milligrams intramuscularly (IM), Potassium 20 micrograms now, titrate the oxygen to keep saturation levels above 90%, and suction. [MEDICATION NAME] 20 milligrams and Potassium 10 micrograms would be given for the next 7 days. The resident received the IM [MEDICATION NAME] 40 milligram prior to hospitalization but was unable to take the oral potassium. After conferring with the resident's family on the telephone, Staff A documented Resident # 31 struggled to breathe, the lips turned blue, and the resident's eyes rolled back. Staff A called 911 and obtained orders to send the resident to the emergency room . The Speech Therapist continued to stay with the resident. The emergency room Physician's note of 05/26/2016 at 11:01 A.M. noted due to the resident's critical condition a complete history and physical could not be obtained. The resident's mental status documented as alert. Vitals: temperature 96.6, pulse 71, respiratory rate 18 per minute, blood pressure 115/51. The oxygen saturation on 10 liters with oxygen mask: 100% The respiratory sounds consisted of bilateral rhonchi, labored and the x-rays identified the following: 1st chest x-ray (portable) 05/26/2016 at 10:58 A.M. showed underlying lung disease, development of focal air space disease (mass) in lower left lobe of lung, old rib fractures, enlarged heart, and clinical correlation request for pneumonia. A physician's note dated 05/29/2016 documented Resident # 31 had an admission [DIAGNOSES REDACTED]. The resident was intubated (tube placed in lungs to facilitate breathing). On 05/30/2016, a Clinical Swallow Evaluation concluded Resident # 31 presented with moderate to severe oral pharyngeal dysphagia and functional bolus manipulation for liquids, pureed or soft foods. Coughing followed drinks with honey liquids. Recommendations included a dysphagia mechanically altered diet with honey thickened liquids, and no straws. Bites and sips should be small with extra time to swallow and a 90 degree upright position. The results of a chest x-ray performed at the hospital on [DATE] showed small pleural effusions (inflammation of the lungs), atelectasis (partial collapse of the lung), and infiltrates (abnormal substance or darkness in the lung). No change from the chest x-ray completed on 05/31/2016. Interviews conducted as follows: On 06/08/2016 at 9:30 A.M., Staff A (Licensed Practical Nurse) was interviewed and stated on 05/26/2016 was the first day Resident # 31 ate in the main dining room. Previously, the resident ate in the assisted dining room. Staff A performed an assessment in the resident's room prior to going to the dining room and described the lungs as sounding wet with no cough or crackles and oxygen saturations in the 80% range. Staff A placed a call into the physician. In the main dining room while passing pills, Staff A recalled Resident # 31 looking around and did not have any fluids or food at that time. Around 9:00 A.M. the ARNP (Advanced Registered Nurse Practitioner) returned the nurse's call. Staff A took the call in the nursing medication room down the A hall from the main dining room. While Staff A received orders from the ARNP, the Speech Therapist came to the medication room and excitedly told the nurse Resident # 31 needed to be checked due to possibly ingesting thin liquids. Staff A obtained orders for oxygen and placed on the resident. Staff A stated she could audibly hear crackles but no cough. The nurse had no recall of food or fluids on the table at that time. Staff A returned to the medication room to obtain further orders for the resident's condition from the ARNP when the Speech Therapist again presented herself at the medication room door and requested suction orders. Staff A gave [MEDICATION NAME] 40 milligrams IM, but could not get the resident to take an oral potassium ordered. The Speech Therapist took Resident # 31 to his/her room in a wheel chair. The Speech Therapist suctioned Resident #31 prior to any nursing staff coming to the resident's room. Staff A described the liquid in a cup as 10 to 20 centimeters (1/3 to 2/3 of an ounce) of clear phlegm. Staff A clarified the clear phlegm was in a cup with nothing in the suction canister. Resident #31 had no cough, but audible wheezes on 3 liters of oxygen and saturations in the 90%. Staff A obtained an order to send the resident to the hospital. On 06/08/2016 at 10:05 A.M., the Speech Therapist was interviewed and verbalized being aware Resident # 31 would be in the main dining room that morning, but could not recall who informed her of the change. The resident still required skilled services for diet at that time. Upon entering the dining room and viewing the resident, the breakfast meal was on the table, but nothing eaten. She could not recall what the meal consisted of. The liquids in front of the resident consisted of 1/2 cup of water and 1/2 cup of cranberry juice without any thicket which she immediately removed. She verbalized not observing the resident drink any of the liquid. The Speech Therapist remembered hearing wet crackles and a cough and observed the resident demonstrated shortness of breath and immediately ran to the medication room on hall A where she found Staff A and informed her of the resident's condition. Upon returning to the resident, she noted the wet crackles, cough, and shortness of breath continued. The Speech Therapist made a second trip to the medication room to tell the nurse to order suction. The Speech Therapist wheeled Resident # 31 to his/her room and picked up the suction on the way. After trying the [MEDICATION NAME] procedure which was not successful, she did 3 throat clears (described as up and down the throat 3 times) into a Dixie cup and estimated the cup to be 1/2 filled with a red tinged clear liquid. The Speech Therapist verbalized the red tinge might have been cranberry juice. She described the resident as complaining of being hot and asking for his/her mother and still having audible upper airway crackles. The Speech Therapist stated the facility never allowed her to participate in the decision-making as to which dining room a resident would eat in. The Dietary Manager or nursing usually told her where to find the resident during meals. On 06/08/2016 at 4:00 P.M. Staff B (Dietary Aide) was interviewed and stated part of her job consisted of placing pitchers of water and coffee on the tables. On 05/26/2016 Staff B passed the juice cart around to the tables in the main dining area. She recalled asking Resident # 31 what he/she would like and giving him/her a 1/2 glass of regular water and 1/2 glass of regular cranberry juice. At that time, no dietary cards were available until the meal came out because the cook used the cards. She verbalized Resident # 31 did not have a meal on the table when she served the fluids. Once she completed serving the juice cart, she left the dining room and did not know what had happened until the Dietary Manager told her. According to Staff B, at the time of serving Resident # 31 the water and juice, the meal had not been served. On 06/8/9/16 at 4:45 p.m. the Dietary Manager was interviewed and stated the facility used pre-thickened products already reconstituted prior to delivery to the facility for all residents. On 05/26/2016, he verbalized not being in the main dining room until after the incident with Resident # 31. He verbalized the process for deciding which dining room a resident would dine in has always been his with input from the restorative aide, a nurse or maybe some of the aides. On 6/13/16 at 11:00 A.M., the Dietary Manager was interviewed and he did not recall asking for nursing's input into the placement of Resident # 31 but did talk to the restorative aide. The Dietary Manager recalled placing other residents who required thickened liquids in the main dining room without having any issues. An interview on 06/09/2016 at 9:05 A.M. with Staff C (Restorative Aide, RA) revealed she was present in the main dining room on 05/26/2016 for breakfast and passed Resident #31's food tray. She verified the diet as correct (Mechanical Soft). Staff C verbalized the resident's table held no drinks and pitchers on it when she delivered the tray. She observed the Speech Therapist and the Dietary Aide in the dining room. Ten to 15 minutes later, the Speech Therapist wheeled Resident # 31 out of the room and the R.A. walked over to the resident's table. A red drink and water sat on the table. She observed the drinks to be thickened. During an interview on 06/08/2016 at 3:40 P.M., the Assistant Director of Nursing (ADON) voiced Resident # 31 already had pneumonia prior to the incident of 05/26/2016. Staff A reported the resident's condition prior to breakfast. The resident ' s oxygen saturation tested low and nursing started oxygen on the resident and placed a call to the physician. At 9:18 A.M. The ADON observed Resident # 31 had thickened liquids and a meal on the table but no regular fluids. The meal had not been touched. Before the resident left the dining room, the nurse gave [MEDICATION NAME] 40 milligrams IM for the crackles in the lungs. On 6/08/2016 at 10:40 A.M., the Advanced Registered Nurse Practitioner (ARNP) was interviewed and stated she assisted with the treatment of [REDACTED]. Review of the resident's past history included many hospitalization s for aspiration pneumonia. The ARNP stated after the resident was hospitalized with aspiration pneumonia (05/06/2016), the resident showed some improvement and then another decline. The ARNP stated she did not believe the episode on 05/26/2016 when the resident possibly ingested some thin liquids impacted his/her overall condition. On 05/27/2016, the attending physician was interviewed and identified the resident as a frail weak resident who would continue to decline and cited the swallow study of 04/22/2016 which showed signs of penetration and pooling of liquids even if honey thickened. On 06/09/2016, in an interview, the physician verbalized he felt the resident would be incapable of feeding himself/herself due to extreme weakness and was not aware the resident did feed himself/herself. The physician stated the initial portable x-ray on 05/26/2016 showed no infiltrates and the pneumonia was resolving. According to the physician, the suctioning results completed at the facility before the resident was hospitalized were not critical to the resident's outcome. The facility instituted the following procedure and in-serviced staff on 05/26/2016 at 2:20 P.M: From this date on, all residents on thickened liquids will eat in the Crystal (assisted dining room) and will always be monitored. On 05/27/2016 the Dietary Staff Thickened Liquids Protocol directed the staff to do the following: 1. A roster of residents on thickened liquid diets will be communicated to dietary as part of a daily pre-service meeting conducted by the on-site manager. 2. Dietary will label thickened liquids for both meals and snacks. Labels are to include the resident's name and liquid consistency and will be attached to a cup. 3. Dietary staff will identify the resident with either a nurse or CNA prior to serving a thickened beverage. Note: Prior to the investigation, the facility provided in-service education to all staff and abated the immediate jeopardy on 5/27/16 (prior to investigation). The in-service education consisted of the following: · On 5/26/16 the Administrator conducted an inservice for all staff related to thickened liquids. On 5/27/16 at the daily QA (Quality Assurance) meeting the team reviewed and signed off on the Dietary Staff Thickened Liquids Protocol that had been implemented that morning as noted above. · On 5/27/16, the dietician conducted an educational meeting with the dietary staff related to the new protocol, Frazer Free Water and dyshagia (difficulty swollowing) in general. A document was created for the new hire packet to be used for educational purposes.

Based on observation, resident interviews and record review, the facility failed to promote care for four (4) of sixteen (16) residents in a manner that maintained their residents' dignity (Residents #12, #11, #16 and Resident #1). The facility reported a census of ninety two (92) residents. Findings include: 1. Record review of Resident #12's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had been cognitively capable of making daily decision independently. The MDS documented the resident had [DIAGNOSES REDACTED]. The MDS documented that the resident required extensive assist of one staff member for transfers, toileting, and personal hygiene. The automated head set Activities of Daily Living Plan of Care dated 4/7/16 documented Resident # 12 required ostomy care and to notify the nurse when care is required for the [MEDICAL CONDITION] bag. During an interview on 5/3/16 at 7:20am and 5/4/16 at 8:30am, the Resident #12 had reported issues with call lights not being answered in a timely manner. The resident's bedside table included a large print digital clock. Resident #12 stated call lights had taken up to an hour and half to be answered. The resident stated the call light had been activated because the Resident's [MEDICAL CONDITION] bag had been full, broke open and stool covered the him/her and the surrounding area. (A [MEDICAL CONDITION] bag is outside of a person's body and collects moving stool through the intestine drain through the stoma.) Resident #12 indicated the call light had been on for an hour and a half. Resident #12 indicated he/she became upset when the call light had been answered and showed staff what had happened. The resident indicated stool had been all over the resident's clothes, body, and recliner cover sheet. Resident #12 stated he/she had difficulty standing up and had to do so at that time to wash up, change clothes, and change recliner cover sheet. Resident #12 stated since this incident, he/she completes his/her own ostomy cares. 2. The MDS assessment dated [DATE], documented Resident #11 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating cognitive level intact. The MDS assessment documented the resident totally independent for ambulation, dressing, toileting, and personal hygiene. During interview on 5/4/16, at 2:00 p.m., Resident #11 stated staff had not knocked on door of room before entered room. The resident reported it had bothered him/her when dressing or doing other personal cares, and staff walked in. The resident stated when he/she sat on the toilet, staff had barged into the bathroom without knocking first, and dumped water in the sink. The resident stated when he/she lived at home, he/she never had people barge in on him/her, and didn't think staff should barge in when he/she in the bathroom, unless he/she asked and needed assistance. While this surveyor talked to Resident #11, a staff member opened the door to the resident's room and walked into the room without knocking or getting acknowledgement from the resident to enter his/her room. When the staff member realized surveyor and resident were talking, the staff member turned around and left the resident's room. 3. The MDS assessment dated [DATE], documented Resident #16 had [DIAGNOSES REDACTED]. The MDS assessment documented the BIMS score of 15 out of 15, which indicated the resident's cognitive level intact. The MDS assessment documented the resident required extensive assistance of two persons for transfers, toileting, and personal hygiene. The MDS indicated the resident had unsteady balance and required staff assistance when moved on or off the toilet. The MDS documented the resident received a diuretic (a medication to remove fluid). The care plan dated 2/29/16, revealed the resident had a self care deficit and had occasional bladder and bowel incontinence. The care plan directed staff to: a. Provide assist of one staff for dressing, hygiene, and bathing b. Use an EZ stand and two staff when transferred and toileted the resident c. Provide incontinence care and apply a barrier cream as needed. During an interview 5/5/16, at 7:45 a.m., Resident #16 reported he/she had waited an hour and a half before staff responded to his/her call light. The resident stated staff assistance required when he/she had to go to the bathroom. The resident reported he/she had waited 90 minutes for staff assistance several times, and he/she had a BM (bowel movement) in pants while waited for staff assistance. The resident reported he/she didn't like it when had BM in pants. Resident #16 reported he/she is [AGE] years old and that shouldn't happen. The resident attributed a shortage of staff to care for all the residents that needed care. The resident had a wall clock and wore a wrist watch to monitor the amount of time it took for staff to respond to the call light. 4. The Annual Minimum Data Set ((MDS) dated [DATE] documented that Resident#1 had [DIAGNOSES REDACTED]. The MDS revealed that the resident required extensive assistance of 2 staff members for personal hygiene, bed mobility, and total dependence of two staff members for transfers. The residents Care Plan with the current goal date of 7/14/16 identified that the resident had been dependent on staff for cares. The Care Plan goal documented that the resident will be neatly groomed and free of bodily orders through the next review. The Care Plan directed staff to assist the resident with dressing daily in clean, and appropriate clothing. The Care Plan directed staff to use two staff members to transfer the resident out of bed with a Hoyer lift. During an interview on 5/4/16 at 9:43 a.m. Staff C, Certified Nurses Aide (C.N.A) reported that cares provided to the resident are charted in the AccuNurse (electronic voice activated computer charting system) computer system. Staff C also reported that information on how to care for the resident is also in the AccuNurse system. The AccNurse electronic records reviewed from 5/1/16 at 7:00 p.m. to 5/4/16 at 4:15 p.m. revealed the following; 5/2/16 at 11:00 a.m. resident transferred, 5/3/16 at 1:45 p.m. resident transferred, 5/3/16 at 4:30 p.m. resident transferred, 5/4/16 at 11:00 a.m. resident transferred. During an interview on 5/5/16 at 9:08 a.m. Staff B, and Staff A both C.N.A's reported that they get the resident up on day shift and second shift would put the resident back to bed. Staff B, and Staff A both reported the resident cares are documented on the AccuNurse. During an interview on 5/5/16 at 9:10 a.m. Staff L, Certified Medication Aide reported that Staff B, and Staff A take care of the resident most of the time on day shift. Staff L reported they get the resident up on day shift, and the second shift staff put the resident back to bed. Staff L reported that the resident cares are documented on the AccuNurse. During an interview on 5/4/16 at 10:00 a.m. Staff E, Activity Staff reported that she did not know how often the resident gets up, but did report that she knew the resident could only be up for two hours at a time. Observation on 5/2/16 at 9:50 a.m. revealed the resident in bed with a hospital gown on. Observation on 5/2/16 at 1:52 p.m. revealed the resident in bed with a hospital gown on. Observation on 5/2/16 at 2:42 p.m. revealed the resident in bed with a hospital gown on. Observation on 5/3/16 at 7:42 a.m. revealed the resident in bed with a hospital gown on. Observation on 5/3/16 at 10:21 a.m. revealed the resident in bed with a hospital gown on. Observation on 5/3/16 at 5:53 p.m. revealed the resident in bed with a hospital gown on. Observation on 5/4/16 at 9:30 a.m. revealed the resident in bed with a hospital gown on. Observation on 5/4/16 at 10:50 a.m. revealed the resident in bed with a hospital gown on. Observation on 5/4/16 at 1:30 p.m. revealed the resident in bed with a hospital gown on. During an interview on 5/4/16 at 1:40 p.m. Resident#20 reported that he/she preferred to remain in bed by his/her choice at all times. The resident also reported that his/her roommate Resident#1 never got out of bed. The Quarterly MDS dated [DATE] for Resident#20 documented that the resident scored a 15 on the brief interview for mental status, which indicated that the resident had been cognitively intact to make daily decisions.

Based on record review and staff interviews, the facility failed to administer the correct dosage of insulin as ordered by the physician to Resident #3 which resulted in a significant medication error. The sample consisted of 8 residents and the facility reported a census of 98 residents. Findings include: 1. A May 2013 Physician order [REDACTED]. The physician ordered staff to check the resident's blood glucose level by a finger stick twice a day and to call the physician if the blood sugar ran less than 80 or greater than 300. The Nurse's Notes dated 5/28/13 at 10:55 a.m. revealed staff had the resident transferred to a local hospital via ambulance after a medication error. The note reflected the resident received 100 units of [MEDICATION NAME] instead of 6 units. The physician was notified and the physician ordered staff to start an IV (intravenous) line and administer [MEDICATION NAME] stat (immediately). The ambulance arrived less than 3 minutes and the ambulance crew started the [MEDICATION NAME] via the IV and transported the resident to the hospital. The Director of Nursing ' s notes identified she contacted the hospital at 3:0 5 p.m. on 5/28/13. The resident had been admitted and remained alert and oriented. The notes indicated the resident had no change in condition at the time. At 5:10 p.m. on 5/28/13, the note reflected the hospital staff was checking the blood glucose every 2 hours. On 5/29/13 at 6:20 a.m., the Director of Nursing contacted the hospital. The hospital reported the resident had no ill effects throughout the night and the blood glucose readings remained within normal. The resident planned to go to [MEDICAL TREATMENT]. During an interview on 12/10/13 at 11:10 a.m. Staff A stated he had "filled in" (worked) for regular staff that normally worked the AB hall. Staff A stated when he/she usually works on Monday when Resident #3 is at [MEDICAL TREATMENT]. Staff A stated this was the first time he had given Resident #3 insulin. Staff A stated he had drawn up 2 syringes (of insulin) for Resident #3 and as he was giving the second syringe (injection), Resident #3 asked him if the insulin dosage had been increased. Staff A stated he immediately knew he had administered the wrong amount (of insulin), stating he had read the concentration amount and administered that amount instead of the actual dosage amount. Staff A stated he had been busy and "rushed" and stated it was the "stupidness" mistake of his career. During an interview on 01/07/14 at 9:03 a.m. Resident #3 recalled the event in which he/she received too much insulin. Resident #3 confirmed that he/she received 100 units instead of the 6 units ordered. Resident #3 stated the male nurse ("a good guy") gave the insulin, and when he/she saw two syringes, he/she asked how much was he/she receiving. Resident #3 stated the nurse informed her/him of the amount of insulin administered. Resident #3 stated he/she informed the nurse "no, no, I get 6 units". The nurse stated, no, it was 100 units, and Resident #3 stated no, it was 6 units. During this interchange of conversation, Resident #3 stated the nurse had injected both syringes and then left the room. Resident #3 stated the nurse returned in 5 or 6 minutes with several more nurses and he/she was going to be transferred to the hospital. The daily interdisciplinary notes dated 5/30/13 at 8:00 p.m. revealed the resident returned to the facility at 6:30 p.m. Upon return to the facility, the resident received a glass of orange juice. The staff checked the resident ' s blood sugar which registered 133. The nurse contacted the ARNP with blood sugar results of 133. The ARNP ordered the [MEDICATION NAME] be held for the night, continue to check blood sugar levels 4 times a day and call the ARNP on 5/31/13 for orders before giving the [MEDICATION NAME]. During an interview on 01/07/14 at 9:03 a.m. the ARNP (Advanced Registered Nurse Practitioner) stated she and the resident ' s physician worked with and cared for Resident #3. The ARNP stated the resident had been kept at the hospital because the insulin that was given (in the overdose) was the long acting type and any effects of the over dose would not be apparent for about twelve hours. The ARNP further explained by keeping Resident #3 at the hospital, the blood sugar levels could be obtained and monitored. If the blood sugar levels dropped then immediate appropriate treatment could be administered. In addition, Resident #3 received [MEDICAL TREATMENT] every other day, and by having the resident stay at the hospital, trips to and from the hospital for [MEDICAL TREATMENT] were eliminated during the observational period After the medication error on 5/28/13, the facility implemented a system of 2 people checking the physician's orders [REDACTED]. In May 2013, the nurses were informed of the medication error and the facility began performing insulin administration audits. A meeting was held with nursing staff regarding the immediate jeopardy and survey on 1/10/14. The eight rights of medication administration and double checking of insulin administration were again reviewed by nurses at a meeting held on January 10, 2014. The facility had corrected the significant medication error prior to the investigation.

Based on record review, resident and staff interviews, the facility failed to assess bowel management and provide timely interventions for 5 of 16 residents reviewed (Resident #2, #3, #6, #9, #18). The facility reported a census of 96 residents. Findings include: The facility Bowel Management Protocol (undated) listed the following interventions: Day 3 without a bowel movement, administer Milk of Magnesia (MOM), Day 4 without a bowel movement, administer a [MEDICATION NAME] suppository, Day 5 without a bowel movement, assess the abdomen, bowel sounds, and perform a digital check by inserting a finger into the rectum to check for stool. 1. The Minimum Data Set ((MDS) dated [DATE] documented Resident #6 had [DIAGNOSES REDACTED]. The MDS documented the resident had intact memory and adequate recall. The MDS documented the resident required extensive of two staff for transfers and toilet use. The MDS documented the resident as continent of bowel and bladder. Review of the computerized bowel movement report on the accunurse system documented the resident did not have a bowel movement from December 10th through December 19, 2012 or nine days without a bowel movement. The MAR (Medication Administration Record) for December 2012 documented staff administered a suppository on December 19th or nine days without a bowel movement. The daily skilled nurse's note dated 12/20/12 during the night shift documented the resident vomited a large amount of dark colored emesis with a moderate amount of fecal matter. The resident's abdomen had distention and painful when touched. The nurse performed a rectal check and felt stool in the rectum. A patient discharge and transfer form from the hospital documented the resident as admitted to the hospital with [REDACTED]. An x-ray dated 12/20/12 documented an extensive amount of stool throughout the colon. The care plan dated 1/10/12 did not address the resident's constipation and interventions to help the resident to have regular bowel movements. During an interview on 2/23/12 at 2:00 p.m., Resident #6 stated there was a time when he/she was constipated and did not have a bowel movement for several days but stated the constipation has resolved. During an interview on 12/29/12 at 9:38 a.m., the Assistant Director of Nursing stated the night shift reviewed the alerts and passed information for the day shift nurse. In order to resolve the problem in the computer system, the Certified Nurse Aides must document the resident's bowel movements. The Assistant Director of Nursing stated he and the Director of Nursing educated the Certified Nurse Aides and continues monitoring the computer charting twice a week. 2. The MDS dated [DATE] documented Resident #2 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. The MDS documented the resident as frequently incontinent of stool. A progress note dated 8/9/11 documented a [DIAGNOSES REDACTED]. Review of the computerized charting for bowel movement report on the accunurse revealed the resident did not have a bowel movement August 18 through August 22, 2011. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the computerized charting for bowel movement report on the accunurse revealed the resident did not have a bowel movement October 1st through October 8, 2011 and October 16th through the 21st The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the computerized charting for bowel movement report on the accunurse revealed the resident did not have a bowel movement December 28th through January 3, 2012 with a suppository given on day 6 January 3, 2012. Review of the computerized charting for bowel movement report on the accunurse revealed the resident did not have a bowel movement January 3rd through January 7, 2012. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the computerized charting for bowel movement report on the accunurse revealed the resident did not have a bowel movement February 3rd through the 8th and February 13th through February 18, 2012. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The care plan dated 12/29/11 did not address the resident's constipation and interventions to help the resident to have regular bowel movements. 3. The MDS dated [DATE] documented Resident #3 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance for bed mobility, transfers, toilet use, and personal hygiene. The MDS documented the resident occasionally incontinent. The discharge summary from the hospital from 1/18 to 1/20/12 documented a [DIAGNOSES REDACTED]. Review of the computerized charting for bowel movement report on the accunurse revealed the resident did not have a bowel movement February 1st through the February 5, 2012. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The care plan dated 12/12/11 did not address the resident's constipation and interventions to help the resident to have regular bowel movements. 4. The MDS assessment with a reference date of 1/12/12 documented Resident #9 had [DIAGNOSES REDACTED]. The MDS documented the resident as totally dependent on staff for bed mobility, transfers, toilet use, and personal hygiene. The MDS documented the resident as always incontinent of bowel. Review of the computerized bowel movement report on the accunurse system documented the resident did not have a bowel movement from January 7th through January 13, 2012. An abdominal x-ray dated 1/29/12 documented a [MEDICATION NAME] distention of the proximal small bowel loops as evidence of incomplete small bowel obstruction or ileus. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 5. The MDS dated [DATE] documented Resident #18 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with bed mobility, transfers, toilet use, and personal hygiene. The MDS documented the resident as frequently incontinent of bowel. Review of the computerized bowel movement report on the accunurse system documented the resident did not have a bowel movement from November 15th through November 26, 2012. An abdominal x-ray dated 11/26/11 documented a moderate volume of feces in the colon without a small bowel obstruction. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the computerized bowel movement report on the accunurse system documented the resident did not have a bowel movement from December 16th through December 21, 2012. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].

Based on observation, record review, and staff interviews, the facility failed to provide adequate supervision to prevent falls and supervise the implementation of the written health care plan for 16 of 19 residents reviewed. Concerns were identified with Resident's #1, #2, #3,# 4, #6, #7, #8, #9, #11, #12 and #14, #15, #16, #17, #18, #19. The facility identified a census of 98 residents. Findings include: Residents #1, #2, #3, #4, #6, #7 and #18 live in the Chronic Confusion Dementing Illness (CCDI) Unit on the South Hall. The facility identified a CCDI Unit census of 17 residents. 1. According to the facility Face Sheet Resident #19 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #19 had severely impaired cognition and required extensive assistance of 1 staff for transfers, ambulation, dressing and toileting. The assessment documented the resident's balance as unsteady. The Assessment Risk for Falls dated [DATE], documented the resident's fall score 10, a high risk for falls. The Daily Skilled Nursing Note documented on [DATE], at 4:00 AM, the nurse responded to Resident #19's alarm sounding. The nurse entered the resident ' s room and found the resident attempting to transfer self to the bathroom. The Certified Nurse's Aide (CNA) assisted the resident to the bathroom. The resident appeared anxious, much encouragement from staff to use his/her call light when needing to get up. The resident stated "I needed to go really bad. " The Nurse's Notes dated [DATE], at 3:15 PM documented staff called the nurse to Resident #19's room. The nurse found the resident lying on his/her back in the doorway of the bathroom with legs curled up and calling out in pain. The resident is able to move his/her upper extremities but guards his/her left lower extremely and complains of pain to the left hip and back. The x-ray report dated [DATE]; documented Resident #19 had a subcapital fracture of the left femoral neck. The Nurse's Notes dated [DATE], at 10:00 AM documented Resident #19, returned to the facility from the hospital via ambulance and transferred to the bed with assistance of 3 staff members. The resident was noted with severe pain, increased anxiety, tremors and the resident's face was red. The resident has oxygen on at 2 liters per nasal cannula. After positioned in bed, the resident continued to have increased anxiety and severe pain. The Nurse's Notes dated [DATE], at 11:00 AM documented the resident continued to have increased anxiety and complains of pain. The Nurse ' s Notes dated [DATE] at 6:00 p.m. indicated the resident moaning at times. Roxanol (Morphine) given every 4 hours and the resident rested quietly after the administration. The Nurse ' s Notes dated [DATE] at 1:00 p.m. indicated the staff administered Roxanol twice during the day shift. The resident appeared comfortable but the resident ' s intake very poor. The Nurse ' s Notes dated [DATE] at 9:00 a.m. indicated Hospice Care involved. The facility staff continued to administer Roxanol for the pain and discomfort. On [DATE], at 10:15 AM, observation revealed Resident #19 in bed unresponsive with oxygen at 2 liters per nasal cannula, and a Foley catheter in place. Staff D, Licensed Practical Nurse (LPN) reported she gave Resident #19 a suppository for an elevated temperature. On [DATE], at 2:15 PM observation revealed Resident #19 unresponsive, and positioned on his/her right side. On [DATE], at approximately 10:30 AM, the MDS/Care Plan Coordinator reported Resident #19's wheel chair and bed alarm were discontinued on [DATE], after the MDS quarterly review. On [DATE], at approximately 1:30 PM, the DON reported the facility discontinued Resident #19's wheel chair and bed alarm on [DATE], after his/her MDS quarterly review. The DON reported the resident had no falls since admission, and no history of self transfers. On [DATE], at 12:09 PM Staff E reported she found Resident #19 in the bathroom on the toilet with no alarm sounding. The resident had shut the alarm off. Staff E stated she assisted the resident back to bed, turned the alarm on and placed it out of the resident's reach. Staff E reported Resident #19's had an unsteady gait. Staff E stated this occurred one to two weeks prior to his/her fall. Staff E stated the 2 to 10 shift would place the resident's bed alarm on his/her bedside dresser within the resident's reach, and the resident had no problem shutting the alarm off. On [DATE], at 12:26 PM, Staff F reported she works the ,[DATE] PM shift. Staff F stated she had never seen Resident #19 self transfer, but she would find Resident #19's bed alarm sounding and when she got to the resident's room she would find the resident with his/her legs over the side of the bed. Staff F reported the resident would be wanting up to the wheel chair or the bathroom. On [DATE], at 2:40 PM, Staff G reported working the Bailer shift 2 PM to10 PM and 10 PM to 6 AM on weekends. Staff G reported Resident #19 would put on his/her call light and you knew to hurry to his/her room. The resident would have the blanket thrown back ready to get up and the resident didn't want to wait. On [DATE], at 11:15 AM, the x-ray reports were requested, at this time. The ADON reported Resident #19 died on [DATE]. 2. According to Face Sheet Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment with a reference date of [DATE], documented the resident required cues/supervision, had short/ long term memory problems, depended on staff for all activities of daily living and required cues/supervision. The Assessment Risk for Falls dated [DATE], documented the resident had a score of 11, the Assessment of Risk for Falls dated [DATE], documented a score of 13. The Assessment of Risk for Falls documented a score of 07 to 18, which indicated the resident at high risk for falls. The Nurse's Notes dated [DATE], 3:45 AM documented the CNA found the resident on the floor lying supine on his/her left side by the bed. The bed alarms did work properly but the resident thought to have unplugged the alarm. The alarm worked properly when tested . The Resident Incident Report dated [DATE], 3:30 AM documented the CNA entered the room and found the resident lying supine on his/her left side by the bed. The resident has a pressure alarm on the bed, the resident thought to have pulled the plug out. The alarm worked when tested . The incident reported documented the resident admitted to the emergency room with a fractured femur. The facility reported the resident had a history of [REDACTED]. The Care Plan documented an update of [DATE]. The Care Plan documented the resident required assistance of ,[DATE] staff with all activities of daily living interventions: a. [DATE], falling star program. b. [DATE], move the pressure alarm box out of the resident's eye sight. c. [DATE], pressure alarm to the bed. d. [DATE], pressure alarm to wheel chair. When interviewed on [DATE] at 11:40 PM, Staff A, stated on [DATE], Resident #1 had behaviors at 1:30 AM and a "hand full" trying to get out of bed and shutting the bed alarm off. Staff A reported the bed alarm didn't sound at the time of the fall. Staff A reported she found Resident #1 on the floor ,[DATE] feet away from the bed lying next to the bathroom door. The night the resident fell , I placed the bed alarm in the drawer of the bedside table, and kicked it under the bed; the resident would still get it. Staff A stated maybe she/he should have gotten him/her up out of bed and placed the resident in the wheelchair. Staff A reported Resident #1 had a history of [REDACTED]. The resident would shut the alarms off and pulls the cords out. On [DATE], at 10:30 AM, observation revealed the resident in bed with the bed alarm laying on the bedside Dresser and within the resident's reach. On [DATE], at 12:20 PM, observation revealed the resident up in his/her wheel chair in the dining room. Observation revealed the wheel chair alarm within the resident's reach. On [DATE], at 1:30 PM, observation revealed Staff B and C place transfer Resident #1 into bed from the wheelchair and place the bed alarm in the bottom drawer of the bedside dresser. Observation revealed the bed alarm cord hanging from the mattress leading to the alarm in the drawer within the resident's sight and reach. On [DATE], at 11:38 PM observation revealed the resident in bed with the bed alarm box lying on the bedside dresser within the resident's sight and reach. On [DATE], at 12:13 AM observation revealed the resident in bed with the bed alarm lying on the bedside dresser within sight and reach of the resident. Observation revealed the bed alarm cord hanging from the side of the mattress leading to the alarm box. 3. According to the facility Face Sheet Resident #9 had [DIAGNOSES REDACTED]. The Assessment of Risk for Falls dated [DATE], and [DATE] documented the resident at risk for falls. The MDS assessment dated [DATE], documented the resident required one person assistance with transfers, ambulation and toileting. The Nurse's Notes dated [DATE], at 12:30 PM documented staff found the resident on the floor in the bathroom. The resident stated, "I hit my head on the toilet." The Resident Incident Report dated [DATE], documented staff found the resident on the floor in the bathroom. The incident report documented the resident went to the emergency room . The Temporary Care Plans dated [DATE], lacked any fall intervention. The Nurse's Notes dated [DATE], at 11:10 AM documented staff found the resident on the floor in the dining room The Nurse's Notes dated [DATE], at 7 PM documented staff found the resident on the floor in his/her room laying flat on his/her back next to the recliner unable to recall what had happened. The Nurse's Notes dated [DATE], at 1 PM documented staff found the resident on the floor lying in the doorway of the bathroom with the transport wheel chair behind him/her. The resident stated, " I was getting off the toilet and went to sit in the wheel chair and it rolled away." The Resident Incident Report dated [DATE], documented the resident transferred him/her self from the toilet to the wheel chair without locking the wheel chair. The incident report documented the facility intervention: pressure alarm to the bed and wheel chair. The incident report documented the resident confused and ambulated with a wheeled walker and assistance of 1 staff person. The Nurse's Notes dated [DATE], at 10:45 PM documented the resident had the bathroom call light on, staff walked into the bathroom and found the resident laying on the bathroom floor. The resident attempted to take self to the bathroom and fell . The Nurse's Notes dated [DATE]; at 7:50 AM documented the resident's roommate came out into the north hallway and stated the resident is on the floor. Staff entered the room and found the resident laying on his/her back in front of the bathroom and the wheel chair to the right side of the resident. The Resident Incident Report dated [DATE], documented the same and the Temporary Care Plans documented Alarms? The Nurse's Notes dated [DATE]; at 3:30 PM documented the resident is noted to be lying on the floor in the North West lobby in front of the flowered chair. The Resident Incident Report dated [DATE], documented staff noted the resident lying on the floor in the North West lobby in front of the flowered chair. The resident stated he/she was going to sit in the chair and missed. The incident report documented the facility fall intervention: pressure alarm to the wheel chair and bed. The Nurse's Notes dated [DATE], at 5:15 PM documented the resident was getting off the toilet and got dizzy and lost his/her balance and fell . The resident hit his/her head on the bathroom/ doorway floor. The resident had a small hematoma noted on the back of his/her head. The Resident Incident Report dated [DATE], documented the resident was getting off the toilet and got dizzy and lost his/her balance and fell . The incident report documented the facility fall intervention: pressure alarm to the bed and wheel chair. On [DATE], at 1:58 PM observation showed the resident in bed with the bed alarm on the bedside dresser within reach of the resident. 4. According to the facility Face Sheet Resident #18 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], documented Resident #18's cognitive status as severely impaired. The MDS assessment documented the resident as dependent on staff for all activities of daily living. The Care Plan dated [DATE], documented the resident had a potential for injury from falls related to weakness, and dementia. The Care Plan documented the resident required extensive assistance of ,[DATE] staff for transfers. The Resident Incident Report dated [DATE], at 11 PM documented staff found the resident in the middle of the resident's floor. The resident had been pushing his/her wheel chair. The resident did not have signs or symptoms or complaints of injury. The Temporary Care Plan dated [DATE], documented the facility fall intervention: Personal Safety Alarm (PSA) applied. The Resident Incident Report dated [DATE], at approximately 11 AM documented the resident sat on his/her walker seat and the walker leg malfunctioned and the resident fell on to left side. The Incident report documented the facility obtained a new walker for the resident. The Temporary Care Plan dated [DATE], documented therapy replaced the resident's broken walker. The Resident's Incident Report dated [DATE], at 6 AM documented Resident #18 had been up in the Merry Walker until 3 AM (he/she would not stay in his/her recliner). At 3 AM the resident was placed in a recliner in the hall way. The resident pulled the recliner over with the use of the hallway rail. The Resident Incident Report documented the resident with a fall history, inability to understand directions, confused/disoriented, with a Foley catheter and totally confused and disoriented x's 2. When interviewed on [DATE], at 12:40 PM Staff C reported on [DATE], when she arrived in the CCDI Unit at 6:00 AM, the night staff had placed Resident #18 in a recliner in the hallway. Staff C reported she observed Resident #18 in the recliner in the hallway at 6:11 AM awake and the resident looked comfortable. Staff C reported she responded to an alarm sounding in Room 14. Then when responding to the alarm in Room 14 she heard an alarm sounding in the hallway. She assisted the resident in Room 14 to a seated position and went to respond to the second alarm sounding. Staff C stated she opened the door and watched Resident #18 fall. The resident flipped the recliner over on him/herself. Staff C reported she was the only staff in the unit at that time. Staff C reported Staff H Registered Nurse (RN) was out of the unit at that time and the only CNA working in the unit that day. Staff C reported she was the only CNA for 17 residents. 5. According to the facility Face Sheet, Resident #3 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE]; documented Resident #3 had disoriented thinking, and depended on staff for all activities of daily living. The clinical record review revealed the resident had falls, on [DATE], and [DATE]. The Assessment of Risk for Falls dated [DATE], [DATE], [DATE], and [DATE], documented the resident at high risk for falls. The Nurse's Notes dated [DATE] at 4:45 AM documented the resident attempted to get out of bed and fell . The resident has an abrasion to the left knee. The Resident Incident Report dated [DATE] at 4:45 AM documented the resident fell getting his/her self out of bed. The incident report documented the facility intervention: pressure alarm to the bed and wheel chair. The Nurse's Noted dated [DATE] at 1:30 PM documented the resident attempted to get out of bed and fell to the floor. The Resident Incident Report dated [DATE], 10:30 AM documented the resident attempted to get out of bed and fell to the floor. The resident incident report documented the facility intervention: pressure alarm to bed and wheel chair. The Care Plan updated [DATE], documented on [DATE], the facility placed a pressure alarm to the resident's bed and wheel chair. The Care Plan documented the alarms were discontinued on [DATE]. The Treatment Record dated [DATE], documented the resident had a pressure alarm to the wheelchair and bed. The treatment sheet documented staff checked the placement and functioning of the alarm every shift. The Treatment record dated [DATE], documented the resident had a pressure alarm to the bed and wheel chair at all times and documented staff checked placement of the alarms every shift The Treatment Record dated [DATE], documented the resident had a pressure alarm to his/her bed and wheel chair initiated [DATE] and documented staff checked the placement every shift. On [DATE], at 2:30 PM, observation revealed Resident #3 in bed with eyes open. Observation revealed the resident's bed alarm lying on the bedside dresser within the residents reach. On [DATE], at 11:04 PM observation revealed the resident awake and sitting on the edge of the bed with the bed alarm sitting within ,[DATE] feet of the resident's reach on the bedside dresser. 6. According to the facility Face Sheet, Resident #4 had [DIAGNOSES REDACTED]. The Assessment of Risk for Falls dated [DATE], and [DATE], documented the resident at high risk for falls. The MDS quarterly assessment dated [DATE], documented the resident had continuous inattention and psychomotor retardation. The assessment documented the resident's balance unsteady when moving from seated to standing position, walking, turning around, moving on/off the toilet and when moving from surface to surface transfers. The Nurse's Notes dated [DATE] at 2 PM documented the resident sitting on the floor this AM. The Nurse's Notes dated [DATE] at 8 PM documented the resident is up and about in room throwing belongings on floor and going through roommates belongings. The resident opened [DEVICE] and tube feeding ran out in bed; much redirection needed. The Nurse's Notes dated [DATE] at 7:30 PM documented staff witnessed the resident leaning on the chair, the chair moved and the resident sat on the floor. The Nurse's Notes dated [DATE], 8 PM documented staff observed the resident sitting on the floor several times. The staff assisted the resident to a chair or bed and the resident continued to sit on the floor. The Nurse's Notes dated [DATE], PM documented staff found the resident numerous times scooting around the floor. The resident uncapped the G Tube feeding and allowed some formula to spill on the floor and spread it all over the floor and clothing. The Nurse's Notes dated [DATE] at 8 PM documented staff observed the resident climbing on his/her roommate ' s bed, chair and hanging from the curtains, crawling on the floor. The Nurse's Notes dated [DATE], 10 PM to 6 AM shift documented the resident as unable to sleep this shift. The resident fell on the floor after swinging on the curtains. The resident hit his/her left scapula on the rocking chair. The Care Plan entry dated [DATE], directed staff to tie the resident's curtains back when not in use. The Nurse's Notes dated [DATE] at 8:30 PM documented the resident as agitated and hanging on the curtains and blinds and flooding the sink with water on the floor. Much redirection needed. Xanax (anti-anxiety) given. The Nurse's Notes dated [DATE] at 2 PM documented staff responded to a noise in the resident's room and found the resident laying against the air conditioner and bleeding from the back of the head. The bleeding was stopped and the neurological assessment intact. A low bed and mat initiated. 7. The Treatment Record dated [DATE]; documented Resident #6 had [DIAGNOSES REDACTED]. The Assessment Risk for Falls dated [DATE], documented the resident at high risk for falls. The MDS assessment dated [DATE] documented the resident dependent on staff for all activities of daily living. The resident's Care Plan dated [DATE], documented the resident required assistance of ,[DATE] staff for transfers and ambulation. The Care Plan documented the following fall interventions: a. [DATE], pressure alarm to bed b. [DATE] pressure alarm to wheel chair c. [DATE], grippy socks or shoes on every AM as the resident tolerates. d. [DATE], non-skid strips to the bedside. The Nurse's Notes dated [DATE], at 4:30 PM documented staff found the resident on the floor on his/her hands and knees in room S 19, near the bathroom door. The resident complained of left hip discomfort. The Nurse's Notes dated [DATE] at 5:17 PM documented staff found the resident laying on the floor in room S-18 on his/her left side. The resident stated he/she got short of breath and fell . The Nurse's Notes dated [DATE], at 8 PM documented an alarm in place on the resident's bed for safety. The Resident Incident Report dated [DATE], documented the resident had dementia, confusion/disoriented with a fall history. The incident report documented staff heard the resident moan in Room 18 and found the resident on the floor laying on his/her left side. The Temporary Care Plan dated [DATE], documented the facility intervention; alarm in place for safety. The Nurse's Notes dated [DATE] at 8 PM documented the resident is up and about per usual non-compliant with alarms. The resident angry at staff about alarms and argumentative. The resident complains of mild discomfort to the left hip area. The Nurse's Notes dated [DATE] at 2 AM documented the resident had been up removing the pressure alarm and taking the batteries out. The Nurse's Notes dated [DATE] at 9 AM documented the resident is non-compliant with alarms, transferring self to and from the wheel chair and bed. Per supervision noted the resident put his/her fingers on the alarm button to silence the alarm and unplug the alarm. Educated the resident the alarm alerts staff for safety. On [DATE] at 7 PM, staff heard alarm sounding, CNA ran to the resident's room and observed the resident going down, and the CNA could not catch the resident from the fall. The CNA stated the resident hit his right side of his/her head and body on the bathroom door and fell to the floor. Staff educated the resident to wait for assistance and use the call light. On [DATE] at 2:37 PM, observations revealed Resident #6 in bed with the bed alarm box lying on the bedside table within the resident's reach. Observation revealed the alarm box cord hanging from the bedside mattress within the sight and reach of the resident. On [DATE], at approximately 11:52 PM, observation revealed Resident #6 sitting up in bed awake. Observation identified the resident's bed alarm lying on the bedside dresser approximately ,[DATE] feet from the resident ' s reach and sight. Staff A showed the resident ' s wheelchair alarm did not sound. Observation revealed the connecting cord from the wheelchair pad to the alarm box with a broken prong preventing a secure connection between the wheelchair pad and alarm box. Observation identified if moved or bumped the alarm would not sound. On [DATE] at 1:36 PM, observation revealed Resident #6 up in his/her wheel chair in the dining room alone, without staff present. Observation identified the wheelchair alarm hanging on the wheelchair handle. 8. According to the facility Face Sheet, Resident #7 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident required one person assistance with transfers, ambulation, dressing, eating and toileting. The Care Plan dated [DATE], directed staff to transfer the resident with assistance of 1 or 2 staff. The Treatment Administration Record dated [DATE], documented Personal Safety Alarm (PSA) on bed for safety. The Nurse's Notes dated [DATE] at 3 PM documented at 9:45 AM, staff heard alarms sounding and noted the resident on the floor. On [DATE], at 12:36 AM, observation identified the resident in bed with the bed alarm setting on the resident's walker seat beside the bed and within the resident's reach. On [DATE] at 12:50 AM, while caring for Resident #7's roommate, Resident #7 reported he/she needed to go the bathroom. Staff A told Resident #7 he/she could go to the bathroom. Observation revealed Resident #7 toilet his/her self and return to bed. The bed alarm remained on the bedside walker seat. On [DATE], the DON supplied the resident's ADL Plan of Care and stated the date [DATE], indicated the day it was printed and not the date of initiation. The DON reported the ADL Plan of Care was in place on [DATE]. On [DATE], at approximately 11:50 PM, Staff A showed Resident #7's bed alarm clasp broken. Observation revealed the bed alarm did not sound when pulled on alarm cord and slid out of the bed alarm box. 9. According to the facility Face Sheet Resident #2 had [DIAGNOSES REDACTED]. The MDS dated [DATE] and [DATE], documented the resident dependent on staff for all activities of daily living and had long/short term memory problems, required cues and supervision. The Assessment of Fall for Risk dated [DATE], [DATE], and [DATE] documented the resident' at high risk for falls. The Nurse's Notes dated [DATE] at 9:30 PM documented the CNA found the resident sitting on the floor near the floor mat. The resident had a quarter size hematoma to the left side of the forehead. The Resident Incident Report dated [DATE], documented the CNA found the resident sitting on the floor near the floor mat, with alarms sounding. The Resident Incident Report dated [DATE], documented the fall intervention; lip mattress to the bed. The Nurse's Notes dated [DATE] at 4 PM and the incident documented staff heard the resident yelling " help me. " Staff found Resident #2 sitting by the bed on the mat. The Resident Incident Report dated [DATE], documented the facility fall intervention: Staff Education. The Nurse's Notes dated [DATE] at 7 AM documented staff found the resident on his/her left side on the floor with alarms going off, bump noted on the right/left side of his/her forehead. The Resident Incident Report dated [DATE], documented staff found the resident on his/her left side on the floor complaining of right hand pain. The Resident Incident Report dated [DATE], documented the fall intervention: new bed per hospice. The Nurse's Notes dated [DATE] at 2:15 PM documented staff found the resident sitting on the floor in the middle of the room. The resident had been in bed, no alarm sounding. The Resident Incident Report dated [DATE], documented staff found the resident sitting on the floor in the middle of the room confused. The resident denied hitting his/her head. The resident stated he/she hurts all over. The Resident Incident Report dated [DATE], documented the facility intervention; hospice consulted for beveled mattress. On [DATE] at approximately 11:45 PM, observation revealed Resident #2's alarmed floor matt not sound as Staff A stepped on it. Staff A checked the alarmed floor matt and found the cord connecting the floor matt to the alarm box had not been connected properly. The cord had not been pushed in far enough to make the connection to the alarm box. On [DATE], at 12:13 AM observation identified the resident in bed with the bed alarm box lying on the bed side dresser and within the resident's reach. Observation revealed the bed alarm cord hanging approximately ,[DATE] feet off the side of the bed leading to the alarm box on the bedside dresser within reach and view of the resident. 10. According to the Care Plan dated [DATE], Resident #8 had [DIAGNOSES REDACTED]. The Care Plan documented the resident required assistance of ,[DATE] staff for transfers. The Assessment for Risk for Falls dated [DATE], and [DATE], documented the resident a high risk for falls. The MDS assessment dated [DATE], documented Resident #8 with difficulty focusing and disorganized thinking. The MDS documented the resident dependent on staff for all activities of daily living. The Nurse's Notes dated [DATE] at 6:25 PM documented the resident got up from his/her wheelchair and fell in the dining room causing a 3.0 by 1.0 centimeter abrasion to the right knee. The Resident Incident Report dated [DATE], documented the resident got up from the wheel chair in the dining room and fell . The Resident Incident Report documented Social Service to contact placement, increased behaviors, wandering related to unit placement. The Nurse's Notes dated [DATE] at 9:45 PM documented the resident had been asleep in bed, alarm heard upon checking and staff found the resident sitting on the wheel chair pedals on the floor by the roommates bed. The Resident Incident Report dated [DATE], documented staff found the resident on the floor by his/her roommates bed sitting on the wheel chair pedals of the roommates wheel chair, with a 3.0 by 2.0 centimeter abrasion to his/her left posterior thigh. The incident report documented the facility fall intervention: check on placement in CCDI Unit. The Nurse's Notes dated [DATE], documented staff found the resident on the floor this AM with alarms sounding. The resident was looking for his/her glasses this AM. The resident's glasses are 'lost'. Will pass on the resident wears glasses as an intervention. The Resident Incident Report dated [DATE], documented staff found the resident attempting to put self in bed. Alarms were sounding the resident appeared anxious this AM as needed Xanax (anti-anxiety medication) was given at 8 AM. The resident was looking for his/her glasses. The Nurse's Notes dated [DATE] at 6 AM to 10 PM documented the resident compliant with staff and cares today, follows commands and able to make his/her needs known. PSA (Personal Safety Alarm) and pressure alarms on at all times. The resident continues to take him/her self to the bathroom and ambulate around his/her room. The Nurse's Notes dated [DATE], documented at 4 PM the resident is very restless this afternoon wanting to go home; redirected several times and will monitor. The Nurse's Notes dated [DATE] at 6 PM documented at 5:15 PM the resident's alarm sounded and staff found the resident sitting/lying on the floor in the dining room. The resident stated he/she was looking for the books. Educated the resident to ask for help and not to get up by self. The Nurse's Notes dated [DATE] at 5:17 PM documented the CNA found the resident in the dining room with the alarms sounding. The incident report documented the facility fall intervention: consult hospice for further interventions. On [DATE], at 10:10 AM observation revealed the resident up in his/her wheel chair in the dining room with the wheel chair alarm within the resident's reach. On [DATE], at 11:54 PM observation revealed the resident in bed sleeping. Observation revealed the bed alarm sitting on the resident's chair next to the bed within the resident's reach. On [DATE]. at 1:40 PM observation identified Resident #8 in a low bed with the bed alarm on the floor next to the bed and within the resident's reach. Observation showed the alarm cord approximately ,[DATE] feet long. 11. According to the facility Face Sheet Resident #12 had [DIAGNOSES REDACTED]. The MDS assessment, with a reference date of [DATE], documented Resident #12 Cognitive Skills For Daily Decision Making as severely impaired and required extensive assistance of two staff for transfers and toileting. The resident required assistance of one staff for ambulation, and bed mobility. The Assessment of Risk for Falls dated [DATE], [DATE], and [DATE], documented a score of 10 and